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DEC 1 3 2012
NOTICE ��f�°_,,��VI 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 the 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 cleariy typing or printing your answer to each quesfion. 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 inforrnation as necessary to ezplain your claim,and the amount of compensation being requested. You will receive a
written acirnowledgement 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��i�'Y11`�Q, � Middle Initial t Last Name ����7
Company or Business Name ���
Are You an Insurance Company? Yes/� If Yes,Claim Number? ���
Street Address�5� �� � �
City�it�' �.t� Staxe��h Zip Code 5510�
Daytime Phone(�)�-`��Cell Phone(�)�Z-��Evening Telephone( ). -
Date of Accident/Injury or Date Discovered ���2�t`�2 Time Z►<2 am/�n
Please state,in detail,what occi�rrec�(happened),and why you are submitting a cl.aim.Please indicate why or how you
feel the City of Saint Paul or its emplo-.ees are'involved and/or responsible for our damages.—' W
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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 tcwed ar�d/or ticketed ❑ I was injured on City property
�Other type of property damage—please specify 1 � �t'�o Gt C�� � *
❑ Other type of injury—please specify N/Ac �
` In order to process your claim you need to include copies of all applicable documents.
For the claims types listed below;please be sure to include the documents indicated or it will delay the handling of
your claim. Documerits V�L NOT be retiuned and become the property of the City. You are encouraged to keep a
copy far yoursel�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
- -$SOO.00;�or�he actua2 bills and7or 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 $SOO.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 comnlete this section
Were there witnesses to the incident? es No Unlrnown (circle)
Provide their names, addresses and telephone numbers: � (�'�c�-,_�jr,¢�2, ��r C�'�
«c u ►J � ic�e cc�rr claw�c�� ��o , 1,�5 no � -�~a ��.-�- �-f,i-�r n S .
Were the police or law enforcexnent called? Ye No Unlrnown (circle)
If yes,what department or agency? ST.�i,� tt�,�, Case#or report# �2,Z�r} �ji
Where did the accident or injury take place? Provide street address,cross street,intersecti n,name of park or facility,
close t lan etc. Please be detailed as pos 'b e. If necessary,atta h a diagram. t�hQ�� �1F�
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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. �' l � (�j
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Vehicle Claims— lease com lete this se rion u cneck box if�his secti�n dozs:��t a 1--
Your Vehicle: Year tqq� Make Model
License Plate Number Sta.te Col �
Registered Owner Iri I
Driver of Vehicle
Area Damaged j
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name) �
Area Damaged
Iniurv Claims—nlease comulete this section ❑ check box if this section does riot applv
How were you injured? ���
What part(s)of your body were injured?
Have you sought medical treatrnent? Yes o Planning to Seek Treatment(circle)
When did you receive treatrnent?_ N/� (provide date(s))
Name of Medical Provider(s):
Address Telephone
Did you miss work as a result of your injury? Yes o
When did you miss work? (provide date(s))
Name of your Employer:
Address Telephone
❑ Check here if you are attaching more pages to tlas 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 knowledg� Unsigned forms will not be processea�
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Submitting a false clairir can<result in pros�cution. Date form was cumpleted > l 2��-{f l 2
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Print tlie Name_of the.Person who Completed this Formc, VQ,►^11� �j �
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Signature of Person Malang the Claim:
Revised February 2011 -