Camozzi (2) NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minnesota State Statute 466.OS 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 ainount 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. Piease 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 DOCUIV�NTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
First Name , �Q C Middle Initial J La.st Name �vV t 0 Z��
Company or Business Name nr-r���a,sr�s
-. _ .__. . _. . .. __ c FYs i�Lr
Are You an Insurance Company? Yes, N� If Yes, CI im Number? 2
Street Address
Z ^ �O�UI
City � - State M� Zip Code
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Daytime Phone(�u 7-�'�ell Phone L� - Evening Telephone(_) -
Date of Accident/Injury or Date Discovered���Z�'�7�(,Z Time �0:OD am/�m
Please state, in deta.il,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 an or res onsible for your damages.
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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 pothole or condition of the street ❑ My vehicle was damaged by a plow
❑ My vehicle was wrongfully towed and/or ticketed ❑ I was injured on C'ty property �
[�'Other type of property damage—please specify � t
❑ Other type of injury—please specify
In�tder to process your claim you need to include copies of all apulicable documents.
For the clairns 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 retumed 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 estunates 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
jS�'`�Other properly damage claims:two repair estimates if the damage exceeds $5.00.00; 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? es No Un�:nown (circle) � _
Provide their names, addresses and telephone numbers: �-- l5 ��1`�M�_�_ � �.GC �1l
Were the police or law enforcement called? Yes � Unknown (circle)
If yes,what deparlment 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 landmark, etc. Please be as deta'led as ssible. If necess , attach a di
�cx..5 <
Please indicate the asnount you �eking in com ensation or what you would like the i o do to resolve this claun
to your satisfaction. ,��� '6 °�4� _ � 1�
Vehicle Claims—please complete this section �heck box if this section does not applv
Your Vehicle: Year Make Model
License Plate Number State Color
Registered Owner
Driver of Vehicle
Area Damaged
City Vehicle: Yeaz Make Model
License Plate Number State Color
Driver of V�hicle(City Employee's Name)
Area Damaged
� Inj urv Claims—please complete this section L9'check box if this section does not apvlv
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 daie(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 I Z
Priat the Name of the Person who Completed this o C�C' • C �'
Signature of Person Making the Claim:
Revised February 2011
Statement
Servpro of Minnetonka
Servpro of Coon Rapids Date
Servpro ofNW Ramsey County �oi3�i2oi2
11503 K-tel Drive, Minnetonka, MN 55343
FED ID 41-1893881 Ph-952-473-4837
To:
Jeff Camozzi
1929 Sheridan Avenue
St.Paul,MN 55116
Amount Due Amount Enc.
$3,664.56
Date Transaction Amount Balance
09/29/2012 Balance forward 3,664.56
1-30 DAYS PAST 31-60 DAYS PAST 61-90 DAYS PAST OVER 90 DAYS Amount Due
CURRENT DUE DUE DUE PAST DUE
0.00 3,664.56 0.00 0.00 0.00 $3,664.56