Atherton 06128/2812 14:53 6517791821 FEDEX OFFICE PAGE 01/07
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06/28/2012 14:53 6517791821 FEDEX OFFICE PAGE 02/07
NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minnesora 5tate Stntute 4[�fi.US sta�e.r tlrai ��...P1�Nl'y�7P!'SUli...Wfw clauns rlumages,/'rorn mx�'IIlU77JCL�IlIIIIV...SII[lII CGUSL l0 v(!yrBSB11(C'CI/O I/1C
�nverni�tg hody o(the municipality ivithin I80 days afte.r t{ee nlleged los.s or injury i,s discrner-erl a nnrice.stating tfie rime,place,and
circum.ruuices t{iere�/;mt�1 the�imveuu nf cnmpensatin�i nr orker mlref demu�:ded."
P[ease complete this form in its entixety Uy clearly typing or printing your ansv�er to each question. If more space is
needed,attach additional sheets. Please note d�at you will not be contacted by telephone to clarl[y answers,so provide as
much infor�nation as necessary to expia9n your claim,an�l tue a�uount of compensation bein�requested. You will reeeive a
written acknowledgement ance yaur form is received. The procass can take up tq ten weeks or longer depending on the
nature of your c}aim. This form must be signed,�nd both pages completed. If something daes not apply,write°N/A'.
SEND COMFLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK,
15 WEST fKELLOGG BLVD, 310 CITX HA.LL, SAINT PAUL, MN 55102
F.irst Name
tj�z�.t�. Middle Initial �' Last Name -������p�
Company or Business�vame
Are You a��Insurance�ompany? Yes No If Yes,Claim Number?
Str.eet Address�'� F�'"�`� S��'' �����
City�'�i�`_ '��'�
C� State �� �ip Code �s�V
Daytime Phone (_._.—' - Cell Phone(���)1�'�'��—Evexiing Telephone( ) -_
Date of Accident/Injury or Date Discovere@__ G� ����2 Time���U am pm
Please state,in detail, what occurred(happened),and why you are subnutting a clai�n.Please indicate why or how you
feel the City of Saint�'auI or its employees aze involved and/or responsible for your damages.
'��,�,�—_ . _ '
Pf.ease check tl�e box(�s)that most closely represent[he reason for completing th'rs form:
p My vehicle was damlged in an accident
❑My vehicle was damag�d during a taw
O My vehicle was damaged by a pothole or condition af the street CI My vehicle was damaged by a plow
❑My vehicle was v�n ongfully towed and/or ticketed ❑I was_injured on City property
�Other type of prop�•.rty damage—please specify 1--.� '�'
Other type of injury—please specify_
In orcler ro process your clai.m v�u neecl to inelude copies of a1l aUUlicable documents.
For the claims types listed below,please be sure to include the documents ii�dicated or it wall delay the handling of
your c11im. Docume»ts WILI.NOT be returned and become the property of the Ciry. You are encouraged to kee� a
copy for ourself bef��re submitting your claim form.
operty c{amaae claims to a vehicle: Cwo eseimates for the re a�rs to your vehicle if the damage excee S
. 500.D0; or che actual bi13s ai�d/or receipts for[he repairs ��y�S ���/ �;�t,�'t,� V��
O Towing claims: legible copies of any ticket issued and a copy of the impound lot receipt
O Othcr proi�erty damage claims: two repair estimates if the damage exceeds$500.00; or the actual biils
and/or receir�ts for the rcpairs;detailed tist of damaged items
O tnjuiy cla�tns: medicat bills,receipts
O Photogra�:�hs are always welcome to document and support your claim but will not be returned.
Pa�e i of 2—Picase con�plete and return both pases of Claina Form
06/28/2012 14:53 6517791821 FEDEX OFFICE PAGE 03/07
Failare tc�c�mplete and return both pages will r,esult in delay in the handling of yovr claim.
All Claimis—Please comp�ete tl�is secti�
Were there witnesses tc�thc incident? Yes No Unknown (circle)
Prov.ide their names addresses nd telerl�one mbers: i1+�;L� '(3�_�
�6�+� •�;,.,n ��},� ��- ��,..�.1 �nJV �;�2 �,�-� ��t�.
Were the police or law enforcernent lled? es No Unknown (circle)
If yes, what depart�neni or agency? � Case#ox report#
Where did the accident or injury take place? Provide street address,cross street,intersection,naine of park or faciIity,
closest lai� k, etc. ?'lease be as detailed as ssible. If necessary,atta t a dia ram.
����u�5 �K ���' s,.,.,..< �— �,.��C. �.�._._�,t��,
Please indicate the a�ncunt you are seeking in compensation or what yau wonld like the City to do to resolve this claim
to your satisfaction.._._ _
�,�L` tec � Cx Js., } •l�,
Vehicle Cla�tms—please co lete thfs see 'on ❑ check box if this section does not a 1
YourVehicle: Year._��_Make i� � Model
_ ���, t���c3CaU X-�censr Plate Number,�/��1 C�]`�'� 5ta e,�1�1 Coloa' +
Regist�;red Owner � �
" ��'^ �'�� ` -Driver of Vehicle
���,.. ��:t-e�' Area L�amaged � �
�City Vehicle: Year_. Make Mociel
���License Platc Number State Color
����t`''"'� Driver of Vehicle{City Employee's Name)
_ �,i' ��i,��,,r Area I►amaged.
Iniurv Claims—please eomnlete this seetion ❑ check box if this section does not aablv
How were you injured"
VJhat part(s) of your b<�dy were injured?
Have you sought medi�;al treatment? Yes No PIanning to Seek Treatment(circle)
When did you receive�reatment? (provide da[e(s))
Name of Medical Provider(s):
Address Telephoi�e
Did you tzvss work as ;�resuit of your injttry? Yes No
When did you miss werk? (provide date(s))
Name of your Employ�:�•:
Address Telephone
❑ Check here if you are attaching more�ages to t1�Ts claim form. Numbec of additional pages
By sigr:ing this form,you are stating that ctll rnforntati.nn you have provided.is true anrl correct to tlae best
nf your knowledge, Unsigned fonns will not be processec�
Submitting a false eiaim c�crx result i�:prosecution. Date f rm was completed�i, f 1�
Print the Name of tht�Person who Complete, this Form: � �`'
Signature of Person P�I�king the Claim: v -'�� ����- -
Revised February 201 1
06/28/2�12 14: 53 6517791821 FEDEX OFFICE PAGE 04/07
Please state, in detail, what occurred, and why you are submitting a claim. Please indicate why or haw
you feel the city of Saint Paul ors employees are involved and/or responsible.
On June 10`h the tree located in front of property 1654 Juno Ave on the city sidewalk had a limb brake
free and fall on top of our vehicle resulting totafing the vehicle. Previous weeks to June 10`h we
contacted the city about prevention methods about the deteriorating condition and safety of the city
trees located on Juno Ave due to Dutch Elm Disease. ln result,the city informed us that the trees were
beyond point of rescue and they have been scheduled to be removed and rep(aced over the next couple
months to years. In aridition to the condition of the tree it is now one of the only trees being removed
after further review from lune 10th from Juno Ave due to the continuing condition and treat(t poses to
the block. Considerin};this information we feel that the city would be responsible for the full
replacement value of the vehicle in question.
06/28/2012 14:53 6517791821 FEDEX OFFICE PAGE 05/07
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