Streier 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 t/ze 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 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 explain 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 � '�" 'r � � � �
Company or Business Name C� �` ���
Are You an Insurance Company? Yes/ o If Yes,Claim Number?
s�.a�ess �� 1� �
City____� pC��,l�- State � � Zip Code 5 S f � �
Daytime Phone((���� Cell Phone(_)��Evening Telephone ;' �j�� �9
Date of Accidentl Injury or Date Discovered� (�,-� � _} Time�_am/�
�
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 esponsible for your d ages.�(�V ��_
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Please check the bo xes)that most closely represent the reason for completing this form:
❑ My vehicle was damaged in an accident ❑ My vehicle was da.maged 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 wrongfull3�towed and/or ticketed -- was injurEd on City prag�r!����
❑ Other type of property damage—please specify
❑ Other type of injury—please specify ' ivU�� � 4 2��
In order to process your claim ou need to include co ies of all a licable documents. �
For the claims types listed below,please be sure to include the docuxnents 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 estimates if the damage exceeds$500.00; or the actual bills
and/or receipts for the repairs;detailed list o�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 own (circle)
Provide their names, addresses and teiephone numbers:
Were the police ar law enforcement called? Yes No Unlrnown (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,
close t�domaylc,et�c. P;ase be as�det�,iled� si e. If�es � h��gr�.
�j� ���
Please indicate the am unt y u are seekin ' corrlpensation or whatyou ould ike the City to do to resolve this claim
to our satisfaction. ���
\
_ —— ---- -- -
Vehicle Claims-please compTete tfiis section -- t7 check box�tr"i'is sec�iori does ri�apply --�
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 Colar
Driver of Vehicle(City Employee's Name)
Area Damaged
In'ur Claims- lease com lete this section ❑ check box if this section does not a 1
How w��u inj ed? `"
What part(s)of your bod�ve�e i ur�d?
0.
Have�you sought medica treatment? Y o Pl mg to ee reatrnen (circle)
When did you receive treatment? (provide date(s))
Name of Medical Provider(s { ' o "
Address Telephone
Did you miss work as a result of your injury? Yes o
� _ _. WhPn,.���!�;��mis���rk�� c.v r� � �<�'V1��,.�_(� � c� � �l�Q�..f� _(provide date(s)) ---
• er: n �.� p " � 7
�lddress 1�QSS -eGM (`�z�. � a--Q �� 7 Telephone
0 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 k�zowledge. Unsigned forms will not be processed.
Submitting a false claim can result in prosecution. Date form was completed�' ( C� l/ Z.
Print the Name of the Person who Completed is Form: h. �S!�{ `S �'C�--Q,l�l
C�
Signature of terson Making the Claim: �9,
Revised February 2011
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