Interinsurance Exchange of the Automobile Club
SOMOBILE CHEC
THERN CALLY
November 12, 2025
INITIAL DEMAND
RIALTO CITY CLERK'S OFFICE
150 S PALM AVE
RIALTO CA 92376-6406
RE: Insured : Juan Travieso
Claimant Name : Jared KISSELOVICH
Claim Number : 017456658 CITY CLERK RECEIVED NOV 20 AM 8: 53 CITY OF RIALTO Date of Loss : 08/06/2025
Type of Loss : Auto
Dear Rialto City Clerk'S Office:
The Interinsurance Exchange of the Automobile Club has a claim against your insured resulting from the loss that has occurred on the above date. The claim consists of:
RENT - Rental $140.00
COLL - Uninsured Deductible $1946.20
Waiver
TOTAL DUE $2086.20
Enclosed are the necessary documents to support our subrogation claim:
Estimate(s)
Photos
Proof of payments)
Rental invoice(s)
Police report
..
Claim Form
To ensure timely and prompt credit to the claim, please note our Claim Number and Date of Loss on your payment, and forward to:
Interinsurance Exchange of the Automobile Club
017456658
Corporate Cashiering, Mail Stop A118,
PO Box 25024
Santa Ana, CA 92799
Ltr No: SCC0104
Rev. Ed.: 10/03/2024
November 12, 2025
Claim Number: 017456658
Should you have any questions or need additional information regarding this matter, do not hesitate to contact the undersigned.
Thank you in advance for your prompt attention to this matter.
Sincerely,
Sharon McCallister
Claims Service Representative 3 - Subro
Phone No: 469-221-2454
Fax No: 972-630-7592
Ltr No: SCC0104
Rev. Ed.: 10/03/2024
Docusign Envelope ID: D96BCB86-B954-4D61-8EB2-CB3CA8B52E2D
CITY CLERKS DATE STAMP
CITY OF RIALTO
LIABILITY
CLAIM FOR DAMAGES
TO PERSON OR PROPERTY 2025 NOV 20 CITY OF
1. Claims for death, injury to person, or to personal property must be filed not later than six (6) months after the occurrence (Gov. Code $911.2).
2. Claims for damages to real property must be filed nat later than one (1) year after the occurrence (Gow. Code §911.2). RETURN TO: ALT
3.READ ENTIRE CLAIM FOR BEFORE FILING Rialto City Clerk's Oilice
4. ATTACH SEPARATE SHEETS, IF NECESSARY, TO GIVE FULL DETAILS Mail: 150S. Palm Ave., Rialto, CA 92376 ° Address: 290 W. Rialto Ave., Rialto, CA 92376
CLAIMANT INFORMATION:
Inter Exch of Auto Club A/S/O Juan Travieso 017456658
FULL NAME DATE OF BIRTH
PO BX 25024 SANTA ANA CA 92799 -
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE NO.
PO BX 25024 SANTA ANA CA 92799 (469-221-2454
BUSINESS ADDRESS INCLUDING CITY, STATE & ZIP BUSINESS TELEPHONE NO.
ADDRESS AT WHICH CLAIMANT DESIRES TO RECEIVE
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above):
8/6/2025 TIME: 9:28 AM Й AM 0 PM
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE:
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.
Intersection of Foothill Blvd and Riverside Ave (west), Rialto
3. HOW DID DAMAGE OR INJURY OCCUR?
IEAC (2015 Ford Explorer) driven by Juan Travieso was stopped at the red light when Officer Jared Kisselovich (2020 Ford Explorer, plate rear ended IEAC
4. WERE POLICE AT THE SCENE? I YES • NO WERE PARAMEDICS AT THE SCENE? • YES X NO
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.
Officer Jared Kisselovich did not maintain proper lookout and failed to maintain control of vehicle
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $_2086.20 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 ostimates.
DAMAGES INCURRED TO DATE:
Item/Date: DAMAGES / REPAIRS PER ESTIMATE Amount: $ 1946.20 RENTAL Amount: $_ 140.00
Item/Date:
Docusign Envelope ID: D96BCB86-B954-4D61-8EB2-CB3CA8B52E2D TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $_2086.20 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: Amount: $_0.00
Item/Date: Amount: $. 0.00
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $ 0.00
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: NAME:
ADDRESS: ADDRESS:
TELEPHONE: L) TELEPHONE: | )
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: JUAN TRAVIESO NAME:
ADDRESS: ADDRESS:
TELEPHONE: () TELEPHONE: |)
TIME: • AM • PM DATE: TIME: •AM • PM
DATE:
9. PLEASE READ THE FOLLOWING CAREFULLY:
or all vehicle accident claims, place on the following diagram, the names of streets, including NORTH, EAST, SOUTH AND WEST directions. Indicate plac f accident by "X* and by showing house numbers or distances to street comers a city/town vehicle 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 vehic carden fre act point imple yen of Cily/Town vehicle at time of accident by "A " and location of yourself or your vehicle at the time of the • NOTE: IF THE DIAGRAM BELOW DOES NOT FIT THE SITUATION, PLEASE ATTACH A PROPER DIAGRAM SIGNED BY THE CLAIMANT.
CURE
PARKWAY
SIDEWALK
- DocuSigned tYCERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT. sharon Melallister
SIGNATURE OF CLAIMANT OR AGENT
Sharon McCallister 11/12/2025
TYPE OR PRINT NAME DATE
Subrogation Claims Representative IEAC/AAA
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 Sensitive Regulated Data Form: PPAIns: JUAN TRAVIESODoL: 08/06/2025Adj: Viviana Madrid (ACE Auto Team D7 - Claim: 017456658 Prime)Claim: 017456658Years of Membership: 7 Financials (Total Incurred: $2,086.20): Checks
Check Number Pay To Net Amount Issue Date Scheduled Status Bulk Invoice Send Date
101125592 GERBER COLLISION & $1,946.20 11/07/2025 11/06/2025 Cleared
GLASS - BANNING
101127628 Enterprise Rent A Car $140.00 11/12/2025 11/10/2025 Cleared Jser: Sharon McCallister Page 1 Nov 12, 2025 7:31 AM
KRATIVE SUPPLEMESTAL
QUNOSLANO CONCMONONS
SUMMAND Pate area in e
we al siveride Ave for red Hame
AREA OFIMPACE
Thee to the lack of misday evidences
CAUSE: Based on the evidener de
calisen by being in vinltim of VC22110
BECOMMENDADIONS
NOT FOR THIRD PARTY RELEA RESTIONED POTH
THE RIAL TD POUCE DEPT RELEASED TO DIAN TRAVESO DI
LOPEZ, MATTHEW ORCH
*LEMENTAL
EACTH
SOMLICATION: 1 wardis
Trepondod from A20 We Moshe All
spends and sausands in thos
Gion To entition, scope
SCENE Al the some of this colle
city went conting of tibe marked tones pach way The watery in seeige and cond pelon
sected by RIVERSIDE AVRIWIRIVERSIDE AVENIN
coction is sighal cumitted, See sagram
PARTIES:
Party fl (Kielovich) Was locatel on scene, Pany 1 was identified In a mall CA driver's license. Kiteelovich was priced as a party be the followieg ime 10n stasement as to driving Vehicle e1:
FORD EXPLORER. Driver I' chicle, wes locatal on is whiche Pany 22 (Travies) was locaet on stone Pan 7 was saleted RyA MiNCA drive's Toena. Treviele was placed is a pony by the following Rote iie aut as to driving Vebicle i2.
FORD EXPLORER, Driver 7k vehicle, was located on its whoe STATEMENTS:
number three lane approaching Riverside Ave. B-1 stated he carne to a stop behind P Party- I (Kisclovich, Jared) sated he was driving cast on Footill Bivd in the
2. P-1 stated he was stopped he was talking with Passer 1 and his foot care off the brake which resuited in Vehicle I moving forward and rear ending P2 Party-2 (Travieso, Just) stated he was stopped and fell his vehicle get bumped from betand. 8.2 stated he saw it was a police vehicle hut did not see the emergency lights parking lot and met with P-1 to exchange information. P-2 informed P-t no damage activated. Aller realizing a collision had occurred, P-2 stated he turod into the was caused as a result of the collision. I asked P-2 if there was any sow damage and he sated there was not and all the damage to the vehicle was old.
Passenger (Villalvazo, Hector) scated In Position 3 in vehicle 1 stated he wan Booking at the MIX in Vehicle I and reading the call when P-I rear ended P‹2
NOT FOR THIRD PARTY PUL BASE THE RIALTO POLICE DEST
RELEASED TO: JAN TRAVE SO ONIO
FOOTHILL BLO
RICTED PC-1INS-1101
0800/2011 NOT FOR THING PARTY RELEASE
THE RILL TO POLICE DEST RELEASED TO JUAN TRAVESO URCIN2S
MMAE PATROL
TRAEFIC COL-ISION BEPORT
OP-DUTY EMERGENCY VENICLE
FECT
FEET
CA
ECHAEL ROSPLOVIEN
pe cartasor era
Opre daR
FOOTHILL ELVO
MATONE COLO
CA PORD EXPLONER BLACH
MINELA LASTI
INTONIO TRAVIESO 38 SAME AD ORIMER
Box 24
EST PAULA CA SELE
200)
там D
G ac Z0S
W 400
АЛА
REnRIMOMERA
EAST KOOTHELL BLMD
• SEAN CRIAR
IDD SAME AS CREVER
най ENTIDATE
MAOR O ALLONI
CONFIDENTIAL COR
BATEN JUSTIN 01023 RESTRICTEOPOR
0* C NOT FOR THIRD PARTY RELEASE
LOPEZ, MATTHEW 0164 10 100 Am
monD AY •THE RIALTO POLICE DEPT RELEASED TO JUAN TRAVIESO ($A0/25 1/.2 GERbER CollisSion
West RAmSEy In BeonipE
Carms AAA AUTO CLUB ENTERPRISES Invoice 11/12/25
TRAVIESO, JUAN File Owner MADRID, VIVIANA
Customer
ACE Rental Agreement # 187QZT
017456658-R-3190 Reservation # WCGZ9T
Make Payment To:
Payment
ENTERPRISE RENT-A-CAR
P.O. BOX 840086
KANSAS CITY, MO 64184-0086
Federal ID: 43-0724835
CHARGE AMOUNT
Amount due $140.00
Overview
INVOICE DETAILS RENTAL BRANCH
Invoice Number: 32J8D187QZT BANNING (32J8)
Invoice Date: November 8th, 2025 2822 WEST RAMSEY STE B BANNING, CA 92220
(951) 922-0515
AUTHORIZATION DETAILS
Policy Holder: TRAVIESO, JUAN
Address: 535.00/S1,050.00
Billed Days:
Phone Number: Rate:
.......-2049 Direct Bill%: 100%
Email: [email protected] Billed Amount: $140.00
Claim Type: INSURED
Vehicle Condition: DRIVEABLE
Date of Loss: August 6th, 2025
017456658-R-3190
Rented Vehicles
Effective Date and Start End Mileage Pate per
Class Year Make Model VIN Mileage Mileage
Time
11/03/2025, 12:26 PM 2025 CHEV EQUI 28049 28576 527 $40.00 9 Rental Charges
Rental Period: 11/03/2025 to 11/06/2025 (4 days)
Billed Period: 11/03/2025 to 11/06/2025 (4 days)
Products and Services Rate Amount
4 DAILY RENTAL RATE $30.97 $123.87
Taxes and Surcharges Rate Amount
4 VEHICLE LICENSE FEE $1.63 $6.53
1 SALES TAX 7.75% $9.60
Direct Bill Percent: 100%
Amount due: $140.00
REPAIR FACILITY
GERBER-BANNING
BANNING, CA 92220
Additional Information
PD LIMITS Escalated Y/N? Policy Max Date
Date Escalated External Id Office Code
58300
Gerber Collision & Glass - Banning Workfile ID: 6918ddb7 Federal ID: 51-0394062
Highly Wreck - ommended! State ID: 4540449
2609 W Ramsey St, Unit B, Banning, CA 92220 Federal EPA: • N/A State EPA: N/A
Phone: (951) 849-0070 BAR: 308919
Supplement of Record 1 with Summary
RO Number: 1900913091
Written By: Crystal Aceves, 11/6/2025 3:31:26 PM
Adjuster: MADRID, VIVIANA, (951) 369-4431 Business
Insured: TRAVIESO, JUAN Policy #: Claim #: 017456658-1-3190 Type of Loss: Collision Date of Loss: 8/6/2025 9:28 AM Days to Repair:
Point of Impact: 06 Rear
Owner: Inspection Location: Insurance Company:
TRAVIESO, JUAN Gerber Collision & Glass - Banning AUTO CLUB ENTERPRISES 2609 W Ramsey St, Unit B AUTO CLUB OF SOUTHERN CALIFORNIA MPR Banning, CA 92220 COSTA MESA
Repair Facility
(951) 849-0070 Business
VEHICLE
2015 FORD Explorer XLT 4WD 4D UTV 6-3.5L Gasoline Sequential MPI Black VIN: Interior Color: Mileage In: 281,414 Vehicle Out: 11/6/2025 License: Exterior Color: Black Mileage Out: 281,415
State: Production Date: Condition: Job #: Ramiro
TRANSMISSION Overhead Console RADIO Head/Curtain Air Bags Automatic Transmission CONVENIENCE AM Radio Hands Free Device Air Conditioning FM Radio SEATS
4 Wheel Drive
POWER Intermittent Wipers Stereo Cloth Seats
Power Steering Tilt Wheel Search/Seek Bucket Seats
Power Brakes Cruise Control CD Player Reclining/Lounge Seats Power Windows Rear Defogger Auxiliary Audio Connection 3rd Row Seat Keyless Entry Satellite Radio WHEELS
Power Locks
Alarm SAFETY Aluminum/Alloy Wheels
Power Mirrors
Heated Mirrors Message Center Drivers Side Air Bag PAINT Power Driver Seat Steering Wheel Touch Controls Passenger Air Bag Clear Coat Paint Power Passenger Seat Rear Window Wiper Anti-Lock Brakes (4) OTHER DECOR Telescopic Wheel 4 Wheel Disc Brakes Fog Lamps
Dual Mirrors Climate Control Traction Control Rear Spoiler Privacy Glass Dual Air Condition Stability Control Signal Integrated Mirrors Console/Storage Parking Sensors Front Side Impact Air Bags California Emissions 11/6/2025 3:31:27 PM 435708 Page 1
Supplement of Record 1 with Summary
RO Number: 1900913091
2015 FORD Explorer XLT 4WD 4D UTV 6-3.5L Gasoline Sequential MPI Black Line Oper Description Part Number Qty Extended Labor Paint Price $
# S01 Final Bill 1
2 QUARTER PANEL
3 S01 R&I RT Wheel opng midg 0.2
Note: LOOSEN ONLY FOR BUMPER R&T
4 * S01 R&I LT Wheel opng midg 0.2
Note: LOOSEN ONLY FOR BUMPER R&
5 REAR LAMPS
R&I LT Tail lamp assy w/level 2 0.3
R&J RT Tail lamp assy w/level 3 0.3
7 8 REAR BUMPER
R&I R&I bumper cover Incl.
10 * <> Rpr Upper cover 4.0 2.4
11 Add for Clear Coat 1.0
Basecoat reduction 0.3
12 # Refin
13 S01 Repl Add for reverse sens 3 0.4
14 ** S01 Repl Non OEM RT Absorber clip W7054365300 4 7.40 15 ** S01 Repl Non OEM CAPA Lower cover BB5Z17F828CA 363.00 1.8 w/park sensors
16 S01 Add for reverse sens 0.4
17 ** S01 Repl Non OEM LT Absorber clip W7054365300 4 7.40 18 ** S01 Repl Non OEM LT Lower cover rivet W7028525300 4 4.40 19 * S01 R&I RT Reflector Incl.
20 * S01 R&I LT Reflector Incl.
21 ** S01 Repl Non OEM RT Lower cover rivet W7028525300 4.40 22 VEHICLE DIAGNOSTICS
23 * Rpr Pre-repair scan m 0.5 M
24 * Rpr Post-repair scan m 0.5 M
25 * S01 Subl Calibrate park assist sensor 1 450.00 Xm
Note: Please Read!
The rear active parking aid sonar system (location: extreme outer left & right of bumper cover) requires an azimuth verification check after rear parking sensor removal or replacement. ADAS targets are required for system verification.
26 * S01 SubI DRIVE OE 1 135,00 Xm
1 15.00 Xm
* 501 Subl OEM access fee
MISCELLANEOUS OPERATIONS
** Non OEM Color tint 1 0.5
29 30 Cover Car 1 5.00 T 0.2
#
31 # Cover Car for Primer 1 5.00 т Ind.
32 # Repl Flex Additive 1 2.50 T
33 # Hazardous Waste 1 5.00 x
34 # S01 Check seat belt 1 0.2
Note: Please Read!
Seatbelts must be inspected after a collision to ensure passenger safety even if the airbags have not deployed.
SUBTOTALS 1,004.10 9.5 3.1
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Supplement of Record 1 with Summary
RO Number: 1900913091
2015 FORD Explorer XLT 4WD 4D UTV 6-3.5L Gasoline Sequential MPI Black
ESTIMATE TOTALS
Category Basis Rate Cost $
Parts 386.60
Body Labor 8.5 hrs @ $57.00/hr 484.50
Paint Labor 3.1 hrs @ $ 57.00 /hr 176.70
Mechanical Labor 1.0 hrs @ $ 103.00 /hr 103.00
Paint 3.1 hrs @ $44.00/hr 136.40
Miscellaneous 617.50
Subtotal 1,904.70
Sales Tax $535.50 7.7500% 41.50
Grand Total 1,946.20
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 1,946.20
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Supplement of Record 1 with Summary
RO Number: 1900913091
2015 FORD Explorer XLT 4WD 4D UTV 6-3.5L Gasoline Sequential MPI Black
SUPPLEMENT SUMMARY
Line Oper Description Part Number Qty Extended Labor Paint Price $
Changed Items
13 Repl Add for reverse sens -0.4
13 501 Repl Add for reverse sens 0.4
Deleted Items
1 LIFT GATE
R& Lower trim panel w/o power lift -0.4
2 gate charcoal
Repl Rear molding w/o Police EB5Z13B482BA 1 -971.07 -0.3 3 Interceptor w/o SPORT,
w/camera, chrome
8 O/H rear bumper -2.1
14 * Rpr Lower cover w/park sensors -2.0
15 * R&I Lower cover w/park sensors Incl.
Added Items
# S01 Final Bill 1
1 2 QUARTER PANEL
3 S01 R&I RT Wheel opng midg 0.2
NOTE: LOOSEN ONLY FOR BUMPER R&I
4 * S01 R&I LT Wheel opng midg 0.2
NOTE: LOOSEN ONLY FOR BUMPER R&
14 ** S01 Repl Non OEM RT Absorber clip W7054365300 4 7,40 15 ** S01 Repl Non OEM CAPA Lower cover BB5Z17F828CA 1 363.00 1.8 w/park sensors
16 S01 Add for reverse sens 0.4
17 ** S01 Repl Non OEM LT Absorber clip W7054365300 4 7.40 18 ** S01 Repl Non OEM LT Lower cover rivet W7028525300 4 4.40 19 * S01 R&I RT Reflector Ind.
20 * 501 R&I LT Reflector Incl.
21 ** S01 Repl Non OEM RT Lower cover rivet W7028525300 4 4.40 25 * S01 Subl Calibrate park assist sensor 1 450.00 Xm
NOTE: Please Read!
The rear active parking aid sonar system (location: extreme outer left & right of bumper cover) requires an azimuth verification check after rear parking sensor removal or replacement. ADAS targets are required for system verification.
* 501 Subl 135.00 Xm
27 * 501 Subl OEM access fee 15.00 Xm
34 # S01 Check seat belt
NOTE: Please Read!
Seatbelts must be inspected after a collision to ensure passenger safety even if the airbags have not deployed.
SUBTOTALS 15.53 -2.0 0.0
CHANGES TO ADJUSTMENTS
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Supplement of Record 1 with Summary
RO Number: 1900913091
2015 FORD Explorer XLT 4WD 4D UTV 6-3.5L Gasoline Sequential MPI Black Deductible $ 1,000.00 to $0.00
TOTALS SUMMARY
Category Basis Rate Cost $
Parts -584.47
Body Labor -2.0 hrs @ $57.00/hr -114.00
Miscellaneous 600.00
Subtotal -98.47
Sales Tax $-584.47@ 7.7500% 45.30
Total Supplement Amount -143.77
Additional Deductible Amount -1,000.00
Supplement Adjustments -1,000.00
NET COST OF SUPPLEMENT 856.23
CUMULATIVE EFFECTS OF SUPPLEMENT(S)
Estimate 2,089.97 Crystal Aceves
Supplement S01 -143.77 Crystal Aceves
Job Total: 1,946.20
INSURANCE PAY: $ 1,946.20
"CUSTOMER HAS BEEN PROVIDED A COPY OF THE ESTIMATE AND THE AAA MEMBER PREFERRED REPAIRS BROCHURE"
11/6/2025 3:31:27 PM 435708 Page 5
Supplement of Record 1 with Summary
RO Number: 1900913091
2015 FORD Explorer XLT 4WD 4D UTV 6-3.5L Gasoline Sequential MPI Black 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 REPAIRED OR REPLACED:
MOTOR ABBREVIATIONS/SYMBOLS: D=DISCONTINUED PART,
A=APPROXIMATE PRICE. LABOR TYPES: B=BODY LABOR, D=DIAGNOSTIC, E=ELECTRICAL, F=FRAME, G=GLASS, M=MECHANICAL, P=PAINT LABOR, S=STRUCTURAL, T=TAXED MISCELLANEOUS, X=NON TAXED
MISCELLANEOUS. CCC ONE: ADJ=ADJACENT, ALGN=ALIGN,
A/M=AFTERMARKET, BLND=BLEND, CAPA=CERTIFIED AUTOMOTIVE
PARTS ASSOCIATION, D&R=DISCONNECT AND RECONNECT,
EST=ESTIMATE, EXT. PRICE=UNIT PRICE MULTIPLIED BY THE QUANTITY, INCL=INCLUDED, MISC=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.
''''CURE 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.
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.
435708 Page 6
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Supplement of Record 1 with Summary
RO Number: 1900913091
2015 FORD Explorer XLT 4WD 4D UTV 6-3.5L Gasoline Sequential MPI Black 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 DR2MF11, CCC Data Date 10/09/2025, 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, A/M 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 CCC 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:
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. Qty=Quantity. Refn=Refinish. Repl=Replace. R&I=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.
CCC ONE Estimating - A product of CCC Intelligent Solutions Inc.
The following is a list of abbreviations that may be used in CCC 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. 435708 Page 7
11/6/2025 3:31:27 PM
Supplement of Record 1 with Summary
RO Number: 1900913091
2015 FORD Explorer XLT 4WD 4D UTV 6-3.5L Gasoline Sequential MPI Black
PARTS SUPPLIER LIST
Line Supplier Description Price
14 Kent Automotive #KT14001 $ 1.85
8770 W. BRYN MAWR Non OEM RT Absorber clip
CHICAGO IL 60631
(888) 937-5368
(999) 999-9999
15 Keystone, Inc #F01115105PP $363.00
15895 VALLEY BLVD, SUITE 100 Non OEM CAPA Lower cover w/park sensors FONTANA CA 92335 Quote: 3203229662
(800) 421-7866 Expires: 12/18/25
17 Kent Automotive #KT14001 $ 1.85
8770 W. BRYN MAWR Non OEM LT Absorber clip
CHICAGO IL 60631
(888) 937-5368
(999) 999-9999
11/6/2025 3:31:27 PM 435708 Page 8
Mobile Auto Solutions
2600 South 25th Avenue Suite T
Broadview, IL 60155
mobile auto solutions
Gerber Collision & Glass - Banning Invoice
2609 W Ramsey St Unit B 975723
Invoice Number:
Banning, CA 92220 1900913091
RO Number:
(951) 849-0070 Date: 11/6/2025 10:18 AM
Year: 2015
Make: Ford
Model: Explorer XLT 4WD
VIN:
Service Amount $ Labor Rate $ Hrs Part Qty Each $ Total S Active Parking Sensor Azimuth - Rear (L3 / LA)
'erformed complete vehicle scan with Ford OEM software and attached results. Researched Rear Active Parking Sensor procedure. Measured and placed targets at specified locations. Executed static rear parking sensor distanc and elevation check with Ford OEM software.
450.00
Subtotal $ 450.00
Taxes $ 0.00
Invoice Total $ 450.00
Technician Notes:
Thank you for your business
Damage Center
Claim Reference Id: 017456658-I-3190
File Name: PHOTO4
File Date: 10/27/2025
Label: Damage Center
Note: Owner:JUAN,TRAVIESO|Style:2015,FORD,Explorer
XLT
WD|Insured:JUAN,TRAVIESO|LossDate:08/06/2025|1
aimRepresentative:MADRID|ShopName:Gerber C
Photo Location: Gerber Collision & Glass - Banning
Photo Taken By: Crystal Aceves
Estimate Indicator: E01
Damage Left
Claim Reference Id: 017456658-I-3190
File Name: PHOTO12
File Date: 10/27/2025
Label: Damage Left
Note: Owner:JUAN, TRAVIESO|Style:2015,FORD,Explorer
Photo Location: Gerber Collision & Glass - Banning
Photo Taken By: Crystal Aceves
Estimate Indicator: E01
Damage Right
Claim Reference Id: 017456658-J-3190
File Name: PHOTO2
File Date: 10/27/2025
Label: Damage Right
Note: Owner:JUAN,TRAVIESO|Style:2015,FORD,Explorer
XLT
4WD|Insured:JUAN,TRAVIESO|LossDate:08/06/2025|C
laimRepresentative:MADRID|ShopName:Gerber Co
Photo Location: Gerber Collision & Glass - Banning
Photo Taken By: Crystal Aceves
Estimate Indicator: E01
Left QP
Claim Reference Id: 017456658-1-3190
File Name: PHOT06
File Date: 10/27/2025
Label: Left QP
Note: Owner:JUAN,TRAVIESO|Style:2015,FORD,Explorer
XLT
/D insured: JUAN, TRAVIESO|LossDate:08/06/2025
imRepresentative:MADRID|ShopName:Gerber (
Photo Location: Gerber Collision & Glass - Banning
Photo Taken By: Crystal Aceves
Estimate Indicator: E01
Left Rear
Claim Reference Id: 017456658-1-3190
File Name: PHOTO3
File Date: 10/27/2025
Label: Left Rear
Note: Owner:JUAN,TRAVIESO|Style:2015,FORD,Explorer
XLT
WD|Insured:JUAN,TRAVIESO|LossDate:08/06/2025|
aimRepresentative:MADRID|ShopName:Gerber C
Photo Location: Gerber Collision & Glass - Banning
Photo Taken By: Crystal Aceves
Estimate Indicator: E01
Left Side
Claim Reference Id: 017456658-1-3190
File Name: PHOTO8
File Date: 10/27/2025
Label: Left Side
Note: Owner:JUAN,TRAVIESO|Style:2015,FORD,Explorer
XLT
WD Insured:JUAN,TRAVIESO LossDate:08/06/2025|(
imRepresentative:MADRID ShopName:Gerber C
Photo Location: Gerber Collision & Glass - Banning
Photo Taken By: Crystal Aceves
Estimate Indicator: E01
404-
LT MOLDING (LOOSEN)
Claim Reference Id: 017456658-1-3190
File Name: PHOTO36
File Date: 11/03/2025
Label: LT MOLDING (LOOSEN)
Note: Owner:JUAN,TRAVIESO|Style:2015,FORD,Explorer
XLT
licyNumber
Photo Location: Gerber Collision & Glass - Banning
Photo Taken By: Crystal Aceves
Estimate Indicator: S01
MARKERS
Claim Reference Id: 017456658-I-3190
File Name: PHOTO28
File Date: 11/03/2025
Label: MARKERS
Note: Owner:JUAN, TRAVIESO|Style:2015,FORD,Explorer
4WD|Insured:JUAN,TRAVIESO|LossDate: 08/06/2025|P
olicyNumber: Representative
Photo Location: Gerber Collision & Glass - Banning
Photo Taken By: Crystal Aceves
Estimate Indicator: S01
$ 100 120
140
1501ED a00
mayor-seo Quack Dial
AJAR 40., AliCalli
- 60 100- incoming Cals
Quicong Cals
60 40 65 E 100
40 Odometer
Claim Reference Id: 017456658-1-3190
File Name: PHOTO16
File Date: 10/27/2025
Label: Odometer
Note: Owner:JUAN, TRAVIESO|Style:2015, FORD,Explorer
Photo Location: Gerber Collision & Glass - Banning
Photo Taken By: Crystal Aceves
Estimate Indicator: E01
281,067
12 9125
Oil Change Sticker
Claim Reference Id: 017456658-1-3190
File Name: PHOTO10
File Date: 10/27/2025
Label: Oil Change Sticker
Note: Owner:JUAN,TRAVIESO|Style:2015,FORD,Explorer
XLT
4WD|Insured:JUAN,TRAVIESO|LossDate:08/06/2025|C
laimRepresentative:MADRID/ShopName:Gerber Co
Photo Locatlon: Gerber Collision & Glass - Banning
Photo Taken By: Crystal Aceves
Estimate Indicator: E01
Photo 08
Claim Reference Id: 017456658-I-3190
File Name: PHOTO23
File Date: 11/03/2025
Label: Photo 08
Note: Oner:JUAN, TRAVIESO/Style: 2015,FORD,Explorer
olicy Number: AN TRAVIES is Representa 2025 P
olicyNumber:
Photo Location: Gerber Collision & Glass - Banning
Photo Taken By: Crystal Aceves
Estimate Indicator: S01
Photo 09
Claim Reference Id: 017456658-1-3190
File Name: PHOTO41
File Date: 11/03/2025
Label: Photo 09
Nate: Owner:JUAN, TRAVIESO/Style: 2015, FORD, Explorer
Photo Location: Gerber Collision & Glass - Banning
Photo Taken By: Crystal Aceves
Estimate Indicator: S01
Photo 10
Claim Reference Id: 017456658-I-3190
File Name: PHOTO34
File Date: 11/03/2025
Label: Photo 10
Note: IT er:JUAN, TRAVIESO|Style: 2015, FORD, Explorer
4WD|Insured:JUAN TRAVIESQ|LossDate:08/06/2025|F
olicyNumber: aimRepresentative
Photo Location: Gerber Collision & Glass - Banning
Photo Taken By: Crystal Aceves
Estimate Indicator: S01
Photo 11
Claim Reference Id: 017456658-1-3190
File Name: PHOTO37
File Date: 11/03/2025
Label: Photo 11
Note: OuTer: JUAN, TRAVIESO/Style:2015, FORD, Explorer
Representativ
Photo Location: Gerber Collision & Glass - Banning
Photo Taken By: Crystal Aceves
Estimate Indicator: S01
Photo 12
Claim Reference Id: 017456658-1-3190
File Name: PHOTO29
File Date: 11/03/2025
Label: Photo 12
Note: Owner:JUAN, TRAVIESO|Style:2015,FORD,Explorer
olicyNumber:
Photo Location: Gerber Collision & Glass - Banning
Photo Taken By: Crystal Aceves
Estimate Indicator: S01
Photo 13
Claim Reference Id: 017456658-J-3190
File Name: PHOTO40
File Date: 11/03/2025
Label: Photo 13
Note: Owner:JUAN,TRAVIESO|Style:2015, FORD,Explorer
XLT
4WD|Insured:JUAN.TRAVIESOILossDate:08/06/2025 P
olicyNumber: Representative
Photo Location: Gerber Collision & Glass - Banning
Photo Taken By: Crystal Aceves
Estimate Indicator: S01
Photo 16
Claim Reference Id: 017456658-I-3190
File Name: PHOTO44
File Date: 11/03/2025
Label: Photo 16
Note: Owner:JUAN, TRAVIESO|Style:2015,FORD,Explorer
XLT
WD|Insured:JUAN. TRAVIESQ/LossDate:08/06/2025|F
olicyNumber: aimRepresentative
Photo Location: Gerber Collision & Glass - Banning
Photo Taken By: Crystal Aceves
Estimate Indicator: S01
Photo 27
Claim Reference Id: 017456658-1-3190
File Name: PHOTO22
File Date: 11/03/2025
Label: Photo 27
Note: XTer:JUAN, TRA VIESO/Style: 2015, FORD, Explorer
Photo Location: Gerber Collision & Glass - Banning
Photo Taken By: Crystal Aceves
Estimate Indicator: S01
Photo 34
Claim Reference Id: 017456658-1-3190
File Name: PHOTO39
File Date: 11/03/2025
Label: Photo 34
Note: OLTer: JUAN, TRAVIESO/Style: 2015, FORD,Explorer
aimRepresentative
Photo Location: Gerber Collision & Glass - Banning
Photo Taken By: Crystal Aceves
Estimate Indicator: S01
Rear
Claim Reference Id: 017456658-1-3190
File Name: PHOTO15
File Date: 10/27/2025
Label: Rear
Note: Owner:JUAN, TRAVIESO|Style:2015,FORD,Explorer
Tain Representative MADe 60251c
Photo Location: Gerber Collision & Glass - Banning
Photo Taken By: Crystal Aceves
Estimate Indicator: E01
Right Fender
Claim Reference Id: 017456658-I-3190
File Name: PHOTO11
File Date: 10/27/2025
Label: Right Fender
Note: Owner:JUAN, TRAVIESO|Style:2015, FORD,Explorer
WD|Insured:JUAN,TRAVIESO|LossDate:08/06/20251
aimRepresentative:MADRID|ShopName:Gerber C
Photo Location: Gerber Collision & Glass - Banning
Photo Taken By: Crystal Aceves
Estimate Indicator: E01
ober
~I GLASS
Right Front
Claim Reference Id: 017456658-1-3190
File Name: PHOTO13
File Date: 10/2712025
Label: Right Front
Note: OuTer:JUAN, TRAVIESO|Style:2015, FORD, Explorer
#WD|Insured:JUAN,TRAVIESO|LossDate: 08/06/2025|
laimRepresentative:MADRID|ShopName:Gerber Co
Photo Location: Gerber Collision & Glass - Banning
Photo Taken By: Crystal Aceves
Estimate Indicator: E01
gerbers
COLLISION & GLASS
Right QP
Claim Reference Id: 017456658-I-3190
File Name: PHOTO18
File Date: 10/27/2025
Label: Right QP
Note: Owner:JUAN,TRAVIESO|Style:2015,FORD,Explorer
XLT
4WD|Insured:JUAN,TRAVIESO|LossDate:08/06/2025|C
laimRepresentative:MADRID|ShopName:Gerber Co
Photo Location: Gerber Collision & Glass - Banning
Photo Taken By: Crystal Aceves
Estimate Indicator: E01
Right Rear
Claim Reference Id: 017456658-I-3190
File Name: PHOTO9
File Date: 10/27/2025
Label: Right Rear
Note: Owner:JUAN,TRAVIESO|Style:2015,FORD,Explorer
XLT
ND|Insured:JUAN,TRAVIESO|LossDate:08/06/2025|
imRepresentative:MADRID ShopName:Gerber C
Photo Location: Gerber Collision & Glass - Banning
Photo Taken By: Crystal Aceves
Estimate Indicator: E01
Right Side
Claim Reference Id: 017456658-I-3190
File Name: PHOTO5
File Date: 10/27/2025
Label: Right Side
Note: Owner:JUAN,TRAVIESO|Style:2015,FORD,Explorer
XLT
ND|insured:JUAN,TRAVIESO|LossDate:08/06/2025|
imRepresentative:MADRID ShopName:Gerber C
Photo Location: Gerber Collision & Glass - Banning
Photo Taken By: Crystal Aceves
Estimate Indicator: E01
RT MOLDING (LOOSEN)
Claim Reference Id: 017456658-1-3190
File Name: PHOTO38
File Date: 11/03/2025
Label: RT MOLDING (LOOSEN)
Note: OTer: JUAN, TRAVESO/Style:2015, FORD, Explorer
aime resentative
Photo Location: Gerber Collision & Glass - Banning
Photo Taken By: Crystal Aceves
Estimate Indicator: S01
TEXTURE BUMPER
Claim Reference Id: 017456658-1-3190
File Name: PHOTO25
File Date: 11/03/2025
Label: TEXTURE BUMPER
Note: Oner:JUAN, TRAVISOIStyle:2015, FORD, Explorer
gimRepresentative
Photo Location: Gerber Collision & Glass - Banning
Photo Taken By: Crystal Aceves
Estimate Indicator: S01
TEXTURE BUMPER
Claim Reference Id: 017456658-1-3190
File Name: PHOTO26
File Date: 11/03/2025
Label: TEXTURE BUMPER
Note: Owner:JUAN, TRAVIESO|Style:2015,FORD,Explorer
olicyNumber:
Photo Location: Gerber Collision & Glass - Banning
Photo Taken By: Crystal Aceves
Estimate Indicator: S01
TEXTURE BUMPER
Claim Reference Id: 017456658-1-3190
File Name: PHOTO43
File Date: 11/03/2025
Label: TEXTURE BUMPER
Note: Owner:JUAN, TRAVIESO|Style:2015,FORD,Explorer
icyNumbe
Photo Location: Gerber Collision & Glass - Banning
Photo Taken By: Crystal Aceves
Estimate Indicator: S01
REAR: 5
T SEE OWNERS MANUAL FOR ADDITIONAL INFORMATION
TIRE AND LOADING INFORMATION FRONT: 2
TOTAL: 77 The con cargo should never exceed: 626 kg or 1382 Ibs. COLD TIRE PRESSURE 240 KPA, 35 PSI 240 KPA, 35 PSI 420 KPA, 60 PSI SEATING CAPACITY SIZE P245/60R18 104H P245/60R18 104H T165/70D18 116M
TIRE FRONT REAR SPARE
5 U5 A-1532-AA (TLU)
VIN Number
Claim Reference Id: 017456658-1-3190
File Name: PHOTO14
File Date: 10/27/2025
Label: VIN Number
Note: OTer: JUAN, TRAVIESO|Style:2015, FORD, Explorer
Tain presentative ADD Name Gerber 0251C
Photo Location: Gerber Collision & Glass - Banning
Photo Taken By: Crystal Aceves
Estimate Indicator: E01