Peterson RECEIVED R��=� "[F��
, MAR 312014 MAi�AR�����01k
NOTICE OF CLAIM FORM to the Cit��f Sain�Patii,� �
Minnesota State Statute 466.05 states that"...every pe�son...who claims damages from any municipality...shall cause to be presented to the
governing body of the municipality within I80 days after the aldeged doss or injury is discovered a notice stating the time,place,and
circumstances thereof,and the umount of compensurion or other relief demancled."
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 wili 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� Middle Initial�Last Name���'{r�0 v�
Company ar Business Name h �
Are You an Insurance Company? Yes No ff Yes,Claim Number?
Street Address ��lJ� 1 n�'t b1-� �'�'�'
City 5�" �'^-Ix'�' State �� Zip Code�
Daytime Phone(�)t��-��Cell Phone(�)��a- 313 Evening Telephone�)��- �J4�-
Date of Accidend Injury or Date Discovered �Y��lui ��t✓� �,�ty Time `�"'�am/�m
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 employees are involved andlor responsibl for your damages. ri v�Z � !10 �a nc�
;Y✓�` � 45�- D k.�o� a v+d ��.vo�� 1�
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Please check the box(es)that most closely rep�ent the reason for corf'ipleting`I�iis form: r� ����rz�r�ln c?�'—!�Q rYv��c�J.
❑My vehicle was damaged in an accident ❑My vehicle was damaged during a tow
�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 conies of all apUlicable 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 tickef 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 Claira Form
Failure to complete and return both pages will resWt in delay in the handling of your claim.
All Claims-alease comnlete this section
Were there wimesses to the incident? Yes No Unknown (circle)
Provide their names,addresses and telephone numbers: `�Q�t� -�d�� na'� c� �"L ���'e- D'�
W ho u u� `�- � v�a �' S � � �
�ou� 5►�� � ��--�-�a,�.s�- � �.�-�
ere the poltce or law enforcement called? Yes � Unknown (circle)
If yes,what de artment or agency? Case#or report#
.�al��C�a,l� `l�� Ci�y �o - WS w�e�•e. �/l�o�+d a� cc•w� �t CcF v� ��Sf � (�`��'
Where did the accident or injury take place? Provide street address;cross street,inte section,name of park or facility, ��►�j
closest landmark,etc. Please be as etailed as possible. If necessary,attach a diagram. r��
� �x�ey5e.c��rn e-� �'a�rvl eu►� a,u c� u..v�.�. -f-�aw� � .
Flease indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction. � �� �q S � � � �
Vehicle Claims please complete this secHon ❑ ctieck box if this section does not applv
Your Vehicle: Year � 00 Make Model p'T C�'(ul5��
License Plate Number S W�> � State �1�Color 6�H�
Registered Owner ' �f�'�
Driver of Vehicle 1'►'1�'rU ►C��_—�y�'�-� �"� �����
Area Damaged � P �,tiD�S �]"�`'� -
City Vehicle: Year Make Model
License Plate Number Sfate Color
Driver of Vehicle(City Employee's Name)
Area Damaged
In1urV Clatms please complete this section �heck 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(circie)
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? I'eS NO
When did you miss work? (provide date(s))
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 information you have provirled is true and correct to the best
of your knowledge. Unsigned forms will not be processed.
a�7 /�
Submitting a false claim can result in prosecution. Date form was compteted�h U��1 �GW� �
Print the Name of the Person who Completed this Fo
: I�ia n tr Y , �'�5 rl v1
Signature of Person Making the Claim:
Revised February 201]
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Parkway Auto Care
1581 Ford Parkway PAGE �
Saint PauI,MN 55116
(651)698-3208
Create Date: 03/21/14 16:26:13
Customer ID: 1581003919 Year: 07 DateRme: 03/22/14 13:06:55
Name: MARGY&PAUL PETERSON Make: CHRYSLER Workorder#: 98417
Address: 1787 PINEHURST Model: PT CRUISER Invoice#: 86928
Address 2: Lic No: SSW509
City,State,Zip Code: Saint Paul,MN,55116 VIN: 3A8FY68687T587890 EmailAddress:
Home Phone: (651)690-5028 Color: PO Number:
Work Phone: (612)746-0133 Engine: FleetlWholesale: N
Other Phone: (612)670-4313 Mileage In: 91571
Tax Exempt#: Mileage Out: 91571
Service comments:
BROKEN TIE ROD?
, ''Qty Part# RFR Loc Description Parts Labor Total
FRONT WHEEL ALIGNMENT
1 @FWA FRONT WHEELALIGNMENT 0.00 0.00 0.00
1 ALL LABOR 0.00 69.95 69.95
FRONT WHEEL THRUST ANGLE ALIGNMENT
TOTAL FRONT WHEEL ALIGNMENT: 69.95
TOW TO OUR LOCATION
1 @TOW TOW TO OUR LOCATION 0.00 0.00 0.00
1 TOW TOW TO OUR LOCATION 95.00 0.00 95.00
TOW TO OUR LOCATION
TOTAL TOW TO OUR LOCATION: 95.00
HAZMAT DISPOSAL
1 HAZMAT HAZARDOUS MATERIALS 2.50 0.00 2.50
TOTAL HAZMAT DISPOSAL: 2.50
OTHER PARTS/SERVICES
2 ES3173 OUTER TIE ROD END 47.04 60.00 214.08 ,
T07AL OTHER PARTS/SERVICES: 214.08
***Customer�shes To Discard Old Parts «""
I HEREBY AUTHORIZE THE WORK TO BE DONE AS DESCRIBED ABOVE.I AGREE TO PAY ON DELIVERY OF THE VEHICLE,
AND UNTIL PAID IN FULL YOU SHALL HAVE A LIEN ON THE VEHICLE FOR THE AMOUNT OWING.I FURTHER AGREE THAT YOU WILL NOT BE HELD
RESPONSIBLE FOR THE VEHICLE ORARTICLES LEFT IN THE VEHICLE IN CASE OF FIRE,THEFTACCIDENTS OR OTHER CAUSES BEYOND YOUR
CONTROL. MY VEHICLE MAY BE DRNEN BY YOUR EMPLOYEES FOR ROAD TEST AT MY RISK 1 AUTHORIZE SERVICE TO BE PERFORMED
INCLUDING SUBLET WORK.I HAVE READ AND UNDERSTAND THE ABOVE TERMS.
SIGNATURE DATE
�—
THANK YOU FOR AY AMOU� ShopSupplies 19.00
YOUR BUSINESS VISA 414.95 PARTS TOTAL 19�•58
SALES TAX 14.42 �
12 MONTH/12,000 MILE TECH:OOOWID-0.00 DICK LABOR TOTAL 189.95 -
PARTS&LABOR WARRANTY GRAND TOTAL 414.95
Thanks for your business.
INVOICE INVOICE ParkwayAuto Care INVOICE INVOICE
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