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Curry NOTIC� OF CLAIM I'ORM to the City of Saint Paul, Minnesota Mrrrnesotct Stute Sta[u�e 466.05 stntes tha� " ...everv persoir...wlro claims dcunuge.s�'ro��ariv municipnlity...sliull e•nu.sP lo he/�re.renlc d to the �o��erning bor1��u/�d�e mur�icipaliN x�ithi�t l80 duys nfter tl�e uNe��ed lnss or injurv is discovered n yintice stnti�ig the time,plcu•e,u�id e�ircuin.xtances tlreren/;nnd!!re clmount n/'con�pensci�irnt or nther relref clem�mded.,. 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 prnvide as much information as necessary to explain your claim,and the amount of compensation being reryuested. 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 DOCUM�NTS TO: CITY CLERK, 15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102 First Name ��--"'� ° �'Z►'�"�— Middle lnitial � Last Name L7Cr'+r�� ir—D Company or Business Name �+^T �� - --�3 Are You an Insurance Company? Yes/No ]f Yes, Clai Number? .. � � lJ'� �C( �YY�.� � I /7� 1'C E R K Street Address � �'1 � Cit �^ �� State �� Zip Code �� Lf Y Daytime Phone ( ) - Cell Phone (��I�- ��5 a Evening Telephone ( ) - ,,�.� �'1� vc� Date of AccidenV Injury or Date Discovered_�� , °�vl 3 Time � � am/pm Please state, in detail, what occurred (happened), and why you are submitting a claim. Please indicate why or how you fee�the City of Saint Paul or itse�ployees are involved a d/or resp nsible for your damages. S W� J c' �� J'�n G�o w�� i 1.._i C z �t-� e�-� (�-t�c� -�--�� n� l e �J c�5 � C��-��1 rn t �c C c.�-�—�u Y1 0�—;— —��h z v� �0.5 G--�'\ U P��r'�G Please check the box(es) that most closely re�resent the reason for completing this form: ❑��M vehicle was damaged in an accident ❑ My vehicle was damaged during a tow t�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 ann<icable 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 Proper[y 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 complete and return both pabes will result in delay in the handling of your claim. All Claims-please comn�ete this section Were there witnesses to the incident'? Yes �2_ Unknown (circle) ,.l Provide their names, addresses and telephone numbers: I � z22��-- _ �-12 CL�'�x�"�- �o`� � LI�3 ' �S��S , ,4�a �, i_ ��c — (.Q �� ,�-�5 'I �� 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, intersecti°� name of park or fac�lity, closest landmark, etc. Please be as detailed as possible. If necessary, attach a diagram. l Lt L� _`�-}-Y��-� Please indicate the amc�u,nt !�u ar seeking in compens•tion or what you would like the City to do[o resolve this claim to your satisfaction. `� �v �°`� � '� �c�-c� -�--�> �� -�-�,�� ;� t'��v� -�-� ✓�5. Vehicle Claims- lease com lete this se tion ❑ chec� box if this section does not a 1 Your Vehicle: Year ,�0 C� Make U��a�- Model �. ✓� ✓�� License Plate Number �P�1 � � I (`1 State olor �� rl v e�. Registered Owner �- �yZc � o�"� L�--C7o r�r��- L�-(U2. Driver of Vehicle Area DamagedT�� 55��-�,G•�Z -�-i 'Q�'�S City Vehicle: Year Make Model License Plate Number State Color Driver of Vehicle (City Employee's Name) Area Damaged In'ur Claims- lease com Iete this section ❑ check box if[his section does not a 1 How were you injured? What part(s) of your body were injured?_�_ � Have you sought medica] treatment? � Yes No Planning to Seek Treatment (circle) When did you receive treatment? (provide date(s)) Name of Medical Provider(s): f� Address Telephone Did you miss work as a result gf 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�. I3y signing t/iis form,yocc are stating ticat ull informatio�a you iaave provided is true and correct to tlze best of your knowledge. Ujasigned forms will not be processed. Submitting a false claim can result in prosecution. Date form was completed Print the Name of the Person who Completed this Form• ��or�-�n-�— ��, Si�nature of'Person Making the Claim: �`�� '1'�n�'— ��1�� Kevised February 201 I Rudy's Tire �� 7 2� Date �� J Hercules & Centennial Customer Nam Chrome Wheels Address� � � •��'1/� 941 W. Minnehaha 5�, St. Paul, MN 55104 City � _State Zip � Tel(651) 487-1002 Tel. Sold B h C.O.D. Char e On Account MDSE Retd Rental Sales Quantity Description Price Amount 2 V .�.�,2 . J� `_ -� Sub. All claims and returned goods MUST be accompanied b�t�iis�bill. Tax Received by: Total (� � � BFGnadr�ti � KELLYISTIRES �jn�ivzop• °� KUMHO TYRES n�`n GOOD�'EAR , ,.� �� '�;, �� ' " .; '��` � ��,a �. : :: � �� c.F,s '�",'.�'p�S 2 s4 � � � � ��- � �,� � �� V � ' '+ � ��y , � F ; k t ti; �� ,k �.}` � �64Y �g.a �' �-�, � .R4 4 t a4 :� `�{. � � ��.�� :°,4 ;�� .� , �„ � �� _�»� ��•.�� „ � � , .� � ��r � � ��Y "' �k �;3. @n � :<?� a�' . t , �. � �� p' ,�� "�°�� " r#� ,..�� y. ��s z. �c � �'�t �+?dt : �"� � - �. �$�r� ,t;•a � � x�,�:��a*^ ,p, ..S '�c ��y,* "�- � t a �� `� �� µ 4.��, �.��{�v ,. ;��g,� �' � ;y�� 3r' �j3�+ ��« . � # S � �` '�e �_ � '��.�e ^�',,� . [j �.Et" �h^:��. r� r�i�ki:'�.,i �� .�` � , �' _ � ' .i d S:hiA°° �: fi �Nt" � Y'.k 'r" i':h:. _ i k�` � �� a� � :� �`�. ;� .c„�:'� � , ° ,� � �> � �� - ,` A�. ;�� k W �;. � g;'` ��: �� . � �% 6� � i. �� : ;a �: � ��.. � �. .;� � � � � �_ c��. 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