Tocko ;<;;.� �_�
. �.:
NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minnesota 5t�ite Statute 466.05.states that"...every person...wlw clairns dumages from uny nwniczpality...shull cuuse to be presented to the
governing body of the municipality within 180 days after the alleged lass or injury is discovered a notice stating the time,place,and
circumstances thereof,and the amnurtt of compensarion ar other relief demunded"
Please compkte this form in its entirety by clearly typing or printing your answer to each question If more space is
needed,attach additional sheets. Pleasc note that you will not be contacted by telephone to clarify answers,so provide as
much information as necessary to egplain 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�pending 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 WFST KELLOGG BLVD,310 CITY HALL,SAINT PAUL, NIN 55102
�t� � �
First Name .1� , /'P.h Middle Initi Last Name d L '� [^- `
Company or Business Name
L.��+d���./
Are You an Insurance Company? Yes�If Yes,Claim Number? ���� �`� 201�
JtCCCt Ad�eSS _ 1 D.7 O �I{�`D " T/`QiG-f- CITY C���K
City_wl.°�� ..ST• �ttk�� 3tate �� Zip Code S�l��
Daytime Phone���'- Oj Cell Phone(�)��Evening Telephone���—��-�--
Date of Accidend Injury or Date Discovered ��7-°11��_Time f 0(� m m
Please state,in detail, what occurred(happened),and why you aze submitting a claim.Please indicate why or how you `
feel the City of Saint Paul or its employg�s are invo ved and/or re �ible for' d ges. �
r h t�/+1►�. /�i yl i s` 2tc
� �- r` �,p�.. � �,a-
� e %'� 8 • m m ve�
. ,r _ t ,_
, �` e..m G�2 r
. k ^
� h !
' 1
Please check the box(es)that most closely represent the reason for completing this form:
O My vehicle was damaged in an accident ❑My vehicle was damaged during a tow
O My vehicle was damaged by a pothole or conditioni of the street �My vehicle was damaged by a plow
0 My vehicle was wrongfully towed and/or ticketed / ❑I was injured on Cit pro rty �
l�Other type of property damage—please specify N!"fi� C� _.
❑Other type of injury—please specify /�
In order to process your claim you nced to include co�ies of all anvlicable docnments.
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 retumed and become the pmperty of the City. You aze 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 pmperty 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
p Injury ciaims:medical bills receipts P n ouI claim but will not be returned•
O Photographs are always W+e�come to doc�eeand r Sb��b p��°f Claim Form
page 1 o f 2—Please�omp
,
� _- -_ __ - -
I
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims—�lease comnlete this section
Were there wimesses to the incident? Yes � Unknown (circle)
Provide their names,addresses and telephone numbers: ��
Were the police or law enforcement called? Yes ]�Io 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 lan mazk,etc.�Please be as detailed as possib e. If necessazy,attach a diagram. or �bt
�N�tK�D�O t S E y1 �/►Dw� v � �t��,IO �!�/D S T �.L/ S1� �
Please indicate the amou t you are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction.���0, BD
Vehfcle 1 ' —
C aims lease com lete this section ❑check box'f this section does not a 1
Your Vehicle: Year,�,QQ,�_Make Model Nt/�
License Plate Number State Color
Registered Ownea
Driver of Vehicle O
Area Damaged /` 2�
City Vehicle: Year Make � Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
IAiurv Claims—alease comnlete this section �check box if this section does not aualv
How were you in�ured? ,
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
O Check here if you are attaching more p�ges to this claim form. Number of additional pages I
By signing this forin,you are starting that all information you have provided is true and correct to the best
of your knowledge. Unsigned forins will not be processed.
Submitting a false claim can result in prosecution. Date form was completed / / ,
Print the Name of the Person who Completed this Form: 1' �. �c�2'�
Signature of Person Making the Claim:
Revised Febmary 2011
Doddway
Collision
995 Dodd Rd.
West St. Paul, MN 55118 �
Phone(651)457-1(��_� �a� ��J � � �
Name��� � -._ Address _City�P/�� Phone--
y��' t
M 1 /_ Year �� Seriai No. Body Style Style No._ __
Mileage Li se No._ __Paint No._ _Trim No. Insurance Co.
Repeir Replace ESTIMATE OF RF.I'AIR COSTS �R PARTS SUBLET
,.-� � ,�----`.
'.....
� /I
- � � _
.-- ,
��
I
�
TOTAL
ItEMARKS:
HRS OF I.ABOR AT$------PER HR $__ -....-.-.-__�....____...__. .
---- _.---° _
-- — ---- ----- �PART S_
a__________ INS[JRANCE DEDUCTIBLE pplN'['Mq1'E S� O O
BY:
- - --- SUBLET $
This estimate is basaci on our inspection and does not cover additicmal parts or labor
whichmayberec�iredaftertheworkhasbee�istarted.Afterthewnrkhasslarted,womor SALESTAX $
daruaged parts wbich are not evident on first inspection may be discovered.Natwally -- --
this estimate cmmot a�ver such conring�cies.Parts Fxicxs subject to change without
notioe.Thisestimateistorimmediateacceptance. ESTIMATETOTAL $_
AllVANCE CIIARGES $
THIS WORKAUCHORI2EDBY:
GRANDTOTAL $
� - , � �.. '`i-
I � . �-i'.__ s�.``� ' � �_
• , �
� f .•'� - _
_ , �. � r
Ii.i � L_
� T
� - _ - �� t_.". .M
�� '
\ • � •
�
\
_ \a
! ��
�
{ _
� „
<.�;
, .. �` r
ti
a � a
. � ' ' . �' � ` ' � ' , ' .
. ' � . � . `.� ' ' . .
, - . . . � 1 . . ' i . ' '
" . • ' - , . .r. � . . . .' _. .. �
. � � . � � - � � � �. . . v'. .
•'.
.. • � . ' ' '♦ .e. . . . � . .. . •
' � ' . • . . V . ' �
� • . . . . � , � � . . .
� �
. � •1 • If ... .1 �/�: . . � �
. � . � .• � ,( � . . w . . . .