Smith, Shara NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minnesota Sra[e Starure 466.05 srares fhar"...et'ei��per.cnn...ir•hn claims damnges fi�m am�municipalit��_..shaIl cause to be presente�f in the
guvrrning buch'uJ the municipuliq�Zvithin 1 RO duys uJ'ter the ullegrd loss ur injury is discovered u no�ice stuting!he lime,place,uttd
circumstunces tkrre��and ihe umuimt uJcumpens�tiun ur uJher relie/'Jrmu�uled•"
Please complete this form in its entitety by cleatly typinS or printing yotu�answer to each question. If more space it
needed,attach additionat sheets. Please note that you will not be contacted bq telephoue te eIarify answers,sa provide as
mnch informatlon as necessary to explain your ciwn,and the amount oI compensation being requested. You wi11 receive a
written acknowledgement ance your form is received. The process can take ap to ten weeks or longer depending on the
nature of your claim This form must be signed,and beth pages cempleted. IE 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����1��i`� �'� ����_ (
?. A!�:k:'+,f...c�r�l�-`
Company or Business Name
Are You an Insurance Company'? Yes i No� f Yes,Claim Number^. SEh� � � ����
`;�� � � .�-����t � Y �
Street Address "•a�j�� •-.# `�`�*:
I-� c'�
City �-� �i�(�l ► �I State ���.,� 1 Zip Code�•�(��
DayUme Phone( ) - Cell Phane(�_)�_����vening Telcphone( ) -
�°} ;�
Date of Accidend Injury or Date Discovered �� ��-� C1� Time�—�� �
Please state,in detail,what occurred(happened),and why you are submitting a claim.Please indicate why or how you
i �a
feel the City of S ' t Paul or its employees are involved and/or res�nsib e for your d,�niage . f
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�'lease cl�eck the box(es)that most closely represent[ reason for completing th�s form: CjQ.,�-. C.�X�- C�jW�i.
❑My vehicle was damaged in an accident ❑My vehicle was damaged during a tow
�My vehicle was damaged by a potholz or condition of the street ❑My vehicle was damaged by a plow
❑My vehicle was wrongfully towed andlor ticketed� O.I was injured on City prop�rty �r�,
�(3ther rype of property damage-please specify �Y'�� �V1 �a 1�I f c� 5--�',►'k,�,j- E i' ( t <1� �'�.
�Other type of injury-please specify
In order to process your claim•au need to include copies of all apUlicable documents-
For the claims types listed below,please be sure to inciude the documents indicated or it wiil delay the handling of
your claim. Docuxnents WII.1.NOT be returned and become the property of the City. You are encouraged to keep a
copy for yourself before suhmitting your ciaim 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 iinpound lot receipt
�Other properiy damage claims:two repair estima[es if the damage exceeds$500.00;or the actual bilis I,
an r receipts for the repairs;detailed list of damaged items i
O Injury claims:medical bills,receipts
�,�otographs are always welcome to document and support your claim but will not be returned.
Page 1 oi 2-Please eomplete and return both pages ot'C1aim Form
Failure to complete and retnrn both pages will result ia delay in the handling of your claim.
All Claims— lease com lete this section
Were there wimesses to the incident? es No Unknown (circle) �j,
Provide their names,addresses and[elephone numbers: ` �'I � � �' (<-% �[A 1:�j-}1'�r i���7 lv''--
, _ 1�� ) - � �"' N� �� � � � ���' P � e ���� • r u I��^(a,�r, �..� �;
Were the police or law enforcement called? Lyes � No Unknown (circle) ��a-�-h-`�'�rl�
�`.���}�"�" yes,whai de ar[ment or a enc � `�� Case#or re rt#
P g Y'. P° �.5� �7`� 3'��j
L�`{����� ���ere 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. ff necessary,attach a diagram. � j�(Z�t.��-,�Y��r,�
CI; ,r�-+�-��-�' i'�-- -�d(.-(���� �1:% ��t�' �'
Please indicate the amount you are seekin�in compensation or what you would like the City to do to resoive this claim
to your satisfaction. � � ► '� I
Vehicle Ciaims— lease com lete this secdon eh ek bax if this sectivn docs not a T
Your Vehicle: Year :�� � Make�i �' �-V' Model _
License Plate Number � �• ? ` State Color�Ti.0 . ��j�,4,��,.
Registered Owner r�' r+�, �� ' �' '
Driver of Vehicle '
, .
Area Damaged ' . �_ �. , ,, ;�. j ,. �,�,+- :j,r� ,J�'�,{�l
City Vehicle: Year Make l' Model �Y�%rl� �_'-I^.��
License Plate Number S[ate Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniurv Claims—please eomulete tivs section ��heck box if this section does not a�uiv
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 resutt of yonr injury`' Yes No
When did you miss work'? (provide date(s))
Name of your Employer:
Addxess Telephone
'' �Check here if you are attaching more pages to this claim form. Number of additional pages
By signing this form,you are staling that all information you have provided is true and eorrect to the best
of your knowledge. Unsigned forms will not be proeessed.
�'' � , ,
Submitting a false claim can result in prosecution. Date form was completed � �� � �
Print the Name of the Person who Completed this r 1 •` , ��- �-� `` ��' �''
� �� ��� . �'�_ !�-,
Signature of Person Making the Claim: � _
Revised Febr�ary 201 I
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