Quamme • -s rr� � i�✓
JUL 16 2013
NOTICE OF CLAIM FORM to the City of Saint Paur'N1�n��s�.K
Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipality...shall 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, SAINT PAUL, MN 55102
First Name���� (; v^ 1 1 •� f1 Middle Initial .� Last Name �;,� a nt �Y1 E=
Company or Business Name
Are You an Insurance Company? Yes/No If Yes, Claim Number?
Street Address � ��:��3 '�f � ;M ��� � e L�� C'' ��'� ��- U °�1
Ci ,�c� w i�t State ,�� Zip Code �.�1 � ,
tY
Daytime Phone �( S �)� i� Cell Phone �C( �i)���Evening Telephone �(_���C`f'- 3� � �
Date of Accident/Injury or Date Discovered ��,. � Z ,j 7 Time 1► ; f� 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.
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Pl se 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
❑ 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
❑ 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 apqlicable 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 properiy 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 Unlrnown (circle)
Provid�e their na�es, addresses and telephone numbers:
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Were the police or law enforcement called? Yes �No ,j Unlrnown (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 facility,
closest landmark, etc. Pleas be as detailed as ssible. If necessary, attach a diagram.
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Please indicate the amount y�u are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction. � lt � . �-�3
Vehicle Claims- lease com lete this section ❑ check box if this section does not a 1
Your Vehicle: Year;,�,G Q�.,� Make C 1f1 C� �'i S�1 Model � dc,v� S E'_-d�`�.'+c�
License Plate Number �!' State t� Colar �,�
Registered Owner �r i � • • �L e.
Driver of Vehicle c�.rri W1 �
Area Damaged � �c�ir' ��1�5 ��►f.�(` S ', d� 1�a h � ��
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
In�urv Claims-please complete this section l�Lcheck box if this section does not ap�lv
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_in�ury? 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 atl 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 7�«-t3
Print the Name of the Person who Completed this Form: /�,� r, �Y n �t�p�rvt 1'K�
Signature of Person Making the Claim:
Revised February 201 1
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�s���Il fE'�AutoGlass
SAFELITE AUTOGLASS Date&Tlme, 06/28J13 05:55PM
1501<GOULEE RD
HUD�ON�WI540�6 ����� � �
**SERVICE QUESTIONS**
**CALL 715-386-1183**
Custamer: Home Phane: 651-264-3312
QUAMME,MARILYN ' Mlark Phone:
8723Promenade Ln ' Corrtact Phane: `651-264-3312 '
St PauI,MN 55125 Work Order#: 01844_303594
Ysar Make Mode1
2002 ! CHEVROLET PR.1 ZM
License Sty I� e StockfUnit#
20$HHU 4 DOOR SED N
Mileage ' VIN" Purchase-Order# `
0 1Y1SK52$3�Z402816<
' Liet Sellin9 Flat '
Glty Psrt Priae Price Labor Kit MTRL
1 FD2030� GTV 183.05 97 02 38.50 0.00 0.fd0 '
TechMclan Name Tech ID
Lee Mlller 1844-962
technician Note:
VEHICLE PRE•INSPECTION
Part&ubtotaL 87.02:
Fiat Labor SabtataL• ; 3 8. 5 0
SubtotaL 13 5. �2
Sales Tax: ' 8.81
Total; 142.4 3
Deducti618: 0.Q 0
Promo Dlscaunt: A.00
Amount to Coflect: ' 0.0 0
Estlmate:$142.43. I authorize Safe�ite AutoGlass to provide'the
above-reterenced goods�ntl services and to`(nstall or repalr glass
and related parts that are'manufactured by Safelite or'another
aftermarket manufacturer. Sublect to eomR�etion ot 3he work,l
asslgn to Safelite any clalm that I have under my Insurance policy
to recover,and authorize my insurance company tv pay Safelite the '
balar�ce due.?If sald amount Is not pald In full by my Insurance
company,l agree to pay any unpald balance, If paying by cneck,and
yaur check Is unpafd far insutticlent or uncollected funds,we may
electronlcally deblt your account tor the princlple check amount and
a servlcs fee as atlowable by law. You have the righf 3o select the
repalr iaclitty:of your cholce. I have read a�d understand the '
Adhesive Cure Time Cautlon an the attached form, In'most cases,the
approximate length ot tlme to compiete the tasks detail�d on this
work order is�5 minutes to"i hour.
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Slgnature: +�� °
Safe to drlve vehicle after:N/A