Crocker �t����`�`�°�;�
DEC 2 � 201Z
NOTICE OF CLAIM FORM to the City o }r���?��1, 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 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 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
First Name �s� S � Middle Initial�Last Name � r��iF—�-I�
Company or Business Name
Are You an Insurance Company? Yes/No If Yes,Claim Number?
Street Address u d b �/�iM�-S �'
City �T ���� State � � Zip Code S , ( ��
Daytime Phone(1�5I)��� �3� ICell Phone( ) - Evening Telephone( ) -
Date of Accidend Injury or Date Discovered �Z I�d 1 �Z Time�_ar /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' s empl ees e involved and/or responsible for your damages.
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Vll � • L
'�/11�Q 1I1�V �-
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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 towed andlor 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 vou 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. Documents WILL NOT be returned and become the property of the City. You aze 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
• 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 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 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 lanc�m ark,e c. P ase be as detaile as possibl . If necessary, att ch a diagram.
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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. �7�2 .�UU
Vehicle Claims—nlease complete this section ❑ check box if this section does not applv
Your Vehicle: Year ��b Make��`10� Model ��
License Plate Number �o��—State '�L"�Color � _
Registered Owner �.�5 0� Cw���
Driver of Vehicle SovYk-C-
Area Damaged ln bv`Q'
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniurv Claims—please complete this section lXcheck box if this section does not applv
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
�heck here if you are attaching more pages to this claim form. Number of additional pages �.
By signing this fornz,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 � �- I Z7'✓ � � �--
Print the Name of the Person who Completed this Form• � ( S� r
r
Signature of Person Making the Claim:
Revised February 2011
DEPARTMENT OF PUBLIC WORKS
Rich Lallier, Director
€��-ry Kevin Nelson,P.E.Street Maintenance Engineer
��� CITY OF SAINT PAUL
�'°°. � 873 North Dale Street Telephone: 651-266-9700
;� Christopher B. Coleman,Mayor
Saint Paul,MN SSI03 Facsimile: 651-266-9736
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December 14 2012 �'�' � � �`'�
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Lisa Crocker ��,`� �",,���� , ,J�� �`��
1108 Thomas Avenue ��"\ , �v � � �
Saint Paul, Minnesota 55104 ��� � ,�h '�`' =�C.�s 7`"
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Re: Vehicle License#689GCW ��.� �� \ng�- ��%�' ��
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Dear Ms. Crocker: ` �`\ � �J�� �'�
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This letter is to express our sincere apology for the inconvenience caused during the recent snow emergency
w�ier�you were towed and/or ticketed.
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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 a�d/or towing charges.
Again, please accept our apology for the inconvenience this has caused during this snow emergency.
Sincerely, . ��
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Kevin Nelson `i� � ,
Street Maintenance Manager � � (}4�(� �r
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� .�K An Affrrmative Actron Equa!Opportunity Emplo/ % SAIN�P+a
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