Easker NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minnesota State Statute 466.05 states that"...every person...who claims damages from any municipaliry...shall cause to be presented to the
governing body of the municipaliry 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 !�(�,r f7 Middle Initial�Last Name � 1� �'`
-�-- -,�.����
Company or Business Name - — - - - � �� �
N/� -_ -y
Are You an Insurance Company? Yes/� If Yes,Claim Number? A�� �. � 2���
Street Address 3S� l, Ie�IP�(�yl���vp /V_ '�o� �i 1 � 1.r►..i:=t�iK
City 5 T : ��� State / 1 N Zip Code � ��
Daytime Phone (��s)�g 1- 6 3�� Cell Phone (���)54� - 3a,1 Evening Telephone( ��s)�g� - 3 a�
Date of Accident/Injury or Date Discovered �f� �i � �D) Time���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 res onsible for your damages.�I (�al ke(� nu'�
� � r
"5- �° � r i M ' � 'G a �
('` � � "a i PS v d
T � � e\ ' S 1 '" � env;.,y 1�
� r�rb , sr ev� i- o C;�,, ,� c�� P ►.) is reS�oA�;bl� -�� �he
.�.�,�es i. c�i11Q� +h� STree�F Nla;�fi�t�v.RC���►;S��n o.��� r�uo�f Pd �1,e d:ar��� �Mr�►��hey,
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
❑ My vehicle was damaged by a pothole or condition of the street �My vehicle was damaged by a plow
❑ My vehicle was wrongfully to�ed and/or ticketed (�I was injureci on City property �
❑ Other type of property damage—please specify 1,
❑ Other type of injury—please specify �I
In order to process your claim vou need to include copies of all applicable 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 ��CE,V��
O Other property damage claims: two repair estimates if the damage exceeds $500.00; or the actual � s
and/or receipts for the repairs; detailed list of damaged items :�� 1� �1�
O Injury claims: medical bills,receipts
O Photographs are always welcome to document and support your claim but will not be returned. �I'����'��
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 wimesses to the incident? Yes No Unknown (circle)
Provide their names, addresses and telephone numbers:_
Were the police or law enforcement called? Yes 1Vo Unknown (circle)
If yes, what department or agency?Esl\e Stre,el' Mwin��c�f� Case#or report#
a;,�;5���
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.1�1 e Q�c i f�e w1 �vo j�
P` r���' ���s�r�2 ��cc�.,�Da�t�p��' 356 Cleve`a� �J2 S� �au1 , MN SjIDy.
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 I c • � �i n � r' i �� fi + ' �T
'�'e f�50 V ` � L
Vehicle Claims- tease cnm lete this section ❑ check box if this section does not a 1
Your Vehiele: Year O� Make Po�1 i cc c Model �r�r��v�If Q S E
License Plate Number �3:5-B N 5 State�i Color S�1 v��/4�p 4
Registered Owner Cat �h J oh�n 6a sKe�"
Driver of Vehicle �"
Area Damaged S;�,� -v�e.� ('�'�t'r o t� F�°.�fi �,� �Y 'S ' {2
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 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 F.mployer: _ -- - — - -
Address _ Telephone
�'Check here if you are attaching more pages to this claim form. Number of additional pages�.
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 /1 P� � � .5 ����'}
Print the Name of the Person who Completed this Form: �c�l�P�(1 E1��L' "(
Signature of Person Making the Claim: �nn�n �
Revised February 201 I
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-g��� Signal Garage Auto Care
.
2050 Grand Ave. Saint Paul, MN SS 105 ,��,�I„�KS,�n,•
�., .
GU ED Phone 651-690-1487 www.Signalgarage.com 419'-''3�
Quote # Q200023
Aaron, Easker 2001 PONTIAC Bonneville SE License# Inv Date: 4/07/2014
Odom: 0
� VIN: Color: Service Writer:
Engine:V6,231 cid,3785cc,OHV,Gas, Fuel Mfg.Date: Status:
Trans: Driver:
Unit# PO#
Vehicle Problems- R�quests fcr Service SeraieesRe ed _ Qty Price Ext
-- -- �-- —J---. _ --_--- �
— --_—
Rppoin#m�nt Cor�cerns:
What Time Wou(�i You Like Your Car Dcne By?:
Who Wou1d Y€�u Uke Me To Gait ANL1 Which Phone''Number?:
Does ynur drir�er's windawr g�up antl dawn?
�1Pp�'oved 'Amount�p ta:�
Are Yc►u A Member flf The Car Ggre Cfc�b bR�o Yo�Mave Any CouponsTcrday?
The Left Outsltle Mirrar needs repair or repfacerttent.
Labor Service-Remove and Replace left outside mirror assembly. 41.34
Part used mirror 1.00 127.45 127.45
Sublet Paint mirror 1.00 100.00 100.00
�
I
_ __ _ _ _ _ _ _ __ _ _
' Warranty ', ' Quote Summary: '
-Limited Nationwide 12 months or 12,000 miles(whichever comes first) ' QUOTE ' Parts 127.45 ',
' -Limited In House Lifetime warranty ' ' Labor 41.34
' Unless noted differently on the invoice. ', Sublet 100.00
', ' Shop Supply and 16.50 :
' , ', Sub Total 285.29
', ', ', Sales Tax(DEF) 17.35 '
Page 1 of 1 C�iscard old parts Original Estimate: 302.64 TOt81 302.64 ;
Signal Garage Auto Care
e.,
2050 Grand Ave. Saint Paul, MN SS 105
G D Phone 651-694-1487 www.Signalgarage.com 4'g'�13�
Quote # Q200023
Aaron, Easker 2001 pONTIAC Bonneville SE License# Inv Date: 4/07/2014
Odom: 0
� VIN: Color: Service Writer:
Engine:V6,231 cid,3785cc,OHV,Gas,Fuel Mfg.Date: Status:
Trans: Driver:
Unit# PO#
�°�-'Vehicie Pr6blems- --Requests fe�Service - SewicaaPe�rmed-- - Qty Price Ext
APPatn�men#Ccmcerns: — a
Wtrat��1�+��tisu iike Y�ue`C�'t3r�e�e B�''t: '
�Fhcx��'��tk�li�"�ts C�ii AI+TIl�Whi�h Pt�oa�°�!i�ur�er7: '
�.'�air��r'�`�f�ii�v�u�z�d;c��rn? °°
��.����R'���
,
�Ys�u i�1��ti��'�TTMer�r G�re+�lub�1R CYc�'1fc�#��ve����T�d�y? _
`�Left��Mi�'n�repatr or r�ls�n�ent
Labor Service-Remove and Replace left outside mirror assembly. 41.34
Part new mirror 1.00 188.89 188.89
Sublet Paint mirror 1.00 100.00 100.00
�'I
�
__ _
WarrantY _ _ __ _ __ _ _ Quote Summary: _ �
', -Limited Nationwide 12 months or 12,000 miles(whichever comes first) QUDTE ! Parts 188.89 ''
-Limited In House Lifetime warranty : Labor 41.34 '
' Unless noted differently on the invoice. ,
Sublet 100.00 '
; ' Shop Supply and 22.51 '
', Sub Total 352J4 '
; i Sales Tax(DEF) 22.03 '
_ _ _ _ __ _ _ _ . _ _ _ '
Page 1 of 1 Discard oid parts Original Estimate: 374.77', TOt81 374.77;