Cook C�ECEIVED
NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota� �Oi4
Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipa[iry...shaU cause��e p ese�e�a'tRe'�
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,and the amount of compensation or other relief demanded."
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 DOCUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
First Name Ma�llOU Middle Initial - Last Name COOk
Company or Business Name NA
Are You an Insurance Company? Yes/�If Yes,Claim Number?
Street Address 764 Arlington Ave W
City St. Paul State MN Zip Code 55117
Daytime Phone( 651) 733 0670 Cell Phone(651)343-9480 Evening Telephone(651�49 -0860
Date of Accidend Injury or Date Discovered 3/30/2014 Time 12:10 �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. MY S011 was drIVI11g
my 4-month-old car heading east on St. Clair. Hit a deep pothole at Syndicate. Next morning we
discovered hubcap missinq Went to dealer on 4/2/2014 and thev showed me that wheel is also
bent explainingwhy steering wheel is now shakinq at higher speeds I went to look for hubcap at
accident location on 4/1/2014, and did not find mine, but found 2 other hubcaps there as well.
Please check the box(es)that most closely represent the reason for completing this form:
vehicl�. ❑ My vehicle was damaged during a tow
���T
My vehicle was damaged by a pothole or condition of the stree� ❑ My vehicle was damaged by a plow
My vehic e was wrong u y towed an 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 vou need to include couies of all aaplicable 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 ourself before submitting your claim form.
�PropeRy damage claims to a vehicle:two estimates for the repairs to your vehicle if the damage exceeds
$500.00; or the actual bills andlor 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 return both pages of Claim Form
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims—please complete this section
Were there witnesses to the incident? Yes � Unknown (circle)
Provide their names, addresses and telephone numbers:
Were the police or law enforcement called? Yes Q 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. St. Clair heading east
at Syndicate
Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction. �3� $45.67 hub�a alread urchased� $239 for new whee • labor to install
per Kline Nissan in Maplewood � �-,L = �7, 5 ; ,.
Vehicle Claims—please complete this section ❑ check box if this section does not avvlv
Your Vehicle: Year 2013 Make NISSaII Model Sentra
License Plate Number 810 KSR State MN Color dark blue
Registered Owner Marilou COOk
Driver of Vehicle uStm 00
Area Damaged right front wheel and hubcap
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle (City Employee's Name)
Area Damaged
Injur_y Claims—please complete this section _ C�check box if this section does not applv
How were you injured?
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? (provide date(s))
Name of Medical Provider(s):
Address Telephone
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
C�Check here if you are attaching more pages to this claim form. Number of additional pages 2 .
By signing this form,you are stating that all information you have 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 4/4/2014
Print the Name of the Person who Completed this Form: Marilau Cook
Signature of Person Making the Claim: �"����-�� 92/1_ �) �-
Revised February 2011
I KLINE NISSAN � $45 .6�
3090 HWY 61 N • MAPLEWOOD, NFN 551U9 �, �
PARTS DIRECT 651.379.4325
PH 6�1.379.4300 • FAX 651.415.9292
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NUMBER 803172 13 :51
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