VonDeLinde � ' ����:�°���:�'
DEC 14 2012
NOTICE OF CLAIM FORM to the �;�����t Paul, Minnesota
Minnesota State Statute 466.05 states that"...every person...who claims damages from any municipaliry...shall cause to be Presented to the
governing body of the municipaliry within 180 days after the al[eged loss or injury is discovered a notice stating the time,place,and
circumstances thereof,and the amaunt 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 wjll not be contacted by telephone to clarify answers,so provide as
much information as necessary to e�cplain your claim,and the amount of compensation being requested. You will receive a
written acknowiedgement once your form is received. The proces.s 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 dces 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 �C,� Middle Initial�Last Name 1/ovt �C L-���
Company or Bu iness Name �/�
Are You an Insurance Company? Yes/�1Q If Yes,Claim Number?
Street Address Z�6' o���u.'�" � '
City `,�,.:,t-t �-r-1 State Zip Code1�'�u-�
Daytime Phone����_�4�U� Cell Phone(o_t2) !��11 Evening Telephone^����`�°�v
Date of Accidend Injury or Date Discovered �Z • �Z• !l� Time z' � 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 i employees are involved and/or responsible for your damages. '
�_�s�'..�G.��' '
I
Please check the box(es)that most closely represent the reason for completing this form: I
�3L 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 �B.My vehicle was damaged by a plow
❑My vehicle was wrongfully towed and/or ticketed ,�I was injured on City property
�Other type of property damage—please specify e(� �Ge..,e.
�Other type of injury—please specify Do • "E' ' ,�✓
In order to pmcess your claim ou need to include co i of all a licable d uments.
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 are encouraged to keep a
copy for yourself before submitting your claim form.
�Property damage claims to a vehicle:two estimates for the repairs_�Q your ve le if the damage exceeds
$500.00;or the actual bills and/or receipts for the repairs lOU� aZL"���-��
O Towing claims: legible copies of any ticket issued and a copy of the impound lot receipt ��,Eo 1�tG� �
O Other property damage claims:two repair esrimates if the damage exceeds$500.00;or tl} actual bills
and/or receipts for the repairs;detailed list of damaged items � � �✓���vw�.:W
O Injury claims: medical bills,receipts ��f� ,¢YG �f'�-Gd�''�' �
O Photographs are always welcome to document and support your claim but will ot be returned. �
�
Page 1 of 2—Please complete and return both pages of Claim Form
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims-alease comulete this section
Were there witnesses to the incident? Yes No Unk�own (circle)
Provide their names,addresses and telepho e numbers: : • C�+�L�+� ���G ,,
, �
L?i ' :o G � � � t,J•'�94,
Were the police or law enforcement c ? Y o Unlrnown (circle)
If yes,what department or agency? : � Case#or report# !Z � Z�=3�z
Where did the accident or injury take place? Provide street address,cross street,intersection,name of park or facility,
closest lan,d1markJ�etc. Please be a$�detailed as possible. /If necess ,attach a�dia am.
W�►•7'tG �/t d✓ Tl✓E k.tLC �.�s.� C��SC � �"y-�' , �w
Please indicate the amount you are seeking in compensation or what y would like the City to do to resolve this claim
to your satisfaction. � < < �s� % a��'- ✓� �� ��'% U'L'`<<
��cca ✓�Ce.E'o r � 4- �- '^��
Vehicle Claims- lease com lete this section ❑check box if this section does not a 1
Your Vehicle: Year Make o a Model �.� .' •` �
License Plate Number State 1 Color �
Registered Owner + �L:
Driver of Vehicle • :�-
Area Damaged ��'�- �e��L -- ,F-e-) 1a s S
City Vehicle: Year Make f-eY.1 Model �.
License Plate Number `�1—r-v��State�l _Color
Driver of Vehicle(City Employee's Name) �����- �' �a�
Area Damaged
In' Claims- lease com lete this secti ❑check box if thi section dces not a 1
How,were you injured? G: 1 a-y�,., d.c� 1c•�. w
� d.e. � �: �..�i... .
What (s)of your body were jured? ��•l -�` r' a a�� '�. .� '-�
:.� '..� a �t�. . .
Have you soug medical treatment? Yes No Planning to Seek Treatment(circle)
When did you receive treatment? � • 1z � 7-OJZ' (provide date(s))
Name of Medical Provider(s): oo e >; - CJo�d6 � •�dl L�• �� -
Address�6����� � �✓ �1 w - �- �w Te phone
Did you miss work s a result of your injury? Ye No �- ��h'' ` "`s
When did you miss work? � (provide date(s))
Name of your Emplo er: 6A►' �-���.� ✓°
Address 3�Za :..� D✓. Telephone �r'1f . `��� Z �
❑ Check here if you are attaching m re pages to this claim form. Number of additional pages .
By signing this form,you are stating that all inforn�ation you have provided is true and correct to the best
of your knowledge. Unsigned forms will not be processed.
Subm�uing a false claim can resull in prosecution. Date form was completed 1 L � ��' La 1 Z
itti ���y�... U«� ��L.���� �0�2�
Print the Name of the Person who Completed ' a
Signature of Person Making the Claim:
Revised February 2011
r ,.
Attachment to Notice of Claim Form—Tyler J. VonDeLinde
The reason for my claim against the City of Saint Paul is due to a vehicle accident caused by an employee
of the City of Saint Paul Public Works Department on the day of 12-12-12. I have suffered from multiple
injuries, my dog (who was in the vehicle) was traumatized and taken to a veterinarian, my vehicle was
damaged,and there was damage to personal property caused by the accident.
I was driving home from my parents' house in Eagan with my dog and got onto White Bear Ave
northbound from I-94 east. I was traveling north on White Bear Avenue and approached the intersection
of Case Street. As I entered the intersection, a City of Saint Paul plow truck, coming from the opposite
direction, turned directly in front of ine. I had the right of way; the truck driver did not. I locked up the
brakes on my vehicle and skidded approximately 20 feet before colliding with the front of the plow truck.
The light at the intersection was green. I was wearing my seat belt and it was a very hard impact and my
head hit the steering wheel. My dog was thrown forward into the dashboard. The accident happened at
approximately 2:50 p.m.
I called 911 and a City Police vehicle arrived on the scene about one minute later. The police officer
talked to the plow truck driver and to a garbage truck driver who witnessed the incident. Those
discussions went on for about 10 minutes before the police officer even spoke to me. While he was
talking to the plow truck driver,and one of the witnesses,a paramedic arrived and asked if I was ok. I told
him my head and neck hurt.
I then spoke with the officer and told him what had happened. There were two other witnesses from the
vehicle behind me who were telling the officer what happened. But, the officer did not take a report from
them. I then asked the officer if the paramedics were pulling around the block to get out of the road or
if he could call another ambulance. Another ambulance arrived about 5 minutes later and I explained to
them how my head, neck, back, and teeth hurt from the impact. They said my adrenaline was wearing
off and that I probably had whiplash. They asked if I needed a ride to the hospital and I asked them what
their opinion was. They didn't think an ambulance transport was necessary. They did not offer or make
an effort to place a brace on my neck. I told them I would get a ride from my parents when they arrived.
My parents, brother and girlfriend arrived shortly thereafter and I was driven to Woodwinds hospital in
Maplewood.
I was admitted as an outpatient in the Emergency Room at Woodwinds at approximately 5:00 p.m. I was
examined by an ER physician,x-rays were taken,and I was released with a prescription for medications.
On 12-13-12 I took my dog to a veterinarian for an evaluation. On the same day I also had my vehicle
towed to Doherty's Auto Body Repair for an estimate of damages. That same aftemoon I went to the
dentist and had repairs done to my permanent retainer and x-rays of my teeth at the Northwood Dental
Clinic in Eagan. On 12-14-2012 I went to a family physician and ophthalmologist at the Woodbury Allina
Clinic for an examination.
This report was submitted as an attachment to my Notice of Claim form delivered to the City of Saint
Paul,City Clerk on 12-14-2012.
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