CITY OF EMERYVILLE CITY OF EMERYVILLE
CITY CLERK'S OFFICE
CLAIM FORM
MAR 0 4 2024 Please Type or Print and return to:
City Attorney's Office, City of Emeryville
RECEIVED 1333 Park Avenue Emeryville, Ca 94608 AMENDED
Phone: 510.596.4380 Fax: 510.596.3724
CLAIM AGAINST Emeryville Police Department
(Name of Entity)
Subro Claims, Inc o/b/o Gieco Ins a/s/o Emeryville Police Department Claimant's name
Claimant's date of birth _Telephone # (800949 5655
28150 N Alma School Pkwy #103-642 Scottsdale, AZ 85262
Claimant's address
Address where notices about claim are to be sent, if different from above: 28150 N Alma School Pkwy #103-642 Scottsdale, AZ 85262 Date of incident/accident: 12/28/2023
Date injuries, damages, or losses were discovered:
Location of incident/accident: Howell and Vallejo in Emeryville, CA What did entity or employee do to cause this loss, damage, or injury? Emeryville police dept vehicle ran stop sign and struck insured's vehicle.
(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)? unknown
What specific injuries, damages, or losses did claimant receive? Damages to the insureds 2018 Honda CRV - supporting documents attached
(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)?. $26,765.99
How was this amount calculated (please itemize)? Geico paid for the damages. Coll $27,686.62 + deduc $500 + rental $379.87 - salvage $1800.500 + car seat out of pocket 119.33 = $26,885.32 AMENDED (Use back of this form or separate sheet if necessary to answer this question in detail) Date Signed: 02 29/2024 staller fi
If signed by representative:
KAITLyn mIyuWAtates 28150 N Alma School Pkwy #103-642 Scottsdale AZ 85262 Representative's Names_
Telephone # 800 949 5655
Relationship to Claimant: obo Geico Ins