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RECEIVED MAR 2 4 2014 NOTICE OF CLAIM FORM to the City of Saint Paul, Mi�r��aLERK Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipaliry...shall cause to be presented to the governing body of the municipaliry within 180 days after the alleged loss or injury is discovered a notice stating the time,place,and circumstances thereof,and the amount of compensation or other 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 ntt�l iddle Initial L. Last Name�.+�n,9�c./ , � i Company or Business Name Are You an Insurance Company? Yes� If Yes,Claim Number? Street Address�y � ��..�.r4Nd� ������'%= City ��-. �r4-�r State�� Zip Code %/ Daytime Phone(�),�-py65_ Cell Phone�)�-C�bS_ Evening Telephone( 5( ),��4y6S� Date of Accidend Injury or Date Discovered ��-�F�-�O�`t Time ' `/S- /pm Please state,in detail, what occuned(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/or responsible for your damages. = t+.,as ��¢.i�•:�•:9 it ,le.v� .:.� 2 � - o r- /F . ��T fGr� �na�.� o�' f�:,��� ;.,�3.�r��� - �r ��� �� v -!�/� Crt� �'�t r� ���r1 v� •,e Gtt .i�-�e ,� f�c c.r� �to�c� �-t, ,.,_,- T !►�n /.�'f.�•,�,�. �k.e s�'-,2�-i�,,.,•� /�,�X J'a-r�TS �.-� �.9�✓Z[T�BR L�3-1�l3_ �1,c li�r+`l� �,��1 I N����� f� �,� �e o..�,►_c.���,.�,> �9!7,y�:'� Please check the box(es)that most closely represent the reason for completing this form: �❑ y 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 City property ❑ Other type of property damage-please specify ❑ Other type of injury-please specify In order to process your claim vou need to include copies of all anulicable 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 aze encouraged to keep a copy for y urself before submitting your claim form. ,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 Failure to complete and return both pages will result in delay in the handling of your claim. All Claims—nlease comulete this section Were there witnesses to the incident? Yes No Unknow (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. �lease be as detailed as possible. If necessary,attach a diagram. Co�2r�Fi� G�f f�4il¢-✓�e..� � Q�-ti-�-��t�7 Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim to your satisfaction. .L,o-�n s c�i-czz�` �/.S�q.��,r�C o�,�c,�,4.�,-Fn,v �..� �e �;�y �� 2E'S��vc `J-his C Id��.•+� `� �ti �.9-rLsF�ac�2vXr. Vehicle Claims— lease com lete this section ❑ check box if this section does not a 1 Your Vehicle: Year f��Make W Model ��}£3 i L- License Plate Number 4l 3 �L� State M� Color�t�9-c!� Registered Owner o++ L..4�.�' w � Driver of Vehicle �� , �o2d.�1-s� Area Damaged /�/���-r�'' /=�� (�O�t PG'�/k Xt��tS City Vehicle: Year Make Model License Plate Number State Color Driver of Vehicle(City Employee's Name) Area Damaged Iniurv Claims—alease comulete this section �check box if this section does not apvlv How were you injured? 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 fornz,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 �T��-/���'9'�� ��L/ Print the Name of the Person who Completed t 's rm: `�a ` A�..?�riG� ,P��4,� Signature of Person Making the Claim: Revised February 2011 Additional Detailed Information On Monday, 17-Mar-2014 @ 05:35 AM, I was traveling North bound on Fairview Avenue. As I approached the intersection of Fairview Avenue and Portland, both my front tires entered the two potholes (*Shown in Photo 1). Please notice that I have measured the depth of these two potholes (*as detailed in Photo 5) and that both of these potholes are approximately 5.5 inches in depth. Please also notice that I have measured the size of these two potholes (*Shown in Photo 1 and Photo 4). The size of the pothole in Photo 1 is about 2 feet round and the size of the pothole in Photo 4 is about 2.5 feet round. Again, each of these potholes are approximately 5.5 inches in depth. As mentioned, I was traveling North bound on Fairview Avenue at the posted speed and because of the time of day (05:35 AM), I was unable to avoid these two potholes. Additionally, because of the position of these two potholes (*as detailed in Photo 3�, both my front tires entered these potholes within a nanosecond of each other thus causing the damage to the front end of my 1996 BMW 740iL (first my passenger side then the drivers side). Immediately after hitting these two potholes my steering system on my BMW740iL was compromised. I have had my vehicle inspected at three (3)Automotive Service Facilities for damage to the steering and have been informed of the following: 1. Both Front Lower Control Arms need to be replaced —the reason stated by all Service Repair Shops is that the sudden violent force impact caused by the potholes have destroyed the bushings in both Front Lower Control Arms. 2. Left Front Forward Control Arm Ball Joint (all one unit) needs to be replaced—the reason stated by all Service Repair Shops is that the sudden violent force impact caused by the potholes has destroyed the Ball Joint in the Front Forward Control Arm. 3. Both Front Sway Bar Link Kits need to be replaced—the reason stated by all Service Repair Shops is that the sudden violent force impact caused by the potholes has destroyed both Front Sway Bar Links. 4. Both Front Strut Assemblies and Both Front Strut Mounts need to be replaced —the reason stated by all Service Repair Shops is that the sudden violent force impact caused by the potholes has destroyed both Front Strut Assemblies and Front Strut Mounts. 5. All Service Repair Shops stated that the vehicle would need to have a wheel alignment. As required by the "NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota" (see attached), I have included "two estimates for the repairs to my vehicle if the damage exceeds $500.00; or the actual bills/and or receipts for the repairs" (I actually submitted three (3) estimates- see attached estimates): Estimates: • Mendota Heights BP Service estimate total is for$2351.87 • Parkway Auto Care estimate total is for$1529.25 • Midas Auto Service Center estimate total is for$955.09 I am requesting the City of Saint Paul, Minnesota to reimburse me a total of$1529.25 for damages/repairs caused to my 1996 BMW 740iL due to improperly maintained motorways �potho s �I —��r�— o1U/ � hank you, John L.Jordan 1843 Eleanor Avenue St. Paul, MN 55116 651-343-0465 Mobile *As of 21-Ap-2014, these potholes are still in existence on Fairview Avenue an .. ` ,I ' �. � � ' . • . _ \ , ' .'Y 1 .A ,` `�}. 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"` ` °►�;..:• . : . : �y � . ,4,,,�� � 4 + � . . .` �.�. '`'�hw�., . . ••� '�,'� !: �� � ,`. � ..a. • , ' ,4��,y1 - * ' .� '.l' ,� 5.a. � ., . ._! '� . . � : .rM� ♦�.. ..� � +-.. ., � .. .,Y�'` . . `._6� ��� 4�,1,�ti�;. # � ♦ � „ . `' . c j e �` . �r _. '. 5M` �.� �.. �� �. . 4� � `�.�t. . . �`v .,, ,� .�. — ; ,4�, .� t >'i _ , . . . � - � �- � '"`+, �. �- . n . 'n-=.` e�. �-��z s .,r�� . �4��� ' ��� `,. . .». w , . � � . �•�f� � . ' . n . , ' f '_ ., i . ': �. �.. .s :2 ��t. �. � .. - tr . x'x .... .{ ,. ..� \ Mendota Heights BP Service Sub Estimate For Order# 2030 Dodd Rd Saint Paul, MN. 55120 094669 Phone-651-454-5622 Fax- ESTIMATE FOR SERVICES Cust ID: 202230 Estimate Date : 3/20/2014 Jordan,John 1997 BMW-740iL-4.4L,V8 (268C1) 1843 Eleanor Ave Lic#: - MN Odometer In: 0 Saint Paul, MN 55116 Unit# : Home 651-343-0465 VIN#: WBAGJ8323VDM02826 _ _��� � _ _ s t. �:.: � FRONT STRUT ASSEMBLY P FR N U 8 .36 � 16 2.00 334.17 668.34 Wheel Alignment 8g.g5 STRUT MOUNT Road test vehicle. Check all suspension and steering parts for wear. 16W 2.00 59.95 119.90 Check tire pressure and condition. Check riding height. Check Shop Supplies 38.73 alignment Adjust caster,camber,toe-in,and thrust angle as needed Haz Mat g.7g Rev Amnt: 1,364.20 Parts: 826.97 Labor: 483.07 Tax: 56.16 Total: $ 1,366.20 TEARDOWN ESTIMATE: I understand that my vehicle will be reassembled within days of the date shown above if I choose not to authorize the service recommended.All Parts removed will be discarded unless instructed otherwise: Save all Parts . NOT RESPONSIBLE FOR LOSS OR DAMAGE TO CARS OR ARTICLES LEFT IN CARS IN CASE OF FIRE,THEFT OR ANY OTHER CAUSE. Signature Date Time H,Sean Page 1 of 1 Copyright(c)2014 Mitchell Repair Information Company,LLC esthrs 09.12.1 NKYK Mendota Heights BP Service Sub Estimate For Order# 2030 Dodd Rd Saint Paul, MN. 55120 094669 Phone-651-454-5622 Fax- ESTIMATE FOR SERVICES Cust ID: 202230 Estimate Date : 3/20/2014 Jordan,John 1997 BMW-740iL-4.4L,V8 (268C1) 1843 Eleanor Ave Lic# : - MN Odometer In: 0 Saint Paul, MN 55116 Unit# : Home 651-343-0465 VIN# : WBAGJ8323VDM02826 ,,,,, ,,,,,, .E�� ,.i ';.. �3"� . .' �" � ;€�f�,.3� .,,.,°Y�� .� . ..,,,, ..... ,.., ` � "" .. :,,�. ...,,.. � �i...,u.,,,.. .,.,��i „ ��:.:" ,.� �. ,��„/,��. � ,,,,>>.,,.;:�, �fi.�?. �'� il. �.w,,,� ��,. FRONT LOWER CONTROL ARM - emove ep ace- 203.66 16W 2.00 129.95 259.90 Lower,Front,Both Sides-[DOES NOT include LEFT FRONT FORWARD CONTROL ARM alignment.] REPLACE FORWARD CONTROL ARM WITH 95.84 16W 1.00 129.95 129.95 REAR OUT FRONT SWAY BAR LINK KIT Wheel Alignment 89.95 16W 2.00 43.95 87.90 Road test vehicle. Check all suspension and steering parts for wear. Shop Supplies 38.73 Check tire pressure and condition. Check riding height. Check alignment Adjust caster, camber,toe-in,and thrust angle as needed REPLACE FRONT SWAY BAR LINKS WITH 35.94 CONTROL ARMS APART Haz Mat 9.76 Rev Amnt: 983.67 Parts: 516.48 Labor: 435.15 Tax: 34.04 Total: $ 985.67 TEARDOWN ESTIMATE: I understand that my vehicle will be reassembled within days of the date shown above if I choose not to authorize the service recommended.All Parts removed will be discarded unless instructed otherwise: Save all Parts . NOT RESPONSIBLE FOR LOSS OR DAMAGE TO CARS OR ARTICLES LEFT IN CARS IN CASE OF FIRE,THEFT OR ANY OTHER CAUSE. Signature Date Time H,Sean Page 1 of 1 Copyright(c)2014 Mitchell Repair Information Company,LLC esthrs 09.12.1 ttKYK �,,,, ` � Parkway Auto Care ���t � ��� ��� � 1581 Ford Parkway PAGE � Saint PauI,MN 55116 (651)698-3208 Create Date: 03/21/14 14:26:28 Customer ID: 1581041248 Year: 96 Date/Time: 03/21/14 00:00:00 Name: JOHN JORDAN Make: BMW Workorder#: 98412 Address: 1843 ELEANOR Model': 7401L Invoice#: Address 2: Lic No: X City,State,Zip Code: SAINT PAUL,MN,55116 VIN: WBAGJ8323VDM02826 Email Address: Home Phone: (651)343-0465 Color: PO Number: Work Phone: ()- Engine: V8-ci 4.4L FI FIeeUWholesale: N Other Phone: ()- Mileage In: 0 Tax Exempt#: Mileage Out: 0 Service comments: Qty Part# RFR Loc Description Parts Labor Total FRONT WHEEL ALIGNMENT 1 @FWA FRONT WHEELALIGNMENT 0.00 0.00 0.00 1 ALL LABOR 0.00 69.95 69.95 FRONT WHEEL THRUST ANGLE ALIGNMENT TOTAL FRONT WHEEL ALIGNMENT: 69.95 HAZMAT DISPOSAL 1 HAZMAT HAZARDOUS MATERIALS 2.50 0.00 2.50 TOTAL HAZMAT DISPOSAL: 2.50 OTHER PARTSISERVICES 1 '31121142087 L.F. LOWER CONTROLARM 140.10 120.00 260.10 2 "31351095695 SWAY BAR LINK(FRONT) 77.41 0.00 154.82 2 '335906-7 FRONT STRUTASSEMBLY 282.70 186.00 937.40 TOTAL OTHER PARTS/SERVICES: 1,352.32 "'•Customer Wishes To Discard Old Parts "** I HEREBY AUTHORIZE THE WORK TO BE DONE AS DESCRIBED ABOVE. I AGREE TO PAY ON DELIVERY OF THE VEHICLE, AND UNTIL PAID IN FULL YOU SHALL HAVE A LIEN ON THE VEHiCLE FOR THE AMOUNT OWING. I FURTHER AGREE THAT YOU WILL NOT BE HELD RESPONSIBLE FOR THE VEHICLE OR ARTICLES LEFT IN THE VEHICLE IN CASE OF FIRE,THEFTACCIDENTS OR OTHER CAUSES BEYOND YOUR CONTROL. MY VEHICLE MAY BE DRIVEN BY YOUR EMPLOYEES FOR ROAD TEST AT MY RISK I AUTHORIZE SERVICE TO BE PERFORMED INCLUDING SUBLET WORK. I HAVE READ AND UNDERSTAND THE ABOVE TERMS. SIGNATURE DATE ShopSupplies 38•8$ TECH: PARTS TOTAL 862.82 SALES TAX 65.60 LABOR TOTAL 561.95 GRAND TOTAL 1,529.25 THIS IS A PHONE QUOTE WORKORDER MIDAS AUTO SERVICE CENTER 1697 WEST SEVENTH STREET PAGE 1 . � � ��� `���� SAINT PAUL,MN 55116 � � � � �� �� '"' ��� �'��.� (651)699-0220 � F�.p � �; ��� � � � �� ��� � � � �J�{�� Customer ID: 2378014594 Year: 97 DateTme: 03/21/14 14:01:58 Name: JOHN JORDAN Make: BMW Estimate#: 103689 Address: 1843 ELENORE AVE Model: 740 Series Invoice#: Address 2: Lic No: 413BLH Key Tag: City,State,Zip/Postal Code: SAINT PAUL,MN,55116 VIN:WBAGJ8323VDM02826 PO Number: Home Phone: (651)690-9396 Color: Email Address: jlmj_55116@yahoo.com Work Phone: (651)343-0465 Engine: V8-4398 4.4L DO FIeeUWholesale: N Other Phone: ()- Mileage In: 81912 Unit Number: Tax Exempt#: Mileage Out: 81912 Service comments: Qty Part# RFR Loc Description List Labor Total *WORKAUTHORIZATION' This Estimate of Repairs is based upon our SHOCKS&STRUTS ' inspection at this time and does not cover 1 71526 RA " RF PASSENGER STRUT 200.99 169.73 370.72 additional parts and/or labor which may be RIGHT required after the work has been started. After Except Electronic Suspension;w/Chassis#E38 the work has been started,worn or damaged parts 1 71527 RA ' LF PASSENGER STRUT 200.99 169.73 370.72 Which are not evident on first inspection may be LEFT discovered. This Estimate of Repairs cannot cover Except Electronic Suspension;w/Chassis#E38 such contingencies. In cases where additional TOTAL SHOCKS&STRUTS: 741.44 work is deemed necessary,customer authorization TOTAL WITHOUT SUGGESTED: 741.44 will be secured prior to commencement of that additional work. This Estimate of Repairs expires SUSPENSION 15 days from date. 1 2652215 RA * RF SWAY BAR LINK 89.99 65.70 155.69 This shop is not responsible for unavailablility FRONT SUSP of parts or delays in parts shipments beyond its TOTAL SUSPENSION: 155.69 control nor for loss or damamge to vehicle or to TOTAL WITHOUT SUGGESTED: 155.69 articles left in vehicle in case of fire,theft, or any other cause beyond our control. I hereby authorize the repairs shown on this *"*Customer Wishes To Discard Old Parts""* estimate to be done along with the necessary material and hereby grant you and/or your employees permission to operate the vehic�e herein RA PART NO LONGER PERFORMS INTENDED PURPOSE described in streets,highways,or elsewhere for the purpose of testing and/or inspection. An express mechanics lien is hereby granted on above vehicle to secure the amount of repairs thereto. I also acknowledge receipt of a copy of this work authorization and estimate of repairs. I Do Do Not request the return of parts replaced,excluding warranty and exchange parts. X SHOPSUPPLIES 19.00 TECH:000667 J. ROBERTSON PARTS TOTAL 491.97 SALES TAX 38.96 LABOR TOTAL 405.16 GRAND TOTAL 955.09 THIS IS AN ESTIMATE, NOT AN INVOICE! DO NOT MAKE ANY PAYMENTS FROM THIS PAPERWORK!