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Wendle 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 governing 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 e�cplain your claim,and the amount of compensation being requested. You will receive a written acknowiedgement 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 K LLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102 ` � � e ��. j-� RECEIVED First Name G�� Middle Initial Last Name Company or Business Name nFr; 17 2013 Are You an Insurance Company? Yes No If Yes,Claim Number? CLERK Street Address �� va�$ � �� `�� ( � �A AS (�-� City t?� C—�l.`7�� State /"�/`� Zip Code � J ��I Daytime Phone(��- �� ell Phone(��) 3f�- � �IEvening Telephone( ) - Date of Accidend Injury or Date Discovered ' �� Time 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 in olved and/or responsible for your damages. r � e.r e S�-�. � �e ^t c c. i s a ou.� � r�r � - �,�,(' �i,n ^ c�ecQ ^ ✓�►� t� ! �sv►��sS�K ¢.,�` . t l c�e Please check the box(es)that most closely represent th�reason for completing this form: ❑ My vehicle was damaged in an accident ❑ My vehicle was damaged during a tow ❑ y vehicle was damaged by a pothole or condition Of the street ❑ My vehicle was damaged by a plow ��VIy vehicle was wrongfully towed and/or ticketed ❑ I was injured on City property ❑ Other type of property damage—please specify ❑ 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 far 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 Failure to complete and return both pages will result in delay in the handling of your claim. All Claims-please comvlete this section /� Were there witnesses to the incident? CYe No Un wn ( ' cle� ��, �(o, G�G� 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 landmark,etc. Please as detailed as possible. If necess attach a diagram. Qst.S�f-g��t.�e., d� �,�r�,,u.-� he�=vre e�. l� �Fa r1- a h .��1�4�J�- Please indicate the amount ou are seeking in co ensation or what you w �d like the City to do to resolve this claim to your satisfaction. �oZl� .�a '�'-�� /� M� �/�, Vehicle Claims- lease com lete this secti n check box if this section does not a 1 Your Vehicle: Year Make J�_Model . License Plate Number State Color Registered Owner .r� � 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-nlease complete this section �check box if this section does not anvlv 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 i � By signing this form,you are stating that all infornzation 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 prosecuhon. 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