HomeMy WebLinkAboutMINUTES - 10142008 - C.12 (13) CLAIM
BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY
BOARD ACTION: OCTOBER 14, 2008
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 Govermnent Codes. You s your our notice of the action taken
�1 ���� on your claim by the Board of
Supervisors. (Paragraph IV below),
D
SEP 12 2008 given Pursuant to Government Code
AMOUNT: $1,858.55 Section 913 and 915.4. Please note all
COUNTY COUNSEL "Warnings".
CLAIMANT: KHOMKEO QUNNIYOM MARTINEZ CALIF.
ATTORNEY: UNKNOWN DATE RECEIVED: SEPTEMBER 12, 2008
ADDRESS: 2565 MAC ARTHUR AVENUE BY DELIVERY TO CLERK ON: SEPTEMBER 12, 2008
SAN PABLO, CA 94806
BY MAIL POSTMARKED: HAND DELIVERED
FROM: Clerk of the Board of Supervisors TO: County Counsel
Attached is a copy of the above-noted claim.
SEPTEMBER 12, 2008 DAVID TWA, Cler
Dated: By: Deputy
II. FROM: County Counsel TO: Clerk of the Board of Sullervisors
( his 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: 9 �7 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. 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— AVID TWA, 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 with this matter. If you want to consult an
attorney,you should do so immediately. *For Additional Warning See Reverse Side of Thus Notice.
AFFIDAVIT OF MAILING
I declare under penalty of perjury that 1 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��,KZ!/�AV1D TWA, CLERK, By Deputy Clerk
� � fe
This warningado� ts nottapply to claims which
are not subject tolthe = alifornia Tort Claims
Act such as actionsjm_Inverse condemnation,
actions for specific.reli, uch,as,mandamus or
injunction, or Federal-Civil Rights claims. The
above list is not exhaustive an'd legal
consultation is essentia146 understand all the
7 .:1.:.9 ��'��°T• .t�
separate limitations periods'tliat'may apply.
The limitations period within which suit must
be filed may be. shorter or longer depending on
the nature of the claim. Consult the specific
statutes and cases applicable to your particular
claim.
The County of Contra Costa does not waive any
of its rights under California Tort Claims Act
...nor does it.waive rights under the statutes of
limitations applicable to actions not subject to
the California Tort Claims Act
4,
�uE/� cc,r�errs
BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY rCp(p P
INSTRUCTIONS TO CLAIMANT
A. A claim relating to a cause of action for death or for injuryto 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.)
in 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.
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RE: Claim By: Reserved for Clerk's filing stamp
_K14OMkEO OuNMr/ Yo^1 )
REd��VED
Against the County of Contra Costa or )
SEP i.2;2008
COWU MW)gr 7V 13U c-- I.Jt?Q,LS District) C4E9K�A,
(Fill in the name) ) conlraACoSqE"VIS0:Js
OaPA-R-1MMeV T )
The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named
district in the sum of$ /, 8S8•SS and in support of this claim represents as.follovvs:
1. When did the damage or injury occur? (Give exact date and hour)
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2. Where did the damage or injury occur? (Include city and county)
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po vc*- atPojers oN o, z or *.
3. How did the damage or injury occur? (Give full details;use extra paper if required)
P12vtJz See •►were. Je-46U'lt on pQu'Ce 1 - Dn 1'i
4. What particular act or omission on the part of county or district officers, servants, or employees
caused the injury or damage?
Ilk Ar �V Lict
5 What are the names of county or district officers, servants, or employees causing the
damage or injury?
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6. WL-at dL-nage or injuries do your claim resulted? (Give full. extent of injuries or damages
Claimed. Attach two estimates for auto damage.)
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7. How was the .amount claimed above computed? (Include the estimated amount of any
prospective injury or damage.)
S. Names and addresses of witnesses,s doctors, and hospitals: SGt�i r �n.t oNl�s
Witrtek p/N S/�/\v ry�mb`AC/ GV01'�S lldGt//ul Sl//9IL1 VtSt��
9. List the expenditures you made on account of this accident or injury:
DATE TItv1E AMOUNT
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) .Gov. Code Sec. 910.2 provides "The claim shall be
) signed by the claimant or by some person on his
.half
SEND NOTICES TO: (Attorney)
Name and address of Attorney )
} (Claimant's Si tur
S6
(Address) _
Telephone No. ) lephone No
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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.
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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 imprisonment and fine.
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S LIFORNIA
T..AFFIC COLLISION REPORTSCANNEDe 1031Y
CHP 555 Page 1 (Rev.7-03) OPI 061 Page ' of
SPECIAL CONDITIONS NUMBERnf.RVx CITY JUDICIALDISTRICT LOCALREPORTNUMBER
INRIRED EELONV
❑
NUMBER NUED MITA RUN C/OOU1'NTY��/�/� //'�j�f�/�_ RE/PPOfRTTIING DISTRICT BEAT N"l9 EEO
Muo1NaR l.�[71`7T'V-1 V`�✓•Rte` .�"� 3 l-/ `-�
COLLISION OCCURRED ONMO. DAY YEAR TIME(3400) NCIC a OFFICER IG.
o uM2r,CL L112-109 I�—II1
�Z MILEPOST INFORMATION DAY OF WEEK TOW AWAY PHOTOGRAPHS BY: NONE
U
FEET/MILES OF S M Tie< T F S ❑YES NO
TION WITH STATE HWY REL
0 AT NTERSEC
2c70{CSi Q
Oft: FE !MILES OF C YES NO
PARTY RIM R5 LICENSE NU MSE STATE CUSS AIR SAG :SAFETYEQUIP. VEH YEAR MAKEIMOD LICOLOR LICENSE NUMBER STATE
' 'Llo q 8 3 CA Q 3 r,,,�[�T4S7) / tzw �L!a 7—. U
_ . -
OHI NAME(FIRST,M/DOLE.LASTJ qj 12t L w.f L7 I �1'L
L �Q OWNER'S NAME E NSI SAME AS DRIVER V I T
TRIAN STREET ADD ESS M1N"J vL,-- i 1��+ I '
C� OWNERS ADDRESS
❑ � �� 5 � ❑ SAME AS DRIVER
PARKED CITY/STATEZP
VEHICLE Lo
❑ G pt y SS DISPOSITION OF VEHICLE ON ORDERS OF: ❑OFFICER❑ DRIVER �OTHER
MCY- SE% HMR EYES EIGHT �L WEIGHT BIRTHDATE RACE w
CLIST / � !!p�ey _Yeu A (c-' PQ
❑ M 8w-) RZL L040 `9� (lP76 I(R� _ PRIOR MECHANICAL DEFECTS: NONE APPARENT REFER TO NARRATIVE
OTHER HOME PHONE BUSINESS PHONE e I VEHICLE IDENTIFICATION NUNSER:_ VF ' /J 1.
❑ '- Dae �Lo S1 0 �3v-J l,�I VFAICLE TYPE DESCRISE VEHICLE DAMAGE _1 YE 3 E.JASHADE IN DAMAGED AREA
WSURANCE CARRIER PoUCYNUMBER L-1-22, ❑UNK. NONE ❑MINOR
L'�_� •�'VVSuJi`'y �� �E-{�'� - 3;.'Z ❑MOD ❑MAJOR❑ROLL-OVER I�
DIR OF TRAVEL ON STREET OR HIGHWAY d7 SPEED LIMIT;.�/ I: CA ppT,l \ >)
Pw� W�� (�iJ! r ( +TJ,. .GALT TCP/PSC - --. MGM%
PARTY1 DRIVER'S LICENSE NUMBER STATE CUSS AIR BAG SAFETYEQUIP.EQUIP. VEH.YFJIR MAKEEAODEUCOLOR LICENSE NUMBER STATE
2 0ICA iI iii - �/
DRIVER NAME(FIRST,MIDDLE,LAST)
tieIV j"T _ LSI OWNEWSMAE __ E "AMEASDRNER
P DES STR - J CO ��U
TRIAN WGI
SAN OWNER'S ADDRESS.-,,
E] � (� M f�C�T'tt-�- SAfd P:^3LO p1il&4;KSAME AS DRIVER
PARKED CTTY/STATE2IP
VELE
HICSA cT
DISPOSITION OF VEHICLE ON ORDERS OF: ❑OFFICER'TE I DRIVER ❑OTHER
CBICY-LIST SEX MR EYES HEIOM WEIGHT BIRTHDATE RACE JLR�
CLIST C Ye
p
❑ r 's I 11 1I O PRIOR MECHANICAL DEFECTS: Xj NONE APPARENT REFER TO NARRATIVE
OTHER HOME PHONE BUSINESS PHONE VEHICLE IDENTIFICATION NUMBER:
BE1J 6C•T / —7.t /'L C V ,{/
El 5)0 -3�~ 7W3 VEHICLE TYPE DESCRIBE VEHICLE DAMAGE SHADE IN DAMAGED
AREA
INSURANCE CARRIER POLICY NUMBER G 1:1 LINK NONE D MINOR
tsTL�— f1�,•JL,L, ' �S S } (- O : I MOD. ❑MAJOR[]ROLL-OVER ...
DIR OFTRAVEL OIV STREET OR HIGHWAY SPEED 1T
OOT
2,ulY�M� /��r ✓ G4T TCPIPSC MCAD —� - law
PARTY B LICENSE NUMBER STATE CLASS AIR BAG :SAFETY EQUIP. Av.,yeAR MAKE/MOOEUCOLOR UCENSE NUMBER STATE
3
DRIVER NAME(FIRST, E,lASTJ
❑ OWNER'S NAME SAME AS DRIVER
PEDES- STREET ADDRESS
TRIAN
ElOWNEWS ADDRESS E AS DRIVER
PARKED CITY/STATE2IP
VEHICLE
E] DISPOSITION OF VEHICLE ON ORDERS OF: OFFICER❑ DRIVER ❑OTHER
BICY- SEX HAIR EYES HEIGHT VVEI BIRTHDATE RACE
CLIST MB- Day Yee'
❑ PRIOR MECHANICAL DEFECTS: NONE APPARE REFER TO NARRATIVE
OTHER HOME PHONE BUSINESS PHONE VEHICLE IDENTIFICATION NUMBER:
❑ VSHICLE•TYPE DESCRIBE VEHICLE DAMAGE OE IN DAMAGED AREA
INSURANCE CARRIER POLICY NUMBER ❑UNK. F�NQNE ❑MINOR `
❑MOD. ❑MAJOR❑ROLL-OVER
DIR OF TRAVEL ON STREET OR HIGHWAY SPEED LIMIT /1
CA
CAL-T CP/PS -'-�
PREPARER'S NAME . DISPATCH NOTIFIED R I S NAME DATER D
l YES
❑ NO ❑ N/A �.Q,,
• OF CALIFORNIA
TRAFFIC COLLISION CODING
CHP 555 Page 2(Rev. 7-03) OPI 061 Paye a o1
MBED
DATE OF COLLISION(MO. OAY YEAR) TIME(1a00) NCIC• OFFICER LO. NU
i Y/LJ � � r C> r 9 0 ,?
ONMER'S NAME OWNER'S ADDRESS NOTIFIED
PROPERTY ❑
DAMAGE oes IDN F D
SEATING POSITION SAFETY EQUIPMENT INATTENTION CODES
OCCUPANTS L-AIR BAG DEPLOYED M/C BICYCLE-HELMET A-CELLPHONE HANDHELD
A-NONE IN VEHICLE M-AIR RAG NOT DEPLOYED DRIVER PASSENGER B-CELLPHONE HANDSFREE
3-UNKNOWN N-OTHER V-NO X-NO C-ELECTRONIC EQUIPMENT
C-LAP BELT USED P-NOT REQUIRED W-YES Y-YES D-RADIO/CD
D-LAP BELT NOT USED E-SMOKING
1-DRIVER E-SHOULDER HARNESS USED F-EATING
1 2 3 2 TO -PASSENGERS F-SHOULDER HARNESS NOT USED CHILD RESTRAINT EJECTED FROM VEHICLE G-CHILDREN
4 5 6 7_STATION WAGON REAR G-LAP/SHOULDER HARNESS USED 0-IN VEHICLE USED 0-NOT EJECTED H-ANIMALS
I 8-REAR OCC.TRK.OR VAN H-LAP/SHOULDER HARNESS NOT USED R-IN VEHICLE NOT USED 1-FULLY EJECTED I-PERSONAL HYGIENE
9-POSITION UNKNOWN J-PASSIVE RESTRAINT USED S-IN VEHICLE USE UNKNOWN 2-PARTIALLY EJECTED J-READING
7 0-OTHER K-PASSIVE RESTRAINT NOT USED T-IN VEHICLE IMPROPER USE 3-UNKNOWN K-OTHER
U-NONE IN VEHICLE
ITEMS MARKED BELOW FOLLOWED BY AN ASTERISK I-)SHOULD BE EXPLAINED IN THE NARRATIVE.
! PRIMARY COLLISION FACTOR TRAFFIC CONTROL DEVICES I ( SPECIAL INFORMATION MOVEMENT PRECEDING
LIST NUMBER C OF PARTY AT FAULT 2 13 2 3 COLLISION
A KS CTM)MOMA.T'F aTEo Y¢s A CONTROLS FUNCTIONING A HAZARDOUS MATERIAL A STOPPED
I ' ;?w/_A �— B CONTROLS NOT FUNCTIONING- _ B CELL PHONE HANDHELD IN USE B PROCEEDING STRAIGHT
B OTHER IMPROPER DRNING': C CONTROLS OBSCURED C CELL PHONE RANDSFREE IN USE C RAN OFF ROAD
D NO CONTROLS PRESENT/:FACTOR:' r D'CELL PHONE NOT-IN USE! D MAKING RIGHT TURN
iC OTHER THAN DRIVER' TYPE OF COLLISION!i I i 0 1 " 1";I E SCHOOL BUS RELATED I E MAKING LEFT TURN
D UNKNOWN' A HEAD-ON - I F 75 FT MOTORTRUCK COMBO F MAKING U TURN
B SIDESWIPE i (�, (_4 iii f G 32 FT TRAILER COMBO G BACKING
C REAR ENO f,41 i :IH H SLOWING/STOPPING
WEATHER OWARK 1 TO 2ITEMS) D BROADSIDE ✓ '•" -
I I PASSING OTHER VEHICLE
A CLEAR E HIT OBJECT (�.1(p?L`t`ilti:;?itli i,t Yi. ':.J J CHANGING LANES
I B CLOUDYF OVERTURNED_ L%L`-�'='=' '/'"' °"' `_' _1 K IK PARKINGMANEUVER
C RAINING G VEHICLE/PEOESTRIAN=I)'I^.,'71. _,,�4 I L ENTERING TRAFFIC
D SNOWING H OTHER': - I M OTHER UNSAFE TURNING
E FOG/VISIBILITY FT, IN N XING INTO OPPOSING LANE
F OTHER- MOTOR VEHICLE INVOLVED WITH-� —.. O.—_.—-------- -- --- - O PARKED
G WIND A NON-COLLISION Sn;�`J'_ _ P MERGING
LIGHTING B PEDESTRIAN �'u c - ""' "-'
- ----"----�� � � - Q TRAVELING WRONG WAY
A DAYLIGHT C OTHER MOTOR VEHICLE.`.rrCOTHER ASSOCIATED FACTORS) R OTHER-:
B DUSK-DAWN D MOTOR VEHICLE ONCTHERROADWAY--'-J.,-?. __,-.3,- -__.(MARK I TO 2 ITEMS)
C DARK-STREETLIGHTS E PARKED MOTOR VEHICLE L�^'.a'`'-'�' - - A WSECTwxN N). uTEO YES
D DARK-NO STREET LIGHTS F TRAIN
NO
vc aecnoN xrnwnaN� urEu
E DARK-STREETLIGHTS N07 G BICYCLE I B res
FUNCTIONING' H ANIMAL: I rvo SOBRIETY-DRUG
vC SE"ON NdAnox: CITEo
ROADWAY SURFACE C O
YES 2 3 PHYSICAL
(MARKT O2IIITEMS)
A DRY I FIXED OBJECT: ❑ND
B WET D V lie, 1A HAD NOT BEEN DRINKING
C SNOWY-ICY j OTHER OBJECT: E VISION OBSCUREMENT: 1B HRD-UNDER INFLUENCE
D SLIPPERY MUDDY,OILY,ETC. F INATTENTION*: I IC HELD-NOT UNDER INFLUENCE'
ROADWAY CONDITION(S) G STOP&GO TRAFFIC I ID HBO-IMPAIRMENT UNKNOWN'
I (MARK I TO 2ITEMS) PEDESTRIAN'S ACTIONS H ENTERING/LEAVING RAMP E UNDER DRUG INFLUENCE-
A HOLES.DEEP RUT' l<A NO PEDESTRIANS INVOLVED I PREVIOUS COLLISION F IMPAIRMENT-PHYSICAL'
B LOOSE MATERIAL ON ROADWAY' 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 I YES AT INTERSECTION I SLEEPY/FATIGUED'
E REDUCED ROADWAY WIDTH NO
F FLOODED' D CROSSING-NOT IN CROSSWALK L UNINVOLVED VEHICLE
G OTHER': E IN ROAD-INCLUDES SHOULDER M OTHER':
H NO UNUSUAL CONDITIONS F NOT IN ROAD N NONE APPARENT
APPROACHING/LEAVING SCHOOL BUS I Q RUNAWAY VEHICLE
,SKETCH MISCELLANEOUS
16
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I INDICATE NORTH 1
I I I PA-� z`
1 . r
S' I -ALIFORNLA _
If,, uRED /WITNESS/ PASSENGERS
CHP 555 Page 3(Rev. 1-03) OPI 061 Paga3 of
GATE OF COLLIN (MZ DAY R) TIM (2900)J NCIC A O ) OFFICER I.D. NUMBER O I 1^
WITNESS PASSENGER EXTENT OF INJURY("X"ONE) INJURED WAS("X"ONE) PARTrI sEAr aR 'saF V
ONLY ONLY AGE SEX FATAL SEVERE OTHER VISIBLE COMPLAINT NUMBE POS. BAG EQUIP. EJECTED
DRIVER PARS. PED. BICYCT THER
INJURY INJURY INJURY OF PAIN ( LISO
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ I ❑ l ;L 9-
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NAMEf D.O.B./ADDRESS TELEPHONE 'J
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(INJURED ONLY)TRANSPORTED BY: J^I OI ,�_ CD I A
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DESCRIBE INJURIES V �
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❑VICTIM OF VIOLENT CRIME NOTIFIED
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NAME .O.B./ADDRESS TELEPHONE
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(INJURED ONLYT TRANSPORTED BY: D O_ TAKEN TO:
DESCRIBE INJURIES
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I . ❑VICTIM OF VIOLENT CRIME NOTIFIED
❑# ❑ I ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ! ❑
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DESCRIBE INJURIES
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❑VICTIM OF VIOLENT CRIME NOTIFIED
❑# ❑ ❑ I ❑ ❑ ID10101 ❑ 101
NAME 10.O.B./ADDRESS TELEPHONE
(INJURED ONLY)TRANSPORTED BY: TAKE
DESCRIBE INJURIES
❑VICTIM OF VIOLENT CRIME NOTIFIED
❑# ❑ ❑ ❑ ❑ ❑ 1 ❑ 10 1 ❑ ❑
NAME/D.O.B.I ADDRESS TELEPHONE
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DESCRIBE INJURIES
VICTIM OF VIOLENT CRIME NOTIFIED
PREPARER'SNAME I.D.NUMBER MO. DAY YEAR R NAME M0. V YE '
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STATE OF CALIFORNIA
NARRATIVE/SUPPLEMENTAL
CHP 556(Rev 7-90)OPI 042 Page
DATE OF INCIDENTIOCCURRENCE TIME(2400) NCC NUMBER OFFICER I.D.NUMBER NUMBER
y! tilo8 talo o9-t ) I 1+-r 1 08- 31 llfo
'X'ONENE TYPE SUPPLEMENTAL rX"APPLICABLE)
.54LNarrative ❑Collision report ❑ BA update ❑Fatal ❑Hit and run update
❑Supplemental ❑Other: ❑ Hazardous materials ❑School bus ❑Other:
CITY/COUNTY/JUDICIAL DISTRICT REPORTING DISTRICT18EAT CITATION NUMBER
N P42L.� &7h5?12 ccksl4 u TJ t C.c xt-
LOCATIOWSUBJECT p STATE HIGHWAY RELATED -
1LA-OAQ LLL g1- j $>z.'.��5.�= �P. 5 .! _ ❑Yes No
1. M -- WAS DtS PA,t e'G�� WN LLLTtoN - V
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04/15/2008 at 05:2 V PM Job Number:
29999
ACCURATE AUTO BODY
License # :AJ196460 Federal ID # : 911829674
1095 BROADWAY
SAN PABLO, CA 94806-2260
(510) 236-5576 Fax: (510) 236-5593
PRELIMINARY ESTIMATE
Written By: ED CICHON
Adjuster:
Insured: KOOT OUNNIYOM Claim #
Owner: KOOT OUNNIYOM Policy #
Address: 2565 MAC ARTHUR AVE. Deductible:
SAN PABLO, CA 94806 Date of Loss:
Day: (510) 236-7003 Type of Loss:
Point of Impact: 1 . Right Front
Inspect ACCURATE AUTO BODY Business: (510) 236-5576
Location: 1095 BROADWAY
SAN PABLO, CA 94806-2260
Insurance
Company: Days to Repair
1996 HOND CIVIC LX 4-1 . 6L-FI 4D SED GREEN Int:
VIN: 2HGEJ6671TH540016 Lic: Prod Date: Odometer: 184850
Condition: Fair
Rear Defogger Tilt Wheel Cruise Control
Intermittent Wipers Tinted Glass Body Side Moldings
Dual. Mir.ror.s Console/Storage Clear Coat Paint
Metallic Paint Power Steering Power Brakes
Power Windows Power Locks Power Mirrors
AM Radio FM Radio Stereo
Driver Air Bag Passenger Air Bag Cloth Seats
Bucket Seats : Recline/Lounge Seats 5 Speed Transmission
Overdrive Full Wheel Covers
-------------------------------------------------------------------------------
NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT
-------------------------------------------------------------------------------
1 FRONT BUMPER
2** Repl RECOND Bumper cover 1 160 . 00 1 . 6 2 . 6
3 Add for Clear Coat 1 . 0
4 FRONT LAMPS
5 Repl RT Headlamp assy 1 219. 97 0 . 5
6 Aim headlamps 0 . 5
7 FENDER
8 Repl RT Fender 1 171 .28 2 . 3 2 . 0
9 Add for Clear Coat 0. 8
10 Add for Edging 0 . 5
11 Deduct for Overlap -0 . 5
12 Repl RT Fender liner 1 42. 45 Incl .
13 Repl RT Body side mldg w/o EX 1 21 . 37 0 . 3
1
04/15/2008 at 05: 27 PM Job Number:
29999
PRELIMINARY ESTIMATE
1996 HOND CIVIC LX 4-1 . 6L-FI 4D SED GREEN Int:
-------------------------------------------------------------------------------
NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT
-------------------------------------------------------------------------------
14** Repl. A/M W.O. MLDG. 1 10. 00 0 . 3
15# Subl Hazardous waste removal 1 3. 00 X
16# Repl Cover car 1 5. 00 T 0 .2
17# Repl Flex additive 1 4 . 50 T
18# Color tint 1 0 . 5
-------------------------------------------------------------------------------
Subtotals =_> 637 . 57 5.7 6. 9
Parts 625. 07
Body Labor 5. 7 hrs @ $ 72 . 00/hr 410. 40
Paint Labor 6. 9 hrs @ $ 72 . 00/hr 496. 80
Paint Supplies 6. 9 hrs @ $ 35. 00/hr 241 . 50
Sublet/Misc. 12 . 50
----------------------------------------------------
SUBTOTAL $ 1786.27
Sales Tax $ 876. 07 @ 8 . 2500% 72 .28
----------------------------------------------------
GRAND TOTAL $ 1858 . 55
ADJUSTMENTS :
Deductible 0 . 00
----------------------------------------------------
CUSTOMER PAY $ 0. 00
INSURANCE PAY $ 1858 . 55
2
04/15/2008 at 05: 27 PM Job Number:
29999
PRELIMINARY ESTIMATE
1996 HOND CIVIC LX 4-1 . 6L-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. NWCPP=NATIONWIDE CRASH
PARTS PROGRAM.
THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF CRASH PARTS SUPPLIED BY A
SOURCE OTHER THAN THE MANUFACTURER OF YOUR MOTOR VEHICLE. ANY WARRANTIES
APPLICABLE TO THESE REPLACEMENT PARTS ARE PROVIDED BY THE MANUFACTURER OR
DISTRIBUTOR OF THE PARTS, RATHER THAN BY THE ORIGINAL MANUFACTURER OF YOUR
VEHICLE.
3
04/15/2008 at 05: 27 PM Job Number:
29999
PRELIMINARY ESTIMATE
1996 HOND CIVIC LX 4-1 . 6L-FI 4D SED GREEN Int:
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived
from the Guide AEG4431, CCC Data Date 04/01/2008, 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 Recond. 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.
4
04/15/2008 at 05:27 PM Job Number:
29999
PRELIMINARY ESTIMATE
1996 HOND CIVIC LX 4-1 . 6L-FI 4D SED GREEN Int:
ALTERNATE PARTS SUPPLIERS
2 RECOND Bumper cover Part No. H01000172 Price $160 . 00
Faith. Bumper. Service (408) 986-1226
1085 DI GIULIO
SANTA CLARA, CA 95050
5