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VanderMeer ��c�ev�� MAR 17 2014 NOTICE OF CLAIM FORM to the City of Saint Pau1, 1��s�,t�ERK Minnesota State Statute 466.05 states that"...every person...who claims damages from any municipality...shall cause to be presented to the governing body of the municipaliry within/80 duys after the alleged loss or injury is discovered a notice stating the time,place,and circumstances thereof,and the amount of compensation or olher relief demanded." 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 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 DOCUMENTS TO: CITY CLERK, 15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102 First Name ��I ✓ Middle Initial L' Last Name v�1��'r '"`��x Company or Business Name_ Are You an Insurance Company? Yes� If Yes,Claim Number? ±:� :�-, i_ Street Address"��Cj '�- . y�� ± � City r`�,�`�I � State!v lN Zip Code ��l �b Daytime Phone(=3� ).� -L`- �� !' Cell Phone( ) - Evening Telephone(_) - Date of Accidend Injury or Date Discovered� , � L-' Time � � `� am� 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 andlor responsible far your damages. � r' �b � �� Sfi. v�,��ti2-� _ r r�l {� � � � � ^ �-- C `� -4- 1 < �� ,, � �� - ---� l` '�� I 1 J -� '�''� . Please check the box(es)that most closely represent the reason for completing this form: d V �� ❑ My vehicle was damaged in an accident ❑ My vehicle was damaged during a tow ��y 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 Cixy property -_.:... ❑ Other type of propertv damage-please specify - ❑ Uther type of injury-please specify In order to process your claim vou need to include copies of all applicable 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$500.00;or the actual bills and/or receipts for the repairs;detailed list of damaged items O Injury claims: medical bills,receipts O Photographs are always welcome to document and support your claim but will not be returned. Page 1 of 2-Please complete and return both pages of Claim Form s� ��.� ��J �v� Y`�`� ��..., w c..� b L�,,u--�, C�---t�-� o�.�g�, V`/� , - .) v`,c�, , � /� �a.:��+'� , �`� ��J�, � (�� -� 1 �.X. _-Ril/�, �.�$�(��G'� � � ��f�2.�, ,,,e�, �vc�'� v��`�o Ir��-c� �'./',��.�C�; ��-�,< ��, c�r� �' �`�-' �--�1� ��'� �b�� l��a�._ . -� c_ `'�'o ��.J2.�J'� "I'�',�.� �-�,�a � rr�,��,��- � � ��.�r� �- D�; �},�-- � tr�I�� -- ��-� �-�''� � �_., -��c� o� �% � . � � � �. �1-- �� .nf� � �..��, �.� �� .�- � �' � C�. � �cs�f'� �� `-'�—'��' � —t-,�,� (�, +�. � � w�n� �. 5� o k=-�., v...��\,�, �:�u._ � " -..�2- �. �.�v�J �� ( � � --� �,�a-, �'�� , �.-�c� �.-� --�,�. C �� --�.� J '�° . `� ti�� J'��C S 1 �U.�-� . �� . � � �� -J` � � � � � Failure to complete and return both pages will result in delay in the handling of your claim. All Claims—please comnlete this section Were there witnesses to the incident? Yes �� Unknown (circle) Provide their names,addresses and telephone numbers: Were the police or law enforcement called? Yes � N 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 dia am. �J1� �INL� � �Cx./� `��' -'�'y�.�f1`✓�'C'./� �s',�J�'�G;�',�I.a� Please indicate the amount you are seeking in compensation or what you would like the Cit to do to resolve this claim to your satisfaction. ��-'! — � � �.� i'v t"'�,�-�,�� -�� j��.4-� �� t-��.e�,lC�t.('4 5 �"✓?C�"'�"Ir��. �� Vehicle Claims—nlease comnlete this section ❑check box if this section does not applv Your Vehicle: Year L oC� Make.`,� Model 6'i)�lh0.�L, License Plate Numbe�l.l�.H—l33"L State M� Color�0.1,/ L.i Registered Owner r C�_4,�. v;�r��l�ear IY��-� Driver of Vehicle J � � Area Damaged -�1LA . / 11 1�nn�w�� City Vehicle: Year Make Model License Plate Number State Color Driver of Vehicle(City Employee's Name) Area Damaged In_iurv Claims—nlease comulete this section O check box if this section does not applv How were you m�ured? t�l 1 � What part(s)of your body were injured? Have you sought medical treatment? Yes No Planning to Seek Treatment(circle) When did you receive treatment? (provide date(s)) Name of Medical Provider(s): Address Telephone Did you miss work as a result of your injury? Yes 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 pages(�, By signing this form,you are stating that all information you have 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 form was completed�� J( �� Print the Name of the Person who Completed this Form�� - U��(� Signature of Person Making the Claim: � `� �� Revised February 2011 N�� How did we do? Please, complete the survey at www.atbcares.com Use password�562iis2 0000s TIRES•S6RVICE•BRAI(ES�BA7TERIEB MN NATL TIRE & BAT # 875 * FINAL BILL -INVOICE** Page 1 2185 FORD PKWY Invoice# 75621132 - RI ST PAUL MN 55116-1816 Order Num 49999051 - WI (651) 690-5007 Date/Time In. . . . . . . . 03/12/14 20 :40 : 18 Date/Time Promised. . 03/13/14 16 :27:41 2003 SUBARU OUTBACK Tag: CHM7332 St: MI Mileage: 130344 Engine: VIN# 4S3BH675337625199 ------------------------------------------------------------------------------- Customer: 35796343 PO#: Ship To: GAGE VANDERMEER 3550 EAST 46TH ST ST PAUL NIN 55406 Opening Salesperson 12983351 Home# 231-360-6414 Work# Email : ------------------------------------------------------------------------------- Item Number Item Description Qty Price Each Extended -------------------------------------------- TN13522606T TBC Arctic Claw TXI � 2 112 . 99 � ' �225 . 98 DOT #:U9AR 7U7 1312 2 ' ' ACT52 225/60R16 98T,ACT52 WORKMANSHIP ' Tire Disposal Charge Tire Disposal Charge , 6 . 00 6 . 00 PTS NC INSTALL 2 VSR RUBBER VALVE STEM 2 NCb WHEEL BALANCE NO CHARGE 2 KMTSL MOUNT AND INSTALL 2 12960644 SKARDA, JEFFREY J. LTRF LIFETIME TIRE ROTATE SVC 2 � WA WHEEL ALIGNMENT 1 89 . 99 � . 89 . 99 6 Months / 6000 Mile 12965205 JOHNSON, JEREMIAH VISA Visa -- -- - --- — 348 . 89- CARD NUMBER 9135 APPR 02119A IF YOU HAVE A QUESTION OR CONCERN PLEASE SPEAK ' � TO OUR STORE MANAGER, WILLIAM PUNCHES AT (651) 690-5007 i , Special Credit: ^^+ ^� ��I�� •� �� New Tire Limited Warrsnty "What is covered 8nd Tor how long: . Every new tire piachased at a Tue Kingdom,Merchanu Tire,NTB or Big O Tires store(collectively'TBC Retail')is wazranted by the manufacturer against defects in worlananship or materials down to 2/32nds of an inch remainin9 tread p�we depth.Additional wazranties may apply to some tires.TBC Retail will honor the manufacturer's wazranty on any such tues,and any such tires which fail under the temu of the manufacture's warranty will be repaired or replaced in accordance with the manufacturets wazranty program.You must comply with the conditions of the manufacture�s wairanty program to receive this wazranty cwerage:' "How credit is deterinined: If a tire covered by this wazranty becomes unserviceable due to a defec[in workmanship or materials(tire sepazation,etc.)during the usable tread life of the tire(usable tread depth is original fread depth minus Z/33nd of an inch),you will receive a aedit for the amount of usable tread remaining on the unse�viceable tire times the cutrent selling price(example 60%usable remaining tread times the ciut'en4 selling price of$80 equals a credit of$48).T'his credit will be applied to the invoice of the replacement tire. "What is not covered: This wazranry does'not cover tires which become unserviceable due to: 1. Conditions resulting from road hazards such as cuts,snags impact breaks or punctures. 2. Conditions resultnSg&om improper installation,wheel misalignment or tire/wheel assembly imbalance. 3. Conditioes resdlti�Sg from consumer damage such as improper 6re and vehicle maintenance,misuse,abuse or accident. 4. Tire unifomuty!complaint after the first 2/32nds inch of treact wear. 5. Use in azry comtnercial application. "See Other General Terms and Conditions below. "' ` � Limited Mileage Warranty "What is covered and for how longc � .. � � � � � If a mileage wazranty is noted on the&ont of the documentation attached hereto,such t'ue whose remaining tread depth grove is reduced to 2/32nds of an inch or less prior to receiving the specified mileage,will be replaced with the same or an equivalencnew tire at the then current retail price,including applicable taxes,less an allowance based on the actual mileage received at the time presented to a TBC Retail store compazed to the specified mileage.Mileage wazranTy claims will only be honored within 6 years of the date of original tire purchase and before the t'ue delivers the wazranted:mileage.The following t'ues are excluded from the limited mileage wazranty:commercial use t'aes,tires wom from excessively aggressive driving conditions such as racing and tires wom from improper maintenance such as lack of rotation,itnpioper au pressure,alignment or mechazucal weaz. •Owner Obligstionsc Proper tire caze is necessary to obtain the maximum mileage and weaz&om a tire.It is your obligation to see that your tire/wheel assemblies aze in balance and properly aligned,that your tires aze operated at vehicle manufacturer's recommended wld inflation presstue and that your vehicle is well maintained.Your tires must be inspected by us a minimum of every 6,000 to 10,000 miles.Check air pressure in each of your tires including the spaze,at least monthly when the tires aze cool.TBC Retail will check alignment,Veadwear,tire pressure and the mechanical condition of the vehicle anytime at no chazge a[any TBC Retail location. "What is not covered? i. Defects in workmanship and/or materials(covered by sepazatehew tire limi[ed wazranty). 2. Failures caused byroad hazards. 3. Tires used on special applications such as light trucks(unless specifically covered),vans,recreational vehicles or commercial vehicles including[axi,police,etc. 4. Tires with premahtre or irregulaz weaz or damage due[o itnproper inflation,misalignment of wheels,mechanical defects of vehicle or tires on vehicles where necessary vehicle repair or maintenance has not been pedormed. 5. Tires damaged by fue,wrecks,obstructions on the vehicle or willful and malicious damage. 6. Repairable punctures or tires run flat. 7. Sidewail damage from scuffing curbs or other cosmetic damage. 8. Tires tra�sfecred from the vehicle on wMch they were originally ic�s[alled. 9. Use in any commercial application. 'See Other Generai Warranty Tertns and Conditions below. Road Hazard Warrsnty •What is covered and for how long: T'his wazranty coveis all tires for which this wazranty has been purchased that has become unserviceable as a result of nonnal road hazards(i.e.cut,snag,bniise,impact breaks or urepazable punc[ures).This lunited wazranty teiminates when the covered unse�viceable tire is adjusted or when the[ire is wom to a level of 2/32nds of an inch,the minimutn tread depth required for safe vehiculaz operation. "What is not covered: Tires remwed from service due to being werloaded,intentional ebuse or tires used in other than noRnal passengervehicle service.Tires that can be safety fixed will be repaired FREE OF CHARGE.Road servite,towing costs and other incidental damages or costs are not covered. *How is replacement price determined? Normal Road Hazards,Run Flats and Worinnanshlp/Material Defects In the event a tire covered under the wazranty becomes unserviceable due to nomial road hazard(example:cuts,snags,impact breaks or non-repairable punctures),(usable tread life is the original tread depth minus 2/32nds of an inch),in the fust 12months or 12,000 miles,whichever comes fust,you will receive fiill credit of the original purchase price of the t've towazds the cost of replacement.After the FREE REPLACEMENT period of 12 months or 12,000 miles,whichever comes first,you will receive a credit for the amount of usable Vead remaining on the damaged tire based upon your original purchase price.(example:50%usable tread remainin�times the original purchase price of$50 equals a credit of$25).This credit will be deducted from the cost of the replacement tire'When the tire is wom down to 2/32nd of an inch or less,the tire is wom out and the warranty ends,regardless of the age of the tue. 'This warrsnty must be purchased for this coverage to apply. •See Other Genersl Terms and CondiUons below. Other General Warrsnty Terms and Conditions `Who gefs the warrsnty? All wazranties apply[o the original purchaser and may not be assigned to a subsequent purchaser or owner of the motor vehicle on which the tire(s)covered by our wazranties aze installed.A tire (s)mounted on any vehicle other[han the vehicle on which it was first mounted is also not covered by these wazranties. •Where to go for warranty replacement and/or service? All TBC Retail wazranties will be honored at all TBC Retail locations,including any Big O,Tire Kingdom,Metchant's or NTB store nationwide.For wa�ranty service,you must present your sales invoice and service records,along with the unserviceable tire(s).TBC Retail store locations can be obtained by calling 1-800-NEW_TII2E,or in PA or N.J.1-888-TIItES NTB or in the white pages or yellow pages under T'ue Dealers Retail.In the event you are unable to locate a TBC Re[ail store or require fiuther assistance,you may contact our CUSTOMER SERVICE OFFICE at 800-926-8473 anywhere in the Continental United States. "Consumer Righfs:' T'his wazranty�ves you specific legal rights and you may have other rights,which vary&om state to state. Some states do not allow limitation on how long an unplied wazranty]asts,so the wazranty limitations may not apply to you. 'Conditions and E:clusions: Nothing in this wazianty is intended to be a misrepresen[ation that tire failure cannot occur.To the extent permitted by law,liability for consequential damages is disclaimed.To the e�c[ent that a manufacturer's wamanty applies,such wazranty shall be primary and the T'BC Retail wazranty shall not apply to the extent of the manufacturer's wazranty. 'Owners Obligations: Proper tue caze and vehicle main[enance aze necessary to obtain maximum Ireadweaz and service from a tire.It is your obligation to properly mai�tain your tires and the vehicle,upon which they are installed,including;operating your t'ues at the vehicle manufacturer's recec�mended cold intlation pressures,insuring your tire and wheel assemblies aze in balance,tires rotated on a regulaz basis(every 6,000 miles is recommended),vehicle in proper wheel alignment and vehicle steeri�g,suspension and driveline components are well maintained.TBC Retail will check and inspect tire conditioq wheel alignment and vehicle condition at any time without chatge. .n_-'---�--`------- '