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Alexander (2) RECEIVE RECEIVED MAR 31 2014 M�►R 2 4 2014 NOTIC� OF CLAIM FORM to t��t��O��nt Paul, N��e��t�ERK Mirutesota Slate Statute 466.05 smtes that "...every persnn...whn rini�n.c dcrmntes.�'roni miv mu��icipn/Ity...slrnll c�nnse!o he pre.ti�evited tu!he governirig l�octy of�the nu�nicipnlity wi�hin I80 dnys nfter the nlle,�ed lnss or injury is discovered a��ntire stnti�rg d�e�ime,place,u�rd cir�tun.stances t/tereof,and Ihe antotutt of compensntinn or nther relief demnndecl.•• 1'lease 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 amo�nt of compensation being reryuested. You will receive a written acknowledgement once your f'orm is received. The process can take up to ten weeks 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 DOCUM�NTS TO: CITY CLERK, 15 WEST KELLOGG BLVD, 310 CITY HALL, S I T PAU N 55102 First Name�_C% Middle Initial Last Name ' � �� '� Company or Business ame Are You an Insurance Comp•iny? e. No If Yes,Claim Number? -� Street Address City State Zip Code' �U� / Daytime Phon�"Z �hone ( )-- Evening Telephone( ) - ,�� — -� l/(/ v Date of Accident/lnjury or Date Discovered Time am/� Please state, in detail, what occurred (happened), and why you are submitting a claim. Please ind' �te why or ho ou feel the City of Saint Paul or its employees are �nvolve • d/or responsible for your damages. - � � . 7 �! ' � - /, . J � J Please check the box(es) that most closely represent the reason for completi this form: ❑ My vehicle was damaged in an accident ❑ My vehicle was damaged d�rring a tow ❑ My vehicle was damaged by a pothole or condition of the street ❑ My 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 O Other type of injury–please specify In order to process your claim y�� ^Ppd 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 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 : Injury claims: medical bills, receipts O Photographs are always welcome to document and suppoR your claim but will not be returned. Page 1 of 2–Please complete and return both pages of Claim Form railure to complete and return both pages will result in delay in the handling of your claim. All Claims—�lease comnlete 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 ( N��' Unknown (circle) ll'yes, wh��t department or agency? �/C;ase#or report# Where did the accident or injury take place? Provide street address,cross street, intersection, name of park or facility, closest,a• � �tc. P� _�� tailed a� possible. ne�ssa , at a d' , J . )� > � p � -J Please intlica e`� �ou� ar , i co ensati n o what� would like the -ity to do to .•olv t is -lai to your satisfaction. � � ' ' .✓ � , � Vehicle Claims—nlease complete this section ❑ check hox if this section does nqt a�� ' 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 In'ur Claims— lease com lete thi ction check b x if th' • section does not a 1 How ere yo inju d? � � ' � � / _ �1�� hat part(s)of your b dy were injured? � � Have you sought medical treatment? Yes No .- nn n to Seek Treat nt�ircle) When did you receive treatment? ��%� � �� "� � ' CU pr�vide date(s)) Name of Medical Provider(s): � " ' ` J Address elephone 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 more pages to this claim form. Number of additional pages By signing tltis form,you are stating tliat ull information yor� have provided is trr�e and correct to the best of yor�r knowledge. Unsigned forms will not be processed. ,� � � Submitting a false claim can result in prosecution. Date form was completed � � � �� Print the Name of the Person who Completed this Form: �� Signature of Person Making the Claim: � , Revised Febru�iry 201 I � � PATIENT ACCOUNT STATEMENT �� 30696*TXLOH9JV5000302 LEROY ALEXANDER PAGE: 1 of 1 :ill�: Regions Hospital� ACCOUNT NO. STATEMENT DATE HealthPartners Fan:ily of Care 3142322 11/21/2013 Mni�sroP izaosa•sno�acKSON sT•sr.anu�,nnN ssioi AMOUNT NOW DUE PAYMENT DUE DATE $191.13 12/09/2013 Customer Service Phone: 651-254-4791 If you do not pay in full now, or call us immediately to make payment arrangements, the account may be sent to a collection agency and to the State of Minnesota Revenue Recapture Program. DATES PATIENT AND SERVICES PREVIOUS pMTS 8 ADJUST YOUR BALANCE BALANCE Admit Leroy Alexander 100559437 09/25/2013 Emergency Room Discharge Previous Balance $191.13 09/25/2013 Insurance Pmts/Adj $-1369.07 Personal Pmts/Adj $0.00 Balance Due $191.13 Total Patient Liability $191.13 30696*TXLOH9JV5000302 ��u��u��u�� Please detach and return bottom portion with your payment and write your account number on your check, See reverse side for important information. _- -_.,�__. — ..___ ____ __ _..� _ , ,. �__ ._._..._,_. ____ ._____ ___._ � �� PATIENT ACCOUNT STATEMENT � IF PAYING 8Y MASTERCARD,DISCOVER,VISA OR AMERICAN EXPRESS,FILL OUT BELOW. � �CHECK CARD USING FOR PAYMENT s1��/„ � � �STERCARD � �COVER `�SA-" �A �p6'� A�MERICANEXPRESS :i��I: Regions Hospital CARD NUMBER � � SIGNATURE CODE EXP.DATE HealthPartners Family of Care SIGNATURE AMOUNTPAID MAIL STOP 12403A•640 JACKSON ST.•ST.PAUI,MN 55101 30696 � �`��l�� wa4��4��`��,��a;�'��„��'"��;�'�;��?lA��ti,�,..�..� RETURN SERVICE REQUESTED 3142322 11/21/2013 , � �+��:r.��;.:�W��;NC1�"�?kl�s,?�.�.,�+. c=:",r..z?.:��+�A�l��';Pa4fi�,r�,`i�,: ;: PAGE: 1 of 1 $191.13 12/09/2013 seasaso�PC2� � 03995 0101 ��I�I ililll �I I �I I �I ��1 I nll III II� I II II � � I ul n � I � I I � � � � I�I� 1�1 �II i il n ii I i iilil II i lui i li i i I I 1 li I li i lillilll lil i i i i I i lu uu il I I ii LEROY ALEXANDER REGIONS HOSPITAL APT 709 PO BOX 77093 469 ADA STREET MINNEAPOLIS, MN 55480-7793 SAINT PAUL, MN 55107-2347 000003142322DOQ0000191137