Oliveira F�ECEI�ED
P�t�R �5 2�14
NOTICE OF CLAIM FORM to the City of Saint Paul, Min,�t���L�RK
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 I80 days after the a[leged loss or injury is discovered a notice staring 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 prceess 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 �.f t�� Middle Initial M Last Name ��t V e 1 rG�.
Company or Business Name
Are You an Insurance Company? Yes/� If Yes,Claim Number?
Street Address �g� 3 N O`�`'�VI �U�'• N `
City tA�2 S�' �w2�CtilL'�. �(ZW i�15�'1��ITD State � � Zip Code �S�Z
Daytime Phone(��'� ) �73_ 21��Ce11 Phone(�DS1 ) 50 3•�� ��Evening Telephone(�)� ?��' �3 L�°
Date of Accident/Injury or Date Discovered ������� Time ���n arr►��
Please state,in detail,what occurred(happened),and why you are submitting a claim. Please indicate why or how you
feel the City of aint Pa 1 or its e loyees aze involved and/or res nsible for your damages. t (,t S d.V�i
" ���UC7i.Q.1� OV1 �` ��Lt �' i/ � Gt.� � e2 i '
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vlad �� r�pa;t�eQ, a��- Cov�-w�a+�'1�, lo� � V►�-X� �.--F�t�el�-�t oo v� ,
Please c eck the bo�d(es)t at most closely represent the reason or co plenng this form:
� My vehicle was damaged in an accident 0 My vehicle was damaged during a tow
,� My vehicle was damaged by a pothole or condition of the street 0 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 conies of all apnlicable dceuments.
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 ourself before submitting your claim form. i
� 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
� Towing claims:legible copies of any ricket issued and a copy of the impound lot receipt
� 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
� Injury claims: medical bills,receipts
� 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 comnlete this section
Were there witnesses to the incident? Yes No Unlrnown (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,intersecrion,name of park or facility,
closest landmark,etc. P ease be as detailed as possible. If necessary,attach a diagr . � �/' � e
2, tC'J � eS � �' � S t1-i/��
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.�3 ' 7 0 'uS CVI� '�y 2' �S e� i,lb �"
( I/� i n —�'�4, e� l ' v� —� a. �i ut se oC. �.
C��a�ns b�'�n� pr�c.� t�l.ow`r� �or �e-v�v�c��- clnav►8e., $311.1g c,�ex'e my�o ou. v�
Vehicle Claims— lease co�n lete this section
check box if this secrion does not a 1 P�hO��i
Your Vehicle: Year 2�C��.% Ma1�e "� - a- Model � C�S�S-
License Plate Number ���� VI�IL' 1�_..__ State 1/11�Color (-s V�e�
Registered Owner J i 11 VII�_ (�1 i��
Driver of Vehicle ��i I 1 YVl. �I i `�P-�Y[�
Area Damaged �!e a�- sh�e�d s r�✓►�- 0.l l a in W1�-�/�'��
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
In'u Claims— lease com lete this section
tl�check box if this section does not a 1
How were you injured?
What part(s)of your body were injured?
Have you sought medical treatment? Yes No Planning to Seek Treatment(circle)
(provide date(s))
When did you receive treatment?
Name of Medical Provider(s): Telephone
Address � YeS No
Did you miss work as a result of your injury. (provide date(s))
When did you miss work?
Name of your Employer: Telephone
Address
�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 in formation you have provided is true and correet to the best
o f your knowledge. Unsigned forms will not be processed.
3�7� i `�
Submitting a false claim can result in prosecution. Date form was completed `
Print the Name of the Person who Completed this Form:
J � �� iM �� �v�ira
Signature of Person Making the Claim: � `
Revised February 2011
x BUERKLE HONDA
•CUS'I'OMER #: CH42986 479965 3360 Hwy 61
u�rz'r# 20322 SERVICE (651) 490-6699
CHAI�LIE OLIVEIR.A *INVOICE* SALES (651) 490-6600
JIL]"� MARIE OLIVEIRA ST. PAUL, MN 55110
1893' NOLAN AVE N
www.buerklehonda.com
STI]�LWATER, MN 55082-1730 PAGE 2
HOMI;': 612-209-1326 CONT: 612-209-1326 THANK YOU
BUS : 651-793-2726 CELL: 651-248-0439 SERVICE ADVISOR: 9 TOM DR.AVES
C:OtOR YEAR 'fNAKE/MODEL - VIN LICENSE M14.EAGE lN/OUT TAG'
GRE13N 06 HONDA PILOT 5FNYF18646B024585 TEA031 83658 83658 T9707
DEL:DATE PROD. DATE WARR. EXP. PROMISEO PO N0. RA'fE PAYN4ENT INV. DATE
07�'JL06 D 16 : 30 12MAR14 134 . 00 CC 12MAR14
R.O. OPEt�ED READY > OPTIONS: STK:20322 DLR: 206806 ENG: 3 . 5 Liter
1) 20322 2) KEY K651 3) CODE 4) 3773 5)GREEN
07 : 35 11MAR14 10 :41 12MAR14 6 GOODYEAR
LINl3 OPCODE TECH TYPE HOURS LIST NET TOTAL
DOWN. OK TO>; REpLACE REAR !HEAT SHTELDS '''
SHIELD REPLACED 3RD WARM UP CATALYTIC CONVERTER
HEAZ' >sSHIELD� '
38 CQH 93 . 00 93 . 00
1, 181:'81-RCA-A00 ''CQVER (S�OWER) ' 1.3 .'16 13 : 1,6 13 . 16
1 18182-RCA-A00 COVER (UPPER) 25 . 16 25 . 16 25 . 16
�' 83��5$ REPLACED THE 3RD ''V�FARM' UP GATALYTIC, C�NUERTER HEAT SHIELDS,,
****************************************************
F** �K TO COMPLETE AN AL,IGNMENT CHECK, OK ''TO ADJUST AS NEEDED IF, OUT OF
SPEC.
4AH HONDA FOUR' WHEEL ALIGNMENT.
38 CH 109 . 95 109 . 95
836'58; PERFORMED 4 WHEEL ALIGNMENT. SEE PRINTOUT FOR SPECS .
****************************************************
SUBI� BUERKLE HONDA' RENTAL CONTRACT#8968
�H 7000 . 00 7000 . 00
REC'iCLING, ENVIRONMENTAL, AND SHOP SURCHARGE 18 .27
CIJSTOMER IN A SELFPAY RENTAL
' l,�T 'DAY >.4� . 74 ANY'' DAY `'AFTER
3!7 . 74 DUE BACK 3/11 @700PM
!: T1�I5 INCLU DES 24 HOLIRS -�TWO
HOUR GRACEPEROID
' ' j
� ��� �
�- � �,,,�`''��
c,�
�y, z. y�
WARRRNTY DISCIAIMER: ALL PARTS AND ACCESSORIES ARE SOLD AND ALL REPAIHS ARE PROVIDED BY THE DEALERSHIP .QESCRIP7ION �� 7OTA
A3cT�'�FIEREBY EXPRESSLY DISCLAIMS All WARRANTIES,EXPRESS AND IMPLIED,INCLUDING ANY IMPUED -" -- --��� � � �
WAISSRANTIES OF MERCHANTABILITY AND FITNESS FOR A PARTICULAR PURPOSE,AND NEITHER ASSUMES NOR AUTHORIZES LABOR AMOUNT 221 . O/}
ANV O"HER PERSON TO ASSUME FOR IT ANV IIABILITY IN CONNECTION WITH THE SALE OF PARTS OR PRODUCTS OR THE
REPAIR.THE ONLV WARRANTIES ON PARTS AND ACCESSORIES OR REPAIRS ARE THOSE WHICH MAV BE OFFERED BY THE PARTS AMOUNT 54 . 87
VEHICLE MANUFACTURER OR THE PARTS MANUFACTURER OR DISTRIBUTOR AND ONLY SUCH MANUFACTURER OR
DISTRIE�UTOR SHALL BE LIABLE FOR PERFORMANCE UNDER SUCH WARRANTIES. CUST�MER SHALL NOT BE ENTITLED TO GAS,OIL, LUBE O . O O
RECOVI=R FROM THE DEALERSHIP ANV CONSEQUENTIAL DAMAGES,DAMAGES TO PROP RTV, DAMAGES FOR LOSS OF USE, SUBLET AMOUNT 7 O O O . O O
LOSS OF TIME,LOSS OF PROFIT OR INCOME,OR ANY OTHER INCIDENTAL DAMAGES.
By signing below, you acknowledge that you were notified of and authorized the Dealership to perform the SHOPSUPPLIES/
service:s/repairs itemized in this Invoice and that you received (or had the opportunity to inspectl any replaced HAZARDOUS WASTE DISPOSAL 18 .2 7
parts a3s requested by you. The vehicle is being returned to you in exchange for your payment of the Amount TOTAL CHARGES 7294 . 18
D�Je' LESS INSURANCE O . O O
I authorize the retrieval of on-board data as needed to facilitate vehicle repair,as well as sharing of that data
with ttia manufacturer for diagnostic and research purposes. SALES TAX 3 . 91
DATE�� CUSTOMER SIGNATURE AUTHORIZED DEALERSHIP REPRESENTATIVE SIGNATURE pLEASE PAY 3�������.�..�-+���
THIS AMOUNT `,'j�g�,, �9 '
ALL PARTS ARE NEW ORIGINAL �
EnUIPMENT PARTS UNLESS
�L1ea1Q�CAP �02006 ADP 101/091 SERVICE INVOICE TVPE 2-2SI2C-"AS-IS"-MINNESO7A-9 OTHERWISE INDICATED.
�S�TOMER COPY
. � BUERKLE HONDA
,CUS'PbMER #: CH42986 479965 3360 Hwy 61
trNrr# 20322 SERVICE (651) 490-6699
CHAI2LIE OLIVEIRA *INVOICE* SALES (651) 490-6600
JILI� MARIE OLIVEIRA ST. PAUL, MN 55110
1893 NOLAN AVE N
STII�LWATER, MN 55082-1730 PAGE 1
www.buerklehonda.com
HOM13: 612-209-1326 CONT: 612-209-1326 THANK YOU
BUS : 651-793-2726 CELL: 651-248-0439 SERViCE ADVISOR: 9 TOM DR.AVES
'' C;flLOR YEAR MAKE/MODEL VIN LICENSE MILEAGE IN/OUT TAG
GRE13N 06 HONDA PILOT 5FNYF18646B024585 TEA031 83658 83658 T9707
DEL. DATE PROD. DATE WARR. EXP. PROMISED PO NO. RATE PAYMENT INV. DATE
07��;JL06 D 16 : 30 12MAR14 134 . 00 CC 12MAR14
>R.O. OPENED READY OPTIONS: STK:20322 DLR:206806 ENG: 3 . 5 Liter
1) 20322 2) KEY K651 3) CODE 4) 3773 5)GREEN
b7 : 35 11MAR14 10 :41 12MAR14 6 GOODYEAR
LIN13 OPCODE TECH TYPE HOURS LIST NET TOTAL
A>;Qc��}5 HONDA STANI�ARD OIL CHANGE- INSPECT' BELTS, HOS:ES, AIR FTLTER,
TIRES & TIRE PRESSURE, INSPECT UNDER CAR VISIBLE COMPONENTS
QC45 QC45 HONDA STANDARD OIL CHANGE- INSPECT
BELTS, HOSES, AIR FILTER, TIRES & TIRE
< PRESSURE, INSPECT UNDER CAR VISIBLE
COMPONENTS
52 CQH 18 . 09 18 . 09
1 15400-PLM-A01 OIL FILTER 7 . 04 7 . 04 7 . 04
1 94109-14000 W-WASHER, DRAIN (14MM) 0 .42 0 .42 0 .42
1 OIL-45 ENGINE OIL 9 . 09 9 . 09 9 . 09
83��58 STANDARD OIL AND FILTER CHANGE. .
****************************************************
B C/`8 HIT POT HOLE AND NOW THERE IS A LOUD GRINDING NOISE WHEN DRIVZNG
AND TURNING PLUS ACCELERATING. OK TO CHECK AND ADVISE
iNC NO CHARGE
38 CH 0 . 00 0 . 00
83i�:58 VERIFIED CONERN ON TEST DRIVE INSPECTION FOUND THE HEAT
SH:IELD ON THE 3RD CONVERTER IS RUSTED AND CRACKED CAUSING A RATTLE
DU]Z.ING ACCELERATION. REPLACED HEAT SHIELDS. ALSO THE LONG HEAT SHIELD
AB��VE THE "B" PIPE IS DEFLECTED AND CONTACTING THE B PIPE CAUSING A
�R.rNDING NOISE. ADJUSTED THE H�AT SHIEL,D TO TNCR�ASE CLEAR.ANCE BETWEEN
TH1� SHIELD AND THE "B" PIPE. TEST DRIVE VERIFIED NO FURTHER NOISE HEARD
` DU]2TNG ACCELERATION.
***************************I*************************
C P]1RFORM COMPLIMENTARY MULTI-POINT INSPECTION
INSP PERFORM COMPLIMENTAR.Y MULTI-POINT INSPECTION
___ _ ___ _._
52 CH _ _ 0;:00 , 0'.0:0
_ ****************************************************
D FLEASE WASH VEHICLE - AS PER CUSTOMER REQUEST - NO CHARGE
W PLEASE WASH VEHICLE - AS PER CUSTOMER REQUEST -
NO CHARGE
52 CH 0 . 00 0 . 00
**�***********************�;*************************
E** DURING INSP TECH FOUND THE REAR HEA SHIELDS CRACKED AND HANGING
WARR�NTV DISCLAIMER: ALL PARTS AND ACCESSORIES ARE SOLD AND ALL REPAIRS ARE PROVIDED BY THE DEALERSHIP bESCRIP710N � TOTALS
AS-T$:�1�7E-6FATEF�FlIF�'FEREBV EXPRESSLY DISCLAIMS ALL WARRANTIES,EXPRESS AND IMPUED,INCLUDING ANY IMPLIED �
w7iFtRANTIES OF MERCHANTABIUTV AND FITNESS FOR A PARTICULAR PURPOSE,AND NEITHER ASSUMES NOR AUTHORIZES LABOR AMOUNT
ANY O"HER PERSON TO ASSUME FOR IT ANY IJABIUTY IN CONNECTION WITH THE SALE OF PARTS OR PRODUCTS OR THE
REPAIR' THE ONLY WARRANTIES ON PARTS AND ACCESSORIES OR REPAIRS ARE THOSE WHICH MAY BE OFFERED BY THE PARTS AMOUNT
- VEHICLE MANUFACTURER OR THE PARTS MANUFACTURER OR DISTRIBUTOR AND ONLV SUCH MANUFACTURER OR
DISTRIqtUTOR SHALL BE LIABLE FOR PERFORMANCE UNDER SUCH WARRANTIES. CUSTOMER SHALL NOT BE ENTITLED TO GAS,OIL, LUBE
RECOVI:p FROM THE DEALERSHIP ANY CONSEQUENTIAL DAMAGES,DAMAGES TO PROPEIITY, DAMAGES FOR LOSS OF USE, SUBLET AMOUNT
LOSS OF TIME,LOSS OF PROFIT OR INCOME,OR ANV OTHER INCIDENTAL DAMAGES.
By sig�ing below, you acknowledge that you were notified of and authorized the Dealership to perform the 5HOPSUPPLIES/
servire s/repairs itemized in this Invoice and that you received lor had the opportunity to inspectl any replaced HAZARDOUS WASTE DISPOSAI
parts a�s requested by you. The vehicle is being returned to you in exchange for your payment of the Amount TOTAL CHARGES
Due. LESS INSURANCE
I authorize the retrieval of on-board data as needed to facilitate vehicle repair, as well as sharing of that data
with th,e manufacturer for diagnostic and research purposes. SALES TAX
� DAT[ CUSTOMER SIGNATURE AUTHORIZED DEALERSHIP REPRESENTATIVE SIGNATURE p�EASE PAY
THIS AMOUNT
ALL PARTS ARE NEW ORIGINAL
EnUIPMENT PARTS UNLESS
� IQrV1G �02006 ADP 107/091 SERVICE INVOICE TVPE 2-2512C-'AS-IS'-MINNESOTA-9 OTHERWISE INDICATED.
��TOMER COPY
� ' �Lt 1'IVI�]II�
' r�, � 3360 HWY 61 N
ST PAI�11�+155110
651�1
N,�„. c�ouv�w
Cpmpwny RO 47�lii
Addtrss _.__.__ __._._.�., , _.. _ _,___.
Tsl�phoM ____...._..._..___._ .._...__. __�._ ____. . . .. .____..__ ...._ _ _ . _. _ _____ _. . . . _..
V�hlal�(VIN) _.___ .__ __ _ _ __ _ __�,..__
Uo�ns� �� _�p__ .
Color �M
Ya�r: �
T� �
MINp� iti0f
TInN prfnbd 3/1?J14 8:65 AM
Honda : Pilot:All Wh�l Drlw: 2003-Os
l�ront: L.�1� I�nast: Ripht
Aotual B�1'on Sp�olfhd Rartp� Aatuwl Bd'or+� 8p�atfNd Ran�
-0.3° -0.3° -1.6•0.6• Cunbsr -0.6° -0.6° -1.6°O.d°
2.0° 2.0° 0.!'�.!° Cwst�r 1.4° 1.4° 0.8°Z.8°
0.00° 0.02° -0.Oi'O.Od' To� -0.01° -0-07° -0.08°O.OS°
11.a° 11.7° aA{ 1Zi' 1Z.i'
11.3• 11.a' Inelud�e!AnON 1 t.T' 11.T
Tuntfrp Anyl�DIR.
front
: Aatwl B�Mn 8p�a1Md Ranq�
Gross Camb�r 0.3' 0.3'
Cross Ca�r 0.6• 0.6'
Cross 8A1 -0.6• -0.�'
Tatal To� -0.01° -0.06° -0.1 i°0.1 s°
. Cross Tum DfR.
R�r: I.M! �'R�
A�lwl �lbn 8p�o1(Md Ran� Aob�l 9slons 8p�aiMd RwnfN
-�.z° -�.�° �.r o.s° can�b.r -�.s° -,.z° -�.r o.s°
0.02° -0.13° -0.Of'O.Oi' TO� 0.00° -0.04° -0.Oa°0.08•
Ratr
Aotwt BNbrr 8 MMd Rwnp�
Cro�Camb�r O.f• 6.2' '
Total To� 0.02° -0.'16° -0.1t°0.1i°
Thrust An4N 0.01° .O6'
BUERKLE HONDA
3360 Highway 61 N
White Bear Lake, MN 55110
651.490.6600
Sale Transaction
03/12/2014 02:52 PM
QB Invoice: 479965
Payment Information
Response: AUTH/TKT 412125
• Card Type: Visa
Account: X2946
' Amount: 412.45
Total: 412.45
TranslD: 20140312145223-0110361-119529
JILL OLIVEIRA
;
https://www.eprocessingnetwork.com/msc/index.pl 3/14/2014
BUERKLEHONDA
3360 Highway 61 N
White Bear Lake,MN 55110
651.490.6600
Return Transaction
03/14/2014 03:54 PM
Invoice: 119794
Amount: 74.68
Payment: 74.68
Card Type: VISA
Card: X2946
20140314155431-0110361-119794
Description: 479965
OLIVEIRA,JILL
(Merchant Copy)
Page 1 of 1
RENTAL AGREEMENT
b�onda BUERKLE HONDA FORATEMPORARY
� 3 3 6 0 HIGHWAY 61 NORTH SUBSTITUTE VEHICLE
CrOU�e$�/ ST. PAUL, NII� 55110
(�ar No $sss
f�rogram Ro
NO
�'USTOMER RENTER CAR VW LICENSE NO STATE
��iRr4 Z ,±ai#A�I
F,OME ADDRESS MILEAGE YEAR/MAKE/MODEUCOLOR/UNIT
1893 NOLAN AVE N IN �
��T�' STATE Z�P MILEAGE DATE AND TIME
��� �t �t�d' :+a�� �``� IN
C�RIVER'S LICENSE NO STATE EXPIRES MILES DATE AND TIME
� , , �� MN 12H2I2014 DRIVEN �
E IRTH DATE HOME TELEPHONE MILES YOU AGREE TO RETURN THE RENTED
1 Z/12/1965 VEHICLE TO THE ABOVE LOCATION ON
(651)493-2531 ALLOWED OR BEFORE
�11370d1E1Q:1lEl81CF.£1T131JIRA#If�fAffflt�AA/1�111N CHARGEABLE ��
; _-:. :: ;
COMPq Y POLICV NO EXPIRES MIIES
<GENT TELE� i� �' , i . ;:;;�3lllYAAi��;E`1��",RIFiT11'�i!�: .
� IN i ; ;
SHOP
�idSURED VEHICLE YEAR/MAKE/MODEL/COLOR F F NAME
3/4 3/4 PHONE
; A11Gf'#!f?NA$.b1�t%f�1R iN�6�l1X3`►kFE
NUMBER
.. �: �' � :;; .: � : :�.; ;; �� �IZ O O go SHOP
�DDITIONAL DRIVER NAME UCENSE NO. STATE BIRTHDATE
1/4 1/4 $ CONTACT
�DDITIONAL DRIVER VEHICLE INSURANCE COMPANY POLICY NO EXPIRES E E MAKIE/MODEL
NAME OF
�GENT TELEPHONE INSURED
l4ATE$#EE1EF.NO'€fNCLflDE�f} ; R£N�#11.fi,�HkR{iES
iIJSURED VEHICLE YEAR/MAKE/MODEL/COLOR
MILES @$
�"DDITIONAL DRIVER NAME LICENSE NO. STATE BIRTHDATE DAILY
RENTAL RATE $
A.DDITIONA�DRIVER VEHICLE INSURANCE COMPANY POLICY NO EXPIRES
<GENT TELEPHONE >:::i:T11YlE;:Bi:M�:E1[G.E..:?;:;:>;;::;;';::;';;:.
' Cf#/�RGiES: ,. ,
iIJSURED VEHICLE YEAR/MAKE/MODEL/COLOR
TAXABLE
`�EHICIE COND�TION OUT: � NO DAMAGE �DAMAGE DESCRIPTION: FUEL GAL. @$ _
b EHICLE CONOITION IN: � NO DAMAGE �DAMAGE DESCRIP ION:
<TA7fA6l;>E
- ;�TU�AI..__..:;:,:::.;::.;:;:
When damage to the Vehicle is covered by Your perso�al insurance T�@ °%
policy, prior payment by You is not required, and We will accept pay- NON-TAX
FUEL GAL. @$
ment from Your insurance company within the time limits of 'nn
Stat. Ann. Section 7 20, NET DUE CUSTOMER
� � '\ - DEPOSIT/REFUND(OTHER:
�F�
`� /� � :�;•` SUBTOTAL
�^�y' �
Q .C�, ��'`,��.�� '/ mTAI:
�,1� �' )( '�,,.>� � � �H�S�G�
V �� ;� ;� �� �•� �� �� PAYMENT REFUND
� � �� � $ $
�� CHECK# CUSTOMER
INITIALS X
You agree to all the terms and conditions on both sides of this Agreement,and You acknowledge
that you were given an opportunity to read this Agreement before you were asked to sign.You
authorize Us to process a credit/debit card voucher in Your name for all c�arges due under this [AE](MC][VJ[ �
Agreement.Your signature below is considered made on the applicable cr diUdebit card voucher.
ALL CHARGES SUBJECT TO FINAL AUDIT.
CARD
1'OUR VERIFIED EXP
�:�IGNATURE:
THANK YOU,WE APPRECIATE YOUR BUSINESS! HONDA MN �oaizoio>
Rental Agreement Terms and Conditions
1.Definitions."Agreement"means all terms and conditions found on both sides of tained the Vehicle,or extended the rental period by giving Us false,freudu-
this form."You"or"Your"means the person identified as the Customer on the lent ar misleading information;(d)under any circumstances that could lie prop•
reverse side of this Agreement,each person signing this Agreement,every Au• erly charged as a crime other than a minor traffic violation;(e)to carry per•
thorized Driver and each person or organization to whom charges are billed by Us sons or property for hire;(f)to push or tow anything;(g)in any race or;�eed .
at its or the Customer's direction. You are jointly and severally bound by this contest;(h)to teach anyone to drive;(i)outside the United States or Ca:�ada,
Agreement."We","Us"or"Uur"means the independent auto dealer.or:its:affiGate or outside the,�eographic area described elsewhere in this Agreement,if
named elsewhere in this Agreement."Vehicle"means the automobile identified in any;(j)on an unpaved surface;k1 when the odometer hasbeen tampere f
this Agreement and each vehicle We substitute for it,and all its tires,tools,acces• with or disconnected;(l)when it is reasonable to expect You to know tliat
sories,equipment,keys and documents.The Vehicle may be a temporary substi- further operation of the Vehicle would damage it;(m)where applicable,by
tute for a Customer-owned or leased vehicle that You have given Us the opporti- anyone who lacks experience driving a Vehicle equipped with manual t��ans•
nity to service or repair.Only Authorized Drivers are permitted to drive the Ve• mission;and,(n)to transpo�t an animal.Permitting the Vehicle to be oper•
hicle."Authorized Driver"means:la►the Customer at least age 21,who may be ated by a person who is not an Authorized Driver is a breach of this Agi'ee•
the registered owner or lessee of a vehicle left with Us for service or repair;(b) ment.
additional drivers at least age 25 listed by Us elsewhere in this agreement;(c)the 6.Insurance.You are responsible for all damage or loss You cause to others.You
Customer's spouse as long as the spouse is at least age 21;and,(d)if the Cus- agree to provide auto liability,collision and comprehensive insurance covering
tomer is a business entity Authorized Driver includes Customer employees at least You,Us,and the Vehicle.Your insurance is primary.If You have no auto liabilit��
age 21 who are permissible drivers on the business entity's auto insurance policy. insurance in effect on the date of a loss,nr if We are required by law to provid�
Each Authorized Driver must possess a valid driver's license."Loss of Use"means liability insurance,We will provide auto liability insurance(the"Policy")that is sec•
the loss of Our ability to use the Vehicle for any purpose due to damage to it or ondary to any other valid and collectible insurance whether primary,secondary.,
loss of it during this rental,including uses other than for rental,such as display for excess or contingent.The Poiicy provides bodily injury and property damage
rent,display for sale,opportunity to upgrade,opportunity to sell,or transportation liability coverage with limits no higher than minimum levels prescribed by the�tate
� of employees.Damages for Loss of Use are often difficult to determine with pre- whose laws apply to the Ioss.You and We reject PIP,medical payments,n�i�
cision.Therefore,You and We agree that Loss of Use will be calculated by multi• fault and uninsured and under•insured motorist coverage where permit�'ed
iplying the number of days from the date the Vehicle is damaged until it is replaced by law.The Policy is void if You violate the terms of this Agreement or if You fail
, or repaired Imaximum 14 days under Minnesota lawl,times 80%of the daily rental to_cooperate in any loss investigation conducted by Us or Our insurer.Giving tl�e
rate,which You and We agree represents a reasonable estimate of actual dam• Vehicle to an unauthorized driver terminates Policy coverage.
ages and not a penalty."Diminished Value"means the actual cash value of the 7.Charpes•You will pay Us all charges due under this Agreement,including:(a)
Vehicle just prior to damage or loss less the value of the Vehicle after repair or time and mileage for the period that You keep the Vehicle;(b)applicable taxes;Icl
replacement. S50 or the maximum amount permitted by law,whichever is greater,if You pa�Us
2.Rental•Consideration;Indemnitv and Warranties.This is a contract for rental of with a check returned unpaid for any reason;(d)all expenses We incur recover ng
the Vehicle.A fee You pay Us,or Our opportunity to service or repair Your Vehicle the Vehicle if it is not returned to the renting location on the date and time pro ti�
and the benefits We receive for the servicelrepair work,is adequate consideration ised;(el all costs,including pre-and post•judgment attoroey fees,We incur col
Eor reo.a{o'tha Veh;cle.'A!e may repossess,he Vehicle st Ycur experse without lecting payment from Vou or otherwise enf�rcing Our righis under this Agreem trt;
notice to You if the Vehicle is abandoned or used in violation of law or this Agree- (f)a 2%per month late fee on all charges due Us that are not paid when due;l)I
ment.You agree to indemnify Us,defend Us and hold Us harmless from all claims, a reasonable fee not to exceed S350 to clean the Vehicle if it is returned su6stan•
liability,costs and attorney fees We incur resulting from,or arising out of,this Agree• tially less clean than when rented;and,(h1 fuel and a refueling fee if You returri the
ment or Your use of the Vehicle.We make no warranties,express,implied or Vehicle with less fuel than when rented.You will pay the appropriate governmi:nt
apparent,regarding the vehicle,no warranty of inerchantability and no war- authorities all parking and taffic fines,toll violations,penalties,citations,forfei�
ranty that the Vehicle is fit for a particular purpose. tures,court costs,towing,storage impound charges and other expenses involu•
3.Inspection;Condition and Return of Vehicle.You must return the Vehiele to Our ing the Vehicle assessed against Us or the Vehicle during this rental;if You fail to
office or other location We identify on the date and time specified in this Agree- pay such charges and we pay them on Your behalf,You will pay Us the fees W�
ment with at least as much fuel as when rented.The Vehicle must be returned in paid to the charging authorities plus Our administrative fee of S50 for each sui;h
the same condition that You received it except for ordinary wear.If the Vehicle is violation.
returned after closing hours,You remain responsible for all damage to the Vehicle 8.Your Property.You release Us,Our agents and employees from all claims
until We inspect it on reopening for business.You must obtain Our prior approval for loss of or damage to personal property or that that was left with Us or carried in th
before servicing the Vehicle or replacing parts or accessories.You grant Us Our Vehicle.If you fail to claim property left in the Vehicle for more than 30 days,'Ne
agents,assigns and each person with a financial interest in the Vehicle the right to may dispose of that property in a manner we choose.
inspect4heil�hicle duringthis�entai. 9.Breach of Agreement.You waive aU recourse apainst Us for criminal prosecu•
4.ResponsibilitV for Damage or lass;Reporting to Police.You are responsible for tions We take against You for breach of this Agreement.
theft of the Vehicle and damage to to it whether or not You are at fault.You are 10.Modifications.No term of this Agreement can be waived or modified except ty a
responsible for damage to the Vehicle caused by weather,road conditions and writing that We have signed or on a form that We provide.If You wish to exteiid
acts of nature.Your responsibility includes the cost of repair or the actual cash the rental period You must return the Vehicle to Our office for inspection and
retail value of the Vehicle on the date af the loss if the Vehicle is stolen,not repair- written amendment by Us of the Date Due In.This Agreement constitutes the
able,or if We elect not to repair the Vehicle.You are also responsible for Loss of entire agreement 6etween You and Us.All prior representations and agreemen's
Use,Diminished Value,and Our administrative expenses incurred processing a between You and Us regarding the use of the Vehicle are void.
claim.You are responsible for replacing missing equipment,Vehicle documents, 11.Waiver.A waiver by Us of a breach of this Agreement is not a waiver of an
and Vehicle keys.You will check and maintain Vehicle f�uid levels.You must additional breach or waiver of the performance of Your obligations under this F yree
report all Vehicle accidents or incidents of theft and vandalism to Us and the po• ment.Our acceptance of payment from You or Our failure,refusal or neglect tc'
lice as soon as You discover them. exercise Our rights under this Agreement does not constitute a waiver of anotl�er
5.Prohibited Uses.The following uses of the Vehicle are prohibited and con- provision of this Agreement.Unless prohibited by law,You release Us from all
stitute a hreach of this Agreement.The Vehicle shall not be used;(a)by liability for consequential,special or punitive damages in connection with this 'rans
anyone who is not an Authorized Driver or not licensed to drive,by any action or the reservation of a vehicle.If a provision of this Agreement is deer�ud
one whose driving license is suspended,(b)by anyone under the influence void the remaining provisions are valid and enforceable.
of alcohol,prescription or non-prescription drugs;(c)by anyone who ob•
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�O 2010 This Page•LaPlaca Law,P.C.,Rockville,MD Minnesota Rental PDP NB 032710
HONDA MN 10312010) ,