HomeMy WebLinkAbout04 CLAIM #94-51 01-16-95ROURKE, WOODRUFF & SPR_iDLIN
A PROFESSIONAL. CORI~C)RATION
NO. 4
1-16-95
MEMORANDUM
TO:
FROM:
DATE:
Honorable Mayor and Members of the City Council
City Attorney
January 5, 1995
Claimant(s): Josephine Simon; Claim No.: 94-51; D/L 11/23/94;
Date Filed w/City: 11/28/94; Carl Warren File No.: S 78691 PRL
After investigation and review it is recommended that the above-referenced claim be
....... rejected and that the City Clerk be directed to give proper notice of the rejection to the claimant
and to the claimant's attorney.
~-~gj';~ ~: Jeffrey lO d
Enclosure:
Copy of Claim
Letter from Carl Warren & Co. dated 12/16/94
CC:
Carl Warren & Co.
Finance Director
City Manager
City Clerk
City of Tustin
.M AGAINST THE CITY OF T :N
(For Damages to Persons or Personal Property)
The law provides generally that a claim must be filed with the City Clerk of
the city of'Tustin within 6 months after the incident or event occurred. Bt,
sure 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, 300 Centennial Way, Tustin,
California 92680
WI{EN 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 claim and information
relative to damage to person and/or property:
·
b. ADDP~ESS OF CI~IMA~T:. / ~
c. CITY/ZIP CODE: ~ ~ .
d. ~PHONE NO: .( ~/ ~ } ~ ~
e. DATE OF BIRTH: ~//
2. 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. p-~. The City of Tustin only.
b. The following employee(s) of the City of Tustin only:
Ce
The City of _~hastin and the following employee(s) of the City
of Tustin only:
4. Occurrence or event from which the claim arises:
a. DATE: ///R 3 /f ~a
b. TIME: '//~
c. PLACE (Exact and specific location): 13J~ D/Az-~ur /~r dL5
d. HOW and under what circumstances did damage or inju~ occur? Specify
~e particular occurrence, event, act or omission you claim caused
~he inju~ or damage (Use additional paper if nece~sa~):
e. ~qiAT particule'- tion Dy the city, or l~ employees, caused
alleged damage ._ injury?
the time of this claim. If ~ere were no injuries, state "no injuries".
.
6. Give the name(s) of the City employee(s) causing the damage or injury:
__
7. Name and address of any other person injured: ~o ;~..~.
8. Name and address of the owner or any damaged property:
9. Damages claimed:
a. Amount claimed as of the date: ·
b. Estimated amount of future costs:
c. Total amount claimed: ~'~0 ~ ...........
d. Attach basis for computation of amounts claimed (include copies
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)
Z have read the matters and statements made in the above claim and I know the
same to be true of my own knowledge, except as to those matters stated to be
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 ~~Dday of /~d~r~/~/~ _,19_~ , at Tustin, California.
I~%NT ' S SIGNATURE
B!: CLFOR/~
Revised 4/29/91
Cafe Auto Spa
1501Nisson Road
l:15pm 11-23-94
SHIFT# 1 TERMINAL# 1
CAR# 34 Slsrnn# 9918
QDS Expr Wax 50.00
Coffee Drink 2.00
SALES TAX 0.16
TOTAL: 52.16
Cash 52.21
CHANGE: 0.05
THANK YOU!
~11111111111111111111
Insurance Adiustets
------ Claims Management and Administration
730 Thc City Drive
Suite 400
Orange, CA 92668
Mail: P.(). Box 2S 180
Santa Aha, CA 92799-3180
(714) 740-7999 /'
(800) 572-6900 /
F,-MX: (714} 740-799/
Ail Ame/ican Asphalt
P. O. ~ox 2229
Coro/, CA 91718-2229
Atyention: Sue Brown
RE: City File
Principal ....
D/Incident
Claimant
Our File
December 16, 199
: 94 -51
: City of Tustin
:
: Josephine Simon
: S 78691 PRL
Dear Ms. Brown:
As claims administrators for the City of Tustin, we are
handling a claim filed by Ms. Simon against the City of
Tustin.
This claim is a result of what we believe to be your working
for the City at the location in question. The claimant
alleges that due to construction in the road, her vehicle was
dirtied and had to be detailed in the amount of $50. As you
were working for the City at this location, we request that
you and/or your insurance company take over the handling of
this claim.
We thank you for your cooperation in this matter and request
that you keep us advised as to the status of this claim and
its ultimate outcome ..... ~
Very truly yours,
CARL,~WARREN & COMPANY
PR: iw
Enclosure: Copy of claim.
\
(Cont.)
Page 2
S 78691 PRL
cc: City of Tustin
Attn: Ron Nault
/cc: Lois Jeffrey
City Attorney
cc: Josephine Simon
1422 Lance Drive
Tustin, CA 92680