Chang, Bao ' NOTIC� OI{' CLAITVI FOIZIVI to the City of Saint P�tul, TViinnesota
rb/innesota Stnte Sln�ule=/66.05 stn�es lhat " ...eve�y persnn...ii�ho claims damnges from anp numicipa(ih�...shall cause lo be presented to the
gonerning body�f the municipnlih�ri�ithin /80 days af/er the a!/egeclloss or injwy is discovered a notice stating the time,pince, and
circunutnnces lhereof, nnd the amount qf compensation nr other relief demanded."
Please complete this form in its entirety by clearly typing or printing yoiu•ans�ver to each question. If►nore sp�ce is
needed,attach additional sheets. Please note that you will not be contacted by telephone to clarify ans�vers,so provide�s
mucli information as necessnry to explain your claim,and the amount of compensation being requested. You �vill receive�
w�ritten aclo�o�vledgement once your form is received. The process can talce up to ten weelcs or longer depending on the
nature of yotn•claim. This form must be signecl,and both pages completed. If something does not apply,H�rite `N/A'.
S�ND COMPL�T�D FORM ANn 0►THER DOCUM�NTS TO: CITY CL�RT�,
15 WEST K�LLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
rirst Name a� Middle Initial Last Name�lit..GL02 C� ���.,�.����
-,-t�s�;:��
Coii�pany oc Business Name
0�2
Are You an Insurance Company? Yes/� If Yes, Claim Number?
Street Address �j� � /yb��- f��(' � � `'�`�
City_�-� ��� State I� � Zip Code s�l 3v
Daytime Phone (�)�,.,�-�7'`�'ell Phone �) - �vening Telephone(_) -
Date of Accident!Injury or Date Discovered Time �m/pm
Please state, in detail, what occurred (happened), and why you are submitting a cllim. Please indicate why or how you
feel the City of Saint Paul or its employees are involved�nd/or responsible for your damages.
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� �� 1 lease checl:the box(es)that most closely represent the reason for completing this form: ��S �.�
� �y vehicle��vas 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 wrongfii(ly towed and/or ticketed ❑ I was injured on City property
❑ Other type of property d�mage—please specify
❑ Other type of injuiy—ple�se specify
In order to process your claim youu need to inclnde copies of�ill npplic�ble documents.
ror 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 ]:eep a
copy for yourself bePore 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: (egible copies of any tic(:et issued and a copy of the impound lot receipt
O Othec 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, ceceipts
O Photographs are always welcome to document and support your claim but will not be returned.
Pnge 1 of 2—Please complete �ncl retnrn both pages of Claim Form
� F�ilure to complete�nd return Uotl� p�ges���ill i-esult i�i delay in tl�e handling of yoi►r claim.
All Cllims—please complete this section
� Wei-e there witnesses to the incident? Yes No Unknown (ci►-cle)
Provide their names, addresses and telepllone numbers:
Were tlle police or law enforcement cal]ed? Yes No Unl:nown (circle)
If yes, what department or agency? Case# or repoct#
Where did tlie accident or injury tal:e place? Provide street address,cross street, intersection, name of parl:or facility,
closest landmarlc, etc. Please be as detailed as possible. If necessai�, aitach a diagram.
��- c��► s--� - Pc� �o<< Q � o n�-►� � 'Le —
Please indicate the amount you are seel:in in compensation o wh�t you ��ould�e the City to do to resolve this claim
to your satisfaction. � .Q�^ j s n oe r' l.Q�j'y� �`�' e� _
� ' J
Vehicle Ciaims—ple�►se com lete this section ❑ checl:.box if this section does not a l
Your Vehicle: Year�_M�l:e�-�1 Model L
License Plate Number �f� tate��Color�'�,,.,,¢�,,r�
Registered Owner v (,t�,�,
Driver of Vellicle u.[� '
Ace1 Damaged -r
City Vehicle: Year Mal:e Model
License Plate Numbec State Color
_ _ _
Driver of Vehicle(City Cmployee's Name)
Area Damaged
In'ur Cl�ims— �lease eom lete this section ❑ checl:box if this section does not a I
IIow 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):
Addcess Telephone
Did you miss ��orl:as a result of your injury? Yes No
When did you miss worl:? (provide date(s))
Name of your Employer:
Address Telephone
❑ Checic here if you nre nttaching more pages to tl�is clnim form. Number of�dditional pages
By signing this forni,yoec are statiizg t1�at rc!!r�iforniation yor� have provided is true aiid correct to tke best
of yorrr I�noyvletCge. Uiisigned forms �vil/nnt be p��ocessed.
Submitting a false cl�rim crrn resrrlt in proseccetio`�. Date form w�s completed _ S'" — , — /Z
Print the Name of the Person who Completed this Form: `�j �} � (� {�( f� � [�
Signature of Person M�Icing the Claim: �--
Revised rebru�ry 201 1