CITY OF EMERYVILLE
CLAIM FORM
Please Type or Print and return to: CITY OF EMERYVILLE
City Attorney's Office, City of Emeryville CITY CLERK'S OFFICE 1333 Park Avenue Emeryville, Ca 94608 JUN 26 2025
Phone: 510.596.4381 Fax: 510.596.3724
Email: [email protected]
CLAIM AGAINST The City of Emeryville RECEIVED
(Name of Entity)
Beverley Anderson
Claimant's name SS#
Claimant's date of birth Telephone #
Claimant's address
10990 Wilshire Blvd., Ste. 1040, Los Angeles, CA 90024
Address where notices about claim are to be sent, if different from above:
Date of incident/accident: May 30, 2025
Date injuries, damages, or losses were discovered: May 30, 2025 Tocation of incident/accident Adjacent to 1300 55th St. - Emeryville, CA What did entity or employee do to cause this loss, damage, or injury? Please see attached. (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) T BD.
What specific injuries, damages, or losses did claimant receive? Please see attached. (Use back of this form or separate sheet if necessary to answer this question in detail) What amount of money is chimant secking, or which is the appropriate court of jurisdiction (Government Code 910(7352,000, des Hor was this amount calculated (please itemize) TBD.
(Use back of this form or separate sheet if necessary to answer this question in detail Dac signed: / 20/75
If signed by representative:
Representative's Names Michael A. Kahn 10990 Wilshire Blvd., Ste. 1040, Los Angeles, CA 90024 Address
Telephone #310-209-1600
Relationship to Claiman: Attorney for Beverley Anderson Anderson, Beverley - Claim Against The City of Emeryville (cont.) What did the entity or employee do to cause this loss, damage, or injury? On May 30, 2025, at approximately 2:30 P.M., Beverley Anderson was walking on the sidewalk located at or adjacent to the north side of 1300 55' Street., Emeryville, CA 94608. At the same time, there was an exposed metal object protruding from the same sidewalk. Ms. Anderson was walking on the sidewalk when she momentarily stepped to her right - while remaining on the sidewalk - to make room for oncoming foot traffic. Once the oncoming foot traffic cleared, she proceeded to continue walking when suddenly, and without warning, she tripped over the metal object protruding from the sidewalk, causing her serious bodily injuries. On information and belief, The City of Emeryville owned, controlled, and/or was responsible for maintaining the sidewalk. The entity who owned and/or controlled the sidewalk negligently failed to routinely inspect and maintain the area so as to eliminate the existence of dangerous conditions to pedestrians, including Ms. Anderson. The defendant's negligence and lack of due care ultimately created the hazardous conditions that directly resulted in Ms. Anderson's injuries.
Please see the attached photos of the subject location and the metal object surfacing from the subject sidewalk.
What specific injuries, damages, or losses did claimant receive? The full scope of Ms. Anderson's injuries is unknown; however, as of this time, Ms. Anderson sustained the following injuries: broken right foot and groin injury.