Post � RECEIVED
JUL 2 210�3
NOTICE OF CLAIM FORM to the City of Saint ������a
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 municipaliry 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 �--�� `e� Middle Initial�� Last Name �'�
Company or Business Name � �-
Are You an Insurance Company? Yes No If Yes,Claim Number?
Street Addre s y,� ��Cl�.S�\ �Ca�l � �J �
`� � � �� Zip Code�S l r �
City_ � � �� State
Daytime Phone ( SI ��� �� Cell Phone(�� �- �� Evening Telephone(�n5�� � �
Date of Accident/Injury or Date Discovered � ' ��`�� Time % 5�/pm
Please state,in detail, what occurred(happened), and why you are submitting a claim. Please indicate why or how you
f el the City of Saint�aul or its employees are involved and/or responsible for your damages.���.���c:
�l��P� c F - y: 3` � vh C� P\� �nY4� �
� �f 1�S Q \�.sc � C�c.. � c1 � � e � �_
, �� � 5 � , � ,-� -r�� ��
� � .CL. , ��;c-�� . — :� '��,c� -L - i.'� ��
,�J- ��; - �c��.-. c�� � �`r���� a �;:� �,�—cP�, � � �.. ,
����
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
❑ 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 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.
�.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
� 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 comp�ete and return both pages will result in delay in the handling of your claim.
All Claims—please comqlete this section .�
Were there witnesses to the incident? Yes No C Unknown ,, (circle)
� ovide their names,addresses and telephone numbers: ''-----�----''"
�\:e � c>S- F:�� 7�:�,�c� � "���c� .��5 �C�z� �v ���P � ;�c�� t- �--- ��c,���
-.
Were the police or law enforcement calle� s No Unknown (circle)
If yes, what department or agency? � , � �l. Case#or report# \ 3 �' �`�7 (v`1�
Where did the accident or injury take place? Provide street address,cross street, intersectio name of park or facility,
closest landmark,etc. Please be as detailed as possible. If necessary, attach a diagram. �c�<�tl���� c+ �
(Z�—�r,SrC�� c�G- ��n�� ���n�S��c�;c�:� r�� ���\P" �- L� h �Fte��- >
Please indicate the amount ou are seeking in compensation or what you would like the City to do to resolve this claim
to your s tisfaction. S — ��^�� �� �h ' �' `�`'�� n � U S �
� �; \: c"� f�� J �. � ��\� �� �R� ; �� �.���
�CUu �' .���'('S�
Vehicle Claims— lease com lete this section ❑ check box if this section does not a 1
Your Vehicle: Year c1 Make Model � �- �
License Plate Number � State Y�►1Color 1�I AC �G�)c� : �� 1
Registered Owner �S �f' 'S�
Driver of Vehicle ` � c
n \ -
Area Damaged"� Pc�� �1 P� �- , , '� - � ' 'k� ��� ��r.�v�e�k
City Vehicle: Year Make Model �
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniurv Claims—please complete this section � check box if this section does not applv
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 fornz,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� � — �C� ' ��
�
Print the Name of the Person who Completed this Form: �^�' S �C=� �-,�
Signature of Person Making the Claim:
Revised February 2011
•Auto' Policy Information Page 3 of 4
Pohcy number 204 7877-At4-23-001
Vehicle descriptlon 1999 SATURN SATURN 2DR YOUf Agent
Mailing address 49 MARYLAND AVE E
SAWT PAUL,MN 5511�4615 � Cary Charlson ins
Phone number (651)500-8817 �� � AgCy InC
More aboui Cary Charison
Email address LESLEE POST@STATE MN US
6993 35th Street Nonh
Oakdale.MN 55128-3144
1851)77P7849
G8tl8i'dl��f��Etiy�titOftl'i8ti4(t Office Hours: M-F Bam-Spm Pdy My Bill �
Zpi'i
Polic t 2 PfiVate Passenger Afler hours by appointment �
Y YP
Pohcyhoider POST,IESLEE
. Renewal date Otl14/2014 �
Premium 3637 71 .
Amount due $0 00
Most recent payment 50 00
Vehicie[)etails . Request insurance Cards
1999 SATURN SATURN 2DR . �,
Annual mileage Dnven over 7 500 miles annuaily. �� ����
Address where prinapally garaged 49 MARYLAND AVE E
SAWT PAUL,MN 5511713615. ��
Lending Institution None associated w�th this vehicle - �
Principal driver LES�EE POST-10-06-1961
Assiqned driver�s2 LESLEE POST-10-05-1961
Coverages
1999 SATURN SA7URN 20R .
Coverage
Coverage Details � Premium
Liabiiity-Bodily Inlury/ $250 000 each person/$500.000 each accident $198.37
Property Dama�e i100:000 eacn accident
See Polic Schedule for Umits $252A3
Personall�jury Protection(PIP� Y
Uninsured Motor Vehicle
$250.D00 each person/$500.00C each accident $12.59
Underinsured Motor Vehicle
$250.000 each person/$500,000 each accident $26.62
---- ---- _-- - '
---- $5023
Comprehemive DeductlWe!Mt►!G�ass $�
$91.60
caa:�+osa,caae $soo
-----------�-------
55.17
Emer�ency Road Service Yes
---- - ------
$0.00
Car Rental and Travel Expenses No Coverage
--------------...-------
30.50
Auto Theft Prevention Surcharge Yes
Total Premium f637.71
;total premium includes your discounts)
https://online2.statefarm.com/apps/pvc/auto/execute.do?APP... 7/19/2013
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As of 7/19/13,the sign that fell on my car was�till sitting in the same spot that the police officer left it.