Newman, Kimberly ����e���
SEP 2 2 2Q1�t OTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipality...shall ca��se to be presented to the
��"�'� �`��aa��body of the municipality within 180 days after the alleged loss or injury is discovered a notice stating the time,place,and
circumstances thereof,and the amount of compensation 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 f Middle Initial�Last Name /U-C_�IVt�� '
Company or Business Name ��-
Are You an Insurance Gompany? Yes/�o If Yes,Claim Number? �
Street Address
City State Zip Code
Da ime Phone ���- �� Cell Phone �� �� �� Evenin Tele hone
y�' (C� (C�).�-� g p ( ) �'c�-0
Date of Accident/Injury or Date Discovered q• ��° ���� Time � ' a0 am/�
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. � r
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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 �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 apulicable 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
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-ulease complete this section
Were there witnesses to the incident? Yes No Unknown (circle)
Provide their names, addresses and te ephone numbers:
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Were the police or law enforcement called? Yes No 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, ame of park or facility,
closest landmark,etc. Please be as detailed as possible. If necessary, attach a d'agram. � O
�CJ'OS `- `�. � r r � .t�
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Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction.
Vehicle Claims-please complete this section ❑ check box if this section does not applv
Your Vehicle: Year MakP Mode1
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'u Claims- lease com lete this section ���� ���f'� ' ❑ heck box if this ection does not a 1
How were you in'ured? r � • � 1q
��t cl�,a � f o�c� w fL� r � . � � ,. L
What part(s)of your body ere injur d? /� � ���� c����
USIv �f-� �(�d�Q S �
Have you sought medical treatment? Yes No Planning to Seek Treatment(cir le ��ji'7
When did you receive treatment? Vt G f �ovi e ate(s))
Name of Medical Provider(s): N .
Address . •�� �`�3 � , v I -` 6 3 Telephone��'d d. S-.3 � . l(���
Did you miss work as a result of your injury? Yes o
When did you miss work? �7 � (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 form,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 �- �� ao1�
Print the Name of the Person who Completed his Form: J l
Signature of Person Making the Claim:
Revised February 2011
`..�-- Pa,�e 1 of'3
�I����--��e�����
A�BOTT NORTHW�STERN EMERGEt�CY dEPART�#ENT
$(?0 E 28TH ST
MiNNEAPOLIS MN 55407
Ph��?� 612-863-40Q0
IMiPOR�'ANT: You were examined and treated tcaday on an emergency basis. This was not a substitute for,
or an effort to provide, compf€te medica!care. In�most cases, you must iet yoWr doctor check yt�u again. Tell`
your doctor about any new or lasting problems. A)copy of the record is availabie to the staff tha#will provide
foilow-up care. We cannot recognize and treat a!I injuries or ilinesses m �ne Em��gency f�epartment visit. if
you had spee±al #ests, such as EKG s or X-Rays, we w�l! tevi�w them again within 24 h�urs. We wi11 caH you af
there aee any r.ew suggestic�r�s.
After you le�ve,you should foNow the instructior�s below. if you do n�t understand any ot these instruc€�ns
€�r�ave�ny�q�estions andior cancerns we would be hapPY to assist yau. t7r you may cati y�ur health ca�e
pravid�r for further information.
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In a couple of weeks you may receive a survey in he mail. We value your feedback and hope you wi#I take
the time to complete and retum it. We feel it is ve�y important to manitor how well every area of the hospital is
perfor�ing from our patienYs perspective.
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Your diagnases were FAl.L , WRIST SRRAIN , KI�E CCtNTUSIQN , and KNEE ABRASION .
You were seen by Horejsi, Thomas G, MD: i
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09/18/14 1427 137t71 mmHg
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Address St Clair Ave& S Saratoga St
�'� :�� � St Clair Ave&S Saratoga St
St Paul, MN 55105
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