HomeMy WebLinkAboutCC 11 CLAIM #89-29 11-20-89.~ ~'~ ~i~ ,~ ~ CONSENT CALENDAR NO. 11
DATE: \..a,.~%,~' - - !
HONORABLE MAYOR AND CITY COUNCIL
TO:
CITY ATTORNEY
FROM:
SUBJECT:
CLAIMANT: COLONIAL PENN INS. CO. (KRUG); D/L: 4/28/89;
DATE FILED W/CITY: 8/2/89; CLAIM NO: 89-29; CARL WARREN
FILE NO: S 59794 NPB
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.
City Attorney
JGR (74,)
Enclosure: Copy of Claim
·
· ('~For Damages to Perso: ' ~' ' Personal Property) ' ~'"~i: ~ ·
I~er-office Xail ...... ~.;~ ~---
Over the Counter ... ~ :~ ¢¢, ~
the City of Tustin within 100 days after which the.incident or event occur~
Be sure your claim is against the ~City of Tustin, not another public entit,
Where space is insufficient, please use additional paper and identify'info]
tion by'paragraph number· Completed claims must be mailed or delivered to
City Clerk, The City of Tustin, 300 Centennial.Way, Tustin, California 926:
TO THE HONORABLE MAYOR AND CITY COUNCIL, City of Tustin, California:~
The undersigned respectfully submits the following claim and information r~
tire to damage to persons and/or personal property:
' ~- c. D~.~ O~ ~.~:- ' - , '
d. SECUKiTY z v ~.~,.-
2~ Name, telephone and post office address to which claimant desires notic
to be senta if other' than above:
3. This claim is submitted against:
a.
b·
The. City of Tustin only.
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: :
Occurrence or event from which the claim arises:
a. DATE: b. 'TIME: c. PLACE (E'xact
and specific location): ~~/'~/~' ~,~/~ ~-.7--~~/~/ '
/
d. How and under what circumstances did damage Or injury occur? SpeciJ
th~ particular occurrence, event, act or omission you claim caused
.t~inJ_ury.o~m~ge JUse, additiona% paper if ne~essarv~. : ' -
.. .
e. what particular action by the city, or its employees,"'cau~d:.'the.'".. -
'aLle ed dama e o ' ju y~ . · '
::' :: '"CJ ........... '- - - - .... ' .... --- . .......
Give a description o~ ~he injury, property dama%~ or loss so far as is
.known at the time of this claim. If there were no injuries', state "no
inj.u~ies"
e
Give t~e--name(s) of the City employee(s) causing the damage or injury':
7. Name' and address of any other person injured:
8. Nam~ and add~ess of t~e owner of any damage~d property:~. ' , ,
9.' Damages claimed:
a. Amount claimed as of this date:
b. Estimated amount of future costs:
c. Total amount claimed:
d. Basis for computation of amounts
invoices, estimates, etc.:
10. Names and addresses of all witnesses,
a.
b.
hospitals, doctors, etc.:
· Any additional information that might be helPful in considering this claim
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
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 tru.
I certify under penalty of perjury that the foregoing is TRUE AND CORRECT.
Executed thi's ~~ day of ~~' , 19 ~g , at Tustin, California..
Q~ffice of 'the City° Clerk,
~tin, California
CLAIM NO:
Revised' 8/05~81
JGR:so:R:8/5/81 (A')
. .