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���, �,�=,� NOTIC� OF CLAIM I'ORM to the City of Saint Paul, Minnesota
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,,�L Mi�uresota Slnte StaUrte 466.05 stntes thnt "...eve�y person...�vFro c•]ni�r�s dnmages.�rom any miuzicipnlity...sha!l cnuse ro be presented to�he
,� go��erning hody of'd�e rn�inicipnlity x�ithin 180 day.r nfter t/ie nlleged/oss or injury is discoverecl n notice stnting the time,p/ace,a�id
��� circuarstances tltereof,and d�e nmowu of con�pensation or nther relief demanded."
Please complete this f'orm 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 explain your claim,and the amount of compensation being requested. You will receive a
written acknowled�ement 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 DOCUM�NTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
First Name��-������/G� Middle Initial�Last Name ���(�'.S�C ^^�^IVE D
Company or Business Name 9 20�4
Are You an Insurance Compa�y? Yes/No If Yes, Claim Number? / /�
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Street Address _ - � � '-���� �
City_��" ��� � State i'�'1}'�/ ' ` Zip Code �7i 6
Da time Phone Cell Phone (�) �f -�Evening Telephone ( ) -
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Date of Accident/Injury or Date Discovered�-��7��?2-Time am/pm
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 employees are involved and/or responsible for� ur damages.
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Please check the box(es) that�nost closely represent the�reason for completing this form: ���� LC�`� �u
O My vehicle was damaged in an accident � ❑ My vehicle was damaged during a tow
❑ My vehicle was damaged by a pothole or condition�f the street ❑ My vehicle was damaged by a plow
❑ My vehicle was wrongfully towed anci/or ticketed ❑ I was injured on City property
❑ Other type of property damage-please specify �� l'-�%�- �� �,'�.8--�'�''� � ��'� '
❑ Other type of injury-please specify
In order to process your claim Y��� nPpd to include copies 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 ticketIissued and a copy of the impound lot receipt
O Other property damage claims: two repair dstimates if the damage exceeds $500.00; or the actual bills
and/or receipts for the repairs; detailed list of�amaged 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.
Were the police or law enforcement called? " Yes No,,,,,1��'" Unkn� (circle)
If yes, what department or agency?6 � ,�t �u���v'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 nec�sary, attach a diagram. �� /3��
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Please indicate the amount you are seel:ing in compensation or what you would like the City to do to resolve this claim
to your satisfaction. ,���� � '
Vehicle Claims— lease com lete this section ❑ check box if this section does not a 1
Your Vehicle: Year �G ?�Make � Model �
License Plate Number State �Color � �
Registered Owner ' . , , - - �',F ���� �
Driver of Vehicle �L,��rr�e.., �J�_. ���'�yz r's S'�"� �
� Area Damaged
City Vehicle:`.� Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
� Injurv Claims—please complete this section ❑ check box if this section does not ap�lv
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
�� ❑ Check here if you are attaching moi•e pages to this claim form. Number of additional pages
By signing tltis form,yoct are stating tliat all information you have provided is tri�e 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
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Print the Name of the Person who Completed t �s �orm: ��l%%1���/�i(�- �� ����'� � �S'I l�
Signature of Person Making the Claim: � �
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Revised February 201 I / �/ �
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