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Flores Diaz, ArgeliaNOTICE 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 this completed form to the Saint Paul City Clerk’s Office by email (cityclerk@ci.stpaul.mn.us), fax (651-266-8574) or mail addressed to “Saint Paul City Clerk, 15 West Kellogg Blvd., Suite 310, Saint Paul, MN 55102”. Claimant: First Name: ________________________________ Last Name: _______________________________________________ Please Indicate Your Pronouns: ☐ She/Her/Hers, ☐ He/Him/His, ☐ They/ Them/Theirs Company or Business Name: ______________________________________________________ ______________________________ Is this claim being made by an Insurance Company? YES / NO If yes, what is your Claim/File Number? _________________________ Is this claim being made by an Attorney? YES / NO If yes, what is your File Number? _______________________________________ If yes, provide your Insured’s/ Client’s Name: ______________________________________________________ _________________ Street Address: ______________________________________________________ _________________________________________ City: ______________________________________________ State: ________________________ Zip Code: ___________________ Daytime/Work Phone: __________________________________ Cell Phone: _____________________________________________ Date of Incident or Date Discovered (Must Complete): _____________________________ Time: _____________________________ Please state, in detail, what happened that prompted you to file a Notice of Claim Form: ____________________________________ Please state why or how you feel the City of Saint Paul is responsible for your Damages? ____________________________________ 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. ☐ 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. Continue to page 2 of Notice of Claim Form. Failure to complete and return both pages will result in delays. 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: ___________________________ If yes, what law enforcement agency responded? ______________________________________________________ ______ Where did the incident take place? Please provide a street address, intersection or name of city park or facility: ______________________________________________________ ______________________________________________________ What would you like to see happen to resolve this claim to your satisfaction? ______________________________________________________ ______________________________________________________ Were there witnesses to this incident? Please provide names and contact phone numbers: ______________________________________________________ ______________________________________________________ For property damage claims, including vehicle accidents. Your vehicle’s information: Year: _________ Make: _________________ Model: __________________ Color: __________________ License Plate #: _________________________ State vehicle is registered in: ___________________________ Registered owner of vehicle: _____________________________ Driver: __________________________________________ Area(s) damaged:______________________________________________ ________________________________________ If a City vehicle was involved, License Plate #: _________________________________ Color: _______________________________ Was there City insignia on the vehicle? YES / NO Driver’s Name: ______________________________________________________ Other property damaged: ______________________________________________________ _________________________________ 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: ______________________________________________________ _______ Signature of Person submitting this form: ______________________________________________________ _ Relationship of person signing to Party making the claim: __________________________________________ Date document is being signed: _____________________ Revised March 2023 4/29/23, 9:42 AMPage 1 of 1 Argelia Flores Diaz NOTICE OF CLAIM FORM to the City of Saint Paul,Minnesota Minnesota State Statute 466.05 states that “…every person…who claims damagesfrom any municipality…shall cause to be presented to the governing body of themunicipality within 180 days after the alleged loss or injury is discovered a noticestating the time, place, and circumstances thereof, and the amount of compensationor other relief demanded.”Please complete this form in its entirety by clearly typing or printing youranswers to each question. If you have additional documentation, you may addthose documents to your submission. You will not be contacted by telephoneunless clarification is needed. The claim process for investigations can takeupwards of four (4) weeks. This form must be signed, dated with all applicablesections completed. Submission this completed form to the Saint Paul CityClerk’s Office by email (cityclerk@ci.stpaul.mn.us), fax (651-266-8574) or mailaddressed to “Saint Paul City Clerk, 15 West Kellogg Blvd., Suite 310, SaintPaul, MN 55102”. Claimant: First Name: ________________________________Last Name:_______________________________________________ Please Indicate Your Pronouns: ☐ She/Her/Hers, ☐ He/Him/His,☐ They/ Them/Theirs Company or Business Name:____________________________________________________________________________________ Is this claim being made by an Insurance Company? YES / NO Ifyes, what is your Claim/File Number?_________________________ Is this claim being made by an Attorney? YES / NO If yes, what isyour File Number? _______________________________________ If yes, provide your Insured’s/ Client’s Name: ______________________________________________________ _________________ Street Address: ______________________________________________________ _________________________________________ City: ______________________________________________ State: ________________________ Zip Code: ___________________ Daytime/Work Phone: __________________________________ Cell Phone: _____________________________________________ Date of Incident or Date Discovered (Must Complete): _____________________________ Time: _____________________________ Please state, in detail, what happened that prompted you to file a Notice of Claim Form: ____________________________________ Please state why or how you feel the City of Saint Paul is responsible for your Damages? ____________________________________ 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. ☐ 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. Continue to page 2 of Notice of Claim Form. Failure to complete and return both pages will result in delays. 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: ___________________________ If yes, what law enforcement agency responded? ______________________________________________________ ______ Where did the incident take place? Please provide a street address, intersection or name of city park or facility: ______________________________________________________ ______________________________________________________ What would you like to see happen to resolve this claim to your satisfaction? ______________________________________________________ ______________________________________________________ Were there witnesses to this incident? Please provide names and contact phone numbers: ______________________________________________________ ______________________________________________________ For property damage claims, including vehicle accidents. Your vehicle’s information: Year: _________ Make: _________________ Model: __________________ Color: __________________ License Plate #: _________________________ State vehicle is registered in: ___________________________ Registered owner of vehicle: _____________________________ Driver: __________________________________________ Area(s) damaged:______________________________________________ ________________________________________ If a City vehicle was involved, License Plate #: _________________________________ Color: _______________________________ Was there City insignia on the vehicle? YES / NO Driver’s Name: ______________________________________________________ Other property damaged: ______________________________________________________ _________________________________ 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: ______________________________________________________ _______ Signature of Person submitting this form: ______________________________________________________ _ Relationship of person signing to Party making the claim: __________________________________________ Date document is being signed: _____________________ Revised March 2023 4/29/23, 9:42 AMPage 1 of 1 1291 Hazelwood st St.Paul Minnesota 55106 651-278-6911 04-21-2023 9:30pm Hit pothole lost control hit curb Resulted junking the vehicle Nothing has been done about the potholes NOTICE OF CLAIM FORM to the City of Saint Paul,Minnesota Minnesota State Statute 466.05 states that “…every person…who claims damagesfrom any municipality…shall cause to be presented to the governing body of themunicipality within 180 days after the alleged loss or injury is discovered a noticestating the time, place, and circumstances thereof, and the amount of compensationor other relief demanded.”Please complete this form in its entirety by clearly typing or printing youranswers to each question. If you have additional documentation, you may addthose documents to your submission. You will not be contacted by telephoneunless clarification is needed. The claim process for investigations can takeupwards of four (4) weeks. This form must be signed, dated with all applicablesections completed. Submission this completed form to the Saint Paul CityClerk’s Office by email (cityclerk@ci.stpaul.mn.us), fax (651-266-8574) or mailaddressed to “Saint Paul City Clerk, 15 West Kellogg Blvd., Suite 310, SaintPaul, MN 55102”. Claimant: First Name: ________________________________Last Name:_______________________________________________ Please Indicate Your Pronouns: ☐ She/Her/Hers, ☐ He/Him/His,☐ They/ Them/Theirs Company or Business Name:____________________________________________________________________________________ Is this claim being made by an Insurance Company? YES / NO Ifyes, what is your Claim/File Number?_________________________ Is this claim being made by an Attorney? YES / NO If yes, what isyour File Number?_______________________________________ If yes, provide your Insured’s/ Client’s Name:_______________________________________________________________________ Street Address:_______________________________________________________________________________________________ City: ______________________________________________State: ________________________ Zip Code:___________________ Daytime/Work Phone: __________________________________Cell Phone:_____________________________________________ Date of Incident or Date Discovered (Must Complete):_____________________________ Time:_____________________________ Please state, in detail, what happened that prompted you to file aNotice of Claim Form:____________________________________ Please state why or how you feel the City of Saint Paul isresponsible for your Damages?____________________________________ Please check the reason that most closely describes the reasonfor your submitting a claim. Please note the documents that willneed to be provided with your completed form. Photographs willbe accepted. All documents submitted become the property of the City of Saint Paul and shall not be returned. ☐ 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. Continue to page 2 of Notice of Claim Form. Failure to complete and return both pages will result in delays. 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: ___________________________ If yes, what law enforcement agency responded? ______________________________________________________ ______ Where did the incident take place? Please provide a street address, intersection or name of city park or facility: ______________________________________________________ ______________________________________________________ What would you like to see happen to resolve this claim to your satisfaction? ______________________________________________________ ______________________________________________________ Were there witnesses to this incident? Please provide names and contact phone numbers: ______________________________________________________ ______________________________________________________ For property damage claims, including vehicle accidents. Your vehicle’s information: Year: _________ Make: _________________ Model: __________________ Color: __________________ License Plate #: _________________________ State vehicle is registered in: ___________________________ Registered owner of vehicle: _____________________________ Driver: __________________________________________ Area(s) damaged:______________________________________________ ________________________________________ If a City vehicle was involved, License Plate #: _________________________________ Color: _______________________________ Was there City insignia on the vehicle? YES / NO Driver’s Name: ______________________________________________________ Other property damaged: ______________________________________________________ _________________________________ 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: ______________________________________________________ _______ Signature of Person submitting this form: ______________________________________________________ _ Relationship of person signing to Party making the claim: __________________________________________ Date document is being signed: _____________________ Revised March 2023 4/29/23, 9:42 AMPage 1 of 1 NOTICE OF CLAIM FORM to the City of Saint Paul,Minnesota Minnesota State Statute 466.05 states that “…every person…who claims damagesfrom any municipality…shall cause to be presented to the governing body of themunicipality within 180 days after the alleged loss or injury is discovered a noticestating the time, place, and circumstances thereof, and the amount of compensationor other relief demanded.”Please complete this form in its entirety by clearly typing or printing youranswers to each question. If you have additional documentation, you may addthose documents to your submission. You will not be contacted by telephoneunless clarification is needed. The claim process for investigations can takeupwards of four (4) weeks. This form must be signed, dated with all applicablesections completed. Submission this completed form to the Saint Paul CityClerk’s Office by email (cityclerk@ci.stpaul.mn.us), fax (651-266-8574) or mailaddressed to “Saint Paul City Clerk, 15 West Kellogg Blvd., Suite 310, SaintPaul, MN 55102”. Claimant: First Name: ________________________________Last Name:_______________________________________________ Please Indicate Your Pronouns: ☐ She/Her/Hers, ☐ He/Him/His,☐ They/ Them/Theirs Company or Business Name:____________________________________________________________________________________ Is this claim being made by an Insurance Company? YES / NO Ifyes, what is your Claim/File Number?_________________________ Is this claim being made by an Attorney? YES / NO If yes, what isyour File Number?_______________________________________ If yes, provide your Insured’s/ Client’s Name:_______________________________________________________________________ Street Address:_______________________________________________________________________________________________ City: ______________________________________________State: ________________________ Zip Code:___________________ Daytime/Work Phone: __________________________________Cell Phone:_____________________________________________ Date of Incident or Date Discovered (Must Complete):_____________________________ Time:_____________________________ Please state, in detail, what happened that prompted you to file aNotice of Claim Form:____________________________________ Please state why or how you feel the City of Saint Paul isresponsible for your Damages?____________________________________ Please check the reason that most closely describes the reasonfor your submitting a claim. Please note the documents that willneed to be provided with your completed form. Photographs willbe accepted. All documents submitted become the property of theCity of Saint Paul and shall not be returned. ☐ Automobile damage from a motor vehicle accident: pleaseprovide two estimates for repairs or actual bill that has been paid. ☐ Automobile damage from a street defect or pothole: pleaseprovide two estimates for repairs or actual bill that has been paid. ☐ Automobile was towed and may or may not have sustaineddamage: please provide copy of towing ticket (if available), receiptfrom Impound Lot, and two estimates for repairs or actual bill thathas been paid. ☐ Snow Emergency: please provide copy of towing ticket (ifavailable), receipt from Impound Lot, and two estimates for repairsor actual bill that has been paid. ☐ Property damage: please provide two estimates for repairs oractual bill that has been paid. ☐ You were injured during a motor vehicle accident: pleaseprovide police report number, details about injury. ☐ You were injured in the City of Saint Paul: please provide policereport number, witnesses, and details about injury. Continue to page 2 of Notice of Claim Form. Failure tocomplete and return both pages will result in delays.This section must be completed for all claims. Is there a police report for this incident? YES / NOIf yes, please provide the police report case number:___________________________ If yes, what law enforcement agency responded? ______________________________________________________ ______ Where did the incident take place? Please provide a street address, intersection or name of city park or facility: ______________________________________________________ ______________________________________________________ What would you like to see happen to resolve this claim to your satisfaction? ______________________________________________________ ______________________________________________________ Were there witnesses to this incident? Please provide names and contact phone numbers: ______________________________________________________ ______________________________________________________ For property damage claims, including vehicle accidents. Your vehicle’s information: Year: _________ Make: _________________ Model: __________________ Color: __________________ License Plate #: _________________________ State vehicle is registered in: ___________________________ Registered owner of vehicle: _____________________________ Driver: __________________________________________ Area(s) damaged:______________________________________________ ________________________________________ If a City vehicle was involved, License Plate #: _________________________________ Color: _______________________________ Was there City insignia on the vehicle? YES / NO Driver’s Name: ______________________________________________________ Other property damaged: ______________________________________________________ _________________________________ 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: ______________________________________________________ _______ Signature of Person submitting this form: ______________________________________________________ _ Relationship of person signing to Party making the claim: __________________________________________ Date document is being signed: _____________________ Revised March 2023 4/29/23, 9:42 AMPage 1 of 1 N McKnight Road Partial reimbursement for labor and cost of parts 2004 Dodge Grey Stratus Minnesota Argelia Flores Díaz Argelia Flores Díaz Both control arms, cv axle/drive shaft and left wheel/rim GML 634 NOTICE OF CLAIM FORM to the City of Saint Paul,Minnesota Minnesota State Statute 466.05 states that “…every person…who claims damagesfrom any municipality…shall cause to be presented to the governing body of themunicipality within 180 days after the alleged loss or injury is discovered a noticestating the time, place, and circumstances thereof, and the amount of compensationor other relief demanded.”Please complete this form in its entirety by clearly typing or printing youranswers to each question. If you have additional documentation, you may addthose documents to your submission. You will not be contacted by telephoneunless clarification is needed. The claim process for investigations can takeupwards of four (4) weeks. This form must be signed, dated with all applicablesections completed. Submission this completed form to the Saint Paul CityClerk’s Office by email (cityclerk@ci.stpaul.mn.us), fax (651-266-8574) or mailaddressed to “Saint Paul City Clerk, 15 West Kellogg Blvd., Suite 310, SaintPaul, MN 55102”. Claimant: First Name: ________________________________Last Name:_______________________________________________ Please Indicate Your Pronouns: ☐ She/Her/Hers, ☐ He/Him/His,☐ They/ Them/Theirs Company or Business Name:____________________________________________________________________________________ Is this claim being made by an Insurance Company? YES / NO Ifyes, what is your Claim/File Number?_________________________ Is this claim being made by an Attorney? YES / NO If yes, what isyour File Number?_______________________________________ If yes, provide your Insured’s/ Client’s Name:_______________________________________________________________________ Street Address:_______________________________________________________________________________________________ City: ______________________________________________State: ________________________ Zip Code:___________________ Daytime/Work Phone: __________________________________Cell Phone:_____________________________________________ Date of Incident or Date Discovered (Must Complete):_____________________________ Time:_____________________________ Please state, in detail, what happened that prompted you to file aNotice of Claim Form:____________________________________ Please state why or how you feel the City of Saint Paul isresponsible for your Damages?____________________________________ Please check the reason that most closely describes the reasonfor your submitting a claim. Please note the documents that willneed to be provided with your completed form. Photographs willbe accepted. All documents submitted become the property of theCity of Saint Paul and shall not be returned. ☐ Automobile damage from a motor vehicle accident: pleaseprovide two estimates for repairs or actual bill that has been paid. ☐ Automobile damage from a street defect or pothole: pleaseprovide two estimates for repairs or actual bill that has been paid. ☐ Automobile was towed and may or may not have sustaineddamage: please provide copy of towing ticket (if available), receiptfrom Impound Lot, and two estimates for repairs or actual bill thathas been paid. ☐ Snow Emergency: please provide copy of towing ticket (ifavailable), receipt from Impound Lot, and two estimates for repairsor actual bill that has been paid. ☐ Property damage: please provide two estimates for repairs oractual bill that has been paid. ☐ You were injured during a motor vehicle accident: pleaseprovide police report number, details about injury. ☐ You were injured in the City of Saint Paul: please provide policereport number, witnesses, and details about injury. Continue to page 2 of Notice of Claim Form. Failure tocomplete and return both pages will result in delays.This section must be completed for all claims. Is there a police report for this incident? YES / NOIf yes, please provide the police report case number:___________________________If yes, what law enforcement agency responded?____________________________________________________________ Where did the incident take place? Please provide a street address,intersection or name of city park or facility:____________________________________________________________________________________________________________ What would you like to see happen to resolve this claim to yoursatisfaction? ____________________________________________________________________________________________________________ Were there witnesses to this incident? Please provide names andcontact phone numbers: ____________________________________________________________________________________________________________ For property damage claims, including vehicle accidents. Your vehicle’s information: Year: _________ Make:_________________ Model: __________________ Color:__________________ License Plate #: _________________________ State vehicleis registered in: ___________________________Registered owner of vehicle:_____________________________ Driver:__________________________________________Area(s)damaged:______________________________________________ ________________________________________ If a City vehicle was involved, License Plate #: _________________________________ Color: _______________________________ Was there City insignia on the vehicle? YES / NO Driver’s Name: ______________________________________________________ Other property damaged: ______________________________________________________ _________________________________ 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: ______________________________________________________ _______ Signature of Person submitting this form: ______________________________________________________ _ Relationship of person signing to Party making the claim: __________________________________________ Date document is being signed: _____________________ Revised March 2023 4/29/23, 9:42 AMPage 1 of 1 Both control arms, cv axle/drive shaft and left wheel/rim NOTICE OF CLAIM FORM to the City of Saint Paul,Minnesota Minnesota State Statute 466.05 states that “…every person…who claims damagesfrom any municipality…shall cause to be presented to the governing body of themunicipality within 180 days after the alleged loss or injury is discovered a noticestating the time, place, and circumstances thereof, and the amount of compensationor other relief demanded.”Please complete this form in its entirety by clearly typing or printing youranswers to each question. If you have additional documentation, you may addthose documents to your submission. You will not be contacted by telephoneunless clarification is needed. The claim process for investigations can takeupwards of four (4) weeks. This form must be signed, dated with all applicablesections completed. Submission this completed form to the Saint Paul CityClerk’s Office by email (cityclerk@ci.stpaul.mn.us), fax (651-266-8574) or mailaddressed to “Saint Paul City Clerk, 15 West Kellogg Blvd., Suite 310, SaintPaul, MN 55102”. Claimant: First Name: ________________________________Last Name:_______________________________________________ Please Indicate Your Pronouns: ☐ She/Her/Hers, ☐ He/Him/His,☐ They/ Them/Theirs Company or Business Name:____________________________________________________________________________________ Is this claim being made by an Insurance Company? YES / NO Ifyes, what is your Claim/File Number?_________________________ Is this claim being made by an Attorney? YES / NO If yes, what isyour File Number?_______________________________________ If yes, provide your Insured’s/ Client’s Name:_______________________________________________________________________ Street Address:_______________________________________________________________________________________________ City: ______________________________________________State: ________________________ Zip Code:___________________ Daytime/Work Phone: __________________________________Cell Phone:_____________________________________________ Date of Incident or Date Discovered (Must Complete):_____________________________ Time:_____________________________ Please state, in detail, what happened that prompted you to file aNotice of Claim Form:____________________________________ Please state why or how you feel the City of Saint Paul isresponsible for your Damages?____________________________________ Please check the reason that most closely describes the reasonfor your submitting a claim. Please note the documents that willneed to be provided with your completed form. Photographs willbe accepted. All documents submitted become the property of theCity of Saint Paul and shall not be returned. ☐ Automobile damage from a motor vehicle accident: pleaseprovide two estimates for repairs or actual bill that has been paid. ☐ Automobile damage from a street defect or pothole: pleaseprovide two estimates for repairs or actual bill that has been paid. ☐ Automobile was towed and may or may not have sustaineddamage: please provide copy of towing ticket (if available), receiptfrom Impound Lot, and two estimates for repairs or actual bill thathas been paid. ☐ Snow Emergency: please provide copy of towing ticket (ifavailable), receipt from Impound Lot, and two estimates for repairsor actual bill that has been paid. ☐ Property damage: please provide two estimates for repairs oractual bill that has been paid. ☐ You were injured during a motor vehicle accident: pleaseprovide police report number, details about injury. ☐ You were injured in the City of Saint Paul: please provide policereport number, witnesses, and details about injury. Continue to page 2 of Notice of Claim Form. Failure tocomplete and return both pages will result in delays.This section must be completed for all claims. Is there a police report for this incident? YES / NOIf yes, please provide the police report case number:___________________________If yes, what law enforcement agency responded?____________________________________________________________ Where did the incident take place? Please provide a street address,intersection or name of city park or facility:____________________________________________________________________________________________________________ What would you like to see happen to resolve this claim to yoursatisfaction? ____________________________________________________________________________________________________________ Were there witnesses to this incident? Please provide names andcontact phone numbers: ____________________________________________________________________________________________________________ For property damage claims, including vehicle accidents. Your vehicle’s information: Year: _________ Make:_________________ Model: __________________ Color:__________________ License Plate #: _________________________ State vehicleis registered in: ___________________________Registered owner of vehicle:_____________________________ Driver:__________________________________________Area(s)damaged:______________________________________________________________________________________ If a City vehicle was involved, License Plate #:_________________________________ Color:_______________________________ Was there City insignia on the vehicle? YES / NO Driver’sName:______________________________________________________ Other property damaged:_______________________________________________________________________________________ For injury claims of any type. What part of your body was injured?_____________________________________________________________________________ Did you go to the emergency room or urgent care? YES / NOWhere?___________________________________________________ Was medical treatment received? YES / NO Where?________________________________________________________________ First day of medical treatment? _____________ Are you stillreceiving 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: ______________________________________________________ _______ Signature of Person submitting this form: ______________________________________________________ _ Relationship of person signing to Party making the claim: __________________________________________ Date document is being signed: _____________________ Revised March 2023 4/29/23, 9:42 AMPage 1 of 1 Argelia Flores Díaz 04/29/2023