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NOTICE OF CLAIM FORM to the City of Saint Paul��a
Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipality...shall cause to be 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 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. If something does not apply,write`N/A'.
SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK,
15 WEST KELLQGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
First Name ��,�h�1 Middle Initial �, Last Name���(���
Company or Business Name�� �`�� ����vc.�� ��( p�p
Are You an Insurance Company? Yes No If Yes, Claim Number? �3 �00 ��C(
Street Address ab� E C�S� �� ��fE�(?k
City ��, � �;,�\ _ _State 1�1 l� Zip Code S U
Daytime Phone(�51 ) iC - j • Q; Cell Phone(�;I�)yI�S -�Evening Telephone(� -
Date of Accident/Injury or Date Discovered � ��� � �3 Time �U 4 a /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 res onsible for your damages. (� �,�c��r I�n�-
-� ��!^ ���ee� � � �, �s; w � � � �,� ►. Vh � �
l'..L��;� locu�� a � �(-.`] EuS4 �Sf'—`' S�ty�e�� S�. 1�a� � �'►'1rv SSlul_ ��e� c1a�a�.
�� �hP Si�,:awel(s ; I�.ha:��_�� la�:.� 1e��'1 !'ec�i�. E.Y,P.-�:Jnt� �,.ti�r
�X�rr<t ��.�r���,Y.��r1�: I,vt.iS• 11PF !'a
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 during a tow
❑ My vehicle was damaged by a pothole or condition of the street ❑ My vehicle was damaged by a plow
� My vehicle was wrongfully towed and/or ticketed ❑ I was injured on City roperty
� Other type of property damage—please specify f�u�e� t�am�,e .}a Sa, 1VIu�,,'S �q�'����G C��%-h
❑ Other type of injury—please specify
In order to process your claim vou 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 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
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims—ulease complete this section
Were there wiMesses to the incident? �1'es� No Unknown (circle)
Provide their names, addresses and telephone numbers: V�nc� Z�� w�.5 �� S I - �/�� ' S � ��
C,��;�ln w�a„1�CJ1Gn� e S�ncr��`SUr
Were the police or law enforcement called? Yes No 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. Tt�� wc�le; ���, �
�f���.�r�c�, , n �1.�� r.,��c.�c�l '� c�� S5 � ���e� � �h `c-ro�,� ���- S� .Y►'�4r�`� C (�J.�h.
Please indicate the amo nt you are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction. �' GI 7 �< i }1,e � c �v �l� a n
C' �E��.r� ��Q. (1„in,-�s a # . M��,�'s C�,��:I�c, C ���h.
Vehicle Claims—please complete this section ❑ check box if this section does not applv
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 Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniury Claims—please complete this section O check box if this section does not applv
How were you injured?
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? (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
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 1 � O g � I 3
Print the Name of the Person who Completed this Form: JO�v� llY'��„��1� _
,,-��" .�/ �;%�'
Signature of Person Making the Claim: C�--�.��•- f���/
Revised February 2011 ��
D�G'AN .�
o�.n�1v�.�,�, r1vc.
6400 Centrai Ave. N.E., Minneapolis, MN 55432
(763)572-2000 •FAX (763) 572-9933
www.advancecompanies.com
January 24, 2013
lohn Uriaub
Catholic Mutuai
St. Mary
26f - $th Street E.
St, Paal, MN 55101-2307
{651) 222-2619
INVOICE
P,� 8160
���t!
Water clean-up as per esttmate. $2,973.10
TOTAL $2,973.10
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EXPERIENCED RECONSTRUCTION CONTRACTORS
CONTRACTOR ID#0004423
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.nv�v .�
o11�PA1�ri'.�,s, �1vc.
6400 Central Ave. N.E., Minneappiis, MN 55432
. (763)572-2000 •FAX (763} 572-9933
www.advancecompanies.com
lanuary 15,2013
John Uriaub
Catholic Mutual
St. Mary
261 - 8th Street E.
St. Paul, MN 55101-2307
(651) 222-2619
ES`TTMATE
�iURCH
SOUTHEAST ENT�Y 9'X 6'X 14'.4'�°7�t' MiD IANDING,
9`X 6' UPPER LANDING ✓
Remove rug, clear� and re-set. $i7.00
Clean and deod�rfze carpet !35 sf @ .48 $64.80 �
Clean and deodorize stairs. 16 @ 4.50 $72.Q0 �/
SdUTHEAST LOWER LANDING 12'X 8'�C 9'
Clean and deadorize carpet. 96 sf @ .48 $46,pg �
NORTHEkS7'ENTRY '�X 6`X 14'.4'6"X fi' MiD tANDING�
�'X 6' UPPER LANDING
Remove rug, clean and re-set. $17.50 ��
Clean and deodorize carpet. 135 sf @ .48 $64.80 �/
Clean and deodorize stairs. 16 @ 4.50 $72.00 f
NQRTHEAST LOWER tANDING 12' X 8`X 9'
Ciean and deodorize carpet. 96 sf @ .48 $46.08 ✓
MAIN FLaOR- ENTRY 30`X$'X 10'
C{ean and deodorize carpet. 240 sf @ .48 $115.20 `�
crKr
�rsrN�w¢orrarv ,�
EXPERIENCED REGONSTRUCTION CONTRACTORS
GONTRACTOR ID#0004423
SQ�IAL NALL '
Clean and deodorize carpet- �artial. 3�4 sf @ .48 $144.00 �
EMEi�GEN�l(�E�E_ .
01
Transport and sefi dehumidi�ica�on
Qquipment. 2@ 1.5 hrs @ 48.Q0 $144:�0 �
F�c�-ac�water and sand from car�et. 2 � i.5 hrs �a 48.00 $14�.OQ �/
E�ctra�t water�nd�nd fr�m pump r�m. 2'@ 1 hr @ �8.00 $96.00 �/
: nit��er to all flaor ar�as. 79$ sf Cc� .18 $143,64 �-°
�p�Y sa
EQUIRMENT ' �
2 D�D00�eries Dehumidifiers. 3 d�ys @ 180.00 $i,Q80.40 �
5 Higfit Vefocity A�r Movers. ' 3 days-�a 25.�0 $375.00
t t�J�3 �utpm�nt Cr�e�c �.00 " �
I
Re-apply �18I as n�ded. $71.50 ,.,/
PI�K-��► ���M/�CH�NE�LEA�1-UR$.��
Z ut�it�@ 38.�U $76.D0 ,�
� , �, :- 5 un�'@ 17.50 �87.�0 �
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°`�' �{�.;_ TOTAL ' �2,9?3.10
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FREMONT NATIONAL BANK CATHOLI�: MUTUAL RELIEF VNO 1 � � ��,��� ��
.FREMONT'.,NEBRASKA 68025 i
i
Mutusl RNNf%�,�. SOCIE't�Y OF AMERICA � ���
PayablsMroughflrstNatbnal DATE 1�25�j3 AMQUNT $1�9��.10 �.
eank omans,Newaske sa�oz OMAHA, NEBRASKA _
PAY One Thousand,Nine Hundred-Seventy Three Dollars and 10/100--------___�_____�________________�_______�___
rHe FIRST NATIONAL BANK �s-a
OF OMAHA,NEBRASKA 104g
ORDEF MOST REV.�"/��� Y �{�C.�(.� D.D.
oF Church of St. Mary&Advance Companies,Inc. IRM'�
�� CQ.�!��✓"�)
�l�,�'��` �;�.�� �����`��� �T� ���;�.; �; � AUTHORIZED SIGNATURE
DETACH BEFORE DEPOSITING CHECK C 17 6 2 9 3
CLAIM# DATE OF LOSS TYPE OF LOSS DATE PAID AMOUNT PAID MEMBERSHIP
1300069 1/l0/13 Water Damage 1/25/13 $1,973.10 Archdiocese of St. Paul&Mpls.
'uR�t.Mary Church CLAIMANT
261 -8th St.E.
St.Paul, MN 55101
-. . _ _ _ _
_ _ _ - — _
RISK CLASS�FICATION NATURE OF LOSS ADJR. AMOUNT
Payment code 08 Repairs to damages
caused by water: $ 2,973.10
Advance Companies, Inc. Less Deductible: $ (1,000.00)
Tax ID#41-1332441 TOTAL: $ 1,973.10
COMP. AMOUNT COMMENTS TYPE PAYMENT STATUS
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