1. Claim for Damages - Lorenzo Rodriguez Luna_Redacted — Vernon City Council, August 4, 2026

KEMPER Policy underwritten by
Infinity Insurance Company
Named insured: LORENZO RODRIGUEZ
Kemper LUNA
123 Town Square Place
MB 785 Claim number: 26123550037
Jersey City, NJ 07310 VERNON
Date of loss: April 23, 2026
SP 05 000030 87345 E 1 ASNGLF 2026 JUL 20 P 4: 17 Date of mailing: June 25, 2026 Vernon City Clerk
4305 S Santa Fe Ave
Vernon, CA 90058-1714 CITY CLERK DEPARTMENT
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Dear Vernon City Clerk:

Hello--please see the attached completed claim form and subro demand for our insured's vehicle damages. Please contact me once the demand packet is received to verify receipt and to advise on your coverage and liability status.

Sincerely,
Mike Denison
Claims Team
T 800-353-6737, ext.5883760
F 888-976-2123
[email protected]
California - 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.

CLAIM FOR DAMAGES RESERVE FOR FILING STAMP
TO PERSON OR PROPERTY CLAIM No.
000030 2/26

INSTRUCTIONS

1. Claims for death, injury to person or to personal property must be fled not later than six (6) months after the occurrance. (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.

4. See page 2 for diagram upon which to locate place of accident This claim form must be signed on page 2 at bottom.

LD CON Attach separate sheets, if necessary, to give full detalls. SIGN EACH SHEET Claim must be filed with City Clerk. (Gov.Code Sec. 915a) TO: CITY OF VERNON CITY COUNCIL Jesus Rodriguez, Jr. Age or Claimant (If natural person) Name of Claimant
Home Address of Clalmant Cily and State Home Telephone Number Business Address of Claimant City and State Business Telephone Number 123 Town Square Place / PMB 785 / Jersey City, NJ 07310 Give address to which you desire notices or communications to be sent regarding this dial 237x5383760 Police officer backed into our insured's parked vehicle How did DAMAGE or INJURY occur? Give full particulars.
4/23/2026 3:00 PM
When did DAMAGE or INJURY occur? Give full particulars, date, time of day, eto.:
57th Street 50 feet east of Santa Fe Avenue, Vernon, CA 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:

The officer caused the collision by unsafe backing.

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:

Damage to our insured's vehicle (see attached photos)
What DAMAGE or INJURIES do you claim resulted? Give full extent of injuries or damages claimed:
$1089.72
WhatAMOUNT do you claim of each item of injury or damage asof date of presentation of this claim, giving basis of computation:
$1089.72
Give ESTIMATED AMOUNT as farasknown you claim on account of each item of prospective injury or damage, giving basisof computation:

COPY
yes, Infinity Insurance Company policy claim 26123550037 Were you insured at the time of the incident? If so, provide name of insurance company, policy numbers and amount of insurance payments received:

N/A
Expenditures made on account of accident or Injury: (Date - Item) (Amount) N/A
Name and address of Witnesses, Doctors and Hospitals:

See attached police report

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 comers.

If City Vehicle was Involved, designate by letter "A" location of City vehicle when you first saw it, and by "B" location of yourself r your vehicle when you first saw City vehicle; location of City vehicle at time of accident by "A-1"and location of yourself or your vehicle at the time of accident by "8 1" and the point of Impact by "X." NOTE: it diagrams do not fit the situation, attach hereto a proper diagram signed by claimant.

FOR AUTOMOBILE ACCIDENTS
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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:

Mike Denison Mike Denison, subro specialist subrogree for Jesus Rodriguez, Jr. 6/25/2026 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 FLING THEN THE CLAIM IS DEEMED DENIED (SEE GOV. CODE SEC. 911.6 & 912.4) Rev. BM/18
Policy underwritten by
KEMPER Infinity Insurance Company
Named insured: LORENZO RODRIGUEZ 000030 3/26
LUNA
Kemper
123 Town Square Place Claim number: 26123550037
PMB 785
Jersey City, NJ 07310 Date of loss: April 23, 2026
Vernon City Clerk Date of mailing: June 25, 2026
4305 5 Santa Fe Ave
Vernon, CA 9005B-1714
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Dear Vernon City Clerk:

We are writing to notify you of our subrogation interest regarding the loss referenced above.

It was reported to have occurred in Vernon, CA.

Your Claim Number: UNK
Your Insured: Alexy Escobedo
Our investigation concluded that your insured is responsible for damages sustained by our insured. Under the terms of our insurance policy, we are subrogated to the right of reimbursement of our insured to the extent of our payment. As a result, we are looking to you for full reimbursement of damages.

We made a vehicle damage payment as follows:

Vehicle damages: $589.72
Deductible: $500.00
Salvage: $N/A -
Rental: $N/A
:
$
Total demand: $1089.72
Please make your check payable to Kemper Services Group as subrogee of our insured and mail your payment to:

Kemper Services Group
Attn: 26123550037
123 Town Square Place
PMB 785
COPY
Jersey City, NJ 07310
If you have already made settlement with our insured, please advise us immediately.

If you have any questions, please contact us and have the claim number available so we can assist you as quickly as possible.

Sincerely,
Mike Denison
T 800-353-6737, ext.5883760
F 888-976-2123
[email protected]
birt
03129
000030 4/26
Canter
Claim Reference Id: 2812355003701
Flle Name: Center
File Date: 04/30/2026
Label: Center
Note: