Testa, Elizabeth-4 -
NOTICE OF a AIM FORM 1D theatydSaint PM, Nla .. ,esota
Minnesota Stott Sto'tuk466..05 stutes that•-~ person_wl,o doims ~ from any rnunicipolity-Shol aJCM tD be ptesmtN tD the~ bocl),af *
mtmicipallty within 180days ~ ~ ~ lossor injury lsdbcow.1l"d a notn stat.mg tM ~ ~ ond~ thelftJL and the amotlftt of ~.soti<ln
or~r~dernond«J.•
Pl••• completa this form In Its •ltltet'y by clealfy typing ot prtntlug your ..... to Heh queatlor .. If you haw addlllonal c:tocumentatlo.~._
you may add those documents lo your submlalon. You wll not be CCMllaCted t,y t.aepMM ut•11• dllrlllcatlon la n11ded. The clan proc••
for inwstlptlons can take upwards of four (4) ... a.. This form muet be signed, dalad wllta al applcable Ndlocw compl•lld. Subml11lon
this COl'ftl1hl Id form to the Salnt Pau'I City Clerk's Office by emal (cll)clw.._.. . ._,.11.INUIS), fa (1514M-8574) or mall ac:tdlN1•d to "Saint
Paul City C1e1t. 15 w.t Kelogg Blvd. Sulla 310, Sant Paul, 11N 551Gr.
Caimant First Name: CJl, z.~e..,+'-'
'
Last Name: re,s. -\-<A,
Please Indicate Your Pronouns: o She/Her/Hers, D He/Him/His, D They/ Them/Theirs
Company or Business Name: _________________________________ _
ls this daim being made by an Insurance Company? YES ~f yes, what ls your Claim/File Number? _________ _
Is this claim being made by an Attorney? YES t@t yes, what is your File Number? _______________ _
If yes, provide your lnsured's/ Oient's Name: ____________________________ _
StreetAddress:_5_t.,_7_l. __ ~_-_' ,_\._\_~_~ __ T_("\0--._-_, _\ ___________ _
City: ~b ~ve. v'\ e.'-JJ State: N >-..l ZipCode~ 55 \ 2 la
Daytime/Wort Phone: ___ -_______ Cell Phone: Gl S \ -4 0 L -C\. S 2-9
Date of Incident or Date Discovered (Must Complete): I {J I { ~ I LO 2-5 Time: 9 : 0 a -9 ·, 3 ~ O..n,.
Ple~se state, in detail, what happened that prompted you to file a Notice of Claim Form: ., {/_ _ :C:C:: ~ < ,e 9=4, ~
~ tS"l""\ ~ ~ ~,~a.9-,\.--'-t_n
Pie~~ why or how you feel the City of Saint Paul is responsible for your Damages? \JJ ~ ~ '~~ ~ ~ ~'-1~ ~~~ ~ ~t~<-i-32'-✓ ~ -~ bo-Jv\.
Please check the reason that most closely describes the rel'son for your submlttina a dalm. Please note the documents that wt'I -
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.
D Automobile damage from a motor vehicle accident: please provide two estimates for repairs or actual bill that has been paid.
D Automobile damage from a street defect or pothole: please provide two estimates for repairs or actual bill that has been paid.
D Automobile was towed and may or may not have sustained damage: please provide copy of towing ticket (if available), receipt
from Impound Lot, and two estimates for repairs or actual bill that has been paid.
D Snow Emergency: please provide copy of towing ticket {if available), receipt from Impound Lot, and two estimates for repairs or
actual bill that has been paid.
D Property damage: please provide two estimates for repairs or actual bill that has been paid.
D You were injured during a motor vehicle accident: please provide police report number, details about injury.
IJ-fou were injured in the City of Saint Paul: please provide police report number, witnesses, and details about injury. ~ ~~ ~ 2. L\"\""°':> 1,-.:i,"'{~ ~ ..\o-M -
Continue to pa1e 2 of Notice of Clalm Form. Failure to complete and return both paps wlll result In delays.
RMS~ March 1023
~Is section must be complet d f ~ -e or all claims
1s there a police report for thi 1 ::. If I s ncldent? YES / r.;:,, yes, P ease provide th ~
If yes, what law enforce~:olice report case number:
ntagencyresponded? ----------
Where did the incident tak 1 " A e Pace? Plea ~ ~ ' 0.,..:l~ , se provide a street address Intersect· ~ \t) ~ ~-, ~ ~-·
' . _ ion or name of c~ or facility:
What would you llke to se h ... . e appen to resol thi e.. \ "'-ve s claim to YOl!r satisfaction?
~a-~ bc.J]__
Were there witnesses to th· • .d
-----l~=-~· ~~ -,s me, ent? ~se provide names and contact phone numbers:
. , G:>S , -~ 2 -(c:, 3 ~ o f-K ,·s
For property dama d I ge a ms, lndudlng vehicle accidents.
Vour vehicle's information: Year: ____ Make:-------Model.· _______ Color: -------
license Plate #: ----------State vehicle is registered in: ----------
Registered owner of vehicle: -----------Driver: --------------
Are a ( s) damaged: -:-------------------
1 f a City vehicle was involved, License Plate #: _____________ Color: ------------
Was there City insignia on the vehicle? YES/ NO Driver's Name: --------------------
0th er propertydamaged: _ ...... ~-·,\--~tt-;::__ ___ ·~----------------------
For Injury claims of any type.
What part of your body was injured? £°G:ec2.a ~ ~ ~ tJSV\ ~ ;f ~ ~ ~
Did you go to the emergency room or urgent care@No Where? \...).__ V\~-\-~\ ~
Was medical treatment received@No Where? lJ.... 1c ~ :\: e C\ 1 ~ ½ e:,..,-~~· \ ~
First day of medical treatment? / 0 -{ {&; -25 Are you still receiving medical treatment? YES 1@
Did you miss any work as result of this incident? YES /~ /J __ fl-:"' __ • £'\
Employer(s): _______________ ..;..~----------------------
-fow much time have you missed from work? ___ -________________________ _
f you are submitting other documents, please state what you are attaching and how many pages: _________ _
ly signing this form, you agree that all Information provided Is true and correct to the best of your knowledge.
'lease NOTE that submitting a false or mfsfeadfn1 clafm can and wm result In prosecution under Minnesota Statutes.
lame of Person completing form:~~::::::.,_· \.:.:.i...:::;2~0::;.b~Q..:i=-~,:__,!___--r.-1-Ji~.-::::..~~.\-....!....::<.'.A..~--------
.ignature of Person submitting this form: -~~1
~1i1C::~::::::::~::-=-H-\~--=--~--~ __ ;_-z:_..,~ ________ _
telationship of person signing to Party making the claim: __ S-e....c;,-~~=~~----------
late document is being signed: ( { / 2--O / Z. 5 Revised March 2023
r
• I
~on must be completed for all daims.
IS there a police report for this incident? YES 1@
If yes, please provide the police report case number: _________ _
If yes, what law enforcement agency responded?
Where did the incident take place? Please provide a street address Intersection or name of d!.Y partc or facility: ~ \..-. ,,,,.
_ s ~ A~-:>""'1.)... ~ ~ ~.o. o ~ ~r':\ ~-G:.t-
What would you like to see happen to resolve this claim to yo~r satl~o~? ~ _ I'\ c.iJ.-_
e..\~" ~ ~~ ~_,Q, ~
Were there witnesses to this incident? Please provide names and contact phone numbers:
\:\~ -~ \ ~ <,,J \ -~" 2 -3 le 3::\ ; ~o
For property damge daims, Including vehlde accidents.
Your vehide's information: Year: Make: Model: _______ Color:----------------
license Plate#: State vehicle is registered in: _________ _ ---------
Registered owner of vehicle: ___________ Driver: _______________ _
Area(s) damaged:: ______________________________ _
If a Oty vehicle was involved, License Plate#: ____________ Color:------------
'
Was there City insignia on the vehicle? YES/ NO Driver's Name: ____________________ _
\.J. ••. ~~~ Other property damaged: _ _l\~ '--"-1::t--~-~~=-===--=-----------------------
\
For Injury dalms of any type.
What part of your body was injured? :£'c;;,,:a.. 1'i-~ ~ ~ ~ J ~ ~ ~
Did you go to the emergency room or urgent care@No Where? _l}..___;:_....;,_V\_,.;_'-\-..;..__~ _<_\...__ ___________ _
Was medical treatment received@No Where? L\.. \c ~ t E-.a i 6 \,,\. C)<" ~~·' ':s."-:A A\\.'"'°'
First day of medical treatment? / 0 --/ ~ -2.5 Are you still receiving medical treatment? YES I@
Did you miss any work as result of this Incident? YES/~ I) _ fr-:" __ • A
Employer(s): ______________ ..... ~----------------------
-How much time have you missed from work? _________________________ _
If 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 mlsleadln1 dafm can and wflf result f n prosecution under Mf nnesota Statutes.
Name of Person completing form:-~-\_, _2_o __ b _____ Q.;_~-~--Y-_...__-e......::;.aa5>~.\...:..-...;;;<3:.;..,;a_ _______ _
Signature of Person submitting this form: -~-~----~~,._·-=-H::)...;;;;...._,___~;;,,;;.._;;.._ ________ _
Refatlonship of person signing to Party making the claim: --~---=L\c)--1t-~---------
Date document is being signed: l l / ~ 0 / Z. 5
Revised March 2023