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Johnson, Melissa .._ .a.� � `p--. � � � ._ � �� = N :,� `_� - _ . " . ' � �•/ q 1 ' a SEP �5 ZOj� NOTIC� OT CLAIM I'ORM to the City of Saint Paul, M' o a � �� Mi�inesu�a S�ale Stutute 466.05.rlate.s[lrnt "...every/�eiso��...wl�n c(nim.c danwges./i�uin aiiy r�+nnicipnlih�....slru!l cuuse��be pre.rentc d tu d�e �nreirirng hoclV u/'llre m�o�icipnlity wid�i�t l80 duvs after tlre uNeKed lo.rs or injury is discovered a nntice stcui�tg dre time,p(nce,und cire•ums�rrnces tlreren/;ancl dre mm�u�rt of compensation or nther relief dentnnc(ecl." Please complete this form in its entirety by clearly typin�or printing your answer to each question. If more space is needed,attach additional sheets. Please note that you will not be contaMed by telephone to clarify answers,so provicte as much information as necessary to explain your claim,and the amoimt of compensation being requested. You will receive a written acknowledgement once your f'orm is received. The process can take up to ten weeks or longer ciependin�;on the n�►ture of your daim. Tliis form must be signed,and both pages completed. If something does not apply,write`N/A'. SEND COMPLETED I'ORM AND OTHER DOCUM�NTS TO: CITY CLERK, 15 WEST K�LLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102 First Name ��-'"% Middle Initial � Last Name �`=�� Company or Business Name O�� uL M/1 5 S/o�-f Are You an Insurance Company? Yes/No I1�Yes, Claim Number? Street Address � �� Cit State� Zip Code--�� y ' �� Daytime Phone (�O�o�)SG°� ��Cell Phone (�o'��(2�'�� Evening Telephone ( Date of Accident/ Injury or Date Discovered Time /'_��<<In/pm . � hw ou Please state, in detail, what occurred (hnppened), and why you are submitting a cla�m. Please �ndicate why e r o y fee�he City of Saint Paul or its employees are involved and/or responsible for yo damages. 1- / � cl . o_ c . w ; � 1 ,. .- p. . � .e.--- � ' � — - �—�—'�—� �� ...v. �.., r '�� f . r .. �+ � : � '�..�'- � 7 Y , j . . ' ;� .- ' ... Please check the box(es) thatVmost closely represent the reason for completing this form: ❑ My vehicle was damaged in an accident ❑ My vehicle was damagecl during a tow ❑ My vehicle was damaged by a pothole or conditi�n of the street ❑ My vehicle was dama�;ed by_a plow ❑ My vehicle was wrongfully towed and/or ticketed �I was injured on City property ❑ Other type of property damage—please specify ❑ Other type of injury—please specify In order to process your claim you need to include copies of all annlicable 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 W1LL 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 damaged items • Injury claims: inedical bills, receipts � Photographs are always welcome to document and support your claim but will not be returned. � Pa�;e 1 of 2—Please c�mplete and return both pages of Claim Form - -�r ror►-c l�'��c,�G�c-P5 �`� � �� Cfll� �-�'o ��o� l��rG G � �� ✓1 G� 1�� °P ('iC��1C�'C4 E� /�/� �� s v�tr�r-�-h ��-E- IV I� I�'ailure to complete and return both pages will result in delay in the handling of your claim. All Claims- lease com lete this section Were there witnesses to the incident`? Yes N� Unknown (circle) Provide their names, addresses and telephone numbers: �►�l �� rl�'�'� _ _ --1 r Were the police or law enforcement called?„��`��Yes No Unknown (circle) If ycs, what dcpartment or agency? . Case#or report# Where did the accident or injury take p1ace? Provide street address,cross street, intersection, name of park or facility, clos st landmark, etc. Please be as detaile as possible�. If necessary, attach a diagram. 5 � u �rc c�^ �us-��l�wg�� t.(� Please indicat� the amount you ure seel:ing in compens�tion or w at you would like the City to do to resolve this claim to your satisfaction. �J'�0• �(�� d Vehicle Claims—please complete this section ❑ check box if this section does not <<nnly Your Vehicle: Year Make Model License Plate Number State Color Registered Owner Driver of Vehicle Area Damaged City Vehicle: Year Make Model License Plate Number State Color Driver of Vehicle(City Employee's Name) Area Damaged In'ur C;laims— �Ieasr com lete this section ❑ check box if this section does not a 1 How were you injured? , What art �) of yo�r b d were injured�,� � � 'a/�� . G �� 6 r . . - . �� ,, . ---°��- �, ;- I- ave you sought medical treatme t? �s No � � Planning to Seek Treatment(circle� � "�-'� '�..-.-�� When did you receive treatment? n'' � - �'7�Z. � , (provide date(s)) Name of Medical Provider(s):� �..� °� � r � Address . , , - - "' , , �' � .r� � ., - ; � �: r•°'�:Telephone ,-�.F _ , �� ,,_ . - Did you miss work as a result of your injury? Yes � �` � �' ��'� " ._ Wl�en d��l ya� rr�is5 wot-k? - -- - __ _ —_ EPrc�v�de date{5)� Name of your Employer: Address Telephone ❑ Check here if you are attaching more pages to this claim form. Number of additional pages By sig�ziitg this form,you are stating tlaat crll informatio�a you have provided is true and correct to tlae best of your knowledge. Unsigned forms will not be processed. Submitting a false claim can result in prosecutiofz. Date f'orm was completed I'rint the Name of the Person who Completed this Form: !/� L , � �'� Si�;nature of Person Making the Claim: � Revise� February 201 1 w ' . -- � � NOTICE OF CLAIM TORM to the City of Saint Paul, Minnesota Miiinesu�ct Slate Stutute 466.05.states tltut "...enerv person...�v/tn e lai�ns dcunrrtes fro�n anv munie�rpa/ih�....cha(I cau.se tn he pre.rentc�!to the goi�ernirtK budp o�'dte mur�icipalily wid�in 180�Icry.s after tlie«lleged lo.ss or injiny is discovered n rrotice strrtri�g d�e lime,p/ace,cuul c-ri•c•umstcutces tltereof,nnd die amount of cnntpensalirnt or otiter relic j'demanded.•• Please complete lhis form in its entirety by clearly typing or printing your answer to e�ch question. If more space is needed,attach additional sheets. I'lease note tht�t you will not be contacted by tele�hone to clariPy answers,so provide as much intormation as necessary to expiain 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 deprnding on the nature of your claim. This form must be signed,and both pages completed. If something does not apply,write`N/A'. SEND COMPLET�D I'ORM AND OTHER DOCUM�NTS TO: CITY CLERK, 15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102 First Name � Middle Initiul �Last Name�� Company or Business Name G � ��J�P��.lfl�1'�S�'��55�(�(� r Are You an Insurance Company? Yes/No If Yes, Claim Number? Street Address � �� City State T�O/� Zip Code � �ja ��47Evenin� Tele hone Daytime Phone ( )��_Cell Phone ( � p - Date of Accident/lnjury or Date Discovered Time ` � a /pm Please state, in detail, what oceurred (hnppened), and why you are submitting a claim. Please indicate why or how you fee] the City of Saint Paul or its employees are involved and/or responsible for your damages. � � � �� ' ! � t -� »� . . ;, , , .. , . , . - , . .< , ___ � %F � I � � i .� i *-� � . . I Please check the box(es) that most closely represent the Keason i'or completing this form: ❑ My vehicle was damaged in an accident ❑ My vehicle was damaged during a tow ❑ My vehicle was darr�abed by a nothole or conditi�n c�f the street � My vehicle wa1 damaged by a plow ❑ My vehicle was wrongfully towed and/or ticketed JZII was injured on City property ❑ Other type of Property damage—please specify C ❑ Other type of injury—please specify In order to process your claim you need to include copies of all annlicable 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 damaged items � Injury claiins: medical bills, receipts @ Photographs are always welcome to document and support your claim but will not be returned. Page 1 of 2—I'lease complete and return both pages of Claim Form � � ��-�h —�-�"c� �—I� 1 K. w�h��`� � s _ � � . a-��,�„� c� � -t-�� ,�--��--e_ �_� �n--� �� -� ✓��1� Failure to complete and return both pages will result in delay in the handling of your claim. All Claims—n��ase complete this section ,�5� Were there witnesses to the incident? Yes No Unknown (circle) ��'�� Provide thcir nam s, addresses and telephone numbers: �LIL°✓l(��°' �1.�� 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, tc Please be as detailed as ossible. If necessziry, attach a diagram. C� O '1�e rS� ��Z�' l�l r'Jr��!`e��i� f�� Please indicat.e the amounl you are seeking �n compe ,a io� n �lrivhat you would like the City to do to resolve this clai�n to your satisfaction. g�/� /'7r,� � �(�n�� C Vehicle Claims—please complete this sectior� ❑ check box if this section does not annly Your Vehicle: Year Make Model License Plate Number State Color Registered Owner Driver of Vehicle Area Damaged City Vehicle: Year Make Model License Plate Number State Color Driver of Vehicle(City Employee's 1Vame) �t�/ Area Damaged In'ur Claims— lease com lete this section ❑ check box if this tiection does not a 1 How were you injured? � r � What part(s) of your b dy wer in�red? ' � � _ �, i� ' � 4',� "{_ : ,�; ,- . . . . Have you sough medical treatment? s No Planning to Seet�Treatment�(circle) � � � � When did you receive treatmenl? �lil�'I�� l�'t! G L-rt (/P_(�`—f"�Z�S �eC�� (provide date(s)) Name of Medical Provi�ier(s): '� � ��f,�_�.� � � � --� ---�-R- � Address � � � ra� i' � f _ ,��. Telephone f E� �'��_ - '� r't°p Did you miss work as a resulf of your`injur . Yes L_`� `' - - When did you miss work? (provide date(s)) Name of your Ernployer: • Address Telephone � ❑ Check here if you are attaching more pages to this claim form. Number of additional pages � By signing tltis form,yoic are stating tliat ccll information you have provided is trice and correct to tlie best of yoz�r knowledge. Unsigned forms will not be processed. Submitting a false claim can reszslt in proseczctiore. Date f'orm was completed � Print the Name of the Person whu Completed this Form: � f Signature of Person Making the Claim: Revitiec3 February 201 I �