Birnberg .�4��.i�:��'�"'�!�
SE� O � 2012
NOTICE OF CLAIM FORM to the City of Sair�I�'�i�,�l�nnesota
Minnesota State Statute 466.05 states that"...every person...who ctaims damages from any municipaliry...shall cause to be presented to the
governing body of the municipaliry 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."
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 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 weeks or longer depending on the
nature of your claim. This form must be signed,and both pages completed. If something dces 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_�91j L- Middle Initial�Last Name �j t21V L�rc.,��r
Company or Business Name n �-
Are You an Insurance Company? Yes No If Yes,Claim Number?
Street Address J��� ' � � '"T1-� !'�V�vt K� ��� 'T?--�
City �i N N EA-�O �- l.� State 1''�/1/ Zip Code Ss��-
x�dl
Daytime Phone�Z)����Cell Phone( ) - Evening Telephone(�12_)�2?- t� �
Date of AccidenU Injury or Date Discovered���I��' Time �3� am/�
Please state,in detail,what occuned(happened),and why you aze submitting a claim.Please indicate why or how you
feel the City of Saint Paul or its employees are involved and/or responsible for your damages.
e�2e.. ��c►�er�
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
O My vehicle was wrongfully towed and/or ticketed ❑ I was injured on City property
C�'bther type of property damage-please specify VI �NV� g�� ���� v.d.f-i ab�
❑ Other type of injury-please specify
In order to process your claim vou need to include couies of all applicable documents.
For the ciaims types listed below,please be sure to include the documents indicated or it will delay the handling of
your claim. Documents WILL 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
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 are always welcome to document and support your claim but will not be retumed.
Page 1 of 2-Please 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—alease comulete this section
Were there wimesses to the incident? Yes � Unknown (circle)
Provide their names,addresses and telephone numbers: .�KaT �t�
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 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. ��Rt7 k�lvNE� ��Qu�ST�2 � �I�cS-T �9�"i "�r v.ecat-E�9
� I�-ZiD Sl� /V L C�Ai i CY�CTS I"N��-T
Vehicle Claims—nlease comulete this section ❑ check box if this section does not avvlv
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 State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniurv Claims please complete this section ❑check box if this section does not anvlv
How were you injured? N cYr i.v i vt'�d
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:
Address Telephone_
C�3'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��/�Y
Print the Name of the Person who Completed this Form: ��
Signature of Person Making the Claim:
Revised February 2011
I was cycling east bound on the bike path that runs along the south shore of the Mississippi River
(officially the west side of the river) near the St. Paul Yacht Club. I was going about 10-15 mph.
Suddenly, without warning, I hit a bump and almost fell off my bike. The attached map indicates
the approximate position of the bump.
I am fine and my bike suffered about 1¢ of scrapping damage to the tire. I don't want any
compensation. I just want the city to fix or at least ameliorate the problem so another cyclist is
not hurt.
After the near spill, I returned to the point I was bumped. I saw the problem. That part of the trail
has several milder bumps and one severe bump. The severe bump,the one I hit, is about 5 inches
high and seems to be the result of a root growing and forcing the pavement up in a pretty sharp
upside-down"V" shape. The other bumps are more likely the result of freeze-thaw cycles.
Upon further examination, I did notice that the bumps are marked with orange paint, but very
faint orange paint. Someone, likely from the city,painted more distinctive orange warning marks
some time ago, I'd guess over a year ago, but the paint is badly faded. It is so faint that it does no
good or not much good. Also, I don't recall any warning sign before the bumps.
The long or medium term solution is to remove the bumps. In the short term, please have
someone at the very least reapply fresh, bright warning paint and if at all possible a warning sign
50-100 yards ahead. Failure to do so will likely lead to a personal injury and a claim for more
than the zero dollars I seek.
Could you please let me know what you plan to do.
Mr.Pau1 Birnberg .
3439 l lth Ave S
Minneapolis,MN 55407 ai
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