Neadeau F�ECEIVED
MAR 21 2014
NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
CITY CLERK
Mimiesota State Stattrte 466A5 s�ates tlant "...every pe��son...wltn clnints dantcr��es.`roin a�iv rn��nicipnlity...slrn!!en��se ro he presentnd tn d�e
governing body of�t{ze nttmicipality witl�in IfiO duys after the t�/legec!Inss or injury is c[iscoverecl a rtotice stntiitg tMe time,p/nce,u�id
circumstances thereo/;and�he amount of compensatinn or other relief derrranded."
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 explain your claim,and the amount of compensation being 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
I , / nI',
First Name /�.��ti� Middle Initial y Last Name I�� ��I��
Company or Business Name
Are You an Insurance Company? Yes/No If Yes, Claim Number?
Street Address �� r �{'l"�5��� � l��
City ��"�r�.e ( State �� Zip Code ��%C�CP
Daytime Phone ( ) - Cell Phone (�) ��- ��5� Evening Telephone( ) -
Date of Accident/Injury or Date Discovered 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 your damages.
.�'. C%
�_ � � ►� � ° � GZ �
� - � .. � �� ��1
C� �✓ � � ' ' �—
� -� , ; �? � ,'1
�� � C�C�Y�-1z��.�C�,
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
❑�Iy vehicle was damaged by a pothole or condition of the street ❑ My vehicle was damaged by a plow
D�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 y��• nPPd to include copies of all apnlicable documents.
For the claims types listed below,please be sure to include the documents indicated or it will delay the hundling 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 ticket issued and a copy of the impound lot receipt
O Other property damage claims: two repair esdmates if the damage exceeds $500.00; or the actual bills
and/or receipts for the repairs; detailed list of da�naged 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
I+'ailure 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? Yes No Unknown (circle)
Provide their names, addresses �nd telephone numbers:
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, intersection, name of park or facility,
closest landmark, etc. Please be as detailed as possible. If necessary, attach a diagram.
Ple�ise indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction.
Vehicle Claims—please complete this section ❑ check box if this section does not a�lv
Your Vehicle: Year Make Model
License Plate Number State Color
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
Injurv Claims—please complete this section ❑ check box if this section does not a�ply
How were you injured?
What part(s)of your body were injured?
Have you sought medical treatment? Yes 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 .o
When did you miss work� (provide date(s))
Name of your Employer:
Address Telephone
❑ Check here if you are attaching more pages to this claim form. Number of additional pages
By signing this form,yoic are stating tlzat all information you have provided is trr�e and correct to the best
of yor�r knowledge. Unsigned forms will not be processed.
S«bmitting a false claim can resiclt in proseciction. Date f'orm was completed
Print the Name of the Person who Completed t is F rm: � �'L� � v-�'���f-PU-�
Signature of Person Makin the Claim: ��� � �--�-����---- � "o�i/ //
� C / 1
Revised Februury 201 I
Fax Server 1/20/2014 5 : 36: 10 PM PAGE 3/004 Fax Server
`���� I � �� ��s
Keep these cards handy--in your glove compartment or wallet.And contact us anytime you have a question or need to report a claim.
If you have a claim,we'll get you back on the road as soon as possible.And while you'll always have a choice where to repair your
vehicle,when you use a shop in our preapprwed network,we'll guarantee}rour repair for as long as you awn or lease your vehicle.
Thank pou imr choosing Progressive.
,.,L>.....
__�''-__.___-_-_-'_____________________________'____-__-- �
I INSURANCE IDEIIRIFICATION fARD-Minnesota �
� I
i Leah Neadeau � �rry rr.��:9o,�acn3 MAIC fWmber.37�4 �
� Valued Customer Since 2013 ` E�'"`°a�'��01«013 �`�101°i�'°u01�2014 �
•, Ir�vxsr:Piagrasire PreFerRd InwranaCo 1-800-5"-s'�8'
I PO Box 6807 CkveLand,OH 11101 �
i Mamed Ins�xed(s} I
� ; IeaA Neadeau �
I ;: Na thwaMy�utance Sent 1-1]&751-0821' �
I ( PO BOX 1 t 29 I
I � ..... :.. F BEMIDII.MN 56619 I
. ..
� ; Year Male Madel YIN I
� ��': ' : 2006 Pon6at Grand Pmc 2G2WP552061117897 �
I u' ':!;_;v;° : �� '� ;; 1996 Caddlac Dev�le 1G6KD52V2TU303388 �
. ,
�: I
� :_ .
� Fvrm A022(03,�11) I
I �
� IF YOURE IM AN Ai.CIDENf �
� 1.Reman#the sane.Don't admR fault �
� 2. Find a safe bra6on,call the poiae,and exchange dtiver infa�ma0on. �
� 3.CaI�Pmgressirerightaway. I
� TO REPORT A C W M I
� Callt-800-274-4499agoroclaims.pogressive.mm. '' I
Manage your poticy anytime �
� �
� with just a few clicksat �
i progressiveagent.com i
i �
i �
� �,R'A,�C'a�E.�/�� i
i
; i
� KEEP THIS CABD IM YOUN VEHICLE WHILE IN OPERAflON.
L________'_________________"________'__. _ . _
Saint Paul Police impound Lot, 830 B��°y�``r�annel Road, Vehicle Release Form
Make: 96 CADILLAC License#: VKU706 CN: 14030406 Invoice#: 149179
Date/Time Released: 02/18/2014 17:18 Tow Charge: $ 60.00
Released to: NEW OWNER Storage Charge: $ 0.00
Paid by: CRE�JIT CARD Admin Charge: � 80.00
Released by: BECKY Tax: (7.625%) � 1U.68
I,the undersigned,have recovered the vehicle described above. Subtotal: $ 150.68
I will check the vehicle for damage or any other problems that
may have occurred while this vehicle was in the custody of the Service Charge: $ 0.00
Saint Paul Police Department. I acknowledge I will report
damage and/or any other problems to the Impound Lot staff Total Charges: $ 150.68
on this form prior to leaving the impound lot.
Damage and/or other problem:
Police Report made: Yes_No_IF Yes, CN , If NO, Why?
TO PROTECT YOUR RIGHTS REPORT ANY PROBLEMS/DAMAGE BEFORE LEAVING THE LOT
5l2000
Signature
y�.---.6. ---e �x —,3
-o � rv o v x rt,n
a __ � .--.� ��x �
� n� x '�
�- - a' 'T'% -.�
` � "' c:.
��
���-� �
� C...—.� G N c��i� 1
m x r..� z�coaf
� Q� c^� "`'Y' ^� .
r% � E� C+DWD
� OC+- f�.T.�
-. � ov. r�z.�
i� � a,�i c� �
= pF+ 0�3�r�3 -
T ~/��• �� �?SC
, �� •y :t� 2>C
-G � w C�Cn�2
C r S. � G N i�-+��
a � e.��
a T � .
Z x
c-� � o� �r.-•
T �- G
C/>
E
-�.C�.? p r.
m 6 � �—