Dorschner, Marissa l��C�l���D
NOTICE OF CLAIM FORM to the City of Saint Paul, �n�s�a��
Minnesota State Statute 466.05 states that"...every person...who clnims damages from any municipaliry...sha��u�e ib bk/i���he
governing body of the municipaliry within 180 days after the alleged loss or injury is discovered a notice stating the time,place,and
circumstnnces thereof,and the amount of compensntion 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 MaY-i S So� Middle Initial�Last Name 17ors c�n e r
Company or Business Name IJ «
Are You an Insurance Company? Yes/� If Yes,Claim Number?
Street Address 47� F�r;mha.11 �)� ��
City �0.�fl� 1J u.�J� State 1✓L I� Zip Code �J�J��S
Daytime Phone((�S�)��Cell Phone(�_)235-7$CoC�Evening Telephone( )��
Date of Accidenb Injury or Date Discovered $�2� 2 ���{ Time : �pm
Please state,in detail,what occurred(happened),and why you are submitting a claim.Please indicate why or how you
fePl the City of Saint Paul or its employees are involved�nd/or responsible for your damages.
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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 of the street ❑My vehicle was damaged by a plow
�My vehicle was wrongfully towed and/or ticketed O I was injured on City property
'C�Other type of property damage—please specify �1� �te.�'li C�e tL')QS daUnrlci@�P� Mf iG��Y1�Ci.��(� b�
❑ Other type of injury—please specify C1+�emPloyee•
In order to process your claim vou 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
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 da�aged 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
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims—nlease complete this section
Were there witnesses to the incident? Yes No Unknowri (circle)
Provide their names,addresses and telephone numbers:
Were the police or law enforcement called? Yes No Unknown (circle)
If yes,what department or agency?�CX f�Ce Case#or report#� "���7 Y�h�
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 possible. If necessary,attach a diagram.
�-i,�la��d �Pc�,-� t z�� I�on 4-r2 c�,l Avt� '-=���Pa.v i M Pl� S�I!
Please indicate the amount you are seeking in compens�tion or what you would like the City to do to resolve this claim
to your satisfaction. Y' h i '� • Z
,
Vehicle Claims— lease com lete this section ❑check box if this section does not a 1
Your Vehicle: Year "ZC;C Ci Make ' '� ' e.- Model A �P�_
License Plate Number i � � State��Color�r I�" _
Registered Owner �QY'�`�S CL ("�C.h�'1(o v
Driver of Vehicle i SSC� Cc''
Area Damaged Y`N(Z u'` 1+^l� ��i�' ��J�' ���� n 1��
City Vehicle: Year Make Model
� I� License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniury Claims nlease complete this section �check box if this section does not avvlv
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 $_���1�
Print the Name of the Person who Completed this Form: '4��lar i SSc� ��C'`��-�i'LCY'
Signature of Person Making the Claim: •v!l/� 1-w� �t
Revised February 2011
Work Order
- Date: 06122I2014
�. �vc;:';t
-� . Work Order#: 3815009
- - Store: Rap�5T6
Rapid Glass A Quality Glass Co
612-333-4539/763-763-0311
651-290-02261952-881-0116
Phone: �
Fax: TAX 1 D#: 411662447 ,
Customer: Insurance-Fleet-Broker:
Marissa Dorschner No Insurance
2127 Grand SVeet Ne �l
#2 �
MINNEAPOLIS, MN 55418
Phone: {651)235-7860 Phone2: (651)699-8229
Mobile: Fax: - - �
Job Scheduled For: August 22, 2014 8:�0 am
Written By: cGg1, Sales Rep:
Technician:
Automobile Information Fleet Information Insurance Information '
Year: 2009 Unit# : Policy# :
Make: Chevrolet Card# : Ciaim# : I
Model: Aveo5 Exp Date: Loss Date:
Style: 4 Door Hatchback Driver Name: Cause:
VIN#: KL1TD66E09B320130 Driver Lic.: Authorization#:
Color. Fleet PO#: AaenUBroker: �
Mileage:
License: State:
Qty Unit Lfat 08�A Discounl Net
MFG Part �e��Pt�� g164.35
DD11791GTNN oor GT,Left Rear 1 Each $164.35 N
� , at •
� or or '
Owner Insurance
Service Address Work Orcler Notes Sub Totel • '
Circus Juventas Marrissa 8/22/14 mobile by 5:30 p
no sheRer T�
1270 Monireal Avenue 3786 exp 12/16 Cvv� Grosg Tolal • '
Deductible �� �
SAINT PAUL, MN 55118 ,��-- Net Tota� � �
Pnrr��ryPhan�: f�51)235-7�6A- - _ ___ - -- --- __ ___
Secondary Phone: (651)699-8229 AMOUNT TO COLLECT $261.88
Mobile Phone:
VehicVe Notes:
DOTA�-_LOTiF
VINf ocaed6�awed bY mY�t�Obila ineurx fw the deme0ed 9ass and I appa�t
to r air or replece my defrw9�sW°'T���B e1eS6'i������o Repid Gless all pollcY W
In oonslderation of RapKiGlase aareain9 BP kliUfef s i9eM�,edlutleB.�RP�efRM2l1Y68��Id Ihifd-Pe�11lidmif7lslreUOfi folBtiVB t0 th�if�su�Mae eleim an Ciadud e myaerl�ithat
Rapid Gless to acl on mY 6eheM�to��'�icele with my insurw end mY I
my automobib glesa is d��yed•�sulh°�'u my i�surance corWeny tn reVeare poliry.coverape end ell other information ralaled to lttis insura��e���m lo Repid Glaiss. I agrea to pey
undersland that if 1 neve no inturance mvorega tor lhis wwf:,1 am responsibl�to paY lar Ihe worK upan notification by Repld Glass.
Signature
Date:
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