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Ortega, Rodolfo NOTICE 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 cause to be presented to the 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 answers to each question. If you have additional documentation you may add those documents to your submission. You will not be contacted by telephone unless clarification is needed. The claim process for investigations can take upwards of four (4) weeks. This form must be signed, dated with all applicable sections completed. Submission is to the Saint Paul https://www.stpaul.gov/departments/city-clerkCity Clerk’s Office. You may < mailto:cityclerk@ci.stpaul.mn.usemail, fax (651-266-8574) or mail the form. Mailing address is “Saint Paul City Clerk, 15 West Kellogg Blvd., Suite 310, Saint Paul, MN 55102” Individuals: First Name ____RODOLFO________________ Last Name ___ORTEGA_____________________ Please Indicate Your Pronouns: She/ Her/Hers ______ He/Him/His __HE___ They/ Them/Theirs _______ Company or Business Name: ______________________________________________________________________________ Is this claim being made by an Insurance Company? ____ If yes, what is your Claim/File Number?: _____________________ Is this claim being made by an Attorney? _________ If yes, what is your File Number? _______________________________ If yes, then provide your Insured’s/ Client’s Name ____________________________________________________________ </ Street Address: ___1392 5TH ST________________________________________________________________________________ City: _______SAINT PAUL____________________________ State ___MN____________ Zip Code _______55106______ Daytime/Work Phone _______________________________ Cell Phone ____651-366-0022________________________ Date of Incident or Date Discovered (Must complete) ____01-18-2023________________Time ____3 PM_____________ Please state, in detail, what happened that prompted you to file a Notice of Claim Form. ___THE CITY WAS PLOWING THE STREETSAND THEY HIT MY VEHICLE WHILE IT WAS PARKED. Please state why or how you feel the City of Saint Paul is responsible for your Damages? ____MY VEHICLE WAS HIT BY A PLOW TRUCK THAT BELONGS TO THE CITY__________________________ Please check the reason that most closely describes the reason for your submitting a claim. Please note the documents that will need to be provided with your completed form. Photographs will be accepted. All documents submitted become the property of the City of Saint Paul and shall not be returned.< _X_ Automobile damage from a motor vehicle accident: please provide two estimates for repairs or actual bill that has been paid. ___ Automobile damage from a street defect or pothole : please provide two estimates for repairs or actual bill that has been paid. ___Automobile was towed and may or may not have sustained damage: please provide copy of towing ticket (if available), receipt from Impound Lot, and two estimates for repairs or actual bill that has been paid. ___Snow Emergency: please provide copy of towing ticket (if available), receipt from Impound Lot, and two estimates for repairs or actual bill that has been paid. ___Property damage: please provide two estimates for repairs or actual bill that has been paid. ___You were injured during a motor vehicle accident: please provide police report number, details about injury. ___You were injured in the City of Saint Paul: please provide police report number, witnesses and details about injury. This section must be completed for all claims. Is there a police report for this incident? Yes No If yes, please provide the police report case number ___23-009-879_____ Revised December 2021 Notice of Claim Form, page two. Failure to complete and return both pages will result in delays. If yes, what law enforcement agency responded? ____SAINT PAUL POLICE DEPARTMENT___________________ Where did the incident take place? Please provide a street address, intersection or name of City park or facility. _____1392 5TH ST SAINT PAUL MN 55106 ___________________________________________________________________ What would you like to see happen to resolve this claim to your satisfaction? ______GET MY CAR FIX __________________________________ Were there witnesses to this incident? Please provide names and contact phone numbers. _____NO_____________________ ________________________________________________________________________________________________________ For property damage claims, including vehicle accidents. Your vehicle’s information: Year ___2009__Make __CHEVY________ Model __SUBURBAN________ Color __BLACK______________ License Plate # _______ELG 151__________ State vehicle is registered in _________MINNESOTA___________ Registered owner of vehicle __RODOLFO ORTEGA____________ Driver ______________________________________ Area(s) damaged ___LOWER_DRIVER’S SIDE_____________ If a City vehicle was involved: License Plate # ______965608_________________ Color ___________BLUE______________ Was there City insignia on the vehicle? Yes No Driver’s Name ________</wSHAWN PHILLIPS___________________ Other property damaged: _______________NO________________________________________ For injury claims of any type. What part of your body was injured? __________________________________________________________________________ Did you go to the emergency room or urgent care? Yes No Where? _________________________________________________ Was medical treatment received? Yes No Where? ______________________________________________________________</ First day of medical treatment? _____________ Are you still receiving medical treatment? Yes No Did you miss any work as result of this incident? Yes No Employer(s) _______________________________________________< How much time have you missed from work?___________________________________________________________________ If you are submitting other documents, please state what you are attaching and how many pages. ______________________ _______________________________________________________________________________________________________ By signing this form, you agree that all information provided is true and correct to the best of your knowledge. Please NOTE that submitting a false or misleading claim can and will result in prosecution under Minnesota Statutes. Name of Person completing form: _______RODOLFO ORTEGA____________________ Relationship of person signing to Party making the claim: _________________________________________________________ Date document is being signed __01-19-2023______________ Signature of Person submitting this form: _______________________________________________________________________ Revised December 2021