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Weimer . - � j�l.�S �! � �c ��( —�� RECEI�ED NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota MAR 2� 2�i4 Minnesota State Statute 466.05 states that " ...every person...who claims damages from any municipality...sha[1 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,��r C L E R K 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 �`vr 1 Middle Initial Last Name `I�r�� Company or Business Name ,r'�'; Are You an Insurance Company? Yes/ �T ` If Yes,Claim Number? Street Address ' '�' t', {� • ��V � City N � i � � U i'1� .I State I� Zip Code �� J Daytime Phone(� J �-�Cell Phone(_� - Evening Telephone L� - Date of Accident/Injury or Date Discovered�l�I j� Time �V �`� am pm 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 P�ul or its employees are involved and/or res onsible or yout� amages. � C. bU�'1-�-`� `> � � . � S � _ 4'1 t,6' � w'1 1 'ik%C S ` � � �2 V�� l� � ' r_ - °�- � V `�I G� i 1 r C ,� �/"� > ��✓G�� J�I- �I��7'� ��3 t '�V ;l� �' C.�l L� �l1 � L��r v�'l S �� Please check the box(es)that most closely represent the reason for completing this form: �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 O Other type of property damage—please specify ❑ Other type of injury—please specify In order to process your claim you 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. � 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 ar�d 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—please comnlete this section �� Were there witnesses to the incident? Yes No �g�n (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 diagam. C��a �i��'1 ��1� �it�� ' � ;::��n t' �i�l Please indicate the amount yo�.are seeking in compensation or what you would like the City to do to resolve this claim to your satisfaction. �;�C�� Vehicle Claims— lease com lete this section ❑ check box if this section does not a 1 Your Vehicle: Year, ��,i�Make �-L -�. Model 1��;� License Plate Number State�Colar �j�.i c� Registered Owner �, � �' Driver of Vehicle � ' � �I � � ' N�t � GL✓ Area Damaged Y11('r��"d �Y City Vehicle: Year . ��I I Make Model �� License Plate Number��_ State Color ' � Driver of Vehicle(City Employee's Name)�� ( PWS Area Damaged�;�=��-�-t� 51� �'t�+rr�fi�' � ��.��L'�I r I��,�.i��Y , ,.� Iniury Claims—please complete this se tion ❑ check box if this section does not applv 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 �heck here if you are attaching more pages to tlus claim form. Number of addiNonal pages � . By signing this form,you are stating that all informadon 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 Print the Name of the Person who Completed this Form: �'l�`h " ��r�+1��✓ Signature of Person Making the Claim: ��✓` • �iV� Revised February 2011 � �LET - • •. • - • 2/10/14 6070826/ r1AU•K �HEUROLET � - � �.dSS HIGNWpV 11F� SERVICEDEPARTMENTHOURS IIIUER GROVE H- �9P� 550 7:o0a.m.to6:00p.m. 2�11�14 Pr'e-InvoiC Monday-Friday iERI'IINBI IU. � �3�1422'lB 8:0o a.m.-�2:0o p.m.Saturday 49094 49094 PIERCHAIiI q; 3?b241�04996 �I�p Bryan Stumpf/7880 - . . . ��#��3957 612-3 6 3-2 5 91 1GNS KBE OXBR3 0 4 2 0 7 SALE BAiCN: 0a�814 IiIVOIGE 06411uE44� �g - • � � DA1E� feU 11� 14 1II�IE� 11�59 612-457-2713 SE�� U�03 �,UiH�Q11939 TAHOE •• 4WD 4DR 1500 LT BEIGE 1'OTAL ��9�-�� UANIEL L b1EI'�� _J�iOPIER COP4 ' �� CUSTOMER HAS MIRROR ORDERED FOR THE DRIVERS SIDE WOULD LIKE TO HAVE INSTALLED. Caused by MIRROR BROKEN/DAMAGED Work performed by Curtis Weaver (CW ) 81.60 Work performed by LAME001 : 702195 66 .44 Installed 20843177 :N-MIRROR (16068-CT) 1@156 . 10 156 . 10 REPLACE DRIVER S SIDE MIRROR Sub Total : 304 . 14 81 . 60 TERMS:STRICTLY CASH UNLESS ARRANGEMENTS ARE MADE. "I hereby authorize the repair LABOR 15 6 . 1� work hereinafter to be done along with the necessary material and agree that you are not respon5- pARTS ible for loss or damage to vehicle or articles left in the vehicle in case of fire,theft,or any other . O O cause beyond your conVOl or for any delays caused by unavailability of parts or delays in parts DEDUCTIBLE shipments by the supplier or transporter. I hereby grant you or your employees pertnission to 66 .44 operate the vehicle herein described on streets,highways,or elsewhere for the purpose of testing SUBLET . 0 0 and/or inspection. An express mechanic's lien is hereby acknowledged on above vehicle to secure SHOP SUPPLIES the amount of repairs thereto' . Q Q HAZARDOUS MATERIALS DISCLAIMER OF WARRANTIES. Any warranties on the products sold hereby are those made by 1 rj . $6 the manufacturer.The seller hereby expressly disclaims all warranties either express or implied,includ SALES TAX OR TAX I.D. . 0 p ing any implied warranty of inerchantability or fitness for a particular purpose,and the seller neither SPECIAL ORDER DEPOSIT assumes nor authorizes any other person to assume for it any liability in connection with the sale of . �O said products. Any limitation contained herein dces not apply where prohibited by law. DISCOUNTS TOTAL DUE 3 2 O . O O �7 --� S.C;�� C��j. � '`�` ----_ � %�`,j^,c� . - . .- .- .-. X