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Curry (2) NOTIC� OF CLAIM TORM to the City of Saint Paul, Minnesota Nfi�rne.roui Stute S�rr�ute 466.05 stntes thn� "...every persnii...�vhu clainr.c dnmages•fronr mrv mwtiripnlrty...shuN ruu.ce!n be pre.eeirted!o!lre gnveniirlg budy uf d�e nrunicipnlity withi�� 180 duys nfter�he ciNe��ed lnss nr injury is discovered«i�olrce stnti�tg tlie tii��e,pince,n»d circunr.stairces tlrereo/;arrd tl�e crmoiutt af conrpenscr�ir»�or nther relief cfenrnnded." Please complete this form in its entirety by clearly typing or printin�your answer to e�uh question. If'more space is neecled,attach additional sheets. Please note that you will not Ue contacted by telephone to clarif'y answers,so provide as much information as necessary to explain your claim,and the amount of compensation being rec�uested. You will receive a written acknowledgement once your form is received. The process can take up to ten weeks or longer ctepending on the n�ture of your daim. This form must Ue signed,and both pa�es completed. If something does not apply,write`N/A'. SEND COMPLETED FORM AND OTHER DOCUM�NTS TO: CITY CLERK, 15 WEST K�LLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102 First 1Vame �=r���°ir`�d` Middle Initial � Last Name ��'2-2-� ��C�� U �� Company or Business Name � I � ��V o4 2��3 Are You an Insurance Company? Yes/-�--]f Yes, Claim Number? n � � �`��'� �`LERK Street Address °�5�� �%e��.C`�^"�h�- � ��a 1-� City �� `��� State �n� Zip Code� `J�� �� Daytime Phone ( ) - Cell Phone (���a�18 �a`�vening Telephone( ) - Date of AccidenU Injury or Date Discovered � � � � �3 Time �a=3° ?am/ m Please state, in detail, what occurred (happened), and why you are submitting a cl'aim. Please indicate why or how�qu feel the City of Saint Paul or ts em�loyees are involved and or responsible for your dama es.d '� � ' � ' �3 J. �GS 1 e.a J� r� � � � u rn 5� [-�f �-1-G--� -�-t�.R.r-�eL=� V i � h� p r. �a�C��-St�n t w,-.r� ci:� -}-�� l� �� c��� S �c,--����Z� C r� J i i�, c v u;n L�ci�-vY�o sZ2 !J�-lo�.�� ��-r� � ��-E- SO m 2-F'1�.�r� �a--}- l�J�'—� l�.x�-r�a-�-t c��1� Z o r-�=�r�v..�d -+c� Y 7 crL -t-c� o--1�r�ti.... l2_{C_� �'sl-i�E'-�--� (1�-�(�G� -�n C� e �v�� o'L ���v�r, --�'1 �'� b rt -f-h� �i 1�t' S c c� �. p..�n r�-r� • o�h c^n a o+r �! b=i j�s a►� ��r. �✓ oa �j Y„�c_e r, h L�< �� v � �� �• 5 � c � v v t c, v i c�h-+- c�1�i b�f L-- oun d n � � 0-1'� q n tv�.-e-,�, Please check the box(es) tha�most closely represent the reason for completing this form: � My vehicle was damaged in an accident ❑ 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 property ❑ Other type of Property damage-please specify ❑ Other type of injury-ple�ise specify In order to process your claim you need to include copies of all annlicable 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. O Property damage claims to a vehicle: two estimates for the repairs to your vehicle if the damage exceeds i $500.00; or the actual bills and/or receipts for the repairs� I O Towing claims: legible copies of any ticket issued and �i 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; de[ailed list of damaged items O I�G'ry claims: medical bills, receipts �TPhotobraphs are always welcome to document and support your claim but will not be returned. Pa�e 1 of 2-Please complete and return both pages of Claim rorm railure to complete and return both pages will result in delay in the handting of your claim. All Claims-please comn�ete this section Were there witnesses to the incident'? es No Unk�own (circle) Provide their names, addresses and telephone numbers: 1+ �-R-�...�- �,-1 fZ.�so� � ��''�-�- ��o' Were the police or law enforcement called? Yes � Unknown (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, etc. Please be as detailed as possible. If necessary, attach a diagram.�v}Cc�-�mo(z� -+-5��ve� Please indicate the a iount�u are see�ng in com�ensation or what you would like the City to do to resolve this claim to your satisfaction. � �J� "= ����t� " Vehicle Claims- lease com lete this section ❑ check box if this section does not a I Your Vehicle: Year O Make �� ��--�- Model ��1 R-�-^�� �`� X License Plate Number l.e "11 CT►� State �Mn• Color Si � � e-►�,- Registered Owner�-c�c�c� (�� �o n - L_a�o��r�- ��-(Z�2-y , Driver of Vehicle O�o v��n o--�. l,E �L-y ` Area Damaged � ' � \n:-+- 5 : el � —' City Vehicle: Year Make Model License Plate Number State Color Driver of Vehicle(City Employee's Name) Area Damaged Iniury Claims-plcase complete this section ❑ check box if this section does not tlpply 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 Ernployer: Address �— Telephone ❑ Check here iFyou are attaching more pages to this claim form. Number of additional pa�;es By sig�aiiig tltis form,yocc are stc�ti�zg that ull informatio�i yoic have provided is trcce and correct to tlee best of yocer knowledge. Unsigned forms will not be processed. Submitting a false claim can result iiz prosecutio�a. Date f'orm was completed � r ' �� ' °Z�� 3 Print the Name of the Person who Completed this Form: �"i7o i�r`O- ��-f�� Signature of'Person Making the Claim• 1-�� �'����- �-�-R-R-'-� Revised February 201 I ���„_ ; . t �������� •-'I!��`L 1-I�J�tl f � . � r �tj 4. I � � , �^� Ty�� r �<<��.; \��r� �t�a .M ��. '., . . .. �. �_�i�CJ� �-i,i� �i.���� I� Ita ��� r�`,s,. �.� � - - - ,_`� . ',7 �,a�it .ii . 1�14-a�1�t?. OFFICE P.O.BOX 7156,SPRINGFIELD,M0.65801 r�.,�iT TO:V��� r���� ��4r-t� PHONE(417)862-3333 BILLTO SHIPTO ��-��T��'.j�Itlt� (`��� �+`-'���'�-a`4�=�' --''t��� � t^C�.-,� -�q;����,�� �,_ .;�4�. __. 'N�'(j �f�t_ �?'.lilii!-I ����I!i`� � _ � TI R i_ �i�t� # e :z �-• rl�,vF' '��iLF .'1 �'T?_ I+�� fl�F_t Li i.��, :-��-' - - !4i ,I, f_I��� �:il,.! (�7L��j���� �alili ;-�illj rli.� r�11� �.��I �_''�_ �'��..�. r. _�' C1ISTOMER TIMEOF �FILLED CMECKED COUNTEP �'�, SPECIALINSTRUCTIONS . SH�P��A I ORDERNO. ORDER � BY I BV NO. r't . � �4..i�r:l �. � � �UNIT � � LIST � NET �DISC I CORE ; E%TENDED TAX. � ; OTV. 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