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HomeMy WebLinkAboutMINUTES - 11142006 - C.37 (3) • H aserJet 3100 SEND CONFIRMATION REPORT for rinter/Fax/Copier/Scanner TASSAJARA VLY RE 9256483279 Apr-26-06 12:07PM Job Start Time Usage Phone Number or ID Type Pages Mode Status 300 4/26 12:06PM 0'56" 9388040.......................... Send.............. 3/ 3 EC144 Completed........................................ Total 0156" Pages Sent: 3 Pages Printed: 0 P"-t- a Of 3 1pacuwnfG dou&x pA&e �Ys�l�t ��GL cPO6-c 6sq-1 a6.L �.� 938-goy E: N�4cc/Zl E NON 605 �7�S -d l-�6 ��"lveD PNoNE �uL �iQ�M 5M0 i. 75�-2> )104 �u,eiN6 rH� Fc.N�7e��-- �t�n76�7vr we- WA-5 iA2 �'a> V acs r0 /nRy a-- w10 p6 15> P�-?JD ova c cT�q S E- /06 w ? V16-4 ffZ.t2y��iD Yo�c ,�oc�F �.�u��eie�s l• � = _ `.s 5--c-1415,7-------- 67 c-c-0��_ _._ A--ru- ._ % uN-7-y May - ----- � ,�/ 1 �l 15 Lo 70 PL --------------- /r/lryJ��'ff pr Y�;67Y .t oc Y - f r� _ -17r�� v //o 74Z ----------- } .�Yf�lllwli➢MYb'Y�1MMMw.'";m.:............_—-- ,y r t� Jd FAXED FROM SYLVIA D. BELLECI FAX NUMBER 925 648-3279. P-SS>rooaD F3�ka�o2/qc C�hr�X- R�}1f�•�/D RSfq N/4, -) Soo-)A L woQKllZ9, -Y+�L QPWrA,t-S TO ' - oVD DATE FAX N , PAGES TO FOLLOW Y ITEMS FAXED: S in�e�u tvN � C L,q%v,2/E ,prJl�tSt ?��alslS9/bN TS F S O Gn„µt!& 0 �- li;,�-��ro�Gxv�- 0 K, !S of HENcn� _ OFFICE PHONE NUMBER 925 736-3500_ I, I 0 :pa}uTud sa6ed 9 :�uaS sa6ed lcZ,E Te;ol _ _p0180woo bb103 9 /9 pueS ..........................Ob088£6 ;£Z Z WdOb: l £Z/L 846 snTe�S apoW sa6ed ad j. 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BELLECI FAX NUMBER 925 648-3279 cCCo u wry �6f2vfC�S +�'o w�Ezv+�-r'o,eSH-� DE16 e.-R TyLE4 o To �}b DATE �y Zo zoo y FAX NUM.bV�i-aR�3 PAGES TO FOLLO ITEMS FAXED: "McuE' To dYF1E� �l�E rr PHONE NUMBER 925 2854801 r� a 0. _ t' F,�bw� �y vi w (3cc �eci P0 (3oK Pc 4-Z)- A-V C- N o7_ --- �� y—'c1e�(-z_ -- - X35-�------------------- CONTCOSTA GRIEVANCE MENTAL RA HEALTH HEAD TH S � Rylib REVIEW REQUEST SER EMENT SERVICES ICES OFFICE USE ONLY 1340 Arnold Dr.,Suite 200 y Martinez,CaAtom'ra Grievance No. �� (� : 94553-4634 Ph 925/957-5134 Daae Received Consumers who are unable to adequately resolve a decision,complaint or who disagree with a decision,including a request for a change of provider,may file a grievance by filling out this form. Your current Contra Costa County Mental Health services will NOT be adversely affected in any way by filing a grievance. SEE REVERSE SIDE OF THIS FORM FOR IMPORTANT INFORMATI N YOU SHOULD KNOW. Please Print or Type I � �a l I> IV( .j--Lt b LD 6 Z 1.The following Information is required to proceed with a grievance hearing: TODAY'S DATE `� f CLIENT NAME�J I� E 6"C) KQ' rI SK j wA 1 v505�5b eiRTHDATE NAME OF LEGAL GUARDIAN r ON BEHALF OF MINOR mv &N SAX V Eb L(= I-P it -7 CITY no Ri`x 117 q� , .L/P"lLUlLLE 64 L- 7 -- PHONE 057-1 Ft) I BEST TIME TO CALL Yrfm 4 - og- 2.Describe the reason(s)for filing a grievance. Be specific by Including names,dates,and time whenever possible. (Attach additional sheets if necessary.) GG % 3. Have you tried to resolve the problems)before filing a grievance? %)a,Yes. Please describe what you have done to try to resolve the problem and include the results. ❑ No. I have not made any prior attempt to resolve the problem(s). 4. What would you like to happen to resolve the grievance? 5. Please add anything else you would like us to know. You may attach additional pages. 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Please note the"WARNING" below. i Claimant: . FRANK BELLECI AND DIGA"I, ST NIREKA CRISIS CENTER SYLVIA BELLECI d ;; Attorney: UNKNOWN QCT1 s 2006 Address: 907 REDWOOD DRIVE COUNTY COUNSEL DANVILLE, CA 94506 MARTINEZ CALIF Amount: AN AMOUNT WITHIN THE By delivery to Clerk on: ; OCTOBER 16., 2006 JURISDICTION OF THE SUPERIOR COURT ATTORNEYS FEE IF ANY, ETC. Date Received: OCTOBER 16 , 2006 By mail, postmarked on:' HAND DELIVERED I. FROM: Clerk of the Board of Supervisors TO: . County Counsel Attached is a copy of the above noted Application to File Late Claim. DATED: OCTOBER 16/06 JOHN CULLEN, Clerk,By: zt!E6� DEPUTY II. FROM: County Counsel TO: Clerk of theiBoard of Supervisors ( ) The Board should grant this Application to File Late Claim (Section 911.6) (� The Board should deny this Application to File Late Claim (Section 911.6). DATED: lU'` 7-0� SILVANO B.MARCHESI, County Counsel,By: '� � DEPUTY III. BOARD ORDER By unanimous vote of Supervilsors present (Check one only) ( ) This Application is granted (Section 911.6). (� This Application to File Late Claim is denied (Section 911.6). I,cee'rtify that this a true and correct copy of the Board's Order entered in its minutes for this date. DATE�t/Gm,,Ab JOHN CULLEN, Clerk, By: DEPUTY WARNING (Gov. Code §911.8) If you wish to file a court action on this matter, you must first petition the appropriate court for an order relieving you from the provisions of Government Code Section 945.4 (claims presentation requirement). See Government Code Section 946.6. Such petition must be filed with the court within six (6) months from the date your apOication for leave to present a late claim was denied. 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. IV. FROM: Clerk of the Board TO: (1) County Counsel (2) County Administrator Attached are copies of the above Application. We notified the applicant of the Board's action on this Application by mailing a copy of this document, and a memo thereof has been filed and endorsed on the Board's copy of this�Claim in accordance with Section 29703. DATED/O,a"ra6t,y/1r/d-A JOHN CULLEN', Clerk,By: �s�` — DEPUTY V. FROM: (1) County Counsel (2) County Administrator TO: Clerk of the Board of Supervisors Received copies of this Application and Board Order. DATED: County Counsel,By: County Administrator, By: APPLICATION TO FILE LATE CLAIM FRANK& SYLVIA BELLECI PAGE 1. 907 REDWOOD DR. 10-12-06 DANVILLE, CA 94506 PHONE 925 736-3500 FAX 925 648-3279 CLERK OF THE BOARD OF SUPERVISORS RFC 651 PINE STREET MARTINEZ, CA 945538 CT-16- RE: 0RE: APPLICATION TO FILE LATE CLAIM o T90 0006 NIREKA CRISIS CENTER,AFFILIATE OF CCC q�sTpFq FOR LAURIE LONGO, DECEASED q�V�sO9s LATE CLAIM SHOULD BE GRANTED ON THE BASIS THAT, WE, P NTS, ON BEHALF OF OUR DAUGHTER LAURIE LONGO, WE FILED IN A TIMELY MANNER ON THE NIREKA SHELTER. WE ONLY KNEW ABOUT THE NIREKA SHELTER WHEN LAURIE WAS SENT THERE ON 3-18-06 AND DIED 3-21-06. WE DIDN'T KNOW ANYTHING ABOUT THE NIREKA SHELTER BEFORE THAT TIME. IT IS OUR UNDERSTANDING THAT MARIE MANN, COUNTY CONSERVATOR DIDN'T PASS ON ANY MEDICAL INFORMATION ABOUT LAURIE TO THE NIREKA SHELTER, WHEN MARIE MANN HAD LAURIE SENT TOO THE NIREKA SHELTER. NIREKA SHELTER, TONY TOLD US, PARENTS THAT, CINDY MAXRASO FROM CRESTWOOD PICKED UP LAURIE'S PERSONAL ITEMS FROM NIREKA SHELTER THE DAY LAURIE DIED, ONLY LAURIE'S CELL PHONE WAS LEFT BEHIND IN THE SAFE. LAURIE'S JEWELRY WAS MISSING SO WE COULD NOT PUT THE JEWELRY ON LAURIE FOR HER FUNERAL. MISSING WAS LAURIE'S GREEN SUITCASE AND TWO SHOPPING BAGS. WE NEVER RECOVERED LAURIE'S TOOTH BRUSH, HAIR BRUSH, COMB, BLOOD MONITOR, OVER COUNTER BREATH INHALER, JEWELRY AND OTHER PERSONAL ITEMS. WHY HER ITEMS WERE PICKED UP THE DAY SHE DIED IS STILL A MYSTERY. IF THE NIREKA HOUSE SHELTER WAS TOLD BY MARIE MANN ABOUT LAURIE'S SLEEP APNEA AND BLACKOUTS THEY SHOULD OF CHECKED ON LAURIE DURING THE EVENING WHILE LAURIE WAS SLEEPING, IT COULD HAVE PREVENTED LAURIE'S DEATH WE, PARENTS, DON'T KNOW IF NIREKA SHELTER TOOK PROPER PROCEDURES TO TRY TO REVIVE LAURIE THE DAY LAURIE DIED. WE, PARENTS WERE NOT TOLD THAT LAURIE HAD PASSED ON UNTIL WE TRIED TO CALL LAURIE AT THE NIREKA SHELTER ON 3-21-06 Z F K AND SYLVIA BELLECI LAURIE LONGO'S PARENTS FRANK& SYLVIA BELLECI PAGE 1. 907 REDWOOD DR 9-20-06 DANVILLE, CA 94506 925 736-3500 ATTENTION, TONY NIREKA CRISIS HOUSE AND SHELTER 1959 SOLANO WAY CONCORD, CA 94520 RE: LAURIE LONGO'S QUESTIONS UP TO AND INCLUDING 3-21-06. SOME THINGS ARE UN-CLEAR TO US, LAURIE'S PARENTS AND WOULD LIKE YOU TO ANSWER THE FOLLOWING QUESTION FOR WE CAN GET A CLEAR PICTURE OF WHAT TOOK PLACE UP TO LAURIE'S DEATH ON 3-21-06. 1. WHO CALLED THE NIREKA SHELTER FOR A BED FOR LAURIE? 2. WHAT DAY AND TIME WAS THE BED RESERVED FOR LAURIE? 3. DID ANYONE FROM THE CC COUNTY HOSPITAL NOTIFY YOU WHAT TIME TO EXPECT LAURIE WHEN DISCHARGED FROM THE CC HOSPITAL? 4. WHAT DAY AND TIME DID CCC HOSPITAL CALL YOU THAT LAURIE WAS COMING TO NIREKA SHELTER? 5. DID MARIE MANN CALL YOU THAT LAURIE WAS ON HER WAY TO NIREKA SHELTER FROM THE CCC HOSPITAL? 6. DID ANYONE NOTIFY YOU FROM CCC HOSPITAL ABOUT LAURIE'S BLACKOUTS, SLEEP APNEA, BROKEN RIBS, MENTAL DISABILITIES, FEARS AND PHOBIAS? 7. DID MARIE MANN, COUNTY CONSERVATOR NOTIFY YOU OF THE ABOVE? 8. WHO BROUGHT LAURIE TO THE NIREKA CRISIS/SHELTER FROM THE CC HOSPITAL? PAGE 2. 9. HOW DID THE 2 SHOPPING BAGS AND GREEN SUIT CASE GET TO THE SHELTER? 10. DID THE 2 SHOPPING BAGS AND GREEN SUIT CASE GET THERE WITH LAURIE OR BEFORE LAURIE GOT THERE NIREKA HOUSE? 11. DID LAURIE BRING THE 2 SHOPPING BAGS AND GREEN SUIT CASE UP THE HILL AND STAIRS WITHOUT HELP? 12. WHERE YOU ADVISED TO CALL CONSERVATOR OR ANYONE ELSE THAT LAURIE ARRIVED SAFELY? 13. WHAT WAS THE EXPECTED TIME FOR LAURIE TO STAY AT THE NIREKA SHELTER? 14. THAT IS THE AVERAGE TIME A PERSON CAN STAY AT THE NIREKA SHELTER? 15. WHAT DISCUSSION DID YOU HAVE WITH MARIE MANN OF HOW LONG LAURIE WAS TO STAY AT NIREKA? 16. DO YOU HAVE THE DISCHARGE PAPERS FROM THE CCC HOSPITAL TO NIREKA? 17. DURING THE DAY, WHO WERE THE DOCTORS/THERAPIST THAT SAW LAURIE AT NIREKA SHELTER? WRITE THE DOCTORS/THERAPISTS NAME AND PHONE NUMBERS. 18. LAURIE WAS RELEASED FROM THE CCC HOSPITAL THEN, WHY DID THE DOCTOR/THERAPIST GO TO THE NIREKA SHELTER? 19. WHAT WAS THE DOCTOR/THERAPIST NAME AND PHONE NUMBER, THAT SAW LAURIE THE NIGHT BEFORE SHE DIED? PAGE 3. 20. DID THE DOCTOR/THERAPIST GIVE LAURIE ANY MEDICINE ON SATURDAY, SUNDAY OR MONDAY? 21. WHO GAVE LAURIE HER MEDICATION TO TAKE? 22. WHAT DID THE DOCTOR/THERAPIST SAY OR DO FOR LAURIE? 23. WHAT DID DOCTOR/THERAPIST DO WITH THIS INFORMATION? 24. DID LAURIE COME WITH ANY TREATMENT PLAN FROM THE CCC HOSPITAL? 25. WHAT WAS THE TREATMENT PLAN FOR LAURIE? 26. ***** WHEN LAURIE ARRIVED AT THE NIREKA SHELTER DID YOU MAKE AN ACCOUNTING OF ALL LAURIE'S PERSONAL ITEMS? SEND US PARENTS A COPY OF THE ACCOUNTING. 27. DID LAURIE HAVE HER OVER THE COUNTER BREATH INHALER AND BLOOD TESTER DEVICE TO MONITOR HER BLOOD SUGAR? 28. WHAT MEDICATIONS DID LAURIE ARRIVE WITH? 29. DID LAURIE HAVE HER HIGH BLOOD PRESSURE PILLS WITH HER? 30. DID LAURIE HAVE HER THYROID OR DIABETES MEDICINE? 31. DID LAURIE HAVE ANY PAIN PILLS FOR HER BROKEN RIBS? PAGE 4. 32. DESCRIBED WHAT LAURIE'S COMMENTS WERE WHEN SHE ARRIVED AT THE NIREKA SHELTER FROM THE CCC HOSPITAL? 33. DID LAURIE DISCUSS THE DETAILS OF WHY SHE HAD TO LEAVE CRESTWOOD AND WAS SENT TO THE NIREKA SHELTER FROM THE CCC HOSPITAL? 34.WHAT DID LAURIE DISCUSS WITH YOU FROM 3-18-06 TO 3-21-06 35.WHAT DID LAURIE DO WITH HER TIME FROM 3-18-06 TO 3-21-06? 36. DO OTHER PEOPLE HAVE THE SAME EXPERIENCE AS LAURIE, BEING SENT TO CCC HOSPITAL, THEN THE COUNTY CONSERVATORS MAKES THEM HOMELESS, AND THEN SEND THEM TO THE NIREKA SHELTER? 37. HOW OFTEN DOES THIS ACCRUE? 38. DID MARIE MANN, CONSERVATOR SEE OR CALL LAURIE WHILE LAURIE WAS AT THE NIREKA SHELTER BEFORE LAURIE DIED? 39.DID LAURIE TELL YOU THAT LAURIE'S PARENTS WERE TRYING TO HAVE A MEETING WITH CONSERVATOR AND CASE MANAGER TO GET LAURIE BACK TO CRESTWOOD? 40. DESCRIBED WHAT LAURIE TOLD YOU? 41. WHAT TIME DID LAURIE GO TO BED ON 3-20-06? 42. WHAT TIME WAS LAURIE'S LAST BED CHECK? 43. WHAT TIME WAS THE BED CHECK BEFORE THE LAST BED CHECK? PAGE 5. 44. WHAT IS THE PERSONS NAME WHO MADE THE LAST BED CHECK FOR LAURIE? 45. WHAT DOES ONE DO TO MAKE A BED CHECK? 46. WHAT TIME DOES EVERYONE GET UP IN THE MORNING? 47. WHAT TIME WAS LAURIE FOUND DEAD? 48. WHO FOUND LAURIE? 49. WHO DID THEY CALL FIRST WHEN LAURIE WAS FOUND DEAD? 50. WHAT DID ANY ONE DO TO TRY TO REVIVE LAURIE? 51. WHAT TIME WAS THE AMBULANCE CALLED? 52. WHAT TIME WAS A DOCTOR CALLED? 53. WHEN WAS CRESTWOOD CALLED? 54. WHAT TIME WAS THE COUNTY CONSERVATOR MARIE MANN CALLED? 55. WHY DIDN'T ANYONE CALL LAURIE'S PARENTS? WE FOUND OUT BECAUSE WE CALLED TO TALK TO LAURIE. 56. DID MARIE MANN GIVE YOU US, PARENTS PHONE NUMBER YO CA„ IN CASE OF AN EMERGENCY? PAGE 6. 57. WHEN US PARENTS CAME TO PICKUP LAURIE'S JEWELRY FOR THE FUNERAL AND HER PERSONAL ITEMS. YOU SAID, "CINDY FROM CRESTWOOD ALREADY PICKED UP LAURIE'S ITEMS." THE ONLY ITEMS AT THE NIREKA SHELTER WAS LAURIE'S CELL PHONE, BECAUSE IT WAS IN THE SAFE. WHERE WAS HER MEDICATION, OVER THE COUNTER BREATHING INHALER AND BLOOD MONITOR? 58. DID YOU CALL MARIE MANN TO PICKUP LAURIE'S ITEMS 59. DID YOU CALL CINDY TO COME TO THE NIREKA SHELTER TO PICK UP LAURIE'S ITEMS? 60. DID CINDY FROM CRESTWOOD CALL YOU TO PICK UP LAURIE'S ITEMS? 61. WHAT WAS CINDY'S REASONING TO PICK UP LAURIE'S ITEMS? 62. DID CINDY TELL YOU WHAT SHE WAS GOING TO DO WITH LAURIE'S ITEMS? 63. WERE YOU TOLD BY MARIE MANN OR ANYONE ELSE TO CHECK ON LAURIE WHEN SHE WAS SLEEPING, BECAUSE SHE COULD STOP BREATHING OR HAVE BLACKOUTS? THIS COULD HAVE SAVED HER LIFE? CC: BOARD OF SUPERVISORS, COUNTY COUNSEL. DISTRICT ATTORNEY APPLICATION TO FILE LATE CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA ew mill BOARD ACTION NOVEMBER 14 , 2006 Application to File Late Claim ) NOTICE TO APPLICANT Against the County, Routing ) The copy of this document mailed to you is your Endorsements, and Board Action.) notice of the action taken on your application by (All Section References are to ) the Board of Supervisors (Paragraph III, below), California Government Code.) ) given pursuant to Government Code Sections 911.8 and 915.4. Please note the"WARNING"below. ry `�d Claimant: AKIM T. HENDERSON & FAMILY D : � +� ` Attorney: UNKNOWN ) OCT 1 7 20006 Address: 6214 RALSTON AVENUE COUNTY CALIF. RICHMOND, CA 94805 OCTOBER i8 2006 Amount: UNKNOWN By delivery to Clerk on: , I Date Received: OCTOBER 18 , 2006By mail,postmarked on:! HAND DELIVERED I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above noted Application to File Late Claim. DATED: OCTOBER 18 , MON CULLEN, Clerk,By: DEPUTY II.`' _ FROM: County Counsel TO: Cl rk of thejBoard of Supervisors ( ) The Board should grant this Application to File Late Claim (Section 911.6) ( The Board should deny this Application to File Late Claim (Section 911.6). DATED: SILVANO B. MARCHESI, County Counsel,By: M �►�_ DEPUTY III. BOARD ORDER By unanimous vote of Supervisors present (Check one only) ( ) This Application is granted (Section 911.6). ( ) This Application to File Late Claim is denied (Section 911.6). I,'cce/ertify that this a true and correct copy of the Board's Order entered in its minutes for this date. DATE;/�'�vJOHN CULLEN', Clerk, By: DEPUTY WARNING (Gov. Code §911.8) If you wish to file a court action on this matter, you must first petition the appropriate court for an order relieving you from the provisions of Government Code Section 945.4 (claims presentation requirement).See Government Code Section 946.6. Such petition must be filed with the court within six (6) months from the date your ap_lication for leave to present a late claim was denied. 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. IV. FROM: Clerk of the Board TO: (1) County Counsel (2) County Administrator Attached are copies of the above Application. We notified the applicant of the Board's action on this Application by mailing a copy of this document, and a memo thereof has been filed and endorsed on the Board's copy of this Claim in accordance with Section 29703. DATEr JOHN CULLEN', Clerk, By: DEPUTY V. FROM: (1) County Counsel (2) County Administrator T1* Clerk of the'board of Supervisors Received copies of this Application and Board Order. DATED: County Counsel,By: County Administrator,By: APPLICATION TO FILE LATE CLAIM --r- 6 ?6VX� 1; j Clerk of the Board of,Supervisors Contra John Cullen County Administration Building Costa Clerk of the Board 651 Pine Street,Room 106 and Martinez, California 9=1553-=1068 County County Administrator Jolui Gioia,District 1 (925) 335-1900 Gavle B.Uilkenta,District II Man,N.Piepho,District III Mark DeSauhtier,District IV F Federal D.Glover, District V •! ST'4 COUtI'- - TO: Akim T. Henderson & Family 6214 Ralston Avenue Richmond, CA 94805 RE: CLAIM OF AKIM T. HENDERSON & FAMILY NOTICE TO CLAIMANT OF LATE-FILED CLAIM (Government Code Section 911.3) The claim you presented to the Board of Supervisors of Contra Costa County, , California, as governing body of the County of Contra Costa on October 2, 2006, has been reviewed by Counter Counsel and is being returned to you herewith because: X Your claim relating to a cause of action for death or for injury to person or to personal property or growing crops was not presented within six months after the event or occurrence as required by law. (See Government Code sections 901 and 911.2.) Your claim relating to a cause of action for anything other than injury to person or to personal property or growing crops was not presented within one year after the event or occurrence as required by law. (See Government Code sections 901 and-911.2.) Because the claim was not presented within the time allowed by law, no action was taken on the claim. Your only recourse at this time is to apply without delay to the Board of Supervisors of Contra Costa County for leave to present a late claim. (See Government Code sections Akim T. Henderson & Family Re: Claims of Akim T. Henderson & Family Page Two 911.4 to 912.2, inclusive, and 946.6.) Under some circumstances leave to present a late claim will be granted. (See Government Code section 911.6.) You may seek the advice of an attorney of your choice in connection with this matter. If you desire to consult an attorney, you should do so immediately. Date:OCTOBER 12 , 2006 JOHN CULLEN, Clerk of the Board of Supervisors and County Administrator By: Ae� Deputy Clerk Enclosure CERTIFICATE OF SERVICE BY MAIL (Code Civ. Proc., §§ 1012, 1013a, 2015.5; Evid. Code, §§ 641, 664) 1 am a resident of the State of California and over the age of eighteen years, and not a party to the within action. My business address is Clerk of the Board of Supervisors, 651 Pine Street, Room 106, Martinez, CA 94553. On OCTOBER 12 , 2006 , I served a true copy of this Notice to Claimant of Late-Filed Claim by placing the document in a sealed envelope with postage thereon fully prepaid, in the United States mail at Martinez, California addressed to Akim T. Henderson & Family, 6214 Ralston Avenue, Richmond, CA 94805, as set forth above. I declare under penalty of perjury under the laws of the State of California and-the United States of America that the above is true and correct. Executed on OCTOBFR 12 _ 2006 at Martinez, California. Depu Clerk I:\TORT\RI S K-MG"I'\CLAIMS\L ATE\H enderson.wpd CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: Claim Against the County, or,District Governed by ) the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section refer c a' ,,, The copy of this document mailed to California Government Codes. you is your notice of the action taken on your claim by the Board of OCT 0 3 2006 10, Supervisors. (Paragraph IV below), COUNTY COUNSEL given Pursuant to Government Code AMOUNT: MARTINEZ CALIF Section 913 and 915.4. Please note all _ "Warnings". CLAIMANT: i-A�� } 1�e �i Yl klfvu�_ ATTORNEY: 11/fL� DATE RECEIVED: ADDRESS: rod +)n ►`11' BY DELIVERY TO CLERK ON: JCS 2- ue c, BY MAIL POSTMARKED: FROM: Clerk of the Board of Supervisors TO- County Counsel Attached isa copy of the above-noted claim. JOHN CULLEN, Dated: I dmb,�Jcllo By: Deputy ,_ II. FROM.: County Counsel TO: Clerk of the Board of Supervisors ( } This claim complies substantially with Sections 910 and 910.2. ( ) This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). (''Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). { } Other: Dated: ( 0-" 14-0(0 By: Y7Y7.C "2,, Deputy County Counsel III. ROM: Clerk of the Board TO: County Counsel (1) County Administrator(2) (VT Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present: ( ) This Claim is rejected in full. ( } Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: JOHN CULLEN, CLERK, By Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions,you have only six(6) months fi-orn 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 wide 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 MAILING I declare under penalty of perjury that C 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, hostage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated__- /4�� :!500 TN CULLEN, CLERK By���� e� 'Deputy Clerk BOARD OF SUPERVISORS OF CONTRA CO'ST'A COUNTY INSTRUC'T'IONS TO CLARdAN �. A claim relating to a cause of action for death or for injury to person or to personal property or growing crops shall be presented not later than six months after the accrual of the cause of action. A claim relating to any other cause of action shall be,presented not later than one year . after the accrual of the cause of action. (Gov. Code � 911.2.) 3. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 146, County Admiftistration Building, 651. Pine Street Martinez,CA 94553. �. If claim is against a district governed by the Board of Supervisors, rather than the County, the -name of the District should be filled in. 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. tt ii ttlttiitttttn■■!t= t■ta all Ka Ica IF. INN ttt ME ItMRMEN:aaIIzeXa aatIElltlet taI RE: Claim By. Reserved for Clerk's filing stamp R E ED'ED Against the County of Contra Costa.or ) OCT - 2 2oo6 District) CLERK BOARD flF SUPERVISORS (Fill in the name) )� CONTRA COSTA Co. The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the sum of$ A qAt� ;"h4 -J and in support of-this claim represents as follows: I. When did the damage or injury occur? (Give exact date and hour) 2. Where did the d age or injury occur? elude city and county) OOP � 1� Ay o ^ 3. How did the damage or injury occur? (Give full details;use extra paper if required) 4. What'particular act or omission on the part of count r or district officers, servants, or employees caused the injury or p4Wd age? �'�� - -t IDPId, / 06- ; , - pf 5 What are the names of county or district officers, servants, or employees causing the damage of injury? ��,rG ,-,- -P . r 6. What damage or injuries do your clam, resulted? (Give full extent of injuries or damages claimed. -Attach-two estimates'-for auto dama e. �'r ) 7. How was the unt claimed aboveco�d? (Include the estimated amount of any pros ective mimy or damage.) 1� 110,. 8. Namet d addre �sses o witnesses doctors and hos i� ' At 1 � 9. List the expenditures you ma&on account of this accident or injure: DATE TIME -AMOUNT agRaaraat taaaaaaSBat aaaa9 a 9miasma raasarstta■tat aaaaatarraa tcaRrc[Iltrata as acrr Iain tat ) .Gov. Code Sec. 910.2 provides "The claim shall be ) signed by the cl ' r by some person on his behalf." SEND NOTICES TO: (Attorney) Name and address of Attorney ) (Claimant's Signature) (Address) rl Telephone No. )Telephone No. 90 �� K's araaatscaaIan22aarrssrai =aaaaaaswas aaaaa9aassoaataa9aaaaaaaaaarassaIaaaaasasssasaaI PUBLIC RECORDS NOTICE: Please be advised that this claim form, or any claim filed with the County under the Tort Claims Act, is subject to public disclosure under the California Public Records Act. (Gov. Code, g§ 6500 et seq.) Furthermore, any attachments,addendums, or supplements attached to the claim form, including medical records, are also subject to public disclosure. t o was ass a a t a a r a a■a■t i a r a a ■=MR I*a t t a a a r a o s a f E a a a t a a a a t a t i r a a R a a t a a t t a t i a R a go a Stan a t a t t NOTICE: Section i2 of the Penal Code provides: Every person v&o, 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 dollars ($1,000.00), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000),or by both such imprisorunent and fine. Office of the Clerk of the Board of Supervisor CONTRA COSTA COUNTY 651 Pine Street, Room 106 Martinez, CA 94553 Phone: 925.335. 1900 Fax- 925.335. 1913 NOTICE OF CORRECTION TO RECORD Board Agenda Item No.: C• 37 Date: NOVEMBER 15 , 2006 Please note that the following correction was made to the record for this item: ON THE SPACE III "THIS APPLICATION TO FILE LATE CLAIM IS DENTED (Section 911. 6)lf THE BOX WAS NOT CHECK MARKED. PLEASE DESTROY ANY PREVIOUS E I ou S C PI O E S OF THIS RECORD O D AND REPLACE C THEM WITH THE E ATTA C NED APPLICATION TO FILE LATE CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA e. BOARD ACTION , Application to File Late Claim ) NOTICE TO APPLICANT NOVEMBER 14 2006 Against the County, Routing ) The copy of this document mailed to you is your Endorsements, and Board Action.) notice of the action taken on your application by (All Section References are to ) the Board of Supervisors (Paragraph III, below), California Government Code.) ) given pursuant to Government Code Sections 911.8 and 915.4. Please note the"WARNING"below. Claimant: ANTHONY BROWN Ex . "! Attorney: JOHN L. BURRIS , Esq. OCT 2 0 2006 LAW OFFICES OF JOHN L. BURRIS COUNTY COUNSEL Address: AIRPORT CORPORATE CENTRE MARTINEZ CALIF. 7677 OAKPORT STREET, SUITE 1120 Amount: OAKLAND, CA 94621 By delivery to Clerk on: OCTOBER 20 , 2006;: OVER $200,000. 00 I Date Received: OCTOBER 20, 2006 By mail,postmarked on: OCTOBER 19 , 2006 I. FROM: Clerk of the Board of Supervisors TO: . County Counsel Attached is a copy of the above noted Application to File Late Claim. DATED: OCT. 20, 20WHN CULLEN, Clerk,By: 14 DEPUTY II. FROM: County Counsel TO: CILfrk of thejBoard of Supervisors ( ) The Board should grant this Application to File Late Claim (Section 911.6) (.� The Board should deny this Application to File Late Claim (Section 911.6). DATED: 10"2-0-0cp SILVANO B. MARCHESI, County Counsel,By:e-n DEPUTY III. BOARD ORDER By unanimous vote of Supervisors present (Check one only) ' ( ) This Application is granted (Section 911.6). This Application to File Late Claim is denied (Section 911.6). I certify that this a true and correct copy of the Board's Order entered in its minutes for this date. DATE:/ JOHN CULLEN, Clerk, By: DEPUTY r WARNING (Gov. Code §911.8) If you wish to file a court action on this matter,you must first petition the appropriate court for an order relieving you from the provisions of Government Code Section 945.4 (claims presentation requirement).See Government Code Section 946.6. Such petition must be filed with the court within six (6) months from the date your ap0cation for leave to present a late claim was denied. 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. IV. FROM: Clerk of the Board TO: (1) County Counsel (2) County Administrator Attached are copies of the above Application. We notified the applicant of the Board's action on this Application by mailing a copy of this document, and a memo thereof has been filed and endorsed on the Board's copy of this Claim In accordance with Section 29703. DATED�dG v?16y/: VV_ JOHN CULLEN', Clerk,By: DEPUTY V. FROM: (1) County Counsel (2) County Administrator TW Clerk of the Board of Supervisors Received copies of this Application and Board Order. DATED: County Counsel,By: County Administrator, By: APPLICATION TO FILE LATE CLAIM LAW OFFICES OF JOHN L BURRIS John I.. Burris www.wohnburrislaw.com J John.BurrLs®JohnBurNsLaw.com Ben Nisenbaum Ben.Niscnbaum@JohnBurrisIaw.com Adante D. Pointer October 19, 2006 Adantc.Pointcr@johnBurrblaw.com REEVED Clerk of the Board of Supervisors OCT 2 0 2006 County Administration Building CLERK BDARD OF SUPERVISORS 651 Pine Street, Room 106 CONTRA COSTA CD. Martinez, CA 94553-4068 RE: Request to File a Late Claim Dear Board of Supervisors: This letter is to request filing of a "late claim" for Claimant, Anthony Brown. Attached, you will find the faxed copy of the claim request that we sent to your offices on September 27, 2006, which was on the six-month date. Mr. Brown have tried to get the police report and/or incident report from the Sheriff's department before filing the claim, in order to incorporate the name of the officer involved, but to no avail. Since those records have not been given to him, so we had no choice but to file the claim on his behalf on the 27tH We would appreciate your cooperation in this matter. Yours truly, THE LAW OFFICES OF JOHN L. BURRIS Maxine on Paralegal "Enclosures AIRPORT CORPORATE CENTRE • 7677 OARPORT STREET,SUITE 1120 • OAM AND,CA 94621 • TEL(510)839-5200 • FAX(510)839-3882 Clerk of the Board of Supervisors Contra John Cullen County Administration Building Costa Clerk of the Board 651 Pine Street.Room 106 and Martinez, California 94553-4068 County County Administrator Jolmi Gioia,District 1 (925) 335-1900 Gayle B.Uilkenia,District 11 Mary N.Piepho,District III Mark DeSautnier,District IV Federal D.Glover, District V TO: John L. Burris, Esq. Airport Corporate Centre 7677 Oakport Street, Suite 1120 Oakland, CA 94621 RE: CLAIM OF BROWN, ANTHONY NOTICE TO CLAIMANT OF LATE-FILED CLAIM (Government Code Section 911.3) The claim you presented to the Board of Supervisors of Contra Costa County, California, as governing body of the County of Contra Costa on September 28,' 2006, has been reviewed by County Counsel and is being returned to you herewith because: X Your claim relating to a cause of action for death or for injury to person or to personal property or growing crops was not presented within six months after the event or occurrence as required by law. (See Government Code sections 901 and 911.2.) Your claim relating to a cause of action for anything other than injury to person or to personal property or growing crops was not presented within one year after the event or occurrence as required by law. (See Government Code sections 901 and 911.2.) Because the claim was not presented within the time allowed, by law, no action was taken on the claim. Your only recourse at this time is to apply without delay to the Board of Supervisors of Contra Costa County for leave to present a late claim. (See Government Code sections J p John L. Burris, Esq. Re: Claim of Anthony Brown Page Two 911.4 to 912.2, inclusive, and 946.6.) Under some circumstances leave to present a late claim will be granted. (See Government Code section 911.6.) Date: OCTOBER 12 , 2006 JOHN CULLEN, Clerk of the Board of Supervisors and County Administrator By: Deputy Cle Enclosure CERTIFICATE OF SERVICE BY MAIL (Code Civ. Proc., §§ 1012, 1013a, 2015.5; Evid. Code, §§ 641, 664) 1 am a resident of the State of California and over the age of eighteen years, and not a party to the within action. My business address is Clerk of the Board of Supervisors, 651 Pine Street, Room 106, Martinez, CA 94553. On OCTOBER 12 , 2006 , I served a true copy of this Notice to Claimant of Late-Filed Claim by placing the document in a sealed envelope with postage thereon fully prepaid, in the United States mail at Martinez, California addressed to John L.Burris, Esq., Airport Corporate Centre, 7677 Oakport Street, Suite 1120, Oakland, CA 94621, as set forth above. I declare under penalty of perjury under the laws of the State of California and the United States of America that the above is true and correct. Executed on OCTOBER 12 , 2006 . , at Martinez, California. Z?6C4�� DeIKuty CI rk 1:\TOR'11RIS1<-MGT\CLAIMS\LATE\Brown,Anthony.wpd J i CLAIM 4 BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: Q( Claim Against the County, or District Governed by ) the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to, ) The copy of this document mailed to California Government Codes. ) you is your notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), given Pursuant to Government Code AMOUNT: Wer .�Z� 000,_ Section 913 and 915.4.Please note all l t "Warnings". CLAIMANT: SATQRNEY:JoII0 br tsi ESQ' DATE RECEIVED: r o28� uI :l :'' a-AbIIRESS: BY DELIVERY TO CLERK ON: q-aS-co CA qzy021 BY MAIL POSTMARKED: FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN CULLEN, C)ei, Dated: ^� By: Deputy H. FROM: County Counsel TO: Clerk of the Board of Supervisors O 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 91.1.3). O Other Dated: ���'"� `�O By: Y)'1(2,ga&y_Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administiator (2) (� Claim was returned as untimely with notice to claimant (Section 911.3). 1V. BOARD ORDER: By unanimous vote of the Supervisors present: O This Claim is rejected in full. O Other: I certify that this is a true and con-ect copy of the Board's Order entered in its minutes for this date. Dated: JOHN CULLEN, CLERK, By Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions,you have only six(6) nhontlrs from the date this notice was personally served or deposited in the n><il to file a eow-t action on this claim.See Government Code Section 945.6.You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney,you should do so immediately. *For Additional Warning See Reverse Side of This Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that 1. am now, and at all times herein'nrentioned, 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: V� ��-e, �. JOHN CULLEN, CLERK By eputy Clerk hep 2706 05: 12p LAW OFGS JOHN L.BURRIS 510 839-3982 p• 2 IKIMOF OYCMfM COSTA CMM A A cW=gddkg e*-&cam of sin Far de&cc far bdury q►pomal•to pamw prmww or g 61e proomW soot tater ttm sin mooft e ' do aoaW of the mm of I A eio im n WaS m ow o0w mm CC aWoR 80 ba: icor Iota*=000!>m year 4w otbe of d w r of ovation. (ON.0061911.x.) a Cia=mW be Siad with to CW&of the Bmd of Sqwa= at Its Am io Rom 106, , Cmmlr Adt*i*ift By D&&651 Pio Std Mm*m V,4A55.3. C, if else is$vima&tric4 pmewd by t11e 1i4oaad sof titiipavistas,other t31sa tttie+Coas><yy th+e ail 08 atom t*mu lie mw ia. D. 31 rile 4alm is qWAM tt ow peb&oft ulmW cWo>aoM be IM so=eat 1. h§A See peadty for buMM claws,bW is Sec.72 at to oeod offt fmmx. otv.rtemve#evvtpmasasnrOpOsniYffm000i#NimaagtmerOiitlwe*ays#dipvWen manages*fv**I RP: C1a#ol� �far t�+e�C's ►P � . &MONY. BROWN } �' � ._._._. RECEIVED I AV!mt*9Crmy of fCotxml Coft or ) SEP 2 8 2006 �SF DEPARTM'I i kuko) CLERK BOARD OF,.SiIPERVISORS i� mm) CONTRA COSTA CO. The to gid dMW bM* a!A►o the COW7 of C'RO66 COMW W dW abotianutll r @itcttiu 3e1 tilt�of�V ?.OQ,�OO olr�i>a a0ppot't of fide cLnist: e:ob ee folios: � 1. Wbm tlitl 6o do4 p oatt'Wwy ooml (din awt do a>sd 9 ow) SEE ATTAGCiMF.N'i' "A" 2 did 4be dome or*&q owO Modwk sod ) SF.F ATTACHMENT "A! - SEE A - SEE ATTACHMW "A." ; t 4. vu pw*Qw a%or owisd=ob 69 poste d onq of di"iot oiiiwsl MV0415,tv=*aYe + the ii�iey at damege'P . SEE ATTACHMENT "A" r 5 t$m tt d aor oiistrie,t o�icees. oa k o the SEE ATTACHMENT "A" , r t 510 839-3882 p'3 rep 27 OB 05s12p LRW OFCS JOHN L. BURRIS . C�c�s ro a�,►�� BOA"OF su"J"O"of COMA QWA COM A A aWn valaft I*a cavae of sad=ft dvA ar ft bdW io i er so PUMW popirty or qM tng Mps a'!ad!tee p vWWd M IRM &M sial as ; aft 63 WMW d*0 tames Of A datura vdMsng m 07 Omar CM Of Ad=&Q 3 a PrMMd SO tater?bare 00ft AW AW the mcow ostite mm of adtctt. (Ovt►.tide 1911)-) C,W= =x be 6W v t ft CWk of the grit of etVoM At its txfax in ll= W, , Ca"Aftft"MUISM&551 Fine ftmA.Mzfim C,k W53. C. If c,M is apbo a stet pvuwd 6Y Sts Dmd of ft 4m s,=dW*An Ike Cmaty,the taama of�}7�fricc s3t�td�Sgr�d Sa. I9. if t9te ctaittt b sit mm tm ono pd&en's, wpm 198ho s be its agimt 6wh IYOU Soft. E. S a4 penalty far frautt"sa&W%Etat Code Sec.73 a:ft and of ft fmL OQCagC Coact*oo00080 efoug Y000 O a Velma Otte 6099.0 ee 0000mo*Von COW$f t ANTl1,ONY BRAWN � ) Ap�timst tlto Comity o�'Ct�tai pE' � _ ;MltTFF n'F..PARIMMr MOW} in is amp) 7bo u4WVW tk=aaaat baeby mdW clam s9k4 ft CDiy Of d oma COM Of ttw acct!n tam QQ.=...amt attppat3 �tf9q ars �Ia L %=did dw dower b#yaeae {c+j0 atad&W=d. r;' SEE Ama r'Arr ; 2. Where didl*e dsm W or tart? ( 9 add SEE ATTACHMENT 3. 3�w tt'td tb dam tar tsa 'P t dais:ttse »if t SEE ATTA04XFN "A'r 4. MW peeDittnw as Oa:audsd=ttxa sate peat af'wmy a dwmct elft urvau,or"Puna" cawed dte atgtreyr ort3a,�a�e7 SEE ATTACHD'IENT `'A" 5 "m mftumu of 60asty rff d siatO aaeS.WYMIOL airawcym $* c3ass W as kGm SEE ATTAORAENT 'W Sep 27 '06 05: 12p LRW OFCS JOHN L.BURRIS 510 839-3882 p.4 ANTHONY BROWN V. CONTRA COSTA COUNTY LAW OFFICES OF JOHN L.BURRIS 7677 OAKPORT STREET,SUITE 1120 OAKLAND,CA 94621 (510)839--5200 ATTACHMENT"A" ',Claimisunt objects to the CONTRA COSTA C:OI INTY Claim Form because it requires information which constitutes an invasion of the Claimant's privacy and which is not required to be provided by the Claimant under California Government Code Section 910. ,k*oir example,Cal fornia Government Code Section 910 does cwt"uire that the Claimants ;provide their home and work numbers,driver's license number,date of birth,auto insurance name and poficy number,a diagram of the location of the incident,any statements by the Claimants as to their reasons"for believing the City is liable for your damages,"or a description of"all damages which you believe:you have incurred as a result of the incidenL" Therefore,Claimant submits the following information in support of hWher Tort Claim pursuant to Government Code Section 910: CLAIMANT'S NAME:ANTI34NY BROWN;BRITTANICA NIARKEE CLAIMANT ADDRESS:C/O LAW OFFICES OF JOI-trl I- Iii IRRIS,Airport Corporate Centre,7677 Oakport Strut,Oaklazzd,CA 94621 CLAIMANT TELEPHONE NUMBER:C/O LAW OFFICES OF JOHN L.BURRIS,ESQ, (510)839-5200 ADDRESS TO WHICH ALL NOTICES ARE TO BE SENT: LAW OFFICES OF JOHN L. BURRIS,Airport Corporate Centre,7677 Oakport Street,Suite 1120,Oakland,CA 94621 PLEASE NOTE:COUNSEL REPRESENTS CLAIMANT AND ALL CONTACT SHOULD BE MADE WITH HER ATTORNEY ONLY. DATE OF INCIDENT:March 27,2006 LOCATION OF INCIDENT:San Pablo Dam Road at Appian Way. "A.GENERAL VESURIMON OFTHE MEBTEDNESS,OBLIGATION,INJURY, DAMAGES OR LOSS INCURRED SO FAR AS IT MAY BE KNOWN AT THE TIME OF PRESENTATION OF THE CLAIM"AND"TAE NAME OR NAMES OF THE PUBLIC EMPLOYEE OR EMPLOYEES CAUSING THE I: AMY,DAMAGES,OR LOSS,IF KNOWN: [Per Government Code Section 9101: (DESCRIPTION OF INCIDENT: This incident took place on March 3,2006 on Sant Pablo Dam Read at Appian Way. At approximately 8:45 p.m.Anthony Brown and Britannica Markee crossed San Pablo Dam Road toward a grocery store on the other side of the roadway. As they approached the curb,a Contra THE LAW OFFICES OF JOHN L.BURRS Sep 27 '06 05: 13p LRW OFCS JOHN L.BURRIS 510 839-3882 p. 5 Mil KONY tsHUM V. CONTRA COSTA COUNTY Costa County Sherirs cruiser travelling westbound in excess of the posted 25 mile an hour speed limit struck Anthony Brown,while Britannica Markee had to dive to the side of the oadway,in order not to,get hit by the cruiser. The cruiser did not have emergency lights or :sirens activated. The cruiser struck Mr.Brown on his right side and caused him to be thrown into the air and onto the cruiser's hood. Mr.Brown bounced off the windshield and landed on the street where he lost consciousness. ,' When Mr. Brown regained consciousness,a sheriff was standing over him asking questions. Shortly thereafter,Mr.Brown was transported to John Muir Medical Cuter in Walnut Creels. Mr.Brown underwent surgery to repair numerous injuries includ ing fractures in his fight leg, right-side hip,acrd knreecaps. Iic sutTcmd bruising and abrasions on the whole of his right side, ,which had to be stitched. Mr.Brown missed more than three months of work DESCRIPTION OF CLAIM: Claimant alleges that the conduct of individual employees,agents and/or servants of the CONTRA COSTA COUNTY SHERIFF DEPARTMENT constitute I+odcral constitutional violations,which includes negligence,assault,battery,and negli�:ent infliction of emotional distress. Claimant alleges that individual employees,agents and/or servani.s of the CONTRA COSTA, COUNTY SHERIFF DF.PARTMF.NT are responsible for Claimant's injuries,and acts and/or omissions committed within the course or scope of employment tender the theory of respondeat superior. Respondeat superior liability includes but is not limited to,negligent training, supervi.iun,control and/or discipline. Individual employees,agents,and/or servants of the CONTRA C DSTA COUNTY,include but are not limited to,WARREN RUFF,head sheriff for the CONTRA COSTA,COUNTY SHERIFF DEPARTMENT,and DOES 1-100,and/or each of theft,individually and/or while acting in concert with one another. Claimant alleges that the assault included,but was not limited to,unwanted contact causing Claimant to experience a reasonable apprehension of immediate[armful or ofr'ensive contact likely to result in death or serious bodily injury. Claimant alleges that the battery included,but was not limited to, subjecting the Claimants to harmful or offensive contact with the intent to cause death or physical injury. Claimant alleges that negligence included,but was not limited to,breach of duty upon failing to exercise due care by placing others at risk of death,injury,or serious bodily harm. Claimant alleges that negligent infliction of emotional distress included,but was not limited to, negligent conduct,which placed the claimant within the zone of danger'of physical impact. The physical impact caused Claimant to reasonably suffer severe menal and emotional distress and attendant physical manif�stations. Claimants will allege other causes of action subject to continuing discovery. .THE LAW OFFICES OF JOHN L BURRl8 2 Sep 2706 05: 13p LOW OFCS JOHN L.BURRIS 510 838-3882 p. 6 r ANTHONY BROWN COMfFtl1 CUS'I'A=WY I} SCRIBE INJURY OR DAMAGE: Claimant has or may have in the future,claims for general damages,including,but not limited to•aclaim for pain,iii0aing and cmotioxW distress in amounts to be detezmined according to I3A M ,�ptug t ; Claimant may have and/or may continue to have in the future,claims for special damages, fj' f including,but not limited to,claims for medical and related expemvs,lost wages,damage to ' ' ; i nreer,damage to educational pursuits,damage to property and/or other Special damages in ; 'latniouhts to be Bete mined according to proof. Claimant may have,and/or may continue to have in the future,dannag ►for ptrxruuleart mental injuries,permanent mental scarring and/or other psychological disabilities in an amount :'according to proof NAME OF PUBLIC EMP'LOYEE(S).BELIEVED.TO HAVE CAUSED INJURY OR DAMAGE: See description of the incident,above. DEMAND FOR PRESERVATION OF EVIDENCE: Claimant does hereby denrmd that the CONTkA COSTA COUNTY SUPRIFF DF,PARTMENT including,but not iimite i'to,the CONTRA COSTA COUNTY SHERWF DEPARTMENT",its employees,servants and/or'attorneys,maintain and preserve all evidence,documents and tangible materials which relate in any manner whatsoever to the:.object mutter of this Claim, including until the completion of any and all civil and/or criminal.litigation arising from the ,events which are the subject matter of this Claim. This demand lbr preservation of evidence includes,but is not limiftdto a demand that all public safety-pf.ties preserve all tapes,logs and/or other tangible'r aierials of any kind until the completion c f any and all civil and criminal litigation arising from(lie subject matter of this claim. AMOUNT OF CLAIM: This claim is in excess of$200,000. '3uxisdiction is designated w "unlimited"and,jurisdiction would be in the United States District Court and/or Superior Court of the,.+ to of California for the County of Contra Costa. DATED: September 27,2OU4 /S/ CsAYLA LIBET.FSO. Attorney for Claimant THE LAW OFFICES OF JOHN L.BURRIS 3 Sep 2706 05: 12p LRW OFGS JOHN L. BURRIS 510 839-3882 P. 1 [IFAX p Wednesday, $epiember 21, 20(l6 e� Number of pages including cover sheel _5 LAW OFFICES OF MAXNE JOHN L. BURRIS FROM: PARI LEGALNSON, A rp; BOARD OF SUPERVISORS i. CONTRA GUSIA COUNTY" SEP 2 8Re; ANTHONY BROWN Phone (510)839-5200 Fax Phone (510)839-3882 Phone (925)335-1900 FAX (925)335-1076 PHONE.- REUARKS: ® Urgent ® FOr your review flap►y A SAP Please Comment NOTE: 77416 FACSMILE TRANSMISSION ORGINA TES FROM THE LAW OFFICES OF JOHN L.BURRIS. IF'THERE ARE ANY PROBLEMS PLEASE CALL(510)839-5200. j,ONFIDENT7AL!TY NOTICE_ THIS FACSIMILE TRANSMISSION MAY CONTAIN CONFIDEN77AL INFORMATION, WHICH IS LEGALLY PRIVILEDGED. THIS INFORMATION IS INTENDED FOR THE ADDpESSEE. THIS IS TO NOTIFY YOU THAT ANY DISCLOSURE,COPYING,DISTRIBUTION OR USE OF ANY F THE INFORM477ON CONTAINED IN THIS 7 RANSMI SSION IS STRICTLY PROHIBITED, IF YOU HAVE RECEIVED THIS TR4NSMISS/ON IN ERROR,PLEASE IMMMEDIA7FLY NOTIFY US 8Y TELEPHONE AND MAIL THE ORIGINAL 7 RANSWSSION TO US, THANK YOU. RE: CLAIM FORM AGAINST THE CONTRA COSTA COUNTY SHERIFF DEPARTMENT V� NOMD OF SUMMISOU 0?tOWA4 Conk COIR DUM9V_Q_=6T A. A ckim rdating to a case of acdon for or lar kimy to pwan or pm"or gra' be pesenW no Batu ibansix of dw csm of wdOW A elm re$dWg to spy oto cmm of acboo 9W be not Ida tm one to , QfWr the WMW of the cam of aWov. (Guy.Code#9112.) B. Cly mug be Med sith t of tte Road of at i2s Offim in RDOM 1061 CMMY 'ai tr oo BUIlft 651 Pirle Stint, CA 945S3. C. if cw=is apim a district governed by the BoW 3uF= jxoxs, mther,fta w County,tae Ume ofte District 9XpAd be&led i& D. If ase CWM i8 againg Mon Ohm Ono puft sSVWU,claim mm be ffkd aglim Mcb < Imblic �. ZOP& Sea ty for ftdolat alp,P Cobs So„72 et ft rid Of tt fam Ot7a O©0001 gvp000gg0voptrti l{p ooWE7aofloS! gtSOQ$fl8g9CiG00(y0©©R©©Rmd OGO©00 00 O OOQ000Ef 0 goof 'a fl �y: hese€ fas Cl °s$Bad amp ' ANTHONY. BROWN K?,f..�... � " *9 County of Coum Coft or ) SHERIFF DEPARTMENT (Fell in do amq) } Ile wiped 49muW hmby clam 86=9 the CMIMy of Coats CoM a'ft above-named 4inde t in to om of$ Md.in SUPPMI of t 9 claim as fe lkmn: f did c o lY�j1u�o=e? {fie=ad SEE ATTACHMENT I died*e or city sed ya SEE ATTACHMENT "A" 3, Hour did to d or' ' (OWO N dgwg; extra Pam IfnVireo SEE ATTAC ITAVI { 4. t P ff set or omission oo the pw of county or digaict of emplayms sed SEE ATTA HMENT "A" 5 VAW tw mm of county og dwet afacm,SWVMM or amploym=AM the or lw SEE TTACHMENT "A" { _ OF SVWRWv-,,OR9 OF COMA CWTA A. A cbim rolating to-a emse of arAun Ifim demb oa for WWY to PMM W to P=MW pw m FvWag Mips sha be prmewed M Bated - Or mMft zft ft a=vd of the caww of ardm A clohn M4%to my oQa cam of amoo sbzU be prawaud aot hita So an year the ammW of'tbe emu of acdm (tea.Cede#9112-) B. claims MIM be MW -ath IW Oark of to R=d of gu at its offim in Ro= 1067 , CffWAy 'on BuU 651 P a '€ ,CA 94553. C, 1f didm is spiat a dict Vv=ed by the Soaxi of 6t s, z , ,Iae Dz d ate- �. 1f to eaku is VA=MM than ori putft c4ty, mum be Mcd qpM=b ' pubu E. eaft- EmA See pewhy ft ftddew daims,PerA Code Sm 72 at ft crA of ft,fam "Sf'SRmL1fla?^J^t7RIIe�S7�+a�^^�E��t�d�0�flv0C47SJGGQia^©v6aQcvC+P,2^C^..�fl^^-a^CvGt^et'45�:.�^'J,ece�da^^.iS . claim Dr: Rwc, f"Claws r5 ANTHONY BROWN Couay of Coutm Cost or SHERIFF DEPARTMENT 1 g, ) (Flu iu ft r1amc) l f' diode21n the M Of$t�v_ 2M.OOC} Md in suppco of tws claim 4 &4-qM&=z Ms fol L Wbim did tho dmmge or Wimy ( ) SEE ATTACHMENT "A►' 2. Where M*e dwmp or ir@ity m ) SEE ATTACHIfM "A" 3, Hoeg dad ft dwmp or Wuu==I (Oiw*daQs.=wra Pam if d ' SEE ATTACHMEN "A°' • f CI Met p s2 0c omission on the pm of cagy or asifict offimn., =Vam oa empa.-Yfts or SEE ATTACHMENT "A1° dMap o$b4 SEE ATTACHMENT { ANTHONY BROWN V. CONTRA COSTA COUNTY 'LAW OFFICES OF JOHN L. BURRIS 7677 OAKPORT STREET, SUITE 1120 OAKLAND,CA 94621 (510)839-5200 ATTACHMENT"A" Claimant objects to the CON'T'RA COSTA COUNTY Claim Form because it requires information which constitutes an invasion of the Claimant's privacy and which is not required to be provided by the Claimant under California Government Code Section 910. For example,California Government Code Section 910does not require that the Claimants provide their home and work numbers,driver's license number,date of birth,auto insurance name and policy number,a diagram of the location of the incident,any statements by the Claimants as to their reasons"for believing the City is liable for your damages,"or a description of" all damages which you believe you have incurred as a result of the incident." Therefore,Claimant submits the following information in support of his/her Tort Claim pursuant to Government Code Section 910: CLAIMANT'S NAME: ANTHONY BROWN; BRITTANICA MARKEE CLAIMANT ADDRESS: C/O LAW OFFICES OF JOHN L. BURRIS,Airport Corporate Centre, 7677 Oakport Street, Oakland, CA 94621 CLAIMANT TELEPHONE NUMBER: C/O LAW OFFICES OF JOHN L. BURRIS, ESQ. (510) 839-5200 ADDRESS TO WHICH ALL NOTICES ARE TO BE SENT: LAW OFFICES OF JOHN L. BURRIS,Airport Corporate Centre, 7677 Oakport Street, Suite 1120,Oakland, CA 94621 PLEASE NOTE: COUNSEL.REPRESENTS CLAIMANT AND ALL.CONTACT SHOULD BE MADE WITH HER ATTORNEY ONLY. DATE OF INCIDENT: March 27,2006 LOCATION OF INCIDENT: San Pablo Dam Road at Appian Way. "A GENERAL(DESCRIPTION OF THE INDEBTEDNESS,OBLIGATION,INJURY, DAMAGES.OR LOSS INCURRED SO FAR AS IT MAY BE KNOWN AT THE TIME OF PRESENTATION OF THE CLAIM"AND "THE NAME OR NAMES OF THE PUBLIC EMPLOYEE OR EMPLOYEES CAUSING THE INJURY, DAMAGES,OR LOSS,IF KNOWN: [Per Government Code Section 910]: DESCRIPTION OF INCIDENT: This incident took place on March 3,2006 on San Pablo Dam Road at Appian Way. At approximately 8:45 p.m. Anthony Brown and Britannica Markee crossed San Pablo Dam Road toward a grocery store on the other side of the roadway. As they approached the curb,a Contra THE LAW OFFICES OF JOHN L. BURRIS • . _ ANTHONY BROWN V. CONTRA COSTA COUNTY Costa County Sheriff's cruiser travelling westbound in excess of the posted 25 mile an hour speed limit struck Anthony Brown, while Britannica Markee had to dive to the side of the roadway,in order not to get hit by the cruiser. The cruiser did not have emergency lights or sirens activated. The cruiser struck Mr. Brown on his right side and caused him to be thrown into the air and onto the cruiser's hood. Mr. Brown bounced off the windshield and landed on the street where he lost consciousness. When Mr.Brown regained consciousness, a sheriff was standing over him asking questions. Shortly thereafter,Mr. Brown was transported to John Muir Medical Center in Walnut Creek. Mr. Brown underwent surgery to repair numerous injuries including fractures in his right leg, right-side hip, and kneecaps. He suffered bruising and abrasions on the whole of his right side, which had to be stitched. Mr. Brown missed more than three months of work. DESCRIPTION OF CLAIM: Claimant alleges that the conduct of individual employees,agents and/or servants of the CONTRA COSTA COUNTY SHERIFF DEPARTMENT constitute Federal constitutional violations,which includes negligence, assault,battery, and negligent infliction of emotional distress. Claimant alleges that individual employees, agents and/or servants of the CONTRA COSTA COUNTY SHERIFF DEPARTMENT are responsible for Claimant's injuries, and acts and/or omissions committed within the course or scope of employment under the theory of respondeat superior. Respondeat superior liability includes but is not limited to, negligent training, supervision, control and/or discipline. Individual employees, agents,and/or servants of the CONTRA COSTA COUNTY, include but are not limited to, WARREN RUPF,head sheriff for the CONTRA COSTA COUNTY SHERIFF DEPARTMENT, and DOES 1-100, and/or each of them,individually and/or while acting in concert with one another. Claimant alleges that the assault included,but was not limited to,unwanted contact causing Claimant to experience a reasonable apprehension of immediate harmful or offensive contact likely to result in death or serious bodily injury. Claimant alleges that the battery included, but was not limited to, subjecting the Claimants to harmful or offensive contact with the intent to cause death or physical injury. Claimant alleges that negligence included,but was not limited to,breach of duty upon failing to exercise due care by placing others at risk of death,injury,or serious bodily harm. Claimant alleges that negligent infliction of emotional distress included,but was not limited to, negligent conduct, which placed the claimant within the zone of danger of physical impact. The physical impact caused Claimant to reasonably suffer severe mental and emotional distress and attendant physical manifestations. Claimants will allege other causes of action subject to continuing discovery. THE LAW OFFICES OF JOHN L.BURRIS 2 ANTHONY BROWN V.. CONTRA COSTA COUNTY DESCRIBE INJURY OR DAMAGE: Claimant has, or may have in the future, claims for general damages, including,but not limited to,claims for pain, suffering and emotional distress in amounts to be determined according to proof Claimant may have and/or may.continue to have in the future, claims for special damages, including,but not limited to, claims for medical and related expenses, lost wages, damage to career, damage to educational pursuits, damage to property and/or other special damages in amounts to be determined according to proof. Claimant may have, and/or may continue to have in the future,damages for permanent mental injuries,permanent mental scarring and/or other psychological disabilities in an amount according to proof NAME OF PUBLIC EMPLOYEE(S)BELIEVED TO HAVE CAUSED INJURY OR DAMAGE: See description of the incident, above. DEMAND FOR PRESERVATION OF EVIDENCE: ,Claimant does hereby demand that the CONTRA COSTA COUNTY SHERIFF DEPARTMENT including,but not limited to, the CONTRA COSTA COUNTY SHERIFF DEPARTMENT, its employees, servants and/or attorneys,maintain and preserve all evidence, documents and tangible materials which relate in any manner whatsoever to the subject matter of this Claim, including until the completion of any and all civil and/or criminal litigation arising from the events which are the subject matter of this Claim. This demand for preservation of evidence includes,but is not limited to, a demand that all public safety entities preserve all tapes, logs and/or other tangible materials of any kind until the completion of any and all civil and criminal litigation arising from the subject matter of this claim. AMOUNT OF CLAIM: This claim is in excess of$200,000. Jurisdiction is designated as "unlimited"and jurisdiction would be in the United States District Court and/or Superior Court of the State of California for the County of Contra Costa. DATED: September 27,2006 /S/ GAYLA LIBET,ESQ. Attorney for Claimant THE LAW OFFICES OF JOHN L.BURRIS 3 0(0 Nd U 0 0 tC~U O ni' a 'f• \v�� ti d Cl 31 NO Q Q r^ar i W O H z ;> H � Q Pa H CO3 ::D �D 00 p U) P=1 l0 l0 } 0 I CID i p �T+ z-e--I C=) CJ� OOM Cy Q H Pi Ln�� Ln CQ O H E-i rn P-VC-) H w CD x H H U E� �E c/) CJI q fZ4 W N o zw x H 0.4 W 'DrgfY a o Ln U U U) H Q� O PY N . w (U • � N a � 4-1 z � � x U U) O � h N ^N 4j • �o C/) cd41 � w pU) rn U O r-4 }.a P < fs+ O O U O U P� k4 .-1 O cd w �4 x •� �o cu H � ^ O 4 AMENDED CLAIM BOARD OF SUPERVISORS OF.CONTRA COSTA-COUNTY BOARD ACTION: NOVEMBER 14 , 2006 Claim Against the County, or District Governed by ) the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references The copy of this document mailed to California Government Codes. D ) you is your notice of the action taken OCT 1 2006 on your claim by,the Board of Supervisors. (Paragraph IV below), COUNTY COUNSEL given Pursuant to Government Code MARTINEZ CALIF. Section 913 and 915.4. Please note all AMOUNT: $3 , 203 . 10 "Warnings". AT.,L STATE INDEMNITY COMPANY CLAIMANT: FOR: JULIE STEFFEN ATTORNEY: UNKNOWN DATE RECEIVED: OCTOBER 19 , 2006 ADDRESS: 3121 W. MARCH LANE, BY DELIVERY TO CLERK ON: OCTOBER 19 , 2006 SUITE 200 RECEIVED FROM STOCKTON, CA 95219 BY MAIL POSTMARKED: COUNTY mUNSFT FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN CULLEN, Cle Dated: OCTOBER 19 , 2006 By: Deputy II. FROM: County Counsel TO: Clerk of the Board of Sup isors (0- 'his 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). O Other: Dated: /D By m ®il/�- 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 ��tth/hii's date. Datec}�Odl����/ r JOHN CULLEN, CLERK, By Deputy Clerk v WARNING(Gov. code section 913) Subject to certain exceptions,you have only six(6)months from the date this notice was personally served or deposited in the mail to file a court action on this claim.See Government Code Section 945;6.You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney,you should do so immediately. *For Additional Warning See Reverse Side of This Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 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. I Datedlr/oJG 'dr'' JOHN CULLEN, CLERK By eputy Clerk I I I i I state® A I STOCKTON 3121 WEST.MARCH LANE, SUITE 200 STOCKTON CA 95219-2367 p g � You're in good hands. OCT 10 2000 COUNTY MARTINE®CALIF. KATHLEEN 0 CONNELL OFFICE OF THE COUNTY COUNSEL, ADMIN BLDG 651 Pine St, 9th Flr Martinez CA 94553-1229 October 17,2006 INSURED: JULIE STEFFEN PHONENUMBER: 800-240-3762 DATE OF LOSS: August 30, 2006 FAX NUMBER: 209-956-5305 CLAIM NUMBER: 3954777267 JDC OFFICE HOURS: Mon-Fri 8:00am-5:30pm YOUR CLAIM NUMBER:DOB 083006 YOUR INSURED: Contra Costa County Dear O CONNELL,KATHLEEN, Per your request,enclosed are the supporting damage documents for the above-mentioned claim.Total damages are $[3,203.10]. Payment should be submitted to:Allstate Payment Processing Center,PO Box 227257,Dallas TX 75222 with reference to our claim number. Thank you. Should you wish to discuss any aspect of this case including this letter,please call me at the number below,and refer to our claim number. Sincerely, I�,,X`f�V",N' 9ZROL L DAWN CARROLL 209-956-5339 Allstate Indemnity Company SUBP001 3954777267 JDC v A �oAPD of Ser?&,aBORSof CONTM CdST,A CO lN'STRUgTIONS TO CLAWAN-F •�-: ti.T w+o;'+^e-:a 210.-..___r..:•.+;.�„`?•.k t..f�.. A claim relaEng to a ca_rse of action for death or for itury to person or tope sohbl prbpibrty tax growing cops shall be presented not later than six months after the accrual, of the cause of action. A 61aim relating to my outer cause of action shall be,presenied not lam than one year after the aGcruat of the-cause of action. (Gov: Code § 911.2.) Claims mist be filed with. the Cleric of the Board of Supervisors at its offim in Room 106, CowatY A.dmitiislzation Btulding, 651 Pine Street;Wfa_*frne4 CA 94553. If claim is, against a di.Ls-trict governed by the Board of Supervisors, rather fly the County, the name of the District should be filled in. 3. If the clamis � Inst more than one public entity, separate claims miist be filed against each, public entity. :. Fraud. S de penalty for:a _71ent claims,Penal Code Sec.72 at the cad of this form. AlKnuawn:ft Rp"lC=81Rk KU if n U xxmx A C Cs z a 9:A IICLLBRIIiR RIN V a C Ia CC eL CiBLycflxg S mxzgzg x v FL CI �E: Clam By- Reserved for Clerk's Bing stamp Against the;Couni�of Contra.Costa.or ) District) (Fill is the name) )' _ The=dersi,gned clahnant hcreby alms claim zj6mst the County of Coma Costa or the above-named district in the suss,of S320 3,'d 0,-and in support of this claim represcuts as follows= . OT7CP L When did the damage or injury ocm=? (Give eaat date and hour) i 2. Where aid the doge or Wuryaccur`1 (Include cite and county) 3. T-lojwEd,�{t/i/. damage or i Jury occur? (Give�f9 deteils,;use�e�Jx}tai paper ifrt- ui d) (r) ' � V�CiC.+ {Y� C�� 'U(�,�(,.� Vim'.V i.L Lam't��'... I �E;�t��i'f`t.ti./G C.,S.. V V`.'✓" f�.�-<a” �'(.�C...C-r.. C.x-.6"l.lX-. C/v..-.,."� . i ni,c� Q r7v2 fir" 1�21'UtC 4. Whatw'particular anuct or oscion on the part of comt,�or district officers, smavants, Or employees caus:d;the injury or damage? A,5z4((,q 7b -5 - r S What are the names of cou aty or district offioeT;servants, or employees causing the damage or injury? C r-2:2_ce Z �_ 590 'ON J UW;,IVNVW Nq TN nn', } 1Nbat &niaige or injuries da year claim resulted? (Give fr�Ii exfeut of iajues or damages claimed: •Attach�two estimates for auto damage.) T, - `f Ye,r e r . -�y�v� � �-�' tru✓' i��re�s l�'`��t3���c��notL.. 7. How was the amnouct claimed above computed? (Include the estimated amount of any praspective injury or dzqinsae;) 4kle- car►-w•tt-� `f hay r Chef."Det c( Y� ar�'s rets ,Z(v2 � IQ, id t Ztv' It7 Gtr' QD , o a C JC, 0- 6 Q 1 tfA 75.00 -,Pt- S. N'ames_and addresses of�;ituesses, doctors, end ho pit t.- 9. List the ek}penditures you rnsde-on account of this accident or injury: I).A.`±E TB4F, AMOUNT 00 t r i;rLaila Caatolt aY�iQ(f�wIRaz 14'R ffVXKwa.Ziaaa[Iaat an aNgon ZWKIW9�11%-xv t KRUJI a R Yeo a KtRc61l KI i .Gov. Code Sec. 910.2 provides "The claim shall b-- signed esigned by the claimant or by some person on his behalf'; SFI M NOTICES TO, (Att , mev) Name and address of Attorney ) �g,� (Claimant Signature) 26d (Address) fig�5-2 Telephone 21'0;. )Telcghone hyo. r . x,aaatra Waaa Raaar Z l[rxataa=i a a a Q t E a a a A r a It r a w a a z I X I I a it a t a a i a a X a l a l X a a t a l It a a it a t a a It r K a PUBLIC RECORDS NOTICE: Please be advised diet this claim foz=�or my claim filed with the County under the Tort Clah s Act,is subject to public diselost= under the California. Public Records Act, (Gov. Code, 5s" 6500 et scq.) Furthermore, any attachmeuts,aiidendums, or supplements attached to the claim farm, including medical reeards,'are also subject to public disrlosire. �allYtalaaalQataaaataatalarRKMINIX azt[aaxaXILR aiaalar RaLatxa[aaaieaaaaEtaa KaalaR!<razarFxLS NOTICE: Section 72 of he Penal Cork provides: Every peron who, wfih kl--nt to d efmud, presents iar allowance or for payment to any stere board or off icer,'or to any =mt�- , city, or duct board or of icer, miffiorized to allow or pay the same if genuiae, any false or fraudulent claim,bill, acc mt voucher, or wrlfm& h punishable either by imprisonmemt in the County fail for a period of not more than one.year, by a fine of not exceeding one thousand dollars ($1,000.00), or by both such impriso=eat and fne, or by imprisonment in the state prison, by a fine of not 5%=6ing ten thousand dollars ($10,000),or by both-such imprisonment and fine. F G90 'nN IN�W�hHNt�W �SI}I �'l l WbZ�:R 9007 * REVIEW INVOICE SUMMARY *** FPL0200 PRO VENDOR : JICA JIM'S CALIF AUTO BODY, INC DATE OF LOSS: 08/30/06 ORIGINAL INVOICE : 0003257506 CLAIM # : 3954777267 CLMT ID: 01 LOG #: S01 GUST NAME: JULIE STEFFEN REPAIR COMP DATE : 09/20/06 VEHICLE: 98 740IL BMW ESTIMATE DATE: 09/06/06 DESCRIPTION UNITS/HRS RATE/PCT AMOUNT AM PARTS AMOUNT 33.00 OTHER PARTS AMOUNT 347.00 SUBLET/MISC AMOUNT 9.00 OTHER DISCOUNT AMOUNT 23. 39 SUBTOTAL 3016.46 TOTAL TAX 111 .64 TOTAL REPAIR COSTS 3128. 10 LESS DEDUCTIBLE 500.00 POLICY REGION: 40 POLICY ROC: 24 TOTAL REPAIR AMT : 3128. 10 POLICY NUMBER: 627125827 ADJUSTMENTS: 500.00 STATUS CODE : P {H=HELD, R= REJECT, P=PAY} NET INVOICE AMT : 1612 . 86 RSN: PF14=INDICATIVE PF15=AUDIT DETAIL PF2I =INV HISTORY DESK: JDC INVOLVED PERSON STATEMENT PAGE : 1 OF 1 395 477726 7 DOL : 08 - 30 - 2006 INSD: JULIE STEFFEN ID: 01 JULIE STEFFEN OWNER/DRIVER HOME PHONE: (925)676-7913 BUS PHONE: (925)890-4201 HRS: - STMT EMPL NAME: SYSTEM DATE : 09 - 02 - 2006 STATEMENT TYPE: PAY EFFECT ON INSD LIAB AND/OR CLMT DAMAGES: (O=NONE 1=FAV 2= UNFAV) NOTIFY: ANALYSIS: FCP CHECK REQ ISSUED. ISSUE DT:09/01 /06 . PROCESS DT:09/02/06 . TIME :06 :35:29 USER: L5D4 COV: DD AMOUNT : $ 1015.24 PAYEE NAME(S) : JULIE STEFFEN PAYEE ADDRESS: 250 MACGREGOR ST PLEASANT HILL CA 94523 COMPANY NAME: ALLSTATE INDEMNITY COMPANY CHECK NUMBER: 540021811 PAYMENT FOR COLLISION COVERAGE FOR LOSS OF 08/30/2006 CHECK POSTED TO SAP. DATE : 09/05/06 TIME : 18:29:00 PFS-SCHED F/U PF7-BACKWD PF8-FRWD PF9-PRINT PF11 -PREV STMT PF12-NEXT STMT *** THIS IS A SYSTEM GENERATED STATEMENT THAT CANNOT BE UPDATED *** DESK: JDC INVOLVED PERSON STATEMENT PAGE: 1 OF 1 395 477726 7 DOL: 08 - 30 - 2006 INSD: JULIE STEFFEN ID: 01 JULIE STEFFEN OWNER/DRIVER HOME PHONE: {925}676-7913 BUS PHONE: {925}890-4201 HRS: - STMT EMPL NAME: SYSTEM DATE: 08 - 31 - 2006 STATEMENT TYPE: PAY EFFECT ON INSD LIAB AND/OR CLMT DAMAGES: (O=NONE 1=FAV 2= UNFAV) NOTIFY: ANALYSIS: CHECK REQUEST ISSUED. ISSUE DT : 08/31 /06 TIME: 14: 12:37 USER: KRMO COV: DD AMOUNT: $ 75.00 MAIL-TO NAME: JULIE STEFFEN ,/ MAIL-TO ADDRESS: 250 MACGREGOR RD PLEASANT HILL CA 945231109 PAYEE : JULIE STEFFEN , CAR SEAT REPLACEMENT 11t CLAIM UNDER COLLISION COVERAGE ARISING FROM ACCIDENT ON 08/30/06 CHECK ISSUED. ISSUE DT: 08/31 /06 TIME: 17:49:24 CHECK NUMBER: 144075159 CHECK PRINTED. PRINT DT : 09/01 /06 TIME: 04 : 55:34 CHECK NUMBER : 144075159 PF5-SCHED F/U PF7-BACKWD PF8-FRWD PF9-PRINT PF11 -PREV STMT PF12-NEXT STMT *** THIS IS A SYSTEM GENERATED STATEMENT THAT CANNOT BE UPDATED *** 09/20/2006 AT 08:03 AM JOB NUMBER: 6322 13030 JIM'S CALIFORNIA AUTO BODY INC. LICENSE #:AF178743 FEDERAL ID #:942227228 EST. 1962 2520 MONUMENT BLVD. CONCORD, CA 94520 (925) 689-6117 FAX: (925) 689-7836 SUPPLEMENT OF RECORD 1 WITH SUMMARY WRITTEN BY: TOM Z 09/20/2006 08 :03 AM ADJUSTER: DD 13336920DVR09052 INSURED: JULIE STEFFEN CLAIM #3954777267-01 OWNER: JULIE STEFFEN POLICY #ALLSTATE INDEMNITY CO. ADDRESS: 250 MACGREGOR RD. DEDUCTIBLE: $500.00 PLEASANT HILL, CA 94523-1109 DATE OF LOSS: 08/30/2006 DAY: (925) 676-7913 TYPE OF LOSS: COLLISION BUSINESS: (925) 890-4201 POINT OF IMPACT: 6. REAR INSPECT JIM'S CALIFORNIA AUTO BODY INC. BUSINESS: (925) 689-6117 LOCATION: 2520 MONUMENT BLVD. CONCORD, CA 94520 INSURANCE ALLSTATE INSURANCE COMPANY COMPANY: 1025 CREEKSIDE RIDGE DR. 5 DAYS TO REPAIR ROSEVILLE, CA 95678 1998 BMW 740IL 8-4 .4L-FI 4D SED SILVER INT: VIN: WEAGJ8327WDM24927 LIC: 4WWU678 CA PROD DATE: 07/1998 ODOMETER: 117983 CONDITION: GOOD AIR CONDITIONING REAR DEFOGGER TILT WHEEL CRUISE CONTROL TELESCOPIC WHEEL INTERMITTENT WIPERS CLIMATE CONTROL KEYLESS ENTRY THEFT DETERRENT/ALARM DUAL MIRRORS ELECTRIC GLASS SUNROOF TRACTION CONTROL FOG LAMPS CLEAR COAT PAINT METALLIC PAINT POWER STEERING POWER BRAKES POWER WINDOWS POWER LOCKS POWER DRIVER SEAT POWER PASSENGER SEAT POWER MIRRORS POWER TRUNK/TAILGATE AM RADIO FM RADIO STEREO CASSETTE SEARCH/SEEK ANTI-LOCK BRAKES (4) DRIVER AIR BAG PASSENGER AIR BAG FRONT SIDE IMPACT AIR BAG 4 WHEEL DISC BRAKES LEATHER SEATS BUCKET SEATS AUTOMATIC TRANSMISSION OVERDRIVE ALUMINUM/ALLOY WHEELS ------------------------------------------------------------------------------- NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT ------------------------------------------------------------------------------- 1# Sol ESTIMATE COPY GIVEN TO 1 CUSTOMER. . . . . . . . . . . . . . . . . . . 24 *** PRO CONVERSION **** 1 3# DATE ASSIGNED:9/5T 1 4# DATE INSPECTED:9/5T 1 5# SOl DATE IN:9/14TH 1 6# SO1 DATE COMPLETE:9/20W 1 1 09/20/2006 AT 08:03 AM JOB NUMBER: 6322 13030 SUPPLEMENT OF RECORD 1 WITH SUMMARY 1998 BMW 740IL 8-4.4L-FI 4D SED SILVER INT: ------------------------------------------------------------------------------- NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT ------------------------------------------------------------------------------- 7 FRONT BUMPER 8 SO1 REPL BUMPER COVER 1 460.00 2.0 2 .0 9 SOl ADD FOR CLEAR COAT 0.8 10 SOl ADD FOR DISTANCE CTRL 0.4 11# SOl -NO CORES AVAILABLE/CORE NO 1 GOOD/LETTER ON FILE 12 REPL LICENSE MOUNT 1 47.00 0.3 13 FRONT LAMPS 14 REPL LT COMBO LAMP ASSY 1 28.50 0.6 15 FENDER 16* RPR LT FENDER-RUB TRANSFERS OFF * 0.1* 0.0* 17 REAR BUMPER 18**SO1 REPL RECOND BUMPER COVER PRIMED 1 347.00* 1.8 2 .2 19 ADD FOR CLEAR COAT 0.9 20 ADD FOR DISTANCE CTRL 0.4 21 REPL CENTER MOLDING W/PARK DIST 1 53 .25 0.3 CONTROL 22 ELECTRICAL 23 REPL SENSOR REAR BUMPER FROM 3/98 1 90.00 24# -RT INNER 1 25 REAR LAMPS 26** REPL A/M LT BRAKE LAMP BULB 1 1.00* 0.2 27 TRUNK LID 28* ALGN TRUNK LID & ADJUST OPERATION * 0.5* 29# RPR SET UP & MEASURE FRAME 1.5 F 30# RPR PULL/SQUARE RR END ASSY 1.5 31# REAR BODY & FLOOR 32 REPL CROSSMEMBER 1 101.00 4.5 0.8 33* RPR FLOOR PAN ASSY S 4.0* 1.0* 34 OVERLAP MINOR PANEL -0 .2 35 ADD FOR CLEAR COAT 0.2 36** REPL A/M CORROSION PROTECTION-PER 1 15.00 PANEL - 37** REPL A/M FLOOR SOUND DEADENER 1 10.00 0.1 38** REPL A/M FLEX ADDITIVE 1 7.00 39# TINT COLOR 1 0.5 40# REPL COVER CAR 1 6.00 41# SUBL HAZARDOUS WASTE 1 3.00 ------------------------------------------------------------------------------- SUBTOTALS =_> 1168.75 18.7 7.7 ------------------------------------------------------------------------------- ESTIMATE NOTES: SPOKE W/LINDA @ ALLSTATE-SHE CONFIRMED FRT END IS PART OF CLAIM 9/5T 3 :25PM! 2 09/20/2006 AT 08:03 AM JOB NUMBER: 6322 13030 SUPPLEMENT OF RECORD 1 WITH SUMMARY 1998 BMW 740IL 8-4.4L-FI 4D SED SILVER INT: PARTS 1168.75 PARTS DISCOUNT $ 779.75 -3.0% -23.39 BODY LABOR 17.2 HRS @$ 63.00/HR 1083.60 PAINT LABOR 7.7 HRS @$ 63 .00/HR 485.10 FRAME LABOR 1.5 HRS @$ 63 .00/HR 94.50 PAINT SUPPLIES 7.7 HRS @$ 27.00/HR 2,07.90 ---------------------------------------------------- SUBTOTAL $ 3016.46 SALES TAX $ 1353.26 @ 8.2500% 111.64 ---------------------------------------------------- GRAND TOTAL $ 3128.10 ADJUSTMENTS: DEDUCTIBLE 500.00 INSURER PREPAID AMOUNT 1015.24 --------------------------------------------------- CUSTOMER PAY $ 1515.24 INSURANCE PAY $ 1612.86 *****VISA MASTERCARD ATM - ACCEPTED FOR DEDUCTIBLE***** DUE TO MANY UNFORSEEN CIRCUMSTANCES IN THE REPAIRING OF AUTOMOBILES, WE REGRET THAT WE CAN ONLY ESTIMATE, NOT PROMISE A COMPLETION DATE AND TIME. 3 09/20/2006 AT 08:03 AM JOB NUMBER: 6322 13030 SUPPLEMENT OF RECORD 1 WITH SUMMARY 1998 BMW 740IL 8-4.4L-FI 4D SED SILVER INT: **** LESS APPLICABLE DEDUCTIBLE **** UNDER CALIFORNIA CODE OF REGULATIONS, TITLE 10, CHAPTER 5, SUBCHAPTER 8, SECTION 2695.8.D.2.C, YOU ARE ADVISED, THAT YOU HAVE THE RIGHT TO HAVE ANY REPAIR FACILITY OF YOUR CHOICE TO DO THE REPAIRS TO YOUR VEHICLE. HOWEVER, YOUR INSURANCE COMPANY CAN REASONABLY ADJUST ANY WRITTEN ESTIMATE PREPARED BY THE REPAIR SHOP OF YOUR CHOICE. IF YOU CHOOSE TO USE A REPAIR FACILITY SUGGESTED BY YOUR INSURANCE COMPANY THEY WILL GUARANTEE THE DAMAGE VEHICLE TO BE RESTORED TO ITS PRE-LOSS CONDITION AT NO COST TO YOU OTHER THAN AS STATED IN THE POLICY [IE. POLICY LIMITS OR DEDUCTIBLE] OR ALLOWABLE DEPRECIATION. IMPORTANT INFORMATION ABOUT ALLSTATE'S CHOICE OF PARTS POLICY THIS ESTIMATE MAY LIST PARTS FOR USE IN THE REPAIR OF YOUR VEHICLE THAT ARE MANUFACTURED BY A COMPANY OTHER THAN THE ORIGINAL MANUFACTURER OF YOUR VEHICLE. THESE PARTS ARE COMMONLY REFERED TO AS AFTERMARKET PARTS OR COMPETITIVE PARTS, AND WOULD BE DESIGNATED ON THIS ESTIMATE AS "QUAL REPL PARTS", "A/M" OR "COMP REPL PARTS" . SUCH PARTS MAY INCLUDE COSMETIC OUTER BODY CRASH PARTS SUCH AS HOODS, FENDERS, BUMPER COVERS, ECT. ALLSTATE GUARANTEES THE FIT AND CORROSION RESISTANCE OF ANY AFTERMARKET/COMPETITIVE OUTER BODY CRASH PARTS THAT ARE LISTED ON THIS ESTIMATE AND ACTUALLY USED IN THE REPAIR OF YOUR VEHICLE FOR AS LONG AS YOU OWN IT. IF A PROBLEM DEVELOPS WITH -THE FIT OR CORROSION RESISTANCE OF THESE PARTS, THEY WILL BE REPARIED OR REPLACED AT ALLSTATE'S EXPENSE. THIS GUARANTEE IS LIMITED TO THE REPAIR OR REPLACEMENT OF THE PART. HOWEVER, IF YOU CHOOSE TO NOT USE ONE OF THE AFTERMARKET/COMPETITIVE OUTER BODY CRASH PARTS THAT MAY BE LISTED ON THIS ESTIMATE IN THE REPAIR OF YOUR VEHICLE, ALLSTATE WILL SPECIFY THE USE OF THE ORIGNAL EQUIPMENT MANUFACTURER PARTS, EITHER NEW OR RECYCLED AT ALLSTATE'S OPINION, AT NO ADDITIONAL PRICE TO YOU. ALLSTATE DOES NOT SEPERATLY GUARENTEE THE PERFORMANCE OF ORIGINAL EQUIPMENT MANUFACTURER PARTS, AND MAKES NO REPRESENTATION ABOUT THE AVAILIBILITY OF ANY MANUFACTURER'S GUARENTEE. 4 09/20/2006 AT 08:03 AM JOB NUMBER: 6322 13030 SUPPLEMENT OF RECORD 1 WITH SUMMARY 1998 BMW 740IL 8-4.4L-FI 4D SED SILVER INT: FOR YOUR PROTECTION CALIFORNIA LAW REQUIRES THE FOLLOWING TO APPEAR ON THIS FORM: ANY PERSON WHO KNOWINGLY PRESENTS FALSE OR FRAUDULENT CLAIM FOR THE PAYMENT OF A LOSS IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN STATE PRISON. THE FOLLOWING IS A LIST OF ABBREVIATIONS OR SYMBOLS THAT MAY BE USED TO DESCRIBE WORK TO BE DONE OR PARTS TO BE REPAIRED OR REPLACED: MOTOR ABBREVIATIONS/SYMBOLS: D=DISCONTINUED PART A=APPROXIMATE PRICE LABOR TYPES: B=BODY LABOR D=DIAGNOSTIC E=ELECTRICAL F=FRAME G=GLASS M=MECHANICAL P=PAINT LABOR S=STRUCTURAL T=TAXED MISCELLANEOUS X=NON TAXED MISCELLANEOUS PATHWAYS: ADJ=ADJACENT ALGN=ALIGN A/M=AFTERMARKET BLND=BLEND CAPA=CERTIFIED AUTOMOTIVE PARTS ASSOCIATION D&R=DISCONNECT AND RECONNECT EST=ESTIMATE EXT. PRICE=UNIT PRICE MULTIPLIED BY THE QUANTITY INCL=INCLUDED MISC=MISCELLANEOUS NAGS=NATIONAL AUTO GLASS SPECIFICATIONS NON-ADJ=NON ADJACENT O/H=OVERHAUL OP=OPERATION NO=LINE NUMBER QTY=QUANTITY QUAL RECY=QUALITY RECYCLED PART QUAL REPL=QUALITY REPLACEMENT PART COMP REPL PARTS=COMPETITIVE REPLACEMENT PARTS RECOND=RECONDITION REFN=REFINISH REPL=REPLACE R&I=REMOVE AND INSTALL R&R=REMOVE AND REPLACE RPR=REPAIR RT=RIGHT SECT=SECTION SUBL=SUBLET LT=LEFT W/O=WITHOUT W1 =WITH/ SYMBOLS: #=MANUAL LINE ENTRY *=OTHER [IE. .MOTORS DATABASE INFORMATION WAS CHANGED] **=DATABASE LINE WITH AFTERMARKET N=NOTES ATTACHED TO LINE. MQVP=MANUFACTURER'S QUALIFICATION AND VALIDATION PROGRAM. OPT OEM=ORIGINAL EQUIPMENT MANUFACTURER PARTS EITHER OPTIONALLY SOURCED OR OTHERWISE PROVIDED WITH SOME UNIQUE PRICING OR DISCOUNT. THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF CRASH PARTS SUPPLIED BY A SOURCE OTHER THAN THE MANUFACTURER OF YOUR MOTOR VEHICLE. ANY WARRANTIES APPLICABLE TO THESE REPLACEMENT PARTS ARE PROVIDED BY THE MANUFACTURER OR DISTRIBUTOR OF THE PARTS, RATHER THAN BY THE ORIGINAL MANUFACTURER OF YOUR VEHICLE. 5 09/20/2006 AT 08:03 AM JOB NUMBER: 6322 13030 SUPPLEMENT OF RECORD I WITH SUMMARY 1998 BMW 740IL 8-4.4L-PI 4D SED SILVER INT: ESTIMATE BASED ON MOTOR CRASH ESTIMATING GUIDE. UNLESS OTHERWISE NOTED ALL ITEMS ARE DERIVED FROM THE GUIDE ERE1916 DATABASE DATE 09/2006, CCC DATA DATE 09/2006, AND THE PARTS SELECTED ARE OEM-PARTS MANUFACTURED BY THE VEHICLES ORIGINAL EQUIPMENT MANUFACTURER. OEM PARTS ARE AVAILABLE AT OE/VEHICLE DEALERSHIPS. OPT OEM (OPTIONAL OEM) OR ALT OEM (ALTERNATIVE OEM) PARTS ARE OEM PARTS THAT MAY BE PROVIDED BY OR THROUGH ALTERNATE SOURCES OTHER THAN THE OEM VEHICLE DEALERSHIPS. OPT OEM OR ALT OEM PARTS MAY REFLECT SOME SPECIFIC, SPECIAL, OR UNIQUE PRICING OR DISCOUNT. OPT OEM OR ALT OEM PARTS MAY INCLUDE BLEMISHED PARTS PROVIDED BY OEM'S THROUGH OEM VEHICLE DEALERSHIPS. ASTERISK (*) OR DOUBLE ASTERISK (**) INDICATES THAT THE PARTS AND/OR LABOR INFORMATION PROVIDED BY MOTOR MAY HAVE BEEN MODIFIED OR MAY HAVE COME FROM AN ALTERNATE DATA SOURCE. TILDE SIGN (-) ITEMS INDICATE MOTOR NOT-INCLUDED LABOR OPERATIONS. NON-ORIGINAL EQUIPMENT MANUFACTURER AFTERMARKET PARTS ARE DESCRIBED AS AM, QUAL REPL PARTS OR COMP REPL PARTS WHICH STANDS FOR COMPETITIVE REPLACEMENT PARTS. USED PARTS ARE DESCRIBED AS LKQ, QUAL RELY PARTS, RCY, OR USED. RECONDITIONED PARTS ARE DESCRIBED AS RECON. RECORED PARTS ARE DESCRIBED AS RECORE. NAGS PART NUMBERS AND BENCHMARK PRICES ARE PROVIDED BY NATIONAL AUTO GLASS SPECIFICATIONS. LABOR OPERATION TIMES LISTED ON THE LINE WITH THE NAGS INFORMATION ARE MOTOR SUGGESTED LABOR OPERATION TIMES. NAGS LABOR OPERATION TIMES ARE NOT INCLUDED. POUND SIGN (#) ITEMS INDICATE MANUAL ENTRIES. SOME 2006 VEHICLES CONTAIN MINOR CHANGES FROM THE PREVIOUS YEAR. FOR THOSE VEHICLES, PRIOR TO RECEIVING UPDATED DATA FROM THE VEHICLE MANUFACTURER, LABOR AND PARTS DATA FROM THE PREVIOUS YEAR MAY BE USED. THE PATHWAYS ESTIMATOR HAS A COMPLETE LIST OF APPLICABLE VEHICLES. PARTS NUMBERS AND PRICES SHOULD BE CONFIRMED WITH THE LOCAL DEALERSHIP. CCC PATHWAYS - A PRODUCT OF CCC INFORMATION SERVICES INC. 6 09/20/2006 AT 08:03 AM JOB NUMBER: 6322 13030 SUPPLEMENT OF RECORD 1 WITH SUMMARY 1998 BMW 740IL 8-4.4L-FI 4D SED SILVER INT: ------------------------------------------------------------------------------- NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT ------------------------------------------------------------------------------- ------- CHANGED ITEMS------- 3# DATE IN:9/11M 1 5# SOl DATE IN:9/14TH 1 4# DATE COMPLETE: 1 6# SOl DATE COMPLETE:9/20W 1 15** REPL RECOND BUMPER COVER PRIMED 1 -386.00 -1.8 -2 .2 18**SO1 REPL RECOND BUMPER COVER PRIMED 1 347.00* 1.8 2.2 ------- DELETED ITEMS------- 7** REPL RECOND BUMPER COVER 1 -362 .00 -2.0 -2 .0 8 ADD FOR CLEAR COAT -0.8 9 ADD FOR DISTANCE CTRL -0.4 40# *****OPEN-ADD. AFTER 1 TEARDOWN?***** ------- ADDED ITEMS ------- 1# SOl ESTIMATE COPY GIVEN TO 1 CUSTOMER. . . . . . . . . . . . . . . . . . . 8 SO1 REPL BUMPER COVER 1 460.00 2 .0 2.0 9 SOl ADD FOR CLEAR COAT 0.8 10 'SOl ADD FOR DISTANCE CTRL 0.4 11# SOl -NO CORES AVAILABLE/CORE NO 1 GOOD/LETTER ON FILE ------------------------------------------------------------------------------- SUBTOTALS =_> 59.00 0.0 0.0 -----------------=------------------------------------------------------------- ESTIMATE NOTES: SPOKE W/LINDA @ ALLSTATE-SHE CONFIRMED FRT END IS PART OF CLAIM 9/5T 3 :25PM! PARTS 59.00 PARTS DISCOUNT $ 460.00 -3 .0% -13.80 BODY LABOR 0.0 HRS @$ 63 .00/HR 0.00 PAINT LABOR 0.00 PAINT SUPPLIES 0.00 ---------------------------------------------------- SUBTOTAL $ 45.20 SALES TAX $ 45.20 @ 8.2500% 3.73 ---------------------------------------------------- TOTAL SUPPLEMENT AMOUNT $ 48.93 NET COST OF SUPPLEMENT $ 48 .93 ESTIMATE 3079.17 TOM Z SUPPLEMENT SO1 48.93 TOM Z -------- CUSTOMER PAY $ 1515.24 JOB TOTAL $ 3128.10 _ INSURANCE PAY $ 1612.86 7 09/20/2006 AT 08:03 AM JOB NUMBER: 6322 13030 SUPPLEMENT OF RECORD 1 WITH SUMMARY 1998 BMW 740IL 8-4.4L-FI 4D SED SILVER INT: *****VISA / MASTERCARD / ATM - ACCEPTED FOR DEDUCTIBLE***** DUE TO MANY UNFORSEEN CIRCUMSTANCES IN THE REPAIRING OF AUTOMOBILES, WE REGRET THAT WE CAN ONLY ESTIMATE, NOT PROMISE A COMPLETION DATE AND TIME. **** LESS APPLICABLE DEDUCTIBLE **** UNDER CALIFORNIA CODE OF REGULATIONS, TITLE 10, CHAPTER 5, SUBCHAPTER 8, SECTION 2695.8.D.2.C, YOU ARE ADVISED, THAT YOU HAVE THE RIGHT TO HAVE ANY REPAIR FACILITY OF YOUR CHOICE TO DO THE REPAIRS TO YOUR VEHICLE. HOWEVER, YOUR INSURANCE COMPANY CAN REASONABLY ADJUST ANY WRITTEN ESTIMATE PREPARED BY THE REPAIR SHOP OF YOUR CHOICE. IF YOU CHOOSE TO USE A REPAIR FACILITY SUGGESTED BY YOUR INSURANCE COMPANY THEY WILL GUARANTEE THE DAMAGE VEHICLE TO BE RESTORED TO ITS PRE-LOSS CONDITION AT NO COST TO YOU OTHER THAN AS STATED IN THE POLICY [IE. POLICY LIMITS OR DEDUCTIBLE] OR ALLOWABLE DEPRECIATION. IMPORTANT INFORMATION ABOUT ALLSTATE'S CHOICE OF PARTS POLICY THIS ESTIMATE MAY LIST PARTS FOR USE IN THE REPAIR OF YOUR VEHICLE THAT ARE MANUFACTURED BY A COMPANY OTHER THAN THE ORIGINAL MANUFACTURER OF YOUR VEHICLE. THESE PARTS ARE COMMONLY REFERED TO AS AFTERMARKET PARTS OR COMPETITIVE PARTS, AND WOULD BE DESIGNATED ON THIS ESTIMATE AS "QUAL REPL PARTS", "A/M" OR "COMP REPL PARTS" . SUCH PARTS MAY INCLUDE COSMETIC OUTER BODY CRASH PARTS SUCH AS HOODS, FENDERS, BUMPER COVERS, ECT. ALLSTATE GUARANTEES THE FIT AND CORROSION RESISTANCE OF ANY AFTERMARKET/COMPETITIVE OUTER BODY CRASH PARTS THAT ARE LISTED ON THIS ESTIMATE AND ACTUALLY USED IN THE REPAIR OF YOUR VEHICLE FOR AS LONG AS YOU OWN IT. IF A PROBLEM DEVELOPS WITH THE FIT OR CORROSION RESISTANCE OF THESE PARTS, THEY WILL BE REPARIED OR REPLACED AT ALLSTATE'S EXPENSE. THIS GUARANTEE IS LIMITED TO THE REPAIR OR REPLACEMENT OF THE PART. HOWEVER, IF YOU CHOOSE TO NOT USE ONE OF THE AFTERMARKET/COMPETITIVE OUTER BODY CRASH PARTS THAT MAY BE LISTED ON THIS ESTIMATE IN THE REPAIR OF YOUR VEHICLE, ALLSTATE WILL SPECIFY THE USE OF THE ORIGNAL EQUIPMENT MANUFACTURER PARTS, EITHER NEW OR RECYCLED AT ALLSTATE'S OPINION, AT NO ADDITIONAL PRICE TO YOU. ALLSTATE DOES NOT SEPERATLY GUARENTEE THE PERFORMANCE OF ORIGINAL EQUIPMENT MANUFACTURER PARTS, AND MAKES NO REPRESENTATION ABOUT THE AVAILIBILITY OF ANY MANUFACTURER'S GUARENTEE. 8 09/20/2006 AT 08:03 AM JOB NUMBER: 6322 13030 SUPPLEMENT OF RECORD 1 WITH SUMMARY 1998 BMW 740IL 8-4.4L-FI 4D SED SILVER INT: FOR YOUR PROTECTION CALIFORNIA LAW REQUIRES THE FOLLOWING TO APPEAR ON THIS FORM: ANY PERSON WHO KNOWINGLY PRESENTS FALSE OR FRAUDULENT CLAIM FOR THE PAYMENT OF A LOSS IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN STATE PRISON. THE FOLLOWING IS A LIST OF ABBREVIATIONS OR SYMBOLS THAT MAY BE USED TO DESCRIBE WORK TO BE DONE OR PARTS TO BE REPAIRED OR REPLACED: MOTOR ABBREVIATIONS/SYMBOLS: D=DISCONTINUED PART A=APPROXIMATE PRICE LABOR TYPES: B=BODY LABOR D=DIAGNOSTIC E=ELECTRICAL F=FRAME G=GLASS M=MECHANICAL P=PAINT LABOR S=STRUCTURAL T=TAXED MISCELLANEOUS X=NON TAXED MISCELLANEOUS PATHWAYS: ADJ=ADJACENT ALGN=ALIGN A/M=AFTERMARKET BLND=BLEND CAPA=CERTIFIED AUTOMOTIVE PARTS ASSOCIATION D&R=DISCONNECT AND RECONNECT EST=ESTIMATE EXT. PRICE=UNIT PRICE MULTIPLIED BY THE QUANTITY INCL=INCLUDED MISC=MISCELLANEOUS NAGS=NATIONAL AUTO GLASS SPECIFICATIONS NON-ADJ=NON ADJACENT O/H=OVERHAUL OP=OPERATION NO=LINE NUMBER QTY=QUANTITY QUAL RECY=QUALITY RECYCLED PART QUAL REPL=QUALITY REPLACEMENT PART COMP REPL PARTS=COMPETITIVE REPLACEMENT PARTS RECOND=RECONDITION REFN=REFINISH REPL=REPLACE R&I=REMOVE AND INSTALL R&R=REMOVE AND REPLACE RPR=REPAIR RT=RIGHT SECT=SECTION SUBL=SUBLET LT=LEFT W/O=WITHOUT W/ =WITH/ SYMBOLS: #=MANUAL LINE ENTRY *=OTHER [IE. .MOTORS DATABASE INFORMATION WAS CHANGED] **=DATABASE LINE WITH AFTERMARKET N=NOTES ATTACHED TO LINE. MQVP=MANUFACTURER'S QUALIFICATION AND VALIDATION PROGRAM. OPT OEM=ORIGINAL EQUIPMENT MANUFACTURER PARTS EITHER OPTIONALLY SOURCED OR OTHERWISE PROVIDED WITH SOME UNIQUE PRICING OR DISCOUNT. THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF CRASH PARTS SUPPLIED BY A SOURCE OTHER THAN THE MANUFACTURER OF YOUR MOTOR VEHICLE. ANY WARRANTIES APPLICABLE TO THESE REPLACEMENT PARTS ARE PROVIDED BY THE MANUFACTURER OR DISTRIBUTOR OF THE PARTS, RATHER THAN BY THE ORIGINAL MANUFACTURER OF YOUR VEHICLE. 9 09/20/2006 AT 08:03 AM JOB NUMBER: 6322 13030 SUPPLEMENT OF RECORD 1 WITH SUMMARY 1998 BMW 740IL 8-4.4L-FI 4D SED SILVER INT: ESTIMATE BASED ON MOTOR CRASH ESTIMATING GUIDE. UNLESS OTHERWISE NOTED ALL ITEMS ARE DERIVED FROM THE GUIDE ERE1916 DATABASE DATE 09/2006, CCC DATA DATE 09/2006, AND THE PARTS SELECTED ARE OEM-PARTS MANUFACTURED BY THE VEHICLES ORIGINAL EQUIPMENT MANUFACTURER. OEM PARTS ARE AVAILABLE AT OE/VEHICLE DEALERSHIPS. OPT OEM (OPTIONAL OEM) OR ALT OEM (ALTERNATIVE OEM) PARTS ARE OEM PARTS THAT MAY BE. PROVIDED BY OR THROUGH ALTERNATE SOURCES OTHER THAN THE OEM VEHICLE DEALERSHIPS. OPT OEM OR ALT OEM PARTS MAY REFLECT SOME SPECIFIC, SPECIAL, OR UNIQUE PRICING OR DISCOUNT. OPT OEM OR ALT OEM PARTS MAY INCLUDE BLEMISHED PARTS PROVIDED BY OEM'S THROUGH OEM VEHICLE DEALERSHIPS. ASTERISK (*) OR DOUBLE ASTERISK (**) INDICATES THAT THE PARTS AND/OR LABOR INFORMATION PROVIDED BY MOTOR MAY HAVE BEEN MODIFIED OR MAY HAVE COME FROM AN ALTERNATE DATA SOURCE. TILDE SIGN (-) ITEMS INDICATE MOTOR NOT-INCLUDED LABOR OPERATIONS. NON-ORIGINAL EQUIPMENT MANUFACTURER AFTERMARKET PARTS ARE DESCRIBED AS AM, QUAL REPL PARTS OR COMP REPL PARTS WHICH STANDS FOR COMPETITIVE REPLACEMENT PARTS. USED PARTS ARE DESCRIBED AS LKQ, QUAL RECY PARTS, RCY, OR USED. RECONDITIONED PARTS ARE DESCRIBED AS RECON. RECORED PARTS ARE DESCRIBED AS RECORE. NAGS PART NUMBERS AND BENCHMARK PRICES ARE PROVIDED BY NATIONAL AUTO GLASS SPECIFICATIONS. LABOR OPERATION TIMES LISTED ON THE LINE WITH THE NAGS INFORMATION ARE MOTOR SUGGESTED LABOR OPERATION TIMES. NAGS LABOR OPERATION TIMES ARE NOT INCLUDED. POUND SIGN W ITEMS INDICATE MANUAL ENTRIES. SOME 2006 VEHICLES CONTAIN MINOR CHANGES FROM THE PREVIOUS YEAR. FOR THOSE VEHICLES, PRIOR TO RECEIVING UPDATED DATA FROM THE VEHICLE MANUFACTURER, LABOR AND PARTS DATA FROM THE PREVIOUS YEAR MAY BE USED. THE PATHWAYS ESTIMATOR HAS A COMPLETE LIST OF APPLICABLE VEHICLES. PARTS NUMBERS AND PRICES SHOULD BE CONFIRMED WITH THE LOCAL DEALERSHIP. CCC PATHWAYS - A PRODUCT OF CCC INFORMATION SERVICES INC. 10 09/20/2006 AT 08:03 AM JOB NUMBER: 6322 13030 SUPPLEMENT OF RECORD 1 WITH SUMMARY 1998 BMW 740IL 8-4.4L-FI 4D SED SILVER INT: ALTERNATE PARTS SUPPLIERS 18 RECOND BUMPER COVER PRIMED PART NO. BM1100111 PRICE 347.00 FAITH BUMPER SERVICE (408) 986-1226 1085 DI GIULIO SANTA CLARA, CA 95050 11 09/20/2006 AT 08:03 AM JOB NUMBER: 6322 13030 SUPPLEMENT OF RECORD 1 WITH SUMMARY 1998 BMW 740IL 8-4.4L-FI 4D SED SILVER INT: ALTERNATE PARTS USAGE AFTERMARKET PARTS AFTERMARKET SELECTION METHOD: MANUALLY LIST NO. OF TIMES USER WAS NOTIFIED THAT AN AFTERMARKET PART WAS AVAILABLE: 2 NO. OF AFTERMARKET PARTS THAT APPEAR IN THE FINAL ESTIMATE: 4 12 W { i r ' �Y �i ''�r '�&���,r'�•�Ws++m�rr��i� .�a � w� - .�:¢�S �� try ::� �}.,�,, e.^�", .,. 4 . ' ' s N. SS 3i� yi Y'w Y' L "k. �'r Ly, ;, �-i K 'X ks"!no-.,AE•C.' fH ,S „"` �a�ya ���$may, � � '��}"�,q�}.�1. "i. �•: � �''$"�'d�y ._ �.� _, � OM x c s tom'.,E" r"' ". "i ,�-, < �x ". sy:t �'r€! i 7 .�� • � r if• gags' w , voy a.""".�'� .::'. "`.-.< ,.-r.Ew r,s,..;k+»x- ..sr,,,,,i, r `�'•Sa.c� g .y,.�� .� �� ....-r....�. .... • '� t �' :3 '✓<1 � of � -.-• »,...,,,� „_ r x�t,Tt`< $r'may "i°"�,�' z t �t WIT • •!_ r a_a. ,,,,,,is-x� _ i.. aw ''� ark.-;i' w.*r�•,;i' y~. �c�.k tCt�„e t C t -r�` '� ...r'a f�y.y - .hk` 'P Z 0000 �"� • t '• • '� r a� =xr+"��,h+c'"' ,fit !!•is ice. _ 1-,,. Y ?"�.� r� � is .;'� .. `9'�si �i --s� '•z ,� �e 7" ��; � 4�,. ,rte 3 K`s t _ r a, s Y—tj jp § EP 14 E 41 of • ••i••• �`i AIR` x fi. l g w 46 ng 1�`4 +'>`� c a r� a � + r a p� eyt ^i TM sr. + v e u ` x 4. g9- In AS „� �i i'�x ���� � "� x� '��vqa}�3. ,�� '��.z -�`� `.��, +r,�' �.,� r"°g* ' �g s�e;x ,z'a� � *�•. �-�' .� >•< -'�:a �°.' ,,�f� ,.� .r .�a. � r",.�. �' r� - �`° ,�� Aga 9I � �: Page 1 of 1 i^ k s F � � F F � b a Page 1 of 1 x , WU678 rr. Ij, ,ty'4 u. .x - a I L AM ti 'L yi- - tl M1 N: 4' F �1 €_ �" i x Page 1 of 1 --A'.-nSIA Am x r IT, '." a �r i r� k^. 4 �v y a , Page 1 of 1 � 4 r � b k t w ; Page 1 of 1 �N r. Ss 1 m � f �FF!", fw k ~ At— ,, ay�. rye .: ✓s: 3 F ..n,_ 1 nit 0 innnll • Page 1 of 1 101 six PERO a ,M s rs ar MAI,Y•35'�'�a„ t a s £ � � ni '" not .-a .. ,� w ,x' t a fl 3 :ram ai a k _ t s 1 Pf e 4 M � 4 Y,r.r �^wM�.s4.'•..at*�T^'e"a S :y S.. _ Page 1 of 1 µ -„Va �Y 2 3 t f Page 1 of 1 snow- 'Mal, V Y � ` s rut :3�•' JjK Lt, cel �w�� .+.p�. +wie3Hw^ k.3_ 's- .�f' 7. Jnr « cm .] n/1 0/lnnc �URNiryM�,�� STATE OF CALWORNIA V W� TkA, FFIC COLLISION REPOR� CHS'555 Page 1 (Rev.7-03)OPI 061 Page 1 of 6 SPECIAL CONDITIONS NUMBERHIT A RUN CITY JUDICIAL DISTRICT LOCAL REPORT NUMBER INJURED fELONV 0 ❑ PLEASANT HILL CONTRA COSTA 06004432-1 NUMBER KILLED HITS RUN COUNTY REPORTING DISTRICT BEAT MISDEMEANOR 0 CONTRA COSTA :3020 2 COLLISION OCCURRED ON MO. DAY YEAR TIME(2400) NCIC# OFFICER I.D. z CONTRA COSTA BL 8 / 30 /2006 11:34 0070900 307 OMILEPOST INFORMATION DAY OF WEEK TOW AWAY PHOTOGRAPHS BY: NONE Q � SMTHTFS ❑X YES � NO AT INTERSECTION WITH STATE HWY REL O El I R OR 200' FEET/MILES S OF GOLF CLUB RD ❑ YES XX NO PARTY DRIVER'S LICENSE NUMBER STATE CLASS AIRBAG SAFETY EQUIP, VEH,YEAR MAKE/MODEUCOLOR LICENSE NUMBER STATE A7719724 CA C M G 2003 FORD/TAURUS/GRY 1092637 CA ------------------------------------------------------ ­-­--------- --- ----------- DRIVER --------- --------------=------------------- DRIVER NAME(FIRST MIDDLE LAST) ❑X GRACE ELAINA CHRISTIANSEN OWNER'S NAME SAME AS DRIVER PEDES- STREET ADDRESS CONTRA COSTA CNTY*0389,GSD FLEET MGMT TRI❑AN 409 TRAI LH EAD WY OWNER'S ADDRESS � SAME AS DRIVER PARKED CITY/STATE/ZIP 2467 WATERBIRD WAY MARTINEZ,CA 94553 VEHICLE MARTINEZ,CA 94553 DISPOSITION OF VEHICLE ON ORDERS OF: OFFICER ® DRIVER [:] OTHER El Mo. OWN TOW BICY- SEX HAIR EYES HEIGHT WEIGHT BIRTHDATE RACE CLIST Mo. Day Year PRIOR MECHANICAL DEFECTS: 1:1F BRO BLU 508 140 10 / 9 / 1962 W X❑NONE APPARENT REFER TO NARRATIVE VEHICLE IDENTIFICATION NUMBER: OTHER HOME PHONE BUSINESS PHONE 707 685-2401 925 335-1600 VEHICLE TYPE JDESCRIBE VEHICLE DAMAGE SHADE IN DAMAGED AREA INSURANCE CARRIER POLICY NUMBER LINKNONE MINOR — CO.CO.CO. RISK MGMNT MOD.®MAJOR ROLL-OVER DIR OF TRAVEL ON STREET OR HIGHWAY SPEED LIMIT CA DOT N CONTRA COSTA BLVD 35 CAL-T TCP/PSC MC/MX — — PARTY DRIVER'S LICENSE NUMBERS TATE CLASS AIR SAG SAFETY EQUIP. VEH.YEAR MAKE/MODEUCOLOR LICENSE NUMBER STATE 2 U6148714 CA C M ! G 1998 BMW/7401L/GRY 4WWU678 CA ------ ------------------------ ---------- ------ DRIVER NAME(FIRST MIDDLE LAST) O JULIE MOFFATT STEFFEN OWNER'S NAME ® SAME AS DRIVER PEDES- STREETADDRESS TRI❑AN 250 MAC GREGOR RD OWNER'S ADDRESS O SAME AS DRIVER PARKED CITY/STATEZIP VEHICLE PLEASANT HILL,CA 94523 DISPOSITION OF VEHICLE ON ORDERS OF: OFFICER DRIVER OTHER ❑ RTO BICY- SEX HAIR EYES HEIGHT WEIGHT BIRTHDATE RACE CLIST Mo. Day Year PRIOR MECHANICAL DEFECTS: ❑ F BLN GRN 500 105 11 / 3 / 1970 W X❑NONE APPARENT REFER TO NARRATIVE VEHICLE IDENTIFICATION NUMBER: OTHER HOME PHONE BUSINESS PHONE 925 676-7913 925 890-4201 VEHICLE TYPE DESCRIBE VEHICLE DAMAGE SHADE IN DAMAGED AREA INSURANCE CARRIER POLICY NUMBER ❑ LINK ❑NONE ❑ MINOR — ALLSTATE 627125827 u MOD.[]MAJOR ❑ ROLL-OVER DIR OF TRAVEL ON STREET OR HIGHWAY SPEED LIMIT CA DOT N CONTRA COSTA BLVD 35 CAL-T TCP/PSC Mc/Mx — — PAR DRIVER'S LICENSE NUMBER STATE CLASS AIR BAG SAFETY EQUIP. VERYEAR MAKE/MODEUCOLOR LICENSE NUMBER STATE 3 D3100264 CA C M G 2003 HOND/CIVIC/BLU 5DGV264 CA ---- ------------- ---------------------------- --- --------- - ---- ------ DRIVER NAME(FIRST MIDDLE LAST) O ROSHAN JASON A PATEL OWNER'S NAME SAME AS DRIVER PEDES- STREETADDRESS AMRIT C PATEL TRI _ 5840 CORTE MARGARITA OWNER'S ADDRESS a SAME AS DRIVER ! -, PARKED CITY/STATE/ZIP ^�- VEHICLE PLEASANTON,CA 94566 DISPOSITION OF VEHICLE ON ORDERS OF: ❑OFFICER X'DRIVER ❑ OTHER ❑ RTO BICY- SEX HAIR EY�E� IGHT WEIGHT BIRTHDATE RACE CLIST Mo. Day Year PRIOR MECHANICAL DEFECTS: NONE APPARENT REFER TO NARRATIVE ❑ F BLK 507 140 6 / 5 / 1985 Z VEHICLE IDENTIFICATION NUMBER: OTHER HOME PHONE BUSINESS PHONE 925 484-5057 925 548-8880 VEHICLE TYPE DESCRIBE VEHICLE DAMAGE SHADE IN DAMAGED AREA INSURANCE CARRIER POLICY NUMBER LINK ❑NONE [X MINOR — PROGRESSIVE 62122770-1 MOD.❑MAJOR❑ ROLL-OVER DIR OF TRAVEL ON STREET OR HIGHWAY SPEED LIMIT CA DOT N CONTRA COSTA BLVD 35 CAL-T TCP/P MC/MX — — PREPARER'S NAME DI NOTIFIED REVIEWER'S�AME iyEEVIEVI(E—DSILLERS, CRAIG NIA (�f� data9l 1. , STATE OF CALWFORNIA TRAFFIC COLLISION CODING CHP 555 Page 2 (Rev.7-03)OPI 061 Page 2 of 6 DATE OF COLLISION(MO. DAY YEAR) TIME(2400) NCIC# OFFICER I.D. NUMBER 08/30/2006 11:34 0070900 307 06004432-1 OWNER'S NAME OWNER'S ADDRESS NOTIFIED PROPERTY []YES [X NO DAMAGE DESCRIPTION OF DAMAGE SEATING POSITION SAFETY EQUIPMENT INATTENTION CODES OCCUPANTS L-AIR BAG DEPLOYED M I C BICYCLE-HELMET A-CELLPHONE HANDHELD A A.-NONE IN VEHICLE M-AIR BAG NOT DEPLOYED DRIVER PASSENGER B-CELLPHONE HANDSFREE B-UNKNOWN N-OTHER V-NO X-NO C-ELECTRONIC EQUIPMENT C-LAP BELT USED P-NOT REQUIRED W-YES Y-YES D-RADIO I CD D-LAP BELT NOT USED E-SMOKING 1 2 3 1-DRIVER E-SHOULDER HARNESS USED F-EATING 2 TO 6-PASSENGERS F-SHOULDER HARNESS NOT USED CHILD RESTRAINT EJECTED FROM VEHICLE G-CHILDREN 4 5 6 7-STATION WAGON REAR G-LAP/SHOULDER HARNESS USED Q-IN VEHICLE USED 0-NOT EJECTED H-ANIMALS B-REA OCC,TRK.OR VAN H-LAP/SHOULDER HARNESS NOT USED R-IN VEHICLE NOT USED 1-FULLY EJECTED I-PERSONAL HYGIENE 9-POSITION UNKNOWN J-PASSIVE RESTRAINT USED S-IN VEHICLE USE UNKNOWN 2-PARTIALLY EJECTED J-READING 7 0-OTHER K-PASSIVE RESTRAINT NOT USED T-IN VEHICLE IMPROPER USE 3-UNKNOWN K-OTHER U-NONE IN VEHICLE ITEMS MARKED BELOW FOLLOWED BY AN ASTERISK 1')SHOULD BE EXPLAINED IN THE NARRATIVE. PRIMARY COLLISION FACTOR TRAFFIC CONTROL DEVICES 1 2 3 SPECIAL INFORMATION 1 2 3 MOVEMENT PRECEDING LAST NUMBER(#)OF PARTYAT FAULT I COLLISION VC SECTION VIOLATED: CITED 1 A []YES A CONTROLS FUNCTIONING A HAZARDOUS MATERIAL X X A STOPPED 22350 I-VC NJ NO B CONTROLS NOT FUNCTIONING' B CELL PHONE HANDHELD IN USE X B PROCEEDING STRAIGHT B OTHER IMPROPER DRIVING': C CONTROLS OBSCURED C CELL PHONE HANDSFREE IN USE C RAN OFF ROAD X D NO CONTROLS PRESENT/FACTOR' D CELL PHONE NOT IN USE D MAKING RIGHT TURN C OTHER THAN DRIVER' TYPE OF COLLISION E SCHOOL BUS RELATED E MAKING LEFT TURN D UNKNOWN- A HEAD-ON F 75 FT MOTORTRUCK COMBO F MAKING U TURN B SIDE SWIPE G 32 FT TRAILER COMBO G BACKING X C REAR END w H SLOWING/STOPPING WEATHER MARK 1 TO 21TEMS D BROADSIDE I I PASSING OTHER VEHICLE X A CLEAR E HIT OBJECT J J CHANGING LANES B CLOUDY F OVERTURNED K K PARKING MANEUVER I C RAINING G VEHICLE/PEDESTRIAN L L ENTERING TRAFFIC D SNOWING H OTHER': M M OTHER UNSAFE TURNING E FOG I VISIBILITY FT. I IN N XING INTO OPPOSING LANE F OTHER-: MOTOR VEHICLE INVOLVED WITH 1 10 O PARKED G WIND A NO -COLLI I P MERGING LIGHTING B PEDESTRIAN Q TRAVELING WRONG WAY X A DAYLIGHT X C OTHER MOTOR VEHICLE 1 2 3 OTHER ASSOCIATED FACTOR(S) R OTHER': B DUSK-DAWN D MOTOR VEHICLE ON OTHER ROADWAY I I (MARK 1 TO 21TEMS) C DARK-STREET LIGHTS E PARKED MOTOR VEHICLEA VC SECTION VIOLATION: CITED pAg ❑YES D DARK-NO STREET LIGHTS F TRAIN ❑NO E DARK-STREET LIGHTS NOT G BICYCLE -`; B VC SECTION VIOLATION: CITED FUNCTIONING' ' ❑VES H ANIMAL: ❑NO SOBRIETY-DRUG ROADWAY SURFACE C VC SECTION VIOLATION: CITED YES 1 2 3 PHYSICAL X A DRY I FIXED OBJECT: B NO (MARK 1 TO 21TEMS) �SNOWY D -s X X X A HADNOT BEEN DRINKING -ICY J OTHER OBJECT: E VISION OBSCUREMENT: B HBD-UNDER INFLUENCE Y(MUDDY,OILY,ETC.) F INATTENTION*: C HBD-NOT UNDER INFLUENCE ROADWAY CONDITION(S) G STOP&GO TRAFFIC D HBD-IMPAIRMENT UNKNOWN (MARK 1 TO 21TEMS) PEDESTRIAN'S ACTIONS H ENTERING/LEAVING RAMP E UNDER DRUG INFLUENCE' A HOLES DEEP RUT- X A NO PEDESTRIANS INVOLVED I PREVIOUS COLLISION FIMPAIRMENT-PHYSICAL' B LOOSE MATERIAL ON ROADWAY' B CROSSING IN CROSSWALK- J UNFAMILIAR WITH ROAD G IMPAIRMENT NOT KNOWN C OBSTRUCTION ON ROADWAY' AT INTERSECTION K DEFECTIVE VEH.EQUIP.: CITED H NOT APPLICABLE D CONSTRUCTION-REPAIR ZONE C CROSSING IN CROSSWALK-NOT ❑YES 'I SLEEPY/FATIGUED' E REDUCED ROADWAY WIDTH AT INTERSECTION QX NO F FLOODED' D CROSSING-NOT IN CROSSWALK L UNINVOLVED VEHICLE G OTHER': E IN ROAD-INCLUDES SHOULDER IM OTHER': X H NO UNUSUAL CONDITIONSF NOT IN ROAD X X X N NONE APPARENT G APPROACHING I LEAVING SCHOOL BUS O RUNAWAY VEHICLE SKTCH ! MISCELLANEOUS,. - ^, g13616(, II`,d 6W& arc. C.S� ae1.01 I Inn 00 STATE OF CALTORNIA -.� INJURED /WITNESSES / PAS( 'NGERS �. CHP 555 Page 3 (Rev.1-99)OPI 042 Page s or 6 DATE OF COLLISION TIME(2400) NCIC# OFFICER I.D. NUMBER 08/30/2006 11:34 0070900 307 06004432-1 EXTENT OF INJURY("X"ONE) INJURED WAS("X"ONE) WITNESS PASSENGER AGE SEX PARTY SEAT AIR ;SAFETY EJECTE ONLY ONLYNUMBER POS. BAG EQUIP. FATAL SEVERE OTHER VISIBLE COMPLAINT DRIVER PASS. PED. BICYCLIST OTHER INJURY INJURY INJURY OF PAIN ❑# ❑X 3 M El 1:1 1:1E] ❑ ❑ ❑ ❑ ❑ 2 6 i O NAME/D.O.B./ADDRESS TELEPHONE BENJAMIN STEFFEN / 10/16/2002/250 MAC GREGOR RD PLEASANT HILL CA 94523 925 676-7913 (INJURED ONLY)TRANSPORTED BY: TAKEN TO: DESCRIBE INJURIES ❑VICTIM OF VIOLENT CRIME NOTIFIED ❑# I -El ❑ ❑ ❑ 1 ❑ jEjjE1 JEI ❑ 101 NAME/D.O.B./ADDRESS TELEPHONE (INJURED ONLY)TRANSPORTED BY: TAKEN TO: DESCRIBE INJURIES ❑VICTIM OF VIOLENT CRIME NOTIFIED ❑# ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ NAME/D.O.B./ADDRESS TELEPHONE (INJURED ONLY)TRANSPORTED BY: TAKEN TO: DESCRIBE INJURIES ❑VICTIM OF VIOLENT CRIME NOTIFIED ❑# ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ NAME/D.O.B./ADDRESS TELEPHONE (INJURED ONLY)TRANSPORTED BY: TAKEN TO: DESCRIBE INJURIES ❑VICTIM OF VIOLENT CRIME NOTIFIED ❑# ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ NAME I D.O.B./ADDRESS TELEPHONE (INJURED ONLY)TRANSPORTED BY: TAKEN TO: DESCRIBE INJURIES ❑VICTIM OF VIOLENT CRIME NOTIFIED ❑# ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ NAME/D.O.B./ADDRESS TELEPHONE (INJURED ONLY)TRANSPORTED BY: TAKEN TO; DESCRIBE INJURIES �4 0 VICTIM OF VIOLENT CRIME NOTIFIED PREPARER'S NAME I.D.NUMBER MO. DAY YEAR REVIEWER'S NAME MO. DAY YEAR SILLERS,CRAIG 307 8 / 30 / 2006 / / data9l l 1.0.0.99 STATE OF CALSFORNIA NARRATIVE/SUPPLEMENTAL_ = _ CHIP 556 (Rev.7-90)OPI 042 Page 4 of s DATE OF INCIDENT/OCCURRENCE TIME(2400) NCIC NUMBER OFFICER I.D. NUMBER 08/30/2006 11:34 0070900 307 06004432-1 "X'ONE 'X'ONE TYPE SUPPLEMENTAL(X APPLICABLE) 1*1 Narrative rx-1 Collision report ❑ BA update ❑ Fatal ❑ Hit and run update ❑ Supplemental ❑ Other: ❑ Hazardous materials ❑ School bus ❑ Other: CITY/COUNTY/JUDICIAL DISTRICT REPORTING DISTRICT/BEAT CITATION NUMBER PLEASANT HILL/CONTRA COSTA/CONTRA COSTA :3020/2 LOCATION/SUBJECT _ STATE HIGHWAY RELATED CONTRA COSTA BL/GOLF CLUB RD ❑ YES ❑x NO SUMMARY: 08/30/06 AT 1134HRS: A NON-INJURY TRAFFIC COLLISION OCCURRED ON CONTRA COSTA BLVD APPROXIMATELY200 FEET SOUTH OF GOLF CLUB RD, INVOLVING FOUR VEHICLES THREE OF THE INVOLVED DRIVERS WERE CONTACTED AT THE SCENE AND IDENTIFIED BY THEIR VALID CALIFORNIA DRIVERS LICENSES. THE FOURTH DRIVER LEFT PRIOR TO MY ARRIVAL, HOWEVER LEFT HER CONTACT INFORMATION WITH ONE OF THE OTHER INVOLVED PARTIES AT THE SCENE AND WAS LATER CONTACTED BY TELEPHONE. INVESTIGATION: PRIOR TO MY ARRIVAL, THE INVOLVED VEHICLES HAD ALL PULLED INTO THE PARKING LOT OF 10 GOLF CLUB RD(GIANT CHEF BURGER) AND HAD BEGUN TO EXCHANGE INFORMATION. ACCORDING TO ALL THE INVOLVED PARTIES, THE AREA OF IMPACT(AOI) WAS DETERMINED TO BE WITHIN THE #1 NB LANE OF CONTRA COSTA BLVD, AT THE BEGINNING OF THE LEFT TURN COLLECTOR APPROXIMATELY 200 FEET SOUTH OF GOLF CLUB RD. THE AOI WAS DETERMINED/APPROXIMATED BASED UPON THE STATEMENTS MADE BY ALL THE INVOLVED DRIVERS. I NOTED MODERATE TO MAJOR FRONT END DAMAGE TO V#l. THE DAMAGE INCLUDED THE HOOD, GRILL, BUMPER AND FRONT FENDERS. V#1'S AIRBAG(S) DID NOT DEPLOY. V#1 WAS TOWED FROM THE SCENE. I NOTED MINOR TO MODERATE DAMAGE TO THE FRONT AND REAR BUMPERS OF V#2. THE REAR BUMPER OF V#2 SUSTAINED THE MORE DAMAGE THAN THE FRONT INCLUDING SCRATCHES, DENTS AND BROKEN PLASTIC REAR BUMPER PARTS. DAMAGE TO THE FRONT OF V#2 APPEARED TO BE MINOR SCRAPES AND SCRATCHES. V#2'S AIRBAG(S) DID NOT DEPLOY. I NOTED MINOR DAMAGE TO THE FRONT LICENSE PLATE AND REAR BUMPER OF V#3. BOTH BUMPERS OF V#2 SUSTAINED SCRATCHES AND DENTS ALONG WITH THE FRONT LICENSE PLATE BEING BENT. V#3'S AIRBAG(S) DID NOT DEPLOY. STATEMENTS: D41(CHRISTIANSEN) TOLD ME SHE WAS TRAVELING APPROXIMATELY 25 TO 30 MPH NORTHBOUND IN THE#1 LANE OF CONTRA COSTA BLVD, APPROACHING THE INTERSECTION OF GOLF CLUB RD. SHE STATED THAT TRAFFIC WAS HEAVY IN BOTH NORTHBOUND LANES AND THAT THERE WERE SLOW MOVING VEHICLES TRAVELING NORTHBOUND NEXT TO THE EAST CURB OF CONTRA COSTA BLVD INTENDING TO PULL INTO THE SUN VALLEY MALL THOSE VEHICLES WERE SHARING THE 42 NORTHBOUND LANE WITH STRAIGHT/NORTHBOUND TRAFFIC. data9ll 1.0.0.99 STATE OF CALIFORNIA NARRATIVE/SUPPLEMENTAL(I C IO CHP 556 (Rev.7-90)OPI 042 Page 5 of 5 DATE OF INCIDENT/OCCURRENCE TIME(2400) NCIC NUMBER OFFICER I.D. NUMBER 08/30/2006 11:34 0070900 307 06004432-1 'X'ONE 'X'ONE TYPE SUPPLEMENTAL f"X APPLICABLE) 0 Narrative 7 Collision report ❑ BA update ❑ Fatal ❑ Hit and run update ❑ Supplemental ❑ Other: ❑ Hazardous materials ❑ School bus ❑ Other: CITY/COUNTY/JUDICIAL DISTRICT REPORTING DISTRICT/BEAT CITATION NUMBER PLEASANT HILL/CONTRA COSTA/CONTRA COSTA :3020/2 LOCATION/SUBJECT STATE HIGHWAY RELATED CONTRA COSTA BL/GOLF CLUB RD ❑ YES NO AS D#1 CONTINUED NORTHBOUND, HER ATTENTION WAS DRAWN TO A WHITE FORD FOCUS TRAVELING JUST AHEAD AND NEXT TO HER IN THE NB #2 LANE. THIS WAS THE SAME FORD FOCUS D#1 STATED SHE HAD A MERGING ISSUE WITH ONE BLOCK SOUTH, AND JUST PRIOR TO THIS COLLISION. D#1 SAID THAT DUE TO THE TRAFFIC BEING"DOUBLED UP" IN THE#2 LANE, THE WHITE FORD FOCUS HAD MERGED ITS LEFT WHEELS PARTIALLY INTO THE#1 LANE AHEAD OF D#1, IN ORDER TO PASS THE SLOWER VEHICLES WHICH WERE TURNING RIGHT INTO THE MALL D#1 SAID AS SHE CONTINUED TO WATCH THE WHITE FORD FOCUS, SHE MOVED V#1 TO THE LEFT SIDE OF HER LANE(91 LANE) DUE TO NOT KNOWING THE INTENTIONS OF THE FORD FOCUS. WHILE CONTINUING NORTHBOUND, D91 SAID SHE DID NOT NOTICED THAT V42 HAD SLOWED TO A STOP FOR TRAFFIC AHEAD IN THE #1 LANE, WHICH WAS INTENDING TO PULL INTO THE IUB LEFT TURN COLLECTOR FOR GOLF CLUB RD. ACCORDING TO D#1, V#2 HAD BEGUN TO PULL INTO THE NB LEFT TURN COLLECTOR AND STOPPED FOR TRAFFIC, AND THAT V#2 WAS PARTIALLY BLOCKING THE NB #1 LANE. WHEN D#1 SUDDENLY REALIZED THAT V#2 HAD STOPPED AHEAD OF HER, D#I SAID SHE SLAMMED ON HER BRAKES TO AVOID A COLLISION WITH VQ, HOWEVER V#1 DID NOT STOP IN TIME, AND SHE REAR ENDED V#2. D#2 (STEFFEN) SAID SHE WAS TRAVELING NORTHBOUND ON CONTRA COSTA BLVD, APPROACHING AND INTENDING TO TURN ONTO WESTBOUND GOLF CLUB RD. AS SHE PULLED LEFT INTO THE LEFT TURN COLLECTOR, TRAFFIC AHEAD HAD ALREADY FILLED THE COLLECTOR AND CAUSED HER TO STOP PARTIALLY BLOCKING THE N/B #1 LANE. IT WAS A MATTER OF A FEW SECONDS LATER THAT D#2 SAID SHE WAS REAR ENDED BY V#1, WHICH IN TURN FORCED HER VEHICLE(V#2) INTO THE BACK OF V#3. D#3 (PATEL) SAID HE WAS TRAVELING NB ON CONTRA COSTA BLVD AND HAD PULLED INTO THE N/B LEFT TURN COLLECTOR AND STOPPED FOR TRAFFIC AHEAD OF HIM WHILE WAITING FOR TRAFFIC TO PROCEED, HE WAS SUDDENLY REAR ENDED BY V#2, WHICH CAUSED HIM TO BUMP THE REAR END OF THE VEHICLE AHEAD OF HIM,A BLACK CHEVY CAVALIER D#3 (PATEL) SAID ALL THE VEHICLES PULLED INTO THE PARKING LOT OF 10 GOLF CLUB RD, WHERE THEY EXAMINED THEIR VEHICLES AND BEGAN TO EXCHANGE INFORMATION D#3 STATED THE DRIVER OF THE CHEVY CAVALIER, DAUNA BALDINI, DID NOT CLAIM ANY DAMAGE TO HER VEHICLE, NOR DID SHE DESIRE A COLLISION REPORT. BALDINI PROVIDED D#3 WITH HER NAME AND ^PHONE NUMBER IF THERE WERE ANY CONCERNS. ON THIS SAME DATE AT ABOUT 1400HRS, I SPOKE WITH BALDINI AFTER HAVING LEFT A MESSAGE FOR HER TO CALL ON HER VOICE MAIL AT(925) 676-6748. BALDINI TOLD ME HER VEHICLE WAS BUMPED BY V#3, HOWEVER THERE WAS NO DAMAGE TO HER VEHICLE (V#4) AS THE RESULT OF THE COLLISION, AND SHE DESIRED NO REPORT. data911 1.0.0.99 STATE OF CAY_iFORNIA NARRATIVE/SUPPLEMENTALC_ CHIS 556 (Rev.7-90)OPI 042 r Page 6 of 6 DATE OF INCIDENT/OCCURRENCE TIME(24001 NCIC NUMBER OFFICER I.D. NUMBER ' 08/30/2006 11:34 0070900 307 06004432-1 "X"ONE "X'ONE TYPE SUPPLEMENTAL(WAPPLICABLE) Narrative Collision report ❑ BA update ❑ Fatal ❑ Hit and run update ❑ Supplemental ❑ Other: ❑ Hazardous materials ❑ School bus ❑ Other: CITY/COUNTY I JUDICIAL DISTRICT REPORTING DISTRICT/BEAT CITATION NUMBER PLEASANT HILL/CONTRA COSTA/CONTRA COSTA :3020/2 LOCATION/SUBJECT STATE HIGHWAY RELATED CONTRA COSTA BL/GOLF CLUB RD ❑ YES NO OPINIONS AND CONCLUSIONS: THE PRIMARY COLLISION FACTOR WAS CAUSED BY D#1 TRAVELING TOO FAST FOR CONDITIONS, A VIOLATION OF CVC22350. RECOMMENDATIONS: NO FURTHER ACTION. CASE CLOSED. PREPARER'S NAME AND I.D.NUMBER DATE REVIEWER'S NAME DATE SILLERS, CRAIG 08/30/2006 data9l l 1.0.0.99 VIP CQ t• r I ''} �(`,''i( � �\` `� � ` ►/'tel � . ..a 4� V