CITY OF EMERYVILLE
CLAIM FORM
Please Type or Print and return to:
City Attorney's Office, City of Emeryville DEC 22 RECD
1333 Park Avenue Emeryville, Ca 94608
Phone: 510.596.4380 Fax: 510.596.3724
CLAIM AGAINST City of Emergville
(Name of Entity)
Claimant's name Benjamin Andrew Stein SS#
Claimant's date of birth Telephone #
Claimant's address.
Address where notices about claim are to be sent, if different from above: Sane address Date of incident/accident: October l4th, December 17th, Dziember 19th 2022 Date injuries, damages, or losses were discovered: December 1 Ith, 2022 Location of incident/accident:
What did entity or employee do to cause this loss, damage, or injury? Lack of desporise, leading to further injure t presention of reactions of in Derogator email reconse. resense to Gishifront
What are the names of the entity's employees who caused this injury, damage, or loss (if known)?. prysicel Managet injury.
Mayor John J. Bateri, City Atorney John Kenness ty, falice service Ditchess Booze,
What specific injuries, damages, or losses did claimant receive? Lack of response leading to further injury ant preventian of fustter injury. leraçatory email response for serious cancern (Use back of this form or separate sheet if necessary to answer this question in detail) Invitin What maur of money chiname scies or lid be approprint out of picion beement cute it on talki -$5,000,000.00, Unlimited Furisdiction
How was this amount calculated (please itemike? This is a fair amount for this response injury. cut lack ot
Date Signed: 12/20/2022 Signature:_ Ben Sti
If signed by representative:
Representative's Names. Address
Telephone #
Relationship to Claimant: