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) VERNON
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. 2026 AUG 18 All: 04 4 See page 2 for diagram upon which to locate place of accident This claim form must be signed on page 2 at bottom.
6. Attach separate sheets, if necessary, to give full details. SIGN EACH SHEET. Y CLERK DEPARTMENT
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)
Jaime Gutierrer
Home Address of Claimant City and State Home Telephone Number Business Address of Claimant City and State Bysiness Telephone Numbe 1785 Pomona RD. Suit B Corona CA. (951) 565-6110
Give address to which you desire notices or communications to be sent regarding this claim:
1785 Pomona RD. SteB Corona CA. 92878
How did DAMAGE or INJURY occur? Give full particulars.
Vehicle was Parked @ 405E. Slauson Ave Maywood CA.
When did DAMAGE or INJURY occur? Give full particulars, date, time of day, etc: July 6th 2026 10:25 am. city of maywood CA. as Truck was Porked
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:
Drivers side door Front Fender - mirror rear view
please set. Attached Report.
What particular ACT or OMISSION do you claim causedthe injury ordamage? Give names of City employees, if any, causing the injury or damage, if known:
please See Attached Report
What DAMAGE or INJURIES do you claim resulted? Give full extent of injuries or damages claimed:
No injuries) Damage-See report
What AMOUNT do you claim of each item of injury ordamage as of date of presentation of this claim, giving basis of computation:
please see attached estimate From Shop
Give ESTIMATED AMOUNT as far as known you claim on account of each item of prospective injury or damage, giving basis of computation:
$ 3,810.07
Were you insured at the time of the incident? If so, provide name of insurance company, policy numbers and amount of insurance payments received:
ye
Expenditures made on account of accident or Injury: (Date - Item (Amount) Name and address of Witnesses, Doctors and Hospitals:
Jaime Gutierrez
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 corners.
NOTE:If diagrams do not fit the situation, attach hereto a proper diagram signed by claimant.
FOR AUTOMOBILE ACCIDENTS
7111,
FOR OTHER ACCIDENTS
SIDEWALK
CURB/
CURBy
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 or his/her behalf, giving Date:
relationship to Claimant:
Jaime Gutierrez 7-23-26
NOTE: ALL CLAIMANTS MAY BE REQUESTED TO BE EXAM NED 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) M.. AILA
Pomona Body & Paint Estimate ID
10946 Kadota Ave, Pomona, CA 91766-3943 29178389
Original
Office: (909) 865-7933
Fax: (909) 868-9093
[email protected]
pomonabodypaint.com
EPA: CAL000453737 License: ARD00297118 Tax ID: 843732155 Owner Appraiser
UNITED PACIFIC Alvino Guzman
(559) 361-5355 (Mobile) [email protected]
[email protected]
Classification
None
Loss Type Deductible Inspection Site Inspection Date
Unknown Unknown Pomona Body And Paint 7/31/2026
10946 Kadota Ave
Pomona, CA 91766
(909) 865-7933 (Work)
2022 Ram 1500 Big Horn 4 Door Crew Cab 145" WB 6 Foot Bed 3.OL 6 Cyl Diesel Injected Turbocharged Base 4WD Exterior Color Interior Color Trim Color License
W12 (White) BLACK CHROME
VIN Condition Drivable Odometer
Good Unknown 123456
Production Date Mitchell Service Code
11/2021 912073
Primary Point of Impact Secondary Points) of Impact
Right Front Corner (1) Right Front Side (2)
Options
4 Wheel Drive 4WD or AWD Air Conditioning Alum/Alloy Wheels AM-FM Stereo Anti-Lock Brake Sys. (ABS) Automatic Headlights Auxiliary Input Bluetooth Wireless Cloth Seat Connectivity
Cruise Control Daytime Running Lights Driver-Front Air Bag Electronic Stability Control First Row Split Bench Seat Fog Lights 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 Privacy Glass Rear Bench Seat Rearview Camera Second Row Side Airbag With Head Protection
Side Airbags Smart Key System Steering Wheel Mounted Telematic Systems Tilt Steering Wheel Audio Control
Tire Pressure Monitoring Traction Control/Electronic Trailer Hitch Trip Computer System
UNITED PACIFIC | 2022 Ram 1500 Big Horn
Parts Profile Parts Profile Version
N/A N/A
Committed On Version Profile Page 1 of 3
Mitchell Cloud Estimating™
Mitchell Estimating 26.2 8/14/2026 System profile
Copyright 1994-2026 Mitchell International, Inc. 02:17 PM Profile Version All Rights Reserved 6.0
LABOR - PART
Line # Description Operation Type Total Units CEG Type Number Qty Total Price Cooling
1 203637 L Cooling Side Rail Remove Body 4.5# 4.5 New 68504697AF 1$362.00 Yes (Steel/HSS/UHSS) / Replace
2 AUTO L Side Rail Refinish Refinish 1.0 C 1.0
Only
Front Fender
201377| L Fender Panel (HSS) Remove Body 0.9# 0.9 New 68632533AA 1 $560.00 Yes / Replace
4 AUTO Frt Bumper Assy Remove Body 1.2# 1.2
/ Install (
5 AUTO L Front Combination Remove Body 0.3# 0.3
Lamp / Install
6 AUTO L Fender Outside Refinish Refinish 2.0C 2.0
Only
7 AUTO L Add To Edge Fender Refinish Refinish 0.5 C 0.5 Only
Front Door
8 204756 L Frt Door Rear View Remove Body 0.9# 0.9 New 68446973AA 1 $1,100.00 Yes Mirror / Replace
9 AUTO L Frt Door Trim Panel Remove Body 0.4 0.4
/ Install
Additional Costs & Materials
10 AUTO Paint/Materials Additional $338.00 Yes
Cost
11 AUTO Hazardous Waste Additional $15.00* Yes
Disposal Cost
Additional Operations
12 AUTO Clear Coat Additional Refinish 1.2 0.0 $0.00
Operation
13 933018 Mask For Overspray Additional Refinish 0.5* 0.0 $0.00 Operation
14 933003 Tint Color Additional Refinish 0.5 0.0 $0.00
Operation
* 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 Estimate Totals
Labor Units Rate Sublet Add'l Amount Totals
Body Labor 8.2 $90.00 $738.00
Refinish Labor 5.7 $90.00 $513.00
Total Labor 13.9 $1,251.00
Taxable $0.00
Tax 0.0000% $0.00
Non-Taxable $1,251.00
Pre-Tax Discount 0.00% $0.00
Labor Total $1,251.00
Parts Amount
Taxable Parts $2,022.00 $2,022.00
Committed On Version Mitchell Cloud Estimating Printed On Profile Page 2 of 3 Mitchell Estimating 26.2 8/14/2026 System profile
Copyright 1994-2026 Mitchell International, Inc. 02:17 PM Profile Version All Rights Reserved 6.0
Estimate Totals
Parts Adjustments $0.00
Tax 7.7500% $156.71
Non-Taxable $0.00
Pre-Tax Discount 0.00% $0.00
Parts Total $2,178.71
Costs Amount
Paint Materials $338.00 $338.00
Shop Materials $0.00 $0.00
Other Additional $15.00 $15.00
Costs
Paint Materials: Taxable $353.00
- Refinish Units: 5.2 units Tax 7.7500% $27.36
- Rate: $65.00 Non-Taxable $0.00
- Rate Max: 99.9 units Pre-Tax Discount 0.00% $0.00
- Additional Rate: $0.00 Costs Total $380.36
Gross Totals Amount
Gross Total $3,810.07 $3,810.07
Taxable $2,375.00
Tax $184.07
Non-Taxable $1,251.00
Pre-Tax Discount 0.00% $0.00
Gross Total $3,810.07
Adjustments Amount
Total Customer $0.00
Responsibility
Net Estimate Total $3,810.07
Estimate Event Log
Job Created 8/14/2026 01:18 PM
Estimate Started 8/14/2026 01:27 PM
Estimate Printed 8/14/2026 02:17 PM
Estimate Committed Estimate Not Committed
Estimate Retrieval ID 1011384203
Committed On Version Mitchell Cloud Estimating™ Printed On Profile Page 3 of 3 Mitchell Estimating 26.2 8/14/2026 System profile
Copyright 1994-2026 Mitchell International, Inc. Profile Version OEM AUG_26_V All Rights Reserved 02:17 PM
6.0 MARIO'S
TREE SERVICE
Motor Vehicle Report
The use of this form is intended to meet the documentation requirements for reporting incidents that resulted in a Motor Vehicle & Equipment Incident while performing work with Mario's Tree Service.
General Information
Co. Driver's Last Name Gutierrez Driver's First Name Jaime Driver License # & State Class Exp. Date C / 6.17.2028
3rd Party Driver's Last Name Clarke Driver's First Name Tony Lewis II Driver License # & State Class Exp. Date C / 8.9.2029
Full Mailing Address Phone No. N/A
Name of Insurance Co. N/A Policy No. N/A
Co. Vehicle Make/ Model 2019 Dodge Ram Pick Up License Plate No. & State 3rd Party Vehicle Make/Model 2023 Ram LY License Plate No. & State Was a Police Report filed for the collision? Yes • No
If yes, was a citation issued to: MTS Driver or • Third Party Driver Was there an Injury • NO • YES - Please provide the following personnel information Name of Injury Person: N/A Employee No. N/A
Immediate Supervisor Name and Contact: Julian Valdez / (951) 5656119 If this incident involved an injury, you would need to complete the Injury/ Illness report.
Site Observations
Weather Conditions Clear sunny skies
Other Observations N/A
Site Condition N/A
Was there property Damage O NO • YES
Type of Damage:
Visible damages: Driver side mirror, driver side front fender.
Internal: Unknown.
Third Party Vehicle: Unknown.
Description of Damage:
Pictures
MARIO'S
TREE SERVICE
Written Statement
name Side Swipe Accident Date/Time 7/6/26 - 10:200m
Location of incident: 1057 East Slauson Ave Maywend
same of Person Winting Satement Jaime Gutierrez he Ganeral Foreman C victim of incident • Witness of inciden Tivolved in inciden e the time of the incident, were you_? (Check a bow)
O injured, I Tired, I Capable of doing the work, Under stress, D Trained to do th work, • Understood the worl plan, LIN/A.
TATEMENT OF INCIDENT. (Please provide details. What was the worle pla a was doing what? What wes the rather Ike? Where others Involved?) What did you ser
7-6-202c a 10:20 am I was Porked at
hit mç. I exchanged infrantin with Driver 3 reported
to my supervisor.
-gal one 7-6-26
OIN XPRESS LOU
SERVICE US
CSL8A 9229
1-2409
SPEED
LIMIT
35 NO PARKING
2AM = 6AM
VERNON
CALIFORNIA
INDUSTRY I COMMUNITY | IRNOVATION
TONY CLARKE
Code Enforcement Officer
O: 323.583.8811 x527
[email protected]
4305 S. Santa Fe Ave.
Vernon, CA 90058
www.cilyofvemonca.gov
Candle Wood
Apartments
35 4057 E Slauson Ave
*VALIDATED REGISTRATION CARDE
MAXE EXPIRES: 12/31/0000
TR. NODE
RAM 2022 2021 2022 To Lie
PZ- 328
31 AC D 2
TYPE VOICE CAN 05262
INTE ISSUED carxico
COMMERCTAL DE DES XECVD
11/22/22 11/22/22 8
PERM FLEED REG PR EXP DATE: 12/31/2022
MARIOS TREE SBRVC NO MISCE: 0227025 ANOURE PAID
937 VIA LATA STE 500 ACCT: 9255 $ 761.00
DONT RECVD
376L 008 CASH
COTTON
CA 92324
SOmE
CHRYSLER CABINAT 022-7025
PO/BX 961272
CALLED
ORT WORTH
76161
H05 173 33 0076100 0239 CB H05 112222 31 03851K3 025
HOW TO FILE A CLAIM WITH THE CITY OF VERNON
Pursuant to the California Government Tort Claims Act (Government Code sections 810-996.6), a claim must be filed if you are seeking money or damages from the City or one of its employees. With very limited exceptions, no lawsuit for money damages may be brought against the City or its employees unless a written claim has been properly filed with the City. Claims for death, injury to person or to personal property must be presented to the City within (6) months from the date of loss (Government Code Section 911.2). Claims related to any other loss must be presented to the City no later than one (1) year from the date of loss (Government Code Section 911.2(a)).
WARNING: This is not intended as legal advice. You should consult with an attorney to determine the time period for filing either a claim or a lawsuit.
The City of Vernon has a standard claim form that can be used for your convenience. This form must be filed in person, or by mail, directly with the Vernon City Clerk located at 4305 South Santa Fe Avenue, Vernon, CA 90058. The City will review, and where appropriate, take action on the claim. However, neither the City Attorney nor any other City official or employee can provide legal advice concerning the claim or litigation against the City.
Please complete Claim Form, sign it, attach any supporting documentation (e.g. repair estimates, invoices, proof of payments, photos of damage, etc.) and either deliver it directly to the Office of the City Clerk or return it by mail to the Office of the City Clerk at the address set forth above.