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NOTICE OF CLAIM FORM to the Ci of$aint Paul Minnesota
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Minnesota State Statute 466.OS states that"...every person...who daims damages from an�municipality...skall cause to be presented w du
governing body of the munici�lity within 180 days afur the alleged loss or injury is di.tcovered a notice stating the time,place,and
cirewnstanees tieereof,and the amount of eompensation or oth�r relief demand�d"
Please complete tliis form�n its entirety by clearly typing or printing your � er to each questioa If more space is
needed,attach additional sheets. Please note that you will not be contacted by phone to clarily answers,so provide ss
much inforawtion as necessaiy to explain your cfaim,and the aaawtt of compe tion being requested. Yon w7l receive a
written acknowledgement once your form is received. The process can talce u to ten weeks or longer depending on the
nature of your claim. This form mnst be signed,and both pages completed. something dces not appty,wrlte`N/A'.
SEND COMPLETED FORM AND OTI�ER DOCUN.�ENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD,310 CITY HALL, S�INT PAUL, MN 55102
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First Name � �� Middle Initial E Last Name�iQ �G�•M.���
Company or Business Name —�� I
Are You an Insurance Compan ? Yes/ io If Yes,Claim Number? i
Street Address 3 3 � � Gt, ✓ �,
City � � �m,t.� State_T,�i Zip Code S.S!! �
Daytime Phone r�s r�,��1�z 7 Cell Phone L�S�'-�''G Evening�Telephone�}S�`�'
Date of Accidend Injury or Date Discovered z-'ZZ '� Z Ti � am/pm
Please state in detail what occurred ha ned and wh ou ` � '
, , ( ppe ), y y are subnutt�ng,a claim.Please mdacate why or how you
fee the City of Saint Paul or its employees aze involved and/or responsible fo�r your damages.
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Please check the box(es)that most closely represent the reason for completin#this form:
❑My vehicle was damaged in an accident �1Vly vehicle was damaged during a tow
❑My vehicle was damaged by a pothole or condition of the street ❑ 11�y vehicle was damaged by a plow
O My vehicle was wrongfully towed and/or ticketed O I Iwas injured on City property
�Other type of propedy damage-please specify �o "� � — � l ,(�o�c-eS
�Other type of injury-please specify
In order to process your claim ou need to include co ies o all a licable documents.
For the claims types listed below,please be sure to include the documents indfcated or it wili delay the handling of
your claim. Documents WII..L NOT be returned and become the property of t�e 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�o your vehicle if the damage exceeds
$500.00;or the actual bills andlor receipts for the repairs I
O Towing claims:legible copies of any ticket issued and a copy of th�impound lot receipt
�Other property damage claims:two repair estimates if the damage�xceeds$5(�0.00;or the act}�al b�s
and/or receipts for the repairs;detailed list of damaged items ��� �-o �� cee.d S��
O Injury claims: medical bills,receipts
O Photogtaphs are always welcome to document and support your cl�im but will not be returned.
Page 1 of 2-Please complete and return Iwth page�s of Claim Form
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Failure to complete and return both pages will result in delay�n the handling of your claim.
All Claims-nlease comulete this section
Were there witnesses to the incident? Yes No nkno ��I (circle)
Provide their names,addresses and telephone numbers:
Were the police or law enforcement called? Yes � Unknown (circle)
If yes,what department or agency? Case#dr report#
Where did the accident or injury take place? Provide street address,cross str�eet,intersection,name of pazk or facility,
closest landmark,etc. Please be as etailed as possible. If necessary,attach�a diagram. .3 3 7 . ��9 lM.t./���.��
2.,�1 S, , S� P�.,� 1.-1 ,.� s s 1/9 �
Please indicate the amount you are seeking in compensation or what you wo�ld like the City to do to esolve this claim
t your satisfaction. � ✓ ti � � � 1 S ,
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Vehicle Claims-ulease complete this section C]check box if this section dces not applv
Your Vehicle: Yeaz Make Model
License Plate Number State Colo�
Registered Owner
Driver of Vehicle
Area Damaged
City Vehicle: Year Make Model
License Plate Number State Colo�
Driver of Vehicle(City Employee's Name) �
Area Damaged
; Iniurv Claims-alease comalete this section 1VA i0 check box if this section does not au�lY
How were you injured?
What part(s)of your body were injured? i
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Have you sought medical treatment? Yes No Planni�g to Seek Treatment(circle)
When did you receive treatment? N/-S (provide date(s))
Name of Medical Provider(s):
Address Telephone
Did you miss work as a resuit of your injury? Yes � o
When did you miss work? I (provide date(s))
Name of your Employer: ,
Address i Telephone '
❑Check here if you are attactung more pages to this claim form.�Number of additional pages
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. '
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Submi#ing a false claim can result in prosecution. Date form was ca��►pleted -Z- �3` �Z
Print the Name of the Person who Completed this Form: ��,����o-<<��+��"� �i
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Signature of Person Making the Claim:
Revised February 2011 i
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