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HomeMy WebLinkAboutMINUTES - 08091988 - 1.17 f CLAIM 1, 7 ' BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT August 9, 1988 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $238. 00 Section 913 and 915.4. Please note all "CaumW-Counsel CLAIMANT: TANA M. JACO 119$8 2409 Pecan Street ATTORNEY: Antioch, CA 94509 Martinez, CA 94553 Date received Ju 1 y 8 , 1988 ADDRESS: BY DELIVERY TO CLERK ON BY MAIL POSTMARKED: July 7 , 1988 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. IL gATCHELOR, Clerk DATED: July 18 , 1988 �b: Deputy L. Hall II. FROM: County Counsel TO: Clerk of the Board of Supervisors (V This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: �7Q Dated: 0 0 BY: ZZ, — Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present kThis Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. AUG 9 1988 Dated: PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: AUG 1 0 1988 BY: PHIL BATCHELOR by eputy Clerk CC: County Counsel County Administrator Claim to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. Claims relating to causes of action for death or for injury to person or to per- sonal property or growing crops and which accrue on or before December 31, 1987, must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1988, must be presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Govt. Code §911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez, CA 94553• C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form. RE: Claim By ) Reserved for Clerk's filing stamp TANA M_ ,]ACO RECEIVED g y ) 0 1988. Against the Count of Contra Costa ) ��' or ) District) CSE.. RqG R V G Fill in name ) By PHIL ' ry The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of $ 238 .00 and in support of this claim represents as follows: ------------------------------------------------------------------------------------- 1. When did the damage or injury occur? (Give exact date and hour) --_.�C11E.UA.Y 41!!f` 2=11_1988 AT 6:45 a. m. 2. Where did the damage or injury occur? (Include city and county) KIRKER PASS ROAD, PITT,SBURG - EAST CONTRA COSTA COUNTY -- -----------------------=----------------------------------------------------------- 3. How did the damage or injury occur? (Give full details; use extra paper if required) THE COUNTY IS DOING ROAD WORK ON KIRKER PASS AND ALL FOUR LANES ARE FULL OF GRAVEL. DRIVING UP KIRKER PASS MANY, MANY PIECES OF GRAVEL FLEW UP AND PELTED MY CAR. I WAS DRVING -ONLY 20 MILES PER HOUR HOWEVER THIS MADE NO DIFFERENCE AND MY WINDSHIELD IS NOW DAMAGED IN A NUMBER OF PLACES. ------------------------------------------------------------------------------------ 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? INSTEAD OF DOING PART OF THE ROAD WORK AT A TIME SO NOT ALL THE ROAD WAY WAS GRAVELED IT GAVE ME NO CHOICE BUT TO TRAVEL ON THE GRAVELED ROAD. THE ROAD WORK AND DAMAGE CAUSED BECAUSE OF IT IS THE RESPONSIBILITY OF THE COUNTY. I NOW HAVE TO TRAVEL IN ANOTHER DIRECTION, OUT OF MY WAY, TO AVOID FURTHER DAMAGE TO MY CAR UNTIL THE ROAD WORK IS COMPLETE AND THE GRAVEL CLEANED LIP. (over) . 5. `'What are the names of county or district officers, servants or employees' eausing the damage or injury? CONTRA COSTA COUNTY PUBLIC WORKS /STREET MAINTAINANCE DEPARTMENT ----------------------------------------------------------------------------------- 6. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. CRACKED WINDSHIELD ON MY AUTO/CHRYSLER LASER, GOLD - 1985 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) ESTIMATES PROVIDED BY REPUTABLE BUSINESS FOR LABOR-AND --COST OF WINDSHIELD. ------------------------------------------------------------------------------------- 8. Names and addresses of witnesses, doctors and hospitals. 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT Gov. Code Sec. 910:2 provides: "The claim must be signed by the claimant SEND NOTICES TO: (Attorney) or by someperson on his behalf." Name and Address of Attorney Claimant' ignature 2409 PECAN ST. Address ANTIOCH, CA 94509 Telephone No.. Telephone No. (415) 757-5664 * �t * * NOTICE Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city or district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is punishable either by imprisonment in the county jail for a period of not more than one year, by a fine of not exceeding one thousand ($1,000), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000, or by both such imprisonment and fine. DAN'S CONTRA COSTA GLASS MOBILE GLASS SERVICE Specializing in Auto Glass and Windshield Repair Concord Pitts/Ant. (415)827-4173 (415)754-0799 ESTIMATE 1985 CHRYSLER LASER WINDSHIELD. . . . . . . . . . . . . . . . . . . . . . . . . . .. . 209.11 KIT. . . . . . . . . . . . . . . . .. . . . .. . . . . . . . . . . . . 9.95 *YIOLDING. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 73.36 LABOR. . . .. . . . . . . . . . . . . . . . . . . . . . . . .. . . . . 45.00 TAX ON PARTS(292.42). . .. .. ... ...... .. .. 19.00 TOTAL. . ... . . . . . . . .. . .. . . .. . . . . . .. .. .0. . 356.42 *May require new molding, depending on the condition of the old molding. iM r a G Ci U F-e ,-JL 1�r^ �ulc•t e No. 06--30-88 ACCT. DATE NO. INSURANCE CO.NAME AGENT'S NAME F2- ANI- JACO ADDRESS CITY.STATE 4t_>9 PECAN rJT AND ZIP NTIOCH CA 94509 PHONE NO. c• r_ POLICY NAME Thank yCrI_t i"C r-r^ yCII_IY^ DI-tS1IrlesS POLICY NUMBER STATE LICENSE #494:305 VERIFIED BY CLAIM CODE DATE OF AUTOMOBILELOSS Y^Y's F.3'r^ c1�'�C=T' MAKE MODEL CAUSE YEAR :I DOORS 4 LICENSE NO. DEDUCTIBLE SERIAL NO. TERM CUSTOMER ORDER SOLD BY SHIPPED VIA SHIPPED FROM DATE SHIPPED L�ash NO uluant It y Part W- Lo I or KIt labor elst biele Comment s MAIL QUOTE RECEIVED BY NOTE: ALL CLAIMS AND RETURNED GOODS 237. 20 MUST BE ACCOMPANIED BY THIS RECEIPT. All material is guaranteed to oe as specified. All work to be completed in a All goods and services ordered or received by the above named party,or their workmanlike manner according to standard practices. Any alteration or principals,are subject to the following conditions which are hereby accepted deviation from above specifications Involving extra costs will be executed only and agreed to by the person ordering or receiving said goods or services. upon written orders. and will become an extra charge over and above the ® estimate. All agreements contingent upon strikes,accidents or delays beyond All claims and returned goods must be accompanied by this receipt. Terms of our control. Owner to carry fire,tornado and other necessary Insurance. Our payment are ten(10)days net from invoice date. All accounts are commercial workers are fully covered by Workman's Compensation Insurance. accounts and not open accounts All delinquent accounts shall bear interest at the rate of 1',7%per month,an annual percentage rate of 18%. • CLAIM BOArD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA and as GOVERNING BOARD OF THE CONTRA COSTA COUNTY FLOOD .CONTROL AND WATER CONSERVATION DISTRICT Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, )' NOTICE TO CLAIMANT August 9 , 1988 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: Unspecified Section 913 and 915.4. Please note all "WarniTrgsj'?�r` CcL�"S_: CLAIMANT: TERRY DEBATTISTA ETAL J U L 1 2 1988 c/o Glenn A. Jennings , Jr. ATTORNEY: Law Offices of James D. Bierat P�"ar �re�, CA 9455.,- 393 Vintage Park Drive Date received ADDRESS: Foster City, CA 94404 BY DELIVERY TO CLERK ON July 11 , 1988 Risk Manage . BY MAIL POSTMARKED: no envelope I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. July 12 , 1988 PHIL BATCHELOR, Clerk DATED: BY: Deputy L. Hall II. FROM: County Counsel TO: Clerk of the Board of Supervisors (✓f This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: l 2 BY:1V, - JY_1� _ Deputy County Counsel. el III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present (X This Claim is rejected in full . ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: A U G 9 1988 PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: AUG 1 .0 19M BY: PHIL BATCHELOR by Deputy Clerk LC: County Counsel County Administrator - dim to: BOAfD 'OF SL'?ERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. Claims relating to causes of action for death or for injury to person or to per- sonal property or growing crops and which accrue on or before December 319 1987, must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1988, must be presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Govt. Code §911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez, CA 94553• C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form. RE: Claim By ) Reserved,_for Cler ' .fi 'n stamp TERRY DEBATTISTA and CHARLIE ) BEBAHTISTA ) RECEIVED Against the County of Contra Costa ) J U L 111988 or ) CONTRA COSTA COUNTY WATER CONSERVATION District) CLE K8 H A ELOR P SOAS Fill in name ) 9y . . . .r„ Ury The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of $ /inde nits ca=arariWd in support of this claim resents as follows: fault, declaration of rights respecting relativetresponsiby----------------------------------- --------- ---- 1. When did the damage or injury occur? (Give exact date and hour) ___Approximately_June of 1986 and is still- ongoing,._________________________________ ----------------- 2. Where did the damage or injury occur? (Include city and county) 213 Oak Knoll Loop_Walnut Creek County of Sa_�ara �alifQrnia_____________ 3. How did the damage or injury occur? (Give full details; use extra paper if required) Excessive water drainage from storm drains, and other drainage systems uphill ----from dam Zfz property----------------------------------------------------------- 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? Negligent planning, installation, implementation, and construction of these drainage systems. (over) 5. 'What are the names of county or district officers, servants or employees causing the damage or injury? -------Iial�a�oaa_at_thi�_ta��� Discov_er� igocess___________________________________ 5. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. -------Sk�1X_fQr_iAditd casatiY�f� lti------------------------------------- 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) Not applicable. ------------------------------------------------------------------------------------- 8. Names and addresses of witnesses, doctors and hospitals. Plaintiff in underlying Action: Arnold and Maxine Erickson, 213 Oak Knoll Loop, Walnut Creek, California. Plaintiff's Attorney: Michael Blevins, 3478 Buskirk Avazue, Suite 200, Pleasant -------------------------------------------------------- 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT Not applicable. Gov. Code Sec. 910.2 provides: "The claim must be signed by t claimant SEND NOTICES TO: (Attorney) or jow person o . his behalf." Name and Address of Attorney Glenn A. Jaznings, Jr.- - (X Law Offices of James D. Biernat Claiman 's Sign 393 Vintage Park Drive, Suite 250 Foster City, CA 94404 393 Vintage Park Drive Suite 250, Foster City, 8R 94404 on behalf of Terry and Charlie Debattista Telephone No. (415) 349-3555 Telephone No. (415) 349-3555 N O T I C E Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presen r '07rallowance or for payment to any state board or officer, or to any county, ¢� r .;strict board or officer, authorized to allow or pay the same if genuine, ai'jy fse E3 �fraudulent claim, bill, account, voucher, or writing, is punishably itPer by imprisonment in the county jail for a period of not more than one rby a'Afi ,gf not exceeding one thousand ($1,000) , or by both such imprisonmen ' ,/,. a or`by imprisonment in the state prison, by a fine of not exceeding ten thousand" f& .16 10,000, or by both such imprisonment and fine. t CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA and as GOVERNING BOARD OF THE CONTRA COSTA COUNTY FLOOD CONTROL AND WATER CONSERVATION DISTRICT Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT August 9,. 1 9 8 8 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: Unspecified Section 913 and 915.4. Please note all "Warnings". CLAIMANT: TERRY DEBATTISTA ETAL c/o Glenn A. Jennings , Jr. JUL 12 1988 ATTORNEY: Law Offices of James D. Biernat 393 Vintage Park Drive Date received �1c:F[� �, , i ADDRESS: Foster City, CA 94404 BY DELIVERY TO CLERK ON July 11, 1988 Risk Manage. BY MAIL POSTMARKED: no envelope 1. FROM: Clerk of the Board of SuFervisors TO: County Counsel Attached is a copy of the above-noted claim. Jul 12 1988 ppHHIL BATCHELOR, Clerk DATED: y BY: Deputy .__ /V,- , A�v L. Hall 1I. FRWThis County Counsel TO: Clerk of the Board of Supervisors claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: �_� 2 BY. Deputy County Counsel 111. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present X This Claim is rejected in full . ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. AUG 9 1988 Dated: PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order an Notice to Claimant, addressed to the claimant as asshown above. „ Dated: G 11CMQ BY: PHIL BATCHELOR by eputy Clerk CC: County Counsel County Administrator Claim 'to:_ BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. Claims relating to causes of action for death or for injury to person or to per- sonal property or growing crops and which accrue on or before December 31, 1987, must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1988, must be presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Govt. Code §911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez, CA 94553.- C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form. RE: Claim By ) Reserved for C1 TERRY DEBATTISTA and CHARLIE ) nF.RATTTSTA ; RECEIVED ) Against the County of Contra Costa ) ,!11 111988. or ) CONTRA COSTA FLOOD P jELDistrict) CLE N R OR^ Fill in name ) 9y f. P� The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of $indemnity, comparatiVand in support of this claim represents as follows: fault, declaration of rights respecting relative ----------------------------------------------------------------- 1. When did the damage or injury occur? (Give exact date and hour) Approximately June of 1986 and is still ongoing. ------------------------------------------------------------------------------------ 2. Where did the damage or injury occur? (Include city and county) 213 Oak Knoll Loop, Walnut Creek, County of Contra Costa, California ------------------------------------------------------------------------------------ 3. How did the damage or injury occur? (Give full details; use extra paper if required) Excessive water drainage from storm drains, and other drainage systems uphill from the damaged property. ------------------------------------------------------------------------------------ 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? Negligent planning, installation, implementation, and construction of these drainage systems. (over) 5. What are the names of county or district officers, servants or employees causing the damage or injury? Unknow at this time, Discovery in process. ------------------------------------------------------------------------------------ 5. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. Only for indemnity and comparative fault. - -------------------------------------------------------- 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) Not applicable. ------------------------------------------------------------------------------------- 8. �Qmi�s pf 4ddressps•of witpesses do��tors d hose ta]s. llaintI in caner yang Action: Arno and Maxine is on, 213 Oak Knoll Loop, Walnut Creek, California. Plaintiff's Attorney: Michael Blevins, 3478 Buskirk Avenue, Suite 200, Pleasant ---------------------------------------------------------- 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT Not applicable.. ' Gov. Code Sec. 910.2 provides: "The claim must be signed by the claimant SEND NOTICES TO: (Attorney) or Wsome. person on his behalf.," Name and Address of Attorney VAL ro A Glean A. Jennings, Jr. (Claiffiah s Si Law Offices of James D. Biernat 393 Vintage Park Drive, Suite 250 393 Vintage P k Drive, Suite 250 Foster City, CA 94404 Foster Ci y,5s 94404 on behalf of Terry and Charlie Debattista Telephone No. (415) 349-3555 Telephone No. (415) 349-3555 NOTICE Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city or district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is punishable either by imprisonment in the county jail for a period of not more than one year, by a fine of not exceeding one thousand ($1,000), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceedingntt; ►` dollars ($10,000, or by both such imprisonment and fine. r �"`: i lt:iuU4;mn n 17 CLAIM / BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT Aiigu s t 9 1 9 8 8 and Board Action. All Section references are to ) The copy of this document mailed to you your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $484. 5 8 Section 913 and 915.4. Please note all "Warnings". CLAIMANT: NORTHBROOK INSURANCE } Claim # 3830274431-W2F c/o Christine Echito 3830274571-W2F ATTORNEY: P. O. BOX 50040 San Jose, CA 95131-9736 Date received ADDRESS: BY DELIVERY TO CLERK ON July 11, 1988 ;.�; 0", '. BY MAIL POSTMARKED: June 29, 1938 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. Jul 12 1988 PpHHIL BATCHELOR, Clerk DATED: y BY: Deputy 01 L. Hall II. FROM: County Counsel TO: Clerk of the Board of Supervisors (This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( } Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: —�?i BY. Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present This Claim is rejected in full. (� `) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. 01 AUG 9 1%8Dated: PHIL BATCHELOR, Clerk, By V, Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. ' You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: AUG 10 1988 BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator t • Northbrook Property and Casuatty Insurance Company Commercial Claim Office P.O.Box 50040 San Jose, 95131 9736 RE VED(408)436-0505 15 ,1U�W 119�� June 27, 1988 A tLO qS GL tJ Y BY '� Clerk of the Board of Supervisors P.O. Box 911 Martinez, CA 94553 Re: Our Insured: Del Monte Electric Our Driver: Francis Maio, Jr. Our Passenger: Michael Suffin Our Claim Numbers: 3830274431-W2F 3830274571-W2F Date of Loss: 4/5/88 Your Insured: Contra Costa County Your Driver: Patrick Hogoboom Dear Clerk of the Board of Supervisors: Our investigation show that your insured was responsible for the above- captioned accident. Both Mr. Suffin and Mr. Maio sustained injuries which are covered under their employer's Workers Compensation policy. Since we are the Workers Compensation carrier for Del Monte Electric, we paid for their medical bills. Neither party remained off of work for more than three days, therefore we did not compensate for lost wages. Enclosed please find our supporting documents and your claim form. We will be looking to your for reimbursement in the amount of $484.58 payable to Northbrook Insurance. If you have any questions or problems, please feel free to give me a call. I am in the office from 8:00 a.m. to 4:00 p.m. Sincerely, C-- k-,I Chris Echito Claim Service Representative CE/dmc /L 04s&%rtzue Jeraice 6)ov�a N B G 7-2 CLAIK TO: • B�r"'RD OF SUPERVISORS OF CONTPA. COSTA COUNTY Instructions' 'to Cha�L.«ant A. Claims relating to causes of action for death or for injury to person or to personal property .or growing crops must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Sec. 911. 2, Govt. Code) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez , CA 94553 (or mail to P.O. Box 911, Martinez, CA) _ C. If claim is against a district governed by the Board of Supervisors , rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. . E. Fraud. See penalty for fraudulent claims , Penal Code Sec. 72 at end of this form. RE: Claim by ) Reserved for Clerk' s filing stamps Northbrook Insurance RECEIVED Against the COUNTY OF CONTRA COSTA) or DISTRICT) JJL 111988. (Fill in name) ) A B E The undersigned claimant hereby makes claim a1 A s f Contra Costa or the above-named District in the sum ePucy and in support of this claim represents as follows : ------------------------------------------------------------------------ 1. When did the damage or injury occur? (Give exact date and hour) April 5, 1988 @ 1510 hours ------------------------------------------------------------------------ 2. Where did the damage or injury occur? (Include city and county) S.R.4 EB - 600 ft W. of Willow Pass Road Concord, Contra Costa County ----------------------------------------------------a----------- d 3. How did the amage or injury occur? (Give full details, use extra sheets if required) Contra Costa County eiTployee rear ended vehicle driven by Francis Maio. He (Hogoboom) was not paying attention and couldn't stop.in time. -----------=----------------- ------------------------------------------ 4 . What particular act or omission on the part of county or district officers , servants or employees caused the injury or damage? Inattention on the Part of the country driver. (over):= 5. What are' the hams• of county or district of1�i.cers, =sez-varus Gorr-. employees causir the damage or..injury? Patrick Joseph Hogoboom ------ ----------------------------------------------------------- am e dor injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage) Francis Maio = neck pain Michael Suffin - neck pain, skull laceration 7--,. H-----ow--wasth------e---amount------------claimed---above--------computed?--------(I -nclu-- d--e---the-- e--- ------ stimated---- amount of any prospective injury or damage. ) Estimated amount of claim $500.00 - All bills and copies of checks enclosed. K-- - ----- -- --------?--7 ------T- -- -------------------------------Names and addresses of witnesses, doctors and hospitals. Lorrie Owens Kaiser Permanente 3074 Brook Street 200 Muir Road Oakland, CA Martinez, CA 94553 (415) 451-4041 ------------------------------------------------------------------------- 9. List the expenditures you made on account of this accident or injury.: DATE ITEM AMOUNT : .... 5/.12... .... ...__ _.__........_...__, Medical Bill $180.26 6/22 Medical Bill $ 72.58 6/23 Medical Bill $ 46.74 6/24 Medical Bill $185.00 Govt. Code Sec. 910.2 provides : f "The claim signed by the claimant • SEND IQOTICES'TO: '(Att r.ne ) 'or b some ersori on his behalf. " Northbrook Insuran Name and Address of Attorney ` Claimant' s Signature P.O. Box 50040 Address San jose, CA 95150 Telephone No. Telephone No. (408) 436-05,15 NOTICE Section 72 of the Penal, Code provides: "Every person who, with intent to defraud, presents for allowance or for payment to any state board or. officer, or to any county, town, city district, ward or village board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is guilty of a felony. " _....O O_-.. I N 1 1 Am Z > m I _ 77. Y" rJ M. m M CC T. f.,• - Y` M {0 iz _ C,lO •• Y _ — -+ o _ j> I r z Im o = 1 f O = t.. 1 S m Ln 1 1 m 1= w03 _+ 1 x _ I' w _ K 1° m lm Zm Y: O C �m pZ 0 Z m �. lm Z 1 m> _ o T SR ! A m I p� v € 1 1 .-�L = C135 I m= F: �� I m 0—. c c w ;n0 n ,: nnn' i J - I Cq BEECH STREET TRANSt/DATC14 l att 94-1105678 612475 0066 KRIS E' }':i;Y<<,ftF:t;Ti CLIENT fiAF'+' ; ALLSTAIE (NORTfiBRQQK)--SAN JQa BOY 12911/1950, FRANKLIN ST PATIENT NAME SUFFINr K OAKLANII, CI. '1460`4 CLAIM NLNIDIE'R X3027457 -REFERENCEt H2F PAGE I OF I SERVICE DATE liSI's PF10I t PROCEDURE DE5CEIPTION BILLED ADJU,"ii4EN1 ALLOWANCE Oir G5-vu^ 12001 REPAIR T8 2.5 C►i 9710 35.80 61,20 04-05-88 HOSPITAL SERVICES 72.00 0100 92.00 04-10';15 i1 905'/0 ENLI I P V IEE E;ir`iti 51.00 "3.54 27.06 §04 TOTAL N^240.00 :yµ59.74- /,r rtti? TO1AL' REI;OPIP,ENDrATION FOR PAYMENT; t180.26 f i f~ a } 1 UNLESS, DINLRfIISL fifi7'EDi ALL NEOA1iVE ADDU TME 1TS ARF DUE TO THE PROVIDER'S CHARGE EXCEED1NIS, lffL FEE SCHEDULE ALLONAN'll, Li A PROCEDURE CODE HAS BEEN USED WHICH APPEARS O BE HORE CONSISTENT WM THE 5ER4'ICES DESCRIBED BY THE PROVIDER, DIRECT INQUIRIES TO: Fla. fi2i.t 1a1NE". Ci; i fi=ii � • DRM NO 241-05 o �^ EASE ATTACH A COPY OF THIS BILL OR \\`11/ IC/>ISCft ��(,1 1 I ;E THIS MR NUMBER ON ALL PAYMEN rS OCEWANE NTEE AND CORRESPONDENCE. LOCATION DATE PREPARED 1950 Franklin Street,Box 12911 MARTINEZ 04/15/88 Oakland,California 94604-2911 IRS NUMBER PREPARED BY INDUSTRIAL OUTPATIENT STATEMENT 94-1105628 S FARC I NK 0 PATIENT NAME KFHP MEDICAL RECORD NO. SUI-FIN, MICHAEL SS -•00077 H 2129629 RXSTREET ADDRESS DATE OF INJURY CARE TO CONTINUE 38 LOIS AVE. 04/05/88 ❑ YES ❑ NO CITY STATE ZIP WCAB • PITTSBURG CA 94565 CARRIER NAME EMPLOYER NAME NORTHBROOK INSURANCE 0El_ MONTE ELECTRIC CARRIER ADDRESS STREET ADDRESS P. 0. BOX 50040 P. 0. BOX 3730 CITY STATE ZIP CITY ST. ZIP SAN JOSE- CA 95150 HAYWARI) CA 94540 DIAGNOSIS SCALP LACERATT011. Lu TREATMENT- INDUSTRIAL-OUTPATIENT DATE OF SERVICE W.C.CODE TYPE OF SERVICE Code AMOUNT 04/05/88 12001 SUTURE REPAIR OF SCALP 28 65: (i -) 04/05/88 99025 PRO FEE 48 32 : C ; 04/05/88 EMERGENCY ROOM USE FEE 07 51 : iii 04/05/88 SUTURE TRAY 33 26 : 04/05/88 XYLOCAINE INJECTION 26 15 : f:? 04/10/88 90500 ER VISIT, MINIMAL 28 51 : 0 , U R ^ v •L`P11 IF YOU HAVE ANY QUESTIONS REGARDING THIS STATEMENT,PLEASE CALL (41 5) 372-1167 TOTAL 240: 95004(REV.10-86) CLAIM NUMBER MONTH/DAY/YEAE�= CONTROL NUMBER POLlryvUMB R K LOC A TI ON INSURED ? { CLAIMANT .`.:-: i.'' .. N8881-2 2_1P002808 13 710 ;i`' ?(1,�' MrABLEIF OEBIRED AT IN THE FIRST NATIONAL BINK -NEAoOt�S OFFICE ' OF GO fMItNOEINTIOIMLSAW PAYMENT CHICAGO,ILLINOIS 3&HO EAG OF PAY BUSINESS INSURANCE DIVISION CLAIM CHECK ACCOUNT NON-NEGOTIABLE ADJ.NO. TO THE ORDER OF AUTHORIZED SIGNATURES 1:0 7 10000 L 3e: S9 0 38 3 Lilo VOID IF NOT PRESENTED WITHIN ONE HUNDRED AND EIGHTY DAYS OF THE DATE OF ISSUE BEECH STREET MAt rc�t# IrwS11 94-1103628 .692340 01M KAISER PERliNNENTE CLIENT NAME . ALLSTATE (NO1;TNBROOK)--SAN JOS . 80 1291//1950 FRRMLIN ST PATIENT KAHL : HAIO, F OAKLAND, CA 94604. CLAIM MMBER 3830214431 REFERENCH 112E PA6f' 1, OF 1 SEROICI DATE !lS6h P OC 0 PROCEma DESCRIPTION. BILLED, ADJUSMENT ALL1VRMCE. 09 Q010 FC VISIT INITIAL 18..26 46.74 TOTAL 65.00 18.26 46.74 TOTAL ENDATION FOR WNW: 1 46.74' ' L RECOtffl f f r e' t i r .MISS QTNERIiiSE.`ItOTED;''ALL!lEEGflTIUE;QDJt>Sl RlEMTS ARE DUE i0 THE Pl;WIDER'S CHARGE EXCEL THE FEE SCHEDULE ALLOR MCE. DIRECT INQUIRIES TO: 800/432--3121 P.O. BOX 16947 IRVINE, CA 92714-6547 =ORM NO 241-05 O k-)ol / -7 '7 J � o-$i'0000-0 tS 00 11 J U D 1-I U U �flb r 00 � 's � sM KNSER PERMANENTEE TELEPHONE: MAIL TO: PATIENT COLLECTIONS DEPARTMENT (415) 987-1166 FILE NO. 3522 P.O. BOX 12911 OAKLAND, CALIFORNIA 94604 PLEASE PUT THIS NUMBER P.O. BOX 60000 ON THE FRONT OF YOUR SAN FRANCISCO, CHECK OR CORRESPONDENCE: GA. 94160 � MEDICAL N0. o DEL MONTE ELECTRIC CO., INC. MAIO FPANCIS J JR P. 0. ROX 3730 3931342 3836, F L L B R OOK CT HAYWARD, CA 94540 AMOUNT ENCLOSED PITTS RG CA 94565 01 S ACCOUNTS ARE PAYABLE UPON RECEIPT PLEASE DETACH AND RETURN UPPER PORTION WITH PAYMENT _ PAYMENTS OR CHARGES RECEIVED AFTER TH;S DATE WILL APPEAR ON YOUR NEXT MONTH'S STATEMENT. DATE: 4/3 0/8 C DATE CODE EXPLANATION CHARGES CREDITS BALANCE 4/05/88 54 PPZOF FEE O/PT 65 . 00 RE EIVED e-'irll 1 71988 IF FULL PAYMENT HAS BEEN MADE SINCE RECEIPT OF YOUR LAST STATEMENT ,PLEASE DISREGARD THIS TOTAL NOTICE. AMOUNT $65 . 00 DUE HOSPITAL 6 CLINIC LOCATION CODES 11 OAKLAND 35 - SOUTH SAN FRANCISCO 54 - MARTINEZ 12 - RICHMOND 37 - REDWOOD CITY 55 - ANTIOCH 14 - HAYWARD 38 - MILPITAS 58 SANTA ROSA 16 FREMONT 39 - SAN RAFAEL 59 - ROSEVILLE 21 VALLEJO 41 - SANTA CLARA 60 - SOUTH SACRAMENTO 22 - NAPA 43 - SUNNYVALE 61 - SACRAMENTO 23 - KAISER FOUNDATION 47 - PLEASANTON 63 - SANTA TERESA REHABILITATION CENTER 48 - SAN JOSE 68 - STOCKTON 31 - SAN FRANCISCO 51 - WALNUT CREEK 72 - FRESNO 75 - GILROY A M.R. NO. 3931342 14191 (REV. 5/87) CLAWWUMIEIER • _ I - ONTROL NUMBER UMBER C INSURED CLAIMANT . N8881-2 04 El 710 PAYABLE s OE81RED AT IN THE FIRST NATIONAL BANK ^iceOFRGE . llowillAw PAYMENT OF CHICAGO 5nd�pPE� OF CHICAGO,ILLINOIS LOB ANBELM CA PAY :T$ - � BUSINESS INSURANCE DIVISION CLAIM CHECK ACCOUNT NON-NEGOTIABLE AD1 N0. TO THE ORDER I OF .. 40 7 10000 L 3i: 59 0 38 3 IVAUTHORIZED SIGNATURES VOID IF NOT PRESENTED WITHIN ONE HUNDRED AND EIGHTY DAYS OF THE DATE OF ISSUE - '1 C9 BEECH STREET . TRfltkIRfBAt#3NE 1443628 633393 KAISER PERROMENTE _ CLIENT 18211E ALLSTATI "(Nmfumj=-SAN JOS Box 12911%1930 FRANK M S1 PATIENT MAIM 11RI0, l OAKLAND, CA 94609 CL IN WDER -3=74431, . . REFERENCE1i . -PUCE- 1.OF 1 00 SE DICE IIATE PR' # PRUCME DESCRIPTION -BALED AOJtWnENT ALL03 wt 04-03-88 40013 . '@EC UI5I1' INITIAL.INTERIIEDIATE 81.00 22:4? 44 38, 04-03-88 :NMTAL.SERUICES _8.00 tl,OG 8.00 77 T07AL 10T AL 1tECOEft1ENQA1I1lM1 FOR PAYflElIT: 5 �' �72.38. - ' }J .. to c _ , S x t. , e MISS DTNEMISE NUTED,'fitt NEGATIVE 4MUSTUNTS.ARE DE IO .INE MCIVIDER'S CHARGE E110EE8I1G TOE: FEE SCHIQULE AL10"ACE. DIRECT INQUIRIES TO: FORM NO 241-05 8001431-3}22 P:D. BOX 16547 IRVINE, CA 92714-6347 -V r�. J =ASE ATTACH A COPY OF THIS BILL O i �m� INil .CR MI _� C' L � ,,,,E THIS MR NUMBER ON ALL PAYMENT; 0I ZMCNTC AND CORRESPONDENCE. LOCATION PARED ? C 1950 Franklin Street,Box 12911 I IART INF_'Z 05f 17/88 Oakland,California 94604-2911 IRS NUMBER PREPARED BY INDUSTRIAL OUTPATIENT STATEMENT 941105628 S E S HABARR PATIENT NAME, KFHP MEDTCA4 RECORD NO. 111--iI0, FRANCE.3 Si -00077 H ;3931 •'int,:: STREET ADDRESS DATE OF INJURY CARE TO CONTINUE 3836 F ALLBROOK COURT ;��,/,;�.;;�s� ❑ YES ❑ NO CITY STATE ZIP WCAB • PITTSBURG CA 04565 CARRIER NAME EMPLOYER NAME 61ORTFIBROOK INSURANCE" DEL MONTE ELECTRIC CARRIER ADDRESS STREET ADDRESS P.O. PDX 501'x) (j F',O. BOX 7730 CITY STATE ZIP CITY ST. ZIP airJCE � 1-1 95150 HAt'WARD CA 94540 DIAGNOSIS '-' ' ' -' '- . TREATMENT- INDUSTRIAL-OUTPATIENT DATE OF SERVICE W.C.CODE TYPE OF SERVICE Code AMOUNT kl')4/(.:I`iiO£; 9,,7) ,> OFFICE VISIT, INUTIAL ( INITERti[DIATr) 28 O7. 04/05/dc!! CERVICAL COI_.I_AI--' (FOAM)M) 33 81 BEECH STREET J U' 0 6 1�;;•;g CUIRIES .-�. c YOU HAVE ANY QUESTIONS , TOTAL :� EGARDING THIS STATEMENT,PLEASE CALL (4 i ) 372--11 r� _:. 004(REV. 10-86) 1 • ate_ _ +��_ � Z- 7—ib ib _J loo Im - I IZ if O I Z 8,, lZ w - m I o LPI L 1 IZ = i G) - _= j ch y r - m Z m i > OZ :I: - I I -4 I m m O .I c m m01- m -m> s � Z MM I n z cl ^Aa #I.14- ' IjBEECH STREET A ,C9 % c - ,g 4 : 7' TonsO'!$itttNb� i„' gra I1D5hT., 6:_ ..79 twit r }(�%i+t it YL7iil 1(rtF 2L - IftJEhi ?!!1K�' .'k l3ii17� :{:} R;'(c8A.4��� J�� J{Id 3 '12911!l."O FRAtt ' l h f1 PATIEM kAME Ufi :i:{tLA t LA'A W?'il:. ' 3830224571 -REFUNCE MIKE t3nT�A i¢ala f'P��G S'fi1€Gt#'4f DESCkIF'ilOt# D1s_LF1J. '::ADJiSME4 C►LL111}l1#Ci 'IA, `�4-+d5-1€'• 7 52 Ss.TtiE FLEt']>lh cr7 w 114.0 i 127 9 .2 au 701At".; 24t.00 b3. r is:00, , • i r f x— , , n�. WLESS OIHI#t)tt"Sc 96TEPi ALL Ksi{i I E`All,1t''SIKERTS APE ItIt 70 HE PROVIDEP.'S CHAPGE MEELING IHE NEE,.S.CNED LE ALLUMAFE DIRECT INQUIRIES TO: YYpp t c I.M )RM NO 241-05 so 0 - / / / EASE ATTACH A COPY OF THIS BI LL 0R KA)SU2 THIS MR NUMBER ON ALL PAYMENTS [1V OCRMANTF AvvD CORRESPONDENCE. LOCATION DATE PREPARED 1950 Franklin Street,Box 12911 ,I L� Oakland,California 946042911 - TT 14 F- _ IRS NUMBER PREPARED BY = INDUSTRIAL OUTPATIENT STATEMENT 941105628 9 MAR17TH01 PATIENT NAME KFHP MEDICAL RECORD NO. T' �.I I I T - 0 -' fl '? STREET ADDRESS DATE OF INJURY CARE TO CONTINUE J' LOTS. AV i;llt�'!)r.-% �� ❑ YES. ❑ NO CITY STATE ZIP WCAB N =.1 I '(' 24565 CARRIER NAME EMPLOYER NAME CARRIER ADDRESS STREET ADDRESS 500412 P. f ;QX -17 a 3 CITY STATE ZIP CITY ST. ZIP DIAGNOSIS SCALP LAC ERAI 101\1. ,R TREATMENT- INDUSTRIAL-OUTPATIENT _ DATE OF SERVICE W.C.CODE TYPE OF SERVICE Code AMOUNT 4%i) i '8113 7::'0,52 CERVICAL SPIHE XRAY, COMPLETE ti?A7- 0 4 _i4.f 05%epi 702610 SKULL XRAY, COHPLETE t' • r4 ".T,� cco 'I'VED TREE1 ,u ; ; ; IF YOU HAVE ANY QUESTIONS TOTAL REGARDING THIS STATEMENT,PLEASE CALLraj . i 4 13-72-1167 _ 95004(REV.10-86) PLUSE TYPF ALL INFORMATION,IF POSSIBLE - State of California Nease complete In triplicate.Retain one y for your files and mail the original and one copy to OSHA Case EMPLOYER'S REPORT NORTHBROOK INSURANCE COMPANY or File No. P.O. BOX 50040 OF OCCUPATIONAL SAN JOSE, CA. 95150 #54 INJURY OR ILLNESS _ PHONE: (408) 298-9420 (Carrier name,address) PICA X X X ELITE XX X a TYPEWRITER ALIGNMENT GUIDE e 1 PICA X X X ELITE X X X California law requires an employer to report within fire days every industrial injury or occupational disease which:(a)Results in lost time beyond the day of injury, or(b)requires medical treatment other than first aid.PLEASE NOTE:In addition,if death results or if the injury or illness:(a)Requires inpatient hospitalization of more than 24 hours for other than medical observation; or (b) results in loss of any member of the body; or (c) produces any serious degree of permanent disfigurement, then the nearest district office of the California Division of Occupational Safety and Health also must be notified Immediately by telephone or telegraph.This notification is not required,however,if the injury or death results from an accident on a public street or highway. t.FIRM NAME NOT (A-POLICY Nt1MBER PLEASE DO 0 E Del Monte Electric Co. , Inc. A1C0602176 USE THIS _ f COLUMN N M 2.MAILING ADDRESS' (1Nanber Mrd Street.Olt V,ZIPI '.2A., NUMBER a �' P _ .P.O. 4B0x.. 3 _-730.,, Hayward, _CA,,,' - , , . 77,117 415-351-94.11 } CASE NO. S. LOCATION.IF DIFFERENT FROM MAIL ADMSS .'Mumber and SOON.City.ZIP) SA.LOCATION,CODE" .= ' 0 2159 National Avenue, Hayward, CA 94545-3730 _ OWNERSHIP y 4A. NATURE OF BUSINESS e.g.,pahhi"O contractor-wholesab Grocei.aawMIt hdel etc .., < .w _-�.5 -STATE UNEMPLOYMENT INSURANCE ACCT NO....-, - .- E -.Electrical Sub-Contractors Com'_1 T. �_ t 115 3447-6-,,,, r R 48.TYPE OF EMPLOYER PRIVATE. ,STATE `CITY _:COUNTY .?,.DISTRICT OTHER GOVERIII —SPECIFY ,INDUSTRY a.EMPLOYEE NAME `: a, f n. .. .. f."DATE OF BATH (MhFOD Yl� Michael Suf fin OCCUPATION•�, ..�. r �-w k �• .�,- . 11/2 7/54 E a.NOME AODRFsfl (Number and Street,-Gtr ZIP) a aA.,PHONE NUMBER , II 38 �8.-Avenue,.,Pittsburg,-,,CA..-.94565 }t u 415-439-8619 '( P 0.SEX: Male Female tt).;'OCCUPATION(Regular lob tile.not epsdNc.adh i1y d flint N.Mjury) 4, 11.SOCIAL`BECURITI NUMBER X Apprentice Electrician 571-08-5298 O ., ., m•.�.z.- AGE 12. DEPARTMENT M WHICH,REGULARLY EMPLOYED x 12A..DATE;OF HIDE (MA4 DD-YY) r Field(WC7220)-_Richmond, CA n _ _ 10/20/86 . ' '= - 1S-HOURS USUALLY-WORKED,HOURS PER DAY }13A:DAYS,PER.WEEK 139 TOTAL WEEKLY HOURS 19C. i s wages assigned? *ley DALY HOURS PN)cyE 8 r r 5190 7 z; 5 � r4oa.. 14.GROSS WAGES/SALARY PER. HOUR '. DAY. WEEK TWOWEEKS )MONTH. O1HER�9PECIFY ' DAYS PER WEEK r4 3 15. WHERE DID ACCIDENT•OR EXPOSURE.OCCUR?- (Wri bei and Street.City) faA:COUNTY; v, 168 ON EMPLOYER S PREMISES? , In Shop AutoA9wy, 4, Pittsburg,CA _Contra. Costa vEs r no XX`° " 1etaY"OURSta.WHAT-WAS EMPLOYEE DOW WHEN M,IURED? be: ft.ldently`tools.�aaripmeet or"material the employea was`wMp) Riding home from work with his Foreman, Frank Maio. They were dr'Vr WEIKLY WAGE at. approximately . 30., miles_.an._hour,._ Both.wore-:.Seat.. 8elts.�.,_,.__ N if.t1pW(ND 111E ACCIDENT OR EXPOSURE OCCUR?(Please'desalbe hdy the events that ro6iWeid in Mfwy or 000upat(onal disease.Tetl what happened"amd how 11 r peened. Shop Truc c�was rearended. Mike's head struck and broke the back couNrr w ndow from the impact of the crash. His head was cute and he has R stitches for same y TARE OF Bf,IURY r, til.pB IECT Cq'SU88TANCE'TFIAT OIiECTLY M M1E0'EMPL01 EE s.p the madti"s"employea elrnekipaMst o►tiiftk�t atradi him fhb wear 09m . ledor awallosisd the chemical that"&led his ski":In cases d strain,the thing he was Ilflfeg,pughp,etc.. . Back window of the truck a~; 'PART OF BODY R _ w ,._.. ...,. ..._. �: "'`his^`•.t -�3.r�- ,..,�_ : ... ..' ...z= >•r._,y_ 19A.DESCRIBE THE MJImY OR'IL1NE33 e.o•:aA, thele;haeturs, 11 PART OF BODY AFFECTED e.g.:bade,len rertat AOM eye.ate Cut Back of His Head ;;. Head salncE h •. -� :...:� .i`i. S'^r'. `"""!'1 R'T *,F+`(' -.+.. Mil-r+t�*'+•�.-ate .- ' .-'g'n 1 20. NAME AND ADDRESS OF,PHYSKXAN - (No be,and Strost.CMT Z U ..-..._. .,rv... - A.. Kaiser Hospital Emergency, aMartinez, CA ACCIDENT TYPE , ` •�. : Z n z._ T ' 21.IIF HOSPITALIZED NAME AND ADDRESS OF HOSPITAL Mlnnber-aad,.8t►eM Cly,Z�),,,,, s., „ :: .a., ...:;. (, .,,. _ .'. r . a k ra..,•-7-' , ter* Wit•`^„. A.O.S. E 2P.D�1E'OF'vM I)URY oa.(L1NEsB.5TIME �Y a p m 24 Bld enpbyea bse si Mid a+s hN esYa work ifFar tM njnM 4 8 �approx 3:30 I X, 4/5/88 S _- . ,;_._:--�. ,- --. -.^•r , '. >^-c' Y' �....af NO r_,,.,,,.,�YEB--Oats LaN Waked' a`e. OF R(JU 2S.HAS EMPLOYEE RETURNED TO W60K4 ;..(MM-DDc`M 2a b10 EMPLOYEE Dff? EXTENT RY X No ati0 off work 'Yea,date returned x NO } YE8—Date of DeaM s l µ CNED BY Completed by(type or print) Signe e _ Thedo Dete Caro a R. DuFrane Office Mgr. 4/6/88 j i FORM 5020(REV.5) APRIL 1987 FILING OF THIS REPORT IS NOT AN ADMISSION OF LIABILITY State of California . . OSHA Case EMPLOYER'S or File No. • . • '• • • ' • C• IIJ / OF OCCUPATIONAL INJURY OR ILLNESS ©©© o00 000 - nog • • • - • f Y_t ,mea Sub-Contractors • ,. ;..-. �'- P''�"5•,�E�6 .�:,� -� is�y 4.h':>ya,.r�{ ,�,. ��s.n- � y,� -�,. �� -t>rayt t ;r s :`Ps. �'; z�3.7 • • •• Pittsburg, y _ 2 b � . .. M _ ..... ,-Kgs+-f 3•✓ �a S.wTir.H.'.e _(.i ! � �,,`t,� • f ... 1" 9 fi ::i�Fb 4. It""s... .1 .t .Y�,4 Y.t' 1' E�"r1 t "S��',t =� ^'�• .,as.,�w:.>,x .�:.x,_a �">�.�, ?+.r-�'-� ^ --n--;r-r` '•-` � c ' �` s .-� �''.f g, :.1L...-.+1-i:. .... Ax"7r�s-::����4� � ."T� 3et�• �a�'�� L. b-...� n� Yt six 9� ,�-. a.'�s�rr� ,�-1'`9yr,.�rE�� � �".fTa ,..r. _ '".5'h 'e �'�•r+ 115 CFs,"r` �, � � -�� ��'2°i ��'yi��- t{,�•'tom ,. �� ,�� �. = x ,�` .p�-� �: '`� e � Contra -„`,'n���"��s't yrs�}� 4 f_�(�, '�r>'• �'t ,z �'� a �. 3 � ,��;`-...-. "'U-� � ..�. - '�.�. 7't "`��''� `..". .'1e, �'�'r�+ ,� � ► .al�.,,..�:�g 1�� ,� e 'rr='s. � `�=#��..,,s::r�.•rr � $ costa : k+'.••! Yt�.• f�"- { ?> 1• _a.4> T" �`+fh`�S'- J' ,X�G�'''4 .1"ir ';�� � y � y' Driving home from work, with employee rider. MU0000M _ • • • • • '#Fig M f_ �'t"�- � , ,, .. :�. ,.. ,F.x��'�.•�„ �^,aw r--r in front of her, Frank KA11a dyly -en his apprentice to the iob in r. • �. • • _ :• •a . •^` 33.-i3' � •.. Yit� t 1�i•-��- ( ....��, fai. �..e+-:� ''CS'rR{'cr"'�.'.,�5� >�- X�"'� 'w� "i' .�;� ."*s xs• �' 5f�Jam, }ctY t rw" �� '. `-Cv`• xs '.?1 i .. _.r_ - +` ';t", '^ .'.-fir�� <�.`,r t 1 ,,'l ,_rit :�m� ':x4 /.'`" ": ♦: �f .+ �t>:i?r i.. Y f4 a-L -ir ,"'` -va: -.+$�-.i.'�' Y:`. x.•'t`. �' t 7 Y'". 5 s c. d N. ff ._i.t�_i r.,..:, --", 4F'y._. ��'"3..` ,,.Y,. t:• t ..'�. < i. li is rY,'�...> --g•F..+.r• yy. „{C•' Y '. A (`�' �l '3>" -e.�R y'Cn .*�,�i. .,� ws A s t {;f L. �` i a`�'"n `�'YiT+sj V. _:,r �E"' g..,y' ,`� - dtf t t 1♦ • wr , J Y x •- ,�. 4 �.0 .t�.y J {sar•.,A..> .ya ::�`' ,v„va � .. L a tiv .,kr�'y-��>.f��'I' -x 11 `�'s -m @.y....' .. -at �y ' .- a .•`yY, , if a 'ls"-�,. ''.tc �3,. � �`S r +' F}y ,�� ..�" :,S' RN?, � �-+5}� .}•+•o�•�.LF'3J� �r � ,i'-„n;',z. art 3 a L. ..w, a1-sryf ".`,:� 'I:,, ?s r"ti a : tf-s •}.:=y . Y e ti'�. „i>x S` �� �-P •,,!«•' e`�.5. i4, �P �' F e .5 .�"y ��+'K'..ad.�L^s:..:ss'��a��,.......:�'... .+�� •"'a �`�`'”�-i�::il.,.ra`etii���ros.�.e:�°���:s^�(>,: �s-..rf',�ws>.'.`�-.__J2�',:1.+&:+3rl 'r+��8''4� . '"?'Sr,.-�.,_�,`,. �,� _ �K=!O•tell wu=w wqq•j•1 s K:1 t i=] • _ r • - =''u'f�'+$ �`3'�,-� IF DOCTOR'S FIRST REPORT OF OCCUPATIONAL IN REPLY REFER To: INJURY OR ILLNESS Medical Record No._H39--134"2 STATE OF CALIFORNIA Did employee notify employer of this injury? Coverage S 1 Group No. C•�t1! t _ Immediately after first examination,mail original to insurer or self-insured employer. Failure to file a doctor's report is a misdemeanor(Labor Code 641:.5). In addition,in the case of diagnosed or suspected pesticide poisoning,you are required to:Send one copy of this report directly to the Division of Labor Statis tics and Research,P.O.Box 603,-San Francisco,Ca 94101;send one copy to your local health officer,notify your local health officer by telephone within 24 ho,rs. ANi�` hiBROOK INSURANCE P.0. BOX 50040 SAN `JOSE CA 951 _`0 1. EMPLOYER NAME AND ADDRESS DO NOT WRITE IN THIS SPACE LEL i'jOh:�TE ELECTRIC P.O. BOX 3730 HA r WARD CA 04540 3. NATURE OF BUSINESS(e.g.,food manufacturer,building construction,retailer of women's clothes) 4. PATIENT NAME(FIRST NAME,MIDDLE INITIAL, LAST NAME) 5. SEX 6. DATE OF BIRTH FRANCES MAI0 [Male pFemale c,i /t)1 /51 7. ADDRESS: NO.AND STREET CITY ZIP 8. TELEPHONE NUMBER 333E FALLBROOK COURT- PITTS F.URG CA 94565 ( ► -9. OCCUPATION (SPECIFIC JOB TITLE) 10. SOCIAL SECURITY NO. '�.. ELECTRICIAN' FOREMAN_._ 11. INJURED AT: NO.AND STREET CITY ZIP COUNTY !Ok( SITE CCif >r.F —00ETA 12.Date&hour of injury/onset of Illness 13.Date& ho}ur of first exam or 14.Date last worked 15.' u( r your office) -yy tretttmerf�7,�' p iously,treated patient? 04/055%/88 X7'4/[)5/88 ❑ YES n NO 16. HISTORY(History of injury or onset of illness. If occupational illness,specify exposures,chemicals and/or compounds.) FATIENT STATES : WAS REAR—ENDE:Ii WHILE G011-ff., EAST ON HIC"'H141A`r 4--IN COMPANY VEHICLE. INJURED NECK 17. MEDICAL FINDINGS (Use reverse side if more space is required and for remarks,if any.) A. Subjective complaints MOTOR VEHICLE ACCIN.".NT—DRIVER. 1-111' FROM REAR.' _ WEARING SEAT BF-J-(•. FAIN ON NECI'Y . HEADACHES. B. Objective findings TM — O.K . THROAT — CLEAR. CHEST--CLEAR. LEEP TENL)CiN REI 1.2. NO SENSORY LOSS. X-ray and laboratory findings(State if none.) NOh��• C. Diagnosis(if occupational illness,identify etiologic agent.) CERVICAL STRi-SIN 18. Are your findings and diagnosis consistent with history of injury or onset of Illness? If"NO",please explain. VES ❑NO 19. Is there any other current condition that will impede or delay patient's recovery? If"YES",please explain. ❑YES �NO 20. TREATMENT TREATMENT RENDERED Further treatment EXAMINEIJ. CERVICAL COLLAR. required? 0-Office ❑Hospital RX GIVEN. ❑ YES ❑ No out-patient Physical therapy? ❑Hospital in-patient ❑ YES ❑ NO IF IN-PATIENT,GIVE HOSPITAL NAME AND LOCATION DATE ADMITTED ESTIMATED STA' 21. WORK STATUS USUAL WO K? MODIFIED WOR$? If no,give date when you estimate Is patient able to perform usual work?E] YES ❑ NO patlent will be able to return to: PERSONAME A. F'LUTC:HOK SEDEGREE MI.) (OF SIGNATUREhD , CIAIE; TRE•A'TING PHYSICIAN DOCTOR OCCUPATIONAL i1EP1:{ THE PERMANENTE MEDICAL GROUP, INC. Date of report 0'-:/17/88 Address x'.00 MUIR ROAD, MARTINEZ, CAI_.IF . 9�5513 90362 (REV. 3-83) No.,Street City 9 t— 72 i i T 4 _ PACE I or SPET2AL CONDRIONB NUMBER . Nt f RL JTV .,K DISTRICT NUIBER INJURED FELONY It'? O ON rR 'cTT 14 /� Ir KMSfR MITA RUN COLNTY REroRTNo DISTINCT BEAtA, _!'.'.T(1(J( KILLED MISD. 10 COLLISION OCCURRED ON f10. DAY TEAR TIME 0100) "CIC 0 OFFICER I.D. z o --- --------- -------------------------------------•---- F MR. Pp- INFORMATION Q DAY OP WEEK TOW AWAY PHOTOGRAPHS BY: oGoo PEIET/we�e l.�1 of MIEro$T -y CCR ( .'�•+ S M O W T F S ro No ,J O AT BR[RSECTKRI BRYN , STATE"SPI REL OR: 1104V RET/Aft" (,J OF A1/4G o&j PwSS xj. (:•R, To❑No NON[ PARTY OPMR'SUCEN9Ef1U4oER RATE CLAS[ SAItTY YETI VOL MAKt IMODEL/COLOR LICENSENUMSER "TAR /V,/.o z/rP�• `09 [GEAR.lz !!2 - -91 FbAO MAI .1J M1"rC E7?Q207 DRIVER NAME("FIST.MIDDLE.LAS, • • • • • • • • • • • • • • • • • • • • • • • • • • • • • . I prof!. STREET ADDRESS OWNERS NAME ❑ SAME AS OMER "AN D i2if7 r �-'1, is ,4,,�:'z /Q y CcpAm" 000-07N PARKED CITII STATE/EI► OWNERS ADDRESSQ SAM[AS DRIVER v[NICL[ ❑ CO3AlC_o0&6 Cry HIS C7 VICY• SES HAIR I EYES [.14EIGHT WEIGHTMRTHDATE RACE DISPOSITION NOOF VENCLE'ONfORDERS OF: OFFICER to DRIVER D OTNtR CUST VOL ; DAY ; YEAR SA✓A' I 0�/ 13 OTHER NOME PHONE SUSNESS►"CNE /ISO"MECHANICAL DEFECTS: MORE APPARENT REFER TO NARRATIVE L /�S Q�- J O J (y��, (��I�j • y�,7 CMP USE ONLY DESCRIDE VEHICLE DAMAGE $MADE IN DAMAGED AREA INSURANCE CARRIER POUCTNUMSER YENCU lY►t ❑UiK. .0. OMIM011 Co�,WCc //h? LSC'. C Lr /�✓r(J/\r O � i M04 OMAJOR ❑TOTAL OAR.OF 10"S"I"o"'OD"WAT SPEED PCF KC ❑ TRAVEL LAS PUC ❑ 1y L= 5,RI � b;yv ?.Sa✓, :•, CMP ❑ PARTY DRIVERS LICENSE NUMBER STATE I CLASS SAFET/ VEK VOL MAKE/MODEL/COLOR UCENSENMOER STATE Z IouP. DRIVER NAME(FIRST.MIDDLE.LAST) orDEL STREET ADDRESS OWNERS NAME SAME AS DRIVER THAM bee- /,t on1'i' f l X7 :'4L>. PARKED CRT/STATE I ZIP OWNER'S ADDRESS O SAME AS DRIVER Yaw LE D Pi 410. 1510>< 3 0 .sF ywAoG C.4 BICv. SCI NUR EYES NEIGNt WEIGHT IST �IR oAIR YEAR RACE PSroSTION OF VEHICLE ON ORDERS Of: a OFFICER ['�DRIVER O OTHER uD / o % / D�'I�� 4�,J,,y uu OTHER HOME PHONE BUSINESS PHONE PRIOR MECHANICAL DEPICTS: NONE APPARENT REFER TO NARRATIVE ❑ /I /Nd - /Cd J/ ' ',� / 7 "J CMP USE ONLY oESCRISE VEHICLE DAMAGE MADE N DAMAGED AREA INSURANCE CARRIER POUCT NUMBER VEHICLE TVI[ .,,.•rn 2cr-- 1;�yvr. L eC Fo2!• ye -Sd �'aa MOD. Cl mom pTOTAL {a`` PUC ❑ 111 Deft OF ON STREET OR HIGHWAY 'PE ED PCI KC Q l ' 1T1AVEl , C .S CNP E3 PARTY OwVER'S LICENSE NUMBER STATE CUSS SAIET/ VIM,VR MAKE I MODEL/COLOR LICENSE NUMBER STAR EOUIP. 3 DRIVER NAME(FIRST.INDOLE.LAST) • • • 0 SDµ STREET ADDRESS OMMERS NAME SAME AS DRIVER D PARKED CITY/STATE/ZIP OWNERS ADDRESS SANE AS DRIVER VE"CLt D BICv- HK 1 NUR LYES "EIGHT Wr1GHT SIRTHDAR RAC[ pSrof1T0N OF VENCLE ON ORDERS OF: ❑OFFICER ❑DRIVER D OTHER NIST MO. • DAY • YGR 0 i OTH[11 MOM[11049 BUSINESS P" ME POOR MECHANICAL DIFECTS: NONE APPARENT O REFER TO RARRATIY[ t } t ) CHI,USE ONIV DESCRIBE VEHICLE DAMAGE SHADE N DAMAGED AREA INSURANCE CARRIER POUCY NUMBER YLNCIE TVP[ C]11NL [:]Nott 0 MINOR AJ MOO. 0 MOR E]TOTAL DAR.Of ON f,REEI OR NGMWAY 6PfE0 DIC/ KC ❑ TRAVEL EMIT PUC ❑ CMP (3REPARER'S NAME DISPATCH NOTIFIED REVIEWER'S NAME DATE REVIEWED /�A s etll AYES p No *wA , '2 HP 555-Page 1(Rev.7-87)OPI 042 PKI[ D< TIME(,NW I NICK NUMBER OFTiCER►D •. El{ —- am . DAY VRAM V J OwNE S NAM IADORES• Nonr, ���� �' ION co NJ Ovo 0. DAMAGE ►noN or RAMAGE SEATING POSITION OCCUPANTS SAFETY EQUIPMENT . EJECTED FROM VEA. I-DRIVER A-NONE IN VEHICLE L•AIR BAG DEPLOYED0.NOT EJECTED �. 2 TO 6•PASSENGERS B-UNKNOWN M-AIR SAO NOT DEPLOYED DRIVER I:FULLY EJECTED T•STA.WGN.REAR C-LAP BELT USED N•OTHER V-NO 2•PARTIALLY EJECTED •RR OCC.TRK-OR VAND•LAP BELT NOT USED P-NOT REGUIRED W-YES 3-UNKNOWN 123 SHOULDER HARNESS USED 0.OTHER UNKNOWN F-SHOULDER HARNESS HOT USED SHI.QHES.IDbIIQ PASSENGER 456 0-LAP I SHOULDER HARNESS USED O-IN VEHICLE USED X-No H•LAP/SHOULDER HARNESS NOT USED R-IN VEHICLE NOT USED Y-YES 7 J•PASSIVE RESTRAINT USED S-IN VEHICLE USE UNKNOWN K-PASSIVE RESTRAINT NOT USED T-IN VEHICLE IMPROPER USE U-NONE IN VEHICLE ITEMS MARKED BELOW WHICH ARE FOLLOWED BY AN ASTERISK(•)SHOULD BE EXPLAINED N THE NARRATIVE PRIMARY COLLISION FACTOR TRAFFIC CONTROL DEVICESTYPE OF VEHICLE 1 2 3 MOVEMENT PRECEmm-_ LIST NUMBER / OF PARTY AT FAULT 1 2131 • AVC SECTION VIOLATED: tl�YA CONTROLS FUNCTIONING A PASSENGER CAR l STA.WGK COLLISION _ I O7 s V.(I. B CONTROLS NOT FUNCTIONING• B PASSENGER CAR W I TRAILER A STOPPED I B OTHER IMPROPER DRIVING- C CONTROLS OBSCURED C MOTORCYCLE J SCOOTER X B PROCEEDING STRAIGM -UNO CONTROLS PRESENT I FACTOR* D PICKUP OR PANEL TRUCK C RAN OFF ROAD C OTHER THAN DRIVER' TYPE OF COLLISION E PICKUP I PANEL TRK W I TLA D MAKING RIGHT TURN D UNKNOWN' A HEAD-ON F TRUCK OR TRUCK TRACTOR E MAKING LEFT TURN i E FELL ASLEEP* B SIDESWIPE G TRK.I TRK TRACTOR W I TLIL F MAKING U TURN C REAR END H SCHOOL BUS G BACKING WEATHER I MARK I TO 2 ITEMS D BROADSIDE I OTHER BUS H SLOWING I STOPPING A CLEAR E HT OBJECT J EMERGENCY VEHICLE I PASSING OTHER VEHCL B CLOUDY F OVERTURNED K MY.CONST.EOUIPMENT j CHANGING LANES _ C RAINING G VEHICLE I PEDESTRIAN L BICYCLE K PARKING MAWLIVER _ D SNOWING I H OTNER-: MOTHER VEHICLE L ENTERING TRAFFIC E FOG i VISIBILITY FT. MOTOR VEHICLE INVOLVED WITH N PEDESTRIAN M OTHER UNSAFE TURNIN<- F OTHER•: A NON-COLLISION OM D N TANG INTO OPPOSING LA IE IGWIND B PEDESTRIAN O PARKED LIGHTING C OTHER MOTOR VEHICLE P MERGING A DAYLIGHT D MOTOR VEK ON OTHER ROADWAY OTHER ASSOCIATED FACTOR O TRAVELING WRONG WAY B DUSK-DAWN E PARKED MOTOR VEHICLE 1 2 3 (MARK 1 TO 2 ITEMS) R OTHER• CDARK-STREETLIGHTS IN AVcsECTloNvwuTKvt CTrcD D DARK-NO STREET LIGHTS G BICYCLE OTn �� E DARK- STREET LIGHTS NOT H ANIMAL' B VC SECMN YIOLATWt CrrFD FUNCTIONING* OVEt ROADWAY SURFACE SOBRIETY-0RUG I FIXED OBJECT: C VC SECTION VID�ATX t CrTEoo 1 2 3 K I TO 2 L A DRY Dyn8 WET ( I To 2 ITEMS 1 C SNOWY-ICY J OTHER OBJECT: D ONO A HAD NOT BEEN DRINKING E VISION OesCUREAENi: B MD-UNDER INFLUENCE D SLIPPERY(MUDDY,OILY,ETC.) C NBD-MDT UNDER NFLU F INATTENTION• ROADWAY CONDITIONS G STOP M GO TRAFFIC D►8D-IMPAIRMENT UNK.- (MAIN(I TO 2 ITEMS) PEDESTRIAMS ACTON E TINDER DRUG NFLU.• =, A PEDESTRIAN INVOLVED H ENTERING J LEAVING MMP F IMPAIRMENT-PHYSICAL' A HOLES DEEP RUTS- CROSSING IN CROSSWALK I PREVIOUS COLLISION G IMPAIRMENT NOT KNOWN B LOOSE MATERIAL ON RDWY.- B AT INTERSECTION J UNFAMILIAR WITH ROAD H NOT APPLICABLE C OBSTRUCTION ON ROADWAY- I(DEFECTIVE VEK EQUIP.: crrEo CROSSING IN -NOT D. I SLEEPY/FATIGUED D CONSTRUCTION•REPAIR ZONE C'AT INTERSECTION ONO SPECIAL INFORMATION E REDUCED ROADWAY WIDTH D CROSSING-NOT IN CROSSWALK L UNINVOLVED VEHICLE A FNZARDOUS MATERIAL F FLOODED' E IN ROAD-INCLUDES SHOULDER M OTHER G OTHER-. F NOT IN ROAD N NONE APPARENT HMO UNUSUAL CONDITIONS G APPROACH I LEAVING SCHOOL BUS O RUNAWAY VEHICLE EKEWN "SCILLANEOUS rN0 CAK RORTM I VAlb, v 1 E-a _ _ _ _ -- rw• - 14-Ll PAGE OAT(OF COLLISIONTME(2400) NCI:NUMBER OFFICER 1.0. FAMIER -� EXTENT OF INJURY("X" ONE) INJURED WAS("X" PART„ WAY /A" ONE) WITNESS PASSENGER AOl as (J[_T[D ONLY ONLY FATAL SEVERE OTHER VmwLE COMPLAINT "UMBER POS. two. INJURY lwtw PULPIT OF FMN D"m PASL FED. BICVCUST OTHER 0* 0 3� 0 0 0 0 0 0 0 C, NAME I O.0./.I ADORES B TELEPHONE er leec, (INJURED ONLY)TRANSPORT90 BY: T EN TO: �^ W,L� SLS- yWitJ DoGTvr DESCRIBE INJURIES C.O,p T NE'Ck /o ❑VICTIM OF VIOLENT CRIME NOTIFIED _-- ❑# ❑ 3M ❑ ❑ ❑ ❑ ❑ ❑ ❑ Da 314 L-o NAME I D.O.L I ADDRESS TELEPHONE /AIcH,gEZ SUFrfAl 3E to S AY, , P,rr�-B✓.eU �.� y3P- E P ___; (INJURED ONLY)TRANSPORTED BY: TAKEN TO: E /Qwt�L, A b1 Q.i 1q,1V 1 /9/ f✓vSP,;n'G Ji DESCRIBE INJURIES 'r ACK s7F, FAJL 0 0,P NFC VICTIM Of VIOLENT CRIME NOTIFIED �" 1 ❑ o F_ ❑ ❑ ❑ D 1EII0101 ❑ 101 NAME 10.0.9.I ADDRESS TELEPHONE 44) R,G FNJUREO ONLY)TRANSPORTED BY: TAKEN TO: N DESCRIBE INJURIES VICTIM OF VIOLENT CRIME NOTIFIED ❑# ❑ 01 ❑ I ❑ ❑ ❑ ❑ ❑ ❑ lol NAME I O.O.B.I ADDRESS TELEPHONE ONJURED ONLY)TRANSPORTED BY: TAKEN TO: DESCRIBE INJURIES ❑ VICTIM OF VIOLENT CRIME NOTTAEO D# ❑ o . ❑ ❑ I o iololol o loi NAME I 0.0.1.I AOORESS TELEPHONE (NJVREO ONLY)TRANSPORTED BY: TAKEN TO: DESCRIBE INJURIES VICTIM Of VIOLENT CRIME NOTIFIED Olt ❑ o ❑ ❑ ❑ ❑ ❑ ❑ ❑ 101 NAME I O.O.L f ADDRBBI TELEPHONE FNJURED ONLY)TRANSPORTED OV: TAKEN TO: I OESCRBE NJVRIES VICTIM Of VIOLENT CRIME NOTIR[D ►REPAA 'S NAME I.O.NUMBER M0. DAY YEAR REVIEWERS NAME MO. DAY YES CHP 555-Page 3(Rev.7.87)OPI 042 . 87 43537 �L.,rr.•.ow I1-+1E 11499) l.c,c wu.EEw lo."c..r,e, NUMErw ' ALL MEASUREMENTS ARE APPROXIMATE AND NOT TO SCALE UNLESS STATED (SCALE. I«DIC A Tr ' «DwTN t w)t,cot-J 1 1 , 1 i 1 i i If 1 ow..v« Ev 1.0.NVMecw Mo, e�T vw, �� «wrvirwrw's �me CHP 555—Page 4 (Rev II.85)OPI 042 PAGE CATEOF'COWSION ME(24W NCCNUMBER OFFCERI.D. NUMBER -� •)r ONE , `II'ONE TTPESUVPLEMENTALCr A►RkAIIA) NARRATryE OOUJAION IIPOIIF M LIPOATE FATAL Q NRA RUN UPDATE 0 SUPPLEMENTAL CHER: ❑ NAZAADMIuArepil" NONOOLow Q o"tat CITYICOUNTY/JUOCA1,0137RICT REPORTING DDT RCT/BEAT CITATIONNUMBER LOCATION I SUBJECT STATE NIOIMIAY RELIT E 1 � YES Nn 1. F7e--r.7 _ 2. 1 RG EI Jr"g F c oP xo,J A c/o - v xelyat-J O t AJL r RT' _ 3. /G c ,URs / aPE'S -OnND E E 9 Q` Sc t S t/LL E ti 4. AIPIR/eWG 41,",I 6 7. S ,� 8. 618 S.R• '9 ?-ZAAu6 Aq eD 4,5,0HALT FtiL-10 R T1c ;OR6 F"OIAIT- 10. C GJt ' o::✓ mss 1. �r'R���P E N0 v G f 1,4 11. t3o n „y 'VES '(i rieE`r-C' 1� T AP1e, t 771F 12. 177AC tr TME ^ 4, S 1'6t o RV S -r- 13. t ).S GO onJ o ) vc M ,,gFPiC- &P eP4-1-oXJ o0v'9SS 14. 15. 16. V E' 1 S 17. -/ e,� Cc&qrcb A -0 t -)-;VG C olygpce 18. C/N T SUST- /NE O D t4 o T 19. D. 20. - \ t.' L, L l uC � Ct/V E/q Ptil&t-,:� IN ) e C � C/21. � 7/11,,34C c 7 22. <Cq",z qtki;))pore, f'. kcqic -.vD ``t CASs e-,),45 23. 24 25. i=JHysie�3� EV�oF�vc�� 26. A 11V 6Z.C- sC'T o F z-. l-W eW k 1/6E�'I� / cP4/i 1 CC.y 6 / 27. CA^.lS ! i9 V .L' C l✓1 OG.P w 6C6 28. P9vC4 i e,-r -C CclCi13 LOP7- eY Y-/ -F 29. L /9f=7rR 1AAP19CT- 30. S a•9.L,14`96E Ts 11WOLV60 ChlJCGFS. 31. 32. PAEPAREASNAME ID.MUMBE MONTH/DAY/nAA REVIEWERSNAM MONTH/ AY/YEAR C P 556(Rev.7.67)OPI 042 urp.ran.s�elrw,uegw.s 87 45311 DATE OF COWSION - liME(2W MCICMUMSER OFFCER LD. MUYSEq 'Jr ONE 'JC ONE TYPE SUPPLEMENIAL('A•APPI JCAKAE ..� MARRATTW Cal IJSION REPORT D MA UPDATE FATAL W A HUM UPDATE SUPPLEMENTAL a CTNERQ IMZARIN"WATERVU SCIIOOLSUS OTMER CITY ICOUNTYMUDICALDISTRICT REPORTING DISTRICT/SEAT 07ATIONNUMSER LOCATODN/SUBJECT STATE HIGHWAY RELA7 E) t • YES rl No 2. De, (UoGosooM) -rJ-,?q-,f57D /I1 svlE E o S (;/B 3. ( 4,0^1 !� GF7 E' Jq t" S'O •..YZ5- 2M, /G aA,9 mo!!2 4. 1tAoeWoQ1LY Ati -S G g a �v )= 5. MOVC6iS 4JAIG 7ZO of MAA LAOS N Lo 6. E 1-4r2c S !✓('Ev a9N LY 7. d l v cJTyAl 8. NE 664VXg 1� A-r- - F 10,101v '-i-" RE14!L9 9. CLCSMJ ons V-eZ L /-� S i of G/? i a .9✓O/D 'TXrf U-T 'J 10. NE B kcz AR c` 4)7- P1 VE / cs it'F1926�/ e� ✓•e7. 11. 12. ZR. *a Al o) IPJ gvasmAoocq w7 NE c gs v5G1,w VB A/ 13. TAr' ' � LA/ rr jogaPAOX S'O P//. IAJ ✓X . /ti S 14. SUED cY -KE21 NFO t3Y 15. i 16. �1/ c�✓S S/o S 17. ¢/ ( oQoo/Vl (,tjQs t S.,p y �7C�i9✓E' c/n/ v7VG W GGo6j 18. 6 Aaq 0 C_'. NIS- 6-<s 5 !_t-or„J/tet/ L47,CdC Z;WeK 4J IG 6,1,-Q4oc.✓r 2o. lo4z SLa,✓,,,/' SA An/ o i'✓w ' /�� T"E' ^e .v CST- To fI/S 21. A^ �,�" O AA--- SEr' 777.4? / L!r.vG C:'j 23. r;: T• a:�-' -/ Fi`*�i'��r'.Jt� �'' i�� 1� /` N� / Al < 24, 25. C- 26. 27. 28. �'.. :�G /; .,. / _✓ ,.. /�i�'-:X Goo -F i/�.F WC 7" dec4040Y 29. CL 6 C O W/4L0W ooAss ' /� alQF. 6' 1`oclTf 0W)' D 30. F F✓8 SSR_ 'S/ 31. G / A CP C197"cv 0 y Y.lICAC E'✓i a C4,00C c 32. PREPARER'SNAME1. .MVMBE MORTMIDAYIYEAR REVIEWERSNAME MONIMIDAYIYEAR �O(,QLLJ)V9617 C,,� CHP 556(Rev.7.87)OPI 042 w'w^'"�•�"�» av 87 4531: NARKATWEISUPPLE ENTAL -- pAGE 7 ATE OF COWSION " TAE(1+uB1 NGICNUMBER OFFICERLD. MU&IMER i s-i a 9 o xONE X oNE TYPESU"%VAENTftCX'&"%CAI" NARIO►Tw OOUJSJ NFEPOIRQ MIR I a Mm ,fTS11UNUmmm SUINUMEMAL ❑ O'TMER Q MAZAPOMMILTOWI SCNOOLVA OTHER CITY I COUNTY IJUDCALDISTRICT REPORTING OISTgICT MEAT CITATIONNUMBER LOCATION/SUBJECT STATE MONWAYRELATED rl YES rl NO 2. DSP. / t,V C09vsC.� IVF Go a/ %W V Al 07-- ' J 4. ✓)C7G.Al7Q v 20:- 6. XC r=6 C vAAc N4Q/477r0N.r oNE, 7. 8. 9. 10. 11. - 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24 25. 26. 27. 28. 29. 30. 31. 32. PREPARERS NAME IO.MU BER MONTMIDMP&AA EVI ERSNA MONTMIDAYIYEAR G C,Oil v CHP 556(Rev.7-87)OPI 042 u«a.�.II.•ewI.IIMIe�Iww 87 45312 Auto Accident April 5, 1988 (Tuesday) 3 : 30-4 :00 P.M. Willow Pass Road(Highway 4) Pittsburg, CA Driver Maio, Frank and passenger, Mike Suffin, were on way home from jobsite when rearended. Bothwere hurt and taken to Kaiser Martinez, CA Mike Suffin was taken by ambulance and Frank drove himself. Mike is in a Neckbrace from whiplash. Mike has stitches in back of his head. Both were wearing seatbelts and Mike 's head from the impact hit the back window and broke window cutting his scalp. Both were released to their homes - requested by attending physician not to go back to work the rest of this week. Rearender was Pat Hagobook- Contra Costa County vehicles, Lic.# E792807 CHP Report Was Files . Accident was reported to Dennis Bowen, Walnut Creek Office Of DME, April 6, 1988 A.M. I called Sheila, Claims Dept. of Gallagher-Bobba, of Dublin, CA She suggested we also file a' `•Torker's Comp Claim.DEL moNTE ELECTRIC CO., 1K P. 0. BOX 3130 HAYWARD, CA 94540 CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT Aufzu s t 9 198 and Board Action. All Section references are to ) The copy of this document mailed to you-is your notice o California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: Unspecified Section 913 and 915.4. Please note all "Warm-n,qg1l9 CuLi ls-.I CLAIMANT: CHRISTINE M. WRAY 310 Westline Drive JUL 12 1989 ATTORNEY: Alameda, CA 94501 Martirle�:., CFS Date received ADDRESS: BY DELIVERY TO CLERK ON July 11 , 1988 Risk Manage. BY MAIL POSTMARKED: 'July 7 , 1988 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. PpHHI:L BATCHELOR, Clerk DATED: July 12, 1988 eputy L. Hall II. FROM: County Counsel TO: Clerk of the Board of Supervisors (tom) This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: -1BY: Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator '(2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present (X ) This Claim is rejected in full. (��) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. AUG 9 198e Dated: PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: AUG 0 1988 BY: PHIL BATCHELOR by ty Clerk CC: County Counsel County Administrator r June 21 , 1988 Gerald T. Mitosinka RECEIVEDAssistant Sheriff 651 Pine Street Martinez , CA 94553 �� ' 111988 Joe Tonda CLER P#q AT Risk Management Division By 'r 4L R 6th Floor Rs 651 Pine Street Puty Martinez , CA 94553 Dear Sirs : At the suggestion of John Dashner , Orinda Police Chief , I am enclosing bills for charges incurred by me for doctors visits and X-rays for injuries to my arm while receiving a blood test at your facility. I was given a blood test on March 31 , 1988 at the Martinez Detention Facility and as a result of this my arm became swollen and discolored and I became unable to straighten my arm. After a week in which it became worse and I was unable to work , I went to see my physican. Dr . Howard Conklin in Orinda advised X-rays and to see him again. It would be greatly appreciated if these charges could be reimbursed. I am enclosing copies of the bills and a picture of my arm. Thank you. Sincerly, Christine Wray 310 Westline Drive Alameda, Ca . Attachments -r`8� »a a MVYrARLJ L. t.k "M L.m, m.✓.. 11,11- *116.LIC.a A-1e1-aa PMYSICIAN A SURQUON ❑MEDICARE I.R.IL 0 94-2'117'1114 3 SANTA MARIA WAY,P.O. BOX $14 ❑OTNtR 1116111L,01gs!}es-Aau ORINDA,CALIFORNIA 94363 TELEPHONE: (415) 254-5544 DATE OF SERVICE PATIENT✓!INSURED(SUBSCRIBER INFORMATION) DATIENT'S N E(First name.middle einsl - DOB INSURED'S NAME(First name,middle Initim.last name) JVA ArIENT'S ADDRESS(Street.City,n 40de) SEX INSURED'S EMPLOYER INSURANCE COMPANY'S ❑ ❑ NAME MF Relationship insured's I.D.No.or LMdinre Nd insured's Group No. (or Group Name) DATE OF ONSET OF ILLNESS OTHER INS.) O NO ❑YES INSURED'S ADDRESS(Street,city,state.ZIPcode) IDENTIFY: ASSIGNMENT: I HEREBY AUTHORIZE MY INSURANCE BENEFITS TO BE PAID TO THE RELEASE: I HEREBY AUTHORIZE THE UNDERSIGNED PHY- UNDERSIGNED PHYSICIAN. I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE SICIAN TO FURNISH INFO. TO MY INSURANCE CARRIERS FOR ANY AMOUNT NOT PAID BY THE INSURANCE COMPANY. CONCERNING THIS ILLNESS OR ACCIDENT. SIGNED I SIGNED (insured Patient,or Parent.If Minor) (insured Patient, or Parent,11 Minor) 3LACE OF SERVICE: ❑OFFICE ❑ Peralta Hospital ❑ Other ADMIT RADIOLOGY 450 30th Street REFERRAL Oakland,CA 94609 DISCHARGE 3ESCRIPTION CPT FEE DESCRIPTION CPT FEE DESCRIPTION CPT FEE I. OFFICE VISITS MEW/EST r,. INJECTIONS/IMMUNIZATIONS CONT. 7. SURGERYISURGICAL ASSIST ❑.,}Imltod 90010 90050 ❑ Therapeutic 90782 ❑ Biopsy of Skin (1) 11100 C�►'Intorm•d. 90015 9� 0060 ❑ TS Tine Test 86585 as add.X-®_ 11101 xtonded 9001 5. OFFICE PROCEDURES ❑ Comp Ex/Px 90020 90080 Cl Cautery of Skin(1) 17100 ❑ Ear Irrigation 69210 ❑ Cautery (2) 17101 ?. HOSPITAL VISITS ❑ EKG 93000 ❑ Caut•►y of Wart 17110 ❑ Initial,compr 90220 ❑ Trigger Point Ini. 20550 ❑ Cryosurgery ❑ Intermed. 90215 90260 ❑ Inter Joint/Bursa 20605 ❑ D d C '$4120 ❑ ExtenOed/Dlsch 90270 ❑ Major Joint/Bursa 20610 ❑ Excision,Son. 914_ ❑ Emer. Room 99064 0 Sigmoidoscooy 45300 Mal 116_ I. EXTENDED CARE FACILITY ❑ ❑ Frn edy Rmvl 10120 ❑ Initial ECF 90315 ❑ 16 O 11100 ❑ Intermed. ECF,Acute 90360 6. LABORATORY ❑ Repair Laceration ❑ Intermed ECF,Chr. 90640 ❑ Blood Sugar 82947 ❑ Supplies 99070 ❑ Gram Stain 87205 Cl 1. INJECTIONS/IMMUNIZATIONS ❑ Hemoglobin 85018 ❑ ,❑ Allergy 95120 C1 mono 86300 Antibiotic: 90788 ❑ t o ❑ Occult Blood 82270 '❑❑ Vit.812 J3420 90782 ❑ Influenza 90724 C3 Throat Culture 87060- 8. OTHER MMR 90707 13 Urinalysis,comb 81000 71Pneumonia 90732 El venipuncture 36415 C3❑ Tetanus 90703 13 wet Mount 87210 AAGNOSIS: COPD 496 Hemorr.thromb. 455.7 Per. Vasc. ins. 443.9 Abdom Pain 789.0 Colitis 558.9 Hepatitis: Chronic 571.40 Pharyngitis 462 Abrasion CHF 428.0 Hepatitis,acute 570 Phlebitis 451._ Allergy 477.9 Conjunctivitis 372.30 Hernia Anemia: Iron Def. 280.0 CVA 436 Herpes zoster 053.` Pneu. Unspec. 486 Porn. 281.0 CV Insuff. 437.9 Hype rcholesterolemia 272.0 Prostatitis 601.0 Und•f. 285.9 Contusion 924.9 Hypertension,vasc 401.1 Sebsc.cyst 706.2 Angina Pectoris 413.9 Cystitis 595.9 Hyperthyroid 242.9 Sinusitis 473.9 Anxiety,Stress 308.0 Cystic Mastitis 610.1 Hypertri•demia 272.1 Sprain Appendicitis 540.9 Dermatitis: Contact 692.9 Hypothyrold 244.9 Arrythmia 427. Fungal 111.9 Influenza 487.1 Strop Throat 034.0 Backache NOS 724 Diarrhea 558.9 Labyrinthitis 386.30 Syncope 780.2 01N0,post mnpsl. 627.1 Diabetes Mellltus 250._ Laryngitis 464.0 Tend.synovitis 727._ Blood In stools 576.1 Discogenic dls. 722._ Mit.valve oral. 394.9 Thyroid nodule 241.0 frochl•ctasis 494 Olverticulitis 562.11 M.I.: Acute 410 Tonsillitis 463 B►nch.pneu. 485 Edema NOS 782.3 Old 412 Bronchitis,Inf, 466.0 Emphysema 692.8 Myositis 729.1 Urethritis 597.80 Bursitis 727.3 Gastritis 535.5 Neuritis 729.2 Urticaria 708.9 aanc•r Gastro•nte►Itis 558.9 Obesity 278.0 Vaginitis unsp. 616.10 274.9 harp.Tun.Synd. 354.0 Goutho: vasc. 784.0 Osteoarthritis 715.9 Monllfa 112.1 C•Ilulitls 682.9 Heart block 426.9 Osteoporosis 733.00 Trich. 131.01 Carob. Isch.Trans. 435.9 Heart dls.Isch. 414.9 Otitis Externa 380.10 Vertigo NOS 780.4 Cerumen Imp. 380.4 Hyp•rten. 402.90 Otitis Media 382.9 Chest pain musc. 786.50 Valvular 424.1 Peptic Ulcer 533.9 Viral Inf unsp. 079.9 Sate O lu RVS No.Mod Tay's ft DIA OSIS: (If Not t Listed Above) TODAYI FEE PATIENT INSTRUCTIONS, DOCTOR ATURE/DATE COMPLETIX SHADED PORTION OF T041S FORM AND SIGN. MAIL THIS FORM DIRECTLY TO YOUR INSURANCE COMPANY. V0*##2 i /-/-----' ATTACH YOUR INSURANCIt COMPANY FORM IF VOU WISSL CAL-LIC.1 A•1Sa-aa PHYSICIAN at SURGEON ❑MEDICARE I.R.sr.0 9iI 4-2217314 11 SANTA MARIA WAY,P.O. SOX $16 13 OTHER LS 0`osa-te ass• ORINDA,CALIFORNIA 94563 TELEPHONE: (415) 254-5544 DATE OFSERVICE PATIENT R INSURED(SUBSCRIBER INFORMATION) ell PATIENT'S N ETF1 Itnartse.nelOdM ilalwej: 008 INSUREDS NAME(First name.middle Initial,Inst name) PATIENT'S ADDRESS(Street.cky. ) SEX INSURED'S EMPLOYER NE INSURANCE COMPANY'S - M❑ F❑ RoUtlonshlp Insured Is 1.0.No.or Modiea►e No Insured-s Group No. (or Group Name) GATE OF ONSET OF ILLNESS OTHER INS.? O NO O YES INSURED-S ADDRESS(Street,city,state,ZIP code) IDENTIFY.- ASSIGNMENT: DENTIFY:ASSIGNMENT: I HEREBY AUTHORIZE MY INSURANCE BENEFITS TO BE PAID TO THE RELEASE:I HEREBY AUTHORIZE THE UNDERSIGNED PHY. UNOERSIGNED PHYSICIAN. 1 UNDERSTAND THAT i AM FINANCIALLY RESPONSIBLE SICIAN TO FURNISH INFO. TO MY INSURANCE CARRIERS FOR ANY AMOUNT NOT PAID BY THE INSURANCE COMPANY. CONCERNING THIS ILLNESS OR ACCIDENT. SIGNED SIGNED (Insured Patient. or Parent, If Minor) (Insured Patient, or Parent,If Minor) PLACE OF SERVICE: ❑OFFICE ❑ Peralta Hospital ❑ Other ADMIT RADIOLOGY 450 30th Street REFERRAL Oakland,CA 94609 DISCHARGE DESCRIPTION CPT FEE DESCRIPTION CPT FEE DESCRIPTION CPT FEE 1. OFFICE VISITS NEW/EST INJECTIONS/IMMUNIZATIONS CONT, 7. SURGERY/SURGICAL ASSIST ❑ Llmlted 90010 90050 ❑ Therapeutic 90782 ❑ Blopsy of Skin (1) 11100 ❑ Intermed. 90015 90060 T� ❑ TB Tine Test 86585 ea add. X 11101 ❑ Extended 90017 90070 5. OFFICE PROCEDURES ❑ Comp Ex/Px 90020 90080 ❑ Cautery of Skin(1) 17100 ❑ Ear Irrigation 69210 ❑ Cautery (2) 17101 2. HOSPITAL VISITS ❑ EKG 93000 ❑ Cautery of wart 17110 ❑ Initial,comer 90220 ❑ Trigger Point Inj. 20550 ❑ Cryosurgery ❑ Intermed. 90215 90260 ❑ inter Joint/Bursa 20605 ❑ D 6 C $6120 ❑ Extended/Ditch 90270 ❑ Major Joint/Bursa 20610 ❑ Excision,Ben. 114_ ❑ Hmer. Room 99064 ❑ S19moldosco0y 45300 Mal. 116_ ❑ 3. EXTENDED CARE FACILITY ❑ ❑ Frn edy Bmvl 10120 ❑ Initial ECF 90315 Cl 1 i O 11100 ❑ Intermed.ECF,Acute 90360 6. LABORATORY ❑ Repair Laceration ❑ Intermed ECF,Chr. 90640 ❑ Blood Sugar 82947 ❑ Supplies 99070 ❑ Gram Stain 87205 ❑ 4. INJECTIONS/IMMUNIZATIONS ❑ Hemoglobin 85018 ❑ ❑ Allergy 95120 ❑ Mono 86300 ❑ ❑ Antibiotic: 90788 ❑ Occult Blood 82270 ❑ Vit.812 J3420 90782 ❑ Throat Culture 87060 ❑ Influenza 90724 8. OTHER 11 MMR 90707 ❑ Urinalysis,comp 81000 ❑ ❑ Pneumonia 90732, ❑ Venipuncture 36415 ❑ ❑ Tetanus 90703 ❑ wet Mount 87210 DIAGNOSIS: COPD 496 Hemorr. thromb. 455.7 Per. Vase. Ins. 443.9 Abdom Pain 789.0 Colitis 558.9 Hepatitis: Chronic 571.40 Pharyngitis 462 Abrasion CHF 428.0 Hepatitis,acute 570 Phlebitis 451._ Allergy 477.9 Conjunctivitis 372.30 Hernia Anemia: Iron Oaf. 280.0 CVA 436 Herpes zoster 053._ Pneu.Unspec. 486 Porn. 281.0 CV Insuff. 437.9 Hypercholesterolemia 272.0 Prostatitis 601.0 Undef. 285.9 Contusion 924.9 Hypertension,vast 401.1 Sebac.cyst 706.2 Angina Pectoris 413.9 Cystitis 595.9 Hyperthyroid 242.9 Sinusitis 473.9 Anxiety,Stress 308.0 Cystic Mastitis 610.1 Hypertri•demia 272.1 Sprain Appendicitis 540.9 Dermatitis: Contact 692.9 Hypothyroid 244.9 Arrythmla 427._ Fungal 111.9 Influenza 487,1 Strep Throat 034,0 Backache NOS 724 Diarrhea 558.9 Labyrinthitis 386.30 Syncope 780.2 Bleed.post mnpsi. 627.1 Diabetes Mellitus 250._ Laryngitis 464.0 Tend.synovitis 727._ Blood In stools 578.1 Dlsco9enic dis. 722._ Mit.valve pro). 394.9 Thyroid nodule 241.0 Brochlactasis 494 Olverticulitls 561.11 M.I.: Acute 410 Brnch.pneu. 485 Edema NOS 782.3 Old 412 Tonsillitis 463 Bronchitis,Inf. 466.0 Emphysema 492.8 Myositis 729.1 Urethritis 597.80 Bursitis 727,3 Gastritis 535.5 Neuritis 729.2 Urticaria 708.9 CancerOIHISItY 278.0 Gastroenteritis 558.9 Vaginitis unsp. 616.10 Gout 274.9 Corp.Tun.Synd. 354.0 Headache: VasC. 784.0 Osteoarthritis 715.9 Monilia 11.1 Cellulitis 662.9 Heart block 426.9 Osteoporosis 733.00 Trlch. 1.01 Carob.Itch.Trans. 435.9 Heart Olt.Itch. 414.9 DIMS Externa 380.10 Vertigo NOS 180.4 Cerumen Imp. 380.4 Hyperten. 402.90 Ot(tls Media 382.9 Chest pain muse. 786.50 Valvular 424.1 Peptic Ulcer 533.9 Viral Inf unsp,. 079.9 e o Ice VS No.Mod T S)S• 's OIAGNO : (If Npt Listed Above) �. v �� FEE AY'S ai� PATIENT INSTRUCTIONS DOCTOR'S SIGN A•TU RE/OATE COMPLETE SHADED PORTION OF THISRJv AND SIGH MAIL THIS FORM DMIECTt�C "A,, �, YOUR INSURANCE COMPANY. YOU MAr ATTACH YOUR INWRANCE COMPANY'! ��- FORM If You WISH. a TOrt H. PIATT, M. D. . INC. PHONE 415 254-5714 12 CAMINO ENCINAS #12 ORINDA, CA 94563 j IRS NO 94-2457338 I STATEMENT RETURN UPPER PORTION OF STATEMENT WITH PAYMENT DONNA K. WRAY 823 TREEHAVEN COURT 1 PA—EN'S NAME PLEASANT HILL, CA. 94523 CHRISTINE M. WRAY yLCSING DA'E PAGE NO NEW BALANCE j4/7/88 1 $55.00 NOTE: Charges and payments not appearing'on this statement will appear on next SHOW AMOUNT s month's statement. PAID HERE CHARGES APPEARING ON THIS STATEMENT ARE NOT INCLUDED ON ANY HOSPITAL BILL OR STATEMENT DATEEXPLANATION• PR,; ',•IAG DEBITS 415788 1 ELBOW 73080 719. 0 55. 00 PREVIOUS BALANCE 0. 00 PMTS. R C' D AFTER 4/7/88 WILL APPEAR ON NEXTMONTH' S STMT. I I I j I � I j I j • . • . • . • 4/7/88 0.00 0. 00 0.001L 55.00 PLEASE PAY THIS AMOUNT =55. 00 CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA f Clair, Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT August 9 , 1988 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $125 . 00 Section 913 and 915.4. Please note all "W +cpOid 'Y Counsel CLAIMAN': LARRY B. GRAGG 137 West Chanslor JUL 111988 ATTORNEY: Richmond, CA 94801 Date received Martinez, CA 94553 ADDRESS: BY DELIVERY TO CLERK ON July 11 , 1988 hand del . BY MAIL POSTMARKED: no envelope I. FROM: Clerk of the Board of SuYerviscrs T0: County Counsel Attached is a copy of the above-noted claim. ' July 11, 1988 ppHHIL BATCHELOR, Clerk DATED: BY: Deputy L. Hall 11. FROM: County Counsel TO: Clerk of the Board of Supervisors (D� ) This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.6). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: r' I BY: `� f_ —� Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Superviscrs present (u) This Claim is rejected in full . (/ \) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. AUG 9 1996 Dated: PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING 1 declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: AUG 10 1988 BY: PHIL BATCHELOR byWitz/__4�6puty Clerk CC: County Counsel County Administrator �e^LAIM TO: BOARD OF SUPERVISORS OF CONTRA CO§WurRWY;W�appllaatlan to. Instructions to Claimant Clerk of the Board P.O.Box 911 A. Claims relating to causes of action for death or to n 1nGuiry�to�533 person or to personal property or growing crops must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of_ the cause of action. . (Sec. 911. 2, Govt. Code) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106 , County Administration Building, 651 Pine Street, Martinez , California 94553. C. If claim is against a district governed by the Board of Supervisors , rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. .- E. ntity. -E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at end of this form. RE: Claim by ) Resery g stamps ia rust $ � Gg4 RECEIVED �7 w • C1�wb to�. ��e,l,,.�,,,..�e1 C�► (6 J U L 1.11988. Against the COUNTY OF CONTRA COSTA) or DISTRICT) 6LC' 5NAR LO eP S (Fill in name) ) 9y De . The undersigned claimant hereby makes claim against th C unty of Contra Costa or the above-named District in the sum of $ Y43 and in support of this claim represents as follows : t 1 .2 ( , o 0 ------------------------------------------------------------------------ 1. When did the damage or injury occur? (Give exact date and hour) 7/b/88 ---------------------------------- --------------------y----------Y----- 2. Where did the damage or injury occur? (Include cit and count ) ------------"-- ---------- ---------------------------------------- 3. How did the damage or injury occur? (Give full details , use extra sheets if required) m C`b` t w£Q e log.-1 og;.-1 ----------------------------- -- ------------------------------------ - --- 4 . What particular act or omissi-on on the part of county or district officers , servants or employees caused the injury or damage? Y (over) -.....r..a.:.-..w.. .. ...._ -:u,.::...,.-.wSi-«...-a.t:::.: _ ..,.,..s._.. -.,gip: <..._,..__ .. .;v:....-.. . .. ._. .....w�v.•..y...ai:.-e.�wL�:1;..+aw._.:....a.4s..�C........v:�:ra..A.a..ira'F'::,a..<'9 5..;.f. What. ar.e.:the,,.names of county or district officers, servanfs..or :employees:: causing the damage or injury? ---- Coo 14)T�2,A► GoS''�. 6'r'1��VT�o N �r t.���Z-�! --------------------------------------------- ------------- 6. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage) ------------------------------------------------------------------------- 7. How was the amount claimed above computed? (Include the estimated amount of any prospective -injury or damage. ) ------------------------------------------------------------------------- 8. Names and addresses of witnesses , doctors and hospitals. --------------------------------- 9 . List"the expenditures you made on account of this accident or injury: ITEM AMOUNT ��. Govt. Code Sec. 910.2 provides : "The claim signed by the claiman SEND NOTICES TO: (Attorney) or by some person on his behalf. Name and Address of Attorney L A QtLI Cp QA C aimant' s ignature 3 7 LLY CL% N s 1 vim. Q.. Address 9q 801 Telephone No. Telephone No. a33-6q/sq NOTICE Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, town, city district, ward or village board or officer, authorized to allow or pay the same if genuine , any false or fraudulent claim, bill , account , voucher or writing, is guilty of a felony. " FACILITY , �._.. ETENTIO `: ... CONTRA COSTA Q ,z IN EPT . .� i. e.. CLojtj 1r3787AADF 5¢. X6!_11.188 {, yAc .FACILITY i" 'DATE: T —TIME. —12305. GRA66 LARRY BARNETT _ �_,__-�� .z: ' - - .: •.'" R. _... . 015137J .: BOONG NBR: :Y88 ?.. SHIRT/BLOUSE H ES/BOOTS AT/JACnET ESS;' '_ HIRT/RSE V S ORTS/PANTI BRA AT/PU OCKSJNYIONS _< DRESS - SWEATER/SWT. SHIRT - OTHER - .. .. 4 �rq.n�'�..•..y t " Vii.... . ' _ - `.� 'fit;•`'t+'=.: .« - '' .,�.� T}'.' _ - X INMATE 4GNATURE 1,:r .a .`3i yVED ALL OF • " I HAVE RECE ,• r . DATE CLOTFiiNG pIpAATESIGNATURE CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION ' tr,e Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT August 9 , 1988 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $2 , 315 . 89 Section 913 and 915.4. Please note all "Warn��s�r�tr C;i.,r-.S 11 CLAIMANT: D.L. GLAZE COMPANY, INC . (Cleola Sue Hubbard) 1515 Oakland Blvd. #200 File # 08-3115-1-250 JUL 11 1988 ATTORNEY: Walnut Creek, CA 94596 Date received Martinez CA ADDRESS: BY DELIVERY TO CLERK ON July 11, 1988 Risk Manage. BY MAIL POSTMARKED: no envelope 1. FROM: Clerk of the Board of Sup=rvisc^s -TO: County Counsel Attached is a copy of the above-noted claim. DATED: July 11 , 1988 EpIL BATCYELOR, Clerk epu L. Hall 11. FROM: County Counsel TO: Clerk of the Board of Supervisors This claim complies substantially with Sections 910 and 910.2. (� ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: 7 l/�I BY: — /N Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present This Claim is rejected in full . Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: AUG 9 1988 PHIL BATCHELOR, Clerk, By�__W, , Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: AUG 10 1988 BY: PHIL BATCHELOR by eputy Clerk CC: County Counsel County Administrator LETTER OF TRANSMITTAL TO: CONTRA COSTA COUNTY Date: July 5 , 1988 MUNICIPAL RISK MANAGEMENT INSURANCE AUTHORITY NOT Oakland Blvd., Suite 200 Walnut Creek, CA. 94596 Attention: George Hills Co. , Inc. RECEIVED FROM: Judy Macfarlane, City Clerk JUL 111988. City of San Ramon sops PD 2222 Camino Ramon e N s u° orR 9y putt San Ramon, CA 94583 REGARDING CLAIMANT: Cleola Sue Hubbard 2801 Fountainhead Drive San Ramon, CA 94583 WE ARE SENDING YOU ORIGINALS X PHOTOCOPIES OF: X NEW CLAIM INTERNAL CLAIMS MEMORANDUM POLICE REPORT SUMMONS DENIAL LETTER AS REQUESTED OTHER: REMARKS: COPY TO: Joe Tonda, Contra Costa County Risk Management SIGNED: PHONE # : A Date: July 5 , 1988 San Ramon CALIFORNIA TO: city Attorney, city Manager, Assistant City `O' pdAtLfl Police Services Manager From: CITY CLERK Attached is the following: Claim No. 006.88 Claimant Cleola Sue Hubbard 2801 Fountainhead Drive San Ramon, CA 94583 Date Received: June 2 , 1988 NOTE: Appropriate department (dept. which is named in claim) to conduct an initial investigation and report to City Attorney and Assistant City Manager within 15 calendar days from the date of this notice. /jm/claimfor ' D. L. GLAZE COMPANY, INC. INSURANCE ADJUSTERS 1515 OAKLAND BLVD.,SUITE 200,P.O.BO%088,WALNUT CREEK,CA 90596(415) f5 2�';.°' "°•' 0I't i.' Ill- May 31-, 1988 4 L' �•, �•L City of San Ramon 2222 Camino Ramon San Ramon, California 94583 Attention: Risk Management Department HOME OFFICE 591 Redwood Highway RE: Our File Number 08-3115-1-250 Suite 2350 P.O.Box 1178 Mill Valley,CA94942 38 (415)383$133 Our Insured CLEOLA SUE HUBBARD Date of Loss May 12 , 1988 Principal Utica Insurance Subject Traffic Accident Involving Officer Mark Klekar Highway Patrol Report 5-145 Gentlemen: D. L. Glaze Company, Inc. , is a claim service for Utica Insurance Company who insures Cleola Sue Hubbard. Please be advised that Utica Insurance will be presenting a subrogation claim to you for the damages to Ms . Hubbard' s vehicle. BRANCH OFFICES If you have special claims forms to properly present a claim SAN FRANCISCO to you within the 100 days, please send them to my attention. OAKLAND WALNUT CREEK PLEASANTON Thank you for your cooperation. SAN MATEO SAN JOSE SAN RAFAEL Very truly yours, SANTA ROSA SACRAMENTO ROSEVILLE D. L. GLAZE C� ?,NY, INC. CHICO STOCKTON SO.LAKE TAHOE SO.CALIFORNIA GLENDALE Barbara North ANAHEIM I Adjuster (Dictated but not read) BN:ah cc: Utica Insurance Company Certified Mail A ' D. Lam. GLAZE C O M PANY, INC. INSURANCE ADJUSTERS 1515 OAKLAND BLVD.,SUITE 200,P.O.BOX 488,WALNUT CREEK,CA 94596(415)945.8824 FZECEIVED � ^ 'tea J I. J. June 21 , 1988 PITy 0e SAN fltll�iOi`� Cit of San Ramon Y 2222 Camino Ramon San Ramon, California 94583 Attention: Risk Management Dept. HOME OFFICE 591 Redwood Highway RE: Our File Number 08-3115-1-250 Suite 2350 P.O.Box 1178 Mill Valley,CA 94942 Our Insured HUBBARD CLEOLA SUE (415)-483-8133 Date of Accident May 12, 1988 / Principal Utica Insurance CHP Report Number 5-145 Gentlemen: Attached is a claim against the City of San Ramon, highway patrol report, statement of Hubbard, statement of witness Stayton, diagram, appraisal estimate, and draft copies. Please be advised that D. L. Glaze Company, Inc. , is a claim service for Utica Insurance Company who insures Cleola Sue Hubbard. We are requesting reimbursement of $2, 315. 89 which reflects BRANCH OFFICES the cost of repairs to Sue Hubbard' s vehicle. This includes SAN FRANCISCO the $200. 00 deductible. OAKLAND WALNUT CREEK PLEASANTON Please send your check payable to Utica Insurance in the amount SAN MATEO of $2, 315. 89 to my attention. I will make sure that Utica SAN JOSE receives the check for SAN RAFAEL proper credit SANTA ROSA SACRAMENTO Y y yours , Ver trul ROSEVILLE y CHICO STOTAHOEO SO.LAKE TAHD. L. GLAZE COMPANY, INC. SO.CALIFORNIA GLENDALE ANAHEIM �' J Barbara North Adjuster BN:ah r Enclosures CLAIM AGAINST THE CITY OF SAN RAMON (For Damages to Persons or Personal Property) Claim No. 006. 88 A claim must be filed with the City Clerk of the City of San Ramon, 2222 Camino Ramon, San, Ramon, California within six (6) months after the incident or event causing the loss or damage occnred Name of Claimant CLEOLA SUE HUBBARD 2801 Founta n $ ad Drive (415) Address San Ramon, �aliefornia Phone 820-5274 Send Notices regarding this claim to D. L. Glaze Company, Insurance Adjusters, P.O. Box 488 , Walnut Creek, California 94596 Time and Date of Incident May 12, 1988 , at 16 : 55 Place (specific location) 2500 San Ramon Valley Boulevard, at the 7-11 parking lot. Circumstances (specify the act or omission upon which you base this claim in as much detail, to include a copy of any police report) On-duty emergency vehicle police car drove at a fast rate of speed through the parking lot as Sue Hubbard entered the lot. The police officer was going after a reckless driver that was on San Ramon Valley Boulevard. As the officer came quickly around the corner of the 7-11 Store , he collided with the front left corner of Sue Hubbard' s _car. Hubbard was traveling at 5 miles an hour, (Add additional sheet if necessary) Name(s) of Public Employees) causing injury, damage or loss, if known Officer Mark Allen Klekar, 2222 Camino Ramon San Ramon California 94583. P" CLAIM AGAINST THE CITY OF SAN RAMON (For Damages to Persons or Personal Property) Claim No. 006. 88 Page 2 Loss Description (Describe injury, property damage or loss. If if there were no injuries, state "No Injuries") No injuries - Property Damage Only - 1985 VW Jetta, license number: 1CFG055 Damages Claimed: Amount claimed as of this date $ 2 , 315. 89 Estimated amount of future expenses $ - Total amount claimed $ 2 , 315. 89 Witnesses, Hospitals, Doctors, etc. .WITNESS : Joe Stayton, 5334 Idlewild Avenue, Livermore, California, 94550, phone at home (415) 447-3807 , phone at work (415) 838-1556. Statement is enclosed. Additional Information (Any additional information that you feel may be helpful in evaluating your claim) Enclosed is the police report, Hubbard' s statement, Stayton' s statement, repair estimate, draft copies , and diagram. �----- - Date• June 21 , 1988 Claimant ' s Signature TR;WFIC COLLISION REPORT PAGE / OF .Z SPFCIAL CGNDMONS NUMBER NIT A RUN , , Jl L DISTRICT NUMBER ^N 0 ur C �r INJURED FELONY -- VHiCILE ❑ SJQ/I /aMON r7L/JfJT' C/1F. Ek' �— I NUMBER MIT A RUN COUNTY REPORTING DISTRICT BEAT V coUfZTe5Y RcpoZI fJ KILLED MISS, 1 SRu1�2A,-noNNP.U. { d ❑ ONT/t.Q CO TA �G 90.2 COLUfiON OCCURRED ON — P/Q/v 7`j pet p oc R T Y ' MO. DAY YEAR TIME(2400) NCIC/ OFFICER 1.0. z I [I'^ Fel.K. . 'A :89 /6S '732010030 MILEPOST INFORMATION DAY OF WEEK TOW AWAY PHOTOGRAPHS BY: FEET/MEES CF MILEPOST S M T W& S ❑YES ®No V ❑ WITHAT INTERSECTION WITH STATE HWY REL 10 OR: —(MILES IJ OF NO/Z/r Is CA�YO� /1D, G.S. ❑Y- N.- SAKI D AMO NON[ PARTY DRIVER'S LICENSE NUMBER STATE CUSS SAFETY VEK YR. MAKE/MODEL/COLOR UCENSENUMBEA STAT. EOUIP. Eo9S5'69S GA 3 G $8' Foi v,cTon�� /wNirt C 0911?8S CA DRIVER NAME(FIRST.MIDOLF,LAST) ON DUYY r:rf)M ISE/JC.Y Ve)%-lCLEC . . . . . . . . . . . ® MR Re i9LItEN KGEkAe? PEDES- STREET ADDRESS OWNER'S NAME ❑ SAME AS DRIVER . TRIAN ❑ 2222 GAriiNo MAmo/V C/TY OF SAN A2 AMo.� PARKED CITY/STATE I IIP OWNER'S ADDRESS ❑ SAME AS DRIVER 9 t/S-9 3 YE HICL[ ❑ SAV I?AMo'VCA. 9ys'sII3' .2 2.2:2 CRM/NO /ZAMpN A„J /2AMOry &ICY• $E. 1HAJ!�TVE"S HEIGHT WEIGHT BIRTHDATE RACE DISPOSITION OF VEHICLE ON ORDERS OF.' OFFICER ®DRIVER E]OTHERCOST MO. I DAY , YEAC] M t3 5-9 /90 $ i SY DRIVEN R6uA OTHER HOME PHONE BUSINESS PHONE PRIOR MECHAMCAL DEFECTS: NONE APPARENT REFER TO NARRATIVE ❑ ❑ ( ) - (y/S) 866- /yo o CMP USE ONLY DESCRIBE VEHICLE DAMAGE $MADE IN DAMAGED AREA NSURANC[CARRIER POUCYNVMBER VEHICLE TYPE ❑ (/�/ • W ❑ K NONE ❑MINO11 /NS u/r Ev U MOD ❑MAJOR []TOTAL DIR.OF ON STREET OR HIGHWAY SPEED PCF ICC ❑ , TA EL LIMIT S"73 PARK I A16 LO 7' _ ., cHn p PARTY DRIVER S LICENSE NUMBER STATE CLASS SAFETY VEH.YR. MAKE/MOOEL/COLOR LICENSE NUMBER STATE 2 SbY--moo/ CA, 3 EQUIP. /_4,,Q / . K 8 S vw rr.a 8c uE /cFG o5-.f . CA, DRIVER NAME(FIRST,MIDDLE,LAST) ® CLEOLA SUe Nu 8 QAR�� PEDES- STREET ADDRESS OWNERS NAME ®SAME AS DRIVER TRI AN ❑ O , ox 2 ?&• Vo oi fouhr�,�,vly Air PARKED CRY/STATE/ZIP OWNER'S ADDRESS ®SAME AS DRIVER VEHICLE ❑ S1i N R A m o.,j C F4 , 9 vs,9.1 NCr• SEE MMR EYES HEIGHT WEIGHT BIRTHDATE RACE DISPOSTION OF VEHICLE ON ORDERS OF: ❑OFFICER ®DRIVER ❑OTHER C LIST MO. DAY YEAR ❑ r BR/V 13R"l S-9 I/3S !/ 2 3 0 ,d i2 i vc N ,q wA r OTHER NOME PHONE �s BUSINESS PHONE { PRIOR MECHANICAL DEFECTS: NONE APPARENT ® REFER TO NARRATIVE .❑ El (! IJ ) �O ^S 2 / y ( ) _ S A M G CHP USE ONLY DESCRIBE VEHICLE DAMAGE SHADE N DAMAGED AREA P4SURANCE CARRIER POUCT NVMBER VEHICLE TYPE �f �f ❑IMC, []NONE ❑MINOR GRRAY CE ARTS /-7Ura194 —� ,2.Z Q/ IXIMOO. ❑MAJOR ❑TOTAL DIOL Of OH Si BEET OR HIGMV AT SPF ED PCF ICCJ ❑ ' ^��Js Ai -q I<" .iG LOT LIMIT CHP p PARTY DRIVERS LICENSE NUMBER STATE. Cuss SAFETY VEK.YFL. MAKE/MODEL/COLOR LICENSE NWSER STATE EON►• �3 DRIVER NAME(RAST_MIDOLE,UST) ❑ KIEL STREET ADDRESS --_` OWNER'S NAME ❑SAME AS DRIVER TRI AN ❑ PAAK[0 OTT/STATE/IIP OWNERS ADDRESS r1 SAME AS DRIVER V,"CLE (_J El ::::::� &ICY• SEE HAIR [T[S HEIGHT WEIGHT B:RTrIDAII RAZ'[, DISPOSITION OFVEMCLE ON ORDERS OF: ❑OFFIC[R ❑OgV[R ❑OTN[R Ca YO. GAY TCAA El ­ OTHER HOME PHONE RVSN[SS PHONE( PRIOR MECHANICAL DEf[CTS� NONE AIIARpR ❑ REfER TO NA ARA TIVI ❑ ❑ ( ) ( ) CHP USE ONLY DESCRIlit-V (CLE DAMAGE $MAO&N MMU DAAGED INSURANCE CARRIER POLICY NUMBER VEHICLE TYPE El- moo. UALMOO. ❑MAJOR []TOYAI 040.OF ION$TRIETOANG"AY SPEED PCF KC c] ' TRAVEL LIMIT ❑ Puc CHP ❑ PREPARER S NAME DISPATCH NOTIFIED in EVILIVERSNAME DAIS REvIE WED .T, �C/A/ZREI TTA ^ C ®YES 13 NO ❑ N/A C, Y"0�� CHP 555-Page I (Rev.7-87)OPI 042 "I HAFFIC CULLISIUN CUUING ,.�E •� OAIE OF CC-LLA56N TIME(7//�--00 R NCIC/NMB OI TYCER E O P0JUSER E1O. DAY I YEAR /(o•� J ^-3 I O O C • ~ OWNERS NAME/ADDRESS NORR[O PROPERTY _ ❑YEs No I)AMAGE DESCRIPTION OF DAMAGE SEATING POSITION OCCUPANTS SAFETY EQUIPMENT MlcelcYCLE-HELIAET EJECTED FROM VEH. 1•DRIVER A-NONE IN VEHICLE L-AIR BAG DEPLOYED 0•NOT EJECTED A 2 TO 6-PASSENGERS B-UNKNOWN M-AIR BAG NOT DEPLOYED DRIVER 1-FULLY EJECTED 7•STA.WGK REAR C-LAP BELT USED N•OTHER Y•NO 2-PARTIALLY EJECTED •-RR-OCC.TRK_OR VAN D•LAP BELT NOT USED P-NOT REQUIRED W-YES 3-UNKNOWN 0•POSITION UNKNOWN E-SHOULDER HARNESS USED 1 Z 3 0-OTHER F-SHOULDER HARNESS NOT USED PASSENGER 4 5 6 G-LAP I SHOULDER HARNESS USED O-IN VEHICLE USED X-NO H.LAP I SHOULDER HARNESS NOT USED R-IN VEHICLE NOT USED Y-YES 7 J-PASSIVE RESTRAINT USED S-IN VEHICLE USE UNKNOWN K-PASSIVE RESTRAINT HOT USED T-IN VEWCLE IMPROPER USE V-NONE IN VE)iCLE ITEMS MARKED BELOW WHICH ARE FOLLOWED BY AN ASTERISK(')SHOULD BE EXPLAINED IN THE NARRATIVE PRIMARY COLLISION FACTOR TRAFFIC CONTROL DEVICES Z 3 TYPE OF VEHICLE MOVFJAENT PRECEDING UST NUMBER I') , OF PARTY AT FAULT 1 Z 3 COLLISION a AVC SECTION VIOLATED: aa°Es A CONTROLS FUNCTIONING A PASSENGER CAR/STA WGK RRO B CONTROLS NOT FUNCTIOHING• B PASSENGER CAR W/TRAILER A STOPPED 17 B OTHER IMPROPER DRIVING• C CONTROLS OBSCURED C MOTORCYCLE 1 SCOOTER B PROCEEDING STRAIGHT D NO CONTROLS PRESENT/FACTOR' t3yPICKUP OR PANEL TRUCK C RAN OFF ROAD C OTHER THAN DRIVER- TYPE OF COLLISION E kKUP I PANEL TRK W I TT.FL D MAKING RIGHT TURN D UNKNOWN A HEAD-0N F TRL4 OR TRUCK TRACTOR 1EMAKING LEFT TURN E FELL ASLEEP' B SIDESWIPE G TRK I K TRACTOR W I TLFL F WAKING U TURN C REAR END H SCIKIOL bys G BACKING WEATHER MARK I TO 2 ITEMS X D BROADSIDE I OTHER BUS H SLOWING I STOPPING A CLEAR E HIT OBJECT J EMERGENCY V NCLE I PASSING OTHER VEHICLE B CLOUDY F OVERTURNED K HWY.CONST.E MENT J CHANGING LANES C RAINING G VEHICLE/PEDESTRIAN L BICYCLE K PARKING MANEUVER D SNOWING H OTHER': MOTHER VEJlCL.E L ENTERING TRAFFlC E FOG I VISIBIUTY FT. MOTOR VEHICLE INVOLVED WITH N PEDESTRIAN M OTHER UNSAFE TURNING F OTHER': A NON-COLUSION OMOPED N XING INTO OPPOSING LANE G YAND B PEDESTRIAN O PARKED LIGHIING C OTHER MOTOR VEHICLE P MERGING A DAYLIGHT D MOTOR VFR ON OTHER ROADWAY OTHER ASSOCIATED FACTOR Q TRAVELING WRONG WAY B DUSK-DAWN1 2 3 (MARK 1 TO 2 ITEMS) E PARKED MOTOR VEHICLE R OTHER.' CDARK-STREET UGH TS F TRAIN AvCSECTONYIOLATIOFt CITED D DARK.NO STREET UGHTS G BICYCLE Orfs ❑NO E DARK- STREET UGHTS NOT H ANIMAL: B vc sEcnoN YIOLAT10It CITED FUNCTIONING' ❑YEs ❑No SOBRIETY-0RUG ROADWAY SURFACE I FlXED OBJECT: CVC SECTION VIOLATTOFc CITED 2 3 PHYSICAL A DAY ❑YEs (►LARK 1 TO 2 ITEMS) B WET J OTHER OBJECT: ❑� Al1AD NOT BEEN DRINKING C SNOWY•ICY D D SLIPPERY(MUDDY,OILY,ETC.) E VISION OBSCUREMENT: B HDO-UNDER INFLUENCE El - I C I18D•NOT UNDER INFLU.' F INATTENTION' D IABD-MAPAIRMENT UNK' ROADWAY CONDITIONS PEDESTRIANS ACTION G STOP i GO TRAFFIC E UNDER DRUG INFLU.• (MARK I TO 2ITEMS) H ENTERING I LEAVING RAMP 77A_-O PEDESTRIAN INVOLVED I PREVIOUS COLLISION F IMPAIRMENT-PHYSICAL' A HOLES,DEEP RUTS' ETEC D CROSS NG IN CROSSWALK G IMPAIRMENT NOT KNOWN B LOOSE MATERIAL ON ROW Y.' B AT INTERSECTION J IWITH ROAD I( EFECiIVEVE VER EQUIP.: CITEo H NOT APPLICABLE C OBSTRUCTION ON ROADWAY• C CROSSING IN CROSSWALK.NOT ❑YEs I SLEEPY I FATIGUED D CONSTRUCTION.REPAIR ZONE AT INTERSECTION ❑"G SPECIAL INFORMATION E REDUCED ROADWAY WID114 D CROSS+NG.NOT IN CROSSWALK L UHIIIVOLVED VEHICLE ZARDOAIS MATERIAL F FLOODED- E IN ROAD-INCLUDES SHOULDER M OTHER': G OTHER': F NOT III ROAD IN NONE APPARENT H NO UNUSUAL CONDITIONS G APPROACH I LEAVING SCHOOL BUS 10 RUNAWAY VEHICLE i S A E TC N Y SCELIAMEOIrS c— el D J-,q — /IDSA NT A/ZEro I V-L SPIN Rf+rlo,.� VRtcEY 8 i✓D. S TO/Z£ _ PAL1. r-rn� .crn r1T5 r'rrr`P�, IIS c., {'rae fi 1 (icv 7 - 6I j Lil•I Ua2 -..---------- --------------- — INJURED / WITNESSES / PASSF '-IERS-' "'' "' PAGE OA4E OF COLLISION TIME E2J001 INCIC NUy,DEA OFFICER I.O. //VVBER TYITNESS PASSENGER EXTENT OF INJURY ( "X" ONE ) INJURED WAS ( "X" ONE ) PARTY SEAT SAFETY ACE SEI! EJECTED ONLY ONLY NUMBER POS. EOVI►. FATAL SEVERE OTHER VISIBLE COMPLAIN! INJURY IfUURi IfUURY OF PNN DRIVER 1 ►ASS. 1 ED. 1 BIC lC UST CTNER 9!1 ❑ 23 f- ❑ ❑ ❑ ❑ ❑ ❑ 11:11 ❑ I ❑ - - - -- NAME I D.O.B.I ADDRESS TELEPHONE .TOE STAY ro^J /O-2 - &Y 5-3 3 Y r c W14-0 AYE Q M yYS'5-0 (INJURED ONLY)TRANSPORTED BY: TAKEN TO: L y7- 3 8'07 DESCRIBE INJURIES 3 3- ❑ VICTIM OF VIOLENT CRIME NOTIFIED ®"2 ❑ 1 .28 M ❑ 1 ❑ 1 ❑ 1 ❑ 10 10 ] [:] 1 D 1011 - 1 -- NAAIE I O.O.B.I ADDRESS TELEPHONE NNlS o TfiER - 1-60 ,S/2 Mlr D/Z 7-;,Qqr- y 9.1737 (INJURED ONLY)TRANSPORTED BY: TAKEN TO: HP 209 23S-OS&(6 DESCRIBE INJURIES wp yis Ft3 � - /ss6 ❑ VICTIM OF VIOLENT CRIME NOTIFIED NAME I O.O.B.I ADDRESS TELEPHONE (INJURED ONLY)TRANSPORTED BY: TAKEN TO: OESCRIBE INJURIES ❑ VICTIM OF VIOLENT CRIME NOTIFIED ❑tt ❑ ❑ ❑ ❑ ❑ Cl ❑ 10 1 ❑ 10 NAME I D.D.S.I ADONESS TELEPHONE ONJUREO ONLY)•RANSPOATED BY: TAKEN TO: DESCRIBE NJVRIES ❑ VICTIM OF VIOLENT CRIME NOTIFIED ❑° ❑ ❑ ❑ ❑ ❑ ❑ ❑ 10 1 ❑ ❑ NAME.D O B:ADDRESS TELEPHONE (INJVAED ONLT)TRANSPORTED BY: TAKEN TO: DESCRIBE INJURIES ❑ VICGM OF VIOLENT CRIME NOTIFIED NAME I D.O.B.I ADOAESS TELEPHONE ONJVREO ONLY)TRANSPORTED IT: TAKEN 70: DESCRIBE INJURIES ❑ VICTIM OF VIOL EM CRIME NOTIRED PREPARERSNAME I.O.NUMBER MO. /DAY YEAR REVIEWERS DAY EA lclA /• X CHP 555-Page 3 (Rev. 7-87) OPI 042 87 43637 VAU I UAL L)liAUht ivl . DATC 01 COIII SIOw 1/001 wCIC wyMeCw O,►IC� D, iwywkCw_ s Dw. / 2 Ff O 1 I /(o SS Zfl ' 110 - 30 , . ALL MEASUREMENTS ARE APPROXIMATE AND NOT TO SCALE UNLESS STATED ISCALE- 1' 1 •t�• • IwDlcwit :`t•: bJ-ACf N T JL PA Rxtf'-'G I;{ xDcr �4REA ^ppaox ,Znl • CANYON All. .; _�- / i-w• 77M 3 SAew[M L.tA11 ?„ •i., IO w iAd~ 1 , i IL.4"rER 6oX t3' .I rtt5 V-1 I,�I $A rJ 7-11 n AMOK Vcr. sAj F: vtr. 1cY0, PcA jrEA 8ov DRI✓rwAv %* 120T►f VIS r+O►'EO PA n. 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DAT Tw, J' .SCi�/1/lE rr� /11P030 1-5- /a CHP 556(Rev 1284) OPl 042 Use previous editions until depleted. 86 4CA74 51.1E nF CALIF(n 41A • S,'4PATIVE/SUPPLEMENTAL Pw► • DAIEOF COLLISION I1ME R• NCCNUMUFt OfiCER10 NUMf1ER 5,=12-8.8 ihSS 9 loo� o 14 S_ 'Jt•ONE w ONE T YPE SUPPLEMENTAL Cx'APPLIGLBLI3 ® HAPAAnyf ® MUSIONREPORT a BAUPDATL FATAL O HR&RUN UPDATE ❑ SUPPLEMENTAL ❑ -OTHER: ❑ HA2APCOW MCAT EAIALS ❑ SCHOOLBUS OTHUt CITY ICOUNIY/VOCAL DIST PUCI REPORT LNG Ob 1 RICT/BEAT CJTATIONNUMBER 25 71 LOCAs CN/SUBJECT ST AT E WC04"AT Pf UkT ED 2500 San Ramon Valley Blvd . 2arking lot YES 2. rear tires to loose traction on the wet asphalt . _ 3. 4. As Daly and I watched the Camero cross the intersection with its tires 5. spinning, it started to loose control as it went s/b on San Ramon Valle y - 6, Blvd. The Camero' s rear end came around and the Camer ran into the 7. center divider. 8. 9. Officer Daly started his vehicle to go over to the Camero ' s location. 1o. Daly had his emergency lights on waiting to go s/b on San Ramon Valley Blvc 11. at the 7/Eleven exit . 12. 13. I started my patrol car #2592 to assist Officer Daly. I pulled up and 14. stopped in the n/parking lot of 7/Eleven before entering the west parking 15. lot I . F.O. 7/Eleven . I looked and saw a blue V.W. Jetta, Lic #1CFG055 16. enter the parking lot from San Ramon Valley Blvd . 17. 18. It appeared I had plenty of time and space for me to pull out into the west 19. parking lot . I pulled out and Officer Daly activated his siren with his 2o. emergency lights . As I entered the parking lot I saw the driver of the 21. V.W. Jetta looking back at Officer Dal ' s location . 22- 23. I almost completed my turn into the parking lot when the driver of the 24. V.W. Jetta turned back around right before she struck the left rear . 25. quarter panel of my patrol car. I estimate the V.W. ' s speed at a roximat< 26. 10 to 15 mph. 27. 28. I asked the driver Hubbard is she was all right and she said yes . 29. 30. Later on while waiting for C . H. P. to arrive Hubbard told me she was so:Eu 31. Hubbard was look in back to see where the Camero was going . Hubbard 32. almost got hit b the Camero. Hubbard was not paying attention. PSE PARER SPIA vE J Nw'tltR I,aiwlnlUAr/FiAR -f.IE.YEFS NA uE !,.\'� ,A. .L, Mark Klekar 34918 5-12-8II -5 C, CHP 556 (Rev. 7.87) OPI G4: STATE OF CAUFCPNIA NARRATIVEISUPPLEMENTAL •� E DATEOF COUJSION TIMEl1A901 NGIC NUMBER OFF/CEALP NUMBER 5- 12-88 16SS9:32(:> lOo3o s— '/C ONE 'j1 OWN E" TYPE SUPREyEN tZ f X-APt'tJCA� © NAAAATTVE ( F[COW]DNREPORT ❑ BA UPDATE ❑ FATAL ❑ NR SF(UN UPDATE OSUPPLEMENTAL L❑lOTHER ❑ N4ZAr(005UATE314K] a SCNOOLEUS ❑ OTHE/E CITY/COUNTY/JUDICAL DIST RCT REPORTING O67 RCT/BEAT UTAT/pNNUrBER 25 71 LOCAT•JN/SUBJECT STATE NCi AYFELATm 2500 San Ramon Valley Blvd, parking lot •ES //D 1. 2 25 W-1 , Sgt . R. Gentry was advised of the accident and responded to 3, my location . C .H. P. was advised. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. .15. 16. 17. 18. 19. 24. 21. 22. 23. 24. 25. 26, 27. 28. 29 30. 31. 32. PNEPAP(R S NAVEJ hyYd(Q Mark Klekar 34918 5"-1r2-88 .(.a CHP 556 (Rev. 7-87) OPI C42 r � / G_ .-61 7 - G G rLe s zo 74671, -7 17 /22 Sj ZZ �C C' ,( 'CL./'f,c t t '- Ad el�//Z Z. 2 0 Iz Glee CJ c ' AT✓ U P%L liL�-2� 1, ,a1f� � .�---- ' / ,�,,} �-- _ � , �c R � , ..., �._..Uig � �� � ._..-.------------ . r �„ _ l i��1 � .�-- � � ��. t..-L � '1 `�� L ,�` �� 7 �`-"`- �� � 70 61 GU f 2 I n G' tY -) ' 1)41-o��_ ) :2-// 7- -F' o')L.�L i- [f.0—c- _ V—,le )&t E+lke Cl i/tit, `LZ-(X-C- !} L 'AlQ YL r J i a-c rt t �...0 / Q� �L �)t c4() - r -2 D —, OL—C&.L lL - r l� < C tJ •--tie_._ ' Cmc ,c GL X cc L Z4-1 -\jL1o)�o � f�L� /� ,[ i� /lC�- �ze- 'C f;" Le . ea co r /y , r V � • INSURED'S NAr•" (LAST NAME FIRST) Loss and Scenc .-)iagram 1-� l HOMEOWNERS LOSSES: DRAW DIAGRAM OF POLICY/CLAIM PROPERTY SHOWING DAMAGED AREA. ,AUTO LOSSES: INDICATE POSITIONS OF VEHICLES (A-INITIAL q L4 -1 :Z i 1 Z7 c OBSERVATIONS,B-POINT OF IMPACT,C-POINT OF REST) DATE/LOSS e LOCATION OF LOSS (CITY,COUNTY) TIME 1 �y DAM q 1S SC.in�umon � Ind S �j Pi I j i j hour Shntkb I ) 11111 • - - 'I hk�'� I I I � � sTa�-�on I, i I . Blucl f I I I ' I 1 , 1 1 � 1 , � ! 1 t I I . I 1 + I •. ' I i � I _ ' _ - , - { -�'— • FF; j 1 ( i I I NUMBERDISTANCES: PfPACED TIMATED PHOTOS MEASURED ❑ ES I_ - - TAKEN? I DIAGRAM PREPARED BY JDAI E OF INSPECTION DISI RICT OFFICE SCALE: ❑ ,a 1"-20' ❑NOT TO SCALE 2 11.1.15 (11 oil) Crawford 8.Company 30Ry, -. 1. . a.n Industrial Court, Suite 112 FM WAMAGMENT SEMOMP.O. Box 306 Automobile ' . San Ramon, CA 94583 .'7 MATERIAL DAMAGE APPRAISAL SERVICES . (415)831-0285 611 2 f . ACM Insured /' ... -/f;' { jr �h`^,y Y'1 it�i�.�yc:y �t_ tr.`�'»�.yZ 1 : •:.-'< _ of Inspection e •/`/ qaf +i �N } Date Loa Date ReCp' D��App d .eAW V Mile S'• Lbeneet,.C:' i; _ Mfg. Enpi LMK Cyl Tr - Auto❑ 3- O t;al ::.1❑ -- -O FM soO Fb,lw c :i p CB Y= Date T Standard * 7,1 'AntKnrna ;D Pirrone -: Equip—d _ Power❑ rirnp windows; ❑Lode.:,. �+ G ❑TtIt:R"• c0 Lupe ,�}❑wM '.�D Sun ❑T Tbo->.',O Wire wheeM aka ❑Seats DetrostK Wtneel•' tib.'T `Rod P. ❑Cn*9*-- ❑Odrr-:5'}: Paint (,per / Dpp. { `' ' Tires:Tread Depth Remakntrnp. �\ ft Cor,dttlon Interior 1)ps Go1ot •p'k Condttlon f3ood�a ,siT '>'�; LF- /32 LR Felr' - Poor; RR ./32 F -v •} r� w Rept RePr Description of Damage , F1atRete .• Part ThW 2. 3. 46 ILI- -., 5. 6. 7. - . - - _ 9. ;t-r4►a�=d.. 2 12. t C r i 13. 14. 16. 17. � �;.. Commem ` n AND DFM GT 0' - 1117 �Saaa 1 BenerrrTerTt Reoorrrner,da6oro: O Yea Fblx to AF WO Jn: •.�.• .�. :�. :Q. Repair f Address Days to „+:.,ate+ r Ths. Xont: k� CRY Stairs I,p StorepaPetDay ~'' Towl^9 ,:i.. ��g Total :,�•.a,a •:i':r: T `_ . r Wair Mal . ADl]ra AQVr .1 :r;i:�SD ''la''G: :t. .7y�,.f�., �.^�`..�.'••s..• `.°(•.: Lti;t-t•RN!� _ .._ . NOTICE TDREPAIRER-'Thb h NOT an almlort:etbn to repair.This is an sisal d damages ony.tiro appraiser a ad uatKr� �:,,;.:,'-�'�. .. . .. •t.'..�. ,. ?.ys:::. �:'.tri*,:!={- ,:�: . has alRlwrity b authortte repairs.MMTorizetion b repair end ppuuararaee of payrr,ent can orgy De made 6y owner.Gewlord i� ;`°,i.;' :.�•.t Tp�al Arrrp�y-,•�•;�� C, ;.s. npery s end Intends than ell repair and Or rt ropiacert,errts listed t1erBOr1 De made kn strkt a000rdenCe rAU1 marNAaP" r.t»`'. ,., w�rKY�and recommendatlons.Gewtord 8 Comperry erW�«na client assumes ro rosporss7bitlty 1«repak quell y;�^- :.;}.� Te R�V!�. 'a/`���.��s - andeatety.SupplememalrepainaresuDJedtorelnspectlon - - tr,.• -.+.- Vis: r-��',�+� •� 'AP029�Ravfl�B Pr4rteGNlneU.SA. •.T: � _ .+r ,t,. .. ...� ,r "'-• j`E r"'.% .yti;7Tj,•� r�`;�•.P•,`C^,+:_ .-•�.if .,A .l. ,w .^'. '. � _ .\: Ff�J� :Y� CIIe�����{/ '�•-i',•: .�.5�..-,`.. 'r• .f.,i .1��}�. 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Y _Lt- s:;i# _ ,f.. `f .i is '"1.•.i. •7ri,..t.< 'rG fr c.:• ".�'.<„r�'L „S`R;s *y��:�t;".'aN- w .`tom +�; T �i.+.4.'.l `.�y..r.:-. - 7 .�x �. a a.'4 ��,, '•,t..,,,-.,. r �k+, ',R(:.�'SS^^.Tit•..• . !�•. :*�',�'C.!' •�. 3a4�, /.�.5%l:a'F1 �,t� aG"i�-1.�+.� �,,al,.,h„{ ik `•► al.::'{";3f11'•;r�:;�-_ �` ,.t. .�,.,.'s� .� �. .Ja' �_ 'aa ! •L •rf.F^ .,lL rt-w ?'' x 'T i:r. Y3 .'�:;-»� r.RAWFORD & COMPANY CELEPHONE:(415)351-8000 CRAWFORD &COMPANY �} 2450 WASHINGTON AYE.,SUITE 130 Su ` lernental Report l O,CALIX 935 SAN LEANDRO,CALIFORNIA 94577-6994 MATERIAL DAMAGE APPRAISAL SERVICE " 1 u �U�1 10 J O To: File Number. Claim Number. _ l � Policy Number. �— ATTENTION: Vehicle Owner. Date of Original Appraisal: � Insured: Y M Q J STY n SERIAL NUMBER M L OE LICENSE NO.v -wST R PL REPR DESCRIPTION OF REPAIRS PARTS APPRAISAL UNIT REPAIR PARTS SUBLET INVOICE ` PARTS TIME TIME 1. �J 1 1 2. 3 a. Q PAGRO B. 7. B' t 9. ,o. JUN 1318 . 12 ti 13 ' REPAIR TIME HRS AT Supplement Requested By: PARTS LESS Original Appraisal $ SUBLET Supplemental Appraisal $ SUBTOTAL i rO X %ON i Recommended Total WINGPPLEMENTAL TOTAL Agreed Repair Figure By: _ _ COMMENTS: ` A/o yjv L00, NOTICE TO REPAIRER—'This is NOT an authorization for repair. This is an appraisal of damages only. No appraiser or adjuster has authority to authorize repairs. Authorization to repair and guarantee of payment can only be made by owner. Crawford&Company specifies and Intends that ail repairs and/or part replacements listed hereon be made In strict accordance with manufacturers specifications and recommendations. Crawford& Company and/or its client assumes no responsibility for repair quality and safety. Supplemental repairs are subject to reinspectlon.' Location of Inspectlo Appraiser Date AP032(9/83) Printed in USA UTICA NATIONAL INSURANCE GROUP W-42' .. 3 5 5 8 UTICA MUTUAL INSURANCE COMPANY 213 3 7 �:'- q. • �� AND ITS AFFIl1ATED COMPANIES P.O. BOX 530 -UTICA, N.Y. 13503 , MARINE MIDLAND BANK, N.A.a ': ;',';°•DATU,OP 1SiUi UTICA. NEW YORK .` !!-�jEr ew G-2 4q Y F.O. CLAIM NUMBER CD $ lOSS DATE FOR ...: rr COLLISION REPAIRS.LESS D YI" `' Nl 41 �!2 16 90 0 1 5-12-88 �� INSURED: R UxLdW_S PAY TO THE ORDER OFR AMUri� `02fWQI , . .y, Symwns Body Shop and Sue I?ubbard 509 San Ranson Blvd. san Ramon, CA 94526JN GUTI�ABLE SU! EINE OF CAUSE TrvE irvE PAYEECE ows SlAMOUNT 1.M• t� a'Y ' rl'�..d�l CLAIM BUSINESS vArT Ezv CT 73 73 26.79 5,.53 S. N.>e 51 59 w Ai 67 1 63 1w 73 ��G I Q ISSUED BY AGENT ❑ ,', f f T t rj.` Z."_ FIELb"OFFICI :t 1 a UTICA NATIONAL INSURANCE GROUP 50-42 3 $ 584 r {W UTICA MUTUAL INSURANCE COMPANY + A •213. Y 1 o �Sf AND ITS AFFILIATED COMPANIES a iT r t4 ft 4 P.O. BOX 530 UTICA, N.Y. 13503 i MARINE MIDLAND BANK,N.A i,V• DATE Op ISSUE, UT1CA..NEW YORK. ...�. ') �a 3fOR -. .! : i EO55 DATE F.O. CLAIM NUMBER CD S N1 41 42 16 90 0 1' 5-12--68 7 Supplement , . 594-2536583 Y , INSURED:aSUO Hubbard is 3 PAY TO THE ORDER OF L a AMOUNT> .$5 2 a 8 r s 3ymmons Body & . Fender,:,' 509 San Ramon Yalley Blvd. • Danvil,le, CA 94526 - •� t �lf.<... � - SV! . Nf OF CAUSE irvE Tr Pf PEE UCI 5,�1L AMOUNT '_ ., v 7 �.; t i r f�Et r 's CLAIM EVLNE S vA•3 Exp CT •'•. a. • r.1 .�Li 'r' �. e3 r3 �+} I ISSUED ,. ! 1 ,r -. 3.w .c•;, if BY !ate �lJa