Yang, Kong ► -
NOZ`ICE OF CLAIlVI FORM to the Cfty of Saint Paul,Minnesota
M'mnesora Stnte�trae 46'�os s�tes rJrca"...e►xaypason...who clai�,►s damaSes.Trom m�Y n�►�c�tt�'...skaTl cayas w be precer2ted to tlre
gov�n�rg body o,f'the muis�ciFaliry t�ithirt 180 dayf a,�v'the alleged lass or injury is�scot�ered a�wti'oe sGatirg ihe time,PlaQe,and
cfirtvxatr�sce.a tiidseof,mtd die mnorart of caxperuatlon ar other relfef denrmuled'°
Pleaae complebe this form in its�bY��9 h'P��r P��Yonr aas�rer tn each qnestion If more space is
aeeded,attach a�dibonal sheds. Pi�se note that yon�not be oontaafed by telephone to clari!'y answers,so Pmvlde as
much informsifon as sa�sary bu ezplain yqnr clsim,and the amoant of compensatbn bdug reqnested. You wflt receive a
wrIt6en aclmowledgement once yonr form ia rc�eived. Tlte process can take ap to ten wee�s or longex depending on the
_ �aatnre of yonr claiffi: Tfi�forin must beslgned,and both-pagrs completed.-I#�ometl�gslcesnotaPP�9._�rlte_`lYf�'.--- - -
SEND COMPLETED FORN�AND 07�R DOCUIV�NTS TO: CITY CLERK,
15 WF.ST KELi,OGG BLVD,310 GZTY HALL, SAINT PAUL,MN 55102 - - - -
��N�B Xs�, �,,�ad,.e z�M LastName y�� RECE IVE D
c��s,��x�e APR 14 2��
. Are You aa Insur�ce C�panry? Yes/No �Y�,c�rn��r ITY CLERK
� s�aaa� eS9/a �o� �+ .
c;m, C� �`'� _s� �l�v �� �s
Daytime Phone(,� - CeIl Phone�}"?��Evening Talephone(_, - ' �
Date of Acci�nt/Tnjury or Date Discovered��_Time ._�am� m�
Please sta�e,m d�sil,wba�occurred(h�)�aad whY Y����a claim.Please indicabe why or how you
feel9ie City of Saint Panl a its e�mpla�ces are involved and/or responsibla far your dmnages. � e� no.c�.����
i ^ o1�ce ��. a �'�
�P check the box(es)that most closely represent�e reason for comgleting this form: . .
velucle was damaged in ffi►accid�rt ❑My velucle was dama8ed during a tow
❑My vehicle was daffiaged bY a Poi�►ole or conditian of the slreet ❑My veIucle was dannaged b3'a plow
C�My vehicle was wrongfullY tnwed and/ar ticketad [7 I was injured on City propeatY
❑4fi�er type of propeaiy damage—please spocifY
❑Othear�type of injury—please specify
In,order to process your claim Yon need 1��mclude copies of aIl annlicable docnmenta
For the claims types Iisbed below,ple�se be sn�e to inclnde the d�ocum,ents indicafiad or it will delay the handling of '
yovr claim. Documents WII.,L NOT be refiarnad and bacoQee the prop�f y of the Gity. You are eacouraged to keep a ,
cogy for yourself befare submitCing your claim form.
O Properiy damage cIaims to a vehicle:two es�mates for tha rep�irs to your velucle if the damage exceeds
$500.00;or the actual b�ls and/or recei�for t1�r�paus �
O Towing clsims:legible capies of any ticlaat issu�l.and a copy of the unpound lot receipt
O Other pmperiy damage claims:two repair eslimates if the da�oage exceods$500.00;or 8�e actual bills ,
and/or receipts for fhe rtpa�s;de�ailed list of dannaged items
O Tnjury claiom�s:medical b�ls,receiprts
O Photographs are atways wetcome to documeat and support yo�claim but will not be rehuned.
Page 1 of2—Please complete and retarn both pages of G7affi Form
Fau"tare to complete and re3,nrn bo�h pages wilt result in delay in the LandNmg of yonr claim.
All 'laim�—,please comn�te ihis seciioa
Were thcre v�rrt�esses to the iacident? Yes No cno (cacle)
Provide their names,addresses and telephone numbers:
Were the police or law�foa+cement called? Yes No Unlmown (c�cl��3
If yes,what d�partment�agenicy`t `Jo.:n-E '�Q� 1 �17 Case#or r�ort# O
--Wlie=e did�e accidei�oiin�pny ta7ce place� r�ovide slreet aadress,cross slree�mte�tion,name o��c or facility,___ _ _-_
closest landmark,�tc. Please be as detailed as possble. If necessary,attach a diagram. L`�����a c,�
� 4�:,e�c�n�� a
Please indicatie the amotmt you are sedang in compensation or what you would l�ce the City to do to resolve this claim
to your sa6sfac�tion. (�o e 5�`;�n q t� e,o m a L��E.e_d` Zl e �
Velude Clsims—pleese comalete t��etion ❑check box if this secfiom does not anvlv
Your Vehiele: Yesr�O_Mske 7c5 yOT/¢' Model �L C��
License Platie Number?CL3�C t��/ State,�Cotor S�L 1��,�
Regisbered Owna NG ,(�?�/JG Y/P'^/��
Driver of Vehicle S /S
Area Damaged �'r r,+�'� S> �
City Vehicle: Year�O� i Make �'o c c� Model
Liceffie Plabe Number F=�,� a�SS Z Stttbe Color 1�:t �e..
Driver of Ve}uicle(City Employx's Name) C i c,��z4 ��-�{o� E�l l �
Area Damaged � �c� c�� e..c��� s�d re., •
Inj_uy Claims please complete t6ia sedion �check box if t�us sedion dces not a�lY
How were you injured?
What part(s)of your body were injured?
Have you sought medical treatment? Yes No Planning to Seek Treatment(oircle)
When did you receive fireatme�`1 (provide date(s))
Name of Medical Frovida(s):
A,ddre� Telephone �
Did you miss work as a result of your injur�l Yes No
When did you miss work? ����S))
Name of your Employer.
,Address Telephone
�Check here if yon are attachiag more pages ta this claim form. Nnmber of additional pages�.
By sfi�niieg this forn�you are stati�tg tltat aA'inforn�atian you have provided is true and corred to ihe best
of your kxowledg� U�signed forms wiJl not be processed
Subm�ng a faJse cla�in can result in prosecutio�. Date form was completed : , --q�' �y
Print the Name of the Persoa who Complebed tl�s Form:�O� M �,,,,}r�'^� �
Signatnre of Person Mai�mg t�e Clsim: `
Revised February 20ll
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912 LOMBARDY LANE N 872 SHERBURNE AVE Y
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RYSTAL 55428 ST PAUL 55104
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912 LOMBARDY LANE TN � N
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REMEM$ER TQ NOTIfY TN�STATE PIlTR01.(rsqllM�d und�f M�1�8.ta3�nd 769.�311}.
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� � Unit #! traveling Weat on Univ�rsity Avenue
� � """"r�"NKf°n0iu� passing thcough Miss�ssippi Veh 12, SPFD BLS
( I I �N ambulance �52 makinq left turn� from E/9
I � ' University to N/8 Hiss�ssippi Di2 stated that
V�1 was in his blindspot and he did not see the
vehicle D�2 cited for Fail to Y1eld Originat
SPPD report completed
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