Wirth NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipality...shall cause to be presented to the
governing body of the municipality within 180 days after the alleged loss or injury is discovered a notice stating the time,place,and
circumstances thereof,and the amount of compensation or other relief demanded."
Please complete this form in its entirety by clearly typing or printing your answer to each question. If more space is
needed,attach additional sheets. Please note that you will not be contacted by telephone to clarify 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 longer depending on the
nature of your claim. This form must be signed,and both pages completed. If something does not apply,write `N/A'.
SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
Middle Initial Last Name�\�
First Name \ �(� Y�y"�`� !'-k ���������
Company or Business Name � 2 9 ���3
Are You an Insurance Company? Yes/�If Yes,Claim Number?
v,�, �e , CLE�K
Street Address
City � � �-'J State_1_��� Zip Code J��
Daytime'P o e��)�7a�Ce11 Phone( ��_Evening Telephone(�)�� T-_1�/n
Date of Accidend Injury or Date Discovered C��� `� ���Q��Time �—_�Q�am�
Please state,in detail, what occurred(happened), and why you are submitting a claim. Please indicate why or hovy yo�
�
feel the City of Saint Paul or its employees are involved and/or responsible for our d ages.
� � � � �
. !
a� � �-
� � � .
w d
f�
�� ro� o��:.,►�� �e � �� ��- cov►�e c��c�s ;v�
Ple�e c e k the box(es)that most closely represent t e reason�or completing tlus orm: �UJYI.
❑ My ve hic le was damage d in a n a c c i d ent ❑ My vehicle was damaged during a tow
❑ My vehicle was damaged by a pothole or condition of the street ❑ My vehicle was damaged by a plow �
❑ My vehicle was wrongfully towed and/or ticketed ❑ I was injured on City pro ert S��
�.Other type of property damage—please specify \ ;�
❑ Other type of injury—please specify
In order to process your claim vou need to include copies of all apnlicable documents.
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.
• 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 pro pert y damage claims: two repair estimates if the damage exceeds $500.00; or the actual bills
and/or receipts for the repairs; detailed list of da�iaged 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
Failure to complete and return both pages will result in delay in the handling of your claim.
�, All Claims-ulease comulete this section
� Were there witnesses to the incident? Yes No Unknown (circle)
� Provide their names, addre�ses and telephone numbers:
��I/`{� ` ^ , � � � ., ' ,L ,, i�'� „ � - G"'v;.,' r; . �, ' C,�/�"�)
� .�..f� �r, ��/`t, l j� �y�'��� L•d �
Were the police or law enforcement called? Yes �o Unknown (circle)
If yes, what department or agency? Case#or report#
Where did the accident or injury take place? Provide street address,cross street, intersections�n.ame of park or facility,
closest landmark, etc. Please be as detaile as possible. If nece ary, attach a d}'agram. ���� J ��Q�
� V'c-�� ^ � 1`' r �
Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction. ,� `��� c �
Vehicle Claims-please com lete this sect'on ❑ check box if 's section does not apply
_ ,— _ ._.
Your Vehicle: Year Make � �1/ Model ^ i� �
License Plate Number State Color ��i�-�
Registered Owner
Driver of Vehicle Ir'
Area Damaged l,� �t' r�� � L�v�
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniurv Claims-qlease complete this section '�,check box if this section does not a�ulv
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 claim form. Number of additional pages � .
By signing this form,you are stating that all information you have provided is true and correct to the best
of your knowledge. Unsigned forms will not be processed.
Submitting a false cluim can result in prosecution. Date form was completed � � ` ��'��
Print the Name of the Person who Completed this Form: � Q�� , �� �^1('�
Signature of Person Making the Claim: ��____����;,�`� `
Revised February 2011
Customer Invoice
Date: 10/21/2013
Invoice#: 8466-0
--� Work Order#: 3453815 �''`
Rapid Giass A Quality Glass Co Ticket#:
612-333-4539/763-783-0311
651-290-0226/952-881-0116
Phone:
Fax: TAX ID# 411662447
Bill To: Insurance-Fleet-Broker:
Donna Wirth ALLSTATE INS CO
1347 Van Buren Ave i �NDLED BY SAFELITE NOW
(800)626-4527
SAINT PAUL, MN 55104 Northbrook, IL 60062
Phone: (651)644-7378 Phone2: (612)625-7220 Phone (800)626-4527
Mobile: F�;
Job Scheduled For: October 17, 2013 8:08 am
Written By: ccg1 Sales Re�:
Technician: J O Invoiced By: LMR
Automobile Information Fleet Information ' Inaurance Infortnation
Year: 2007 Unit#: Policy#: 911048289
Make: Chevrolet Card#: Claim#: 376126
Model: Uptander Exp Date: Loss Date: 10/11/2013
Style: Mini Van Driver Name: , Cause:
VIN#: 1 GNDV23107D187348 Driver Lic.: ' Authorization#: 09015
^.olor. Fleet PO#: ' AaentBroker.
Aileage: �
License: State:
MFG Part Descrlptlon Qty Unit List 03A DiscouM Net
Owner Insurance
Sub Tot81 $0.00 $673.86
Tex $0.00 $30.03
I Gross Total $0.00 $703.89
� p��qjb� $0.00 $0.00
Net Total $0.00 $703.89
Adjustments 50.00 $0.00
p�� $0.00 $0.00
Balance 50.00 $703.89
�n aornlaeraaon a Rapia Gless aqreeirp ro reae+r or raWace mr tlemeoetl eutonabMS qless,�nsrsby aeeipn ro Rapd c�lns al�pdky wocesds owea br mr euromooi�e insurer ror ene damaged g�ass and�a�w
c3laas ro aa on my xnatr am m comrtwrycaro wtm my�nsurx aw my unurara apwttt,aCVwEa�s,rsp�Kw�tives,and vwro�party adrtunsuamrs relanve to me tr�rance dafm thet anses out a me taa that my
phse ia demeged.�autl,orize my nwranoe company ro robeae paicy.ooveraps ana ap anx irtomietlon ieleoed ro a:s nsurance aaim ro Rapa c�lesa. i apree ro pay any aeau�iae mysen. i unaerscarw n,at
in6urarxe coverage for tNs wak I am reaponside to pay for the wak upon ratllfatlon by Rapld C�ess.
��
� �
Signature �f�+�ti�- ��
�,f
Invoice
Date: 10/21/2013
Invoice#: 8466-0
._. Work Order#: 3453815 �"f
Rapid Glass A Quality Gtass Co Ticket#:
612-333-4539/763-783-0311
651-290-0226/952-881-0116
Phone: ,
Fax: TAX ID# 411662447
Bill To: Customer:
Donna Wirth
ALLSTATE INS CO
HANDLED BY SAFELITE NOW(800)626-4527 I 1347 Van Buren Ave
Northbrook, IL 60062 I
SAINT PAUL, MN 55104
Phone: (651)644-7378 phone2{612)625-7220
Job Scheduled For: October 17, 2013 8:08 am
Written By: ccg1 Sales Rep:
Technician: J O Invoiced By: LMR
Automobile Information Fleet Informetion Insurance Information
Year: 2007 Unit#: Policy#: 911048289
Make: Chevrolet Card#: ' Claim#: 376126
Model: Uplander Exp Date: Loss Date: 10/11/2013
Style: Mini Van Driver Name: Cause:
VIN#: 1 GNDV23107D187348 Driver Lic.: Authorization#: 09015
Color. Fleet PO#: AaenUBroker.
Mileage: �„i
��� License: State: �
MFG Part Description Qty Unk Lfst O&A Dlscount Net '
DB70720YPNN Back Window YP, 1 Each $208.35 Y -66°h $345.86 '
DB10720YPNN Back Window Labor 2.8 Hrs $100.00 Y $280.00 �
HAH000004 Adhesive 1.5 Urethane,Dam,Primer 1 Each $28.00 Y flat $48.00
Service Address Work Order Notes Sub Total $s�a.as
Donna Wirth 1a17/2013,8am-1pm Tau $30.03
1347 Van Buren Ave must get signature!!!! Gross Total $703.89
Dedudible $0.00
SAINT PAUL MN 55104 NetTotal �o3.ss
Primary Pho,�e: 6516447378
Secondary Phone:6126257220
Mobile Phone:
wiper motor bad and coROded prior to install!
Fri Oct 25 16:04:04 2013 by JK:Client is going to be calling with her fax#on Monday to have us send a copy of the bill. The City is reimbursing
her since a lamp from a street light broke the glass.
fax#612-624-4908
email to:holme533�umn.edu
In considetation of Rapitl Glass agreeirp to repair or replaoa my dartiaped a��0ortabile gless.I tbroby assipn to Rapid Glass all policy proceetls owed by my eulomodle insurer for the damagea glass and I app
Glass W ect on my�haA and to communieate wBh my insurer and my Insurers apeMS.edjus0e�s,represaMatives.and 1Nrd-perty administrators relstive ro the ins�uance Gaim that arises out of the fact tliat rtr
�lass is tlamageC 'a�C.onze my insur�ce oomp�y to rebase pollcy,coveraye and dl atl�er irkormedon related to this insurance dann to Repid Gless. I agree to pay arry deducUble myself. I understand ttia
wrance�verage for this wak,I am responside ro pay for the worlc upon not�ication by Rapid Glasa. \,�
�.
� � Signature l )�Y1�'�/1l� �.�J