CITY CLERK'S DATE STAMP
CITY OF RIALTO
CITY OF RIALTO
LIABILITY
2025 OCT 20 AM 8: 29
CLAIM FOR DAMAGES
TO PERSON OR PROPERTY RECEIVED
CITY CLERK
1. Claims for death, injury to person, orto personal property must be filed not later than six (6) months after the occurrence (Gov. Code 5911.2).
2. Claims for damages to real property must be filed not later than one (1) year after the occurrence (Gov. Code 59112). RETURN TO:
3.READ ENTIRE CLAIM FOR BEFORE FILING Rialto City Clerk's Office Mail: 150 S. Palm Ave., Rialto, CA 92376
4.ATTACH SEPARATE SHEETS, IF NECESSARY, TO GIVE FULL DETAILS Address: 290 W. Rialto Ave., Rialto, CA 92376 CLAIMANT INFORMATION:
MARIaEMendoza MuRillo DATE OF BIRTH
FULL NAME
-
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE NO.
BUSINESS TELEPHONE NO.
BUSINESS ADDRESS INCLUDING CITY, STATE & ZIP
ADDRESS AT WHICH CLAIMANT DESIRES TO RECEIVE
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above):
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: Oct. 4th 2025 TIME: 1:49 DAME PM
2. PLACE OF ACCIDENT (OCCURRENCE) BE SPECIFIC - Describe fully and (if applicable) locate on diagram on reverse side of this sheet.
Where appropriate, give street names and addresses, measurements and landmarks.
L was codina and heard a "cRash" and my neidhbor Alma called me that a tree fell on my car. i went outside, to see and saw the thee in the left side of my car parked on the street by my home on Jackson St. Ria Ho.
3. HOW DID DAMAGE OR INJURY OCCUR?,
TRee fell on my caR while parted. Called police and
they tok a Report and I took pictures of the tRee
on my car.
4. WERE POLICE AT THE SCENE? EYES D NO WERE PARAMEDICS AT THE SCENE? DYES SONO
5. WHAT PARTICULAR ACT OR OMISSION DO YOU CLAIM CAUSED THE INJURY OR DAMAGES? Give the name of the city/town employee causing the injury or damage, if known.
Rialto LA 92376 city tRee fell on my car while
parked on street by my chase.
$
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: 10/08/25 Amount: $ 2,035.52
Item/Date: 10 / 18/25 Amount: $2,708.96
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $.
ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: Amount: $.
Item/Date: Amount: $_
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: AMa MaRez NAME:
ADDRESS: ADDRESS:
Rialto CA 92376
TELEPHONE: TELEPHONE: L)
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTOR(S) OR HOSPITAL(S) VISITED:
NAME: NAME:
ADDRESS: ADDRESS:
TELEPHONE: L) TELEPHONE: |)
DATE: TIME: • AM •PM DATE: TIME:
9. PLEASE READ THE FOLLOWING CAREFULLY:
For all vehicle accident claims, place on the following diagram, the names of streets, including NORTH, EAST, SOUTH AND WEST directions. Indicate place of accident by "X and by showing house numbers or distances to street comers. a cy/lown venice was involved, designate by letter "A" location of the City/Town vehicle when you first saw it, and by "B" location of yourself or your vehi en you first saw City/Town vehicle; location of City/Town vehicle at time of accident by "A-1" and location of yourself or your vehicle at the time of accident by "B-1" and the point of impact by "X.
• NOTE: IF THE DIAGRAM BELOW DOES NOT FIT THE SITUATION, PLEASE ATTACH A PROPER DIAGRAM SIGNED BY THE CLAIMANT.
CURB
PARKWAY
SIDEWALK
HAVE READ THE FOREGOING CLAIM AND KNOW THE CONTENTS THEREOF; AND CERTIFY THAT THE SAME IS TRUE OF MY OWN KNOWLEDGE EXCEPT AS T HOSE MATTERS WHICH ARE HEREIN STATED UPON MY INFORMATION AND BELIEF; AND AS TO THOSE MATTERS I BELIEVE THEM TO BE TRUI I CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
Maria Mendaza
SIGNATURE OF CLAIMANT OR AGENT
MariaF Mendora Murillo 10-20-25
TYPE OR PRINT NAME DATE
RELATIONSHIP TO CLAIMANT
NOTE: PRESENTATION OF A FALSE CLAIM IS A FELONY (CA PENAL CODE 72) RETURN CLAIM TO: RIALTO CITY CLERK'S OFFICE - 150 S. PALM AVE., RIALTO, CA 92376
Your lI ards
Keep these cards handy--in your glove compartment or wallet. And contact us anytime you have a question or need to report a claim.
If you have a claim, we'll get you back on the road as soon as possible. And white you'll always have a choice where to repair your vehicle, when you use a shop in our preapproved network, we'll guarantee your repair for as long as you own or lease your vehicle.
Thank you for choosing Progressive.
Adam Fabian Loza Garcia California Evidence of Liability Insurance Maria Fernanda Mendoza Murillo olicy Number: 92079123 NAIC Number: 11770 ffective Date: 04/04/202 Expiration Date: 10/04/2025
Valued Customer Since 2018 insurer: Un Bor 3120 ampa, 1 30-76 4737 Named Insured(s):
Adam Fabian Loza Garcia
Maria Fernanda Mendoza Murillo
Year Make Model VIN
2005 Chevrolet Equinox
2002 Chevrolet Silverado C1500k1500
2012 Nissan Sentra
Form A022 CA (08/24)
IF YOU'RE IN AN ACCIDENT This policy complies with Section 16056 or 16500.5 of the Califomia
1. Remain at the scene. Don't admit fault. Vehicle Code.
2. Find a safe location, call the police, and exchange driver informatio Evidence of financial responsibility shall at all times be carried in the
3. Call Progressive right awa vehicle.
TO REPORT A CLAIM Insurance information has already been submitted directly to the DMV Call 1-800-274-4499 or go to claims.progressive.com. By brial, smit his document to DAY only if secially requested
PROGRESSIVE
KEEP THIS CARD IN YOUR VEHICLE WHILE IN OPERATION.
:
18370A110
03013038
Rialto Police Courtesy Notice
Date 100425 пто 1349 Dav of Week SATURDAY
em # 257004 - 0134
Comment
D.STEWARD 373
Officer Badge No.
CONTACT RIALTO P.D.-(909) 820-2550 FOR FURTHER INFORMATION (Over)
i
62:8 021305202
Estimate of Repairs* ALL-PRO
Collision Repair
435 E. LINCOLN SIF
BANNINGY CA 922Z01
DATE " 1909-370-8071
1079/25
OWNER Adem Lazs:
ADDRESS
LICENCE SERIAL No COMPANY
MAKE YEAR PHONE #
MILEAGE IT ENGINE
N. PAINT* K2A
•POC
1 SinGN aner mannel
2 $245.00 4.20 3.00
amp L/S new after manz
3 X $195.00 1,00
and align hood
4 1.00
5 Repair and adjust bumper 2701
X Cover for over spray
X Color match $5.00 0.50)
Add for di 050
Body shop materials 1.80
2.00 Leave open inspect & check air bag light on a b
Front grill new al er market.."*
Haz mat disposal $85.00 * 0.70
312.00
13 :14
15 8
19 20
21 23
29 30
31 11200-
Hris Bedy Labor at $70.00 per Hour $588.00
HasMech Labor at $06.00 per Hour
$170.00
Has Pilet Labor at $70.00 per Hour
$420.00
The shove t ,Sublet
$0.00
or labor wi Parts
$542.00
work hes! Point Materials
t on thri $252.00
"Misc
ARS Bub Total
$1,972.00
7.15% Sales Tax
$83.52
Eurate Total :: $2,035.52
Advents Charges
Amount Due $2,036.52
01700301110
Islas Auto Body Estimate ID
300 S Sycamore Ave Building B, Rialto, CA 92376-6579 25333255 Original
SLAS Office: (951) 904-0479
AUTO BODY [email protected]
islasautobody.com
Owner Appraiser
ADAM LOZA Julio Islas
[email protected]
Classification
None
Loss Type Deductible
Unknown Unknown
RECOYERK 2025 OCT 20 AM1 8:30 CITY OF RIALTO
2012 Nissan Sentra Base 4 Door Sedan 2.0L 4 Cyl Gas Injected Auto Trans FWD VIN Drivable Mitchell Service Code
Unknown 910811
Options
Air Conditioning AM-FM Stereo Anti-Lock Brake Sys. (ABS) Automatic Headlights Auxiliary Input CD Player Cloth Seat Driver-Front Air Bag Electric Defogger Electronic Stability Control First Row Bucket Seat Left-Curtain Air Bag Passeriger-Front Air Bag Power Door Locks Power Steering Power Windows Rear Bench Seat Rear Spoiler Remote Decklid Or Tailgate Second Row Side Airbag With Release Head Protection
Side Airbags Tilt Steering Wheel Tire Pressure Monitoring Traction Control/Electronic System
ADAM LOZA | 2012 Nissan Sentra Base
Parts Profile Parts Profile Version
AM and QR Parts 2.0
LABOR PART
Line # Description Operation Type Total Units CEG Type Number Qty Total Price Tax Front Bumper:
1 001399 Frt Bumper Cover Remove Body 1.2# 1.2 Existing / Install
2 002547 Frt Bumper Cover Repair Body 4.0*# 2.0 Existing AUTO Frt Bumper Cover Refinish Refinish 2.6C 2.6 Existing Only
000012 R Frt Bumper Bracket Remove Body 0.1# 0.1 New 62222- 1 $28.51 Yes / Replace ETOOA
000013 L Frt Bumper Bracket Remove Body 0.1# 0.1 New 62223- 1 $28.51 Yes / Replace ETOOA
Grille.
6 001401 Grille Assy Remave Body INC# 0.3 Existing
/ Install
Front Lamps
Committed On Version Mitchell Cloud Estimating TM Printed On Profile Page 1 of4 Mitchell Estimating 25.3 Copyright 1994-2025 Mitchell International, Inc. 10/18/2025 System profile 11:23 AM Profile Version
OEM OCT 25_V All Rights Reserved
11.0 LABOR PART
Line # Description Operation Type Total Units CEG Type Number Qty Total Price Tax 001403 R Front Combination Remove Body 0.3# 0.3 Existing Lamp / Install
001404 L Front Combination Remove Body 0.3# 0.3 Existing Lamp / Install
Hood:
Hood Panel Remove Body 1.0 1.0 Aftermarket NN1230172P 1 $422.00 Yes 000028
/ Replace New
10 AUTO Hood Outside Refinish Refinish 2.6C 2.6
Onty
11 AUTO Add For Hood Underside Refinish
Only
Front Fender :
12 001413 R Fender Outside
13 001414 L Fender Outside
14 001419 Render Mudguard
15 001420 L Fender Mudguard
Additional Costs & Materials
Paint/Materials Additional Yes
16 AUTO
Cost
Shop Materials Additional Yes
17 AUTO
Cost
Hazardous Waste Additional Yes
18 AUTO
Disposal Cost
Additional Yes
19 936014 Flex Additive
Cost
Additional Operations
20 AUTO Clear Coat Additional
Operation
21 933003 Tint Color Additional
Operation
22 933007 Feather, Prime & Block Additional
Operation
23 933021 De-Nib And Finesse Additional
Operation
24 933018 Mask For Overspray Additional
Operation
25 931127 Pre Repair Scan Additional
Operation
26 931128 Post Repair Scan Additional
Operation
* Judgment item
T included in Two Tone Calculation
#Labor Note Applies
d Discontinued by Manufacturer
Committed On Version Mitchell Cloud Estimating TM Printed On Profile Page 2 of4 Mitchell Estimating 25.3 Copyright 1994-2025 Mitchell International, Inc 10/18/2025 prate orale( OEM OCT 25 _V All Rights Reserved 11:23 AM
Parts Vendors
KEYSTONE PP
15895 VALLEY BLVD. #100
FONTANA CA 91761
(800) 421-7866 (Work)
Line Part # Total
Price
9 NI1230172PP $422.00
Disclaimer: This estimate has been prepared based on the use of crash parts supplied by a source other than the manufacturer of your motor vehicle. Any warranties applicable to these replacement parts are provided by the manufacturer or distributor of the parts, rather than by the original manufacturer of your vehicle.
Estimate Totals
Labor Units Rate Sublet Add'l Amount Totals
Body Labor 7.4 $75.00 $555.00
Refinish Labor 14.3 $65.00 $929.50
Mechanical Labor 1.0$120.00 $120.00
Total Labor 22.7 $1,604.50
Taxable $1,604.50
Tax 0.0000% $0.00
Non-Taxable $0.00
Pre-Tax Discount 0.00% $0.00
Labor Total $1,604.50
Parts Amount
Taxable Parts $479.02 $479.02
Parts Adjustments $0.00
Tax 7.7500% $37.12
Non-Taxable $0.00
Pre-Tax Discount 0.00% $0.00
Parts Total $516.14
Costs Amount
Paint Materials $531.00 $531.00
Shop Materials $5.00 $5.00
Other Additional $10.00 $10.00
Costs
Paint Materials: Taxable $546.00
- Refinish Units: 11.8 units Tax 7.7500% $42.32
- Rate: $45.00 Non-Taxable $0.00
- Rate Max: 99.9 units Pre-Tax Discount 0.00% $0.00
- Additional Rate: $0.00 Costs Total $588.32
Shop Materials:
- Rate: $5.00
Gross Totals Amount
Gross Total $2,708.96 $2,708.96
Committed On Version Mitchell Cloud Estimating™ Printed On System profile Page 3 of4 Mitchell Estimating 25.3 Copyright 1994-2025 Mitchell International, inc. 10/18/2025 11:23 AM Profile Version
All Rights Reserved 11.0
Estimate Totals
Taxable $2,629.52
Tax $79.44
Non-Taxable $0.00
Pre-Tax Discount 0.00% $0.00
Gross Total $2,708.96
Adjustments Amount
Total Customer $0.00
Responsibility
Net Estimate Total $2,708.96
Disclaimer: For your protection California law requires the following statement to appear on this form. Any person who knowingly presents false or fraudulent information to obtain or amend insurance coverage or to make a claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
Estimate Event Log
10/18/2025 11:18 AM
Estimate Started 10/18/2025 11:20 AM
Estimate Printed 10/18/2025 11:23 AM
Estimate Committed Estimate Not Committed
Estimate Retrieval ID 1007999625
Committed On Version Mitchell Cloud Estimating™M Printed On Profile Page 4 of 4 Mitchell Estimating 25.3 Copyright 1994-2025 Mitchell International, Inc. 10/18/2025 System profile OM 025V All Rights Reserved 11:23 AM Profile Version
11.0