HomeMy WebLinkAboutItem No.5REPORT TO CITY COUNCIL,
TO: MAYOR & CITY COUNCIL
FROM: RON MOLENDYR, CITY MANAGER
DATE: June S. 1993
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.
-The following claim has been recommended for rejection by Carl
Warren & Company:
Claim 193 -9 - Virginia Uscanga
FISCAL IMPACT
None..
RECOMMENDATION - -
Reject the Claim listed above and direct the City Clerk to send a
letter informing the Claimant of this decision.
I
PREPARED BY:,
VICKI CITY CLERK
-APPROVED FOR
AGENDA LISTING.
MOUMYK, CITY MANAGER
AGENDA ITEM NO. 5
PAGE I OF 3
�i CLAIM AGAINST THE CITY OF LAKE ELSINORE
(For Damages to Persons or Personal Property)
4-P. (/) L/2.
Received By.
41S1q�
t{; co fry)
(Time /Date Received)
0 A claim must be filed with the City Clerk of the City of Lake Elsinore
thin six (6) months after which 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, California 92330.
TO THE HONORABLE MAYOR AND CITY COUNCIL, CITY OF LAKE ELSINORE, CALIFORNIA:
The undersigned respectfully submits the following claim and information
relative to damage to persons and /or personal property:
1. NAME OF
a. Addre
b. Phone No. ( �(a oZy c. Date of Birth
d. Social ,Security No.�5 (nR- M- _P)2r-jL. Drivers Lio. No.
2. Name, post office address and telephone to which claimant desires notices
to be sent, if other than the above:
L n u.e.,
3. Occurrence or event from which this claim arises:
a. Date �' 1 b. Time
ac� � Tyr` IT'
c. Place (Exact and specific location), L+Aic& Cl5;goVL
g1
v
How and under what circumstances did damage or 'injury occur? Specify
the particular occurrence, event, act or omission you claim caused the
injury or damage (use additional paper if necessary).
e. ,What particular action by the City or its employees, caused t2� •,
alleged damage or injury?
Y
i�
AGENDA ITEM NO.
PAGE Q OF 3
4.''-Were there any injuries at the time of this incident? if
there were no injuries, state "No Injuries ".
5. Give the name(s) of the City employee(s) causing the
damage or injury:
i
6. Name and adpress of aq other person injured:
7. Name and address of the owner of any damaged property:
-- 8. 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 all bills, invoices, estimates, etc):
9. Names and addresses of all witnesses, hospitals, doctors,
etc:
r c;
a. �/ r1 i:'hn6Jt1.0
b. h C IA r eaz Q t. Z w UA ; "IA&o
c. lc�wk -e.� o�Q�nc u_ nnor. th T.rLr�oA \/r, Ki r�i;
10. Any addit o al of rmation that might be helpful In
considering this �claim:
b /l h Q V Ct,
lil WARNING: IT IS A CRIMINAL OFFENSE TO FILE A FALSE CLAIM!
(Penal Code 72 /Insurance Code 556.1)
I 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 stated 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.
SIGNED THIS L�_DAY OF 1 ` 1990? AT , 6-4;L PM
rJVS t1G ; nore , CALIFORNIA.
CLAIMANT'S SIGNATURE:
- _
.............. _
>s
,r
ApENDA ITEM NO. .
PAGE 3 OF-1.