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Home My WebLink About12 CLAIM DENY PELAYO 05-16-05 AGENDA REPORT Agenda Item ~ Reviewed: L City Manager Finance Director MEETING DATE: May 16, 2005 TO: WilLIAM A. HUSTON, CITY MANAGER FROM: RONALD A. NAULT, FINANCE DIRECTOR SUBJECT: CONSIDERATION OF CLAIM OF Bianca Rosa Pelayo, CLAIM NO. 05-18 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 05-18, Bianca Rosa Pelayo, and direct Staff to send notice thereof to the Claimant. FISCAL IMPACT: None. DISCUSSION: While traveling North on Interstate 5, Santa Ana Freeway, Ms. Pelayo was involved in a three- vehicle rear-end accident. One of the vehicles involved was an S-10 Chevrolet Blazer with Orange County Fire Authority signage. Ms. Pelayo's attorney has mistakingly filed this claim against the City of Tustin. Staff recommends deniel of the claim. ROO~ Finance Director ATTACHMENT: Copy of Claim No. 05-18 U:ICLAI M SIConsiderationOfClaimBianca RosaPelayo.doc Office of the City Clerk ""--:;:-";;"'-~'<--;;:::-~;;'-";;;:;-;;-- "'=";;:::=--"';¡;;"';;:;;¡¡";;;;;;¡ U'st;n ~ u... April 28, 2005 Centennial Way Tustin:CA 92780 714.5733026 FAX 714.832..0825 Alex Barrios Ward North America, Inc. P.O. Box 2422 Tustin, CA 92781-2422 Re: Transmittal of Document(s) Claimant: Bianca Rosa Pelayo City Claim No: 05-18 Filed With City: 4/28/05 Receipt of Claim/Summons/Complaint l By: Certified Mail The enclosed records were presented to this office as indicated above and have been referred to the appropriate City department for investigation and also to the offices of Woodruff, Spradlin and Smart, Attn: Lois E. Jeffrey, City Attorney. By this letter, you are authorized to commence the necessary investigation of this claim on behalf of the City. We request that you give such notices as may be appropriate to the City's insurance carrier(s) and further request that you submit your preliminary and all subsequent reports to the City, with a copy to the City Attorney and to the insurance carrier(s) if they so request. Upon receipt of advice from the City Attorney, we will plan to present this matter to the City Council and/or take such other steps as are directed by the City Attorney. A copy of this letter and enclosures were sent on April 28, 2005 to the City Attorney and Department Head, and the original was forwarded to the Finance Department. Sincerely, .. rf) OJ.tU:'ìfM~v.r---- Marcia Brown City Clerk's Office Enclosures: (as above) C: City Attorney Department Finance Department (orig copies) CLAIM ~BT THE CITY OF TUSTIN (For DaU#f/~or Personal Property) .Biceived Via: ~]/8,.# ~ U.S. Mail ,If'r~ 0 Inter-Office Mail ,r./I, I 0 Over the Counter "c.. r,IT" 0:: TUSTI;! ¡rme Stamp: 70'\ t,PR 2 R 'Claim No: A, c,: 05 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 death, injury to person or to personal property must be filed no later than 6 months after the occurrence (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 information, please attach sheets, identifying the paragraph(s) being answered. F. A claim must be presented, as prescribed by the Government Code of the State of California, by the claimant or a person acting on his/her 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 mailed or delivered to the City of Tustin, City Clerk's Office, 300 Centennial Way, Tustin, California 92780. 1. Name and Post Office address of the Claimant: Name of Claimant: Bianca Rosa Pelayo Social Security No.: Post Office Address: 2. Post Office address to which the person presenting the claim desires notices to be sent: Name of Addressee: Post Office Address: Rihhard A. Torres, Esq. Telephone: 450 W. Fourth Street, Suite 100 Santa Ana, CA 92701 (714) 558-7782 3. The date, place and other circumstances of the occurrence or transaction from which the claim arises. Date of Occurrence: 12/14/2004 Location: 5 Freeway Northbound Circumstances giving rise to this claim: AutJDmobile Report) Time of Occurrence: 8;20 a.m. Accident (See attached Police 4. General description of the indebtedness, obligation, injury, damage or loss incurred so far as you now know. Personal Iniurv: S5ft tissue. Back/Neck Sprain/Strain Property Damage: 2000 Nissan Altima: $ 1,652.43 Page1of4 5. The name or names of the public employee or employees causing the injury, damage, or loss, if known. Lynn Mar;ean Gelling 6. If amount claimed totals less than $10,000: 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 $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.) [j¡] Limited Civil Case D Unlimited Civil Case You are required to provide the information requested above in order to comply with Government Code §910. Additionally, in order to conduct a timely investigation and possible resolution of your claim, the Cit of Tustin re uests that ou answer the followin uestions. 7. Name, address and telephone number of any witnesses to the occurrence or transaction from which the claim arises: None 8. If the claim involves medical treatment for a claimed injury, please provide the name, address and telephone number of any doctors or hospitals providing treatment: Aliso Creek Phvsical Therapy-26671 Aliso Creek Rd., # 102, Aliso Viejo, CA 92656 -Dr. Richard K. Petyn, M.D~, Tèl No.: (949) 349-9555 Trinidad Cisneros, D.C.-1201 E. 17th St Santa Ana, CA 92701 (714) 550-6399 If applicable, please attach any medical bills or reports or similar documents supporting your claim. 9. If the claim relates to an automobile accident: Claimant(s) Auto Ins. Co.: State Farm Insurance Address: P. O. Box 21419 Bakersfield, CA 93390-9888 Telephone: (800) 754-8135 Claim No.: 74A910675 Insurance Policy No.: C987866A2875C Insurance Broker/Agent: Frank Jones Address: 900 Old River Road Bakersfield, CA 93311 Claimant's Veh. Lic. No.: 4KAM730 Claimant's Drivers Lic. No.: N5797079 Telephone: (714) 895-5688 Vehicle MakelYear: 2000 Nissan Altima Expiration: 6/24/08 Page 2 014 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, South, and West; indicate place of accident by "X" and by showing house numbers or distances to street corners. If City/Agency Vehicle was involved, designate by letter "A" location 01 CitylAgency Vehicie when you first saw it, and by "B" location of yourself or your vehicle when you first saw CitylAgency Vehicle: location of CitylAgency vehicle at time 01 accident by "A-1" and location of yourself or your vehicle at the time 01 the accident by "B-1" and the point 01 impact by "X." NOTE: If diagrams below do not fit the situation, attach hereto a proper diagram signed by claimant. SEE ATTACHED POLICE REPORT -fI(1 I~ L SIDEWALK CURB --4' CURB -" r¡j¡/ PARKWAY in nF- SIDEWALK Warning: Presentation of a fals~ 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 filed which is later determined not to have been brought in good faith and with reasonable cause. """"""c Date: 4/25/2005 Page30f4 jtt~ CITY OF TUSTIN RECEIPT OF CLAIM Receipt of Claim/Summons and Complaint by the City Clerk's Office: Date: f\-pn' (2 'D,' &éD 5 Time: .::L.-(Þ1\1vì By: - Personal Service Upon the Undersigned Regular Mail ~ Certified/Registered Mail 1Y\0Jt~~ City Clerk's Office