Loading...
Dunbar, Elaine ����iv�� JUN o� 201� NOTIC� OI' CLAIM I'ORM to the City of Saint Paul, Mi(�hTe�'o�LERK Min�resntn Stnte Stutute 466.05 stntes d�nt " ...everv persnn...wlio rini�ns dumngesfrorn nny mtmicipnliry...shull enu.ce tn he pre.�•e�ucd to!he gn��ernirtg bod y q/'the ntunicipality wilhr�t 180 dcn�.r nfter(he uNe��ed loss or injury i.r c(iscuverec(a notire statiiig die time,pinre,u�id circums7ances Ihereo/;and tlte amoturt of compensatinn or other relief deninnded.° Please complete this f'orm in its entirety by clearly typing or printing your answer to each question. If more spuce 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 beinb requested. You will receive� written acknowledgement once your f'orm is received. The process can take up to ten weeks or longer dependin�;on the nature of your claim. This form must be signed,and both pages completed. If somethin�does not apply,write`N/A'. SEND COMPLETED FORM AND OTHER DOCUM�NTS TO: CITY CLERK, 15 WEST KELLOGG BLVD, 310 CITY HALL, S NT PAUL, MN 55102 First Name � ��� � � Middle Initial Last Name � � Company or Business Name / � '- Are You an Insurance Company? Yes/(No�If Yes, Claim Number? ��� � � � _� Street Ad ress U \ . . l �� / O �� City ` � 1 State /v Zip Code �j� Daytime Phone ���O h�Ce ne - .vening Telephone (��2 -GQ� �� � � �� a� Date of Accident/Injury or Date Discovered � � � 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. '� G�. 1..� �5 � �'� _ � Q "� ,�_ � c G� --�D cu (i C.�� � � � Ple�►se check he box(e.) t at most closely represent e reason for completing this form: ❑ My vehicle was damaged in an accident ❑ My vehicle was damaged during a tow ❑�A-y vehicle was damaged by a pothole or condition of the street ❑ My vehicle was damaged by a plow Lf My vehicle was wrongfully towed anci/or tickete ❑ I was injured on City property ❑ Other type of property damage-please specify ❑ Other type of injury-please specify � � ' � O� �L (V � In order to process your claim you need to include cop�es of al applic�b�e cuments. 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 $5,�0.00; or the actual bills and/or receipts for the repairs �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-Please comptete 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— lease com lete this s tion /�.�' Were there witnesses to th inciden . � No Unknown (circle) Provi h�ir na�nes, addresses and te p one numb r�. � � � � � G� G�liL� � � �^ Lv t't' cc � v �- o Were the police or law enforcement •1�?Ql(� �� No Unl�nown lI(circle)c^ If yes, what department or agency?�v, 1 U \l Case#or report# N� ' t � ��o�—� Where did the accident or injury take place? Provide street address,cross street, intersection, name of park or facility, closest,landmark, etc. P ease b as etailed s�os�ible. necessary, attach�iagram. w.. ��---�� C> � � ��� , Please indicate the amount you are seeki�ic• m�e��atyOn or what you would like the City to do to resolve this claim to your satisfaction. � � � Vehicle Claims— lease �m lete this s c ion check box if this section does not a 1 Your Vehicle: Year Mak.g v� Mode License Plate NumbeYf S �te CQlor ��' Registered Owner -� � �� � Driver of Vehicle `- ` Area Damaged /v ' City Vehicle: Year Make Model --License Plate Number State Color Driver of Vehicle (City Employee's Name) Area Damaged In'ur Claims— lease com lete this section ❑ check box if this section does not a 1 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 Dicl 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 additional pages I3y signing this form,you are stating tliat ull information you Izave provided is triee and correct to t/ie best of yoi�r knowledge. Unsigned forms will not be processed. Submitting a false claim cart resttlt in prosecittion. Date form was completed L�t, � I `� Print the Name of the Person who Completed this Form: \ � �/ Signature of'Person Making the Claim: Revised February 201 I Saint Paul Police Impound Lot, 830 Barge Channel Road, Vehicle Release Form Make: 98 HONDA License#: 489MND ✓N; 14095329 invoice# 150897 Date/Time Released: 06/01/2014 18:48 Tow Charge: $ 60.00 �� Released to TOTO Storage Charge: $ 0.00 � Paid by: CREDIT CARD Admin Charge: $ $0.00 � Released by: TABITHA Tax: (7.625%) $ 10.68 i,the undersigned,have recovered the vehicle described above. Subtotal: $ 150.68 i will check the vehicle for damage or any other problems that may have occurred while this vehicle was in the custody of the Service Charge: $ 0.00 Saint Paul Police Department. I acknowledge I will report damage and/or any other problems to the Impound Lot staff Total Charges: $ 150.68 on this form prior to leaving the impound lot. Damage and/or other problem: Police Report made: Yes_ No_ IF Yes, CN , If NO, Why? TO PROTE�T YQUR RIC�HTS REPORT ANY PROBLEMS/DAMAGE BEFORE LEAVING_THE LOT _, r .., � `�� Signature �- -- �'"`"`—� -�` - � � ____^ sr2000 1�1'IC�e, ��i'UfEtiS101711�ISill c� P�U'rilel'S�lt�) 83b�BARGE�CHANNEL RD SAINT PAUL, MN. 55107-295� I�(.)I)l) Rlpllkp1iA1 651-26&-5642 Pr�li����O/%ircr Merchant ID: k5f�b638N144 — --- ---- — Term ID: �017340000800638kf199F�8 �%"�� [�oL.ICt ULPAR'�1�9EN"T� Sale �,~ :. , .�a, C l I�ti pI�S 11NT P,�UI. �j < < �� � ,, , �;�� ,,�, � �,-_,� ���,,�,,� �, zzzzzzzzzzz10�8 ���,��ro,�; , „�;,, �r, .�;�,� ;,��;�, �, �,.. ,,�,,;, ,,, '� RMEX Entry Method, Swiped \_� ' ��..� � 3�cc�. � �u J/ �) � I� ��iu h3� �u�,unn r �_ardimz���ur rr����i� r:ill: �O�a�� � �����$ �ainl I'nul Polic��Ricnrds l''nif �M1�I)?h6-j70f! �; , � �—�� �6�41�14 18;48:16 Inv �: 060009 Rppr Code: 552964 AAArvd; Online Customer CoPv TfiRNK YOU!