The URL can be used to link to this page

Poepping, Joseph NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota Minnesota State Stntute 466.05 states that"...everv person...who claims damages.from anv municipaliry...shall eause to be presented to the governing bodv of the municipalitv within 180 days afier the a!leged loss or injirrv rs disco>>ered a notice stating the time,ptace,and circumstance.r therenf,and the amount of cnmpensation or other relief demanded." Please complete this form in its entirety by clearly typi�g 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 infurmation as necessary to explain yuur claim,and the amount uf compensatiun being requested. You will receive a written acknowledgement unce yuur furm is received. The prucess can take up tu ten weeks ur lunger 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�_� Middle Initial�Last Name � �v� RECEIVED Company or Business Name �� 201� Are You an Insurance Company? Yes/� If Yes,Claim Number? LERK Street Address ��Q � �;� Q.�_ �o+�-`f� City /�in��5 State �,�(� Zip Code ss�� Daytime Phone(W r2)�7-��Cell Phone(��L-f7�D F.�e}g-Telephone(�)a�3S>o'Z Date of Accidend Inj ury or Date Discovered � Time �dU am/� Please state,in detail, what occurred(happened), and why you are submitting a claim. Please indicate why ur how you feel the City of Saint Paul or its employees are involved znd/or res nsible for your damages. : ` i dveK b , � 1 u, � k � r.. ; f , � � � �� { � r+c �� k •-f-c, -td.� � .1� �,,� :-v61r,� � . 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 ot�the street ❑ My vehicle was damaged by a plow My vehicle was wrongfully towed and/or ticketed ❑ I was injured on City property O Other type of property damage—please specify ❑ Other type of injury—please snecify_ 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 beaome the property of the City. You are encouraged to keep a copy for yourself before submitting your claim form. i O Property damage claims to a vehicle: two esti�nates 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—alease comnlete this section Were there witnesses to the incident? es No Unknown (circle) n � Provide their names,addresses nd telephon numbers: /'l_i � � }� -f�•u' t'at,l�O� �.-, i' a � Were the police or law enforcement called? Yes � Unknown (circle) I�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, closest landmark,etc. Please be as deta�led as possible. If necessary,attach a diagram.�1 P�,1�.n ,,.., �x�'"�� C')�{'� � CL�L � � r�lS�I f �� . �-�te, � ��-t � �`- -.c. � � c-. Please indicate the amount you ar�seelcing in compensation or what you would like the City to do to resolve this claim , to yqur satisfaction. �f("1 :� "%l�-� `rc-l��.c l�.`� �, �.,�� r`t,�.��✓c� �� r --��,�u._. a.:��_�Yl— 1��-� re_ -� 5-1 �c�� 1 e ,s s� r , Vehicle Claims—please complete this section IZSlcheck box if this section does not applv 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 Iniurv Claims—please complete this section �check box if this section does not applv How were you injured? What part(s)of your body were injured? I 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 �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 proeessed. Submitting a false clair� can result ire prosecution. Date form was completed � � �Lj Print the Name of the Person who Completed this Form: � � J v � /� ?/? � �Signature of Person Making the Claim: � i - Revised February 2011 % �r '� % � Gmail - Raymond& Energy Park Page 1 of 1 . �� Joe Poepping <joepoepping@gmail.com> btl��;)t1,��i .. Raymond & Energy Park 1 message Joe Poepping <joepoepping@gmail.com> Thu, Apr 10, 2014 at 8:09 AM To: potholes@ci.stpaul.mn.us Hi, The following areas are in need of pothole repair. They have been previously repaired and have now reopened in all their glory. Intersection of Raymond and Energy Park Raymond befinreen energy park and como (both lanes) Pelham between Doane ave and Otis avenue (intersection of Pelham and Otis was previously repaired) west bound lane and bike lane on Como between Raymond and scudder Thank You for your great work. Joe Poepping 651-632-3512 https://mail.google.com/mail/u/0/?ui=2&ik=2eb655a1 fc&view=pt&q=potholes%40ci.stpaul... 9/3/2014 ��-��,�' , �� The Hub, U of M Bike Cerrter 401 SE Oak St Minneapolis, MN 55414 612-624-9468 Sales Receipt 9/2/2014 4:30 PM Ticket: 220000236276 Register: Oak R Employee: BenE Customer: Joe Poepping 612-437-9780 !'�. Price Work order #�43008, tt�m: track wheel black black Inr:,tall c�g; loc�kring, and freewN�eel on new �vh�el. Cust�mer will �aick up tomorrow 9/3/14. OUT: New freewheel installed. Custorner decided to use cog and lockring on another bike. -BenE Remove/l nstall 1 $7.00 Cass/Freewheel RR Formula Fixed/Free/ 1 $90,00 T Black Subtotal $97.00� Tax $90.00 @ 7,775% $7.U0 Total $104.00 Payments 1 CreditlDebit Card Payment $104.00 Card Num: 7104 Type: Visa Cardholder: POEPPING, JOSEPH MICHAEL Entry: Stivipe Approval: 035010 ID: 997830824 Find The Hub Bike Co-ap's Return and Exchange Pnlicy at: thehubbikecoop.org/returns If you have further questions please email thehub�trrehubbikecoop biz, call us,ior visit during business hours. Thank You Joe Poe��in�! _ _ __ __�4��i i ii,i,ii�ii ii��i iii, ii i iii ii(I 2 3b_�b4 rt1'j� r; �-�h�� ---�� a � z� �