Hecimovich, Adam NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minneso�a Stnte Statute 466.05 states that"...every person...w/zo claims dainages from any mundcipality...shall cause to be presented to the
governing body of dre�nunicipality witliin 180 days after the alleged loss or injury is discovered a notice stating the ti�ne,place,and
cire�imstances thereof,and the amoi�nt of co�npenscrtion 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 tonger 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�_x'�t Middle Initial�Last Name � �r/=�' �� -.
Company ar Business Name E C E I VE D
Are You an Insurance Company? Yes No �Yes,Claim Number? JUL 2 4 2014
StreetAddress J���� ����� /--��.� � ''�jTy r'LERK
City��f-���1� State,�' '�1-1�J Zip Code �/ ._�i;
Daytime Phone(`^��):�{L-��Cell Phone�"�l-.�/17 Evening Telephone(_) -
Date of Accidend Injury or Date Discovered,"f �' � Time�.'Y� am/�m
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�mployee�are involved�nd/or responsible for your damage� ''`< <"� '-'
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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 o�the street ❑ My vehicle was damaged by a plow
/�y vehicle was wrongfully towed and/or ticketed ❑ I was injured on City property
❑ Other type of property damage—please specify
0 Other type of injury—please specify - -----
In order to process your claim you need to include copies of all aAUlicable 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
�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 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 comqlete this section
Were there witnesses to the incident? Ye`.., No`, Unknown (circle) ,
Provide their ames,add esses and ephon�numbers: J,.�,e,l( �rar_��—�„;:c-�
�/ /�_�S'�' .-.1..��. ���'�s ����/'�l 1a'S '�%v
Were the police or law enforcement called? Yes �NQ.� Unknown (cirde)
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 ar facility,
�sest landmark,etc. Please e as detailed as possible. If necessary,attach a diagram.
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Please indicate the amount you are seeking in compensation or what yo would like the City to do to resolve this claim
to your satisfaction.�� �' �
Vehicle Claims— lease com lete this se tion �heck box if this section does not a 1
Your Vehicle: Year,-.2,�r��Make • Model
License Plate Number � State l47,�t1 Color
Registered Owner � � ��- �� �
Driver of Vehicle f' ^ � <_.'
Area Damaged� ���ard �' �.��`��� �
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Injurv Claims—please complete this section � �check box if this section does not auplv
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 additional pages
By signing this fornz,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�������.�
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Print the Name of the Person who Completed this orm: � %�'•
Signature of Person Making the Claim: � '
Revised February 201 1
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