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NOTICE OF CLAIM FORM to the City of S��i�t`Pa�il,�Viinnesota
Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipality..:sh"all 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 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 OTHEIa DOCUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
First Name �/t V� Middle Initial�Last Name f�a�� h
Compan}�o:Business Name /r/' � � Je �0 0 ___
Are You an Insurance Company? es No If Yes, Claim Number? � �D 7�,3Z 83� �
Street Address / �_/ __��r��� �h �r- �
City �� �i�}u � l'�'LL� State rn� ZipCode .��0 7�
Daytime Phone b( S�) /�- O`��Cell Phone �( S1 )Z31- a7� Evening Telephone(l�� ) 3/ - �f a 7�
Date of Accident/Injury or Date Discovered ��%� /2. 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 int Paul or its employees are involved andJor responsible for your damages.
���'
�P_le�e check the box(es)that most closely represent the reason for completing this form:
C�7My 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
❑���� �'y vehicle was wrongfully toweci and/or tickete CI 1 was injured on City property
�'Other type of property damage—please specify� '����`� �C�(,
❑ Other type of injury—please specify
In order to process your claim vou need 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 WILL NOT be returned and become the property of the City. You are encouragec�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 andlor 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 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 complete 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 N� 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 landmJark, etc. lease be as detailed as possible. If necesLsa�r�y,,,�a�,ttach a diagram.
�GvT OOu ��'1 Uhi✓e2S,`�''/ -/9ye b2rw�r1 Mi°.�S1S�\��1 Q'�� �� <n�S�QR..�L
Please indicate the amount you are s eking in com ensat��n or hat you would like the City to do to resolve this claim M��
to yo}�r satisfaction. �e c� � uG ��e- ° Sc.� 'o� i S � 33 Z
7� .�e , ` �' / -
__ — ---
---- --
- -VebicIe Claims- lease com lete this section ❑ check box if this section does not a 1
Your Vehicle: Year �o��� Make r��` %nc Model
License Plate Nuxnber 0 State mh Color �,/ /
Registered Owner �✓ ,/ a
Driver of Vehicle — a h -�-���
Area Damaged U�- � 1 o D� �'n o � �� �
City Vehicle`. Year Ma e odel
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Injurv Claims-please complete this section 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 treatrnent? (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
�Check here if you are attaching more pages to this claim form. Number of additional pages 3
By signing this forrre,you are stating that all information you haveprovided is true and correct to the best
of your knowledge. Unsigned forms will not be processea�
Submitting a false claim can result in prosecution. Date form was completed /��y��O'�
� /� v '
Print the Name of the Person who Completed this o m: � � �V ��c�r�
Signature of rerson Making the Claim:
�
Revised February 2011
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Page 1 �oglund Body & Equipment,Tnc. N°�a",c'evg
Printed. 09/2Dl20�2 2:D4:49 PM E5Gm2,te:6681
Created:os�zol2oy a � S T I M A T E
P.O.BOx 114y
MOntiCello,MN 55362
(783)295-5000 FPJC:(763)295-3300
www,haglundbodyandeguipment.com
howardQhaglunGbod}r3ndeq uipment.com
Customer:ansufi�d V�hi�e: In$.C4rqPany:
Nolan,Cleve UCense:FRT
909 IINCOLN aVE Unit#:FR7
St.PaUl,MIV 55071 VIN:()N 71ME
HOme�(B51)231-9278 Orivable;UnknOwn
ritten by:
an
Item Rrice �xt,Frice tJnits l.lnits P`f 67
i REMOVE/REPLACE LH FRONT CQRNER CAP 80.81 90.81 2,1 B Q
,
2 FIEMOV�E�fiEPLAG�]3H.FRQt1T�ORNER GAP 90..8i 80.81 2.'t B 0
,.._��___.._m..3_ REM4V�/iIEPI.ACE�NT PG4t)tt13 � _ `_ 115.92 _ "°i.''fT5�32—� 1,$B O
.
4 AEMOVEIR�PLAC�#3b0� , 643.50 643.54 2fl:09 O
5 REM�VElREPLACE ROQF STAR7ER BDW 38,OS 36,05 D.3 B O
6 S�CTION RM TQP RAELFRONT$:F��T 229.3� 229.35 $.Q$ 0
,.. , ,.. ..
7 **RIVETS 40.Otl 44.00 M
.
8 "*SEAM S�A�R , 50.0'0 5q:iDD !vt
9 "*,1 S7RIP 115,04 115-DD Incl. 0
1d �pEV+/1R�.COI�N���LIGHT$ 1';0'B L
. SITMiV#A�Ir
LABOR
PARTS TOTA�$
Department Units Rate Amount
New(OEM)Parts: $1,321.44 6otly 32.3 $85.OD $2,745,50 P�r'tsTptal: $1,321.44
Labor 7�tdl: $2,7a5.SO
Body/Materill: $155.00
Hazardous Di5posal: $20.00
T�; $90.85
Total: $4,332.79
NOtfln,Cleve PAYAB�E R�PAIR TOTAL $4�332•7'9
AUTWORIZED AND ACCEPTED: Hoglund 8ody&Equipmeni is hereby authorized to make ths above specified repairs. I re�iiZe this work order is
ba5ed upon a detailed inspection of our vehicle and does not indude repair8 ot11Br than itemize abpve. Occasionally,additianal damege will be
discovered once tne worx is 1�gun and I reali�e additional repairs may be required. An express mechanic's lien is hsreby acknowledged on the
above vehicle to secure the amouf+t Of rgpalrs thQr�tp. 1 und�rstand that payment in full will be due prior ta release of vBhiCle.
I here�y grant Hoglund 8ody and Rs employee's permi59iCn to ppera;e fhe vshicl�as n�csssary to complete repairs.
Old parts removed from vehicle will be junked unless oCherwise inStruCted.
Repair Order authorized by Date
Estimaies are only va�id for 30 days.
Labor ept es: - y - e i �a9�s06vc - ecmcs - rame - M-Mechanieal P-Pa�nt 5-StruCWYa1
PT•Price Types;
p.New(QEM);A-New{Npn-OEM);V-Used Parts;R-Reconditioned:Spac6-NO Type
L-Labor,M-Material;H-Ha�rdous;S-Storage;T-Towing;U-SublBt
BT-Billing Typea:
No CodB-Ir13UPaflCe C118rge',CC•CUetomer�harge;B7.Betterment AP•Appearance Allowsnce
PO-Prmr Damage;NC-No Charge
('�tndicates Estimator Judgement.
CatCUlations of 11z6 E9iim81e are performetl by a compater program creaietl 6y YADA SyeFeme,Inc.
PPOfiWe1(Ver,$.00,+630a�1589�201$NAQA.Sysiems,rn�..,4t1 nphts teserved.Uceased by'Flo.g[unC F�adY��QUfAment,�nc.
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