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 than six (6) months after the occurrence. (Gov. Code Sec.9112) RECEIVED
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.
See page 2 for diagram upon which to locate place of accident APR 25 2024 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
Abimael C. Garcia TAge of Claimant (If natural person)
Home Address of Claimant
City and State I am Assass
Business Address of Claimant City and State
business elephone Numbe
5801 S. Alameda st, Los Angeles, Ca 323-584-9225
Give address to which you desire notices or communications to be sent regarding this claim:
How did DAMAGE or INJURY occur? Give full particulars.
I was traveling in the southwest direction on S. Atlantic blvd to merge towards District Blvd.
Upon entering the curve which merges both streets, my motorcycle slid out from underneath me due to the road being slippery from oil that was spilled from an accident that recently occurred down the street.
When did DAMAGE or INJURY occur? Give full particulars, date, time of day, etc.:
Accident occurred on 04/24/24 at 7:25am
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:
Accident happened right in front of the address 5107 District Blvd. I received scrapes to both knees and minor scrape on right knuckle. Vehicle has a scratches on exhaust, front fork, rear brake, rear brake guard, throttle and front brake.
What particular ACT or OMISSION do you claim caused the injury or damage? Give names of City employees, if any. causing the injury or damage, if known:
The fall was a direct result of the oil spilled from the vehicle which was towed away from the crash site 30-40yds away. I believe the clean up crew which was on site should have closed the lane until everything was correctly cleaned up. I spoke with one of the cleanup crew "Ell," which has taken pictures of the evidence if verification is needed. Case # CR24-0638 taken by officer B. Silva. assured me everything was cleaned up, however i have the oil on my clothing as proof from my fall. Vernon pd has already made a report and What DAMAGE or INJURIES do you claim resulted? Give full extent of injuries or damages claimed:
Injuries incurred are scrapes on both knees, slight abrasion on right knuckle, exhaust from motorcycle, rear brake lever, rear brake guard, throttle, front brake, and scratches on front fork.
What AMOUNT do you claim of each item of injury or damage as of date of presentation of this claim, giving basis of computation:
Dollar amount of damage has yet to be calculated as insurance company is in the process of reviewing my claim.
Further examination by the insurance co. will be completed by 7:30 04/25 and a report can be provided once Give ESTIMATED AMOUNT as far as known you claim on account of each item of prospective injury or damage, giving basis of computation:
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, insurance provider is Progressive ins., policy # No payments have been received from ins. provider as of yet
Expenditures made on account of accident or Injury: (Date - Item) (Amount) Name and address of Witnesses, Doctors and Hospitals:
No witnesses remained on site to document
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 comers.
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 yourself 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
FOR OTHER ACCIDENTS
CURB/
CURB 1
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:
Abimael C. Garcia relationship to Claimant: 04/24/24
NOTE: ALL CLAIMANTS MAY BE REQUESTED TO BE EXAMINED AS TO THEIR CLAIM UNDER OI STA. 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)