The URL can be used to link to this page

Johnson, Melissa (2) � � �� ,�� - � __ - -- _� � �, . - � : ` SL�P �5 2014 NOTIC� OF CLAIM rORM to the City of Saint Paul, M�q�.e�.C�� Minnesuta Stnle Suttute 466.05 state.r�hnt " ...eve��v persoi�...�vl�n c•laims dcu�ra,�e.c/i�on�cutv��rruiicipalih�....shuR cuuse tn be pre.senteaf tn!he go��ernirtg botly qf d�e m�inic�rpa/ity withi�i !80 duvs ttfter dre u//e�ed/ns.r or rnjury is discovered a r�otice stati�ig d�e time,p/ace.��nd circumstances tHereof,an�!d�e anrnunt of compens�rtinn or uther relic,/'demnnded.•. Please complete this form in its entirety by clearly typing or printin�your answer to e�ch question. If more sp�ce is nceded,attach additional sheets. Please note th:tt 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 f'orm is received. The process can take up to ten weeks or longer depending on the nuture of your claim. This form must be signed,and both puges completed. If something does not apply,write`N/A'. SEND COMPLETED FORM AND OTHER DOCUM�NTS TO: CITY CLERK, 1_5 WEST K�LLOGG BLVI), 310 CITY HALL, SAINT PAUL, MN 55102 First 1Vume ��<-'�'% Middle Initial�Last N�une �•�—�� Company or Business Name �'(� � � _f}� _" �auL. Nlrl 5 S�/O� Are You an Insurance Company? Yes/No Ii�Yes, Claim Number? Street Address � �� City � State Zip Code--��1/� Daytime Phone (�DI o�)��'a ��7 Cell Phone (�� S�P��4 Evening Telephone ( Date of Accident/lnjury or Date Discovered Time /��_am/�m_ Ple�ise state, in detail, what occurred (happened), 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 yo damages. 1� / i Gl a_ C . � < .. � �_. . .,. , _ ,.. � ,. � ; � � , : _ , '. . ; ;. „ .._ __ _ � � , ° . _. _ _� Please check the box(es) that'�nost 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 conditi��n of the �treet ❑ My vehi�le �as dama�ed_by_�i 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 y^�� ^PPd to include copies of all applicable documents. For the claims types listed below, ple�►se 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 bilis and/or receipts for the repairs; detailed list of damaged items � Injury claims: medical bills, receipts � 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 G r ,� - ` �+ v C� --�f' � (� jG-�+,rC. �ror�. ��,��c.PS �� ( h�� o � ��{ � <<�I N�'�K �s �tDr--�-h ��-+-�,-2 c� 1 V1�►'��r' �3<<�.�� 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 ro the incident'? Yes N� Unknown (circle) Provide their names, addresses and telephone nwnbers: � (i� ' --? � Were the police or law enforcement called:�P��Yes No Unknown (circle) If yes, what dcpartment or agency? Case#or report# Where did the accident or injury take Place'? 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 , Gl �1'"i u�'�' "+"'lrC`�`l�-r`gi � Please indicate the amount you are seel.ing in compens�tioi� or w at you would like the City to do to resolve this claim to your satisfaction. �J'��• �� r� '�'�tG� Vehicle Claims-please complete this section ❑ check box if this section doeti not apply 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 Claims- lease 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 injui-ed� � � � � '�G-wFt Gi � (� 6 , . .- �r:�� ._..-- � � ;. �ave you sought medical treatme t? �s No ` ' Planning to Seek Treatment(c�rcle� � �` `-'° �_�� When did you receive treatinent? !Y' . �'7�Z. � , / (provide date(s)) ,-, Name of Medical Provider(s):� � ��'�_ � , ° _ � � , _ Address - � �'� �' '�. , , '� � � �� `.., , - .� ,;:'�Telephone - � _" -��' � �- Dicl you iniss work as a result of your injury? � � Yes o �� ` � �' ��-'�� W#�€.n d�dyo� �is�wc3�-�2 —_ _ _ - --- _ Eprewidc date-�5)3 Name of your Employer: AcJclress Telephone ❑ Check here if you are attaching more pages to this claim form. Number of additional pages 13y signiiig this form,you are stating tjiat c�ll inforrr�cztiora you have provided is true and correct to tlze best of your knowledge. Unsigned forms will not be processed. Submitting a false claim can resi�lt in prosecictio�z. Date f'orm was completed Yrint the Name of the Person who Completed this Form: {�� '� Signature of'Person Making the Claim: {� Kevised February 201 1 I , � 9 .. NOTIC� OI' CLAIM I'ORM to the City of Saint Paul, Minnesota Minnesotu Slate Stutute 466.05.rtnte.s!l�cit "...every persun...�vl�u c•Inints da�ila�e.s/i�om mtv�'n�uucipnllry...shn!l cu�e�•e tn he pres•e�rted to t{ie �uver�tirt�budy u/�!lte mtuticipnlity wid�iii JfiO dcrv.r trfter tlre nlle�ed lo.��s or iitju�y is discovered n rrofice statuir;[he lime,plare,uncl �rrc�umsruiTCes tlrerenf;ancl the a�r�ount of c:•ompen.cutinn or other relie/�derrznnded.., I'lease complete this f'orm in its entirety by clearly typing or printing your answer to each c�uestion. 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 amoimt of compensation being requested. You will receive a written�cknowled�!ement 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 something does not apply,write `N/A'. SEND COMPLETED FORM AND OTHER DOCUM�NTS TO: CITY CLERK, 15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102 First Name � Middle Initiul �Last Name� �� G .`,j�al�S�i�l�e I./n,1�s�"� ��55�pc� Company or Business Name --� b�- , Are You an Insurance Company? Yes/No If Yes, Claim Number? Street Address � �� City State �--�� Zip Code � Daytime Phone ( )��Cell Phon�(!� ��4�Evening Telephone - Date of Accident/ Injury or Date Discovered Time ` � a /pm 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. � , -,°i-�" --�� . ,� � F .'� , , , , , _. ; , _ _t , . , � . �8 . I ' ..... f ib ' , � f.�.� ��. Please check the box(es)that most closely represent the �-eason t'or completing this form: 0 My vehicle was damaged in an accident ❑ My vehicle was damaged dw�ing a tow ❑ My vehicle was damabed by a pothole or conditi�n c�f the streel ❑ My vehicle wa�damaged 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 apPlicable 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 d<image claims to a vehicle:: two estimates 1�or 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: medical bills, receipts @ Photographs are always welcome to documem and support your claim but will not be returned. Page 1 of 2—Please complete and return both pages of Claim Form � (��'1 —{��-G��'(� i� ��- w�l C��x�`�� /V� �5 � � . a�r a-,� �„r�„� � c� --t��- ��c-t�►--e_ �=v�n -ti� �r'� `� L°� l�� 1�'ailure to complete and return both pages wiil result in delay in the handling of your claim. All Claims- nlease complete this section ,.,�,�5 Were there witnesses to the incident? � Yes No � �U�nknown � �ircle) ��'��.. � Provide their na�n s, addresses and telephone numbers: � Z,.° '�°� C Were the police or 1�►w 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 necessary, attach a diagram. G�t O '1�/ � �r'��' t�l rl��(�"� � � '�-w y y Please indicate the amoun ou are seel:in �n com en,a �on hat ou would like the Cit to do to resolve this claim to your satisfaction. /�1 /7�-r-� ��1� �1��-l��(',H�)C C _��_°�� ( Vehicle Claims- please complete this section � ❑ check box if this section does not anply Your Vehicle: Year Make Mode) 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 Claims- lease com lete this section ❑ check box if this section does not a 1 How were you injured'? r . W at part(s)of your b�Q dy wer in�red? ' R � / ;- I� � - - ..- ' � �� '� f .,�r Have you sough medical treatment? s No P anning to See�.Treattnent�(circle) � � � When did you receive treatment? l�1r �Zv�F ("'(./Yl I G (� �/P�-�"-f��5 ��,r' (provide date(s)) Name oi'Medical Provi�ier/s): � ,p�' �`� �°�� l � w �—y� �-f �f—T'i,�Cit��i--pd!F i °� C Address "'� . �_, -. �.. ,, . ' � � ;. d ��+ �.- , , - . ,�� Telephone �'.- ��` ,.,�' c �' � ��.,�,. � � � ----�P� :-� Did you miss work as a resul�of yourinjur . � � Yes � � o 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 this form,you are stating tJtat ccll information yorc have provided is true and correct to the best of your knowledge. Uizsigned forms will not be processed. Submitting a false claim can reszclt in prosecutio�z. Date form was completed Print the Name of the Person who Completed this Form: � /� . Si�;nature of'Person Making the Claim: ' Revised February 201 1