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Home My WebLink AboutClaim No. 2024-25 Incident 08-31-2024 Received 09-10-2024City of Lake Elsinore Claim for Damage or Injury Use Black or Blue Ink Type Attach Additional Pages if Necessary Mail Claim Form To: City Clerk City of Lake Elsinore 130 South Main Street Lake Elsinore, California 92530 ITY CLAIMANT, NOTIFICATION AND GENERAL INFORMATION CLAIMANT FULL NAME CLAIMANT ADDRESS (Ke qulncd) PERSON TO BE NOTIFIED OF ANY ACTION TAKEN ON CLAIM NOTIFI-CAT ION ADDRESS (IF DIFFERENT AN ABOVE) CLAIMANT DATE OF BIRTH MEDICARE BENEFICIARY PHONE NUMBER(S) Yes k No DATE OF ACCIDENT ACCIDENT TIME AMI PM SSP L-(-- A. D pjrL i11)r UC- Mq kJor& VJCAS V10 c4k C NOTICE TO CLAIMANT In order for your claim to receive proper consideration you are requested to supply the information called for on this application form. All material facts should be stated on this form, as it will be the basis of further action upon your claim. The instructions set forth should be read carefully before the form is completed. INSTRUCTIONS Claims must be signed by the property owner, injured party, or the person representing the claim. Unsigned claim forms cannot be honored. See Government Code §910.2, the amount claimed must be sustained by competent evidence before a claim can be paid. Whether attached to the claim form, or submitted subsequently, evidence supporting the amount claimed may include: a) In support of a claim for the personal injury or death, the claimant should submit documentation evidencing the injuries sustained, treatment rendered, the period of hospitalization, future treatment, the degrees of permanent disability, the prognosis, and evidence of medical bills received and paid. It is recommended that such medical evidence NOT be attached to the claim form, but that such substantiation of damages be provided upon request. The Claim Form and attachments thereto is a public record and subject to public inspection. b) In support of claims for damage to property which has been or can be economically repaired, submit at least two itemized signed repair estimates or statements of damage by reliable, disinterested persons, or if payment has been made, the itemized signed receipts evidencing payment. c) In support of claim for lost property or property that cannot be economically repaired, submit documentation of the original cost of the property, the date of purchase, and the value of the property before and after the accident. The statements demonstrating the value of the property should be disinterested competent persons, preferably reputable dealers, persons familiar with the type of property, by two or more competitive bidders, or advertisements for the same or similar property. The completed Claim Form must be mailed or delivered to the City Clerk at the address on the prior page. Questions or requests for further information should be directed to the City Cleric's Office at (951) 674-3124. INSTRUCTIONS REGARDING INSURANCE COVERAGE In order that claims may be properly adjusted by the City or your insurance company, it is essential that the claimant provide the following information regarding any insurance coverage available for the loss or injury. If: A CLAIM HAS BEEN FILED, WHAT ACTION HAS YOUR INSURER TAiSEN, OR WHAT ACTION DOES IT PURPOSE TO TAKE WITH THE REFERENCE TO YOUR CLAIM? I C 1 NSU aivf- U-7Vi To Cbvf-9, Tiw- Doww,c- to M" F IS 4 0 ISS 1 6)-J , VU YVU UAKKY YUd Lit: DAMAGE COVERAGE? IV AND 0A P_ . -V-W=ni 6n w caUFrL P I -T wc,n1 A D k . TF7 Y-Es" GIVE NAME OF INSURANCE CARRIER: 1. 6. limp, T U% = i~ Y'. ;ice •f r ' - DEV( -r2 R 1 I T U% = i~ Y'. ;ice •f r ' - DEV( -r2 r 41 Ak I Alrt- -L Aw Zt: NA 4nA-Ilk ANOI bi Insured: Type of Loss: Point of Impact: Owner: SILVER AUTO COLLISION Preliminary Estimate Written By: George Cerda Policy #: Date of Loss: Inspection Location: SILVER AUTO COLLISION VEHICLE TOYO Corolla #: CONVENIENCE Stereo Bucket Seats Air Conditioning Search/Seek WHEELS Intermittent Wipers CD Player Wheel Covers Tilt Wheel Auxiliary Audio Connection PAINT Cruise Control SAFETY Clear Coat Paint Rear Defogger Drivers Side Air Bag OTHER Keyless Entry Passenger Air Bag Traction Control Message Center Anti -Lock Brakes (4) Stability Control Steering Wheel Touch Controls Front Side Impact Air Bags California Emissions Telescopic Wheel Head/Curtain Air Bags Power Trunk/Liftgate RADIO Hands Free Device AM Radio SEATS FM Radio Cloth Seats Page 1 Preliminary Estimate TOYO Corolla Job Number: Line Oper Description Part Number Qty Extended Labor Paint Price $ 1 FRONT BUMPER 2 O/H front bumper 2.1 3 Rep! A/M CAPA Bumper cover Japan 5211912963 1 245.98 Incl. 2.6 built 4 Add for Clear Coat 1.0 5 Add for fog lamps 0.3 6 Repl A/M CAPA Absorber 5261102250 1 75.00 Incl. 7 Repl A/M CAPA Reinforcement 5202102151 1 350.00 0.3 8 Repl A/M Seal 5339502040 1 39.00 0.1 9 Repl Emblem 7530102010 1 48.10 Incl. 10 Repl A/M Bumper cover clip #1 5216102020 8 76.08 11 FRONT LAMPS 12 Repl A/M RT Lens & housing 8113012F10 1 193.33 0.5 13 Aim headlamps0.5 14 GRILLE 15 Repl A/M Grille Japan built beige 531001244000 1 194.03 Incl. 1.0 16 Add for Clear Coat 0.4 17 Repl A/M CAPA Lower grille 5311202280 1 100.00 Ind. 18 Repl A/M Grille clip 5216102020 4 38.04 19 RADIATOR SUPPORT 20 Refinish Components 1.5 21 Repl A/M CAPA Radiator support 5320112B70 1 483.98 s 8.7 Incl. 22 Evacuate & recharge m 1.4 23 Refrigerant recovery m 0.4 24 Add for auto trans m 0.2 25 HOOD 26 Repl A/M CAPA Hood Japan built (HSS) 5330112A80 1 332.00 1.3 2.4 27 Overlap Major Non-Adj. Panel 0.2 28 Add for Clear Coat 0.4 29 Add for Underside(Complete) 1.4 30 Repl RT Hinge Japan built 5341012550 1 40.31 0.3 0.3 31 Add for Clear Coat 0.1 32 Repl A/M LT Hinge Japan built 5342012520 1 38.28 0.3 0.3 33 Add for Clear Coat 0.1 34 Repl Latch assy Japan built 5351012A61 1 67.86 Incl. 35 FENDER 36 Repl A/M CAPA RT Fender Japan built 5380112A70 1 173.00 2.0 2.0 37 Overlap Major Adj. Panel 0.4 38 Add for Clear Coat 0.3 39 Add for Edging 0.5 40 Repl RT Upper seal Japan built 5382302030 1 18.27 Incl. 41 VEHICLE DIAGNOSTICS 42 Rpr Pre -repair scan m 0.5 M 9/4/2024 12:30:54 PM 420986 Page 2 Preliminary Estimate Basis Job Number: TOYO Corolla Parts 43 * Rpr Post -repair scan Body Labor m 0.5 M 75.00 /hr 44 ROOF Paint Labor 16.6 hrs @ 75.00 /hr 45 * Rpr Roof panel Japan built all Mechanical Labor 1.0 hrs 77 2.8 46 Overlap Major Adj. Panel Paint Supplies 16.6 hrs @ 0.4 47 Add for Clear Coat Miscellaneous 0.5 48 R&I RT Drip molding 0.3 49 R&I LT Drip molding 0.3 50 # Subl Hazardous waste removal 1 6.00 T 51 # Rep[ Cover Car 1 10.00 T 52 # Color tint / color match 1 54.00 1.0 53 # Rpr Color sand and buff 1.0 54 # Rep] Corrosion protection primer 1 10.00 T 55 # Repl Flex additive 1 10.00 T SUBTOTALS 2,603.26 29.6 16.6 ESTIMATE TOTALS Category Basis Rate Cost $ Parts 2,567.26 Body Labor 28.6 hrs @ 75.00 /hr 2,145.00 Paint Labor 16.6 hrs @ 75.00 /hr 1,245.00 Mechanical Labor 1.0 hrs @ 125.00 /hr 125.00 Paint Supplies 16.6 hrs @ 55.00 /hr 913.00 Miscellaneous 36.00 Subtotal 7,031.26 Sales Tax $ 3,480.26 @ 8.7500% 304.52 Grand Total 7,335.78 9/4/2024 12:30:54 PM 420986 Page 3 Preliminary Estimate TOYO Corolla 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. Job Number: 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. 9/4/2024 12:30:54 PM 420986 Page 4 Preliminary Estimate Job Number: TOYO Corolla PARTS SUPPLIER LIST Line Supplier Description Price 3 Express Body Parts Inc. TO1000380C 245.98 7295 COLDWATER CANYON AVE. A/M CAPA Bumper cover Japan built NORTH HOLLYWOOD CA 91605 818) 764-0707 818) 764-0797 6 Quality Plus San Diego QT313 75.00 1333 30TH ST STE C A/M CAPA Absorber SAN DIEGO CA 92154 619) 424-9991 619) 424-3031 7 Quality Plus San Diego QT134 350.00 1333 30TH ST STE C A/M CAPA Reinforcement SAN DIEGO CA 92154 619) 424-9991 619) 424-3031 8 Keystone -Complete -B -Ontario TO1044120 39.00 2530 LINDSEY PRIVADO A/M Seal ONTARIO CA 91761 800) 421-7866 909) 986-4586 10 NAPA BK 6653267 9.51 2999 CIRCLE 75 PARKWAY A/M Bumper cover clip #1 ATLANTA GA 30339 833) 627-2265 999)999-9999 12 Quality Plus San Diego T141A 193.33 1333 30TH ST STE C A/M RT Lens & housing SAN DIEGO CA 92154 619) 424-9991 619) 424-3031 15 Metro Distributors Inc. TO1200394 194.03 2800 E LA CADENA DR. A/M Grille Japan built beige RIVERSIDE CA 92507 951) 682-1025 951) 682-1025 17 Quality Plus San Diego QT473 100.00 1333 30TH ST STE C A/M CAPA Lower grille 9/4/2024 12:30:54 PM 420986 Page 6 Preliminary Estimate Job Number: TOYO Corolla SAN DIEGO CA 92154 619) 424-9991 619)424-3031 18 NAPA BK 6653267 9.51 2999 CIRCLE 75 PARKWAY A/M Grille clip ATLANTA GA 30339 833) 627-2265 999) 999-9999 21 Express Body Parts Inc. TO1225285C 483.98 7295 COLDWATER CANYON AVE. A/M CAPA Radiator support NORTH HOLLYWOOD CA 91605 818) 764-0707 818) 764-0797 26 Keystone -Complete -B -Ontario TO1230211PP 332.00 2530 LINDSEY PRIVADO A/M CAPA Hood Japan built (HSS) ONTARIO CA 91761 800) 421-7866 909) 986-4586 32 NAPA NOE820474 38.28 2999 CIRCLE 75 PARKWAY A/M LT Hinge Japan built ATLANTA GA 30339 833) 627-2265 999) 999-9999 36 Keystone -Complete -B -Ontario TO1241224PP 173.00 2530 LINDSEY PRIVADO A/M CAPA RT Fender Japan built ONTARIO CA 91761 800) 421-7866 909) 986-4586 9/4/2024 12:30:54 PM 420986 Page 7 Date: Estimate ID: Estimate Version: Preliminary Profile ID: 914/2024 01:05 PM 2344 0 body shop A & J AUTO BODY 28030 HWY 74, Perris, CA 9257 951)245-6901 Fax: (951) 245-9022 Damage Assessed By: MITCHELL MITCHELL A&J Auto _ ' ' Classification: None EXCELLENCE GiJARANTEE,D Deductible: UNKNOWN Description: Toyota Corolla L ESTIMATE RECALL NUMBER: 09/04/2024 12:49:02 2344 Mitchell Data Version: OEM: MAR -20_V Copyright (C) 1994 - 2020 Mitchell International Page 1 of 3 Software Version: 7.1.238 All Rights Reserved Body Style: 4D Sed Drive Train: 1.8L Inj 4 Cyl 4A FWD VIN: OEM/ALT: 0 Search Code: None Options: PASSENGER AIRBAG, POWER LOCK, POWER WINDOW, POWER STEERING, REAR WINDOW DEFOGGER AIR CONDITION, TILT STEERING COLUMN, AM/FM STEREO, DRIVER AIRBAG FRONT SIDE AIRBAG WITH HEAD PROTECTION, ANTI-LOCK BRAKE SYS., TRACTION CONTROL TIRE INFLATION/PRESSURE MONITOR, AUXILIARY INPUT, CD PLAYER POWER ADJUSTABLE EXTERIOR MIRROR, AUTOMATIC TRANSMISSION, FIRST ROW BUCKET SEAT CLOTH SEAT, SIDE AIRBAGS, SECOND ROW SIDE AIRBAG WITH HEAD PROTECTION MP3 PLAYER, DAYTIME RUNNING LIGHTS, ELECTRONIC STABILITY CONTROL KEYLESS ENTRY SYSTEM, POWER FOLDING EXTERIOR MIRRORS, REAR BENCH SEAT Line Entry Labor Line Item Part Type/ Dollar Labor Item Number Type Operation Description Part Number Amount Units 1 933037 FRM ADD -L OPR Frame/Unibody Repair And Setup 5.5* 2 AUTO BDY OVERHAUL Frt Bumper Cover Assy 1.2 # 3 103583 BDY REMOVEIREPLACE Frt Bumper Cover QUAL REPL PART 211.00 * INC # 4 AUTO REF REFINISH Frt Bumper Cover C 2.5 5 103589 BDY REMOVEIREPLACE R Frt Bumper Cover Support QUAL REPL PART 28.00 * INC # 6 AUTO BDY REMOVEIINSTALL Frt Bumper Cover INC 7 104218 BDY REMOVEIREPLACE Frt Bumper Emblem 75301-02010 48.24 INC 8 103594 BDY REMOVEIREPLACE Frt Bumper Grille 53112-02280 66.95 INC 9 103598 BDY REMOVE/REPLACE R Frt Bumper End Cover QUAL REPL PART 28.00 * INC 10 103603 BDY REMOVEIREPLACE Frt Bumper Impact Absorber QUAL REPL PART 35.00 * INC 11 103604 BDY REMOVE/REPLACE Frt Bumper Reinforcement Bar (UHSS) QUAL REPL PART 185.00 * INC' # 12 104269 BDY REMOVE/REPLACE Grille Assembly QUAL REPL PART 350.00 * INC # 13 103643 BDY REMOVE/REPLACE R Frt Combination Lamp Assembly QUAL REPL PART 195.00 * INC # 14 AUTO BDY CHECK/ADJUST Headlamps 0.4 15 100651 BDY REMOVEIREPLACE Hood Panel (HSS) QUAL REPL PART 300.00 * 1.4 16 AUTO REF REFINISH Add For Hood Underside C 1.2 17 AUTO REF REFINISH Hood Outside C 2.3 18 103034 BDY REMOVEIREPLACE R Hood Hinge 53410-02170 29.00 * 0.2 # 19 AUTO REF REFINISH R Hinge C 0.5 20 AUTO BDY REMOVE/INSTALL Hood Assy INC 21 103035 BDY REMOVEIREPLACE L Hood Hinge QUAL REPL PART 29.00 * 0.2 # 22 AUTO REF REFINISH L Hinge C 0.5 23 101678 BDY REMOVE/REPLACE Cooling Radiator QUAL REPL PART 315.00 * INC # 24 104348 MCH REMOVE/REPLACE A/C Condenser Assy -M QUAL REPL PART 125.00 * INC # 25 AUTO MCH REMOVE/REPLACE Evacuate & Recharge A/C -M 1.4 ESTIMATE RECALL NUMBER: 09/04/2024 12:49:02 2344 Mitchell Data Version: OEM: MAR -20_V Copyright (C) 1994 - 2020 Mitchell International Page 1 of 3 Software Version: 7.1.238 All Rights Reserved 26 91412024 01:05 PM Labor 27 100749 BDY 28 AUTO REF 29 AUTO REF 30 100750 BDY 31 AUTO REF 32 AUTO REF 33 103819 BDY 34 103820 BDY 35 100762 BDY 36 AUTO REF 37 AUTO MCH 38 100676 BDY 39 AUTO REF 40 936003 41 100324 BDY 42 100139 BDY 43 AUTO REF 44 933003 REF 45 933017 REF 46 933018 REF REMOVEIREPLACE REFINISH REFINISH REMOVEIREPLACE REFINISH REFINISH REMOVE/REPLACE REMOVEIREPLACE REMOVEIREPLACE REFINISH REMOVEIREPLACE REPAIR REFINISH ADD'L COST REMOVE/REPLACE REMOVE/REPLACE ADD'L OPR ADD'L OPR ADD'L OPR ADD'L OPR Bent from accident R Fender Panel R Fender Outside R Add To Edge Fender L Fender Panel L Fender Outside L Add To Edge Fender R Fender Liner L Fender Liner Frt Body Radiator Support -S Radiator Support Complete Add To R&R Mechanical Components -M R Frt Body Apron Assy -S R Apron Assembly Complete Coolant Engine Under Cover W/Shield Washer Tank Clear Coat Tint Color Finish Sand And Buff Mask For Overspray Judgment Item Labor Note Applies C - Included in Clear Coat Calc I. Labor Subtotals Body Refinish Frame Mechanical Labor Summary Units Rate 19.4 75.00 20.4 75.00 5.5 100.00 2.2 125.00 Taxable Labor Labor Tax 47.5 III. Additional Costs Taxable Costs Sales Tax Total Additional Costs Estimate Totals Add'I 91412024 01:05 PM Labor Sublet Amount Amount 0.00 0.00 25.00 0.00 0.00 0.00 0.00 0.00 @ 8.000% 8.000% Totals 1,455.00 T 1,555.00 T 550.00 T 275.00 T 3,835.00 306.80 4,141.80 Amount 85.00 6.80 91.80 Date: 91412024 01:05 PM Estimate ID: 2344 Estimate Version: 0 Preliminary Profile ID: body shop QUAL REPL PART 160.00 * 1.3 # C 1.6 C 0.5 QUAL REPL PART 160.00 * 1.3 # C 1.6 C 0.5 QUAL REPL PART 75.00 * INC QUAL REPL PART 75.00 * INC QUAL REPL PART 400.00 * 9.5 # 1.5 0.8 # Existing 3.5* # 1.0 85.00 * QUAL REPL PART 88.00 * 0.4 QUAL REPL PART 89.00 * INC 4.3* 1.2* 1.2* II. Part Replacement Summary Taxable Parts Sales Tax @ Total Replacement Parts Amount IV. Adjustments Customer Responsibility I. Total Labor: Il. Total Replacement Parts: III. Total Additional Costs: Gross Total: ESTIMATE RECALL NUMBER: 09104/2024 12:49:02 2344 Mitchell Data Version: OEM: MAR 20 V Copyright (C) 1994 - 2020 Mitchell International Software Version: 7.1.238 All Rights Reserved 25.00 * 8.000% 239.38 3,231.57 Amount_ 0.00 4,141.80 3,231.57 91.80 7,465.17 Page 2 of 3 Date: Estimate ID: Estimate Version: Preliminary Profile ID: 914/2024 01:05 PM 2344 0 body shop IV. Total Adjustments: 0.00 Net Total: 7,465.17 This is a preliminary, estimate. Additional changes to the estimate may be required for the actual repair. ESTIMATE RECALL NUMBER: 091041202412:49:02 2344 Mitchell Data Version: OEM: MAR 20_V Copyright (C) 1994 - 2020 Mitchell International Page 3 of 3 Software Version: 7.1.238 All Rights Reserved