CLAIM FOR DAMAGES RESERVE FOR FILING STAMP
TO PERSON OR PROPERTY CLAIM No. _
INSTRUCTIONS
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 Sec. 9112) RECEIVED
2. Claims for damages to real property must be filed not later than one (1) year after the occurrence. (Gov. Code Sec.911.2)
3. Read entire claim before filing. MAR 02 2023
See page 2 for diagram upon which to locate place of accident This claim form must be signed on page 2 at bottom. CITY CLERK'S OFFICE Attach separate sheets, if necessary, to give full details. SIGN EACH SHEET.
Claim must be filed with City Clerk. (Gov. Code Sec. 915a) TO: CITY OF VERNON CITY COUNCIL
Name of Claimant Age of Claimant (If natural person)
58 CIV
Home Address of Claimant City and State Home Telephone Number Business Address of Claimant City and State Business Telephone Number 4920 S. m Bayle Ave Vernon CA 90058
Give address to which you desire notices or communications to be sent regarding this claim:
How did DAMAGE or INJURY occur? Give full particulars.
The vehicle was parked on the street. City workers arrived to do lawn work. One worker used a weed wacker which hit a rock, causing it to hit the rear window of Vehicle.
When did DAMAGE or INJURY occur? Give full particulars, date, time of day, etc.:
February 21 2023 Inciden occured Some time between 10:30am-1lam Where did DAMAGE or INJURY occur? Describe fully, and locate on diagram on reverse side of this sheet, where aproximate, give street names and adress and mossurements femlast. The nearest cross street Vehicle was parked halfwny through 50 was Alcoa Ave.
What particular ACT or OMISSION do you claim caused the injury ordamage? Give names of City employees, if any, causing the injury or damage, if known:
The act of servicing the lawns and hitting the rock directly cuused the damage.
What DAMAGE or INJURIES do you claim resulted? Give full extent of injuries or damages claimed:
Rear window was left shattered which needs to be replaced completely.
What AMOUNT do you claim of each item of injury ordamage as of date of presentation of this claim, giving basis of computation:
$1500
Give ESTIMATED AMOUNT as faras known you claim on account of each item of prospective injury or damage, giving basis of computation:
$ 1490.12
Were you insured at the time of the incident? If so, provide name of insurance company, policy numbers and amount of insurance payments received: Yes Vehicle is insurd. AAA Insurance Policy
Expenditures made on account of accident or Injury: (Date - Item) (Amount) N/A
Name and address of Witnesses, Doctors and Hospitals:
NA
READCAREFULLY
For all accident claims place on following diagram names of streets, including North, East. South, and West: indicate place of accident by "X" and by showing house numbers or distances to street corners. vehicle at the time of accident by "8 1" and the point of Impact by "X." NOTE: If diagrams do not fit the situation, attach hereto a proper diagram signed by claimant
FOR AUTOMOBILE ACCIDENTS
LILU
7AT7.
FOR OTHER ACCIDENTS
///L
SIDEWALK
CURB/
CURB,
PARKWAY
SIDEWALK
77 I declare, under penalty of perjury, that the foregoing, including any attachments, is true and correct.
Typed/Printed Name: Signature of Claimant or person filing on his/her behalf, giving relationship to Claimant:
Juan Negrete 3-1-23
Juan Negrete
NOTE: ALL CLAIMANTS MAY BE REQUESTED TO BE EXAMINED AS TO THEIR CLAIM UNDER OATH. PRESENTATION OF A FALSE CLAIM IS A FELONY (CAL PEN. CODE SEC. 72). CLAIMS MUST BE FILEDWITH CITY CLERK (GOV. CODE SEC. 915a). STATE LAW PROVIDES THAT IF YOU ARE NOT NOTIFIED OF ANY ACTION BY THE CITY OF THIS CLAIM WITHIN 45 DAYS OF FILING THEN THE CLAIM IS DEEMED DENIED (SEE GOV. CODE SEC. 911.6&912.4) Honda
I OF DOWNTOWN
H Honda LOS ANGELES Honda
780 W. Martin Luther King Jr. Blvd. • Los Angeles, California 90037 Service (213) 234-2130 • Sales (213) 267-9087
www.hondaoflosangeles.com
0101IHOCS698245 CELL:
CUSTOMER NO. ADVISOR TAG NO. INVOICE DATE INVOICE NO.
178147 ANTHONY GARCIA 1786 9999 100003/01/23 HOCS698245 LABOR RATE LICENSE NO. MILEAGE STOCK NO.
JUAN NEGRETE 151, 438 BLACK/
YEAR / MAKE / MODEL DELIVERY DATE DELIVERY MILES
06/HONDA/PILOT/5DR 4WD EX-L RES AT
VEHICLE ID. NO. SELLING DEALER NO PRODUCTION DATE
F. T. E. NO. P. O. NO. R. O. DATE
03/01/23
RESIDENCE PHONE BUSINESS PHONE COMMENTS
MO: 151438
1 CHARGES-
LABOR -
At Honda of Downtown Los
J# 1 O2HOZTELLUS TELL US MORE TECH(S) : 8888 0.00
GUEST REQUESTS QUOTE FOR REAR GLASS REPLACEMENT. Angeles, we strive for $380 - FOR LABOR excellent service. If for any
$1110.12 - FOR PARTS
PROVIDED CUSTOMER WITH ESTIMATE. $1490.12 PARTS AND LABOR reason you feel we did not PQ 32505 provide the highest quality
service, please notify our
JOB# 1 TOTALS.
service team immediately.
JOB# 1 JOURNAL PREFIX HOCS JOB# 1 TOTAL 0.00
JOB# 2 CHARGES
Thank You.
LABOR 1
J# 2 01H0Z1 CAR WASH TECH(S) : 8888 0.00
COMPLETE COURTESY VEHICLE RINSE?
YES NO GUEST INITIAL
PLEASE NOTE WE ARE NOT RESPONSIBLE FOR LOOSE TRIM OR VEHICLE SCHEDULE YOUR NEXT DAMAGE. THANK YOU SERVICE @
JOB# 2 TOTALS [email protected]
JOB# 2 JOURNAL PREFIX HOCS JOB# 2 TOTAL 0.00
JOB# 3 CHARGES -
LABOR CUSTOMERS NEED TO REMOVE
J# 3 01HOZ21POINTS MULT -POINT INSPECT TECH(S): 8888 0.00 ALL PERSONAL PROPERTY PERFORM HONDA COMPLIMENTARY MULTI-POINT VEHICLE INSPECTION. FROM VEHICLE, WE ARE NOT
HONDA MULTI-POINT COURTESY VEHICLE INSPECTION RESPONSIBLE FOR LOST OR Multi-Point Inspection All
STOLEN PERSONAL ITEMS.
JOB# 3 TOTALS-
ALL PARTS ARE NEW HONDA
JOB# 3 JOURNAL PREFIX HOCS JOB# 3 TOTAL 0.00
ORIGINAL EQUIPMENT PARTS
JOB# 4 CHARGES -
UNLESS SPECIFIED OTHERWISE
LABOR
J# 4 17HOZPS TIRE PRESSURE CHECK TECH(S) : 8888 0.00
CC672177 • (07/201
PERFORM TIRE PRESSURE CHECK ADJUST TIRES TO FACTORY
SPECIFICATION - RESET TIRE PRESSURE INDICATOR AS
NECESSARY
TIRE PRESSURE CHECK
LINTSHAE Tire Pressure Check All
JOB# 4 TOTALS
JOB# 4 JOURNAL PREFIX HOCS JOB# 4 TOTAL 0.00
ESTIMATE
Reynold CUSTOMER HEREBY ACKNOWLEDGES RECEIVING
ORIGINAL ESTIMATE OF $0.00 (+TAX)
The Reynold:
PAGE 1 OF 2 CUSTOMER COPY [CONTINUED ON NEXT PAGE] 01:42pm Honda
TOWN
H Honda LOS ANGELES Honda
780 W. Martin Luther King Jr. Blvd. • Los Angeles, California 90037 Service (213) 234-2130 • Sales (213) 267-9087
www.hondaoflosangeles.com
0101IHOCS698245 CELL: OCEA
CUSTOMER NO. [ADVISOR TAG NO. INVOICE DATE
178147 ANTHONY GARCIA 1786 9999 10003/01/23 HOCS698245
LABOR RATE LICENSE NO. MILEAGE STOCK NO
WAN NEGRETE 151, 438 BLACK/
YEAR / MAKE / MODEL DELIVERY DATE DELIVERY MILES
06/HONDA/PILOT/5DR 4WD EX-L RES AT PRODUCTION DATE
VEHICLE ID. NO. SELLING DEALER NO.
F.T.E. NO. TRO. NO. R. O. DATE
03/01/23
BUSINESS PHONE COMMENTS
MO: 151438
9263 TOTALS -
THANK YOU FOR YOUR BUSINESS HERE AT HONDA OF DOWNTOWN LOS TOTAL LABOR.... 0.00 At Honda of Downtown Los ANGELES. YOUR SATISFACTION IS OUR NUMBER ONE PRIORITY. TOTAL PARTS.... 0.00 TOTAL SUBLET... 0.00 Angeles, we strive for
TOTAL G.O.G.... 0.00 excellent service. If for any
THANK YOU FOR TAKING THE TIME TO ALLOW US TO SERVICE YOUR TOTAL MISC CHG. 0.00 VEHICLE, WE STRIVE TO PROVIDE EXCELLENT SERVICE!!! TOTAL MISC DISC 0.00 reason you feel we did not TOTAL TAX...... 0.00 provide the highest quality
**AMERICAN HONDA MAY BE CONTACTING YOU THROUGH EMAIL AND WE TOTAL INVOICE $ 0.00 service, please notify our WOULD APPRECATE YOUR TIME IN COMPLETING THE SURVEY. service team immediately. • IF WE DID NOT EARN AN EXCELLENT RATING PLEASE CONTACT * ALFREDO MEJIA AT 213-234-2130. THANK YOU! WE APPRECIATE Thank You.
CUSTOMER SIGNATURE BELOW ACKNOWLEDGES RECEIPT OF FINAL
INVOICE AND VEHICLE.
SCHEDULE YOUR NEXT
CUSTOMER SIGNATURE SERVICE @
[email protected]
CUSTOMERS NEED TO REMOVE
ALL PERSONAL PROPERTY
FROM VEHICLE, WE ARE NOT
RESPONSIBLE FOR LOST OR
STOLEN PERSONAL ITEMS.
ALL PARTS ARE NEW HONDA
ORIGINAL EQUIPMENT PARTS
UNLESS SPECIFIED OTHERWISE
CC672177 O (07/20|
PAGE 2 OF 2 CUSTOMER COPY I END OF INVOICE 1 01:42pm