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
See attached
CLAIM AGAINST.
(Name of Entity)
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:
Date of incident/accident:
Date injuries, damages, or losses were discovered:
Location of incident/accident:
What did entity or employee do to cause this loss, damage, or injury? (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)? What specific injuries, damages, or losses did claimant receive? (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(f)]?.
How was this amount calculated (please itemize)?.
(Use back of this form or separate sheet if necessary to answer this question in detail) Date Signed: Signature:
If signed by representative:
Representative's Names _Address
Telephone #.
Relationship to Claimant:
SCRANTON LAW FIRM
May 18, 2023
Via Certified U.S. Mail
1333 Park Avenue
Emeryville, CA 94608
CITY OF EMERYVILLE CLAIM FORM
To: City Attorney's Office
Claim Against City of Emeryville
Claimant's name Kyle Ching
SS#
Claimant's date of Birth
Telephone #
Claimant's address
Address where notices Jamie Retmier, Esq.
about claim are to be sent, Scranton Law Firm
if different from above: 2450 Stanwell Drive
Concord, CA 94520
Date of incident: 12/09/2022
Date injuries, damages, 12/09/2022
or losses were discovered:
Location of incident: 53d St., between Hollis St. and Boyle St.
What did entity or On 12/09/2022, Claimant was riding his bike home from employee do to work when the front tire of his bike got caught in a road defect, Cause this loss, damage, causing Claimant to fly off his bike and hit the ground. The street Representing accident victims for over 35 years
Main California Office FAX 925 676 9999
2450 Stanwell Drive 925 602 2727
Concord, CA 94520-4825 www.scrantonlawfirm.com
SCRANTON LAW FIRM
or injury? where Claimant was injured was negligently owned, managed, maintained, and/or controlled by the City of Emeryville.
What are the names of City of Emeryville employees, whose names are unknown to the entity's employees Claimant.
who caused this injury,
damage, or loss (if known)?
What specific injuries, Claimant sustained a concussion, multiple fractures in skull, damages, or losses scrapes to face and knuckles, a bleeding nose, damage to did claimant receive? his teeth, and lost consciousness at the time of the incident, incurring medical specials, lost wages, and property damage.
General damages according to proof.
What amount of money In excess of $100,000.
is claimant seeking, or
which is the appropriate
court of jurisdiction
[Government Code 910(f)]?
How was this amount Medical bills, lost wages, and property damage. General damages calculated (please itemize)? according to proof.
If signed by representative:
Representative's Names Jamie V. Retmier, Esq.
Address Scranton Law Firm, 2450 Stanwell Drive, Concord, CA 94520 Telephone # (925) 288-6863
Relationship to Claimant: Attorney
Dated: May 18, 2023 SCRANTON LAW FIRM
TIER, ESQ.
Auousey for cramant
Kyle Ching
Representing accident victims for over 35 years
Main California Office FAX 925 676 9999
2450 Stanwell Drive 925 602 2727
Concord, CA 94520-4825 www.scrantonlawfirm.com