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Home My WebLink AboutCC 4 CLAIM #92-40 01-19-93CONSENT CALENDAR NO. 4 ;'i"G 1-19-93 fj Inter -Com DATE: JANUARY 41 1993 TO: HONORABLE MAYOR AND CITY COUNCIL FROM: CITY ATTORNEY SUBJECT: CLAIMANT: FARMERS INSURANCE; CLAIM NO: 92-40; D/L: 6-25-92; DATE FILED W/CITY: 9-1-92; CARL WARREN FILE NO: S 72776 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. JAN&P/Gw.�OURKE, City Attorney JGR: jab:123092(CL-9240. jab) Enclosure: Copy of Claim cc: Carl Warren & Co. Finance Director City Manager City of Tustin cl •. AGAINST THE CITY OF TUE erty) (For Damages to persons or Personal -rop of y_.. ll that a claim must be f iled withthee City nt occurred. Be law provides generally of Tustin within 6 months after the incident or not another public entity. the City against the City of T sure your claim is ag paper and identify ace is insufficient, please use additional P P Where SP number. Completed claims must be umailed a Tustin, information by paragraph 15222 Del Amo delivered to the City Clerk, City of Tustin, California 92680 PLEASE TYPE OR USE BLACK INR WHEN COMPLETING THIS FORM, City of Tustin, California: TO THE HONORABLE MAYOR AND CITY COUNCIL, submits the following claim and information The undersigned respectfully relative to damage to person and/or property: 1. a. NAME of CLAIMANT:Farmers Insurance ExcbanF-e P. 2 b. ADDRESS OF CLAIMANT: 0. Box 1 G - 95 C. CITY/ZIP CODE: 1 2 d. TELEPHONE NO: N A e. DATE OF BIRTH: f. SOCIAL SECURITY NO: g. DRIVERS LICENSE Name, telephone and post t office address to which claimant desires notices to be sent (if other than above): Attention: Cassie Hamer Claim # - �.. �..,,,., r,.o 4- i •ten 30 This claim is submitted against: a. X The City of inonly. b. T he following employee (s) of the City of Tustin only: em to ee s of the City C. The City of Tustin and the following p Y ( ) of Tustin only: 4 Occurrence or event from which the claim arises: a. DATE: b . TIi LACE Exact and specific location): B StWrUeoe� iVeoss sirTu tin. ee c. P ( Ne injuryor occur? Specify OW and under what circumstances did damage eomission you claim caused d • H . event, act o the particular occurr Use additional paper if necessary) the injury or damage Rotten tree belonging to Cit e. the City, or it' mployees, caused the WHAT particular :ion by alleged damage ..n4ury? 5. Give a description of the injury, property damage or loss so far }-sown at the time of this claim. If there were no injuries, state � "no injuries" injuries. See attached retiair estimate, bill -and proof •f pz. � 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: Carol Glassford 18 Broo1.nmunt , Irvine, CA 92714 9. Damages claimed: $1220315.14 + Deductible $100s$23,135•- a. Amount claimed as of the date: b. Estimated amount of future costs: Nnne .14 c. Total amount claimed: $2.213 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. WARNING: IT IS A CRIMINAL OFFENSE TO 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 matters and I know the ed be same to be true of m}c y own nowledgetesuchtas to matt matters Ithose believe the same to be upon information or belief and as to true. I certify under penalty or perjury that the foregoing is TRUE AND CORRECT. Executed this 31st day of DATE FILED: i Charlotte eiller Irv_ne August- _ - , 19 9=, at Tustiin, California. CLANIAI�jT' S IGNATURF AutL or11zedepresen ative of Farmers Insurance Bl:CLFORM Revised 4/29/91 THE FARMERS INSURANCE GROUP OF COMPANIES ^ate Irvine Branch Claims Office July 20, 1992 CLAIM OF CAROL GLASSFORD & FARMERS INSURANCE EXCWHANGE -Vs- CITY OF TUSTIN TO: CITY OF TUSTIN Civic Center Drive 15222 Del Amo Avenue Tustin, CA 92680 PO Box 19520 Irvine, CA 92713-9520 (714) 857-8622 VERIFIED CLAIM FOR PROPERTY DAMAGE YOU ARE HEREBY NOTIFIED that Carol Glassford whose Ex dress is 18 a whose Brookmount, Irvine, CA 92714 and Farmers Insuranceg address iS P. O. Box 19520, Irvine, CA 92713-9520 claims damages from the City of Tustin in the amount computed as of the date of presentation of this claim .$2.,135.14. This claim is based on property damage sustained.by the claimant on or about June 25, 1992 on B Street (cross street is Newport Avenue) in Tustin. The damage sustained by the claimant, as far as is known as of the date of presentation of this claim, consists of damags to iand the F vehicle in the amount of Two Thousand One Hundred Thirty Fve urteen Cents. Attached is a copy of the repair bill. All notices or other communications with regard to theis claim should be sent to Farmers Insurance Exchange, P. O. Box 19520, Irvine, CA 92713-9520. DATED I �� SIGNED Erlinda G. Cabalda v Farmers Insurance Exchange Subrogation Claims On this 20th day of July, 1992, personally appeared before me Erlinda G. Cabalda, with Drivers License #A6293943, to me known to be the individual who executed the foregoing instrument and duly acknowledged signing the same. OFFICIAL NOTARY SEAL LILY LEE i- e�*�"_i.�" Notary puNjc— CL IQ:nia r ^,` `�.'�.�►R,,�!} O;Ah:'sc CO'JN'rY �. '✓// Ny Cor_ Extras MAR 28, IT TO 03 COMPLETC7D BY it�SURAN CL0;%QS REPR S�INTATIVE: FARMERS INSURANCE .;ROUP OF COMPANIES I-P1I!•aa+av■ AUTHORIZATION GLASSFORDo CAROL 6/25/92 84 068489 DATE OF LOSS SALN NSUREO 97 106627267 ED LOVETTE CLAIMS REPRESENTATIVE SIGNATURE DOun NUMBER PART 1 INSTRUCTIONS TO POLICYHOLDER 7179 CR. I.D. r 6/30/92 DATE A) Present this form and our estimate to the repair shop. 13You must authorize repair. When repairs have been completed and you have inspected your vehicle, sign this form below. • 9 C) Your signature indicates the repairs are acceptable and you authorize the amount shown to be paid direct to the repair facility. 2,035.14 1 have inspected my vehicle and repairs are complete. I authorize the Company to pay $ to this repair shop on my behalf. EDUCTIBLE AMOUNT $ 100.00 t .L REPAIR COST $ -�Z' �" � �►DATE INSURED'S SIGNATOR , ' INSTRUCTIONS TO REPAIR SHOP PART 11 A) If you have any questions about the estimate, contact the Farmers Representative. 13Any deviation from the original estimate amount must be approved in advance. C) Please complete this section. _ SHOP ^ CiC.�� >/ r/ SHOP PH MBER SHOP MANAGER/OWNER A Federalb Social Shop Incorporated? El Yes No Tax # 3� v Security Tax # D Date repairs started Date repairs completed E) Return to us your itemized repair invoice, together with this original, signed document to: Farmers Insurance Group of Companies IRVINE BRANCH CLAIMS OFFICE OHIO ONLY: Any person who, with intent to P.O. BOX 19520 defraud or knowing that he/she is facilitating a IRVINE, CA 92713-9520 fraud against an insurer, submits an application 714-857-8622 or files a claim outlying a false or deceptive state- ment is guilty of Insurance fraud. cnn)e►pj Ic *r^lam IM Al "rC:D=n :ONDA ACCORD 2 DOOR HATCHBACK PAGE 2 Al LOG NO 7730598 DATE 06/30/92 84 68489 234.00 PAINT MATERIAL 676.97 'AR':S TOTAL TAX ON PARTS & MATERIAL @ 7.750% 52.47. LABOR RATE REPLACE HRS REPAIR HRS , 520.00 1 -SHEET METAL 26.00 1.7 18.3. 2-MECH/ELEC 45.00 3 -FRAME 40.00 26.00 15.6 405.60 , 4 -REFINISH 5 -PAINT MATERIAL 15.00 925.60 ,ABOR TOTAL TAX ON LABOR 480.10 SUBLET REPAIRS TOWING & STORAGE 21135.14 3RCSS TOTAL 100.00 - LESS: DEDUCTIBLE 2,035.14 NET TOTAL ADP AUDATEX Al U ES LOG 7730598 DATE 06/30/92 15:57:36 045 *99* 927014 PY N PXN:NN/00/00/00/00' CUM:00/00/00/00 NSU ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF AUTOMOBILE PARTS NOT MADDE IN THE ESTIMATE) U p BY THE ORIGINAL MANUFACTURER. .ARTS (IDENTIFIED By EP ANUTERMS CT RER RE THAN THE ORIGINAL MANUFACTURER I 'F.E REPAIR OF YOUR VEHICLE BY AT LEAST EQUAL IN OTHER LIKE A QUAL- :,, .!RED TO BE ITY AND PERFORMANCE TO THE ORIGINAL ANUFACTURERU SLITY PARTS THEY ARE REPLACING. -------=----------------------------------------------- ------------------------- INSURED: POLICY NUMBER: SALN NUMBER: DATE OF LOSS: PHOTO MOUNTING SHEET r _ CLAIMANT: DATE TAKEN: ADJUSTER: VEHICLE: REQUEST FPR CLAIMS CHECK INSURED. PAYMENT FOR: ❑ INJURY LIABILITY ❑ INJURY MEDICAL MATER L DAMAGE ❑ OTHER DAMAGE ❑ PROPERTY IS 1099 ❑ YES IS PAYMENT ❑ YES IF PYMT IS FORD, IS PAYMENT ElYES APPLIES TO REOUIRED?: ANO-ADDIT'L./SUPPL.?: ' NO NEED CR. NAME ASSOCIATED? �'� OF u SE NO' � WAIVEuu DEO >> N T USE I Z Cal PLUS NTAL CLAIMANT'$ NAME: A REIMUTO BUPBUP SEMEMENT TYPE OF PROPERTY LOSS: ❑ BUILDING ❑ ALE ❑ CONTENTS ❑ OTHER J SPL EOIHP , CB. ETC) v CHECK IDENTIFIER INFORMATION IMay also be used lot Payee Name(s)) PAYEE(S) NAME(S) �JMp�n ANL) 5THEET f CITY l AMT. OF �.(� 3 5 , . ;""-K: $ FINAL ❑ PARTIAL �. SHOP CODE: CODE ❑ SUB ❑ NO SUB INSTRUCTIONS: I zf:). ^- FIELD ❑ HANDLE STATE IIP CODE , TOTAL CASH OWNER ❑ LOSS ❑ IN LIEU ❑ RETAINED SALVAGE ' DATE ��" REQUESTED BY: REQUESTED �PPROVED BY: . _ IF RF0LUREn Santa Ana Regional Office Check Number 1177016712 Date 07/09/92 �AyVOID VOID VOID VOID VOID VOID VOID VOID VOID VOID VOID VOID VOID ' VOID VOID VOID VOID VOID VOID VOID VOID VOID VOID VOID VOID VOID TO Amount $2,035.14****** -e GOLDEN STATE COLLISION 1r 16191 CONSTRUCTION CIR. UNIT.B IRVINE, CA 92714.