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Glaubitz NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota Minnesota S1ate Statute 466.05 states that "...even�person...who claims damuges from am�municipulity�...shal!cause to be presented to the goveming body of the municipnlity widiin 180 dai�s after the alleged loss or injun�i,r discovered a notice stating the time,place,and circumstances thereof,and the amount of compensariore 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 � ->i � Middle Initial �� Last Name ' a��\�'� �'' First Name '�.��1_.�. . � _,1 Company or Business Name Are You an Insurance Company? Yes/IVo If Yes,Claim Number? Street Address ��$ L-�-X 1 n'�(TC�'C1 �Q�`�h W a v(- �bl'�"� City �J�• ��il►1 State � Zip Code �� 'l Daytime Phone( ) - Cell Phone(�)��q Evening Telephone( ) - Date of Accident/Injury or Date Discovered Time am/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 or its employees are involved and/or responsible for your damages. . � - i � 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 �VIy vehicle was wrongfully towed and/or ticketed ❑ I was injured on City property ❑ Other type of property damage—please specify ❑ Other type of injury—please specify In order to process your claim ya�• ^�°d 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. 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 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 comulete 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 No Unknown (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, 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. ��, � `7� Vehicle Claims please comnlete this section ❑ check box if this section does not applv Your Vehicle: Year�_Make Model �i� ��, o_�� License Plate Number State 1� N Color �oW�'�a'� Registered Owner � �r1A ��P '��a.K�'Ji� �t- Driver of Vehicle Area Damaged Ciry Vehicle: Year Make Model License Plate Number State Color Driver of Vehicle(City Employee's Name) Area Damaged Injurv Claims nlease complete this section ❑ check box if this section does not apply 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)) Name of your Employer: Address Telephone 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 infornaation 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 `o� � ��..�J..� .�,(�' �� Print the Name of the Person who Completed this Form: �� YJ�� L Signature of Person Making the Claim: Revised February 2011 DEPARTMENT OF PUBLIC WORKS Rrch Lallier•, Director CITY OF SAINT PAUL Kevin Nelson,P.E.Street Maintenance Enginee�• Christopher B. Colemun, A�layor 873 North Dale Street Telephone: 651-266-9700 Saint Paul,MN 55103 Facsimile: 651-266-9736 i � Tha Mm�liwWe Gry in Ameriu � December 14, 2012 Chelsie Glaubitz 718 Lexington Pkwy. N. Saint Paul, Minnesota 55104 Re: Vehicle License#UJK873 Dear Ms. Glaubitz: This letter is to express our sincere apology for the inconvenience caused during the recent snow emergency where you were towed and/or ticketed. The Department of Public Works needed to make snow emergency plow route changes in your area due to the light rail construction. Due to a gap in notification, you were not aware of these changes when we declared the December 9th snow emergency. For this snow event, due to the lack of communication regarding these route changes,the ticket will be forgiven and any towing and impound lot fees will be refunded to you. Please contact us at 651-266-9800 to arrange for reimbursement. For all future snow emergencies, you should note that the day plow/night plow rules will be followed and no additional allowances will be made to ticket fees and/or towing charges. Again,please accept our apology for the inconvenience this has caused during this snow emergency. Sincerely, �,�%D . ! ia',.,.� � Kevin Nelson Street Maintenance Manager .e 5e,. `14fl 4Q . 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