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)
Mike Klouvidakis
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: July 04 2023
Date injuries, damages, or losses were discovered: July 04 2023 Locaion of incident/acident: Shellmound Street between 66th & 67 Streets What did entity or employee do to cause this loss, damage, or injury? Sidewalk construction resulting in bodily fall of said claimant.
(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? Frontal bodily fall of said claimant resulted in left knee abrasion, impact to left hip and left arm. (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(₺)?.
None at this time. If lower back discomfort and pain does not subside, will pursue medical attention and possible damages.
How was this amount calculated (please itemize)?.
(Use back of this form or separate sheet if necessary to answer this question in detail) miko thoma
Date Signed: 08/21/2023 Signature:
If signed by representative:
Representative's Names. Address.
Telephone #
Relationship to Claimant: