Loading...
MacLennan • RECEIVED r �IAR 0 3 2014 NOTICE OF CLAIM I'ORM to the City of Saint Paul, Minnesota CITY CLE�K Mi�r�resota State Stntute 466.05 stntes thnt "...every persrni...wlto clnims damnges.frn���n�iy m�uiicipnlity...shaR cn��se m be presentec to the governing hucly of'the mur�icipality witllin 180 dcrys nfter the a//eged bss or injury i.r discoverec/a notice stnting the tinte,p/nce,ancf circumstnnces thereof,nnd die mm�unt of compensatinn or other relief demnnded." Please complete this form in its entirety by cleariy 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 answers,so provide as much information 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'. SEND COMPLETED FORM AND OTHER DOCUM�NTS TO: CITY CLERK, 15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102 First Name /�Li��e.- Middle lnitial E Last Name /' 1 f���-°NNA�I Company or Business Name Are You an Insurance Company? Yes/� If Yes, Claim Number? Street Address /5 3� 7 j�i R�� �'��"�' ��� City S�" pA tr-� State /Y1 n/ Zip Code 5 sj U�o Daytime Phone ((Q�L)��-_3.�_'t�ell Phone ( ) _�yT• Evening Telephone ( ) ,V/� I � Date of Accident/Injury or Date Discovered U�'l/g �/� Time ' O am/ m �� Please state, in detail, what occurred (happened),and why you are submitting a claim. Please indicate why or how you feel the City of Saint Paul or its employees are involved and/Por responsible for your damages.fi'- lw�A�S ��2i r�iw� �v �- � h • � d � . � G� h u : O N ' n� f� N�t�t p-F'�A�ef',�V�-h��trec hR-d o b� -b�d �pr� `°, fRa�K dei��e. SA�d �g y�lh Please che the box(es) that most closely represent the reason fo'r complet�ng this form: �5v.� ❑ My vehicle was damaged in an accident ❑ My vehicle was damaged during a tow � �My vehicle was damaged by a pothole or condition of the street ❑ My vehicle was damaged by a plow My vehicle was wrongfully towed and/or ticketed ❑ I was injured on City property ❑ Other type of property damage—please specify ❑ Other type of injury—please specify In order to process your claim�ou need to include copies of all aqnlicable documents. For the claims types listed below, please be sure to include the documents indicated or it will delay the handling of your claim. Documents WILL NOT be returned and become 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 damage exceeds$500.00; or the actual bills and/or receipts for the repairs; detailed list of da�aged items O Injury claims: medical bills,receipts � O Photographs are aiways welcome to document and suppoR your claim but will not be returned. Page 1 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. All Claims—�lease comnlete this section Were there witnesses to the incident'? Yes No Unknown (circle) Provide their names, addresses and telephone numbers: Were the police or law enforcement called? Yes No Unknown (circle) If yes, what department or agency? Case#or report# Where did the accident or injury take place? Provide street address,cross street, intersection, name of park or facility, closest landmark, etc. Please be as detailed as possible. If necessary, attach a diagram.�t.l►�a-eA. -I-h� Vrq�i��.7' vn� �Dhw�6�,v p�llw�+- f2�����TL L,l��s �ibt�,��;�r' ��1��. Please indicate the amo�mt you are seel:ing in compensation or what you would like the City to do to resolve this claim to your satisfaction. � �l-7-�7 .-- Ct95 f' O� �°.�Ai I'c�, Vehicle Claims— lease com lete this section ❑ check box if this section does not a 1 Your Vehicle: Year /99 Make Model �,G� License Plate Number /I� ��.-�r State,m�Color M�E6 J Registered Owner /�L��� �. M�e � .O A_/�J��(] Driver of Vehicle��T��, �'- /j")�ar•-�.,vn�/�N Area Damaged ���-� �,,v� _. �e- City Vehicle: Year Make Model License Plate Number State Color Driver of Vehicle(City Employee's Name) . Area Damaged �urV Claims—please complete this section La check box if this �ection does not ap�lv How were you injured? What part(s)of your body were injured? Have you sought medical treatment? Ye5 No Pla�ning to Seek Treatment (circle) �� When did you receive Creatment? � (provide date(s)) Name of Medical Provider(s): Address Telephone _. Did you miss work as a result of your in;ury? �'es No When did you miss work? (provide date(s)) Name of your Employer: Address Telephone ❑ Check here if you are attaching more pages to this claim form. Number of additional pa�;es By signing tliis form,yoic are stating tliat ull information you lzave provided is true and correct to the best of your knowledge. Unsigned forms will not be processed. Submitting a false claim can result in prosecution. Date f'orm was completed ���.y7�aG/� Print the Name of the Person who Completed this Form: �.-L�L�e- �. /�'��4� [,�,vn�l��/ Signature of Person Making the Claim: i �p� � Revised February 201 1 � � Invoice#133412 • Venburg Tire Co. :. 3001 Highway 61 North,Maplewood,MN 55109 Phone: (651)483-2601 Fax: (651)483-2881 , � www.venburgtire.com - FAMILY OWNED AND OPERATED S/NCE 1968 Customer Informatian Invoice Additionai i�armation rAlice Maclennan ;Date: 2/21/2014 PO Number: ' 1535 3rd St E 'Reference: 133412 Work Order#: W-378161 � St Paul, MN 55106 i !Salesperson: Joel McFarlane WaiUNumber. no Offer Code: Notes: NOTIFIED � Route: P:651-771-3754 Contact: Delivery Date:2/19/2014 �Entered By: Paul Bewick ! _ _ _ - _- 1_—,_ ___ ---- --- ----.. -- ___ _ __ __ _ - Vehicle:1995 Mercury Grand Marquis GS Lic No:111 DZJ Unit: Mileage IN: Desc: VIN:2MELM74W7SX617133 Mileage OUT:125191 � QtY Description � FET ,-Unit P�ice �' Ext Price � "''�'check front end...something in LF suspension broke--WAS TOWED IN 2.00 104226, �ower Ball Joint(1 Year Warranty), Master Ride, Front End 40.00 80.00 1.00 18833, Idler Arm Assembly(1 Year Warranty), Master Ride, Front 70.00 70.00 End 1.00 190143, Pitman Arm Assembly(1 Year Warranty), Master Ride, 60.00 60.00 Front End 1.00 ES-3495,Outer Tie Rod End(1 Year Warranty),Master Ride, 40.00 40.00 Steering '"'LF 1.00 Mechanical Labor 480.00 480.00 1.00 Alignment(Front End) 69.95 69.95 Taxable Subtotal: 799.95 MN Sales Tax: 17.19 Transit Improvement Tax: 0.63 � TotaL• $817.77� Balance T- -_5817.77 ,_ ...a.� . - Account Balance Currerrt 0-29 Days 30-59 flay� 60-�� �'�lt� 5817.77 , 5817.77 5817.7T � ;0.00 50.00 �� 50.00 Re-Torque Lug Nuts After 100 Miles. W-378161 2/22/2014 11:12 AM Page: 1 Entered By:Paul Bewidc Signature Venburg Tire Company 3001 Hwy.61 N. Maplewood,MN 55104 Phone Number:(�Sl)483-2601 Faa Nnmber: (651)483-2881 Customer: Alice Maclennan ate: 2J21/2014 9:40:10 AM Company: 2MELM74W7SX617133 License No: 111 DZJ echnician: Brad Odometer: 125191 der No.: W-378161 VEffiCLE ALIGNMENT REPORT MERCURY, 1995,GRAND MARQUIS Primary Angles �� Specifications Final Min. Max. Left 5.7° 4.8° 6.3° 5.7° C�� Right 6.1° 4.8° 6.3° 62° Camber Left -0.4° -1.3° 03° -0.5° Front Ri t -0.7° -1.3° 0.3° _p 7° Left -112" -3/32" 1/32" 0" Toe Right 1/8" -3/32" 1/32" 0" Total -3/8" -3/16" 1/16" 0" Left -0.3° -0-3° Camber Right -Q_5° ------ ------- -0-4° Left 3/32" ------- ------ 1/16�� R� Toe Right -3/32" -- -3/32" Total 0" ------- ------- -1/32,� Thrust An le -0.2° ------- ------- -02° Secondary Aagles �i�ial Specifications F�� Min. Max. Left 10.9° 11.0° 11.0° 10.9° SAI ��t 112° 11.0° 11.0° 11.2° Left 10.5° ------ ------ 10.4° IncludedAngle ��t �Q 5e _ 10.5° Left ------- 1.5° 1.5° ------- Toe Out On Turns ��t 1.5° 1.5° Left ------- ------ ------- ------- Maximum Tums ��t Left ----- ------- ------ ----- Toe Curve Change ��t Front 0.0" ------- ------- 02,� Setback Re� p��� ______ _----- 0.6" Track Width Diff. -1.0" -1.0" Wheel Base Diff. -0.2" -0.4" Left ------- ------- ------- ------ II Front Ride Height ��t _______ Left ------ ------ �___ _ Rear Ride Height � t _______ ! Frame An e ------- Thank you for your business!