Perez Banos I a RECEIVED ,�
NOTIC� OF CLAIM FORM to the City of Saint Paul, l��r�eg��a4
Miiutesotn Stare Stcrtute 466.05 stntes thnt "...eveiy person...wl�n clnim.r damages�frona nnv municipnliry...sliuA�l�ir4e k�1�J�.4en1e�'42f the
governireg hody of t/re municipa/ity wit/�i�t 180 dcrys n/'ter the ci!leged lnss or injury is discovered a notice stntiitg�/�e[ime,pince,ancl
circiunstnnces tliereof,nnd die amount qf compe�t.ratinn or other relief denutncled."
Please complete this form in its entirety by clearly typin�or printin�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 clnim,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 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
�� Middle Initial_�Last Name ��YQ�__/�'��S
First Name� l a��.
Company or Business Name
Are You an Insurance Company? Yes/No If Yes, Claim Number?
Street Address � (0 6 ��i n-S�� � �
' �+�� State �'1 � " Zip Code J s l r�
City��.1 h,,�
Daytime Phone ( ) - Cell Phone ( ) - Evening Telephone( ) -
Date of Accident/lnjury or Date Discovered
�Z — j — � � Time am/pm
Please state, in detail, what occurred (happened), and why you ar�-submitting a claim. Please indicate why or how you
fee( the�ity of Saint Paul or its employees are involved and/or responsible for your damages.
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Please check the box(es) that most closely represent the reason for completing this form:
❑ My vehicle was damaged in an accident
❑ My vehicle was damaged during a tow
❑ My vehicle was damaged by a pothole or condition of the street ❑ My vehicle was damaged by a plow
L�f 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 you need to include conies of all apnlicable documents.
For the claims types listed below, ple�se be sure to include the documents indicated or it will delay the handling of
your claim. Documents WIL___ I-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 $500.00; or the actual bills
and/or receipts for the repairs; detailed list of damaged items
O Injury claims: medical bills,receipts
O Photographs are always welcome to document and support your claim but will not be returned.
Page 1 of 2—Please complete and �eturn both pages of Claim Form
i�
;
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims-nlease comnlete this section
Were there witnesses to the incident? � No 1�Unknown (circle) r ^�
Provid thei names, addresses and te e hon umbers: ��1 � i �l l �b '� �'�
� � - �� � � _
Were the police or law enforcement called? Yes �� Unknown (circle)
If yes, what department or agency? Case#or report#
Where did the accident or injury take place? Provide street address,cross street,intersectCion� name of park o��r�f�• -ility,
�se$t l�ndmark, etc. Please be as detailed as possible. If necessary, �►ttach a diagram. �c .�l1Slh�(� �N�d-
� ��
ase indicate the amo o are see� ng in compensation or what you would like the City to do to resolve this claim
to your satisfaction.��.;2 � �- ��
Vehide Claims- lease com lete this section ❑check box if this section does not a 1
Your Vehicle: Year_�_Make C Model
License Plate Number �B �,ZS State Color
Registered Owner
Driver of Vehicle
Area Damaged
City Vehicle: Ye�ir Make Model
License Plate Number State Color
� Driver of Vehicle (City Employee's Name)
- Area Damaged ,
-_ _ �._
Iniury Claims-please com�lete this secfion �
_- _ -c eck box it ti�15 sec,tion dcy�� not ar,�,lr
How were you in�ured?
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?
Name of Medical Provider(s): (provide date(s))
Address
Did you miss work as a result of your injury? 1,eS Telephone
When did you miss work? No
Name of your Employer: (provide date(s))
Address
Telephone
❑ Check here if you are attaching more pages to this claim form. Number of additional pages
I3y signing t/iis form,yoic are stating t/iat ull information you lzave 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_ � � ' O� -� ��
Print the Name of the Person who Completed this Form:�� -��� `�
Si�nature of'Person Making the Claim:
Revised Febru.uy 201 1