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HomeMy WebLinkAboutMINUTES - 08151989 - 1.23 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 August 15 , 1989 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: $35 . 00 Section 913 and 915.4. Please PQ1J t1V'�nings". �nsel CLAIMANT: KENNETH E. CARRETHERS JUL 2451 Folivera Road #D13 nyan�n 1c 1989 ATTORNEY: Concord, CA 94520 Date received ez' A 946— 003 ADDRESS: BY DELIVERY TO CLERK ON July 18 , 1989 inter-office 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. DATED: July 19., 1989 gbiL BAATTCYELOR, Clerkepu L. Hall II.. FROM: County Counsel TO: Clerk of the Board of Supervisors ir ) 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: _�T�(, � 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. (1O Dated: AUG 15 1989 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: A U G BY: PHIL BATCHELOR by Deputy Clerk 77 CC: County Counsel County Administrator �'y,:LAI,N1 J TCS N BOARD OF SUPERvISORS OF CONTRA CO A ' �' - •� �U-' �el-ur�n bTnSt application to: "= Instructions to Claimant Clerk of the Board P.O.Box 911 A. Claims relating to causes of action for death or Zorn nDDuryhto4533 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 mast be- filed against each public entity. .- E. ntity. -E. Fraud, Seep penalty for fraudulent claims, Penal Code Sec. 72 at Via^'_ of this form. f RE: Claim ) Reser 1.e < <; RUE6VfiED Against the COUNTY OF CONTRA COSTA) JUL 10.19€39 or DISTRICT) CLE. r ARD TC Y1 OR isca� (Fill in name) ) r�T r ' �Y F.nuty The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of $ and in support of this claim represents as follows : -------------------------------------------- ---------------------------- 1. When did tne .damage or injury occur? (Give exact date and hour) 2. Where did the damage or injury occur? (Include city and county)- Co ✓r f ro- co S AL-, Cb lJki 7ty 3. How did the damage or injury occur? (Give full details , use extra sheets if required) o h 74A 17 A ,14 ' 0Ze' �,/Q•S 0 r-� C'/a->1 -/ o n f a r b r, o �fi i� �'. /� � Pr'o Per' �'lam. 6'�e� on A- Codd/e, �' .�D� t . ✓1 4�- e Ic o r i'f a r+d �✓o-s �0/� i f %✓A-s /o s�o - ---------------------------------' - 4 What particular-- --act or---omission on the part of county or district officers , servants or employ es es caused the injurx or/amage? (over) '.:5..:,:•fiat. are-the -names of county or district officers, servants 'or• 4 ! employeescausing the damage or injury? OF ------------------------------------------------------------------------- 6 . What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed, Attach two estimates or auto damage) �dS f. 6 C'o&-7 01 -a1^y PIa Soe) t ProPer71y 3s ------w was ------------------------------------------------------------- 7. How was the amount claimed above computed? (Include •the estimated amount of any prospective injury or damage. ) ds � ; ProPcr21Y C6�► r� •S3o-ry /lee"Jr J P,ejri- 1emS ,l 3 ---------------------------------------=--------------------------------- 8. Names and addresses of witnesses , doctors and hospitals. .±/ -A 9 . List .the expenditures you�maae on account of this accident or injury : DATE ITEM AMOUNT Govt. Code Sec. 910 .2 provides : "The cla in signed by the claimant SEND NOTICES TO: (Attorne y)w ' or biso e Bison' c�v%is behalf. " Name and Address of 'Attorney laimant's 'Signature i CRI I? IL Address Telephone No. t Telephone No. ".q, - d qlz NOTICE Section 72 of the Penal Code provides: "Every person who, with intert 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. " 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 August 15 , 1989 .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: DOHERTY' S TRUCK AND AUTO RENTAL, INC. c/o Walter K. Dods County ATTORNEY: Law Offices of. Walter K. Dods Counsel 7 Mt. Lassen Drive #C-150 Date received ,f(�� l Qp ADDRESS: San Rafael, CA 94903 BY DELIVERY TO CLERK ON JkUV 11 , 19'tTy9 July ; cA BY MAIL POSTMARKED: %*553 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 17, 1989 fid: Deputy 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 f ri 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 ORD F_&r By unanimous vote of the Supervisors present 7( ) TThhis 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 15 J.QR 9 PHIL BATCHELOR, Clerk, By F 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 15 1989 BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator NOTICE OF INSUFFICIENCY AND/OR NON-ACCEPTANCE OF CLAIM TO: Doherty's Tr k and Auto Rental, Inc. c/o Walter K. ds Law Offices of Wa ter K. Dods 7 Mt. Lassen Drive # 150 San Rafael, CA 94903 Re: Claim of DOHERTY'S TRUCK AND AUTO RENTAL. INC. Please Take Notice As Follows: The claim you presented against the County of Contra Costa or District governed by the Board of Supervisors fails to comply substantially with the requirements of California Government Code section 910 and 910. 2, or is otherwise insufficient for the reasons checked below: _1 . The claim fails to state the name and post office address of the claimant. _2 . The claim fails to state the post office address to which the person presenting the claim desires notices to be sent. 3 . The claim fails to state the circumstances of the occurrence or transaction which gave rise to the claim asserted. _4 . The claim fails to state the name(s) of the public employee(s) causing the injury, damage, or loss, if known. X 5 . The claim fails to state whether the amount claimed exceeds ten thousand dollars ($10,000) . If the claim totals less than ten thousand dollars ($10, 000) , the claim fails to state the amount claimed as of the date of presentation, the estimated amount of any prospective injury, damage or loss so far as known, or the basis of computation of the amount claimed. If the amount claimed exceeds ten thousand dollars ($10,000) , the claim fails to state whether jurisdiction over the claim would rest in municipal or superior court. _6 . The claim is not signed by the claimant or by some person on his behalf. X 7 . Other: Complaint with proof of service not attached. VICTOR J. WESTMAN, County Counsel B Deputy County Co sel CERTIFICATE OF SERVICE BY MAIL C.C.P. SS 1012, 1013a, 2015 .5: Evid. C. SS 641C.C.P. 1012, 1013a, 2015 .5: Evid. C. 641, 664) My business address is the County Counsel's Office of Contra Costa County, Co. Admin. Bldg. , P.O. Box 69, Martinez, California, 94553, and I am a citizen of the United States, over 18 years of age, employed in Contra Costa County, and not a party to this action. I served a true copy of this Notice of Insufficiency and/or Non Acceptance of Claim by placing it in an envelope(s ) addressed as shown above (which is/are place(s) having delivery service by U.S. Mail) , which envelope(s) was then sealed and postage fully prepaid thereon, and thereafter was, on this day deposited in the U.S. Mail at Martinez/Concord, Contra Costa County, California. I certify under penalty of perjury that the foregoing is true and correct. Dated: , at Martinez, California. cc: Clerk of the Board of Supervisors (or. inal) Risk Management (NOTICE OF INSUFFICIENCY OF CLAIM: GOV.C.§§ 910, 910 . 2, 920 .4, 910 .8) LAW OFFICES OF WALTER K. DODS WALTER K.DODS CREEKSIDE CENTER CABLE:TRYS 7 MT. LA55EN DRIVE.SUITE C-150 SAN RAFAEL,CALIFORNIA 94903 14151 499-1238 July 10 , 1989 �1k V JriD Clerk, Board of Supervisors JUL 1 11989 County of Contra Costa 651 Pine rrrLBA cH*,toc Martinez , CA 94553 CLERKCONTRA BOARD COSTA CO.SCRs CONTRA COST;.C Re: Contra Costa Superior Court Action No. C89-01377 , Nelson v. County of Contra Costa, et al . , Date of Accident: October 21 , 1988 My File: Doherty ' s Truck, Nelson v. Dear Clerk: Enclosed please find an original and three copies of a claim for contribution and indemnity made on behalf of Doherty ' s Truck and Auto Rental , Inc . as against the County of Contra Costa, Paula Christiansen and the Montara Bay Community Center. Would you please place this matter on the appropriate spot on the agenda for the next regular meeting of the County of Contra Costa, Board of Directors. I would appreciate it if you would return to me three endorsed, filed copies of the claim. A stamped, self-addressed envelope is enclosed for your convenience. Very truly yours, WALTER K. DODS WKD/klp Enclosures CLAIM v. PUBLIC ENTITY TO: County of Contra Costa, Board of Supervisors c/o Clerk, Board of Supervisors 651 Pine Martinez, CA 94553 CLAIMANT: DOHERTY' S TRUCK AND AUTO RENTAL, INC REM ED ADDRESS: JUL 10895 San Pablo Avenue El Cerrito, California 94530 P AT pD yORS CLER RD _F ¢y PHONE NUMBER: By NT ��v (415) 499-1238 (Law Offices of Walter K. Dods) MAILING ADDRESS: Walter K. Dods Law Offices of Walter K. Dods 7 Mt. Lassen Drive, Suite C-150 San Rafael , California 94903 DATE OF INJURY, DAMAGE OR LOSS: May 12 , 1989 PLACE OF INJURY, DAMAGE OR LOSS: In, around, on or near certain pumpkin fields near the City of Tracy, San Joaquin County, California. GENERAL DESCRIPTION OF LOSS OR DAMAGE OR CIRCUMSTANCES: This is a claim for contribution and indemnity which arises out of a claim for contribution and indemnity filed by Contra Costa County and Paula Christiansen as the result of , apparently, a vehicle accident which is allleged to have occurred on October 22 , 1988 , when plaintiff , Carolyn Nelson is alleged to have been a passenger on a vehicle operated by Paula Christiansen. A copy of Ms. Nelson' s complaint in Contra Costa County Superior Court action No. C89-01377 is attached hereto for reference purposes. -1- ALLEGATION OF RESPONSIBILITY AS TO COUNTY OF CONTRA COSTA, MONTARA BAY COMMUNITY CENTER AND PAULA CHRISTIANSEN: The complaint of plaintiff Carolyn Nelson alleges negligent acts and failure to act by the County, the Community Center, and Ms . Christiansen which are alleged to have caused injuries and damages to Ms. Nelson. There is no allegation in the complaint of any negligence by Doherty ' s . Doherty ' s is solely and only the owner/rentor of the vehicle operated by Ms . Christiansen who, apparently, was within the course and scope of her employment with either the County or the Community Center; thus , the legal responsibility of Doherty ' s is derivative, only, and the negligence of Christiansen, if any, is active thus entitling Doherty ' s to contribution, comparative ihdemnLty., and/or apportionment from the County, the Community Center, and Christiansen. NAME OF COUNTY OF CONTRA COSTA EMPLOYEE CAUSING THE ALLEGED INJURY, IF KNOWN: Paula Christiansen WITNESSES: None yet known AMOUNT OF CLAIM: The exact nature and amount of damages are for indemnity, contribution and apportionment and are, therefore, presently unknown. DATED: July 1:0., 1989 LAW OFFICES OF WALTER K. DODS WALTER K. DODS -2- 4• ' L V 7 1 V"\ o Ln r-1 U u� 0 O +1 cn .0 in S4 4-) ' M N U) N M U r) --zr m in ra L LW mo < 4J m 0 r. 0 61 - U U U) —i (;s N N O w :.: r6 m CY1 O N N �; u-; r- 14 r0 - >4-,-I 6J • C4 4J !L-ri r. N 7-3 1� S4 ,0 O an ;0 H I J R.. CO frrr__J, ��..ryry t"�j OU _. �-ia'O :I m i - / 2-3 . 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 August 15 , 1989 4.nd 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 p rsuant to Government Code Amount: $158 . 10 Section 913 and 915.4. PIeag%flp�yad "Warnings". �4nsel CLAIMANT: JAMES R. ZiJPANCIR ,JUL 1989 57 W Broadway ATTORNEY: Pittsburg,. CA 94565 A9ar"ez, C Date received $ ADDRESS: BY DELIVERY TO CLERK ON July 17 , 1989 BY MAIL POSTMARKED: July 14, 1989 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. , Jul 19 , 1989 PpHHIL BATCHELOR, Clerk DATED: y BY: Deputy e z L. Hall I 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: /?(_� � BY: Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Admin ator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD OR - 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_1 .9j 1989 PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code sec n 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: A U G 15 1989 BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator •'r LAlIMitTO BOARD OF SUPERVISO a OF CONTRA CO.SRTPt fSb e Ur i i7l appllcetlon to. Instructions to Claimant Clerk of the Board P.O.Boz 911 A. Claims relating to Gaus s of action for death or torn injuryntto�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 S'^.ard 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. Fraud. See penalty for fraudulent claims,• Penal Code Sec. 72 at end of this form. RE: Claim by ) Reserved for_C k�l' stamps RECEIVED Against the COUNTY OF CONTRA COSTA) JR 17 '19N or DISTRICT) c�eR P D Y R OR, (Fill in name) ) R s °ty . The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of $_�". 6t- f and in support of this claim represents as follows : i. Een When did the damage or injury occur? (Give exact date and hour) w OL SA r A w s-�ec,r e on. � r•n rr, C I o opt) o N J k yve, A 3 ,e �}-- � 2- o 0 olc(oc (L ---2 --•-- ----------------------------------------------------------------- � ' . . where did thedama a or injury occur? (Include city and county) Clot +DfV Ve,4e,J (t C (01�+0P I Co co ccq"vJ4� ` -- ----------- ----=--------------------(---------------- ----------------- 3. How did the damage or injury occur? (Give full detailis , use extra sheets if required) lo �'f P�'��°'vim � 8^� A� ��^ •tt� Wdi � )� 10 COti - 3'er44L yr � Nrl►vc .� rfa�3p6�)p� �ej -- ----•----------------------------------_..-------------------J----- --- 9 . W-hat---p--articular act or omission on the part of county or district officers , . servants or employees caused the injury or damage? O r q, t ` t vo atr i f w e ` e,. C a A F o d-od Q fir e t (over) 5.:,.•? iat: ar.e...the...:names of ccivunty- or district officers , servants or employees:causin the damage or injury? �• Te e_40 j 31858 -_' - ---- ------------------------------------------------------- 6 . at damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto - damage) C.o s+ Pers m.,,a, jr 0 P e w `( �-- C®n-t � e s$ra.r%aA n! A-m ©K A/4' 04- l S 9 LQ ------------------------------------------------------------------------- 1 the a?i^tini claimed above computed? (Include the estimated amount of any prospective injury or damage. ) profer� j oN sef04.f,4 ,,TeCc4 04 rG.G.Pea- hsgec� Gat k 14ev., •glee. d«4eaA ------------------------------------------------------------------------- 8. Names and addresses of witnesses , doctors and hospitals. SarSevo't - _ 14 n+cke - -------------=-------------------------------------------------------- 9-.--., List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT Govt. Code Sec. 910.2 provides :. ; "The claim signed by the claiman SEND NOTICES TO: (Attorney) or by some verson on his -behalf.- Name isbehalf.Name and Address .of Attorney r(2 Claim YtYs d�U�al�9Signature Rv��i S R Z %4 QV.) t 040 i-i HC dde ssl.Q01�0r AtJ fA Telephone No. r �5�� " I Telephone NoY.��/S- •S �-Secy , 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. " Otte Coe �. + � , c� ® ;5 pq%% o Key ��— ---- 6. Za4 q-4 Ket4 py 0 � � It t�o 0 A, T_c ®y ntl� a. S� _ t as --- ----- _- ���= _-�-e � 1 y 7 O 5 . 10--- ------ _ _ --' kt' 45_1 1/1 a ► 7 S cry_ ! 5 C — —_ 7. ! 13gc k ka$ ®o Y_®® -- -- ow 14 _ Qf ------ t : INMATE REQUEST CONTRA COSTA fOUNT-Y DETENT70N FACILITY NAME: --21 k� '-' NC lu J 6-ME s R BK.#: Last First Mi e / �y DATE: 6 ` (,' MODULE: ROOM: 7 CHECK. ONE: O REQUEST GRIEVANCE O APPEAL // REQUEST: 1/ qyzz- �U L4 !Ili + 41 n o n�Z2 r �.D11 t�r)A 44'- f 6 e R4 ; Av k J/" der t RECEIVED •Y,B� � 6 ROUTED TO: O ..PROGRAMS O CUSTODY O MEDICAL ANSWER: O APPROVED jo DENIED - (State reason) -c- ++AvG7 s ki2c -t� �2 ( oPt72ry 200 drN O CALL F�D Amy 211020172 _ YOU20-y 6cMv1APLE—j E BY: 7:��� Title Employee Name - Emp oyee # Pink kept by inmate, Yellow to inmate, White to Booking file 4 -• J � aD +F Q X � a -� -�- I Ake x n m 3L 0 s4 � to '. kA _ Y p �1 i CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA / 2 J Claim Against the County, or District governed by) BOARD ACTION th, Board of Supervisors, Routing Endorsements, j NOTICE TO CLAIMANT Augu s t 15 , 1989 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Governmerit Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $4, 000- 00 Section 913 and 915.4. Please note all "Warnings". CLAIMANT: BRENDA GAINES COunty CounS c/o Leslie Russell, Claims Adjuster for Prudsotial Insu�ance ATTORNEY: P. O. BOX 1825 19 /go. Woodland Hills , CA 91365 Date received A#artine 0,7 ADDRESS: BY DELIVERY TO CLERK ON J�Y1� �7tc�989 BY MAIL POSTMARKED: July 13 , 1989 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. DATED: July 19 , 1989 PpHHIL BATCHELOR, Clerk BY: Deputy 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: 120 BY: I` Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County rator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present (Pef 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 15 1989 PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code sec ion 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: AUC 15 5 1989 BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator A_Cla l to: BOARD OF SUPERVISORS OF CONTRA COSTA CX INSTRUCPIONS 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 aim By ) Reserved for Clerk's filing stamp REC EWIVD Against the County of Contra Costa ) JUL 117 1�$$ or ) PH A7 H LOR District) CLE KE TPD ST PER IQ RS Fill in name ) ev fl The undersigned claimant hereby makes claim against the Colinty of Contra Costa or the above-named District in the sum of $ Q — and in support of this claim represents-as-follows:---- M4A- S IL-Di---------------------- l. _________________1. When did the damage or injury occur? (Give "exact date and hour) --= - IJ--------- pA----------------------------------- 2. W,,heere did the damage , or injury occur? (Include city and county) s_ � l N `.a'�'� in 3. How did the damage or i Injury occur? Give',full details; use extra paper if required) t �(C) � � (5n Hff Y.) 4. What particular act or omission on the part of county or district officers, e vants or employees caused the injury or damage? ` F i bao 4 T �!P.hit (over) 5. What are the namesOcounty or district officers, s vants or employees causing � the damag (or injury? ���e ° arne� -I SK;� ups g . v 6yq6 Ile 6. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed: Attach two estimates for au damage. *�Ql(, ts�yf a-)U, L)VO2�� ff f 90 ----------=------ -------- ---------------------------------- -------- 7. How was the amount claimed abov compu pdl ,J Include the estimated amount of proPpeC �cCG ( e.) f 7 .,1 n CL l.0 a ----------------------------s 8. Names and addresses of Witnes es, doctors hospital ��� �� ��� �J���SS�. ` Lam_ ►��-��� ,`���` 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 some person ^^on^^nnhis be alf." Name and Address of Attorney ti C�ULISu'U.l lam" �ingcn�at � 0� Address I�aS Aclip W)II Telephone No. Telephone No. J. 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. STATE OF CALR.DrfU TRAFFIC COLLISION REPORT PAGE/OF SPECILLCONDRIONS NUMBER MR\RV4 CRV JUDICIALDISTKT LOCAL R[PORNIRISER ""Mat" FELON CIA/ k7V / Wb ) 9RPRrSBOOUT MLL0 _ Q 7 Ved/ te � OLLAUON OCCURRED Op Y0. DTII YEAHTWf(SIDf) NCKS OFRC[Rl0. �+ z� YII.EPOR NR)RWTK)N DAY OF WILK TOW AWAY PHOTOGRARMS SV: F U "ErIMILES or MTWTFS ❑vn ®mo ❑AT WMASECTION WITH ^/� RATE KWV REL 9"' 2i-7 FEET/04!W v/,✓/1 Or '��7/ "/ "'-�(/. �0��-/ ❑y" 1NO JE�ml PARTY OWVER9 LICENSE NUMBER RATE CIA" SAFETY YEN VERB MARS Imo04 NWfER RATE 1 A13i/7 /40f- Q,l ? v'F�e�o�i<} . . 0992 2-- DRIVER NALIE(FIRST.MIDDLE.LAST IOA!-ON ' :-,T?2oS�/ CUNT. �/JJ/C L T11 ADD OWNS"NAY[ 0M o. AV/ �g/. .OC/vV1 PARKED CITY I STATE ZIP OWNERS"ORE" BANK ASDMERR VEHICL■❑ /m/ J;/ez-L �' OCT. SEE/tf R Et NiIOM WHOM BIRTHDATE RAGS OtSPOSRION OF VEHICLE ON ORDERS OR ❑OFFICER &RIVER ❑OTHER CUR Y0.. ; DAI ; YEAR OTN❑ER eUMNEg>=SHONE WOR MECHANICAL DEFECM- NONE APPARENTa REFER TO NARRATIVE CH►LBE ONLY DESCRIBE VEHICLE OMAOE SNARE V4 DAMAGED AREA �{ Y�w VENICE[TYPE INS wBu v.% v zJ,- ❑❑- Y00. EIMAJOR �R O'n' O/ ON RRERORY4WfM SPEED PCP ICC1 ' Tom` /n VAI 2 z2-1o6 ✓ wo PARTY DRIVER'S LICENSE NUMBER RATE CLASS tAFETr V[K VEAR MAKEIMODELICOLOR [NS[NUMOEM RAT[ [our 2 (�-SSS =G4. DRIVER NAYE(RRR,MIOME.LAR) OWkI pi STREET l�ip` Gv �/ ' yGC-�tAYEYDJ '\/ PARKED CRV I/JtJ/.rump OWNERS ADDRESS AME At DRIVER 4Cr• NO. DAY UAB til[ R [ nOOM WOOIff WPMDATI RACE OISPOBRIONOP YaKCLE ONORDERS OF: ❑OFFICfR EORYu ❑OTnu ir GUST OR � [J — ❑ � � — PISOIL rECNANCAI D[RC7S: HONG Av1111EP� REFER TO NAl11Um[ —/FJA•J/ CHP USE ONLY DESCRIBE VEHICLE DAMAGE SHAD[w DAYAOED ARu DIB ECARPo[R FONCY NUWu VEHICLE TVPI 1�"N`a o� -/ 59�g0907¢¢ Ol " pIa [:]Now pTO.w ORA Of JONSTREETOWHISMINM SPEED jPCF K%[ TRAVEL ,///J / �, LI —� IVC❑ C „/ IV CHF0 PARTY DRIVERS LICENSE NUM BER RATE CLASS SAFETY VEK YEAR MAKE/YOD[LI COLOR ENS[NUYB[R RATE 3 EQUIP. .. . . . . . . . DRIVER NAME(FIRST.MIDDLE.LAST) PEOES. STRERADDRESS OWN[RSNALIC11 ❑SAYE DRIVER THAN PARKEDCTIISTATEIEIP OWNER?ADDRESS -a SAY A9 DRIVER VEWLE cl SICY• SEE HMR REB HEIOHT WEIG - SIRTHDATE RACE DISPOSITION OF VEHK:LE ON ORDERS OF: ❑OFRGER ❑DRIVER ❑OTHER CLIR - 'YQ ; DAY ; YEAR - _ - - ) OTHER HOPE PHONEt NE58 PITON[ PRIOR MECHANICAL DEFECTS: [APPARENT REFER TO NMRATVE❑ ❑ ( ) ( ) CHP USE DEECRISEl KCL DAMAGE SIU DEIN DAMAGED AREA INSURANCE CARRIER POLICY NUMBER V[HICL[TP[pa . ❑{EGL ❑ ❑MINOR [:]Moo. ❑Y OR [:]TOTAL TR OF pIfTR[R OR HIDMWAY SPEED PCF ICC TMYft UYR PUC a CHP PREPARERS NAYS /' -/ DISPATCH NOTIFIED REVIEW EP'S NAME OATc: S REVIEWED Q (t6�?1�Ti T6 • 7fT! QIVES O NO 13 NA _ t"-I jq !G7 O CNP SSS PAGE t (RAv T-88) OP1042 88 48667 STATE OF CALIFORNIA ! Y • -Z TRAFFIC COLLISION CODING \ PAGE DATE OF COWSION Twit am NICK NUYYEA pFric 1.0 NUMBERMo. DAY Z/ YEAR IS/ �715� ,j o, Q7/.S �► OWNER'S HAMS/ADDRESS / NOTIFIED PROPERTY /UD E DES El ND DAMAGE [DESCRIPTION OF DAMAGE SEATING POSITION SAFETY EQUIPMENT EJECTED FROM VEHICLE OCCUPANTS L-AIR BAG DEPLOYED - -r- F. uE'7 _ CTED A-NONE IN VEHICLE M-AIR BAG NOT DEPLOYED DRIVER 0-FULLY HOT EJECT B-UNKNOWN N-OTHER I-FULLY EJECTED V-No C-IAP BELT USED P-NOT REQUIRED 2-PARTIALLY EJECTED f-DRIVER D-LAP BELT NOT USED W•YES 3.UNKNOWN 1 2 3 2T06-PASSENGERS E-SHOULDER HARNESS USED PASSENGER 4 5 6 T-STATION WAGON REAR F-SHOULDER HARNESS NOT USED CHILD RESTRAINT X-NCI 8-REAR OCC.TRK,OR VAN G-LAP I SHOULDER HARNESS USED 0-IN VEHICLE USED Y-YES Y-POSITION UNKNOWN H-LAP/SHOULDER HARNESS NOT USED R-IN VEHICLE NOT USED 7 0-OTHER J-PASSIVE RESTRAINT USED 8-IN VEHICLE USE UNKNOWN K-PASSIVE RESTRAINT NOT USED T-IN VEHICLE IMPROPER USE U-NONE IN VEHICLE ITEMS MARKED BELOW FOLLOWED BY AN ASTERISK(•)SHOULD BE EXPLAINED IN THE NARRATIVE- PRIMARY ARRATIVEPRIMARY COLLISION FACTOR TRAFFIC CONTROL DEVICES 2 ',� TYPE OF VEHICLE 2 3 MOVEMENT PRECEDING- UST NUMBER (E) OF PARTY AT FAULT COLLISION S {QVC SECTION VIOLATED: cla%s- ACONTROLS FUNCTIONING I IAPASSEHGFR CAR/STATION WAGON I IASTOPPED —22/Dy, 4290 B CONTROLS NOT FUNCTION NG 1 113PASSENGER CAR W/TRAILER N IB PROCEEDING STRAIGHT E BOTHER IMPROPER DRIVING CCONTROLS OBSCURED I IC MOTORCYCLE/SCOOTER I IC RAN OFF ROAD D NO CONTROLS PRESENT/FACTOR• D PICKUP OR PANEL TRUCK ID MAKING RIGHT TURN C OTHER THAN DRIVER• TYPE OF COLLISIONPICKUP/PANEL TRUCK W I TRAILER E MAKING LEFT TURN JE DUNKNOWN' HEAD-ON CK OR TRUCK TRACTOR FMAKING U TURN fn M E L LE B SIDESWIPE GTRUC RUCK TRACTOR W/TRLFL BACKING REAR END SCHOOL B SLOWING/STOPPING WEATHER( MARK 1 TO 2ITEMS) D BROADSIDE I OTHER BUS I PASSING OTHER VEHICLE ACLEAR E HIT OBJECT J EMERGENCY VEHICLIL, J CHANGING LANES BCLOUDY FOVERTURNED K HIGHWAY CONST.EOUIPWNT KPARKING MANEUVER C RAINING VEHICLE/PEDESTRIAN L BICYCLE L ENTERING TRAFFIC D SNOWING OTHER•: OTHFJR VEHICLE - OTHER UNSAFE TURNING E FOG I VISIBILITY FT. MOTOR VEHICLE INVOLVED WITH N PEDESTRIAN XING INTO OPPOSING UNE F OTHER•: ANON-COLUSION MOPED PARKED G WIND PEDESTRIAN P MERGING. LIGHTING OTHER MOTOR VEHICLE TRAVELING WRONG WAY ADAYUGHT D MOTOR VEHICLE ON OTHER ROADWAY ' 2 3 OTHER ASSOCIATED FACTOR(S) OTHER-: B DUSK-DAWN E PARKED MOTOR VEHICLE (MARX T T02ITEMS) C DARK•STREET LIGHTS FTRAIN AVC SECTION YaLATlo": CITED D DARK-NO STREET LIGHTS BICYCLE (]Ya ONO E DARK-STREET LIGHTS NOT ANIMAL: B Vc SECTION VIOLATION: CITED , FUNCTIONING• H ❑r0 ROADWAY SURFACE C3NO SOBRIETY-DRUG FIXED OBJECT: CVC SECTION Mau CITED 1 2 3 PHYSICAL A DRY I J]YD (MARK 1 TO 21TEMS) B WET OTHER OBJECT: c3No HAD NOT BEEN DRINKING C SNOWY-ICY 'I D BHBD-UNDERINFLUENCE D SLIPPERY(MUDDY.OILY,ETC.) E VISION OBSCUREMENT: 96W_W,5= HOD-NOT UNDER INFLUENCE• , ROADWAY CONDITION($) F INATTENTION•. HBO-IMPAIRMENT UNKNOWN' PEDESTRIANS INVOLVED G STOP i GO TRAFFIC (MARK f 70 2ITEMS) ){ENTERING/LEAVING RAMP E UNDER DRUG INFLUENCE' A NO PEDESTRIAN INVOLVED F IMPAIRMENT-PHYSICAL PREVIOUS COLLISION A HOLES.DEEP RUT• CROSSING IN CROSSWALK IMPAIRMENT NOT KNOWN B LOOSE MATERIAL ON ROADWAY• B AT INTERSECTION UNFAMILIAR WITH ROAD NOT APPLICABLE C OBSTRUCTION ON ROADWAY• K DEFECTIVE VEIL EQUIP.: CSO CROSSING IN CROSSWALK-NOT oYES I SLEEPY/FATIGUED D CONSTRUCTION-REPAIR ZONE AT INTERSECTION Ofa SPECIAL INFORMATION E REDUCED ROADWAY WIDTH DCROSSING-NOT IN CROSSWALK L UNINVOLVED VEHICLE AHAZARDOUS MATERIAL FLOODED• IN ROAD-INCLUDES SHOULDER IWOTHER' G OTHER•: F NOT IN ROAD rfl IN NONE APPARENT H NO UNUSUAL CONDITIONS APPROACHING/LEAVING SCHOOL BUS I 1 10 RUNAWAY VEHICLE SKETCH - MISCELLANEOUS b(;,)J Et.0 A-/ Intq _7 A-AN L-Iy. - - �($H • ---.--_ MA _NORTH - - 3 5/ V-2 BAILc Y R�. , RATE'OF CALD°ORNA plNk%REQL/ W!f•NESSES / PASSE Y.RS PAGE LLISION TIME R4DD) iNCIC NUM ER OFFICE D. NVMSER �� GzS-a/ -89 �9s Sao ��s MNESS PASSENGER ADS SEE EXTENT OF INJURY( "X" ONE) INJURED WAS ( "X" ONE ) PARTY SEAT SAFETY EJECTEDONLY ONLY FATAL SEVERE OTHERVISIBLE COMPLAINT NUMBER POS. EOUIP. INJURY INJURY INJWIY OF PAIN DRIVER PASS PEO. BICYCLIST OTHER ❑# Z r El El El ❑ ElCl ❑ I ❑ I ❑ 2 a NAME I D.O.S.I ADDRESS A TELEPNONfi �u � s -i3- / �l y1i77�1 �niG✓. �ZOr Gr/a'T i7.ZT�u.� CA' �i-r (INJURED ONLY)TRANSPORTED BY: TAKEN TO: DESCRIBE INJURIES ❑ VICTIM OF VIOLENT CRIME NOTIFIED 2 f 0 1010101 El 101 leg- NAME I D.O.B.I ADDRESS T PHO 4"TN/4 14P, war irrr�..eb, may. �isJ ¢s-�5 43 INJURED ONLY)TRANSPORTED BY: TAKEN TO: DESCRIBE NJURIES ❑ VICTIM OF VIOLENT CRIME NOTIFIED ❑# ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ NAME I D.O.B.I ADDRESS TELEPHONE ONJURED ONLY)TRANSPORTED BY: TAKEN TO: DESCRIBE INJURIES ❑ VICTIM OF VIOLENTCRIME NOTIREO ❑# ❑ ❑ Cl ❑ ❑ ❑ Cl ❑ ❑ NAME I O.O.S.I ADDRESS _ TELEPHONE ONJURED ONLY)TRANSPORTED BY: TAKEN TO: DESCRIBE NJUNES LACTIM OF VIOLENT CRIME NDTIRED NAME I D.O.B./ADDRESS TELEPHONE (INJURED ONLY)TRANSPORTED BY: TAKEN TO: DESCRIBE INJURIES ❑ VIC MOF VIOLENTCAME NOTIFIED ❑# ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ NAME 10.0.11./ADDRESS T EPHONE ONJURED ONLY)TRANSPORTED BY: - _ TAKEN TO: DESCRIBE INJURIES VICTIM OF VIOLENT CRIME NOTIRED PREPAREE 1.0 BER M0. DAY YEAR REVIE WER9 NAME M06 DAY_ _YEA CHP 555-Page 3(Rev.7.87)OPI 642 87 43637 FACTUAL DIAGRAM OAT!OF COLLI[ION . 0 TIM! ■\vi/_' MCI9NU M[[w O.91C1w 1 VVY[[w 4 A// - J • ALL MEASUREMENTS ARE APPROXIMATE ANO NOT TO SCALE UNLESS STATED (SCALE. 1 ! 20 BusciEs �Yc�o�✓e FE,vcL D,2�vcw4Y �' 4' 35� f�Sf'F/RLT /eOlyY. v'2 41 27-0 / ON LR.cTE BA ILL V RL- OwAwN v // 1.0. NVYesw Yo, oAv rw, w[V ICWY'w'S NAYc Yo. oAv rw. ��l�n��Z T o. I g7iS I OSzi �y CHP 555—Page 4 (Rev 11.85) OPI 042 IAARiUAME/SU.PPLEMENTAL PAGE DATEOFINCIDEf.TIOCCURENCE TIMEI240q _ NCC NUMBER OfF AUMSER S%b2 Of`s-z - /7/.s' ya20 1 7is- 'KONE WONE TYPE SUPPLEMENTAL fA'APPLICABLE) NARRATIVE �COWSION REPORT ❑ BAUPDATE O FATAL ❑ HIT;RUNUPDATE OSUPPLEMENTAL ❑ OTHER ❑ N42ARDOUS MATERIALS ❑ SCNOOLBUS OTHER CITY I COUNTY;JUDiCALDISTRICT REFORTINC DIS1fUCTTIISEAT GTATCN NUMBER /'rV C G//ll CA•7'V//c-^f C_O S LOCATION)I S.UWE T STATE HIGHWAY RELATED -4I// /IVAl Z / Gt� /!��/LES E9 O 2. /N I�O L dii✓lr ��t�/fj� l/N/> �7r.0�d / 3vey,�!. S/ ir� acv 3. IlAer. 4. /3116ef 5. 6. �G��/E' /1/Ii9�l /�ir/.� 4V /S tSiDFic%stL ST AT dam. i�•`/�-v- 7. CONsixil�7�ox1 �tcw./✓G ��9vT=u/t-sT- f�oT�/ .�Aw _ ��6Ezs 8. 9. rA� xt� Li/dE /�o7w 4S,a6T o� fT.4�zf w,7' 141177/ ���✓�� 10. A107-zr// u;�' itiya �9vo ocr�o� 11. �Nf3t- «+'///GE c� Bim/�j� �,D� v7� n���-.c7u/ /�/2/✓L2r/ 12. G 1tZ'&Zc Z:14-000 J-- /9�T/LLE�YT �Yy/l'PLj;t- /`f 13. Go /fG�.✓s7- N TlJW c�6� /�i1/O W r� .�/�/� 14. 15. yyE- 1s. pis �i2/rt7j.9- A 17. diEw / Gt/�"Srt��r �i�EL�Ti ! /j� /✓ . 18. cS E 19. 20. 7793-' -i vd•� S% n'O/ exr l/'/ Gri�a,r/ y i �ilZ.. 22. 7211 /j9 dfl� h �i4/ !/A>,�D L7/�!lil�S LlEEX/SE"_/ic/ 41JtjJi 23. / 24. OZ u/fI3 p yJ .si�c� ��✓� //Z 6,)", 25. o-.P, NE <! 1/.�uD 7�,e�riE�l f G.c sc i/�/ f/ �ess�-sirn✓ 26. vTs . 27. 28. S/C=-fIZ �1/ibt�✓CE; 30. 31. 32. PREPARER i,D.N ER MONTN IDAY/YEAR REVIEW ERS NAME MONTHIDAY/YEAR CHP 556(Rev.7-87)OR 042 UAAPI "Mf .blEAd MW 88 4WI NARRATIVE/SUPPLEMENTAL PAGE DATE OFINCIDENTIOCCURENCENr r2 OFFICE LD. ABER'5917 I� /Z/5- ;Zo • /S �IJr •ICgNE X'ONE TYPE SUPPLEMENTALTIC APPLICABLE) NARRATIVE1X1 COLLISION REPORT ❑ BA UPDATE FATAL ❑ HIT&RUN UPDATE ❑ SUPPLEMENTAL IL❑J OTNER: O HAZARDOUS MATERIALS ❑ SCHOOLBUS ❑ OTHER: CITY I COUNTYIJUDCAL DISTRICT REPORTING DISTRICT/ T WATION NUMBER u/v.A,Jc- Co nA Cos.�s- D�-Z /-/"V,• S-oo LO / � ,V• STATE HIGHWAY RELAT ED YES !Eimo- 2. 3. P�L 7�/�' �i�- was c :� o�✓ �'J� .�i L.�. 4. 5. &Zf SAT lF u/>'ts Gd/,�G S� ffirro T<�E- �c�.o C.ff� 6. G .5�. .I �4fo cf/!E /T�dis�� /Ll2r Tli !� �U QF 7. Gly �JiO ,t/OT Lift✓E kyrG:�v �iGr� oiQ -Si,P��t/ 6�/. 8. s. O//ry/crt✓.5151ma ,o7v 2�-u s/a�v,3 /2727'1 11. 5�2-o Pa•eSE/in,G ..�7� �//��. -����v�-.�/G- /�"-Sisi 12. -/ '✓�«.t,�l cam_ l v/ G� /�/�Z`,eiv�� ti 13. fou �� �ii2�C7�Qy✓ / u/i9S t�r2iv� �1 G�a� 14. _C rwj 15. C77a 16. ! 18.19. 20. /0-/s l//sl o,1J m 21. .,Z2&.u- to 41ed;?,2 Lsv. 22. 23. ri.o�.�-rives o� Z2sa� �/e�,; /.�rr� ��Er i��</ :� /�Z w•�i/�cf/ //�� 24. 25. �X/ �T�GtG� %7/f L FiPovT �✓G �� l/2, 26. 27. s/ ���z y �uc�E' i✓J 28. __4 �h� 29. 30. 31. 32. PREPARER' i. .NU R AgHTH/DAY/YEAR REVIEW ERS NAME MONTH/DAY/YEAR 7/� OS-Z/-S9 CHP 556 (Rev. 7.87)OPI 042 aS 48641 71TEOr UFORNIA //� NAR4ATIVE/SUPPLEMENTAL. PAGE DATE OFINCItlENT/OCCURENCE TIMEI2001 NCIC NUMBER OFF IOERI.D. NUMBER 'os.--2/- .F9 1 .9-3 Z-0 4 ��r 'Jr ONE '%rOONNE� TYPE SUPPLEMENTAL Cr APP1JCABL.E) NARRATIVE IyT rAWSION REPORT a SA UPDATE ❑ FATAL HRIRUNUPOATE ❑ SUPPLEMENTAL O OTHER ❑ H4ZAR000SMATERIALS ❑ SCHOOLBUS ❑ OTHER CITY,COUNTY%JUOICAL DISTRICT /�t•� C--B��/��-y- �OS/ - i//��ji REPORTING DISTRICT GTATiON NUMBER 40 LOCAT SUBJE T e--JZ `JV_ STATE HIGHWAY RELIT ED n YES NO 2. 3. ✓/ L !/lDt.4T?vn/ 1i2�b(o �L' . 4. / 5. - 6. 7. 8. 9. 11. _ 12. 13. - 14. _ 16. 17. 18. _. 19. 20. 21. 22. - 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. PREPARERS LD USER WNTHIDAY/YEAR REVIEWER5NAME MOMH/DAY/YEAR 71,r CHP 556(Rev.7.87)ON 042 u..a.Mau.saxrumlarl«w .88 48641 7-1 17 BEAT OCCURRED -2/ FORM C 179,Casa File No. rc e/ClaaHlrtatrdn 181. Deu 11 lode 1 j182. Detail Code 2 187.8 font. Supc. 184.Victim Name IL FM) 185.Dau Ong. licit. lies .Gate•Tmu This Rpt. 1187.Grd Code 188. Suspect Peine (Lr FM) lag. OESCRtR10N Ilmpwndy.Retwend.Frond.loo.Sulenl hero No..AnrcN.drerrhtY.Mnd/Make/Manuhctum Model Nwnber.Santo NumeM.114uc4114news Destnpbon,l,ocn.on a a taken.Vatun.Include total Lose-LIST IN FOLLVVING ORDER.A)Currency.Noce 8)Jewret.Y,CICloV".Furs.Ol Vehrctee EI Office Eouomert F)Rado.TVs.Inc.Gl FrreermsMINwsenoW Goods II Consumapte hems JI Lnnstxs x1 Msc N 3 t ? F /P 7-ItS ILO Z Orel �Q n T Pd-XJ0;-L or- A SE)LELI 00VIC1,5. T S ON/Jilf-9 l0ifZ CC K-dPAs 4 ATN 6Jk i r X" 7Nz�U a` Ory �.K' SNE ,-&7- i t u ,C't Avo1/ ,2 % d//l/ E G S? ✓14rV/ 190•Distribution. 8_DE_DA_L_0_SR_V Coroner_Nartotics_Imiestlgation_Juv. _fnte111 Bence Ylce_Ccaplelnt Oft. Fog 1 /.Reporting OP r' _ it Em6 ! 193.9isposition Patrol Cap. press $tat, other d(•/T .ppprovmg SuPv n 195.Ema a "' " 196.Due 197. ?aqe CON7 COSs A COUNTY SHERIFF-CORONER'S DEPARTMENT -- P. 0. Box 391, Martinez, CA 94553-0039 -- (CA0070000) Rev 5/86 — 1 PAC 2319NY Etl.3.x86 ❑ Prudential Property and Casualty 1*-�3nce Company ❑ Prudential General Insurance Compc[ ❑ Prudential Commercial Insurance Co -y ❑ The Prudential Property and Casualty Insurance Company _ of New Jersey ❑ The Prudential Commercial Insurance Company of Delaware ❑ Other Payment For CLAIM NO. DATE Ll !/ INSURED Detach CLAIMANT this stub before - cashing POLICY NO. LOSS DATE Retain for your PROVIDERS TAX-ID SERVICE FEE PLEASE NOTE records Prudential Property and Casualty ,nI Insurance Company and Affiliated Companies Western Regional S ce Office YY- 4199724 Subsidiaries of The Prudential Insurance Company of America Voidable ninety days after this date CLAIM NO. DATE The Prudential Z taxr, '],g '2. 0 z Pay �. .. AMOUN , - / r Not valid for more than $99,999.99 / 40 /7 L �¢ r��!/� 1, 51-44 Tothe f\.�1 Ci`O-SR V er l •" /''te � „g orr r/@ �•.�/•" tn,/A• -_ of s - ` NON•NEG,OTIA der gj,� �• �i-/--/5 .- -'`i fr, e? FILE COPY BY _�i�../t`.%z;i% •; Gri�Z•��f'-'✓'', SX KS ID Amt.j� SX KS ID Amt. SX KS ID Amt. • Fp,IljiEkT14 F'P:vFrfNc e P,fi, E:i'i 21261 BURBANK* ✓_ 'j1"•7 - ,t:cl n LOSS PTE; ' 5.�!ir,9 �lii jC�C°ilii ON; {.ji,..•_. I_I!i',NTM E: RUN[ (ITL IrI ilii KR. CLAIM I 1 `If•. ALLEN Li#j JE4 w_i r�1f_`''}; !r) :._•I!�iiti:<.i% tly _ i_i� 1.4. 'rC�p� _ i-t" TOAFIIr2iA Cryrr;ICt : rrMi.4C Glii tl0:802_ !' . SG MAE410 10.565 ....LO'':, __!':!i T40 _I:ilif`.L_, .. Ud y;i%;LI!:L-. I'{ .LI 0!M1i n PTl!NS; i:jr•FER rMFi=::_T -yin iF'j, . IrxC Jti .•, tNL iEA L;',VPSYSTEM, P,GER FOK? ntlTENHA, POOR -,rF4G, POWER BROTSk_LE17FI• 10dJF, CRUISE CONTROL ], ? fy_.'y. . Er.uj 91.1. J1 ..JT,. ?.Lr., ;I _ KE FFL IP. ENL! ;\,.,.E _ r:.,., cUTQPtAI I_ T4 i,ii:-,l1 b, 11);i . LIME ENTRI I n_;IY _IN _ii =C;hi YF E VOLLAR`" `"'H.`-: i k ,: C. ERAT rrr, Es GA. 1,8.:,.!!.T AIT . TEn tl,!?E�cR „ E iJ�'_:.H{,u., _�t5!_:::��:\.. ..�'i 1_iE{?Er ..:'i.._!, ,:,.! '. 11161. REFIR it EFlidl:iH. =: '-, Ei<e . :'.'FI"SIN __' T .i 31lr^i L;-. /,:.!C �ni ar. J , re,: I q_T.•• ;.r: -, .�.d _,q/ h'Fi;.i�_iEc< .�,.E E:,•_:• r'S'I OL.I,L(... DRILL E!'IF ?:..,rL�nl. 31001 iPY °EMOVE.pEFLAC r 'FlL Ff:+4K'3 irEF . !.03101 155,20 ... a AUTO RE=!N REF1N.r SH lG i.c; LE'T _. _ 5 112090 HI,r1Y nC.MOVE/R X ACE F_!QER KFT 1:035017 . . 4 312550 BODY Rt_MOVE!N4rl UE ADKE!!.._, NT O iiA, FE2ER 07 _N I 0K.6 P. 1'I!Fi.141]TYi:L :!JO ?.ICI i_i.!�%h. �.'_�i R,32 I.r•S QFIN REFINISH sH ..__ F91 .1 is iSE._ p,._r_"il+t __ , it AUTO F.Eri'! 2EVINIS14 NOR 017':.._, REFINISP LEFT 12 321100 SPY I1F,;r'LAC OIj!ii,_ti!iii FROM iDGIR !EFT 0:11037 i 911010 MECA ;I I, _ENT PINT ISENTON L'.`5 14 933012 REFI . n[I_:'_ _y ;i:F OPS _:TRIPE is AND P&L COST PPIAT H 1 i.KS 1. XOR 'j{BT9 ijL n PAM_ a(i!E 70GLE t 1. 1 A;T L R C E 'il_I, 3 UI)T� EDDY 5.1 14 237.20 'ArAiLE ✓u;;T. 2:1.60 REF IN i.I .•iii, HEM _ cc 00 ._.Vi` ,,;'.LES ..:_ -'t!1'}Xn.R 0 T A I S ...... 27,.jil ... .I`PL,yi_.EP!_iIT . ...',I , SAES O . 40K 4.S-1. .ldL . :.�iilQ:'�iM1l. i:1=f.[. 10 f 11_.Ilt':YR _t'_i:{.ii E' lj ?0"Eii t'E .1-'i liJ_•!"l _�.i f: . ...:, ET 010 -.... VEHHL INfSPEi Ti"-'- I_FiL yTj_ RES ;t:Ijt': Ph?!_I rtti'i __,�'Pijj:E i_k�.i_ .' ilii `:r.•' .i!fi's ' 1531 NY'T . :i ._,1 ,., tU?'H ,.� .34557 TKI9 15 NOT aj ~ iT '�'I=E7 ;'EP:r'(F, ORDERH: 'ZU F'I Et7FM,1S FOR. n!f[Ij i IuNri. (:riNi;L OF: Qf EN I i:_. _ i. LL -1i i�:, _ .I MGM!iO ^N, !11 'r MYRED •iil E.�? ��r n -4 f; YOUNEW 7i F_i _. _ �'N. !{.Int?L'•a-L_ HT MITI PF-E 7_Is•P"'N ...r! Fzr -Iy7 ;GRE"MENT WITH _: 1j r, ;„ _� TO, '!,JC F : T1 ti.:ifN,! 1 i TH= UPIDE R.SITCHED „GE:E=_ TO r+lti LETE UPPIRS AS ITEMY' 70l,'IRACH-E, Ts: T ;h_ M'__ OF I Ad S:iiOr" REP: iTLEH:_17! f_ijgt.,l.,ji_ TFp TC 'r'Ei IC,E IldlEn. 't• 00 V; DRUT i_':TD? 0"—"'`+.l ._lljii P.CPfiE'?i "•lil lv)E ij�?vw 14R= I_ MS� ._ ^.�:._;i,.Y`' (s': L:_Ci1'-_..= ':II; l.L�l�C Y'ii1R, RE hitf_W CgREFULLY :EI AUTO .DEWS SI__.r, AS I,NINGY I'LMiil_ii.,ir. .flr .A i_R(4H' e.. r..^r_Ll I:Y} TO SNr EL' -,EPAN; itM, ilF TIr;riTEsiti.iLL N1 iER ";�j(f1;`5' '',7 21 -_ .r .I.ii'1'IPli_I'', vT s ::• rtI1G!'EL+_�l« INTi;. , i.,, 13 v' OIEC X R�L�SON 1 to La�;x�N�s PKaja 4 A1L LOS MEDANOS CHIROPRACTIC GROUP A Professional Association of Independent Chiropractic Practices 3978 Railroad Ave., Pittsburg,Califomia 94565 (415)432-1300 WILLIAM WHITNEY,D.C. JEFFREY SIINO,D.C. ❑GENLRAL PRACTICE ❑GF.NF.RAL PRACTICE ❑DISABILITY EVALUATION ❑DISABILITY EVALUATION James Armstrong, D.C. RE: BRENDA GAINES D/I: 5/21/89 CLM#: 13I 07032 036 RVS DATE CODE PROCEDURE CHARGE 6/1/89 90015 INITIAL HISTORY & EXAMINATION $ 61.42 6/2/89 72050 X-RAY: CERVICAL, COMPLETE 120.00 6/7/89 95842 ELECTRICAL MUSCLE TEST 75.00 6/2/89- 90050- 14 OFFICE VISITS 054.22 INCLUDING 6/21/89 97200-52 TREATMENT WITH PHYSICAL THERAPY 759.08 6/21/89 TOTAL AMOUNT DUE TO DATE: $ 1,015.50 1 *NOT A FINAL BILL DATES OF OFFICE VISITS: 6/1,2,3,5,6,7,8,9,17.,13,14,15,16,19,21/89 ' ASSIGNED MAKE CHECK PAYABLE TO: DOCTOR JAMES ARMSTRONG, D.C. SIGNATURE` 7/8 ADDRESS 3978 RAILROAD AVENUE DATE �b/23 PITTSBURG, CA 94565 SS# r47-X:?-6765 ,uuanuai uaneral Insurance Company N' ��ttNntty ` Attending Physician's Report Prudential Commercial Insurance Company s1 of The Pttdential Irmeama Comparry of America Pfudenhal r tient's name and address BRENDA GAINES 141 SPENNAKER WAY PITTSBURG, CA 94565 Age (if known) 46 lOccuoation NURSES AIDE (1A) History of occurrence as described by patient PATIENT STATED THAT A SHERIFF'S CAR BACKED UP INTO THEM. (B) Diagnosis and concurrentcc ACUTE SEVERE &"AL SUBLUXATION SYNDROME ACUTE SEVERE THORACIC SUBLUXATION SYNDROME (C) .Were X-rays taken? f'yes,where? CK Yes ❑ No _ THIS OFFICE MAI When did symptoms first appear? (8) When did patient first consult you for this condition? 5/21/89 6/1/89 Date .................................................................................... 19.................. Date............................................._.............................._..... 19.................... (C) Has patient ever had same or similar condition?/If"Yes" (0) Is condition solely a result of this accident?/If no explain, state when and describe' ❑Yes ®No ©Yes ❑ No (3A) Nature of surgical procedure, if any?/Describe fully" Date performed N A (8) Charge to patient for this procedure including (C) If performed in hospital,give name of hospital post operative care .........NLA................... ❑ Inpatient ❑Outpatient (4) Give dates of other medical (non-surgical) Charge per call treatment,if any. Off ice ......_..............._...._.. ... ..._...._. . $...................._... ....._. „„. ............................... SEEATTACHED BILLING Home......................................................................_.........._ $.......................................... Hospital...._........................................................................... ............................. .. Nursinghome...._.................................._.......... w. ....... $..._.__... .... ...... _.. Total (non-surgical)charges......_.............................._....... 5..........................._......_...... (5) What other service,if any,did you provide patient?/Itemize,giving dates and fees* (6A) Is patient still under your care for this condition? If"No” (B) If"Yes',give estimated date of termination and cost of give dates your services terminated further treatment PATIENT WILL BE RE—EVALUATED EVERY 10-12 CfYes ❑ No Date........................_......................................... OateOFFICE.,VISITS?..... Cost............................... (7A) HOW long was or will patient be.constantly totally disabled (unable to work)? From.....Ua ...L................ 19.8.9....Thru.....June....3................. 19....1�s. (B) How long was or will patient be partially disabled? From..................................... 19......... Thru...................................... 19.......... (C) Was house confinement necessary?JIf "Yes"give dates ❑Yes ® No From......:.............................. 19..........Thru...................................... 19......_.. �(8) What if any,permanent impairment will result?" Date Signature(attending physician) Degree Telephone 11RS ident.no. 6/23/89 D.C. (415) 547_43-6706- LStreet address C r State or Dravince Zip Code 3978 RAILROAD A NUE P1"QS CA 94565 "Use reverse side if additional space is needed. Approved by Council on Medical Service,AMA 1968 PCO 1976 ca 12 82 Printed in U.S.A. AUTHORIZATION AND ASSIGNMENT OF BENEFITS To Dr. William Whitney /Dr. Armstrong, 1. You are authorized to release any information you deem appropriate con- cerning my health condition to any insurance company, attorney or adjuster in order to process any claim for reimbursement of charges incurred at the Whitney Chiropractic Office by me. 2. I authorize and assign the direct payment to you..of any sum I now or hereafter .owe you by my attorney out of the proceeds of any settlement of my case, and by any insurance company obligated to reimburse me for the charges for your services or otherwise obligated to make payment to me or you based in whole or in part upon the charges made for your services. 3. I give assignment and lien against any claims against a third party whose negligence may have caused the patient's injury, up to the amount of the bill for treatment. 4. In the event any insurance company obligated by contractual agreement to make payment to me or to you for the charges made for your services refuses to make such payment upon demand by you, I hereby assign and transfer to you the cause of action that exists in my favor against any such company (the names) of which is believed to be correctly set forth under pertinent data below) and authorize you to prosecute said action either in. my name or your name as you see fit and further authorize you to compromise, settle or otherwise resolve said claim as you see fit. However, it is understood that until all reasonable efforts have been made to col- lect the sums due from the insurance company (or companies) contractually obligated, you refrain from attempts and efforts to collect the amounts owed directly from me. L understand that whatever amounts you do not collect from insurance proceeds (whether it be all or part of what is due) I personally owe you. 5. I waiver the Statute of Limitations regarding my doctor's right to re- cover. 6. A photocopy of this Assignment shall be considered as effective and valid as the original, c� DATE �/ — / SIGNED X I�L�{� Z.J-A0A) WITNESS PERTINENT DATA: Date of Injury; 5/21/89 Name of insurance company; PRUDENTIAL Policy #; CLM#o 13I 07032 036 t, LOS MEDANOS CHIROPRACTIC GROUP '8 A Professional Association of Independent Chiropractic Practices 3978 Railroad Ave., Pittsburg,California 94565 (415)432-1300 WILLIAM WHITNEY,D.C. JEFFREY SIINO,D.C. ❑GENERAL PRACTICE ❑GENERALPRACTICE ❑DISABILITY EVALUATION ❑DISABILITY EVALUATION James Armstrong, D.C. RE: LETHA QUILLENS D/I: 5/21/89 CLM#: 13I 07032 036 RVS DATE CODE PROCEDURE CHARGE 6/1/89 90015 INITIAL HISTORY & EXAMINATION $ 61.42 6/2/89 72050 X—RAY: CERVICAL, COMPLETE 120.00 6/7/89 95842 ELECTRICAL MUSCLE TEST 75.00 6/2/89- 90050- 13 OFFICE VISITS 054.22 INCLUDING 6/21/89 97200-52 TREATMENT WITH PHYSICAL THERAPY 704.86 6/21/89 TOTAL AMOUNT DUE TO DATE:** $ 961.28 "NOT A FINAL BILL DATES OF OFFICE VISITS: 6/1,2,3,5,6,7,8,9,12,13,14,16,19,21/89 DENEIUFFTS ASSIGNED MAKE CHECK PAYABLE TO: DOCTOR JAMES ARMSTRONG, D.C. SIGNATURE ADDRESS 3978 RAILROAD AVENUE DATE 6/23/89 PITTSBURG, CA 94565 SS# 547-4.3-6706 Prudential Property and Casualty loaur>_ Company" C Prudential General Insurance Company. Attending Physician's Report Prudential Commential Insurance Company staDsidiries of The Pndemial Irwance Corllpartr of America Prudential 17 ent's name and address LETHA QUILLENS 104 CLEARLAND DR. #3 PITTSBURG, CA 94565 Age 62 (Occupation (if known) (1A) History of occurrence as described by patient PATIENT STATED THAT A SHERIFF'S CAR BACKED INTO THEM. (B) Diagnosis and concurrent conditions* ACUTE SEVERE CERVICAL SUBLUXATION SYNDROME (C) Were X-rays taken? If yes,where? IN Yes C] No IN THIS OFFICE 12A) When did symptoms first appear? (B) When did patient first consult you for this condition? Date 5/2.1 89 19.................... ........�»................................................... 19..................» Date........_........6�1�6............................. (C) Has patient ever had same or similar condition?/If"Yes" (D) Is condition solely a result of this accident?/tf no explain* state when and describe' ❑Yes ® No I El Yes 13 No (3A) Nature of surgical procedure, if any?/Describe fully* Date performed N/A (B) Charge to patient for this procedure including (C) If performed in hospital,give name of hospital post operative care $........................................ 0Inpatient 13 Outpatient (4) Give dates of other medical (non-surgical) Charge per call treatment,if any. Office $...................». Home................................................._............................... $......................................»... SFEATTACHED BILLING Hospital................................................................................. $_................................._,..» Nursinghome.....................»............................................_. $................................._..... Total (non-surgical) charges........................................... $......................................... 115► What other service,if any,did you provide patient?/Itemize,giving dates and fees* (6A) Is patient still under your care for this condition? If"No"' (B) If"Yes".give estimated date of termination and cost of give dates your services terminated further treatment PATIENT WILL BE RE—EVALUATED EVERY 10-12 OFF [1t Yes 13 No Date................................................................... Date.........ICE VISITS. Cost..................................... ....................... (7A) How long was or will patient be.constantly totally disabled (unable to work)? From..................................... 19.......».Thru...........................: .. 19.......». (B) How long was or will patient be partially disabled? From............... ............... 19......... Thru...................................... 19.......... (C) Was house confinement necessary?/If"Yes'give dates 13 Yes CR No From..................................... 19..........Thru..................................... 19......».. �(8) What if any,permanent impairment will result?' Date Si nature(attendingphysigcian)� D ree Telephone IRS ident, no. 6/23/89 1 Q D.C. (415) 5�!7-43-6706 Ann IStreet address I City or town St to or province Zip Code 3978 RAILRO AVENUE PITTSBURG CA 94565 *Use reverse side if additional space is needed. Approved by Council on Medical Service,AMA 1968 PCD 1976 ctj 12 82 0,....,..a.,r t e s AUTHORIZATION AND ASSIGNMENT OF BENEFITS To 'Dr. William Whitney /Dr. &Mtrong, 1. You are authorized to release any information you deem appropriate con- cerning my health condition to any insurance company, attorney or adjuster in order to process any claim for reimbursement of charges incurred at the Whitney Chiropractic Office by me. 2. I authorize and assign the direct payment to you of any sum I now or hereafter- owe you- by my attorney out of the proceeds of any settlement of my case, and by any insurance company obligated to reimburse me for the charges for your services or otherwise obligated to make payment to me or you based in whole or in part upon the charges made for your services. 3. I give assignment and lien against any claims against a third party whose negligence may have caused the patient's injury, u� to the amount of the bill for treatment. 4. In the event any insurance company obligated by contractual agreement to make payment to me or to you for the charges made for your services refuses to make such payment upon demand by you, I hereby assign and transfer to you the cause of action that exists in my favor against any such company (the name(s) of which is believed to be correctly set forth under pertinent data below) and authorize you to prosecute, said action either in, my name or your name as you see fit and further authorize you to compromise, settle or otherwise resolve said claim as you see fit. However, it is understood that until all reasonable efforts have been made to col- lect the sums due from the insurance company (or companies) contractually obligated, you refrain from attempts and efforts to collect the amounts owed directly from me. I understand that whatever amounts you do not collect from insurance proceeds (whether it be all or part of what is due) I personally owe you. 5. I waiver the Statute of Limitations regarding my doctor's right to re- cover. 6. A photocopy of this Assignment shall be considered as effective and valid as the original. X DATE — /! " SIGNED_\ WITNESS O_J�t�y�at %liY� PERTINENT DATA: Date of Injury: 5/21/89 Name of insurance company: PRUDENTIAL Policy 0: CLM#: 13I 97032 036 LOS MEDANOS CHIROPRACTIC ROUP ` A Professional Association of Independent Chiropractic Practices r 3978 Railroad Ave., Pittsburg,Califomia 94565 (415)432-1300 WILLIAM WHITNEY,D.C. JEFFREY SIINO,D:C. ❑GENERAL PRACTICE ❑GENI::RAL PRAC'TIC'E ❑DISABILITY EVALUATION ❑DISABILITY EVALUATION James Armstrong, D.C. RE: JUANITA ELLIS D/I: 5/21/89 CLM+#: 13I 07032 036 RVS DATE CODE PROCEDURE CHARGE 6/1/89 900,115 INITIAL HISTORY & EXAMINATION $ 61.42. 6/2/89 72110 X-RAY: LUMBAR, COMPLETE 170.00 5/16/89 95842 ELECi-RICAL MUSCLE TEST 75.00 6/2/89- 90050- 12 OFFICE VISITS 054.22 INCLUDING 6/23/89 97200-52 TREATMEN^: WITH PHYSICAL THERAPY 650.64 6/23/89 TOTAL AMOUNT DUE TO DATE:''*'' $ 957.06 *'-`NOT A FINAL BILL DATES OF OFFICE VISITS: 6/1,2,3,5,6,8,9,i4,1_5,16,19,21,23/89 L'I' MAKE CHECK PAYABLE TO: DOCTOR JAMES ARMSTRONG, D.C. SIGNATURE G ADDRESS 3978 RAILROAD AVENUE DATE 6/23/89 PITTSBURG, CA 94565 SS# _547-43-6706 Prudential Property and Casualty lnsura- Company- r Prudential General Insurance Company ` Attending Physician's Report .Prudential Commercial Insurance Company 34 of The Pttdemial Irmame Corr>pertf of America Prudent►al Patient's name and address JUANITA ELLIS 2901 MARYANN LN. PITTSBURG, CA 94565 Age Occupation (if known) 4.g CERTIFIED NURSE 0A) History of occurrence as described by_patient PATIENT STATED �T A SHERIFFS CAR BACKED UP INTO THEM. (B) Diagnosis and concurrent conditions' ACUTE SEVERE THORACIC SUBLUXATION SYNDROME . LUMBAR SUBLUXATION SYNDROME (Cl Were X-rays taken? if yes,where? Qt Y i IN `►`HIS OFFICE (2A) When did symptoms first appear? (B) When did patient first consult you for this condition? Date 6/1 89 5�21/89.................................................... 19......._........._ Date..............�.. ......._........._......................................... 19.................... (C) Has patient ever had same or similar condition?/If"Yes" (D) Is condition solely a result of this accident?/If no explain' state when and describe* O Yes ® No 1 93 Yes O No (3A) Nature of surgical procedure, if any?/Describe fully* Date performed N/A (B) Charge to patient for this procedure including (C) If performed in hospital,give name of hospital post operative care $........................................ O Inpatient O Outpatient (4) Give dates of other medical (non-surgical) Charge per Cali treatment.it any. Office ....................... . $.._................_... Home............................................._.................................... S.......................................... SEE ATTACHED BILLING Hospital...._........................................................................... $.......................... ................ Nursinghome......_............._...................._........._................ $..................................._... Total (non-surgical)charges................................................ $........................I..-.............. (5) What other service,if any,did you provide patient?/Itemize,giving dates and fees' WA) Is patient still under your care for this condition? If"No" (B) If"Yes give estimated date of termination and cost of give dates your services terminated further treatment IENT TO BE RE-EVALUATED„EVERY 10-12 OFFICE lyes13 No Date............................................................ PA ate.......................................... ..ost......................... S. (7A) How long was or will patient be.constantly totally disabled (unable to work)? From..................................... 19..........Thru...................................... 19.......... (B) How long was or will patient be partially disabled? From................................... 19....... Thru....._............_................. 19.......... (C) . Was house confinement necessary?/It "Yes"give dates OYes QNo From..................................... 19..........Thru...................................... 19.......... �(8) What if any,permanent impairment will result?' Date Signature(attending physician) Degree Telephone IRS ident.no. 6/23/89 g L D.C. (415)41?,-1-1 n —[ 547-43-6706 Street address �1 City ort wn State or province Zip Code 3978 RAILROAIaVENUE PITTSBURG CA 99565 'Use reverse side if additional space is needed. Approved by Council on Medical Service,AMA 1968 PCD 1976 Ed 1282 AUTHORIZATION AND ASSIGNMENT OF BENEFITS To Dr, William Whitney / Dr: Armstrong, 1. You are authorized to release any information you deem appropriate con- cerning my health condition to any insurance company, attorney or adjuster in order to process any claim for reimbursement of charges incurred at the Whitney Chiropractic Office by me. 2. ,I authorize and assign the direct payment to you of any sum I now or hereafter.owe youbymy attorney out of the proceeds of any settlement of my case, and by any insurance company obligated to reimburse me for the charges for your services or otherwise obligated to make payment to me or you based in whole or in part upon� the charges made for your services. 3. I give assignment and lien against any claims against a third party whose negligence may have caused the patient's injury, ub to the amount of the bill for treatment, 4. In the event any insurance company obligatgd by contractual agreement to make payment to me or to you for the charges made for your services refuses to make such payment upon demand by you, I hereby assign and transfer to you the cause of action that exists in my favor against any such company (the name(s) of which is believed to be correctly set forth under pertinent data below) and authorize you to prosecute said action either in my name or your name as you see fit and further authorize you to compromise, settle or otherwise resolve said claim as you see fit. However, it is understood that until all reasonable efforts have been made to col- lect the sums due from the insurance company for companies) contractually obligated, you refrain from attempts and efforts to collect the amounts owed directly from me. I understand that whatever amounts you do not collect from insurance proceeds (whether it be all or part of what is due) I personally owe you. 5. I waiver the Statute of Limitations regarding my doctor's right to re- cover. 6. A photocopy of this Assignment shall be considered as effective and valid as the original. 9 C DATE (T/ / SIGNED WITNESS PERTINENT DATA; Date of Injury: 5/21/89 Name of insurance company: PRUDENTIAL Policy q: CLEF#: 131 07032 036 °ap ca N o D a � mw co o O N� 30 p1 ' < K C.� d 0 w N C . K C7 r� 1 " 1 oo cis , }AAA}AAA}.RR1R 1 rt 1 { 1 it 7 l�� CLAIM 2J 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 Augu s t 15 , 1989 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: $1 , 748 . 00 Section 913 and 915.4. Please note all "Warnings". CLAIMANT: RICK HEYMANN 2078 Pacific ATTORNEY: San Francisco, CA 94109 Date received ADDRESS: BY DELIVERY TO CLERK ON July 17 , 1989 hand del. 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. Jul , IL BATCHELOR, Clerk DATED: Y 201989 �b: Deputy L. Hall II. FROM: County Counsel TO: Clerk of the Board of Supervisors ( j 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: BY: Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Admi 'strator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present ( V) 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 15 1989 ?HIL 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. L-low-& Dated: AUG 15 1989 BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator r r" NOTICE OF INSUFFICIENCY AND/OR NON-ACCEPTANCE OF CLAIM TO: R.i Heymann 2078 P ' fic San Franci o, CA 94109 Re: Claim of RICK HE N Please Take Notice As Follows: The claim you presented against the County of Contra Costa or District governed by the Board of Supervisors fails to comply substantially with the requirements of California Government Code section 910 and 910 . 2, or is otherwise insufficient for the reasons checked below: _1 . The claim fails to state the name and post office address of the claimant. _2. The claim fails to state the post office address to which the person presenting the claim desires notices to be sent. x 3 . The claim fails to state the date, place or other circumstances of the occurrence or transaction which gave rise to the claim asserted. _4 . The claim fails to state the name(s) of the public employee(s ) causing the injury, damage, or loss, if known. 5 . The claim fails to state whether the amount claimed exceeds ten thousand dollars ($10,000) . If the claim totals less than ten thousand dollars ($10,000) , the claim fails to state the amount claimed as of the date of presentation, the estimated amount of any prospective injury, damage or loss so far. as known, or the basis of computation of the amount claimed. If the amount claimed exceeds ten thousand dollars ( $10,000) , the claim fails to state whether jurisdiction over the claim would rest in municipal or superior court. _6 . The claim is not signed by the claimant or by some person on his behalf . 7 . Other: VICTOR J. WESTMAN, County Counsel By; I \ Deputy ounty 1 CERTIFICATE OF SERVICE BY MAIL C.C.P. §§ 1012, 1013a, 2015 .5; Evid. C. §9 641 , 664 ) My business address is the County Counsel's Office of Contra Costa County, Co. Admin. Bldg. , P.O. Box 69, Martinez, California, 94553, and I am a citizen of the United States, over 18 years of age, employed in Contra Costa County, and not a party to this action. I served a true copy of this Notice of Insufficiency and/or Non Acceptance of Claim by placing it in an envelope(s) addressed as shown above (which is/are place(s ) having delivery service by U.S. Mail) , which envelope(s ) was then sealed and postage fully prepaid thereon, and thereafter was, on this day deposited in the U.S. Mail at Martinez/Concord, Contra Costa County, California. I certify under penalty of perjury that the foregoing is true and correct. Dated: at Martinez, California. cc: Clerk of the Board of Supervisors ( iginal) Risk Management (NOTICE OF INSUFFICIENCY OF CLAIM: GOV.C.§§ 910, 910 . 21 920 .4, 910. 8) Claim to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT Y 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 '7-[7 -g'(q Reservvedd for Clerk's filing stamp ley low Against the County of Contra Costa ) JUL 17 196-3 or ) rn L e,A, F11 .Oa District) 'ER BOARD OF PE VISCR5 Fill in name ) .9 6• !ONTRACC¢J.A.. .�De uh, The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of $ (`7#"p C>D and in support of this claim represents as follows: ------------------------------------------7------------------------------------------ 1. en did the damage or injury occur?,, (Give exact date and hou ) &1,4c T T i,®,e A-)f9 . /7 /S ?//E Ti ----------------------------- ------------------------------- --------- 2. Where did the damage or injury occur? (Include city and county) -supeyeip,e e_v(44T ole- eoWA4 eD STfl -------------------------------------------- --------------------------------- 3. How did the damage or injury occur? (Give full details; use ext a paper if required) l�f7�/e ,2EP��9T�/� c�tlGG s F���" �� 11iflsplEQ fwedl,J/%iE/-� Gr ?'!!, R�'6fJie0 /�O� 1h Y �hifs/ir/6 � OZe Ty ------------------------------------------------------------- What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? (over) 5. What are the names of .county or district officers, servants or employees causing the damage or injury? VOL &1EG' 1 .t> 19PJ 44 PIC eTl 94� DSc,<ET ------------------------------------------------------------------------------------ 5. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. t AryrO� � �(e 7q)/ CX"K7/qc,/ T 62, �iq � p6G,C & C a_'------- 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage. ) 56e /490 V9 ------------------ ------------------------------------------------------------------ 8. Names and addresses of witnesses, doctors and hospitals. ,DEP17 Ge, CaaVry ------------------------------------------------------------------------------------- 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 some person on his behalf." Name and Address of Attorney C1 mant's Signature �207d &i elclG Address Telephone No. Telephone No. �t it N 0 T I C E Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents for allowance or for payment to any state boardlor 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.. . AMENDED 23 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 August 15 '. 1989, 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:RICK JOSEPH DONNELL county Counsel c/o Law Offices of Steven H. Henderson ATTORNEY: 3715 Railroad Ave. #D JUL 30 jgg� Pittsburg, CA 94565 Date received ADDRESS: BY DELIVERY TO CLERK ON Jul yMa tin&4-�,'A BY MAIL POSTMARKED: July 25 , 19.89_ �d 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. IL gATCHELOR, Clerk DATED: July 23 , 1989. ��: Deputy L. Hall I. 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: l Dated: �T 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. c1 Dated: AUG 1 5 1989 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: -Al IG 15 1989 BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator I STEVEN H. HENDERSON ATTORNEY - ABOGADO 2 3715 Railroad Avenue Suite D R C IYE 3 Pittsburg, CA 94565 415/427-1771 4 J���„ ° 1989 5 Attorney for Claimant. PH'ARDOF UPPER CLEACITRAC SUPERVI90R6 \TRA CO A C NoW S L 6 7 In the Matter of the 8 Claim of 9 RICK JOSEPH DONNELL 10 Claimant, AMENDED CLAIM FOR DAMAGES 11 vs. 12 COUNTY OF CONTRA COSTA, and DOES I through 10, inclusive, 13 Respondents. 14 / 15 I. 16 RICK JOSEPH DONNELL hereby presents this claim to the 17 COUNTY OF CONTRA COSTA, and DOES 1 through 10, inclusive, . 18 pursuant to Government Code § 910, et seq. 19 II. 20 The name and post office address of Claimant is as 21 follows: 22 RICK JOSEPH DONNELL 3915 Delta Fair Blvd. , #C18 23 Antioch, CA 94509 24 III. 25 The post office address to which Claimants desire notice 26 of this claim to be sent is as follows: 27 Law Offices of Steven H. Henderson 3715 Railroad Avenue, Suite D 28 Pittsburg, California 94565 -1- I IV. 2 At all times herein mentioned, the COUNTY OF CONTRA 3 COSTA was a public entity and at all times herein mentioned 4 DOES 1 through 10, were employees and/or agents of the above- 5 named public entity and were acting in the course and scope 6 of their employment and or agency. 7 V. 8 On or about February 13, 1989, Claimant, RICK JOSEPH 9 DONNELL, was caused to be injured in an automobile accident 10 proximately caused by a dangerous condition that defendants, 11 and each of them, allowed to exist at Willow Pass Road, 12 Contra Costa County, State of California at its intersection 13 with Manor Drive, Contra Costa County, State of California, 14 having known or should of have known of the existence of the 15 dangerous condition of loose gravel, mud and water on the 16 roadway and street conditions and the combination thereof at 17 said location. At all times herein mentioned, defendants, 18 and each of them were in possession and control of said 19 roadway. 20 VI. 21 At all times mentioned herein, the COUNTY OF CONTRA 22 COSTA and defendants DOES 1 through 10, allowed the dangerous 23 condition to exist despite the fact that the dangerous condi- 24 tion created a reasonably foreseeable risk of the kind of 25 injury which was incurred by Claimant. 26 VII. 27 At all times herein mentioned the COUNTY OF CONTRA COSTA 28 and defendants DOES 1 through 10, negligently failed to —2— 1 provide a signal, sign, marking or other device which was 2 necessary to warn of the dangerous condition which endangered 3 the safe movement of traffic, said dangerous condition having 4 been one that would not have been reasonably apparent to, and 5 would not have been anticipated by, a person exercising due 6 care. 7 VIII. 8 At all times mentioned, the dangerous condition afore- 9 mentioned existed due to the negligent plan, design and 10 construction of the roadway and the combination thereof at 11 the location mentioned in a manner which was not reasonably 12 prudent. 13 Ix. 14 At all times mentioned herein, the COUNTY OF CONTRA 15 COSTA and DOES 1 through 10, failed to take reasonable action 16 to protect against the risk of injury created by the condi- 17 tion in an unreasonable manner. 18 X. 19 At all times mentioned herein, the COUNTY OF CONTRA 20 COSTA and defendants DOES 1 through 10, negligently allowed 21 roadway to remain in a state of disrepair. 22 XI. 23 At all times herein mentioned, the COUNTY OF CONTRA 24 COSTA, and DOES 1 through 10, had actual and/or constructive 25 notice of the existence of the dangerous condition which 26 existed. 27 XII. 28 As a result of the aforementioned hazardous condition —3— 1 which the Respondents, and each of them allowed to exist, 2 Claimant has suffered great emotional damage, physical dam- 3 age, and loss of earnings loss of personal property. The 4 amount of these damages greatly exceeds the sum of 5 $10, 000. 00, due to the extreme severity of Claimant's inju- 6 ries. 7 XIII. 8 Therefore, Claimant, RICK JOSEPH DONNELL, seeks relief 9 for the damages he has sustained as a result of the negligent 10 failure of the County Of Contra Costa and Does 1 through 10, 11 to properly maintain safe roadway conditions. 12 Dated: July 24, 1989. 13 14 STEVEN H. HENDERSON 15 Attorney for Claimant 16 17 18 19 20 21 22 23 24 25 26 27 28 1 PROOF OF SERVICE 2 3 I hereby certify that I am a citizen of the United States, 4 over the age of 18 years, and not a party to the within entitled 5 cause. My business address is 3715 Railroad Ave. , Suite D, 6 Pittsburg, California. On the date shown below, I personally 7 caused to be served the following AMENDED CLAIM FOR DAMAGES in 8 said cause, addressed as follows: 9 Board of Supervisors County Counsel 's Office of Contra Costa 10 P.O. Box 69 11 Martinez, CA 94553 12 I declare under penalty of perjury that the foregoing is true and correct and that this declaration was executed at 13 14 Pittsburg, California, on the date shown below. Dated: July 24, 1989 15 , 16 17 Sue McKnight 18 19 20 21 22 23 24 25 26 27 28 �y $/ \ / \ � W% #�90 ■ Oc ■ ¢k o. § C)-% i 0 k k2 \ k \ 0 . \ 0 � . ( 2 , 0 t / t . yr \ r )\ \ § 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 August4'15 , 1989 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 joie all "Warnings". CLAIMANT: RICK JOSEPH DONNELL Ounty counsel c/o Law Offices of Steven H. Henderson JUL 1 1989 ATTORNEY: 3715 Railroad Avenue #D Martlne2 A Pittsburg, CA 94565 Date received , (,' 44ee�� ADDRESS: BY DELIVERY TO CLERK ON Ju1y 14, 1?PS3hand del. BY MAIL POSTMARKED: no envelope 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. DATED: July 17 , 1989 ��IL geP�tyLOR, Clerk L. Hall II. FROM: County Counsel TO: Clerk of the Board of Supervisors This claim complies substantially with Sections 910 and 910.2. �f•• ) 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: _�/i1 13q 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. 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: BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator NOTICE OF INSUFFICIENCY AND/OR NON-ACCEPTANCE OF CLAIM TO: Rick Joseph Donnell c/o Law Offices of Steven H. Henderson 3715 Railroad Avenue #D Pittsburg, CA 94565 Re: Claim of RICK JOSEPH DONNELL Please Take Notice As Follows: The claim you presented against the County of Contra Costa or District governed by the Board of Supervisors fails to comply substantially with the requirements of California Government Code section 910 and 910. 2, or is otherwise insufficient for the reasons checked below: _1 . The claim fails to state the name and post office address of the claimant. _2 . The claim fails to state the post office address to which the person presenting the claim desires notices to be sent. 3 . The claim fails to state the circumstances of the occurrence or transaction which gave rise to the claim asserted. _4 . The claim fails to state the name(s) of the public employee(s) causing the injury, damage, or loss, if known. X 5 . The claim fails to state whether the amount claimed exceeds ten thousand dollars ($10, 000) . If the claim totals less than ten thousand dollars ($10, 000) , the claim fails to state the amount claimed' as of the date of presentation, the estimated amount of any prospective injury, damage or loss so far as known, or the basis of computation of the amount claimed. If the amount claimed exceeds ten thousand dollars ($10,000) , the claim fails to state whether jurisdiction over the claim would rest in municipal or superior court. _6 . The claim is not signed by the claimant or by some person on his behalf. 7 . Other: VICTOR J. WESTMAN, County Counsel By: Deputy Count nsel CERTIFICATE OF SERVICE BY MAIL C.C.P. §§ 1012, 1013a, 2015 .5; Evid. C. 69 641 , 664 My business address is the County Counsel's Office of Contra Costa County, Co. Admin. Bldg. , P.O. Box 69, Martinez, California, 94553, and I am a citizen of the United States, over 18 years of age, employed in Contra Costa County, and not a party to this action. I served a true copy of this Notice of Insufficiency and/or Non Acceptance of Claim by placing it in an envelope(s) addressed as shown above (which is/are place(s) having delivery service by U.S. Mail) , which envelope(s) was then sealed and postage fully prepaid thereon, and thereafter was, on this day deposited in the U.S. Mail at Martinez/Concord, Contra Costa County, California. I certify under penalty of perjury that the foregoing is true and correct. Dated: , at Martinez, California. 1 cc: Clerk of the Board of Supervisors (o -.'ginal) Risk Management (NOTICE OF INSUFFICIENCY OF CLAIM: GOV.C.§§ 910, 910 . 2, 920 .4, 910 .8) 1 STEVEN H. HENDERSON ATTORNEY - ABOGADO 2 3715 Railroad Avenue Suite D , 3 Pittsburg, CA 94565 ' 415/427-1771 ,, � ' `tr D 4 5 Attorney for Claimant. JUL 14 1989 6Y-- A-R' ATC -LOR CF P SOAS By ........ puty 7 In the Matter of the 8 Claim of 9 RICK JOSEPH DONNELL 10 Claimant, CLAIM FOR DAMAGES 11 vs. 12 COUNTY OF CONTRA COSTA, and DOES I through 10, inclusive, 13 Respondents. 14 15 I• 16 RICK JOSEPH DONNELL hereby presents this claim to the 17 COUNTY OF CONTRA COSTA, and DOES 1 through 10, inclusive, 18 pursuant to Government Code § 910, et seq. 19 II. 20 The name and post office address of Claimant is as 21 follows: 22 RICK JOSEPH DONNELL 3915 Delta Fair Blvd. , #C18 23 Antioch, CA 94509 24 III. 25 The post office address to which Claimants desire notice 26 of this claim to be sent is as follows: 27 Law Offices of Steven H. Henderson 3715 Railroad Avenue, Suite D 28 Pittsburg, California 94565 -1- 1 IV. 2 At all times herein mentioned, the COUNTY OF CONTRA 3 COSTA was a public entity and at all times herein mentioned 4 DOES 1 through 10, were employees and/or agents of the above- 5 named public entity and were acting in the course and scope 6 of their employment and or agency. 7 V. 8 On or about February 13, 1989, Claimant, RICK JOSEPH 9 DONNELL, was caused to be injured in an automobile accident 10 proximately caused by a dangerous condition that defendants, 11 and each of them, allowed to exist at Willow Pass Road, 12 Contra Costa County, State of California at its intersection 13 with Manor Drive, Contra Costa County, State of California, 14 having known or should of have known of the existence of the 15 dangerous condition of loose gravel, mud and water on the 16 roadway and street conditions and the combination thereof at 17 said location. At all times herein mentioned, defendants, 18 and each of them were in possession and control of said 19 roadway. 20 VI. 21 At all times mentioned herein, the COUNTY OF CONTRA 22 COSTA and defendants DOES 1 through 10, allowed the dangerous 23 condition to exist despite the fact that the dangerous condi- 24 tion created a reasonably foreseeable risk of the kind of 25 injury which was incurred by Claimant. 26 VII. 27 At all times herein mentioned the COUNTY OF CONTRA COSTA 28 and defendants DOES 1 through 10, negligently failed to -2- 1 provide a signal, sign, marking or other device which was 2 necessary to warn of the dangerous condition which endangered 3 the safe movement of traffic, said dangerous condition having 4 been one that would not have been reasonably apparent to, and 5 would not have been anticipated by, a person exercising due 6 care. 7 VIII. 8 At all times mentioned, the dangerous condition afore- 9 mentioned existed due to the negligent plan, design and 10 construction of the roadway and the combination thereof at 11 the location mentioned in a manner which was not reasonably 12 prudent. 13 Ix. 14 At all times mentioned herein, the COUNTY OF CONTRA 15 COSTA and DOES 1 through 10, failed to take reasonable action 16 to protect against the risk of injury created by the condi- 17 tion in an unreasonable manner. 18 X. 19 At all times mentioned herein, the COUNTY OF CONTRA 20 COSTA and defendants DOES 1 through 10, negligently allowed 21 roadway to remain in a state of disrepair. 22 XI. 23 At all times herein mentioned, the COUNTY OF CONTRA 24 COSTA, and DOES 1 through 10, had actual and/or constructive 25 notice of the existence of the dangerous condition which 26 existed. 27 XII. 28 As a result of the aforementioned hazardous condition -3- I which the Respondents, and each of them allowed to exist, 2 Claimant has suffered great emotional damage, physical dam- 3 age, and loss of earnings loss of personal property. The 4 amount of these damages has not yet-been ascertained, due to 5 the extreme severity of Claimant's injuries. 6 XIII. 7 Therefore, Claimant, RICK JOSEPH DONNELL, seeks relief 8 for the damages he has sustained as a result of the negligent 9 failure of the County Of Contra Costa and Does 1 through 10, 10 to properly maintain safe roadway conditions. 11 Dated: July 13, 1989. 12 13 EN • N 14 Attorney forClaimant 15 16 17 18 19 20 21 22 23 24 25 26 27 28 -4-