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HomeMy WebLinkAboutMINUTES - 10011991 - 1.11 CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT OC o eer T, 1991 and Board Action. All Section references are to ) The copy of this document mailed to you is yr notice of California Government Codes. ) the action taken on your claim by theoK ,pervisors (Paragraph IV below), given pursuant to E nQ'%ode Amount: $396.20 Section 913 and 915.4. Plea re notey �1.Wan,�r�cs . CLAIMANT: STATE FARM INSURANCE COMPANIES/ BEDFORD, dames and Alicia � l Claim No. *05 1837 254 ' ATTORNEY: State Farm Insurance Companies Date received ADDRESS: Northern California Office BY DELIVERY TO CLERK ON September 5, 1991 6400 State Farm Drive Rohnert Park, CA 94926-0001 BY MAIL POSTMARKED: September 4,' 1991 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. DATED: September 9, 1991 PpHHIL BATCHELOR, Clerk BY: Deputy OAi,. 0,P I/I., 11. FROM: Cobnty Counsel TO: Clerk of the Board of Supervisors This claim complies substantially with Sections 910 and 910.2. { ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). { ) Other: Dated: _9 1 I _ BY: I S• Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present (� This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date._ _ • 0 � Dated: 0 C T 0 1 1991 PHIL BATCHELOR, Clerk, By d Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: 0 C T 0 3 1991 BY: PHIL BATCHELOR by _2a Deputy Clerk CC: County Counsel County Administrator ESTATEFARMState Farm Insuranc.e Companies September 4, 1991 RECE VY lam.©- Northern California Office 6400 State Farm Drive Rohnert Park,California 94926.0001 LfL!�!— CLERK County of Contra Costa BOARD OF SUPER Room 106, County Adminstration Bldg. CONTRA COSTA CO. 651 Hines Street Martinez, CA 94553 ATTENT'ION: Clerk of Board of Supervisors IMPORTANT -- PLEASE WRITE OUR CLAIM -- NUMBER* ON YOUR REPLY OR PAYMENT. THANK YOU. Re: Our Claim Number: *05 1837 254 Our Insured: James and Alicia Bedford Date of Loss: July 23, 1991 State Farm Mutual Automobile Insurance Company on behalf of Subrogee James and Alicia Bedford hereby makes claim for $396.20 and makes the following statements in support of the claim. 1 . Notices concerning this claim should be sent to State Farm Insurance Companies, 6400 State Farm Drive, Rohnert Park, California 94926, referencing the above claim number. 2. The date and place of the accident giving rise to this claim are; on July 23, 1991 on Pleasant Hill Road in Pleasant Hill, California. 3. The circumstances giving rise to this claim are as follows: Our policyholder, Alicia Bedford, was operating her vehicle on Pleasant Hill Road. A county crew had loose gravel on the road while they were resurfacing. Loose gravel struck and cracked our policyholder's windshield. 4. There were no injuries reported. 5. Our total claim is as follows: Company's Net Payment $296.20 Insured's Deductible Interest $100.00 Total Property Damage $396.20 HOME OFFICES: BLOOMINGTON, ILLINOIS 61710-0001 ' [STE FAR MState Farm Insurance Companies 1040b)URANCE Page 2 Northern California Office 6400 State Farm Drive Rohnert Park,California 94926-0001 NOTICE: This form is to provide notice of our claim for damages in accordance with the six (6) month statute. If this form is not acceptable for compliance with the statute, please rush the necessary forms to my attention for proper filing. STATE FARM INSURANCE COMPANIES -- Dated: ,- �7/ By: -- Mickey Bo ito Claim Specialist - ROAC (707) 584-6470 MB/CM:bv 03-012 AC-51 cc: 2614 Enclosure: Supporting Documents HOME OFFICES: BLOOMINGTON, ILLINOIS 61710-0001 .Claim .to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. Claims relating to causes of action for death'or for injury, to person or to per- sonal property or growing crops and which accrue on or before December 31, 1987, must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to'causes of action for 'death"or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1988, must be presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be• presented not later than one-.year after the accrual .of the cause of action. (Govt.;.Code §911.2.) B. Claims must tie filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez, CA 94553. C. If .claim is against a district governed, by .the Board of Supervisors, rather-than the County, the name of the District should be filled in-. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Perial. Code Sec. 72 at the end of-this form. RE: Claim By ) Reserved for Clerk's filing stamp F C E a V E s_D Against the .County of Contra Costa Y. 5 1991 4 'ICLERKBOARP.OF PER District) iCONTkA,COSTA CO. Fill in name ) — _ The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the. sum of $ and in support of this claim represents as follows: ------------------------------------------------------------------------------------- 1. When did the damage or injury occur? (Give exact date and hour) --------------a.�-G.--•• -NT=�------------ ---N-------------------------------- 2. Where did the damage or injury occur? (Include city and county) --------------N�-i_--------NN--M--�� N--N------------------------- 3. How did the damage or injury occur? (Give full details; use extra paper if required).Ga� lll'j/�y. UJ L0� �z� jF41, .dA) � f� --N--N`---N----------------------------------- 4. What particular act or- omission on the part of county or district officers, servants or employees"caused -the injury or damage? IV-Ta Z (over) 5. What are the names of bounty or district officers, servants or employees causing the darpage or injury? 111 --- -- ------------ 5: What damage-'or injuries 'do' you -claim resulted?,, (Give full extent.of injuries or damages claimed. ;Attach. two�estimates 'for auto damage: ------------------------- t7. +:How was, the amoun -claimed above computed?. (Include the estimated amount of any prospective injury or�damage,.) mzor, TG ' 8. L- .Names and:addresses=of witnesses., doctors and.,hospitals,. . :--------------- _ 9. List the expenditures^you made on account of this accident or injury: DATE ITEM AMOUNT Gov -Code Sec. 910.2 provides: • "The claim must be signed .by the claimant SEND NOTICES TO: (Attorne ) or bv sfte person on has b ha ." Name and Address of Attorney Claimant s Si 'ture Jgddress Telephone No. Telephone No. 0 Z : * V V V V V V 9 * ,*• * Ir1 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 ofnot more than :one-year, by,a fine of not exceeding one thousand" ($1,000'), or by both such imprisonment and fine, or by` imprisonment in the state prison, bi*a fine of not exceeding ten• thousand.dollars ($10,000, or by both such imprisonment and fine. 1 ADDENDUM TO THE CLAIM. OF g (PIrint your fu 1 name) ( 1) Do you use the roadway as part of a daily commute? Yes ( ) No ( 2) Were you aware that construction would be commencing n the roadway? 'Yes ( } No r ( 3) Was an alternate route available? Yes ( ) No ( 4) Did you read about the impending resurfacing in the local newspaper? / ` Yes ( ) No (5) Did you see warning signs advising of loose gravel and a 25 mile per hour advisory sign? 4 Yes ( No ( } ( 6) Did the damage result from another vehicle exceeding the 25 mile per hour advisory? Yes ( ) No (7) Did a vehicle traveling in the same direction and exceeding the 25 mile per hour advisory sign attempt to pass you? Yes ( ) No ( t (8) Did a vehicle coming from the opposite direction cause gravel to be thrown onto your car? J Yes ( } No ( 9) Was the vehicle located directly in front of you exceeding the speed advisory? Yes ( ) No Q, • zMi • _ • • 9WAVA --------------- .a .Jbt_,. y'L '� t"9a�' c''�'u�.; .:n 'g.....�u�. � �� ekW � _t o� h�` '� --•d �Yiu'�•aw .mrs�..z�..-n ..,• .,xsY.-a-c y ,t�.et � "T'y's-''.'L r � 5 :'."-"-� Ag.x '^�n•10:9(Q �el31�Q� li�y�_���2� � � y } YY x cY 1 �J' .u� aM'-;�e3_P '."r�6't_e — S sr. 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