Pirkl NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minnesota State Statute 466.05 states that"...every person...who claims damages from any municipality...shall cause to be presented to the
goverrting body of the municipality within 180 days after the alleged loss or injury is discovered a notice stating the time,place,and
circumstances thereof,and the amount 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 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� T� /' !• �S Middle Initial �Last Name� � 1''�.�"� ������
Co::;pw^;�cr Busir.�ss Name "�' �'i ' ��UN��"tf �(
7 20�3
Are You an Insurance Company? Yes/ o If Yes, Claim Number?
Street Address / �lTY CLERK
City f` 6�t�' �- State � � Zip Code _�Cl
Daytime Phone�)�� , - Ce 1 Phone( ) - Evening Telephone( ) -
Date of Accident/Injury or Date Discovered P�/7� U� � �� �'�m�'��"��am/pm
Please state,in detail, what occurred(happened), and why you are submitting a claim.Please indicate why or how you
feel the City of Saint Paul or its employees are involved and/or responsible for your damages.
�� � 'T , � �� � C� �]
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
�uther type of property damage-please specify��}�C�� 7- �-r ��✓H" �
Other type of injury-please specify
In order to process your claim vou need to include copies of all apnlicable 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 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
andlor 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
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? Yes No nkno (circle)
Provide their names, addresses and telephone numbers:
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 street address,cross street, intersection,name of park or facility,
closest la ar ,�L��e�s detail��ossible. If�ce��,J ttach a diagram.
�
Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction.
,
l 1 �` �' ✓� �' _S
Vehicle Claims—please complete this section ❑ check box if this section does not applv
Your Vehicle: Year Make Model
License Plate Number State Color
Registered Owner
Driver of Vehicle
Area Damaged
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Injurv Claims—please complete this section ❑ check box if this section does not applv
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 Employer:
Address Telephone
Q'Check here if you are attaching more pages to this claim form. Number of additional pages�.
By signing this fornz,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 prosecution. Date form was completed �� �`� �
Print the Name of the Person who Completed this Form: �J � � r� �
Signature of Person Making the Claim: ' °�
Revised February 2011
Hampton Bay 3-Head Outdoor Post Light-HB7017P-OS at The Home Depot Page 1 of 2
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q.��Fixture ColodPinish:Black V�
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PRODUCT OVERVIEW '
_ _ _ _
1'he Hamplon Bay 3-Head Outdoor Post Light enhances the secunty of
your property while addiny sophisticated charm ro your landscape. �nf0$�GUIf�@S '
Three French-style lantems wilh 6ent.beveled glass are matcheA?o a . �.
cast aluminum post in a long-lasting black finish.Exquisite detailing Instructions/Assembty ��.
adds to the posYs timeless good looka �� .
You will need Adobe�Acrobat�Reader to view
• Ruggsd cast-aluminum housing is ideal for outdoor ' PDF documents.Dowr:lead a free copy from the
installation Adobe Web site.
• Bent;beveled glass for an elegant look when illuminated __ _
- French-style lanterns provide a transitional European style
• Weather-resistant housing protects against moisture
• Assembled dimensions:24 in.W x 83-1/Z in.H
• MFG Model#:H87017P-05
• MFG Part#:H67017P-05
SPECIFICATIONS
Assembled Depth{in.) 24 in Assembled Height(in.) 83.5 in
Assembled Width(in.) 24 in Bulb Type incandescent
Certifications and Listings 1-UL Listed ColodFinish Black
--- -- _
Dusk to Dawn No ENERGY STAR Certified No
Exterior Lighting Product Type Post Light Fixture Material Cast Aluminum,Steel,Glass
GlasslLens Type Clear Light Source Incandescent
Manufacturer Warranty One Year Limited Warranty Motion Sensor No
Number of Bulbs Required 3 Outdoor Lighting Features Weather Resistant
_
Product Height(in.) 83.5 in Product Length(in.) 24 in
Product Weight Qb.) 1975 Ib Produd Width(in.) 24 in
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Retumable 90-Day Size Large
Solar Powered No Style Transitionai
http://www.homedepot.com/p/Hampton-Bay-3-Head-Outdoor-Post-Light-HB7017P-05/1... 11/12/2013