Stakick 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 180 days after the alleged loss or injury is discovered a notice stating the time,place,and
circumstances thereof,and the amount of corrtpensation or other relief demanded."
Please complete this form in its entirety by clearly typing or prinring 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
muc6 information as necessary to ezplain your claim,and the arnount of compensation being requested. You wiil receive
a written aclatowledgement 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 somethiag 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�--I a.r�2�-I- Middle Initial �--Last Name�-�-� �'�1 � '_� RE����i'��
Company or Business Name N�� n ] 20'�
Are You an Insurance Company? Yes �o If Yes,Claim Number?
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street Address ,.� 7 1 ("�c�� , � r?c�l� L �' "f
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City State ,'n n�S����� Zip Code��5
Daytime Phone(�O " -'SC`___�,_S� Cell Phone�� - Evening Telephone(_) -
Date of Accidentl Injury or Date Discovered'C�o"(5 u � 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 Paul or its,employees are involved and/or responsible for your damages. ^
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'Please cl�ck e box(es that most closely represent the reason for completing this form:
M vehicle was damaged in an acciden My vehicle was damaged during a tow
�vehicle was damaged by a pothole or condition of the street My vehicle was damaged by a plow
My vehicle was wrongfully towe an on c�ke�d— I was injured on City property
Other type of properiy damage-please specify
Other type of injury-please specify
In order to process your claim you need to-include eopies of all apnlicabk doeuments
For the claims types listed below,please be sure to include the documents indicated or it will delay the handling of
your claitn. 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.
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
Towing claims: legible copies of any ticket issued and a copy of the impound lot receipt
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
Injury claims:medical bills,receipts
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 iacident? Yes No Unkno��wn ' (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 tbe accident or injury take place? Provide street address,cross street,intersection,name of park or facility,
closest landm k,etc. Please be as detailed as ossible. If ngcess�ary,attach a diagram.
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�lease indicate the ount you are seeking ' ompensation or wh�w uld like the City to do to resolve this claim
to your satisfaction. �-�i("�
Vehicle Claims-�jease com�ete this section check box if this section does not annlv
Your Vehicle: Year��L_Make �;� � C �. Model C_�`�c�!�; �
License Plate Number�` ' — v� State ,'u Color (.,' h�
Registered Owner '
Driver of Vehicle -�t , c t- �c" � ,
Area Damaged� r � �• -
City Vehicle: Year Make � Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
�jurv laims-please com�lete this section check box if this section does not anolv
How were you injured?
Wt�at 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
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: (�����P-�1 �� D�i �C- �� —
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Signature of Person Making the Claim: S� .--� _��.� r: ��/,� ��
Revised February 2011