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Wolhat nCl.s�647�� . . MAY ? 1 2012 NOTICE OF CLAIM FORM to the Ci�T�f��c 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 dcrys after the alleged 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 additio.nal sheets. Please note that you will not be contacted by telephone to clarify answers,so provide as much information as necessary to egplain your claim,and the amount of compensation being requested. You witl 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`N/A'. SEND COMPLETED FORM AND OTHER DOCLTMENTS TO: CITY CLERK, 15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102 First Name��� ljf�l/� Middle Initial � Last Name �IS��.���-- �ompany or Business Name �� �...� , Are You an Insurance Company? Yes/� If Yes, Claim Number? ���---- Street Address `75� �Z�i'c���',-..�2 �.� �' �� City � State �/►,�,/ Zip Code ��,�J il(�� . ,;:,Daytirr�e Phone S(- �� �. .. ell Phone .(1¢S�),,Z(,�-�fi'UU Evening Telephone.��'�1.��-�.-_�-. /� d'�rX�- , _ Date of Accident/Injury or Date Discoverecil�d�i+ce� � 7y Time "� am/�i�, -�' y1-�-e.�- 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 ar�d/or responsible for your damages. (.� et .�.e.�,..0 v4� �'�,�i � f'I�o�� � , _ �� 3. SC � `rL....o-�-- ' �� _, �r.iG1.e_ e.:��g � ",...�� ~.�,�p .;�r o,�,�fJ �' k..�+-4.tz � -,. �,� �`i-�. � � �7.0 fi'�-��.s�-- Zo Gri, f Z $� pL✓ cSS' /, cc lRro,,�_ � `� �,l�.� Plea e_check the bo es)that most�lose y repr�t e reaso�'For mpl�this form: R �� ❑ My vehicle was damaged in an accident C�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 towe�and,��r t-�cketed �I was injured on Ci�y properi.y ❑ Other type of property damage-please specify Q'Other type of injury-please specify ,[ �„u� ,�, n,we�. �_�� /�� In order to process your claim youu need to include copies 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 your claim. Documents WILL NOT be returned and become the property of the City. You are encouraged to keep a I 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 cop.ies of any ticket issued and a copy of the impound lot receipt O Other properly damage claims: two repair estimates if the damage exceeds $500.00; or the actual bills and/or receipts for the repairs; detailed list of da.ma.ged items `fd�Injury claims: medical bills,receipts ��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 � � , ����s��� ; Failure to complete and return both pages will result in delay in the handling of yonr claim. � ' MAY ? 1 2012 All Claims—please complete this section Were there witnesses to the incident? Yes No Unknown (circle) ��"�" ^ ���� Provide their mes, addresses and tel hone numbers: .C�a �� �Z.'��..e_ �'���'- ✓ � ', �f�1 � ��tJ{ue,t �1� j Were the police or law enforcement called? I� �e' Unlrnown (circle) � If yes,what department or agency? Case#or report# Where did the accident or injury take place? Provide stxeet address,cross street ug ersection,name of park or facility, closest landmark, etc. Please be as detailed as possible. If necessary,attach a diagrarii: �: GL-.S2 �"-��'�5"� � r�„l� 1�v /��o�" �.� �.:��� %v�-°� /Li•�3/�1/ - - - — z Please indicate the amount you are seelflng in compensation or what ou would like the City to do to resolve this claim j to your satisfaction. i � J I S � - .•--�- ? r;..,,�ti �Z..� e.r-�-- � r�. 0`` :� `�' � `� ' �-g,��.� � �G (n�-� "ar--�- �'�^�'� VehicIe Claims—please complete this section �check box if this section does not applv ;. Your Vehicle: Year Make Model � License Plate Number State Color � I Registered Owner � , Driver of Vehicle i Area Damaged ' , _City Vehicle:.s,Year�Make _ Model � , : ._ : -_ _ .._ . : . { License Plate Number State Colar � � Driver of Vehicle(City Employee's Name) j Area Damaged , In'u Claims— lease com lete this section ❑ check box if this section does not a 1 �Iow w re you injured? _.-P.� C �- �'` �" �! - ��J ; G.� �1 �- S�-�'� ./t'� What part(s)of your body were injured. �- � �` ( J �. �- -� 5°�� �� ) Have yo sought medical treatment? es No Planning to Seek Treatment(circle) ; When did you receive treatment? ' f � (provide date(s)) Name of Medical 1'rovider(s): ' Address S �lu�(.� ,�c� Telephone `�.- - '— ' Did you miss work a a result of our injury? s No �n p� �' When did you miss work? }�t.^�c9 �,rQ i1.��-�c✓� . 5�°� �� /V(��'o�vi6�date(s)) Name of your Erriployer: �„�-- �'.���✓ � �-`� ' Address Telephone �Check here if you are attaching more pages to this claim form. Number of additional pages ', i By sigrzing 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 ih prosecution. Date form was completed � Print the Name of the Person who Completed this Form: ` - , Signature of Person Making the Claim: �/�i.�✓`v � Revised February 2011 '�o�ri,I�irk�{1t�R#�€�237313}gQB: �1I231117Q Page I �f 4 K��k�1ilitftt�a�t i��scri�cu,: 49 ��d�1� �1�2d3'1��.4t3�1�U!�ff'�V'�# �rfl�er #��t�ns,�ilat#hev�r�lt�ony . �:�0237�3 �epa��en� tl��()�opaec� Diagr�ses Osteoarth NOS-t/teg -Primary . 715_96 �r��ea�taiir�� i�lo�cexts,Matthew�A�thrmy HP F�l�'�'�C�.�l �t1$�2�J12 90:11 F�1 Sigr�ed . E�CTHf�EE�CISPQ�#t'�S�E)tC�E F€?�.�#€)P CC:knee pain P��EI�tfl�i�iTl�i�l��t)�:�Cirk��bl�ar�t�ss��9 pr i� vvh,ri��set�s frir�val��of #�rtee�ain. ��r�t�itia�seen�8141#1. He�as tra�a his�ory ofi bitaterat tefit men�sc�#�ars and�history�f two previous arths-oscopies(don�at Summit)and a right arthroscopy done in 20QJ for"loose carrtitage. He suffered a fait in 7t91 wifh increased knee pain,SP IR ster�i�tjedion done by f€�is aufhor ort cwr��'iat visit in 8111. Had not returned for FtJ. �iVT�Rif�}-iX: faA�rt�13�1�32 while�vai�cirig�n�road�nirth a�riertti. �ast�mday vvas wa#king a"cat�ht�is icnee"and, : i`e�: `�€t�+��a`t�i�� �r���r��t�;ta'�rt��` ro n= ���e�p�ince.�t►at:fime with ongoi�g,sense of futiness�and catching. n��`�et��n�tt7�,t#�e�jt#3���e�1fl�r�ef�7-���Frs-�i�#��ii�t#�a�ai�. Mir�ima!pain�r�the right kn�. Since�#as�saw him t�e had twe nedc surgerias. ACDF C5/6f7.iUfost recen# �urgecy�by dr_ t�E�re�i�eacl� '��t2l�t'�. �v�j. G, a t5"d l N`b�/ `t o`L o i-� �,-�� `P°v �'Y'� �w �c b �e�/�/1. S n/ti`e� � AAEDlCATlONS: � �, Uu#�atient Presc�iptions Prior to V�sit M�ic�t�� == : S+9:�....._ : w.:;::,.. .. . .,,.i�spe�se ; . , �ef�l� _ • ACTC35�5 MG tabiet TAKE '1 TABLET 8Y MOUTH �0 Tal� fl 63l�tGE QA#LY • aspi�in 84 MG table� Take 8'! mg by�daily. _ • ATENaIoI{AKA TENORMtN)25 TAKE 1 TA8 BY MOUTH DA1�Y. 94 Tab 3 AAG tabl�t • bltx�ci glucose 1/#{VflGAL POINT Us�as dir�cted.P#rar�acy PRN �L40D GLUC�SE TES�st�ip dis�ense brand based an it�suratic�_ - c�lecc��b(Alt�.CELEB€�EX} �tUi3 T�lce 1 Cap by moc�th twa times £tl Cap 1 MG capsuie aday as needed for Pain. • citalopt�m{AtCA CELEXA�40 Take 9 Tab by�ut?�da7y. 3D Tab 3 �UIG tabie# • ergoca�crferof(AKA�RISDOL) Take '! Cap by mouth once every 92 Cap 0 54000 UNtT capsule wee[c for 84 days. • gabapentin(NEURONTIN)304 Take'i Cap by mvuth Ettree times 90 Cap 0 MG capsule a day.Take with 60Qmg tabs for a total of 1�tKtr�g�ree�mes tlaiiy ' • gabapentin (NEURONTiNj 6fl0 Take by mouth_Take 2 tabs �80 Tab 0 NEC tabiet {'l2dfl�ng)three tit�r�es da�y with 3QOr��g tabs for a tatat of 4 SflOmg three�imes daity • t��1��F�L{;����.���f�,�� ��B���S b�il'IDt1#�l�1Nfl�tlTl�'S �U���7 � XL)10 MG 24 ht�ur release#ablet a r3ay. • insulin giargine(AKA LANTUS) Injec#5U Units subcu#aneously 30 mL 0 't 00 UNITtML�nject�on tinro ti�a day f�3E3 days. � insulin syringe-needte 30G X 112 AdmirtES#er witt�insu6n daily as 100 Each pm inch 0.5 mL 30G X 1J2"0.5 ML instructed 'U�flll�art,Kixk E(MR#5023�913)P�n�b3�{3��12)at 5I18lt2 ��.14 AM • Pictures from Sprint: View Message Page 1 of I .� - -� � ��� ���` � ,Nf: r'.,g �: ,-7 � x ��y�� i ��."��� �--�` °�`i+�;�`�'ut, �'�� �����.� ���.�'��s �-3�-� •q� � � Q�� � � � �� �(�,,�,�L- � �✓�',�c- ( S d`.�' v� �`�`!�-`� ; `�P/l�- d �� •JO✓ C�'1. ` .� `�`�'�s �wv��.�v� \ � http://pictu.res.sprintpcs.com/sh�:�`13�nvl�epn��+l't�� �;, ,,; ';� ';i,, ,� , - - �-���� � �� . 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