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Roble, Omar 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 this completed form to the mailto:Saint%20Paul%20City%20Clerk’s%20OfficeSaint 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: Omar______________ Last Name: Roble_______________________________________________ Please Indicate Your Pronouns: ☐ She/Her/Hers, ☒ He/Him/His, ☐ They/ Them/Theirs Company or Business Name: Progressive Direct Insurance Company__________________________________________________________________________ Is this claim being made by an Insurance Company? YES If yes, what is your Claim/File Number? <24-2541360_______________________ Is this claim being made by an Attorney? YES / NO If yes, what is your File Number? Iverson Law Office_______________________________________ If yes, then provide your Insured’s/ Client’s Name __Omar Roble and Adow Ahmed_________________________________________________________________ </ Street Address: __2649 University Ave W Suite 230W_____________________________________________________________________________________________ City: _St Paul_____________________________________________ State __MN_______________________ Zip Code 55114___________________ Daytime/Work Phone _(651) 647-1100_________________________________ Cell Phone ______________________________________________ E-mail _JED@IVERSONLAWOFFICE.COM________________________________________________ Date of Incident or Date Discovered (Must complete) 5/25/2024Time _____________________________ Please state, in detail, what happened that prompted you to file a Notice of Claim Form. _Police vehicle struck our customer’s vehicle after running red light__________________________________ Please state why or how you feel the City of Saint Paul is responsible for your Damages? _Officer ran red light___________________________________ 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 If yes, please provide the police report case number: _24093313__________________________ If yes, what law enforcement agency responded? __St Paul PD__________________________________________________________ Where did the incident take place? Please provide a street address, intersection or name of city park or facility. ___University Ave & Maryland St _________________________________________________________________________________________________________ What would you like to see happen to resolve this claim to your satisfaction? Acceptance of liability and repair of our customer’s vehicle____________________________________________________________________________________________________________ Were there witnesses to this incident? Please provide names and contact phone numbers: </w:t></w:r></w:sdtContent></w:sdt><w:r w:rsidR="0031571E" w:rsidRPr="00 __No__________________________________________________________________________________________________________ For property damage claims, including vehicle accidents. Your vehicle’s information: Year _2013________ Make _Chrysler________________ Model __Town & Country________________ Color _Gray___________________ License Plate # _LKB563________________________ State vehicle is registered in __MN_________________________ Registered owner of vehicle _Omar Roble_____________________________ Driver __Omar Roble________________________________________ Area(s) damaged _Front end_____________________________________________________________________________________ If a City vehicle was involved: License Plate # _unk________________________________ Color _________________________________ Was there City insignia on the vehicle? YES Driver’s Name </w__unk____________________________________________________ Other property damaged: _______________________________________________________________________________________ For injury claims of any type. What part of your body was injured? _Left leg, right shoulder/hand____________________________________________________________________________ Did you go to the emergency room or urgent care? YES Where? ___Regions Hospital________________________________________________ Was medical treatment received? YES Where? </__Aligned Chiropractic______________________________________________________________ First day of medical treatment? 5/25/2024 Are you still receiving medical treatment? YES Did you miss any work as result of this incident? 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: _Sarah Arnsdorff____________________________________________________________ < Signature of Person submitting this form: Sarah Arnsdorff______________________________________________________ Relationship of person signing to Party making the claim: _Auto Insurance_________________________________________ Date document is being signed 7/9/2024__ Revised March 2023