Douglas RECEIVED
NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesot��B �3 ���4
Minnesota State Statute 466.05 states that"...every person...who claims damages from any municipality...shall cause to be preS�It�d td th�L E RK
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 egplain your claim,and the amount of compensation being requested. You will receive a
written acl�owledgement 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 sometlung does not apply,write`N/A'.
SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
First Name ��z��7�.C`�" Middle Initial� < Last Name ��������i�
Company or Business Name
Are You an Insurance Company? Yes�o If Yes,Claim Number?
Street Address;����1 ri�'�� �' �7"�
City �\�(1�L P��.k; i>�1 c� State �1�, ���lt�.����l Zip Code..�� I I
Daytime Phone(�S 1)�- ��%'�rl Cell Phone( ) - Evening Telephone(�'�'��- ���
Date of Accidend Injury or Date Discovered � R�u��c'�.1 _�1�� �Time �.� 7 am l�
Please state,in detail,what occurred(happened), and why you are subnutting a claim.Please indicate why or how you
feel the City of Saint Paul or its employees are involved and/or responsible for your damages.
S�� �x-�-F�c h a � 1�, ' � ��
Please check the box(es)that most closely represent the reason for completing this form:
❑ My vehicle was damaged in an accident ❑'�vehicle was damaged during a tow
❑ My vehicle was damaged by a pothole or condition of the street �{a'1viY vehicle was damaged by a plow
❑ My 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����� ^°°d to include copies of all anplicable 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.
�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 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 complete this section
Were there witnesses to the incident? `Yes No Unknown (circle)
Provide their names, addresses and telephone numbers�i ^ ��t5 �`" � � , �`c1 N
lv i�.-3 d-�l� � 1 1 i
Were the police or law enforcement called? �Yes No Unlrnown (circle)
If yes,what department or agency?S-C'*�0.u� O i���c_�. Case#or report# ►� Dil�- 10�
Where did the accident or injury take place? Provide street address,cross street,intersection,name of park or facility,
closest landmazk,etc. Please be as detailed a possible. If necessary,attach a diagram.��,�5,`�' '�'n Id��
�� � , � `— L' .
Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction. �� Q•�(_„� �T4��� �U r,�� � 'C, �e�-���0.r d. �;n�°�',T, �r�e C�c�-��,
Vehicle Claims-please complete this section ❑ check box if this section does not applv
Your Vehicle: Year�n� Make Model��b\�
License Plate Number "1`l y ��t?�� State�p'Color`�i �r!r2�c'
Registered Owner ��' �
Driver of Vehicle � c� � � �
Area Damaged � `
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniurv Claims-please complete this section check box if this section does not applv
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
�heck here if you are attaching more pages to this claim form. Number of additional pageso�.
By signing this forna,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 G�hr��a r��. �.D\�
Print the Name of the Person who Completed this Form:�f�'�r�c�('� �- � �11,���
, �
Signature of Person Making the Claim: -/U�Z�-��� G� ����'/��
�
Revised February 2011
What happened:
My car was parked on Johnson Parkway service road when one of the renters at the home
where my son is living was looking out of the window. All of sudden a blue St. Paul city plow tried to
squeeze on to the service road, which is too small when cars are parked there. The blue plow hit two or
three cars knocking mirrors off a few cars. One was mine. The plow driver stopped,got out and looked
at what he did. He looked around and then jumped back into the plow and went on doing his work. My
son tried to get out the door to confront the plow driver, but all my son got was 2503 off truck when it
came back on the other side of street. The one fact is a blue St. Paul plow did the damage.
.�;.' % .� ��' /},�
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YJ5/2014
RO i�L �si5s ��'s One Stop Shops -Lezington Store xo�L ,�15�
9073 3onth High�vay Drive
Leaington,Minnesota 65014
Telephone: (763)786-2646
Faz: (763) 786-8285
�
�'""G` ftEPAIIt OItDEK -THIS IS YOUR RECEIPT `�`"�`
Customer. DOUGLAS AIItB Vehide Year: 2002 Ins.Co:
Address: 2099 BURR ST Mzke:11�RC[JRY Policy No:
City: MAPLEWOOD Model: SABLE Claiman�
Stat� MN Zip:55117 Body Styl� 4 DOOR Claim N«
Home Phone: (661)771�699 Color. SII.VIIt Insare�
Wor�Phone: (6i�706-3327 ext license Nos 1 Adjuster.
Pager. (612j 386-0240 In Mileage: 1 Adj.P6one:
Ds#e: 12U14 ���= 2 Deductible: S�.00
�p�� Pat Meviss� VIN: 1MEFM5UU72G621145 TevL: D MAYVII I.E
Probl�: LEET M1RftOR �epair:mNE
line It�Detail
Lne# - D�iption Parts Le�or P Lal�er P Mat7s Total Tech
1 $PL LEFT DOOB MIIiBOS E166.67 �l1.80 0.0 �0.00 ;209.87 DRM
8 S.PL�ROB COVIIt �5�3.58 �0.00 0.5 $14.OA $94.58 DRA4
g �D.00 �0.00 0.0 �0-00 �0.00 DRM
3�arv of CLar=es
Items Category Amoant I.abor Charges Hours Rate Amount 8ales Taa Rate Amount
Body Parts: �-U5 Paint Labor. 0.5 $54-00 $27.00 City Taa: 0 $0.00
Mech Put� $U.00 Mech Labor. 0.0 $95-(30 $0_00 County Taa: 0 $0.00
Glass Parts: 80.U0 BodY I.abor. 0.8 $Ei4.00 $43.Zt1 State Taa: 0.0713 $16.68
Paint Materials: $14.00 Frame Iabor. OA $85_00 $0-� 3ales Taa Total: $16.68
Towing. SO-00 Glass_I.abor. F7at $0.00
Haz Waste Disp: $0.00 L�bor Snbtotal: $7020 ��Q Snbtotal• 51.3�1.05
Misc Sales: 5�-00 Est.Totxl: $320.93 PaymeIIt S�mary Labor Subtotal• �'10.20
Shop Suppiies: 8�-� $O Total: $3`m•� Cash: $0•a1 BO Subtotai: $30425
Diseounts: $0-� SaPpimea� S�•� Checs� �•� S s T T tal: $16.68
Sable� 50.00 Ins.Pay� $0.� Ban�Card: �0.00
Items Subtotal: $�-� Cnst Pays: �i2U.9Ci ��� $320.93 BA Grand TotsL• $320.83
Notes/Su�ested Ite.ms
I authorize COOK'S to repau my velucle and opeaQe it for te�ng and iaspocxioa I will not Lold COOK'S respoavibk for loss or damage to my vchick or its conteuts
due to fire,tt�,ar accid�,or any ather cau�beyand C'OOB'S oonttol I unde�staodthad old p�tts w�be DISCARDED tmless I r�theY be teUuned to me. All
Chazges are CQD. I admo�e a ma�'s lim m ffie v�ide to ae�we iepair d�ges�d oogec�ian casts. I�mdastand thae is a savice charge�$20.00 on
reduaed�CS. I agee to pay a mouAily seavice rLazge af 1.5%oa my b03mne due a�er 30 days. I agee to pay collectiwn fees of op to 40°/s of b�lance ctue ptus
legal fees and adtamey's fces incaared'm the oolledion �� ,.
�
��:x � �-�° ..� �: a - � -l�
THANK YOU FOR YOUR BUSINESS-WE DO AUTO BODY,MECHATTICAL,AND AUTO GLASS REPAIlt
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