Steele 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 fhe municipality within I80 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° _
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Please complete this form iq its entirety by clearly typing or printing your answer to each question. If more space is
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needed,attach additional sheets. Please note that you will not be contacted by telephone to clarify answers,so provide as
mnch'infoi'm�tioti a's neCessa�tdexpl�in your claim,�atitl ti�e�mount�of compensation b�fng requested. You will receive a
wriften acl�o�vIedgement onee'youir form is received, �T&e prttCess can take�up to ten weeks,or longcr depemding on th� ,
nature of your claim. This form must be signed,and both pages rnmpleted. 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 C��S�o���•:--2- Middle Initial Last Name �C� C R E�.�\/_�
Company or Business Name �lCl' � �, �n�3
Are You an Insurance Company? Yes� If Yes,Claim Number? K
Street Address 15$O L.AS i S�u¢.t,. l" -J� c72���
City Si• 1��''`— State �� Zip Code S 5 t o!p
Daytime Phone(_) - Cell Phone(�2)�- �� Evening Telephone(� -
Date of Accident/Injury or Date Discovered �'Z-� 15� t 3 Time ►`��o+�l am/pm
Please state;in tietail;what;oeeurted•(happened),:and why you are submitting.a claim.Please indicata why�,oz.hovv you
f�el the City of`Sairit Paul'oi its��'ni�loyees'are;involved and/or responsihle for-yQUr dam�ge�.; , - . _ .. ,• .. .;.. ;,,
;•-Sr16vV 7�ov1; •� tr.w10`Ck��j" , . OJ C 4_ o u 2 Nr_At�'R�t ; .J�+}+� S�Vir�ti c.Y ; < � ,, . .
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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 ❑ 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
{�('Other type of properly damage—please specify
❑ Other type of injury—please specify
In order to process your claim vou need to include conies of all annlicable 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 WII.L NOT be retumed 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 vek�icle: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
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
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Failure to complete and return both pages will resWt in delay in the handling of your claim.
All Claims–ulease comvlete this section
Were there witnesses to the incident? Yes No nknown (circle)
Provide their names,addresses and telephone numbers:
Were the police or law enforcement called? Yes N� 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 landmark,etc. Please be as detailed as possible. If necessary, attach a diagram.
�S�p L,. 5 l�tvR.C.. Q2�Jir 5"�• �Av�
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. r?.4� —
Vehicle G7aims–gjease co�nlete this section ❑check box if this section does not apnlv
Your Vehicle: Yeaz 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 nlease complete this section ❑ check box if this section does not annlv
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
[S.Check here if you are attaching more pages to this claim form. Number of additional pages 2- .
By signing this form,you are stating that all information you have provided is true and correct to the best
of your knowledge. Unsigned fornts will not be processed.
Submitting a false claim can result in prosecution. Date form was completed t 2��6 t`3
Print the Name of the Person who Completed this Form: C��+l�s"tb��'R-' St�`=�`_ _
Signature of Person Making the Claim: ��(� `�"� `
Revised February 2011
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