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Greer � . ' � NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota Minnesota State Statute 466.05 states that "...every person...who claims damages from any 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 demanded" w ` r 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 ezplain your claim,and the amount of compensation being requested. You will receive a written acl�towledgement 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 First Name � __Middle Initial_�- Last Name �r' �� n.c�Cl\iE� � Company or Business Name _ `�r� � �' Z0� JCr V f Are You an Insurance Company? Yes No If Yes,Claim Number? � , Street Address ��- �j t�1��--r' � Y' f� 1 ,� City �.)w O� C State � Zip Code �� ; Daytime Phone (c(��I -al��Cell Phone �l��_-15��Evening Telephone(_��-'�he-- Date of Accidend Injury or Date Discovered g" nt "' 1� Time � (s am� _ Please state, in detail,what occurred(happened), and why you are submitting a claim.Please indicate why or how you feel the Ciiy of Saint Paul or its.employees are involved and/or responsible for your damages. 1�.1 -- a.' 1��R- ,� �..c,v� ,� -p�J�N ��Y' ' r '�' '�V. �P Se-Ih cJ ` �'o--`r' ' \ '�-}- �a� S Q,�i r s�r � a- � ' 4�� ` `� -, �c- �. ��S �A+N"�'��at�N C2.. �� c1 2 �� L2 ' � r� Si��v � c � v� � ^}�A �1'Z 'C.ks 21 �,�' �,�y �- c� e��c�� Please check tYle bo (es�that most c osely r present the reason for completing this form: ' ❑ My vehicle was damaged in an accident ❑My vehicle was damaged during a tow • c�itiotg��strcet b�`a�°R` Q I�I3� . ❑ My vehicle was wrongfully towed andlor ticketed ❑I was injured on City property ,�Other type of property damage—please specify ' ❑ Other type of injury—please specify _ In order to process your claim��•� np°d to include copies of all applicable 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 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 repairs O Towing claims: legible copies of any ticket issued and a copy of the impound lot receipt •Other property damage claims:two repair estimates if the damage exceeds$500.00; or the actual bills and/or receipts for the repairs; deta.iled list of damaged items O Injury claims: medical bills,receipts O Photographs are 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 � 4 Failure to complete and return both pages will result in delay in the handling of your claim. - � � All Claims- lease com lete this sectio Were there witnesses to the incident? Yes No Unknown (circle) ` ,- Provide their names,addresses and telephon ers: �' P-Av`� �c`�� \�=C' SQ('J tc� � Qe_ _ 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 pazk or facility, closest landmark,etc. Please be as detailed as possible. If necessary,attach a diagram. 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. 10l a,i ,�,� �� -`��}.�, . - _ Vehicle Claims-ulease comnlete this section ❑check box if this section does not a„pulv 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 In'u Claims- lease com lete this section ❑ check box if this section does not a 1 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 ; V�ien did �_-,. -� � _._ _ ___._ ��_._,=.,,...�- `_ ovi. e a e s _ �-atiss wsri�. - _. � � -�� - =-- Name of your Employer: j 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 haveprovided is true and correct to the best 0 our knowled e. Unsi n .fY ed orms wil g g f l not be processea� � ' Submitting a false claim can result in prosecution. Date form was completed �'�� i Z- i Print the Name of the Person who Completed this Form: _ ��jQ.�'1` � (��'�1L�(�' ' Signature of Person Making the Claim: �-� Revised February 2011 � GREER ROBERT E_&_KA Bat6room/lower level DESCRIPTION QUANTITY UNIT COST RCV DEPREC. ACV R&R Countertop-flat laid piastic 10.00 LF 39.50 395.00 (0.00) 395.00 laminate R&R Toe kick-pre-finished wood- 10.00 LF 9.86 98.60 (0.00) 98.60 1/2" As per insured,insured didnt want to replace the vanity just put vents on the bottom of the damage to the veneer.2 extra LF of Tce kick was added. Contents-move out then reset-Small 1.00 EA 37.11 37.11 (0.00) 37.11 room Totals: Bathroom/lower level 530.71 0.00 530.71 Living Room/lower level DESCRIPTION QUANTITY iJNIT COST RCV DEPREC. ACV Carpet cleaning-Minimwn charge 1.00 EA 130.00 130.00 (0.00) 130.00 Content Manipulation charge-per 2.50 HR 39.22 98.05 (0.00) 98.05 hour Reset contents,removal was included with insureds cleanup rime Water Extraction&Remediation(Bid 20.00 EA 15.00 300.00 (0.00) 300.00 Item) 5 of the insureds family and friends 4 hrs each=20 5rs x$15tu=$300.40 for water clean up and contents removai prior to the mirigation company showing up.includes bathroom,living room and laundry room. Totals: Living Room/lower level 528.05 0.00 528.05 Debris Removal DESCRIPTION QUANTITY LTNIT COST RCV DEPREC. ACV Haul debris-per pickup truck load- 1.00 EA 123.22 123.22 (0.00) 123.22 including dump fees _ _ - -- -- Totals: Debris Removal 123.22 0.00 123Z2 Line Item Subtotals: GREER ROBERT E_&_KA 1,181.48 0.00 1,181.98 Adjustments for Base Service Charges Adjustment General Laborer 3g'22 GREER_ROBERT_E_& KA 8/14/2012 Page:5 � Adjustments for Base Service Charges Adjustment Total Adjustments for Base Service Charges: 39.22 �. Line Item TotAls: GREER ROBERT_E_&_KA 1,221.20 0.00 ' 1,221.20 � GREER ROBERT E & KA 8l14/2012 Page:6 Distribution Division � ' 1900 Rice St � Saint Paul MN 55113 Liz Quicksell TECHNICIAN Phone•651-266-6875 Fax•651-266-6878 E-mail•liz.quicksell@ci.stpaul.mn.us c�� .�, �