RPVCCA_CC_SR_2013_09_03_E_Claim_Against_City_O'KeefeTO:
FROM:
DATE:
SUBJECT:
REVIEWED:
HONORABLE MAYOR & CITY COUNC L MEMBERS
CARLA MORREALE, CITY CLER ~
SEPTEMBER 3, 2013
CLAIM AGAINST THE CITY BY MICHAEL OKEEFE
CAROLYN LEHR, CITY MANAGER Q)l_
RECOMMENDATION
Reject the claim and direct staff to notify the claimant.
BACKGROUND
The claimant alleges that on June 17 , 2013 , he was driving on Pa los Ve rdes D riv e
West through an area where a paving project was underway and loose asp ha lt p ieces
and gravel struck and cracked his windshield .
The City 's Claims Administrator , Carl Warren and Company , has reviewed the c la im
and advised the City to reject the claim as the claim has been tende red to Ha rd y &
Harper, Inc. (paving contractors) for processing and investigation .
Attachment:
Claim
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FILE WITH:
CITY CLERK'S OFFICE
City of Rancho Palos Verdes
30940 Hawthorne Blvd.
Rancho Palos Verdes, CA 90275
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 Sec . 911.2.)
2. Claims for damages to real property must be flied not later than 1 year after
the occurrence. (Gov. Code Sec. 911.2.)
3. Read entire claim form before fillng.
4. See Page 2 for diagram upon which to locate place of accident.
6. THIS CLAIM FORM MUST BE SIGNED ON PAGE 2 AT BOTTOM.
6. Attach separate sheets, if necessary, to give full details. SIGN EACH SHEET.
TO: CITY OF RANCHO PALOS VERDES
0 1 K-e .e.k
Home Address of Claimant
(
RESERVE FOR FILING STAMP
CLAIM NO.~ DI 3 -tJi'
~UV.L I VU.&.
RECEIVED
CITY OF RANCHO PALOS VERDES
JUN 2 5 2013
CITY CLERK'S OFFICE
Where did DAMAGE or INJURY occur? Describe fully, and locate on diagram on Page 2. Where appropriate, give
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street names and address and measurements from landmarks: . , .
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Describe In detail how the DAMAGE or INJURY occurred.
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Why do you claim the city is responsible?
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Describe in detail each INJURY or DAMAGE.
This Claim Must Be Signed on Page 2
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The amount claimed, as of the date of presentation of this claim, Is computed as follows:
Damages incurred to date (exact): i:t() Estimated prospective damages as far as known:
Damage to property .................... $ I ')CJ, Future expenses for medical and hospital care . $ b
Expenses for medical and hospital care ... $ ....& Future loss of earnings ..................... $ '8-
Loss of earnings ...................... $ .e Other prospective special damages .......... $ -A=
Special damages for ................... $ ±>-· Prospective general damages ............... $ fr
Total estimate prospective damages ....... $ -er-
General damages ...•.................. $ ~
Total damages incurred to date ........ $ .&-
Total amount claimed as of date of presentation of this claim: $ l~O { 00
Was damage and/or Injury investigated by police? 0 c) If so, what city? ________________ _
Were paramedics or ambulance called? //) <) If so, name city or ambulance---------------
If Injured, state date, time, name and address of doctor of your first visit __________________ _
WITNESSES to DAMAGE or INJ . RY: List all perso M and addrmes of persons b nowa+o have information:
Name c n·~+t. ()I ~C· . Address • I ••• I • m!!!J I Phon
Name 1 "~ Address l 1 I 1 1 1 tr 1 1 Phone
Name Address Phone ________ _
DOCTORS and HOSPITALS:
Hospital h /JA..
Doctor I
Address ______________ Date Hospitalized ______ _
Address Date of Treatment ______ _
Doctor ____________ Address Date of Treatment ______ _
READ CAREFULLY
For all accident claims place on following diagram names your vehicle when you first saw City vehicle; location of
of streets, including North, East, South, and West; Indicate City vehicle at time of accident by "A-1" and location of
place of accident by "X" and by showing house numbers yourself or your vehicle at the time of the accident by
or distances to street corners. If City Vehicle was "B-1" and the point of Impact by "X." NOTE: If diagrams
involved, designate by letter "A" location of City Vehicle below do not fit the situation, attach hereto a proper
when you first saw it, and by "B" location ·of yourself or diagram signed by the claimant.
CURBJ
Signature of Claimant or person filing on
his behalf giving relationship to Claimant:
SIDEWALK
PARl<WAV
SIDEWALi\
Typed Name:
L
CURB-,_
Date:
NOTE: CLAIMS MUST BE FILED WITH CITY CLERK (Gov. Code Sec. 915a). Presontatlon of a false claim is a felony (Pen. Code Sec. 72.)
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