CITY CLERK'S DATE STAMP
CITY OF RIALTO CITY OF RIALTO
LIABILITY
2023 APR 20 PM 1: 26
CLAIM FOR DAMAGES
TO PERSON OR PROPERTY RECEIVED
CITY CLERK
1. Claims for death, injury to person, or to personal property must be filed not later than six (6) months after the occurrence (Gov. Code §911.2).
2. Claims for damages to real property must be filed not later than one (1) year after the occurrence (Gov. Code §911.2). RETURN TO:
3.READ ENTIRE CLAIM FOR BEFORE FILING Rialto City Clerk's Office
4.ATTACH SEPARATE SHEETS, IF NECESSARY, TO GIVE FULL DETAILS Mail: 150S. Palm Ave., Rialto, CA 92376 Address: 290 W. Rialto Ave., Rialto, CA 92376
CLAIMANT INFORMATION:
SOUTHERN CALIFORNIA EDISON COMPANY (SCE)
FULL NAME DATE OF BIRTH
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE NO.
P.O. BOX 900, ROSEMEAD, CA 91770 (626) 302-6650
BUSINESS ADDRESS INCLUDING CITY, STATE & ZIP BUSINESS TELEPHONE NO.
ADDRESS AT WHICH CLAIMANT DESIRES TO RECEIVE
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above):
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: August 29, 2021 TIME: 1:14 MAMDIPM
2. PLACE OF ACCIDENT (OCCURRENCE) BE SPECIFIC - Describe fully and (if applicable) locate on diagram on reverse side of this sheet.
Where appropriate, give street names and addresses, measurements and landmarks.
N. Linden Avenue & Bohnert Avenue, Rialto, CA 92377
3. HOW DID DAMAGE OR INJURY OCCUR?
SCE has been served with a lawsuit by plaintiffs Katelyn Brown, Ruth Brown, and the Estate of Gary Brown. The complaint is related to a motor vehicle collision in which defendant Betzareli Garcia rear-ended Katelyn Brown and her father, Gary Brown. Ms. Brown's vehicle overtumed and collided with SCE Pole No. 2332408E, causing it to catch fire. Gary Brown was not able to escape the burning wreckage and subsequently died at the scene.
4. WERE POLICE AT THE SCENE? EYES DINO WERE PARAMEDICS AT THE SCENE? EYESINO
5. WHAT PARTICULAR ACT OR OMISSION DO YOU CLAIM CAUSED THE INJURY OR DAMAGES? Give the name of the city/town employee causing the injury or damage, if known.
SCE is seeking defense and indemnity from the City of Rialto.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage sPending HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: SCE Pole No. 2332408E, August 29, 2021 Amount: $24,778.91 Item/Date: Amount: $
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM:
ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: Amount: $_
Item/Date: Amount: $-
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: See associated police report NAME:
ADDRESS: ADDRESS:
TELEPHONE: | ) TELEPHONE: | 1
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTOR(S) OR HOSPITAL(S) VISITED:
NAME: See associated police report NAME:
ADDRESS: ADDRESS:
TELEPHONE: TELEPHONE: | )
DATE: TIME: DATE:
9. PLEASE READ THE FOLLOWING CAREFULLY:
For all vehicle accident claims, place on the following diagram, the names of streets, including NORTH, EAST, SOUTH AND WEST directions. Indicate place of accident by "X* and by showing house numbers or distances to street comers.
If a city/town vehicle was involved, designate by letter "A" location of the City/Town vehicle when you first saw it, and by "B" location of yourself or your vehicle when you first saw City/Town vehicle; location of City/Town vehicle at time of accident by "A-1" and location of yourself or your vehicle at the time of the accident by "B-1" and the point of impact by "X°.
→ NOTE: IF THE DIAGRAM BELOW DOES NOT FIT THE SITUATION, PLEASE ATTACH A PROPER DIAGRAM SIGNED BY THE CLAIMANT.
CURB
2023 APR 20 PM 1: 26 CITY OF RIALTO
PARKWAY
SIDEWALK
I HAVE READ THE FOREGOING CLAIM AND KNOW THE CONTENTS THEREOF; AND CERTIFY THAT THE SAME IS TRUE OF MY OWN KNOWLEDGE EXCEPT AS TO THOSE MATTERS WHICH ARE HEREIN STATED UPON MY INFORMATION AND BELIEF; AND AS TO THOSE MATTERS I BELIEVE THEM TO BE TRUE.
I CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
AARON LOPEZ, SR. ADVISOR 4/12/2023
TYPE OR PRINT NAME DATE
SCE CLAIMS DEPARTMENT
RELATIONSHIP TO CLAIMANT
NOTE: PRESENTATION OF A FALSE CLAIM IS A FELONY (CA PENAL CODE 72) RETURN CLAIM TO: RIALTO CITY CLERK'S OFFICE - 150 S. PALM AVE., RIALTO, CA 92376