The URL can be used to link to this page

Home My WebLink About2023-07-24 Rougely, Charlotte1 Gloria Sanchez From:Tim Varon <TVaron@carlwarren.com> Sent:Tuesday, July 25, 2023 4:51 PM To:Gloria Sanchez Cc:Andrea Staehle; Amber Molina Subject:FW: 3049226 - City of Palm Desert - Claim Against the City 899 - Charlotte Rougely Attachments:2023-07-24 Rougely, Charlotte.pdf; 20230725 Progressive Ins (aso Charlotte Rougely) Palm Desert NOTIFICATION LETTER 3049226.pdf Hi Gloria, Please find aƩached a copy of our NoƟficaƟon LeƩer for your records. Have a great day! Tim Tim Varon Claims Supervisor TVaron@carlwarren.com Tel: (657) 622-4287 | Fax: (866) 254-4423 Carl Warren & Company, LLC | A Venbrook Company CA Entity License No: 2607296 PO Box 2411, Tustin, CA, 92781 Because Quality and Integrity Matter... please EMAIL my Supervisor about the service you received. Important Notice: This email (including any attachments) is intended solely for the use of the individual or entity to which it is addressed, and may contain information that is confidential, proprietary, non-public and/or privileged. If you are not the intended reci pient, you are hereby notified that any use, dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this email in error, please delete it from your system and advise the sender immediately. Please be advised that we are unable to bind, endorse or amend coverage via voicemail, email, or facsimile until confirmed in writing by an authorized representative of this office. We accept no liability for any damage caused by any virus transmitted by this email. It is your responsibility to check this email (including any attachments) for viruses. From: Gloria Sanchez <gsanchez@palmdesert.gov> Sent: Monday, July 24, 2023 5:27 PM 2 To: PublicEntity Claims <PublicEntityClaims@carlwarren.com>; Todd Hileman <thileman@palmdesert.gov>; Isra Shah <Isra.Shah@bbklaw.com> Cc: Robert Hargreaves <robert.hargreaves@bbklaw.com>; Chris Escobedo <cescobedo@palmdesert.gov>; Andrea Staehle <astaehle@palmdesert.gov>; Anthony Mejia <amejia@palmdesert.gov>; Tim Varon <TVaron@carlwarren.com> Subject: 3049226 - City of Palm Desert - Claim Against the City 899 - Charlotte Rougely Good aŌernoon, AƩached for your review and/or appropriate acƟon is Claim No. 899 – CharloƩe Rougely. If you have any quesƟons or need addiƟonal informaƟon, please do not hesitate to me. Have a nice evening. Gloria . . M. Gloria Sanchez Records Coordinator 760.776.6354 gsanchez@palmdesert.gov | www.palmdesert.gov 73510 Fred Waring Drive, Palm Desert, CA, 92260 PO Box 2411, Tustin, CA 92781 T: 657-622-4200 | F: 866-254-4423 | www.carlwarren.com CA License #2607296 July 25, 2023 Progressive West Insurance Company Attn: Lindsey M. Baker P.O. Box 94639 Cleveland, OH 44101 RE: Claimant : Progressive West Insurance Company Date of Loss : 4/21/23 Claim Filing Date : 7/24/23 Your File Number : 23-8383089 Our File Number : 3049226 LSV Carl Warren & Company is the claims management company for the City of Palm Desert. The above-captioned claim has been assigned to Laurie Stroud for handling. Ms. Stroud may be reached at 951-550-0493. When our investigation is complete, we will advise you as to whether or not we can recommend settlement. Very Truly Yours, CARL WARREN & CO. Timothy M. Varon Timothy M. Varon Claims Supervisor cc: Member Agency: City of Palm Desert, attn:Gloria Sanchez SRO REI /VE' Payment Address Document Address 24344 Network Place P.O. Box 94639 Chicago, IL 60673-1243 Cleveland, Ohio 44101-9908 Phone: (877)818-0139 Fax: (888) 781-6947 7/7/2023 3:01:00 PM Certified Mail certified 9489 0090 0027 6512 2526 43 Return Receipt Requested City Clerk, City of Palm Desert, 73-510 Fred Waring Drive, Palm Desert, CA 92260 Your Client: POST, JEFFERY M Your Claim Number: N/A Our Insured: ROUGELY, CHARLOTTE Our Claim Number: 23-8383089 Amount Subject to Reimbursement: $6,734.02 Amount of Insured's Deductible: $500.00 Please be advised our insured has incurred out of pocket expenses of $69.71. Please handle this directly with our insured. Please take this as formal notice of our subrogation rights relative to the above -captioned claim. We have completed our investigation into the facts of the above -captioned loss and find that your insured was the proximate cause of the accident. Location of Loss: WASHINGTON ST & EISENHOWER LAQUINTA, CA USA Date and Time of Loss: 04/21/2023, 05:30 PM PT Description of Loss: Please make your draft payable to Progressive West Insurance Company as subrogee of "ROUGELY, CHARLOTTE", in the amount stated above and mail it to the attention of the undersigned at your earliest convenience. All supporting documentation is enclosed. Thank you for your anticipated, prompt attention to this matter. 'ri%f _ /( aher Progressive Subrogation Progressive West Insurance Company Tel. 877-818-0139 Fax. 888-781-6947 GovernmentStatus@email.progressive.com a e r..) Gra r r-s • rri • col Fr ca c"? CLAIM AGAINST THE CITY OF PALM DESERT For Damage(s) to Person(s) or Personal Property ASSIGNED CLAIM NO. Received by: Via: U.S. MAIL Interoffice Mail Over -the -Counter A claim must be filed with the City Clerk of the City of Palm Desert within six (6) months after which the incident or event occurred. Be sure your claim is against the City of Palm Desert, not another public entity. Where space is insufficient, please use additional paper and identify information by paragraph number. Completed claims must be mailed or delivered to the City Clerk, City of Palm Desert, 73-510 Fred Waring Drive, Palm Desert, CA 92260 TO THE HONORABLE MAYOR AND CITY COUNCIL, CITY OF PALM DESERT, CALIFORNIA: The undersigned respectfully submit(s) the following claim and information relative to damage(s) to person(s) and/or personal property: 1. CLAIMANT INFORMATION NAME Progressive West Insurance Company A/S/0 ROUGELY, CHARLOTTE ADDRESS PO BOX 94639 CLEVELAND, OH 44101 PHONE NO. (877 ) R1R-n139 DATE OF BIRTH: DRIVER'S LICENSE NO. 2. Name, telephone number and post office address to which claimant desires notices to be sent, if different than above: 3. Occurrence or event from which the claim arises: a. DATE: 4-21-2023 b. TIME: 5:30 PM WASHINGTON ST & EISENHOWER LAQUINTA, CA USA c. PLACE (Exact and specific location) d. How and under what circumstances did damage or injury occur? Specify the particular occurrence, event, act or omission you claim caused the injury or damage. (Use additional paper if necessary.) Our insured was traveling at Washington St & Eisenhower in LaQuinta. CA when a city Police debt vehicle with plate # 1535464 operated by Post, Jeffery M. failed to maintain proper lookout and control of vehicle, rear -ended, and struck our insureds vehicle, pusning our insured into the vehicle in front of them. we are seeking rcimburocmcnt for our inourcd'a vehicle damaged. e. What particular action by the City, or its employees, caused the alleged damage or injury? Our insured was traveling at Washington St & Eisenhower, in LaQuinta, CA when a city Police dept vehicle with plate # 1535464 operated by Post, Jeffery M. failed to maintain proper lookout and control of vehicle, rear -ended, and stnlcK our Insured s vemcie, pushing our ensued into one vehicle In hoot oT rhem. Jve are seeR1ng reimbursement for our incurod's vohiclo damagos. Page 1 of 2 4. Give a general description of the indebtedness, obligation, injury, damage, or loss incurred so far as it may be known at the time of presentation of the claim. If there were no injuries, state "no injuries": 2023 TOYOTA CAMRY -1RONfREATDAMAGES 5. Give the name(s) of the City employee(s) causing the damage or injury: POST, JEFFERY M 6. Name and address of any other person(s) injured: 7. Name and address of the owner of any damaged property: 8. Damages Claimed: a. Amount claimed as of this date: $ 6,734.02 b. Estimated amount of future costs: $ c. Total amount claimed: $ 6,734.02 d. Basis for computation of amounts claimed (include copies of all bills, invoices, estimates, etc.): ESTIMATES 9. Names and address of all witnesses, hospitals, doctors, etc.: 10. Any additional information, including police reports, which might be helpful in considering this claim: PALM DESERT PD REPORT # CA231110056 WARNING: IT IS A CRIMINAL OFFENSE TO FILE A FALSE CLAIMI (CALIFORNIA PENAL CODE 72 AND CALIFORNIA INSURANCE CODE) I have read the matters and statements made in the above claim, and I know the same to be true of my own knowledge, except as to those matters stated upon information or belief as to such matters, I believe the same to be true. I certify under penalty of perjury that the foregoing is TRUE AND CORRECT. Signed this 7TH day of JULY 2023 at CLEVELAND, OH and". ✓�G• noire/ Progressive West Insurance SUBROGATION SPECIALIST �mpany SIGNATURE OF CLAIMANT SIGNATURE OF CLAIMANT Office of the City Clerk, Palm Desert, California Page 2 of 2 DOC. NO. DATE FILED Form W.9 (Rev. October 2018) Department of the Treasury Internal Revenue Service Request for Taxpayer Identification Number and Certification ► Go to www.lrs.gov/FormW9 for Instructions and the latest Information. Give Form to the requester. Do not send to the IRS. • Print or type. See Specific Instructions on page 3. 1 Name (as shown on your Income tax retum). Name Is required on this line; do not leave this line blank. PROGRESSIVE WEST INSURANCE COMPANY 2 Business name/disregarded entity name, If different from above 3 Check appropriate following seven ❑ Individual/sole single -member • Umited liability Note: Check LLC if the LLC another LLC that Is disregarded • Other (see instructions)► box for federal tax classification of the person whose name is entered on line 1. Check only one of the boxes. 4 Exemptions certain entities, instructions Exempt payee Exemption code Of any) (ropie'n accounts (codes apply only to not individuals; see on page 3): code Of any) 5 proprietor or 0 C Corporation • S Corporation • Partnership • Trust/estate LLC company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership)► the appropriate box In the line above for the tax classification of the single -member owner. is classified as a single -member LLC that Is disregarded from the owner unless the Is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single from the owner should check the appropriate box for the tax classification of its owner. from FATCA reporting Do not check owner of the LLC is -member LLC that maintained outside the U.S.) 5 Address (number, street, and apt. or suite no.) See instructions. 6300 WILSON MILLS RD W33 Requester's name and address (optional) 6 City, state, and ZIP code MAYFIELD VILLAGE, OH 44143 7 List account number(s) here (optional) Part I Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For Individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN, later. Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and Number To Give the Requester for guidelines on whose number to enter. Social security number or Employer Identification number 9 5 2 6 7 6 5 1 9 Part II Certification Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and 3. I am a U.S. citizen or other U.S. person (defined below); and 4. The FATCA code(s) entered on this form Of any) indicating that I am exempt from FATCA reporting is correct. Certification Instructions. You must cross out Item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, Item 2 does not apply. For mortgage Interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than Interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part II, later. Sign Here Signature of U.S. person ► Pansz 7Jo Data► 3/30/22 General Instructions Section references are to the Internal Revenue Code unless otherwise noted. Future developments. For the latest Information about developments related to Form W-9 and Its instructions, such as legislation enacted after they were published, go to www.lrs.gov/FormW9, Purpose of Form An individual or entity (Form W-9 requester) who is required to file an Information retum with the IRS must obtain your correct taxpayer Identification number (TIN) which may be your social security number (SSN), Individual taxpayer Identification number (ITIN), adoption taxpayer Identification number (ATIN), or employer identification number (EIN), to report on an Information return the amount paid to you, or other amount reportable on an Information return. Examples of Information returns include, but are not limited to, the following. • Form 1099-INT (interest earned or paid) • Form 1099-DIV (dividends, including those from stocks or mutual funds) • Form 1099-MISC (various types of income, prizes, awards, or gross proceeds) • Form 1099-B (stock or mutual fund sales and certain other transactions by brokers) • Form 1099-S (proceeds from real estate transactions) • Form 1099-K (merchant card and third party network transactions) • Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T (tuition) • Form 1099-C (canceled debt) • Form 1099-A (acquisition or abandonment of secured property) Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN. If you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding, later. Cat. No. 10231X Form W-9 (Rev. 10-2018) Form W-9 (Rev. 10-2018) Page 2 By signing the filled -out form, you: 1. Certify that the TIN you are giving is correct (or you are waiting for a number to be Issued), 2. Certify that you are not subject to backup withholding, or 3. Claim exemption from backup withholding If you are a U.S. exempt payee. If applicable, you am also certifying that as a U.S. person, your allocable share of any partnership income from a U.S. trade or business is not subject to the withholding tax on foreign partners' share of effectively connected income, and 4. Certify that FATCA code(s) entered on this form Of any) indicating that you are exempt from the FATCA reporting, is correct. See What is FATCA reporting, later, for further information. Note: If you are a U.S. person and a requester gives you a form other than Form W-9 to request your TIN, you must use the requester's form If it is substantially similar to this Form W-9. Definition of a U.S. person. For federal tax purposes, you are considered a U.S. person If you are: • An Individual who is a U.S. citizen or U.S. resident allen; • A partnership, corporation, company, or association created or organized in the United States or under the laws of the United States; • An estate (other than a foreign estate); or • A domestic trust (as defined in Regulations section 301.7701-7). Special rules for partnerships. Partnerships that conduct a trade or business in the United States are generally required to pay a withholding tax under section 1446 on any foreign partners' share of effectively connected taxable income from such business. Further, in certain cases where a Form W-9 has not been received, the rules under section 1446 require a partnership to presume that a partner is a foreign person, and pay the section 1446 withholding tax. Therefore, if you are a U.S. person that is a partner in a partnership conducting a trade or business in the United States, provide Form W-9 to the partnership to establish your U.S. status and avoid section 1446 withholding on your share of partnership Income. In the cases below, the following person must give Form W-9 to the partnership for purposes of establishing Its U.S. status and avoiding withholding on its allocable share of net Income from the partnership conducting a trade or business in the United States. • In the case of a disregarded entity with a U.S. owner, the U.S. owner of the disregarded entity and not the entity; • In the case of a grantor trust with a U.S. grantor or other U.S. owner, generally, the U.S. grantor or other U.S. owner of the grantor trust and not the trust; and • In the case of a U.S. trust (other than a grantor trust), the U.S. trust (other than a grantor trust) and not the beneficiaries of the trust. Foreign person. If you are a foreign person or the U.S. branch of a foreign bank that has elected to be treated as a U.S. person, do not use Form W-9. Instead, use the appropriate Form W-8 or Form 8233 (see Pub. 515, Withholding of Tax on Nonresident Arens and Foreign Entities). Nonresident alien who becomes a resident alien. Generally, only a nonresident alien individual may use the terms of a tax treaty to reduce or eliminate U.S. tax on certain types of income. However, most tax treaties contain a provision known as a "saving clause." Exceptions specified in the saving clause may permit an exemption from tax to continue for certain types of income even after the payee has otherwise become a U.S. resident alien for tax purposes. If you are a U.S. resident alien who is relying on an exception contained in the saving clause of a tax treaty to claim an exemption from U.S. tax on certain types of Income, you must attach a statement to Form W-9 that specifies the following five items. 1. The treaty country. Generally, this must be the same treaty under which you claimed exemption from tax as a nonresident alien. 2. The treaty article addressing the income. 3. The article number (or location) in the tax treaty that contains the saving clause and its exceptions. 4. The type and amount of income that qualifies for the exemption from tax. 5. Sufficient facts to Justify the exemption from tax under the terms of the treaty article. Example. Article 20 of the U.S.-China income tax treaty allows an exemption from tax for scholarship Income received by a Chinese student temporarily present in the United States. Under U.S. law, this student will become a resident alien for tax purposes if his or her stay in the United States exceeds 5 calendar years. However, paragraph 2 of the first Protocol to the U.S.-China treaty (dated April 30, 1984) allows the provisions of Article 20 to continue to apply even after the Chinese student becomes a resident alien of the United States. A Chinese student who qualifies for this exception (under paragraph 2 of the first protocol) and is relying on this exception to claim an exemption from tax on his or her scholarship or fellowship Income would attach to Form W-9 a statement that includes the Information described above to support that exemption. If you are a nonresident alien or a foreign entity, give the requester the appropriate completed Form W-8 or Form 8233. Backup Withholding What Is backup withholding? Persons making certain payments to you must under certain conditions withhold and pay to the IRS 24% of such payments. This is called "backup withholding." Payments that may be subject to backup withholding include interest, tax-exempt Interest, dividends, broker and barter exchange transactions, rents, royalties, nonemployee pay, payments made in settlement of payment card and third party network transactions, and certain payments from fishing boat operators. Real estate transactions are not subject to backup withholding. You will not be subject to backup withholding on payments you receive If you give the requester your correct TIN, make the proper certifications, and report all your taxable interest and dividends on your tax return. Payments you receive will be subject to backup withholding if: 1. You do not furnish your TIN to the requester, 2. You do not certify your TIN when required (see the instructions for Part II for details), 3. The IRS tells the requester that you furnished an incorrect TIN, 4. The IRS tells you that you are subject to backup withholding because you did not report all your interest and dividends on your tax retum (for reportable interest and dividends only), or 5. You do not certify to the requester that you are not subject to backup withholding under 4 above (for reportable interest and dividend accounts opened after 1983 only). Certain payees and payments are exempt from backup withholding. See Exempt payee code, later, and the separate Instructions for the Requester of Form W-9 for more information. Also see Special rules for partnerships, earlier. What is FATCA Reporting? The Foreign Account Tax Compliance Act (FATCA) requires a participating foreign financial institution to report all United States account holders that are specified United States persons. Certain payees are exempt from FATCA reporting. See Exemption from FATCA reporting code, later, and the Instructions for the Requester of Form W-9 for more information. Updating Your Information You must provide updated information to any person to whom you claimed to be an exempt payee if you are no longer an exempt payee and anticipate receiving reportable payments in the future from this person. For example, you may need to provide updated information if you are a C corporation that elects to be an S corporation, or if you no longer are tax exempt. In addition, you must furnish a new Form W-9 if the name or TIN changes for the account; for example, if the grantor of a grantor trust dies. Penalties Failure to furnish TIN. If you fail to furnish your correct TIN to a requester, you are subject to a penalty of $50 for each such failure unless your failure is due to reasonable cause and not to willful neglect. Civil penalty for false information with respect to withholding. If you make a false statement with no reasonable basis that results In no backup withholding, you are subject to a $500 penalty. Form W-9 (Rev. 10-2018) Page 3 Criminal penalty for falsifying information. Willfully falsifying certifications or affirmations may subject you to criminal penalties Including fines and/or imprisonment. Misuse of TINs. If the requester discloses or uses TINs in violation of federal law, the requester may be subject to civil and criminal penalties. Specific Instructions Line 1 You must enter one of the following on this line; do not leave this line blank. The name should match the name on your tax retum. If this Form W-9 Is for a Joint account (other than an account maintained by a foreign financial Institution (FFI)), list first, and then circle, the name of the person or entity whose number you entered In Part I of Form W-9. If you are providing Form W-9 to an FFI to document a joint account, each holder of the account that is a U.S. person must provide a Form W-9. a. Individual. Generally, enter the name shown on your tax return. If you have changed your last name without Informing the Social Security Administration (SSA) of the name change, enter your first name, the last name as shown on your social security card, and your new last name. Note: !TIN applicant: Enter your individual name as it was entered on your Form W-7 application, line 1 a. This should also be the same as the name you entered on the Form 1040/1040A/1040EZ you filed with your application. b. Sole proprietor or single -member LLC. Enter your individual name as shown on your 1040/1040A/1040EZ on line 1. You may enter your business, trade, or "doing business as" (DBA) name on line 2. c. Partnership, LLC that Is not a single -member LLC, C corporation, or S corporation. Enter the entity's name as shown on the entity's tax return on line 1 and any business, trade, or DBA name on line 2. d. Other entitles. Enter your name as shown on required U.S. federal tax documents on line 1. This name should match the name shown on the charter or other legal document creating the entity. You may enter any business, trade, or DBA name on line 2. e. Disregarded entity. For U.S. federal tax purposes, an entity that Is disregarded as an entity separate from its owner is treated as a "disregarded entity." See Regulations section 301.7701-2(c)(2)(110. Enter the owner's name on line 1. The name of the entity entered on line 1 should never be a disregarded entity. The name on line 1 should be the name shown on the income tax return on which the Income should be reported. For example, if a foreign LLC that is treated as a disregarded entity for U.S. federal tax purposes has a single owner that is a U.S. person, the U.S. owner's name is required to be provided an line 1. If the direct owner of the entity is also a disregarded entity, enter the first owner that is not disregarded for federal tax purposes. Enter the disregarded entity's name on line 2, "Business name/disregarded entity name." If the owner of the disregarded entity is a foreign person, the owner must complete an appropriate Form W-8 instead of a Form W-9. This is the case even if the foreign person has a U.S. TIN. Line 2 If you have a business name, trade name, DBA name, or disregarded entity name, you may enter It on line 2. Line 3 Check the appropriate box on line 3 for the U.S. federal tax classification of the person whose name is entered on line 1. Check only one box on line 3. IF the entity/person on line 1 Is a(n) ... THEN check the box for ... • Corporation Corporation • Individual • Sole proprietorship, or • Single -member limited liability company (LLC) owned by an individual and disregarded for U.S. federal tax purposes. IndividuaVsole proprietor or single- member LLC • LLC treated as a partnership for U.S. federal tax purposes, • LLC that has filed Form 8832 or 2553 to be taxed as a corporation, or • LLC that is disregarded as an entity separate from Its owner but the owner is another LLC that Is not disregarded for U.S. federal tax purposes. Limited liability company and enter the appropriate tax classification. (P= Partnership; C= C corporation; or S= 5 corporation) • Partnership Partnership • Trust/estate Trust/estate Line 4, Exemptions If you are exempt from backup withholding and/or FATCA reporting, enter in the appropriate space on line 4 any code(s) that may apply to you. Exempt payee code. • Generally, Individuals (Including sole proprietors) are not exempt from backup withholding. • Except as provided below, corporations are exempt from backup withholding for certain payments, including interest and dividends. • Corporations are not exempt from backup withholding for payments made in settlement of payment card or third party network transactions. • Corporations are not exempt from backup withholding with respect to attorneys' fees or gross proceeds pald to attorneys, and corporations that provide medical or health care services are not exempt with respect to payments reportable on Form 1099-MISC. The following codes identify payees that are exempt from backup withholding. Enter the appropriate code in the space in line 4. 1—An organization exempt from tax under section 501(a), any IRA, or a custodial account under section 403(b)(7) if the account satisfies the requirements of section 4010)(2) 2—The United States or any of its agencies or Instrumentalities 3—A state, the District of Columbia, a U.S. commonwealth or possession, or any of their political subdivisions or Instrumentalities 4—A foreign government or any of Its political subdivisions, agencies, or instrumentalities 5—A corporation 6—A dealer in securities or commodities required to register in the United States, the District of Columbia, or a U.S. commonwealth or possession 7—A futures commission merchant registered with the Commodity Futures Trading Commission 8—A real estate investment trust 9—An entity registered at all times during the tax year under the Investment Company Act of 1940 10—A common trust fund operated by a bank under section 584(a) 11—A financial institution 12—A middleman known in the investment community as a nominee or custodian 13—A trust exempt from tax under section 664 or described in section 4947 Form W-9 (Rev. 10-201 e) Page 4 The following chart shows types of payments that may be exempt from backup withholding. The chart applies to the exempt payees listed above, 1 through 13. IF the payment is for ... THEN the payment Is exempt for... Interest and dividend payments All exempt payees except for 7 Broker transactions Exempt payees 1 through 4 and 6 through 11 and all C corporations. S corporations must not enter an exempt payee code because they are exempt only for sales of noncovered securities acquired prior to 2012. Barter exchange transactions and patronage dividends Exempt payees 1 through 4 Payments over $600 required to be reported and direct sales over $5,000' Generally, exempt payees 1 through 52 Payments made in settlement of payment card or third party network transactions Exempt payees 1 through 4 ' See Form 1099-MISC, Miscellaneous Income, and Its Instructions. 2 However, the following payments made to a corporation and reportable on Form 1099-MISC are not exempt from backup withholding: medical and health care payments, attorneys' fees, gross proceeds paid to an attorney reportable under section 6045(f), and payments for services paid by a federal executive agency. Exemption from FATCA reporting code. The following codes Identify payees that are exempt from reporting under FATCA. These codes apply to persons submitting this form for accounts maintained outside of the United States by certain foreign financial Institutions. Therefore, If you are only submitting this form for an account you hold In the United States, you may leave this field blank Consult with the person requesting this form If you are uncertain if the financial institution is subject to these requirements. A requester may indicate that a code is not required by providing you with a Form W-9 with "Not Applicable" (or any similar indication) written or printed on the line for a FATCA exemption code. A —An organization exempt from tax under section 501(a) or any individual retirement plan as defined In section 7701(a)(37) B—The United States or any of its agencies or instrumentalities C—A state, the District of Columbia, a U.S. commonwealth or possession, or any of their political subdivisions or Instrumentalities D—A corporation the stock of which is regularly traded on one or more established securities markets, as described in Regulations section 1.1472-1(c)(1)(1) E—A corporation that Is a member of the same expanded affiliated group as a corporation described in Regulations section 1.1472-1(c)(1)(I) F—A dealer in securities, commodities, or derivative financial Instruments (Including notional principal contracts, futures, forwards, and options) that is registered as such under the laws of the United States or any state G—A real estate investment trust H—A regulated investment company as defined in section 851 or an entity registered at all times during th'e tax year under the investment Company Act of 1940 I —A common trust fund as defined in section 584(a) J—A bank as defined In section 581 K—A broker L—A trust exempt from tax under section 664 or described in section 4947(a)(1) M—A tax exempt trust under a section 4030) plan or section 457(g) plan Note: You may wish to consult with the financial institution requesting this form to determine whether the FATCA code and/or exempt payee code should be completed. Line 5 Enter your address (number, street, and apartment or suite number). This Is where the requester of this Form W-9 will mail your Information returns. If this address differs from the one the requester already has on file, write NEW at the top. If a new address is provided, there is still a chance the old address will be used until the payor changes your address in their records. Line 6 Enter your city, state, and ZIP code. Part I. Taxpayer Identification Number (TIN) Enter your TIN In the appropriate box. If you are a resident alien and you do not have and are not eligible to get an SSN, your TIN Is your IRS Individual taxpayer identification number (MN). Enter it in the social security number box. If you do not have an ITIN, see How to get a TIN below. If you are a sole proprietor and you have an EIN, you may enter either your SSN or EIN. If you are a single -member LLC that is disregarded as an entity separate from its owner, enter the owner's SSN (or EIN, if the owner has one). Do not enter the disregarded entity's EIN. If the LLC is classified as a corporation or partnership, enter the entity's EIN. Note: See What Name and Number To Give the Requester, later, for further clarification of name and TIN combinations. How to get a TIN. If you do not have a TIN, apply for one immediately. To apply for an SSN, get Form 5S-5, Application for a Social Security Card, from your local SSA office or get this form online at www.SSA.gov. You may also get this form by calling 1-800-772-1213. Use Form W-7, Application for IRS Individual Taxpayer Identification Number, to apply for an ITIN, or Form SS-4, Application for Employer Identification Number, to apply for an EIN. You can apply for an EIN online by accessing the IRS website at www.irs.gov/Businesses and clicking on Employer identification Number (EIN) under Starting a Business. Go to www.irs.gov/Forms to view, download, or print Form W-7 and/or Form SS-4. Or, you can go to www.irs.gov/OrderForms to place an order and have Form W-7 and/or SS-4 mailed to you within 10 business days. If you are asked to complete Form W-9 but do not have a TIN, apply for a TIN and write "Applied For" In the space for the TIN, sign and date the form, and give it to the requester. For Interest and dividend payments, and certain payments made with respect to readily tradable Instruments, generally you will have 60 days to get a TIN and give it to the requester before you are subject to backup withholding on payments. The 60-day rule does not apply to other types of payments. You will be subject to backup withholding on all such payments until you provide your TIN to the requester. Note: Entering "Applied For" means that you have already applied for a TIN or that you intend to apply for one soon. Caution: A disregarded U.S. entity that has a foreign owner must use the appropriate Form W-8. Part II. Certification To establish to the withholding agent that you are a U.S. person, or resident alien, sign Form W-9. You may be requested to sign by the withholding agent even If Item 1, 4, or 5 below indicates otherwise. For a Joint account, only the person whose TIN Is shown in Part I should sign (when required). In the case of a disregarded entity, the person Identified on line 1 must sign. Exempt payees, see Exempt payee code, earlier. Signature requirements. Complete the certification as Indicated in items 1 through 5 below. Form W-9 (Rev. 10-2018) Page 5 1. Interest, dividend, and barter exchange accounts opened before 1984 and broker accounts considered active during 1983. You must give your correct TIN, but you do not have to sign the certification. 2. Interest, dividend, broker, and barter exchange accounts opened after 1983 and broker accounts considered Inactive during 1983. You must sign the certification or backup withholding will apply. If you are subject to backup withholding and you are merely providing your correct TIN to the requester, you must cross out item 2 in the certification before signing the form. 3. Real estate transactions. You must sign the certification. You may cross out item 2 of the certification. 4. Other payments. You must give your correct TIN, but you do not have to sign the certification unless you have been notified that you have previously given an incorrect TIN. "Other payments" Include payments made in the course of the requester's trade or business for rents, royalties, goods (other than bills for merchandise), medical and health care services (Including payments to corporations), payments to a nonemployee for services, payments made In settlement of payment card and third party network transactions, payments to certain fishing boat crew members and fishermen, and gross proceeds paid to attomeys (Including payments to corporations). 5. Mortgage Interest paid by you, acquisition or abandonment of secured property, cancellation of debt, qualified tuition program payments (under section 529), ABLE accounts (under section 529A), IRA, Coverdell ESA, Archer MSA or HSA contributions or distributions, and pension distributions. You must give your correct TIN, but you do not have to sign the certification. What Name and Number To Give the Requester For this type of account: 1. Individual 2. Two or more Individuals Qolnt account) other than an account maintained by an FFI 3. Two or more U.S. persons (Joint account maintained by an FFI) 4. Custodial account of a minor (Uniform Gift to Minors Act) 5. a. The usual revocable savings trust (grantor Is also trustee) b. So-called trust account that Is not a legal or valid trust under state law 8. Sole proprietorship or disregarded entity awned by an Individual 7. Grantor trust filing under Optional Form 1099 Filing Method 1 (see Regulations section 1.671.4(b)(2)(1) (A)) Give name and SSN of: The Individual The actual owner of the account or, if combined funds, the first Individual on the accounts Each holder of the account The minorz The grantor -trustees The actual owners The owner3 The granter For this type of account: 8. Disregarded entity not owned by an Individual 9. A valid trust, estate, or pension trust 10. Corporation or LLC electing corporate status on Form 8832 or Form 2553 11. Association, club, religious, charitable, educational, or other tax- exempt organization 12. Partnership or multi -member LLC 13. A broker or registered nominee Give name and EIN of: The owner Legal entity° The corporation The organization The partnership The broker or nominee For this type of account: 14. Account with the Department of Agriculture In the name of a public entity (such as a state or local government, school district, or prison) that receives agricultural program payments 16. Grantor trust filing under the Form 1041 Flling Method or the Optional Form 1099 Filing Method 2 (see Regulations section 1.871-4(b)(2)(1)(B)) Give name and EIN of: The public entity The trust 1 List first and circle the name of the person whose number you furnish. If only one person on a joint accoun has an SSN, that person's number must be furnished. 2 Circle the minor's name and furnish the minor's SSN. 3 You must show your Individual name and you may also enter your business or DBA name on the "Business name/disregarded entity" name line. You may use either your SSN or EIN (if you have one), but the IRS encourages you to use your SSN. 4 List first and circle the name of the trust, estate, or pension trust. (Do not fumish the TIN of the personal representative or trustee unless the legal entity Itself is not designated in the account title.) Also see Special rules for partnerships, earlier. `Note: The grantor also must provide a Form W-9 to trustee of trust. Note: If no name Is circled when more than one name is listed, the number will be considered to be that of the first name listed. Secure Your Tax Records From Identity Theft Identity theft occurs when someone uses your personal information such as your name, SSN, or other identifying information, without your permission, to commit fraud or other crimes. An identity thief may use your SSN to get a jab or may file a tax return using your SSN to receive a refund. To reduce your risk: • Protect your SSN, • Ensure your employer is protecting your SSN, and • Be careful when choosing a tax preparer. If your tax records are affected by Identity theft and you receive a notice from the IRS, respond right away to the name and phone number printed on the IRS notice or letter. If your tax records are not currently affected by identity theft but you think you are at risk due to a lost or stolen purse or wallet, questionable credit card activity or credit report, contact the IRS Identity Theft Hotline at 1-800-908-4490 or submit Form 14039. For more information, see Pub. 5027, Identity Theft Information for Taxpayers. Victims of Identity theft who are experiencing economic harm or a systemic problem, or are seeking help In resolving tax problems that have not been resolved through normal channels, may be eligible for Taxpayer Advocate Service (TAS) assistance. You can reach TAS by calling the TAS toil -free case intake line at 1-877-777-4778 or TTY/TDD 1-800-829-4059. Protect yourself from suspicious emalls or phishing schemes. Phishing is the creation and use of email and websites designed to mimic legitimate business emalls and websites. The most common act is sending an email to a user falsely claiming to be an established legitimate enterprise In an attempt to scam the user Into surrendering private information that will be used for identity theft. Farm W-9 (Rev.10-2018) Page 6 The IRS does not Initiate contacts with taxpayers via emails. Also, the IRS does not request personal detailed information through email or ask taxpayers for the PIN numbers, passwords, or similar secret access Information for their credit card, bank, or other financial accounts. If you receive an unsolicited email claiming to be from the IRS, forward this message to phishing@irs.gov. You may also report misuse of the IRS name, logo, or other IRS property to the Treasury Inspector General for Tax Administration (TIGTA) at 1-800-366-4484. You can forward suspicious smalls to the Federal Trade Commission at spam@uce.gov or report them at www.ftc.gov/complaint. You can contact the FTC at www.ltc.gov/idthef or 877-IDTHEFT (877-438-4338). If you have been the victim of Identity theft, see www.IdentifyTheftgov and Pub. 5027. Visit wwwiragov/ldentityThet to learn more about Identity theft and how to reduce your risk. Privacy Act Notice Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons (including federal agencies) who are required to file Information returns with the IRS to report interest, dividends, or certain other Income paid to you; mortgage interest you paid; the acquisition or abandonment of secured property; the cancellation of debt; or contributions you made to an IRA, Archer MSA, or HSA. The person collecting this form uses the information on the form to file information returns with the IRS, reporting the above information. Routine uses of this information Include giving it to the Department of Justice for civil and criminal litigation and to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use In administering their laws. The information also may be disclosed to other countries under a treaty, to federal and state agencies to enforce civil and criminal laws, or to federal law enforcement and Intelligence agencies to combat terrorism. You must provide your TIN whether or not you are required to file a tax return. Under section 3406, payers must generally withhold a percentage of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to the payer. Certain penalties may also apply for providing false or fraudulent Information. 7/7/23, 2:58 PM Claim Payment Detail ( 23-8383089 ) Payment Information Claim Payment Detail Disbursement Number: 787621506 EFT Trace Number: 461542 Pay to the Order of: ENTERPRISE RENT A CAR CO Mailing Address: PO BOX 840086 KANSAS CITY, MO 64184 USA In Payment Of: Progressive Invoice Number: 112078427 Total Amount: $1,450.00 Invoice Number: 112078427 evieweo summary Issuing Rep: A139425 Issue Date: 06-21-23 Last Updated Rep: A139425 Approved By: Review Date: Reviewed By: Bank Information Type: Stop Reason: Stop Date: Loss Bank Code: CTB Cleared: 06-24-23 Exposure Detail: RENTAL Party Name: ROUGELY, DAMARR Property Description: 23 TOYOTA CAMRY Payment Type: FINAL PAYMENT Amount Paid: $1,450.00 Deductible Taken: $0.00 Property Damage: $0.00 Rental: $1,450.00 https://claclaimsum-web-prod.prod.glb.pgrcloud.app/20238383089/claim-payment-inquiry 1/1 7/7/23, 2:58 PM ARMS® -Automated Rental Management System ARMSPROGRESSIVE Rental Company: ENTERPRISE RENT -A -CAR Invoice: D9L55GN-3263 Alternate Invoice Number: 9L55GN Bill To: PRO77SL PROGRESSIVE ATTN: LOSS REPORTING _UNASSIGNED 6300 WILSON MILLS 4 FL, 4 CORE MAYFIELD VILLAGE, OH 44143 RENTER INFORMATION: Renter: ROUGELY, DAMARR RENTAL INFORMATION: Rental Branch Location: ENTERPRISE RENT -A -CAR (3263) 68350 E PALM CANYON DR CATHEDRAL CITY, CA 922345414 (760) 328-9377 ADDITIONAL CLAIM INFORMATION: Claim Number :23-8383089 Claim Type: Insured Vehicle Condition: Driveable Date Of Loss: Insured Name: Owner's Vehicle: 2020 OTHERITOYOTA OTHERICAMRY Additional Driver: Repair Facility: CALIBER #1035 COACHELLA VALLEY CATHEDRAL CITY, CA 922345326 (760) 328-5669 VEHICLES RENTED: RENTAL DETAIL: Rental Period: 4/27/23 to 5/25/23 (29 days) Billed Period: 4/27/23 to 5/25/23 (29 days) Products and Services TIME & DISTANCE Quantity Rate Amount 29 46.99 $1,362.71 VEHICLE LICENSE RECOVERY FEE VEHICLE LICENSE RECOVERY FEE SALES TAX Total Charges: Less Amount Received: Total Amount Due: 28 1.30 $36.40 1.36 $1.36 1 8.75% $119,24 $1,519.71 $69.71 $1,450.00 Effective Date and Time Year Make Model VIN Starting Mileage Ending Mileage Mileage Rate Charged 4/27/23 9:38AM 2021 CHRY PACH 2C4RC1L74MR578160 36492 36499 7 $46.99 4/27/23 11:22 AM 2022 HOND PASS 5FNYF7H53NB005485 15122 15129 7 $46.99 4/27/23 11:26AM 2021 CHRY PACH 2C4RC1L74MR578160 34022 36534 2512 $46.99 4/27/23 4:57 PM 2022 MAZD CX5 JM3KFBXY8N0647744 8239 9038 799 $46.99 Rental Invoice Please Return This Portion with Remittance Make Payment To: ENTERPRISE RENT -A -CAR P.O. BOX 840086 KANSAS CITY, MO 64184-0086 Federal ID: 43-0724835 Total Charges: $1,519.71 Less Amount Received: $69.71 Total Amount Due $1,450.00 Please include on your check: Invoice: D9L55GN-3263 https://www.armsweb.com/armsweb/closedcustomerfile.do 1/1 7/7/23, 2:58 PM Claim Payment Detail ( 23-8383089 ) - Payment Information Claim Payment Detail Disbursement Number: EFT Trace Number: Pay to the Order of: Mailing Address: In Payment Of: 787547714 405400 CALIBER COLLISION 36705 PEREZ RD CATHEDRAL CITY, CA 92234 USA Progressive Invoice Number: 111959309 Total Amount: $4,784.02 Invoice Number: 111959309 - Kevlewe n summary Issuing Rep: A135888 Issue Date: 05-24-23 Last Updated Rep: A135888 Approved By: Review Date: Reviewed By: Bank Information Type: Stop Reason: Stop Date: Loss Bank Code: CTB Cleared: 05-27-23 Exposure Detail: COLL Party Name: ROUGELY, DAMARR Property Description: 23 TOYOTA CAMRY Payment Type: FINAL. PAYMENT Amount Paid: $4,784.02 Deductible Taken: $500.00 Property Damage: $0.00 Rental: $0.00 https://claclaimsum-web-prod.prod.glb. pgrcloud.app/20238383089/claim-payment-Inquiry Owner DAMARR ROUGELY Supplemented By Enrique Regla enrique.regla@calibercollision.com Caliber - Coachella Valley - 1035 36705 Perez Rd, Cathedral City, CA 92234-5326 Office: (760) 328-5669 Fax: (760) 770-3035 1035Assignments@CaliberCollision.com Insured CHARLOTTE ROUGELY Underwriter Progressive West Ins Co FINAL Estimate ID 23-8383089-01 51 Claim Number 23-8383089-01 Appraiser Enrique Regla enrique.regla@calibercollision.com Progressive West Ins Co Insurance Company Progressive West Ins Co Reported Date 04/25/2023 Claim Number 23-8383089-01 Loss Date 04/21/2023 Adjuster NOBLE WOODS (858) 609-2751 (Work) a157130@progressive.com Inspection Site Caliber Collision- Coachella V alley (SWE) 36705 Perez Rd Cathedral City, CA 92234 (760) 328-5669 (Mobile) Deductible 500.00 - Not Waived 2023Toyota Camry SE 4 Door Sedan 2.5L4 CyI Gas Injected 8 Speed Auto Trans FWD Exterior Color 1K6 Drivable Yes Primary Point of Impact Rear (6) Options Air Conditioning Automatic Headlights Daytime Running Lights Electronic Stability Control Left -Curtain Air Bag Power Remote Mirror Rearview Camera Steering Wheel Mounted Audio Control Traction Control/Electronic License CA-CK16R68 Odometer 4083 Secondary Point(s) of Impact Front (12) Alum/Alloy Wheels Ancillary Input Driver Seat With Power Lumbar Support First Row Bucket Seat MP3 Player Power Steering Remote Decklid Or Tailgate Release Telematic Systems Trip Computer VIN 4T1T11AK9PU114836 Production Date 11/2022 AM -FM Stereo Bluetooth Wireless Connectivity Driver -Front Air Bag Heated Mirror Passenger -Front Air Bag Power Windows Satellite Radio Theft Deterrent Sys. Condition Good Mitchell Service Code 912022 Anti -Lock Brake Sys. (ABS) Cloth Seat Dual A/C Keyless Entry System Power Door Locks Rear Bench Seat Second Row Side Airbag With Head Protection Tilt Steering Wheel Auto Air Condition Cruise Control Electric Defogger Leather Steering Wheel Power Driver Seat Rear Spoiler Side Airbags Tire Pressure Monitoring System Committedai 5/23/2023 02:16 PM Vex Mitchell Estimating23.1 OEM APil_23 V Mitchell Cloud Estimating Copyright 1994-2023 Mitchell International. Inc. All nights Reserved Printed On 5/23/2023 02:16 PM Profile Page 1 of 9 CALIFORNIA ALL PART TYPES ProSWE 17.00VeNm 17.0 CHARLOTTE ROUGELY 12023 Toyota Camry SE Parts Profile Parts Profile Version CALIFORNIA ALL PARTTYPES NW 4.0 SWE LABOR PART Line# Description Operation Type Front Bumper 1 200426 Frt Bumper Cover Remove/ Body INC# Existing Install 2 AUTO Frt Bumper Cover Assy Overhaul Body 3.4# Existing 3 204821 Frt Bumper Cover Repair Body 4.0'# Existing 4 AUTO Frt Bumper Cover Refinish Refinish 2.8 C Existing Only 5 201652 R Frt Bumper Pad Remove/ Body INCr Existing Install 6 201653 LFrt Bumper Pad Remove/ Body INCr Existing Install 7 205337 R Frt Bumper Fog Lamp Remove / Body INC New 81481-06220 1 $176.85 Yes Opening Cover Replace 8 205338 L Frt Bumper Fog Lamp Remove / Body INCr Existing Opening Cover Install 9 203664 Frt Upr Bumper Seal Remove/ Body INCr Existing Install 10 204992 Frt Bumper Grille Remove/ Body INC New 53102-06390 1 $156.07 Yes Replace 11 200470 RFrt Bumper Moulding Remove/ Body INCr Existing Install 12 200471 L Frt Bumper Moulding Remove/ Body INCr Existing Install 13 205003 R Frt Lwr Bumper Moulding Remove / Body INCr Existing Install 14 205004 L Frt Lwr Bumper Moulding Remove / Body INCr Existing Install 15 205007 Frt Lwr Ctr Bumper Remove/ Body INCr Existing Moulding Install 16 205010 Frt Bumper License Plate Remove / Body INC New 75101-06110 1 $79.16 Yes Bracket Replace Grille 17 202077 Grille Assy Rear Body Remove / Install 18 201205 Rear Body Panel(SteeVHss) Repair 19 AUTO Rear Body Panel Refinish Only zo 201201 R Rear Body Reinforcement Remove/ Body (HSS) Replace 21 201203 L Rear Body Reinforcement Remove / Body (HSS) Replace 22 200490 Rear Body Trim Panel Remove/ Body Install 23 201207 R Rear Body Side Trim Panel Remove / Body Install 24 zones L Rear Body Side Trim Panel Remove / Body Install Body Body Refinish 2.0 C Total Units Type Number Qty Total Price Tax INC# 9.0.# 1.0 1.0 INCr 0.6r# 0.3r# Existing Existing Existing New 58303-06030 1 $58.67 Yes New 58304-06050 1 $58.67 Yes Existing Existing Existing Committed On Version 5/23/2023 Mitchell Estimating 23.1 02:16 PM OEM APR_23 V Mitchell Cloud EstimatingTM Copyright 1994-2023 Mitchell International:Inc. All Rights Reserved Printed On Fmllle Page 2 of9 5/23/2023 CALIFORNIA ALL PART TYPES 02:16 PM SWE Profile Verson 17A Line# Description Operation 25 201210 Rear Bady Spare Wheel Well Remove / Cover Install 26 201630 Rear Body Wheel Tray Remove/ Install Rear Bumper 27 AUTO 28 202365 Rear Bumper Cover 29 900501 30 AUTO 31 201696 32 201700 33 201701 Rear Bumper Cover Assy PART PRICE MATCH AFTERMARKET Rear Bumper Cover R Rear Bumper Reflector Rear Bumper Energy Absorber Overhaul Remove/ Replace Refinish Only Remove / Replace Remove / Replace Rear Bumper Reinforcement Remove / Bar (Alum) Replace 34 AUTO Rear Bumper Cover Remove / Install Additional Costs & Materials 35 AUTO Paint/Materials 36 936012 Hazardous Waste Disposal Additional Cost Additional Cost LABOR Type Body Body Body Body PART Total Units Type Number Qty Total Price Tax 0.1" Existing 0.1* Existing 1.8 Existing INC New Refinish 2.8 C Body INC Body INC Body 0.4# Body INC Additional Operations 37 AUTO Clear Coat Additional Refinish Operation Special/ Manual Entry 3s 900500 PRE -REPAIR SCAN Remove / Replace s1 39 900500 POST -REPAIR SCAN Remove/ Replace ao 900500 COVER CAR FOR Additional OVERSPRAY Labor a1 900500 SEAM SEALER (REPAIRING Additional EXISTING PANEL) Labor 42 900500 PULLS AS NEEDED Repair 43 900500 SET UP AND MEASURE Repair 51 44 900500 Static Calibration -Adaptive Remove / Cruise Control - Lid Replace 51 as 900500 Static Calibration - Blind Remove / Spot Warning Replace s1 46 900500 TRIP FEE Additional Labor ' Judgment Item T Included in Two ToneCalculation # Labor NoteApplies d Discontinued by Manufacturer Body" Body" Body" Body" Body' Frame' Body" Body" Body" 0.5" Existing 2.1 New New New 0.5" 0.5" Sublet Sublet 0.2* Aftermarket New Aftermarket New 2.0" Existing 2.0' Existing 0.0' Sublet Sublet 0.0" Sublet Sublet C Included in Clear Coat Calculation A Included in Clear Coat and Two ToneCalculation r CEG RSA Time Used for this Labor Operation [ ] Verify the part number and price beforeordering 52159-0X915 1 $290.00" Yes 81910-06070 1 52615-06190 1 52171-06170 1 $42.98 $40.80 $285.14 $436.50' $4.00' $0.00 1 $40.00' 1 $80.00' "(teal Repl Part 1 $10.00" "Qua! Repl Part 1 $13.00" 1 1 1 $540.00" 1 $540.00' 1 Disclaimer: This estimate has been prepared based on the use of crash parts supplied by a source other than the manufacturer of your motor vehicle. Anywarranties applicable to these replacement parts are provided by the manufacturer or distributor of the parts, rather than by the original manufacturer of your vehicle. Yes Yes Yes Yes Yes Yes committed on 5/23/2023 02:16 PM Version Mitchell Estimating 23.1 OEM APR 23 V Mitchell Cloud EstimatingT Copyright 1994-2023 Mitchell International. Inc. All Rights Reserved PrinedQt 5/23/2023 02:16 PM Profile Page 3 of9 CALIFORNIA ALL PART TYPES SWE Profile Version 17.0 Estimate Totals Body Labor Refinish Labor Frame Labor Total Labor Taxable Parts OtherAdditional Costs Paint Materials Paint Materials Rate: $45.00 Rate Max: 99.9 units Additional Rate: $0.00 GrossTotals Gross Total $5,284.02 Units " 25.5 9.7 2.0 37.2 ..x..N.-.,..- '� Rate ,_yak, Sutilet Adel Amount $60.00 $60.00 $88.00 ^Amolint�" $1,211.34 Amount a,JL $4.00 $436.50 Ram - Deductible Total Customer Responsibility -- Amount -$500.00 Shop agrees to perform the specified repairs at the price indicated. Repair Facility Authorized Signature All manufacturers requirements regarding seat belt and supplemental restraint system replacement must be adhered to. If additional parts or operations are necessary to properly accomplish this, please -�-" Tofals $1,530.00 $582.00 $176.00 $2,288.00 Taxable $0.00 Tax 0.0000% $0.00 Non -Taxable $2,288.00 Labor Total $2,288.00 Parts Adjustments Tax 8.7500% Non -Taxable Parts Total Taxable Tax 8.7500% Non -Taxable Costs Total Taxable Tax Non -Taxable $1,211.34 moo $105.99 $1,200.00 $2,517.33 $4.00 $436.50 $436.50 $38.19 $4.00 $478.69 $5,284.02 $1,647.84 $144.18 $3,492.00 Gross Total $5,284.02 -$500.00 -$500.00 Net Estimate Total $4,784.02 Less Original Net Total $3,634.02 Net Supplement Amount $1,150.00 S1: Enrique Regla $1,150.00 CunmittedOn 5/23/2023 02:16 PM Varga) Mitchell Estimating23.1 OEM APR.23 V Mitchell Cloud Estimating TM Copyright 1994-2023 Mitchell International. Inc. All Rights Reserved Prirteden 5/23/2023 02:16 PM Pmrne Page 4 ot 9 CALI FORN W ALL PART TYPES SWE Pro17.0 ersm 17.0 contact the estimating claims rep. THIS APPRAISAL HAS BEEN PREPARED BASED ON THE USE OF CRASH PARTS SUPPLIED BYASOURCE OTHER THAN THE MANUFACTURER OF YOUR MOTOR VEH ICLE. ANY WARRANTIES APPLICABLETOTH ESE REPLACEMENT PARTS ARE PROVIDED BYTHE MANUFACTURER OR DISTRIBUTOR OF THE PARTS, RATHER THAN BYTHE ORIGINAL MANUFACTURER OF YOUR VEH ICLE. WE WARRANT THE PARTS AREAT LEAST EQUALTOTHE ORIGINAL MANUFACTURER PARTS IN TERMS OF KIND, QUALITY, SAFETY, FIT, AND PERFORMANCE. ************* IMPORTANT INFORMATION: READ CAREFULLY************* The customer has the right to select the repair shop. Pursuant to CA Code of Regulations sec 2695.8(e) Progressive does not require you to have your vehicle repaired at a specific repair shop. The customer has the right to select a repair shop of their choice. This is a damage appraisal only based on damage visible or certain at the time it was written. Per Business & Professions Code section 9884.9 the customer, not Progressive, must give authorization for the repairs before they can begin. This appraisal is not an authorization for repairs. If frame or unibody repair is included on this appraisal, the amount shown includes time or allowance for measuring before, during and after those repairs. To ensure proper and prompt payment for additional damage discovered during the course of repairs, contact Progressive for supplement procedures. Progressive honors the prevailing labor market rate in your area for your property. If you choose a shop that charges in excess of prevailing labor market rates, you will be responsible for the difference. Lifetime guarantee for sheetmetal and plastic parts. The replacement parts written on this appraisal are intended to return Committed Q, Vadon 5/23/2023 Mitchell Estimating 23.1 02:16 PM OEMAPK23V Mitchell Cloud Estimating TM Copyright 1994-2023 Mitchell International, Inc. All RlghtsReserved Printed on Profile Page 5 at 9 5/23/2023 CALIFORNIA ALL PART TYPES 02:16 PM SWE ProfIleVadm 17.0 your vehicle to its pre -loss condition with proper installation. After repair, if any sheet metal or plastic body part included in this appraisal fails to return your vehicle to its pre -loss condition (assuming proper installation), in terms of form, fit, finish, durability or functionality, Progressive will arrange and pay for the replacement of the part, to the extent not covered by a manufacturer's or other warranty. This service will be performed at no cost to you (including associated repair and rental car costs). To obtain service under this Guarantee, call Progressive at 1-800-274-4641. This Guarantee applies as long as you own or lease the vehicle. This Guarantee is not transferable and terminates if you sell or otherwise transfer your vehicle. THIS GUARANTEE DOES NOT COVER NORMAL WEAR AND TEAR OR DAMAGE CAUSED BY IMPROPER MAINTENANCE, NEGLECT, ABUSE OR SUBSEQUENT ACCIDENT. THIS GUARANTEE IS LIMITED TO ARRANGING FOR THE SELECTION OF REPAIR PARTS THAT WILL RETURN YOUR VEHICLETO ITS PRE -LOSS CONDITION. ACCORDINGLY, PROGRESSIVE WILL NOT BE LIABLE FOR ANY INDIRECT, INCIDENTAL OR CONSEQUENTIAL DAMAGES THAT RESULT FROM THE INSTALLATION OR USE OF THESE PARTS. California Residents: As required by California regulations, the legend below should be used to identify whether replacement parts listed on this appraisal are "new", "used", "rebuilt", or "reconditioned" and whether the crash parts described on this appraisal are "original equipment manufacturer" (OEM) parts or "non -original equipment manufacturer aftermarket crash" parts. New, OEM or part number displayed = New, original equipment manufacturer part Aftermarket New, nonOEM aftermarket = New, non -original equipment manufacturer aftermarket crash part Remanufactured = Rebuilt used OEM part Committed On Verson 5/23/2023 Mitchell Estimating 23,1 02:16 PM OEM APR.23V Mitchell Cloud EstlmatingTM Copyright 1994-2023 Mitchell International. Inc. All Rights Reserved Printed On Pram Page 6 of 9 5/23/2023 CALIFORNIA ALL PART TYPES 02:16 PM SWE Prrtik Verdun 17.0 Used, Quality Recycled Part = Used OEM part Re -cored = Reconditioned used OEM part Re -chromed = Reconditioned used OEM part Sublet = Repair work assigned to third party Existing= Part is already on the vehicle Progressive's Lifetime Guarantee does not cover repairs you request the shop to make that are not related to this accident, including but not exclusive to unrelated prior damage and pre-existing damage. "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." Disclaimer: For your protection California law requires the following statement to appear on this form. Any person who knowingly presents false or fraudulent information to obtain or amend insurance coverage or to make a claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. Cycle Time Information Estimate Event Log Due In 4/27/2023 Estimated Completion Date 5/26/2023 Arrived At Shop 4/27/2023 Job Created 4/25/2023 09:14 AM Supplement 1 Started 5/4/2023 11:25 AM Supplement 1 Printed 5/23/2023 02:16 PM Supplement 1 Committed 5/23/2023 02:16 PM Estimate Version 1 Committed On Venial 5/23/2023 Mitchell Estimating23.1 02:16 PM OEMAPR_23V Mitchell Cloud EstlmatingTM Copyright 1994-2029 Mitchell International. Inc. All Rights Reserved Pitted On Profile Page 7 of 9 5/23/2023 CALIFORNIA ALL PART TYPES 02:16 PM EWE ProrlleVerslen 17.0 Date: Estimate ID: Supplement: Profile ID: Supplement Delta Report Comparison of Estimate 23-8383089-01 Supplement 0 and Supplement 1 Damage Assessed By: Enrique Regla Supplemented By: Enrique Regla Insured: CHARLOTTE ROUGELY Owner: DAMARR ROUGELY Vehicle: 2023 Toyota Camry SE Date of Loss: 04/21/2023 Line Labor Item Type Operation Line Item Description 5/23/2023 2:16:48 PM 23-8383089-01 1- 5/23/2023 2:16:47 PM CALIFORNIA ALL PART TYPES SWE Part Type/Num Dollar Labor CEG Amount Units Unit Changed Entries 39 Body REMOVE/REPLACE POST -REPAIR SCAN 39 Body REMOVE/REPLACE POST -REPAIR SCAN Sublet Sublet Sublet Sublet 40.00* 0.5* 0.00 80.00`.40.5* 0.00 Added Entries 44 Body REMOVE/REPLACE 45 Body REMOVE/REPLACE 46 Body ADD'L LABOR Global Changes Static Calibration - Adaptive Cruise Control - Lid Static Calibration - Blind Spot Warning TRIP FEE Sublet Sublet Sublet Sublet Existing Existing 540.00* 0.0* 0.00 540.00` 0.0* 0.00 0.00* 0.5* 0.00 No Deductible, Deductible Reduction Credit, Customer Responsibility, Labor Rate, or Part Adjustment changes were made. Original Estimate Amount 3,634.02 Committedon 5/23/2023 02:16 PM vim Mitchell Estimating 23.1 OEM APR 2S V Mitchell Cloud EsumatingW Copyright 1994-2023 Mitchell International, Inc. All Rights Reserved PdrtSOn 5/23/2023 02:16 PM Prole Page 8 of9 CALIFORNIA ALLPARRYPES SWE PmfiteVerdan 17.0 Software Version: Supplement 1 Orig Total Tax Supp 1 Total Tax Net Supplement Amount 1,150.00 144.18 144.18 1,150.00 Net Total 4,784.02 Program Calc Data Versions Version Supp 0 22 APR_23_V Supp 1 26 APR_23_V 23.1 Copyright (C) 1994 - 2023 Mitchell International All Rights Reserved ranmftted Version 5/23/2023 Mitchell Estimating 23.1 02:16 PM OEM APR23V Mitchell Cloud Estimatingh Copyright 1994-2023 Mitchell International. Inc. All Rights Reserved Prirteda, Profile Page 9 of 9 5/23/2023 CALIFORMA ALL PART TYPES 02:16 PM SWE Prof lleVer ,i 17.0 7/7/23, 3:00 PM Claim: 23-8383089 01 Claim: 23-8383089 01 Photo 05.jpg DAMARR ROUGELY https://progressive.mymitchell.com/Claim/ClaimFi IeViewer/PhotoThumbnailView.aspx7C ID=1067098497&SID=1098161452&F ID=1272003763&C NU ... 1/2 7/7/23, 3:00 PM Claim: 23-8383089 01 Claim: 23-8383089 01 Photo 14.jpg Photo 20.jpg DAMARR ROUGELY Photo 31.jpg https://progressive.mymitchell.com/Claim/ClaimFileViewer/PhotoThumbnailView.aspx?CID=1067098497&SID=1098161452&F ID=1272003763&C N U... 2/2 F A The UPS Store #4781 79405 Hwy 111 Ste 9 to quints, Ca 92253 Tel 760.771,6311 Fax 760.771.6322 0 00 000 000 000 To: Fax number: Jy_ 3( 0o From: Fax number: 760,771.6322 Date: Gzs Regarding: A cc;ete Jae oM�l° # Pages Including Cover Sheet: 7 STATE OF CALIFORNIA DOPNITIABOR OF CALIFORNIA FOOHNAY PATROL PORT Page 1 ef e Vann. catiOnlans ninon Ronan 0 Wn1 0 arta LA Quoin Dun pe COI • '-rA 3111 cog 4 Wit 17101TOMPS FREW I ° ON.OUtY BREROOICY VEKCLE 1 In&rnm 0 anal. ,roa=an Wank,. 1T314 L 0 A T I N cowecameawace cm WASHIIIGmN ST n 04121/2322 2500 ca. SRO of IA 117112 SLOW FEET op osicaanantia LUTTUDS 33.7511152 mourns 411447700t Br 0 Gin LJ AT IS a; u§ FEET NORTH 0, =mown W3lEIffIVRfl. 1:1 ITS PARTY 1 of OrIOMIZ EA CATAIJ0gNItR nuiz04 ME CA iitnn C Pai BAG II SAFEIYEAUtR O vroa 2010 TOYOTA AVALON PWnESJfla4 MEC • arCleal CA (FUII“ rata HELEN PARCH Mtn Aug HELEN KUTASH igi SArtePil DRIVER ji STROM Amin Mal LAVENSIER COURT wAsonanolOaa Cam Laval0ER C01317 R4 mammon= IA OM% CA02132 1 Gail mins a GrrennAra LA °UINTA / CA / 22253 DIEVORITIONGF GOGGLE ON WOMB OS IDOFFICER &WEBER a OTHER 0 F BRO Ain BRO IIW4V NG 0HT WC att. 0110 mow MCE WMb DRIVEN NAY nianwtn'nrn: tt CAPPARRNT 0 REFERIO NARRM11•2 Own D Home PONE (21M117114LTS Pan) Mann rannwasit vINICLETTE , 1 DEURSA GERMS anon& 0 laat 0 NONE 12/ 0 moo. 0 MAJOR a ROLAIWEA MCA SHOE IN DOGARGEMEA a fre.) raisuNca GSICO IfifiuRNICZ GAUGER pinianallABER nanUtina en MAL EOM onmelizT WAIROMOR oft wa)ftW AIM tin Ma' acneac Pr I GMECI '2 pAiTV 2 orin CONLiATILICEtan 1442113111 Mina UWE CA CLAP An o ilia il emErr Eou. G wtontla MA TOYOTA WWII0.IC2B WIRT WIC carat= QOM aT RA nun OntaiNSOLEAAST ORIGAMI mans RotaIELY VA , Werianalf Y013010 ovnizaTi 0.1/1URR KARIN 110110CCI a SMI6n 0RN GM pi Annan SICIBCATIIRORAL CANYON OVIVERSMX:Ot C2 ONO AO DRIVER n.10.6 Bil GRY/LITAIS CATKERRAL /LP are 1 CA / 12234 TOYOTA PORCROT CORP PO EIX10201 ATLANTA CITY 0A $(440 ounomTitinn ecoveNAWAT 14111GUIONOROMMOn OccrICAR IN pRival 0 OTHER CO- GUST sag " Gm BLit Erni BRO Henri 142 wens I tea MTN GAM I eturtint p.m WM won e 1 MI NONEAPivazra 0 RV cm nutravmVE ono 0 1.03 9l1E (niel UMW MARI020Rrot82 ) peal We VDU el TWO amc vets WW2 0 UM( 0 NOGG CC rem 0 SHADE IN IMMA05 ARCA r-ser%1 12 rNaECAMa MOOR/Wm I1401IRA14C2 pamYMSt UMW, 0 moo 0 MCA ROLLOVER GP laid ealLik7 CS BOUM IWASIKNOTON AVE LI SO AA car GALT CAM JtE� 16;2ED ea Avery 3 GenCRa LOAM meniER B272120 r . *Ai . . D out lianas Wm FORD EXPLORER GRAY USEHIS MAGER 11$4116 OTAIE CA GSM 13 MOW lam o We artlitirainilJUNG1 JeGseiti 20CMAEL P027 A 0 As DRIVER COWRY OP RIVERSIDE RAMA AIRPOITT BLVD Greanswane U SABERS ORIVIR 23411WASHINGTON BIRZET MEWS= CA 02601 0 CRYISTA1EIZP THEWS 1 CA I 02714 remains pun* onceneCei Ueonern XI DRIVER a OTHER OMEN AWAY „ail CI GM u MAR IWO 0BOO 160 ellEellin RAGA POICIValcALGEFEmEi X NONENTARENT D REFER TO RAMO OMNI 0 num wow PO) 2034900 BUSOUSOPHOIC GOMA Wean CATION 001IoIE TYPE Oaten= VENCLCOAMACA BMOC 11112MW:EMEA 411 0 WM 0 Acta IR RIM a Iii4 --- risunintlCOARCIG priumnaLOAGER MP INSIMAD 0 MOM 0 an 0 imam 9 Gimp BOIJTH ca EGRESTORMISMOTAY WARNING/OR ST INWen co 00T a en Tonne erothilato IU82 itagniOnci. EL In= 0103812H Kama 0 Tw CI ,i, 0 01MAKIII.SHAIRCIINI SATE Manna Calt21121 • a STATE OFCAUFON1 A PER VONENT OF CALIFORNIA HICAMAY PATROL TRAFFIC COLLISION CODING CHP 555 Page 2 (Rev a11) OPI 080 Paget OE MITI WcOWmom . YFAN D6PI11R022 19fe V10m 000 Nmoa 3300 IkFlfLxln INYMBCI (T ''rr N,6tJ' 1 3 { !f I 00@l' YPOIME MAIAM AMAMI NAME &won Ammo) NOMEB 0 Yea 0 No — OTVPoP?DONCP WMW-1 SEATING POSMON SAFE"CY EQUIPMENT B-L'NIV OWN R- IN VEHICLE NOT OWED 0.LLAAPPB6.T Uan,SED B-IN VEICLEUCE UNIwOM WED AIR SAG UNKNOWNPPpp��poyyEE�D !..-AIR N RIR BAD ^“-fly YED N• OTHER INA1TENi1ON CDOES A - CELLPIIONE HANDHELD C. Witt RANDOMIZE 1 3 3 4 5 E 7 yyEEpp RTD�B SFENGBRB 0- PM 000. CNOR VAR B-OTHITION VNWOWN D•OTHER ,�Bg Fo:SHOULDERpHPApNHEepffiNN5NOT USE u-� VEHICLE O �u LE Lpp GULDEN HAftAEE99A USE J-FAMSfllERE50wMUSED V,No %-Np KK rIM NOY USE W,YES Y.YEB - T E NFFn P - MDT REWIRED EJECTED FROM VEHICL 1•M YYEJECTED EJECTED 2-PAROMLYEIEDI[-n S•UA'IBOONN F- N H.-AWN-8 PrADI NALN/GIENS K- THER K-OTHER 11E1E3 MARKED GELDW FOLLOWED BY AN MERE R r) SHOULD BE EXPLAINED W THE NARRATIVE g JAIAIV OLUSIOO cr WAMF ATMULY N PALM 1RAFRCCOKR0L DEVICES 1 2 3 SPECIAL IBwRMATON 1 2 3 MDYYME�m O 3 A w.clwTwm X A Cot ia9FV61NNINO A REAM= RETINAL X X AMEPPEO • 27T03 R Daum =NOT FUNc7INwr 0 CEL1.19101E HANDHELD MEE X. b w+0o3:0 iS EAAWW B omnA ILORaRERlrewa- C CONTROLOOSWIRW -0 OGL*ME IMw9I69 EWE 0 MHOE ROAD 0 NOCEWMOLF MEatmkecfre )(X X5.23 CCLAWm NOYNJa6 0 MxNMP IWMNWH C OMFRTWIDElma1. RPE-OF COLLEON E 3014001.8010131391 EMxbhW LWTTWW 0 to oijo M• A HOE -ON F 76FTMOMERGKOO8BO P moo lima B EWEEAWE 6 92flWt +COM O 0 BMftoO X 0 FEAREw 14 SLOYMOIBIOPPING WEATHER IMA1* 1 Tot num DMANNDE IPMAnw OMR NTIOA X A mFAN E NR mom J EINEMOVMS B D.0WY F OwmAMNFD x FIIOVIfOLEItT-ANER WANG 6 MCA 1411)1WWW1 L ENtEHn/o TEEM —'D tHWONO N 0Tha1 H OMEN UNSAFE TIRMw rE FDAIym0IUNN FT N IWWNYOOROBM LEE P 0T1lT. MOTOR VEHICLE INVOLVEDLMMN OPrR G MN0 A AWN-CmSBION P NER0IN0 UGK1M0 B PaesnaN VE1010 ONO O TMWAY DLYWNI X —Pi c PnIERMO1mi 4EHCLE 1 P f GTXERAS9000LI DFACIOR(S) N ORBFT- WSx.MNM Homo V'NOe MOnEBMCIDNNY (MMK1 RI OI1flS) C tow*1TEDrLflrm E PIWRDMDTORVDICIL wmm.�a OREO B DMC-w SWEET LWHR P WANA E BT(df-41PFkTLWMONDT 0 EMUS1 • Bwm:mwwAw CITED 0 1 s L SOBRIETY-ORUO FHYSOAL AwcRWIMa• H %L 1:?1 ROAEWAYBUIWAcE +ry OwmmlxamT OM D X A ARV RAW OBJECT: „" —L' B NET 1 XXX AKw NTWAIa ND Mow .= J 00117100=1! E NIS=LEECBREMEeT B NBO•UNDENNHYOWE 0 B2roERYIRMO% OILY E1C4 P RUTIEII118t 0 MIS -NOT UWIAMUIEPCE.• G TOP ainaTIC D Mi-0IANRM5TWMCYe' asztommaminumnO® PEOEi1WANSAc110NS H IM iffAIP UOERORW ROU.EI, IEPFMm X A wiO�IRWIaINW..— I PPGTPNSeaIwW F IIM➢✓LBR•PIOBWxI` re LHOLES,OME 8 bOmMIIEEMIXi MnFONAT• R apeEmw J WKMIIWA MTHROAD B !UPHEAVE' NTNNONN WeTA10TDNONROTCAIxT AT OEFECTIMMw PoUR N NOTMHICABE DCAEM® EAVLX• 6 a o N 0 0 1 aL6PTIFMouEO' YM�aONE ELETI N F FLEXILE' 0 CAOWP= warn/ 0N0Em1M% L WMN0JEP VEIMLE D 08181. I E W comaxuart woNsoER MOWER X H so mom cardamom F NTINROAD 'XS X N WNCMA+PDR 0 AwconcnoOI UANW 0011001. OW CRux+NAYYma1E 2E °EeeAter e2 SSW ❑ 'See ADawwd WDAWI WR21Am• MBC3D300EUS DEPARTMENT OF CAUFORaA WI W PATROL INJURED! WITNESS PASSENGER HP555 Page3 (Rev.411) 0PI O60 Pages ere DAWCif COW$IDN 0Ia ntt nnAlq 00/212021 YemRAee 26O0 NCICI 23OD OPICULO. MS NRplR�-2�1�q� 1 1 9e31 I O µf V sae ME e4 EXTENT OF INJURY pc, -ONE) INJURED WAS Cr ONE) �, EX 1/n - EAc� MTRL MAY *NM IN M ny ...satann. ...Own w ORasR M S PEG 6105UAY aMFn 0 13 w 0 0 0 0 ❑ ❑ ❑ ❑ 0 1 a R G 1 NAe1Rl oR.a/ADDRESS neap/taro !RWI7I NUTAU I OAMM I 10181 LAVIEMOCR COURT LA 0UINTA CA972A2 US (101)07Sa]25 ONNtl9aArlvtMacrtino et DPRUN 301/0i mono DECCIME Inaumai ❑ I t1 F 0 ❑ ❑ 0 ❑ ❑ ❑ ❑ ❑ 1 a 11 U D NAME/ DL.S IASOREOS TtlSplldle CAROLYCON 1 0110W1910 / a0712 LAVENDER COURT tag11MO1CA 17230 US (201) 17OC926 1914131/00/41.1)TPANSPORMISY ES imandeep ahe,.tu CEMA=wnaeF% ❑ ® I N N ❑ 0 I 0 ❑ ❑ ❑ ❑ ❑ ❑ 1 0 1 N 0 4 NAME/GALE./ T$Np0OU PETER CALTON / 0917AIM2 / 601021JWBDPRCOURP IA°UINTA CA02263 U6 11111070a210 wueWOKT10aMPpe10 m ea Rummel TWINTe DeSCRw6WAWE1 ❑ )o J CI I ❑ I ❑ ❑ 0 010 ❑ I line1O. /A0033:93 alepeone I I (INJURED DMr1 TRANBWWIiDOY en Raw MWOCR TANWIT0 @tORGEINJUI6E ❑ I ❑ 1 1 ❑ I ❑ 0 I ❑ ❑ ❑ 1❑ 1 ❑ ❑ f NAVE/O.O.9./ADDNESS Telephone I ammo elan TPN0PORI8CBY QAMRUNIPAI9U TaRENTO oem33111NAMES ❑ (� o CI 0 0 0 [0 ❑ ❑ ❑ D I NAME /D.w . IAOORESS Telephone II /tre.ruRa3mapiwayonnonw Eva sal NUMU MINT0 cialiatia KUM PRiTAREoon RodAauea D. M7620 IOMMMA NT832 110 DAY TEAR 0313112022 I3IEV.ms RANI CNFFITN. SHAUN 4104 DID DAV WAR 0420/2022 in g6 -45 STATE OF CALIFORNIA COMMENT OF C UFORMAMIG1?MY PATROL NARRA TI EIS UPPLEEMEINTAL DAM OFCOLtI1ION FAQ Okf. YtNO aka a4Pu2Oar CC. 3200 ; OFFICBUD, WPM Notifieatiom o I was dispatched this traffic collision on Friday, April 21, 2023 at 1837 hours. I responded from Monterey Ave and Dinah Shore, I arrived on scene at 1855 hours. All times, speeds, and measurements are approximate. Measurements were obtained by Google Earth. r Statements: 9 P-1 (Kutash) stated she was traveling in V-1 (Toyota) southbound in the number three lane of 10 Washington Street. As she approached the intersection on a green light, she noticed traffic in the I T intersection stopped. She was unable to move forward therefore she waited for traffic to move. 12 As she was waiting she felt an impact from the rear. 13 1.1 P-2 (Rougely) stated he was traveling in V-2 (Toyota) southbound in the number three lane of 1s Washington Street. As he approached the intersection on a green light he noticed " a few cars" 10 in the intersection and was unable to move forward. As he was waiting for traffic to move, he 17 felt an impact. 9 P-3 (Post) stated he wes traveling in V-3 (Ford) southbound in the number three lane of %:u Washington Street. As he approached the intersection, he noticed vehicles stopped at a red light 71 and started to slow down his vehicle. As he was coming to a stop ,he noticed the light turn ;,a green, and proceeded forward. While proceeding forward he turned his head and noticed cam 23 around him stopped. When P-3 Looked forward he realized he was going to collide with the rear 24 ofV-2. 25 26 Snmmarv: 27 2e V-1 (Toyota) and V-2 (Toyota) were stopped in the number three southbound lane on Washington St. V-3 was traveling southbound in the #3lane of Washington St. P-3 (Post) was so following to closely and rear ended V-2 causing V-2 to collide with rear of V-1, 32 Area of Impact: 33 34 The AOI was determined by drivers statements, physical evidence and matching vehicle 35 damage; 36 37 AOl #1 21 feet east of the west curb line of Washington St and as 48 feet north of the north curb line prolongation of Elsenhower.Notificatien: 41i I was dispatched this traffic collision on Friday, April 21, 2023 at 1837 hours. 1 responded from 41 Monterey Ave and Dinah Shore,' arrived on scene at 1855 hours. All times, speeds, and 42 measurements are approximate. Measurements were obtained by Google Earth. 43 42 S2M0020at2: 45 Pages are PRtflRo5Yl( Riverside County Sherlf-ForraubConnnuanon eynowloss 3- ws ROOrpuez D. N7333 Nra88 r202a OnIFFnW, 9RAUN 4154 MO CMYtA 04IO=R022 STATE OF CALIFORNIA oerARrMENT OF eauFORMAMONWAY PATROL NARRAPage TIVE/SUPPLEMENTAL /UPPLEMEENO NTAL rdF ammo/ONA DAY. YBARI me RNA) 12o23 2900 MC• 3300 N7033 Papeete NUMBER Ta3,IfDdill 1 P-1 (Kutash) stated she was traveling in V-1 (Toyota) southbound in the number three lane of 7 Washington Street As she approached the intersection on a green light, she noticed traffic in the intersection stopped. She was unable to move forward therefore she waited for traffic to move. As she was waiting she felt an impact from the rear. G P-2 (Rougely) stated he was traveling in V-2 (Toyota) southbound in the number three lane of 7 Washington Street. As he approached the intersection on a green light be noticed" a few cars" a in the intersection and was unable to move forward. As he was waiting for traffic to move, he 9 felt an impact. is P-3 (Post) stated he was traveling in V-3 (Ford) southbound in the number three lane of t 7 Washington Street. As he approached the intersection, he noticed vehicle's stopped at a red fight and started to slow down his vehicle. As he was coming to a stop ,he noticed the light turn green, and proceeded forward. While proceeding forward he turned his head and noticed cars around him stopped. When P-3 looked forward he realized he was going to collide with the rear y of V-2. 11 13 ,Summary: ;9 2.1 V-1 (Toyota) and V-2 (Toyota) were stopped in the number three southbound lane on 7 •: Washington St. V-3 was traveling southbnund in the #3 lane of Washington St P-3 (Post) was 22 following to closely and rear ended V-2 causing V-2 to collide with rear of V-I. 23 24 Area of Impact: 25 25 The AOI was determined by drivers statements. physical evidence and matching vehicle 27 damage; %4 2'J AOI #121 feet east of the west curb line of Washington St and 48 feet north of the north curb line prolongation of Eisenhower. 32 AO1 #2 21 feet east of the west curb line of Washington St and 3a 33 feet north of the north curb line prolongation of Eisenhower. :id 35 AOl #2 21 feet east of the west curb line of Washington St and 3^, 33 feet north of the north curb line prolongation of Eisenhower. :37 38 Cause: i3 40 Cause was determined by drivers statement's, physical evidence, and matching vehicle damage. .,1 P-3 ( Post) caused this collision by being in violation of 21703 CVC, The driver of u motor 12 vehicle shall not follow another vehicle more closely than is reasonable andprndent, having 13 doe regard far the speed afsach vehicle and the tragic upon, and the condition of the roadway. aREAweeF RWefSide County Sheriff -For la meek Continuation oyaegsed 3- IJ2iY9e ,AMB Reerpqu40, D. Ma99 R761s a4,2u2029 I GRIFFITH BMAUR 4134 MD QAYYEAR O4262023