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CC - Item 4A - Reject Claim - Zing Zhen Ma //S F M F\ °g. e staffep ort TO: HONORABLE MAYOR AND MEMBERS ROSEMEAD CITY COUNCIL FROM: NANCY VALDERRAMA, CITY CLERK DATE: MAY 19, 1999 RE: AUTHORIZATION TO REJECT CLAIM AGAINST THE CITY- XING ZHEN MA, ET AL The attached five (5) claims were received in this office on May 11, 1999 for: Xing Zhen Ma, Kenny Liu, Robea Huang, Tony Huang, and Jeanne Liu. Copies were sent to the City's claims adjuster, Carl Warren& Company the same day. Carl Warren & Company sent notices on May 13, 1999, recommending that all five of the claims be rejected by the City. Also included is correspondence from Carl Warren& Company, the Claim for Damages forms, the City's Vehicle Accident Report, and the Sheriffs Traffic Collision Report. RECOMMENDATION It is recommended that the City Council approve the rejection of those claims and authorize a • letter of rejection be sent to the claimants. • • COUNCIL. AGENDA vtp:agenda MAY 2 51999 ITEM No. de -14 2 REM F May 13, 1999 CITY C,c ur.- MAY 1 71999 CITY CLERK'S OFFICE TO: City of Rosemead ATTENTION: Nancy Valderrama, City Clerk RE: Claim Ma v. Rosemead Claimant Xing Zhen Ma D/Event 1/4/99 Rec'd Y/Office : 5/11/99 Our File S 100666 SWQ 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 & COMPANY icIZdrd'V. Alarqu&i 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•Santa Ana,Ca 92799-5180 Phone:(714)740-7999•(800)572-6900•Fax:(714)740-9412 May 13, 1999 �l! , CE!"E r . MAY 17 1999 CITY CLERK'S OFFICE TO: City of Rosemead ATTENTION:Nancy Valderrama, City Clerk RE: Claim Liu v. Rosemead Claimant Kenny Liu D/Event 1/4/99 Rec'dY/Office : 5/11/99 Our File S 100666 SWQ 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 & COMPANY Rt izarctri(7. A-farquei Richard D. Marque cc: CJPIA Atm: 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 Phone:(714)740-7999•(800)572-6900•Fax (714)740-9412 �JJJ May 13, 1999 C MAY 17 1999 CITY CLERK'S OFFICE TO: City of Rosemead ATTENTION:Nancy Valderrama, City Clerk RE: Claim Huang v. Rosemead Claimant Robea Huang D/Event 1/4/99 Rec'd Y/Office : 5/11/99 Our File S 100666 SWQ 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 & COMPANY Richard'V. /Varga& 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•Santa Ana,Ca 92799-5180 Phone:(714)740-7999•(800)572-6900•Fax:(714)740-9412 May 13, 1999 � !„ Er QTY ' ` MM 171999 CITY CLERK'S OFFICE TO: City of Rosemead .ATTENTION:Nancy Valderrama,City Clerk RE: Claim Huang v. Rosemead Claimant Tony Huang D/Event 1/4/99 Reed Y/Office : 5/11/99 Our File S 100666 SWQ 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& COMPANY Richard '!. /VIalrga& 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•Santa Ana,Ca 92799-5180 Phone:(714)740-7999•(B00)572-6900•Fax.(714)740-9412 May l3, 1999 R!` CITY C;` r,:' S:_ MAY 17 79gg TO: City of Rosemead tin'CLERK'S OFFICE ATTENTION:Nancy Valderrama, City Clerk RE: Claim Liu v. Rosemead Claimant Jeanne Liu D/Event 1/4/99 Rec'd Y/Office : 5/11/99 Our File S 100666 SWQ We have reviewed the above captioned claim and request that you lake 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 & COMPANY Rz iiant D. 1-facque- 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•Santa Ana,Ca 92799-5180 Phone'. (714)740-7999•(800)572-6900•Fax:(714)740-9412 e6: ,67it) n1A REGEpp / « OF RCiJ__lYC ri Next Report Due: 7/15/99 fr MAY 1 7, L. c--- CITY CLERK'S OFFICE May 12, 1999 UVJ INVESTIGATIVE REPORT - REPORT ; 2 Carl War.-n and Company 750 Th- City Drive Suite 400 Oran-e, CA 92868 Attention: Richard Marque / Re: 0/Principal: CJPIA Member City: Rosemead Claimant: Zing Ma/Farmers Ins. Group D/Accident: 1-4-99 Our File No. : S 100666 SWQ Ladies and Gentlemen: PREVIEW: A City vehicle operator was involved in a motor vehicle accident. Farmers Insurance Group, the insurance carrier for the other motorist involved in the accident, has filed a subrogation claim. MEMBER CITY: City of Rosemead, 8838 E. Valley Bl. , P.O. Box 399, Rosemead, CA 91770. Business phone number is (626) 288-6671- DATE, TIME, AND PLACE: This motor vehicle accident occurred on January 4, 1999 at approximately 2:15 p.m. The collision occurred at the intersection of Hellman Avenue and Rockhold Avenue in the City of Rosemead, California. OWNERSHIP/CONTROL: Per discussion with Nancy Valderrama at the City of Rosemead, we have established that Silvia Llamas is an employee of the City of Rosemead. Furthermore, Ms. Llamas was operating a City owned and maintained vehicle within the course and scope of her employment when the accident occurred. GOVERNMENT CODE REQUIREMENTS: 1. Date Verified Claim Filed: The subrogation claim of Farmers Insurance Group was timely filed on april 20, 1999. CARL WARREN & CO. CLAIMS MANAGEMENT-CLAIMS ADJUSTERS 750 The City Drive - Suite 400 - Orange, CA 92868 Mail: P.O. Box 25180 - Santa Ana, CA 92799-5180 Page 2 S 100666 SWQ 2. Action Taken by Public Entity: At the present time, the City of Rosemead has taken no action. 3 . Statute of Limitations: 6 months from the date of denial or 2 years from the date of occurrence. FACTS IN BRIEF: Silvia Llamas was traveling westbound on Hellman Avenue directly behind the claimant vehicle. The claimant apparently was initiating a left turn at the intersection of Rockhold and the City employee started to pass her on the right. As the City vehicle passed, the claimant made an abrupt right turn and impacted the City vehicle. PHOTOGRAPHS: Enclosed in this report are photographs taken of the accident intersection. These photographs are supplied with captions and are self explanatory. At an earlier date, the undersigned conducted a scene inspection and surveyed the area. Hellman Avenue is east/west traveling roadway which traverses a section of the City of Rosemead, California. It intersects Rockhold Avenue at approximate right angles. Rockhold Avenue, however, becomes staggered as it intersects Hellman Avenue in Rosemead, California. Hellman Avenue has no traffic controls at Rockhold except the posted speed limit. Hellman Avenue is one lane in each direction of travel and has no left turn pockets or right turn pockets available at or about the area of collision. In the westbound direction, Hellman Avenue is 16 feet 3 inches in width and in the eastbound direction, it is 15 feet 5 inches in width. Specifically speaking, this roadway in the westbound direction is capable of accommodating 2 westbound traveling vehicles. The roadways are straight, level, and flat. Lastly, we would like to make mention that the claimant apparently would have been turning into her residential property as she resides at 3403 Rockhold Avenue in Rosemead, California. POLICE REPORT: The City of Rosemead has supplied us with a copy of the Traffic Accident Report. We note that on the date of accident the weather was clear, the surfaces were dry and it was daylight outside. No unusual conditions existed. Motorist Ma was deemed to be the primary collision factor as she made a right hand turn from an improper position. Furthermore, she was deemed to be inattentive. No other causative factors were discussed. Page 3 S 100666 SWQ CITY MEMBER VERSION: Silvia Llamas, 9332 E. Valley Bl. , Rosemead, CA 91770. Ms. Llamas is employed by the City of Rosemead as a recreation leader. Date of birth: 2-18-77. In essence, this city employee will relate the following information: The collision occurred on January 4 , 1999 at approximately 2:15 p.m. The accident took place at the intersection of Hellman and Rockhold in Rosemead, California. Ms. Llamas was driving a 9 passenger City van. Rudy Camacho and Diane Davila were also in the van. These 2 individuals are also City employees. She was driving the City vehicle within the course and scope of her employment. On the date of accident, the weather was clear and the surfaces were dry. The City employee was traveling westbound on Hellman approaching Rockhold. Hellman Avenue is one lane in each direction. The other vehicle involved in the accident was a Mazda family van. The Mazda was also westbound on Hellman directly ahead of the City vehicle. There was one adult and 4 children in the Mazda van. The driver was a female. The City employee first saw the van stopped on Hellman at Rockhold appearing to prepare to make a left turn. The City vehicle was traveling at approximately 10 to 15 miles per hour and was approaching from behind. The van had its left turn signal indicator activated. Ms. Llamas stopped behind the van. After being stopped for approximately 2 to 3 seconds, she attempted to pass the van on the right. The City employee activated her right turn signal indicator and started to pass to the right. While passing on the right at 5 to 10 miles per hour, the claimant started to make her left turn crossing the center median and then immediately started to make a right turn into the side of the City vehicle. The City vehicle operator swerved to the right to avoid the accident but was impacted anyway. The claimant vehicle's right side was impacted by the left front of the City vehicle. The collision occurred along the north curb line of Hellman Avenue. At the time of impact, the claimant vehicle would have been traveling at approximately 5 to 8 miles per hour. The City employee honked her horn to notify the claimant of her presence, all to no avail. The City vehicle was actually stopped along the curb line when it was impacted by the claimant vehicle. Although the parties in the City vehicle appeared to be stiff and sore after the accident, no one in the claimant vehicle appeared injured. There were no independent witnesses that viewed this accident. The police wrote a Traffic Accident Report. Both vehicles were driveable after Page 4 S 100666 SWQ the accident. Lastly, only the claimant driver was seat belted when the accident occurred. For further information, please refer to the enclosed written statement of Silvia Llamas. PROPERTY DAMAGE: Farmers Insurance Group, 117 E. Duarte Road, Arcadia, CA 91006. Farmers Insurance Group insures motorist Zing Ma. Apparently Farmers Insurance Group has paid for Ms. Ma's vehicular damages and has filed a subrogation claim with the City of Rosemead. The claimant vehicle sustained moderate damage to its right side in the amount of $6,076.73. Ms. Ma has a $500 deductible so the payment issued to Zing Ma by Farmers Insurance Group totals $5,576.73. Farmers Insurance Group's claim, however, is for the amounts of money paid and their insured's $500 deductible. Supporting documentation was supplied which includes the estimate, photographs of the damaged vehicle, etc. INJURIES: Zing Ma, 3403 Rockhold Avenue, Rosemead, California 91770. Contacts have been made with the City of Rosemead by John Wolcott, Attorney at Law, 3318 Del Mar Avenue, Suite 202, Rosemead, California 91770 . Business phone number is (626) 288-1088. Mr. Wolcott has been mailed a claim form by the City as he apparently represents Zing Ma regarding her accident with the City employee. To date, however, it is our understanding that a claim has not been formally filed on behalf of Zing Ma. We would surmise, however, that this will be accomplished shortly. We will have more information regarding this in our next report. LIABILITY: This appears to be a claim of very questionable liability with regards to the City. It appears that the claimant vehicle was attempting to make a left turn at an intersection and the City vehicle was passing it on the right. For unknown reasons, the claimant vehicle initiated a right turn from the center of the roadway impacting the side of the City vehicle. The police report is adverse to the claimant vehicle operator and indicates that she made a right turn from an improper position on the roadway and that the claimant vehicle operator was also inattentive. In the absence of any independent witnesses, this appears to be a claim of extremely questionable liability with regards to the City. Page 5 S 100666 SWQ WORK TO BE COMPLETED: A. Investigation: 1. Determine if the attorney that represents Zing Ma timely files a claim for injuries. 2. Determine if the City of Rosemead rejects the claim of Farmers Insurance Group. B. Claims Remaining Open: 1 . Zing Ma - ABI. ENCLOSURES: 1. City employee statement. 2. Farmers Insurance Group's claim form and subrogation documentation. 3 . Scene photographs. COMMENTS: Our handling of this matter continues. Our next report will follow upon receipt of additional information or on or about July 15, 1999. Very truly yours, C L WARREN & CO. SAW:ck S ephen A. White cc: CJPIA Attn: Executive Director (With copy of enclosures) ammillocc: City of Rosemead Attn: Nancy Valderrama JOEvvAsvuE_ ' C 9� 1 \V. �i� MARGARET PROTEM' �� C GARET CLARK couvaLMA MSEes: ��* 5838 E.VALLEY BOULEVARD•P.O. BOX 399 ROBERT W s.Ru_scH K• ROSEMEAD,CALIFORNIA 91770 JAY T iMPERu; T. TELEPHONE(626)288-6571 GARY A TAYLOR FAX(626)307-9218 May 11, 1999 Dwight J. Kunz Senior Account Manager 750 The City Drive, Suite 400 Orange, CA 92668 RE: XING ZHEN MA ET AL S 100666 SR'Q Dear Mr. Kunz: The following five claims were received in my office today. On February 17, 1999, I forwarded information to you regarding this incident which included the correspondence from the law firm to the City's employee, Rosemead's Vehicle Accident Report, estimates to fix the City van, and, the Sheriffs Report. A Claim for Damages form was mailed to the law firm on February 17, 1999, of which five were returned today_ A separate claim involving the same accident was filed by Farmers Insurance on behalf ofJie Ying Huang (filed on 4/20/99), and, is scheduled to be considered at tonight's City Council Meeting. If the Council rejects the claim, then appropriate correspondence will be forthcoming. Please adeise us of the steps you wish to take in this matter. Sincerely, NANCY VALDERR&M A City Clerk City of Rosemead Attachments cc: City Attorney LAW °PFICES JoHN F. WOLCOTT 331a DEL MAR AVCNUE FAX SUITE W2 ROSEMEAD, CALIFORNIA DITTO 626-2ea ice° REICE!\'ED CITY nc PflSEME.D Na/ 7 , 1999 MAY 111999 city of Rosemead 8838 E . Valley 131 . Rosemead , CA 91770 CITY CLERK'S OFFICE Attn : City Clerk, Nancy Valderrama RE: Claim No. Date of Loss : 1-4-98 Our Client : Xing Then Ma et al Your Employee: Silvia Llamas Dear Sir/Madam: Enclosed please find the Claim for damages and Injury forms regarding the above loss . Should you have any questions , please call the undersigned. Very truly yours , V V v \ Wendy Li Legal Assistant LAW OFFICE OF JOHN F. WOLCOTT • FILE WITH: CLAIM FOR DAMAGES RESERVE FOR FILING STAMP CITY CLERK'S OFFICE TO PERSON OR PROPERTY CLAIM NO. 7 Q3 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.9112.) 2.Claims lot damages to real property must be filed not later than 1 year after the occurrence (Gov.Code Sec 9112.) 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.Mach separate sheets,if necessary,ID give lull details.SIGN EACH SHEET Date of Birth of Claimant • TO: CITY OF ROSEPIEAD, 8838 E. Valley Blvd. , Rosemead 91770 6-20-63 Name of Claimant XING ZHEN MA Occupation of Claimant HOUSEWIFE Home Address of Claimant City and State Home Telephone Number 3903 ROCKHOLD AVE. ROSEMEAD, CA 91770 626-572-3724 Business Address of Claimant City and State Business Telephone Number NONE NONE Give address and telephone number to which you desire notices or communications to be sent Claimant's Social Security No. regardingthisclaim: 3318 DEL MAR AV. y202 ,ROSEMEAD,CA 91770 605-39-9372 When did DAMAGE or INJURY occur? Names of any city employees involved in INJURY or DAMAGE Date 1 -d-99 Time 14 -19 SILVIA LLAMAS If claim is for Equitable Indemnity,give date claimant served with the complaint: Date Where did DAMAGE or INJURY occur?Describe rutty,and locate on diagram on reverse side of this sheet.Where appropriate,give street names and address and measurements from landmarlcs: HELLMAN AVE AND ROCKHOLD AVE. CITY OF ROSEMEAD,CA SEE THE DIAGRAM Describe in detail how the DAMAGE or INJURY occurred. AT ABOUT 14 : 15 , I , WITH 4 KIDS I PICKED UP FROM THE SCHOOL AT MARSHALL ST TO MY HOME AT 3903 ROCKHOLD AVE WHERE I HAVE BEEN LIVING FOR EIGHT YEARS. MY HOUSE IS AT THE CORNER OF ROCKHOLD AVE AND HELLMAN, BUT MY GARAGE IS ON HELLMAN,FACING HELLMAN AV. I WAS DRIVING W/B ON HELLMAN AVE. WHEN 100 FEET AWAY FROM THE GARAGE I TURNED ON THE RIGHT TURN SIGNAL. WHEN I WAS TO TURN, THE CAR BEHIND ME RUSHED UP AND HIT MY CAR ON MY RIGHT BOTH DOORS AREAS. WHEN THE IMPACT OCCURRED, MY CAR' S FRONT PART AND FRONT WHEELS WERE ALREADY ON THE SIDEWALK.THE OTHER CAR 'S FRONT RIGHT WHEEL Why do you claim the city is responsible? WAS ALSO ON THE SIDEWALK. I WAS DRIVING IN FRONT OF YOUR EMPLOYEE ' S CAR. I WAS MAKING A RIGHP TURN INTO MY GARAGE. ABOUT 100 FEET AWAY, I TURNED THE RIGHT TURN SIGNAL ON. YOUR EMPLOYEE HIT ME WHEN I TURNED.SHE WAS NOT PAYING ATTENTION TO THE TRAFFIC IN HER FRONT AND ALSO SHE WAS DRIVING TOO FAST AND FOLLOWED ME TOO CLOSE. Describe in detail each INJURY or DAMAGE PAIN AND STRAIN ON MY NECK, BACK 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 $ Trap Future expenses for medical and hospital care . . . .$ 'tte Expenses for medical and hospital care $ ?DOD Future loss of earnings $ fit 'Z Loss of earnings $ H,o,vl Other prospective special damages $ N-tn^L' Special damages for $ 11-6"— Prospective general damages $ -7I41 %l, Total estimate prospective damages $ 71.-tr e. General damages $ Total damages incurred to date $ Total amount claimed as of date of presentation of this claim: $2c rrc Was damage and/or injury investigated by police? /25 If so,what city? F°='-'1 44 Were paramedics or ambulance called? he If so,name city or ambulance If injured,state date,time,name and address of doctor of your first visit ' cK, b '--K. , b tS -,1.(['Ur5 re.;,„ /cintsiet, LIye L°-t /P/TA4,-5: (taJY . /f9 E, L, 4 ct c4 1(1, %yc €/ A 9 / WITNESSES to DAMAGE or INJURY:List all persons and addresses of persons known to have information: Name lie Address Phone Name Address Phone Name Address Phone DOCTORS and HOSPITALS: Hospital Address Date Hospitalized Doctor L i't'6cJC4i0 CLmT<v Address Czy E. L lye t5c1U4-te 'ic?4K:e,k,ti. Date of Treatment FJ` 99 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"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-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. •L Y ._ t_ I \.... SIDEWALK J \\ CURB.__} / CURB 7 ! PARKWAY SIDEWALK — ^ Signature of Claimant or person filing on Typed Name: Date: his behalf giving relationship to Claimant: Iv2r-6y Z. :C4v'' F7-- (! La,;O r ich cf X44/1 F. (1/A:Tt— ,L— C %-L - / NOTE: CLAIMS MUST BE FILED WITH CITY CLERK(Gov. Code Sec 915a). Presentation of a false claim is a felony(Pen, Code Sec. 72.) 40 4✓ t � %- k ;Tr- crHiceud . �Ii zfi -heel,¢-r-e I � I I i m • FILE SOFFICE CLERK'S OFFICE CLAIM FOR DAMAGES RESERVE FOR FILING STAMP TO PERSON OR PROPERTY CLAIM NO. c�cl _a3F - 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 locale place of accident S.This claim form must be signed on page 2 at bottom. 6.Mach 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 2$— 9 2- Name Name of ClaimantT Occupation of Claimant r ject VtE LII LI 11-t.t'li-C� City and State Home Telephone Number Home Address nilofClaimant /`� �_ (e 7Z 'Pit IMuScRkai � /2—sPhuei (4 9)I7p C Business Address of Claimant City and State Business Telephone Number Yom' Fic Give address and telephone number to which you desire notices or communications to be sent Claimant's Social Security No. regarding this claim: 331 g—Ptf Mar Ar?*)-12- 1✓wv:.'-t. (9- 7770 When did DAMAGE or INJURY occur? Names of any city employees involved in INJURY or DAMAGE Date y— y'- Ir'I Time I v.f_i(� If claim is for Equitable Indemnity,give date claimant served 3',CP with the complaint: Daterve street Where did DAMAGE or INJURY occur?Describe Cully,and locate on diagram on reverse side of this sheet Where appropriate,g names and address and measurements from landmarks: Tr-r- 17ert8L' 32`t� • Describe in detail how the DAMAGE or INJURY occurred. Why do you claim the city is responsible? Src n-� Describe in detail each INJURY or DAMAGE hEayir;cos, ficzv ar_c�i+,•y • SEE PAGE 2(OVER) THIS CLAIM MUST BE SIGNED ON REVERSE SIDE , tk_ ye(„L,uiJ 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 tar as known: Damage to property S -7€0-2 Future expenses for medical and hospital care — . .S Expenses for medical and hospital care S rPW Future loss of earnings S Loss of earnings S Other prospective special damages S ' Special damages for S Prospective general damages S Total estimate prospective damages $ / General damages S Total damages incurred to date $ [.. Total amount claimed as of date of presentation of this claim: $ ),L'V Was damage and/or injury investigated by police? Ycy If so what city? getP in r<-r{ Were paramedics or ambulance called? N,z If so,name city or ambulance If injured,state date,time,name and address of doctor of your first visit /-5-99 "F""t Yet 4e-.fl" ¢-6 ti..uc w.r.i.,:c..{' Cede-uf tv'4 f40-,,614 tlwt . WITNESSES to DAMAGE or INJURY:List all persons and addresses of persons known to have information: Name IAA Address Phone Name Address Phone Name Address Phone DOCTORS and HOSPITALS: Hospital Address Date Hospitalized Doctor/eve &Jc/I lit (1nr e Address 1O7 C L(Ve (CK 4Vf 4 4. Ata-.ik_Date of Treatment /—s---674; 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"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-1"and the point of impact by"XI' If City Vehicle was involved,designate by letter"A"location of City NOTE: It 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. . ..,:///(// .c,-e_E__ Ottte-CLAN___ SIDEWALK / \ CURB CURB""; / PARKWAY ____.1 \ / SIDEWALK Signature of Claimant or person filing on , Typed Name: � AA Dale: his behalf giving relationship to Claimant: Ve'-c( Lr 'Tn--. (urQCCTI— NOTE:CLAIMS MUST BE FILED WITH CITY CLERK(Got Code Sec 915a). Presentation of a false claim is a felony(Pen. Code Sec. 72.) FILE WITH: CITY CLERK'S OFFICE R- _7 S CLAIM FOR DAMAGES RESERVE FOR FILING STAMP TO PERSON OR PROPERTY CLAIM NO. i _ 3-6 INSTRUCTIONS 1.Claims tor death.injury to person or to personal property must be filed not later than six months after the occurrence.(Gov.Code Sec.9112.) 2.Claims for damages to real properly 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 Date of Birth of Claimant • TO: CITY OF ROSEMEAD, 8838 E. Valley Blvd. , Rosemead 91770 /-/--i7—pp Name of ClaimantOccupation po�f�C/�laimant KeklitS LILT, (lLC Home Address of Claimant City and Stale Home Telephone Number 3361 Mitscit r<-! A-ve - Rtsv4ukJ e4 7,70 624- 2.,FP. —69]2 Business Address of Claimant City and State 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: 33id 1nA7Nw/M,.e420Z, /�C g.nti4 e/ 7!770 When did DAMAGE or INJURY occur? Namesof any city employees involved in INJURY or DAMAGE 9 Date /—U- 5 Time I -lS t„, Vt.,- Llettrur-} If claim is for Equitable Indemnity,give date claimant served with the complaint: Dateive street Where did DAMAGE or INJURY occur?Describe roily,and locate on diagram on reverse side of this sheet.Where appropriate,g names and address and measurements from landmarks: Describe in detail how the DAMAGE or INJURY occurred. -C-CI - Why do you claim the city is responsible? ;JCL"15kti' fa-txx'L. [Yin Describe in detail each INJURY or DAMAGE p/2a,, w, I/Fck C.ntT-T�, &m'I� >?i SEE PACE 2(OVER) THIS CLAIM MUST BE SIGNED ON REVERSE SIDE • K; II Ilk ILtt The amount claimed,as of the date of presentation of this claim,is computed as follows: Damages incurred to date(exact): r Estimated prospective damages as far as known: Damage to property S 7J' t Future expenses for medical and hospital care . .. .S h"vC Expenses for medical and hospital care S-.._(iT'a' Future loss of earnings S r`ci-K Loss of earnings S Ftr Q Other prospective special damages S h.,-'r Special damages for S '`k'-`L Prospective general damages S ,Q Total estimate prospective damages S "'-mri General damages Si Total damages incurred to date S lite Total amount claimed as of date of presentation of this claim: $ `"T/r` -' Was damage and/or injury investigated by police? y II so.what city? /24"1-P"`l-i"t Were paramedics or ambulance called? H-e If so,name city or ambulance If injured,state date,time,name and address of doctor of your first visit t K "- 4±oil'Iji ¢ /'rc..:, 1-1\4- c`°'(—NI S( Cz_nt • il E, L-t'vP A`1t'4ve 4/off. AYc A. 64 V/2( WITNESSES to DAMAGE or INJURY:List all persons and addresses of persons known to have information: Name hO Address Phone Name Address Phone Name Address Phone DOCTORS and HOSPITALS: Hospital Address Date Hospitalized Doctor L1 ke AOI'M<<4 CcAitt' Address lLIE,LiteetKA-V±$cg 4K 4'-_t-- Date of Treatment 7-S`471 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"A-I"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 signedsby claimant. / /4/ 2� Pen 1GLtn` (2/(.._ — \ SIDEWALK / CURB CURB / PARKWAY / 7 /SIDEWALK Signature of Claimant or parson filing on (up ,y Lf' Typed Name: Date: n / Date: his behalf giving relationship to Claimant: nd [/Tv(17 -F JrLn F. il'Hce rt UtYf] (t L...; k 44j SAIL— 1 ' `r D"1j -Th NOTE: CLAIMS MUST BE FILED WITH CITY CLERK(Gov.Code Sec.915a).Presentation of a false claim is a felony(Pen. Code Sec 72.) FILE WITH: CITY CLERK'S OFFICE CLAIM FOR DAMAGES RESERVE FOR FILING STAMP TO PERSON OR PROPERTY CLAIM NO. -03 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 tot damages to real popery must be filed not later than 1 year after the occurrence. (Got Code Sec 9112.) a 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 lull details.SIGN EACH SHEET. Date of Birth of Claimant • TO: CITY OF ROSEMEAD, 8838 E. Valley Blvd. , Rosemead 91770 Occupation of Claimant Name of Claimant �J a evvu -' e � fJI�Yt♦ N Q' r Home Address of Claimant City and State Home Telephone Number S 4 ° -vl��u-Er /'-vs . Re.c«wetij (A mi70 Ess- 1-7z — T72 Business Address of Claimant a City and State 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 clai3 � -[ 111nd Ave ticz / - ern.ec {1 ('A- 4/)7L Ec — (6 6/Jo When did DAMAGE or INJURY occur? , � Names of any city employees involved in INJURY or DAMAGE Date -LL-ti Time I If claim is for Equitable Indemnity,give date claimant served S1'F vtC_ LL«'tIuS with the complaint: Dateive street Where did DAMAGE or INJURY occur'?Describe wily,and locate on diagram on reverse side of this sheet.Where appropriate,g names and address and measurements horn landmarks: (1.4-,,/ '.c'LYQ Describe in detail how the DAMAGE or INJURY occurred- _ i a✓ 1-� Why do you claim the city is responsible? Describe in detail each INJURY or DAMAGE Nc ✓✓^rub • SEE PAGE 2(OVER) THIS CLAIM MUST BE SIGNED ON REVERSE SIDE NtlrilLy �c (2,,L..- � J The amount claimed,as of the date of presentation of this claim,is computed as lollows: Damages incurred to date(exact): / Estimated prospective damages as far as known: j Damage to property $ 7 S� Future expenses for medical and hospital care .. . .5 Expenses for medical and hospital care $ A91.1 Future loss of earnings 5 / Loss of earnings $ Other prospective special damages $ / Special damages for $ Prospective general damages S / Total estimate prospective damages S ' General damages $ Total damages incurred to date $ Total amount claimed as of date of presentation of this claim: 5 75-00)/, Was damage and/or injury investigated by police? Vel If so.what city? ype"✓'r-r�. Were paramedics or ambulance called? b1-0 If so.name city or ambulance If injured,state date,time,name and address of doctor of your first visit )—c—q Q f�✓epf-kroadc<„t,-. dt:Jk-wtr e/at.,,,�t, w, WITNESSES to DAMAGE or INJURY:List all persons and addresses of persons known to have information: Name Address Phone Name l/t'd Address Phone Name Address Phone DOCTORS and HOSPITALS: Hospital Address Date Hospitalized Doctor L[✓P�OI( Wci (c.1- Address LI-0Ebroe(Lek/11^447t,P4rcc./c -• Date of Treatment /— (`(17 Doctor Address C 4 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 '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-1"and the point of impact by"XI' 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. / / je-e /j-Tra I(-'(..-L.a..d-( — SIDEWALK / CURB CURB ?a / PARKWAY _J -**\ / SIDEWALK � • Signature of Claimant or person filing on Typed Name: -{ Date: his behalf giving relationship to Claimant: W�t"�J Li t.gt; VI'LL" J F.. 1,,c 1,4, -ft- . L� sr,,k _ C7-,1-0 NOTE:CLAIMS MUST BE FILED WITH CITY CLERK(Gov.Code Sec 915a). Presentation W a false claim is a felony(Pen. Code Sec.T2.) FILE_WITH: CLAIM FOR DAMAGES RESERVE FOR FILING STAMP CITY CLERK'S OFFICE ( )_ 0 TO PERSON OR PROPERTY CLAIM Na 7 INSTRUCTIONS 1.Claims for death,injury to person or to personal property must be filed not later than six months after the occurrence.(Gay 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 locale place of accident. S 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: CITY OF ROSECEAD, 8838 E. Valley Blvd. , Rosemead 91770 3-/f'—JL Name of ClaimantOccupation of Claimant clt.t'L HR11nt,. • Home Address of Claimant //11 00 City and State Home Telephone Number 3yor Nen: Kt Pd be . PcW .:,j (A9i770 —x72 -372 Business Address of Claimant City and Stale Business Telephone Number fs-4 kr.) Give address and telephone number to which you desire notices or communications to be sent Claimant's Social SecurityNo. regarding this claim:oriNJ l '14 ='14 = / c S-E'^u"tv{ P /4- q/ 77 CL-±-7?3jg Dv When did DAMAGE or INJURY occur? Names of any city employees involved in INJURY or DAMAGE Date (— Time Time jV ' 1 /1 If claim is for Equitable Indemnity,give date claimant served SJ-f 4it -L Lissit,ts with the complaint: Daterve street Where did DAMAGE or INJURY occur?Describe tally,and locate on diagram on reverse side of this sheet.Where appropriate,g names and address and measurements from landmarks: -LSC ,A,LC-is C( Etv.. /<.,w Describe in detail how the DAMAGE or INJURY occurred. {�P ;:p.ie 41tJ 0. R [_.. Ct-U4,1,r Why do you claim the city is responsible? I Describe in detail each INJURY or DAMAGE Pere I . 1. Jr"V t C'4L j "� i � J SEE PAGE 2(OVER) THIS CLAIM MUST BE SIGNED ON REVERSE SIDE 'TC,� , 6I Ft: ccce 1 . I CITY OF ROSEMEAD — VEHICLE ACCIDENT REPORT I • DEPT. 2 Parks & Recreation _ X CITY VEHICLE 5 ?ERt11T E 7 Jeh,C)e _a. N=.- _ CONTRACT DIV. 3 Recreation _ Een,a N_ 6 _ Lorne Cu. _—---_---____ SERVICE [I SECTION 4' - _-_ __ L Na 437661_ Policy Ne _ Yes ❑ No INCIDENT 9. 1-9-9B HOUR 2 C 17 r-,1,;, ,4,'DCE X- Yes POLICE AGENCY DATE _ REPORT - l T No REPORTING empeCity _._- STATION CITY _ Rosemead_ PLACE INCIDENT HAPPENED OR AREA -- -. (STREET, ROAD, ETC.) __Hellman. Avennp - DRIVER IO Silvia_Llamas . __..-._ Job Title 11 Recreation Tparierr.er s Lie No B7078386 = Address: Hon.,. .9332_E Valley B1 .d,_Rosemead,_CA_J1770_ ._—— Phone (626) 280-4103 Lii WorkLoco'ion_8838_E—ValleyBlvd,_Rosemead.,_SA 91770 Phone (6251 288-6671 U LIU PoH= DoE Year,ed 152 9ft-fen.ake IIdeS117-ghi/.le£t- aLt Model nf bnmld _IIZ- p per_ - Passenger _ Passenger I. Name __DianaDavila. _ . 2. Nome - Rudy C'amaeho Home Address 2417 Gladys, Rosemead home Address33 RB Al as --. .. - u- . • - 573-s2S` ST� ,ness IElrn Phone: Home288-gF ETI 16,1- 1 Phone: Homo Bus _ - Business N DRIVER Xing Zhpn Ma . 3401 Rockhold Avenue- Rosemead CA 91770 'NAMEN (ADDRESS) laIY) (STATE) ZIP CODE) (PHONE) U DRIVER'S LIC. NO. _A15/1629 INSURANCE COMPANY Farmers- II1Sur ance.f.XS'hange J V = EMPLOYER Lu INANE OF PERSON COMPANY OR ORGANIZATION) (AODRESSI IOTYI ISTATEI )ZIP CODE) IPHONEI > sr VEHICLE 16 .__1997___ Mazda MV_E..Mini Van Veh. Lie. No. RVSD908 CA Lu IYEARI NE) (MODEL OR TYPE) IYEARI INOMSER1 (STATE) s Ports Damaged 17 The right side F- - o OWNER - INANE) in OTHER PROPERTY DAMAGE 18 Yes:` ' No rH I LOSS OR DAMAGE TO CITY AND/OR EMPLOYEE NON-VEHICLE, Q If yes, describe N/A I EQUIPMENT OR PROPERTY? 19 Yes FT NoI I If yes, describe a ceU Lu = 0 o I en NAME - N/A ADDRESS In NATURE OF INJURY _ TAKEN TO ce D 2 NAME N/A ADDRESS _ NATURE OF INJURY TAKEN TO DRAW A DIAGRAM AND SHOW HOW INCIDENT OCCURRED I EXPLAIN dearly hew incident occurred: SHOW the locationand position of Vehic 1e(s) al point of impact. I/ 1 I The lady in the mazda had her SHOW your Vehicle as f > the other Vehicle as i�C� r/2 at) I left blinker on going to make SHOW the name of the street(s), location as stop signs, signals. 1 a left turn. I, . Silvia went NORTH 1 ) I on the right side going I 1 past her and all of a sudden A ,4' ,42 r,L,/ A.Jv 7 she made a right turn hitting E A 1 the Van. S S T — — — —Tt 1 I 1 L7 < LL,' p�--� S 0 U I H I If Additional Space Necessary, Use Blank Sheet. /� /./.regi OVER Leave no section °lank For cask category. cneck iXt Te ONE boa in each column INSTRUCTION: thot best applies- Wncre there ore rv. ns of bores, trio right Fiend column for vehicle e2. In the lorper bakes IiII in toe correct I oFies. 20 PERSONAL INJURIES 25 WAS YOUR VEHICLE LEGALLY PARKED AND UNATTENDED% - Yes 37 ROADWAY If No, compete tne _ I. z 3, and 4- No • � I r= isNLXe IfYr ignore Co 2 0, di. n bottomof page IStraight 2 ' 2i Dive- & Passenger 21 Curve 3 3J Driver Only 26 LOCALITY 3❑i Wirding 4',_ 4' j Passenger(.) Only 1 ❑ Rural-Hwy Roodwa. 31 AMOUNT OF TRAFFIC I EI I tin No Other 38 TERRAIN 5— 5'' City Employee Not in Veh. 27 Residential 6 : 6 Pedestrian 3L11 Business Shopping 2 X 3i -I Medwm 17 Level 7t i 7❑ Other 47 Freeway 21 Upgrade 1 _ -I 2. 1 Total No. Injured 5F Minor Way (Mtn) �i d❑ Heavy-lowing 31 ; Downgrade 1 j1 2' Tafel Na. Fool 6J-1 Open Field 5 5 Congested 477 Hill Crest 717 Private Rood 32 SPEED(enter ESTIMATED mph) 5� Dip 21 INVOLVING el Other 1 ( _J 2 I 1 I` I sign or Danger 39 ROAD SURFACE I Non-City Vehicle V OPERATING AREA 2 Timeof Impact '' 2L Another Cif). Vehicle -_ IConcrete 1 I Non-intersection 3 3'I I Posted 31 I Fired Object (Other than - 2 Asphol, 2❑ Nearing Intersection a❑ Moving Object vehide) 3❑ In Intersection 33 CONTRIBUTING FACTORS 3❑ oued'Grovel 5 I I Pedestrian4 I Unpaved 41 Leaving Intersection 117 I :7 Rood or Vehicle Defects 6❑ O• ther5 I Entering Driveway 2: 2❑ Unsafe Passing 5❑ Other 22 LOCATION OF ` 61 Leaving Driveway 37 31� Unsafe Lone Change _ 40 ROAD CONDITION 7 Construction Zone 4 �'. 4 XI Improper Turn r VEHICLE DAMAGE -- R' ori BI 1 Parking/Bus. Lot 51 : 5❑ Following Too Closely i we I Li 1 ❑ Left Side t 9: Other 6 i 61,_1 Too Fast For Conditions 2 2x 1 2❑ Left Front — 3❑ Muddy 7 n 7 LI Violated Sign/Signal , 31 1 3 Front 28 DIRECTION J Snowy or Icy 47 41 Right Front County Vehicle and other B Imo-' 6❑ Far ed to Yield or Wait v 91 9_ Other Failure 7 57• Lx Right Side Vehicle or Pedestrian 0 B .. No Fault 41 NUMBER OF LANES 6❑ _ m 6 1 Right Rear I � 7 Both Going SO Direction Your Side I 1 71 71 Rear 2❑ Crossing in Opposite Direu- 34 EVASIVE ACTION Opposing 1 8 I 18 J Left Rear 31 1 Gong in Opposite I ❑ i ❑ Locked Brakes 91 1 91 1 Other or Multiple 4❑ Not a Vehicle or Pedestrian 21 _2 Hord Brakes 42 WEATHER o❑ 0 1 None29 MOVEMENT 37 3_ , Slower/Stopped 1 X Clear23 NATURE OF 1 '�'-1 11 straight Ahead 4 41 steered Awav ; Rain 217 2- Lane Change 5❑ 5❑ Accelerated Ecg VEHICLE DAMAGE — 4'. --� Dusty 1 1 Bumper(s) 373 M• aking Right Turn 61 I 6 i 113 and Above — 41 14.. Making Lcft Turn 2❑{ 71 14and5 Above 511 Snow 7 2 0 Door(s) Note: - 61 Heavy Smog 57 5,- Slowing, Stopping 67 6(—I None 3 - 37 Fender(s) Check 6i61 Standing 9_ ! 9_] Omer 7❑ Other 4] d 1 Frame all 7, 7i Porkud 5❑ 5❑ Grill ,nm B' i B' Backing 351 L 1 I SKID MARKS -(het) 43 VISIBILITY 6l 1 6 1 Hood Apply 9❑1 91 Rolling Bock I Good 7❑ 7 1 Light(5) 27 Fair 00 Moving Unattended Bl l87 Radiator 36 DRIVER CONDITION 31 Poor 911 91 r Steering 30 TRAFFIC CONTROLS (Just prior to incident) 4❑ Very Poor 101 ❑0 rap in I ❑ None Present IR Good 11 III 1 Trunk Deck/Lid 27 2! G• reen Signal 27 Weary 44 SAFETY BELTS 127112 1 Wheel(s)/Tire(s) 3 3(__ Yellow Signal 3'. 1 Drowsy I ❑ Installed, Not Worn 13713] I Windshield/Window(s) 4_ j 4L Red Signal j Nervous 2X_,I Installed and Worn 141 14 LI Other 5R-I 5':g Flashing Signal 5 E-1 Worried 3 Na, Installed 61 I6; I Stop Sign 617 Irritated 47 Vehicle Unoccupied 24 VEHICLE DAMAGE (EST.) 7❑! 7warning sign 7'—_ In Pain I 1 Over $200.00 6718❑❑I C• onstruction Sigh 8 Illness 45 On emergency response? 21 2E Under $200.00 9 91 '. O• ther 9:` Other Yes ❑ No 77 • Employee Name© Silvia Llamas Age Bell 21 / 0 I SIG ATTIRE OF SUPERVISOR Total r,.- D,i.- 4�,_ at& r1 Priv. ..City ,s r(y9/2 Total Its- this type,W/%n DeD1-5 `l��Jj 9 Signature of Driver-Driver "'^s- _ Dine��'l�f=� SIGNATURE OF DEPT HEAD OR AUTHORIZED REPRESENTATIVE Dote STATE OF CALIFORNIA TRAFFIC COLLISION REPORT CAP 555 PAGE 1 (Rev 252) OPI 042 A. .am. rwe 1 or (araou cwunw �. JAL. . Na0rtM.r. 8ls .IeL� xl+ RD Heeur I11-0v17 — wEaTT a.ORT.EOs,MOT 05 33-•-1-1Z a.m "`o L.'JS 0.3 .(.c$ 5 cr. an �p TWA Ilia I roc mean e 0. 1�✓ne+r3 f1VaN`3c Cl 10'1 n1 1 \41 tM. 19170 40156, P < SI TWTFS ❑.o (SSM, °, WCATanaICT,a W„ R0LIC f.c)1.W4 RV;•a3RT ❑D• ,wLn or ❑.n N... ($Ran PARTY DREER.uceae KLIMA I STATE CLAY rues YR YEAR M.aiMoouiwaoa LCD .NI aR STATE 1 {E�57-2Co2°1 IC.A C 6f 97 n ,a-zv4TvAt ,eAc:4-iN SVs1�g0a C4 vivre. AME CR rST.Wnnu.LAST) ❑ vtaG 2+4_N1n>4 "U 3-�03aRpakt i-D Av M. Ma OVEN "Mr.AODREAS ®&AMM AS DRIER pe Ro7.=ttie,i7,e {�4i aiI")7O __ `❑ r 91-' 3L.14 15U2. 11 Co oCo iLOni !o O Oi2Ar ENc RwA l DA"`" EDM ER ❑O n 0 (&26)>72-372h ( —.)NaP4a Mo.M.eM Oricr Taa. , MCMOAnmerra .DEINDMAAT..� 10,411/46nS_ So (Li2fr1.6442$ ❑ SRL"❑amu OCT S CAD Eco rw o A3E _!1-E-L..1.01.14 lam✓ 30 2.2910CJJ3VC. PARTY DIVES"ucauc MESA" n.T< cuv Y^ KS" 'MOD.StE°1 S suaa x�W1ER STAR 2 - 70�838� 6a C `� 9`f. F¢?p/vP.. . wr.1 . . ' 74 I. cA DM R aMa r,aT.MDaa.Wn, El SiL'/1A 1....L-140-64--5 T A 332- ta . vs��-I-7e Cit_ . c 1 ❑e.Me.. .a '05.C-ramD LE Erg a DMYEA "I 1770 Veo 12:23E/n€P4). edi. 9 1770 "'5 $Fr3$' E. vrt1,L fl %, RPk.�"Ek9, 64 , MCY. SEX`o ....... >30� 0'2N 50.3 7.a> VI i• \$l ! 7' ft DQ(ver-1 P.w W-^I ❑O.MeER P)DMVER nom. O❑A (624)z D-y193 (626 )zet-6671 °"°R MEORMACWDanLTS. .P:1nir R. MCAD.IN DAMADw.REA O .MW.LR Maan.. p, c-0MDa666 0-- .. - DR.. \ A- sY6T3' 02_7Co WIa . ❑MAR ❑TOTAL mnEEl Dn ncrcn.. r DOTS CA icco ruco 11191/43 SeVIClet•YeAlgiSa fI"'J. V0 - l PARTY Dmaws"EASE"OEM STATE CLASS !CRAP_ En YEAR 'LACE:MODLU DOLOR _CENSE NUMBER STATE 3 OWL! NAME 1 AR,T.aDDLE.LAST I 0 IOS S.ME STREET ADDRESS O.,ER.MAYE Er. STY WIATe.n. OWNERe.DDRESS YE ❑SAME A,DMYa O[Y REE R n .MD M AY RACE D,e.OMOD.Of YEKLE DR ORDERS Or ❑O. CE ❑DME ❑OT.ER rR E E MDR MECKMA_ALDEFECTS. NONE RE.ERTDMAAa NE❑ mMe.ROME COMM ss.ROM O ❑ ( ) ( ) c,USEE ONLY STYE M. LLE O.M stun I IN DAMAGED AREA VENCL.,SOR..,LEe.RMER POUCYMWa.CA p,„ ELINEA* ❑W ❑so ❑M., R ❑TOTAL SAY` IDM STREET OR MDm... SPEED PC! POTS CA a Mco roc CI ARAE: E DESPATCH NOTIP EO NAME I '-(0736 I OS 0 No ZwA«E DEP.zD.MILLER 162522 D./RI J_D 2�' TRAFFIC COLLISION CODING _/� PALS a. MO CO .off (S l 4-I (5 4YLS . I9Oo ''/J%3( ,-/ t9,S-o017.7r-.n3- 472., PROPERTY xNc..may!)„w0.[.. O i D. DAMAGE pacornm OF CAaA s EQUIPMENT EJECTED FROM VEHICLE SAFETY SEATING POSITION Y/CBrYCLF-HEl LIFT 1 L-MR BAG DEPLOYED 0-NOT EJECTED Adk. A-NON �VEHICLE it-MR BAG NOT DEPLOYED DRIVER t.FULLY EJECTED B-UNKIO'WN N-OTHER V-MO Z•PARTIALLY EJECTED I C-LAP BELT USED P-NOT REOURED W-YES 3-UNKNOWN 1-DRIVER 0-LAP BELT NOT USED 2 3 2 TO 6-PASSENGERS E•SHOULDER HARNESS USED PASSENGER 4 5 6 7•STATION WAGON REAR F-SHOULDER HARNESS NOT USED cIELD RrSTRAIM A-p 6•REAR PCC.TRK DR VAN 0-LAP I SHOULDER HARNESS USED 0'IN VEHICLE USED i.YES P.POSITION UNKNOWN H.LAP I SHOULDER HARNESS NOT USED R-IN VEHICLE NOT USED J.PASSIVE RESTRAINT USED S•IN VEHICLE USEUNKNOWN 7 0.0iHEP K-PASSIVE RESTRNNT NOT USED T-IN VEICLE IMPROPER USE H. V•NONE IN VEHICLE ITEMS MARKED BELOW FOLLOWED BY AN ASTERISK('1 SHOULD BE EXPLAINED IN THE NARRATIVE P;IIMARY COLLJSON FACTOR UST NUMBER (•) OF PARTY AT CONTROLFAULT ipAFgc DEVICES 1 123 TYPE OF VEHICLE 1 2 3I uwEYCOLExTUSION PRECEDING ' A VC SE CRON VIOLATED CTEDE. ISI ACONTROLS FUNCTIOPING APASSENGER CARR STATION WAGON ASTOPPED I I j2100((^) 20 I g CONTROLS NOT FUNCTIONING' BPASSENGER CAR WI TRAILER B PROCEEDING STRAIGHT • Ig OTHER IMPROPER DRI'NO': GOONTRO'S OBSCURED C MOTORCYCLEISCOOTER RAN OFF ROAD /D NO CONTROLS PRESENT/FACTOR• ID RCKUP OR PANEL TRUCK DMAKJNG RIGHT TURN IC OTHER THAN DRIVER' TYPE OF COLLISION IE RCKUP I PANEL TRUCK WI TRAILER E MAKING LEFT TURN ID LINKxOWN' .--(AHEAD-ON iF TRUCK OR TRUCK TRACTOR IF MAKING U TURN -ELL ASLEEP- Ig SDESWIPE IGTRUCK(TRUCK TRACTOR WI TRLR. BACKING • I` IC REAR END H SCHOOL BUS SLOWING/STOPPING WEATHER I MARK L TO 2 ITEMS I ,./IID BROADSIDE I OTHER BUS 1 PASSING OTHER VEHICLE /A CLEAR C Hi OBJECT JJELERGENCY VEHICLE J CHANGING LANES B CLOUDY IF OVERTURNED 1K HGHWAV CORSI,EOUIPIENT K PARKING MANEUVER (RAINING IG VEMCLE I PEDESTRIAN IL BICYCLE L ENTERING TRAFFIC ID SNOWING IH OTHER-, (MOTHER VEHICLE M OTHER UNSAFE TURNING IE FOG:VISIBILITY F'. MOTOR VEHICLE INVOLVED WITH 1 IN PEDESTRIANRING INTO OPPOSING LANE IF OTHER': ANON-coW ON 0 MOPED PARKED IG WIND 16 PEDESTRIAN (TIN I—vArJ IPMERGING M1 UGHIING OTHER ACTOR VEHICLE I/ IF)Lt, Si Zp ✓ttJ TRAVELING WRONG WAY �IA DAYLIGHT DMOTOR VEHICLE ON OTHER ROADWAY T Z 3 OTHER ASSOCIATED FACTORIS) OTHER: 19 DUSK-DAWN IE PARKED MOTOR VEHGLE I MARKT TO:ITEMS) IC DARK-STREET UGNTS IF TRAIN Arc [Dev rbuTwa. O'M ID DARK NO STREET LIGHTS S BICYCLE Ow C STREET LIGHTS NOT NAMYALI BvoFrnw rouTcx' ca DARK- FUNCTIONING' Ow SOBRIETY.DRUG ROADWAY SURFACE FIXED OBJECT: .[luno• P PIH PHYSICAL /ADRY I CV:a[LTw DYES (MARKT TO 2 ITEMS) 19 WET J OTHER OBJECT: /1 A HAD NOT BEEN DRINKING IC sUP E nor D 9HELD-UNDER INFLUENCE D SLIPPERY(MUDDY,OILY.ETC.) IE VISION OBSCUREMENT: HUD•NOT UNDER INFLUENCE INATTURON': /1 IF UNDER DRUG(NFL UNKNOWN"- ROADWAY CONDITIONS) PEDESTRIAN'SINVOLVED I GSTOP L GO TRAFFIC (E UNDER DRUG INFLUENCE' I (MARK I TO:ITEMS) 7A NO PEDESTRIAN INVOLVED I IR ENTERING I LEAVING RAMP I I I PREVIOUS COLLIF)ypypyENIPHYSICAL' 9OX 0 IMPAIRMENT NOT KNOWN IA HOLES,DEEP RUT' 13 CROSSING IN CROSSWALK 'J UNFAu'JAR WITH ROAD —T� Ira LOOSE MATERIAL ON ROADWAY' AT INTERSECTI'JN KDEFECTIVE VER ' IN NOT APPLICABLE IC OBSTRU CRON ON ROADWAY' r CROSSING IN CROSSWALK•NOT EDUIP. Qrn i IISLEEPY/FATGUED ID CONSTRVCI1OF•REPAIR ZONE AT INTERSECTION DNo SPECIAL INFORMATION I_ REDUCED ROAM",AY Wi Dili I ID CROSSNG-NOT IN CROSSWALKI IL UNINVOLVED VEHICLE I IAHAJARDOUS MATERIAL IF FLOODED• IC IN ROAD-INCLUDES SHOULDER I IM OTHER'. IG OTHER': IIIFr.NOT IN ROAD 1 / IN NONE APPARENT ),./1:1 NO UNUSUAL CON TU LIONS ` APPROACHING I LEAVING SCHOOL BUS I IO RUNAWAY VEHICLE SKETCH ANS:ELLAAwus . tL.r—cLOYrIJ ( N) 1 ,I N /I\ ' IA IZCCK:: D !+✓I 1.4 —c-c- Mn/tN ret-,1 CHP ELS PAGE f( R.+1a)OP1042 INJURED / WITNESSES / PASSENGERS / PAGE-'j Dt-�"4-`9� i`}-3 H+aS. N'9oo 736`Y -i9QRoo 17 23-12533-v7Z EXTENT OF INJURY( "X" ONE) INJURED WAS( "X" ONE ) 0„L, oNL. ACE uR OMPLAINT W ER AS EMIR. EJECTED INUJUR 10" ❑ 35 F ❑. LI �SSEVERE OTHER "PUN ❑ ❑ ❑ El I o _., ORES. V4MED own TRANSPORTED BY: "XXX"' DESCRIBE S L9✓Krl-EA NT o Y-1 -TO 9JE4c iL or iUec-k ❑ V .ORvIOLENTCRIMEwnnED ❑° 1 c, 1'Y) ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ I (p 6z XIMIE ID B.'�LcLEFRIONE NrYDt o 17-1-2.7-88,33(ol MU5C$-7E -\J RDS--PAQAD,RESS `1r77O 42b*E2&E-6772 w..URED own TRANSPONTFO S,: TAKEN TO. DESCRPRE'JURIES ❑ INDn.OF OLENT CRIME innREC ❑* ,1 to c ❑ ❑ ❑ ❑ DODO ❑ 1 � 67 O jCOr ;Sr 91770 626- ZYfr-6472 C-DVIU-L$-�12 33L�I rn osc a 1, ay. 2us c m�RD. TAXER TO: DESCRIBE INJURIES 0 R.OF VIOLENT CRIME NOT,RED ❑° 7 Rn ❑ ❑ ❑ ❑ OEIDE ❑ 1 4 '1 o TE,EPNONE S °i ;°!77) =1I 03- 15-9Z I ONJUNEO ONLY)TRANSPORTEDBY, TAKEN TO. DES.rvSE INJURIES ❑ n r.OFVOLENT CRIME run"ED OIX dLp9_4 4J11n&c7 es.-a5'-q3 ��1 INJURED ONLY)TRANSPORTED TAXER TO 0 VILMA OR VIOLENT CRi.E wnRED ❑^ zc- ❑ ❑ I ❑ ❑ SEULI ❑ Z 3 4 o Dter KRDAVILAO6-7/-77,z`'1176,LAOYS4V QJ]�ti++ r'i 1770 62( SP ' S-CPS owURED ONLY)TRANSPORTED BY: TAXER TO. DESCRIBE wJURiFs 0 .D,,.oP.aLENTC MENonREO '. (tNieraS cr--1 401;15 04 of D'I 4E4 NI�E.uEN..E .D. D.. „A, CHP 555-Page 3(Rev.7-87)OPI 042 87 43637 SIMI OF CYDioRN. LLE ` , INJURED / WITNESSES / PASSENGERS j r... R c• , _ 0-1- gei I'1tS *2S. N190o `Io�3VT iq% arra- 'r33-`172 "As 50,76„ER EXTENT OF INJURY("X"ONE ) INJURED WAS( "X" ONE ) ..re SEAT SAFETY EJECHEll FATAL o 0 0 0. D. ❑_ X Z2 rn ❑ ❑ ❑ ❑ ❑ a /0 o a.or• DY 4A AcAc (2 -09-7C0 3338 ktlwa<cv Rv. aoe,+,zrtbM.-7r 62:-z?Fr-999 / (NAMED own TRwSEOSTED a.: ' ` T..EN TO, DESCRIBE NAMES O .. ,M O.nu.ENTwIREND,REO ❑° 0 0 ❑ ❑ 0 ❑ ❑ ❑ ❑ ❑ TELEPHONE (INJURED ONLY}TRANSPORTED It. TEN TO. O .,E,.e.,,r.EM DR,.E NOTIFIED 0* ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ I ❑ ❑ ENURED ONLY)TR...SPORTED RT: TANEN TO: DESCPSE INJURIES O ,, ,.OF VIOLENT CRIME wnRED ❑° 0 0 ❑ 0 ❑ ❑ ❑ ❑ ❑ ❑ TELEPSONE auLRED ONLY)TRANSPORTED BY. "FAXEN TO. O NCH.OF VIOLENT CRIME rcnFIED ❑° 0 0 0 0 0 ❑ ❑ ❑ ❑ ❑ TE..P.ONE (.,..011LYpTIWZSPORTED St. TAXE„70 O .CNN OF VIOLENT CRIME NOTIFIED ❑° 0 ❑ ❑ 0 0 ❑ ❑ ❑ ❑ ❑ rz.E..ONE DN.URED ONO.TRu5roRTED D., T..EN TO. DESCENDS ONJUNIES O .E,v OF nOLOJT O L4E NOTTRED PREPARERS ▪,-rr NAME E-lo73c.'1 vI o'! 15 REVIEWER'S NAME MD. D.. YEAR CHP 555-Page 3(Rev.7-67)OPI 042 e,.43.337 STATE OP ALIFORNIA NARRATIVE/SUPPLEMENTAL CHP HP 566(Rev]-90)OPI D42 Page j— - NUMBER 1DATE CW MCOENTOcOJRRENCE TIME(NCO) ROCNMBER DEICER I O. NUMBER tDl'D''11—/ ! Wl50,25 'Di o73fo I99 -Oonff-os33-Y2 FO CONE TYPE SUPPLEMENTAL CrAPPLC4RLE) (q� 011151M report ❑BA update ❑Fatal 0 Hit and run update 0 SueVe )(}1.Supplemental ❑Omer: ❑School bus ❑Other:0Hazardous materials - REPORTINGDISWICT/BEAT CITATION NUMBER LI 0.5.TYLlUOCLLL OISTRILL y� -1�4(� / Los Angeles //310 f}cN IDe7 Io573->sr)/Pm M1D�/S JEC _YT(.! STATE HIGYWAY RELATED R� LOCATOR/SUBJECT DYes 52ND t}cwJt1M-1 PrV, 1?0r.41F1oU> l tj , 1. 1 - FACTS: 2. A . Scene: 3, 1 . Roadwa - # 1 : Name : —1.S ,' J 4V . (M. Asphalt Surfaced ( ) Cement Surfaced ( ) Other : - 5_ ( ) Business/Commercial ( ` Residential ( ) State Hwy (S/R # ) _.- 16 ( ) Private Property ( ) Parking Lot ( ) Other : - 17 (>4 Straight ( ) Curved (XL Level ( ) Incline ( ) Left Turn Bays y 8. ( ) North/South SX East/West Divided By;a✓b11-Ce4 14:71.1.0*., Lars E.• 9. Lanes in each Direction: ) Additional Descrigtion: 10. 11. 1 12. I14. 2. Roadway # 2 : Name : R0414.. f3 A'. - 115 ()Q Asphalt Surfaced ( ) Cement Surfaced ( ) Other : _ 16. ( ) Business/Commercial ('k) Residential ( ) State Hwy (S/R # ) �' I! 17. ( ) Private Property ( ) Parking Lot ( ) Other : - JI ' 18. (X) Straight ( LCurved Level_( ) Incline ( ) Left Turn Bays , 19. (Jel North/South ( ) East/West Divided By:Y7Q' Izpra 1L1„LD(Ll LtroE' i :20. Lanes in each Direction : ) Additional Description: _ _ • 21. _ '22. __—. - - 23 _ _ ._ . 24. _. 25. 3. Traffic Controls : ( ) None ( ) TrrPhased ( ) Left Turn Arrows_ • 26. (ZQ Stop Signs ( ) Other Control ( s ) : 2L Controls Located at: ( ) Four-Way : or _ (HCl Other ;40C4bht-C> • _ 28. 29. _.- 30. 31. PREPARERS NAME AND I.D.NUMBER DATE REVIEWERS NAME DATE le reat;t1-1 4.0, 6Wr f vi-o4-41 Use previous editions until depleted. m 5/541TEM SLATE OF CALIFORNIA NARRATIVE/SUPPLEMENTAL page '4p CHP 556(Rev 7-90)OPI 042 DATE OF INCOEHLOCCURRENSE TIME RIX) NCC NUMBER OFFCER ID.NUMBER/ NUMBER o(–Otd-1i 144IS—rf3S_ mop 4,73 6,4 19 o0I78'-as33-4-72 "X"ONE 'r ONE TYPE SUPPLEMENTAL fa-APLCARLEJ ❑ arras0 Other n M rep 0 BA update 0 Fatal ❑Flit and run update S ❑supplemental 0 Other. E]Hazardous materials_ 0 School bus ❑Other REPORTING DISTRICT/BEAT CITATION NUMBER CT}yCq/M VOIAICML DISTRICT / Los Angeles / STATE HI 4WAY RELATED LauTlows�e,Ecr El No ❑Yes 1, B. Measurements : Obtained By Of) Pace ( ) Rol-A-Tape ( ) Other: 2. (All measurements are approximate & rounded to the nearest foot) • 3. 4. 1. AOI # 1 : ,R'. Ft 5 of the ,3 Curbline of rh=7LHfr5+ k✓. 5 - ( Ft W of the Curbline of 2DL14d-D 4-✓_ • 6. 7. AOI # 2: Ft of the (`urbtine of . 8. Ft of the Curbline of I 9. 110- AOI # 3: Ft of the Curbline of ktFt of the Curbline of 12. 13. 14. 15. C. Physical Evidence: I 16. 1 . Skid Marks: ov-'- ST12441614-41-- $1GrC:4 17T4v24? /T m4 w/ l3 LAG 1 17. or- 1-L-01"--s A-V, APPro c r mE -S`S 2 r r c as'r o)= 4,90"k/ . Tt,2: 1 18. ✓nr+t2it Or R-Zt Vert(C.LE. 19. - 20. J 21. 2. Debris : ND.- c - - 1 22, 23. 124. 25. 126. 3. Other : NQr-3L= 28. 29. _ _- 130. 131. 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' PREPARERS NAME AND ID.NUMBER DATE I REVIEWER'S NAME 'DAIE 2=))-.E-:1z5v4a '4b734S( 1p1V0 '1-95 - - Use prevviiouu s editions until depleted. so 57541 STATE OF CALIFORNIA NARRATIVE/SUPPLEMENTAL (, CHP 556(Rev 7,90)OPI 042 Page 6 DATE OF VCIDEATNYIIRRENfE TIME(7400) ACC NUMBER OFFICER ID.MIMBE NUMBER pt- 0'-t-434 1415- 1900 qv-732,54 t91.00l72r-01033- Y7Z -,C DYE or DIE TYPE SUPPLEMENTAL pr"APPLICABLE) ❑Narralive 0 Collision repot ❑BA update ❑Fatal ❑Hit and run update ❑Supplemental ❑Other: ❑Hazardous materials 0 School bus ❑Other. CIIYFLVNIY/nOCLLL DISTRICT REPORTING DISTRCTiBEAT CRATON NUMBER LOCATION/SUBJECT STATE HIGHWAY RELATED ❑Yes ❑No 1. A- . 4-.'2T r`5 CoQ+i 2. 3. A-3 7- 1 T'G/lwQi#T' IN ror . r PLC P-Z ) '1'-Z 4 DOV-O paw ?2r4/2-E5 /3 v< -to A."DIC) 5. etQLL1 LING ,NI-ft n- 1. 6. 7. 9. yyL.., OPIto-'s 14a°2 Gari cLJta It).]S 9. A, Yrwt Aa'-1 , 10. 1. c3A , -L Po tom] rrsrr��. ^n2,.n-S cooPLir ) 12. Wt 114- fn-1 o/35.2v.4794.9r-+S l i t m `! OPI- 13. 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