Mayer, KarlNOTICE OF CIAIM FORM totheCrtyof Saint huL Minnesoh
Minnesota State Stdtute 466.05 stdtes that "...every person..:who claims damoges from any municipality...shall cause to be presented to the governing bady of the
municipality within 78O doys after the olleged loss or injury is discovered o notice stoting the time, place, and circumstsnces thereof, ond the omount of compensotion
ar other relief demanded.'
Please complete this form in its eotirety h/ clearly typing or printing your answeG to each question. lf you have additional docurnentation, you may add those documents
to your submission. You will not be contacted by telephone unless clarification is needed. The claim process for investigations can take upwards of four (4) weeks.
This form must be signed, dated with all applicable sections completed. Submission this completed form to the Saint Paul City Clerks Office by email
(cityclerk@ci.stpaul.mn.us), fax (651-266-8574) or mail addressed to "Saiot Paul City Clerk 15 west Kellogg Blvd., Suite 31q Saint Paul, MN 55102".
Claimant: First Name: _KARL N._ Last Name: _MAYER
Company or Business Name: _TECH TAILOR, lNC.
ls this claim being made by an lnsuran€e Company? YES I [NO] lf yes, what is your Claim/File Number? _NO.
ls this claim being made by an Attorney? YES / [NO] lf yes, what is your File Number? _NO.
lf yes, provide your Insured's/ Client's Name:
Street Address: _P.O. Box 236
City:HAMMOND State: _Wl Zip Code: 54015_
Dayti me/Work Phone : _7 15 -293-39 14_ Cell Pho ne : _7 t5 -293-39 t4
DateoflncidentorDateDiscovered(MustComplete}:4/75/2an-Time:-8:30pm.
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: _Damage to tires, towing required_
Please state why or how you feel the City of Saint Paul is responsible for your Damages? _Poor Maintenance of Roads
Please check the reason that most closely describes the reas{rn for your submitting a claim. Please note the documents that will
need to be provided with your completed form. Photographs will be accepted. All documents submitted become the property of
the City of Saint Paul and shall not be returned.
il Automobile damage from a motor vehicle accident: please provide two estimates for repairs or actual bill that has been paid.
[Xj Automobile damage from a street defect or pothole: please provide two estimates for repairs or actual bill that has been paid.
il Automobile was towed and may or may not have sustained damage: please provide copy of towing ticket {if available), recelpt
from lmpound Lot, and two estimates for repairs or actual bill that has been paid.
E Snow Emergency; please provide copy of towing ticket {if available), receipt from lmpound Lot, and two estimates for repairs or
actual bill that has been paid.
E Property damage: please provide two estimates for repairs or actual bill that has been paid.
E You were injured during a motor vehicle accident: please provide police report number, details about injury.
E You were injured in the City of Saint Paul: please provide police report number, witnesses, and details about injury.
Continue to page 2 of Notice of Oaim Form. Failure to complete and return both pages will result in delays.
This section must be completed for all claims.
ls there a police report for this incident? YES / t NO I
lf yes, please provide the police report case number:
lf yes, what law enforcement agency responded?
Where did the incident take place? Please provide a street address, intersection or name of city park or facility:
-NeartheintersectionofShieldsAveandFrySt,inSt.Paul(Midway}
What would you like to see happen to resolve this claim to your satisfaction?
_Reimburse our actual expenses totaling S353.41 Copies attached.
Were there witnesses to this incident? Please provide names and contact phone numbers:
_Susan Simone, (651) 278-9910 or (651) 583-7775.
For propertv damase claims, including vehicle accidents.
Your vehicle's information: Year: _2017_ Make: _TESLA_ Model: _S_ Color: _BLUE_
License Plate #: APR 8766_ State vehicle is registered in; _Wisconsin
RegisteredoWnerofvehicle:-TEcHTAlLoRlNc-Driver:-KARLN.MAYER-
Area(s) damaged: TIRE (REAR DRIVER SIDE).
lf a City vehicle was involved, License Plate #: _N/A.Color:
Was there City insignia on the vehicle? YES / NO Drive/s Name: _N/A
Other property damaged :
For iniurv claims of any tvpe.
What part of your body was injured? _N/A
Didyougototheemergencyroomorurgentcare?YES/NoWhere?-N/A
Was medical treatment received? YES / NO Where? _N/A
First day of medical treatment? _N/A_ Are you still receiving medical treatment? YES / NO
Did you miss any work as result of this incident? YES / NOEmployer(s): YEE
How much time have you missed from work? 8 HRS
lf you are submitting other documents, please state what you are attaching and how many pages:
By signing this form, you agree that all information provided is true and correct to the best of your knowledge.
Please NOTE that submitting a false or misleading claim can and will result in prosecution under Minnesota Statutes.
Name of Person completing form: _KARL N. MA'
Signature of Person submitting this form:
Date document is being signed: _412512A23_
EMPLOYEERelationship of person