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HomeMy WebLinkAboutMINUTES - 06181991 - 1.15 r RWE1VE® CLAIM MAY '4 1991 BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA COUNTY COUNSEL Claim Against the County, or District governed by) AZA6 ►1�1 the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT JUNE' 1 8 , 199 1 and Board Action. All Section references are to The copy of this documenf.'.-maileAo'you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant �o Government Code Amount: $599, 758 . 31 Section 913 and 915.4. :please note all "Warnings". CLAIMANT: ALVARADO, Norma L. ATTORNEY: John M. Starr, Esq. 1985 Bonifacio St. , Ste. 102 Date received ADDRESS: Concord, CA 94520 BY DELIVERY TO CLERK ON Mai 1 5 1 QQ1 Chanrl r1pl i vered'. BY MAIL POSTMARKED: 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. ppH gg DATED: May 22 , .,1991 BIL DepuiyLOR, Clerk II. FROM: County Counsel TO: Clerk of the. Board of Sbper<isors 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,: 5/�� �`�I BY: ) . Deputy County Counsel 111. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). 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:)U N 18 1991 PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code sec ion 913) Subject to certain exceptions, you have only six (6) aonths from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING 1 declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over-age 18; and that today I deposited in the United States Postal Service in Martinez. California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: JUN 2 5 1991 BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator 1 LAW OFFICE OF JOHN M. STARR ! { 2 1985 Bomfacio Street;-Suite $0 102 RMEIVED. Concord, California 94520 3 Telephone: (415) 685-9000 14AY 1 5 1991 4 CLERIC BOARD OF SUPERVISQFk• 5 Attorney for NORMA AT.VARAn(L CONTRA COSTA CO. 6 7 , 8 Claim of: 9 NORMA L. ALVARADO, CLAIM FOR PERSONAL INJURIES 10 Claimant, (Government Code 11 v. Section 910) 12 THE COUNTY OF CONTRA COSTA. 13 14 TO: THE COUNTY OF CONTRA COSTA: 15 YOU ARE HEREBY NOTIFIED that NORMA L. ALVARADO, 16 whose address is 942 Meadowvale Court, Martinez, California 17 94553, claims damages from THE COUNTY OF CONTRA COSTA in the 18 amount computed as of the date of presentation of this 19 Claim, of $599,758.31. 20 This 'Claim is based on personal injuries and 21 damages sustained by Claimant on or about January 17, 1991, 22 .. in the vicinity of .MorellofAvenue, near the intersection of 23 Elderwood Drive, Martinez, Contra Costa. County, California, 24 under the follbwing 'circumstances3 25 Plaintiff was involved in .a multiple vehicle- head- 26 on collision which occurred on Morello Avenue when a Deputy 27 1 " 28 1 Sheriff of Contra Costa County on duty and so employed was 2 engaged in ahigh speed chase of another vehicle southbound 3 on Morello Avenue in the -single northbound lane, traffic ' 4 . lanes of Morello Avenue at the location being divided by a 5 raised center divider. 6 At the time of the high speed auto chase engaged in 7 by . the Contra Costa County. sheriff's deputy, the deputy 8 failed to operate the motor vehicle in a. reasonably safe and 9` prudent manner in the circumstances, negligently and 10 wrongfully conducted the high speed auto chase, and engaged 11 in the high speed auto chase contrary to the policy and 12 regulations of the County of Contra Costa and of the State 13 of California, thereby proximately causing the injuries and 14 damages suffered by Claimant. 15 The County of Contra Costa and its agents, officers 16 and employees negligently failed to adequately hire, train, 17 control, supervise and employ the deputy sheriff involved 18 in the traffic accident and thereby also proximately caused 19 the injuries and damages suffered by Plaintiff. 20 The name of the •public employee as so far known 21 causing ` Claimant's 'injuries under' the described 22 circumstances is MICHAEL R. COSTA. 23 The injuries sustained by- Claimant, as far as known, 24 as of the date of presentation of this Claim, consist of 25 fractured ribs,_ concussion and, 'brain damage, bruising, 26 contusions and lacerations of her body, memory loss, severe 27 2 28 LAW OFFICE OF JOHN M. STARK 1985 Bonifacio Street Suite 102 Concord, CA 94520 (415)685-9000 1 mental and emotional damage, stress, shock, disorder, and 2 physical pain and discomfort. 3 The amount claimed, as of the date of presentation 4 of this Claim is computed as follows: . 5 Expenses for Medical 6 and Hospital Care $ 16, 108.31 7 Wage Loss 10,800.00 8 Property Damage 5,750.00 9 General Damages 350,000. 00 $382,658.31 10 Estimated Future Damages as far as known.: 11 Expenses for. Medical 12 and Hospital Care $ 7,500.00 13 Future Loss of Earnings 9,600.00 14 Prospective General Damages . 200,000.00 15 $217,100.00 TOTAL AMOUNT CLAIMED as of 16 the date of this Claim: $599,758.31 17 All. notices or other communications with regard to 18 this Claim should be sent to Claimant at:. 19 Law Offices of JOHN M. STARR 1985 Bonifacio Street, Suite 102 20. Concord, California 94520 ("415) 685-9000 21 Dated: May , 1991 22 23 24 ).. A M. TARR orney for Claimant 25. 26 27 3 28 LAW OFFICE OF JOHN M. STARR 1985 Bonifacio Street Suite 102 Concord, CA 94520 (415)685-9000 � 41 CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT 11 and Board Action. All Section references are to The copy of this document mailed to yJbHF yJu8 fioMCCP of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $1, 107 . 39 Section 913 and 915.4. Please note all "Warnings". CLAIMANT: California State Automobile RECEIVED Association Inter-Insurance Bureau_ MAY 2`4 1991 ATTORNEY: Attn:' Joellen White P.O. Box 4019 Date received COUNTY COUNSEL ADDRESS: Concord, CA 94524-2019 BY DELIVERY TO CLERK ON May "T1NEJq:RL�F. (via Risk Mbmt) BY MAIL POSTMARKED: I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. DATED: May 22 , 1991 ��IL DepuLy OR, Clerk 11. FROM: County Counsel TO: Clerk of the Board of isors (�1 ) 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: c Dated: '� /`�f BY:_1 Deputy County Counsel I11. FROM: Clerk of the Board TO: County Counsel (1) County Admii trator (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: 1 certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: JUN 18 1991 PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code sec 913) Subject to cei,tain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above.JUN UN 2 5 1991 BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator K .r Claim For Damages ¢� In accordance with Section 910 of the California Government Code, this is to formally place you on _ rogated claim for the loss descri below. RECEIVED Na n 91 myo,= R° ,� 199 Date: May 8' , 19 MAY 2 1 1991 Mai 1 : 20 ��a Costa County CLERK BOARD OFSUPeffinso B . ?�QEIV Concord , California CONTRA COSTA CO. MAY 2 0 1991 1sk Mara � Contra Costa Count Clerk of the Claim is hery made and iled against the y Board of Supervisor as follows: IName of Claimant: California State Automobile Association Inter-Insurance Bureau Address of Claimant: (Send notices to this address) 651 Pine Street / Martinez, California 94553 Date of Occurrence: January 31, 1991 • Place of Occurrence: Pleasant Hill .Library / Pleasant Hill, California Nature and Amourit of Damages Rearend damage $1,107.39 Items Making up said Amount: Vehicle repair and car rental .reimbur"sement Name of Public Employee(s) causing said Damage(if known): Margaret Stevens Facts & Details: Your insured driver backed up and hit my insured's car causing damage to the left rear of my insured's vehicle. California State Automobile Association Inter-Insurance Bureau B F1688 (REVS-78) CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of'Supervisors, Routing Endorsements, } NOTICE TO CLAIMANT JUNE 182 1991 and Board Action. All Section references are to The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by,the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $100,000 . 00 Section 913 and 915.4. Please note all "Warnings". RECEIVE® CLAIMANT: EVANS, James Leander ATTORNEY: Richard W. Zimmer MAY ,4 1991 Andersen and Zimmer Date received COUNTY COUNSEL ADDRESS: 385 Grand Ave . .. Ste. 300 BY DELIVERY TO CLERK ON T1Nt;3 pLIF9 91 Oakland, CA 94610-4825 May 10 1991 BY MAIL POSTMARKED: Y s 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. DATED: May 22, 1991 Jy1L DeputyLOR, Cler 11-.. FROM: County Counsel TO: Clerk of the Board of ervisors N ) 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: BY: �• Deputy County Counsel U T 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 OR 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: JUN 18 1199 1 PHIL BATCHELOR, Clerk. By Deputy Clerk WARNING (Gov. code sec 13) Subject to certain exceptions, you have only six (6) months from th? date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING 1 declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: JUN 2 5 1991 BY: PHIL BATCHELOR b Deputy Clerk CC: County Counsel County Administrator ANDERSEN AND ZIMMER ATTORNEYS AT LAW DAVID L.ANDERSEN 385 GRAND AVENUE,SUITE 300 RICHARD W. ZIMMER OAKLAND,CALIFORNIA 94610-4825 (415)835-4952 RECEIVED CLER May 9, 1991 Clerk of the Board of Supervisors Contra Costa County Room 106 County Administration Building 651 Pine Street Martinez, CA 94553 Re: Claim of James Leander Evans Dear Madam: Enclosed you will find an original and copy of a claim against Contra Costa County on behalf of James Leander Evans. Would you please file the original and return the copy to=me with your stamp showing that the original has been filed. I have enclosed a return envelope for you convenience. Thank you for your assistance. Sincerely, ANDERSEN & ZIMMER f //r Richard -W-. mmer RWZ/rsa cc: file client enc. • Claim It,o: BOARD OF SUPERVISORS OF CONTRA COSTA U CLAIMANT v INSTRUCTIONS TO v A. Claims relating to causes of action for death or for injury to person or to per- sonal property or growing crops and which accrue on or before December 31, 1987, must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1988, must be presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Govt. Code§911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez, CA 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form. RE: Claim By ) Reserved for Clerk's filing stamp James Leander Evans ) RECEIVED Against the County of Contra Costa ) MAY 31991 or ) CLERK BOARD OF SUPEWSORS District) CONTRA COSTA CO. Fill in name ) The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named Districtin the sum of $ 10 0`000:,' and in support of this claim represents as follows: ------------------------------------------------------------------------------------- 1. When did the damage or injury occur? (Give exact date and hour) December 25; 1990 between 11 :00' PM_arid fit:GUAM ------------------------------------------------------------------------------------ 2. Where did the damage or injury occur? (Include city and county) Vicinity of Martinez on Highway 4 3. How did the damage or injury occur? (Give full details; use extra paper if required) ------------------------------------------------------------------------------------ 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? (over) 5. What are "the' names of county or district officers, servants or employees bausing the damage or'injury? Sheriff of Contra Costa County Deputy Frank. Parrish Deputy Lee ------------------------------------------------------------------------------------ 6. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. : Attach two estimates for auto damage. Permanently scarred ear, pain, suffering. -------------- ------------------------------------------ 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) Damages for permanent scarring and the pain and suffering incident to an unprovoked attack which resulted in a portion of Evan' s ear being severed. ------------------------------------------------------------------------------------- 8. Names and addresses of witnesses, doctors and hospitals. See number 5. Evans was treated at the County Hospital in MArtinez; ------------------------------------------------------------------------------------- 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT None to date' lA�� r 9E•+ *N* w Gov. Code Sec. 910.2 provides: "The claim must be signed by the claimant SEND NOTICES TO: `. (Attorne ). V or by some person on his behalf." Name and Address of Attorney Mr. Richard W. Zimmer, Esq. Andersen & Zimmer Clai s SignatureT Attorneys at Law �s-G�� 385 Grand Ave. , Ste 300 Oakland, CA 94610 5v�z 23Address �aG✓r�uc�� Gid 9r(l-� Telephone No. (41 5) 835-4952 Telephone No. �//S%�3 y5 NOTICE Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city or district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is punishable either by imprisonment in the county jail for a period of not more than one year, by a fine of not exceeding one thousand ($1,000), or by both such imprisonment and fine., or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000, or by both such imprisonment and fine. 3. How did the damage or injury occur? Mr. Evans was handcuffed in the back of a sheriff' s patrol car to be transported to jail. An individual named David Collins, who had been arrested by another sheriff' s deputy in a separate incident, was subsequently placed in the same vehicle. While on the way to jail, Collins attacked Evans and bit one half of his ear off. 4. What particular act or omission on the part of the county or district officers, servants or employees caused the injury or damage? Collins had just been arrested by the sheriff's deputy, in a bar, for an :unprovoked assault with force likely to cause great bodily harm. The deputy knew Collins was drunk and violent. Placing Collins in the same vehicle as Mr:..,.Evans, who was hand- cuffed and defenseless, violated the duty of the deputy to ex- ercise due care for the safety of Mr. Evans. This duty was further breached by the failure of the deputy to restrain Collins after he initiated the attack on Evans. W N O (0 0 ! O N Q t 0 0 N 7 � W Z a W Q Q } Z Z W W Z Z a O W o o zi U Z6 � Q � u W 0 2 � m a m J z Y Q O i �.. RECEIVED Z . /6 CLAIM MAY N 4 1991 BOARD Of SUPERVISORS Of CONTRA COSTA COUNTY, CALIFORNIA COUNTY_���poUNSR Claim Against the County, or District governed by) BOAiUbd jt� CALIp. the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT JUNE 18 , 1991 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $28 . 00 Section 913 and 915.4. Please note all "Warnings". CLAIMANT: HARVEY, Howard 2839 Rheem Avenue ATTORNEY:' Richmond, CA 94804 Date received ADDRESS: BY DELIVERY TO CLERK ON May 213, 1991 (hand delivered) BY MAIL POSTMARKED: 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. DATED: May 22 , 1991 PPHHIL BATCHELOR, Clerk Bl': Deputy II. FROM: County Counsel TO: Clerk of the Board of isors � ) 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: 5 2 91 BY: S. Deputy County Counsel I11. FROM: Clerk of the Board T0: 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 ( kf This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: J U N 18 193� PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptiois. you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that 1 am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California. postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: JUN 2 5 1991 BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator l Claim for BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY IIJSTRIICTIONS TO CLADWU A. Claims relating to causes of action for death or for injury to person or to per- sonal property or growing crops and which accrue on or before December 31, 19879 must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1988, must be presented-not later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Govt. Code §911.2.) B. Claims must be filed With the Clerk of the Board of Supervisors at its. office in Room 106, County Administration Building, 651 Pine Street, Martinez, CA 94553• C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form. RE: Claim By ) Reserved for Clerk's filing stamp RECEIVED Against the County of Contra Costa ) MAY 2 1 1991 or )' l•!5 p.m District) CLERK BOARD OF SUPERVISORS Fill in name ) CONTRA COSTA CO. The undersigned claimant hereby makes claim against the Coun y of Contra Costa or the above-named District in the sum of $ 02 I�s Th I�s and in support of this claim represents as follows: � � �2- /5 c/d ------------------------------------------------------------------ f =` - 1. When did the damage or injury occur? (Give exact date and hour) --_--------------------- 2. Where did the damage or injury occur? (Include city and county) Iclimoy� e;,( /?/_`' LL_� �----- ---- -----_ 3. How did the damage or injury occur? (Give full details; use extra paper if _ �required) S� po�7� , �GGI�` L 5, 19 Ct J`'l a 4X �1�1P�1l� �P� eck'_15 ©u� ---------------- 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? ro /_r e /� ,z (over) 5. What are the names of county or district officers, servants or employees causing the damage or injury? 6. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. 7. How was the amount claimed above computed?(Include the estimated amount of any prospective injury or damage.) 8. Names and addresses of witnesses, doctors and hospitals. ----------------------------- ------------------------------------------------------ 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT -�f Qj is h` A Gov.= Code Sec. 910.2 provides: "The claim must be signed by the claimant SEND NOTICES Td P(`Axttorne`) � or by some erson on his behalf." Name and. Address`E=of`-Attorney Claimants SLg ure Address Telephone No. Telephone No. 41S C11 NOTICE Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents'for allowance or for payment to any state board or officer, 'or to any county, 'city or district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, acccunt, voucher, or writing, is punishable either by imprisonment in the county jail for a period of not more than one year, by a fine of not exceeding one thousand ($1,000), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000, or by both such imprisonment and fine. CLAIM JUN 19-1 BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA COUNTY COUNSEL Claim Against the County, or District governed by) BOARD ACTION MARTINEP., CALIF, the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT JUNE 18 , 1991 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: Unspecified Section 913 and 915.4. Please note all "Warnings". CLAIMANT: HOLT, Lois M. 1280 Chelsea Way ATTORNEY: Concord, CA 94521 Date received ADDRESS: BY DELIVERY TO CLERK ON May 28 , 1991 (via Risk, ftmt) BY MAIL POSTMARKED: 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. PpHHIL BATCHELOR, Clerk DATED: June 4 , 1991 61': Deputy 1I. FROM: County Counsel TO: Clerk of the Board of & er ' ors 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: BY: Deputy County Counsel �T III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER- By unanimous vote of the Supervisors present ( ) This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. c► Dated: JUN 18 1991 PHIL BATCHELOR, Clerk, B , Deputy Clerk WARNING (Gov. code ecti 913) Subject to certain excepti ns, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California. postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. JUN 2 5 1981 Dated: BY: PHIL BATCHELOR b Deputy Clerk CC: County Counsel County Administrator Claim to�. OF SUPERVISORS SOF CONTRA CQ(INTY - INSTRUCTIONS TO CLAIMANT A. Claims relating to causes of action for .death or for injury to person or to per- b .. .sonal.property.or.-growi-ng crops-and -which accrue-on-or'-before December- 31; -1987, must 'be presented-Ingt.,later ,than.:the 10Qth'.•day•after :the 'he ;of, the 'cause of action. Claims relating to}causes-of,acti.on,,for death or_,;for.injury'to: person or to personal property or growing crops and which accrue on or after January 1, 1988, must be presented not later than six months after. the accrual of the cause m. . of-action..,....:.Claims-relating to-'any other .cause-of,action must -be presented not later .than,:one;-year after;,, he accrual°c-of;:the-cause -of action. r;"(Govt. Code . 911.2.) B. Claims must be filed with the Clerk of the.Board of Supervisors at its offiee .in Room 1069 County Administration Building, 651 Pine Street, Martinez, CA 94553• C. Ifmclaim•-is against .a district governed Hby.-the,Board of, Supervisors;•rather than the County, the name,_of the,Distret should be. filled 'in:. 1 D. If the claim is against more than one public entity, separate ciaims must be filed against each public entity. E. Fraud. -See penalty..for-fraudulent.,claims•,.=?ena1 Code'.Sec-,-72 at-they end �of• this form: ._. . W04 FW. RE: Claim By ) Reserved for Clerk'-s filing stamp RECEIVED Against the County,,of,Contra :Costa ) MAY 2 8 1991 _ CLERK. OF SUPERVISORS. Dlatrlet) ' a ;CONTRA COS A'CO. Fill in name , ) The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District ,in the sum of $ and in support of this"claim"'represents.as`followsi 1. When. did the damage or, :injury occur? (Give'exact .date and hour) - �'�� =-- -----=-=---------------- 2. Where did the damage or injury occur? (Include city and county) ' 3. How did the damage or injury occur? (Give full details; use extra paper if h n required.).,. _ �,-��1.: ILI �► , ' � � - 4. What particular, act'4or omsso on:t part ;of county or district officers, servants or employees caused*;the• injury or,:damage?- UV (over) 7. what are the names county or district officers, s�ants or employees causing the damage or::. n ur ''?`� s;. _.,4 :;.. � ` -=-- -- =- _-- - - ---- - ---- - ------- ---- ------------ -------- tt 5:•;< What. damage or_injuries:,,do�,you.cla'iin resulted? (Givef;full extent -of. injuries or t - _ damages, claimed.(, Attac "Itwo =.estimates .forauto damage Y K°t •f :�.:.• 1 L'` t !"' ' i ca`� +' _ _ f•..+� Jj f � r.,i. f{. S y -i���'_,',�, ;�. � .. f , ".r 47,'. :,How was the ,amount,.claimed-above' computed?_-,:(In lude the`;estimated amount of any prospective injury or damage.) y i. ..f • - ---------------iJi --�-_--_� -�----_---_YY_- _-_ ------__ $.- Names and addressesof.:wtnesses; doctors and h'os ItdIs + ,8",Lk -- -- -----= -------, ._. . - r- - -- ---------------------------------. --------- 9. List the expenditures. you made on account of this accident or injury. DATE ITEM ,� AMOUNT Sec:••910:2 provides: it The claim must be signed by the claimant "SEND NOTICES,-704 , ;(Attorney) or by some person on his behalf." Name and Address`'of-Attorney T: C ai is Signature .�. .. '—•. . . .i>.� -`'. .... / /x. ILe,;�.2 _ —. .. Address Telephone No. Telephone No. NOTICE .-Section -72 •of••the Penal--Code provides•: m :' "Every person who, with intent to defraud, presents for allowance 'or-for payment to any state board or officer, or to any county, city or district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is punishable either by imprisonment in the county jail for•.a--period of-not more than-one -year, by-a• fine of not-exceeding one thousand,($1-,:000); or..by•both such iinprisonmentzand'�-fine,' or 'by imprisonment in the state'prison, by a fine.of not exc-eeding, ten 'thousand dollars '('$10,000, or by both such imprisonment and fine. ���• •-• Attendin Physicians Report � a` 1.NA E OF INJURED o i S K 2.DATE OF INJURYDATE OF Y � 3 G OUR FIRST EXAMINATION INJURED 1I f r _ y PERSON 3.HAD INJURED RECEIVED FIRST AID OR OTHER YES 4. FROM WHOM? CITY TREATMENT FOR THIS INJURY BEFORE COMING TO YOU? ❑ NO 9Q 5.WAS PATIENT ❑ YES NAME OF HOSPITALPERIOD HOSPITALIZED? a-NO ACCOUNT OF ' `"` 3 I ACCIDENT AND HISTORY ` . Qt OF COMPLAINTS DIAGNOSIS fav v�J" ` l rim (Describe and :.• locate character ` grid extent Cx.,V of injury) DESCRIBE ANY OTHER INJURY OR DISEASE AFFECTING PRESENT HAVE YOU EVER PREVIOUSLY TREATED ❑ YES IF YES, WHEN? CONDITION PATIENT FOR THE SAME OR SIMILAR NO CONDITION WERE X-RAYS TAKEN? IF YES,BY WHOM? ❑ YES --B�NO - X-RAY NATURE IS TREATMENT TOTALLY ELATED TO THIS ACCIDENT? OF1Q4 TREATMENT C3 YES ❑ NO - (Explain) tel' '�•���-� a DATE INJURED WAS TREATED BY YOU IS FURTHER TREATMENT NEC SSARY? I FURTHER i I ❑ YES ❑ NO S" TREATMENT IF YES,TO WHAT DATE? HAS THE PATIENT MADE A COMPLETE RECOVERY? IF YES, ON WHAT DATE? 'V O PROGNOSIS IF NOT, DO YOU ANTICIPATE A COMPLETE RECOVERY? IF YES, ON WHAT DATE? (Include estimate of IF A C MPLETE RECOVERY IS NOT EXPECTED, EXPLAIN IN DETAIL total and partial disability, and of probable permanent DATE TOTAL DISABILITY BEGAN DATE RELEASED TO RESUME PART-TIME WORK DATE RELEASED TO RESUME FULL-TIME WORK result) ESTIMATED FUTURE DURATION OF TOTAL DISABILITY DATE OF THIS REPORT SIGNED BY \ -\cb -91 IRS NO. AN PH IIYM P R d !UIsJ 11 A"lC P q►a F-1T.., PqwR.� M.D. ❑ CHIROPRACTOR S 19a='� - 11T�T;ORNEY* �\ � n ir• *IF ATTORNEY,GIVE NAME AND ADDRESS 150 ta Can j Zjr �;; j iJ !�•j u., Walnut Creek, CA 94598 I °�°�•SM• Autompile DamageEvaluation � California State Automobile Association Inter-Insurance Bureau sured - RESIDENCE PHONE: _ Claimant REGISTERED OWNER: BUSINESS PHONE: I I Sl V E 1-11(, I I _ HOLT) CAR Ci , Wj f- L..0 � M LEGAL OWNER: - ry 07 4 93 2MAKE AND YEAR I.D. NO.:, lI o!=,] (_.C.N .0 8' c T..) CPI=.- UNKNOWN 1Ll•ILiP�Tt3f t5(-YtS(}�.e:�OfJt ;C'1»_ ()t7r? (t COLOR: MODEL: LICENSE: ( .:aC,S'....--F'ti^YL::.I: CON 1• ••.?•-?�^;'�} ✓✓fie . 2c�� -7-7 I L � .� CONDITION OF BRAKES: MILEAGE: ]INSPECTED AT NO. PHOTOS: JINSPECTED BY: DATE INSPECTED: Z NO. REPL REPR DETAILS:REPLACE/REPAIR LABOR UNITS PAINT UNITS PARTS SUBLET 1 / 2 / l cr76 4 < 1F. he 5 j 7 1.g 9 10 11 12 13 14 15 16 17 18 19 20 IRS# - ` Labor Units �: #@ _$ COMMENTS: I Pain Units r? #@ =s �� =$ ' Paint Meat^enema Parts z03: Less% s-�— =$203: 7Q -- . Tax @'77. %on.$ Z./7) =$ 32.35 This is not an authorization by C.S.A.A for repair.Present this estimate to the repair. Sublet shop before you authorize the repairs. The labor rate is adjustable to the shops Other $ hourly rate. All supplements or changes must be approved by C.S.A.A)before repairs are started. Notes: Total$� D.O.STAMP-ADDRESS Betterment$ Deductible$-05;D, � Net$!aL,a� F1725(3-86)" OWNER/,SHOP CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA M AY N 4 1991 Claim Against the County, or District governed by) BOARD ACJMTy coUNSEI the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT JUNE 181ARTIF9!9QALIF. and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $696 . 85 Section 913 and 915.4. Please note all "warnings". CLAIMANT: HOLT, Lois (07-4932992) ATTORNEY: Calif. State Automobile Assoc. P.O. Box 401 . Date received ADDRESS: Concord, CA 94524-2019 BY DELIVERY TO CLERK ON May 21 , 1991 Cert. P504 284 743 BY MAIL POSTMARKED: May 16 , 1991 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. GATED: May 22 , 1991 IVIL DeputyLOR, Clerk 11. FROM: County Counsel TO: Clerk of the Board of rvisors 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: Q0Dated: rj` '2`{ ' q( BY: Deputy County Counsel 111. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) { ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present ( kr 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:_JUN l 8 pqq PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code section 913) ',ubject to certain exceptions, you have only six (6) months from the date this noticewas personally served or deposited .in the mail to file a court action .on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING .1 declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 16: and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: J UN 2 5 1001 BY: PHIL BATCHELOR b Deputy Clerk CC: County Counsel County Administrator Claim For Damages Certified Nubmer: P 504 284 743 In accordance with Section 910 of the California Government Code,this is to formally place you on notice of our subrogated claim for the loss described below. '— Date: March 7, 19 91 RECEIVED MAY 2 1 1991 Concord , California CLERK ONTAA COSTA CO OF SOBS Claim is hereby made and filed against the County of Contra Costa as follows: Insured/Claimant's: fCalifornia State Automobile Association Inter-Insurance Bureau Address of Claimant: (send notices to this address) P.O. BOX 4011 Concord, California Reference File 07-4932992 Date of Occurrence: December 31, 1990 Place of Occurrence: Cowell Road in Concord, California Nature and Amount of Damages 1990 Nissan Truck License #* 4BOO122 CA Items Making up.said Amount: Repair estimate and draft copies Pnrinaerl Name of Public Employee(s) causing said Damage(it known): John Peter Chase Facts & Details: John Peter Chase was North/Bound on Cowell Road driving a 1986 Ford Truck License # 497151 CA registered to Contra Costa County, he was unable to stop and rearended a car which was pushed into Lois Holt, Concord Police Report #: 90-31189 California State Automobile Association Inter-Insurance Bureau By: F1688(Rev.11-87) <*> assi nment of claim and RECEIVED subrogation agreement MAY 2 11991 B SAD OF SUPEtiV=_ RS In consideration of the payment to the undersigned of ® the sum of Six Hundred ❑ a sum estimated to be Ninety—six and 85/100 -------------------------------------------------------- $696.85 Dollars, being the full amount of loss and damage insured against under an automobile insurance policy, number 4932992 issued to the undersigned by --the CALIFORNIA STATE AUTOMOBILE ASSOCIATION INTER-INSURANCE BUREAU, said loss and damage having occurred on or about the 31st day of December 19 90 the said undersigned hereby assigns and transfers to said Bureau her her said claim in the above amount plus additional claim for damage resulting from said accident, not covered under said policy of insurance in the amount of$ b C2xa total p y , constituting ❑ a total estimated claim in the amount of$ 696.85 1 ga'tJ Said Bureau is hereby subrogated in my place and stead to the extent of the above amount of the said total claim and is hereby authorized and empowered to sue, compromise or settle in my name or other- wise to the extent of said total claim for loss and damage, and to endorse in my name any check made payable to me therefor, and collect and receive any money payable thereby. The undersigned covenants that she ha s not released or discharged any such claim or demand against such party or parties and that she will furnish to said Bureau any and all papers and information in her possession, necessary for the proper prosecution of such claim, 620r'� Q jk Dated at nnlfl ' i=' this day of 19 r l� WITNESS F1433 (REV.7-77) JM IN 12 48 CONCORD POLICE DEPARTMENT SPECIAL CONDITIONS NUMBER HIT&RUN TRAFFIC COLLISION -REPORT INJURED FELONY Cp ❑ [CR No. SPECIAL VEHICLES NUMBER HIT&RUN COUNTY 1 2 DATE IN TIME REPORTED PAGE CITY POLICE OTMfiR ALL KI ED MISD Z. 7I 1 EMER OJ ER ❑ Contra Costa '� .�h- / OF CLASSIFICATION k.)15 •DATE &J-TIME g OCCURRED NCIC O. OFFICER I.D. NO. 0704Au-Fc) VD A,,)T� AAL-1-TO 1L 3� OCCURRED ON: PRIMARY STREET SPEED I DAY OF WEEK TOW AWAY STATE HWY PHOTOS Z Cove EL.t_.. 1�l� LIMIT REL 1- ✓ 35 S W T F S (4y-OS NO ( )YES V ❑ AT INTERSECTION WITH (SECONDAR TREET) SPEED ID SUPP .I F OR: , 'FEET MILES N S E 'W OF D RRVR DRIVER'S LICENSE NO. STATE CLASS SAFETY VEH.YR. (MAKE/MODEL/C/O,L�OR LIC ENSE NO. STATE ..i 5-112P4 -7 J -L EOUIP. . . �. P PED NAME (FIRST,MIDDLE,LAST) A J 0�-i N Pt✓T c-E4 i 1� PKD STREET ADDRESS OWNER'S NAME ( )SAME AS.DRIVER R VEH G'Q.�VT't�•o GoST � CAJ�T T Y .Y BIKE CITY/STATE/ZIP OWNER'S ADDRESS ( ) SAME AS DRIVER O,4KLC `/ , rte, . SIL{ S(a 1 .1_8Q5_L 5E-.1.L_ /-,-uL • M T t OTHR SEX I HA.�II/R�� EYES �HGHT jWGHT.j TBIRTHDATE RACE DISPOSITION OF VEHICLE ON ORDERS OF: ( )OFFICERYAR RIVER B 1�.1•.� Vr� I I LY DAIY •,✓E� P 2 VF_^.I I )OTHER HOME PHONE /� o �,� 5 1 BUSINESS PHONE PRIOR MECHANICAL DEFECTS: )NONE APPARENT ( )REFER TO NAR RATIVE . � (l.t, )I,, I_ - z QL TOWED BY JDESCRIBE VEHICLE DAMAGE SHADE IN DAMAGED y1 Vl/-✓ t lY 1G' AREA: INSURANCE CARRIER POLICY NUMBER �- ( )UNK I )NONE ( )MINOR IIAOD, I )MAJOR ( )TOTAL DIR.OF ON STREET OR HIGHWAY PCF ICC X E L C,/(- ( ) IvIiCQ-,LQ CMP DRVR DRIVER'S LICENSE NO. STATE CLASS SAFETY VEH.YR. MAKE /MODEL/COLOR LICENSE NO. STA TTE EgUCT L 'E ( h JTrvI;5 ! 101 /7� . . . . . . . . . . . . . . . . . . . PED AME (FIRST,MIDDLE,LAST) Pv/ L'e y'2'1 E' �- A PKD STREET ADDRESS , OWNER'S NAME ( )SAME AS DRIVER VEH T BIKE CITY/STATE/ZIPC OWNERS ADDRESS ( )SAME AS DRIVER Y CI C p n1 . A. 11 L4 sle I Li C9 2ND 5T . SAN �F_4ZA r•/ 2 OTHR SEX JHAIR EJK2IY1,ES HGHT JWGHT BIRT�H/)DAT(/E� JRW ACE DISPOSITIO/�N)OF VEHICLE ON ORDERS OF: ( )OFFICER DRIVER 1 I I.A 5_ 1.. 13.3 MDSEN'E� V )�1 Vrj I AR (OTHER HOME PHONE BUSINESS PHONE PRIOR MECHANICAL DEFECTS: ONE APPARENT ( )REFER TO NARRATIVE TOWED BY DESCRIBE VEHICLE DAMAGE SHADEAIRNED+AMAGED INSURANCE CARRIERPOLICY NUMBER ( )UNK ( )NONE ( )MINOR A" G 12 ) "5 , � 6/'4.P(v Lf my r z (p (\,)AOD ( )MAJOR ( )TOTAL DIR.OF ON STREET OR HIGHWAY P.CF ICC ( 7— TRAVEL \ t .l PUC ( ) w C `�`� f I� CHP DRVR DRIVER'S LICENSE NO. STATE CLASS SEAFETYPVEH.YR. MAKE/MODEL/COLOR LICENSE NO. STATE UI , a g � '�. � U GG p nl T`c.f P/A)K W C.7G 577 C/� PED NAME (FIRST,MIDDLE,LAST) - - - - P ::: VVVYYY A LOl S T PKD STREET ADDRESS R VEH T 17 .s cH�=c.s G a w`/ THIS REPORT I� E�[�Nt COPIED, �fi9�ATED"ER IA ' v BIKE CITY/STATE/ZIP c� ' q� QR FURNISHED � RYv R$ F aA 0 d (VER 3 Lr- I�n!.c t T OTHR SEX MAIR EYES jHGHT JWGHT BIRTH T. R CLE" O�SIf ION F VEHICLE ON ORDERS OF: ( )OFFICER ( DRIVER /ry77 MO. DAY • YEA�JR� �^�U Immik /t I L) � I (OTHER HOME PHONEQ� L� BUSINESS PHONE q p }I� ,PRIOR MECNANI L ECTS: ( ONE APPAREN REFER TO NARRATIVE (l•)lC ) f•v ✓ ( ) L/�I Y�.eleased o ESCRIBE VEHICLE�DA�MA SHADE ARIN DAMAGED INSURANCE CARRIER POLICY NUgER (� },.�l K ( )NONE (JCI....,. R�j EA: 4 Q _ 3 Z )MOD ( )MAJOR ( )TOTAL DIR.OF ON STREET OR HIGHWAY PCFRecords c CC ) , T%:i L Coiord Poli:; Pg-_'4, meet CMP REPORTING OFFICER �-1 1� ,�-/�'jl,•/� � JBEA.�T JDA�& TIME R; W ITTEN SUPE VI �A'PPROVING CP-28-1 JUN 87 `/'' 3 I13Z CONCORD POLICE DEPAATENT , TRAFFIC COLLISION CODING PAGE MA�O.L= CDAtn YEw RJ TIME L4490 NCIC NU07OAR OFF_ICF�I.Q, NUMBn [/- OWNER'S NAME/ADDRESS - Y l) NOTIFIED PROPERTY Q / !� ( )YES ( )NO DAMAGE DESCRIPTION OFD Mf%/� SEATING POSITION •' / SAFETY EQUIPMENT EJECTED FROM VEH. OCCUPANTS: M/C BICYCLE- _ 1 -Driver A-None in Vehicle HELMET L-Air Bag Deployed 0-Not Ejected B-Unknown 2 to 6-Passengers M-Air Bag Not Deployed 1-Fully Ejected 7-Station Wagon Rear C- Lap Belt Used N-Other DRIVER 2-Partially Ejected 8-RR.Occ.Truck or Van P-Not Required V-No 3-Unknown D-Lap Belt Not Used 1 2 3 0-Position Unknown-Other E-Shoulder Harness Used CHILD RESTRAINT W Yes 0 F-Shoulder Harness Not Used Q-In Vehicle Used PASSENGER 4 5 6 G- Lap/Shoulder Harness Used R-In Vehicle Not Used X-No 7 H-Lap/Shoulder Harness Not Used S-In Vehicle Used Unknown Y-Yes J-Passive Restraint Used T-In Vehicle Improper Use K-Passive Restraint Not Used U-None In Vehicle ITEMS MARKED BELOW WHICH ARE FOLLOWED BY AN ASTERISK (*)SHOULD BE EXPLAINED IN THE NARRATIVE. PRIMARY COLLISION FACTORTRAFFIC CONTROL DEVICES 1 2 3 TYPE OF VEHICLE 1 213MOVEMENT PROCEDING LIST NO. (#) OF PARTY AT FAULT COLLISION # A VC Section Violated: Cit d: A Controls Functioning A Passenger Car/Station Wagon A Stopped ZZ3c�� cmi._( )Yes( No B Controls Not Functioning* B Passenger Car With Trailer 113 Proceeding Straight # B Other Improper Driving C Controls Obscured IC Motorcycle/Scooter IC Ran Off Road C Other Than Driver* D No Controls Present/Factor* x D Pickup or Panel Truck D Making Right Turn TYPE OF COLLISION E Pickup/Panel Trk.W/Trailer I E Making Left Turn D Unknown" A Head-On F Truck or Truck Tractor I F Making U Turn # E Fell Asleep* B Sideswipe G Truck/Trk.Tractor W/Trailer G Backing WEATHER (MARK I TO 2 ITEMS) C Rear End H School Bus H Slowing/Stopping A Clear D Broadside I Other Bus I Passing Other Vehicle 8 Cloudy E Hit Object J Emergency Vehicle J Changing Lanes C Raining F Overturned 1 1 IK Hwy.Const. Equipment K Parking Maneuver D Snowing G Vehicle Pedestrian I IL Bicycle L Entering Traffic E Fog/Visibility Ft..L H Other*: IM Other Vehicle I I I M Other Unsafe Turning F' Other*: MOTOR VEHICLE INVOLVED WITH N Pedestrian I IN Xing Into Opposing Lane G Wind A Non-Collision O Moped O Parked LIGHTING B Pedestrian - P Mer in A Daylight C Other Motor Vehicle 10 Traveling Wrong Way B Dusk-Dawn D Motor Veh.on Other RoadwayOTHER ASSOCIATED FACTOR R Other*: E Parked Motor Vehicle (MARK 1 TO 2 ITEMS) C Dark-Street Lights D Dark-No Street Lights F Train A VC Section Violation: Cited: G Bicycle Yes No E Dark-Street Lights Not B VC Section Violation Cited: Functioning* H Animal: SOBRIETY DRUG Yes No PHYSICAL ROADWAY SURFACE MARK 1 TO 2 ITEMS 1 Fixed Object: C VC Section Violation Cited:' A Dr Yes No A Had Not Been Drinking B Wet J Other Object: . D B HBO-Under Influence C Snowy- Icy IE Vision Obscurement C HBD-Not Under Influence* D Slippery (muddy,oily,etc.) IF Inattention* D HBD-Im airment Unknown* ROADWAY CONDITIONS PEDESTRIAN'S ACTION G Stop&Go Traffic E Under Drug Influence* (MARK 1 TO 21TEMS) _ Impairment-Phsical* A NO Pedestrian Involved H Entering/ Ramp A Holes Deep Ruts* Crossing in Crosswalk I Previous Collision G impairment Not Known B Loose Material on Roadway* B at Intersection J Unfamiliar with Road H Not Applicable C Obstruction on Roadway* C Crossing in Crosswalk-Not K Defective Veh. Equip.: Cited: I Sleepy/Fatigued D Construction-Repair Zone at Intersection Yes No SPECIAL INFORMATION E Reduced Roadway Width D Crossing-Not in Crosswalk L Uninvolved Vehicle A Hazardous Material F Flooded* E In Road-Includes Shoulder M Other*: B Fire Involved* G Other*: F Not in Road N None Apparent C Tire Defect/Failure H No Unusual Conditions I IG Approach/L us O Runaway Vehicle SKETCH: •t• MISCELLANEOUS: E • Z INDICATE NORTN 4v 0 vZ vI - Pv� Rik CP-29-2 JUN 87 cow E CONCORD POLICE DEPARTMENT INJURED/WITNESSES/PASSENGERS ' PAGE DATE OF COLLISION71ME 2A00 NCIC NUMBER, OFFICE I; Nun; -Z� 0704 ' / `7 Qj EXTENT OF INJURY("X"ONE) INJURED WAS("X"ONE) WITNESS �.�...E.G.. ppRTY BEAT bAFETY AGE SEX ELECTED ONLY ONLY FATAL SEVERE OTHER VI6IB LE COMPLAINT DRIVER PAb6. PED. BICY CLI6T OTHER NUMBER POS. EOUIP. IN)URV INJURY INJURY OF PAIN ❑# o ❑ ❑ ❑ I ❑ I ❑ 1 ❑ ❑ ❑ 5 3 - NAME ADDRESS TELEPHONE -7 fa- �s TRANSPORTED BY (INJURED ONLY : TAKEN TO' DESCRIBE INJURIES I A ❑ VICTIM OF VIOLENT CRIME NOTIFIED ❑# ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ NAME D.O.B. ADDRESS TELEPHONE TRANSPORTED BY (INJURED ONLY): TAKEN TO: DESCRIBE INJURIES ❑ VICTIM OF VIOLENT CRIME NOTIFIED ❑# ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ o NAME D.O.B. ADDRESS TELEPHONE TRANSPORTED BY (INJURED ONLY): TAKEN TO: DESCRIBE INJURIES • ❑ VICTIM OF VIOLENT CRIME NOTIFIED NAME D.O,B. ADDRESS TELEPHONE TRANSPORTED BY (INJURED ONLY): TAKEN TO: DESCRIBE INJURIES ❑ VICTIM OF VIOLENT CRIME NOTIFIED ❑# ❑ o' ❑ ❑ ❑ ❑ ❑ ❑ a'o NAME D.O.B. ADDRESS TELEPHONE TRANSPORTED BY (INJURED ONLY): TAKEN TO: DESCRIBE INJURIES • ❑ VICTIM OF VIOLENT CRIME NOTIFIED ❑ ❑ ❑ ❑ ❑ ❑ 11:11DIEll Ell ❑ NAME D.0.B. ADDRESS TELEPHONE TRANSPORTED BY (INJURED ONLY): - TAKEN TO: DESCRIBE-INJURIES ❑ VICTIM OF VIOLENT CRIME NOTIFIED' REPORTING OFFICER BEAT DATE AND TIME REPORT WRITTEN SUPERVI R P O NG J=rz AND TIME REPORT TYPED CP-29-1 JUN 67 PAGE o [CR # v .J �� �L �� �>1 N S 1 E� E-74 C, t-t E So 4,L-( E r-> 1�2�ICF 1 C, A P�'U_c H�=; v Ko'�K S �v T w�-,s �►�r>�c o A"-.'rJ L_L (� , C-) (-ac�l,T F--�ASI C-A4�Y G0K�2-6AT 1✓C-D ID— I �l i oto T' ZZ?�� <U��� u,Js�� PSE✓ F� P- C C CdNC TICUT I-b(�>Sr Co^I � c i1 v ��S (3E Tl-OAT � 'LF.� � v � � ��v �� ►� 1JA-\-C , S ToPP /0P. N- T i-1 � Ar3��� vlvl��t 1p� i S �3i���� vPo rJ 4�2r �St✓ � T C-' C 1- f REPORTING OFFICER/� 1\ ^ BE�Tj D T.6 /LN IME®OR%WRITT� SU PERVI5O A V G TYPIST DATE AND TIME REPORT TYPED CP-100A SEP B.7 �'1 </�) ; \/.'!-).,I `�>r 0>61'511 >�Nl� California State AutomobileAssociationlnterR' o v ,5 e. k: °� ¢R '%t� � , ?,�f':.:' 3? ..c�.a .r ,d. hAser ` CL'AIMr :y- s," "€ r �INS'RED'S AME htl ,1..: •�'F wl t e�ii..., Sk �.I �. L '�^,:1 P�U�.�Ox �# �.�{ S��F. �.'•�� xts,.. � '� a a 2 }' _ c, .°.3 .r. a y# ;R i'; 'sn :.{,�p .,,�`d�?p'4 ..:3� `',�``.[ t t'` �4'�F �" „t ✓. t1 � e. , �� �t # fi PUR "..9a '& � ult " atiVr.' � T qtr 3wtTu3 k�F L_7F �fi 3 tt `t POLICY—STYPE' KIND OFLOSS `q 5�, ;SUFFIXN '""' dg i ClAIMAtNTT'�SINAME"„ r"lw''p"!�'�+yx# _'�'�+ tN tie t1' 1.d F�� ;.;} PAYt ,.F4t.Cf t°,�€' t���. Z—i {k .3 f! k �tl,�pa �:r� iT '' 4 R"'R as L.F�r�'}:.k 1"1 x<,�'f ;F'* „fin-A s u:f+(J 7..G2,� �7 ) -,.j 0 2 �r• k..,1�U �."' r t 4`LJi.. t>�ai[ ...r �^p � r ,`i '* �i s '-r^"k" 7+�r°i r.nF3-7 t.. Oto .a ""s� "M S(d. 3'3a± t ,�3� 4z`�''fi+�a' a; r "di. ,_ ,�,.f�.*.5 �'sF`,"v zk ss,w`' r,�, hi":Fz.°✓ `tt.., '�``t .^ � a .x, siD{0 + v ADJUSTER NOS`"^ §' asINP,AVMEN OF*V;'; e .A�6tsr .r ;�k�' ;:4,Gas+.. y,.s . tis a> e ^Fr g" t,.? Througli ,i5 , € ;,. m> ,tp�] a, +�._' �` Seeupty,Pacllic National Bank, :sti i4, ,' 'i' F.$ ,,; .` P"ifS R G"i'/t f"1R7 }'.''': Y- 0 .�a+.w F any^.# .'> 4i ;,, iks t.�`° .,�.,`�..'u., c;;.,t. Sen Pranolaco Mein Oliice N0512 p ja :1210 : Z 3 i tg5ta3 xale� ..+�P3 `'k ' �9s "ss ":i a�' _ One Ertibercedero Center v..3q x�*/ e ;fiTsrl t 1 t k Asa' ' p�� b. r'd�7 NTY ' q m t d, l hUlyY li ,ga+a+rr ::X" C v' $t 3r ,a �. s ,g � mm Yes, +, ur $x't ; �aS (� $; -r "x � "` r �' m e r 7 ,n tr: ,e . fi s, i" �, E,+,�;$ t 2 S'a.r .g r f .,jMs.. Sd�'m- .l C;3 §Yom" I- .J..'a.f{' _«r r= =,1 0 � 63 ,•�`g44^� .n �.�.� df�1"B�S.�:«C�4Y-"• .�$.p. t VC. $ ( 'T ,e^.f.. �L'�Y� "^ .�w `z <� :,>��;� � }k�£,�` 3] T r;ay 7! +r, g ;�4h O t art � � m m I " rr,/r���s .�j :4 , .,.g fnrs I �'J.Sf'9��Q �;Li ,�.�� � �i''4 �n x Sx:-§ 3 +;. �:-=, +g, d. '�f., $.:�_., rr.,�':,�.^3 �, �x ziR �„ ,..r ,� ': ''� t�..�.. sa — I Mkt",Fc x ,sStiF�r� a �rt cry �a"°� � P� � �'� � � i���4F ,�aF 1r� � �!`, �' ' �yFF�7L�w� � to�.,�'`'�.� �s^ �t'r��':; `' ��'� �"t:�""� ,��„'"`�' €� ✓r fif�':', t�r `,fj ° �,.r; °net,b � F ! � �. m a �^.y{��,�+. ,.�.,y�y 9a Al 1�,41141u ,R 11.F �z't,:8 t g,.THE,tr`gtg g q a i :.�� z�€i�`= �+� �:4� t `dt�F`f .•=s'��j�s �,a:9r 7�a,��'i ,r-�a�''�� �'.. c� �,"� 'r�. �.+,� s..� s.$� a,+^. x h. E9 !, FONDER W-1-� .� :°4S3t tt'OF. qai sY d ''.< s + Ti yr"'rha $ .».hrmz��gtea5 �F ,&�.a'. .� >z,,,'� >vr'3' s t E i s .a � � E,•:a`t.7 i l;,"1�w r�r� tf, rtoa'S. �d,.•.:;t�"dr�,.. A� rx'.. "2 �'� p zt6 ;.;I�fi. .b..:�w:7 •aa t'�, ^� , � .� "r.,. k ��,�:�.,_��; ��t �w� r COPS r.' s i Automobile Damage EvaluatiNh- 1,` California State Automobile Association inter-Insurance Bureau SUred RESIDENCE PHONE: Claimant REGISTERED OWNER: BUSINESS PHONE: LEGAL OWNER: kj f MAKE AND YEAR I.D. NO.: cf:)65, 1/Z COLOR: MODEL: LICENSE: L_IJ El. X,40V,�5_ I)WK FiF -7--7 CONDITION OF BRAKES: MILEAGE INSPECTED AT: NO. PH TOS: JINSPECTED BY: D NO. REPL REPR DETAILS:REPLACE/REPAIR LABOR UNITS PAINT UNITS PARTS SUBLET 2 7E 3 Z, 4 RT 75, 5 6 7 8 9 10 Z� 11 12 13 14 15 16 17 18 Lzae 19 20] IRS N Labor Units 27, @ 46Y $124.2.0 16e, COMMENTS: Paint Units LZ #@ 4W-a-C=s 20 =$ Parts Less% Tax @ %on$4/,,Z =$ 32 , This is not an authorization by C.S.A.A for repair.Present this estimate to the repair Sublet $ shop before you authorize the repairs. The labor rate is adjustable to the shops Other hourly rate. All supplements or changes must be approved by C.S.A.A. before repairs are started. Notes: Total$ D.O.STAMP-ADDRESS Betterment$ Deductible$ Net F1725(3-86) M.O. CLAIMS • i �Y 1✓ y� rq� t cc "? U F� Cd � a 0 tf1 ' U CdVA G .. GO cd SaOSMl13dl1S d0 Gli�pe Xa3'p 1661 1 Z �, C13A1333H u a }� z 0 m`O 0 ti" O' O S hyo u d' 4 N m m N 0 as -; 0, 00 o -z L) z 0 u