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Home My WebLink AboutMINUTES - 10181994 - 1.14 I JL CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA October 18, 1994 Clain, Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to The copy of this document wailed 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: $25,000.00 + Section 913 and 915.4. Please note all • am " CLAIMANT: McNALLY, Maureen ' SEP 2 9 99 ATTORNEY: Robert Beles Date received o:UUPJTYCOUNSEL MARTINEZ CALI F. ADDRESS: 1 Kaiser Plaza, Ste. 1750 BY DELIVERY TO CLERK ON Se.ntember 29- 1994 Oakland, CA 94612 BY MAIL POSTMARKED: September 28, 1994 J. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. I 11 ATCMELOR Clerk �g DATED: - 10 !�: Deputy ( aa,�_ JI. 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 IS 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: f �21� —1� Li BY: Deputy County Counsel JIJ. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). JV. BOARD ORDER: By unanimous vote of the Supervisors present (� This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: OCT 18 1994 PHIL BATCHELOR, Clerk, By �9 . QQ�� Deputy Clerk MiARNiNG (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 wail to file a court action on this claim. See Government Code Section 945.6. Frau way seek the advice of,an attorney of your choice in connection with this atter. If you want to consult an attorney, you should do so immediately. *For additional warning see reverse side of this notice. AFFIDAVIT OF MAILING ? declare under penalty of perjury that I am now, and at all times heroin 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 Clainat, addressed to the claimant as shown above. fated: OCT 2 0 1994 BY: PHIL BATCHELOR by l ��SC1l�� Deputy Clerk LC: county Counsel County Administrator ROBERT J. BELES ATTORNEY AT LAW THE ORDWAY BUILDING PHONE (510) 836-0100 1 KAISER PLAZA, SUITE 1750 OAKLAND, CALIFORNIA 94612 FAX (510) 832-3690 Tuesday, September 27, 1994 Contra Costa County Sheriff's,Department RECEIVE c/o Clerk, Contra Costa County Board of Supervisors 651 Pine Street .Wn 2 9 Martinez, California co OF SUm A CLAIM FOR DAMAGES Claim against: Contra Costa County Sheriff's Department, unknown officers and agents of Contra Costa County Sheriff's Department Claimant's Name: Maureen McNally Claimant's Address: 5908 Merriewood Drive, Oakland, CA 94611 Address to which notic- c/o Law Offices of Robert Beles es are to be sent: 1 Kaiser Plaza, Suite 1750 Oakland, California 94612 Tel. (510) 836-0100, fax (510) 832-3690 Date of Incident: July 14-15, 1994 Location of Incident: Main Detention Facility, City of Martinez, County of Contra Costa, California. Description of Incident: Claimant is a graduate of U:C. Riverside and presently works as a substitute teacher in Oakland. She had no prior criminal record when she was detained. On July 14, 1994, at about 11:30 P.M., claimant was detained at the Main Detention Facility in Martinez for suspicion of driving under the influence of alcohol. She was held about 5 hours in the holding cell. She asked for permission to make a telephone call. The officer, (a male in his late 20's, approximately 5'9", dark short hair, thin mustache), told her that she would have to be searched before she could make her phone call. He said that she could wait for a female officer or let him search her. Claimant very much wanted to get out of the holding cell and never having been in jail before, chose not to wait an undetermined time for the female officer. Claimant was wearing shorts, a T-shirt, shoes and socks. - 1 - The officer took her around a corner to an area out of view of the other officers and inmates. The officer made her take off her shoes and socks for the search. He had her put her arms out and spread her legs. He then touched her in a very sexually offensive manner, He grabbed her breasts with both hands, let his hands linger and squeezed her breasts three times. He put his hands full in the crotch area and grabbed her vaginal area about three times. He then let her make her telephone call and placed her in the common area with other female detainees. Claimant then asked the other detainees if this was a standard sort of search. The other detainees told her it was not. She then approached the officer at the desk and asked him for the name and badge number of the officer who had searched her. The desk officer became quite hostile and uncooperative. He said he didn't know anyone who looks like claimant's dscription, suggested that claimant wasn't searched, and then told claimant that if the officer did not find anything, he must have searched her properly. Claimant persisted and the other officers (there were about two or three in the area) were uncooperative and made similar comments. Finally the officer who had searched her came out, seemed upset, and wanted to know why claimant wanted his name and badge number. Claimant complained that the search was rather personal. The officer claimed that it was a legal search. Claimant again persisted and the officer said that he wanted to resolve the dispute. Claimant said she was unable to settle anything because she was detained. She persisted and finally, the officer wrote a name and number on a piece of paper, gave it to her, and left, seeming upset. Claimant looked for the paper when she left the jail, but has misplaced it. She is positive she can identify the sheriff's department officer who sexually molested her. She thinks his name was something like "Heath" or "Heathrow". Under Penal Code 4021(a), it is illegal for any officer to search the person of any prisoner of the opposite sex. Claimant's rights were violated and she was embarrassed and humiliated. Torts Committed: Unknown officers and agents of Contra Costa County Sheriffs Department: Illegal search, Violation of Penal Code 4021(a), Invasion of privacy, sexual battery, abuse, and harassment, intentional infliction of emotional distress, general negligence, denial of civil rights. Contra Costa County Sheriffs Department: Respondeat superior liability, negligent supervision, hiring, training, and placement of unknown officers and agents of Contra Costa County Sheriff's Department, denial of civil rights. Damages Incurred: Pain and suffering, worry, humiliation, inconvenience, denial of liberty, denial of civil rights, violation of rights under Penal Code 4021(a), excessive force, invasion of privacy, sexual battery, other damages not yet known. Officials, employees, and agents causing damages: Unknown officers and agents of Contra Costa County Sheriff's Department. Itemization of claim: Specials presently unknown GeneralsIn excess of $25,000, Superior court to have jurisdiction Attorney's fees presently unknown Total In excess of $25,000, Superior court to have jurisdiction Signed by or on behalf ofer4J. BeleCs/J—j - claimant: Attorney for Claim nt Dated: Tuesday, September 27, 1994 - 3 - , tn 1 .rt ol is 1 N � tf1 o M r � N � rn Ln o cu VA Aj _N S, tea..) cd o� � A W 0 H � M V 1 . CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA October 18, 1994 Clain, Against the County, or District governed Dy) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to The copy of this document nailed to you is your notice of California Government Codes. 1 the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Cod�eett�� Amount: $36,000.00 Section 913 and 915.4. Please note all •Y in3��' CLAIMANT: RICHARDS, Charlene; RICHARDS Nathaniel; RICHARDS Melody SEP l 'a ATTORNEY: Jonathan Brand T COUNTY COUNSEL Date received ADDRESS: 1800 Sutter St. , Ste. 350 BY DELIVERY TO CLERK ON September 28, 1994 Concord, CA 94520 BY MAIL POSTMARKED: Hand Delivered 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. pp Il ATCMELDR, Clerk /� DATED:_ c ) v�9 dq: puty � ea, .c ]I. FROM: County Counsel TO: Clerk of the Board of Supervisors ( r100'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 IS 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�2a 44 BY:— Deputy County Counsel III. FRDM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. IDARDDORDER: By unanimous vote of the Supervisors present (✓) This Claim is rejected in full. . ( ) Other: I certify that this is a true and correct copy of the Board's order entered in its minutes for this date. Dated: OCT 18 1994 PHIL BATCHELOR, Clerk, By , ��,�1QP�� • Deputy Clerk YARNING (Gov. code section 913) Subject to certain exceptions. you have only six (6) months from the date this notice ass personally served or posited in the wail to file a court action on this claim. See 6overnment Code Section 94S.6. Tom any seek the advice of an attorney of your choice in connection arith this matter. If you went to consult an attorney, you should do so immediately. *For additional warning see reverse side of this notice. AFFIDAVIT OF MAILING 3 declare under penalty of perjury that I an now, and at all times herein mentioned. Rave been a citizen of the United States, over age 28; and that today I deposited in the United States Postal Service in Martinez, ralifornia. postage fully prepaid a certified Copy of this Board Order and Notice to Claimant, addressed to the Claimant as shown above. hated: OCT 2 a 199 BY: PHIL BATCHELOR by � , ( �,�,`Q�a� Deputy Clerk tC: County Counsel County Administrator 'VMW vr' MCMU OF CU O=4A COisMT f - +1,1-r}t�IONS TO 9ARM A.�,XlaiMS relating to causes of,action for death or for in4ury ..o person or to per- -sonal property or growing. crop3 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 %hich accrue acs or after January I, 1988, must` be presea eti -not later-than sir months after-the accrual of,the cause of action. Claims relating to any other oause of action must be presented not later than one year after the adarual of the oaule of action. (God. Code $911.2.) B. Claims mast be filed with the Clerk of the Boom of Supervisors at its office 16 Room 146, County Adminiatraticn"`Building, 651 Pirie Street, lbnines, CA 94553• • . C. If Claim. is against a district governed byy �the Board of supervis'Ora rather 'thari the ,County, the name of the District should be fined in. l D. If the olaim is against more than one public entity,, separate claim.must be filed against each public entity:, E. Fraud. See penalty for fraudulent claims, Penal Code See. 72 at the and of this Form. � • � N � * M A IF'� � * .r � M � � # ! � � * � ,� A � M M # ! � Mf i i w M ii � # � it � RE: Claim By, } Resarved for Clerk's filing stamp CHSRT,xtir UrTr�r_...,A, ang; Nn.-.. Tw"I&?.. .._) RECEIVED RICHARDS AND MELODY• RICHARDS } ga nst a unty,o ntra a ) s2 a - or } District{}/ oFs� gv�s►o�t NM r in RN) Mw M� r�l/iw w�wrY�1i`�" The undersigned claimant hereby makes clakik apinst the County of Contra 008ta,or the above-named District in the sum of 0-d4 and in support of this claim reprwnts as followsi please see .Attachment #1 * 1. When did the damage or injury occur? (Give exact .date and hour) April 1, 1994 at 8:19 a.m. 2. Where did the damage or injury occur? (Include city and county) The intersection of .Allen Street and Alhambra Avenue in Martinez. 3. Now did the damage or injury scour? (Give 1x11 details; use extra paper if required) Please see Attachment. #1 „ 4. What particular act or'odaission on the part of oounty or district officers+ servants or ft loyees caused the injury or damage? waynette Denise Jeffrey, an employee of- Contra CoiBta County, caused the aforementioned damages and injuries, because -she failed to" yield when, making a -left turn, while Ms. Richards war- 'already within the intersection - - a violation of Cal,. vehicle Code Section 21801(A) . (Continued on Attachment. 1) (Over) 5, What are the rams of City district offioers, serva,,., c. J=ployees Causing the damage or injury? waynette Denise Jeffrey 6: . What damage or injuries do you claim-resulted? (Give full extent of injuries or ' _ ''damages, claimed. Attach-two estimates, for auto dwMe. r See Attachment.# "i 7. How wa.s the.amount cl.aimed.ibove computed? (Include the estimated, amount of any prospective injury or damage.) The. aforementioned amounts claimed are based ,on receipts peovided by claimant, consultation- with the medical providers, medical billings, and costs as provided by insurance adjuster. 6. Names and addresses of witnesises, doctors and hospitals. Jerome C. Bernholt, M.D. ,, San Ramon valley Physical Th.evapy, 915 San"Ramon. Valley Blvd. #160, Danville,- ,CA 94526 (Continued on Attachment # 1.) w�.�.r..•..•..,...••�..+w.ws•,ww.�.�wiwr�wswwwirsr••i..,�•ww..i•�e+w.s•.rs«.s..ww�•••.�w..�.r..�••ar• List the expenditures you made on account of this accident or Injuryt DATE rM see Attachment. # I` A` 1r 0 0 A • � .� M N * M M It 11- i � � A • M � R '� eF • � � ! � � � ! • � f ! ! 4 ! � Cov, Code Seca 910.2 p idea "The claim must be $i d by the claimant SEND NOTICES TO: (Attormea ) orb on on s behalf." ' Vaw ,rnd ddress of Attorney Peri De Masco, Esq. State Bar # 139782 a mstlt s gna uY`e LAW OFFICES OF JONATHAN BRAN 1800 Sutter Street, Suite 354 Concord, CA 94520 9a Telephone No.(510), 602-2770 Telephone No. a • • f .• rer «' : eeEereset see N0TICB Section 72 of the Penal,Code providea: *Every person oho,-with `intent to defraud, presents for allowance or for- Payment to any state board or officer, or to any county, city or district board or officer, authorized to allow or pay the- same if genuine, .any false or fraudulent. . claim, bill, account,, voucher, or Writing, is punishable either by imprisonment in the county jail for a period of not more than one year, by a fine of not exceeding one thousand (U,000), or by both each imprisonment and fine, or by imprisonment in the state prison# by a fine of not exceeding Len thousand dollars {$1090000 or by both such imprisonment and fine. A,Z"I'ACi3MENT .if 1 Y - The undersigned claimants hereby makes claims against the County -df Contra Costa' in the sum of $25.0OO.OQ for CHALENE R ICHARDS" S� for " NATHANIEL RICIHARDS, and $ ,5QO.Od for MELODY RICHARDS, and in support. of the claims represents as follows: 3. How did injury and damages occur? (.Give full details)) Me.. Richards was traveling westbound on Allen Street. Arriving at the stop sign at the intersection of Alhambra Avenue, Ms. Richards came to a 'complete stop. ; After checking in both directions, Ms.- Richards proceeded to cross the Intersection. Just as Ms. Richards was about to leave the intersection, Ms. Jeffrey, travelling eastbound on Allen Street, hit Ms. Richards' car, impacting the door on the driver's side and continuing ; through the front corner panel. POLICE REPORT: (Ms. Richards' car) was stopped at the stop sign on the east side of Alhambra Ave. at Allen St. � She saw 'a ,break in the N/B (north { bound) Alhambra Ave. traffic and proceeded through the intersection. She saw V-1 " (the vain Wayne Denise Jeffrey's was driving) stop at the stop sign E/s (east bound) Allen St. at . the west side of Alhambra Ave. V-2 saw V-1- make a left turn directly in front of her. She was not able to avoid , & T.0 (Traffic Colli- sion), 4. What particular act or omission on the part of county or district officer, servants or employees caused the injury l or damage? ' (CONTINUED) Police Report: "P-1 (J,effrey) caused the T.C. " because she , 'failed to yield, when making a left turn, to V-2, who had already entered the interstection, - and -presented a hazard. A 'violation . of CVC - " n i f , 6. What -damages or injuries resulted? A. Damages.'to claimant°s auto 1990 Ford Tempo - $3451.46 B. Car ,Rental for . 8 days at 016.99 per day , $ 135.92 C. Car towing $ 147.00 DT Help-to drive daughter- Melody to Dance Class $ 25.00 ` f E. Total for Orthopedic Therapy at San Ramon Valley Ortho Group for Charlene Richards $ 1700.00 F. Total for Chiropractic Treatment by Dor►ald Bowes D.C. 'in Martinez .for Charlene Richards $ 1059.00 G. Total-.for Chiropratic Treatment by Donald Bowes D.C. in Martinez for Nathaniel Richards $ 1150.00 G. Kaiser .Permamiante prescription.. $ 10.00 8,. .Names and addresses of .witnesses, doctors and. hospitals. (continued) Donald S. Rowes,' D.C. 1034 Court Street, Martinez, CA 94553 9. List the expenditures you made on account of this accident or injury? - �T AHOUNT 4/94 Car rental $135,92 j. E 3/23 Taking Melody to Dance class $ 25.00 j . 4/1 Kaiser Fermamente J prescription $ 10.00. 7/1 Expenses incurred for E school (nurses training) unable to ;take classes due to -injuries $ 76.00 • ;i `i Ctot ° by '710 - 3 °A �r f -4 �` �4 t 1 �k: a r ��r v Y .t LL, j r�� 7! �• r Ik 7 t, _y dl'yl9l'� •:�' �l�vr j;°'�` �� 4:.hS�tyLr.t.. �_ t IkC� P >f M 1 { f� � � r .�+) Nor „r�"".^' ,� y i Sf',r�,1a'T. 1��61 X11 ,>t I'S•w"'�ti,4`'� F �7 � +..J � � , �' N'4 2 j'F r r'�t y rV f f't 1 i yr +. il "' '`T'•.e"iIIr^' --r .-n�. � +�..5' -`l ` = �, 'tT.: 3 A . !� �� 1 �Y �-.. �IM a i.--�'. 2.Y .7' .!Y °Vf`i^'`� � '�rr C'”..•', --rr .*T�rr� v`--�,� -4a3.urw,,, _ �� _�� F—kt � {etlw a r1 x sS t ap�+�.�A+i.�is�, G�.,q';r�� r 4� ..r� ��, •�t�.ter." aon� T ml-••Pea,_,u�`�,»,��ts...n1.�L1 :-1 � Z • �� (�� .K + 1•' �'3 R.... ^it�r r��}t t��+4" J _ � )f°��.� tt� I v�::.� J r�,�r ` jll } ��,�t 4r f Irv" Tfj) - �i )1 y 1��/y'r y: ry:.;�f((j��1 . a ":i�"�{� T"'`r} J'v1�i.•�'u�-4i��/�::+�1..+ra...{>'4}'++`'' ,1.�, p�y� !,r �d Ar+�,,_ _ , ��1 ��;-' Y`r - � .t j1y,'�� - l �ri ' rr r i (r/- fur a �� ,��r�C�:,:�"`"..,�J' •mrjc'-�� t .9 �j A " WLF.'�.: �,r..ia. w—I.,r—! is,'f j� t 1••? 1�. '4 f G r 5�J Aa Pk` ^1 '�PfH�� RMV,� yr��"��N�''i�°7''� i w - { t� fl✓iii cl r 1ff}l� r�r . r�Ja ti c ' Ji' t'�atil i k`A�f j r `y "f;",a,` s CNV t �- Atten -i-..,,Ph sicians -eport ..✓.. CuIllornla State utomoWle Association 11+1e0na-ance Bu(94y i t. INJURE � AVE 2.DATE Of trIJURY GATE DF YOUR FIRST$XAMiNRT10N INJURED PERSON 9.HAD INJURED RECEIVED.FIRST AID OR OTHER L FRphA WNOAI CiTv TREATMENT FOR t4s INJURY BEFORE C01,41"TO YOU? 3.WA*.PATIENT Q YNAME OP HOSPITAL @g PERIOD �! !'�BPITALIZEO? NO -I-- PATIENT'S r L 1vx, L>� 1.C� CM "CS' b ACCOUNT OF ACCIDENT AND \ i HISTcORY + O CrJhAPtAtNT$ s DIAGNOSIS (Deatute and locale character \ ` and extent of Inlu7) � DESCRIBE ANY OTHER INJURY OR r. DISt:A8E _ AFFECTING PAEGENT' HAVE YOU EVER PREVIOUSLY TREATED Q Yet: IF YEg,WHEN? CONDITION PATIENT FOR THE SAME OR SIMILAR p CONDITION WERE X-RAY*TAKEN? IF &,BY WMOM7 X•fiAY vt NATURE ' Ig�TREA,TM NT TOTALLY RELATED O I CCi T? TREATMENTOF 54 es G]NO•(Explain) DATE INJURED WAS TREATED BY !B FURTHER MOATMENT NtECEjVARY? FURTHER S'd�.`5 I MCATMBNT tF r ,70 NMAT OA` v RAS THE PATI NT MADE A COMKE E RECOVE Y? to YES,ON WHAT DATE.? � PROGNOSIS if.NOr,a0 U ANTICIPATE A COMPLETE RECOVERY? IF YES,ON WRAT DATE? . jinctude "�� estimate of WA COMPLETE RECOV Y IS NOT EXPECTED,EXPLAIN INDETAIL total and par#et disability And of wobable wma"At DATE TOTAL Ot9ABILITY E AN DATE IIILEASED TO RESVIoIrPARt,UME WDRK DATE RELEASED T R FULL•TIME WO09 RTI1MATED FUTURE DU ION OF MIAL OISAOIUTY - - OATI OF T 18 REPOR SIONE0 Brj Y D, Q CLI proctor D Physiotherapiat O Attorney" •0 ATTpRN Y,GIVE NAME AND ADDAF•58 ' rl/t7lMw.4 stI At1endi ItchsiciansReort. ;4- 1>7 �� Marlene S. Richards 37 rawer INJURY DATI OF YOUR FIMINA +NItDRItD 411/94 4/6194 PERSON S.HAD INJURED REGENItD FIRST APO OR OTHER. ®YE8 <, ROM W ? CITY COMI 0 f0 YTMEW O MitDINJURY raEFORE p NO KaiLscr Martinez tWAISPATIENT Q YES' NAME ITAL P (OD HO$PITALFZgp4 ( 'NO AccouNT S While crossi A L wd=a Ave. in Martinez a van sudc'lertly'pul led'out i n front of me ACCIDENT AND HISTORY m:crashed into the lefti side of Mi car. '40MPLA1NT8 DIA0NO81$ C"lervicaI Lspraintstrain. Rt. shoulder &,arm sprain/strain. �. (0080(lbe and IooeN character Thoracic S pr .ane extent pr�iin/strain. Lw'11k�Cr-sacral s di1'1,/strain. of inlury) DESCRIBE ANY OTHER INJURY OR DISEASE AFFEOTINp PRESENT HAVE YOU EVER PREVIOUSLY TREATED - p YES IF YES,WI4EN? CONDITION PATIENT FOR THE SAME OR SIMILAR NO WIRE X—RAY ES,8 ? wMpow d YES M NU , X-RAY- - � Consez-vative Chi actic care with physical thexap madalities & observation. NATURE TREA E T LLV LAT D TO THIS IDENT? OF TREATseENT M YFA 11 NO (Expleln) DAVE jNJUAIE0 WA& FAT{ BY WU" 0 FUR HWA TREATMENT NEC SdA YT - j�ATIIENT FITHER ` t. *YES ❑NO t..YES,To WIAT DATE? 7415494 MAS THE PATIENT MADE A IF YES,ON WHAT DATE? No• PRdQNd$i6 NOT, W YERY? e ,ON W OTE? anblude Yes. 7/15/94 estimate of IF A URKErt 41MVERY4 NOT EXPECTED,9 PLAIN IN DETAIL 1011811 and pe►tiai diaabilltY and of prob8ble permanent AL DISAFMV 50=4 DWATE RIIII.FASED T0 RESUME PART-TiCM WORKPART—T FIELVM TO R ULL-TIME WORK rasultl p UT DON AL DISAM fl. . F H T - 4/11/94 6 –0047045 ❑ M.D.' CHIROPRACTOR d PHYSIOTHERAPIST ATTORNEY" AT—TOVNEY,ANE NAME AND'ADDRESS , OAV Of wii row#wA it ATE N194MATA 120- . El TARTY 0 i "i S IKH /BBRB Of CIABB BA1' iq\Rf. g"ADSM K VC s Vii NO AREA OR NAMs Tr MOOLR i. a PHONE NUM001 PRO. {T 40 NORTH ►K YiNi -�RIR[N0 T1NBU iCARW\R N4M10[R c,T��P t r� r JW irCTCIB it AVEL RlR ORM OTNlR 21 ! l J oL R G i fdR Rt� v1K Tv p,/,pry p V4 PAPTY 01#q C i EAI WAK 0KA0E DAMAO$* - p viR [!RIBA i404! l�pi1 �^' B sER AREA ' REO. Wtiii••,• 1}'r, gTYf iT T;7 f ` Z_ •Li�� `^f" - r PKV!" 0l RT OATR kei i AAAYEN T M"O rclA OyK an K 0 TRiiT OR NI - if 01,18'T eTNaR v J l J OsAR t '�- iii vi+t ► hA�TY , Q•. ;Rta "I etx NAMB A OREis ""t 04"W% PAN"N0. L) 0AN •K NAME A00RTii f MWiER t Nqr PROP, A0l i, OAUA 96AWAIM OWNER IMPORTANT.-- REAM CARP-FULLY` Keep this report. This is your record of this accident. '1`o comply with California Vehicle Code (VC) Section.,, 20002 (duty vdiere property dar»eged);you must ait'liar: a. Give the owner or person i:i charge of such property the name anti address of the driver and owner of the . yehicie; or in the absence,of ,the ownet, b: reeve a written notice in a conspicuous place.or�, the ether vehicle or damaged property; giving the name and address of the'driver.and owner of the vehicle involved and a statement of the circumstances, This information ;s necessary for the completion of your state SR-1j Form, 'Report of Traffic Accident, and your insurance report. VEHICLE CODE SECTION 16000 The driver of e vehicle lnvolve'd in an accieent"resulting in damage to the property of any ONE party"n excess " of the amount stated in VC Section 16000 or 6 the in y.-or,death'of any perspn:MUST submit a SR-1 Form to the California Department of Motor Vehicles'within 10 Lys Dote: Failure to comply ma,/result in suspension of your driver's license, Form 4'R•1 may be obtained from the Departrnen: of Motor Vehicles,, the Ca ifomia H,ghwaV Psieol, any police station, motor vehicle club, or insurance agent. if cite or state property is damag6j,you will be contacted regarding possible liability, , ,; .,l:ut . Ili�Y, ik• NMI'! 1AT RIMP601", 1�11F� qv }�• t ft t " ,Nt iA E i +• w �' MI o�P! ^ ! , ParkawnR l I{ _ ' '�' I i y iV is tOf t, . ., Itrt f1SR ,rC r t hs ,tri 4rt�ik`dhe t}{ rt.tt� i r j}y(,� �i• J. .h�iA .194'_11,}}� > ��':�r�t � �"d�n�� y1�'�M;s�f,{� f Mt s:� r;�; ' j ` i .al+Aw �-i„J1•XtTirt a t"r'Tr< rr- j.'�3 k � t k' Iii+ �, t � :J'I, I �•!t k'R 6 nj1 tt qA,}y h pry-" + ,�, � f ,,y�it,�.�4*t�1. �,�,i� ri_;kty �, t' t "i 4 4�} �'R �,f '��s t 'S} ''�'�R��F�rQ�•J t r t t ;_J r rY i+ tzf r "��`t <`• i� _ >. ��p(' kg � q�� rt,} ,�'�r'�!"i� ,��.�ti�'ky,,.F'$+h�'^��Ft�ir��t^ '�t t S�,'r,��L , ut .� '.4 t w.e• rwF. t * e l.kW,.Y' �+St.i4t' J•1 •.1` t ./ft4 ,:� r4„. pn+n1`r' 47 ?l Spins t i a viii ti+ 1 q#7213$0 $$ Elbow$Moot ` 72!70r�2 99,, 1 er lass MateriaE ti 48 pelvis i i!�! -�r,�,1* .r>. t S1a r'r old+«_ 4s Sacrum�Cta�cyxu{ i.i �`I�1728 103 .fit Orttiatic +fi,. jr�1►r Y' , $riel 80040 ,tt.. >99;1l� 50 _Ci�viCle i x y r s 73000, 104 Finger$pent Um�t9tJ _ ., Pad/s IntB!Tod 4*4�"^ 9006b ?I P?! `"'t' 52 Shoulder i'731)20+fQ7 Heei Ciup. +: Extol .� rl. Cld70y :b 9$214 i 1x3 A. Joints r '4" 73050 140 Knee Brace Corgpi"ehe r $OpO ,*9�21+� 1 1 $4 Humerus 73480 ”1,2..Shoulder Iniobiirzer Pre-Op Iii{ 9002�t t r 9921gsi2 _u' 55ib6w r t�- ' b R - 7307Q �73080 113 ;Sling PoBt 894 4 58 Forearm 11 s. tWellk Welker pr�.S;v6"Sd1b1r1Ati i .. ;w,� a k" #�fawk 1+ . . 58 fiend 73120;'73110 :#4 O Wrist I4, r 1 59 FinBe W _._ 73140 131.10 117 Warmri8i orm Corset•¢° n WI t°�+ a ::,9080b $92Q2 -- e s intertrtadiate 73 - ---w--- ---W wxtertded ' 4 64840 982 }� 8 Fflrqur, t 73bt)0 73510,73 ¢t int Wrist$rao r" `4 ' 62 Knee ' „t ' ' ' 73580 73582 735$4 �amPrehertsiye 80620 a $9244 ` '22 Ctimpiehenslvellii;P, 80220 =XtanBirre 90630 8$24'5 ,, 83 1 ib►8 and Fitwia ?3580 9922e o(lovy ups ' y +r '$s?f43 j Y ' 99241 r: 5A� Ankle 123i t., tit „1 ^#, 3e �;8' C0�aioear ne€u ;y;• v, 7382''0^�X7338930 '. Day Vis# S 65 _Fool 124 •En Visit s 60 -Nursing 'Home { t 9051 15 690025683000 126 Mospitd;Discharrge . `fl996662232Q9t;1 ' -M292- ; 682U .OAJ APpf©epo' `90075..;_."' nc t r + speciaI Fioport.', � 990130 � �r BATE - y, S9CCSidS FteVieW ' 99:Z80 yi s y I. 70 _Lon Aitr'p i t s Aft? -Wes $�'1 10 < 11) (pay iS� y✓ n t t ,.,:7.0140 71 Short Arm i 2907$ MEIPDR( t�duil " 4830 i"` 4 u` 72" riseuntief +I - X9085 , -, r-" o Pled Recoil -$9080 =' , 73 Splint S40 'Arm d`1 t ,r°„` 1.294 t r` 1111 CYo U u } t 1tAc t t p r e1 .�.. ,.� 74 -$punt iLong Arm"' 29106 V 75 Long Le ' rit4 t 29345 •}i w1 { 8'• � �s 76 long L'o—Walkln$ t} . 29355' 4� x,r ' >: ; t ,• - ;""� �` al,: � - /f ->3t `t'•ryli,..b'��s' 7� Cylinder"C 1� I'y.�sr�� '29366 a , -� un816-joli l a 20840 C. t til? CI 'l1 C R E iq�t 1 }� j qdf �2V4 a � .. H1rtrtaa@bjrart&ir�rstiFcJ4►7en�d{is1y r"t�iyy�vvr�{da1,vj��ut rti'X9afs36vo5:700o , .v.:' $i 'SGphRtdcunit1tt LjS�t h99a:"'W�Art4E•al$eft 4 g 4��vgt+t:i du,''�t --~"229944 (Q� OtY 294x78 u20605 'r Fojrt Spll2954nt tonp Gt,ublOot_r7 82 7 11 fi � . �,., u•t �. .�, to r i rtw ayl'a c.. ? I ,trr u •' -.>', , :. ,ird,.: , }1 , 4 :Jfr ty'u.a.{ {Q >d tr '" „�„ �,,;c..>� �r)e�_N,� ..,•..1...� s,�s ,;,�, �,. ,- �_. bC)GTORSStGNATt3EtE.. ,•;- r+ yr r 'S/tom`. r1iU1�b �iud;i?I .4tb r?Y'•kttlrf rt, =u"Y , '.�`i 1t,U'4; .a `' AN AF*9ME � t . t- .�t . _�} dr-"t8i K ;4"�,'«,+Ft L'g1I7 'r.ti{i ai. t r ' r b " �' `�7'lLyrtiia � tiu•,�.:r: tt.i.s,. i't:+;...%.►', P .rte ,''yT »'�s. 'w 7 r .1 ,' �,M1}t �+as :.r' + i i}� e .- , _ C�S BY i tTrA' TtSi►Ai*'8 FEE t� Y _, jC kw ti aO g 9bdSc; a .L►i,'ai,. �:;�u ..i t lkl Ciedlt -oLo SALAm:i.>... . .r. 34Ltr ffiSY� trm„C f t i 1 4 y.t3i: i. „. .: y ,. G1ry8(1 'r- - -- -= h ,: � �lL1C-..TJ.CRStt�L�641C...,..., - - ,rrAa 00 fiALttrOte�AA "�" TRAFFIC COLLISION REPORT->gropert DamagAOnly *;WooltoMkw;aanrt mn• fi w 3Vg�,tllG 4'OMd7lQili Illi•RON 217 C 414CNCr mums K � - - aoe.uw L`VI1RlgO � Alit'.. A- f Cali oto a t tam_obi Moll tio ,ri a in f.YL�.•, yb ,,7� CL j.`t M 'k;'4t'4'Ti� 'i•,.. � ,�, ',i,�+�r4; ' Kid OF LMcS►h�! .��i�i0�! ^fsJ �g �]'•�dtw rii!:0 16 pA: - ,°t�"IM1r��rP�'��,� a � �'^ i i1 •t ,"r�o-;..��V"i _ , ;YY P ut NFtp. Wi � ,� .}f�� „•� 7,/a' ��{� Mt. 7!•M' { r�,L °t�f, r '1. F @?' ,�'' } {'IY�'t t r.Y f F q- RU?n 7't 5'J��l1Jtrr•r ,� >,d ,� ,j�M1� h •^, Y� ..r SS�ti 1 �, � i: t d t 1 y>♦ T , k� tl 1MMMM�,,, 10.00. ' 1 K41SCR�P�M�fVCNTC- • ��•.F� T�� t �L+w;� + 1� i d t i l Y � ' �9j yV'r,�,,,,,J1 t�: S r., rg�./�L,,f �,i" T; °6 4 .i4 St�y�y��•q y ,. -T'e'a M•¢r�.�,• ,�liK��i'S..yr4¢�� ry�t�'Q��(+'�.�� r� 1 r .. ♦, • ne ^v• Y F'w F,lif• r.4" .t}.. ? p':' i+ 'F+'',•,T.�J 11J �uryd" � T r Jr Y1�yrP+ATF;' • y '� l? 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U •� :, r:,,tFry,��v .,� P•i'�Ru,i'♦ji Y�7i�LlL �["MIA/t 9 h rqV'. —a� ^, 1 BFItk}4'�• •' S � ', w,j u 11-3$' Payhwta E/. r N � ► �>� .pn r >'�yr�'V' �'r Ys�'G:A' 'a/ J'i �'tq °•>rt'M1: �, y �g�, �r'R I y ,]7,�,�y �Sf � w: 'r 'h y r .dt v, , •^'h,'�'.0,'F' I C•. k�� -illy n�� .+ ! f'�., _ Sr'e jy,5t,'A�r ti vZ l•5 ('� "' kr i ��G'G4Z «�d jA'/ iN!,��YV. fr �A1 t a a ,Q- p �w :�( `hrrr►,'^dj ,)r /�„N.` day �'f5 sy4t .y �' c,} `� .i', f Z'�J'n � �'hJ�'f;�i'i��(1 yCi°r>'i�ry/l� w�r ',��jY�y�ay' f�'R`JJ•� � v�+�i ,, � ,�`�r y.� �' ,"�Ar�Y,':e:, w ,,� ,, tl �; (T.i .y iF��' ( fih.�i,��,�7•�•�4�'�• .YYt@@@,R,x; /f,•�d ro� r '�J�7 n' • ' •� 'Y i.a'.. .y�' `d:lf' 7a' ' f• ,f,�y, r y �};. fi� 1. 1 :.'�Na ..•,�.._�.+i�'�....+:.�•�...1.�.-...°,r....r do TiP' nY,y i�h':� 4 � 17 ,�. � }�•t��'�:',, i :�'Ya1i� Al 1 z,., U .0 ,� - '• ' RETIREb `�—+-r IAUTNORQB THE REIrFA 1�, PATMlNT OF OD+rlRNAN 0 THISOLAI4.I ALSO nFOu66T t,. PW OR BUPnUEq ISEA BlL,Ww ��5 + T8AS9gNN NT.U6LOW.so Neo Sign#% 1 � ' - � 2 .0 �' V U� �'I- � � �'� DAPS son file, AUINOR 008 ' PUMM 14,w EDF: , , W1/94 3 4 3 0 0 yk nON OONBLIL a °ILLN 8s n"wAsivRY' pATE6�' CN NeR�t 4/6/94 RlTUgN To WORE�° "TellAR 1 0� 16 NnM!OF REPt pO PIPI U FROM J.. . NO$"MRA Mfg TEg To tt1=_t ANDAODRESEOI' FOR ICE) 82,WAS lA8p1{ATORYWORItPtRFpRMBO0VT610EY0URory10E4 FS a. YE8 NO c"AAoliC ; NATUR! ILLNESS -UP_Y R EA bpl�flhi131t1 Yd Vfrillai: R 1 LIMN D NUMBERS 1:2,i•1TC,DR DX CODE ' Coxvical sppraaini/7,strain. 847.'0 EPSOT ,ie NO 4. Rt. i1IIp at 81�O111dI. s _ pr im/fitrain 840.0 FAMILY PLAM141HO YtS• LJ NO .., �haracic ;sprainhtra3n. 847.1 -__-____- . _.�__ • .. 2a. . ,. A. B ! I ICAL IClB OR SUPPLIES . ', AUTN qt IIDN N - "ROM or bEOv" MACE' k DATG OMEN OF DATE DAYS F. K TO RVICE - PLAIN UNUSUAL SERVXKS OR CIRCUMSTANCE DIAGNOSIS OR O. 'r .► 8 UNITS T. ,S. 4 6 94 3 99204 ` 1 >Ix; Exam. px:'& 1-4 155 0 __..4Z7/94 3 99213 Expanded O.V. & mann 1 4 48,0 4/7/94 "3 -,97128 Ultmgoundo Attended. 1-4 :.20;.0 —4/7/04 •`3 97124` znt tat traction. 1-4 20' 0 4/9/94 3 : 99213_` -0NTExpanded O.V. 1.:4 ..:48i p 4/9/94 .3 97010 Hot,.Packs• 1-4 1.21.0 . ___419/94 3 971'18 MWc"le•'stim Attera«�ed. 1-4. Z0,.0 419/94 3 97128 ULtre�soLnd. Atfiended 1-4 20,0 26,SIGNATURE OF PNY ` OR SUPPLIER[1NCLVDING r gOVERNMEN Qi TOTALCNAROt I >re.AMOUNT,PNp r 4a:8AyWClOUE CAE°ENTNL ULELRTIFY TNAT 7Nt tTATE>RENi8 ON THE REVERSEONLYroj(8EE BA�IQ - ' APPLY TO TNy Ill AND E MAD!A PART TNl11QDF) c343 00 343.00 J a T { ► r r ! �yyy z �t 1I S 81 PNY&iCUW8,SUPPLIOR'R ANIYOR DRDUP NAME.•ADD21P 1•� �” RE83 80.YouR 80Cu1L 68WNIY NOF ,DODE"AND TfsLEPNO!+E NQ t :. f �, '.•r r' ' a ;>tiirf.: -,� .. .r:'l. a/WKiLU aV1N�F ywC�. 264 v$fi 94b1 1034 Court.Stxeet 32-VOUA PATIEM'sACDOU TOLrR_! I.D.ND Martinez, CA 94553 .'68.00470451,15101 229-•1.300 R BEwC,AND TYPE of 6tRVICi(►O 8J CODES ON11W BACKAPPROVED 9V AMA COUNCIL Farm HCFA-1500(C-1):(1-84)15627 Fotm OWCP-1600 . ' 100-0040(t•P�Y 2YLRC OEpI - ON MEDICAL SERVICE 543Form CHAMPUS-501 Form PAR-1908 y. PAY.: F. ! •' q X CHAf2D5, ONAtI.ENlry 1, t 6600 60tt11AAgA t:+•. ! tT y�,�t� F S7 i •�,�nJ « J� C� �� Y 1 1�t IM pf�RNApi N7i$A lQd Int_ y > f4ro"T"l c a dkt<rb k r "e i ;Etoi ltNts �i�1t ';} 1 Et4 {:Y.y.'yr .'�,fy,. i 'S � 4 � Tk,t��sr�:c��?�i"�'�f ,yi�i�•7+xr� y 4�t. r . � > . I t r, �' r �t' �' •. r,v� . � n, r t>NK iir yt y "' t�! t 7- l r. fvlo�� oYH�amw- 0 l . ; k7 T 'r i tr4tl,� ' tt �' �y rl ; 4 .;Oi t JlR, °I7` '� )•r1"1.' ti' iry iv L' 7 a :+ J .fix k), ,i ut r a• .f•r r r 4! ty„-+� r. A., } rsr4tb.•�,,y tri.Y� ; }�r1 ttJ r.a't��'�. �" 1 �h i.' iY ay .1 ii;.a r °a�• � �!�(• t YYYy�ii 4.£i.F -n s�,. ,f's� t r�'e✓'�: 'r'Y.} � S i. �1 t5 ' .5 ,_'.".� ?Ft rrt rjrb K2i.iYs! ,1 a.t r`'j t� of 31 a �f 2' '� - t c t - }t •S r, i 'll�Mci'r"Ti�+.�ali" `�/+•I'h n• Xf I 4./r�"' i IV 14m- - 4 �}A 'n�7 Sn1 jq•�. j d �rq�� t� '1�[i�'?T i+'!r jV 4 ,1�.�0 !J !` rf t} 'k Iyir�' �• I�l,� [a ii'J}�fy C..ar ti�jN"I .i•�' I a1i�Jj f g y.�, t�.�j'T- ,•��yy1 �'i4,,.. "100 Iii 81P `7 ;r.D 9V I• YI a' ' J:�AY�Ti�te 1 S rtOP ti ra a wr �•�� ° t }A';� 1''; `{ y I�\" ri�1•t qt i,,+,�F M�.tr7t A Ay ,',;rt '.x.'� - 'Y a �' t�Y+v' i• r C �Ft p i•, } 'fr?4 ".s @ a '"G ,•/r'� ¢ti•�, r +!r-, ! S i l�i } ,.'t 7 c'tiy' r ..''s+� e1 r:r•,•,NTti � .: >r• yS.',,.5, Ct, F#'r i�j rl?�`;.�1 'k, . 'a r ..+•• • r r., F rst e`' rr ,. r ,!rrh ri•G. r'.. f am+:Y,Y'*�{R.t'-"^r—...r..�. •--•.,«.yy.:�+rr....+,.-.' +rwri r�r.wr+'...r.-...,,r-�+.r..+r-- :+e:rwr�..An'Ia:�.rAni�'ar.'irrsieAece+'.`+'••"n'•^sfi"n>T,•cNk4�irsr'e'.'."'Y..r"ai•. • A5$1 L i� .4. � `� A.PAhEFmB EMP�QYMENT � 9' ' . G " • .� ., TEIEPWQNE NQ, .r • ti,e, CNAMFUS,SPONSOR'$ r t $.AQCiOENT , CDOTMER $CATV$i °imp (NRCEASEC , Mum U • ..r S i A C Fi tY.t ALAI)NR t •TQ P E6$*rii8 GWM.4 A184 t4EWiEBT i PNY$lGIAN $NRPIIEA FOR$ERMICE 8CR18 D14 L VAYMENT i„ ' R Nt40 A P S A$SIONMENT 611L". i on file: SIQNEO 1 �' PATE 610NEDiiNSUREbORAUlMOF1UEOPEf150Ny. ` VAN R SUPPLIER INFORMATION. v i 14.FIVEOF; CO ULT 0 VC>V POR i 116 91 PATCNT MAC 14ADGAME II i6AR i .s. i' ,.� Z • 7. • ,ANWT+ON WASSOROWRY.Oiv1VASE$ CME RE 4/1 3 a .• ,�J6/94, t Y.OA E PwTiEN OATES ARTMI ClSA9lLfG! RETtrRN tOY• {. ' FROM tMROUOM IVCES tASEO O NI IAA! O! ` • co.NAM REPAS � - - •',%, ' � .� � � Mo$PrtAcatATtQN QATEB - r a , n y !t.NAME AN0 A0C# - �, ,� '' c t >;Y,W cAS6FiATORY WOAti PERfONMEppItSOf OFf t f • VE$ HO 4MAAOES, 1, MA A. IA S!$`OA - }�; VM Y Cervic- Q 040TNo Et- . 11YES T. Ran , ::< •V FAWtY PL"NiNG YES NC !° Thoraco a ' ♦. AVTH T P4, CNV ES R MI 0. to tY8 WE Of se"cE O AQNCI$13 E' OR tI.' ! FROM .S $OR CIRCUMSTANCES AFOES UNIT 04/12/9' i O.V. 1-4 481,0( } 04/'12191 ,t1m: Attended. 14 20 60 04/12/94 Atte n a 1-4 20 04/12/94 .,.v Cold a ks, 1-4 12 10 it .04/14/94 3 99213 Expanded 0-V. 1:4 48 i 4 94 3 7118 Mled& stun. Attended. 1_4 2020 '0 04/1.4/94 3 -97128 Ultrasound: Attended. 1-4 ,0 Q4/14194 4 0 C r i 1 D1l law. 1-4 48 F 0 04/16/94 3 99213 ' Expand.ed .O.V, 1-4 48 ; DC 1 � ' t h a a ks 1-4 04/16/94 3 . 97012 ,Mot.. Flexion Distraction 1- 94J 3 -9 712-4 ntal-traction. 1 i ' 14 2O i 0 S. 10MATURE Of PNYSICIANORSUPPLIE14V(MCLV dOEORgES( OA 64 P N RNMENT It,TOTALCMAROE t sE:AMOUNtPA1V E9•eAWIC REVENtlAL5 N CEATiFY THAT THE STATEMENT$QN TtiE pE I E C4�`µ?3 ONLY)(6EE WV4 /y`t t h- - APPS,Y t0 txt�$FU,'ANV$At MAO(A PART THEREOF) - CONTINUED' YE$ N8 r 91.PHYSICIAN'$,SUPPLIER'S.AMNWR GROUP NAME.AOORB$$. COOt AND YELEFHbNE NO 77 .I >4.YOUR CUAtYY NV. y?aN�Yr Donald S. 'mss, D.C. .,E' 264-86-1461 103 Court,Stm�� 3 " YOvA 4ncNt's.�rntw+ , - .. HEALTW INSURANCE CLAIM FORM ' yVKKAkt PRgarM k6ag N t A mom 'S ISN p1 ��All/ALE ND. C�l�p��BN L�� CIRTIFICATO SON .INFOflMAT�Ni 1,1PA7)ENT'SDATEOFBIRTH J.1147 ED'S NAME RASTNAM .FIRST NAME,MI OLE INITIAL) I. 09 02 78 Richards, Daniel & Charlene O.PATI£NT'O SEX C I"BURMl lE RS) HO.(ION PROGRW CHECKED A.• MAAA I 'I PIMALR '.. .$53 625-01,-5865 V.RNIM 111117Y17F1M To INSURED 0-INSUR15.8 oftwo 40 MR ORDVP NAME OR PECA C M�M�i.11 BLP 6"" CHILD OTHER. Claim # 01-F50915-8 INSURED 10 EMPLOYED AND COVERED OV EMPLOYER 8721 HEALTH PLAN ERNAMlD►PCXiCY• Y ,WA CON i ELATEptO, II INSURED'8 AOPflUS)STREET.CITY,STATE.ZI COOS) eOANO POLICY OR ME A,PATFENY`M IMPIOVMkNT TIME] MXIIO TELEPHONE NO. � 11... ONAMPUB BPON$iM4'8 e. AVTOR -MOTHER `AWE oguaEIS BTATU$ t aid SE NATUPIB ttR KBE NIN� } v3-I U MEN IAL 8 UNDROM `�' �@ LASE OF Ahr EDI hl I�fORM.+.TK'>*I N!C! OARY TO;T(%$S THA$CLAIM,I ALSO REOUEST PHY$fCIAN OR SUPPLIER Po OERVECE DESCRIBED BlLOW. 11NMSNT 6ENEFITB fE1 NlR 10 MYBFLP OR TOjHE PARTY WHO ACCEPTS ASSIONMENT NOW. I tore on tile.. On file OAT! r1oNEotR+OUPH.+OORAUTNaFgzt<oPERSDNI PHYSICIAN OR SUPPLIER INFORMATION - ICMail M DM fl J13 FARO CONSULTED YaU F THIS 13.IF PAYieNTHAO MAD —(LAM �tE...IF MERU IACCIOEN•Y)OR PREONANMY ILMP) CONDITION - LLNESS ORJNJURY•SIU@ DATE$ CN E e - 04/01/94 04/12/94 1C CAM Of lorn DjUNLITY DATES OF AT PARTY plSA814iTY WORK r FROM - Y 6t4 FROM TNROUott NAM FERRINGRYSICIANORDTHEASOURCE 14B.PVSLICHEALINAOENCT) 40. SERVICES lA7EDTOHOSPITALI TIONdI j '. R06FLTwL1YATIQN DAY!$ � i ADMITTEDADMIrTED MCHAR IIF,NAME AND ACOKSO OF FACTLITY WHIRE$ERVIGES RENDEREOIti OTHER THAN HOME OROFFIM) 29.WAS LABORAYOgY WORKPERFORMBD OUTSIDE YOUACIFFICET.; I - _ YES CDM NO .....'CHARGES' x - ff NUMSENS$1,Y.B:ETC oR 0 C LOLdNEE INJURY,REtA I I EDUR 1 ' Cervical. sprain/strain. , 847.0 EPSDT YEO ND E ftachisl neuritis. 723.4 FAMILYPLAh"o YE$ ULj ' 3. — �, AVY""ItAlI N e.. - 8-• ,FULL PROLEpvREB MEDICAL SE VICES OR Ur vols F. L j RNI R CH DATE OIYRN. p. DAYS . oArE DwP 6EAVICE PLACE £ DfA0NCS 3 E OR (L• i ` FROM TO- 8eR1'tCE t - XPLAIN UNUSUAL SERVtCC9onCIRCUMSTANCES COD gOE6 UNITS Y, .b: 04 WONG1-2 97012 Mot� �F'lexion/01straction 1-2 20100 -04/19/94 4— 97124 n ersegmen a a . Yo . - 20 :00 4 1 94 3 99213 Ex ended-03. 1-2 48 ,001 04/21-/94 .3 97012 Mot. HeXlOnWstraction 04/21 94 3 97124 lnterse mental traction. 1-2 20100 047[23194 -T-pandecl * 04/23/94 3 47010 V. FloiSt heatpacks. 1-2 1200 04/23/94" 3 97128 Ultrasound. Attended. 04/28/94 3 99213 Expanded O.V. 1-2 48 ;00 0472U/94 —3-197M o ex on is Tac ion I 04/28/94 3 97124 Interse mental traction, 9-2 20 00, 2$ SIONATURE�OqF�PHYSICMN VPPL'£R INCLUOIN40E6AEE515 OR .A t6NM N ( OQ1ANMENT YTAOTALCNARO 797AMOUNTPAID ItB.BALANCK W E 'lCIYPLY TO TfttE BILLRANO AR6 MLT,�oAENICI�YS ON THE NEVE SE OULiMB ONLYI ISLE BACCKI ,. OFS 344 ;00 0 40 344.00 • VE$M �NO It PHYSICIAN'$.SUPPLI£R'E,AN"R ORCUP NAME,AD REBS,VF.' ! BOCUL CUIUTYNo. OOOE AND TELEPHONE No 4j11.0 1034 Court Street SAYE: Y 264-96-1 61 - Martinez, CA 94553 —Y ATIE `S ACCOUNT)NO. ._, .V R MPLOYR I.O h RJ'1 0 1 2213-1300 68- 047045 1, No, 15827 •PLACE O/ElRVrCE ANOTYPE OP gFRVICE tt.0 S CWS ON I"(BACK APPROVED BY AMA COUNCIL Form HCFA-1500(0-1)(1-84) Form 01n1�P•l 00 ow MARKS: ON MEDICAL ORRVICE 5-83 >sq'0o46 i7 PLY oARdODEDI Forth CHAMPUS-601 Fortri RfiB�i I Z H�ftD� :D IEL k'CHARLEIV AN ,yP to _n' _0A A' r NC � ,AREA ir[FUPt' � i Hf AIsvTM IN6 kJI%'t4C9ww�ax Kl"M NOS iMEW A+D NO (SPOtI S SS (VA FILE NO I 101ATIFICATI SSN PATIENT AND INSURED 8U88CRIBER tNFORMATiON t. ATIENT'S —6w T N . IItsT NAA,4 INITIAL) t,PAT( N 'B OATS OF MATH S.IN UR !tA ( F NAME.N ST NAME,MI�iLE!Nt tAt) Charlene S. Ri2hA ds 12- 1 30 56 Daniel arCiaxlene Richards .,pAsiEN' SSTETpfEF.0 TE.ZIPCOQEI 6.PATIEIlT'bBEX aALL1,Et'15R$�.NO,fOR PROOMM G, [d ABOA,1 UOE 1935 Estudi l to St, uke rrMALe Martinez, CA 94553 336-514-9377 tE i.uI$U1tEO°B GR NO.TOR ORCXIP VAMC OR FECA O4AIM .) I w4f SPOVS(- CHILD OTHER GIST # 01—x'50915-8, INURED 49 EMPLOYED AND COVEREO SY EMPLOY[P VELIPHCRt@ NO. 514 -228-8731 OFAUN PLAN. �. f. rH .+EAI N tN RANCF COVERAG LENtER NAME GF POt+CY• +D.WA OOMv It1pNpELATEOTQ; I t,IN O'$ADDRESS PTET,CITY,8 ATE,aw ) FKILOEp AND PIAN NAME ANO ApDR[i$AJ.O POIY'Y VPI 1,tED+CAt ' A8it8txNC!NVMffR{ - _. .p • A,PATIENT'S EMPLOYMENt ,� . TELEPMOIFIE NO, , s.,woloeNT i+... CHAMPus 8PpN8GR'B AUTO [:)OT,N[R 1 ACTTIYE GEC$A66D B H . 8rA7us; °� RETtR2D t$:rATWNT*S 09 AUTWAiU PERSOWS 5RINATume(RFAO( FABACK OEFORE 8 INO1 t 1 AU HOR PAY ENT F M OICAL EN 1 UN N I AUTHORIZE THE RE.EAB OF ANY MEDICAL INFORMATION NECESSARY to PROCESS THIS Cr3SIO 4 ALSO RF, v, pJ,11,1 AN OR I ;EN POR 5[RVICE OESCRiB@0 BELOW, PAYMENT OF GOYERNM[NT BE+tEitTB EITHER TO uvi[LF OR TO THE TARTY WHO xCCFPTd xSS10NMENT.aELOW. Si�p hire on file. On fi l.e. WWI), 7""' DATE. ,b/GN[O(INSURED ORAUTHONZEDPERSO!J tt � }} PH ttCiAN OR SUPPLIER INFORMATION 6 r..DAT{OF: (ACCIDENT]OR PgE4NAHCY 4LMpU 'OC(r18UlTED rOV FO TH 1eillN[ 8NOR{WURAD 11E ATlSMILARt 4 IFEEgagN4/1/9MY It$ 4/6/941 I T. TE PATIENT Ai>E TO Is. A E T Al 01"A IL, Oxri oP PA TIAL W A$IIITr RET11 URN TO Y= FROM rNROV" - ° FROM - IHROVOH ' it NAM[OFR[F pRfNGpHYSK;IAF/ORDTHE $QURCE(#Q.PViLC3+EALTHAOfN4Y) AV tReLAT O 1 l t GI , � - - HOSPITALIZATION DATE$ - - - ADMTweoA }' _lI.HAV[ANO ATfORCBi OF FACILITY WNERl SEAYIGES RENOEpED tiF OTHER THAN NOME OR OFME) fY.WAS LA)! TORY WORK PERF ORATED OUTSIDE YOUR aFFIC[T i YEd �NO CHARGE$, AXA . •M,IVA, N A PWt[�#iCORD%CGDIN UMN iY FE $ 'il Cervical sprain/strain. 847.0 EPSVT vef ( �� No >:. Rt, 'arm & `shoulder sprain/strain. '840.0 FAMILY PLANNING YEd ' Thoracic sprain/strain. 847.1 _ �• $. f�C�R�S MEDICALS AME$OR BUPPLaES F. H. A LAN A. PLACE FURNISHED F 0 ADH DATE GIYfN - D. DAYS ROM 70 OF SERVICE TO OF DIAGNOSIS E on, G.• +. $ERVICE I ) xPLA14 UNUSUAL SERVICES OR CfRCUMSTANCESI ODE CMAROES UNITS T•O.S. 04/19/94 3 , 99213 Expanded O.V: 1-4 , 48 00 04 19 4 3 97010 Cold asks. 1»4 12 p0 --04-T1 9 4 3 9 i18 Muscle stun., Attended. 1-40 0 04Z19/94 3 97128 Ultrasound Attended. 1-4 20 p0 04/21/94 3 13 Ex#pfan eO.V. 04/21194 3 97118 Muscle stim. Attended. ( 1-4 20 0 04/21/94 3 97 10', Mo st.heat.packs. 1 2 04123'Z94 3 99213 4Ex ended 03. ' 1-4 48 DO'. rr . 04/23/94 3 97010' - Moist heat' packs. -4 12 0. &234944 33 9971188 MUuscle st#m. Attended. 1-4 20 p0 411094 3 99 3 xpande n�:uAttended. ;4 p St"A VR OF PHY'SICMN oa SUP LER 1LNCLUOIHG'OEdREEgg !£d.ACCEPT IO-WENT{G ERNMENT -Er.TOTAL,CHARD€ 8 I , 'ZS.AMOUNT PIJD ?S.6 . CRECENTIALS44 A CERTIFY THAT THE VAT€MENTS ON TME A@VER7E CLAIMS ONLY)(SEE SACK)' - ,i APPLY TO 1'H($SILL AND ARE MADE.A PART THEREOF) i YES E3 dl. PHYSIGAR'E,$UPVER$,'AND/W GROUP NAATE,AOORQl�S.' IP CODE AND TE4RPHONE NO Sp.Y SEGt)RITTIIO,�Y Donald S. 04o0 7 & F D.C. A- N$ALTH IN9VRAHCE'CLAIM FC"m FC -- CY AMa ►110GAw MCC[ LOMjr . AAFit1 N0.} IGEA WICATE M . L.,�S PpT1 ANUWASURED SUBSCRIBER INFORMATION ! p.PATIFNT'$DATE OF SIMTN $,INSURED NAME{u$Y NAME,fFR$1 NAME.MIgOI:E INav1W i 12 3456 Danie! or CharLene, 6.PATt£NT'$SIX � � p Alert t£Tt�RB'�.{FOR PROORAM CHECKED A9014,i MU:53 Pew 335-54-9377 X945phnomrs mL $.NIStIfO' N0.(OM GROUP NAME OR p d sELP $roust cNILO OTM€p Claim #01-F5C191$-8 IH a£o I8 EIAPLOYE�ANO COYEaEb bit itMPtOVER 514 228-8721 HEAt�N PLAN 1(m NAM1 QP nOIicy. D, - OITIONR LAT 0T0i I+-I+i6URE0'6A00MES$( TREET,CITYATAY9,0POW) AND AOOR E$ANP P OUCY OR MlOICAt _ k PATICNT'3 MKOYMENY • ' YS$t.3ONO .. TtLiPNONe NO. l i OMAM> 9MIN60a'$ .. ' 0.AOC10EkT ' AvT'0OrNEa Lj OGC6A6£0 $TATVs� t�T'IREo f5 ` NA R {{ AD 6E 'b } 1 11 AU N E A FHT M601CA4 ENE V N 0 ' •1 AUTNORI2E THE REIE 6E Of ANY M OlCRL W;OR]AATpN N1 $$ART TO> E�$rNIg.CLAIM.I A so REOV£$T PNY$KYAN OR$UPPUER FOR 6ERVKiE OE$GRISEO EIeLOW. PAYMEN►OP OOYEAMM£HT 9ENEFITS EIYNen TO MYSELF OR TME PARTY WNO AOCEPTS A$$IONMENT SELOW, - ' $IQMEv Signature On file. PArEsaNEPfsii,nooRAvTNOR1rTDPERSOHi r PHYSICIAN OR SUPPLIER INFORMATION y H.OATEO�: ILN (tIR T 6YMPTOM} TY Y tg'.DATE fIRST CON$UITEQ YOU ipq THIS 18.ii P1!��TIENt HAS kA0 GAME 3 118,01 fAcCiOENT�Oa PREONAHGY ttMPi epiDITION ILlkEB$OR IFUURv,01YE OATl6 C R£ 4/1/94 4/6/94 EL +t.OATS PA LENT ABLE 1H.WE TAt K OATS$OF PARTIAL DISA$ILITY RETURN TO WORK IRON THRiRJOM. FROM THAM014 si NAME PHY$IQ+AN OR OCH ER SOVRGE i••0 V$LK:NEALTN AOENCr1 FQ. ERN eRIL*TEP 0. A WAT GPM .. Ht PiiAVINS,A OAT£$ - .. ADMITTU - 01 ARO ft.NAMpANQAWReSsopFAr:iso TwHEMESERWCESRENDEREO{lFOTN aTHAN EOROffrCEl 2p.aNA8LAGOPWORYWOPKPMORMIMOUT9106YOU FIGET4 V1E NO CNAROES: TSIA ON i$ A IttNFSS O Ni/ Y,RELATE Ni t D Sr REFE NU1A6Eit't 4.V,S:ETC.Oa Ox CODF cervical sprainjotrain.• 847.0 n ePsat R ao 2: Rt, "m $ shouldersprain/$train. 840.0 PAMILV PLANNINOyes _ +w _ Thoracic sprain/strain. 84741: 'PTuoa__ _- 4: Y AUTHORIZATION O. _ AL$ERViCE$OA$UPPIIES ' P M GATE YEN D OA�fS V WK :, OA TE OF SERVICE P Of E UFIC DOOR FROM - TO BEMVIGF i @%►LAIN UNV$UAL$ENTICE$Oq CIgCVM6TANCE61 WA@ODrQ 61fi CHAWES ES UNIT M01st ea paC S. _ I 04/28 94 3 97118 Muscle stim. i Attended'. 1-4 20 X00 Ultrasound en e - I 04/34/94 3 99213 Expanded 0411. 1-4 48 '-00 04j30/94 3 97040 Moist heat packs'. i-4 12 100 1 Y4 20 100 . 04/30/94 3 97128 Ultrasound, Attended. 1-4 20 14100 i E).NONA VRE NY8 CAN R L OEGMEEg�S�pR ASW ( ERNMENT 7T.TOTALCHARGE 1 p'0•AM NTPAIO n,SAIA G WE ; CMEQENYN1lS1 P CEMTIFv TNAT t'HE STA EMIN►$ 'TUE AEV€11$E GLAIMB ONLY!(SE€SAGKi. i APPLY TO TH4 SILL AHO AHE MAOk A PART TNEREOn 816 100 pNYBN01AN&9VPPLICR'S.ANO00 OROL+P NAM£ 00®£AND YELBPNONE NO, iD.rifv►►SOgiA1.6ECmTYNO. Donald $."BowesD.0 264-PF14A1 1034 Count.•Street rc,Y.l l2rs 11 o�v DAiE• �D � - - - . Trr '�.A:'f7,zVr3•eF+'n jrt 1"!�`rP a�', ,'+:r 7 ak A rr J OA 01 °g4 NF. ilftt TV s' Y�.`,O�i%R �',GhIA►1"jL: �JE.'s�5;';`: _ ;I : 4;.684.''C10 '� S y �."+��, •F� �+L114R�'''T�dj�i% �A I'ftPf,v+ � r¢r <4' �� N ' iTdOiLpwy:SAe1 �+ `Tt''""dr�.�y�'�II; 1x1p, L�,. y�F� /� . ,rC�naot0 CA 1t+aap}y v:rsr >E 5, "� r t i ro 11� itis y. �J]+,��'♦ !Vy. on l�,3s I.Sb, hr� + t ° �,"�' ,�'� rt'�N rr'�,;i,�+. •i "Mi �, v tiYS. r ASL i 0 4� .d. } ��NN� 2e9• I41}rl,t iN eti - t?. �tvut^ i,�•.�t1T'�7,�'re � ` t y Q 1��' fL�� la,f•�r,'r;� ,C''{,^� �' �+L es ,�`fty.r¢�S � �'� f1f�,1 ,+ �?t ryy `+4 wty .(�.y^-y+ r + 1q� v. � `■_w.y. -� .rr�Ay tYb � r{.'( r fi ,' , , !i." } / f ry� l;�i •7" rP{� � )_Wy' s �t1 � a'1t. �� .�1a �T�jyZ .! #!>!' { ( ,,�lY�,,Yi 1 1.'• `'� l�ti �!y P• �> 1.d 38".1 , ,� +e, i P :.:¢ ? r Y i V�f !F sy �`� !`L,'�' K 1'!L 7 r �•�y�, ', f:{��si9f�',s'v V j � w t + 0'J+ `"".1,'_"r�Af%�" .�� .r..1.� r r r,..��Kret ,: .�:"��y:;�'1�., pl� r�'.Y +'Pr;'1�' r >z•�'f• 1 }.S � I.,tii. , - ..��:iw�-t i=-a.'�-,�:-+�Yr--•K--�.��.r'--�....,..rte..(�. , - TSteP11ONE N0. - , - - 0.AOMNT ' J 1... O+IAMPUS SPONSOR'S V �Y DEC[ASSO r � STATUS RETIRED ' I AUrNORRE TIIE AEtFAbE 4F.AHv►ME01CAt INFOAMAYY, prCE88ARY TO IN US 13.I V NORM . NNNArMENT OP OOVERNIuEA'7 BENEFITS liTHER 10 MYSELF OR T6 THE PARTY WWO$AOCEP8T6 ASSIGNMENT 1if,0W`' YIAEN ME E L 0I ! UN - PHYSICIAN OR SUPPLER FOR SERVICE bE9CRieEO SELOw."- AlbtlEo Signature on file. On file, s, VATfi - SIOW[0INBVAEOORAVTHORI2EDPERSONI tt' 1A11�� PHV81 AN OR SUPPLIER INPORMAYIOrV tl tArE OF MCC+OFMT}OR pREDNANC VItMp1 r 13 CONGTgij CONSULTED YOU POR TWiB 1 IF PAtIEN NAS NAO SAME 0 iultAR IS...1 Y 4/1/94 QI6/94 ItLNE980RfWVRY.GfVE bAYES CHECK IN f f r ►A 1 N wel[T +E / wl 01 I - TEfURN TO WORX' OAT[S Of M11A1 D18A81LIfY II 1 I' MME Of REfERRINO PYSICWFROM TWr10u0H FROM TNRCdyOk V / ` NN OR OrNE SOURCE 1r F.rustic HEAL1kAGENCrp EP.'F g[R S RELAT TO Wpb TAIf ON ,. NOSPI'fALIZATION OATTES [f T+A�+ wNPwbOPIEBSOrfhGIUTYWIYEREBERVIC'� - -ADMIrrii • IBCMAR • I . ESRENOEAEOPFOiWERrlulNhfM1E0ROFrICFy it.WA8LA00RATOAYWORK PEAFORA4DOUTSIDE YM04 efrow j ij VISr•.J7 0 1 0 CHAHOCS: -V E OF IL►N R INJU r,nEIAYI 1 PURE I UMN 0 BV NCF UMTTERS f.S,3.ETC.OR OX CODE S. _ - cervical sprain/strain. 647.0 n . [F= VES ►Ip Rt. arm A/.shoulder sprain/strain. 840.0 _ Fhi PLANNING YES ® NO , iI I Thoracic sprain/strain. 647.1 _ - 1{ - A R TIOHW s.• [ 1.WA AL SRAvvCq9 OR SUPPLIES .. F - PLACE R 1 W F ACN OAtE ARH OATS Of SERVICE OF DIA DAYS f. F. O, ,Ito M - TO 6 RVICE I V EX►LAIN VNVBVAL SERVICES OR CIRCUMSI ANCE ARO[ 11NITs T.O.S. -' 3 1 Expan_e _ 48, 05/03/94 _ . 3 97010 Not Packs. 1-4 12 ,00 use e s im. tten ed. 1-4 20,;00 05/03/94 3 97128 Ultrasound, Attended. 1-4- 20.;00 05105194 3 99213 Ex anO.V. 1-4 48,'00 __- 05/05/94 .. 3 97010 HN Packs. 1-4 12100 05765/94 3 97118' Muscle stim. Attended. 1-4 20.100 05105/9471L28 Ultrasouhd. Attended- goo 05/07/94 3 99213 Expanded O.V. 1-448,'00 I 05107/94 7 1 1w4 12:00 9 118 Muscle stim. Attended. 1-4 2Q•�pQ .05/07/94 31 97128 Ultrasound. Attended.' 1-4 20 QO T� tONATURE Of vNYS+CiAN OR SUPPLIER INClUOmo OEOREESIS OR, P ASSIONMENI ii OVE .ENT E7,TOTAL CHARGE I` 10.AMOVNT PAfp E0.6AlAM E WE REDENTIALSiiR CERTIFY THAT TME STA�FMENTSOQNn TWE REVE0 WIMSONIvI(8EE LACXI 1 PPLY TO TH18 SJU AND ARE MADE APART THEREOn - 'LES NO 3f PHYSICIAN'$,SUPPLIER'S,ANO*R GROUP NAME,AObRlSS,ZIP CODE ANO TELEPHONE HO 70,Y SOCIALBECUAItYNOL Donald S. B6ws I D.C. 05/24/94 1034 Court Street 264-86-1461 Martinez, CA 94553 68-0047045 (510) 229-1300 15827 S ,. 1lEAtTN INIWIANCE CL1.1M FOPM . ' \ I noon er tx No. 18PONSOII'8 SSVA A FILE NO 1 Ea YFWATE O N ,, ► IID T •:• �j� ,1 PATIENT ANt? NSUREb l3U9SCRIBE INFOf1MATION I i . N AM YNI IA 1 e. PPF' DA OFSIRIH 2. O' H µAar NAM M/THAM ,Marx "TLA4 ' lene 'S. Richards 12 X30 56 Daniel or gW1 n ,IT SET. ,0 ATE. COOEI S►AIMNT'S SEX s.Ak I � .N0. PRpORA N CSD ►`'.1935 Estudillo St. �I�te❑ �nMAtE Martinez,. CA 94553 336-54-9377 INSURED's OROV . OR OROVP NAMe OR FECA GMW ,• Ili, OT'OUS£ CMILO .OTHER C1 _- 01»F50915-8 - H�TH[r� TEWPI.64E NO. (510) 228-8721rovoo AND 004010,OY sumvla Y+ER I+EAL IN LIRANCE VVY11 AD IENTfIt NA 4E OF POLICY' $0,WA IIONRELATEO TO 11.INSUIIE A E Ej 1s7 T.CITV,a A ip COOdI NOLTNI0 ANOF't/Vt NAME AND ADDRESS AND POLICY OtTMEDICAI AssINANCE NWfIR1 _ A.OATi*NY EM'L01'M*NT . - .. TELEPHONE NO. - 11.1, CHAMPUS 41PORIWA'S .. O.A�,+eINY OTMlR 1 DUTY OECEAOEO ♦UtO� BTAtUOI AE11RE0 A/ N7' 0f1A 110 It! 90N' �I NATU�FIOR Wli.1:N lite bw INE I AU/MdlRf THE RQlEA9E W ANv MEDICAL INTOnMATION NFO*ssAPY TO ORocess THIS CWV.I ALSO R(OVES7 PHYSICIAN OR BUPPIIER fon BERNCE D SCRIS OOEIOW. PAYYfNI OF OOVERNME NI 194fFIT9 111NER TO MYSELF OR TO IN(PAR1Y WIIO ACCEP IS ASSIONM£NT sf LOW. - P. - Si,�y�Y�t=e on file. On file. SIDMEO 7 DATE ' !CWIDONSUM10ORAUTHORIZED PERSON)_ (t IT tMEPW f PHYSICIAN OR SUPPLIER INFORMATION "r r 1I OA11�• JAOCIIOf11Q OR►REDNANCY It1LP1 Y If CCO+IDITION nst t7l T! iH19 t.ti(NE880R MJUAY,OIVE OA1tS Y LAR 1 .f.CHE It HERE' 4/1/94 4/6/94 17 OA1E PATIENT OkOtt TO _ 11 VATESOF 10TA1,013ASILFTYLOA7 S OF OARTUt DISABILITY . - +IfTVRN TO WOA11 ►ROM_ _ _ 'IIIROVOH FROM TNROVON ITNAMEOFREIERRIY!DONVSICIANOnOTHERSOURCEH9PUSGCHEAl1HA0ENCY) FbASERVYGEE11EAItV10HO8PITAU TIONONt _ - HOSP11ALIZATION DATES, _ 21 NAME AmOADOnESSOFrAC+LIIYMliIERESEFIVICESOil NOEAEDOFOt"I N 1 it.WAS IASORATOAYWORRPEAFORME000T8 pFEET_ yes - NO CHARD*a: - � "NUM8ERs 1•PA TC OROK CODE 1 Cervical sprain/Strain. !347.0 lreor vw No r ' Rt. arm & shouLder sprain/strain. 840.0 PAMItVPLANNING — res_ ._ _ ' 7boracic sprain/strain. 847.1 - �.LIIIIbO-.SAcr �-.- } G A 1 TION•M - 7t I.• FCi L VICES OR SUPPLIES /,/ A. PLACE / Y N N VATS OrAN O DAYS .k DA It OF 8tMvKE OF VR OIAON0818 - €�_ OR 0. TO - EAVIC! FY 1 XPtNN UNUSUAL SERVICES OR CInCUMOTANCEb MA S UNIIS T•O�S" absupplies. co pac s 1-4 : 05/10/94 3 99213 Expanded O.V. 1.4 48 00 n of -a c k s. 1-�4 12400 05/10/94 3 , 971181. Muscle Stim. Attended. 1-4 20;00 05/10/94 3 97128 Ultrasound, Attended. 1,-4 20.00 1-4 48'00 05/92/94 3 97010 Hot Packs. 1-4 12100 05 12 94 3 97118 Muscle stim. -Attended. 14 20,00 05/12/94 3 97128 Ultrasound. Attended: 1-4 20;0 05117Z94 3 99212 1 Limited 0j. - 05/17/94 3 97010 - Hot Packs. 1-4 12.0 05/17194 3 971.18 Mus le $ `m. Att 1-4 20 0 26 SYOUA1VnL OF PHYSICIAN OR BVP►tt1R VNQUDWO DEOREEfYB pppp G A8810NME Ni OYERNMENI IT,TOiAI GRAAO! I t0,AMOUNF PA10 r.OALANDE DUE CP101411KII ITCENTIFV THAI THE SIAI££MENTS ON TME AEVE�9E - CIAIMO Wtl!1i5EE�bR) Continued. + + I A►PLV TO TOR$FILL AND ARE MACE A FARC TMEPE011. . COnt 1 nU@d. 1 yes fl �NO SI ►NYSICIAN's,IVI•►LIER'S•ANOIOR GROW NAME,AWAESS,ZIP >0,VOW IALSECUAITVMO LED!ANDTEllPHONE NO. Donald S. Ra+aes, 1).C. t j 05/24/94 1034 Court Street PATE 264-86-11461 Martinez, U00 15827 94.553 684047045 ) II t + ...!!!1!L 1. /rAYtYAl. .rw ............. ...... ..1- 3,yi• ♦tea .. J t — Amy"tN9URA"m CLOW FORM r ww waar . 1 MiE -110 IfnONEOa'S um L 10VIMIC11,NO ER IFPwAT 'T ., PATIENT AND INSURED SUDSCRIBEF INFORMATION z ",.r,t 1 r M . IRLi 7, w MT' DATF OF a TN 7.M 0' NA i NAME,FatST NAME, i u . ' r lane S. Richards 12 30 56 A z Char leM RIChardsn 9 E 1.0ty, ► ,r1P 11 $PAtIENT'sSIX - - •ASUnlgE 0 • r i 1935 Estudi!lO St• MALE FeMAtE. trtine:a1 CA 94553 336-54-9377 a NAAEt onPEOA ,1 II act► aroL,sE cl+ao o1NEa Cha Jpf 41-F'50915�8 .I ` r� a�7 a1$Uato IS EA mmv AND omfoo sY mitovt" TEL{INANE NO.. S 1 4 i ZZ47�V!Z 1 NEAIT}t PLAN P, yr a Y VPIANCE CDVE OE I{M1Ea NAME O FOLIC+'• 1 A CON01110NaEtA EO tO ,r-yN VREo'!AFIESSIsTrilly,MY.97 1E,5F WOEi _ Hpp�� EEa PLAN AME AND AOpa{as ANb POLICY OR MEOt"t ' Affl9fAt N4p+yblal A,Mu{MT a'EMPtOYM1N1 TiE1YPigNE H0, .� 8.ACCIbEN1 ii... OAA"fP094900110 A0101 00141" STATUS I ENVY dEOaASEO • � FIEINIED - '' I AUlik>riit tlr hetEAAE nt ANr M1o1CAl itUAt"RAO'Waff-A4."strong t1 paMAtNwI HFCE9SARY AYMINI OF WOK 0, too,rlpCFaf 1Y115 CLAIM.!ALSO ItEOtIESt y 3.PMYS,CIAf10q SVPWIIth►OR s!a O>teCareEO e l DA7MEHt OF 00vttIMMENf 111141!119 EIrMEa 10 MYSELF TNI t0►!1T PAatY WiW`AOCEPtS 090FNEN4 BELOW. - ' on file. StONEO Sicwature.on file. DALE siDNED NSUAEDORAUtMOFtiiEOPE PNY$ICIAN 4 BR UPP iEFi INFORMATION 00 DA 01 - OF t CCiOE�tiOa�AEOH MEYILMPt i TiQN 0014 Ul7EDY 0 1 14.14 OX Y 9109-11m, f A. 4/1104 _ 4/6194' ty D*1 4AWi 11 111►fi" E c Y bA1E5 Aar1AL p9Aen1►v aEtUeNtOwOnK - �► '� r+IDM it111DTlOM FpOM rHItpVOM . it NAM 0r ItEtEINUN0P1tY5GuN0hoty+ERSOURCetr0ORMIClit At114AOENCYI frob BE nvlcS6W EO TOPIPWITAVISAIMPROrn - NOePiiAE11At10Mw1Ea ll , 7r N► EA ADI Cf Of,IRCiI�lYvwiE a{alRvIGE9al NDEAFd iN 01H1ry THAN 1roME 011 bri 1 l7:WAS tASONA1opY wDaN fEaPOaMEDDUraiol Y04a OFlICE,'1 � NO CNAp0E9; j ��r t XON 1iA1 W1�:iii 1Lt1tFS50f1 ipjUTllY alts /r�jin[Mt'TK UH 4y�r� E. ) � NVMSEa �1.l,f:E1C Oaprco+DF - - e.9or Yes ND v L. cervical slcain/strain. 847.4 NA r t , Rt. ar'm' & shouldear sprain/strai.n. 840.0 FA►MLY_►tAtdN,NA __Y'la_ ThoraC.1,C spxai,n/strain. 047.1 11iFT!lp1i1Z/\i --...T,�10+ s�CrY+ VlCE9 PLIES v DAYS K . AP{OAfCf r ulsi( F AG 1 44 .o thOAluiiE of S{awCE 10 >l1MYICE fV a 1 XPtAM1 UWSVAt 919-1"1 Qa EI UMStAMES � {S A OEs VN�i19 05/17/94 '3.' - 97128" Ultrasound. Attended. 1-4. 20foo , 05/19/94. 3 99212 Limited,-O.V. 1-4 3510 05!19194 3 97010 Hot Packs. 1"-4 120 I 06119/94 3 9711:8 . MuscIe sti.m. Attended. 1-4 2011.0 05119/94 3 97128 . Ultrasound. Attended. 1-4 1 1 is j S IAIIAtUat rMY IA a �Jrvl 51 op 7E N M IINMEN} � !►. OtALGH a0E 1 >b;- 1 AID CaED101144 }ypCEar v111A1 imINA#IAENt10e1rNEi$Y[RSE ;AA9AfOMY1(34 Moll A A (1�t ry APPLY 10.lya9 Srtt ANO ARE UADt A PAa1 1M06,011 - - 684• 0 0v ti YE9 .ONA" 71 PHYSICIAN'S. ItKA'S.ANW01t OR"NAME,ADDR$ 10 COOS*ANO tE�+tEPNEO�N�E.M�O t1 30,Y t 11ECURITY HO _ Donald S.a .Dcrtma t D it c e 1,034 Court Street # ►Aa 5/2 /94 264-86-.tQ61 Martinez, CA94553i( 68-0047045 510 229-130.0 � � � 7 15827 � J * 1 ill:; � • .; � ( '. i y� it t' •( 'r'rT ',rpw ,1.%..:.}.i2-.ira_i`.a '.�.:tI4.C':.' '.t..'�.'.. ,.+-.,.:� iw,aAa..:e..:�:�.:'�•..• •� 0 LVNN F.SHAOFA,M.rx SAN RAMON VAUSY ORTHOPARM aROUP 0 J014N K,WILHELMY,M.D.,INC, ++ECtCARiC'PR4V rZZZt�63rZ iRSYW o0ob5oS 0 JEF40ME H.DAVIS,MA,,INC 0 130 La Cess Via,8v4#103,Watnul Creak,CA 94318 + (514 932.1 i ,0 JOHN M.KNIGHT,M.O, 0 EDWARD A,:91'OKEL,M.O. 0 SZ01 Norris Canyon Road,Suitt 30R Son Ramon,CA 94503 •.{510 ss9.9 O JEROME C.9ERNHOFT,M.D. "64SAM(7EL$ JORGENSON,M.O, 907 Ben Ramon Valley Blvd,.Suite 2011,Danville.CA 945@8 + j51oj 82"Tu )FF10EVtS1�::'iEyy�.0 ` .,t,. �s':, ru q. "R•F1A t;;/� , n • T$ '� i«a. lz a ..i.�...r.: ' 1S P004»19$070 s Brief 80+}00 99201 40 Ribs 7itD0, 71110, 84 Ace Bandage Limited. w 99202 42 Sternum 71120 88 Ankle Brace Into modiste1. �t 99243 43 C-Spins 72040 ,72050 72052 92 Cervical Pillow ' 44 Dorsal Spina 72070 72074 93 Cast Cover Extended -'-9Wf99204 Comprehensive 90020 99205 45 SooliOsis - 72t990 94 Cervical Colter 46 ,4•Spins 72100 72110 72114 95 Cast Root 1 47 T-1,Spins 72080 96 Elbow Brace F ICE VtfitY�-EBT 8L�8HI;D li; r . 48, Pelvis 72170 77190 9$ Fiberglass Material 49 SacrumfCoccyx. 72220 103 Foot Orthotic, Brief $0040 95211 50 Clavicle 73000 104 Finger Splint Limited 90060 99212 51 Scapula 73010 105 Hs�Padle .:. Intermediate 90060 99213 52 Shoulder 73020 107 Hast Cup _.,._...r..r .,.. Extended 80DT0 99214 53 A•C Jointg 73080 it0 Kass Brace ComprshensWs 90D80 99215 54 Humerus 73080 112 ShoulderlmobiilZer- Pre flp 90025 99214 55 Elbow 73010 73080 ria Sling Post-Op OW24 99024 56 Forearm 730$0 i15 81,Walker 67 Wrist 73110 tie ,Post-Op Shoo . N t10N$ g' 58 hand 73120 73130 117 Quadrieisor 6o Finger . 73140 its Wean&For'rrt Corset -: intermadiaie 90805 99242 80 Hip 73500 73510 73520 121 Wrist Brace Extended 90610; 98243 8t Femur 73560 .{ { r{{• a Comprehensive $0620 99244 82 Knee 73580 73582 73584 Erxlensive . 900630 $9245 63 Tibia and Fldula 73560 1�2 CWAomprehenslve/H&P 90220 .9920, Follow-up •90843 9$243 64 Ankle 73600 73810' 123 .Day Vlsit 80250 "$$211,'( Second Opirdan 90826 99274 85 Font 73820 73630. 124 ER Visit 90515 90580 992K, 86 Calcaneus 73850, t26 Nursing Horne 90t330 9$901 . . 67 Toes 73660 126 Hospital Qiacharga 90292 9923E. )ft. GB►t A' TRt L f 68 Other GA�1Ft8Pk.tNa16ttRQSRY;:` 1 `,curt Apptt)epo; $0075 r.. special Report- 99060 DATE., tacixds Review 9$080 70 hong Arm 29085 71 Short Arm 29075 . Ra Ravlew 76140 AEIPDR Consult.. ' 90830 TZ Gauntlet 29085' 73 Splint Short Arm ' 2x3125 L i'�af ., .ter /Gy Opy Med Records '99090 74 Splint Long Arm 28106 29341 75 4ota9 Log Cott 29 55 CTtOMlASPItiA1NDN lt," 'a+.s t«. *� .1 Long Leg Walking j 77 Cylinder G . 29385 I man Joint 20600 78 Short Leg yilencing 29405 i lermediate " .20605 70 Shod Leg Cast qor Joint 20510 80 Splint Short Leg 2943529405 199or Point .,. . 20550 6/ Spent Long Leg 89070 82 Clubfoot 29450 arusone 99070 83 Other f DQCTOR9 SIGNATURE 4' � fsle. 40 30 10 t; IN APPOINTMENT: a i INTO WORK tfATl:: REC'p a1f_ TOTAL TODAy,v FEf ri p Credit OLD BALANCE Card AMY.ALC'dTODAY a I u,.ITY STATUS. .�0118F1 i { t�Check NEW BALANCE aRIxAT1ON t: i[t PLEASE t3f ADVISED THAT YOU ARE RESPONSIBLE TO pAYl►NY AP,OUWT NOT PAID FOR BY YOUR iNSURANCE CO G'�'�� tai �'�;�'�'�i -!-_Lf�I�C'�7i�itl�Z ��1�!1�?'I�' ►.13'`� I/Z7��_II",t�� 1F%F'OnWZ' W..-AM! �f �Inv" !►1 ©IWMVSM Z,0w I� MMM 00th t I1 '�A =MI I�I� I t i I I ii I I =,HIM t l f 1 I�11�1 I ;tl Li I � ) I ,� I J _ �I , I •��7� ( f t I� 1 IFTZrJ SAVA f �i 1 . ►1fllirfln].;r]. iff �1 17 J.4.! 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'�4► i � �.1M•�1.... k i►`�i � �t ��+�_ a f � psi J �►t ... �f! s ti � ;�� _ �� ` r � �� w * "',►� � >•'.d. lit t4� •�i w � .. �► %l `l''i��` 'vitr'!► : �_ is�` `► .. .«sem- f" . i �� :cit ��+a ?:'� �r. �' ....rte�.+,�. �-MS •. ':�i� d �•/ :�il �� - �.� _..w ** �tw .w[ r: >�� _i Ili M alt♦ a/i�� / �,��'.�. �. r�� fl�•%w � � rl�I., .��. �u.� i�f•'y��d'. ♦�.i Ir TRAFFIC COLLISION REPORT.Pro Damaga Only �.�`' 104W000;Mr Oqb EPSWA,LCONO�IN:N• NTaRUNOil HmNllila CWI 10 Y 1 - fIT . AT • lCTIOREAtM - '- .' - DAY WI/KAWAY Y • I', oP; nErfL•Ln 8'M TWT*$PARTY If• 0 R One NU •i +-� - jNkj •AI IOUIP. •f1A0R KEwN ( O ER NAYR ,fi •L •• NLYLEh AAd:lo - MY{AK■�J'E�� ►K VOI •IRTNO R FAARIIR NIRIRERL I - I /par. wv�a ' Y0. RE 0 A - .. _ /, �~�t•VY Y ME L E• tE A YEN NPI PARIV PAT • E,►y; R aC P, •NADA DAIA"10 . Un A0MA P o I i• r P PKYIN1 IUt n r ARhER � n An Y6ll 6114" VIILTVPB PARTY O, , AOE EEE an AA011E•• _ /NONI NIIM•EA MD. j O E3 "ArM AD•n•w " PROP. .' r +. :... . ,._ •AIAAos•• OWNER 7 ►MMARYNUMBE OOW810N PARTY ATED APwC OON7ROL DEVICES -g TYPE OF VENOL.M - ...� •j ,UST NUMBER(N 1 OF►ARTY AT FAULT .. . . :..•, BION � I pVCSECTON I. ROLS►UNCITONINO PASSENOERCAR ISTATION WA00N' STOPPEO j ROPASSENGER CAR w ffRA1LER PAOCEEDINO B HTOTHER 1 PROPER 0• ROL*OBSCURED MOTORCYCLE f B0001EA RAN OFFORTAOIS 1 t PACTOA PICK P oR PANEL TRUCK MAKINGROWTURN OTHER THANDRIVYPE OF COLLISION PICKUPI PANEL TINICK W r"wLER M.KINOLEPTTU I UNKNOWN• -ON TRUCK OR TRUCK TRACTOR MASKINOU U N FELL ASLEEP' BYYIPTRUOK I TRUCK TRACTOR W f TRIG bACKINp (01 ENO SCHOOL SUS S t TOWETHER MARZ DMDEOTNEAbub ' . OI onvrmeCLEAR BJECT EM6 -a' ' ' CHANOINOLACLOUDY TURNERAINING CLEIPEDESTRIAN' CYCLE .• ENTERINGSNOWING R• OT OTIIIiA UN N FOG t VISIBILITY AN '^ XI T.AOTHER: •C IBION HOPED .' AR r WIND PEDESTRIAN fsN C OTHER MOTOR ve1MCLE OTHER ASvOCI �„ SI A ELINO WRONGWA DAYLIGHT; MOTOR YEMCLEONOrNLU1H10HWAY_, Z ♦MARK 1 OTHER•a ' DUSK-DAWN PARKED MOTOR VEHICLE DARK•BTAEE7l10N1S TRAM! ' DARK•NO STREET UaHTAalpE•DYW E DANK-STREET LIGHTS NOT NI : Y MA�(12+ BOBiOIr .OAyp FUNCTIONiNO �". SURFACEROADWAY ' s 1 (PARK 1 TO E iTEMIi 1 DRY 1011111 OWECT WET NAD NO 0 UNDER 14ftv EL SNOWY+ICY IENCI VIBIONOBSCWIEMFNT: HBD•N07UN AINPW C, DSUPPFRY I MUDDY.OILY,ETC I INATTENTION• NBD•IMkAIRME LINK ROADWAY CONDITioMe) PEDESTRIAN'!ACTION Us—Topa 00 TRAFFIC UNDER 9RU If MARK 1'TO I ITEMS) NO PEDESTRIAN INVOLVED ENTEpINO/LEAVING RAMV INPM NT• bICAI PREVIOUS COLLISION HOLES,DEEP RUTS' CROSr3IN01NCRODBANAUI JA PAIRMEMi !K WOSE MATERIAL ON ROADWAY' AT INTERSECTION UNFALALIAR WITH ROAD T APPLICABLE DEFECTIVE VEk EQUIP.: 098TRuCTONONROAbwAY• CROSBINOINOROSSWALK•NOT EEPYrPAII DCONSTRUCTION•REPAIR ZONE AY INTERSECTION IA bINFIF16 i, E REDUCED ROADWAY WIDTH DCROSSINO-NOT IN CROSSWALKI—L ILUINNYOLVEO VIRCLE HAZARODUa TERIAL 9NO ODED• H•ROAO-INOLUD *HOU ER OTHER HER': NOTMROAO NONE APPARENTUNUSUAL CONDITIONS APPRDACFpNOIR{AVRIOSCPOOLBUS RUNIIWAYVEIBCLB ` CMP•56-09(REVY1�ryOP101? ` , � 1L08DIf'�A, 4: .hi �►f il'i�� F- k 0 i4 1.36:1.1 RAM(IN 'VALLEY Cli-eYHO GROUP DAN 86 N t�;ll:�tON ffl. 'l;:i»t..t�Y .,..'k'!49;? T'1»LEPI-IONE 51 VI r'l10...6Q3 1 Xnw NO. 611• 0VRi:.t".'541.a ClIARI-;:HE' 1'?ll7flNNE" RTCHAR D,3. 5T (o(;t.;E1i1M`t .;:'8'?14 Ck 94511;Is ,*ROM��h TCI LOC D* COT (�D(AG. hf�` TDF.18r/:RlrP*r><ON r t rL' )cLiEfr�l'fr f h1J♦♦74 5/212 /t94 1�t/ ! 91211,/*3 e-1,/yw2 �o i*T(,i: �Y�l�t.,pi�r 1,11741 INTC:R _ �l Sraw fr,Jo i iJ/74 :Y '14.5 94 •moi., - 1 72 110 04/ .2 'X-ROY I,;.�..+iff X I i IF TOT'ALS FOR 0/00/00 I-HRU 99/99/75' �-�-- CHAi`!sixi::#ryry;. CHG ADJUST �°!11'f`11':Mlb -CLAY' ADJUST, M,FT j��!d , L� CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA October 18, 1994 Claim Against the County. or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to The copy of this document sailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV bele++), given pursuant ®•vt �ytCod�ek Amount: $253,511.75+ Section 913 and 915.4. Please note atlYrnnfn`gs CLAIMANT: PATANIA, Glen SEP 23 '°��J COUNTY cOUn� ATTORNEY: Michael Goforth A4ART/N_mZ pu_L One Concord Centre Date received ADDRESS: 2300 Clayton Rd. , Ste. 1460 BY DELIVERY TO CLERK 0 St—tambPr 91 1 QALL Concord, CA 94520 BY MAIL POSTMARKED: September 22, 1994 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. N 1l gATutyCHELOR, Clerk \ ,� DATED a app1: Dep ?ui r. ]1. FROM: County Counsel TO: Clerk of the Board of Supervisors ({XThis 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: `� Z�'- g BY: 1 Deputy County Counsel 111. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). JV. BOARD ORDER: By unanimous vote of the Supervisors present { ✓) This Claim is rejected in full. ( Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: OCT 18 1994 PHIL BATCHELOR, Clerk, By 12 � Deputy Clerk MARKING (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 wail to file a court action on this claim. See Government Code Section 94S.6. iu say 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 warning see reverse side of this notice. AFFIDAVIT OF }WILING declare under penalty of perjury that I an now, and at all times herein mentioned, have been a citizen of the United States. over age 28; and that today 1 deposited 1n 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 sho.n+ above. paled: OCT 2 199 BY: PH1l BATCHELOR by Deputy clerk tC: County counsel County Administrator m V V •.� y'J l .G' a - m O vm vcs (n4-3 U)c� - c m zc�u � 4--3 d N U a v Z p a w u �0M LL � oaw o x U w < ?r Z U U 5u$ O z N OU 0 ° z 0 U u LAW OFFICES GOFORTH & LUCAS CLAIM AGAINST THE COUNTY OF CONTRA COSTA TO: CONTRA COSTA COUNTY ATTN: CLERK OF THE BOARD Pursuant to Section 910 of the Government Code, claim is presented to the County of Contra Costa, California, as follows: (a) The name, mailing address and phone number of the claimant: Glen Patania, 4266 Palo Verde Drive, Pittsburg, CA 94565, (510) 439-3166. (b) The date, place, time, location and other circumstances or transaction which gave rise to the claim asserted: Date: July 23, 1994 Time: 4 : 30 p.m. Place: Somersville Road at intersection with James Donlon Boulevard, Antioch, Contra Cost County, California. i� m Circumstances: x Count One: Negligence: Claimant was driving his 1980 c 6" Dodge D-50 pick up travelling westbound on James Donlon Blvd. at 80 N IM the intersection with Somersville Rd. , within the posted speed , W Z limit when claimant's vehicle was struck by an approaching vehicle D M m travelling in the opposite direction. Due to the poor condition, rn PM v negligent engineering and negligent maintenance of the intersection and road, the approaching vehicle collided with Claimant's vehicle. 0 As a proximate result of the County's said negligence, claimant sustained the below-outlined injuries. Count Two: Willful Failure to Warn (Civil Code Section 846) : The defendants willfully and maliciously failed to guard or warn claimant against said dangerous condition. As a proximate result of the County's failure to warn claimant against said dangerous condition, claimant sustained the below-outlined injuries. Count Three: Dangerous Condition of Public Property: The defendant Contra Costa County, a public entity, had actual and constructive notice of said dangerous condition and sufficient time prior to the injury to have corrected it. As a proximate result of the County's failure to warn or correct said dangerous condition, claimant sustained the below-outlined injuries. (c) Nature of claimant's injuries: Claimant sustained cervical, thoracic, lumbosacral, temporal mandibular, sacroiliac and neurological injuries. LAW OFFICES GOFORTH & LUCAS (d) Location of Incident: Intersection of Somersville Road and James Donlon Boulevard, Antioch, Contra Costa County, California. (f) The name or names of the public employees or employees causing the injury, damage, or loss, if known: Unknown. (g) A general description of the indebtedness, obligation, injury, damage or loss incurred so far as it may be known at the time of presentation of the claim: Claimant sustained bodily injuries, property damage and incurred loss of wages as a result of the incident which is described in Section (b) . (h) The amount claimed as of the date of presentation of the claim, including the estimated amount of any prospective injury, damage, or loss, insofar as it may be known at the time of the presentation of the claim, together with the basis of computation of the amount claimed: 1. Dr. Gregory Castillo, D.C. , . . . . .$ 817. 00 2 . Dr. Aubrey Swartz, M.D. , . . . . . . . $ 423.75 3. Merrithew Memorial Hospital . . . . . $ 211. 00 4 . John Gilbert, D.D.S. . . . . . . . . . $ Unknown 4. Future medical care . . . . . . . . . $ Unknown 5. Wage loss. . . . . . . . . . . . . . $ Unknown 6. Future wage loss . . . . . . . . $ Unknown 7. Property damage. . . . . . . . . . . $ 2, 100.00 8. General damages . . . . . . . . . . . $250, 000.00 TOTAL. . . . . . . . $253,511.75+ I declare under penalty of perjury that the foregoing is true and correct. Executed at Concord, California on October 6, 1993 . OFORTH & UCAS MIC&Z D. GOFORTH, Attorney for claimant .TATE QF CALIFORNIr - f TRAFFIC COLLISION REPORT-Property Da: ,.go Only Orkjtna/toa►ker,-copy(ias)totnro/vedpanyftesl SPECIAL CONDITIONS HIT RUN GTY JUDICIAL DISTRICT NUMBER COUNTY REPORTING pISTNCT BEAT REPORTING OFFICER COLLISION OCCURRED ON MO. DAY YEAR TIME 124") - NGC OFFICER I IL LJAT INTERSECTION WITH DAY OF WEEKT�OWywAY STATE HIGHWAY RELATED OR: FEET/MILES of �dMFt 1ip+JLo� �L <,- S M T W T F S g�iEs �No ❑rEE PARTY DRIVER'S LICENSE NUMBER - STATE CLASS SAFETY EOUIP. SHADE KETCH 1 ( -Z t>'�Z-U� '{b C DAMAGED DRIVER NAME(FIRST,MIDDLE,LAST) PHONE NUM ER AREA 0 t C-u ��v�-�� G ASL (457 �G�-Z INDICATE PED. STREETADDRESS _ ^CIT'Y/STATE/ZIP e _ NORTH 2 �1 tJ �t l .�11�,� 'Z� Tt �u ICA PK VEMBIRTHDATE I _NSURANCE CARRIERPOLICYNUMBER BE% - t-' `\ 6 „r1i a C-M74ti'l' 'VSy BICYCLE OI R.TRAVEL ION STREET OR WGHWAY SPEED LIR. - OTHER VEKYft IMAKEI MODEL/COLOR LICENSE NtUYB�Rr' STA VEK TYPE P%RTY,� - - - (.,1LJ �t?✓� ^.�c.t7 G T C4�1 Z IL IGL tCJJ.� =:L-;'1 PARTY DRIVER'S LICENSE NUMBER - STA CLASS SAFETY EOUP, SHADE 2 C G�1'It`3.S L - DAMAGED _ DRIVER NAME(FIRST,AA1p\DLE,UST) PHONE NUMBER - AREA fes+ 1.I"_" ��1_...l,r• - 1%(.(p PED. STREET ADDRESS /STATE/LP PKVEM SEX BIRTHDATE SURANCECARRIER POLICYNUMBER - - t2 t (o a Ju .— (CYCLE DIR.TRAVEL ON STREET OR HIGHWAY SPEED LAR. _ OTHER EK YR MAKE/MODEL/COLOR LICENSE NUMBER `TE V'KTYPE PAR Fitz �0?�1.1 F Nh-SZ� SctL l l.l.Sto`-I -A 1 �• RIO AGE SEX NAME ADORE" ( PHONE NUMBER PARTYNO. ❑ ❑ AGE IBEX NAME - ADDRESS h PHONE NUMBER PARTY NO. I PROP. AME ADDRESS DAMAGED PROPERTY OWNER IMPORTANT — READ CAREFULLY Keep this report. This is your record of this accident. To comply with California Vehicle Code (VC) Section 20002 (duty where property damaged), you must either: a. Give 'the owner or person in charge of such property the name and address of the driver and owner of the . vehicle; or in the absence of the owner, b.' ,Leave a written notice in a conspicuous place on the other vehicle or damaged property, giving the name and address of the driver and owner of the-vehicle involved and a statement of the circumstances. This information is necessary for the completion of your state SR-1 Form, Report of Traffic Accident, and your insurance report. VEHICLE CODE SECTION 16000 . . The driver of a vehicle involved in an accident resulting in damage to the property of any ONE party in excess of the amount stated 'in VC Section-16000 or 'in fhe injury or death of any person MUST submit a SR-1 Form to the California Department of Motor Vehicles within 10 days. Note: Failure to comply may result in suspension of your driver's=license. - Form SR-1 maybe obtained from the Department of Motor Vehicles, the California Highway Patrol, any police station, motor vehicle club, or insurance agent. If city or state property is damaged, you will be contacted regarding possible liability. �'Q V1T-88)OPI042 .. - �u — SYN •�� w��Sk c} t��td G'i�r x� '+t,. �-F(`�re y.�� L '< x t� h'"`a,�?x"� • . ''tr� x ��':° P.d� aF. .n��S'y�twrt.l �`• ^`?ir`�,','�"} �"F- a1„�. Xd��>�� v r -� '� �i` 'w'1• st � ' '*'..'�'`7pfis"•1'. "^ a� .:►r Y '��`�v ,rte n �� v:xx✓i X � �'�.�5.4�'r�"•,^ �, 4��a4��.�. 3d,+� >..,� ya r�� l�'.��i2.{::e.�c ys , � �.�-9Y� r4.�t r �,��%}.3 � ,�'`�"'`•P'!�2} r tn4' ai.se�.- � t z.-�af' �,l,.'„ ;Nr^5 �..�,r�8 t�• ��.;t a xS�r ':�.�•:��+;� t~'s Y� ''� i' .�::. � 3 �"J �.•`.:r -,1 r} v.•� n x t-!''�S, �.� �� `fin.e;y�t a� � �*�'�'�-��5'films MD sm-:0-1 „(ytc�•R. Y tw r q� r" i /r wx � ' x = IM. k° r 1 / 1 Ir i 1 � ' r �r 1 E i q s 142 ?MIX .gynv'd`, ly "' +2^•%h.,N,. '�'^ Nil a A,.... 'viva' l .�...:.,.r c31+...�,,,y,�yy,,.._.va,.- Y�• °�� xr �2•^�,y�^�i`•:'y.. � �ie��'�1' � a� r j� _ _ S�Y �rsx�s�w wrr i ,; 6 '' - 7 i� I. ,��. - :. � � I�� : :1 �wtr .� ��; � 11 f+"'�„a ,,,'k� _ �'�. �==�..,,,.,�„~�: I, ��C h �" �}} t w.S � `��11�� fi�i1 r a � �_ _ _ ! x. ;. ,. ��, , �{ �` -.f_s F'3:�.'.ir.F.Ct�"sv'C+So-t"G'#T+J.v�.�t.�r:;,c rv+�.-�,,t�ti'a_ k�B��e., �� 0 { .� �:� ., .. .•; T �1 3t�£I, ��..��.� _� �Kp.S \��xS�t \{d fug � 'e�;i�i /tom l 2 CERTIFICATE OF SERVICE BY MAIL 3 The undersigned, at Concord, California, certifies to be 4 true, under penalty of perjury as follows: 5 That he is a citizen of the United States, is employed in 6 Contra Costa County, California, is over the age of eighteen (18) 7 years and is not a party to this action or proceeding. 8 That his business address is Goforth & Lucas, One Concord 9 Centre, 2300 Clayton Road, Suite 1460, Concord, California 94520; 10 telephone number being (510) 682-9500. 11 That he served a copy of the attached: 12 CLAIM AGAINST THE COUNTY OF CONTRA COSTA 0 U � o v 13 by placing said copy sealed in an envelope addressed as W a W & Z follows: u o °� o a o 14 CONTRA COSTA COUNTY IL 3 N z L u 15 Clerk of the Board 5 uo �, & 651 Pine Street, Room 106 o 16 Martinez CA 94553 O O N Z 0 17 with postage thereon fully prepaid, and thereafter was deposited 18 in the United States mail at Concord, California, County of Contra 19 Costa. That there is delivery service by United States mail 20 between the place of mailing and the place so addressed. That the 21 date of deposit in the mail and the date of execution of this 22 certificate was September 21, 1994. 23 ` 24 By Keith Domingo 25 26 27 28 LAW OFFICES GOFORTH & LUCAS A LAW PARTNERSHIP MICHAEL D.GOFORTH ONE CONCORD CENTRE CHRISTOPHER R.LUCAS 2300 CLAYTON ROAD.SUITE 1460 CONCORD.CALIFORNIA 94520 FACSIMILE(510)682-2353 TELEPHONE(510) 682-9500 September 21, 1994 REFER TO FILE NO: 49-140 CONTRA COSTA COUNTY Clerk of the Board 651 Pine Street, Room 106 Martinez, CA 94553 RE: Glen Patania vs. Contra Costa County Dear Sir/Madam: Enclosed please find a duly executed claim form on behalf of my client Glen Patania and one copy. I have also enclosed a copy of the traffic collision report and photographs of the property damage and accident scene for your reference. Please return a filed-endorsed copy to our office in the envelope provided. Your prompt response will be greatly appreciated. Sincerely, -7 MICHAEL' D GOFORT Attorney ,at L MDG:kad Enclosures `~ CLAIM II BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA October 18, 1994 Claim Against the County, or District governed Dy) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT And Board Action. All Section references are to ) The copy of this document nailed 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: $ 150,000.00 Section 913 and 915.4. Please note all rnci CLAIMANT: PITTO, Michael SEP 2 101 ATTORNEY: Mark V. Murphy CollNTYCaUNSEL MARTINEZ CALIF. Date received ADDRESS: P.O. Box 5026 BY DELIVERY TO CLERK ON September 28, 1994 San Ramon, CA 94583 BY MAIL POSTMARKED: September 27, 1994 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. oG/. �9S,Y 11IL LATCNELOR, Clerk DATED:— � �.0�� putt' 71. FROM: County Counsel TO: Clerk of the Board of Supervisors (V< This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying I claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: L BY: Deputy County Counsel 111. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). 7V. BOARD ORDER: By unanimous vote of the Supervisors present { r/ 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: OCT 18 '994 PHIL BATCHELOR, Clerk, By=�� Q1J„ j , Oeputy Clerk WARNING (Gov. Code section 813) Subject to certain exceptions, you have only six (6) months from the date this notice ass personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You My seek the advice of an attorney of your choice in Connection with this utter. If you want to consult an attorney, you should do so immediately. *For additional warning see reverse side of this notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I all now, and at all times herein mentioned, have been a Citizen of the united States, over age 18; and that today 1 deposited in the United States Postal Service in Martinet. California, postage fully prepaid a certified Copy of this Board Order and Notice to Claimant, addressed to the Claimant as shown above. Dated: OCT 2 01994 BY: PHIL BATCHELOR by Deputy Clerk .cc: County Counsel County Administrator aaa a+ Yaaaaaaa 10` G� Q iZH' Y •v hew Ys� d� ..r f �r of a N 0p • a � N SA ro i.n ' 0`4 0 N • �. 7y rA -N UO � (43) ol �U 'Z') zg z V •c Claim *,o: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. Claims relating to causes of action for death or for injury o 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 uhich accrue an or after January. 1, 1988, must be presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Govt. Code §911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez, CA 94553• C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this oorm. RE: Claim By ) Reserved for Clerk's filing stamp MICHAEL PITTO RECEIVED Against the County of Contra Costa ) 2 8 or ) District) CLERK BOARD OF SUPERVISORS Fill in name ) CONTRA CO TACO. The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of 150,000- 00 and in support of this claim represents as follows: 1. when did the damage or injury occur? (Give exact date and hour) April 10 , 1994 - 5:00 p.m. 2. where did the damage ornjurHy occur? (Include city and county) Sunrise Ho se, private residence of Dar 1 Gr sez, .135 Mason Circle, City of Concord, Cour�ty of1Contra Costa 3. How did the damage or injury occur? (Give full details; use extra paper if required) Plaintiff Pitto was-injured when a piece of porch framing wood crave way_ due to the 'rotted condition of the wood. Plaintiff was injured when he fell to the ground. 4. what particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? The county was negligent in its care and maintenance and inspection of the private residence of Daryl Grisez being utilized by Sunrise House. (over) 5. What are the names of county or district officers, servants or employees causi;3g the damage or injury'? DARYL GRISEZ 6. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. Plaintiff fell to the ground as a result of county' s negligence and broke his foot resulting in medical damages and loss- of work for -3 months. 7. How was the amount claimed above computed? (Include the estimated amount: of any prospective injury or damage.) Medical costs to treat broken foot and reimbursement for lost wages 6. Names and addresses of Witnesses, doctors and hospitals. Shawn Bradley - witness Dr. Shea -Piedmont, CA Merrithew Hospital - Martinez, CA ". Dr. Ritter, Concord, CA 9• List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT &AMA am ov Code Sec. 910.2 provides: ITh claim must be signed by the claimant SEND NOTICES TO: (A to e ) or some person on his behalf." { Name and Address of t srrneysi:lw a c 34 v MARK V. MURPHY � K3�lr;�?�°1��4?S 3 a ' BUCHTA & MURPHY, A Legal Assn , (Claidants Zigroture P.O. Box 5026 San Ramon, CA 94583 P.O. Box 5026 Address San Ramon, CA 94583 Telephone .No, ( 510 ) 866-6677 Telephone No. (510) 866-6677 ti #t ti t tc x : at : s : a s s As s s LL a 4 1r1rT f 0 NOTICE Section 72 of the Penal Code provides: "Every person who, With intent--to-defraud, presents for allowance or for payment to any state board or officer, or to any county, city or district board or officer, authorized to allow or pay the same if genuine, any-false or fraudulent claim, bill, account, voucher, or writing, is punishable either by imprisonment in the county jail for a period of not more than one year, by a fine of not exceeding one thousand ($1,000), or by both such imprisonment and Pine, �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. CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA October 18, 1994 Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document exiled 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 Go rnment Code Amount: Unknown Section 913 and 915.4. Please note all i rr vvp CLAIMANT: JAYNE, CandiceSEP 2 Coujyry ATTORNEY:AlankTalbotTalbot, Inc. Date received M1Aq 1N OOUNCzFc. L. ADDRESS: 1990 N. California Blvd. , #740 BY DELIVERY TO CLERK ON September 23, 1994 Walnut Creek, CA 94596 BY MAIL POSTMARKED: September 22, 1994 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. , Jl R, Clerk waeDATFO: puty � � ) o ll. 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 IS 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: Z �'a q a BY:.� i �'�� Deputy County Counsel 311. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.)). IV. BOARDD 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. p Dated: OCT 18 1994 *NIL 0_eL,0_, BATCHELOR, Clerk, By � , �D�� , Deputy Clerk :- YARNING (6ov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice Brat personally served or deposited in the nil to file a court action on this claim. See Government Code Section 945.6. Tau my Seek the advice of an attorney of your choice in connection with this atter. If you want to consult an attorney, you should do to immediately. *For additional warning see reverse side of this notice. AFFIDAVIT OF NAILING 3 detlart under ,penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the Ifiited States, Over age 18; and that today 1 deposited 1n the united States Postal Service in wrtiner, California, postage fully prepaid a certified copy of this Board Order and Notice to Clainnt, addressed to she tlainnt as shorn above. Dated: OCT 2 -0- 1994 BY: PHtL BATCHELOR byDeputy Clerk tC: County Counsel County Administrator r W cr LLr x U c i W O � y M u E* V 0 7n UM o > Ln m M ® m F w Er p a Q -0 E-+ a ° s cn N zO V Z0 a a O o . O z � 3 Claim -to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. Claims relating to causes of action for death or for injury -�o 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 6911.2.) B. Claim must be filed with the Clerk of the Board of Supervisors at its office in Room 1069 County Administration Building, 651 Pine Street, Martinez, CA 94553• C. If claim is ag~irst a district caverned by the Board of .Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form. * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * RE: Claim By ) Reserved for Clerk's filing stamp CAN.D ICE,:_JAYNE gainst the County of Contra Costa ) X61XX ) 2 3 XXXXXXXXXXXXXXXXXXXXXXXXXzydt* bto CLERK BOAS �F Fill in name ) CoNTRACOSTA CO. The undersigned claimant hereby makes claim against .the County of Contra Costa or the above-named District in the sum of $ unknown y to be and in support of this claim represents as follows: determined . 1. L4he_n sad the da.ama a fvw i ;ua=y occur? (%Give )AGt, date Lnd h-oLL ) 5/17/94; 6 : 20 a.m. 2. Where did the damage or injury occur? (Include city and county) Lone Tree Way, City o Antioch, County of Contra Costa, California 3. How did the damage or injury occur? (Give fui-1 details; use extra paper if required) SEE ATTACHED "ATTACHMENT A" 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? James B. Perez failed to stop for traffic and rear-ended claimant' s vehicle. (over) 5. What are the names of county or district officers, servants or employees causing "- " .. the damage or injury? James B. Perez . 6. What damage or injuries do you claim resulted? (Give full extent of injuries or door claimed. Attach two estimates for auto damage. See property damage-,estimate for 799. 60. Claimant has injuries to her upper and lower back and neck, the extent of which is still to be determined. We are presently awaiting recruestgd_ 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) See attached property damage estimate. Unknown as to future medical costs. 8. Names and addresses of witnesses, doctors and hospitals. Kaiser, Martinez , 200 Muir Road, Martinez , CA 94553 Noble Elcenko, D.C. , 2800 Lone Tree Way, Antioch, CA 94509 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT To be deter-maimned,. t V. Code Sec. 910.2 provides: "The claim must be signed by the claimant SEND NOTICES T0: ( tonne ) or by some person on his behalf." Name and Address ra dd&O ne��c�,°� ; BROOKMAN & 1990 N. California Blvd. , 4`0— RkWMkW_*A ttorney for Claiman Walnut Creek., CA 94596 � ALAN M. TALBO , X � P Telephone No. 510-932-4008 Telephone No. 510-932-4008 s f e s f • e e f f e f f e s f * e NOTICE Section 72 of the Penal Code provides: 4 "Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city or district board or officer, authorized to allow or pay the same if genuine, any false. or fraudulent claim, bill, .account, voucher, or writing, is punishable either by imprisonment in the county jail for a period of not more than one year, by a fine of not exceeding one thousand ($1,000), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($109000, or by both such imprisonment and fine. ATTACHMENT A Claim of Candice Jayne against the County of Contra Costa 3. Claimant was in her 1989 Chrysler LeBaron vehicle, travelling southbound on Ione Tree Way in Antioch, California and was stopped for a.red light on Lone Tree Way, at its intersection with the westbound Highway 4 on-ramp. When the light turned green, claimant could not go forward because of stopped traffic ahead. At that time and place, claimant was rear-ended by a certain vehicle, make and year unknown, which was and is owned by the County of Contra Costa and was being driven and operated by James B. Perez, employee of Contra Costa County. .3, c.�o yJ I " 12' - I cc �.� {`� of� z \m X co c <50 o T N Al m NZ *� CoYj O O CD T 21 13 71 5 u o o m c-3 v n > z z W N L m O { o OI rI r ,`� O N a v' m P. U) m m I �> n �' a � � t ao y 67 0 0 o N.n. o m Ct a _o 0< p N 3 m I a � N i N N m -0 E; ° b N F N G 7 N CD I'D "IN a o 0 I OI DI OI D<i I I~ \ D m •y� % v11� >` N(� m Wit^ m Ulm I I O mCmm` _. i N C7 >.--- -- --- --- -- +r�-- ��-- -- -- -- -- -- -- -- -- -- -- -- -- -- - m9 C R. .._ G �� 1 1 PROOF OF SERVICE BY MAIL -- CCP, &2015.5 & &1013(a) 2 3 I, the undersigned, declare under penalty of perjury of the laws of the State of California: 4 That I am a citizen of the United States and over the age of eighteen years; that I am not a party to the within action or proceeding; that my business address is 1990 N. California 5 Boulevard, Suite 740, Walnut Creek, California 94596; that on the date set forth below I served a true copy of: 6 CLAIM AGAINST THE COUNTY OF CONTRA COSTA 7 8 9 by depositing said copy in the United States Mail, at Walnut Creek, California, in a sealed 10 envelope, postage thereon prepaid, addressed as follows: 11 12 Clerk Board of Supervisors 13 651 Pine Street, Room 106 Martinez, CA 94553 14 VIA CERTIFIED MAIL - RETURN RECEIPT REQUESTED 15 16 17 18 19 20 21 At said time, there was regular delivery of the United States Mail between said places of deposit 22 and address(es). 23 Executed at Walnut Creek, Contra Costa County, California, on September 20, 1994. 24 25 26 SHARON HANNEY 27 28