Cummings f
i
RECEIV�D
MAR 2 0 Z013
NOTICE OF CLAIM FORM to the Cit�����i��aul, Minnesota
Mi�inesota State Siatute 466.05 states that "...every person...who claims damages from any nzunicipality...shall cause to be presented to the
governing botly of the rnunicipality within 180 days after the alleged loss or injury is discovered a notice stating tlte time,place,and
circtnnstances 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
First Name �' i� �1�I�Q�I V.S Middle Initial Last Name C �)/��/��Gi � _
Company or Business Name �/►
Are You an Insurance Company? Yes/ To� If Yes,Claim Number?
Street Address S� S U /3 � `��1 S fi 1'V
City �U G (? State �N Zip Code �s U 3
Daytime Phone (l,S 1)��� -��l Cell Phone �� - Evening Telephone( �,Si) 77 - ��i U
Date of Accident/Inj ury or Date Discovered C�3 " U �^ �� �v 1�L Time ��i G r /pm
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 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
f� My 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��ou need to include copies 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 estirnates 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—please complete this section
Were there witnesses to the incident? Yes No Unknown (circle)
Provide their names, addresses and telephone numbers: �,�({ v� �.�Q��n/S��„/ � S�— `/��7— 7S �/ l}
,q�� Hte�� _ vsi - saS� -i �/ l�
Were the police or law enforcement called? Yes No Unlrnown� (circle)
If yes,what depariment 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. .T �U ; � S
_� h� �b�l'�l� ,4-��.ST P,4il�L �'LJ nl
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. � �1�l.. S!�
Vel�icle Claims— lease com le�t this section check box if this section does not a I
Your Vehicle: Year Mal� Model
License Plate Number State Color
Registered Owner
Driver of Vehicle
Area Damaged
City Vehicle: Year Make Mo
License Plate Number State olor
Driver of Vehicl�rty Employee's Name)
Area Damaged
In'ur Claims— lease m lete this section ❑ check box if this section does not a 1
How were you injured?
What part(s)of your body were injure .
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 ' �ury? Yes No
When did you miss work? (provide date(s))
Name of your Employer:
Address Te ephone
❑ Check here if you are attaching more pages to this claim form. Number of additional pages
By sigiziiig this forjn,you are stating that all iizformation you laave provided is true and correct to the best
of your kiiowledge. U�asigned forms will�:ot be processed.
Submitting a false claim can result in prosecutio�Z. Date form was completed
Print the Name of the Person who Completed this Form: �� S � �
Signature of Person Making the Claim: � '�
Revised February 201 I
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