Roberts (2) 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 municipaliry...shall cause to be presented to the
governing body of the municipaliry 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 �-IALL, SAINT PAUL, MN 55102
1 f Middle Initial Last Name a��.rt" ��°-°
First Name �-✓Y1 r"I S - � ����
Company or Business Name ��� �,� ��.��
Are You an Insurance Company? Yes No If Yes,Claim Number?
CiTY CLE�?�
Street Address o�c�. �{ �O�Cx�, � � �
City �C� �t�,t-i-� State m� Zip Code 5s(�J
Daytime Phone (fosl)�-�.Cell Phone(�L)���Evening Telephone(laSl )�- ��
Date of Accident/Injury or Date Discovered �l"1�'l� /�/�1� ���me i am pm
Please state,in detail,what occurred(happened),and why you are submitting a claim.Please ind��irc,ate why or how you
feel t e City of Saint P ul or its employees are involved and/or res onsible for your damages. C�-'a .. �
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Please cileck the box(es)that most closely represent the reason for completing this orm:
❑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
❑ I was injured on City propefty
❑ My vehicle was wrongfully towed and/or ticketed I �� t� �m��� ���;�h i�-�o ��e�.,�-e.
,�Other type of property damage-please specify �R�r�C'
❑ 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.
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
�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
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—please complete this section
Were there witnesses to the incident? Yes No Unknown (circle) , �--
Provide their names,addresses and telephone mbers: �u �G�t.�h�'� ( t..r.>i s he� l-�►--C�'1C'�..+'�
�y Gl�a'e � 5 l--vZ°l 3�' (o`�
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 lan mark,etc. Please be as detailed as possible. If necessary,attach a diagram.
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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. �i rn,ht�.rS�p r��' -�'�' �"���1+"S � ��"�`�'' ��'��r
Vehicle Claims please complete this section L'�1 check box if this section does not ap�ly
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
Iniurv Claims please comulete this section check box if this section does not apply
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
❑ 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 prosecution. Date form was completed �5 ��
Print the Name of the Person who Completed this Form: 1=.17t—� �j►�"� �� /` �k'�
Signature of Person Making the Claim: r ► l� �'`�
Revised February 201 1
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i . � score#:3oi� Phone:651-457-2609 PAGE 1 OF 2
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�, WEST ST PAUL Fax:
_ 1445 ROBERT STREET SOUTH
GUEST ESTIMATE WEST ST PAUL,MN 55118-31�STIMATE #: 301720989525
Fri Nov 22 12:10:44 CST 2013
QTY DESCRIPTION SKU
1 Door only 3G' X 84" 6 Panel, Single Door, Steel 4000446
Right Hand lnswing
No Bore and Not Mortised with No Deadbolt Bore
No Kickplate . No Mailslot
No Peepsite or Knocker
Interior Primed Ready to Paint , Exterior Primed Ready to Paint
Actual Size 35 13/16" X 83"
** Estimated lead time for this item is 7 days **
Features Glass Outside View Inside View
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**PL�;ASI: NO"TE THF.. FOLLOWING** 1'ODAY'S LS"TIMA"I'ED PRICE
Door coloc,the background, and accessories are for representation only. Dooc .D25S�72
units ordered without deadbolt will still have the deadbolt prep into the frame. Price is good for all items on this page.
A deadbolt coverplate will be supplied.
Total price for all items $589.93
i'his is an estimate.h is given unly for gcneral price infunnatiun.This is not an offer and there can be no legally binding contract be[ween[he parties based upon tliis estimate.The prices staled herein are subject�o change
depending upon the market cunAiiiuns.The pnces stated on this estimate are not firm for any time period unless specifically written otherwise un this fonn and are not mclusive of taxes,delivery,pnckaging or any other
charees which inaY or may not need to be added when iJtimately purchasing products from Ihis estiinate.The availability o(materials is subject to inventory conditions.MENARDS 1S NOT RESPONSIBLE FOR ANY LOSS
I��CURRED Bl'THE GUEST WHO REUES ON PRICES SET FORTH HEREtN OR ON THE AVAILABIUTY OF ANY OF THE MATERIALS STATED HEREIN.All infonnation on this form,other than price,has
been provided by euest and Menards is not responsible tbr any errors in the infonnatiun on this estimate,including but no�limi[ed to qunntity,dimension and qualiry.Please examine this es[imate carefully.MENARDS
MAKES NO REI'�RBSENTATIONS,ORAL,WRITTEN OR OTHERWISE THAT THE MATERIALS USTED ARE SUITABLE FOR ANY PURPOSE BEING CONSIDERED BY THE GUEST,BECAUSE OF W IDE
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� '.. � � r� ��' Store#:3017 Phone:6�I-4��-260�) PAGE � �F 2
��"��1��^ � w. WGS��S`I PAUI., Fax:
-°''°`°`�� 144� R013ERT STREE"l�SOU'TI-I
GUEST ESTIMATE WEST ST pA"�. "'N 55"x-3'�STIMATE #: 301720989525
Fri Nov 22 12:10:44 CST 2013
Q�I'y DESCRIPTION SKU
1 Door only 36" x 84" 6 Panel w/22"x36" Lite, Single Door, Steel ,Clear Low E 22" x 36" 4000446
Right Hand Inswing
No Bore and Not Mortised with No Deadbolt Bore
No Kickplate ,No Mailslot
Interior Primed Ready to Paint , Exterior Primed Ready to Paint
Actual Size 35 13/16" X 83"
** Estimated lead time for this item is 7 days **
Features Glass Outside View Inside View
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**PLEASE NOTE THE FOLLOWING** TODAY'S ESTIMATED PRICE
Door color,the background,and accessories are for representation only. Door
$331.22
units ordered without deadbolt will still have the deadbolt prep into the frame. Price is �ood for all items on this page.
A deadbolt coverplate will be supplied.
Total price for all items $589.93
onl�tbi aeneral n�ice information This is nui em o(ler nnd there can be no legnlly bmding cuntract betwcen the�.utics L�tied�� 1 are�not Inelu+ive ut ta<es�delivery�p:�ckaging oli'atnY utlher4e
lh i.�an .timalt It i: .iven � I
J��cndins.upun thr mnrket conditions The prices sta�ed on this estimate are not firm for any tiine periud unl"v ilabiliti1lof materials�is tubject tolinventorylcundi�ion's.titENARDS IS NUl'RBSPONSIBLE FOR ANY LOSS
I
chnrges�vhlch mnv or may not need tn be ndded when iJtlmately purchasing produots from this estimate-�fhe a n }
IhCURRIr.0 BY fHL'GU[ST���I10 RELIES ON PRICGS SEl'FORTH HEREIN OR ON THE A��Ae�ing idiTl'�OF.�NY O�T����E��ine yion�ndED�ER�le se�esamine di s��es'timate careful�ly�MENARDS�a�
beeu pruvidcd hg guest and 4lcnau�ds is not responsible for any ermrs in the infonnation un Ih S
hi:1KFti��O RLPRESEN"PA'I'IONS.ORAI,.WRITTEN OR OTHERWISE THAT THE MATERIALS LISTED ARE SUITABLE FOR ANY PURPOSE QEING CONSIDERED I3Y THE GUEST,BECAUSE OF WIDL
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100-1 Entry Steel Doors Slab Only Slab Only Right 35.75 x 83 1 $509.78 $509.78
Call Width = 36
1° i�j'�'���`'�, Call Height= 84
"�n�.,+�o�rs Include Lockset= No
Mail Slot w/Sleeve= None
Door Bore = Double Bore �
Bore Backset= 2 3/8" i 'Y'
Lockset Bore Position = Custom } �
Custom Lockset Bore Position =48 I �' �
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��aw B�lt Sor� !'�s;ticn = 5 1;2"
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Bore Diameter=2 1/8" i
Hinge Prep= 3-Hinge Prep ; °�-� �-.�
Hinges Included = No i °
Hinge Size =4" x 4° I
First Hinge Position = 6 3/4" ;
Second Hinge Position = 38°
Third Hinge Position = 69 1/4" i _
Catalog Version Date= 11/01/2013
Room Location = None ' �'s'� A
Reorder= No
Door Type = Doors with Inserts
Door Thickness = 1 3/4"
Door Style = 2-Panel 1/2 Lite
Door Cut Out= None
Door Finish Type = None
Plant Location = Grinnell (DI)
Plant Contact= 1.800.246.9131
Building Code = Standard
Qualify for Tax Stimulus Credit Option =All Products
Energy Star Needed = No
Overhang Flyer= Yes
Unit Type= Slab Only
Operation /Venting = Right
S�rirg Cpt�o� = R�g�t insw�ng
Door Glass Insert Size & Shape = 22 x 36 Rectangle
Door Glass Insert Option = Decorative
Door Glass Type = Standard Glass
Door Glass= Langford
Door Glass Caming = Nickel
Door Glazing Type =Triple Insulated
Door Glass Texture/Privacy= None
Door Glass Privacy Rating =6
Door insert Grille= None
Door Order Method = Store Delivery
Overall Frame Width = 35.75
Overall Frame Height= 83
Overall Rough Opening Width = 36.75
Overall Rough Opening Height= 83.75
www.HomeDepot.com Page 1 of 2 Printed By: ELIZABETH Date Printed: 1 1123/201 3 1:22 PM
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Quote Summary:
Line# Item Summary Price Qty Total Price
100-1 Entry Steel Doors SI83 Only Right 35.75 x $509.78 1 $509.78
Pretax Total Price: $509.78
www.HomeDepot.com Page 2 of 2 Printed By: ELIZABETH Date Printed: 11/23/2013 1:22 PM