Johnson, Donna REC�IVED
APR 0 9 2014
NOTICE OF CLAIM FORM to the City of Saint Paul, Minn�qt� CLE�K
Minnesota State Statute 466.05 states that"...every person...who claims damages from any municipaliry...shall cause to be presented to the
governing body of the municipality within 180 days after the alleged loss or injury is discovered a notice stating the time,place,and
circumstances thereof,and the amount of cornnensation 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 eacplain 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 appiy,write`N/A'.
SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, NIN 55102
�/
First Name� � Middle Initial�Last Name 4l c1d�1 _S�r 4 l'�
- Comparry or Business Name
Are You an Insurance Company? Yes� If Yes,Claim Number?
Street Address � ` % � � = �ti� � S ��
City �L � �� State�/�,�,�� Zip Code �� ` Z
Daytime Phone ( ' `E�- �� Cell Phone( ) - Evening Telephone�) "6 - 5 t,?
Date of Accident/Injury or Date Discovered / Time � - �Y.%
Please state,in detail,what occurred(happened),and why you are submitting a claim.Pl e indicate why or how you
feel the City of SainX Paul or i�emplo ees�involved and/or respo sible for your damages.
� � t�" `�"
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. ` �`_,
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Please check the box(es)that most closely represent the reason for completing this form:
,�`: y vehicle was damaged in an accident ❑My vehicle was damaged during a tow
, y e y a po o e or condition of the str ' ❑My vehicle was damaged by a plow
��_� � y ve ic e was wrong y towed and/or ticketed ❑I was injured on City property
�_:_: ❑ Other type of properiy damage-please specify
❑Other type of injury-please specify
In order to process your claim vou need to include copies of all analicable 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 f self before submitting your claim form.
Property damage claims to a vehicle:two estimates for the repairs to your vehicle if the damage exceeds
.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-ulease complete this section �--,�
Were there wimesses to the incident? Yes � No Unlrnown (circle)
Provide their names,addresses and telephone numbers.
r
Were the police or law enforcement called? Yes No Unlrnown (circle)
If yes,what department or agency? C e#or report#
Where did the accident or injury take place? Provide street address,cross street,intersection,name of park or facility, 7
clo st la�dmark,etc. ease be as d 'led as �iss'ble. -If nec sary attach a diagram.
L` �"e? ' � ��� -r'- e� �°L �'� �� ����
Please indicate the amqµnt o�,u�a�see�p' g in cornp sation or what you would like e City to do to resolve this claim
to your satisfaction. 1 f� ���
_ - - -- --
Vehicle Claims- lease com lete this section ❑chec box if this section does not a 1
Your Vehicle: Year � Make - _Model_ . � r-
License 1 t Number t('['! �� i State�!Color L'
Registered Owner��s k� i��� �� �?�'��.� ��;�,�
Driver of Vehicle �' < <
Area Damaged�_-S�;n -� ti i S � `��'� �' S
City Vehicle: Yeaz �Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
'u Claims- lease com lete this section ❑check if this sect' dces not a 1
How were you injured? "`T� � '—'
;
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 youi`�� Yes No • �
When did you miss work? _ � ' � (provide date(s)}
Name of your Employer:
Address > Telep
Check here if you are attaclung more pages to claim form. Number of dditional pages
By igning this form,you are stating that all information you have provided is true and correct to the best
o your knowledge. Unsigned forms will not be processed.
Submitting a false claim can result in prosecution. Date form was completed
Print the Name of the Person who Completed this Form:
Signature of Person Making the Claim:
Revised February 2011
LERUM AUTO Repairorder#0034138
6420 PENN AV. S. Estimate#0034403
Date : 4/3/2014
RICHFIELD, MN 55423 Page: Page 1 of 1
612-866-8822 Center :
AUTOMOTIVE SERVICE WITH INTEGRITY
Customer: JOHNSON, DONNA Vehicle : 1994 FORD ESCORT
Address: 7205 BLOOMINGTON AVE. License : SCC113 Date :
City: RICHFIELD, MN 55423- VIN : 1 FARP15J8RW242979
HOME : ( 612 ) 869-8508 Ext: Engine : 4-116 1.9L Trans : AUTO
WORK : f 612 ► - Ext: Mileage: 6548 Colo :
Op Tech Description Labor Parts Subtotal
Quan Part Number Part Oescription Reason for Replacement Price
Service Requests:
CHECK FOR IANG TRIP
SS 0 TN RffiK1VE AND REPI+P+CE SOTH FRONT STRUT l�1ND 3PRINGS. LEFT E'kONT BROKEN SPRING. 195.78 491.78 687.56
�,�� FRC?+T STRUT/ScRiNG 491.78
_�.��._ ._., _. �
gN p RTT'✓REMpVE AND RBPLACE ENGINE OIL PAN GASRET. LEAKIN6 OIL 225.15 55.89 291.04
1.00 �T_L PAN SE'� SS.�9 -- -
UCI002 TN SAFE CAR INSPECTION - EOUND LEAXING OIL PAN GA3KET. FOUND LEFT FROZ7T COIL SPRIN( 30.00 30.00
HROICEN. SU3PECT POSSIBLE BAEAKAGE E'ROM BITTZNG POTHOLE.
3
OK Bad Recommendatian OK Bad Recommendation OK Bad Recommendation
I hereby authorize the =epair �rork ta be done along with the necessary parts 1.8b0�: $450.93
and materials and hereby q=ant you and/or your employees permission to operate Parts: $547.67
the vehicle herein described on streets, highpays or slseahere, at your aes- Sublet: $�.��
cretion, for the purpose of testing and/or inapection. An expsesa mechanies OtherFees: $0.00
lien is hereby acknowledged on the above vehicle to secure the amount of re- ShOp Supp. $39.8J
pairs thereto. I underatand that dealer/owner ia not responaible for delay or SUbtO�l: ��,038.49
other conaequence due to the unavailability of parts ahipments beyond their Sales Tax : $39.71
control. Not reaponsible for damage or articles left in car in case of fire,
Paid By: �,078.2a
theft or any other cause beyond our control. TOt31: �
WARRANTY IS 36 MONTHS OR 36,000 MILES Wtt2CH EVER OCCVRS FZRST, UNLE33 pay Ref: P81d: $O.00
SPECIFIED OTHERWISE!
x
Due: $1,078.20