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Shields - JUL 12 2013 NOTICE OF CLAIM FORM to the City of Sai�I�Xi��f�esota � Minnesota State Statute 466.05 states that "...every person...who claims damages from any munacipality...shall cause to be presented to the governing body of the municipality within 180 days after the a[leged loss or injury is discovered a notice stating the time,place,and circumstances thereof,and the amount of compensation or other relief demanded." Please compiete 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 �ITY HALL, SAINT PAUL, MN 55102 First Name (� Middle Initial�Last Name �j � ,' L� I_ � Cj_ Company or Business Name �–_ Are You an Insurance Company? Yes/ �� .� ����v�� � _ __ _�k�- �.-��. If Yes,C�Number� •-� Street Address ----, City „__^ State — Zip Code ', Daytime Phone((����ell Phone��- Evening Telephone f��) ��e�'(���,/ �� Date of Accident/Injtiry o�,Date Discoverec�' 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 jand/or responsible for your damages. ' ,` � ,- Please check the box(es)that most closely represent.t�e Feason for completing this form: ❑ My vehicle was damaged in an accident ❑ My vehicle was damaged during a tow ❑ My vehicle was damaged by a pothole or condition of the street ❑ My vehicle was damaged by a plow � ,���vehicle was wrongfully towed arici/or ticketed ❑ I was injured on City property -- ---�� ther type of property damage–please specify ❑ Other type of m�ury–please specify � � In order to process your claim vou need to include copies of all applicable documents. ' For the clairns types listed below,please be sure to include the documents indicated or it will delay the handling of , your claim. Documents WII.L NOT be returned and become the properiy 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 ' � 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 , f 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�nd return both pages of Claim Form . ;,: Failure.to complete and return both pages will result in delay in the handling of your claim. J All Claims—please complete this section -. � Were there witnesses to the incident? � No U own (circl Provide their names, addresses an d te lep hone num bers: -.... Were the police or law enforcement called? Yes w Unknown (circle) ff yes,what department or agency? - - Case#or report# --� Where did the accident or injury take place? Provide street address,cross street,intersection,name of ark or facility, closest landmark,etc. Please be as detailed as possible. If necessary,attach a diagam. :�� 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. L��� �D�„ Vehicle Claims— lease com lete this section check bo if this se ' n s n t a 1 ,__�, r . eaz . <,.__ a.�1Vfake �..,. _ .; _,_: l�odeT-. .._ ., : . _ ... . - . License Plate Number State Color Registered Owner T 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—please complete this section �check box if this section does not apnlv How were you injured? What part(s)of your body were injured? Have you sought medical treatrnent? Yes No Planning to Seek Treatment(circle) When did you receive treatrnent? (provide date(s)) Name of Medical Provider(s): Address Telepho e Did you miss work as a result of your injury? Yes No When did you miss work? (provide date(s)) �-- --�a�e e�f your���pioyer: --- - _ _ _. - -- -- -- 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 resutt in prosecution. Date form was completed � o� � �,�; Print the Name of the Person who Completed this rm: t � I Signature of Person Making the Claim: f Revised February 2011 � `���, ; �Q�-f,�' � � G�� ��.� .��.�'� .,�, � �, �, r� - � -� ;�o � � � � _ . e-.� --�� , ��--� � � � . ����, -� ��� � � �� _� , , , , �-�`' , . ,: � _ �. �� � w� ,:��� � �.= �����- _�.�--���.� �,� '' �";i�",���; `�►-�,� ��.�r�--� .���� -�� � � .�G�� -�- ..��.���-'lr�'YL � �t�L' '��"Y� ,��i`L�' !�ia��Q �UU � � � C�."Z�--`L{�-�.�-�.� �/���.Nc.c+ , � ,�, : -�`�t��� � ��� y --� �� �t n _ ,� , �� � �'l�' ��,�/ �t,�//� j�- ��� ' i �,' /� _V_ �`1,�G�`'�/� �L.��� � ��L��� -�,C��-�vr C�/ LJ t��./� � ..�(/�'1 - y.,�.(.� `I/1��'(�' _�� , ,C�r • � `1 � tl . _�!�� `�� � �� r � � -��'7 l � , � � � ���� '� ✓'�l����-�_� , ; 9 Qi��� 1 � ���i��1'Q' ' :��—',�'Y�� ��� ��—u� � �y�� �,'/5_ � M C�.�'��,� � � � � f � � '_ ; � , � . � � ��� �.i�'�Z�. ��' ��;i�-�.� �,.7�G ��, _,:�,%y"�'-%,�'�iru r��� ./�' ���-c�. � i�� � �, � � .� � �" � ,/y�����'�� " ` � /` � r / .�t e� . 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