Ramos NOTIC� OI' CLAIM I'�RM to the City of Saint Paul, Minnesota
iYlriure.suta Stute Slntute 466.05 stntes that "...everv perso��...wlio c/nrnrs damcrge.r,J'rnnr miv ir�urtictpalih�....rlin//rni�.se�n be pre.senled!n the
go��erning bocfy q/�tlie muriicipnlity wi�hiii 180 d��y.r after the c�Neged/oss or injurv is cliscovered a�rotice stnting the time,p/ace,nncl
circwn.�•tcinces tl�ereo/;and tlre amn�uu o/�conrpenscuinn or ot{rer relief demanded.„
Please eomplete this form in its entirety by clearly typing or printing your answer to e�ch question. If more space is
needed,attach additional sheets. Please note th.it you will not be contacted by telephone to claril'y answers,so provide as
much information as necessary to explain your claim,and the amount of compensation being requested. You will receive a
written acknowledgement once your form is received. The process can take up to ten weeks or lon�er depending on the
nature of your daim. This form must be signed,and both pages completed. If'something does not apply,write `N/A'.
SEND COMPLETED FORM AND OTHER DOCUM�NTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
First Name ���1SS�^ Middle Initial � Last Name �1���� R�(����E�
Company or Business Name � �J � C�. � �� ' �. �� f1f`T n�� 9013
�T�z
Are You an Insurance Company? Yes -No lf Yes, Claim Number? RK
Street Address �� � ��]�'�'� rl��� ���'
City � `��� � State ��� Zip Code �� ���
Daytime Phone ( �)� � t`�'�C le I�hone ( ) - Evening Telephone( ) -
Date of Accident/lnjury or L?ate Discovered___���a� \� Time am/pm
Please state, in detail, what occurred (happened), and why you are submitting a claim. Please indicate why or how you '
feel the City of Saint Paul or its employees are involved and/or responsible for your damages. ',
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Please check the box(es) that most closely represent the reason for completing this form:
❑ My vehicle was damaged in an accident ❑ My vehicle was damaged durinb a tow �,
❑ My vehicle was damaged by a pothole or condition of the street ❑ My vehicle was damaged����VED
❑ My vehicle was wrongfully towed and/or ticketed ❑ I was injured on City prop
❑ Other type of Property damage–please specify T 2� 20�3
❑ Other type of injury–please specify
In order to process your claim vou need to include copies of all applicable docum�,Ic�:Y CLERK
For the claims types listed below,please be sure to include the documents indicated or it will delay the handling of
your claim. Documents WILL NOT be returned and become the property of the City. You are encouraged to keep a
copy for yourself before submitting your claim form.
O Property damage claims to a vehicle: two estimates for the repairs to your vehicle if the damage exceeds
$500.00; or the actual bills and/or receipts for the repairs
O Towing claims: legible copies of any ticket issued and a copy of the impound lot receipt
O Other property damage claims: two repair estimates if the damage exceeds $500.00; or the actual bills
and/or receipts for the repairs; detailed list of damaged items
O Injury claims: medical bills, receipts
O Photographs are always welcome to document and support your claim but will not be returned.
Page 1 of 2–Please complete and return both pages of Claim Form
I
I�'ailure to complete and return both pages will result in delay in the handling of your claim.
All Claims—please complete this section ,-��
Were there witnesses to the incident`? Yes �N� Unknown (circle)
�
Provide their names, addresses and telephone numbers:
:-- .
Were the police or law enforcement called? Yes No � Un� (circle)
If yes, what department or agency? Case#or report#
Where did the accident or injury take place? Provide street address,cross street, intersection, name of park or facility,
closest landmark, ete. Please be as detailed as possible. If necessary, attach a diagram.
Please indicate the amount you are seel:ing in compensation or what you would like the City to do to resolve this claim
to your satisfaction. �v'� ���'(h� 1pC�.-G�- ��'C' ���'�..�< <�t't o�`�c.� '(Y��Y���
����
Vehicle Claims—eleaSe complete this section �check box if this sec[ion does not applv
Your Vehicle: Year Make Model
License Plate Number State Color
Registered Owner
Driver of Vehicle
Area Damaged
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle (City Employee's Name)
Area Damaged
Injury Claims—plcase complete this section ��check box if this section does not applx
How were you injured?
What part(s) of'your body were injured?
Have you sought medical treatment? Yes No Planning to Seek Treatment (circle)
When did you receive treatment? (provide date(s))
Name of Medical Provider(s):
� Address Telephone
Did you miss work as a result of your injury? Yes No
' When did you miss work? (provide date(s))
Name of your Employer:
Address Telephone
❑ Check here if you are attaching more pages to this daim form. Number of additional pabes
By sig►ting tltis form,you are stating tltat ull information yozc lzave provided is trrce and correct to tlie best
of your knowledge. Unsigned forms will not be processed.
Submitting a false claim can resz�lt in prosecution. Date f'orm was completed
Print the Name of the Person who Completed Form: �� ��\� / ��
Signature of'Person Making the Claim: ��' 1�,����
Revised February 201 I