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
City of Emeryville; Emeryville Police Department
CLAIM AGAINST
(Name of Entity)
Muneer Nageeb Mohamed Ali
Claimant's name SS#
Claimant's date of birth Telephone # (
Claimant's address
4929 Wilshire Blvd., Suite 960, LA, CA, 90010
Address where notices about claim are to be sent, if different from above:
02/03/2023
Date of incident/accident:
02/03/2023
Date injuries, damages, or losses were discovered:
Hollis St. & W. MacArthur Blvd, Emeryville CA
Location of incident/accident:
Officer Andrew Gary Shelby, Emeryville
What did entity or employee do to cause this loss, damage, or injury? Police Department
(Use back of this form or separate sheet if necessary to answer this question in detail.) Officer Andrew Gary Shelby
What are the names of the entity's employees who caused this injury, damage, or loss (if known)? Emeryville Police Department
door panel is dented inwards, multiple scratches on
What specific injuries, damages, or losses did claimant receive? he door as well as above the front right tire. Mr. Ali is actively treating for bodily injuries sustained. (Use back of this form or separate sheer 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(Đ]? Over $25,000
How was this amount calculated (please itemize)?
Over $25,000
(Use back of this form or separate sheet if necessary to answer this question in detail) 06/05/2023
Date Signed: Signature:
If signed by representative:
Kelsey M. Gitlin 4929 Wilshire Blvd., Suite 960, LA, CA, 90010 Representative's Names Address.
877.750.6500
Telephone #
Attorney
Relationship to Claimant: