RPVCCA_CC_SR_2013_06_18_G_Claim_TawaTO:
FROM:
DATE:
SUBJE~T:
REVIEWED:
CITY OF RANCHO PALOS VERDES
HONORABLE MAYOR & CITY COUNCIL MEMBERS
CARLA MORREALE, CITY CLER®
JUNE 18, 2013
CLAIM AGAINST THE CITYBY RYAN GLENN TAWA
CAROLYN LEHR, CITY MANAGER QQ__,
RECOMMENDATION
Reject the claim and direct staff to notify the claimant.
BACKGROUND
The claimant alleges that he was involved in a police pursuit incident, was allegedly
beaten and sustained injuries.
The City's Claims Administrator, Carl Warren and Company, has reviewed the claim
and advised the City to reject the claim because the officers involved are not employees
of the Sheriff's Department and were not acting on behalf of the City of Rancho Palos
Verdes. Accordingly, the City of Rancho Palos Verdes has no liability to the claimant.
Attachment:
Claim
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!'ORM CONT. loo.A (Rev. 7/01)
CLAIM FOR DAMAGES
TO PERSON OR PROPERTY
INSTRUCTIONS . .
1. Claims for death, injury to person or to personal property must be filed not
later than six months after the occurrence. (Gov. Code S·ec. 911.2).
2. Claims for damages relating to any other type of occurrence mnst be filed riot
later than one year after the occUITence. (Gov. Code Sec. 911.2).
3. Read entire claim before filing. Claim can be mailed or filed in person. No faxes
accepted.
4. See Page 3 for diagram upon which to locate place of accident.
5. This claim fonn must'be signed on Page 3 at bottom.
6. Attach separate sheets, if necessary, to give full details. SIGN EACH SHEET.
7. Fill out in duplicate. ONE COPY TO BB RETAINED BY CLAIMANT.
8. Claim must be fi!Cd with ClTY CLERK, (Gov. Code Sec. 915A)
200 NORTH SPRING STREET ROOM 395, CITY HALL LOS ANGELES CA 9-0012
TO: CITY OF LOS ANGELES
Name of Claimant -r \2-\Jl (A y) t-} le, V) (l I bt V\J {4
usiness address of Claimant
~ {Pr
City, State and Zip Code
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Give address to which you desire notices or communications to be sent reg
RESERVE FOR FILJNG STAMP
CLAIM:NO. :L.D{3 -O(j;
/fu'5.e/a/m /JYm /5
Jrom my of J.os/fft~h
RECEIVED
OiTVOF P · 1r · Pl\l.OS VERDES
MAY 2 O 2013
CITYC . .. r: -... . ~ t--·, ..... ,CE
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Business Telephone Number
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How did DAMAGE or IN Y occur? ease include as much etail as poss1 le. + \!\)VIS Ofl (V\V\ \/{ \f\ I(,\..( \fll I \•Vi V\ll~ fVU.11\ <A tt111d V\JU.S 0 tl-f VV\p\1Yl<a---~o d 0 a v ·-··\-"V(Vl . :-.r-,
~-Vl.en \r\eiHu.<A +lr\e. p>\' ~ lo1'."3c:cr\ ·to f-u1\0V'I \JS. M'-\ Fn.e.vici ·r\.\.Qlfl ·ro\o jV\.Q. vu. had a 0"v1.
j ·1·¥\.e V1 o;:,\-£A( t-ev\ + o Fl.JU.. ·\-\A-Q po\ l Ul s1 VIC-e r ptitV1 t c v-e.d be ca 0 ,r.{ ·::c.. cvv r-e V1f'I ± --7
When did DAMAGE or INJURY occur? Please include the date and time of the damage or injury.
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Where did DAMAGE or INJURY occur? Please describe fully. and locate on the diagram on the reverse side of this sheet.
Where appropriate, please give street names and addresses or measurements from specific lan,dmarks:
P.1lvic00 P4los v .. eirdl.~, lA-til.v-i1s;
What particular ACT or OMISSION do you claim caused the injury or damage? Please give names of City employees
causing the injury or damage and identify any vehicles involved by license plate number, if known.
OF-f1L€Y'S 1· V\JtH\LtV-::J'.Dif '300'2.3 i Of-P.1UlY-j. vuYltU.y U...l J::D·#:'39000
V\l~ V1 ·:r... V\l t< s on ·t1'\..t P 1 o a r v\J i ·th rvi ~ n 6l vi vi s w h , V1 d YYP·v-b Vt c \L t-N.-'d-
St 111 l?fpt+ YVlf-.
Please list names and address of Witnesses, Doctors and Hospitals:
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F3o 0 V'J. I jVJ s+ <.,-e.-cn by :JA vrl..{ hCA 0( IM. D.
SEBPAGB3
PAGE2
G-2
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~ v0-eV1+-OVl ~ floov Avid pvi-mt havidr behtvid mi" bCll~ ~ IVt-e.
pO\\LJl Offlurs ~V\ brutallt k;>ea+ WLe.. 1~ th.e,Vl tvavisporteuf
W\Q. tc) l\ ttU ( OvYl pavt 0 F l'vUtVlf lfOS-pt tar -'[;uV] Ped Y/J.
G-3
What DAMAGE or INJURIES do you claim resulted? Please give filll extent ofinjuries or damages claimed:
'frnCtVMd ('IAi\\ r b\G<(\[.. e'-{.e r S.\-CC\l\.OS ovi fCAU, lo\JS-\'td l\¥71 Y'OtiicA b\iYVl ovi faUl r VUtc.\l\o~
cet\\i( \oulf\.Q., -r.. Vie<t\ to oR ().. c..ul!'-l to Wtt\ It f (If Cevt-era I ct~c. Bue~~ Upp-er, rvi rd a I/I'
l 011\lf'{ btA (, \L.
What is the AMOUNT of your claim? Please itemize your damages:
nosp\tco Bin.: SIO,lQYC..w 1ota\:'t.1,1'3,1e '11
lO~S V'J{)S"tS: : ~=3, 000 . 0 0 $ '3 eo I 0 I \) 1
hev\.et a 1 Dawittt)lS ¢ =300, ooo. 0 0 $ "6 131 I 0'h .o D
If you have received~ insurance payments. please give the names of the insurance companies:
\f\ON.
For all accident claims please place on the following diagram the names of the streets where the accident occurred and
the nearest cross-streets; indicate the place of the accident by an "X0 and by showing the nearest address and distances to
street comers. Please indicate where North is on the diagram.
-
Note: if the diagram does not fit the situation, please attach your own diagram •
• ...
... .
·' ·.
Signature of Clairliant or person filing
on claimant's behalf giving relationship ·
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Print Name:
PAGE3
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... . . .. .. ··,
Date:·
G-4
OFFICE OF THE CITY CLERK
City of Los Angeles
Claims for Damages Form
Please mail the original signed form to (copies and faxes not accepted):
Address: Office of the City Clerk
· · 200 North Spring Street
Room 395, City Hall
Los Angeles, CA 90012
Hours: 8:00 am to 4:30 pm, Monday -Friday
Phone: (213) 978-1133
RECEIVED
CITY OF RANCHO PALOS VERDES
MAY 20 2013
CITY CLERK'S Of;TiGE
You may also bring the form to our Public Counter at the at>ove address
during regular business hours.
Reminder: Please make a copy for your own records.
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Providence LCMMC San Pedro
P.O. Box 541024
Los Angeles, CA 90054-1024
(800) 750-6603
1
FINAL
TAWA,RYAN ZA0021605217 01/25/13 01/25/13 01/29/13
LA POLICE DEPARTMENT 3441512
*** M/S SUPPLY GENERAL ***
01/25/13 45Q000420 SUTURE TRAY PLASTIC 1 474.00 ---------
474.00
*** CAT SCAN GENERAL ***
01/25/13 350000005 CT HEAD/BRAIN W/O CONTRAST 1 3489.00
01/25/13 350000140 CT MAXILLOFACILAL W/O CONTRAST 1 4385.00 ______ ._. __
7874.00
*** EMERGENCY ROOM GENERAL ***
01/25/13 450000021 ER VISIT LEVEL IV-M 1 1229.00 ---------1229.00
*** EMERGENCY ROOM :::-n.ocEDURE ***
01/25/13 450000217 ER PROCEDURE 4 1 611. 00
---------
611.00
ZA0021605217
10188.00
G-6