Kanneh I�TtJTICE aF CLAIM FURM to the City of Saint Pau�, Minnesota
Minnesnta,Stdte Stntuie 4bh.05 strates tluet` ...euery pers»n.._wha ctaim,s da»ur�es�'ir.rm riny munic�ipality...shalt caus�io he presenfed tu the
gaverni�rk bo�fp c,/'the munrcipu/itv witkirr I�days nfter the alleged leiYS ar injury is�tia�cuvered tt»r�tice a7uting Che time,place,u�ut
G77Y.'UJTt.S![IriCPS IItY.tEn,t,l71tl11ITP Qlti[Jtltlf C�,��~nm�renscuion rrr pther rpdief de.mnnded.'�
1'least ec►mplete this Pi►�rtn in it�entlrety by clearly typing e►r pr�ntfn�;your ans�vt�r tu each yu��stlttn. 1f m��re spa��c ty
needed,attach additions�l�hee�. I'Itis�se nate that yuu will nat i�e��otacted by telephon�to clarify�uswers,�►prc►vlde x�
n�uch infarmutiun as nect,:s,wry tu explain your claim,and tt�e um�unt�►P com{nn.ration tx�tn�requestt,�d. You wlll rcx e[re a
w ritten acknowled�ement once yuur furm is cecelved. The pr��e�s can lake up eu ten weeky crr lon�er dependtag un the
nuture of yuur claim. Thi�farm must t�e signed,and Iwth pxg�cumpleted. I�t sun�ething dut.�s not s�pply,write'iV/A'.
SENll CUMPLEI'�U NUItM AND O'I'HER UUCUMENTS TO: C1TY CLERK,
15 W�S`1' �.ELLU�G ��L�ll, 31U C1TY HALL, �A1N1' �'AUL, MN� 551(�2
First Name���� Middle Initial�Last Name /�fi�v►rt p ,_1,� R�('_������
Cc�n�pany or Business Name 2 v 2��3
--- - A��'��-�n-�t�ar�ce Com�a� ? �c;s�If Ycs,Ctaim Numt�;r? __ _-- -
����ti laaax�ss_I r�`�� ��� �� � pli,�r1 -�k�.c�7
CLERK
City (,,,,,,,G�v� U'�-�i�C.) State �� Zip Cacie r7�7y rj
�
DaytimK;Phone( 6�,��-!�Cell Fhc�ne(��)24�-��fiu Evenin�Telephc�ne �( 6; �7q 1_��Y t�
Date af Accidentl injury or Uute Di,c:ov�.,rc:d Time am/pm
Please�tate,in detail,what cx;cucred(hapgened),and why you are subrnitting a claim.Please indicate why or how you �
feei the City of Saint Paul ar it empl�yecs are invc�lved and/c�r res� �ihle f�r yc�ur dama es, j��j G)2. i
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Flcase che*,ck the box{es}that mosC c3nsely represent the ccasc�n ti�r cc�mpleting thi�form:
D My vehicle was damaged in an accicient D My y�ehicle was damaged during a tow
❑� M�vehicle was damaged by a pothole ar ec�ndition af the street ❑ My vehicle was damaged ry a ptaw
�'Nty v�hicle was wrctngfuliy toweci ancl/or tickctcd �(was injured on City pr���:rty
❑t7Che:r type of propc;rty damage—glea.�e sgecify
❑(7ther type of injury—pt�ase specify
In�rder tv�rocess your c1�im y�u n�d tc�include couies vf a�l auplicable d�cuments.
Far the claims ty�s listed hclow,please tx;sure to inclucic:lhe cicx;uments inciicatc;e]c�r i[will delay th�hac►dting c�.�'
your claim. Documents WILL NOT be returned and become the property of the City. You are encouraged to keeg a
cc�py for yaurself F�;fc�re submittin�yc7u�r clairr�Ccarm.
Q Pc�perCy damage claims to�vehicle: lwo estimates far khe repairs to your vehicle i:t�the dama�e exceeds
$SQ0.00; vr the actual biI[s and/or receipts for the repairs
4 Tawing claims: le�;iblc;cc�pies c�f any ticktt issued and a cc�py c�f the impc�and lot receipt
O C)ther pmp�;rty dam��;e claims: twv repair c:stimate;s it'the damage excc.:c;ds$S(x).t)fl;t�r the actual bills
and/or receipts for the repairs;detailed tist of damaged items
O Injury claims: medicul bills,rec:eipts
O Phc�to�ra�hs are always welcnme to dc�cument and sup�rt yc�ur claim l�ut will nc>t be returned.
Page 1 of Z—Please complete and return both pa�es of Claim Form
Failure to complete and return both pa�es will res�dt In de[ay ln the handlIng of your clatm.
�,11 Clatm�—ulease cumalete thls Section
Were there wimesses ts�the incidenk`? Yes Na Unknown (circle)
Frc�v.i�1u Cheir names,acic�rc.5s�;s an�kelephczn�;numb�:rs:
Werc}the�c�licc or law enfc�rcement called? es No Unl�ncywn (circle� o 3�� $
If'yes, what c�epartment ar a�ency`? Case#or report# ��\� S 1 ''t e�+� �� ^
� P��..,1 � +'l Cew�,'' P�<<c�.�P�
Where dici the acc.id�nt car itt,�ury take place`? Pr�vide stcee�acidress,cross str�et,initrsecti�,n, name of park c�r facility,
closetit lan�fmark,�tc. Please bf;as detailed as pt�ssihle. If necessary,aCtac:h a c�iagram.„�� .•�•.( ,.0 1.`�'�
J�:� !"s../ m^ f,J�o.-+� (..>o-C �s,r..Ll
Please ine�icate the arnount you are s king n conipensation or what you would like�he City to do to resolve this claim
Cc�your satisfaclic�n. ) {,.so�,�,�� `� �e 'b-�.a _r.r tTC' W�t a� t� L� lr b�r`�'�.-
Vehtele Claitns— lease cam tete this sectiou ❑check box if this section da�s not a 1
Your Yehic,lc: Year cru i Make M<7c1e1 �
License Plate Numt�:r Stale�,�Cc�lor Cs��`1
Regist�;red t�wner�����;. �ti� P �,�
Driv�r of Vehicte
�rca Damage>d
City Vehicle: Year Make Model
License Plate Nurnber State Calor
Driver�f V�;hicle{CiCy Empl�ayce's Namc)
Area.Damag�d
In ur Glaims— lease cum lete thts�;ecti+�n �heck lx7x i�t�is SecLic�n d��es nat a 1
Haw were you injured`?
� What part(s)of yc�ur body were injured?
i
Have you sou�ht�nedical treatment? Yes No Planning to Seek Treatment(circle)
When did yrau rcceive,treatm�nt? (prcxv3dr;clat�fs))
Nam�of Medic�1'r�7vider(s):
� Acidress Tef�phone
Did you miss w�rk as a result of yovr injury? Yes No
Whwn dicl yc�u rniss wc�rk7 (prc�viciu c�at�:(s))
Name�f yaur Employer:
r�c�dress Telephone
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❑Check here if you are attaching more pages ta this ciaim form. Nun�ber of addlttanal pages
l3y si�,�tttt�this for�rty yau are stalin�;tjaat all in/'i�rmutiafa yt�u have pruvidet!is true and currecl tw the best
�f your kiaUwledge. Unsigned forms will not be processed.
.Sr�h�nitting a fa�re claim can result in prosecution. Date form was campleted � �/� � D � � �
Prir�t the Name of the P�raur�who Cumpletw�d this Form: ��C�,�� �KV�2.�
Si�nature of Person�'Iaking the Claim:
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Re�ised February 201 I