Party Statement: INTERINSURANCE EXCHANGE OF THE AUTOMOBILE CLUB, AN INTERINSURANCE EXCHANGE VS EDER FLORES, ET AL.

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                                'OR
                                                                  - DO NOT FILE WITH THE COURT-                                                              CIV-050
           - UNLESS YOU ARE APPLYING                          FOR A DEFAULT JUDGMENT UNDER CODE OF CIVIL PROCEDURE 0 585-
      ATTORNEY OR PARTY WITHOUT ATTORNEY (Name           snd Address).                          TELEPHONE NO                          COURT USE ONI. Y
                                                                                      (213)741-4598
      James H. Aguirre, ESQ. CSB¹81442
      Law         Offices of Richardson, Fair                              g Cohen
      2601 South Figueroa Street
      2601 SOUTH FIGUEROA STREET
      Los Angeles, CA 90007
      ATTORNE'r FOR(name(            luteriusurauce Excbaupe ofthe Automobile Club. an iuterinsurance exchen e
      SUPERIOR COURT OF CALIFORNIA, COUNTY OF                                  LOS ANGELES
           sTREETADDREss             111 North Hill Street
           MAILINGADDREss            ill North Hill Street
           c(TYANDzlpcoDE            Los Angeles, CA 90012
                 SRANCHNAME:         CENTRAL JUDICIAL DISTRICT
                  P(A™ r(FF:         iuteriosurance Exchange of the Automobile Club, an intennsurance exchange
                 DEFENDANT:          Eder Flores, et              al.,
p(aintiff                                   STATEMENT OF DAMAGES                                                                     20STLC02409
                                         (Personal Injury or Wrongful Death)
     To (name of one defendant only):                    Eder Flores
     Plaintiff (name ofone        onl):                    luteriuaurauce       Sxchaccre of the Automobile          club, an iutericeurauce exchange
     seeks damages in the above-entitled action, as follows:
                                                                                                                                                     AMOUNT
     1. General damages
            a.    M        Pain, suffering, and inconvenience                                                                                   $

            b.    ~        Emotional distress                                                                                                   $

            c.    M        Loss of consortium
            d.    D        Loss of society and companionship (wrongful death actions oniyj               ..
            e.    ~~       Other (specify)
                           Other (specify)
                           Continued on Attachment 1.g.
     2.     Special damages
            a.t        z
                    Medical expenses (to date)                .




            b.    M        Future medical expenses (present va/ue)
            c.    ~~       Loss of earnings (to date),

            d.
            e.
                  ~
                  MX
                           Loss of future earning capacity (present va/ue).
                           Property damage
                                                                                                                                                $
                                                                                                                                                $       5.161.04
            f.    M        Funeral expenses (wrongful death actions only) .
            g.    ~        Future contributions (present value) (wrongful des(h actions            only)........                                $

            h.    M Value of personal service, advice, or training (wrongful death actions only) ..                                             $

                           Other (specify)                                                                                                      $

            j.    ~        Other (specify)
            k.    i~       Continued on Attachment 2.k.

      S.    (      .   Punitive damages: Plaintiff reserves the right to seek punitive damages in the amount of (specify)..$
                       when pursuing a judgment in the suit filed against you.
      Date:       March         jt.,       2020

     James H. Aauirre, ESO. CSB¹81442
                                       (TYPE OR PRINT NAMEI                                           (SIGN/FORE OF PLAINTIFF OR ATTORNEY FOR PLAINTIFF)
                                                                          (Proof of service on reverse)                                                           Pace 1 of 2
  Form Adopted for Mandatory Use                                        STATEMENT OF DANIAGES                        I mon)       code of civil procedure, 55 n2511, 425115
      Jud oal Counol of Californ a
   CIV-050(Rav January I 2001(                                       (Personal Injury or Wrongful Death)          Sotu~tnns