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NOTICE OF CLAIM FORM to the City of Saint Paul, lVlinnesota
. Minnesota State Statute 466.OS 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 discover�a!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 ezplain 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 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 -1 a-n►pS Middle Initial 1 Last Name �(ar�►�C� o�r+�����
� Company or Business Name N �/4 ' _� �����
_ . _ _ __ _- . . .
Are You an Insurance Company? Yes No If Yes,Claim Number?'
Street Address 2��t�' ��►+be�C �f�N� � � �
Ci.ty I�a.��ew�xi�Q State /'4ch�� Zip Code �5 /�
Daytime Phone(�i�) qg3 D31 f Cell Phone(�S�r++e. Evening Telephone(�Sa�E
Date of Accident/Injury or Date Discovered �u,tKS�' 4,atOl Z- Time a:Uv am/�m
• 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 and/or responsible for your damages:S • � j? �
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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�othole or condition of the street ❑ My vehicle was damaged by a plow
❑ My vehicle was wrong�ully 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 ou need to include co ies of all a licable docume ts. ,�
�1�xswra.,r.cv� �s+Q.rhe.►� �Oa�¢. a
For the claims types listed below,please be sure to include the documents indicated or rt 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
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-ulease comnlete this section
Were there witnesses to the incident? es_ � � Unknown (circle) �
Provide their names,addresses and telephone numbers: J�vr. Sc�t ram� , ne�a h bor. �
w r E1 1 r► r' '
Were the police or law enforcement called? Yes �o nkno � (circle)
If yes,what department or agency? Case#or rt#
Where did the accident or injury take place? Provide street address,cross street, intersection,name of park or facility,
clo �st landmark,etc. Please be as detail as possib e. ff necessary,attach a diagram. F.",-e /
�rre i-1 s err• w- � E� a� �2 S , r,e `
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. �S� �p t i�'�� .� �r's c ist �- c�
e�5 -�r�i*� se.e�t P �Ee o S ►,o� cov
- - Vehicte Claims-�lease complete thia section __ _ ��q� --. -- _ _�7-�hesJc_hox if this.section does n4�P1?�v
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
Injury Claims-please comulete this section N�I� ❑ check box if this section does not apply
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))
ame o your Employer: - �- - -
_-- - _ _ _ - -__ - - - -
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 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
Print the Name of the Person who Completed this Form: ..1G�Q S �.Y�b 4//I I�,f L
Signature of Person Making the Claim: �Q"�''6 9 II �0 Z
Revised February 2011
This ENDORSEMENT age, V1/ith the Fo�ms And Endorsements (� � '� � �
Listed Below AME S Your HOMEOWNERS POUCY. � ` � �° 1�
CHANGE � 02 E F TIVE 10-11-11
A
15 l � . '��e
INSURER: PROPERT & CASUALTY INS. COMPANY OF HARTFORD ��p
200 HOP W STREET, 5IMSBURY, CT 06089 '� � � !�
DECLARATIONS
PLIC 2004 HO POLICY NO. 55 RBC792203
Named Insured and VARRO,JAMES J & JOYCE A `5 on�
RESIDENCE PREMISES 2268 TIMBER TRL E • � �-
�L�WOOD 1�1 5 5119
Policy Period 1201 A.M. Standard Time
at the Residenca Premises-� FROM 10-11-11 TO 10-11-12 TERM: 1 YEAR
Producer Nsme: CODE: 5 78 3 33 3L8
CUSTOMER SERVICE: 1-800-423-0567 CLAIM SERVICE: 1-877-805-9918
TOTAL POLICY PREMIUM: $ '81$.28
COVERAGE IS PROVIDED VVI�RE A L1MIT OF LIA6ILITY IS SHOWN FOR THE COVERAGE.
COVERAGES � �V\ �� LIMIT OF LIABILITY
SECTION I c�/�`°,Cr�'� � q OLD LIMIT NEW LIMIT �S�G
��, s * �,��, .� i
a DwELLUVG J�;:° , � $ 196,400 $ 21�,400 ��
= -- 8. OTF�R STRUC�URES r a� &- �i�'� ^� $ 19,fi40- - -�-- 21,24 Q :-�� c
C. PERSONAL PROPERTY �� �' � �'� ' $ 13 7,48 0 $ 14 8,68 0
D. LOSS OF USE a $ 3 9,2 8 0 $ 4 2,48 0
'�,. `��,, �o
SECTION 11 � �°� ��
�
E. PERSONAL LIABILITY: EACH OCCURRENCE b'��,.� '`$ 3 0 0,0 0 0 $ 3 0 0,0 0 0
F. MEDICAL PAYMENTS TO OTHERS: EACH PERSON '�,_ $ 5,0 0 0 $ 5,0 0 0
DEDUCTIBLE - S'CCTION l : WE COVER ONLY THAT PART OF J� LE�S OVER $ 500
.��
RATING INFORMATION: �� ^����� p r �`"m'�Y
1 FAMI LY ALUM OR PLASTI C DWELLI NG BUI LT I N 1984 �� s � • � ��'..�.
STATE 22 TERR. 00035 PROTECTION CLASS 5 � �` � `J'y�'F'i�� '�-
FI RE PROTECTI ON PROVI DER MAPLEWOOD 1^��'V`�'� a� � � f � T
WITHIN 1000 FEET OF A FIRE HYDRANT AND WITHIN 4 MILES OF A FIRE STATION
I NS I DE C I TY L I MI TS PREMI UM GROUP 1.0 0 T 14 � _, , Y� ��� ��� ,a `_ ., , t .
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COUNTERSIGNED BY �• AUTHORIZED AGENT
----CONTINUED ON PAGE 2-
fORM H-525 (9/03) 3062