CC SR 20200218 F - Claim for Damages Flores
CITY COUNCIL MEETING DATE: 02/18/2020
AGENDA REPORT AGENDA HEADING: Consent Calendar
AGENDA DESCRIPTION:
Consideration and possible action regarding a claim against the City by Larissa Flores.
RECOMMENDED COUNCIL ACTION:
(1) Reject the claim and direct Staff to notify the claimant.
FISCAL IMPACT: None
Amount Budgeted: N/A
Additional Appropriation: N/A
Account Number(s): N/A
ORIGINATED BY: Emily Colborn, City Clerk
REVIEWED BY: Kit Fox, AICP, Interim Deputy City Manager
APPROVED BY: Ara Mihranian, AICP, Interim City Manager
ATTACHED SUPPORTING DOCUMENTS:
A. Larissa Flores claim (page A-1)
BACKGROUND AND DISCUSSION:
The claimant alleges that, while driving along Palos Verdes Drive East, she sustained
damage from a rock that hit her windshield after driving past a lot containing rocks.
The City’s Claims Administrator, Carl Warren and Company, has reviewed the claim
and advised the City to reject it due to the determination that the rocks came from a
private property that is being developed, not from City property.
1
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 filed not later than 1 year after
the occurrence. (Gov. Code Sec. 911.2.)
3. Read entire claim form before filing.
4. See Page 2 for diagram upon which to locate place of accident.
5. THIS CLAIM FORM MUST BE SIGNED ON PAGE 2 AT BOTTOM.
6. Attach separate sheets, if necessary, to give full details. SIGN EACH SHEET.
Give address and telephone number to which you desire or
communications to be sent regarding this claim:
Where did or INJURY on on
RESERVE FOR FILING STAMP
CLAIM NO. ~01q-( f
RECEIVED
CITY OF RANCHO PALOS VERDES
NOV 21 2019
CITY CLERK'S OFFIC E
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Describe in detail how the DAMAGE or INJURY occurred. • '
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Describe in detail each INJl/RY or DAMAGE. ,_
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This Claim Must Be Signed on Page 2 A-1
The amount claimed, as of the date of presentation of this claim, Is computed as follows:
Damages Incurred to date (exact): i1 if Estimated prospective damages as far as known:
Damage to property .................... $ 4' \. 2 Future expenses for medical and hospital care . $. ___ _
Expenses for medical and hospital care ... $ Future loss of earnings ..............•...•.. $. ___ _
Loss of earnings ...................... $ Other prospective special damages .......... $. ___ _
Special damages for •......•...•....... $ Prospective general damages ..•.•.......... $ ___ _
Total estimate prospective damages ....... $ ___ _
General damages ...................... $ . .....,.r.:-::.....,..,.-
Total damages Incurred to date ........ $ iill:f t.4'L
Total amount claimed as of date of presentation of this claim: $
Was damage and/or injury investigated by police? \(\.0 If so, what city? _______________ _
Were paramedics or ambulance called? V\ Q If so, name city or ambulance---------------
If Injured, state date, time, name and address of doctor of your first visit-------------------
WITNESSES to DAMAGE or INJURY: List all persons and addresses of persons known to have information:
Name Address Phone _______ _
Name Address Phone _______ _
Name Address Phone _______ _
DOCTORS and HOSPITALS:
Hospital ____________ .Address ______________ Date Hospitalized.:--------
Doctor Address Date of Treatment -------
Doctor Address Date of Treatment -------
READ CAREFULLY
For all accident claims place on following diagram names your vehicle when you first saw City vehicle; location of
of streets, including North, East, South, and West; indicate City vehicle at time of accident by "A-1" and location of
place of accident by "X" and by showing house numbers yourself or your vehicle at the time of the accident by
or distances to street corners. If City Vehicle was "B-1" and the point of impact by "X." NOTE: If diagrams
involved, designate by letter "A" location of City Vehicle below do not fit the situation, attach hereto a proper
when you first saw It, and by "B" location of yourself or diagram signed by the claimant.
R ~~S IDEWALK (1\;vt4S \'\0 \\&U-
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Pct\ol \)v l~ ttt \ t
Signature of Claimant or person filing on
his behalf giving relationship to Claimant:
PARKWAY
SIDEWALK
Typed Name: Date :
NOTE: CLAIMS MUST BE FILED WITH CITY CLERK (Gov. Code Sec. 915a). Presentation of a false claim Is a felony (Pen. Code Sec. 72.)
THIS DOCUMENT IS A PUBLIC RECORD AND MAY BE PROVIDED TO A REQUESTOR UPON DEMAND. A-2
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