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Omeara NOTIC� OI' CLAIM I'ORM to the City of Saint Paul, Minnesota lYlinnrs�o�n Stnte Statute 466.05 stn�e.r drat "...evPrv persnn...wl�n rinims dainu,�es fronr miv nt��nicipalitv...slrall criu.ce tn 1�e pre.sc��tcd to die �orenring hudy of d�e ntru�icipnlity wi!/�iii /80 dcrys n/�ter 1/re a/le�ec(loss or i�rjury is clisconered n natice stntiiiq tl�e[inre,p/nce,cnrc( circrrnrstances lJrereo/;crnd tlie amounf nf crnnpen.entinn or i�lher relie�'denrnnded." Please complete this form in its entirety by clearly typing or printing your answer to e�ch c�uestion. If more space is nceded,attach additionai sheets. Please note that you witl not be contacted by telephone to clariCy answers,so provide as much information as necessary to explain your claim,and the amount of compensation bein�;requested. You will receive a written acknowledgement once your form is received. The process can take up to ten weeks or lon�er depending on the n�ture of yc►ur claim. This form must Ue signed,and both pages completed. If somethin�docs not�pply,write`N/A'. SEND COMPLETED TORM AND OTHER DOCUMENTS TO: CITY CLERK, 15 WEST I��LLOUG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102 rirst Name �� t� '�'� v,-- Middle Initial� Last Name � M.�- H � � �� Company or I3usiness Name ��J C7 P-� l r' . J,�N 23 20�4 Are You an Insurance Company? Yes�'No If Yes,Claim Number? Street Address �� >_� C�. (�,�'�� 1TY CLERK City �`�'; �C�� `'` State i� 1� Zip Code s+�r`� � Daytime Phone ( )�t�_Cell Phone ( )�-i�� Evening Telephone ( )�C�� Date of Accident/Injury or Date Discovered ��/ 5 j/ '� Time l �, am/ m,,3 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 ernployees are involved and/or responsible for your damages. (� �SK �a t�: �!. �- -, ,-, �t' . \::�\ ~; e=-�- _ . > ,�' , r- r's' 1'�'t> � � � 'j" . C S�� 'S �I ��C f` 1.:.'Z t' ! /� � . - cu��Q. - .�t c� �u � � �" - � " �' ` v .. -f � � 4c �� e i�' `�1 ti 1� � `�'y�J CJ �% 1 iv1r� \C�: V`� �� `'i C.i��` 5�-i:�'l3 n ��G�� {�.C�c:`?�'C5�n�i Y� �'��4� C- �' ` C 7' � �.. li t G\� -�'1..�- �i-�:'�i.'�-� � � ` � �l � C:,.'VJ''. - - C"` � � ,:' ` -�v\ , G Yl/1 � : " . ' Y'� �.�n. •\� C: �:' '� �`• s�- R��-��,_��c1..�.�--� :. T��n P v ��°r��'c� � , � �'c�`_ �'��, C ��. �i �� `2_ 's�C?n5 r �� F �'��'v�? Please check the box(es) that most closely represent the reason for completing this form:��'�,� �:,1..�` � �c,c� ;� ❑ My vehicle was damaged in an accident ❑ My vehicle was damaged during a tow(��.�lc`s`� ❑ I�1y vehicle was damaged by a pothole or condition of the street ❑ My vehicle was damaged by a plow��..,�S � ❑ My vehicle was wrongfully towed and/or ticketed ❑ I was injured on City property �\,..� �.1�� ❑ Other type of property damage—please specify � '��Other type of injury—please specify�":r�,. C`:ci� ��c;`�,,� i,� ,� ti �c� j r� 1.,,r�'� �N C� Y�C1 CYYt�_ L.\��.�ti �'.S Gb t`��'�r v _.?._f\C�G i'v�p.�.nc�.�,�!�tc'.O�:J S��:r i�}i In order to process your claim Y^•• nPPd to include con�es 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 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 of damaged items O Injury claims: medical bills,receipts O Photographs are always welcome to document and support your claim but will not be re[urned. Page 1 of 2—Please complete and return both pages of Claim Form Failure to co�nplete and return both pages will result in delay in the handling of your claim. All Claims—plcase comnlete this section _____� -� Were there wimesses to the incident'? Yes No ;�Unknown � (circle) Provide their names, addresses and telephone numbers: ~"' ��---- f ,..__:.�...��.-� Were the police or law enforcement called? Yes No �Unknown.,- (circle) .d �.. 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. c �'�'�--�- � i �n ��1 c'�-` u v G ��c� '��r`�;v��4 PS-4 r�'3��ca v�t CJ��`l � �1 �1 rL°l�S�°v ��_u �� • , Please indicate the amount you are seeking in compensation or whut you would like the City to do to resolve this claim to your satisfaction. , �� ' cz �..-� c� �- � �.�-" ' G� --" . - _.. ' ' ' --��.�`,:�?�-+�._�� C��. �_,��_��--_�.� S��Q_�C\�-��_G�!__��..__� 1�-±�.-- �r�z.�-, c,�.S �,� _ , � .s�- v m u.; ;�-�,c,.��C� l� �.�r�S � -wa� ` � ��.?�o :'� ;-�`�r-�c, ��N vr�� Z��cZ ! `T. S �l c�1 �' Vehicte Cl�ims— lease com lete this sectior� ❑ check box if this secfuY2loes not ann`Iv� ` Your Vehicle: Year "— � "� Make ►._� Model License Plate Number State Color Registered Owner Driver of Vehicle Area Damaged City Vetiicle: Year �--_c��— Make � i'� 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 section does not a 1 How were you injured'? 'r-� 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? �lV� t�'` (provide date(s)) Name of Medical Provider(s): Address Telephone Did you miss work as a result of your i.njury? Yes �oj p n When dicl you miss work'? "� 9� � (provide date(s)) Na�ne of your Employer: AdcJress Telephone � 1 ❑ Check here if you are attaching moi•e pages to this claim form. Number of additional pages�„ I3y sigrai�tg tliis form,yocc are stating tltat all informalion you laave provided is tr�ce and correct to tice best of yorcr knowledge. Unsigned forms will faot be processed. Submitting a false clainz ca�t resc�lt i�i proseciction. Date form was completed Print the Na�ne of'the Person who Completed this Form: �.,o �1 E'� VZ 1`� . (� �'v( C=,/�J 1� {''� ; Signature of Person Makin�;the Claim: >c3�Ui�C�.,-,•� ��_�'1 Q�_��,L Revised February 201 1 �,��`�.�k.�;:r-��` ��a_ ��,�.�'�6--�''t-�,�_ N,,,,,,.,.....�,,,,.� � � �� f� #�J�, j,` � �`��-i�':�.... t��'�� Z:��I. ;��,.�'-' � � '.� � �' ,._�, z.-.� � ��,, � :. :�5�_ ,n t �'�"...�s��'+�..��.:� �r��. ;�a � `�"*�...�, Y�� '< � .. � . 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