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CC SR 20241001 E - Claim Against the City Nieto CITY COUNCIL MEETING DATE: 10/01/2024 AGENDA REPORT AGENDA HEADING: Consent Calendar AGENDA TITLE: Consideration and possible action regarding a claim against the City by Matthew Nieto. RECOMMENDED COUNCIL ACTION: 1) Reject the claim and direct Staff to notify the claimant, Matthew Nieto FISCAL IMPACT: None Amount Budgeted: N/A Additional Appropriation: N/A Account Number(s): N/A ORIGINATED BY: Enyssa Sisson, Deputy City Clerk REVIEWED BY: Teresa Takaoka, City Clerk APPROVED BY: Ara Mihranian, AICP, City Manager ATTACHED SUPPORTING DOCUMENTS: A. Matthew Nieto claim (page A-1) BACKGROUND AND DISCUSSION: The City of Rancho Palos Verdes (City) is a member of the California Joint Powers Insurance Authority (Authority), which provides risk management services and handles any liability claims received by the City. Under the current practice, claims presented to the City Clerk are forwarded by the Authority to a third-party claims administrator, Carl Warren and Company (Carl Warren) for adjusting. Carl Warren’s staff reviews each claim on its merits and contacts the City with any requested action pertaining to the disposition of the claim. The City Clerk and the City Attorney review each claim when received and work closely with Carl Warren throughout the claims process. 1 CITYOF RANCHO PALOS VERDES Claimant: On September 13, 2024, the City received a claim for damages from Matthew Nieto. The claim was referred to Carl Warren for review and investigation. The claimant states that his vehicle suffered damages on July 10, 2024. The claimant alleges that the City is responsible for the damage to his vehicle due lack of warning signs of hazardous roadway along Palos Verdes Drive South. Deposition: Carl Warren has reviewed the claim and advised the City to reject it due to the determination that the City had adequate signage placed in numerous locations, inspects the roadways regularly, and addresses dangerous conditions to the best of its capability. Carl Warren recommends denying the claim for damages. 2 A-1 September 6, 2024 CITY CLERK'S OFFICE City of Rancho Palos Verdes 30940 Hawthorne Blvd. Rancho Palos Verdes, CA 90275 RE: Loss Date: Ge ico In sured : Ge ico C laim#: SubroClaims#: Dear Claims, 7/10/2024 Matthew Nieto u O CLAIMS I RECEIVED CITY OF RAN(, 10 PALOS VERDES SEP 1 3 2024 CITY CLERK'S OFFICE Our office has been retained by Geico In surance to help exped ite payment on the above c la im . Ge ico In surance has already conc lud ed their investig ation of the acc id ent and has found your in sured liable for our damages . Payment for damages has been made. Documentation is attached . Please honor our c la im. Property Damage: ln sd Ded : TOTAL: $2033.42 $ 250.00 $2283.42 Please make your check payable to SubroC laims In c. and mail it to us at the following address. Shou ld you require any ass istance in resolving this matter, please contact us at 800-949-5655 or info@subroclaims .com . Please refer to the Subro Claims number when ca llin g about this claim. Sincerely, Insurance Department On Beha lf of Geico Please be advised that any payment in an amount less than that set forth in this lette r that is forwarded to SubroClaims without it s prior authorization as described below will not constitute a full and final sett lement and will be accepted as partial payment only . Since payments received in the mail are processed by clerical staff and deposited as a matter of course without examination, unauthorized payments for less than the full amount demanded may be processed inadvertently. Although such payments may be demarked as "payment in full" or have other words of s imil ar meaning written on them, their processing will not constitute an accord and sat isfaction, as SubroClaims/Geico has not agreed to acceptance of such payments. 28150 N Alma School Parkway #103 -642, Scottsdale, AZ 85262 Tel : (800) 949-5655 Fax (408) 369-9169 Emai l :info@subrocla ims.com https ://subrocla ims.com A-2 FILE WITH: CITY CLERK'S OFFICE City of Rancho Palos Verdes 30940 Hawthorne Blvd. Rancho Palos Verdes, CA 90275 CLAIM FOR DAMAGES TO PERSON OR PROPERTY INSTRUCTIONS 1. Claims for death, injury to person or to personal property must be filed not later than six months after the occurrence. (Gov. Code Sec. 911.2.) 2. Claims for damages to real property must be filed not later than 1 year after the occurrence. (Gov. Code Sec. 911.2.) 3. Read entire claim form before filing. 4. See Page 2 for diagram upon which to locate place of accident. 5. THIS CLAIM FORM MUST BE SIGNED ON PAGE 2 AT BOTTOM. 6. Attach separate sheets, if necessary, to give full details. SIGN EACH SHEET. TO: CITY OF RANCHO PALOS VERDES Name of Claimant Subro Claims, Inc o/b/o Geico Ins a/s/o Matthew Nieto Home Address of Claimant City and State Business Address of Claimant City and State Give address and telephone number to which you desire notices or communications to be sent regarding this claim: RESERVE FOR FILING STAMP CLAIM NO. _____ _ RECEIVED CITY OF RANCHO PALOS VERDES SEP 1 3 2024 CITY CLERK'S OFFICE Date of Birth of Claimant Occupation of Claimant Home Telephone Number Claimant's Social Security No. When did DAMAGE or INJURY occur? Date 0111012024 Time ______ _ Names of any city employees involved in INJURY or DAMAGE n/a If claim is for Equitable Indemnity, give date claimant served with the complaint: Date Where did DAMAGE or INJURY occur? Describe fully, and locate on diagram on Page 2. Where appropriate, give street names and address and measurements from landmarks: Describe in detail how the DAMAGE or INJURY occurred. Insured struck pothole. Why do you claim the city is responsible? The city is responsible because the city did not properly maintain the road. Describe in detail each INJURY or DAMAGE. Damages to the insureds Nissan Cube 2009 -supporting documents attached. This Claim Must Be Signed on Page 2 A-3 The amount claimed, as of the date of presentation of this claim, is computed as follows: Damages incurred to date (exact): Estimated prospective damages as far as known: Damage to property .................... $ 2,283.42 Future expenses for medical and hospital care . $ ___ _ Expenses for medical and hospital care ... $____ Future loss of earnings ..................... $ ___ _ Loss of earnings ...................... $____ Other prospective special damages .......... $ ___ _ Special damages for ................... $____ Prospective general damages ............... $ ___ _ Total estimate prospective damages ....... $ ___ _ General damages ...................... $ 2,283.42 Total damages incurred to date ........ $ ___ _ Total amount claimed as of date of presentation of this claim: $2,283.42 Was damage and/or injury investigated by police? No If so, what city? ________________ _ Were paramedics or ambulance called? No If so, name city or ambulance _______________ _ If injured, state date, time, name and address of doctor of your first visit __________________ _ WITNESSES to DAMAGE or INJURY: List all persons and addresses of persons known to have information: Name NIA Address _________________ Phone ________ _ Name _____________ Address _________________ Phone ________ _ Name _____________ Address _________________ Phone ________ _ DOCTORS and HOSPITALS: Hospital _N_IA __________ --'Address ______________ Date Hospitalized ______ _ Doctor Address Date of Treatment ______ _ Doctor Address Date of Treatment ______ _ READ CAREFULLY For all accident claims place on following diagram names of streets, including North, East, South, and West; indicate place of accident by "X" and by showing house numbers or distances to street corners. If City Vehicle was involved, designate by letter "A" location of City Vehicle when you first saw it, and by "B" location of yourself or CURBJ your vehicle when you first saw City vehicle; location of City vehicle at time of accident by "A-1" and location of yourself or your vehicle at the time of the accident by "B-1" and the point of impact by "X." NOTE: If diagrams below do not fit the situation, attach hereto a proper diagram signed by the claimant. SIDEWALK PARKWAY SIDEWALK Signature of Claimant or person filing on Typed Name: Date: . . . . . NOTE: CLAIMS MUST BE FILED WITH CITY CLERK (Gov. Code Sec. 915a). Presentation of a false claim is a felony(Pen. Code Sec. 72.) THIS DOCUMENT IS A PUBLIC RECORD AND MAY BE PROVIDED TO A REQUESTOR UPON DEMAND. A-4 9/6/24, 10:43 AM 0 Rancho Palos Verdes, California Goog le Street V iew Feb 2023 See more dates -Image capture : Feb 2023 © 2024 Google https://www.goog le .com/maps/@33.7376484,-118 .3570052,3a,75y,332 .26h ,90.21 t/data =!3m7 I1 e1 !3m5!1 sfbWxh-A 1 rlTF-cP4k1 wrRQ!2e0!6shttps:%2F... 1 /1 A-5 C laim Number Pay To The Order Of Flnanolo ls Gross Amount Net Amount Backup Withholding Paymsn t Identifi cation Issu ed Date Mail To Name Mail TO Address Memo Payment Typ e Check Number Re lated Documents Document Na me Reserve Li ne All ocation Exposure , Matthew Anthony Nieto -Col lision (2009 NI SSA N) Matthew Ant hony Nieto $2,033.42 $2,033.42 $0.00 07/24/2024 Matthew Anthony Nieto • Collision Coverage Customer Choice - Reserve Une Collision Cost Type 'Loss Arnount $2 ,033.42 A-6 Insured: Type of Loss: Point of Impact: Owner (Insured): Matthew Nieto GEICO GENERAL INSURANCE COMPANY California Request a Supplement: CCC Facility: Use CCC Estimate Share Non-CCC Facility: partners.geico.com PO Box 509060 Claim#: San Diego, CA 92150 Workfile ID: Matthew Nieto Collision 12 Front Supplement of Record 1 Summary Written By: THEARY LY, 7/19/2024 12:57:31 PM Adjuster: Brown, Constance, (478) 444-6398 Business Owner Policy#: Date of Loss: Deductible: 07/10/2024 11:10 AM 250.00 Claim#: Days to Repair: 1 Inspection Location: Appraiser Information: (657) 368-9714 Repair Facility: Virtual VEHICLE A&E AUTO SERVICE LLC 1660 W 25TH ST SAN PEDRO, CA 90732 (424) 494-9158 Evening 2009 NISS cube S w/Continuously Variable Transmission 4D WGN 4-1.8L Gasoline SMPI Steel Gray Pearl Met VIN: Production Date: Interior Color: Black License: Odometer: 206449 Exterior Color: Steel Gray Pearl Met State: CA Condition: TRANSMISSION CONVENIENCE Stereo Bucket Seats Automatic Transmission Air Conditioning Search/Seek Reclining/Lounge Seats POWER Intermittent Wipers CD Player WHEELS Power Steering Tilt Wheel Auxiliary Audio Connection Wheel Covers Power Brakes Cruise Control SAFETY PAINT Power Windows Rear Defogger Drivers Side Air Bag Clear Coat Paint Power Locks Keyless Entry Passenger Air Bag Metallic Paint Power Mirrors Alarm Anti-Lock Brakes ( 4) OTHER DECOR Rear Window Wiper Front Side Impact Air Bags Traction Control Dual Mirrors RADIO Head/Curtain Air Bags Stability Control Privacy Glass AM Radio SEATS Console/Storage FM Radio Cloth Seats 7/19/2024 12:57:31 PM 453702 I 1.9.05.12010 Page 1 A-7 Claim#: Workfile ID: Supplement of Record 1 Summary 2009 NISS cube S w/Continuously Variable Transmission 4D WGN 4-1.8L Gasoline SMPI Steel Gray Pearl Met Line Oper Description Part Number Qty Extended Labor Price$ 1 FRONT SUSPENSION 2 * S0l Rep! RT Strut auto trans E4C021FC1C 1 212...5.1 m Q.Q 3 * S01 Repl LT Strut auto trans E4C031FC1C 1 215.51 m 0.0 4 MISCELLANEOUS OPERATIONS 5 # S01 Agreement Reached 1 1,297.16 X NOTE: This estimate is based on a specialized estimate and may contain some concessions. This should be considered one time and not set precedent 6 REAR SUSPENSION 7 * S0l Rep! RT Shock E6B101FC0C 8 * S01 Repl LT Shock E6B101FCOC 9 ENGINE / TRANSAXLE 10 * S01 Repl RT Front mount auto trans 112101FC0A 11 * S0l Repl LT Front mount auto trans 11220ED000 12 COOLING 13 * S0l Repl Mount bracket 216131JY0B 14 * S0l Rep! Belt tensioner 11955JD21A 15 # S01 Rep! Belt SUBTOTALS NOTES Prior Damage Notes: No wheel covers on vehicle. Scratching on RT side of forornt bumper cover is UPD. 7/19/2024 12:57:31 PM ESTIMATE TOTALS Category Parts Miscellaneous Subtotal Sales Tax County Tax Other Tax 1 Total Cost of Repairs Deductible Total Adjustments Net Cost of Repairs 453702 I 1.9.05.12010 1 112.21 1 11U1 1 ~ 1 25.18 1 63.64 1 80.87 1 25.18 2,197.85 Basis $ 900.69 @ $ 900.69 @ $ 900.69 @ m m m m m 0.0 0.0 Q.Q 0.0 0.0 0.0 Rate 6.0000 % 1.2500 % 2.2500 % Paint 0.0 Cost$ 900.69 1,297.16 2,197.85 54.04 11.26 20.27 2,283.42 250.00 250.00 2,033.42 Page 2 A-8 Claim#: Workfile ID: Supplement of Record 1 Summary 2009 NISS cube S w/Continuously Variable Transmission 4D WGN 4-1.8L Gasoline SMPI Steel Gray Pearl Met SUPPLEMENT SUMMARY Line Oper Description Part Number Qty Extended Labor Paint Price$ Deleted Items 1 # ++++++SHOP, CUSTOMER IS 1 REPORTING DAMAGE++++++ 2 # ++++++ TO UNDERCARRIAGE 1 AND TO SUSPENSION++++++ 3 # ++++++PLEASE INSPECT AND 1 ADORES ON SUPPLEMENT++++++++ 5 # Agreement Reached 1 Added Items 1 FRONT SUSPENSION 2 * S0l Rep! RT Strut auto trans E4C021FC1C 1 215.51 m 0.0 3 * S0l Rep! LT Strut auto trans E4C031FC1C 1 215.51 m 0.0 5 # S0l Agreement Reached 1 1,297.16 X NOTE: This estimate is based on a specialized estimate and may contain some concessions. This should be considered one time and not set precedent 6 REAR SUSPENSION 7 * S01 Rep! RT Shock E6Bl01FC0C 1 112.21 m 0.0 8 * S0l Rep! LT Shock E6B101FC0C 1 112.21 m 0.0 9 ENGINE / TRANSAXLE 10 * S0l Rep! RT Front mount auto trans 112101FC0A 1 ~ m Q.Q. 11 * S0l Rep! LT Front mount auto trans 11220ED000 1 25.18 m 0.0 12 COOLING 13 * S0l Rep! Mount bracket 216131JY0B 1 63.64 14 * S0l Rep! Belt tensioner 11955JD21A 1 80.87 m 0.0 15 # S0l Rep! Belt 1 25.18 SUBTOTALS 2,197.85 0.0 0.0 NOTES Prior Damage Notes: No wheel covers on vehicle. Scratching on RT side of forornt bumper cover is UPD. 7/19/2024 12:57:31 PM 453702 I 1.9.os.12010 Page 3 A-9 Claim#: Workfile ID: Supplement of Record 1 Summary 2009 NISS cube S w/Continuously Variable Transmission 4D WGN 4-1.SL Gasoline SMPI Steel Gray Pearl Met TOTALS SUMMARY Category Basis Rate Cost$ Parts M iscel la neous 900.69 1,297.16 Subtotal 2,197.85 Sales Tax County Tax Other Tax 1 $ 900.69 @ $ 900.69 @ $ 900.69 @ 6.0000 % 1.2500 % 2.2500 % 54.04 11.26 20.27 Total Supplement Amount 2,283.42 NET COST OF SUPPLEMENT 2,283.42 CUMULATIVE EFFECTS OF SUPPLEMENT(S) Estimate 0.00 CONSTANCE BROWN Supplement SO 1 2,283.42 THEARY LY Worktile Total: $ 2,283.42 TOTAL ADJUSTMENTS: $ 250.00 NET COST OF REPAIRS: $ 2,033.42 This is not an authorization to repair. All GEICO customers have the right to have their vehicle repaired in the shop of their choice. No Supplement will be honored unless authorized by GEICO. NOTICE: Vehicles constructed of special metals may require the use of specialized welding and bonding equipment. Proper measuring and structural repair systems are required on today's vehicle to accurately accomplish vehicle repairs. Make sure your shop has the proper equipment to repair your vehicle. ALTERNATE PARTS DISCLAIMER: IF A QUALITY REPLACEMENT PART (A/M, LKQ, RECOND OR OPT OEM) APPEARS ON THIS ESTIMATE, IT INDICATES THAT THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF ONE OR MORE CRASH PARTS SUPPLIED BY A SOURCE OTHER THAN THE MANUFACTURER OF YOUR MOTOR VEHICLE. GUARANTEES, IF ANY, APPLICABLE TO THESE REPLACEMENT CRASH PARTS ARE PROVIDED BY THE PART MANUFACTURER OR DISTRIBUTOR RATHER THAN BY THE MANUFACTURER OF YOUR VEHICLE. ***IN ADDITION TO ANY SUCH GUARANTEES, GEICO PROVIDES THE FOLLOWING: ****OWNER LIMITED GUARANTEE**** WE GUARANTEE THAT ALL QUALITY REPLACEMENT BODY PARTS (PARTS NOT MANUFACTURED BY THE MANUFACTURER) IDENTIFIED ON YOUR ESTIMATE, ARE FREE OF DEFECTS IN MATERIAL AND WORKMANSHIP AND MEET GENERALLY ACCEPTED INDUSTRY STANDARDS. THIS PARTS AND LABOR GUARANTEE WILL BE IN EFFECT FOR AS LONG AS YOU OWN THE VEHICLE DESCRIBED IN THE ESTIMATE. THIS GUARANTEE COVERS THE COST OF THE PART, LABOR TO INSTALL, AND INCIDENTALS SUCH AS PAINT AND MATERIALS AND IS SPECIFICALLY LIMITED TO THOSE ITEMS. THIS GUARANTEE DOES NOT COVER LOSS OR DAMAGE THAT IS UNRELATED TO DEFECTS IN THE QUALITY REPLACEMENT PARTS. THIS IS NOT TRANSFERABLE. 7/19/2024 12:57:31 PM 453702 I 1.9.05.12010 Page 4 A-10 Claim#: Workfile ID: Supplement of Record 1 Summary 2009 NISS cube S w/Continuously Variable Transmission 4D WGN 4-1.SL Gasoline SMPI Steel Gray Pearl Met IF ANY QUALITY REPLACEMENT PARTS ARE DEFECTIVE IN EITHER MATERIAL OR WORKMANSHIP, CONTACT YOUR LOCAL GEICO REPRESENTATIVE. FOR YOUR PROTECTION 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=DIAGNOSTIC, 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=CERTIFIED AUTOMOTIVE PARTS ASSOCIATION, D&R=DISCONNECT AND RECONNECT, EST=ESTIMATE, EXT. PRICE=UNIT PRICE MULTIPLIED BY THE QUANTITY, INCL=INCLUDED, MISC=MISCELLANEOUS, NAGS=NATIONAL AUTO GLASS SPECIFICATIONS, NON-ADJ=NON ADJACENT, O/H=OVERHAUL, OP=OPERATION, NO=LINE NUMBER, QTY=QUANTITY, RECOND=RECONDITION, REFN=REFINISH, REPL=REPLACE, R&I=REMOVE AND INSTALL, R&R=REMOVE AND REPLACE, RPR=REPAIR, RT=RIGHT, SECT=SECTION, SUBL=SUBLET, LT=LEFT, W/O=WITHOUT, W/_=WITH/_ SYMBOLS: #=MANUAL LINE ENTRY, *=OTHER [IE .. MOTORS DATABASE INFORMATION WAS CHANGED], **=DATABASE LINE WITH AFTERMARKET, N=NOTES ATTACHED TO LINE. OPT OEM=ORIGINAL EQUIPMENT 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. 7/19/2024 12:57:31 PM 453702 I 1.9.05.12010 Page 5 A-11 Claim#: Workfile ID: Supplement of Record 1 Summary 2009 NISS cube S w/Continuously Variable Transmission 4D WGN 4-1.8L Gasoline SMPI Steel Gray Pearl Met 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 ARF3640, CCC Data Date 07/01/2024, 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. 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. O/H=Overhaul. Qty=Quantity. Refn=Refinish. Repl=Replace. R&I=Remove and Install. R&R=Remove and Replace. Rpr=Repair. RT=Right. SAS=Sandwiched Steel. Sect=Section. Subl=Sublet. UHS=Ultra High Strength Steel. N=Note(s) associated with the estimate line. CCC ONE Estimating - A product of CCC Intelligent Services Inc. The following is a list of abbreviations that may be used in CCC ONE Estimating that are not part of the MOTOR CRASH ESTIMATING GUIDE: BAR=Bureau of Automotive Repair. EPA=Environmental Protection Agency. NHTSA= National Highway Transportation and Safety Administration. PDR=Paintless Dent Repair. VIN=Vehicle Identification Number. 7/19/2024 12:57:31 PM 453702 I 1.9.05.12010 Page 6 A-12 Claim#: Workfile ID: Supplement of Record 1 Summary 2009 NISS cube S w/Continuously Variable Transmission 4D WGN 4-1.8L Gasoline SMPI Steel Gray Pearl Met WE WARRANT THAT ALL PARTS USED IN THE REPAIR OF THIS VEHICLE ARE EQUAL TO THE ORIGINAL EQUIPMENT MANUFACTURER PARTS IN TERMS OF KIND, QUALITY, SAFETY, FIT AND PERFORMANCE. THIS PARTS AND LABOR WARRANTY WILL BE IN EFFECT FOR AS LONG AS YOU OWN THE VEHICLE DESCRIBED IN THE ESTIMATE. THIS WARRANTY COVERS THE COST ASSOCIATED WITH RETURNING THE PART AND THE COST TO REMOVE AND REPLACE THE NON-ORIGINAL EQUIPMENT MANUFACTURER PART WITH A COMPLIANT NON-ORIGINAL EQUIPMENT PART OR AN ORIGINAL EQUIPMENT MANUFACTURER PART. THIS WARRANTY DOES NOT COVER LOSS OR DAMAGE THAT IS UNRELATED TO DEFECTS IN THE QUALITY REPLACEMENT PARTS. THIS WARRANTY IS NOT TRANSFERABLE. IF ANY QUALITY REPLACEMENT PARTS ARE DEFECTIVE IN EITHER MATERIAL OR WORKMANSHIP, YOU MUST CONTACT YOUR LOCAL GEICO REPRESENTATIVE. If a customer subsequently chooses a repair shop, GEICO shall prepare a supplement using the prevailing rate in the Geographic Area of the customer's chosen shop. This is not an authorization to repair. The undersigned repair facility is in agreement to the estimate prepared by GEICO in the amount of$ ________ . No supplements will be honored by GEICO without prior approval. Signed: ________ _ Print Name: _______ _ Date: _________ _ We are required under sect 2695.?(b) of the Unfair Claims Settlement Practices Regulations to provide the following notice: If you believe that your claim has been wrongfully denied or rejected, you also have the right to have the California Department of Insurance review this matter. The Department of Insurance is located at 300 South Spring Street, Los Angeles, CA 90013, telephone number (800) 927-4357. As part of the estimating process, GEICO may elect to inspect or re-inspect the vehicle in person, after photos have been received. 7/19/2024 12:57:31 PM 453702 I 1.9.05.12010 Page 7 A-13 ---Mlllat :llla&NI SLt,~: ..._, ..... ~-·-..... fw.,w!ft20!IDl1lJ.'ln141~,...... VW:.MU.ZIMIIT111'U1 ---lm1Dllli9:fl1nlm'4 ---~:n..vLy Pl:a,pHLfflllt:4-- l'llmlT_Ouo_...,-11t11:U:11~-- VW..OMw-~-- ~N ...... :o1 .,_,___. _, __ SJic:.itav-J : ---•~v-,...- .,.,....,..,._:cci:l'Oak,u.1m,1.u,151 .... WI :M&Anlltll111lm P.afl9l.allal--O• LGU0.:flffllW31M ---~:niur,Lv Pdq>NUll'ltlw:4mNND c.py:su,~ .... ,Nm&AN 81.e,~: Mlldll:...■~•lt'lllfklNT~ ~Fa.Hilr.le:ec109M1U.111141Ml11 ..... VIN:JMIAl'Jlltlllt17U1 ~Labll:i.eee ---,.....,n-v1.y f'dlcJN\ffllW:4_, PhcmT-.Ollla:al...,-'n11:U:11-6tlrl'III--.W ........ a....:IWI"-..... ~!~:01 A-14 (Rev. Oc;lober 201&) Otpartment of tho Treasury !ntemal Revenue Smlk:e Request for Taxpayer Identification Number and Certification Give Form to the requester. Do not send to the IRS. ► Go to www.irs.gov/FormW9 for Instructions and tf1e latest Information. 1 Name (8.11 shQwn on your Income ta,11 retum). Neme ii.I required on this lino; do not leave lhli line blank. SubroClalms, Inc l Buslnt!S3 nwne/dlsregan:led entity namo, II different from !WQ118 c,; i :s Check approprlale boll for lederat tax cl!lllsificatloo ol the person whose name is mternd on me 1. CMdl only one of 1he 4 El<fflTlpllons (codes apply only to follOWtng ~ boXes. eertaln entitles, not Individuals; 11811 Q, 6 0 lndividual/soie proprietor or O C Corporation 0 S CorpOf'tlllon O Pertnemhip 0 Trust/estate lnstroellooa on page 3): Exempt ~code(if atlY) __ _ ,! f! mg1t-mwbor u.c E, t O Limited lia.blllty company. Entor tho tax ctas,mcatiul'I (C,::C co,poratlon, s,.s C(lfJ>Ollition. P=Partnership) ► __ _ .. ,: _s Noto: CMCI( 11\e 11pproprlate bOx rn the line abow for the tax WISSlfication of the single-member ()Wf1f;lf. Po not chook Exemption fmm FATCA reporting i;; ! l.l.C If the LLC Is clesslfled as a single.member LLC that la dlsregarde(t rrom the owner unteu the owner of the U.C ls code ~f eny) 'C -another LLC that is not disregarded fl'Qm Iha OWl\8f lor U.S. federal tllll pl,ltp0$es. Otherwise, a ,Ingle-member LLC Iha! a. u 111 dllll'egarded from the owner should check the appropriate box for lhe taic cl~tlon of itn owner. I Olher(seelnstl\lC!ions)► ~•0 --...-,,..11.s.1 j 1-:S,.,,..Ad...,.d.,;;,,;1'8S$.;;.;;;.,:(n;;.;.umber;..;..;;;..;:.:.streel.:....;,..,.;;.:.and_ap-t.-or_$1,1.,..ito-nei-.)..,,.$e_e,....lns_lfl.l_ctl..,...,;>n-s.--------..,.,~-ues-1er..,..'s-na_m_e an1-d.,..,_1i..,...dd-,,_----,-{op-ti0nal)__,.---- j Taxpayer Identification Number {TIN) Enter your TIN In th& appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally YoUr social $tlcurity number (SSN). Howev-. for a resident alien, sole proprietor, or d"isregarded entity, see the instructions for Part I, later. F<J1 other entitles, l1 is your employer Identification number (EIN). If you do not have a number, see How to get a TIN, later. Social HCUrfly number DIJ-DJ Nate: If th& account i$ In more than ooe name, sea lhe instructions for line 1. Al&o see What Name and Number To Give tm, Requester for guldG!lnes on whose number to enter. Certification Under penalties of perjury, I certify that: 1, The number shown on this fmm Is my correct taxpayM identif!C8tion numbef (or I am waiting for a number to be issued to me); and 2. I am not subject to backup withhOldlng because: {a) I am ex.empt from backup withttolc.fing, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup wlthholdir,g as a result of a failure to report all interest or dhliClends. or (c) the IRS has notified me that I am no tonger Sl.l~ to backup wtthholding; 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 (tf any) indicating that I am exempt from FATCA repot11r,g is correct. Certltlcmlon Instructions. You must cross out item 2 ab0\T$ if you have been noUflfld by the IFIS that you era currently subject to backup withholding because you have tailed 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, paymf)flts other than interest and dividend$, you are not required to sign the certification, but you must provide your Col'l'f!Ct TIN. See lhe Instructions for Pert II, latl!lf. Sign Here General Instructions Section references are to the Internal Revenue Code unless otherwise noted. Future developments. For u,e latest lnformatloo about develOpments rela1ed to Form W-9 and its Instructions, such as legislation enacted after !hey were published, go to www.lrs.gov/FormW9. Purpose of Form .Al"l lndlllldual or entity (Form W•9 rea,uester) who is required to file an Information retum with the IRS must obtain your correct taxpayer ldenliflcallon number (TIN) which may be your 80<liel security number (SSN), lndMdual te>lpayer identification number (ITIN), adoption taxpayer lden!lflcelion number (ATIN), or employer Identification number (ElN), to report on an Information retum the smount paid to you, or other amount reportable on an Information retum. Examples of information retums include, but are not limited to, the following. • Form 1091'MNT Qntereat eamed or paid) ..... , ,. Cat. No. 10231X Dato ► • form 1099-0IV (dividends, lneludlng those from stocks or mutual funds} • Form 1099-MISC {variou$ types of income, prizes, awards, or gross proeeedS) • Form 1099·8 (stock or mutual fund sales and certain other transactions by brokers) • Form 1099·$ (proceeda from real estate transaction11) • Form 1099•K (merchant card and tlllrd party network transactions) • Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098• T (tuition) • Form 1099"C (canceled debt) • Form 1099-A (acqui!lition or abandOnment or secured property) Use Form W-9 only If you are a U.S. person ~ncluding a resident alien), to provide your correct TIN, If you do not mum Form W-9 to the req,.,e,ter with a TIN, you might be subjoct to backup Withholding. SH What le backup withholding, later • .. 1 FQtm W-9 (RIV, 10-2018)