HomeMy WebLinkAboutCC 5 CLAIM #92--38 10-05-92CONSENT CALENDAR NO. 5
G E N1 D _/02 10-5-92
Inter -Com
LATE: SEPTEMBER 21, 1992
TO: HONORABLE MAYOR AND CITY COUNCIL
FROM: CITY ATTORNEY
SUBJECT: CLAIMANT: WHITNEY SECOR; D/L: 04-13-92; DATE FILED W/CITY: 08-
10-92; CLAIM NO: 92-38; CARL WARREN FILE NO: S 72746 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. �i ,007
S G. ROURKE, City Attorney
JGR:jab:091992(CL-9238-jab)
Enclosure: Copy of Claim
cc: Carl Warren & Co.
Finance Director
City Manager
City of Tustin
C A AGAINST THE CITY OF TUL
(For Damages to Persons or Personal Property)
r
law provides generally that a claim must be filed with the City Clerk of
_.,e City of Tustin within 6 months after the incident
another public occurred.
entitye
sure your claim is against the City of Tustin, paper and identify
Where space is insufficient, please use additional pap y
information by paragraph number. Completed claims must be mailed or
delivered to the City Clerk, City of Tustin, 15222 Del Amo Avenue, Tustin,
California 92680
WHEN COMPLETING THIS FORM, PLEASE TYPE OR USE BLACK INR
TO THE HONORABLE MAYOR AND CITY COUNCIL, City of Tustin, California:
The undersigned respectfully submits the following claim and information
oiat;VP to damage to person and/or property:
1, a. NAME OF CLAIMANT: WO
b. ADDRESS OF CLAIMANT:
c. CITY/ZIP CODE:
d. TELEPHONE NO:
e. DATE OF BIRTH:
f. SOCIAL SECURITY NO:
g. DRIVERS LICENSE NO:
Tt1Gq SCC.of—,(NNeF-) qo 0 -DW
F.Cp� 49MJC4Qfi- WCc"-
Name, telephone and post office address to which claimant desires notices
to be sent (if other than above):
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 employee(s) of the City
of Tustin only: -
4. Occurrence or event from which the claim arises:
a. DATE: AMU I � � �—
b. TIME: 0 k M
C. PLACE . ( Exact and specific locat
C�T • cErPc�-t�
cify
d. HOW and under what circumstances did damage or injury occur? Scaused
pe
the particular.occurrencer event, act or omission you claim
the injury or damage (Use additional paper if necessary): � o �
VJ K lT ' S PcGe W PSS CVT W I+V.F t°L� J Nu ' � IS
e pen
G W CPcLI.E 11 1�G� tVer S"i'1 his
�- �ETz
e. WHAT particuli. action by the City, or employees, caused the
alleged dama a injury?
i0 A JF
5. Give a description of the injury, property damage or loss so lar jcnvwii aL.
the time of this claim. If there were no injuries, state "no injuries".
(-fit c ,4cic- WAS Gu
6. Give the name(s) of the City employee(s) causing the damage or injury:
KO a F
7. Name and address of any other person injured:
8. Name and address of the owner or any damaged property:
/VoAr
9. Damages claimed: L4949.
(f
a. Amount claimed as of the date:
b. Estimated amount of future costs: -9-
c . Total amount claimed: -
Ci SS a-1
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.
AAeQ-
e�
4-S D 0 U"7 Sl.
D o eTD05 AMgol►� 1 g 5 [— 1-7 d
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 and
I know the
ed be
same to be true of my own knowledge, except as to those matters
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.
Executed this % day ofA144:nlel-, 19-ft2:=, at Tustin, California.
DATE FILED.. FT14J &(u 16??
CLAIMANT'S SIGNATURE
B1:CLFORM
Revised 4/29/91
• 714 S?,
.. C:• 177711 C SIC)
DESCRIPTION OF SERVICE
4 5 C I ..L,COUNT NUMBER
STATEMENT DATE t_
AMOUNT
DA I t
�44.0�7 `i7P•i T<�n C —SANTA r
PLEA E' I ENCH AT IiN
AND RETURN THIS STUB AND YOUR
T... .,.. •r• . •r•rl/•• ..• ...... r••., ... •rl•, r•r ....,.......r .,r
PAYMENT IN THE ATTACHED ENVELOPE
TO ASSURE PROPER CREDIT ,
DUE DATE
jAiv'J. R.AYArL= • THANK YOL.
ICE•: 4/I:SJ!�'_''
• TOTAL ACCOUNT BALANCE { A., n C
PAYMENT CURRENT AMOUNT DUE
K -ED CT;R—SANTA ANA AGREEMENT AMOUNT
iX C-11912 r4�. cc-
.NA
L.NA CA 42711` DOfla
AS A CONSIDERATION, YOUR ACCOUNT
WITH OUR HOSPITAL MAY NOW BE PAID BY
USING YOUR VISA, MASTER -CARD, OR
AMERICAN EXPRESS.
❑ VISA ❑ MASTER -CARO ❑ AMERICAN EXPRESS
CARO ACCOUNT NUMBER $
AMOUN-
X,
EXPIRATION DATE SIGNATURE -MUST BE SIGNED TO BE t
GUARANTOR NAME AND ADDRESS
J:?ti17 C . SL'CC"
7 C5
DUE DATE CURRENT AMOUNT DU
7./33/9;: 244e G>
. , 4551 GLENCOE AVENUE. SUITE 230. ,'- PLEASE•DETACH b^RETURN THIS
' - ; MARINA DEL Rt_1( GA 90292-6357 „ ; ' • `t : ; • - STUB WITH YOUR PAYMENT.
JANZEN, JOI-ITVSTON &
:'ROCKWELL INC: - (310) 305-7340 • (800) 637-6756 -
(A MEDICAL CORPORATION) :-1r—r— -, Porfavprdesprbndasey
. �, • �•'' � v' devuA►vase con el pa9o.
.: ,,, :,,.. •. , r--, r:!i:_� t : STATEMENT Fecha!!e
PATIENT NAME/Nombre del Paciente iACC.OUNU/NumeroderiJente _r.'�actura MAKE CHECKS PAYABLE T0:
_ DATE Gire sus pagas a nomore del
r^ WHITNEY0.321240 5-27-92` JANZEN, JOHNSTON &
R ROCKWELL, INC.
.-.-_______ :..r -• «— -- =DX CODE •AM10UN P io
Fecha ' PROCEDLIR - . DESCRIPTION OF SERVICES -'Description de Servicios~ ACCOUNT tt�Numero de Cuenca
Procedimiento - ... .... ..... ................. ..::-;�. 0 fll_ZC3212456
-13-92 12011 LACER�TICN R.M.— UP TO Z•
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PLEASC Rci�ZT'-OR.CCNTALT,...,
5 -SANTA ' AI�iA -= iA 9Z7Q5 T AR ESPONSI3ILITYe- .
NE OJR CPPICE- *1M?-EC1ATELY� THANK YOU -
T SEE REVERSE FOR
A MORE INFORMATION ,
CES PROVIDED BYJJSR IN EMERGENCY DEPT. AT: kESTERN u.ED CNTR-.ljti _-A: - Vease'lrtformacion at dorso
'••-----,rcionados por JJ3R an la seccibn de erner5e6&t Oe: Copyright Q, JJBR Medi66 Data System, Inc. 1986- -
DOCTOR'S
AMBULANCE SERVICE
23091 Terra Dr.
Laguna Hills, CA 92653
Office Hours: 9 a.m. to 4 p.m.
Monday thru Friday
PHONE (714) 951-1708
07/24/92
F—PATRICIA SECOR Patient SECOR, WHITNEY
RE: WHITNEY 04/13/92
2274 10:25
Invoice #: Time:
L_
.230 WEST FIRST STREET TO:WESTERN MEDICAL CENTER — SA
From.
RVS HCPS OTY
DESCRIPTION OF SERVICE CHARGES BALANCE
201.50 201.50
0001 A0010 BASE RATE, INC EMERGENCY 17.00 218.50
0003 A0020 2 MILEAGE .
CODE
DESCRIPTION
Q a sr �'t-
f
ORIGINAL CHARGES ► 218.50
• DATE CREDITS BALANCE
This Statement can be used for most claim purposes. If you LPLEASE PAY THIS AMOUNT ► 218.50
IMPORTANT NOTICE
have MEDI-CAL, attach a POE sticker for the month of service and return to us Subject to Interest Charge of 1.5% Per Month After 30 Day:
immediately. Claims must be submitted within 60 days
IRS #95-332797
MEDI-CAL # ZZZ73666Z