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MINUTES - 04062004 - C26
CLAIM BOABR OF SUPE1tVTSORS OF CONTRA COSTA COUNTY BOARD ACTIC)N:APRIL 06 x 20 4 Claim Against the County, or District Governed by ) the Board of Supervisors,Routing Endorsements, } NOTICE TO CLAIMANT and Board Action. All Section references are to } The copy of this document mailed to you is your California Goverxunent Codes. } notice of the action taken on your claim by the { Board of Supervisors, (Paragraph 1V below), giver. Pursuant to Government Code Section 913 and FES 2 4 200.4 915.4. Please note all"Warnings". AMOUNT: UNKNOWN YCOUNSD- "N" CLAIMANT: KENNETH CARREniERS E. - 46110 ATTORNEY: UNKNOWN DATE RECEIVED: FEBRUARY 24, 2004 ADDRESS: SAN QUENTIN STATE PRISON BY DELIVERY TO CLERK ON; FEBRUARY 24, 2004 SAN QUENTIN, CA 94974 BY MAIL POSTMARKED: FEBRUARY 23, 2004 FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SVVrxEEE> Dated: FEBRUARY 24, 2004 By Deputy 11, FROM: County Counsel.. TO Clerk.of the Beard of Supe isors (This claim complies substantially with Sections 910 and 910.2. { } This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant.The Board cannot act for 15 days(Section 910.8). ( } Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claire(Section 911.3). ( ) Other: r . : . Dated: By: Deputy County Counse, 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. OARD ORDER.; By unanimous vote of the Supervisors present: (V This Claim is rejected in full. ( 3 tither: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date, a Dated; Cr+ JOHN SWEETEN, CLERK, By ,Deputy Clerk WARNING(Gov, code section 13) Subject to certain exceptions,you have only six (6)months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. *For Additional Warning See Reverse Side of This Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned,have been a citizen of the United States, over age 18; and that today I deposited.in the United States Postal Service in Martinez, California,postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. 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All Section references are to } The copy of this document mailed to you is your California Government Codes. ) notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), given Pursuant to Government Code Section 913 and 915.4. Please note all "'Warnings". AMOUNT: $19,500.00 CLAIMANT: ROMMEL ITII ATTORNEY: JONATHAN J. WERNER DATE RECEIVED: MARCH 01, 2004 ADDRESS: LAW OFFICES OF JONATHAN J. WERNER BY DELIVERY TO t..LERK ON: M 247 CALIFORNIA DRIVE, SECOND FLOOR ARCH Q1, 2(704 BURLINGAME, CA 94010 BY MAIL POSTMARKED: FEBRUARY 27, 2004 FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SWEET , Dated: MARCH 01, 2004 By: Deputy II. FROM: County Counsel, TO: Clerk of the Board of Superv" rs ( O/This claim complies substantially with Sections 910 and 910.2. { } This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days(Section 910.8). ( ) Claim is not timely filed.The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: �I- ( J By: Deputy County Counse: 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. ARD ORDER: By unanimous vote of the Supervisors present: (1 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. Datei4!_ e JOHN SWEETEN, CLERK, By , Deputy Clerk WARNING(Gov. code se ion 913) Subject to certain exceptions,you have only six(6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. *For Additional Warning See Reverse Side of This Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that i am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited.in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: ir.'I C ` JOHN SWEETEN, CLERK By Deputy Clerk Dec 02 03 12: 16p C i c of the Hoard 32.: >335 1913" P. 1 Claim to: BOARD OF SUPERVISORS OF CONTRA COSTA CO INSTRUCTIONS TQ C` LAZIANT A. Claims relating to causes of action for death or for injury to person or to personal property crops and which accrue on or before December 31, 1987, must be presented not later than the ay after the accrual of the cause of action. Claims relating to causes of action for death or Sor injury to person or to personal property or growing craps 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 latter than one year after the accrual of the cause of action. (Gov't Cade 911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office-in Room 1036, County Administration Building, 651 Pine Street,Martinez, CA 94 553. 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. Eraud. See penalty for fraudulent claims,Penal Code Sec. 72 at the end of this form. RE: Claim By Reserved for Clerk's filing stamp ROMMEL ITIL ) ) Against the County of Contra Costa or ) District) (Fill in name) ) The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the sure of$ t 9.5{10,0and in support of this claim represents as follows: 1. When did the damage or injury occur?(Give exact date and hour) 10/14/2003, 8:00 p.m. 2. 'Where did the damage or injury occur?(Include city and county) Eastbound San Pablo Avenue, .south of Tara Hills Drive, in an unincorporated city, County of Contra Costa 3. How did the damage or injury occur? (Give full details;use extra paper if re ired� Mr. Itil was driving eastbound on San Pablo Avenue, whenbIic e ployee T. Allen, driving az., sheriff's vehicle, in violation of Vehicle Code Section 22350, travelling too fast for conditions, rear—ended Mr. Itil's vehicle, causing damages and..injuries. A police report regarding the accident is also attached herewith along with a demand. Dec Cyt 03 12: 16P G 1 of the Huard 92F 335 1913 P.2 4. 'What particular act or omission on the part of county or district officers, servants; or employees caused the injury or damage? Violation of Vehicle Code Section 22350, travelling toff fast for conditions. 5. 'V4''hat are the names of county or district officers, servants, or employees causing the damage or injury? Contra Costa County Sheriff Deputy I. Allen 6. 'tiithat damage or injuries do you claim resulted?(Give full extent of injuries or damages claimed. Attach two estimates for auto damage.) See attached demand. 7. Hove was the amount claimed above computed?(Include the estimated amount of any prospective injury or damage.) See attached demand. 8. Names and addresses of witnesses,doctors, and hospitals. Police Report has information of witness Michelle Diaz. See attached police report for name of hospital and doctor seen by Mr. Itil. 9. List the expenditures you made on account of this accident or injury. P—&U— See, attached demand. Gov. Code See. 910.2 provides"The claim must be signed by the claimant or by some person on his behalf" NEM NQDCFS - rn r 1 Name and Address of Attorney ) £ JONATHAN J. WERNER ) *�.z •, }�' t € > LAW OFFICES OF JONATHAN J. WERNER } (Claim tt's'Signature) ATTORNEY FOR MR. ITII 247 CALIFORNIA DRIVE, SECOND FLOOR } BURLINGAME, CA 94010 ) 1 51 VIEWPOINT BOULEVARD (Ad ) RODEO, CA 94572 Telephone Na. (650) 348-0333 TelephoneNo. (510) 799-4504 NCYT�CI . Secd on 72 of the Penal Code provides: Every person who,with intent to defraud,presents for allowance or the paytrttni to any state board or officer,or to any county,city,or district board or officer.authorized to allow or pay the same if gernmit,any false or fraudulent claim,bill,account, voucher,or writing,is punishable either by imprisonment in the c ounty.lail for a period of not more than one year,by a fine of not exceeding one thousand{S 1,00OX or by bout such imprisonment and fine,or by Imprisonment in the state prison.by a fine of not exceeding d ng ten thousand dollars(S 10.0W),or by bode such imprisonment and fnt. LAW OFFICES OF JONATHAN J. WERNER 247 CALIFORNIA DRIVE,SECOND FLOOR FREMONT BURLINGAME,CALIFORNIA 94010 OAKLAND TELEPHONE(510)797-1395 TELEPHONE(850)348-0333 TELEPHONE(510)834-9000 FAX(850)348-1298 February 26, 2004 (Clerk of the Beard of Supervisors Contra Costa County County Administration Bldg., Room 106 651. Pine Street Martinez, CA 94553 Re: Our Client: Rommel Itil Your Insured: Contra Costa County Your Claim No: 54615 Date of Accident: 10/14/2003 Dear Sir or Madam: In the hope of reaching an amicable disposition of this case without the necessity of formal litigation,we offer the following evaluation and demand,with supporting documentation for your review and consideration. LIABILITY Our independent investigation of this matter confirms what the police report (Exhibit A) indicates: my client was in a vehicle traveling eastbound on San Pablo Avenue in Contra Costa County,when your insured, in violation of Vehicle Code Section 22350, travelling too fast for conditions, rear-ended my client's vehicle, causing the resulting damages and injuries. Thus, liability in this case is clear. INJURIES SUSTAINER Upon impact, which caused over $7,000.00 damage to my_client's vehicle (see Exhibit B-- repair estimate and photographs of damages), my client felt pain in his back as indicated on page three of the police report. He sought emergency treatment at Kaiser Hospital, whose records (Exhibit C) indicate that he complained of stiffness and pain in his neck, shoulders and upper back. He was examined which revealed that both trapezius muscles were tender and tense. He was RE: Itil February 26, 2004 Page 2 diagnosed with whiplash syndrome and was prescribed Motrin 600mg. and Vicodin, was given a soft cervical collar to wear and was taken off work from 10/15/2003 through 10/17/2003. He was then seen for follow-up treatment on 10/20/2003 due to persistent pain in his neck as well as complaints of being stressed, as well as anxious and fearful of driving since the auto accident. The exam notes indicated that Mr. Itil was anxious and had cervical muscle tenderness. He was given medication and his disability was extended until 10/27/2003. Mr. Itil then sought treatment from Albany Accident and Pain Center, under the care of Dr. William Schlee,whose records (Exhibit D) indicate that he was seen there due to continued neck and back pain and stiffness, arms/shoulders pain since the automobile accident. He also complained of dizziness, headaches, fatigue, tension, stomach upset, nausea and difficulty sleeping. Mr. Itil was examined which revealed pain, tenderness and muscle spasms upon palpation of the cervical, thoracic and lumbar spine; the cervical ranges of motion were restricted and painful; the dorso-lumbar ranges of motion were painful and restricted at flexion and lateral extension; and foramina compression tests were positive. My client was diagnosed with cranial cervical syndrome with cranialgia, cervicalgia, strain/sprain; dizziness; brachial radiculitis; thoracic sprain/strain; lumbar sprain/strain, ilio- sacral dysfunction and upset/nausea. Treatment provided consisted of chiropractic manipulation as well as electrotherapy and shortwave diathermy. Note that my client will make an excellent witness on his own behalf in that he is intelligent, articulate, and makes a good appearance. As a result of the negligence of your insured, my client has had to endure pain and discomfort for over three months. Perhaps the most significant element of damages, however, are the non-economic damages,which in this case consist of the effect that these particular injuries have had in diminishing my client's quality of life. These injuries have jeopardized my client's mobility and flexibility, making simple activities such as driving, sitting, walking, and standing, more difficult. In Capeulto v. Kaiser Foundation Hospital (1972) 7 Cal. 3rd, 859, the Supreme Court restated the general principals underlying the broad right of recovery for pain and suffering stating "...pain and suffering has served as a convenient label under which a plaintiff may recover not only for physical pain, but for fright, nervousness, grief, anxiety, worry, mortification, shock, humiliation, indignity, embarrassment, terror or ordeal." Injured parties are also entitled to additional damages based on anxiety caused by their condition and inability to function, see Freiberg v. Israel (1919) 45 Cal. App. 138, 142, as well as loss of enjoyment of life, see Huff v. Tracy (1976) 57 Cal. App. 3rd 939, 843. My client took pride in the level of physical activity he was able to maintain prior to this accident. For an active person, whose health is very important to him, such an injury and RE: Itil February 26, 2004 Page 3 having to go to the doctor for treatments has been extremely stressful and frustrating for my client. His physical activities at home and at work became limited and made more difficult by the symptoms of his injuries. We view this case as one of clear liability, major property damage, consistent medical treatment with significant interruption to my client's personal and professional life. MEDICAL SPECIAL DAMAGES A summary of the medical special damages incurred to date is as follows: 1. Kaiser Hospital $ 1,117.60 2. Dr. William Schlee $ 2,260.00 TOTAL $ 3,377.60 TRANSPORTATION To receive the above treatment, our client was required to incur travel expenses as follows: 25 doctors visits at $5.00 per visit $ 75.00 WAGE LOSS At the time of the accident, our client was gainfully employed with West Contra Costa Unified School District as a teacher. His rate of pay was $5,946.00 per month or approximately $297.30 per day. Due to the accident, our client was unable to perform his duties for 7 days (Exhibit E), supported by disability slips given by Kaiser, resulting in the following: Total wage loss (7 days X $297.30/day) $ 2,081.10 MISCELLANEOUS EXPENSES A summary of the miscellaneous expenses incurred to date is as follows: 1. Rental (out-of-pocket rental expenses) (see Exhibit F) $ 832.28 TOTAL $ 832.28 RE: Itil February 26, 2004 Page 4 TOTAL SPECIALS Medical Bills $ 3,377.60 Medical Transportation $ 75.00 Wage Loss $ 2,081.10 Miscellaneous expenses $ 832.28 TOTAL $ 6,365.98 DEMAND In light of the clear liability, the injuries sustained by our client, and the specials that have been incurred to date, we are authqriieto settle our client's claim for the sum of NINETEEN THOUSAND FIVE HUNbRED 4ND 00/100 DOLLARS ($19,500,40)if this case can be settled within twenty-one (�1) days ftom the date of this letter. f 1 Thank you in advance for your prompt and'courteous attention to this matter. Very truly yours, ANONAT N J. WERNER JJW/erc Enc. cc: Rommel Itil ............. ............................................... ....................................................................................... STATE Of CALIFORNIA TRAFFIC COLUSION REPORT CHP 555("RS Page I(Rev 8M)OPI 042 POP Of SPEC141 CONDITIONS FAA" W&OM CITY JUDICLAL DISTRICT ON-DUTY EMERGENCY VEHICLE "X000 mow LOCAL REPORT NUMBER I [—I UNINCORPORATED RICHMOND SUPERIOR NUMWA KILM t>a KM COUNTY REPORTING DISTRICT BEAT 186 CONTRA COSTA 100 COLLISION OCCURRED ON: No DAY YEA 14 TIME(24001 NCIC I# OrmEft I.D. 0 Z SAN PABLO AVE 10/14/2003 2000 9370 017193 MILEPOST INFORMATION: DAY OF WEEK TOW AWAY PHOTOGRAPHS BY. ❑NONE TUESDAY fil YES L]NO SOT GRoTrKAu At INTERSECTION WITH: STATE HWY RFL #48810 PXIOR! 302 FEET WEST OF TARA HILLS DR YES [;Kl No COCO SO PARTY DRIVERS LICENSE NUMBER ATE CLAW SAFETY VE14-YEM MWEIMODEL/COLOR LICENSE NUMBER STATE EQUIP. I A1436076 CA c G 00 FORD CROWN vi wm 1042088 CA ----TS(l -------I............... .............. ..... . . DRIVER NAMZ(FtRST,MIDDLE.LAST) ON DUTY EMERGENCY VEHICLE [X-1 T ALLEN OWNERS NAME SAME AS DRIVER PEDES- STREET ADDRESS TRtAN CONTRA COSTA COUNTY 5555 GIANT HWY OWNERS ADDRESS F]SAME AS DRIVER PARKED CrrYlSTATEQIP VEHICLE 2467 WATERBfRD WAY MARTINEZ CA 94553 F-� RICHMOND CA 94801 DISPOSITION Of VEHICLE ON ORDERS OF: OFFICER DRIVER OTHER BICY. 11 F 11 CUST SEX HAIR EYES HEC44T BIRTHDATE I I w Dov RACE FREEMANS TOW-(5 110)233-08718 M_ JBRN fl� 16-00 =18103- 01/31/1971 w PRIOR MECH-DEFECTS I x INONE APP. f I REFER TO NARRATIVE OTHER HOME PHONE BUSINESS PHONE VEHICLE IDENTIFICATION NUMBER: (925)646-2"1 CHP USE ONLY DESCRIBE VEHICLE DAMAGE SHADE IN DAMAGED AREA INSURANCE CARRIER POUCYNUMBER VEHICLE TYPE DNK HHONE TwvmV -SELF INSURED CONTRA COSTA COUNTY 48 X MA:jo. M OF TRAVEL1 ON STREET OR HIGHWAY SPEED LIMIT CA DOT L A E SAN PA13LO AVE 45 CAL.T TCPMSC MCA" --Lj STATE CLASS SAFETY VEH.YEAR MWE I MODEL I COLOR LICENSE NUMBER STATE D1875454 CA 00 MITSMONTEROSIL 42HW NUMBER I I C G 4LBK688 ....................... ........T DRIVER NAMR11"T,MIDDLE,LAST) L Y I ROMMEL SEGURA ITIL OWNERS NAME SAME AS DRIVER PEDES- STREET ADDRESS TAM F] 1151 VIEWPOINT BLVD OWNERS ADDRESS f 1SAMEASDRIVER PARKED CITY I STATE!ZIP VEHxm D RODEO CA 94572 DISPOSITION OF VEHICLE ON ORDERS OF: OFFICER EDRIVER []OTHEA BICY- SEX I IR IEYES JHEIGHT WEIGHT IV WRTRACE CE 1-1 CUST 4 c* yew DRIVEN FROM SCENE _a M BLK BRN 5-07 150 08125/1957 10 PRIOR MECHANICAL DEFECTS REFER To NARRATIVE OTHER HOME PHONE BUSINESS PHONE VEHICLE IDENTIFICATION NMBERt (510)7994304 (510)758-1000 CHP USE ONLY DESCRIBE VEHICLE DAMAGE SHADE IN DAMAGED AREA INSURANCE CARRIER POLICY NUMBER VEHICLE TYPE Elow 0-ONE ElwDR mpm WESTERN UNITED CAW 000586070 07 FEMOD_]�OR FRW-OVER DIR 01 TRAVEL l ON STREET OR HIGHWAY SPEED LIMIT CA DOT E SAN PABLO AVE 45 CAL-T TCP/PSC -:Mcw PARTY, y DRIVERS LICENSE NUMBER STATE OLASS., SAFETY VEH.WAR MAKEIMODEL/COLOR LICENSE NUMBER STATE DRIVER NAME(FIRST,MIDDLE,LAST) ......... ....................... ............. ...... . 0 OWNER'S NAME El SAME AS DRIVER 9S- PE0STREET ADDRESS TAJAN _a OWNERS ADDRESS SAME AS DRIVER PARKED CITY/STATE i zip VEHICLE -17 DISPOSITION OF VEHICLE ON ORDERS OF: OFFICER DRIVER HER ofCy. '17 17 ITT CLIST SEX EYES HEIGHT w BIRTHDATE RACE Dw Year PRIOR MECHANCAL DEFECTS FINONE APP. -�EFER TO NARRATIVE OTHER HOME PHONE BUSINESS PHONEF VEHICLE IDENTIFICATION NUMBER: CHP Use ONLY DESCRIBE VEHICLE DAMAGE SHADE IN DAMAGED AREA INSURANCE CARRIER POLICY NUMBER VEHICLE TYPE nUNK HNONE HMINOR r7moo MAJOR ROLL-.OVER OR OF TRAVEL REST OR HIGHWAYS 0 LIMIT CA DOT CAL-T TCP/PSC M r MC/MX PREPARERS NAME DISPATCH NOTIFIED REVIEWER'S NAME DATE REVIEWED D GEYER 017193 My yes NO WA El L STATE OF CALIFORNIA TRAFFIC COLLISION CODING Clip s55 CARS P89Q OPI 042 P&P 2 9 DATE OF COLLISION(MO..DAY YEM)... TIME124'101.. ... NCIC N OFPiCER W. NUMBER 10114/2003 2000 9374 1017193 Q OWNER OWNERAODRESS N �Ep PROPERTY [ YES ❑NO DAMAGE bESCRIVT'SONO,DAMAGE SEATING POSITION OCCUPANTS MIC BICYCLE-HESAFETY EQUIPMENT LMET EJECTED FROM VEHICLE L-AM BAC,DEPLOYED 0-NOT EJECTED A:NONE IN VEHICLE M-AIR SAO NOT DEPLOYED I-FULLY EJECTED 8-UNKNOWN N-OTHER DRIVER 2-PARTIALLY EJECTED I-ORiVER C-LAP BELT USED P•NOT REQUIRED V-NO - 3-UNKNOWN D'LAP BELT NOT USED W-YES 2 TO S•PASSENGERS E-SHOULDER HARNESS USED CHILD RESTRAINT 7-STA.WGN REAR F-SHOULDER HARNESS NOT USED Q-IN VEHICLE USED PASSENGER 8-RR.OCC TRK.OR VAN G-LAP/SHOULDER HARNESS USED R-IN VEHICLE NOT USED X-NO S-POSITION UNKNOWN S-IN VEHICLE USE UNKNOWN Y-YES 0-OTHER J-PASSIVE RESTRAINT USED T-IN VEHICLE.IMPROPER USE K•PASSIVE RESTRAINT NOT USED U-NONE IN VEHICLE ITEMS MARKED BELOW FOLLOWED BY AN ASTERISK ' SHOULD BE EXPLAINED IN THE NARRAATWE. PRIMARY COLLISION FACTOR TRAFFIC CONTROL DEVICES 1 2 TYPE OF VEHICLE j 2 3 MOVEMENT COLLISION LIST HUNGER OF PARTY AT FAULT A vc#gclxwvSturmr. cases A CONTROLS FUNCTIONING I A PASSENGER CAR I STATION WA A STOPPED 22350 X B CONTROLS NOT FUNCTIONING` 18 PASSENGER CAR W/TRAILER X B PROCEEDING STRAIGHT B OTHER IMPROPER ORWWG` C g TROLS OBSCURED I C MOTORCYCLE f SCOOTER C RAN OFF ROAD X D NO CONTROLS PRESENT/FACTOR- I D PICKUP OR PANEL TRUCK D MAKING RIGHT TURN C OTHER THAN DRIVER' TYPE OF COLLISION E PICKUP/PANEL TRUCK Wl TRAILER -E MAKING LEFT TURN D UNKNOWN' A HEAD-ON F TRUCK OR TRUCK TRACTOR F MAKING U TURN E FELLASLEEP• SIDESWIPE G TRUCKITRUCKTRACTOR W?TRLR. :' BACKING X C REAR END, H SCHOOL BUS X I H SLomnNIG 1 STOPPMN3 WEATHER MARK I TO 21TEMS D BROADSIDE t OTHER BUS i PASSING OTH tVEHICLE X A CLEAR E HIT OBJECT J EMERGENCY VEHICLE J CHANGING LANES B CLOUDY F OVERTURNED I lK HIGHWAY CONST.EQUIPMENT IK PARKING MANEUVER C RAINING G VEHICLE f PEDESTRIAN BICYCLE ENTERING TRAFFIC D SNOWM)G H OTHER`: M OTHERVEH)CLE M 27HERUNSAFETURNING E FOG/VIm RY FT. N PEDESTRIAN N XING INTO OPPOSING LANE F OTHER- MOTOR VEHICLE INVOLVED WITH CI MOPED--- O PARKED G WIND A NDN-COLLISION P GING LIGiiC�fG B PEDESTRIAN (1 TRAVELING WRONG WAY A DAYLIGHT X C OTHER MOTOR VEHICLEOTHER ASSOCIATED FACTORS R OTHER•: B DUSK-DAWN D LLM ROTOR VEHICLE ON OTHER ROADWAY NARK 1 TO 2ITEMS X C DARK-STREET LIGHTS E PARKED MOTOR VEHICLE IIIIIIIIIIIIIIIA vc aEcr"v'mATw c^`w YES D DARK-NO STREET LIGHTS FTRAIN NO 11 E DARK-STREET LIGHTS NOT G BICYCLE B vc fec�or�vaurev circ YES FUNCTIONING! H ANIMAL: NO ROADWAY SURFACEC c aeamwviaure0 YES :1 2 131 SOBRIET G PICAL X A DRY I FIXED OBJECT: NO (MARK I TO 2 ITEMS) B WET C3 X X 8w-HAD NOT BEEN DRINKING C SNOWY-ICY J OTHER OBJECT: E VISION OBSCUREMENT: 8 HBD•UNDER iNFLULN D SLIPPERY MUDDY,OILY,ETC. X F INATTENTION`:Y•OT1EiIiR R_1480-NOT UNDER dNIFLUENCE' ROADWAY CONDITIONS) STOP GO TRAFFIC i3 moo-IMPAIRMENT UNKNOWN` MARK i TO 2 ITEM PEMTRIAIVS ACTIONS H ENTERING I LEAVING RAMP E UNDER DRUG INFLUEN HOLES DEEP RUT' X A NO PEDESTRIANS INVOLVED I PREVIOUS COLLISION F IMPAMMENT-PHYSICAL- LOOSE MATERIAL ON ROADWAY $ CROSSING IN CROSSWALK +� UNFAfiA1LtAR WITH ROAD IMPAIRMENT NOT KNOWN C OBSTRUCTION ON ROADWAY' AT I CTION K DEFECTIVE VEH.EQUIP.: CITED H NOTAPPLICA$LE D CONSTRUCTION-REPAIR ZONE C CROSSING IN CROSSWALK•NOT YE8 I; SLEEPY!FATK$UEO E RED CED ROADWAY WIDTH AT INTERSECTION NO SPECIAL H8"ORMA- F FLOODED" D CRb3SiNG-NbT IN CROSSWALK L UNINVOLVED VEHICLE A HAZARElE3US MA7ERIAl G OTHER': L' IN ROAD-INCLUDES SHOULDER M OTHER': �►i�tN X H NO UNUSUAL CONDITIONS I IFNOT HV RAO X N NONE APPARENT /A I Cs APPROACHING/LEAVING SCHOOL$US O RUNAWAYVII X /V D P11E (.tAJl4 SKETCH MISCELLANEOUS 0 SNCNCATE NORTH SEE PAGE 6 FOR SKETCH ......... _........ ......... ......... ......... ...... . .. _ ..... ............ ......... ......... ......... ......._. .._...... ......... ......... ......... ......... ....... _. __... . _...... ......... ........... ..................... STATE OF CALIFORNIA INJURED t WITNESSES 1 PASSENGEF 22-555,QM f2,v MOPI gj2 tense, 3 of R DATE OF COLLISION(MO. DAY YEAR) TiME(240b} NCIC k OFFICER 1.07 NUMBER 10114/2003 2000 9370 417193 jd�rr�6 WITNESS PAWNGER Ar+e. sex EXTENT Of INJURY(`X`ONE) INJURED WAS CX`ONE) PARTY ee►T aAfeTv ONLY ONLY BJHCTE6 FATAL SEVERE OTHER YISfdLE COMPLAINT NUMBER POS. EOUIP.. INUURY tNJUiRY ftURY OF PAIN ORfVE# PASS. PED. BK:f.VGLIST OTHER 46 M D ❑ ❑ 0 N ❑ ❑ ❑ ❑ 2 1 C 4 NAME I D.O.S./ADDRESS TELEPHONE ROMMEL SEGURA ITIL (08/2511957) 1151 VIEWPOINT BLVD RODEO CA 94572 (510)799-4504 (INJURED ONLY)TRANSPORTED BY: TAKEN TO: SEEK OWN AID DESCRIBE.INJURIES: BACK PAIN,REFUSED MEDICAL TREATMENT AND TRANSPORT AT SCENE. VICTIM OF VIOLENT CRIME NOTIFIED a a 4 1:11 ❑ ❑ a ❑ ❑ ❑ Elo NAME i O.O.B./ADDRESS TELEPHONE MICHELLE DIAZ 05/06/1958 16401 SAN PABLO AVE#l03 SAN PABLO CA 94806 (51Q)724-0537 (INJURED ONLY)TRANSPORTED BY: TAKEN TO: DESCRIBE INJURIES: VICTIM OF VIOLENT CRIME NOTIFIED El 1 7 NAME i D.O.S.t ADDRESS TELEPHONE (INJURED ONLY)TRANSPORTED BY: TAKEN TO: DESCRIBE INJURIES: VICTIM OF VIOLENT CRIME NOTIFIED ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑. NAME 1 D.Q.B./ADDRESS TELEPHONE (INJURED ONLY)TRANSPORTED BY: TAKEN TO: DESCRIBE INJURIES: VEC'nM OF VIOLENT CAME NOTIFIED NAME t D.O.B.I ADDRESS TELEPHONE (INJURED ONLY)TRANSPORTED BY: TAKEN TO: DESCRIBE INJURIES: VICTIM OF VIOLENT CRIME NOTIFIED ❑# ❑ ❑ _ ❑ ❑ ❑ ❑ D aD a NAME I D.O.S.I ADDRESS TELEPHONE (INJURED ONLY)TRANSPORTED BY: TAKEN TO: DESCRIBE INJURIES: VICTIM OF VIOLENT CRIME NOTIFIED PREPAREWS NAME I.D.NUMBER MO. DAY YEAR REVIEWER'S NAME IdO. DAY YEAR D GEYER 417193 14114!2443 STATE OF CALWORNIA FACTUAL DIAGRAM CHP 535 Pa-M 4 Rev."7) ON 042 rig. Vor DATE OF COL 1.18M OAO DAY YE Immes OFFSCERY.D. NUIiIEM /0 g3-70 /7133 ;�ac�r8 ► ALL WASURIMENTS ARE APPROXI MATE AND NOt TO SCALE UNLESS STATED(SCALE• / ''•./p AN PArBLO ;Avg ( to urvm' 1 INDICATE NORTH GRA1SQTi ! �,.,.�t1.e7tt#N L.t t31t W1.1 i T'ry ' Livt�r I 1 i Rp.lS LTJ { >kt +i dv x f 4.& it It t IgA' a VIP & � 'MdA Mfttb At At 4f 46 It � r PREPARED$Y S:D.NI ER MD. DAY YEAR REVIME 8 NAME i MO. DAY .YEAR 6-3 `�._1 OSP 99 28973 .............................................................................................................................................................................................. . ....... ..........._...._........... ._._..... ........._.._......_...........__... ......... . ....._.... ........_. .......__.... .....__......_...... STAT F-DF CALIFORNIA NAREADYWAUEELEMENM Q01 El ' DATE OF INCIDENT TIME NCIC NUMBER OFFICER LD. NUMBER 10-14-03 2€144 9370 17193 100186 1 Physical Evidence: 2 3 Vehicle##1-point of rest 4 Right rear tire- 315 feet south of the south roadway edge prolongation of Tara Hills Dr and 3 5 feet 6 inches west of the east roadway edge ofNlB San Pablo Ave. 6 Right front tire- 305 feet south of the south roadway edge prolongation of Tara Hills Dr and 8 7 feet 3 inches west of the east roadway edge of NIB San Pablo Ave. 8 9 Item A-Tire Friction Mark ending under V-1's right front tire. 10 Start: 341 feet 6 inches south of the south roadway edge prolongation of Tara Hills Dr and 8 11 feet 6 inches west of the east roadway edge of Nl.B San Pablo Ave. 12 End: 305 feet south of the south roadway edge prolongation of Tara Hills Dr and 8 feet 3 inches 13 west of the east roadway edge ofNB San Pablo Ave. 14 15 Item B-Tire Friction Mark ending under V-1's left front tire. 16 Start: 340 feet 6 inches south of the south roadway edge prolongation of Tara Hills Dr and 3 17 feet 6 inches west of the east roadway edge ofN/B San Pablo Ave. 18 End: 305 feet south of the south roadway edge prolongation of Tara Hills Dr and 3 feet 3 inches 19 west of the east roadway edge of N/B San Pablo Ave. 20 21 Vehicle Debris- Headlight and lens debris from V-1 and tail lens debris from V-2 covering the 22 width of the #2 lana extending from the front of V-1 and ending 264 feet south of the south 23 roadway edge prolongation of Tara Hills Dr. PREPARER'S NAME I.D.NUMBER DATE REVMWER'S NAME, DATE D. GEYER 17193 10-14-03 .................................................................................................................................................................................................... . ..... .._.......... .._.............. ..._..... .........__.......... ........ ........_... ........... ....__..... ._....._..... ............_....._.... ITATE Of CAtWORWA ;HP SW PM ift,tt-kh OF-4 442 kArs or CfitfaYm On fits "M) 7M (240) .MCS s s+Gsa r a M#�aIER. td Iy 03 .2M q3-70 ALL MEAitNAIEfi MS AIR APOWXWATE AND NOT TO SCALIE UNLE"lrTATED ISCALS• I N PA LO AwC (NOO-` 6wNt>) I CCtdCT i H �MiED�'A�+rt i f I i pctivth�►t��t ?At2Al C 'dMEC aY 10,NUMa811 WO, WY YEM OE1t1E'i ptls K*A* 63 O5p 99 28973 ................................................................................................................................................................................... .......... STATE OF CALIFORNIA NMUMMUEELIEMENIAL QE DATE OF INCIDENT TIME NCIC NUMBER OFF ER I.D. NLWMER 10-14-03 2000 9370 17193 100186 i Facts: 2 3 Notification: 4 5 1 was dispatched to a non-injury collision on San Pablo Ave at Tara Hills Dr at 2005 hours. I 6 responded from the Oakland area CHP office and arrived on scene at 2030 hours. All times, 7 speeds and measurements are approximate. Measurements were established by rollmeter. 8 9 Scene: 10 i i At the scene of this collision San Pablo Ave is a County of Contra Costa maintained roadway. 12 There are four asphalt lanes with two lanes traveling northbound and two lanes traveling 13 southbound. The northbound and southbound sides are divided by a 16-foot wide raised 14 concrete median. This collision occurred in the northbound lanes. The lanes are'delineated by 15 a painted broken white line. The northbound lanes are bordered to the west by the concrete 16 center median and to the east by a 6-foot asphalt shoulder and then a raised concrete sidewalk. 17 The roadway is straight with a slight down slope while traveling north. The speed limit for this 18 portion of San Pablo Ave is 45 mph. There are street lamps providing some artificial light to 19 the area. See factual diagram. 20 21 Parties: 22 23 Party #1 (P-I/Allen) was located at the scene outside of Vehicle #1 (V-1/Ford). P-1 was 24 identified by his valid California driver's license; P-1 was placed as a party by his statement. 25 26 Vehicle#1 (V* I/Ford)was located in the#2 lane of NIB San Pablo Ave. V-1 is a,Contra Costa 27 County Sheriff's patrol vehicle. V-1 sustained major damage to the front bumper, grill, hood, 28 and engine compartment. Both airbags were deployed. No prior mechanical defects were noted 29 or claimed. 30 31 Party #2 (P-2/1til) was located at the scene outside of Vehicle #2 (V-2/Mitsubishi). P-2 was 32 identified by his valid California driver's license; P-2 was placed as a party by his statement 33 and his being the registered owner of V-2. 34 35 Vehicle #2 (V-2/Mitsubishi)was located in the parking lot to the south of San Pablo Ave near 36 the scene. V-2 sustained moderate damage to the rear of the vehicle. No prior mechanical 37 defects were noted or claimed. 38 39 PREPARERS NAME I.D.NUMBER DATE REVIEWER'S NAME, DATE D.GEYER 17193 10-14-03 STATE OF CALIFORNIA E, TAL3,2g`1 DATE Of INCIDENT TIME NCIC NUMBER OFFICER I.b, NUMBER 10-14-03 2000 9370 17133 100186 i Phvslcal Evidegre. 2 3 Locked wheel skid marks ending under V-l. 4 5 Statements: 6 ;r Panty#1 (Alyn) stated in essence he was driving Vehicle #1 (Ford) northbound on San.Pablo 8 Ave in the#2 lane at 35.40 mph. He was on duty as a Contra Costa County Sheriff's deputy 9 and was patrolling the area looking in the surrounding parking lots for a stolen vehicle. When to he looked back at traffic in front of him he saw that the vehicle in front of him had stopped. He i i applied the brakes of his vehicle but was unable to stop before colliding with the rear of the 12 vehicle in front of him. 13 14 Party #2 (Itil) stated in essence he was driving Vehicle #2 (Mitsubishi) northboundon,San is Pablo Ave in the#2 lane at 35-40 mph. There was one car in front of him. He suddenly felt an 16 impact to the rear ofhis vehicle. 17 Ig Witness #1 (Diaz) was contacted at the scene and related that she had been standing on the i9 sidewalk along the east edge of San: Pablo Ave at a pay phone. She saw s blue.car slow'and 20 make a right turn.off`San Pablo Ave into the parking lot to the east of San Pablo Ave. She saw 21 the silver SUV slow behind the blue car and then saw the police car collide with the rear of the 22 SUV. 23 24 0g ntons and ConcLusionst 25 26 The Summary,A01, and Cause are fused on statements, and physical evidence. 27 28 SgMM4 : 29 30 Party #1 (P-I/Allen) was driving Vehicle #1 (V-1/Ford) N/B on San Pablo Ave south of Tara 3 i Hills lir in the#2 lane at 35-40 mph. Party#2(P-2/I1il)was driving Vehicle#2 32 (V-ZMitsubishi)in front of V-1 in the##2 lane at 35-40 mph. An uninvolved vehicle slowed in 33 front of V-2 causing P-2 to slow V-2. P-1 saw V-2 slowing ahead of him and he applied the 34 brakes of V-1, but due to his unsafe speed he was unable to prevent the front of V-1 from 35 colliding with the rear of V-2. After the collision P-2 moved V-2 into the parking lot'east of 36 San Pablo Ave and south of Tara Hills Dr and V-1 remained at rest in the #2 lane of>N/B San 37 Pablo Ave. 38 39 40 PREPAREIt'S NAME I.D.NUMBER DATE REVIEWER'S NAME DATE D.GEYER 17193 10.14-03 _. .. ......_...._..... ..._..._. ......... ......... ......... ......... ......... ........._..... _. ........ ......... ......... ......... ......... ..................... .___................................. STATE OF CALIFORNIA NARBADMEMUEELEBIENIAL -1 DATE Of INCIDENT TIME NCIC'NUMBER OFFICER I.I}. NUMBER 10-14-03 2000 9370 17193 1OCtl$S 1 Area of Impact• 2 3 The A01 (V-1 vs. V-2) was located 302 feet south of the south roadway edge prolongation of 4 Tara Hills Dr and 6 feet west of the east roadway edge ofN/B San Pablo Ave. 5 6 Cause; 7 8 Party #1 (Allen) caused this collision by driving in violation of section 22350 v.c. Unsafe 9 speed for slowing traffic conditions. 10 11 Recommendations: 12 13 Nene. PREPARER'S NAME I.D-NUMBER DATE REVIEWER'S NAME' DATE D.GEYER 17193 10-14-03 02/09/2004 12:20 7074278?9.7 WATSON AUTO BC)W PAGE 02 02/09/2004 e.t 12 .26 FM iTob Numbar: 7372 :14932 WAWS N AUTO DORY, INC. 885 BECK AVENUE BAR#AD221411/EPA000207227 FAXRFIl^LD, CA 94533 {707)427-2417 Fax: 007)427-8207 9UPPLHb3F.').+7`T' OF RECORD I WITH SCARY Written by: MATT PADGZTT # 12/03/2003 05:38 PIS Adjusters insureds ROMMELL ITIL claim #79599 owno r n RO MMELL T'S'IL Policy # Address: 1151 VIEW POINTBLVD Deductible: 5009.00 T2.CDSO, CA 94525 Date of Laws! Copular: (310)579-0475 Type of Losec Other, (5.1,0)799-4$04 Point of Impact: luspect WATSON AUTO BODY, INC. Ruainees: (707)427-247.7 Location,: 895 BECK AVEI'nM BAR.#AD221411/EPA0002,07227 'AIRFIELD, CA 94533 Insurance WES'T`ERX UNITED cnmpanys Day# to Ropo i r ;�Oot:i MITS MONTERO SPORT 4X4 LS 6-3.0L-FI 4D UTV GRAY Irnt; VZM% JA4MT31H4YP817371 Lics. 4LSK668 CA Prod Date. 05/20tts3 Odometer: .5968:1. Air Conditioning Rt-tar Defogger Tilt Wheel Crii.i se Control Intermittent Wipers ' 'ear wiper Dual mirrors Privacy class Roof Console clear Coat. Paint Two Tone Paint Metallic Paint Stone Guard Power Steering Power 8,rakes Powa r windows Prower Lucke power mirrors Ants.-Look brakes (4) nriver Air Sag Passensger Air Bag 4 'Wheel Discs BXakes Cloth Seats Bucket Seat`: Aluminum/Alloy Wheels -NO. op. DESCRIPTION QTY XXT. PRICE LABOR PAINT 1# OPIG EST PREPARED BY DONALD l SELIX y# *,tiers.****CA -499 S' 1 APPRAISERS********" 3 REAR I)OOR 4 Blnd. L'T' Door shell w/o ES 0.9 ri R&I LT Belt- w+sxt.rip o.3 6 R&I .LT Handle, outside blank 0.3 R&I R&I trim panel 0.4 0* Repl LT Molding strip silver 1 78.32 0.3 015 9 Sol REAR LAMPS 10 S01 R&I LT Tail lamp asey 11 901 REAR BODY & FLOOR 1 02/09/2004 12:20 707427B.'797 WATSON AUTO BO'v PAGE 03 02/09/2004 at 12:29 PM Job Number! 7372 2000 MITS mONTERO SPORT 4X4: LS 6-3.OL-FI 4D Un? CnAAIa Int; NO I ------------------------------------------------ OP. iDASCRIPTION QTY EXE'. PRICEY LABOR PAINT. i. 501 V- :....Repl Spare carriO 1 47-43 1-0 t'3#F Sol Rpa. R]-AR X MEMBER 0 SPAP3 MN 1_4 }4* S 0 1 Rept. Rees crc,ssmeMber *cuter 1 1-14_87 2.5 1 .2 15* 901 Rpr Reda floor pan w/o gate 2.:-a 1.S mounted eyare 1.6# SOI.. R&I REAR TRIM &, Rtd,RDWARE 0.3 I7 QuA TER PANEL 18 Ft&J LT Flare accessory n•8 1. ]* R&I LT (;laSs Mitsubishi green 2. 5 x0 x Rpr LT Quarter panel w/o Spare carrier on tail gate w/o flare 21. Add for Clear Caa.t {3 � 22+ S01 Add for Stene Guard 23# S 0 2 Res r LT IM. EX QTR .h4# SOl Rept RT QRT SEAM SZALER 1 8. 00 25* SC}1 Repl LT Pressure vent 1 t 26 S01 Repl, LT Rear extra 1 21.9.E 1.10 274 Sol Rpr R.ELEIF PULL LT QTR 28# Sal Bln. 3, RT LOWER QUARTER PA.NEL 29 T.I,,r T GATE : c}* Repl LKQ lifts gate +25n }, 1,197,50 x. 2 .2 9. Overlap Major Adj. Panel. -0.4 3.^;. Add for Clear Coit 0.4 ,.3 R&I glass 2. 34 R&I nameplate 0.2 35 Rego underside 1.1 :18 Repl* Nameplate "MITSUBISHI" 0.2 -;7* Repl Lack all 1 44.75 39 R&I Wiper arm assy O.3 39 Repl striker 1 401v R&I Cyl a keys W/O keyless entry 1* Rept Nameplate "LS" 4.2* R.epl Nameplate "4WD" silver 1 1.05 4,6 0.2 4::3* Repl Nameplate 11M. LATERO SPORT" 1 It-. 9 n.2 ,i,4* 'Peel Weatherstrip 1, 9.93 * Repl Emblem 3 diamond max'], 1 1.,.!,0 n.2 46 REAR BUMPER 4-1 001 O/H rear bumper 4$`-*�F0a1. Repl RECOM Scamper CO-Ver 1 ' 7 ' 0 Incl. :3 .4 1.9 S01 Add for Clear Coat 1.0 !;0 SOl Add for Two 'Tone 110 51. Sol Repl Reim beam 1 108.00 incl. 52 Sol Repl Step plate 1. 65.98 ia�ol. 53 ,Sol Reel. LT Reflector 1 11.67 7n:rl. 54ft. x:051. Repl RT Reflector 1 1.1..67 ncl. 55# sol Repl, J.tT BUMPER. END BRACKET 1, 121 ,72 dk n.]. Repl RT BUMPER, ENT} BRACKET 1 1.7, 74' 57,4 S01 Repl LT BUMPER REFLECTOR BRACKET I 3.1s 2 02/09/2004 12;20 707427Q?,07 WATSON AUTO BODY PAGE 04 02/09/2004 At 12:26 ISM :rob Number: 73721 1-1932 2000 MITS i+MC1WTVRO SPORT 4X4 LS 6-3.O.L,-FI 417 i1TV GRAY Int NOOP.__ DESCRIPTION QTY ZXT� PRICE LABOR PATNT _ ----------- :,Sit Si# q0-1, Reyl RT SUMPRR RZFLrECTOR BRACICST 1 r3.3.8 !3# Sol Rpr.° PULL & SQUARE RVAR APITURE ),.5 fi!? Rept FLEX ADDITIVE 1 00 ILIPPI. E>�#} Rpr COLOR. SAIM & POLISBI 1 .0 624 Re fr).a ADD FOR 2 TONE 2.1 t.3#} Regal C7h DERC"OA 64# S03. R.apl CORROSION PROTECTION 654 501 Reel. PROTECT INTERIOR 1 0.3 660 501 kept COVER CAR 0.3 67# Sol R&I D&R BATTERY'' FOX WELDING 684 Sol Repl SEAM SEALER RR BODY 1 22-50 50 �5}t 69### S 0 1. Repl TINT COLOR 2 COLORS 1 70# ,301 Repl UNDERCOAT 1 18.01) 0.3 '71, OTHER CHARGES 7241 JS01 Elp.c. 73 if S01 ',Cawing 1 233.'7 s Subtotals 2403 .98 33 .1 21.3 Parts 21GS.94 Body Labor 33 .1 lir s u' 0.88 Paint Labor 21.3 Lars (,71 68,00/hr 1448.40 Paint Supplies 23..3 hrs 32.110/hr .6,8.1. .G() Other Charges Y35.14 ------------------------------------------------------ Sales Tax $ 2850.+74 rri 8-25001; 235.16 ---------------------------------------------------- GRAM TOTAL q 7019.94 CUSTOMFSR PAY s o o.0 0 I fsTSVRANCE PAY 6519.94 ** ALL 1='A72T PRICES ARE SVBJECT TO INVOICE ** PLEASE REMEMBSIZ TTIIAT DUE TO MAN-y- r:71,TFORSEEN C.4X R.cumS'TANCES IN THE; REPAIRING OF A.L7',I OMOBX L,E:S, WE CAN ONLY ESTIMr ,T.f , NOT PROMISE A COMPLETION DATE. TILXh5K YOU FOR YC1L., UNDER.STAx+DING , 3 10/29/2003 at 12:01 F le# 14932-00018307 Claim# 79589 Owner: ITIL,ROMNtELL Appraiser: WAB WAD 2000 MITE MONTERO SPORT 4X4 LS 6-3.OL-FI 4D UTV GRAS' Int,: WATSON AUTO BODY, iNc. 885 BECK AVENUE BAR#AD221411/EPA000207227 FAIRFIELD, CA 94533 Business: {707}427-2437 IMAGE REPORT � sSk� r z i . � y 10/28/2003 : EST01: < w 9� r . s Y+ a 10/28/2003 : EST01: 1 20/29/2003 at 12 :01 P ile# 14932-00018307Claim# 79589 Owner: ITIL,ROMMELL Appraiser: WAB wAB 2000 MI'T'S MONTERO SPORT 4X4 LS 6-3 .OL-FI 4D UTV GRAY Int: IMAGE REPORT a +r t 10/28/2003: EST01: +x r N � lx P7 � r 10/28/2003 : EST01: 2 10/29/2003 at 12:01 P.: ile# 14932-00018307 Claim4 79589 Owner: ITIL,ROMMELL Appraiser: WAB WAB 2000 MITS MONTERO SPORT 4X4 LS 6-3 .OL-FI 417 UTV GRAY Int: IMAGE REPORT ¢ r v u r` �L 8 Sy 10/28/2003 : EST01: t �! y,�sR 10/28/2003 : EST01: RR VIEW OF FLOUR 3 10/29/2003 at 12:01 P.— ile# 14932-00018307 Claim# 79589 Owner: ITIL,ROMMELL Appraiser: wAB wAB 2000 MITS MONTERO SPORT 4X4 LS 6-3 .OL-FI 4D UTV GRAY Int: IMAGE REPORT I I 1 10/28/2003 : EST01: ^4+ f 10/28/2003 : ESTO1: 4 10/29/2003 at 12:01 F dile# 14932-00018307 Claim# 79589 Owner: ITIL,ROMMELL appraiser: WAg WAE3 2000 MITS MONTERO SPORT 4X4 LS 6-3.OL-FI 4D UTV GRAY Int: IMAGE REPORT �y hsv k 10/28/2003: EST01: Pathways - A product of ccC Information Services Inc. 5 STOPI* The following pages are medical records. 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Paper MSE: ]w Re th; AMA: LWBS: Industrlai: Kaiser Permanente Priority: :kr Medical �creenina Exam Arrival Date: 10114/2003 Arrival Tlmie:2207 MSE stet:2218 s�� Last Name: ITIL F;r<,st Name:#�C)MMEL 2>i C5 MRN: 10152069 DOB:0812511957 Age;46Y 1N# sex:M Mode of Arrival:iRr}eked informant:Sslfnuage:English Fr ans#ator used: rrived From:Nome Hx of Present Illness: Chief Complaint: EAR ENDED BY A POLICE CAR,PATIENT A DRIVER W1 SEAT BELT ON, BACK PAIN, S/P MVA RUNNING APPROX.35 MPH, Distress:Mild Domestic ViolencelAbuse:N FLyinq�31P If Applicable: Standing BtP#f Appiicatsle: 2 Sat;98 Can: eight: emp: SS.0 Temp I ocatlon:L)ralip: 1681103 Pulse; 90 Resp:20 Pujse; BfP: PuEse: Peak Flow: 2.5 K s Health History; M edication: Ailerglest HYPERTENSION He vTZ,KLOR-CON NKA ardiac Assessment: Started: Lasting: U Assessment: Started. Lasting: U Symptoms: Regular Cap refill<2sec: Edema: Location: Radiation: iac Symptoms: Pads/Hr: LMP: LMP Description: Provocatlon: Radiation: Gravada: Para: AS: Resp,Assessment: Started: Lasting: Neuro Assessment: Orientation; Resp.Symptoms: CNS Assessment- Provocation: Cough/Sputum: Any LOC: Duration of LOC; Psych Assessment: ssoc#ated CP or Edema: pupil Response: ASs@5sment: Started: Lasting: G##scow:Eye:4 Verba#:5 Motor;6 GCS Total: 15 I Symptoms: Muscular Skeletal/Trauma Assessment: Radiation, #Assessment: uscfSkel Assessment: Mucous Membranes: Location of Injury: ENT Assessment: Started; Lasting'. Description of Injury: N7 Symptoms: #eedingtDeformity: ENT Radiation: Positive pulses distal to Injury: Last Tetanus: ursIng Assessment: MD Consult: Paln Assessment.Pain Scale:4 TIENT APPEAR SLIGHTLY ANXIOUS. Pain Description,[Turning Skin Signs- Nursing Actions @MSE Field Care MO Comments: Clinic Building: Disposition: Clinic Station:App i Time: Disposition:ED Patient Location:WAIT RM SE RN:Collier,Doty MSE Finish Tirne: 70!1412003 2227 Clinical presentation does not suggest an emergency medical condition exists per standardized procedure: MD-. # Time: Print C0PY= Facility: RCH Enc ID: 3514201 MSE Update Status. Form Rev.ti8t1312003 11:27:22 k _ 11 Jill t KAISER : PERMANFN7E a ;'IMERGENCY DEPARTMENT PHYSICIAN RECURC3 phTE -' ..c PR1tD r�. w 6Ai i , _ h4SE REVIEWED CIaSREVIEWEta I t t 00, 7 -A-W-," -, } + _ VITAL SI t tS MF_[uCATt0NS M ,At j Ste` IL RCiCSM CfHiE t IS If ._ rTAKEN: s1 13vaF'RIrfTAAEA PROVIDE EXrArM�R�E— . > C SA __F?AtL}z Umi 2 Wt __ _Kg rLast d T_ ._._ { brsct{a "' ALLERGIES NKDA Jot.o CfIART ORbORED INDUSTRIAL YES NO r r` History obtained from: Old chart reviewed atlen Family Inlercreter Other Unable to obtain complete due CHIEF COMPLAINT. aCyt✓ HPI CODING: Levels 1 3. i-3 element Level 4,5: 4 or more elements or status of 3 multiple chromic conditions MEDICATIONS NONE INSTRUCTIONS(PMH,FAM HX,SOC FIX,and ROS sections):Slash=Not Present,Circle=Present _ PMH:., No serious illness PMH,FAM HX,SOC HX CODING: Level 4:1 out of 3(PMH,Fam Hx or Soc Hx) ,_ Level 5:2 out of 3(PLASH,Fam Hx aitdlor Soc Hx'} Immune Status: 4Anemia Hill Chemo Steroids Spienectomy Leukemia CA�__ u_ Cardiac HX_TMT A'b--CHF ~CAD CABG MI PTCA Cardiac cath _Pacemaker Cardiac RF: Smoker HTN DM Fam.HX CAD Hypercholesterole+nia_ Pulmonary HX., Asthma - CDPD Steroids GI Disease:_ PUD^�GERD Liver/Biliary/Pancreatic disease IBDry GI Bieed Diverticuli Renal Dlsease: Renal insuff Dialysis Renal transplant Urolithiasis16 GYN HX:v� G_.__ P__ TAB_... SAB__ LMP_ _ HX STD HX IUD HX Ectopic Preg, Tubal Ligation HX Endometriosis _C Seetfon� Surgical HX: Appy,�C'Iolecyst^ uSOO AAA Hysterectomy Hernia Neuro HX: CLIA TIA Seizures HA Dementia Aizheimers Parkinsons Psych HX: Anxiety Depression FAMILY HX: None Diabetes Hypertension Heart disease CA Other: — SOCIAL HX Tobacco ETDH-.__ -Drugs___ Lives aioneiw r.._.___ S M D W Domestic violence Homeless Care facility:._ Occuoatlon _�____.__ ,___,__ __ �___ __—____.—___ __� _ Other: REVIEW OF SYSTEMS: ROS COOING: Level 1.0 sys Level 2-3:pp ..` Levet 43 2-9sys Level 5: 10+Sys _ All other systems negative CONST: Fever Chills W1,loss Weakness� Fatigue Diaphoresis MUSC: Bone or joint pairs Back,Neck problems Trauma Arthritis -�LL EYES: Acuity change Photophobia Painµ~v Diplopia _ NEURO: Syncope Focal weakness HA Seizure Dizziness ENMT:_ Hearing loss Earacbe Nasal drainage Sore throat Hoarseness T Decreased LOC Dementia Numbness RESP SUB Cough µSputum Wheezing Stridor Hemoptysis PSYCH: Prior psych hx Depression _Anxiety fvtemory Sulcldal - Pleuritic Pain ODE -� INTEL: Skin lesions Rash Bruising' _ Cv: Chest Pain Palcitations PND Orthopnea DOE W _ HEMEILYMPH: Bruising Aderiopathy Anemia Edema GI: Nausea vomiting Diarrhea Pain Melena ENDO: Polyuria Polydipsia Neat/cold intolerance Hematochezia Constipation Gallstones Anorexia ALLERGICAMMUNO: Urticaria Hayfever GUIGYN: Dysuria Urgency Frequency Nocturia Hematurfa _ Bleedings Discharge Cramping _ E-D M.D.SIGNI ' ROS Other: _ _- �_ _.___FFI_ __._---_.-_. 90736(REV 2.03) SMART TOOL- — DISTRIBUTION:W141TE=MEDICAL RECt}RD•CADJA =$USJNESS OCE•WHITE=ED . .... . .... PHYMCAL EXAMINATION#NSTRUCTIONS FOR PE ✓=Normal exam finding, ;Area for description of abnormal or relevant finding «,4 PE CODING: C NGFA reg.elements [ Levet t 1 , '.�ments in 1+sys L__'Level 2-3:8 elements in 1+sys Level 4.2+elements from 6 sys or f �,ments from 2+sys Leven 5:2+elements from 3 sys CONST: C Vitals(See MSE) 0 WDWN [ Well hydrated E]No resp.distress ?Appears well NAME Eyes: C PERRL,irises ni C Lids,Conjunctiva/Cornea/Ant.chamber nl [ Discs&fundl ni > EOMI ENMT: C Nearing grossly intact i�'Ext,Ears.Nose ni C Nasal mucosa rii F--'TMs,Canal nl L Lips,Teeth,Gums ni C Oropharynx nl Neck: Supple/No masses/No C-spine tenderness/FROM w10 pain i_'Thyroid ni . Resp: C Resp effort nl r Palpation ni 7— Percussion ni Clear to auscultation O B/S equal No pleural rub Chest: <Breasts> C Inspection ?__�Palpation nl -� CV: Regular rhythm No murmur,rub or gallop [ No carotid bruits C No abdominal bruits Palpation nl C No,JVD :Capillary refill nl <Pulses> ED Femoral nt _ Dorsalis pedis ni ['No peripheral edema <.%Post tibial ni «All equal bilaterally GI: <ABD> L Nondistended/BS ni/Soft/No masses or tenderness/No guarding or rebound/No palpable pulsatile mass LJ Liver,Spleen ni C No hernia <Rectal> C Tone M/No masses or tenderness C Stool hemocult neg. Quality control done GU: <Male GU> [-]Prostate ni C Penis nt [1 Scrotal contents nl/Testicular position and size ni/No tenderness or masses <Female GU> [. Ext.genitalia ni __ Cervix ni/Os closed/No CMT Urethra nl l_i Uterus ni No vagina!discharge E_ No adnexal tenderness or mass Rectovaginaf confirmatory 4 <Urinary> INo bladder distension or tenderness No CVAT MS: <Back> No vertebral tenderness FROM wlo pain <Pelvis> Stable,nontender <Ext.> RUE of _7 LUE ni LJ RLE n C LLE nl r_ Inspection/Palpation:No Cyanosis/No Edema/No calf swelling/tenderness 1 Gait&station ni Digits,Nails nl Neg.straight leg raise Neuro CN I#-XII intact Sensation ni DTRs/Babinski nl :J Motor Speech nl Follows commands Psych _ A&0x3 :,lodgement/insight ni Mood/affect ni Memory n! :' No suicidal ideation Skin No rash/No lesions Palpation ni Lymph Nodes: Adenopathy; _ No cervical No axillary ! No inguinal '__l Other: Viswa" A-_uitd a _ — COMPLETE FOR INDUSTRIAL PATIENTS ONLY `v t.hate of injury: _/ _ / 2.Date last worked:_—_.J--! } — 3. Are your findings and diagnosis consistent witli history of injury or onset of Illness? Yes i._ No If"No;'explain: CONSULTANT Time Called: t• — r�_ _—_ _ 4. Is there any other current condition that will impede or delay patient's recovery? 2 — Yes No If"Yes,"explain: DISCHARGE DIAGNOSIS: 5. If occupational illness,specify etiologic agent and duration of exposure: r 6. Were chemical or toxic compounds involved? Yes No ___ ------`-- 7• '! Return to work without restriction on t_ i (date) Remain off work until (date) Modified duty as of until �J—_— / (dates) ----- Copy/V-mail i Fax sent to Dr._ ------ —��_ DISPOSITIONk)Home Admit:Hm.#— Transfer to Referral/Follow-up request to Deceased ... Discharge medications LWBS ' AMA `- Notified CONDITION YP9N LEAVING E.D.: _ Chart was dictated computer dp owed tahfe _. Guarded Critical CHART COMPLETE: — , • 1T1L, ROMMEL S �f 10152069 46y M' "SER pE„J73 ANEMM— Day: (510)758- 1000 Eve:(510)799-4504' NoteWriter Primary Care Provider: SURENDRA T SHENOY,M.D. Problems Recent Kaiser Ptrarmacv Medioations Chronic pancreatitis Hydrochlorothiazide 25mg tablets 0.5 QD Qty:50 Refil€s:0 8/11103 Potassium chloride 20meq sa table 1 QD Qty:100 Refills:1 5/12103 10/15/03 Emergency 46 yo male was the restrained driver of a car going 30mph when he was hit feorn behind by a very fast moving police car about 5 hours ago. He braked to a halt; he sustained no direct trauma. Now he has stiffness and pain in his lateral neck and shoulders and upper back. CIPS, MSE and Allergies reviewed and noted,otherwise no significant problems. EXAM: Alert,cooperative, no distress. HEENT:unremarkable. NECK:supple with FROM, no JVD.Both trapezius muscles are quite tender and tense.CHEST: No swelling, deformity, ecchymosis or crepitus noted. EXT:no edema. SKIN: no lesions. Medical Decision Making and Discharge:typical whiplash syndrome; HO given. RX: Motrin 6€10rmg and Vicodin with ERPs of lit. RTC PCP prn. Visit 131agnoseslProcedures Mva/potent€al TPL liability Ward F1ad, N1d Strain, cervical Ed level 3 expanded/moderate comp€.Visit n Signed:101151031:17am Printed: 101151031:17am oil i?ERt i TIME fNIT X-RAY'"".4:SG. TIME tNiT CXfrage of EXAM ROOM fvllS X-RAYS coy TIME a p h�' Visual Acuity: OS: OD: REAP OU: EKG Oz I/Min. E:cannula mask ABGsafety � Cardiac Rhythm { t7THEfi INITIAL SIGNATURE : r NkTIA SIGNATURE pplEG `l,..l`r LURES JAMYIJASE E BP P R T PAIN GCS pulse Ox PR DRESS NOTES l JL b � 1I 4TA--Rr p L TIME W PE A 'TIME INL tICATl1CCENS VOSE cfuT` SITE RN fNIT n "'WE TYPE AMOUNT TIME TYPE AMOUNT w � f ?p?Al DT 0.5 cc IM I t. Lot# �.Lite DISCHARGE DISPOSITION Ambulate 0 w Q Gurney L�EMS Tlme xc ed a SNIECF � VanDisposition Assessment: TX Admitted Rm.# verbalizes understanding of dfC instructions Patient Helonpinps: wltnn patiem C3 wttn tamit member (initia#s) Other. low • • w415E EMERGENCY DEPARTMENTF' PER MANENM e PHYSICIAN ORDERS 6ADERS > Old Charts. outpatient Inpatient EKG X-ray L rrS 101. 02 Umin via ,: I S U b ( B 57 02 SAT on RA or. L via V( Solution Rate x Liters DATE, � IMPRINT�REA _ Saline Luck _ acro I 'L CIRCLE LABS r+€suL Xao +t+rtai, __'CIRCLE LABS a sorts k Postural VS Gia---- ❑ ? Y Hold Clot Digoxin- EKG Rate ..e Rhythm:C_'NSR CBC/DIFF ET{3H _ STff abnis:0 None H1H Dilantin Ectopy:C None Pits Type&Ril ]—J No change compared to J_ EKG Na Type&Cross Other Findings u K units of PTANR Monitor:Rate _ Rhythm:F-NSR _ CO2 PTT Ectopy:C]None Indication_ Bun HCG gual PCXR / CXR Creat HCG quant - Other X-rays Glucose Uine HCG ED/LAB CK-MB UA:Lab ED Ills 1 roponin Vold Cath CT Bili Cultures PEER_ after Tx (s) SGPT 1 SGOT Blood Urine _ l Albuteroi MDI with spacer puffs Alk Phos Sputum Throat Nebulized Albuterol 0.5%soln 2.5 mg Q Amylase/Lipase Other: w1Neb Atrovent 0.02%sola 0.5 mg fl _ i Ca/Uric Acid GC1Chiamydia ABG on pH PCO2 PO, HCO, dT 0.5 cc IM with info FS8.1%— J — 7 T TIEEDIN At CtD1TlQ ORDERS TIME -PROGRESS NOTE/MEDICAL DECISION-MAKING I Discharge from ED with instructions Critical Care Time: minutes STAFF SIGNATURE INITIAL ED MD SIGNATUR INITIAL ORDER TIME STAFF SiGNATUREY+ �` ' y *INED MD SIGNA �b,.. 90647(REV. 11.00) — _ ___ DISTRIBUTION.WHITE=MEDICAL RECORD•CANARY-BUSINESS OFFICE•WHITE=ELI _ . 77 7 fi THE pERMANENTE 0,"-71#P,INC. Emergency pep;::.;%ant , r 901 Nevin Avenue,Richmond,CA 94801 (610) 307-1555 a { it r . 1 S20b 9 + - NPRiNT AREA ` FOLLOW-01'INSTRUCTIONS: Please contact your regular doctor or the department Indicated below for any unexpected problems.If you are unable to`obtainYthe recommended follow-up treatment,return to the emergency Department. The following Instruction sheets have been given to you. ❑Sack r ❑Cast care ❑Cast/splint care ❑ Head injury ❑Kidney stone ❑Lacerations and abrasions k care El Fever or vomiting/diarrhea Pother: - ADDITIONAL INSTRUCTIONS* IJ Elevate above the level of your heart. ❑Drink plenty of fluids. ❑Avoid doing anything that aggravates the problem. ❑ Take aspirin,lbuprofen(Advil*,Nupr€ns')or acetaminophen, rugs.total,every hours,as needed for pairiffever. "Apply an ice bag/heat for utas 'mes per y w ile awake for (days). ease contact your physician4 to arrange follow-up, ❑ Other Instructions: - An appointment has been scheduled In the clinic with dr. 0 on (date)at (time). Cl An appointment has been requested for you In the clinic. Call there In 5 days If they have not Called you. ❑ Cell today or the next weekday to make an appointment In the clinic checked below. Tell the receptionist you were seen In the Emergency Department and advised to be seen In about drays or - weeks. El Allergy Clinic................___................307-1525 ❑ Head&fleck Surgery.........................307-1540 ❑ Orthopedic Clinic...,............................307-1534 ❑ Chemical Dependency Clinic...............307-1591 ❑ Medical Clinic....................,.............__ 307-1555 ❑ Pediatric Clinic....................................307-1543 ❑ Dermatology........__..........................307-1540 ❑ t1BICYN Clinic.....................................307-1588 ❑ Psychiatry Clinrc....,.............,..............307-1591 ?, E3Eye Clinic ............................................307-15313 13Occupational Medicine........................307-1580 ❑ Rich mond Health Clinic........... 1-800-495-8885 F; Surgical Clinic.......:.............................307-1550 Your treating M.D.today has been Gv' I hereby acknowledge that I have reviewed these instructions and {� have had my questions answered regarding my treatment,medication, and any further follow-up plans. i understand that I may call the X Emergency Department at any time if I have further questions. PATIENT OR raEsaNsrsLr PARTY Imus 00rr am urn r wrn rrrr aImn an err 2000 Imre nus 0020 Also 0020 riles 2020 arra SOME anIm rrr rna 2000 NONE Vale alar urn rnr aru arra urs ern mass 20u 0000 asrr"a�urr anus>'r20a VAI�z VISIT VERIFICATION KRMANEWEe DIAGNOSIS Patient: UP- Has been Ila and unable to work from �t(�(0� through Q States he!she has been III and unable to work from through This patient is advised to return to work/school f PE ❑ NO RESTRICTION$. [] TEMPORARY Activity Restrictions(indicated below)until 0 Physical Therapy (if restricted work is NOT available,this patient is unable to work until this date.) ❑Further treatrnent tact. } No ilttrng rrorr�floor,aquaSEing,bending 0 May do 11gin duty Involving sitting,standin ,reaching, �^ 9 g,graspMg, walking n Weight fining capabaftles 0 0-10 lbs. C311-25 rbs.028.40 Ibsdl over 40 lbs. C)beep wound clean and dry for5.7 days � RLMARrty� G , Srr3NAT , E NAME > LOCATION DATE SEEN 07724-18 7 7.00) nISTRISUTION.SLUE CHART•WHITE=PATIENT-PINK-ER RECORD ��N ...... � . w �*ws. :�,' mss.•.. to 00 Pyr i + ; - LATE tlF PATIENT PROGRESS RECOR .$ CgF-'RECORD ATtOFt q PATIENT`S NAME(LAST,FIRST,fyStL7I5LE) 't _ tJtST NAME �'. yF+�(i �t �t�i�-�`�'T�t xei➢r' .� :INITIAL ADDRESS , q n g BIATHOATE F.°HEALTH IUMMANCE C/,A.IM NUMBER N h, CITY R V i... 13Ay > AR Y i MEDICAL AEC OR [1MBF=p 'NECK DIGIT1 Q ` BIRTH DATE PHONE CODE GROUP -X COVERAGE GN t. OUP:NUMBEA ACCOUNT NUMBER- SUB ortoUp R, � DATE TIME rY k fm of I no an I Clinic #S iz er ..R()cent QUWLast 12 Mos. 1 , _Non-Smokor t. 7eo Dr. S. Shy*; sir V - f, C . .. �, 04 5 d' �t Gi I'cvxd t f vt ki }'17 IV o 1p s t w QN wit P-Ab s t F yam,' + iw. OA-W SER KAI i'F!'MANENTEa VISIT VERIFICATION/FAMILY LEAVE Heath Care Provider Certification N 9 L � {. {This section must be completed and determined by ireating provider onty) THE ABOVE NAMED PERSON: C�NO,does not have a"Serious Health Condition"(see reverse for further information)OR ► x-- Ej YES,has a'Serious Health Condition",as defined below(check one): 1.C)#fosplta!care 4.0 Chronic condition requiring treatment 2,J Absence plus treatment D Is currently Incapacitated IMPIUNT AREA A 3.C Pregnancy D Is not currently incapacitated S.C?Permanentltong-term condition requiring supervision 6.C11 Multiple treatments(non-chronic condition) 0 Has a"Serious Health Condition"and requires a family member to take time off from work to provide basic medical,personal or safety needs,transportation,or psychological comfort. The probable frequency and duration of this need is_. J Estimated date of Surgery/Procedure I Delivery: #:7 Diagnosis(Complete on patient request only): &INIEABOVE NAMED PERSON: as seen at this office on: > ` e''3 L U Has been given telephone advice:on: f J Has been ill and unable to attend work/schoollphysicai education._,. /!Z1through C States he/she has been itt and unable to attend work/school/physical,,education through C�sn return to full duties with NO RESTRICTIONS on� ---�,.7 — -- OR C Can participate In a modified work program starting and continuing to f (Please note:If modified Work Is not available,this patient Is then unable to work for this time period.) C Restrictions: hours per day __ hours per week BASED ON AN 8-HOUR DAY EMPLOYEE CAN: stand/walk - minutes per hour total hours .... ......,C no restrictions sit minutes per hour total hours .... .. ....,tEl no restrictions drive minutes per hour _ _total hours ......,...,1-1 no restrictions LIFTICARRY(Occasionally=up to Va workday.Frequently r up to 2/9 workday). 0-10 tbs. ...................... .... ......0 not at all ❑occasionally C frequently no restrictions 11-25 lbs. ............................0 not at all CJ occasionally C frequently C no restrictions 26-40 tbs. ....... .... ....... .............C not at all 0 occasionally El frequently no restrictions Can tlft/carry up to tbs. EMPLOYEE I5 ABLE TO: bend . .... ......._— ..................0 not at all ❑occasionally 11 frequently E3 no restrictions squat ..... . ........ ........ .... not at all C)occasionally 0 frequently 0-no restrictions kneel ......,.—.......................CC not at all LD occasionally 0 frequently ❑no restrictions climb ... ...... ... . ............. ..... ...0 not at all ❑occasionally D frequently C no restrictions reach above shoulders .................. ..C not at all C occasionally ❑frequently J no restrictions perform repetitive hand motions .............�not at all 0 occasionally C-1 frequently 0 no restrictions ASSISTIVE DEVICES?(e,g.,cast,brace,crutches) _ -- RESTRICTIONS: OTHER: - TREATMENT PLAN: - J Medication effects which could Impair performance: _ :'A D Physical therapy required. Frequency 0 Re-evaluation on: NOTE: if patient is Industrial, physician signature is REQ IRED, 5lCiNAT RE AND ITLE F{ D d 3 NAME(PRINT) V-1� LbCATICEN A[S4R�SS - PHbN.`�__..._... BILLING RECORDS HEALTHCARE RECOVERIES FEDERAL TAX Id 61-1141758 P.O. Box 36380 TELEPHONE NUMBER. (800)723-3365 Louisville, Kentucky 40233 PAGE 1 OF I CONSOLIDATED STATEMENT OF BENEFITS PATIENT'S NAME: RC3MMEL iTIL HEALTH PLAN: KAISER FOUNDATION HEALTH PLAN DATE OF INJURY: 10/14/2003 SERVICE PERIOD: '1011412003-10/2212003 Subject to change.. EVENT NUMBER: 4844678-4838099 Instructions: • If remitting payment, make checks payable to: Healthcare Recoveries. nDateof he bent's name RC�MMEL ITIL and event number, 48446784838099on the check f'Servide Diagoosis Cade Claim Number cvlcs Procedure Code(s) Blgel',Amt. Provided nefi#e I�LAE1►>'kAi'ARt3 B MD ;23.1 7 RVICALCIA R-d5p'fMeg 10/1412003 M83 EMERGENCY MIT 1335.00 $335.0€1 723.1 CERVICALGIA R-60130689" MUM= 450 EMERG ROOM $425.00 $425.OQ KINOSHITA USA L M 723.1 CERVICALGAIA R-7610556' 1012012003 48499 P4HARMACY $T60 $7.60 1012012003 99212 OFMCEOUTPATIEN 125.OD $125.Ot3 ' 10 2212003 72050 SPINE CERVICAL; $22 .00; $225:00 Now Total tilled Ghs tis x'.,177.84 Amount Received $0yt10 'Total Paid Char s $1,117.60 Balance Due $1111117.60 STOP ! The following pages are medical records. Do not print or distribute without written consent from County Counsel. ........................................................................................................................... ............................... ............................................................................................................................................................ ................ . ................................ ... ......................... ... ........................................ ......................... .......................................................................................................................................................................................................................................................... ...................... ................................................. .......................................................................................................................................... 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Aliv cchrent ana vain center 930 San Pablo Avenue, Albany, California, 94706 (510)527-1636 Fax: (510)527-1922 William Schlee, D.C. January 20, 2004 Jonathan Werner 247 California Dr. 2"d Fl. Burlingame, CA 94410 RE: Rommel Itil DOI: 10/14/03 Dear Mr. Werner, Enclosed is the final billing records on Rommel Itil. Should you have any questions please contact me at the above address. Very ly yours, illiam Schlee D 5 . 0. 4 450UT YOU t Today's Date:. _.- _I._ _t File#: Patient Name. -��"1>! lS �!I f"F�� � � ST FIRST What You Prefer To Be Galled: .__ Mate U Femate Birthdate: 7/- .3 Age;_. +. SS#: Mailing Address: ;1 1''llioin tp— 'B1,d. Rodeo CA- ?-*AS 72 01 � y STATE - -- _.__..ZIP Horne Phone ' Work Phone#;,5111 " 7S--- - -.16D0.-- 47S- Lf .S Ext: Other Phone#s; � "`'.�7_f-__0 4 7 -_ _ Co. Name: E-Mail Address: . _._ _ . _,_ .__--.___.. _.._ ___.., ----_.-. Address:-, .._.____ j Referred By: -T n&;t &in We 1-me t^ - _ CITY - __ STATE ZIP Employer: _. _ .__.. How Long? _.-- t f Phone#: Employer's Address: ,� � �__ .___.__�L i!r`E'._•___. Insured's SS#: CITY j STATE _ZIP Group#(Plan,Local,or Po4icy#): Occupation: -C±r ,c tin ` _ _ lnstlred's Name:._ Status:,J Minor Single U Married U[Divorced U Separated U Widowed Spouse's Name: Relation:.__.._— Date of Birth: .. _ _ . ._._ __ _._ _ insured's f tnployer Do you have children's U Yes _. o Now many? Please inform front desk of 2nd.insurance source. v The reason for this visit is a result of (Please circle): work,sports, 0 utolauma or chronic. (Explain what happened): i✓'4t&r C-1'l+.CL �T i t^. Please describe the pain&its location: G r.6"*n:It PCL t Y'll I When did condition begin? Is this condition getting worse? t Yes Q No Cl Constant U Comes and goes ` is this condition interfering with your(Please Circle) work ileaail ro i if so, please explain: G Have you had this or similar conditions in the past? 1-1 Yes ANo If so, please explain; _ t.S ' ' =31 6f Have you been treated by a Medical Physician for this condition? 1 jYes Q No If so, vsrhere7Q^ )Aj Have you ever been treatedb a Chir opractor before? Yes U No ^ j If so, whom? .. .I-_. _.._.. _._ Phone#: AW Who should we contact? + i —� /"`teL o leL 4 J E r Relation:_ �"t � Home Phone #410-70� Fwork Phone#: Who is your Medical Doctor?_ f'- -5hC h P Ph.ne#: ,1xt o- j Are you taking any of the foitowing medications? � IJ Nerve pills XPain killers(including aspirin) 0 Muscle relaxers Stimulants iJ Blood Thinners Cl Tranquilizers U Insulin U Other(s) " Do you have or ever had any of the following diseases or conditions? Y N Heart Attack/Stroke Y N Heart surg,/Pacemaker Y N Heart Murmur Y N Congenital Heart Defect Y N Mitral Valve Prolapse Y N Artificial Valves Y N Alcohol/Drug Abuse Y N Venereal Disease Y N Hepatitis Y N HIV+f Aims Y N shingles Y N Cancer Frequent Neck Pain Y N Emphysema/Glaucoma Y N Anemia .:, High/Low Blood Pressure Y N Psychiatric Problems Y N Rheumatic Fever Severe/Frequent Headaches Y N Kidney ProblemsYN Ulcers/Colitis N Fainting/Seizures/Epilepsy (Di sinus Problems Y N Asthma Y N 5abetes/Tuberculosis Difficulty Breathing Y N Chemotherapy j Y N Lower Back Problems Y N Artificial Bones/Joints Y N Arthritis ` ,t Please list any other serious medical condition(s) you have or ever had: .. F �L j Person ultimately responsible for account Please list anything that you may be allergic to: . .. Name: Relation List previous surgeries/treatments with dates: Billing Address:___.. _. _._--------- CITY CITY _.-STATE__. ZIP C( List any Past serious accidents with dates: -,,, BSN: I Family Health History: _ ._.__ Work Payment method: lJ CASH Chick Do you:Take Supplements or Vitamins?Utes U No Exercise?❑Yes tJ No r: Are you on a special diet: U Yes YNo/Since: 1 ! G Credit Card-Enter card#above(if accepted) t Do you smoke?)I No{J Yes/How Much?_ _ . How Long?....... ► hereby authorize assignment of Are you wearing: iJ Heel Lifts U Sole lifts!J loner sales D Arch supports tnit(ats my insurance rights and benefits directly to the provider for services ran- What is the age of your mattress?,-2- is it comfortable? } Yes IJ No dered. I fully understand t am solely respon- � Por women: Are you taking Birth Control? lJ Yes �J No Lance ible for any balance not paid by my incur- � company fif offered at this! office).Are you Pregnant? i:1No UYes/How long?_-, _.__ Nursing?UYes d No _ a We invite you to discuss with us any questions regarding our services.The best health services are based on a friendly,mutual understanding between provider and patient. ! let Our policy requires payment in full for all services rendered at the time of visit,unless other arrangements have been made with the business manager. If account is not paid within 90 days of the date of service and no financial arrangements have been made, you will be responsible for legal fees,collection agency fees,and any other expenses incurred in collecting your account. { Nil l authorize the staff to perform any necessary services needed during diagnosis and treatment.I also authorize the provider and or managed care organization,to release any information required to process insurance claims. l IN! I understand the above information and guarantee this form was completed correctly to the best of my knowledge and understand it is my responsibility to inform this off ic f any chang t Inf r o have provided. Signature y — Date AduH Patient 4I Warani ar Guardian l;1 Spous�i First Impression Forms Inc. 1 800 99FORMS FORM# 1MCA1.6 Copyright 02001 r y ✓ ? h F^( y w A rgn, gn;No t �. 5OUT YOU Today's Date:I#J._!2/ / 4.�'t=€€e#W_�'(__ Da e &Time of Acc€dent: -- a.m. yp.m. _. _. Were you the: gDriver LtFront Passenger U Rear PassengerName: �' _ .__-- -'-_ � .: #f a traffic violation was issued,to whom was €#issued? Number of people in accident vehicle? { Did the police come to the accident site? . ,XYes U No t,. , Was a police report filed? . . . , . . . . . . . . . .I Yes L3 No Were there any witnesses? . . . . . . . . . . . . .)(Yes U No t: Were you wearing your seat belt? , . . . . ._WYes No te Was this vehicle equippers with airbags? . VYes ❑No If yes, did it/they inflate? . . . . . . . . , , . . .0 Yes At No In relation to the base of your skull, where was the headrest? . . . . . .#*Above Ll Below At base of skull ` What did your vehicle impact?C:1 Another vehic€e C] Cather '•4 Date&`time of Accident: C3 a.m. U P.M. Was your accident directly related to your work? If other, explain:-__ tJ Yes G No Chid any part of your body strike anything in the vehic#e?U YesNo Briefly describe the events that occurred just before and It yes, please describe: during your accident:_ __.__ _- -------_. _—.-.._._. Make & model of the vehicle you were occupying? _. _ _ ___._.. Name of the location/street on which you were traveling? Give the address where accident occurred: (if other than r Tom. _ _ employer's address)__._. _____._ _._ __..__.__..... In which direction were ou headed? ]N �'S UE U1 Was anyone else present during your accident? What was theapprox. speed of our vehicle._a __3.$" CJ Yes Na Did the impact to your vehicle come from the: U Front lRear Did you report your accident to your employer? Cf Right Side U Left Side Q Other Yes No During impact, were you facing: URight QLeft((Forward Ll Were you t_l aware orsurprised by the impact? What recommendations did your employer make just if accident vehicle made impact with another vehicle.,. after your accident? , _.. _. _._ __._ . ______. -__ .__._.-._ Make and model of that other vehicle? Has this type of accident happened to you before? Direction other vehicle was headed?UN VS UE UW U Yes No Speed of the other vehicle?�s .. A 1 To the best of your knowledge, has this accident occurred , in your workplace before? . . . . . . . . . . . . . Yes 0 No f In general: to your words, please describe the accident: Is your job physicalty stressful? . . , . . ,. .IJ Yes U No Is your job mentally stressful?., . . .....,U Yes U No Is your workplace noisy? , ,.. .. .. .. . . ., .. ..U Yes ❑No Have you changed jobs in the last year?U Yes Ll No rl+ti-+t k �^ , r. 4 A: .............. V. M ;a di& r: of-owe r r j Did accident render you unconscious? . . . . .0 Yes No To evaluate the effect that continuing work wi(I have t` on your recovery please comb lete the followin If yes, for how tong?__--__.—_—_ _ F Please describe how you felt immediate) after the accident ?y How many hours are in your normal work day?_ y Please indicate Wryour daily job duties and any activities ' �_USM t4A t"Y+- which you are occasionally asked to perform. — ' � '`'_...- _-- f Standing g U Driving U Operating equipment Sifting U Twisting U Work with arms above head Have ou gone to a H;spital or seen any othertYes U Na Wailang U Crawling U Typing did you go?U Just after accident tThe next day U 2 days plus Lifting U,Bending U StoopingAl .„. How did you get there? iJ Ambulance or IPrivat transportation U Other N me of Hospital a dlor A##ending doctor:. .► F;' What positions ca ou work;in with minimum physical n: -.. _ effort and for how long? g U N/A , Was he/she a: U D.C. )4 M.D. U D.O. U D.D.S. Prior to the injury were you capable of working on an Describe any treatment you received:_ G wequal basis with others your age?. .XYes U No U N/A Do you work with others who can help you with, any- —� heavy lifting? .U Yes No U N/A Were X-rays takers? ..... ...:................0 Yes V No While in recovery, is•there any light duty work you could Was medication prescribed? . . . . . . . . . . . . .t0fYes U No request? Yes C]No U N/A Have you been able to work since this injury?U Yes a No t: . . . . . . Are your work activities restricted as a result of this injury? y ;. Yes U No Indicate fYthe symptoms that are a result of this accident. jfDizz"messifficulty sleeping UJaw problems Nausea ` } )Wemory loss {J Irritability Arms/Shoukter pain Back pain 'ANeadache(s) 1 dFatigue U Numb Hands/Fingers .]Lower backpain (( C11 $` r Blurred vision Tension U Chest pain Back stiffness Buzzing in ear eck pain „Shortness of breath ULe g pain ,: ML � IJ Ears ringing eck stiff Stomach upset UNumb Feet/3oes i:IClther ._ 2nd insurance Source or Auto Insurance Is your condition getting worse? Type of Insurance: _ Yes U No U Constant U Comes&goes Co. Name: Indicate your degree of comfort while performing the MAW- "4 following activities: Address: Comfortable Uncomfortable sometimes Painful even en9tf only Phone #: , _ 1 ��n -�Q�_--��j� t-4.3 # l Lying on back . . . . . . . . .U . ❑ . Lying on side . . . . . . . . ,U. . . . . . . . . U . . . . . . Insured's Name: fw trnrne t } Lying stomach. . . . . . ..). . . . . . . . U Policy#: CAW 060�� Claim Sitting t . . Standing . . . . . . . . . .0. . . . . . . . . .I . . . . . . . U Insured's SS#: G pq..{t� -" ! 515 rs Stretching . . . . . . . . . . . .0. D.O.B. /2 Lovemaking . . . . . . . . . .U. . . . . . . . . . U . . . . . U Insured's Employer: o f CO Uc.Asx u S Walking . . . . . . . . . . . . .0 U . . . U Agents Name:_ Running U . . U . . . . . . . i� - _ Sports . . . . . . . . . . . . . . .0 U. Working . . . . . . . . . . . . . . . . . : . . . . . . . Ll fj U ff any of your medical or account Information has changed, 5 Lifting . . . . . . . . . . . . . . .0. U iBending . . . . . . . . . . . . .U . . . . . . . . . . . 0 Please inform our front desk personnel. Kneeling . . .r,y. . . . . . . . . . C:] U Please remember you Pulling are ultimately responsible for your . . .0. . . . . . . . . . accou t � } j Reaching . . . . . . . . . . . .r]. . . . . . . . . U . . . . . . . l 1 d Have you retained an attc ey: Yes U No �r - OFf ” USE ONLY OFFICE USE ONLY OFFICE USE ONLY OFFICE USE ONLY OFR E USE 0 LY j If yes, whom: Jiy*AA , W w His/Her Phone #: First Impression Forms,Inc 1 800-99FORMS FORM It 2CAWAf copyright y . t .,. MM Name: _ File#t: . What is your current weight: 6 S lbs., and height, J Ft. In.. Please describe your condition: Signature: J . . '`.'t date: /6 / 1// Please mark area(s)of injury or discomfort as shown in the example below. Mark all areas with the appropriate symbols and indicate the degree of pain using a scale from 1 (discomfort)to 10(extreme pain). Description > Numbness Pins & Needles Burning Aching Stabbing Symbol > NNNN PPRP BBBB AAAA SSSS Circle any area of pain not represented by a symbol. I AAAA C t, '-- ii r Example right left left right t � Right Front Back Left µ t PLP-4-'f,-QLCYCI.I=30 TL14T\\/P-NJ4Y TVFI 1--AL.TIA Of 0 Uz PLAIL T First Impression Forms Inc t_800 99FORMS FORM#2CHIRO.3 02002 A-1145 P H Y S I C A L E X A 14 1 N A T 1 0 NAME tD fi AGE:�4 WEIGHT f bs L. ... ALAxc HEIGHT Pain -A. Tenderness Huetcle Ssasms Left. Right Lef Blood Pressure _ �.,t�t 1'ulee C1 s' C1 age o Nation. Sitting (Cervical) C2C2 Cervical Flexion 650e Extftaion "o C3 Lateral Flexion 400 L 01 VPRC4 t G4 Rotation 550 RL tri.# f> C5 C5CC C C& Flexi an LOW Standing (Doren-Lumbar) C7 C7 Flexion 95atan$ion 350--.- r Trap Lateral 400 L 04 P H ��` 'J1 f Di Rotation 350 L R ✓' D2L4= D2 D3 Peripheral Sensitivitnwheel) y P. .r...,..,,t-- � i D4 D4 Back: L D5 ' tither D5 Db D6t Tests in Prone Position: D7 t D7 Ely D8- ......_..,_. Deltoid D8 Femoris Gluteal D9 i D9HYPerextension Latissimus D1 t7 D1 O Leg Length Nachlas D11 � D11_..— .._ SCM__. -- Teres t 1 D1 D12 ( Trapezius L1 L1 f Other L` L2 Tests in Supine Position:! Ll, Ll, L& EBraggard L4Fabere Patrick L5 Hiatal Ileocecal, x L5 Laseque ._ , Sac t Sac Cr Log Lowarer__j:t R Ili' R Ili Leg Raiser ��-L1 Psoas � L IliL Ili __L Sit-up_ t;. Soto-Hall _ Coe Other ..... Coc Via] Postural Anal • 3 R /Jl ,,,•Ref axes Shoulder R-•�� �P' L- Scapula L •R ',�,,. Biceps L R Triceps L ''� R ✓ '" ---......_ ` Other>. Radials � R � Patellar L r''� R Y'' Additio_ al Com eats Tee s: , .., Report Codes •- Abriviations IS Initial Symptoms NP Neck Pain HA Headache MBP Mid-Back Pain LBP Low Back Pain SP Sacral Pain UX Upper Extremity LX Lower Extremity VF Vertebral Fixations MS Muscle Spasm SD Structural Deviation C Cervical Thoracic T Thoratic L Lumbar P Pelvis T/EI Tens/Electrical Therapy SWD Short Wave Diathermy ET Electrotherapy IST Intersegmental Traction ff � ....�`7r"! l� ...���moi►/��/ Diagnosis(pi'uncvV. Vertebral f aMon/stnxturd uspnawty IS A/PkA NP L - SP - Ux - Lx MC I 6 7 8 9 + VF/MS - 5D - LM mnw: C u - m - I / T u - m - / L - 1 2 3 4 5 6 7 8 + Adjust ( C ) ( T ) ( L ) ( P ) TI/EI - ET - - IST .............j. . ........................ . ............. IS A/P HA - MSP BP SP Ux - Lx MC 1 2 5 6 7 8 9 + VF/MS - SD - LM mnw: C u - - I / T u - m, / L 1 2 3 4 5 6 7 8 9 + Adjust ( ) ( ! ) ( ) # P ) TI/EI C-,- SIAO IST ............... ..... , ., y ..... ....................... ...................... ..,... IS A/P N MB - SP - Ux - Lx y MC - 1 P5 6 7 8 9 + VF/MS - SD - LM mnw: C u - m - I / Tu - m - I / L 1 2 3 4 5 6 7 C5>� 9 + Adjust`( C ) ( � ) ( ) ( P ) TI/EI .� SWD -.,,IST -.1-0/wile.. . .''tom....................................................... ,, IS A/P -PrN—P-)rmBp)- LBP - SP - Ux - Lx` MC - 1 ' 5 6 7 8 9 + VF/MS - SD - LM mnw: C u - m - I / T u - m - 1 / L I 2 3 t 4 5 6 8 9 + Adjust (A ) # ) # L ) # P l II/El -( ✓! S'VV'I IST IS A/P - } 4"`N - M../* BP - LBP - SP - Ux - Lar MC 6 7 8 9 + VF/MS - SD - LM mnw: C u - m - I / u - m - 1 / L I 2 3 4- 5 6 � 81 + Adjust Vt ) #r t )�A )j/7P } TI/EI - "SWn IST .::...::............::..;:r"..:: !'!'t L.�?.................................................. ................................. .. .......... IS A/P - NP BP - LBP - SP - Ux - Lac Mc 1 35 6 7 8 9 + VF/MS - SD - LM mnw: C u - m / T u - m - I / L 1 2 3 4 5 a 7 9 + Adjust ( ){, .....L..).( ,) .,) TI...., ............'E.. S. ,. IST <J3 C111RC7 RACl7C REMARK ABSTRACT" POB 10600,ZC NV 89448 � < l Db%nostsfp(tmarIO: Vert+ebrciftvaat�tvrVsstrucct+urd a ite�etijIj .....I....... .. ! ::... ......... . .3 f` .............."+�................,........ ..,,..... ...... €S A/P NP M0 - LBP - SP - Ux - Lx MC 1 5 6 7 8 9 + VF/MS - SD - LM mnw: C u - m - / T u - m - I /L 1 23 * � 4 5 7 8 7. 9 + Adjust ( Cf) f T� f' �/ j vp TI ET - S'fiITD IST ............../....... ............. .L. : °. „..,.................... ................ .... . IS A/P . . NP - BP - LBP - 1 5 6 7 8 9 + VF/MS - SD - LM mnw: C u - m - / T u - mi - I / L 1 3 4 56 7 8 + Adjust ( C f T ) f ) i P ) TI EI - ET -5 - Is'C is A/P - NP MBP LBP - SP - Ux - Lx MC - 1 --'' 5 6 7 8 9 + VF/MS - SD - LM mnw: C u - - I / T u - - I / L 1 2 3 4 5 k 6 ? 8 9 + Adjust f f ... ....L ) { P ) II/El ......E I ....... ........IST €S AJP HA NP BP LBP - SP - Ux - Lx MC 1 4 5 6 7 8 9 + VF/MS - SD - LM mnw: C u - 1 / T u - m. - I / L 1 2 3 4 �( `5� ) 6 7 8 9 + Adjust f C� (.Y).f .L.... . P l ..✓fit/EI..... ....ET IIID -,..1ST I.....I....... ....... ... ..!/. ..ez....................... .............. Is A/P -eI j -NP MBP - LBP - SP - Ux - Lx MC - I !k—" 5 6 7 8 9 + VF/MS - SD - LM mnw: C u - I / T u - m - I / L - 1 4 - 6 7 8 + Adjust f C { T L f P�}' TI/EI - ET - SVtD IST ............... .. ...............................,,..... ..........I............ ... l..�. f s ...................... . ............. Is A/P - A NP - B - LBP - SP - Ux - Lx MC 1 2 5 6 7 8 9 + VF/MS SD - LM mnw: C u M-"-I - I / T u - m - l / L - 1 2 3 4 w6 7 3 + Adjust f C ) f L f f L f P ) TI/EI - ET - IST ............... ..... ......... 93 C1I1RO OTIC REMARK ABST14ACT POB 10600, ZC, NV 89448 Diagn,,s -,1pr n V,eftebrcJJL% dJotVst►wcturd aWnawtrlj• Is A/P .. ......... P wl � LBP - SP - Ux - Lx MC - I 6 7 8 9 + VF/MS - SD - LM mnw., C - m - I / T u - m - I / L I 3 l:t.-�' 5 6 7 8 + Adjust ( C } f L } f ) II/El,... ET S ...IST .......................... . :..................... .... .............. is A/P .. HA ..NP BP LBP - SP - Ux - Lx MC - I - - 5 6 7 8 9 + VF/MS - SD - LM mnw: - m - I / T u - m - I / L - 1 2 3 V 5 6 7 9 + Adjust ( C ( } ( } ( �"'} TI/EI - E`I' - SWD - IST ............................. ........................... ............. :......... . . :........................... ............. Is AN -� p LBP - SP - Ux - Lx MC - I 2 3 5 6 7 8 9 + VF/MS - SD - LM mnw C - m - I / T u - m - I / L 1 2 3 (4) 5 6 7 3 + Adjust(.. ( T ) (r } ( } Tl/El - ET SWD - IST is A/P - H P DP - LBP - SP - Ux - Lx MCAoh? 1 6 7 8 9 + VF/MS - SD - I, mnw: - m - I j T u - m - I / L 1 2 3 5 6 7 8� 9 + Adjust ... (1..................} fIfP } 11/EI............... ...................S MBP - LBP - SP - Ux - Lx MC 1 3 5 6 7 8 9 + VF/MS - SD - LM nw. C u - m - I / T u - m - I / L - 1 2 4 5 6 78 + Adjust ( C } f T } ( L } f P } TI/El - ET - SWD IST .................................... ....... - LHP - SP - Ux - Lx.. MC - 1 5 6 7 8 9 + VF/MS - S - LM mnw. C u - m - i / T u - m - I / L I 2 3 4 6 7 9 + Adjust ( C } ( } f } f P ) TI/EI - ET IST 93 CHIROPRACTIC REMARK ABSTRACT..............' + + . POB 10600, ZC. NV 89448 Physical Examination _ Date- Name: ,., "� �/ e t Age: _ Weight 4. Balance. Height: .:1r r Pan &Tenderness muscle Spasms Left Right Left Right CI Cl C2 C2 r C3 C3 C4 C4 C5 C6 _" C7 C7 TRAP TRAP ii", D1 Dl D2 D2 D3 D3 D4 D4 D5 D5 D6 ✓ D6---' D7 , D7 D8 D8'- D9 8___.D9 D9--•--- DIO D10 DI1 Dll D12 D12 L1 L1 L2 L2 _ L3 L3 L4 1A L5 LS . . SAC SAC R Ili R Ili L Ili L Ili COC Coe Biceps L R Triceps L Radial L ! Patellar Page l of 2 Blood Pressure: .:. Pure; Range of Motion: Sitting(Cervical) -- rvical Flexion 55 ✓ --0 Lateral Flexion 40 0r'`- C— R�,Extension S50o Ration 55 L R F`oramine cot preg*i0n,: . Ran�of MatinSn � L _b. R ictandig orso Flexion 95 Extention 35 Lateral 40 L R , Rotation35 L Peripheral 80"itivi Back: I. Other: Tests in Praise Fositiotz• Ely Femoris ------.. Deltoid Hyperextention Gluteal Leg Length . ! Latissimus SCM Hechlas Trapezius Teres Other Test in Sunin� Position Braggard Hiatal Fabere-Patrick Laseqe Ileocecal Lag Raiser -- ---- Leg Lower Sit-up Psoas . Other Soto-Hall Visual'Postural Analysis, Shoulder L R Scapula .`_""`_"` "`� ' Hip L Other Addition Comm ` NP 2 of 2 BILLING RECORD.....::....:...........:.....�..... S ...................................................................................................................,............................................�............................................................................-...................................... .....,........,...,.. AlbanyAccident anti Vain carter 930 San Pablo Avenue,Albany, California, 94 706 (510)527-1636 Far:(510)527-1922 William Schlee, D.C. t January 18,2004 Rommel ltil DCII: 10/14/03 Diagnosis: 1) Cranial Cervical Syndrome(723.2)with cranialgia(784),cervicalgia(723.1),strain- spmin(847.0) 2) Dizziness/Vertigo(780.4) 3) Brachial Radiculitis(723.4) 4) Thoracic strain-sprain(847.I_ 5) Lumbar strain(847.2) 6) Ilio-sacral dysfimction(739.4) 7) Stomach dysfunction/upset and nausea(536.8) Dates of Service: CPT Codes: Fee: 10/21/03 99204 $125.00 10/21/03 98941-$65/971124-$25 $ 90.00 10/27/03 98941-$65/97024-$25 $ 90.00 10/28/03 98941-$65/97024»$25 $ 90.00 10/31/03 98941465/97024425 $ 90.00 11/03/03 98941-$65/97024-$25 $ 90.00 11/04/03 98941-$65197024-$25 $ 90.00 11/05/03 98941-$651970224-$25 $ 90.00 11/07/03 98941-$65/97024-$25 $ 90.00 11/10/03 98941-$65/97024-$25 $ 90.00 11/11/03 98941-$65/97024-$25 $ 90.00 11/12/03 98941-$65/97024-$25 $ 90,00 11117/03 98941-$65/971124-$25 $ 90.00 11/19/03 98941-$65/97024-$25 $ 90.00 11/21103 98941-$65/97024-$25 $ 90.00 11/24/03 98941-$65/97024-$25 $ 90.00 12/10/03 98941-$65/97024-$25 $ 90.00 12/12/03 98941-$65/97024.$25 $ 90.00 12/15/03 98941-$65/97024-$25 $ 90.00 12/17/03 99941-$65/97024-$25 $ 90.00 12/19/03 98941-$63/97024-$25 S 90.00 01/05/04 98941-$65/97024-$25 $ 90.00 01/09/04 98941465197024425 $ 90.00 01/16/04 98941-$65/97024-$25 $ 90,00 01/16/04 99213-25:Final Exam $ 65.00 TOTAL BALANCEM: $2.,,260,_.00 RE: EMPLOYER: West Contra Costa Unified School District INJURED EMPLOYEE: Rommel Itil DAt`F OF INJURY: 10/14/2003 1. bate employment commenced with your company: D8 - 1 -91 2. Title of position held with you immediately prior to the above date of injury: 3. Gross earnings per month for a period of six months prior to the above date of injury: 4. Gross rate of pay immediately prior to the above date of injury (indicate whether gross pay is per hour, day, week or month): (0 t 00 5. The total number of working clays missed by the employee after the above cute of accident: 6. Total amount of lost earnings of the employee to date, according to your records (include normal pay increases the employee would have received): 7. Amount of additional compensation lost by the employee,such as sick leave,welfare benefits, vacations, overtime or loss of seniority: A&LAD d(t' GCS - Dated: `1] 703 ignature fkm Print or Type Name PAYaOL-L- Title or Position Telephone Number ilcq� N56efl Ay-eAuc .Address rnr MIN am Hare arar w e arr aaat aaat yam War cart aaas arr arpr aaw rrt as rrat aw+aaa aaaR rw s rar err r�r+wa aar arr aur arrr aa*am w aar Mar a"w l as r aw `l`�t11fJ KAISERVISIT VERIFICATION F-63'41Y4rilYCJY1.FQd •y; 4 },•x j r . DIAGNOSIS Patient: E_6* 101 c, r Has been III and unable to work from y�n W1 t to--Is through _ Fj Mates he/she has been ilt and unable to work from _ through r ' This patient is advised to return to work l school I PE.._...�-ffj� . 0 FIC RESTRICTIONS. Q TEMPORARY Activity Restrictions(indicated below) until Q Physical therapy i, (If restricted work is Ft(7`t'available,this patient Is unable to work until this date.} Q Fttrtner treatment req.. ED No lifting from floor,squatting,twndln 0 May do light duty irwofvtng sitting,standing,reaching,grasping,w0drig C3 Weight lifting capabilities: 00-101113s. 1:311-25 lbs.028.40 lbs.Cj over 40 lbs. 0 Keep wound clean and dry for 6.7 days. REMARKS S413NA7 RE " NAME LOCATION �____�_ OATS SEEN a- 077 4-1ff Y 7-f30)� _..- pf+3TRtBUTION:BLUE CHART-WHITE.PATIENT PINK.ER RECORD h ..` ` KAISER �x '-,.' PERMANENTE e 4. VISIT VERIFICATION/FAMILY LEAVE Healh Care Provider Certification P� [ (This section must be completed and determined by treating pIr vv€der only) rmt `t sx THE ABOVE NAMED PERSON'. f,J NO,does not have a"Serious Health Condition"(see reverse for further information)OR f C I YES,has a"Serious Health Condition",as defined below(check one): i i.Ci Hospital care 4.C1 Chronic condition requiring treatment 2.-U Absence plus treatment CJ Is currently incapacitated IMPRINT AREA 3.0 Pregnancy 0 is not currently incapacitated 5.Ct Permanentilong-term condition requiring supervision 6.D Multiple treatments(non-chronic condition) FJ Has a"Serious Health Condition"and requires a family member to take time off from work to provide basic medical,personal or safety needs,transportation,or psychological comfort. The probable frequency and duration of this need is CJ Estimated date of Surgery IProcedure iDelivery: 0 Diagnosis(Compiete on patient request only): /:_',ME ABOVE NAMED PERSON: `� + (, Was seen at this office on: LJ Has been giver?telephone advice on: '~ 0 Has been Ill and unable to attend workischootiphysieal education_Z9���_ _ through Cl States he/she has been ill and unable to attend workischooliphyslcal education through an return to full duties with NO RESTRICTIONS on_ "y7 QR 0 Can participate In a modified work program starting and continuing to - t (please note:if modified work is not available,this patient Is their unable to work for this time period.) 0 Restrictions: hours per day hours per week BASEL?ON AN 8-HOUR DAY EMPLOYEE CAN: stand/walk _ minutes per hour total hours . ... .......D no restrictions sit _minutes per hour total hours ...... . ..,,CJ no restrictions drive minutes per hour total hours ...........0 no restrictions LIFTtCARRY(Occasionally=up to 113 workday.Frequently=up to 2t8 workday): 0-10 lbs. .. _ .. .... .... .................O not at all ❑occasionally 0 frequently 0 no restrictions 11-25 tbs. .. ... .. .......... ....... .C1 not at all 0 occasionally 0 frequently C_]no restrictions 26-40 tbs. .., .....__........ ...........CJ not at all ❑occasionally C._i frequently ❑no restrictions Can lift/carry up to_ _ tbs. EMPLOYEE IS ABLE TO: bend ..... .......... .... ........... .....CJ not at all ❑occasionally 0 frequently G no restrictions squat .. ............................o,,.[ not at all CJ occasionally ❑frequently 0 no restrictions kneel . ......... .......... ... ...... not at all ❑occasionally 0 frequently O no restrictions climb .. .. ... ... .. .... ... . .. .. ......... .L J not at all CJ occasionally 0 frequently 0 no restrictions reach above shoulders . ... ... .. .. . ..... .. .Ci not at all ❑occasionally ❑frequently _.l no restrictions perforin repetitive hand motions ... ... .. _,. .❑not at all 0 occasionally C frequently no restrictions ASSISTIVE DEVICES?(e.g.,cast,brace,crutches) RESTRICTIONS: OTHER: TREATMENT PLAN: O Medication effects which could Impair performance: 0 Physical therapy required. Frequency: 1--1 Re-evaluation on: S15NATIlaE AND TITLE NOTE: if patient is industrial, physician signature is REQ /RED DAT Z U 3 FitNTj Lt}CATiflNiADDRESS f\ IAT NAME{P _........ ......... ......... ......... ... .......................... ......... ......... ......... ......... ......... ..............._.. _.. .. ......... ......... ......... ......... ......... ......... . ............................................................... Ptsperw For MOM"Maros CAMKV glair Pie 3�f t3 ROMMEL 5 ITIL XXXX-XXXXX9-51001 19=/03 Naw Activity iL*al7atnt n od . 11/09/03 —" EtiTDbA ENTAL RICHMt3NE� cA Location Date Rental: RICHMOND CA 03110/16 Return: RICHMOND CA 83/11/09 AgnwftM Number,1411604t)4t1 Reciter Name_ITIL/ROMMEL Rs%rgnge Number:126212 «11tM03 fi 'ATZCAN► 4ENTAL AICHMUND CA 588.70 Location t3ata mai: RICHMOND CA 03/1 t/10 Return: RICHMOND CA 03111r Ayreemeot Number;1169241456 Renter Name:ITEL/ROMMELL P&Mrence NuffiW:120016 t 212"9103._. Periodic FkAkfi Cl1ARGE 27i7 29.00 fats of Kw AaRity 878." Finartaa Charges Averr►ge 0 '1 Daily a�all' Norm naI #. Perive�� SIMM days this period:29 gatanbe Periodic Rate PERCEWRAA� PERCENTA RATE t�tAli+C1C E#r Purchasers 2,759.630.0342% _ 12.48% _ ~12,.48% _ _.27:37 Gash Ao%tences 0.00 0,8465% 0.00% 16.98% Butt _ 0.00 Certain of the periodic rates and APRs above may be variable.Ttwe rates may very .. based upon the prime rate Identified in the Well Street Journal,as described in your Cardmember Agreemork as currently in ef ei- 'afsh Rebate t'..41RnOS Sununaty As of AM 56055 81199-Stilft+ititr;a_1 ROMMEL S ITIL Year To U490 Total Qualified Spend $2,313.66 Rebate br Spend $6.57 Bonus Pabote for Revolving a Balance 89.22 Total Cash Robato #1$.79 breMgott utt Rsbake Maa:ssps Remember to pay at feast the minknum Oue by the payment due date to be es# _ for a cash rebeto and to avoid 40tional finance charges and tate tees. b=oa Cash Uro the hthea cau�f Evatywhees You Earn cash back by usi.._your American Express Costar Cash Rebate Credit Card averywhere American Xpross Cards are welcome. Your cash rebate will be awarded to you In the form of an in-store coupon In trour tilling stat+amorlt. Rebels aunts shown an this statement are subOd to e4bility retluirements and other terms and conditions of your Gardnvambsr Agr nt. 3 a< wee ot+6 4d reg ( ITIL, ROMMEL #3 FAN RA M1160404I VI�H 4377255 f CLS YF MdL 03 TOYOTA LI975C 5CA 5BIV573 '4N# 4TiBE32K13U7373 7UEL: 6 18 OUT 618 IN :OP 1,16$491 EDIXESTERN UNITED. IRVINE �o 79584 RENTED,ofrta 1011612443 18:51 RICHMOND HLE RURN:o"o 11/4912043 09.00 CRICHMOND HLE PLAN ft HI.F WF:OUT: HLE WE RATE CLAS,3 YF MlLt;AGE ltd 9041 TOTAL MILES DRIVEN 2155 MfLEAGE OUT 8786 MILES ALLOWED TMR X M LESSE# +! 2145 BASE RATE 222 gBfDAY $ 574.75 Vl H UPGRADE 2 9.44 t pqY 225.44 MILEAGE CHG 215.4 0 /MILE S q 00 SUBTOTAL 1 799.75 LDW DECLINED $ 4.44 Al pFf✓ DECLiNgD $ 4.00 DECLINED LUPURCHASE OPTION $ 0,0 fEL NARGES SUET&TAL 7 S 793.75 Tf}TAL TAh To L CHARr.91,%OF S 799.7 $ 86565.73.s8 BILL TO Ct)MPANY CHARGE $ 6232. 97 7 CUSTOMER CHARGE 24 ,5 CUST DEPOSIT CHARGE CIV: AX XXXX7(XXX74XXX'1U41 243.56 CUSTOMR BALANCE: COMPANY BALANCE: $ 622. 17 STATEMENT OF CHAROL:S.NOT VALHI FOR RENTAL Rtt RA H30241456 VI^H 0119513772563 CLS YF IDL 133 TOYOTA LIC CA 561V573 L RNTED>"+0 11i1Q13 D �o RICHNII#3 ttt R� .UI knlo 11/261= 12m RICIfMC�Vf3 HL Puth I : >'trstm OUT. Custom i,ATE CLAS:S YF MILEAG ALIT KOK M LE5 A LOW �/EI 6 MILES E RIVEN 559 TR-X MILES 0 SASE RATS; 17 @$22.99 #DAY $ 390.83 �IILjAGE CNG 559.1; @$0 1 MILE $ 0.00 St181nTAL 1 $ 545.83 ADDITIONAL CHARGES $ 153.00 L ovi DECLINED $ 0.00 AI.IsEt; DECLINED $ 0.00 DECLINED UQ L PJR HASE OPTION 4HARGES.L0 0� C $ 543 83 "OTAL TP. 8.26%OF $ 543.83 544.87 TOTAL CHARGES , 44.87 CUSTOMER CHARGE S 588.70 SIT CUST DEHARG90 N: AX XXXXXXXXXX)(Xl101 ` 8$.7p C T"MER BALANCE: Ct7MPANY BALANCE ' 0.04 F,. LAW OFFICES OF JONATHAN J. WERNER 4R p 247 CALIFORNIA DRIVE, SECOND FLOOR FREMONT BURLINGAME,CALIFORNIA 94010 TELEPHONE(510}�s�-lass TELEPHONE{650)348-0333 C Oq OAKLAND TEL NE 10)834.9000 FAX(650)348-1298 February 26, 2004 VIA CERTIFIED MAIL RETURN RECEIPT REQUESTED Clerk of the Board of Supervisors Contra Costa County County Administration Bldg., Room 106 651 Fine Street Martinez, CA 94553 Re: Our Client: Rommel Itil Your Insured: Contra Costa County Your Claim No: 54618 Date of Accident: 10/14/2003 Dear Sir or Madam: Enclosed is the original Claim form with attachments plus one copy of the claim form and a self-addressed, stamped envelope. We are requesting that the copy of the claim form be stamped received and returned to us in the stag paid envelope, confirming receipt of the original claim form. If you have any questions, please feel fr to call s. ry truly yours, r JONATHAN J. WERNER JJW/erc Enc. cc: Rommelltil t CEAU3S31d S1H316 777 sdsn WOZAadnd83-4 d0ld3 j Vr of,-:n m= n n � "�: �Ifslrrro {x'2{'{7.1;{.'�{d}{:{�f.'•:ti:.^.t•',:: �'.3'} yr. ( .�.+rr.�. '�}•f{{f �f•,•A ••�•{f V(f.� •vl•:r 55 } tut tib ki IY. f$ f C3 e� :ar V6 M CO co LU a • 50 4N y+ crt gar• ., t t ui f$. �� ► �� W 14 -elzs.4 --4 to 4 -14 44, C> W Lj N I f+`y� W ,��.�... ca Z. H �4 H O r �. -•- r lti 2f +Q m J eF „� '— r r 4. I ,. W J � . N v „ • , g ' L , ►., - a m •. ... .....;: :.:.:................ .. : :::: . 1r• .... ...�... v r ci �.. C, r- ftj z N ... j r W W `s .... _. 00 0) v a b J •- m uj fa .¢ ..10, �. ° QaaQ W g ' b C C t� E.. W y � k . Q fi d Q b 3 rI b asC C ? Q O G� t•� at C v .., ti N W .. F.. iii F• Cc Q� y �? Fr d '' ................................... 4. 4 V D ..; o L �J Thiss fadm9kV Is Me pmperty of the U.S.Postal Service and Is provided solely for use In sending Priority Mail. Misuse may be a violation of federal law. k:. _. _ .... ....... CLAIM MARD OF SUPERVISORS OF CONTRA COSTA COUNTY IFlii.tlU BOARD ACTION.APRIL 06, 2004 Claim Against the County,or District Governed by ) the Board of Supervisors,Routing Endorsements, } NOTICE TO CLAIMANT and Board Action. All Section references are to } The copy of this document mailed to you is your California Government Codes. } notice of the action taken on your claim by the Board of Supervisors, (Paragraph IV below), given Pursuant to Government Code Section 913 and 915.4. Please note all"Warnings". AMOUNT: .$1,190.64 CLAIMANT: ROB KILLORAN ATTORNEY: UNKNOWN DATE RECEIVED: MARCH 03, 2004 ADDRESS: 1216 LINDELL DRIVE, BY DELIVERY TO CLERK ON, MARCH 03, 2004 WALNUT CREEK, CA 94596 BY MAIL FOSTMAP KED: RECEIVED THROUGHTf�t'�•-OFFI :F, MAIL FROM RISK MANAGEMEN FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. MARCH 03, 2004 JOHN SWEE 1 k Dated: By: Deputy II, FROM: County Counsel. TO: Clerk of the Board of Supe isors ( This claim complies substantially with Sections 910 and 910.2. i ( ) 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 91(3.8). { ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim(Section 911.3). ( ) Other: Dated: ` ' ' By: -'- Deputy County Counsel 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., ARD ORDER: By unanimous vote of the Supervisors present: (y)' 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 Dated: .Ydo JOHN SWEETEN, CLERK.,By , Deputy Clerk WARNING(Gov. code secti913) Subject to certain exceptions,you have only six(6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. *For Additional Warning See Reverse Side of This Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States,over age 18; and that today I deposited.in the United States Postai 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. f Dated: ✓ ' JOHN SWEETEN, CLERK By Deputy CIerk Penny Bailey .Claire to: BOARD OF SUPERVISORS of COMTA COSTA COUNTY MAR 3 1 2004 } INSTRUCTIONS TO CLADONT A. Clam relating to causes of action for death or for injury to person or to per- sonal property or growing craps and which accrue on or before December 31, 1987, must be presenter) not later than the 100th day after the accrual of the cause of action. Claims relating to causesof action for-death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1968, 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 Cleric 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 clams 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 Against the County of Contra Costa } MAR 0 3 2004 CLEn , COty j' # A9sp14S District) Lr ill. �.n r The undersigned claimant hereby, makes claim against the County of Contra. Costa or the above-rimed District in the sum of $ ,�� / �'� � ;�' r and in support of this claim represents as follows: 2. When did the damage or injury occur? (Give exact date and hour) 2. Where did the damage or injury cacur? (Include city and county) 1`LJ__food , ( tea _ AY11 L.,° /Z'- �� � "`' `k`^` �, `` -) 3. How did the damage or injury occur? (Give full details; use extra paper if .I qy_ required) ��,Ut�*� � r�.r /�H- !A y-, '�-Lv " '. f f v'_K f'1t✓ (/ iJ vi + t c fist+ �$j c' 4. What particular act or omission on the part of county or district officers, servants or.employees caused. the,injury or damage'. writ are toe names of county or district officers, servants or employees causing the darr-age or injury? ..,_. 11,11_ ..__......._..._._.,_._._�� _..r._r.........-._............._.......r,.�....._.-_11_11__ __ 5. What damageorinjuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) � Naves and addresses of witnesses, doctors and hos itals. rs ;tom (mac. (,Jr�e_�_ c � 9. Listtheexpenditures 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 T0: (Attorney) or me erson on h s.behalf.", Name and Address of Attorney aimantIs Signature ��Address J 1 _ Telephone No. Telephone No. C/ 21�" * nn 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 ($1,00010 , or by both such imprisonment and finei 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. ..........:::::::::::::::N......::.N:::::::::::::::::::::: ........ ....1111. O. RKTRANSAC? Ir ON 4: I Nt,t1'. 528 Created Fron, P. rlres Plus Total Car CareKfttbFrAtl r .. � Res VEIi ■ W L I NDEL.L DR LICENSE: -4 t,IW362 WALNU"r CREED:, C6 945c?6 ��� ; as �'� ,; :MILEAGE. 11550 , H: (925)9;3'i--"1 81 Wlt (4J,t-)27c�lr11.Ec t VIN/ST00f:::: ACCOUNT# 006eP"68 i. a PO#: t y " As a Wheat works cuslomer,you have a choice of whether or not any work will be pedormett n your vehicle.It Is important to us that we provide the Peoessary Information so that you are able to make Informed decisions.Therefore,we have Itemized the parts and services by the following categories. IMPRtX1/ED pry You tnay Heard thea itatrts clot to: The"art optional Items: These ato optioned Items; " Ca*-Ont no for"perlorrns Untended purpose • Comply with`malmensnos recommendations by the vehicle's + Address a au+tomar request or convenience(sdfMn We,enhance + doral nta rrsaet a ds igri spsoisaaa,{regardttrss orli ftw m manufacturer(OEM) pedormanoo,eliminate noise,etc. Of • Comply w atbna by the tiro manufacturer + Although many aftermarket manufac#arera claim improved componard to missing Cotaponarl 6`o1*to She end of Iia uaefnl tut{lust above the pedormanop over the original equipment manufacturer,we can only d#Xeartt r or weak,etc.) rely upon timet feeling maw and cannot confirm their claims of performance, OTY NUMBER C PARTS LABOR/OTHER EXTENSION PUT ALIGIV, 0 FSI ,E fAME ar 2.0WHE.EL BMW , 1B INCH .1 ' 8-'8 4 i r, 1- P1ease tYheCk' w ,}rou �,,r ere a they are non- .eturnable :and, c.anno: . be exchanged after installation .' 3 OT!RE .255-45-1 PL T 'SPT N I CH ,. w76 93,* , 3.()RVS RUBBER VALVE. STEM :6 OL 1299 MOUNT AL C6Y 1 S+° INCH I _ �. 51 t i 8.0L 1 P99 ALLOY BALANCE o 1-4.40 S.0WHEEL. WT ALLO . AL.L OY P I Mu' WHEEL: WEIGHT 3 ' .) ,{ S.OL_1' 99 STATE DISPOSE. .CIW14U3= WNL' WC1l :S iSPC]SfL FEE 2. ,5. 1 .00OMMENTs,'', Invp, ce ,,q,9Mrq r ts' 1 .(:)TOWEDo,.IN LF� H •S SPARE LRz FLAT; �iAi J CIVET- AO'LE 2 ENT 18 INCH;1 oiAs $ r TO PICK C �= L. � ;� 'SIS I T •ON 6140 oes (`:t,+ ( ( ( ( .,(..t t -CASTER '5, ,9, t 1 .0TGRQUE WHEELS " 80 .b-ft " LOCH)". WHL TDRQU ..`80 !1b--ft`{, ` PRESSURE Front SSIFea►r 35 Iwo i f�•-�a��•a:•�t••��•�•�N�t•� '�a��•;'1•a�•��•�•��'�•+f•�;�(• ����-�•Ii�1�••��••�•��'�•.�'�'•�'�• �'i�•�••��-�, ,,-.�..�.�..:..��•i��•� :* * CAUTION: -If -,your cal- has 'aftermar1=:et. all:_ � aAg trtr i w,{�; -„ ,tri •+t• * wheels, you must` re'—ch cks the l'tg nttts or; eatI'i wheei 20 miles. BY sighting el0w, I arc-knowledge 'this as +- L-a_ that rw -9-chec.k al the vehicle 's 1LIg r%lts efts; + rr;. 4.e:: ._�• ifrlpe�rt nsr.e f re-CheC,k:'i.ng thea It-to nLits. � �•an�%•�EIE••?t••lF#iEiE•iF•IE� iEaEal•^IFS•i4iEdt••If••i�E�E#c•l�•iEat�1E#�•lf'3'•�••)€�'tt9F��4••Y:i�v..t.�.y:.k•r.'•�.aE••}F#r ,.,Ir�..c.,.e�;c�,.,�.1;(. .� t ii, ff s• Total Parts 1°39.75 labor 1:0.64 Char: w 0,0 W I Cash _ Check':, s Card 1 =3262.ic Card 2z i ars�ar rsne�s 0 0 : 13 Q OAIIYIA#t M Yew ser has surmarw alleoyy,,Milo or aluminum winter,you must twtsrque tin lug Huls aft stitfIt whrwsI attar so s,after thlt Intonation, 1Y#u #Works WN provide tide Wifftitt frig M tMtsrotr.Hy alpnlnobsWAk I sstufowiedQe this as netts ilea#3 moat rw� [� rqus ail the ea tug nuts after 20 mlia after this tnaWtatlatl,WdIm of fade t A nuts, TOTAL PARTS AN;LABOR►tfafaby auUaelite repair Worktit ba derealong4f3IQIfI ESTiM�iT AI}E}I3IQNpiL IX3ST$ SALES TAXwittin nsotgwry Matu"Wheat Work l WWft empl Ya rrsb'Operate above vahbteforptsppof?sakq,hepwtbnordelh*yatmyrWAn . ..we FW machanlo'k b adwomledgod an above Il 4 vetrlale to waua the amount of»pots thereto.It Is alas urderekood that Wt”Weft,Will not tae had reaporsible lar lose or damage b'Vehlolo or arWas AUTHORIZED 1 acknowledge that ft Itemized parts and services lett ill vehicle In rums of firs,W or any other performed on my vehicle are the Name that I authorized. cava bry4nd WMst Works oontrd ALL tr�IltT$ By ;' iN PERSON© PHONE 0 1 agree to pay the sanotmt atknvn an taie Intiroice,and AND MERC4 A 400 ARE NEW t7Mt M NOTEt? acknowledge soon of my vehicle and all (rt MANUPACTUAgo,U-Uazo), DATE' 1 TIME £ CALLED BY PHC3N ENO personal Is that ail nems left at © i Mire 0 Whhe Wed d mY own sk and will hold them In nt of any rw an IMMASS orVnello stitiaavinv d prprIW }� � _.IGt4ATUAE t 6 v• �' .� in ,y �,.� f '„t a '�.: - !4'9' •W fi%y;'v°` ep y Lr . 9 ^. s X r J�9? }A- i � } `'� Y ✓'"tY Ao''f J•/tr'?K w}l "'Y �.� .�� yy. -41 1-4 a @ ¢-;9w gY �.. :. Y” ✓' > r, r+.,Kfy'^,^d xx w,ta,�''.q .� ' � ' ' �: t a .v�' ^'r � `A�FTP� � , �f✓ ��� � ` ��� a Y�t�J�f�fb' r` �'` r} ✓ fir�Y'✓�s���`r��? h� � sCS"��k�. �,�.,2'r µ ��" 3 k v , 9 $Yt ,$ �g r"� } .y r tj' +� ksa�y,•x k a'4 �3'�`',�q q wan�i # �.. a � ��., a ,,.,A' s "* .kr a ✓ ry ',�.,v Al QEN xe } � : • . .�\ �« . <\ . ...................................................................... .................... ................I........................................... CLAIM .14 BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION-.. APRIL 06 2004 Claim Against the County, or District Governed by the Board of Supervisors, Routing Endorsements, NOTICE TO CLAIMANT and Board Action. All Section references are to The copy of this document mailed to you is your California Government Codes. notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), given Pursuant to Government Code Section 913 and 915.4. Please note all"Warnings". AMOUNT. UNKNOWN CLAIMANT: ANGELA ABAD ' ...... ATTORNEY: UNKNOWN DATE RECEIVED: MARCH 03, 2004 ADDRESS, 2137 ANN ST. BY DELIVERY TO CLERK ON: MARCH 03, 2004 CONCORD, CA 94520 RECEIVED THROUGH BY MAIL POSTMARKED: INTER OFFICE MAIL FROM RISK MANAGEME1 FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim, JOHN SWEET % Dated, MARCH 03, 2004 By: Deputy_ W4,V t M FROM: County Counsel, TO: Clerk of the Board of Suporvi;rrs (v This claim complies substantially with Sections 910 and 910.2. 4 This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days(Section 910.8). Claim is not timely filed, The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim(Section 911.3). Other: Dated: -0. By: S:::1Z a 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 ( CARD 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: I&V,/ 40f,, .24W;80HN SWEETEN, CLERK,By Deputy Clerk %F WARNING(Gov. code section 913) Subject to certain exceptions,you have only six(6)months from the date this notice was personally served or deposited in the mail to file a court action'on this claim,See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. *For Additional Warning See Reverse Side of This Notice, AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited.in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: l o JOHN SWEETEN,CLERK By Deputy Clerk .............................................. ............ ............................................ ......... ....... ... .. .... PHOSE NO. 510 6ES 3936 Tan. 28 2004 06:23PM P1 :1--C RID-, K5 3135 14-1 P 1r3'. Clain to: BOARD OF SUPERVISORS OF MMA =A M7Y INSMCTIONS TID CLAMn A. Lai= relatIng to causes of action for death or for injury to WSOI Or 1,0 Palr- %0 sonal property or grcving crops and thich accrue on or before Dmember 31, 1987, =t be presented rust later Lhm N 100th day after the a=x-0 of the case cf action. Claim relating to causes of action for-death Cr for in,jury to person or to personal property or graving crops and which accrue on or after Janmry 1, 1988t ='V' be presented not later than six months after the actNal Of the cause of actio. Claims relating to any other cause of action must bee presented not later than one year after the accrual of the, cause of action. (Govt. ccde B. Clai= ont be filed with the Clerk of the Board of Supervisors at its office in Row 1%, C6MtY ,Adz,1riztraUon Building, 651 Pine Stmt, %rUmz, CA 94553. C. !f alain is against a district governed by the Board of Supervisors, rat- t!L- Comty, ane name- of '16 )e District should be fMed in. D. if the clait is assirst more than one public entity, separate clai= rr-Lst be fled against each public '--ntity' E.' Fraud. Son. Penal ty for frudul-ent olai= Penal. Cade Ser. 2 at the en of this # # # # # # * # # Claim By Reserved for Clerk's filing st=P RECEIVED Against the Comty of Contra Costa or MAR 0 3 7004 District) CLERK BOARD OF SUPERVISORS CONTiPill"COSTA CO. (PM in ;;m*-5 I The undersigned clai=nt hereby makes claim against the County of Contra Costa or the above-rid District In the sum of $ and in support Of this claim represents as fol-lo-,is: 1. When-, did the damage or injury occur? (Give exact date and hour) L) 2. lqiere did the damage or injury occur-. (Include city and county' Jo dpngC�-7-/ 04� C,0)71)2W C&17 Cd 3. How did the damage or injury occur? (Give fuU details; use extra paper if required) �uyrw I && -f--UL-Lq Ra�KeD tv� ar 'to(Mee-, Dr M e-.ar' 4- What particular act or omission an the Wt Of W',MtY Or district I officers. servants or. layees minged.tht.WurY cr da=P? FROM TPS.ABAD. PHONE NO, 510 695 3936 jar. 29 2204 06:25PM F1 92S ZL5 1421 P.O. Wnar art tze Manes of COMZY or district officer3l Stryut'S 01, 122p loyee3 CaUsIrls the damp or injurl? ........... Xnat age or injuries de YOU Cly rC3ated? (Giva full extort Qf InJuries Or damps clamed. Attach tuo eevimtes 7. Rry was t�ie mzit__claimed above computed? (InalUde the eStiMted amotrit d any pospective Injury or, da&'Lit-) .Nz=es and addresses of witnesses, doctors Lid 110sPital8- List the ex;- p-nditires YOU Mde on ac=t of this accident or ir*L"Y. 4kik # A * tilt Govq Code Ift. '910;2 provides: "The claim mist be signed by the :WMq, SM IMIM TO: (Attorney) Tra—ze and Address of Attorney lat,'s Signature ter.. Telepn6ne No I ephone No. 797 * * ; I * * *T 'v V WTV Wo telephone # 77 's I IF ; rT I ; * I F * f N 0 T I C Z Section 72 of the Penal Code providess ViEvery person who, with intent to defraud, presents for allowance or for payment to any state bo-ward or offie—er, or to any county, city or district board or Officer, authorized to allow or pay the semen 1.14 ,ganuine, any false or fraudulent claim, bila, v_omt, voucher, or writing, is purtshable either by izprizorummt in 'hcounty jail for a period of not mare than crze•year, by a fine of not exceeding Qe thousand ($1,0W), or by,both such imorisonment and fine,-,or by imprisomaent in the state prison, by a fine of not exweding ten thousand dollars ($10,000, or by both such izpr1sonv>e*nt and fine. PPOM TPS.A3PD. . . . . . . . . . . . PHONE NO. 510 585 3936 Jan. 28 2004 06:26PN P2 Job Number:01/28/2004 at 04 :10 PM 17908 MIKE ROSE IS AUTO BODY INC» License #:BAR# AA07562 Federal ID #: 942621349 WHERE DUALITY COUNTS 2001 FREMONT STREET CONCORD, CA 94520-2616 (925) 686-1739 Fax: (925) 686-2744 PRELIMINARY ESTIMATE Wry tten_ CLIFF PER.EIRA #�CAD981159189 ' Adjuster: Insured. r` Claim # Ow►rier ANGELA ABAD Policy # Address 2137 ANN ST. Deductible: CONCORD, CA 94520. / Date of Loss: Cellula: (925) 383-9158 , Type of Loss: Collision Point of Impact: 6. Rear Inspect :C,ocati,on: Insurance Company: nays to Repair 7.996 ACUR INTEGR.A LS 4-1.8L-F1 3D RED VIN: JH4DC4457TS000297 Lia: 3PRPS77 CA Prod Date: 01/1996 Odometer: 96995 Air Conditioning Rear Defogger Tilt Wheel Cruise Control Intermittent Wipers Rear Window Wiper ainted Glass Body Side Moldings Dual Mirrors 'lectric Glass Sunroof Clear Coat Paint Power Steering Power Brakes Power Windows Power Locks Power Antenna Power Mirrors Anti-Lock Brakes (4) Driver Air Bag Passenger Air Bag 4 Wheel Disc Brakes Cloth Seats Bucket Seats Recline/Lounge Seats NW3. OP. DESCRIPTION OTY" EXT. PRICE LABOR PAINT ------------------------------------------------------------------------------- 1 REAR BUMPER 2 O/H bumper asst' 0 0 . 00; 1. 5 0. 0 3 Repl Bumper cover 3 dour 1 331 . 67 Incl. . 2.3 4 Add for Clear Coat 0 0 .00 0. 0 0.9 5 REAR BODY & PLOOR 6 Rept Skirt 1 130 . 57 1. 5 0.8 7 Ada for Clear Coat 0 0 . 00 0. 0 0.2 8 R&I Rear panel trim 0 0. 00 0.6 0.0 9# Repl FLEX ADDITIVE 3 10. 00' T 0.0 0.0 10## Refn TINT COLOR 0 0. 00 0.0 0.5 11# Repl HAZARDOUS WASTE MATERIAL 1 5 . 00 0 . 0 0 .0 ------------------------------------------------------------------------------- Subtotals r=> 477.24 3 . 6 4.7 Z , R.C)m JPs.ABAD... ...... PHOt4E X10. : 510 585 3936 = Jan28 2004 05:26PM P3 .«r 01/28/2004 at 04:30 PY, Jab number: 17908 PRELIMINARY ESTIMATE 1996 ACUR INTEGRA LS 4-1.8L-FI 3D RED Parts 467.24 Body Labor 3.6 hrs $ 70.00/hr 252.00 Pant Labor 4.7 hrs $ 70.00/hr 329.00 Paint Supplies 4.7 hrs 2 $ 30.00/hr 141.00 Suh14tjMigc. 10,00 ---------------------------------------------------- SUBTOTAL $ 1195.24 Sales Tax $ 618.24 @j 8.2500 51.00 ---------------------------------------------------- GRAND TOTAL 1250.24 ADJUSTMENTS: Deductible 0.00 ---------------------------------------------------- CUSTOMER PAY $ 0.00 !NUFANCE PAY 1250.24 THIS IS A PRELIMINARY ESTIMATE AND ADDITIONAL CHARGES MAY BE REQUIRED FOR THE ACTUAL REPAIR. THE FOLLOWING IS A LIST OF ABBREVIA'T'IONS OR SYMBOLS THAT MAY BE USED TO DESCRIBE WORK TO BE DONE OR PARTS TO BE REPAIRED OR REPLACED: MOTOR ABBIRE+`( IATI(}N5/3YSvfBOL5.'i D=DISCON1INTJED ,'ART A=APPROXIMATE: PRICE LABOR TYPES., B=BODY LABOR. D=DIAGNOSTIC E=ELECTRICAL P=FRAME G=GLASS M=MECHANICAL P=PAINT LAPOR S=STRUCTURAL T=FAXED MISCELLANEOUS &NO3 TRIED M15CELLANBQTJS PATEWAYS; ADJ=ADJACENT ALGN=ALIGN A/M=AFTERMARKET BLND=BLEND CAPA=CEPTIFIED AUTOMOTIVE PARTS ASSOCIATION D&R=DISCONNECT AND RECONNECT E'S'T'=ESTIMATE EXT. PRICE=UNIT PRICE MULTIPLIED BY THE QUANTITY INCL=INCLUI)ED MISC=MISCELLANEOUS NAGS=NATIONAL AUTO GLASS SPECIFICATIONS NON-ADS'=NON ADJACENT O/Ti=OVERHAUL OP=OPE:'RATION NO=LINE NUMBER QTY-QUANTITY QUAL RECY=QUALITY RECYCLED .PART QUAL REPL=QUALITY REPLACEMENT PART COMP R.EPL PARTS=COMPE'TITIVE REPLACEMENT PARTS RECOND=RECONDITION REFN=REFINISH REPL-REPLACE R&I=REMOVE AND INSTALL R&R.=REMOVE AND REPLACE RPR=RE.PAIR R'I=RIGHT SECT-SECTION SUBL=SUBLET LT=LEFT W/O=WITHOUT W =WTTNJ— 9MOU: *=MANIGAL LINE ENTRY *--OTHER [IE. .MOTORS DATABASE INFOR.MTION WAS CHANGED] **--DATABASE LINE WITH AFTERMARKET N=NOTBS ATTACHED TO INE MQVP=MANUFACTURRR'S QUALIFICATION AND VALIDATION PROGRAM. Estimate based on MOTOR CP-kSH ESTIMATING GUIDE. Unless otherwise noted all items are derived from tare Guide ART4812 Database Date 12/2002 and the parts selected are 07M-parts manufactured by the vehicles original Equipment Manufacturer, Asterisk (*) or Double Asterisk (**) indicates that the parts and/or labor information provided by MOTOR may have been modified or mai have coon from an alternate data source. Non-original. Equipment Marufacturer aftermarket parts are described as AN, Qual Real Parts or Comp Rept Parts which stands for Competitive Replacement Farts. Used parts are described as LX0, Qual Recy Parts. RCM, or USED. Reconditioned parts are described as Recon. Recored parts are described as Recore. 9=5 Part Numbers and Prices are provided from National Auto Glass Specifications. Inc. Pound sign (#) items indicate manual entries. Pathways - A product of CCC Information Services Inc. 2 FROM : .TPS.ADAD. .. .. .. .. . . PHaiE t10. 510 665 3956 Jan. 28 2004 06:27Ptl P4 SLAT$OF CALIFORNIA PAGE 1 TRAFFIC U LLI5'.ON REPORT-PROPERTY DAMAGE ONLY SPECUL CO,IN15NS HIT&RUN cay JUDICIAL DESTttICi NUMMUR YESCINOD a 0p tit-'�~d1 BEAT is3 . COLLISION OCCURREDONN4rj� jk# DATE TIME TtCC �G'ERID AT INTERSECTION'WITH DAY OF THE TOW AWAY STATE OR: KEETIMWL� OF Su M T W�Sa YES CI r A NO PARTY DMVER'S LICENSE STATE rLAss SEATBELT RECORD ONLY.NOT SUBSTANTIATED ox 1 p ,13*�t o 'C) YES S NO 0 1NYTSTICATEID BY CHP [>}t! NAME(FIRST,NMDLE,LAST) *0 _3VA Prr3�[!?NE ((, PEDEST. STREET ADt1RM C Y,STA ,EIP REPORT TAKEN AT 1A?,'I "14 C-%-• L'ov�.vlo 01CONTRA COSTA,CHP PK 9" 1 BIRTH ku INSUUNCE rouc'yt NO. $001 BLUM RD. 'IF 05 b';:3 1 A W, S-_Mr u 014W Ib MAATINn,CA sass BICYCLE VEKYR OsERX0UM STAT t"*""m tit; lkkkk - I ©ER DI L T TRAVEL ON SRUT HIGHWAY BRED DATE, I�AM'SL,'ICL�%l �y STATE CLASS SEATBELT PARTY t ob 7 "f V YES Q NO o DRrvER NAME FI3tSf,MIDDLE:,LASO mum fl NEEDS FOLLOW-UP LAI FED£ST T ADDRESS Cm,STATE.ZIP D lh' I v�t> SGic ►t?GM C4; '1511A, Px V H5r s rn uRnr+CE PaLlcx NO. ® FOLLOW UP COML'I.TE BICYCLE VEX" MAIffNODEUCOLOR `vEH LICE. S'TAIT 'Qc. OTHER DUL TRAVEL I ON STREET OR HIGHWAY SPEEDLIMIT PARTY DRIVERSLIC E ATE: CLAWS I SEATBELT 3 m NE? 0 DR NAME(FIRS[,I4l9D m'LAST) PHONE FEDEST STIEEET ADDRESS CrfY,STATE,ZIP PK YETI SiJJC BIttTIIDATE II�SI RANCTz POLICY NO. BICYCLE VELI.YR I MAKL MOIIEUCOLOR VER LICENSE STATS Q OTHER DI L TRAVEL ON STREET OR RIGI3WAY SPEED LIMIT El PARSWIT. AGESEX NAME ATIS PHONE o a o PASS WET. RJD AGF: SEX NAME AMR PiiOIVE n 0 a PROPERTY NAME ,►t1bRLS5 DAWE,IE PROPLItTY OWNER a FROM = JF .ABAD. . . . . . . . . . . < PHONE NO. 520 685 3935 Jar,. 28 2004 06:2BPM P5 STATE Or CALIFORNIA PAGE 2 TRAFFIC COLLISION REPORT-PROPERTY DAMAGE ONLY REVIEW AND ANSWER ALL OF THE FOLLOWING QUESTIONS(THAT APPLY). PLEASE PRINT LEGIBLY. 1. What county were you in? C 4 ow 2. What city were you in or near? MillI�T 1 'What freeway/street were you driving opt? 4. What direction were yo'u traveling? S. 'What was the nearest overcrossing or street?, <= ... 6. What were the traffic conditions?(Light,heavy,etc.) ?'. What lane were-you in?(Counting from left to right) S. How fast were you going? 9. What is the speed limit? 10- What freeway//street was the other driver on? 11. What direction was the other vehicle traveling? 12. What but was the other vehicle in? 13. How fast was the other vehicle traveling? 14. What were the weather conditions? PROM JPS.ABAD. . . . . . . . . . . . PHONE NO. 510 585 3936 Jan. 28 2004 06:29PM P5 STATE OF CALIFORNIA PAGE 3 TRAFFIC COLLIS;ON REPORT-PROPERTY DAMAGE ONLY 15. Did the weather contribute to this collision? it so how? 16. What were you doing just prior to the collision? (For example,were you looking to your left to make s lane change ; trying to pick up a cigarette that you dropped; tinting the radio; etc.) c �-t�KrNGy SdcL� �r� C3�� p.��d RiGyHr r�tnuct . �����.s�t7 0w 17. How did this collision occur? (He specific, include as much detail as possible.) S r l✓l 1paC-r- cur T-0 l g11'y saw 71y oZ CdPv V fftO M C- Tor $416r Hr p-r- t,, T*e V,'aV. L()014M S6tW- tNft .c �O VS%A6t yvq t1ieA) 011 P-PDXI W i �°A� Jti4� 'r!'�'d7' LT ir`d�' C�tt �` � �SCxU�-� b�t�'" ✓#�=� SLAX (• H *Waf V=uUq IRA WfP 0�4r i f L Wky 0vtv 'A wt � u> �+� , 1)rto- -qw* M Vie -, _ V _--- �f1Y - - I .•YIn� 11 PPON : JPS.ABASE. . . . . . . . . . . . . PHONE N0. 510 S85 3536 Jan. 28 2004 06:213PM P7 srATi Of CALIFORMA TRAFFIC COLLC: oN REPORT-PPOPERTY DAMAGE ONLY PAGE 4 IS. What happened after the coilisiou? 6Vf1O- TkW cox-! ib r-. &-9F tea . Ire ID . - � ► � ray c 4 =2 � �. 19. Did you speak with the outer driver? If so what was said? V1 S. { N61 24. If not, did you attempt to stop the driver to get his/her.attention?(Explain) 21e Describe the other driver: (sex, race, height, weight, build, color ,of hair, facial hair, scars, tattoos, etc.) rvty\at ve r� ##U1 G CAS 22. Describe the other vehicle: (year, make, model, color, license, identifying marks, etc.) 4, FF?0� .JPS.AHAD. . . . . . . . . . . . PHONr= N0. : 510 585 3936 Jan. 28 2004 06:29PM P3 STATE OP CALIFORNIA PAGE 5 TRAFFIC COLL1S"'ON REPORT-PROPERTY DAMAGE ONLY 23. Shade in the damage. OTHER VEHICLE YOUR VEMCLE YE YOUR VEHICLE WAS DAMAGED OR STRUCK BY AN OBJECT, COMPLE'T'E THE FOLLOWING: 24. Can you identify the object? (Example-golf hall size rock, fire tread, small metal object, etc.) 25. Did the object fall from or was it kicked up by a vehicle? 26. Did yoru actually seethe object come off of the vehicle, or did you seethe object come from the area of the vehicle" 27. Do you think tate other driver was aware of the fact that something had fallen from his/her vehicle? (Explain why you think the driver had knowledge.) FROM JPS.ABAD. .. ...... PHONE NO. 512 585 3936 Jar.. 28 220 06:29FM P9 STA SE OV CALIFORNIA PAGE 6 TRAFFIC COLLISION REPORT-PROPERTY DAMAGE ONLY. 28. If you feel that you have any other pertinent information, please explain. e 1WORTANT-READ CAREFULLY Keep this report` This is your record of this collision. To comply with the CWoreiia Vehicle Code (VC)Vection 20002(duty where property damage)you most either: 1. (sive the owner or person in charge of such property the name and address of the driver and owner of the:vehicle or in the absence of the owner: 2. Leave a written notice in a conspicuous place on the other vehicle or damage property, giving the nadie and address of the driver and owner of the vehicle involved and a brief . statement of circumstanccs. This infort nation is necessary for the completion of your State SR-1 form; Report of Traffic Report, and your Insurance Report. VEHICLE CODE SECTION 16000 The driver of it vehicle involved in an accident resulting in damage to the property of any ONE party in excess of 5500 dollars as stated in VC Section 16000 or in the injury or death of any person MUST submit a SR-1 form to the California Department of Motor Vehicle within 10 days. NOTE: Failure to comply may result in the suspension of your drivers license. Form SR-1 may be obtained from your insurance agent, a motor vehicle club, the Department of Motor Vehicles, the Calefamia Highway Patrol, or a local police station. If city or State prope was damaged, yo be contacted.regarding possible litbfiity. SIGNATIMI TODAYS DATE: � I � o44 TIME: Ig t� 30 prn ...... ,. ,:aux...._ CLAIM # BOAM OF§UEERVI§ORS OF CONTRA COSTA COUNTY BOARD ACTION:APRIL 06<, 2004 Claim Against the County,or District Governed by ) the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to you is your California Government Codes. ) notice of the action taken on your claim by the Board of Supervisors, (Paragraph IV below), given Pursuant to Government Code Section 913 and 915.4. Please note all"Warnings". AMOUNT: $255.91 CLAIMANT: JOHNNY E. HASKINS, JR. ATTORNEY: UNKNOWN DATE RECEIVED: MARCH 04, 2004 ADDRESS: 329 BISSELL AVENUE, BY DELIVERY TO CLERK ON: MARCH 04, 2004 RICHMOND, CA 94801 BY MAIL POSTMARKED: HAND DELIVERED FROM: Clerk of the.Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN S WEE EN erk Dated: MARCH 04, 2004 By: Deputy II. Mom: 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: By, r q 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. ARD 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. n Dated: JOHN SWEETEN,CLERK, By , Deputy Clerk ig WARNING(Gov. code section 913) Subject to certain exceptions, you have only six(6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. ' For Additional Warning See Reverse Side of This Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all tinges 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. e Bated: Awzo# JC'HN SWEETEN, CLERK By Deputy Clerk Clain to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIl1Att'I' 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. Claim relating to-causes of.action for-death or for inJury to person or to personal property or growing crops and tahich accrue on or after January 1, 1988, must be presented not later than six months after the accrual of the cause of action. Claim 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 Hoard 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 ---� RECEIVE Against the County of Contra Costa MAR 0 4 2004 or CLERK BOARD OR SUPER iSO�tB D trice} CONTRACOSTAM Fi11 in name) , The undersigned claimant hereby makes claiminst the County of Contra Costa or the above-named District in the sum of $ 2� . �� � _ and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) Pei.tm L9�-r~ �7_H '4-2-001), 2. 'Where did the damage or injury occur? (Include city and county) 3. Hoer did the damage or injury occur? (Give full details; use extra paper if required) , ► - 4. What particular act or omission on the part of county,or district officers, servants or.employees caused. the.injury or damage ZS CA, Coi� tt 19LLI� ,. wnar. are the names of county or district officers, servants or employees causing the damage or injury? not 5wv-e C�- + V1 �. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto doge. � r Cr __-__._-----------------r_... - - ----- - 7. Hoer was the amount claimed above computed? {Include the estimated amount of any prospective injury or damage.) tit fixd . Names and addresses of witnesses, doctors and hosgitals. 9. List the expenditures you made on account of this accident, or injury': a DATE ITEM - NT t • 2- i_0#S 67 0-S gib- X3 .0 I - P T� l U 10.00 Gov. Cade Sec. '910:2 provides: nThe claim must be signed by the claimant SEND NOTICES TO: (Attorney) or erson on his.'b Name and Address of Attorney Cla` is Sign4t r c Address tyl _. 3 6 . Telephone Na. Telephone No � IF W ." 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 eithany er or fraudulent in claim, bill, account, voucbert, or writing, punishable the county jail for a period of notmar ► t a nment and fart ine ; orfinebyfim�isonnot mentn �n one thousand ($11000)t or by both u the state prison, by a fine of not exceeding tern thousand dollars ($10,00{3, or by both such imprisonment and fine. It 0-Y t #/ f c / AS Jew WIM r r/ 1" 614. 1 i I I ..... . . ..... ua. . -a .. d .�� .:� .,........;�W.,._......:. ... ...... .v...... ...... ... Connell AutoCntr Parts Estimatp (P K, q) as of 17:05:25 03 Mar P-004 Rifer-€'Ttce — Ref code GM01 /GRAND AM SEI jEll-NNY HASKINS , Part Number, Description Sin Loc Uty Price Extension Qav Or: GM22 13597_. MIR--[)S/RV _ _ �3206 � 1 _ 79. 36 .,936 79 . 36 1 _ 'Total Parts 79. 36, 'Total Labor _ � Grand Total 0 nitel"I Auto Center W, Co �, ,,,.,..w.-.•••---+• 3093 BROADWAY•OAKLAND,CA 94611 •(510)893-9111 x21 Fax:(510)588-2697 STEVE TAM Service Advisor Direct(510)588-2442 PONTIAC. GMCraucR BL1IiCK' NISS _ _......__ CONNELL AUTO CENTER 3093 BROADWAY AUTO ROW OAKLAND, CA 94611 001648 PHONE 510-588-2444 _____ -- s = FAX 510588-2697 Page of, Pages NAMWi� HONE DATE TIME " k'Vt y ADDRES$';j9( tPREPARED r YEARO' MA ��„.�_t�yy� MODE,4 `tiA�t f TAG NO �t ODC3METER SERIAL NO INSURANCE CO. ie 1/ / ADJUSTOR REPLACE REPAIR DESCRIPTION PARTS LABOR REFINISH SUBLET r 1 y PROPOSED WORK COMPLETION DATE ESTIMATE CHARGE $ CUSTOMER INTENDED METHOD OF PAYMENT TOTAL PARTS $ DESCRIPTION OF CUSTOMER'S PROBLEM OR REQUEST FOR REPAIR WORK OR SERVICE TOTAL LABOR $ TOTAL REFINISH $ TOTAL SUBLET $ The above is an estimate based on our inspection and does not cover any additional parts or labor TOWING $ which may be required after the work has been started.Occasionally,worn or damaged,parts are discovered which may not be evident on the first inspection.Because of this,the above prices are EPA/WASTE DISPOSAL. $ not guaranteed.Quotations on parts and labor are current and subject to change. AUTHORIZATION FOR REPAIR.You are hereby authorized to make the above repairs and to charge SUB TOTAL $ DAILY STORAGE in the amount of$ beginning with the 4th day after your notification that the repair work has been completed. SALES TAX $ Signature: Date: TOTAL $ ES-697-8 C .ABOARWOF SCJP CLAIM VIS RS OF CONTRA COSTA COUNTY BOARD ACTION: APRIL 06!, 2004 Claim Against the County, or District Governed by } the Board of Supervisors,Routing Endorsements, } NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to you is your California Government Codes. ) notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), given Pursuant to Government Code Section 913 and 915.4. Please note ill"Warnings". AMOUNT: $400.00' ' CLAIMANT: SCOTT A. ZIMMER ATTORNEY: UNKNOWN DATE RECEIVED: MARCH 04, 2004 ADDRESS: 13 TUNIS WAY, BY DELIVERY TO C..LERK ON: MARCH 04, 2004 PACHECO, CA 94553 MARCH 03, 2004 BY MAIL POSTMARKED: FROM: Clerk of the.Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SWEETEN. k Dated: MARCH 04, 2'004 By: Deputy 71. FROM: County Counsel. TO: Clerk of the Board of Supe sors {L I-nis claim complies substant ally with Sections 910 and 910.2. ( } This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). { } Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). { ) Other: Dated: By: Deputy County Counse 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. d Dated: 74 / t9OUOf4 JOHN SWEETEN, CLERK, By Deputy Clerk WARNING(Gov. code sec on 913) Subject to certain exceptions, you have only six(6)months from the date this notice was personally served or depositec in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney,you should do so immediately. *For Additional Warning See Reverse Side of This Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now,and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited..in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. e Dated: X11 JOHN SWEETEN, CLERK By Deputy Clerk BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CGAIMAN A Claims relating to causes of action for death or fur injury to person or to personal property or growing crops and which accrue on or before December 31, 198'x, must be presented not dater than the 1411th dray after the accrual of the cause of action. Claims relating to causes of action for death ©r for injury to person or to personal property or growing Crops and which accrue on or after January 1, 1488. must be presented not hater than six months after the accrual of the cause of action. Claims relating to any other rause of action must be presented not later than one year after the accrual of the cause of action. (Gov't 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, Nlartinez,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 Incest be filed against each public entity. E. Fraud, See penalty for fraudulent claims,Penal Code Sec.72 at the end of this form. as**..................... ......tii.�ss.rsa"...iyf•'Y C..y-....:rft•'.•'.i1/.'... RC. Claim By: Reserved for Clerk's filing stamp RAE MAR 0 4 2004 Against the County of Contra Costa or ) � GLE}3 So if)OF SUPERV€S RS District) z... �+Ct35TA C3. (Fill in the name) ) The undersigned Claimant hereby ma esC tin against the County of Centra Costa or the above-named district in the sutra of S. -IW. and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) — 11)a � , 7 2. Where did the da tag r injury occur? {Include city and county) 3. How did the damage or injury occur? (Give full detalls; use extra paper;if required) - 401 7 T `d CIST See SZ6 R-+nnH 044 .fQ ` JOID gee:60 ipu se Uui' 4. What particular act or omission on the part of county or district officers, servants,or employees caused the injury or damage? 12::) 16 VP. 7-69 ...�-)4 1 C�9� 4/ a 5 What are the names of country or district officers, servants,or employees causing the damage or in jury'. 6. What damage or injuries do your claim resulted': (Girre full extent of injuries or damages claimed. ,Attach two estimates for auto damage.) 7. How was the amount claimed above computed? (include the estimated amount of any prospective injury or damage.) _ 8. Names and addresses of witnesses,doctors, and hospitals. 9. List the expenditures you made on account of this accident or injury. DATE TIME AMOUNT *,*a............... Y....w... ) +Gov. Code Sea 9102 provides"The claire must be )signed by the claimant or by some person on his behalf:" SENT N{)TICES TO: Attornevl 1 :dame and address of Attorney ) � .r (Claimant's Signature) (Address) Telephone No. Telephone :■..■..vasa..a.r..rw■■■r.i..a.ara.wase■■■r.....■.owes................■•wy's.r'i Y�ri.yril NOTICE Section 72 of the Penal Code provides. Eti er•y Im-son who, with intent to defraud, presents for allowance or the payment to any state board or officer, or to any county, city=, or district board or officer, authorized to allow or pati the same if genuine, any false or fraudulent clalrn, bill, account voucher, or writing, is punishable either k imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars($10,000),or by boar such imprisonment and fine. ;3 -Cl Ei6t See 'Sees p,aetrg 044 Jo M-1013 acre r60 400 9Z uirr r »>: fir IV cr _ �. to cm C..') L rCcLiu ! 1 w�i.eee 0Lu 6J a� CLAIM. BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: APRIL 06, 2004 Claim Against the County, or District Governed by ) the Board of Supervisors,Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action, All Section references are to ) The copy of this document mailed to you is your California Government Codes. ) notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), given Pursuant to Government Code Section 913 and 915.4. Please note all"Warnings". AMOUNT: $240.45 CLAIMANT: RAMONA GARCIA ATTORNEY: UNKNOWN DATE RECEIVED: MARCE 04, 00� 4 ADDRESS: 1157 RIVER ROCK LANE BY DELIVERY TO CLERK ON: MARCH 04, 2004 DANVILLE CA. 94526-4002 BY MAIL POSTMARKED: MARCH 03, 2004 FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SWEETEN r Dated: MARCH 04, 2004 By: Deputy IL OM: County Counsel, TO: Clerk of the Board of Supervisor (,j'This claim complies substantially with Sections 910 and 910.2. i { ) 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: j Dated: . By:�` ' 1 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. a Dated: AZ2 a i oe 02 JOHN SWEETEN, CLERK., By , Deputy Clerk WARNING(Gov. code secti n 913) Subject to certain exceptions,you have only six(6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. *For Additional Warning See Reverse Side of This Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited.in the United States Postal Service in Martinez, California,postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. 7 Bated: 26 •+ 401Ez o246JOHN SWEETEN, CLERK By Deputy Clerk Claim to: BOARD 4F SUPERVISORS OF CONTRA COSTA COUNTY INSTRt3C'ONS TO CLAIMANT A. Claims relating to causes of action for death or for injury to person or to per- sonal property or growing craps 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 =ps 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 5911-2.) B. Claims must be filed with the Clerk of the Baird of Supervisors at its office in Room 106, County Administration Building, 651 Fine 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 Q(AM1204 RECEIVED RECEVED Against the County of Mira Costa j FCLEF 0 4 2004 or . OF GUPERVtSC?Rc ar . District) Fillrn name The undersigned claimant hereby makes claim against the County of Contra. Costa or the above-roamed District in the sum of $ Aqo. 1+5 and in support, of this claim represents -as follows 1. When did the damage Y or injury occur? (Give exact date and hour) vc� 2. Where did the damage or injury occur? (Include city and c�t))____......._.._............ 3. How did the damage or injury occur? Give full details; use extra paper if required) 4. What particular act or omission on the part of county or district officers, servants or ,employees caused. the.injury or damage? 7, Wnat are toe 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. 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) 8. Names and addtiesses of witness s, doctors and hos ls. 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT � P 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 - Claimant's Signature _ Address Telephone No. Telephone No. oZ Jam- 't NOTICE Section 72 of the Penal Code provides.- "Every rovides:"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 ,fail-for a period of not more than one•year, by a fine of not exceeding one thousand ($1,000), or by both such imiprisonment 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 from Ramona Garcia January 20, 2004 3. How did the damage or injury occur? I was driving west on Tassahara Road and a little west of Blackhawk Drive when I hit a large deep hole in the road. This incident ruined my new left rear tire and created a loud noise in the left rear area of my vehicle. The noise turned out to be damage to my shock absorber. At the time of this incident, road work was being done at this area. There were orange poles around the road as well. 6. What damage or injuries do you claim resulted? Ruined tire and broken shock absorber. I have attached the repair order. I had my vehicle repaired immediately because I need my car. .. J. pq v�?s Eno SRM MTT 20.20 FOUND 1.07 put inch As MKI, TRAVir hL PAYS "I ME SNOTHA MON 11 07910�: 05 7511 4=18 VIKK X MAIN M To H to too Mn To MGM KNERTIL. 10050 Y 0 MAM AT 41 Rio. mot Sum YOU M4 NOT BE Fall 459YART Top 450 aR BAGE To :000 is : .} F qJ r t t cn r t4 4 � .« cs 1 ° r- r .4 l� Z3 CS i APPLICATION TCI FILE LATE.CLA BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA BOARD ACTION Application to File Late Claim ) NOTICE TO APPLICANT APRIL 06, 2004 Against the County, Routing ) The copy of this document mailed to you is your Endorsements, and Board.Action.) notice of the action takenn on your application by (All Section References are to ) the Board of Supervisors (Paragraph III,below), California Government Code.) ) given pursuant to Government Code Sections 911.8 and 915.4. Please note the"WARNING"below. I Claimant: LINDA F. SMITH t Attorney: UNKNOWN Address: 600 S. 37th STREET, APT. #6 RICHMOND, CA 94804 Amount: $691..30 By delivery to Clerk on: FEBRUARY 27, 2004 Date Received: FEBRUARY 27, 2004 By mail,postmarked on: FEBRUARY 26, _2004 L FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above noted Application to File Late Claim. DATED: FEBRUARY 27, 256*N SWEETEN,Clerk,By: DEPUTY II. FROM: County Counsel TO: Clerk 6f thejBoard of Supervisors ( ) The Board should grant this Application to File Late Claim (Section 911.6). . The Board should deny this Application to File Late Claim (Section 911.6)1 . , DATED: ! r SILVANO B.MARCHESI,County Counsel,By(:- DEPUTY III. BOARD ORDER By unanimous vote of Supervisors present (Check one only) ( ) This Application is granted (Section 911.6). ( This Application to File Late Claim is denied (Section 911.6). I certify that this a true and correct copy of the Board's Order entered In its minutes for this date. DATE: Y JOHN SWEETEN,Clerk,By: DEPUTY e JWAZ. - - WARNING (Gov. Code §911.8) If you wish to file a court action on this matter,you must first petition the appropriate court for an order relieving you from the provisions of Government Code Section 945.4(claims presentation requirement).See Government Code Section 946.6.Such petition must be filed with the court within six(6)months from the date your anlil cation for leave to present a late claim was denied. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney,you should do so Immediately. IV. FROM: Clerk of the Board TO: (1)County Counsel (2) County Administrator Attached are copies of the above Application. We notified the applicant of the Board's action on this Application by mailing a copy of this document,and a memo thereof has been filed and endorsed on the Board's copy of this Claim in accordance with Section 29703. DATED: Y! ' JOHN SWEETEN, Clerk,By: DEPUTY V. FROP: (1)County Counsel (2) County Administrator TO: Clqfk of the Board of Supervisors Received copies of this Application and Board Order. DATED: County Counsel,By: County Administrator,By: APPLICATION TO FILE LATE CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANTyp A Claims relating to causes of action for death or fur injury to person or to persona �f ' property or growing crops and which accrue on or before December 31, 1987, :must be presented not later than the 100"' 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 ;oust be presented not later than one year after the accrual of the cause of action. (Gov't 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 :mustbe filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form. i i■Y i■i i i i i i i i N i i r i i i i i i i i i i i Y i•i i i A i i i i i i i'f i i i Y i i i i i f i i i i•i i i i i.Y i i i i Y■■i i i i a RE: Claim By: IV 4- 3 t C - Reserved for Clerk's filing stamp Against the County of Centra Costa or ) IP-6 U� District) (Fill in the fiame) ) The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the sum of$ f 30 and in support of this cliim represents as follows: 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) 4. What particular act or omission on the part of county or district officers, servants, or employees caused the injury or damage '-- 5 What are the names of county or district officers, servants, or employees causing the damage or injury? 54 Z24" ;� 6. What damage or injuries do your claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage.) SX, > 7. Frol"W�A the amount claimed above comp�ied? {In the the estimated amount of any prospective injury or damage.) S. Names and addresses of witnesses, doctors, and hospitals. 9. List the expenditures you made on account of this accident or injury. DATE TIME AMOUNT Gov. Code Sec. 9102 provides "The claim must be signed by the claimant or by some person on his behalf." SEND NOTICES TO: (Attorney) Name and address of Attorney (Claimant's Signature) (Address) Telephone No. Telephone No. NOTICE Section 72 of the Penal Code provides: Every person who, with intent to defraud, presents for allowance or the 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 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. w . ..: rn r p .. `�� .f � r' SO- �1< '1 ,,,G .ct,1" / 115' 49 _._._..-.... .. .._.....- .< a•i; 1�'d�. .....,.��:1',�.._.. �-�"°.-C_..__. '!,.(I <.1 �7 ....f�.h✓.tip _�`i4./s�"� .._. _.... .- -_...... C- 1. R _. . ......................................................................................................................................................................... . ... ..................................................................... W11 i iANA f3. WAI KI R, M. D- TA 1[,v i,, S w,,([s Dmi: if);; CONTRA COS DONNA M. W1(;AN1'. 1,CSW MENTAL HEALTH M rj i;,, Hii,,i i, D,:z Ai,,mi OUIPAIWO SIRVICIS 1" Street, Room 2400 CONTRA CO101) 38 T SA �4ichrnond, California HEALTH SERVICES 94805 Ph (510) 374---06" Fax (5110) 374-3068 12/31/03 MERRITHEW MEMORIAL HOSPITAL Martinez, CA To Whom This May Concern: This is to certify that LINDA SMITH is a patient in this clinic. She carries a diagnosis of Schizophrenia, paranoid, chronic. Patient is on several medications including an antipsychotic and a mood stabilizer to control her multiple psychotic symptoms. Has had several psychiatric hospitalizations where she was disorganized, psychotic and incapable of taking care of herself and her personal belongings. If you have further questions, please feel free to call us at(510)231-1261. Sincerely, CYN_ HIA C. PA L ad Psychiatrist '(,,r)t a Cos-a Emergency Memc�'d Sc""Iccs - Contra Casl,i Fraormprtol Hca'tr (,intraCosta 11eAith Filn Pro mail; •;ontr,i mt�N/intal-IcaWi • Co'):ra Costa Pu�fli( Hpajtj: oq,Re;cnal(,ed,4 anter • C,-n-,'Ao(rsta Helitn(,?nte,s .......... . WILLIAM B.WnLKEPL, M.D. �.....,... J CONTRA COSTAflswsxr+SeRVFtes#lF#EcrtsR _ REGIONAL JEFFKFY V.SMITH, M.D. Kt ExccusFvc DiRe<xos MEDICALCENTER Msa►caF_CENTER nNv CONTRAtit;atxw CExrtrRi COSTA CONTRA COSTA STEVEN C. TIaMAw, M.D. HEALTH � � �V � C � � HEALTH CENTERS DIRECTOR,0PF10E tit AMsuLAvoRY CARE 2500 Alhambra Avenue SENIOR MEOFcat DIRECTOR 2500 California 94553-3191 Pit (925) 370.5000 December 2, 2003 Linda Smith 600 S. 37`x' Street, Apt. 6 Richmond, CA 94804 Dear Ms. Smith: Your claim for the glasses ($691.30) lost during your inpatient stay has been denied. Patients are informed that if they elect to keep personal items in their 'possession while hospitalized, they are responsible for those items. After reviewing the facts surrounding your claim, I do not feel that the staff was in any way responsible for the loss to your property. Sincerely, Chris Grazzini Associate Executive Director Contra Costa Regional Medical Center Centra Costa Health Centers CG:aw cc: Sharon.Shaw,R.N.,Nurse Program Manager, Psych Services/Geriatrics' Gayl Belfor, Patient Ombudsman �"� • Contra Costa Alcohol and Other Drugs Services • Contra Costa Emergency Medical Services • Contra Costa Environmental Heath Contra Costa Health Plan * Contra Costa Hazardous Materials Programs•Contra Costa Mental Heath + Contra Costa Public Health • Contra Costa Regional Medical Center • Contra Costa Health Centers CONTRA COSTA HEALTH SERVICES CONTRA COSTA REGIONAL MEDICAL CENTER INPATIENT PSYCHIATRIC SERVICE P'ATIENT'S PERSONAL PROPERTY INVENTORY CLOTHING & PERSONAL ITEMS This is a list of all of your personal belongings, including those valuables you decide to keep with you, including jewelry, watch, glasses, contacts,dentures, hearing aid,etc.,as well as your clothing. With In Patient Locker Gate item(Description)) M Gate Released Patient initials Staff Initials ye en w SJK J v' �-- I certify that this is a correct list of my/the patient's belongings. I understand the hospital is not responsible for additional items brought in by family or friends. I further agree that no item shall be taken home or brought in during this admission without the consent of the nurse in charge. I take the entire responsibility of retaining in my possession the clot ing and personal items noted above. Date of Admission Signature of Patient or Re esentative S#;ifrWitness to Patient`s Signature DISCHAh PR EDURE: All belongings,including any that were secured,wer c e by me at tim of discharge. . 190 2 .VW CONTRA.GOSTA HEALTH SERVICES CONTRA COSTA REGIONAL MEDICAL CENTER INPATIEIiI'#� -PSYCHIATRIC SERVICE LINDA E R 10 510 x`45-096 u1. PATIENT'S PERSONAL PROPERTY INVENTORY 00 1 � � � - '1 '� CLOTHING & PERSONAL ITEMS This is a list of all of your personal belongings, including those valuables you decide to keep with<you including jewelry,` watch, glasses, contacts, dentures, hearing aid, etc., as well as your clothing. With In Patient Locker Date ltem(Description) Date Released Patient Initials Staff €nitia€s tonlalo ,. Ho ` ly ���� ` G c � 041�7 t I certify that this is a correct list of my/the patient's belongings. I understand the hospital is not responsible for additional items brought in by family or friends. I further agree that no item shall be taken home or brought in during this admission without the consent of the nurse in charge. I take the entire responsibility of retai In my possession the c€ thing and personal items noted above. -------A�4 Date of AdmT ton Signature ofient or'R esentative rtaff Witness t at ent's Signature DISCHARGE PROCEDURE: All belongings, including any th t were secured,were r ceived by rite at time f discharge. ;nnattire of Patlenf or ReprO ntative S#af€Witness o Patie Ys e IminnAL NURSfiNG i<#SSES$MENT;L'�1,1T1IN1Clli`© r -Ll� dc,;, VA7il Nr&BELONGINGS EMCHED,Epockctslpat search) as By°whom LfiCKERwNUlV1BERs . PATIENTS:SELONGINGS#arm completed yC`� Signature 17M;(circle.as appropnate), CommentslDescriptic�tis ;Parselhandbag -a ftf. rtns =CTed"itlbank.cards List' ; f GI §s '-- ,n. .yyDy/4���t{{dyiY�rlp. pp''">,a yP, rv* � 4 k� v M v ♦;4'. - �ot'tact lenses `y K f Z 14t - \1 Light erlmatches/cigarattes- Clothes $ ' pis r• �, u >< Faotwear :Dascribe W� $ © fUo Footwear' r ,.j aca, " �.��'• "Jewe�r��Lt�tx 4 1rtNa • � ..'J y c f ' :Watch; Keys Meds: See list r � r, Other items: List and explain CrJ ` ci CI t iu , z ui "' 1,4 4 t APP KATION TO L ` BOARD OF SUPERVISORS OFC NTRA COSTA COUNTY CALJFORNIA ��_ • BOARD ACTION SIL ;06, 2004 Application to File Late Crim ) NOTICE TO APPLICANT Against the County,Routing } The copy of this document mailed to you is your Endorsements, and Board Action.) notice of the action taken on your application by (All Section References are to } the Board of Supervisors(Paragraph III,below), California CroveM ent Code.) ) given pursuant to Government Code Sections 911.8 _. and 915.4..Please note the"WARNING"below. a Claimant: DANIEL L. FLAW Attorney: UNKNOWN Address: 476 GREEN VIEW DRIVE, WALNUT CREEK, CA. 94596 Amount: $3,939.46 By delivery to Clerk on: MARCH 04, 2004 Date Received: MARCH 04, 2004 By mail,postmarked on:1 MARCH 03 2004 I. FROM: Clerk of the Board of Supervisors TO: County Co' nsel Attached is a copy of the above noted Application to File Late Claim. DATED: LARCH 04, 2004 JOHN SWEETEN,Clerk,By: DEPUTY II. FROM: County Counsel TO: Mrk of thejBo rd of Supervisors ( ) The Board should grant this Application to File Late Claim (Section 911.6), i The Berard should deny this Application to File Late Claim (Section 911.6). t DATED: - SILVANO B.MAARCHE I,County Counsel,Byk- EPUTY III. BOARD ORDER, By unanimous vote of Supervisors present (Check one only) ( ) This Application is granted(Section 911.6). ( This Application to File Late Claim is denied(Section 911.6). I certify that this a true and correct copy of the Board's Order entered in its minutes;for this date. DATE: ti''I'/�cJA44N SWEETEN,Clerk,By: DEPUTY WARNING(Gov. Code§911.8) If you wish to file a court action on this matter,you trust first petition the appropriate court for an order relieving you from the previsions of Government Code Section 945.4(claims presentation requirement).See Government Code Section 946.6.Such petition must be filed with the court within six(6)months from the date your apocation for leave to present a late claim was denied. You may seek the advice of an attorney of your choice in connection with this matter.; If you want to consult an attorney,you should do so immediately. IV. FROM: Clerk of the Board TO: (1)County Counsel (2)County Administrator Attached are copies of the above Application. We notified the applicant of the Board's action on this Application by mailing a copy of this document,and a memo thereof has been filed and endorsed on the Board's copy of this Claim In accordance with Section 29743. a DATED:/0 V// &0 4 & JOHN SWEETEN,Clerk,By: DEPUTY V. FROM. (1)County Counsel (2)County Administrator TO: Clerk of the Board of Supervisors Received copies of this Application and Board Order, DATED: County Counsel,By: County Administrator,By: APPLIC,AT10—N TO FILE LATE CLAIM 476 Green View Drive Walnut Creek,CA 94596 Telephone: (925)947-1909 Fax:(925)937-2754 March 2, 20041 CL Mr.John Sweeten, Clerk MAP 0 4 Zt7�� S The Board of Supervisors # BGA County Administration Building CLER CC¢. R''- 651 Pine Street, Room 106 r � s, CO Martinez, CA 94553--1292 " Dear Mr. Sweeten, I am in receipt of your notice of March 1, 2004 sent by your Deputy Clerk. This letter indicates that my claim is rejected because it was not presented within six months. For reasons below,I believe this premise is mistaken. In seeking how to file my original claim I first inquired at several agencies, including the Court and the Sheriff's Department. In addition I examined the County and court web sites. I found no mention of a County procedure for claims. I was advised to file a claim with the Government Claims Beard. Consequently, I completed and filed a claim with the State Claims Board on November 19,2003. The Express Mail receipt which is attached to the instant claim confirms this mailing. It was not until January,2004 that State returned the claim with a form instructing me to file with the County. After receiving this form, once again I telephoned many official county offices, including the district attorney's office and the Sheriff's office. Finally, and only after I explained the nature of the notice I received and insisted that there must be a claims procedure,an officer from the Sheriff's office suggested I telephone your offices. Then, a clerk at your office acknowledged a County claim process and faxed me the claim form which you rejected on March 1. Your letter refers me to§91.1.2. €911.2 refers to a claim "relating to a cause of action for death or for injury to person or to personal property." However the majority of my claim relates to consequential damages arising from a wrIongful arrest rather than from injury to person or personal property. The small item relating to personal property concerns conversion, not injury to, this property. The,medical expense is also a minor portion of the entire claim. Therefore I do not believe the claim is properly rejected under the express language of 911.2 statute. Page 1 of 2 ................................................................................ . .......................................................... Nevertheless, should you maintain that this claim has not been timely submitted, I wish to submit the claim as one presented within a reasonable time under§911.4(a)- (b) for the reasons explained in paragraph 3, above. I respectfully request that the Board permit a late claim under §911.6(b)(1) for at least these reasons In fairness, I hope you will see clear to accept this claim and consider that I suffered great expense, harm and humiliation without cause for doing no more than attempting to discharge my civic duty. Sincerely yours, Daniel L. Flamm Enclosure Affidavit of Mailing I declare under penalty of perjury that I am a citizen of the United States, over age 18, and that today I deposited in the United States Postal Service in Walnut Creek, California,postage fully prepaid, a copy of the Board's Notice To Claimant, a copy of a Board Action dated April 6, 2004, original claim first submitted on February 27,2004 together with pages comprising a Government Claim submitted on November 81, 2003 and a copy of an Express Mail receipt for the Government Claim submission. 0 Daniel L. Tamm Date Page 2 of 2 The Board of Supervisors Contra JohniSweeten C1St enri County Administration Building County Administrator 651 Pine Street,Room 106 {925)335-1900 Martinez.California 94553-1293 County John Gioia,1 sl District v amr Gayle B.tiilkema,2nd District Donna Gerber,3rd District Mark De$aulnler,4th District Federal Glover,5th District 0 4L,couch TO: Daniel L. Flamm 476 Green View Drive Walnut Creek, CA 94596 NOTICE TO CLAIMANT (Of Late-Filen Claim) (Government Code Section 911.3) The claim you presented to the Board of Supervisors of Contra Costa County, California, as governing body of the County of Contra Costa on February 27, 2004, has been reviewed by County Counsel and is being returned to you herewith because: X Your claim for an injury to person or personal property was not presented within six months of the event or occurrence as required by law. (See Government Code sections 901 and 911.2) Your claim relating to a cause of action other than injury to person, personal property or growing craps was not presented within one year after the event or occurrence as required by law. (See Government Code sections 901 and 911.2) Because the claim was not presented within the time allowed by law, no action was taken on the claim. Your only recourse at this time is to apply without delay for leave to present a late claim. (See Government Code sections 911.4 to 912.2 and 946.6) Under some circumstances leave to present a late claim will be granted. (See Government Code section 911.6) Daniel L. Flamm Re: Claim Page Two You may seek the advice of an attorney of your choice in connection:with this matter. If you desire to consult an attorney, you should do so immediately. Date: MATCH 01, 2004 JOHN SWEETEN, Clerk of the hoard of Supervisors and County Administrator By: /bepufy Clerk Enclosure Affidavit of Mailinq I declare under penalty of perjury that I am now, and at all fimes, 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 copy.of the above NOTICE TO CLAIMANT (OF LATE-FILED CLAIM.), addressed to the claimant as shown above. Date: MARCH 01, 2004 DepClerk 1:\,-i'ORT'\RISK-MGT,CLAIMS\LATE%Flamm.wpd CLAIM BOARD!2F SUPERVISORS OF CONTRA COSTA COUNTY BOARDS ACTION APRIL 06, 2004 Claim Against the County, or District Governed by ) the Board of Supervisors,Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to you is your California Government Codes. ) notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), giver Pursuant to Government Code Section 913 and 915.4. Please note all``Warnings". AMOUNT: $3,939.46 CLAIMANT: DANIEL L. FLAM ATTORNEY: UNKNOWN DATE RECEIVED: FEBRUARY 27, 2004 ADDRESS: 476 GREENVIEW DRIVE BY DELIVERY TO (..LERK ON: FEBRUARY 27, 2004 WALNUT CREED, CA 94596 BY MAIL POSTMARKED: HAND DELIVERED FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SWEET k Dated: FEBRUARY 27, 2004 By: Deputy II. Mom: 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: <7 t� By: 1Deputy County Counse III. FROM: Clerk of the Board TO: County Counsel(1) County Administrator.(2) (V 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. O Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: JOHN SWEETEN, CLERK, By , L?eputy Clerk WARNING(Gov. code section 913) Subject to certain exceptions, you have only six(d) 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 .,t+.,..«.,..,.C.,.M......4.,,..... .«, ,......,.... ._... _...at., aL._...__+. _v rr.._.. ....__. ._ __.__..y. _._ _.._.�_. _.. _t_..r, �,. -- Claim toBOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAI�lA1�1 A. Claims relating to causes of action for death or for injury to person or to personal property or growing craps and which accrue on or before December 31, 1987, must be presented not later than the I tt&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, 1989, 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. (Gov't 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. Ifclaim 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 fcrrrn. RE: Claim By Reserved for Clerk's fling stamp ; � Against the County of Contra Costa or ) � FEB 2 7 2004 t District) CLERK O RACOFF Up.ERVISORS (pill in name) The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the Burn of S 3931.yC and in support of this claim represents as follows: I. When did the damage or injury occur?(Give exact date and hour) SfaA,*W✓ 6,y- P•'3 C-,4oti 114Au 200 200.3. 2. Where did the damage or injury occur?"(Includ'e city and county) j A ''the- G.ox,�t + 4,.. �a t_GI.S74 d 0�vt t d di✓t fT�YJ�+ I,#V fv1L�ailslN�� �!✓+�'i�s•i wa S lwG� 0Wit',;�. 7�dt TGY c Ae d}, + i. 6j 2-2> 0 3, 3. How did the damage or injury occur?(Give fu l details;use extra paper if required) , { 1� at,CG1e s7Qir rwi, +�'I�2►rJvt k/�t,'cvPrt, St ` Gt Cd , lei t"'Ok✓ cel, 7 . a st44 Rodej S�.,n7" Me. rt ,' ► -Z 10 r h6xti`vGt ,� toq� -r�� SA art it -r r✓ Yk V ` Ate' T t I 4. ghat particular act or omission on the part of county or district officers, servants, or employees caused the inor daage? ?�oT f,damage? 1 yr " a , arrerd juad wt 4e, rt,; petit Cox�.re- . 14;s 't 10'0 ZGt �rJ: S G ►P/lt tt►`l`C�1^ $'G i" t v S. What are the rtatn s of county or district officers, servants,or employees causing the damage or injury? .a tZ Yq;12 ti» /f^A n e w C A 21-41 b +-.> J 6. What damage or injuries do you claire resulted?(Give full extent of injuries or damages claimed. Attach two estimates fo�rf auto damage.) .��T f�Y'1�'-�"` 't�rLiXt✓t��1.�`i{>t r'V'.� �7tI /VC F�T J t"+l t�j1+t � f +/"�"'t A ,, w. A a d 7n pa id la a 1 7'�P t� 10 o.r A3 of + 1 et�,ae p.a►.ro J'-.,a /O eo ph t� war t�oe AO-f 7. How was the Yrnount claimed above computed?(Include the estimated amount of any prospective injury or damage.) f �M2r �'��►» c�te�,-��s � 33�. �G'. $vrtJ��i 1 � � I.�.�t9 H05W f;e e- � � �D btu 0` S. Flames and addresses of witnesses, doctors,and hospitals. JAW A401'v Emev(2Kc kovmj D),, hegiet Va r ted rJ-l' vY't7YS 9. List the expenditures you made on account of this accident or injury. A TITS t�Ctl`7C3T -S 3l��d 3 31100. 010 D 3 3 DOD- 00 Gov_ Code See. 910.2 provides"The claim must be SE-ND QTSS TO: Attorne signed by the claimant or by some person on his behalf" Name and Address ofAttomey y (Claimant'sSignature) 7YO-et4 Yr rlty (Address) Telephone , Telephone No. }Telephone No, Z..1 7 t NOMCE Sten 72 of the Penal Code provides: Every p=wn who,with intent to>defraud presents for alloR�ance Or the payment to any state beard of offietar,Or 10 any county,city,or district board or officer,authorized to allow or pay the sante if genuine,any false or fraudulent claiM bill,account, voucher,err,%iiting,is punisha It either by imprisonment in the county jail for a period of not morn than one year.by a fine of not exceeding one thousand(S 1,000),or by both such imprisonment and fine,or by imprisonment in the state prison,by a fiat of riot exceeding ten thousand dollars{S 10,4M},or by both such imprisonment and fine. State of California Please read"instructions for Filing a Claim„ Board of Control If you are filing this claim beyond six months from the incident date,Please GOVERNMENTCLAIM see instructions forfiling a late claim application on the opposite Page. SBOC-GC-0002(Rev.€100) C Section 1: Claimant Information Nance of Claimant Telephone Number(ndweareamck-) (fzr) Ifo - -_ Mailing Address city Sate Zi Code Section : Claim Information r l o r;Iew n filed on beh al€cyf a rninor? ,j';'6s,WNo it yes,please indicate:Relationship to the minor Date.of birth of the rrsinor l Io rr of State A.pe rc�ytagainsst which this clairn:s filed Incident mate DollarAmountof Claire Month S Day 20 Yr,2003 It 1110,part rt)unt exceeds$10,000,indicate type of CiVll case: Explain how the dollar amount claimed was computed. (Attach three copies of the~supp odintg docurnemtion forthe . f.irrt2ted Civil case Non-Limited Civil Case amountclairnedwith this fotm.) [)c s<ril)e the sp et clfic damage or injury incurred as a result of 4 4r�i IiuCteYT.thda Q � .E 1 ero1» 4' C Location of the incident(If applicable,include street address,city tDaty,G, .lis �C, ,vNc�lt_ + +? • �+.. tie orcourilyfrrgtiv�rayntrrrtberpostmienuniberanddirectionofttavel.) an1l�r�u._ ' _. .s� 'a r ^cry PiPferredHeatingLoGationMar'aaply--ar&ceisnecdssary): Sacrwriento tJ Les Angeles 00akland J San Diego E xplr visa tf+e orcunistrances that lett to the allegod damage ar injury,State all facts that support your claim against the State of California,and by {x$tat lit-'ve the State is responsible for the alleged damage,or in ury if known,provide the narne(s)of the State employee(s)who lr�$5.c1ly z 'a r, s the irrjtary,d arnage or lass.(If more space is needed,please atfach additional sheets.) '_e , ...1.11.......................................................................................................... ................................................................... .. . ... ............................. State of California Submit completed clairn form and three copies to: Board of Control STATE BOARD OF CONTROL GOVERNMENT CLAIMS BRANCH GOVERNMENT CLAIM P.O.Box 3035 SBOC-GC-0002(Rev.6/00)Reverse Sacramento,CA 958112-3035 Section 4: FOR STATE AGENCY USE ONLY(must be completp(i by the State agency preseritinq''C[Aim) Name of State agency Budget Act Appropriation or Iter q Nm ctrl e ApprWri Wb Plicable. Nameof fund or accourt Name of agency budget offic6r. wrl Title r orrepresen wo Signature of agency budget officer or represdrtt6We 5- Representative Information ,iinisi be rornplefed it claim is boing filed by an Zip 0r .1 k'ce and Signature j'r,flg:;r e 01 -1 V.- M On May 20, 2003, at 8:35 am, I arrived at the courthouse on Court Street in Martinez for jury duty. I was in a line of jurors, following in line and there was a large crowd of jurors arriving and trilling about. I entered the courthouse in the line, approached the security inspection area, and pint the contents of both of my pants pockets into a red plastic personal contents basked on the security table. I also had a backpack with my computer and books. After depositing the contents of my pockets. I removed my backpack from my back and placed it on the x-ray conveyer belt. Next, I approached the security rnagnetotneter. As I was standing in front of the machine, the attendant in a uniform a made a remark about the pocket nail file-knife and brittle opener on a key ring which had been in my front right hand pocket and was then in the red basket. The red basket was about 5-6 feet from where I was standing. I did not understand what she said. The knife/nail file and opener were small,each about two inches long. I remember answering to the attendant that she could hold onto the pocket knife. I recall that she summoned me forward at that point. She stood in front of me or slightly off to the right side (which was where the security basket with my pocket contents were). The next thing I was aware of is that I was grabbed by a police officer. He gripped my arm so;hard that it caused intense pain and I asked hire to take his hands off of me. I did not move nor did I do anything else. At that point the officer seized me violently, twisted my right arm behind my back, forced me forward and threw me against a concrete courthouse wall. He then handcuffed me and led me around a bend to the right into the courtroom corridor. He held me there. Within a minute or two a second officer, Sergeant Chertkow, arrived. The two officers took me from the courthouse and into their police station. They sat me down in a room; still handcuffed, and began to ask a series of questions including questions about medical history, drugs, and various personal information. After asking these questions, he read me Miranda rights from a card. I said I wanted to phone my wife and an attorney. They refused to allow me access to any of my belongings or to phone anyone. They would not remove the handcuffs. Sergeant Chertkow took my lunch and discarded it. A third officer"Mike"came in. He was dressed in a suit and told me that I should have retrieved the pocketknife and walked back to my car with it, and that if I had done so none of this would have happened. He showed no interest in what actually did happen. 1 was then taken to jail and imprisoned until late in the afternoon. Although I explained that I have a medical condition which requires that I only eat very low fat foods, I was not permitted any food which I could eat nor given anything to drink that day. At mid-afternoon my wife was permitted to take me with her after paying $3000 in bail. Ultimately we found Sergeant Chertkow who, upon request, returned my backpack. He identified the officer who hurt me as Sergeant Farris. On May 21, I went to the John Muir Hospital Emergency room in Walnut Creek to have the bruises and my arm examined by a doctor. The emergency room charges were $339.46. Subsequently it was necessary for the to retain an attorney because the officer made a claim that I was resisting arrest. It cost$3500 to retain the attorney. MADSEN & WOLCH, L.L.P. A T T 0 R N F Y 5 A T L A W 20155 North Broadway,Suite 100 Walnut Creek,California 94596 telephone:(925)974-0800 oseph H.Wolch facsimile:(925)974-0808 r e-mail:MWLLP@aol.com Richard A.Madsen,Jr. MEMORANDUM OF AGREEMENT This is a memorandum of an agreement entered into at Walnut Creek,California,on the below elate. MADSEN & WOLCH, L.L.P., hereby agree to represent the undersigned. The tindersigned hereby agrees to pay to the firm of MADSEN&WOLCH, L.L.P.: (1) N/A A minimum NON-REFUNDABLE retainer fee of is:to be paid immediately. It is specifically understood that the retainer is to guarantee that this firm will be available to represent this client in this action and we will not represent the opposing party. This office will reserve administrative capacity and resources to take on this matter and will reject other cases,if necessary,to insure capacity and resources to handle this case. However,the retainer will be credited toward the total fee, THIS IS ONLY A RETAINER IEEE AND NOT THE TOTAL COST OF CLIENT REPRESENTATION IN THIS,MATTER. WHEN YOUR RETAINER FEE IS DEPLETED,YOTJR LITIGATION NEEDS WILL BE ASSESSED IN ORDER TO DETERMINE IF ADDITIONAL RETAINER FEES WILL BE REQUIRED. If the required additional-retainer fee is not paid in full when required,this firm reserves the right to suspend work for the client or withdraw as attorney of record. The current charges for services rendered are as follows: $250.00 per hour for attorney's services; $100.00 per hour for the services of paralegals; $ 75.00 per hour for the services of law clerks and legal secretarial work. Client shall be charged a minimum of 15 minutes for any service by any employee of the firm.of MADSEN&WOLCH,L.L.P. (2) X Client will pay all costs and fees of experts/investigators,if any. These costs(if any)will not be incurred without advance authorization from Client. (3)_NZ A Interest on the unpaid balance at the rate of ten percent(10%)per annum commencing thirty(30)clays after billing. (4) N/A THIS CASE IS TAKEN ON A CONTINGENCY BASIS at the rate of _.%of the award. Fee Agreement Page Two (5) X THIS MATTER IS TAKEN ON A FLAT FEE of$3,500.00;due immediately upon execution of Memorandum of Agreement; plus costs, if any :there are. Representation shall include all-criminal proceedings [P.C.Section 148(a)] in the Contra Costa County Superior Court (Martinez) pertaining; to incident which occurred on or about May 20,2003;up to,but NOT including,trial, Client further understands and agrees that trial preparation and time will be billed at the rate of$250.00 per hour in the event that such representation is required. TIw above fees are payable and due in advance and are NON-REFUNDABLE,regardless of the outcorne,except that all costs which are advanced by clien t and are not actually incurred Will be refunded to client. The firm of MADSEN&WOLCH, LLP., cannot and does not promise any specific result, judgment, verdict, sentence, or compromise of any kind or nature and client understands that any representation in this regard is only that of counsel's opinion. Client understands that this agreement does not include any retrial, appeal, probation modification, violation of probation, or representation in any other matter arising out of the sante or collateral arrest or proceeding. t Dated: 5 /'30-/ 03 Daniel Lawrenc ami Dated: _5j / 03 Richard A.Madsen,Jr. MADSEN&WOLCH,L.L.P. -,......11...................................................................... ................. ........................................... d0firl Wjulf, IvIt"tCut 1,_Crtt�l ,Beef.fluriter,MD.Medital Dirtoor Dart Bottler,M.D. John Chilt-s"M.D. Miles Cougress,M-M JOHN MUIRA MT.DM Mary Jame Colintil,M.D. lidefonso Corpus,M-D. I'lin Drazek,M.D. Paul Freitas.M.W Catherine Hurt,WO. CarolJoilin,WD, H E A L T H S Y S T E M Andrm hives.M.D. Theophile Koury,M.D. 'fed Kloth,M.D. William Mitts,M.D. Stacy Prescott,ML,J). Ken Robinson.MI). Vil yg1jocio I Wjer R11 Wit/init Creek CA 94598 925-9.40-58100 Lewis Shepler,M.D. Mark Slornoff,M.D. 'Pana"Tighe,D.O. Wury'Furk-0,M.D. John Zecherle,M.D. Tilke-Home Instructitntsfor Me Patient 2003052 1 1 7 1059 °ttfieiWvNttnte: Daniel rjaivim Date: 05/21/0-15:IOPM Wagilosis: CONTU SIGN 'BRU ISE) k'contusion'is the medical term for a bruise(an injury to'soft fissue'Which includes skin, fat, muscle and connective tissue). Ifan x- ay was obtained,no fracture was see". ("T'he x-ray will also be checked by a radiologist within 24 hours).Treatment is aimed at -educing swelling and speeding up recovm, fitsirtiction.v: dthe iln jury is to an arm or leg,elevate higher than the level of the heart to reduce swelling. Apply ice to in ured area for 10-15 minutes -veru 1-2 hours during first 2 days after injury.(Place cloth between ice and skin.) Do not apply heat as this will increase pain and ;wefling. If a splint was applied,do not remove until seen by your Dr or advised to remove it. Rest injured area until much better. '"Anttrcl the Doctor ff. ;ymptonvs persist for more than 3-4 days or earlier if getting worse. 4(Nitiollol Insirlic-lions: 'till ininteeflitte1v to itrninge to see titer p1losvinn pItysichin in 2-4 doysfi)rfollow tip wre. NNETGASTONIM.D. (925)837-4226 I understand that I have/lot/enterqeiuv treatment and drat I mtr b 'atient signature M.D.Mgnature TIMOTHY DRAZ1`K M.D. I have ewpained the instritedons to fire tient andlor hislIter repreventative has earbalized understanding of the insi: rdanx I hurt,given a c4ripy of the ittoructions to(ftepatient. Nurse+,v,Vlgnalure *401yarn(1111jor oil ollpointinent,sac thol you were reji rredfranc ricin Enrergen(�r Department 4f.rou have problems making this appoinintent rail tire mergencl,Department so we 4,Wn it),to help you. If new or warvesymptonts develop ytru should vallyaur iloetor as soon as ismsible, Ifyou curinot see the above rotor and your candifian worsens so that you require eittergenty treartuent come Nick to this department. 'lease note: The and treatment thar you have received In the Entergency Delmrtinent,have been rendered on apt einergent�j,basis only and are nvi ,fended to beasubstiturejororan effort to provide romplett,(nediralserrice. ,ain as reconitnended above and report aqj,new or rernahfing*problinev at that time,because it hr impossible torecognize and treat all elententv of injury'or 111nevs o.single Emergency Depariftient visit.fit adifition,ft an X-Ra-has been taken here,it nuk;,hit ve been read on a preliminary only,and a final review will he nde hr the Radiologists. ffthe Radiologist's reading differs signi teural,fironr the prefinfirtury reading.you will be contacref4 t Piease reed the information on the reverse side before completing this authorization I hereby authorize the use or disclosure of ray health information as follows: 1`dame and tia(adrr s s of �iutlhonzed to disclose the information: ,,;~�r,klhn Muir Medical Conteer Mt, Diablo Medical Center t 01 Y4li1taCi0 Vailtl;' POrACt W- i;Iut Creek CA 9479 2)40 E�isi Street,Concord CA 94520 `�i�rr,-t SurgiCunter _ t:Vier Yr,3n3fiio Valic,V Floud INilnt,tl Creek �.A 945-95 1 ; ,ttx`i um'- Iht' tollowing persons,'organizations to reaceive tray health information (include address): 1-11is author l'ation applies to: Only the, following records or tyre} of he;<altlj jitforrr"}Kation},or spec--ftcdaies of treatmeril. 2 / t 7 c5 C2'%tal _ t.._f...+0._1..-4.t"cfir'LZ` All hellth information pertaining to any niedic:al history, mental or physical cunditiorn and treatment received Includes information related to drug, alcohol tandior psychiatric conditions or conditions I)e,rtarnmig to sexually transmitted diseases, incluc.irng AIDS, HIV test result information will NOT be released unless specifically rcqueste{j, List 4)ecif;c dates cif treatment needed for use (iisclusure: 3 Fh)e receiver r7i,-ay rase the medic al information for the fodawing ,purposes only: C,alifornia l aG'v prohibits the recef Iver froin rnakirrca fUlthOt disclosure of my health Information unless tfie recetvor obtains another au-thorization frorn rr,fp of unless such disclosure is specifically required or porrnit!ed by law. �f. This At.lt"O;ization expires: Wd.tte;t It blank, authorization will expire 't year from .late of =ptgnature. >u:trzzat,tr.�; Pnlionl ( C Le(ga,I . �serrtativ e ) Spouso, Financially Responsible Party (4 AUTHORIZATION FOR USE/DISCLOSURE OF PHI "'r" JOHN MUIR MEDICAL CENTER,SIERRA SURGfGENTE'R M7 DIABLO MEDICAL CE -NnblW� � (J ,;VW S.J rfAiwi 3` 0 Date Rec. :._,_ _. Pert Info lz See A(Ith. ; Other;- Z I t ; Ri� -t)(�i t.i��i:E�.1�. � 1 � l 1� �(f�:ti 1� ._ . .. _.., � 1} . � � ,� � "'ij� t i_j`i �j.. _ �� i. . � i 1 . . i-. �. r .. - l . ._ E � .. , .'. � ._. ,1� .. - "..(!-- � �,�I.�`� _ �!:_.1.A,� l �. it.� ;, )j';'. :�t.'2 ,.�., �, � � '� If s , . � � ;, �. � � �.it ,.;`� ���.,, ti(:;�li��al l:c)t`urti L1i:Erii�tntc�r:C ,�,� ,)_�-� ,��..i ........... TATIONS,ETC.DATE NOTE PROGRESS OF CASE,COMPLICATIONS q2!�SLUL TC- PHYSICIAN MUST Siqy EACH ENTRY. PLAAft*0A9jXL LAVACOCE i,MW 32 ............. Pt�":, ...... 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