HomeMy WebLinkAbout3.3 Shirley Seronello Claim CITY OF DUBLIN
AGENDA STATEMENT
MEETING DATE: May 9 , 1983
SUBJECT Claim of Shirley J. Seronello
EXHIBITS ATTACHED Claim
RECOMMENDATION Deny claim, notify claimant and refer to insurance
carrier .
FINANCIAL STATEMENT: Damages claimed in the amount of $1 ,077 .05
DESCRIPTION On April 13 , 1983 , the City received a claim from
Shirley J. Seronello, 7777 Castilian Road, Dublin,
for damages as a result of an alleged accident which
occurred on March 24, 1983.
It is Staff ' s recommendation that the City Council
deny the claim, notify claimant and refer to the
City ' s Insurance Carrier .
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COPIES TO: Shirley J. Seronello
Ben Fernandez
ITEM NO. City Attorney
t". C: EIVED
CLA' AGAINST THE CITY OF DUBL-
APR 131983
Control
(Offices' l o '
vame of Claimant: J. S E,'� 6,R)EJ-1-0
'%ddress of Claimant: 7 'D0x3< �n�
;Und Notices to: S,g n-)
jaL Q and /rime of Occurrence:
,lace of Occurrence-i. (Provide detailed diagram describing exact location,
including physical landmarks or distinguishing land features, if appropriate. '
A,0127-
:ircumstances of Occurrence: (If an accident, describe physical conditions
surrounding occurrence, such as weather, road and traffic conditions, etc.)
Lam/,'1 it)//c/6 .D iE' y ,/ E //v i y
i.v o eo r e F —
/.�s (J A) .0-,�5w i
a,LJ r
,ist names, addresses and phone numbers of any witnesses:
)ascription of Damage or Loss:
� .,L�C'yi S �0 T,s?/,� ,�i��r/c�� S FcJc�C r✓/E./�0 1,�r/��S �r �'�., �� ,��i �✓
laim-N and Department of- Involved City Employee (if any)
'oral Amount Claimed; _J.}. . ?� Breakdown of Amount Claimed:
P/,? v rr-E/z ,NG - � 000, 00
gated: ?�.c Signed: .
:)Le: A claim relating to a cause or action for death or for injury to person or to personal
roperty or growing crops shall be presented not later than the 100th day after the accrual
the cause of action. A claim re latuig to any ottkex cause of action shaU be presented not
Ater than One (1) year after the aca n:a]. of the cause of action.
iQhen a clal i that i.s^zequixed to be presented not later than the.10®th day after the
ccrual of the cause of act On Is not Presented within such time, a writte i application may
m:-02 to the City Council for leave to present such claim. 11he aWlication shall be pre-
nted within a rea=uble timo not to exceed one (1) year after thfl accrual o the cause
action and Ahall state the reason for the delay in presentinq the claim. The proposed
aim shall be attached to the application.
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PHONE 829-5111
CITY PHARMACY
FAMILY MED CAL 1P. I .RMACY IRS 942680897 Phone 828-1122
\r PRESCRIPTION PHARMACY
11837 Dublin Blvd. Dublin,California I
Alcosta Medical Arts Plaza
9260 Alcosta Blvd. an Ramon.California
t - THIS IS YOUR RECEIPT
THIS IS YOUR RECEIPT Have this for your Income Tax Deduction
Save this for your Income Tax Deduction Thank you for the privilege of filling your prescription. Ills
Thank you for the privilege of filling your prescription.It is filled with filled with the best obtainable standardized ingredients.For:
the best obtai ble(/ytandard)'zed ingr"�d\ie�ms,.For: n e� ��\ �.v L f
Name�lli-�.�<<` S 1�Y-' i Name ) t s PA
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RAC L s Rc
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P.— S Date -2_�f—�C�_5 Total
� Date- Total s _
To save time have your Doctor call your prescription to: To save time have your Doctor call your prescription to:
FAMILY MEDICAL PHARMACY DRUG CITY REXALL PHARMACY
j WE DELIVER WE DELIVER
Telephone us for your... Telephone us for your . . .
PRESCRIPTION REFILLS-FILMS-BABY SUPPLIES PRESCRIPTION REFILLS-FILMS-BABY SUPPLIES
GENERAL DRUG NEEDS GENERAL DRUG NEEDS
j A minimum order required on Drug Sundries,Film,etc. A minimum order required on Drug Sundries.Fllm,etc.
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-- -- - =--
777.
- FAMILY MEDICAL CENTER '.
• r - OF } :! - x ACCOUNT NO.
.. VALLEY MEMORIAL HOSPITAL 627277
DATE APPT.TIME 9280 ALCOSTA BLVD.,SAN RAMON,CA 94583
03 30 8 3 (415)829-5050
::.._ DEPT. SERVICE CHARGE
BID (415)829-8240 DESCRIPTION r
ADMIT TIME PIA RETURN DATE
3: 00 PTA MED.RECORD NO. l.•
PATIENT INFORMATION 0 C b 3 21
Seron>rllo, Shirley VL -
. _ GUAR.NO. -
01' 'Q•4'-32 06b32I
T;' �A i c ..
Rd CODE R DOCTOR NO.
11..27 ,�astilian 3 77 d
_ �1;_Ca. 94563
ubZ.i.n DOCTOR ME
P 'ZI$a 17 7 7 T r
O E-S b ICDA/I -
FIIJAfd�1, L V
PRINIAAY INSUF;A-'ICE _
CLINIC PATIENT
RELATIONSHIP a ND
INSiiRED ?J4`aE � YES
•LIB. NO.'
GROUP NUPa Eicn CODE D CODE A
3
SECONDARY j,,SURANC: ' REFERRED -
INSURED NAME
. -- RELATIONSHIP FROM TO
In PiO, GROUP Iii L!�1°En ICDA/2
PATIENT'S E:aPLOYER
REMARKS .. ICDA 13 -
AC, 0 3 23 83 3:00 Pt1 PATIENT REP.
Auto accident, now has head and YP
neck pain .
TOTAL CHARGES $ ttIJJJ
.�: PATIENT PAYMENT
NL1R�E PLEASE REMIT BALANCE TO:
M.D.SIGNATURE VALLEY MEMORIAL HOSPITAL
BALANCEDUE'" $
1 EAST STANLEY BLVD.
O
LIVERMRE,CALIFORNIA 94550
ORM 1 TELEPHONE 14151 447.7000
- IRS#94-1429628