Warkel RECEIVE�
APR 012014
NOTICE OF CLAIM FORM to the City of Saint Pau1, 1V���iL�s�aERK
Minnesota State Statute 466.05 states that"...every person...who claims damages from any municipaliry...shall cause to be presented to tlie
governing body of the nzunicipa/ity within 180 days after the alleged loss or injury is discovered a notice stating the tirne,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 .�L�v� Middle Initial�Last Name �N c���e.�
Company or Business Name
Are You ati Insurance Company? Yes��If Yes,Claim Numbei�
Street Address � 2-� ���`" �^�� ''� ��
City l=c:.c c� State M� Zip Code �� �a �
Daytime Phone( ) - Cell Phone(�) ����Evening Telephone( ) -
Date of Accidend Injury or Date Discovered 3 - I� - ��(�� Time ��'�� am 7�ir
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 and/or responsible for your damages. 1 Wa S
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Pl ase check the box(es)that most closely represent the reason for completing this form:
i e unng a tow
M vehicle was damaged by a pothole or condition of the street ❑ e ic e was amage y a p ow
ype o property amage�p ease sp i
in�ury—p ease speci y
In order to process your claim vou need to include copies of all applicable 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 WILL 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-please complete this section
Were there witnesses to the incident? Yes �o Unknown (circle)
Provide their names, addresses and telephone numbers:
Were the police or law enforcement called? Yes � Unknown (circle)
If yes,what department or agency? Case#or report#
Where did the accident or injury take place? Provide street address,cross street, intersection,name of park r facility,
closest landmark,etc. Please be as detailed as possible. f ne��s sary, attach a diagram. C'(-��`� +� ���
;J�c-�b c;�v�c� S;�Q ����'�'�e v�. S��#-�-`2� ��� c1 v�c,� �r fi �� ►`��� .
Please indicate the amount ou are ekin in compensation or what you would like the C�ty to do to resolve this claim
to your satisfaction. � •�� , ��i � o C1� �-1n� rnW10 '� �lS���
� .�C� f l�Y c:h Vl � 'U �� � (' D ,n fi�^-Q C ('n Wl A � G�
�y �� pv t- v�e , 'T y,�S � �l l u c �� `x Pny E cv�.}- ��M F ��,,� �,�;� e (�
Veh1'le Claims-please complete this section � ❑ check box if this section does not apvlv
Your�ehicle: Year o�U 1 a- Make �n� �� Model �=of-v�S
License Plate Number State ��1� Colar Cz r`L
Registered Owner �S ,l� � �.`�«�k e ��� < <.� 1� W�r ����
Driver of Vehicle v � L.v�.�, e
Area Damaged F('�.�l ��SS�v�G e r �- S��e ���+c.\ � � r�--
City Vehicle: Year 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 apnlv
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 moFe pages to this claim form. Number of additional pages�.
�
By signing this fornz,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 � I � — �� � �
Print the Name of the Person who Completed this Form: �K� �� �J �2 ���
Signature of Person Making the Claim:
,%:. '
Revised February 2011
Customer Invoice TIRES PLUS Service Advisor:
193323 EAGAN 03 STEPHEN
03/16/2014 3595 KRESTVVOOD LN 651.452.4091
EAGAN, MN. 55123-1018
2012 FORD FOCUS SE
WARKEL, JOHN 4-1999 2.OL DOHC
3527 COUCHMAN RD Lic#: 1AH197 MN Vin#:
EAGAN, MN 55122 In: 03/16/14 11:30AM Mileage: 31,326
651.999.9948 x1 st Out: 03/16/14 2:30PM
Store#244209 RETAIL SALE
Rev Hist Unit Extended Job
` Description _ _ IArticle# ID Qt�_ Price Price Total
-- -- — - - ----------------------
---- -------- - ----
COURTESY CHECK 03
COURTESY CHECK 7046930 20NS 1 N/C N/C
FIRESTONE TIRE PACKAGE 03 487.80
122545 AFFINITY TOURING BL 215/55R16 93H 70,000 122545 20TN 4 131.99 527.96
Mile Limited Warranty
DOT# W2B3A1 A4813
DOT# W2B3A1 A4813
DOT# W2B3A1 A4813
DOT# W2B3A1 A4813
TIRE-DISC DISCOUNT AFFINITY TOURING BL 7011082 20TN -4 33.00 -132.00
215/55R16
NEW TIRE WHEEL BALANCE PARTS 7018708 20TN 4 3.99 15.96
NEW TIRE WHEEL BALANCE LABOR 7018716 20NS 4 9.00 36.00
TPMS VALVE SERVICE KIT LABOR 7008190 20NS 4 2.99 11.96
VS950 TPMS VALVE 6-207A 7009357 20TN 4 3.99 15.96
SCRAP TIRE RECYCLING CHARGE (1) 7075078 20TN 4 2.99 11.96
TIRE INSTALLATION 7015016 20NS 4 N/C N/C
ALIGNMENT CHECK N/C 03
NO CHARGE ALIGNMENT CHECK 7074810 20NS 1 N/C N/C
Technician(s):
20 DAVID ACEVEDO
Payment History: Summary:
Visa 7141 522.02 016257 Parts 427.88
; Total Tendered 522.02 Labor 59.92
� Shop Supplies 2.88
�_ .. Sub-Total 490.68
Tax(7.125%) 31.34
Total � $522.02
Tfiave received the above goods and/or services. If this is a credit �
card purchase, I agree to pay and comply with my cardholder �( , �
agreement with the issuer. �_-----------
� i 3v . �I
Customer Signature
Initial here to indicate you have received '
the Tire Warranty Maintenance and
Safety Manual.
All parts are new unless otherwise specified. •
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