Ryan Plumbing & Heating ' � " �"�CVLei Y e��
DEC 2 � 2012
NOTICE OF CLAIM FORM to the City of Saint�-��nesota
Minnesota State S'tatute 466.05 states that "...every person...who claims damages from any municipality...shall caase to be presented to the
gmerning body of the municipality within 180 days after the alleged loss or injury is discovered a notice stating the time,place,and
' " ei'rcumstances 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 ezplain 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 Middle Initial�Last Name
r n .
Company or Business Name � 1/ U Y�'� ;7V '� �/
Are You an Insurance Company? Yes�`.J If Yes,C'aim Number? _
�
Street Address i �Q�S � V
City �T QR 1�� S te /�')� Zip Code ' 1
Daytime Phone��-�Cell Phone��I - Evening Telephone(_� -
�
Date of Accident/Injury or Date Discovered � � Time � a /pm
. � .
Please state, in detail,what occurred(happened), and hy you are submitting a claim.Please indicate why or how you
fe, the City of Saint Paul or its err�ployees are involved and/or responsible for your damag s.
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Please check the box(es)tha.t most closely represent e reason for completing this form: -
❑My vehicle was damaged in an accident ❑ My vehicle was da.maged during a tow
❑My vehicle was damaged by a pothole or conditio of the street ❑ My vehicle was damaged by a plow
0 My vehicle was wrongfully towed and/or ticketed ❑ I was injured on City property
❑Other type of property damage—please speeify
❑Other type of injury—please specify '
In order to process your claim vou need to include copies of all aaalicable doeuments.
For the claims types listed below,please be sure to�clude the documents indicated or it will delay the handling of
your claim. Documents WIIrL NOT be returned an 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 da.mage exceeds
$500.00;or the actual bills andlor receipts for the repairs .
O Towing claims: legible copies of any ticl�et issued and a copy of the impound lot receipt
O Other property damage claims:two repair estimates if the damage exceeds$500.00;or the actual bills
and/or receipts for the repairs;detailed list of damaged items
O Injury claims:medical bills,receipts
O Photographs aze always welcome to document and support your claim but will not be returned. -
� Page 1 of 2—Please complete and return both pages of Claim Form
i '
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims-nlease comnlete this section
Were there witnesses to the incident? Yes No Unknown (circle) ,
Provide their names,addresses and telephone numbers: Gl�q ��,n,r. {�
Were the police or law enforcement called? Yes �T Unknown (circle)
If yes,what department or agency? �� Case#or report#
Where did the accident or injury take place? Provide street address,cross street,intexsecti name o`�f k or facility,
closest landmark,etc. Please be as detailed as possible. If necessary,attach a diagram. ��7 G �1_�
Please indicate the amount you are�seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction. �7�b �
--Vei�iele-�lai�as--�lease eemple�e-��is-seetie�-- _— --- __- —---- C7�e�-i€�i�.���dees�a�$�-
Your Vehicle: Year Make Model
License Plate Number State Color
Registered Owner
Driver of Vehicle
Area Damaged
City Vehicle: Year Make Model �
License Plate Number State Colar
Driver of Vehicle(City Employee's Name)
° ' Area Damaged ` '
Iniurv Claims-please complete this section ❑ check box if this section does not applv
How were you injured?
_.What part(sJ 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))
l�iame o your-E�p�ayer: -------- - — --— - --_ ____
--_ --- - _— _�._ _ __-_ _
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 information you have provided is true and correct to the best
of your knowledg� Unsigned forms will not be processed
Submitting a false claim can result in prosecution. Date form was completed
Print the Name of the Person who Completed t ' Fo . �r�-01 j*�/Q!�
Signature of Person Making the Claim:
Revised February 2011 ,