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CC - Item IV.CC-C - Authorization To Reject Claim Against The City From Cynthia Cota & Gilbert Gonzalez Attch. TO: HONORABLE MAYOR AND MEMBERS ROSEMEAD CITY COUNCIL FROM: NANCY VALDERRAMA, CITY CLERK DATE: MARCH 30, 2000 RE: AUTHORIZATION TO REJECT CLAIM AGAINST THE CITY FROM CYNTHIA A. COTA AND GILBERT ANDREW GONZALEZ The attached claim was received in this office on February 23, 2000. A copy was sent to the City's claims adjuster, Carl Warren & Company on February 26i, 2000. All information received after that date has been forwarded to them. Carl Warren & Company sent a notice on March 27, 2000, recommending that the aforementioned claims be rejected by the City. RECOMMENDATION It is recommended that the City Council approve the rejection of these claims and authorize a letter of rejection be sent to the claimants. staf epor TO: City of Rosemead Cli MAR 2 20n 19 March 27, 2000 ATTENTION: Nancy Valderrama, City Clerk RE: Claim Claimant D/Event Recd Y/Office Our File Cota v. Rosemead Cynthia A. Cota 2/10/00 3/21/00 S 101964 SWQ Crc'CE We have reviewed the above captioned claim and request that you take the action indicated below: a 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 & COMPANY 26ch wd1D. M"quPl Richard D. Marque cc: CJPIA Attn: Executive Director CARL WARREN & CO. CLAIMS MANAGEMENT-CLAIMS ADJUSTERS 750 The City Drive • Ste 400 . Orange, CA 92868 - Mail: P.O. Box 25180 a Santa Ana, Ca 92799-5180 Phone: (714) 740-7999 • (800) 572-6900 • Far: (714) 740-9412 . March 27, 2000 TO: City of Rosemead ATTENTION: Nancy Valderrama, City Clerk RE: Claim Claimant D/Event Rec'd Y/Office Our File Gonzalez v. Rosemead Gilbert Andrew Gonzalez 2/10/00 3/21/00 S 101964 SWQ -le tom. tw f0;l~ zoo, . roc We have reviewed the above captioned claim and request that you take the action indicated below: i 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 Attn: Executive Director CARL WARREN & COMPANY 2i~,Cdl D. MGLt qu,Pi Richard D. Marque 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 • (800) 572-6900 • Fax: (714) 740-9412 March 23, 2000 Dwight J. Kunz Senior Account Manager Carl Warren & Company 750 The City Drive, Suite 400 Orange, CA 92668 RE: CYNTHIA ANN COTA & GILBERT GONZALES CLAIM YOUR FILE S 101964 SWQ Dear Mr. Kunz: The attached letter and two Claims for Damages were received in my office today regarding the aforementioned claim. The conformed copies requested were mailed back to the law firm today. Please advise us of the steps you wish to take in this matter. Sincerely, NANCY VALDERRAMA City Clerk City of Rosemead Attch. LAW OFFICES OF CTORELICK & ASSOCIATES 14724 VENTURA BOULEVARD SUITE 1009 SHERMAN OAKS. CALIFORNIA 91403 ROBIN A. GORELICIC MAURICE 13. PILOSOF ALSO AO W7EO TO THE WS OF WASHINGTON GC. AM) TENS March 21, 2000 VIA CERTIFIED MAIL WITH RETURN RECEIPT REQUESTED City of Rosemead 8838 E. Valley Blvd. Rosemead, CA 91770 TELEPHONE: (818) 9864444 57 FACSIMILz: (818) 986-4639 CSJ IJ~~R 2 3 Zg~l Re: Our Clients: Cynthia Cota and Gilbert Andrew Gonzalez Date Loss February 10, 2000 Dear Sir or Madam: Enclosed please find the two Fully executed Claims for Damages for Ms. Cota and Mr. Gonzalez. Please file the executed Claims and conform the attached copies. Thereafter, kindly mail us the conformed copies in the postage paid envelope attached herewith. If you have any questions do not hesitate to contact the undersigned. Very truly yours, LAW OFFICES OF G~O~RR~E~LLIIjICK & ASSOCIATES ROBIN A. GO R IC K RAG/gg Encls. CC: Carl Warren & Company -P.O.-Box-25180 Santa Ana, CA 92799-5180 Attn: Richard Mark FILE WITH: CLAIM FOR DAMAGES ' RESERVE FOR FILING STAMP S OFFICE CITY CLERK TO PERSON OR PROPERTY CLAIM NO. _ Q r7 INSTRUCTIONS C.1?',' .P 1. Claims for death, injury to person or to personal property must be filed not later than six 1 9 2 r n k . 1 months after the occurrence. (Gov. Code Sec Ifl h ' U 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 forth before filing. - - C• - 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. fi Attach separate sheets, if necessary, to give full details SIGN EACH SHEET. Date of Birth of Claimant TO: CITY OF ROSEMEAD, 8838 E..Valley Blvd., Rosemead 91770 1 - q -(Do Name of Claimant C~AJTIt/(-~ R " C07 tY Occupation of Claimant PlicTOi F-61.3 T& 0-f Home Address of Ciaimant City and State q~3 uj125HH1,(. `bT- 20* Yf o Cit -117--~ D Home Telephone Number (P1(o p7 S Business Address of Claimant City and State 301 5 IZAYti+oNo:) 11Ji/6 PL1t1Jtv)1321t r- 9/~i3 Business Telephone Number ~2b - Z6'Z SSL3 EF+.fI )L Give address and telephone number to which you desire notices or communeEatrans to be sent Z f1SSOCIt4TG~ t ~1 C Claimants Social Security No, _ CJ regarding this claim: Lnw OFFrC(-S OF ADC lr)d4 e)I+L2MA-DAVS.CP-"Wall ':N "I "~3-131 When did DAMAGE or INJURY occur? Date --1C'' Time 61asoM If claim is for Equitable Indemnity, give date claimant served with the complaint: Names of any city employees involved in INJURY or DAMAGE ,J)(501 I`-l(LI+ EL- / ~Vv t, S Where did DAMAGE or INJURY occur? Describe tully, and locate on diagram on reverse side of this sheet. Where appropriate, give street names and address and measurements from landmarks: t t p ¢S (kA t l S~ N~ C-Ft« It f~a P c . Describe in detail how the DAMAGE or INJURY occurred. J~ 6'~ \G'cl P G i. AS i G\ t O F . iZOS6 f`'~C-!fin Er''\'~i,C E E I W l~ ~+-%~lS J hJ TK6- C.~T ~ / ~ t-C PcT\.. ~ Cc?~CL `rJ Ord J C.: \t l L E S I'S C(-f11N/\(\NT ~jJFF'C-2EC> SeVo Q-G Why do you claim the city is responsible? ~1 ~CLT to Cry SCE P, CC- DC- ('a tS C,\ CF 2c~c-MERp C-iti~~i,OVr~i> TIC U~2~J tN~ f~ JGIrt\CI-C-. C`~%IJL~ 13~ G1 Describe in detail each INJURY or DAMAGE RCO-V ~GSI ^l'QP.I~MP~t~- C.Ep(+AL(o/!t- L~(~v\cp.1_ ~VR-etc-+ 1 s~2~rrJ l^umt3rilL s ~fL rte,.; (S~ar nl C1C1~m°rr~i' 5~1-1^t. TR-r-(-''II r.) tD w,z t+ ENE ~cc\O R_ SEE PAGE 2 (OVER) THIS CLAIM MUS"I 13E JIGNtU UN ncvcnac of 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 : ' e"' ' ' Damage to property S'm7n L. LoSS Future expenses for medical and hospital care v"- .3 ^ J Expenses for medical and hospital care .....S L'P't^'C'.' ,J - Future loss of earnings ecial damages ctive s O ~ . S',h% v/ S unt i.a F1-:-P . LOSS of earnings .....S p ther prospe 3v'3 1 " t-' Special damages for .....S o vlcNnv113 Prospective general damages . 3 J rJ ILr1- w Total estimate prospective damages . General damages Sv''r+`1~ "C'+hinro.r; 5T1.'- pecew-*;" ".6r.Iwr Ch2e Total damages incurred to date ..............5 V N41401 rJ Total amount claimed as of date of presentation of this claim: S . v~~%adwN '4T "PV-L-5'NT- Tt^c- Was damage and/or injury investigated by police?A C-f> If so, what city? (2,0'5 G M E A r7 Pp~ C-- Were paramedics or ambulance called? if so, name city or ambulance fit`" V- If injured, state date, time, name and address of doctor of your first visit &2-6PTT-(2- &I- (no,~Te tkq-,Q CrP+L FIRST JISIT alta1 D~ WITNESSES to DAMAGE or INJURY: List all persons and addresses of persons known to have information: Name N 0 N t- Address Phone DOCTORS and HOSPITALS: HospitaI&EZ &T- &U MoN - (tds<iTrfiL Address /t 5rN?r AN Doctor F+PrR1- LFkOoPinLt [ > tlr -LAT V 0AAddress ' ti I+r+zr Ave Doctor f lzLr1-O Address i1SO S- ~r'Sbr Hospitalized"1 U ~OU 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. Fast, South, and West; indicate place of accident by at time of accident by'A-1" 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 "&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. Vr.) Typed Name: Signature of Claimant or person filing on his behalf giving relationship to Claimant: NOTE: CLAIMS MUST PE FILED WIT/4-CITY CLERK (GQJCode Sec. 915a). Date: of a false claim is a felony (Pen. Code Sec. 72.) FILE WITH: CLAIM FOR DAMAGES . RESERVE FOR FILING STAMP CITY CLERK'S OFFICE TO PERSON OR PROPERTY CLAIM NO. INSTRUCTIONS _ 1. Claims for death, injury to person or to personal property must be filed not later than six months attar the occurrence. (Gov. Code Sec 911.2.) nce , 1 3 3 2 2. Claims for damages to real property must be filed not later than t year after the occurre , . . ! (Gov. Code Sec 911.2.) 3 Read entire claim form before filing. See page 2 for diagram upon which to locate place of accident. - - 5. This claim form must be signed on page 2 at bottom. S. Attach separate sheets, if necessary, to give full details. SIGN EACH SHEET. ~ Birth of Claimant Date o TO: CITY OF ROSEMEAD, 8838 E. "Valley Blvd:, Rosemead 91770 ( 1 - lCl- ? Occupation of Claimant Name of Claim-aa nt 11ee-T V~, 016Ve-" (~0002RL&Z 6 1 Home Address of Claimant City and State C F~- I (o I d k ek ` C Home Telephone Number (01Lo • 301-ST37c-1 , 32M•ec, D 4a3~p t-koo S w,M b Busines Address of Claimant City and State I er Business Telephone Num Give address and telephone number to which you des re notices or communications to be sent Claimant's Social Security No. ) o:F[eS ~~Gc2t t,c p-dAc.n~E-5 (ts(8) -586-9ti4y regarding this claim: crrv c7 e3 C119 r t5TL4UcwineonlIoUA She(,An kt Names of any city employees involved in INJURY or DAMAGE When did DAMAGE or INJURY occur? Date a"1 ° - CID Time b : as p! \ f~ 1 C 114 F✓ ~1J 45 It claim is for Equitable Indemnity, give date claimant served - ...1 with the complaint: e. Where did DAMAGE or INJURY occur? Describe Cully, and locate on diagram on reverse sme or Mrs sneer..ri _ =rr•~r ~ - - names and address and measurements from landmarks: Mct- Shc.tl 5-(-_ N, .c r E4~,r1- Describe in detail how the DAMAGE or INJURY occured. Ivey ~r c-h=.e, ~ . ~\J4 5l a. C,-1-y of C~u~e-mf4c~ en-,ptoY~e, ~=~b 1`7~S Cr~~in5 ~ V¢htcl•e. C~wr~ed, h~ ~u C,~~--1~ r~c.t- -erlc~c~. Ve4ttcl? C141h f cis Clti,rv SoFFere '(2 S u 1 \J C~ ,J, -TVA- (~SSS4v ~e r L ~e v v r Why do you claim the city is responsible? ~~S¢.hti~rti,d WVtC C~,.~Secl CC.rcLEn. A5 C,'-, Describe in detail each INJURY or DAMAGE L S i` I SS B C I ( A Q "CIA, ~ ~cuh2. L1 S I . L.e(u cal S~ c,.r (S rc.r W~Yx.r S~;c,. LS~r r L plc n-f S Ft 1Y 1✓ec t , { Lc c,4-,o 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 dale (exact): Estimated prospective damages as far as known: Damage to property $ t LO'S Future expenses for medical and hospital care .S L`~UKNCt,~" Expenses for medical and hospital care S v NL 1JvW Future loss of earnings s 0N r rjcw SULJ %JIJr- Loss of earnings 5" a-N ~ Other prospective special damages Special damages for . . . . . . . . . . . . . . . . ..5 ut.:.-NILtF~ Prospective general damages s~'NIGNL`UJ!- Total estimate prospective damages S V N (t:N;n..~r General damages .....S UNa-NOv.wN-C ~nr w.nr+T St~~r' 2GCe w,dv.'r{(-oil Cg2E- Total damages incurred to date S uNLI-Nowlnj Total amount claimed as of date of presentation of this claim: S UN L'NCw"') P7 PP-CSErJ-I Tart Was damage and/or injury investigated by police? ~4 E S II so, what city? n o ` ~M~r4 f\ Were paramedics or ambulance called?_ If so, name city or ambulance (iM (L A-rr1 Amt ~A'-t C- - If injured, state date, time, name and address of doctor of your first visit GP-7c-rE-fz ec, MoN-rc- PtTP L rttisi Utslr I0Iov WITNESSES to DAMAGE or INJURY: List all persons and addresses of persons known to have information: Name N o N E Address Name DOCTORS Doctor Doctor no 1 S. ffrUTf+ F1Nt -CA /`}V& - Date Hospitalized -to -OD 3S03' A-, + ftiL S (41 f-C. 'Po I Date of Treatment 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, Fast, South, and West; indicate place of accident by at time of accident by 'A-1- 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-l" 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 fif the situation, attach hereto a proper Vehicle when you first saw it, and by "B" location of yourself diagram signed by claimant. CURB 71- a3g . Munt~,~ l 5t - SIDEWALK Signature of Claimant or person filing on his behalf giving relationship to Claimant: Typed Name: NOTE: CLAIMS MUST BcILED WITH,6I1W CLERK (Gov. Code Sec 915a). Presentation of a false claim is a fe t /I / ' SIDEWALK CURB F Date: Code Sec. 72.) MAYOR: JOE V45OUEZ MAYOR PRO TEM: MARGARET CLARK COUNCILMEMBERS: ROBERT W BRUESCH JAY i IMPERIAL GARYA TAYLOR March 15, 2000 Robin A- Gorelick, Esq. Gorelick & Associates 14724 Ventura Boulevard, Suite 1000 Sherman Oaks, CA 91403 f icy osemead 8838 E. VALLEY BOULEVARD - P.O. BOX 399 ROSEMEAD, CALIFORNIA 91770 TELEPHONE (626) 288-6671 FAX (626) 307-9218 Re: Your Client Cynthia A. Cota & Gilbert Gonzales Dear Mr.Als. Gorelick: Your claim, which was received by the City Clerk's office on February 23, 2000, is being returned because it failed to comply substantially with certain Government Code Sections. Pursuant to Government Code Section 910, a claim shall be presented by the claimant or by a person acting on his or her behalf and shall show all of the following: The name and posts office address of the claimant; The post office address to which the person presenting the claim desires notices to be sent; Description of the date, place, and other circumstances of the occurrence or transaction which gave rise to the claim asserted; A general description of the indebtedness, obligation, injury, damage or loss incurred so far as it may be known at the time of presentation of the claim; The name or names of the public employee or employees causing the injury, damage or loss, if known; The amount claimed as of the date ofthe presentation of the claim, including the estimated amount of any prospective injury, damage or loss, insofar as it may be known at the time of the presentation of the claim, together with the basis of computation of the amount claimed, if less than 510,000.00. No dollar amount shall be included in the claim if the amount claimed exceeds 510,000.00. The claim must, however, state the court in which jurisdiction of the claim lies. Gorelick & Associates Cynthia Ann Cota Claim March 9, 2000 Page 2. The claim must be signed unless the claim is for supplies, materials, equipment or services and the claim is presented on a billhead or invoice regularly used in the conduct of business of the claimant. For your information, consult Sections 910. 910.2. 910.4 and 910.8 and other sections of the Government Code pertaining to the filing of claims against a public entity. Due to certain time requirements for filing these deficiencies, this should be corrected immediately. Sincerely, NANCY VALDERRAMA City Clerk City of Rosemead Encl. FILE WITH: CLAIM FOR DAMAGES RESERVE FOR FILING STAMP CITY CLERK'S OFFICE TO PERSON OR PROPERTY CLAIM NO. 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. GG . Code Be-- 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. fi Attach separate sheets, if necessary, to give full details. SIGN EACH SHEET. Date of Birth of Claimant 10. CITY OF ROSEMEAD, 8838 E. Valley Blvd., Rosemead 91770 Occupation of Claimant Name of Claimant Home Address of Claimant City and State I Home Telephone Number Business Address of Claimant City and State I Business Telephone Number Give address and telephone number to which you desire notices or communications to be sent Claimant's Social Security No. regarding this claim: When did DAMAGE o. INJURY occur? Date Time if claim is for Equitable Indemnity, give date claimant served with the complaint: Names of any city employees involved in INJURY or DAMAGE Where did DAMAGE or INJURY occur? Describe fully, and locate on diagram on reverse side of this sheet. Where appropriate, give sneer names and address and measurements from landmarks: Describe in detail how the DAMAGE or INJURY occurred. Why do pu claim the city is responsible? Describe in detail each INJURY or DAMAGE 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 E Future expenses for medical and hospital care S Expenses for medical and hospital care S Future loss of earnings S loss of earnings $Other prospective special damages s Special damages for b Prospective general damages 5 Total estimate prospective damages S General damages Total damages incurred to date b Total amount claimed as of date of presentation of this claim: 5 Was damage and/or injury investigated by police? If so, what city? Were paremediCS or ambulance called? If so, name city or ambula If injured, stale dale, time, name and address of dolor of your first visit WITNESSES to DAMAGE or INJURY: List all persons and addresses of persons known to have information: DOCTORS and HOSPITALS: Doctor Doctor PPAn rAPPFULLY 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 Hospitalized of Treatment . of Treatment or 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 al the time of the accident by "13-1" and the point of impact by "X:' NOTE: If diagrams below do not fn the situation, attach hereto a proper diagram signed by claimant. SIDEWALK CURB SIDEWALK Signature of Claimant or person filing on his behalf giving relationship to Claimant: Typed Name: CURB'- IF Date: NOTE: CLAIMS MUST BE FILED WITH CITY CLERK (Gov. Code Sec 915a). Presentation of a false claim is a felony (Pen. Code Sec. 2.) TO: City of Rosemead ATTENTION: Nancy Valderrama RE: Claim Claimant D/Event Rec'd Y/Office Our File March 13, 2000 MAR 1 2000 CIT 'S OFFICE Cynthia Cota v. Rosemead Cynthia Ann Cota 2/10/00 3/6/00 S 101964 SWQ We have reviewed the above captioned claim and request that you take the action indicated below: • CLAIM INSUFFICIENCY: Please send a notice of insufficiency, which must be mailed to the claimant no later than March 27, 2000 . THIS MUST BE MAILED TO THE CLAIMANT WITHIN 20 DAYS OF RECEIPT OF THE ORIGINAL CLAIM IN YOUR OFFICE. DO NOT SUBMIT A "REJECTION LETTER. See Government Code Sections 910 and/or 910.2 and/or 910.4. Use the attached format for responding and give the reasons indicated for insufficiency. 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 & COMPANY Richard D. Marque Enc. Form letter format cc: CJPIA w/enc. 1 CARL WARRED & C®• 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 Ext. 140 • (800) 572-6900 • Fax: (714) 740-9412 f FORM LETTER #2a CITY LETTERHEAD March 13, 2000 NOTICE OF INSUFFICIENCY Your claim, which was received by the City Clerk on (date), is being returned because it failed to comply substantially with certain Government Code Sections. Pursuant to Government Code Section 910 a claim shall be presented by the claimant or by a person acting on his or her behalf and shall show all of the following: e The name and post office address of the claimant; ® The post office address to which the person presenting the claim desires notices to be sent, e Description of the date, place, and other circumstances of the occurrence or transaction which gave rise to the claim asserted; e A general description of the indebtedness, obligation, injury, damage or loss incurred so far as it may be known at the time of presentation of the claim; e The name or names of the public employee or employees causing the injury, damage or loss, if known; • The amount claimed as of the date of the presentation of the claim, including the estimated amount of any prospective injury, damage or loss, insofar as it may be known at the time of the presentation of the claim, together with the basis of computation of the amount claimed, if less than $10.000.00. No dollar amount shall be included in the claim if the amount claimed exceeds $ 10,000.00. The claim must however, state the court in which jurisdiction of the claim lies. The claim must be signed unless the claim is for supplies, materials, equipment or services and the claim is presented on a billhead or invoice regularly used in the conduct of the business of the claimant. For your information, consult Sections 910. 910.2: 910.4. and 910.8 and other sections of the Government Code pertaining to the filing of claims against a public entity. Due to certain time requirements for filing these deficiencies this should be corrected immediately. City Clerk 14AR 2000 TO: Carl Warrerf & Company 750 TWCity Drive, Suite 400 CA 92868 DATE: 03/03/00 CLAIMANT: C. Cota & G. Gonzales FILE NO: 2-10-00 FILING DATE: 2-23-00 PRINCIPAL/CITY: CJPIA/City of Rosemead S 101964 SWQ SIX MOS.: YES RECOMMENDED ACTION ON CLAIM: Send letter of Insufficiency to the claimants attorney regarding both claimants. FACTS: City vehicle operator rear-ended the claimant vehicle. POSSIBLE CO-DEFENDANTS: There would appear to be no co-defendants. EVALUATION: If sufficient claims are timely filed, these would appear to be claims of potential liability with regards to the city. RESERVES TYPE OF CLAIM AMOUNT 1. Cvnthia Cota ABI $10.000.00 2. Cvnthia Cota APD $5.000.00 3. Gilbert Gonzales ABI 52.500.00 COMMENT/WORK TO BE COMPLETED: Our further report will follow shortly. Very truly yours, CAR RREN & COMPANY s ephen A. White cc: City of Rosemead, Attn. Nancy Valderrama cc: CJPIA - Attn.: Executive Director 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 MAYOR: JOE VACOVE_ MAYOR PRO TEM: MARGAREI CLARK COUNCILMEMBERS: ROBERT W ERUESCN JAY T IMPERIAL GAPY A IAYLOR March 6, 2000 Robin A- Gorelick, Esq. Gorelick & Associates 14724 Ventura Boulevard, Suite 2009 Sherman Oaks, CA 91409 Powfftcad 8838 E. VALLEY BOULEVARD • P.O. BOX 399 ROSEMEAD. CALIFORNIA 91770 TELEPHONE (626) 288-6671 FAX (626) 307-9218 Re: Your Client Cynthia A. Cota Date of Accident: 2/10/2000 Dear Mr. Gorelick: Your letter dated March 1, 2000, addressed to Joey Michael Rivas, was forwarded to this office. All claims and correspondence regarding this claim will be sent to the City's claims adjusters, Carl Warren & Company, at 750 The City Drive, Suite 400, Orange, CA 92868. Please forward any further correspondence from your office regarding this claim to this office or to Carl Warren & Company. If you have any questions, please give me a call at 626 569-2100, extension 171. Sincerely, NANCY VALDERRAMA City Clerk City of Rosemead cc: City Attorney LAW OFFICES OF GOREEICK & ASSOCIATES 14724 VENTURA BODLEVARD Su= 1009 SAERHAN 0Axs. CALIFORNIA 91403 ROBIN A. GORELIC MAURICE B. PILOSOF ' ALSO AOMIITEO TO THE SANS OF WASHINGTON O.O ANO TDAS Mr. Joey Michael Rivas 8602 E. Edmond Dr. Rosemead, CA 91770 RE: Our Client Date of Accident Dear Mr. Rivas: March 1, 2000 Ms. Cynthia A. Cota February 10, 2000 O. C; s ~Qn This law office represents the above-named client in her claim against you for injuries received as a result of the above- referenced accident. This office has information which indicates that said accident occurred as a result of negligence on your part or those you are responsible for. Please inform this office of the name of the insurance company that insures you in connection with such claim. If this office does not hear from you within five (5) working days of the date of this letter, legal action will be taken in order to protect the rights of our client. This is a'matter of utmost urgency and if no response is received immediately you will leave us with little option but to commence legal action forthwith. Please complete the information on the second page of this letter and return an executed copy to our office as soon as possible. I will await your immediate reply. Very truly yours, LAW OFFICES OF GORELICK & ASSOCIATES TELEFRONE: 1818) 9884444 FACSIMILIC (818) 988-4839 Robin A. Gorelick, Esq. RAG:GG March 1, 2000 Page 2 Re: Ms. Cynthia A. Cota File#: 0002103 I did not have liability insurance on the date of the accident. I did have liability insurance on the date of the accident. Insurance Company Name: Address: Policy Number: Phone Number: I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date: Signature: March 2; 2000 Dwight J. Kunz Senior Account Manager Carl Warren & Company 750 The City Drive, Suite 400 Orange, CA 92668 RE: CYNTHIA ANN COTA AND GI LBERT GONZALES CLAIM Dear Mr: Kunz: The attached Traffic Collision Report regarding the aforementioned claim was received in my office on March 2, 2000 Please advise us of the steps you wish to take in this matter. Sincerely, NANCY VALDERRAMA City Clerk City of Rosemead Attachments cc: City Attorney mna maa ~ u Nsm m - Nnsn o- M _ v o~0 voo mvi _3m c m off 4mD o'm 9 ~ u < o ~ m m D ~ 8~S o<9 vw m o - n - y aor 32y n 2 0~ T ` N C J m~ ~ D r. ~ H 30 pmt N ~ m c o' a ~ „~3 m • m nn 3 ~ o c n0 _ 1' O T~ cm mj o 0 . 1 F 2 S_ o>> n ~ mT mm~ a = o"~ n3 F o ~ nm > m~ 'oo 0 n ~ m o' o v b m< C y ~ r yy _ m Nn m I m` v - Dm ( ~ VV N mo m V P Dm n U r > r m I o H +r rc m ~ rt O > D T V o' a T o a r ~ ~ 1V/ ~1 T \ o O O Vn a ~m oo > O O m D c ~-+D D m ti r n T v D 1 _ n ~ o O D y ~ -i m C v m y D ti m C D m < N S a I z m z C o m m m to 3 m m o n - m m v m m m o N J m m V. N V ~ m ~ o N O m n O C O T O N D z m m r p O ~ N m M m O T N v m v D a 1 mm z 1 P V\ 9 P 0 r 7;z~- rb 4- (t r LA (b 0- r ul T\- LP o a7-r ~ crn^p~ rb (D P N 0 STATE CW CAUFOFV A TRAFFIC COLLISION REPORT CHIP 555 PAGE 7 fRev 7-921 OR 042 al s]>s] 39 Y . / 7 {raauCaronldr r[Tl Rill 0 rtY o P wYGALdsTSCT vt LOEJI RapRTYW{u ; OS t ~ 0 av X~ off NT(RW OL[aTY -os /&KE2Es OS3 / G[AT S3Ta f~1 O 53 / - A/ i / _ OCCUFRm Cr 5TR T AgesImL1 / YO. wT )O Yw :oo TY{((L{rl /gas YCY:r 9GYJ Ome[RL D. ~/o989y - ~ WILrWTMARIMTGY , (C i wT OrruR TTnY AWAY r{Y{TOOR m.v: < Y tF S " f IS MY W ❑Yms o- U RR/YIL D• - J ❑AT rTLAZ L trtY •TATL rl`TY RLL 300 PER/1Yr E Dr /142T A UENI jE ` 4 rD RDY[ PARTY UCO6[YW IU DT RAn CEW LY[}T F. VLMYw YA[l YDD[L/CLL1M 7 [MW[LR r 5 / a G 95! "Foeg cu8, w.4~ay 3,1o~11C DFrv[R N.YL InRrt, roou.tArtl Tay 4x-w4---.L RIVq-S FROM RLRADORau oYRa[n E IAW [Atf[u DRHu O S(o ba E. gl)WiM)b DR 1 VE R056w6AD /T" X~~ L `.X99 V[NCL I ❑R/Rgn/LY orRr{n ADDIIW ❑lAY(u wYU /7x ❑ osFjP1EAD / AG/F /q/7,70 ME f VAU,EY & V17" c, P7EAb,c { - E ARE, RNR Rn wart roonT rRTYegn RA4 DYPOrIIOY Orr4t6[or oRD[Rl On ❑orncu rvsR ❑DTYf{{ O /r1 /J S// 130 lo 9 I O E 80 h/ OTN[R IgY(rN]YC [Yrrfll Npl( DV¢n: YoNa AwAwwr ur[R TO YARRAnv[C ❑ cw ME OK OF Y YYD[W DAYAOm ARU r(r{cLR nr[ D[(CIER[r[nc1[DAYADa IY1 V114{ICYMLR rD{LYNW [LR ❑{LOC ❑N7Nf ~L. rDR , ❑{{06 ❑YLpR TLL dR Of OR LTR[R OR NDNWAY [ rCI DOT D U O IC 13 ruc O MIA IeM-5// 5Ti?F~T .AFT 35 21703 V. c. PARTY 2 --19" uctNEE -"A" A ~5~5/ y9 rtgn CA CLARE C {FEET ` Y(N Yw Iroou/coLOR D„/}Ts /asox ~B~P/~l (w(YW[LA n 93Y/lT~e!` Drrvu NA{E((nRtr, roou,LArt) - - NT/!/ ANN c4o TA rEOEi. RELTADDREL[ OWM[l{lMW[ tAYCASD.&A 0 9a3 8 ~A25 ALL 5 K, T ~ rARFFD Yl~tc CmlrtArcl ar _ or..[rE AOOFCS{ ~[Ar(u DYYCR ❑ ROSEd~EA D CAG/F 9/ )7 70" .Cl. {[i nun ara RDCNr rooYr rRTNOgn A Rua dtrOVTM Or V(NCIL OR ORO(R)W: ❑ornc[R T~o Nru ❑OYNu O BkAJ BkoAI 5(d6 180 o/ 0 9 1GO - orNER ❑ No•.{rNON[ l~nw[u rNOY[ (6a6) 3~ -S S c~z~> s "6 r{toR YECNAwcAt DLrtrn: Lu{•l Arr.- RlFTATOY.TYY[[ a a- a DN. ViFDNL. DE-F151YINCL(DAYAD( ruoawD YADm AREA ugruu roue YWtu / VENCLE TYPE e- o- ° E/ 1E/2AG aeA-easy 9 usuQAN~E roD YAYOR Toru o L , U . o-R Or wCTRER OR .rcmvAY aPE[D rcr Doi D CA O Icc ❑ 'm o M X4es,,z1,q1- ~ s72EEr uw PARTY ONVUS UCr>+sFNwtu STATE Cuss {AF[TY V{n Tw YARL IYDDFLI COLOR us[Rwtu tT, 3 EWY. ONV[R rv41{(RRST. WDOLf.LAST) 1' 0 1 El /EDES S TFiW TR[RLDOFLSt v' ~ / ~ OWNiwY NUF ❑iAY[AI DNVN . 1. ETO IA.RCO F LE C YISTATL/af \J ~\G~ OWNENS ADDF[37 ❑SI "OnYER C ❑ rQ uCY. sEi nun "El NfADM .O..!. rrtnOATF DAY • TEAR YD MC[ diroYnCN OF Y[NCILWORDFRS Of: ❑OFnCER ❑DNV[A ❑OTN[ CVST . ❑ ~I OThER nO.E'.t L' {.N[K I.W MOR YECNANCK DEFECT: N'W(1//AFLM❑ REFERTO-M MEC ❑ ( ) ( ) CNVENCL[/IAE CNLY TTI[ DE[Cn[[Y[wCL[D-FOR [N-SDEW OY GID MEA W SVR/.NCLCMNCR pIJCTYW{LR ❑Nf ❑YIYOR - ❑ ❑ ❑ pD YAJOR TOT/1 .1 01 J F.vEL ON {TFEROR NO.IWAT {-ED UY KF pOT F. 13 ICC O tUC ❑ nl;cn *4 F IR FEi AFEq[ NI CE D:SPATCN NOTIFIED A RENEW D MOSES t.L4 Ai{gEWEW [D , ^ NSON ❑YES L] NO $t WA ~j ` x#2234187 ~ 02-/ -OO . C,,' CALIFORNIA RED / WITNESS / PASSENGERS YBDB, 555 Paae 3 (Rev. &971 OPI 042 BA03 -la-1 1 DAY YEAR' "VE/ A S / 70 CFFI`"/ 098 /7 NOaV - o~/rS-OAS EXTENT OF INJURY ("X" ONE) INJURED WAS ("X" ONE) YJI1NESS FASSENDu AGE u PART. SEAT SAFETY EJ ONLY ONLY , fATAL SEVERE OTHER WBIE [OYRAMT pRNER FABB. KID. BICYIT OTHER NUMBER FIGS. EQUIP. INJURY WJURY AWRY OF FART ❑ ❑ ❑ ❑ I 'K X ❑ ❑1❑ ❑ / I G- o 111NA1RED A MT0.W;POR ^mrJu~~~c 1 _ TA4JIT0.' lnK f! r P _ 477,e EL /~Sv7T VICT14 OF NIXEM LRME HOl1FIED ® to (n ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ IF 13 1 G NAMEJD.O B 'ADDRESS TELEPHONE GIL Saf IJDeE O Goa?ALES D -6-89 339 uAAQSNau. ST RSw\ ONJINED Olin TRANSPORTED BY: TAKEN M DESCRIBE (JURIES I u VICTIM OF NO.EM CRIME NOTIFIED 10# 1 ❑ 1 I I ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ NAMEID.O. B.'ADORESS TELERJ0N4 (IN RED CHLY) TRANSPORTED BY TARN TO DESCRIBE.NURIES u VICTIM OF VIOfEHf CRIME NOPFNio ❑ I I ❑ F-T ❑ ❑ ❑ ❑1❑I❑I ❑ I❑I NAME I D. O. B. I ADDRESS TELEPHONE FN RED ON.Y) TRANSPORTED By. TAKEN TO OESCRISE I.RIES ' VICTIM OF VIOLENT CRIME NOTIFIED I❑ ❑ ❑ I ❑ ❑ 1 ❑ ❑ ❑ ❑ ❑ NAME' D. O. B. I ADDRESS TELEPHONE ONJUREO ON;YI TRANSPORTED BY: TAKEN TO DESCRIBE INJURIES - - - ❑ VICTIM OF VIOLENT CRIME NOTIFIED ❑ ❑ ❑ ❑ ❑ 1 0 1 01 01 ❑ ❑ NAME I D. 0. 9.' ADDRESS TELEPHONE (INIUREOONLY) T NSPDRTEDBY: TAKEN TO. DESCRIBE IHNRIES ❑ VICTIM OF VIOLENT CRIME NOTIFIED PREPARER'S NAME 9rl ~Tolld-Son I.D. NUMBER c 969 O. DAY YEAR 00 02 io R"VI Yt_RS NAME MO. DAY YEAR STATE OF CALRDRNIA NARRATIVEISUPPLEMENTAL CHP 556 (Rev 7-90) OPI 042 Paae 70/ DATE OF WrIDENTIOCCURRENCE - oa-1D-Do TWE (NrD) NCC NUMBER /9OO OFFICER ID. NUMBER NUMBER V. 'r DNE X'ONE - TYPE SUPPLEMENTAL rX-APPL.CABLE) Narrative ~%Hision report ❑ BA update ❑ Fatal ❑ Hit and run update ❑ Supplemental ❑ Other. ❑ Hazardous materials ❑ School bus ❑ Other: CrTYICOUNTYI UDCIAL DISTRICT ~onJ0 ~7F ~ ~E~ / ( REPORTING D RCTIBEAT ' CITATION NUMB: osE / 4D o5 S /v i 0 O.5 / 53~.7~1 LUI.wI R1WJVtYtLl SUlt HA AT HtIA I tM /''/AR_Sfl9~L Sr, p E,/HA~/`~✓E• ❑Yes ZNo L)1 a. /0/j 50 77/E ADa1R ,45 WE-77 Auer IJV USe~ AS 4 R• 6~ o Or1 L t o. tT IPACFIC /'AA1TOn/-t 12. 15. 16. B UE ANZ r LD. I IV Ili I - 26. Q C) 0 E 29. DE-bv-vs ) 30. MASTIC '{&PS PAQ-TS Auo C RDv~tE QA'Zrs AT EOTE2 F .D,Z, 31. PREPARERS NAME AND I.D. NUMBER DATE REVIEWERS NAME DATE so K) w. ()'a-11-00 Use previous editions until depleted. W s>s.l STATE OF CALIFORNIA NARRATWE/SUPPLEMENTAL CHP 556 (Rev 7-90) Opt 042 PaeeC~,O/ DATE OF INCIDENTIOCCURRENCE OP-/0-00 TIME,7I ) MCC NUMBER /96b- OFFICER LD. NUMBER yo 89/ NUMBER /60-00 l'y5--0131-V '%'ONE TYPE SUPPLEMENTAL rX-APPL1GBLE) 5i.Narra6ve report @:flision ❑ 13A update El Fatal ED Hit and run update ❑ Supplemental Other. ❑ Hazardous materials ❑ School bus ❑ Other. L COUNTY/JUDICIAL DISTRICT k)/ c E A L f 1 REPORTINGD TRICT/BEAT CITATION NUME , N Do os. LEs is osE.utEAD N 0.53 s3i~-P - LOCATIONWBJECT STATE HIGHWAY RELATED r ❑ Yes XNo I 1. J.. V/L c/c.T N7✓/'7LC / - 3T:JJ(11 a. -EM THE Rlc-Hxr iezoo-r P~ssEn1GER S6-A-7- of Pla'- s. "JU- ICLE. ///E SA/o g/s /?Io&7 u1,4S DP-W/t1G /414E cal' ,6. SToP ED N 17. E Q/J co ts. A LEfT T (Z.t1 19. cz cIC- 20. /N Doa1,v 21. BP cu - P E 22. E hE 23. f T I.3 ( 24. T 1 Gt~p 25.. 26. 27. ADDmb0P,( -TO rrcRMaTli P /l LAJ A-5 D f2101 tQ 6 '-,5.14,1 U ST . P/a 1 S ASJ.4e- o,y AlJ C gou5E . SN,< tJAS . ctA s-sz so 51,1E Coyer UE%.JAY. Pl( RFAru~C-t Td 1 PREPARE}:S NAME AND I.D. NUMBER DATE REVIEWERS NAME DATE ,l oIM oa-1l-cDo Use previous editions until depleted. - W 57541 STATE OF CALFOPMA NARRATIVE/SUPPLEMENTAL ~ nr w.na t ravl DATE OF MIDENT,0=RRENCE TWE p4M NCIC NUMBER OFrCER lD. NUMBER 4 Oct Ref 4 UMBER 100 -021q5-o531- 1 192-5 02--10-00 *r ONE '%~C'7ONE s; CoQisicn report ❑ Narrative a TvPE SUPfl.EMEWAL MAPPLCARLEI ❑ 8A update ❑ Fatal ❑ Hit and run update . supplemental ❑ Other. ❑ Hazardous maWKWS ❑ School bus ® Other. DATE: 0 2 -1'f - 0 0 ® THIS FILE TO STAND INACTIVE. < > PROSECUTION TO BE SOUGHT AGAINST PARTY FOR VIOLATION OF THIS FILE TO STAND INACTIVE. < > PENDING RECEIPT OF WORKABLE INFORMATION, THIS FILE TO STAND INACTIVE. < > DUE TO LACK OF A WITNESS(ES) TO MAKE POSITIVE IDENTIFICATION OF . OF THE DRIVER OF VEHICLE #I, NO FURTHER ACTION TO BE TAKEN. THIS FILE TO STAND JNACTTV THIS FILE IS UNDER INVESTIGATION. REPOMS)-TO FOLLOW. THIS REPORT TO REMAIN ACTIVE. PATROL ASSIGNMENT. (by) DEP. D. MOSES #223487 TRAFFIC INVESTIGATOR ASSIGNED: TEMPLE STATION TRAFFIC - MAYOR: JOE VASOUE MAYOR PRO TEM: MARGARET CLARK COUNCILMEMBERS: ROBERT W. BRUESCH JAY T. IMPERIAL GARY A. TAYLOR February 26, 2000 Dwight J. Kunz Senior Account Manager Carl Warren & Company 750 The City Drive, Suite 400 Orange, CA 92668 Roscffread 8838 E. VALLEY BOULEVARD • P.O. BOX 399 ROSEMEAD, CALIFORNIA 91770 TELEPHONE (626) 288-6671 FAX (626) 307-9218 RE: CYNTHIA ANN COTA AND GILBERT GONZALES Dear Mr. Kunz: The attached claim was received in my office on February 23, 2000. Attached also is the City of Rosemead's - Vehicle Accident Report. The Sheriffs report will be forwarded to you as soon as it is received. Please advise us of the steps you wish to take in this matter. Sincerely, NANCY VALDERRAMA City Clerk City of Rosemead Attachments cc: City Attorney m BECK & ASSOCIATES 3660 Wilshire Blvd., Suite 1100 Los Angeles, CA. 90010 213 365-6521 (Tel) 213 365-6520(Fax) February 18, 2000 ROSEMEAD CITY HALL 883S E. Valley Blvd. Rosemead, CA. 91770 A 'tm City Clcrk [ C F r r t CITY Oc FEB 2 3 2000 CITY rt ~7r•'S OFFICE RE: Our Client(s) CYNTHIA ANN COTA AND GU-BERT GONZALES Your Driver Joey Michael Rivas Your Vehicle 94 Ford Club Wagon LP"' 437661 Date of Loss : 02-10-00. Dear Sr. /Madame: Please be advised that this office represents the above named client(s) for injuries sustained and property damages sustained a s a result of the above referenced accident. Please forward to my attention a claim form so we can formally file this claim. `,'.'e shall transmit all pertinent information including the special damages as soon as we receive and verify them. In the meantime, please provide us with a written statement of your insured's policy limits as well as the nature and identity of any coverage provisions. Please do not hesitate to caii our office if we can be of any assistance tc expo-'i:e this clai Very truly yours, PETER BECK, Esq. PB/nh Encls: Declaration of Designation BECK & ASSOCIATES Attorneys at Law 3660 Wilshire Blvd. Suite 1100 Los Angeles. CA 90010 TO: RE: C:,AIM NO. DATE OF LOSS 2 C"::~nT-ON pr ^ TrNn,TT .N STATE OF CALIFORNIA, COUNTY OF LOS ANGELES GONZALES I/aE,CITHYA A. COTA & GILBERT, hereby declare, pursuant to California Unfair claim settlement Practices Regulation, Section 2"5.2(c), Title 10, Chapter of t.`,e California Code of Regulations, the following: That I%aE desicnate the IA-4 or-:=s cF PETER BECK as my attorney and legal representative; and, That I%aE authorize the LA-,T orFT_c=s or PETER BECK to handle all :ratters arising frca -y actaxbila accidnn.t clai3 that occurred or. February 10,2009 at MARSHALL ST. & HART AVENUE Wherefcze 11*4Z here=t= set my hand - 11 . -Y February , 2000 , in t e city of LOS ANGELES. California. C:.i_n:'s Signature.y (Nam.e.'C~NTHIL.A. COTA Client's signature;L (Name:ICYNTHIA A. COTA FOR minor ) Client's signature: -J~ (Na-g: C ) C l GILBERT GONZ.ALES m N_a ,tea a v r -~ti Q u f/i o 0 O S O C~ T _ v m' m ~ 9_~ m m o urn m 1 v _ ~ w v Z N • . n m o - n Dm0 2m m m m o T my ~ _ r ~1 Dc~ 350 ° = m sn m \ n ?C' 'na< ~ s ..m C V m omo 139 N , o v ' r ' 3 o 1 m m 3 0 3 1 O . z. 2 mD . < o z ` , _ O A am 0n~ m C y r r \ ~ om O n om mn~n v m _ v 3 \ z a a 0, 0 ° - UI A D m D v O m rn ) C) ~ 2 im o0? a z OOmD ° n ' ~ ° ° ' 9 v o m 3 o i m rr z- m a mZm i mu nm' > m C p © -1 n 0 n m J v m m m C _D r (n m O p ° D m O 0 - O C m x = Vim D C E .c ,2 N n m m m N 3 u ~ D m n m 7 m u n m m m o = r m m r m J C m 7 o m m O 0 O O C Z O. T O N D z m O -V m O mm ~ N ~ O mm 9 T O T O m T n 9 1 mm z 1 6 9 c A 9 S o~ 7c rb Ct o- + N cb ro (b CL- Po ~ ~ ~ ~ V= ro ~ ~-o ~ N 1 j~N NHS o~ Cc) (D" 9 U 1 I I I CITY OF ROSEMEAD - VEHICLE ACCIDENT REPORT p DEPT. 2 ~enarkrr C- CITY VEHICLE C IJ PE RMT TEE E71 Vehicle Ua No. CONT^A, DIV. Equip. No. 6 U. Insvr ..Cc Co. SERVICE SECTION 1 3 lIo T Policy Noy r yes INCIDEIJT 1,-L DATE ~(O'00 HOUR POLICE IL Ycs POLICE AGENCY `,1 11 CITY REPORT [1] No REPORTING ~1YC-rJS t•5TATION T~"'°~ cc S ` -SI;, PLACE IJT HAP?EIJED OR AREA Q ~ot1'1Li S- ODUn A ' °s)n"""' PLACE T. , ROAD, ETC.; t~ qN U.e II S~. DRIVER 1D ~oeJ A s S Job Thle ice, P 1 de x5831' Dri.er's Lie. No. SLS~L_ ` Address: Hom ~10 C C~h7 11 nr Phone 62b-'Z65-L~`t IL W4 It Locolion ~Sj e. C6(6,J W L Phone {%2b- S 69 "2I 2 VEHICLE Yeor L 19 II IZ 4 f.!ol.e €I3 ?-p M d l IQ T URN/LLa6-U\l~SO Ports Dom ed B 1 nV'G(Z E o or e ype - } p .RONT Fzu mPFe U Passenger 1. Nome Passenger r 2, Nome H,,, Address IS~REt I one Hom P Home Add, r_s (CITY) (STREETI ICITY) : e , ,usiness Phone Home Business 1: ~l~(1 DPIVER }o Vc`-,Ce- ce,>Dr~ : FILe No. loo -o-;LH5- C)S3I OCAMEI (ADDRESS) (CITY) (5T ATE) )ZIP CODE) IPRON FI W J _U E W LU W O DRIVER'S LIC. NO. INSURANCE COMPANY EMPLOYER (NAME OR PERSON, COMPANY OR ORGANIZATION) (ADDRESS) (CITY) ISTATEI IZIP CODE) (PN ON E) VEHICLE 16 IY_Aq) Veh. Lic. No. IMAGE) IMOOEL OR TYPE) [YEAR) (NUMBER) (STA Pars Domogea :i7 -2~c.cK •mnev ~n OWNER NAM`) Ili OTHERPROPERTYDAMAGE R Yesu No`i I LCSS OR DAMAGE TO CITY AND/OR EMPLOYEE NON-VEHIC Q If yes, 2ezCrlbe I EQUIPMENT OR PROPERTY? il9 Yes❑.N.F If yes, dcsn O LU W 2 I ~ I O a N"uE ADDRESS _ NATURE OF INJURY TAKEN TO Z N,1Y..E ADDRESS NATURE OF INJURY TAKEN TO DRAW A DIAGRAM AND SHOW HOW INCIDENT OCCURRED - - I EXPLAIN deadly how mcl2cm occoNed: S-GR lac IOCitJ.n and ci `..c is l; (s) m point c( S-Cyavr Veh4le as 1-i the at., Vehicle as 72-> I 5i: 'F ;Se name of :he zaeel(z). Iccc:ico as slop s enc L-. N 0 R TIf r~ E I IA CrZSFir^-LC. 5 i 1 IT 5 Ac A I S I l i I C I T I -zo ) I I I ;-cz i-. acne c`ea C' eY~c~~ C I I I I \\1 L`rvn ~~-.`Y~P . Leave no section blank. For each category, check the ONE boa in each column INSTRUCTION: that, 6e;t applies. Where the,e ore two columns of b.-es, the right hand column. for vehicle Q. In the longer bo.CS (O), fill in the correct ligmes. i". 20 PERSONAL INJURIES I ❑ I ❑ One 2t 2 I Driver 8 Pessenoer, 3 31; Driver Only 4❑ 4❑ Passenger(s) Only 50 5❑'City Employee Not in Veh. F-1 61___) Pedestrian 7F--1 71--1 Other 1= 2 F-T-] Total No. Injured 1 = 2O Total No. Fatal 21 INVOLVING 1 Non-City Vehicle 2❑ Another City Vehicle 3F-] Fi,ed Object (Other than 4 I-? Moving Object Vehicle) 5❑ Pedestrian 6 ❑ Other Z2 LOCATION OF VEHICLE DAMAGE 1 n I F- Leh Side Z 20 Left Front 31 3 ❑ From 4 F- i 4 n Right Front 5❑ Sri Pioht Side 6 ❑ 6 ❑ Right Pa., 7F 71 ! Reor a❑ a LLJ Leh Rear 9(-1 9L7 Otber or Multiple 0M 01❑1 N.,,a 23 NATURE DE VEHICLE DAMAGE 1 ❑ I ❑ Bumper(z) 2 ,~ry❑--~I 2❑ Dom(z) Note: 3LL' 3❑ Fender(s) Check 41- _h Fmme all 5i .51-1 Grill. thm 5n 6~ 11 Hood Apply 71 : 71a' 31 Si-1 Rgdic!or 9 9❑ Ste Crinq 10_10 L~_ Top I I ^1lTte.k Deck/Lid 12 _12"h6ecl(s)i Tirc(:) 13i 131 ''4'indsh is ld.r'Nincowls) u _ u l_ .other 24r VEHICLE DAMAGE (EST.) I - I XOvcr _200.00 ? 2 _ Undo. SX0.00 -pbp<e :de.. e G ~m 5l TJt.;I Y, z. Driv. 48 T el Yrs. 25 WAS YOUR VEHICLE LEGALLY PARKED AND UNAT T ENDED? Ycs .U No, complete the report a , including Col. 2, 3, and 4. IJo _ '.IE Yes, ignore Col. 2, 3, end 4, go to bottom of page.- _ _ 26 ITY - - _ - - - I EJ ❑ Ru,ol.Hwy!Roodwo%- 31 AMOUNT OF TRAFFIC 2 Rcsidentiol g 1 1 n No Other h n 2 ❑ L 3 ig t 2 gusiness!$hopping 4 ❑ Freeway 30 30 Medium 5❑ Motor May (hil-) 4[D 4[] Heavy. flowing " 6F-1 Open Field 5❑ 5❑ Congested 7❑ Private Rood 80 Other 32 SPEED (enter ESTIMATED mph) Z7 OPERATING AREA I Non-intersection 2❑ Nearing Intersec:ion 3 ❑ In Interseclion 4 ❑ Leaving Intersection 5❑ Entering Driveway 6 ❑ Leoving Driveway 7 ❑ Construction Zone 8 ❑ Parking/Bus. Lot 90 Other 28 DIRECTION County Vehicle and other Vehicle or. Pedestrian I ~ Both Going Same Direction 2 Crossing in Opposite Direct. 3❑ Going in Opposite 4 ❑ Not a Vehicle or Pedestrian 29 MOVEMENT I I ❑ Straight Ahead 2 ❑ 2 ❑ Lone Change 3 ❑ 3E] M.king Right Turn 40 4n IAokmq Left Turn S❑ $ Slowing, Stopping 6E] 617 Standing - 7❑ 7❑ Parked a ❑ 80 Backing 9❑ 9❑ Rolling Back 0D 0f7 Moving Unoncndcd 30 pTTRnnAFFIC CONTROLS I (V\ I _ None P:cscnt 2 ❑ 21 G,ccn Signal r 3❑' 3, i Yellow $icncl 11_ J! Rcd Signal Sh 51 Fleshing Signal 6 6' Step Sign 7 7' warning Sign 3! d~ Conztmuion Sign 9 911 O:hcr 1 © 1 -10 Sign of Danger 2 ® 2 ® Time of Impact 3 ® 3 L~0 Posted 33 CONTRIBUTING FACTORS 1010 Rood or Vehicle Defects 20 2 ❑ Unsafe Passing 30 3 ❑ Unsafe Lone Chance 4 4 ❑ Improper Turn 5❑p~ 50 Following Too Clozaly 6 N 60 Too Fast For Conditions 70 70 Violated Sign/Signal a F-1 3 ❑ Failed to Yield or Wait 9❑ 90 Other Failure 0 ❑ 0 fi No Fault 34 EVASIVE ACTION 10 1 ❑ Locked Brakes 2 2❑ Hard Btokcs 3! 3 ❑ Slower/Stopped 4 ❑ 40 Stewed Avv cy 5 ❑ 5 ❑ Acccleroted 60 6E] 3 and 4 Above 7 ❑ 7E] T 4 and 5 Above ac aI7~~I Nonc 91~ 9u Other 351 I SKID MARKS - ((cat) 36 DRIVER CONDITION (Just prior. to incident) I : Good 2 YCmy D,owzy .1 Nct vous Worried ~ htitotcd 7 In Pain Illness 9 Other Z rhvn~~5 r,e •-'v rn-1Y .9 T.tel Yrs. this type Vch. $0 DJIC• LY_ b ATUFE OF Su PERVISC 37 gDWAY 1 Straight Z Curve 3E] Winding 38 TERRAIN Level 2 Upgrade 3 ❑ Downgradr 4❑ Hill Crest 50 Dip 39 ROAD SURFAI I Concrete 2 Aspholt 3 Oiled/Gray 4E] Unpaved 5 ❑ other 40 ROAD CONDIT 10 Dry 2 was 3 Muddy 4 ❑ Snowy or Ic 41 NUMBER OF LA Your Side FT--1 Oppo: n9 C17 u2 WEATHER I ❑ Clear 2t Rain 3 Fog 4❑ Dusty 5 ❑ Sm.- 6 Heavy Smog 7E:] Other 43 VISIBILITY 111 Good 2❑ Fair 3 ❑ Poor A ❑ Vety Poor 44 SAFETY BELTS 11~ Installed, Not 21;~- Installed and J I Net r',laned 41~ Vehicle Un., 45 On emergency 'es Yci i N. ID Do I - _ _ _ - - - - - -