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MINUTES - 03241992 - 1.1 (2)
A /C 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 March 24, 1992 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 $150,000.00 (Paragraph IV below), given pursuant to Government Code Amount: Section 913 and 915.4. Please note all "Warnings". CLAIMANT: y, HAMILTON, Mar. RECEIVED ATTORNEY: Robert J. Lange FEB 27 1992 James D. LuhmannCOUN Y COUNSEL Glynn, Cella & Lange Date rece INEZ, CALIF. ADDRESS: y g 100 Pringle Avenue, Suite 600 BY DELIVERY TO CLERK ON February 25. 1992 Walnut Creek, CA 94596 BY MAIL POSTMARKED: February '24, 1992 I. FROM: Clerk of the'Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. , gH (L 01 d DATED: February 27, 1992 gdILATCELOR, Clerk : 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 1.5 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: 2 121 /92. BY: /tet Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present ( ✓) This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: MAR 2 4 1992 PHIL BATCHELOR, Clerk, By aA11VI Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: MAR 2 4 1992 BY: PHIL BATCHELOR by i Deputy Clerk CC: County Counsel County Administrator a GLYNN, CELLA & LANGE ONE WALNUT CREEK CENTER SUITE 600 RECEIVED 100 PRINGLE AVENUE WALNUT CREEK, CALIFORNIA 94596 TELEPHONE (415)210-2800 FEB 2 5 1992 FACSIMILE(415)945-1975 WRITER'S DIRECT DIAL NUMBER CLERK BOARD OF�SUPERVIS CONTRA COSTA CO. (510) 210-2807 February 21, 1992 Re: Claim by Rolland Hamilton and Mary Hamilton Clerk Board of Supervisors Room 106 County Administration Building 651 Pine Street Martinez, CA 94553 Dear Sir/Madam: Enclosed for filing are an original and one copy of: 1. Claim by Rolland Hamilton Against the County of Contra Costa; Contra Costa Sheriffs Department and its Employees. Please file the original, conform the copy, and mail the latter back to me in the postage prepaid envelope provided. 2 . Claim by Mary Hamilton Against the County of Contra Costa; Contra Costa Sheriffs Department and its Employees. Please file the original, conform the copy, and mail the latter back to me in the postage prepaid envelope provided. Your anticipated courtesy and cooperation in this matter are greatly appreciated. Very trul yo4rs,. Sarka Trenciansk Secretary to James D. Luhmann Encs. Aky 110 Claim to: BOAno OF SUPERVISORS OF CONTRA COSTA INSTRUCTIONS TO CLAIMANT A. Claims relating to causes of action for death or for injury to person or to per- sonal property or growing crops and which accrue on or before December 31, 1987, must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1988, must be prespmted 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 1069 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 Mary Hamilton RECEIVED Against the County of Contra Costa; ) FEB 2 51992 Contra Costa Sheriffs Department and its employees District) CLERK BOARD OF SUPER CONTRA COSTA CO. Fill in name ) The undersigned claimant hereby makes claim against the County o ntra =Costaor the above-named District in the sum of $ 150 ,000 and in support of this claim represents as follows: ----------------- -------------------------------------------- 1. When did the damage or injury occur,? (Give exact date and hour) November 4, 1991 approximately between 4 :30 P.M. and 5 :00 P.M. 2. Where did the damage or injury occur? (Include city and county) At my home--2088 Stewart Avenue, Walnut Creek, California 94596 . 3. How did the damage or injury occur? (Give full details; use extra paper if required) Contra Costa Sheriff Deputies WANG and CAMPISI without warrant,. justification or permission entered my home. The deputies grabbed Captain Hamilton .(U.S. Navy Retired) and threw him down. After doing this one deputy took Captain Hamilton outside, but despite Captain Hamilton having asked both to leave one remained inside our home. ----------------- 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? Warrantless and unathorized entry into our home. Unjustified and excessive force in throwing Captain Hamilton down. intentional detention and search and negligent infliction of emotional distress. (over) 5. What are the names of county or district officers, servants or employees causing the damage or injury? Deputies WANG and CAMPISI were directly involved. Sheriff Rainey and Contra Costa County are also responsible. ------------------------------------------------------------------------------------ 6. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. Emotional trauma and injury to reputation. Damage amount is approximately $150 ,000 and continues to accrue. ------------------------------------------------------------------------------------- 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) Damages include the sum of medical costs, legally compensable, pain and suffering, emotional trauma and injury to reputation. Severity of and longevity of injury is presently unknown. ------------------------------------------------------------------------------------- 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 Gov. Code Sec. 910.2 provides: "The claim must be signed by the claimant SEND NOTICES TO: (Attorney) or by some person on his behalf/" Name and Address of Attorney 41Z)� ;� Robert J. Lange (�laimVs gnature James D. Luhmann Glynn, Cella & Lange 2088 Stewart Avenue 100 Pringle Avenue, Suite 600 Address Walnut Creek, CA 94596 Walnut Creek, CA 94596 Telephone No. (510) 210-2800 Telephone No. (510) 935-0395 * * * * * * * * * * * * 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)9 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 BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claier Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT March 24 , 1992 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: DOW, Donald RECEIVED ATTORNEY: FEB 2 7 1992 Date received ADDRESS: 169 Oak Road BY DELIVERY TO CLERK ON F=P2!W , 1992 Danville , CA 94526IF. BY MAIL POSTMARKED: via Risk Management I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. February 27 1992 PpHHIL BATCHELOR, Clerk DATED: ' 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: 2 z `(2 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. Dated: MAR 2 4 1992 PHIL BATCHELOR, Clerk, By44a_01JAdi Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Noti a to Claimant, addressed to the claimant �panspshown above. Dated: MAR 2 4 1999 BY: PHIL BATCHELOR by Deputy'Clerk CC: County Counsel County Administrator NOTICE OF INSUFFICIENCY AND/OR NON-ACCEPTANCE OF CLAIM TO: Donald Dow 169 Oak Road Danville, CA 94526 Re: Claim of Donald Dow Please Take Notice As Follows : The claim you presented against the County of Contra Costa or District governed by the Board of Supervisors fails to comply substantially with the requirements of California Government Code section 910 and 910. 2, or is otherwise insufficient for the reasons checked below: 1 . The claim fails to state the name and post office address of the claimant. 2 . The claim fails to state the post office address to which the person presenting the claim desires notices to be sent. 3 . The claim fails to state the date, place or other circumstances of the occurrence or transaction which gave rise to the claim asserted. 4 . The claim fails to state the name(s) of the public employee(s) causing the injury, damage, or loss, if known . XX 5 . The claim fails to state whether the amount claimed exceeds ten thousand dollars ($10, 000). If the claim totals less than ten thousand dollars ($10,000) , the claim fails to state the amount claimed as of the date of presentation, the estimated amount of any prospective injury, damage or loss so far as known, or the basis of computation of the amount claimed. If the amount claimed exceeds ten thousand dollars ($10,000) , the claim fails to state whether jurisdiction over the claim would rest in municipal or superior court. 6 . The claim is not signed by the claimant or by some person on his behalf . 7 . Other: VICTOR J. WESTMAN, County Counsel 0 By: Deputy 9unty Counsel CERTIFICATE OF SERVICE BY MAIL C.C.P. S5 1012, 1013a, 2015 .5; Evid. C. 99 641 , 664 ) My business address is the County Counsel's Office of Contra Costa County, Co. Admin. Bldg. , P.O. Box 69, Martinez, California, 94553, and I am a citizen of the United States, over 18 years of age, employed in Contra Costa County, and not a party to this action. I served a true copy of this Notice of Insufficiency and/or Non Acceptance of Claim by placing it in an envelope(s) addressed as shown above (which is/are place(s) having delivery service by U.S. Mail) , which envelope(s ) was then sealed and postage fully prepaid thereon, and thereafter was, on this day deposited in the U.S. Mail at Martinez/Concord, Contra Costa County, California. I certify under penalty of perjury that the foregoing is true and correct. Dated: February 27, 1992 , at Martinez, California. cc: Clerk of the Board cf Supervisors o ginal) Risk Management (NOTICE OF INSUFFICIENCY OF CLAIM: GOV.C.§§ 910, 910 . 2, 920 .4, 910 . 8 ) Claire; to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. Claims relating to causes of action for death or for injury to person or to per- sonal property or growing crops and which accrue on or before December 31, 1987, must,be presented. not later than.the, 100th day after the•accrual of�-the,cause of action. Claims relating to,causes of -action for death-.or for, injury to„person or to personal property-,,pr growingcrops 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. j Rese ved for.Clerk' filing stamp EE R s Against the. County .of Contra :Costa ) . � _. � }.• or ) FEB 2 7 1992 District) CLERK BOARD OF SUPERVISORS Fill in name ) CONTRA COSTA COTI. The undersigned,.,claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of $ and in support of this claim represents as follows: --------------- ---------..Me---------------------------------------- 1. When did the damage or injury occur? (Give exact date and hour) _�---------.� ----------- -- e _� I----------------.--------- ------ 2 Where di ' the a or injury occ r? Include city and county) �J% �_N_N---__ --.YN_---_-N1N-N---M-----_---_N--N--s--N-------------- 3. How did the damage or injury occur? (Give full .details; use. .extra paper if require --- --------------------=------------=--------------------- 4. What particular act-or omission'.6n the part of county-'or,district:officers, servants or employees,:caused t e injury: or damage? 7 ' (over) 1 5. wnat are the names of county or district officers, servants or employees causing the damage or injury? ° -------------- ------------------------ ------- --- --------------- ------------------ 5. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach. two,estimates for auto damage. s---- ------------------------------------------------------------------------------ 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. - ----------------------------------------------------NN----------------------------- 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT , Gov. Code Sec. 910:2 provides: .. 4 "The claim must be signed byte claimant SEND NOTICES .TO:.._r-Wtto&6 ) or by someerson on his- " Name and Address•of aAttorriey= �J - - Clai 's Si t "Z) Address Telephone No. Telephone No. ..* * . 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, ajpjA*ass y�'r i�alent claim,. bill, Adhount, voucher, or writing, is punishable a er by imprisonment in the county jail for a period -of not more than-one year, by a)&in fes t exceeding one thousand ($1,000),. or by both such imprisonment and fin , br qq risonment in the'-state prison, by a fine of not exceeding ten thousand dolldW(($ Jg000, or by both such imprisonment and fine. AlNf100 d1S00 dUN00 vo � t 4 J _ RECEIVED CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA F E B 7 1992 Cla`i'm Against the County, or District governed by) BORYMAYT=NSEI the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT 11 arm-2-4L+LPYVZ 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: $920.89 Section 913 and 915.4. Please note all "Warnings". CLAIMANT: FITTS, Bruce ATTORNEY: Date received ADDRESS: 14211- Woodhaven Drive BY DELIVERY TO CLERK ON February 25, 1992 ' San Jose, CA 95127 BY MAIL POSTMARKED: Unreadable I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. pPHH gB DATED: February 27, 1992 JY DeputyLOR, Clerk -I I. a.O'�J A 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: ? 1 x BY: J 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. BOARDORDER: By unanimous vote of the Supervisors present (✓)S 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: MAR 2 4 1992 PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. 0 Dated: 'MAR 2 4 1992 BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator Claim to:' BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. Claims relating to causes of 'action for death or for injury to person or to per- sonal property or. growing crops .and which accrue on or before, December 31, 1987, must be presented not' later than the 100th day after 'the. accrual,of the cause of action. Claims relating- tocauses of action for death or for injury to person , or to personal property or,growing crops and which accrue on or after January 1, 1988i ,must be presented not later than six months after theaccrual 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,' P6nal. Code See. 72 at the end of this form. RE: Claim By Reserved for Clerk's filing stamp L RECEIVED cA) Against the County of Contra, VED 092 SUPERV S A T tr 1;s or or, FEB 2 5 1992 VR, _ District) KBOARDOF UPER (Fill irr/name) CONTRA COSTA_C0 The undersigned claimant hereby makes claim against the County of Contra sta or the above-named District in the sum of $ and in support of this claim repres6ntsas f6llowi:' —--------—-------- 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 required) 'r rossa � .7 e_ff) (A, 7_7 cLro(& C Gike, V�,e_ &A ct f.cip- 4. What particular act or omission on the part of county or district officers, servants or employees .caused the-injury or dabiage? -f-br ro as -re- f,,� 6r r v over r;(- tov Z�C" STATE OF CAURORNIAI TRAFFIC COLLISION REPORT PAGE I OF SPECIAL CONDITIONS NUMBER WTI RLN CRY JU010AL OIXTR ICT LOCAL REPORT NUMBER WJURED FELONY ❑ ffinPp>c�- NUMB€R HIT A RUN COLIRY REPORTING DISTRICT BEAT KILLED MISO. COLLISION OCCURRED ON MO. DAY YEARiSTATE ME(BI00) NGC I OFFlCER L 0. _ n - - �_i 1 i 6Z ----- -------------- MILEPOST WFORMATgNQAYOFWEEK W AWAY PHOTOGRAPHS BY: U FEET!MILES OFSMTWTFSER ❑NOO OATINTERSECTIONWITH NWT REL J 13OR: FEET/MILES OF ❑YES ❑NO ❑NONE PARTY DRIVER'S LICENSE NUMBER STATE CLASS SAFETY VEK YEAR MAKE/MOOELICOLOR � LICENSE NUMBER STATE Q L.1 Da C'�L1 .(� E P. DRIVER NAME(FIRST. t T�GI�.� 1 t� (�N 1 !tel Li i1tL. �L31J illi..(t:..I_it4 .cY i .tLJ .4.J E?Wl�,- L4-V1t) Fl772> PEDES- STREEIAZORESS OWNERS NAME ❑SAME AS DRIVER TRIAN PARKED CRY I STATE ZIP OWNERS ADDRESS ❑SAME AS ORNER VEHICLE ❑ �11� ���i..-� �..�: Com}.�'r SICY• SEX I NNR EYES HGOHT' WIDOW BIRTHOATE RACE DISPOSITIONOFVEHICLEONOROERSOF: ❑OFFICER EpRIVER DOTH EA CUST /� L f) rMO. f'DAY • YEAR ❑ 3!l ,jet. s 10 � I L1 4� i .+G� �1 OTHER' NOME PHONE BUSINESS PHONE t �{ t��r T''J 1f y�f G( r PRIOR MECHANICAL DEPICTS: NONE APPARENT© REFER 7O NARRATIVE ❑ tos (Xg- I"f' /4 ` I(„1Q )'f 1 ( =- -,I L CHP USE TYPE ONLY DESCNEBE VEHICLE DAMAGE SHADE IN DAMAGED AREA E INSURANCE CARRIER VEHICL POLICY NUMBER ❑LINK ❑NONE MINOR. ❑MOO. ❑MAJOR TOTAL DIR.OF ON STREET OR�NIGGNWtAlY SPEED PCP 4CC❑ TRAVEL 'I IC C '71A�'~- �,7 LIMIT Puc 13 CNP© PARTY ORIV£R'S LICENSE NUMBER t� �y STATE CLASS SAFETY VEK YEAR MAKE/MODEL/COLOR LICENSE NUMBER STATE 2 G )<Z33 O C EGiAP. DRIVER NAME(FIRST.MIOOLE.LAST) l_7"� . . . - u N 1 a, M U�\-N PEDES- STREET ADDRESS OWNERS NAME ❑SAME AS DRIVER TRIAN PARKED CRY I STATE I ZSP OWNERS ADORES• ❑SAME AS DRIVER VEHICLE .ICY• SEX I HAIR I EYES HEIGHT WEIGHT BIRTHDATE RACE pSPOSMONOFVEISCLIONORDERSOF: OFFICER DRIVER OTHER CUST MO. • DAY • YEAR ❑X ❑ d 1V9 Atv�-`f OTHER HOME PHONE BUSINESS PHONE P'IIAR OR MECHANICAL DEFECTS: � NONE APPEM� R[FER TO NARRATIVE ❑ ( ❑ CHP USE ONLY DESCRIBE VEHICLE DAMAGE SHADE W DAMAGED AREA INSURANCE CARRIER POLICY NUMBER VEHICLE TYPE • LINK. NONE ❑IBNOR ❑MOD. ❑MAJOR ❑TOTAL OIR OF JONSTREETORHIGHWAY SPEED PCF ICC❑ TRAVEL LIMIT PUCE] CHP Q PARTY DRIVER'S LICENSE NUMBER STATE CLASS .SAFETY VEIL YEAR MAKE/MODEL/COLOR LICENSE NUMBER STATE EOU4P. DRIVER NAME(FIRST.MIDDLE.LAST) • • ' • • • • • • • • • • . • • • . . . ' . ' . ' ' ' ' ' 11 PEDES. ISTREETACORESS OWNERS NAM£ ❑SAME AS DRIVER TITIAN ❑ PARKED jCIrYlSYATEllDP OWNER'S ADDRESS ❑SANE AS DRIVER VEHICLE ❑ SICY. SEX HAIR EYES HEIGHT WEIGHT BIRTHDATE RACE DISPOSITION OF VEHICLE ON ORDERS OF: QOFFICER aOWVER _]OTHERCUST MO. • DAY • YEAR ❑ • I OTHER NOME PHONE BUSINESS PHONE PRIOR MECHANICAL DEFECTS: NONE APPARENT REFERTO NARRATIVE❑ ❑ YEHCLE CHP TYPE DESCRIBE VEHICLE OAMAOE SHADE IN OAMAG ED AREA INSURANCE CARRIER POLICY NUMBER I DUNK ❑NONE C]MINOR ❑MOD. DMAJOR ❑TOTAL OULOf JONSTRISTORMONWAYSPEED PCF ICCQ TRAVEL LIMIT Puco 01,l CNP❑ L----� PREPARER'S NAME DISPATCH NOTIFIED REVIEWER'S NAMEDATE REVIEWED ❑yEs C3NO O N/A CHP SSS PAGE I (RIv 1.88) OP1042 98.fig; • b • ' THOMAS JORDAN 845 ROSEMOUNT ROAD OAKLAND, CA. 94610 (510) 451-5201 On February 9, 1992 at approximately 1:45p.m. I was a passenger in a car driven by Bruce Fitts. I was seated in the back seat on the right (passenger) side of the car, next to Bruce's mother, Mary Fitts. Bruce's father, Richard was in the front seat next to Bruce. We were on Pinehurst Road in Contra Costa county, heading west towards Alameda county, in the series of switchbacks just before the intersection with Skyline Blvd. in the Oakland hills. A fire engine approached us from the opposite direction and I noticed immediately that it was straddling the double yellow line. Bruce also saw this and pulled over to the right as far as he could and came to a complete- stop to give the other driver as much room as possible but the fire engine came straight on without moving over into its own lane. As a result the left side of the engine sideswiped the left side of our car. As I said, we were completely stopped when we were hit and did not move until we left the scene approximately twenty minutes later I got out of the car to check the damage and noticed that our car was a good two feet inside the yellow line. I then returned to the car and remained inside with Bruce's parents until we left. G' i4, -�-- Budget Rent a Car Bay Zone P.O. Box 2926 So. San Francisco, CA 94083-2926 (415) 875-7540 Budget February 14 , 1992 Bruce Fitts 14211 Woodhaven Drive - San Jose, CA 95127 RE: Our Claim No: 92A 04354 Amount of Damage $750. 89 Date of Loss : 2/9/92 Loss of Use (2x35 ) : $ 70. 00 Admin. Charges $100. 00 Total Amount Loss $920. 89 Dear Mr. Fitts, This letter is regarding the above captioned loss . Please let this letter serve as acknowledgement of our property damage claim. Please be advised that we will attempt to collect our property damage claim against the responsible party. If Budget Rent A Car is unsuccessful, we will look to you for our property damage claim, since you chose not to accept our Loss Damage Waiver. If you carry Collision Insurance, please notify your insurance company of the above claim and complete and return the enclosed insurance questionnaire. Thank you for your attention in this matter, if you have any further questions, please contact our claims office. Resp c full. , L h'i Ye C ms Adm nistrator one Claims Dept. Sy/ms Enclosure Budget Rent a Car Bay Zone P.O. Box 2926 So. San Francisco, CA 94083-2926 (415) 875-7540 ,.r43io a.tial�3'i� . ..,,s:•.,., Tr.1.�s,:m't, .r..cw.z4f$.�3'.4i rec •.w �. �`c Budget DATE MAILED INSURANnCE QUESTIONNAIRE BUDGET .CLAIM NUMBER DATE OF LOSS YOUR DRIVER };i'`u C.-,— REGISTERED OWNER OF VEHICLE I AM insured for this accident. l� I AM NOT insured for this accident. NAME OF INSURANCE COMPANYr fi VA h' ADDRESS �O �_:SS 0—) ti CITY, STATE, ZIP CODE �L L VKnl V 4 �� L' 931 Z- AGENT OR BROKER'S NAME � `Sjm CL. S 6� �ZrVS - TELEPHONE NUMBER 90 U `- 2-7 LF 1 CLAIM NUMBER D O (� POLICY NUMBER I HAVE reported this Caccident to my Insurance Company. Date 2 / t I HAVE NOT reported this- accident to my Insurance Company. SIGNED: > DATE: Z 2 Date of this Aeport. ` r L- Check it phoned In ❑ I t '� H 'RENTAL SCTATION h t t t t. x ACCIDENTREPORT.FORM `} -0,0 = ,ti BRAC CLAIM J. ® DUU UE Y ngigincle RENTER/ IVER INFORMATIO , '1 (circle oneone) A erriver a Wit— l MF Home`Addre - City ,J �d.SP `State S E : ,Zip�7 f 2 City t_ State Zip Home phone(t f J Home phone !:Work phone Mork phone aEmployer Employer Drivers Llc.,# State Dfivers Llc # State 0 Renters Insurance/S(S� �� Pol #O f s� Dnvers Insurance` yrr ' r Pol # x . �.. R O t Renters"Soc Sec=#n Drivers So'. c Sec:'# •'• AW 0 - PASSENGERS IN RENTAL 1)Namet fc.�a�� (hdN�`t 1 5 Add es s � . :1 U�hAr tS �Fj�-e xCIty S fr»` b (2{�)' X'� 4"2 � 2)Name City k t. Phone# :J�,sK Sx ! .r.,•y - 'm. P $w''Y"•s y ro„ t% f ,-. 3 «., „..s - r Address � < .(,'Ity1 ,k r Phone#( r{ f FACTS - r `Y K r Date of accident t "2}' Time N 2��_Location ` !N'�rl�r Sa ( 1, ` Police Dept. handhng�µ �7tr" �> Report # �`' - Weather condmons De4alls of Accident(must be Y 'Y' s 1 -r. _ G s 1 � NI 'ib�Q ��� �'� 'h �"'.�k �• :....� -.-•�- AY. -. n , recti - � ` � � .W a �r - {' - �. x 1 - AAo,f�- ,., 3s3}-r'T`_�fI SG.1'�5t^.�.`.y Fx iZf't .� .�T�l .t"� {- Y'F t.,''+w S �# ,� rf Jn+ p a k ,:) •; V `\ "Y "L.. 4y $ ",�L'y '� 'k `. A '{�'`•z 5, Ta to't +daS "'k j �.''t•�,x'a F`.4' ,S I t •� r 1';'• r .: ..r.�...:es. � •�>�a ,"� nr -_`_'�� i—E 1 tJV S '..'.1t�}-7• 4�.•- + ,z q rff Indicate location of vehicles when .° Indicate,'points of ' accident occurred and direction :,compass(N,S.E.Nn r: ':,Driver's Signature of travel. k Identify Budget vehicle with CIRCLE DAMAGED AREA }'x i} CIRCLE DAMAGED AREA "B"(i.e., © ). OF BUDGET VEHICLE F THER VEHICLE F R r u Were seatbelts worn by driver? Y S NO T ' T Were seat belts worn by passengers? : YES ❑ NO :'DAMAGE TO OTHER CAR OR INVOLVED PROPERTY le SAM = q t Ocie one) (circ one) E 1f ,1V,1 Owner PRO(0�/�. �f(� t aU�t ge �.___ Dnver ��P As f i �t tiJl1�t/�A Age.( r F Address 8b fat a a ,. Address :. .. �. ;City D State' Zip City 4 State 'Zip yF Home phonew( Work phone(�.I Work phone Y r G • d� �. .,r Type of vehicle �/� lrL� Year Model Lic # f g0�0 S t . - t�g Describe damage ¢*'N �Q 'Color"of Vehicle e` : r ` d til t 4 j ti l M W ,y *, r k , heck rfnvea e t .Name of Insurance Co s If known t F °F � •n Y~ Policy# x. PASSENGERS IN OT ERC R 7 '�',y ° s. axe �-2 P Address z r CIty r�ss � Phone r' ��i'''3�t` @�, d 3AddreSS •C ..r .r r Clty .y .Jks r Phone•# �tf '_•s'� �z a. 3)~Name 'r • sn t+ °` 'r Address aClty " Y •Phone#( ) s. 4 PERSONS INJUREDr ,b w R,3 r n t)Name �. ` r �fiAge( )Address r Address _ ental car? YES ❑ NO ❑ Phone#( r ) _ Extent of Injury r i .. r J� .y,� � L i ty .. Ind+' r y � t' �•^ b r , Ci State y -'✓t.ty� 2.teF. c?., t t h� tis ,,t s�?� sEv*a;t'�•ro�r'F/t'. ��3t S t ^5 ,. .1� 5' r a 's � ntal �Y Phone#( ) r Extent Of IrtJUry r ti :r �a y /s,� srs t , ro' _ SES K�� �' In re r1,.� ❑ �-NO ❑ EMERGENCYMCA ��E ��m PHONE i-800- �� mn�d '� ------'�� ADDRESS ALL CORRESPONDENCE i c ofi i r a ` s SAVE TIME WITH. s E � ,,� When you returned thenar,xwhat was the RAPID }RETURN SERVICE ` k AM Please ririt marlin# address clean DATE TIME '° MILEAGE P . g . Y z, , r (This well' be used as your jihaiting label) ihdil �-� 0 me ❑ 0 r :. ga 50 you purchase YE e If yes, circle the current fuel level s `F r> Drop complete folder and°all copies of renta a a agreement'In the Rapid Return box Your cop y w ll,:b6'marled to you <x t -ADDRESS STATE ZIP THE S14ION`EY IS ON BUDG T CITY MART E v p rp O. 4 O y � ❑ ❑ ❑ ❑ ❑ 1 , � x o � ❑ ❑ ❑ ❑ ❑ x ❑ ❑ ❑ 0 ❑ *� C5 N Qy ,W o0 0 �l 1 C J %m M 19 rn m 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 March 24, 1992 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 "Warninnsit ��� VE® CLAIMANT: FUJISAKA, Thomas, Sandra, Sandy, Minors Tadashi and Travis ") FEB `' 8 199 Dale Minami ti 2 ATTORNEY: Mi nami , Lew, Tamaki , & Lee COUNTy 388 Market Street, Su.ite 1080 Date received 4MRttly coy�8 ADDRESS: San Francisco, CA 94111 BY DELIVERY TO CLERK ON February 28, ly�CLIf, BY MAIL POSTMARKED: Hand delivered I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. February 28, 1992 ppHHIL BATCHELOR, Cler DATED: 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: 2 2 'i 9 2 BY: "� �. Deputy County Counsel f 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 datq..`_ Dated: _1 AR 24 1992 PHIL BATCHELOR, Clerk, By 1 a Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. O Dated: MAR 2 4 1992 BY: PHIL BATCHELOR by4 Deputy Clerk CC: County Counsel County Administrator Claim of Thomas, Sandra, ) CLAIM AGAINST THE COUNTY OF ALAMEDA, Sandy Fujisaka, Minors, ) LIVERMORE VALLEY JOINT UNIFIED Tadashi and Travis ) SCHOOL DISTRICT, CONTRA COSTA COUNTY, Fujisaka, ) STATE OF CALIFORNIA Claimants, ) V. ) ROJA41J La RECEIVED Livermore Valley ) Joint Unified School ) District, Alameda County > FEB 2 81992 Contra Costa County, ) State of California, Respondents ) CLERK BOARD OF SUPERVISORS CONTRA COSTA CO. CLAIMANT'S NAME: Thomas and Sandy Fujisaka ADDRESS: 1382 Cobblestone Court, Concord, CA 94521 TELEPHONE: Home (510) 287-5339 Work (510) 689-5245 ADDRESS TO WHICH NOTICES ARE TO BE SENT IF DIFFERENT FROM ABOVE: MINAMI, LEW, TAMAKI & LEE Attn: Dale Minami 388 MARKET STREET, SUITE 1080 SAN FRANCISCO, CA 94111 (415) 788-9000 DATE OF- ACCIDENT/INCIDENT: August 29, 1991 TIME: 1: 30pm LOCATION: The Andrew Christensen Elementary School expansion Project, 5757 Haggin Oaks Ave, Livermore, CA. DESCRIBE ACCIDENT/INCIDENT: Claimant, Thomas Fujisaka, an employee of N.V. Heathorn, Inc. , a contractor of Respondents, was working in a trench at the jobsite when a pipe joint coupling failed, causing Claimant to be propelled 30 feet into a concrete foundation wall, causing serious and permanent injuries. Respondents, and each of them, were owners/possessors of the property on which the accident occurred and had control over such property. Respondents, and each of them, created and/or caused a dangerous condition at the work site described above and failed to warn Claimants of such dangers. Respondents, and each of them, failed to take special .precautions against an unreasonable risk of harm, thereby creating a peculiar risk of harm to Claimant. Respondents, and. each of them, failed to construct and maintain the work site and improvements in a reasonably safe condition, and failed to provide a safe place for Claimant to work. Respondents,' and each of them, failed to exercise their non- delegable duty of due care to avoid hazards and ensure compliance with appropriate safety standards. Respondents, and each of them, were negligent in their supervision over the activities of the contractor Respondents; and each of them, on information and belief, failed to provide adequate medical treatment to Claimant after his injury, and failed to promptly summon adequate medical assistance. DESCRIBE INJURY OR DAMAGE: Massive head and neck injuries, fracture of the neck and spinal , cord, brain damage, quadriplegia, among others. Claimant, Sandra Fujisaka, is married to Thomas Fujisaka and has suffered loss of consortium because of her husband's injuries. Claimants, Travis and Tadashi Fujisaka, minors, are the natural sons of Thomas Fujisaka and have suffered loss of consortium because of their father's injuries. NAME AND/OR I .D. NUMBER OF PUBLIC EMPLOYEE(S) INVOLVED: Exact identity of specific employee unknown at this time. NAMES OF EYEWITNES (ES) and TELEPHONE NUMBER(S)- (continue on back) : Darren Ma, Address unknown, Employee of N.V. Heathorn, Inc. Claim amount exceeds $10, 000, jurisdiction is in Superior Court (over $25, 000) I DECLARE UNDER PENALTY OF PERJURY, THAT THE ABOVE IS TRUE AND CORRECT. SIGNED BY OR ON BEHALF OF CLAIMANT: DATED: SIGNED: a E ( o n I 0 I n I � � o � O Q 1 � I U z E o' I � � I W I a m a I a Id 1 m x > a W z U 2 t tq = 0AH�3l�tlSdSlOOLlO4tlLdt9tlZ398 (tl�4 ltlq}3 3SHlNJNIAH3S agN3SS3 371V ttl o 6 M � N x w D .a a6 d 4rn 4 �4 �W U a o U �uJ, O � Z J^r�d a �iQ co N CLAIM RMIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA FEB '27 1992 Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT Marc h R � TI IF 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: $250,000.00 Section 913 and 915.4. Please note all "Warnings". CLAIMANT:HAMILTON, Rolland , ATTORNEY: Robert J. Lange James D. Luhmann Date received ADDRESS: Glynn, Cella & Lange BY DELIVERY TO CLERK ON February 25, 1992 100 Pringle Avenue, Suite 600 Walnut Creek, CA 94596 BY MAIL POSTMARKED: February 24, 1992 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. February 27, 1992 PpHHIL BATCHELOR, Clerk DATED: BY: Deputy 11. FROM: County Counsel TO: Clerk of the Board of Supervisors moi ) 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: 2 �Z BY: I �• Deputy County Counsel L—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 ('V) 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. _a MAR 2 4 1992 Dated: PHIL BATCHELOR, Clerk, By L, Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: MA9 2 4 19k BY: PHIL BATCHELOR byA-0 `' Deputy Clerk CC: County Counsel County Administrator r - r1 Za OOD D C-0 m O Lin 0 t3z t C a ft too 0 o + uMi 3 C/) Ec/)53 CO U� 5 00¢C O Z-0 .4, Q--- pp�� °� L L E O a- `ted O N000M0 CN 14� N � LM Claim-to BOArw OF SUPERVISORS OF CONTRA COSTA INSTRUCTIONS TO CLARAM 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, 19871 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, to, 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 See. 72 at the end of this form. RE: Claim By Reserved for Clerk's filing stamp Rolland Hamilton RECEIVED Against the County of Contra Costa)- > FEB 2 51M Contra Costa Sheriffs. Departnent and its employees CLERK BOARD OF SUPERV District) I CONTRA COSTA CO. " —7—ill in name) The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of $ 250 ,000 and in support of this claim represents as follows: -—----—------------------—--- ----—--—--------—---------------------- 1. When did the damage or injury occur? (Give exact date and hour) November 4, 1991 approximately between 4 :30 P.M. and 5:00 P.M. --—-—--- -—-——---- -------------- 2. Where did the damage or injury occur? (Include city and county) At my home--2088 Stewart Avenue, Walnut Creek, California 94596. ------- ---------- 3. How did the damage or injury occur? (Give full details; use extra paper if required) Contra Costa Sheriff Deputies MNG and CAMPISI without warrant,.. justification or permission entered my home. The deputies grabbed Captain Hamilton .(U.S. Navy Retired) and threw him down. After doing this one deputy took Captain Hamilton outside, but .despite Captain Hamilton having asked both to leave one remained inside our home. 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? Warrantless and unathorized entry into our hare. Unjustified and excessive force in throwing Captain Hamilton down. ' intentional detention and search and negligent infliction of emotional distress. (over) 5. What are the names of county or district officers, servants or employees causing the damage or injury? Deputies WANG and, CAMPISI were directly involved. Sheriff Rainey and Contra Costa County are also responsible. ------------------------------------------------------------------------------------ 6. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. Back injury, emotional trauma and injury to reputation. Damage amount is approximately $250 ,000 and continues to accrue. ------------------------------------------------------------------------------------- 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) Damages include the sum of medical costs, legally compensable, pain-and suffering, . emotional trauma and injury to reputation. Severity' of and longevity of injury is presently unknown. ------------------------------------------------------------------------------------- 8. Names and addresses of witnesses, doctors and hospitals. Dr. Asland, Kaiser Hospital, Walnut Creek Dr. Olwin, Kaiser� Hospital, Walnut Creek ------------------------=------------------------------------------------------------ 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT 11/07/91 Doctor $62. 00 11/07/91 Prescription medication $81.70 to date 12/02/91 Doctor $62.00 Gov. Code Sec. 910.2 provides: "The claim must be signed by the claimant SEND NOTICES TO: (Attorney) or by some person on his half." Name and Address of Attorney - 4 Robert J. Lange James D. Luhmann Claimant' ignature Glynn, Cella & Lange ; 2088 Stewart Avenue 100 Pringle Avenue, Suite 600 Walnut Creek, CA 94596 Address Walnut Creek, CA 94596 Telephone No. (510) 210-2800 Telephone No. (510) 935-0395 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)2 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. i; CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or Distrifct governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT March 24, 1992 and Board Action. All Section references are to Zhe copy of this document mailed to you is your notice of California Government Codes. ) ctii n taken on your claim by the Board of Supervisors (Pah IV below), given pursuant to Government Code Amount: Unspecified ($400,000) y§ tion 913 and 915.4. Please note all "Warnings". I CLAIMANT: LUCERO, Tim �ritiQ 99� ATTORNEY: C/0 Ronald M. Schwartz, Esq. Schwartz, Silber & Hiles Date received ADDRESS: 540 Lennon Lane, Suite 250 BY DELIVERY TO CLERK ON February 24, 1992 Walnut Creek, CA 9,4598 BY MAIL POSTMARKED: February 21, 1992 Certified P 865 854 670 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of th'e above-noted claim. Februar 25, 1992 PpHHIL BATCHELOR, Clerk DATED: February a,' 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: I z rj P � !' BY: I 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 (v< This Claim is rejected 'in full. ( ) Other: i I certify that this is a true and correct copy of the Board's Order entered in its minutes for this datee../� Dated: MAR 2 4 1992 PHIL BATCHELOR, Clerk, By011AJ9 , Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. u, AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: MAR 2 4 1992 BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator i; SCHWARTZ, SILBER & HILES An Association of Attorneys 540 Lennon Lane, Suite 250 Paul D. Hiles Walnut Creek, California 94598 Telephone Gary J. Silber (510)932-4314 Ronald M. Schwartz - Facsimile -� 6-3950 February 20, 1992 � � j �,:.Y, Y LL 2 41992 LE RK BOARD UPERVIso 1 _ CONTRA CQSTA Co J Clerk, Board of Supervisors Certified/Return 651 Pine Street, #106 Receipt Requested Martinez, CA 94553 Re: My Client: Tim Lucero D/Accident: 09-15-91 Dear Sir/Madam: Please file the enclosed Claim and return a filed endorsed copy to our office in the self-addressed stamped envelope provided. If you have any questions, please do not hesitate to call. Very truly your RONALD M. SCHWART RMS:nis Enc. Ronald M. Schwartz, Esq. SCHWARTZ, SILBER & HILES 540 Lennon Lane, Suite 250 Walnut Creek, CA 94598 U:z (510) 932-43 14 Attorney for Claimant TIM LUCERO CLAIM against COUNTY OFCOYvTRA COSTA The undersigned hereby presents the following claim against the County of Contra Costa. 1. Date of Accident or Occurrence: September 15, 1991 2 . Name and Address of Claimant for Notices: Tim Lucero, c/o his attorney, Ronald M. Schwartz, Esq. , Schwartz, Silber & Hiles, 540 Lennon Lane, Suite 250, Walnut Creek, CA 94598; (510) 932-4314. 3 . Description and Place of the Accident or Occurrence: While riding a bicycle on Sonoma Street in Rodeo, claimant struck a defective portion of the roadway, creating a dangerous lip and dip, which caused him to be ejected from the bicycle, and strike the ground, and thereby sustained the injuries of which he complains. 4 . Names of employees involved, and type, make and number of equipment, if applicable and if known: Not known at this time. 5. Description of the kind and value of damage: Medical bills, wage loss, emotional distress and general damages for personal injuries sustained by Tim Lucero as a result of the incident as described above. Cost estimates or bills are not attached. 7. Amount of Claim: $400, 000. 00 special Damages: Emergency care, radiology; lab work, hospital inpatient care, physician treatment, home nursing treatment, domestic help, and therapy cost: Amount Not Yet Determined Wages Lost: Amount Not Yet Determined General Damages: $350, 000. 00 DATED: February 20, 1992 ONALD M. SCHWXR7111. Attorney for Clai t Tim Lucero p u' ''f � Saxgdurug'Hvaq°H " z 46 ra u to lz v C3 Cp w r- U) p 04 Ln Q) a Cc 04 0 w ,urn w { ro w �c „ �, a a ro v N C vIZ i 4P 44 .H �4 41 +J (U ri S4 Q r-' 'n v v Ln w x L o ON r 0 ¢ .cU H o -j .o 0 <C _ti0U O � � QL � 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 March 24, - 1992 and Board Action. All Section referlences 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: $800.39 Section 913 and 915.4. Please note all "WarnikWOVE® CLAIMANT: MARKER, Kevin FEKBI ` � 8 1992 ATTORNEY: COUNTY (�OU Date received MEIRTINEL ADDRESS: 315 Lake Dale Court BY DELIVERY TO CLERK ON February 28, 1992 NSR �F• Martinez, CA 945531: BY MAIL POSTMARKED: Hand delivered I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. ppH IL BATCHELOR, Clerk DATED: Fpbruary� 1992 BY: Deputy _ - R I1. FROM: County Counsel TO: Clerk of the Board of Supervisors �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: 7 -7Dated: 2 2 I. BY: ' _ Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). .IV. BOARD ORDER: . By unanimous vote of the Supervisors present ( ✓) This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. rte Dated: MAR 2 4 199 ' PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a',certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: MAR 2 4 1992 BY: PHIL BATCHELOR bya Deputy Clerk CC: County Counsel County Administrator C ClaArb'to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. Claims relating to causes of action for death.or for-:injury to person or 'to per-r conal property or griowing crops and which Iaccrue.on, or-before,*December 31, 1987 must te.:presented not later than the 100th day' 'after the.'accrual of the-cause_ of action,., Claus relating to causes. of adtion '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;presen,ted not later than six months after-.the accrual of, the cause of action. Claimsrelating 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 Burd 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 00A( rf} Against the County of. Contra Costa . } RETE or p } FEB 281992 District) l4ac�-A+ - Fill in name) - >�- CLERK BOARD OF SUPERVISORS CONTRA COSTA CO. The undersigned claimant ''hereby makes claim against a oun y of Contra Costa or the above-named District yin the sum of $ 900.39 and in support of this claim represents as follows.*,- 1. When did the damage or injury occur? - (Give exact date and hour) .N.___..—iw.r..r___r..s_-----__rr_r__—__-_--- 2. Where did the damage 'i;or injury occur? (Include city and county) 1V0k++% 100v d PI.e46c.-v%+ Witt PC( . . Usk b4fle tLk TA1104. bhJA 1 (rt«.y Rd SP A+ •, k� u _Ct �o,�► _n 54A CoYr► Ijj��/_ .. �� A�i�rpt,�d A4 � 3. How did the damage or injury occur? (Give full. details;.-use extra paper if required). , j E E A;H,,A--2c;1.. 5 'f �e,.►�$-.. - -__NwP_-----_#___r_s__.11__Il�r_r!_r,Mt_ 4. What particular act or omission on the part ,of county or district officers, servants or employees, °caused the injury or damage? ,U AJ &a 0) 5 4-y vCA1_Wf V SoJe a.t tN eo•+1pto#�.e (over) ,. wicti are ane names or county or district officers, servants or employees causing the damage or in jury? P`3 Con r4Yvdf1;' 1 01- 4,Ws k- q► dog%Y�ca(5 1 ----------------------------------------Y-1-__----M-M------_--_---------------`s---__ 5. What damage or. injuries, do you 'claim resulted? (Give full extent of injuries or - . damages claimed. - Attach two estimates for auto damage. , -----------------------------------YYM--Y-------Y-Y-M--N-M--Y+Y-w-----.Y_-i_-Y--.RY-__ 7. How .was the amount claimed "above computed? (Include the estimated amount of any prospective injury or damage.) J C 4v(J g5 -r7d 1`4v!e S. A4 _----.-_---..-....,....... -------------- - -----i-_-ill-----Y-YY-YY----YiY - -- $. Names and addresses of witnesses; doctors and hospitals. --Y----------------------M------ YIU-iNI-Yy--N-- ---fl--Y-----Y--------_-----_i-Y---l4_ 9. List the expenditures you made on account of this accident or injury:,. T DATE ITEM _ AMOUNT 1 ;F Gov. Code See: 910:2.-provides: _ "The .claim must be signed _by the claimant SEND NOTICES TO: (Attorney). or JAtsqMe pgrson on his behalf." Name and Address of Attorney Claimant's Signature 31 Address 1 r-/ Z', CA. 9 Telephone No. Telephone No. eT V V I IF I �t „it . * N0TICE > 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 fora 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 ($10,000, or* by both such imprisonment and- fine. 3 ) I was travelling north bound on Pleasant Hill Road, in the left lane , at the area where Pleasant Hill Road splits into Geary Road and Taylor Boulevard. At the end of the new median barrier that was recently constructed, there is a new manhole that did not have a cover/grate . I hit it at about 25-30 MPH with my driver ' s side front tire . The impact blew out the tire and bent the rim. I subsequently discovered it had bent the frame and control arm, as well as damaged the wheel bearing. I originally thought the damage was limited to the wheel , tire and alignment , and had those repaired on December 18 , 1991 at the 'IWheel Works in Concord. The car pulled to the left, didn' t handle correctly, and there was a humming sound coming from �,the drivers side front wheel . After' returning the car to the Wheel Works , they determined the new tires were not atlifault and they did not know what caused the problem: I then tooklit to Concord VW and they diagnosed the`' problem as a damaged wheel bearing, bent control arm and bent frame (where control arm attaches ) . I had them repair the damage. u I FOf? 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ALFA-ROMEO 1 17/y fps d ZS -,e ✓ 2 3 b /T If ICS �' V, 4 �j LfL?� -71 3 7 -7? 9 -711, 10 a 11 r 12 / 71 711119,x' fi 13 7/l Obi8�a 14 i' 7217 .7 ,ir it 15 )7/ j Z.. 16 17 18 1 I 19 20 21 ALL PARTS INSTALLED 22 ARE NEW UNLESS 23 SPECIFIED OTHERWISE TOTAL rte, SALES ti GRAND TOT4, 1-13082.1 N RICK OKLAHOMA CITY 11vxom) S �.8 p m ?' rMi it ': Yr Y yo. P •1 '.P >r f Ya N _ � .• � ' „ � � yq f �r t f/j � r`.�MY �:°r I M� 1 4L r'fir y� .Tj � 1 Sq t :r5 { frt 1' } ' yi ri ' t. ! t a �9��2 � � �'„lt.,r�� R�' :3 t3 �,. �r T3� r t� r '1 � •. I �? • � } m> r t �? .�. � r. 3'^ :m G � }tt�i 'r{3 �'£S'� a� e�+'a a a. � p� '=.. r '�� *m •11 y m ..�� �.� C� h:Z rs" �^�. :g :':� s�' .�'' p P � <�. ^4�� ❑ '01#t v &$ NMI, ,, tl: �� `.t Z "v r � 'S ❑ u4 i' f G�r tXr� „ kT tyfR�` �' tg `. a"'' ri' r'1 is d f z' iti•� J $ t� to �' �n '.'+,r} #G 4 r ^u oytM `.�At' W:_ � t. t�S� � �' t �t�# }-, ✓ ta.+.�., L 7'`,.+. 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M�� •€,fit § �1> '7 k�*far ` t �!`� � _� i�r + ''t`' k.-x -5+ t9 � �f tl 1 r r In t S tfi ��6 $r ,y- Me ik s i*N3aNs� r,fib �IA utr O:O £ 3"F zC_N yN ., 't t -r v t } . mwr�piw.•^'i q$+'&m �. ulo�m6r ym 4: . ..X" 3 1 es< f T, rr 1S S is - i r1�e t,�i1,�ir p Ik 11�.�1 sll�N♦ :f Ji tis .r >F i l7 r' t i 9 ' a t {�J. 4 1�{ DDADD�DpDD �•"Y�1���S.nODi��m r ! Tr R�'r �T � u spa 1 k ti r'*��u .J C N: edrG' 'a v a t'�,'�r8'�'>n'.+K" '�r(�P'r�� �7•.C'. t •,r. ..tsY. "� .2yS' ;i��t k.: t.. -d.66�i'te.$.�."..�:1"9�„a 3';.r4 l'jls��� i `a P M � � O 1116 CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY,`CALIFORNIA Cloi',Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT March 24, 1992 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: $150,000.00 Section 913 and 915.4. Please note all "Wrnings". WkEIVED CLAIMANT: MICHAELS, Gene FEB 2 81992 ATTORNEY: Ronald M. Schwartz,! Esq. couNTy OD v Schwartz, Silber & Hiles Date received February"Na,1 ADDRESS: 540 Lennon Lane, Suite 250 BY DELIVERY TO CLERK ON Walnut Creek, CA 194598 BY MAIL POSTMARKED: February 26, 1992 Certified P 890 626 912 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. i i L February 28, 1992 PpHHIL BATCHELOR, Clerk DATED: y BY: Deputy 1. FROM: County Counsel TO: Clerk of the Board of Supervisors ,) This claim complies substantially with Sections 910 and 910.2. 1 ( ) 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). II , ( ) Other: Dd JU J A Dated: Z z < 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). l� IV. BOARD ORDER: By unanimous vote of the Supervisors present ( ✓} This Claim is rejected iin full, ( ) Other: j I certify that this is a true and correct copy of the Board' Order entered in its minutes for this date. i Dated:- MAR 2 4 1992; PHIL BATCHELOR, Clerk, B I LAI I Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a cout 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. �I 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 6rtified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: MAR 2 4 199 BY: PHIL BATCHELOR by Deputy Clerk ...-: CC: County Counsel County Administrator SCHWARTZ, SILBER & HILES • An Association of Attorneys 540 Lennon Lane, Suite 250 Paul D. Hiles Walnut Creek, California 94598 Telephone Gary J. Silber (510)932-4314 Ronald M. Schwartz Facsimile February 20, 1992 1 RECEIVED (510)256-3950 FEB 2 71992 CLERK BOARD OF SUPERV CONTRA COSTA CO. Clerk, Board of Supervisors Certified/Ret 651 Pine Street, 4106 Receipt Requested Martinez, CA 94553 Re: My Client: Gene Michaels D/Accident: .09-01-91 Dear Sir/Madam: Please file the enclosed Claim and return a filed endorsed copy to our office in the self-addressed stamped envelope provided. If you have any questions, please do not hesitate to call. Ve truly //yours ONALD M. SCHWAR RMS:nis Enc. r • Ronald M. Schwartz, Esq. RECEIVED SCHWARTZ, SILBER & HILES 540 Lennon Lane, Suite 250 FEB 2 72 Walnut Creek, CA 94598 Telephone: (510) 932-4314 CLERK 0 Attorney for Claimant Gene Michaels CONTRA STA CO CLAIM Against County of Contra Costa The undersigned hereby presents the following claim against the County of Contra Costa: Name of Claimant: Gene Michaels Address of Claimant: 1647 Matheson Road, Concord, CA 94521 Send Notices to: Ronald M. Schwartz, Esq. Schwartz, Silber & Hiles 540 Lennon Lane, Suite 250 Walnut Creek, CA 94598 Date of the Accident: September 1, 1991 Place of the Accident: Oakhurst Drive in the City of Clayton General Description of the Accident: Claimant was struck from behind by a third party while traveling eastbound on Oakhurst Drive. Act or Omission on the part of Public Employees that Caused the Injury or Damage: Failure to adequately barricade and/or mark off lane closures; lane closure, barricades and cones set up so as to create a dangerous condition; lack of warning of said dangerous condition. Names, if known, of any Public Employees Causing the Injury or Loss: Not known at this time. Names and Address of Witnesses: Other than claimant, Lee Alan Teicheira at 262 Bigelow Street, Clayton, California 94517; Russell Lee Teicheira, 262 Bigelow Street, Clayton, California 94517 ; Kevin Lewis Weeks, 1676 Matheson Road, Concord, California. Names and Address of Doctors and Hospitals Where Treated: Mt. Diablo Convenient Care Center 1520-A Kirker Pass Road Clayton, CA 94517 Robert A. Farmer, D.C. 1212 Contra Costa Boulevard Concord, CA 94523 General Description of the Loss, Injury or Damage Suffered: Back pain, neck pain, muscle strain, left knee contusion and strain, chest pain, headaches, left ankle pain and contusion, and right scapular strain. Total Amount Claimed: $150, 000.00 The Basis of Computing the Total Amount Claimed is as follows: Damages incurred to date: Medical Expenses: Approximately $2, 500. 00 Loss of Earnings: Unknown at this time A copy of the police report, #91-0562, is attached. DATED: February 26, 1992 ONALD M. SCHW Attorney for Claim GENE MICHAELS 2 ..._- 1 COND,TfONS ;..� p.,. NUMBER' HIT i RUN : / •J i --'�� .NO/K,. 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DRIVER NAME(FIRST.MDOLE:LAST) ' ! j »•JY.3E•RJMYI.T PEDES- STREET ADDRESS-:--: t__.'-,•„�,,,,,�,�,^' _ ,,, OWNER'S NAME :.'i3V;'G��%ty.4AMEA3 DRIVER r TRIAN 16-6 L PARKED CfT`II T///ATE1210 rc� J- y t//! ` - STA i- OWWER'S ADORESS-_.____:l SAME A4-DRIVER VEHICLE _�./1 I V�� - ~ /..� r�+i��{ E 7C S ... ❑ tom. ;�� _ _ ,..y - BICY- SEX HAIR EYES: FREIGHT' :WEIGHT _ '- BUITHOATE `. RACE: .DISPOSTION OF VEHICLE ON ORDERS'OF:AT{`��IOFFICER DRIVER OTHER MO. . DAY 1 YEAR ._ - i t{_t�_.^��._.., __❑--'_.- CLIST /� ' J..� ❑ N/.: 8,2� /�.' Z s - - - - - —----- - - - L,! „ s OTHER HOMEPHONE 3w.. -�.BU7rNE41 PHONES_/'�- "s PRIOR MECHANICAL DEFECTS: TONE AF9AREM .—REFER TO NwRRATVE ❑ ' ❑ 1 �f�b)-�jz�-� 3m�V�-C�7/O)�v KJ Z Z V CMP USE ONLr-� DESCRIBE VEHICLE DAMAGE_ V�SMO!N DAMAGED AREA-- - NSUR ECARRIER �) � _ POLICY NUYSE :. , _ LF,TYFE LINK - .. . . y//'L�l�l Gf J-/r.J�'C/�/'1[�r•V -; V-' !,>/ ❑MOO ❑mAJOR ■TOTAL .. DiROF ON STREET OR HIGHWAYsQO.—�`- SPEED' ICF �j —y. K TRC ❑ s.yrvt�s. }�.,.. —' _ L LV HT4t, _Y CHp Q PARTY DRIVER'S LICENSE NUMBER STATIC CLASS I SAFETY VEKxR MAKE/MOOEL/COLOR UCENSENUMSER— [TATE T_ DRIVER NAME(FIRST.WOOLS.LAST) _. ..-�_ ,--_V. OVBNERS NAME E]SAMS AS DRIVER I� "DES. STREET ADDRESS y �_.. I. _�_t... __>_ - __—_ TRIIN PARKED CITY/STATE ZIP ! OWNER'$ADORES! r'SAME AS DRIVER VEHICLE ' u SIC7• SFX HAIR ITIS! .HEIGM WEtGNT �i BIATHDATE RACE DISPOSITION OF VEHICLE ON ORDERS OF: ❑OFFICER ❑DRIVER ❑OTHER CUST MO. I _DAY I Y[AR Orman HOME PHONE IN PHONE PRIOR MECHANICAL DEFECTS: NONE APPARENT ❑ REFER TO NARRATIVE El ❑ ( _ ' ( ' ) CHP I/SE ONLY DESCRIBE VEHICLE DAMAGE SHADE N DAMAGED AREA VEHICLE TYPE fl } INSURANCE CARRIER ( ►OUCV NUMBER - I I tr ❑UNIL ❑NONE ❑MNOR i ( J` ❑MOD. ❑MAJOR ❑TOTAL DIR.OF ON STREET OR HIGHWAYSPEED PCF KC ❑ ! • ' TRAVEL LSAT • PUC ❑ CHP C3 .._ i PAEPAq E DISPATCH Non REVIEWER'S NIDI GATE REVIEWED 1 C WYES ONO M N/A i CHP 555-Page 1 (Rev. 7-87) OPI 042 87 453M FiArf ll: t:VLLIti1VIV I:VUING ,_ _ f .Ao[ DAM OF c/ lr EAR q/ nM[ oo� a NcNwoR�m OFFICER LD MO. n ea CJ OWNER-[NAME I ADDRESS _ it _ _.. ;•. _._! NOnRED PROPERTY ' C ,� I in El No -65 DAMAGE w 2p � d W T__._._.___ ocscNvnoN OF DAMAG SEATING POSITIONQCcuaANTs I' . SAFETY EQUIPMENT _ tK! .Blcrc F_►+ M T EJECTED FROM VEH. 1-DRIVER A.NONE IN VEHICLE L-AIR BAG DEPLOYED _ __---.-- 0-NOT EJECTED 2 TO 6-PASSENGERS B-UNKNOWN M-AIR BAG NOT DEPLOYED DRIVER I-FULLY EJECTED 7-STA.WGN.REAR C-LAP BELT USEfl - H-OTHER ..V-NO 2-PARTIALLY EJECTED t-RA OCC.TRK_OR VAN D-LAP BELT NOT USED --- -' P-NOT REQUIRED -W-YES .. ._._____._ -.0-UNKNOWN t-POSITION UNKNOWN E-SHOULDER HARNESS USED 1 Z 3 0-OTHER F-SHOULDER HARNESS NOT USED CHILD gFSTRAI PASSENGER . 4 5 6 H I- A GLLAP!SHOULD SHOULDER HARNESS USED -.- O-IN VEHICLE USED -•-•-.X-NO.-.... -.._...._ .. ... ER HARNESS NOT USED R-IN VEHICLE NOT USED Y-YES 7 J-PASSIVE RESTRAINT USED j S-'IN VEHICLE USE UNKNOWN K-PASSIVE RESTRAINT NOT USED ! T-IN VEHICLE IMPROPER USE U-NONE IN VEHICLE ITEMS MARKED BELOW WHICH ARE FOLLOWED BY AN ASTERISK_(')SHOULD BE EXPLAINED IN THE NARRATIVE PRIMARY COLLISION FACTOR TRAFRC CONTROL DEVICES j 2 3 -TYPE OF VEHICLE1 Z 3 - MOVEMENT PRECEDING LIST NUMBER t)OF PARTY AT FAULT ii t A VC SECTION VIOLATED:o? _ 0uJ 0 A CONTROLS FUNCTIONING A PASSENGER CAR!STA.WGK COLLISION J ohL/00(XJ r ND B CONTROLS NOT FUNCTIONING- . . B PASSENGER CAR W I TRAILER A STOPPED BOTHER IMPROPER DRIVING• C CONTROLS OBSCURED C MOTORCYCLE I SCOOTER B PROCEEDING STRAIGHT Q HO CONTROLS PRESENT!FACTOR•- D PICKUP OR PANEL TRUCK C RAN OFF ROAD C OTHER THAN DRIVER' TYPE OF COLLISION E PICKUP I PANEL TRK W I TLR IDMAKING RIGHT TURN D UNKNOWN• AHEAD OH F TRUCK OR TRUCK TRACTOR 1EMAKING LEFT TURN SIE FELL ASLEEP. B SIDESWIPE G TRK!TRK TRACTOR W!TLA IFMAKING U TURN C REAR END H SCHOOL BUS / G BACKING WEATHER MARK1T021TEMS pBROADS�,DE I OTHER13US'--- __.._ H SLOWING I STOPPING A CLEAR E NIT OBJECT J EMERGENCY VEHICLE 1 PASSING OTHER VEHICLE B CLOUDY F OVERTURNED _ _ K HWY.CONST.EQUIPMENT J CHANGING LANES C RAINING G VEHICLE:!/PEDESTRIAN L BICYCLE K PARKING MANEWER D SNOwiNG H OTHER•:lj _ MOTHER VEHICLE. L ENTERING TRAFFIC E FOG/VLSIBILITY FT. MOTOR VEHICLE INVOLVED WITH INPEDFSTRUM '"—. _ M OTHER UNSAFE TURNING j F OTHER': A NON-COLLISION O MOPED N)aNG INTO OPPOSING LANE G WIND B PEDESTRIAN _ O PARKED LIGHTING C OTHER MOTOR VEHICLE P MERGING A DAYLIGHT D MOTOR VER ON OTHER ROADWAY 1 Z 3 OTHER ASSOCIATED FACTOR Q TRAVELING WRONG WAY B DUSK-DAWN EPA RKED,MOTOR,VEHICLE (MARK 1 TO 2 ITEMS) -- R OTHER:• C DARK-STREET LIGHTS HFTRAIN VC SECTION VlouunON: WED D DARK-NO STREET LIGHTS ❑"o G BICYCLE:. . ..._.__ _ ❑No- - E DARK- STREET LIGHTS NOT H ANIMAL- B vc SEcnoN VIOunON: C3MO FUNCTIONING* X r;❑res Z 2.3 Sd (r! SOBRIETY-DRUG ROADWAY SURFACE ! FIXED OBJECT: —... ENO - PHYSICAL A DRY I C rc J!j TMoN VIOIATXWC CFMOE]YIES 1 2 3 (MARK 1 TO 2ITEMS) B WET - J OTHER OBJECT: '- - - - ❑NO A HAD NOT BEEN DRINKING C SNOWY-ICY -. _ _.. I '--- -• D B HBO-UNDER INFLUENCE D SLIPPERY(MUDDY,OILY,ETC.) E VISION OBSCUREMENT:.-. .. C HBO-NOT UNDER DIFLU: F INATTENTION' :_.. ROADWAY CONDITIONS •- :� G STOP i GO TRAFFIC '. D FAD-IMPAIRMENT LINK' -i (MARK t TO 2 ffE1tS) PEDESTRIANS ACTION E UNDER DRUG 1►FLU .� ANO PEDESTRIAN INVOLVED - H ENTERNG I LEAVING RAMP PHYSICAL- IN COLLISION G IMPAIRMENT NOT KNOWN )X?L£S DEEP RUTS' CROSSING M CROSSWALK : . NOT APPLICABLE B .. _ J UNFAMILIAR WITH ROAD B LOOSE MATERIAL ON RDWY.• AT INTERSECTION H K DEFECTIVE VEH.EQUIP.: crTED C OBSTRUCTION ON ROADWAY' C CROSSING M CROSSWALK-NOT ❑rEt I SLEEPY/FATIGUED D CONSTRUCTION•REPAIR ZONE AT INTERSECTION ❑ SPECIAL INFORMATION No E REDUCED ROADWAY WIDTH Q CROSSING•NOT IN CROSSWALK L UHINVOLVED VEHICLE A HAZARDOUS MATERIAL F FLOODED- E IN ROAD;=INCLUDES SHOULDER OTHER% G OTHER-: F NOT IN ROAD N NONE APPARENT H NO UNUSUAL CONDITIONS G APPROACH!LEAVING SCHOOL BUS Q RUNAWAY VEHICLE SK , - ._ - ._ _ .. __— MtCELL1WE0Ut LIJ,D/ �,I�Q,O 7� - F,rZ4ll Cs 7a c.J IND,CATt -� /'j Aj . '. 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L.l#C 41V AO S 4e j �/ t IJ 31. ! /� �re�/J�% D le- / i PREP R'S AME AND I.D.NUMBER DATE REVIEWER'S NAM DATE Use previous editions until depleted. 90 57541 STATE OF CALIFORNIA a /_ NARPATIVE/SUPOLEMENTAL CNP 556(Rev.7-90)OPI 042 j Page DATE OF INCIDENTIOCCURRENCE TIME(2400) NCIC NUMBER OFFICER I.D.NUMBER NUMBER '7 Zp 0703 / 9/ - 0562 'X'ONE TYPE SUPPLEMENTAL rX-APPLICABLE) ®Narrative ®Collision report ❑BA update ❑Fatal ❑Hit and run update ❑Supplemental El Other: ❑Hazardous materials ❑School bus ❑Other: CITY/COUNTY/JUDICIAL DISTRICT REPORTINGSTRICT/BEAT CITATION NUMBER J 3 LOCATION/SUBJECT C / STATE HIGHWAY RELATED d�}��U,�S T ,� C' ��L7/i9-rJ t ❑Yes �?No 1. c5779-7-6 lvl TS �C c 2. T)2 .5119L/10, A76 (f0L4: 4 7 ��MEM Ems/ E 3. cS 64-051^J6 1)4 4. 5. Q/�/N / /Js n� /O 6. / S7aXPiiJ ! 2 Lc Q cqfq6 D c 7. QR ALLf,ls T ,c'J�2 o AAffe SS gfr 8. 0 L4 7- 7M A'7-fme 7-A2./ 11 r0✓ l 7- 9. >aA+ei d G'D nl / ✓ / r.l 10. 616 /.�/ Z 6 0,z' ©44HU e-s T 11. / /✓1A-i L !-�i�l . 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A aw O a) v H >4-r-I C: w n n n cr S4 C .0 E-c n n O Ln (a w v a UU �10X U W a . rb-ir t„ o� o R k • • N <:> cc' c,, , W GO v o � L p� CA ¢ a U N o v c v Q iy o CGU c U C; �r V) ¢ cn f' CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA ,; Iaim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT March 24, 1992 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: $7,859.06 Section 913 and 915.4. Please note all "Warnings". CLAIMANT: MODERN, Alexander E.R. RECEIVED ATTORNEY: Stanley L. Smith, Jr. FEB 2 8 1992 Attorney at Law Date received � UNSEI ADDRESS: 2575 Grand Canal Boulevard BY DELIVERY TO CLERK ON February 27=�°, Suite 201 February 26, 1992 Stockton, CA 95207-8260 BY MAIL POSTMARKED: y I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. PpHHIL BATCHELOR, Clerk DATED: February 28, 1992 BY: Deputy _ (1.4414 II. FROM: County Counsel TO: Clerk of the Board of Supervisors This claim complies substantially with Sections 91.0 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: 2 2 2 BY: U . ANDA Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present (� This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. 4 Dated: MAR 2 4 1992 PHIL BATCHELOR, Clerk, By 0a Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. if you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: MAR 2 4' 199 BY: PHIL BATCHELOR b Deputy Clerk CC: County Counsel County Administrator STANLEY L. SMITH, JR. ,} • ATTORNEY AT LAW 2575 GRAND CANAL BOULEVARD, SUITE 201 STOCKTON, CALIFORNIA 95207 (209)474-6336 February 26, 19 2 (RECEIVE® Clerk of the Board of Supervisors FEB 2 7 1992 COUNTY OF CONTRA COSTA County Administration Building CLERK BOARD OF SUPER 651 Pine Street, Room 106 CONTRA COSTA CO Martinez, CA 94553 Ladies and Gentlemen: Re: Claim of Alexander E. R. Modehn Enclosed herewith please find original and copy of Claim by Alexander E. R. Modehn against the County of Contra Costa. Please file the original claim and return the filed-endorsed copy in the self-addressed postage-paid envelope provided. Thank you for your attention to this matter. Ver tru y you s, S LEY L. MITH, J l ✓ SLS/lrs Enclosures: 3 pc: Mr. Alexander E. R. Modehn Claim to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. Claims relating to causes of action for death or for injury to person or to per- sonal property or growing crops and which accrue on or before December 31, 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 again-,t each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this orm. RE: Claim By ) Reserved for Clerk's filing stamp ALEXANDER E. R. MODEHN ) RECEIVED Against the County of Contra Costa ) FEB 2 7 W2 or ) District) CLE BOARD OF SUR COM RA OSTA CO. Fill in name ) The undersigned claimant'hereby makes elaim'against the County of Contra Costa or the above-named District in the sum of $ 7, 859 . 0 6 and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) November 6,1991 , at 3 : 40 p.m. -----------------.._---____�_�------------- 2. Where Ofd the damage or injury occur':' (Include city and county) State Route 4 at its intersection with Sellars Avenue, 'Contra Costa County, 3. How did the damage or injury occur? (Give full details; use extra paper if required) Please see attached copy of State of California Traffic Collision Re Port. 4. What particular act "or omission on the part of county or district officers, servants or employees caused the injury or damage? The failure to post warning signs on Highway 4 heading east to slow down for dangerous intersection, .and/or the failure to install traffic controls .at the intersection:. (over) 5. What are the names of county or district officers, servants or employees causing the damage or injury? Unknown. 6. What damage or injurries'do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. See Attachment (6) . --------------------------------------------------------m How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) See Attachment (7) . ------------------------------------------------------------------------------------- 8. Names and addresses of witnesses, doctors and hospitals. See Attachment (.8):. ------------------------------------------------------------------------------------- 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT 1 See Attachment x(:9)4 ; s f Y . x Gov. Code Sec. 910.2 provides: "The claim must be signed b the claimant rrtg Y SEND NOTICES To: CAttorney) or by some person on his behalf." Name and Address of Attorney I I I--- STANLEY L. SMITH, JR. AN-Q, ,�- -;� — Attorney at Law Claimant's Signature 2575 Grand Canal Boulevard Suite .201 316 Sparrow Lane Stockton, CA 95207-8260 Address Lodi, CA 95240 Telephone No. (209) 474-6336 I Telephone No. (209) 368-5521 �t 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 ($10,000, or by both such imprisonment and fine. S�RTI UOf Ca.U.'trM C4RNiA . OLLISION REPORT 131991 PAGE of SPECIAL CONORIC^.A NUMBER NTS RUN CR)Y�A' A JUDICIALDI"RICT LOCAL REPORTNUMBER INTSO "Lot" ham NUMBER NTi RUN REPORTING DISTRICT BEAT ,I ru Eb p aoc-srAJ60 4J/vt L.I COLLISION OCCVRj��+ ___�--~ _ _r-____-___`_-_-_ -_ AT = IME i+'i/ } t OFFICER 2 MILEPOST NFORMATWN .OAYO EK TOWAWAY PHOTOGRAPHS SY: < N' 0 C C q0 4� S M J � F S ]YES SND U II /-'} f j� (,�/�y/ {TATE HWY REL AT NTER*ECT101E WITH �C _ . ", OR: FEET.!NLf$ OF MY" 0,40 NONE PARTY DRIVER'[LICENSE NUMBER STAT[ I CLAS{ SAFETY Vtll Y4M MAKE/MODAL/COLOR LICENSE NUMBER STATE OPoVER NAME(FIRST.WOOL[.LAST} y� G (•/eP sc-OI/ LC PEOM STRUT ADORES$ OWNER'S NAME ❑SAME At ONVER p ZYC3 qu-�1�<?N 'r=04 A PARKED CRY/STATE I=II O'NN[R't ADORE" SAME AS DRN[R ❑ y+'1 OCI�/N � �i`t Lr. � �L.�._.'��i �� �. t�l�. �.�T �... vir.� •J v�� NMR tVt{i FIitONT YPppiiT BIRT�1OAtt PACE OMPOBRTWNOFY[NIC4t ONORD[RBOP: afRC[R pY[R OTHER CUST CAY Y ❑ ❑ OTHER HOME►NONE BUSINESS/HONE PRIOR MECHANICAL DEFECTS: NONE APPARENT REFER TO NARRATIVE ❑ (S/,(�--)y��r-- �9 (Y/.s 571<111— '� o CHf UBE ONLY OEStN$E YEHCL[CAM A09 SNADtNDAMAGED AREA INSURANCE CER .00YINCLE TYPE 0Y NUMBER i QiNK. NON! ❑MINOR ❑MOD. MAJOR OTOTAL pR.0l ONS}TR.�ElET OR NONVtAY � ! �t SPEED IPuc CC Q CJ4L.�C�*G/"'*✓ / +}i,J i �E«+}- )jV�.. clRvCHP Q PARTY DRIVtR1UCENSENUMBER STATE CLAtt SAFETY YtH Y MAK[I MODEL[CWO ENSENUASE# itATE a ,©Zo2.s-Z s� � C E r�oS1�- (Ac i ' . OPoVER NAM[(FIR*T.MIDDLE,LAST) • . & AC �-,Xv9,06< PEDES- STREET ADO RES* Q OWNERY NAME 4AMR AS DRIVER TRIAN 316 S t-QPm'o -/ PARKED CITY/$TA�T�RIZIP „ p �r�t- ? (/ OWNS"ADORES$ SAME AS DRIVEN VENCLE /�,I BIGr• Six I HAIR [YES NE761R YYpaNT' BIRTHDATE RACE OIBPO MON OFVVICLI ON ORDERS Of' QOfiFlCtR DRIV4R QOTNER CLQ tri �J�A3 ZZ S%3 Lt/ -PIZ4 VL"Q OTNCR HOME PHONE /j BUSINESS PHONE PRIOR MECHANICAL DEFECTS: NONE APPARENT REiER T6 NARRATIVE Q ❑ (Z6�� CHP USE ONLY Disc VEHICLE DAMAGE 04ADC N OAMAOED AREA VEHICLE TYPE �] INSURANCE CARRIER SOUCY NUMBER r]mots OMINOR I MOD. OMAJORTOTAL DIK Of ON�t)TRSdT OR HW�AY lspni—i—oR'CI W ,...._�w f cc Q �•~' •' PUC CHPQ PARTY DRIVER t LICENSE NUMBER STAT[ CLASS SAFETY RAI MAKE 1 MOOEI+COLOR K ENS[NUM*ER iTATE 3 ��� y hLJ �tAV?? CA DRIVER NAME(ARST.WOOLK.LAST} Plot$- STREET ADDR99S OWNERJNAy� OSAMS At DRIVER PARKED CRY/STATE ID► • OWNER'S ADDRESS DSAME At DRIVE�IAwl YEa E , �,rs't. l2f S' v, CA '?` BICY• SEXk�AJR EYES HEIGHT INUGHT SIT"DATI MO. I DAY ; YEAR RACE DISPOSITION Of VEMCLt ON ORDERS Of: ❑OfFlCER RIPER DOTHE.R CLO M �, QC.�c' �? ra'C� / �►/ ; y.3 i� 7)1'-kfVc u OTHER HrOME PHONE �} BUSINESS PHO UN JE ,( PRIOR MECHANICAL DEFECTS: NONE APPARENT REFER TO NARRATIVEQ ❑ (S/0 ) -54,80p 5 ,8OV S' (51 0 I7�5U CHP USE ONLY DESCRIBE VEHICLE DAMAGE SDS W OAMAGED AREA i V[NCLt TVP[ INSURANCE CARRIER POLICY NUMBER 0/ I ^ ❑ '� TOTAL OIR.OP ONSTREETORNGHWAT $►EEO ICP =13 �AqO, Y Pvc 4y e"P Q nr Q PREP A-* a DISPATCH NOTIFIED IFIRA77 DAT4fREVA*11O r5rv� 5-b `? �V v OYES ONO E3 VA 4A // ��/ =j II CHP SSR PATES 1 I RSV t.R61 (W4 042 STATE OF CALFORNA TRAFFIC COLLISIOWC , DINGA • PAGE DIS?E OF COLLISION 9 nYE(1001 NCK NUMBER �J FIIC[R I.D NUIS[R - MO.. I DAY L74YEARI/ 15 / OWNER'S NAM[I ADDRESS NOTIFIED PA e DAMMAGEAGE ❑r[s ❑No DESCRIPTION OF DAMAGE SEATING POSITION SAFETY EQUIPMENT EJECTED FROM VEHICLE OCCUPANTS L-AIR BAG DEPLOYED M/C BICYCLE-HELMET - A:NONE IN VEHICLE M-AIR BAG NOT DEPLOYED DRIVER •NOT EJECTED B•UNKNOWN N-OTHER DRIVER 1-FULLY EJECTED C-LAP BELT USED P-NOT REQUIRED V-No 2-PARTIALLY EJECTED I-DRIVER D-LAP BELT NOT USED WO 3-UNKNOWN 1 2 3 E.SHOULDER HARNESS USED 2 TOE-PASSENGERS F-SHOULDER HARNESS NOT USED SHLD RESTRAINT PASSENGER 4 5 6 T•STATION WAGON REAR G-LAP/SHOULDER HARNESS USED Q-IN VEHICLE USED X E•REAR OCC.TRK. VAN H•LAP I SHOULDER HARNESS NOT USED R-IN VEHICLE NOT USED Y-YES 0-POSITION UNKNOWN J-PASSIVE RESTRAINT USED S-IN VEHICLE USE UNKNOWN 7 0.OTHER K-PASSIVE RESTRAINT NOT USED T-IN VEHICLE IMPROPER USE U-NONE IN VEHICLE ITEMS MARKED BELOW FOLLOWED BY AN ASTERISK(•)SHOULD BE EXPLAINED IN THE NARRATIVE PRIMARY COLLISION FACTOR TRAFFIC CONTROL DEVICES 'Z 3 TYPE OF VEHICLE MOVEMENT PRECEDING UST NUMBER (B)OF PARTY AT FAULT 'I 2 3 COLUSION B Avc SEECTIOfP OLATED: c'.T..0 ACONTROLS FUNCTIONING APASSENGER CAR/STATION W OH ASTOPPED YES ZI■`+ `A V�+ No B CONTROLS NOT FUNCTIONING• B PASSENGER CAR W/TRAI B PROCEEDING STRAIGHT B B OTHER IMPROPER DRIVING•: CONTROLS OBSCURED MOTORCYCLE/SCOOTER C RAN OFF ROAD [)NO CONTROLSPRESENT/FACTOR• CKUP OR P!':N�L TRU D MAKING RIGHT TURN (;OTHER il;Z d DRIVE:• TYPE OF COLLISION E PI P/PANEL TRUCK W/TRAILER JE MAKING LEFT TURN D UNKNOWN• HEAD-ON F TRUC TRUCK ACTOR F MAKING U TURN B E B SIDESWIPE G TRUCK/tkUCK MACTOR W/TRLR IG BACKING I IC REAR END H SCHOOL BUW Hamm/STOPPING WEATHER( MARK 1 TO 2ITEMS) D BROADSIDE I OTHER BU I PASSING OTHER VEHICLE ACLEAR E HIT OBJECT J EMERGE Y VE ,1 CHANGING LANES B CLOUDY F OVERTURNED K HG Y CONST.F&41PMENT K PARKING MANEUVER C RAINING G VEHICLE/PEDESTRIAN L 111 4LE L ENTERING TRAFFIC D SNOWING ffOTHER MsftHFR VEHICLE M OTHER UNSAFE TURNING E FOG/VISIBILITY FT. MOTOR VEHICLE INVOLVED WITH M PEDESTRIAN I IN XING INTO OPPOSING LANE F OTHER IANowcowsooi 0 MOPED I I PPARKED G WIND IB PEDESTRIAN P MERGING LIGHTING C OTHER MOTOR VEHICLE TRAVELING WRONG WAY A DAYLIGHT D MOTOR VEHICLE ON OTHER ROADWAY OTHER ASSOCIATED FACTOR(S) OTHER*: B DUSK-DAWN E PARKED MOTOR VEHICLE 1 2 3 (MARK 1 TO 2ITEMS) CDARK-STREET LIGHTS FTRAIN Avcs[cnONrlOLAnON: CFTEp D DARK-NO STREET LIGHTS G BICYCLE Grp 1]No DARK.STREET LIGHTS NOT ANIMAL: B vc s[cnoN vloLAnoN: eITEo FUNCTIONING• E3Yp ROADWAY SURFACE OM SOBRIETY.DRUG FIXED OBJECT: VC SECTION VIOLAn PHYSICAL A DRY 1 C oy 1 2 3 WET ❑rEs (MARK 1 TO 2ITEMS) B OTHER OBJECT: ONO SNOWY-ICY J DX Y N JAHAD NOT BEEN DRINKING D SLIPPERY(MUDDY,OILY,ETC.) E VISION OBSCUREMENT: B HOD-UNDER INFLUENCE F INATTENTION': HBD-NOT UNDER INFLUENCE; ROADWAY CONDITIONS) HBD-IMPAIRMENT UNKNOWN (MARK 1 TO 21TEMS) PEDESTRIANS INVOLVED G STOP L GO TRAFFIC E UNDER DRUG INFLUENCE' A NO PEDESTRIAN INVOLVED H ENTERING/LEAVING RAMP A HOLES,DEEP RUT`' I PREVIOUS COLLISION F IMPAIRMENT-PHYSICAL' _ B CROSSING IN CROSSWALK UNFAMILIAR WITH ROAD IMPAIRMENT NOT KNOWN IjLOOSE MATERIAL ONROADWAY* ATINTERSECTION NOT APPLICABLE C OBSTRUCTION ON ROADWAY• CROSSING IN CROSSWALK-NOT K DEFECTIVE VEH EQUIP.: p7ED pr[B I SLEEPY/FATIGUED D CONSTRUCTION-REPAIR ZONE AT INTERSECTION ONO SPECIAL INFORMATION E REDUCED ROADWAY WIDTH D CROSSING-NOT IN CROSSWALK I I IL UNINVOLVED VEHICLE AHAZARDOUS MATERIAL FLOODED• IN ROAD-INCLUDES SHOULDER IM OTHER-: OTHER.: I IF NOT INROAD NONE APPARENT IHMO UNUSUAL CONDITIONS APPROACHING/LEAVING SCHOOL BUS I 1 10 RUNAWAY VEHICLE SKETCH � MISCELLANEOUS ' I s 11101'ATU RTN _�-HQ HODOT vim( -•---_CR CRN"? ._._19C CN.p SIB CT OTHER ' S�LJhK Qj. 3 STATE OF CALIFORNIA i WAR RATNE/SUPPLEMENTAL CHP 556(Rev 7-90)Opt 042 Page DATE OF INCIDENTIOCCURRENCE TIME(24 i NCIC NUMBER OFFICER I.D.NUMBERMBER //- 06 -9/ 1 IWO 173Z-10173Z-10NU nsl //-6 •X'ONE 'X'ONE TYPE SUPPLEMENTAL,.t'X'APPLICA$LEI J Narrative Collision report ❑BA update ❑Fatal ❑Hit and run update ❑Supplemental ❑Other: ❑Hazardous materials ❑School bus ❑Other: CITY/COUNTY/JUDICIAL DISTRICT REPORTING DIST RICTlBEAT CITATION NUMBER LOCATIOWSUBJECT STATE HIGHWAY RELATED ❑Yes ❑No 2. ��. PJ�TGt � Tti A Tk mr—15s0 /Aq AM4 ifs? o 0 SCcl-g Ar /60,6 t 3. 4. ( Zi- (MM s 6 /Mf /?/. ��f ��1 1 1,7r "4 9 ? 't'�l�E L�-i r• .5. Iw fR Si'1 .f 1�?'r�'A4f A(/V& R-L(Artf 1�'1._ 7.?- 3 p M _IV16 �Z UW /?V SiM) /N' art x, �- atm v-Z . A-s n, Z ,1rZu a ra AVa J) V- / !- rk�Ab [6. 8 1h( Vt' lkt,� si r- v-l. �t J�-! x/D�n IVOC44 l� 9: t A NT' C5 ' v-! / t V Ca t_.c_1 D� w r?� i7 i'f �r' Ux" '-3 . 10. w l geAA in1ED t1. V -1 /t Rt) '2. l>1b' 12. 13. ta�NT` - Sika ,#AW 6` -T6Y VIC s E PSK ae 14. v w 6!-~ mv E` Qfs4!r' dy -5j=U/mU AIV- (t-�,r 15. 16. 17.-D—/ &'S�UPI C -b r c-.— t V l h L1Nf7#Al Gl'-- --2-1.r6 MV u<_._. 18. ( /&6f6!� 173 yj 19. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. PREPARER'S N NO I.D.NUMBER DATEREVIEWER'S NAME DATE I//—0VL rqI Use previous editions until depleted. 90 57541 Claim by ALEXANDER E. R. MODEHN (continued) Attachment (8) : Names and Addresses of Witnesses, Doctors Witness: James Allen Oliver 1180 Sunset Road Brentwood, CA 94513 Doctors: R. C. Jensen, D.C. 2531 N. California Street Stockton, CA 95204 Anthony Rishwain, M.D. 2800 N. California Street Stockton, CA 95204 Attachment (9) : Expenditures Made on Account of this Accident and Injury DATE ITEM AMOUNT 11/15/91 Automobile repair . . . . . . . . . . . . $3 , 257 . 58 12/4/91 Automobile rental . . . . . . . . . . 945. 61 12/6/91 Automobile repair . . . . . . . . . . . . . 39.50 12/20/91 Prescription medicine . . . . . . . . . . 46. 05 12/9/91- Medical treatment . . . . . . . . . . . . 1, 570. 32 TOTAL . . . . . . . . . . . . . . . . . . . . . . . $5 , 859. 06 Claim by ALEXANDER E. R. MODEHN Attachment (6) : Damages and Injuries Claimed Actual and estimated costs of repairing damage to claimant's automobile; actual cost of renting a car while claimant's automobile was being aligned; costs to date for medical treatment of claimant's personal injuries, which include neck pain, severe headaches, and low pack pain, and which require continuing treatment; cost of medicines prescribed; compensation for pain and suffering and the inconvenience of losing time from work, for a total of $7,859. 06. Attachment (7) : Computation of Damages and Injuries The amount claimed above was computed as follows, ' and copies of estimate and invoices are attached: A. Estimate, Friendly Body Shop. . . . . . . . . . . . . $3 , 257.58 B. Invoice, Enterprise Rent-A-Car. . . . . . . . . . . . 945. 61 C. Invoice, K & K Tire and Wheel (front-end alignment only) . . . . . . . . . . . . . . . . . . . 39 .50 D. Invoice, R. C. Jensen, D.C. , . . . . . . . . . . . . 305. 32 E. Invoice, Anthony Rishwain, M.D. *. . . . . . . . . . . 1, 265. 00 F. Invoice, Longs Drug Stores, prescription medicine 46. 05 G. Pain and suffering and inconvenience. . . . . . . . . 4 , 000. 00 TOTAL . . . . . . . . . . . . . . . . . . . . . . . . $9 , 859 . 06 *$55. 00 has been added to fees stated on invoice to cover scheduled follow-up appointment. The amounts attributed to pain and suffering are concomitant to the physical injuries suffered by claimant. Claimant has also been inconvenienced by visits to his physicians and lost income from his profession as a certified life underwriter. rrv-� 2 32.`L ' jge` of Pages 0 FRIENDLY BODY SHOP 3805 N. West Lane Suite A-2 STOCKTON. CALIFORNIA 95204 (209) 465-9851 DAME PHONE DATE 3TREET CITY YEAR COLOR MAKE MODEL tll Oyu I, IV(•D f ,2EGISTRATION NO. SERIAL NO. - ODOMETER ESTIMATE PREPARED BY WSURANCE CO. ADJUSTOR REPLACE REPAIR t� DESCRIPTION PARTS LABOR REFINISH SUBLET $2 U -7 • v o O CA I >1- . i �� E � »-.• tl tet. Q .:,. u s o , 3 � . J. r tl d N c e b d `T TOTALSq The above is an estimate based on our inspection and does not TOTAL PARTS ............... . $ 9 7' !:F—e) cover any additional parts or labor which may be required after the work has been started. Occasionally. worn or damaged parts are TOTAL LABOR ................ $ 0 e--.D discovered which may not be evident on the first inspection.Because of this.the above prices are not guaranteed.Quotations on parts and TOTAL REFINISH .............. $ :2 labor are current and subject to change. AUTHORIZATION FOR REPAIR.You are hereby authorized to TOTAL SUBLET .............. . $ 7 ' 3 make the above repairs: TAX ......................... $ r t/ U • 7 SIGNED: �_� $ ;? S 1� DATE: ��- / S ��f TOTAL ....................... $ ENTERPRISE RENT -A -Cj�R _ h i: r r •I .:L1 � F r 11E I� Ni• •: :r.— E, (,,."P' T1 7:31)A- 6•-'Xl- ZMA � a'r i!._ L _ IIETi 7 It'. 730A- 6j. OOP ' • .1,. ..'l; Ol i F[i.•7} I�:Ia' 6:00P SA 9:WA- 1 t.00P . ' YEAR , }G�{iC•l+({- •.. f.{L,F,,_ ` D P-57x7,/' •.� ,1.. —/ 1 RENTAL 7 q'.. , J/ N iYF'i ! —i---- REN�F! •1 YEAR, O 4�lb f ' .... F.•'_. 11 r_jiIi ':I :•L,..,: M'1\V'°CHAkGE - nAILd .0 ub rt,tl Nr nl/1114,•,••. .-..�- ., .. ,. /�}y`VII�`lL ' --1A ORIGIN .f i). :.IAlf. AL VEHICLE; LUCA[AUUIII.:..., PHONE ,. 7)_..11-117 5TA[E,«+ EXPIRE} r C HOURS _... _._ &(.:1%c/5',J 10.00 _ _ - .v:11y. IH:(ylU , , wElt.y r,,l.. :L.4yy .{rp :, UAYsIN . e , ..1_•.. • .. :,GE � -- 1 ..w.:A� r►r pNl[.,.., I:M1'I 0411!.; DRIVEN - - �. � x CONDI NOUT INTO BILL �' l•i/MI"rr _ r M DR/FDR \ AuoNLss DRfFD— R STATE ZIP UH/FDH� ,nr URIFD ` n11N — — PHUNI &XT. 1 _—�— RI NU II ACCEPTS Hf NJE FI NI NrEN NE Wnsls e•Nn•I u•uA.,l wu.IN H •II INK,!PARE \ UAMAI,[ row Ar nul.n1 s»Dwn IN uuuINlN.r cul �'' "�. —`- RI-SP,1Nt,IHILIFY X N NII Af vI NSI IN1I IS NUr.NSUNANfF X �.. %L COVERS HF NTER DECi INES iENTF.R ININiIU NfDUESI1 VfNWN•I ACQUENl lNsuN Ell - 1� ■� .�1. VE HS[INAI ,(/{ ANC .VAn Ai DAII.Fir,NOWN IN AD,Ar'.FN1 E 1/s 1A Vs 1/2 'F• 'M T/a F ACCII,I NI IN.',IIIIA NE:f X ,`'' l ]YI/MN AND wAi WAD INF M CY cf.".If.A 11 X IN E 1A 1/4 3/a 1/2 $/i 3/14 T/a F REQUEST FOR PERMISSION FOR PERSON OTHER THAN RENTER TO DRIVE. Nr it VAI ill UNI I SS A""Iri I:i 11 BY LNII.NW/ISL•::RFP1iLSLN JAI IVL t• ' EPLACEMENT VEHICLE IIPVunNl lntarynat's pcuruSywn D SJATE EXP. TAX OR SURCH;�7��y i I .•J! .gq. 9 r..aro.e:.,,.r,..-rr...m r:.Ixn n,:.•xo 1r r:I mr uIa.r•mr Mnau n rs xM wa ana.preen Ina 1 ana I a relDUname Fy r'FNta NO Aul Ine+:Inn.rnnl•I•J xnr+nxe ¢ 'Alt l•r FL ' ' M acllnp 1,-) Ural r r .( A01H BY KV X I I NiFH iF F'C' /V f-y 't FNTE.RPRISE'S REP L' w PERMISSION GRANTED FOR VEHICLE TO LEAVE THE STATE. 1.1 Y!S NO STATE:'. AUTH BY 011l 1 7 EN TLRPHISL'• NEI' - WIIVLN I 1 I ! T. AL CHARGES CONDITION roof l IN 1 '°' 'p"'#`N "� 'F ((u� LESS REFUNDABLE 6 y1 i/, ,n✓ J r r, , s ?_,ik �` 4 I EXP LNSES — -- - ;III'f-(1j( - F: v,vlw w �,. .._— :.,, , , `!'�+°tI.:r yam- 1 w f~,ar.1 �l .pry' fJI:-T AMOUNT t , 4. DEPOSITS lil NI11, AIL IIII'I IRI ,, —a-� i rilr[;LASS i X r _ '�IREFUND FNTFR RISE - EMPL1NKISPANE x • �.,_r,1' _ 7. o IL.COVERS L Afl (1NIL. AMOU rAlp PI DA E PAID 1 1 CLOSED BY HI IIIHN S/lr\_ rr i'1� z5 uul E Iys Ih va 1/2 Sri s/4 T/8 F CAR BY .:. •DEP VV 1 . 'N E Ve 1/4 2/s 1/2 % 2/4 Ma F EXT. ADUrL ID CASH CHECK CR. ARD CHARGE TO L �� LR v U FJ X I F BY EXT. , I Anul'1 RECEIPT FOR CASH REFUND TO DATE -- EXT. ADDT'L �(� RECEIVED AMOUNT _TO DFv tta BY X ' EXT nonrl "`' XT DFP CLAIM INFORMATI N,;,:{. , - -- - -- �—_._ ADDI110NAL INF OHMAIION POL. ON LOSS DATE THEFf--___1CCi0ENT_ x PHONE NAME ' --_ _- - -- uE F , IIFPAIR SHOP ' HN -- At . h . r TYPE CAR L"c257379 amG c x D G G W a yr c'a m ^� o a_no4 �m Q�io 'N m m D a3cm Zoa r r r ❑ G C • .. 00 �u� �iSZ y r to C oo p r r r- = tt2 w %E ym$p3 m z "' o i�)e zm S^ • Km �S > Cl) m "' i..l umy n m m T �' m^A m.1a1yr oCl) 0 0 [� s N a o z RmpSo� Z 3 "^ y m m m 2 per' c 3 ❑ N ❑ ! o O a SZ m CD oo CA 0 9 pfg�jg OR Co ����°° � � m coo �.. . .. -i � '•` oaoB� o O to •�n a R. -+ in r pt-1 -A O ' m$ 1it'll r -, m a a N N 'S m cm ao cl E. 'v A .n Z �. �oi ra m 3w m a x �ren C') ... �. .�. ". CA n > y C)c Z 0 mDm co so ow a rn o �`: Z r m Q S D >. �� 3 o'Z rn b m m ? -i m ro y �°• m a y c r �tZx �t c 21, F m "` > m 0,v a Z9 oz m m ,.,c cs m e p p m p So cop 2 O.t m D 13rt .m Z 7aD N N `y{2r .�� z z !^ XG)m y �4�o c �a'e 3 vi m (x� Q 3� R1 mm y mG 1 ! Cl 0 ❑ r �' PLEASE DONOT NEW YORK L1. STAPLE IN P.O. BOX 600-A ' THIS AREA STOCKTON CA 95201 t' MEDICARE MEDICAID CHAMPUS CHAMPYN FECA BLACK LUNG O'MER (MEDICARE NO.) - (MEDICAID NQ) ISPONSOR'S SSV) (VA FILE NMI ISSN( ICE1rt1FlCATL fSN) PATIENT AND INSURED(SUBSCRIBER)INFORMATION 1. PATIENTS NAME ILAST NAME.FIRST NAME.MIDDLE INITIAL) 2. PATIENT'S DATE OF BIRTH a INSUREO'S NAME(LAST NAME,FIRST NAME,MIDDLE INmALI MODEHN ALEXANDER E MODERN ALEXANDER 4. PATIENTS ADDRESS(STREET.CITY.STATE.ZIP CODE) S. PATIENTS SEX S. INCLUDE ALLLET.(FDA PROGRAM CHEft; ABOVE• 316 SPARROW LANE MALE FEMALE 550-56-7769 LOD I CA 95240 T. PATIENT'S RELATIONSHIP TO INSURED 8. INSURED'S GROUP NO.DOR GROUP NAME OR FICA CLAIM NO.) SELF SPOUSE CHILD OTHER G-610 EMPLOYEE 309874 - INSURED IS EMPLOYED AND COVERED BY EMPLOYER TELEPHONE NO. 0 Ej HEALTH PLAN S. OTHER HEALTH INSURANCE COVERAGE(ENTER NAME OF POLICYHOLDER AND 10, WAS CONDITION RELATED TO 11. INSURED-S ADOHESC(STREET.CRY,STATE.ZIP CODE) PLAN NAME AND ADDRESS AND POLICY OR MEDICAL ASSISTANCE NUMBER( A PATTENr'9 EMPLOYMENT 316 'SPARROW LANE NO SECONDARY CARRIER YE3E-1 M- I,QDI CA 95240 NE TELEPHONO. (`209) 368-5521 B ACCIDENT Ila C1AA"SPONSOWB: AUTO1 ^I OTHER 1 ACTIVE 0 DECEASED BRANCH OF SERVICE LTJ STATUS I DUTY 1 RETIRED 12. PATIENTS OR AUTHORIZED PERSON'S SK"TURE(READ BACK BEFORE SIGMN{) 13. 1 AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO UNDERSIGNED I AUTHORIZE THE RELEASE OF ANY MEDICAL INFORMATION NECESSARY TO PROCESS TMS CLAIM.1 ALSO REOIJEST PAYMENT pF4ySIG IAN OR SUPPLIER FOR SERIAL rlf WARMED BELOW. OF GOVERNMENT BENEFITS EITHER TO MYSELF OR TO THE PARTY WHO ACCEPTS ASSIGNMENT BELOW. S].gna to re On File 9 0NED Signature on File DATE 12/1-3/91 %NED(INSURED OR AUTHORIZED PERSON) PHYSICIAN OR SUPPLIER INFORMATION L. DATE OF. f ESS``FIRST SYMPTOM OR MURY S. DATE FIRST CONSULTED YOU FOR THIS 18 IF PATIENT HAS HAD SAME OR 18e. IF EMERGENCY 11/06/91 IACCIDEINT)OR PREGNANt?Y(LMP) CONDITION 12/09/91 SIMILAR ILLNESS OR INXIRV•ONE DATES CHECK ER 11.DATE PATIENT ABLE TO IS,DATES OF TOTAL DISABILITY DATES OF PARTIAL DISABILITY RETURN TO WORK FROM THROUGH FROM h1ROl10H 10. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE(wO•,PUBLIC HEALTH AGENCY) 20. FOR SERVICES RELATED TO HOSP101LIZATION ONE HOSPITALIZATION DATES M"T1E0 OIBCIOIRGED 21. NAME AND ADDRESS OF FACLrtY WHERE SERVICES RENDERED(1F OTHER THAN HOME OR OFFICE) 22. WAS LABORATORY WORK PERFORMED OUTSIDE YOUR Offr0 VES NO CHARGE& 23. A DIAGNOSIS OR NATURE OF ILLNESS OR"JURY.RELATE DIAGNOSIS TO PROCEDURE IN COLUMN D BY REFERENCE 1.2.3. B ETC.OR DX CODE 1.847.OWFC. FLEX ACCELERATION DECELERATION SYND. EPBDr YES ❑NO 2. - FAMILY PLANNING YESEl ANO 3. ——--——————————- -————-- AUTHORIZATION NO. 4. 24. A 8• FULLY DE DUREB,_MEDICAL SERVICES OR SUPPLIES D. F. H. LEAVE BLANK OATS OF SERVICE PLACE FURNISHED F EACH DATE Olrvv�eN OF PROLE 1- MAONOWS E. OR O. N SERVICE ( Tl r ) IE PLAM RW C T JDE S T9 To 1 1 1 I 1 i I 1 1 1 1 25. SIGNATURE `YS IAN OR SUTHAT STA TA#MMENDI G THE REVOR ERSE APPLY TO 18. ACCEPCLAIMS ONLY)(SEE KOOVERNMENt 27. IOTA(,CHARGE I 28. AMOUNT PROD 2/.BALANCE 011E THIS BILL AND ARE MADE A PART THEREOFI 2343 00 23.37 YES17 NO 3l, FAnM1HYSICLWFQNpS SSUPPII IIIFR'S AND/OR(10 NAME.ADDRESS,ZIP CODE 30. YOUR SOCIAL SECURITY NO. 0 v+v'- I v 2� JENSEN CHIROPRACTIC CLINIC. 2531 N. CALIFORNIA ST DATE: 32. YOUR PATIENTSACCOUNTMo. 33. roupEMPLorERI.O.No. STOCKTON CA 95204 ID NO. 3206 9112006X 94-2583765 • PLACE OF SERVICE AND TYPE OF SERVICE(T.OS.)CODES ON THE BACK APPROVED BY AMA COIJ14CIL ON MEDICAL SERVICE 8/83 Form HCFA-1500(1-84)(C-2) Form OWCP-1500 Form CHAMPUS-501 Form ARB-1500 Z/13/91 - PATIENT FINANCIAL HISTORY page 1 JENSEN CHIROPRACTIC OLIKIC, INC.. Accounts $205 - 3205 All Dates .ect Date Dep I Neae Oro Procedure Diag Units Amunt 846 140DERN,ALEgAl4DBR Previous Balance ; 0.00 . 12/09/91 0 NODBHN,ALBXANDER 1 91200 0 V WITH KODALITIBS 847.OWF 1.00 23.37 12/09/91 0 NODERN,ALBXANOER 1 90030 OFFICE vISIT LIMITED 847.0NF 1.00 32.00 12/09/91 0 NODBHN,ALRXANDBR 1 72100 LUMBAR AP/LAT 847.ONF 1.00 53.00 12/09/91 0 KODERN,ALRXAMDER 1 12050 CERVICAL COKPLBTS 0.5 847.OVF 1.00 75.00 12/09/91 0 KODIHN,ALBXANDER 1 90015 INITIAL INTERMEDIATE EXAM 847.OKF 1.00 64-58 12/11/91 0 NODEHN,ALBXANDER 1 90050 OFFICE VISIT LINITBD 647.0NF 1.00 32.09 12/11/91 0 KODBHN,ALEXANDBR 1 97200 0 v WITH MODALITIES 847.0NP 1.00 23.37 --,------ ------ ----- TOTALS FOR ACCOUNT 3206 PAYMENTS : 0.00 ADJUSTS : 0.00 CHARGES 305.32 7.00 305.32 REFUNDS: 0.00 _. .... ............ ............ 0.00 305.32 305.32 12-13-91 , PLEASE BE ADVISED TEAT THIS IS NOT A FINAL BILLING NOR CAN WE GIVE A FUTURE ESTIMATE OF COST FOR FUTURE CARE AT THIS TIME, IF YOU SI4OULD HAVE ANY QUESTIONS PLEASE CALL THIS OFFICE. SANDY NEER OFFICE MANAGER (209) 464-7738 • ! � .I...I JAN. pro.I IIi MAN, A►AIL1MAV1JUN[�JULV�A UO.�[[►1,�OCT.�NOV.ID[C. NO � a_ L -_ III 11 swi D Z fiOLLOWUR It OLORST ITEM y Dh. R.iahwa.in Accident Account. NAME MODEHN, ALEX NAME OF 1 t nuaeANo oa wlFa j i ADORES l6 SPARROWLK. 95204 TELEPHONE 368-5521 i OCCUPATION REFERENCE C NARG ES CR Epi TS OLD DATE O A 8 C O 11-1 MISC. ON ACCT. CASH ADJ. BALANCE BALANCE ?a� 7d5 7 � 9?" 7opp ! So X05 sly ' 1 r t l�rtt �v '/Zlk L rf z1;/ I r 1 040 100 Wed Lodi Ars.Lodi,CA 95240 PHONE 369-3648 _ 12/20/91 F? x *t: 4B E3 MODERN, ALEX 316 SPARROW LANE LOD I, CA 95 :40 RISHWAIN. ANTHONY MD - PRICE $22. 05 4*40 F IO'RIIUAL_ CAPSULE (SA) CONSULT YOUR PHARMACIST NDC#0007x3-o 103 05 EDS 1(::) OR PHYSICIAN WITH A LIST OF REG # ZK0 _4 MEDICATIONS YOU ARE CUR- RENTLY TAKING IF YOU HAVE FOR QUICK REFILL SERVICE--CALL ANY QUESTIONS ABOUT AT LEAST 24 HOURS IN ADVANCE_ ADVERSE DRUG REACTIONS f4S 04ww VAW u.J940.V `r V 100 Wast Lodi Ara.Lodi,CA 95240 PHONE 369-3648 MODEHN, ALEX 316 SPARROW LANE LODI, CA 5540 RISHWAIN, ANTHONY PID . PRICE $24. 00 ; v #30 CYCLOBENZAPRINE •..1..OMG TABLE"I" (NY) NDC#003780751- 1 EDS 30 CONSULT `. REG # Z K O i YOUR PHARMACIST OR PHYSICIAN W MEDICATIONS YOU ARE CURT ' FOR GNU ICt: R>~.F=I1._L SERVICE--CALL RENTLY TAKING IF AT LEAST 24 HOURS IN ADVANCE ANY QUESTIONS ABOUTVE ADVERSE DRUG REACTIONS p rA , va N `r-A �9 O 1 a WA Nd o � o 0 r rA 010 v 0 H C� CLAIM ? BOARD OF SUPERVISORS OF CONTRA- COSTA COUNTY, CALIFORNIA Claim Ag"dinst the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT March 24., 1992 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 Gover Wift Amount: $25,000.00 Section 913 and 915.4. Please note all "Warnings", CLAIMANT: SHAVENS, Ruben I. FEB 2 g 1992 OOU" COUNM ATTORNEY: c/o Kenneth W. Jenner MARTINEZ, Attorney at Law Date received ;ADDRESS: 100 Webster Street BY DELIVERY TO CLERK ON February 27, 1992 Penthouse Suite Oakland, CA 94607 BY MAIL POSTMARKED: Hand delivered I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. IL gATCHELOR, Clerk DATED: February 28, 1992 �b: Deputy CL 4 0�1 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: z Z BY: J - Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present ( +�) This Claim is rejected in full. ( ) Other: I certify that this is a,, true and correct copy of the Board's Order entered in its minutes for this date. Dated: MAR 2 4 1992 PHIL BATCHELOR, Clerk, By ° , Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 16; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a 'Icertified copy of this Board Order and Not'ce to Claimant, addressed to the claimant as shown above. MAR 2 4 1992 Dated: BY: PHIL BATCHELOR by 44j4LDeputy Clerk CC: County Counsel County Administrator ,I` 1 KENNETH W. JENNER RECEIVES ATTORNEY AT �LAW / STATE BAR #99357 2 , 100 WEBSTER STREET FB 2 7 1992 PENTHOUSE SUITE ; 3 OAKLAND.,, CA494607 CLERK BOARD OF SUPERVISORS CONTRA COSTA CO. 4 (510) 893-7333 5 ATTORNEY for Claimant RUBEN I. SHAVENS 6 7 8 SUPERIOR COURT OF THE STATE OF CALIFORNIA 9 COUNTY OF CONTRA COSTA 10 CLAIM AGAINST 11 CLAIM OF ) GOVERNMENTAL ENTITY PURSUANT TO 12 RUBEN I. SHAVENS ) GOVERNMENT CODE SECTION 910 13 ) 14 RUBEN I. SHAVENS hereby makes claim against the County of 15 Contra Costa, State of California, for the sum of $25, 000.00 and 16 makes the following statements in support of his Claim: 17 1. Claimant's post office address is c/o KENNETH W. 18 JENNER, Attorney at Law, 100 Webster Street, Penthouse Suite, 19 Oakland, California 94607. 20 2 . Notices concerning this Claim should be sent to RUBEN 21 I. SHAVENS, jc/o KENNETH W. JENNER, Attorney at Law, 100 Webster 22 Street, Penthouse Suite, Oakland, California 94607. 23 3 . The date and place of the occurrence giving rise to 24 this Claim `'mare February 3, 1992 , at approximately 12 : 55 A.M. , 25 through and 'including February 3 , 1992, at 2 : 00 P.M. 26 4. The circumstances giving rise to this Claim are as 27 follows: 28 1 A. Claimant's brother was originally arrested for 2 driving under the influence and gave the arresting officers the 3 name of Claimant as his true name when arrested. 4 B. As a result of the aforementioned, Claimant went 5 to Court in the Municipal Court of the State of California, 6 County of Contra Costa, Bay Judicial District, and appeared on 7 November 20, 1987, in Docket No. 709058-2 and explained to the 8 Judge then presiding in open Court that the Defendant in the case 9 filed under the above-referenced Docket, being identified as 10 RUBEN I. SHAVENS, was not RUBEN I. SHAVENS but was in fact his 11 brother, RONALD SHAVENS, who had misidentified himself to the 12 arresting officer when arrested for the offense underlying the 13 above Docket number. 14 The Court then and there verified the informa- 15 tion of Claimant and ordered that a warrant be issued for the 16 arrest of RONALD SHAVENS. 17 C. Instead of the Clerk issuing an arrest warrant 18 for RONALD ' SHAVENS, the Clerk of the County of Contra Costa, 19 State of California, Bay Judicial District, issued an arrest. 20 warrant for RUBEN I. SHAVENS, Claimant. 21 D. As a result of the aforementioned, Claimant was 22 stopped by a member of the Emeryville Police Department for a 23 traffic citation and arrested on the outstanding erroneous 24 warrant. Claimant was then and there taken to the Oakland City 25 Jail, booked, held in custody and transferred to the North County 26 Jail for the County of Alameda and thereafter transferred to 27 Santa Rita Jail, where he was ultimately released some fourteen 28 1 hours afteri'being taken into custody. I� 2 5. ;Claimant's injuries are for false imprisonment, false I'E 3 arrest, and intentional or negligent infliction of emotional 4 distress and he has been injured in mind and body in the sum I' 5 specified above. 6 6. The names of the public. employees causing the 7 Plaintiff 's injuries are the Clerk, and any Deputy Clerks, of the i. 8 Bay Judicial District Municipal Court as well as the personnel I 9 then presiding which caused the issuance of the warrant afore- 10 mentioned. ' 11 7. lifThe Claim of Claimant as of the date of this Claim 12 is $25, 000. 00. 1 13 8• ;The basis of computation of the above amount is as 14 for general) damages for humiliation, pain and suffering, and �I 15 emotional distress, as well as general damages to the mind and f, 16 body of Claimant, all aggregating to the sum of $25, 000. 00. 17 i' IJIJ 18 Dated: February ods , 1992 KENNETH JE NER 19 Attorney r laimant RUBEN I. SHAVENS 20 21 22 23 24 25 26 27 j 3 28