11-G
TO:Honorable Mayor and Members of the City Council
ATTENTION:Jeffrey L. Stewart, City Manager
FROM:Susan Crumly, Human Resources and Risk Manager
SUBJECT:Consideration and possible action to receive and file denial of a claim submitted by Irma Rodriguez.
DATE:January 24, 2022
EXECUTIVE SUMMARY
Ms.Irma Rodriguez filed a claim for the tree branch that fell on her vehicle causing scratches.The location of the alleged incident occurred on Cerritos Avenue in Bellflower.
Carl Warren & Company denied the claim on the City’s behalf. No further action is required by the City.
RECOMMENDATION TO CITY COUNCIL
1)Receive and file denial of claim submitted by Irma Rodriguez;or 2)Alternatively, discuss and take other action related to this item.
FISCAL IMPACT
None
ATTACHMENTS
Claim from Irma Rodriguez.…………………………………….........................................2 Denial of Claim from Irma Rodriguez…………………………………...............................4
CLAIM AGAINST THE CITY OFr ---~LLFLOWER
(For Damages to Persons or P __ ,..onal Property)
Received by S ,_ Ci ✓VV\ l f via
United States Mail /
Over the Counter 1/ ·
Date Stamp
Claim must be filed with the City Clerk of the City of Bellflower within one hundred eighty days (180) or six (6) months after which the incident or event occurred, unless the claim pertains to Bellflower Municipal Code Section 16-5.13(a), which must be filed within one (1) year following the date of payment of the tax proposed for refund.
Be sure your claim is against the City of Bellflowerl 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 Bellflower, 16°6D0 Civic Center Drive, BeHflower, California 90706-5494.
HONORABLE MAYOR AND CITY COUNCIL MEMBERS, City of Bellflower, California. The undersigned -respectfully submits the followi!lg claim and information relative to damage to person(s) and/or personal property:
1. NAME OF CLAIMANT t r-m~ L e-tici Of. C2.c:Jcl:r;tfl.U~2
2. ADDRESS OF CLAIMANT
(Sb'eJit Address or 1-'ns;, , "'" --· -
{Ciiy. Stat~, Zip Code)
3. TELEPHONE NUMBER_]
4. DATE OF BIRTH
5. SOCIAL SECURITY NUMBER.
6. DRIVER'S LICENSE NUMBER_
7. IF A MINOR, PLEASE LIST PERSON PR~SENTING CLAIM ON BEHALF OF MINOR AND RELATIONSHIP
8. Name, telephone number, and address to which claimant desires notices to be sent if other than above:
9. Occurrence or event from which the claim arises:
a.
C.
d.
Doc 115653
DATE /0//1/2,,01.-/ b. TIME 2~50pn,
PLACE (specific location): I tf i 00 ce r-rii0.5 . uf\t)•e Be!f :t:ta w·,c,r cA 6/D?o fo
How and under what circumstances did damage or mJury occur? Specify the ·particular occurrence, event, act or omission you claim caused the injury or damage (use additional paper if necessary).
Tree bY?lncn
Revised 4/12/05
9. 10.
e. What particular action by the City, or its employees, caused the ai:eged damage or injury? (/f;j fret' 5~ovlCJ hAve to~-en '1Y7.._h1W\:;u:(c~
Give a description of the injury, property damage or loss, so far as is known at the time of the claim. If there are no injuries, state "no injuries."
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On.
12. Name and address of any other person(s) injured:
13. Name and address of the owner of the damaged property:
TY7Y!Ci 1 ct-re r"o-/Locl 0g u c:i-
14. Damages claimed:
a. Amount claimed as of this date: $ __________________ _ b. Estimated amount of future costs: $--:-::::~_,,1._I to=--. 2.,.-,_0~2__._8 ________ _ c. Total amount claimed: $_~-r--· _/ _~_"'-2_ ... _2 ____ 8 _____ _....;,.._ d. . Basis for computation of amount claimed {attach copies of all bilJs, invoices, estimates, etcetera):
15. Names and addresses of all witnesses; hospitals, doctors, etcetera:
a.
b.
C.
16. Any additional information that might be helpful in considering this claim:
-EXECUTED ON ( 2 / 91202._J 20-2.J_, AT BELLFLOWER, CALIFORNIA. I declare under penalty of perjury under the laws of the State ot,-G lifornia that the above is true and correct. --/ . ()kc
C-lai-·m-a_n_t's-S:;....ig-n-atu...,_re _____________________ _ Doc 115653 Revised 4/12/05