Orozco ����i����
ROBICHAUD, ANDERSON & ALC,4NTARA P.A. t�QV OL� LQ�J
ATTORNEVS AT LAW CITYCLE{��C
November 1, 2013
City of St. Paul
City Clerk
15 West Kellogg Blvd
310 City Hall
St. Paul, MN 55102
RE: Our Client: Israel Viernes Orozco
Claim#: unknown
Date of Loss: Oct 08, 2013
Our File #: R12,509
Dear City of St. Paul-Auto Claims:
Enclosed please find the completed claim forms for the above referenced client. Thank
you for your immediate attention to this matter and if you have any questions please
contact me directly.
Sincerely,
ROBICHAUD,ANDERSON & ALCANTARA,PA
� I
Madison Fischhaber
Paralegal
madi son@robichaudlaw.com
enclosure
211 Washington Avenue North, Minneapolis, MN 55401
Tel. b12-333-3343 Fax 612-332-8166 ToIlFree 1-888-333-9080
RECEI!/�D
I�aV 04 2013
NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
CITY CLERK
Minnesota State Statute 466.05 states that"...every person...who claims damages from any municipaliry...shall cause to be presented to the
governing body of the municipality within 180 days after the al�eged loss or injury is discovered a notice stating the time,place,and
circumstances thereof,and the amoun!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 acl�owledgement 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 �ITY HALL, SAINT PAUL, MN 55102
First Name ��CQ�, Middle Initial Last Name V�l�C1C5 ���
Company or Business Name N�_
Are You an Insurance Company? Yes� ff Yes,Claim Number? ���'c
Street Address D� \ � •���• � J
City �•'r��► State M N Zip Code�S l o t�
Daytime Phone(�)s�'s�Cell Phone(]�l���0 Evening Telephone(tOb 1)�-�_�o
Date of Accidend Injury or Date Discovered '��'����3 Time � am/�
Please state,in detail,what occurred(happened),and why you are submitting a claim.Please indicate why or hov�you
feel the Ci of Saint Paul or i s employees are involved and/or responsible for your damages. �
`C �`�� ���1 �1. '�
-� ,
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 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
❑ Oiher type of property damage—please specif��
�Other type of injury—please specif}r�P[�'k��r1�f1'►'�"�'�N�IP�11C.�e
In order to process your claim v�'• nppd to include copies of all applicable 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
$500.00; or the actual bills andlor receipts for the repairs
O Towing claims: legible copies of any ticket issued and a copy of the impound lot receipt
O Other properly 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
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Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims-nlease complete this section �
Were there witnesses to the incident? Ye No Unknown (circle)
Provide their names,addresses and telephone numbers:.���•►�c�n�'�'.�,\�ve� a�t"��G'���
Were the police or law enforcement calle � Y s No Unlrnown (circle) •t
If yes,what department or agency? �. C�.i� Case#or report# 1'3 2 i�"1'�O
Where did the accident or injury take place? Provide street address,cross street,intersection,name of park or facility,
closest andmark etc. Please be as detailed as pos i�ble._Necessary,attach a diagram. �C�d[�e. ��I'�P."4"
1 �'►Y1�nP�ndlr�_�IG. � .�.lu��
Please indicate the amount you are seeking in compensat�on or what you would like the City to do to resolve this claim
to your satisfaction.
Vehicle Claims- lease com lete this section ❑ check box if this section does not a 1
Your Vehicle: Year Make Model
License Plate Number State Color tJ
Registered Owner
Driver of Vehicle '
Area Dama e
City Vehicle: Year Make � Model �N�S
License Plate Number State M Color w ���rQ'.
Driver of Vehicle(City Employee's Name)�-�!4'a�'�,,'�Cl�,.�..CL�.e.C�.VCt.�t£C
Area Damaged
Iniurv Claims-please comnlete this section � ❑check box if this section does not avplv
How were you injured?
What part(s)of your body were injured?
Have you sought medical treatment? e No Planning to Seek Treatment(circle)
When did you receive treatment? 1 1 (provide date(s))
Name of Medical Provider(s): �
Address • . Telephone �'ZJy'�4 �
Did you miss work as a result o your'njury? s No
When did you miss work? (provide date(s))
Name of your Employer: - �
Address ' Telephone f �� �- 7 �'�"'-� ���Z
❑ 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 fornzs will not be processed.
Submitting a false claim can result in prosecution. Date form was completed i�-7i- '�i���
Print the Name of the Person who Completed this Fbrm: �Slf'[]►£., V ����tl� ���
Signature of Person Making the Claim: T�Ir'A CI L':r v.��Y,,�n�p n z r�
Revised February 2011
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