Crain RECEIVED
APR 2 6 2013
NOTICE OF CLAIM FORM to the City of S��YP�,,.N,,��nesota
�.�_tKK
Minnesota State Statute 466.05 states that °..,every person...who claims damages from any municipaliry...shall cause to be presented to the
governing body of the municipality within 180 days after the alleged loss or injury is discovered a notice stating the time,place,and
circumstances 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 dces not apply,write`N/A'.
, SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK,
. 15 WEST KELLOGG BLVD, 310 �ITY HALL, SAINT PAUL, MN 55102
_--
First Name Middle Initial I` • Last Name � /^CP 1`vl . J �'° �
Company or Business Name
Are You an Insurance Company? Yes� If Yes,Claim Number?
/ �--; f
Street Address �% � � �--� t u���G � t/t/`
City '�0���p !/ �.� . ) � e State�Y/ � Zip Code
Daytime Phone ( /�)���-��Cell Phone( ) - Evening Telephone( ) -
Date of Accident/Injury or Date Discovered �"' � '—�� Time���am/ m
Please state, in detail,what occurred(happened),and why you are submitting a claim.Please indicate why ar how you
feel the City of Saint Paul or its employees are involved and/or responsible for.your damage j
,1 � �. ' �< r � r e� r .�' � �, d•c �
r ,
� �� �� ��-� ��tF✓ �"r�.,�,..,•:,rk .�. �� '�° ..�*i ., .. �,
r
�� � .r ,�. ' (i - s �'.'- p' r f° �- .0 .
,.�� �,.- ���r. .� °�` - r � �. � .,r< � � ✓ i,
Please check the box es that most closel re resent the reason for com letin this form: III
( ) Y P P g
❑My vehicle was damaged in an accident I ❑ My vehicle was damaged during a tow '
❑ My vehicle was damaged by a pothole or condition bf 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�s ecify ,
❑ Other type of injury—please specify (9i��r ,�^��� �r _. °sr �..- �� t�r.�r��. ��pc��
In order to process your claim vou need to include copies of all anplicable documents.
For the claims types listed below,please be sure to incl'ude 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
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-nlease complete this section
Were there witnesses to the incident? Yes � Unknown (circle)
Provide their names,addresses and telephone numbers:
Were the police or law enforcement called? Yes :I�d 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 landm ,etc. Please be as detailed as po,rssible. If necessary, attach a diagram.
U�^'���'��--�`�iw�l �":1��"A�
T
Please indicate the amount you are seeking in compensa�tion or what you would like the C�ty to do to resolv this claim
to your satisfaction. � r T � • �
� , ., ' I r�
���� �—�is av,+�w,�{ t a,a� � �d4 .� �a0� it � .
Vehicle Claims-please complete this section ❑ch ck box if this section does not avvlv
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 Color
Driver of Vehicle(City Employee's Name)
Area Damaged
In'ur Claims- lease com lete this section ❑ check box if this section does not a 1
f�ow were you injured? %1 t^o!tr �a
What part(s)of your body were injured? 11 �
Have you sought medical treatment? es No Planning to Seek Treatment(ci cle)
When did you receive treatment? � t' � �� �(provide date(s))
Name of Medical Provider(s): � � �� y
Address N� ��- °7 0 �v -t� � e ephone �► - �-�'Z ' !1 a0
Did you miss work as a result of your injury? ; es �
When did you miss work? �V" (provide date(s))
Name of your Employer: , � ►er°�F r
Address Telephone
❑ Check here if you are attaching more pages to this claim form. Number of additional pages
By signing this fornt,you are stating that all infarmation you have provided is true and correct to the best
of your knowledge. Unsigned forms will not be processed.
Submitting a false claim can result in prosecution. Date form was completed y --- � � - ��
Print the Name of the Person who Completed this Form: �����Jc r,c � � i"��� �`(f� .
Signature of Person Making the Claim: r'�� :��� �?
Revised February 20l 1
I