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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 aZleged 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 ciearly 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 explain your claim,and the amount of compensation being requested. You wili 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 both pages completed. If something does not apply,write`N/A'.
SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 C TY IiALL, SAINT PAUL, MN 55102
First Name Middle Initial Last Name , ■
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Company or Business Name
Are You an Insurance Company? Yes/No If Yes,Claim Number?
Street Address �u � • �l�� ��'��
City State Zip Code a��-
Daytime Phone(� �ell Phone(�_cC��,'��vening Telephone(_� -
Date of Accident/Injury or Date Discovered� • �, �,L� Time ` am m
Please state,in detail,what occurred(happened),and why you are submitting a claim.Please indicate why or how you
fee e City of Saint Paul or its empl es are involved and/or respo sible for your dama.ges.
9 � ° 71�/
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�e�se`c�kY �io(e�that most closely represent the Teason for completing is form:
❑ M vehicle was damaged in an accident ❑ My vehicle was damaged during a tow
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❑ 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 ' _ C�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 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 ticket issued and a copy of the impound lot receipt
O Other property damage claims: two repair es `�mates if the damage exceeds$500.00; or the actual bills
and/or receipts for the repairs;detailed list of da ged 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 comulete this section �.
Were there witnesses to the incident? Yes No Unlmown (circle) �i i e
Provi their mes, ddr se�s and teleph e n ers: � r��Or
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Were tl�pol�c�eeor aw en orce e a1Ted�`5 es� rn��=_:-J n o � `�(circ e�/
I f yes, w hat department or agency? Case#or repo rt#
Where did the accident or injury take place? Provide street address,cross street, intersection,name of park or facility,
closes dmar etc. le be as detailed as possible. If necess ,attach a dia am.
�
Please indicate the amountyou are seelang in compe sation or what you would like the City to do to resolve this claim
to your satisfaction. �����r �,� ,��� ���..-�_�
Vehicle Claims- lease com lete this section ❑ c eck box if this section does not a 1
our e ic e: ear a e o e
License Plate Number State Colar
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 ete this section ❑ check box if this section does not a 1
How were ou injur � � t d
at part(s)of our ody were injured?
�� -1�`�ah .
Have�you ought medic eatme t? es No Planning to Seek Treatment(circle)
When did you receive treatment? (provide date(s))
Name of Medical Pro �der :
Address elep ne (�
Did you miss work as a resul of o injury? Yes �
When did you miss work? (provide date(s))
N e of our Em lo er: ,
Address Telephone �02 �
�Check here i ou are attaching more pages to this claim form. Number of additional pages�.
By signing this for�n,you are stating that all information you haveprovided 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 for was completed .2 GQ
Print the Name of the Person who Completed this Fox•m: ' (Mq,� �i LF-���
Signature of Person Making the Claim:
Revised February 2011 '
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