HomeMy WebLinkAboutAgenda Report - March 21, 1984 (52)CLA INIS
CITY COUNCIL MEETING
MARCHW, 1984
On recommendation of the City Attorney and L. J. Russo
Insurance Service. I ne. , on m t i on of Counc i I Nkmbe r Reid,
Nbrphy second, denied the following claim and referred then
back to L. J. Russo Insurance Services, Inc.:
11) Li 11 i an flirt sock
b) Joyce Denton
1X1, /19/84
IXA, 1/27/84
I
ri
sj
r.
7
I
ri
sj
r.
I
Kze
SUS1E/J DATE'. v "'
MESSAGECI i f Ct_`R�C .4
H
SIGNED
as ass NO REPLY NECESSARY
FREPLY REQUESTED USc REVERSE SIDE
I
r
S
FREPLY REQUESTED USc REVERSE SIDE
AUTO/GE.,.=v LIABILITY
Leonard J. Russo, Inc.
SdjInsurawr Administrators
❑ PRELIMINARY REPORT
❑ STATUS REPORT
❑ CLOSING REPORT
1. ADOR ESSEE �6- ',
2. SUBSIDIARY
3. LOCATION
ATTN:
4. i
A
OCCUPATION
7. DATE OF L SS
M NO.
9. C i T ,.c_
11. OCCUPATIONL
A
13. AD -DRESS
r; (go /y • �' _4 C/
i14. RESERVES AND PAYMENTS B.i. P.D. LEGAL EXPENSE TOTAL TO DATE
CLAIMANT RESERVESS 2 ��� • S
$ $
PAYMENTS S S
S $
15. FACTS IN BRIEF
-/
,i/Ll/i LL+IiL Gt'� e' �2'41a� �` t l�(J ii�1►l ��ri�
�9 /
,J. �r L� f, �fi1.0 L� . L''1L%
dy7 ejX
16 ILI7Y ANALYSIS 17. PLAINTIFF ATTORNEY
16. DEFENSE AT TO NE1I
%ADVERSE ADDRESS �/�d Jv
ADDRESS
19. INJURIES/PROPERTY DAMAGE: (�'r✓ /V,/ £
LOSS OF WAGES
SPECIALS:`
WEEK(S) DAYS
MEDICAL SC --3U-31 PROPERTY DAMAGE S
ATS PER
EMPLOYER
S S
$ $
20. INVESTIGATION
ITEM COMPLETED ATTACHED ITEM CO PL�EDITTACHED SUBJECT
POLICE REPORT ❑ ❑ CLAIMANT STATEMENT
y ❑
PACIFIC INDEX INSURED EMPLOYEE
BUREAU FILING ❑ ❑ STATEMENT
❑ ❑
PHOTOGRAPHS ❑ ❑ WITNESS STATEMENT
❑ C1 —
SCENE DIAGRAM ❑ ❑ WITNESS STATEMENT
❑ ❑
P.D. ESTIMATE ❑ ❑ WAGE LOSS VERIF.
❑ ❑ —
SUMMONS/COMPLAINT ❑ ❑ MEDICAL REPORT
❑ ❑
DISMISSAL ❑ ❑ MEDICAL REPORT
❑ ❑
RELEASE ❑ ❑
❑ ❑
❑ ❑
❑ ❑
21. COMMENTS/TO BE DONE
7114
; dll •)7 /9- 4- F T
22. EXAMIN�ER ;./
3. DATE�,
J
24. NEXT REPORTING DATE
�.�r.auax�s�:��xtia�:�+��s:x..�•.:��;vasr��;r.��� .h�:.�.::... ,:_: ....:,�... __.., :... ....�,..�.�. _.. c.-__. �;,�_ ..ux��:t_..�x"�?.+i��e�s�"c�a -
Hit
To FROM
az e.
In
SUBJECT DATE
/FL
MESSAGE
Wil- 4S 468
'Q' "A IM WM A -MM
SIGNED
F] NO REPLY NECESSARY F] REPLY REQUESTED - USE
v 1e: ..:i ts' . •:. �., .,, s; �;r `X 7
AUTO/GENERAL LIATY
Leonard I. Russo, Inc.
Self Arbwrorrce Administrators
❑ PRELIMINARY REPORT
- • ❑ STATUS REPORT
❑ CLOSING REPORT
1. ADDRESSEE
2 SUBSIDIARY
3. LOCATION
1ATTN:
4. INSURE -D EMPLOYEE'
AGE
S. ATION7.
DATE OF LOSS I& UR CLAIM NO.
//- zz
2. CLAMANT
• �� ��/'✓��
? Ste`-'"
I 't, OCCUPA'L
oY . - �<.
STATUS
?
13. ADDRESS
are?' --I-
1 RVES AND PAYMENTS
P.D. LEGAL EXPENSE AL TO DATE
�^B.1.
CLAIMANT RESERVES S 7J D�i S
S S ;;rS_0Ck
PAYMENTS S S
S S
15. FACTS IN BRIEF
7',eL 04) Wog,SfO v/cJcrG�h'�K S�r�(1 �,Vctt)crr I'• 1I DEAk
J7/�F�t' /PE<"�'.eiT .SilJF c-ciALK' h'Fi✓'�•h' /,d !�I £/�.
.�!> >f'.�'/cd.(J .UOT/F���'- '�J•c1 70 C17j:
_C/or,wi/< Is -/7y F,aSmFur i'c'e 61EJ
o_'cz.,eerD RT bt3»I owl ,QC_
0C-Cr1A AC CEJ lei z�{! ,d&t
Z31 S. Cfi,e��1t� n�, AJCU
LIABILITY ANALYSIS
17. PLAINTIFF ATTORNEY
13. DEFENSE ATTORNEY
S70 %ADVERSE
ADDRESS
ADDRESS
----
S `lo C-
19. INJURIES/PROPERTY DAMAGE:_;y(: � �,;� fl.w►^+:I� T t7i' A�t�
19.
LOSS OF WAGES
32
SPECIALS:MEDICAL
WEEMS) DAYS
577L107 PROPERTY DAMAGE S
AT S • 3Z P'ER
EMPLOYER
D4N r� S Z Z-3 • $
i- •- t �,k' g S I Z5a
20. INVESTIGATION
ITEM COMPLETED ATTACHED ITEM
COMPLETED ATTACHED SUBJECT
POLICE REPORT ❑ ❑ CLAIMANT STATEMENT
❑ ❑
PACIFIC INDEX INSURED EMPLOYEE
❑
❑
BUREAU FILING ❑ STATEMENT
PHOTOGRAPHS ❑ ❑ WITNESS STATEMENT-
❑
SCENE DIAGRAM ❑ ❑ WITNESS STATEMENT
❑
P.D. ESTIMATE ❑ ❑ WAGE LOSS VERIF.
❑ ❑
SUMMOVVCOMPLAINT ❑ Cl MEDICAL REPORT
❑ ❑
DISMISSAL ❑ ❑ MEDICAL REPORT
❑ ❑
RELf •,SE ❑ ❑
❑ ❑
O 0
❑ ❑
21. COMMENTSITO BE DONE
/F 7Wf- c117_,Kr Q£coerl , £f�iuw WCeE nrv.IC Cd»t fc C j -C rlw/s cmc: .ISE �>
c�1?St OF A177L £ •.1196141 Ty hoLvt vce_1
Nrt 3 �ZA7' a� n� �ac c .,cf a'? (t_ CSS 'r)y f y (,J,��n ic 47,)-tj
c AS II AlzILk 4-t o f P,-J�/ AC�.< vFA-I
Ra�O ttihill QiC£N�t`( �hK� L iT�( /'-" A)d TAa"("J& 04 pj-f4 AJ 7-S.
: f � COKL) L) iCFE ,0A) 6-- W14,L & AI 1924 i7 .ri IvE
1))/4-Y
qtr C2,,61
22. EXAMIN ,/�' - DATE—
24. NEXT REP RTIN T
FORM * LRS23C 12-,0) /