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Wivinus �EB 1 �► �(��3 NOTICE OF CLAIM FORM to th���t�,�o:��aint Paul, Minnesota Minraesotn State Statute 466.05 states that " ...every person...who claims damages from any municipa[ity...shall cause to be presented to the governing body of the muiiicipality within 180 days afYer the alleged loss or injury is discovered a notice stating the time,place,and circumstances thereof,and the nmount 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 KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102 First Name � ��� Middle Initial�Last Name �/V � V I � � � Company or Business Name �V�� r Are You an Insurance Company? Yes N� If Yes, Claim Number? ��� Street Address �`I l � ��,.) If� ���^ 1 V ��� v�/ �-pat�m��� �#�D� City S�_ �G'((�. � State J� � Zip Code '�"�S� � Daytime Phone (�)� //ZZ Cell Phone (�)�_��Evening Telephone ( ) - Date of Accident/Injury or Date Discovered��� � Time D• � am/pm Please state, in detail, what occurred(happened), and why you are submitring a claim. Please i icate why or how you Ceel t� City of Saint Paul or i�employees a}-e involve �and/or responsible for your damages. `/ ✓� ` e/ �J l'� � �6 P � �� � C � - � 0 � -�l �- � � �an-h r�u-t r� �l��- Please check the box(es) that most closely represent the reason for completing this form: �CGL �G(�.°Y' ❑ 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 O My vehicle was damaged by a plow �Iy vehicle was wrongfully towed and/or ticketed ❑ I was injured on City property ❑ Other type of property damage—please specify ❑ Other type of injury—please specify In order to process your claim you need to include copies of all applicable documents. Far 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 �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 da�nage 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. 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Z C) o � m m a m O � Z � � � -a u�D, ` W � a = N o -°, � , � � � � ? � � � � W �o � 3 a cD "- r � �. o � � C� C� (O r, � � „" � O Z � � � � (�p 0^r C�D � � (� --I N � � � � .�„ (A � a 0 O � C� o � � x � -+ � .P � O �? �• $ ._ 3 co C� �-' ''� � , � m � � � m '' � � � � � � �` m � � � .. N a�i � � � � � 1 I T � ca p�i � cp � � � � cn � �' � cD CD m � � � m � � �, � �, � �' � .J t� � < N � � � � N �• � � � O U1 0 W � � `° ° � �, ° ° `° � � N � o 0 0 � o � � � Z v �, � rn W rn � � O � � � � f N O � O �� Failure to complete and return both pages will result in delay in the handling of your claim. All Claims—please complete this section Were there wimesses to the incident? Yes No nknow (circle) Provide their names, addresses and telephone numbers: 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, intersec ion,na. e of�rk or acility, closest la dmark, etc. Ple� ��s de iled as possible. If necessary, attach a diagra . � s U�.I v".Q If of I'I�l i�'l�/ �G ��/Pf�i��'- Please md�cate t elam unt yo are seekin in ompensation or what you wo ld l�ke t e City to do o r�ol�thi claim to your atisfaction. � � r�/ � -�i�� �53-pd. Vehicle Claims— lease com lete this section ❑ check box if this section does not a 1 Your Vehicle: Year Make Model .S�Z License Plate Number State�Color LI/�►1�� Registered Owner �1�'�� lsl�l✓1�1!/�-� Driver of Vehicle M41 r►�, M �/ t//�jd� rea Damaged City Vehicle: Year Make Model License Plate Number State Color j'��� Driver of Vehicle (City Employee's Name) Area Damaged Iniur�Claims—please complete this section �,check box if this section does not apply 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 cart result in prosecutiort. Date form was completed Print the Name of the Person who Completed this Form: � Signature of Person Making the Claim: Revised February 2011