Vang, Lee K�I.tIVC.0
APR 16 2014
CITY CLER K
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 municipality...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 compiete 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 ot be contacted by telephone to clarify answers,so provide as
much information as necessary to explain your claim,and t�ie amount of compensation being requested. You will receive a
written acknowledgement once your form is received. Th�e 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 4 Q�� Middle Initial Last Name ��
Company or Business Name
Are You an Insurance Company? Yes No If Yes, Claim Number?
Street Address �� �Q� `s � � �
City �� ' l'�"�`' StatG dVl�" Zip Code .�s /b�
Daytime Phone(�OS��iC:�Phone( ) - Evening Telephone( ) -
Date of Accidentl Injury or Date Discovered 3 � s' �01� Time�am/�
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.
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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 towed and/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 you 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.
�Property 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
andlor 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—nlease 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 c lled� Yes No Unknown t (circle)
If yes,what department or agency? � � � Case#or report# I �
Where did the accident or injury take place? Provide street address,cross street, intersection,name of park or facility,
clo 1 ndmark,etc Please be as det,ailed s ossiblg. If n cessary, attach diagr
��U�j rti5�r���` �-� �71�'Q��' �r,. �—.-�G�,�,t.�m.
Please indicate the amou�nt you are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction.�
Vehicle Claims—please comalete this section ❑check box if this section does not apvlv
Your Vehicle: Year?!,�Make ' Model �1�n.����.�.✓�,
License Plate Number ' � State�Color i��ui .2
Registered Owner i -2-� 1��t n��
Driver of Vehicle <
AreaD maged ,�1riU�(' S��� �_G' Y�,r d6c� •
City Vehicle: Year�a 1�Make 1=rr ri� Model � X �— �
License Plate Number � State�An^� Color Cti L
Driver of Vehicle(City mployee's Name) l�G }-/�
Area Damaged til,(��k�'1,
In'ur Claims— lease com let this section ❑ check box if this section does not a 1
How were vou iniured� N
What part(s)of your body were injured? Q�l>'
Have you sought medical treatment? Yes o Planning to Seek Treatment(circle)
When did you receive treatment?_N�� (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? A �1�� (provide date(s))
Name of your Employer:
Address Telephone
�Check here if you are attaching more pages to this claim form. Number of additional pages
i �
By signing this fornz,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 complete � �
. f /� �C� v l
Print the Name of the Person who Completed this Fotm: vv��' � �
. ��L'�'-
Signature of Person Mal�ing the Claim:
Revised February 2011
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