Gomez, Maria R����'�°��
NOTICE OF CLAIM FORM to the City of Saint Paul, Minnes�ota� ���4
Minnesota State Statute 466.05 states that"...eve erson...who claims dama es om an munici ali shall cause o bi�resen��o���
rY P 8 .�'' Y P �Y... p
governing body of the municipality within 180 days after the alleged loss or injury rs discovered a notice stating the rime,place,and
circumstances thereof,and the amount of compensation or other relief demanded."
Please complete t6is form in its entirety by dearly 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 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 I��A�1/7�.- Middle Initial�� Last Name ��'I/l-e�
Company or Business Name
Are You an Insurance Company? Yes/ o ff Yes,Claim Number? /�
Street Address 1�`"i ���
City �� ��' State �1� Zip Code SS� l9-0
Daytune Phone(_) - Cell Phone(���U 1 Evening Telephone( ) -
Date of Accident/Injury or Date Discovered 7i7i1 �.0� _ Time � am�
Please state,in detail,what occurred(happened),and why you are submitting a claim.Please indicate why or w you
feel,th�Cixy of Saint au or its employees az involved d/or responsib �or yqur ama es.
.�� � �'
,
Please check the box(es)that most ciosely 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 o�the street ❑ My vehicle was damaged by a plow
O My vehicle was wrongfully towed and/or ticketed ❑ was injured on City property
�,Other type of properly damage-please specify V� Q.UrVI �'���
❑ Other type of injury-please specify
In order to process your claim vou need to include copies of all aanlicable 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 andlor 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 clauns: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
�Photographs aze 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 resWt in delay in the handling of your claim.
AU Claims—nlease comt�ete this section
Were there witnesses to the incident? Yes Ny� Unknown (circle)
Provide their names,addresses and telephone numbers:
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 pazk or facility,
closest k,et . Please be as de ed as �SSibl If necess�ryT�ttac� gr�.
�I���s �, -- ��,��r,�r�'°,n �-� 1�-�- ��� �
Please indicate the amo t you aze seeldng in c nsa 'on or wha you wo ¢lik the i to do to reso�e tlus cl '
to your satisfaction. �"
/ u��,
,
Vehiele Claims—please complete this section ❑ check box if this section does not anplv
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 '
Insiurv Claims alease comnlete this section ❑check box if this secrion does not avplv
How were you injured?
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 injuty? Yes No
When did you miss work? � (provide date(s))
Name of your Employer:
Address Telephone
C eck here if yau 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.
' can result in rosecution. Date form was completed �JDI���
Submuting a false claim p
Print We Name of the Person who Complet orm: ' � � �
Signature of Person Mal�ng the Claim:
Revised February 2011
.i ��, - �
4 �C *�y : g _ �'s� ��� , x �"'�
:.`.^ e �1 � � °�" r,,, 9 ,
r«�
- - � �'�f�x� ��i G �I � � �= sd �i� �, m..
� �_4� ���� � ��19� T .E ,� :� _ . +�.w��«� a�e' ,rat . . r �{ •
.... - . ._-� �,` -',`
B't 7 c � ^ � �'� �`'fIR,.'1A�:' �, � _ � �
. = a� .�3ii+�� �+ , *��
�. . �, y r , '����•.
- � sa _ s i �
�
:�y �;,..,�w
\� ��, �� '�y4, f '� � � ,�� a��,� ;;1
�+,. �. � y * .
II � * IRi e y� .;1=�1! il-
� ` . 1 � � ��� � ` '� y, �+1 \{ l( j{ ' k` -`l �` .
' )• ,i t i���F� � ���lk, -�� t 1� � . � �i� .
, � ���� ;� � � � � ��.� �� I I i � ;' �: . �
— �'— — — — — — �'� '�� � � � t'"� 4 � + -"�l � � v�" ,
�� � �
I �
� �
��.nf. /.? ;i•>
+ •
, �„ _' ..
-- I� �� A�' _. ��j.,�},�.�,�..- .
.. � � ����� +���'� ,
*����. , .. nc« ++,�s!�M'` '_�'. .- .