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 City of Emeryville
(Name of Entity)
Andrea Arriaga
Claimant's name SS#
Claimant's date of birth Telephone #
Claimant's address
Address where notices about claim are to be sent, if different from above:
3/14/2023
Date of incident/accident:
Date injuries, damages, or losses were discovered: 03/14/2023 Location of incident/accident: City Hall- Back employee parking lot What did entity or employee do to cause this loss, damage, or injury? The tree planted in parking lot planter, folion my car. Tree falling may have been caused by the rain and high winds that day. Another employee alerted me that the tree had fallen and may have damaged my car. Went outside and the tree was laying on the ground, pushed up against my car. (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) No employees What specific injuries, damages, or losses did claimant receive? On the back driver's side of car, scratches and dent by gas tank. Please see attached pictures.
(Use back of this form or separate sheet if necessary to answer this question in detail) What amount of money is claimant seeking, or which is the appropriate court of jurisdiction [Government Code 910(t)? $1,433.86
How was this amount calculated (please itemnize) Please see attachments.
Geico Auto Deductible $1,000.00 and Enterprise Car Rental $433.86 5 days. (Use back of this form or separate sheet if necessary to answer this question in detail) Date Signed: 04/20/2023
Signature:
If signed by representative:
Representative's Names. Address
Telephone #
Relationship to Claimant: