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PW Damage to City Property SettlementViking Insurance Company of Wisconsin May 15, 2017 PO BOX 8040 Stevens Point, WI 54481-9996 DAL LAND T T Claim Number: �y �J Insured: -AJL1—rC3. Regarding: Date of Loss: CITY OF SAN RAFAEL INVOICE #11897 1400 5TH AVE SAN RAFAEL CA 94901-1943 97AO49103-378 HERIBERTO ALVARADO CITY OF SAN RAFAEL 11/26/2016 We have concluded our investigation into the accident which occurred on 11/26/2016. We have determined that the total amount of the property damage claims being presented resulting from this loss exceeds the limit of coverage available to our policyholder. The available coverage limit is $10,000 for property damage. To conclude this claim in a manner that is as equitable as possible, we hereby extend the following offers based on a proportionate share of the available coverage: Name Presented Pro -rata Offer City of San Rafael $4,752.73 $3,036.60 AT&T $10,898.77 $6,963.40 Total $15,651.50 $10,000.00 All parties must agree to our offers and sign the release of all property damage claims confirming they will take no further action against our insured before any payments can be issued. Please have your insured sign the release as well as a representative of your company. Or you may submit a made whole letter on behalf of your insured, if you have made your insured whole or will make them whole once you receive our settlement check. Once we are in receipt of all the properly executed release, the settlement checks will be issued accordingly. Please sign the enclosed property damage release, and return it to my attention as soon as possible. We thank you in advance for your cooperation and if you have any questions or concerns, please do not hesitate to contact me at (949) 930-5339. Jessica Urena, Claims Representative II Viking Insurance Company of Wisconsin A Member of the Sentry Insurance Group 800-334-0090 Ext 1675339 888-729-2225 Fax jessica.urena@sentry.com Enclosure: 170515020226 0300 01-3-qu 003009086a400100000094901194300 9 7 A 0 4 9 1 0 3- 3 7 8 Viking Insurance Company of Wisconsin PO BOX 8040 Stevens Point, WI 54481-9996 DAIP.. YLAN D CITY OF SAN RAFAEL INVOICE #11897 1400 5TH AVE SAN RAFAEL CA 94901-1943 111"11111111 1111111 Jill May 15, 2017 Claim Number: 97A049103-378 Insured: HERIBERTO ALVARADO Date of Loss: 11/26/2016 Please complete the enclosed Property Damage Release Form so we may proceed with the handling of this claim. If you have any questions, contact me. Jessica Urena, Claims Representative 11 Viking Insurance Company of Wisconsin A Member of the Sentry Insurance Group 800-334-0090 Ext 1675339 888-729-2225 Fax jessica. urena@sentry.com Enclosure: Property Damage Release 170515020226 5919 0030090868400100000094901194300 9 7 A 0 4 9 1 0 3- 3 7 8 Claim Number: 97AO49103-378 Date Of Loss: 11/26/2016 Date: May 15, 2017 Insured: HERIBERTO ALVARADO Sent to: CITY OF SAN RAFAEL [/We, CITY OF SAN RAFAEL, being of lawful age, acknowledge settlement of property damage only in the sum of $3,036.60 (three thousand thirty six and 60/100) in return for which I1\Ne hereby release Viking Insurance Company of Wisconsin and HERIBERTO ALVARADO, from any and all claims for property damage only, as the result of an accident on or about November 26, 2016. This release includes all known and unknown property damages. In making this agreement, I/We am relying wholly on my own judgment concerning the nature and extent of property damages only and [/We understand this release is full and final. CAUTION: READ BEFORE SIGNING! IANE HAVE READ AND UNDERSTAND THIS RELEASE. I/We acknowledge and agree that by reason of the release contained herein, and for the valuable consideration received, I/we assume the risk of such unknown and unanticipated claims and agree that this release applies thereto. In this regard, I/we expressly waive the benefits of Section 1542 of the California Civil Code, which Section reads as follows: A general release does not extend to claims which the creditor does not know or suspect to exist in his or her favor at the time of executing the release, which if known by him or her must have materially affected his or her settlement with the debtor. For your protection California law requires the following to appear on this form. Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines confinem . s ate prison. X Jim/hSchtZ. City )lana r Signature Date 1/ Signature STATE OF } ( ss: COUNTY OF ) Date Personally appeared before me the person(s) whose signature appears above on this day of 20 , and executed this instrument in my presence. (signature of Notary) (NOTARY SEAL) Notary Public, State of My commission expires: 170515020226 5919 0030090868400100000094901194300 9 7 A 0 4 9 1 0 3- 3 7 8 DOCCLMS 97AO49103 ViNng Insurance Company of Wisconsin PO BOX 8040 II�I'IIIIII�IIIIIIIIIII) REL Stevens Point VVI 54481-9996 Please fold for return envelope window. 378 LEG ACKNOWLEDGMENT A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document. State of California County of Marin On S12 a /2oi before me, E. Beirne, Notary Public (insert name and title of the officer) personally appeared '� SC u U , z who proved to me on the basis of satisfactory evidence to be the person(s) whose name(O/are subscribed to the within instrument and acknowledged to me thato/she/they executed the same in ri /her/their authorized capacity(ies), and that by &her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. WITNESS my hand and official seal. E. BEIRNE COMM. #2112433 z ce Notary Public • California o Z Marin County My Comm. Expires June 10, 2019 Signature -'e `'`� (Seal) CITY OF SAN RAFAEL, CALIFORNIA DEPARTMENT OF PUBLIC WORKS I INTERDEPARTMENTAL MEMORANDUM PRIVILEGED & CONFIDENTIAL TO: JIM SCHUTZ DATE: May 18, 2017 City Manager FROM: TALIA SMITH 15 4Tµ FILE NO: Senior Administrative Analyst SUBJECT: Damage to City Property — Settlement On November 26, 2016, Heriberto Alvarado Suarez, hit and knocked down a traffic signal pole and destroyed the communication box located at Kerner and Bellam Blvd. DC Electric did the repairs to the pole and property. They sent an invoice to DPW in the amount of $4,752.73. DPW prepared and sent a cost report to Finance. In turn, Finance sent an invoice to Mr. Suarez. His insurance company responded with a settlement amount of $3,036.60, $1,716.13 short of the full amount owed. DPW was notified by the Marin County Probation Department, Adult Services Division that the City could seek to recover the full amount through the restitution process with the Court. DPW emailed Lonnie Morris, Deputy Probation Officer for a recommendation on how to proceed. He advised the following: In reviewing the claim letter your agency submitted dated 2-2-17 for $4,752.73, 1 would accept their offer (for $3,036 60). Currently this defendant's whereabouts are unknown and his mailing is being returned. Please sign the attached Release Form. DPW will return it to the insurance company and will follow up with them for payment. Thank you. CONTRACT ROUTING FORM INSTRUCTIONS: Use this cover sheet to circulate all contracts for review and approval in the order shown below. TO BE COMPLETED BY INITIATING DEPARTMENT PROJECT MANAGER: Contracting Department: Public Works Project Manager: Talia Smith Extension: 3354 Contractor Name: Viking Insurance Company — Settlement — Damage to City Property - Suarez Contractor's Contact: Jessica Urena Contact's Email: Jessica.urena@sentry.com ❑ FPPC: Check if Contractor/Consultant must file Form 700 Step RESPONSIBLE DESCRIPTION COMPLETED REVIEWER DEPARTMENT DATE Check/Initial 1 Project Manager a. Email PINS Introductory Notice to Contractor Click here to ❑ enter a date. N/A b. Email contract (in Word) & attachments to City Click here to Atty c/o Laraine.Gittens@cityofsanrafael.org enter a date. N D M 2 City Attorney a. Review, revise, and comment on draft agreement Click here to and return to Project Manager enter a date. N b. Confirm insurance requirements, create Job on Click here to LG PINS, send PINS insurance notice to contractor enter a date. ❑ _N/A_ 3 Project Manager Forward three (3) originals of final agreement to Click here to ❑ contractor for their signature enter a date. 4 Project Manager When necessary, * contractor -signed agreement ❑ N/A agendized for Council approval *PSA > $20,000; or Purchase > $35,000; or Or ❑ Public Works Contract > $125,000 Date of Council approval Click here to enter a date. PRINT CONTINUE ROUTING PROCESS WITH HARD COPY 5 Project Manager Forward signed original agreements to City Attorney with printed copy of this routing form 6 City Attorney Review and approve hard copy of signed 5-1/ agreement // N"d' 7 City Attorney Review and approve insurance in PINS, and bonds (for Public Works Contracts) 8 City Manager/ Mayor Agreement executed by Council authorized official Z, 9 City Clerk Attest signatures, retains original agreement and u forwards copies to Project Manager �•?°�— i'y �r13_ q-3-40