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Barnett RECEIVED NOTIC� OF CLAIM FORM to the City of Saint Paul, Minnesota�� CITY CLERK Mi�uiesotu Slate Statute 466.05 stntes thnt "...everv persnn...wl�n rinims dantcrges from mry mt�nicipn/ity...sl�a/l cnttse In be/»'ese�ttet tn!he gorerning budy of'the rnunicipnlity withi�i I80 days nfter the n!/eged/oss or injury is discovered a notice stnti�rg the time,p/ace,anrf circuntstcrnces t/tereof,and dte mm�unt of compensatiort or other relief demanded.° Please complete this form in its entirety by clearly typinfi or printing your answer to each question. If more space is needed,attach additional sheets. Please note th:it 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 WE�T KELLOGG BLVD, 3�0 CITY HALL, SAINT PAUL, MN 55102 First Name �� Middle Initial Vv Last Name f�tl" ��'�� Company or Business Name Are You an Insurance Company? Yes No If Yes, Claim Number? Street Address lQ�d �U`-�� -'�/� '� 'V " �v City`,'��,FJU'V� State T� Zip Code �i G� Daytime Phone �)�l �L!�Cell Phone (�� `�-��Evening Telephone��-�� r Date of Accidentl Injury or Date Discovered .�)" Time�am/ Please state, in detail, what occurred (happened), and why you are submitting a claim. Please indicat w or how you f el the C.it of Saint 1 or 'ts em 1 yees are invol�� or res onsi le for your dam� es. � � rl 1 ' . Please check the box(es)that most closely represent the reason for completing this form: ��ehicle was damaged in an accident ❑ My vehicle was damaged d�rring a tow y vehicle was damaged by a pothole or condition o�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 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 Faiture 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 Unknown (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? ase#or report# Where did the accident or injury take place? Provide street address,cross street, intersec name of ark�or facility, c sest la dm �, etc.��j ase.be a• eta�ledf��,�ossibley If necessary, attach a diagram.� i �9�' l�t 1li Please indicate the • unt ou are seel:ing in co� pensati or w at o w d �ke th Ci y to do to resolve,� is clai t �(satisfactio . �.J U ' { ��,. ;..� r� . . . - ..o,..;,.-, + --- --rrt�i��c�cifiiiifS- �@€19�t't'i E'�c��}f �iAfk- - - - _ _ Check�an 1��n3�,c�.�Frfii'.S itc�I ' ^� . Your Vehicle: Year Make Model License Plate Number S e Color ' � Registered Owner � — Driver of Vehicle Area Damaged City Vehicle: Year Make Model License Plate Number State Color Driver of Vehicle (City Employee's Name) Area Damaged In�urv Claims-nlease complete this section ❑ check 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 Provider(s): Address elephone Did you miss work as a result of your injury? Yes No When did you miss work� (provide date(s)) 1Vame of your Employer: -----—.—. - -- _ _ _ - --- __ H ress Telephone ❑ Check here if you are attaching moi•e pages to this claim form. Number of additional pages By signing this form,yore are stating tliat all information you have provided is true and correct to the best of yor�r knowledge. Unsigned forms will not be processed. Stebmitting a false claim can result in prosecrition. Date f'orm was completed ,f- ' �4 �(��--- Print the Name of the Person who Comp ted thi orm: Signature of Person Making the Claim: Revised February 201 I LE'S AUTO TECH Sub Estimate For Order# 468 UNIVERSITY AVE ST. PAUL, MN. 55103 019033 Phone-651-222-2337 Fax-651-291-5365 Customer Satisfaction is Our#1 Priority! ESTIMATE FOR SERVICES Cust ID: 6178 Estimate Date : 4/3/2014 BARNETTE,TAJUANA 2004 Jaguar-X-Type-3L,V6 (181CI) Lic#: 545KAX-MN Odometer In: 97293 Unit# : VIN# : SAJEA51C94WD91729 .,, „ .. . �. , r ' , � , � '; �...� �� ,"�� ;�� 'r. S53�A5, - � ..�(�i 'Y s ,...:.�. _ . . ... . .rw... v,:_ . . , , .....'a ... �- :� , --..�-.,,zs . _ . � ....,y . -„ ..... � �,.>rav , „ Front Hub Assembly - emove ep -�- 80.4i3 513169 1.00 167.83 167.83 Front,One Side Shop Supplies 4.00 Rev Amnt: 264.63 Parts: 171.83 Labor: 80.00 Tax: 12.80 Total: $264.63 I hereby authorize the above repair work to be done along with the necessary materials.You and your employees may operate the above vehicle for the purpose of testing,inspection or delivery at my risk.An express mechanic's lien is acknowledged on the above vehicle to secure the amount of the repairs thereto.You will not be responsible for loss of damage to vehicles to articles left in the vehicle in case of fire, theft,accident or any other cause beyond control. Signature Date Time Page 1 of 1 Copyright(c)2014 Mitchell Repair Information Company,LLC esthrs 09.12.1 ttKYK v�scouNt� T 1 R E ��1�,�, discounttire.com DA7E: Q�3-31-�0i4 TIME: 9:�5 AM . .- . .• . .- . . TAJL�flIVA PARNETT �Q�Q�4 3AGUAR MNM Q�fi 1'3�� FER�NIA AVE X-TYG'E 1350 UNIVERSITY AVE WEST 17-INCN 3.0 SF'ORT SAINT RAUL. MN JJiQ��F SAINT F�f�UL PiN JJ1�4 MILEAGE: 57, 1E6 F'HDNE: 651-641-8�1� (H) E�51-`1E-�4Q�8 0L1 DANIEI. A WOODS TORG?UE 5F'EGS: Q+75 WORK �RDER# .. . . • • �875� NRI� 4 L3�i45ZR-17 XL 97W FALKEh1 ZIEX ZE-51� .0u E�1.�6 245.04 WARRANTY: MILEA6E- 3Q�,Q�00 SEE REUERSE SIDE FOR W�IRRANTY DETAILS COMMENTe BOLT RATTERIV: 5-iQ�B COMh1Ei�T: I NFLAT I DN F:�5 R:33 8��4 NRM 1 WA5TE TI RE DISF�05AL FEE •�� •�� •�� BQ��19 NRI� 4 I NSTALLA7I OiV R L I FET IME SF'I N PflLANC I N� .Q�� 16.�Q� 64.@0 8Q�4Q�� NftM 4 VALVES/RCiTAT I ONS/ L I FET I I�E REG'A I RS I NGLUDED . �0 . �� •�� 8Q�13(� NR�i -3 TRADE-IN TIRES TRADE-Ii� TIRES .�� .�� -7�.�� The tir�e and/or, wheel yo�_� have chosen is different from the original equipment provided with yo�_�r� vehicle and may change its handiing or stability chat,acter�istics. Further infarmation is available from your Disco�_�nt Tire s�lesperson. SUPTOTAL: 237.@4 TAX: 1:'_.96 TOTAL: �SQ�.�� CASH: �00.0Q� XXXXXXXXXXXX iQ�40 VISA: 50.Q�� TENDERED: �5@.Q�Q� 5ignature on file �� i oo�� recyclable paper :�;;�., .� �-�":�..� � -y. .., ��.<, �I'1'ED WARRAN'I'IES �' ' �r' .��' Discount Tu e and America's Tire Stores �A., �. .�.-;}F. . ��RT/F/CATE � $LIGIBILII'T-These Limited Warranties apply to all owners of the tire using •�„ � it in noncommercial service,except for the Mileage Warranty which is limited �:o to the original purchaser. �4�, FOR REPAIR REFUND OR REPLACEMENT ` :��7 ` + ,v TO MAKE A CLAIM-Present your t've(s)and original sales invoice to any �;; � Discount Tire or America's Tire Store.To locate a store you may call 1{888)774- For a fee collecred at[he time of the ori tire urchase or for a fee collected to sub ect "'�� 6560,or visit[he Discount Tire web site at www.discounttire.com.The vehicle 1."' 8� P I other tires[o the[erms of this certificate, Discount T've or America's Tire stores will on which the tire was used must be available for inspecUon.You will be askea �+' refund the purchase price and[he sales tax,if any,on any tire covered in the event of a w to complete the customer portion of the adjustment claim form. ��'' failure due to workmanship and materials or a non-repairable road hazard for the service �;' � ��•:�ry of the original tread down to 3/32 inch remaining, or 3 years from date of purchase, .a. �NARRANPS COVERAGE �':ti' whichever occurs first.Upon refund or credit of sales[a7c,wstomer hereby acknowledges �` � � New Tires-Workmanahip and Materials-If our examination shows �/�;�_ by actual signamre or electronic signature capture such credit or refund.This additional �� that a assen er,SW,or li t truck tire covered b this waman has become 4��t : acknowled ement satisfles a technical re uirement in the sales tax statuces and/or p g � y ty g Q unserviceable due to a workmanship or materials defect dw�ing the service /��:4 regulations for many jurisdictions that a signed receipt must be obtained upon the refund �;,�p down to 3/32 of an inch,i[will be replaced on a pro rata vead weaz basis. a,y+� or credit of sales taxes.At the election of the purchaser,we wID sell a replacement tire _ ''��g to the purchaser at the original price paid for the damaged tire,plus the required sales 1=¢�'� New Tires-Road Hazard(if applicable)-If our examination shows that �+��`r - �"`'�`�'a a assen er, SW,or li ht truck tire covered b kt�'+: . tax.In the even[the covered tire is discontinued or unavailable,a tire of similar value will �;;:;�)� p g g y this warranty has become :�� -:�.y,� unserviceable due to a normal road t�azard(i.e.,non-repairable puncmre,cut, ;,:;:� be substimted � — s�g,bruise,or impact bmak)during the service down to 3/32 of an inch,it "�� wil!be re laced on a ro-rata tread weaz basis. If in our opinion,the tire can be safely repaired,we will do so free of charge.The cost of P P this certificate is set for[h on the receipt issued for the purchase of t've(s). -=a;�,, New Tirea - Mileage Warranty (if applicable) - In addition ro the ��'%"'" warranties above, eve milea e warranted assen er, SUV or li t truck . This certificate will be honored at any Discount Tire or America's Tire stores.This certiticate �-�;�f ry' g p g � �-:�� tire is warranted to the original purchaser for the specifled number of miles dces not cover damage caused by collision,vandalism,chain damage,mechanical defects :�:�� of tread wear and a au�st normal road hazazds for the same milea e (if '�� of the vehicle or willful abuse.No other property damage or consequential damage of any r.c=''�'��' g g �. appticable).If our examination shows that the tire covered by this warranty L�, kind is covered by this certificate .-.,a";�vy� has wom down to its tread indicators before giving the specified number '"�' �''.�'''' of miles of noncommercial service on the assen er,SW or li > There wi11 be additional charges to purchase a new certificate for a replacement[ire and P 8 ght uvek on �'�.+. ; to balance a replacement tire. -.;:;;} which it was installed,it will be replaced on a pro-rata mileage buis. �">' =`.'%'� ATV/Trailer Tirea - If our examination shows that a trailer or ATV tire �.1,^ By redeeming this certiticate,the customer relinquishes the right to any manufac[urer's �:j�� covered by tltis warranty has become unserviceable,other than b a road 4ti'r�',. - warranty that may apply,and Discount Tire or America's Tire may claim for its own benefit ' .��,�}�' hazard,during the three year period following its date of purchase,it will any such manufacturer's warranty. „=., ;�e, be replaced based on a charge of 33%per year or part thereof of the original �� purchase price. � • � • • ��.:?s��,.. �;�aa - ` �,� CAI.CUI.AIYON OF REPI.ACSMEIVT CHARGES - Tires are replaced under these limited warranties with a comparably priced new tire at a prorata i'�' ��;j? cost to the customer.Tread weaz is ro-rated on the basis that the tire is wom eY D'��Q�� {;!,r ou[when ffie tread is wom down to 3/32 of an inch remaining tread groove n''�� ;�� depth or to the tread weaz indicators on tires containing them.Tire replacement �`� �., cost is determined by multiplying the original cost of the tire by the percentage T ' � � of tread used For example,if the original tread was I1/32 of an inch,and the �:• ." '"'•`�' tire has 5/32 of an inch of tread remaining at the time of replacement, the �+' 1, replacement cost will be 75%of the original cost((11/32-5/32)/(11/323/32) �';.• �y, x 100).The replacement cost for mileage warranted tires is prorated at a set h�l•� r��v�:� �,.,� charge per 1,000 miles drivea F.E.T.and state taxes are added to the mplacement � ;> ��'� cos4 Addidonal chazges for mounting and baLwdng apply. �� P�iti�: s;� �'w • . � A�1�1.�.��r5a!,�,�,�9.�tie�O�y�. 'S r!��Ay'i ��f�'�'��'' � 'f ��}'t� I1'EMS NOT COVERED-These warranties do not cover: The cost of any tire includes any wheel weights used in the balancing of the tire. • Use in commercial service such as commercial truck racing,street sweepers,off-the-highway taaci,limousine,or similar service(however commercial service does not include use by the owner as transportation in his/her regular trade or business); TI PS TO I M PROVE TI R E ' Damage,deswction,or faifure due to accident,fire,or vandalism; • Irregular or premature tread wear caused by improper intlation, M I L EAG E A N D SA F ETY misalignment,imbalance of wheels,or wom out shock absorbers or br,�krs; • Damage or failure due[o non-tire causes such as being run flat,mechanical condition of the vehicle,cuts from rims or chains,or any willful abuse; �J�ROTATE TIRES � REPLACE • Problems related to the appearance of the tire after the first 10%of weaz. �� every 6,000 to 8,000 miles or when worn-out tires when built•in wear bars OWNER'S DUTIES-Ic is the owner's responsibility to: necessary to equalize treadwear. appear across the tread surface. • See that the tires are operated at proper inFlation,pressure and loads; , �REBALANCE � REMEMBER TO RETURN ' Pay applicable taxes and dealer services such as mounting and balancing; every other rotation to promote even to any Discount Tire/America's Tire store ' Retum the adjustable t've and complete the customer portion of the tire wear and a smooth ride. for a tire inspection. ad��scmenc�taim torm. DURATION OF COVERAGE-These warranties expire three(3)years from MAINTAIN AIR PRESSURE � the date of purchase. as recommended by the vehicle or tire manufacturer.Cheek your air pressure at least � 1 � � CONDITIONS AND EXCLUSIONS - These timited warranties are cne exclusive warranties of Discount Tire or America's Tire stores,are in lieu of the onee each month when tires are cool. warrancies or cne manufaccurer,and set forth the exclusive remedies available to the tire user.In the event that the terms of an applicable manufacturer's warrenty �MAINTAIN ALIGNMENT exceed the protection given under these warranues,Discount Tire or nmerica's �F�Of1t&R@8f)�2P�8CE WOffl SUSp@fISI0f1 PdrtS �. Tire srores will honor those terms.Discount Tire or America's Tire may claim A'� ��,+' for its own benefit any such manufacturer's warranty These limited warranties �"" � do not provide compensation for any consequential, special, incidental or �PLEASE DO NOT USE � contingent damages. Some S[ates do not allow the exclusion or limitation of incidental or consequendal damages,so the above limitation or exclusion may any"Fix-a-Flat"type produets. � \�� .�' not apply to you.Tires presented for a claim remain the property of Discount S� � , �+��t� Tire or America's Tire Stores.No representative or employee of Discount T've or INSPECT America's Tire Stores may enlarge or alter these warranties. tires occasionally for excessive wear,tread eoxsuniEn nisx�rs - �rnese i;micea warranues �;ve you specie,c iegal or sidewal�cuts,or other damage. righcs,and you may also have other rights which vary hom State to State. .r� �`� s � � � � � � � � � � s � � � � � � i :i � � � � � ,�