Smith, Tera RECEIVED
MAR 2 6 2014
NOTICE OF CLAIM FORM to the City of Saint Pau1, 1��r�sQ��E�K
Minnesota State Statute 466.05 states that"...every person...who claims damages from any municipaliry...shall cause to be presented ta 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 Tera Middle Initial � Last Name Smith
Company or Business Name N/A
Are You an Insurance Company? Yes C'�� If Yes,Claim Number? N/A
Street Address 6781 15th Street Court North
City Oakdale State MN Zip Code 55128
Daytime Phone(651 )241 _9875 Cell Phone(651 �253 _ 1529 Evening Telephone(651 )253 -1529
Date of Accident/Injury or Date Discovered 03117/14 Time 6:10 am a� /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 Paul or its em lo ees are involved and/or res onsible for our dama es.
he stretch of North Lexington Parkway roadway between University Ave W and Energy Park Drive is in hazardous condition due to lack of road
maintenance.Numerous potholes can be describe better as trenches or canyons,with some measuring over 6 feet in length,over 1 foot in width
nd 4-6 inches in depth.In addition to the previously described pothole,there are dozens of others with dimensions of several feet and creating a
oid of 5+square feet.Compounding the issue of maintenance,there was no warning of these conditions to assist in avoidance. Such warning
ou�d be signs,cones,directing traffic around major hazards,or something that would provide advance warning to drivers. My new car was
everely damaged on 3/17/14 during my commute to work at Allina on Energy Park Drive. I struck a pothole that immediately ruptured the new tire,
amaged the wheel and alignment. The lack of maintenance and/or proper advance warning to avoid damage is why this claim has been filed.
Not only is the above situation a hazard to vehicles,but more importantly it creates hazards to the driver,other drivers and pedestrians as an
ccident may be caused by a damaged vehicle or an attempted maneuver to avoid these conditions. (see attached photos)
Piease 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
18J 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 you need to include eopies of all auplicable 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 WII,L 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—ulease complete this section
Were there witnesses to the incident? Yes No Unknown (circle)
Provide their names,addresses and telephone numbers: Unknown if witnesses at time of accident however coworkers are aware of
ama e u on m arrival at Allina Bandana S uare .
Were the police or law enforcement called? Yes No � Unknown (circle)
If yes,what department or agency? N/A Case#or report# N/A
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 ossible. If necessar attach a dia ram.
Pothole that caused damage was on northbound N Lexington Pkwy,between Blair Ave and Van Buren Ave.
see attached hotos
Please indicate the amount ou are seekin in com ensation or what ou would like the Cit to do to resolve this claim
to your satisfaction. eeking$300 compensation,although my repair biils may exceed$800.(Also requesting city repair N
Lexington Pkwy).This is a lease vehicie where damaged wheel may mandate replacement(OEM wheel
353.48 but it"may"be possible to repair for$100,replaced 2 tires at$400.38-see receipt,alignment$75).
Vehicle Claims—please complete this section ❑ check box if this section does not applv
Your Vehicle: Year 2013 M�e Kia Model Optima SXL
License Plate Number 301 MJX State MN Color White
Registered Owner Derrick Smith
Driver of Vehicle Tera Smith
Area Damaged Front Passenger Tire Wheel and front alignment
City Vehicle: Year N/A Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniurv Claims please complete this section � check box if this section does not avplv
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 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 3/21/14
Print the Name of the Person who Completed this Form: Tera Smith
Signature of Person Making the Claim: ����� c�'�-���'�—
Revised February 2011
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DDB T�1 R E PAGE 1 OF � 76555`1
discounttire.com
DATE: 03-17—�Q�14 TIME: 9:07 AM
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DERRICK S�1ITH ��+13 KIA �fz�-�,�kl M�7��WHITE PEAR AUENUE N
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19°BA5E SXL� ���� MAF'LEWOOD M1V 5�iQ��.
5AINT F'AUL MN 551�8 MILEAGE: 44, 17C F�HONE; 651-773—�0�67
(H? 763-258-6701 � PLATE # 301 MJX st� 09� TERRENCE N PDYD �
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WRRRANTY: MILEAGE— 55,Q�00 SEE REVER5E BIDE FOR WARRAN7Y DETAILS
CD�IMENT: ADLT RATi'ERIV: 5—i14.3
CDMINENT: INFLATIOIV F:36 R:36
80Q�17 NRM .�. CERTIFIGATES FQR REFUND,RE�'LRCEMENT .0Q� 2�:Q�Q� 44.0Q�
BQ���4 NRM 1 WASTE TIRE DISF'OSAL FEE � .�+� �•�� �•��
80�19 NRM � INSTALLRTION & LIFETIME 8�'TN PALANCING .OQ� 16.@Q� 32.00
86666 IVRM � LIFETIME RDTATION LI�ETIME RERAIRS INCLUDED .Q�O .@0 .00
8659� NRM 8 #7020K TQ-7@ PWE T�'MS REPUILD KIT .00 •�� •�� f
CDMMENT: t^eplace 1 in tr��nk/and other rear....return t�ke—off on the vehicl�... �
Since you have p�trch�sed fewer than faur tires (or wheels), we will mottnt the new tires on the
rear of your vehicle for best s�fety and handling. �
Michelin Fl�t Tire Assistance — 1-888-553-43�7 ,
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DATE: 03-17—�Q�14 TIMEs 9:Q�7 t�M
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6781 i�TH ST GRT NDRTH ORTTMR �57Q� WHITE BEf�R AVENUE N �
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9AINT F'AUL MN JJ1�B MILEAGE: 44,�7� PHOfVE: 651-773—�0fi7 �
tH) 763—��B—€,7�A1 � RLATE # 301 MJX f�93 TERRENCE N POYD �
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TQRQUE SF'EG5: �180 WDRK ORDER# `
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Rromation Type: DEFERREDINU INT IF RD IN FULL �
Pramotion Reriad: Q��i MONTHS �
F'romotinn�l ARR: 8fi.39% �
�urchase APR: 2fi.99X
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No In�erest Ch�rges will be 2t56E5S2CI if the promatianal p�mchase bal�nre is paid in full within �
the Pramational F�eriod stated above. If the prnmotianal pi�rchase balan�e is not p�id in f!iil by �
the efld of the Promntional Periad, interest wi11 be imposed from the date af purch�se at the �
Rurrh�se Annual Rercent�ge R�te tflPR> stated abnve. Minimum monthly payments are req��i�^ed. �
Reg�tlar account terms apply to non—promotional purchases and, after promotion ends, to �
pramotional pt�rchase. !
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For any questions regarding yo��r account contact GE Capital at 865.396.8`54. j
Rayments ran be made online for free at www.gogecapit�l.com ar remit p�yment directly to ;
GE Capitai, F'.0. Pox 960061, Orlando, FL 3�8'36—Q�061. �
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