On July 25, 2022 a
Clerk Notice
was filed
involving a dispute between
Plummer, Gilbert,
and
Calmex Engineering, Inc.,
Does 3-30,
J. Mcloughlin Engineering Co., Inc,
Mcdaniel, Michael,
State Of California,
for Other PI/PD/WD Unlimited
in the District Court of San Bernardino County.
Preview
vxemmem Claims Pfogrom
STATE OF CALIFORNIA DEPARTMENT OF GENERAL SERVICES
GOVERNMENT CLAIM FEB 2‘! 2022
OFFICE 0F RWD “fig RANCE MANAGEMENT
Des ORIM 006 (Rev. 08/19)
RECENED 33%”
CLAIMANT INFORMATION
LAST NAME FIRST NAME MIDDLE lNlTlAL
PLUMMER GILBERT S.
:NMATE 0R PATIENT IDENTIFICATION NUMBER (it applicable) Busmess NAME(ir applicable)
N/A N/A
TELEPHONE NUMBER EMAIL ADDRESS
(951) 722-7893 dark5id992571 @gmai|.com
MAILING ADDRESS CITY STATE ZIP
1526 KENAN WAY POMONA CA 90950
IS THE CLAIMANT UNDER 18 YEARS 0F AW? INSURED NAME(Insurance Company Subrogation)
D Ya:
I No
Is THIS AN AMENDMENT To A PREVIOUSLY exISTING CLAIM? exssrme cLAuM NUMaER (srappncame) ensnne CLAIMANT NAME(«appncable)
D Yes
E No
ATTORNEY 0R REPRESENTATIVE INFORMATION
LAST NAME FIRST NAME MIDDLEINITIAL
LAW OFFICE OF JEFFREY S. DAWSON, APC Jeffrey S. Dawson/Mary Luetto Nichols
TELEPHONE NUMBER EMAIL ADDRESS
(949) 861 -21 91 DAWSONeSERVICE@pi-attorney.com
MAILING ADDRESS CITY STATE ZIP
9841 IRVINE CENTER DRIVE, SUITE 210 IRVINE CA 92618
CLAIM INFORMATION
STATE AGENCIES 0R EMPLOYEES AGAINST WHOM THECLAIM Is FILED DATE 0F INCIDENT
STATE OF CALIFORNIA, DEPARTMENT OF TRANSPORTATION 08/27/2021
LATE CLAIM EXPLANATION (Required, If incident was more than six months ago)
N/A
DOLLAR AMOUNT OF CLAIM CIVIL CASE TYPE(Required.ifamount is morethan $10,000)
Claim Exceeds $10,000.00 [Gov't Code, Sect. 910(f)] [T Non—Limited (over$25.000) D Limited($25.0000rlass)
DOLLAR AMOUNT EXPLANATION
SEE ATTACHMENT TO CLAIM AGAINST THE STATE OF CALIFORNIA, DEPT. OF TRANSPORTATION
INCIDENT LOCATION
WESTBOUND 60 FREEWAY, APPROX. 600 FEET EAST OF EUCLID AVENUE, IN ONTARIO, CA
SPECIFIC DAMAGE OR INJURY DESCRIPTION
SEE ATTACHMENT TO CLAIM AGAINST THE STATE OF CALIFORNIA, DEPT. OF TRANSPORTATION
CIRCUMSTANCES THAT LED TO DAMAGE OR INJURY
SEE ATTACHMENT TO CLAIM AGAINST THE STATE OF CALIFORNIA. DEPT. OF TRANSPORTATION
EXPLAIN WHY YOU BELIEVE THE STATE IS RESPONSIBLE FOR THE DAMAGE OR INJURY
SEE ATTACHMENT TO CLAIM AGAINST THE STATE OF CALIFORNIA, DEPT. OF TRANSPORTATION.
Page1 of 2
I
STATE OF CALIFORNIA
'
c
\ I ‘
‘
' .
V
DEPARTMENT OF GENERAL SERVICES
GOVERNMENTCLA'M OFFICE OF RESKANDINSURANCE MANAGEMENT
DGS ORIM 006 (Rev. 08/1 9)
AUTOMOBILE CLAIM INFORMATION
DOES THE CLAIM INVOLVE A STATE VEHICLE?
VEHICLE UCENSE NUMBERm known STATE DRIVER NAME
m Ya I No 7HMK881 MICHAEL McDANlEL
(if known)
HAS A CLAIM BEEN FILED WITH YOUR INSURANCE CARRIER? INSURANCE CARRIER NAME INSURANCE CLAIM NUMBER
Yes
D No ALLIANCE UNITED INS. 21 123779171
HAVE YOU RECENEDAN INSURANCE PAYMENT FOR THIS DAMAGE OR INJURY?
AMOUNT RECEIVED (n any) AMOUNT 0F DEDUCTIBLEM any)
D Yes No
'
NONE N/A
NoncE AND'sIGNATURE '
'
|declare under penalty of perjury under the laws of the State ofCalifornia
that ali the information have provided istrue and l
correct to
the best of my information and belief. Ifurther understand that if
have provided information that is false, intentionally incomplete,
|
or
misleading may
sacz'onm
l
ber
with
A.
ny punishable by up to four yearsin state prison and/ora fine of up
‘
to $1 0.000(PenalCode
sr NAT PRINTED NAME DATE
-
Jeffrey S. Dawson/Mary Luetto Nichols 02/18/2022
,,
v
ms-raucnons ' V
V
- Include a check ormoneyorderfor$25.payableto the State ofCalifornia.
0 $25filing fee is not required for
amendments to existing claims.
o Confirm all sections relating to this claim are complete and theform is signed.
o Attach copies ofany documentation that supports your claim. Do not submit originals.
Mail the claim form and all attachments to:
Claim forms can also be delivered to:
Office of Riskand Insurance Management Office of Risk and Insurance Management
Government Claims Program Government Craims Program
P.O.Box 989052, M8414 707 3rd Street. 1st Floor
‘
West Sacramento,CA 95798-9052 West Sacramento.CA 95605
1-800-955-0045
Department of General Services Privacy Notice on Information Collection
This notice is provided pursuanttothelnformation Practices Act of 1977. California CivilCode
Sections1798.17&1798.24and the Federal
Privacy Act (Public Law93-579).
The Department of General Services(DGS).Office of Risk and Insurance Management
(ORIM),is requesting the information specified on this
form pursuantto Government Code Section 905.2(c).
The principal purpose forrequesting this daia is to process claims against the state The information
provided willlmay be disclosed to a person,or
to anotheragency where the transfer is necessary forthe transferee-agencyto
perform its constitutional or statutory duties.and the use is
compatibre with a purpose for which the information was collected and the use or transfer is accounted for in accordance with California Civil Code
Section 1798.25.
Individuals should not provide personal information that is not requested.
The submission ofall information requested is mandatory unless otherwise noted. If you faii to provide the information requested toDGS,or if the
information provided is deemed incomplete or unreadabte, this may result in a delay in processing.
Department Privacy Policy
The information collected by DGS ls subject to the limitations in the Information Practices Actof 1977and
statepolicy (see State Adminis‘rative
Manual 531 045310.71. For more information on howwe care foryourpersonal information. please read the
DGS PrivacyPolicy.
Access to Your Information
ORIM responsible formaintaining collected records and retaining them for5 years.
is
You have a right to access records containing personal
information maintained bythe state entity. To requestaccess,contact:
DGSORIM
Public Records Officer
707 3'dSt., West Sacramento,CA 95605
{915) 376-5300
Page2 of 2
Document Filed Date
July 25, 2022
Case Filing Date
July 25, 2022
Category
Other PI/PD/WD Unlimited
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vxemmem Claims Pfogrom STATE OF CALIFORNIA DEPARTMENT OF GENERAL SERVICES GOVERNMENT CLAIM FEB 2‘! 2022 OFFICE 0F RWD “fig RANCE MANAGEMENT Des ORIM 006 (Rev. 08/19) RECENED 33%” CLAIMANT INFORMATION LAST NAME FIRST NAME MIDDLE lNlTlAL PLUMMER GILBERT S. :NMATE 0R PATIENT IDENTIFICATION NUMBER (it applicable) Busmess NAME(ir applicable) N/A N/A TELEPHONE NUMBER EMAIL ADDRESS (951) 722-7893 dark5id992571 @gmai|.com MAILING ADDRESS CITY STATE ZIP 1526 KENAN WAY POMONA CA 90950 IS THE CLAIMANT UNDER 18 YEARS 0F AW? INSURED NAME(Insurance Company Subrogation) D Ya: I No Is THIS AN AMENDMENT To A PREVIOUSLY exISTING CLAIM? exssrme cLAuM NUMaER (srappncame) ensnne CLAIMANT NAME(«appncable) D Yes E No ATTORNEY 0R REPRESENTATIVE INFORMATION LAST NAME FIRST NAME MIDDLEINITIAL LAW OFFICE OF JEFFREY S. DAWSON, APC Jeffrey S. Dawson/Mary Luetto Nichols TELEPHONE NUMBER EMAIL ADDRESS (949) 861 -21 91 DAWSONeSERVICE@pi-attorney.com MAILING ADDRESS CITY STATE ZIP 9841 IRVINE CENTER DRIVE, SUITE 210 IRVINE CA 92618 CLAIM INFORMATION STATE AGENCIES 0R EMPLOYEES AGAINST WHOM THECLAIM Is FILED DATE 0F INCIDENT STATE OF CALIFORNIA, DEPARTMENT OF TRANSPORTATION 08/27/2021 LATE CLAIM EXPLANATION (Required, If incident was more than six months ago) N/A DOLLAR AMOUNT OF CLAIM CIVIL CASE TYPE(Required.ifamount is morethan $10,000) Claim Exceeds $10,000.00 [Gov't Code, Sect. 910(f)] [T Non—Limited (over$25.000) D Limited($25.0000rlass) DOLLAR AMOUNT EXPLANATION SEE ATTACHMENT TO CLAIM AGAINST THE STATE OF CALIFORNIA, DEPT. OF TRANSPORTATION INCIDENT LOCATION WESTBOUND 60 FREEWAY, APPROX. 600 FEET EAST OF EUCLID AVENUE, IN ONTARIO, CA SPECIFIC DAMAGE OR INJURY DESCRIPTION SEE ATTACHMENT TO CLAIM AGAINST THE STATE OF CALIFORNIA, DEPT. OF TRANSPORTATION CIRCUMSTANCES THAT LED TO DAMAGE OR INJURY SEE ATTACHMENT TO CLAIM AGAINST THE STATE OF CALIFORNIA. DEPT. OF TRANSPORTATION EXPLAIN WHY YOU BELIEVE THE STATE IS RESPONSIBLE FOR THE DAMAGE OR INJURY SEE ATTACHMENT TO CLAIM AGAINST THE STATE OF CALIFORNIA, DEPT. OF TRANSPORTATION. Page1 of 2 I STATE OF CALIFORNIA ' c \ I ‘ ‘ ' . V DEPARTMENT OF GENERAL SERVICES GOVERNMENTCLA'M OFFICE OF RESKANDINSURANCE MANAGEMENT DGS ORIM 006 (Rev. 08/1 9) AUTOMOBILE CLAIM INFORMATION DOES THE CLAIM INVOLVE A STATE VEHICLE? VEHICLE UCENSE NUMBERm known STATE DRIVER NAME m Ya I No 7HMK881 MICHAEL McDANlEL (if known) HAS A CLAIM BEEN FILED WITH YOUR INSURANCE CARRIER? INSURANCE CARRIER NAME INSURANCE CLAIM NUMBER Yes D No ALLIANCE UNITED INS. 21 123779171 HAVE YOU RECENEDAN INSURANCE PAYMENT FOR THIS DAMAGE OR INJURY? AMOUNT RECEIVED (n any) AMOUNT 0F DEDUCTIBLEM any) D Yes No ' NONE N/A NoncE AND'sIGNATURE ' ' |declare under penalty of perjury under the laws of the State ofCalifornia that ali the information have provided istrue and l correct to the best of my information and belief. Ifurther understand that if have provided information that is false, intentionally incomplete, | or misleading may sacz'onm l ber with A. ny punishable by up to four yearsin state prison and/ora fine of up ‘ to $1 0.000(PenalCode sr NAT PRINTED NAME DATE - Jeffrey S. Dawson/Mary Luetto Nichols 02/18/2022 ,, v ms-raucnons ' V V - Include a check ormoneyorderfor$25.payableto the State ofCalifornia. 0 $25filing fee is not required for amendments to existing claims. o Confirm all sections relating to this claim are complete and theform is signed. o Attach copies ofany documentation that supports your claim. Do not submit originals. Mail the claim form and all attachments to: Claim forms can also be delivered to: Office of Riskand Insurance Management Office of Risk and Insurance Management Government Claims Program Government Craims Program P.O.Box 989052, M8414 707 3rd Street. 1st Floor ‘ West Sacramento,CA 95798-9052 West Sacramento.CA 95605 1-800-955-0045 Department of General Services Privacy Notice on Information Collection This notice is provided pursuanttothelnformation Practices Act of 1977. California CivilCode Sections1798.17&1798.24and the Federal Privacy Act (Public Law93-579). The Department of General Services(DGS).Office of Risk and Insurance Management (ORIM),is requesting the information specified on this form pursuantto Government Code Section 905.2(c). The principal purpose forrequesting this daia is to process claims against the state The information provided willlmay be disclosed to a person,or to anotheragency where the transfer is necessary forthe transferee-agencyto perform its constitutional or statutory duties.and the use is compatibre with a purpose for which the information was collected and the use or transfer is accounted for in accordance with California Civil Code Section 1798.25. Individuals should not provide personal information that is not requested. The submission ofall information requested is mandatory unless otherwise noted. If you faii to provide the information requested toDGS,or if the information provided is deemed incomplete or unreadabte, this may result in a delay in processing. Department Privacy Policy The information collected by DGS ls subject to the limitations in the Information Practices Actof 1977and statepolicy (see State Adminis‘rative Manual 531 045310.71. For more information on howwe care foryourpersonal information. please read the DGS PrivacyPolicy. Access to Your Information ORIM responsible formaintaining collected records and retaining them for5 years. is You have a right to access records containing personal information maintained bythe state entity. To requestaccess,contact: DGSORIM Public Records Officer 707 3'dSt., West Sacramento,CA 95605 {915) 376-5300 Page2 of 2