Loading...
Zuniga .�F' 'R F s..'� 'g i � �; a....` ��� � �_� ������ NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota ��`�°�a_,�_� 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 municipality within I80 days after the qlleged loss or injury is discovered a notice stating the time,place,and circumstances thereof,and the amou�tt 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 �U�� Middle Initial � Last Name ���� q.�— ' � Company or Business Name Are You an Insurance Company? Yes No f Yes, Claim Number? Street Address �/`�4� �v�r'd� �J• SG���(ik State ��v 7� City /� Zip Code Daytime Phone(�)?g� 3�77Ce11 Phone (�St )7 8`3- ,�.o77 Evening Telephone( �/)� s�a�� Date of Accidentl Injury or Date Discovered a ' �/— l 3 Time ����am/ r�n 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�P ..�1 or its er�ployees e involved and/or res onsible for your damages. �,� � O O 3 �Fv�- I�Ji.,i�d .4� �✓, � ! (�. v.��!-S .v�d J _ rl�,���,.� -.�-��,� e-.ti-�� cl Q-c �c� - c7 ° 3 . � �� �_ a,,..1 �v �r--�� C!/��� d G LA-� �� �..C7 �. � �� ."'1"'s Q c.+�f J . = c- 2 .,.� o._.� c.� J� �f�5' i�D,S ce- a EC� �� c�PJ S .ucili.�� vvA'S 2� r �-•�J ' � ov 2 C' i .S c o�.� :L1-n�i �� i.-}i u.re_S` ,3' ,r1�,J � v�� f`a v-� $._ �d� -1- ;�l�F-f 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 hy a pothole or condition of the street ❑ My vehicle was damaged by a plow �i������a}�irlv�t�ac �.irnnaf+�llv tn�u�rl�nl�/�1T t�CtiPtP.(� C1,�,_w,,�,_j�tii�Pd 4n Gity propertV. _ _-_ �"`!'.'3T-:.,.- .'�^'-:t-a;, ...c::�.-.:ay—c�„-r�'+�"�--=.�:=-r-- _ ,, ❑ Other type of propeny damage—please specify ❑ Other type of injury—please specify In order to process your claim vou need to include couies 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 • 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-alease complete this section �°� Were there witnesses to the incident? <�Y�gsJ No Unknown • (circle) Provide�nir names, a dr ses and telephone numb� grs: �� �'+` � �9�5 C�-�� ��s � �-v �-5`f!��3 -- 3�� Were the police or law enforcement called? Yes N� 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. 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. Vehicle Claims- tease com lete this section ❑ check box if this section does not a 1 Your Vehicle: Year �� �3 Make � Model = L7 .S<� License Plate Number State Color Registered Owner � ,� ��� � . Driver of Vehicle �Q.y,:�.-� �vt Q J�J rl G L� Area Damaged City Vehicle: Year Make Model License Plate Number State Color Driver of Vehicle(City Employee's Name) Area Damaged Injurv Claims please com�lete this section C�'check box if this section does not apuly 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)) - --- ___-- _ ""'"'"`�aYpe UI Yuur nmpiuyei: - Telephone Address ❑ 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. i�nsigned forms will not be proeessed. Submitting a false claim can result in prosecution. Date form was completed o�- (3 � � 3 ��Gt.rJ �- . ,.�cJ r �- Print the Name of the Person who Completed t ' , , �. -� Signature of Person Making the Cla' __ Revised February 2011 ________q "�'����� � -, ST PqUL IMPOUND LOT $3�BARGE CHANNEL RU SAINT PAUL, MN. 55107-2q50 651-266 56q2 Merr.hant TU: 2fbk163g�14q Terrn ID: �0173q0000g�y638k�14406 Sale zzzzzzzzzzzz0637 VISA Entrv Method: Swiped Total; 8 219.50 02�11�13 22;04;26 InV a; �57 AAAP COd2; 2$1�8Q ApArud: Online CuStomed CopY 1HANK YOU!