CLAIM FOR DAMAGES RESERVE FOR FILING STAMP
TO PERSON OR PROPERTY CLAIM No.
INSTRUCTIONS RECEIVED
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 Sec. 9112)
2. Claims for damages to real property must be filed not later than one (1) year MAR 2 0 2024 after the occurrence. (Gov. Code Sec.911.2)
Read entire claim before filing.
See page 2 for diagram upon which to locate place of accident CITY CLERK DEPARTMENT This claim form must be signed on page 2 at bottom.
Attach separate sheets, if necessary, to give full details. SIGN EACH SHEET.
Claim must be filed with City Clerk. (Gov. Code Sec. 915a) TO: CITY OF VERNON CITY COUNCIL
Name of Claimant Age of Claimant (If natural person)
Kevin Yee 58
Home Address of Claimant City and State Home Telephone Number Business Address of Claimant City and State Business Telephone Number 4900 S. Eastern Avenue #100, Commerce, California 90040 323-890-5313 Give address to which you desire notices or communications to be sent regarding this claim:
How did DAMAGE or INJURY occur? Give full particulars.
It was medium heavy rain condition at the time. I work at 4900 S. Eastern Ave. #100 in Commerce, CA. Got off 710 South and turn right on Bandini Bivd. Driving on the number 2 lane (right lane). Right about Yeager Way, I felt a very violet impact on my driver's side front and rear wheels as if hitting a giant pothole. Thankfully, I made it to work around the corner. About lunch time, I went out and checked on my wheels and noticed both driver's side front and rear tires were damaged and deformed.
When did DAMAGE or INJURY occur? Give full particulars, date, time of day, etc.:
January 23, 2024 at 5:57AM
Where did DAMAGE or INJURY occur? Describe fully, and locate on diagram on reverse side ofthis sheet, where approximate, give street names and address and measurements from landmarks:
Happened in the City of Vernon. On Bandini Blvd, about the intersection of Yeager Way.
What particular ACT or OMISSION do you claim causedthe injury or damage? Give names of City employees, if any, causing the injury or damage, if known:
The pavement of the roadway around Bandini Blvd and Yeager Way is badly torn. It was a giant pothole that caused the damage.
What DAMAGE or INJURIES do you claim resulted? Give full extent of injuries or damages claimed:
I would like to claim a replacement of the driver's side front and rear tires. The vehicle is a 2022 Tesla Model 3 Performance
Tires are Pirelli P-Zero PZ4.
What AMOUNT do you claim of each item of injury or damage as of date of presentation ofthis claim, giving basis of computation:
Claim amount: $975.18. This is the lower amount from two estimates. Please see attached pictures and the two estimates.
Give ESTIMATED AMOUNT as far as known you claim on account of each item of prospective injury or damage, giving basis of computation:
Claim amount of $975.18 for two tires (driver's front and rear). The breakdowns are in the estimates enclosed Were you insured at the time of the incident? If so, provide name of insurance company, policy numbers and amount of insurance payments received:
Yes. Wawanesa Insurance. Policy number: I did not claim from my insurance because I have $1000 deductible.
Expenditures made on account of accident or Injury: (Date - Item) (Amount) Name and address of Witnesses, Doctors and Hospitals:
Lisa Acosta 4900 S. Eastern Ave. #100, Commerce, CA 90040 Vincent Estrada 4900 S. Eastem Ave. #100, Commerce, CA 90040 Chama Toldson 4900 S. Eastern Ave. #100, Commerce, CA 90040
READCAREFULLY
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 If City Vehicle was Involved, designate by letter "A" location of City vehicle when you first saw it, and by "B" location of yourself 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 your vehicle at the time of accident by "8 1" 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
I NORTH
/ / Bandini Blud.
7^ Г
FOR OTHER ACCIDENTS
CURB/
CURB;
PARKWAY
SIDEWALK
I declare, under penalty of perjury, that the foregoing, including any attachments, is true and correct.
Typed/Printed Name: Signature of Claimant or person filing on his/her behalf, giving Date KEVIN YEE relationship to Claimant: 2/14/2024
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 FILED WITH 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) Rev. 8/4/16
Driver's. Front # l
Driver's Front # 2
Driver's Rear
CODES ONCE STAT LOAD 6 3 0
# /
Driver's Rear # 2
outaoor plants
Parsec Sheila St
BNSF Lot 119 Il'Saggio itali
Rocky's Food S Atlantic Bivd
Distributors, Inc
Unified Grocers O
Classic Home
Smart.
Distribution
Lineage Q
eight C rmy Band
De Well Group 9
Fambrands •
307th Chemica
Compan
Bandini Bile
lan Group 9
Individual FoodService 9
Asendia USA
Bandini Bivd
FedEx Home Delivery 9
DG Brands 9 •H&T Seafood
Los Angeles River
& Events
ational
The Salvation Army
Bell Lighthouse Corps
Above is the location of the pothole.
I was driving Eastbound on Bandini Blvd.
on the number two lane (right lane).
Pothole at Bandini Blud + Yeager Way
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Subtotal $885.34
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Local Sales Tax $35.80
Items in your Shopping Cart will be saved on this computer for 30 days Print Cart Total $975.18
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3/ 13/24, 3.04 FI vernon - Googie maps
Google Maps Vernon
Bandini Blvd and Yeager Way
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Imagery ©2024 Airbus, CNES / Airbus, Maxar Technologies, U.S. Geological Survey, USDA/FPAC/GEO, Map data ©2024 200 ft C8
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Vernon
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CARL WARREN & COMPANY
Claims Management and Solutions
A OVENBROOK Company
2/6/2024
Kevin Yee
CLAIM REJECTION NOTICE
RE: Claimant: Kevin Yee
Our Client: City of Commerce
Claim Filed: 02-05-2024
Date of Loss: 01-23-2024
Our File Number: CJP-3050694
Dear Mr. Yee:
Carl Warren & Co. is the claims management company for the city of Commerce, Ca.
Notice is hereby given that the claim which you presented to the City on 02-05-2024 was rejected on February 06, 2024. The location of where your damage occurred is outside the city's jurisdiction. You will need to re-file your claim with the city of Vernon.
Subject to certain exceptions, you have only six (6) months from the date this notice was personally delivered or deposited in the United States mail to file a court action on this claim. (See Government Code Section 945.6) The six-month time for filing such a court action is neither enlarged nor extended by the provisions of CCP Section 335.1. This time limitation applies only to causes of action arising under California law for which a claim is mandated by the California Government Tort Claims Act. Government/Code Sections 900 et. seq...
Other causes of action, including those arising under federal law, may have different time limitations for filing.
You may seek the advice of an attorney of your choice in connection with this matter. If you desire to consult an attomey, you should do so immediately.
Very Truly Yours,
Janice Baluyut
Janice Baluyut
Claims Examiner
Carl Warren & Company, LLC | A Venbrook Company
Email:
* This was my initial claim to the city of commerce. It's because my workplace is only a little further down on Eastern Ave in Commerce, of the pothole was
However, they confirmed that the location
at the crty of vernon.
PO Box 2411, Tustin, CA 92781
T: 657-622-4200 | F: 866-254-4423 | www.carlwarren.com
CA License #2607296