Loading...
HomeMy WebLinkAbout2009-02-24 City Council Agenda Item No. 5CITY OF LADE ov LSIIYC)Iti,E DREAM EXTREME REPORT TO CITY COUNCIL TO: HONORABLE MAYOR AND MEMBERS OF THE CITY COUNCIL FROM: ROBERT A. BRADY CITY MANAGER DATE: FEBRUARY 24, 2009 SUBJECT: CLAIMS AGAINST THE CITY Background Claims filed against the City of Lake Elsinore are reviewed and handled by Carl Warren & Company, Claims Administrators. When received, each claim is logged in the City Clerk's Office and forwarded to this company for investigation. After initial review and investigation, direction is issued to the City to take one of several actions such as rejection, notification of late claim or reservation of action until further information is obtained. Discussion The following claims have been recommended for rejection by Carl Warren & Company: CL# 2008 -11 2008 -12 2008 -13 2008 -14 2008 -15 2008 -16 2008 -17 2008 -18 2008 -19 2008 -20 2008 -21 2008 -22 2009 -3 Mike Matthews Lisa Matthews Pam Eslinger Jim Eslinger Virginia Sherfey Dora Munoz Daniel Munoz Robert Balthrope Vivian Balthrope Byron Quiroz Gladys Hinojosa Eduardo Hinojosa Donald Johnson Agenda Item No. 5 Page 1 of 67 Claims Against the City February 24, 2009 Page 2 Fiscal Impact None. Recommendation Reject the claims listed above and direct the City Clerk's Office to send a letter informing the claimants of the decision. Prepared by: Jessica GuzmaI Office Specialist Reviewed by: Carol Cowley Interim City Cler* Approved by: Robert A. Brady City Manager WWW"' Agenda Item No. 5 Page 2 of 67 February 13, 2009 FEB j 'd aco� TO: City of Lake Elsinore ATTENTION: Jessica Guzman, Office Specialist CITY CLERKS OFFICE RE: Claim Matthews, et al. v. City of Lake Elsinore Claimant Mike & Lisa Matthews, et al. D /Event 4/3/08 Rec'd Y /Office 5/9/08 Our File 1476562 RWQ We have reviewed the above captioned claim and request that you take the action indicated below: • CLAIM REJECTION: Send a standard rejection letter to all 12 claimants and their attorneys. Please provide us with a copy of the notice sent, as requested above. If you have any questions please contact the undersigned. Very Truly Yours, CARL WARREN & CO. Richard Marque cc: CJPIA Attn: Executive Director CARL WARREN & CO. CLAIMS MANAGEMENT(CLAIMS ADJUSTERS 770 Placentia Avenue, Placentia, CA 92870 -6832 Mail: P.O. Box 25180, Santa Ana, CA 92799 -5180 Phone: (714) 572 -5200 ( (800) 572 -6900 ( Fax: (714) 961 -8131 Agenda Item No. 5 Page 3 of 67 CITY OF J00 �. LADE � LSIfi0R E 1 12 DREAM May 15, 2008 Dwight Kunz Carl Warren & Company P.O. Box 25180 Santa Ana CA 92799 -5180 Dear Mr. Kunz: Enclosed for your handling is a claim received on May 9, 2008 from Lori Guthrie on behalf of Mike Matthews (CL #2008 -11). Please keep me advised of appropriate City Council Action. For further assistance, please contact me at (951) 674 -3124 ext. 269. JESSICA GUZMAN, OFFICE SPECIALIST CITY OF LAKE ELSINORE Enclosure 951.674.3124 130 S. MAIN STREET LAKE ELSINORE. CA 92530 W W W. LAKE- E LSI NORE.ORG Agenda Item No. 5 Page 4 of 67 CITY CrF LA.E by: DREAM EXTUME- CLAIM AGAINST THE CITY OF LAKE ELSINORE (For Damages to Persons or Personal Property) A claim must be filed with the City Clerk of the City of Lake Elsinore within six (6) months after the incident or event occurred. Be sure your claim is against the City of Lake Elsinore, not another public entity. Where space is insufficient, please use additional paper and identify information by paragraph number. Completed claims must be mailed or delivered to the City Clerk, City of Lake Elsinore, 130 South Main Street Lake Elsinore, MAY 0 9 2000 CITY CLERKO OFFICE The undersigned respectfully submits the following claim and information relative to damage to persons andiur personal property: 1. Name of Clairr a. Address of b. Phone No. d. Social Sect 2. Name, post office address and telephone to which claimant desires notices to be sent, if other than the above: 3. Occurrence or event from which this claim arises: a. Date: c. Place location) b. Time: d. How many and under what circumstances did damage or injury occur? Specify the particular occurrences, event, act at omission l you claim caused the injury or damage (use additional at paper if necessary). 64A 6 1/'yA e. What particular action by the City of its employees, caused the alleged damage or injury? Agenda Item No. 5 Page 5 of 67 4. Were there any injuries at the time of this accident? If not, state "No Injuries. P- 6�, t (u W 5. Give the name(s) of the public employee(s) causing the injury, damage, or loss, if known. 6. Name and address of any person injured: 7. Name and address of the owner of any damaged property: P CLn J�: r r . i 8. Damages claimed a. Amount claimed as of this date: $ i r\ b. Estimated amount of future costs: $ c. Total amount claimed: $ 1 ^\ 6 d. Basis for computation of amounts claimed (include cop of aY bills, invoices, estimates, etc.)' 9. Names and addresses of all witnesses, hospital, doctors, etc: a. 5 u— o p t 6a C. 10. Warning: It is a criminal offense to file a false claim! (Penal Code 72 /Insurance Code 556.1) 1 have read the matters and statements made in the above claim and I know the same to be true of my own knowledge, except as to those matters state upon information or belief as to such matters, I believe the same to be true. 1 certify under penalty of perjury that the foregoing is true and correct. Claimants Signature I Da Agenda Item No. 5 Page 6 of 67 Any additional information that might be helpful in considering this claim: Attachment to Claim for Damages to Real Property 2. Name, post office address and telephone to which claimant desires notices to be sent, if other than the above: All correspondence in this matter should be sent to claimant's attorney: Lori Guthrie, GRACE HOLLIS & HANSON LLP, 3555 Fifth Avenue, San Diego, CA 92103 3. Occurrence or event from which this claim arises: a. Date: The damage to claimant's property has been ongoing since the development and construction of surrounding properties, including but not limited to the Fairfield Development (Ridgestone Apartments) and the Centex and Lennar Developments (Rosetta Hills). b. Time: See response to question 3.a. above. c. Place (Exact and specific location): Claimant's property (address listed in response to question La.) has been harmed due to flooding caused by the development and construction of the properties listed in response to question 3.a. above. d. How many and under what circumstances did damage or injury occur? Specify the particular occurrences, event, act or omission you claim caused the injury or damage (use additional paper if necessary). Water damage and flooding has occurred and affected several properties, including claimant's property, located below the Fairfield, Centex and Lennar Developments. Reckless and negligent acts of the City of Lake Elsinore caused the damage to claimant's property in that the City did not make provisions for, or require the Fairfield, Centex and Lennar developments to make provisions for, adequate drainage, landscaping and flood control. The resulting flooding and water damage has interfered with the use and enjoyment of claimant's property. e. What particular action by the City or its employees caused the alleged damage or injury? Reckless and negligent acts of the City of Lake Elsinore caused the damage to claimant's property in that the City did not make provisions for, or require the Fairfield, Centex and Lennar developments to make provisions for, adequate drainage, landscaping and flood control. 4. Were there any injuries at the time of the accident? If not, state "No injuries. " Claimant is not alleging any personal injuries. Rather, claimant's real property has been damaged, and continues to be damaged, due to flooding and water damage as described above. Agenda Item No. 5 Page 7 of 67 5. Give the name(s) of the public employee(s) causing the injury, damage, or loss, if known. This information is unknown at this time. 6. Name and address of any person injured: Claimant is not alleging any personal injuries. Claimant's property, listed in response to question I .a., hay been damaged, and continues to be damaged, as a result of the flooding and water damage described above. 7. Name and address of the owner of any damaged property. See claimant's response to question 1. 9 Names and addresses ofall witnesses, hospital, doctors, etc.: No hospitals or doctors are involved in this claim as this is not a claim for personal injuries. Witnesses to the damages caused to claimant's property include: a. Mike and Lisa Matthews, b. Daniel and Dora Munoz, c. Julio Bustos d. Virginia Sherfey, e. Robert and Vivian Balthro e f Jim and Pam Eslin er g. Byron Quiroz, h. Eduardo and Gladys Hinojosa, Agenda Item No. 5 Page 8 of 67 CITY OF LAKE LSI DREAM EXTREME May 15, 2008 Dwight Kunz Carl Warren & Company P.O. Box 25180 Santa Ana CA 92799 -5180 Dear Mr. Kunz: Enclosed for your handling is a claim received on May 9, 2008 from Lori Guthrie on behalf of Lisa Matthews (CL #2008 -12). Please keep me advised of appropriate City Council Action. For further assistance, please contact me at (951) 674 -3124 ext. 269. Sincerely, _...: _.__....._._..__ r F_- JE A GUZ N, O FICE SP CIALIST CITY OF LAKE ELSINORE Enclosure 951.674.3124 130 S. MAIN STREET, LAKE ELSINORE, CA 92530 W W W. LAKE -E LS NOREORG Agenda Item No. 5 Page 9 of 67 CITY OF MSS a ERIE ( � S1U0RE W DREAM EXTREMEN CLAIM AGAINST THE CITY OF LAKE ELSINORE (For Damages to Persons or Personal Property) A claim must be filed with the City Clerk of the City of Lake Elsinore within six (6) months after the incident or event occurred. Be sure your claim is against the City of Lake Elsinore, not another public entity. Where space is insufficient, please use additional paper and - identify information by paragraph number. Completed claims must be mailed or delivered to the City Clerk, City of Lake Elsinore, 130 South Main Street, Lake Elsinore, 'q MAY 0 9 2960 �l J CITY CLERKS OFFICE. The undersigned respectfully submits the following claim and information relative to damage to persons and/or personal property: 1. Name of C a. Addres b. Phone d. Social 2. Name, post office address and telephone to which claimant desires notices to be sent, if other than the above: 3. Occurrence or event from which this claim arises: a. Date: CV\ b. Time: ter c. Place (Exac d spe ific location) d. How many and under what circumstances did damage or injury occur? Specify the particular occurrences, event, act or omission you claim caused the injury or damage (use additional paper if necessary). .F 4 e. What particu r action by the City of its employees, caused the alleged damage or injury? Agenda Item No. 5 Page 10 of 67 4. Were there any injuries at the time of this accident? If not, state "No Injuries." 5. Give the name(s) of the public employee(s) causing the injury, damage, or loss, if known. 0 U- - V-,tl'I1ti� 6. Name and address of any person injured: 7. Name and address of the owner of any damaged property: 8. Damages claimed: a. Amount claimed as of this date: $ L e K UC b. Estimated amount of future costs: $ c. Total amount claimed: $ 1 /1 Q.Y CQ 4 a`� 1 515 d. Basis for computation of amounts claimed (include copies o II bills, invoices, estimates, etc.): 9. Names and addresse _� all witnesses, hospital, doctors, etc: a. k��R _ 0-± CL1c -k9 b. C. 10. Any additional information that might be helpful in considering this claim Warning: It is a criminal offense to file a false claim! (Penal Code 72 /Insurance Code 556.1) 1 have read the matters and statements made in the above claim and I know the same to be true of my own knowledge, except as to those matters state upon information or belief as to such matters, I believe the sa to be true. I certify under penalty of perjury that the foregoing is true and correct. li y3 C aimant's Signature D to Agenda Item No. 5 Page 11 of 67 Attachment to Claim for Damages to Real Property 2. Name, post office address and telephone to which claimant desires notices to be sent, if other than the above: All correspondence in this matter should be sent to claimant's attorney: Lori Guthrie, GRACE HOLLIS & HANSON LLP, 3555 Fifth Avenue, San Diego, CA 92103 3. Occurrence or event from which this claim arises: a. Date: The damage to claimant's property has been ongoing since the development and construction of surrounding properties, including but not limited to the Fairfield Development (Ridgestone Apartments) and the Centex and Lennar Developments (Rosetta Hills). b. Time: See response to question 3.a. above. c. Place (Exact and specific location). Claimant's property (address listed in response to question La.) has been harmed due to flooding caused by the development and construction of the properties listed in response to question 3.a. above. d. How many and under what circumstances did damage or injury occur? Specify the particular occurrences, event, act or omission you claim caused the injury or damage (use additional paper if necessary). Water damage and flooding has occurred and affected several properties, including claimant's property, located below the Fairfield, Centex and Lennar Developments. Reckless and negligent acts of the City of Lake Elsinore caused the damage to claimant's property in that the City did not make provisions for, or require the Fairfield, Centex and Lennar developments to make provisions for, adequate drainage, landscaping and flood control. The resulting flooding and water damage has interfered with the use and enjoyment of claimant's property. e. What particular action by the City or its employees caused the alleged damage or injury? Reckless and negligent acts of the City of Lake Elsinore caused the damage to claimant's property in that the City did not make provisions for, or require the Fairfield, Centex and Lennar developments to make provisions for, adequate drainage, landscaping and flood control. 4. Were there any injuries at the time of the accident? If not, state "No injuries. " Claimant is not alleging any personal injuries. Rather, claimant's real property has been damaged, and continues to be damaged, due to flooding and water damage as described above. Agenda Item No. 5 Page 12 of 67 5. Give the name(s) of the public employees) causing the injury, damage, w loss, if known. This information is unknown at this time. 6. Name and address of any person injured, Claimant is not alleging any personal injuries. Claimant's property, listed in response to question I .t . Ij,1.) been damaged, and continues to be damaged, as a result of the floodinL- ,uid water damage described above. 7. Name and address of the owner of any damaged property. See claMILMI response to question 1. 9 Names andaddresses ofall witnesses, hospital, doctors, etc No or doctors are involved in this claim as this is not a claim for personal injuric� Witnesses to the damages caused to claimant's property include: a. Mike and Lisa Matthews, b. Daniel and Dora Munoz, c. Julio is Sh e d. Virginia Shrfey, e. Robert and Vivian Balthro e f. Jim and Pam Eslin er g. Byron Quiroz, h. Eduardo and Gladys Hinojosa, Agenda Item No. 5 Page 13 of 67 CITY OF LADE LSINORE DREAM May 15, 2008 Dwight Kunz Carl Warren & Company P.O. Box 25180 Santa Ana CA 92799 -5180 Dear Mr. Kunz: Enclosed for your handling is a claim received on May 9, 2008 from Lori Guthrie on behalf of Pam Eslinger (CL #2008 -13). Please keep me advised of appropriate City Council Action. For further assistance, please contact me at (951) 674 -3124 ext. 269. Enclosure 951.674.3124 130 S. MAIN STREET LAKE ELSINORE. CA 92530 W W W.LAKE -ELSI NORE.ORG Agenda Item No. 5 Page 14 of 67 CITY OF LAKE ELSINORE CITY OF LA I-E ILSMORE DREAM EXTREME- l� u V i P!AY 0 9 2088 CITY CLERKS OFFICE CLAIM AGAINST THE CITY OF LAKE ELSINORE (For Damages to Persons or Personal Property) A claim must be filed with the City Clerk of the City of Lake Elsinore within six (6) months after the incident or event occurred. Be sure your claim is against the City of Lake Elsinore, not another public entity. Where space is insufficient, please use additional paper and identify information by paragraph number. Completed claims must be mailed or delivered to the City Clerk, City of Lake Elsinore, 130 South Main Street, Lake Elsinore, CA 92530. D ST.✓ 2 W J i t MAY 0 9 2008 LJ� CITY CLERKS OFFIC,L The undersigned respectfully submits the following claim and information relative to damage to persons and/or personal property: _ 1. Name of Claimant a. Address of Claimai b. Phone No.M d. Social Security No. 2. 191 Name, post office address and telephone to which claimant desires notices to be sent, if other than the above: wk y bmeni Occurrence or event from which this claim arises: rDee 0 -00(` hil lee a. Date: b. Time: c. Place (Exact and specific location) d. How many and under what circumstances did damage or injury occur? Specify the particular occurrences, event, act or omission you claim caused the injury or damage (use additional �_ A" paper if necessary). c , r ��,. � s e. What particular action by the City of its employees, caused the alleged damage or injury? Agenda Item No. 5 Page 15 of 67 4. Were there any injuries at the time of this accident? If not, state "No Injuries." ATP_ aqa&nwn 5. Give the name(s) of the public employee(s) causing the injury, damage, or loss, if known. 6. Name and address of any person injured: 9r-e- O&A ky)i )enl 7. Name and address of the owner of any damaged property: 8. Damages claimed: . oWahi1r1C-,I4 a. Amount claimed as of this date: $ b. Estimated amount of future costs: $ c. Total amount claimed: $ n � Y d. Basis for computation of amounts claimed (include copies of a 1 bills, invoices, estimates, etc.): 9. Names and addresses of all witnesses, hospital, doctors, etc:? a. b. C. 10. Any additional information that might be helpful in considering this claim: u � f Warning: It is a criminal offense to file a false claiml (Penal Code 72 /Insurance Code 556.1) 1 have read the matters and statements made in the above claim and I know the same to be true of my own knowledge, except as to those matters state upon information or belief as to such matters, I believe the same to be true. I certify under penalty of perjury that the foregoing is true and correct. 3 -,-2 Z o F Claiman Signatur Date Agenda Item No. 5 Page 16 of 67 Attachment to Claim for Damages to Real Propertv 2. Name, post office address and telephone to which claimant desires notices to be sent, if other than the above: All correspondence in this matter should be sent to claimant's attorney: Lori Guthrie, GRACE HOLLIS & HANSON LLP, 3555 Fifth Avenue, San Diego, CA 92103 3. Occurrence or event from which this claim arises: a. Date: The damage to claimant's property has been ongoing since the development and construction of surrounding properties, including but not limited to the Fairfield Development (Ridgestone Apartments) and the Centex and Lennar Developments (Rosetta Hills). b. Time: See response to question 3.a. above. c. Place (Exact and specific location): Claimant's property (address listed in response to question La.) has been harmed due to flooding caused by the development and construction of the properties listed in response to question 3.a. above. d. How many and under what circumstances did damage or injury occur? Specify the particular occurrences, event, act or omission you claim caused the injury or damage (use additional paper if necessary). Water damage and flooding has occurred and affected several properties, including claimant's property, located below the Fairfield, Centex and Lennar Developments. Reckless and negligent acts of the City of Lake Elsinore caused the damage to claimant's property in that the City did not make provisions for, or require the Fairfield, Centex and Lennar developments to make provisions for, adequate drainage, landscaping and flood control. The resulting flooding and water damage has interfered with the use and enjoyment of claimant's property. e. What particular action by the City or its employees caused the alleged damage or injury? Reckless and negligent, acts of the City of Lake Elsinore caused the damage to claimant's property in that the City did not make provisions for, or require the Fairfield, Centex and Lennar developments to make provisions for, adequate drainage, landscaping and flood control. 4. Were there any injuries at the time of the accident? If not, state "No injuries.'" Claimant is not alleging any personal injuries. Rather, claimant's real property has been damaged, and continues to be damaged, due to flooding and water damage as described above. Agenda Item No. 5 Page 17 of 67 S. Give the name(s) of the public employee(s) causing the injury, damage, or loss, if known. This information is unknown at this time. 6. Name and address of any person injured. Claimant is not alleging any personal injuries. Claimant's property, listed in response to question l .a., has been damaged, and continues to be damaged, as a result of the flooding and water damage described above. 7. Name and address of the owner of any damaged property. See claimant's response to question 1. 9 Names and addresses ofall witnesses, hospital, doctors, etc., No hospitals or doctors are involved in this clairn as this is not a claim for personal injuries. Witnesses to the damages caused to claimant's property include: a. Mike and Lisa Matthews, b. Daniel and Dora Munoz, c. Julio Bustos d. Virginia Sherfey, e. Robert and Vivian Balthro e f. Jim and Pam Eslin er g. Byron Quiroz, h. Eduardo and Gladys Hinojosa, Agenda Item No. 5 Page 18 of 67 CITY OF LAKE LSI 1�? DREAM EXTREME May 15, 2008 Dwight Kunz Carl Warren & Company P.O. Box 25180 Santa Ana CA 92799 -5180 Dear Mr. Kunz: Enclosed for your handling is a claim received on May 9, 2008 from Lori Guthrie on behalf of Jim Eslinger (CL #2008- 14). Please keep me advised of appropriate City Council Action. For further assistance, please contact me at (951) 674 -3124 ext. 269. Sincerely, IUA GUZMAWOFFI CE'SPECIALIST OF LAKE ELSINORE Enclosure 951.674.3124 130 S. MAIN STREET LAKE ELSINORE, CA 92530 W W W. LAKE- E LS I NORE.ORG Agenda Item No. 5 Page 19 of 67 CITY OF LADE DRE EXtpumE,r CLAIM AGAINST THE CITY OF LAKE ELSINORE (For Damages to Persons or Personal Property) by: A -claim must be filed with the City Clerk of the City of Lake Elsinore within six (6) months after the incident or event occurred. Be sure your claim is against the City of Lake Elsinore, not another public entity. Where space is insufficient, please use additional paper and identify information by paragraph number. Completed claims must be mailed or delivered to the City Clerk, City of Lake Elsinore, 130 South Main Street, Lake Elsinore, �I MAY 0 J NO, CITY CLERKS dffiG The undersigned respectfully submits the following claim and information relative to damage to persons and /or personal property: 1. Name of Claimant TmY ,ill' \Glt'i' a. Address of b. Phone No c. Date of Birth d. Social Security No:. e. Drivers LIc. No. 2. Name, post t ti offi address + a ` nd telephone to which claimant desires notices to be sent, if other than the above: ` et✓ 0h2n Pf4 3. Occurrence or event from which this claim arises: S ec Q - f 1 UN )n - 'enl — a. Date: b. Time C. Place (Exact and specific location) d. How many and under what circumstances did damage or injury occur? Specify the particular occurrences, event, act or omission you claim caused the injury or damage (use additional paper if necessary). e. What particular action by the City of its employees, caused the alleged damage or injury? Agenda Item No. 5 Page 20 of 67 4. Were there any injuries at the time of this accident? If not, state "No Injuries." See. aA► ki) cc-, 5. Give the name(s) of the public employee(s) causing the injury, damage, or loss, if known. See 011-�hhn 6. Name and address of any person injured: `_gee OA(Aft l eC) 4 7. Name and address of the owner of any damaged property: See aq@&1Y MJ= 8. Damages claimed: Se Q•k&MOn+ a. Amount claimed as of this date: b. Estimated amount of future costs: c. Total amount claimed: d. Basis for computation of amounts claimed 91 fi[#a $ (include copies of J bills, invoices, estimates, etc.): Names and addresses of all witnesses, hospital, doctors, etc: 9 e o4o(q, jl g ej �� a. b. C. Any additional information that might be helpful in considering this claim Warning: It is a trim offense to file a false claim! (Penal Code 72 /Insurance Code 556.1) I hav r ad the m ers and statements made in the above claim and I know the same to be true of my ow kno ledge ce t as to those matters state upon information or belief as to such matters, I believe th sam to under penalty of perjury that the foregoing is true and correct. Date Agenda Item No. 5 Page 21 of 67 Attachment to Claim for Damages to Real Property 2. Name, post office address and telephone to which claimant desires notices to be sent, if other than the above: All correspondence in this matter should be sent to claimant's attorney: Lori Guthrie, GRACE HOLLIS & HANSON LLP, 3555 Fifth Avenue, San Diego, CA 92103 3. Occurrence or event from which this claim arises: a. Date: The damage to claimant's property has been ongoing since the development and construction of surrounding properties, including but not limited to the Fairfield Development (Ridgestone Apartments) and the Centex and Lennar Developments (Rosetta Hills). b. Time: See response to question 3.a. above. c. Place (Exact and specific location): Claimant's property (address listed in response to question La.) has been harmed due to flooding caused by the development and construction of the properties listed in response to question 3.a. above. d.. How many and under what circumstances did damage or injury occur? Specify the particular occurrences, event, act or omission you claim caused the injury or damage (use additional paper if necessary). Water damage and flooding has occurred and affected several properties, including claimant's property, located below the Fairfield, Centex and Lennar Developments. Reckless and negligent acts of the City of Lake Elsinore caused the damage to claimant's property in that the City did not make provisions for, or require the Fairfield, Centex and Lennar developments to make provisions for, adequate drainage, landscaping and flood control. The resulting flooding and water damage has interfered with the use and enjoyment of claimant's property. e. What particular action by the City or its employees caused the alleged damage or injury? Reckless and negligent acts of the City of Lake Elsinore caused the damage to claimant's property in that the City did not make provisions for, or require the Fairfield, Centex and Lennar developments to make provisions for, adequate drainage, landscaping and flood control. 4. Were there any injuries at the time of the accident? If not, state "No injuries." Claimant is not alleging any personal injuries. Rather, claimant's real property has been damaged, and continues to be damaged, due to flooding and water damage as described above. Agenda Item No. 5 Page 22 of 67 5. Give the name(s) of the public employee(s) causing the injury, damage, or loss, if known. This information is unknown at this time. 6. Name and address of any person injured: Claimant is not alleging any personal injuries. Claimant's property, listed in response to question l .a., has been damaged, and continues to be damaged, as a result of the flooding and water damage described above. Name and address of the owner of any damaged property: See claimant's response to question 1. 9 Names and addresses ofall witnesses, hospital, doctors, etc.: No hospitals or doctors are involved in this claim as this is not a claim for personal injuries. Witnesses to the damages caused to claimant's propert include: a. Mike and Lisa Matthews, b. Daniel and Dora Munoz, c. Julio Bustos d. Virginia Sherfey, e. Robert and Vivian Balthro e f. Jim and Pam Eslin er g. Byron Quiroz, h. Eduardo and Gladys Hinojosa, Agenda Item No. 5 Page 23 of 67 CITY OF ^ LADE LSINOIZE DREAM May 15, 2008 Dwight Kunz Carl Warren & Company P.O. Box 25180 Santa Ana CA 92799 -5180 Dear Mr. Kunz: Enclosed for your handling is a claim received on May 9, 2008 from Lori Guthrie on behalf of Virginia Sherfey (CL #2008 -15). Please keep me advised of appropriate City Council Action. For further assistance, please contact me at (951) 674 -3124 ext. 269. Sincerely, C CITY OF LAKE Enclosure 951.674.3124 130 S. MAIN STREET LAKE ELSINORE. CA 92530 W W W. LAKE -E LS I NORE.ORG Agenda Item No. 5 Page 24 of 67 CITY OF DREAM EXTREME- CLAIM AGAINST THE CITY OF LAKE ELSINORE (1`91-Daffoqu to Persons or Personal Property) A claim must be filed with the City Clerk of the City of Lake Elsinore within six (6) months -afte,: the- incident -or event occurred- ...ae.suzynur-. claim is against the City of Lake Elsinore, not another public entity. Where space is insufficient, please use additional paper and identify information by paragraph number. Completed claims must be mailed or delivered to the City Clerk, City of Lake Elsinore, 130 South Main Street, Lake Elsinore, ca— T �T MAY 0 9 2008 CITY CLERKS OFFICE The undersigned respectfully submits the following claim and information relative to damage to persons and /or personal property: I , 1. Name of Claimant a. Address of Claimal b. Phone No.. d. Social Security No. 2. Name, post office ` address and telephone to which claimant desires notices to be sent, if other than the above:L 3. Occurrence or event from which this claim arises: C''� Gi(`�}(�'(MV Yl�?I'l a. Date: c. Place (Exact and specific location) b. Time: d. How many and under what circumstances did damage or injury occur? Specify the particular occurrences, event, act or omission you claim caused the injury or damage (use additional paper if necessary). ��... c/ = t .,.. 41 e. What particular action by the City of its employees, caused the alleged damage or injury? Agenda Item No. 5 Page 25 of 67 4. Were there any injuries at the time of this accident? If not, state "No Injuries." 5. Give the name(s) of the public employee(s) causing the injury, damage, or loss, if known. 6. Name and address of any person injured: Name and address of the owner of any damaged property: Damages claimed: Jp e c4w O a. Amount claimed as of this date: $ (� a i X "} ; M". b. Estimated amount of future costs: c. Total amount claimed: $ d. Basis for computation of amounts claimed (include copies of aft bills, invoices, estimates, etc.): 9. Names and addresses of all witnesses, hospital, doctors, etc: 'DCP- 1- a. b. C. 10. Any additional information that might be helpful in considering this claim: i. l Warning: It is a criminal offense to file a false claim! (Penal Code 72 /Insurance Code 556.1) 1 have read the matters and statements made in the above claim and I know the same to be true of my own knowledge, except as to those matters state upon information or belief as to such matters, I believe the same t o be true. I certify under penalty of perjury that the foregoing is true and correct. laimant's Signature Date Udy Agenda Item No. 5 Page 26 of 67 Attachment to Claim for Damages to Real Property 2. Name, post office address and telephone to which claimant desires notices to be sent, if other than the above: All correspondence in this matter should be sent to claimant's attorney: Lori Guthrie, GRACE HOLLIS & HANSON LLP, 3555 Fifth Avenue, San Diego, CA 92103 3. Occurrence or event from which this claim arises: a. Date: The damage to claimant's property has been ongoing since the development and construction of surrounding properties, including but not limited to the Fairfield Development (Ridgestone Apartments) and the Centex and Lennar Developments (Rosetta Hills). b. Time: See response to question 3.a. above. c. Place (Exact and specific location): Claimant's property (address listed in response to question l.a.) has been harmed due to flooding caused by the development and construction of the properties listed in response to question 3.a. above. d. How many and under what circumstances did damage or injury occur? Specify the particular occurrences, event, act or omission you claim caused the injury or damage (use additional paper if necessary). Water damage and flooding has occurred and affected several properties, including claimant's property, located below the Fairfield, Centex and Lennar Developments. Reckless and negligent acts of the City of Lake Elsinore caused the damage to claimant's property in that the City did not make provisions for, or require the Fairfield, Centex and Lennar developments to make provisions for, adequate drainage, landscaping and flood control. The resulting flooding and water damage has interfered with the use and enjoyment of claimant's property. e. What particular action by the City or its employees caused the alleged damage or injury? Reckless and negligent acts of the City of Lake Elsinore caused the damage to claimant's property in that the City did not make provisions for, or require the Fairfield, Centex and Lennar developments to make provisions for, adequate drainage, landscaping and flood control. 4. Were there any injuries at the time of the accident? If not, state "No injuries. " Claimant is not alleging any personal injuries. Rather, claimant's real property has: damaged, and continues to be damaged, due to flooding and water damage as described above. Agenda Item No. 5 Page 27 of 67 5. Give the name(s) of the public employee(s) causing the injury, damage, or loss, if known. This information is unknown at this time. 6. Name and address of any person injured: Claimant is not alleging an personal injuries. Claimant's property, listed in response to question l .a., has been damaged, and continues to be damaged, as a result of the flooding and water damage described above. Name and address of the owner of any damaged property. See claimant's response to question 1. 9 Names and addresses of all witnesses, hospital, doctors, etc.. No hospitals or doctors are involved in this claim as this is not a claim for personal injuries, Witnesses to the damages caused to claimant's property include: a. Mike and Lisa Matthews, b. Daniel and Dora Munoz, c. Julio Bustos d. Virginia Sherfey, e. Robert and Vivian Balthro e f Jim and Pam Eslin er g. Byron Quiroz, h. Eduardo and Gladys Hinojosa, Agenda Item No. 5 Page 28 of 67 CITY OF LAKEE 092LSIHORE u DREAM May 15, 2008 Dwight Kunz Carl Warren & Company P.O. Box 25180 Santa Ana CA 92799 -5180 Dear Mr. Kunz: Enclosed for your handling is a claim received on May 9, 2008 from Lori Guthrie on behalf of Dora Munoz (CL #2008- 16). Please keep me advised of appropriate City Council Action. For further assistance, please contact me at (951) 674 -3124 ext. 269. Singly, JESSICA GUZMAN, OFFICE SPLCIALIST CITY OF LAKE ELSINORE Enclosure 951.674.3124 130 S. MAIN STREET LAKE ELSINORE, CA 92530 W WW.LAKE- EISINORE.ORG Agenda Item No. 5 Page 29 of 67 CITY OF D)tEAM EXTPEME� CLAIM AGAINST THE CITY OF LAKE ELSINORE (For Dar gib ss to Persons or Personal Property) by: A claim must be filed with the City Clerk of the City of Lake Elsinore within six f6) months after the incident or event occurred. Be sure your claim is against the City of Lake Elsinore, not another public entity. Where space is insufficient, please use additional paper and identify information by paragraph number. Completed claims must be mailed or delivered to the City Clerk, City of Lake Elsinore, 130 South Main Street, Lake Elsinore, o C`��" n 1 7 r, MAY 0 9 2000 CITY CLERKS OFFICE The undersigned respectfully submits the following claim and information relative to damage to persons and /or personal property: 1. Name of Claimant �OY(.v 1L1_OZ _ a. Addres b. Phone d. Social 2. Name, post office address and telephone to which claimant desires notices to be sent. if other than the above: 3. Occurrence or event from which this claim arises: See 0 koh/Y)['r4 a. Date: G. Place (Exact and specific location) b. Time d. How many and under what circumstances did damage or injury occur? Specify the particular occurrences, event, act or omission you claim caused the injury or damage (use additional paper if necessary). e. What particular action by the City of its employees, caused the alleged damage or injury? Agenda Item No. 5 Page 30 of 67 4. Were there any injuries at the time of this accident? If not, state "No Injuries." 5. Give the name(s) of the public employee(s) causing the injury, damage, or loss, if known. See. (11920h MM1- 6. Name and address of any person injured: 5e a&Ohin � 7. Name and address of the owner of any damaged property: 8. Damages claimed: See a. Amount claimed as of this date: $ b. Estimated amount of future costs: $ c. Total amount claimed: $ d. Basis for computation of amounts claimed (include copies of all invoices, estimates, etc.): 9. Names and addresses of all witnesses, hospital, doctors, etc: a. b. C. 10. Any additional information that might be helpful in considering this claim: Warning: It is a criminal offense to file a false claim! (Penal Code 72 /Insurance Code 556.1) 1 have read the matters and statements made in the above claim and I know the same to be true of my own knowledge, except as to those matters state upon information or belief as to such matters, I believe the same to be true. I certify under penalty of perjury that the foregoing is true and correct. Claimant's Signature J Date Agenda Item No. 5 Page 31 of 67 Attachment to Claim for Damaees to Real Propertv 2. Name, post office address and telephone to which claimant desires notices to be sent, if other than the above: All correspondence in this matter should be sent to claimant's attorney: Lori Guthrie, GRACE HOLLIS & HANSON LLP, 3555 Fifth Avenue, San Diego, CA 92103 3. Occurrence or event from which this claim arises: a. Date: The damage to claimant's property has been ongoing since the development and construction of surrounding properties, including but not limited to the Fairfield Development (Ridgestone Apartments) and the Centex and Lennar Developments (Rosetta Hills). b. Time: See response to question 3.a. above. c. Place (Exact and specific location): Claimant's property (address listed in response to question La.) has been harmed due to flooding caused by the development and construction of the properties listed in response to question 3.a. above. d. How many and under what circumstances did damage or injury occur? Specify the particular occurrences, event,, act or omission you claim caused the injury or damage (use additional paper if necessary). Water damage and flooding has occurred and affected several properties, including claimant's property, located below the Fairfield, Centex and Lennar Developments. Reckless and negligent acts of the City of Lake Elsinore caused the damage to claimant's property in that the City did not make provisions for, or require the Fairfield, Centex and Lennar developments to make provisions for, adequate drainage, landscaping and flood control. The resulting flooding and water damage has interfered with the use and enjoyment of claimant's property. e. What particular action by the City or its employees caused the alleged damage or injury? Reckless and negligent acts of the City of Lake Elsinore caused the damage to claimant's property in that the City did not makeprovisions for, or require the Fairfield, Centex and Lennar developments to make provisions for, adequate drainage, landscaping and flood control. 4. Were there any injuries at the time of the accident? If not, state "No injuries. Claimant is not alleging any personal injuries. Rather, claimant's real property has been damaged, and continues to be damaged, due to flooding and water damage as described above. Agenda Item No. 5 Page 32 of 67 Give the name(s) of the public employee(s) causing the injury, damage, or loss, if known. This information is unknown at this time. 6. Name and address of any person injured. Claimant is not alleging any personal injuries. Claimant's property, listed in response to question I .a., has been damaged, and continues to be damaged, as a result of the flooding and water damage described above. Name and address of the owner of any damaged property: See claimant's response to question 1. 9 Names and addresses ofall witnesses, hospital, doctors, etc.: No hospitals or doctors are involved in this claim as this is not a claim for personal injuries. Witnesses to the damages caused to claimant's property include: a. Mike and Lisa Matthews, Daniel and Dora c. Julio d. Virginia Sherfey e. Robert and Vivis f. Jim and Pam Esl g. Byron Quiroz,a h. Eduardo and Gla Agenda Item No. 5 Page 33 of 67 CITY OF ins LADE ?LSIHORE v DREAM May 15, 2008 Dwight Kunz Carl Warren & Company P.O. Box 25180 Santa Ana CA 92799 -5180 Dear Mr. Kunz: Enclosed for your handling is a claim received on May 9, 2008 from Lori Guthrie on behalf of Daniel Munoz (CL #2008 -17). Please keep me advised of appropriate City Council Action. For further assistance, please contact me at (951) 674 -3124 ext. 269. Sin CITY OF LAKE ELSINORE Enclosure 951.674.3124 130 S. MAIN STREET LAKE ELSINORE. CA 92530 W W W LAKE ELSINORE.ORG Agenda Item No. 5 Page 34 of 67 CITY OF DREAM EXTREME. CLAIM AGAINST THE CITY OF LAKE ELSINORE (For Dam to Persons or Personal Property) A claim must be filed with the City Clerk of the City of Lake Elsinore within six (6) months after the incident or event. occurred. Be sure your claim is against the City of Lake Elsinore, not another public entity. Where . space is insufficient, please use additional paper and identify information by paragraph number. Completed claims must be mailed or delivered to the City Clerk, City of Lake Elsinore, 130 South Main Street, Lake Elsinore, h n�eft MAY 0 u 2008 CITY CLERKS OFFICE The undersigned respectfully submits the following claim and information relative to damage to persons and /or personal property: 1. Name of Claim a. Address of b, Phone No. d. Social SeCL 2. Name, post offi the above: 3. Occurrence or event from which this claim arises: �'„ C� 4c� a. Date: b. Time: c. Place (Enact and specific.location) d. How many and under what circumstances did damage or injury occur? Specify the particular occurrences, event, act or omission you claim caused the injury or damage (use additional paper if necessary). e. What particular action by the City of its employees, caused the alleged damage or injury? Agenda Item No. 5 Page 35 of 67 a f e ddress and telephone to which claimant desires notices to be sent, if other than 4. Were there any injuries at the time of this accident? If not, state "No Injuries." awe_ " (-) hme � 5. Give the name(s) of the public employee(s) causing the injury, damage, or loss, if known. .�e ad a ah glen ,� 6. Name and address of any person injured: � v. C,(Ano l-) M en I 7. Name and address of the owner of any damaged property 8. Damages claimed: Sce cg4i ohI1 ►4 a. Amount claimed as of this date: $ P r. S b. Estimated amount of future costs: $ a. b. C. 10. c. Total amount claimed: $ iv \iv \ J ) d. Basis for computation of amounts claimed (include copies of all%ills, invoices, estimates, etc ): Names and addresses of all witnesses, hospital, doctors, etc: a-'f l Ofk%lohme n —+ Warning: It is a criminal offense to file a false claim! (Penal Code 72 /Insurance Code 556.1) 1 have read the matters and statements made in the above claim and I know the same to be true of my own knowledge, except as to those matters state upon information or belief as to such matters, I believe the same to be true. I certify under penalty of perjury that the foregoing is true and correct. Claimants Signature Date Agenda Item No. 5 Page 36 of 67 Any additional information that might be helpful in considering this claim: Attachment to Claim for Damages to Real Property 2. Name, post office address and telephone to which claimant desires notices to be sent, if other than the above: All correspondence in this matter should be sent to claimant's attorney: Lori Guthrie, GRACE HOLLIS & HANSON LLP, 3555 Fifth Avenue, San Diego, CA 92103 Occurrence or event from which this claim arises: a. Date: The damage to claimant's property has been ongoing since the development and construction of surrounding properties, including but not limited to the Fairfield Development (Ridgestone Apartments) and the Centex and Lennar Developments (Rosetta Hills). b. Time: See response to question 3.a. above. c. Place (Exact and specific location): Claimant's property (address listed in response to question l.a.) has been harmed due to flooding caused by the development and construction of the properties listed in response to question 3.a. above. d. How many and under what circumstances did damage or injury occur? Specify the particular occurrences, event, act or omission you claim caused the injury or damage (use additional paper if necessary). Water damage and flooding has occurred and affected several properties, including claimant's property, located below the Fairfield, Centex and Lennar Developments. Reckless and negligent acts of the City of Lake Elsinore caused the damage to claimant's property in that the City did not make provisions for, or require the Fairfield, Centex and Lennar developments to make provisions for, adequate drainage, landscaping and flood control. The resulting flooding and water damage has interfered with the use and enjoyment of claimant's property. e. What particular action by the City or its employees caused the alleged damage or injury? Reckless and negligent acts of the City of Lake Elsinore caused the damage to claimant's property in that the City did not make provisions for, or require the Fairfield, Centex and Lennar developments to make provisions for, adequate drainage, landscaping and flood control. 4. Were there any injuries at the time of the accident? If not, state "No injuries. " Claimant is not alleging any personal injuries. Rather, claimant's real property has been damaged, and continues to be damaged, due to flooding and water damage as described above. Agenda Item No. 5 Page 37 of 67 S. Give the name(s) of the public employee(s) causing the injury, damage, or loss, if known. This information is unknown at this time. 6 Name and address of any person injured: Claimant is not alleging an personal injuries. Claimant's property, listed in response to question l .a., has been damaged, and continues to be damaged, as a result of the flooding and water damage described above. Name and address of the owner of any damaged property: See claimant's response to question 1. 9 Names and addresses of all witnesses, hospital, doctors, etc.: No hospitals or doctors are involved in this claim as this is not a claim for personal injuries. Witnesses to the damages caused to claimant's property include: a. Mike and Lisa Matthews, b. Daniel and Dora b c. Julio Bustos d. Virginia Sherfey, e. Robert and Vivian f. Jim and Pam Eslin g. Byron Quiroz „= h. Eduardo and Glad Agenda Item No. 5 Page 38 of 67 CITY OF i/`n LADE L LSIHOPT u DREA May 15, 2008 Dwight Kunz Carl Warren & Company P.O. Box 25180 Santa Ana CA 92799 -5180 Dear Mr. Kunz: Enclosed for your handling is a claim received on May 9, 2008 from Lori Guthrie on behalf of Robert Balthrope (CL #2008 -18). Please keep me advised of appropriate City Council Action. For further assistance, please contact me at (951) 674 -3124 ext. 269. Sincerely, - — GA� CITY F LAKE ELSINORE Enclosure 951.674.3124 130 S. MAIN STREET LAKE ELSINORE, CA 92530 W W W LAKE - ELSI NO RE.ORG Agenda Item No. 5 Page 39 of 67 1 . CITY OF LA^� '(qLS DREAM EXTREME. CLAIM AGAINST THE CITY OF LAKE ELSINORE (For Damages-to Persons or Personal Property) Receive by: ( \� Clty e to �=', A claim must be filed with the City Clerk of the City of ake Elsinore within six (6) months after the incident or event occurred. Be sure your claim is MAY 0 9 �00(I l.� against the City of Lake Elsinore - , not another public entity. Where space is insufficient, lease use additional t--�� p paper and identify information by paragraph number. Completed claims must be mailed dkeretl to the CITY rye ER K S O FFI CE City Clerk, City of Lake Elsinore, 130 South Main Streetet La , Lake Elsinore, CA 92530. IV Il9'Ll.. The undersigned respectfully submits the following claim and information relative to damage to persons and /or Personal propertv: Name of Clairr a. Address of b. Phone No. d. Social Sect 2. Name, post office address and telephone to which claimant desires notices to be sent, if other than the above: 3. Occurrence or event from which this claim arises: �� L_ a. Date: c. Place (Exact and specific location) b. Time: d. How many and under what circumstances did damage or injury occur? Specify the particular occurrences, event, act or omission you claim caused the injury or damage (use additional paper if necessary). e. What particular action by the City of its employees, caused the alleged damage or injury? Agenda Item No. 5 Page 40 of 67 4. Were there any injuries at the time of this accident? If not, state "No Injuries." 5. Give the name(s) of the public employee(s) causing the injury, damage, or loss, if known. 6. Name and address of any person injured: 7. Name and address of the owner of any damaged property: 8. Damages claimed a. Amount claimed as of this date: $ Vn f `kb -q b. Estimated amount of future costs: $ —� c. Total amount claimed: $ 1 d. Basis for computation of amounts claimed (include copies of all @ills, invoices, estimates, etc.): i, I 9. Names and addresses of all witnesses, hospital, doctors, etc: �'tz ((j1 ,L a. a C. 10. Any additional information that might be helpful in considering this clai i 1 N I r\ n s, , l7 Warning: It is a criminal offense to file a false claim! (Penal Code 72 /Insurance Code 556.1) 1 have read the matters and statements made in the above claim and I know the same to be true of my own knowledge, except as to those matters state upon information or belief as to such matters, I believe the same to be true. I certify under penalty of perjury that the foregoing is true and correct. Glaimant's Signature Date Agenda Item No. 5 Page 41 of 67 Attachment to Claim for Damages to Real Property 2. Name, post office address and telephone to which claimant desires notices to be sent, if other.than the above: All correspondence in this matter should be sent to claimant's attorney: Lori Guthrie, GRACE HOLLIS & HANSON LLP, 3555 Fifth Avenue, San Diego, CA 92103 3. Occurrence or event from which this claim arises: a. Date: The damage to claimant's property has been ongoing since the development and construction of surrounding properties, including but not limited to the Fairfield Development (Ridgestone Apartments) and the Centex and Lennar Developments (Rosetta Hills). b. Time: See response to question 3.a. above. c. Place (Exact and specific location): Claimant's property (address listed in response to question La.) has been harmed due to flooding caused by the development and construction of the properties listed in response to question 3.a. above. d. How many and under what circumstances did damage or injury occur? Specify the particular occurrences, event, actor omission you claim caused the injury or damage (use additional paper if necessary). Water damage and flooding has occurred and affected several properties, including claimant's property, located below the Fairfield, Centex and Lennar Developments. Reckless and negligent acts of the City of Lake Elsinore caused the damage to claimant's property in that the City did not make provisions for, or require the Fairfield, Centex and Lennar developments to make provisions for, adequate drainage, landscaping and flood control. The resulting flooding and water damage has interfered with the use and enjoyment of claimant's property. e. What particular action by the City or its employees caused the alleged damage or injury? Reckless and negligent acts of the City of Lake Elsinore caused the damage to claimant's property in that the City did not make provisions for, or require the Fairfield, Centex and Lennar developments to make provisions for, adequate drainage, landscaping and flood control. 4. Were there any injuries at the time of the accident? If not, state "No injuries. " Claimant is not alleging any personal injuries. Rather, claimant's real property has been damaged, and continues to be damaged, due to flooding and water damage as described above. Agenda Item No. 5 Page 42 of 67 Give the name(s) of the public employee(s) causing the injury, damage, or loss,'ifknown. This information is unknown at this time. 6. Name and address of any person injured. Claimant is not alleging any personal injuries. Claimant's property, listed in response to question l .a,. lids been damaged, and continues to be damaged, as a result of the flooding and water damage described above. Name and address of the owner of any damaged property. See claimant's response to question 1. 9 Names and addresses of all witnesses, hospital, doctors, etc.. No hospitals or doctors are involved in this claim as this is not a claim for personal injuries, Witnesses to the damages caused to claimant's property include: a. Mike and Lisa Matthews, b. Daniel and Dora Munoz, c. Julio is Sh e d. Virginia Shrfey, e. Robert and Vivian Balthro e f. Jim and Pam Eslineer. g. Byron Quiroz,� h. Eduardo and Gladys Hincjosa, Agenda Item No. 5 Page 43 of 67 CITY OF i�� LADE LSINORE DREAM EXTREME May 15, 2008 Dwight Kunz Carl Warren & Company P.O. Box 25180 Santa Ana CA 92799 -5180 Dear Mr. Kunz: Enclosed for your handling is a claim received on May 9, 2008 from Lori Guthrie on behalf of Vivian Balthrope (CL #2008 -19). Please keep me advised of appropriate City Council Action. For further assistance, please contact me at (951) 674 -3124 ext. 269. Sincerely, CITY OF LAKE ELSINORE Enclosure 951.674.3124 130 S. MAIN STREET LAKE ELSINORE, CA 92530 W W W. LAKE- E LS] NORE.ORG T Agenda Item No. 5 Page 44 of 67 CITY OF by: DREAM EXTREmEn CLAIM AGAINST THE CITY OF LAKE ELSINORE (For Dam to Persons or Personal Property) A claim must be filed with the City Clerk of the City of Lake, Elsinore within six (6) months after the incident or event occurred. Be sure your claim is against the City of Lake Elsinore, not another public entity. Where space is insufficient, please use additional paper and identify information by paragraph number. Completed claims must be mailed or delivered to the City Clerk, City of Lake Elsinore, 130 South Main Street, Lake Elsinore, R I! V-1) M` MAY Q 9 200E 0 CITY CLERKS OF FICE The undersigned respectfully submits the following claim and information relative to damage to persons and /or personal property: 1. Name of Clain a. Address of b. Phone No. d. Social Sect 2. 3. Name, post office address and telephone to which claimant desires notices to be sent, if other than the above: Occurrence or event from which this claim arises: a. Date: b. Time: c. Place (Exact and specific location) d. How many and under what circumstances did damage or injury occur? Specify the particular occurrences, event, act or omission you claim caused the injury or damage (use additional paper if necessary). e. What particular action by the City of its employees, caused the alleged damage or injury? Agenda Item No. 5 Page 45 of 67 4. Were there any injuries at the time of this accident? If not, state "No Injuries." 5. Give the name(s) of the public employee(s) causing the injury, damage, or loss, if known. 6. Name and address of any person injured: 7. Name and address of the owner of any damaged 91 G Damages claimed: a. Amount claimed as of this date: b. Estimated amount of future costs: c. Total amount claimed: $ $ d. Basis for computation of amounts claimed (include copies of aAills, invoices, estimates, etc.): Names and addresses of all witnesses, hospital, doctors, etc Jl._ a. 3 C. 10. Any additional information that might be�helpful in considering this claim: Warning: It is a criminal offense to file a false claim! (Penal Code 72 /Insurance Code 556.1) 1 have read the matters and statements made in the above claim and I know the same to be true of my own knowledge, except as to those matters state upon information or belief as to such matters, I believe the same to be true. I certify under penalty of perjury that the foregoing is true and correct. o a cv D - J� z�_O— q— i a aog Claimant's <Signature I Date Agenda Item No. 5 Page 46 of 67 Attachment to Claim for Damaees to Real Property 2. Name, post office address and telephone to which claimant desires notices to be sent, if other than the above: All correspondence in this matter should be sent to claimant's attorney: Lori Guthrie, GRACE HOLLIS & HANSON LLP, 3555 Fifth Avenue, San Diego, CA 92103 3. Occurrence or event from which this claim arises: a. Date: The damage to claimant's property has been ongoing since the development and construction of surrounding properties, including but not limited to the Fairfield Development (Ridgestone Apartments) and the Centex and Lennar Developments (Rosetta Hills). b. Time: See response to question 3.a. above. c. Place (Exact and specific location): Claimant's property (address listed in response to question La.) has been harmed due to flooding caused by the development and construction of the properties listed in response to question 3.a. above. d. How many and under what circumstances did damage or injury occur? Specify the particular occurrences, event, act or omission you claim caused the injury or damage (use additional paper if necessary). Water damage and flooding has occurred and affected several properties, including claimant's property, located below the Fairfield, Centex and Lennar Developments. Reckless and negligent acts of the City of Lake Elsinore caused the damage to claimant's property in that the City did not make provisions for, or require the Fairfield, Centex and Lennar developments to make provisions for, adequate drainage, landscaping and flood control. The resulting flooding and water damage has interfered with the use and enjoyment of claimant's property. e. What particular action by the City or its employees caused the alleged damage or injury? Reckless and negligent acts of the City of Lake Elsinore caused the damage to claimant's property in that the City did not make provisions for, or require the Fairfield, Centex and Lennar developments to make provisions for, adequate drainage, landscaping and flood control. 4. Were there any injuries at the time of the accident? If not, state "No injuries. " Claimant is not alleging any personal injuries. Rather, claimant's real property has been damaged, and continues to be damaged, due to flooding and water damage as described above. Agenda Item No. 5 Page 47 of 67 S. Give the name(s) of the public employee(s) causing the injury, damage, or loss, if known. This information is unknown at this time. 6. Name and address of any person injured: Claimant is not alleging any personal injuries. Claimant's property, listed in response to question I .a., has been damaged, and continues to be damaged, as a result of the flooding and water damage described above. 7. Name and address of the owner of any damaged property. See claimant's response to question 1. 9 Names and addresses ofall witnesses, hospital, doctors, etc.. No hospitals or doctors are involved in this claim as this is not a claim for personal injuries. Witnesses to the damages caused to claimant's property include: a. Mike and Lisa Matthews, b. Daniel and Dora Munoz, c. Julio Bustos d. Virginia Sherfey, e. Robert and Vivian Balthro e f. Jim and Pam Eslin or g. Byron Quiroz, h. Eduardo and Gladys Hinojosa, Agenda Item No. 5 Page 48 of 67 CITY OF ^ LADE LSINORI DREAM May 15, 2008 Dwight Kunz Carl Warren & Company P.O. Box 25180 Santa Ana CA 92799 -5180 Dear Mr. Kunz: Enclosed for your handling is a claim received on May 9, 2008 from Lori Guthrie on behalf of Byron Quiroz (CL #2008- 20). Please keep me advised of appropriate City Council Action. For further assistance, please contact me at (951) 674 -3124 ext. 269. Sincerely, CITY OF LAKE ELSINORE Enclosure 951.674.3124 130 S. MAIN STREET LAKE ELSINORE, CA 92530 W W W. LAKE- ELS INORE.ORG Agenda Item No. 5 Page 49 of 67 CITY OF DREAM EXTREME. CLAIM AGAINST THE CITY OF LAKE ELSINORE (For Damages to Persons or Personal Property) by: A claim must be filed with the City Clerk of the City of Lake Elsinore within six (6) months after the incident or event occurred. ae sure your. claim is against the City of Lake Elsinore, not another public entity. Where space is insufficient, please use additional paper and identify information by paragraph number. Completed claims must be mailed or delivered to the City Clerk, City of Lake Elsinore, 130 South Main Street, Lake Elsinore, �. � l ' r U l'l MAY 0 9 2000 u CITY CLERKS OFFICE The undersigned respectfully submits the following claim and information relative to damage to persons and /or personal property: 1. Name of Cla a. Address b. Phone N d. Social Se 2. Name, post office _address and telephone to which claimant desires notices to be sent, if other than the above: , - ]Pp 044fic VAV" PYlA-- 3. Occurrence or event from which this claim arises: � G.kr >wwr )4 a. Date: b. Time c. Place (Exact and specific location) d. How many and under what circumstances did damage or injury occur? Specify the particular occurrences, event, act or omission you claim caused the injury or damage (use additional paper if necessary). e. What particular action by the City of its employees, caused the alleged damage or injury? Agenda Item No. 5 Page 50 of 67 4. Were there any injuries at the time of this accident? If not, state "No Injuries." 5. Give the name(s) of the public employee(s) causing the injury, damage, or loss, if known. a'e ( ae lumen 6. Name and address of any person injured: 9�e Gl. oahmon4- 7. Name and address of the owner of any damaged property: 8. Damages claimed: See O/ Oc lveM a. Amount claimed as of this date: b. Estimated amount of future costs: �i c. Total amount claimed: $ .,`,` t ; asa\ )� d. Basis for computation of amounts claimed (include copies of all\bills, invoices, estimates, etc.): 9. Names and addresses of all witnesses, hospital, doctors, etc: A J o a. b. C. 10. Any additional information that might be he in considering this claim: Warning: It is a criminal offense to file a false claim! (Penal Code 72 /Insurance Code 556.1) 1 have read the matters and statements made in the above claim and I know the same to be true of my own knowledge, except as to those matters state upon information or belief as to such matters, I believe t e same to be true. I certify under penalty of perjury that the foregoing is true and correct. c Claimant's ig, ature Date Agenda Item No. 5 Page 51 of 67 Attachment to Claim for Damages to Real Property 2. Name, post office address and telephone to which claimant desires notices to be sent, if other than the above: All correspondence in this matter should be sent to claimant's attorney: Lori Guthrie, GRACE HOLLIS & HANSON LLP, 3555 Fifth Avenue, San Diego, CA 92103 3. Occurrence or event from which this claim arises: a. Date: The damage to claimant's property has been ongoing since the development and construction of surrounding properties, including but not limited to the Fairfield Development (Ridgestone Apartments) and the Centex and Lennar Developments (Rosetta Hills). b. Time: See response to question 3.a. above. c. Place (Exact and specific location): Claimant's property (address listed in response to question La.) has been harmed due to flooding caused by the development and construction of the properties listed in response to question 3.a. above. d. How many and under what circumstances did damage or injury occur? Specify the particular occurrences, event, act or omission you claim caused the injury or damage (use additional paper if necessary). Water damage and flooding has occurred and affected several properties, including claimant's property, located below the Fairfield, Centex and Lennar Developments. Reckless and negligent acts of the City of Lake Elsinore caused the damage to claimant's property in that the City did not make provisions for, or require the Fairfield, Centex and Lennar developments to make provisions for, adequate drainage, landscaping and flood control. The resulting flooding and water damage has interfered with the use and enjoyment of claimant's property. e. What particular action by the City or its employees caused the alleged damage or injury? Reckless and negligent acts of the City of Lake Elsinore caused the damage to claimant's property in that the City did not make provisions for, or require the Fairfield, Centex and Lennar developments to make provisions for, adequate drainage, landscaping and flood control. 4. Were there any injuries at the time of the accident? If not, state "No injuries. " Claimant is not alleging any personal injuries. Rather, claimant's real property has been damaged, and continues to be damaged, due to flooding and water damage as described above. Agenda Item No. 5 Page 52 of 67 5. Give the name(s) of the public employee(s) causing the injury, damage, or loss, if known. This information is unknown at this time. 6 Name and address ofany person injured: Claimant is not alleging any personal injuries. Claimant's property, listed in response to question l .a., has been damaged, and continues to be damaged, as a result of the flooding and water damage described above. Name and address of the owner of any damaged property. See claimant's response to question 1. 9 Names and addresses ofall witnesses, hospital, doctors, etc.: No hospitals or doctors are involved in this claim as this is not a claim for personal injuries. Witnesses to the damages caused to claimant's property include: a. Mike and Lisa Matthews. b. Daniel and Dora N c. Julio Bustos d. Virginia Sherfey, e. Robert and Vivian f. Jim and Pam Eslin g. Byron Quiroz,� h. Eduardo and Gladys Hincjosa, Agenda Item No. 5 Page 53 of 67 CITY OF i LADE LSII`LOI�E u DREA May 15, 2008 Dwight Kunz Carl Warren & Company P.O. Box 25180 Santa Ana CA 92799 -5180 Dear Mr. Kunz: Enclosed for your handling is a claim received on May 9, 2008 from Lori Guthrie on behalf of Gladys Hinojosa (CL #2008 -21). Please keep me advised of appropriate City Council Action. For further assistance, please contact me at (951) 674 -3124 ext. 269. Sincerely, 4 SI A GUZ AN, Fic CITY OF LAKE ELSINORE Enclosure 951.674.3124 130 S. MAIN STREET LAKE ELSINORE. CA 92530 WWW LAKE- ELSI NORE.ORG Agenda Item No. 5 Page 54 of 67 CITY OF LADE DREAM E,?lTUME. CLAIM AGAINST THE CITY OF LAKE ELSINORE (For Damages to Persons or Personal Property) Received A claim must be filed with the City Clerk of the City of Lake Elsinore within six (6) months after the incident or event occurred. Be sure your claim is against the City of Lake Elsinore, not another public entity. Where space is insufficient, please use additional. paper and identify information by paragraph number. Completed claims must be mailed or delivered to the City Clerk, City of Lake Elsinore, 130 South Main Street, Lake Elsinore, D It V e MAY 0 9 ZQ9J8 1, CITY CLERKS OFFICE The undersigned respectfully submits the following claim and information relative to damage to persons and /or personal property: (' ` Til 1. NameofClaimant (:An vc' l ")f'aK'a a. Address of b. Phone No. A Social Security No. c. Date of Birth e. Drivers Lid. 2. Name, post office address and telephone to which claimant desires notice o be sent, if other the above: 3. Occurrence or event from which this claim arises. (,,;) P t l; .. t__I, a. Date: t kv t vin b. Time c. Place (Exact and specific L'�-Ac:1 r k 1dP_ d. How many and under what circumstances did damage or injury occur? Specify the particular occurrences, event, a or omission you claim caused the injury or damage (use additional paper if necessary). h wll.\\ r _ �l� a v1r1 e. hat particular action by the City of Its employees, caused the alleged damage or injury? 1�V�P.?�_ -D ���l��ti� �i Ji "f '�I��tf'. ol. Agenda Item No. 5 Page 55 of 67 4. Were there any injuries at the time of this accident? If not, state "No Injuries." krl tz \ v 5. Give th name(s) of the public emplo .ee(s) causing the injury, damage, or loss, if known. L��� «C�UU�vJ ✓� 6. Name and address of any person injured: 7. Name and address of the owner of any damaged property: 1 8. Damages claimed a. Amount claimed as of this date: $ i Is* b. Estimated amount of future costs: $ tid'u :v 7/1 o. Total amount claimed: $ �� � d. Basis for computation of amounts claimed (include copies of all bills, invoices, estimates, etc.): 9. Names and addresses of all witnesses, hospital, doctors, etc: a. b. C. 10. Any additional information that might be he ; Pul in considering this claim: Warning: It is a criminal offense to file a false claim! (Penal Code 72 /Insurance Code 556.1) 1 have read the matters and statements made in the above claim and I know the same to be true of my own knowledge, except as to those matters state upon information or belief as to such matters, I believe the same to be true. I certify under penalty of perjury that the foregoing is true and correct. I mant's Signature Date Agenda Item No. 5 Page 56 of 67 Attachment to Claim for Damages to Real Property 2. Name, post office address and telephone to which claimant desires notices to be sent, if other than the above: All correspondence in this matter should be sent to claimant's attorney: Lori Guthrie, GRACE HOLLIS & HANSON LLP, 3555 Fifth Avenue, San Diego, CA 92103 3. Occurrence or event from which this claim arises: a. Date: The damage to claimant's property has been ongoing since the development and construction of surrounding properties, including but not limited to the Fairfield Development (Ridgestone Apartments) and the Centex and Lennar Developments (Rosetta Hills). b. Time: See response to question 3.a. above. c. Place (Exact and specific location): Claimant's property (address listed in response to question La.) has been harmed due to flooding caused by the development and construction of the properties listed in response to question 3.a. above. d. How many and under what circumstances did damage or injury occur? Specify the particular occurrences, event, act or omission you claim caused the injury or damage (use additional paper if necessary). Water damage and flooding has occurred and affected several properties, including claimant's property, located below the Fairfield, Centex and Lennar Developments. Reckless and negligent acts of the City of Lake Elsinore caused the damage to claimant's property in that the City did not make provisions for, or require the Fairfield, Centex and Lennar developments to make provisions for, adequate drainage, landscaping and flood control. The resulting flooding and water damage has interfered with the use and enjoyment of claimant's property. e. What particular action by the City or its employees caused the alleged damage or injury? Reckless and negligent acts of the City of Lake Elsinore caused the damage to claimant's property in that the City did not make provisions for, or require the Fairfield, Centex and Lennar developments to make provisions for, adequate drainage, landscaping and flood control. 4. Were there any injuries at the time of the accident? If not, state "No injuries. " Claimant is not alleging any personal injuries. Rather, claimant's real property has been damaged, and continues to be damaged, due to flooding and water damage as described above. Agenda Item No. 5 Page 57 of 67 5. Give the name(s) of the public employee(s) causing the injury, damage, or loss, if known. This information is unknown at this time. 6. Name and address of any person injured. Claimant is not alleging any personal injuries. Claimant's property, listed in response to question La., has been damaged, and continues to be damaged, as a result of the flooding and water damage described above. 7. Name and address of the owner of any damaged property. See claimant's response to question 1. 9 Names and addresses of all witnesses, hospital, doctors, etc.. No hospitals or doctors are involved in this claim as this is not a claim for personal injuries. Witnesses to the damages caused to claimant's property include: a. Mike and Lisa Matthews, b. Daniel and Dora Munoz, c. Julio Bustos d. Virginia Sher fey, e. Robert and Vivian Balthro e f Jim and Pam Eshruxer. g. Byron Quiroz,� h. Eduardo and Gladys Hinojosa, Agenda Item No. 5 Page 58 of 67 CITY C LADE LSIHOKE \�? DREAM EXTREME May 15, 2008 Dwight Kunz Carl Warren & Company P.O. Box 25180 Santa Ana CA 92799 -5180 Dear Mr. Kunz: Enclosed for your handling is a claim received on May 9, 2008 from Lori Guthrie on behalf of Eduardo Hinojosa (CL #2008 -22). Please keep me advised of appropriate City Council Action. For further assistance, please contact me at (951) 674 -3124 ext. 269. Sincerely, Enclosure 951.674.3124 130 S. MAIN STREET LAKE ELSINORE, CA 92530 WWW LAKE -E LS INORE.ORG Agenda Item No. 5 Page 59 of 67 CITY OF DREAM EXTREME. CLAIM AGAINST THE CITY OF LAKE ELSINORE (For Damages to Persons or Personal Prooertv) by: A claim must be fled with the City Clerk of the City of Lake Elsinore within six (6) months after the incident or event occurred.. Be sure your claim is against the City of Lake Elsinore, not another public entity. Where space is insufficient, please use additional paper and identify information by paragraph number. Completer) claims must be mailed or delivered to the City Clerk, City of Lake Elsinore, 130 South Main Street, Lake Elsinore, RGITM- TV 5 0 0 MAY 0 9 2000 CITY CLER OFFICE The undersigned respectfully submits the following claim and information relative to damage to persons and /or personal property: 1. Name of Claimant a. Address of Claimal b. Phone No.. d. Social Security No. c. Date of Birth e. Drivers Lic. No. 2. Name, post office address and telephone to which claimant desires notices to be sent, if other than the above: 3. Occurrence or event from which this claim arises: a. Date: c. Place (Exact and specific location) b. Time- d. How many and under what circumstances did damage or injury occur? Specify the particular occurrences, event, act or omission you claim caused the injury or damage (use additional paper if necessary). e. What particular action by the City of its employees, caused the alleged damage or injury? Agenda Item No. 5 Page 60 of 67 4. Were there any injuries at the time of this accident? If not, state "No Injuries." 5. Give the name(s) of the public employee(s) causing the injury, damage, or loss, if known. l �L (I � 6. Name and address of any person injured: 7. Name and address of the owner of any damaged property: 8. Damages claimed: r a. Amount claimed as of this date: $ b. Estimated amount of future costs: $ c. Total amount claimed: d. Basis for computation of amounts claimed (include copies of all bil invoices, estimates, etc.): 9. Names and addresses of all witnesses, hospital, doctors, etc: a. b. C. 10. Warning: It is a criminal offense to file a false claim! (Penal Code 72 /Insurance Code 556.1) 1 have read the matters and statements made in the above claim and I know the same to be true of my own knowledge, except as to those matters state upon information or belief as to such matters, I believe the same to be true. I certify under enalty of perjury that the foregoing is true and correct. Claimant's Signature Date Agenda Item No. 5 Page 61 of 67 Attachment to Claim for Damaees to Real Property 2. Name, post office address and telephone to which claimant desires notices to be sent, if other than the above: All correspondence in this matter should be sent to claimant's attorney: Lori Guthrie, GRACE HOLLIS & HANSON LLP, 3555 Fifth Avenue, San Diego, CA 92103 3. Occurrence or event from which this claim arises: a. Date: The damage to claimant's property has been ongoing since the development and construction of surrounding properties, including but not limited to the Fairfield Development (Ridgestone Apartments) and the Centex and Lennar Developments (Rosetta Hills). b. Time: See response to question 3.a. above. c. Place (Exact and specific location): Claimant's property (address listed in response to question La.) has been harmed due to flooding caused by the development and construction of the properties listed in response to question 3.a. above. d. How many and under what circumstances did damage or injury occur? Specify the particular occurrences, event, act or omission you claim caused the injury or damage (use additional paper if necessary). Water damage and flooding has occurred and affected several properties, including claimant's property, located below the Fairfield, Centex and Lennar Developments. Reckless and negligent acts of the City of Lake Elsinore caused the damage to claimant's property in that the City did not make provisions for, or require the Fairfield, Centex and Lennar developments to make provisions for, adequate drainage, landscaping and flood control. The resulting flooding and water damage has interfered with the use and enjoyment of claimant's property. e. What particular action by the City or its employees caused the alleged damage or injury? Reckless and negligent acts of the City of Lake Elsinore caused the damage to claimant's property in that the City did not make provisions for, or require the Fairfield, Centex and Lennar developments to make provisions for, adequate drainage, landscaping and flood control. 4. Were there any injuries at the time of the accident? If not, state "No injuries. " Claimant is not alleging any personal injuries. Rather, claimant's real property has been damaged, and continues to be damaged, due to flooding and water damage as described above. Agenda Item No. 5 Page 62 of 67 S. Give the name(s) of the public employee(s) causing the injury, damage, or loss, if known. This information is unknown at this time. 6. Name and address of any person injured: Claimant is not alleging any personal injuries. Claimant's property, listed in response to question l .a., has been damaged, and continues to be damaged, as a result of the flooding and water damage described above. 7. Name and address of the owner of any damaged property: See claimant's response to question 1. 9 Names and addresses of all witnesses, hospital, doctors, etc.: No hospitals or doctors are involved in this claim as this is not a claim for personal injuries. Witnesses to the damages caused to claimant's property include: a. Mike and Lisa Matthews, b. Daniel and Dora Munoz, _ c. Julio Bustos d. Virginia Sherfey, e. Robert and Vivian Balthro e f Jim and Pam Eshn er g. Byron Quiroz, h. Eduardo and Gladys Hinojosa, Agenda Item No. 5 Page 63 of 67 February 3, 2009 RECEIVED TO: The City of Lake Elisinore ATTENTION: Jessica Guzman, Office of the City Clerk RE: Claim Claimant D/Event Rec'd Y /Office Our File Johnson v Lake Elsinore Donald Johnson 12/10/08 01/14/09 1490134 DBQ FEB 0 9 CITY CLERKS OFFICE We have reviewed the above captioned claim and request that you take the action indicated below: • CLAIMREIECTION: Send a standard rejection letter to the claimant. Please provide us with a copy of the notice sent, as requested above. If you have any questions please contact the undersigned. Very truly yours, CARL WARREN & COMPANY DebIr / Been CARL WARREN & CO. CLAIMS MANAGEMENT•CLAIMS ADJUSTERS 770 Placentia Avenue, Placentia, CA 92870 -6832 Mail: P.O. Box 25180 • Santa Ana, Ca 92799 -5180 Phone: (714) 572 -5200 . (800) 572 -6900 • Fax: (714) 961-8131 Agenda Item No. 5 Page 64 of 67 CITY OF LADE 10 LSI� O1ZE DREAM EXTREME January 16, 2009 Dwight Kunz Carl Warren & Company P.O. Box 25180 Santa Ana CA 92799 -5180 Dear Mr. Kunz: Enclosed for your handling is a claim received on January 14, 2009 from Donald Johnson (CL #2009 -3). Please keep me advised of appropriate City Council Action. For further assistance, please contact me at (951) 674 -3124 ext. 269. Sincerely, ((�A GUZI OF LAKE Enclosure 951.674.3124 130 S. MAIN STREET LAKE ELSINORE, CA 92530 W W W.LAKE -EL$I NORLORG Agenda Item No. 5 Page 65 of 67 CITY OF LADE LSINOR E DREAM EXTREME. CLAIM AGAINST THE CITY OF LAKE ELSINORE to Persons or Personal Property) Receive by: i Time /Date Received 'rty'�Rep es t RECEIVED A claim must be filed with the City Clerk'bf the_�ity Lak F� More within six (6) months after the incident or event occurred. Be sure your claim is s against the City of Lake Elsinore, not another public entity. Where space is JAN 1 '_ insufficient, please use additional paper and identify information by paragraph number. Completed claims must be mailed or delivered to the City Clerk, City of Lake Elsinore, 130 South Main Street, Lake Elsinore, CITY CLERICS OFFICE CA 92530. The undersigned respectfully submits the following claim and information relative to damage to persons and /or personal property: 1. Name of Claimant _Awwz-/) T liu sr o/ a. Address b. Phone N d. Social Security No. e. Drivers Lic. No. 2. Name, post office address and telephone to which claimant desires notices to be sent, if other than the above: GdZ2 �Fl ez Cs�KEc�s C 4 3. Occurrence or event from which this claim arises: a. Date: _ A c - tZ ao�� b. Time: C t o 6 /� c. Place (Exact and specific location) 1 d. How many and under what circumstances did damage or injury occur? Specify the particular occurrences, event, act or omission you claim caused the injury or damage (use additional Paper if necessary). e. What particular action by the City of its employees, caused the alleged damage or injury? Agenda Item No. 5 Page 66 of 67 4. Were there any injuries at the time of this accident? If not, state "No Injuries." /VO 5. Give the name(s) of the public employee(s) causing the injury, damage, or loss, if known. 6. Name and address of any person injured: 7. Name and address of the owner of any damaged property: S 696 sz� E -/z GR / r,u� o�� 8. Damages claimed: a. Amount claimed as of this date: $ b. Estimated amount of future costs: $ c. Total amount claimed: $ V —' d. Basis for computation of amounts claimed (include copies of all bills, invoices, estimates, etc.): 9. Names and addresses of all witnesses, hospital, doctors, etc: a. C. 10. Any additional information that might be helpful in considering this claim: Warning: It is a criminal offense to file a false claim! (Penal Code 72 1Insurance Code 556.1) 1 have read the matters and statements made in the above claim and I know the same to be true of my own knowledge, except as to those matters state upon information or belief as to such matters, I believe the same to be true. I certify under penalty of perjury that the foregoing is true and correct. I �Wa /�, - r�Soz /— Claimant's Signature Date Agenda Item No. 5 Page 67 of 67