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Atherton (2) �, �iE�El1t'�[� ��.!! 0 2 2012 NOTICE OF CLAIM FORM to the City af ,�..�t,��Minnesota Miitnesoru Stnle Stntute 4fi6.05 stat��s tJrat "...el�ery per.ran...w{t0 CIlIII)7S IIG1nlJ�L'S fi•orn am��nuniciprilin�...shall cuuse to be presented ta lhe govern{n�;bacly nf zhe»�tmic,ipality itiilhir2 180 day,r¢fter•the alleged loss or injur}�is drscnvered a nntice.staling tlie tin:e,place,and circumstur2ce,r ther-eq/;and the arnnurrt of compen.ration or other relie f venwnded." 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. Pleasc note that you will not be contacted by telephone to clarify answers,so provide as much information as necessary to explain your claim,and the amount of compensation being requested. You will receive a written acknowledgement once your form is received. The process can take up to ten�eeks or longer depending on the nature of vour claim. This form must be signed,and both pages compteted. If something does not apply,wrife`NIA'. SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK, 15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55i02 F.irsC Name ��`L� Middle Initial �' Last Name ��U� Company or Business Name Are You an Insurance Company? Yes No If Yes, Claim Number? Street Address �� -�� S�c-�� c`��1 v City ��,f'v�JC�� State �� ZipCode �=�5_ ��_ Daytime Phone ( ) - Cell Phone (��-)��'�� Evening Telephone( ) - Date of Accident/Injury or Date Discovered �� F��. Time�\�� am pm Please stat�,in deCail, what oceurred(happened),and wh�r you are submitting a claim.Please indicate why or how you feel ihe City of Saint Paul or its e:mployees are involved and/or responsible for your damages. �� Please check the box(es)that most closely represent the reason for completing this form: 0 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 towed and/or ticketed � � � ❑I was_injured on City property �Other type oti property damage—please specify L..,+.r, Other type of injury—please specify In order to process y�ur claim you need to include copies of all apulicable dacuments. For the claims types listed below,please be sure to include the documents indicated or it will delay the handling of your claim. Documents WII.L NOT be returned and become[he property of the City. You are encouraged to keep a copy for �urself before submitting your claim form. operty damage claims to a vehicle: two estimates for the re. airs to your��ehicle if the damage excee , _500.(30; or the actual bills andlor i-eeeipts for the repairs ��;�;,j ��,}.n,i ��-t� `�J��d 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�SOO.Od; or the actual bilis andfor receipts for the repairs; detailed list of damaged items O Injuiy clairns: medical�ills,receipts O Photographs are always welcome to document and support your claim but will not be returned. Page 1 of 2—Ptease complete and return both pages of Claim Form Failure to complete and return both pages will result in delay in the handling of your claim. All Claims-ulease complete this section Were there witnesses to the incident? Yes No Unknown (circle) Provide their names, addresses nd telerhone mbers: �,n � c S r ��,t: �v�t-� 1�� ,�, ��- ��.�.\ .M�� r;i�- �, �- �� t�? �- Were the police or law enforcement�lled? es No Unknown (circle) If yes, what department or agency? t1�5 4. Case#or report# Where did the accident or injury take ptace? Provide street address,cross street,intersection,name of park or facility, closest landmark,etc. Ptease be as detailed as ssible. If necessary, atta a dia ram.—�- t��' -�;,,,r� f-� �� a....�` �- �,� �-'�,�.�.��' — Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim to your satisfaction. �..w\\ `' ��-r �' � r ��'� Vehicle Claims- lease com lete this section ❑ check box if this section does not a 1 Your Vehicle: Year�_Make i s ` Model �.-.CV�tl►T - �{��, S'3'��puv License Plate Number � �' � Sta e,�1N Color �a� U-[/' Registered Owner v^- � � " �`�`�' �� ` Driver of Vehicle _��. �j��.�z�r'Area Damaged " � City Vehicle: Year Make Model ��License Plate Number State Color ��`� Driver of Vehicle (City Employee's Name) _ �,(7 �I�,��;r Area Damaged I�iurv Claims-please complete this seetion ❑check box if this section does not applv How were you injured? What part(s)of your body were injured? 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 resuit of your injury? Yes No When did you miss work? (provide date(s)) Name of your Employer: 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 irt prosecution. Date f rm was completed__�� — ,n t � ; � Print the Name of the Person who Complete�l this Form: Signature of Person Nlaking the Claim: v -�' � - Revised Februarv Z01 1 Please state, in detail, what occurred, and why you are submitting a claim. Please indicate why or how 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 totaling the vehicle. Previous weeks to June 10th we contacted the city about prevention methods about the deteriorating condition and safety of the city trees located on luno Ave due to Dutch Elm Disease. In result,the city informed us that the trees were beyond point of rescue and they have been scheduled to be removed and replaced over the next couple months to years. In addition to the condition of the tree it is now one of the only trees being removed after further review from June 10th from Juno Ave due to the continuing condition and treat it poses to the block. Considering this information we feel that the city would be responsible for the full replacement value of the vehicle in question. �/I �� _ l i ✓ 1 � � � � � 1 � -_----.� �� n �-. (` . � � �"J � ', - � c �� -"r—� � �I �: ��` .�-�° �� .t. �� "' � ,�:�� :,��. 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