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,IAN 0 4 2�13
NOTICE OF CLAIM FORM to t�ie Ci���o�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
goveming body of the municipality within 180 days ufter 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. ff 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 5���'�j� Middle Initial�Last Name���_���
,
Company or Business Name
Are You an Insurance Company? Yes/ To If Yes,Claim Number? -
, �1� o [� �-l-�-4..L��-� ✓
Street Address (� � ��1 � �
City,�T �(�v L State �, Zip Code�LQ
Daytime Phone(�)���Cell Phone( ( ?S-t'Z40�Evening Telephone(__�C��
Date of Accidenb Injury or Date Discovered �c�'c�'�� c7EJ� t�- Time .� 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.��� `��U.�. ��
�
�
€�T�-'�.7�f( �1 �' ��.A-IYl AC�,� . ��'�A-T1_� Ti.�l A-TTFaE'_N-�l Pfc�C'�T�EIJ`�
i E-'p(�(Z i � ��sLL�'����T_�tJ �tr"_['_Pr 7��iTZ �C'J i�f�S> ��- �t �r- -
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Plea�se check the box(esj tha mos�c�losely repres�th�ason for c�ompleting 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 ihe street �My vehicle was damaged by a plow
❑ My vehicle was wrongfully towed and/or ticketed ❑ I was injured on City pmperty
❑ Other type of property damage-please specify -r
❑ Other type of injury-please specify -t
In order to process your claim vou need to include couies of all applicable dceuments.
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 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
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Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims-alease complete this section
Were there witnesses to the incident? Yes No Unknown (circle)
Provide their ames,addresses and telephone numbers: 7�T��1�(Yl,(Ylrs
�G�� �,� .�o.� Ac�� ���AU�., r+ �> �Sl(R
F�T� �3
Were the police or law enforcement called? es No Unknown (circle)
If yes,what department or agency?� Case#or report# �c���!'1,���Q�
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 ecessary,attach a diagram.`�U�.{ R�O
b�S� ���� .�►.� �. ���I�
Please indicate thea�p unt ou are seeking in compensation or what ou would like the,C�i�Y to do to resolve this claim
to your satisfaction.`'1�� N '��f.(�C-� �������V.�j-{-�'C'�F.
Vehicle Claims- lease com lete this section O check box if this section does not a 1
Your Vehicle: Year�Make Model
License Plate Number�i L� E V� State��Color ''�,.�'l
Registered Owner ► —
Driver of Vehicle�,� l�rtv`t'� "��F��
Area Damaged -" �
City Vehicle: Year �.L �� Make J Model
License Plate Number � State Color /
Driver of Vehicle(City Employee's Name) "(�kk� L-ti�2G,�,�Q� c1tiZ���`8 �!�6 c�
Area Damaged `�f�'?2� ��n Arl_L. M(�l�C C�r1J C.�'�"'� SL71� CLF t���C+7
Iniurv Claims-please comalete this section ❑check box if this section does not apvlv
How were you injured? —n � �- —
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? - /� l�'- . (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,�. Rr�D $ ����"-�
By signing this form,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 � - � - �� � 3
Print the Name of the Person who Completed this Form: �����"��S� .1 ) I�A�(7 1�
Signature of Person Making the Claim: '
Revised February 2011
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Page 1 of 1
Accident Report
C,S�,; _____a
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12303592 N �^T� `�'" �
tir.voww �*�► �"� 10"� ""a° "M 12 29 2012�at 0241 �
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62 �ry. St. Paul
aaM��rare■.� n,ec aiu� na.nc ye,*o„
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02 O1 R988157631025 I+IN B O1 O1 ��,,,, ,K,�„
a,�a�„ .,�pprwatwn 06 O1 86
r�.cro�: w�t�t�.00�twn 02 02 62 QUIENTEN LAVENC.'E CORNELL
15 30HN GEORGE 30HNSON O1
N
. 06 21k3 MARION ST Y 99 2361 Nokomis Ave �
. �n.ar 612��i���6 O1
pnfa � � 651�97�6]5 St. Panl 55119
O1 ST PAVL 55117 �^ :99 06 05 N a�
"� � �4
"c°"° � '° t�°" '��0^ p6 OS N 7� �"�
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w►iwU.R� �.oa f.n nVa n.s �oMO.► a� �rwW�1Y1�MCE
� mc o�uu �..c m�ar nrura�. wr.�.c�� '�. 98 � 98 23 �„
'� 98 [�'� 98 N, p M� , . M,e «a.
ac o�.a,wir N O1
�. w.c,�.�c rT DAVIS STEPHANIE DENISE
Q1 CITY OF ST PAUL INC y° pqM
.o.m
�,w,» N A210 HtJMBOLDT AVE �«�.r
38 891 N DALE ST � � �,�„�,+, u� 98 O1
w,�» rn.sun� �' 98 MINNEAPOLIS l�T 55412 ��
14 ST PAUL MEi 55103 „�, 99 RED 08
,� ,vw ma �yC AF
°'°"°" """` CpL 198
08 FORD � .,.,a. n.co ,u�,ce ,., "'" 13 04
uv �.n� i.�ro ."�rco ,R.,, jd@j 3 O1 13
13 918evz
02 939608 NQd 4 O1 13 ���n en�c�..rH
•� '°"r"'� GeiCO 41Q9-37-49-02
..Nr. wsr.* �e'
� �w��n r'lOCnP,� ��'`�� IFACCDEMfNVOIVWACOMIIEAGALNUTORVHMCRE�tCMO0LN1a.OR!lJ�DtTARTBII� .
� tvoe
u1fON Yi/M.7A Md iN.1311�.
. . , RlMEMBtlt TO IqTiFV THE i[ATH PATNOI.l�� oor���w
royy/�bu�ewnFruea��•ro�alu��
�K yVqjM�111 HO�f1M1W� OOT�IIII�J
YK I�M/G 11Lf M1tY �ONI�IIWIYGN� ���e y�IR�l� �
yMT rwG�EO�M Od �'M O�
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w �
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yyyp�p�p�ItYiMI.Ow AO MII�M
dM*10�O��01 W����I�1�0 0[N�R�0�O�N�Ola�Qi�Nd�Y{S10M rIAMI�1
OMIZ
: �+*�- 98
..o.Y. , . . c�.
�1 1��
�� " •; priver ot Unit 1 rna traveling 8B on Ruth J �c
'� �; approaching wiison and attempted to curn
03 °�
'��M �•: Fa��.bound onto wileon. Drive�ilsonnwhen Unit 1 ' 98
s= 4 ( a : travellnq NB on Auth peasinq �,,,,,
O1 N * :' turned into the driver�a aide �xcenaive dama9eht .� 04
a� �;'. O � " ', 1EfC edge of the plovr cauaing
N :,; � vnua+ . �yit 2, Driver oE Unit 1 wae la�ued citation ;t ,�
�a„n:,: :' number 620900146417 [or lnattentive drivinq. ,
98 T '. There vere no lndependent witnesaeo to the cra�h• G`M�
— — � O1
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St Paul PD 'a"'"°` �� �
o�r.caw+�wenouoae� 3�� '
Officer Brian Ficcadenti B09
u ort.org/dvsinfo/accidentrecords_2008/Includes_LE/PrintReportIndiv_LE...• 12/29�2�12
http:l/dvsles pp
Page 6 of 7
Saint Paul Police Department
ORIGINAL OFFENSE / INCIDENT REPORT
Date and Time oi Report
�omplarnt Number �zeterence�N �2/2g/2012 04:51:00
12303592
Primary offense:
TRAFFIC ACCIDENT-PROPERTY DAMAGE ACCIDEN
�ther Corneli, Wilfred Lavence
2351 NOKOMIS AV 000-000-0000
ST PAUL, MN 55119
Other Johnson, John George
1113 MARION ST OQO-000-0000
ST PAUL, MN 55117
Mcnamara, Bob 873 DALE ST N
000-000-0000
Other ST PAUL, MN 55117
Suspect
NARRATIVE
Squad#1077 No ICC available.
On 12129/2012 at 0241 hrs I, Squad 341 (B. Ficcadenti�Wauck struck another veh cle f Upon arr��ival'in the a ea
property damage acci den t in w h i c h a c i t y o f S t. P a u l p l o ar ke d faci n g n o rt h w e s t i n t h e
I observed a 1995 GMC Safari van, red in color, with MN plates 918 EVZ, P . nse as WILFRED
southb
ound lane of Ruth approximately 200 feet north of Wilson. There was extensive damage to the front
driver's side of the van. I then met with�th2361'NokomisrA eeStf'PaulyMN 55119SC/P 612-886-4246).
LAVENCE CORNELL (DOB: 10/11/196 ,
stated that he was at home when he got a call on his ph1986 r2361'Nokomis A e St!�Pa byMN °is
WILFRED home.
driver's license as QUIENTEN LAVENCE CORNELL (DOB: 06/01/ ,
55119, CNIP: 612-886-4246), who stated that heNTEN st been hit by a snow plow while on his way
WILFRED then came to the scene to meet QUIE
1 then m
et with QUIENTEN who stated that he was exited off o��e snow plow com ng�southbaund on Ruth and
driving northbound on Ruth ab�ut to pass Wilson he observe eared as if the plow was weaving
was attempting to turn eastbound on Wilson. QUIENTEN stated that it apP TEN stated that the car
over into h�s lan
e and stated that he didn't think the plow driver saw hi o�QQUE NEN then stated that the plow
turned left and struck the front of his vehicle with the left edge of t e p ve out of sight. The plow then drove
shook and he w
as eventually able to stop it where it was currently par��e�d. The vehicle was no longer operable.
QUIENTEN added that the pfow turned eastbound onto W��sone�at Ruth and Wilson.
back westbound approximately two minutes later where it stopp
JOHNSON
1 then m
et with the plow driver who was also on scene, wh PaU SMN 55104bC PN651-497'-4635) as JOH S
GEORGE JOHNSON (DOB: 02/02/1962, 1113 Marion t• ° ened. JOHNSON stated that he wa
stated that he knew nothing about the incident and didn't see what�haPP Ruth and Witson "yelling and
plowing his route e
astbound on Third street to McKnight Rd. He then�we�ft southbound on McKnight and back
westbound on Wilson when he observed QUIENTEN at the �ntersec ened and QUIENTEN was accusing
cursing". JOHNSON stated that he got out of the plow to see what happ
� vehicle with the plow. JOHNSON stated that he t 51 260-4066)S 1V�CNAMARA soon showed
him of h�tting his
BOB MCNAMARA (DOB: 01/16/1958, 873 Dale St. St. Paul, C/P.
up at the scene.
SP522D88B564EF6
Page 7 of 7
Saint Paul Police Department
ORIGINAL OFFENSE / INCIDENT REPORT
Date and Time of Report
;omplaint Number Reference CN �2/2g/2012 04:51:00
12303592
�rimary offense:
TRAFFIC ACCIDENT-PROPERTY DAMAGE ACCIDENT
! observed fresh red paint marks and scratches on the left edgatch the d�amage OHiN�sOeN d onriving, City of
St. Paul plow with piate 989608. The markings appeared to m
QUEINTEN'S vehicle. At this time Squad 340 (S er ort fo afurthe information� took photographs of the
damage to both vehicles. See his supplemental p
I then issued JOHNSON citation number 620900146f{h f nc dent ntMCNAMARA added that JOHNSON was the
scene. I spoke with MCNAMARA and advised him o
only city plow working in the area at the time of the incident.
QUIENTEN had his vehicle privately towed from the scene by AAA•
A state accident report was completed.
PUBLIC NARRATIVE
4n 12/2912012 at 0241 hrs squads were sent to the ther vehicle°f Ruth and Wilson on a property damage
accident in which a city of St. Paul plow truck hit ano
(
�
SP522D888564EF6
Page 1 of 2
Saint Paul Police Department
SUPPLEMENTAL OFFENSE / 1NCIDENT REPORTofReport
Complaint Number Reference CN �2/2g/2012 06:45.��
12303592
Primary offense:
TRAFFIC ACCIDENT-PROPERTY DAMAGE ACCIDENT
Name of location/business:
Prrmary Reporting O�cer: SfY11'StICk, Jamie �ocation of incident: RUTH ST &WILSON
Primary squad: 340
ST PAUL, MN 55106
Secondary reporting o�cer:
,approver.� Meyer, Michael
orsrpct: Eastern Date&trme of occurrence: 12/29/2012 02:41:00 to
12129t2012 03:00:00
Site:
Arresi made:
Secondary offense:
Police O�cer Assaulted or fnjured:
Poiice Officer Assisted Suicide:
Crime Scene Processed:
OFFENSE DETAILS
TRAFFIC ACCIDENT-PROPERTY DAMAGE ACCIDENT�pAears to be Gang Related:
Attempt Only.•
SOLVAB1tiTY FACTORS
ey:
Suspect can be ldentified.�
Stolen Property Traceable:
Photos Taken: Tumed In:
Property
Evidence Tumed In:
Related Incident:
Lab �ingerprinfs Taken:
Biological Analys+s:
Items Fingerprinted:
Narcotic Analysis:
Lab Comments:
Participants: Phone:
Person Type: Name:
Address:
NARRATIVE
On 12129I2012, 0241 t�ours, I, Officer Smrstick, responded to Ruth and Wiison for an acciden .
List of Photos for CN 12303592:
1. 12303592-12292012_044731-TRAFFICACCDNT-1.jpg - Ruth and Wilson
SP522D888584EF6
Page 2 of 2
Saint Paul Police Department
SUPPLEMENTAL OFFENSE / INCIDENT REPORT
Date and Time of Report
Complaint Number Reference CN
12303592 12/29/2012 06:45:00
Primary offense:
TRAFFIC ACCIDENT-PROPERTY DAMAGE ACCIDENT
2. 12303592-12292012_044744-TRAFFICACCDNT-2.jpg - plow truck 939608
3. 12303592-12292012_044807-TRAFFICACCDNT-3.jpg - plow blade
4. 12303592-12292012_044815-TRAFFICACCDNT-4.jpg - plow blade with red paint
5. 12303592-12292012_044818-TRAFFICACCDNT-5.jpg - plow blade
6. 12303592-12292012_044824-TRAFFICACCDNT-6.jpg - plow blade with red paint
7. 12303592-12292012_044833-TRAFFICACCDNT-7.jpg - plow biade with red paint
8. 12303592-12292012_044839-TRAFFICACCDNT-8.jpg - plow blade ciose up
9. 12303592-12292012_044844-TRAFFICACCDNT-9.jpg - piow blade
10. 12303592-12292012_044850-TRAFFiCACCDNT-10.jpg - plow blade
11. 12303592-12292012_044855-TRAFFICACCDNT-11.jpg - piow blade
12. 12303592-12292012_044900-TRAFFICACCDNT-12.jpg - plow blade
13. 12303592-12292012_044910-TRAFFICACCDNT-13.jpg - plow blade with red paint
14. 12303592-12292012_044919-TRAFFICACCDNT-14.jpg _ �oken bl�nke�W blade with red paint
15. 12303592-12292012_044930-TRAFFICACCDNT-15.jpg
16. 12303592-12292012_044940-TRAFFICACCDNT-16.jpg - blir►ker in intersection
17. 12303592-12292012_045112-TRAFFICACCDNT-17.jpg - 918EVZ
18. 12303592-12292012_045150-TRAFFICACCDNT-18.jpg - drivers side fender
19. 12303592-12292012_045156-TRAFFICACCDNT-19.jpg - drivers door and fender
20. 12303592-12292012_045202-TRAFFICACCDNT-20.jpg - drivers door
21. 12303592-12292012_045223-TRAFFICACCDNT-21.jpg - drivers side
22. 12303592-12292012 045233-TRAFFICACCDNT-22.jpg - rear
23. 12303592-12292012_045240-TRAFFICACCDNT-23.jpg - passenger side
24. 12303592-12292012 045250-TRAFFICACCDNT-24.jpg - front
25. 12303592-12292012_045300-TRAFFICACCDNT-25.jpg - drivers side damage
The labeled photos were TRANSFERRED to the Media Vault.
PUBLIC NARRATIVE
Supplemental photo report.
i
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SP522�888564EF6
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