HomeMy WebLinkAbout04 DENY CLAIM 04-04-05
AGENDA REPORT
Agenda Item 4
Reviewed: -if
City Manager
Finance Director
MEETING DATE:
APRIL 4, 2005
TO:
WILLIAM A. HUSTON, CITY MANAGER
FROM:
RONALD A. NAULT, FINANCE DIRECTOR
SUBJECT:
CONSIDERATION OF CLAIM OF CHRIS DELFIN TELLEZ, CLAIM NO. 05-14
SUMMARY:
After review by the Finance Director and the City's Claims Administrator, it is recommended the
City Council deny the claim.
RECOMMENDATION:
That the City Council deny Claim Number 05-14, Chris Delfin Tellez, and direct Staff to send
notice thereof to the Claimant.
FISCAL IMPACT:
None.
DISCUSSION:
While traveling on Jamboree Road, the Claimant's vehicle hit a pot hole - causing one of the tires
to fiy off. The amount claimed for damages includes replacement of the tire and rim plus
reimbursement for loss of work time.
Staff has investigated the location of this ciaim and found that it is east of the centerline on
Jamboree Road, within the City of Irvine.
R~
Finance Director
ATTACHMENT: Copy of Claim No. 05-14
U :ICLAIMSICooside,aliooOfClaimOfCh,isDelfi 0 T ellez.doc
CLAIM AGAINST THE CITY OF TUSTIN
(For Damages to Person or Personal Property)
~EC.F,,'r - r-
Rec~.Via:.. a. .
Eiýú.S. Mail
0 Inter-Office Mail '. '1"-. ~//J8.' .
0 Over the Counter _,1 ~/'~flli.
PLEASE NOTE:
A. Read entire claim before filing.
B. Be sure your claim is against the Citv of Tustin, not another public entity.
C. Claims for deatJ;1, injury, to person or jo per¡¡on!j!: PF<!ßerty must be filed no later than 6 months after the occurrence
(GovemmentCode,§911.2). .
D. .Cláims,fÐtda!T1a9~¥' real proPl!rty must be file? np)~te~than one year .e.f\erthe oocu"",pce (Govemm!'nt Codl" § 9.11.2).
E. If additional space is heeded to provide your information"please attach sheets, Identifying thl! paragràpn(s) being ans¡vered.
F. A claim must be presented, as prescribed by thejGovemJÛent Code óttheState of CalifornIa, by the,claimant li)r ap~rson
acting on hislher behalf and shall provide the information shown below and must be signed by the claimant 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 city. Claimant is advised to consult a private
attorney If legal advice is desired. No employee of the City may give legal advice to any claimant relating to private claims.
H. Completed claims must be mallEtd or delivered to the City of Tuatln, City Clerk's OffIce, 300 Centennial Way, Tustin,
California 92780.
.
. CiTy-a". T¡'.I~JHJ
Time Stån\p:' '.. " 111
lOOt¡ flAR 18 A 10: OS
Clalmf' o:
1.
Name and Post Office address of the Claimant
2.
Name of Claimant:
Social Security No.:
Post Office Address: ~
~~~ 1~1 ~~~'ð~' ~rhrua-eí ~ve. ~
eeJ{
f' 7/':(i'i't./J
The date, place and other circumstances of the occurrence or transaction from which the claim arises.
Date of Occurrence: ~e.. S . 3! 51 ~ s . Time of Occurrence: q.. 3 C> ~ m
Location:
Circumstances giving rise to this claim:
I.i)
3.
4.
ry, damage or loss incurred so far as you now know.
I
Page10f4
5.
',z
6.
If amou~t ~Iaìmedtotals less than $1Ö,OÖO:"Provlde the amount clalm$difinõt8ls less than ten thousand
dollars ($10,000) as of the date of your clai!T1, includin9 the estimated amount ofåhyrelätedpotentiäl fulUre- 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.)
If amount claimed exceeds $10,000: If the amount claimed exceeds ten thousand dollars ($10,000), do not
provide a dollar amount in the claim. However, your claim must indicate whether it would be a"limited civil case.
A limited civil 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.)
0 LImited Civil Case
0 Unlimited Civil Case
You are required to provide the Infol1T11ition reques~ above In order-to comply with Government Code
§910. Additionally, in order tb conduct a'tlmely llilvestigatlon'and posslbl l1'8Solutlon of your claim, the
C of Tusti ,re ueatathat ou answer the followin uestions.
7.
Nama, address and telephone number of any witnesses to the occurrence or transaction from which the claim
arises:' '.
8: '
If ,the claIm 'involves medical treatment for a clai,med injury, please provide1he name, address and teiephone
number of any doctors or hospilalsprovidingtreatment:
If applicable, please attach any medical bills or reports or similar documents supporting your claim.
9.
If the claim relates to an automobile accident:
Clairriani(s) Auto Ins. Co.:
Address:
Telephone: ,
, Insurance 'Policy No.:
Insurance BrokerlAgent:
Address:
Telephone:
Claimant's veil. Llc..No.:
Claimanfs Drivers Lic, No.:
Vehicle MakelYear:
Expiratlor!'.
Page2of4
If applicable, please attach any repair bills, estimates or similar documents supporting your claim.
READ CAREFULLY
For all accident claims, place on following diagram name of
streets, Including North, east. $åÜili,aÎldWes!;' Indicate placEt òf
acciden,t)y ~X" ,and by showln9 hq~se nUnJÞ!!rs. ,Qr dlsianpes.. to.
street cOmers." .If CItY/AgenPi' VEihiéle VIJIsjnvolved,deslgnateby
letter °AO location of Clty/Agency Vehicle when yell fitStsewlt,
and by °BO location of yourself or your vehicle when you first saw
CitylAgency Vehicle; location of Clty/Agancy vehicle at time of
'accident by °A~1° and 'location of yourself or yeur'vehicle at the
,tim~ oftl)e,!\cci$lentb~ :B-1° an~ th~ polnt~fimp~ct b~ °x.-
NOTE, Ifdiagi'ams bEllow do not fit the slttJation~ attach :hereto a
proper diegram signed by claimant.
~
W j¡L
a~~ oJ-9tW 'I ~ ~ð't-+4
L ~~bÐr~~ 1/ L
""~',. r~
:;pr-
~ ~ tf. CURB ~
P.ARKW"AY"" ,m' ~.'Fr---",.,
'Ð>W~ I ' r-
Warning: Presentation of a false claim 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 fiied which is ¡¡iter determined not to have been brought in good
faith and with reasonable cause,
Signature:
~4 Ii ~
Date:
:;) ( ~j, (£
Page 3 of4
IF LATE CLAIM: COMPLETE ITEMS 1- 9 AND THIS APPLICATION.
SIGN BOTH FORMS.
APPLICATION FOR LEAVE TO PRESENT A
LATE CLAIM TO THE CITY OF TUSTIN
The undetsigned hereby' applies for cleave to present a late olaim to the City of Tustin. This application is being made
within a reasonable time, not exceeding one (1) year, after the accrual of the caUSE! of action. Under some circumstances,
leave to present a late claim will be granted (Govemment Code § 911.6): The reason for delay in presenting the claim is:
"
'"' ,
Date
Signature of Claimant
Revised 1212004
Page 4 of4