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) DEC 2 6 2024
3. Read entire claim before filing.
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 CITY CLERK DEPARTMENT
6. Attach separate sheets, if necessary, to give full details.
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)
Travelers Commercial Insurance Company also Andrea Garcia-Schmidt, Eugenia Schmidt, and Armando Garcia Home Address of Claimant City and State Home Telephone Number PO Box 5076, Hartford, CT 06102-5076
Business Address of Claimant City and State Business Telephone Number Travelers Claims Hartford, PO Box 660339, Dallas, TX 75266-0339 (payment address) 508-324-8325 Give address to which you desire notices or communications to be sent regarding this claim:
PO Box 5076, Hartford, CT 06102-5076
How did DAMAGE or INJURY occur? Give full particulars.
The traffic lights were out at the intersection of DOWNY RD/ BANDINI BLVD VERNON CA 90058.
Police officers were directing traffic. Due to a miscommunication, officers directed both our insured (Andrea Garcia-Schmidt driving 2018 Mercedes Benz) and another party (Pedro Ruvalcabra-Hidalgo driving 2011 Toyota Camry) to proceed at the same time. The vehicles collided in the intersection.
Please see the attached police report.
When did DAMAGE or INJURY occur? Give full particulars, date, time of day, etc.:
6/26/2024 18:30
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:
DOWNY RD/ BANDINI BLVD VERNON CA 90058
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:
Officer R. Hernandez (ID #665) and Officer T. Flores (ID # 660) instructed the involved parties to enter the intersection at the same time, subsequently causing the vehicles to collide.
What DAMAGE or INJURIES do you claim resulted? Give full extent of injuries or damages claimed:
Front driver side corner, sensor damage. Please see the attached estimate and photos for itemized damages.
Rental was paid partially by Travelers and partially by our insured. Please see the attached rental bill.
What AMOUNT do you claim of each item of injury or damage as of date of presentation of this claim, giving basis of computation:
$10,959.94 ($8,413.00 COLL paid by Travelers + $900 rental paid by Travelers + $1,000.00 deductible paid by insured + $646.94 out of pocket rental paid by insured) Give ESTIMATED AMOUNT as faras known you claim on account of each item of prospective injury or damage, 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 Yes, Travelers Commercial Insurance Company paid for damages under claim # 15G9613. Travelers paid a total of $9,313.00 for repairs and rental. Our insured paid a $1,000.00 deductible and $646.94 for out of pocket rental that was not covered under the policy.
Expenditures made on account of accident or Injury: (Date - Item) (Amount) Name and address of Witnesses, Doctors and Hospitals:
READ CAREFULLY
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.
If City Vehicle was Involved, designate by letter "A" location of City vehicle when you first saw it, and by "B" location of yourself or your vehicle when you first saw City vehicle; location of City vehicle at time of accident by "A-1" and location of vourself or vour 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
1 ^ 1 1/
L
CURB/
CURB,
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 Sarah Poole relationship to Claimant:
Travelers Claim Representative - Subrogation Neare arch 121/6/24 [email protected]
NOTE: ALL CLAIMANTS MAY BE REQUESTED TO BE EXAMINED AS TO THEIR CLAIM UNDER OATH. PRESENTATION OF A FALSE CLAIM IS A FELONY (CAL
TRAVELERSJ
CLAIM PROFESSIONAL
SARAH POOLE
[email protected]
Vernon City Police Department Call or send a text to (508) 324-8325 4305 South Santa De Ave
Vernon, CA 90058
Claim number: I4V6594-001
Date of loss: June 26, 2024
December 13, 2024
Dear Vernon City Police Department,
We believe you are responsible Loss location:
DOWNY RD/ BANDINI BLVD
We're writing about the incident which happened on June 26, 2024, involving our VERNON CA 90058 insured ANDREA GARCIA-SCHMIDT. Our review of the facts of the case suggest that you are responsible for the damages from the incident.
To date, we've paid $9,313.00 in benefits, and our insured incurred an additional deductible loss of $1,646.94. We're asking that you pay us the amount of Insured name: ANDREA $10,959.94 by 01/17/2025. GARCIA-SCHMIDT
If you do not have insurance, please contact us at the telephone number or email Underwriting Travelers address listed to discuss repayment options or answer any questions you may Company: Commercial have. Insurance
Company
Where to send payment
Otherwise, please make your check payable to Travelers Commercial Insurance Company, indicate the claim number on the check, and mail to:
Travelers Claims Hartford
PO Box 660339
Dallas, TX 75266-0339
All other written correspondence
Please note that any correspondence other than payments should be directed to our attention at:
Travelers
PO Box 5076
Hartford, CT 06102-5076
P1997 9/21
Thank you for your attention to this matter.
Please do not delay
If we do not hear from you within ten (10) days of the date of this letter, we may refer this matter to our legal counsel for evaluation, which may result in civil litigation and additional expenses.
Additional Information
Please note - our insured paid a $1,000.00 deductible and $646.94 for out of pocket rental.
Questions?
If you have any questions, please contact us.
P1997 9/21
12/13/24, 2:56 PM I4V6594 | 001 | ANDREA GARCIA-SCHMIDT | ARMANDO GARCIA, EUGENIA SHMIDT, ANDREA GARCIA SCH | 6/26/2024 Financials
Expand All I Collapse All
Financials
Friday, December 13, 2024
NOL Insured Information: Claim Number:
ANDREA GARCIA-SCHMIDT
I4V6594
RP Sequence Number:
001
Responsible Party Information:
VERNON CITY POLICE DEPARTMENT
4305 SOUTH SANTA DE AVE
VERNON, CA 90058
Loss Date: Accident State:
06/26/2024 VERNON, CA
Summary of Loss:
Claimant Summary
Claimant Name Type Cov Code Deductible Reduction Total Subro Number Demand
001 ANDREA GARCIA-SCHMIDT INSD COLL $ 1,000.00 $ 0.00 $ 9,413.00 RR $ 0.00 $ 0.00 $ 900.00
001 CMT (SUBTOTAL) $ 0.00 $0.00 $ 10,313.00
TOTALS (AMOUNT DUE) $ 0.00 $ 0.00 $ 10,313.00
Payment Details
PERS
Cim Nbr Cov Cd Reference Sea Transaction Amount Payee or Sold to For Explanation Auth Name
Nbr Date
Id
INT. EST. 2018 INT. EST. 2018 MERCB
001 CMC5 COLL 0033465887 001 08/20/2024 $ 2,153.32 MERCEDES-BENZ OF
LONG BEACH
001 ENT$ RR 0007283837 003 10/01/2024 $ 900.00 ENTERPRISE RAC 001 BSM2 COLL 0033636055 004 10/08/2024 $ 197.50 CLASS AUTO REPAIR SUPP 2146594 CENTER
CLAIM I4V6594
001 SFIS COLL 0001185335 006 10/28/2024 6,062.18 ANDREA GARCIA- STOPPED CHECKS
SCHMIDT
PAYMENT
Indemnity Net Paid Amount:
$9,313.00
claimportalch.prodib.travp.net/claimportalcommon2/SubTabContainer.aspx?StartPage=https://claimplatformch2.prodlb.travp.net/tortfeasor2/tfsform.asp... 1/1
TRAVELERS - TRAVELERS COMMERCIAL INSURANCE COMPANY
N. California-NV Claim Center (PI-260)
Request Supplements at https://supplements.travelers.com PO Box 650293
Dallas, TX 75265 Claim #: 14V6594001
Phone: (800) 727-3995 Vorkfile ID: 614f954a
Supplement of Record 3 Summary
Written By: JAVIER ROMO, 10/18/2024 7:40:13 AM
Adjuster: CORDNER, CYNTHIA, (702) 479-4306 Business
Insured: ANDREA Owner Policy #: Claim #: I4V6594001
GARCIA-SCHMIDT
Type of Loss: Collision Date of Loss: 06/26/2024 12:00 AM Days to Repair: 5 Point of Impact: 11 Left Front Deductible: 1000.00
Owner (Insured): Inspection Location: Appraiser Information: Repair Facility:
ANDREA GARCIA-SCHMIDT CLASS AUTO CENTER [email protected] CLASS AUTO CENTER CLASS AUTO CENTER (626) 221-8523 3031 CHERRY AVENUE
LONG BEACH, CA 90807 LONG BEACH, CA 90807
Virtual (562) 595-6400 Business
(562) 595-6400 Business (562) 427-3575 Fax
953745833 Federal ID
VEHICLE
2018 BENZ GLA-Class 4MATIC 4D UTV 4-2.0L Turbocharged Flex Fuel Gasoline Direct Injection WHITE VIN: Production Date: 06/2017 Interior Color:
License: Odometer: 101167 Exterior Color: WHITE
State: Condition: Good
TRANSMISSION Console/Storage RADIO Hands Free Device
Automatic Transmission Overhead Console AM Radia SEATS
4 Wheel Drive CONVENIENCE FM Radio Bucket Seats
POWER Air Conditioning Stereo Leather Seats
Power Steering Intermittent Wipers Search/Seek WHEELS
Power Brakes Tilt Wheel CD Player Aluminum/Alloy Wheels Power Windows Cruise Control Auxiliary Audio Connection PAINT Power Locks Rear Defogger SAFETY Clear Coat Paint
Power Mirrors Keyless Entry Drivers Side Air Bag OTHER
Heated Mirrors Alarm Passenger Air Bag Fog Lamps
Power Driver Seat Message Center Anti-Lock Brakes (4) Rear Spoiler Power Passenger Seat Steering Wheel Touch Controls 4 Wheel Disc Brakes Signal Integrated Mirrors Memory Package Telescopic Wheel Traction Control TRUCK
DECOR Climate Control Stability Control Power Trunk/Liftgate Dual Mirrors Backup Camera Front Side Impact Air Bags
Privacy Glass Remote Starter Head/Curtain Air Bags
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Claim #: I4V6594001
Workfile ID: 614f954a
Supplement of Record 3 Summary
2018 BENZ GLA-Class GLA250 4MATIC 4D UTV 4-2.0L Turbocharged Flex Fuel Gasoline Direct Injection WHITE Line Oper Description Part Number Qty Extended Labor Paint Price $
1 FRONT BUMPER & GRILLE
2 O/H bumper assy 3.8
3 ** Repl A/M CAPA Bumper cover w/o P29778 1 700.63 Incl. 3.3 surround view w/o park asst
4 Add for Clear Coat 1.3
5 Add for fog lamps 0.6
6 R&I License bracket 1568857500 0.2
R&I R&I upper grille as an assy 1568806400 Incl.
8 S03 Repl RT Fog lamp bezel 15688560002A17 1 436.00 Incl. 9 * Repl LKQ Center cover w/o night pkg 3K8XZK 1 593.75 silver +25%
10 Repl LT Mount plate 156885970164 1 16.00
NOTE: mounting bracket from fender to bumper
S01 Repl Bumper cover rivet 1249900492 10 29.00
12 * S03 Repl LT Fog lamp bezel 15688559002A17 1 432.00 Incl. 13 S01 Repl Emblem 0008171306 1 55.00 0.1
14 S01 Repl Lower support 1568853600 1 314.00 Incl.
15 ** S01 Repl A/M Lower grille w/o park asst MB1036174 1 100.00 Inc. 16 * S01 Repl LKQ Impact bar +25% MDRTCK 1 346.25 0.7
** S01 Repl A/M LT Side trim P28504 1 104.32 0.1
18 S01 Repl Emblem grommet 2019972281 1 3.70
19 FRONT LAMPS
20 ** S02 Repl A/M CAPA LT Fog lamp assy P12928 1 64.28 Incl.
NOTE: PAC VENDOR.- REF #8540213--PER GC AVAILABLE AND DELIVERS TO LONG BEACH 21 ** S01 Repl A/M LT Fog lamp assy bracket MB2602100 1 31.00 22 R&I RT Fog lamp assy 2518200856 Incl.
23 ** S02 Repl A/M CAPA LT Headlamp assy P10902 1 470.40 0.7 NOTE: PAC VENDOR-- REF #8540213--PER GC AVAILABLE AND DELIVERS TO LONG BEACH 24 S01 R&I RT R&I headlamp assy 1569063000 0.6
25 S01 Repl Aim headlamps 1 0.5
26 HOOD
27 * S01 BInd Hood (STL) 156880005764 1.4
28 FENDER
29 ** Repl A/M RT Wheel opng midg MB1291100 1 124.00 0.3 NOTE: PARTS: Part cannot be reused/reinstalled.
30 Repl LT Fender liner GLA250 1566907300 1 175.00 0.5
31 ** Repl A/M LT Wheel opng mldg MB1290100 1 119.46 0.3 NOTE: PARTS: Part cannot be reused/reinstalled.
32 Repl LT Front seal 1568890195 1 6.00
33 * Rpr LT Fender 1568800118 2.0 1.8
NOTE: dented and pulled down at the edge by bumper with fender 34 Add for Clear Coat 0.7
10/18/20247:40:14 AM 124511 | 1.9.05.12010 Page 2
Claim #: I4V6594001
Workfile ID: 614f954a
Supplement of Record 3 Summary
2018 BENZ GLA-Class GLA250 4MATIC 4D UTV 4-2.0L Turbocharged Flex Fuel Gasoline Direct Injection WHITE 35 Repl LT Bracket 1566280114 1 7.00
36 ELECTRICAL
37 S01 Repl LT Horn GLA250 0005406303 1 87.00 0.2
38 ** S01 ReplA/M Mount and Balance 1 20.00
39 WHEELS
40 * S03 Repl LKQ LT/Front Wheel, alloy 18" WHE017 1 175.00 m 0.3 wheel code: R31
41 # S03 Subl Balance Wheel/Tire +25% 1 18.75 X
42 WINDSHIELD
43 * S01 Repl LKQ Reservoir assy GLA250 N9ZRCT 1 75.00 0.6 +25%
44 ROOF
45 S01 R&I LT Roof molding w/o roof rails 1566901900 0.8 46 MISCELLANEOUS OPERATIONS
47 * Repl Cover car/bag 1 5.00 0.2
48 ** Repl A/M Restore Corrosion Protection 1 10.00 T 0.2 49 # S01 Refn Color Tint 0.5
50 # S01 Rpr Sand and Polish 1.0
NOTE: 3 per panel
51 ** S01 Repl A/M Flex Additive 1 8.00 Incl.
52 ** S01 Repl A/M Mask Jambs 5.00 0.5
53 ** S01 Repl A/M Clean and Retape Molding 1 5.00 0.5
54 # S03 Subl TEST & CLEAR CODES 347.86 X
55 # S03 Subl CALIBRATE LANE ASSIST 1 347.86 X
56 # S03 Subl Four Wheel Alignment 1 695.71 X
57 # S03 Subl CALIBRATE LEFT HEADLIGHT 1 347.86 X
58 # S03 Subl CALIBRATE COLLISION 1 347.86 X
PREVENTION ASSIST
59 OTHER CHARGES
60 # E.P.C. 1 3.00
SUBTOTALS 6,626.69 14.7 9.0
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Claim #: 14V6594001
Workfile ID: 614f954a
Supplement of Record 3 Summary
2018 BENZ GLA-Class GLA250 4MATIC 4D UTV 4-2.0L Turbocharged Flex Fuel Gasoline Direct Injection WHITE
ESTIMATE TOTALS
Category Basis Rate Cost $
Parts 4,507.79
Body Labor 14.7 hrs $ 75.00 /hr 1,102.50
Paint Labor 9.0 hrs $ 75.00/hr 675.00
Paint Supplies 9.0 hrs @ $ 55.00/hr 495.00
Miscellaneous 2,115.90
Other Charges 3.00
Subtotal 8,899.19
Sales Tax $ 5,012.79 @ 10.2500 % 513.81
Total Cost of Repairs 9,413.00
Deductible 1,000.00
Total Adjustments 1,000.00
Net Cost of Repairs 8,413.00
10/18/2024 7:40:14 AM 124511 | 1.9.05.12010 Page 4
Claim #: I4V6594001
Workfile ID: 614(954a
Supplement of Record 3 Summary
2018 BENZ GLA-Class GLA250 4MATIC 4D UTV 4-2.0L Turbocharged Flex Fuel Gasoline Direct Injection WHITE
SUPPLEMENT SUMMARY
Line Oper Description Part Number Qty Extended Labor Paint Price $
Changed Items
8 S01 Repl RT Fog lamp bezel 15688560002A17 1 -139.00 Inc. 8 * S03 Repl RT Fog lamp bezel 15688560002A17 1 436.00 Incl. 12 S01 Repl LT Fog lamp bezel 15688559002A17 1 -124.00 Incl. 12 S03 Repl LT Fog lamp bezel 15688559002A17 1 432.00 Incl. :
40 S01 Repl LKQ LT/Front Wheel, alloy 18" WHE017 1 -171.25 m -0.3 wheel code: R31 +25%
40 * S03 Repl LKQ LT/Front Wheel, alloy 18" WHE017 1 175.00 m 0.3 wheel code: R31
Added Items
41 # S03 Subl Balance Wheel/Tire +25% 18.75 X
54 # S03 Subl TEST & CLEAR CODES 347.86 X
55 # S03 Subl CALIBRATE LANE ASSIST 1 347.86 X
56 # S03 Subl Four Wheel Alignment 1 695.71 X
57 # S03 Subl CALIBRATE LEFT HEADLIGHT 347.86 X
58 # S03 Subl CALIBRATE COLLISION 347.86 X
PREVENTION ASSIST
SUBTOTALS 2,714.65 0.0 0.0
TOTALS SUMMARY
Category Basis Rate Cost $
Parts 608.75
Miscellaneous 2,105.90
Subtotal 2,714.65
Sales Tax $ 608.75 @ 10.2500% 62.40
Total Supplement Amount 2,777.05
NET COST OF SUPPLEMENT 2,777.05
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Claim #: I4V6594001
Workfile ID: 614f954a
Supplement of Record 3 Summary
2018 BENZ GLA-Class GLA250 4MATIC 4D UTV 4-2.0L Turbocharged Flex Fuel Gasoline Direct Injection WHITE
CUMULATIVE EFFECTS OF SUPPLEMENTS)
Estimate 3,153.32 FLAVIA VERISSIMO
Supplement S01 3,285.13 FLAVIA VERISSIMO
Supplement S02 197.50 JAVIER ROMO
Supplement 503 2,777.05 JAVIER ROMO
Workfile Total: $ 9,413.00
TOTAL ADJUSTMENTS: $ 1,000.00
NET COST OF REPAIRS: $ 8,413.00
All supplements must be pre-approved by Travelers.
Supplement repair charges may be subject to rejection unless approved by Travelers prior to repairs.
This instrument is a damage estimate only and not an acceptance of liability or authorization to repair.
Repair must be pre-authorized by the vehicle owner.
Vehicle owner maintains the right to repair vehicle at a repair facility of their choice.
Please present this estimate to the repair facility prior to repairs.
Necessary Information for Photograph and Video Estimates (READ CAREFULLY):
This estimate may have been completed based wholly or in part using photographs and/or video. Because of the use of photographs and video, this estimate may not be complete, as there could be hidden damage. You should provide this estimate to the shop of your choice prior to commencement of work. If your shop finds additional damages or undiscovered damages, Travelers will work with your repairer to assess the appropriate scope of work. Your shop is instructed in this estimate to contact Travelers through its supplement process and the damages they discover must be reviewed and approved prior to repairing the vehicle In the event that you are not repairing your vehicle and believe that our estimate does not account for all of your damages, please contact your Claim professional to discuss and address your concerns and options.
10/18/2024 7:40:14 AM 124511 | 1.9.05.12010 Page 6
Claim #: I4V6594001
Workfile ID: 614f954a
Supplement of Record 3 Summary
2018 BENZ GLA-Class GLA250 4MATIC 4D UTV 4-2.0L Turbocharged Flex Fuel Gasoline Direct Injection WHITE
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.
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.
10/18/2024 7:40:14 AM 124511 | 1.9.05.12010 Page 7
Claim #: I4V6594001
Workfile ID: 614f954a
Supplement of Record 3 Summary
2018 BENZ GLA-Class GLA250 4MATIC 4D UTV 4-2.0L Turbocharged Flex Fuel Gasoline Direct Injection WHITE 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 ERI5732, CCC Data Date 10/09/2024, 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 Services 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. 10/18/2024 7:40:14 AM 124511 | 1.9.05.12010 Page 8
Claim #: 14V6594001
Workfile ID: 614f954a
Supplement of Record 3 Summary
2018 BENZ GLA-Class GLA250 4MATIC 4D UTV 4-2.0L Turbocharged Flex Fuel Gasoline Direct Injection WHITE Travelers warrants that any non-original equipment manufacturer replacement crash parts shown on this estimate are at least equal to the original equipment manufacturer parts in terms of kind, quality, safety, fit, and performance.
Traveler's warrants these parts for the same conditions and period of time that the manufacturer would have warranted the original equipment crash parts.
Nothing in this warranty shall prohibit Travelers from seeking reimbursement or indemnification from a third party for the costs associated with Traveler's obligation to warrant, modify, return, remove or replace a non-original equipment manufacturer crash part.
--
Travelers warrants that any non-original equipment manufacturer replacement crash parts shown on this estimate are at least equal to the original equipment manufacturer parts in terms of kind, quality, safety, fit, and performance.
Traveler's warrants these parts for the same conditions and period of time that the manufacturer would have Nothing in this warranty shall prohibit Travelers from seeking reimbursement or indemnification from a third party for the costs associated with Traveler's obligation to warrant, modify, return, remove or replace a non-original equipment manufacturer crash part.
AUTO BODY REPAIR CONSUMER BILL OF RIGHTS
A CONSUMER IS ENTITLED TO:
1. SELECT THE AUTO BODY REPAIR SHOP TO REPAIR AUTO BODY DAMAGE COVERED BY THE INSURANCE COMPANY. AN INSURANCE COMPANY SHALL NOT REQUIRE THE REPAIRS TO BE DONE AT A SPECIFIC AUTO BODY REPAIR SHOP.
2. AN ITEMIZED WRITTEN ESTIMATE FOR AUTO BODY REPAIRS AND, UPON COMPLETION OF REPAIRS, A DETAILED INVOICE. THE ESTIMATE AND THE INVOICE MUST INCLUDE AN ITEMIZED LIST OF PARTS AND LABOR ALONG WITH THE TOTAL PRICE FOR THE WORK PERFORMED. THE ESTIMATE AND INVOICE MUST ALSO IDENTIFY ALL PARTS AS NEW, USED, AFTERMARKET, RECONDITIONED, OR REBUILT.
3. BE INFORMED ABOUT COVERAGE FOR TOWING AND STORAGE SERVICES.
4. BE INFORMED ABOUT THE EXTENT OF COVERAGE, IF ANY, FOR A REPLACEMENT RENTAL VEHICLE WHILE A DAMAGED VEHICLE IS BEING REPAIRED.
5. BE INFORMED OF WHERE TO REPORT SUSPECTED FRAUD OR OTHER COMPLAINTS AND CONCERNS ABOUT AUTO BODY REPAIRS.
6. SEEK AND OBTAIN AN INDEPENDENT REPAIR ESTIMATE DIRECTLY FROM A REGISTERED AUTO BODY REPAIR
SHOP FOR REPAIR OF A DAMAGED VEHICLE, EVEN WHEN PURSUING AN INSURANCE CLAIM FOR REPAIR OF THE VEHICLE.
COMPLAINTS WITHIN THE JURISDICTION OF THE BUREAU OF AUTOMOTIVE REPAIR Complaints concerning the repair of a vehicle by an auto body repair shop should be directed to:
Toll Free (866) 799-3811
Bureau of Automotive Repair 10949
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Claim #: I4V6594001
Workfile ID: 614f954a
Supplement of Record 3 Summary
2018 BENZ GLA-Class GLA250 4MATIC 4D UTV 4-2.0L Turbocharged Flex Fuel Gasoline Direct Injection WHITE North Mather Blvd.
Rancho Cordova, CA 95670
The Bureau of Automotive Repair can also accept complaints over its web site at: www.autorepair.ca.gov
COMPLAINTS WITHIN THE JURISDICTION OF THE CALIFORNIA INSURANCE COMMISSIONER Any concerns regarding how an auto insurance claim is being handled should be submitted to the California Department of Insurance at:
(800) 927-4357 or (213) 897-8921
California Department of Insurance
Consumer Services Division
300 South Spring Street
Los Angeles, CA 90013
The California Department of Insurance can also accept complaints over its web site at: www.insurance.ca.gov Insurance Code 11580.11 Coverage for replacement of child passenger restraint system; insurer obligation; surrender of replaced system
11580.011.
(a) As used in this section, "child passenger restraint system" means a system as described in Section 27360 of the Vehicle Code.
(b) Every policy of automobile liability insurance, as described in Section 16054 of the Vehicle Code, shall provide liability coverage for replacement of a child passenger restraint system that was damaged or was in use by a child during an accident for which liability coverage under the policy is applicable due to the liability of an insured. (c) Every policy of automobile liability insurance that provides uninsured motorist property damage coverage, as described in paragraph (2) of subdivision (a) of Section 11580.26, shall provide coverage for replacement of a child passenger restraint system that was damaged or was in use by a child during an accident for which uninsured motorist property damage coverage under the policy is applicable due to the liability of an uninsured motorist. (d) Every policy that provides automobile collision coverage, as described in Section 660, or every policy that provides automobile physical damage coverage, as described in Section 660, shall include a child passenger restraint system within the definition of covered property, if the child passenger restraint system was in use by a child during an accident or, if the child passenger restraint system was in the vehicle and it sustained a loss covered by the policy. (e) Upon the filing of a claim pursuant to a policy described in subdivision (b), (C), or (d), unless otherwise determined, an insurer shall have an obligation to ask whether a child passenger restraint system was in use by a child during an accident or was in the vehicle at the time of a loss that is covered by the policy, and an obligation to replace the child passenger restraint system or reimburse the claimant for the cost of purchasing a new passenger restraint system in accordance with this section if it was in use by a child during the accident or if it sustained a covered loss while in the vehicle.
10/18/2024 7:40:14 AM 124511 | 1.9.05.12010 Page 10
Claim #: I4V6594001
Workfile ID: 614f954a
Supplement of Record 3 Summary
2018 BENZ GLA-Class GLA250 4MATIC 4D UTV 4-2.0L Turbocharged Flex Fuel Gasoline Direct Injection WHITE (f) An insured, upon acquiring a replacement child passenger restraint system, may surrender the child passenger restraint system that was replaced to the nearest office of the Department of the California Highway Patrol. 10/18/2024 7:40:14 AM 124511 | 1.9.05.12010 Page 11
Claim #: I4V6594001
Workfile ID: 614f954a
Supplement of Record 3 Summary
2018 BENZ GLA-Class GLA250 4MATIC 4D UTV 4-2.0L Turbocharged Flex Fuel Gasoline Direct Injection WHITE
ALTERNATE PARTS SUPPLIERS
Line Supplier Description Price
3 Pacific Auto Company Paramount #P29778 $ 700.63
Jimmy Wong A/M CAPA Bumper cover w/o surround view w/o park asst 7901 SOMERSET BOULEVARD # A
PARAMOUNT CA 90723
(888) 888-8686
Cherry Auto Parts #3K8XZK $ 475.00
Sales Representative LKQ Center cover w/o night pkg silver +25% 11911 Sheldon St BUMPER COVER FR-INSURANCE QUALITY COVER,S#2558 - 156 TYPE, GLA250, W/O SPORT PACKAGE; W
Sun Valley CA 91352
(818) 767-0047
15 KEYSTONE-LOS ANGELES, CA #MB1036174 $ 100.00
13642 ORDEN DRIVE A/M Lower grille w/o park asst
SANTA FE SPRINGS CA 90670 Quote: 2642369502
(562) 944-6422 Expires: 10/17/24
16 K&& P Auto Dismantlers #MDRTCK $277.00
Sales Number LKQ Impact bar +25%
15295 Whittram BUMPER REINF FRONT-FRT REBAR,S#R9.23 - 156 TYPE, GLA250 Fontana CA 92335
(909) 428-6898
17 Pacific Auto Company Paramount #P28504 $ 104.32
Jimmy Wong A/M LT Side trim
7901 SOMERSET BOULEVARD # A
PARAMOUNT CA 90723
(888) 888-8686
20 Pacific Auto Company Paramount #P12928 $ 64.28
Jimmy Wong A/M CAPA LT Fog lamp assy
7901 SOMERSET BOULEVARD # A
PARAMOUNT CA 90723
(888) 888-8686
21 KEYSTONE-LOS ANGELES, CA #MB2602100 $ 31.00
13642 ORDEN DRIVE A/M LT Fog lamp assy bracket
SANTA FE SPRINGS CA 90670 Quote: 2642369502
(562) 944-6422 Expires: 10/17/24
23 Pacific Auto Company Paramount #P10902 $ 470.40
Jimmy Wong A/M CAPA LT Headlamp assy
10/18/2024 7:40:14 AM 124511 | 1.9.05.12010 Page 12
Claim #: I4V6594001
Workfile ID: 614f954a
Supplement of Record 3 Summary
2018 BENZ GLA-Class GLA250 4MATIC 4D UTV 4-2.0L Turbocharged Flex Fuel Gasoline Direct Injection WHITE 7901 SOMERSET BOULEVARD # A
PARAMOUNT CA 90723
(888) 888-8686
29 Perfect Fit West #MB1291100 $ 124.00
3383 Olive Ave A/M RT Wheel opng midg
Signal Hill CA 90755 Quote: 2714655049
(310) 956-4667 Expires: 08/25/24
31 Go-Parts (FedEx) #MB1290100 $ 119.46
6485 SHILOH RD B #400 A/M LT Wheel opng midg
ALPHARETTA GA 30005 Quote: 3334-33604067-1696
(770) 965-6400 Expires: 08/25/24
40 Bells Auto Parts- Fenix Parts #WHE017 $ 137.00
8777 San Fernando Rd LKQ LT/Front Wheel, alloy 18" wheel code: R31 Sun Valley CA 91352 000 RR 4DR SUV - 156 Type, GLA250, 18x7, 10 spoke (818) 983-1135 Quote: CCC-250195437
Expires: 09/12/24
43 Benzeen Auto Parts Prp #N9ZRCT $ 60.00
Sales Number LKQ Reservoir assy GLA250 +25%
3811 Recycle Road WASH RESERVOIR ASSY-WASH RESERVOIR ASSY,S#41093G - 156 TYPE
Rancho Cordova CA 95742
(916) 273-9395
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10/16/24, 3:12 PM ARMS® - Automated Rental Management System Rental Company: ENTERPRISE RENT-A-CAR
ARMS Travelers Invoice: D5GMDG3-32DA
Alternate Invoice Number: 5GMDG3
Bill To: TRA3001 RENTAL DETAIL:
TRAVELERS
ATTN: CYNTHIA CORDNER Rental Period: 8/21/24 to 9/27/24 (38 days) Billed Period: 8/21/24 to 9/19/24 (30 days)
PO BOX 15439
SACRAMENTO, CA 958510439
Quantity Rate Amount
RENTER INFORMATION:
Renter: GARCIA, ARMANDO Products and Services
TIME & DISTANCE 10 35.00 $350.00
RENTAL INFORMATION: TIME & DISTANCE 28 35.00 $980.00
Rental Branch Location:
ENTERPRISE RENT-A-CAR (32DA) Taxes and Surcharges
2750 CHERRY AVE VEHICLE LICENSE
SIGNAL HILL, CA 907552011 RECOVERY FEE 28 2.29 $64.12
(562) 427-5522
VEHICLE LICENSE 1.50 $16.50
RECOVERY FEE
ADDITIONAL CLAIM INFORMATION:
Claim Number :I4V6594-001 SALES TAX 1 10.25% $136.32
Claim Type: Insured Total Charges: $1,546.94
Vehicle Condition: Driveable
Date Of Loss: 6/26/24 Less Amount Received: $646.94
Insured Name: ARMANDO GARCIA, Total Amount Due: $900.00
EUGENIA SH
Owner's Vehicle: 2018 MERCEDES-BENZ
Additional Driver:
Repair Facility:
CLASS AUTO
LONG BEACH, CA 908075209
(562) 595-6400
VEHICLES RENTED:
Effective Date Starting Ending Rate
Year Make Model VIN Mileage Charged
and Time Mileage Mileage
8/21/24 1:07 PM | 2023 JEEP RENE 16023 16105 |$35.00
8/31/24 12:00 AM 2023 DODG DURA 28676 31274 2598 $35.00 Rental Invoice
Please Return This Portion with Remittance
Make Payment To: Total Charges: $1,546.94
ENTERPRISE RENT-A-CAR (V3BD) Less Amount Received: $646.94 PO BOX 840086 Total Amount Due...... $900.00
KANSAS CITY, MO 64184-0086 Please include on your check:
Federal ID:43-0724835 Invoice: D5GMDG3-32DA
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