CLAIM FOR DAMAGES RESERVE FOR FILING STAMP
TO PERSON OR PROPERTY CLAIM No.
INSTRUCTIONS RECEIVED
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)
2. Claims for damages to real property must be filed not later than one (1) year OCT 1 1 2023 after the occurrence. (Gov. Code Sec.911.2)
3. Read entire claim before filing. CITY CLERK'S OFFICE See page 2 for diagram upon which to locate place of accident
5. This claim form must be signed on page 2 at bottom.
6. Attach separate sheets, if necessary, to give full details. SIGN EACH SHEET.
7. 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)
State Farm Mutual Auto Ins Co a/s/o Evette Calderon n/a Home Address of Claimant City and State Home Telephone Number n/a
Business Telephone Number
Business Address of Claimant City and State
PO Box 106172 Atlanta, GA 30348-6172 615-692-3868
Give address to which you desire notices or communications to be sent regarding this claim:
Same as above
How did DAMAGE or INJURY occur? Give full particulars.
State Farm insured vehicle driven by Yader Antonio Rayo Noguera was pulling away from gas pump when struck by your insured vehicle
When did DAMAGE or INJURY occur? Give full particulars, date, time of day, etc.:
5/20/2023 @ 10:30 pm
Where did DAMAGE or iNJURY occur? Describe fully, and locate on diagram on reverse side ofthis sheet, where approximate, give street names and address and measurements from landmarks:
3081 Vernon Ave in Vernon CA
What particular ACT or OMISSION do you claim causedthe injury or damage? Givenames of City employees, if any, causing the injury or damage, if known:
Inattention. Your insured driver Marissa Renee Velez
What DAMAGE or INJURIES do you claim resulted? Give full extent of injuries or damages claimed:
Property damage to front of 2016 Toyota Corolla
What AMOUNT do you claim of each item of injury ordamage as of date of presentation of this claim, giving basis of computation:
$3207.05
Give ESTIMATED AMOUNT as faras known you claim on account of each item of prospective injury or damage, giving basis of computation:
$3207.05 for vehicle repairs and rental
Were you insured at the time of the incident? If so, provide name of insurance company, policy numbers and amount of insurance payments received:
State Farm Mutual Automobile Insurance Company, policy # Expenditures made on account of accident or Injury: (Date - Item) (Amount) Name and address of Witnesses, Doctors and Hospitals:
n/a
READCAREFULLY
or all accident claims place on following diagram names of streets, including North, East. South, and West: indicate pla accident by "X" and by showing house numbers or distances to street corne NOTE: If diagrams do not fit the situation, attach hereto a proper diagram signed by claimant.
FOR AUTOMOBILE ACCIDENTS
FOR OTHER ACCIDENTS
///L
BIDEWALK
CURB/
CURB Y
PARKWAY
SIDEWALK
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 Date:
relationship to Claimant
Adema Serifornic antonic 09/21/23
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 FILED WITH 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) Rey. 8/4/16
From:"Tammy Bartell" <[email protected]> Sent:Mon, 11 Sep 2023 20:40:46 +0000
To:"HOME CLMS-STATEFARMCLAIMS" <[email protected]> Subject:75-50G4-94L signed claim form.pdf
Attachments:75-50G4-94L signed claim form.pdf
Providing Insurance and Financial Services 8o State Farm® Home Office, Bloomington, IL
September 11, 2023
Office Of The City Clerk-City Of Vernon Subrogation Services 4305 S Santa Fe Ave PO Box 106172
Vernon CA 90058-1714 Atlanta GA 30348-6172
RE: Claim Number: 75-50G4-94L
Our Insured: Evette Hermelinda Calderon
Date of Loss: May 20, 2023
Your Insured: City Of Vernon
Your Insured Driver: Marissa Renee Velez
Your Claim Number: CV2252023
Your Policy Number: Unknown
Loss Location: 3081 Vernon Ave Vernon, CA
To Whom It May Concern:
We have been informed you are the liability carrier for the party involved in this loss with our insured. Our investigation indicates your insured is responsible for this claim. Therefore, we are seeking recovery from you. This letter is to notify you of our subrogation claim and request your cooperation in settling this matter.
To assist you in your review, here is a breakdown of the amounts State Farm® paid by Cause of Loss:
Total Amount Paid by State Farm: $2,707.05
Insured Deductible Amount: $500.00
Total Amount Due to State Farm: $3,207.05
If you have paid the deductible to our insured, please reduce the Total Amount Due to State Farm by the deductible amount.
Property Damage
042 - Uninsured Motorist PD $
300 series/400 - Comp/Collision $1507.05
501 - Rental/Loss of Use $1200.00
Other Property Damage
Salvage Recovery
Insured Deductible Amount $500.00
75-50G4-94L
September 11, 2023
The total amount of the rental bill was $1237.77. Based on our insured's policy provisions, State Farm paid $1200.00. The remaining amount was paid by the insured as part of their co-pay under Rental coverage. State Farm will not negotiate and will return the check if the insured's co-pay is included. Please contact the insured with respect to their rental co-pay and any other out of pocket expenses.
Based on the assessment of liability between the parties, State Farm Mutual Automobile Insurance Company is seeking 100% of the Total Claim Amount listed above. The amount payable to State Farm Mutual Automobile Insurance Company for this loss is $3,207.05.
State Farm insured vehicle driven by Yader Antonio Rayo Noguera was pulling away from gas pump when struck by your insured vehicle.
Please remit payment of this claim, or contact us at (877) 787-8276 Ext. 6156923868 to discuss settlement. Please include our claim number on the payment. If you reimburse our insured's deductible directly, please advise us at time of payment. Thank you for your cooperation.
In order to assist you in evaluating and processing the subrogation claim we are asserting, we may provide nonpublic personal information about our customer. We are sharing this information to effect, administer, or enforce a transaction authorized by the consumer. However, you are neither authorized nor permitted to: (1) use the customer information we provided for any purpose other than to evaluate and process the subrogation claim, or (2) disclose or share the customer information we provide for any purpose other than to evaluate and process the subrogation claim.
If you have questions or need assistance, call us at (877) 787-8276 Ext. 6156923868.
Sincerely,
Tammy Bartell
Claim Associate
(877) 787-8276 Ext. 6156923868
[email protected]
For your protection, when emailing State Farm, please do not include sensitive personal information such as Social Security Number, credit/debit card number (financial account number), driver's license number, or health/medical information in an email.
Please contact us at (877) 787-8276 Ext. 6156923868 to discuss sensitive information.
State Farm Mutual Automobile Insurance Company
Enclosure(s):
Other insurance carriers with access to st8.fm/oic-self-service can check for claims and review claim status online, including some payment details such as issue date, status, and amount. They can also view principal damage information and upload documents for an open claim. All insurance carriers can file an auto claim online on statefarm.com/claims.
Rental Agreement # 9ZHOSL
enterprise
Renter Information Trip Information
Renter Name Pickup Return
YADER NOGUERA *Tuesday, June 6, 20235:35 PM Friday, June 30, 20234:37PM
HUNTINGTON PARK-VERNON HUNTINGTON PARK-VERNON
Renter Address 6024 PACIFIC BLVD 6024 PACIFIC BLVD
HUNTINGTON PARK, CA 90255-2931 HUNTINGTON PARK, CA 90255-2931
USA USA
Vehicle Information
HIGH Bill-To: STATE FARM
License #:| Rental Rate Time & Distance 1 Day at $10.06 / Day $10.06 State/Province: AZ Time & Distance 24 Day at $43.00 / Day $1,032.00 Unit #L
Taxes and Fees Vehicle License Recovery Fee (S0.49/ Day) $0.49 Vehicle #: NS136066
Sales Tax (1025%) $106.81
Vehicle Class Driven Vehicle License Recovery Fee ($2.11 / Day) $50.64 Standard SUV 5 door/Automatic/Air Subtotal ($1,200.00)
Vehicle Class Charged
Standard SUV 5 door/Automatic/Air Renter Charges
Odometer Mileage/Kilometers Rental Rate Time & Distance 1 Day al $32.94 / Day $32.94 Starting: 20654 Ending: 21539 Add-Ons Refueling Charge (s7.01 / Galion) $41.36 Total: 885 Mileage Unlimited Mile age Included
Fuel
Taxes and Fees Motor Vehicle Fuel Sales Tax (5.25%) $1.80 Starting: 9.5g Ending: 3.6g Vehicle License Recovery Fee ($1.62 / Day) $1.62 Adjustment ($39.85) /Rental) ($39.95)
Thank you for renting
Total $1,237.77
with Enterprise Rent-A-
Car (Subject to audit)
We appreciate your business! Amoun changed on tune 8, 202310 1S ($150.00) This email was automatically generated APN: VISA DEBIT
AID: A0000000031010
from an unattended mailbox, so please
do not reply to this e-mail. Verified: Signature
If you have any questions about your Entry: Chip
rental, please view our Frequently TSI: 6800
Asked Questions or send us a secured Amount charged to STATE FARM ($1,200.00) Amount Due ($112.23)
message by visiting our Support Center
RBZ0006Z
State Farm State Farm Mutual Automobile Insurance Company Auto Payments by COL
Route To: Leslie Schweitzer
BASIC CLAIM INFORMATION
Claim Number: 75-50G4-94L
Date of Loss: 05-20-2023
Policy Number:
Named Insured: CALDERON, EVETTE H
400 - COLL
C denotes consolidated payment
E denotes EFT payment
P previously converted payment from CAT/CMR
Payment Payable Pay Rsn
Number Issued Date Participant COL Cd Status Amount Auth ID Cd 123896183J 07-04-2023 Named Insured(s) 400 3 Paid $92.53 VAC8HL 123881459J 06-23-2023 Named Insured(s) 400 3 Paid $599.57 VAEGPF VR 123865617J 06-14-2023 Named Insured(s) 400 1 Paid $814.95 XCYK 123860407K E 06-11-2023 Named Insured(s) 400 2 Void $814.95 VACSTZ 123855870K E 06-08-2023 Named Insured(s) 400 1 Void $814.95 ECSAPY Total: $1.507.05
501 - RENT
C denotes consolidated payment
E denotes EFT payment
P previously converted payment from CAT/CMR
Payment Payable Pay Rsn
Number Issued Date Participant Cd Status Amount Auth ID Cd 123894166K E 07-02-2023 Named Insured(s) 501 1 Paid $1,200.00 ECSAPY Total: $1,200.00
Date: 09-13-2023 Page 1
STATE FARM CONFIDENTIAL INFORMATION
Distribution on a Business Need to Know Basis Only
California.
-or Customer Support reter to the
appropriate platform below
LexisNexis®
Police Records Retrieval
RISK SOLUTIONS 800-934-9698
[email protected]
Accurint for Insurance
866-277-8407
[email protected]
For tips on ordering visit:
statetips.lexisnexisrisk.com
PAGE COUNT: 13
CLIENT: 6625
DIVISION:
ADJUSTER: VADT9B
CLAIM: 7550G494L
TRANSACTION #: 2195184462
DATE: 2023-07-05 14:51:53.0
DATE OF LOSS: 05/20/2023 TIME OF LOSS: 0:0:0
STREET: SOTO STREET
CITY: VERNON
COUNTY: LOS ANGELES
STATE: CA
INVESTIGATING AGENCY: HUNTINGTON PARK PD
REPORT NUMBER: 23-02761
REPORT TYPE: AUTOACCIDENT
PARTY1: EVETTE HERMELINDA CALDERON
PARTY2:
PARTY3:
CAR: COROLLA S PLUS W/CON MAKE: TOYO YEAR: 2016
TAG:
ADDITIONAL INFO:
NOTE:
THANK YOU FOR YOUR ORDER!
STATE FARM INSURANCE COMPANIES
CA
Take this initial estimate to the repair facility of your choice. If additional damage is found have the repair facility use the "Request Supplement" link at b2b.statefarm.com. ** This is not an email address; it is the site to submit a Supplement**. All supplements must be approved by State Farm.
Claim #: 75-50G4-94L01
Workfile ID: 358feaab
Rate Table: Default
Supplement of Record 2 Summary
Written By: ROBERT MIYAHARA, 7/3/2023 1:58:52 PM
Claim Rep: Team, Express, (855) 341-8184 Business
Insured: EVETTE CALDERON Owner Policy #: Claim #: 75-50G4-94L01 Type of Loss: Collision Date of Loss: 05/20/2023 10:30 PM Days to Repair: 0 Point of Impact: 12 Front Deductible: 500.00
Owner (Insured): Inspection Location: Repair Facility:
EVATTE CALDERON J & R Auto Collision Ind J&R Auto Collision 2119 Rosemead Bivd 2119 ROSEMEAD BLVD
SEI Monte, CA 91733 SEL MONTE, CA 91733-1527
Virtual
VEHICLE
2016 TOYO Corolla S Plus w/Continuously Variable Transmission 4D SED 4-1.8L Gasoline Sequential MPI Red VN: Production Date: 07/2016 Interior Color: Black
License: 7UEJ661 Odometer: 85404 Exterior Color: Red
State: CA Condition:
TRANSMISSION Intermittent Wipers Auxiliary Audio Connection PAINT Automatic Transmission Tilt Wheel Equalizer Cear Coat Paint POWER Cruise Control SAFETY Metallic Paint
Power Steering Rear Defogger Drivers Side Air Bag OTHER Power Brakes Keyless Entry Passenger Air Bag Fog Lamps
Power Windows Steering Wheel Touch Controls Anti-Lock Brakes (4) Traction Control Power Locks Telescopic Wheel 4 Wheel Disc Brakes Stability Control Power Mirrors Climate Control Front Side Impact Air Bags Rear Spoiler Heated Mirrors Backup Camera Head/ Curtain Air Bags Signal Integrated Mirrors DECOR RADIO Hands Free Device Xenon or L.E.D. Headlamps Dual Mirrors AM Radio SEATS California Emissions
Tinted Gass FM Radio Coth Seats Power Trunk/Liftgate
Console/Storage Stereo Bucket Seats
CONVENIENCE Search/Seek WHEELS
Air Conditioning OD Player Aluminum/Alloy Wheels
7/3/2023 1:58:52 PM 443845 | 1.9.02.05150 Page 1
Claim #: 75-50G4-94L01
Workfile ID: 358feaab
Supplement of Record 2 Summary
2016 TOYO Corolla S Plus w/Continuously Variable Transmission 4D SED 4-1.8L Gasoline Sequential MPI Red
ESTIMATE TOTALS
Category Basis Rate Cost $
Parts 802.33
Body Labor 4.9 hrs @ $ 65.00/hr 318.50
Paint Labor 6.5 hrs @ $ 65.00/hr 422.50
Feather Prime and Block 0.5 hrs @ $ 65.00/hr 32.50
Paint Supplies 6.5 hrs $ 48.00/hr 312.00
Other Charges 5.00
Subtotal 1,892.83
Sales Tax $ 1,114.33 @ 10.2500% 114.22
Total Cost of Repairs 2,007.05
Deductible 500.00
Total Adjustments 500.00
Net Cost of Repairs 1,507.05
For more information regarding State Farm's promise of satisfaction relating to new non-original equipment manufacturer (non-OEM) and recyded parts, please visit:
https://static1.st8fm.com/en_US/downloads/st/non-oem-recyded-parts-California-only.pdf or QR code.
Register online to check the status of your claim and stay connected with State Farm®. To register, go to http://www.statefarm.com/ and select Check the Status of a Claim. If you are already registered, thank you! 7/3/2023 1:58:52 PM 443845 | 1.9.02.05150 Page 3
Caim #: 75-50G4-94L01
Workfile ID: 358feaab
Supplement of Record 2 Summary
2016 TOYO Corolla S Plus w/Continuously Variable Transmission 4D SED 4-1.8L Gasoline Sequential MPI Red
SUPPLEMENT SUMMARY
Line Oper Description Part Number Qty Extended Labor Paint Price $
Changed Items
23 # Refn Corrosion Protection -0.1
24 # S02 Refn Corrosion Protection 0.2
Deleted Items
10 Repl USED Grille assy + 25% G144 1 -62.50 Ind.
Added Items
10 S02 Repl USED Grille assy +25% G144 1 93.75 Ind.
NOTE: Toyo Parts Only Dave 7/3/23
11 # S02 Repl Clean and Re-tape 1 0.3
25 # S02 Repl Feather Prime Block Material 1 7.50
26 # S02 Repl Additional Cover Car 1 5.00 0.2
SUBTOTALS 43.75 0.5 0.1
TOTALS SUMMARY
Category Basis Rate Cost $
Parts 43.75
Body Labor 0.5 hrs @ $ 65.00 /hr 32.50
Paint Labor 0.1 hrs @ $ 65.00/hr 6.50
Paint Supplies 0.1 hrs @ $ 48.00/hr 4,80
Subtotal 87.55
Sales Tax $ 48.55 @ 10.2500% 4.98
Total Supplement Amount 92.53
NET COST OF SUPPLEMENT 92.53
CUMULATIVE EFFECTS OF SUPPLEMENTS)
Estimate 1,314.95
Supplement S01 599.57
Supplement S02 92.53
Workfile Total: $ 2,007.05
TOTAL ADJUSTMENTS: $ 500.00
NET COST OF REPAIRS: $ 1,507.05
7/3/20231:58:52 PM 443845 | 1.9.02.05150 Page 4
Claim #: 75-50G4-94L.01
Workfile ID: 358feaab
Supplement of Record 2 Summary
2016 TOYO Corolla S Plus w/Continuously Variable Transmission 4D SED 4-1.8L Gasoline Sequential MPI Red
ALTERNATE PARTS SUPPLIERS
Line Supplier Description Price
3 FitParts - C #TO1000400C $ 154.60
17800 S Main St, Ste211 Non OEM CAPA Bumper cover
Gardena CA 90248 Quote: 1546894274
(424) 331-9599 Expires: 06/14/23
EXPRESS BODY PARTS. NH # TO1070179C $ 40.98
7295 Coldwater Canyon Non OEM CAPA Absorber
North Hollywood CA 91605 Quote: TemplD-2306222305
(818) 764-0707 Expires: 06/22/23
8 Toyo Parts Only #G144 $ 50.00
Sales Number USED Lower grille + 25%
11540 Hart Street GRILLE. - UPPER, MESH DESIGN (S MODELS) North Hollywood CA 91605
(800) 835-2444
10 Toyo Parts Only #G144 $ 50.00
Sales Number USED Grille assy + 25%
11540 Hart Street GRILLE. - UPPER, MESH DESIGN (S MODELS) North Hollywood CA 91605
(800) 835-2444
13 JP AUTO #JP-A25751 $ 219.00
Sam Eoon Non OEM CAPA RT Headlamp assy
20 Haypress Road Suit 312
Cranbury NJ 08512
(973) 317-0656
15 JP AUTO #JP-A25197 $ 219.00
Sam Eoon Non OEM CAPA LT Headlamp assy
20 Haypress Road Suit 312
Cranbury NJ 08512
(973) 317-0656
7/3/2023 1:58:52 PM 443845 | 1.9.02.05150 Page 8