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)
Read entire claim before filing.
See page 2 for diagram upon which to locate place of accident JAN 2 9 2025 This claim form must be signed on page 2 at bottom. 11:388 Attach separate sheets, if necessary, to give full details. SIGN EACH SHEET.
Claim must be filed with City Clerk. (Gov.Code Sec. 915a) CITY CLERK DEPARTMENT TO: CITY OF VERNON CITY COUNCIL
Name of Claimant Age of Claimant (If natural person)
LANUO CORTEZ 47
Home Address of claimant City and State Home Telephone Number Business Address of Claimant Business Telephone Number
Give address to which you desire notices or communications to be sent regarding this claim:
How did DAMAGE or INJURY occur? Give full particulars
I WAS DRiViNG NOVAT ON SOTO: STREET PASSiNGS LEONIS BEVA. THERE IS CONSTRUCTION/DEMOLITON GOING ON. WHEN I PASSED BY A TRUCK THAT WAs WOrKING THEKE WHEN I BELENE IT KICKED UP A ROCK THAT STRUCK MY WINDSHIELD.
When did DAMAGE or INJURY occur? Give full particulars, date, time of day, etc.:
JANUARY 14,2025 AT 10:20 AM. I HURSDAL
Where did DAMAGE or INJURY occur? Describefully, and locate on diagram on reverse side of this sheet, where. approximate, give street names and address and measurements from landmarks:
CORNER OF LEONIS BLUD AND SOTO STREET. CONSTRUCTION/ DEROLITION 2801 LEONIS BLUD.
What particular ACT or OMISSION do you claim causedthe injury or damage? Give names of City employees, if any. causing the injury or damage, # known THAT WAs MovING Kicked lp Rock/ DeerIs CAUSiNG FRONT HINDENTIELO TO CANCE AND CHID.
hat DAMAGE or INJURIES do you claim resulted? Give full extent of injuries or damages claimed
CRACK AND CHIP TO THE FRONT ININDSHIELA OF MY
2018 TOYOTA CAMIRY.
What AMOUNT do you claim of each item of injury or damage as of date of presentation of this claim, giving basis of computation:
$2457 24
Give ESTIMATED AMOUNT as farasknownyou claim on account of each item of prospective injury or damage, giving I HAVE AN ESTIMATE OF # 2457,24 (ARCHED)
SLITHIA
DCH Toyota of Torrance #725
2955 Pacific Coast Highway Torrance, CA 90505
(310) 325-7508
www.torrancetoyota.com
REMIT PAYMENT TO: LITHIA MOTORS SUPPORT SERVICES
PO BOX 679811, Dallas Texas 75267-9811
RETURN/REFUND POLICY: ALL RETURNS MUST BE ACCOMPANIED BY THIS INVOICE AND ARE SUBJECT TO A 35% HANDLING CHARGE. RETURNED ITEMS MUST BE IN THE ORIGINAL UNOPENED BOX OR CONTAINER. PLEASE NOTE THAT THE DEALERSHBGHLLTADOTACEPF HEORRANEMAKE REFUNDS AFTER 30 DAYS. NO REFUNDS OR RETURNS ON SPECIAL Q509B PARTSIREEJBICAL PARTS.
DISCLAIMER OF WARRANTY: ALL PARTS ANB-ACCESSORs ARE SORE OUR DEALERSHIP AS IS. OUR DEALERSHIP DISCLAIMS ALL WARRANTIES, EXPRESS AND
TOTED, INCLUDING IMPTED WARRANTIES OF MERCHANTABILITY AND FITNESS FOR A PARTICULAR PURPOSE, IN CONNECTION WITH THE SALE OF PARTS AND ACCESSORIES. THE ENTIRE RISK AS TO THE QUALITY AND PERFORMANCES OF THE VEHICLE AND PARTS AND ACCESSORIES IS WITH THE CUSTOMER AND, IF APPLICABLE, THE MANUFACTURER. IF THE VEHICLE OR ANY INSTALLED PARTS OR ACCESSORIES SHOULD PROVE DEFECTIVE FOLLOWING THEIR PURCHASE, THE CUSTOMER AND POSSIBLY THE MANUFACTURER AND NOT THE DEALERSHIP ASSUME THE ENTIRE COST OF ANY NECESSARY SERVICING OR REPAIR. CUSTOMER
SHALL NOT BE ENTITLED TO RECOVER FROM THE DEALERSHIP ANY CONSEQUENTIAL DAMAGES, DAMAGES TO PROPERTY, DAMAGES FOR LOSS OF USE, LOSS OF TIME, LOSS OF PROFITS OR INCOME, OR ANY OTHER INCIDENTAL DAMAGES.
DATE ENTERED YOUR ORDER NO. DATE SHIPPED INVOICE DATE INVOICE 16 JAN 25 18 CAMRY 16 JAN 25 NUMBER 093431
**QUOTE**
S S
ACCOUNT NO. T11 H PAGE 1 OF 1
010
RCASH
ENTER ADDRESS
ENTER CITY STATE ZIP!
SHIP VIA SLSM. B/L NO. TERMS F.O.B. POINT
101402 CASH Torrance CA
PART NO. DESCRIPTION LIST NET AMOUNT
SP 56101-06B80 GLASS SUB-1032.391032.39 1,032.39
SP 75535-06010 MOULDING, 70.73 70.73 70.73
1 SP 75536-06010 MOULDING, 70.73 70.73 70.73
INSTALLATION INSTALLATI 610.65 295.00 295.00
REPROGRAM A REPROGRAM 1438.20 765.00 765.00
2018 CAMRY
VIN# 4T1BZ1HK230001
THANK YOU
**** NVORCE QUOTE - DO NOT PAY ****
TOYOTA
PARTS 2,233.85
SUBLET
FREIGHT 0.00
SALES TAX 223.39
CUSTOMER'S SIGNATURE
X TOTAL $2,457.24
NOTICE TO CONSUMER: PLEASE READ IMPORTANT INFORMATION ON REVERSE SIDE.
CONSTRUCTION TRUCK
BLUE
Were you insured at the time of the incident? If so, provide name of insurance company, policy numbers and amount of insurance payments received:
ES
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 veyle are time of ace by and he poor may time dent by -1 and location of yourself or your NOTE: If diagrams do not fit the situation, attach hereto a proper diagram signed by claimant.
FOR AUTOMOBILE ACCIDENTS
71171
FOR OTHER ACCIDENTS
N 2801 LEONIS BLUD
//x/L
SIDEWALK
CURB/
LEON/S BLUE
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 relationship to Claimant:
PEN. CODE SEC. 72). CLAIMS MUST BE FILEDWITH CITY CLERK (GOV.CODE SEC.915). 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)