Cole RE��IVED
NOTICE OF �LAIM FORM to the CityN�S�i�t Paul, Minnesota
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Minnesota State Stafute 466.05 states that "...every person...who clainas damages from any municipality...shall cause to be presented to the
governing body of the municipality within 180 days after the alleged loss��s�¢ot���iotice stating the time,place,and
circumstances thereof,and the amount of compe t o 0 ot �'P�1Ce emanded."
Please complete this form in its entirety by clearly typi�►g or printing your answer to each question. If more space is
needed,attach additional sheets. Please note that you wilk not be contacted by telephone to clarify answers,so provide as
much information as necessary to eaplain 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 btlth 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 PALTL, MN 55102
�
First Name Middle Initial� Last Name��I �
Company or Business Name
_ _ _ ---. . _ __ ____ ___, _.— _, _ _,
Are You an Insurance Company? Yes/`N�f Yes, C1aim Number? -
Street Address � t�
City Sta.te � Zip Code���
Daytime Phone(_) - Cell Phone � ���,Evening Telephone�) -
Date of Accidentl Injury or Date Discovered � � Time 7 %l�(��pm
Please state,in detail, what occurred(happened),and why you are submitting a claim. Please indicate why how you
feel the�ity of S ' t Paul or its em lo ees are involved and�o responsible for ur damages. �1►�.e •i
� � �11 rU t 6 � ��
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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 tQwed and/or ticketed ❑ I was in'ured on Ci property
Other type of property damage—please specify � W0� � �
❑ Other type of injury—please specify � _ _
In order to process your claim you ne�d to include copies of all applicable documents.
For the claims types listed below,please be sure to i�clude the documents indicated or it will delay the handling of �
your claim. Documents WII,L 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 tick t issued and a copy of the impound lot receipt
O Other property damage claims: two repai esrimates if the damage exceeds $500.00; or the actual bills
and/or receipts for the repairs; detailed list damagerl 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.
6 ''
All Claims—please complete this section
Were there witnesses to the incident? Ye No Unknown (circle
Provide their names, addresses and telephone umbers:�N. Mi�'���I�1�'�1
Were the police or law enforcement called? ,���rs/ No Unlrnown (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 ark or facility,
closes landmark,etc Please be as detailed as possible. If necessary, attach a diagram.���U �rn�IQ�'�
S-- i�'�� vl-� ,t� .�_H/l�t
Please indicate the�ount you are�g in compensation or wha.t you would like the City to do to resolve this claim
to your satisfaction. (7Y�
�7.h'.�In �'ln'w. ln +n 1+: o� 4+n� nl+or r}.�� if �+ n*inn r1nPO nn4 v�v����
Your Vehicle: Year Make Yvlodel "
License Plate Number State Color
Registered Own�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
Injurv Claims—please com�lete 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 treahnent? 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 nf T��r Fmz ln�Pr• __ _ -- -- --- — - -- — _— — —
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 ����/ � �
n �
Print the Name of the Person who Completed this Form: �v-O�c-NV G� l. p��
Signature of Person Making the Claim: -�r��� J
Revised February 2011