Divine OS/1�/2012 U8:47 'FAX B5126K8S74 SAINT PAUL CITY COUNCIL
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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„��„�
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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
�,,,,�,�( ���;� `.�. � (
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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� ������—�- ---
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Si;nature of I'et:sun 1Vlrikin4 the Claim��'�'�J����--_ --.__..� ,�_._
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