Neff � � RECEIVED
APR 0 8 2014
NOTICE OF CLAIM FORM to the City of Saint Paul, Minne�tlt�Y C L E R K
Minnesota State Stalute 466.05 states that".._every person...who claims rlamages from mry mtoticipality...shaU cause to be presented to the
governing body of the municipaliry within 180 days after the alleged loss or injury rs discovered a notict stating the time,place,and
circumsrances thereof,and the amount of compensation or ot3ur relief demanded." .
Please complete this form in its eQtirety by clearly typing or printing yonr answer to each qaesdon If more space is
needed,attach additional sheefs. Please note that yoa w71 not be contacted by telephone to clarify aaswers,so provide as
nauch information as necessaiy to e�plaia your claim,and the amount of compensatlon beimg reqnested. You wiIl receive a
written acknowledgement ouce yonr forna is received. The process can take ap to ten weeks or longer depending on the
nature of yonr claim. This form mnst be signed,and both pages rnmpleted. If something daes not apply,write`N/A'.
SEND COMPLETED FC?RM AND OTHER DOCUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD,310 CITY HALL, SAINT PAUL,MN 55102
First Name Middle Initial � Last Name '`�
Company or Business Name
Are You an Insuzance Company? Yes/�No� If Yes,Claim Number?
�� r� � `_' G
Street Address c��li.1'`l�'�� J�
City l.�`� � y �`v� _State /�'l 'v Zip Code_�1L1.�(D
Daytime Phone(_� Cell Phone((9`�1 )�,2� `� 7Evening Telephone(�
Date of Accident/Tnjury or Date Discovered s��5 Time am pm
Please state,in detatl,what occuired(happened),aud why you are submitting a claim.Please indicate why or how you
feel the City of Saint Paul or its e loyees are involved and/or responsible for your damages.
� �-a� �' t f c/ � ' C � .5
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Ple�ase check the box(es)that most closely represent the reason for completi.ng this form: ��""�[� ��s�� �
�y velucle was damaged in an accident ❑My vehicle was damaged during a tow
My vehicle was damaged by a pothole or conditian of the street ❑My vehicle was damaged by a plow
❑My vehicle was wrongfully towed and/or ticketed ❑I was injured on City properry
❑ Other type of properry damage—please specify
❑ Other type of injury—please speci.fy
In order to process your claim von need to include conies af all anulicable 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 velucle 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 imponnd lot receipt
O Other property damage ciaimy:two repair esti.mates if the damage exceeds$500.00;or the actual bills
and/or receipts for the repairs;detailed list of damaged items
O Injury claims:medicai bills,receipts
O Photogzaphs aze always welcome to document and support your claim but will not be rettuned.
Page 1 of 2—Please complete and return both pages of Claim Form
Failurc to rnmplete and return both pages will restilt iia delay in the handling of your claffi.
All Cla�s—nlease comulete this section
Were there wi�esses to the incident? Yes No Unl�own (circle)
Provide their names,addresses and ulephone numbers:
Were the police or law enforcement called? Yes No Unlmown (circle)
If yes,what department or agency? Case#or report#
Where did the accident or injury take place? Provide street address,cross s�eet,intersection,name of pazk or facility,
closest landmark,�c. Plea�se�be� 1as detailed as possible. If necessary,a�tach a diagram.
j• . CIA�y�� �h!OvWT� /��'_ ri Q. grt" IPa��-c,�� (3Y` `7�i C �p,�
Please indicate the amount you are seaking' compensation or what you would Iike the City to do to resolve this claiun
to yowc satisfaction.
� � �
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Vehicle Clam�s— lease com lete this section ❑check box' this sec'on o
Your Vehicle: Year � Make S r Model
License Plate Number > 2 State�LS1Colar �o-��
Registered Owner �' s `} `�� C� g
Driver of Vehicle �k�ti '�
Area Damaged. �w� 1 C�
City Vebdcle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniurv Claims—please complete this seclion ❑check boz if this section does not avvlv
How were yon injured?
What part(s)of your body were injured?
Have you sought medical�eatment? Yes No Plaxming 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 N
When did you miss work? (provide date(s))
Name of your Employer.
Address Telephone
�Check here ii yon are attaching more pages to this claim form. Number of addftional pages
By signing this form,you are stating that all information you have provided is irue and correct to the best
of your knowledge. Unsigned forms will not be processed
Submitting a false clairre can result in prosecution. Date form was completed
Print the Nanne of the Person who Completed this Fo r v
Signature of Person Malang the Claim:
I
Revised February 2011
Iricident Details Page 1 of 1
������������
Curtis J Neff
Policy#: 30085387
10/30/2013 - 04/30/2014
Diamond Membership
Common Questions
What is the average time it takes to settle a claim?
We usually settle claims within the first seven days, so you can get back to your normal routine.
Does Progressive need a copy of the police report?
Your claims representative will determine if a copy of the police report is needed and will contact the appropriate police
department to obtain a copy. You may also want to obtain a copy for your records by contacting the appropriate police
department.
How is fault determined?
Your claims representative will determine liability based on state laws and individual accident circumstances. If another person is
found to be at fault for the accident, we will work with you to collect your deductible and any money paid for the repairs. Be sure
to discuss your individual accident circumstances with your claims representative.
Incident Details
Claim #: 14-4716292
Curtis 7 Neff
Incident date & time 04/06/2014 at 08:45 p.m. CT
Reported to Progressive 04/06/2014 at 09:49 p.m. ET
Property SATURN ASTRA
We'll work to get you back on the road quickly.Learn how Progressive's Claims Service
works.
See the steps in resolving your claim. Your claims representative will work with you and
explain the process.
https://onlineservice7.progressive.com/SelfService.Web/SelfService.aspx?Page=Claims.Su... 4/7/2014
, � Pay Less Tires �
698 University Ave • • �� ■
Estimated St. Paui, MN 55104
Time Due 651-298-8473 Invoice #24332
Monday,Apri17,2014
9:47:04 AM
Curtis Neff Ordered on
Monday,April 7,2014
St. Paul MN 55104
Workorder#28895
`�'i1V��:&'t�t(�,�� ,,.. FLEET NQ�, ; �FfOISt� REP CSH' # �'�RMS`
2008 SATURN ASTRA XE 651-335-9167 NMED SO LS Cash
L:#C�f�S�N�: :11A4tES fN1C34JT 1;l��F; 'Tf�R�t1�: ENGtNE St�� ' TRAIVSMISSIQt�i° C�'1L;t7R �RD`Df►TE'
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SNT321 W08AR671885119692
CATAL DESCRIPTION QTY PARTS IABOR DISC FET TO�AL Code `
UTP Used Tire(Right Front) 1 26.02 $26.02 AS
CSB Computer Spin Balance 1 17.00 $17.00 AS
WTS Wheel Weights � 1 .00 $0.00 AS
RF Recycling Fee 1 3.00 $3.00 AS
TR13 Sho�t Rubber Valve Stem 1 .00 $0.00 AS
SL Repaiu Wheel 1 50.00 $50.00 AS
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We/come, We a reciate our business.
PAID BY Parts $26.02 Taxable $26.02
M/C$98.01 Labor $67.00 Non-Taxable $70.00
Freight $0.00 Local Tax $�•99
Other $3.00
FET �o.00 TOTAL $98.01
Supplies $0.00 i
paRs aiM Lado�wardnUes f00%1o�90days or4A00mi/es,whrchevercnmes fxs1.This wairanly%imr2d to the�+nrk on dhis fomr onty.�eh�/e must be ielumed lo ourshop at custome/s e.rpense,to/roiro�
warranty./he2by audronze Uie ie,aair xnnF to de done ab�wiAh d�e necessarymalena/s.You and yDUremp�foyees may opie2le�hk�e kxpuiposes aflesB�inspeicb'on orde/iveryal myiisk.An exp2ss
M�dianic9s tien a acknowledged on vehrde M serwie lhe amount ofiepairs dreielo.You wi1/rmt de hekJrosP�nsibk for,bss ordamage!o�hide aard'raes/eR in vehrc,�fe in case ofAie,dheJf,acraident orany od�er
puse beynnd yourcnn�m/,Because ofthe extent olthe fearo'own and insp�ecd'on,fhe veh�mayiroiperfoim as we0as befaie•No ielu�ds on instalko'TiBS a�o�Wheek,Sp�aa/ONeis adaconbnoed ilems.
AAielums aie subject M 15%handung cha�ge.Any depasils aie subJc�ct to toiled ifcance/led.
Print Name Signature Date
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