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� ' NOTICE OF CLAIM FORM"to th �l' f Saint Paul, Minnesota
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' Minnesota State Statute 466.05 states that"...every person...who claims damages from arry municipality...shall 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 demandeaC"
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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 eaplain your claim,and the amount of compensation being requested. You will receive a
written aclaiowledgement 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 F�RM AND OTHER DOCUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
First Name d��'l�S Middle Initial L- Last Name�G�i2�9/YJ EL
Company or Business Name
Are You an Insurance Company? Yes/�If Yes,Claim Nu�xiber?
Street Address �� ��o ���%/2 %� L�
City^���L�l�f/U� State /� /1� ; Zip Code S �
Daytime Phone Lli�J���s`d�ell Phone�) - Evening Telephone L�� 73 - a�S�3
Date of Accidend Injury or Date Discovered �— ���p/.�3 Time_ 2 am/�
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Please state, in detail,what occurred(happened),and why you are submitting a claim.Please indicate why or how you
feel the C' f S 'nt Paul or its emplo ees are involved and/or responsible for your damages.
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Please c eck the box es)that most cl e y represe� r co p et' g 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 vehicle was wrongfully towed and/or ticketed ❑ I was injured on City property
f�'Other type of property damage—please specify��,� B��
❑ Other type of injury—please specify .
In order to process your claim vou need to include conies of all apnlicable 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 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 aze always welcome to document and support your claim but will not be returned.
Page 1 of 2—Please complete and return both pages of Claim Form
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Failure to complete and return both pages will result in delay in the handling of your claim. '
All Claims—ulease comnlete this section •
Were there witnesses to the incident? Yes No Unknown (circle)
� Provide their names,addresses and telephone numbers:
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Were the police or law enforcement called? Yes No 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 landmark,et�Please be as d 'led as ssible. If necessary,attach a diagram.
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Please indicate the amount yo e s king in compensation or what you would like the City to do to resolve this claim
to your satisfaction. ,���,.�•-
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Vehicle Claims—please comptete tLis section ttf check box if this section does not annlv
Your Vehicle: Yeaz Make Model
License Plate Number State Color
Registered Owner
Driver of Vehicle
- Area Damaged � �
City Vehicle: Year Make Model
License Plate Number State Color -
Driver of Vehicle(City Employee's Name)
Area Damaged
Injur_y 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 rtiiss work? - - - - -- - (provide date(s))
Name of your Employer:
Address Telephone
L7 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 7 ' � —aG/Z
Print the Name of the Person who Comp ted this Form: �/9 �S �L � C �i ll/!7�L
Signature of Person Making the Claim
Revised February 2011
September 4, 2012
City Clerk
15 West Kellogg Blvd
310 City Hall
St. Paul, MN 55102
I am sending a listing of e�enses that I incurred because of the hydrantlwater meter problem
caused by a city employee on August 9�on Timber Trail. I am requesting reimbursement for
the following expenses:
The clean up rates that I am using was provided by Rodney Coni of Restoration
Professionals.
Water Clean up 30 @ sq foot-730 sq feet of floor space .................. 216.00
Carpet lift up @ .15 sq ft- 120 sq feet................................................. 18.00
Electricity for eight dryers @ 1.00 per day each- 4 '/2 days.................. 36.00
Electricity for two dehuxnidifiers @ 2.00 each daily-4 '/2 days............. 20.00
Two rolls doubled faced carpet ta.pe to resecure foam backed carpet.... 20.00
One damaged 22"x48" counter top.......................................................... 75.00
Carpet Cleaning(caused by workers dragging equipment)...................... 100.00
Reorganize basement after clean up 4 hours @ 20.00 per hour.............. 80.00
Loss of use of basementl recreation room 5 days @ 20./00 per day........ 100.00
Total Amount requested:......................................................................... $665.00
Please refer to Liz Quicksell for photos, she was at the site the day of the damage,
she took many pictures.
James L. Schramel
2276 Timber Trail E.
Maplewood,MN 55119
651-738-2543