HomeMy WebLinkAboutCC 4 CLAIM #81-13 08-03-81DATE:
July 15, 1981
O~gENT CATRN~AR
8-3-81
Inter-Corn
FROM:
SUBJECT:
HONORABLE MAYOR AND CITY COUNCIL
JAMES G. ROURKE, CITY ATTORNEY
CLAIMANT: LIBERTY MUTUAL INSURANCE CO.; D/L: 3/31/81;
FILED W/CITY: 5/21/81; CLAIM NO: 81-13; CARL WARREN
~Tr.~ ~n. ~n~n nc
After investigation and review it is recommended
that the above-referenced claim be denied and the City Clerk
directed to give proper notice of the denial to the claimant
and to the claimant's attorney.
JGR:se
Enclosure
1. Copy of Claim
'.-:;r; '- CLAIM AGAINST THE C"~Y OF TUSTIN
(Fo: Damages to Persons or ..]rsonaI Property)
~eceived By
U.S. Mail
Inter-office Mail
Over the Counter
via
The law provides generally that. with
of Tustin - .... which the incident or
City of TUuun, not another public entity. Where space Is in~uTficiel
Clerk's
Time
s "yP2 1 1981
0-,~.~-~m City C~
the City Clerk of the City
Be sure your claim is ag~ns: the-
please use addition~ paper and
identify information by paragraph number. Completed claims must be mailed or delivered to the City
Clerk, The City of Tustin, 500 Centennial Way, Tustin, California
TO THE HONORABLE MAYOR AND CITY COUNCL, City of Tustin, California
The undersigned
persons and/or personal property:
NAME OF CLAIMANT:
a.
b.
d.
eo
PHONE NO: (7/d) ,}~- ~¢O ) =. DATE OF B~
50C~L SEGURI~
DRIVE~5 MCENSE NO:
respectfully submits the following claim and information relative to damage to
Z. Name, telephone and post office address to which claimant desires notices to be sent, if other
than above:
Occurrence or event from which the claim arises:
a. DATE: ,~/~/,~//~/ b. TIME: ~'~ ~,?~.,, c. PLACE (exact: and speclfic
d. H~ ~d ~der what circum~tance~ did damage o~ injmy occur? Specify t~ p~ticula~
occurrence~ event, act or omission you claim caused the injury or damage (use ad~tion~
pap~ if nece~y).
Give a description of~ injury, property damage or los(-}o far as is known at the time of
this claim. [f there wer~ no injuries, state "no injuries".
Name, and address of any other person injured-" I:) ~fl'& ' I
b. Estimated amount of futu~ costs== (11~ P r.(~ ~ -- ~/. ~:~ ~
c. Total amount claimed: ' (~>'l~[~ 0,'~ ~ -~(~ ~'/')~ ~
d. Basis for computation of amounts claimed (include copies of alt bills~ invoices~ estimates~
Names and addresses of all witness, hospitals, doctors, etc.
d.
10. 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 t~ue of my
own knowledge, except as to those matters stated to be upon information or belief as to such matters I
I certify under penalty, of perjury that the foregoing is TRUE and
believe the same to be true.
CORRECT.
Executedthls c;~ .dayof ~/~d
Office of the City Clerk,
Tustir~ California
CUA M .o.
Claimant's Signature
, California.
D^TE riLED=
3GR:se:D:2/5/80
T/Claim Form D:ll