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MINUTES - 04032007 - C.17
CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: 3 Claim Against the County, or District Governed by ) the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section re The copy of this document.mailed to California Government Codes. a7 , ou is ouh•notice of the action taken Y Y INFMEB2 2 2007 on your claim by the Board of Supervisors. (Paragraph IV below), COUNTY COUNSEL given Pursuant to Government Code Q AMOUNT: MARTINEZ CALIF Section 913 and 915.4. Please note all �� 9 5 .'1 "Warnings". CLAIMANT: J=ne, C.aretwnght ATTORNEY: >/a- DATE RECEIVED: oZ�o�,oZ 07 ADDRESS: ..�4l "(�� Or. BY DELIVERY TO CLERK ON: BY MAIL POSTMARKED: a. vu 107 FROM: Clerk of the Board of Supervisors T0: County Counsel Attached is a copy of the above-noted claim. JOHN CULL Cler Dated: a'C�-a- By: Deputy - LI. FROM.: County Counsel TO: Clerk of the Board of Supervisors (v�'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: 2-3' o7 By: 69- ---Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator(2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV./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. D Dated: 7//" JOHN CULLEN, CLERK, By Deputy Clerk WAR NG (Gov. code section 913) Subject to certain exceptions,you have only six(6) montlis 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. 1.f you want to consult an attorney,you should do so immediately. *For Additional Warning See Reverse Side of This Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today i deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the clainnan.f as shown above. Dated: l'��I/�'�, �lx JOHN CULLEN, CLERK By Deputy Clerk t BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. A claim relating to a cause of action for death or for hijury 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 Cleric of the Board of Supervisors at its office m'Room 146; County Administration Building, 661 Pine Street;Maidnez,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. ■■aaaaaaaaaaaaaaaaaKMM a a a a a a a a a a a a a a a a a it a it a a a a a a a agaaaaaaaaIaaaaKaaaaaaaaaaIXaI RE Claim By: Reserved for Clerk's filing stamp 1< W } E::] Against the County of Contra Costa orDistrict)111 in the name CF ) The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the sum of$ %/9 r and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) lf 2-j0�, 09: ;0 /9M 2. Where did the damage or injury occur? (Include city and county) 3. How did the damage or injury occur!((? (Give full details;use extra paper if required) 6_4.n r S-e'r" c k M '6r k& 4. What-particular act or omission on the part of county or district officers, servants, or employees caused the injury or damage? . j " <( Y ', dr r c, VN o X01, !S-f SU ✓Ko � V. c7cbr�✓�� 5 What are the names of county or district officers,servants, or employees causing the damage or injury? w , .5 r k.., ey () a JISI 6. What damage or injuries do your claim resulted? (Give full extent of injuries or damages claimed. -Attach-two estimates for auto damage.) -t h -2 t'o r N rn c. < . 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) GarK--,, ; fL. r GLd /11aC� ; s- 8. �1 8. Names and addresses of witnesses,doctors, and hospitals: _LL q390 d' 9. List the expenditures you rhade-on account of this accident or injury: OK I c c, r DATE TIME AMOUNT a [[[[[rt[[[[[[man[[[[eass[entci[[[[[[[[[[[[[[•■■[[[[[■[[[[■[[Run[[[[[[[[[[[[[[[[[[[[[[But .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) Name and address of Attorney } ) } (Claim t' Signature) (Address) Z)rrr✓i l e, Telephone No. )Telephone No. ■[ [[[[[[[[[[[[[[[ Nauss tt■ t■t■[[[[i•■[[■[[[[[[[[[[[[[[[[[[[[[[[[[[[[[mean[[[[[[•[[[[t 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, ■■an■ass[[[■■■■■sum[BURR■ ■ ■[[[[[[[[[[[[[[[[[[[[[\■[[[[■■[[[[[[[[[[[[[[[[[[[[Boom[[[[t NOTICE: Section 71 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. LIVERMORE CYCLERY 7214 SAN RAMON RD, DUBLIN, CA 94568 995-829-4310 WWW.LIVERMORECYCLERY.COM RETURNS:BIKE_; 7DAYS/ACCESSORIES 30 DAYS PEGASUS BICYCLE WORKS Monday 01/19/07 4:59 pm #03 112254 439 Railroad Avenue Danville, CA 94526 CARTWRIGHT, 3EANNE 4134 9253622220 7937 PARKMONT DR. ALAMO, CA 94507 ! Store: 1 (925)-838-2496 Date Printed: 01/07/2007 Receipt Date: 01/07/2007 Receipt Time: 2:25:19 PM 70005 DELUXE ROAD & MTN TUNE-UP Register: 1-5 1 @ $90.00 Ea . $90.00 Receipt:RC00001000046498 70011 W/TUNE UP,BRAKE PARTS NECESSARY Tran Type: Sale 2 @ $15.00 Ea $30.00 Cashier: 2 70126 TAPE NOT INCL.,TAPE BARS STYLE � DESCRIPTION 1 @ $15.01-1 Ea $15.00 SZ SUBSZ QTY @ PRICE SUBTTL 84399 BLACK,BONT GEL TAPE 1 @ $14.99 ea $14.99 04-�- CASTELLI KNICKERS BR2155 BLACK,'SHIMANO ROAD,KOOL BRAKE PAD N/A 1 @ 80.99 80.99 2 0 $9.99 ea $19.98 192339 4iiCM,EAST.EC9ii ::LX ROAD BAR (Reg. Price: 89.99 Savings (9.00)) 03 GIRO ATMOS 1 @ $249.99 ea $249.99 N/A 1 @ 157.49 157.49 -CH0710 95FC,SHiM CHAIN PIN (Reg. Price: 174.99 Savings (17.50)) 1 @ $1.99 ea $1.99 04 GIORDANA SHOE COVERS' LD55i17 DOUBLE,DA 'STI LEVER_; 7700 N/A 1 @ 40.49 40.49 1 0 $389.90 ea $389.90 (Reg. Price: 44.99 Savings (4.50)) BR2247 MTN,CABLE TIP _ I @ $0.10 ea $0.10 SubTotal� 278.97 BR2246 ROAD,CABLE TIP Total Tax 23.02 2 0 $0.10 ea $0.2(i Total 301 .99 BR1341 ALUMINUM,4MM,FERRULE Card# 301.99 4 0 $0.50 EA $2.00 Work in Progress, # 13626 Balance 0.00 AMERICAN EXP aFP#596613 Payment History_ _ _ Card # XXXXXXXXXXX1002 0407 01/07/2007 -Card# -_�-301.99 X---------------------------------- Your total savings: 31.00 Subtotal $679.15 ALL BICYCLE SALES FINAL Tax $59.43 All other merchandise may be returned Nontaxable items $135.00 for exchange or refund within 14 days INVOICE TOTAL $8 r . 58 of purchase and must be in new, resalable condition Special orders Card Received $873.58 are non-returnable. All DISCOUNTED items are non-returnable Z Windows POS Software www.camcommerce.com GRACIAS AMIGO'S! -rsc� zs� �rm.�o th .o N m sO• UK 3V' T-iaQ cn o a. :I inwarn 0. (0 N X ci C \ �OA ¢ O �N .. O 1'JZ .. '0 Vi0¢ON O O n. .. V 5 mmcmwMo �� ���ff rt) D(A) %l O O *1 •• tC N t+� W `-+W U3 = i�(a .asp rnrDc• to w O = tc 0 O N) rV3 .. (D CO CD C1 „ Q N- ornd O Z O N01TQ . tD O St v QDbn U Dt" .- a toC:M: NLA o cn E %t! n °D*C rn O ocLA0 (D oaa N TXiNalley Orthopedic Specialists, Inc 5601 Norris Canyon Road#130 San Ramon CA 94583 Total Balance clue by patient: $5.34 Billing Questions: (925)560-9300 Patient: Cartwright, Jeanne M Fax: (925)560-0648 Account Number: 82905 Statement Date: 01/22/2007 Cartwright,Jeanne M Home Phone: 82905 (925)648-7575 211 Portola Dr Payment Enclosed: $ Danville CA 94506 Remit to:Tri-Valley Orthopedic Specialists,Inc Card# Exp / Signature ........................................................................................................................................................6................... ate bode escnphhon Changes =,Pa-y,.,mts A f�lustYn .'fii, .�¢ .,,�,^r ,�,i.,. .t: t t, " •+P SwR.Beawr.kt u r wL`uuu ^. 11/15/04 Ticket#77020 Roaer D Dainer DO $75.00 $51.24 $38.76 11/17/04 United Health Care originally billed 11/15/04 73000 RADIOLOGIC EXAM;CLAVICLE, $75.00 COMPLETE 11/15/04 Patient Payment Check 1192 $15.00 12/03/04 UNITED HEALTHCARE Check UH $36.24 10059170 12/03/04 Contract Adjustment UNITED' $38.76 HEALTHCARE ll/B/04 " 99024 POSTOPERATIVE FOLLOW-UP VISIT; IN GLOBAL SERVICE Balance due by patient: $-15.00 12/¢4/06 Ticket¢#206220 Roger DjDai erDO ' *` ° $419`00 $18302 ,, x$215 64 ' w y y Y' b' ' k 1 ! �" ' t"x,..c 'e, ,� x a ,[ ya�' �$ ' i 12/08/06 x ' AUmted Health Care onguially tilled , `s ,r '12/04/06 = 9924'4 sur� 9 s OFFICE CONSULTATION, { ; ,$329{00 � _ "y "U 5 s CYe§���7 �pq i9 A 1'» 12/28/0692CoInsurance UNITED t ! 3+*a k v fi 3 s+G r HEALTHCARE ' 3 err'' Y< 12/28/06 i � UNITED HEALTHCARE EFT {�.1- N. x t ,� � 100152081�1 4 �t°ref{ °� s f caro X15�Y � .C niact Ad ustment UNITED ' r �, r r� $149 80 12/28/06 gq'. Z,G` t a .r Y ," tHEALTHCARE04 ! "; f Y# 4 ab�i a 12/04ffi /06 73080` RADIOLOGIC EXAM,ELBOW, � � , $90 00w a .COMPLETE 3+VIEWS0AW -14P 4 i'l : .S 1 38£ a'.y Y a- xY ' y. e �'� t' ?' a-cc .3". a 7N 6fiy S« <1 a 12/28/06 4 $2 42 Coinsurance UI�IITED � w' HEALTHCARE ' dd'r t 12/28%06 '# + ` ;UNITED HEALTHCARE3 EFTa� v . k ` s ?£1001520811 � r Q a'" � i r' t ryd h S "� �i' r j �„r x�4r� k'ii�^�'r a'r` �},u�"'�}� ��", '`fin�-.s � � 1��k��x� a S7 �.��a a3'`� �� A�� �`,7 a i.ay r�-a#E V'�, ✓'':`s @ ?ig,+.��.r�"� "3�^.y^."L�'� � s.°:5''�' a�'� Page 1 of 2 Txi-Valley Orthopedic Specialists,Inc 5601 Norris Canyon Road#130 San Ramon CA 94583 Total Balance clue by patient: $5.34 Billing Questions: (925)560-9300 Patient: Cartwright, Jeanne M Fax: (925)560-0648 Account Number: 82905 Eccoun`''t n Current " da s days days days Charges Payments Adjustments Total Balance clue by patient: $5.34 PAYMENT DUE UPON RECEIPT. Page 2 of 2 ;! �� ' STATE OF CALIFORNIA CALIFORNIA HIGHWAY PATROL DEPARTMENT OF CALIFORNIA HIGHWAY PATROL COLLISION REPORT INFORMATION 4999 GLEASON DRIVE CHIP 418(Rev.9-05) OPI 065 DUBLIN,CA 945M-3310 DATE TIME (925)828-0966 NCIC NUMBER OFFICER'S I.D.NUMBER 161V YOUR VEHICLE WAS REMOVED TO: A copy of the collision report can be obtained from the address above and will normally be available within 8 days from the date of the collision. A request by mail is preferred and must include: date,time,NCIC number,and Officer's I.D.number printed above. The certification for purchase information(see reverse) must also be completed,signed and attached to your written request with your check for payment. Make your personal check or money order payable to the California Highway Patrol(CHP)for$10.00. Reports may also be obtained in person during the office hours stamped above. Please call to determine if the report is ready. In the event the cost exceeds$10.00,you will be notified. Reports are retained 4 years. y y gR Nr LP d a �O U p c9 H V to � UQ i\ N Q S. j r ` CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: APRIL 03, 2007 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 k!q Supervisors. (Paragraph IV below), given Pursuant to Government Code D111 FEB 2 3 2007 Section 913 and 915.4. Please note all AMOUNT: QNKNOWN CQ "Warnings". COUNTYCOUNSEL CLAIMANT: MARIAN GENTRY &IARTINIEZ CALIF. ATTORNEY: UNKNOWN DATE RECEIVED: FEBRUARY 23, 2007 ADDRESS: 212 WOOD STREET, #1601 BY DELIVERY TO CLERK ON:FEBRUARY 23, 2007 LIVERMORE, CA 94550 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. FEBRUARY 23, 2007 JOHN CULLEN, Cle Dated: By: Deputy I.I. FROM: County Counsel TO: Clerk of the Board of Supe isors ( 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 91.1.3). O Other: Dated: By: Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator(2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. 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. D Dated: ��� -&4.-,*JOHN 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 niail 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 attorney,you should do so immediately. *For Additional Warring 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. o ri Dated: co �7�` JOHN CULLEN, CLERK By Deputy Clerk r BOARD OF SUPEASORS OF CONTRA CC?STA. COUNO INSTRUCTIONS TO CLAIIY.IANT FF �/ A. A claim relating to a cause of action for death or for injury to person or to personal property ori 2006growing 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. tt (Gov. Code § 911.2.) 1 B. Claims must be filed with the Clerk of the Board of Supervisors at-its office in Room 1:06, 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 fiaudulent claims,Penal Code Sec. 72 at the end of this form. aaaaaaaaaaaaaaaaaaaar■ a■a■■ME.MEX a as aaaasaaaasaasaaINC aaaaaaaIan a�Ito aaaUSX aacaaat RE: Claim By: Reserved for Clerk's filing stamp IVED Against the County of Contra Costa or } } FEB ,2 3 2007 District) (Fill in the name) )' CLERK gQARD OF soQaRviscf+s } CQNTRA COSTACO• The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the sum of$ and in support of this claim represents as follows: I. When did the damage or injury occur? (Give exact date and hour) 2. Wh re did the damage or injury occur? (Include city and county) � 1 3. . How did the damage or injury occur? (Give full details;use extra paper if required) 4. What pP articular act or omission on the part of county or district officers, servants, or employees caused the injury or damage? y -� Ace, C/O, I& -;a&�' 4441- he ,PW4A,,) ka &a, 5 What are the names of county or district officers,servants, or employeescaus ig"tTie 1 damage or injury? . 6., What damage or injuries do your 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 the estimated amount of any prospective injury or damage.) 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 / f 1�t� . i./ Ate— o157, crv .. IL r r r r R r r r R R Orr/r r'■r r2MER R t r r r r r MRSERN wagon*r r*Kenn i r r t t r In r t r r!=1 r i i R as Knew r i r r i i t at .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) . Name and address of Attorney } ' } ClaimantSignature) (Address) Telephone No. )Telephone No. %02 S ��� �'f�f � 3/3 ■rrRRrreRrrrRrrrr■rrrrrRaINanone RRrrrrrrrrRrtRRRRRRRRRrrRRRrrRRrrR:RRRNUN rrrarrrRrrrR1 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, 59 6500 et seq.) Furthermore, any attachments,addendums, or supplements attached to the claim foram, including medical records, are also subject to public disclosure. ■ rrrr rrr■rrr Rr Rr■r■rnr■r■ 4 ■rr■RRrrRrrrrrrrrma■rRrrrRirRrriR■rrRKtRRrrRrrrrrirERrRKrRS NOTICE: Section 72 of the Penal Code provides: Every person who, with intent to defraud, presents far 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. 01/26420'07 at 10 : 01 AM Job Number : 26834 DUBLIN AUTO BODY License # :AH235001 Federal ID # : 943381281 EXCELLENCE GUARANTEED ! I-CAR GOLD CLASS www. DublinAutoBody. com 6920 VILLAGE PARKWAY DUBLIN, CA 94568-2406 ( 925) 833-9292 Fax: ( 925) 833-9450 PRELIMINARY ESTIMATE Written By: DESK DESK Adjuster : Insured: Claim #61742 Owner: MARIAN JENTRY Policy # Address: 212 WOOD STREET Deductible: LIVERMORE, CA 94550 Date of Loss: 10/31/2006 Cellular: ( 925) 487-8233 Type of Loss: Point of Impact: Inspect DUBLIN AUTO BODY Business: ( 925) 833-9292 Location: www. DublinAutoBody. com 6920 VILLAGE PARKWAY DUBLIN, CA 94568-2406 Insurance CONTRA COSTA COUNTY Company: 3 Days to Repair 2000 VW PASSAT GLS 4-1 . 8L-T 4D SED BLK Int : VIN: WVWMA23B2YP291630 Lic: 4LGH137 CA Prod Date: Odometer: Air Conditioning Rear Defogger Tilt Wheel Cruise Control Telescopic Wheel Intermittent Wipers Keyless Entry Theft Deterrent/Alarm Body Side Moldings Dual Mirrors Traction Control Fog Lamps Clear Coat Paint Power Steering Power Brakes Power Windows Power Locks Power Mirrors AM Radio FM Radio Stereo Cassette Search/Seek Anti-Lock Brakes (4) Driver Air Bag Passenger Air Bag Front Side Impact Air Bag 4 Wheel Disc Brakes Cloth Seats Bucket Seats 5 Speed Transmission Overdrive ------------------------------------------------------------------------------- NO. OP . DESCRIPTION QTY EXT . PRICE LABOR PAINT ------------------------------------------------------------------------------- 1 REAR BUMPER 2* Rpr Bumper cover 1 . 5 2 . 4 3 Add for Clear Coat 1 . 0 4 O/H bumper assy 1 . 2 5* R&I Molding Incl . 6* Rpr Molding 1 . 0 0 . 6 7 Add for Clear Coat 0 . 1 1 01/2642007 at 10 : 01 AM Job Number : 26.834 PRELIMINARY ESTIMATE 2000 VW PASSAT GLS 4-1 . 8L-T 4D SED BLK Int : ------------------------------------------------------------------------------- NO. OP. DESCRIPTION QTY EXT . PRICE LABOR PAINT ------------------------------------------------------------------------------- 8# COLOR SAND, . 5 PER PANEL 1 0 . 5 9# FLEX 1 8 . 00 T 10# HAZARDOUS WASTE EPA #000006008 1 2 . 00 X 11# TINT (COLOR MATCH OPERATION) 1 0 . 5 ------------------------------------------------------------------------------- Subtotals =_> 10 . 00 4 . 7 4 . 1 Parts 0 . 00 Body Labor 4 . 7 hrs @ $ 78 . 00/hr 366 . 60 Paint Labor 4 . 1 hrs @ $ 78 . 00/hr 319 . 80 Paint Supplies 4 . 1 hrs @ $ 36 . 00/hr 147 . 60 Sublet/Misc. 10 . 00 ---------------------------------------------------- SUBTOTAL $ 844 . 00 Sales Tax $ 155 . 60 @ 8 . 75000 13 . 62 ---------------------------------------------------- GRAND TOTAL $ 857 . 62 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. 2 Date: 1/11/2007 11:29 AM Estimate ID: 3922 Estimate Version: 0 Preliminary Profile ID: CONTRA COSTA COUNTY PRECISION PAINT & COLLISION 1932 ARNOLD INDUSTRIAL PLACE CONCORD,CA 94520 (925)609-8585 Fax: (925)609-9407 Tax ID: 68-0022850 BAR#: AJ112956 Damage Assessed By: Frank Mercado Payer: Customer Deductible: Claim Number: 61742 Insured: CONTRA COSTA COUNTY Claimant: MARIAN GENTRY Address: 212 WOOD STREET#1601 LIVERMORE,CA 94550 Mitchell Service: 913368 Description: 2000 Volkswagen Passat GLS Body Style: 4D Sed Drive Train: 1.8L Turbo Inj 4 Cyl 5A FWD VIN: WVWMA23B2YP291630 License: 4LGH137 CA Color: BLACK Options: ALUM/ALLOY WHEELS,AIR CONDITIONING,POWER STEERING,POWER WINDOWS POWER DOOR LOCKS,TILT STEERING WHEEL,CRUISE CONTROL,ELECTRIC DEFOGGER AUTOMATIC TRANSMISSION,AM-FM STEREO/CDPLAYER(SINGLE) Line Entry Labor Line Item Part Type/ Dollar Labor Item Number Type Operation Description Part Number Amount Units REAR BUMPER 1 302903 BDY REMOVE/INSTALL REAR BUMPER ASSY 1.6 # 2 302905 BDY REPAIR REAR BUMPER COVER Existing 1.0*# 3 REF REFINISH REAR BUMPER COVER C 2.0 ADDITIONAL OPERATIONS 4 REF ADD'L OPR CLEAR COAT 0.8 5 ADD'L COST PAINT/MATERIALS 61.60 6 ADD'L COST HAZARDOUS WASTE DISPOSAL 2.00 *-Judgement Item #-Labor Note Applies C -Included in Clear Coat Calc Add'I Labor Sublet I. Labor Subtotals Units Rate Amount Amount Totals II. Part Replacement Summary Amount Body 2.6 45.00 0.00 0.00 117.00 Refinish 2.8 45.00 0.00 0.00 126.00 Total Replacement Parts Amount 0.00 Non-Taxable Labor 243.00 Labor Summary 5.4 243.00 ESTIMATE RECALL NUMBER: 1/11/200711:29:55 3922 UltraMate is a Trademark of Mitchell International Mitchell Data Version: DEC_06_A Copyright(C)1994-2003 Mitchell International Page 1 of 2 UltraMate Version: 5.0.215 All Rights Reserved Date: 1/11/2007 11:29 AM Estimate ID: 3922 Estimate Version: 0 Preliminary Profile ID: CONTRA COSTA COUNTY III. Additional Costs Amount IV. Adjustments Amount Taxable Costs 61.60 Customer Responsibility 0.00 Sales Tax @ 8.250% 5.08 Non-Taxable Costs 2.00 Total Additional Costs 68.68 I. Total Labor: 243.00 II. Total Replacement Parts: 0.00 III. Total Additional Costs: 68.68 Gross Total: 311.68 IV. Total Adjustments: 0.00 Net Total: 311.68 This is a preliminary estimate. Additional changes to the estimate may be required for the actual repair. ESTIMATE RECALL NUMBER: 1/11/2007 11:29:55 3922 UltraMate is a Trademark of Mitchell International Mitchell Data Version: DEC_06_A Copyright(C)1994-2003 Mitchell International Page 2 of 2 UltraMate Version: 5.0.215 All Rights Reserved Couniy Administrator Contra Risk Management Division Costa 2530 Arnold Drive,Suite 140 County Liability Claims (925)335-1440 Martinez, California 94553 Fax Number (925)335-1421 s_ .t January 05, 2007 o RECEIVE,) osrq.cdFEB,D 4 3 . 200/7 CLERK BOARD Marian Gentry p�h� CONTRA SUP�p tSCtiS 212 Wood Street# 1601 �&rr`� Livermore, CA 94550 FFB8✓ 2 1 Z r /l7_; T iT....la Gentry ntr y ODS/ rte. %-Aaililtiiit: ivtaiiaii v:uu j Insured: Contra Costa County D/Accident: 10/31/2006 Claim No.: 61742 Dear Ms. Gentry: The above captioned matter has been referred to my office for investigation and handling on behalf of the Contra Costa County Department of County Administrator. I have enclosed a claim form that must be completed in order to file a formal claim against the-County. Be advised that you have six months from the accident date to file a formal claim as stated in the California Government Code beginning with Section 900. This also notifies you that you must comply with the claims presentation and timely suit filing requirements of California law in order to preserve your claim. Our investigation of your claim does not affect your duty to comply with time limits set by law, and by investigating, considering, and discussing your claim with you or your representative, we do not waive our right to assert your failure to comply with those time limits as a complete defense to any claim or action you may bring. Should you have any questions, please do not hesitate to contact the undersigned. Sincerely, �Pp� �&+ - Penny Bailey Liability Claims Adjuster (925)`33.5-1455 Enclosure BOARD OF SUPERVISORS OF CONTRA COSTA COUI�� x INSTRUCTIONS TO CLAMANT .. A claim relating to a cause of action for death or for injury to person or to personal property cr 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.) �. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street,Mardnez,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. ). If the claim is against more than one public entity, separate claims must be filed against each. public entity. ?. Fraud. See penalty for fraudulent claim,Penal Code Sec. 72 at the end of this form. saaasxassxxaaxaassasus Nunn suns sassssssaaaaxsxsxxat=is aaasssxRaxxiaaman aaaxaxxxa1 ZE: Claim By: /1 Reserved for Clerk's filing stamp Against the County of Contra Costa or ) RE'WQ" . MAR 0.V District) (Fill in the name} } taK eoa ._. } CONTI. The undersigned claimant hereby makes claire against the County of Contra Costa or the above-named district in the sun of$ and in support of this claim represents as follows: 1. When dial the damage or injury occur? (Give exact date and hour) /© 3. How did the damage or injury occur? (Give full details;use extra paper if required) U/u /Vt/es-�d' . �,�c, -e , - k/ �� GJory ,x/44"s� 4. What*particular act or omission on the part of county or district officers, servants, or employees caused the injury or damage? 7� LG.J ,t/a4 5 What are the names of coin o district fico Jt county r distn officers,servants,or employe cau�&the damage or injury? � 6. What damageor injuries do your 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 the estimated amount of any prospective injury or damage.) ifee-xci� 8. Names and addresses of witnesses,doctors, and hospitals: 3 AJ A4 9. List the expenditures you rnada on account of this accident or in % f jury: DATE TEVM AMOUNT (- 40r, a BE mammas Issas BURNS BEER a K mass*glass WEERX22 BE mass max an BE NESKUNKII Ross 9 a SURE NaRnexx 411 ) 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) Name and address of Attorney (Claimant* Signature) (Address) Telephone No. Telephone No. �5- - W.2 an a a*was as x ....................x X............................... PUBLIC RECORDS NOTICE: Please be advised that this claim f6rm, or any claim Med with the County under the Tort Claims Act, is subject to public disclosure under the California Public Records Act. (Gov. Code., 55 6500 et seq.) Furthermore, any attachments,addendums, or supplements attached to the claim form, including medical records, are also subject to a WERN"I REISSUES ERNE ERNE MR MEN XENBBRRRNDXKNB a Run SURNNNNII 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 fame 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 BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: APRIL 03, 2007 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 youM097', r notice of the action taken Rc=4P )i-- �ri on your claim by the Board of FEB 2 3Supervisors. (Paragraph IV below), 2007 given Pursuant to Government Code COUNTY COUNSEL Section 913 and 915.4. Please note all AMOUNT: $1.307.07 RMARTINEZ CALIF, "Warnings". CLAIMANT: CALIFORNIA STATE AUTOMOBILE ASS. FOR: PEDER C. OR JANIS D. BUNK BYY ATTORNEY: UNKNOWN CHARLINE WILLIAMS UNDATE RECEIVED: FEBRUARY 23, 2007 ADDRESS: P•0- BOX 920 BY DELIVERY TO CLERK ON: FEBRUARY 23, 2007 SUISUN CITY, CA 945Q5-0920 RECEIVED FROM RISK BY MAIL POSTMARKED: MANAGEMENT FROM: Clerk of the Board of Supervisors TO: County Counsel Attached isl a copy of the above-noted claim. JOHN CULLEN, Cl •k Dated: FEBRUARY 23, 2007 By: Deputy 11, FROM.: County Counsel TO: Clerk of the Board of Sup Gisors ( ) This claim complies substantially with Sections 910 and 910.2. (',Kihis 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 91. 1.3). O Other: Dated: ���3.1 07 By: C` �Deputy County Counsel 111. FROM: Clerk of the Board TO: County Counsel (1) County Administrator(2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. 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: ;/ 04 4fjeHN CULLEN, CLERK, By Deputy Clerk WARNNG G (Gov. code section 913) 71, 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 I am now, and at all times herein mentioned, have been a citizen of the 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 clainnan.t as shown above. s Dated: -0,40,0-JOHN CULLEN, CLERK By Deputy Clerk OFFICE OIF THE COUNTY COUNSEL S�- Z SILVANO B. MARCHESI COUNTY OF CONTRA COSTA , :"� ' =_'_0;�+ COUNTY COUNSEL Administration Building ; _ Ste; 651 Pine Street, 9'h Floor SHARON L. ANDERSON Martinez, California 94553-1229 CHIEF ASSISTANT (925) 335-1800 09 d izl�`1�t1� `i� GREGORY C. HARVEY . ' VALERIE J. RANCHE (925) 646-1078 (fax) ASSISTANTS �OSrA-�COU�� NOTICE OF INSUFFICIENCY AND/OR NON-ACCEPTANCE OF CLAIM TO: California State Automobile Association Inter-Insurance Bureau P.O. Box 920 Suisun City, CA 94585 RE: CLAIM OF CALIFORNIA STATE AUTOMOBILE ASSOCIATION/PEDER or JANIS BUNCK Please Take Notice as Follows: The claim you presented against the County of Contra Costa or District governed by the Board of Supervisors fails to comply substantially with the requirements of California Government Code Section 910 and 910.2, or is otherwise insufficient for the reasons checked below: [X] 1. The claim fails to state the name and post office address of the claimant. [X] 2. The claim fails to state the post office address to which the person presenting the claim desires notices to be sent. [X] 3. The claim fails to state the date, place or other circumstances of the occurrence or transaction which gave rise to the claim asserted. [X] 4. The claim fails to state the name(s) of the public employee(s) causing the injury, damage, or loss, if known. [ ] 5. The claim fails to state whether the amount claimed exceeds ten thousand dollars ($10,000). If the claim totals less than ten thousand dollars ($10,000), the claim fails to state the amount claimed as of the date of presentation, the estimated amount of any prospective injury, damage or loss so far as known, or the basis of computation of the amount claimed. [ ] 6. The claim is not signed by the claimant or by some person on his or her behalf. Odlifornia State Automobile Association Re: Claim of California State Automobile Association/Peder or Janis Bunck Page Two [X] 7. You are required to submit your claim on the proper form, which is enclosed. Please resubmit your claim on the enclosed fonn, including all the required information. Gov. Code, § 910.4. Please be aware that you have only a limited period of time in which to file an amended claim. See Gov. Code, § 910.6. [ ] 8. Other: SILVANO B. MARCHESI COUNTY COUNSEL By: Monika L. Cooper Deputy County Counsel CERTIFICATE OF SERVICE BY MAIL (Code Civ. Proc., §§ 1012. 1013a, 2015:5; Evid. Code, §§ 641, 664) I am a resident of the State of California, over the age of eighteen years, and not a party to the within action. My �b-ussi-ness address is Office of the County Counsel, 651 Pine Street, 9th Floor,Martinez, CA 94553-1229. On C 7,4U , I served a true copy of this Notice of Insufficiency and/or Non-Acceptance of Claim by placing the document in a sealed envelope with postage thereon fully prepaid, in the United States mail at Martinez, California addressed to California State Automobile Association,Inter-Insurance Bureau,P.O. Box 920, Suisun, CA 94585, as set forth above. I am readily familiar with Office of County Counsel's practice of collection and processing of correspondence for mailing. Under that practice, it would be deposited with the U.S. Postal Service on that same day with postage thereon fully prepaid in the ordinary course of business. I declare under penalty of perjury under the la s.of the State of California and the United States of America that the above is true and correct. Executed on 0 2AD7 at Martinez, California. Kathleen O'Connell cc: Clerk of the Board of Supervisors (original) Risk Management Page 2 California State Automobile Association Inter-Insurance Bureau P.O.Box 920 Suisun City,CA 94585-0920 February 14, 2007 REcEIVED Contra Costa County Risk Management INV 2530 Arnold Dr#140 Martinez,CA 94453 FEB 2 3 2007 CLERK BOARD OF SupERVISOt,S, CONTRA COSTA Co. RE: Your Insured: ZZ Your Claim No.: Unknown Our Insured: Peder C Or Janis D Bunck Our Claim No.: 17-P I3622-2 Date of Loss: 10/12/2006 Dear Contra Costa County Risk Management: This will confirm our subrogation interest arising from this loss. We have settled the claim with our insured and based on the following facts,request payment directly to California State Automobile Association Inter-insurance Bureau (CSAA-IIB): In order to assist with and expedite the evaluation and processing of this subrogation demand,we enclose the relevant documentation in support of our claim, This information may contain personal or privileged information about our insured,and is being provided to you pursuant to California Insurance Code Section 791.13 and may not be used for any unauthorized purpose. Based upon this information,we ask that you issue payment of$1307.07 Repair Bill $807.07 Deductible $500.00 Loss of Use $0.00 Tow/Storage $0.00 Miscellaneous $0.00 -------------------------- TOTAL $1,307.07 Please be advised that any payment in an amount less than that set forth in this letter that is forwarded to CSAA without its prior authorization as described below will not constitute a fill and final settlement and will be accepted as partial payment only. Since payments received in the mail are processed by clerical staff and deposited as a matter of course without examination,unauthorized payments for less than the full amount demanded may be processed inadvertently. Although such payments may be demarked as"payment in full"or have other words of similar meaning written on them, their processing will not constitute an accord and satisfaction,as CSAA-has not agreed to acceptance of such payments. Only an authorized Subrogation Specialist may communicate,orally or in writing,CSAA's specific agreement to accept an amount less than that demanded in this letter. If you have any questions,please feel free to contact the CSAA Subrogation Department. Sincerely, Subrogation Specialist F268K(Apr 2002) (888)900-6520 extension 6206 Fax 707-863-9052 Enclosure W Date: 115/2007 10:13 AM Estimate ID: 117 Estimate Version: 2 Supplement 2(P) 10/31/2006 05:39:39 PM FINAL Profile ID: CSAA Abel Chevrolet-Pontiac-Buick CO. 1012 Highway 12 Rio Vista,CA 94571 (707)3744348 Fax: (707)374-6160 Tax ID: 94 0266430 BAR#: AA 002857 EPA#: CAD 02BB9838 DamageAssessed By: DALE MCGINNIS Supplemented By: BOB SIEVE Date of Loss: 10/12/2006 Final to Owner 11/1312006 Deductible. NONE P` File Number. F CD Policy No: P138222 Claim Number: A171313622201 CD Insured: PEDER BUNCK Mitchell Service: 916492 Description: 1997 GM Sonoma SLS >_ Body Style: 2D P kupXCb G'Bed 12211 WB Drive Train: 4.3LInj6CV12WD VIN: IOTCSISXOV8527039 License: 5P66900 CA Mileage: 116,971 W OEIVVALT: A Search Code: C318012 All CRASH parts on this estimate are "new" original equipment W manufacturer parts, unless otherwise specified. Parts described as rechromed, recored, remanufactured or, reconditioned are considered" rebuilt" parts. Crash parts described as "quality replacement part" are non-original equipment manuicictuter aftermarket new parts. ,, Line Entry Labor Line Item Part Typel Dollar Labor Item Number Type Operation Description Part Number Amount Units STRIPE TAPE S21 6007116 BDY REMOVE/REPLACE R FRT STRIPE TAPE PICKUP BED ORDER FROM DEALER 17.44 0.3 # S22 600720 BOY REMOVE/REPLACE R REAR STRIPE TAPE PICKUP BED ORDER FROM DEALER 14,99 02 # S23 600724 BDY REMOVE/REPLACE R REAR STRIPE TAPE BUMPER EXTENSION ORDER FROM DEALER 14.18 02 PICKUP BED 4 631769 BDY REPAIR R PICKUP BED SIDE PANEL ASSY Existing 5 REF REFINISH R BED OUTER PANEL C 2A S26 631747 BDY REMOVE/REPLACE PICKUP BED DECAL KIT 12343342 GM PART 46.00 0.3* REAR LAMPS 7 601500 BOY REMOVE/INSTALL R REAR COMBINATION LAW 0.3 MANUAL ENTRIES 8 900500 BOY* ADO'L LABOR OP SUBSEQUENT BAGGING New 02* REAR BUMPER SI 9 629850 BDY REMOVE/REPLACE REAR BUMPER ASSY 0jV 10 BDY OVERHAUL REAR BUMPER ASSY 09 S211 629900 BOY REMOVE/REPLACE REAR BUMPER FACE BAR Remanufactured 1186115' INC 12 REF REFINISH REAR FACE BAR C is 13 ESTIMATE RECALL NUMBER: 10116J200617:05:112 117 UltraMate is a Trademark of Mitchell International Michell Data Version: OCT 06—V Copyright(C)19%-2003 Mitchell International Page 1 of 3 UllraMate Version: 5.0215 All Rights Reserved Date: 115/2007 10:13 AM Estimate ID: 117 Estimate Version: 2 Supplement 2(P) 110/31=0605:39:3913M FINAL Profile ID: CSAA S214 630010 BDY REMOVE/REPLACE R REAR BUMPER EXTENSION -Qual Repi Part 40.25' 02 # 15 REF REFINISH R REAR BUMPER EXTENSION C 0.6 ADDITIONAL OPERATIONS 16 REF AD D'L OP R CLEAR COAT 1A 17 933003 REF AD D'L OP R TINT COLOR 0.5* Is AD D'L COST PAINT 180901 19 ADDT COST HAZARDOUS WASTE DISPOSAL Judgement Item Labor Note Applies C -Included in Clear Coat Calc Add'l Labor Sublet 1. Labor Subtotals Units Rate Amount Amount Totals Il. Part Replacement Summary Amount Body 6.1 60.00 0.00 0.00 366.00 Taxable Parts 319.71 Refinish 6.7 6000 0.00 0.00 402.00 Sales Tax 7X546 23M Non Taxable Labor 768.00 Total Replacement Parts Amount 34329 Labor Summary 122 768.00 Ill. Additional Costs Amount IV. Adjustments Amount Taxable Costs 180.90 Insurance Deductible 5D0.00- Sales Tax 7.375% 13.34 Customer Responsibility 500.00- Non-Taxable Costs 1.54 Total Additional Costs 195.78 1. Total Labor. 768.00 Il. Total Replacement Parts: 34329 Ill. Total Additional Costs: 195.78 Gross Total: 1,307.07 IV. Total Adjustments: 500.00- Net Total: 807.07 Less Original Net Total: 517.26 Net Supplement Amount 2B9.81 SI: BOB SIEVE 162.65 S2: BOB SIEVE 127.16 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. insurance Co: CSAA Insurance ESTIMATE RECALL NUMBER: 10/16/200617:05:12 117 URraMate is aTrademark of Mitchell International Witchell DataVersion: OCT 06_V V Copyright(C)1994-2003 Mitchell International Page 2 of 3 UltraMate Version: 6.0216 All Rights Reserved Date: I/5=07 10:13 AM Estimate ID: 117 Estimate Version: 2 Supplement 2(P) 10131a00605:38:39PM FINAL Profile ID: CSAA THIS ESTIMATE IS BASED ON OUR VISUAL INSPECTION AND DOES NOT COVER ADDITIONAL PARTS OR LABOR WHICH MAY BE REQUIRED AFTER THE REPAIRS HAVE BEEN STARTED. QUOTATIONS ON PARTS ARE SUBJECT TO INVOICES. 11 we appreciate your business ESTIMATE COPY GIVEN TO THE CUSTOMER Cycle Time Information Drop Off Date. 10/13,2006 Time:03:00 Repair Dates: Promise Date: 1012012006 Start Date: 10116/2006 Pick UpDate: 11/132006 Time:04:00 Completion Date: 11/13/2006 Is Vehicle Driveable(YIN)?: y Assisted With Rental(YIN)'?: N ESTIMATE RECALL NUMBER* 10116/200617:05:12 117 uitramate is aTrademark of Mitchell International Mitchell Data Version: OCT 06_V V Copyright(C)1994-2003 Mitchell International Page 3 at 3 UIIraMate Version: 5.0215 All Rights Reserved Date: 11 5=07 10:13 AM Estimate ID: 117 Estimate Version: 2 Supplement 2(P) 10/311200605:39:39 PM Profile ID: CSAA Abel Chevrolet-Pontiac-Buick CO. 1012 Highway 12 Rio Vista,CA 94571 (707)3744= Fax: (707)374-6160 Tax ID: 94 0266430 BAR#: AA 002857 EPA#: CAD 02899838 Supplement Delta Report Comparison of Estimate 117 Supplement I and Supplement2 Damage Assessed By: DALE MCGINNIS Supplemented By: BOB SIEVE Insured: PEDER BUNCK Owner. PEDER BUNCK Vehicle Description: 1997 ONE Sonoma SLS Date of Loss: 10/122006 Line Labor Line Item Dollar Labor CEG Item Type Operation Description Part Type Amount Units Unit Changed Entries 3 BDY REMOVEIREPLACE PICKUP BED DECAL KIT New 46.00 0.0 T S2&< BDY REMOVEIREPLACE PICKUP BED DECAL KIT New 46.00 0.3.< T S1 a BDY REMOVE/REPLACE REAR BUMPER FACE BAR Remanufactured 185.00 INC 0.9T S2 11< BDY REMOVE/REPLACE REAR BUMPER FACE BAR Remanufactured 186.85 1< INC 0.9T 11 BDY REMOVE/REPLACE R REAR BUMPER EXTENSION —Qual Rept Part 26.16 02 02T S2 14< BDY REMOVE/REPLACE R REAR BUMPER EXTENSION —Qual Repl Part 40.25*< 0.2 0.2T Added Entries - S2 I BOY REMOVEIREPLACE R FRT STRIPE TAPE PICKUP BED New 17.44 0.3 0.3T S22 BDY REMOVEIREPLACE R REAR STRIPE TAPE PICKUP BED New 14.99 02 03T S23 BDY REMOVE/REPLACE R REAR STRIPE TAPE BUMPER EXTENSION New 14.18 0.2 0.2T Global Changes No Deductible,Labor Rate,or Part Adjustment changes weremade. Amount Original Estimate: 517.26 Supplement 1 162.65 Supplement 127.16 Supp I Total Tax 32.31 Supp 2 Total Tax 36.92 Net Supplement Amount 289.81 NetTotal 807.07 Data Versions Supp I AUG—06—V Supp 2 OCT06V ESTIMATE RECALL NUMBER: 10/16/200617:05:12 117 UltraMate is aTrademark of Mitchell Intemational UltraMateVersion: 5.0215 Copyright(C)I SW-2003 Mitchell International Page 1 of I All Rights Reserved C14 O CHECK NO.: 711 L334015-9—R L) DATE: 01-10-2007 O > NAME AND ADDRESS INFORMATION: Lu ABEL CHEVROLET PONTIAC BUICK PO BOX 696 RIO VISTA CA 94571-0696 INSURED: BUNCK,PEDER,C;OR JANIS D PAYMENT INFORMATION/DESCRIPTION: DATE OF LOSS: 10-12-06 CLAIM NO: 17—P13622-2 CLAIMANT: BUNCK,PEDER,C;OR JANIS D PAYEE: ABEL CHEVROLET PONTIAC BUICK AMOUNT: S807.07 IN PAYMENT OF: REPAIR LESS DED ADJUSTER: LINDA BRYAN—FINCHER ADJUSTER NO.: 35216 KIND OF LOSS: COL 16610702 DETACH AND RETAIN FOR YOUR RECORDS No. 711 L33401 5-9-R DATE OF LOSS CLAIM W&M DATE 10-12-06 17—P13622-2 ',,PEDER,C;OR 'JANIS D 101-10-2007 POLICY TYPE KIND OF LOSS SUFFIXCLAIMANT'S NAME PAY AUTO COL 01F BUNCK,PEDER,C;OR JANIS D $807.07 D.O. ADJUSTER NO. IN PAYMENT OF BANK OF AMERICA rA-127 DR2 35216 REPAIR LESS DED 8.,* of America customer Connection 611 Bank of America, N.A. TIN: 94-0266430-00 Allarda, Ockalb County, Georgia PAY *EIGHT HUNDRED SEVEN 07/100* This check must be property endorsed on the reverse side by all payees. ABEL CHEVROLET PONTIAC BUICK TO THE ORDER OF fa i 4 n uy, gt l 3 \ f rs c xg- i'. L ai s � , r g, V, X�hww� ar a > - 3y -,��" #>..• � "�,"'4 �� ..: � ..�� .r fie`.�'��` ';`�.�.w:x+ 4«; '��� w`� '� , wy*(P " Y7AIr WWI 3. ar ,� t . . . . . . � � " . . y . . . w y : . . . � . . � . . . wy : . \ <:. .� .: � : �. ,�, . \ � � . : � . . . . ,: w w . .�� . ,: �� : � . : .m . : � � .m�� ��«w � _,© �® � ƒ .. . � yr w»< ? ° ��^� \-� , .v ^y « d: � < . - .. � : . . . �1r »» \� �� � ^ : r , \. � - �\ . �� \ \/�\�� `�\ � � � /. � \ \ �� ` ^ � »\� < . .� . . >. . . � >. � . . .. �� 2 2� : . y \ \ \ \ NMI, . . . y . . a � } �: � � : . . . ^ � . � � �� � » �\ � . z : v, °a — � �© �� < � �� . . \ \. » � \ \ / \ � } : /� .ri ; . ��\ - :� » � y >. < / g d ✓/'// „-yam;: n' a ti a3 ` s� � L � S K'^ � by � M � F F 43 Y 5 r r� / CLA[M BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION:APRIL 03, 2007 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 FEB 2 6 Section 913 and 915.4. Please n 1 AMOUNT: $500,000.00 2007 ease ote al "Warnings". COUNTY COUNSEL CLAIMANT: LYDIA JARO MARTINEZ CALIF. ATTORNEY: JOHN R. GRELE DATE RECEIVED: FEBRUARY 26, 2007 ADDRESS: 703 MARKET STREET, #550 BY DELIVERY TO CLERK ON:FEBRUARY 26, 2007 SAN FRANCISCO, CA 94100 BY MAIL POSTMARKED: FEBRUARY 23, 2007 FROM: Clerk of the Board of Supervisors T0: County Counsel Attached i&a copy of the above-noted claim. FEBRUARY 26, 2007 JOHN CULLEN, lent Dated: By: Deputy _ II. FROM.: County Counsel TO: Clerk of the Board of Supervisors ( 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: —O 7 By: /1'7 eputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (]) County Administrator(2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). I.V. ARD 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 correct copy of the Board's Order entered in its minutes for this date. 0 Dated0&4,tHN CULLEN, CLERK, By Deputy Clerk WARNING (Gov. code section 913) 11 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 i. am now, and at all times herein mentioned, have been a citizen of the United States, over age 1.8; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. ee � Dated:,f x X110 le 'P'11_ JOHN CULLEN, CLERK By _ eputy Clerk 02�13/2007 10:56 CONTRA COSTA COUNTY.CLERK OF THE i 914153480364 N0.090 G101 ' BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY Ai INSTRUCTIONS TO C—L—A".1 A A. 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 auy other cause of action shall be presented not later than one year aft the accrual of the cause of action. (Gov. Code § 911.2.) B. Claims must be filed with the Clark 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 mm 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 penaltyfor fraudulent claims,Penal Code Sec.72 at the end of this form. 0"we"ass""a 2060984484*was 008 0606056 08990968285 0 as**a 06096age assownwasys was I RE: Claim By: Reserved for Clerk's filing stamp Lydia Jaro RECEIVED Against the County of Contra Costa orE13 2, 6 2007 F District) iici CR BOARD OF SUPERVISORS BOARD OF SUPERVISORS IS RS CONTRACOSTA 0 (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$. 5 00,,0 0 0 -0 Oand in support of this claiin represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) August 31 , 2006 at approximately 8 :35 a.m. 2. Where did the damage or'jury occur' (Include city and county) M The intersection of First Street and Mt. Diablo Blvd. , Lafayette, CA. I How did the damage injury njury occur? (Give full details;use extra paper if required) Pedestrian struck by a motor vehicle 4. What particular act or omission on the part of county or district officers, servants, or employees caused the injury or damage? Failure to correct a known dangerous intersection. Failure to desirp), build, inspect , and maintain safe intersection. 5 What are the names of county or district officers,servants,or employees causing the damage or injury? Unknown .at this time 02'/13/2007 4M.5_ CONTRA COSTA COUNTY CLERK OF THE 4 914153480364 NO.090 IP02' 6. What damage or injuries do your claim resulted? (Give W extent of injuries or, damages claimed. Attach two estimates for auto damage.) Victim suffered disabling fractured tibial plateau, subdural hematoma, post-traumatic vertigo, brain, and neck injury n 1 7. How was the amount claimed above computed? (Include the estimated amount of any Pr0SPer-tiVeiVjUTY0rdaMa9C-) Injury ($200 ,000) ; Care ($250 ,000) ; Loss �of mobility, enjoyment of lif ($100 ,000) ; Trauma ($50 ,000) 8. Names and addresses of witnesses,doctors,and hospita.1s, John Muir Medical Center , 1601 Ygnacio Vdlley Rd. ' Walnut Creek, CA; San Francisco General Hospital , 1001 Potrero Ave. , San Francisco , CA; Jaime Fukumae , 635 Kern, Richmand,CA- 9. List the expenditures you made on account of this accident or injury: DATE Tag AMOUNT Ongoing Medical estimated $200 ,000 Ongoing Legal estimated $ 15 ,00.0 wasswoom8*9548 me wave see all ffesswa ) Gov.Code See. 910.2 provides"Me claim shall be )signed by the claimant or by some person on his )behalf" SEND NOTICES TO. fAbDMe_Y J Name and address of Attorney John R Grele Attorney 'at Law (Claimant's Signature) 703 Market Street , #550 San Francisco , CA 94103 c/o Law Offices of John R Grele (Address) 703 Market Street , Suite 550 , San Francisco, CA 94103 Telephone No. 4,15). 348-9300 )Telephone No. (415) 348-9300 a assume**moves ogles asp$Mosul PUBUC 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, 55 6500 et seq.) Furthermore, any attachments,addendums,or supplements attached to the claim form, including medical records, are also subject to public disclosure. $0 8 In No assent NOTICE: Section 72 of the Pend 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 five 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. DECLARATION OF SERVICE BY OVERNIGHT DELIVERY RE: Claim By Lydia Jaro Against the County of Contra Costa I, Leslie Gangi , declare that I am over 18 years of age and not a party to the within cause; my business address is 703 Market Street, Suite 550, San Francisco, CA, 94103. I am a resident of said county. On February 23, 2007, I served a true copy of the attached Claim By Lydia Jaro Against the County of Contra Costa on the following by placing same in an envelope provided by an overnight delivery carrier addressed as follows: Clerk of the Board of Supervisors County Administration Building, Room 106 651 Pine Street Martinez, CA 94553 Said envelope was then, on February 23, 2007 , sealed and deposited in the regularly utilized drop box of the overnight delivery carrier for collection at San Francisco, California, the county in which I am employed; I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Executed on February 23. 2007 , at San Francisco, California. v Leslie Ga gi ECFak VE D: John R Grele Attorney at Law FEB 2' 6 2007 " 703 Market Street, Suite 550 CLERK BOARD OF SUPERVISORS San Francisco, CA 94103 CONTRACOSTACO. Telephone:415-348-9300 ext. 204 Facsimile:415-348-0364 February 23, 2007 Clerk of the Board of Supervisors County Administration Building, Room 106 651 Pine Street Martinez, CA 94553 Re: Claim By Lydia Jaro Against the County of Contra Costa Dear Clerk of the Board of Supervisors: Please find enclosed an original and one copy of the above entitled claim. Please file the original claim and return a conformed copy in the provided self addressed stamped envelope. Should you have any questions or concerns,please don't hesitate to contact our office at any time. Sincerely, Leslie Gangi • i� - �oEedEX 18p0 A63333g a� �e eXCpm 180 N jcv tM 03 a ` c. 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C y 1 J o to Z 3H3H 133d :1N3ldE33H N ' 6CCET9v WOR X3P@JO9'008l woa•xaPOJ CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION:APRIL Q3, 2007 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 isD our notice of the action taken on your claim by the Board of FEB 2 8 2007 Supervisors. (Paragraph IV below), given Pursuant to Government Code AMOUNT: $2,108.01 COUNTY COUNSEL Section 913 and 915.4. Please note all _. MARTINF?!r`A1 Ic "Warnings". - CLAIMANT: GEICO DIRECT FOR: JACK Q: LE ATTORNEY: UNKNOWN DATE RECEIVED: FEBRUARY 28. 2007 ADDRESS: ONE GEICO WEST BOX 509090 BY DELIVERY TO CLERK.ON: FEBRUARY 28. 2007 SAN DIEGO, CA 92150-9090 RECEIVED FROM RISK BY MAIL POSTMARKED: MANAGEMENT P9S-TKED FEBRUARY �3, 2007 . FROM: Clerk of the Board of Supervisors T0: County Counsel Attached is a copy of the above-noted claim. FEBRUARY 28, 2007 JOHN CULLEN, le Dated: By: Deputy II. FROM.: County Counsel TO: Clerk of the Board of Supervisors ( 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 Clei-k 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: 1 ff-01 By: Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (]) County Administrator(2) ( ) 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. e Dated 1y// � 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 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:,// e`3� �°'�� J014N CULLEN, CLERK By Deputy Clerk GEICO ■ Government Employees Insurance Company RECEIVE® ■ GEICO General Insurance Company ■ GEICO Indemnity Company ■ GEICO Casualty Company FEB 2 8 2007 One GEICO West, Box 509090 ■ San Diego,CA 92150-9090 CLERK BOARD OF SUPERVISORS CONTRA COSTA CO- PAYMENT RECOVERY NOTICE OC)-r(A p� �e1'c�kScnS Date: I�a / Our File#: Our Insured: 50LCL Q Le.- Your Insured/Driver: WHEN RESPONDING- Your File#: rl 9n tom,, PLEASE REFER TO OUR Your Vehicle: I U+�V �jtD1�C11 Tag#: CLAIM NUMBER Our investigation shows your insured to be at fault in the accident. > 1. Repair or replacement of our vehicle has been concluded. Our subrogation claim will be forwarded. Please protect >Oour interest. ayment for repairs has been made. Documentation is attached. Please honor our claim. CO's Interest: $ CQC7C Q Insured's Deductible: $ .1700, Rental: $ Total: $ �j 1 . 0 > 3. Our vehicle was declared a total loss. Documentation is attached. Please honor our claim. Amount paid to the insured: $ Insured's Deductible: $ Net salvage recovery: $ Total: $ > 4. We have subrogation rights for no fault benefits paid. Our documentation is attached. Please honor our claim. Medical: $ Wages: $ Other: $ Total: $ > 5. Since notifying you on of our subrogation claim,we have paid additional damages of Please include this in your payment to us. Documentation is attached. Our Total Claim is$ > 6. Documentation of our claim was sent to you on When may we expect payment? > 7. Arbitration was filed and a decision was rendered in our favor on When may we expect payment? > 8. Please make your check payable to: ❑ C1EICO ❑ GEICO Indemnity Company ❑ GEICO Casualty GEICO General Insurance Company ❑ Thanks For Your Prompt Attention Signature: NanL\ Phone: 95S-& l MEMBER NATIONAL INSURANCE CRIME BUREAU S-54-B(10-02) BOARD OF SMFaVISORS OF CONTRA:COS'T'A COUNTY INSTRUCTIONS TO CLAWAW A claim relating to a cause of action for death orfor injury i�- ` person- o-rto-per'--s-o-=-Apr6P-e*-- 1)-r growing crops shallbe presented not later than sial months after the acMal of the cause of action. A claim relating to any other cause of action shall be,presented not later than one y ar after the acenml of fl=cause,-of action. (Gov. Code§911.2.) 1. Claims must be filed with the Clerk of the Board of Supervisors at it office in Room 1 6, County Ad6iiiistration Building,651 Pine Street,Mardnez,CA 94553. I if claim is against a distriol governed by the Board of Supervisors, raft timi the County, he name of the District should be filled in. I If the claim is amd'ust more than one public entity, separate claims roust be filed against e 101, public entity. R. Fraud. See penalty for fraudulent claims,Pend Code Set% 72 at the end of this form. EVAR VEXX*x&RRNXZX SM alt 9 a n4abal lCotZENN NINURRINXPORK611 UK K MON 91INIZIERMIN XK RKSMIZZ 221 RE: Claim By: Reserved for Clerk's 4bngstamp RECEIVED Against the County of Contra Costa or FEB 2 8 2007 CLERK BOARD OF—SUPERVISORS (Fill ia the rime} District) CONTRA COSTA CO. The undersigned claim�f-.hereby makes claim aidust tbe Comfy of Comma Com or the above- cd district iTL tbz sunt of$ and in support of this claim represents as follows: L When did the damage or injury occur? (Give-exact date and hour) 5q*ryl te-ir C00 0 10..15 0, 2. Where did the damage or injury occur? (Include,city and county) 13-,JC0LrV-ICM— P.)Cv--,Ojp, lr,,_ 3. How did the or injury,occur? (Give full details;use extra paper Getco-Woec U�ts slt an sy, X11- kq(z- OA-CLGI-eer-, L 1 On*\u Olick ON6\ uns Get 6bl)(2wer 4. What'particular act or omission on the put of 00MAY or district o cern, servants, orerne]h3mes Oa (71. V)I— =7ar� Ct1 mused the injury or damage? Mon k*C(U If-X\i e-P Ncy) 'NLA. IYM ly�IQUC- ��)IeW What are the names of county or district officers,servants,or employees cmLsing,the damage or*Jury? In! es 1N3A39VNVA KA DDO —.AVZE:6 LOOT 'ZZ 'NVP 6, 'What damage or injuries do your claim resulted? (Crive full extent of injuries ordamges -daimetL -Attach-two estimates for auto damage.) - 7. How was the amount claimed above computed? (Eadude the estimated amount o any prospeative injury or damage,) ` �cLrnQ �Ls O$ .C>) 8. Names and addresses of witnesses,doctors,and hospitals. 9. 'List the expenditures you made-on account of this accident or injury: DATE TRVM AMOUNT a asaeaRMaaaaaaaaaaaaaMaaaaz"maaaaaMlaaaaaYhaaaaasaaaaRRaaaaaRaaeaa=aaaaa=aaaRea sea m .Gov.Code see. 910.2 provides"The claim small be signed by the claimant or by some person on his )behalf." C-�emco '�,>\v-eck OL 9- bt 'd,j�1',e' SEND NOTICES TO: (Attome-0 yeh 'GV)k-A Name and address of Attorney ) j (Claimant's signature) (Address) Telephone No. )Telephone No. �'s 5 \3 t�,D BEE Rua Env INK WEE Kip canal PUBLIC RECORDS NOTICE: Please be.advised that this claim form, or any claim filed with The County under the Tort Claims Act,is st bjed to public disclosure under the Califaxuia Public Records Act. (Gov. Code, 59 6500 et seq.) Furtherm , any aitachmteats,addendums,or supplements a whed to ihe claim form,including medical records, are also si bject to public disclosure, ■aaaaaaaaRISEN anas641MRkaMEN aaaRYyaaaaaaRrseaaaaaKILN Nam aaaREBENZ aaeRIFE a0HIRE aaa 3REaa' NOTICIE. Section 72 of the Penal Code provides: Every person who,with intent to defiaud,presents for allowance or for payment to any state board oro licer,or to any county, city, or district board or officer, aafhorized to allow or pay the same if genuine, any false or f3andulent claim,bill, account voucher, or writing, is punishable either by imprisonment in the County ail for a i Period of not more than one.year, by o.fine of not exceeding one thousand dollars ($1,000,00), or by t th such imPrisonmeaat and fine, or by impxiso=W in the state prison, by a fine of not exceeding ten thousan I dollars ($10,000),or by both such imprisonment and fine. i 'd —LE l 'ON AINI 'd M KIS )DO W E:6 coot 'zz 'NVP CLAIM PAYMENT SCREEN REVERSE CLAIM_$# LOSS_ ADJR _TIME_ FCC _IRS_FIELD_ _ISSUED_ 0286976590101032 09 22 06 F342 12290526 03 12 05 06 _CHECK_$# TYP ID CO CHECK AMT FEAT_C_S_AMT EXP FEAT_C_S_AMT EXP 079378921 A LP 13 1608 . 01 01COL Y 1608 . 01 CLAIMANT JACK Q LE USER ID U79Z50 IN_PAYMENT_OF INSURED _AG_ _ONP_ _TYPE_ COLLISION COVERAGE JACK Q LE P/L LESS $500 DED PAY TO JACK Q LE ENCLOSURE P=POLICE REP F=FORM LETTER C=CORRESPOND L=PROOF/LOSS MAIL TO JACK Q LE M=MISC. I=INVOICES 12 PLATEAU CT R=RELEASES HERCULES, CA 94547-1427 VECTORING IRAN: CLIA KEY: 0286976590"llo 032 01COL Page 1 of 8 12/04/2006 AT 09:31 AM 0286976590101032-01 1330 010YOF6X GEICO CONTRA COSTA NORTHERN CALIFORNIA VISIT US AT GEICO.COM SUPPLEMENTS CALL 800-742-2347 P.O. BOX 509060 SAN DIEGO, CA 92150 (925) 698-2672 ESTIMATE OF RECORD WRITTEN BY: ROBERTO ALCALA 12/04/2006 09:22 AM ADJUSTER: F342 EXT: 5483 FCC: INSURED: JACK LE CLAIM #0286976590101032-01 OWNER: JACK LE POLICY #4047608825 ADDRESS: 12 PLATEAU CT DATE OF LOSS: 09/22/2006 AT 12 :00 AM HERCULES, CA 94547-1427 TYPE OF LOSS: COLLISION EVENING: (510) 821-2448 POINT OF IMPACT: 6. REAR INSPECT CAR WEST DAY: (925) 674-9700 LOCATION: 165 MASON CIRCLE DRIVE-IN CONCORD, CA 94520-0000 REPAIR CAR WEST AUTO BODY BUSINESS: (925) 674-9700 FACILITY: 165 MASON CIRCLE 4 DAYS TO REPAIR CONCORD, CA 94520 LICENSE ## 1993 ACUR LEGEND L 6-3 .2L-FI 4D SED BLACK INT: VIN: JH4KA7664PC000293 LIC: 4WQB346 CA PROD DATE: ODOMETER: 140231 AIR CONDITIONING REAR DEFOGGER TILT WHEEL CRUISE CONTROL TELESCOPIC WHEEL INTERMITTENT WIPERS THEFT DETERRENT/ALARM TINTED GLASS BODY SIDE MOLDINGS DUAL MIRRORS ELECTRIC GLASS SUNROOF CLEAR COAT PAINT POWER STEERING POWER BRAKES POWER WINDOWS POWER LOCKS POWER DRIVER SEAT POWER ANTENNA POWER MIRRORS AM RADIO FM RADIO STEREO CASSETTE SEARCH/SEEK EQUALIZER BOSE RADIO ANTI-LOCK BRAKES (4) DRIVER AIR BAG PASSENGER AIR BAG 4 WHEEL DISC BRAKES LEATHER SEATS BUCKET SEATS RECLINE/LOUNGE SEATS AUTOMATIC TRANSMISSION ALUMINUM/ALLOY WHEELS ------------------------------------------------------------------------------- NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT ------------------------------------------------------------------------------- 1 REAR BUMPER 2 O/H REAR BUMPER 2 .0 3** REPL RECOND BUMPER COVER 4 DOOR 1 360.00 INCL. 3 .0 STANDARD & L 4 ADD FOR CLEAR COAT 1.2 5 FRONT LAMPS 6** REPL QUAL REPL PARTS LT LENS & 1 67 .34 0 .2 HOUSING 4 DOOR file://C:\Documents and Settings\u09348\Local Settings\Temp\pdi\0286976590101032-01-... 2/22/2007 Page 2 of 8 7 FRONT BUMPER 1 12/04/2006 AT 09:31 AM 0286976590101032-01 1330 010YOF6X ESTIMATE OF RECORD 1993 ACUR LEGEND L 6-3 .2L-FI 4D SED BLACK INT: ------------------------------------------------------------------------------- NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT ------------------------------------------------------------------------------- 8 0/H FRONT BUMPER 2 .5 9** REPL RECOND BUMPER COVER STANDARD 1 276.00 INCL. 2.5 & L 10 ADD FOR CLEAR COAT 1.0 11# SUBL HAZARDOUS WASTE 1 3.00 X 12# FLEX ADDITIVE 1 8.00 T 13# COLOR MATCH 1 0.3 14# SET UP & MEASURE FRAME 1 2 .0 F 15# PULL TO SQUARE LT QRTR 1 1.5 N 16# ***TEARDOWN NEEDED FOR DMG TO 1 LT RAIL ------------------------------------------------------------------------------- SUBTOTALS =_> 714 .34 8.5 7.7 LINE 16 : GAP BETWEEN LT QRT AND LT REAR DOOR OVERLAPPING, ------------------------------------------------------------------------------- ESTIMATE NOTES: ESTIMATE HEADING CORRECT (Y/N)Y VEHICLE ID IS CORRECT (Y/N)Y DRIVEABLE (Y/N)Y TOWED(Y/N)N PAID TOW BILL (YIN OR WHY)N DEPRECIATION (YIN) N WHY DEPRECIATION ALT PARTS (Y/N)Y ZERO QUOTES (Y/N)N FLAT RATE ADJUSTMENT (Y/N)N REFINISHED LABOR & MATERIALS (Y/N)Y PRIOR DAMAGE (Y/N)Y REPAIR VS TOTAL:R PAYMENT ISSUED (YIN) Y CHECK #: COMPANY CODE:13 ------------------------------------------------------------------------------- PRIOR DAMAGE NOTES: PAINT FADED ALL AROUND VEH, DINGS ON LT QRT,RT QRT, PAINT CHIPS ON RT/LT REAR DOOR EDGES, SCRATCHES ON FRONT SPOILER. PARTS 703.34 file://CADocuments and Settings\u09348\Local Settings\Temp\pdi\0286976590101032-01-... 2/22/2007 Page 3 of 8 BODY LABOR 6.5 HRS @$ 68.00/HR 442.00 PAINT LABOR 7.7 HRS @$ 68.00/HR 523.60 FRAME LABOR 2.0 HRS @$ 68.00/HR 136.00 PAINT SUPPLIES 7.7 HRS @$ 28.00/HR 215.60 SUBLET/MISC. 11.00 ---------------------------------------------------- SUBTOTAL $ 2031.54 2 12/04/2006 AT 09:31 AM 0286976590101032-01 1330 010YOF6X ESTIMATE OF RECORD 1993 ACUR LEGEND L 6-3 .2L-FI 4D SED BLACK INT: SALES TAX $ 926.94 @ 8.2500% 76.47 ---------------------------------------------------- TOTAL COST OF REPAIRS $ 2108.01 ADJUSTMENTS: DEDUCTIBLE 500.00 ---------------------------------------------------- TOTAL ADJUSTMENTS $ 500.00 NET COST OF REPAIRS $ 1608.01 "WE ARE PROHIBITED BY LAW FROM REQUIRING THAT REPAIRS BE DONE AT A SPECIFIC AUTOMOTIVE REPAIR DEALER. YOU ARE ENTITLED TO SELECT THE AUTO BODY REPAIR SHOP TO REPAIR DAMAGE COVERED BY US. WE HAVE RECOMMENDED AN AUTOMOTIVE REPAIR DEALER THAT WILL REPAIR YOUR DAMAGED VEHICLE. IF YOU AGREE TO USE OUR RECOMMENDED AUTOMOTIVE REPAIR DEALER, 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 INSURANCE POLICY OR AS OTHERWISE ALLOWED BY LAW. IF YOU EXPERIENCE A PROBLEM WITH THE REPAIR OF YOUR VEHICLE, PLEASE CONTACT US IMMEDIATELY FOR ASSISTANCE. " NO SUPPLEMENT WILL BE HONORED UNLESS AUTHORIZED BY GEICO. AUTHORIZATION MUST BE OBTAINED PRIOR TO ANY REPAIRS ***FOR ALL SUPPLEMENT REQUESTS CALL***1 800 742 2347 THIS ESTIMATE IS NOT AN AUTHORIZATION FOR REPAIR **************************************************************** NOTICE: NEW HIGH STRENGTH STEELS MAY REQUIRE THE USE OF MIG WELDER FOR PROPER REPAIRS. NEW DESIGNS REQUIRE MEASUREMENT TO PROPERLY ALIGN THE VEHICLE. MAKE SURE YOUR SHOP HAS THE RIGHT EQUIPMENT TO REPAIR YOUR VEHICLE. ***** ALL QUALITY RECYCLED PART PRICES REFLECT MARKUP AND ARE PRICED AS CLEAN AND UNDAMAGED ***** NO SUPPLEMENT WIL BE HONORED UNLESS AUTHORIZED BY GEICO DIRECT file://CADocuments and Settings\u09348\Local Settings\Temp\pdi\0286976590101032-01-... 2/22/2007 Page 4 of 8 **************************************************************************** 3 12/04/2006 AT 09:31 AM 0286976590101032-01 1330 010YOF6X ESTIMATE OF RECORD 1993 ACUR LEGEND L 6-3 .2L-FI 4D SED BLACK 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 fileWCADocuments and Settings\u09348\Local Settings\Temp\pdi\0286976590101032-01-... 2/22/2007 Page 5 of 8 DISTRIBUTOR OF THE PARTS, RATHER THAN BY THE ORIGINAL MANUFACTURER OF YOUR VEHICLE. 4 12/04/2006 AT 09:31 AM 0286976590101032-01 1330 010YOF6X ESTIMATE OF RECORD 1993 ACUR LEGEND L 6-3 .2L-FI 4D SED BLACK INT: IF QUALITY REPLACEMENT PART (QRP) APPEARS ON THIS ESTIMATE, IT INDICATES THAT THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF ONE OR MORE CRASH PARTS SUPPLIED BY A SOURCE OTHER THAN THE MANUFACTURER OF YOUR MOTOR VEHICLE WARRANTIES, IF ANY, APPLICABLE TO THESE REPLACEMENT CRASH PARTS ARE PROVIDED BY THE PARTS MANUFACTURER OR DISTRIBUTOR RATHER THAN BY THE MANUFACTURER OF YOUR VEHICLE. *** IN ADDITION TO ANY SUCH WARRANTIES, GEICO PROVIDES THE FOLLOWING: **** OWNER LIMITED WARRANTY**** WE WARRANT THAT ALL QUALITY REPLACEMENT BODY PARTS (PARTS NOT MANUFACTURED BY THE MANUFACTURER) IDENTIFIED ON YOUR ESTIMATE, ARE FREE OF DEFECTS IN MATERIAL AND WORKMANSHIP AND MEET GENERALLY ACCEPTED INDUSTRY STANDARDS THIS PARTS AND LABOR WARRANTY WILL BE IN EFFECT FOR AS LONG AS YOU OWN THE VEHICLE DESCRIBED IN THE ESTIMATE. THIS WARRANTY COVERS COST OF THE PART, LABOR TO INSTALL, AND INCIDENTALS SUCH AS PAINT AND MATERIALS AND IS SPECIFICALLY LIMITED TO THOSE ITEMS. THIS WARRANTY DOES NOT COVER LOSS OR DAMAGE THAT IS UNRELATED TO DEFECTS IN THE QUALITY REPLACEMENT PARTS. THIS IS NOT TRANSFERABLE IF ANY QUALTY REPLACEMENT PARTS ARE DEFECTIVE IN EITHER MATERIAL OR WORKMANSHIP, CONTACT YOUR GEICO REPRESENTATIVE. ESTIMATE BASED ON MOTOR CRASH ESTIMATING GUIDE. UNLESS OTHERWISE NOTED ALL ITEMS ARE DERIVED FROM THE GUIDE AET4805 DATABASE DATE 11/2006, CCC DATA DATE 11/2006, AND THE PARTS SELECTED ARE OEM-PARTS MANUFACTURED BY THE VEHICLES ORIGINAL EQUIPMENT MANUFACTURER. OEM PARTS ARE AVAILABLE AT OE/VEHICLE file://CADocuments and Settings\u09348\Local Settings\Temp\pdi\0286976590101032-01-... 2/22/2007 Page 6 of 8 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 GEM'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 W 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. 5 12/04/2006 AT 09:31 AM 0286976590101032-01 1330 010YOF6X ESTIMATE OF RECORD 1993 ACUR LEGEND L 6-3.2L-FI 4D SED BLACK INT: ALTERNATE PARTS SUPPLIERS 3 RECOND BUMPER COVER 4 DOOR PART NO. AC1100102R PRICE 360.00 9 RECOND BUMPER COVER STANDAR PART NO. AC1000120R PRICE 276.00 KEYSTONE - COMPLETE (800) 339-5033 4067 WEST SHAW AVE (559)271-6750 FRESNO, CA 93722 KEYSTONE - COMPLETE (800)264-7560 3615 NE. 109TH AVE (360)260-8400 VANCOUVER, WA 98682 KEYSTONE - COMPLETE (800)421-7866 1754 CEDAR ST. STE A (909) 986-4586 ONTARIO, CA 91761 KEYSTONE - COMPLETE (800) 992-7550 file://C:\Documents and Settings\u09348\Local Settings\Temp\pdi\0286976590101032-01-... 2/22/2007 Page 7 of 8 8333 ARJONS DR. SUITE A (858) 547-4401 SAN DIEGO, CA 92126 KEYSTONE - COMPLETE (509)534-7844 3200 E. TRENT AVE BLDG 3 STE B SPOKANE, WA 99202 KEYSTONE - COMPLETE (800) 263-9727 632 SOUTH ELDORADO ST. (209) 948-1101 STOCKTON, CA 95203 6 QUAL REPL PARTS LT LENS & H PART NO. AC2532101 PRICE 67.34 COLLISION PARTS NETWORK (800) 734-7757 1990 ENTERPRISE BLVD. (916)372-0692 W. SACRAMENTO, CA 95691 COLLISION PARTS NETWORK (800)427-5659 321 W. AMADOR ST. (559)445-4350 FRESNO, CA 93721 COLLISION PARTS NETWORK (800)427-5659 1269 ALMA COURT (408)291-0950 SAN JOSE, CA 95112 COLLISION PARTS NETWORK (800)498-9808 14306 WICKS BLVD. (510) 895-8257 SAN LEANDRO, CA 94578 COLLISION PARTS NETWORK (800)427-5659 3723 SAN GABRIEL RIVER PARKWAY PICO RIVERA, CA 90660 6 12/04/2006 AT 09:31 AM 0286976590101032-01 1330 010YOF6X ESTIMATE OF RECORD 1993 ACUR LEGEND L 6-3.2L-FI 4D SED BLACK INT: ALTERNATE PARTS USAGE AFTERMARKET PARTS AFTERMARKET SELECTION METHOD: AUTOMATICALLY LIST NO. OF TIMES USER WAS NOTIFIED THAT AN AFTERMARKET PART WAS AVAILABLE: 3 NO. OF AFTERMARKET PARTS THAT APPEAR IN THE FINAL ESTIMATE: 1 file://C:\Documents and Settings\u09348\Local Settings\Temp\pdi\0286976590101032-01-... 2/22/2007 Page 8 of 8 OPTIONAL OEM PARTS OPTIONAL OEM SELECTION METHOD: AUTOMATICALLY LIST NO. OF TIMES USER WAS NOTIFIED THAT AN OPTIONAL OEM PART WAS AVAILABLE: 0 NO. OF OPTIONAL OEM PARTS THAT APPEAR IN THE FINAL ESTIMATE: 0 RECONDITIONED PARTS RECONDITIONED SELECTION METHOD: AUTOMATICALLY LIST NO. OF TIMES USER WAS NOTIFIED THAT A RECONDITIONED PART WAS AVAILABLE: 2 NO. OF RECONDITIONED PARTS THAT APPEAR IN THE FINAL ESTIMATE: 2 RECYCLED PARTS NO. OF TIMES USER WAS NOTIFIED THAT A RECYCLED PART WAS AVAILABLE: 2 NO. OF RECYCLED PARTS THAT APPEAR IN THE FINAL ESTIMATE: 0 7 file://CADocuments and Settings\u09348\Local Settings\Temp\pdi\0286976590101032-01-... 2/22/2007 Photos for claim no 0286976590101032-01 Page 1 of 12 Photo 1 from Estimate for Claim no 0286976590101032-01 Photo date: 04/12/2006 09:26:31:00. Size: 18664 Description: gap overlapping Insured: LE, JACK. Policy_no: 4047608825. Claimant: . Vehicle: 93,ACUR, LEGEND L. VIN: JH4KA7664PC000293. Loss date: 09/22/06. Estimator: ROBERTO ALCALA ' x Photo 2 from Estimate for Claim no 0286976590101032-01 Photo date: 04/12/2006 09:26:31:00. Size: 22109 Description: dent It of plate Insured: LE, JACK. Policy_no: 4047608825. Claimant: . Vehicle: 93, ACUR, LEGEND L. VIN: JH4KA7664PC000293. Loss date: 09/22/06. Estimator: ROBERTO ALCALA file://C:\Documents and Settings\u09348\Local Settings\Temp\pdi\0286976590101032-01-... 2/22/2007 Photos for claim no 0286976590101032-01 Page 2 of 12 r Z 2, Photo 3 from Estimate for Claim no 0286976590101032-01 Photo date: 04/12/2006 09:26:31:00. Size: 29159 Description: Insured: LE, JACK. Policy_no: 4047608825. Claimant: . Vehicle: 93, ACUR, LEGEND L. VIN: JH4KA7664PC000293. Loss date: 09/22/06. Estimator: ROBERTO ALCALA file://C:\Documents and Settings\u09348\Local Settings\Temp\pdi\0286976590101032-01-... 2/22/2007 Photos for claim no 0286976590101032-01 Page 3 of 12 � a �' rY Y E✓ a � �' 8 � 2 6 r .y Photo 4 from Estimate for Claim no 0286976590101032-01 Photo date: 04/12/2006 09:26:31:00. Size: 26799 Description: Insured: LE, JACK. Policy_no: 4047608825. Claimant: . Vehicle: 93, ACUR, LEGEND L. VIN: JH4KA7664PC000293. Loss date: 09/22/06. Estimator: ROBERTO ALCALA file://C:\Documents and Settings\u09348\Local Settings\Temp\pdi\0286976590101032-01-... 2/22/2007 Photos for claim no 0286976590101032-01 Page 4 of 12 �a x YE B•ry�dj a 3 Photo 5 from Estimate for Claim no 0286976590101032-01 Photo date: 04/12/2006 09:26:31:00. Size: 29843 Description: Insured: LE, JACK. Policy_no: 4047608825. Claimant: . Vehicle: 93, ACUR, LEGEND L. VIN: JH4KA7664PC000293. Loss date: 09/22/06. Estimator: ROBERTO ALCALA file://C:\Documents and Settings\u09348\Local Settings\Temp\pdi\0286976590101032-01-... 2/22/2007 Photos for claim no 0286976590101032-01 Page 5 of 12 Photo 6 from Estimate for Claim no 0286976590101032-01 Photo date: 04/12/2006 09:26:31:00. Size: 26623 Description: Insured: LE, JACK. Policy_no: 4047608825. Claimant: . Vehicle: 93, ACUR, LEGEND L. VIN: JH4KA7664PC000293. Loss date: 09/22/06. Estimator: ROBERTO ALCALA file://C:\Documents and Settings\u09348\Local Settings\Temp\pdi\0286976590101032-01-... 2/22/2007 Photos for claim no 0286976590101032-01 Page 6 of 12 s ,3 v - a l ri Photo 7 from Estimate for Claim no 0286976590101032-01 Photo date: 04/12/2006 09:26:31:00. Size: 26207 Description: warp/spider cracks upper part f/bmpr Insured: LE, JACK. Policy_no: 4047608825. Claimant: . Vehicle: 93, ACUR, LEGEND L. VIN: JH4KA7664PC000293. Loss date: 09/22/06. Estimator: ROBERTO ALCALA file://C:\Documents and Settings\u09348\Local Settings\Temp\pdi\0286976590101032-01-... 2/22/2007 Photos for claim no 0286976590101032-01 Page 7 of 12 ce , 21 Photo 8 from Estimate for Claim no 0286976590101032-01 Photo date: 04/12/2006 09:26:31:00. Size: 22982 Description: dents/chips rt of plate Insured: LE, JACK. Policy_no: 4047608825. Claimant: . Vehicle: 93, ACUR, LEGEND L. VIN: JH4KA7664PC000293. Loss date: 09/22/06. Estimator: ROBERTO ALCALA file://C:\Documents and Settings\u09348\Local Settings\Temp\pdi\0286976590101032-01-... 2/22/2007 Photos for claim no 0286976590101032-01 Page 8 of 12 mow. q e Photo 9 from Estimate for Claim no 0286976590101032-01 Photo date: 04/12/2006 09:26:31:00. Size: 22035 Description: upd on f/spoiler Insured: LE, JACK. Policy_no: 4047608825. Claimant: . Vehicle: 93, ACUR, LEGEND L. VIN: JH4KA7664PC000293. Loss date: 09/22/06. Estimator: ROBERTO ALCALA file://C:\Documents and Settings\u09348\Local Settings\Temp\pdi\0286976590101032-01-... 2/22/2007 Photos for claim no 0286976590101032-01 Page 9 of 12 Photo 10 from Estimate for Claim no 0286976590101032-01 Photo date: 04/12/2006 09:26:31:00. Size: 29080 Description: Insured: LE, JACK. Policy_no: 4047608825. Claimant: . Vehicle: 93, ACUR, LEGEND L. VIN: JH4KA7664PC000293. Loss date: 09/22/06. Estimator: ROBERTO ALCALA file://C:\Documents and Settings\u09348\Local Settings\Temp\pdi\0286976590101032-01-... 2/22/2007 Photos for claim no 0286976590101032-01 Page 10 of 12 S8 y 3 A Photo 11 from Estimate for Claim no 0286976590101032-01 Photo date: 04/12/2006 09:26:31:00. Size: 26100 Description: Insured: LE, JACK. Policy_no: 4047608825. Claimant: . Vehicle: 93, ACUR, LEGEND L. VIN: JH4KA7664PC000293. Loss date: 09/22/06. Estimator: ROBERTO ALCALA file://C:\Documents and Settings\u09348\Local Settings\Temp\pdi\0286976590101032-01-... 2/22/2007 Photos for claim no 0286976590101032-01 Page 11 of 12 v Photo 12 from Estimate for Claim no 0286976590101032-01 Photo date: 04/12/2006 09:26:31:00. Size: 26964 Description: Insured: LE, JACK. Policy_no: 4047608825. Claimant: . Vehicle: 93, ACUR, LEGEND L. VIN: JH4KA7664PC000293. Loss date: 09/22/06. Estimator: ROBERTO ALCALA file://C:\Documents and Settings\u09348\Local Settings\Temp\pdi\0286976590101032-01-... 2/22/2007 Photos for claim no 0286976590101032-01 Page 12 of 12 F AN g D 7 i file://C:\Documents and Settings\u09348\Local Settings\Temp\pdi\0286976590101032-01-... 2/22/2007 d 0 d N G " oo .^� n P `: c CA t• 7= T1 VCO m P O 0 r C7 c a cr- D cc 5� f t C� LLI N a-eC oo w U I cS C%) a 0 ` to �tAT 3 tl- ii KG �j ✓ y � n Y Fy. '. �n m Government Employees Insurance Company mGEICO General Insurance Company G E ' C C® 0 GEICO Indemnity Company aa 0 GEICO Casualty Company 1-800-841-3000 0 Criterion Insurance Agency,Inc. (Colonial County Mutual Ins.) 4-1 On 11-'ico 'West ';3ox 5,09119 Sari Dieq:)? CA 921550-9119 nny Bailey Fabr.uary 14, 2007 2 6 2006 Contra Costa Co'hlntt' Suite 140 2530 Arnold Drive Martinez, CA 94553-4359 CLAIM INUMBER: 0286976590101013-2 LOSS DATE: INSURED: Jack Le YOUR INSURED: Hercules Fire YOUR CLAIM : 61557 YOUR VEHICLE: unk FORD TAG 4: Explorer D--ac P'--.Ainy' Unk'nown: :qui investigation shows your insures l to be at fault in the ..qccident4 Llaym,-nt for repairs has been iaiade.- Documentation is se honor our claim. a t ta c h c-d. P I ea,- CO' s. Interest: $1j608. 01 -Ens d I s 3 d i i c t I b I e: S`500 TOT.A.L: ;E21108. 01 TaANKS FOR YOUR PROMIPT ATTENTION,, JANET WAtRD (S3143) PAYMENT RECOVERY UNIT 600-654-5896 exti.. Tisioli D699 GEICO General Insarance Company 35 RECEIVED FEB2 8 2007J CLERK BOARD OF SUPERVISORS I CONTRA COSTA Co. PL)EASE REFE'R TO OUR CLAINUMBS-R WHEN WPITIN"G Of? CALLING ABO W]" -THIS CLA.IM CLL14 CLAIM PAYMENT SCREEN REVERSE CLAIM # LOSS ADJR TIME FCC _IRS_FIELD_ ISSUED 0286976590132 09 22 06 F342 X290526 03 12 05 06 'CHECK # TYP ID CO CHECK AMT FEAT C_S_AMT EXP FEAT_C_S_AMT EXP 079378921 A LP 13 1608 . 01 01COL Y 1608 . 01 CLAIMANT JACK Q LE USER ID U79Z50 IN PAYMENT OF INSURED_ _AG_ _ONP_ _TYPE_ COLLISION COVERAGE JACK Q LE P/L LESS $500 DED PAY TO JACK Q LE ENCLOSURE P=POLICE REP F=FORM LETTER C=CORRESPOND L=PROOF/LOSS MAIL TO JACK Q LE M=MISC. I=INVOICES 12 PLATEAU CT R=RELEASES HERCULES, CA 94547-1427 VECTORING IRAN: CLIQ KEY: Page 1 of 8 12/04/2006 AT 09:31 AM 0286976590101032-01 1330 010YOF6X GEICO CONTRA COSTA NORTHERN CALIFORNIA VISIT US AT GEICO.COM SUPPLEMENTS CALL 800-742-2347 P.O. BOX 509060 SAN DIEGO, CA 92150 (925) 698-2672 ESTIMATE OF RECORD WRITTEN BY: ROBERTO ALCALA 12/04/2006 09:22 AM ADJUSTER: F342 EXT: 5483 FCC: INSURED: JACK LE CLAIM #0286976590101032-01 OWNER: JACK LE POLICY #4047608825 ADDRESS: 12 PLATEAU CT DATE OF LOSS: 09/22/2006 AT 12:00 AM HERCULES, CA 94547-1427 TYPE OF LOSS: COLLISION EVENING: (510) 821-2448 POINT OF IMPACT: 6. REAR INSPECT CAR WEST DAY: (925) 674-9700 LOCATION: 165 MASON CIRCLE DRIVE-IN CONCORD, CA 94520-0000 REPAIR CAR WEST AUTO BODY BUSINESS: (925) 674-9700 FACILITY: 165 MASON CIRCLE 4 DAYS TO REPAIR CONCORD, CA 94520 LICENSE # 1993 ACUR LEGEND L 6-3.2L-FI 4D SED BLACK INT: VIN: JH4KA7664PC000293 LIC: 4WQB346 CA PROD DATE: ODOMETER: 140231 AIR CONDITIONING REAR DEFOGGER TILT WHEEL CRUISE CONTROL TELESCOPIC WHEEL INTERMITTENT WIPERS THEFT DETERRENT/ALARM TINTED GLASS BODY SIDE MOLDINGS DUAL MIRRORS ELECTRIC GLASS SUNROOF CLEAR COAT PAINT POWER STEERING POWER BRAKES POWER WINDOWS POWER LOCKS POWER DRIVER SEAT POWER ANTENNA POWER MIRRORS AM RADIO FM RADIO STEREO CASSETTE SEARCH/SEEK EQUALIZER BOSE RADIO ANTI-LOCK BRAKES (4) DRIVER AIR BAG PASSENGER AIR BAG 4 WHEEL DISC BRAKES LEATHER SEATS BUCKET SEATS RECLINE/LOUNGE SEATS AUTOMATIC TRANSMISSION ALUMINUM/ALLOY WHEELS ------------------------------------------------------------------------------- NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT ------------------------------------------------------------------------------- 1 REAR BUMPER 2 0/H REAR BUMPER 2.0 3** REPL RECOND BUMPER COVER 4 DOOR 1 360.00 INCL. 3.0 STANDARD & L 4 ADD FOR CLEAR COAT 1.2 5 FRONT LAMPS 6** REPL QUAL REPL PARTS LT LENS & 1 67 .34 0.2 HOUSING 4 DOOR file://C:\Documents and Settings\u09vl8\Local Settings\Temp\pdi\0286976590101032-01-... 2/19/2007 Page 2 of 8 7 FRONT BUMPER 1 12/04/2006 AT 09:31 AM 0286976590101032-01 1330 010YOF6X ESTIMATE OF RECORD 1993 ACUR LEGEND L 6-3.2L-FI 4D SED BLACK INT: ------------------------------------------------------------------------------- NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT ------------------------------------------------------------------------------- 8 0/H FRONT BUMPER 2.5 9** REPL RECOND BUMPER COVER STANDARD 1 276.00 INCL. 2.5 & L 10 ADD FOR CLEAR COAT 1.0 11# SUBL HAZARDOUS WASTE 1 3.00 X 12# FLEX ADDITIVE 1 8.00 T 13# COLOR MATCH 1 0.3 14# SET UP & MEASURE FRAME 1 2.0 F 15# PULL TO SQUARE LT QRTR 1 1.5 N 16# ***TEARDOWN NEEDED FOR DMG TO 1 LT RAIL ------------------------------------------------------------------------------- SUBTOTALS ==> 714 .34 8.5 7.7 LINE 16 : GAP BETWEEN LT QRT AND LT REAR DOOR OVERLAPPING, ------------------------------------------------------------------------------- ESTIMATE NOTES: ESTIMATE HEADING CORRECT (Y/N)Y VEHICLE ID IS CORRECT (Y/N)Y DRIVEABLE (Y/N)Y TOWED(Y/N)N PAID TOW BILL (Y/N OR WHY)N DEPRECIATION (Y/N) N WHY DEPRECIATION ALT PARTS (Y/N) Y ZERO QUOTES (Y/N)N FLAT RATE ADJUSTMENT (Y/N)N REFINISHED LABOR & MATERIALS (Y/N)Y PRIOR DAMAGE (Y/N)Y REPAIR VS TOTAL:R PAYMENT ISSUED (Y/N) Y CHECK #: COMPANY CODE: 13 ------------------------------------------------------------------------------- PRIOR DAMAGE NOTES: PAINT FADED ALL AROUND VEH, DINGS ON LT QRT,RT QRT, PAINT CHIPS ON RT/LT REAR DOOR EDGES, SCRATCHES ON FRONT SPOILER. PARTS 703.34 file://C:\Documents and Settings\u09vl8\Local Settings\Temp\pdi\0286976590101032-01-... 2/19/2007 Page 3 of 8 BODY LABOR 6.5 HRS @$ 68.00/HR 442.00 PAINT LABOR 7.7 HRS @$ 68.00/HR 523. 60 FRAME LABOR 2.0 HRS @$ 68.00/HR 136.00 PAINT SUPPLIES 7.7 HRS @$ 28.00/HR 215. 60 SUBLET/MISC. 11.00 ---------------------------------------------------- SUBTOTAL $ 2031.54 2 12/04/2006 AT 09:31 AM 0286976590101032-01 1330 010YOF6X ESTIMATE OF RECORD 1993 ACUR LEGEND L 6-3.2L-FI 4D SED BLACK INT: SALES TAX $ 926. 94 @ 8.2500% 76.47 ---------------------------------------------------- TOTAL COST OF REPAIRS $ 2108 .01 ADJUSTMENTS: DEDUCTIBLE 500.00 ---------------------------------------------------- TOTAL ADJUSTMENTS $ 500.00 NET COST OF REPAIRS $ 1608 .01 "WE ARE PROHIBITED BY LAW FROM REQUIRING THAT REPAIRS BE DONE AT A SPECIFIC AUTOMOTIVE REPAIR DEALER. YOU ARE ENTITLED TO SELECT THE AUTO BODY REPAIR SHOP TO REPAIR DAMAGE COVERED BY US. WE HAVE RECOMMENDED AN AUTOMOTIVE REPAIR DEALER THAT WILL REPAIR YOUR DAMAGED VEHICLE. IF YOU AGREE TO USE OUR RECOMMENDED AUTOMOTIVE REPAIR DEALER, 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 INSURANCE POLICY OR AS OTHERWISE ALLOWED BY LAW. IF YOU EXPERIENCE A PROBLEM WITH THE REPAIR OF YOUR VEHICLE, PLEASE CONTACT US IMMEDIATELY FOR ASSISTANCE. " NO SUPPLEMENT WILL BE HONORED UNLESS AUTHORIZED BY GEICO. y AUTHORIZATION MUST BE OBTAINED PRIOR TO ANY REPAIRS ***FOR ALL SUPPLEMENT REQUESTS CALL***1 800 742 2347 THIS ESTIMATE IS NOT AN AUTHORIZATION FOR REPAIR **************************************************************** NOTICE: NEW HIGH STRENGTH STEELS MAY REQUIRE THE USE OF MIG WELDER FOR PROPER REPAIRS. NEW DESIGNS REQUIRE MEASUREMENT TO PROPERLY ALIGN THE VEHICLE. MAKE SURE YOUR SHOP HAS THE RIGHT EQUIPMENT TO REPAIR YOUR VEHICLE. ***** ALL QUALITY RECYCLED PART PRICES REFLECT MARKUP AND ARE PRICED AS CLEAN AND UNDAMAGED ***** NO SUPPLEMENT WIL BE HONORED UNLESS AUTHORIZED BY GEICO DIRECT file://C:\Documents and Settings\u09vl8\Local Settings\Temp\pdi\0286976590101032-01-... 2/19/2007 Page 4 of 8 **************************************************************************** 3 12/04/2006 AT 09:31 AM 0286976590101032-01 1330 010YOF6X ESTIMATE OF RECORD 1993 ACUR LEGEND L 6-3.2L-FI 4D SED BLACK 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 0/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 WARRkNTIES APPLICABLE TO THESE REPLACEMENT PARTS ARE PROVIDED BY THE MANUFACTURER OR file://C:\Documents and Settings\u09vl8\Local Settings\Temp\pdi\0286976590101032-01-... 2/19/2007 Page 5 of 8 DISTRIBUTOR OF THE PARTS, RATHER THAN BY THE ORIGINAL MANUFACTURER OF YOUR VEHICLE. 4 12/04/2006 AT 09:31 AM 0286976590101032-01 1330 010YOF6X ESTIMATE OF RECORD 1993 ACUR LEGEND L 6-3.2L-FI 4D SED BLACK INT: IF QUALITY REPLACEMENT PART (QRP) APPEARS ON THIS ESTIMATE, IT INDICATES THAT THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF ONE OR MORE CRASH PARTS SUPPLIED BY A SOURCE OTHER THAN THE MANUFACTURER OF YOUR MOTOR VEHICLE WARRANTIES, IF ANY, APPLICABLE TO THESE REPLACEMENT CRASH PARTS ARE PROVIDED BY THE PARTS MANUFACTURER OR DISTRIBUTOR RATHER THAN BY THE MANUFACTURER OF YOUR VEHICLE. *** IN ADDITION TO ANY SUCH WARRANTIES, GEICO PROVIDES THE FOLLOWING: **** OWNER LIMITED WARRANTY**** WE WARRANT THAT ALL QUALITY REPLACEMENT BODY PARTS (PARTS NOT MANUFACTURED BY THE MANUFACTURER) IDENTIFIED ON YOUR ESTIMATE, ARE FREE OF DEFECTS IN MATERIAL AND WORKMANSHIP AND MEET GENERALLY ACCEPTED INDUSTRY STANDARDS THIS PARTS AND LABOR WARRANTY WILL BE IN EFFECT FOR AS LONG AS YOU OWN THE VEHICLE DESCRIBED IN THE ESTIMATE. THIS WARRANTY COVERS COST OF THE PART, LABOR TO INSTALL, AND INCIDENTALS SUCH AS PAINT AND MATERIALS AND IS SPECIFICALLY LIMITED TO THOSE ITEMS. THIS WARRANTY DOES NOT COVER LOSS OR DAMAGE THAT IS UNRELATED TO DEFECTS IN THE QUALITY REPLACEMENT PARTS. THIS IS NOT TRANSFERABLE IF ANY QUALTY REPLACEMENT PARTS ARE DEFECTIVE IN EITHER MATERIAL OR WORKMANSHIP, CONTACT YOUR GEICO REPRESENTATIVE. ESTIMATE BASED ON MOTOR CRASH ESTIMATING GUIDE. UNLESS OTHERWISE NOTED ALL ITEMS ARE DERIVED FROM THE GUIDE AET4805 DATABASE DATE 11/2006, CCC DATA DATE 11/2006, AND THE PARTS SELECTED ARE OEM-PARTS MANUFACTURED BY THE VEHICLES ORIGINAL EQUIPMENT MANUFACTURER. OEM PARTS ARE AVAILABLE AT OE/VEHICLE file://C:\Documents and Settings\u09vl8\Local Settings\Temp\pdi\0286976590101032-01-... 2/19/2007 Page 6 of 8 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 GEM'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. 5 12/04/2006 AT 09:31 AM 0286976590101032-01 1330 010YOF6X ESTIMATE OF RECORD 1993 ACUR LEGEND L 6-3.2L-FI 4D SED BLACK INT: ALTERNATE PARTS SUPPLIERS 3 RECOND BUMPER COVER 4 DOOR PART NO. AC1100102R PRICE 360.00 9 RECOND BUMPER COVER STANDAR PART NO. AC1000120R PRICE 276.00 KEYSTONE - COMPLETE (800) 339-5033 4067 WEST SHAW AVE (559) 271-6750 FRESNO, CA 93722 KEYSTONE - COMPLETE (800) 264-7560 3615 NE. 109TH AVE (360) 260-8400 VANCOUVER, WA 98682 KEYSTONE - COMPLETE (800) 421-7866 1754 CEDAR ST. STE A (909) 986-4586 ONTARIO, CA 91761 KEYSTONE - COMPLETE (800) 992-7550 file://C:\Documents and Settings\u09vl8\Local Settings\Temp\pdi\0286976590101032-01-... 2/19/2007 Page 7 of 8 8333 ARJONS DR. SUITE A (858) 547-4401 SAN DIEGO, CA 92126 KEYSTONE - COMPLETE (509) 534-7844 3200 E. TRENT AVE BLDG 3 STE B SPOKANE, WA 99202 KEYSTONE - COMPLETE (800) 263-9727 632 SOUTH ELDORADO ST. (209) 948-1101 STOCKTON, CA 95203 6 QUAL REPL PARTS LT LENS & H PART NO. AC2532101 PRICE 67 .34 COLLISION PARTS NETWORK (800)734-7757 1990 ENTERPRISE BLVD. (916) 372-0692 W. SACRAMENTO, CA 95691 COLLISION PARTS NETWORK (800) 427-5659 321 W. AMADOR ST. (559) 445-4350 FRESNO, CA 93721 COLLISION PARTS NETWORK (800) 427-5659 1269 ALMA COURT (408) 291-0950 SAN JOSE, CA 95112 COLLISION PARTS NETWORK (800) 498-9808 14306 WICKS BLVD. (510) 895-8257 SAN LEANDRO, CA 94578 COLLISION PARTS NETWORK (800) 427-5659 3723 SAN GABRIEL RIVER PARKWAY PICO RIVERA, CA 90660 6 12/04/2006 AT 09:31 AM 0286976590101032-01 1330 010YOF6X ESTIMATE OF RECORD 1993 ACUR LEGEND L 6-3.2L-FI 4D SED BLACK INT: ALTERNATE PARTS USAGE AFTERMARKET PARTS AFTERMARKET SELECTION METHOD: AUTOMATICALLY LIST NO. OF TIMES USER WAS NOTIFIED THAT AN AFTERMARKET PART WAS AVAILABLE: 3 NO. OF AFTERMARKET PARTS THAT APPEAR IN THE FINAL ESTIMATE: 1 file://C:\Documents and Settings\u09vl8\Local Settings\Temp\pdi\0286976590101032-01-... 2/19/2007 Page 8 of 8 OPTIONAL OEM PARTS OPTIONAL OEM SELECTION METHOD: AUTOMATICALLY LIST NO. OF TIMES USER WAS NOTIFIED THAT AN OPTIONAL OEM PART WAS AVAILABLE: 0 NO. OF OPTIONAL OEM PARTS THAT APPEAR IN THE FINAL ESTIMATE: 0 RECONDITIONED PARTS RECONDITIONED SELECTION METHOD: AUTOMATICALLY LIST NO. OF TIMES USER WAS NOTIFIED THAT A RECONDITIONED PART WAS AVAILABLE: 2 NO. OF RECONDITIONED PARTS THAT APPEAR IN THE FINAL ESTIMATE: 2 RECYCLED PARTS NO. OF TIMES USER WAS NOTIFIED THAT A RECYCLED PART WAS AVAILABLE: 2 NO. OF RECYCLED PARTS THAT APPEAR IN THE FINAL ESTIMATE: 0 r 7 file://C:\Documents and Settings\u09v18\Local Settings\Temp\pdi\0286976590101032-01-... 2/19/2007 Photos for claim no 0286976590101032-01 Page 1 of 12 Photo 1 from Estimate for Claim no 0286976590101032-01 Photo date: 04/12/2006 09:26:31:00. Size: 18664 Description: gap overlapping Insured: LE, JACK. Policy_no: 4047608825. Claimant: . Vehicle: 93, ACUR, LEGEND L. VIN: JH4KA7664PC000293. Loss date: 09/22/06. Estimator: ROBERTO ALCALA y i E # Photo 2 from Estimate for Claim no 0286976590101032-01 Photo date: 04/12/2006 09:26:31:00. Size: 22109 Description: dent It of plate Insured: LE, JACK. Policy_no: 4047608825. Claimant: . Vehicle: 93, ACUR, LEGEND L. VIN: JH4KA7664PC000293. Loss date: 09/22/06. Estimator: ROBERTO ALCALA file://C:\Documents and Settings\u09vl8\Local Settings\Temp\pdi\0286976590101032-01-... 2/19/2007 Photos for claim no 0286976590101032-01 Page 2 of 12 5 � d \4 8 .. All Photo 3 from Estimate for Claim no 0286976590101032-01 Photo date: 04/12/2006 09:26:31:00. Size: 29159 Description: Insured: LE, JACK. Policy_no: 4047608825. Claimant: . Vehicle: 93, ACUR, LEGEND L. VIN: JH4KA7664PC000293. Loss date: 09/22/06. Estimator: ROBERTO ALCALA file://C:\Documents and Settings\u09v18\Local Settings\Temp\pdi\0286976590101032-01-... 2/19/2007 Photos for claim no 0286976590101032-01 Page 3 of 12 3 y � Ls9 ? ^ U z K $ k' i N yk' Photo 4 from Estimate for Claim no 0286976590101032-01 Photo date: 04/12/2006 09:26:31:00. Size: 26799 Description: Insured: LE, JACK. Policy -no: 4047608825. Claimant: . Vehicle: 93, ACUR, LEGEND L. VIN: JH4KA7664PC000293. Loss date: 09/22/06. Estimator: ROBERTO ALCALA file://C:\Documents and Settings\u09v18\Local Settings\Temp\pdi\0286976590101032-01-... 2/19/2007 Photos for claim no 0286976590101032-01 Page 4 of 12 4 �E 2 d, 2 Photo 5 from Estimate for Claim no 0286976590101032-01 Photo date: 04/12/2006 09:26:31:00. Size: 29843 Description: Insured: LE, JACK. Policy_no: 4047608825. Claimant: . Vehicle: 93, ACUR, LEGEND L. VIN: JH4KA7664PC000293. Loss date: 09/22/06. Estimator: ROBERTO ALCALA file://C:\Documents and Settings\u09v18\Local Settings\Temp\pdi\0286976590101032-01-... 2/19/2007 Photos for claim no 0286976590101032-01 Page 5 of 12 r 6v. sg < y_ „ S..x Photo 6 from Estimate for Claim no 0286976590101032-01 Photo date: 04/12/2006 09:26:31:00. Size: 26623 Description: Insured: LE, JACK. Policy_no: 4047608825. Claimant: . Vehicle: 93, ACUR, LEGEND L. VIN: JH4KA7664PC000293. Loss date: 09/22/06. Estimator: ROBERTO ALCALA file://C:\Documents and Settings\u09vl8\Local Settings\Temp\pdi\0286976590101032-01-... 2/19/2007 Photos for claim no 0286976590101032-01 Page 6 of 12 , gyp, a T Photo 7 from Estimate for Claim no 0286976590101032-01 Photo date: 04/12/2006 09:26:31:00. Size: 26207 Description: warp/spider cracks upper part f/bmpr Insured: LE, JACK. Policy_no: 4047608825. Claimant: . Vehicle: 93, ACUR, LEGEND L. VIN: JH4KA7664PC000293. Loss date: 09/22/06. Estimator: ROBERTO ALCALA file://C:\Documents and Settings\u09vl8\Local Settings\Temp\pdi\0286976590101032-01-... 2/19/2007 Photos for claim no 0286976590101032-01 Page 7 of 12 P �zf Y° t Y � f, la d 3�� i Photo 8 from Estimate for Claim no 0286976590101032-01 Photo date: 04/12/2006 09:26:31:00. Size: 22982 Description: dents/chips rt of plate Insured: LE, JACK. Policy_no: 4047608825. Claimant: . Vehicle: 93, ACUR, LEGEND L. VIN: JH4KA7664PC000293. Loss date: 09/22/06. Estimator: ROBERTO ALCALA file://C:\Documents and Settings\u09vl8\Local Settings\Temp\pdi\0286976590101032-01-... 2/19/2007 Photos for claim no 0286976590101032-01 Page 8 of 12 �b m 'fix II ryilil Photo 9 from Estimate for Claim no 0286976590101032-01 Photo date: 04/12/2006 09:26:31:00. Size: 22035 Description: upd on f/spoiler Insured: LE, JACK. Policy_no: 4047608825. Claimant: . Vehicle: 93, ACUR, LEGEND L. VIN: JH4KA7664PC000293. Loss date: 09/22/06. Estimator: ROBERTO ALCALA file://C:\Documents and Settings\u09vl8\Local Settings\Temp\pdi\0286976590101032-01-... 2/19/2007 Photos for claim no 0286976590101032-01 Page 9 of 12 Photo 10 from Estimate for Claim no 0286976590101032-01 Photo date: 04/12/2006 09:26:31:00. Size: 29080 Description: Insured: LE, JACK. Policy_no: 4047608825. Claimant: . Vehicle: 93, ACUR, LEGEND L. VIN: JH4KA7664PC000293. Loss date: 09/22/06. Estimator: ROBERTO ALCALA file://C:\Documents and Settings\09v18\Local Settings\Temp\pdi\0286976590101032-01-... 2/19/2007 Photos for claim no 0286976590101032-01 Page 10 of 12 v 3 - Photo 11 from Estimate for Claim no 0286976590101032-01 Photo date: 04/12/2006 09:26:31:00. Size: 26100 Description: Insured: LE, JACK. Policy_no: 4047608825. Claimant: . Vehicle: 93, ACUR, LEGEND L. VIN: JH4KA7664PC000293. Loss date: 09/22/06. Estimator: ROBERTO ALCALA file://C:\Documents and Settings\u09vl8\Local Settings\Temp\pdi\0286976590101032-01-... 2/19/2007 Photos for claim no 0286976590101032-01 Page 11 of 12 Photo 12 from Estimate for Claim no 0286976590101032-01 Photo date: 04/12/2006 09:26:31:00. Size: 26964 Description: Insured: LE, JACK. Policy_no: 4047608825. Claimant: . Vehicle: 93, ACUR, LEGEND L. VIN: JH4KA7664PC000293. Loss date: 09/22/06. Estimator: ROBERTO ALCALA file://C:\Documents and Settings\u09vl8\Local Settings\Temp\pdi\0286976590101032-01-... 2/19/2007 Phot.)s for claim no 0286976590101032-01 Page 12 of 12 4, r rs file://C:\Documents and Settings\u09v18\Local Settings\Temp\pdi\0286976590101032-01-... 2/19/2007 CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: APRIL 03, 2007 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: } Thecopy of this document mailed to California Government Codes. ) you is your notice of the action taken Lillon your claim.by the Board of ; Supervisors. {Paragraph IV below}, Pd�AR 0 1 2007 given Pursuant to Government Code AMOUNT: $175,000.00 Section 913 and 915.4. Please note all COUNTY COUNSEL "Warnings". MARTINEZ CALIF. CLAIMANT: FAROKH JALIL ALGHADR ATTORNEY: UNKNOWN DATE RECEIVED: MARCH 01, 2007 ADDRESS: 2070 NORTH BROADWAY, BY DELIVERY TO CLERK ON:MARCH 01, 2007 WALNUT CREEK, CA 94596 BY MAIL POSTMARKED: HAND DELIVERED FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN CULLEN, MARCH 0I 2007 By: Deputy Dated: ,r _...._ II. FROM: County Counsel TO: Clerk of the Board of Sup6rvisors } This-claim complies substantially with Sections 910 and 910.2. { This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( } Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911:3). { } Other: Dated: By:' �Q� ---duty County Counsel 1.11. FROM:: Clerk of the Board TO: County Counsel (1) County Administrator(2) ( } Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present: (v}! This Claim is rejected in full. ( } Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated��! 'jf 0.9 JOHN 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 with this matter. If'you want to consult an attorney,you should do so immediately. *For Additional Warming 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. a �' " Dated?���i/�� �`' " d.� JOI-IN CULLEN, CLERK By� —�`��eputy Clerk OFFICE OF THE COUNTY COUNSELSILVANO B. MARCHESI 5E L COUNTY OF CONTRA COSTA rj+ �.'U;� COUNTY COUNSEL Administration Building =r 651 Pine Street, 91" Floor -'�w SHARON L. ANDERSON Martinez, California 94553-1229 CHIEF ASSISTANT (925) 335-1800 (925) 646-1078 (fax) "'�� GREGORY C. HARVEY O: - " �`,�, �`Y VALERIE J. RANCHE ; ASSISTANTS �Osr"� COL31a'� G NOTICE OF INSUFFICIENCY AND/OR NON-ACCEPTANCE OF CLAIM TO: Farokh Jalil Alghadr General Delivery 2070 North Broadway Walnut Creek, CA 94596 RE: CLAIM OF FAROKH JALIL ALGHADR Please Take Notice as Follows: The claim you presented against the County of Contra Costa or District governed by the Board of Supervisors fails to comply substantially with the requirements of California Government Code Section 910 and 910.2, or is otherwise insufficient for the reasons checked below: [ ] I. The claim fails to state the name and post office address of the claimant. [ ] 2. The claim fails to state the post office address to which the person presenting the claire desires notices to be sent. [X] 3. The claim fails to state the date, place or other circumstances of the occurrence or transaction which gave rise to the claim asserted. [X] 4. The claim fails to state the name(s) of the public employee(s) causing the injury, damage, or loss, if known. [ ] 5. The claim fails to state whether the arn.ount claimed exceeds ten thousand dollars ($10,000). If the claim totals less than ten thousand dollars ($10,000), the claim fails to state the amount claimed as of the date of presentatioil,'the estimated amount of any prospective injury, damage or loss so far as known, or the basis of computation of the amount claimed. [ ] 6. The claim is not signed by the claimant or by some person on his or her behalf. Farokh Jalil Alghadr Re: Claim of Farokh Jalil Alghadr Page Two [ ] 7. You are required to submit your claim on the proper form, which is enclosed. Please resubmit your claim on the enclosed form, including all the required information. Gov. Code, § 910.4. Please be aware that you have only a limited period of time in which to file an amended claim. See Gov. Code, § 910.6. [ 18. Other: SIL,VANO B. MARCHESI COUNTY COUNSEL By: Monika L. Cooper Deputy County Counsel CERTIFICATE OF SERVICE BY MAIL (Code Civ. Proc., §§ 1012, 1013a, 2015.5; Evid. Code, §§ 641, 664) I am a resident of the State of California, over the age of eighteen years, and not a party to the within action. My business address is Office of the County Counsel, 651 Pine Street, 9th Floor,Martinez, CA 94553-1229. On �Z-i 200Z , I served a true copy of this Notice of Insufficiency and/or Non-Acceptance of Claim by placing the document in a sealed envelope with postage thereon fully prepaid, in the United States mail at Martinez, California addressed to Farokh Jalil Alghadr, General Delivery, 2070 North Broadway, Walnut Creek, CA 94596, as set forth above. I am readily familiar with Office of County Counsel's practice of collection and processing of correspondence for mailing. Under that practice, it would be deposited with the U.S. Postal Service on that same day with postage thereon fully prepaid in the ordinary course of business. I declare under penalty of perjury under the 1 ws of the State of California and the United States of America that the above is true and correct. Executed on _20D , at Martinez, California. ez,l Kathleen O'Connell cc: Clerk of the Board of Supervisors (original) Risk Management Page 2 BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. 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. (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.' RE: Claim By: Reserved for Clerk's filing stamp RECEIVED Against the u-n—ty-oTContra Cos-, MAR SUPERVISC�'S LERK BOCONARD OF -TRACOS-TACO' District) C (Fill int e) The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the sum of$173,000,0() and in support of this claim represents as follows: 1. Whe did the damage or injury occur? (Give exact date and hour) Of(,A M OS6(esm,4 C-eo r% 2. Where did the damage or injury occur? (Include city and county)'�������� (6vvra &:,; ('00/1_(. 3. How did the damage or injury occur? (Give full details; use extra paper if required) 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, or employees causing the damage or injury? � - ---t -- -4 L a LJ ` 6. What damage or injuries do your 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 the estimated amount of any prospective injury or damage.) OJ 8. es and addresses of witness s, doctors,,and hospitals: R . U_5- t-} off\ pC cc uJ3 A�-���PC , �; 9. List- e expenditures you made on account of this accident or injury: DATE TIME AMOUNT ..............................anon n o w a............0 m o■..................n WON M O.....■ 1 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) Name and address of Attorney ) Y/ 1 XaIaL ' ' nature) �1Itj7/J 1/'` fit%J� ' ►�Ja. Additt/ss Telephone No. ) Telephone No. ffo± 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. 0.........................5 0 0 a a a a a 0 0 0 0 0 a a a a 0 a a a 0 a 0 0 0 0002 0.0 0 0...\5 5 0 0 a a 0 a a 0 a 0 a 0 a 0 a 0 1 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.