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HomeMy WebLinkAboutMINUTES - 09262006 - C.22 CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: SEPTEMBER 26, 2006 Claim Against the County, or District Governed by ) the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The.copy of this document mailed to California Government Codes. ) you is your notice of the action taken D �gIIly on your claim by the Board of Supervisors. (Paragraph IV below), AUG 2 1 2006 given Pursuant to Government Code AMOUNT: $1,169.79 Section 913 and 915.4. Please note all COUNTY COUNSEL. Warnings", MARTINEZ CALIF. CLAIMANT-.HECTOR JIMENEZ ATTORNEY:UNKNOWN DATE RECEIVED: AUGUST 21, 2006 ADDRESS: 222 DENISE DRIVE BY DELIVERY TO CLERK ON: AUGUST 21, 2006 SAN PABLO, `CA 94806 RECEIVED FROM BY MAIL POSTMARKED: RISK MANAGEMENT FROM-. Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. AUGUST 21, 2006 JOHN CULLEN, r ? Dated: By: Deputy 11. FROM: County Counsel T0: 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). ( ) Claini 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). ( ,4KOther: U 0,,v-7 6 1 a ✓Y) (A )_ L-A "rte COL--)r)47-4 wool A ).-,�,e_ h b1e - Dated: 'oZJ-(xD By: - 1.-. Deputy County Counsel 111. FROM: Clerk of the Board TO: County Counsel (1) County Administrator(2) O Claim was returned as untimely with notice to claimant (Section 911.3). IV�OARD ORDER: By unanimous vote of the Supervisors present: ( This Claim is rejected in full. O Other.. 1 certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: -'"GHN CULLEN, CLERK, By eputy Clerk WARM G (Gov. code section 913) Subject to ceilain exceptions,you have only six(6)nionlhs from the date this notice was personally served or deposited hi the mail to filen 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 wmit to consult fill attoi-ney,you should do so immediately. *For Additioual Wariiaig See Reveise Side of This Notice. AFFIDAVIT OF MAILING 1 declare under penalty of perjuiy that I am now, and at all times herein meutioued, have been ,a citizen of the United Shales, over age 8; and that today I deposited in alae United States 1'oslal Seri'ice ill 111,ti-tiuez, California, postage firlly prepaid ar certified copy of tills Ilo€ird l)viler sturd Notice to C'Iaini.rnt, addressed to the claitu,tnt as shown above. Dated: /' `'e 46�261401lf� CUI_J_:I_N, CLERK 13y Jel)uly Clerk o( 74/ -7�' BOARD OF SUPERVISORS OF CONTRA,CQSTA COUNTY INSTRUCTIONS TO CLAIMANT A claim relating to a cause of action for death or for injury to person or to personal property or growing crops shall be presented not later than six months after the accrual of the cause of action. A claim relating to any other cause of action shall be.presented not later than one year . after the accrual of the cause of action.. (Gov. Code § 911.2.) 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. 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. �. If the claim is against more than one public enti)c, separate claims must be filed against each. public entity. s. Fraud. See penalty for fraudulent claims,Penal Code Sec. 72 at the end of this form ■.tt t t t tl Rita[[tttt l t(L alt G ttCan Cham RtRtltttttttUR Q C CCC CQlttt[t■(■■ttttRttttt Rl tE: Claim By: Reserved for Clerk's filing stamp REtE/VE® Against the County of Contra Costa or ) AUG 1 2 /tell ) �LBRKB . 1 2006 &�- l� l mAX_M �Z�- District CO ARD OF SUP (Fill in the name) )' NTRACosU C��/SpRs The undersigned claimant hereby makes claim against the County of Coma Costa or the above-named district in the sum of$ .1q and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) 11 6 j9 M u ` 5-- o� 2. Where did the damage or injury occur? (Include city and county) �-)cz.vawo O'C.' Cvv&vC' Ccbb�k 3. How did the damage or injury occur? (Give full details;use extra paper if required) 4. What'particular act or omission on the part of county or district officers, servants, or employees caused the injury or damage? 5 What are the names of county or district officers,senants, or employees causing the damage or injury? k')'. ,D,jV-L ;. What damage or injuries do your claim resulted? (Give full extent of injuries or damages -- °claimed: Attach-two estimates for auto damage.) . - - 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or dainage.) 8. Names and addresses of witnesses, doctors, and hospitals: 9. List the expenditures you made-on account of this accident or injury: DATE TWE AMOUNT ■ aaaaaaoeeaaeeeeaBar aaeaaaseaaasaaasaataaaaaRitualism Salinas Its Mass caaaaaaaall lies aaaaaasat ) .Gov. Code Sec. 910.2 provides"The claim shall be ) signed by the claimant or by some person on his behalf." SEND NOTICES TO: (Attorney) Name and address of Attorney } �— C s Signature) 2-7i7i iCA� , (Address) Telephone No. ) Telephone ho. ■aa as at a aatalaata■III aaaaaaMEaa■■eaaaaaaaaaaaaaaacaaaaaaaaaacaaaaaaacaaaaaa aunit saaaaaaa1 PUBLIC RECORDS NOTICE: Please be advised that this claim form, or any claim filed with the County under the Tort Claims Act, is subject to public disclosure under the California Public Records Act. (Gov. Code, §§ 6500 et seq.) Furthermore, any attachments,addendums, or supplements attached to the claim form, including medical records, are also subject to public disclosure. ■aaatataaaaaaaaaaaaasataaaInusaaaaaataataaaaaacaaaaaaaaaaaaaaaaaaaaaaaaataaaaNunn aaase 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 couni3,, 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 dollars ($1,000.00), 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. CARLOS' AUTO . • DS IN = • • . Job Number: 107 -7ee Estimates CARLOS AUTO,BODY SHOP :ARLOS AUTO BODY SHOP 221 24th Street Richmond, CA 94804 107-1544 Fax: (510) 307-1507 '1-24th STREET, • I PHONEAJAL 1 1 � � ' PRELIMINARY ESTIMATE t ;1, FAX 1 1 By: Carlos Carbajal Adjuster: Insured: HECTOR JIMENEZ Claim # Owner: HECTOR JIMENEZ Policy # Address: 222 DENIS DR Deductible: SAN PABLO, CA 94806 Date of Loss: Day: (510) 223-3838 Type of Loss: Point of Impact: Inspect CARLOS AUTO BODY SHOP Business: (510) 307-1544 Location: 221 24th Street Richmond, CA 94804 Insurance Company: Days to Repair 1980 GMC C15 4X2 CAB. & CHASSIS 8-5.7L-4 2D SHORT Int: VIN: UNKTCD14AZ501422 Lic: Prod Date: Odometer: Power Brakes 4 Speed Transmission ------------------------------------------------------------------------------- NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT --------------=------------------=--------------------------------------------- 1 FRONT DOOR 2* Rpr LT Door shell 6.0. 4 . 0 3 R&I LT Mirror outside 0.3 4 R&I LT Handle, outside 0.4 5 FENDER .& LAMPS 6* Rpr LT Fender 3.0 2.2 7 Overlap Major Adj . Panel -0.4 8 R&I LT Nameplate Sierra 15 0.5 9# Subl HAZARDOUS WASTE DISPOSAL . 1 5.00 T 10# Repl CAR, COVER/ MASK FOR OVERSPRAY 1 5..00 T 0.2 Il# Rpr TINT COLOR 0.5 ------------------------------------------------------------------------------- Subtotals =_> 10. 00 10. 9 5. 8 Parts 0.00 Body Labor 10. 9 hrs @ $ 60.00/hr 654 . 00 Paint Labor 5. 8 hrs @ $ 60.00/hr 348 . 00 Paint Supplies 5. 8 hrs @ $ 25.00/hr 145. 00 Sublet/Misc. 10. 00 ---------------------------------------------------- SUBTOTAL $ 1157 .00 Sales Tax $ 155.00 @ 8 .25000 12 .79 ---------------------------------------------------- GRAND TOTAL $ 1169.79 ADJUSTMENTS: Deductible 0. 00 ---------------------------------------------------- CUSTOMER PAY $ 0.00 INSURANCE .PAY $ 1169.79 1 ` 08/02/2006 at 06: 13 PM Job Number: 107 98473 PRELIMINARY ESTIMATE 1980 GMC C15 4X2 CAB & CHASSIS 8-5.7L-4 2D SHORT Int: FOR YOUR PROTECTION CALIFORNIA LAW REQUIRES THE FOLLOWING TO APPEAR ON THIS FORM: ANY PERSON WHO KNOWINGLY PRESENTS FALSE OR FRAUDULENT CLAIM FOR THE PAYMENT OF A LOSS IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN STATE PRISON. THE FOLLOWING IS .A LIST OF ABBREVIATIONS OR SYMBOLS THAT MAY BE USED TO DESCRIBE WORK TO BE DONE OR PARTS TO BE REPAIRED OR REPLACED: MOTOR ABBREVIATIONS/SYMBOLS: D=DISCONTINUED PART A=APPROXIMATE PRICE LABOR TYPES: B=BODY LABOR D=DIAGNOSTIC E=ELECTRICAL F=FRAME G=GLASS M=MECHANICAL P=PAINT LABOR S=STRUCTURAL T=TAXED MISCELLANEOUS X=NON TAXED MISCELLANEOUS PATHWAYS: ADJ=ADJACENT ALGN=ALIGN A/M=AFTERMARKET BLND=BLEND CAPA=CERTIFIED AUTOMOTIVE PARTS ASSOCIATION D&R=DISCONNECT AND RECONNECT EST=ESTIMATE EXT. PRICE=UNIT PRICE MULTIPLIED BY THE QUANTITY INCL=INCLUDED MISC=MISCELLANEOUS NAGS=NATIONAL AUTO GLASS SPECIFICATIONS NON-ADJ=NON ADJACENT 0/H=OVERHAUL OP=OPERATION NO=LINE NUMBER QTY=QUANTITY QUAL RECY=QUALITY RECYCLED PART QUAL REPL=QUALITY REPLACEMENT PART COMP REPL PARTS=COMPETITIVE REPLACEMENT PARTS RECOND=RECONDITION REFN=REFINISH REPL=REPLACE R&I=REMOVE AND INSTALL R&R=REMOVE AND REPLACE RPR=REPAIR RT=RIGHT SECT=SECTION SUBL=SUBLET LT=LEFT W/O=WITHOUT W/ =WITH/_ SYMBOLS: #=MANUAL .LINE ENTRY *=OTHER [IE. .MOTORS DATABASE INFORMATION WAS CHANGED] **=DATABASE LINE WITH AFTERMARKET N=NOTES ATTACHED TO LINE. MQVP=MANUFACTURER' S QUALIFICATION AND VALIDATION PROGRAM. OPT OEM=ORIGINAL EQUIPMENT MANUFACTURER PARTS EITHER OPTIONALLY SOURCED OR OTHERWISE PROVIDED WITH SOME UNIQUE PRICING OR DISCOUNT. Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide D01GA76 Database Date 07/2006, CCC Data Date 07/2006, and the parts selected are OEM-parts manufactured by the vehicles Original Equipment Manufacturer. OEM parts are available at OE/Vehicle dealerships. OPT OEM (Optional OEM) parts are OEM parts that may be provided by or through alternate sources other than the OE/Vehicle dealerships. OPT OEM parts may reflect some specific, special, or unique pricing or discount. Asterisk (*) or Double Asterisk (**) indicates that the parts and/or labor information provided by MOTOR may have been modified or may have come from an alternate data source. Tilde sign (-) items indicate MOTOR Not-Included Labor operations. Non-Original Equipment Manufacturer aftermarket parts are described as AM, Qual Repl Parts or Comp Repl Parts which stands for Competitive Replacement Parts. Used parts are described as LKQ, Qual Recy Parts, RCY, or USED. Reconditioned parts are described as Recon. Recored parts are described as Recore. NAGS Part Numbers and Benchmark Prices are provided by National Auto Glass Specifications. Labor operation times listed on the line with the NAGS information are MOTOR suggested labor operation times. NAGS labor operation times are not included. Pound sign (#) items indicate manual entries. Some 2006 vehicles contain minor changes from the previous year. For those vehicles, prior to receiving updated data from the vehicle manufacturer, labor and parts data from the previous year may be used. The Pathways estimator has a complete list of applicable vehicles. Parts numbers and prices should be confirmed with the local dealership. CCC Pathways - A product of CCC Information Services Inc. 2 STATE OF CALIFORNIA DEPARTMENT OF CALIFORNIA HIGHWAY PATROL COLLISION REPORT INFORMATION Com•Highway Patrol CHP 418 Rev.10-04 OPI 061 3601 Telegraph Avenue DATE TIME Oakland, CA 94609 (510),450-3821 A-F 8* NCIC NUMBER OFFICER'S I.D.NUMBER 4 YOUR VEHICLE WAS REMOVED TO: A copy of the collision report can be obtained from the address above and will normally be available within 10 days from the date of the collision. A request by mail is preferred and must include: date,time,NCIC number,and Officer's I.D.number printed above. The certification for purchase information(see reverse) must also be completed,signed and attached to your written request with your check for payment. Make your personal check or money order payable to the California Highway Patrol(CHP)for$10.00. Reports may also be obtained in person during the office hours stamped above. Please call to determine if the report is ready. In the event the cost exceeds$10.00,you will be notified. Reports are retained 4 years. CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY e BOARD ACTION: SEPTEMBER 26, 2006 Claim Against [lie County, or District Governed by ) the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Sectio vr­ "--� The copy of this-docwnent mailed to California Government Code j you is your notice of the action taken AUG 2 3 2000 on your claim by the Board of Supervisors. (Paragraph IV below), COUNTY Z iven Pursuant to Government Code MARTINEZ CALIF.CAt_ii=. Section 913 and 915.4. Please note all AINIOUNT.: EXCEEDS $25,000.00 ,Warnings". CL AI.NI AN T: LEATHON GAGE, C/0 DARLENE LATTY ATTORNEY: UNKNOWN DATE RECEIVED: AUGUST_ 22, 2006 ADDRESS: 929 MANOR ROAD, BY DELIVERY TO CLERK ON: AUGUST 22; 2006 EL SOBRANTE, CA 94803 HAND DELIVERED BY MAIL POSTMARKED: FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN CULLEN, Dated: AUGUST 23, 2006 By- Deputy 11. FROM: County Counsel T0: Clerk of the Board of Supervisors This claim complies substantially with Sections 910 and 910.2. ( ) This Claiin 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). O 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 9113). O Other: Dated: By: Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) O Clainr was returned as untimely with notice to claimant (Section 911.3). 1V. ARD ORDER: By unanimous vote of the Supervisors present: ( This Claim is rejected in full. O Other: 1 certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. llated: CULLEN, CLERK, By Deputy Clerk WARM G (Gov. code section 913) Subject to ceiiain exceptions,you have only six(6)months;from the date this notice was personally served or deposited in the unad to rile a court action ou this claim.See Govenunent Code Sectiou 945.6.You may seek the advice of all attorney of your choice in connection with this matter: If you want to consult all attorney,you should do so immediately. *For Additioutd Wanting See Reverse Side of 11tis Notice. AFFIDAVIT OF MAILING 1 declare lender penalty of per juiy that I am now, and at all times herein mentioned, have been a citizeu of the United States, over age 18; and that today I deposited in the United Slates Postal Service in 1\I;u tinez, California, postage rally prepaid ;e certified copy of this lloard Osler :end Notice to Claimant, whivessed to the clainumit .ns shown above. I)a(ed "4' ! �9 "C5 IO.IIN CUI_;L:LN, CLERK BS Truly Clerl: LCLERK CE1 VED Z 3 2006 1 CLAIM AGAINST CONTRA COSTAA�pSTACpVISORS (Pursuant to Government Code Section 910, et seq. 2 3 TO: CONTRA COSTA COUNTY: 4 The claimant herein presents the following claim for damages against the above-named 5 governmental agency and in compliance with Section 910 of the California Government Code sets 6 forth in detail the following information: 7 a. The name and post office address of the claimant is: Leathon Gage,c/o Darlene Latty, 8 929 Manor Road, El Sobrante, CA 94803. 9 b. The post office address to which notices in connection with this claim are to be sent 10 is: Darlene Latty, 929 Manor Road, El Sobrante, CA 94803. 11 C. The date, place and circumstances of the occurrence which give rise to the claim are 12 as follows: On February 27,2006,on Atlas Road at or near it's intersection with Richmond Parkway 13 in Richmond, California, Leathon Gage was a passenger in a Contra Costa County Sheriff's vehicle 14 which rear ended a vehicle in front of it. Upon impact, Mr. Gage was injured. 15 d. A general description of the injuries and the loss incurred, so far as is known at the 16 present time, is as follows: Back pain and stiffness, and neck pain. 17 e. The name of the public employee causingthe the inju _ is: Contra Costa County Sheriff's 18 Office driver, Jose Luis Ramirez. 19 f. The amount claimed as of the presentation of this claim is: The amount claimed on 20 behalf of the claimant herein exceeds $25,000.00. Jurisdiction of this claim would rest in Superior 21 Court. 22 Dated: August 2-2, 2006 23 By RLENE LATTY for 24 LEATHON GAGE 25 26 6TATE OF CALIFO."NIA TRAFFIC COLLISION REPORT RECORNR E CH,P 555 CARS Page 1 (Rev 1-03)OPI 061 Page 1 Of 5 SPECIAL CONDITIONS NUMBER HIT RUN CITY JUDICIAL DISTRICT LOCAL REPORT NUMBER ON-DUTY EMERGENCY VEHICLE INJURED FELONY 2 p RICHMOND BAY MUNI NUMBER KILLED MIT&RUN MISDEMEANOR COUNTY REPORTING DISTRICT BEAT 06-1721,1 0 CONTRA COSTA COLLISION OCCURRED ON: MO DAY YEAR TIME(2400) NCIC IN OFFICER I.D. zATLAS RD 2/27/2006 0821 0710 1200 MILEPOST INFORMATION: DAY OF WEEK TOW AWAY PHOTOGRAPHS BY: ❑NONE vMONDAY YES XO No SGT C.HUGHE 0 AT INTERSECTION WITH: STATE HWY REL CCSO OR: RICHMOND PARKWAY VA YES J(] NO PARTY DRIVER'S LICENSE NUMBER STATE CLASS AIR UIP. VEH.YEAR MAKE I MODEL/COLOR LICENSE NUMBER STATE i C6933734 CA B M G 2000 GMC GMC3500 WHI 1045517 CA DRIVER NAME(FIRST,MIDDLE,LAST) ON DUTY EMERGENCY VEHI LE �I .LOSE LUIS RAMIREZ- OWNER'S NAME El SAME AS DRIVER PEDES- STREET ADDRESS- CONTRA COSTA COUNTY TMAN FjCONTRA COSTA CO SHERIFF OWNER'S ADDRESS D SAME AS DRIVER PARKED CITY/STATE/ZIP 2467 WATERBIRD WAY MARTINEZ CA 94553 VEHICLE �-� f—1 MARTINEZ CA 94553 DISPOSITION OF VEHICLE ON ORDERS OF: OFFICER Ili(DRIVER 70THER BICY- I SEX HAIR F_l'ES HEIGHT WEIGHT BIRTHDATE RACE DRIVEN AWAY LJ CLIST Mo Day Year M BLK BILIV 5-10 190 9/19/1970 H PRIOR MECH.DEFECTS X NONE APP. El REFER TO NARRATIVE OTHER HOME PHONE BUSINESS PHONE VEHICLE IDENTIFICATION NUMBER: / ❑ (925)646-4664 VEHICLE TYPE DESCRIBE VEHICLE DAMAGE SHADE IN DAMAGED AREA INSURANCE CARRIER POLICY NUMBER DUNK ONONE [-]MINOR SELF-INSURED 11 MOD F MAJOREl ROLL-OVER DIR OF TRAVEL I ON STREET OR HIGHWAY SPEED LIMIT E ATLAS RI) 25 CA DoT CAL-T ----TCP/PSC MC/MX PARTY DRIVER'S LICENSE NUMBER STATE CLASS AIR BAG SAFETY EQUIP. VEH.YEAR MAKE/MODEL/COLOR LICENSE NUMBERSTATE 2 A4479295 CA C M G 1999 TOYT COROLLA BLU 4CGY738 CA DRIVER NAME(PIRST,MIDDLE,LAST) ® RAENELLE MAE ENCISCO ALDANA OWNER'S NAME SAME AS DRIVER PEDES- STREETADDRESS TRIAN D3024 AVON LANE - OWNER'S ADDRESS SAME AS DRIVER PARKED CITY(STATE/ZIP VEHICLE SAN PABLO CA 94806 DISPOSITION OF VEHICLE ON ORDERS OF: []OFFICER NDRIVER ❑OTHER BICY- SEX HAIR I EYES HEIGHT WEIGHT Me BIRTHDATE RACE DRIVEN AWAY CLIST D F BRN BRN 5-n 1 129 2/4/1975 ay Year L-f A PRIOR MECHANICAL DEFECTS )( NONE APP. REFER TO NARRATIVE OTHER HOME PHONE BUSINESS PHONE VEHICLE IDENTIFICATION NUMBER: . INXBR12E8XZ182073 D (51.0)860=0136 VEHICLE TYPE DESCRIBE VEHICLE DAMAGE SHADE IN DAMAGED AREA INSURANCE CARRIER POLICYNUMBER DUNK �❑nN""''ONE MINOR FARMERS 96-15377-03-76 01 ❑ I_IMOD I MAJOR ROLL-OVER DIR OF TRAVEL ON STREET OR HIGHWAY SPEED LIMIT CA __,. DOT E ATLAS RCI 25 CAL-T TCP/PSC MC/MX PARTY DRIVER'S LICENSE NUMBERSTATE CLASS AIR BAG SAFE-TY EQUIP. VEH.YEAR IMAKE/MODELICOLOR LICENSE NUMBER STATE 3 DRIVER NAME(FIRST,MIDDLE,LAST) D - OWNER'S NAME ❑SAME AS DRIVER PEDES- STREETADDRESS TR IAN OWNER'S ADDRESS ❑SAME AS DRIVER PARKED CITY I STATE/ZIP VEHICLE DISPOSITION OF VEHICLE ON ORDERS OF: ❑OFFICER []DRIVER OTHER BICY- SEX HAIR EYES HEIGHT WEIGHT BIRTHDATE RACE U CLIST IM. Day Year 11PRIOR MECHANCIAL DEFECTS NONE App, -]REFER TO NARRATIVE OTHER HOME PHONE BUSINESS PHONE VEHICLE IDENTIFICATION NUMBER: VEHICLE TYPE DESCRIBE VEHICLE DAMAGE SHADE IN DAMAGED AREA INSURANCE CARRIER POLICY NUMBER ❑LINK ❑NONE 1-1 MINOR MOD MAJOR ROLL-OVER DIR OF TRAVEL ON STREET OFi HIGHWAY SPEED LIMIT CA DOT CAL-T TCPIPSC MCIMX PREPARER'S NAMEDISPATCH NOTIFIED REVIEWER'S NAME DATE REVIEWED T.GRAY 1200 ❑YES []NO ONIA - 2 (1Z3 S-TQTE OF CALIFORNIA TRAFFIC COLLISION CODING CHP 555 CARS Paget(Rev. 1--03)OPI 061 Page 2 of 5 DATE OF COLLISION(MO. DAY YEAR) TIME(240D) NGIC# OFFICER I.D. NUMBER 2/27/2006 0821 0710 1200 06-17211 OWNER OWNER ADDRESS NOTIFIED PROPERTY DYES D NO DAMAGE DESCRIPTION OF DAMAGE SEATING POSITION SAFETY EQUIPMENT INATTENTION CODES OCCUPANTS L-AIR BAG DEPLOYED M/C BICYCLE-HELMET A-CELL PHONE HANDHELD A-NONE IN VEHICLE M-AIR BAG NOT DEPLOYED DRIVER PASSENGER N-OTHER V-NO X-NO B-CELL PHONE HANDSFREE B-UNKNOWN C-ELECTRONIC EQUIPMENT C-LAP BELT USED P•NOT REQUIRED W-YES Y-YES D-RADIO/CO 1 Z 3 1-DRIVER D-LAP BELT NOT USED E-SMOKING CHILD RESTRAINT 2 TO 6-PASSENGERS E-SHOULDER HARNESS USED EJECTED FROM VEHICLE F-EATING 4 5 6 7-STA.WGN REAR F-SHOULDER HARNESS NOT USED Q-IN VEHICLE USEDG-CHILDREN G-LAP/SHOULDER HARNESS USED 0-NOT EJECTED 8-RR.OCC TRK.Oft-VAN R•IN VEHICLE NOT USED H-ANIMALS H-LAP/SHOULDER HARNESS NOT USED 1-FULLY EJECTED 9-POSITION UNK14)WN S-IN VEHICLE USE UNKNOWN I- PERSONNEL HYGIENE J-PASSIVE RESTRAINT USED 2-PARTIALLY EJECTED 0-OTHER T-IN VEHICLE IMPROPER USE 3-UNKNOWN J• READING K-PASSIVE RESTRAINT NOT USED U-NONE IN VEHICLE K•OTHER ITEMS MARKED BELOW FOLLOWED BY AN ASTERISK(*)SHOULD BE EXPLAINED IN THE NARRATIVE. PRIMARY COLLISION FACTOR MOVEMENT PRECEDING LIST NUMBER(#)OF PARTY AT FAULT TRAFFIC CONTROL DEVICES 1 2 3 SPECIAL INFORMATION 1 2 3 COLLISION 1 VC SECTION VIOLATED: CITED ES X A CONTROLS FUNCTIONING A HAZARDOUS MATERIAL A STOPPED A 21703 ®NO IB CONTROLS NOT FUNCTIONING' B CELL PHONE HANDHELD IN USE I IB PROCEEDING STRAIGHT B OTHER IMPROPER DRIVING C CONTROLS OBSCURED C CELL PHONE HANDSFREE IN USE C RAN OFF ROAD D NO CONTROLS PRESENT/FACTOR` X X D CELL PHONE NOT IN USE D MAKING RIGHT TURN C OTHER THAN DRIVER' TYPE OF COLLISION E SCHOOL BUS RELATED E MAKING LEFT TURN D UNKNOWN' A HEAD-ON F 75 FT MOTORTRUCK COMBO F MAKING U TURN 8 SIDE SWIPE G 32 FT TRAILER COMBO G BACKING X C REAR END H X X H SLOWING/STOPPING WEATHER (MARK 1 TO 2 ITEMS) D BROADSIDE 1 I PASSING OTHER VEHICLE A CLEAR E HIT OBJECT J J CHANGING LANES B CLOUDY F OVERTURNED I IK I K PARKING MANEUVER X IC RAINING G VEHICLE/PEDESTRIAN L L ENTERING TRAFFIC D SNOWING H OTHER': M M OTHER UNSAFE TURNING E FOG/VISIBILITY FT N N._XING_INTO OPPOSING LANE F OTHER:' MOTOR VEHICLE INVOLVED WITH O O PARKED G WIND _ A NON-COLLISION P P MERGING LIGHTING B PEDESTRIAN Q Q TRAVELING WRONG WAY X A DAYLIGHT X IC OTHER MOTOR VEHICLE OTHER ASSOCIATED FACTORS R OTHER': B DUSK-DAWN D MOTOR VEHICLE ON OTHER ROADWAY L 2 3 (MARK 1 TO 2 ITEMS) C DARK-STREET LIGHTS E PARKED MOTOR VEHICLE A vc SECTION CITED YES oN vlo D DARK-NO STREET LIGHTS F TRAIN BNO E DARK-STREET LIGHTS NOT G BICYCLE B VC SECTION VIOLATED CITED BYES FUNCTIONING' H ANIMAL: NO SOBRIETY-DRUG ROADWAY SURFACEVC SECTION VIOLATEDCITED YES 1 2 3 PHYSICAL C A DRY I FIXED OBJECT: 8 NO (MARK 1 TO 2 ITEMS) X B WET X A HAD NOT BEEN DRINKING C SNOWY-ICY J OTHER OBJECT: E VISION OBSCUREMENT: B HBD-UNDER INFLUENCE D SLIPPERY(MUDDY,OILY,El-C.) F INATTENTION-: C HBD-NOT UNDER INFLUENCE' ROADWAY CONDITIONS) G STOP&GO TRAFFIC I ID HBD-IMPAIRMENT UNKNOWN" (MARK 1 TO 2 ITEMS) _ PEDESTRIAN'S ACTIONS H ENTERING/LEAVING RAMP I JE UNDER DRUG INFLUENCE" A HOLES,DEEP RUT* X JA NO PEDESTRIANS INVOLVED 1 PREVIOUS COLLISION F IMPAIRMENT-PHYSICAL* B LOOSE MATERIAL ON ROADV/AY• B CROSSING IN CROSSWALK IJ UNFAMILIAR WITH ROAD G IMPAIRMENT NOT KNOWN C OBSTRUCTION ON ROADWAY* AT INTERSECTION K DEFECTIVE VEH.EQUIP.: CITED H NOT APPLICABLE D CONSTRUCTION-REPAIR ZONE C CROSSING)N CROSSWALK-NOTYES I SLEEPY/FATIGUED E REDUCED ROADWAY WIDTH AT INTERSECTION B NO F FLOODED' D CROSSING-NOT IN CROSSWALK L UNINVOLVED VEHICLE G OTHER': E IN ROAD-INCLUDES SHOULDER M OTHER': X JH NO UNUSUAL CONDITIONS F NOT IN ROAD X N NONE APPARENT G APPROACHING/LEAVING SCHOOL BUS 1 10 RUNAWAY VEHICLE SKETCH MISCELLANEOUS INDICATE NORTH vF— A—i co\S K-16 P I STATE OF CALIFORNIA INJURED /WITNESSIES / PASSENGERS CHP 555 CARS Page 3(Rev,1-03)OPI 061 Page 3 of 5 DATE OF COLLISION(MO. DAY YEAR) TIME(2400) NCIC# OFFICER I.D. NUMBER 2/27/2006 0821 0710 1200 06-17211 WITNESS PASSENGER AGE SEX EXTENT OF INJURY('X'ONE) INJURED WAS('X'ONE) PARTY SEAT AIR SAFETY EJECTED ONLY ONLY NUMBER POS. BAG EOUIP. FATAL SEVERE OTHER VISIBLE COMPLAINT DRIVER PASS. PED. BICYCLIST OTHER INJURY INJURY INJURY OF PAIN ❑# ❑ 19 M ❑ ❑ ❑ ❑X ❑ ❑X ❑ ❑ ❑ 1 3 M B 0 NAME/D.O.B./ADDRESS TELEPHONE CHRISTOPHER MONTGOMERY (09/26/1986) 160 SOUTH 33RD ST RICHMOND CA 94804 (510)799-3381 (INJURED ONLY)TRANSPORTED BY. AKEN TO: N/A �A N/A DESCRIBE INJURIES: COMPLAINT OF PAIN TO RIGHT KNEE. MAR 2 2006 T ❑ VICTIM OF VIOLENT CRIME NOTIFIED ❑# 1127 I M ❑ AL Elblv 1:1 ❑X Ijo 1:1 ❑ 1 5 M B 0 NAME I D.O.B./ADDRESS 11 TELEPHONE ALEXANDER DELOSREYES_ (01/23/1979) (INJURED ONLY)TRANSPORTED BY: TAKEN TO: N/A N/A DESCRIBE INJURIES: COMPLAINT OF PAIN FROM RIGHT KNEE. ❑ VICTIM OF VIOLENT CRIME NOTIFIED ❑# 0 t ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 1 4 P B 0 NAME/D.O.B./ADDRESS - TELEPHONE WILLIAM LAFEVER _ (INJURED ONLY)TRANSPORTED BY: TAKEN TO: -- DESCRIBE INJURIES: ❑ VICTIM OF VIOLENT CRIME NOTIFIED ❑# lil ❑ ❑ ❑ ❑ ❑ ❑ 1 ❑ ❑ ❑ 1 1 5 1p 113 0 NAME/D.O.B./ADDRESS TELEPHONE LEATHON GAGE _ (INJURED ONLY)TRANSPORTED BY: TAKEN TO: DESCRIBE INJURIES: ❑ VICTIM OF VIOLENT CRIME NOTIFIED ❑# a ❑ ❑ ❑ El El o ❑ I ❑ I 0 1 16 P 13 0 NAME/D.O.B./ADDRESS TELEPHONE RODERICK JOHNSON _ (INJURED ONLY)TRANSPORTED BY: TAKEN TO: I DESCRIBE INJURIES: ❑ VICTIM OF VIOLENT CRIME NOTIFIED ❑# ❑X I El ❑ ❑ ❑ ❑ :1 El El1 6 p B 0 NAME D.O.B./ADDRESS TELEPHONE ELLIOT MARTIN _ (INJURED ONLY)TRANSPORTED BY: TAKEN TO: DESCRIBE INJURIES: ❑ VICTIM OF VIOLENT CRIME NOTIFIED PREPARER'S NAME I.D.NUMBER MO. DAY YEAR IREVIEINES NAME MO. DAY YEAR T.GRAY 1200 2/27/2006 Z^"=--'� , "23 - [ - STATE OF CALIFORNIA INJURED/WITNESS E,S /PASSENGERS CHP 555 CARS Paqe 3(ReV'1-03)OPI 061 Page 4 of 5 -DATE OF COLLISION(MO. DAY Y(D\R) TIME(2400) NCIC# OFFICER I.D. NUMBER 2/27/2006 0821 0710 1200 06-17211. WITNESS PASSENGER AGE SEX EXTENT OF INJURY('X'ONE) INJURED WAS('X'ONE) PARTY SEAT AIR SAFETY EJECTED ONLY ONLY NUMBER POS. BAG EQUIP. INJURY FATAL SEVERE OTHER VISIBLE COMPLAINT INJURY INJURY OF PAIN DRIVER PASS. PED. BICYCLIST OTHER ❑# ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 1 6 P B 0 NAME 1 D.O.B./ADDRESS TELEPHONE ERNEST HAYES (INJURED ONLY)TRANSPORTED BY: TAKEN TO: DESCRIBE INJURIES: o(�6 U ❑ VICTIM OF VIOLENT CRIME NOTIFIED ❑# o j ❑ ❑ ❑ ❑ o ❑ 1 P B NAME/D.O.B./ADDRESS TELEPHONE VAN WHITE _ (INJURED ONLY)TRANSPORTED BY': TAKEN TO: DESCRIBE INJURIES: ❑ VICTIM OF VIOLENT CRIME NOTIFIED ❑# � j ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 1 6 P B 0 NAME/D.O.B./ADDRESS TELEPHONE RICHARD SHELTON _ (INJURED ONLY)TRANSPORTED BY'; TAKEN TO: DESCRIBE INJURIES: ❑ VICTIM OF VIOLENT CRIME NOTIFIED ❑# ❑ j ❑ ❑ ❑ ❑ ❑ o ❑ ❑ ❑ 7- NAME TELEPHONE (INJURED ONLY)TRANSPORTED BY: TAKEN TO: DESCRIBE INJURIES: I (' El VICTIM OF VIOLENT CRIME NOTIFIED ❑# ❑ ❑ Lo ❑ u ❑ ❑ ❑ ❑ NAME/D.O.B./ADDRESS TELEPHONE (INJURED ONLY)TRANSPORTED BY. TAKEN TO: DESCRIBE INJURIES: VICTIM OF VIOLENT CRIME NOTIFIED ❑# ❑ j ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ I 1:fl NAME/D.O.B./ADDRESS TELEPHONE (INJURED ONLY)TRANSPORTED EN TAKEN TO: DESCRIBE INJURIES: ❑ VICTIM OF VIOLENT CRIME NOTIFIED PREPARER'S NAME I.D.NUMBER MO. DAY YEAR REVIEW E MO. DAY YEAR T.GRAY 1200 2/27/2006 L I Z 3 s - L -pr STATE OF CALIFORNIA NARRATIVE/SUPPLEMENTAL PAGE s OF 5 DATE OF INCIDENT TIME NCIC NUMBER OFFICER.I.D. NUMBER 02/27/2006 0800 0710 1200 06-1.7211 1 FACTS: 2 3 NOTIFICATION: I was dispatched to a call of a non-injury collision at 0821 hours. I 4 responded from Hilltop Mall Rd and Blume Drive and arrived on scene at 0830 hours. All 5 times, speeds and measurements in this investigation are approximate. Measurements 6 were taken by estimation, except where otherwise indicated. 7 8 SCENE: At the scene of this collision, Atlas Rd is a eastbound/westbound city street 9 consisting of three lanes. The roadway is straight and has a ascending grade. The surface 10 is composed primarily of asphalt. Atlas Rd is intersected by Richmond Parkway. Richmond 11 Parkway is a northbound/southbound city street consisting of three lanes. The roadway is 12 straight and has a descending grade. The surface is composed primarily of asphalt. The 13 intersection is signal controlled. See diagram. 14 15 PAR17IIES: 16 17 PARTY # 1 (Ramirez) was located standing next to his vehicle. Party Ramirez was 18 identified by a valid California driver's license. Ramirez was placed as a party by the 19 following items: 20 21 - Driver statements 22 - Driver in possession of keys 23 24 25 26 GMC GMC3500 Driver# 1's vehicle, was located on its wheels as shown on the diagram. 27 Vehicle damage is minor damage to front bumper and license plate housing. 28 PREPARED BY I.D.NUMBER DATE REVIEWER'S NAME DATE T. GRAY 1200 02/27/2006 �1z,� _ i 0-J.- STATE OF CALIFORNIA NARRATIVE/SUPPLEMENTAL PAGE 6 OF 5 DATE OF INCIDENT TIME NCIC NUMBER OFFICER I.D. NUMBER 02/27/2006 0800 0710 1200 06-17211 1 PARTY # 2 (Aldana) was located seated in her vehicle in the driver's seat. Party Aldana 2 was identified by a valid California driver's license. Aldana was placed as a party by the 3 following items- 4 5 - Driver statements 6 - Driver is registered owner 7 - Drive.,r in possession of keys 8 9 10 11 TOW COROLLA Driver# 2's vehicle, was located on its wheels as.shown on the diagram. 1.2 Vehicle damage is minor damage to rear bumper. .13 14 PHYSICAL EVIDENCE: None collected. 15 16 17 18 STATEMENTS: 19 20 PARI-Y # 'I (Ramirez) 21 1 was traveling East on Atlas Rd at approximately 10 to 15 mphs when I turned into the left 22 turn only lane. I was traveling behind a Toyota Corolla approaching the intersection when 23 the signal light turned yellow for east bound traffic. As the light cycled to red, the driver in 24 the Corolla stopped in the left turn lane. I then applied my brake preparing to stop behind 25 the Corolla when my vehicle wheels locked up. I then slid into the back of her vehicle. 26 27 28 PREPARED BY I.D.NUMBER . DATE REVIEWER'S NAME DATE T, GRAY 1200 02/27/2006 ,�.23 3-1-0 � STATE OF CAL FORMA --_- NARRATIVE/SUPPLEMENTAL PAGE 7 OF s DATE OF INCIDENT TIME NCIC NUMBER OFFICER I.D. NUMBER 02/27/2006 0800. 0710 1200 06-17211 1 OPINIONS AND CONCLUSIONS: \� 1 2 3 SUMMARY: Driver #1 Ramirez was traveling East on Atlas Rd behind a Toyota Corolla 4 when the signal light controlling the left turn lane cycled from yellow to red. The Toyota 5 Corolla stopped at the intersection as the light turned red: Driver#1, Ramirez traveling 6 immediately behind the Toyota'then applied his brakes preparing to stop. Due to the 7 roadway and weather conditions (raining) Driver#1(Ramirez) vehicle brakes locked up and 8 his vehicle slid into the back of the Toyota causing minor damage to both vehicles. 9 10 AREA OF IMPACT: The POI was approximately fifteen feet west of the west limit line of 11 Richmond Parkway. This was noted by debris found on the roadway. 12 13 CAUSE: Driver#1, Ramirez cause this collision by being in violation of CVC 21703 14 "Following foo closely." The statute relates as follows- "The driver of a motor vehicle. 15 shall not follow another vehicle more closely than is reasonable and prudent, having due 16 regard for the speed of such vehicle and the traffic upon, and the condition of, the roadway. 17 18 19 20 RECOMMENDATIONS: 21 22 None. 23 24 PREPARED BY I.D. NUMBER DATE REVIEWER'S NAME DATE T. GRAY 1200 02/27/2006 —� 0-(- %. Feb. 27 06 021.: 34p CCCSO Transportation Unit 925 646-1146 p_ 2 ACCIDENT NARRATIVE CONTINUED: tj �l t J �T C ill-tt� c?IF' ol'; f&100 y nQ i G Page_3of 5 CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY • BOARD ACTION: SEPTEMBER 26; 2006 Claim Against the County, or District Governed by ) the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Sectio F i The copy of this document mailed to California Governntent Code you is your notice of the action taken AUG 2 1 2006 on your claim by the Board of Supervisors. (Paragraph IV below), COUNTY COUNSEL given Pursuant to Governinent Code MARTINEZ CALIF. given 913 and 915.4. Please note all AMOUNT: $1,550.44 - $300.00 NOT INCLUDED IN TOTAL "Warnings". CLAIMANT: 21st CENTURY INSURANCE FOR: . PHILLIP ANDERSON BY: STEVE ALEXANDER AUGUST 21, 2006 AT"fOIZNI✓�_PUNKNOWN DATE RECEIVED: ADDRESS: P.O. BOX 4430 BY DELIVERY TO CLERK ON: AUGUST 21, 2006 WOODLAND HILLS, CA 91365 BY MAIL POSTMARKED: AUGUST 17, 2006 FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN CULLEN, C1 Dated: AUGUST 21, 2006 By: Deputy It. 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). O Claini is not timely Fled. 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). O Other. Dated: �"z� 3-t">CP By: Vl/-X �" Deputy County Counsel Ill. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) O Claim was returned as untimely with notice to claimant (Section 911.3). IV.YOARD ORDER: By unanimous vote of the Supervisors present: ( This Claim is rejected in frill. O Other 1 certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated �N CULLEN, CLERK, By puty Clerk WARNING (Gov. code section 913) Subject to certain exceptions,you have ouly six(6)niouths from the date this notice was personally served or deposited iu the mail to filen court action ou this claim.See Government Code Section 945.6.You may seek the advice of au attorney of your choice in conuectiou with this matter. U you want to consult fug attor lley,you should do so immediately. *For Additional Waning See Reverse Side of This Notice. AFFIDAVIT OF MAILING 1 declare under penalty of per juiy that I am uow, 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 Stales lost-A 9ci-vicc in Martinez, California, postage 1'11113, prepaid a certified copy or this flosu-d Order avid Notice to Cliiilmint, addressed to Me claiimi it as shown above. Ualed: 02 •2.w.G IOl li`! CULLEN, CLERK Hy I_►epuly Clerk 21st Century Insurance I 1 0Qo ® 21st.com 1-800-211-SAVE FCLEERKARD IVED P.O. Box 4430,Woodland Hills,CA 91365 Office Number 1-800-322-8200 $ 2006 August 15, 2006 F SUPERVISORS CERTIFIED MAIL CONTRA COSTA CO. RETURN RECEIPT REQUESTED Clerk of the Board of Supervisors 651 Pine St Room 106 Martinez, CA 94553 ATTENTION: Claims Section Your Insured Sgt Nelson Your Claim/Policy No. : Unk Date of Accident 06/20/2006 Our Insured Phillip Anderson Our Claim No. 0000453665 CS 14 Collision Payment $ 1425.44 Rental Reimbursement $ 125.00 Deductible $ (300.00 not included in total ) Total Subro Claim $ 1550.44 Dear Clerk of the Board of Supervisors : We are enclosing documentation of our subrogation claim for your consideration and payment. Your driver made an unsafe U-turn and struck our insured. Refer to attached police report for details . Our insured will file a separate claim for the $300 deductible. Please make your check payable to 21st Century Insurance Company as subrogee for Phillip Anderson. Please refer to our claim number when responding. Thank you. Sincerely, Steve Alexander 21st Century Insurance Company 1-818-719-5233 LE TCC-45 OGT-�1-2005• l.i 4� GGG K15K MHNHUMtY I 14e1 r.told BOARD OF SUPERVISORS,OF CONTRA COSTA COUNTY u 1 INSTRUCTIONS TUCLAIMAW A. A claim relating to a cause of action for death or for injury to person or to personal property or k growing crops shall be presented not later than six months after the accrual of the cause of action. A claim ielating to any other cause of action shall be presented not later than one year after the accrual of the cause of action. (Gov. Code § 91 l.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, + County Administration Building, 651 Pine Street,Martinez,CA 94553. !' C. if claim is against a district governed by the Board of'Supervisors, rather than the County, the- name of the District should be filled in. - J.i� i D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form. song aamssaamem@games%slam■`ssmail atassaaaaaasasaasas a sssaasaaaaaissaaaaaassumeac RE: Claim By. Cl4J`1411 Reserved for Clerk's filing stamp RECEIVED E a Against the County of Contra Costa or } AUG 2 f 7006 ) CLERK BOARD OF SUPERVISORS District) CLERK COSTA CO. f (Fill in the name) . The undersigned claimant hereby makes claim against the County of Contra Costa or the above-earned . district is the sum of$_ / ,r,�`p `�- d in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) ! ! 25'/�M , (- Zv - Zoo-o i + 2. Where did the /7age or injury occur? Include city and county) e y 3. How did the damage or injury occur? (Give full details; use extra paper if required) r yD �U<<� I/ t„q,CV/C c� �. G� 5,t ice V �w�� p� 5 1_4 c /T 4. What particular act or omission on the part of county or district officers, servants, or employees caused the injury or damage? N d C vG Z �. P y v fle /z 5 What are the names of county or district officers, servants,or employees causing the damage or injury? r, 6. What damage or injuries do your claim resulted? (Clive full extern of injuries' or dai`nages claimed. Attach two estimates for auto damage. v,K �- ��C, W, 9- e /Ak l 7. How was the amount claimed above computed? //(Include the estimated amount of any l prospective injury or damage.) S'e e ��z c hi(Y/ 8. Names and addresses of witnesses,doctors, and hospitals: t 9. List the expenditures you made on account of this accident or injury: DATE TRY E AMOUNT IlZ� ..........a.a...a.....,a...sata.a.aaat..aa.....a.aaa..l.Ysr'.Y.a ..aat.saaaaaaaiaat g ) .Gov. Code Sec. 910.2 provides "The claim shall be signed by the claimant or by some person on his ` )behalf." SEND NOTICES TO: (Attomev) i Name and address of Attorney ) } C tsSY-fl Vlea- 2 e �d� Q �/ G.LI. . 2(s t Cep - G let Dooa �5�3 6 C S� (Ad ess) ,A Telephone No. ) Telephone No.�(h - 7/c/` S-Z 32 t ""age as 6 somsesessm we as a anomeagessa a a no a cause saw( { PUBLIC RECORDS NOTICE: Please be advised that this claim form, or any claim filed with the County under the Tort Claims Act, is subject to public disclosure under the California Public Records Act (Gov. Code, §§ 6500 et seq.) Furthermore, any {� attachments, addendums, or supplements attached to the claim form, including medical records, are also subject to 41 , public disclosure. gone t s s a a t l a t a s a a l a a a a a s gas a t t a a a a.s■t/ata■t e a t t t s t.a s t a a a a s s a a s■a/a s a a s e g sag sea auto at 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 im nsonment in the County ail for a �. � P P � ty J period of not more than one year, by a fine of not exceeding one thousand dollars ($I,000.00), or by both such ii, imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollar 1` ($10,000), or by both such imprisonment and fine. . 1 TOTAL P.0 Choicepoint 7/20/2006 9:30 PAGE 002/005 Fax Server STATE OF CALIFORNIA ;.® TRAFFIC COLLISION REPORT CHP ;55 Page 1(Rev.7-03) OPI 061 Page ! or SPECIAL CONDITIONS NV✓A:.t HT&RUN CITY ©wiJUDICIAL DISTRICT LOCAL REi�ORTNUMBER I btkT INAAYN ".EIOM• �lM 1�IL13J1 ❑ 9,U M>' AIM COUNTY_ REPORTING DISTRICT BEAT V1/(r�r c•Cr ❑ �L�t6v/T �.f3Qi Ll /y �� COLLISION OCCURREDON MO. DAY YEAR TIME(24M NCICt OFFICER LD. Z. r`1_G L.VJ C 0� za '06 llZ5 `I3Zo. I MILEPOST INFORMATION DAY OF WEEK TOWAWAY PHOTOGRAPHS BY: ❑NONE FEETIMLES OF S NI TOW T F S ❑YES [16 NO .`..�A. S.TfT 0 �AT INTERSECTION WITH /�1)o Lb A...G U STATE M W REL {U r�� 'h' I ❑OR: FEETIMLES OF ❑YES © NO `' PARTY ORNER•S LICENSE NUMBER STATE CLASS AIR BAG ;SAFETY EQUIP. VEH.YEAR MAKEIMODEUC LICENSE NUMBER STATE MO Ve"7 J ••• DRIVER NAME IRRST.MIODGE,(ASnC fR •.•••••::•..••.•••••••• • •••••• 0 LINA IF-F- VAS A I.t qe%l. OWNERS NAME SAME AS DRIVER PEDES. STRT ADDRESS TRIAN 1:11EE7 `( OWNER'SADDRESS SAME AS DRIVER PARKED CITYISTATEIZIP VEKCLE - �-CC�y ❑ w R�L cp_s: . ?V C-j;; DISPOSITION OF VEHICLE ON ORDERS OF: a OFFICER®•DRIVER O OTHER Calcy-UST SEX HAIR £YES 111EIGHT WEIGHT BIRTHDATE/ RACE ) \ ❑ �" ,,pp Mo.. Day Year :.`` �•.. /N" *0. (3-7/)T•4'.7: PRIOR MECHANICAL NOVEAPPARENT REFER TO NARRATIVE OTHER HOME PHONES .� INESS PHONE VEHICLE IDENTIFICATION NUMBER: ❑ 3.Z ` !g' �•. .. av O VEHICLE TYPE DESCRIBB VEHK%LE OAMAOE SHADE IN DAMAGED AREA INSURANCECARRIER POLICY NUMBER [JUNK. [_]NONE EM1NOR 1 77977 L{ + [JMOD. ❑MAJOR[]ROLL-0VER > DDROFTRAVEL ONSTREETORHIOMVAY SPEED LIMIT CA E �0OLb �{� q� CA DGT i L•T TCPlPSC IACJMW_ PARTY DRIVER'S LICENSE NUMBER STATE , CLASS JAIR BAG ;SAFETY EQUIP. VEH.YEAR MAKENOOELMO O LICENSE NUMBER STATE 2 C 1 6�, �-(� °! (;AWL vl �1� �-4T lzZz20Z 2�� e !.?r•i --- ............ DRIVER NAME fFIRST,MIDDLE,LAST) ® I' q �C� F LOVYWERS NAME .J' c[JSAME AS DRIVER PEDES- STREET ADDRESS Qo-\l ^ - [J L'Ko U f�,(A.( (� OWNERS ADDRESSSAME AS DRIVER ISS•3 v ide CIT/ISTATEMP 7l4�7 W R"--q_X$a" kin .,❑ Id.i.11�.. ! 'Z. . , .:* •�;'!:.',F2.•N",.�: 3 gsPOsmoNOFVEHICLEONORO£RsoF:..... .❑.OFFICER m DRIVER'O;OTHER BICY• SEX ? HAIR EYES HEIGHT WEIGHT BIRTHDATE RACE ibk•�°JY.t� CLISTDay Year ❑ (,{a� !� r! s 0 PRIOR MECHANICAL DEFECTS: NONE APPARENT REFER TO NARRATIVE OTHER HOME PRONE USINESS ONE }•�. 6 VEHICLE IDENTIFICATION NUMBER: ❑ S ` w � J VEHICLE TYPE DESCRIBEVEHiCLE DAMAGE SHADE IN DAMAGED AREA INSURANCE CARRIER POLICY NUMBER [JUNK. NONE ❑MINOR ILX�yN�� []MOD. ❑MAJOR❑ROLL-OVER 011 OP TRAVEL ON STREET OR HIGHWAY SPEED LIMIT CA DOT ?. GC�\ 4GL7 4V 1 CAL•T TCPIPSC MWMX PARTY DRIVERSUCENSE NUMBER STATE CLASS AIRBAG ;SAFETYEQUIP. VEH.YEAR MAKFIMODWCOLOR LICENSE NUMBER STATE 3 pleM INAME(HRST,ARODLE,LAST) ' OWNER'S NAMEElSAME AS DRIVER EPEDES• STREET ADDRESS TRIAN ❑ OWNER'S ADDRESS ❑ SAME AS DRIVER PARKED VEHICLE CITYlSTATEIZIP I ❑ DISPOSITION OF VEHICLE ON ORDERS OF: 13 OFFICER D DRIVER O OTHER SICY.•..-SEX.. ...HAIR ....•....EYES INEIGHT '.WEIGHT...,.. BIRTHOATE RACE CLIST Mo. Day Yam a PRIOR MECHANICAL DEFECTS: NONE APPARENT REFERTO NARRATIVE OTHER,HOMERHONE.. BUBINESSP.HONE VEHICLE IDENTIFICATION NUMBER: VEHICLE TYPE DESCRIBE VEHICLE DAMAGE SHADE IN DAMAGED AREA INSURANCE.CARRI£R.—..,. 0, .•.. „. POLICY NUMBER LlUNK. []NONE ❑MINOR [JMOD. ❑MAJOR[]ROLL-OVER DIROFTRAVEL ONSTREF,'rORHIGHWAY SPEED LIMIT .. ...-...... CA 007 CAUT TCPIPSC MCRM_ PREPARER'S,(1( E,„�,,,,,,,;,.,. - '6” ••.,.DISPATCH NOTIFIED NAM DATER WED *YES []NO C]N/A C555 703.frD ,Choicepoint 7/20/2006 9: 30 PAGE 003/005 Fax Server TRAFFIC COLLISION CODING CHP 555 Page 2(Rev.7-03) OPI 061 Page Ghat DATE OF COLLISION(MO. DAY YEAR) TIME(2400) NCIC f OFFICER J.D. .•1 KL0r1aER Ian-��-off, tlz5 93�o e©Y/y O%WER'S NAME OWNFUM ADDREW NOTIFMo PROPEFF'fY /U�(�� E]yes 0 ND DAMAGE DESCRIPTION OF DAMAGE SEATING POSITION SAFETY EQUIPMENT INATTENTION CODES OCCUPANTS L-AIR BAG DEPLOYED M C 131MLE-HELMET A-CELLPHONE HANDHELD ^ A-NONE 1N VEHICLE M-AIR BAG NOT DEPLOYED DRIVER PASSENGER 8-CELLPHONE HANDSFREE / ` B-UNKNOWN N-OTHER V-NO X-NO C-ELECTRONIC EQUIPMENT C-LAP BELT USED P-NOT REQUIRED W-YES Y-YES D-RADIO ICD D-LAP BELT NOT USED E-SMOKING 1 2 3 1-DRIVER E-SHOULDER HARNESS USED F-EATING 2 TO 6-PASSENGERS F-SHOULDER HARNESS NOT USED CHILDRESTRAINT EJECTED FROM VEHICLE G-CHILDREN A 5 6 7-STATION WAGON REAR G-LAPISHOULDER HARNESS USED 0-IN VEHICLE USED 0-NOT EJECTED H-ANIMALS 8-REAR OCC.TRK OR VAN H-LAP/SHOULDER HARNESS NOT USED R-IN VEHICLE NOT USED 1-FULLY EJECTED I-PERSONAL HYGIENE 7 9-POSRION UNKNOWN J-PASSIVE RESTRAINT USED S-IN VEHICLE USE UNKNOWN 2-PARTIALLY EJECTED J-READING 0-OTHER K-PASSIVE RESTRAINT NOT USED T-IN VEHICLE IMPROPER USE 3-UNKNOWN K-OTHER U-NONE IN VEHICLE ITEMS MARKED BELOW FOLLOWED BY AN ASTERISK(-)SHOULD BE EXPLAINED IN THE NARRATIVE. PNUMBER# OF PARTY AT FAULT TRAFFIC CONTROL DEVICES 2 3 SPECIAL INFORMATION 2 3 MOVE COLLISR�CEDlNG LISTENT 1 A VCSECTION TIOMTEA CITED S A CONTROLS FUNCTIONING A HAZARDOUS MATERIAL A STOPPED B CONTROLS NOT FUNCTIONING' B CELL PHONE HANDHELD IN USE 13 PROCEEDNNG STRAIGHT B OTHER IMPROPER DRMNG•: C CONTROLS OBSCURED C CELL PHONE HANDSFREE IN USE C RAN OFF ROAD D NO CONTROLS PRESENT 1 FACTOR' D CELL PHONE NOT IN USE D MAKING RIGHT TURN C OTHER THAN DRIVER' TYPE OF COLLISION E SCHOOL BUS RELATED JE MAKING LEFT TURN D UNKNOWN' A HEAD-ON F 75 F7 MOTORTRUCK COMBO F MAKING UTURN B SIDE SWIPE G 32 FT TRAILER COMBO 10 BACKING C REAR END H H SLOWING I STOPPING WEATHER MARK 1 TO 2ITEMS D BROADSIDE I . I PASSING OTHER VEHICLE _ A CLEAR E HIT OBJECT J J CHANGING LANES B CLOUDY F OVERTURNED K K PARKING MANEUVER C RAINING G VEHICLE)PEDESTRIAN L L ENTERING TRAFFIC D SNOWING H OTHER' M M OTHER UNSAFE TURNING E FOG/VISIBILITY FT. N N XING INTO OPPOSING LANE _ F OTHER': MOTOR VEHICLE INVOLVED WRH 1 0 O PARKED G WIND A NON-COLLISION I P MERGING UGHTING B PEDESTRIAN Q TRAVELING WRONG WAY A DAYLIGHTOTHER IA070R VEHICLE OTHER ASSOCIATED FACTOR(S) R OTHER•: B DUSK-DAWN D MOTOR VEHICLE ON OTHER ROADWAY 1 2 3 (MARK 1 TO 2ITEMS) : C DARK-STREET LIGHTS E PARKED MOTOR VEHICLE c+i t` A VC SECTRINMOMTM N: CIIEDOYES D DARK-NO STREET LIGHTS F TRAIN _ E PARK-STREET LIGHTS NOT G BICYCLE ; ),., B VCSECW4 VIOLATION: CITED YES FUNCTIONING' H ANIMAL MO SOBiRETY•DRUG 'f Nl^.,f�,: VCaECT*NNoUnCM. CITED ROADWAY SURFACE ', C YES 1 2 3 PHYSICAL A DRY ( FIXED OBJECT: Xft rlik" NO I (MARK 1 TO 2ITEMS) B WETD 1} ? A HAD NOT BEEN DRINKING C SNOWY-ICY J OTHER OBJECT: E VISION OBSCUREMENT;- B HBO-UNDER INFLUENCE D SLIPPERY MUDDY,OILY ETC. F INATTENTION": C HBD-NOT UNDER INFLUENCE' ROADWAY CONDITION(S) G STOP&GO TRAFFIC D HBD-IMPAIRMENT UNKNOWN' {MARK 170 2 ITEMS) PEDESTRIAN'S ACTIONS H ENTERING I LEAVING RAMP E UNDER DRUG INFLUENCE- A HOLES,DEEP RUT' A NO PEDESTRIANS INVOLVED I PREVIOUS COLLISION F IMPAIRMENT-PHYSICAL- B LOOSE MATERIAL ON ROADWAY' B CROSSING IN CROSSWALK- _ J UNFAMILIAR WITH ROAD G IMPAIRMENT NOT KNOWN C OBSTRUCTION ON ROADWAY' AT INTERSECTION K DEFECTIVE VEH.EQUIP: CITED I H NOT APPLICABLE D CONSTRUCTION-REPAIR ZONE C CROSSING IN CROSSWALK-NOTn�YES I SLEEPY 1 FATIGUED' E REDUCED ROADWAY WIDTH AT INTERSECTION HMO F FLOODED' D CROSSING-NOT IN CROSSWALK L UNINVOLVED VEHICLE G OTHER` E IV ROAD-INCLUDES SHOULDER M OTHER': H NO UNUSUAL CONDITIONS Id-#7-NOT IN ROAD N NONE APPARENT G APPROACHING/LEAVING SCHOOL BUS I 1 10 RUNAWAY VEHICLE SKETCHE; MISCELLANEOUS Pn�H AGO A L-V LCA V- INDICATE NORTH ^ DOT V !�• Il�� rLl�•w•�EjWEipl'1[ V fV��I�y A 1 A �� CR CRNR 19C CHP .....DA PD/SO �.�._. �lLT ETHER ;q=F; OSP 03 79147 Choicepoint 7/20/2006 9; 30 PAGE 004/005 Fax Server STATE OF CALIFORNIA NARRATIVE/SUPPLEMENTAL CHP 556 (Rev. 7-90) OPI 061 Fage J DATE OF INCIDENT/OCCURRENCE TIME 1'2400) NCIC NUMBEROFFICER IA.NUMBER NUMBER 1), 3Z10 "X'ONE "• X" NE TYPE SUPPLEMENTAL(•'X-APPLICABLE Lj= Narrative � Collision Report ❑ BA Update u Fatal ❑ Hit and Run Update ❑ Supplemental ❑ Other: ❑ Hazardous Materials ❑ School Bus ❑ Other: CITY/COUNTYIJUDIC)AL DISTRICTREPORTING DIS7RICT/8EAT CITA71011 NUMBER LIZ LOCA7lON/SUBJEC7 p 1 ` /� STATE HIGHWAY RELATED C:F�c_C.O 1r V�+ i-l"t- �iL�a �►� VJ�1 gz ❑ Yes No `3"1 C) t-4 i 2. g&C-E t1-r,A 3. 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W LJ-�O T ..7r er t< xt 25. l_J /2 w s w64("'';6L e A-0016 �r�;�� 1J,/�� = U&41 26. A'l44S SMuL G'° V4 F.. L��'� F1��e�l� or V&4+. CA-US/;3- C-r 27. 28. 29..t.�W,,\41N �- t 30. P�/��I. 31. mConitnued PREPARER'S NAME and I.D.NUMBER JDATEAEVlEWEA'S NAME DATE C...] 1F.1.S�/•.1 h -�{?^' C)Lia Use previous editions until depleted. OSP 04 82787 Choicepoint 7/20/2006 9: 30 PAGE 005/005 Fax Server STATE OF CALIFORNIA NARRATIVE/SUPPLEMENTAL CHP 556 (Rev.7-90) ON 061 L/ Page oATe OF INCIDENT/OCCURRENCE TIME(2400) NCIC NUMBER OFFICER I.D.NUMBER NUMBER o� --Z-4t.- o� 1(25 X320 /vly 'X'ONE X"ONE TYPE SUPPLEMENTAL("X"APPLICABLE) Narrative ® Collision Report ❑ BA Update Fatal ❑ Hit and Run Update ❑ Supplemental ❑ Other: ❑ Hazardous Materials ❑ School Bus ❑ Other: CITY/COUNTY/JUDICIAL CISTRiCT REPORTING DISTRICT/BEAT CITATION NUMBER � z LOCATIONISUBJECT STATE HIGHWAY RELATED ❑ Yes ® No PR7tr(, 4P Z 2. p i 4. 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R— OSP 04 82787 BRMBR 4 .2 _ BANK RECONCILIATION SYSTEM 08/14/06 ------------=- CHECK MASTER FILE - BROWSE -=-- CLAIMS -21ST CI & CC 14 :44 PM NEXT CHECK# OR POLICY# ^„= STATUS: 'HONORED 07/14/06 SOURCE: APS POLICY# , Y778774 MOD 02 CHECK# 1265323 ACC 896 MCO / LOC 05 00 -AMOUNT: 1, 425.44 OPERATOR SYSTEM LOSS SEQ ' CO/LOC/DIV 21ST/CA/CSR WDL HLS LOSS DATE 06/20/06 GNTL NBR , i tri �..x) Z,SSUE (0) : 07/11/06 SYSTEM HONOR PEND (HP) : 07/14/06 SYSTEM HONOR (H) : 07/14/06 SYSTEM REVERSE HP REV HONOR: STOP PAY (S) REVERSE SP -s. PAYEE LINDA L ANDERSON AND DIRITO BR MAILED TO: DIRITO BROTHERS COLLISION CENT t INSURED: ANDERSON LINDA L 1260 DIAMOND WAY IST NOTICE ON: OFFICIAL ON: CONCORD, CA 94520 NEXT FUNCTION: ----------'` --------------- ----------------------------------------------- k:# PFl/13=HELP 3%15=PREV 4/16=MENU 6/18=RFSH 7/19=BKWD 8/20=FWD 9/21=CUR CLEAR=EX i w: ;.AL J. S Y zzt , S F' e. 1 tiRS j. :fl \ BRMBR 4.12 BANK RECONCILIATN SYSTEM 08/14/06 : ®-------------- CHECK MASTER FILE - BROWSE CLAIMS -21sT CI & cc 14 :44 PM NEXT CHECK# OR POLICY# \ \ STATUS: HONORED 09/21/06 SOURCE: ats \ FO ticY# 1778774 Moo 02 ceECK# : 1272151 ACC : 896 Kco Z LOC : 05 00 \ . AM Ov T, . 125.00 OPERATOR : SYSTEM toss SEo . \ \ c TL )BR G 7 CO/LOC/DIV : 21ST/CA/CSR w� HLS LOSS DATE : 06/20/06 �} . y . \\1 SUE (m : 07/19/06 SYSTEM HONOR PEND (HP) : 07/21/06 SYSTEM { \\\NOR () : 07/21/06 SYSTEM REVERSE B2 . f v HONOR: : smog PAY (S) : { \ . REVERSE s2 . \ § PAYEE : ENTERPRISE RENT A CAR MAILED TO: } \ ENTERPRISE RENT A CAR } INSURED: ANDERSON LINA t 2550 MOwOM£m2 BLVD \ \/ST NOTICE ON., OFFICIAL o: comco&o, CA 94520 Q° NEXT FUNCTION: ----------------------------------------------------------------------------- �\ £� v \ ?FlZ13=HELP 3/15=PR v 4X16=MENU 8X18=RESE 7X19=BKWD 8/20=FW o 9/21=COR CLEAR=EX �/ 2/ � ARMS - Automated Rental Management System (Patent Pending) Page 1 of 1 Rental Company:ENTERPRISE RENT-A-CAR @ _ 21ST CENTURY INS Invoice: D124531-2331 Bill To: Billing Detail: 21ST CENTURY INS ATTN: DEBORAH FENISON Rental Period: 7/10/06 to 7/14/06(5 days) } P. O. BOX 2252 Billed Period: 7/10/06 to 7/14/06(5 days) BREA, CA 92622 Description Rate: Amount: RENTER INFORMATION: 5 DAYS @ $24.99 $124.95 Renter: ANDERSON, LINDA 5 DAYS DW @ $8.99 $44.95 5 DAYS PAI @ $3.00 $15.00 RENTAL INFORMATION: 1 SALES TAX% %8.25 $10.31 Rental,Branch Location: ENTERPRISE RENT-A-CAR(2331) TOTAL CHARGES: $195.21 1260 DIAMOND WAY ,, CONCORD, CA 945205226 Less Amount Received: $70.21 (925)674-1110 AMOUNT DUE.......... $125.00 ADDITIONAL CLAIM INFORMATION: Claim Number:0000453665 Claim Type::Insured Vehicle Condition: Driveable Date Of Loss:6/20/06 Insured Name: PHILLIP ANDERSON Owner's Vehicle: 2000 SAAB Additional Driver: SPOUSE Repair Facility: DIRITO BROS CONCORD, CA (925)82572444 VEHICLES RENTED ;i Effective Date and Time Year Make Model VIN Mileage 7/10/06 8:35 AM 2006 CHEV COBA lGlAK55F467817473 135 Rental Invoice r. : Please Return This Portion with Remittance Make Payment To: Total Charges: $195.21 ENTERPRISE RENT-A-CAR(23CC) Less Amount Received: $70.21 2550 MONUMENT BLVD. Total Amount Due.................... $125.00 CONCORD„ CA 945203107 Federal ID:36-3041733 Please include on your check: Invoice: D124531-2331 . 8/14/2006 https://www.enterprise.com/armsweb/closedcustomerfile Print Selected Images Page 1 of 7 ,.�. M .. Y k'' �i Ma*yFt 1 .v,.; ,.u'h .a . a - e 3 f s s - a.. RON a s � s = jfP "AIMP � Claim Number: 3375160 Vehicle Year: 112000 Policy Number: 1778774 jVehicle Make: JSAAB Date of Loss: 06-20-2006 Vehicle Model: 9-3 SE Insured: Anderson Phillip Vin: =FVS3DF78K1Y7001930 Date Inspected- 707-06-2006 Vehicle Color: gray Estimator: Lewis Williams Vehicle License: 4YTA185 CA Request Number: 3375160 JFDeliver to: IlGriffin Nels Print Date: 08-14-2006 11 http://dilprod.20theentins.com/pages/localprint.cfm?file=3375160-T07061234329.j pg_337`... 8/14/2006 Print Selected Images Page 2 of 7 i 4 : � E4 xt J� F Claim Number: 3375160 JFVehicle Year: 2000 Policy Number: 1778774 Vehicle Make: ISAAB Date of Loss: 06-20-2006 Vehicle Model: 9-3 SE Insured: Anderson Phillip IVin: YS3DF78K1Y7001930 Date Inspected: 07-06-2006 Vehicle Coloi7l gray Estimator: Lewis Williams I Vehicle License: 4YTA185 CA Request Number: 3375160 Deliver to: Griffin Nels Print Date: 08-14-2006 http://dilprod.20thcentins.com/pages/localprint.cfm?file=33 75160-TO7061234329.jpg_337`... 8/14/2006 page 3 of 7 Print Selected images X' all (-ti h ar Si��2� t 2044 Claim Number: 3375160 Vehicle Year: 1778774 Vehicle Make: SAAB Policy Number: -' 06.20_2006 Vehicle Model: 9-3 SE Date of Loss: 06-20-2006 Insured: Anderson Phillip Vin: 07-06-2406 Vehicle Color: gray Date Inspected: -- Estimator: Lewis Williams Vehicle License: 4YTA185 CA �^ Deliver to: Griffin Nels Request Number: 3375160 Print Date: 08-14-2006 http://dilprod.20thc entins.com/pages/localprint.cfm?file=3375160-T07061234329.jpg=�37 8/14/206 2 - 1 Mg fin eq-t-77- r �` - 'rc1 :.. i +,�.+.k- a -�.: '_,� . �s•'��ir-£�'� �'��� �.xm �.,r� �1.E� ��iY 77ay1 1• �4 �A .YH"1 e��P� �'^'_*4� ". ZVI N \ Iz 1?� . �"y ��'GT"T.' kti1} \ -� 4�•t v. Y. a "�^�L�P'"[i�i,�st�'i ,�. `S,. ]]II J{ 9 a: r�'b n __�..•'cs^' . S. N. ^'may �y JIL x 'UT.. 2'4= .sir 7 t.v �'..i,.J_ -la !y wr �} �.. .s y} `� �"�� �,..y t'�e.. r 'iy' < 4•w� y.l�+'���' ,,,�s _ - ,-, 1. - • • 106-20-2006 ••- 1 Insured: _[Anderson Phillip IYS3DF78KIY7001930 Date Inspected: • ILewis Williams - ,VA M Print Selected Images Page 5) of 7 .a AM 'ZMEMO z 3 c— 4. .`erb & wt €3 'Ru ... -, .ss�i"' - ,-is,.. .. ,z, •-. 4Yra:.�x-ffi_..,. 'h_.� e_ c� m..,a� "�' ..: . Claim Number: 3375160 IrVehicle Year: IF2000 Policy Number: 1778774 =Vehicle Make: SAAB Date of Loss: 06-20-2006 Vehicle Model: 9-3 SE Insured: Anderson Phillip Vin: YS3DF78K1Y7001930 Date Inspected: 07-06-2006 Vehicle Color: 11gray Estimator: =lLewis Williams IlVehicle License: 4YTA185 CA Request Number: 3375160 Deliver to: Griffin Nels Print Date: 08-14-2006 http://dilprod.20thcentins.com/pages/localprint.cfm?file=3 3 75160-TO7061234329.j pg_337`... 8/14/2006 Print Selected Images Page 6 of 7 y7 1< xy't3r- • w 1 m G r ) ; is f y y c q 13^ + t V _ S•�. pie ; Claim Number: 3375160 =lVehicle Year: 2000 Policy Number: 1778774 IlVehicle Make: I SAAB Date of Los0-2006 =lVehicle Model: 9-3 SE Insured: Anderson Phillip Vin: YS3DF78K1Y7001930 Date Inspected: 07-06-2006 Vehicle Color: gray Estimator: =Lewis Williams Vehicle License: 4YTA185 CA Request Number: 3375160 Deliver to: Griffin Nels Print Date: 08-14-2006 http://dilprod.20thcentins.com/pages/localprint.cfm?file=3 3 7 160-TO7061234329.j pg_33 7::.. 8/14/2006 -Print Selected Images Page 7 of 7 http://dilprod.20thcentins.com/pages/localprint.cfm?file=3 375160-T07061234329.jpg_337`... 8/14/2006 Estimate Screen Page 1 of 6 Estimate Data for Loss #0000453665 This data is current as of 08-14-2006 02:45:38 f 3375160 97655 21ST CENTURY INSURANCE COMPANY CONCORD FOR SUPPLEMENTS CALL 707.590.3274 1140 GALAXY WAY SUITE # 500 CONCORD, CA 94520 (707) 590-3274 FAX: (707) 421-2667 ESTIMATE OF RECORD WRITTEN BY: LEWIS WILLIAMS 07/06/2006 08:27 AM ADJUSTER: INSURED: PHILLIP ANDERSON CLAIM #3375160 OWNER: PHILLIP ANDERSON POLICY #1778774 ADDRESS: 16 SIMPSON DR DATE OF LOSS: 06/20/2006 AT 11:25 AM WALNUT CREEK, CA 94596 TYPE OF LOSS: COLL INSP & PAY OTHER: 1(925) 930-7366 POINT OF IMPACT: 11. LEFT FRONT DAY: (925) 324-3489 INSPECT DRIVE-IN LOCATION: REPAIR .DIRITO BROS. COLLISION CENTER BUSINESS: (925) 825-2444 FACILITY: .,126 DIAMOND WAY 5 DAYS TO REPAIR CONCORD, CA 94520 LICENSE # 71-0967969 2000 SAAB 9-3 SE 4-2. OL-T 2D CNVT GRAY INT:BLACK VIN: YS3DF78M7001930 LIC: 4YTA185 CA PROD DATE: ODOMETER: 122000 AIR CONDITIONING REAR DEFOGGER TILT WHEEL CRUISE CONTROL TELESCOPIC WHEEL INTERMITTENT WIPERS CLIMATE CONTROL THEFT DETERRENT/ALARM STEERING WHEEL CONTROLS BODY SIDE MOLDINGS DUAL MIRRORS FOG LAMPS CLEAR COAT PAINT POWER STEERING POWER BRAKES POWER WINDOWS POWER LOCKS POWER DRIVER SEAT POWER PASSENGER SEAT POWER ANTENNA POWER MIRRORS AM RADIO FM RADIO STEREO CASSETTE SEARCH/SEEK ANTI-LOCK BRAKES (4) DRIVER AIR BAG PASSENGER AIR BAG FRONT SIDE IMPACT AIR BAG 4 WHEEL DISC BRAKES LEATHER SEATS BUCKET SEATS AUTOMATIC TRANSMISSION OVERDRIVE ALUMINUM/ALLOY WHEELS ------------------------------------------------------------------------------- NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT ----------------------------------------------------- ------------------------- 1 FRONT BUMPER 2 0/H BUMPER ASSY 2. 6 :3 REPL BUMPER COVER 1 776.00 INCL. 3.0 http://dilprod.20thcentins.com/pages/estimate.cfm?comparekey=3375160 8/14/2006 Estimate Screen Page 2 of 6 1 07/06/2006 AT 08:28 AM 3375160 97655 ESTIMATE OF RECORD 2000 SAAB 9-3 SE 4-2.OL-T 2D CNVT GRAY INT:BLACK ----------'--------------------------------------------------------------------- NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT ------------------------------------------------------------------------------- 4 ADD FOR CLEAR COAT 1.2 5 REPL ABSORBER 1 163.00 INCL. 6 FRONT LAMPS 7 REPL LT SIGNAL LAMP 1 115.00 0.3 8# REFN COLOR MATCH 0.5 9# RPR COLOR SAND AND BUFF 30% FULL 0. 9 REFINISH PANEL 10# REPL FELX ADDITIVE 1 8.00 T .11# SUBL HAZARDOUS WASTE DISPOSAL 1 5.00 X SUBTOTALS =_> 1067 .00 3.8 4 .7 PARTS 1054 .00 BODY LABOR 3.8 HRS @$ 54 .00/HR 205.20 PAINT LABOR 4 .7 HRS @$ 54 .00/HR 253.80 PAINT SUPPLIES 4 .7 HRS @$ 24 .00/HR 112.80 SUBLET/MISC. 13.00 ---------------------------------------------------- SUBTOTAL $ 1638.80 SALES TAX $ 1174 .80 @ 7.37500 86. 64 ---------------------------------------------------- TOTAL COST OF REPAIRS $ 1725.44 ADJUSTMENTS: DEDUCTIBLE 300.00 ---------------------------------------------------- TOTAL ADJUSTMENTS $ 300.00 NET COST OF REPAIRS $ 1425. 44 http://dilprod:20thcentins.com/pages/estimate.cfn?comparekey=3375160 8/14/2006 Estimate Screen Page 3 of 6 2 07/06/2006 AT 08:28 AM 3375160 97655 ESTIMATE OF RECORD 2000 SAAB 9-3 SE 4-2.OL-T ZD CNVT GRAY INT:BLACK "WE ARE PROHIBITED BY LAW FROM REQUIRING THAT REPAIRS BE DONE AT A SPECIFIC AUTOMOTIVE REPAIR DEALER. YOU ARE ENTITLED TO SELECT THE AUTO BODY REPAIR SHOP TO REPAIR DAMAGE COVERED BY US. WE HAVE RECOMMENDED AN AUTOMOTIVE REPAIR DEALER THAT WILL REPAIR YOUR DAMAGED VEHICLE. IF YOU AGREE TO USE OUR RECOMMENDED AUTOMOTIVE REPAIR DEALER, WE WILL CAUSE THE DAMAGED VEHICLE TO BE RESTORED TO ITS CONDITION PRIOR TO THE LOSS AT NO ADDITIONAL COST TO YOU OTHER THAN AS STATED IN THE INSURANCE POLICY OR AS OTHERWISE ALLOWED BY LAW. IF YOU EXPERIENCE A PROBLEM WITH THE REPAIR OF YOUR VEHICLE, PLEASE CONTACT US IMMEDIATELY FOR ASSISTANCE. " FOR SUPPLEMENT CALL MY CELL NUMBER AND FAX MY NUMBER. FOR CAR RENTAL, CLAIM QUESTIONS, PAYMENT QUESTIONS CALL 877.562.7865 ***NO SUPPLEMENTS WILL BE PAID WITHOUT PRIOR AUTHORIZATION*** INVOICES REQUIRED ON ALL SUPPLEMENTS BEFORE PYMT IS MADE] FOR YOUR 'PROTECTION CALIFORNIA LAW REQUIRES THE FOLLOWING TO APPEAR ON THIS FORM: ANY PERSON WHO KNOWINGLY PRESENTS FALSE,OR FRAUDULENT CLAIM FOR THE PAYMENT OF A LOSS IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN STATE PRISON. THE FOLLOWING IS A LIST OF ABBREVIATIONS OR SYMBOLS THAT MAY BE USED TO DESCRIBE WORK TO BE DONE OR PARTS TO BE REPAIRED OR REPLACED: MOTOR ABBREVIATIONS/SYMBOLS: D=DISCONTINUED PART A=APPROXIMATE PRICE LABOR TYPES: B=BODY: LABOR D=DIAGNOSTIC E=ELECTRICAL F=FRAME G=GLASS M=MECHANICAL P=PAINT LABOR S--STRUCTURAL T=TAXED MISCELLANEOUS X=NON TAXED MISCELLANEOUS PATHWAYS: ADJ=ADJACENT ALGN=ALIGN A/M=AFTERMARKET BLND=BLEND CAPA=CERTIFIED AUTOMOTIVE PARTS ASSOCIATION D&R=DISCONNECT AND RECONNECT EST=ESTIMATE EXT. PRICE=UNIT PRICE 'MULTIPLIED BY THE QUANTITY INCL=INCLUDED MISC=MISCELLANEOUS NAGS=NATIONAL AUTO GLASS SPECIFICATIONS NON-ADJ=NON ADJACENT O/H=OVERHAUL OP=OPERATION NO=LINE NUMBER QTY=QUANTITY QUAL RECY=QUALITY RECYCLED PART QUAL REPL=QUALITY REPLACEMENT PART COMP REPL PARTS=COMPETITIVE REPLACEMENT PARTS RECOND=RECONDITION REFN=REFINISH REPL=REPLACE R&I=REMOVE AND INSTALL R&R=REMOVE AND REPLACE RPR=REPAIR RT=RIGHT SECT=SECTION SUBL=SUBLET LT=LEFT W/O=WITHOUT W/_=WITH/_ SYMBOLS: #=MANUAL LINE ENTRY *=OTHER ?IE. .MOTORS DATABASE INFORMATION WAS CHANGED? **=DATABASE LINE WITH AFTERMARKET N=NOTES ATTACHED TO LINE. MQVP=MANUFACTURER'S QUALIFICATION AND VALIDATION PROGRAM. OPT OEM=ORIGINAL EQUIPMENT MANUFACTURER PARTS EITHER OPTIONALLY SOURCED OR OTHERWISE PROVIDED WITH SOME UNIQUE PRICING OR DISCOUNT. 7 http://dilpr6d'20thcentins.com/pages/estimate.cfin?comparekey=3375160 8/14/2006 Estimate Screen Page 4 of 6 3 07/06/2006 AT 08:28 AM 3375160 97655 ESTIMATE OF RECORD 2000 SAAB 9-3 SE 4-2.OL-T 2D CNVT GRAY INT:BLACK ESTIMATE BASED ON MOTOR CRASH ESTIMATING GUIDE. UNLESS OTHERWISE NOTED ALL ITEMS ARE DERIVED FROM THE GUIDE ERK7315 DATABASE DATE 06/2006, CCC DATA DATE 06/2006, AND THE PARTS SELECTED ARE OEM-PARTS MANUFACTURED BY THE VEHICLES ORIGINAL EQUIPMENT MANUFACTURER. OEM PARTS ARE AVAILABLE AT OE/VEHICLE DEALERSHIPS. OPT OEM (OPTIONAL OEM) PARTS ARE OEM PARTS THAT MAY BE PROVIDED BY OR THROUGH ALTERNATE SOURCES OTHER THAN THE OE/VEHICLE DEALERSHIPS. OPT OEM PARTS MAY REFLECT SOME SPECIFIC, SPECIAL, OR UNIQUE PRICING OR DISCOUNT. ASTERISK (*) OR DOUBLE ASTERISK (**) INDICATES THAT THE PARTS AND/OR LABOR INFORMATION PROVIDED BY MOTOR MAY HAVE BEEN MODIFIED OR MAY HAVE COME FROM AN ALTERNATE DATA SOURCE. TILDE SIGN (-) ITEMS INDICATE MOTOR NOT-INCLUDED LABOR OPERATIONS. NON-ORIGINAL EQUIPMENT MANUFACTURER AFTERMARKET PARTS ARE DESCRIBED AS AM, QUAL REPL PARTS OR COMP REPL PARTS WHICH STANDS FOR COMPETITIVE REPLACEMENT PARTS. USED PARTS ARE DESCRIBED AS LKQ, QUAL RECY 'PARTS, RCY, OR USED. RECONDITIONED PARTS ARE DESCRIBED AS RECON. RECORED PARTS 'ARE DESCRIBED AS RECORE. NAGS PART NUMBERS AND BENCHMARK PRICES ARE PROVIDED BY NATIONAL AUTO GLASS SPECIFICATIONS. LABOR OPERATION TIMES LISTED ON THE LINE WITH THE NAGS INFORMATION ARE MOTOR SUGGESTED LABOR OPERATION TIMES. NAGS LABOR OPERATION TIMES ARE NOT INCLUDED. POUND SIGN (#) ITEMS INDICATE MANUAL ENTRIES. SOME 2006 VEHICLES CONTAIN MINOR CHANGES FROM THE PREVIOUS:YEAR. FOR THOSE VEHICLES, PRIOR TO RECEIVING UPDATED DATA FROM THE VEHICLE•:MANUFACTURER, LABOR AND PARTS DATA FROM THE PREVIOUS YEAR MAY BE USED. THE PATHWAYS ESTIMATOR HAS A COMPLETE LIST OF APPLICABLE VEHICLES. PARTS NUMBERS AND PRICES SHOULD BE CONFIRMED WITH THE LOCAL DEALERSHIP. CCC PATHWAYS - A PRODUCT OF CCC INFORMATION SERVICES INC. http://dilprod.20thcentins.com/pages/estimate.cfm?comparekey--3375160 8/14/2006 Estimate Screen Page 5 of 6 4 07/06/2006 AT 08:28 AM 3375160 97655 ESTIMATE OF RECORD 2000 SAAB 9-3 SE 4-2.OL-T 2D CNVT GRAY INT:BLACK ALTERNATE PARTS USAGE AFTERMARKET PARTS AFTERMARKET SELECTION METHOD: MANUALLY LIST NO. OF TIMES USER WAS NOTIFIED THAT AN AFTERMARKET PART WAS AVAILABLE: 0 NO. OF AFTERMARKET PARTS THAT APPEAR IN THE FINAL ESTIMATE: 0 http://dilprod.20thcentins.com/pages/estimate.cfin?comparekey=3375160 8/14/2006 Estimate Screen Page 6 of 6 5 t> . http://dilprod.20thcentins.com/pages/estimate.cftn?comparekey=3375160 8/14/2006 21st Century Insure. 6301 Owensmouth Avenue,Woodland Hills,CA 91367 s PITNrY BOWES 02 1A $ V5.VO® 7204 2890 000 9 0004627167 AUG17 2006 - -_—-�-- MAILED FROM ZIP CODE 9136 7 RECEIVED AUG 2 12006 CL K BOARD OF SUPERVISORS 'CONTRA COSTA CO. >, l 1 1 t 21st Century Insurance ® 21st.com FCLERKBOARD E�VE0 1-800-211-SAVE P.O. Box 4431,Woodland Hills,CA 91365 1-800-322-8200 1 2 2006 OF SUPERVISORS October 9, 2006 COSTA CO. Contra Costa County 651 Pine Street, Rm 106 Martinez, CA 94553-1293 Dear E. Sharp: Attached please find the correspondence you recently sent us. From this correspondence, we are still unable to identify an existing claim file. In order for us to assist you, please provide the additional information, as indicated below, and return this letter and the attached correspondence to us. Thank you for your assistance. Yours truly, Z S", Brigitte Oliva Claims Department Our Insured's Policy Number: Name: PHILLIP ANDERSON/LINDA ANDERSON Address: Home Phone Number: Business: 21St Century's Policy/Claim Number: 0000453665 CS 14 Date of Accident: JUNE 20, 2006 Accident Location: ARNOLD DRIVE AT PACHECO BLVD. Has this accident been reported to 21s' Century Insurance Co.: _ Yes _ No If yes, how was it reported? By mail By.telephone Office location where accident was reported: Name of 21St Century's adjuster, if known: STEVE ALEXANDER 1-818-719-5233 TCAC-4(10/03) CLAIl11 } 1l0A1w OFPLRVISORS OF CONTRA COSTA COUNTY SU BOARD ACTION: SEPTEMBER 26, 2006 Claim Against the County, or District Governed by ) the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Sectior"1' The copy of this document trailed to California Government Code 5 you is your notice of the action taken AUG 2 1 2006 on your claim by the Board of COUNSupervisors. (Paragraph IV below), NIAR IN COUNSEL given Pursuant to Government Code IE.IAR7Il���CALIF.C:�!lF. Section 913 and 915.4. Please note all A1vlOUN1': $1,550.44 - $ DO..lJQ— IOT INCLUDED "Warnings". -' `SIN TOTAL CLAIMANT. lst CENTURY INSURANCE FOR: PHILLIP ANDERSON BY: ATTO Et: STS ODER DATE RECEIVED: AUGUST 21, 2006 -'iiNKNO(n1N AD D KE : P.0. BOX 4 B Y DELIVERY TO CLERK ON: AUGUST 21 2006 W HILLS, CA 91365 BY MAIL POSTMARKED: AUGUST 17, 2006 FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN CULLEN, CI Dated: AUGUST 21, 2006 By: Deputy IL PROM: County Counsel TO: Clerk of the Board of Supervisors 0,) 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). O 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). O Other: Date& By: � 4 Deputy County Counsel Ill. FRO1v1: Clerk of the Board TO: Couilly Counsel (1) County Administrator (2) O Claim was returned as untimely with notice to claimant (Section 91 1.3). 1V. jOARD ORDER: By unanimous vote of the Supervisors present: (t-K This Claim is rejected in full. O Other: 1 certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated5 '� 7` 0'(A'pHl'd CULLEN, CLERK, By eputy Clerk WARMING (Gov. code section 913) Subject to ceilain exceptions,you have only six(6)months from the date this notice was personally served or deposited in Ihe mrnil to file an count anctiou on this claim.See Government Code Section 945.6.You may seek floe advice or nu attormy of your choice iu comneclion with this matter. U you wrunt to cousult rw otlonatey,you should do so immediately. *For Additiouatl Warring See Reverse Side of TLis Notice. AFFIDAVIT OF MAILING I declare under pemilty of per juiy that I am now, and at all times herein mentioned, have been a citizetr of the United SlnleS, over age 18; nud that today I deposited iu the United Stales l'osral Service in INlau liuei, Catlirurniaa, postage fully prepaid sa certified culay or this llom t1 t_11-11cr 111111 Notice to Clnimmit, addressed to (lie claitnatnl ars shown above. i L.►nlecl:'��� t��'�d'fl�" )SII IIJ Cl_ll_,I_.L�N, CI_,Lli_t� 1.3} % ;_!_)E:pul} Clerl; s� %119 f W. co H' Cn r N in r.� CA;° O M M w 4- 0, � cr 0Z t R3 O y U O C/) u , • r r^ ( �l�+cv rn O ��a N N U. w ... t-' tol sa9.L�a►� a.o ... .: ss��ca as�a►� 1 s;} W � M CP .� ts Q G� .r G/ Y•. ems':, N CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: SEPTEMBER 26, 2006, Claim Against the County, or District Governed by ) the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to California Government Codes. ) you is your notice of the action taken D on your claim by the Board of Supervisors. (Paragraph IV below), given Pursuant to Government Code AMOUNT: $530.00 - AUG 2 5 2oo6 Section 913 and 915.4. Please note all . COUNTY COUNSEL "Warnings". CLAINIANT: LISA VIELAND MARTINEZ CALIF ATTORNEY: UNKNOWN DATE RECEIVED- AUGUST 25, 2006 ADDRESS, 131. CLEOPATRA DRIVE BY DELIVERY TO CLERK ON: AUGUST 25, 2006 PLEASANT HILL, CA 94523 AUGUST 24, 2006 BY MAIL POSTMARKED: FRO1v1: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN CULLEN, C erk , Dated: AUGUST 25, 2006 By: Deputy 11. FROM: County Counsel T0: Clerk of the Board of Su ervisors ( his claim complies substantially with Sections 910 and 910.2. I ( ) 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). ( ) Clain) 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). O Other: Dated: By: �Deputy County Counsel 111. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) O Claim was returned as untimely with notice to claimant (Section 911.3). 1V. ARD ORDER: By unanimous vote of the Supervisors present: (� This Claim is rejected in full. O Other: 1 certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: & JOHN CULLEN, CLERK, By eputy Clerk WARN64G (Gov. code section 913) Subject to ce,lain exceptions,you have only six(6)months from the date this notice was personally served or deposited in the mail to filen court action on this claim.See Govenrment Code Section 945.6.You pray seek the advice of au attorney of your choice ur connection with this matter. U you want to consult mi attorney,you should do so hu mediately. *For Additional Warring See Reverse Side of This Notice. AFFIDAVIT OF MAILING 1 declare uuder penalty of per juiy that I am now, and at all tinges herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States foslal Service hi Martinez, California, postage fully prepaidst certified copy of this Ho:u-d Order mud Notice to Cl.thumnt, addressed to the claimant as shown above. Uatec) _ °C ��J )II1� C.UI_,LL'I�, CLER[� B}' L�el�u(y Clerk BOARD OF SUPERVISORS OF CONTRA COSTA COUTY INSTRUC'T'IONS TO CLAIMANT A A claim relating to a cause of action for death or for hijiuy to person or to personal property-or' growing crops shall be presented not later than six months after the accrual of the cause of action. A claim relating to any other cause of action shall be.presented not later than one year . after the accrual of the cause of action. (Gov. Code § 911.2.) 3. 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. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled -n. D. -if t;ae ciahn is against mare than one p:'blic entity, separate claims must be filed against each. public entity. E. Fraud. See penalty for fi audulent claims, Penal Code Sec. 72 at the end of this form. t■■■■■■Z1 t■LRIL RS■.t WE 11 ■t■Q■.K.■Q G ii ace G C[III Ina Yi■Q Q C GCC C a us;Ann!t[E[Ism C! 1 RE: Claim By: Lisa vieland Reserved,for Clerk's filing stamp j RECEIVED y�99�oc �D Against the County of Contra Costa or ) AULG 2 5 2006 oos Contra Costa County Flood District) CLE RKCBOARD OF O TRA COSTACOUISORS 9�9so9s (Fill in the name) ) - The undersigned claimaLt hereby makes claire against the County of Contra Costa or the above-named district in the sum of$ 530 . 00 and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date"and hour) Sunday, July 9 , 2006 around . 7 :00 a.m. 2. Where did the damage or injury occur? (hielude city and county) ray backyard at 131 Cleopatra Drive, Pleasant Hill, CA Contra Costa County 3. How did the damage or injury occur? (Give full details;use extra paper if required) to very large' limb fell off a eucalyptus tree which is located on the Iron Horse Trail, The limb fell into my backyard, landed on the fence between the 4. What particular act or omission on the partof county or district officers, servants, or employees ***see attached caused the injury or damage? Fai lure to maintain care of eucalyptus trees nn their property, tree trimming and preventative maintenance of trees . 5 What are the names of county or district officers,servants, or employees causing the damage or injury? N/A 4 _y 6. R. What damage" or injuries do your claim resulted? (Give full extent of injuries or damages claimed."-Attach-two estimates for auto damage.) -: Smashe_d� ._broken_plants," avacado tree was uprooted and flattened, sprinkler/drip system sustained damages, few lines cut through, risers bent, smakhed or -broken off by weight of tree fence caved n from we ht of tree and o ed over 7. How was the amount clamed above computedicJ"�iqlte` std `id c ' prospective injury or damage.) Removal of branches from fallen limb - handyman sawed up most of the branches and removed them off of my plants and out of the pathway ,�i7n my yard (4 hrs labor @$80/hr = $240 ) . Landscaper to replace 8. Names°a�ei 'dcagn`d1 jai ls�ystem to new plants , fix other damages to sprinker system ( $290 estimate ) N/A 9. List the expenditures you made-on account of this accident or injury: DATE Ta4E AMOUNT 7/9/06 10 :00 a;m. $240. 00 R GaQaCaaa GaaaEa9a aasaaaaa a Manata aaaasasaaaaaaeaaataaaaaaaacaaaaeeacaaaaaaaaa a aaaeaeai .Gov. Code Sec. 910.2 provides"The claim shall be } signed by the claimant or by some person on his )behalf." SEND NOTICES TO: (Attomey) 1 Name and address of Attorney ) (Claimant's Signature) / 131 .Cleopatra Drive . (Address) Pleasant Hill, CA 94523`- . ) ) Telephone No. )Telephone No. 925-686-8421 •a l a a t a a a a a a c a a a Xmas KKKKK t a an MKINEKSK KNEXXX a a a a a a Ran f a a a a a fat WKERKINK Kan a EKE KRZINNEXI PUBLIC RECORDS NOTICE: Please be advised that this claim form, or any claim filed with the County under the Tort Claims Act, is subject to public disclosure under the California Public Records Act. (Gov. Code, §§ 6500 et seq.) Furthermore, any attachments,addendums, or supplements attached to the claim form, including medical records, are also subject to public disclosure. aeaaeasaaacaaaa■asan%aaaa ■mirk&acaaaaaails Raw aaaaaaRuns aaaaanow aaaaaaaaaaa[ aaaaraw[aaa[ 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 file of not exceeduug one thousand dollars ($1,000.00), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000),or by both such imprisoiunent and fine. fS ATTACHMENT TO CLAIM FORM 1' 3. How did the damage or injury occur? A very large tree limb fell off a eucalyptus tree which is located on the Iron Horse Trail. The limb fell into my backyard, landed on the fence which separates my property from the Iron Horse Trail. The limb fell from a very tall tree and upon making its way to the ground built up quite a bit of force, one end of the limb landed on the fence, caving in the chain link underneath the weight of the tree,while the rest of the limb dug itself into the ground and spread itself halfway across my backyard. I awoke that morning to the sounds of the tree limb breaking free from its trunk, tearing and breaking though surrounding tree branches and the noise of the force when the limb landed on the ground. The weight of the tree smashed and killed a large number of plants, broke risers and cut through several parts of the drip watering system and even knocked over parts of the rock wall along the pathway in my garden. \\usoakfpadvieland$\LYeland\ATTACHMENT TO CLAIM FORM-CCFD.doc 33111�1 Customer's Order No Date Name Address r'-)l LLf-0PK&fA--- Cy SOLD BY CASH I C.O.D. I CHARGE I ON ACCT. MDSE.RETD,PAID OUT DUAN. DESCRIPTION PRICE AMOUNT �!7 f ALL claims and returned goods MUST be accompanied by this bill. Rec'd by 331117 Customer's Order No. Dater .. = Name Address SOLD BY CASH I C.O.D, CHARGE oN nccr. MDSE.RETD,77' eUAN. DESCRIPTION PRICE AMOUNT rx _\ ALL claims and returned goods MUST be accompanied by this bill. Recd by r Creafivt Touch 178 Beverly Drive , Pleasant Hill,CA 94523 Work Order 925-570-4463 Customer Maine: I i sa Date: * _ Job Location: 3 pto�c N / �F �b '•` , .,A s *Y Y / r fV t �l v dg s ca NZ, f �� .'k q �' �.z � �(' �t� 1 is A di .'A' �+^{�Ji*y' A� �N,. 1iu .": k ,;� ✓ ; ,e'x '�^�: ia .a�; .. „, wr: ;.... -�.`... ��('7,�. - �5 �•-\:tea c�-�,t•..:y.y�'O a 4l1 .r..F.a .. ''4 -,K M t° xt `y, Am .��x x� €,: 7 k�., rx``j�`�"S'�� � ^5'.r CS1 ✓`��a'.z,� *4 t � �y��` � '�e � ,�5 [ z -= s � l- r� >�,. -- t fin: S 3 .', ih^a a'F, £s � +'E �t .t^. " xh ', C... k r e+� �'^ w•t .i b t i �`J~ hx`i,wr a. t e ° aa§ t < �w baa s spa b s h e a A aR w n �w x' _j & 'y� ` +.'nt, - ."' .5 -M "',a�"'"' x `5 ';.�.ag f ro "^-' ''fir ' k dq. �3 3 % e c +s k _ :t �T�otgt Estimated Cast of Total Estunated Cost ofLabor a Do!lurs s 7 : IEr .a � Totai.Estimated_�ost �'w T.� `Wi�„ ,t x�Kyt'•• `��,rjS ssa„¢�'°{`� r ,� k �„ fir""i���'',4+r��.�E�"'�a v ° � a'?:' � t e`j`'�'4 ,5� "".. `^ �. ': � a � ��x)'� tq .wg' .... With^payments to be�mode asfollows ��a - t �1E lx 5I ._:r �We propob`so'hereby fo furmshhmaterial and labor: ompletem aceordan a with these speiif cations at above''stoted pricer j '� ` a f � U t"1 &s."4 ME a�'+� -" ra " „�,,,` -�, .�.,+, ;yyrxg to-S^,� w"'+r � sx xespe u!ly submdfed x 4 rnr-.y,;� :, x $ x: ACCEPTANCE OF WORK TO BE PERFORMED; The above°prices,spec�ficahon`stand-conditions aze satisfactory and are he a y.accep}ecl You are authorized to do�th�e work as ¢��pp��ified'�PaymentS�wlll be made aS outtmed�above }�',�' ��'We, '�` ➢"Kam— kf ar � ° � a wy,`k a 5+ 4g+- ti.� 'k` '� �° � °"� �� R � � al. ra". o N (� ..� ® � J N 7� Nom r CCF (00 _ cc « m e N � r O L O O G CO V �' co caeCo ca = y 0) O Lo ! � � '• r x c, b" t CO d N J @°t . .,:, •fit ,`�' : r � Lo 56 1 {L r 4z . C O •= g N N CD d O N CO i p C) tO - CO — 4�0-- co is c 'CO c.^u ouo ell x co d� p i . ?p Cfa tG cs ;i h? pJ L `