PROGRESSIVE
Payment Address Document Address
24344 Network Place P.O. Box 94639
Chicago, IL 60673-1243 Cleveland, Ohio 44101-9908
Phone: (877)818-0139
Fax: (888) 781-6947
10/19/2023 5:07:00 PM
Certified Mail 9489 0090 0027 6568 2325 52 Return Receipt Requested City Clerk
City of Vernon
4305 South Santa Fe Avenue, RECEIVED
Vernon, CA 90058
Your Client: CITY OF VERNON OCT 3 0 2023
Your Claim Number: NA
Our Insured: GIORGADZE, GVANTSA CITY CLERK DEPARTMENT
Our Claim Number: 23-7228124
Amount Subject to Reimbursement: $1,977.10
Amount of Insured's Deductible: $500
Please take this as formal notice of our subrogation rights relative to the above -captioned claim. We have completed our investigation into the facts of the above-captioned loss and find that your insured was the proximate cause of the accident.
Location of Loss: 4505 BANDINI BLVD VERNON, CA USA
Date and Time of Loss: 09/12/2023, 02:00 PM PT
Description of Loss: Our insured's vehicle was parked at 4505 Bandini Blvd in Vernon, CA when a city vehicle with plate # 1067189 failed to maintain proper lookout and control of vehicle, struck our insureds parked vehicle. We are seeking reimbursement for our insured's vehicle damages.
Please make your draft payable to Progressive West Insurance Company as subrogee of "GIORGADZE, GVANTSA", in the amount stated above and mail it to the attention of the undersigned at your earliest convenience.
All supporting documentation is enclosed. Thank you for your anticipated, prompt attention to this matter.
Christine Jones
Progressive Subrogation
Progressive West Insurance Company
Tel. 877-818-0139
Fax. 888-781-6947
[email protected]
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 RECEIVED 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 after the occurrence. (Gov. Code Sec.911.2)
3. Read entire claim before filing. OCT 3 0 2023
4. 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. CITY CLERK DEPARTME
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)
Progressive West Insurance Company ASO GIORGADZE, GVANTSA NA Home Address of Claimant City and State Home Telephone Number PO BOX 94639 Cleveland, OH 44101-9908 877-818-0139
Business Address of Claimant City and State Business Telephone Number SAME 877-818-0139
Give address to which you desire notices or communications to be sent regarding this claim:
[email protected]
How did DAMAGE or INJURY occur? Give full particulars.
Our insured's vehicle was parked at 4505 Bandini Bld in Vernon, CA when a city vehicle with plate # 1067189 failed to maintain proper lookout and control of vehicle, struck our insureds parked vehicle. We are seeking reimbursement for our insured's vehicle damages.
When did DAMAGE or INJURY occur? Give full particulars, date, time of day, etc.:
09/12/2023, 02:00 PM PT
Where did DAMAGE or INJURY occur? Describe fully, and locate on diagram on reverse side of this sheet, where approximate, give street names and address and measurements from landmarks:
4505 BANDINI BLVD VERNON, CA USA
What particular ACT or OMISSION do you claim causedthe injury or damage? Give names of City employees, if any, causing the injury or damage, if known:
failed to maintain proper lookout and control of vehicle What DAMAGE or INJURIES do you claim resulted? Give full extent of injuries or damages claimed:
2020 TOYOTA COROLLA- RIGHT REAR DAMAGE
What AMOUNT do you claim of each item of injury or damage as of date of presentation of this claim, giving basis of computation:
2020 TOYOTA COROLLA- SEE ATTACHED $1,977.10
Give ESTIMATED AMOUNT as faras known you claim on account of each item of prospective injury ordamage, giving basis of computation:
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 PROGRESSIVE CLM# 23-7228124
$1,977.10
Expenditures made on account of accident or Injury: (Date - Item) (Amount) Name and address of Witnesses, Doctors and Hospitals:
READCAREFULLY
-or all accident claims place on following diagram names of streets, including North, East. South, and West: indicate plac f accident by "X" and by showing house numbers or distances to street corner:
NOTE: if diagrams do not fit the situation, attach hereto a proper diagram signed by claimant.
FOR AUTOMOBILE ACCIDENTS
FOR OTHER ACCIDENTS
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 Date:
relationship to Claiman
CHRISTINE JONES- PROGRESSIVE REP Christine Jones 10/19/2023 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) Rev. 8/4/16
10/19/23, 5:04 PM Claim Payment Detail
Claim Payment Detail (23-7228124 )
- Payment Information
Disbursement Number: 788744706 Total Amount: $399.90
EFT Trace Number: Invoice Number: 117382201
Pay to the Order of: ENTERPRISE RENT A CAR CO
Mailing Address: ENTERPRISE RENT-A-CAR
11575 VENTURA BLVD
STUDIO CITY, CA 91604- USA
In Payment Of: Progressive Invoice Number: 117382201
- Reviewed Summary
Issuing Rep: A190417 Approved By:
Issue Date: Review Date:
Last Updated Rep: A190417 Reviewed By:
-Bank Information
Type: Loss Bank Code: CTB
Stop Reason: Cleared: No
Stop Date:
- Exposure Detail: RENTAL
Party Name: GIORGADZE, GVANTSA Amount Paid: $399.90
Property Description: 20 TOYOTA COROLLA Deductible Taken: $0.00 Payment Type: FINAL PAYMENT Property Damage: $0.00
Rental: $399.90
https://cla-claimsum-web-prod.prod.glb.pgrcloud.app/20237228124/claim-payment-inquiry 1/1 10/19/23, 5:05 PM Claim Payment Detail
Claim Payment Detail ( 23-7228124 )
-Payment Information
Disbursement Number: 387239153 Total Amount: $1,077.20
Draft Number: Invoice Number: 117118240
Pay to the Order of: GVANTSA GIORGADZE AND TOYOTA OF NORTH HOLLYWOOD Mailing Address: 4645 LANKERSHIM BLVD
NORTH HOLLYWOOD, CA 91602 USA
In Payment Of: Progressive Invoice Number: 117118240
- Reviewed Summary
Issuing Rep: A127685 Approved By:
Issue Date: 09-21-23 Review Date:
Last Updated Rep: A127685 Reviewed By:
- Bank Information
Type: Loss Bank Code: 1CD
Stop Reason: Cleared: 10-03-23
Stop Date:
-Exposure Detail: COLL
Party Name: GIORGADZE, GVANTSA Amount Paid: $1,077.20
Property Description: 20 TOYOTA COROLLA Deductible Taken: $500.00 Payment Type: FINAL PAYMENT Property Damage: $0.00
Rental: $0.00
https://cla-claimsum-web-prod.prod.glb.pgrcloud.app/20237228124/claim-payment-inquiry 1/1 Drive Insurance Co Estimate ID
23-7228124-01
Original
Claim Number
23-7228124-01
Owner Insured Appraiser
GVANTSA GIORGADZE GVANTSA GIORGADZE RAITH ROBINSON
(818) 303-5501 Work)
[email protected]
Underwriter
Drive Insurance Co
Drive Insurance Co
Claim Number Adjuster Deductible Reported Date
23-7228124-01 KYLE CHRISMAN 500.00 - Not Waivec 09/12/2023 (440) 620-3169 (Work)
[email protected]
Loss Date Inspection Site
09/12/2023 NORTH HOLLYWOOD
TOYOTA
4645 Lankershim Blvd
North Hollywood, CA 91602
(818) 508-2900 (Mobile)
2020 Toyota Corolla SE 4 Door Hatchback 2.0L 4 Cyl Gas Injected Auto Trans FWD Exterior Color VIN Condition
1F7 (Classic Silver) Good
Drivable Odometer Production Date Mitchell Service Code Yes 31469 03/2020 912086
Primary Point of Impact
Right Rear Corner (5)
Options
Air Conditioning Alum/Alloy Wheels AM-FM Stereo Anti-Lock Brake Sys. (ABS) Auto Air Condition Automatic Headlights Auxiliary Input Bluetooth Wireless Cloth Seat Cruise Control Connectivity
Daytime Running Lights Driver-Front Air Bag Electric Defogger Electronic Stability Control First Row Bucket Seat Heated Mirror Keyless Entry System Leather Steering Wheel Left-Curtain Air Bag MP3 Player Passenger-Front Air Bag Power Door Locks Power Remote Mirror Power Steering Power Windows Rear Bench Seat Rear Gate Wiper Rear Spoiler Rearview Camera Satellite Radio Second Row Side Airbag With Side Airbags Smart Key System Steering Wheel Mounted Telematic Systems Head Protection Audio Control
Theft Deterrent Sys. Tilt Steering Wheel Syderessure Monitoring Tonneau Cover Traction Control/Electronic Trip Computer
Committed On Printed On Profile
9/21/2023 Michel Estimating 233 Mitchell Cloud Estimating™ CA SFV ALL PARTSNNW Page 1 of5 Copyright 1994-2023 Mitchell international, Inc. 9/21/2023 12:24 PM OEM SEP_23_V All Rights Reserved 12:24 PM Profile Version
4.0 GVANTSA GIORGADZE | 2020 Toyota Corolla SE
Parts Profile Parts Profile Version
SFV ALL PART TYPES 2.0
LABOR PART
Line# Description Operation Type Total Units Type Number Qty Total Price Tax Rear Bumper
1 200292 Rear Bumper Cover Assy Overhaul Body 2.0# Existing 2 201635 Rear Bumper Cover Repair Body 3.0*# Existing
3 AUTO Rear Bumper Cover Refinish Refinish 2.7 C Existing Only
4 201640 RRear Bumper Seal (2 @ Remove / Body INC New 52191-47030 2 $16.78 Yes $8.39) Replace
5 900501 Par Toyota Non-Reusable
6 201641 58.395 Bumper Seal 12 e Remove / Body INC New 52191-47030 2$16.78 Yes Replace
7 900501 Per Toyota Non-Reusable
Part
8 201702 R Rear Bumper Pad Remove / Body INC New 52462-47010 1 $2.93 Yes Replace
9 900501 Per Toyota Non-Reusable
Part
10 201642 L Rear Bumper Pad Remove / Body INC New 52462-470101 $2.93 Yes Replace
11 900501 Per Toyota Non-Reusable
Part
12 201721 R Rear Bumper Reflector Remove / Body INC# Existing Install
13 201689 L Rear Bumper Reflector Remove / Body INCr# Existing Install
14 201700 Rear Lwr Bumper Cover Remove / Body INC# Aftermarket T01195129 1 $318.00 Yes Replace New
15 900501 GLOSS AND SCUFFS ON
PART.
16 AUTO Rear Bumper Cover Remove / Body INC#
Install
17 201701 Rear Bumper Pad (3 @ Remove / Body INC New 52461-12080 3 INC Yes $0.00) Replace
18 900500 Rear Bumper Step pad Remove / Body* 0.3* New 1 $70.00* Yes Replace
19 900501 SEE INVOICE
Additional Costs & Materials
20 AUTO Paint/Materials Additional $215.00• Yes
Cost
Additional Operations
21 AUTO Clear Coat Additional Refinish 11 $0.00
Operation
22 933003 Tint Color Additional Refinish* 0.5° $0.00
Operation
Special / Manual Entry
23 900500 PRE-REPAIR SCAN Remove / Mechanical* 0.5* Existing Replace
24 900500 POST-REPAIR SCAN Remove/ Mechanical" 0.5* Existing Replace
Committed On Version Printed On Page 2 ofs
9/21/2023 Mitchell Cloud Estimating™ 9/21/2023 CASF VALL PARTS NW Mitchell Estimating 23.3 Copyright 1994-2023 Mitchell International, Inc. 12:24 PM OEM SEP_23_V 12:24 PM Profile Version
All Rights Reserved 4.0
LABOR PART
Line # Description Operation Type Total Units Type Number Qty Total Price Tax 25 900500 FLEX ADDITIVE Remove / Refinish" 0.0* Aftermarket *Qual Repl Part 1 $10.00" Yes Replace New
26 900500 R&I PARTS AS NEEDED Remove / Body* 0.0* Existing 1 Install
27 900500 BATTERY Remove / Body* 0.3* Existing
Install
• Judgment Item C Included in Clear Coat Calculation
T Included in Two Tone Calculation A Included in Clear Coat and Two Tone Calculation # Labor Note Applies r CEG R&R Time Used for this Labor Operation d Discontinued by Manufacturer [ ] Verify the part number and price before ordering Parts Vendors
LKQ SUN VALLEY, CA
11651 SHELDON STREET
SUN VALLEY CA 91352
(888) 330-5558 (Work)
Total
Line Part#
Price
14 TO1195129 $318.00
Supplier Notes: Part sourced from SurePart
(powered by PartsTrader)., Certs/Programs:
KEYSIQ
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 5.6 $72.00 $403.20
Refinish Labor 4.3 $72.00 $309.60
Mechanical Labor 1.0 $150.00 $150.00
Total Labor 10.9 $862.80
Taxable $0.00
Tax 0.0000% $0.00
Non-Taxable $862.80
Labor Total $862.80
Parts Amount
Taxable Parts $437.42 $437.42
Parts Adjustments $0.00
Tax 9.5000% $41.55
Non-Taxable $0.00
Parts Total $478.97
Costs Amount
Other Additional Costs $0.00 $0.00
Paint Materials $215.00 $215.00
Committed On Version Printed On Profile Page 3 of5
9/21/2023 litchell Estimating 23 9/21/2023 CA SFV ALL PARTS NNW 12:24 PM EM SEP 23] 12:24 PM Profile Version
4.0 Estimate Totals
Taxable $215.00
Tax 9.5000% $20.43
Paint Materials Rate: $50.00
Rate Max: 99.9 units Non-Taxable $0.00
Additional Rate: $0.00 Costs Total $235.43
Gross Totals Amount
Gross Total $1,577.20 $1,577.20
Taxable $652.42
Tax $61.98
Non-Taxable $862.80
Gross Total $1,577.20
Adjustments Amount
Deductible -$500.00 -$500.00
Total Customer -$500.00
Responsibility
Net Estimate Total $1,077.20
Shop agrees to perform the specified repairs at the price indicated.
Repair Facility Authorized Signature
All manufacturers requirements regarding seat belt and supplemental restraint system replacement must be adhered to.
If additional parts or operations are necessary to properly accomplish this, please contact the estimating claims rep.
THIS APPRAISAL 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. WE WARRANT THE PARTS ARE AT LEAST EQUAL
TOTHE ORIGINAL MANUFACTURER PARTS IN TERMS OF KIND, QUALITY, SAFETY, FIT, AND PERFORMANCE ************* IMPORTANT INFORMATION: READ CAREFULLY************* The customer has the right to select the repair shop. Pursuant to CA Code of Regulations sec 2695.8(e) Progressive does not require you to have your vehicle repaired at a specific repair shop. The customer has the right to select a repair shop of their choice. This is a damage appraisal only based on damage visible or certain at the time it was written. Per Business & Professions Code section 9884.9 the customer, not Progressive, must give authorization for the repairs before they can begin. This appraisal is not an authorization for repairs. If frame or unibody repair is included on this appraisal, the amount shown includes time or allowance for measuring before, during and after those repairs.
To ensure proper and prompt payment for additional damage discovered during the course of repairs, contact Progressive for supplement procedures. Progressive payments will not exceed the prevailing labor market rate in the area where the property is to be repaired. Contact us if you choose a shop with rates higher than those reflected on this appraisal to determine whether an adjustment is appropriate. If you choose a shop that charges in excess of prevailing labor market rates, you will be responsible for the difference.
Lifetime guarantee for sheet metal and plastic parts. The replacement parts written on this appraisal are intended to Mitchell Cloud Estimating™ Page 4 of 5
9/21/2023 Mitchell Estimating 23.3 9/21/2023 CA SFV ALL PARTS NNW Copyright 1994-2023 Mitchell International, Inc. Profile Version 12:24 PM OEM SEP 23V All Rights Reserved 12:24 PM
4.0 return your vehicle to its pre-loss condition with proper installation. After repair, if any sheet metal or plastic body part included in this appraisal fails to return your vehicle to its pre-loss condition (assuming proper installation), in terms of form, fit, finish, durability or functionality, Progressive will arrange and pay for the replacement of the part, to the extent not covered by a manufacturer's or other warranty. This service will be performed at no cost to you (including associated repair and rental car costs). To obtain service under this Guarantee, call Progressive at 1-800-274-4641. This Guarantee applies as long as you own or lease the vehicle. This Guarantee is not transferable and terminates if you sell or otherwise transfer your vehicle.
THIS GUARANTEE DOES NOT COVER NORMAL WEAR AND TEAR OR DAMAGE CAUSED BY IMPROPER MAINTENANCE, NEGLECT, ABUSE OR SUBSEQUENT ACCIDENT. THIS GUARANTEE IS LIMITED TO ARRANGING FOR THE SELECTION OF REPAIR PARTS THAT WILL RETURN YOUR VEHICLE TO ITS PRE-LOSS CONDITION.
ACCORDINGLY, PROGRESSIVE WILL NOT BE LIABLE FOR ANY INDIRECT, INCIDENTAL OR CONSEQUENTIAL DAMAGES THAT RESULT FROM THE INSTALLATION OR USE OF THESE PARTS.
California Residents: As required by California regulations, the legend below should be used to identify whether replacement parts listed on this appraisal are "new", "used", "rebuilt", or "reconditioned" and whether the crash parts described on this appraisal are "original equipment manufacturer" (OEM) parts or "non-original equipment manufacturer aftermarket crash" parts:
New, OEM or part number displayed = New, original equipment manufacturer part Aftermarket New, nonOEM aftermarket = New, non-original equipment manufacturer aftermarket crash part Remanufactured = Rebuilt used OEM part
Used, Quality Recycled Part = Used OEM part
Re-cored = Reconditioned used OEM part
Re-chromed = Reconditioned used OEM part
Sublet = Repair work assigned to third party
Existing = Part is already on the vehicle
Progressive's Lifetime Guarantee does not cover repairs you request the shop to make that are not related to this accident, including but not exclusive to unrelated prior damage and pre-existing damage.
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
Job Created 9/20/2023 03:44 PM
Estimate Started 9/21/2023 12:09 PM
Estimate Printed 9/21/2023 12:24 PM
Estimate Corsinted 9/2/20231224 PM Estimate Version
Committed On Version Printed O Profile Page 5 of 5
Mitchell Cloud Estimating™ 2/21/202 CA SFV ALL PARTS NNW 9/21/2023 Copyright 1994-2023 Mitchell International, Inc 12:24 PM Profile Version
12:24 PM All Rights Reserved
4.0 10/19/23, 5:05 PM ARMS® - Automated Rental Management System Rental Company: ENTERPRISE RENT-A-CAR
CARMS PROGRESSIVE D2137C8-32A5
Alternate Invoice Number: 2137C8
Bill To: PRO65TX RENTAL DETAIL:
PROGRESSIVE
ATTN: KYLE CHRISMAN Rental Period: 9/19/23 to 9/26/23 (8 days) 10700 N LAMAR BLVD SUITE 150 Billed Period: 9/19/23 to 9/26/23 (8 days) AUSTIN, TX 787533055
Quantity Rate Amount
RENTER INFORMATION:
Renter: GIORGADZE, GVANTSA Products and Services
TIME & DISTANCE 8 43.98 $351.84
RENTAL INFORMATION: Taxes and Surcharges
Rental Branch Location:
ENTERPRISE RENT-A-CAR (32A5) VEHICLE LICENSE 1.83
RECOVERY FEE 8 $14.64
11575 VENTURA BLVD
STUDIO CITY, CA 916042611 SALES TAX 1 9.50% $33.42
(818) 762-0225
Total Charges: $399.90
ADDITIONAL CLAIM INFORMATION: Less Amount Received: $0.00 Claim Number :23-7228124 Total Amount Due: $399.90
Claim Type: Insured
Vehicle Condition: Driveable
Date Of Loss: 9/12/23
Insured Name: GVANTSA GIORGADZE
Owner's Vehicle: 2020 OTHER|TOYOTA
OTHER|COROLLA
Additional Driver:
Repair Facility:
TOYOTA OF NO.HOLLYWOOD B/S-32PW
NORTH HOLLYWOOD, CA 916021801
(800) 442-1385
VEHICLES RENTED:
Effective Date Starting Ending Mileage Rate
and Time Year Make Model VIN Vileage Mileage Charged
9/19/23 4:31 PM 2021 TOYO RAV4 45811 45970 159 $43.98
Rental Invoice
Please Retur This Portion with Remittance
Make Payment To: Total Charges: $399.90
ENTERPRISE RENT-A-CAR Less Amount Received: $0.00
P.O. BOX 840086 Total Amount Du................... $399.90 KANSAS CITY, MO 64184-0086
Federal ID: 43-0724835 Please include on your check:
Invoice: D2137C8-32A5
https://www.armsweb.com/armsweb/closedcustomerfile.do 1/1
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PAGE COUNT: 1
Please see explanation below.
CLIENT: 107040
DIVISION: TEXASK980C
ADJUSTER: A190417
CLAIM: 23-7228124
TRANSACTION #: 2295406811
DATE: 2023-10-10 14:05:14.0
DATE OF LOSS: 09/12/2023 TIME OF LOSS: 14:00
STREET: 4505 BANDINI BLVD VERNON, CA USA
CITY: VERNON
COUNTY: LOS ANGELES
STATE: CA
INVESTIGATING AGENCY: VERNON PD
REPORT NUMBER: CR23-1391
REPORT TYPE: AUTOACCIDENT
PARTY1: GVANTSA GIORGADZE
PARTY2:
PARTY3:
CAR: COROLLA MAKE: TOYOTA YEAR: 2020
TAG:
ADDITIONAL INFO: 1 Page via SFT Tue, 10 Oct 2023 20:21:44 GMT WE HAVE CONTACTED VERNON PD REGARDING YOUR REQUEST FOR THIS REPORT.
NOTE: ACCORDING TO THIS AGENCY, THEY ARE PROCESSING REQUESTS AND WE WILL FORWARD UPDATES AS WE RECEIVE THEM.