Klosner RECEIVED
NOTICE OF CLAIM FORM to the City of Saint Paul, ll�Yn��3
Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipaliry...sha cl��e�b����he
governing body of the municipality within 180 days after the alleged loss or injury is discovered a notice staring 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 questioa 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
'----- iv�ten-acl�owledgement once your form is received. T6e process can take up to ten weeks or longer depending on the
nature of your claim. This form musE be signed,and both pages completed. If sometLing dces 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 ��� Middle Initial�Last Name ��� S��_
Company or Business Name
Are You an Insurance Company? Yes 1�If Yes,Claim Number?
Street Address �-.5 � m`�l � n� r t �i �-��' �' '
-- SS �v L,
City S � � ��� � Sta e � � ' Zip Code
Daytime Phone� �.��� ell Phone�sl) -� �.�U�Evening Telephone(_) -
Date of Accidend Injury or Date Discovered ��° 13 � �� � � Time j���-�� am��
Please state,in detail,what occurred(happened),and why you are submitting a claim.Please indicate why�r�ho�you
feel the ity of Saint Paul or its employees e involved and/ r re nsible for your damages. d_
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Please check the box(es)that most closely represent the ,eason for complering this form:
❑ My vehicle was tiamaged in an accident ❑My vehicle was damaged during a tow
C]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 i ured pn City roperty �� � �
�LOther type of property damage—please specify LI�-�-� � � Tt���� f�� ��� � �4
❑ Other type of m�ury—please specify
In order to process your claim vou nced t�include cooies of all apulicable doctiment�.- -
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 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 comulete 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? � , No Unknown (circle)
If yes,what department or agency? S'7, 1�'�.� I� �`l C1L Case#or report#
Where did the accident ar inju�tal�e place? PrQVide_street address,cross street,intersection,name of park or facility,
closest landmark,etc. Please be as detailed as possible. If necessary,a ach a r�iagra�.-- ---__
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Please indicate the amount you are seeking in compensation or wh t you would like the City to do to resolve th' claim
to yo�j�s;',�faction. O V--�- ,r�,� L,J ti L �,U �, ( �
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Vehicle Claims-nlease comqlete this section �heck 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
Injury Claims-nlease complete this section �heck 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 treatment? (provide 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 �
� Check here if you are attaching more pages to this claim form. Number of additional pages
By signing this form,you are stating that all information 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 s— / � — �v ) 3
Print the Name of the Person who Completed this Form: �C��`T�� /�(�US�'l4�`
Signature of Person Making the laim:
Revised February 2011