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HomeMy WebLinkAbout11 CLAIM 07-33, CHAD GARRETT 11-06-07Agenda Item 11 _ • Reviewed: + AGENDA REPORT City Manager _~ tv Ilj `~I Finance Director MEETING DATE: November 6, 2007 TO: William A. Huston, City Manager FROM: Ronald A. Nault, Finance Director SUBJECT: CONSIDERATION OF CLAIM OF CHAD GARRETT, CLAIM NO. 07-33 SUMMARY: It was reported by the Claimant's parents that while playing basketball at the Columbus Tustin gym, the Claimant was guarding another player and the player elbowed him in the mouth. The Claimant's front tooth was chipped and the cost to have it repaired with bonding was $300.00. RECOMMENDATION: That the City Council deny Claim Number 07-33, Chad Garrett, and direct Staff to send notice thereof to the Claimant. FISCAL IMPACT: None. DISCUSSION: The City's Claims Administrator has found no fault attributable to the City of Tustin in this incident. The Claimant was participating in a basketball camp which was being run by a contract company, when he was accidentally hit in the mouth by the other child. The Claimant's parents have been provided with the information to present their claim directly to the Contractor, Trifytt Sports. Staff is recommending that the claim be denied at this time. Ronald A. Nault Finance Director ATTACHMENT: Copy of Claim No. 07-33 ConsiderationOfClaimOfChadGarrett07-33. doc .~ ~ ~ -33 B. ~~g sure your claim is against the ~ of Tustin. not another pubNc entity. C. Claims for death, injury to person or to personal property must be filed no later than 6 months after the oax~rrenoe (Government Code § 911.2). D. Claims for damages to real property must be filed no later than one year after the occurrence (Government Code § 911.2). E. If additional space is needed to provide your irrforrnation, please attach sheets, identifying the paragraph(s) being ansvrered. F. A claim must be presented, as prescribed by the Government Code of the State of Catifoimia, by the da~nent. or a person acting on hisTher behalf and shall provide the information shown below and must be signed by the claiman# or a person on his behalf (Government Code § 910.2). G. This form is for the convenience of those desiring to present claims against the dty. Claimant is advised to consult a private attorney if legal advice is desired. No empbyee ofi the City may give legal advice to any c~irr~t relating tp private claims. H. Completed claims must be mailed or delivered to the City of Tustin, Cfty Clerk's Office, 300 Centennial Way, Tustin, CalMornia 82780. 1. Name and Post Office address of the Claimant: Name of Claimant: ~ ~ a.~ ~~"~ Y'r/' Home Address: ~ ~~ t~'~C' ~ av-~ ~ ~ '~ V1brk Telephone: 2. Post Office address to which the person presenting the claim desires notices to be sent: (If different from above) ~- _~ ~~ -~ f ~'e~- Name of Addressee: ~G~~y,.f pt g ~;~~ ~ ~ Telephone: Post Office Address: 3. The date, place and other arcumstances of the occurrence or transaction from which the claim arises. Date of Occurrence: ~ ~ ~ (a -- ©~- Time of Occurrence: '~, , ~ P~ y~x location: p i/LIiVL `~vt ' rVl Circumstances giving rise to this claim: p ~' _ Z.( rn fif'' ~' -~~' 4. General description of the , damage or loss i so far as you naw~kno~w~ Page 1 of 4 • 5. The name or names of the pubUc employee or employees causing the injury, damage, or loss, if known. 6. ff amount claimed totals less than 610,000: Provide the amount claimed if it totals less than ten thousand dollars ($10,000) as of the date of your claim, including the estimated amount of any related potential future injury, damage, or loss, insofar as it may be known as of the date of your claim, together with the basis of computation of the amount claimed (include copies of all bills, invoices, estimates, etc.) Amount Claimed and basis for computation: If amount claimed exceeds 610,000: If the amount claimed exceeds ten thousand dollars ($10,000), do not provide a dollar amount in the claim. However, your claim must indicate it would be a limited civil arse. A limited dull case is one where the recovery sought, exclusive of attorney fees, interest and court costs, does not exceed $25,000. An unlimited civil case is one in which the recovery sought is more than $25,000. (See CCP § 86.) ^ Limited Civil Case ^ Unlimited Civil Case You are required to provide the information requested above in order to comply with Government Code 8910. Additionally, in order to conduct a timely investigation and possible resolution of your claim, the City of Tustin requests that you answer the following questions. 7. Name, address and telephone number of any witnesses to the occurrence or transaction from which the claim apses: ~, ~~ ~'~°.%li'l ~~I~U~-l.~ -' ~a~~'e~S ~1~ ~!~'~- ~~ ~~tiISI.U~ , ~iU Gi,.g 8. If the claim involves medical treatrnent for a claimed injury, please provide the name, address and telephone number of any doc#ors or hospitals providing treatment: 1r~ tc~ t~ ~ ~~ If applicable, please attach any medical bills or reports or similar documents supporting your claim. 9. If the claim relates to an automobile acd ent: Claimant(s) Auto Ins. Co.: ~ ~ Telephone: Address: Insurance Policy No.: Insurance Broker/Agent Telephone: Address: Claimant's Veh. Lic. No.: Vehicle MakelYear: Claimant's Drivers Lic. No.: Expiration: 1f applkable, please attach any repair bills, estimates or similar documents supporting your claim. Page 2 of 4 • • READ CAREFU~.LY For aN acddent claims, place on following diagram name of stnrets, including North, East, South, and West; indicate place of accident by 'X' and by showing house numbers or distances to street comers. If City/Agency Vehicle was imohred, designatie by letter 'A" location of City/Agency Vehicle when you first saw it, and by 'B' location of yourself or your vehicle when you first saw City/Agency Vehicle; location of City/Agency vehicle at time of N ~~ accident by A-1 and location of yourself or your vehicle at the time of the aoddent by 'B-1" and the point of impact by'X.' NOTE: If diagrams below do not fd the situation, attach hereto a proper diagram signed by claimant. SIDEWALK CURB -~ PARKWAY SIDEWALK CURB ~, Warning: Presentation of a false daiifi is a felony (Penal Code §72). Pursuant to CCP §1038, the CitylAgency may seek to recover all costs of defense in the event an .action is filed which is later determined not to have been brought in good faith and with reasonable cause. Signature: ~: g 2~-0~ Page 3 of 4 ADA Dental Claim Form HEADER INFORMATION ~ Page 1 of 1 1. Type of Transaction (Check all applicable boxes) Statement of Actual Services - OR - ~ Request for PredeterminatioNPreauthorization EPSDTlTitle XIX 2. PredeterminatioNPreauthorization Number PRIMARY SUBSCRIBER INFORMATION 12. Name (Last, First, Middle Initial, Suffix), Address, City, State, Zip Code PRIMARY PAYER INFORMATION Garrett Terese 3. Name, Address, city, state, Zip Code Metlife Ins. Co. P.O. Box 981282 , EI Paso, TX 79998-1282 13. Date of Birth (MM/DD/CCYY) 14. Gender ^ M Q F 15. Subsciber Identifier (SSN or ID#) ` OTHER COVERAGE 16. PIaNGroup Number 17. Employer Name 4. Other Dental or Medical Coverage? a No (Skip 5-11) ~ Yes (Complete 5-11) Newport Corp. 5. Subscriber Name (Last, First, Middle Initial, Suffix) PATIENT INFORMATION 18. Relationship to Primary Subscriber (Check applicable box) 19. Student Status 6. Date of Birth (Mt.UDD/CCW) 7. Gender 8. Subscriber Identifier (SSN or ID#) ~ Seff Spouse Dependent Child Other ~ FTS ~ PTS ~M ~F 20. Name (Last, First, Middle Intitial, Suffix) Address, City, State, Zip Code 9. PIaNGroup Number 10. Relationship to Primary Subscriber (Check applicable box) self ~ spouse ~ Dependent ~ other Garrett, Chad 21. Date of Birth (MM/DD/CCYY) 22. Gender XD M ~ F 23. Patient ID/Account # (Assigned by Dentist RECORD OF SERVICES PROVIDED 24. Procedure Date (MM/DD/CCW) 25 Area ~ Oral Cavity 26. Tooth System 27. Tooth Number(s) or Letter(s) 28. Tooth Surface 29. Procedure Code 30. Description 31. Fee 1 08/21 /2007 JP 9 MIFL D2335 RESIN-FOUR OR MORE SURFACES, ANTERIOR 300 00 2 3 4 5 6 7 8 9 10 M ISSING TEETH INFOR MATION Permanent Primary 32.Other ' ' 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 A B C D E F G H I ~ Fee(s) on each missing tooth) 34. (Place an X 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 T S R O P O N M L K 33.Total F 300 00 35. Remarks AUTHORIZATIONS ANCILLARY CLAIM/TREATMENT INFORMATION 36. I have been iMonned of the treatment plan and associated fees. I agree to be responsible for all charges for dental services and materials not paid by my dental benefit plan, unless prohibited by law, or the treating dentist or dental practice has a contractual agreement with my plan prohibiting all or a portion 38. Place of Treatment (Check applicable box) X^ Providers Office ~ Hospital ~ ECF ~ Other 39. Number of Enclosures (00 to 99) Rad' re (s) oral Im e(s) Model s) of such charges. To the extent pemtitted by law, I consent to your use and disclosure of my protected health information to carry out payment activities in connection with this Gaim. X Terese Garrett Signature on File 08/22/2007 40. Is Treatment for Orthodontics? X^ No (Skip 41-42) Yes (Complete 41-42) 41. Date Appliance Placed (MM/DD/CCW) Patient/Guardian signature Date 42. Months of Treatment Remaining 43. Replacement of Prosthesis? 44. Date Prior Placement (MM/DD/CCYY) 37.1 hereby authorize payment of the dental benefits otherwise payable to me, directly to the below named dentist or dental entity. X Terese Garrett Signature on File 08/22/2007 ~ No ^ Yes (Complete 44) 45. Treatment Resulting from (Check applicable box) ^Occupational illnessrnjury Auto accident Other accdent Subscriber signature Date 46. Date of Accident (MM/DD/CCW) 47. Auto Accident State BILLING DENTIST OR DENTAL ENTITY (Leave blank if dentist or dental entity is not submitting TREATING DENTIST AND TREATMENT LOCATION INFORMATION aim on behalf of the patient or insured/subscriber) 53. I hereby certify that the procedures as indicated by date are in progress (for procedures that require 48. Name, Address, City, State, Zip Code GUY R. BIAGIOTTI, D.D.S. multiple visits) or have been completed and that the fees submitted are the aGual fees I have charged and intend to collect for those procedures. X GUY R. BIAGIOTTI, D.D.S. 08/22/2007 1442 Irvine Blvd., Ste. 116 Signed (Treating Dentist) Date Tustin, CA 92780 5a. Provider ID 55. License Number 39757 56. Address, City, State, Zip Code 49. Provider ID 50. License Number 39757 51. SSN or TIN 1442 Irvine Blvd., Ste. 116 Tustin, CA 92780 52. Phone Number (714) 838-0540 57. Phone Numer( 714) 838-0540 ~' Sr~e Provider 1223G000IX