Loading...
Kapaun \ RECEIV�D MAR 2 5 2014 NOTIC� �F CLA�M I'ORM �o the City of Saint Paul, M�'n�e�o�ERK Minnrs��tu Stnre Stanrte 4b6.05 states tha� "...erery person...wh�clnims damages frnni nny municipnlity...sh�r!/cairse to be presented to th� governing Gody vf tlie municipnliry within /80 days nfter tire hlleged loss or injirrv is discovered a nocice stntin,g the ti�ne,plare,n�rd circ�unstances ti�ereof,and the mnnunt of compensatinn or other relief demnnded." Please complete this form in its entirety by clearly typing or printing your answer to each ryuestiun. If more space is needed,attach additional sheets. Please note tl�at you wilt 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 acknowtedgement once your form is received. The process can take up to ten weeks or longer depending on the nature of your ciaim. This form must be signed,and both pages completed. XP something daes not apply,write`N/A'. SEND COMPLET�D FORM AND OTHER DOCUM�NTS TO: CITY CLERK, 15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PALTL, NIN 55102 First Name ����i Middle Initial�Last Name ���4�r 1 Company or Business Name Are You an Tnsurance Company? Yes No If Yes,Claim Number? Street Address �� �" �� Caty �,!M`Q V��t� State �,�' Zip Code ��Z" �' Daytime Phone (_� - Cell Phone�2�-1�Evening Telephone�_) - Date of AccidenU Injury or Date Discovered ?>�I\I1`� Time 1•��� /pm Please state, in detail, wht�t occurred (hnppened),and why you are submitting a claim. Please indicate wh or how you feel the City of Saint Paul or its e�nployees are involved flnd/or responsible for your damages. � 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 dunng a tow �1 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—ptease specify ❑ Other type of injury—please specify In order to process your claim you need to include conies of aIl apnlicabie 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 WTLL NOT be retumed nnd become the property of the City. You are encouraged to keep a copy for yourseif 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 bilis andlor receipts for the repairs O Towing claims: legibie copies of�►ny ticket issued�nd a copy of the impound]ot receipt O Other property damage claims: two repair estimates if the damaEe exceeds$500.00; or the actual bills and/or receipts for the repairs;detailed l.ist of damaged items O Injury cIaims:medical bilIs,receipts O Photographs are alw�ys welcome to document and support your daim but will not Ue returned. Page 1 of 2—Please coinplete and return both pages of Claim Form Failure to connplete and return both pages will result in delay in the handling of your claim. All Claims�piease complete this section Were there wimesses to the incident? es U nown (circle) Pr ide their ames, ad�iresse and telephon number :_ � �� ' � Ut��� ' � Were the police or law enforcement called? Yes No Unknown (circle) If yes, what depaRment or agency? Case#or report# Where did the accident or injury take ptace? Provide street address,cross street,intersection,name of ark or faci 'ty, closest landmar}:,etc. Please be as detai ed as possible� If necess , t ach a dia ram. � � � � � ' i'L "1 . �i-f-�i�U�l� 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. Vehicle Claims— tease c m Iete this s ction ❑ check box if this section dces not a I Your Vehicle: Year Make Model L License Plate Number � State Color �I� Registered Owner � � Driver of Vehicle �1 _ Area Damaged � � City Vehicle: Year Make Model License Plate Number State Color Driver of Vehicte(City Emp�oyee's Name} Area Damaged Tn�urv Claims—�leASe complete this section �chcck box if this section does not apply 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 Prdvider{s): Address Telephone Did you miss work as a result of your injury? Yes No When did you miss work? (provide date(s)) 1Vame of your Employer: Address Telephone �heck here if you are attaching more pages to this claim form. Number of additioual pages By signing this form,yorc are stating tltat all informaiion you have provided is true and correct to tlze best of your knowledge. Unsigned forms will not be processed. Submitting a false claim c�cn result in prosecution. Date form was completed�I��J�� Print the Name of the Person who Completed t orm: �� Signature of Person Making the Claim: Revised February 201 1 Notice of Claim �t��.�, City of St. Paul: � This incident occurred 3/11/14 at 7:35am on my way to work. I was leaving the lifetime fitness off of Ford Parkway,turned right onto Cretin and took that all the way up until Princeton (cross street), which is where the damage in the road was extremely terrible. It was still some-what dark out, which made it extremely difficult to pin point where they all were, plus rainwater covered the majority of the pot holes. After running over the destruction I immediately knew my tires went flat. When the tires were removed the technician found that the tires were not repairable due to multiple ruptures in both tires. Both aluminum rims were chipped and bent on the right side as well. If this was an error on my part, I wouldn't be filing a claim. However, because there has been multiple repairs on my car due to the roads I have to travel to work on daily, I feel as if being reimbursed for the dollar amount I've spent over this past winter on tires, suspension problems, and rims completely justifiable. I just replaced a tire and a bent rim 3 months ago due to another pot hole that was off of the exit ramp off 55E and Edgecumbe in St. Paul. Please grant me a reimbursement. It's very hard trying to cover these extra expenses. I have the receipts attached, along with photos. You can contact me by email at kapaun2006@vahoo.com or by cell phone, 952 2701453. Thank you, Nicole Kapaun Tires Plus Of Rogers 13560 NORTHDALE BLVD. INVOICE Rogers, MN. 55374 146251 Phone-763-428-5050 Fax-763-428-5017 Org. Est. #325444 Call Drop Wait Due • INVOICE I Print Date : 03/11/2014 THORNELL AUTO - JUSTIN THORNELL 2014 carry out Lic# : - MN Odometer In : 0 , Unit# : Home 952-994-6364 Vin# : Cust ID : 37913 Hat# : Ref# : P�:. � � . ���o,�"�� � �a�- _ _ - �� - � ��. � _ .....� � .. .. h .. .� _..__ ,. .. .__,_ _.., ����- �,� < • S ���!.� �:., � P2354517 BFG G-FORCESUPER 2.00 95.00 190.00 SPORT AS 94H [Technicians:technician,TIRES INSTALLED] Org.Estimate �203.82 Revisions a 0.00 Current Estimate a 203.82 Labor: $0.00 Parts: $190.00 Sublet: $0.00 Sub: $190.00 Tax: $13.82 i Total: $203.82 [Payments- ] Bal Due: $203.82 MON-FRI 7AM-7PM, SAT 7AM-SPM, SUN CLOSED RECOMMENDED LUG NUT RETORQUE BETWEEN 50-100 MILES I hereby authorize the above repair work to be done along with the necessary material and hereby grant you and/or your employees permission to operate the car or truck herein described on street, highways or elsewhere for the purpose to testing and/or inspection. An express mechanic's lien is hereby acknowledged on above car or truck to secure the amount of repairs thereto. Warranty on parts and labor is one year or 12,000 miles whichever comes first. SIGNATURE................................................................................................ Date......................................... Time......................... Writ/en By:LAU,ALEX-Technicians:technician,TIRES INSTALIED Page 1 of 1 Copyright(c)2014 Mitchell Repair Information Company,LlC InvHrsNoPartNos 1 t18.10JD • � ' � i � • � — � . : . �OTAL CAR CARE WHY BEPAIR OH REPLACEME�R SUGGESTEO WHY BEP��R OH REPLeaEMENT RE2UlNED Y88f Make Model 7.CLOSE�END OF USEFUL LIFE A.NO LON6ER PERFORMS INTENDED PURPOSE 2.ADDRESS CUSTOMER NEED,CONVENIENCE OR RE�UEST B.DOES NOT MEET DESIGN SPECIFICATION N I I I I I I I I I I I I I I I I I I 4.TECHN C AN PECOMMEN ATION BASED ONNE�XPER ENCE C.MISSING � MILEAGE; MUFFLER/PIPES ❑CLAMPS 1 2 3 4 ❑HANGER Eng.Size Lic.# Trans.Type(cirde) Auto Manual � INSPECT ��R� • � SPEED RATING INSPECTED BY FOWER STEERIN�HOSE ❑PRESSURE ❑RETURN TIRE SIZE: 92M� P81IN v&OUT Acc 6W1 REA WHY RECOMMENDEO U-JOINT ❑FRONT ❑REAR IDLER ARM LR PITMAN ARM �I��I� RR CENTER LINK 1`j RF CONTROL ARM BUSHINGS � LF SWAY BAR BUSHINGS SP LINK PINS SERVICE RECOMMENDED BASED UPON TIRE CONDITIONS TIE ROD ENDS ❑�our ❑L IN ❑R IN ❑R ouT ❑SLEEVE(S) BALL-JOINTS ❑L UPPER ❑R UPPER INSPECT i WHY RECOMMENDED'i ❑L LOWER ❑R LOWER SPEC_ACTUAL_ BELLOWS BOOTS ROTATION .�' CV BOOTS �L OUT ❑L IN ❑R IN ❑R OUT' BALANCE WHEEL BEARINGS ❑LF ❑RF ❑LR ❑RR ❑SERVICEABIE ❑SEALED ❑4 WHEEL ALItiNMENT p THRUST STRUTS ❑FRONT ❑LEFf ❑RIGHT ❑REAR ❑LEFf ❑RIGHT � � ❑FRONT ❑LEFf ❑RIGHT SHOCKS ❑REAR ❑LEFT �RIGHT INSPECT "�"�` �C,�°� i WHY RECOMMENDED'� INSPECT "SOAL . , •- • • ACC SUO REQ ACC SUCi REQ WIPER BLADES N/A FRONT PADS LF RF FRONT HEADLIGHTS N/A FRONT CALIPERS Estimate0 mm's Remaininp Estimatetl mm's Remaining FRONT ROTORS ❑LF ROTOR ❑RF ROTOR MINI UGNTS N/A ❑BRAKE ❑TURN SIGNAL ❑PARKING �SaEC. ACTUAL SPEC. ACTUAL HARDWARE AIR FILTER VENT FILTER BRAKE HOSE(S) ❑LF ❑FiF ❑REAR REAR SHOES/PADS LR RR TRANS.FLUID LEVEL ❑•AUTO L]MAN. ❑NOT INSP. REAR REAR CALIPERSI WHEEL CYL. Estimatetl mm's Hemaining Estimate0 mm's qemaininp COOLANT LEVEL REAR DRUMS/ROTORS ❑LR DRUM/ROTOR ❑RR DRUM/ROTOR SPEC. ACTUAL SPEC. ACTUAL WASHER FLUID WA HARDWARE/ADJUSTER OIL LEVEL � � � POWER STEERING � i FLUID LEVEL MA.4TER CYLINDER A FLUID LEr/EL ` 3 BELTS ❑� ❑a-T ❑PS BELTS ❑SERP ❑A/C ' ❑WP 1 2 3 4 4 COOLANT HOSES N/A ❑UPPER ❑LOWER ❑BYPASS ❑HEATER 5 BATTERY ACCESSORIES ►�A ❑CABLE ENOSlCABLES 0�S O HOLD DOWNS c v BATTERY GUARD wA ❑CORROSION ❑PREVENTIVE � NOTES: Q Hubcep Missing? Windshield Cracked? Scratches/Dents? Equipped w/ABS Brakes? v • Y N Y N Y N Y N � Check Engine/SES Light On? Air Bag Light On? ABS Light On? 4x4/AWD? i O Y N Y N Y N Y N .� COMMENTS: INSPECTED BY RE-INSPECTED BY � J � / � • 'G � !, l � i � �t � . ���`` `` � , . � ` ' � � �. , \ � A � �� � .> � `� � � �. �� -'o i y `! ` ^. � - .�+� �r� �, � � .., �c.'., — ,.\ ��i�.: :`�' ,,/� 'i � �� � ��F,. . � � -�, � � � ; Cd ' � � � .-. � � � - I fi � � �� i �� � � = I � � r-- � � � � 4 �i�r fM '�, `' "'!C*►,�'F�„ syw'� _ �r .�,�:,�.�.�.. � , � .. .. . � �. � .��'�.,t Y � � � . y�. �t� . .. � .� ... ' -. ' �� . .w.... . .... -.. �.... '�, .! .� � . �µ � � .. wIR`� . - ..y � . s . ' .y., �° � ..i 9.� �°'"d,r� - c � ` ,�p.�.. • c�. �� �+•',�4y�� �.�;� � „{�� C`�,,.,�„y��;• �� �'�r�` ,�t� -s�:a. .w h� ap� ,k ��. .� • .«.,. �'�{' � � �� ..��,, � _, r. , � � ' ' . �, � W �,W H ��� � ��! *I�t �� � Ai �,,, �^ , �, �.' yr � .�a;.. �� ',�6 �..��,. ', ���5..` .:�:.� .L:.. ,� ���� �A r I 4 ' 1.�ly.r 'Y. �_ � . .. . . '.'A! - _.I� VW��:^ .J �V- /; � �Y. `. .,s- . �V., ,�s.. +�"d6,y '>� . r. a � ,, e J � ft. . , , ' . �+5� r� � *� ' �,� ��� .. ry�� �� �. "��� . ).i � � . . .+5' ,� 4 .�3.ry �♦ ��,+ , 6 �t ' � '� � ,+T? rd'r . i . � � ..��. . .. �; �i�, ptt 1,�' . y,. , f *i, �. '. �� }��' +' �,, , . �' ' .:����_. ��� ,� . r ° i;7�J�j �'�"'o, . . , , �; -4.f:, � 1 ^�, ' �t � � � / . \ � , ' �I./., 'M,fi .!'� �» . � . � .�. 3 , , k .