HomeMy WebLinkAboutMINUTES - 07271993 - 1.17 CLAIM
BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA JUN 3 0 1993
Claim Against the County, or District governed by) BOARD
S!. rALIF.
the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT JULY 27, 1993
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: $564,200.00 Section 913 and 915.4. Please note all "Warnings".
CLAIMANT: BEM,4, Bruce
ATTORNEY: Casalina & Disston
418 Third Street Date received
ADDRESS: Oakland, CA 94607 BY DELIVERY TO CLERK ON June 29, 1993
BY MAIL POSTMARKED. hand delivered
I. FROM: Clerk of the Board of Supervisors TO: County Counsel
Attached is a copy of the above-noted claim. eB
DATED: June 29. 1993 �tIl Deputy OR, Clerk
I1. FROM: County Counsel TO: Clerk of the Board of Supervisors
( 111, 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: �� , /1�g3 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
(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: `J U L 2 7 1993 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. *For additional warnina see reverse side of this notice.
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 16; 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 2 1993 BY: PHIL BATCHELOR b Deputy Clerk
CC: County Counsel County Administrator
CLAIM AGAINST CONTRA COSTA COUNTY, CALIFORNIA 6/23/93
To: Clerk of Board of Supervisors ---- ---
Contra Costa County RECEIVED
651 Pine Street, Room 106
Martinez, CA 94553
JU 2 9 1993
Claimant: Bruce Benton 3 2621 Benvenue Avenue CLERK BOARD OF SUPERVISORS
Berkeley, CA 94704 CONTRA COSTA CO.
(510) 841-3813
Date of occurrence: December 30, 1992
Place of occurrence: Grizzly Peak Blvd. , approximately 0.8
miles southeast of Centennial Drive
I, Bruce Benton, am presenting this claim for damages
against Contra Costa County for the amount of $564,200.00
This claim arises from the following circumstances: I
was riding my bicycle in a northwest direction between South
Park and Centennial Drive along Grizzly Peak Blvd. ,
approaching a sharp turn on the outside lane at about 5:45
p.m. on December 30, 1992 . A vehicle coming from the
opposite direction on the inside lane came through the turn
too wide, crossed over into my lane and struck me on my left
side. I believe this turn on Grizzly Peak Blvd is a
hazardous section of road and its negligent design,
construction, and maintenance proximately caused this
accident and the resulting injuries.
Description of nature and extent of injuries: I
sustained a closed fracture of my left forearm (radius) and
a compound fracture of my left femur. I currently have a
plate and a pin installed in my arm and have restricted
rotational motion in my forearm. Approximately a four inch
by one inch strip of my left femur was removed and a
fourteen inch rod installed. There is significant loss of
range of motion in my left leg. I have only recently been
able to return to work on a limited basis. Medical bills to
date are approximately $60,000 .00 and continuing. Wage loss
to date is approximately $4 ,200.00. General damages at this
time are approximately $500,000.00.
Please send notices to: CASALINA & DISSTON, 418 Third
Street, Oakland, CA 94607
Z
Bruce Benton
i EXTRA
✓9(= ,
CLE COLLISION REPORT COPY TO INCIDENT NO,
(�ahlanr� Police 1/90)Department NO.INJ. KILLED HIT L RUN INVESTIGATED REPORTED COLLISION OR REPORT NO.
`. 536 564 (11/90) 1 6 F ❑ M ❑ W, ❑ 1259 $ �.
1 ARREST ❑ SECTION(S) l COURT DATE DEPT. DISPATCHED ON-VIEW
CITE NO. ❑ A
^ ARREST ❑ SECTION(S) COURT DATE DEPT. DATEMME REPORTED
C1TEN0. 30 1)C L�� f�t
COLLISION OCCURRED ON: BLOCK NO. DAY/DATE/TIME OCCURRED NCIC NO. OFFICER ID
IAC J�.)L ► t_�/Cj (,�r_{j 3 =c-c 0109 '7 1'1 `4
EJ.AT INTERSECTION WITH: INJURY(�I FATAL I TOWAWAY STATE HWY.RELATED
L7YOR FT.IZAIL SIN) �E) (S) Mn or: ��=tj I'e- &I K/ hl O�Z- —'�SLYES ❑ NO ❑ YES G� NO
PARTY NAME (LAST FIRST MIDDLE) VEHICLE OWNER IZAME AS DRIVER
1
-3 C'�JTDK) (?-� � j
DRIVER RESIDENCE ADDRESS CITYIZIP PHONE OWNER'S ADDRESS CITYIZIP SAME A$DRIVER
PED BUS.ADDRESS CITYIZIP PHONE VEH.DISPOSITION ❑ OPD TOWED TO:
❑ �rt2!CcLczy ct .I -1 G''k O.R. 4
PARKED DRIVER'S LIG NO. STATE D.O.B. SEX RACE I DIRECTION ON:(STREET) VEH SPEED ZONE SPEED;
VEH. OF TRAVEL
❑ A. ��t l X 2.o c•4- (�.J.�� 5 r�w W G 21 VZ O-i p(Z-/-jL 03 0
BICYCLE AGE I HEIGHT WEIGHT HAIR I EYES INSURED INSURANCE COJPOLICY NO. EXTENT OF DAMAG. SHADE IN DAMAGE AREAS' `
Tom' t C (�.' ��AJ ❑ YES ❑ MINOR ❑ MAJC,R
/ (1 ( (- ('��-�� Cl NO ❑ MODERATE ❑ TOTAL
OTHER LICENSE NO. ( STATE VEH. YR. MAKE MODEL COLOR(S) PED CLOTHING �:::::D
E] (,4T-M ��(G:t C-L�: ❑ LIGHT
CROSSWALK
as u -ZJ-rw lt` l-Af3-3 21 -SjW3 Noe. 'J ❑ DARK
(J ❑ MARKED ❑ PED INSIDE
❑ UNMARKED ❑ PED OUTSIDE
PARTY NAME (LAST FIRST MIDDLE) VEHICLE OWNER SAME AS DRIVER
DRIVER RESIDENCE ADDR SS CITY/ZIP IPHONE OWNER'S ADDRESS CITY/ZIP SAME AS DRIVER
r
PED BUS.ADDRESS CITY/Zip IPHONE V VEH. DISPSITION ❑ OPD TOWED TO:
❑ (. ) C., I ❑ O.R.
PARKED DRIVER'S LIG NO. STATE D.O.B. SEX RACE II DIRECTION ON:(STREET) VEH SPEED ZONE SPEEC
VEH. I OF TRAVEL
❑ � 'I ��"�5 � c , o:��-�`) Mc t G2122t-y I�lf.!L I� 3 �
BICYCLE AGE I HEIGHTI WEIGHT I HAIR I EYES INSURED I INSURANCE COJPOLICY NO. EXTENT OF DAMAGE 1 SHADE IN DAMAGE AREAS
❑ (2 i� rYES , MINCR E3 MAJOR
I i
a ❑ NO 4,1. >~C i. ❑ M,OERATE El TOTAL `
E
OTHER LICENSE NO. I STATE VEH.YR. v MAKE MODEL COLOR(S) PED CLOTHING ;
❑ LIGHT CROSSWALK
❑ J (S ILx C( S� C/' G L
1:70c-co F'X P �,,(AI ❑ DARK L1 MARKED 7 PED INSIDE
UNMARKED PED OUTSIDE
Eno Dr:DnOTED CCLUSMNS nNLv
NAME (LAST) FIRST MIDDLE) RESIDENT CITYIZIP (PHONE
1
( )
BUSINESS ADDRESS CITY/ZIP ! PHONE
( )
NAME (LAST) FIRST MIDDLE) RESIDENT CITY/ZIP j PHONE
W ( )
Z BUSINESS ADDRESS CITYIZIP PHONE
3 NAME (LAST) FIRST MIDDLEI RESIDENT CITY/ZIP j PHONE i
( ) i
BUSINESS ADDRESS CITY/ZIP PHONE
) 1
DESCRIPTION OF DAMAGE
W Q OWNER'S NAME ADDRESS CITYIZIP PHONE NOTIFIED i
O YES I
( ) Cl N O
CL DESCRIPTION OF DAMAGE
CL OWNER'S NAME ADDRESS CITYIZIP I PHONE NOTIFIED
c YES
TPAFFIC COLLISION CODING
DATE OF COLLISION TIME NCtC NO i SERIAL NO. COLLISION or REPORT NO.
14U U=n FVq t APPROX.POINT OF IMPACT DETERMINED BY: ❑ VEH.#—POS:
s. ❑ DIRT ❑ WITA
... ❑ DEBRIS ❑ DRIVER#
❑ SKIDS ❑ DAMAGE
DESCRIBE COI.LISION:
y...._.
P-( fLL6rS i L e 'sF Dt3
5
- L
COLLISION ANALYSIS
PRIMARY COLLISION FACTOR RIGHT OF WAY CONTROL 1 PAR} 4 TYPE OF VEHICLE 1 P2
R3 a MOVEMENT PRECEEDING
A PASSENGER CAR/STATION WAGON
COLLISION
A V.C.VIOLATION:21202 A CONTROLS FUNCTIONING A STOPPED
B CONTROLS NOT FUNCTIONING 8 PASSENGER CAR WITRAILER
r� OTHR IMPROPER DRIVING: C MOTORCYCLElSCOOTER B PROCEEDING STRAIGHT
C CONTROLS OBSCURED�EIE
AN DRIVER D NO CONTROLS PRESENLD PICKUPIPANEL TRUCKC RAN OFF ROAD
N E PICKUPIPANEL TRK.WTTRLR D MAKING RIGHT TURN
TYPE OF COLLISION F TRUCK OR TRUCK TRACTOR E MAKING LEFT TURN
WEATHER (1 to 2 items) AHEAD-ON G TRK/TRK TRACTOR W TRLR F MAKING UJURN
B SIDESWIPE G BACKING
A CLEAR C REAR END H SCHOOL 8US
3 CLOUDY I OTHER BUS H ,SLOWING—STOPPING
D BROADSIDE
I PASSING OTHER VEHICLE
C RAINING E HIT OBJECT J EMERGENCY VEHICLE
D SNOWING F OVERTURNED K HWY.CONST.EQUIPMENT J CHANGING LANES
S FOG G AUTOIPEDESTRIAN I L BICYCLE K PARKING MANEUVER
F OTHER: H OTHER M OTHER VEHICLE ENTERING TRAFFIC FROM
L SHOULDER.MERIDIAN.PARKING
G WIND N PEDESTPUN STRIP OR PRIVATE DRIVE
MOTOR `:EH. INVOLVED WITH: 'A OTHER UNSAFE TURNING
LIGHTING A NON-COLLISION ( ( N X TNG INTO OPPOSITE LANE
A DAYLIGHT PARTY
B PEDESTRIAN 1 � �
OTHER ASSOCIATED O PARKED
2 1
B DUSK—DAWN C OTHER MOTOR VEHICLE FACTOR ( t0 3 items) I I P MERGING
C DARK—STREET LIGHTS ON D MOTOR VEH.ON OTHER RDWY. A VIOLATION. \ „' I V I I Q TRAVELING WRONG WAY
D DARK—NO STREET LIGHTS E PARKED MOTOR VEH. _ B VIOLATION: I R OTHER:
DARK—STREET LIGHTS OFF F TRAIN
ROADWAY SURFACE G BICYCLE C VIOLATION:
H ANIMAL: I PARTY. SOBRIETY-DRUG-PHYSICAL
11 tto 2 items)tIAL
A DRY
D vwunoN'.
A HAD NOT BEEN DRINKING
C 5NOWY-ICY I FIXED OBJECT: E VISION OBSCUREMENT: I 8 H80—UNDER INFLUENCE
D SLIPPERY IMUDDY,OILY ETC.1 C HBO—NOT UNDER INFLUENCE
J OTHER OBJECT: F INATTENTION
ROADWAY CONDITIONS D H130—IMPAIRMENT UNKNOWN
G STOP 6 GO TPAFFIC E UNDER DRUG INFLUENCE
A HOLES.DEEP RUTS
B LOOSE MATERIAL ON ROADWAY PEDESTRIAN'S ACTION H ENTERING"EXITVNG RAMPI I F IMPAIRMENT—PHYSICAL
C OBSTRUCTION ON ROADWAY A NO PEDESTRIAN INVOLVED 1 PREVIOUS COLLISION I I G IMPAIRMENT UNKNOWN
0 OCNSTRUCTION—REPAIR ZONE d CROSSING IN CROSSWALK— I i UNFAMILIAR WIROAO
H NOT APPLICABLE
E REDUCED ROADWAY WIDTH AT INTERSECTION K DEFECTIVE VEHICLE EQUIPMENT I SLEEPYIFATIGUED
F FLOODED C CROSSING IN CROSSWALK—
NOT AT INTERSECTION L UNINVOLVED VEHICLE
G OTHER PARTY
0 CROSSING—NOT IN CROSSWALK I M OTHER Ie.maln In narralrvel t } A SPECIAL INFORMATION
H .NO UNUSUAL CONDITIONS
E IN ROApINCWDING SHOULDER I N NONE APPARENT I A HAZARDOUS MATERIALS
FACTORS NOT LISTED ABOVE: F NOT IN ROAD O RUNAWAY VEHICLE 8 FIRE INVOLVED
A G APPROACHILEAVING SCHOOL BUS I I C TIRE OEFECTIFAILUHE
B
REPORTING OFFJCER SERIAL Na ASSISTING OFFICER TIME CONSUMED FCLLOW UP SERIAL NO. ` CLEARED t FILED
�< 1992
VEHICLE COLLISION EXTRA 4 9`%'Um .Zjv 1-w d " 7I O J I 1 FACE
IhJUR,ED PARTY REPORT COPY TO INCIDENT NO.I J y I I OF
Oakland Police Department
536-564-1 (11/90) INJURED PARTIES - USE FOR INVESTIGATED COLLISIONS ONLY
DATE I TIME LOCATION OF SCENE COLLISION or REPORT NO.
Ce;jiEN)✓tAL � �r
AGE . SEX RACE XTENT OF INJURY INJURED WAggg. PARTY SEAT SAFETY EJECTED
❑ ❑ ❑ ❑ ❑ ❑ ❑ POS. EQUIP,
2� M Ij FATAL SEVERE OTHER COMPLAINT DRIVER PASS PED 81 CLE OTHER
�J INJURY WOUND INJURY OF PAIN
NAME RES.ADDRESS CITY/ZIP PHONE
PiAf�ry
BUS.ADDRESS CITYIZIP PHONE TAKEN TO(INJ. ONLY) AMBULANCE CO. --
DESCRIBE INJURIES f• "c
i�0r't-i� U:A.o�_� l=r.-A—C;Z.( LL 1=�{+-t Lt r-
AGE SEX RACE EXTENT OF INJURY INJURED WAS: PARTY SEAT SAFETY EJECTED
POS. EQUIP.
FATAL SEVERE OTHER COMPLAINT DRIVER PASS PED BICYCLE OTHER
INJURY WOUND INJURY OF PAIN
NAME RES.ADDRESS CITY/ZIP I PHONE
( )
BUS.AOORESS CITY/ZIP PHONE TAKEN TO()NJ. ONLY) I AMBULANCE CO.
( )
DESCRIBE INJURIES
AGE SEX RACE EXTENT OF INJURY INJURED WAS: PARTY SEAT SAFETY EJECTED
POS. I EQUIP.
FATAL SEVERE OTHER COMPLAINT DRIVER PASS PED BICYCLE OTHER
INJURY WOUND INJURY OF PAIN
NAME RES.ADDRESS CITY/ZIP I PHONE
( )
BUS. ADDRESS CITY/ZIP PHONE TAKEN TO (INJ. ONLY) I AMBULANCE CO.
( )
DESCRIBE INJURIES
AGE SEX I RACE _ EXTENT OF INJURY INJURED WAS: PARTY SEAT SAFETY EJECTED
❑ _ El El E! n POS. I EQUIP.
FATAL SEVERE OTHER COMPLAINT DRIVER PASS PED BICYCLE OTHER
INJURY WOUND INJURY OF PAIN
NAME RES.ADDRESS CITY/ZIP I PHONE
( )
BUS. ADDRESS CITYIZIP PHONE TAKEN TO(INJ. ONLY) I AMBULANCE CO.
( )
DESCRIBE INJURIES
AGE SEX RACE EXTENT OF INJURY INJURED WAS: PARTY AT SAFETY I EJECTED
❑ r ❑ S ru ❑ ❑ POI EQUIP
FATAL SEVERE OTHER COMPLAINT DRIVER PASS PED BICYCLE OTHER
INJURY WOUND INJURY OF PAIN
NAME RES.ADDRESS CITYIZIP I PHONE
BUS.ADDRESS CITYIZIP PHONE TAKEN TO(INJ. ONLY) AMBULANCE CO.
( )
DESCRIBE INJURIES
SEATING POSITION SAFETY EQUIPMENT
EJECTED FROM VEHICLE
1-DRIVER OCCUPANTS L-AIR BAG DEPLOYED MIC BICYCLE-HELMET
A-NONE IN VEHICLE M-AIR BAG NOT DEPLOYED 0-NOT EJECTED
2 TO 6 PASSENGERS B-UNKNOWN N-OTHER DRIVER 1-FULLY EJECTED
7-STA.WGN.REAR C-LAP BELT USED P-NOT REQUIREpV-NO 2-PARTIALLY EJECTED
8-RR.00C.TRK.OR VAN D-LAP BELT NOT USED W-YES 3-UNKNOWN
1 2 3 9-POSITION UNKNOWN E-SHOULDER HARNESS USED CHILD RESTRAINT
0-OTHER F-SHOULDER HARNESS NOT USED O-IN VEHICLE USED PASSENGER
4 5 6 G-LAP/SHOULDER HARNESS USED R-IN VEHICLE NOT USED X-NO
7 H-LAPISHOULCER HARNESS NOT USED S-IN VEHICLE USE UNKNOWN Y-YES
J-PASSIVE RESTRAINT USED T-IN VEHICLE IMPROPER USE
K-PASSIVE RESTRAINT NOT USED U-NONE IN VEHICLE
01AGRAM ' '�=� "�'�'" i Oakland Police Department
TIME LOCATION OF SCENE
• « COLLISION OR R.D.NO.
3J 1�t G' yZ 1-7 `fl (,2(22Cy l?C- Cb CCwTLiV.v/�L `fit
NO.I DRIVER OR COMPLAINANT-NAME DIST.TRAVELED SKIDS: LF RF LR RR
AFTER IMPACT: BEFORE IMPACT:
3�� AFTER IMPACT:
NO 2 DRIVER-NAME DIST.TRAVELED SKIDS: LF RF LR RR
j--il M CAL✓( AFTER IMPACT: BEFORE IMPACT:
AFTER IMPACT:
NO.3 DRIVER-NAME DIST.TRAVELED SKIDS: LF RF LR RR
AFTER IMPACT: BEFORE IMPACT:
AFTER IMPACT:
NO.4 DRIVER-NAME 01ST.TRAVELED SKIDS: LF RF LR RR
AFTER IMPACT: BEFORE IMPACT:
AFTER IMPACT:
N
POINT OF IMPACT NATURE OF INCIDENT
P.I.1 _ P.I.2 (J
'31 6Y= EE DETERMINED BY:
'0 arc DRIVER! ❑DIRT
O POSITION VEH.
P-I.3 P.I.♦ p DEBRIS O SKIDS
.............. ....•••.•..... WDAMAGE gkWITNESS
i
_
t - i
x ..
f
i
t
-
......._...__-___.... - I
4711
--..
w _
...-..... -_------------.__.._
i
REPORTING OFFICER SERIAL NO. ASSISTING OFFICER SERIAL NO.
/C - -7 r
-%IENT
-land Police Department ' 536-200-1 (e/87) 2. R.D. No.
i.
Cordpl a i nanf Offense/Crime
3. Name of Person Giving Statement Sex/Race/DOB A] Complainant (] Suspect
r1AtJ I J^AJ r`F [] Reporting Person [] Witness
4.. Residence Address City/Zip Phone
-L(�c.i E;2.)1e(. 1 Q•i-i c;`t I ( ) b'{ I -31-1.3
5. Employment (Name-Address-Phone-Occupation) or Supplemental Information if Unemployed or Transient
C3 E'r.- b.�, ,�,.�.�.A,•t� L:i _ Q C
6. Statement Taken By Serial No. Date Time Started - Completed
Location Where Statement Taken Names/Addresses of Persons Present During Statement
tJ l tai G fw IA-LL
- FOR VEHICLE COLLISIONS ONLY - j
License No. I State Veh. Yr.1 Make I Model I Type Color(s) Driver License No. State
07- 0 �Z�p4tS�DIJc i�i3-3 rtE+��1 21-JVO MT-j? ;3l CC C.._:,
Registered Owner Address City/Zip Res./Bus. Phone
ADMONITION: You have the right to remain silent. Anything you say can be used against you in a court of law. You have the right
to talk to a lawyer and have him present with you while you are being questioned. if you cannot afford a lawyer, one
will be appointed to represent you before any questioning if you wish one.
WAIVER: Do you understand each of these rights I have explained to you?
Having these rights in mind, do you wish to talk to us now?
STATEMENT:
i
i
i
I
Page of
J1ENT
0 arra ,Police Department 536-200-1 (8/87) 2. R.D. No. c
1. Complainant Offense/Crime
C)
3. Name of Person Giving Statement Sex/Race/DOB [1 Complainant [1 Suspect
_ P
7-p/ ( C���- V! �� iaE SIL M C_ 5-1)F-C- S—ci (1 Reporting Person [1 Witness
4. Residence Address City/Zip _ Phone r
7 r..f. lift C[ fz r_G f ( (j)< !7 �f G' ( ) q.�d d
5. Employment (Name-Address-Phone-Occupation) or Supplemental Information if Unemployed or Transient
N o^iE _
6. Statement Taken By Serial No. Date Time Started - Completed
s �``i•J 171?',�T ?ly 05-0-1 l k- Q. F)",I
Location Where Statement Taken Names/Addresses of Persons Present During Statement i
- FOR VE1iICLE COLLISIONS ONLY -
License No. I State Veh. Yr. Make Model Type Color(s) Oriv License No. State
3 3 )-/v-cr 3 a Z i=o�aS Y� ti.,ul f-7 �, 3
Registered Owner Address City/Zip Res./Bus. Phone
ADMONITION: You have the right to remain silent. Anything you say can be used against you in a court of law. You have the right
to talk to a lawyer and have him present with you while you are being questioned. If you cannot afford a lawyer, one
will be appointed to represent you before any questioning if you wish one.
WAIVER: Do you understand each of these rights I have explained to you?
Having these rights in mind, do you wish to talk to us now?
STATEMENT:
/Z—
(Z-J)
L
(Z-J) r3 .�c� 0-4<, r2 C!l L
sip,—f=.n , ,✓ ry-�� ;lit = G..a ;;?,ovcC.�i,.�/ arJ �, iZZL�/
/,,'C-F4 /�. T 6-1
-71� !�r G c.1.7- C-(r�:�1� Gc.�.2 v� ,c{i3C:.<i �(.c,L_c= L�,�� i•�o ��CC'
(j57"/ 50/1AC13C131 '< <✓fr
l3 / C y CL /ZC-C:7 CCj OILS /ill�' ..1 ,u ky
.�.C:,— Tv F ,J/ c LI- .rT GSE roT61 I
C7ti1 7�C 6 c L-, r /J.S 1-1 F t C /�S ..n i✓� �2C.=G E C 7 G/L. f
1011,
v� ,?C 71 /��nom. ^' i� T C ,-;7/ y C L ; -T G.•.-,I
- 2^v c (_ j i /C- v; /'A,3 Lx CT / i ,J 1, ! ,✓ Teti:r= C,c.L;Z+✓e /-tl— I
i
Tr 6` 1 AA t= -r-6-4 4E: LL 7711S I-S .a .JT—T-'/.I E"
e6 J7-
i �
Page of I
rr1 Pd I 1?m L= b` 3- U
,Mand Pol ice Department ' 536-200-1 (8/87) 2. R.D. No.
I. Complainant'' Offense/Crime 1l�a)t7t � ]] �jj
(7�
3. Name of Person Giving Statement Sex/Race/DOB [] Complainant [] Suspect
DYet 2 Lei /J' L /9,/L:C [] Reporting Person Witness
4. Residence Address City/Zip Phone
ZJ (=LCISC Lc=;.iS,ar N1 GL 9�'/S'23 1 ( ) L-FT- I/g-7
5. Employment (Name-Address-Phone-Occupation) or Supplemental Information if Unemployed or Transient
6. Statement Taken By Serial No. Date Time Started - Completed
Location Where Statement Taken Names/Addresses of Persons Present During Statement
- FOR VEHICLE COLLISIONS ONLY -
License No. I State Veh. Yr. Make IModel I Type I Color(s) Driver License No. State
Registered Owner Address City/Zip Res./Bus. Phone
ADMONITION: You have the right to remain silent. Anything you say can be used against you in a court of law. You have the right
to talk to a lawyer and have him present with you while you are being questioned. If you cannot afford a lawyer, one
will be appointed to represent you before any questioning if you wish one.
WAIVER: Do you understand each of these rights I have explained to you?
Having these rights in mind, do you wish to talk to us now?
STATEMENT:
i E-LC tit-( C—", )VerzE"T7 c, (,,4 F4 D- Iff A:-i— ��2vk, r�.y7-6-
L D b J 1-((2,5 -r nl(�(_ (✓rT 't� /t S C AxC
p,�SF�ZVc r�L.( / S�/Gni i JO/i�i /�% /i.?crc�t� J'• �J /inn Z i,. cT
2 / V l .i C-- L`7 ��.v i�_ �L�� �»2c k/.n.�,--7--c= [ `'I ,C-/V F C aZ
LL , /Cr?-A4-r /SCrte iq
E Z C PQiLL Az--o
6 02,
T!,(C j/
r7�C nl t T7 O �.J -77d �Z (7- ,T/ D�
Lcw c--- ty a Vic' cucz
_ laZZ.Nz CZ s,:)L-..--b 10 Et C(-a 4-� ti
E�7iZ �.o�.� t Cc �=x�� J rbc/` C.Zu C-r f� t/c/L 7z�lr
I
F-P,
of
Oakland Police Department
ATE T IME PHOTOG PHS LOCATION
-j0 T,7GC 11� (-14l 0Yes �No
Indicate area and nature of damage by shading. Whenever possible,get measurements between striations and height from ground.
VEHICLE#1
U
m -
:OLOR OF VEHICLE L_
0 0
:OLOR OF TRANSFER i
DESCRIBE DAMAGE IN FULL:
VEHICLE #2
I
J
I�
v -
COLOR OF VEHICLE
O
:OLOR OF TRANSFER /
'• I I I
DESCRIBE DAMAGE IN FULL: //= C.J;z..�✓��/'._ O,� yr�-i �,i C-' �- �. �.�c �Z- ,•i��.-! �( SIT
OFFICER SERIAL NUMk1El.
Please enter address or insurance changes on,back and check this box U. Please detach along dotted line and return this portion with your payment.
PLEASE PAY THIS AMOUNT VUE BY
HIGHLAND GENERAL HOSPITAL 42 579 . 05 04/10/93
R it PO BOX 12958 -AMOUNT PAID 10- Is
OAKLAND, CA 94604
ACCOUNT NUMBER AND NAME
41
HIGHLAND GENERAL HOSPITAL 89222145
SEND PO BOX 12958 BENTON ,BRUCE
PAYMENT
OAKLAND, CA 94602
TO FOR INFORMATION ON ACCOUNT,PLEASE CALL
� 5104374814
Y ` .5c
`Y5 3
F ADM DT: 123092
R DSH DT: 010893
H SB : S0005
° 510-841-3813 89222145
Y P BD: 01151954 BRUCE BENTON
" s HR : H30 2621 BENVENUE AVE
r, a BERKELEY CA 94704-3404
Page No. 1
Account Number: 89222145
Patient Name: BENTON ,BRUCE
Service Start: 12/30/92 Service End: 01/08/93
Statement Date: 03/11/93 Last Statement Date: 0 3/0 4/9 3
QUESTIONS? Please Call: 5104374814 Contact:
ACCOUNT BALANCE ESTIMATED INSURANCE DUE TOTAL PATIENT CREDITSlw= •
42 ,579 . 05 . 00 42,579 . 05
TRANS DATE DESCRIPTION AMOUNT
PREVIOUS BALANCE 42 ,579 . 05 ;
H I R1 HO 30 ACCOUNT BALANCE 442,579 . 05
PROMPT PAYMENT IS NEEDED NOW. PLEASE CALL THE
NUMBER ABOVE TO MAKE PAYMENT ARRANGEMENTS.
X
¢,�� *�f, .zt,# t, �r':.:.t'*i,: "�,,F� j..�,,. . I • • • • •a • ,`.i". � i-'. . t;: ,
ua Until your insurance has paid,the PLEASE PAY THIS AMOUNT represents the balance we estimate you owe.
Any balance unpaid by your insurance will be due from you... Thank you.
V 1 Q t>e_(1q1 V 0E--03-9 3 APPROVED OMB NO.0938-0279
1 2 3 PATIENT CONT
FAIP !MONT HOSPITAL
1"54G•0 —F�OOTHILL BLVD . CCGGf�t/� 23017916
SAN L EA N D R 0 C A 5 BC/BS PROV.NO. B FEDERAL TAX NO. 7 MEDICARE NO. 9
94578-1091 510-667-3033 946000501W
10 PATIENT'S LAST NAME FIRST NAME INITIAL 11 PATIENT'S ADDRESS CITY - STATE, ZIP
BENTON BRUCE 2021 VENVENUE QERKELEY CA:'94704 '.
12 BIRTH DATE 13 SEX id MS - -- ADMISSION - 19 A.H.120D.H. 121STAT.122 .:STATEMENT COVERS PERIOD :-<:-., 23 COV.D. 24 N C.D. 125.C4.D. 26 L40. 27 c15 DATE 16 HR.17TYFE 18SRC FROM THROUGH _ C
01-15-54 M _:S 01 -08-93 15 3 ` 1 21 01 . 01-08-9301 -27-93 '•19PT =. U
29 �- OCCURRENCE I •• 31 OCCURRENCE 3 'C-' -;(:-c OCCURRENCE SPAN .- ✓i h.-!
CD I CAT I C13J DATE CD I DATE CO I DATE CD DATE CD FROM THROUGH
o w' - CONDITION CODES -• BLOOD RECORD IPINTSI :" 44 SP. 45 -
R U C E B E N T O N 36 36 40 FURN 41 REPL 42 NOT RP. 43 DED. FROG.
2621 :,VENVENUE �t
BERKELEY, CA 94704 46 "'':VALUE 48 i::,• VALUE
CD AMT CD AMT CO AMT CU AMT
°O1 99999
G.fs +� '"�•a a-•1'9"^} .^fi a•�y`r,.+� _' 3�.
50 DESCRIPTION 51 R.CODE 52 S.UNITS 53 TOTAL CHARGES 54 55 56 PT AMT
REHAB/WARD 550 . 00 158 19 1 0450:00 10450'00
PHARft--ACY 250 269 Y' 3$7. 25 � _5G3€70 .
DRUGS%TAKEHOME. -' 253 91 12085 120is5
HED SUR,.SUPPLIES y _ 270 '7 _x.. 94.00
LABORATORY OR ( LAB) 300 6 21119 21119 _
DX X—RAY 320 3 e 17860__ :1.78:60 _
PHYSICAL THERP 420 29 189500 1895:00
OCCUPATION TNER 430 28 165$:00 155$:00
EKG/ECG 730 1 54:00 54:00
e-r.......a 1xr..v m...a<a�:_. ._ .... _.,_.__. �,. ....: _._.. ,_...,._a ......f.�. __,�. ^.__......_, -._q:. .-.L<._.:✓_': _.....- .. ,. .._._ ._.< -. :r1«tic,
TOTAL CHARGt7: IS 2:D r-:
r
• '-' .,x-..,_ 1'�}e•«.m ,.. «.,-.a:-, 37:.`.:: .:. :,;s'. ., '�. 4,"ya:. xt- .. _ x t.- � .., K" .. r.z'
57 PAYER 60 DEDUCTIBLE 61 CO-INSURANCE 62 EST.RESPONSIBILIT)' 63 PRIOR PAYMENTS 64 EST.AMOUNT DUE
APP 3RD PRTY L IAB Y Y 1 5225:04
C
65 INSURED'S NAME 66 SEX P.REL. 7U-INSURANCE GROUP NO.
ABENTON 6 R U C E 1,40-1 ��� SZ -736
C
i 1 E10 72 ESC 73 EMPLOYER NAME 74 EMPLOYEE ID. 75 EMPLOYER LOCATION
S•i;^7:•(±;'.:.•C;i:.:.s:•....^,-..:C,;. .. .....c!....C...:..:;;'o-`.•:; :C::::: ::;%.•::; -.:::°7. :::... .......... .. .......:........... .: . .....:tR•. :o-. ::r..,.:•..
:. •:.:-::C!..:•:�c`. ;' .....::... . .. ........::....:. :..:•.::•...::..i..._:: .:..:::•:.:•::m. •:�'::.....;..:.�.....t'....C,.,:.9..::::...:...:::.-::.......^.....,...,..C!.....�:.......,....9...•..•.:•.
Il:.;:>.;.,�--�-�•-_ _-" ':'._may. `, ;:.'.",�
NOTICE TO The hospital is acting solely as an agent for the patient in filing for insurance benefits
THE PATIENT assigned to it, however, the hospital can assume no responsibility for guaranteeing payment
of covered charges as shown on the face of the bill. Credit is shown only when the hospital
�B'=ill has actually received payment. Should an overpayment be made, a refund check will be
p: ;9 sent to the authorized party that is due the overpayment. 01r
..•. ..--._.�:—�--�,�.�.-,��. �--� ..�.-,.._.-_,:�-_.,_-.----.<_�..:: _.------�--_— - - ...:�-•� ...-ter:
... .. t^ .. .:.!l:•:-.;•!9.•... C ::. ::r::.-�:�-J:•C'•.-::r*,.•:n:`w.:: ^:•!Ltvr::, ...::C•..:. ::.::. :.::;:•R•::=:�:":-:. ::-:::.�:::�:'.. :>,::•. :f::,.:R.::?;•:. ::r::....... :>--:. ::.-:..:.::0•:..:�..
:':.,,..r.:�::r.:J•::•.1.r,:•1;:::rrr;.:::::•::�;:�,;•;.�:;::::,.x':::.,.••.,...;,;,;r•.;:.•;.•,rr•:•.:,::�:;•{,,,,..,.,,::•,�.•,:,,:r•�•�„•r,;;�,•:,: ,��r,:,.;,;,�.�:i�:ti�j�•;;::ii•:r•:;,:
:���:'�:�''•''':�i;:•.'.;:::�+::?:•:::;t+�1•:'•':l:'T.:l:`::•;'•:;:::'.ji!S':(i;it;t.tr'�.�::'�:•:�i i��;�i•��r���•
��.=:r�:=:`�O�%=::+:,j�-.`=�:<�L_5:-...,,_ _ _ �_ _J J_ _.r'.=::J __ _J ._v'_-::-��=lr•J�`:=•_�it::_'��9�-='J�•'.. .�..�_w .. v...-;� •..•.q• _'�.9�:r.,.•D.- ,'r al•:'r':•J�:"o-:D� �1
US-82 HCFA-1450