HomeMy WebLinkAboutMINUTES - 10282008 - C.15 (18) . 1 I
CLAIM
BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY
BOARD ACTION: OCTOBER 28, 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 Government Codes. ) you is your notice of the action taken
� on your claim by the Board of
��
Supervisors. (Paragraph IV below),
• given Pursuant to Government Code
AMOUNT: $39990.66
SEP 2 5 2008 Section 913 and 915.4. Please note all COUNTY COUNSEL "Warnings".
CLAIMANT: MERCURY CASUALTY COIINEZ, CALIF.
FOR: LESLIE HAWS
ATTOINEY__KAT"0YN SILVER DATE RECEIVED: SEPTEMBER 25, 2008
ADDRESS: P.O. BOX 997195 BY DELIVERY TO CLERK ON: SEPTEMBER 25, 2008
SACRAMENTO, CA 95899 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 claim.
SEPTEMBER 25, 2008. DAVID TWA, C er
Dated: By: Deputy.
11. FROM: County Counsel TO: Clerk of the Board of upervisors
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).
YOther: I'Lt 5 6 4((n aok k /
Co n Aya asin,LO S �e �i�I ed i19
r i tv�
Dated: 10 B : ounty Counsel
I11. 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. JOARD ORDER: By unanimous vote of the Supervisors present:
(vf This Claim is rejected in full.
( ) Other: .
I certify that this is a true and correct copy of the Board's Order entered in its minutes for
this date.
DatedAZ(&4/, DAVID 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 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 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: �9 tog DAVID TWA, CLERK, By Deputy Clerk
This warning does not apply to claims which
are not subject to the California Tort Claims
Act such as actions in inverse condemnation,
actions for specific"relief sucli as mandamus or
injunction, or Federal Civil Rights claims. The
above list is not exhaustive and legal
consultation is essential to understand all the
separate limitations periods-that 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
�rgor
does-.it waive rights under the statutes of
alimitations applicable-to actions not subject to
the California Tort Claims Act
♦ r
.k '
SEP• 12. 2008 2: 30PM CCC RISK MANAGEMENT NO. 490 P. 2
BOARD OF SUPERVISORS OF CONTFA COSTA COUNTY
s INSTRUCTIONS TO
A. A claim relating to a cause of action for death or for injury to person or to personal property or
growin, 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.)
S. Claims must be filed with the Clerk of the Board of Supervisors at its office in RODm 106,
County Administration Building, 651 Pine Street,Martinez, CA 945 53.
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 eacb
public entity.
E. Fraud. See penalty for fraudulent claims,Penal Code Sec. 72 at the end of this form.
■[[LLFti[\\[[LL[LLu■L\\LLL■\\�t\\\LLLRae�[L[L■\\\\L■L\\\\[\L[■\\•LLL[[CL\f LLRLt
RE: Claim By: Reserved for Clerk's filing stamp
d, RECEIVED
)
Against the County of Contra Costa or ) FCONTRA
2008
OFF_RVISORS
District) A CO.
(Fill in the name) )
The undersigned claimant hereby mikes claim against the County of Contra Costa or the above-named
distdctiathe.sumof$-3, 79C, and in support of this claim represents as follows:
1. When did the damage orinjury occur? (Give exact date and hour)
1411 (o =So /4w,
2. Where did the damage or injury occur? (Include city and county)
Orivt+ s %c.12 Gfprtt C.G(` h� � . GohCrr✓c� 1 Co,\+ra CoSfq
3. How did the damage or injury occur? (Give full details;use extra pa er if required)
Ya�v 0,hic,kC twr heal u cor ►mer A-wo S ketro,.C,l S t-rcLc.W
t7gj- iASvrtok •
4. What particular act or omission on the part of county or district officers, servants, or employees
caused the injury or damage? �f'
YOv,r 6(A 4ri jr tu,rv�Q c.( to. 1''� �d v� Ow('
rutsur�cl k.r\a1 Caksed ktr- 016L,4A0L99
5 What are the names of county or district officers, servants, or employees causing the
damage or m1ury?
-i G0.rd U KcJ f i c, tit Z , Coh '-rtk. C4:PStrA- Coc,•^. -y /m n5: ,t•
SSP. 12, 2008 2.30PM CCC RISK MANAGEMENT N0, 490 P. 3
6-' dans Qe or injuries do your claim resulted? (Give full extent of injuries or damages
claimed. Attach two estimates for auto damage.)
9 r i✓�{`
9 (00- F rd^t Go r �Q r c,�l`2 a . ^C) L rte't rl
7. How was the amount claimed above computed? (Include the estimated amount of any
prospectiveinjury or damage.)
8_ Names and adc jesses of witnesses, doctors, and hospitals:
9. List the expenditures you made on account of this accident or injury:
DATE TIME AMOUNT
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srfy�l� Sad.��
■as man wpm sRoom aaIa0aass a■aaaIahasamassoanwassaw%a9mvxass%KKamsPIasaaPI%KaaaamasmRKaaPIat
.Gov. Code Sec. 910.2 provides "Tlie claim shall be
signed by the claimant or by some person on his
behalf."
SENT NOTICES TO: (Attorney) )
Name and address of Attorney
}
(Claimant's Signature)
Pa (3ou '�'( ct71 K
(Address)
jSctcOct ryP fa, C
Telephone No.
arasa/O MIR a■Kaaaaaaas on a BE sR a a as It OR a an avow It seas as alas a as a woman van sasas a IF a■R KK a ZEN PICK a
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, §5 6500 at seq.) Furthermore, any
attachments,addeadums, or supplements attached to the claire 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
=pnsomnent 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.
0003-025345
P.O. BOX 997195
MERCURY SACRAMENTO CA 95899
CASUALTY COMPANY
A member of Mercury Insurance Group
09/23/2008
Mailed to:
CONTRA COSTA COUNTY RISK MANAGEMENT
2530 ARNOLD DRIVE, SUITE 140
MARTINEZ CA 94553
ATTENTION:
OUR INSURED: LESLIE HAWS
OUR FILE NO: 2008 0003 002038-16
DATE OF LOSS: 04/15/2008
YOUR INSURED:
YOUR FILE NUMBER: 2008074752
Dear CONTRA COSTA COUNTY RISK MANAGEMENT
We have obtained information regarding the above date of loss suggesting that damages incurred were caused
by your insured's negligence.
Enclosed for your review please find copies of our supporting documentation. The breakdown of our payments
is as follows:
Initial Repairs 3,490.66
Deductible 500.00
Supplements
Rental Expense
Out of Pocket Expense
Other
Salvage +
VLF, if applicable
Total 3,990.66
Total Amount Due 3,990.66
Our insured's version of the loss is as follows:
SHE MADE A RIGHT TURN AT A STOP SIGN, YOUR DRIVER CUT HIS TURN SHORT AND HIT OUR INSURED.
Please return a copy of this form with your payment, to ensure proper credit.
Should you have any questions or need additional information, please contact me. Thank you for your
cooperation.
Sincer ly,
Kathryn Silver
(916) 636-1534 Ext 2383
Enclosures
C21 05/2007
Date: 6/19/2008 01:16 PM
i EstimateID: 080003002038-1600101
a5fimate Version: 0
Committed
Profile ID: CUSTOMIZED
Jim's California Auto Body
2520 Monument Blvd.,Concord,CA 94520
(925)689-6117
Fax: (925)689-7836
LARGEST SHOP IN THE BAY AREA
30 YEARS OF EXPERIENCE
Damage Assessed By: STEVE SCOTT Appraised For: KATHRYN SILVER
(916)636-1534 ext.2383
Date of Loss: 4/15/2008 Arrival Date: 6/19/2008 '
Payer: Insurance Deductible: 500.00
Claim Number: 080003002038-1600101
Owner: HAWS,LESLIE
Address: 1561 GLAZIER DR,CONCORD,CA 94521
Telephone: Work Phone: (925)6915000 Home Phone: (925)685-3609
Mitchell Service: 914498
Description: 2003 GMC Yukon XL C1500 SLT
Body Style: 4D Ut Drive Train: 5.31-Inj 8 Cyl 2WD
VIN: 3GKEC16T73G165472 License: 6TKL147 CA
Mileage: 52,000
OEM/ALT: O Search Code: None
Color: GRAY
Line Entry Labor Line Item Part Type/ Dollar Labor CEG
Item Number Type Operation Description Part Number Amount Units Unit
1 400049 BDY OVERHAUL FRT BUMPER ASSY 2.0 # 2.0
2 402755 BDY REMOVE/REPLACE FRT BUMPER FACE BAR Remanufactured 375.00 ' INC # 2.OT
3 400053 BDY REMOVE/REPLACE FRT UPR BUMPER COVER 12477935 GM PART 191.06 INC # 1.3T
4 AUTO REF REFINISH FRT MOULDING CAP C 1.2 1.2
5 400055 BOY, REMOVE/REPLACE FRT BUMPER AIR DEFLECTOR 88980801 GM PART 111.22 INC # 0AT
6 400059 BDY REMOVE/REPLACE FRT BUMPER RETAINER 4@4.54 15733970 GM PART 18.16 INC T
7 400060 BDY REMOVE/REPLACE FRT BUMPER PIN 5@4.35 15733971 GM PART 21.75 INC T
8 400062 BDY REMOVE/REPLACE L FRT OTR BUMPER BRACE 15705657 GM PART 29.72 0.2 # 0.2T
9 403013 BDY REMOVE/REPLACE L FRT BUMPER FILLER PANEL 15049381 GM PART 17.55 0.2 # 0.2T
10 403015 BDY REMOVE/REPLACE L FRT BUMPER RETAINER 21110201 GM PART 4.68 INC T
11 400071 BDY REMOVE/REPLACE GRILLE 19130787 GM PART 385.16 0.1 0AT
12 400073 BDY REMOVE/REPLACE GRILLE EMBLEM 15706323 GM PART 48.30 INC # 0AT
13 400083 BDY REMOVE/REPLACE L H/LAMP ASSEMBLY 15289275 GM PART 275.10 0.3 0.3T
14 AUTO BDY CHECK/ADJUST HEADLAMPS 0.4 0.4
15 400109 BDY REMOVE/REPLACE L H/LAMP ADJUSTING SPRING 2@4.16 15845413 GM PART 8.32 T
16 400115 BDY REMOVE/REPLACE L FRT COMBINATION LAMP ASSEMBLY 15199560 GM PART 83.07 0.2 # 0.2T
17 400146 REF BLEND HOOD OUTSIDE" C 1.3 3.1
18 400152 BDY ALIGN HOOD PANEL Existing 0.3* 1.1
19 402979 BDY REPAIR COOLING RADIATOR SUPPORT Existing 0.0*# 6.3
20 OPEN TO INSPECTION
21 400237 MCH ACCESS/INSPECT AIR COND CONDENSER -M Existing 0.0*# 1.0
0 AUTO MCH REMOVE/REPLACE EVACUATE R RECHARGE A/C -M 1.4
22 INSPECT A/C OPERATION INOP AFTER CRASH
23 400309 BDY REMOVE/REPLACE L FENDER PANEL 19168845 GM PART 233.80 1.9 # 2.2T
24 AUTO REF REFINISH L FENDER OUTSIDE C 2.0 2.0
ESTIMATE RECALL NUMBER: 06/19/2008 13:11:19 080003002038-1600101
Mitchell Data Version: OEM: MAY_08_V UltraMate is a Trademark of Mitchell International
Copyright(C)1994-2008 Mitchell International Page 1 of 3
UltraMate Version: 6.5.017 All Rights Reserved
Date: 6/19/2008 01:16 PM
c i Estimate ID: 080003002038-1600101
'astimate Version: 0
Committed
Profile ID: CUSTOMIZED
25 AUTO REF REFINISH L FENDER EDGE&INSIDE C 1.2 1.2
26 400315 BOY REMOVEIREPLACE L FENDER LINER ORDER FROM DEALER d35.02 0.3 0.3T
27 402061 BOY REMOVE/REPLACE L FRT FENDER RETAINER 15958694 GM PART 0.45 T
28 405213 BOY REMOVE/INSTALL L RUNNING BOARD ASSY 0.6 0.6
29 900500 BOY * REMOVEIREPLACE BUG SHIELD "QUAL REPL PART 210.00 * 0.6' T
30 401148 REF BLEND L FRT DOOR OUTSIDE C 1.1 2.7
31 401170 BOY REMOVE/INSTALL L FRT REAR VIEW MIRROR 0.2 0.2
32 402766 BOY REMOVE/INSTALL L FRT OTR BELT MOULDING 0.6 # 0.6
33 401176 BOY REMOVE/INSTALL L FRT DOOR ADHESIVE MOULDING Existing 0.2 0.2
34 R&R Time Used in R&I Operation
35 401228 BOY REMOVE/INSTALL L FRT DOOR HANDLE 0.2 # 0.6
36 900500 BOY ' ADD'L LABOR OP PULL TO SQUARE Existing 3.0`
37 900500 BOY ' ADD'L LABOR OP COLOR SAND&BUFF 0.3 PER PANEL 1.5 MAX Existing 1.0'
38 900500 BOY * REMOVE/REPLACE MASK FOR OVERSPRAY Sublet 10.00 * 0.0'
39 900500 BOY ' ADD'L LABOR OP COLOR SAND&BUFF 0.3 PER PANEL 1.5 MAX Existing 0.6'
40 933006 FRM ADD'L OPR FRAME/RACK SET UP 1.5`
41 900500 BOY * REMOVE/REPLACE FLEX ADDITIVE "QUAL REPL PART 8.00 ` 0.0` T
42 AUTO REF ADD'L OPR CLEAR COAT 2.1
43 AUTO ADD'L COST PAINT/MATERIALS 249.20 * T
44 AUTO ADD'L COST HAZARDOUS WASTE DISPOSAL 3.00 *
* -Judgment Item
#-Labor Note Applies
d -Discontinued by the Manufacturer
C-Included in Clear Coat Calc
Remarks
Estimate Totals
Add'I
Labor Sublet
I. Labor Subtotals Units Rate Amount Amount Totals II. Part Replacement Summary Amount
Body 12.9 67.00 0.00 0.00 864.30 Taxable Parts 2,056.36
Refinish 8.9 67.00 0.00 0.00 596.30 Parts Adjustments 73.17-
Frame 1.5 67.00 0.00 0.00 100.50 Sales Tax @ 8.250% 163.61
Non-Taxable Labor 1,561.10 Non-Taxable Parts 10.00
Labor Summary 23.3 1,561.10 Total Replacement Parts Amount 2,156.80
Ill. Additional Costs Amount IV. Adjustments Amount
Taxable Costs 249.20 Insurance Deductible 500.00.
Sales Tax @ 8.250% 20.56
Customer Responsibility 500.00-
Non-Taxable Costs 3.00
Total Additional Costs 272.76
I. Total Labor: 1,561.10
II. Total Replacement Parts: 2,156.80
III. Total Additional Costs: 272.76
Gross Total: 3,990.66
ESTIMATE RECALL NUMBER: 06/19/2008 13:11:19 080003002038-1600101
Mitchell Data Version: OEM: MAY-08_V UltraMate is a Trademark of Mitchell International
Copyright(C)1994-2008 Mitchell International Page 2 of 3
UltraMate Version: 6.5.017 All Rights Reserved
Date: 6/19/2008 01:16 PM
/
Estimate ID: 080003002038-1600101
cstimate Version: 0
Committed
Profile ID: CUSTOMIZED
IV. Total Adjustments: 500.00-
Net Total: 3,490.66
Point(s)of Impact
11 Left Front Corner(P)
Insurance Co: MERCURY CASUALTY INSURANCE
Address: P.O.BOX 997195
SACRAMENTO,CA 95899
Telephone: (916)635-0423
(916)635-0423
Due to many unforseen circumstances in the repairing of automobiles,we
regret that we can only estimate, not promise a completion dateand
time.
Date vehicle driven in/towed in:D
Date vehicle inspected:6/19/08
Number of photos:10
Estimated number of days to repair:6
Closing Type:R
Send check to facility:Y
Copy of estimate give to owner:Y
************CARS INSPECTION CLOSING REPORT***************
LKQ PARTS AVAILABLE:NONE
SOURCE:RANCHO AND CAD
PHONE AND REFERENCE:
ESTIMATE RECALL NUMBER: 06/19/2008 13:11:19 080003002038-1600101
Mitchell Data Version: OEM: MAY_08_V UltraMate is a Trademark of Mitchell International
Copyright(C)1994-2008 Mitchell International Page 3 of 3
UltraMate Version: 6.5.017 All Rights Reserved
Date: 6/19/2008 01:16 PM
Estimate ID: 080003002038-1600101
cstimate Version: 0
Committed
Profile ID: CUSTOMIZED
Jim's California Auto Body
2520 Monument Blvd.,Concord,CA 94520
(925)689-6117
Fax: (925)689-7836
LARGEST SHOP IN THE BAY AREA
30 YEARS OF EXPERIENCE
Damage Assessed By: STEVE SCOTT Appraised For: KATHRYN SILVER
(916)636-1534 ext.2383
Date of Loss: 4/15/2008 Arrival Date: 6/19/2008
Payer: Insurance Deductible: 500.00
Claim Number: 080003002038-1600101
Owner: HAWS,LESLIE
Address: 1561 GLAZIER OR,CONCORD,CA 94521
Telephone: Work Phone: (925)6915000 Home Phone: (925)685-3609
Mitchell Service: 914498
Description: 2003 GMC Yukon XL C1500 SLT
Body Style: 4D Ut Drive Train: 5.31-Inj 8 Cyl 2WD
VIN: 3GKEC16T73G166472 License: 6TKL147 CA
Mileage: 52,000
OEM/ALT: O Search Code: None
Color: GRAY
Line Entry Labor Line Item Part Type/ Dollar Labor CEG
Item Number Type Operation Description Part Number Amount Units Unit
1 400049 BOY OVERHAUL FRT BUMPER ASSY 2.0 # 2.0
2 402755 BOY REMOVE/REPLACE FRT BUMPER FACE BAR Remanufactured 375.00 ' INC # 2.OT
3 400053 BOY REMOVE/REPLACE FRT UPR BUMPER COVER 12477935 GM PART 191.06 INC # 1.3T
4 AUTO REF REFINISH FRT MOULDING CAP C 1.2 1.2
5 400055 BOY, REMOVE/REPLACE FRT BUMPER AIR DEFLECTOR 88980801 GM PART 111.22 INC # OAT
6 400059 BOY REMOVE/REPLACE FRT BUMPER RETAINER 4@4.54 15733970 GM PART 18.16 INC T
7 400060 BOY REMOVE/REPLACE FRT BUMPER PIN 5@4.35 15733971 GM PART 21.75 INC T
8 400062 BOY REMOVE/REPLACE L FRT OTR BUMPER BRACE 15705657 GM PART 29.72 0.2 # 0.2T
9 403013 BOY REMOVE/REPLACE L FRT BUMPER FILLER PANEL 15049381 GM PART 17.55 - 0.2 # 0.2T
10 403016 BOY REMOVE/REPLACE L FRT BUMPER RETAINER 21110201 GM PART 4.68 INC T
11 400071 BOY REMOVE/RFPLACE GRILLE 19130787 GM PART 385.16 0.1 OAT
12 400073 BOY REMOVE/RFPLACE GRILLE EMBLEM 15706323 GM PART 48.30 INC # OAT
13 400083 BOY REMOVE/RFPLACE L H/LAMP ASSEMBLY 15289275 GM PART 275.10 0.3 0.3T
14 AUTO BOY CHECK/ADJUST HEADLAMPS 0.4 0.4
15 400109 BOY REMOVE/RFPLACE L H/LAMP ADJUSTING SPRING 2@4.16 15845413 GM PART 8.32 T
16 400115 BOY REMOVE/REPLACE L FRT COMBINATION LAMP ASSEMBLY 15199560 GM PART 83.07 0.2 # 0.2T
17 400146 REF BLEND HOOD OUTSIDE" C 1.3 3.1
18 400152 BOY ALIGN HOOD PANEL! Existing 0.3' 1.1
19 402979 BOY REPAIR COOLING RADIATOR SUPPORT Existing 0.0'# 6.3
20 OPEN TO INSPECTION
21 400237 MCH ACCESS/INSPECT AIR COND CONDENSER' -M Existing 0.0'# 1.0
0 AUTO MCH REMOVE/REPLACE EVACUATE&RECHARGE A/C -M 1.4
22 INSPECT A/C OPERATION INOP AFTER CRASH
23 400309 BOY REMOVE/REPLACE L FENDER PANEL 19168845 GM PART 233.80 1.9 # 2.2T
24 AUTO REF REFINISH L FENDER OUTSIDE C 2.0 2.0
ESTIMATE RECALL NUMBER: 06/19/2008 13:11:19 080003002038-1600101
Mitchell Data Version: OEM: MAY 08_V UltraMate is a Trademark of Mitchell International
Y Copyright(C)1994-2008 Mitchell International Page 1 of 3
UltraMate Version: 6.5.017 All Rights Reserved
Date: 6/19/2008 01:16 PM
1
Estimate ID: 080003002038-1600101
estimate Version: 0
Committed
Profile ID: CUSTOMIZED
25 AUTO REF REFINISH L FENDER EDGE&INSIDE C 1.2 1.2
26 400315 BDY REMOVE/REPLACE L FENDER LINER ORDER FROM DEALER d35.02 0.3 0.3T
27 402061 BDY REMOVE/REPLACE L FRT FENDER RETAINER 15958694 GM PART 0.45 T
28 405213 BDY REMOVE/INSTALL L RUNNING BOARD ASSY 0.6 0.6
29 900500 BDY ' REMOVE/REPLACE BUG SHIELD QUAL REPL PART 210.00 * 0.6* T
30 401148 REF BLEND L FRT DOOR OUTSIDE C 1.1 2.7
31 401170 BDY REMOVE/INSTALL L FRT REAR VIEW MIRROR 0.2 0.2
32 402766 BDY REMOVE/INSTALL L FRT OTR BELT MOULDING 0.6 # 0.6
33 401176 BDY REMOVEANSTALL L FRT DOOR ADHESIVE MOULDING Existing 0.2 0.2
34 R&R Time Used in R&I Operation
35 401228 BDY REMOVE/INSTALL L FRT DOOR HANDLE 0.2 # 0.6
36 900500 BDY * ADD'L LABOR OP PULL TO SQUARE Existing 3.0*
37 900500 BDY * ADD'L LABOR OP COLOR SAND&BUFF 0.3 PER PANEL 1.5 MAX Existing 1.0*
38 900500 BDY * REMOVE/REPLACE MASK FOR OVERSPRAY Sublet 10.00 * 0.0*
39 900500 BDY * ADD'L LABOR OP COLOR SAND&BUFF 0.3 PER PANEL 1.5 MAX Existing 0.6*
40 933006 .FIRM ADD'L OPR FRAME/RACK SET UP 1.5*
41 900500 BDY * REMOVE/REPLACE FLEX ADDITIVE "*QUAL REPL PART 8.00 * 0.0* T
42 AUTO REF ADD'L OPR CLEAR COAT 2.1
43 AUTO ADD'L COST PAINT/MATERIALS 249.20 * T
44 AUTO ADD'L COST HAZARDOUS WASTE DISPOSAL 3.00 *
* -Judgment Item
#-Labor Note Applies
d -Discontinued by the Manufacturer
C-Included in Clear Coat Calc
Remarks
Estimate Totals
Add'I
Labor Sublet
I. Labor Subtotals Units Rate Amount Amount Totals 11. Part Replacement Summary Amount
Body 12.9 67.00 0.00 0.00 864.30 Taxable Parts 2,056.36
Refinish 8.9 67.00 0.00 0.00 596.30 Parts Adjustments 73.17-
Frame 1.5 67.00 0.00 0.00 100.50 Sales Tax @ 8.250% 163.61
Non-Taxable Labor 1,561.10 Non-Taxable Parts 10.00
Labor Summary 23.3 1,561.10 Total Replacement Parts Amount 2,156.80
III. Additional Costs Amount IV. Adjustments Amount
Taxable Costs 249.20 Insurance Deductible 500.00-
Sales Tax @ 8.250% 20.56
Customer Responsibility 500.00-
Non-Taxable Costs 3.00
Total Additional Costs 272.76
I. Total Labor: 1,561.10
It. Total Replacement Parts: 2,156.80
III. Total Additional Costs: 272.76
Gross Total: 3,990.66
ESTIMATE RECALL NUMBER: 06/19/2008 13:11:19 080003002038-1600101
Mitchell Data Version: OEM: MAY-08_V UltraMate is a Trademark of Mitchell International
Copyright(C) 1994-2008 Mitchell International Page 2 of 3
UltraMate Version: 6.5.017 All Rights Reserved
Date: 6/19/2008 01:16 PM
EstimatelD: 080003002038-1600101
cstimate Version: 0
Committed
Profile ID: CUSTOMIZED
IV. Total Adjustments: 500.00-
Net Total: 3,490.66
Point(s)of Impact
11 Left Front Corner(P)
Insurance Co: MERCURY CASUALTY INSURANCE
Address: P.O.BOX 997195
SACRAMENTO,CA 95899
Telephone: (916)635-0423
(916)635-0423
Due to many unforseen circumstances in the repairing of automobiles,we
regret that we can only estimate, not promise a completion dateand
time.
Date vehicle driven in/towed in:D
Date vehicle inspected:6/19/08
Number of photos:10
Estimated number of days to repair:6
Closing Type:R
Send check to facility:Y
Copy of estimate give to owner:Y
************CARS INSPECTION CLOSING REPORT***************
LKQ PARTS AVAILABLE:NONE
SOURCE:RANCHO AND CAD
PHONE AND REFERENCE:
ESTIMATE RECALL NUMBER: 06/19/2008 13:11:19 080003002038-1600101
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,�TATE OF CALIFORNIA L I C L
TRAFF�HP 555 pIIC COLLISIONage 1 ooRE-PORT Page DIS
'BPEGAL CDHDITIDNS Nu.5ER MTRm CRY 2UO3 APR 19 Ft!_ I' 23 JUD21AL DISTRICT LOCAL R ORT NUMBER
J.NRED FEtoN(
O i"p
NUMBER WLIED MTARUN COUNTY REPORTING DISTRICT BEAT /-� 4
M6l VEAN]N ' 1 - t1 I q r7
❑ Wti�r� rO t V
COLLISION OCCURREDON MO. DAY YEAR TIME ROOD) NCICY OFFICER I.D.
o atili�a is T - —IS-D�S O S D704 03LDO
MILEPOST INFORMATION DAY OF'WFEN TOW AWAY PHOTOGRAPHS BY: ®HONE
U
FEETIMILES OF S MQW T F S,❑YES NO
O AT INTERSECTION WITH STATE HWY REL
OR: FEETIMILES OF ❑YES NO
PARTY DRIVER'S LICENSE NUMBER STATE CLASS AIRBAG ;SAFETYEOUIP. VEH.YEAR MAREIMODFUC^_LOR LICENSE NUMBER STATE
...... CA...
DRIVER HAME(F/AST,MICOLE,IAST) �—s
® ��. suE E �T'l� OWNER%NAME lyl SAME AS DRIVER
PEDES STREET ADDRESS K
TRIAN Ls 61- /� _
Elc2 ,,GI L 7 I OWNERS ADDRESS SAME AS DRIVER
PARCED CRYJSTATE2IP y/ -
VEHICLE / ' �����
El .( R.i.--) 1 DISPOSITION OF VEHICLE ON ORDERS OF: 11 OFFICER[gORIVER ❑OTHER
BICY- SEX HAIR EYES HEICW WEIGHT BIRTHDATE (RACE
0.Q r 1 6Z SD1 i E 's oay_IN,
1Y•V1 r
PRIOR MECHANICAL DEFECTS: NONEAPPARENi REFER TONARRATIVE
OTHER HOMEPHONE HU21NEESSS PHONE VEHICLE IDEWIFICATION NUMBER
{ p�5-�p�� �9 l`l ��'✓—NJ O—J VEHICLE TYPE DESCRIBE VtHICLE DAMAGE SHADE IN DAMAGED AREA
INSURANCE CARRIER POLICYNUMBER DUNK ❑NONE ❑MINOR `
MOO. ❑MAJOR ROLLOVER /
DIR OF TRAVEL 1011 STREET OR HIGHWAY SPEED LIMIT 1I >11.
Oti1 Iz _� CA DDT
CAL-1 TCP/PSC MC!)—
PARTY DRIVER'S LICENSE NUMBER STATE CLASS AIRBAG :SAFETY EOU(P. VEH.YEAR IMAXE"ODEMOLOR LICENSE NUMBER STATE
s ,5 3a:. r' N ?.�oz G,f. .1U,,.ias�-�40 ... ).).l5s�ts..(E .CA ....
DRIVER NAME(F)RST,MIDDLE.IASL)
h OWNERw'S NAME ❑ SAME AS DRIVER
PEDETRIAN STREET ADDRESS 1 CV4_rA
❑ O�� "I ' OAANqERlM DOREss O❑ SAME ASJDRNERY w ^AD
PARKED CITY)STATE2IP 5••� ,/fit l/..I!_Y,Vlfi/EG
VEHICLE '1%+,S3
R
C�{I DISPOSRION OF VEHICLE ON ORDERS OF: ❑OFFICER❑DRIVER X OTHER
BICY• SE%. t HAIR EYES HEIGHT WEIGHT BIRTHDATE RACE
D❑ Ma. I Da� ..,"'Etr `\ PRIOR MEcwvncAL OEFEcrs: NONE APPARENT REFER TO NARRATIVE
OTHER HOMEPHONE BfUBrINTE58�PHONE ,
^ ` VEHICLE IDENTIFICATION NUMBER: t�
11 ' —q r741 (0 6 VEHICLE TYPE DESCRIBE HIC EDAMAGE SHADE IN DAMAGED AREA
INStBUNCE CrARRIER + PDLI W;ABER DUNK [:]NONE ❑MINOR
v � j H~� MOO. [:]MAJOR[ ]ROLL
DIR OF TRAVEL ON STREET OR HIGHWAY SPEEDUMIT CA DOT
rJ,l7— 2 CAL-T TCP)PSC MCAlX
PARTY DRIVER'S LICENSE NUMBER STATE CLASS AIRBAG ;SAFETYEOUIP. VEH.YEAR MAKFIMODELJCCLOR LICENSENUMBERSTATE
.... ........... .......----- .............. J
pgrvER NAME(HAST,
❑ ':.; ::
-� OWNERS NAME f-1 SAME AS DRIVER
PEDES- STREET ADDRESS L�
TRIAN
❑ JrF%J: 'J'.:. '.
NIP-r)C=Jf-'' {irT)`�I :�^1_J;t,-71A,.;O� I__�1 V� R'S ADDRESS
.. ❑ SAME AS DRIVER
VEHICLE CITYJSTATE P I n !,
❑ T" ')(�"^`^ ) DISPOSITION OF VEHICLE ON ORDERS OF:
/ OFFICER❑DRIVER ❑OTHER
BICY SEX HMR EYES HEIGH' WEIGHT BIRTHUATE RACE
uaT Mo. Bey Year
❑ 1 1
PRIOR MECHANICAL DEFECTS: NONEAPPARENT REFERTONARRATNE
OTHER HOME PHONE BUSINESSPHONE VEHICLE IDENTIFICATION NU MBE '
❑ VEHICLE TYPE SCRIBE VEHICLE DAMAGE SHADE IN DAMAGED AREA
INSURANCE C IER POLICY NUMBER ❑UNK ❑NONE ❑MINOR
❑MOO. ❑MAJOR❑ROLL-OVER
OFTRAYEL ON STREET OR HIGHWAY SPEED LIMIT
G DOT —
4 TCPIPSC MCJMX
PREPARER'S NAME y� DISPATCH NOTIFIEDREVIEWER' N DATE RPVIEVfD
r R ^ YES ❑NO ❑N/A 6
0555 703.IrD
,STATE Or CALIFORNIA
TRAFFIC'COLLISION CODING
CHP 555 Page 2(Rev.7-03) OPI 061 P291 2my
DATE OF COWSION 010. DAY YEAR) TIME 1 a. NCIC• OFFICER I.D. NUh19ER
OVMER'S NAME OWNER'S ADDRZSS NOTIFIED
PROPERTY ❑YES E] NO
DAMAGE DESCRIPTION OF DAMAGE
SEATING POSITION SAFETY EQUIPMENT INATTENTION CODES
OCCUPANT$ L-AIR BAG DEPLOYED MIC BICYCLE-HELMET A-CELLPHONE HANDHELD
^ A-NONE IN VEHICLE M-AIR BAG NOT DEPLOYED DRIVER PASSENGER 8-CELLPHONE HANDSFREE
B-UNKNOWN N-OTHER V-NO X-NO C-ELECTRONIC EQUIPMENT
C-LAP BELT USED P-NOT REQUIRED W-YES Y-YES D-RADIOI CD
D-LAP BELT NOT USED E-SMOKING
1-DRIVER E-SHOULDER HARNESS USED F-EATING
1 2 3 2706-PASSENGERS F-SHOULDER HARNESS NOT USED CHILD RESTRAINT EJECTED FROM VEHICLE G-CHILDREN
4 S 6 7-STATION WAGON REAR G-LAP/SHOULDER HARNESS USED D-IN VEHICLE USED 0-NOT EJECTED H-ANIMALS
8-REAR OCC.TRK OR VAN H-LAP/SHOULDER HARNESS NOT USED R-IN VEHICLE NOT USED 1-FULLY EJECTED I-PERSONAL HYGIENE
e-POSITION UNKNOWN J-PASSIVE RESTRAIN-USED S-IN VEHICLE USE UNKNOWN 2-PARTIALLY EJECTED J-READING j
7 0-OTHER K-PASSIVE RESTRAINT NOT USED T-IN VEHICLE IMPROPER USE 3-UNKNOWN K-OTHER
p
U-NONE IN VEHICLE
ITEMS MARKED BELOW FOLLOWED BY AN ASTERISK 4')SHOULD BE EXPLAINED IN THE NARRATIVE.
PRIMARY COLLISION FACTOR TRAFFIC CONTROL DEVICESSPECIAL INFORMATION MOVEMENT PRECEDING
DST NUMBER N OF PARTY AT FAULT 1 2 3 COLLISION
A yr scenox vpITEM cam A CONTROLS FUNCTIONING _ A HAZARDOUS MATERIAL A STOPPED
-_ Yun ES B CONTROLS NOT FUNCTIONING' B CELLPHONE HANDHELD IN USE B PROCEEDING STRAIGHT
B OTHER IMPROPER DRNING': C CONTROLS OBSCURED _ C CELL PHONE HANDSFREE IN USF. C RAN OFF ROAD
_ D NO CONTROLS PRESENT I FACTOR' D 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 F 75 FT MOTORTRUCK COMBO F MAKING U TURN _
B SIDB SWIPE G 32 FT TRAILER COMBO G RACKING
C REAR END _ H _ H SLOWING I STOPPING
WEATHER MARK 1IO 21TEMS D BROADSIDE I I PASSING OTHER VEHICLE
E HITOBJECT J J CHANGING LANES _
B CLOUDY _ F OVERTURNED K _ K PARKING MANEUVER
_ C RAINING G VEHICLE I PEDESTRIAN L _ L ENl'ERINGTRAFFIC
D SNOWING H OTHER': M M OTHER UNSAFE TURNING
E FOG l VISIBILITY FT. I N N XING INTO OPPOSING LANE
F OTHER' _ MOTOR VEHICLE INVOLVED WITH O _ 0 PARKED
G WIND A NON-COLLISION P MERGING
LIGHTING B PEDESTRIAN Q TRAVELING WRONG WAY
A DAYLIGHT _ C OTHER MOTOR VEHICLE _ OTHER ASSOCIATED FACTOR(S) R OTHER"
B DUSK-DAWN _ D MOTOR VEHICLE ON OTHER ROADWAY 1 2 3 (MARK I TO 2 ITEMS)
C DARK-STREETLIGHTS E PARKED MOTORVEHICLE i; A ve""T'Ou mo"Tom: `v ODYES
D DARK-NO STREET LIGHTS F TRAIN ""_ `'.�i
E DARK-STREET LIGHTS NOT G BICYCLE - _' IcsEcnoN vwArroN Oren
FUNCTIONING' ❑YEE
H ANIMAL: ❑ND
ROADWAY SURFACE 'u _..'-C vcucnoN aawrrort crrEo SOBRIETY-DRUG
ICAL
A DRY ) FIXED OBJECT: ("''z` ❑yNE05 1 2 3 (MARK Ff TO 2ITEMS)
B WET _D '0 " �'I! !x +I;' A HAD NOT BEEN DRINKING
C SNOWY-ICY J OTHER OBJECT: E VISION OBSCUREMENT'. B Hal)-UNDER INFLUENCE
D SLIPPERY MUDDY OILY ETC. _ F INATTENTION': C HBD-NOT UNDER INFLUENCE-
ROADWAY CONDITION(S) G STOP&GO TRAFFIC D HBD-IMPAIRMENT UNKNOWN'
(MARK l TO 21TEMS) PEDESTRIAN'S ACTIONS _H ENTERING I LFAMNG RAMP E_UNDER DRUG INFLUENCE'
A HOLES,DEEP RUT• _A NO PEDESTRIANS INVOLVED { 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-N07 ❑YES I I I SLEEPY I FATIGUED.
E REDUCED ROADWAY WIDTH AT INTERSECTION ONO
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
G APPROACHING/LEAVING SCHOOL BUS I r 0 RUNS/AAWWA�\YYVJ\�EHICLE
SKETCH `-Y MISCELLANEOUS
� F1r)O �T
c�—
v
I
a,; OSP D3 79147
S7A E OF CALIFORNIA
INJURED I WITNESS I PASSENGERS
CHP 555 Pace 3(Rev.1,03) QPI(1161
DATE OF COLLIS1091MO. DAY YEAP.) TIME(2100) IN NUMBER OFFICER LD. NNJBER
I U70 -f I D3D0 O$� `19�j'
I EXTENT OF INJURY("X"ONE) INJURED WAS("X"ONE)
WITNESS PASSENGER PARTY: SEAT MR SAF 1 EJECTED
ONLY ONLY ADE 4E% FATAL SEVERE OTHER VISIBLE I COMPLAINT NUMBS i POS. BAG EOUIP. i
I INJURY INJURY I INJURY OF PAIN I DRIVER I. PEO. BICYCLIST OTHER 11
❑ 8 ❑ ❑ - RI ❑ CIn-
011 ..
n
NAM O0 B./ADDRESS TEL HDNE
AoHAS �►C .FoRD+ -i3-so, r soS .K,RsEe_�5s_ i?5 D �3�i,Crxt�iG► 952/
(INJURED ONLY)TRANSPORTED BY: T V / A TAKEN TO.
DESCRIBE INJURIES Cpt!l PL"9//JT of
❑VICTIM OF VIOLENT CRIME NOTIFIED
❑ ❑ ❑ ❑ 10WO N> A
NAMED.O.B./ADDRESS TELEPHONE
rz d L rohd Ste! �rr�1Et_ti2� tiS. JtoQX? 9gslg (q;-w "E-NgL3ao
(INJURED ONLY)TRANSPORTED BY: TAKEN TO:
DESCRIBE INJURIES
- ❑VICTIM OF VIOLENT CRIME NOTIFIED
❑# ❑ isPiFE, C ❑ ❑ ❑ ❑ ❑ b A ' o
NAME 10 O.B.I ACORESS TELEPHONE
o �1,t ^ ' �1� �8-Soy I'7"1(r� LAGLWA �f�3!!j C WWkbo 4A q'KZU, �,gA- - ll;Dr
(INJURED ONLY)TRANSPORTED BY: / Y TAKEN TO:
DESCRIBE INJURIES
VICTIM OF VIOLENT CRIME NOTIFIED
❑" ❑ 4b1 F ❑ ❑ ❑ 101Ql ❑ 1111 ;,l o P fl
NAME ID.O.B.i ADDRESS TELEPHONE
GAQ�Ez bQ y! Co►.)cs�Le�_Ch°I`tsz� ti/on�E
(INJURED ONLY)TRANSPORTED BY: AKENK 70: -
DESCRIBE INJURIES
VICTIM OF VIOLENT CRIME NOTIFIED
❑� ❑ ❑ : ❑ ❑ ❑ J ❑ ❑ ❑ ' ❑ ❑
NAME ID.O.B.I ADDRESS TELEPHONE
;INJURED ONLY)TRANSPORTED BY: TAKEN TO: _
_..__
DESCRIBE INJURIES
l-VICTIM OF VIOLENT CRIME NOTIFIED
❑ E: ❑ 11 ❑ ❑ ❑ ❑
NAME/D.O.B./ADDRESS TELEPHONE
(INJURED ONLY)TRANSPORTED BY: TAKEN TO:
DESCRIBE INNRIES
VICTIM OF VIOLENT CPJME NOTIFIED
PREPARER'S NAME O.NUMBER REVIEWER'S NPW IAO. DAY EAR
c.Sc�til 3Da
VR
-PAGE
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REPORTING OP PIGER HEAT DATE AND TIME REPORT WRITTEN SUPERVISOR AP OVIND TYPIST DATE ANG MIME REPORT TYPED
CA2L,
CP-SODA SEP!t
( PAGE
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CASE c.,c.D
RGPQRT NG OFFICER BEAT DATE AND TIME REPORT WRITTEN SUPERVISO APP ING TYPIST DgTE AND TIME REPORT TYPED
CP-JODA SEP 84
STATE OF CALIFORNIA
FACTUAL DIAGRAM
_dHP 555 Page 4(Rev. 1-03) OPI 061 Page °r
OATC OF COLLISION(PAO. DAY YEAR; TIMc(2400) NOIOL (OFFICER I.D. (NUMBER
ALL MEASUREMENTS ARE APPROXIMATE AND NOT TO SCALE UNLESS STATED (SCALE- J
a
INDICATE
NORTH
PREPARED BY Lo,NUMBER MO. DAY YEAR REVIEWER'S NAME MO, DAY YEPA
OSP 03 75578
Claim Number 2008'0003002038=16 Handling Unit '0003 CORDOVA . '.
Policy Number 04011 05 1 3002061 9 Bate of Loss '04115/200806:45 AM
8 N'.
- Named Insured Leslie Haws Clain Status Regular Open
+ 025345 Kathryn Silver (916)636- y
Adjuster Ong Cost of Vehicle,37,967.00
1534 Ext 2383 : 1
Loss Check Issued ,lit
`tt�
r Check Maintenance Type' Y Payee Type .Reportable
Check Number 460888289 Control Code Vendor Code 61004248
i
Payee - JIM'SAUTO BODY -.- - -
Additional Payee AND LESLIE HAWS'-,
Address 2520 MONUMENT BLVD.,CONCORD,CA 94520
Issued:By 025345 Kathryn Silver Issue Date-088712008
'Honored Date ,:091098008
- Coverage Amount Type Adjuster Code Total Loss
i
COLL Final 025345
, N
+
Check Amount 3,490.66,- - In Full Settlement OF CN Claims
Backup Withholding 00.00 To Be Authorized By Tamara Pruett
Net Check Payee - 3,490.66 •Authorized By Mark Herbers
i
'GlaimantAteference Leslie Haws. Authorized Date -08888008
Comment 2003 GMC YUKON XL
Dom
— 1C�i a3 ,C m Trustedsites __--'A
�"" —`— o- tutu rt+ .o-a rratrr,(rr{M DO[ument5 (rtx.Recorded IMervre.,. _
;5�,'�Start ® "j�Q 2Microsof[Offrc��� 3kfiternet EsRL.31 +�5 y � '�t;r� l �" j�j f� zia PM��
MO
j Claim Number 2008 0003 002038-16 Handling Unit 0003 CORDOVA
r _05130020619 Dale of Loss 0411502008 06:45 AM
Named Insured Leslie Haws Claim status Regular Open t ;
Policy 111
025345 Kathryn Silver (916)636- dtt
- Adjuster 1534 Ext 2383 :Orig.Cost of Vehicle,,37,967.00
Loss Check Issuer!Maintenance - -- - g
'Check Mandenance Type. Payee Type Reportable
tid
Check Number 460879628 Control Code.El Vendor Code 61004248
.Payee JIM'S AUTO BODY
i
.: Additional Payee
Address .2520 MONUMENT BLVD.,CONCORD,CA 94520
Issued By 025345 Kathryn Silver Issue Date 082272008
- Honored Date 09/0921108
Coverage Amount Type Adjuster Code IMal LOSS
COLL 500.00- Additional - 025345 N
Check Amount 500.00 In Full Settlement Of ON Claims
-Backup Withholding 00.00 - 'To Be Authorized By 'Tamara Pruett
Net Check Payee 500.00 Authorized By Tamara Pruett
ClaimardiReference .Leslie Haws Authorized Date 08222008 i
comment 2003 GMC YUKON)rLC1500 Slt DED WAIVED
Sukgmk, ,�. . .„_......Clear � Exi[• -
Dode _ ( � w{�Trusted rtes w_ '
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