HomeMy WebLinkAboutResolution No. 5252RESOLUTION NO. 5252
A RESOLUTION AUTHORIZING THE SIGNING
OF AN INSURANCE RELEASE
THE CITY COUNCIL OF THE CITY OF SAN RAFAEL HEREBY RESOLVES as follows:
The MAYOR and CITY CLERK are authorized to execute, on be-
half of the City of San Rafael, a release with MICHAEL M. FEDEROFF,
a copy of which is hereby attached and by this reference made a part
hereof.
I, MARION A. GRADY, City Clerk of the City of San Rafael,
hereby certify that the foregoing Resolution was duly and regularly
introduced and adopted at a regular meeting of the City Council
of said City held on Monday the 7th day of February
1977, by the following vote, to wit:
AYES: COUNCILMEN: Jensen, Miskimen, Mulryan, Nixon and Mayor Bettini
NOES: COUNCILMEN: None
ABSENT: COUNCILMEN: None
MARION A. GRADY, City Cl rk
��
IGI�1AL
RELEASE OF ALL CLAIMS
Tobe executed by City -o ... Sari .1 of -1-------------------------------------------------------------------------------------------------------------_-----
The undersigned do(es) hereby acknowledge receipt of Draft No.. ....)48.06266L ----------------- --------------------------------------
for.. -ONE TH-- -- - D_.EIGHT_-INNDRBD.. F..A;I�1A__8_��lOQ-----�!--�-"-- ,���--Dollars ($..1 803.87------�
Payableto ....... -CAy.of Sart Rafael--•-----------•-••--------------------------------_...........---•••-•----.................
................................. ...•-...................................................................................................................................... ..........................
which draft is accepted in full compromise settlement and satisfaction of, and as sole consideration for the
final release and discharge of, all actions, claims and demands whatsoever, that now exist, or may hereafter
accrue, against ------- Nichae]-. M•._FedRxo;U_....._..._.
.. _ .....--•-•-----------------------------------------------------------------------------------------•-•-........------------------------------------------- -.
and any other person, corporation, association or partnership responsible in any manner or degree for injuries
to the person and property of the undersigned, and the treatment thereof, and the consequences flowing
therefrom, as a result of an accident, casualty or event which occurred on or about the ---------- I----------------------
-------..19_...76at or near -�afael�___f'a�iforrii8 ...........................
dayof _.,�ej?teml2ex------------------------ _._..-•-•---.._....----------------•-
- - - - I �-..........'.-•--•'-•��•---hel--•,-I--I �' ers� {�s ' r pg?' 1 �e g y � ---r--------------------
.... ........... .�_ t _ - p 11 P ;-fi....l .._L._........... .
fitnd for wli chhe unde igned cla s t above; named t'es ar legally iia le in damages
k liwbi,cli legal•Iia, lily and amages (Fe dispu, ed,gnd ` eniec,
�I 'The undersigned Warrants, that r}q promise or�nducement; � qs been offered except 9s herein set forth;
that this release, its execui4d without re i� nqe upon � any statem�t 4r repress �ation by the perrson or parties
released, ori their representatives of ph siciotns� concerniif
j g the' a ilre and 'e tent of the injuries and conse-
ue tial da a s if an and of lega 1 ability therefor, if' ariy; hat the unde igned is f legal age, legally
q P gg y,, .
�competent to ex ute tl'is,ieleas� and afcepts full, responsibility 141ef9r, an�li
iThe undersig ied agrees, as ;a �#urthrr consideration and induct ent for is compromise settlement, that
it sl3alj atrpl� to a 1 unkpown and unanticipated injuries a a dounq!Fes resulting flrom said accident, casualty
or event, I as �vell to tllose now Oi�clo$ d. j
`I 'The un8ersig ed hereby exprgsslyw waives the provisi ns of tSet;tioi 1542 of tti Civil Podi of the tate of
Ctrl fornig, which eads,as follows:
"A general ,release does not tend to laims which the credi r does not kr}ovz or suspect to exist in his
favor at the timg f executing the lease, wVch if kriown l�y hiT ust have materially of acted his settlement
with the debtor.'( �
And. -We ----- do de lore that ----- thj__ apat#1 teB...U1e--.slit�tils�plsAf.....Qf--mY---------
t............• -,----------------------------------
_.claim- _arising aut.-af- TVe C 4�d._c]a3m... .. I
II i ----------------- ----•----•- ----------••-----•---••---.
i"" ,
--------------------------------------------------------- •------------------------ ----------------- -------------------------------------
i
t
Signed at ----- r _�__'`"=---------thisi--/v7kd[y of__._c_6_•!-�_:.
.. 19 --- .7..7
)y� CITY/ STA E CAUTION: READ BEFOBE SIGNIIVG
WITNESS TO SIGNATURE.
(-
-'�-1---"--- DRES SIGNATURE
11
2
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UR ,/ii �WITNESS7 51GNATZ J
�C � L — ------------•-----•----------------------
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ADDRESS (� I
SIGNATURE
............. ........___..•_-..__--___-._
For your protection California law requires the following to appear on this form. 556. Its unlawful to: (a) Present or cause to be presented any
false or fraudulent claim for the payment of a loss under a contract of insurance. (b) Pre are, make, or subscribe any writing, With intent to present
or use the same, or to allow it to be presented or used in support of any such claim. Every(person who violates any provision of this section is pun-
ishable by imprisonment in the State prison not exceeding three years, or by fine not exceeding one thousand dollars, or by both.
(OVER)
F 1480 (REV. 8, (18)