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CC - Item IV C - Authorization To Reject Claim Against City From Inez MartinezTO: HONORABLE MAYOR AND MEMBERS ROSEMEAD CITY COUNCIL FROM: NANCY VALDERRAMA, CITY CLERK, CMC DATE: SEPTEMBER 7, 2000 RE: AUTHORIZATION TO REJECT CLAIM AGAINST CITY FROM INEZ MARTINEZ The attached claim was received in this office on June 12, 2000. A copy was sent to the City's claims adjuster, Carl Warren & Company on the same day. Carl Warren & Company sent a notice on August 7, 2000, recommending that the aforementioned claim be rejected by the City. Recommendation: It is recommended that the City Council approve the rejection of this claim and authorize a letter of rejection be sent to the claimant. Attch. COUP4CIL AGENDA 0 C T 2 4 2000 ITEM No. staf epor o-z'5- C / MAYOR'. MARGARET CLARK MAYOR PRO TEM.JAY T IMPERIAL COUNCILMEMBERS: ROBERT W. BRUESCH GAR) A. TAYLOR. JOE VASOU'c2 October 3, 2000 Dwi_eht J. Kunz Senior Account Manager Carl' arren & Company 750 The City Drive, Suite 400 Orange, CA 102665 t~C~ ~ ~sei~e8d 8838 E. VALLEY BOULEVARD • FO. BOX 399 ROSEMEAD: CALIFORNIA 91770 TELEPHONE (626) 569-2100 FAX (626) 307-9218 Re: Andrea Marie Chavarin (Minor) Claim Dear Mr. Kunz: The attached Claim was received in my office today. The City does not have any prior information on this claim. Please note that this incident occurred at Janson Elementary School, which falls within the Rosemead School District. Please advise as to the steps you wish to take in this matter. Sincerely, NANCY VALDERRAMS City Clerk cc: City Attorney FILE WITH CLAIM FOR DAMAGES RESERVE FOR FILING STAMP CITY CLERK'S OFFICE EE3E E. Valley Boulevard TO PERSON OR PROPERTY CLAIM. NO. Rosemead, CA 91770 RECEIVED INSTRUCTIONS t. Claims for death, injury to person Or to personal property musl be filed no; later than six CITY OF ROSEMEAD months alter the occurrence. (Gov. Code Se_ 971.2.) 2. Claims for damages to real property muss be filed not later than t year alter the occurrence. OCT 3 2000 (Gov. Code Sec 97 ~zJ 3 Read entire claim form before filing. 4. See pane 2 for diaoram upon which to locate place of accident CITY CLERK'S OFFICE S. Tnk claim Corm must be signed on page 2 al bottom. E. Anach separate sheets, if necessary, m dive full oezails. SIGN EACH SHEET. hC a h Dated5i0 O: EE3E Oallec Bivd:, R.asemead °1770 C77 y T EDS_AD, ~ / U / l1lV1 3 Na. a Dt Claimant CAF °ac~ r n IRc~Sem yc Abr e Ch mant D..~u pooh Clai f r t l l a Incarecz Hor~meq Adorers of C pimant C and Sate ~ St1"~°~~t; ~os(rnrac~CA .11770 rf a ~ 3 me ie ephone Number ab) -221L -aa7g ar o U 1 3 ee Andress of Claiman; Cny and Slate I Busin usmesst~ hone Number l ~ l t anndd telephone number to which you desire Tit DT communications to b~senl Give adore= -ardinn this ^ im: `C0 ' J S e -C 7 re n 's Social Secumv Na a Clarm ~p l'I _ ' -3 Nana ~ l v s? ~3G d s4z do ~ / (f~ C When did DAMAGE or INJURY occur? y"~ Names o' any ctf• employees involve,, in INJURY or DAMAGE Date P-) -I LG'Go Time If claim is for 2oui:able Indemnify, give date claimant served with the complaint: n~ Where did DAMAGE or INJURY occurl Des: nDe Tully, and locale on dlaoram on revere sine of this snee-L vn ieTe y names and address and meesuremerrs from Iandmarim: School GrovnJ3 6y p,,S+ area, 5',- t4on VJ)r~ S rani ler- Ben i- r I Des=ripe in detail how the DAMAGE or INJU"rl' Deco; red. . ~~{a ( (n ciGi~oSS yG rd FDD1~ ~IDf CC) y Ca u S i n ,j d eP C i)- W sJh I S S~ on Spr-)n `fci►1soh pry ~ ,p q V6&crrioad,, C9- ci I776 Wry oc you claim the city is responsible? Schcrl Shgajl d ~GUid~ Sc~ rlrcvw~) on owni-eoorre Qnd rc~cirs rera« 11~CCalyd'5 wC C fcves~e-d , Desnripe in oetail each INJURY or DAMAGE ash +0 Sh l nr? 5 1 r'd)!~3 f owfr -i hmin k► , ke( )rl VC s h -hc , I ~rnv,nc ism ~trr~ d t - Igvnq/Pj SEE PAGE 2 (OVER) THIS CLAIM MUST BE SIGNED ON REVERSE SIDE The amount claimed, as of the dale of presentation of this claim, is computed as follows: Damages incurred to.date (exact) Damage to property F ZtZt- Expenses for medical ~an"d hospital care S:: . Ott Loss of earninos.~.kLnuo.... Special damages for f aai t) 1.5, .'t- tel. r-7.4!. f (T'G General damages... _ S Total damages incurred rred to to date date ..............S Total amount claimed as of dale of presentation of this claim. _ 5 Estimated prospective damaoes as tar as known: Future expenses lot medical and hospital care ....5 t Future loss of earnings S Other prospective special damaoes S Prospective oeneral damaoes Total estimate prospective damaoes ..........5 Was damage and/or injury investigated by 'Dot=e? If so, what city? Were paamedics or. ambulance called? If so, name city or ambula, If injured, state date, time, name and address of doctor of your firs; visf_1-4A nf- Y"'Oo', rP~rrkD 'f7> >c f-,e;h n?n Al/In rhl, a WITNESSES to DAMAGE or INJURY: Lis; all persons and addresses of persons Y.nown to have iinformati~J' i Name r-Ih Address M-3 rryiq~LL Syr QetiSCi~?E?--- ?hond Name: l1~ I U f ~Q!''I" nfZ Address - Il}(ZQ$E~ 1~ ?none NameC~i1(A',~IG 1-fPl ~P{~C(_ Address Jon VWr fie, Y) a!"U 1~Cl1)Phone DD-RS and HOSPITALS: or your vehicle when you firs saw City vehicle: location of City vehicle at time of accident by "A-i" and location of yourself or your vehicle at the time of the atzident by "B4" and the point of impact by "X:' NOTE: If diaorams below do not fit the situation, a;ach hereto a proper diammm signed by claimant. Hospial Address Date Hospitalized Doctor Address (r0 N G'rt('A Y77i¢? ('tl Dateoftreatment r- Doctor Address Date of Treatment 5-I h - r)c READ CAR==ULLY For all accident claims place on following diagram names of streets, including North, Eas?, South, and West: indicate place of accident by "X" and by showinc house numbers or distances to street comers If City Vehicle was involved, designate by letter "A" location of City Vehicle when you first saw it, and by "B" location of yourself PARKWAY SIDEWALK Signature of Claimant or person filing on his behalf givinc r elafio` ship to Claimant: typed Name: rQ l l t~ TD5f~ Date: Thavar i. n FILED WIT, H CITY CLERK (Gov. Code Sec 91.5a). Presentation of a false claim is a felony (Pen. Cod Sec. 72.) SOUTHWEST ADMINISTRATORS " Pro. Box 1121 ALHAMBRA, CA 91802-1121 HEALTH INSURANCE CLAIM FORM W a U PICA MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHER Ia.INSURED'S I.D. NUMBER (FOR PROGRAM IN ITEM - - -.(Mebicaid AT ❑(Sponsas SSNI (VA File HEALTH PLAN BLK LUNG El ❑ (SSN d, ID) .`SSN, (ID) 559-37-3125 :NAME (Last Name. First Name, MOble Initial) 3. PATIENTS OD BIRTH DATE SEX MM YY 4. INSUREDS NAME (Last Name, First Name, Middle Innial) VARIN, ANDREA M. 10 31189 M F FVI CHAVARIN JOSE L. ADE ESS (No.. Street) 6. PATIENT RELATIONSHIP TO INSURED INSUREDS ADDRESS (NFF_ Street) 5''''CORTADA ST, Sell ❑ Spouse❑ Cni ONar❑ SAME AS N5 L{' - STATE 8. PATIENT STATUS CITY STATE 2 ~ARDSEMEAD r,{l Single 11 Manned ❑ Other ❑ p,CODE .J 1 TELEPHONE (Incl ude Area Code) ZIP CODE TELEPHONE (INCLUDE AREA COD'cj 1770 s<( ? / - Emplo eo Fvn-Time Pan- y ❑ ❑ nt a❑ " ` Slutlenl Stude C =:5. HER SURED'5 NAME (Last Name, slot Name. Middle Initiah h i r 10. IS PATIENT'S CONDITION RELATED TO. 11. INSURED'S POLICY GROUP OR FECA NUMBER W z _ RUflED'S POLICY OR GROUP NUMBE R a. EMPLOYMENT' (CURRENT OR PREVIOUS) a. INSURE DATE OF BIRTH SEX W ¢ M27TS'r LI YES NO © MM MM i. DD VY M0 ' ❑ f t; i `L' J DT /ER INSUREDS DATE Of BIRTH 5E Y-Y J~qR rl I % C AUTO ACCIDENT? PLACE (State) b. EMPLOYER'S NAME OR SCHOOL NAME _ . . ~I Y .!Terrill-~ I 'AI r F ❑VES ONO I Q P,COI NAME OR SCHOOL NAME . a.,y c. OTHER ACCIDENT? c INSURANCE PLAN NAME OR PROGRAM NAME H" Y4 AYES ❑NO W h B~LAN NAME OR PROGRAM NAME IDb. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN? Q n SY}! _.ti0 ♦ ❑YES O NO n yes, return to and complete item 9 atl. U". READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. j¢ 7DENT'S OR AUTHORIZED PERSON'S SIGNATURE aulnonie Ile release of any medical or other information necessary 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize m nt f di l . iC %CWim..l also rea l payment OF Government henelns either to mysell or 10 the party who accepts assignment pay e o me ca benelns to me undersigned physical or suppler for services, besp-bed below ~ - E . . -SEE ATTACHM NT GNED SEE ATTACHMENT DATE SIGNED URRENTILLNESS (First sympto a t INJURY(A¢ipenll OR r m) OR 15 . IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. GIVE FIRST DATE r : 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM 1 00 l VV MM r DO YV A V 4 V PREGNANCV(LMP) fO 1 bo 9 FROM 1. i TO IREFEF)RING PHYSICIAN OR OTHER SOURCE Ina. LD. NUMBER OF REFERRING PHYSICIAN 16. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES FROM I TO DD VY - BcESEA,yED FOR LOCAL USE i- 20. OUTSIDE LAB? $ CHARGES .-kr~i'tis'~ ❑VES ❑ NO _ DIAGNOSIS OR NATURE OF ILLNESS OR INJURY IRELATC ITEMS T23 OR a TO ITEM 24E BY LINE) 22. MEDICAID RESUBMISSION CODE ORIGINAL FEE. NO. ELI" b , . 23. PRIOR AUTHORIZATION NUMBER a, _ 12aCfD!I,1L1 lm." B C D E F G H I J K `1CNt§DAAE(S) OF SERVICE To a 9'P+ Alone dl Type 01 PROCEDURES. SERVICES OR SUPPLIES (Explain Unusual Circ m tan IAGNOSIS DAYS ESERVED FOR z U b , ~b1 W MM OD °V 5eric Ser.. o u s ces) CPIiHCPCS tiO0r-1=R CODE SCHARGES OR W^S Family P:an EMS DOE LOCAL USE 1- c 99243 125 ' 1 1 180 00 1 l ¢ 0 ;6h00 11 u 1 4 200 1100 1 460 00:: 11 t A4550 1 SO 00 12 a J X i 11 90703 20 00 1 O x:~ 1 11 90213 1 70100 1 Z Q D 00 . 11 A4550 1 30 00 6 a $ IM I,D- NUMBER SSN EIN d - 's9 3876041 26. PATIENT'S ACCOUNT NO. 2 AC EPT ASSIGNMENT' i (Far ovt, stands. see back) 2B. TOTA RGE 00 ~ 25. AMOUNT PAID 30. SAL DUn ~ 0 - ❑ ~J YES ❑ NO . $ S 0100 Co $ %3(i$UN1YN960~ PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTALS 32 NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE RENDERED IT mliei th h ui 33. PHYSICIAN'S, SUPPLIER'S BILLING NAME. ADDRESS. 21P CODE W {ibrtlly Nat Ne statements on Ile reverse an ome or G se) &PHONE, AN CH I EH HU, M. D , R~YJ4Ml a dll arro are matle a an Nereol ~ t 1r . y 600 N. ,ARE I ELD AVE. y305 3„ relfl MONTEREY PARK, CA 9175 ~ SKINAin s DATE A39881 §Z4/571-5505 PIN, B 1t;w'{APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 81881 PLEASE PRINT OR TYPE FORM HCFA-1500 (12 90) + - FORMOWCP.1500 FORM RRB 1500 CITY OF POS_IV:EAD OCT 10 2000 CITY CLERK'S OFFICE TO: City of Rosemead ATTENTION: Nancy Valderrama, City Clerk RE: Claim Claimant D/Event Recd Y/Office Our File October 6, 2000 Chavarin v. City of Rosemead Andrea Marie Chavarin 16-May-00 03-Oct-00 S-108753-MRQ We have reviewed the above captioned claim and request that you take the action indicated below: • CLAIM REJECTION: Send a standard rejection letter to the claimant. Please provide us with a copy of the notice sent, as requested above. If you have any questions please contact the undersigned. Very truly yours, cc: CJPIA w/enc. Attn.: Executive Director CARL WARREN & COMPANY Dwight J. Kunz CARL, WARREN & CO. CLAIMS MANAGEMENT-CLAIMS ADJUSTERS 750 The City Drive • Ste 400 • orange, CA 92868 Mail: P.O. Box 25180 • Santa Ana, Ca 92799-5180 Phone: (714) 740-7999. (80D) 572-69.70. Fax: (714) 74D-9412