CLAIM FOR DAMAGES
RESERVE FOR FILING STAMP
TO PERSON OR PROPERTY CLAIM No..
INSTRUCTIONS
1. Claims for death, injury to person or to personal property must be filed not later RECEIVED than six (6) months after the occurrence. (Gov. Code Sec. 9112)
2. Claims for damages to real property must be filed not later than one (1) year after the occurrence. (Gov. Code Sec.911.2)
3. Read entire claim before filing.
4. See page 2 for diagram upon which to locate place of accident DEC 11 2023
5. This claim form must be signed on page 2 at bottom.
6. Attach separate sheets, if necessary, to give full details. SIGN EACH SHEET.
7. Claim must be filed with City Clerk. (Gov.Code Sec. 915a) CITY CLERK DEPARTMENT TO: CITY OF VERNON CITY COUNCIL
Name of Claimant
Age of Claimant (If natural person)
Simon Perez 40
Home Address of Claimant City and State Home Telephone Number Business Address of Claimant City and State Business Telephone Number N/A n/a
Give address to which you desire notices or communications to be sent regarding this claim:
Law Offices Of Payam Y. Poursalimi
8383 Wilshire Blvd. Suite 830 Beverly Hills, CA 90211
How did DAMAGE or INJURY occur? Give full particulars.
Mr. Perez was hit by an officer driving their police vehicle owned by the city of Vernon.
When did DAMAGE or INJURY occur? Give full particulars, date, time of day, etc.:
Accident happened on 10/14/2023 at 12:00
Where did DAMAGE or INJURY occur? Describe fully, and locate on diagram on reverse side of this sheet, where approximate, give street names and address and measurements from landmarks:
Mr. Perez was coming out of the driveway at 2522 E. 37th Street and made a right turn onto East bound 3oth street. At which time the police officer driving the vehicle owned by the city of Vernon also travelina east hound on 38th Street collided with Mr. Perez at a hiah rate of sneed What particular ACT or OMISSION do you claim caused the injury ordamage? Give names of City employees, if any, causing the injury or damage, if known:
The police officer was driving twice the speed limit which caused the damages to Mr. Perez's vehicle and person. Mr. Perez sustained injuries as a direct result of the impact.
What DAMAGE or INJURIES do you claim resulted? Give full extent of injuries or damages claimed:
Mr. Perez sustained a fractured left hand, pain in the neck, back, arm and waist. Mr. Perez's vehicle was damaged completely due to the impact sustained.
What AMOUNT do you claim of each item of injury or damage as of date of presentation of this claim, giving basis of computation:
A specific amount cannot be claimed as of yet. Mr. Perez is currently treating and his vehicle has not begun the evaluation process.
Give ESTIMATED AMOUNT as faras known you claim on account of each item of prospective injury or damage, giving basis of computation:
A specific amount cannot be claimed as of yet. Mr. Perez is currently treating and his vehicle has not begun the evaluation process.
Were you insured at the time of the incident? If so, provide name of insurance company, policy numbers and amount of insurance payments received:
Mr. Perez is issued by Bristol West Insurance. Policy number is No payments have been issued for this claim.
Expenditures made on account of accident or Injury: (Date - Item) (Amount)
N/A N/A
Name and address of Witnesses, Doctors and Hospitals:
Hospital: Los Angeles General Medical Center. Address: 2051 Marengo St, Los Angeles, CA 90033
READ CAREFULLY
For all accident claims place on following diagram names of streets, including North, East. South, and West: indicate place of accident by "X" and by showing house numbers or distances to street corners. f City Vehicle was Involved, designate by letter "A" location of City vehicle when you first saw it, and by "B" location of yoursel or your vehicle when you first saw City vehicle: location of City vehicle at time of accident by "A-1" and location of vourself or vou vehicle at the time of accident by "81" and the point of Impact by "X." NOTE: if diagrams do not fit the situation, attach hereto a proper diagram signed by claimant.
FOR AUTOMOBILE ACCIDENTS
71'
CURB-
CURB y
I declare, under penalty of perjury, that the foregoing, including any attachments, is true and correct.
Date:
Typed/Printed Name: Signatura of clamant or person nine on hither behalt, gring Payam Poursalimi relationship to Claimant: 11/06/2023
NOTE: ALL CLAIMANTS MAY BE REQUESTED TO BE EXAMINED AS TO THEIR CLAIM UNDER OATH. PRESENTATION OF A FALSE CLAIM IS A FELONY (CAL. PEN. CODE SEC. 72), CLAIMS MUST BE FILEDWITH CITY CLERK (GOV. CODE SEC. 915a). STATE LAW PROVIDES THAT IF YOU ARE NOT NOTIFIED OF ANY ACTION BY THE CITY OF THIS CLAIM WITHIN 45 DAYS OF FILING THEN THE CLAIM IS DEEMED DENIED (SEE GOV. CODE SEC. 911.6 & 912.4) → Finite Nil
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Payam Y. Poursalimi