The URL can be used to link to this page

Home My WebLink About07 CLAIM GLORIA SEPULVEDA 06-19-06AGENDA REPORT MEETING DATE: JUNE 19,2006 TO: WILLIAM A. HUSTON, CITY MANAGER FROM: RONALD A. NAULT, FINANCE DIRECTOR SUBJECT: CONSIDERATION OF CLAIM OF GLORIA SEPULVEDA, CLAIM NO. 06-15 SUMMARY: The Claimant reported that she was walking on the south side of Warner between Harvard and Construction North, and she fell in a section of sidewalk that was torn up. Her left arm was broken - requiring surgery and four pins. RECOMMENDATION: That the City Council deny Claim Number 06-15, Gloria Sepulveda, and direct Staff to send notice thereof to the Claimant's attorney. FISCAL IMPACT: None. DISCUSSION: Staff and the City's Claims Administrator have determined that the location of the Claimant's accident is within the city limits of the City of Irvine. The recommendation is to deny the claim and direct the Claimant to the City of Irvine. Ronald A. Nault Finance Director ATTACHMENT: Copy of Claim No. 06-15 \\cot-secondlusers$\ TSkafflCLAIMSIConsiderationOfC/aimOfGloriaSepulveda.doc Y"{"V ~;\'" /~/~'t~\ :~\\ :"~'I \ .$. ' Pi.:";" .. / \~'\':~.., ,~ '. .II ,,'"t_ ~".7' '''''' """.. ~ "..,_..~f__'Jf:""/ C\~ ~ CLAIM AGAINST THE CITY OF TUSTIN (F or Damages to Person or Personal Property) CITY Of TUSTIN Time Stamp: Rec~ed Via fiil/U.S Mall o Inter-Office Mail o Over the Counter '\0 .." r, ; " ~.Un \;'i,.,"$Q 7i,'" 1" Y J ~ ~ L:)IJ ,:L .J ~i> /\ S: 0:" Claim No (0-15 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 9 911.2). D Claims for damages to real property must be filed no later than one year after the occurrence (Government Code 9 911.2). 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 9 910.2). 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. Name and Post Office address of the Claimant: Name of Ciaimant: Home Address: GLORIA SEPULVEDA C/o LAW OFFICES OF JOSEPH M. TOSTI 15615 ALTON PARKWAY, SUITE 175 IRVINE, CA 92618 Work Telephone: 949-450-1200 Home Telephone: N/A 2 Post Office address to which the person presenting the claim desires notices to be sent: (If different from above) Name of Addressee' Post Office Address: Telephone: 3. The date, place and other circumstances of the occurrence or transaction from which the claim arises. Date of Occurrence: 1/23/06 Time of Occurrence: 6:30 P.M. Location SOUTH SIDEWALK OF WARNER BETWEEN HARVARD & CONSTRUCTION l'l.- Circumstancesgivingrisetothisclaim CLAIMANT WAS WALKING ON SAID SIDEWALK AND FELL IN SECTION OF SIDEWALK THAT WAS TORN UP. 4 General description of the indebtedness, obligation, injury, damage or loss incurred so far as you now know CLA.-iMA_NT BROKE H~RT ARM REOllIRING STlRGERY AND 4 PTNS -----~-_.,_._-------'-- Page 1 of4 5 The name or names of the public employee or employees causing the injury, damage, or loss, if known. UNKNOWN 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: $125,000 - (MEDICAL PAST AND FUTURE $40,000.00, LOSS OF EARNINGS AND LOSS OF EARNING CAPACITY $50,000, PAIN AND SUFFERING $45,000) 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 9 86.) o Limited Civil Case ijg Unlimited Civil Case You are required to provide the information requested above in order to comply with Government Code 1910. Additionally, in order to conduct a timely investigation and possible resolution of your claim, the CI of Tustin re uests that ou answer the followln uestlons. 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: DOCTORS & SURGEONS AT UNITED HEALTH CARE; IRVINE REGIONAL HOSPITAL, SAND CANYON, IRVINE DR. BRUCE ALBERT, 4980 BARRANCA PKWY. #201 IRVINE, 727-0770 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. Address: Telephone: Insurance Policy No.: Insurance Broker/Agent: Address: Telephone : Claimant's Veh. Lie. No.- Claimant's Drivers Lie. No.: Vehicle MakelYear: Expiration: If applicable, please attach any repair bills, estimates or similar documents supporting your claim. Page 2 of 4 READ CAREFULLY For all accident claims, place on followmg 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 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 accident by "A.1" and location of yourself or your vehicle at the time of the accident by "B-1" and the point of impact by "X" NOTE. If diagrams below do not fit the situalion, attach hereto a proper diagram signed by claimant -. '.Y t,1Dft!JAl~ L 0 \.. 'l 2 CURB -,. <t :::r I SIDEWALK CURB ""AQNtE\2 ~ SIRv."dK Warning: Presentation of a false claim is a felony (Penal Code !F2). Pursuant to CCP ~1038, the City/Agency 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: ~-- Date </ ~ M. TOSTI NEY FOR CLAIMANT Page 3 of 4 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 undersigned hereby applies for leave to present a late claim 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 (Government Code 9 911.6). The reason for delay in presenting the claim is: Date Signature of Claimant Revised 12/2004 Page 4 of4