The URL can be used to link to this page

Madison IRE��l�� NOTICE OF CLAIM FORM to the City of Saint Paul, l��aneso��a `j 7� ��'�.��erC Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipality...shall��s'e to D"e 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 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 IiALL, SAINT PAUL, MN 55102 First Name �o�'eiL�1�H Middle Initial!�Last Name ��f� i S(5 n l ,__ --- — _. _ -- -- - — -- — - Company or Business Name �� /l}`� �(/`�.4- ' Are You an Insurance Company? Yes No If Yes,Claim Number? ./�/ r4-- Street Address�� '1"�� , � City s� .��A l� � State �� Zip Code Daytime Phone L� ^1�� Cell Phone ��.- Evening Telephone lV �ftC��_n'6� � � "''� /��4'� Date of Accidend Injury or Date Discovere ime�i am/pm W�e�,`�'�j wQn� �:y�;�-�wo�i 0 n�-�•�S Please state,�n detail,what occurred(happene ,and why you are submitting a claim. Please indicate why or how you feel the City of Saint Paul or its employees are involvec�and/or responsible for your damages.�� ,v5 � � , , � L �r ' i ' � � j � ' 1 � 1 � Please check the box(es)that most closely represent the reason for completing this form: ❑ M vehicle was dama ed in an accident ❑ My vehicle was damaged during a tow � y ve ic e was amage y a po o e or c i " ❑ My vehicle was wrongfully towed and/or ticketed ❑ I was injured on City properly `�l Other type of properiy damage-please specif}t�rr� -��-#�(��-�pi �� ❑ Other type of injury-please specify In order to process your claim yon 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 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 �" i O Photographs are always welcome to docuxnent 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�laims—please�omplete this section � ' Were there witnesses to the incident? � No Unlrnown ' ` '(cYrcle) �- . . -�� ', �.-� : Provide their names, addresses and telephone numbers: Were the police or law enforcement called? Yes I o 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. o,,�, n�Q. 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.�.,4 u �t� d�J-1- R -E�K -�o � /�� i' �►.Lc(r` �GJ�a��s Vehicle Claims- lease co lete this secti ❑ check box if this section does not a 1 Your Vehicle: Year Make Model License Plate Nu ber State Color Registered Owner Driver of Vehicle Area Damaged City Vehicle: Year ake Model License Plate N b.er State Color Driver of Ve � le(City Emplo e's Name) Area Dama d In'u Claims— lease com lete is section '� ❑ check box if this section does not a 1 How were you injured? What part(s)of your body were injured? Have�you sought medical treatment? Yes No � g to Seek Treatment(circle) When did you receive treatment? (provide da.te(s)) Name of Medical Provider(s): Address Telephone ,. When did you miss work? (provide date(s)) Name of your Employer: � Address Telephone ❑ Check here if you are atta hing 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 I of your knowledge. Unsigned forms will not be processed. � u, . i � _. ;. . .. � . - • . . ; .S'u�imitting a false claim can result in prosecution. Date form w.as completed � -�� , : �. _ ��.:. � � � j, ^ _. .F� _, ..� f f . . �. . Print the l��ine oft�ie`Pe�rso�i�vhb Compl 's Form: � . ,. , t f Signature of Person Making the Cl ' Revised February 2011 i 1893 Taylor Ave. �ROPOSAL St. Paul, MN 55104 _________ ---�---- -� Direct: 612- 619-8484 DATE I PROPOSAL# � . �--_ _--'---------- FAX: 866-342-1389 �� 12/27/2012 � EN1378 !-------�------- �_ - -- --- _ ---- - ------ ------- � ESTIMATOR ; CLIENT ----- ----- -- --- ---- —---- -- --i rBobbie Madison Res : 651-646-5301 I Eddie Jet _ � �875 Howell St L---- -- i St. Paul,MN 55104 Bus : i Living Rm wall repairs CeN : I II Fax: i . � � i �-mail : r - ---1. ___ _- -- - ---------- - __ _—__--—_---------- ---- ' --------- ii DESCRIPTION � TOTAL Repair cracks on living room walls by taping, floating and sanding smooth. 950.00 Paint living room walls two coats. Note: T'his price is based on the living room being completely empty of all contents. �No content removal is included in this proposal. i � � � � I i � � � i � ; I � I � � il I I � j I � i ' i � � � , , I � � I� �� i � , ' � ', J.E.T. Services Inc.,hereby proposes to furnish all -- — ------ ----- ---�--�- --- - -------- --- ---i equipment, supplies, materials and perform all the labor $950.U0 � _T _ TAL -- --- ------ ---'. necessary for the completion of painting,taping,texturing, � staining a►�d%or r.,pairs at the above address as specified in ACCEPTANCE SIGNA'iURE detail above. Ali labor is guaranteed 1 year and the abova wurk to be performed in accordance with the detail submitted for above work and completed in a substantial worlcmanlike manner.Payment is due upon completion.This Proposal — expires 30 days after the above date. I . ., . � , ' �. �_...... . �� '_ __ - 1 ,�,,,1�-�_ - c,.�� ;2.��-�.�.-u_ -.�.. ,� �, ' `f n , �� ,,;�.:=n.�ti-'� 1 �,� r' � ._ % ' �:-'C U ( 1 ! � -�'1�� '�"�� --�.c' Z� C-��?L� --��2/9 _ f: -4�-- �,�-l�r- �=�'11��- 1 .��i. }ti��-� ��'�_ `� �,' , , �, , `� ..._.__ ,, � ._�;, _, . _r__.__ /� f/G�� ' ,:.,��'�.�. ��._ � ' ,� �� ) ' �<..�� j � . -a�'�� G' L .� ' � �' .. �- _ �'1,.�... c._L,,L � c � � �. , � �, -� --- ' , / �i ; _ _ ' J , l -��,{� ,..r�=J'�,L"�LG�C�'l.� , , , , 1 � ��'��C -� . , _ ., �� _.. . . �,` !��-,.�� -'� ^ 9 . �� .. / ^ / - _' / � / ,; i�-��Jy��-�:_- � �". ;. � �,� � ;; ; �,� :.��.,.-�._ � �;��-1;� ...��--�'�� ; �.� _ � � ,_._� � _„_ f'.. ,_� _ � ,� ;�,�- � `�.� ' �� }=� �� , ,�. �i�.-��=��. � -��-�J�� . . ,; c.�-�.��'�� ;�.�.-�- _ � �� ,_ a ; � - ,�� , ; z- , ;; �-, ` , , �:, � ,.-�;�,��/G�- C% - .�: --��,�_.�'-� U: =�. �� l C.E_ . � C C..�� .� -�� 1, � ' � , �„ � `� f;'::'.. ' ,z. C_'„ . ;� �t. �': ��!1� ;�._._ � -� , _ ,,.,�-�L�- ,� ,� ��- , �-2�'i ��'�-t' �,c" �- �� ,�.�, ; ; ' ;, � .r' � �t �_ ,n J /7 !/C t��--�... ��'�� j�� ,/ ',� 1` �� .// �"`l,� C; - ��, �" ' � / �� } �, , �--,�� r.�- ��(,,' / G , ��y,� ��J� �_:-.�.G' ,�L�� : G j f, f; , � � ----,�-. `�; � L� ;�� / j �;�' _ ,;,� � '''��.G'%�c �' .,''��.'�.c�ZC� , � � . r' — �� -- ;�_:�C'�� "�� - �z� �, �J��LCG ./ G'� �� ! �.J , �� ,� �? _._..._ ; _ j -- � � , r�� 'r-C.-�i''�''� /� �/��c<<��.. ^ , , -� , � ; , � , � �t�. ..-- ��`1,��--�' L � � _ � _ �,__� L . ,� , �_� �_ l.��' �� . , � l_.- / ' � .,�`�`!f f..� ��___ t; � / �" (. r�' i . /..�,. J( . .�� ..�� 4� . .!`l- 'i �. L ��/ , � l - / L�� , . ��' -_._.___ , . i �� ,,(�v� _. , . : t ,` ��, G.�...._-�:=.� � � ) / \ "� v C�� ._�.