Hilbert, Otis RECEIV�{�
, SEP �21Q1�t
NOTIC� OI' CLAIM I'ORM to the City of Saint Paul, Minne�,o�� ,�����
Minnr.sn�n Sla�e Stnlute 466.05 stntes N�nt "...enery persrni...who rinim.c dan�ages,fro�ri��rv municipnlity....chn11 cau.re(o he pre.se�rtcr!to the
�;overnirrg bot/V q/�dre mnrticipr�/ity wr�hi�t IcSO den�s after dre n!le�edloss or i�tjury is discovered cr nolice s[atirtg t/re lime,place,ancl
circrrmstcr�ices lherc of,and�he cintount of corrtpen.rcrlinn or other relief denrnnded.•'
Please complete this fi�rm in its entirety Uy clearly typing or printing your answer to each question. II'more space is
nceded,attach additional sheets. Please note th.�t you will not Ue 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
nuture of your claim. This t'orm must be signed,and both pages completed. If something does not<ipply,write `N/A'.
SEND COMPLET�D FORM AND OTHER DOCUM�NTS TO: CITY CLERK,
15 W�ST KI:LLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
r' � �-� �I�b
First Name � ,�'y'�S Middle Initial �- Last Name ��T
Company �r I3usiness Name 1�K �� rn yy�O v�4. �d h Q O �S D�f�/�'7"l o t�1
�re You an Insurance Company? Yes/No If Yes, Claim Number?
Street Address 'q`1� � �K�/��(
City �, /�t 1J�li C � 1 _ State I� I�dJ N�S O C�J i�' Zip Code �5� I 1 (0
i
Daytime Phone (��)���Cell Phone (�) - Evening Telephone (�)���
Date of Accident/Injury or Date Discovered /Y `/Z l ����i Time am/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 i volved and/or res onsible for your damages.
�"'`N� C;�av�tiG�o� vV►�O �Zr�1.�D �t�� t�� 51�w'/-��K Ann,�G�t�
Ou� IJkNVN S�Ri�KI.Ef� S`(Si rM D�.( �UfZ 51�E O� INE Si�EW�-L�< ,
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Please check the box(es) that most closely represent the reason far completing this form:
❑ My vehicle was damaged in an accident ❑ My vehicle was damaged du►-ing 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 towec� and/or ticketed ❑ I was in�u_recl on City property_ _
-- --
I,$Other tyPe of proPerty damage—please specify 1.h+rvN SPR�N►�1.G2 s�S7�1� I
❑ Other type of injury—please specify ,
In order to process your claim vou 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 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: ]egible 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 re�urned.
Page 1 of 2—Please complete and return both pages of Claim I'orm
Failure to complete and return both pages will result in dclay in the hundling of your cl�im.
All Claims-pleasc complctc this scction
Were thet-e witnesses to the incident? es No Unknown (circle)
Provide thcir names, • ddresses and telc hone numb rs: W►N 1 F��Dp
°'1 t &� ��ti1 � �/�l.. SI co — I - q - '1 I
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>
closes landmark, ete. Please be as detailed as possible. If necessv�y, attach a cliagram.
� � +�`nl xF h�i 1�1�1► �� ��r►,e�� i v�Y �►- /h 1J ►
Please indicale the amau t you are��king in cotnpensation or what you woulcl like the City to do to resolve tl�is claim
to your satisfaction. � �t���_, -
�
V�t�icic �t��im�� t��S'r���n�f�t��t�n sectiur� �� - - ❑e�ieekt�c��x-fi€tkis�eetycxirt}Het_��c�t st�t�F�
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
►njur�Claims pltase compl�te this section ❑ chech box if this section docs not �ipplY
How were you injured?
What p�irt(s)of your body were injured?
Have you sought medical treatment? Yes No Planni��g to Seek Treatment (circle)
When did you receive U-eatment? (provide date(s))
� Name oi'Medical Provider(s):
Address Telephone
Dicl you miss work as a resuit of your injury? Yes No
When dicl you miss work? (provide date(s))
Name of your Employer: _
'�---— ------ --— - --- — - _-- -- -
�tis--- _ - __ - 'I'e7ephone -
�Check here if you are attaching mot-e pages to tliis claim form. Number of additional pages � .
�
� I3y sigfai�lg tleis form,you are stating t/iat call informatiofz you Itave Provided is trrce aitd correct to t/ie best
of your k�towledge. Ufisigned for�ns will not be processed.
Srebmitting a false clairn caft result in prosecutio�z. llate f'orm was completed r �l��'v ST 2�1 , ao�d
Print the Name of the Person who Completed this Form: �T� S �� ���- �� i2 �
Si�nature of'Person Makin� the Claim: � Y`i/�� � W'�� ��0 /�SO C �Y�lfl�
i R
Itevitic�i Fcbruary 201 I `�Y S ,� �� ,�S ���/�S U��V`
� LMS Irrigation, Inc. � �nvoice
P.o. BoX 29s �ho,�. = �5�- ��c� - 75b�.
Date Invoice#
Forest Lake, MN 55025
8/27/2014 16579
Bill To
PARKWAY COMMONS
1941 FORD PARKWAY
ST PA[JL,MN 55116
P.O. No. Terms Project
Due on receipt
Quantity Description Rate Amount
3.5 Service 3.5 hours of labor 81.50 285.25
14 CLAMP 1.95 27.30T
7 1804 SPRAY I-�AD RAIN BIRD 14.95 104.65T
3 1.25"POLY FITTING 5.95 17.85T
3 1"OR SMALLER POLY FITTING 3.95 11.SST
Damage done by sidewalk installation.This is the damage on the building side of the
sidewalk.
Sales Ta�c 7.625% 12.33
Total $459.23