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MINUTES - 12052006 - C.25
CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: DECEMBER 05, 2006 Claim Against the County, or District Governed by ) the Board of Supervisors; Routing Endorsements, ) NOTICE TO CLAIMANT 'and Board Action. All'Secti The copy of this document mailed to California Government Cod �7 you is your notice of the action taken NOV 03 2006 on your claim by the Board of Supervisors. (Paragraph IV below), COUNTY COUNSEL given Pursuant to Government Code AMOUNT: $918.13 MARTINEZ CALIF. Section 913 and 915.4. Please note all "Warnings". CLAIMANT: DAVID J. HARTMAN- ATTORNEY: UNKNOWN DATE RECEIVED: NOVEMBER 029 2006 ADDRESS: 1960 MUIR ROAD 1st FLOOR BY DELIVERY TO CLERK ON: NOVEMBER 03, 2006 MARTINEZ, CA 94553 BY MAIL POSTMARKED: HAND DELIVERED FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. NOVEMBER 03, 2006 JOHN CULLEN, ler Dated: By: Deputy II. FROM: County Counsel TO: Clerk of the Board of Su ervis rs (1J,,,rh_is 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). O Claim is not timely filed. The Clerk should return claim on ground that it was filed late and sena warning of claimant's right to apply for leave to present a Late claim (Section 911.3). O Other: Dated' By: n� t__Deputy County Counsel III. .FROM: Clerk of the Board TO: County Counsel (]) County Administrator(2) O Claim was returned as untimely with notice to claimant (Section 911.3). FV./,BOARD OR-DER' By unanimous vote of the Supervisors present: ( This Claim is rejected in full. O Other: I certify,that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated//ta,e�v-v*r JOHN CULLEN, CLERK, By �eputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions,you have only six(6)months from the date this notice was personally served or deposited in the mail to file a court action on this claim.See Government Code Section 945.6.You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney,you should do so humediately. *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;ve� e��� JOHN CULLEN, CLERK By Deputy Clerk BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. A claim relating to a cause of action for death or for mjuiy to.person or to personal property or growing crops shall be presented not later than six months after the accrual of the cause of action. A claim relating to any other cause of action shall be.presented not later than one year . after the accrual of the cause of action. (Gov. Code § 911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 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. E. Fraud. See penalty for fraudulent claims,Penal Code Sec. 72 at the end of this form. ■a at a a a a a■■as■■BE.aaa mum aaaaaasaanaaaads a uua BE as a in a a a a s u a a it a a as a■e asci■m RE: Claim By: Reserved for Clerk's filing stamp DAVID J. HAX-r>7AIV ) RECENED Against the County of Contra Costa or, ) NOV 0 N 7006 District) CLERK BOARD Or SUPERVISORS (Fill in the name) )' CONTRA COSTA c0. The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the sum of$ 9/r. /3 and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) I U- 20 -0 L )1-r APPA o x /0 5o NAS. 2. Where did the damage or injury occur? (Include city and county) /r1A2T//✓s2- r CcW-rgA COSTA e0"N7`7 3. How did the damage or injury occur? (Give full details;use extra paper if required) In If UcH/GGA aa1+5CZ�F•4CCy A,,P /-MCJP,07Cy Or IetFIO /N 7?ye' "7- Or_ 77lt� ConOwt� s C3HNTN, GnvvAJO5 /17fN1v7ZFoVAA/G6 EAIPLOYLT[> &+CjC&"D A CCwI�✓T 7 �t'f1[GCs /n/Tv /»N' VEhhGt t/ STRIKI�I INC— &4mPt-ri. 7V5 0+&19ttD A ^w C7-14n-6 TO M7 SK✓h/�C�, 4. What particular act or omission on the part of county or district officers, servants, or employees caused the injury or damage? 2 w pKLD' /MPEG//✓6 TNq� -721i em//cv v -z �1 ^'o' SEC My ✓E1--1CL,6- O/ /,v/}S /Vor uS/NL /*s /22A-n. View /",/410/lS 5 What are the names of county or district officers, servants, or employees causing the damage or injury? "DZIve2 - 6-115 3AJ1E2 6teeiz,2 LO COL ' # 09//vz7-7 0525' c*5r,7o 5r. ./SGT. 3 po,3 •' 3-19-$I CAa"S AGUILAR 6. What damage or injuries do your claim resulted? (Give full extent of injuries or damages claimed. Attach-two estimates for auto damage.) pqt ac.T,41ve-o pe-wrea tz"mPL-n rwv esr�, res 9l�. 1 A�� 196-5. 2-0 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injiuy or damage.) :T c or is n E 5 F novvN cyst" 's -ro (Bony pot. /-�D F-nor^ MIKE (LOPES 4.-ro BDON Z.-JC, GOTH Gl S1,JCSStj '4/LC? ) J T'jC GiT"I OF EST,.K417ES A4G i�'TACktP., 8. Names and addresses of witnesses,doctors, and hospitals: 9. List the expenditures you made on account of this accident or injury: DATE TIME AMOUNT ■ aa a RUN onaaMsaa as Raanman MEa10[ataa[omit[[Rana ononaInana an am as a■m m is m an an o a a am among an .Gov. Code Sec. 910.2 provides"The claim shall be signed by the claimant or by some person on his behalf." SEND NOTICES TO: (Attomev) 1 Name and address of Attorney ) �� (Claimant's Signature) /9(e0 InalA /Lp, st pc.Oy2 MhAnma2,C4. 9y5S3 (Address) Telephone No. )Telephone No. (r 2�5) 313 — 2-,PS-0 ■aRIa NIlm■■•laffaaas ala[a■ flea[al[[m/[a[aRaa[[Box aa[aasa[m now mammaf[a man mal Romans Env PUBLIC RECORDS NOTICE: Please be advised that this claim form, or any claim filed with the County under the Tort Claims Act, is subject to public disclosure under the California Public Records Act. (Gov. Code, §§ 6500 et seq.) Furthermore, any attachments,addendum, or supplements attached to the claim form, including medical records, are also subject to public disclosure. ■Neu ulaRaRRSNams■■NRIC■ ■ MEN an Nsouom/umsaREIN a Rasa mamas MEN summation Ins a■■Masao moan NOTICE: 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 genuine, 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 dollars ($1,000.00), 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 imprison-nent and fine. 11/01/2006 at 03 :55 PM Job Number: 17163 CASEY'S AUTO BODY INC. License #:AB220391 Federal ID #:300016136 Quality is our Number 1 Concern 4515 O'Hara Brentwood, CA 94513 (925) 634-2211 Fax: (925) 634-7257 PRELIMINARY ESTIMATE Written By: Mike Casey Adjuster: Insured: DAVE HARTMAN Claim # Owner: DAVE HARTMAN Policy # Address: 1006 SUTTER CK.WAY Deductible: BRENTWOOD, CA 94513 Date of Loss: Day: (925) 516-7032 Type of Loss: Point of Impact: Inspect CASEY'S AUTO BODY INC. Business: (925) 634-2211 Location: 4515 O'Hara Brentwood, CA 94513 Insurance Company: Days to Repair 1998 HOND ACCORD EX 6-3 . OL-FI 4D SED GREEN Int: VIN: IHGCG1652WA013578 Lic: 3XTM857 CA Prod Date: odometer: Air Conditioning Rear Defogger Tilt Wheel Cruise Control Intermittent Wipers Climate Control Keyless Entry Theft Deterrent/Alarm Body Side Moldings Dual Mirrors Electric Glass Sunroof Clear Coat Paint Power Steering Power Brakes Power Windows Power Locks Power Driver Seat Power Mirrors Power Trunk/Tailgate AM Radio FM Radio Stereo Search/Seek CD Player Anti-Lock Brakes (4) Driver Air Bag Passenger Air Bag 4 Wheel Disc Brakes Leather Seats Bucket Seats Recline/Lounge Seats Automatic Transmission Overdrive Aluminum/Alloy Wheels ------------------------------------------------------------------------------- NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT ------------------------------------------------------------------------------- 1 REAR BUMPER 2 Repl Bumper cover 1 284 . 66 1. 1 3 .2 3 Add for Clear Coat 1 . 3 4# Color Tint 1 0 .5 5# Hazardous Waste Removal 1 2 .50 ------------------------------------------------------------------------------- Subtotals =_> 287 . 16 1. 6 4 .5 1 1 11/01/2006 at 03 :55 PM Job Number: 17163 PRELIMINARY ESTIMATE 1998 HOND ACCORD EX 6-3 . OL-FI 4D SED GREEN Int: Parts 287 .16 Body Labor 1. 6 'hrs @ $ 74 . 00/hr 118 .40 Paint Labor 4 .5 hrs @ $ 74 . 00/hr 333 .00 Paint Supplies 4 .5 hrs @ $ 32 . 00/hr 144 . 00 ---------------------------------------------------- SUBTOTAL $ 882 . 56 Sales Tax $ 431 . 16 @ 8 . 2500% 35 .57 ---------------------------------------------------- GRAND TOTAL $ 918 . 13 ADJUSTMENTS: Deductible 0 . 00 ---------------------------------------------------- CUSTOMER PAY $ 0 .00 INSURANCE PAY $ 918 . 13 This is just an estimate of repairs, if on futher inspection, additional parts or repairs are needed, you will be contacted for authorization. We are not responsible for loss or damage from fire, theft accidents or causes beyond our control to your vehicle. Storage charges will occur 48 hours after customer is not ified that vehicle is completed. Casey' s Auto Body guarantees all repairs performed on your vehicle including parts, workmanship and refinishing for a period of not less than one year from the time of completion of repairs . Defects in craftmanship or refinishing are warranteed for as long as you own your vehicle. Failure to present an Insurance estimate at time of repairs may result in additional costs to you. 2 11/01/2006 at 03:55 PM Job Number: 17163 PRE=41NNARY ESTIMATE 1998 HOND ACCORD EX 6-3.OL-FI 4D SED GREEN Int: FOR YOUR PROTECTION CALIFORNIA LAW REQUIRES THE FOLLOWING TO APPEAR ON THIS FORM: ANY PERSON WHO KNOWINGLY PRESENTS FALSE OR FRAUDULENT 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 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. OPT OEM=ORIGINAL EQUIPMENT MANUFACTURER PARTS EITHER OPTIONALLY SOURCED OR OTHERWISE PROVIDED WITH SOME UNIQUE PRICING OR DISCOUNT . Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide ARG4422 Database Date 10/2006, CCC Data Date 10/2006, and the parts selected are OEM-parts manufactured by the vehicles Original Equipment Manufacturer. OEM parts are available at OE/Vehicle dealerships. OPT OEM (Optional OEM) or ALT OEM (Alternative OEM) parts are OEM parts that may be provided by or through alternate sources other than the OEM vehicle dealerships. OPT OEM or ALT OEM parts may reflect some specific, special, or unique pricing or discount. OPT OEM or ALT OEM parts may include "Blemished" parts provided by OEM's through OEM vehicle dealerships. 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 Benchmark Prices are provided by National Auto Glass Specifications. Labor operation times listed on the line with the NAGS information are MOTOR suggested labor operation times. NAGS labor operation times are not included. Pound sign (#) items indicate manual entries. Some 2006 vehicles contain minor changes from the previous year. For those vehicles, prior to receiving updated data from the vehicle manufacturer, labor and parts data from the previous year may be used. The Pathways estimator has a complete list of applicable vehicles. Parts numbers and prices should be confirmed with the local dealership. CCC Pathways - A product of CCC Information Services Inc. 3 CLAIM �� BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: pECF gFR 05� 2006 Claim Against the County, or District Govemed 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 California Government Codes. ) you is your notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), NOV 0 3 2006 given Pursuant to Government Code AMOUNT: $13,194.20 Section 913 and 915.4. Please note all COUNTY COUNSEL Warnings". CLAIMANT: STATE FARM INSURAN I I�LIF. FOR: JEANNE FURNESS ATTORNEY: BY: JESSICA GRIFFIN DATE RECEIVED: NOVEMBER 03, 2006 UNKNOWN ADDRESS: P.O. BOX 2371 BY DELIVERY TO CLERK ON: NOVEMBER 03, 2006 BLOOMINGTON, IL 61702-2371 BY MAIL POSTMARKED: OCTOBER 31, 2006 FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN CULLEN 1 r Dated: NOVEMBER 03, 2006 By: Deputy IL FROM: County Counsel TO: Clerk of the Board of S pervisors ( 0his 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). O Other: Dated: _ �(]�' By: MDeputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) O Claim was returned as untimely with notice to claimant (Section 911.3). I V. BOARD ORDER: By unanimous vote of the Supervisors present: (V)' This Claim is rejected in full. O Other: I certify that this is a true and con-ect copy of tine Board's Order entered in its minutes for this date. Dated:&&,;Pn4�Ar�i HN CULLEN, CLERK, By Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions,you have only six(6) months from the date this notice was personally sewed or deposited in the mail to file a court action on this claim.See Government Code Section 945.6.You may seek the advice of an attorney of your choice in connection ,vitin 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 1 am now, and at all times herein mentioned, have been a citizen ofthe United States, over age 18; and that today 1 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. DatedAee,>whw JOHN CULLEN, CLERK By Deputy Clerk ,. •+ STATF FARM State Farm Insurance Companies INSYRANCE State Farm Insurance Subrogation Services October 30, 2006 PO Box 2371 Bloomington, IL 61702-2371 Certified Mail-Return Receipt Requested Contra Costa County Risk Mgmt REGE ED Clk of the Board 651 Pine St ,Martinez, CA 94553 NOV 0 L?006] CLERK BOARD OF SUPERVISORS CONTRA COSTA CO. _ RE: Claim Number: 05-5301-469 _ Our Insured: Jeanne Furness Date of Loss : July 5 , 2006 Your Insured: Contra Costa County-Sheriff Your Insured Driver: Christopher L Simmons Your Claim Number: 60962 Your Policy Number: SELF INSD GVT AGENCY Dear Penny Baily: It is our understanding that you are self insured. Our investigation indicates you are responsible for this claim. Therefore, we are seeking recovery from you. This letter is to notify you of our subrogation claim and request your cooperation in settling this matter. To assist you in your review, here is a breakdown of the amounts State Farm paid by Cause of Loss : 041/045 - Uninsured Motorist BI $ 042 - Uninsured Motorist PD $ 300 series/400 - Comp/Collision $15, 033 . 02 501 - Rental $252 . 18 600-050 - Med Pay/PIP $ Other $ Salvage Recovery $2 , 591 , 00 Amount State Farm Paid $12 , 694 . 20 Insured Deductible $500 . 00 Total Claim Amount $13 , 194 . 20 State Farm is seeking 1000 of the total claim Amount Payable to State Farm: $13 , 194 . 20 Please remit payment of this claim and include our claim number on the payment . If you have any questions, please call HOME OFFICES; BLOOMINGTON, ILLINOIS 61710-0001 Page 2 October 30, 2006 877-457-8276 and any member of Team #60 may assist you. Thank you for your cooperation. In order to assist you in evaluating and processing the subrogation claim we are asserting, we may provide nonpublic personal information about our customer. We are sharing this information to effect, administer, or enforce a transaction authorized by the consumer. However, you are neither authorized nor permitted to: (1) use the customer information we provided for any purpose other than to evaluate and process the subrogation claim, or (2) disclose or share the customer information we provide for any purpose other than to evaluate and process the subrogation claim. Sincerely, Jessica Griffin Claim Processor (877) 457-8276 , Team 60 State Farm Mutual Automobile Insurance Company Enclosure (s) .. ...... RBZ0006Z . date: 10-30-06 page : 1 .,.....m rO.U66 t4'+ Ite tiethi Cotter STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY AUTO PAYMENTS BY COL ............................................. c;la�m number! policy number E75 5C1 4 0430 - 099 -05C named insured date of loss- FTj E S S ALL EN O 7 — 0 5 — 0 5 C O L 4 0 0 C denotes consolidated payment E denotes EFT payment P denotes previous data COL: 400 indemnity: 15 033 . 02 dir rcov: 0 . 00 expense: 0 . 00 payment number payee amount status COL pay cd rsn reporting party 102312857J ALLEN FURNESS & 4, 611 . 93 PAID 400 1 Named Insu 102311893J PACIFIC SERVICE 10 , 421 . 09 PAID 400 2 Named Insu tort re.� RB Z 0 0 0 6 Z date : 10-30-06 page: 1 STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY AUTO PAYMENTS BY COL policy number clasm number G15 ...i3 ( 1 fa9< 0430 - 099 - 05C named insured date of loss F URN E S S , ALL EN O 7 — 0 5 — 0 6 C O L 5 0 1 C denotes consolidated payment E denotes EFT payment P denotes previous data COL: 501 indemnity: 252 . 18 dir rcov: 0 . 00 expense: 0 . 00 payment number payee amount status COL pay cd rsn reporting party E 102313715K ENTERPRISE RENT 252 . 18 PAID 501 1 Named Insu 07/07/2006 AT 02 : 37 PM JOB NUMBER: 6954 21975 MARTINEZ AUTO BODY SHOP LICENSE # :BAR AB085474 FEDERAL ID #: 942574428 615 ALHAMBRA AVE MARTINEZ, CA 94553 (925) 228-3689 FAX: (925) 372-6546 SUPPLEMENT OF RECORD 1 WITH SUMMARY WRITTEN BY: KELLY SHAVER 07/07/2006 02 : 37 PM ADJUSTER: KYM ALEEM INSURED: ALLEN FURNESS CLAIM #05-5301-46901 OWNER: ALLEN FURNESS POLICY # ADDRESS : 1141 DELACY AVE DEDUCTIBLE: $500 . 00 MARTINEZ, CA 94553 DATE OF LOSS: 07/05/2006 AT 03 : 05 PM DAY: (925) 228-9377 TYPE OF LOSS : COLLISION POINT OF IMPACT: 12 . FRONT INSPECT LOCATION: INSURANCE STATE FARM INSURANCE COMPANIES COMPANY: 1818 TROUSDALE DRIVE DAYS TO REPAIR BURLINGAME, CA 94010 2005 FORD FOCUS ZX4 S 4-2 . OL-FI 4D SED GOLD INT:TAN VIN: 1FAFP34N65W300911 LIC: 5PXC775 CA PROD DATE: 06/2005 ODOMETER: 17300 CONDITION: GOOD AIR CONDITIONING REAR DEFOGGER INTERMITTENT WIPERS TINTED GLASS DUAL MIRRORS CLEAR COAT PAINT METALLIC PAINT POWER STEERING POWER BRAKES AM RADIO FM RADIO STEREO SEARCH/SEEK CD PLAYER DRIVER AIR BAG PASSENGER AIR BAG CLOTH SEATS BUCKET SEATS AUTOMATIC TRANSMISSION OVERDRIVE ----- -------------------------------------------------------------------------- NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT ------------------------ ------------------------------------------------------- 1# SO1 ADP# 17721246 1 2# 07-07-2006 DATE ASSIGNED 1 3# 07-06-2006 DATE WRITTEN 1 4 FRONT BUMPER 5 O/H FRONT BUMPER 1 . 9 6** REPL RECOND BUMPER COVER W/O 1 207 . 00 INCL. 2 . 6 APPEARANCE 7 ADD FOR CLEAR COAT 1 . 0 8 REPL ENERGY ABSORBER 1 55 . 82 INCL. 9* REPL IMPACT BAR 1 122 . 93 2 . 0 0 . 0* 10# REPL FLEX AGENT/ADDITIVE 1 5 . 00 T 11# REPL BMPR FASTENER/RETAINER KIT 1 19 . 95 T 12 GRILLE 13 REPL GRILLE W/O APPEARANCE PKG. 1 68 . 25 0 . 2 CHROME 1 07/07/2006 AT 02 : 37 PM JOB NUMBER: 6954 21975 SUPPLEMENT OF RECORD 1 WITH SUMMARY 2005 FORD FOCUS ZX4 S 4-2 . OL-FI 4D SED GOLD INT:TAN ------ -------------- ----------------------------------------------------------- NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT - ------------------------------------ ------------------------------------------ 14 FRONT LAMPS 15 REPL RT HEADLAMP ASSY W/O SVT 1 186 . 90 INCL. 16 REPL LT HEADLAMP ASSY W/O SVT 1 186 . 90 INCL. 17 AIM HEADLAMPS 0 . 5 18 REPL LT SIDE MARKER LAMP W/O HIGH 1 22 . 95 INCL. INTENSITY 19 RADIATOR SUPPORT 20 REPL RADIATOR SUPPORT 1 111 .47 4 . 5 1 . 3 21 ADD FOR AUTO TRANS M 0 . 2 22 REPL SIGHT SHIELD 1 35 . 73 0 . 1 23 REPL LOWER TIE BAR 1 32 . 68 0 . 5 24 REPL RT SIDE SHIELD W/AC 1 16 . 32 0 . 3 25 REPL LT SIDE SHIELD W/AC 1 16 . 32 0 . 3 26 REPL SIGHT SHIELD CLIP 1 5 . 06 27# REPL CAULKING/SEAM SEALER 1 5 . 00 T 28# REPL CORROSION PROTECTION 1 5 . 00 T 0 . 3 29# REPL WELD THRU PRIMER @ SUPT 1 7 . 95 T 0 . 5 30 COOLING 31 REPL COOLING MODULE AUTO TRANS W/AC 1 731 . 96 M 1 . 9 32 DEDUCT FOR OVERLAP -0 . 3 33# REPL COOLANT 1 12 . 00 T 34# RECHARGE R134 A/C SYSTEM 1 187 . 50 X 35 R&I RESERVOIR 0 . 3 36 HOOD 37 REPL HOOD 1 332 . 67 1 . 0 2 . 6 38 ADD FOR CLEAR COAT 1 . 0 39 ADD FOR UNDERSIDE (COMPLETE) 1 . 3 40 REPL RT HINGE 1 30 . 22 0 . 3 0 . 3 41 REPL LT HINGE 1 30 . 22 0 . 3 0 . 3 42 REPL LATCH W/O ANTI-THEFT 1 37 . 85 INCL. 43 ENGINE / TRANSAXLE 44 R&I AIR CLEANER ASSY M 0 . 5 45 ELECTRICAL 46 R&I BATTERY 2 . 0 LITER 0 . 3 47 FENDER 48 REPL RT FENDER 1 206 . 23 1 . 9 1 . 8 49 OVERLAP MAJOR ADJ. PANEL -0 . 4 50 ADD FOR CLEAR COAT 0 . 3 51 ADD FOR EDGING 0 . 5 52 DEDUCT FOR OVERLAP -0 . 5 53 REPL LT FENDER 1 206 . 23 1 . 9 1 . 8 54 OVERLAP MAJOR ADJ. PANEL -0 .4 55 ADD FOR CLEAR COAT 0 . 3 56 ADD FOR EDGING 0 . 5 57 DEDUCT FOR OVERLAP -0 . 5 58 REPL LT APRON ASSY 1 566 . 62 S 9 . 0 1 . 5 59 OVERLAP MAJOR NON-ADJ. PANEL -0 . 2 60 DEDUCT FOR OVERLAP -1 . 0 2 07/07/2006 AT 02 : 37 PM JOB NUMBER: 6954 21975 SUPPLEMENT OF RECORD 1 WITH SUMMARY 2005 FORD FOCUS ZX4 S 4-2 . OL-FI 4D SED GOLD INT:TAN -------------------------------------- ----------------------------------------- NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT --------------------------------- ---------------------------------------------- 61 REPL RT APRON ASSY 1 618 . 30 S 9 . 0 1 . 5 62 OVERLAP MAJOR NON-ADJ. PANEL -0 . 2 63 DEDUCT FOR OVERLAP -1 . 0 64# SUBL SUBLET LABOR TO R&I ENGINE 1 2350 . 00 X 65 FRONT SUSPENSION 66 O/H SUSPENSION BOTH SIDES M 6 . 8 67 FRONT DOOR 68 BLND LT OUTER PANEL 1 . 1 69 R&I LT BELT W' STRIP 0 . 2 70 R&I LT MIRROR ASSY MANUAL 0 . 3 71 R&I LT DOOR GLASS FORD 0 . 6 72 R&I LT HANDLE, OUTSIDE 0 . 4 73 R&I LT R&I TRIM PANEL 0 .4 74 BLND RT OUTER PANEL 1 . 1 75 R&I RT BELT W' STRIP 0 . 2 76 R&I RT MIRROR ASSY MANUAL 0 . 3 77 R&I RT DOOR GLASS FORD 0 . 6 78 R&I RT HANDLE, OUTSIDE 0 . 4 79 R&I RT R&I TRIM PANEL 0 .4 80# MASK VEHICLE EXTERIOR FOR 1 5 . 00 T 0 . 2 REFINISH 81# COLOR TINT TO BLENDABLE MATCH 1 0 . 5 82# HAZARDOUS WASTE DISPOSAL 1 3 . 00 X 83# RPR SET UP TIME (ON BENCH) 2 . 0 F 84# RPR PRE-PULL CORE SUPT 1 . 0 F 85# RPR PULL LT RAIL FOR SWAY 1 . 0 F 86# RPR PULL RT RAIL FOR SWAY 1 . 0 F 87# SUBL 2 WHEEL ALIGNMENT 1 89 . 00 X 88# TOWING ADVANCE CHARGES 1 300 . 00 X 89# TOWING TO SHOP 1 190 . 00 X 90# 07-06-2006 DATE TOWED IN 1 --- -------------------------------- -------------------------------------------- SUBTOTALS =_> 7008 . 03 50 . 7 19 . 6 PARTS 3828 . 63 BODY LABOR 45 . 7 HRS @$ 70 . 00/HR 3199 . 00 PAINT LABOR 19 . 6 HRS @$ 70 . 00/HR 1372 . 00 FRAME LABOR 5 . 0 HRS @$ 70 . 00/HR 350 . 00 PAINT SUPPLIES 19 . 6 HRS @$ 30 . 00/HR 588 . 00 SUBLET/MISC. 3179 .40 --- ------------------------------------------------- SUBTOTAL $12517 . 03 SALES TAX $ 4476 . 53 @ 8 . 2500% 369 . 31 ---------- --------- --------------------------------- GRAND TOTAL $1288,6 . 34 ADJUSTMENTS : DEDUCTIBLE 500 . 00 3 07/07/2006 AT 02 : 37 PM JOB NUMBER: 6954 21975 SUPPLEMENT OF RECORD 1 WITH SUMMARY 2005 FORD FOCUS ZX4 S 4-2 . OL-FI 4D SED GOLD INT:TAN ---------------------------------------------------- CUSTOMER PAY $ 500 . 00 INSURANCE PAY $12386 . 34 IF YOU HAVE COVERAGE FOR DAMAGE TO YOU VEHICLE UNDER THIS POLICY IT IS OUR OBLIGATION TO INFORM YOU THAT UNDER CALIFORNIA CODE OF REGULATIONS, TITLE 10 , CHAPTER 5, SECTION 2695 . 8 .D. 2 . E, YOU HAVE THE RIGHT TO SELECT THE VEHICLE REPAIR FACILITY OF YOU CHOICE. WE ARE PROHIBITED BY LAW FROM REQUIRING THAT REPAIRS BE DONE AT A SPECIFIC SHOP. YOU ARE ENTITLED TO SELECT THE AUTO BODY SHOP TO REPAIR DAMAGE COVERED BY US . WE HAVE RECOMMENDED A REPAIR SHOP THAT WILL REPAIR YOUR DAMAGED VEHICLE. AS YOU HAVE AGREED TO USE OUR RECOMMENDED REPAIR SHOP, WE WILL CAUSE THE DAMAGED VEHICLE TO BE RESTORED TO ITS CONDITION PRIOR TO THE LOSS AT NO ADDITIONAL COST TO YOU OTHER THAN AS STATED IN THE POLICY OR AS OTHERWISE ALLOWED BY LAW. IF YOU EXPERIENCE A PROBLEM WITH THE REPAIR OF YOU VEHICLE, PLEASE CONTACT US IMMEDIATELY FOR ASSISTANCE. AUTO BODY REPAIR CONSUMER BILL OF RIGHTS A CONSUMER IS ENTITLED TO: 1 . SELECT THE AUTO BODY REPAIR SHOP TO REPAIR AUTO BODY DAMAGE COVERED BY THE INSURANCE COMPANY. AN INSURANCE COMPANY MAY NOT REQUIRE THE REPAIRS TO BE DONE AT A SPECIFIC AUTO BODY SHOP. 2 . AN ITEMIZED WRITTEN ESTIMATE FOR AUTO BODY REPAIRS AND, UPON COMPLETION OF REPAIRS, A DETAILED INVOICE. THE ESTIMATE AND THE INVOICE MUST INCLUDE AN ITEMIZED LIST OF PARTS AND LABOR ALONG WITH THE TOTAL PRICE FOR THE WORK PERFORMED. THE ESTIMATE AND INVOICE MUST ALSO IDENTIFY ALL PARTS AS NEW, USED, AFTERMARKET, RECONDITIONED, OR REBUILT. 3 . BE INFORMED ABOUT COVERAGE FOR TOWING SERVICES . THE INSURER SHALL PAY REASONABLE TOWING AND STORAGE CHARGES INCURRED BY THE INSURED TO PROTECT THE VEHICLE AND PROVIDE REASONABLE NOTICE TO AN UNSURED BEFORE TERMINATING PAYMENT FOR STORAGE CHARGES SO THAT THE INSURED HAS TIME TO REMOVE THE VEHICLE FROM STORAGE. 4 . BE INFORMED ABOUT THE EXTENT OF COVERAGE, IF ANY, FOR A REPLACEMENT RENTAL VEHICLE WHILE A DAMAGED VEHICLE IS BEING REPAIRED. 5 . BE INFORMED OF WHERE TO REPORT SUSPECTED FRAUD OR OTHER COMPLAINTS AND CONCERNS ABOUT AUTO BODY REPAIRS . COMPLAINTS WITHIN THE JURISDICTION OF THE BUREAU OF AUTOMOTIVE REPAIR COMPLAINTS CONCERNING THE REPAIR OF A VEHICLE BY AN AUTO BODY REPAIR SHOP SHOULD BE DIRECTED TO: TOLL FREE (800) 952-5210 4 07/07/2006 AT 02 : 37 PM JOB NUMBER: 6954 21975 SUPPLEMENT OF RECORD 1 WITH SUMMARY 2005 FORD FOCUS ZX4 S 4-2 . OL-FI 4D SED GOLD INT:TAN CALIFORNIA DEPARTMENT OF CONSUMER AFFAIRS BUREAU OF AUTOMOTIVE REPAIR 10240 SYSTEMS PARKWAY SACRAMENTO, CA 95827 THE BUREAU OF AUTOMOTIVE REPAIR CAN ALSO ACCEPT COMPLAINTS OVER ITS WEB SITE AT: WWW.AUTOREPAIR. CA.GOV COMPLAINTS WITHIN THE JURISDICTION OF THE CALIFORNIA INSURANCE COMMISSIONER ANY CONCERNS REGARDING HOW AN AUTO INSURANCE CLAIM IS BEING HANDLED SHOULD BE SUBMITTED TO THE CALIFORNIA DEPARTMENT OF INSURANCE AT: (800) 927-HELP OR (213) 897-8927 CALIFORNIA DEPARTMENT OF INSURANCE CONSUMER SERVICES DIVISION 300 SOUTH SPRING STREET LOS ANGELES, CA 90013 THE CALIFORNIA DEPARTMENT OF INSURANCE CAN ALSO ACCEPT COMPLAINTS OVER ITS WEB SITE AT: WWW. INSURANCE. CA.GOV ALL SUPPLEMENTS MUST BE PRE-APPROVED BEFORE ANY WORK CAN BE COMPLETED. 5 07/07/2006 AT 02 : 37 PM JOB NUMBER: 6954 21975 SUPPLEMENT OF RECORD 1 WITH SUMMARY 2005 FORD FOCUS ZX4 S 4-2 . OL-FI 4D SED GOLD INT:TAN FOR YOUR PROTECTION CALIFORNIA LAW REQUIRES THE FOLLOWING TO APPEAR ON THIS FORM: ANY PERSON WHO KNOWINGLY PRESENTS FALSE OR FRAUDULENT 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 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. OPT OEM=ORIGINAL EQUIPMENT MANUFACTURER PARTS EITHER OPTIONALLY SOURCED OR OTHERWISE PROVIDED WITH SOME UNIQUE PRICING OR DISCOUNT. ESTIMATE BASED ON MOTOR CRASH ESTIMATING GUIDE. UNLESS OTHERWISE NOTED ALL ITEMS ARE DERIVED FROM THE GUIDE DR2JK00 DATABASE DATE 06/2006, CCC DATA DATE 06/2006 , AND THE PARTS SELECTED ARE OEM-PARTS MANUFACTURED BY THE VEHICLES ORIGINAL EQUIPMENT MANUFACTURER. OEM PARTS ARE AVAILABLE AT OE/VEHICLE DEALERSHIPS.. OPT OEM (OPTIONAL OEM) PARTS ARE OEM PARTS THAT MAY BE PROVIDED BY OR THROUGH ALTERNATE SOURCES OTHER THAN THE OE/VEHICLE DEALERSHIPS . OPT OEM PARTS MAY REFLECT SOME SPECIFIC, SPECIAL, OR UNIQUE PRICING OR DISCOUNT. 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 RELY PARTS, RCY, OR USED. RECONDITIONED PARTS ARE DESCRIBED AS RECON. RECORED PARTS ARE DESCRIBED AS RECORE. NAGS PART NUMBERS AND BENCHMARK PRICES ARE PROVIDED BY NATIONAL AUTO GLASS SPECIFICATIONS . LABOR OPERATION TIMES LISTED ON THE LINE WITH THE NAGS INFORMATION ARE MOTOR SUGGESTED LABOR OPERATION TIMES . NAGS LABOR OPERATION TIMES ARE NOT INCLUDED. POUND SIGN (#) ITEMS INDICATE MANUAL ENTRIES . SOME 2006 VEHICLES CONTAIN MINOR CHANGES FROM THE PREVIOUS YEAR. FOR THOSE VEHICLES, PRIOR TO RECEIVING UPDATED DATA FROM THE VEHICLE MANUFACTURER, LABOR AND PARTS DATA FROM THE PREVIOUS YEAR MAY BE USED. THE PATHWAYS ESTIMATOR HAS A COMPLETE LIST OF APPLICABLE VEHICLES . PARTS NUMBERS AND PRICES SHOULD BE CONFIRMED WITH THE LOCAL DEALERSHIP. CCC PATHWAYS - A PRODUCT OF CCC INFORMATION SERVICES INC. 6 07/07/2006 AT 02 : 37 PM JOB NUMBER: 6954 21975 SUPPLEMENT OF RECORD 1 WITH SUMMARY 2005 FORD FOCUS ZX4 S 4-2 . OL-FI 4D SED GOLD INT:TAN ------------------------------------------------------------------------------- NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT ----------------------------------- -------------------------------------------- ------- ADDED ITEMS ------- 1# SOl ADP$# 17721246 1 ------------------------------------------------------------------------------- SUBTOTALS =_> 0 . 00 0 . 0 0 . 0 PARTS 0 . 00 -------- -------------------------------------------- SUBTOTAL $ 0 . 00 ESTIMATE 12886 . 34 KELLY SHAVER SUPPLEMENT SO1 0 . 00 KELLY SHAVER -------- CUSTOMER PAY $ 500 . 00 JOB TOTAL $12886 . 34 INSURANCE PAY $12386 . 34 IF YOU HAVE COVERAGE FOR DAMAGE TO YOU VEHICLE UNDER THIS POLICY IT IS OUR OBLIGATION TO INFORM YOU THAT UNDER CALIFORNIA CODE OF REGULATIONS, TITLE 10, CHAPTER 5 , SECTION 2695 . 8 .D. 2 . E, YOU HAVE THE RIGHT TO SELECT THE VEHICLE REPAIR FACILITY OF YOU CHOICE. WE ARE PROHIBITED BY LAW FROM REQUIRING THAT REPAIRS BE DONE AT A SPECIFIC SHOP. YOU ARE ENTITLED TO SELECT THE AUTO BODY SHOP TO REPAIR DAMAGE COVERED BY US . WE HAVE RECOMMENDED A REPAIR SHOP THAT WILL REPAIR YOUR DAMAGED VEHICLE. AS YOU HAVE AGREED TO USE OUR RECOMMENDED REPAIR SHOP, WE WILL CAUSE THE DAMAGED VEHICLE TO BE RESTORED TO ITS CONDITION PRIOR TO THE LOSS AT NO ADDITIONAL COST TO YOU OTHER THAN AS STATED IN THE POLICY OR AS OTHERWISE ALLOWED BY LAW. IF YOU EXPERIENCE A PROBLEM WITH THE REPAIR OF YOU VEHICLE, PLEASE CONTACT US IMMEDIATELY FOR ASSISTANCE. AUTO BODY REPAIR CONSUMER BILL OF RIGHTS A CONSUMER IS ENTITLED TO: 1 . SELECT THE AUTO BODY REPAIR SHOP TO REPAIR AUTO BODY DAMAGE COVERED BY THE INSURANCE COMPANY. AN INSURANCE COMPANY MAY NOT REQUIRE THE REPAIRS TO BE DONE AT A SPECIFIC AUTO BODY SHOP. 2 . AN ITEMIZED WRITTEN ESTIMATE FOR AUTO BODY REPAIRS AND, UPON COMPLETION OF REPAIRS, A DETAILED INVOICE. THE ESTIMATE AND THE INVOICE MUST INCLUDE AN ITEMIZED LIST OF PARTS AND LABOR ALONG WITH THE TOTAL PRICE FOR THE WORK PERFORMED. THE ESTIMATE AND INVOICE MUST ALSO IDENTIFY ALL PARTS AS NEW, USED, AFTERMARKET, RECONDITIONED, OR REBUILT. 3 . BE INFORMED ABOUT COVERAGE FOR TOWING SERVICES . THE INSURER SHALL PAY REASONABLE TOWING AND STORAGE CHARGES INCURRED BY THE INSURED TO PROTECT THE VEHICLE AND PROVIDE REASONABLE NOTICE TO AN UNSURED BEFORE TERMINATING PAYMENT FOR STORAGE CHARGES SO THAT THE INSURED HAS TIME TO REMOVE THE VEHICLE FROM 7 07/07/2006 AT 02 : 37 PM JOB NUMBER: 6954 21975 SUPPLEMENT OF RECORD 1 WITH SUMMARY 2005 FORD FOCUS ZX4 S 4-2 . OL-FI 4D SED GOLD INT:TAN r STORAGE. 4 . BE INFORMED ABOUT THE EXTENT OF COVERAGE, IF ANY, FOR A REPLACEMENT RENTAL VEHICLE WHILE A DAMAGED VEHICLE IS BEING REPAIRED. S . BE INFORMED OF WHERE TO REPORT SUSPECTED FRAUD OR OTHER COMPLAINTS AND CONCERNS ABOUT AUTO BODY REPAIRS . COMPLAINTS WITHIN THE JURISDICTION OF THE BUREAU OF AUTOMOTIVE REPAIR COMPLAINTS CONCERNING THE REPAIR OF A VEHICLE BY AN AUTO BODY REPAIR SHOP SHOULD BE DIRECTED TO: TOLL FREE (800) 952-5210 CALIFORNIA DEPARTMENT OF CONSUMER AFFAIRS BUREAU OF AUTOMOTIVE REPAIR 10240 SYSTEMS PARKWAY SACRAMENTO, CA 95827 THE BUREAU OF AUTOMOTIVE REPAIR CAN ALSO ACCEPT COMPLAINTS OVER ITS WEB SITE AT: WWW.AUTOREPAIR. CA.GOV COMPLAINTS WITHIN THE JURISDICTION OF THE CALIFORNIA INSURANCE COMMISSIONER ANY CONCERNS REGARDING HOW AN AUTO INSURANCE CLAIM IS BEING HANDLED SHOULD BE SUBMITTED TO THE CALIFORNIA DEPARTMENT OF INSURANCE AT: (800) 927-HELP OR (213) 897-8927 CALIFORNIA DEPARTMENT OF INSURANCE CONSUMER SERVICES DIVISION 300 SOUTH SPRING STREET LOS ANGELES, CA 90013 THE CALIFORNIA DEPARTMENT OF INSURANCE CAN ALSO ACCEPT COMPLAINTS OVER ITS WEB SITE AT: WWW. INSURANCE. CA.GOV ALL SUPPLEMENTS MUST BE PRE-APPROVED BEFORE ANY WORK CAN BE COMPLETED. 8 07/07/2006 AT 02 : 37 PM JOB NUMBER: 6954 21975 SUPPLEMENT OF RECORD 1 WITH SUMMARY 2005 FORD FOCUS ZX4 S 4-2 . OL-FI 4D SED GOLD INT:TAN FOR YOUR PROTECTION CALIFORNIA LAW REQUIRES THE FOLLOWING TO APPEAR ON THIS FORM: ANY PERSON WHO KNOWINGLY PRESENTS FALSE OR FRAUDULENT 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 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. OPT OEM=ORIGINAL EQUIPMENT MANUFACTURER PARTS EITHER OPTIONALLY SOURCED OR OTHERWISE PROVIDED WITH SOME UNIQUE PRICING OR DISCOUNT. ESTIMATE BASED ON MOTOR CRASH ESTIMATING GUIDE. UNLESS OTHERWISE NOTED ALL ITEMS ARE DERIVED FROM THE GUIDE DR2JK00 DATABASE DATE 06/2006, CCC DATA DATE 06/2006 , AND THE PARTS SELECTED ARE OEM-PARTS MANUFACTURED BY THE VEHICLES ORIGINAL EQUIPMENT MANUFACTURER. OEM PARTS ARE AVAILABLE AT OE/VEHICLE DEALERSHIPS . OPT OEM (OPTIONAL OEM) PARTS ARE OEM PARTS THAT MAY BE PROVIDED BY OR THROUGH ALTERNATE SOURCES OTHER THAN THE OE/VEHICLE DEALERSHIPS . OPT OEM PARTS MAY REFLECT SOME SPECIFIC, SPECIAL, OR UNIQUE PRICING OR DISCOUNT. 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 BENCHMARK PRICES ARE PROVIDED BY NATIONAL AUTO GLASS SPECIFICATIONS . LABOR OPERATION TIMES LISTED ON THE LINE WITH THE NAGS INFORMATION ARE MOTOR SUGGESTED LABOR OPERATION TIMES . NAGS LABOR OPERATION TIMES ARE NOT INCLUDED. POUND SIGN (#) ITEMS INDICATE MANUAL ENTRIES . SOME 2006 VEHICLES CONTAIN MINOR CHANGES FROM THE PREVIOUS YEAR. FOR THOSE VEHICLES, PRIOR TO RECEIVING UPDATED DATA FROM THE VEHICLE MANUFACTURER, LABOR AND PARTS DATA FROM THE PREVIOUS YEAR MAY BE USED. THE PATHWAYS ESTIMATOR HAS A COMPLETE LIST OF APPLICABLE VEHICLES . PARTS NUMBERS AND; PRICES SHOULD BE CONFIRMED WITH THE LOCAL DEALERSHIP. CCC PATHWAYS - A PRODUCT OF CCC INFORMATION SERVICES INC. 9 07/07/2006 AT 02 : 37 PM JOB NUMBER: 6954 21975 SUPPLEMENT OF RECORD 1 WITH SUMMARY 2005 FORD FOCUS ZX4 S 4-2 . OL-FI 4D SED GOLD INT:TAN ALTERNATE PARTS SUPPLIERS 6 RECOND BUMPER COVER W/O APP PART NO. FO1000572R PRICE 207 . 00 KEYSTONE - FPPP (800) 263-9727 1069 HENSLEY STREET (510) 234-6960 RICHMOND, CA 94801 KEYSTONE - FPPP (800) 263-9727 632 SOUTH ELDORADO ST. (209) 948-1101 STOCKTON, CA 95203 KEYSTONE - FPPP (800) 263-9727 1045 E. TRIANGLE COURT (916) 372-0287 W. SACRAMENTO, CA 95605 10 07/07/2006 AT 02 : 37 PM JOB NUMBER: 6954 21975 SUPPLEMENT OF RECORD 1 WITH SUMMARY 2005 FORD FOCUS ZX4 S 4-2 . OL-FI 4D SED GOLD INT:TAN ALTERNATE PARTS USAGE AFTERMARKET PARTS AFTERMARKET SELECTION METHOD: AUTOMATICALLY LIST NO. OF TIMES USER WAS NOTIFIED THAT AN AFTERMARKET PART WAS AVAILABLE: 15 NO. OF AFTERMARKET PARTS THAT APPEAR IN THE FINAL ESTIMATE: 0 11 Copart Access -Salvage Tr.ansm'itw Page 1 of I 05-53e1-469 DF Salvage Transmittal To: Copart Date: 03 Aug 2006 MARTINEZ (Yard#: 78) Lot #: 7255316 2701 WATERFRONT ROAD VIN: IFAFP34N65W300911 MARTINEZ, CA 94553 Claim 05-5301-469 Date of Loss: 5 July 2006 ACV: USD $14,278.00 Cost to Repair: $0.00 (0%) USD Disposition Damage Threshold to use for Title Processing is 0% _X—Please process an application for a: Salvage Title/Certificate Clean Title Other: Enclosed please find: Executed Title Odometer Statement Lien Release VLF Application Power of Attorney Theft Letter Keys Waiver Letter X Others: reg 262 (877) 587-6240,_, 6280 Name Phone Ext http://www.copart.corri/cgi-bin/seller/accesOotdisplay/salvage.dtw/show 8/3/2006 Choicepoint 7/21/2006 10 :59 PAGE 002/006 Fax Server 170266021 -STATE OF�CALIFORNIA TRAFFIC COLLISION REPORT CHP 555 Page 1 (Rev 7-03)OPI 061 Page 1 SPECIAL CONDITIONS NO.INJURED HITS RUN FELONY CITY JUDICNL DISTRICT LOCAL REPORT NUMBER EMERGENCY VEHICLE MARTINEZ MTDIABLO 06-3016 NO,KILLED HIT B RUN MISD COUNTY REPORTING DISTRICT BEAT C CONTRA COSTA 131 1 --� COLLISION OCCURRED ON. V MO DAY YEAR TIME NGICK I OFFICER I.O._ 0 COURT STREET 07/05/2006 1441 CA00714001 69 C MILEPOST INFORMATION DAYOFWEEK TOW AWAY PHOTOGRAPNSBY: Ln� A r NONE T WEDNESDAY1XIYES D No 1 0 LXJ AT INTERSECTION WITH GREEN STREET STATE HWY REL f N OR 171 YES X NO PATRTy DRIVERS LICENSE NUMBER STATE CLASS AIRSAG SAFETY EQUIP, VEHYEAR I MAKFJMOOEVCOLOR LICENSE NUMBER STATE 1 A5416943 CA C P G 2000 CHEV/MALIBU/DK.BL 4HXK797 CA DRIVER NAME OWNER NAME �~ '❑SAME AS DRNER � 0 CHRISTOPHER LELAND SIMMONS CONTRA COSTA CNTY.#0436 _ PEOEST STREET ADDRESS OWNER ADDRESS �:SAW AS DRIVER []n 1980 MUIR ROAD 2467 WATERBIRD WAY,MARTINEZ,CA.,94553 _ KOVEH CITYISTATEIZIP DISPOSITION OF VEHICLE ON ORDERS OF: OFFICER DRIVER L]OTHER - ■ MARTINEZ,CA 94553 - ROTATION TOW u _� BICYLST SEX HART EYES HEIGHT YIEIGH7 BIRTHDATE RACE PRIOR MECH.DEFECTS FX-1NONE APP. REFER TO NARRATIVE M BRO GRN 6'2" 200 08/24/1973 W VEHICLE IDENTIFICATION NUMBER: OTHER HOME PHONE BUSINESS PHONE CHP USE ONLY REDESCRIBE VEHICLE DAMAGE SHADE IN DAMAGEDAA 925646-2441 VEHICLE TYPE m ,❑VNK Q NONE I�MINOR MOD MAJOH❑ROLL-0VER INSURANCE CARRIER POLICY NUMBER O COUNTY SELF-INSURED N/A- �— OIROFTRAVEL ON STREET OR HIGHWAY LIMIT W GREEN STREET 25 CA DDT CAL-Y __ TCPIPSC PARTY DRIVERS LICENSE NUMBER STATE CLASS AIRBAG SAFETY EQUIP. VEHYEAR MAKEIMODEMCOLOR LICENSE NUMBER $TATE 2 N3658163 CA C P G 2005 FORD/FOCUS/GRY. SPXC775 CA DRIVER NAME OWNER NAME [X JEANE MARIE FURNESS UsAMEASDRIVER i PEOEST STREET ADDRESS - OWNER ADDRESS SAME AS DRIVER DELACY STREET O KDVEH CITY/STATE2IP DISPOSITION OF VEHICLE ON ORDERS OF: OFFICER ]( ORIVER ❑OTHER D MARTINEZ,CA 94553 ROTATION TOW BICYLBT SEX HAIR EYEB HEIGHT WEIGHT BIRTHDATE RACE MOR MECH,OEFECTS 11u0uE APP, REFER TO NARRATIVE F BLN BRG 5,10" 150 04/02/1953 W VEHICLE IDENTIFICATION NUMBER L^J OTHER HOME PHONE BUSINESS PHONE CHP USE ONLY DESCRIBE VEHICLE DAMAGE SHADE IN DAMAGED AREA 1 925-228-9377 925-680-8733 VEHICLE TYPE ❑UNK ❑NONE []MINOR INSURANCE CARRIER POLICY NUMBER MOD ZX MAJOR❑ROLL-OVER {Sl`d 'Q4C3,, E5v STATE FARM INS.,CO. #43 0099-C04-OSC `-' DIR OF TRAVEL ON STREET OR HIGHWAY SPEED LIMIT S COURT STREET 25 DOT— S CAL-T iCPlPSC DARTY DRIVERS LICENSE NUMBER STATE CUSS AIRBAG I SAFETY EQUIP. VEHYEAR MAKEIMOpE(/COLOR LICENSE NUMBER STATE 3 DRIVER NAME OWNER NAME ❑ SAME AS DRIVER PEDESTSTREETADEIRESSRO;j e•Z i ( F^ QWXR ADDRESS ❑SAME AS DRIVER KD VE CITYISTATEIZIP 1 I P1 IC T DISPOSITION OF VEHICLE ON ORDERS OF: OFICER 0DRIVER ElOTHER BICYLST SEX HAIR EYES I HEK, V' 1 HT yi„; A \V PRIOR MECH.DEFECTS NONE APP. El REFER TO NARRATVE • VEHI EIDENTIFICATION NUMBER: OTHER HOME PHONE B IN DESCRIBE VEHICLE DAMAGE SHADE IN DAMAGED AREA n P USE ONLY Releasel8 t0 ! .VEHICLE TYPE �,� 0 LINK ❑NONE El MINOR INSURANCE CARRIER ICY NUMBER - P A100❑M0.10R❑ROLL-0VER DIR OF TRAVEL ON STREET OR HIGHWAY $PEED LIMIT CA OOT MAR-iiNEZ A { CAL-T TCP1P$C PREPARED BY DISPATCH NOTIFIED REVIEWEDBY PATE REVIEWED WILLIAM KRUTA 69 Q YES No wA WILLIAM KRUTA 69 07/06/2006 Choicepoint 7/21/2006 10 : 59 PAGE 003/006 Fax Server 170266021 -STATE OFCALIFORNIA TRAFFIC COLLISION CODING CHP 555 Page 2(Rev 7-03)OPI 061 Page 2 DATE OF COLLISION(MO.DAY)EM) TIME(1d00) NCICk OFFICER I.D. NUMBER 07/05/2000 1441 CA0071400 ---rrr.--- 69 06-3016 OWNER OWNERAODRESS NOTIFIED PROPERTY DAMAGE DESCRIPTION OF DAAUGE El YES ❑NO SEATING POSITION SAFETY EQUIPMENT INATTENTION CODES OCCUPANTS L -AIR BAG DEPLOYED MIC-DSYlAa-HE ME1 A-CELLPHONE HANDHELD A-NONE IN VEHICLE M-AIR BAG NOT DEPLOYED DRIVER PASSENGER B-CELLPHONE HANDSFREE B-UNKNOWN N-OTHER V-NO X-NO C-ELECTRONIC EQUIPMENT C-LAP BELT USED P-NOT REQUIRED W.YES Y_YES O-RADIO/CD 1 2 3 1-DRIVER D-LAP BELT NOT USED E-SMOKING 2 T08-PASSENGERS E-SHOULD HARNESS USED CHILD RESTRAJESTF, INT EDFROMVEHICLE F-EATING 456 7-STA.WEN REAR F-SHOULDER HARNESS NOT USED 0-IN VEHICLE USED 0-NOT EJECTED G-CHILDREN 8-RR,OCC TRK,OR VAN G-LAP/SHOULDER HARNESS USED R-IN VEHICLE NOT USED 1-FULLY EJECTED H ANIMALS ER OVAL HYGIENE 7 9-POSITION UNKNOWN H-LAP/SHOULDER HARNESS NOT USED S-IN VEHICLE USE UNKNOWN 2-PARTIALLY EJECTED - 0-OTHER J -PASSIVE RESTRAINT USED T_IN VEHICLE IMPROPER USE 3-UNKNOWN J-READING K-PASSIVE RESTRAINT NOT USED U-NONE IN VEHICLE ITEMS MARKED BELOW FOLLOWED BY AN ASTERISK I')SHOULD BE EXPLAINED IN THE NARRATIVE PRIMARY COLLISION FACTOR , i 2 3 MOVEMENT PRECEDING LIST NUMBER(W)OF PARTY AT FAUL TRAFFIC CONTROL DEVICES SPECIAL INFORMATION 2 3 COLLISION I q vC SECTiONYgUTE¢ alEO[j YES ';A CONTROLS FUNCTIONING :A HAZARDOUS MATERIAL _ A STOPPED 21804(x)CVC Q ND 'B CONTROLS NOT FUNCTIONING :0 CELL PHONE HAND14ELD IN USE X X B PROCEEDING STRAIGHT B OTHER IMPROPER DRIVING* CONTROLS OBSCURED !C CELL PHONE HANDSFREE IN USE _ C RAN OFF ROAD X i D NO CONTROLS PRESENT/FACTOR' lo CELL PHONE NOT IN USE D MAKING RIGHT TURN C OTHER THAN DRIVER' _• TYPE OF COLLISION !E SCHOOL BUS RELATED E MAKING LEFT TURN D UNKNOWN' A HEAD-ON _ i F 75 FT MOTOR TRUCK COMBO F MAKING U TURN E FELL ASLEEP' _ �B SIDESWIPE IG_32_FT TRAILER COMBO G BACKING C REAR END _ ! H SIDESHOW H SLOWING/STOPPING WEATHER MARK 1 TO 21TEMS X D BROADSIDE I STREET RACING 1 PASSING OTHER VEHICLE X JA CLEAR E HIT OBJECT ~ J CHANGING LANES B CLOUDY F OVERTURNED K PARKING MANEUVER C RAINING G VEHICLE-PEDESTRAN L ENTERING TRAFFIC D SNOWING 'H OTHER _ ,M OTHER UNSAFE TURNING E FOGNISIBILITY _ IN XING INTO OPPOSING LANE F OTHER' MOTOR VEHICLE INVOLVED WITH _ 0 PARKED G WIND JA NON-COLLISION _ _ P MERGING LIGHTING B PEDESTRIAN w_ 0 TRAVELING WRONG WAY X A DAYLIGHT -i-IC OTHER MOTOR VEHICLE OTHER ASSOCIATED FACTORS R OTHER' B DUSK-DAWN __ ,D MO_T_OR_VEH ICLE ON OTHER RDWAY 1 2 3 (MARK i TO Y ITEMS) _ C DARK-STREETLIGHTS IE PARKED MOTOR VEHICLE A VCSECTIONN lcv CITED Yes D DARKK=NO STREET LIGHTS_ F TRAIN NO E DARK-STREET LIGHTS NOT G BICYCLE a VCSECwe ATEO-. CSD vES FUNCTIONING H ANIMAL: __ NO SOBRIETY-DRUG ROADWAY SURFACE C VC SECTION Vq TEO C'TF.o YES PHYSICAL X A DRV 1 FIXED OBIT:CT: NO 1 2 3 (MARK 1 TO 2ITEMS) 8 WET D X X A HAD NOT BEEN DRINKING C SNOWY-ICY J OTHER OBJECT. E VISION O_BSCUREO: B HBO-UNDER INFLUENCE ID SLIPPERY(MUDDY.OILY,ETC.) _ F INATTENTION: C HBD-NOT UNDER INFLUENCE' ROADWAY CONDITIONS G STOP 8 GO TRAFFIC D HBD-IMPAIRMENT UNKNOWN' (MARK 1 TO 2 ITEMS) PEDESTRIAN ACTIONS N ENTERING/LEAVING RAMP E UNDER DRUG INFLUENCE' A HOLES,DEEP RUT' X A NO PEDESTRIANS INVOLVED 1 PREVIOUS COLLISION I IF IMPAIRMENT-PHYSICAL' B LOOSE MATERIAL ON RDWAY' B CROSSING IN CROSSWALK J UNFAMILIAR WITH ROAD G IMPAIRMENT NOT KNOWN C OBSTRUCTION ON ROADWAY' AT INTERSECTION K DEFECTIVE VEH EQUIP: CITED H NOT APPLICABLE D CONSTRUCTION-REPAIR ZONE C CROSSING IN CROSSWALK-NOT YES 11 SLEEPYIFATIGUED E REDUCED ROADWAY WIDTH IN INTERSECTION NO F FLOODED' D CROSSING-NOT IN CROSSWALK L UNINVOLVEDVEHICLE _ G OTHER' E IN ROAD-INCLUDES SHOULDER M OTHER* _ X H NO UNUSUAL CONDITIONS F NOT IN ROAD X X N NONE APPARENT G APPROACHINGILFAVING SCH BUS O RUNAWAY VEHICLE SKETCH O MISCELLANEOUS NOT TO SCALE* INDICATE NORTH Choicepoint 7/21/2006 10: 59 'PAGE 004/006 Fax Server 170266021 STATE OF CALIFORNIA TRAFFIC COLLISION CODING CHP 555 Page 3(Rev 7-03)OPI 061 Page 3 DATE OF COLLISION(MO.DAY YEAR) TIME(7400) NCICp OFFICER LO. NUMBER 07/05/2006 1441 CA007I400 69 06-3016 WRNESS PASSENGER EXTENT OF INJURY('X'ONE) INJURED WAS('X'ONE) PARTY SFAT SAFETY ONLY y AGE SEX _ EJECTED FATAL SEVERE OTHER VISIBLE COMPLAINT NUMBER POS. EQUIP DRIVER PASS. PED. BICYCLIST OTHER INJURY INJURY INJURY OF PAIN ❑ ❑ 32M ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 1 1 G 0 NAMEID.O.BJADDRESS TELEPHONE CHRISTOPHER LELAND SIMMONS (08/24/1973) 1980 MUIR ROAD,MARTINEZ,CA 94553 (H)925 646-2441 (INJURED ONLY)TRANSPORTED BY TAKEN TO N/A- DESCRIBE INJURIES ❑VICTIM OF VIOLENT CRIME NOTIFIED ❑ ❑ 53 1 F ❑ ❑ _l.__ ❑ ; ❑ ❑ ❑ ❑ ii ❑ 2 1 G 0 NAME/D.O BJADDRESS TELEPHONE JEANE MARIE FURNESS (04/02/1953) 1141 DELACY STREET,MARTINEZ,CA 94553 (H)925-228.9377 (B)925.680-8733 (INJURED ONLY)TRANSPORTED BY TAKEN TO NIA- INJURIES - -- -_ ❑VICTIM OF VIOLENT CRIME NOTFIEO X❑ 41 DX 18 1 M ❑ ❑ [] ❑ ❑ ❑ D O ❑ z 3 D 0 NAMEID.O.BIADORESS TELEPHONE MICHAEL EDWARD FURNESS (10/2211987) 1141 DELACY AV,MARTINEZ,CA 94553 (H)925-228-9377 (INJURED ONLY)TRANSPORTED BY TAKEN TO N/A- DESCRIBE INJURIES ❑VICTIM OF VIOLENT CRIME NOTIFIED DX #2 DX 18 M ❑ � ❑ ❑ ❑ ❑ ❑ ❑ ❑ 2 1 6 j G j 0 NAMEM.0,114ADDRESS TELEPHONE GRANT GILBERT TRAVERS (11/02/1987) 19 FOSTER ST,GREELEY HILLS,CA 95311 (H)209-878-3762 (INJURED ONLY)TRANSPORTED BY TAKEN TO N/A- DESCRIBE INJURIES ^u ❑VICTIM OF VIOLENT CRIME NOTIFIED ❑ ❑ ❑ ❑ ❑ ❑ ❑ ol ❑ ❑ ❑ NAMEM.O.B.IAODRESS TELEPHONE (INJURED ONLY)TRANSPORTED BY TAKEN TO DESCRIBE INJURIES ❑VICTIM OF VIOLENT CRIME NOTIFIED ❑ ❑ ❑ ❑ ❑ ❑ ❑ E]I ❑1 ❑ ❑ NAME/D.O.BJADDRESS TELEPHONE (MAIRED ONLY)TRANSPORTED BY TAKEN TO DESCRIBE INJURIES I�1 VICTIM OF VIOLENT CRIME NOTIFIED NAME OF PREPARER I.D.NUMBER MO. DAY YEAR NAME REVIEWER MO. DAY YEAR WILLIAM KRUTA 69 07/05/2006 WILLIAM KRUTA 07/06/2006 Choicepoint 7/21/2006 10 :59 PAGE 005/006 Fax Server 17.0266021 STATE OF CALIFORNIA 'NARRATIVEISUPPLEMENTAL CHP 556(Rev.7-90)OPI 042 Page 4 DATE OF INCIDENT/OCCURENC£ TIME(2400) NCIC NUMBER OFFICER I.D.NUMBER NUMBER 07/05/2006 1 1441 CA0071400 69 06-3016 ONE 'X'ONE TYPE SUPPLEMENTAL('X'APPLICABLE) Ill Narrative Collison Report Bq update Fatal []Hit and run update 6 SuPPlemenl E1Olher: Hazardous Materals �Schoo bus []Other: CITY/COUNTY/JUDICIAL DISTRICT REPORTING DISTRICT/BEAT CITATION NUMBER MARTINEZ/CONTRA COSTA/MT DIABLO 131 LOCATION/SUBJECT STATE HIGHWAY RELATED COURT STREET/GREEN STREET Q Yes QX No NOTIFICATION: Dispatched to a non-injury accident involving(2) two vehicles. Measurements obtained by the use of my hand held "Pro Laser 111"Lidar Unit programmed for distance. SCENE: Court Street has one lane in each direction north and south.Roadway is divided by a solid double yellow line. This roadway is posted 25 M.P.H. Green Street has one lane in each direction east and west, and is divided by a solid double yellow line. Roadway is posted 25 M.P.H. PARTIES: Both vehicles were moved prior to my arrival. "D-1" (Simmons)was standing on the S/W corner of Court St. and Green St. "D-2" (Furness)was standing on the N/W corner of Court St. and Green St. along with both of her passengers. PHYSICAL EVIDENCE: None. STATEMENTS: "D-2"(Furness) said she was S-B Court Street in heavy traffic traveling at about 25 M.P.H. "D-2"said all of a sudden she saw a vehicle("V-1")drive out of a parking lot from behind a parked bus(Sheriffs Transportation Bus) in front of her traveling W-B onto Green Street. "D- 2"said she tried to stop,but was unable to, and broadside"V-1". "D-I"(Simmons)'said he was coming out of the parking lot to the Main Detention Facility and stopped prior to crossing Court St. "D-1" said traffic had stopped in the N-B lane of Court St. "D-1"said the driver stopped in the N-B lane of Court St. waved him across the street. "D-1"said he proceeded across Court St. to travel W-B on Green St. when he was broadside by"D-2". "D-1"believes"D-2"was speeding, and that's why he didn't see her until it was too late. Passengers I and 2("W-I","W-2")gave the same account of what occurred. Both said they were traveling S-B Court St. at approx. 25 M.P.H.when "D-1"drove in front of them, and they were unable to stop in time. Both said they then broadside"V-1". OPINIONS AND CONCLUSIONS: "D-2"was traveling S-B Court St. when"D-1"failed to yield to "D-2" when coming out of the parking lot. "D-2"broad sided "V-I". AREA OF IMPACT(A.O.I-): A.O.I. is approx. 10'.7"east of the west prolongation curb line of Court Street, and approx. 17'.3"south of the north prolongation curb line of Green Street. CAUSE: "D-I"caused the accident by being in violation of 21804(a) CVC-Driver Failed to Yield to Oncoming Traffic Close Enough to be a Hazard. PREPARERS NAME AND I.D.NUMBER Dale: REVIEWER'S NAME DATE WILLIAM KRUTA 69 07/05/2006. 1 WILLIAM KRUTA 07/06/2006 Use previous etlitims until depleted. 90 57841' Choicepoint 7/21/2006 10 : 59 PAGE 006/006 Fax Server 17.0266021 STATE OF CALIFORNIA 'NARRATIVE/SUPPLEMENTAL CHP 556(Rev.7-90)OPI 042 Page 5 DATE OF INCIDENT/OCCURENCE TIME(2400) NCIC NUMBER OFFICER I.O.NUMBER NUMBER 07/05/2006 1 1441 CA0071400 69 06-3016 'X'ONE 'X'ONE TYPE SUPPLEMENTAL("X'APPLICABLE) Narrative Collision Report BA update Fatal E]Hit and run update Supplement Other. Hazardous Materials School bus DOther. CITY/COVNTY/JUDICIAL.DISTRICT REPORTING DISTRICT/BEAT CITATION NUMBER MARTINEZICONTRA COSTA/MT DIABLO 131 LOCATIONISUBJECT STATE HIGHWAY RELATED COURT STREET/GREEN STREET ❑Yes No RECOMMENDATION:None, PREPARER'S NAME AND I.D.NUMBER Date: REVIEWER'S NAME DATE WILLIAM KRUTA 69 07/05!2006 WILLIAM KRUTA 07/06/2006 Use previous editions until depleted. 9057841 10: 50 AH PDT 071131: 6 Page 1 19 Claim:05.530148901 Autosource Valuation 2005 Fad Focus Zx48 40 Sedan AS Request:17721248 Audatex Autosource Valuation 'Administrative Data 2005 Ford . Martinez Auto Body „'.; hGlaitnait State Farm Insurance " i.nsurad;Allen Furness Emeryville Repair Fac.Branch C1altn:05-5301-46901 1475 66th St. ::::::LdWDdil 07/05/2006 . Emeryville CA 94608 tC997yp4Collision Pp►1cy , Other: Estim.star Name;Kelly Shaver r1aInl;Ft60 NaTr1ti',Kym Aleem License Nulnbtr5PXC775 L[cerise State.;CA tioegselxplratrOn 07106 VIN80URCE Analysis, 2005 VIN 1 FAFP34N65 W300911 Deaodes.ra2005 Ford Focus Zx4 S 4D Sedan iAbtUfacy;Decodes Correctly History;:No activity was reported NICS Report 00 . . Focus Zx4 8 4D Sedan No NICB115OActivity Reported00 No Vehicles Advertised at (925)228-9377 Vehicle Valuation Det all 2005 Ford Focus Zx4 8 Q 86 clan� Loss Vehicle Adjustment pedlSt Hayward Ford Go..ntact;Vaughn Banks letephtane (510) 881-1200 ..... ..... . C15ntact.Dste 07/13/06 ........... . Distariae 23 Miles x: xxxx Ity/StAle;Hayward, CA Martinez, CA XXX Price. $14,888 $14,888 Version:2 Page: 1 07/13/0810:45 10: 58 AN PUT 071131: 6 Page 2 Claim:05.5301.48901 Autosource Valuatlon 2005 Ford Focus Zx4 S 40 Sedan AS Request:17721246 �Cornparable VehiCle I Loss 1't302005 2005 Mai4gi Ford Ford ;Model Focus Focus EdltiOtf:Zx4 Se ZO S ............................... XXX D©pt:4D 4D SOY:Sedan Sedan grave 2WD 2WD Engle 4 Cylinder 2.0 Engine 4 Cylinder 2.0 Engine 0 Trar18d3tsslGrr;4 Speed Automatic 4 Speed Automatic 0 Calor Red Gold OdotntltO 12,887 MI(Actual) 17,300 Mi(Actual) -300 8 69 AdiustM.Ont:(SeeVOW...... N toS) -305 < cnvenil 0 Options Air Conditioning Air Conditioning Rem Trunk-L/Gate Release Rem Trunk-UGate Release Rear Window Defroster Rear Window Defroster C>ther: Jpti4nd( quipm6ht Dual Airbags Dual Airbags . ....................... Center Console Center Console ...... ........................... ........ ................................................. Intermittent Wipers Intermittent Wipers Lighted Entry System Lighted Entry System ::Overhead Console 0 XXXX Tinted Glass Tinted Glass Power Aaoessorles Power Brakes Power Brakes :::Power Door Locks -135 Power Steering Power Steering Power Windows -180 ................ ... ................... .... R&d►Off?hr}t1e1A1O(M Opl M MP3 Player 0 .. . Alarm System 0 ........... .. ................................................. Compact Disc Player Compact Disc Player Seat Optfriris Velour/Cloth Seats Velour/Cloth Seats ? Splif Folding Rear Seat Split Folding Rear Seat xxx. Wheel Opt►a�s;Aluminum/Alloy Wheels -170 Autasouce Vaiue,Before Gotxlitiort`Adjustmets 13,798 .. Good Good XX xxx Carpets.;Good Good XXXIntt►rrt!Good Good ;:;Glass.Good Good Headilner Good Good a . .X.S qty Good Good Paint:Good Good Ext:Telin.Good Good Version:2 Page: 2 07/1310610:46 10: 50 AH POT 071131: 8 Page 3 19 Claim:05.5301.46901 Autosource Valuadon 2005 Ford Focus 2k4 S 4D Sedan AS Request:17721248 Erlgll Well Maintained Well Maintained Transmissiars Well Maintained Well Maintained Front Tires Good Good ROOM*:Good Good .. . . TCt&E GOtldltl4tl'449/u9ttt'1eals 0 "Total $13 788 Comparable Vehicle 2 Loss Vehicle Adjustment I Deate.r;Lithia Sun Valley Ford Contact Dick Gonzales T�I�ph9ii ;(925) 686-5000 G...Itact Date'07/13/06 UI&tana Immediate Area .!'Gtylftte Concord,CA Martinez, CA Pr[tie;$14,995 $14,995 ............... .................... . .. Year:2005 2005 Make;Ford Ford Model Focus Edition Zx4 Se Zx4 S 130ot 4D 4D Baily:Sedan Sedan T1nve 2WD 2WD Engine 4 Cylinder 2.0 Engine 4 Cylinder 2.0 Engine 0 Frensmissiin 4 Speed Automatic 4 Speed Automatic 0 oEac White Gold Odometer:25,834 W(Actual) 17,300 Mi(Actual) 555 (9&Be4tCju5ttn61iE:.f5841IRkut�4� 1Ot9), -305 CbdVahleiice Optiarts Air Conditioning AirCanditioning Rem Trunk-UGate Release Rem Trunk-UGate Release Rear Window Defroster Rear Window Defroster ptht3rC7ptton61EO ipmo lL Dual Airbags Dual Airbags Center Console center Console Intermittent Wipers Intermittent Wipers Lighted Entry System Lighted Entry System Overhead Console 0 . ............ ............'... ...I. ..: ::' :Tinted Glass Tinted Glass . . ........ .............. _... ................. ................................................. .Pawer:A6oessarles::Power Brakes Power Brakes ......... Power Door Locks -135 . . Power Steering Power Steering Power Windows -180 Version:2 Page; 3 0711310810:46 10: 50 AH PDT 071131: 6 Page 4 19 Claim:05.5301.46901 Autosource Valuatlon 2005 Ford Focus Zx46 40 Seden AS Request:17721246 Comparable Vehicle 2 Loss Vehicle Adjustment ♦?Ad�Off>hGnBfA,I&fmOpt�aA9 MP3 Player 0 Alarm System 0 Compact Disc Player Compact Disc Player v86t E?pGon$:Velour/Cloth Seats Velour/Cloth Seats Split Folding Rear Seat Split Folding Rear Seat Wtiael C3ptJORS Aluminum/Alloy Wheels -170 .4ut084u1C8 V6lu9 iBef4i Gndlfl4rt AdJu9lfn8;n 14,760 • seats;Good Good :Carpeti Good Good int Trlrrt Good Good Glass:Good Good Headlifier'Good Good • Bb V Good Good Paint Good Good EiitT(IM1 Good Good „ ig;Well Maintained Well Maintained Transmission.Well Maintained Well Maintained ........................ rront.TirosGood Good ::Rd0 Tlres:Good Good TotaE Gondttloli;Adltlstiert& 0 **Total Condition Adjusted Market Value Comparable 2 _,,..... ........ .I.,..... . .._........ ....... .............. . .. liFnal'Mar AtVAlu$'Caf ul tion . . Marltet.1/alue Based on Comparable 3; $13,798 Market 1lalue Baked on ComparablO 2 $14,760 Avata Condttioll Ad ustod Mfto valmo $14,279 • $14 279 Ge tl9raf 8df89 Tex;:8.25056 1,178.02 Tit...Fee ..,..W Tansfer Fee Daducbt3le Net Adjuste[t VaEue, vii#ivAgB/tytier,. This value is not certified by Autosource(see Valuation Notes). Version:2 Page: 4 07113/0610:46 10: 58 AH POT 071131: 6 Page 5 Claim:05.5301.48901 Autosource Valuation 2005 Fad Focus Zx4 S 4D Sedan AS Request:17721246 Valuation Notes 2005 Ford Focus Zx4 8 s Sedan Adjustments of Special Note The value of the loss vehicle was established by using comparable vehicles supplied by your claim representative. Therefore, this valuation does not necessarily represent our independent opinion of what this vehicle is worth. Information provided by State Farm Insurance Loss vehicle description was provided by State Farm Insurance All values are in U.S.dollars. Autosource Valuation Process Over 2,000,000 vehicles are entered weekly into the database used for researching this value. This database includes dealer inspected, dealer inventory, dealer advertised, phone verified and advertised private party vehicles. The originating search area for this valuation was Martinez,California. The VIN decoded correctly. The tax was calculated based on a date of loss of 07/05/2006 using zip 94553, in Martinez,Contra Costa County,California,The city may vary from search area to reflect correct tax location. Other Adjustments or Comments As requested by Daphne Scales on 7-13-08 , Autosource has revalued the loss vehicle with provided comparables. Salesman Vaughn Banks direct line: 510-828-1920.Salesman Dick Gonzales cell:925-787- 8827. The base adjustment(s) will include differences in year, make, model, edition and equipment that is standard on one vehicle but not on the other. Replacement Vehicles 2005 Ford Focus Zx4 8 . Sedan The following replacement vehicles may include a sampling of the actual vehicles used to calculate the selling price. The replacement vehicles represent vehicles that have recently been offered for sale in the marketplace. These vehicles have similar attributes and characteristics to the total loss vehicle. Dealer i. ?;2005 Ford Focus Zx4 8 4D Sedan »;....!!Laat:G)atedi:07/08/08 laeN 1?1164 814 996 ....... .. ........................ ........... _. ......................... ... ...................... . . .. .................. :s FlrataJrled Flat;.. ce> 25,000 Mlles Distance:ZO Mllesocatcrii;Antioch,CA 4 Cylinder 2.0 Engine Automatic Transmission Qfle�ad!9y:Antioch Toyota )?Power Brakes Power Steering Goritact;Sterling West SpIIt Folding Raw Seat Valour/Cloth Seats 5tgdc llltlalbp;i UN11830 Compact Disc Player Raw Window Defroster 7ala hanei`.(925)778.4900 Rem Trunk-UGate Release Center Console `....::Market:Ar66::945 Dual Airbags Intermittent Wipers Lighted Entry System Tinted Glass .. Z.. 7006 Ford Focus Zx4 8 4D Sedan twat Uelad::07/06/06 Laaf Arlbe.:$19,995 Details', is FlidElt]etedl Flyd:Pdca, .. 31,841 Mlles VIN;1FAFP34N25W109521 X.1,cationlAntioch,CA Distance:20 Mlles 4 Cylinder 2.0 Engine xOffd[4,d',By Antioch Toyota AutomaCc Tranamiselon Power Brakes ORt:ll:Sterling West ys`Power Steering Split Folding Rem Seat 5:�oc1 ;N,um6eei U0852 i? >i Veiour/Cloth Seats Compact Disc Playa 7e ephor;e:;(925)778.4800 Rear Window Defroster Rem Trunk-UGate Release arket:Araa:!945 Center Console Dual Alrbags -Intermittent Wipers Lighted Entry System 'i'.. Tinted,.Glass......... II 3. 7006 Ford Focus Zx4 8 4D Sedan Ladt:llated 07/08/00 Lpat,P'rice 817,968 ... DeWlk : si FIr6tIJafed Flret>.Pdoe> 43,237 Mlles VIN,1 FAFPM55W109578 t QCtItIQlI i Dublin-San Ramon,CA „,:'X:;Distance:22 Mlles 4Cylnder2.0Engine _;;i!i; 4fte�ed!,Ey:DublinHonda Version:2 Page: 5 07/13/0810:45 10: 50 AM PBT 071131: 6 Page 6 Claim;05.53011-469011 Autoscurce Valuation 2005 Ford Focus ZO 8 4D Sedan AS Request:17721240 ........... ..... . ........ ........ ....... Automatic Transmission Power Brakes COhttlGt.Reyes Garlea X .:::.:Power Steering Split Folding Rear Seat %o*:NUm*:7347R Velour/Cloth Seats Compact 015c Player : T6Ohcno�:(M)828-8030::. 1i , .. . .... ....... Nr Conditioning Rear Window Defroster .. ........... ........x.:Rom Trunk-L/Gate Release Center Console . .. ..... .. . . . ....... Dual Alrbags Intermittent Wipers Uphilej X Entry System .. .. .. .......nnte.d.Qlams..... ................. ..................... .......... ......... ..... X .......... . ... ........................ ............ 2006 Ford Focus ZO 6 Q Sedan OGM3/00 Last $13,996 Flksl ... ............ . ..... ........ .. . . .. ..... 8:::::�:x x:x:x 15,000 Miles 4 Cylinder 2.0 Engine 0*6h.:.Sunnyvale,CA Power Brakes Power Steadrig 1504 ........... Split Folding Rear Seat Velour/Cloth Beds (OW)583-0975 ... ............ ...........��1.�I I��I :::..Compact Disc Player Air Conditioning rkbItAr....::940 .......... ........... Raw Window Defroster Rom Trunk-L/Gats Release Center Console Dual Alrbage ................ .. . Intermittent Wipers Ughted Entry System .................... ............... ....... . .................... . . .................. . ........ ..... .................... X .......... . 2005 Ford Focus ZO 6 4D Sedan Ljs(:UslOd: 06120/00 Leet Pirloe:::$13.996 ........ .. .... .. ........... 28,643 Miles VIN:IFAFP34NI5WIO9624 140*0 Antioch,CA ::Dlstancs:20Mlles 4 Cylinder 2.0 Engine By:Antioch Toyota ::::::::Automdc Transmission Power BrakesSterling West ....... ...... :Power Steering Split Folding Raw Seat :,,ft. *.NU0Jo*::UN11804 :::Veour/Cloth Seats Compact DIso Player TO.I.O.pnp::(925)778-46M ::xxx Rear Window Defroster Rom Trunk-UGate Release :�:::::::M6rkst:Arft::W ............. ..... Center Console DualAlrbags . . .. .. ............ ....... Intermittent Wipers Lighted Entry System TInted Glass ... ..... . ..... . . ......... .......... ..................... ......... . ... ..................... 2006 Ford Focus ZO 6 4D Sedan Last Uitad::06/20/00 818,988 Qetalls,...... ... . . ...... Pflc6: 20,140 Miles VIN:I FAF P34NGSW290512 Ibt 6.n. Dublin-San Ramon,CA Distance:22 Mlles 4 Cylinder ZO Engine ON*BY. Dublin Honda AutomatIcTransmiselon Power Brakes Reyes Garica Power Steering Split Folding Rear Beat :I;I;i;i5oCl ;Numbq;i 7183 ..............Velour/Ol oh Seats Compact Disc Player .. Tslsb on6..:(925)828.8030 AlrConditioning CruiseContrd W Rear Window Defroster Rom Trunk-LJGate Release ...... ............ . . ............ Center Console Dual Alrbaga . ......... ... .......... .. ... ..... ..... Intermittent Wlpere Ughted Entry System .......... ...... ... .. .. ....... Tinted Glass ::��::::� .:.:. ................ ........ ................... . ............. .. .. . . ...... ........ .. ... ..... ...... .. .. . .... .. .. ....... ......... ........................ ... ........ ...... .............. ... ....... ....... ....... . .... ........... .............. . .. Ford Focus 4D Sedan 07108/00 Last Pfts:::$11777 ........... ... ......... Detail . ........ ... ........... . ............ ..... ... 13,949 Mlles Distance:15 Miles Aoh::Pittsburg,CA 4 Cylinder 2,0 Engine Automatic Transmission Offered BV Diablo Ford Power Brakes Power Steering Roy :::::::VeJour/CJoth Seats AM/FM Stereo Mock: MJW:FW09 Air Conditioning Rear Window Defroster Telepliotei,(925)432-9717 Rom Trunk-L/Gats Release Center Consoleet Areali 945 Dual Alrbags Intermittent Wipers ...... .. ..... .. ........... ..... . ...... . .............. Ughted Entry System Tinted Glass ............. .......... Last 2005 Ford Focus 4D Sedan O'd $11998 ....... ad:U0bd..::07110/00 X:............ ............ ................................... I Ate:: .......... - ....... ...... . ...... F tM:.U 9tAd:' 21,462 Miles VIN:I FAFP34N46W29W55 CA Distance:14 Miles 4 Cylinder 2.0 Engine Broadway Motors Autorrido Transmission Power BrakesContact.Dee Dannewitz Power Steering Velour/Cloth Seats :.x:.::'<::::Stodf.NyFiiPX5= ........ .. ;;Compact Disc Player Air ConditioningTe.10'0hdn*(510)832-6800 Cruise Control Rear Window Defroster :Ar a:'W Rem Trunk-UGats Release Center Console ....... Dual Alrbage Intermittent Wipers ..... . ...... Version:2 Page: 8 07/13/0610:45 10: 50 AM PUT 071131: 6 Page 7 121 Claim:05-53014001 Autowurce Valuation 2005 Ford Focus Zx4 8 4D Sedan AS Request:17721240 ............ ....... .. . . .......... .... ......I......... .......... ............... .. ..............I........ � Uvhjed Entry Mrited Glass __2�stsrn ..... Private Party Vehicles 2005 Ford Focus Zx4 6 4D Sedan :::::Lsst:U06.d:: 07/07/06 Last:PH6a:::811,808 Details, ........... �FIM:UoW:121INS 511,801 X. ............. ice 8,000 Mlles 4 Cylinder 2.0 Engine q9rc6:Diablo Dealer.S.Bay/Peninsula Power Brakes Power Steering Lcioaftn'.Heyward,CA Spilt Folding Rear Seat Velour/Cloth Sods (800)735 8902 Compact Disc Player Ar Conditioning Market Area is 945 Rear Window Defroster Rom Trunk-UGate Release .......... ....... Center Console Dual Alrbage .......... ................. — Intermittent Wipers Ughted Entry System .nntsd Glass........... . .............. .... .......... . ....... ........................... . ............................ . . ...... ...... .. . ..................... .......... x ....... . .. . ............ ....... ... . .......... .............. .. . ...1-1. 1...........:.. :::::: : :::: .. ............ 40 2005 Ford Focus Zx4 8 40 Sedan Eget ud6d:::05/05100 $13995 .... ...... .... . .................. ......... FirmUstid:04121/00 ........I... rd:Prl;*:$13,995 14,004 Mlles 4 Cylinder 2.0 EnUlne 8tlurg4l Dlablo Dealer-S.Bay/Penlnsula ......Power Brakes Power Steering Hayward,CA Spilt Folding Row Seat Velour/Cloth Beads Tslpphons, (800)463.1930 Compact Dloo Player Row Window DefrosterMe- it Ae iu:9M ea.: Rom Trunk.L/Gate Release Center Console .::X.Xd...... .... . . ......I...I ... . . �. ..... ... . ... ... Dual Alrbags Intermittent Wipers ..... .... . . .. Ughted Entry System tinted Glass ..... .......... ...... ........................ Orig inal Equipment G Ulid e 2005 Ford Focus ZO 8 4D Sedan' ................... ......... .... ...................... ............ ............ .. .................... .. ............. X.: Ong::: .......... .......... . ...... 4 Cylinder 2.0 Engine STD 5 Speed Manual STD 4 speed Automatic $815 .......... Men ............ q4 ... Xx Vth.O.r.P0Jti.dA8I:F. 1p....... Anti-look Brakes $400 * Air Conditioning $910 • Center Console STD * Rear Window Defroster STD • Dual Airbags STD * Rem • Trunk-LGate Release...... :.. S TD ... ..............I...... ...I.I........ ...... ........... ..... ... .. .. ............ . . ..... Intermittent Wipers STD ower.Add6st6fi6s ....... ............... • Lighted Entry System STD * Power Brakes STD Side Airbags $350 * Power Steering STD .......... ......... - .. .... ..... .. ........ ............ .............. . . ....... .......... .................. ...... • Tinted Glass STD . .. ....... ....... ......... ... . ......... .............. ......... ... .......... XXX ....................... .... ............... 10 "$:. -....I.......... -om ....... * Split Folding Rear Seat STD ROW 10 ....... . I ..... Compact Disc Player STD * Velour/Cloth Seats STD .............. ........ .......... . . .. ......... ............. ... ... . ......... ane retail........... ........ ....... X: .............. ...... ...... Ode. 14,150 Loss Vehicle manufacturer's suggested retail price as reported Editions available for the some body style(in order of original cost, increasing):"Zx4 8,Zx4 Se,Zx4 Ses,Zx4 at *Indicates loss vehicle equipment. Recall Bulletins 2005 Ford Focus ZO 8 41)Sedan No recall bulletins have been issued that apply to this vehicle Version;2 Page: 7 07/13/0810:40 10: 50 AH PDT 071131: 6 Page 0 Claln 05.5301-48801 Autosouree Valudon 2005 Ford Focus Zx4 S 40 Sedan AS Request:17721246 Vehicle Locator Servic e 2005 Ford Focus Zx4 8 4D Sedan After your claim is settled, Autosource provides free assistance in locating your next vehicle. Your request can be submitted online 24hrs. per day at www.support.audatex.us/Autosource. Please click the Online Submission link and then click the Vehicle Locator Service Form link to complete the VLS form. Or you can call us Monday through Friday, between 8:00 AM and 5:00 PM, Pacific time at (800)351-3133, ext 7428. Our specialists will work with you to find a new or used vehicle in your area. Report Generated byAudatex,a Solera Company 0 2006 Audatex North America, Inc.All Rights Reserved. Verelon:2 Page: 8 07/1 We 10:46 AUTOMOBL9 L A E C TI ADToxoExLILE waenaa laa Iry rmwr j 1PAPP34N65A3OO9II wroel 2005 FORD SPXCC775 �>»Rm u wean wa vweelm �nru wesuoW , _ 4D G 516 07/26/2006 wm mas w n nwnmwrwrw scone 2005 DL KV 7255316 08/08/06 ( Iniaw..eeaweaaw 8/04/2 ao17300u 08/09/2006 ��17700 NI �remorey ACTUAL MILEAGE .7 STATE FARM MUTUAL AUTO INS CO C/o ODPART , 4665 BUSINBSS.CMTER DR r PAIRFIEW SCA 94534. xur.nwraawno ' WARMING: The veldde,deectlbed heresl has been d�Qaolqe�red a 97tal loss asMapB vsld�,per. e CVC 11516andmay not be radstered wnhnm a vehids Itlen80c�NOn mfr Ifn w _ (VIN) per CVC 5505 and a dreke end IIphlinapectlan.m etkltlttl, eartfRcatbn of o w0ance(smog)may be required ' y, To trenefer,ownarehip.of Ova v shade the seller and Mvr must,comoele.Ilia masefprimaM on the back of Mia certificate. CVC 115i6remvres the.aeller and arty subsequent selient Met transfer owram*of a.total loss vehicle purduam to a property endorsed Salvage cenlflcete to disclose to fhe been dsela perchoser at or red a�,to, a time o f w*Olaf the vehicle has, fir salvage t 1 FORD FOCUS�ZI®C00 o �E 63 9 ,� 000143 ss} ARAI ffi • J � S x + v ) p fi� p R` 5 now r t N 4 r Y l •1 .� —wry .. •, � a, .. �" f 's d , vmaa 9 m ,� w-+a E-- au C'�er-• `�.i';iu , s keie $+r.. 4= k�c � °' �.:,"r; ,.rwm""*>- ry , }x 4 � rr � E " . i �i �; Y, ��. �...m.m _ �` i ti _> Y A? s m a g* t 1 ....: �. ^s3: {. .. ... #an S 1 � ��sr__� � ..?.�k �' it *q�� A i ; .. _µ ,. _.__ � � �� .� � � � �f� _ ,.___� ��_ �..� � �.�._ _m_. v y i �r � MS i Ai { i a ia j J �' � Y v. . u s 3 4 L � n 4 9 rnr86i..a--�� r✓A`� i���t � .` :w E as�r°",p+aG'. a Oki +.'"#....f'^4�'^t',�+-i9a cn.1{6- r, r f „,_ ... #�.,;, ,£r "�•„� ,aSL s .�x- 11" # x+e: nf °.+u ,..p 4`" ✓# t` °'k A p„yup Y. y16, tia �ti..x V t a � �'=sax's 3 �,'- r ” 4: •', '� , is --•- F r : Ya 4 . , ) f � s.rV yp � �• Yw � ti El��}{/.`'d i ( �f i# ^` qh� A Y F +;z k s YS "C s �' ing° � r•.. a , I i 1 '• '�� S v 1' ..�... g., sk F` Y s �a�5 ? �- 3tiY ss� s #t t c r p 1 R { tI y'!t try. fr1.. Y# C�e' I07' Y frpk YTe#' IV � i e'f 1f a y i iti s ro s rt'"F P sr £ it isle ds afJrr y, rI n mt r '�wv 4n✓ Nr.:. �..1 by .a<.Ek`'sT v x.� �q kM1 =�v.««..,..T.._..... .._%•C. .,Fe.c. .:'.8 t .h '.,....�Mw n � e e ' e n.. Y b � 1 } � ry +� b t t ' t tea; am t#t e ! jgtpyy Ll f k v` u j' 9x uas x ry y. s5 Y b a y s y=< Kenneth Cotter Rental Invoice Rental Vendor Information Billing Detail Enterprise Rent-A-Car(23CD) ENTERPRISE RENT A CAR Description Rate Amount MARTINEZ,CA 94553-3821 925-335-0870 17 DAYS @ 20.80 353.60 16 DAYS DW @ 8.99 143.84 16 DAYS PAI @ 3.00 48.00 1 SALES TAX% 8.25 29.17 Claim Information Claim Number: 055301469 Insured Name: FURNESS,ALLEN Total Ticket Charges: $574.61 Renter Name: FURNESS,JEANNE Driver Name: Total Amount Received: $322.43 Date of Loss: 07/05/2006 Total Billed to Others: Total Amount Due: $252.18 Rental Information Payment Information Bill Start Date: 07/05/2006 Tax Identification#: 363041733 Bill End Date: 07/18/2006 Remit To Address: 2550 MONUMENT BLVD. CONCORD CONCORD, CA 94520-3107 Invoice Number: 23CDD316160 Group/Branch Location: 23CC http://sfnet.opr.statefarm.org/RentaiManagement2/aspx/Pages/frmV iewBill.aspx?format=... 10/30/2006 State Farm Insurance �gtP Subrogation Services ; RINEV HOy�q;s PO Box 2371 02 1A $ 06.32 . • 000461:2273 OCT31 Bloomington, IL 61702 MAILED FROM ZIP ODE 32026 [OR MAL u�p Ir CM0 0 o 0 o w I w n 1 1 a5 ,w r � ..o — r � r i i r � i f _ a i o - '.� RETUK RECFig I�":EP iA•v. ( REQUESTED to.. S CLAiM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY ' BOARD ACTION: DECEMBER 05, 2006 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 California Government Codes. '_}� is your notice of the action taken �C our claim by the Board of N0V O 6 2006 ervisors. (Paragraph IV below), given Pursuant to Government Code AMOUNT: UNKNOWN AT PRESENT COUNTY COUNSELSection 913 and 915.4. Please note all MARTINEZ CALIF. "Warnings". CLAIMANT: JOSE BERNARDO GUZMAN AND SANTOS VILLALOBOS ATTORNEY: ROBERT J. GONZALEZ, Esq. DATE RECEIVED: NOVEMBER 06, 2006 ADDRESS: P.O. BOX 221239 BY DELIVERY TO CLERK ON:NOVEMBER 06, 2006 SACRAMEMTO, CA 95822 RECEIVED FROM RISK BY MAIL POSTMARKED: MANAGEMENT FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claire. NOVEMBER 06, 2006 JOHN CULLEN, er Dated: By: Deputy fl. FROM: County Counsel TO: Clerk of the Board of S ervisors ( 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). O Other: Dated: By: Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) O Claim was returned as untimely with notice to claimant (Section 911.3). IN/ ,BOARD ORDER: By unanimous vote of the Supervisors present: (� This Claim is rejected in full. O Other: i certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated CULLEN, CLERK, By Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions,you have only six O niontlis from the date thisnotice was personally served or deposited in the mail to file a covet action on this claim.See Government Code Section 945.6.You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attonney,you should do so immediately. *For Additional Warning See Reverse Side ofThis Notice. AFFIDAVIT OF MAILING declare under penalty of perjury that i ann now, and at all times herein mentioned, have been a citizen of the United States, over age 13; 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:�Gz'�m��,�°'.� JOHN CULLEN, CLERK By Deputy Clerk 1 BOARD OF SUPERVISORS OF CONTRA COSTA COUTY INSTRUCTIONS TO CLAIMANT A claim relating to a cause of action for death or for injury to person or to personal property or growing crops shall be presented not later than six months after the accrual of the cause of action. A claim relating to any other cause of action shall ba.presented not later than one year . after the accrual of the cause of action. Penny eaiie (Gov. Code § 911.2.) NOV 0 2 y Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 1d6, 2006 County Administration Building, 651 Pine Street,Ma_rdnez,CA 94553. 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. 3. If the claim is against more than one public entity, separate claims must be filed against each. public entity. s'. Fraud. See penalty for fraudulent claims,Penal Code Sec. 72 at the end of this form. [[[[Man[t[tt[[[t[[[[tt [t[[[t[[ttt[[[t[[!![1)[![[[IIII 2 van[[e[[![[[t[[[[t[[[[[[t[1 tE: Claim By: Reserved for Clerk's filing stamp Be► r4ra� Gvz�,�,., REGENED Against the County of Contra Costa or ) NOV 0 6 2006 District) CLERK BOARD OF SUPERVISORS (Fill in the name) )' CONTRA COSTA CO. _ The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the sum of WAOtava..at freuAhnd in support of this claim,represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) I ..p-Iqv.b.v-. 20) Loo 6 4 -6 PM . 2. Where did the damage or injury occur? (Include city and county) 3. How didthe damage or injury occur? (Give full details;use extra paper if required) 1 A CDv t v�ej,C U (L.e.PvnleA 4. What particular act or omission/on the part of county or district officers, servants, or employees caused the injury or damage? 5 What are the names of county or district officers,servants,f or employees causing the f damage or injury? ?e-jCe— "w.w Fi. What damage or injuries do your claim resulted? (Give full extent of injuries or damages claime(dd.Attach-two estimates for auto damage.) S�r,,.�1q(�C�. i� _ vP..1.:alR.. IS a'n �-.oT�� toll _ ��t.GS4 T.u. �-�c.■.� �Wo CZ� Lolaf ('�.o-��oS. 1. How was th? amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) w.d- ,,^eA.ra41 etre, c,r2 on5o,ti._7lc✓rte 4i.7 be,,'p lftc.,rreQ 8. Names and addresses of witnesses,doctors, and hospitals: a���' q41002. }4;y�,1w.d L .?us rn,&s�.c-� {2ao. :— 1411 31 Sim}- D Cl) Dr. Clr.;y L, To-110 n 9. List the expenditures you made on account of this accident or injury: DATE THVIE AMOUNT a■a2at9t tal2alH5■R258taa a a 1052113 ua2■ta2■taatt5ataa uat■aR2aa22a■a■R■at l■■s%aa■cave, .Gov.Code Sec. 910.2 provides "The claim shall be signed by the claimant or by some person on his behalf." SEND NOTICES TO: (Attorney) 1 Name and address of Attorney ) ,�ip (+ ,,n-tQleL 'I✓ . =�r� ("ter (Claimant's Signature) �'�� „4r� G„��,�•,`�- /`T'r SAn4-9 l�i Ila l06or x.0 . 2212-31 (Address) 5aCrC,1,-1", CA- c15622--- Telephone 15622Telephone No. )Telephone No. ), 1(6— 455 —R9 9 1 a,taca■■t■a■taa■■ata■■■Rana a East■2a5aa■aa5t2a■ass■■■21c2 aa■■■tatasR■■a te■5■E aRa■t2E■1 PUBLIC RECORDS NOTICE: Please be advised that this claim form, or any claim filed with the County under the Tort Claims Act, is subject to public disclosure under the California Public Records Act. (Gov. Code, s§ 6500 et seq.) Furthermore, any attachments,addendums, or supplements attached to the claim form, including medical records, are also subject to public disclosure. ■a a a a a a 2 t a 2 a a a t a It t a aa aaa a10a■■a5as2a■a n a l a5 t a t as aaataR t o MR a■■a a a a 2■a■■2 a■a a a 2 a a■■a aat NOTICE: Section i2 of the Penal Code provides: Every person udYo, 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 genuine, any false or fraudulent claim, bill, account voucher, or writing, is punishable either by imprisonment in the County jail for e period of not more than one year, by a fine of not exceeding one thousand dollars ($1,000.00), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000), or by both such imprisonment and fine. r� YYY 4 t y 3V y`� t �y� Y jji�777-77-777 V tyre r!FI � rA$�,J�,��°:'^w a! a F 1 7 jyS K; � i YJi 9kY t �J A e Page 2 Very truly yours, LAW OFFICES OF ROBXR7 J- /GONZALEZ `Robert J. Gonzalez Attorney at Law RJG/rs Enclosures) P.O.Box 221739®SAcRAMExro,CALIFORNIA 95$22 PmoNE:(9167 455-9991•PAX:(916)455-9992 f., NAN a� o to 0,� cr) �dNOd m�-0v ' N p.�. N CD C Z cn cb (:;; a� O N :?.. o� N G O (7 d � CA N N N , N4` 5 2 % . .� . � §% 0.% \ k « \? � w 16 7 ~ � ` &v\ . � N < a - <& �\\ BOARD OF SUPERVISORS OF CONTRA COSTA COUNT _ INSTRUCTIONS TO CLAMANT A claim relating to a cause of action for death or for injury to person or to personal property-or growing crops shall be presented not later than six months after the accrual of the cause of action. A claim relating to any other cause of action shall be.presented not later than one year . after the accrual of the cause of action. �"Iny Novo 2 eagle (Gov. Code § 411.2.) y Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, Zoos County Administration Building, 651 Pine Street,Martinez, CA 94553. if claim is against a district governed by the Board of Supervisors, rather than the County, the :naive of the District should be filled in. r, If the claim is against more than one public entity, separate claims must be filed against each. public entity. Fraud. See penalty for fraudulent claims,Penal Code Sec.72 at the end of this form. tons Ma"Mtttattae■etaatatatoennaeseeetoeaeeuuut as tnaeeete RINMR■Rettto 11%Simi tE: Claim By: Reserved for Clerk's#fling stamp :Sean-fir V'c llslQ 6 s - Against the County of Contra Costa or ) ECLERK V � C 2006 RD OFSUPERVISORS District) TRA COSTA CO. (Fill in the name) ) The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the sum of$()AKA*k ..4 reU^i-and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) Se Lkrv.�-e zo, 2-oo G I- aper r�.ti-F�� 41 15 P^N . 2. Where did the damage or injury occur? (Include city and county) 3. How did the damage or Miury occur? (Give full details;use extra paper if required) ��1e11Y N,Jt.kdfN. > A Lovn}y ti+e�iclQ des-re�.cly/� G<arMc.n�S� +r"C* 4. _..What particular act or omission/on the part JJof comity or district officers, servants, or employees caused the injury or damage? 4-o e, f,,U d,r0'cv cc- u;l ,-A -1� jt=F 5 What are the names of county or district officers,servants, or employees causing the damage or injury? ?e-icer— "C'r xa. %-joa ,5 r� What damage or injuries do your claim resulted? (Give full extent of injuries or damages claimel -Attach-two estimates-for auto damage.) 0�+ w L>.t.� �4;1.. . �l e.wZ Q4 -�`1^'�•'�1 .r-1-r i�= f��•l e�:.b w 1•.U��,, �f.. �. Ve-t vc-l¢ ?Leese. t;r- 4w. (a) 4*1%r j"A--'as. How was th2 amount claimed above computed? (Include the estimated amount of any prospective injury or dama`g�e�-) i l� D . �,.d M Gc.I C o.f2 JnsG V+y /L"J/fei.Tl� bQi^9 inGurreA 1: Names and addresses of witnesses, doctors, and hospitals: ✓✓L` F/mv- ze scj g,,— 141, 315.:�!J441m+ 0c, "&,,1j CA 946oZ 2 lac. Lir'; 1-, Ta-110f. 9. List the expenditures you made-on account of this accident or injury: DATE TINE AMOUNT tis ■ ■Basunutsalamnou as s Ensan a n Mauna■amsmBmetu NmeBa[l■tmBaBSBes■BBatBtaBass Bauman Bauman at ) .Gov. Code Sec. 9101 provides"The claim shall be ) signed by the claimant or by some person on his behalf." SEND NOTICES TO: (Attorney) 1 Name and address of Attorney ) _ may) -J- (Claimant's signature)sS��er••c,�� Cz r��.` — S �` ! ) Sen•*t �i 11c 1a6�sJ P.0 ,3-,,e 221239 (Address) CA- 13-6 2,'L- Telephone No. )Telephone No. L o" 4 S 5 —`1T 5 9 1 ■.B a sit an.NBN■B,sas a,,ana■NsuBstmssmn■a not an am Isms■ANN ass NINE a As■■a m BEE a■a an PUBLIC RECORDS NOTICE: Please be advised that this claim form, or any claim filed with the County under the Tort Claims Act, is subject to public disclosure under the California Public Records Act. (Gov. Code, §§ 6500 et seq.) Furthermore, any attachments,addendums, or supplements attached to the claim form, including medical records, are also subject to public disclosure, ■ ■mummmmmaamltantass mass aaMamatlnatunemesasnIssmnaatmema■nmBnatttEaBtatsanaRuns&mass NOTICE: 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 genuine, any false or fraudulent claim, bill, account voucher, or writing, is punishable either by imprisonment in the County jail fors period of not more than one year, by a fine of not exceeding one thousand dollars ($1,000.00), 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 eve BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: DECEMBER 05, 2006 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 California Government Codes. D }� 9016M you is your notice of the action taken �JC �/ on your claim by the Board of NOV 0 6 2006 Supervisors. (Paragraph IV below), given Pursuant to Government Code AMOUNT: $1,021.22 COUNTY COUNSEL Section 913 and 915.4. Please note all MARTINEZ CALIF. "Warnings". CLAIMANT: CALIFORNIA STATE AUTOMOBILE ASS. BY: CRYSTAL EDDY ATTORNEY: UNKNOWN DATE RECEIVED: NOVEMBER 06, 2006 ADDRESS: P.O. BOX 920: BY DELIVERY TO CLERK ON:NOVEMBER 06, 2006 SUISUN CITY, CA 94585-0920 BY MAIL POSTMARKED: NOVEMBER 02, 2006 FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN CULLEN 1 r Dated: NOVEMBER 06, 2006 By: Deputy - 11. FROM: County Counsel TO: Clerk of the Board of S ervisors (i.�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). O 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: t '--0 4—©(O By: Deputy County Counsel iII. FROM: Clerk of the Board TO: County Counsel (1) County Administrator(2) O 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. O Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: e42,wher,O /BHN CULLEN, CLERK, By Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions,you have only six(6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim.See Government Code Section 945.6.You may seek the advice of an attorney of your choice in connection widr this matter. if you want to consult an attonrey,you should do so immediately. *For Addi6aial Warning See Reverse Side of Tbis 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 certitied copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated:,Q"x,,,!�,e, 06 JOHN CULLEN, CLERK By Deputy Clerk "-12-2003 09:23 .. , •, CCC RISK MANAGMENT 925 335 1421 P.02 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, 1987, mast be presented not later than the lUUth 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. (Govt. Code §911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 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. 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 RECE EED ApTubt the Cowty f tra Costa NOV 0 6 2006 \ trict) CLERK BORED OF SUPERVISORS F in new ) CONTRA COSTA CO. The undersigned claimant hereby makes cla m nst County of Contra Costa or the above—named District in the sum of _ and in support of this claim represents as foLowp: 1. When did the damage or injury occur? (Give exact date and hour) 2. Where did/the damage or injury occur? (Include city and county) � �q 3. Hou did the damage or injury occur? (Give full details; use extra paper if 4. What particular A4 or omission on-the pant of county or, district officers, servants or-employees caused.the.injury or.damage? JUN-1-`20W 09:23 CCC RISK MRNRGMENT 925 335 1421 P.03 D F- 616 j, wnat are the names of county or district officers, servants or employees causing the damage or injury? 5. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. - 7. How was the amount claimed above computed (Include h esUmated amount of any prospective injury or damage.) 8. Names and addresses of.witne�bes, doc c s and hospitals. -— --- -» 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT Gov. Code Sec. 910:2 provides: "The claim must be signed by the claimant SM NOTICES TO: (Attorney) or b some person on his.behalf.° Name and Address of Attorney .Claimant's Signa Address Telephone No. Telephone No.M N 17 1 +t * NOTICE 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.genuine, any false or fraudulent claim, bill, account, voucher, or Witing, 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*.1#)ri3obment and fine;,or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars (,$10,0009 or by both such imprisonment and fine. >r o� m N� wcoo G CD a , nUL, (-a :. ' t qk vv, IKk l ll o . N o - N .75 w m Q om a' cD �v ' 10 p tV O C O c d at. C..op V P [7 0 3 N 10 N ui 0 !/100 ` ` Z Ocoo Dcr A LL 6 N 4!j' ,.i a' ooh d CQ kph ® ca t.tl k1 N ' •w y ul m � � R mon � otg y W � o Ypams�ngg Q '22'H v4� nv �u�Ap u0. x a