American Commerce Insurance Company. Toll free (877)

Transcription

1 REcEiveo A The Cennnuerce Grum), Inc. 20 MijciZ010 American Commerce Insurance Company Commerce West Insurance Company HUMAN RESOURCES CG EASTERN CLAIMS OFFICE 11 Gore Road, Webster, MA SM Toll free (877) RECEIVFD May 14, 2010 Office of the City Clerk 65 Civic Ave Pittsburg, CA MAY cay CLERK Att: Alice Evenson RE: Insured: Tamara Threadgill File #: CSV Date of Loss: 04/27/2010 Responsible Party: City of Pittsburg Amount: $ Property Damage: $ Medical: $ Wage: $ Dear Ms. Evenson: Our investigation reveals the City of Pittsurg is responsible for damages sustained by our insured. We have settled the loss with our insured and would appreciate your payment of the amount listed above. Please find a completed City of Pittsburg Claim Form attached to our supports. We have paid our insured for damages and are seeking reimbursement. Enclosed are our supporting papers for your review. if you have any questions or dispute this claim, please call me at , ext Sincerely, COMMERCE WEST INSURANCE COMPANY Eric Olson Subrogation Adjuster Enclosure EO/dg S-9 CWIC Reimb for Damages to insd Req to Town (Rev. 06/07)

2 CLAIM PRESENTED TO THE CITY OF PITTSBURG Please read the instructions on the back before com,oletin q. FORM Claimant's Name: (Please Print) d4 Claimant's Address:,, ( /2a) ILL /Ati r Ce-- 4p4,-;e6 'S/ City, State, Zip: ig /1 --i-j 0c, )2. 6' 14 9q Day Phone: ( ) Eve: ( ) 2, When did the damage or injury occur? Month: /) Day: 7 Year t)0/6 Time:/, ç6 a.m. c J -n.) 14 Reserved for Filing Stamp,_ HLUEIVED MAY I CITY CLERK City Claim No.: pr, L 3. At which location did the damage or injury occur? Police Report No.: AIL.,, f), 4-4-biAre'lA 36t,p_e4--, t 4. a. What happened and why is the City responsible? (---. /yr) p l) le, ii.-1,.5-1-e. it- (1,-6 trl i '11 S Yr) iti /lei 0 Y1 LL.- ) I / (,S 4 n (. ) c 1/7' 9 I A)) z, /c_- b. Name and position of re gponsible City Employee(s), if known: bi n K nocu n 5 What damage,pr injury occurred? r ) 1 /1-71- '5' 1()n 1- S / On- Wi nolske../ Claim amount (only if less than $10,000): 4 / 3. AiLa if the amount exceeds $10,000, please check the court for appropriate jurisdiction: Municipal Court (claims up to $25,000) Superior Court (claims over 325,000) 7. How did you arrive at the amount claimed? Please attach documentation. a-1-16e,/he e-- 64)pra,f.sei-, 1 8. I declare under penalty of perjury under the laws of the State of California that the following information is true and correct, and that this declaration was executed on IY)41 ii-i, 20/ L), at..:3 : / 0 O13 14f) ')-)A,si..-,Al2/4---- Signature of ClaimanVor Representative 9. Official Notices and Correspondence If represented by an insurance company or an attorney, please provide the information requested below: Name and Capacity:(p/ease print) /1. L-02-7 m CC- e_.- (.7roi_t_io J-n5ttce://-2c.:e_, 6."6 0 CA. Address: /1 (76, re,- R c.)1..-- City, State, Zip: We,ils 1-i,---- tr) 4 6 i --"- 7 0 Daytime Phone: 5'6 '' ' ' 9 4--) el - 5.3,2 "--i Evening:

3 SHE WAS AT THE COURT HOUSE IV WAS PARKED/OCCUPIED INSURED WAS TALKING TO HER DAUGHTER IN THE VEHICLE IV WAS PARKED FOR 5 MINUTES IV WAS PARKED NEXT TO A HANDICAPPED SPACE HANDICAPPED SIGN FELL OVER AND HIT IV HOOD AND SCRATCH WINDSHIELD INSURED HAS HER DAUGHTER GO IN AND GET A POLICE OFFICER CAME OUT WITH AN ADMIN AND OFFICER INSPECTED THE SIGN AND POLE POLE WAS RUSTED THROUGH SIGN WAS STANDING UP STRAIGHT PRIOR TO TIPPING OVER POLE WAS ANCHORED INTO THE GROUD WITH CONCRETE POLE WAS RUSTED TI TROUGH AT THE BOTTOM OFFICER PULLED THE POLE OUT OF THE GROUND TIIE ADMIN TOOK INSURED INFO AND TOOK PHOTOS INSURED DAUGHTER TOOK PHOTOS AS WELL

4 -4 ' N, 110 Sil'oe.1,1 \ BASIC INFORMATION Spell Check NEXT>> Claim # C5V Contact Made? Yes 1 Date of Loss 104/27/2010, Policy Type CSV Type of Loss Comp. Other Agent Code 9999 Method of Receipt Phone Source INS Named Insured Loss Description IV involved in collision w/animal, bird or falling object Additional Information Iv was parked/occupied in parking space. A handicap sign in the next parkin space fell ' Time of Loss Location of Accident [12:30pm 45 Civic Ave. Parking Lot Pittsb urg, Ca. Who do you think was at Fault? Call Type 1st REPORT Page 1 of 1

5 comriierce utitex p r,e ti Server c.,&t.1 OTAI.Vintlik` ratirMAYes y27 15a. to - PEW 11-rag:177.11!:121r 1 claim Transaction 41 I-2d d 17 Claims I Ilk I History I ST.ibIrdo I Rotes 1E3 r- Nun Eİ4neW 1 TrdriSaCtiOn Ceegt47 10,0 Pc,.- 21 Type P.'s,: Indemnity 00100# r Tracking Cade I Current Reeentearticipated 003 r AddYntl& PiediRecelved Trar * i.,5,1, `2 Arrinsil I Cl.-Linets) Of Coiraeage Exposure Stt.Exposure 001 Covered Auto 2002 VOLRVAGEN PASS Con Treeneetion RarealISS., PANE NT 203 VW PAS SAT I Royale:at - r Pedal Pedant LJ find Payment Cb6d, C5:1. Indemnity Salvage Payee/Mello Claimant ( Horne Tax 14 Type 1..., in RE46,11, Current Roecryoreireolp010a W041,.,D4 PeaReceivecl E6-3',JILEUR AVE APT XA(r.. MICE ROSES ALTO BODY S Mo3 TC,01I7511 f,',24530.g) Transactions 3 ramara ThiREAWLL Payee Category Typo Date int Reserve Aelmliesealion Setop Clam r to Reader of CPO ass. Payment Paylliefit 06c7i20 I'MIKE ROSE'S AUTO ) TAMARA TRFIERDITI Reserve Mmnistration Pies.-Reserve Chong 05: I 004 Oenoral ArInerivernon Close Cairn 05i67( Subrogation Recovery Anticipated &boast lora/may saivant So Other Rao Espense Exo Recovery! Cierarl Rosary 544:14.' Pakeliecelyes Check -r,pe r Pleura' r Enlaneal life a d.i Pstard I A, ChM, Ho /2C I-00i Eflebo Compiehen-sit;# MM Actin4 I I III ILAJ CSV / /04/21119 TIVEADDILL; TAMARA iv rd6e r06/1 4/ PM 1.5TO55WOOt780Prvt0.bnt Iat OAWINDOWS system32... I DAVANCIOWS losysten3z. II The Diamond System 'A' The ) Co., la The Diatrund System Co I

6 Date: 4/29/ :03 AM Supplement: 0 Kirks Appraisal Service 2420 Sand Creek Rd #101, Brentwood, CA (925) Fax: (925) APPRAISAL REPORT DAMAGE ASSESSED BY: KIRK APPLEGATE FILE NUMBER: ASSIGNMENT DATE None CLAIM NUMBER: c CONTACT DATE None DATE OF LOSS; 4/ INSPECTION DATE 4/28/2010 TYPE OF LOSS: RECD DATE None APPRAISED FOR: INSURED: Tamara Threadgi 600 Wilber A Antioch, CA CLAIMANT: None OWNER: None BODY SHOP: time of inspection FAX: INSPECTION SITE: owners home QUALITY RECYCLED PARTS: No AFTERMARKET NEW PARTS: No VEHICLE DRIVEABLE: Unknown Comments: Inspected vehicle at owners home. minor collision damage to rt frt side and w/shield has small crack owner claims is part of loss. Mailed copy to owner. COMPARISON ESTIMATE: 0.00 TOWING: 0.00 ACTUAL CASH VALUE: 8, APPRAISER ESTIMATE: STORAGE: 0,00 SALVAGE VALUE: 0.00 AGREED UPON AMOUNT: 0.00 DEDUCTIBLE: SETTLEMENT: 0.00 REPAIR VS. ACV: 0.00 DRAFT/CHECK NUMBER: 0 ESTIMATE FEE: 0.00 DRAFT/CHECK AMOUNT: 0.00 TRAVEL EXPENSE; 0.00 DATE ISSUED: 4/29/2010 PHOTO EXPENSE: 0.00 MISC EXPENSE; 0.00 TOTAL CHARGES: 0.00 UltraMate is a Trademark of Mitchell International Copyright (C) Mitchell International Page 1 of 1 All Rights Reserved

7 Date: Estimate ID: Estimate Version: Committed Profile ID: 4/29/ :04 AM C-west CALL KIRK'S OFFICE FOR ALL SUPPLEMENTS ( ) Kirks Appraisal Service 2420 Sand Creek Rd #101, Brentwood, CA (925) Fax: (925) Damage Assessed By: KIRK APPLEGATE Date of Loss: Deductible: File Number: Policy No: Insured: Address: Telephone: 4/27/ stonewood v Tamara Threadgi 600 Wilber A, Antioch, CA Home Phone: Arrival Date: 4/29/2010 Claim Number: c Mitchell Service: Description: Body Style: VIN: OEM/ALT: Options: 2003 Volkswagen Passat GLS 4D Sed Drive Train: 1.8L Turbo Inj 4 Cyl 5A FWD VVVWPD631393P License: 5DCX314 CA 0 Search Code: None VEHICLE ANTI-THEFT, PASSENGER AIRBAG, DRIVER SIDE AIRBAG, POWER LOCK POWER WINDOW, POWER STEERING, REAR WINDOW DEFOGGER, MANUAL AIR CONDITION CRUISE CONTROL, TILT STEERING COLUMN, HEATED EXTERIOR MIRROR, SUNROOF (POWER) ANTI-LOCK BRAKE SYS., TRACTION CONTROL, FOG LIGHTS, ALUM/ALLOY WHEELS REMOTE FUELDOOR RELEASE, CD PLAYER, POWER ADJUSTABLE EXTERIOR MIRROR TINTED GLASS, TRIP COMPUTER, FIRST ROW BUCKET SEAT, SECOND ROW BENCH SEAT KEYLESS ENTRY, SECOND ROW FOLDING SEAT REAR HEATING, VENTILATION & AIR CONDITIONING, OUTSIDE TEMPERATURE GAUGE CLOTH SEAT, TACHOMETER, SIDE AIRBAGS, FRONT SIDE AIRBAG WITH HEAD PROTECTION SIDE HEAD CURTAIN AIRBAGS, REMOTE DECKLID OR TAILGATE RELEASE DAYTIME RUNNING LIGHTS Line Entry Labor Line Item Part Type/ Dollar Labor Item Number Type Operation Description Part Number Amount Units BOY REMOVE/INSTALL Frt Bumper ASsy 0.8 # BOY REPAIR Hood Panel Existing 0.5" 3 AUTO REF REFINISH Hood Outside REF BLEND R Fender Outside GLS REMOVE/REPLACE WIShield Glass Sublet * 0.0*# BOY REMOVE/REPLACE R W/Shield Wiper Blade Arm 3B C # BOY REMOVE/INSTALL R %Ai/Shield Washer Nozzle Existing 0.2 r BOY REMOVE/INSTALL L W/Shield Washer Nozzle Existing 0.2 r 9 AUTO REF ADD'L OPR Clear Coat BDY * ADD'L OPR TINT COLOR 0.5* BDY ADD'L OPR RESTORE CORROSION PROTECTION 5.00 * 0.2* BDY * ADD'L OPR MASK FOR OVERSPRAY 5.00 * 0.2* 13 AUTO ADD'L COST Paint/Materials * 14 AUTO ADD'L COST Hazardous Waste Disposal 1.15 * ESTIMATE RECALL NUMBER: 04/29/ :04: Mitchell Data Version: OEM: APR_10_V UltraMate is a Trademark of Mitchell International Copyright (C) Mitchell International Page 1 of 3 UltraMate Version: All Rights Reserved

8 Date: 4/29/ :04 AM Estimate ID: Estimate Version: 0 Committed Profile ID: C-west * - Judgment Item # - Labor Note Applies C - Included in Clear Coat Cale r CEG R&R Time Used For This Labor Operation Estimate Totals Add'i Labor Sublet I. Labor Subtotals Units Rate Amount Amount Totals 11. Part Replacement Summary Amount Body Taxable Parts Refinish Sales 9.250% Non-Taxable Labor Total Replacement Parts Amount Labor Summary 7, III. Additional Costs Amount IV, Adjustments Amount Taxable Costs Insurance Deductible Sales 9.250% Customer Responsibility Non-Taxable Costs 1.15 Total Additional Costs Paint Material Method: Rates!nit Rate = 32,00, 'nit Max Hours = 99.9, Add! Rate = Total Labor: Total Replacement Parts: III. Total Additional Costs: Gross Total: 1, IV. Total Adjustments: Net Total: Insurance Co: Commerce West Ins Address: 4301 Hacien Pleasanto, CA Telephone: Fax Phone: Inspection Site: owners home Inspection Date: 4/ Body Shop: Undecided time of Inspection THIS IS NOT AN AUTHORIZATION FOR REPAIR. AUTHORIZATION FOR REPAIR CAN ONLY BE OBTAINED FROM THE VEHICLE OWNER. ESTIMATE RECALL NUMBER: 04/ :04: Mitchell Data Version: OEM: APRJO_V UltraMate is a Trademark of Mitchell International Copyright (C) Mitchell International UltraMate Version: All Rights Reserved Page 2 of 3

9 Date: 4/ :04 AM Estimate ID: Estimate Version: 0 Committed Profile ID: C-west FAILURE TO PRESENT THIS APPRAISAL TO THE REPAIR FACILITY PRIOR TO REPAIR MAY RESULT IN ADDITIONAL EXPENSE TO YOU. ANY SUPPLEMENT TO THIS APPRAISAL MUST BE AUTHORIZED BY A COMMERCE WEST INSURANCE COMPANY REPRESENTATIVE. COMMERCE NEST INSURANCE COMPANY SHALL NOT CONSIDER PAYMENT OF NEW PART PRICES ABOVE THE MSRP (MANUFACTURER'S SUGGESTED RETAIL PRICE). DRIVABLE VEHICLES ARE TO BE SCHEDULED FOR REPAIR SO WORK CAN BE COMPLETED WITHIN THE SAME BUSINESS WEEK. ESTIMATE RECALL NUMBER: 04/ :04: Mitchell Data Version: OEM: APR_10_V UltraMate is a Trademark of Mitchell International Copyright (C) Mitchell International Page 3 of 3 UltraMate Version: All Rights Reserved

10 Date: :04 AM Estimate ID: Estimate Version: 0 Committed Profile ID: C-west Itemized Totals I. Labor Subtotals Units Rate Totals II. Part Replacement Summary Body ' Taxable Parts Remove/Replace ,60 New II Repair ,00 Sublet II Remove/Install ,60 Additional Operation ($) 0.0 N/A Additional Operation Sales Refinish Blend 0, Total Replacement Parts Amount Refinish Only 2.6 II Additional Operation 1.2 II Non-Taxable Labor Labor Summary III. Additional Costs Amount IV. Adjustments Taxable Costs Insurance Deductible Sales Tax 9.250% Customer Responsibility Non-Taxable Costs 1.15 Total Additional Costs Paint Material Method: Rates!nit Rate = 32.00, [nit Max Hours = 99.9, Addl Rate = 0.00 Total Labor: II. Total Replacement Parts: Ill. Total Additional Costs: Gross Total: IV. Total Adjustments; Net Total: 9.250% Amount , Amount ' Total includes Additional Labor ($) dollar amounts as shown within the group ESTIMATE RECALL NUMBER: 04129/ :04: Mitchell Data Version: OEM: APR_10_V UltraMate is a Trademark of Mitchell International Copyright (C) Mitchell international UltraMate Version: All Rights Reserved Page 1 of 1

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