CLAIM AGAINST CITY OF FOSTER CITY
610 Foster City Blvd., Foster City, CA 94404 Please
return to: Risk Manager
COMPLETE THE FOLLOWING, ADDING ADDITIONAL SHEETS AS NECESSARY
1. CLAIMANT'S NAME (Print):
2. CLAIMANTS ADDRESS:
(Street or P.O. Box Number -City - State - Zip Code)
3. AMOUNT OF CLAIM $167,000.00
HOME PHONE:
-
(Attach coples of bills/estimates)
WORK PHONE:
IF AMOUNT CLAIMED IS MORE THAT $10,000 INDICATE WHERE JURISDICTION RESTS:
Limited Civil Case
Unlimited Civil Case X
4. ADDRESS TO WHICH NOTICES ARE TO BE SENT,
IF DIFFERENT FROM LINES 1 AND 2 (Print):
(Name)
(Street or P.O. Box Number)
(City - State - ZIp Code)
5. DATE OF INCIDENT: 3-25-2025_ TIME OF INCIDENT: 2:30pm LOCATION OF INCIDENT: Shell Bld south bound, Foster
City._
6. DESCRIBE THE INCIDENT OR ACCIDENT INCLUDING YOUR REASON FOR BELIEVING THAT THE CITY IS LIABLE FOR YOUR DAMAGES:
Please see the police report. I was driving down Shell Boulevard in the left-hand lane when a Foster City vehicle failed to stop and yield before making a left turn. Instead, they turned directly into my vehicle, causing me to be pushed toward the right-hand side of the road. I have pictures attached to this claim.
7. DESCRIBE ALL DAMAGES WHICH YOU BELIEVE YOU HAVE INCURRED AS RESULT OF THE INCIDENT:
As a result of the accident, my car was totaled. It was a very special vehicle with a manual transmission, and unfortunately, I had to purchase a new car and settle for an automatic, which was not my preference.
I suffered severe whiplash from the impact and required multiple treatments, as documented in the attached medical records. I had to take pain medication and muscle relaxants to manage the discomfort.
Additionally, I was in the process of recovering from a shoulder replacement at the time and also have a serious heart condition. The physical and emotional stress caused by the accident significantly affected my well-being, and it took several months for me to recover and cope with the aftermath.
8. NAMES(S) OF PUBLIC EMPLOYEE(S) CAUSING THE DAMAGES YOU ARE CLAIMING:
6/23/25
Date
Any person who, with intent to defraud, presents any false or fraudulent claim may be punished by imprisonment or fine or both.
Note: You must file a claim in compliance with Government Code Section 911.2. 8/02 ABAG PLAN Corp. - CM1-1