HomeMy WebLinkAboutClaim #716 - L. Roberts �i � �
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CITY OF PALM DESERT
CITY CLERK DEPARTMENT
STAFF REPORT
REQUEST: CLAIM AGAINST THE CITY (#716-SUPPLEMENTAL) BY
LAURA ROBERTS IN AN UNSPECIFIED AMOUNT
SUBMITTED BY: Rachelle Klassen, City Clerk
DATE: March 14, 2013
CONTENTS: • Staff Report
• Recommendations of Claims Adjusters and Staff
• Claim No. 716-SUPPLEMENTAL
Recommendation
By Minute Motion, reject the Claim and direct the City Clerk to so notify the
Claimant.
Background
Based on a review of the subject Claim and the recommendation of the Claims Adjuster,
Risk Manager, City Attorney, and staff, it is recommended that the Claim be rejected.
Discussion of this item should be held in Closed Session pursuant to Government Code Section
54956.9(b), potential litigation.
Fiscal Analysis
City of Palm Desert participates in the self-insurance pool of the California Joint Powers Insurance
Authority (CJPIA). Action to reject the subject Claim does not have a fiscal impact on the City at
this time.
Submitted by: A,p oved:
� 1
, ( � �^, � ���
Ra elle D. Klassen, MMC, ity Clerk Jol�n M. Wohlmuth, City Manager
/
rdk �ITY�COUNCILA
CTION
Attachments (as noted) A �20VED- ✓ DENTFD
RECEIVED OTHER �
MF,E'TING DATE -_ �-/�l-a0/3
AYF.S: ��
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AE3SF,IVT: N b►1 e.
A[3STA[1V: � � —
VI:RIFIED I3Y: IQ.�rL
Original on File with City Clej•k's +� Ftice
Klassen, Rachelle
From: McNulty, Peter[pmcnulty@cariwarren.com]
Sent: Monday, March 04, 2013 1:23 PM
To: Klassen, Rachelle
Subject: Roberts vs Palm Desert
We have recommended that the city reject this claim. Please forward a copy of the rejection notice or advise on status.
Thanks.
Pete McNulty
Carl Warren &Co.
10509 Vista Sorrento Parkway#420
San Diego, CA 92121
Phone 858-526-1823
Fax 866-254-4423
Cel I 760-415-7231
Email: pmcnultvC�carlwarren.com �
Peter McNuliy
Claims Adjuster
Carl Warren &Company
An Employee-Owned Company-Where Quality is Assured
10509 Vista Sorrento Pkwy., Suite 420
San Diego, CA 92121
Office(858) 526-1823
Please visit our website at www.carlwarren.com to learn more about our Gold Level Claim Service.
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Company(CWC)andlor its subsidiaries.Finally,the recipient should check this e-mail and any attachments for the presence of viruses.CWC accepts no
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1
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�.�!!/,J' � 2013 JAN 28 PM 4� 22
C:rlltl. 1VAN..NEN �'�: (:OIl�tl':�N'�`
i>i%:�i`TIS fV�;9rI<ir;t:^C�',<';tt Ear,Ci ;,(;I{iti�7'.lc;
January 25, 2013
TO: The City of Palm Desert
ATTENTION: Rachelle D. Klassen, City Clerk
RE: Claim : Roberts vs. The City of Palm Desert
Claimant : Laura C. Roberts
D/Event . 11/6/2012
Rec'd Y/Office : 11/6/2012
Our File : 5-1768797-PMQ
We have received and reviewed the above claim and request that you take the action indicated below:
CLAIM REJECTION: Send a standard rejection letter to the claimant.
Please provide us with a copy of the notice sent, as requested above. If you have any questions please
contact the undersigned.
Very truly yours,
CARL WARREN &COMPANY
.
� ��' \.
Rich d D. Marque
cc: CJPIA w/enc.
Attn.: Executive Director
COF'YTO �� '�rc.�.%,i�
"""�` �r c��..____.
11N E.�1Pt_OYGF-OrVNED COMPANY
DATE J` � ����
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' CI1Y OF AALM DESERT
CLAIM AGAINST THE CITY OF PALM DESERT C i T Y C l�E�R K'�5�0 f�!C E �� c,n��
(For Damage(s) to Person(s)or Personal Property) P A L H D E 5 E R T, C A S�Qu"'J"''"�
�
���="`� � ' �'� 20i2 NOV 28 AM tl�51
Received by: 't7( '
via: US. Mail Interoffice Mail Over-the-Counter
_ ,
A CLAIM MUST BE FILED CI CLERK O THE q Y F PALM DESERT WITHllV SIX
MONTHS AFTER 1UHICH THE INCIDENT OR EVENT OCCURRED. BE SURE YOUR CLAIM LS
AGAINST THE CITY OF PALM DESERT, NOT ANOTHER PUBLIC ENTITY. WHERE SPACE IS
INSUFFICIENT, PLEASE USE ADDITIONAL PAPER AND IDEN1'IFY INFORMATION BY
PARAGRAPH NUMBER. COMPLETED CLAIMS MUST BE MAII.ED OR DELIVERED TO ?HE CITY
CLERK, CITY OF PALM DESERT, 73-510 FRED WARING DRIVE, PALM DESE1tT. CA 92260.
TO THE HONORABLE MAYOR AND CITY COUNCIL, City of Palm Desert, California:
The underslgned respectfully submit(s) the following claim and information relative to damage(s) to
person(s) and/or personal property:
1. �LAIMANT INFORMATION:
.
NAME �0�.�,'� �___ �+�5��
ADDRE S � -
PHONE NO. E O B R H: � "
SOCIAL SEGuRITY�O. `- DRIVER'S�l�.c��c ivv.
2. Name, telephone number and post office address to which ciaimant desires notices to be
sent, if other than above:
3. Occurrence or event from which the claim arises:
a. DATE: /� �� b. TIME: �� ��� c. PLACE (exact and specific
lxation .e,�
,
-a-o
�
d. How and under what circumstances did damage or injury occur? Speclfy the particular
occurrene�, event, act or ommiss�on ou claim caused e ' 'ury or ma e. (Use
additional paper if necessary.} '�X. " ,�
,�,.�r . <��:�C�
� ��
� °`".,--��
C�e�.. t-..... �.G.-a-ti.—�lvr-.- .w.-4..:r.,�..��1 •
e. What particula�' artion by the City, or its ernployees, caused the alle ed mage or�-'"'f°'`'�'"
injury? `=; � _ � �, r: �.�,�C,4
r; . � ,�_ d. '
�
Page 1 of 2
1
'�' � � �
� ����
., 4. Give a general description of the indebtedness, obligation, injury, damage, or loss in�urred
' so far as it may be known at the t e of pr tion of the cl�im. there were no
in' r' s, s te"no in'urieS"• ' ,�.�-
e�
Q�1.�_� .e-v�.. ,
, , x,,�.4,�
S. Give the name(s) of the City employee(s)causing the damage or injury:��,.�� �p_ _ ���
6. Name and address of any other person(s) injured: �Ct�r�..St..
7. Name and address of �t�e owner of a�y dam�ged property:�y,��� ��j Q.�'-�-5�_
8. Damages clalmed: �� �"7�
a. Amount clalmed as of this date: $ ��� �Q �
b. Estimated amount of future costs: $ _��U ,.
c. Total amount claimed: �
d. Basis for computati n of amoun s clai e i u copiss�—Ia-1-6i lI s;in�oices,
e ti ates, et .): .. � � , �
r
C
9. Names an ad�ires es of ail witnesses, hospitals, doc ors, etc.: � �. ��e�f.f i�t �
..1� . ' e. t
.+.¢,v ,
,�'
10. Any additional infor at'on, including police reports, which might be 1pful in cons�dering
this clai : � j/
� �f i i � .��
�G. J l.
WARMN : LS A CRIMINAL OFF SE TO FII.E A LSE CL ! ENAL 0 E 2;
INSURANCE CODE 556.1).
I have read the matters and statements made in the above claim, and I know the same to be true of
my own knowledge, except as to those rnatters stated upon informatlon or belief as to such matters
I believe the same to be true. I certify under penalty of perju�y that the foregoing�s��TRUE AND
CORRECT. t
signe�,.#his�y 9f ,2o L, at_ - - - - - , -
�SIGNATURE vr c:Ln�nnnu�� I U E � CL I N?
Office of the City Clerk, Palm Desert, California DOC. NO. DA7E FILED
� Page 2 of 2 "
Pacific Collision Cenber-Cathedral �te EPA: cnR000���i�
� C�� BAR: ARD00239230
kmckay�pacificml lision.com
36705 Perez Road,Cathedra)City,CA 92234
Phone: (760)328-5669
FAX: (760)770-3035
Estimate
RO Numbe�: 7001718
Customer: Insurance: Adjuster: Esdmator: Nestor Oelangel
ROBERTS,LAURA MERCURY tNSURANCE GROUP Phone: Create Dater 11/7/2012
Clalm: 120039007435-1900
!O1
Lass Date: 11/6/2012
Ded�xu'ble: SOU.00
Year: 2012 Style: 3D WGN VIN: '" Mileage In: 732
Make: MtNI Color: Blue Miteage Out;
Model: Coop�Clubman Lkense: lob Number: YeMcle Out: 11/Ib/2012
Line Ver OperoNon Descriptioo Qty Ex�nded Type La6or� Type Paint
Prite�
1 E01 Remove/Replace R Quarter Moulding qip 2 1.68T OEM
2 E01 Remove/Repiace L Quarter Mouidk�g Clip 2 1.68T OEM
3 �1 Rertwve/Replace R Back DoorShetl 1 399.59T OEM 171.00 Body
4 E01 Reflnish R Back Door Outside 76.00
5 E01 Reflnish R Add For Jambs&lnterior 38.��•,
6 E01 Remove/Replace L 8adc�oor Shell 1 399.59T OEM 171.00 8ody �
7 E01 ReBnish L Back Door Outside 60�
8 E01 Refinish L A�For h�mbs&Irrterlor 38�
9 E01 Remove/Install R BaCk Door Belt Mouiding O.pp �, i
SO E01 Remove/Instail L Back Door Bdt Moulding p,pp g�Y
il E01 RP�t�ove/Instaii R Badc Door Fnisher p.� � I
12 E01 Remove/Instali L Badc poor Finisher 0.00 Body
13 E01 Remove/Repiace Back Door AdheSMe Embkm 1 26.34T OEM 0.00 8ody I
t4 E01 Remove/Repiace 8ack D�r Adt�esive Namepiate 1 26.34T OEM 0.00 Body
15 Edl Rert�we/Install R Upr poor Trim Panel p.pp g�,
16 E01 Remove/i�ll L Upr poor Trim Panei p,pp �
17 E01 Remove/I�tall R Lwr poor Trim Panel �.� �Y
16 E01 Rertiove/Instail L Lwr Oow Trim Par�el Q.Qp �y
19 E01 Remove/Install R Otr poor Handle �.� �,
20 E01 Remove/instaN L Ob Door Handle �� �
21 E01 Remove/Install R eack Window �� a�
Z2 E01 Renwve/Install L Back YVfndow 7.60 Glass
23 E01 Rema�e/Replace Bddc Door Glass AdhesNe 1 24.00T A/M
24 E01 (LT gle�J
25 E01 RemoveJReplace Back Door Glass Adhesive 1 24.00T A/M
T.Tmrehk Imry RPD a RWH9d prbr p�msqe.M e�pppay��µ�q�UPD a UirdRed PritX Da�e,PDIt�P�OGnt R@D�.M`��Nkrmifknt,RlCllr+Rafiromed�Rlmen a
SGucl���'�'��IuiDmaM MrwfathRtr.Remr.Rrt.mrtd LKQ.L�t I�tl QueBly a US��Dd9'OUOr�ostk,5ee=Ektpka'.Mech=MYCUirNa.N!F�(kWpSh,SAuc=
11/8R0121230:23 PM
Page 1
Estimate
• RO Number:70017'18
Vehicle:2012 MINI Cooper pubman 3D WGN 8iue
?6 E01 (RT Glass)
27 E01 Overhaul Rear Bumper Cover Assy 91.20 Body
28 E01 Remove/Replaoe Rear Upr eumper Cover 1 371.72T OEM 0.00 Body I
29 E01 Retnove/G15tdll Rear Bumper Cover
0.00 Body
30 E01 Reflnish Rear Upr Bumper Cover
45.60
3I E01 Repalr R�r lwr B�xnper Cover 114.00 Body �
32 E01 Reflnish Rear Lwr Bumper Cover 60.80
33 E01 Remove/Replace Rear Bumper Ucense Plate Bracket 1 28.82T OEM 0.00 Body
34 E01 Additlonal Ciear Coat 87.40
3S E01 AddiNonal TIPIT COLOR 19.00 BOdy
36 EDl Additlonal FINISH SANO AND BUFP S�,pp g��,
37 E01 Additlonal MASK FOR OVERSPRAY 1 10.00 Other
39 E01 Remove/Replace License Plate Bracket Chrome Cwers 4 2.00T OEM
Estimate ToW1s Discount$ Markup; Rate; Total�
Parts (62.89) 1,252.87
�����Y 38.00 623.20
Labor,Reflnish 38.00 4p6.6p
��G G� 38.00 15.20
Material,Palrn Z�.�
Sub6ota!
Z�597.47
Sales Tax
134.97
Gnnd 7ota1 2,732.44
Estimate Versioo Toeal$
Originel 2,732.44
I�uance Total#: 2,232.44
Recelved from Insurance$: O.pp
Balance due from Insurance$: 2,232.44
Customer Totai$: 500.00
Received from Customer;: 0.00
Balance due from Customer�: 500.00
A TION TO DISASSEMBLE VEHt0.E FOR INSPECTION
t hereby a dRc Cdlision Centers to dfsassemWe the( da rea of the stated vehkle for the
P�►P�of inspecdn9 mating the mst of repairs. I understand o 5200.00 tor�sassemble,inspect, reassembie
in tlx ever�t that the vehkle is ired at Paciflc ,or the vehide is deemed a"total loss".
if I choose not to have the , Gston Cert�s wiil attempt ta reassembie the vehkle at no cost other than the s200.00 Iisted
above. I u some cases a vehide may 6o be reassernbied due to the fit of the damaged parts. If Pacific Collision Centers
nes Uwt the vehtcle can be reassemMed in the damaged on,the reassemble process wili be completed within 30 days fran the tlme the
vehicie owner signed this authorizadon. .
".Ta��bl!item,RPO s RNikd R.or pyn�ye.M�Ap087ranCe ACOwaru4 UPD.tkrll�d PtMr Osn�age,FDR r PeNitledS D!M Repak.NM�Aftnme�YeC RedY a Rldva�red.R�IIun c
a�raauree,OEN.qer,OrIpInM Epdoment ntamracuaer.aeaor=nrcaea.uW=l iae�ora QuaRy a Ihea,aa9=D�agnostic.Hec�EkcMwl,►Aan�Meenmxpl,nar.ner�,swc=
ShU[tteal
il/8/2012 12:30:23 PM P�2
' Estimate
• RO Number:700i718
Vehicle:2012 MINI CAoper pubman 3D WGN Biue
�9�1 Oate
AUTHORIZAT[ON Td REPAIR VEHICLE
1 hereby authorize Pacific Co1lBion Centers to perform the repairs documented a�this Irnoke for the above stab�l vehicle. I understand that some
�epairs may requfre additional services be performed by vendors other than Pacific CaiNsion CeMers. I hereby authodze Padfk Collisbn Cente�s to
utilize tl�ese vendors in the repak process of the above sWted vehicle. I hereby autl�orize Paciflc Cdifslon Centers to ope�ate thls vehkle for the
purpose of testing,inspecdng a�d transporting to additional vendors(�1et). Atl parts used in the repair process wiU be Originai Equ(pment(O.E.Mj
parts,un stated otherwise.
�9 Date
Esdm Compietlon date: j Customer i k
POWER OF ATTORNEY
By sigMng this Invoi�, I hereby authorize Paciflc CoNision Centers to act as a"Power of Atto�y"in signtng any draRs or checks that are relabec!to
this claim
Thank you to�thoosing Pacific Collision Centers
Addldonal IEgencl
E.P.C.=Environmentai Protectl�on Commission
tIA2=Flazardous waste
REMOVAL OP PRiVATE PROPERTY
Pacifk Coiifslon Centers is not responsibte for lost or damage to this vehide from flre,accident or any cause beyond our control.
1 acknowiedge I have removed aN per�nal bebngings from the vehkk prior to drop off,
x c�comer miaa�s
x Esdmator init�ls
DESIC,NATION OP PERSON TO PICK UP VEHICLE
if you are unable to ptdc up yaur vehide upon rnmpiedon,please InForm Paciflc CdlLsion Centers in advante.
• 1 wdl be pidcing up my vehkle upon compfeUon Cus[omer initlals
• t will not be pidcing up my vehicle upon compietion Customer fnitlals
1 hereby auttrorize the Indivlduai named below bo pidc up my vehkie upon canpletion. I understand that I may need to sign finai paperwork pripr to
my car being pkked up by anoU�er person.Rnai paperwork may be faxed or emalied. !f a tax or emaii is not ava�ade,I understand I wNl need to
make arrengements to come to Padfic�olpsion before my vehicte can be released to anyaie to sign the paperwork.I understar►d ail COD payments
must 6e paid prior to the vehicie being picked up. Please refer to the rnetl�od of payments sectlon.
Name Of person designated to pidc up my vehide:
Phone number of designee:
OESIGNATION OF PERSON TO AUTHORIZE ADDITIONAL WORK OR PART5.
T.TmteW!ItM'4 PPD s RaWttl PMr OMNqB.M.AppmranCe lUbwEKY.IWO a lHYe1�.M Rfor pamfyq PDR.Pa1N1ia 0!M Replk.AM�Altemoarkat,ita[hr a QKlppmd.Ramr�.
nemKwtaclurm.OEM:�+iw Ortginer Eq�prent►un�tacn,rzr.Remr-aetnrcd.U�4.uke Itrid Qu�uty a tJsaa.QaD=Wapnostk.Ekc-�ectrka4 rlan-r�ec+�.Rd=Refm�sn,Shuc=
Structura�
11/8/2012 12:30:23 PM Page 3
Estimate
' RO Number:7001718
Vehkie:2012 MINI Cooper Qubman 3D WGN elue
[f you are unable to be reached d�uing tlie repair process,ycw may efect to designate an addibonal per�on your behave.
• I wi�not need Oo designate another person Customer initl�s
• I wlti need to designate another person Customer inidais
t hereby designate the Individual named bebw to authorize any addkion�work not specifled or pa�ts not Induded in the orlginal wrttOen esdmated
price for parts and labor on my 6ehave:
Name of designee; Des(gnee phone#
Designee Fax#:
Designee Emaii address:__
Signed Date
ACCEPTABLE METNODS OF PAYMENT
We accept Debit,Visa,Master Card,Discovery and Amertcan express up to�1000.QD per daim. G�tomer or immediate famiiy(I.e.Spouse or parent)
transactions only. No third party trarnadions.
We also accept personal checks up to�3000.00 per claim.Customer transactions or�y. We can not accept personai CheCks from deslgnees,spouses or
parencs etc. All personal chedcs must be presented In persan by the astomer oniy. No third party transactlons.
AN personai checks are subJect to approval by Gosscheck at Ume of completlon.In the event the personal d�edc ts not approved,another method of
payment wiq be reqWred at time of delivery
Methods of payment have been ex�ained to me. Customer Midal
T e Tm�aM!Itrn.RND.RekOed P�IOr Oam3pe�M s Apptarance AlWwatx,��L�D�Untclite0 Pror OMt�epe,POR e V�Ntles DaM Repair.A!M.ARemulrlC RlO+t�Rl�aOrtKtl.Rartwe.
RemsnufeRunO.OEM�N!w OriCYW EqulPmeot MtinufMWrer,Reoor a�rup�lK4 e lJlw Wnd Que�H Or Usc4 D�eg'Dk�o��4 EkL.Ekctrkal,Mtth�Me[hankil.R!/�PeM1nnh.Sdu[.
SbumxM
i l/8l2012 12:3023 PM P�e 4
ROBERTS,LAURA;MR#:0002644027;�:1231100520;Arrivai D�:11/06/201210:14;Chert Status:MD Final
Eisenhower Medical Center TRANSITION
39000 Bob Hope Drlve
Rancfio�Atrage,�A RECORD: Visit
T60-340-3911
Highlights
PatieM Name: ROBERTS,LAURA Sex:
8irthdate: Age:
Acct No: Medicai Rec No:
M'iV81 Dt.: 11/08/201210:14 1at Chert I.sunCh Dt.: 11/06/201210:15
P�imary MD: Patiertt has no PCP.
Attending IAD: STEVEN L STEPHANIDES
MD
Chart Stetus: MO Final
Chief Complair�t .
1) MVA (L1SA D BERG AN t fI06/20t2 i024:05) 2) Back pain (l.1SA D BEAG RN 11I06J�20i2 f024:o5�
Patient Reported Aliergies
No Known Allergies[Confirmed by MEAGEIV L BEAVERS RN on 11/06/201210:15:41.j
Patien# Reported Medications
1) Flexeril 10 mg Tab By Mouth Dose: 1 tablet(s) Every 8 hours[Confirmed by STEVEN L
STEPHANIDES MD on 11/06/201211:51:10.]
2) Naprosyn 500 mg Tab By Mouth Dose: 1 tablet(s) 2 Times A Day[Confirmed by STEVEN L
STEPHANIDES MD on 1 i/O6/201211:51:11.J
' Clintcal impression
Motor vehicle accident,driver Low back pain Pain in thoracic spine
Primary DK
1) Motor vehicle accident,driv8r(STEVEN L STEPHANIDES MD i t/06�10121 f:50:3�
2) LOlM baCk pa{11(STEVEN t STEPHAWIDES MD f 1�'1012!�:50:37j
3) Pain in thoracic spine(STEVENL STEPHAN/DESMD i1�10121f:50:37)
Disposition
SCRIBE DOCUMENATION:Written by JOSHUA KASPER SCRIBE acting as scribe for D�.
Stephanides--JOSHUA KASPER SCRIBE(electronic signature). Disposi�on decision is
discharge. Discharged home. Condi�on at discha�e-stable. Etectronically signed by STEVEN
L STEPHANIDES MD. A(i Medical record entries made by the scribe were at my direction. I have
reviewed the chart and agree that the record accurately reflects my persona!performanoe of the
hlstory,physical exam, medicat declsion making, and the emergency department course for this
patient. I fiave also personaily directed reviswed and agree with the discharge instruc�ons and
disposition.--STEVEN L STEPHANIDES MD(electronic signatu�e),
Dtscharge Prescrlptlons
cyciobenzaprine hcl(Flexeril)Oral 10 mg Tablet 1 tablet(s) By Mouth Every 8 Hours (20{twer�ty)
tablet(s))
Naprosyn (naproxen) Oral 500 mg Tabiet 1 tabiet(s) By Mouth 2 Times A Day(20 (twenty)tabiet(s))
���o�zo12��.3e ConfidsnNal Nledical Record,give to follory up provider. Page� ot�
Page 1 of 1
Eisenhower Medical Center
Depa�tment Admitting
CARDHOLDER RECEIPT
Patient Information
Patient First Name Patlent Account Number .
ROBERTS
Patfent Last Name
kAURA
Card Information
v"'lsp� Authorization Number
LAURA C ROBERTS 666440
XXXX-XXXX-XXXX• Transaction ID
** **** 3577444523 ,
Explrat�on Date / , Transaetion Date/Time
il/6/2012 11:50:52 AM
Marchant ID
08741$40001
Description Total
COPAY 100.00 $lOQ.QO
• I agree to pay the above char�es in
accordance with my cardholder agreement
Customer Signature
Retatn this statement for your records.
https://gate.link2gov.com/passporthealth/Print.aspx?TransII�3577444523 11/06/2012
��+� 6586 �'�;�,��,c��u7o ; �01fO�^��+� 6Sg6 �l81 MON'1'EREY AVE.
wrM: 1399561 -o -ossas (T60)674-4738 � Raa: 1399561 -o •obsab (7�68N7�738�'Cn 9zno
LAURA RO$ERT i'r�saibec$TEVEN STEpHANIDES ; LAURA ROBFRT Pre,scriber.STEVEN S7EPHANIDES
---- , ,
Phrnk )
Drug r�wrROXEN SOOMC TABLET ctcy: 20 ; � NAPROXEN 5001KG TABLET �� Qry: 20
t�snCK: 31722-0342-05 �ai n� l l/06/2012 S4S5 � Nncr: 317Z2-0342-OS Fa�nauc i 1/06/ZOi2 S4S5
We can call yonr doctor for a refii6 Pieace ask. � We c�w call yonr doctor for a rei�L Plase adc.
PAPCR9999 Paid N� FAPCIl9999 P�id
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nMw�r�cr p 40101 MOIYfEREY AVE. �
40101 MOM'EREY AVE.
-0�06586 RANCHO MiRA(iE,CA 9227C1 � �^�Y 6SH6 RANCHO MIRAGE.CA 92270
R�w 1399562 (?60�744738 ; rt�e: 1399562 -o -�� (760)674-4738
LAURA RARFQT Pte�ib¢r;$7'EVEN S'fEPHANI�S � LAtJRp ROBERT P�riber.S'fEVEN S7'EP1'L�NiDES
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Drug: CYCLOBEliZAPRUYE lBMG TA$LE�T�Q�y; Zp ; pn,�g; CYCLOBENZAPRIIVE 18MG TABLE�T�� Qty: ZO
NDCf►: 00603-3079-32 Fiti Dacc 11/06I2012 SS.11 ; AtDC+�: 40603-3079-32 Fiil Da� 11/06/2012 55.11
We can cW yonr doctor for a reNL Pleuse ash. ; We cau all yoar doctor for a retW.Pleaae ask.
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Please visit onr website at www.albertsonssavonphsrmaciea.com to start a web account today! Order
refllls,get instaat Ru ready notificaHons via e-mail,and print Ra taa reports at 6ome.
$�on�.
TOTAL AMOUNT DUE: 59.66
LAURA ROBERT
TOTAL PRESCRIPTIONS IN ORDER 2 ���
Call your docoor for me�iicsi advice abouc side t�.You may rop�xt side effecta to FDA at l-800-FDA 1088. Page 1 of 1
����� M �r a
40101 tlONTEREY AVE.
RANCHO MIRAGE. CA 92270
phone M (?60) 674-4769
Store Director - Pete Roc�'1Auez
Cashler:John Z
li/Q6I12 12:44:01
PHARMACY
PRESCRIPTIONSUBTOT�O1U0000 g.� H
TOTAL TAX •�
TOTAI. 9•�
D�i t TEt�ER 9.66
Acct;XliXXX)QA(ilM�
pppRVL. t�O�E 1676up
Cas RefN 1696A �
Cash ��
I�lkBER 0� ITF.MS 1
-- FSA Total $9.66 --------
Use Yau� II��1 th Ca►'e sPending card her'e.
Iteos ending with 'H° c�uatifv for
FSA Wy'�.
Trx:19 Oper 367 tere: 62 Sti e�65,�86
� 11/O6/12
Thank Y��iS�in0 At
Pha►'nacy Phone N t760) 674-4738
www.albertsons.con
C�to� Quesiic�ns
or party Tray Order's
1-877-9Ci2-7946
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6o to: rrw.albert�onsllstens.co�i
Enter Code: 11A66 58600 620019
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STATE OF CALIFOt�11A
�PARTMENT OF CAUFORNIA HK�FNYAY PATROL
TRAFFtC COLIISION REPORT-Property Damage Oniy
CHP 555-03(Rev.7-03) OP1085 O�fo 011�r,er;c�py(les)to ir+volve�party(les)
_. _ _ _ __._ _. _ _
anEcw cor�anoNs rrrsnu� ertr .wo�cw.asm�cr
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I:OUNfY R�ORTNCi018'fRICf BEAT ��IC�p, ..
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q�y �uce►a�►rre�e ... ar^� a�ga ��neaw s�rr¢a�r sM+►oE (ALLIED AC�ENCY USE ONLY)
. 1 �.. t'; �•- pAl�l►GED
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IMPORTANT-READ CAREFULLY
Keep this report. This is your record of thls acxcx:irdent. To aompiy wi#h Califomia Vehide Code(VC)Secti�on 20002(duty where
property dama�d),you must either.
a.Give the ovmer or person in charge of such property the name and address of the drive�and owner of the vehide;or in the
absence of the owner,
b.Leave a w�itten notice in a consplcuous place on the other vehide or damaged property,giving the name and addness of the
dtiver end owner of the vehtGe involved and a statemeM of the arc;umstances.
This infaYnation is nece.s�ry for the completion of ya�r state SR-1 Form,Report of Trafftc Accident,and your insurance report.
VEHICLE CODE SEC170N 16000
The driver of a vehicle invoived in an accident resulting in damage to the properly of any ONE party in excess of$750 or in the
injury or death of any person MUST submit a SR-1 Fam to the Califomia Department of Motor Vehicles wi#hin 10 days,o�as
soon as possibfe.
Note: Failure to comply may result in suspension of your d�ivers lioense.
Form SR-1 may be obtained from the Department of Motor Vehides,the Califomia Highway Patrol,any pdice stadon, motor
vehicle club, insurance agent,or DMV intemet web site(SR-1A).
If city or state property is damaged,you wiA be contacted regarding paBsible liability.
Law enforcement reports do not satisfy the OMV report requiremeM.
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