Curella, Anthony f��:���`��� R�C�I�I�9�
SEP 2 5 �jTICE OF CLAIM FORM to the City of Saint Paul, Minn6�8tr�5 2�1�+
C� 1 1Me��'th�tatute 466.05 states that"...every person...who claims damages from any municipality...shall cause��r�re e tc-�tli��
governing 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 sp�ce is
needed,attach additional sheets. Please note that you will not be contacted by telephone to clarit�answers,so provide as
much information as necessary to eacplain your claim,and the amount of com�nsation being requested. You will receive$
written acl�owledgement 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 dces 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 ar Middle Initial�Last Name ��<<-° � �a--
Company or Business Name 1M wtPorC�a ( (�-�� 1�7'►,es, �?'Y'
Are You an Insurance Company? Yes/�o If Yes,Claim Number?
Street Address�����1�'t" �� �-
City ���(Y.w� State �� Zip Code c�•sl� �
Daytime Phone���-,�3'3o Cell Phone�J�c -�_Evening Telephone(_� -
Date of Accidend Injury or Date Discovered Time am/pm
Please state,in detail,what occurred(happened),and why you aze submitting a claim.Please indicate why or how ou
feel e City of Saint Paul or its e pl yee are involved d/or respon 'ble for your dama es. C i�-� DF S�• C��-�-�
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Please check the box(es)that most closely represent the reason for completing this form: I
❑My vehicle was damaged in an accident ❑My vehicle was damaged during a tow
❑My vehicle was damaged by a pothole or condition o�'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
0 Other type of injury-please specify
In order to process yoar claim vou need to include couies of all aaolicable 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 WII..L 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 actuat 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 aze always welcome ta document and support your claim but will not be returned.
Page 1 of 2-Please complete and retarn both pages of Claim Form
Failure to complete and return both pages will result in delay in the handling of your claim.
All C7auns-nlease comnlete this section
Were there wimesses to the incident? Yes No ) Unknown (circle)
Provide their names,addresses and telephone numbe -�
Were the police or law enforcement called? Yes No Unl�own (circle)
If yes,what department or agency? Case#or report#
Where did the accident or injury take place`? Provide street adtlress,cross street,intersection,name of park or facility,
closest landmark,etc. Please be as detailed as possible. If necessary,attach a diagram.
Please indicate the amount you aze seekin in c nsation or what you would like the City to do to resolve this claim
to your satisfaction.������
Vehicie Clam�s-nle�e comnlete this section ❑check box if tlus section does not agplv
Your Vehicle: Year Make Model
License Plate Number State Color
Registered Owner
Driver of Vehicle
Area Damaged
City Vehicle: Yeaz Make Model
License Plate Number State Color
Driver of Vehicle{City Employee's Name)
Area Damaged
Iniu_r�Claims-please eomplete this section ❑check box if this secti.on does not av�lv
How were you in}ured?
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
0 Check here if you are attaching more pages ta this elaim form. Number of additional pages .
By signing this form,you are stating that all informahvn you have provirled is true and cvrrect to the best
of your knowledge. Unsigned forms will not be processed.
Submittirtg a faTse claim can result in proseeution. Date form was compieted �l� � � �
Print the Name of the Person who Compl this � m: �6 hL t,�re 1 L a�
I
Signature of Person Making the Claim:
Revised February 2011