CITY OF EMERYVILLE
CITY OF EMERYVILLE
CITY CLERK'S OFFICE , CLAIM FORM
JAN 2 9 2024 Please Type or Print and return to:
City Attorney's Office, City of Emeryville
1333 Park Avenuc Emervville, Ca 94608 See Ponco RepoRt
RECEIVED # 2312-0063
Phone: 510.596.4380 Fax: 510.596.3724
LITY OFEMERIVILLE
CLAIM AGAINST
Name of Entit
ANDREW MAROWIZ
Chandar SS#
Clamman date of birth Telephone #
Charant's address
Ac Where notees about claim are to be sent, It ditterent from above:
Date oFincident/accident: DECEMBER LTH, 2023
DECEMBER iTH, 2023
Date injuries, damages, or losses were discovered:_ APPROS 6300 SUVA
Location of incident/accident: 6320 St. +, SAN DABLO AVE ONKLKND 94608 SAN PABLO lIVE W entity or employce do to cause this loss, damage, or injury? ACCORDINA TO BUCE DISPATCHES RECORONES SippOSEDLy SHORT POLLE PURSUT OR EVIANE VEHICLO LED TO VEHILE COLMDINE WITH MABOILINE (Use back of this form or separate sheet if necessary to answer this question in detail.) 2312 - 0063
c names of the entity's employees who caused this injury, damage, or loss (if known)? +13 / DiFFERME STATEMENS FROM DEBATEHER RODREWEL
OFILER RODRIGUEZ No PURSUTT
ValiCEO RIpOLTOR STUEN PORTION OF
Neigene? BUILD's SOUTH WALL, tWINDOW VESTRONO
DAMALES, EATER AMA VALVE DANDO, STOS BRUEEN, DRAN PARE FROM SECOND FOR DeSTROYED, EL SUCCO
PAst the as this amount calculated (please itemize)? + Prep
CONTRACTERS ESTIMATOS
1 (Use back of this form or separate sheetil necessary to ans this question in derit
JAn 17, 2024
D. Signature
representative:
presentative's Names Waldress
*phone #
Beationship to Claimant: