HomeMy WebLinkAboutC.C. 05 CLAIM 91-55 04-21-92CONSENT CALENDAR NO. 5
4-21-92
At%Elnluw
/_,
Inter -Com
APRIL 2
-)ATE: , 1992
TO: HONORABLE MAYOR AND CITY COUNCIL
FROM: CITY ATTORNEY
SUBJECT: CLAIMANT: CHRIS TWOGOOD; D/L: 12-10-91; DATE FILED W/CITY: 12-
17-91; CLAIM NO: 91-55; CARL WARREN FILE NO: S 66869 PRL
After investigation and review it is recommended that the
above -referenced claim be rejected and the City Clerk directed to
give proper notice of the rejection to the claimant and to the
claimant's attorney. �.•�
JAMZS G%!WSRKE, City Attorney
!G R: jab:032692(CL-91 SS. jab)
- Enclosure: Copy of Claim
cc: Carl Warren & Co.
Finance Director
City Manager
City of Tustin
ZX AGAINST THE CITY OF Tr h
(For Da jes to Persons or Persona_ roperty)
The law provides generally that a claim must be filed with the City Clerk of
`1e City of Tustin within 6 months after the incident or event occurred. Be
.lure your .claim is against the City of Tustin, not another public entity.
Where space is insufficient, please use additional paper and identify
information by paragraph number. Completed claims must be mailed or
delivered to the City Clerk, City of Tustin, 15222 Del Amo Avenue, Tustin,
Califorhia 92680
WHEN COMPLETING THIS FORM, PLEASE TYPE OR USE BLACK INK
TO THE HONORABLE MAYOR AND CITY COUNCIL, City of Tustin, California:
The undersigned respectfully submits the following
relative to damage to person and/or property:
1, a. NAME OF CLAIMA
b. ADDRESS OF.CLA
• c. CITY/ZIP CODE:.
d. * TELEPHONE NO:
e. DATE*OF BIRTH:
f. SOCIAL SECURIT
Cr. -DRIVERS LICENS
claim and information
2. Name, telephone and post office address to which claimant desires notices
to be sent (if other than above):
cc S Gl bo Wf
3. This claim is submitted against:
a. The City of Tustin only.
b. The following employee(s) of the City of Tustin only:
C. The City of .Tustin and the following employees) of the City
of Tustin only:
4. Occurrence or event from which the claim arises:
a. DATE: 1-2-116
b. TIME: /
C. PL&CE (Exact .and specific location):
HOW and under what circumstances did damage or injury occur? Specify
the particular occurrence, event, act or omission you claim caused
the injury or damage (Use additional paper if necessary)
WHAT particul--
action by
the City, or
its employees,
caused the
alleged damac
.: inj ury
5. Give a description of the injury, property damage or loss so far known at
the time of this claim.- If there were no injuries, state "no injuries"*
!M y ! tJ
6. Give the name(s) of the City employee(s) causing the damage or injury:
7. Name and address of any other person injured:
8. Name and address of the owner or any damaged property:
F���ctfc Cit (` �G`4G 3- `� J� . ,,.� cv+� as f rc •.�� -�br f }�• ?fit t s
9. Damages claimed: /,4 my 4CX)cX-k b (C
a. Amount claimed as of the date:
b. Estimated amount of future costs: ?
C. Total amount claimed: -7
d. Attach basis for computation of amounts• claimed (include .copies of
all bills, invoices, estimates, etc.
10. Names and addresses of all witnesses, hospitals, doctors, - etc.
Dail.! v
WARNING: IT IS A CRIMINAL OFFENSE VO FILE A FALSE CLAIM!!
(Penal Code Section 72; Insurance Code Section 556.0)
I have read the matters and statements made in the above claim I know the
ed be
same to be true of my own knowledge, except as to thosematters
upon.information or belief and as to such matters I believe the same to be
true. I certify under penalty or perjury that the foregoing is TRUE AND
CORRECT.
1 at Tustin, California.
Executed this %-7 day ofJ,)eG:feA � 19�—�
DATE FILED: ZI I7�C%
C 'S SIGNATURE
B1:CLFORM
Revised 4/29/91
TAAFI=�C COLLISION RE
POR" TUSTIN POLICE DEPARTMEI`' •AGE (a•
� fPECIAt COMoR1oMs Mvr[tR •wr i •V .TT .AL OMTMCT !•ViE[R
"C31 TUSTIN CENTRAL
MLWSER MIT t RUN courm RtroMrW. pSTRCT SEAT ` O p
ORANGE Z c 03
MO. OAT YEAR T1Yt (31 MGC • OPACER L0.
•a
coLuaoN RED oM� U. �V l �- ' � � 'cI / r1.'i,3 � 3022 to Z3
-------/+e-----------------
� �RLtPOST INPOR>rAT10N -DAY of w[XK TOW AwAT iriOtOOR►iMs
►= S MIVW T F S
u STATS MwY REL
a � AT I►RERStCT�ON� 6E-L(,
� % D�+
J J V V E3 MO t
r—O� 1 rtcT 64"s S Of
PARTY ru�,�-RS '^[NSEM"wREJ� STATt CLASS SAFETY Y[lIYR YAK[/�O[�lCOLOR UCi�stMUY[ER [TAS
• � � �-
.......
o MAMt (/IRST. MOO'", LAST) �/�- B Ll.c F
w S vf� A � j TW a &o o�
OwMtR'S wwE SAMt Ai owv[R
PEO[S• STRtET A00RE3S
THAM -
❑ 1 OwMtR s ADDRESS SAME AS DRIVER
PARKEDOTT1STATE /VP
vE QE7)-
RAct asrosmoM op vtMat oM oRotRi or. �'-1 ornctR owV[R � oT»[R
SICI. fEi yu A LYES 11EIGMT wOGMT •RT»OATt }� /�� t.._i
!' G. AT CAR
CLIST
Q T '
❑ M ❑
GT»ER Most rraMt
Suswtss PMaNE PMOR ir[C»AMCAL OtPECTf: MOM[ AMARtM /t REFER TO MARRAnvt
\\ -[!
/ roucrMwSSR vEMcu TYPE � ❑M°"E QMMS
wsuRANcEwRtR
-
Sj r{ j C •� .(
oM Lis
ET OA PEG AT SPEET Pcf �. cc13
a
A66 LL ,01y
oRIVER•s LJCENst ML -SER STATE CLASS SAFETY VEP. TILMAKE / MODEL/COLOR LICtMit MLEA4ER STATE
PARTY
EouP-
Z... . . . . . . . . . . .
eR MAME (ARST.IMOOLE LAST)
PEOE&
STREET ADOMISS
TM AM
PARKED
CtN I STATE I ZIP
vEMCLE
MICY.
SEX
MASA
CUST
aO
MOMEPMONE
❑
\ "
wSUMAMCE CARRIER
EYES MEIC+ct wt)C1Tt SIRTMOATE • TW
Mo. � OAT
SaswEss H•ONt
PoucY AL-G[R
(Notof oN STREET ow wcMwwr
TRAVEL
PARTY OAwER•S uCENSE t+wASER
3
wme (ARST, Mloom LAsn
Ploca! ItTRIET
ADORESS
T1EAN
PARKEOI OTTI STATE LP
VEMiCLt
SICT. SEX MAIR
CLWT
QT"fAMOPE PMONE
J \ /
wEUR.Mct CARRIER
CWHI11•f NAMt 0 SAME AS DRIVER
OWN[R•f ADORtfi (] SAME AS 01YVER
RACE I IMSPvanva w'- •s..... ----- - - u L...J `-.&
PRIOR YECMAFdCAL DtPECM*
CHP USE ONLY
VtMCLt TYPE
SPEED PCP cc ❑
LSiT WC ❑
G»► ❑
STATEcuss � vanYR.
MOVE APPAROfT
o[sc1ESE VEMvCLt OAMACE
0 t pw�. 0 pwMi 0 M-om
[7.00. n mA1oR ❑ TOTAL
REFER To NARRATIVE
SPADE w OAMACtO AREA
YAREtrWO[L./COLOR ucsmsEML-GER STATE
Ow«ER s MArE LiSAME AS DRIVER
OwMt" ACCAESS 0 SAME AS O#mvER
SAM"OATE RACE psPOsmoM of
trti nEK:MT wt►Crtt ya • OAT • YEAR
pR. OI (ON sTR[Cf OR..CMwAr
TRAVEL
r..Jo ;rr,.o42„A , fpo!V 7.87n 091 042 -
0OPPICER 0 onveR Li
eman
/uswESS PMON[, • pMQR MEdN
1ACAL DIFICTS: MOPE AMMIENT C
C»P Lot O«Lr DESCIE4E vtwcLs OAAiACt
vDvCLX TTPt ❑ ur+c. 0 p,0,4MMgR
roucr ML -GER
(-I 0 MAJOA (] TOTAL
SPEED PCs 'cc u
LM/T P11C ❑
CMP Q
AtP[R TO k&A$tAnVE
SA^ot w OAYAGEO AREA
OAF f. 149VICWCC I
TRAFFIC COLLISION CODIN
II�ti W GDt13ii0•+ G _ 1r� L i� )
IZ OAT 1 Tull 1
Cww.l S w�r(� •00�[li
PROPERTY �--
DAMAGE
oZ z
L,
3
/-a 93o �3 7
V r C7 a b 1
S
I - SAFETY EQUIPMENT EJECTED FROM VEH.
SEATING POSITION OCCUPANTS y,Ic�Yr• • Nc� uC_T_
I • DRIVER A - NONE IN VEHICLE L • AIR SAO DEPLOYED
o • NOT fJE::F'J
O 2 TO i - PASSENGERS B - UNKNOWN M - AIR BAG NOT DEPLOYED DRIVER I • FULLY E;::TED
7 • STA. WGN. REAR C - LAP BELT USED N • OTHER V - No 2 • PARTIAL:! EJEt. ED
i . AR. OCC. TRK_ OR VAN D - LAP BELT NOT USED P • NOT REOUTAED W. YES 2 • UNKNOWN
9 . PCSITION UNKNOWN E • SHOULDER HARNESS USED
.23 0 •OTHER F. SHOULDER HARNESS NOT USED CHLO aOSTPAINT PASSENGER
4 S 6 G • LAP I SHOULDER HARNESS USED O • IN VEHICLE USED z
N • LAP I SHOULDER HARNESS NOT USED R - IN VEHICLE NOT USED Y - YES
% J • PASSIVE RESTRAINT USED S -IN VEHICLE USE UNKNOWN
K. PASSivE RESTRAINT NOT USED T • IN VEHICLE IMPROPER USE
U . NONE IN VEHICLE
ITEMS MARKED BELOW WHICH ARE FOLLOWED BY AN ASTERISK (•) SHOULD BE EXPLAINED IN THE NARRATIVE.
PRIMARY COLLISION FACTOR TRAFFIC CONTROL DEVICES 2 3 TYPE OF VEHICLE MOVEME.i7 PROCED(NG
UST NUMBER (+1 OF PARTY AT FAULT 1 I Z 13 C= I isON
A VCSEC VIOLATED: a AAs A CONTROLS FUNCTIONING A PASSENGER CAR I STA. WGiI
B PASSENGER CAR W I TRAILER I A STOPPED
8 CONTROLS NOT FUNCTIONING'
i C MOTORCYCLE / SCOOTTdt B OTHER IMPROPER DRIVING • C CONTROLS 083CUREDNrTCf B RANPROOFF aO STAI►IGNT
Ip No CONTROLS PRESENT I FACTOR* p PICKUP oR PANEL TRUCK C RAN OFRIGHT
C OTHER THAN OiIlVER• TYPE of COLLISION E PICKUP I PANEL TTI!(. w I TLR: p YOKING RIGHT TURN
F TRUCK OR TRUCK TRACTOR E MAKING LEFT TURN
HEAD-ON UNKNOwHP A HEAON G TRK /TRK. TRACTOR W /TLA F MAKING u TURN
a E Fill ASLEEP,8 SipESWIPE .
C REAR ENO H SCHOOL Bus G BACIUNG
WEATNEAI MARK i TO 2ITfiM51 p BROADSIDE 1 OTHER Bus H SLOWINGi STOPPING
_
E HIT OBJECT .� EMERGENCY VENCLF ! PASSING OTHER VEHICIA
A CLEAR _ CHANGm4 LANES
S CLOUDY F OVEATUANED K HWY. CONST-• EOUIPMENT J
G NNIG G VEHICLE/ PEDESTRIAN L BICYCLE K PARKING wWUEVER
D SNOWING j•! OTHER': MOTHER VEHICLE L ENTERING _'&FFlc
(+J PEDESTRIAN M OTHER UN AFE TUANING
E FOr- I VISIBILITY FT. MOTOR VEHICLE INVOLVED WITH N la NG IN{C piPOSING LANE
F OTHER% A NON40LU ION O MOPED
0 PARKED
G WIND e PEDESTRIAN P MERGING
LIGHTING I C OTHER MOTOR VEHICLE Q TRAVELING WRONG WAY
A DAYLIGHT O MOTOR VEHL ON OTHER ROADWAY OTHER ASSOCIATED FACTOR
(MAR( 7 To 2 ITEMS) R OTHER:'
8 DUSK • DAWN E PARKED MOTOR VEHICLE
A vc "C7Wft VGMAT Ore OTIC
C DARK. STREET LIGHTS F TRAIN (3vss
p DARK. NO STREET LIGHTS G i1CYCLE GN
B vc "C'noN vOLAnoft also
E DORIC . STREET LIGHTS NOT H ANIMAL Arcs sosRa y.aRUG
FUNCTIONING• Om* PHYSICAL
ROADWAY SURFACE nAXED O&ACT: C ve SIZE N woLArme ano ( MARK i TO 2ITEMS)
A DRY ! t A !Sa A E�(yAw ❑NO
G� A HAD N07 BEEN DRINKING
8 WET J OTHER OBJECT: pI B HBO - uNIIEA INFLUENCE
C SNOWY • ICY VISION OQscuREMENT
E C }IgD -NOT UNDER INFtu.•
C) SUPPEAY ( MUDDY. CILY. ETC.) F INATTEN110N• p HBO • IMPAIRMENT UNK.•
ROADWAY CONDITIONSG STOP NL Go TRAFFIC E UNDER DBVG:NFLU.•
( MARK 1 TO 2 ITEMS) PEDESTRIAN'S ACTION H ENTERING I LEAVING RAMP
F 11•IPAIRHsE'/T • PHYSICAL!
A NO PEDESTRIAN INVOLVED ! PREVIOUS COLLISION' • G IMPAIRME4T NOT KNOWN
A HOLF,S. DEEP RUTS B CROSSING IN CROSSWALK . ;) uNfAiRUAA WITHAOAO arc° H NOT API• -:CABLE
B LOOSE MATERIAL ON ROWY.• AT INTERSECTiOl1 !( OEfECTIVE YEN. EOUIP.: C3Tts ! SLEEPY IPA TIGUED
C OBSTRUCTION ON ROADWAY- C QXMMNG IN CROSSWALK - NOT. ❑r.o SPECIAL INfOOMAflON
I'D CONSTRUCTION , REPAIR ZONE AT mTERSECT)OM A HAUROCUS MATERIAL
AE
REDUCED ROADWAY WIDTH p CROSSING - NOT IN CROSSWALK L uraNVOLvw VEHICLE
FLOODED- E u( ROAD • INCLUDES SHOULDER M OTHER•:
1GOTHER F NOT IN ROAD N NONE APPARENT
APPROACH /LEAVING SCHOOL BUS 0 RUNAWAY VEHICLE
HMO UNUSUAL CONDITIONS G �rsCiWwsoArs
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CHP 555 -Page 4 (Rev 11-85) OP1 042