Brandy . REC���'E�
JUN 0 5 2012
NOTICE OF CLAIM FORM to the City of Saint Paul������a
Minnesota State Statute 466.OS states that "...every person...who cZaims damages from any municipality...sha11 cause to be presented to the
governing body of the municipality within 180 days 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 additional 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 will receive a
written acluiowledgement 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 DOCUIVMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
First Name�,�T�J � ��_ Middle Initial Last Name
Company or Business Name
Are You an Insurance Company? Yes/ o If Yes, Claim Number?
Street Address -
City State � ,4 f Zip Code �
_... ._ Daytime Phone ,�S���;�.t_. _Cell Phone( .) . -._, �v.ening Telephone( )
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Date of Accid�ti Inju�ry� ate 13i��ed Time am/pm
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 'nvolved and/or responsible for your damages.
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P ease check e box(es)that most close y represen e re for completing this form:
❑ 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 vehicl_e was vv�-c�ngfi�.11y towe�zncUor t?eketed n i vvas injuxed or_City properly
❑ Other type of property damage—please specify
❑ Other type of injury—please specify
In order to process your claim vou 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�III,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 far 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
O Other 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,receipts
O Photographs are always welcome to document and support your claim but will not be returned.
Page 1 of 2—Please complete and retnrn 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 wiCnesses to the incident? Yes No Unknown circle)
Provide their names, addresses and telephone numbers:
Were the police or law enforcement called? Cs No Unlrnown (circle) '
If yes,what department or agency? � Case#or report#
Where did the accident or injury ta e place? Provid street address, cross street, intersection,name of park or facility,
closest landmark, etc. Please be as detailed as poss' le. ecessary, attach a diagram. -
Please indicate the amount you are see 'ng in c pensatio r what you would li the City to do to resolve this claim
to our satisfaction. ��. �;
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�T��:cle r'!z���– 1Q�sp c��nniPtP tha. ect�nn . _ __,_ 0_check box if this section does not appl���
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Your Vehicle: Year M e Model " -
License Plate Number ;�`� State Color
Registered Owner .� r
Driver of Vehicle �'' � s�' �°
Area Damaged ' � ° �` ''�
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City Vehicle: Yeax M e � l�odel
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License Plate Numb r te or
Driver of Vehicle ity E` oyee's Name
Area Damaged
In'ur Claims– lease com 1 te this sectio ❑ heck box if this section does not a 1
H were ou injured? -
� _
t part(s)of your bod ere injur ?
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):
Address Telephone
Did you miss work as a result of your injury? Yes No
When did you miss work? (provide date(s))
Name oi your Empioyer:
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 ���--�'� "�J `�
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Print the Name of the Person who Completed this Form:
Signature of Person Making the Claim: �
Revised February 2011
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