Johnson, Doris �"-�� � RECEIVED -
NOTICE OF CLAIM FO.RM to the Cit of Saint Pa ��B 2� ���4
Y ul, Min��CLEP.K
Min�tesota State Statute 4�6.05 states that "...every persois...who claims damages frorn arry municipality....rhall cause to be presented to the
governing body of the municipality within I80 days after the alleged loss or injury is discovered a notice stating the time,place,and
cir•cuntstances thereof,and the amount of compensation or other relief demanded."
Piease complete tl�is form in its entirety by clearly typing or printing your answer to each question. If more space is
neecled,attach additional sheets. Please note that you will not be contacted by telephone to clarify answers,so provide as
mucta information as neccssary to explain your claim,�nd the amount of compensation being reyuested. You will reccive a
written acknowledgement once your form is received. Thc process can talte up to ten wecks or longer depending on the
n�ture 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 CITY HALL, SAINT PAUL, MN 55102
rirst i��ame_ j��r�S Middle.lnitial Last Name S� h n��r-�
Company or Business Name ��� _ _
_.�_ _.
Are You an Insurance Corr�any? �'�s � �o If Yes, Claim Number? ��`' ��
Strcet Address (�q 3 (,,�es-�- �j,l,n��� ���
City_ _ �o S e.V`,�� � State_ rn � Zip Code S S 113
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Daytime Phone((�$��-���_y Cell Phone � - Evening Telephone�� _ �
Date of�lcciclentl Injury oi•Date Discovet•ed � � � �� Time 1 �� a�nJ/pm
_�
1'lease state, m detail,what occurred(happened),and why you are submitting a claim. Please indicate why or how you
fccl the City of Saint Paul or its employees are involved and/or responsible for your damages.
m V V Cln;cl e l�cs h` �- �r�o rr1 �e1�`�r�c� 1'J.� c� • �- �o � �-4- 1��,.\ �r e_., '
(��. � '� G� �1 �e. a \ �� dr�� � � a� ti '
-r-,r <, l�L��c� le.7c�.S '}'_ S r Y
�ri a �l�. ,m '� �, �� ; � } S4 �� �� • � �
Pleasc check tl�e box(es)that most closely represent the reason for completing this form:
�9-Mv vehicle was damaged in an accident ❑ My vehicle was damaged during a tow
❑ My vehicle was damaged by a potholc or condition of the street ❑ My vehicle was damaged by a plow
❑ My vehicle was wrongfiilly towed and/or ticiceted ❑ I was t�j?,red or.City propert_y �
❑ Gtiler type of property damage—please specify
�Other type of injuiy—please specify ���.a,` � � �
In order to process your claim you need to include conies of all applicable documents '
Foi•tl�e claims types]isted 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 properry of the City. You are encouraged to keep a
copy for yourself before submitting yo�u 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 '1'owing 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 d�unaged items
�Injuiy 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
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�''✓ Failure to complete and return both pages will result in delay in the handling of your c(aim.
All Claims— lease com lete this section
Were there witnesses to the incident? Yes No Unlrnown (circle)
Provide their names, addresses and telephon mbers:
Were the police or law enforcemeni:called� Yes No Unknown (circle)
If yes,what depa��tment or agency? � � Case#or report#
�I
Where did i11e accident or injury ta.lce place? Provide street address,cross st�•eet, intersection,name of parlc or faciliiy,
closest landmarlc, etc. Please be as detailed as possible. If necessary,attach a diagram. rZ�ne1�l 011 (-�ve. �
�'�- P4�.� m r�
Please indicate the amount you are seelcing in compensation or what you would Iilce the City to do to resolve this claim
to your satisfaction.�,,� lr„��,, ...,. ct}- }.�,��S }�rvl e
Vel�icle Claims—please corr�plete.tt�is section ❑ checic box if this section does not lpplv
Your Vehicle: Y�ar o o Mal:e � ,E�, Model a„n r�.(
License Plate Number-���= ,�State p�r Color l �/u�
Registered Owner�_s�r15 �h v�s o,n
Driver of Vehicle ��,�; s �01�►�so r�
Area Damaged h�c 1C. F,�- u eln; e.l-�
City Vehicle: Year Ma1ce S� ,,,n� �r� Model �;�� �'�cl�� cl�e
License Plate Ntunber State�Color
Driver of Vehicle(Cii�y�mployee's Name) T so✓� O r�-vr��v� _
Area Damaged_ �-r�on-}- �� L�¢,In� �t --
Injnx-v Claims—please complete this section ❑ checic box if this section does not anplv
How were you injured? In;� �r��-►n� �a \e.��;�-�o�. C�', Pe�.,,� �i c� �e�n�c��
What part(s)of your body were injured? ��c,1C�i-�ac1�T a- So�er�es S a.J.� �v e�
Have you sought medical treatnient? , Yes No Planning to Seelc Treatment(circle)
When did you receive treatmeiit? • • • • provide �e(s))
Name of Medical Pro ider(s): � ' I,� � lG ' , n' '.
Address ' / '; ` � Telephone — - (�G'`
Did you miss worlc as a result o your �n'ury? , Yes o
When did you miss worlc? � '"� " (provide date(s))
Name of your&nployer: �7�;"� n �
t�d.dress �- Telephane
�Checic here if you are att�ching more pages to this claim form. Nnmber of additional pages�_.
I3y sibninb this form,you are stating tliat all information you liave providerl is tYUe and correct to the best
q f your knowledge. Unsigned forms will not Ge processetl.
SuGmitting a false cic�im can resttlt in prosecution. D1te form was completed X �� �l— �._
Prini;the Name of the Person who Completed tl�Form: (�o�i S �o h r�Co r� 1 Lal.� �r►�
l. , J �'L
Sig�iatui•e of Person Malcing the Cl�im: -�--/ � i' �
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Reviscd Pebruary 2011
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�ECEI��D
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GRIFFEL DORSHOW JOHNSOl��TY CLEF�K
� ATTORNEYS AT LAW
February 25, 2014
NOTICE OF CLAIM IN ACCORDANCE WITH MINN. STAT. 466.05
City Clerk CERTIFIED MAIL
15 West Kellogg Blvd. RETURN RECEIPT REQUESTED
310 City Hall
St. Paul, MN 55102
RE: Client: Doris Johnson
Date of Injury: 1-31-2014
Dear Sir or Madam:
Pursuant to Minn. Stat. � 466.05, entitled Notice of Claim, "(e)very person . . .
who claims damages from any municipality or municipal employee acting
within the scope of employment . . . shall cause to be presented to the
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,
the names of the municipal employees known to be involved, and the amount
of compensation or other relief demanded.”
As such, this Notice of Claim is hereby served upon the City of St. Paul,
through the, City Clerk of St. Paul, MN.
Name of Claimant: Doris Johnson
Address: 693 West County Road C
Roseville, MN 55113
Attorney: Loren H. Dorshow, Esq.
GRIFFEL, DORSHOW F� JOHNSON,
CHARTERED
333 Wells Fargo Bank Building
1809 Plymouth Road South
Minnetonka, MN 55305
(612) 529-3333
3�:�Wt:LI.S FARGC)B,-\'�K - RIDGED\IJ:
IRO�)SOUT�H PLY1�101,��t�l I R[), SUITf�:�33
MINNE"IONK:\, M\ �5305
T 6l2 529 ��3? F 952 593 075(1 W E�12LA1�'�333.r��m
Page 2 of 2
Date and Time of Day of
Accident/Incident: January 31, 2014 at 10:30 a.m.
Location: Randolph Avenue
St. Paul, MN
Facts: That on January 31, 2014, at approximately
10:30 a.m., Claimant was stopped at the light on
Randolph Avenue when she was rear ended by a
City of St. Paul fire vehicle being driven by Jason
Ortman. Claimant sustained injuries to her
neck, back and general soreness all over.
Damages: Precise amount of damages are unknown at this
time. Again, Claimant sustained injuries to her
neck, back and general soreness all over.
Submitted by: Claimant's attorney
Date: February 24, 2014
Please refer this Notice of Claim to your attorney, y-our insurer, if any, and all
other necessary parties.
Very � u s,
LHD/cs Lo n . Dorshow
Enclosures Attorney at Law
SEE ATTACHED NOTICE OF CLAIM FORM TO THE CITY OF ST. PAUL, MN
List of Medical Providers
Fairview Clinic
1151 Silver Lake Road NW
New Brighton, MN 55112
612-706-4500
Dr. David Lindgren, MD
Fairview Clinic
6341 8s 6401 University Ave. NE
Fridley, MN 55432
763-586-5844
Institute for Athletic Medicine
19�5 (:ounty Road B2
Roseville, MN 55113
651-697-1313
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