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Walker (2) ��iv�� NOTIC� OF CLAIM FORM to the City of Saint Paul, Minnes�t� �� 701'� Mrrures•ota SIaIe SmtiNe 466.05 stnte.r that "...everv perso�t...whu c/nims dcu�iages,/'rom ttnv�r�unicipn/iry...sl�a/I cnuse In l��eAtccl4A��R�� gorerning/�orly of!/re mu��icipality withi�t /80 dcrvs after the nl/eged loss or injury is discovered a nolice statiag fhe tirne,p/nre,and crrcrrmstances tlterc:of,anc!Ilte nmount of compensntinn 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 f'orm 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 �G�� Middle Initial � Last Name ��/�e✓� Company or Business Name Are You an Insurance Company? Yes N If Yes, Claim Number? Street Address O � � 3 " �� J '�" City ��✓� .��'�//� State ,/ �� Zip Code '�� 2, Daytime Phone ( )�' r Cell Phone (�) �75 7 �" �C�Evening Telephone ( �/� Date of Accident/Injury or Date Discovered Time 1 6:�� am� Please state, in detail, what occurred (happened),and why you are submitting a claim. Please indicate why or how you feel the City o Saint Paul or its employees are involv�d and/or res onsibl for your amages. � Cdt�' -�' ��t� r ►M � e 4 �'1 d C r � g(Mev C� � a o N�,s-�J P✓ m� . � � > (,r,,e L.� ' l�o � � . 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 damagecl during a tow ❑ My vehicle was damaged by a pothole or condition o1'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 s ecify �'Other type of injury—please specify e N c�✓� � y � In order to process your claim y^�� „Ppd to include opies 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 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—n�ease 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 No 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 possRible. If r}ecessar , attach a diagram. .�aw�2S S}� �K �rdk� �/' .�� l�v�C� ��►^Qlit.2Y'1/ Please indicate the amount you are seeking in co� ensatio or what you w uld li the ity to do to resolve is claim to your satisfaction. O� � 'i!M h � - �t- C� P✓� �l��• Vehicle Claims— lease com lete this section ❑ check box if this section does not a 1 Your Vehicle: Year 2vc��' Make /V..rrR+� Model ,��M License Plate Number oJ G T State t�N Color /3 a� Registered Owner J ;�/ 9 G Driver of Vehicle �'f a a �f Area Damaged ,�0 City Vehicle: Year�Make J(/�1`�' Model �f� License Plate Number �//f) State � Color / Driver of Vehicle (City Employee's Name) Area Damaged , In"ur Claims— lease com lete this section ❑ check box if this section does not a 1 How were you iniured? _ _/V What part(s)of your body were injured?��1� . � 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 o When did you miss work? (provide date(s)) Name of your Employer: Address Telephone f�Check here if you are attaching moi•e pages to this claim form. Number of additional pages ' / By signing tliis form,yocc are stating tliat ull information you have provided is trice and correct to tlze best of your knowledge. Unsigned forms will not be processed. Submitting a false claim can resiclt in prosecution. Date form was completed �� 1.2 � �7 Print the Name of the Person who Completed this F � C�a/�-C!� Signature of Person Making the Claim: Revised February 201 I � �Ut1�PL�►[N�` � �� 62�9�42��r785 s�a9oo2osa�s : DL t�umber C�1 M �. Name ��e ta� Address— Street,Api� ��, State � Opg(mm{ddlyyyy) Eyes �ieight 1Kelght Sex t�ace Ethriici�y _ Veh' lice pla�e Year 5►aie t�e Type t�odel Color I � ��'" o'�o� �#I� 1SSq� 1�� 11�-r t e � �AcaderdlCrasti , . r ��j a Q�v a F� ❑�a� � Par1c'sng Meter 1Vt�mbet lVeighbofioad Code D Hous+n918ui�ding CodQ � 4 C3 Saoked �'OQerate ❑� D Passenger C3 Or'sver � � �� ,� � ��, � � �� 5 a `S� � c� �,� , on� ��`" 1 to!, � � Na 2 4t#ense �� ha 3 0#fense s�urerordina�oe ❑Speed i69.14(Subd._�___._.-,):._...----mA� zOne ❑�So Seat$eit Use 1&9.68B.t{a) ❑Ho �root ot Ir�ur2�e 169,791(2) !uC 7atcen—AC: 7esi type: Ci Refused C] $reath L3 Bbod O tfrine Q Hexarda�s Matetiel {D0� 0 Unsafe Condidons ❑ School7�ne ❑End ' Liie 8� i' t�Woric Z�e O Commeraai 11ah. �OT# tdentiHcation: ❑S�I_. ❑DV5 Web Q Ph4t� �D Q Okher ��Y�.��e��na„��n.naa cau►c u,st n,e�a s�etw , Omcer{s)Biame(S? t,(f Qif'wes t�lc�fs?. C�# C+dhg Oepk �wts�ea a�� a� �� cou�