Khalif Randle :�'�::..��.E��:i�_�.�
St�' 2 � ZQ12
�o_ �� ,��`��'` Minnesota
F CLAIM FORM to the Cit`y �� �����aul,
NpTICE O shall cause to be presented to the
es om any municipaliry... lace>and
eve erson...who claim.s d°"�+g � is discovered a notice stating the time,p
Minnesota State Sratute 466.OS states t1�a`thiri 180 days a.fter the alleged loss or in ury
governing body of the municipaliry a��he amount of compensation or other relief demanded."
circumstances thereof, u¢Stion. If more space is
b clearly typ�ng or pr�nting your answer to each q
lete this form in its entirety y not be contacted by telephone to discuss your claim
Please comp or may nsation being
to explain Yo�'�la'm,and the amount;f Wm��N/A'.
needed,attach additional sheets. Please note that you may leted. If sometivng does not app Y+
circumstances,so provide as much informed and both Pag comp
requested. This form must be sign
SEND COMPLETED FORM AN�OCTTY H�LUSAIN`�p AL,MN 55102
CITY CLERK,15 WEST K E L L O G G B L V D�3 1 0 �f���` �
� � Middle Initial Last Name
First Name
an or Business Name,if applicable
Comp Y � 1 ��h� A r �
J� �Street Address Zip Code `�_=
, ` State �
�� 5 � Tele hone(__)
City ��� ��O Evening P
ime Telephone(_—) � �/pm(circle)
Dayt Time--
Date of Accident/Injury or Date Discovered or how you
ou are submitting a claim. Please indicate why �
Pleas�state,in detail,what occurredlone s�e involved andlor res �ible. � N�,�-� e,� �
feel the City of Saint Pau�or its emp y ,� �,
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hV'� �r
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resent the reason for completing this form: a tow
that most closely rep p Ve�cle was damaged during
Please check the box(es) ed b a low
❑ Vehicle was damaged in an accident ❑ Vehicle was damag Y p
ed by a pothole or condition of the street � ��ured on City property
❑ Vehicle was damag toWed andlor ticket � ;
ehicle was wrongfully ^�� yj
�, er t e of property damage-please spe �y
`-' ��' yp - lease specify
p pthcr typ�of injury P lease specify
e not listed-p licable documents. T1us is a general
❑ pther typ be asked to
In order to process your claim ou need to include co ies of a11 a
ould be submitted with a claim form,but it is not all inclusive. You may .cle or�e
guideline of what sh on our claim. our velu ,
provide additional information depending Y
d�age claims to a vehicle: at least two estimates for the repa�rs to Y cei ts
O ProPertY ound lot re p
actual bills and/or receipts for the rep�rs tickets issued and copies of the imp
claims: legible copies of any ed items
O Towing e, re au estimates, detailed list of damag
• Other property damag ' P
p Injury claims: medical bills,receipts
p photographs can be Provided but will not be returned. �of Claim Form
page 1 of 2-Please complete and return both pag r��sing.
' ure to provide a completed claim form will result in delays in p
Fail
Notice of Claim Form, City of Saint Paul,page two
All Claims— lease com lete this section N
U�o�,n (circle)
'tnesses to the incident? YeS h�numbers:
Were there wi
If yes,please provide their names, addresses and te ep
U�o�,n (circle)
o '
Were the police or law enforcement called? YeS Case#or report#
If yeS,what department or agency?
e lace? Provide street address,cross Sful attach a diagram me of par
Where did the accident or injury t� P ossible. If help ,
or facility, closest landmark,etc. Please be as detailed as p
'n in compensation from this claim or what you would like the City
Please indicate the amount you are scclu g
to do to resolve this claim to your satisfaction.
❑ check box if this section does not a 1
Vehicle Claims— lease com let�hke section Model
Your Vehicle: L ce se Pla e Number
State__Color
Registered Owner
Driver of Vehicle
Area Damaged M�e Model
City Vehicle: Ye�'---
State__Color
License Plate Number Employee's Name)
Driver of Vehicle (City
Area Damaged ❑ check box if this section does not a 1
In•u Claims— lease com lete this section
How were you injured?
of our body were injured?
What part(s) Y pl�ning to Seek Treatment (circle)
Have you sought medical treatment? Yes
No (provide date(s))
When did you receive treatment? 'relephone
Name of Medical Provider(s): YeS No
Address our in ury? (provide date(s))
Did you miss work as a result of y J
When did you miss work? Telephone
Name of your EmploYer:
Address form• Number of additional Pages '
ou are attaching more pages to this claim e Un igned
❑ Check here lf y our know B • }� ,p
ou have prov►ded u tr�e a►�correct to the best o y r /, ��
gy signing this form,You are stahn8
that aU information Y rosecution• '���'�' ��
rocessed. Subneittin8 a false claim can resuU in P rm'
forms will not be p t]11S
print the Name of the Person who Compl ' � '
Signature of Person Making the Claim:
Revised Apri12007
Date form was completed
Complaint or Request for Repair _�_�
City of St. P,aul Public Works
Street Maintenance Division
873 N. Dale St.
�
Date: 3/20�?
Caller: Rhonda Randle Caller Address:
Sherburne, 884
Day Telephone: 330-8511 Other Telepbone:
•Mail or WWw�
' _S' ��E�;�-��'3 at/BT:
Repair Location: Sherburne, 884 and:
Surface: ���' ��Q�- ��-� ��U
Dist: 9�—
� � � f � �
� a �_�.. South• ��:�� � ��
Alley Number: riorth: �
� � . ➢.�'+.�i A�
Surface: '�'r��,� West• �'Y1 ► �'�'D11�--
A �
Jr' / �
Shape: East: �C'i C.'�'O V'(
:.� Dist:
n, � ��,
.�, � ..
� ��
`��� \ est: In alley behind callers address caller stat�ba hk to her but never did ey damage
Requ
her apron and was told forman woul ge
• caller wants someone to look at it and be contacted back
Private Prop• Status: Pen_ ding-- —
Summary: Dama�e - Entered by: Stella,K.
Category: Alley
Referred to: Asphalt Office .�„� !
�' � }� ? ��1j �\ i rt� ' jj/~.., �. r*„� +.i.;�,�j) //'!I
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�
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Res�onse: , , /� ? � �, � ' ,� , , ;�.'� � �✓F.�3� �-�` �U� n(�
1 + 1 . �`. !' { ! 1 � ��Jy}•�� j` J �.:'1, ��� :,�..✓'
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p-^"°� ' ' ���" �_`' � Status: Pendin�
A � f�..,
Supervisor: . , Closed by:
� �--, •
Repair Date: `"' �� „
Pleas
e return completed Request for Repair form to Complaint Office
DEPARTMENT OF PUBLIC WORKS
Rich Lallier,Director
CITY OF SAINT PAUL Daniel A.Haak,Assistant City Engineer
25 W.Fourth Street Telephone: 651-266-6084
Christopher B. Coleman,Mayor 900 City Hall Annex
Saint Paul MN 55102-1660 Facsimile: 651-292-6315
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An Affirmative Action Equal Opportunity Employer
Responsive Services . Quality Facilities . Employee Pride
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 I80 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 egplain 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 Middle Initial Last Name �/�I�11 �����
_ Company or Business-Name
Are You an Insurance Company? Yes/� If Yes,Claim Number?
Street Address
City�,�7 ' �GCC.I State Q�N Zip Code��
Daytime Phone(��- ��� Cell Phone c� Evening Telephone�) -
Date of Accidentl Injury or Date Discovered � Time am/pm
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 Pau ar its e ployees ar involved and/or spo sible fo our a es.
�. � '�
� �I
G�-- i
Piease check the box(es)that most closely represent the reason for completing this form:
❑ My vehicle was da.maged 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 vehic}e v�as vnrorigfultytowed and/or ticketed I a inj ured n City property.
�Other type of property damage—please specify
Other type of injury—please specify
In order to process your claim vou need to include copies of all auplicable 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
O Other property damage claims: two repair estima.tes 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 returned.
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—please comnlete this section
Were there witnesses to the incident? Yes No Unlrnown (circle)
Provide their names,addresses and telephone numbers:
Were the police or law enforcement called? Yes No Unknown (circle)
If yes,what depariment or agency? Case#or report#
Where did the accident or injury take place? Provide street address,cross street, intersection,name of park or facility,
c st 1 dmar etc. Please be as detailed as possibl If neces� atta diagram. �
�, .
Please indicate the amo t you are_,�geldng in compensation or what you would like the City to do to resolve this claim
to your satisfaction. �f�
Vehicle Claims— lease com lete this section ❑ check box if this section does not a 1
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
i InLrv Claims—please comQlete this section ❑ check box if this section does not avnlv
How were you injured?
i
What part(s)of your body were injured?
Have'you sought medical treatrnent? Yes No Planning to Seek Treatment(circle)
When did you receive treatment? (provide da.te(s))
Name of Medical Provider(s):
I Address Telephone
Did you xniss work as a result of your injury? Yes No
_ --�vtii�aiu-yozrmis�work�---- — - —- _,(provide date(s))
Name of your Employer:
Address Telephone
❑ Check here if you are attaching more pages to this claim form. Number of additional pages
By signi�ag this form,you are stating that all information you have provided is true and correct to the best
of your k�owledge. Unsigned forms will�ot be processea�
Submitting a false claim can result in prosecution. Date form was completed
� /�,�
Print the Name of the Person who Completed this Form: �I Id�"
Signature of Person Making the Claim: �/vv
Revised February 2011