Harstad ����r���
�9AY 151014
NOTICE OI' CLAIM I'�RM to the_City of S�int Paul, Min��CL
Mr��nr.sura S�ate S�nnite 466.05.stntes tha "...everv pe� �'�'S ''���` ���" `�'�""� !nicipnlit>>...shal!cniisP���he pre.ee�itcd tu���
,�oi�erning budy u/'dre ntunicipality withij: I80 derys wc�r�{-Q.t t ��,.-� �ered a�ro�ice stntiir�dre tinre,pluce,aiid
circunrstcrirces!/iereu/;crnd ��.}�{--t;�L�G� -��r w� �lief demancled.„
C��nn�l�e {-e t\ et n q
1'lease complete this f'orm in its entirety by cle ��eCg, ��„��L ��j er to et�ch c�uestion. II'more space is
needed,att�ch additional sheets. Please note tha �ro t c b`� '^`� Phone to clarify answers,so provide as
much information as necessary to explain your cl: �,5 c� ��• lion being requested. You will receive��
written acknowledgement once your f'orm is reo �,L`�� ten weeks or longer depending vn the
n�ture of ycT«r claim. Tliis form must be signec I _ �__ __._.,_..._... ..��mething does not apply,write`N/A'.
SEND COMPLET�D TORM AND OTHER DOCUM�NTS TO: CITY CL�RK,
15 W�ST KI+�LLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
First Name � �"t'v'C Middle Initial p Last Name ���'�� fi��
Company or Business Name 1v01'✓`�
Are You an Insurance Company? Yes/� If Yes, Claim Number?
Street Address �� � P��?f' � ,�^^t� A il`� �
��
Ciry ��' P/�UL— State �/� Zip Code ��GG �� �
Daytime Phone ( ) - Cell Phone (�1�`�« �� Evening Telephone( ) -
Date of Accident/Injury or Date Discovered�� �•�/ � [ � Time � �1'� am/pm
Please state, in detail, what occurred (happened),and why you are submitting a claim. Please indiaite why or how you
feel the City of Saint Paul or its employees are involved and/or respon ible for your d mages.
� s T��� 9v �°�n �'� ��.� s�'r�� ,c C G' � 1V1 r n�N r� sc r� � �, b
�' �✓�. C w-�, /`V\ t
Cr -C °r �? Y1 u7 L a�13 �__c�_t'�� � 4/'V2 t� f� y C� )'v !1'I �
,�,� ��' L ,Q � S �- ��t.G l� l�� ,�4C �_—(J o 1,.� e C�/�►J � t'
.IQ'l��`_.-�� - .4-r � c �z� �f'�,.� C �t-�� o t��i e.e, /�-���� c�� �e ��
'�"'6- � �G c,. i� �' �' G e �"cs.� �'(�, 9,�1` P S r,J L..4-'T � t.? � �7
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 duiing 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 proper[y
❑ Other type of ProPerty damage—please specify_
❑ Other type of injury—please specify �(rg T N�l� L -Q �% f" �✓�.e r �,� �2e Pc,�p� �
In order to process your claim vou need to inelude copies of all annlicable doeuments.
For the claims types listed below,please be sure to include the doc«ments indicatecl 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. j
O Property damage claims to a vehicle: two estimates for the repairs to your vehicle if the dama�e 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
�►nd/or receipts for the repairs; detailed list of damaged items
O Injury cluims: medical bills, receipts
O Photographs are always welcome to document and suppoR your claim but will not be returned.
Page 1 of 2—Please complete and return both pages of Claim Form
l+uilure to complete and return both pages will result in delay in tlie hundling of your claim.
All Claims–n�ease complete this section
Were thcre witnesses to the incident? Yes No Unknown (circle) p
Provide their �ames, addresses and telephone numbers: �U� '� kl C Z<' i>-�` � oUO�'S �7�� f
�u r� � �
Were the police or law enforcement called? Yes � Unknown (circle)
If yeS, whac 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,
c(osest landmark, etc. Please be as detailed as possible. If necessary, attach a diagram. �.�. ��Y� ��
► �r� � �G�t"�. 5 �' -
Please indicate the amoti t you are seel:ing in cotnpensation or what you would like the City to do to resolve this claim
to your satisfaction. Wl � t�l !� v✓� 1 � �`a �'� �
NQ ..¢ t r✓ �'✓�`i L N �t dvt 2 v �I�N
Vt,hicic Claims pl�aSe compl�tc, this sectiori ❑ check box if this section does not ap�ly
Your Vehicle: Year Make Model
;
License Plate Number State Color
`' Registered Owner
Driver of Vehicle
Area Damaged
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Are�i L�ama��l — ^_—_---
In'ur Clain�s– lease com Iete this section ❑ check box if this section does not a I
How were vou iniured� � � T' L � ei ���.{ r.eJ l4 �dT �OL -2,
What part(s) ol�your body were injured? �, -C ��f�<�h�-�-2 w t� �C � ('.✓� (�,Q #�L t�c. 4
Have you sought medical treatment? es No Planning to Seek Treatment (circle)
When did you receive treatment? (provide date(s))
Name oi�Medical Provider(s):
Address Telephone
Did you miss work as a resuit of your injury'? Yes No
� (provide date(s))
When did you miss work.
Name of your Employer:
Address Telephone
❑ Chcck here if you are attaching more pages to this claim form. Nun�ber of aclditional pages
13y signi�zg this form,you are stating tliat ull inforrnatio�z you liave provided is true a�:d correct to 1/ie best
of your k�aowledge. U�zsigfzed forms will not be processed.
Secbmitting a false clair�i cu�a result ira prosecictiofi. Date form was completed �`"-' � �f` ��
Print the Name of the Person who Completed this Form: �il �W"L �` �'�v�"������'J�
Si�nature of Person Makin�;the Claim: ���P N�
Rcviscd February 201 I
In order to properly submit your claim to the Personal Injury
insurance company the following information must be
completed and returned.
Patient Name:
Patient date of birth:
Type of injury: Motor Vehicle r Personal Injury
Name of the insured :
Insurance carrier: '
Insurance Company Address:
Adjuster Name:
Adjuster Telephone#:
Claim#:
Date of Injury:
Body area injured:
�
Without the above information, our clinic requires you to �
either present private insurance or pay at the time of service.
' Thank you.
Please return this form
Phone # 651/968-5050 Fax # 651/651-968-5900