Skelly, ChristopherNOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
governing body of the municipality witttin 180 days after the allegetl loss or injtu"¡, is cliscot,erecl q no[ice stating the tinte' place, attcl
circun.tstan.ces thereof, and the anloLLtlt of con'tpen,sation or other relief denrunded,"
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 ansìrers' so provide as
much inf<rrmation 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'.
SE,ND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD,310 CITY HALL, SAINT PAUL' MN 55102
First Name tì I'Middle Initial Last Name
Company or Business Name
Are You an Insurance Cornpany? V", @ If Yes, Claim Number?
Street Address
City State A^/Zip cocre ßlot
Daytime Phone (-)-- Cell Phone ("lan90-fú-LL-Evening Telephone
Date of Accident/ Injury or Date Discovered 3/5t 3,A Time { ant@l
Please state, in detail, what occurred (happened), and why you are submitting a claim, Please indicate why or how you
feel the City of aint Paul or its lo s are involved and/or sib for
Please check the box(es) that most closely represent the re¿ison for completing this form:
tr My vehicle was damaged in an accident n My vehicle was damaged during a tow
F tUV vehicle was damaged by a pothole or condition of the street I My vehicle was damaged by a plow
h VIy vehicle was wrongfully towed and/or ticketed ! I was injureci on City property
I Other type of property damage - please specify
fl Other type of injury - please specify
In order to process your claim vou need lo_include co.pies of all applicable docurytents.
For the clairns types listed below, please be sure to include the clocuments inclicatecl or it will delay the handling of
your claim. Documents WILL NOT be returned and becorne 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 copy of the impound lot receipt
O Other property damage claims: two repair estimates if the darnage exceeds $500.00; or the actual bills
and/or receipts for the repairs; detailed list of damaged iterns
O Injury claims: medical bills, receipts
O Photographs are always welcome to docunrent and support your claim but will not be returned.
Page I of 2 - Please complete and return both pages of Claim Form
Failure to complete and return both pages will result in delay in the handling of your claim.
- nlease comolete section
Were there witnesses to the incident?Yes No (circle)
Provide their names, addresses and telephone numbers
All
Were the police or law enforcement called? Yes
If yes, what department or agencY?
Where clid the accident or injury take place? Provide street address,
Unknown (circle)
Case # or report #
-
Çross street,park or facility,
land Please be detailed ible. If a
Please indicate the
to your satisfaction.
seeking in compensation or what you would like the City to do to resolve this claim
on box if does not
Your Vehicle: Year lþ'î.5 Make
License Plate Number
Registered Owner
Driver of Vehicle
Area Damaged
City Vehicle:Year Make
State Color
state -- color
Model
License Plate Number
Driver of Vehicle (City Employee's Name
Area Damaged-
this
How were you injured?
What part(s) of your body were injured?
Have you sought medical treatment? Yes
When did you receive treatment?
Adclress - TelePlione
Did you miss work as a result of your iniury? Yes No
Name of your Employer:
No Planning to Seek Treatment (circle)
e date(s))
Name of Medical Provider(s):
When did you miss work?(provide date(s))
Telephone-
E Check here if you are attaching more pages to this claim form. Number of additional pages
---.
By signing this form, you &re støting thqt alt informøtion you have provided is true ønd correct to the best
of your knowledge. Unsigned forrus will not be processed.
Submittíng afalse claim can result in prosecution, Date firrm was completed s/t lrt"
Print the Name of the Person who Completed
Signature of Person Making the Claim:
Revised February 201 1
this Form:0t 1,,"r- SI<J[
0a/o6/2026
08:11 AM
TBEAIIWELL: N
CHRIST'OFHER SKELLY
M: 612 - ?50 -?,622
2O2S GHEVROLET
BOLT EV HATCHBACK,
O.E. (F): 215/50 R17 8L
O.E. (R): 216t59 R17 8L
CONDITION
COLOR:
FLATE:
MILEAGE: 33105
CARRY_OUT: N
WHEEL LOCKr N
LOCATION:
MNM Ofi
2570 IA'HITE BEAR AVE
N
MAPLEWOOD, MN
55109 - 5136
65,1 -779-2A67
$ALES ORttER #: 5f¡64665870
ORDER TYPE: STOFTEORDER
EVERETT L
ESTIMATED COMFLETION TIME: fìg:44 AM
ARTICLE AXLE DESGRIPTION PH¡CË OTV AMOUNT
125206 215 t50 H17 95V XL
BSW
YOK YOKOHAIIA
YK-GTX A[t $EATÍ)N
$1i3,00 4 $692.00
TIRE MILEAGE WARRAI{TY: 70000
45969 ntL vs20 Tq12 T10
$NAP - IN
TPMS RBK VALVE KITv8-20
$0,00 4 $0.00
00017 CERTIFICATES FOR
REFUI{0, REPLACEIIÊNT
$20.88 4 $03.52
00221 WA$TE TIRE
OISPOSAt FEE
$î.$0 I $14.00
80¿19 ll{srÀttATt0N &
LIFE OF TIRE MAIHTENANCE
$25.00 4 $1f10,00
$UBTOTAL:
SATES TAXE$:
Tolall
PÀYMENT STATIJ$:
$089.S2
$57.98
û9{?.18
PAID
COMMENTS: