Andrews NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minnesota State Statute 466.05 states that "...every person...who claims dsmages from any municipality...shall cause to be presented to the
governing body of the municipality within 180 days a,fter the alleged loss or inju��.c' ��e��notice stating the time,place,and
circumstances thereof,and the amount of compensatior{d�e ��t manded."
Please complete this form in its entirety by clearly typing or printing�aas�v efj��rach question. If more space is
needed,attach additional sheets. Please note that you will not be contacted by telep�ione to clarify answers,so provide as
much information as necessary to explain your claim,and the amount of � t �eing requested. You will receive a
written acknowledgement once your form is received. The process can�xke up��n 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, SAINT PAUL, MN 55102 ,
First Name_�j�-�'J� Middle Initial � Last Name /'�1��)1�-�W S 'I
Company or Busii�ess Name ' �
I
Are You an Insurance Company? Yes,� If Yes, Claim Number? �-----
Street Address �'f Z ��'�,/kLL''S'(C�1'L- S 1"���'1"�
� 7
City S I • ( /�1/l�- State �� Zip Code � ��`�
Daytime Phone �C S I)�j�f� �D 3I 7 Cell Phone G�c s� �7��- �3y9 Evening Telephone(�S[) �/�'�y36
Date of Accidend Injury or Date Discovered ��G . �-t� l � Time am/pm
o � . , .
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.
� r ,r�f �F v
" � � S
• , � �,,..
. � w�•-�t.,
, ,, , t
, � � ��
Please check the box(es)that most closely represent the reason for completing this form: �' �PiOC�'
❑ 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
S�ather type of property damage-please specify
❑ Other type of injury-please specify r �
In order to process your claim vou need to include copies of all apulicable 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 WII.,L 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
p�d Other property damage claims: two repair estimates if the damage exceeds$500.00; or the actual bills
andlor 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 witnesses to the incident? Yes No Unlmown (circle)
Provide their names,addresses and telephone numbers: '�'
Were the police or law enforcement called? Yes � Unlrnown (circle)
If yes,what department or agency? ""!"—" Case#or report# '
Where did the accident or injury take place? Provide street address,cross street,intersection,n e of park or facility,
closest landmark,etc. Please be as detailed as possible. If necessary,atta.ch 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. ' p0 % � �`
� oJ .��-ZOIZ
Vehicle Claims please co�lete this section ���' ❑ check box if this section does not apply
_ _ —Y"�ur V�cte: Year - -----Ivlake -- -- — �`vlad�- - -- ----_ -- --�— - -- __—
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 • � • !
Iniurv Claims-please com�lete this section /"'�" ❑ check box if this section does not apnlv
I�ow were you injured? .
�
What part(s)of your body were injured?
Have you sought medical treatment? Yes No Planning to Seek Treahnent(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 iruss work? (provide date(s))
Name of your Employer:
_ _ __ _ - — --- - ------ _ _ _ _ —
Address Telephone
❑ Check here if you are attaching 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
Submitting a false claim can result in prosecution. Date form was completed � '" Z S�' ��/ r''7
Print the Name of the Person who Complete\ his Form � - ����
Signature of Person Making the Claim:
Revised February 2011
COMMERCIAL UTILITIES,INC.
1146 EAST SEVENTH STREET
ST. PAUL,MN 55106
PHONE 651-774-0330 FAX 651-771-8983
cuicurella@me.com
INVOICE
Apri13,2012
— - � __.
Job No. 8949
__ _ ---�IIVOice No.6149 _ _ _ ____�_ __--__,__.
��
Richard Andrews �
412 Macalaster Street �
St. Paul,MN 55105 �
i
RE: New water service '
412 Macalaster Street
Furnished labor,equipment, material,and permit to install a new 1" copper water
service at the above mentioned project.
AMOUNT DUE: $2,30Q.00
,
- _ _ - --�--- -� - _ - ----
�
;
i