Barnwell � .....�_. - --
MAY 17 2013
NOTICE OF CLAIM FORM to C�T_ �t ;����nt Paul, Minnesota
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Minnesota State Statute 466.05 states that"...every person...who claims damages from any municipality...shall carese to be presented to the
governing body of the municipality within 180 days after the alleged[oss or injury is discovered a notice stating the time,place,and
circttmstances tkereof,and the amoun�of comperesation 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 eTCplain 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 KELLQG� B�VD, ��Q �ITY HA�.,L, S�►I�T PA�,UL, MN SS1Q2
First Name � Middle Initial ��/ Last Name ��L'V� � �
���,� , �;abe�r-��-�nlBa�-r�w�11 � � vna�`1. ��n�
smess
Are You an Insurance Company? Ye No Yes,Claim Number? '
StreetAddress �D��T /\i ' VVf`1�1 J��� 1
City �� ��� ` State m� v Zip Code� �
Daytime Phon���� �Jc��.aC�ll Phone��0-4�� vening Telephone(�me-
Date of Accidend Injury or Date Discovered f � C.�t�/ ��� Time �rT am/�
Ple�se state,in detail,wha�occazr�s�(happe��d),and why yo�are subnnit�ing a cl��n. Pleas��dic�t�lhy�or ow yau
feel the City of Saint Paul or its em loy es are invol ed and/or esponsible for your ama es.
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Please check the box(es)that most closely represent the reason for completing this form:
��M3�vehicle was dannag�d in an a�cident I��Iy v�hicle was�amag�d during a tow
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 injured on City property
❑ 4ther type of property damage-please sgecify
❑ Other type of injury-please specify
In order to process your claim vou need to include copies of all anulicable documents.
For the claims types listed below,please be sure to include the documents indicated or it wiil delay the handling of
your claim. Documents WILL NOT be returned and bacome the property of the City. You aze encouraged to keep a
copy for your before submitting your claim form.
operty 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 aad a copy of the impound iot receipt
O Other property damage claims:two repair estimates if the damage exceeds$500.00;or the actual bills
and/or receipts for the repairs;detailed list of damaged items
O Injury claims: medical bills,receipts
O Photographs are always welcome to document and support your claim but will not be returned.
Page 1 of 2-Please complete and return both pages of Claim Form
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims-please comqlete this section
Were there wimesses to the incident? Yes No nknown circle)h
Provide th ir names, addr ses and telephone numbers: s c�Y� r
�-� S��e� rn o �- c3� 3
Were the police or law enforcement called? Yes ��.c�-� Unknown (circle)
If yes,what department or agency? Case#or report#
Where did the accident or injury take place? Provide street address,cross street,intersection,name of park or facilit ,
el sest lanctmarl�,e�c. Please be as detailed as possible. If neJce+ssary,atta h a ctiagram. � �E'C oh y
Ct►� O'r�r�t . CV r ►'►'� _ • 1
C�e'� L7r1Cbr �C� �
Please indicate the amount you are sgeking in compens�tion s�r what you would like the City o dp to�esolv�thi$clai
to your satisfactio . .� c�ul d o� c�i a.`� rn L1�r" ` "� ��� �K
n a o� re u ' _
c� �a;� • o�- b �� e c ��-� •
Vehicle Clauns- lease com lete this secNon ❑check box if this section does not a 1
Your Vehicle: Year o�OQ' Make U ro e Model C� � ' '`
License Plate Number U� State �Color (�faC�
Registered Owner �Q �--nt� �
Driver of Vehicle �' � a^
Area Damaged �
City Vehicle: Year Make Model —
License Plate Number State
Driver of Vehicle(City Employee's Name)
Area Damaged �--------
Iniurv Claims-glease complete this section �-�f eck box if this section does not annlv
How were you injured?
What part(s)of your body were inju �
Have you sought medical treatment? Yes No Planning to Seek Treatm ' e
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
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 a►td correet to the best
of your knowledge. Unsigned fornts will not be processed.
Submitting a false claim can result in prosecution. Date form was completed� � G�(0 l �
Print the Name of the Person who Completed orm: �-� .�
5ignature Qf Persan Making the Claim: "
Revised February 2011