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Russell � ' �� RECEIVE� ��T 2 � 2Q1i F�B�I ZoT2 NOTICE OF CLAIM FORM to the City of Saint P� lYiinnesota :��T��.� ' �I� ��-�RK Minnesota State Statute 466.OS states that "...every person...who claims damages from any municipality:..sha11 cause to be presente to governing body of the municipality within 180 days after the alleged Zoss or injury is discovered a notice stafing the time,pZace,and • circumstances thereof,and the amount of compensation or other relief demanded." Please complete this farm 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 ezplain your claim,and the amount of compensafion being requested. You will receive a written.acl�owiedgement 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'. �END COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK, 15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAITL, MN 55102 .....--� , First Name _ Middle Initial�Last Name 1/�C� I_; �, -'-�C7 Company or Business Name Are You an Insurance Company? Yes No If Yes, Claixri Nurnber? Street Address �� Q City State �� Zip Code,�� ,",,,,�� c�a.- Daytime Phone(��-�'�j�_Cell Phone:( . . )---��. EYening Telephone��--j--:.— G�vC` `�-- �� T�-- � �� t%�� Date of AccidentJ Injury or Date Discovered /��- �(�' r Time�/1�am/� c � Please state,in detail,what occurred(happened),and why you are submitting a claim.Please indicate why or how you feel the City of Saint Paul or its employees are invo ved and/or resp sible for your damages. ` � � � --2l� •�- ` '� n av�c(a� � - . o u ` ' . Please check the hox(es)that most closely represent the reason for completing this form: �My vehicle was dama.ged in an accident ❑My vehicle was damaged during a tow , �J.VIy vehicle was damaged by a pothole or condition of the street ❑My vehicle was damaged by xplow �My vehicle was wrongfully towed and/or ticketed ❑ I was injured on City property ❑Other type of property damage-please specify ❑ O�her type of injury-please specify In order to process your claim you need to include conies 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 yoixr claim. Documents WII.L NOT be returned and become the property of the City. You are encouragec�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 � $500.00; or the actual bills andlor receipts for the"repairs O Towing claims:legible copies of any ticket issued and a copy of the impound lot receipt O Other property damage claims:two repair estimates if the damage exceeds$SQ0.00; or the actual bills and/ar receipts for the repairs; detailed list of damaged items O Injury claims:medical bills,receipts O Photograp�s 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 Failnre to complete and return both pages will result in delay in the handling of your claim. All Claims-ulease complete this section Were there.witnesses to the incident? Yes �To � Unknown (circle) Provide their names, addresses ax�d telephone numbers: � Were the police or law enforcement called? 'Yes No ' Unknown (circle) If yes,what department or agency? Case#or report# Where did the accident or injury take place? Provide street address,cross sireet, intersection,name of park or facility,. closest landmark,etc. Please be as detailed as possible. If necessary, attach a diagram. Please indicate the amount you are seelang in compensation o what you would like the Ci to do to resolve this claim to your satisfaction. � VeIucIe Claims—nlease comulete this section �check box if this section doe�not anplv Your Velucle: Year Make Model License Plate Number Sta.te Colar 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—ulease comulete this section C�check box if this section does not applv How were you�n�ured? What part(s)of your body were injured? Have you sought medical treatment? Yes No Planning to Seek Treatrnent(circle) When did you receive treatment?. (provide date(s)) Name of Medical Provider(s): Adr3ress Telephone Did you miss work as a result of your injury? Yes No When did you miss work? (provide da�e(s)). Name of your Employer: Address Telephor�e ' ❑ Check here if yon are attachi.ng more pages to this claim form. Number of additional pages '� By signing this form,you are stating that all information you haveprovided is true and correct to the best of yout�knowledge. Unsigned forms will not be processed. �i i Submitting a false claim can result in prosecution. Date form was completed �: �� Print the Name of the Person who Completed this Form: � �;� �J � Signatare of Person Mal�ng the Claim: �j��- ' � , � ` . � Revised Febraary 2011 , � � o � � v � � �. 3 m w m � n�i � : . � � � � � � ~� c� c � � w � � � � � .-+ m � � �D o � cm � n' o- � Q- � � � . � -� � � n m � . � m o � � Q � o ,� v, ,� D o � O c -� � o o• ° �• c �� v = � ��-p � � � � o � su m � � Q 171 � � . � m � p•� 0 Q- � � O p m p ci 70 � m o� � °- < � •°•" � cD m � � j T � � N O C � � � Q 1 = 0 I,1 � = I � (� '� � � Q. � N 0 3 � � c , -1 z � � :-• < 3 m o. � o - � — � � CD � Q- 70 I � � a� �m °- 1 r r- � 'p N C) A .-� � C O 7 (D � � � � �-r , � TI � .,. O `z A> < � � dp � � �' f3D � c�l� � � � � W - D N � 3 tQ � O � � ,... � m � W � � Z p � � � Q � � � j � A � N � (� 37 p. _ � p � �1 (D ' W °-�a n m c� D � m � o � � Q- � � � ° �' � a� �. ... v n �' � � ° z m 0 , J � � D Q � � � � � � � � Q. � < .-+ � � � � N � G n � � V � (Q n � � 3 � � � (D m � u� c� '' N � c� �' � „ .� .J � � $� � (Q , � (Q � o � (p (7 m N (Q � (�p �p (D � � � r � � � � � � � � � � . � J � � � i � � � � O � � � � � O � _ � � � N O�D O O (�p � m � � � � w � � 0 w ca u, N . O O O y �� l� /� /� � ` This claim form is being returned without having been set up as a elaim for the followir�g reasons: . , , . . , : : �'Failure to proYide a written description as to what happened and why a claim form _. . , was being submitted(page one).� ► �• y �- � - _�IZCf (i�Q,q (�'p�it:i�e 7`�tc�',p�7 .. , �� - � �� - �Failure to provide.the proper and required.documentation�page one).' � � �•� . �f� �� Failure to provide a date of accident or injury(page one). � �Failure to indicate the amount of compensation being sought (page two). �Failure to provid information about the vehicle involved (pa e two). /t�..2-� ��GU2� �i��e� ��'LQ c�P, �G�L.Q2 OL'�`�, Failure to provicle information about the in�ury claimed(page two). b� �Lt1l�lQ�/Z ' � Failure to sign the claim form(page two). _. Failure to print the naxne of the person who completed the claim form(page two). Other: Please return the completed claim form to: � Office of the City Clerk Cifiy of S�.iTit Paul . - 15 W. Kellogg Blvd. � 310 City Hall � . Sa,int Paul, NIN 55102 If you do not return the completed claim fortn with the appropriate documentation or information completed, then a claim file will NOT be established and an investigation WILL NOT be done. Iri other words, NO FLTRTHER ACTION will be taken until the information requested is provided by you. Please remember that it is a crime to submit a claim form or to pursue compensation falsely or under false circumstances. .. ' ' . .. y .. . � � - .. . . . . .. FiECE11�E� _ .. � .- .._ . .. <<-:. DEC 2 3 2011 _ CIT��LER�C , � � , ,� . r , e - , + — � I � � R ` i Y C v . � i