RPVCCA_CC_SR_2012_11_20_J_Claim_Against_City_Lucia_VasquezCITY OF RANCHO PALOS VERDES
TO:
FROM:
DATE:
SUBJECT:
REVIEWED:
HONORABLE MAYOR &CITY COU~MEMBERS
CARLA MORREALE,CITY CLERK ~
NOVEMBER 20,2012
CLAIM AGAINST THE CITY BY LUCIA VASQUEZ
CAROLYN LEHR,CITY MANAGER~.~·
RECOMMENDATION
Reject the claim and direct staff to notify the claimant.
BACKGROUND
The claimant alleges that she was driving on Western Avenue near Westmont Drive
and she hit a pot hole which damaged her tire rim.The alleged incident occurred on
September 14,2012 and the claim was filed on October 22,2012.
The City's Claims Administrator,Carl Warren and Company,has reviewed the claim
and advised the City to reject the claim.The rejection is based on the fact that the City
has no liability for the accident,since the roadway is owned and maintained by
Caltrans.
Attachment:
Claim
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OCT 22 2012
CITY CLERK'S OFFICE
RESERVE FOR FILlJIIG STAMP
CLAIM NO.c<D I~-oil
RECEIVED
CITY OF RANCHO PALOS VERDES J\,_/
~
CLAIM FOR DAMAGES
TO PERSON OR PROPERTY
90275
INSTRUCTIONS
1.Claims for death,injury to pelSOn 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 filed not later than 1 year after the occurrence.
(Gov.Code Sec.911.2.)
3.Read entire claim form before Dllng.
4.See page 2 for diagram upon which to locate place of accident.
5.This claim furm must be signed on page 2 at bottom.
6.Attach separate sheets,if necessary,to give full details.SIGN EACH SHEET.
FII£WITH:
City CLERK'S OffiCE
30940 Hawthorne Blvd.
Rancho Palos tTe;rdes,CA
TO:CITY OF Rancho Palos Verdes
Name of ClaImant
Give address and telephone number to which you desire notices or communications to be sent
regarding this claim:.see..:Ve--.
When did .QA~AGElrINJURY occur?
Date ~Ll1~k:Time I')')
If claim is for Equitable Indemnity,give date claim otserved
with the complaint:
Date::::-:;;-::;-=-:::-:::==--;:-:-::-::=:-:_--::-:::-_~-:-::_---:-:~_---::----:--:---:-.--:---:--~:-::--:--_:--_
Where did DAMAGE or INJURY occur?Describe'fully,and locate on diagram 00 reverse side of this sheet.Where appropriate,give street
names and address and measurements from landmarks:
I:YfV\\~Dn
Describe in detail how the DAMAGE or INJURY occurred.
D\t1 OIW t1~
Why do you claim the cily is responsible?
\Nt%rn
Describe in detail each INJURY or DAMAGE
1'11'Y\.
SEE PAGE 2 (OVER)THIS CLAIM MUST BE SIGNED ON REVERSE SIDE
J-2
1e amount claimed,as of'the date of presentation or thiS Claim,IS computeo U IUIIUWl:I.
amages incurred to date (exact):.Estimated prospective damages as far as ~nown:
Damage to property .........•.............•.$Future expenses for medical and hospital care ...•$----
Expenses for medical and hospital care $Future loss of earnings ...•••.................$-----
-Lossofearnings :$Otherprospectlvespecialdamages $,----
Special damages for ,.....•.......$Prospective general damages •.•..............$----
,/Total estimate prospective damages .,$_
General damages $_lffi·.
Total damages incurred to date ........•.:$$ )~/'
Dial amount claimed as of date of presentation of this claim:."J
Vas damage and/or injury Investigated by p~liqe?I-J Q If so,what city?'_
Vere paramedics or ambulance called?f'J ()If so,name city or ambulance _
f injured,state date,time,name and address of doclor of your first visit _
NITNESSES to DAMAGE,or INJURY:list all persons and addresses of persons known to have information:Phone ~''''_c:.A<1'~";;>S::>.,'/
\lame [..gIt'?\"\Ik,.Ii ri ~Address 2-~IO \S.we.~;eyV\Ave .4:FID\~v,/-.::r.0 -~c..>"'_
\lame Address ,Phone _
:'lame Address-Phone _
P'Address Date Hospitalized _
---Address Date of Treatment _
--Address Date of Treatmenl _
DOCTORS and HOSPITALS:
Hospital -
Doctor
Doctor
READ CAREFULLY
For all accident claims place on following diagram names of streets,or your vehicle when you first saw City vehicle;location of City vehicle
including North,East,South,and West;indicate place of accident by at time of accident by ''A-1''and location of yourself or your vehicle at
"X"and by showing house numbers or distances to street corners.the time of the accident by "B_1"and the point of impact by "X:'
If City Vehicle was involved,designate by letter ''Au location of City NOTE:If diagrams below do not fit the situation,attach hereto a proper
Vehicle when you first saw it,and by "8"location of yourself diagram signed by claimant.
'----
SIDEWALK
CURB
Date:Typed Name:
WITH CITY CLERK (Gov.Code Sec.915a).Presentation of a false claim is a felony (Pen.Code Sec.72.)
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Writte By-------···....
Date'Time _
J\'.~::';S '.,'';:
Wo •Es no..._.._.._
IN00094253
Bar No.-·--·_--
L -.:::t.":'::;
R,'s~k No .._......_...._·.._._......
P.O.No .._
29701 S.Western Ave.#101 INVOICE
Rancho Palos Verdes,CA 90275
Tel:(310)548-5221 EPA #CAL 000312628 NQ 2575 a
Tires •Wheels •Shocks •Alignments
Account No ..__._...__...Home Phone Reference No ..
IN00094253
I MHeage---
All PARTS NEW UNLESS "1 8 1184OTHERWISESPECIFIED.L ... .....L ...L-_
LuCIA
COASTLINE
TIRE CENTER
www.coastlihetire.com
\]);SQlJEZ J
Name Address............__
flE\i!5W'!
REVf:".E.Lf ,~.--'.".
fjr;J.i~"1ZJ BFGoodrich UNIROYAll.AEL7T<~DUNLDPC.OOlJ;ti'EAR .dllIOtiESTOIIE "tre$tone'
Parts &Others Labor
Qty Part No.Description Each Extension Qty Description Extension
F.STlMATE AUTHORIZATION I hereb,.luthorbt tIM repait work htrtht set forth to be done along with the nf'({(>!sa,y material and 8gru that you i'I1C'nel rf!sponsible for IOS5 or damage to vehicle or
Hticle~left in vehicle In ta..offt,.,th«ft or.n)'otMr (lUff:beyond you'<ontrol tU fur any dt'!"ys tdused by unavaihlbUityof paprts or dr-l.ys in pa,ls shipmf'nt5 by 'liuplier or transporter.!hereby grolnt
~:~~~~!::~::.~~~~~::~:~.::~:.':-:Pr:'':~:'r::~~;~~~:~~~:~(;~::~:f(:~~7:;sTi~~g~:n~~~'~I~I~:~~:~~.~~~~e~;r:::~:::::~i~1 :;~~:~~~?;~~~~~A;:9:.~~~:~~;;:.s~e;:~~~at~I~,:~i::si:~:::~y X _
:tcknl:lwledgl'd on .boft ...hk"to MKUN IM.mount of repairs thereto,Not re~ponsibll!for oIny dctm4ge done to custom whet!ls or m"gs.This ~5timate shall expire If notacc.epted withln)O days.Customer's Signature
ACDelco
Cash Amount Check Amount CheckN".C.C.Amount On Account
Parts
Lab"r
other
Sublet
SubTotal
Tax
TOTAL
~Xiilj;'"'tOTALS
0.00
155.00
0.00
0.00
155.00
0.00
155.00
c.co
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