Tromiczak-Neid ����F��l.�d
FEB 1 5 20�3
NOTICE OF CLAIM FORM to t��`K��t�Saint Paul, Minnesota
Minnesota State Statute 466.05 states that "...every person...who claims damages from arry municipaldry...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
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 KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
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First Name � +L���7Z1'1,�� Middle Initial Last Name �'u'-�C�Y1'1 i �=�-�����C%l
Company or Business Name�� ��
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Are You an Insurance Company? Yes/�Vg� If Yes,Claim Number?
Street Address \` `�� � �� L't-� l�-`�'�1 �-�T�C'�
City �� a �t,l;��.�.. Staxe �����'f Zip Code ��>/��
Daytime Phone �( �� )�C�7�?� Cell Phone(���(�-'� -���1 Evening Telephone(���)�- �lv��
Date of Accidenb Injury or ate Disc erevo d< �� "„����>(3 Time ��� am/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
feel the City of Saint Paul or its employees are involved and/or responsible for your damages.
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Please check t�ie box(es)that most clo ely represent t�i reason for completi this form::,�,��z f �,j��,i} c�{ �-�- �t�� ;�?c,s�„
❑ My vehicle was damaged in an accident ❑ My vehicle was damaged during a tow ��A
❑ My vehicle was damaged by a pothole or eondition of the street ❑ My vehicle was damaged by a plow �'��d
y ve ic e was wrong y owe an or tc e e wa �ure n rope ,
� Other type of property damage—please specify
❑ Other type of injury—please specify
In order to process your claim vou need to include conies of all apnlicable 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
� Other property damage claims: two repair estimates if the damage exceeds $500.00; or tl}e actual bills � ,
and/or recei ts for the repairs;detailed list of damaged items ��l�C�-r°� S�i� pv�I��u-�,���►�.P^%h�`z ��
O Injury claims: medical bills,receipts �tic-�, �� C�' �l'��U�E1-� '�0 fil.ur'YZ ,��i,t1d�'eti;
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 Ctaims—please complete this section
Were there witnesses to the incident? Yes No i�r known (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#
n'� Where did the accident ar 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.
Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction. U � � `�-e �►'� ��`�
��ehicle Claims—please complete this section ❑ check box if this section does not applv
our 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
� ^ In'u Claims— lease com lete this section ❑ 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 No Planning to Seek Treatment(circle)
When did you receive treatment? (provide date(s))
Name of Medical Provider(s): i
Address Telephone
Did you miss work as a result of your injury? Yes No
���WhP,����,,���5. ,.«1.7 (nrnvir�P t�atPl cll
Name of your Employer: �
Address Telephone
�Check here if you are attaching more pages�to this claim form. Number of addiNonal pages �. t ViC�u..c�FS`
�e�����E�
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: 1��h n� �� � �La-k�e i�,
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Signature of Person Making the Claim: ` 4��� �-
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Revised February 2011
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: iNUOicE#: 3 6:�7 �
� � � DATE: � '� c� � ST#: `3 c.� � a � �
NSTOMER NAME(Financ'rally Respq�sib�e PartY} CALLER NAME JOB CONTAR NAME
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' ` JOB ADDRESS CITY STATE ZIP
1- • Since 1918 '� %l �I /��. � 7` . � ��' �v°w �'S��
640 GCdQd AVet1Ue g�LLIN�ADDRESS(If Different� PH'1 PH2 I
St.Paul, MN 55105 � �5 j - 7�/ - 'Q I
65�-228-92�� E-MAICADDRESS '
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www.mspplumbing.com
ORIGINAL REASON FOR THE CALL l��3 L.,i��R � � � l O �
f tj Nt,G - �U 5S. l' f�n Z�' �.i' �
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SUMMARY: j
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�See Summary of Fndings sheet �
tor additional irdormation
WORK AUTHORIZATION: 6 the undersigned,am ownedauthorized representative/te�ant of premises at which the work above is being done:l hereby auttwrize you to Foryour peacenf rru�tl
for aIl work dorre is due�on : �r+ " ��-�y
perform the above recommendation,and to use sudi labor and materiats az you deem advisable rior-authorization for bilGng,paymerrt � -.
completion(C.O.D.).A 510.00 BILLIN6 CHARGE is due thereafter.An office billing dlarge and/or finance rge of t JS%per month(21%per annum)will 6e added after 10 days � �e�e�r uafue aur �
past due.I agree to pay reasonable attomey's fees,court cosis aml collec[ion fees in the everrt of legal a�.tioa:.i have read this contraR;induding the terms and conditions on the ��qa������ I
reverse side hereof and agree to be 6ound by all the terms contained het�in.AII old paRS will be removgd from premises and discarded,unless otherwise specified herein: j���of optio�+slor '
I HEREBY AUTHORIZE YOU . ��\ � , �' � ��'(F t� K i� • �roih repairing ar�replacing �
�arA�...—�.�L.kt�s_.5-� j L( ,.�' � �� �, t
TO PROCEED WITH THE A80VE t"' j # . "�- — I�C'1 Et the�4wP�f't
WORK AT THE UPfRONTFEE OF S • Signature: � Print Name: v�}�1(f'C �f;� E
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����: >� Raie
Q�l Tasl� : � �
Service Call Charge �
Service Partner Membership �
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� ' DISCOUNT ' �jf�6`` �U
❑Pre-Approved Financing Terms: ❑PI ase pay from this invoice-Work performed C.O.D. SUBTOTAL
PAYMENT T Cash ❑'Check : Check#: . � �' � � Tp�(
MC ❑ Visa ❑ Disc ❑ AmEx ❑ Auth#: N{y 5 ��ct�Tee����e'��'��
Exp:�m ���r�+a�' �e bene�s r�- TOTAL COST `��t �
Card#: .
PAYM�WT 2 �ash ❑ Lheck ❑ Check#: i�+var��sa�re�s!v�Y�t� �_�`� , . ., . • �
� � � �ra��Service°Partrr�r '��.�
MC ❑ Vsa ❑ Disc ❑ AmEx ❑ Auth#: �; oe� j' � � ;, ' �
� �t#thrs�=�tfne f d�cl'�e�otf�r �
Card#: Exp:m m , ,.
AtCEPTANCE Of WORK PERFORMED:F adcnowledge satisfactory completion of $ERVICE TECHNft1AN AtKNOWLEDGEMENT ��STOMER SERVICE IS OUR#1 FOCUS
the abope described work and that the premises has been leh in satisfactory condition.l Priw m the customer entering into the contract,I have
understand that"rf my chedc does not dear,I am liable for the check and any charges from the'" discussed the nature of the service and cost and 1 have �f you are not cotppletely saiisfied for .
bank.I agree to pay 1.75%per month for past due cocrtracts(minimum charge S15):In the given a copy of the conVact to the customer.NI wak 1 any Geason,� leas,�,�(I a d ask to speak
event that collection efforts'are initiated agaiost mQ I shall pay for all assaiated fees at the have done has been in compliance with company with the�115t��'S2fv�JU1anager.
posted rates as well as all cost of cdlectiort fees and reasonable attomey fiees.l agree that the standards in a work aoship manner,to building codes YOUf f.��TJE�aCIC'�5 Ve(�I ItiIPQ t0 U5.
amount set forth in th�sp�xe marked"7oT�l-�!63T"is.the total flat price I have agreec!to. when applicable- �ti�lt/ � ° • ,
! •• THANK YOtl'fAR-G1�0' SING US fOR
�}{¢,�,f ���"����':� 1 �- � SIGNATURE �` YOUR SERVICE NEEDS?
SIGNATURE ,
F decline to have th recommended work armed at tfiis�me. SIGNATURE DATE o ca�,�qfic zooa Ne,aw�.ai n�yna n��d: