Rothschild, Emily . �� �;�. � \
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NQTICE O�' CLAIM FORM �o the Ci� af Saint Paui, Minnesota�����`� ��_��`�-c:::,�
Minnesora Szate Szasute 466.0�stcues that "...even person_..who claims damages jrom arz�-municipatit}�...shall ca�cse ro be presented to the
governirzg boai-o,r tlze munictpaiin wifnm 180 days after the aleege�toss o-iniurp is discoverec a notice statirzg the teme,place,and
circumstan,^,es tnereoj.and th�mnount of comDensarior.nr otner reiie;'d.emanded.°
Please complete this form in its entaretF by clearif typing or prini�ing vour answer to eacb 4uesbon If more spcace is
needed.attach addifional sheets. Please note that von w11 not be contacted b�telephone to c2arife answers,so provide as
mnch informabon as necessarF to egplain vour claim,and the amount of eompensation beiug reguested. You will receive a
written acknowledgement once ponr form is received. The process can take np to ten weeks or louger depending on the
natare of vonr elaim. Thss form must be sgned,and both ga�es eompleted. If something does not app��,write`N/A'.
SE'V� COMPLETED FORM A.�TD OTHER D4CUN�hTTS TO: CITY CLERK,
15 RrEST KELLOGG BLVD, 310 CITY gALL, S��I' PAUL, NL�' SjIQ2
� `� Middle In.itial�Last?�ame �o`"�SC."\� `�
First N ame ^^�
Company or Business Na.me
.4re You an Iusurance Comgany? Yes vo If Yes,Claim Number^
StreetAddress l� 1 g SAu-� c�'LS ���'
Cirn � �`'-'` State 1M\r� � Zip Code�_�� �
I?aytime Phone(1��_� �C CeIl Phone(b�)3�-s°�� Evenin�Telephone(�'d-
Date of AccidenU Injury or I?ate Discovered ��' °��r (� Time � �`pm
Please state;in detaii, what occuffed(happened), and why you are submitting a claim.Please indicate why or how you
teel the City of Saint Paul or its emPloyees are involved and/or responsible f your dama.ges.
_'Cti1�e. �� ro c..`r' S C�
s„J ` �- � .S v��.
Please check the box(es) that most closely represent the reason for completina this form:
� My vehicle was dama�ed in an accident ❑ My vehicle was damaged during a tow
❑ Iviy vehicle was damaged by a pothole or connition of the street � My vehicle was damaaed by a plow
❑ My vehicle was wron6fully towed and/or ticketed (� n,,-❑ I was injvred on City propeny
„�Other type of properly damage-please specify S`Y' � ��-'�"'� S�^�`�-��"�'
D Other type of injury-please specify
In order to process your claim vov need to inciude covies of ail appticable documents.
For the clai.ms types listed below,please be sure to include the documents indicated or it will delay the handlin�of
vour c;aim.. Documents R'LLL NOT be returned and become the propertv of the City. Yon are encouraged to keep a
coPS�for yourself before submitti.ng your claim form.
O Property dama�e claims to a vehicle: two estimates for the regairs to your vehicle if the da�age exceeds
$540.OQ; o:the actua?bills and/or receipts for the regairs
O Towing claims: legible copies of any ticket issued and a copy of the impound lot receipt
O Other property damage claims: two regair estimates if the damage exceeas �SO�.OQ; or the actual bills
and/o:receig�for the repairs; detailed Iist of damaaed items
O Injur�� ciaims: medical bi11s,receipts
O Photo�aphs are always welcome to document and support your claim but will not be returned.
Page 1 of 2-Please compleir.e and return both gages of Claun Form
Failtu-e to eomplete and return both g�es will res2ilt in deia�°in the handiinc of your e�aim.
A11 CFaims-piease complete tlnis seetion
Were there witnesses to the incident? Yes No � (circle)
Provide their names, andresses and telephone numbe:s:
�v�re the poiice or�aa>enforcement calied? Yes � Un�own (circle)
Lt ves, what department or agency? Case# or report�
�'here aid the ac�ident or injur��take piace? ProvidP street address, cross s�eet intersectio�,uame oi par�o_iacilit�;
ciQSest 1and�arb, eL�. Piease be as detailed as possioie. li necessary. attacb ap',a��am. �
t`l 1 $ S a.�..�.c}2�.s � � . �- m �' . S 5 I (
Piease indica�.the a.mount you are se��in�in compensation o:whaz you would Iike the Cit��to do to resolve this claim
to vour satis�action.
. � �
Vehicle C�aims-v)ease complete this secfaon / - � ❑ check box if this section does not apnlv
Your Vehicie: Year Make Model
Licease Plate Number State Color
Registered Owner
I>river of Vehicle
.Area I?amaged
City Vehicle: Year Make 2v�odel
License Piate Number State Color
Driver of Vehicle(Ciry Employee's Name)
Area I?a�aged
Iniur� Ctaims-please complete this section /" JQ' ❑ check box if this section does not ap�l��
How were you injured?
What part(s)of your body were injured?
Have you sought medical�ea�ent? Yes No Planning to Seek Treatment(circle)
VrThen did you receive treatment? (provide date(s))
I�ame 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
"�Eheck here if von are attaching more pages to this c�aim form. Number of additional gages � .
By szgning this form,you are stating that all information you have provided is true and correct to the best
of your knowledge. L%nsigned forms will not be processed.
Submitting a false claim can result in prosecution. I?ate form was compSet �U - � '- �
� � `
Print the Rame of the Person who Compjeted this Form: ��M� � v� SC
Si�ature of Person Makia�tbe C�aim: ` ^ \
Revised Febniary 201 l
Invoice
I
� �r� 11"Clgat(On Date Invoice#
. , 10/1/2014 3092
Lawr� Spr�nklers aT T T�
SYNCE 1974
B'ii To 11031 Vincent Avenue So.
Emily Rothschild and Sue Brix Bloomington, MN 55431
1718 Saunders Avenue
st.raui,Mrr ssi i6 952.888.3627
N►1AI�Il
Due Date
Due on recei t 10/16/2014
Quantity Description Rate Amount
1 T&M SERVICE CALL 75.00 75.00
-WORK ORDER 1907
OFFICE COMMENTS:
- THIS WAS TO REPAIR THE DAMAGE THE CITY CAUSED WHEN THEY
EXPANDED THE SIDEWALK.
TECH COMMENTS:
-REPLACED 3 ROTORS ALONG SIDEWALK,IN 2 ZONES.
3 Hunter PGP Geaz Driven Sprinkler Head 23.95 71.85
3 Funy pipe set 3.95 11.85
I Clamp(s) 0.25 0.25
1 End up 1.79 1.79
Total $160.�4
-Make checks payable to: Mr.Rain Irrigation
-Please write invoice number on check
-Please return payment to: 11031 Vincent Ave S.
Bloomington,MN 55431 -Remit payment by due date to avoid late charges.
www.mrraininigation.com