CC - Item 4A - Reject Claim - Godakalan Gunaratana 5 E M E
II. % stat
eport
TO: HONORABLE MAYOR
AND MEMBERS
ROSEMEAD CITY COUNCIL
FROM: NANCY VALDERRAM., CITY CLERK 0
DATE: AUGUST 5, 1997
RE: AUTHORIZATION TO REJECT CLAIM AGAINST THE CITY BY
GODAKALAN GUNARATANA
The attached claim was received in this office on July 22, 1997, on behalf of Godakalana
Gunaratana. 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 4, 1997, recommending that this 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.
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wy:agenda '
COUNCIL AGENDA
AUG 121997
ITEM No. "Z. . CC-4.
July 28, 1997
RECEIVED
CITY OF ROSEMEAD
p,J. 41007
T0: City of Rosemead CITY CLERK'S OFFICE
ATTENTION: Nancy Valderrama. City Clerk
RE: Claim Gunaratana v. City of Rosemead
Claimant Godakalana Gunaratana
D/Event 25-Apr-97
Rec'd Y/Office : 25-Ju]-97
Our File S-94282-DBK
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,
CARL WARREN Sc COMPANY
7
Dwight J. Kunz
cc: CJPIA w/enc.
Attn.: Executive Director
CARL WARREN & CO.
CLAIMS MANAGEMENT•CLAIMS ADJUSTERS
75D The City Drive•Ste 400•Orange,CA 92558
Mail. P.O.Box 25180•Santa Ana,Ca 92799-5180
•
JAY imo..EMAL
05 C a - PoS${DC ad
MAYO EM. :p . 4
ROBER1 BRIIESC
oourvoiMEMBERs.. 8839 E. VALLEY BOULEVARD - P.0. BOX 399
mAgGA
?MaRe ROSEMEAD, CALIFORNIA 91770
GARY AFiAROn'
JOE MASQUE ELEPHONE(818) 28&66]1
TELECOPIER 8193079218
July 22, 1997
D-aieht J. Kunz
Senior Account Manager
750 The City Drive, Suite 400
Orange, CA 92668
RF' GODAIST L:xk GL_ty`ARATANA
DearMr Kunz:
The attached claim was received on July 22, 7997. The City does not have any information on
this claim_
Plerse advise as to the steps you wish to take in this this matter.
Sincerely_
NANCY G ALDERP 9'sf%
City Clerk
Attachment
cc: Circ Attorney
FILE
CITY CLERK')CSS CLAIM FOR DAMAGES RESERVE FOR FILING STAMP
OFFICE
[Address) TO PERSON OR PROPERTY CLAIM NO.
INSTRUCTIONS RECEIVED
1.Claims for death,injury to person or to personal property must be Ned not later than six CITY OF ROSEMEAD
months after the occurrence.(Gov.Code Sec.9112.)
2.Claims for damages to real property must be tiled not later than 1 year after the occurrence. uL ;., .; 1997
(Gov.Code Sec.911.2.)
a Read entire claim form before filing.
4.See page 2 for diagram upon which to locate place of accident. CITY CLERIC'S OFFICE
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.
Date of Birth of Claimant
TO: [Name of city]
pc?SElMC AD. q - 2r - SO
Name of Claimant /' Occupation of Claimant
Gi oDf}lc-'LPA✓/9 l_7ui✓R/2r7(An/A pGrEci.
Home Address of Claimant City and State Home Telephone Number
x$31 6✓rtgCoN ft. . .ers/,rnSAD c-,0 77.0 8'S12-Czo z (3
Business Address of Claimant City and Stateusiness Telephone Number
R3? %mFgcr PG . VoS m, D rAa/77t I/ /2 ) 2Sit' - /273
Give address and telephone number to which you desire notices or communications to be sent Claimant's Social Security No.
J k
regarding this claim: (_3F 2 /2-73
5 /, /, - �. �,3 3
-7yd 9 Girt?or/INJURY
/
When did Fy7AGE or NJURY occurP Names of any city employees involved in lNJUR1'or DAMAGE
Date at,/ T / '77 Time
If claim is folr Equitable Indemnity,give date claimant served
with the complaint:
Date
Where did DAMAGE or INJURY occur?Describe fully,and locate on diagram on reverse side of this sheet.Where appropriate,give Street
names and address and measurements from landmarks:
TC i a-bi (REGI I/JF/20T— CF SG
Describe in detail how the DAMAGE or INJURY occurred.
Tr n_.T--C.N cc/5-C 2 u Ci ( riL( /3tr/?'n'(r T'.,`�l Ghr F& Gc
H t -
Why do you claim the city is responsible?
2c -C. Lei/ L---) / , '✓ S Pi P:s( %/L.(`y C C !Ty .
(TL/ r,:r-s grficl��� rZ�iJ - _;�'c/J �� PO :c-ri !/7-- �/2 21Prn46-5
I;:( 'USF &yrEsrrvE
Describe in detail each INJURY or DAMAGE
wj2cv1C--1.17 IRch' FGrJ c BENT ,9,i St2c1?G7-4 •
SEE PAGE 2(OVER) THIS CLAIM MUST BE SIGNED ON REVERSE SIDE
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 $S[-Z v Future expenses for medical and hospital care . . .5 —CC_
Expenses for medical and hospital care S C Future loss of earnings S —4-
Loss of earnings $ e Other prospective special damages 5 •-
Specialdamagesfor S -6" Prospective general damages 5 IT
$_ Total estimate prospective damages S
General damages $
Total damages incurred to date $ 3 OC- e
Total amount claimed as of date of presentation of this claim: $}N
Was damage and/or injury investigated by police? A/d If so,what city?
Were paramedics or ambulance called? Al O' 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 V-12J 4 %t?;Aa Address 75=2,5 fm,cce ' Pt'CC v:54-G Phone
Name <2 / P U $✓2,27ii'h Ai Address 7 P 3 / S m it SAN O. ?'F %c'' Phone
Name Address Phone
DOCTORS and HOSPITALS::
Hospital Address Date Hospitalized
Doctor ..----
octorAddress Date of Treatment
Doctor Address Date of Treatment
READ CAREFULLY
For all accident claims place on following diagram names of streets, or your vehicle when you first saw City vehicle:location of City vehicle
including North, East, South, and West; indicate place of accident by at time of accident by"Al"and location of yourself or your vehicle at
"X" and by showing house numbers or distances to street corners. the time of the accident by"B-1" and the point of impact by"X"
If City Vehicle was involved,designate by letter"A"location of City NOTE: If diagrams below do not fit the situation,attach hereto a proper
Vehicle when you first saw it, and by "B" location of yourself diagram signed by claimant.
//(/
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//'
SIDEWALK \ I
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Signature of Claimant or person filing on Typed Name: Date:
his behalf giving relationship to Claimant -ir.%\,9-c4z-,,9'eAr 4ui✓A297-1.7wl
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NOTE: CLAIMS MUST BE FILED WITH CITY CLERK(Gov. Code Sec. 915a). Presentation of a false claim is a felony(Pen. Code Sec.72.)