Vang, Lora ' / ., . . � . . . ' .. ,. . .. . _ , ' .'r �" � ' �I � . ' " .!�- . . .
NO"I'ICE OF CLAIM EORM to the City of Saint Paul, Minnesota
�Il�irnc��n�a.ti(�ue,tilulrue�(G.l)i.clute.e!lta� " .eve�y fu�rsnn...who elctinrs c7?ctntages/i�unt u�lt-�u�uti�r��u;�li�_ cir<rll e�n�.����n�hE���resrul�cl lo llrt
,L��rcr���ini�hndi�n!�he nturiiri/wlih�urthi�t I�4/)da}'s a%tc�r tht�c�11r,Qec!lnss nr r�ryurv ar drscoccred�r nolice sluii�t,�the�linte./�luce.�md
��irctin�siuncr.c lhereo/.und�h<�nn�nunt u/'cnm�,e�tsution oi�n�hr��rrliE°i�J��rnu�t,lr�f
Please complete this form in its entirety by clearly typing or printing your answer to each question. If more space is
oeeded,attach additional sheets. Please note that�nu will not be contacted by tetephone to clarify ans�►ers,so provide as
much infurmation as necessary to explain your claim,and the amount of compensation being requested. Y'ou aill receive a
written:�cknowledQement once your form is receivrd. 7'he process ean take up tn ten H�eeks or longer depending on the
nature of your claim. This form must be signed,and both pages completed. If somethin£does not apply,w rite`N/A'.
SEND COMPL'CTF,D FOR�'i AND OTHER DOCUMENTS TO: CITY CLERK,
I S WEST KF,LLOGG BLVD, 310 CITY HALL, SAiNT PAL1L, MN 551�2
1 ir�t Namz �� r__c� _ ___ Middle fnitial � Last Name_ �o�,__ __��������
(`��mpany c�r Rusine�s Name �
------- - ------- __ _ - ---��-8-� 2013
- - Are You an Insurancc Company? Yes!No ff Yes.Claim Number?
-- -- -- - .
\� � 2 � __-- — �11���' i��c�K
Street /lddress-- — r1"�Zc� �._ —— -------- - _ _
(�ic� _�_.�o�`.�.1 - —stacc- '�+'� - - —�ip code �j��1�
Daytime Phone(�°S`_)Z'�l_-��OCcll Ph��ne( )----- -- Ercning felephone ( _ 1-----
Date ��f nccidenti fnjwy or Date Discovered _ _ __ ___�fime_ _am !pm
Plea,e state. in detai(, what occurred(happene�l), and why y��u are submitting a clai���. I'lease indicate why or how you
icel the Cit}� of Saint Paul or its emplo}�ces are in�-ol��ed and/or responsible lor y<,ur daina��es.
`' / _ �t�cv��w�..a..r�k ._ 1�vG.s---���GL_-� �oQ-----�[-���'C�S�i �°1�_(�o,r
"�G`� ----
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_�o_,��5�_.J!!�—�?�,---�r�e-Q �--- -���o re».•p_:�-� �-w2- —G��—_ ---
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-�Q---'f�_pA�1c_�^'��.'1-C�-.�--.�-��-- �e-�n�4 �--m -�2'�-.�-�--_�. �?�3 ���-�-'�`1e✓
�.i��--��.�. . -G ��,��_ �� 0 t- �� �- ��4.�c�_ �,�Q_.A.th._��--�--— '��'-1 O�r .`v
!�'-t�_°��C G+�d__�..].Ss_�_ �4�r�� �..iQt�[�__�P'e- C� �Lsv�c'�e--G�L .—_- — - - --
Please ciieck the bn�(es)tliat most closzly represent the rease�n (or completin;this (orm:
❑ M� �ehicle ��as dama�ed in an act�ident ❑ My vchicle wa>dama�cd du��in�,a to�
❑ Mv ��ehicle wa;dama��ed by�a pothoie or c��ndition of the .�treet ❑ M} ��ehic(e was dama��ed by� a plow
❑ My �ehicic �vas �vronnfully tU���ed and%or ticketed � ❑ f was injured on Cit} property
❑ (itl�er typ4 of propem dai»age-pleas�,s�ecilj� .
'' , . -_ ------- ----
--- - }- - - - ----
�Other t}'pe of in_jur� - plea>c ;�eciiy. _______ T-- --__._ ----- ------
In ordcr to process your claim vou need to include con�es of all ann�icable docUments.
,< , .
I�or the claims typcs listed b�lciw, please be sure to��irtclude the documents indicated i>r it ���ill dela�� the handlii�g o1�
your claim. Docuinents WILL NOT bc returned and become thE propetty� ofthe(�ity. You are encourabed to keep a
cop} ii,ryourself before submittin�,,your claim I�qrm. .
O�P'r��peirty dama�e�claiir���to a �2liicle:�two cstirnatcs lor thei�pairs tu yoiir���ehicle if the damage e�ceeds
'��00.00: ��r the actua) bills and/or reeei.pts I��r_the repairs
,: :
O To�cin�claims: legih��4.�ipic��c>!a�iiv ticket iy,u�i1'aiiJ a cop� of thc impound�l��Ti•ec�i�7`t`�� � -
O Uther-property� damage claims t��o rcpair c;timates ifthe damage c�cecds $500.00: or the actual bills
and/�r receipts li�r the repairs; detailed list uf�damaged iteirts
O Injury claims: medical bills, r�ceipts
O Photc�'raphs are always wcicome to document and support yx�ur ciaim hut wil I not be returned.
Pa�e 1 of 2-Please complete and returrt both pa�es of Claim Form
Failure to complete and return both pages will result in delay in the handlin�of y�our claim.
All Claims- please complete this section
\�'ere there ���itnesses ti�the incident'? Ycs No Unl.no�vn (circicl
I'r��vide thcir naiYies. addresses and telephone numbers: _
\4'ere the police or law enti�rcement called'? Yes No l!nkno��n (circle)
It've:. what department or agenc�'? _Case�? or report�_
�'b'here did Ihe accident ur injury take place'' Provide street address,cro�s street, intersection, name of park or facilit_y,
cic�sest landmark, etc. Please be as detailed as possible. f necessary. attach a diatraiTi.
f'leasc indicate the amount you arc: se8kin� in compensation e�r what you ��ould like the City t��do to resol�e this claim
to vour satisfaction. I __ , ______
- - Vehicle Claims- lease corn lete this sectian ❑ check box if this�ectie�n d�es not apn��
Y��ur Vcliicic: Ycar Make Modcl
Liccnsc Platc Numb�r � Statc Color
_ - ___ -- _ --
Rcgistcred Own�r _
Driver of Vehicle _ —_
Arca Damaged_ -- _ -_ --
Citv Vchicic: Year Makc Modcl ____
Liccnsc Plate Numbcr Statc Cc�lor _
Drivcr of Vchicle(City F,mployec's Namc)_ ___ —
Arca Damagcd _ ----- -
Injurv Claims- lease com lete this section ❑ check hi�� if this section does not applv
H��w �tcrc yc�u injured'.' __ -- — --
Vl'hat part(sl of�uur body wer� iiijurcd`> .-__ _ -----
_ -- - —� -- ----
I#a�c yciu soii��ht medical treatment`' Ycs No Plannin�to S�ek 1 rcatmcnt(circl�)
W'hcn did vou rcccivc trcatmcnY? (providc datc(s))
Namc of�9cdical i'rovidcr(s): ---- -- -- —
Address � _ --- _ l�elcphonc
Did ��ou miss w���rk as a result of your injury:' Ycs �1��
4b'hcn did vou miss w��rk? --- — — -------(Provid�date(s))
Namc c�t�y�iiir Empl��ycr: -------- -_ — ----- ------- -
-----
Address l��cleph�,nc
--�---- --- ---- ---------- ------ -- -
�Check here if you are attaching more pa�es to this claim form. Number of additional pages�.
B�'S/f;ill/tx 1I11SlOYi11,y0[! f1Ye Stllllltg lllQl QII I/1fOYltl�ll0l1}'OLI IlQI'e�IYOVI(fell%S IYUe 11Kl�COYYeCI l0 1/1C�CSt
i�J voru�k�rowledKe. U�:si�ned jnrn:s will not be proeessed.
Suhn:itlii:K a false clnim ca�t result i�t prosecr�tinn. Date form was completed � �
Nrint the Name of the Person who Complc this Form: `�r � V��_
Si�;nature of Person Makin�the Claim: .__y__ - __ --- -- — -
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MIDW1�Y ST,WER SEIiVICE COMF'A1�1TY �
Y OF ST. PAiJi, �
13�2 Grand Avenue • St. Paul, Minr�e�ta �5I� 3
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� Telephone: (6 51) 6 9 8 4f�3�3��>-�tg�it
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