Yang, Mai NOTIC� OF CLAIM I+'ORM to the City of Saint Paul, Minnesota
Mrnne.sota S�ute Stcr�trte 466.05.��tnte.r that "...everv person...who c/ain�s drrnrnge.r fi-om nnv numicipnlrry...sh�r!!carrse tn be pre.sented to�he
gm�erning bodv qf'ti�e nurniripnlih�within 180 dat�s after Ihe alleged lo.rs or injury is cliscovered a notic•e stntirig the tinre,place,a�rd
circumstc�nces tltereo%crnd the anrount o/'enmpensation or other relieFdemandecl.°
1'lease complete this f'orm 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 ackn�►wledgement 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���l�L Middle Initial � Last Name ���
__. _ ED
Company or Business Name _
A 4 013
Are You an Insurance Company? Yes No If Yes, Claim Number?
Street Address ���� Ies��'(!��.�'le �4de. f � CITY CLERK
City __ �,7� -��f 11 L State %Y I N Zip Code �s�d
Daytime Phone (�63)�0��-���- Cell Phone (76� )�i?�- ���Z Evening Telephone ( ) -
Date of Accident/lnjury or Date Discovered �—�� ' �� 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 and/or responsible for your damages.
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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 dam�iged during a tow
�My vehicle was damaged by a �othole or condition of the street ❑ My vehicle was damaged by a Plow
O 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 �o include conies of all annlicable 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 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 coinplete and return buth 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 na�nes, addresses and telephone numbers:
Were the police or law enforcement called? Yes No 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 facility,
closest landmark ete. Please be as detailed as possible. If necessary, attach a diagram. G tY'ee v '1
�[.� cn �G� S� 0� �e�C t -1 u -t;h�. �,�r-� h cs�.� G 1� �'v`.� r
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�'uS�{ � '��C7
Vehicle Claims— lease com lete this section ❑ check box if this section does not a 1
Your Vehicle: Year ► �� Make �- V �Y� Model o�J'v� C o K�t ►^
License Plate Number Z��� M State M Color ����t�
Registered Owner G{L �:�P `�CA f1 c-',
Driver of Vehicle
Area Damaged �-��-� S i �2 1-r cn C�C �,�:,� c�o ul
City Vehicle: Year Make Model
License Plat�e Number State Color
Driver of Vehicle (City Employee's Name)
Area Damaged
Injury Claims—please complete this section L�,Ycheck box if this section does not apply
How were you injured'?
What part(s) of your body were injured?
Have you sought inedical treatment? Yes No Planning to Scek Treatment(circle)
� When did you receive treatrnent? (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))
Na►ne of your Employer:
Address Telephone
�(Check here if you are attaching more pages to this claim form. Number of additional pages
I3y sigjtirig tlzis fornz,you are statirig tlaat ull ifzfornzatiofa you lzave provided is true and correct to the best
of your knowledge. Uiisigned forms will not be processed.
Submitting a false claiin cafz result in prosecutio�i. Date form was completed �'�y'—��
Print the Namc of the Person who Completed this F rm: �U l. L�{' \/(�'1�'1
Signature of Pcrson Making the Claim: � ° � /
Reviticd Fcbruary 201 I
Enrployee: Please Provide lhis card to citi.en ividz alleg�properry dmnage.
If you wish to make a claim for damage
to your property, please call the
City Clerk's Office at
651-266-8688
Ask for A NOTICE OF CLAIM
form to be sent to you:
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