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Carter
�iOTICE OF CLAIY� FORIVI to the City of Sain� Paul, Minnesota ;t-lirrire.soln S�uJc•Statulc'�66.O�s�arc:s Nun ".._�re�-t�p��1oe.._n•(ro cluilns danroQes fivm unti��xmticiper/rtp...s/rall crttrse�o be pre.cer:te�/io�he gmrnti�{g Gndp o/'!!rc•mruriciptrlily+riN+iR 18q dql'SlJJltr►/!C R(/cgCd IOS'S Ur(J jtOT 1_r disCU�°ered a�rolicc�sl�uin�dre tintC,plcrce,a1�t! eiretmrsta�rcec tGereo%'and 1J+c cmrnrrnt of caupexscirion nr orlter retiejrlelafaiarlr.d" P�ease complete this form in its entiret��b►�clearl�h�ping or printing your ans��•cr to eacli question. If more sp�ce is needed,attacli additional sheets. P(ease note tliat}ou may or ma}�not be eontacted by telephone to discuss your claim circeimstanees,so provide as mucli informltion as necessary tv esplain}our claim,and the amuunt of eompensation bein� req�cested. This form must be signrd,and bath pages compteted. If something does not apply,write�n/���. SEND C01°I.PLETED FORl1I AnD OTHER DOCtiNIENTS TO: CITI'CLERK, 1� `'VEST KELLOGG BLVD,310 CITY HALL,SAINT PAtiL, NIl� 5�1U2 First Name MiddIe Initial� Last Name Company or Bu.siness Name, if applicable Street Address � � � � State �, � City-- � r �� =�y\,�� Zip Code v� D1��time Tele hone �-� � - � �---� � Evening Telephone{_�"��Q J� � Date o!�Accident/Injury or Date Discovercd -- -1� ZC� I y Time��;�circle) Please state, in detail, i�l�at occurred, and why you are subrnitting a claim. Please indicate�Ihy or ho«�you fccl the City of Saint Pau1 or its cmployees are involved ancUor rc �onsible. � � � � � �, , S � �(�A V�1�fA G � � L Please chcck the box(es) that most closely represent the reason for completin�tllis form: ❑ Vehicle was damaged in an accident Vehicle«�as damaged during a tow ❑ Vehicle tivas damaged by a pothole or condition of the street �Vehicle uTas dama ed b a loti � Y P � D Vehicle�.vas wrongfully towed and/or ticketed � Injured on City property ❑ Other type of property damage-please spccify ❑ Other type of injury--please specify ❑ Othcr type not listed—please specify In order to process your claim ��ou need to include cooies of all auplrcable documents This is a general guideline of'what should be subm�tted �vith a claim form, but it is not aIl inclvsive_ Yau may be askcd to provide additional inforn�ation depending on your claim. O Property dama�e claims to a vehicle: at least two estimates for the�epairs to your vehicle'�r the actual bills andlor rcceipts for the repairs - ����V� c_ �•Stoc y o� �C- �e����'S � O Totivin?claims: legible copies of sny tiekets issued and copies of the impound lot reeeipts Wc- d Other property damage:repair estimates, detailed]ist of dnma�ed items ������� O Injury claims: medical bills, receipts O Photo�aphs can be provided but will nat be returned. . Page 1 of z—Ple�se complete and return both pa�es of Claim Form ��C E I V E Failure to grondc a completed claim form jtirill result in delay�s in processing. ��B 2 0 2�14 CiTY CLERK Notice of Claim Form, City of Saint Paul,pagc hva Ali Claims-please completc fhis section Were thcrc��itnesses to the incident? Yes \10 Unknotivn {circl�e) If yes,please provide their names, addresses and telepl�one numbers: Were the police or law enforcement called2 Yes No Unknown (circle) If yes,what department or agency? Case Y or report# ��Vhere did the accident or injury take place? Provide street address, cross street, intersection,name of park or facility, clo�es landmark, etc. Please be as d�ailed� oss' le. If�elpfu atta�h a diagram. � � . Please indicale the amount you are seeking in coinpensation from this claim or what you��oul like the Gity to do to resolve this claim to your satisfaction. C.cv� c�c:��.c „� CZ��r�,�- 1�S�GQ � �.sz e ' . � e C Veliicle Claims- lease com lete this section ❑ chcck box if this sectian does not a 1 Your Vehicle: Year C'� �Make �' Model License Plate Num er �!1 G � �� State�Y �Color • Registered Owner Driver of Vehicle Area Damagcd City Vehicic: Year Make , odcl License Plate�tumbcr ' State Color Driver of Vehicic(City Emplayee's N e} Area Damagcd Iniurv Claims-piease complete this section � check box if this section does not a�lv Ho��v wcre you injured? l�t'hat part(s) of your body �vere injured? Have you sought medicaI treatment? Yes I�TO Planning to Seek Treatment {circle) ���hcn did you receivc treatment? (provide date{s)) Name of MedicaI Provider(s): Address Telephone Did you miss work as a result of your injury? I�es No When did you miss���ark'? (pro�ride date(s)) Name of your Employer: ; Address a Telephone D Check here if��ou are attaching rnore pages to this claim form. Number of additional pages B}•sig�iirtg Pltis furm,J ntr are cJaling t/rat al/infornta�ro�t}-oir have prus�ided is true and cnrrect tv Ylte best nf�nar knott�le[lge. (,'�rsiened fnrms wiJ1 nnt he processed. Strbmitting a fatse claim cun resull in prosec�ttiurr. � � Print the Name af#he Pcrson �;�ho Compiet d,this Form: �' 0 Signature of Person Nlal:.ing the C[aim: � � 1 Date form�<<as completed �P �-' �� � �('�I --` ReVi��d Ann�z��,� , b0 L55 NW'invd'ig•SZOb XO8 Od y�p�'OOHtlAQo Atl3A0�3tl�1d SONf10dW�Altl3dOtld 31VAItld g sinor�o-�`sidvis-dwn� SL8L-bb9-659x°� M a391m E8L6-LbZ-659 3D1��� `JNIMOl 1��1133H 'g � � � I�ano�aa�g 6uinnol�ld = � '� �•-�. .Wally McCaYthy's Cadillac, L.L.C. t Re: GEORGECARTER 203 EAST WHEELOCK PARKWAY SAINT PAUL MN 55117 1GYEE63A550158821 2005 Cadillac SRX LiCENSE# 561GZK ,`:' To Whom it May Concern: �'}$ `3 On February 18, 2014, George Carter came to Wally McCarthy's Cadillac for service on the family's 2005 ��- <s � ��'�, e � Cadillac SRX. The customer's concern was that the vehicle was driving straight until the vehicle was J�.. �� �i towed during a snow emergency event. Upon inspection,our technician noticed significant damage to ���� � the front steerin g gear where the inner tie rod end meets the outer tie rod end. It appears that under � severe stress the metal tie rods were compromised and will no longer be able to perform service in the �' vehicle. Our recommendation is to replace the steering gear due to damage caused by the towing service. Please feel free to contact me with any questions: 651.746.1920. Sin e ely, ��Cdli"� Stev Pavlicek Service Advisor �3?��'r-ic�Y�riz�cr�ard�N�rt!! • d'avseville, IVlitaf�rsotu �5113 • (i5�. E�?(�.�Od�� • 'r��t:r� ��1_. ?��t�.:%?�r� XFTNITY Connect Page 1 of 1 XFINITY Connect bertcarter@comcast.ne +Font Size- 2005 SRX From :steve pavlicek<steve.pavlicek@gmail.com> Wed, Feb 19,2014 04:17 PN Subject:2005 SRX To:bertcarter@comcast.net Hello George, The cost to replace the steering gear and to perform a four-wheel alignment is$1250. Thank you, Steve Pavlicek http://web.mail.comcast.net/zimbra/h/printmessa�e?id=524060&tz=America/Chica�o&xi... 2/19/2014 � �, � - � • R � ► ��,.� �., „„� �, „».����F � �f;'�`.. V � . . �i .+! . W�.1�',.�� ' � . . ~,Ty � • ,. +Y � . � ...'4� .. R�R�.��� *5.�. ./ }� �'L �t' �"�s�; ^.^�� v �. ' . . . � '�.,�: �* �r; ' �S.y �+ ... 4 �Y., . ✓bx� �V �i .. n5y .,i�,•,�,lF�. ,� � . .. ...r�+" s,� r � y «; � �.° ' b� . . � � ., ��' =,��: . , ;� �,�� .. ! . , .•, � ;�� .;y,: .4. ._, .. �: � .�� ,. ' k_4µ� !� �_� • r^ . j > �,.�y��� ... . '� a .: /a�'�` ���. ���` � � : r , 4,. 7 ..� �y,�'7,.�+`� � 4 . ., . :,` `,� N Y �y,.\ .. „ nS �� � �, +' ' ',�\ `. � '�� � i t,t:' ^° . •���yp'''"'yy�. , � ��1_ , �.4 ^ ��'T C r �r:L��t • .. . . /^' . 1�`�; �_ �� �..�,,.:t�„���„a ��* �"'; j `kq.� '' ` W ..�, Sy/..,�<..�„ .. 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