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NOTICE OF CLAIM FORM t ' f Saint Paul, Minnesota
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Minnesota State Statute 466.05 states that"...every person...who clatms damages from any murucipahty...shall cause to be presented to the
AUG � � Lu I�body of the municipaliry within 180 days after the alleged loss or injury is discovered a notice siating the time,place,and
circumstances thereof,and the amount of compensation or other relief demanded"
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��i'F��a�cti�hplete 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 acl�owledgement 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 DOCUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
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First Name � �rl't � Middle Initial � Last Name w� � � {
Company or Business Name /t-��
' _ -�r��u at��f;o�p�ay? �es/�_If��s;�ia�Nt�ber`�— „—. -----
Street Address Z Z. cI 8 / i m �i P.f-�6'0� ; � � �
City // r A � LU G�� Cd State /�� Zip Code_� ��
Daytime Phone�� - Cell Phone(� �z) Z�Z- 937 Evening Telephone(_� -
Date of Accident/Injury or ate Discovered �v q � �v I Z Time ti�J• �am/�
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 involved andJor responsible for your damages.
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Please check the box(es)that most closely represent the reason 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
' ' �.II Iw�.�uajured on City propertX�L/_ _ ir
�Other type of property damage—please specify (-.�a. cf �G m -L—(S Jc�w�l���s dvc �-v wa/�'` `�M�``
❑ Other type of injury—please specify
In order to process your claim you need to include copies of all apAlicable 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 WII,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 Properiy 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 repairs
O Towing claims: legible copies of any ticket issued and a copy ofthe impound`lot receipt
�Q Other property damage claims:two repair estimates if the damage exceeds�500.00; or the actual bills
andlor receipts for the repairs; detailed list of damaged items
O Injury claims:medical bills,receipts
�Photographs aze always welcome to document an/d support your claim but will not be returned.
�/�U'�oS wC!C 7`q�c'h � �-;z QJ�cKSc�/ arc�.L ha,Ke SarKe � •
Page 1 of 2—Pleas�complete and return both pages of Claim Form
'
Failure to comp�ete and return both pages will result in delay in the handling of your claim.
All Claims—ulease comalete this section
Were there witnesses to the incident? � No U owYr (circle) P
Provi e their names,addresses and telephone numbers: �';�o�,�, �a�� t t�o�7-�r ��P�� �<' ��`a
� ,z Q�, ckse�/ i , .
Were the police or law enforcement called? Yes � Unknown (circle) �
If yes,what department or agency? Case#or report#
Where did the accident or injury take place? Provide street address,cross street,intersection,name of park or facility,
closest landmar etc. Ple e be as detailed as possible. If necessary,attach a diagram. 2'z 9� T i�n b er Tru� �
a �e wvrJ rn� ' /
Please indicate the amount you are seeking in compensa ion or what you would 1' e the City to do to esolve this claim
to your satisfaction. �,ri av�, � accme ' o� �A � a� 'n a • ��r� a rcas•
e i+' o r c c�ne� o wov 5 d 'w � aMa
Vehicle Claims—please complete this section �check box if this section does not anulv
Your Vehicle: Year Make Model "
License Plate Number State Color
Registered Owner
Driver of Vehicle
Area Damaged �
City Vehicle: Year Make Model
License Plate Number Sta.te Color -
Driver of Vehicle(City Employee's Name) �
Area Damaged
Iniurv Claims—please complete this section 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 result of your injury? . Yes No
When did you miss work? (provide date(s))
Name of your Employer: _ _ ---- —_�w___��-
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 a11 information you have provided is true and correct to the best
of your knowledge. Unsigned for»rs will not be processec� .
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Submitling a false claim can result in prosecution. Date form was completed �1'
Print the Name of the Person who Completed this Form: %i /� �� w a-'/ � 0�'
Signature of Person Making the Claim:
Revised February 2011