Winner (2) Microsoft Word-Claim form 2.11.doc- 15774 R��'��I7�'ww.stpaul.gov/Docurnent nter/Home/View/15774
EIVED n�. ..- �� ���+
REC E/VED
NUTIGE UF +CLA��`61� to the ����.t Paul, Minneso�R 2g ?�13
Minraes�ta Sk�te 5ir�ru���9fi(.OS s�nats rf�;I��r'�1�'� ��cte�irns darne�ges{ro�»ar.t murzicipality...shall cdu�e to be�'i�i�e.Jer j�d a t#ae
go��enrirrg borl y o�'the rnunicipulrrl��31r�l�I!18(�ricT�s a ter'tfie cr7l�ged toss or ir.jurY is tfiscnvered n natice sta�irag the tirne,/�la�e,ar*��'�-:.,`; 'E; '%
circurnstances�thereof arrrl the«ntount ujcornperuntinr.or c�tlxerrelief rlrrnartdec�."
I'Eease ccimplete this�c.�ern in its c�tirety by clez�rl�t,ypin�c�r printin�;y�ue�nsu er tc�euch yuesticrn. I�Ynarc�pace is
nectifecl,�itt�h adclitir�n�l shc�et3. Plt��se nr�t�that yau will nc�t be cc�nt:�tctc�i!�y-t�leptxxte tc�clar�fy s�nswers,sc>pn.��idc ros
murh information�s ntxcss�ar�ta expl�in your clutm,ancl the arnaunt vf carnpens�ti�n being request�i. �iou�•ilt rc�eive�
�ritten acknow�ledgernent once your forn�is receiveil. The process can take up to tcn weeks or longer dependin�on the '
n��ture af y�our cluim. Thls forrn must be slgnecl,anri both pas;es cornpleterl. If sornething does nat appiti-,write'NtA'.
SEND COMPLETED �'ORM AND UTHER DQCUMENTS TO; CITY CLERK,
15 WEST KELLOGG BLVD, 310 �CITY HALL, SAINT PAUL, NiN �5102
i
First Nr�n�e�0�1�iC',��� Middle Init��l � E�a� N�n� ��NN� �
�
C`i�t7in�+nt;or C3��.in4ss Nat�3e �
rlre Yau an Insurance Co�n�3any? Yes/ o It l�e�,Cluim Number`? 'I
� Stre�t Ac�dre4. �J S 5 ��'L S /�v� � _
ctty �ai,vt �cu�-� 5tac� M I�%r z;p eode s�f�(o
L)ayti�iyc Phun4( j - C�;II Phc�n�t4�)546-Cn0 Fvet�in�TeleE�nc�ane(__) -
[�ate c�f�cr.idcnt/ Injur}� c�r[3ate I)i�overc;ci I Timc`����(��i�n/t�m
[?le���:5t€�le.in detail,v�-1�at occurre�l {hr►p�a�ne;c3), c���d w°hy`yc�u are s��k�►r�ittiif� a claim. Pleti.�e inciic�te whV«r how yau
teel the Cit�r of'S�unt Pa��t �r i��ernployees are inti•t�l�°ed andJor responsible f�or tfour damages.
.� pc�ke 1 o u -►�l.�t,. �+��l o v.� s,d¢� oE�� d t o�s�
vJ l�..e,r..� Z sa� l�c{+�-S �� -r(.�_ 5c�u n.,-t Pa.�,.D P-t.�c.IL. 'T�.ta fo1c� Atie. i'(•�I' ►�
� M.c� �� J�M� c.cx.Q- to � o�1,.Q.R- s�ae.. b� -ttnt� sta�.Q:F. Z wou�N� b� �-owe-�1 -
� o V e.d 'd i��r.i+ �e�.• ci. -�-i�.Y.JZ-t c�N �t.t�t� C_cU2 �' �.
�vv�-� - Tw o wtZ-s Iate.R� b�.n��tiu�, pA,�e� -�ft� ;-�
` �2 �u- 1- S�d� o �'1.�� 5t RR.4_� - I'�,v� l�.lo'�' c�-i`S p +i� '1'(i.2
C.i�0� � � j�S�-'�1nSt.. �v i i�o )c�. '�Z�2-5.
Please check the Y>c�x1e5I that t�x�st cic�u:ly repre�;e�1t e recason f'or c�mpletin�this forin:
O My Fehicle wr►. drt�i3a�ed in �in acc�ident I ❑ My vehi�le w��.� ciamaged durine a tovs�
❑ 141�� vel�ic:le was clama�ed bv a pc�thole or cc�nditic�n bf tt�e st�et O My vehicle��as damaged by a plc�w
�.h4y= F�ehicle�a��.���ron�fullt�tot���cl andlc�r ticketec� � I w�injur�d on Cit}�pcopett��
G'�!�;:he,t}pe �f p,�pe:t, darr:��c—�'.�a ;: sp:�E:4 _ _ �
�Chhertype of injurY—ple�se specify_
Ii� c�rder tcy prc�ce�;s yoi.�r cl:4�im vr�u n�c�d{tt�inct�de c�3pies r�f�II apPlic�ai�le ds�cument��.
fic�r the clillIllS C��1t',S�[�t�CI��IOW, pl�i3.ti�k3�SUf'�YU ECICIU{I�tFIC CIOCCIIIl�11E5 IflCI1Ci�ed or it w�ill delay the handlin�?af
yc���r claim. Dc7cume��ts,V4rILL NOT be returned and b�come the prc�perty�ot the City. �'c�u rire encoura�ed to ktep a
copy� for y°c�ur�elf befare�ubrnitti n�y our cl�ii rxi forts�.
O Propert�d dan�age clairns tz�rr vehicle: two e�imates for the repairs tu your r•ehicle if the d�zi�age exceed4
.��Q0.00; �r th�actua( bills r�nd/�?r rec�i�ts for the r���airs
�.Toc�Ting cl�i�n,�: legi�le eopies of'aiat'tir�Cet is��ed and a copy�f'tt3e im ound lot receipC
�Chher prc7pert��d�ina�e cl�iinis: t�ca i�;pr�i�•efitimrzt�s if the dam��e<xc�;ccl�,'SO�.�{�;c�r ehe aecuK�l bills
and/car r�:x;ci}�t5 t�c�r the rc�pairs;cletkiiled lis[ c}f ciamaged item5
O [njury claim5: n�eclic:al hi11s, rtii4ipts
O Phc�to�:r�aphs�tt�always welcc�me to doc��u�ent and�ppc�rt y�c�e�r elaim but will nat t�e iettit�ned.
Page I of 2—Please complete and return both pages of Claim Form
1 of 2 2/26/2013 11:22 AM
Microsoft Word-Claim form 2.11.doc- 15774 http://www.stpaul.gov/DocumentCenter/Home/View/15774
Failure to complete and return buth pa�;es wlll result in dela� in the handling of y��u.r claim.
�11 ClaUns–please camt�lete this section
t�€ere thec�witnesre,to the inc�ident? � Nc� Unkno��°n �circle}
Pmtfide [h�ir names,addr�5���nd tel�phone numt�ers: ��1'ti j ic:i��st, e�i�t.�-�10��S u� �esu;�
� ��
t�ferc fht�palir;e��r la����1�txrcerr�cnt called`? Yes r? U►tknc3wn (�ircle)
E��ye5,what departmer�t or�ency? �ase#�oc repr�rt#
V4'heee did th� accident ar injury take pl�c:�:? Frc�ti-ide�ree:t acid�s�,cros5 �treet�intersectian, narne at pack or facilitr,
close�landrnark,etc. Flease be as d�et�riled as possible. tt nec�ssary, attaeh �di�gram.
�5 (,3�-1-�-5 ���'� �c;�ec1 v u c�J est Sti�l 2 0� St curs�-t w � � s fi Si��.
—° 6 Sfi��
� PEea�indicate the amount vc�u ace se�kin in compen��t�on�r what you w�ould iike the City to da to resolv�thi�el•aii1�
tc�yoe�r��xtisf�tction. � a�� s rJ
�ehl�le Claims– lease com lete this sectian ❑check bax if thi�section does not a I
Y�ur Yehicle. Ye��r `LbO\ Make �'0 0.- Mode.l L�-o�
Licen�e Plate Number MT_ � l� �" St�rte I1nT Color S� (Ve�
I�e�istered Ownee ��NQ. l�'�N�24�
I?river of Vehicle i' i uN � �–
P�re�Da��aezd � N S �sJ` � S
City Vchicle: Yc�ir V Make , c�del
I..icen�;t I�I��te Numk�er __T State Colc�r
Drivcr ol't�ehictc.(City�mployee's Nanie)
Area:Darnaged
In1urS Claims please complete this sectlon �c,hec:k�c�x it'thi::s�cti�n d�e�not :�RU1v
T
Hnw were you injtrred?
��hat p�rt(s} of your bc�d�`��ere injureri?
H��ve you �ou�ht n�e�iic�tl tre�tinc;nt`? Yc;s N« I'la�lnins�to Seek Triatm�:nt (cin:I�)
V4'hen di�i ynu re�:cive trc;atm�nt`? {provide ci�itets))
Name of Medical Prc�>-ide�•f�t: —
Address i Telephc�ne_ ,
L?id vou mis.w�ork as a result c�f ya�r in���ry•'? �'I�`es No
Z'ti hen di�i you rni�a uxork"? {pre�vide d�te(s))
Nam�of}rour Empla}°er: —
Addre�5 Telephone
p Check here if�ou are attachin�mnre pa� tc►this clalm form. 1Vumber of additional pa��
By signing this farrn, you are stnttng that all in fvrmatior� you have �r�vided is true and correct ta the best
af your knoxltedge. Unsi�fted fortt�s will nat be �racessed.
3 �0� �3 , s��N�-d 31a5I� 3
�ubnaitling a false clain� ccrn resu�`t rn prnsecu#ion. Dete form was completed
Pcint the Name of the Persnn who Completed this For;m: ��.N i ej�I�.i Q� )/�l I��_
Signatw?e ofPerson hiaktn�the Clatm:
�c�4'kSCC.�1"Gf?I'U:U}''�)��. .
2 of 2 2/26/2013 11:22 AM
Saint Paul Police Impound Lot, 830 Barge Channel Road, Vehicle Release Form
Make: 99 fiONDA License #: 4C130SG CN: 13036203 Invoice#: 19642
DatelTime Released: 02/23l201314:54 Tow Charge: $ 123.95
Released to: TOTO Storage Charge: $ 0.00
Paid by: CREDIT CARD Admin Charge: $ 50.00
Released by: ELISE Tax: (7.625%) $ 15.55
I,the undersigned,have recovered the vehicle described above. Subtotal: $ 219.50 �
I will check the vehicle for damage or any other problems that
rnay have occurred while this vehicle was in the custody of the Service Charge: $ 0.00
Saint Paul Police Department. I acknowledge I will report
damage and/or any other problems to the Impound Lot staff Total Charges: $ 219.50
on this form prior to leaving the impound lot.
Damage and/or other problem:
Police Report made: Yes_No_IF Yes, CN , tf NO,Why?
TO PROTECT YOUR RIGHTS REPORT ANY PROBLEMS/DAMAGE BEFORE LEAVING THE LOT
Signature si2000
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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).
Failure to provide the proper and required documentation (page one).
Failure to provide a date of accident or injury(page one).
Failure to indicate the amount of co�npensation being sought(page two).
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 (page two).
� Failure to print the name of the person who completed the claim form (page two).
,, / . /, `,� .-
(�. Other: � .t.tti:2 `� � `�Q-- f'�\
-� � `�17 � G�.. _ _ � 1 .6�`�
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 NOT be done. In other words, NO FURTHER ACT'ION will be taken until the
information requested is provided by you.
Please remember that it is a crime to subrr�it a claim form or to pursue compensation
falsely or under false circumstances.