Jones, Trenton � _ _ . � /� /�c� ��� _ �
NO'�'I+CE OF �LAITl�I FOR1Vi to the City of Saint �Pai�l, IViii�nesota
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�it 1�!��:,;
il-lh�nesotri S7nIe Sta�i�te 466.0�s7ales�h�at " ...e»eiy perswz...��i�ho clninis damages fr•om an��n�iu�aicipnlil��...shnl!enuse lo be�reserired to Ihe
goi�ernino bor/v qFthe nlauzicipolil��ri�iNiaii Ib'0 dm�s nfler Ihe alleget!loss or inj�rn is discovered a i�oNce slati� t Gn e, ��d �
. , circtzmstai�ces Ihereof, nnd the amounl of cona1�ensatior�nr otlier relref den2nncled." � ��L���
Please complete tl�is form in its eutirety by clearly typing or printing yoin-ans�ver to each quest���'`�3r`���e��ace is
needed,<�ttacl� additional sheets. Please note that yoii will not be contacted i�y telephone to clarify ans�vers,so provide�s
much information as necessary to explain your claim,and the amount of compensation being requested. You will receive a
H�ritten acicnowledgement once you�•form is received. The p►-ocess can talce up to ten weelcs 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'.
S�ND COMPL�T�D FORM AND OTH�R DOCUM�NTS TO: CITY CL�RK,
15 WEST K�LLOGG BLVD, 310 CITY I�ALL, SAINT PAUL, MN 55102
First Name���b� Middle Initiai '� Last Name �d�r S -_
. �
Company or Business Name ��N� � �"�°_ �� �119� ��-� C��r �
Are You an Insurance Company? Yes� If Yes, Claim Number?
Street Address �� C�-S � '
City ��D��� State � i'V Zip Code���
Daytim�����e`���_���Il Phone ( ) - �vening Telephone ( ,��!����
Date of Accident/ Injury or Date Discovered 7"'��"` � Time Za.3 oam pm
. �
� Please state, in detail, w occurred (happened), 1nd why you are submitting a claim. Please mdicate why ar how you �B�
_ � el h �int a 1 o its e� I ees are involy�d and/or �e sibl f r our d ��
�e�- . �`�o� ��/�vL° !�'�GoL � ��y�'�-�� Q�.
0 D� 1'�l�C- r � fi�C O
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�rv� T3 ���� `� /?'C�-�- u....f /ti. ,� / (J� tccc j
Please c�ec"rtl�� boa( s��(iiost closely r resent he i �s for complet►ng this form.
❑ My vehicle was damaged in an accident ❑ ed during a tow �
❑ My vel�icle was damaged by a pothole or condition of the street ❑ My vehicle was damaged y a plow �
❑ My vehicle was wrongfiilly towed and/or ticl�eted ❑ I was injured on City property �
❑ Other type of�property damage-please specify y
❑ Other type of injury-please specify� ► '
In order to process your claim you need to include copies of nll annlic�ble documents.
For the claims types listed below, please be sure to include the documents indicated or it will delay the handling of
yoiu�claim. Documents WILL NOT be returned and become the property of the City. You are encouraged to l:eep a
copy for yourself before submitting your claim form.
O Property damage claims to a vehicle: two estimates for the repairs to your vehicle if the damage exceeds
$500.00; or the actual bills and/or receipts for the cel�airs .•
O Towing claims: legible copies oPany ticicet issued and a copy ofthe impound lot ceceipt �
O Other property damage claims: two repair estimates if the damage eaceeds $500.00; oc the actual bills
and/or receipts for the repairs; detailed list of damaged items
- O Injuiy cllims: medical bills, receipts
� O Photographs ai�e always welcome to document and support your claim but will not be returned.
T�ge 1 of 2-Please complete a���l ��turn both pages of Claim Form
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_ -� . ......�.,-..-,.___....- __
Failure to complete�nd retin•n botli pages�vill result in delay in tl�e hancllinb of your cl�im.
All Claims—nlease complete ihis section
��/ere there witnesses to�the incident? Yes N tJyll:n (c�l.e) �
Prov�de th lt'111111P�S, c1CICIl'2SSES �il(I tBIe��I1011 mbers: Gt�N!� �d
�lfL' �4�1� l�
Were the police or law enforcement called? Yes No Unl:nown (circle)
If yes, what department or agency? Case# or report#
Where did tl�e accident or injtny tal:e place? P►-ovide street address, ccoss stceet, intersection, name of parl:oc f�cility,
closest l�ndmarlY etc. Please be as detailed 1s possible. If necessary, 2ttach a diagcam. �y�T,s
��l.G,�� ltit�-c---
Please indicate the amount yo i are seel:ing in c m ensati o•�vhat u would lil:e the City t lo to resol e this claim
ta y ���-s�t;sf��t�o�,. yt�t-2-���ct�'� ��'2, c�D k���• �__
o.� -
Vel�icle Cl�tims— �lease com lete this secti n ❑ checl:box iFthis section does not a �I
Yow-Vehicle: 1'ear Mal:e Model
License Plate Number State Color
Registered Owner 'B/t�'l�i�
Driver of Vehicle � �!�
A►-ea Damageci J
City Vehicle: Year � M� : Mode _ L
License Plate Numbei State Color t•l�'/ ��J��1ul.J�
Driver of Vehicle(C�Cmployee's Name)
Area D�maged ��r,.
, Inji�ry Claims-piease complete tl�is sectinn �eck box if this section etoes not �I'v ,
. • 'I Iow 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? , (pcq,vide date(s)) r
Name of Medical Provider(s): •
Address —� Telephone
Did you miss worl:as a result ofxour injury? Yes No ,
When did you miss worl:? t-� (provide date(s))
Name of your Em�lo er: p �d '
Address Telepllon , �
❑ Checic here if yoi� 1re �ttacliing more pnges to tl�is cl�im form. Number of�dditional pages
By signi�zg this form,)�OLL QYC'St![tlila t/iat rrl/informatio�z you /tane provided is true �rt�l correct to the best
of your h�tow/e�lge. Unsigned fornzs ���i/1 nnt be pj�ocessed.
Srlbnzitting t�fnlse c/�rinT c�n result in prosecr►tiore. Date form was completecl � � �� � �� �
Print tiie Na�ne of the Person who Coinpleted tl�is Form: �1�--����N ��C�iC���1---� ��
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Signature of Person Nlaking the Claim: -- —"
Revised February 201( ��� �..����—�� �� �� � �
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