Wandmacher �
R�CEIVED
MAY 2 21013
NOTICE OF CLAIM FORM to the City of Sain��-�l�i��sota
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 municipaliry within 180 days after the alleged loss or injury is discovered a notice stating the time,place,and
circumstartces thereof,and the amount of compensation or other relief demunded."
Please complete this forrn 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 pmcess 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 CITY HALL, SAINT PAUL,MN 55102
First Name �I� Middle Initial�Last Name 1f�iU���,(1i���
Company or Business Name
Are You an Insurance Company? Yes/ i�o ff Yes,Claim Number?
Street Address_�G��? (,l�„Q
i � .�- ..
City � .�1111/L1 State�,� Zip Code�_�
Daytime Phone����11 Phone(�'�Evening Telephone(�'��
Date of Accidend Injury or Date Discovered � �� Time���/pm
Please state,in detail,what occurred(happened),and why you are submitting a claim.Please in 'cat why or how you
feel the City of Saint Paul or its employees are involved and/or responsible for your damages. �
4
Please check the box(es)that most closely represent the reason for completing this form:
�My vehicle was damaged in an accident ❑My vehicle was damaged during a tow
�Iy 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
❑ Other type of property damage—please specify
❑ Other type of injury—please specify
In order to process your claim vou need to include copies of all anplicable dceuments. �
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 complete this section
Were there witnesses to the incident? Yes No Unknown (circle)
Provide their names,addresses and telephone numbers:
Were the police or law enforcement called? Yes � Unknown (circle)
If yes,what department or agency? Case#or report#
Where did the accident or injury take place? Provide street address,cross street,intersecfon, ame o park or cil' y,
ses lan mark,etc lease e s d taile'ti as o sible. If ec s ttac aY,dia am.
Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction. `
�
Vehicle Claims— lease com lete this section ❑check box if this section does not a 1
Your Vehicle: Year�_Make Model
License Plate Number State,�Coloi
Registered Owner
Driver of Vehicle ' L(.
Area Damaged �
City Vehicle: Year M e Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniurv Clairns—please complete this section ❑check box if this section does not avnlv
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 fornt,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 �� � • � -J
� t �-
Print the Name of the Person who Comple this Form: � �. '�`
Signature of Person Making the Claim: / ' �`
Revised February 2011
Auto Rescue
- feedbackC�inmctnsautorescue.com
Date '-- _.� I.C. �
` "? r�; 1 � , Motor Club � �,:`'
-,`� �_
. ; { ,�
P.O.Number � ;- -,_� .,: +� y��, f ,.,-
,;t---> Name ; ,:
�� : ��_ =' : -
�` '__ �„' r �..,./:�,' '`..,� �°,.�,
r-.:-' f:. �.- --__°
Member Number Phone -'�
.
,z: ..: , _.
r, -.� a. , �f -,��
. _
� : < ,.;
, :� ; 7� �i
Address � ' "'
s`� �.� �,r �._�,��� .,,�,_ City
. :_, ,,�
Location 8 Service Information
Apt./Business Buildin #
9 Apt.# Gate Code
Location Notes
Call Time AM
PM ETA Start PM Finish AM
�_._....
PM
Lock Out ❑ Jump Start ❑ Fuel - 0 Tire Change ❑ Tire Air ❑ GOA/NSR
Vehicle Information
Year, Make, Model '; ` ' '
,, ,
� f' ; j 1 � 4y ,','�' !' Color f; ; LP# State
, �
' ) �� j � ," � i - ,...
_
3 - _
J ; � � i , �, �-._ . _
� • ; ; g t�,.��f` *-.... �r �, �'� � d 1 f...p �;�� . � �' ` J �,...J 1 t ,� ,fi s�� .-�dOfTl@f@f �� '
' - ' ,) C .�, -��- �
. .. ...-, ..�...� : i �.� ���_ •� , ,r,..,..
- {.r•�` _ _ _......- � � ��.I
Lockout Release Section-Condition of Door(s)upon arrival
❑ Previousiy attempted opening by another party— Damage to Door/Doorframe Passenger poor
Driver poor
❑ Worn/Dama ed weather stri Passenger poor
9 pping—Window Broken /Scratched— Tint Scratched Driver poor
❑ Non Functioning Door handle/ Door lock—Missing Door Handle/Lock Passenger poor
Driver poor
Notes
I have requested that my vehicle be unlocked using lockout tools and/or keys. I understand that there is a possibility of
damage to the door, door frame, weather stripping, locking mechanism,glass, or air bags when using these tools and thereby
release the person(s)and/or company of all responsibility, both civil and criminal, in a court of law. I will accept full responsibility
should an dama e occur. lnitial:
General Vehicle Condition
Jump Start: ❑ Battery cracked/Broken ❑ Cables and/or Clamps/Loose/Corroded/Broken / Missing
Tire Change: ❑ Vehicle/Rim Damaged ❑ Missing/Damaged Lug Nutc ❑ Missing/ Damaged,Studs����...
Customer understands that the spare tire is designed to get the vehicle to a tire repair facility, as soon�sT"w""����
ossible, and the wheel fasteners lu s shou/d be retor ued before drivin more than 40 miles.lnitia/�;,f'��� �
Fuel Delivery: ❑ Fuel Door Missing/Broken ❑ Fuel Cap Missing/Damaged `"""'��.?6
Notes
GOA/NSR
GOA/NSR Authorized by: Reason:
Method Of Pa ment for Retail Non Motor Club calls
Cash Visa MC AMEX Discover DL#: ST
CC#: i
� �
� � � �� ``� 1 XP� APProval#
Authorized Siqnature 4'��k( {��� �1 a���? � '�` V`� `�;+ , )�;" /ytq?
.. ' :t:._.. 1. ' .. j t�,1 i.," lk.I 7 ; � �E� 1-..-'. \__.rW
I have had the oppo�tunity to inspect my vehicle and have found it to be in good working order, Gas(+)
and that no damage has occurred to the vehicle including doors, door frames, paint, glass,
window tint, rims, lug nuts/studs, body or undErbody as a result of the service. Sub Total(_)
I.also acknowledge tti,at alLequipment such�s}acks, lug wre�ches, lug nut keys,and special
tools belonging'tc�e or�th2 vehicle have been retumed in gbbd working order. Customer Pay(-)
/nitia/:� .1_:�, � r�;�,' . �; � � ,, �,, � ,;, ;,,,} '`
. . �
� .. . . ,
���.,,. -_ '4SThvnk� ou for using Auto "�eSCL�e Invoice Amount(_)
.�_��� f 4� CUSTOMER