Hanson REC�6o�°�D
I�AR 28 2��4
NOTIC� �F CLA�VI F4K11�'� ta the Cit3� of Saint Paul, I��e�6�RK
Miruirsvtr�State Stntute 466_t}5 srates tf-�rrt "_..ti�er�+�ersnn.._►e�n rini�.�rrrxu,eea frQta ur2y muni��i}�tin�._..rhnit crrrrse�a t�e prest�rrted to thr
gcat�erning brady�f Ilta mtatriciyafitv e��tt�crt 1$0 dcrys afler rJre altegetl loss or ininry it discnaeter�rt nntrc-e stntirtg t}�e timr,plare,a�rd
circurnsruncrs rhereof,��a�tkr rnan�r�rt rif rc�r�srti�n os c�ther r�lirf dr�rrrmdE�.,>
Piease complete ihis form in i#s entirety by clearly typing or printing yoar ans►ver to each c}uestian. IC more sgace is
needed,attach additionaf sheeLs. Please note that you w�I not 6e coniacted bp telephone to clarify answers,so provide as
much informatian as necessary to espla(n yo�claim,and t6e amaunt o#'co[npensatiaa being reqnested. Yau will receive a
writt�n acit�owleaget�tnt onct rour Iorm is received_ The prx�s can take up to t�n weeks an-longer depe�xli»�nn the
nature of your eiaim `Ch�€orm mgst be s�n+ed,and both pa�es cnmpk#ed. If sorn�.3h'rng daes not apptv,write`tiT/A'.
SEND CUMPLETED �ORNi AND 4`THER D4CUIVLCNTS T(J: CIT'kX CLERK,
IS WEST KEI.L�GG BLVD, 310 CITY HALL, SAINT PACTL, :Mi'�I 55102
First�t�me ��_ Midd�e Ir�itial�l�t Narn�e � 1 ��lJ�l !
Company or IIusiness R3�
Are You an insurance Company? �es� If Yes,€;Iaim Number?
Street Address,�.� �� ��
C�cy � .��Ut�,` � �- S�te ��Q z;p C��� 1 (�lo
L?ay�me P�ane �� - Cell I"ttc�rte �5 U��v�5 �Evenirsg TeIephone c ;, -
Date of Accidentl Injury or Date Discovered��,�,�.F��i��Time � t� pm
i'lease state, in detail, what occurred (happenecfj,and eafi:y yoa are submitting a daim.P3ease indicate�vhy r how you
fe ty of Saini P-aul flr i�s ernployec:s a�inva ved arrdl r��nsih)e for yaur damaaes_ � W(k� � 1
0� � OI,V� �V � e. '��C�'�
^ -� a-- ' 1n 'YYI. _ � C��h��2�
2 0 � �`/Z �e _ r��t�.
� � a W �S 1/�.!'� t V �
__ . -
O �0 aV2 0
G
1n i�-- -1-� �Sc.�e. P�t ino 8,
Please check the l�ox(es)t�at most ciosely reg�sent t�r�asa�fr�camp�eting tl�s form:
❑ My�ehicle was dama�d in an aceident �My vehiele was damaged daring a tow
�1y <<ehicle was damaged by a pothole or condition of the street L7 My vehicle was damaged by a ptow
❑ My vehicie was wrongfulIy towed ancUor izc'_�ceted ❑ I�vas injured on City property
CJ Other type of property damage—please specify
❑Other type of injury—piease specify _ ______-_--__
In order to �ro�ess your claim vou need to inciude rnpies of all applicabie documents.
For the claims types listed below,please be sure t�incIuc�e the doeuments indicated or it wiIl delay!he handlzng of
your claim. Documents WILL NQT be returned and become the proQerty of the City. You are encouraged to lceep a
copy for yourseIf before submiiting yUUr claim form.
O Froperty damage clairrvfi tc�a veficle: two estirnat�s fQr the�s ta ycu�r Yehic2e if the dam�ge eacceeds
�StlD.b(};or the acr�al bitIs sn�lor r�cc��i�cs far tt�re�rairs
�Towing claims: legible copies of any ricket issued and a copy of the impound lot receipt
O Chher property ciamaae clairns: two repair estimates if the damage exceeds$500.00; or the actual bilIs
and/or x-eceipts for the repairs;detailed list of damaged items
� Injury cIaims:medicat biIIs,receipts
O Photographs�m always welciMr�t�dc�cu�nent and su��pcxt yo�r ctaim bc�t will not he ret�rned_
Page 1 of 2—Please cornpleie and reLurn tx�th pages af Claim Fonm
Failure tc�connptete and return both pages witt result in deEay in the handling of your claim.
All Claims—nlease camnlete this section
Were there witnesses to t�he incident? Yes Na Unknown (circle)
Pratizde their names,addre�s�s and telephane numh��
Were the police ar iaw enforcement c�Iled? "k'es No Unknown (circle
If yes, what department or agency'�•�e�.�1 ����� Case#or report#wov\c�� �\V ���Vl Q�
(NoN-
Where did the acxic�e�t or in�cm,r talce place�ide��ddress,cross sc�eea,inte.rsectic�n,name�f park�faciliry:
closest landmark etc.�east.br as c�e Cl��s�ssibTe. If nee�Sary,attach a di �m_ _
c�� ���, �k � �a- .� c�a�,�d�, �-. ��.�a���� ��_�—���
Please indicate the amount you are seeking in c�mpensation or wha you would like the City to do to solve this ctai
t voyr a �sfaction. " `�= �YIS��D iS _�/1�(�
0�1 � .
�'ehicle Claims—�le�se camplete this section �check box if this section does not applv
Your Vehicle: Year 20\�j 141ake $G10Y1 Model �`�'i
---- ___ _
License Plate Number 5 • _ State�Color ��c�C�.
_ ___ ------
Registered awner a.� o�Y1SOY1
Driver of Vehicle �0.� o�1S�Y1
AreaDamaged�►o�yl�' P0.SSP.yIAPX' �'►�C'f� � �i1M
- - _ _
City Vehicle: Year ake_ Model
---- _ _- _
License Plate Number State Color
Driver of Vehicte(City Empioyee's Name)
Area Damaged
Inivrv Clairns—please rnm�l�te tt�is secti�n �c:2�ck.box iC chis sec�.ic�n do�na[anoly
Hau�rtiere yau injured?_____ ___ T-
----_ _-_—
What gart(s)of your body were injured? _..__.___
Have you sought medical tic�eatment? Yes No Planning to Seek Treatment(circle)
When did you receive treazm��t? (prnvide date(s))
Ivame of Medical Praviderts):
Address Teleghone
Did yau miss work as a resuIt of your injury? Yes No
When did you mzss work? (provide date(s))
Name of your Eanployer:
Address Telephone
�(:heck here if yau are attaching ma�-e pages to this cfaim form. Nomber of additional pages�reG�2�'S
-�� �i G���
By signing this,f'orm,you are stating that all in,formaiion you have provided is true and correct to the best
of your knowledge. 1rinsigned forrrzs will not be processed.
Submi#tittg a false etaim can resuit in prosecutirrn. Date fonn was compfeted ��
Print the�1ame of the Person wlao C�mgleted this Form:��_�"`1��1`` _�^?_�0�____---
Signature af Person li-�king the Claim.
Rr,vesed I=ebrnary 2fl]l
CUSTOMER #: 739322 517357 Walser lOyOl�
*INVOICE* 4401 American Boulevard West
CRYSTAL HANSON Bloomington, MN 55437
648 EAST IVY DUPLICATE 1 Phone: 1952) 888-5581 • Fax: (9521 885-5491
ST PAUL, MN 55106 PAGE 2 www.walser.com
HOME :415-827-8151 CONT:415-827-8151
BUS : CELL: SERVICE ADVISOR: 5787 MICHAEL WHEELAND
COLOR YEAR MAKE/MODEL ' VIN LICENSE MILEAGE IN /OUT TAG
13 TOYOTA SCION TC JTKJF5C79D3057240 11421 11421 T7012
DEL. DATE PROD. DATE WARR. EXP. PROMISEO PO N0. RATE PAYMENT INV. DATE
25MAR13 D 21 : 00 19MAR14 0 . 00 CASH 19MAR14
R.O. OPENED READY oPTioNS: DLR: 3 6 9 0 ENG: 2 . 5 Li ter
09 : 01 18MAR14 11 : 59 19MAR14
LINE OPCODE TECH TYPE HOURS LIST NET TOTAL
********************************************* h
***CASH VMC DZSC AE CHK ***
*********************************************
THANK YOU FOR YOUR BUSINESS
IJRISFk bWOM11J(iION IOYOIA
4401 �IIERICAN HLVU LItST . � � �
BLOOIIIN(iIUN, fIN 55437 � � �� � � �� � � � �
�952) 8NU-S5F31
II„�hant lU: k7tltl01�J324129 - _
Ref n: U�11.
. . . .._.. .... .
Sale
, .
_ ; , i.:
.
;:. ; ., ' _ �;�._.f
�.��
_ _ _. _
��XxxKi�.x;xx.ti21i2
VISR Entry Method: Saiped
lotal: Z1,94
n3�19�14 15;34;3S
Ina �; 51�35Z Rppr Code; O�i944
iransactia� ID; 1644Z8740�SZ331 .
Rparvd; Online Batcha: 00��11 \
_ PAID
� Custumzr Covr . . .. .� .v �+v`V/ �
1HANK YOU FOR YOUR BUSINESS! I
�
ALL PART� NEW ORIGINAL EQUIPMENT, UNLESS OTHERWISE SPECIFIED DESCRIPTION TOTALS
Thank you for this opportunity to serve you. It is our aim to perform all the repairs requested �ABOR AMOUNT 10 9 . 9 9
on this repair order to your complete satisfaction. If our service was satisfactory tell your PARTS AMOUNT 4 7 8 . 4 0
friends. If not please tell us immediately. GAS,01�, LUBE 0 . 0 0
"Any warranties on the products sold hereby are those made by the manufacturer. The SUBLETAMOUNT 48 . 59
seller Walser Toycta hereby expressly disclaims all warranties, neither express or implied, MISC. CHARGES -2 9 . S 4
including any implied warranty of inerchantability or fitness for a particular purpose, and TOTAL CHARGES 6 0 7 . 14
neither assumes nor authorizes any other person to assume for it any liability in connection
with the sale of said products." LESS INSURANCE � . 00
SALES TAX 3 4 . 8 0
X PLEASEPAY
CUSTOMER SIGNATURE THIS AMOUNT 641 . 94 �
��l/�
c�or�eni zpoo nov,m�.seAViCe ir+voiCe rvve 2�Si�C CUS TOMER COPY
CUSTOMER #: 739322 517357 V1/alser Toyota
*INVOICE* 4401 American Boulevard West
CRYSTAL HANSON Bioomington, MN 55437
648 EAST IVY DJPLICATE 1 Phone: 1952y 888-5581 • Fax: i952} 885-5491
ST PAUL, MAI 551�5 PA�E l www.walse►.com
HOME:415-827-8151 CONT:415-827-8151
BUS: CELL: SE:RVICE ADVISOR: 5�87 MICHAEL WHEELAND
COLOR YEAR MAKE/MODEL VIN LICENSE MILEAGE IN!OUT TAG
�3 'T'f1Y(�`PA_ �CZQLiI TC �7TK�7E5C79��3057240 11421 11421 7012
OEL [3ATE PRQD. QATE WAflR�EXP. PRQh11SE-� PO F10. RATE PAYMEi�1T INV_ OATE
25MAR13 D 2I: 00 19MAR14 0 . 00 CASH 19MARI4
R.O. QPENED FEADY oPrtoNS: DL Z:3 6 9 0 ENG:2 .5 Li ter
09 : 01 18MAR14 11:59 19MAR14
LINE OPCL�L�E TECH TYPB HL�LtRS LIST NET TOTAL
A CTJSTOMER STATES HIT POTHOLE ON PASSENG:ER FRONT. CHECK AND ADVISE ON
AN'� r�I3DITIONAL P.fAa'�sE. WILL I+tEED NE�'7 R�?�7 AI�T� T'IRE i���
235/35/19
CAUSE: The tire was demounted, and replacement tire was remounted,
balanced, and tixe pressure was set. (One}
WH10 Mount & Balance Tire {1)
i��� �g 2Q_OQ 20. 00
T�RViI WHEEL WEIGH'I'S/FZCTBSER VALVE STE�'1 IF NEEDE�
2 .Ofl 2_QQ
TIRD1 TIt2E DISPOSAL ONE 3 . 00 3 . Oa
1 PTR56-21.11.0 TRD TC 19 7SPK WHEEL 275 .00 275 . 00 275 . 00
1 DT001-98040-TY TOYO 203 . 40 203 .40 203 .40
CX9YEFH2�ll ,
, , , , 11421 z-ep3aced rirtr and tire, na �ent sus�e�tsion cozripr�nents, all ok
, , , ,at this time
�*�***��*�*****�*�***�*****�***�#*��**��***�*-���**�*
B** CUSTOMER IN NQ CHARGE RENTAL
SB1 Sublet Rental
99 CP 0. 00 0. 00
RVE DISCOUNT-RENTAL VEHICLE DISCOUNT -46 . 59 -48 . 59
SUBL CUSTOrTER IN NO �?A�FtGE RENTAl, P0�'s2U392
CP 48. 53 46.53
***�***�***��*��*��**�****�*���t�*��#��*#��**��*�****
C** WHEEL �',LIGNNfENT
CAUSE: An alignment was performed on toc�ay' s visit. Any adjustments
needed were made to the caster, camber, and toe angles .
AL1 WHEEL ALIGNMENT
165 CP 8�• g� $�' ��
, , , , 11421 PERFDRI�ED 4 W�iEEI� AL7GNI�IENT
*****************�***�**��**�***�******�************
�
ALL PAR'-S NEW ORIGINAL EQUIPMENT, UNLESS OTHERW(SE SPECIFIED DESCRIPI'ION TOTALS
Thank you for th�s opportunity to serve you. It is our aim to perform all the repairs requested �gOR AMOUNT
on this repair order to your complete satisfaction. If ou� service was s�tisfactory tefl your PARTS AMOUtJT
friends. ff not ptease teti us immediatety. GnS,oi�,LUBE
"Any warranties on the products soid hereby are ttiase made by [he martuPacturer. The SuBtET AMOUr�T
seller Walser Toyota hereby expressly disclaims all warranties, neither express or implied, MISC.CHARGES
inciuding any implied warranty of inerchantability or fitness for a particufar purpose, and TOTAL CHARGES
neiiher assumes nor author'rzes arty other persorr to assume for it arry�+ability in conr�eci+on
with the sale of said products." IESS INSURANCE
SALES TAX
X PLEASE PAY
CUSTOMER SIGNA7URE THIS AMOUNT
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