HomeMy WebLinkAboutCC 3 CLAIM #86-27 07-21-86I ~T~: ~Y ~o, ~a~ ~~/ Inter-Corn
To: EOMO~.E ~YO~ ~D ¢I. CO0~CI~.~
FROH:
CITY ATTORNSY
SUBJECT: CLAIMANT= STATE FARM/ROBERTS; D/L: 3/14/86; DATE
FILED W/CITY= 6/5/86; CLAIM NO= 86-27; CARL WARREN
FILE NO: 48317CVH
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.
JGR (F4. se )
Enclosure:
Copy of Claim
be
The following employee, s) of the City of Tustin only:
Ce
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: March 14. ]956b. 'TIME: 2:55pm c. PLACE (Exact
and specific location): Redkill Ave., ~ Sycamore Ave., T]]sTiu~
d. How and under what circumstances did damage or injury occur? Specif}
,CLAIM AGAINST THE CIT~ OF TUSTIN
(~For Damages to Person~' or Personal Property)
Received by via
U.S. Mail
Inter-office Mail /
Over the Counter ~/
The law provldes generally that a claim mus~ be ~iled with the City Clerk o~
the City of Tustin within 100 days after which the incident or event occurre~
'Be sure your claim is against the City of Tustin, not another public entity.
Where space is insufficient, please use additional paper and identify inform~
tion by paragraph number. Completed claims must be mailed or delivered to t~
City Clerk, The City of Tustin, 300 Centennial Way, Tustin] California 92680
TO THE HONORABLE MAYOR AND CITY COUNCIL, City of Tustin, California:
The undersigned respectfully submits the following claim and information rel~
tire to damage to persons and/or personal property:
1. NAME OF CLAIMANT: STATE FARM INSURANCE COMPANY ~
a. ADDRESS OF CLAIMANT: 3333 Hyland Ave., Costa Mesa~ Ca. Q~676
b. PHONE NO: (CLAI~ 55 N 857 833 c. DATE OF BIRTH:
SOCIAL Insrd:Frank Roberts DRIVERS
d. SECURITY NO: e. LICENSE NO:
2. Name, telephone and post office address to which claimant desires notice~
to be sent, if other than above:
STAT~ FARM INSURANCE COMPANY 3~S% Hy~ Av~ c~ ~e~a, Ca. 92§2g---
Attn: Claim Superintendant: Tom Fisher- Clai~ 55 N 857 833
3. This claim is submitted against:
The City of Tustin' only.
The following employee(s) of the City of Tustin only:
The City of Tustin and the following employee(s) of the
City of Tustin only:
4. Occurrence or event from which the claim arises:
DATE: March 14. !986b. 'TIME: 2:53pm c. PLACE (Exact
and specific location): Redhill Ave., ~ Sycamore Ave_, T1;~t~
How and under what circumstances did damage or injury occur? Specif}
the particular occurrence, event, act or omission you claim caused
the injury or damage (Use additional paper if necessary).
Accident caused by mai-function m~ tr=~ir ~g~
e. What particular action by the City, or its employees, caused the
~nle~ed damage or injury?
Known
''5. Give a description of the injury,, property damage or loss so far as is'
known at the time of this claim. If there were no injuries,.stgte "no
injuries".
Intersection accident which involved in_4ur~e~ cm,~6 By mo~-_~unction
'Of ~ra~lC llShts
®
Give the name(s) of the City employee(s) causing the damage or injury:
Unknown
7. Name and address of any other person injured:
Beth Roberts ~ Julie Gyor
8. Name and address of the owner of any damaged property:
Beth Roberts-8392 Bryant Street, Huntin~to~ ~each~ C~.
Damages claimed:
a. Amount claimed as of this date:
b. Estimated amount of future costs:
c. Total amount claimed: Total amount unknown at %his time
d. Basis for computation of amounts claimed (include copies of all bills,
invoices, estimates, etc.:
10. Names and addresses of all witnesses, hospitals, doctors, etc.:
a. See Tustin Police Report #86-022 68
11.. 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 true
I certify under penalty of perjury that the foregoing is TRUE AND CORRECT.
Executed this ~ day of ~...>~% , 19.~.~3 , at Tustin, California.
Office of the City Clerk,
Tustin, California
Revised 8/05/81
JGR:se:R:8/5/81 (A)
Fred Schwart~AIMANT's SIGNATURE
'Riviera Adjusters for
State Farm Insurance Co.