Dill, Bill �-CC.V c� v ��-
MAY 3 0 2014
CITY CLERK ���' / I
�
This claim form is being returned without having been set up as a claim for the following I�,
reasons: '
Failure to provide a written description as to what happened and why a claim form
was being submitted(page one).
Failure to provide the proper and required documentation(page one).
Failure to provide a date of accident or injury(page one).
�L—Failure to indicate the amount of compensation being sought(page two). ,�� � (
Failure to provide information about the vehicle involved(page two).
Failure to provide information aboui the iiijury claimed (page two).
Failure to sign the claim form (page two).
Failure to print the name of the pe�son who completed the claim form (page two).
�/ . �
�`�"Other: , �'r�
� / �'' � �i �P�
l �n v
he com leted claim form to: c��/�
Please return t p
Office of the City Clerk
City of Saint Paul
15 W. Kellogg Blvd.
310 City Hall
Saint Paul, MN 55102
If you do not return the completed claim form with the appropriate documentation or
information completed, then a claim file will NOT be established and an investigation
WILL NOT be done. In ether words,NO FURTHER ACTION will be taken until the
information requested is provided by you.
Please remember that it is a crime to submit a claim form or to pursue compensation
falsely or under false circumstances.
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�ECEI�.��D
����iv��Q�TICE OF CLAIM FORM to the Cit of Saint Paul . MAY �14 2014
M AY 3 0 Ztl��r Y ' ����EF�K
' Minnesota State Statute 466.05 states that' ...every person...who claims damages from any municipaliry...shall cause to be presented to the
Y pv��nn��c�of the municipaliry within 180 days after the alleged loss or injury is discovered a notice stating the time,place,and
CIT ���-�-- circumstances thereof,and the amount of compensarion 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 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 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 ,��l� Middle Initial _.J Last Name � /i �f
Company or Business Name
; _ - �. �x_._
Are You an Insurance Company? Yes/I�1 If Yes,Claim Number?
Street Address � � ��' �� ��e �S� ��
City ��� 1- ���� State ��'� Zip Code
Daytime Phone(�-5_1 )�- 5 3 j Cell Phone(L 5�� ��3�= - E�`'�� Evening Telephone(�''� ) ��- �"�
� / � 5 Time ��'``'am
Date of Accidend Inj ury or Date Discovered ��. ,rn r- �prr
Please state,in detail,what occuned(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.
.•
�,� �-�� �c ��c;�� h;�-t- ��� hv� � •��;-�-/�� �-
� „ c.s �E_ �l,-r- �l—'G=.-,�` ,�-� ��� ��� 7` �-ts w�:�1,
P e check the box(es)that most closely represent the reason for completing this form:
vehicle was damaged in an accident ❑My vehicle was damaged during a tow
—j y 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
nn�fi,......` r...... ..... a..-, ,..,..., . ,•� -
�. vici..i �yY v. �.liv�i.i�� Uu�1ic`l�V-��l1liUJli:�YV�.ti�%
❑ Other type of injury–please specify
In order to process your claim you need to include copies of all apnlicable 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 , - a':;}��
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 suppoR your claim but will not be returned.
Page 1 of 2–Please complete and return both pages of Claim Form
� � . - .. .,, ��,-�., ..- . .�__ - --. ���z�%i� 'a a r�� rMr[�1��- �_
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims—alease comnlete this section ---..
Were there witnesses to the incident? Yes CN� Unknown (circle)
Provide their names, addresses and telephone numbers:
Were the police or law enforcement called? Yes �% 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 ossible., If necess ,attach a diagram.
,
�'',:� �- ���m,�- �;,� i��-�<<S�`Cc;�� ����.-✓ �-✓�c.l�fi 5-f �- ,/t/ �7��:.'� S'7-'
Please indicate the amou t �o_�u�see $,m c m ensation or what ou would like the Cit to do to resolve this claim
to your satisfaction.�,:��--' � �(.�� p y y
�check box if this section dces not avulv
- ' —.,..y..-=,�, � _ --
Your Vehicle: Year /H-� Make ��� � Model �f�` � ��
License Plate Number �77/�Jr^�7� State !'��Color
Registered Owner /�?� 3 �� ���
Driver of Vehicle n?� -1`���� ��/
Area Damaged /��a r f"ve �- ,��h�e/
City Vehicle: Year Make Model g,�,y � � ;(`i{�
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Injurv Claims—please complete this section l7check box if this section does not aunlv
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:
�iu:iress Telephone
❑ Check here if you are attaching more pages to this claim form. Number of additional 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_S/ ����
Print the Name of the Person who Completed this For •- �.�' �I ± � /' ��
Signature of Person Making the Claim: �f�-'���' a�� �
Revised February 2011