Curtis NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minnesota State Statute 466.05 states that°...every person...who claims dumages from uny municipuliry...shall cuuse to be presenied lo�he
governing body of the municipality within/80 days after the alleged loss or injury is discovered a notice stating the time,pluce,und
circumstances thereof,and the amount of compensation or o�her 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 Eo c}arify answers,so provide as
much information as necessary to explain your ciaim,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
First Name�b �}il Middle Initial J Last Name��f,.t��i� R�r���/E D
Company or Business Name 9 ���3
Are You an Insurance Company? Yes No If Yes,Claim Number?
Street Address ����/*-✓� 'p n-�--- � th° `� TY C L E R K
City �� �l�'i L� � Stat�� ,/�1 Zip Code_:��b
Daytime Phone( ) - Cell Phone(�.�)�>b�s 7 Evening Telephone( ) -
Date of Accident/Injury or Date Discovered ��d 3—�-3 Time 5 � D.�am�
Please state,in detail, what occurred(happened),and why you are submitting a claim.Please indicate why or how you
fee]t!:e City�Ssir.t Paul or its emglqyees are invo?ved a:��o:respo i :e ;;rour damages. �j���'����
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Please check the box(es)that most closely represent the reason for completing this form:
❑My vehicle was damaged in an accident I ❑ 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 a ❑ I was injured on City property /
�Other type of property damage—please specify ra n r c��,,��noD � f�k� �c�-�'{✓,�i�/�T a��
❑ Other type of injury—please specify
In order to process your claim vou need 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.
j�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 property 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
�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–please complete this section 3 Stu���/��� �'�'�'�'� b�'�����'� s�/'�� �'�" v��� " `
Were there witnesses to the incident? ��Yes No Un own (circle) �n'' � ��Q ��b''��'"`�,� ,
Provide their names, addresses and telephon'��mbers: S - �w�r ��
�� - o –S –
Were the police or law enforcement called? Yes No Unknown (circle)
If yes,what department or agency? Case#or report#
Where did the accident or injury take place? Provide stre�t address,cross street, intersection, name of park or facility,_
closest landm rk,etc. Please b as detailed as p�ssible. If necessary,attach a diagram. 7�/ �_ /� -� �
S� � � � ; �
Please indicate the amoupt you are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction. ����C/
Vehicle Claims– lease com lete this section ❑check box if this section does not a 1
Your Vehicle: Year ` � Make Model �'—
License Plate Number - S�ate�1 ,j�[Color���t.2_-
Registered Owner � - �-�
Driver of Vehicle b
Area Damaged �
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniurv Claims please comqiete this section I �check bo�if this section does not auplv
How were you injured? "
What part(s)of your body were injured?
Have you sought medical treatment? Yes o 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 in' ? 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 claim can result in prosecutiort. Date form was completed ��— b �/�
� ' �
Print the Name of the Person who Completed this Form: 1 f'?"✓' l
Signature of Person Making the Claim:
Revised February 2011 �
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`Roseville, MN 55113
(651�633-83�lQ Fa�c(651)633-8844 � F«�.T�: r�By
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781 MONTANA AYE
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and I authoriie tnv Insorance 6omt�ro to aav Auto Glass Today,Inc.
dirxtly for the glass and instaitation eharges>or repairs.
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