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CITY OF EMERYVILLE
CLAIM FORM
Please Type or Print and return to:
ity Attorney's Office, City of Emeryvil
333 Park Avenue Emervville, Ca 946C
Phone: 510.596:4380 Fax: 510.596.3724
CLAIM AGAINST City of Emeryville PD
(Name of Entity)
William James Roslin SS#
Claimant's name
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: 07/18/23
07/18/23
Date injuries, damages, or losses were discovered:_
Outside Starbucks - 1405 65th St, Emeryville, CA 94608(65th and Hollis) Location of incident/accidenr:
What did entity or employee do to cause lusloiss, damage, or injury winessed Officer attempted autum in the middle of the road.
Vehicle struck my parked vehicle, scratching from left rear q-panel-both doors-front quarter panel and spun sideview mirror. (Use back of this form or separate sheet if necessary to answer this question in detail.) Whar are the razes of the endys eployes solo caused this injury, ilamage, or loss (fknown Emeryville PD Officer Nicolas Sebastian Drexler - Report prepared by Eric D Castillo 023347 what specific injuries, damages, or losses did claimant receives Sustalned $3950 as estimäted from body shop(document supplied) Damage from rear left quarter panel, both driver side doors, front left quarter panel and driverside side mirror. (Use back of this form or separate sheet if necessary to answer this question in detail) What araount of money is claimant seeking, or which is the appropriate court of jurisdiction Gorernment Code 910()P 83953.38 (as per body shop estimate and time spent waiting for police report, awaiting a response from city after mutiple. attempts at communicalton.
How was this amount calculated (please itemize) Please see supplied estimate document(53953,38 Total Body Labor -14.2 hours - $1988. Paint Labor - 8,9 hours - $1246. Mechanical labor - 5 hpurs - $90 Paintsupplies - 8.9 hours - $551.80 (Use back of this form or separate sheet if necessary to answer this question in detail) Date Signed: 8/23/23 illiam J hastin
Signature:
If signed by representative:
Representative's Names Address:
Telephone #
Relationship to Claimant: