Cagle-Kemp 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 municipatity...shall cause to be presented to the
goverreing bocty of the municipaliry 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 rnmplete this form in its entirety by cleady typing or printing your answer to each quesdon If more space is
needed,attach additional sheets. Please note that you will not be rnntacted by telephone to clarify answers,so provide as
mnch information as n�ary to explain your claim,and the amount of compensation being reqnested. You will receive a
written acimowledgement once your form is received. The process can take up to ten weeks or longer depending on the
nature of your claim. T6is form must 6e signed,and boW pages compteted. 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
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First Name � C�� r c��CC Middle Initial� Last Name C-�R\'Z -
. , .
-- - - � , :4�5'��
Company or Business Name
Are You an Insurance Company? Yes/ 1�o If Yes,Claim Number? DEC 1 7 2012
Street Address �� �� � ��Q-�' o v ► }�-�- �"1�+�.���
City �`� �C�.�� State �\� Zip Code���1
Daytime Phone � � ,�L-`�y�� Cell Phone(�� l��- `' 3��Evening Telephone(,��)y8'�- `�� `�
x �a�
Date of Accident/Injury or Date Discovered Ti� ��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 r it em oyees are involv an or responsible or your es.
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Please check the box(es)that most closely represent the reason for completing this form:
�My vetricle was damaged in an accident �My vehicle was damaged during a tow
0 My velucle was damaged by a pothole or condition of the street C]My vehicle was damaged by a plow
�My vehicle was wrongfutly towed and/or ticketed �]I was injutaed on City property
❑Other type of pmperty damage—please specify
❑Other type of injury—please specify
In order to process your claim vou need to include coui�s of all analicable 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 WILL NOT be ret�rned and become the property of the City. You are encowraged 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 ricket 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 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 botl�pages w71 result in delay in the bandling of your claim.
All Claims-nlease comnlete this section
Were there witnesses to the incident? Yes No Unknown • (circle)
Provide their names,addresses and telephone numbers:
Were the police or law enforcement called? Yes N_� Unknown (circle)
ff yes,what department or agency? Case#or report#
Where did the accident or injury take place? Provide street address,cross stre,et,intersection name of r facility,
tre
closest land�nark,etc. Please be qs detai as possible. If necessary,attach a diagram. �c� 0.�L� �=.�
��� 1 i\ \ ,,c.� '. c\v v\v
Please indicate the am unt yoyt,are seeking in co pe�sation or wh t you wQuld ' e City to do to sol this claim
to your sarisfacrion. �d�`f `-�D ct�� ho.v� -�� `fi:c,�Q-� ��c���
Vehicle Claitns- lease com lete secdon cbeck box if tlus section dces not a 1
Your Vehicle: Year ��� Make_\c>� o o. Model � r�
License Plate Numbe ��f�t �v�tate �'� Color C=��-�.
Registered Owner �1��r c v,+��e C�.. � � �`� G� --
Driver of Vehicle i� `�
Area Damaged �
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
InLur�,Claims pIC�Se Cpmp]C�C�115 SCCtjOII �check box if this secrion dces not avalv
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
� rovide date(s))
When did you miss work. _ � __
Name of your Employer:
Address Telephone
c�Gheck here if you are attaching more pages to thiis claim form. Nmnber of additional pages� .
By signing this form,you are stating that aU information you have provided is true und correct to the best
of your knowledge. Unsigned fornis will not be processed.
ubmittin a alse claim can resull in prosecution. Date form was completed ����3�a
S g f
Print the Name of the Person who Completed this Fo���s C,���C C-"' `� � 1 `Q
Signature of Person Maldng the Claim: � ��'�- "
Revised February 2011
. Citation# $8 8 ������ .
� ST. PAUL
STATE�F MINNESOTA-RAMS�Y DIST'RICT CbURT � ��: � � ;
'llie undersigned,being duy swom,upon his/her oath deMsts and says:
:* 88g751895' *
Date of O�ense `� f* � "«:�% / '� Time of Offsen� � �. � . :
".:�
r,,.�4 �t°y t�- 4�;y, Plate � �
Veh.Lieense No. "'� Year State ,�_Make ,�.:(.x Styie ��$3 , Cfllor f`���"+
Location of Otfense:`� *= '� �` ?' �'�' :,�;� ��fi ` ,> .� �
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v�o�.anoN:�"`� SNOW EMERGENCY St.Paul Ortlinance i67.oa FIN� $53,00
,, _ £ :��~ `",2 tAmounrindudes rrmrxiatory stai�s sufcharges ot S13.uo)
CN ,.; :
Citing �. �'i Officer �._! Citing
Officer °'� '°.
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CI Pci�t'ed Night Plow ',; �Qay Plow �Pbwed'in(Windrow) :�Taggetl 8efor�PbMC C��C�FF '
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OFFlCER'S NOT£S
O NO PLATE VIN:
Citation cae be'paidat ihe imponnd Lot:Pie�ase read the.badc of ihs citaUon tor paymentinsh�ctlons.
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