Kramer Dec 02 13 11:45a Automatic Systems Co. 651-631-0027 p.1
NOTICE OF CLAIM FORIVI to the Ci�`(/of Sai
.'�1iRnesora State Statute 466.05 states tltat ". ° nt Paul� Mj]]]]�0�
governing bodp ofrhe manicipality wirhiR 180 y nerson...who claims damages from an
days afTer�he Q�1e8ed loss or rn'u y munrcipaLfty.,,S��1f cause to l�e presenled lo the
circurrutance,r rhereof,arrd d�e amourtt of eomPen,sation or other relief demarrded."
J ry is discovered¢nor�e s�Qr«8 ihe tinee,Dlace,ond
Please compiete thu form in its entirety 6y clearly typing or printin
ueeded�attach additiona!sheets. Piease note that yo��y���not be contacted by telephone to clari
m�ch information as neoe�ary to explain s Your answer to each qnestion. If
more space is
written acknow�edgement once your form is reeived. The process can take up to ten wee[cs or �a�wers,so provide as
nature of your claim This form must be s�gned,anda�th e amount of compensation being requested, y��.i��r�eive a
p ges completed. If something do�j��ar dependiRg on the
SEND COMPLETED FORM AND OTHER DOCUMENTS T , pp1y�Wr�te N/A .
15 �'VEST KELLOGG BLVD,3I0 CITY HALL,SAINT p�LCITY C`�ERK,
First Name��� , MN 55102
Middle Tnitial 1� Last Name K
Company or Basiness Narne �ME�
Are You an Insurance Company? YeS/�If yes,C(aim Number? VE D
Street Address I��ZS �A S � 2Q�3
c�cy_�r PA��.
State 1'hN) Zip Code J��Y CLERK
Daytime Phone (651)
�'�.$a'�Cel!Phone(�SI},�_ / 3 Evenino Te]ephoRe (,57
Date of AccidenV Injury or Date Discovered �-��_��
/l�2`�l3 Time G:� ��pm
Please state,in detail, �-hat occurred(happened),and wh
feel the City of Saint Paul or i[s em lo ees are involved nd/or�es submi[ting a c(aim.PJease indicate why or how yoU
P y ponsible for your damages. A1 Y Iq98
w ^` $4.�
� ^ A �G�- ''`� .0 v M�r R� �ct
° SGL -r ��E �� , —
7�o GET Y M1� �N n+ cAR 'E e
'�►D AS I T py ' V • o u ,�,v �
�o �A L.V H�7Tw► TNi: a�lT �r "'� �E
fN �� ' c�F in R �"'T ;p iwa � c.�r�N
ST`oP AND OQ,O✓E AwaKcFRo,q � a� � -
Please check the box(es)that most closely repres n�t tNhe�rea on�~omPl�ng���orm: +��w�� s ` � af��r
77Ic+SrRa`+��- o�c� �
❑ My vehicle was damaged in an accident a �oo�t d�z ,�,e PA�
O My vehicle was damaged by a pothole or COr1ditiot1 of the street � My veh�cle was damaged during a cow T��'
��Ny veh�cic was ���ronbfuJly towed and/or ticketed '�My vehicle was damaged by a pfoee�,sT,tE�r
Q I was injured on City property 3wa�0.
❑Other type of property damage-please specify
❑Other type of injury-please specify
In order to process your claim you need to incIude copies of all applicable documents
For the claims types listed below,p]ease 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.
�� Propetty damage claims to a vehicle: two estimates for the repairs to your vehicle if the damage exceeds
5500.00;or�he 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
1� �� O Injury claims:medical bills,receipts
O Phocographs are always welcome to document and support your claim but will not be returned.
�� : �,�����-�\easee�mQ�e,�e ana�.���e�.tiQa��,oc c��m�o�
?, �
,` �
.��. � �. �\ _
Dec 02 13 11:45a Automatic Systems Co. 651-631-0027 p2
Failore to complete and return both pages will result in delay in the handling of y�our claim.
All Clairns-please complete this section
Were there witnesses to the incident? Yes No nkno� (circle)
Provide their names,addresses and telephone numbers:
Were the police or la�v enforcement calted? es No Unknown (circle)
Ff yes,what department or agency? ST PAut,. Reu c� Case#or report# 13� ZS3 •0 7L
Where did the accident or injury take place? Provide streec address,cross street,intersection,name of park or facility,
closest landmark,etc. Please be as detailed as possible. If necessary, attach a diagram. Da PASC,.A L� STitEBT
J�fita�lT oF l��.5 A1 PA�r�.- 5T'
Please indicate the amount you are seeking in compensation or�vhat you would like the City to do to resolve this claim
to your satisfaction.
Vehicle Claims please complete this section ❑check box if this section does not apply�
Your Vehicle: Year 149� Make BuecML Model LfiSAB2x"
License Plate Number 487 EZH State M1�Color Tw�J Ih i zGA�� 19s�`334
RegisteradOwner 1G�ve�l M i�r3�n+► /!-
Driver of Vehicle N/A — v6►��C.L� G�l►S ?A/t�J
AreaDamaged I.EFJ' �c•.+rFEHDtR urFr��NSKrAsse�ne�.Y, F��uTB.�•osR,��uveS �R
Ciry Vehicle: 1'ear biake Model K�"aFE.i Si,JEEPEi�
License Plate Number State Color
Driver of Vehicle(City Employee's 1Vame)
Area Damaged
Iniurv Claims please complete this section �check box if this section does not anplv
Ho��were you injured?
VVhat part(s)of your body were injured?
Have you sought medica]treatment? Yes No Planning to Seek Treatment(circle)
V�'hen did you receive treatment? (provide date(s))
I�Iame of Medical Provider{s):
Address Telephone
Did you miss work as a result of}�our injury? Yes �o
V�'hen did you miss work? (provide date(s))
Name of your Employer:
Address Telephone
6� Check here if you are attaching more pages to this claim form. Number of additional pages �.
By sianing tliis form,you are stating that all information you have provided is true and correet to the best
of your knowledge. Unsigned forms will not be processed.
Submitting a false claim can result in prosecution. Date form was completed ��/Z��3
Print the Name of the Person who Completed this Form: ueV iA s �2A^'�E/�
Signature of Person Making the Claim: ''�`''� ' --=--r'�4l�"�''
Reviscd Eebruory 20l 1
Dec 02 13 11:46a Automatic Systems Co. 651-631-0027 p.3
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