Morrison NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minnesota State Statute 466.OS 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 a[leged 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`lV/A'.
SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
First Name�/ISr/i�� Middle Initial �T Last Name � .l S
E�IVED
Company or Business Name __
Are You an Insurance Company? Yes� If Yes, Claim Number? `� � � �'�
Street Address �S 3 C� � �l-e �I �����
City J� ST. G� State �� Zip Code 55/1�
Daytime Phone(��-7foo 3 Cell Phone cjps r )�-�Evening Telephone(� -
Date of Accident/ Injury or Date Discovered �/3� //� Time am/pm
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 involved and/or responsible for your damages. �.�y� �,.C ��
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Please check t bo s)that most closely re esent the reason for completing this form: � 7�
❑ My vehicle was damaged in an accident ❑ My vehicle was damaged during a tow C4'"`���"""'
❑ 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 rvas injured on City property
�Other type of property damage—please specify ��.���n.a�r+� (,�.�1�--� �c+�--�-
❑ Other type of injury—please specify
In order to process your claim you need to include copies of all apnlicable 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 handling of your claim.
All Claims—please complete this section
Were there wimesses to the incident? Yes No Unknown (circle)
Provide their names, addresses and 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 street, 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 seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction., �►,Q�.�,v� � c�✓��7(� e�e , ��►.Q c c�.�,�.L7�
Vehicle Claims—please complete this section ft�'check box if this section does not anplv
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
IniurYClaims—please complete this section �eck 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 you are attaching more pages to t6is 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.
Submitting a false claim can result in prosecution. Date form was completed
Print the Name of the Person who Completed this Form: �,h� (l S�"I h C �O�( �S 0 ►'1
Signature of Person Making the Claim: ��
Revised February 201 1 •
March 16, 2012
City of St Paul
City Clerk
15 West Kellogg Blvd
310 City Hall
St Paul, MN 55102
To whom it may concern:
A gentleman came to the house to replace the water meter back in December.The main water pipe is in
our basement in the south side of the house. He was able to access the old meter and replace with the
new one. I was not told that there were any complications with replacing the new meter. The cover was
put back into the wall and I didn't think twice about it until I received a call from my husband stating
that the carpet in the area by where the main water pipe is located was wet.This was on 1/30/12 and it
was the first time we had noticed anything. My husband pulled the cover off and noticed the pipe was
leaking. He called the water department that day and a gentleman did come that day to fix the pipe.
I am not aware if the gentlemen that fixed the pipe made note that the carpet was wet or not. The
carpet did take about 3 days to completely dry.
I debated about taking pictures and sending them, but the carpet is navy blue and the pictures wouldn't
show anything, but it does stink. I certainly don't want to pull the carpet up to take pictures.
I am requesting that the carpet either be cleaned or replaced at this point.
Sincerely,
�--�—�' .
Christine and Gordon Morrison