CITY OF EMERYVILLE
CLAIM FORM
Please Type or Print and return to:
City Attorney's Office, City of Emeryville
1333 Park Avenuc Emeryville, Ca 94608
Phone: 510.596.4380 Fax: 510.596.3724
City of Emeryville
CLAIM AGAINST
(Name of Entity)
Claimant's name Steven Goldenberg
Claimant's date of birth
Claimant's address
Address where notices about chaim are to be sent, if different from above: 3345 Golden Gate Way, Lafayette CA 94549 Date of incident/accident: September 4, 2024
Date injuries, damages, or losses were discovered: September 4, 2024 Location of incident/accident: northbound Horton Street at the intersection of 45th Street What cic enuty or empipses crease unis ioss, carnage; or injury. The road surface was removed without proner signage. Mr. Goldenberg hit a drop off/pothole that knocked him from his bike and caused injury. (Use back of this form or separate sheet if necessary to answer this guestion in detail.) What are the names of the entity's employces who caused this injury, damage, or loss (if known)? What specific injures, damages, or losses did claimant reccive Right tibial plateau fracture, right femur fracture, and humerus fracture.
(Use back of this form or separate sheer 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).
Claimant is seeking in excesss of $500,000 and the case will be pursued in unlimited civil jurisdiction.
How was this amount calculated (please itemize) To date, Plaintiff's total medical bills exceed $250,000. He has not fully regained the ability to walk. His recovery is ongoing. (Use back of this form or separate sheet if necessary to answer this question in detail) Date Signed: December 3, 2024 Signature:
If signed by representative:
Representative's Names Kyle R. Smith Address 3445 Golden Gate Way | Lafayette CA 94549 Telephone #510.735.6804
Relationship to Chimant: Attorney