Jehle N4TICE 4F CLAIM FORM to the City of Saint Paul, Minnesota
:L/i�irresolu Sru1e Stattrle lb6_f1�slutcts tkal "...everv pe�:srin...irlro claitns dantaQes;fi•om mit'»ttuliciptrlily...slrall cturse�10 be presenled�n dre
�m�enri�t,�horly�jtltc municir�tlffy trlNtin I811 da}s ttJter 1he tr!legecf loss a•i��ttry is rliscvvered a�rolice slr�li�;r,�i/re tinre,pluce,rrird
circttnrstauces�/rereof nrirl tlre aum�ait oj'co�+ipe��scition r�r ot/rer relicf denani�rlerL"
P�ease eompiete this form in its entiret}�by clearl�°typing or printing}�our ans�rer to eacl�question. If more space is
needed,attach additional sheets. Please note that you may or ma}�not be contacted by telephoac to discuss your claim
circumstances,so provide as mucl�information as necessar,y to explain your claim,and the amount of eompensation being
reyucsted. This[orm must be signed,and bath pages compicted. If somcthing does not apply,ti4rite`n/A'.
SEND COti�iPLETED FOR11I f1ND OTHER DOCGR�IENTS TO:
CITI` CLERK, 15 WEST KELLOGG SLVD,310 CITY HALL, SAI�IT PAUL, NIn 551U2
First Name ���ISS� Middle Initial ►� Last Name J �c��e RECEIVED
Company or Bu.siness Name, if applicable_�' ��Y4X� (M;Q,Qs� �RN �8 2���F
Street Address _ ��U v.l ���.�.ti� � �, /�ve CiTY CLERK
- -Ci ty_JC!��n tW�ya e�'f State ►'�� Zip Code �S�-{o S
Daytime Telephone{ �I SZ) �3 � - ZS2�'� Evening Telephone(�f�2 � �3 g - 2�Z�
Date of Accident/Injury or ate Di es overe �`��`� � �~ Time << a�'pm (circle)
Piease state, in detail, «hat occurred, and why you are subrnitting a ciaim. Please indicate why or how you
fccl the City af Saint Paul ar its cmployees are involved and/or responsible.
�'ar c.,c+� -�a�,.co� o n ��is, �`n �.�-�f-�.ro'� U.c+'1 /'G" .
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Please check the box{es) that most clasety represent the reason for completinb this form:
❑ Vehicle was damaged in an accident J�'Vehicle«�as damaged durin�a tow
❑ Vehicle was damaged by a pothole or condition of the street CJ Vehicle was damaged by a plow
L7 Veliicle wa.S wrongfully towed and/or ticketed ❑ Injured on City property
0 t7ther type of property damage-please spccify
� Qther type��#�}�ry—�lease�pecify
❑ Other type not listed—please specify
In order to pr�cess your claim �ou need to include copies of all applicable documents. This is a general
�uideline of what should be submitted with a claim form, but it is not a11 inclusive. Yau may be askcd to
provide additional information depending on your claim.
� Property damage claims to a vehicle: at least two estimates for the repairs to your vehicle;or the
actual bil]s andlor reccipts for the repairs
O Tocving claims: legible capies of any tickets issued and copies of the impaund lot receipts
� Other property damage:repair estimates, detailed list of damaged items
O injury claims: medical bills,receipts
O Photographs can be provided but will not be returned.
Page 1 of 2—Please complete and return both pages of Claim Farm
Failure to providc a completed claim form�vill result in delays in processing.
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General Milis Auto Service Center
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Bill To Alyssa]ehle Plate 028 KYR
Description 2006
Make Toyota Camry XLE
Engine L4-2362 2.4 USA
Odometer 181,515
Phone (763) 764-2523 VIN 4T16E30K86U661169
Mobile (952) 738-2525
Email Alyssa.)ehle@genmills.com PO # N/A
Work Order# 0000084893
Invoice Date Jan 22 2014 Invoice # N/A
Appointment Jan 22 2014 11:32 am Svc Advisor Grenson,]oe
Promised Jan 22 2014 5:00 pm Technician Slabiak, Paul
Services Requesred
_Accessdri�s-Repafr/Service/ Replace `
Provide estimate for plastic skid plate hanging down on vehicle
Labor $43.20 *
Sub $43.20
Total Labor $43.20
Total Parts $0.00
Total Before Taxes&Miscellaneous Charges $43.20
(*) Shop Supplies $2.16
Totals $45.36
Authorization Comments
Customer Signature:
1 General Mills Blvd. Golden Valley MN 55426
763-764-4276, asc.appointment@genmills.com,
Work Order#0000084893 Page 1 of 1
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