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Schmitt NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota Miiuresnta Stute Sluhrte 46h.05.ti•t�rles dtat "...e��er��pi�rsnn...whu rluint.s dmna,Se.s fi�nnr any mrmicipaliry....shuf(cnu.se[n hr pre.sentrd tu�/ie gui�erning hur/�'oJ�t/te mrt�ticipality�ritltin I�SO d�i�'s q%ter the�a!/e,�c•r/ln.ss ur injurv i.r disrm�ered a notire stcrtiirg the time,p/uce,unJ i'irctunslunces lheren/;and Ihe crmowtt n(ru�rrpen.crrlion nr o►her relie�/'denrrrnded." Please complete this form in its entirety by clearly typins 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 t�►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 yoar form is received. The process can take up to ten weeks or lon�;er depending on the nature ot'your claim. This form must be signed,and both pabes completed. If something does not apply,write`N/A'. SFND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK, 15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102 First IVame ��Q-12L,4-�J Middle Initial� Last Name �� /�L`f/ T� Company or Business Name VED Are You an Insurance Com an � Yes(QVo) If Yes, Claim Number? �2Q�3 P Y• `J Street Address �+LERK City ��% �� State _��J Zip Code S�l Daytime Phone��)��Cell Phone (��)_�� Evening Telephone(!"s/ ) 6�ro---3s j'3 Date of Accident/Injury or Date Discovered�i,LS/- �9t�C Time �,�s 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. � � � %�U' . �,.G L�—��a!!r� tr>iPi�4 T /�-w��/�5-1?11c`'7? .S�.�a /-iP �i �� //�� 7D � - � 1s1�s�L/L �-lo i .�fi��i7 /2�7�l�i .tl�/Uy f��Zr° �E�� 6 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 dumaged by a plow ❑ My vehicle was wrongfully towed ancUor ticketed ❑ I was injured �n City property �ther type of property damage-please specify��T�n,y �Lc,��l,v��-i.-�^j� � Other type of injury-please specify In order to process your claim vou need to include conies of all aanlicable 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 cc�py 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 dxmaged items O Injury claims: medical hills, receipts O Photographs are always welcome to clocument and support your claim but will not be returned. Page 1 of 2-Please complete and return both pages of Claim Form i Failure to complete�nd return buth pages will result in delay in the handling of your claim. All Claims- Iease com lete this sectio ,- Were there witnesses to the incident? Yes No Unknown (circle) Provide their names, addresses and telepho numbers: ��j2/�- /� �� X� _L . �. . Were the police or law enforcement called? Yes No Unknown (circle) If yes, what department or agency? Ca�e#or report# Where did the accident or injury take place? Provide street address,cross street, intersection, name of park or facility, closest landmark,etc. Please be as detailed as possible. If necessary, attach a diagram. _ /,�S��/��,1_Ti�.��i-� c�.!'� ,/,rt-rJ L �-1,n/ ��/ _ 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 alease complete this section check box if this section does not applv Your Vehicle: Year Make Model License Plate Number State Color Registered Owner Driver of Vehicle Area Damaged - City Vehicle: Year Make Model - License Plate Number State Color __ Driver of Vehicle(City Employee's Name) Area Damaged In',�urY Claims please complete this section c eck box if this section does not aaplv How were you injured? What part(s) of your body were injured? Have you sought medical treatment? Yes No Planning to Seek Treutment(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 youmiss work? (provide date(s)) Name of your Employer: Address Telephone �heck here if you are attaching more pages to this claim form. Number of additional pages By signing this form,you are stating tl:at all information you have provided is true and eorreet to the best of your knowledge. Unsigned forms will not be proeessed. Submitting a false claim can result in prosecution. Date form was completed Print the Name of the Person who Completed this F m: �g��l o��N��J ,7— � Si�nature of Person Makin�the Claim: _ Revised Februaiy 201 I ;h � ; , � ; � � �� r. �r�5 GJ�-�L- K�-t�"�^� ' �,��- G�.�� y� ��: t. }; _�vJ� ,4- �v��" .�.� , , �� ;; �y- y�9�J� �x/ ' ;; �� .,� �". �� /�i�f��j'"L;� � ;� 1, ' �'�y�v'l� �.S�c�-��2 _ ;` 7�3 -�'�3 ��3U _ �LL ��.�/` o�• c� L�w y �`l `,,� � �. �<,. c�-z� Sf�o2r,. ��v G f� (�/� � , � C� ( s � i , /��.��ti_��: �'��/�(/�/�/�y. sss� west vdn��he Ra. - --- _ Estimate �� Fridle�y, M N 55432 • � � � � � 95�_922_�g�o t��,6�t e , Date �.��- � � �� 651-635-9171 WINDOW CLEANING 763-571-5347 Fax . starbritewindows @yahoo.com Billing Information Job Site Address Name Name �v � i 1--1 5C �)�'i�c�� Address� � �� Address I �"� }; � C�� I c�►�� T�=r v-�c C ��..,. �� City � � � � � �� City ��fi ��'��-V� � � Phone - — Phone �'s l` (��'t= -- ?�3� Email Email Price �Cleanin all erimeter lass insi � g p g , 'de a�d out....rl�:'`'"s.`.:..................�"� �OS . � Cleaning all perimeter glass outside onl ............................... , Y....... ❑ Deck cleaning .............................................................:.............. .:. �7( Cleani ................. .. ..: ti.e c1 c..� P r�c-� 7''� ng screens .. . . ......................................... ...... .� (� i ❑ Cleaning skylites............................................................................. ❑ Cleaning chandelier ........................................................................ ❑ Cleaning gutters.............................::. .................... Cleanin sidin soft brush 1 . �"• � ' , ow pressure) ....�v.�>.... ...............�-3 q s � g g � ❑ Pressure washing - object •-••••••�••�••••�•••�•••••• �Storm windows included ❑ Storin windows not included ❑ Add 7.775%tax ❑ Add 6.875% fax ��Add 7.625%tax ❑ Add 7.275%tax ❑ Add 7.125% tax ❑ Non Tax Notes: ' rlh�_, ��. �d �-� ��c�t F:. S'ic�� ; C.G �2-0 �.�� l _ -�� .� ' / �� e/'�!� c�w� Starbrite Window Cleaning is fully insured. Estimate prepared by: � �� S Fer more about us, please visit www.starbritewindoweleaning.com / �CJ ��,��.. � �5�/!'>'JU?�' �� ` � � � � SOLp TO i , SHIP TO '' J �✓/I YI � 1 i.� ��'l�!' � (� y 1%�l ADDRESS � ADDRESS " i � 1 �� 's � n � c�' � �- r� '` �i'c�,�e��r �Y��/ ��' /� ; CITY,STATE ZIP CITY,S TE,ZIP . �"r �I1.1 S�-rj �� 1D f� � � 'i�► �.� 5 s3��' CUSTOMER ORDER N0. SOLD BY TERMS F.O.B. DATE � l3 � ORDERE� SHIPPEU DESCRIPTION PRICE ;UNIT AMOUNT � � r� / . �� , , � ,� a ;v � d A-5P40 T-4670E/467.'.7 . � �01-11