Gust . __ _ _ �EG�:a���F.
NOV 2 � 2012
NOTICE OF CLAIM FORM to the City of Sa�}�����('Iinnesota
Minnesota State Statuie 466.05 states that "...every person...who claims damages from any nzuriicipality...shall cause to be presented to the
governing body of the municipality within I80 days after the c�lleged loss or injury is discovered a notice stating the time,place,and
circumstances thereof,and the amou�t 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 yQU_will not be contacted by telephone to clarify answers,so provide as
much information as necessary to egplain your claim,and the amount of compensatioa being requested. You will receive a
written acknowledgement once your form is received. T�he process can take up to ten weeks or langer 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 O�HER DOCUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 ICITY HALL, SAINT PAUL, MN 55102
First Name �O��Z���y-N Middle Initial W Last Name v '� S "j
Company or Business Name
Are You an Insurance Company? Yes� If Yes,Claim Number?
Street Address � � ��- ��^�f
City �� ��U-L �� S te Zip Code �^(d�
`� Daytime P no eh (� 33� 3��eil Phone�) - Evening Telephone(_� -
__ - L9G� Zr Z� Time ��� � a�m 'pm
Date of Accident/Injury or Date Discovered
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 involv�d and/or responsible for your damages.
�
I
Please check the box(es)that most closely represent t]�e 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
�. .,.__�_.__ _C.�_My vehicle was wrongfully towed andlor ticketed ❑ I was injured,on City pro L(�
�COther type af property dama.ge-please specify �. v I �
❑ Other type of injury-please specify .
In order to process your claun you ne�d to include copies of all apnlicable 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 WII,L NOT be returned and become the property of the City. You axe 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 dama.ge exceeds
$500.00; or the actual bills and/or receipts for the repairs
O Towing claims: legible copies of any tick�t issued and a copy of the impound lot receipt
�Other property damage claims: two repair estimates if the dam� ��exceeds $ 00• or the actual bills
and/or receipts for the repairs;detailed list of damaged items �1'��- ������1��. � �'��i+'�'
O Injury claims: medical bi11s,receipts � �?'��.I�►'T� ., � (p�
O Photographs are always welcome to document and support your claun but will not be returne�
- - --___ ----- __:_;.�___ .— _- ___ _______ � ___ ---- _ --- - -- --
� Page 1 of 2-Please complete and return both pages of Claim Form
__. _. _ _
_
_ _ _ _ _ __ _.__
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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 nlrno (circle)
Pro D de�na�s, add�esse,s and telephone numb,�ers: — ' '
��L OCG.U/'r M-Cn�L�i►^ S
Were the police or law enforcement�alled�-- �es � Unlrnown (circle)
-- ---�€-qes,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 landmark, etc. Please be as detailed as possible. If necessary,attach a diagram.
Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction. �3 6 Q
� Vehicle Claims— lease com lete this section ❑ check box if this section does not a 1
' Your Vehicle: Year Make Model
License Plate Number State Color
II Registered Owner
�� Driver of Vehicle
i�
� Area Damaged
City Vehicle: Year Make Model =---- --"
Licens�Plate Nurxiber - Sta.te" Co�or
Driver of Vehicle(City Employee's Name)
Area Damaged
Injury Claims-please complete this section ❑ 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 date(s))
--i Name of vou_r Emg�yer' - - —- ---�---
Address - Telephone
�Check here if you are attaching more pages to this claim form. Number of additional pages
By sig�zing 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 ��U �fl� �� �
Print the Name of the Person who Completed 's Form: �b N����4"l� ��5 T
Signature of Person Making the Claim: �"1`�
Revised February 2011
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