HomeMy WebLinkAboutItem No. 4REPO
TO:
"FROM
DATE:
SUBJECT:;
M., on
j
RT TO CITY COUNCIL --
MAYOR & CITY COUNCIL
RON MOLENDYE, CITY MANAGER
October 26, 1993' `
Claims Against the City.
Claims filed against the City of Lake, Elsinore are 'reviewed and
handled by Carl Warren & Company, Claims Administrators. When
received, ea ' ch claim is logged in the City,kClerkfs-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 -18 - Arthur Fernandez, Jr.
FISCAL IMPACT
None. c
RECOMMENDATM1'
Reject the Claim listed above and ,direct` the „City Clerk to send
letter informing the�Claimant of this decision.
PREPARED BY;
APPROVED FO]
AGENDA LI:
AGENDA ITEM Sa. - •�
FA3E �L 6F--g-
M AGAINST THE CITY OF LAKE ELSINORE O`
Damages to Persons or Personal Property) SEP 2 'jyaj
ived By �... - --- --- - - - -- _
(Name) (Time /Date Received)
claim must be filed with the City Clerk of the City of Lake Elsinore
ithin six (6) months after which the incident or event occurred. Be sure
our claim is against the City of Lake Elsinore, not another public entity.
here space is insufficient, please use additional paper and identify
{nformation by paragraph number. Completed claims must be mailed or
slivered to the City Clerk, City of Lake Elsinore, 130 south Main Street,
,ake Elsinore, California 92330.
THE HONORABLE MAYOR AND CITY COUNCIL, CITY OF LAKE ELSINORE, CALIFORNIA:
undersigned respectfully submits the following claim and information
tive to damage to persons and /or personal property:
NAME OF CLAIMANT m r-mur t-f rna nriez. J f
a. Address.of Claimant 33ayD Lk_)1r-J�7ee Ave •
b. Phone No. &q)LP]q -981e) c. Date of Birth
d. Social Security No. 5 9 -35 -39- lore. Drivers Lic. No. V-7o l q 30q
Name, post office-'address and telephone to which claimant desires notices`
to be sent, if other than the above:
NSA
Occurrence or event from which this claim arises:
a. Date Ai - , S) I �U b. Time q: DO GL• M )) rr
c. Place
l (Exact and specific location) ' 4 44y)r _ ► .� ye� 1041 ELI) kMPA
I �,j, � n� ����..� ��c 1vin rP- PLI IA)/VIAG
d. 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 the
alleged damage or injury ?.
Igo
5i4 as a-P Lrq kind _,err .pos W
OF
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:
n 1 _
6. Name and address of any other person in7urea:
K, la
7. Name and address of the owner of any damaged property:
.. 1 11 _ _ _ . I) A 1
Damages Claimed: a
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 xitu-sAM, hospitals, doctors,
etc:
a
b.
-_ D-S43
C.
10. Any additional information that might be helpful in
considering this claim:
A:ARNINC: IT I£ A CRIMINAL OFFENSE TO FILE A FALSE CLAIM!
(Penal Code 72 /Insurance Code 556.1)
I have read the matters and statements m
and I know the same to be true of my own
to those matters stated upon information
matters, I believe the same to be true.
penalty of perjury that the foregoing // is
h�
SIGNED THIS�DAY OF , 19"l3
rtL��raS"E wa/
ids in the above claim
knowledge, except as
or belief as to such
I certify under
TRUE AND CORRECT.
AT Q ��
M016
17EM NO.4
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AGENDA t'EM. FAO.
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Tige Boats Of So. California 01777
12158 Severn Way
Riverside, CA 92503
(909) 737 -9801
RkPLF RM TERMS • NET CASH
NO GOODS HELD OVER 30 DAYS
4545°,4P45j POLY PAK (50:i7 5; ,
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