Brown, Nathanial NOTIC� OF CLAIM I'ORM to the City of Saint Paul, Minnesota
Mr�uteso[a State Stan�te 466.05 stntes tlrnt "...eve�y person...wl�n clninrs dnma��es.�'rrnn miv municipalitv...sha!l cause to he pre.sented tn�he
governing hotly of the rrtuniciper(ity��it/�i�i 180 dcrys after�/re ulleged loss or injury is discovered n notice statiiig the ti�ne,p/nce,ancl
circumstcinces thereo/;and the nmount n`contpen,ratinn or other relief deinnntled."
Please complete this form in its entirety by clearly typinfi 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 f'orm 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 DOCUM�NTS TO: CITY CLERK,
15 W ST �ELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
,
First Name i �G�t� � Middle Initial � Last Name!�����<7 ���'���/�I�l
Company or Business Name C1Ct` � � �n1�
Are You an Insurance Company? Yes No If Yes, Claim Number? K
Street Address l/ !'c� cf ���'-
T��
City �� .. �v� State �� Zip Code �- lGl �
� Daytime Phone (�ls'�)(����'� ell Phone (lp�/)��� y.�S��vening Telephone( ) -
Date of Accident/Injury or Date Discovered �5 ��` ��/�' Time am/pm
Please state, in detail, what occurred (happened), and why you are submitting a claim. Please in�i.�ate why or how you
feel the C;ity of Saint aul or its emp�oyee,� are i olve _and/��esponsible or you damag�s.-:-� "
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��c��`f` ��''✓�
Please ch�c�fhe�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 J� 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 you 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
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 oP 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 comnlete this section
Were there wimesses to the incident`? `y��s No ,Unknown (circle) -
Prp vide he}�r ames, addresses nd telephone�n mbers: f f���''� �r�'c'° r s^ ��'�
,/-��- � !'��✓ �r"��=�� � `? �' ��'�� >...�� �-� t�'E' L C�rv c ��' G,����
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 be deta� ed as ossible. neces� r a ch a ia ram.
f �` Y� � g
�, '"`� .� ���,�'i--J�9� �y� ;f'! .�'o;4/ n�� �f' �n �/'ro�n �- �!�?`��/Z�;C,�-'� �v.
Please indicate the amount you are seehi g in co, ►j� ensat�o�j or what ou would�1� e the�ity to do to resolve t claim
to your satisfaction. � c��o �� /�C •�`� �� '`� y° ���� r �� ��'z'<�
�O �/�°� 1`f%''' .d�L� ri �i?✓ � ' � � � �7
' !3� i•�SC��C C''�'�, j
Vehicle Claims-please com�lete 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
In'ur Claims- lease com lete this section ❑ check box if this secti s not a I
How were you iniured? /B�v�'� � � c� �S�%� � �= ",✓`�� l oL �
n
What part(s)of your body were injured? �'� :-' � � �c' 2d'v�
Have you sought medical treatment? Ye� � No Planning to Seek Treatment(circle)
When did you receive treatment? �5�� ��'�'` (provide date(s))
Name of Medical Provider(s): t� �;"�f"-<� �� l Q'-' n���'
Address Telephone
Did you miss work as a resul your injury? lf�— No
When did you miss work? ! � - (provide date(s))
Name of your Employer: � ��� � _
Address l-'- �. � , Telephone 7Cn� �. 1_ �
❑ Check here if you are attaching more pages to this claim form. Number of additional pages
By signing this form,yocc are stating tltat ull 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 f'orm was completed
Print the Name of the Person who Completed t 's : .��'�� '`-�r"fo.-�� �l/ ���
Signature of Person Making the Claim: =I�� /� �,���-��c
v
Revised February 201 1