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)
Claimant's name Yolanda Nesbitt
SS#
Claimant's date of bir Telephone
Claimant's address.
Address where notices about claim are to be sent, if different from above: . 24003A Ventura Blvd, 2nd Floor Calabasas, CA 91302 Date of incident/accident: 05/26/2023
Date injuries, damages, or losses were discovered: 05/26/2023 Location of incident/accident: 5700 Christie Ave, Emeryville, CA 94608 What did entity or employee do to cause this loss, damage, or injury? Ms. Nesbitt was riding the bus when city employee, the bus driver, slammed on the brakes causing Ms. Nesbitt to hit a metal pole. (Use back of this form or separate sheet if necessary to answer this question in detail.) What are the names of the entrys employees who caused this injury, damage, or loss (if known) Name unknown What specific injuries, damages, or losses did claimant receive? Soft tissue injuries (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))? $1,000,000
How was this amount calculated (please itemize) Medical expenses, future medical expenses, pain and suffering (Use back of this form or separate sheet if necessary to answer this question in detail) Date Signed: 11/22/2023 come 522
If signed by representative:
Representative's Names Shaun Bauman Address 24003A Ventura Blvd. 2nd Floor Calabasas, CA 91302 Trlephone #818-285-0222
Relationship to Claimant: Attorney