Forest, David F�EC�1��'�C�
NOTICE OF CLAIM FORM to the City of Saint Paul, Minneso�a�9 2014
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�n3'P� �3�'��3'�is�ip�alit�...ai�aLl�s�to ���to
gouevniAeg.+b�y of dae wxaoaici�adit�xi�vdxin 1�0 Aarya Q/'t�r tlae aL1ta�Yoas or a�j�y as di�r�d a�s da,ting des ti�ne pla�ct aosd
circumstances thereof,and the amount of compensation or other relief demanded."
P1C�C t�CtC 1�fAiflt��C f�I.P��L�AC'�l"����IM1AVlC fA t![`�IiL'�UOr. �f OIp[tt f(I�OC�
/[fM�E�91f�[���. �t9i1C�C 1�p�N���19�bE Q0�[t��'t!�[�t fi9��'���l'I�V�C�C
much information as necessary to explain your cisim,and the amount of compensatioa 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
e�rie�f pawr cla�w. [Ui�c f�nt�t be d�ed,a�d b�o11t p�,aorplett�d, If.�c1ii��rt appl�,wrife`11T/,A'.
SEND C+lJMPLETED FORM AND OTHER DQCUMENTS TO: CITY CLEItK,
15 WEST KELL4GG BLVD,310 CITY HALL,SAINT PALJL,MN 55102
First Name �q J S d Middle Initial Q Last Name '1'-0 � c s �
C,om�tty�ar�u�ines�I��ne N�
Are You an Insurance Company? Yes/QIf Yes, Claim Number?
�tr�t A��_ _ Z 3 Q S C o-�a�Q � � ��� .. ,`� ,�'Z ('
City /vo.—� 5''� i'"�✓ � State ..Q S o7� Zip Code S S�0 g
1�3�ame Ph�n��(� �S �S �ll Ph�oue(_�l - Eveniag Te�hone(_�l -�
Date of Accident/Injury or Date Discovered S��l � 1�{ Time y= O �/�
Ple�se�,in�il,vvbet�eunr�d�appcncd�l,aad a+ahy g��ou anc:suib�muing a claim Pleasc indic�tc e�vhg��or taw you
f�cl ihe C`i!y�f�aiut P�1 Ar ita ecs " votved aad/�or re:spousible fior yaonr da�. '"' �
or
"� � c��- � 1. n 4^ I` ^ ..�
� � �'" 01 � � �v
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%� v �-o� a o '
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
�M�a��t�a+v��da�d b�++a po�Ole�or c�ondit%vn�f'the street ❑ My evehicle a�vas daroagod by a pl�v
��4tgr��icl��a�s a�ttc�n�uli��ed aad/'or t�e�d �3[�$injurrd�n�'
,�Other type of property damage—please specify 1n� �•�-<<c�a.i�(r (�C�—�*� > ��„��SQ J
❑ Other type of�n�ury please specify
In��pnoeess g�iour cl�im Yon need to inclnd�e aooies af alt anolical�le documa�ts.
For the claims types listed below,please be sure to include the documents indicated or it will delay the handling of
your claim. Documents WIL.L NOT be returned and become the property of the City. You aze encouraged to keep a
�f�or�qursclf befAne saibmu.�tin�y�wr claim fi�rm.
O Pr� claiu�s tA���hicle:te+��Gstim�s for the rrg�irs t�y�ur wchicle if d�e dama�ge excted�
$500.00;or the actual bills and/or receipts for the repairs
O Towing claims: legible copies of any ticket issued and a copy of the impound lot receipt
��'P�P��°�claims:ta�o re�eir�matcs if�damage exceed�s.$�OA.A4;or the actual bili�
and/�r's�eeipt�f�the r�air�,ddaiilcd lis�4af daa�od itea�s
O Injury claims: medical bills,receipts
O Photographs are always welcome to document and support your claim but will not be returned.
P�e 1�f 2—Ple�e ao�plete awd c+dnrs b�oW pages of C�aim F'�rm
Failure to coraplete and return both pages will result in delay in the handling of your claim.
AU Claims—dease c�dete tl�is�n
N��t�arc�it�cs�cs�tf�c i�? �x No Ualauoa�wn (circic�l
�ovide the'r names, addresses and telephone numbers:
a� i� /_ ; .. d��a.r- 6 IZ V 56��
1��t#ee�lae��vr i���f+oraett�t�a11e.�� Y� �� IJn�n �ciccle�l
If g��,�t c�ct,m�t qr a�,�cg�? sc i��or ne�oct#�
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 etailed as possible. If necessary,attach a diagram. ��.�.. k e� G c..�.�
�o...,... a Gc�n C BivG�d�1i
!'L���t1� ac?e seelcia�an e�n�pen�ti�ou�r avh�t g��ou+�w�d like the�"iiy t�o d�o w c�lve tlus claim
ou
to our satisfaction. ��. e � � 2 e c, o. '� S��� � S
v s s' ` - c��- �-- a�e •�c��.�,-, � S�
�S Ts��4 S 2r G c>S�'��
Ve�c1e�—drx�e�oe�lett tl�is�a ��cl�ck l�oac if d�i� s�ati�n�n��
Y�taa���aic�: Y�r � 11�+t�odd
License Plate Number State Color
Regis[ered Owner
Dci�er�of Ve�CI�
,�1r�[�d
City Vehicle: Year Make Model
License Plate Number State Color
Dria��r�f U�hicl�e�(Citg�Em�layec's i1T.an�e�
�►r�a�
Iniurv Claims—please complete th3s section �check box if this section does not applv
How were you injured?
Wh�p�(s�af'��rr b�ody ar�ere injuc�d?
Have you sought medical treatment? Yes No Planning to Seek Treatment(circle)
VfJhea did��u t�i�+e�tcn�7 (p�de date(��l)
Name�of'Medieal Pr�s�l:
Address Telephone
Did you miss work as a result of your injury? Yes No
'�a�id��oa��i�s��v�cic� �(pho�de data(s)�
It�a�e�f yc�r F.�er.
Address Telephone
�j t",I�ec1c hex+e i[�r �ne s� pa�e�to this e�fiorm. Number d�dditioeal p�ra�
/
By signing this forne,yo are stating that al 'nformatio ou have provided is true and eorreet to the best
of your knowtedge. Unsi ed forms will n t e processed.
���bnr�g a falst ela�m can i� Date[ �vas o�pitt�ed �//3 ,�/7
Print the Name of the Person who plete t ' Form:
�re�ot'Pei�s�ou Mald�tbe(�: �
Revised February 2011
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��siru z�tirx
�,oa�Cbrrs��z���:�r..�
�1225 �;stabrook Drive
Sain�Paul, Mirinesota 55 i a3
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��ate: ..,< R ; � �-"�� Time: `� „`s�. _
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C�____. ..
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■Incic�ent IZecapient Inforanatian
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Add�ess �:`� ����,•�'��.�' � x��_,°.1�r"° ` Cin;"€ a "r.,: ~ �'" '
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Phone: (�,.�� � ��. �� �."�'�t.��-�
■Reason recipient was here at the Co�no Park ZoQ a,na� Conf:rvatory:
❑Visiting Como Regional Park ❑Visiting Como Town
❑Visiting Como Zoo ❑Como Z.00 and Conseroatory Rental/Event
�isiting the Marjorie McNeel��Consert=atcry ❑Ou'�er:
■Nature of the Incident: (tJse other side if more space is needed.) _
V�, ' ? ' � �,�r�Z'•t�J "l.,'�t'd '� �.,�'l�C.���
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Staff person reporring incident: *Original to Diana Berchem - MZB/8270
Name: ���fj, Routed to:
' Campus Manager
Title: G,�J�;��'�.� Operations Manager
Marketing/PR Manager
Phone number: �� �,,4` Park Security
� `� �� Visitor Services Supeavisor
f�ther —�
G:ICAMPUS1Cusfomer Se��ice OfficeIFORMS1lncidentReport2012.doc
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A DELIVERY QUOTE
Dabe 5J20/2014 S:QS:a6 PM
•�'� Saies O�del' B0839
3115 East 38th Str�et,Minneapobs,MN 55406-3214,Phor�e: (612j 722-90(� Cu�on�er IO 13536
C�onter FORfST,DA1/ID DOB 12/22Ji957 Height 57 in. Weight 2ifl Ibs. Sdc 1M
�t+o 2395 O�TTAGE D�tT9/� De�r b 2395 OOTTAGE OR1VE
SAI1�1T PA111.,,PMi 551�9 �11INT PAUI.,,MI�155109
(651)285-1507 (651) 285-1507
Insuranca
Ca�n�M�s or Spedni Instryrdions H�AA 5'igna��e on t�c Yes
R�L: P�tMOBr1F C35!�
SRL#: 43201806
QUOTE OI�X
Q�:�G�54�34 �
De�very Dafie 77me CSR B�d�
5/20/2014 TROY APA MED
Qt�► Ty►pe 8in Item E�ct.Mrt. Tax Co-Pay
War�touse East 38f#�St
�. PurChase REPAIR 2U0/P'OIIVEtt 1M1MEELCHAiit �fl.00 $U.UO $0.�0
i2TGFfT F40TPLATE B�ICdd
1 Purchase K12 M-w(p/W�im�AiR P�tT $289.38 $O.UO $289.38
1827560 RIGH'f FOOTPLATE
4 Purchase LABOR/CNARGES(15 MIN) $56.00 $0.00 $56.00
TQTAL $345.38 $0.00 $345.36
!B�r�'�ry,'� ���S�me � �i�(� � ��
Thank You for Your Business!!!
Page 1 of �
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