Vietor - - • RECEIVED
MAY282013
NOTICE OF CLAIM FORM to the City of SaCITYa�L��nesota
Minnesota State Stat:�te 466.05 states that "...every person...who claims damages from any municipality...shal!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 does not apply,write`N/A'.
SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL, SAIN� PAUL, MN 55102
First Name y /. Middle Initial�"¢ 1� Last Name�� � �<"�/
Company or Business Name
Are You an Insurance Company? Yes No If Yes, Claim Number?
Street Address � �
City ' � State Zip Code ��/a�
Daytime Phone ���_���Cell Phone �� - Evening Telephone (�'�1�G��
Da�e of Accident/Injury or Date Discovered �� ���"5 Time am/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.
� �
- a, .S � `
. � , — � �..G �e G�
/� �//�c =�' c��' i i/l f/�Z�e
U ..5. .r� ,t - r�G i I� -
..S %,�7
� ,s � �s.� l.4� f°
,� � c� u m r �o u/ j��t,� ou str�. f � f9n : �'�aJ�" o�v
Please check the box(es�hat most closely represent the reason for completin�is f �},�:� 4 ���z�Y�e����
❑ M vehicle was dama ed in an accident ❑ I4Iy v��fi�c ei'"was�ar�a�d'dunng a tc�j�y�,Q �s
Y g
❑ My vehicle was damaged by a pothole or condition of the street ❑ My vehicle was damaged by a plow �'�' '
� y vehic?e was wrongfully towed and/or ticketed ❑ I was in'ured on City r e �y��/n_„
/��
er type of property damage—please speci
Other type of injury—please specify
In order to process your claim You 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 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 e�timates 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 Unlrnown (circle) � /�
Provide their names, addresses and telep ers: ` /� ��f��/�!���;
j ` � - s v- �� �I,�'�P�L
Were the police or law enfarcement called? es No Unlrnown (circle) d����
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 deta' d � ible. If necessary, attach a diagram.
Please indicate the amount ou are s ekin � compensation or w at you uld l�ke the City to do to resolve this claim
to your satisfactior�._ � (� ° �'f
� 0 p .
/S o//� �,� �� Q �o�' �r!'Q'r! /?��/ lr ,p �(J / ///
Vehicle Claims- le�e��m Te���iis s�cti ' ���1 u`"e' ch�'ck b�f�his��ui � s tio�a '���t�
Your Vehicle: Year Make Model
License Plate Number State Color
Registered Owner
Driver of Vehicle
Area Damaged
City Vehicle: Year Make odel
License Plate Number tate Color
Driver of Vehicle(City Empl � e s e
Area Damaged
In'ur Claims- lease com lete this section ❑ check box if this section does not a 1
How were you injured?
What part(s)of your body were injured?
Have you sought medical treatment? Y s o 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?r 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 �-�jl�- ��
. �
Print the Name of the Person who Complete this For •
�� d
Signature of Person Making the Claim:
Revised February 2011
�� � � .. �. "� 110 . .� i � C
,/ � � N � C (�0
,�� ,``^ � � O � 'U'�
� � '
�a1 � � � n. � � � +�-+
� ~ ` F" •�"n � � •( L � N � c6 O
� { a �J � � � l�, +-� � � -�
�^ Q !L 7 W 'p � fl- � � +�
ti� _f , L) � � � � � n0 Q
r s �, `� L V � o � o � �
Y >. � ?�., �. -�s }. � � � E .. m
�- s
(4... 0 V� �' "� S ~ � � om � �
� �--1 �, � S` G m � — a°�i 3 0 � � �
n, � >+ T N >
�) �`� ,..,� s o � � � � � > � !�'.�Mm
� � � m
� y ` � c},o � � � o °
� � t � f N � � � O U
� ` t6 r=-
� � �'� '_ � � C � � C .
A , � � � l�� t" p (6 . t�C N V � C;�4
1 � � � �� � � � � � � .
� ('�V O c � y, � �� 3 � 3 L o `#'..�;�,
� _ `' o � '� -.
V� Z t/� � �. � m c� cn � o N � ,;�`
� ` N
� Z o ! ,, J �-.. `,J) '-_, � � � � 3 � � � _
� -i � O , , a a� a� � .. :
,J � _ ?� �•,` p � � � � °' � � � � •.
� m ¢ a Ii i � " � Z � o '� � �n v `'� i
O. u `{,. � � � ,m a Q: � � � ai ��
Z , �C `� 0 c m � — m •°. _;
o � � ... � �` � S � o � O � � N � `\`�,'.�
�-+ 7 cp �
� V `,`��1 , �j L 5 � U � � C p � `,.\.,�
�� � �� � ^ , .� � � C � .� � O �
� Q � �.,, � S � � \.., c � � � ', 3 � c�n
�'� � � °� , f¢ C L N � N •— ++
'1 a `t `" `-�= y �� L co Q E � � n� � �
u� � � '�- c-• � �
S m � QN � � � ;� �:
� � d �� '.� E o `� o > °-'� � v � '�
� � � ~ � � �� q� L a @ � C U C N N` \'.
� ? 1�l� Q `� � � � • �p � O � N ��,,, �'
a � to � ''� � .�Y �. J ❑ � �p +_� L cn � u� `��
� �• .Q C V f0
i�1 � � � Z � ���� ` C'1) � � `J 'N a N m a`'i � cN�i ``• y ✓ ,
- o o . -�. t....,.-�. �3 .,� � i v � � °. � 3 � o •�
� � ' � W � o � f S� � � . v (�') -a v� � � o � o-__/
;_ - W� � '-- `t`-� �,,� s ``....'`y� , � S r�-�, o � o � � � �
� � �� J Y r /'�a..� �� � � ` ,� �� o � . `�...� �,'�) 3 X � � �� N �
v= (0
i � � n r �/3 � h � � - W � �� � '� � -a u� � � X'
00
� � g-�° ` `..,_..'� _ -� Z � �k � `�C�*' � � °—' � Y 'm W
.� i`�n' tii 'C �f��" Z �' �°r � V ❑ � =o j � v�Qi c�r� � a�u �
� _ W ZD V! Q � �� L -� J Q � '�� fl. L i i. Y j �
��� ,�-� S � = �. �- ?� i., tA �p V � }� -a O �n o � a co Q
�"�` v_ �+- d � V[ n. ,° ,"' �`"- _`.f � tlj �"' �/1�a..f6 +�+ fn � � U � � z
� ti ° � W � '� >'--I- j j 0 1,, � `L° ami a� a; o � a�
a � p � ' � W� -a� ° a� m � � � 3
o O � � '�- �,! . ;� � � O U � `m � � � � o a� �
o � a = L � .n ¢ 3 a w m �
U
� `� rJ �f� :�7 � V"
fl. �` a
� t� � �� � �,,� �
e..
�;� � �� � ��
-r c�"n � o --._ CL-1 � r�t
•.� ,-,� _, z
� � o
' �j ,.� ,.� � � ❑ �- ::. `�•.
.
• \- `-' � � v ~� C'3 .� W .-. � W
� ) ,:-,• t.W., � � � u� � ? � a �`�,-.. �u,i
`-' � � m � � � �i � � Z �_.a L� � �o
V J SQ = J �C = J C �' _� "'Z
� � � � 1
a � � ¢ �V � � �� a= � �=t �° �t O�
o a � � �? � �a ' a� 3� � o� ¢ :�; � �¢