Grohovsky RECEIVED
NOTICE OF CLAIM FORM to the City of Saint Paul, MinnesotaMAR 2 0 2014
Minnesota State Staaete 466.05 states that "...every person...who claims damages from any municipaliry...shall cause to be pre.����h,C L E R K
governing body of the municip�l.ity 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 re[ief demanded."
Please complete this form in its entirety by cleariy typing or printing your answer to each question. If more space is
needed,attach additionai sheets. Please note that you will not be contaeted 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 dces 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
/� � �y
First Name,!//����L Middle Initial �y Last Name V �b(���`�/
Company or Business Name
Are You an Insurance Company? Ye /No Yes,Claim Number?
Street Address_��6� �� v� ���1 ��J�
a0��� �-�,r
City �� rt�'' State�� Zip Code f�
Daytime Phone (G s��v��Cell Phone(G C� �����EV�ing Telephone(l�) �'�� `���"'�
Date of Accident/Injury or Date Discovered Time am/pm
Please state,in detail,what occuned(happened), and why you aze 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.
!��{ .ftir �- <i�J s �i �ti��t �, c ✓ t�a � G1 rJ� �/'�e rf- /'e�.�:i�
4� _ _ /� :N e ,�' � / o L� C,v � c`�i r-e.�J vt�-�
—�2y!� �li 5:��'IP-�f 6x^--� �__ C!''�10� ,,�'!�/ �.2 a�3 /f/'�..r-/'..�f.t/ ..I"'�-rh2/',
" �i jl 4'�c _ �'-� �r/rJ�__ . � - -c �v��o -�. _ _
l�1ic %o��r��ri ��.✓ a.�r �•� r'!'-c-�•f-' -S'. o•f Q��PI'� � o� �u o .�.�.
,.
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 qf the street ❑ My vehicle was damaged by a plow
My vehicle was wrongfully towed and/ar 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 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.
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
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims—please comulete 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 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. .r'.Gl� o�
�iL,it.o,v .�n�:�'✓rc..�'v.� G,r-�-Pr��e Gj: � r�e ��,�� l.✓.�-�TP2 �
�i��
Please indicate the amount you are seeking in com ensation or what you would like the City to do to resolve this claim
to your satisfaction. ��r�(I
Vehicle Claims— lease com lete this section ❑ check box if this section does not a 1
Your Vehicle: Year � U� Make .�'.1.4�'1 Model P� 7« `j
License Plate Number �7 D/h c c State ��-Color f/v r�
Registered Owner !!?/G %�Ac-'� ��c �f���/'��
Driver of Vehicle �
Area Damaged f—r���r P,� � �/,,yi,�nP��
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
In'ur Claims— lease com lete this section ❑ check box if this section does not a 1
How were vou iniured? ,/'(7
What part(s)of your body were injured?
Have you sought medical treatment? Yes 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 E ployer: � �` ; vh 1 �� l � �'- `/n�����
Address �4 r s(/ Telephone ..lr�/—a ��' 2%
f1-T. �c� L
❑ 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
Print the Name of the Person who Completed this Form: _ ��Cl��� � �"` ��6��� Y1'�y
Signature of Person Making the Claim: %��
Revised February 2011
F FELOMANN�IMPORTS
9961 AMERICAN BLVG WEST
CUSTOMER #: 161463 587279 � BLOOMINGTON. NN 55437
952-837-6367
*INVOICE* Merchant ro: a�eie2zis
MIKE GROHOVSKY Te�� ID: 9775
84 O 1 QUINN AVE SOUTH S a 1 e
BLOOMINGTON, MN 55437 PAGE 1
HOME: 952-831-3713 CONT: 612-508-8970 MASIERCARD
BUS : CELL: 612-508-8970 SERVICE ADVISOR: 353 Ric
COLOR YEAR MAKE/MODEL VIN ,� LICENSE �XXXXXXXX�XX5�66
Entrv Method: Swiped
GRAY 13 NISSAN SENTRA 3N1AB'lAP7DL733533 170MCC Apprud; Online Batcha: 080000
DEL. DATE PROD.';�ATE WaRR. EXP. PROMISED' PO NO. RATE ''.
O1JAN13 z 03i15i14 10.36;11
O1JAN13 D WAIT 15MAR14
R.O. OPENED >' READY ' OPTIONS: DLR:2117 ENG: 1. 8 Liter Inv�: 095872Z9 Rppr Code: 03Z66P
08 : 19 15MAR14 10 : 22 15MAR14 iotal; � 110,90
LINE OPCODE TECH TYPE HOURS LIS'I
A' 4-WHEEF�' ALIGNMEN�'' SET-:UP AND ADJUSTMENT AS NECESSARY. r CoPv
CAUSE: REGULAR MAINTENANCE
___ _ _
ALIGN 4�WHEEL ALZGNMENT< SET-UP AND ADJUSTMENT<AS
_ _ _ _ ___ _ __ _ _
NECESSARY.
_ _ _ _. __ __ _ _ _ __ .._ _. _ _ _
703'2 C'PN ' 99: 95 99 . 95
PARTS : 0 . 00 LABOR: 99 . 95 OTHER: 0 . 00 TOTAL LINE A: 99 . 95
COMPLETED'' 4-WHEEL :ALIGNMENT.
****************************************************
_ _ _
B CUSTOMER STATES MAKE SURE RIMS ARE OK HIT A HOLE IN ROAD
39 TIRES AND WHEELS
703'2 CPN , 0 . 00 0 . 00
PARTS : 0 . 00 LABOR: 0 . 00 O'THER-: 0 . 00 TOTAL LINE B: 0 . 00
„ . „
DURING MPI; FOiJND NO RIMS TO BE BENT.�/Nb LOO5E�;.:3U8;PENST:ON
COMPONENTS.
****�*;t****,�*,�*:***,x�ei��;*�r.*�#*.,t;,,r*��:�t�r,r�a�:'�*********�***
;; .. ., , ,..�. . ..;..
�.
C PERFORM MULTI POINT VEHICLE INS,PECTION .
MPI PERFORM MULTI PC7INT' U�H����.�Ti��PE��Ok�T .. ...._ ...: <
7032 CPN 0 . 00 0 . 00
PARTS: _- 0 . 0 0 LABOR; '' 0 . (�(� . .OTH�R:' '" 0.Q>0 ' TOTAL LINE C: 0 . 0 0
COMPLETE.
****************�****�r*�r:i�*,*******:w**�****,r**********
: ,. ,. .. ,
D GREEN TIRE TREAD DEPTH - 6/32 TO 12/32 - GOOD TIRES ,
�AL1SE: TIRE TR.EAD D��TH :i:INSPECTION
_ _ __ ___:_ _ _,, <
GT GREEN TIRE TREAD DEPTH - 6/32 TO 12/32 - GOOD
TIRES'
_ 7032 CPN _ _ 0 . 00 0 . 00
PP,RTS: 0 . 00 LABOR:' 0;00 OTHER: 0 . 00 TOTAL LINE D: 0 . 00
GREEN.
***************************,*************************
__ _ _ _
DISCLAIMER OF WARRANTIES QES�RIi'TfON TOTALS
THE ONLV WARRANTIES APPLYING TO TH�S PART(5)ARE THOSE WHICH MAV BE OFFERED BY THE MANUFACTURER.THE SELLING DEAIER HEPEBV -������� � �
EXPRESSIV DiSCLA1MS ALL WARRANTIES,EITHER EXPRESS OR iMPLIED,iNCLI.�JING ANV IMPLIED WARRANTIES OF MERCHANTABIIITY OF FITNESS FOR LABOH AMOUNT
A PARTICULAR PURPOSE,ANO NEITHER ASSUMES NOP AUTHORIZES ANV OTHER PERSON TO ASSUME FOR IT ANV IIABILITV IN CONNECTION WITH THE �
SALE OF THIS PARTIS)AND/OR SERVICE.BUVER SHALL NOT BE ENTITLED TO RECOVER FROM THE SELLING DEALER ANV CONSEOUENTIAL DAMAGES, PARTS AMOUNT
DAMAGES TO PNOPERTV,DAMAGES FOP LOSS OF USE,1055 OF TIME,LOSS OF PROFIT,OR INCOME OR ANV OTHER INCIDENTAL DAMAGES.
Any wartanties on the p�oEUC[s aold hereby are those of the manufacturcr.As batween this rotail seller snd buye�.the product is to be soid'AS IS'and the GA$,���, LUBE
entire risk�s to Ihe puality and peRormance of the product is with the buyer.The setler exprculy tlisclaima all warronties,tither express or implied,inctuEing
any implied warnnty of inerchan[ability or titneas for a O�rticular purpose,and tha seller neither assumes nor authorizes any other person to aasume for it any SUBLET AMOUNT
liability in connecNo�with the sa4 of said Oroduct3.Thif Cisclaimer by this se��er in no way affects the items o�the manu�acturer's wa�ranty.Th�buye�
acknow�adges being ao intormed o��or ro sab. MISC.CHAf�CiE$
Feldmenn Nissen ia a regiatered tredemerk of Feldmenn Impord,Inc. TOTAI CHARGES
X LESS INSURANCE
LAST INVOICE�/DATE: CLAIMS FOR WORK PERFORMED ALL PARTS NEW ORIGINA(. SALES TAX
SHOP SALES MUST BE MADE WITHIN 90 DAYS OR EQUIPMENT UNLESS
4,000 MILES WHICHEVER COMES OTHERWISE SPECIFIED P�EASE PAY
FIRST FROM DATE OF WORK. THIS AMOUNT
THANK-YOU
�.,._.....��.�P�.. �.o�eoiwvnicFTVrea.srzc f'TTCTr1MF'1� I�I1DV