Whitehead NOTICE OF CLAIM FORM to the City of Saint Paul;�nnnesota
Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipality�!"sTial!c�s��o�be presented to the
governing body of the municipality within 180 days after the alleged loss or injury is discovered a��4t�'� t}'�g t �e�place,and
circumstances thereof,and the amount of compensation or other relief derAieitila��L+L�t'�1't
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
«atut•e of yaur ctaim. 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, 5AINT PAUL, MN 55102
� � C�E�C�
First Name � Middle Initial � Last Name w� ��
Company or Business Name -�v� J° l,�-1���TL�1�t� �
Are You an Insurance Company? Yes/�If Yes, Claim Number?
Street Address �`�� ��� 6+O � UE
City •�• J�f1 t,�(, �I/1 State /�N Zip Code c5c�7�� �
Daytime Phone(�S� ) ; Q� ell Phone �S( 3�� �� Evening Telephone(_) -
Date of Accident/Injury or Date Discovered �" f ' j 3 Time am/pm
Please state,in detail, what occurred(happened),and why you are submitting a claim.Please indicate why or how you
feel th City of Saint Paul or its employees are involved and/or res onsible for your damages.
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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 property
�-Other type of property damage—please specify ��►'��GC' f n► ���.YCA qC -- �f�a Z,frY'l1
D Other type of injury—please specify
In order to process your claim vou need to include copies of all auplicable 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. I
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—please complete this section
Were there witnesses to the incident? Yes No U 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#
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. ���cessary,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. f1�1�-
Vehicle Claims—please complete this section ❑ check box if this section does not apply
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 Colar
Driver of Vehicle(City Employee's Name)
, � Area Damaged , , . �
Injur_y Claims—please complete this section ❑ 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 treatrnent? (�rovide 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
ld'C;heck here if you are attaclung more pages to this claim form. Number of additional pages
By signi�zg this form,you are stating that all information you have provided is true and correct to tlze best
' of your knowledge. Unsigned forms will not be processed.
� Q
Submitting a false claim can result in prosecution. Date form was completed � " � 7 �'�3
Print the Name of the Person who Completed this Form: �� 5• ����`1��'�d
Signature of Person Making the Claim: �'� r�°
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Revised February 2011
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