CITY OF EMERYVILLE
CLAIM FORM
Please Type or Print and return to:
City Attorney's Office, City of Emeryville
1333 Park Avenue Emeryville, Ca 94608
Phone: 510.596.4380 Fax: 510.596.3724
CLAIM AGAINST Public Works City of Emeryville
(Name of Entity)
Claimant's name Sunny Pak SS#
Claimant's date of birth Telephone #1
Claimant's address.
Address where notices about claim are to be sent, if different from above:
June 17th, 2022
Date of incident/accident:
Date injuries, damages, or losses were discovered: June 17th, 2022 at 3:35PM 2300 block of Powell St (facing eastbound)
Location of incident/accident:
Weed wacking/grass cutting was done on side walk
What did entity or employee do to cause this loss, damage, or injury?. of where the car was parked. Visible freshly cut weeds/grass was on vehicle as well as multiple rocks all over the vehicle with rock chips and shattered windows. (Use back of this form or separate sheet if necessary to answer this question in detail.) What are the names of the entity's employees who caused this injury, damage, or loss (if known)? Public Works of Emeryville Unable to specify employees that worked that block
What specific injuries, damages, or losses did claimant receive? Shattered front passenger window, damages on hood, windshield, both passenger doors, fender, and quarter panel. (Use back of this form or separate sheet if necessary to answer this question in detail) What amount of moncy is claimant seeking, or which is the appropriate court of jurisdiction [Government Code 910(f)|? Amount towards damages to the vehicle per insurance claim and other expenses due to damages How was this amount calculated (please itemize)? Please refer to insurance claim adjuster and total estimate. (Use back of this form or separate sheet if necessary to answer this question in detail) Date Signed: 08/31/2022 Signature: Sunny Pake
If signed by representative:
Representative's Names. Address.
Telephone #.
Relationship to Claimant: