Overby NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minnesota State Statute 466.05 states that "...every person...who c/aims damages from arry municipality...shall cause to be presented to the
governing body of the municipa[ity 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 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 information as necessary to explain your claim,and the amount of compensation being requested. You will receive a
written acknowledgement once your form is received. The process can take up to ten weeks or longer 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, 5AINT PALTL, MN 55102
First Name ,��'y���1-��1r" Middle Initial`�Last Name (��'V'�V V�M
Company or Business Name �'��l-�' ��'��YVl j_.�-C' v��i--'� i� R�CEII�ED
Are You an Insurance Company? Yes/� If Yes,Claim Number? FE6 1 6 ZOi2
Street Address 1`'L'% ►�o�.(, �� ( o f�� �%�� �L���
City � � State }'}�} � ZipCode 5��`1��
3 c��i� i s���
Daytime Phone � � �-�� e Phone(_) - Evening Telephone U -
Date of Accidend Injury or Date Discovered ]1�I�), I; C% Time am/pm
Please state, in detail,what occurred(happened),and why you aze submitting a claim.Please indicate why or how you
feel the City of Saint Paul or its employees aze involved and/or responsible for your damages.
1..� �- r� � - � �"� � � �-'�-Jr
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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 of the street ❑ My vehicle was damaged by a plow
❑ My vehicle was wrongfully towed and/or ticketed ❑ I was injured on City property
�Other type of pmperty damage—please specify 4 '
❑ Other type of injury—please specify
In order to process your claim you need to include copies of all aunlicable 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 become the property of the City. You are encouraged to keep a
copy for yourself before submitting your claim form.
O Property damage claims to a vehicle:two estimates 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 handGng of your claim.
All Claims—please complete this section
Were there witnesses to the incident? Yes No n cno (circle)
Provide their names,addresses and telephone numbers:
Were the police or law enforcement called? Yes �Te Unknown (circle)
If 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 detailed as possible. If necessary,attach a diagram.
����,� �tr�n �r � �(,� � ,� a U, �?U .��`:�tt�'���,_�iLl Iv
Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction. �} j � �i� � 1
Vehicle Ctaims—please complete this section I�%�; ❑ check 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
Injur�Claims—please complete this section ti �Yk O check box if this section does not applv
How were you injured?
What part(s)of your body were injured?
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 yon are attaching more pages to this claim form. Number of additional pages 1 .
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 processed
Submitting a false claim can result in prosecution. Date form was completed 2-' �5- 12-
Print the Name of the Person who Comple ed this Form: i
Signature of Person Matang the Clai • � _
\,
1
Revised February 2011 `"
_ %
Work Authoraation�: 462264
Notification Dat�e: 219/2072
QW e S t�A� Paymerrt Due Dabe: Upon Receipt
PLEASE MAKE CHECK PAYABLE TO:
Qwest
Claims Cerrter
PO BOX 47604
PLYMOUTH,MN 55447
OVERNIGHT DELIVERY ADDRESS
St Paul Regional Water Services qN,est
1900 Rice St Claims Center
Saint Paul MN 55113 7001 E FISH LAKE RD.SUITE 100
MAPLE GROVE,MN 55311
FOR INQUIRIES CALL 1 -800-471 -7107 OR FAX 866-233-9627
� � � e
Damage Location: Century Ave N &4th St N Oakdale, MN 55128
Damage Date: 11/18/2008
Damage Description: BACKHOE/WATER EXCAVATION/BURIED CABLE
. • • . • •
Labor: $719.11 '
�
Material: ; $452.80 !
�
� ;
Equipment: ; �586.80
�
Contractor Labor: ; $0.00 '
�
,
Repair Expense: I $0.00 ;
,
__---- -_____--------____------- ------___---__-- - L- --- ---�
. •
� PLEASE DO NOT PAY WITH YOUR QWEST UTILITY BiLL ,�•��75H.7•�
OR TO ANY OTHER lWEST LOCATION
— — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — —
Retum U►is�ortion with vour oavment-Please indude our daim number on vour chedc
Work Authorization#: 462264
• . � AmouM Remit6ed
N�ification Date: 2/9I2012 �+���' + ��'�1
Plsase comulete information below if vou wish to�av bv credit card
Credit Card Number. Th�e digit security number on badc of card:
Name on Card: E�cpiration Date: � �
Amourrt to be charged to your carcl: $ Signature:
(�� St Paul Regional Water Services
Clairr�Ce�rter 1900 Rice St
PO BOX 47604 SaiM Paul MN 55113
PLYMOUTH,MN 55447