Mie CITY OF EMERYVILLE mls CLAIM FORM
Please ‘Type or Print and return to: RECEIVED City Attorney’s Office, City of Emeryville 1333 Park Avenue Emeryville, Ca 94608 Phone: 510.596.4381 Fax: 510.596.3724 OCT 16 2025 Email: [email protected] CITY MANAGER'S OFFICE clam aGansr City of Emeryville . CITY OF EMERYVILLE
(Name of Entity)
Claimant's name RODErto Aguilera Velazquez. oo OE
Claimant's date of birth ne oa Telephone # | eee
Claimant's address.
Mirador Law, 6601 Owens Drive, Ste. 238, Pleasanton, CA 94588 Address where notices about claim are to be sent, if different from above:
5/2/2025 Date of incident/accident:
Date injuries, damages, or losses were discovered: 9/2/2025 Alco Iron & Metal, 2140 Davis St., San Leandro, CA 94577 See Exhibit A, attached herein.
Location of incident/accident:
What did entity or employee do to cause this loss, damage, or injury? (Use back of this form or separate sheet if necessary to answer this question in detail.) Unknown at this What are the names of the entity's employees who caused this injury, damage, or loss (if known)? time. See Exhibit A, attached herein.
fin Sinbad oy a: __, Traumatic brain injury, Post Traumatic Stress Disorder What specific injuries, damages, or losses did claimant receiver. / IN INJUTYs ’ and sprain of the cervical spine. See Exhibit A, attached herein, for further details. (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)]? $5,000,000, Unlimited Civil Jurisdiction in Alameda County Superior Court How was this amount calculated (please itemize)? Damages for medical specials, wage loss, loss of earning capacity, pain and suffering, emotional distress, inconvenience, loss of enjoyment of life. (Use back of this form or separate sheet if necessary to answer this question in detail) 1 0/08/2025 Signature: Uly Dili
If signed by representative:
Date Signed:
Emily L. Dahm Aidvess 6601 Owens Drive, Suite 238, Pleasanton, CA 94588 Representative’s Names 925-460-8484
Attorney for Claimant
Telephone #
Relationship to Claimant: