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HomeMy WebLinkAboutMINUTES - 10072003 - C18 CLAIM BOARR OF allPERVYISMS +13F CCINTRA 4STA COUNTY B0ARIr3A.CTI ?N:OCTOBER -7, 2003 Claim Against the County, or District Governed by ) the Board of Supervisors,Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to you is your California.Government Codes. ) notice of the action taken on your claire by the Board of Supervisors. (Paragraph IV below), given Pursuant to Government Code �Section 913 and i AMOUNT: $2,972.94 CLAIMANT: GEICO DIRECT BY. ANDREA ZOLEZZI FOR: DEBORAH BELMONTE � t ATTORNEY: Uwwo DATE RECEIVED: AUGUST 25, 2003 ADDRESS: GEICO DIRERBY DELIVERY TO CLERK ON. AUGUST 25, 2003 P.O. BOX 509090 SAN DIEGO, CA 92150-9090 BY MAIL POSTMARKED' AUGUST 19, 2003 FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the 0ove-noted claim. AUGUST 25, 2003 JOHN SWEET rk Dated. By: Deputy II. FROM: County Counsel TO: Clerk of the Board of Supervi rs AThis claim complies substantially with Sections 914 and 914.2. { ) This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days(Section 910.8), { ) Claim is not timely filed.The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim(Section 911.3), { ) Other: Dated: By: Deputy County Counse: III. FROM: C erk of the Board TO: County Counsel(1) County Administrator(2) ( } Claim was returned as untimely with notice to claimant(Section 911.3). IV. ARD ORDER.: By unanimous vote of the Supervisors present: {; This Claim is rejected in full. { ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: 'Z"-c/ t,04-a3 JOIN SWEETEN, CLERK, By , Deputy Clerk WARNING(Gov. code section 9 ) Subject o certain exceptions,you have only six(6) months from the date this notice was personally served or deposited in the 'I to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorne .of your choice in connection with this matter. If you want to consult an attorney, you should do so imediely. *For Additional Warning See Reverse Side of This Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now,and at all times herein mentioned,have been a citizen of the United States,over age 18; and that today I deposited in the United States Postal Service in Martinez,California,postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: C HN SWEETEN,CLERK:By Deputy Clerk Claim to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. Claims relating to causes of action for death or for injury to person or to per- sonal property or growing crops and which accrue on or before December 31, 1937, must be presented not later than the 100th day after the accrual. of 't the cause of action. Claims relating to causes of action for-Meath or for injury to person or to personal property or growing drops and which accrue on or after January 1, 1988, must be presented not later than six months after the accrual of the cause of action.' Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Govt. Code §911.2.) B. Claims wast be filed with the Clerk of the Board of Supervisors at its office in Room 1036, County Administration Building, 651 Fine Street, Martinez, CA 94553» C. If claim is against a district governed by the Board of Supervisors, rather than; the County, the name of the District should be filled in. D. If the claim is against more than rine public entity, separate claims rust be filed against each public entity. E. ' Fraud. See penalty for fraudulent claims, Penal. Code Ser. 72 at the end of this form. lily. yY yy, y, Y y ,yyy y •Y YY .y yyy. y, ] Y yy yy, YY RE: Claim By ) Reserved .for Clerk's filing stamp 6no-Li } rc, } RECEIVED } Agdin3t. E9 County of Contra Costa } AUG 55 2003 or } " CLERK BOAR-)0F SIB)cR,,'.�ORS District) TIVI in name } The d rs gned claimant hereby makes claim against the County of Contra Costa or the aho named District in the sum of $ _ L and in support of this clay_ represents as follows: WILT 1. WhW did the doge or injury occur? (Give exact date and .'hour) 4jua 6t& 2. Where did the damage or injury occur? (Include city and county) 3. How did the damage or injury occur? (give full details, use extra paper i required) L M �Y1 `i 't , 1,tt �r 1�C I. t�'", e� ^1\ido led - Ufa I n 4. What particular act or omission on the part of county or district officers, servants or .employees causedth inJury or damage?< ta (over) .......... _ ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......._. ......._ _ ......... __ _ _ ......... .......... ......... ......... ......... ......... ........_......__. 5. Wnat are the names of county or district officers, servants or employees causing the damage or injury? H iYA YO C -2,id,� 5. What damage or injuries do you claim resulted?(Give full extent of injuries or damages clamd. Attah�two estimates for auto damage.�� // �� � Ce4� f / � )f (s4 ut 7. How was the amount claimed above computed? (Include t e estimated amount of any prospective injury or damage.) ,A ICX lt�ti I 1-vt 8. Names and addresses of witnesses, doctors and hospitals. 9. List the expenditures you made on account of this accident or injuryz DATE ITEM AMOUNT � ) Gov. Code Sec. 910;2 provides: "The claim must be signed by the cimant SEND NOTICES T0: (Attorney) or b some _ son on his. behalf." Name and Address of Attorney 6 Gd 060 cl t"s Signature �y NO La Ad ess ` Telephone No. Telephone No. S56 X13 t,�Mt! +� * * N O T I C E Section 72 of the Penal. Code provides: "Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any 'county, city or district board or officer, authorized to allow or pay the same if .genuineg any false or fraudulent claim, bill, account, voucher, or writing, is punishable either by imprisonment in the county jail for a period of not more than one year, by a` fine of not exceeding one thousand ($1,000), or by both such. imprisonment and fine,- or by imprisonment in the state, prison, by a fine of not exceeding ten thousand' dollars ($10,000, or by both such imprisonment and fine. CLAIM PAYMENT SCREEN REVERSE CLAIM # LOSS ADJR TIME FCC IRS FIELD ISSUED 0115695331010 U6 17 U7 H609 X361899 03 - - - U6 30 03 CHECK # TYP ID CO CHECK AMT FEAT C S AMT EXP FEAT C S AMT E ',58565-631 C LP 01 2477. 94 01COL -Y- 2-47-2-.-9-4 - CLAIMANT GALICANO D BELMONTE USER ID U79X69 IN PAYMENT OF INSURED AG ONP TYPE COLLISION COVERAGE GALICANO D BELMONTE - - - - -TYPE- PARTIAL LOSS LESS DED PAY-TO DEBORAH BELMONTE ENCLOSURE P=POLICE REP F=FORM LETTER C=CORRESPOND L=PROOF/LOSS MAIL TO GALICANO D BELMONTE M=MISC. I=INVOICES 3814-W AVENUE K15 R=RELEASES LANCASTER, CA 93536-4958 VECTORING IRAN: CLTQ KEY: 01,1569533010102/2 01CO Pagel of 8 06/30/2003 AT 12:31 PM 0115695330101022-01 32426 GEICO CHATSWORTH P.O.BOX 5504 CHATSWORTH, CA 91313 (818) 585-0683 FAX: (818) 998-6876 ESTIMATE OF RECORD WRITTEN BY: MARK VALDEZ 06/30/2003 12:22 PM ADJUSTER: MARK VALDEZ (818) 585-0683 INSURED: GALICANO BELMONTE CLAIM #0115695330101022-01 OWNER: GALICANO BELMONTE POLICY #45789030 ADDRESS: 3814 W AVENUE K15 DATE OF LOSS: 06/17/2003 AT 12:00 AM LANCASTER, CA 93536-4958 TYPE OF LOSS: COLLISION EVENING: (661)722-5962 POINT OF IMPACT: 6. REAR INSPECT 5 STAR AUTO BODY BUSINESS: (661) 951-9110 LOCATION: 44733 N. SIERRA HWY DRIVE-IN LANCASTER, CA 93534 REPAIR OWNERS CHOICE 10 DAYS TO REPAIR FACILITY: LICENSE # 1996 TOMO 4RUNNER 4X2 4-2.7L-FI 4D UTV BLACK VIN: JT3GM84R2T0005283 LIC: 3SIB969 CA PROD DATE: 05/1996 ODOMETER: 240853 AIR CONDITIONING INTERMITTENT WIPERS TINTED GLASS CLEAR COAT PAINT POWER STEERING POWER BRAKES AM RADIO FM RADIO STEREO CASSETTE SEARCH/SEEK DRIVER AIR BAG PASSENGER AIR BAG CLOTH SEATS BUCKET SEATS RECLINE/LOUNGE SEATS REAR STEP BUMPER AUTOMATIC TRANSMISSION OVERDRIVE ALUMINUM/ALLOY WHEELS --------------------------------------------------------------------------------- NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT ------------------------------------------------------------------------------- 1 REAR BUMPER 2 O/H REAR BUMPER 1.3 3** REPL QUAL REPL PARTS FACE BAR DARK 1 150.00 INCL. 1.2 GRAY 4 ADD FOR CLEAR COAT 0.5 5 REPL UPPER PLATE 1 128.26 INCL. N 6# REFN TOW HITCH 0.5 7 LIFT GATE N 8* RPR GATE SHELL W/O REAR WIPER 8.0* 2.3 9 ADD FOR CLEAR COAT 0. 9 10 R&I FINISH PANEL 0. 4 11 REPL EMBLEM 1 19.23 0.3 12 REPL NAMEPLATE "4 RUNNER" 1 27.52 0.2 13 REPL NAMEPLATE "TOYOTA" CHROME 1 9.22 0.2 14 R&I LOCK ASSY 0.4 15 R&I GLASS TOYOTA, STANDARD DUTY 1.0 h ecf e ge c e e Page 2 of 8 UNHEATED, GREEN 1 06/30/2003 AT 12:31 PM 0115695330101022-01 32426 ESTIMATE OF RECORD 1996 TOYO 4RUNNER 4X2 4-2.7L-FI 4D UTV BLACK ----------_---------------------------------------------------------------------- NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT -------------------------------------------------------------------------------- 16 R&I WIPER ARM 0.2 17 R&I NOZZLE 0.2 18 R&I R&I TRIM PANEL 0.4 19 R&I BELT W'STRIP 20 R&I RUN CHANNEL 0.3 21 REAR DOOR N 22* ALGN RT DOOR SHELL WIO LIMITED ALL 0.5* 23 FRONT DOOR 24 BLVD LT DOOR SHELL W/O LIMITED 1.1 25 R&I LT MIRROR ASSY MANUAL 0.4 26 R&I LT HANDLE, OUTSIDE BASE 0.4 27 R&I LT R&I TRIM PANEL 0.4 N 28# ALGN LT DOOR TO BODY 0.5 N 29* ALGN RT DOOR SHELL W/O LIMITED 0.5* 30 FRONT BUMPER 31 O/H FRONT BUMPER 1.3 32** REPL QUAL REPL PARTS FACE BAR DARK 1 155.00 INCL. 1.4 GRAY 33 ADD FOR CLEAR COAT 0.6 34** REPL QUAL REPL PARTS RT FACE BAR 1 19.00 INCL. MOUNT BRACKET 35** REPL QUAL REPL PARTS LT FACE BAR 1 19.00 INCL. MOUNT BRACKET 36** REPL QUAL REPL PARTS VALANCE PANEL 1 81.00 INCL. 1.0 W/O LIMITED 37 OVERLAP MAJOR NON-ADJ. PANEL -0.2 38 ADD FOR CLEAR COAT 0.2 39 REPL RT BUMPER GUARD MOUNT 1 63.08 40 REPL LT BUMPER GUARD MOUNT i 63.08 41 GRILLE 42** REPL QUAL REPL PARTS GRILLE DARK i 85.00 0.4 0.5 GRAY 43 REPL LT FILLER PANEL 1 20. 98 0.1 0.2 44 FRONT LAMPS 45 R&I RT PARK LAMP ASSY TO 1/97 0.2 46** REPL QUAL REPL PARTS RT SIGNAL 1 33.00 INCL. LAMP ASSY 47** REPL QUAL REPL PARTS LT SIGNAL 1 33.00 INCL. LAMP ASSY 48 R&I LT PARK LAMP ASSY TO 1/97 INCL, 49 HOOD h ed e ge c e e .. ... ........ Page 3 of 8 50 BLND HOOD 1.5 51 WINDSHIELD 52* R&I RT NOZZLE 0.2* 53* R&I LT NOZZLE 0,2* 54 FENDER N 55 REPL LT FENDER BASE & SRS W/O FLARE 1 240.02 1.8 2.0 56 OVERLAP MAJOR NON-ADJ. PANEL -0.2 2 06/30/2003 AT 12:31 PM 0115695330101022-01 32426 ESTIMATE OF RECORD 1996 TOYO 4RUNNER 4X2 4-2.7L-FI 4D UTV BLACK -----------------------------__------------------------------------------------- NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT ---------------------------------------------------------------------------------- 57 ADD FOR CLEAR COAT 0.4 58 ADD FOR EDGING 0.5 59 DEDUCT FOR OVERLAP -0.4 60 R&I LT FENDER LINER INCL, 61 PILLARS, ROCKER & FLOOR 62 R&I LT ROCKER MOLDING LIGHT GRAY 0.5 63# MISC 1 64# SUBL HAZARDOUS MATERIAL DISPOSAL 1 3.00 X 65# REPL MASK FOR OVERSPRAY 1 8.00 N 66# RPR FRAME REPAIR 4.0 F ---------------------------------------------------------------------------------- SUBTOTALS =_> 1157.39 23. 9 14.4 LINE 6 SPOT REFINISH PER DAVE LINE 8 6.0 OUTER PANEL 2.0 INNER SHELL LINE 22 : AGREED PRICE WITH DAVE LINE 28 AGREED PRICE WITH DAVE LINE 29 : AGREED PRICE WITH DAVE LINE 55 AGREED PRICE WITH DAVE LINE 66 2.0 SETUP 2.0 SWAY AGREED PRICE WITH DAVE ------------------------------------------------------------------------------- ESTIMATE NOTES: PC:2 CO:01 OLD DAMAGE ON VEHICLE AT TIME OF INSPECTION 2 1.0 DENTS TO HOOD, RT REAR SUMER EXTENSION WAS DMGD PRIOR TO LOSS. ESTIMATE WAS WRITTEN FOR VISIBLE DAMAGE ONLY. RATES ARE LOCAL PREDOMINANT FOR THE AREA. OWNER WAS NOTIFIED IN WRITING AND VERBALLY OF RENTAL CAR LIMITS. LKQ OR A/M PARTS WERE AVA FOR THIS VEHICLE. OWNERSHIP OF VEHICLE WAS VERIFIED THROUGH VISUAL CONFIRMATION OF DOCUMENTS. PARTS 1154.39 h ecf e ge c e e Page 4 of 8 BODY LABOR 19. 9 HRS @$ 34 .00/HR 676. 60 PAINT LABOR 14.4 HRS @$ 34 .00/HR 489. 60 FRAME LABOR 4 .0 HRS @$ 45.00/HR 180.00 PAINT SUPPLIES 14.4 HRS @$ 24 .00/HR 345. 60 SUBLET/MISC. 3.00 ------------------------------------------------------ SUBTOTAL $ 2849.19 SALES TAX $ 1499.99 @ 8.2500% 123.75 ---------------------------------------------------- TOTAL COST OF REPAIRS $ 2972.94 ADJUSTMENTS: DEDUCTIBLE 500.00 3 06/30/2003 AT 12:31 PM 0115695330101022-01 32426 ESTIMATE OF RECORD 1996 TOYO 4RUNNER 4X2 4-2.7L--FI 4D UTV BLACK ------------------------------------------------------ TOTAL ADJUSTMENTS $ 500.00 NET COST OF REPAIRS $ 2472.94 THIS IS NOT A NOTICE TO REPAIR NO SUPPLEMENT WILL BE HONORED UNLESS AUTHORIZED BY GEICO DIRECT NOTICE: NEW HIGH STRENGTH STEELS MAY REQUIRE THE USE OF A MIG WELDER FOR PROPER REPAIRS. NEW DESIGNS REQUIRE MEASUREMENT TO PROPERLY ALIGN THE VEHICLE. MAKE SURE YOUR SHOP HAS THE RIGHT EQUIPMENT TO REPAIR YOUR VEHICLE. 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 PATHWAYS: ADJ=ADJACENT ALGN=ALIGN A/H AFTERMARKET BLVD=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 QUAL RECY=QUALITY RECYCLED PART QUAL REPL=QUALITY REPLACEMENT PART COMP REPL PARTS=COMPETITIVE REPLACEMENT PARTS RECOND=RECONDITION REFN=REFINISH REPL=REPLACE R&2=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. MQVP=MANUFACTURER'S QUALIFICATION AND VALIDATION PROGRAM. THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF CRASH PARTS SUPPLIED BY A h ecf e ge c e e Page 5 of 8 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. 4 06/30/2003 AT 12:31 PM 0115695330101022-01 32426 ESTIMATE OF RECORD 1996 TOYO 4RUNNER 4X2 4-2.7L-FI 4D UTV BLACK GEICO DIRECT ALTERNATE PARTS DISCLAIMER IF QUALITY REPLACEMENT PART (QRP) APPEARS ON THIS ESTIMATE, IT INDICATES THAT THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF ONE OR MORE CRASH PARTS SUPPLIED BY A SOURCE OTHER THAN THE MANUFACTURER OF YOUR MOTOR VEHICLE. WARRANTIES, IF ANY, APPLICABLE TO THESE REPLACEMENT CRASH PARTS ARE PROVIDED BY THE PART MANUFACTURER OR DISTRIBUTOR RATHER THAN BY THE MANUFACTURER OF YOUR VEHICLE. *** IN ADDITION TO ANY SUCH WARRANTIES, GEICO PROVIDES THE FOLLOWING: **** OWNER LIMITED WARRANTY **** WE WARRANT THAT ALL QUALITY REPLACEMENT BODY PARTS (PARTS NOT MANUFACTURED BY THE MANUFACTURER) IDENTIFIED ON YOUR ESTIMATE, ARE FREE OF DEFECTS IN MATERIAL AND WORKMANSHIP AND MEET GENERALLY ACCEPTED INDUSTRY STANDARDS. THIS PARTS AND LABOR WARRANTY WILL BE IN EFFECT FOR AS LONG AS YOU OWN THE VEHICLE DESCRIBED IN THE ESTIMATE. THIS WARRANTY COVERS THE COST OF THE PART, LABOR TO INSTALL, AND INCIDENTALS SUCH AS PAINT AND MATERIALS AND IS SPECIFICALLY LIMITED TO THOSE ITEMS. THIS WARRANTY DOES NOT COVER LOSS OR DAMAGE THAT IS UNRELATED TO DEFECTS IN THE QUALITY REPLACEMENT PARTS. THIS IS NOT TRANSFERABLE. IF ANY QUALITY REPLACEMENT PARTS ARE DEFECTIVE IN EITHER MATERIAL OR WORKMANSHIP, CONTACT YOUR LOCAL GEICO REPRESENTATIVE. ESTIMATE BASEL? ON MOTOR CRASH ESTIMATING GUIDE. UNLESS OTHERWISE NOTED ALL ITEMS ARE DERIVED FROM THE GUIDE ARM8414 DATABASE DATE 5/2003 AND THE PARTS SELECTED ARE OEM-PARTS MANUFACTURED BY THE VEHICLES ORIGINAL EQUIPMENT h ecf e ge c e e .................................................. Page 6 of 8 MANUFACTURER. ASTERISK OR DOUBLE ASTERISK INDICATES THAT THE PARTS AND/OR LABOR INFORMATION PROVIDED BY MOTOR MAY HAVE BEEN MODIFIED OR MAY HAVE COME FROM AN ALTERNATE DATA SOURCE. NON-ORIGINAL EQUIPMENT MANUFACTURER AFTERMARKET PARTS ARE DESCRIBED AS AM, QUAL REPL PARTS OR COMP REPL PARTS WHICH STANDS FOR COMPETITIVE REPLACEMENT PARTS. USED PARTS ARE DESCRIBED AS LKQ, QUAL RECY PARTS, RCY, OR USED. RECONDITIONED PARTS ARE DESCRIBED AS RECON. RECORED PARTS ARE DESCRIBED AS RECORE. NAGS PART NUMBERS AND PRICES ARE PROVIDED FROM NATIONAL AUTO GLASS SPECIFICATIONS, INC. POUND SIGN ITEMS INDICATE MANUAL ENTRIES. PATHWAYS - A PRODUCT OF CCC INFORMATION SERVICES INC. 5 06/30/2003 AT 12:31 PM 0115695330101022-01 32426 ESTIMATE OF RECORD 1996 TOYO 4RUNNER 4X2 4-2.7L-FI 4D UTV BLACK ALTERNATE PARTS SUPPLIERS 3 QUAL REPL PARTS FACE BAR DA PART NO. 701102220 PRICE 150.00 32 QUAL REPL PARTS FACE BAR DA PART NO. T01002161 PRICE 155.00 34 QUAL REPL PARTS RT FACE BAR PART NO. T01067121 PRICE 19.00 35 QUAL REPL PARTS LT FACE BAR PART NO. 701066121 PRICE 19.00 36 QUAL REPL PARTS VALANCE PAN PART NO. T01095174 PRICE 81.00 42 QUAL REPL PARTS GRILLE DARK PART NO. 701200203 PRICE 85.00 46 QUAL REPL PARTS RT SIGNAL L PART NO. 702531125 PRICE 33.00 47 QUAL REPL PARTS LT SIGNAL L PART NO. T02530125 PRICE 33.00 KEYSTONE W/O SM - B (619) 656-2050 1670 BRANDYWINE AVE. #D SAN DIEGO, CA 91911 KEYSTONE W/O SM - B (800) 421-7866 610 EAST STATE ST (909) 986-4586 ONTARIO, CA 91761 KEYSTONE W/O SM - B (800)794-6911 h ecf e ge c e e Page 7 of 8 1069 HENSLEY STREET (57.0)234-6960 RICHMOND, CA 94801 KEYSTONE W/O SM -- B (800) 339-5033 1927 SOUTH VAN NESS (209) 268-8146 FRESNO, CA 93721 6 06/30/2003 AT 12:31 PM 0115695330101022-01 32426 ESTIMATE OF RECORD 1996 TOYO 4RUNNER 4X2 4-2.7L-FI 4D UTV BLACK ALTERNATE PARTS USAGE AFTERMARKET PARTS AFTERMARKET SELECTION METHOD: AUTOMATICALLY LIST NO. OF TIMES USER WAS NOTIFIED THAT AN AFTERMARKET PART WAS AVAILABLE: 8 NO. OF AFTERMARKET PARTS THAT APPEAR IN THE FINAL ESTIMATE: 8 h ecf e ge c e e ............................... Page 8 of 8 h ecf e ge c e e Es.i ate Photos - Claim 0115695330101022-01-00 Page 1 0 AD Query ;Estimate Photo 01 for Claim Number 0115695330 .01022-01-00 lPhoto dateo30/06/2003 12:€18:59:00 Size-144860 ,:Descriptions 'policy Numberm45789€030 'Vehic1em96, TOY0, 4RUNI NT E:R 4X2 X14>JT3 M84 2 `0005283 Loss te:06/17/03 Estimator:MARK VALDEZ , 9 4y .. Estimate Photo 02 for Claim Number 0115695330101022-01-00 Estimate Photos ® Claims; 0115695330101€}22-01-00 Page 2 ova Toto date:3 0/06/2003 12:08:59:00 Size:141048 Description: Insured:BELMONTE, GALICANO Policy Number:45789030 Vehicle:96, ' OYO, 4RUNNER 4X2 VIN.-JT 3GM84R2T0005283 Less d teo06/17/03 Estimator:MARK VALDEZ ''estimate Photo 03 for Claim Number 0115695330101022-01-00 hot€a d ate:3€I/{6/2003 12:09:00:00 Size-.125272 'Description: Insured: GALICANO Policy Number:45789030 Lid' ec- e ge C e Est;Nate Photos a Claim Oi 15695330101022-01-0Page 3 of !Vehicle:96, 'T OYO,4EU? NTE 4X2 IVIN-JT3 M84R2TO€O05283 ,Loss date:06/17/03 !Estimator:M, ARK VAI.DEZ E .a Estimate Photo 04 for Clair Number 0115695330101022-01-00 Photo dates30/06/2003 12.09:00:0€1 Size-1.21360 Description: Insu `ed:BELli ONTE, GALICANO Police umber:45789030 Vehicle.96, TOMO, 4RUNNER 4X2 t'IVI ;.T3GM84R2T0005283 ;Loss date;06/I 7/03 `:Esti tor:MARK VALDEZ estimate Photos - Cla 0115695330101X322-01-00 ."age 4 of/6" , 'estimate Photo 05 for Claim Number 0115695330101022-01-00 ;Photo daten3€/06/2003 12:€39:00:00 Size:176224 Policy NumberE45789030 Vehicle. 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"f%rrlr�J` . .�} r;J:%%iJIJ f• .� .Jrf:%;':ll:. :::::;•.f:•' y.'%' } •''i'_r ,/r'��iJ'k J. r'�l.-;9. iJIJJ'r.!r'fr`J .�.'rirl.�; r�/J / /frr} f 'J-�ff`s: ,/,''�'fi .rr� '.•�J�l' r,f �''! ,� ,r '..r l Jf•J r' rl'•r� ,,. f}vrf�r r JJ r':•fJ J % / .fr''''%rf,•}:'{i'',J;1}.:�•iJr�J� ,r' J AMERM ----CLAIM' BOARD!2F SUPERVI QRS OF CONTRA COSTA COUNTY BOARD ACTION:OCTOBER 71 2003 Claim Against the County, or District Governed by ) the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document marled to you is your lr i Codes. ) notice of the action taken on your claim try the A E Board of Supervisors, (Paragraph IV below), given Pursuant to Government Code Section 913 and 915.4.Please note all"Warnings„ CLAIMANT: GEICO DIRECT BY: ANDREA ZOLEZZI FOR: DEBORAH BELMONTE ATTORNEY: UNKNOWN DATE RECEIVED: SEPT. 18, 2403 ADDRESS: GEICO DIRECT BY DELIVERY TO CLERK.ON: SEPT. 18, 2003 P.O. BOX 509030 SAN DIEGO, CA 92150-9090 BY MAIL POSTMARKED: SEPT. 16, 2003 FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SWEETEN, Dated: OCTOBER 181 2003 By: Deputy.... II. FROM: County Counsel TO: Clerk of the Board of Supervisors PThis claim complies substantially with Sections 910 and 910.2. ( } This Claim FAILS to comply substantially with Sections 914 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days(Section 910.8). ( } Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim(Section 911.3). ( ) Other: H f Dated: B i Deputy County Counsel 111, FROM: Clerk ofthe Board TO: County Counsel(1) County Administrator(2) ( } Claim was returned as untimely with notice to claimant(Section 911.3). IV, 40ARD ORDER: By unanimous vote of the Supervisors present: (t4''" This Claim is rejected in full. ( } Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this elate. Dated: JOHN SWEETEN,CLERK, By , Deputy Clerk WARNING(Gov. code section 913) _. ... ......... ......... ......... ......._. ._.... ..._...._...__.......... ......... ........... ........... ................. ......... ......... ..... .... . ........... ......... ......... ......... j� G=t INSLTIi.ANCEcxOUPL�'l Ole GEICO West,Box 50,9090 ■ San Diego,CA 52150-9090 ( [j PAYMENT RECOVERY NOTICE SSP �tk �z DateSs 1 U55 -P\' f,, �C)'ir Our Bile#:_ Ji t om? '2,2,,," ` 11` f , Our Insured: Your Insured/Driver: } � jr ' WHEN RESPONDING— Your File #: C,t PLEASE REFER.TO OUR Your Vehicle: Tag 64 CLAIM NU.'VMER. Our investigation shows your insured to be at fault in the accident. )► 1. Repair or replacement of our vehicle has been concluded..Our subrogation claim will be forwarded. Please protect our interest. Do- 2. Payment for repairs ha been made. Documentation is attached. Please honor our clip. CO's Interest: $ -+2—` Insured's Deductible: $ Rental: $ Total: $ Y—T4 Z 3. Our vehicle was declared a total less. Documentation's attached. Please honor our claim. Amount paid to the insured:$ insured's Deductible:$ Net salvage recovery $ Total $ ►- 4. We have subrogation rights for no fault benefits paid. Our documentation is attached. Please honor our claim. Medical:$ Wages, $ Other: $ 'Total: $ Since notifying you on oof our subrogation claim, we have paid additional damages of 1 11'iease include this in your payment to us. Documentation is attached. Our Total Claim is S "'- 2— )0- 6. Documentation of our claim was sent to you on When may we expect payment? 7. Arbitration was filed and a decision was:rendered in our favor on When may we expect payment? 01 8. Please make your check payable to: CEICO ❑ GEICO Indemnity Company dGEICO Casualty © GEICO General'Insurance Company r3 �� ,! Thanks For Your Prompt Attention ■ Government Employees Insurance Company Signature: • GEICO General Insurance Company r • GEICO Indemnity Company a ■ Criterion Casualty Company Phone: ahatah lder Owned'Companies Not A{ttlla£ed with tate U.S,Cbvemntent S-54-B(1-99) ....................................................... ........................................................................................................... .................... CLAIM PAYMENT SCREEN REVERSE CLAIM # LOSS ADJR TIME FCC IRS FIELD ISSUED 115 0695330101171 71 17 77 H609 21361817 03 - 06 30 073 CHECK # TYP ID CO CHECK AMT FEAT C S AMT EXP 04 - - FEAT-CSAMT E 158565131 C LP 01 2472. 94 01COL _Y__ 2-07777- 7 CLAIMANT GALICANO D BELMONTE USER 1D U79X69 IN PAYMENT OF INSURED _AG_ _ONP_ - -TYPECOLLISION COVERAGE GALICANO D BELMONTE PARTIAL LOSS LESS DED PAY-TO DEBORAH BELMONTE ENCLOSURE P=POLICE REP F=FORM LETTER C=CORRESPOND L=PROOF/LOSS MAIL TO GALICANO D BELMONTE M=MISC. I=INVOICES 3814-W AVENUE K15 R=RELEASES LANCASTER, CA 93536-4958 VECTORING IRAN: CLIQ KEY: 0115695330101022 01CO ...........................................................................................................................................I... ............... ........I.................I..........I............I............................................................ ................. .......... CLAIM PAYMENT SCREEN REVERSE CLAIM # LOSS ADJR TIME FCC IRSFIELD- ISSUED =6953371TI= -076 17 -0-7 H609 1-940291-5 03 - - 08 28 0-5 CHECK # TYP ID CO CHECK AMT FEAT C Q AMT EXP FEATCS-AMT E U67837116 A LP 01 218-9. 78 01COL- -Y- 21TU77719- - - CLAIMANT GALICANO D BELMONTE USER ID U79X58 IN PAYMENTOF INSURED -AG- -ONP- -TYPE- COLLISION COVERAGE GALICANO D BELMONTE P/LOSS SUPPL I PAYTOBURGESS AUTO BODY # 954245705 ENCLOSURE P=POLICE REP F=FORM LETTER C=CORRESPOND L=PROOF/LOSS MAIL TO BURGESS AUTO BODY M=mISC. I=INVOICES 146 'EAST AVE K-4 R=RELEASES LANCASTER, CA 93535 VECTORING IRAN: KEY: 01CO ... ... ..... ...... FEATURE (2) CLAIM NUMBER NOSYM CLAIMANT NAME CO FCC LOSS DT LOSS ST 0115695330101022 01REN GALICANO D BELMONTE 01 03 06/17/03 CA --------------------PAYMENT RECOVERY DATA---------------- ENTRY RESERVE/ CHECK/ ACCT ATTY-ADJ/ R DATE ACTIVITY ID EXP AMOUNT VOUCHER# NO IRS FIELD V USER 09/15/03 SUBRO 0 U796 09/11/03 3 CL U796 09/09/03 LP 750 . 00 E00023617 430724835 SYST 09/09/03 753 R U79M 07/23/03 CL U796 06/17/03 0 U792 CLPOST (PF3) CLAIMI (PF7) CLAIM2 (PF8) FEAT1 (PF9) FEAT2 (PF11) EXIT (PF12) VECTORING TRAM: CLTQ KEY: 01REN ...................................................................................................................................................................................................... .................................... ........ .... ............................................. A411ORT ARMS/400 Automated Rental Management System OFFICE: GEI11 03 View Reservation/Rental Adj : DOWNING, LESLI Status : PAID RENTAL Claim# : 011569533-0101-022-01 Renter: BELMONTE MARGIE 3814 WEST AVE K15 Type: I INSURED LANCASTER CA 93536 Repair: BURGESS AUTO BODY-32 Work: 661-722-5962 Ext : 0000 Ph/Veh: 661-945-6551 96 TOYOTA Home: 661-722-5962 Policy Coverage Authorized Rental : ENTERPRISE RENT-A-CAR Loc: 3293 Daily: 25 . 00 Rate: 811 WEST AVENUE K Res : 342954 Max: 750. 00 # Days: 30 LANCASTER CA Tkt: 288187 . Pct: 100 % 661-945-4611 Rental Start: 8/05/03 Auth Terminated: 9/03/03 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - A Date S/R Message Auth Total : 750 . 00 Max Days Tot 9/10/03 S INVOICE PAID 0 30 9/10/03 S REFERENCE# 000106483 AMT: $750 . 00 0 30 9/08/03 R INVOICE SENT FOR APPROVAL/PAYMENT. 0 30 9/08/03 R AMOUNT DUE $750 . 00 0 30 9/06/03 R TICKET 288187 CLOSED 09/03/03 @ 17 : 14 : 00 0 30 More. . F2=Invoice Info F3=Exit F9=Surcharges F12=Pre Press <ENTER> to Continue __... ......... ......... ......... ......... ......... ......... ......._......_. ... ........ .......................... ...__...... ..__....... .............._.........._._...._...... ......... ......... ......... ......... Page 1 of 15 08/27/2003 AT 09:51 AM 0115695330101022-01 44940 GEICO CHATSWORTH P.O.BOX 5504 CHATSWORTH, CA 91313 (818) 585-0683 FAX: (818) 998-6876 SUPPLEMENT OF RECORD 1 WITH SUMMARY WRITTEN BY: BRUCE HALEY 08/27/2003 09:08 AM ADJUSTER: MARK VALDEZ (818)585-0683 INSURED: GALICANO BELMONTE CLAIM #0115695330101022-01 OWNER: GALICANO BELMONTE POLICY #45789030 ADDRESS: 3814 W AVENUE K15 DATE OF LOSS: 06/17/2003 AT 12:00 AM LANCASTER, CA 93536-4958 TYPE OF LOSS: COLLISION EVENING: (661) 722-5962 POINT OF IMPACT: 6. REAR INSPECT 5 STAR AUTO BODY BUSINESS: (661) 951-9110 LOCATION: 44733 N. SIERRA HWY DRIVE-IN LANCASTER, CA 93534 REPAIR OWNERS CHOICE 10 DAYS TO REPAIR FACILITY: LICENSE # 1996 TOMO 4RUNNER 4X2 4-2.7L-FI 4D UTV BLACK VIN: JT3GM84R2T0005283 LIC: 3SIB969 CA PROD DATE: 05/1996 ODOMETER: 240853 AIR CONDITIONING INTERMITTENT WIPERS TINTED GLASS CLEAR COAT PAINT POWER STEERING POWER BRAKES AM RADIO FM RADIO STEREO CASSETTE SEARCH/SEEK DRIVER AIR BAG PASSENGER AIR BAG CLOTH SEATS BUCKET SEATS RECLINE/LOUNGE SEATS REAR STEP BUMPER AUTOMATIC TRANSMISSION OVERDRIVE ALUMINUM/ALLOY WHEELS -------------------a-----------------------_---------------------_-------------- NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT ---------------------------------------------------------------------------------- 1 REAR BUMPER 2 O/H REAR BUMPER 1.3 3** REPL QUAL REPL PARTS FACE BAR DARK 1 150.00 INCL. 1.2 GRAY 4 ADD FOR CLEAR COAT 0.5 5 REPL UPPER PLATE 1 128.26 INCL. N 6# S01 REPL TOW HITCH 1 314.55 1.5 7 S01 REPL RT FACE BAR MOUNT BRACKET 1 14.78 INCL. 8 S01 REPL LT FACE BAR MOUNT BRACKET 1 14 .78 INCL. 9 LIFT GATE N 10* RPR GATE SHELL W/O REAR WIPER 8.0* 2.3 11 ADD FOR CLEAR COAT 0.9 12 R&I FINISH PANEL 0. 4 13 REPL EMBLEM 1 19.23 0.3 14 REPL NAMEPLATE "4 RUNNER" 1 27.52 0.2 15 REPL NAMEPLATE "TOYOTA" CHROME 1 9.22 0.2 h ecf e ge c e e ..... Page 2 of 15 16 R&I LOCK ASSY 0.4 1 08/27/2003 AT 09:51 AM 0115695330101022-01 44940 SUPPLEMENT OF RECORD 1 WITH SUMMARY 1996 TOMO 4RUNNER 4X2 4-2.7L-FI 4D UTV BLACK -------------------------------------------------------------------------------- NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT ------------------------------------------------------------------------------- 17 R&I GLASS TOYOTA, STANDARD DUTY 1.0 UNHEATED, GREEN 18 R&I WIPER ARM 0.2 19 R&I NOZZLE 0.2 20 R&I R&I TRIM PANEL 0.4 21 R&I BELT W'STRIP 22 R&I RUN CHANNEL 0.3 23 REAR DOOR N 24* ALGN RT DOOR SHELL W/O LIMITED ALL 0.5* 25 FRONT DOOR 26 BLND LT DOOR SHELL W/O LIMITED 1.1 27 R&I LT MIRROR ASSY MANUAL 0.4 28 R&I LT HANDLE, OUTSIDE BASE 0.4 29 R&I LT R&I TRIM PANEL 0.4 N 30# ALGN LT DOOR TO BODY 0.5 N 31* ALGN RT DOOR SHELL W/O LIMITED 0.5* 32 FRONT BUMPER 33 O/H FRONT BUMPER 1.3 34** REPL QUAL REPL PARTS FACE BAR DARK 1 155.00 INCL. 1.4 GRAY 35 ADD FOR CLEAR COAT 0.6 36** REPL QUAL REPL PARTS RT FACE BAR 1 19.00 INCL. MOUNT BRACKET 37** REPL QUAL REPL PARTS LT FACE BAR 1 19.00 INCL. MOUNT BRACKET 38** REPL QUAL REPL PARTS VALANCE PANEL 1 81.00 INCL. 1.0 W/O LIMITED 39 OVERLAP MAJOR NON-ADJ. PANEL -0.2 40 ADD FOR CLEAR COAT 0.2 41 REPL RT BUMPER GUARD MOUNT 1 63.08 42 REPL LT BUMPER GUARD MOUNT 1 63.08 43 GRILLE 44** REPL QUAL REPL PARTS GRILLE DARK 1 85.00 INCL. 0.5 GRAY 45 REPL LT FILLER PANEL 1 20. 98 0.1 0.2 46 FRONT LAMPS 47 R&I RT PARK LAMP ASSY TO 1/97 INCL, 48** REPL QUAL REPL PARTS RT SIGNAL 1 33.00 INCL. LAMP ASSY 49** REPL QUAL REPL PARTS LT SIGNAL 1 33.00 INCL. LAMP ASSY h ecf e ge c e e ......... ......... ......... ......... ......... ......... ........._....... ...... .......... ......... ........... ...._...._....._.._...........__....... ._....... ......... ......... ......... ......... Page 3 of 15 50 R&I LT PARK LAMP ASSY TO 1/97 INCL. 51 S01 ' REPL RT HOUSING 1 45.18 0.3 52 S01 REPL LT HOUSING 1 45.18 0.3 53 S01 AIM HEADLAMPS 0.5 54 HOOD 55 BLND HOOD 1.5 56 S01 R&I R&I HOOD ASSY 0.5 2 08/27/2003 AT 09.51 AM 0115695330101022-01 44940 SUPPLEMENT OF RECORD 1 WITH SUMMARY 1996 TOYO 4RUNNER 4X2 4-2.7L-FI 4D UTV BLACK -------------------------------------------------------------------------------- NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT ------------------------------------------------------------------------------- 57 S01 REPL LOCK 1 39.70 INCL. 58 WINDSHIELD 59* R&I RT NOZZLE 0.2* 60* R&I LT NOZZLE 0.2* 61 FENDER N 62 REPL LT FENDER BASE & SR5 W/O FLARE 1 240.02 1.8 2.0 63 OVERLAP MAJOR NON-ADJ. PANEL -0.2 64 ADD FOR CLEAR COAT 0.4 65 ADD FOR EDGING 0.5 66 DEDUCT FOR OVERLAP -0.4 67 R&I LT FENDER LINER INCL. 68 PILLARS, ROCKER & FLOOR 69 R&I LT ROCKER MOLDING LIGHT GRAY 0.5 70# MISC 1 71# SUBL HAZARDOUS MATERIAL DISPOSAL 1 3.00 X 72# REPL MASK FOR OVERSPRAY 1 8.00 N 73# S01 RPR FRAME REPAIR 6.0 F 74 S01 QUARTER PANEL 75* S01 RPR RT QUARTER PANEL W/O LIMITED 2.0* 2.5 W/O OPNG MLDG 76 S01 OVERLAP MAJOR ADJ. PANEL -0.4 77 S01 ADD FOR CLEAR COAT 0.4 78* S01 RPR LT QUARTER PANEL W/O LIMITED 2.0* 2.5 W/O OPNG MLDG 79 Sol OVERLAP MAJOR ADJ. PANEL -0.4 80 Sol ADD FOR CLEAR COAT 0.4 81 S01 R&I RT QTR GLASS TOYOTA GRAY, W/O 1.5 ANTENNA 82 S01 R&I LT QTR GLASS TOYOTA GRAY, W/O 1.5 ANTENNA 83 S01 AIR CONDITIONER & HEATER 84**S01 REPL QUAL REPL PARTS CONDENSER ASSY 1 182.00 MINCL. 85 S01 EVACUATE & RECHARGE M 1.4 M 86 S01 REFRIGERANT RECOVERY M 0.4 M 87 S01 COOLING h eef e ge c e e Page 4 of 15 88 S01 REPL SUPPORT ASSY 1 379.22 6.5 1.5 89 Sol ADD FOR AC OPTION M 0.5 M 90 Sol ADD FOR AUTO TRANS M 0.2 M 91 S01 REPL LOCI{ SUPPORT 1 29.10 INCL. 92 S01 FRAME 93 S01 REPL LT FRONT EXTN 1 44 .53 ------------------------------------------------------------------------------- SUBTOTALS ==> 2266.41 44 .4 20.4 LINE 6 SPOT REFINISH PER DAVE NEED REPLACEMENT SAFETY PRICE PER SHOP LINE 10 : 6.0 OUTER PANEL 2.0 INNER SHELL LINE 24 : AGREED PRICE WITH DAVE LINE 30 : AGREED PRICE WITH DAVE 3 08/27/2003 AT 09:51 AM 0115695330101022-01 44940 SUPPLEMENT OF RECORD 1 WITH SUMMARY 1996 TOYO 4RUNNER 4X2 4-2.7L-FI 4D UTV BLACK LINE 31 : AGREED PRICE WITH DAVE LINE 62 : AGREED PRICE WITH DAVE LINE 73 : 2.0 SETUP 2.0 SWAY AGREED PRICE WITH DAVE 2 HR ADDITIONAL AFTER BUMPER WAS REMOVED -------------------------------------------------------------------------------- ESTIMATE NOTES: PC:2 C0:01 OLD DAMAGE ON VEHICLE AT TIME OF INSPECTION 2 1.0 DENTS TO HOOD, RT REAR BUMER EXTENSION WAS DMGD PRIOR TO LOSS. ESTIMATE WAS WRITTEN FOR VISIBLE DAMAGE ONLY. RATES ARE LOCAL PREDOMINANT FOR THE AREA. OWNER WAS NOTIFIED IN WRITING AND VERBALLY OF RENTAL CAR LIMITS. LKQ OR A/M PARTS WERE AVA FOR THIS VEHICLE. OWNERSHIP OF VEHICLE WAS VERIFIED THROUGH VISUAL CONFIRMATION OF DOCUMENTS. PARTS 2263.41 BODY LABOR 35. 9 HRS @$ 34.00/HR 1220. 60 PAINT LABOR 20.4 HRS @$ 34.00/HR 693.60 MECHANICAL LABOR 2.5 HRS @$ 55.00/HR 137.50 FRAME LABOR 6.0 HRS @$ 45.00/HR 270.00 PAINT SUPPLIES 350.00 SUBLET/MISC. 3.00 ---------------------------------------------------- SUBTOTAL $ 4938.11 SALES TAX $ 2613.41 @ 8.2500% 215. 61 ---------------------------------------------------- TOTAL COST OF REPAIRS $ 5153.72 ADJUSTMENTS: h ecf e ge c e e ..... . ..... .... ...... Page 5 of 15 DEDUCTIBLE 500.00 ---------------------------------------------------- TOTAL ADJUSTMENTS $ 500.00 NET COST OF REPAIRS $ 4653.72 THIS IS NOT AN AUTHORIZATION TO REPAIR NO SUPPLEMENT WILL BE HONORED UNLESS AUTHORIZED BY GEICO DIRECT NOTICE: NEW HIGH STRENGTH STEELS MAY REQUIRE THE USE OF MIG WELDER FOR PROPER REPAIRS. NEW DESIGNS REQUIRE MEASUREMENT TO PROPERLY ALIGN THE VEHICLE. MAKE SURE YOUR SHOP HAS THE RIGHT EQUIPMENT TO REPAIR YOUR VEHICLE. 4 08/27/2003 AT 09:51 AM 0115695330101022-01 44940 SUPPLEMENT OF RECORD 1 WITH SUMMARY 1996 TOYO 4RUNNER 4X2 4-2.7L-FI 4D UTV BLACK 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 AWAPPROXIMATE 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 PATHWAYS: 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 QUAL RECY=QUALITY RECYCLED PART QUAL REPL=QUALITY REPLACEMENT PART COMP REPL PARTS=COMPETITIVE REPLACEMENT PARTS 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 WI =WITH/_ SYMBOLS: #=MANUAL LINE ENTRY *=OTHER [IE. .MOTORS DATABASE INFORMATION WAS CHANGED] **=DATABASE LINE WITH AFTERMARKET N=NOTES ATTACHED TO LINE. MQVP=MANUFACTURER'S QUALIFICATION AND VALIDATION PROGRAM, ESTIMATE CALCULATED USING A PRESET USER THRESHOLD AMOUNT FOR THE PAINT AND MATERIAL COST. 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. h ecf e ge c e e .............................................................. Page 6 of 15 IF QUALITY REPLACEMENT PART (QRP) APPEARS ON THIS ESTIMATE., IT INDICATES THAT THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF ONE OR MORE CRASH PARTS SUPPLIED BY A SOURCE OTHER THAN THE MANUFACTURER OF YOUR MOTOR VEHICLE WARRANTIES, IF ANY, APPLICABLE TO THESE REPLACEMENT CRASH PARTS ARE PROVIDED BY THE PARTS MANUFACTURER OR DISTRIBUTOR RATHER THAN BY THE MANUFACTURER OF YOUR VEHICLE. *** IN ADDITION TO ANY SUCH WARRANTIES, GEICO PROVIDES THE FOLLOWING: OWNER LIMITED WARRANTY**** WE WARRANT THAT ALL QUALITY REPLACEMENT BODY PARTS (PARTS NOT MANUFACTURED BY THE MANUFACTURER) IDENTIFIED ON YOUR ESTIMATE, ARE FREE OF DEFECTS IN MATERIAL AND WORKMANSHIP AND MEET GENERALLY ACCEPTED INDUSTRY STANDARDS THIS PARTS AND LABOR WARRANTY WILL BE IN EFFECT FOR AS LONG AS YOU OWN THE VEHICLE DESCRIBED IN THE ESTIMATE. THIS WARRANTY COVERS COST OF THE PART, LABOR TO INSTALL, AND INCIDENTALS SUCH AS PAINT AND MATERIALS AND IS SPECIFICALLY LIMITED TO THOSE ITEMS. THIS WARRANTY DOES NOT COVER LOSS OR DAMAGE THAT IS UNRELATED TO DEFECTS IN THE QUALITY REPLACEMENT PARTS. THIS IS NOT TRANSFERABLE IF ANY QUALTY REPLACEMENT PARTS ARE DEFECTIVE IN EITHER MATERIAL OR WORKMANSHIP, CONTACT YOUR GEICO REPRESENTATIVE. 08/27/2003 AT 09:51 AM 0115695330101022-01 44940 SUPPLEMENT OF RECORD 1 WITH SUMMARY 1996 TOYO 4RUNNER 4X2 4-2.7L-FI 4D UTV BLACK ESTIMATE BASED ON MOTOR CRASH ESTIMATING GUIDE. UNLESS OTHERWISE NOTED ALL ITEMS ARE DERIVED FROM THE GUIDE ARM8414 DATABASE DATE 7/2003 AND THE PARTS SELECTED ARE OEM-PARTS MANUFACTURED BY THE VEHICLES ORIGINAL EQUIPMENT MANUFACTURER. ASTERISK (*) OR DOUBLE ASTERISK (*-) INDICATES THAT THE PARTS AND/OR LABOR INFORMATION PROVIDED BY MOTOR MAY HAVE BEEN MODIFIED OR MAY HAVE COME FROM AN ALTERNATE DATA SOURCE. TILDE SIGN (-) ITEMS INDICATE MOTOR NOT-INCLUDED LABOR OPERATIONS. NON-ORIGINAL EQUIPMENT MANUFACTURER AFTERMARKET PARTS ARE DESCRIBED AS AM, QUAL REPL PARTS OR COMP REPL PARTS WHICH STANDS FOR COMPETITIVE REPLACEMENT PARTS. USED PARTS ARE DESCRIBED AS LKQ, QUAL RECY PARTS, RCY, OR USED. RECONDITIONED PARTS ARE DESCRIBED AS RECON. RECORED PARTS ARE DESCRIBED AS RECORE. NAGS PART NUMBERS AND PRICES ARE PROVIDED FROM NATIONAL AUTO GLASS SPECIFICATIONS, INC. POUND SIGN ITEMS INDICATE MANUAL ENTRIES. PATHWAYS - A PRODUCT OF CCC INFORMATION SERVICES INC. h ecf e gec e e _.._._ ......... ......... ......... .. ......... ......... ......... ......... ......... ......... ......... ................. __............_................_................ Page 7 of 15 6 08/27/2003 AT 09:51 AM 0115695330101022-01 44940 SUPPLEMENT OF RECORD 1 WITH SUMMARY 1996 TOYO 4RUNNER 4X2 4--2.7L-FI 4D UTV BLACK -------------------------------------------------------------------------------- NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT --------------------------------------------------------------------------------- ------- CHANGED ITEMS------- N 5# REFN TOW HITCH -0.5 N 6# S01 REPL TOW` HITCH 1 314.55 1.5 41** REPL QUAL REPL PARTS GRILLE DARK 1 GRAY -85.00 -0.4 -0.5 44**S01 REPL QUAL REPL PARTS GRILLE DARK 1 GRAY 85.00 INCL. 0.5 44 R&I RT PARK LAMP ASSY TO 1/97 -0.2 47 S01 R&I RT PARK LAMP ASSY TO 1/97 INCL. N 65# RPR FRAME REPAIR -4.0 F N 73# S01 RPR FRAME REPAIR 6.0 F h ecf e ge c e e .......... .... ._.. ._.. ...... Page 8 of 15 -------- ADDED ITEMS ------- 7 S01 REPL RT FACE BAR MOUNT BRACKET 1 14.78 INCL. 8 S01 REPL LT FACE BAR MOUNT BRACKET 1 1.4 .78 INCL. 51 S01 REPL RT HOUSING 1 45. 18 0.3 52 SOl REPL LT HOUSING 1 45. 18 0.3 53 SO1 AIM HEADLAMPS 0.5 56 S01 R&I R&I HOOD ASSY 0.5 57 SO1 REPL LOCK 1 39.70 INCL. 74 SO1 QUARTER PANEL 75* SO1 RPR RT QUARTER PANEL W/O LIMITED W/O OPNG MLDG 2.0* 2.5 76 SO1 OVERLAP MAJOR ADJ. PANEL -0.4 77 SO1 ADD FOR CLEAR COAT 0.4 78* S01 RPR LT QUARTER PANEL W/O LIMITED W/O OPNG MLDG 2.0* 2.5 79 SOl OVERLAP MAJOR ADJ. PANEL -0.4 80 SOl ADD FOR CLEAR COAT 0.4 81 SO1 R&I RT QTR GLASS TOYOTA GRAY, W/O ANTENNA 1.5 82 SO1 R&I LT QTR GLASS TOYOTA GRAY, W/O ANTENNA 1.5 83 S01 AIR CONDITIONER & HEATER 84**SO1 REPL QUAL REPL PARTS CONDENSER ASSY 1 182.00 MINCL. 85 SO1 EVACUATE & RECHARGE M 1.4 M 86 SOl REFRIGERANT RECOVERY M 0.4 M 87 S01 COOLING 88 S01 REPL SUPPORT ASSY 1 379.22 6.5 1.5 89 SOl ADD FOR AC OPTION M 0.5 M 90 SOl ADD FOR AUTO TRANS M 0.2 M 91 SO1 REPL LOCK SUPPORT 1 29.10 INCL. 92 SO1 FRAME 93 S01 REPL LT FRONT EXTN 1 44 .53 ------------------------------------------------------------------------------- SUBTOTALS ==> 1109.02 20.5 6.0 LINE 6 : SPOT REFINISH PER DAVE NEED REPLACEMENT SAFETY PRICE PER SHOP 7 08/27/2003 AT 09:51 AM 0115695330101022-01 44940 SUPPLEMENT OF RECORD 1 WITH SUMMARY 1996 TOYO 4RUNNER 4X2 4-2.7L--FI 4D UTV BLACK LINE 73 : 2.0 SETUP 2.0 SWAY AGREED PRICE WITH DAVE 2 HR ADDITIONAL AFTER BUMPER WAS REMOVED ------------------------------------------------------------------------------- ESTIMATE NOTES: PC:2 CO:01 h ecf e ge c e e Page 9 of 15 OLD DAMAGE ON VEHICLE AT TIME OF INSPECTION 2 1.0 DENTS TO HOOD, RT REAR BUMER EXTENSION WAS DMGD PRIOR TO LOSS. ESTIMATE WAS WRITTEN FOR VISIBLE DAMAGE ONLY. RATES ARE LOCAL PREDOMINANT FOR THE AREA. OWNER WAS NOTIFIED IN WRITING AND VERBALLY OF RENTAL CAR LIMITS. LKQ OR A/M PARTS WERE AVA FOR THIS VEHICLE. OWNERSHIP OF VEHICLE WAS VERIFIED THROUGH VISUAL CONFIRMATION OF DOCUMENTS. PARTS 1109.02 BODY LABOR 15.1 HRS @$ 34 .00/HR 513.40 PAINT LABOR 6.5 HRS @$ 34 .00/HR 221.00 MECHANICAL LABOR 2.5 HRS @$ 55.00/HR 137.50 ADDITIONAL SUPPLEMENT LABOR 103.60 PAINT SUPPLIES 6.5 HRS @$ 24 .00/HR 156.00 ADDITIONAL SUPPLEMENT YIATERIALS/SUPPLIES -151.60 ---------------------------------------------------- SUBTOTAL $ 2088. 92 SALES TAX $ 1113.42 @ 8.2500% 91.86 ---------------------------------------------------- TOTAL SUPPLEMENT AMOUNT $ 2180.78 NET COST OF SUPPLEMENT $ 2180.78 ESTIMATE 2972. 94 MARK VALDEZ SUPPLEMENT Sl 2180.78 BRUCE HALEY -------- TOTAL ADJUSTMENTS $ 500.00 WORKFILE TOTAL $ 5153.72 NET COST OF REPAIRS $ 4653.72 THIS IS NOT AN AUTHORIZATION TO REPAIR NO SUPPLEMENT WILL BE HONORED UNLESS AUTHORIZED BY GEICO DIRECT NOTICE: NEW HIGH STRENGTH STEELS MAY REQUIRE THE USE OF MIG WELDER FOR PROPER REPAIRS. NEW DESIGNS REQUIRE MEASUREMENT TO PROPERLY ALIGN THE VEHICLE. MAKE SURE YOUR SHOP HAS THE RIGHT EQUIPMENT TO REPAIR YOUR VEHICLE. 8 08/27/2003 AT 09:51 AM 0115695330101022-01 44940 SUPPLEMENT OF RECORD 1 WITH SUMMARY 1996 TOYO 4RUNNER 4X2 4-2.7L-FI 4D UTV BLACK 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 h ecf e ge c e e Page 10 of 15 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 PATHWAYS: 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 QUAL RECY=QUALITY RECYCLED PART QUAL REPL=QUALITY REPLACEMENT PART COMP REPL PARTS=COMPETITIVE REPLACEMENT PARTS 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. MQVP=MANUFACTURER'S QUALIFICATION AND VALIDATION PROGRAM. ESTIMATE CALCULATED USING A PRESET USER THRESHOLD AMOUNT FOR THE PAINT AND MATERIAL COST. 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. IF QUALITY REPLACEMENT PART (QRP) APPEARS ON THIS ESTIMATE, IT INDICATES THAT THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF ONE OR MORE CRASH PARTS SUPPLIED BY A SOURCE OTHER THAN THE MANUFACTURER OF YOUR MOTOR VEHICLE WARRANTIES, IF ANY, APPLICABLE TO THESE REPLACEMENT CRASH PARTS ARE PROVIDED BY THE PARTS MANUFACTURER OR DISTRIBUTOR RATHER THAN BY THE MANUFACTURER OF YOUR VEHICLE. *** IN ADDITION TO ANY SUCH WARRANTIES, GEICO PROVIDES THE FOLLOWING: **** OWNER LIMITED WARRANTY**** WE WARRANT THAT ALL QUALITY REPLACEMENT BODY PARTS (PARTS NOT MANUFACTURED BY THE MANUFACTURER) IDENTIFIED ON YOUR ESTIMATE, ARE FREE OF DEFECTS IN MATERIAL AND WORKMANSHIP AND MEET GENERALLY ACCEPTED INDUSTRY STANDARDS THIS PARTS AND LABOR WARRANTY WILL BE IN EFFECT FOR AS LONG AS YOU OWN THE VEHICLE DESCRIBED IN THE ESTIMATE. THIS WARRANTY COVERS COST OF THE PART, LABOR TO INSTALL, AND INCIDENTALS SUCH AS PAINT AND MATERIALS AND IS SPECIFICALLY LIMITED TO THOSE ITEMS. THIS WARRANTY DOES NOT COVER LOSS OR DAMAGE THAT IS UNRELATED TO DEFECTS IN THE QUALITY REPLACEMENT PARTS. THIS IS NOT TRANSFERABLE IF ANY QUALTY REPLACEMENT PARTS ARE DEFECTIVE IN EITHER MATERIAL OR WORKMANSHIP, CONTACT YOUR GEICO REPRESENTATIVE. 9 08/27/2003 AT 09:51 AM 0115695330101022-01 h ecf c ge c e e ...................I.......................................................................................I............. ...................................................................................................................................... .............................. Page I I of 15 44940 SUPPLEMENT OF RECORD 1 WITH SUMMARY 1996 TOYO 4RUNNER 4X2 4-2.7L-Fl 4D UTV BLACK ESTIMATE BASED ON MOTOR CRASH ESTIMATING GUIDE. UNLESS OTHERWISE NOTED ALL ITEMS ARE DERIVED FROM THE GUIDE ARM8414 DATABASE DATE 7/2003 AND THE PARTS SELECTED ARE OEM-PARTS MANUFACTURED BY THE VEHICLES ORIGINAL EQUIPMENT MANUFACTURER. ASTERISK (*) OR DOUBLE ASTERISK (**) INDICATES THAT THE PARTS AND/OR LABOR INFORMATION PROVIDED BY MOTOR MAY HAVE BEEN MODIFIED OR MAY HAVE COME FROM AN ALTERNATE DATA SOURCE. TILDE SIGN (-) ITEMS INDICATE MOTOR NOT-INCLUDED LABOR OPERATIONS. NON-ORIGINAL EQUIPMENT MANUFACTURER AFTERMARKET PARTS ARE DESCRIBED AS AM' QUAL REPL PARTS OR COMP REPL PARTS WHICH STANDS FOR COMPETITIVE REPLACEMENT PARTS. USED PARTS ARE DESCRIBED AS LKQ, QUAL RECY PARTS, RCY, OR USED. RECONDITIONED PARTS ARE DESCRIBED AS RECON. RECORED PARTS ARE DESCRIBED AS RECORE. NAGS PART NUMBERS AND PRICES ARE PROVIDED FROM NATIONAL AUTO GLASS SPECIFICATIONS, INC. POUND SIGN ITEMS INDICATE MANUAL ENTRIES. PATHWAYS - A PRODUCT OF CCC INFORMATION SERVICES INC. 10 h cef e ge c e e Page 12 of 15 08/27/2003 AT 09:51 AM 0115695330101022-01 44940 SUPPLEMENT OF RECORD 1 WITH SUMMARY 1996 TOYO 4RUNNER 4X2 4-2.7L-FI 4D UTV BLACK ALTERNATE PARTS SUPPLIERS 3 QUAL REPL PARTS FACE BAR DA PART NO. T01102220 PRICE 150.00 34 QUAL REPL PARTS FACE BAR DA PART NO. T01002161 PRICE 155.00 36 QUAL REPL PARTS RT FACE BAR PART NO. T01067121 PRICE 19.00 37 QUAL REPL PARTS LT FACE BAR PART NO. 701066121 PRICE 19.00 38 QUAL REPL PARTS VALANCE PAN PART NO. T01095174 PRICE 81.00 44 QUAL REPT, PARTS GRILLE DARK PART NO. 701200203 PRICE 85.00 48 QUAL REPL PARTS RT SIGNAL L PART NO. T02531125 PRICE 33.00 49 QUAL REPL PARTS LT SIGNAL L PART NO. T02530125 PRICE 33.00 KEYSTONE W/O SM - B (619) 656-2050 1670 BRANDYWINE AVE. #D SAN DIEGO, CA 91911 KEYSTONE W/O SM - B (800)421-7866 610 EAST STATE ST (909) 986-4586 ONTARIO, CA 91761 KEYSTONE W/O SM - B (800)794-6911 1069 HENSLEY STREET (510)234-6960 RICHMOND, CA 94801 KEYSTONE W/O SM - B (800)339-5033 1927 SOUTH VAN NESS (209)268-8146 FRESNO, CA 93721 84 QUAL REPL PARTS CONDENSER A PART NO. CA01989 PRICE 182.00 1-800 RADIATOR HOTLINE (800)472-7016 2990 BAY VISTA CT. BENICIA, CA 94510 1-800 RADIATOR HOTLINE (800) 472-7016 3018 ALVARADO #C SAN LEANDRO, CA 94577 1-800 RADIATOR HOTLINE (800)472-7016 5821 FLORIN PERKINS SACRAMENTO, CA 95828 1-800 RADIATOR HOTLINE (800) 472-7016 196 BARNARD AVE. SAN JOSE, CA 95125 1-800 RADIATOR HOTLINE (800) 472-7016 1550 S. SUNKIST ST. UNIT I ANAHEIM, CA 92806 h eef e ge c e e ......... ......... ......... ......... ......... ......... ....... .. ...... ........... ............ ......... ......... ......... ......... ......... ......... ......... .............. .... .._....... ......... ......... ......... Page 13 of 15 11 08/27/2003 AT 09:51 AM 0115695330101022-01 44940 SUPPLEMENT OF RECORD 1 WITH SUMMARY 1996 TOYO 4RUNNER 4X2 4-2.7L-Fl 4D UTV BLACK ALTERNATE PARTS SUPPLIERS 1-800 RADIATOR HOTLINE (800) 472-7016 10773 SHERMAN WAY SUN VALLEY, CA 91362 1-800 RADIATOR HOTLINE (800)472-7016 603 S. MILLIKEN #E ONTARIO, CA 91761 1-800 RADIATOR HOTLINE (800) 472-7016 825 CIVIC CENTER DR. #4 SANTA CLARA, CA 95050 1-800 RADIATOR HOTLINE (800) 472-7016 1550 SOUTH SUNKIST, SUITE 1 GARDEN GROVE, CA 92806 1-800 RADIATOR HOTLINE (800) 472-7016 10773 SHERMAN WAY NORTH HOLLYWOOD, CA 91352 h eef e ge c e e ......... ......... ......... ......... ......... ......... ......... ......... ........._.. 11.1.1. ........ ....................................._.... ......... .._......_....__.._. ...._.......... _......... ......... ......... ......... ......... Wage 14 of 15 12 08/27/2003 AT 09:51 AM 0115695330101022-01 44940 SUPPLEMENT OF RECORD 1 WITH SUMMARY 1996 TOYO 4RUNNER 4X2 4-2.7L-FI 4D UTV BLACK ALTERNATE PARTS USAGE AFTERMARKET PARTS AFTERMARKET SELECTION METHOD: AUTOMATICALLY LIST NO. OF TIMES USER WAS NOTIFIED THAT AN AFTERMARKET PART WAS AVAILABLE: 11 NO. OF AFTERMARKET PARTS THAT APPEAR IN THE FINAL ESTIMATE: 9 h ecf e ge c e e ............................................................................. ......I....I...........I................................. Page 15 of 15 13 eef e ge c e e Estimate Phows 4 Claim 0115695330101022®01-O fags z of 5 AD Query ;Estimate Photo 01 for Claim Number 0115695330101022-01-01 iThoto da.te;27/08/2003 09:06:22:00 Size."60728 IDescr€ptio t Insured:BELMO TE, GALICANT IO Policy Number-.45789030 •.Vebiclea96, TOMO, 4RLTNNER 4X2 VI :JT3 M84R2T0005283 Loss date.-06/17/03 Esfimator:MARK VALDEZ E } i a Estimate Photo 02 for Claim Number 0115695330101022-01-01 h cef e ge c e Estima pe Photos - Caim 0115695330101022-01-01 Page 2 of 5 E Photo date-.27/08/2003 09:06:23:00 Size:160516 E Description: Insure :BEL,? ONNTE, GAL,ICAN0 Policy N hcr:45`89030 Vehicic:96, TOMO, 4RT TN--NER 4X2 VIN93T GM841=0005283 �Loss date:06/17/03 Estimator-MARK VAL DED # i stimate Photo 03 for Claim Number 0115695330101022-01-01 Photo date:27/08/2003 09:06:23:00 Size."!42484 Description: ;'Insured:BEL,MO TE, GAL,ICANO Policy hcr:45789030 Estimate Photos o Claim 0115695330101022901-0f Page 3 of 5 I Vehicle-.96, TOY 0, 4R1 NNER 4X2 VIN.TF3 M84PUT0005283 Loss datea06/17/03 ,Estimator- VALDEZ s y, d I� l Y„ � f E e e i c c stun. e Photo 04 for Claim Number 0115695330101022-01-01 Photo d te;2i/08/2003 09:06.24:00 Size:149716 il Description:Ins red.BELMO.LN TE, GAL ;Polley Number-.45789030 :Vehicle:96, TOYED, 4R1N-, INER4X2 ;VIN:3T3GM84R2TOE1E15283 loss date-06/17/03 [Esiimator':MARK VALDEZ h ed' ge e e e Estimate Photos - Claim 01 i5695330101022-01-01 Fags 4 of 5 ,A --------------------- --------------- 6 { estimate Photo 05 for Claim Number 0115695330101022-01-01 'Photo date;27/08/2003 09°06°24°00 Size:125212 Description: Policy Number:45789030 Vehicle:96. 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Mon p a 'wl' : rt,oma..',. .............:::::.... .................. :...: +S ) :r{ t y�x h .................................................. $S` d i t 1^6.. "4 IX a .3;. ~ t• i » za. 4.'e» vw� f f 4 i S ..::.;: {^ j ..-•: ,a„n...,. .rte r ............................ ....................::::.. :r t•. ::,•,'/ r, ............i is ai�:i..... 8 f r r�%'rJr. vx l _ y•C. C+ } rte. ::: .................. C i' CLAIM BC? OF SUPERVISORS OF CONTRA COSTA fiJUITY BOARD ACTION: OCTOBER 07, 2003' Claim Against the County, or District Governed by ) the Board of Supervisors,Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action, All Section references are to ) The copy of this document mailed to you is your California Government Codes. ) notice of the action taken on your claim by the Board of Supervisors, (paragraph IV below), given Pursuant to Government Code Section 913 and 915.4. Please ngte alj,"Wamings' AMOUNT: $16,324.08ti � � } CLAIMANT: OREGON MUTUAL INSURANCE COMPANY FOR: BARBARA BREASHERS `A <NT�-,'i ,u yw7E1 ATTORNEY: MICHAEL R. AUDLEY DA'Z'E Rlft � C's?�€5- AUGUST 25, 2003 ADDRESS. 1AW OFFICES OF AUDLEY AND AUDLEY BY DELIVERY TO CLEF:ON: .AUGUST 25, 2003 80 EL CAMINO REAL BERMEY,''CA 04705 BY MAIL POSTMARKED: AUGUST 12, 2003 FROM: Clerk of the ward of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. AUGUST 25 2003 JOIN SWEE k Dated: , $y: Deputy II. FROM: County Counsel 57 Clerk of the Board of Sup sons This claim complies substantially with Sections 910 and 910.2. ( ) This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days(Section 910.8). { ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim(Section 911.3). { ) Other: Dated: By: Deputy County Counse: III, FROM: Clerk of the Board TO: County Counsel(1) County Administrator(2) { ) Claim was returned as untimely with notice to claimant(Section 9113). IV. ,ARD ORDER,: By unanimous vote of the Supervisors present: This Claim is rejected in full, { ) Other: I certify that this is a true and correct'copy of the Board's Order entered in its minutes for this date. Dated: 3 JOHN SWEETEN, CLERK, By , Deputy Clerk WARNING(Gov. code section 913) Subject o certain exceptions, you Have only six(6)months from the date this notice was personally served or deposited in the '1 to file a court action on this claim. See Government Code Section 945.5. You may seek the advice of an attorne of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. *For Additional Earning See Reverse Side of This Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned,have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California,postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed'to the claimant as shown above. Dated: an4v 4 oAA3 JOHN SWEETEN,CLERK By Deputy Clerk ......... _..._....._.. _. ._ ......... ........... ......... ............ . _...... ......... ........ ... _... LAW OFFICES AUDLEY&AUDLEY 80 FL CAMINO REAL r:a >.`•" , BERKELEY,CA 94705 3 } (510)548-4740 °f�� 0,AUG �'? FAx(510) 548-7886 EMAIL:MIKE@?Q AUD1,EYI.,AW.00M R.RICHARD AUDLEY ORINDA OFFICE s MICHAEL R.AUDLEY (925)258-6813 AIS�IAWAII BAR E C August 12,2003 D J i t AUG S V i 0031 Contra Costa County Li 111 U Dept Public Works 255 Glacier Dr PUBLIC WORKS DEPT � Martinez,CA 94553 File Name: BREASHEARS D/Loss: 3/20/03 Claim#: 680517 Our File: 24.266 Dear Sir or Madam: This office has been retained by Oregon Mutual Insurance Company to assist it in its efforts to recover the money it paid on behalf of its insured,Barbara Breashears, for damage she suffered when her automobile struck a fallen tree on Olympic Blvd, in Walnut Creek, on March 20, 2003. That tree was located on property owned and controlled by you and we are informed that the tree in question had already been identified as needing care by you. At present the damages suffered by Mrs Breashears and Oregon Mutual total$16,324.08 and that amount is due from you, as the tree constituted a dangerous condition on your property, of which you were aware,when it fell and caused the collision in question. Pursuant to California Govenment Code sections 910 and 910.2,please consider this claim as brought pursuant to law and in accordance with all requirements set forth therein. If the County has a specific form it uses for the submission of property damage claims, then Oregon Mutual will complete such a form upon receipt,but in so doing it does not waive its reliance on this letter as complying with the applicable filing requirements and meeting all statutes of limitation regarding such filing. We expect to hear from you i ediately regarding this claim. Thank you for your time and consideration in this matter. Should you have any questions or comments regarding the foregoing,please feel free to contact this office. Very truly y , L ES OF AUDLEY&AUDLEY ae }idleY c; c eI t a k g q ,•\( .3.1 1 wry l m'ra�.S Et k .i3:f3 cc .�.,C3 Us LO ?C U-) Us .:. U0 na c ss►n U LL co 0 -J (D i © W rn - c 4 uUL Ecc � o 3: -' �u � co � CLAIM Bl7A �? SUPERVISORS •F CONTRA COSTAO'CiNTY BOARD ACTION: OCTOBER 47, 2043 Claim Against the County,or District Governed by ) the Beard of Supervisors,Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to you is your California Government Cedes. ) notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), given { Pig uant to Government Cade Section 913 and < 1`aA. Please nate all"Warnings". r AMOUNT: In excess of $25,000,40 4 CLAIMANT: CASSANDRAGYBE .. A.Jf•:.:.. ATTORNEY: DARRELL JOE CAMBELL, ESQ. DATE RECEIVED: AUGUST 26, 2003 ADDRESS: LAW OFFICES OF EUGENE M. HANNON, P DELIVERY TO CLERK ON: AUGUST 26, 2003 1846 BONANZA STREET, WALNUT CREEK, CA 94596 BY MAIL POSTMARKED: HAND DELIVERED FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SW E T Clerk Dated: AUGUST 26, 2043 By: Deputy H. FROM: County Counsel TO: Clerk of the Board of Supeftisoirs Ilk- This claim complies substantially with Sections 910 and 910.2, ( ) This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant, The Board cannot act for 15 days(Section 910.8). ( } Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim(Section 911.3). ( } Other: S Date By: < IMDeputy County Counse; III. FROM:' Clerk of the Board TO: County Counsel(1) County Administrator(2) ( ) Claim was returned as untimely with notice to claimant(Section 911.3), IV. JUYARD ORDER: By unanimous vote of the Supervisors present: ti ( This Claim is rejected in full. ( } Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Bated: JOHN SWEETEN, CLERK, By , Deputy Clerk WARNING(Gov. code recti 913) Subject o certain exceptions, you have only six(6)months from the date this notice was personally served or deposited in the `l to file a court action on this claim. See Government Code Section 945.6, You may seek the advice of an attorne of your choice in connection with this:matter. If you want to consult an attorney, you should do so immediately. *For Additional Warnin See Reverse Side of This Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now,and at all times herein mentioned.,have been a citizen of the United States, over age 1$, and that today I deposited in the United States Postal Service in Martinez, California,postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed'to the claimant as shown above. Dated: JOAN SWEETEN, CLERK.By Deputy Clerk CLAIM AGAINST COU ONTRA COSTA A �(yy�' THE CGl1N'}''�f OFC4. �". 1.9 200 {Government Code Section 910. et seq.l �� �J un . Name, address and phone number of claimant. Cassandra Esq. 1806 Bonanza Street, Walnut Creek, CA 94596; {925) 938--2188 Name, address and phone number of person to receive notices concerning this claim. Contra Costa County c/o Board of Supervisors, 651 Pine Street, Martinez, CA 94553; cc: County counsel, 651 Pine St. , Martinez, CA 94553 Date and time when damage or injury occurred. On or about 2/2 7/03 Location of occurrence. Adventist Health, California Specialty Hospital, 525 Oregon St. , Vallejo, CA 94590 Circumstances of occurrence. Whi I n being car fpr an a & An i nr_h1Mf- F)i abs3 injury to Cassandra Bybee resulting in breaking of her leg. Description of toss, damage or Injury. Medical ex enses for treatment of broken le mental and emotional injury, pain and sufferin , future medical bjlls, past and future wage loss Name(s) of County employee(s) causing injury, damage or loss, it known. Possibly "Ken" ,- no further information known at this time J Amount claimed at present Including estimated amount of any prospective loss. In excess of $25, 000 Names and *ddraesses of witnesses, doctors and/or hospitals. f-Ken" , "Tanya" and Dr. Mason at Adventist' Health, California Specialty Hospital, 525 Oregon Street, Valle_ o CA 94590 Claire must be signed and dated by claimant or person acting on claimant's behalf. LAW OFFICES OF EUGENE M. HANNON, PLC By: DARRELL JOE CAMPBELL, ESQ. DATED: ����'_�.�x-� � !SINNED: Cialme {e} SEE SACK DF LAST PAGE FOR INSTRUCTIONS CLAIM • 11!2ARD OF SUPER'V'ISORS OF CONTRA COSTA COUNTY BQABR ACTIQN: OCTOBER 07, 2003 Claim Against the County, or District Governed by } the Beard of Supervisors,Routing Endorsements, } NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to you is your California Government Codes. } notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), given 1 pursuant to Government Code Section 913 and 915.4.Please nate all"Warnings". AMOUNT: $197.40 CLAIMANT' LETICIA SERRMO GA' ATTORNEY: UNKNOWN DATE DECEIVED: .AUGUST 27, 2003 ADDRESS: 3461 CORTESE CIRCLE BY DELIVERY TO CLERK ON: AUGUST 27, 2003 SAN JOSE, CA 95127 BY MAIL POSTMARKED: AUGUST 26, 2003 FROM., Clerk of the ward of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOAN SWEET Dated AUGUST 27 200 By: Deputy— H. >uty ,7II. FROM: County Counsel' TO Clerk of the Board of Supe ors (XX This claim complies substantially with Sections 910 and 910.2. { ) This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days(Section 910.5). { ) Claim is not timely filed. The Clem should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim(Section 911.3). ( ) Other: Dated: B : Deputy County Counse: M. FROM: Clerk of the Board TO: County Counsel(1) County Administrator(2) { } Claim was returned as untimely with notice to claimant(Section 911.3). IVB, flARi}ORDER: By unanimous vote of the Supervisors present: ( This Claim is rejected in full. ( ) Other, I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: .94e'.3 JOHN SWEETEN, CLERK, By Deputy Clerk WARNING(Gov. code section 913) Subject o certain exceptions,you have only six(6)months from the date this notice was personally served or deposited in the '1 to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorne of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. *Far Additional'W arm Lnj Spee Reverse Side of This Notice. AFFIDAVIT OF MAKING I declare under penalty of perjury that I am now, and at all times herein mentioned,have been a citizen of the United States,over age 1,8; and that today I deposited in the United States Postal Service in Martinez, California,postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: a-mss- JOHN SWEETEN,CLERK,By . Deputy Clerk _.. ._ ......._. ......... ......... ......... ......... ......... ......... ......_........ __.._. _.. .......... ._........ ......... ........_ ._.._.._. ...._.__. ......... ......... ......... ......... ......... Claim to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAMANT A. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or before December 31, 1987, must be presented not later than the 10&day after the accrual of the cause of action. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1988, must be presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Gov't',Code 911.2.). B. Claims must be filed with the Clerk of the Board of Supervisors at its ofl'ice1n Room 146,County Administration Building, 65I Pine Street,Martinez, CA 94553. C. If claim is against a district governed by the Board of Supervisors,rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. I. E. Fraud. See penalty for fraudulent claims,Penal Code Sec. 72 at the end of this form. RE: Claim By Reserved for Clerk's filing stamp L� ' } � Against the County of Contra Costa or } AUG 2 7 2003 # CLERK BOARD Or"��r-ERV€,OR District) CONTRA COSTA CO. S (Fill in name) ) The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the sum of and in support of this claim represents as follows: `351927. y.0 1. When did the damage or injury occur?(Give exactdate and hour} 2. 'Wheredid the damage or injury occur?(Include city and county) 3. How did the damage or injury occur?(Give full details,use extra paper if required) r 4. What particular act or omission on the part of county or district officers, servants, or employees caused the injury or damage? :S AA d ttO..611-0 01 5. What are the names of county or district officers, servants, or employees causing the damage or injury? 6. What damage or injuries do you claim resulted?(Give fish extent of injuries or damages claimed. Attach two estimates for auto damage.) _ 7. How was the amount claimed above computed?(include the estimated amount of any prospective injury or damage.) 8. Names and addresses of witnesses,doctors, and hospitals. Q,'.CK�1 9. List the expenditures you made on account of this accident or injury. DATE TIDE AMOUNT } Gov. Code Sec 910.3 provides"The claim must be } signed by the claimant or by some person on his behalf." SRM E —I&tatmu Name and Address of Attorney ) r } (Claimant's Signature) (Address) Telephone No. ) Dy Telephone No. q -2. o l' - Cot 3 ta-lc NOTICE Section 72 of the Penal Gide per: Every person who,with intent to d&aud,p mints for allowance or the payment to any state board or officer,or to any minty,city,or district board or officer,authorized to allow or part'the same if genuine,any false or fiaudulent claim,bilk wwunt, voucher,or writing,is punishable either by imprisonment in the c=rAy ja l for a period of not more than one year,by a fine of not exceeding este thousand(SI tom,or by both such imprisonment<and fine,or by imprisonment in the state prison,by a fine of not exceeding ten thousand dollars(S 10,000),or by both such imprisonment and fes. Claim to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY 1. When did the damage or injury occur? (Give exact date and hour) The damage occurred on Monday July 215, 2003 around loam. 2. Where did the damage or injury occur? (Include city and county) The injury occurred on the Second Floor Surgery Waiting Room at the Contra Costa County Regional Medical Center in Martinez, California. That would be in Contra Costa County. 3. How did the damage or injury occur? (Give full details; use extra paper if required) I was waiting for my mother to get out of surgery. I went to sit down on one of the love seat sofas in the waiting room. It was the one located closest to the elevators. When I sat down on the sofa and rested my back on the backrest,it tilted back and we both fell backwards. I hit my head on the floor and my body rolled over towards my left side and off the sofa. I moved the sofa to its original standing position and noticed that one of the back legs was broken. In the early afternoon, when I went into the recovery area to pick up my mother I informed the nurse(Caroline Adelaine)of what had happened. She then informed the Nursing Program Manager(Caroline Billings)and they both removed the sofa from the waiting room area. At this time I simply had a mild headache. I took my mother home and proceeded back to San Jose, where I reside. That night I was very uncomfortable and could not sleep. I had a lump and a sharp pain in the back of my head,my neck was sore and my lower back was bothering me. On the mid-morning of July 22"d, 2003: I called Caroline Billings and asked her if an Unusual Occurrence Report had been filed and mentioned my discomfort. She mentioned she was would have one filed and if my head hurt that I should come into the hospital. I work and reside in San Jose, California. I had to take time off of work to head back to the hospital in Martinez, California to be treated in the Emergency Room at no charge. I was seen by Dr. Goldstein in the Emergency Room and given a pain killer and an anti-inflammatory drug. I was not able to obtain this medicine at the pharmacy, thus my own insurance paid for it. 4. What particular act or omission on the part of the county or district offices,servants,or employees caused the injury or damage? The sofa that was located on the 2"d Floor Surgery Waiting Room had a loose/broken back leg. My'accident was a result of this sofa's condition. Fortunately it was not a child or an elderly person who sat there. The injuries may have been greater. 5. What are the names of county or district officers,servants, or employees causing the damage or injury? The injury was caused by a discrepant sofa that was located in the 2°d Floor Surgery Waiting Room Area. When the sofa was lifted and taken out of the area by Caroline Billings and Caroline Adelaine, you could see the back leg wobbling while the other three were sturdy. Leticia Serrano vs.County of Contra Costa 8/25/03 1 of 2 6. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage) A bruised head,neck and back strain resulted from my falling back from the waiting room sofa and hitting my head on the floor. I had to take time off of work to be seen for these injuries (a total of 4 hours). I was advised by the nurse that if I was in pain that I should be seen at the Contra Costa County Regional Medical Center at no cost to me and thus had to drive all the way to Martinez from San Jose. (55 miles each way). Since my payment code had not been settled yet, I had to use own personal insurance to obtain my two prescriptions. I paid$20 out of pocket as my co-payment. My visit to the emergency roam was taken care of by the hospital. 7. Howe was the amount claimed above computed? (Include the estimate amount of any prospective injury or damage) Time off of work: $140 4 hours x$35/hour Mileage: $18.70 $0.34/mile x 54 miles[San Jose(work)to CCC Hospital] Mileage: $18.70 $0.34/mile x 56 miles [CCC Hospital to San Jose—(home)] Pharmacy $20 $Ia co-pay/prescription x 2 mschptions Total: 197.40 8. Names and addresses of witnesses,doctor,and hospitals. • The hospital where I was injured and seen was the Contra Costa County Regional Medical Center in Martinez, California • The nurses who removed the sofa from the waiting room and filled out the "Unusual Occurrence Report"were: Caroline Billings and Caroline Adelaine Caroline Billings—Nursing Program Manager: (925) 370-5343 or(925)603-4808 pgr Caroline Adelaine—Surgery Recovery Nurse: (925)370-5349 • I was treated by David Goldstein,M.D. in the Emergency Room of the Contra Costa County Regional Medical Center 2500 Alhambra Avenue Martinez,CA 34553 My patient number was: 74652744 9. List the expenditures you made on account of this accident or injury. They have all been listed above in Question#7. Leticia Serrano vs.County of Contra Costa 8125/03 2 of 2 �`ig� RA� �a � � L � � N°t`ER 1 't�Ca+lEC7I3TiitzBD eft©M 'R DEPARTMENT X t DUE TO: ©INJURY C]ILLNESS The Cara au`received here has been givlen on an,, v. :, kM e �# i �l Yc -�X t;�e # I�ler,teata or • y #� fesa'ftrt �. #T _*T � gamer y {!! RESTRICTIONS. ff.}rr�tr cl�ndlti©r} itrsevnpectedYY return; F: M here Cfysu feet your recc� erf is qct Pocee+tlirEg .yy}}'a'�.ry�j (re0 ,<. y ^ems �ry/� •"' xf Cor'}•ta�'it S�KK%SJ = ysio 4 Li t7 7 iJ Ad Nurse 1-800 4 5-8885: � i`RS7iUi: ' .ii '�t� i#�agta Si Sienle gi.:ie su,retbpdrR,01 �r d1d6mol wkpe .,. EQMATUf{ .y(��j,��L+ ..?! }k .1�7 �/. �I qol Vi�jla %i�1' Gl. . fE3(' '..5 1, y In r"""S 111 • 1/�jy' yl� �j /y,�y Abp y7 �}.y���/,�, a n rmera de L1Jnsela 1`-8W 49& 8885• n ; YI ti " F= PATE. DTHER] GIVEN: , M �lit` cl`` � � �`, +r }-dip! "!' E�#1MVE HOME FROM THIS VISIT; .c�':' •'.,:' .. � `, t{tUC"S'I41N8{)li ii�VE�SE�PAPENs PAktiD WSTRUdfi0US WVB ' CS E ,:Q:SPRAIAI f zT44ar ;Yf�M#TlttK 4 eIARRH AREADMS❑LiTt Q ASTHMA/CDPD ❑ XRAY GI• rnnese #❑#lif AD tR#7tIRY . CASTS J$PL#NT 5 ,. DLOS f'CLtt 0 EARLY PREGNANCY EAR#NFECT#DN { # Q DRtVINti GAUTIOH EYLZ:WJURY ❑BACK f NECKWAIR l-0- VARZON't"R%, t 0.VA,GINAL KEEPING,;:;�.ABWMIt,4X,_'AIN _i-i i Pqk IIA? Y, ❑ REGtN,,"Pft"DER OTHER MSTRUCTIONS. C AC AUN T WC3l�V AIL-PP TR"s.A3°IYOINTMEI�I !h1 SA S f lAt 1=K5 fiET1JJRN TO.)=EI�ERGSt1CY'dSFARTiAEN 1N DAYS x Q 4' I��E Li t c nl t r,�a amtT IrNr. , Q'M SS1�G �EFoT A�'.APP1✓JWTt rEAT.Uf T YOU i+ILL BE:CONTA�fBD *CLINIC` DAYS)WEEKS k#YY� !c�1 1 r�rvr wrsl til �PAW IF AIIAVE NaT r�i CpA1 rtTED ,xL> I�PPOtNTMENT-IANIT AT, � > . APPQIl1TiiEEI BCHEDkiLEI4 Q.NOS O A EN LAIatEFIKtE YEAS. CLItdC J PIkbVIDEfi 'SITE u coNTACTAD0 DENTIN>DE 2fAs HAsILES.si NO HA SIDO :.��#�WACTAW'OO,.lf:AME ALJS q-4 CLINIC t PROVIDER SITE, DATE TIME SIGNATURE ,y6U NEED 70 PiCIE;UF 1 LIN T DTH E 1 rfiUCT N'S S tftisnt Signa#ur®j REMAINDER OF M:DJFNP PRESCRIPTION ` TIME DIStJF#Af3{fED r` C3N A Cf35TA EGIONAL•MEDICAL CENTER EMERGENCY DEPARTMENT STRIVE TG DELIV04THE BEST POSSIBLE YOUR CC)MMENTS AND SUGGESTIONS;ON OUR PATIENT SURVEY ARE APPRECIATED. YOUR PROVIDER TODAY WAS. h BaCgr r M .0 G and I tartid M D;y N$il Jayasekera,M.D. ❑ Herbert Slgrr#bnd,M.D. ❑ Christian Weinman, M.D. , BeauC}arT#p .E., Q Jahn 1 !k fut D,"' john Pabers,M.D. ❑ Alan Spain',M.D. Q 1=red Seek,M.D. Chr�a,Farnita s�,M.D Q David leedy,'M.17. ❑ Mark Stin$on,W.D. Q Q !r#grltt}Beliwdod M.O.'4 3avld 6cl tetlt,M D d^Si ott Schmidt,Cvi.D. Q David'Stichow;M.D: e, ,, PATI�NT's GOpY rr.CnriClliriv AL'!!7 flti�t%Ywt?foC tl�iC'if+<l#!_'�7laN�k` CONTRA COSTA HEALTH SERVICES 595 CENTER AVENUE,SUITE 304 MARTINEZ, CALIFORNIA 94553 FINAL € 8/05/03 (925) 313.6500 OUT � tANr, LETICIAM '74652744 7rz«3 7l2 1t3 1 . LE'TICIA SERRANO PRIVATE PAY 3461 CORTESE CIRCLE SAN JOSE, CA 95127 PLEASE RETURN TOP"PORTION WITH YOUR PAYMENT 07ZZ03 1 EMERGENCY ROOM 45300003 65. 00 072203 1 ER BRIEF VISIT 45324398 38. 00 �8� Citi *« TOTAL EMERGENCY ROOM VISITS 103.00 1 f3'3„ 00 SUMMARY OF CHARGES BY DEP RTMENT EMERGENCY ROOM VISITS 103. 00 103'.'.00 SUB--TOTAL, CHARGES 103. 40 103i.U0 TOTAL LIABILITY 103. 00 1t 3« QO '. i 011 a ' 7 31 8651812.02-0001 103. 00 NU�REFER TO fAT1ENT A[SD1TtONht PATfEHT Kitt MAY ENE A f R A Y EiAf.i.INgU}AiES CNAAOES hit3T'Pt38TED WHEN Ti#IS Bitt WA$P ED OR , 7/ >iy' 2 4 ANOCORA99P0N0fNOS. IE INSURANCE ChRRfEfiB DD NOT PAY hNY f>Af3T{7F FH> AMOUNTS SHOWN UNDER EST{MATEp iNSURANCE COVEAAOE. s Make checks payable to.CONTRA COSTA HEALTH SERVICES d y m cis ..r a-c? P3 cis � t `j CLAIM BOARD OE SUPERVISORS OECONTRA CCISTA COUNTY BOA; ACTION: OCTOBER 07, 200' M II Claim Against the County,or District Governed by ) the Board of Supervisors,Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to you is your California Government Codes. ) notice of the action taken on your claim by the r� .x ... Board'of Supervisors.(Paragraph IV below), given x <. Pursuant to Government Code Section 913 and w 915.4. Please note all"Warnings". AMOUNT. UNKNOWN , CLAIMANT: jUERGEN' WELTZ ATTORNEY: UNKNOWN DATE RECEIVED: AUGUST 27, 2003 ADDRESS: 137 BRITANNIA COURT BY DELIVERY'T'O CLERK ON: AUGUST 27, 2003 vALLE,30, CA 94591 RECEIVED THROUGH BY MAIL POSTMARKED: INTEROFFICE MAIL FROM: Clerk of the.Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SE Clerk Dated: AUGUST 27, 2003 By: Dep uty H. FROM: County Counsel TO: Clerk of the Board of Su isors This claim complies substantially with Sections 910 and 910.2. ( } This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days(Section 910.8). { } Clain is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim(Section 911.3). { } Other: Dated: B Deputy County Counse; III. FROM: Clerk of the Board TO: County Counsel(1) County Administrator(2) { } Claim was returned as untimely with notice to claimant(Section 911.3). IVB ORDER: By unanimous vote of the Supervisors present: { This Claim is rejected in full. ( ? Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: '3JOHN SWEETEN, CLERK,By , Deputy Clerk WARNING(Gov. code section 913) Subject o certain exceptions,you have only six(6)months from the date this notice was personally served or deposited in the '1 to file a court action on this claim. See Government Code Section 945,6. You may seek the advice of an attorne of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. *For Additional Warning See Reverse Side of This Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now,and at all times herein mentioned,have been a citizen of the United States,over age 18; and that today I deposited in the United States Postal Service in Martinez, California,postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: 7` JOHN SWEETEN, CLERK By Deputy Clerk