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NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minnesota S�ate Stahde 466.05 states�ha� "...ever�•person...x�/2o claims dainages from any rnunicipaliry...shaU ca�ise to be presented to the
governing body of the mianicipalitv within 180 da}�s af'ter the alleged loss or injury is discovered a notice stating the time,place,and
circumstances tltereof,and dte amo��n�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 3�ou 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 Jc e (l_ Middle Initial�Last Name �Ya�e a�n.— "-���V E D
Company or Business Name - 2��3
Are You an Insurance Company? Yes No If Yes,Claim Number?
Street Address �3�� �.�� �de- � E R K
City S'� • �� State �/� Zip Code .�S l��
Daytime Phone ( ) - Cell Phone(�)`��Z-�Evening Telephone( ) -
Date of Accident/Injury or Date Discovered_���5 ! 3 Time ��'� a 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 emplo ees a:e involved andlor responsible for your damages. � ,'v v o S-�
{�i¢ Q i.e. o� °'`., �c 7�i•
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Please check the box(es)that most closely represent the reason for completing this form: ¢tC,�
❑ My vehicle was damaged in an accident ❑ My vehicle was damaged during a tow �e.�,Oe,�,
❑ 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 inj�}red on City property
LB�Other type of property damage–please specify 6ral�ev� w?ndou� ..,_,)� ho
❑ 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.
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��'owing claims: legible copies of any ticket issued and a copy of the impound lot receipt
PlOther property darr�a�e claims: twa�epair 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
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Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims-nlease complete this section
Were there witnesses to the incident? Yes Nor Unknown (circle)
Provide their names, addresses and telephone numbers: J o aG�. l�-o�a s�.c�- - �36 g �a.u.r�/.Q� -
s� . ?o�-�� nn1 ss�oY �s'�-voz- 5�67 /
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, etc. Please be as d tailed as possible. If necessary, attach a diagram.
No�`�e a s�' �o�rt�,•-- o��i o�r�. a�-- ���g L a,ur�2�/' �v� . s�. a.c.ur M/� 5 s��y
Please indicate the amoun�u are seeking in com ensation or what you would like the Cit to do to resolve this claim
to your satisfaction. / ow! fa ,� �e 6 0�P..►�_
u.►�d � � s' M
Vehicle Claims-please complete this section �heck 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
Injurv Claims-please complete this section L�l check box if this section does not avnlv
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
Ct�'Check here if you are attaching more pages to this claim form. Number of additional pages J .
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 result in prosecution. Date form was completed ��6� �
Print the Name of the Person who Completed this Form: �co� � ��a.uqe�—
Signature of Person Making the Claim:
Revised February 201 I
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QUOt@
Date: 08/27/2013
Rapid Glass A Quality Glass Co Quote #: 3397642
612-333-4539/763-783-0311
952-881-0116/651-290-0226
Federal I D#:411662447
Phone:
Fax:
Customer: Insurance-Fleet-Broker:
Scott Haugen No Insurance
1368 Laurel Avenue
SAINT PAUL, MN 55104
Phone: (651)402-8360 Phone2:
Mobile: FAX:
Job Scheduled For:
Written By: JK Sales Rep:
Technician:
Automobile Information Fieet Information Insurance Information
Year: Unit#: Policy#:
Make: No Vehicle Card#: Claim#:
Model: Exp Date: Loss Date:
Style: Driver Name : Cause:
VIN #: Driver Lic.: Authorization#:
Color: Fleet PO#: Aqent/Broker:
Mileage: �
License: State:
MFG Part Description Qty Unit List O&A Discount Net
flat glass estimate flat glass estimate � Each $0.00 N 0.00
Service Address Notes: owner Insurance
09/05/13 9am to 11 am-Call w/ETA Sub Total $0.00 0.00
Bedroom in northeast corner;top part of double Tax 0.00 0.00
hung window;double paned; Gross Total 0.00 0.00
Good for 30 days; Deductible 0.00 0.00
Primary Phone: Net Totai o.00 o.00
Secondary Phone:
Mobile Phone: �S� ��
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