Ryan Plumbing & Heating ?-t��,:�.o v c� tr�v�..►�`�
JAN i 5 2013 DFC 2 � 2012
NOTICE OF CLAIM FO to ��City of Saint�-��nesota
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Minnesota State Statute 466.OS states that "...every person...who claims damages from any inunicipality...shall cause to be presented to the
governing 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 comperrsaKon or other relief demanded"
Please complete this form in its entirety by ctearly 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
mnch information as necessary to egplain your claim,and tLe 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
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Company or Business Name � � U m ;N "t"
Are You an Insurance Company?'�'es" o If Y�s,Claim�T�miser? °
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Street Address��� V oEl 1 J�rS�T�� a V� �
City �T QRk� � State /,'�� ZipCode J �
Daytime Phone�2�. -�Cell Phone�) - Evening Telephone�� -
Date of Accident/Injury or Date Discovered C�''���2� Time � a /pm
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Please state, in detail,what occurred(happened),and why you are submitting a claim.Please indicate why or how you
fe, the City of Saint Paul or,its erqployees are involved and/or responsible for your damag s:
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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 durin�a tow -
❑My vehicle was damaged by a pothole or condition of e street ❑ My vehicle was damaged by a plow
❑My vehicle was wrongfully towed and/or ticketed ❑ I was injured on City property
_ _ _ �Ot�er e of rb . . .s e— leas�s ' __� __ ,._, -- - ----
�YP P��Pe�Y�$$ P ��Y
❑ Other type of injury—please specify '
In order to process your claim vou need t�include copies of all aunlicable 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 Properly damage claims to a vehicle:two estimates for the repairs to your vehicle if the da.mage exceeds
$500.00; or the actual bills and/or receipts for the repairs .
O Towing claims: legible copies of any ticket i ued and a copy of tlie impound lot receipt
O Other property damage claims:two repair est�ates if the damage exceeds$500.00;or the actual bills
and/or receipts for the repairs;deta.iled 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
�
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Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims-ulease comolete this section �
Were there witnesses to the incident? Yes No Unknown (circle) _ .
Provide their names,addresses and telephone numbers: 7�q ��q 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, intexsectippa�e of��rk��ility,
closest landmark,etc. Please be as detailed as possible. If necessary,attach a diagram. j O C ffL�.
Please indicate the unt you are�seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction� '�� �
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�'Elii��f��ic?uiYtC— �G; °o C3 �s'g i�ilfS-S ^tifr34 � �1�`i'� � ( ❑ i.�'ieCii�OX ii i�'lIS SFJCtiflTl�3ES IlOt 1
Your Vehicle: Year N Make �-P" Model � - � - -
License Plate Number j��Q Sta.te Color - :.-��=,
Registered Owner
Driver of Vehicle
Area Damaged
City Vehicle: Year�_Make Model � � � -�� 2Q13
License Plate Number State Color �
Driver of Vehicle ity Employee's Name)�� s �„-r � -
� ! Area Damaged ° � �� ,
In'u Claims- lease com lete this section /U ❑ 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 Planning to Seek Treatment(circle)
, - When did you receive treatment? (provide date(s))
Name of Medi Provider(s): _
Address � Telephone
Did you miss . ork as a result your injury? . Yes o
When did you miss work? (provide date(s))
_ _-�Aiame ofyour Em 1 er: __ � �rw�i�_ _ ,l _! ' �---- =---�- _ _ — __ _
Address � r ephone � ., . _
❑ 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 be�t
of your knowledge. Unsigned forms will not be processed
Submitting a false claim can result in prosecutio�. Date form was completed
Print the Name of the Person who Completed t ' Fo . �r�1 I��/Q�
Signature of Person Making the Claim:
Revised February 2011
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E DATE ORDERED CI�TOMER ORDER NO,
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pUANT. DESCRIPTION OF IAAIERIK USED PRiCE AMOUHT
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� ARRNE TANE: DEPART T��AE:
� FIOUtS IABOR �� �
i TOTAL
FIRST 112 tiOUR CHARGE MATERIALS
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4 ��re a mdm��@nieaesc'��ee`�wmk. TOTAL LABOR � .
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S'�"""T"�E � °�� �- TOTAL �.�} �
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This claim form is being returned without having been set up as a claim for the following
reasons:
'� � Failure to provide a written description as to what happened and why a claim form
was being submitted (page one). (,� �� ?
" � 17`--Failure to rovide the proper and required documentation(page one).
lzece��pfs, p�o tos � e�-c
Failure to provide a date of accident or injury(page one).
� Failure to i dic�he amount of c�tio_r}bein sought (page two).
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� Failure to provide information about the vehicle involved(page two).
Failure to provide information about the injury claimed(page two).
Failure to sign the claim form (pag�two).
Failure to print the name of the person who completed the claim form (page two).
� Other: �� � L�� �Q C��v
Please return the completed claim form to:
Office of the City Clerk
City of Saint Paul
15 W. Kellogg Blvd.
310 City Hall
Saint Paul, MN 55102
If you do not return the completed claim form with the appropriate documentation or
information completed, then a claim file will NOT be established and an investigation
WILL NO i be done. In other words,NO�'URTHER ACTIQI�T will be taken unt:?the
information requested is provided by you.
Please remember that it is a crime to submit a claim form or to pursue compensation
falsely or under false circumstances.
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