KEMPER Policy underwritten by
Infinity Insurance Company
Named insured: ISRAEL VALENCIA
Kemper VAZQUEZ
P.O. Box 2843
Clinton, IA 52733
Claim number: 25123708851
Date of loss: October 9, 2025
Date of mailing: October 31, 2025
150 PA ANETSH ASGIP
Rialto, CA 92376-6406
2025 NOY -4 PM 4: 34 CITY OF RIALTO
Dear CITY OF RIALTO:
We are writing to notify you of our subrogation interest regarding the loss referenced above.
It was reported to have occurred in Rialto, CA.
Your Claim Number: Pending
Your Insured: City of Rialto/Ricardo Esteban Padilla
Our investigation concluded that your insured is responsible for damages sustained by our insured. Under the terms of our insurance policy, we are subrogated to the right of reimbursement of our insured to the extent of our payment. As a result, we are looking to you for full reimbursement of damages.
We made a vehicle damage payment as follows:
Vehicle damages: $221.78
-
Deductible: $1,000.00
Salvage: $
Rental: $
$
$
Total demand: $1,221.78
Please make your check payable to Kemper Services Group as subrogee of our insured and mail your payment to:
Kemper Services Group
Attn: 25123708851
P.O. Box 2843
Clinton, IA 52733
If you have already made settlement with our insured, please advise us immediately.
If you have any questions, please contact us and have the claim number available so we can assist you as quickly as possible.
Sincerely,
Gary Williams
T 800-353-6737, ext.5883226
F 888-976-2123
[email protected]
CITY CLERKS DATE STAMP
CITY OF RIALTO
CITY OF RIALTO
LIABILITY
2025 NOY -4 PM 4: 34
CLAIM FOR DAMAGES
TO PERSON OR PROPERTY RECEIVED
CITY CLERK
1. Claims for death, injury to person, or to personel property must be filed not later than six (6) months after the occurrence (Gow. Code $911.2). :
2. Claims for dameges to real property must be filed not later than one (1) year after the occurrence (Gov. Code §911.2). RETURN TO:
3. READ ENTIRE CLAIM FOR BEFORE FILING Rialto City Clerk's Office
4.ATTACH SEPARATE SHEETS, F NECESSARY, TO GIVE FULL DETAILS Mail: 150S. Palm Ave., Rialto, CA CA92376 Address: 290 W. Rialto Ave., Rialto, CA 92376
CLAIMANT INFOFIMATION:
Isreal Valencia Vazquez
FULL NAME DATE OF BIRTH
-
HOME ADDRESS INCLUDING CITY, STATE &ZP HOME TELEPHONE NO BUSINESS ADDRESS INCLUDING CITY, STATE &ZIP BUSINESS TELEPHONE NO.
ADDRESS AT WHICH CLAMANT DESIRES TO RECEVE P.O.Box 2843
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above): _Clinton, IA 52733
1. WHEN DID DAMAGE OR INJURY OOCUR? DATE: 10/09/2025 TIME: 04:20 • AMD PM 2 PLACE OF ACCIDENT (OCUFFENCE) BE SPECIC - Describe fully and it appicable) bcate on degram on reverse side of this shoot Where appropriate, give street names and addresses, measuremerts and landmarks. 356 S Riverside Ave, Bloomington, CA 92316
3. HOW DID DAMAGE OR INJURY OOCUR?
The police vehicle hit our parked vehicle.
- 4. WERE POLICE AT THE SCENE? DY YES NO WERE PARAMEDICS AT THE SCENE? • YES NO
5. WHAT PARTICULAR ACT OR OMISSION DO YOU CLAIM CALISED THE INJURY OR DAMAGES? Give the name of the city/town employee causing the injury or damage, if known.
The employee failed to maintain control of their vehicle.
6. GIVE TOTAL AMOUNT OF CLAIM Indude estimate of amourt of any prospective injury or darnage $ 1,221.78 HOWWAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCUPPED TO DATE:
Item/Date: See attached estimate Amount: $ 1,221.78
Item/Date: Amount: $
COPY
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $ 1,221.78
ESTIMATED PROSPECTIVE DAMAGES, AS FARAS KNOWN
Item/Date: Amount: $_
Item/Date: Amount: $_
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $ 1,221.78
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: NAME:
ADDRESS: ADDRESS:
TELEPHONE: (1 TELEPHONE: | )
& IFINJURED, PROVIDE NAME, CONTACT INFOFMATION AND DATE/TIME DOCTORS) OR HOSPITALS) VISITED:
NAME: NAME:
ADDRESS: ADDRESS
TELEPHONE: |) TELEPHONE: ()
DATE: TIME: DAMO PM DATE, _ TIME: DAMO PM
9. PLEASE READTHE 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 accidentby "X' and by showing house numbers or distances to street comers.
If a city/town vehide was involved, designate by letter "A' location of the City/Town vehide when you first saw it, and by "B' location of yourself or your vehicle when you first saw City/Town vehide; location of City/Town vehicle at time of accident by "A 1" and location of yourself or your vehicle at the time of the accident by "B-f" 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
I CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
ary o. William 10/30/2025
YPE OR PRINT NAN DATE
Claims Adjuster
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, CÁ 92376 KEMPER Claim payment
Policy underwritten by
Infinity Insurance Company
Kemper
PO Box 2843 Named insured: ISRAEL VALENCIA 000003
Clinton, IA 52733-2843
VAZQUEZ
Claimant: ISRAEL VALENCIA VAZQUEZ
ISRAEL VALENCIA VAZQUEZ Claim number: 25123708851
Date of loss: October 9, 2025
Date of mailing: October 31, 2025
Coverage: Collision
Payment for: Claim 25123708851
- -
Your claim payment
We attached a check representing payment on the above noted claim. For full explanation or if you have any questions, please contact your claims representative.
Benaiah Cabell
Claims Team
T 800-353-6737, ext.1512110
F 888-976-2123
[email protected]
Policy Number: 10197140601 Issue Date: 10/30/2025 6153011137 alm Number: 2512370885 66-156
ndenwritter by Infinity Insurance Compar
VOID VOL VOID
ISRAEL VALENCIA VAZQUEZ
VOID VOID VOID Ve
Two Hundred Twenty One and 78/100 Dollars 221.78
Wells Fargo Bank, N.A. Vold alter 180 days from date issuec → [7 mile
0000000000557(
COPY
Facsimile Document
-
MOSS COLLI SI ON SAN BERNARDI NO forkfile it 864207a3
ederal lE 952803540
At Moss You're The Boss State EPA: CAD981572506
1100 SE ST, SAN BERNARDINO, CA 92408 BAR: ARD-043821
Phone: (909) 884-8255 x2400
FAX: (909) 884-4675
Supplement of Record 1 with Summary
Customer: VALENCIA VAZQUEZ, ISRAEL Job Number:
Written By: JUSTIN WILLIAMS, 10/29/2025 11:42:35 AM
Adjuster: CABELL, BENAI AH, (800) 353-6737 x1512110 Business Insured: VALENCIA VAZQUEZ. Pollicy #: 10197140601 Claim #: 2512370885101 ISRAEL
Type of Loss: Collision Date of Loss: 10/9/2025 4:20 PM Days to Repalr: 4 Polnt of Impact: 06 Rear
Owner: Inspection Location: Insurance Company:
VALENCIA VAZQUEZ, ISRAEL MOSS COLLISION SAN BERNARDINO INFINITY INSURANCE COMPANY - -
1100 SE ST Infinity Insurance Compan
SAN BERNARDINO, CA 92408 KEMPER-DALLAS
Repalr Facility DALLAS
(909) 884-8255 x2400 Business
VEHICLE
2020 NISS Versa SV w/Continuously Varlable Transmission 4D SED 4-1.6L Gasoline Sequential MPI Maroon VIN: Interior Color: Mileage In: 113,328 Vehicle Out:
License: Exterior Color: Maroon Mileage Out:
State: CA Production Date: 8/2019 Condition: Job #:
TRANSMISSION Alr Conditioning Stereo SEATS
Automatic Transmission Intermittent Wipers Search/Seek Cloth Seats POWER Tilt Wheel Auxiary Audio Connection Bucket Seats
Power Steering Cruise Control Satellite Radio Reciining/Lounge Seats Power Brakes Rear Defogger SAFETY WHEELS
Power Windows Kayless Entry Drivers Side Air Bag Aluminum/Alloy Wheels Power Locks Message Center Passenger Alr Bag PAINT
Power Mirrors Steering Wheel Touch Controls Anti-Lock Brakes (4) Three Stage Paint - OTHER -
Heated Mirrors Telescopic Wheel Front Side Impact Air Bags DECOR Backup Camera Head/Curtain Air Bags Traction Control Dual Mirrors Parking Sensors Hands Free Device Stabillty Control Tinted Glass RADIO Rear Side Impact Air Bags Signal Integrated Mirrors Console/Storage AM Radio Bilnd Spot Detection
CONVENIENCE FM Radio Lane Departure Warning
10/29/2025 11:42:35 AM 024112 Page 1
COPY
-
Supplement of Record 1 with Summary:
Customer: VALENCIA VAZQUEZ, ISRAEL Job Number:
2020 NISS Versa SV w/Continuously Variable Transmission 4D SED 4-1.6L Gasoline Sequential MPI Maroon Line Oper Description Part Number Qty Extended Labor Paint Price $
1 QUARTER PANEL
2 S01 Rpr AT Quarter panel 20 2.2
3 Add for Three Stage 1.5
4 # S01 Refn Partlal Baseccat Refinish -0.5
5 REAR LAMPS
6 •
Repl ..LK AT Tall lamp assy 285605EE0A 1 102.00 0.3
7 REAR BUMPER
R&I R&l bumper cover 0.9
• < S01 Apr Bumper cover 2.0 2.8
10 Overlap Major Non-Adj. Panel -0.2
11 Add for Three Stage 1.0
12 Repl Add for reverse sens 1 m 0.4 M
13 # S01 Rein Partial Basecoat Refinish -0.5
14 MISCELLANEOUS OPERATIONS
15 # Subl Hazardous waste removal 5.00 X
16 # Color tint / color match 0.5
17 # Repl Flex additive 1 5.00
18 # S01 Rpr Denib & polish 0.3
SUBTOTALS 112.00 6.4 6.3
NOTES
Prior Damage Notes:
Front bumper, grille, hood & radiator
ESTIMATE TOTALS
Category Basis Rate Cost $
Parts 107.00
Body Labor 6.0 hrs @ $60.00/hr 360.00
Palnt Labor 6.3 hrs $ 60.00 /hr 378.00
Mechanical Labor 0.4 hrs $ 150.00 /hr 60.00
Paint Supplies 6.3 hrs $ 44.00 /hr 277.20
5.00 Subtotal 1,187.20
Sales Tax $ 384.20 9.0000% 34.58
Grand Total 1,221.78
Deductible 1,000.00
CUSTOMER PAY 1,000.00
INSURANCE PAY 221.78
10/29/2025 11:42:35 AM 024112
Supplement of Record 1 with Summary
Customer: VALENCIA VAZQUEZ, ISRAEL Job Number:
2020 NISS Versa SV w/Continuously Varlable Transmission 4D SED 4-1.6L Gasoline Sequential MPI Maroon 0000035/12
SUPPLEMENT SUMMARY
Line Oper Description Part Number Qty Extended Labor Paint Price $
Changed Items
2 Rpr RT Quarter panel -4.0 -2.2
S01 Rpr RT Quarter panel 2.0 2.2
8 Rpr Bumper cover =3,0 -2.8
< S01 Rpr Bumper cover 20 28
eleted Items
16 # Rpr Color sand and buff -1.0
Added Items
4 # S01 Refn Partial Basecoat Refinish -0.5
- 13 # 501 -0.5 -
Refn Partial Basecoat Refinish
18 # S01 Rpr Denib & polish 0.3
SUBTOTALS 0.00 -3.7 - 1.0
TOTALS SUMMARY
Category Basis Rate Cost S
Parts 0.00
Body Labor -3.7 hrs @ $ 60.00 /hr -222.00
Palnt Labor -1.0 hrs @ $ 60.00/hr -60.00
Palnt Supplies -1.0 hrs $ 44.00 /hr -44.00
Subtotal -326.00
Sales Tax $-44.00 9.0000% -3.96
Total Supplement Amount -329.96
NET COST OF SUPPLEMENT -329.96
CUMULATI VE EFFECTS OF SUPPLEMENTS)
Estimate 1,551.74 JUSTIN
WILLIAMS
Supplement S01 -329.96 JUSTIN
WILLIAMS
- -
Job Total: $ 1,221.78
CUSTOMER PAY: $ 1,000.00
INSURANCE PAY: $ 221.78
I acknowledge notice and oral approval of an increase in original estimated price. x_
Customer signature
10/29/2025 11:42:35 AM 024112 Page 3
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-
Supplement of Record 1 with Summary
Customer: VALENCIA VAZQUEZ, ISRAEL Job Number:
2020 NISS Versa SV w/Continuously Variable Transmission 4D SED 4-1.6L Gasoline Sequential MPI Maroon I acknowledge notice and oral approval of an increase in original estimated price.
Customer signature
FOR YOUR PROTECTION CALIFORNIA LAW REQUIRES THE FOLLOWING 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.
THIS ESTIMATE IS FOR REPAIRS TO MEET VEHICLE MANUFACTURER AND INDUSTRY STANDARDS. AS THE
CUSTOMER, IT IS YOUR RESPONSIBILITY TO CONTACT THE THIRD-PARTY PAYOR FOR PAYMENT OF THE REPAIRS YOU HAVE AUTHORIZED.
THE FOLLOWING IS A LIST OF ABBREVIATIONS OR SYMBOLS THAT MAY
BE USED TO DESCRIBE WORK TO BE DONE OR PARTS TO BE REPAI RED OR REPLACED:
MOTOR ABBREVIATIONS/ SYMBOLS: D=DISCONTINUED PART,
A= APPROX MATE PRICE. LABOR TYPES: B= BODY LABOR, D=DIAGNOSTIC, E= ELECTRICAL, F= FRAME, G= GLASS, M= MECHANI CAL, P= PAINT LABOR, S= STRUCTURAL, T=TAXED MISCELLANEOUS, X= NON TAXED
MISCELLANEOUS. COC ONE: ADJ= ADJACENT, ALGN- ALIGN,
AIM=AFTERMARKET, BLND= BLEND, CAPA= CERTI FIED AUTOMOTIVE PARTS ASSOCIATION, D&R= DISCONNECT AND RECONNECT,
EST= ESTIMATE, EXT. PRICE= UNIT PRICE MULTIPLIED BY THE QUANTITY, INCL=INCLUDED, MI SC= MISCELLANEOUS, NAGS= NATIONAL AUTO GLASS SPECIFICATIONS, NON-ADJ= NON ADJACENT, O/H= OVERHAUL,
OP= OPERATION, NO-LINE NUMBER, QTY= QUANTITY,
RECOND= RECONDITION, REFN= REFINISH, REPL= REPLACE, R&I=REMOVE AND INSTALL, R&R=REMOVE AND REPLACE, RPR= REPAIR, RT= RIGHT, SECT= SECTION, SUBL= SUBLET, LT= LEFT, W/O=WITHOUT, W/_=WITH/_ SYMBOLS: # = MANUAL LINE ENTRY, * = OTHER [IE.MOTORS DATABASE INFORMATION WAS CHANGED), ** = DATABASE LINE WITH AFTERMARKET, N= NOTES ATTACHED TO LINE. OPT OEM= ORIGINAL EQUIPMENT
MANUFACTURER PARTS EITHER OPTIONALLY SOURCED OR OTHERWISE PROVIDED WITH SOME UNIQUE PRICING OR DISCOUNT.
''''URE TIME MEANS THE LENGTH OF TIME THAT, PER THE ADHESIVE
MANUFACTURER, THE WINDSHIELD ADHESIVE NEEDS TO CURE UNTIL THE
WINDSHIELD CAN PROPERLY FUNCTION AS A SAFETY DEVICE PURSUANT
TO THE FEDERAL MOTOR VEHICLE SAFETY STANDARDS AND THE
VEHICLE MANUFACTURER'S SPECIFICATIONS.
10/28/2025 11:42:35 AM 024112 Page 4
Supplement of Record 1 with Summary
Customer: VALENCIA VAZQUEZ, ISRAEL Job Number:
2020 NISS Versa SV w/Continuously Variable Transmission 4D SED 4-1.6L Gasoline Sequential MPI Maroon Estimate based on MOTOR CRASH ESTIMATING GUIDE and potentially other third party sources of data. Unless otherwise noted, (a) all items are derived from the Guide ARF3782, COC Data Date 10/17/2025, and potentially other third party sources of data; and (b) the parts presented are OEM-parts. OEM parts are manufactured by or for the vehicle's Original Equipment Manufacturer (OEM) according to OEM's specifications for U.S. distribution. OEM parts are available at OE/Vehicle dealerships or the specified supplier. OPT OEM (Optional OEM) or ALT OEM (Alternative OEM) parts are OEM parts that may be provided by or through alternate sources other than the OEM vehicle dealerships with discounted pricing. Asterisk (*) or Double Asterisk (**) indicates that the parts and/or labor data provided by third party sources of data may have been modified or may have come from an alternate data source.
Tilde sign (~) items indicate MOTOR Not-Included Labor operations. The symbol (<>) indicates the refinish operation WILL NOT be performed as a separate procedure from the other panels in the estimate. Non-Original Equipment Manufacturer aftermarket parts are described as Non OEM, AM or NAGS. Used parts are described as LKQ, RCY, or USED. Reconditioned parts are described as Recond. Recored parts are described as Recore. NAGS Part Numbers and Benchmark Prices are provided by National Auto Glass Specifications. Labor operation times listed on the line with the NAGS information are MOTOR suggested labor operation times. NAGS labor operation times are -
not included. Pound sign (#) items indicate manual entries.
Some 2024 vehicles contain minor changes from the previous year. For those vehicles, prior to receiving updated data from the vehicle manufacturer, labor and parts data from the previous year may be used. The COC ONE estimator has a list of applicable vehicles. Parts numbers and prices should be confirmed with the local dealership.
The following is a list of additional abbreviations or symbols that may be used to describe work to be done or parts to be repaired or replaced:
SYMBOLS FOLLOWING PART PRICE: Ent
m=MOTOR Mechanical component. s= MOTOR Structural component. T=Miscellaneous Taxed charge category.
X= Miscellaneous Non-Taxed charge category.
SYMBOLS FOLLOWING LABOR:
D=Diagnostic labor category. E= Electrical labor category. F= Frame labor category. G= Glass labor category.
M= Mechanical labor category. S= Structural labor category. (numbers) 1 through 4= User Defined Labor Categories.
OTHER SYMBOLS AND ABBREVIATIONS:
Adj.=Adjacent. Algn.=Align. ALU= Aluminum. A/M=Aftermarket part. BInd= Blend. BOR=Boron steel.
CAPA= Certified Automotive Parts Association. CFC= Carbon Fiber.
D&R= Disconnect and Reconnect. HSS= High Strength Steel. HYD=Hydroformed Steel. Incl.=Included. LKQ-Like Kind and Quality. LT= Left. MAG=Magnesium. Non-Adj.=Non Adjacent. NSF= NSF International Certified Part.
O/H= Overhaul. Oty=Quantity. Refn= Refinish. Repl= Replace. R&l=Remove and Install. R&R=Remove and Replace, Rpr=Repair. RT=Right. SAS- Sandwiched Steel. Sect= Section. STS=Stainless Steel, Subl=Sublet. - UHS-Ultra High Strength Steel. N= Note(s) associated with the estimate line. - COC ONE Estimating - A product of COC Intelligent Solutions Inc.
The following is a list of abbreviations that may be used in OO ONE Estimating that are not part of the MOTOR
CRASH ESTIMATING GUIDE
BAR-Bureau of Automotive Repair. EPA= Environmental Protection Agency. NHTSA= National Highway Transportation and Safety Administration. PDR=Paintless Dent Repair. VIN=Vehicle Identification Number. 10/29/2025 11:42:35 AM 024112 Page 5
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Supplement of Record 1 with Summary
Customer: VALENCIA VAZQUEZ, ISRAEL Job Number:
2020 NISS Versa SV w/Continuously Variable Transmission 4D SED 4-1.6L Gasoline Sequential MP! Maroon
THE INSURANCE COMPANY THIS ESTIMATE WAS PREPARED BY OR FOR WARRANTS THAT ANY NON-ORIGINAL
EQUIPMENT MANUFACTURER REPLACEMENT CRASH PART INCLUDED IN YOUR ESTIMATE ARE AT LEAST EQUAL TO
THE ORIGINAL EQUIPMENT MANUFACTURER PARTS IN TERMS OF KIND, QUALITY, SAFETY, FIT, AND PERFORMANCE.
10/29/2025 11:42:35 AM 024112 Раде 6
Supplement of Record 1 with Summary
Customer: VALENCIA VAZQUEZ, ISRAEL Job Number:
2020 NISS Versa SV w/Continuously Varlable Transmission 4D SED 4-1.6L Gasoline Sequentlal MPI Maroon
PARTS SUPPLIER LIST
Line Supplier Description Price
6 LKQ Corp #-408662380 $ 102.00
11200 ALDEN ROAD LKQ RT Tall lamp assy
ADELANTO CA 92301 Tall Lamp S,4DR R, QUARTER PANEL MOUNTED, RS# $Y4249 (800) 525-3667 Quote: 3191278660
Expires: 12/08/25
10/29/2025 11:42:35 AM 024112 Page 7
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000003 8/12
Claim Reference Id : 2512370885101
Flle Name : PHOTO1
File Date : 10/24/2025
Label : Rear
Note : Owner:ISRAEL, VALENCIA VAZQUEZ|StY
le:2020, NISS, Versa SV w/Continuousl
y Variable Transmission/Insured: ISR
L, VALENCIA VAZQUEZ|LossDate: 10
25|PolicyNumber:10197140601|0
Representative:CABELL|ShopName:MOS
S COLLISION SAN BERNARDINO|Claimant
ISRAEL, VALENCIA VAZQUEZIVIN:
nsuranceCompany:INFINI
TY INSURANCE COMPANY|InsuredisOwner
Photo Location
Photo Taken By : JUSTIN WILLIAMS
Estimate Indicator : E01
COPY
Claim Reference Id : 2512370885101
File Name : PHOTO2
File Date : 10/24/2025
Label : Left Rear
Note : Owner: ISRAEL, VALENCIA VAZQUEZ|StY
le:2020, NISS, Versa SV w/Continuousl
y Varlable Transmission|Insured:ISR
AEL, VALENCIA VAZQUEZ|LossDate: 10/09
/2025|PollcyNumber:10197140601|Clal
Representative:CABELL|ShopName:MOS
S COLLISION SAN BERNARDINO Clalmant
:ISRAEL. VALENCIA VAZQUEZIVIN:
nsuranceCompany:INFINI
TY INSURANCE COMPANY!Insured|sOwner
: Y|Estimator:JUSTIN,WILLIAMS|
Photo Location : MOSS COLLISION SAN BERNARDINO
Photo Taken By JUSTIN WILLIAMS
Estimate Indicator
000003 9/12
- -
Claim Reference Id : 2512370885101
Flle Name : PHOTO3
Flle Date : 10/24/2025
Label : Right Front
Note : Owner: ISRAEL, VALENCIA VAZQUEZ Sty
le: 2020, NISS, Versa SV w/Continuousl
y Varlable Transmission/Insured: ISR
202: Poly/umber-01/190/Ci9
Representative: CABELL|ShopName:MOS
S COLLISION SAN BERNARDINO|Claimant
: ISRAEL, VALENCIA VAZQUEZ|VIN:
InsuranceCompany: INFINI
TY INSURANCE COMPANY|InsuredisOwner
:Y|Estimator:JUSTIN,WILLIAMS|
Photo Location : MOSS COLLISION SAN BERNARDINO
Photo Taken By : JUSTIN WILLIAMS
Estimate Indicator : E01
COPY
Clalm Reference Id : 2612370885101
File Name • РHOTO4
Flle Date : 10/24/2025
Label : Left From
Note : Owner:ISRAEL, VALENCIA VAZQUEZ|StY
le:2020, NISS, Versa SV w/Continuousl
y Varlable Transmission|Insured: ISR
EL, VALENCIA VAZQUEZ|LossDate:10/1
025|PolicyNumber:10197140601|Cl
isuranceCompany:INFINI
TY INSURANCE COMPANY InsuredisOwner
:Y[Estimator:JUSTIN, WILLIAMS|
Photo Location : MOSS COLLISION SAN BERNARDINO
Photo Taken By : JUSTIN WILLIAMS
Estimate Indicator : E01
000003 10/12
Claim Reference Id : 2512370885101
File Name : PHOTO5
File Date : 10/24/2025
Label : Right QP
Note : Owner: ISRAEL,VALENCIA VAZQUEZ|Sty
le:2020,NISS, Versa SV w/Continuousl
y Variable Transmission|Insured:ISR
- EL, VALENCIA VAZQUEZ|LossDate: 10/0
2025|PolicyNumber:10197140601|Cl
SOLISION SAN BENARON HIMOS
TY INSURANCE COMPAN insuredewar
: Y|Estimator: JUSTIN, WILLIAMS|
Photo Location
Photo Taken By
Estimate Indicator : E01
COPY
Claim Reference Id : 2512370885101
Flle Name : PHOTO6
File Date : 10/24/2025
Label : Right Rear
Note : Owner: ISRAEL, VALENCIA VAZQUEZ|StY
le:2020,NISS, Versa SV w/Continuousl
Representative:CABELL|ShopName:MOS
S COLLISION SAN BERNARDINO Clalmant
:ISRAEL, VALENCIA VAZQUEZIVIN
insuranceCompany:INFINI
TY INSURANCE COMPANY|InsuredisOwner
:(Estimator:JUSTIN,WILLIAMS]
Photo Location : MOSS COLLISION SAN BERNARDINO
Photo Taken By EUSTIN WILLIAMS
Estimate Indicator
000003 11/12
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Claim Reference Id : 2512370885101
File Name : PHOTO7
File Date : 10/24/2025
Label : Photo 01
Note : Owner:ISRAEL, VALENCIA VAZQUEZ|Sty
le:2020, NISS, Versa SV w/Continuousl
-
Representative: CABELL|ShopName:MC
COLLISION SAN BERNARDINO ClaimE
nsuranceCompany:INFINI
Y INSURANCE COMPANY insuredlsOwne
: Y[Estimator:JUSTIN, WILLIAMS|
Photo Location : MOSS COLLISION SAN BERNARDINO
Photo Taken By : JUSTIN WILLIAMS
Estimate Indicator : E01
COPY
VUTACTURED
GAUR FR. 2907
CLE CO
VIN.
NBL
MODELT EDTALE
Claim Reference Id : 2512370885101
Flle Name : PHOTO8
File Date : 10/24/2025
Label : VIN Number
Note : Owner: ISRAEL, VALENCIA VAZQUEZ|StY
le:2020, NISS, Versa SV w/Continuousl
y Variable Transmission|Insured: ISR
AEL, VALENCIA VAZQUEZ|LossDate: 10/09
/2025|PolicyNumber:10197140601|Clai
Representative:CABELL|ShopName:MOS
S COLLISION SAN BERNARDINO/Claimant
:ISRAEL.VALENCIA VAZQUEZ/VIN
InsuranceCompany: INFINI
TY INSURANCE COMPANY|InsuredlsOwner
:Y|Estimator:JUSTIN,WILLIAMS|
Photo Location : MOSS COLLISION SAN BERNARDINO
Photo Taken By : JUSTIN WILLIAMS
Estimate Indicator : E01
000003 12/12
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3:55 PM
& Warning
Claim Reference Id : 2512370885101
File Name : PHOTO9
Flle Date : 10/24/2025
Label : Odometer
Note : Owner:ISRAEL, VALENCIA VAZQUEZISIY
le:2020, NISS, Versa SV w/Continuousl
y Varlable Transmission/Insured: ISR
AEL, VALENCIA VAZQUEZ|LossDate: 10/09
/2025 PolicyNumber:10197140601|Clai
Representative: CABELL/ShopName:MOS
S COLLISION SAN BERNARDINO|Claimant
:ISRAEL, VALENCIA VAZQUEZVIN:
nsuranceCompany:INFINI
TY INSURANCE COMPANY|InsuredisOwner
: Y|Estimator:JUSTIN,WILLIAMS
Photo Location : MOSS COLLISION SAN BERNARDINO
Photo Taken By : JUSTIN WILLIAMS
Estimate Indicator : E01
COPY