CITY OF SACRAMENTO - CLAIM FORM ry Ax by and through his guardian ad tem Selena Mann Fate Bea | clo PANISH SHEA & BOYLE, LLP, 11114 Santa Monica Bhat, Sute 700 i= wan i es iy, ate, zpe_L28 Angeles, CABOOZS ane G10) 828-6200 eng B10) 926-6200 linn type of LoseQPencnaliiey Dorner Monat Death _polie Report OPreperty Damage © indomnty-Date complaint served hen ldinuryor damage occur? March 18,2018 Sunday _ Approx. 10:30 P-Myurn Name of Cisina sep -u P 13g Home Aes ar — Sea ; Were id go damage oc? ses my ste Ate co Sacramento, CA 95822 How dld Injury or damage occur? (ont wut arccraey) ‘See Attachment {What action or inaetion of City employoe(e)causod your injury or damage? SeetAtachment What injury oF damage did you surtere SeelAtiachmenty Name of any witnesses: S22 Attachment ae aa a aa ra Name of oy employes mvlved: Sacani Ps Du © i 1: Personal Injury § See Attschmont Property Damas state the amount of your el the otal snort 79000809 es te oer 81400000 o dsl amounts be tte ut aa eo cuttin woud be atesel nse eal smut fi done mt oewed $25.20 ‘Amount of C [ALL NOTICES ANDIOR COMMUNICATIONS SHOULD BE SENT TO: Nome BianPanish Esa, atime Phone (810) 9288200 ‘Adios (Sow cy, Sit 2) 7 ANISH SHEA & BOYLE, LLP- 11114 Santa Monica Bid, Sulte 700, Los Angeles, CA 90025. urea toning reece ote esr any ste in aes ay. SET) EY eo ee satoeypacase pone we on oe fee, eh yon ry nie He ey aa) anno nt rae § 08 yay eo ec ens ens ne Seer Statin domred cto rav beer btn estar th ese cae a se ra geal tpt hav ra reagan apna on Be ce Ce tne no tbe on see ar eo a = — elton Allomey fr Claimant pate ‘Shs 4‘You ate cequire by aw to provide the information requested on page tn arder to comply with ‘Government Code § 910 and §920.2. Additionally, in order to conduc timely investigation the ‘ity of Sacramento requests that you provide aaitional information: 4. Caimane(s) Social Security Number(s): _ 2, Claimant(s) Date of Bith: 3. Claimant's Driver's License Number and Stat 4, areyoua Medicare Benefcary? [ves [lho 5, Medicare HIEN number: 6. Ifthe claim involves a motor vehicle incident, please provide the following information Claimants) Insurance Company: Telephones Insurance Polly No. Insurance Agent: eee eleghee Caimant’s Vehicle Yeu/Nake/Model teense Plate No please check here if there was nolnsurance coverage in effect at the time of the incident {Phase oac any epi il, estimates, en pPetographs of your vehicle damage) 41 tf this claim involves medical treatment fra cllmed injury, please provide the name, ‘address and telephone numberof any doctors, hospitals or other medial providers. Chiropractors, physica therapist, acupuncturist, et.) providing treatment, (Government Code 5985) 8. Additionally, please provide the name, address and telephone numberof ny insurance company (or ather sila entity, which has or is expected to make payments to you or any trees! peevider on your behalf axa result of your claimed injuries (e, Medi-Cal, unemployment insurance, disability Insurance, etc). (Government § 985(e))CLAIM AGAINST THE CITY OF SACRAMENTO INSTRUCTIONS jease provide an origina ofthe "City of Sacramento- Claim Form.” The cxginal, together ttn one copy ofa attacimerts, ae tobe fled ith the Ofie of the City Clerk Retain ‘one copy for Your records, Please send fo this address Office ofthe City Clerk 915 | Street ‘th Floor, New City Hall Bldg Sacraments, CA 95814 NOTICE: The City Clerks Office is the ONLY office to which claims may be submited. Claims are NOT to be sent to the Cty Alfomey, Rsk Management, or any other City Department, Please fill out claim form as instructed. Missing Information will delay the processing of your claim. Please Print, PROCEDURES Claims received by the Office ofthe Cy Cer are forwarded to the City’s Claims ‘Raministratoc.Alleaimants are then notfied what ction will be taken within 45 days (plus ‘ckltional days if the form is mailed tothe City Clerk), or otherwise noted 2s tothe claim ite. Ityour claim s record! for denial you wil be sont letter notifying you ofthe action taken, and any furbir acon necessary or avaliable to you “The Sacramento Housing and Redevelopment Agency, Sacramento Regional Transit, County of Secramento, Sacramento Municipal tities Dsticl, ad the Sacramento Unified Schoo! Distt are separate from the City of Sacramento and ary claims agains them must be submitted direc to the Agency or Author “ALL CLAIMS ARE PUBLIC RECORD"