HomeMy WebLinkAbout2025-03-27 Ayon, Luz Esthela - 956y f. t
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Claim Against the City of Palm Desert jniK AM || •For Damage(s) to Person(s) or Personal Property * ' • oO
Instructions; Please fill out this form completely. Failure to provide sufficient information may result in
delays in claim processing. If you need an accommodation to complete or submit this form, please contact
the City Clerk's Office Claims Coordinator at citvclerk@palmdesert.gov or (760) 346-0611.
Important Information:
1. Claims for death, injury to person or to personal property must be filed no later than six (6)
months after the occurrence.
2. Claims for damages to real property must be filed no later than one (1) year after the
occurrence. See Government Code §911.2.
3. Be sure claim is against the City of Palm Desert, not another public entity.
4. Claimant is advised to consult a private attorney if legal advice is desired. No employee of the
City may give legal advice to any claimant relating to private claims.
Instrucciones: Complete este formulario en su totalidad. Si no brinda informacion suficiente, pueden
demorar el procesamiento del reclame. SI necesita alguna acomodacion para completar o enviar este
formulario, comunlquese con el Coordinador de Reclames a la direccion de correo electronico
citvclerk@palmdesert.gov o al telefono (760) 346-0611.
Informacion importante:
1. Los reclames per muerte, lesiones personales o dafios a la propiedad deben presentarse a mas
tardar seis (6) meses despues de haberse producido el hecho.
2. Los reclames per dahos a bienes inmuebles deben presentarse a mas tardar un (1) aho despues
de haberse producido el hecho. Consulte al codigo §911.2 del gobierno de California.
3. Asegurese su reclame es hacia la ciudad de Palm Desert y no otra entidad publica.
4. Se aconseja al demandante consultar con un abogado privado si asi lo desean. NIngun empleado
de la ciudad puede brindar asesoramiento legal al demandante en relacion con reclames privados.
Received bi^ / DAM/AN (}^tVAPgg U.S. Mail
Assigned Claim No. Interoffice
Claimant Name/Nombre de Demandante: ■..^""^ver-the-Counter
—JFirst Name (Nombr^ M. I. (Inicial de Segundo Nombre)
M Qn_
Last Name (Apellido) Suffix (Sufijo)
Home Address/Domicilio:
l ^ Tfnp PJf n
Street Number and Name (Numero y Nombre de Calle)
Unit Number (Numero de Apartamento/Unldad)
City (Ciudad)
^2^3'y
Zip Code (Codigo Postal)
State/Province/Region (Estado)
Preferred Phone Number/Numero de telefono preferido:
ti
Email/Correo Electronico:
if represented by an attorney, provide name and address - Si cuenta con ia representacion
de un abogado indique su nombre y domicilio:
First Name (Nombre)
Address/Domiciiio:
Last Name (Apeilido)Suffix (Sufijo)
street Number and Name (Numero y Nombre de Caiie)
Unit Number (Numero de ApaHamento/Unidad)
City (Ciudad)State/Province/Region (Estado)
Zip Code (Codigo Postal)
Date and time of damage/injury/loss - Fecha y la hora del daho, la lesion, o la perdlda:
^025 _J H 30 -P wv.'
Date (Fecha) Time (Hora)
Location of damage/lnjury/loss (If known, Include specific address) - Lugar donde ocurrlo el
daho, la lesion, o la perdlda (si conoce el domlclllo, Indrquelo):
Provide a general description of the Indebtedness/obligatlon/damage/lhjury/loss so far as It may
be known at the time of presentation of this claim. If there were no Injuries, state "no Injuries"
- De una descrlpcjon general del endeudamlento, obllgaclon, daho, lesion, o perdlda al
momento de este reclame. SI no hubo leslones, Indlque "no leslones":
7:16 0 2) -
rtii n , a S ? N[ C«T> . , f ^ ^ ^
Specify how the damage/lnjury/lpss occurred - Especlflque como se produjo el daho, la lesion,
o la perdlda:
What particular action/omission by the City, or its employee(s), caused the damage/injury/loss?
- ^Que accion u omision especifica de la ciudad o su(s) empleado(s) ocasionaron el daho, la
lesion, o la perdida?:
Provide the name(s) of the City employee(s) involved in the damage/injury/loss, if known - Si lo
conoce, indique el nombre(s) de el/los empleado(s) de la ciudad involucrado(s) en el daho, la
lesion, o la perdida.
no . '
Name(s) and address(es) of any other person(s) injured - Nombre(s) y domicilip de otra(s)
persona(s) que sufrio lesiones:
Name(s) and address(es) of witness(es), if any - Nombre(s) y domicilio(s) de el/los testigos, si
los hubiera:
Name(s) and address(es) of all physician(s) or hospital(s) where claimant was treated, if any -
Nombre(s) y domicilio(s) del medico(s) u hoSpital(es) donde el demandante recibio tratarniento
si lo hubiera:
Was a police report filed? - ^Se hizo denuncia a la policia? YES x NO
If yes, provide the police report nurriber - Si se hizo una denuncia, indique el numero de la
denuncia:
WO
Any additional Information that might be helpful in considering claim - Incluya cualquier otra
informacion que pueda resultar util para procesar el reclame:
DAMAGES CLAIMED / DANOS RECLAMADOS:
If the amount claimed exceeds $10,000, it is not required that a dollar amount be provided. However, your claim
must indicate whether it would be a Limited Civil Case. A Limited Civil Case is one where the recovery sought,
exclusive of attorney fees, interest, and court costs, does not exceed $25,000. An Unlimited Civil Case is one
in which the recovery sought is more than $25,000.
Si el monto reclamado supera los $10,000, no es necesario indicar la cantidad en dolares. Sin embargo, el
reclame debe indicar si se tratase de una Accion Civil Limitada. Una Accion Civil Limitada es una accion en la
que el resarcimiento pretendido no super los $25,000, sin incluir honorarios de abogados, intereses y costos del
tribunal. En una Accion Civil sin Limite, el resarcimiento pretendido supera los $25,000.
Damages Clalmed/Dahos reclamados:
a Limited Civil Case (damages between $10,000 - $25,000) - Accion Civil Limitada (los dahos ascienden
a $10,000-$25,000)
a Unlimited Civil Case (damages exceed $25,000) - Accion Civil sin Limite (los dahos superan los $25,000)
If the amount claimed is under $10,000, state amount claimed - Si el monto reclamado es menos
de $10,000, indiquelo:
Basis for computation of amount claimed (include estimate/bills as an attachment, if possible)
- Base por lo que calculo el monto reclamado (si es possible proporcione con este reclamo
presupuestos/facturas):
WARNING: IT IS A CRIMINAL OFFENSE TO FILE A FALSE CLAIM. (CALIFORNIA PENAL CODE 72 AND
CALIFORNIA INSURANCE CODE)
I certify under penalty of perjury that the facts herein above set forth are true and correct to the best of my
knowledge.
ADVERTENCIA: ES UN DELITO PENAL PRESENTAR UN RECLAMO FALSO. (CODIGO PENAL DE
CALIFORNIA 72 Y CODIGO DE SEGUROS DE CALIFORNIA) For la presente certifico bajo pena de
perjurio que los hechos establecidos anteriormente son verdaderos y cOrrectps a mi leal saber y enteder.
Signed thisr^^ "2^ day of-0 ^ 20 at C / /V Ua vX
Signature of Claimant/Firma de Demandante Signature of Claimant/Firma de Demandante
FIX AUTO CATHEDRAL CITY
36085 CATHEDRAL CANYON DR./CATHEDRAL
CITY, CA 92234
Phone: (760) 770-8082
FAX: (760) 770-3042
Workfile ID:
Federal ID:
State ID:
Federal EPA:
State EPA:
BAR:
C97e8057
330894112
NA
NA
CAL000183214
ARD00212152
Preliminary Estimate
Customer: AyoriA Esthela
Insured: Ayon, Esthela
Type of Loss:
Point of Impact:
Owner:
Ayon, Esthela
(760) 905-9327 Cell
Written By: Jose Olmos
Policy #:
Date of Loss:
Inspection Location:
FIX AUTO CATHEDRAL GUY
36085 CATHEDRAL CANYON DR.
CATHEDRAL CITY, CA 92234
Repair Facility
(760) 770-8082 Business
Claim#:
Days to Repair: 4
Insurance Company:
CUSTOMER PAY
VEHICLE
2018 HOND CR-V EX 4D UTV 4-1.5L Turbocharged Gasoljne Gasoline Direct Injection
VIN:2HKRW1H55JH517682 Interior Color:Mileage In:Vehicle Out:
ise:Exterior Color:Mileage Out:
:: CA Production Date:Condition:Job #:
TRANSMISSION Air Conditioning FM Radio ROOF
Automatic Transmission Intermittent Wipers Stereo Electric Glass Sunroof
POWER Tilt Wheel Search/Seek SEATS
Power Steering Cruise Control Auxiliary Audio Connection Cloth Seats
Power Brakes Rear Defogger Satellite Radio Bucket Seats
Power Windows Keyless Entry SAFETY Reclining/Lounge Seats
Power Locks Alarm Drivers Side Air Bag Heated Seats
Power Mirrors Message Center Passenger Air Bag WHEELS
Heated Mirrors Steering Wheel Touch Controls Anti-Lock Brakes (4)Aluminum/Alloy Wheels
Power Driver Seat Rear Window Wiper 4 Wheel Disc Brakes PAINT
DECOR Telescopic Wheel Traction Control Clear Coat Paint
Dual Mirrors Climate Control Stability Control OTHER
Privacy Glass Backup Camera Front Side Impact Air Bags Fog Lamps
Console/Storage Remote Starter Head/Curtain Air Bags Rear Spoiler
Overhead Console Intelligent Cruise Hands Free Device Signal Integrated Mirrors
Wood Interior Trim RADIO Blind Spot Detection
CONVENIENCE AM Radio Lane Departure Warning
Get live updates at www.carwise.CQnn/e/53xSfO
3/26/2025 12:56:19 PM 434194 Page 1
Preliminary Estimate
Customer: Ayon, Esthela
2018 HOND CR-V ex 4D UTV 4-1.5L Turbocharged Gasoline Gasoline Direct Injection
Lirie Oper Description Part Number Qty Extended
Price $
Labor Paint
1 FENDER
2 RepI RT Fender liner 74100TLAA00 1 160.75 0.4
3 *Rpr RT Fender - buff panel M
4 RepI RT Wheel opng midg 74115TLAA02 1 49.85 0.3
5
.
Rppl Mud guard kit 08P00TLA100 1 120.00 0.2
vvheEs
7 **RepI RECOND RT/Rear Wheel, alloy 42700TLAL87 1 277.00 m 0.3
18", w/o touring Asahi
8 #RepI Bridgstprie ecopia 235/60-18 -1 380.00
per invoice
9 #mount and balance 1 20.00
10 FRONT DOOR
11 *Rpr RT Outer oanel - buff oanel 2ja
12 RepI RT Lower molding w/o chrome 75312TLCA01 1 138.73 0.4
13 RepI RT Belt molding 72410TLAA01 1 61.30 0.3
14 RepI RT Applique 72430TLAA01 1 16.43 0.2
15 RepI RT Upper molding 72425TLAA01 1 79.67 0.3
16 *Rpr RT Handle, outside w/body color LQ.M
white diamond
17 *Rpr LT Handle, outside w/body color 132
white diamond
18 REAR DOOR
19 *Rpr RT Outer panel - buff oanel ZQ.£LQ
20 RepI RT Lower molding w/o chrome 75313TLCA01 1 94.10 0.4
21 RepI RT Wheel bpng mIdg 75390TLAA01 1 70.52
"I
0.2
22 RepI RT Belt molding 72910TLAA01 1 57.05 0.3
23 RepI RT Applique rear 72721TLAA01 1 13.55 0.2
24 RepI RT Applique front 72930TLAA01 1 16.43 0.2
25 *Rpr RT Handle, outside w/body color LQ.
white diamond
"26 QUARTER PANEL
. •. . .W.v.-,. V.v.v v.v.v.-,-. .• v.v.... .v....
27 *Rpr RT Quarter panel 18" wheels M M
28"'""'"^
29 *Rpr Lift gate w/o power M QJ2
30 *Rpr Lift gate glass Honda, w/o privacy M
w/o Indiana built
31 *Rpr Wiper arm LQ
32 R8a Wiper arm 0.2
33 REARLAMPS
. v............ V....................v,v.vv.....v
34 *Rpr RT Tail lamo assv - buff panel LQ
35 *Rpr LT Tail lamp assy - buff panel LQ
36
37
38
REAR BUMPER
*Rpr Bumper cover
0/H rear bumper
ZQ
2.4
M
3/26/2025 12:56:19 PM 434194 Page 2
PreliminaiV Estimate
Customer: Ayon, Esthela
2018 HOND CR-V EX 4D UTV 4-1.5L Turbocharged Gasoline Gasoline Direct Injection
39 R&I R&I bumper cover
40 * Rpr RT Side Cover
41 * Rpr LT Side cover
42 MISCELLANEOUS OPERATIONS
43 RepI Cover car/bag
44 # RepI Precision mask
Incl.
LQ.
M
0.2
2.0
ILQ
M
SUBTOTALS 1,555.38 31.5 0.0
ESTIMATE TOTALS
Category Basis Rate Cost $
Parts 1,555.38
Body Labor 31.5 hrs @ $ 85.00/hr 2,677.50
Subtotal 4,232.88
Sales Tax $ 1,555.38 @ 8.7500 %136.10
Grand Total 4,368.98
FOR YOUR PROTECnON CALIFORNIA LAW REQUIRES THE FOLLOWING 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.
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=DIAGNOST[C,
E=ELECTRICAL, F=FRAME, G-GLASS, M=MECHANICAL, P=PAINT LABOR,
S=STRUCTURAL, T=TAXED MISCELLANEOUS, X=NON TAXED
MISCELLANEOUS. CCC ONE: ADJ=ADJACENT, ALGN=ALIGN,
A/M=AFTERMARKET, BLND=BLEND, CAPA=CERT[FIED AUTOMOTIVE
PARTS ASSOCIATION, D&R=DISCONNECT AND RECONNECT,
EST=ESTIMATE, EXT. PRICE=UN1T PRICE MULTIPLIED BY THE QUANTITY,
INCL=INCLUDED, MISC=MISCELLANEOUS, NAGS=NATIONAL AUTO GLASS
SPECIFICATIONS, NON-ADJ=NON ADJACENT, 0/H=0VERHAUL,
OP=OPERATION, NO=LINE NUMBER, QTY=QUANTrrY,
RECOND=RECONDrnON, REFN=REFINISH, REPL=REPLACE, R8J=REM0VE
AND INSTALL, R&R=REMOVE AND REPLACE, RPR=REPAIR, RT=RIGHT,
SECT=SECnON, SUBL=SUBLET, LT=LEFT, W/0=WITH0UT, W/_=WITH/_
SYMBOLS: #=MANUAL LINE ENTRY, *=OTHER [IE..MOTORS DATABASE
INFORMATION WAS CHANGED], **=DATABASE LINE WITH AFTERMARKET,
N=NOTES ATTACHED TO LINE. OPT OEM=ORIGINAL EQUIPMENT
3/26/2025 12:56:19 PM 434194 Page 3
Preliminary Estimate
Customer: Ayon, Esthela
2018 HOND CR-V EX 4D UTV 4-1.5L Turbocharged Gasoline Gasoline Direct Injection
MANUFACTURER PARTS EITHER OPTIONALLY SOURCED OR OTHERWISE
PROVIDED WITH SOME UNIQUE PRICING OR DISCOUNT.
""CURE TIME"" MEANS THE LENGTH OF TIME THAT, PER THE ADHESIVE
MANUFACTURER, THE WINDSHIELD ADHESIVE NEEDS TO CURE UNTIL THE
WINDSHIELD CAN PROPERLY FUNCTION AS A SAFETY DEVICE PURSUANT
TO THE FEDERAL MOTOR VEHICLE SAFETY STANDARDS AND THE
VEHICLE MANUFACTURER'S SPECIFICATIONS.
Estimate based on MOTOR CRASH ESTIMATING GUIDE and potentially other third party sources of data. Unless
otherwise noted, (a) all items are derived from the Guide ARG4464, CCC Data Date 03/17/2025, and potentially other
third party sources of data; and (b) the parts presented are OEM-parts. OEM parts are manufactured by or for the
vehicle's Original Equipment Manufacturer (OEM) according to OEM's specifications for U.S. distribution. OEM parts
are available at OE/Vehicle dealerships or the specified supplier. 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 with discounted pricing. Asterisk (*) or Double Asterisk (**) indicates that the parts and/or labor data
provided by third party sources of data may have been modified or may have come from an alternate data source.
Tilde sign (~) items indicate MOTOR Not-Included Labor operations. The symbol (<>) indicates the refinish
operation WILL NOT be performed as a separate procedure from the other panels in the estimate. Non-Original
Equipment Manufacturer aftermarket parts are described as Non OEM, A/M or NAGS. Used parts are described as
LKQ, 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 2024 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 CCC ONE
estimator has a list of applicable vehicles. Parts numbers and prices should be confirmed with the local dealership.
The following is a list of additional abbreviations or symbols that may be used to describe work to be done or parts to
be repaired or replaced:
SYMBOLS FOLLOWING PART PRICE:
m=MOTOR Mechanical component. s=MOTOR Structural component. T=Miscellaneous Taxed charge category.
X=Miscellaneous Non-Taxed charge category.
SYMBOLS FOLLOWING LABOR:
D=Diagnostic labor category. E=Electrical labor category. F=Frame labor category. G=Glass labor category.
M=Mechanical labor category. S=Structural labor category, (numbers) 1 through 4=User Defined Labor Categories.
OTHER SYMBOLS AND ABBREVIATIONS:
Adj. = Adjacent. Algn.=Align. ALU=Aluminum. A/M = Aftermarket part. Blnd=Blend. BOR=Boron steel.
CAPA=Certified Automotive Parts Association. CFC=Carbon Fiber.
D&R=Disconnect and Reconnect. HSS=High Strength Steel. HYD=Hydroformed Steel. Incl.=Included. LKQ=Like
Kind and Quality. LT=Left. MAG=Magnesium. Non-Adj.=Non Adjacent. NSF=NSF International Certified Part.
0/H=0verhaul. Qty=Quantity. Refn=Refinish. Repl=Replace. R&I=Remove and Install. R8iR=Remove and
Replace. Rpr=Repair. RT=Right. SAS=Sandwiched Steel. Sect=Section. STS=Stainless Steel. Subl=Sublet.
UHS=Ultra High Strength Steel. N=Note(s) associated with the estimate line.
3/26/2025 12:56:19 PM 434194 . Page 4
Preliminary Estimate
Customer: Ayon, E$the!a
2018 HOND CR-V EX 4D UTV 4-1.5L turbocharged Gasoline Gasoline Direct Injection
Line Supplier
PARTS SUPPLIER LIST
Description Price
7 Keystone, Inc
15895 VALLEY BLVD, SUITE 100
FONTANA CA 92335
(800)421-7866
#ALYHT022U15
REGOND RT/Rear Wheel> ailoy 18", w/o Touring Asahi
Quote: 2915398858
Expires: 05/10/25
$ 277.00
3/26/2025 12:56:19 PM 434194 Page 6