Pinson Microsoft Word-Claim form 2.l l.doc- 15774 http://www.stpaul.gov/DocurnentCenter/Home�ew/15774
NOTICE OF CLAIM F4RM to the City of Saint Paul, Nlinnesata
dlinrrrsaa Sxire S�atute�J66.Oi saues rhar"...n•ery persna...whn rkii�ns daranges%raa cuz v�nur:irilxililt�...shal!cnu.re m hr presrr�rrd tn thr
guren:ir:t hrxf�•n/ihr mun.iri�xrlin��rirhii�130 dnrs�r}'rer�he a!le�ed lass or irjurv rs dr.crorrrrd a r.nrire sunir.g thr time.pl�u•e,and
� eircunutur.<�rs�htrro(,unr!rhe a�xour.t o j'i�anpertsatior,ur othrr relief demm:ded...
Please ccarnpletc this timn in It�c�tUret�'b}'cle.�rlt t}�ping or pHi�ting�<wr ans�ti er to eacPi c�uestion. IP more spuce[s
oeecied,�tt�x�h:�cicliticxia+l sheets. Please nc�te that F�cw�vill not be ccmt�ctcKl b}teleptxate to clarif�ai�s�eers,so pm�ide as
mucU iuforniation as necessarv to exptAin your cl�im,aixl khe ar�xwnt of compensuttcxi bein�requested. You will recei�e a
wr{tten acknowlcdgcrncnt once your form is trceived. 'fhe process c�n take up to ten H�teks or longer depending on the
nature of r•ixu rlaim. This torrn roiist be si�meci,and both pages cornpletecl. If u>rnethinr ck�s nc�t::�pply,���Nte`N/A'.
SEND COI�IPLETED FORNI f1ND OTHER D�UCtTMENTS TO: CITY CLERK,
IS W ST KELLOGG BLVD,310 CITY HALL,SA[NT P?�UL,A-IN 55102
Fint Name ���1 �,� Middte[nitial�L�7st Nan� �
� /�14
Cc�mpan��c,r Businc.�� �n�e
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Are You an fnsu�ance Comp�ny�'� Y s o [�Yes,C'Irii �Number? �
Stttrc.�ddrr::: �
Cit� ..,I State 'l.iP C'odr�
Daytime Phone(�)� � P me(_)= Evenin�,Telephone(_1=
Date of.�ccident/[njury ar[�ate DiKOVered Time �un/pm
Ylease state,in detail.�uhat oc�uired(happened),and��� y y�u ar�submitting a claim.Please indi�ate why or how y�u
f�eel the C_'ity of S�iin Puul cx its�mplovee�<�re i �ol��ad;�d/or c�ponsil e for your daintige;s.
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Pl�a� check the twxfrs)thnt nx�st cic>k�ly rcE»•a�nt the reason ibr coir�pletin�thin�F�rm:
❑A9y vehicle.��us d�inriged in an acciJent ❑ My ��ehicle�+���s d<im<i��eJ during u to�v
❑ v vehi�le N�a.d�imaged by a pothole orcondition ol'th�shret ❑ M�y vehicle���,d�rna�ed M�a pk>��
, h1y vehic.le�vas�ti�r<�n�full��to�ved andlor tickctc:d ❑ t wa�injur�:d on City prc�p�rty
❑(hher ty��e of pre,pe�ty damage–pleak .pecifv– —
❑Othertype cxFinjui-��–pleaK:pecify–
Cn��rder to process your claim y�►u neal to include copies of all ap���licable clacumenfs.
Ft>r the ci,iim�t�ypes li�tcxl below.pleasc be!;ure t�,>include t'hi dvc•uments indicat'ed ar it will delt�y the handlin����f
yutu�claim, D<x:uments W ILL N(�T be z+�turned and bec�nx;the propeaty�>f t�hc City�. Yoa are ei�c:ourageJ tc>keer u
copy for}iaunelf b�Core:ubit�itti ny ouur clai m form.
O Propeity dankige claims to a vehicle:two estimates for the repaie.�Co��our��ehicle if the dama�e exceeds
fi>O�.00;or th�actual bills and/or recc,ipts f'or th�,rep�iirs �
'��c,��in�cl�ums: I�gible copies of an� ticket i�uaed and a ca�y��f�he irnpound Irit rccript
�__,
O C.hher proptrtv damaee claims:l���o n pt�ir e,tim:rtes it�the damuge excecds�.5O0.00:r>r Che�ctusil t�i Ils
zindlor receipts for the repai��:det.iilc^d li.�t of dama�ed iterns
O lniur��claiins: rnedicai bills,receipts
O PhoCOgriphs are always���elcome to doc:ument�and ui�port yuur claim but will not be returned.
Page I of 2–Pleasc�complete and return hoth pages of Claim Form
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4/2/2013 4:541
Microsoft Word- Claim form 2.l l.doc- 15774 http://www.stpaul.gov/DocurnentCenter/Home/View/15774
E�allure to com��lete ancl mturn bnth pages�+�ill result in del���in the handling of�rour claim.
All Claims–please con►ulete this sechon � � //�U '—
�'4'ere there��itne��es m the incidenC? Yes No LJnknawn (cireteJ
� Pro��i�� the�i ,n.i�me+, idresse.��,�nd����enumhe . _ �
_i ITI L(,�l� :// 6 ��
� � � �
�L'cre the rolice or Iaw enforcenx;nt called.' Yes ive Uuknown (ciiclej v
If yes,what�dep�rtment��r��ency? C�se#or r�ort# �
V4'herc di<l the accid�n[or in�utytak4 pl�Ke? Pro��id��tr�t��ddi�,�.�.cro�.ureet,�ntcrce.ctis�n,nume of 7.��rk o �wilit�. �
clo �u landnw •,etc P(e� c b as t�iled ei: oasi ' f �ce�: r ,at� � a dr�� <m.
�.
Please indirate the rimount�=o� e e�'n�>'n c p�*�'.�j�it�ion or��h�it����u���ould like Che City to c�u to rrsol��e thi�claim ��,��
to your satisf'aclic>n. ���i � �/ ��
T�
�`ehicle Clalms– lease com� lefe this section ❑�check bo ' i',�er.tion dcic,not a �I �
Yoin�Vehicle: Ye.jr 1�1ake .,.� � �el
I.icrnu� Plate Nurnb�r t ° C Ir>r
K��iste�ti:d Owner �2�(,�
Driver of Vehicle
Area D,imzige�d
Citv Vehicle: l"eur Mttkc Model
Liccn�Pl��r�Number SCat�e Color
I�)river�,f Vehicle tCit�y Empl��ry�e's N��miai
Arcti���ma�ed �
Iniurv Claims–Dlease compiete this�ceti�n ❑check b�x iF this s�tion does not apt>l�
Ho�i ��ere you ir.iure�l'? _
Wtiat pt�irt(s)<��i'Vaur bo�ly were injured`? _
Ha��e y��u s��ught rnedical h•eatmcut'? 1'e. No Nlanning to Seek Ti�atment Iciirlel
VVhen did�-ou n;ccice[matmcnt'? � (provide d�itel�))
�� Nr�itye of'h1edicul Pro��ider(+l: _
Address Teleph<�ine
Dic1 you mi�s�c��rk as�re,ult of y��ur injwy'? Yes No
VVhen did you n�i�s���ork".' � lproaiJe datc^(sj}
Name of you�•Ei��pl�yer:_ —
Addr�ss Telephone
�Chc�ck hen:if��ou are attachUig mcrre pages to thls clahn form. Nutnber af add itional pages_.
By signing this•f orm,VarF are s•tating tE�at rrll inf'orn�rrticm yc�u{tave J�rovid�d is Jrrte and eorsectto the best
of v�rttr know�ledge. UnsiKn��d fnrnts H�ill not he processed.
S►�bntitti�rg�r false clnim cnn res•r�lt in��rose crrtion. Date form�ti as completed
Print the Name of thc Person�i ho Completcd tlil•Form: � � �� , e.i�
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Signatuir ofPerson l�laking the Claim: % �ti
Rc�ised FeM1cu-�201 I ,
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2 of 2
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A�� o� ��i3
Dear Sir/Madame: �����shift at the
I am writing to share my story
about arri��ng home aft
Pioneer Press at 1:30 am on M�'�h 6 .
hatsworth and Linwood where I ha�e li�e�s°o f 1 ving
I live in a condo on m e��in mY�'age �and have n e v e r o n c e d u rin g mY y
years. I always park Y
here not been able to access it. e is located had snow piled
ved home,the a11ey where my g�ag I checked the back of
On this night,when I am �ows had left that was knee deep. ed out of my
ce that snow p 't see it, so I hopp
up across the ent� a�vinter shovel and didn �age.No shovel there
my prius where I generally keep shovel was in my g
�a�.and walked though�e snow to see if my
either• on the Linwood side of our
ark in the dnveway �oWS had
oint that I W°�d p S�ce I had
I decided, at that P �e corner,I saw a smaller mound of snow that the snow
condo. As I turned that was about calf deePhought my
alley entranCe,
left at the intersection of Linwooas de PCasa�e Snow at my ��has a low front
no shovel, and it wasn't nearly lt I did and I got stu�k.My
best option was to trY and�°e��u� ears that Pve owned it.
end and it's the first time I've gotten stuck in the three y
ardening shovel in our tool shed, so
I retrieved it ande d
I remembered that I had a g
out. I had one side of the car shovelend H agreea t he p m and Was
s h o v e l i n g m Y"�a y ulling fo 1 k s ou t o f b a d s rt u a t l o
appear.He d been out p et me out of the mound•
able to back my car up enough to g
et towed and asked him where I should park it figuring
I told him that I didn't want to S told me to p
ark across the street from my condo
e to ark on that side and he
— on the east side e f�C�WO 1�o to�me there. So I did. �
said y��that th tY
to o to work,I went outside to get in my car and �
The next day when I got ready g o to the impound lot then because I had no one
discovered that it been towed. I couldn't g � I r��e bus to the Barge
to take me and I ha at$� 4.50 to get mYl car�l��ng y�
Channel Rd and pai
I ha�e been to the city hall and they voided my fine of$53.00 after hearing my situation,
but I believe that$234.50 towing, storage and administrative charge is an awful lot of
money for someone to have to pay when I tried to do everything I could to keep this from
happenin8, especially in such a tough winteT, and als°consid�ering the time of nigbt 1
arrived home and the circumstances.
In closing,I am writinS to ask for a refund of this money. If yousaw the size of my
condo compazed to the size of my property taxes,you would watltt one too,especially
under these circumstances.
Thank you for your time,
Virginia Pinson
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