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�1AY 14 2014
NOTICE OF CLAIM FORM to the City of Saint Paul, l�'��@��K
Minnesota State Statute 466.05 states that "...erer��person...who claims damages from any municipality...shall cnuse to be presented to tlie
governing bndy of die mamicipnliry within 180 dcay;s after the alleged lass or injury is discovered a notice stating the time,place,c�nd
circumstances thereof,and tlae anwunt of compensation or other relief denTanded." �
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. 1?he process can take up to ten weeks or longer depending on the
nature of your claim. This form must be signed,and bdth 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 1�..���,1.�,.ZE'_ Middle Initial�Last Name���,�1
Company or Business Name
Are You an Insurance Company? Yes/Qo If Yes,Claim Number?
Street Address �(��[`l�'� a��,��
City�X2 A tJ State Y"\N Zip Cod��S 1 ��
Daytime Phone��JJ�/�ell Phone��-dl I 1 Evening Telephone( ) -
Date of Accident/Injury or Date Discovered � ' � ��' Time am/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/ r res onsible for your dama es. C�
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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 propeRy 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.
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—Plea complete and return both pages of Claim Form \,�—
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Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims—nlease complete 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 deta'led��possible. If necessar , attach a diagram.
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Please indicate the amount you e seeking i compens�tion or what you would like the City to do to resolve this claim
to your satisfaction. ��,'�jT�� �
Vehicle Claims— lease com lete this section ❑ check box if this section does not a 1
Your Vehicle: Year�_Make Model �S
License Plate Number StateM Color V�
Registered Owner
Driver of Vehicl
Area Damaged �--
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged .
Iniurv Claims—please complete this section �lieck box if this section does not avplv
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))
Nam�of your Employer:
Address Telephone
fl Check here if you are attaching more pages to this claim form. Number of additional pages�.
By signing this for►n,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 i�a prosecution. Date form was completed � �a� � ��
Print the Name of the Person who Comple d t is �
Signature of Person Making the Clai •
Revised February 2011