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Divine OS/1�/2012 U8:47 'FAX B5126K8S74 SAINT PAUL CITY COUNCIL l�OOY/003 �UiV U �� Li1�L l�OTICE O� CLA�M FORNI tu tlh� City �����t���1, 1'��Y�nesota rLli�inCSwu Stniv Srirkur-lbo.05 stu�r.�Jhal ".,,evrri�persn�r...m(ir�rlriin�.,��/�i�nu�,csJir�in t�rrv municipa.lit�•. sli.r!(�.�u�s� ro bc presrnred cn rht ;i�G�vn�ing hpt/}'t?f Nu'���ur�lc,pullrp u�i1{tiiz/8U dlq�s<(ftr.rlhe a/(c'�;ec!Iu58 rn•injtu�'ts dia�cni�err�l��an.� �r:'�c1G;^g Jl�c lirnC,pk�Ce,[l��d Ctl'C1Gr1falRnres tl�erea/:und rlyC anrol�ql o�rUilipe�rSCNion c�r uther r•�rlrnf dcnta; 'eti.'. !'lease Co1m��lete this fora�in its ertiirety by clet�rly typing nr��iryntita�yopr ansNVer io Eu�I q,���;fon. iP mure Space i� needed,t�ktach.:dditiaial shects. P1C:�.Se nUte tl�at you will npi be C��l,t&CtELI by t61epR1pn�t� Clt..rif,• Mnxx�ers,su providr.as ���ueh information s�s�eCer�saAy to explain your clpitn,atld ihe umount Uf compens&tiun bei� ;n;qL r�slc d. You will receive a writtert aclrno'wl�dgement unce your Yorm is receivecl, Th�proc�ss ean t31:c up to ten wee 1 s ur l+inger dependiug on the nature aX your clain�. This Yorin must be si�ned,and both pa�es completed. Yf somethin;!dc•es�kot �t��p!)�,vvr�te°N/A', SEND CO�'x�E'l��ll FOR�VI AND O'1`H�;lf� DOC�U'IVIIEN"1'S 7 J; �:,"�'�'Y CLERI�, 15 '(�ST T�F.LLUGG ]BL,`V]D,310 CT1�Y HALT., SAINT P�� UL, MN 55102 Fi�•st Name _....,�. v2idille L�icial L Last�lai»a �i�✓� v�.[__---_� C:umpuny or Business N.ami���,�„�r_ __ _ Arc Y�u:�n Insui'anc:e Conip�tny'? Yes Vo If Yes,Clairn Numb�r'?_ !� �. Sil'z�i.Addr�ss����r� ��_ ✓��yL �,�—/�_ ��[r:,._._...,.,.—. —_..—. V City_�• �r�.�.�..� —.,_,..�,,. State�,,,,�.,_.,�..�Gi C'.�dr �S�f (`"f Uaytiltle Yhon� (6ry)��-fAR�j,CeII Phone('Z,�)72.Z-���t�ening'f'elephona �7L3 R3Z-�R�� U;IiZ OF ACCide�l[/III�UPY Ot'DA[c lliSCOVered S_������1'ime `?� ��V ,ar��/ m Pleflse state,in detail, wh7t occu,r�d(happenedj,and wl�y you ar�subrrut�ing a claim, F�:a��e i�idi�,:ate why or how you feel Ctta City oF Saint Aau!nr its employees�lt'e itivolved 2ncUor r�s��onsiblr. t'a•your dan���r,s,'�"�,,,,,�„�,�_�,� CA�Crit� ;s Irr.w .�C�,��.�,,�_ -'CKF.�t' e�r!" �r/�`.t .�,_ —��,—�,��-�1„��„� � rl�+�q�ci� ��—r°� �... ` t�..�Yd�d-�.�'i�h� �;CG o r� Zo ` S c��. s- to .f.��.F- Ft-� W i{�C( �d ort c�f�a,l'�er.�.S f� `. i s cf�,,��cx�i ��5���k,�_.��� Sflaoef ln.<SCS b e.c5 , Please chect;tha hox(es) that most closely represent the reasan fat cc,mplcting tr�i� f�r�r �� 0 vly vehicle wa�d�ma�ed in au accident O My vehicle Nzs d,�rnttgec�clurino a tnw �i My vehic2e was d�rnag�d by a pothole oi•eondition of�h�sfr�4t L7 My vehicic N��u:uni���d by H plow Cl lvly v�hicle was wron�Pully tow�d aa�d/or ticketed � I was 'tnjur��1 i�n l"ity prope��y O Other Eype of�roperty darnnge�please specify__,�_____,.,,�,,,,�,_„� J_,_ �Other type �t'injury w please specify___�,�, ._,,,_,._,,,,_.,,�_ ln orcler to pro�.ess yot�r clai�n vou nEed to include cn�ieb of all anpl.i�ablc dacuments. l=��r tha elttin'is types ►isted below,l�lea�z be surr t�includc: the d�c�tments i�ldicate•d or wi][ ieltiy IIZ��1111C�Ltlo U� your claitn. Doeumen�s W1LL NOT be retuc�led and becunie th�propecty of�he City. ou�u e er�r.ouraged�o keep a copy for yoursr.tf bet'or�submi[ting your claim form. O }�•ope,�t��d�ntagc cl�im�tu a vehicle: two eslimaces toa•ihe rapaics to your vr �icle i r th�,damaae exceeds 5S()O.�p;nr t.l�e actuaL bills and/or recti�ts fur the repairs O Tnwing claii��s: legible copies of any tickct issuc:d r�ncl:�copy ot[h� irnpuun. 1cc r��ccip�: O Othe,�pruper[y damv;�cl�iims: two�-epa��•estimates if the�damaae excz.ed�� Q(�.0��; o,Che accual hials and/or receipts for the r�pairs;detailed list of damaoed i�ems O lnjury claims: nleijical bills,reezipcs O Photo�raE�hs�u�aiw�ys wcJco�ne to ctucurncn�1n�supp�n your clflim but v� Il noc b� returnecl. P��;e 1 ot'?--Pleuse comptete�ir�d r�tarn both pa�es of t:l�i a l'or m �,,,,�,�( ���;� `.�. � ( 1 E0/T0 �Jdd 1�/1 NMOldfl 9Eb9bZ8Zt9Z �b�LZ ZZ0ZIb0/90 o5/1B/'1012 0&:48 FA$ 6512�B8574 SAINT PAUL CLtY COUNCl� �j003/003 THilure to totnplete and return buth pages wilt resutE in delay in lhe hand! n�;oi yuur claim. All C1Hims-�►leas�*complete thix s�tioln We:rc there w;tnesses to the ineidcnt? Yes No Unknot�vn (circl. � Providt their r�ames,addresses anci telephone nurnUars; ,�)��__ . �.—..—.__ Wcre che police or law enForCCtticn[C�llled'? Ycs 'Vc Un.known {�ircl�:i lf yes, whc�t de�,�artment ur a�ency'?� Case#pr rc;port#_ ��_.r Wl�ere did the�cc.i[icn[.or i»ju�y take place'? Provide su�eec acldr�ss,crOSs str�;z[, intiea•�ec: o��,n:t['t1r,' of pa3•k or facility, closesc l�zndmark,etc. Please be as detailed as possible, lf necessary,actaeh a diagrarn. r1✓��]n,� Ce�rl��f ��..,�.C.� ��rtC?f"e�t�l —�. --._„ Please indica�� the�mount you are sc�king in com�ensation or what yau would likr.ihe ic, tc �c�tu�•esalva this cl�im tu your s�t.islaction..�33.(�.,�.9 'f"n ���P_ W__1 �� 1�.�.�.'�i.C��1�Ndr�L. Cr-c^5 d�]{'r.�.z�',r. _ _ ----� -- Vehicle Claims--nlease cutt�lete this sectiun ❑check bo; iP thi: se�:r.inn does not applY YoUC Vzhicle: Ye:u�oo�_1V��i:e T��� Model�L�,,,�,�t�� �1[a.��.�.�"��� �,ic:ense Platc Nun,b�r State�Color��_s�--.�.��. lZegistered Uwn:;r_�,�,n,.�( L 7�;Y�v.t. �........._ _�.___.., Driver ut�Vehicle A�y,+ Z��_ �:,/i�lt_ _ .�. _._.....M..—.—.u,�— Area llamaged �r'�� '��Ti�- ,— --•--. City Vehi�Le: YeAt'�,�M�l:e ..r,�.,,�:�lcxiet ,� A�.. --._..r... ._ Lice�ise Plate:Vumber a�,4 _ Sl'ute��Color�(� __,.,,_,_ L�river of Vel�icle(City Employe�.`s Nnme) �,/.� -,_ ��,, --.�..— Area Dan�agcd ,...� ---.-�.....- Tniurv L'laims-I�l�ase cqmnleCe this sectinn cheek bc, ii'th,�sc:cci�n does not a lv How were you it�}ured? _ � .�-- •�— -- Wl�at part(s)oF yaur body were injurcti'?_..� � � .�..--..� --—•- I�1ve you soubh[ medict►1 d'e�ttmi;nt? M Yes No Plannin�cu Seek'• 'e�.[m'At�circte) � WE,en dici you receive treaunenC?,_ .� _�„� —._—(P3'ovide date(s)) Ndm�;uf Medic�zl Provider{s):_......,,,__.r,,.�� —__-�.��_,,,,—_ .— Ad�iress _ . .�_'I'elcphc� e.^.._.__. Dici yull 1i115S WOf�:aS 3['�sCll[Ory0U1'Utijury'? Yes Na When did yuu nuss work?`.� __..,,_^(p�'uvide dat�(s)) N�me uf yout'&mployer:._.„ „ �.,__ w.� _-...,..__ �-..». Address ^Celeph .�e�.__�.,..� J�Check he��'it''you�xre�ttaching more na�;es to thib claim Ya•m. Numl�cr o dcldi'.ional pages � . 13y se��ing thia furin,yozt ar�statirtg that all info�'rnatio�x you h�ve providec�is !�•ue G:�zd co�•rect tv the hest of your krtowledge. IJrzsigrced fnrnas will rrot be processed. Secbmittzr�g a false clazna earz resulE in p�•asecutiora. Date forna ►+'as eompletec],� �o=�'r print lt�e Name of the Persori who Completcd tlxis kurm: _g� ������—�- --- � � � Si;nature of I'et:sun 1Vlrikin4 the Claim��'�'�J����--_ --.__..� ,�_._ ,�- l FZeYISe.d FLbC11iiS)'�U�I _ ,�\�1/� �� � � ,�,,,,�,� . �e�ze �J�7d 1�(1 N�101df1 9Eb9bZ8ZT9Z �b�LZ ZZ0ZIb0/90 06/04/2012 17: 43 16128246436 UPTOWN UET PAGE 03/03 y � � V� T f��` � s-r y y� � - - Gr ��� � a � o o, oOm� 0O N n � tooNa� oh y • • r-I �0 �WMh�O �'..� m M Fro �'� M .� O �� O � �� • � ,•� F�.vj �G�1�0 a00000000o wyF,E+ O O O o O O O O 6 p � WOOa�p�p�pObOo P7 �lnOnfo�C�000ph .`. . .. . 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