Flanagan, James . .
�ECEIVED
h1AY 2 3 2014
� NOTICE OF CLAIM FORM to the City of Saint Paul, Mi�p�s�o��R K
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 municipality 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 ques6on. 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 rnmpleted. If sometlung 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� I�M i�� Middle Initial I�Last Name F L�N �o �1�V
Company or Business Name
Are You an Insurance Company? Yes/�f10 J If Yes,Claim Number?
✓
Street Address �/ C�?.r�c-�-c.Y ���L�
City cf' (��-t,i � State �f n� Zip Code ���c.� Z—
Daytime Phone(��- � � Cell Phone(�)J� � 3��b Evening Telephone(`�% 2 Z y- �5`'J f
Date of Accidend Injury or Date Discovered �.c��r �2�1 t� Time am/pm
Please state,in detail,what occurred(happened),and why you aze 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. au n .v�ti G-,d�i�5,�2L�
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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 datnaged 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-�ou need to include copies of all apalicable 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 WII.,L NOT be retumed 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 retumed.
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 called? Yes . No � Unl�own (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 pazk or facility,
closest landmazk,etc. Please be as detailed as possible. If necessary,attach a diagram.
�; c�c � �2. id--�� i.lS
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. � `/J"� "�'1 d'"F'� E-�S i� c�� i�(f�L-t�-c�l 1� �%- rf'�d-C'�
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Vehicle Claims-please comnlete tlus section ❑check box if this section does not apvlv
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)
Area Damaged
Iniurv Claims-nlease complete this section ❑ check box if this section dces not anvlv
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 Employer:
Address Telephone
❑ Check here if you are attaching more pages to this claim form. Number of addiNonal 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 �� ` �
Print the Name of the Person who Completed tlus Form: �'1 f�: � �G
Signature of Person Mal�ing the Claim: 0.
�
Revised February 2011
� '1 Date:
Order#: 322947 , '� Tuesday�MaY 20,2014
Technician: '
Shawn S •srnce i9�s 65�'228-9100
640 Grand Ave,St Paul,MN 55105
Customer Name Don Flanagan Contact Person
�ustomer Address 97 Crocus pl. City Stpaul Zip 55102 State MN
BillingAddress Gty Zp�� State MN
Phone Number Phone Number �-];Email Address: SarahvFlanagan@gmail.COm
SOLUTIONS ACCEPTED BY CLIENT
Service Call Charge W11V@d
Replace outside faucet 455.00
Service Partner Plan NOT Selected By Customer • r--�
►� Subtotal• �
Customer DID NOT Select an Opti�That Indudes Duct Clea�i L_._
Service Partner Discount: C�
TOT L COST TODAY: 455.00
Cust Si
WO AUiHORIZA710N:I,the undeaig�ed,am ownex/autAori�d d the D��rt���� � ' d��I hereby auM ze
you to perform tlie above wludons reconrnended,and to use wd�ka6w and materials n you deem advisable lhdess Drior- Ror bdYn9 ard document on
this page,paYment for afl work is due upon cortpleHon(C.O.D.).M oRice bafn9 dwr9e and/w fina�ce charge d 7.75%per month(2 anum)w71 be added after 10
days past due.I agree to pay reasonable attomey fees,court costs,and ooYecUOn fees in the event d legal x8°^�I have read this contract,inchidGg 1he terms and
conditions on the folbwing W9e he+eof and agree to be bourd to all the terms contained hereia•,"Curtomer agrees to term lis[ed on fdbwin9 page wF�en boxes are
checked."'Duc[CleaMn9 is paid for in advance.Curtomer wW receive a caY from our duei deanin9 sd�efider to havetfils work completed M providing an ema0 address
on this invdce you agree to receivecanpanY newsletters You havethe rigM to opt-ou�W«��ei�9��iO1^°�CO�''
PAYMENT k1 AMT: 455.00 PAYMENT N2 AMT:�
Invoice copy: Customer Requested to be Emailed
Warranty Included:
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Check#-CC last 4-Financing last 4 Check#-CC last 4-Fin�irg last 4 1 year
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