Hamilton NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minnesota State Statute 466.05 states that "...ever}�person...who c/aims damages from any municipalit}�...shaR cause to be presented to the
governing body of the rnunicipalit��within 180 dnys after the alleged loss or rnjury is discovered a notice,rtating the time,place,and
circumstnnces 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 I�1ame��iel l��' Middle Initial�Last Name r� T�// i�LT��
Company or Business Name
Are You an Insurance Company? Yes/ i�jc If Yes, Claim Number?
Street Address � ��� �x����`-�� ��'
City 1( �1i� �V/�L� State /v//� Zip Code_����L-L,�
Daytime Phone (�r��Cell Phone( ) - Evening Telephone( ) -
Date of Accidend Injury or Date Discovered Time am/pm
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.
Please check the box(es)that most closely represent the reason for completing this form:
❑ 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 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 Z—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-nlease complete this section .--
Were there witnesses to the incident? Yes No �Unknown�� (cirde)
�_.__._ _
Provide their names, addresses and telephone numbers:
Were the police or law enforcement called? Yes CNo' Unknown (circie)
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 or facility,
closest landmark,etc. Please be as detailed as possible. If necessary,attach a diagram.
�� . �m� s-�-T-�,�- � sr�,�z�� .��� , �� ����rL .
Please indicate the amount you are seeking in com ensation or what you would like the City to do to resolve this claim
to your satisfaction. � � '- ✓� �
� . _ . - ia G�r�e�1�r�
�!'� !�b
Vehicle Claims-gl�ase complete this sectian ❑ check box if this section does not apply
Your Vehicle: Year 2U�Make V Vl� Model ��TT'�-
License Plate Number State�Color�''�/ 1��_
Registered Owner ��,�/ti11� ��j'�i� j///V �LZ,{�!�?��% )
Driver of Vehicle ��'T,�I/LJf3 ,�'�/Li D�1
Area Damaged��11�?(��13�i ;t�,L-/!/��-�fYO� �2G��1"��,��1�1",� j/2t=�//rU �'�6/Y'
City Vehicle: Year Make Model �'�N�
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 more pages to this claim form. Number of additional pages.�.
� �
By signing this form,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 �����5 � /��
Print the Name of the Person who Completed this Form: ��� / ��/v� 7%����TU�°L/.
Signature of Person Making the Claim: `
Revised February 20l 1
.. � Luthe W�stside �
� Volkswagen
\ 2370 South Highway 100
St. Louis Park, MN 55416
Ph: (952) 377-410b Fax: (952) 374-0755
www.westsidevw.com
CELL: 651-274-1403
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RES��EP�op�_1403 ��SS�-9525 ,�°M�°,E"TS � � Mo: 68452
•--•-------------•---------------------•-----------------•--•----------------------------- We believe n� followmg certain principles when we
Interact with others_Our behavlor should be a reflection
*,r**************************************�r�r****,t*****�x****�x TOTAL LABOR.... 203.65 �!u,es�p-����pies:.
TOTAL PARTS.... 424.92 /airness human d;gniry potential
Thank you for selecting Luther Westside Volkswagen for your TOTAL SUBLET... 0.00 ��reg�;ry service growth
service needs. You may be receiving a survey from the TOTAL G.O.G... 0.00 Tnese������o�es�a�be«a�s�aced��to P�a�t��es Wn��n
manufacturer in the near future. We would appreciate you TOTAL MISC CHG. 20.37 9�'de�S'�°�"�`e'a°°°�S""in ome�peoP�e.
taki ng a few moments to compl ete and return thi s survey. The TOTAL MISC DISC u we a�P fair We clearly state our expectations.We do
not intemionally misrepresent ourselves or our
information is very valuable in helping us to improve the TOTAL TAX...... 30.91 products.
servi ce we provi de to you. I f you have any questi ons or ---•---- ❑we keeP�,om;ses a�d,�,,;,,eXPe�,a,;o�s.
concerns, please contact us at (952)377-4100. TOTAL INVOICE$ 629.8.5 r;�ye treat everyone with respect and courtesy.We
acknow!edge and greet every person.We answer
****'�'*******'F**i`�`**�`�`i`**�`*'ti�`***�`�`********�t****************** the telephone in a friendry manner, giving the
company or departmeni name and our own name.
V151t our web site at www.l utherauto.com or our Facebook ' wE are unconditionauy ot service to our customers,
page at www.facebook.com/luther.auto.dealerships for special �omm���t�es a�d each other. We welcome me
offers, contests, videos and more!! oPPo�1���}v 1�be of service.
�We respect the environment.We do not litter,polWte
or��ntentlona�ly damage the environment.
� We believe that every person has potential. We
provide each other with an environment that
encourages growth and development. We are
patient with others.
� tl�� Kecp a(Great Thing Going
�� Gcnuinc VW Parts&Scr�ice
STATEMENT OF DISCLAIMER
The factory warranty constitutes all of the
warranties with respect to the sale of this
item/items. The Seller hereby expressly
disclaims all warranties,either express or
implied, including any implied warranty of
merchantability or fitness for a particular
purpose. Seller neither assumes nor
� authorizes any other person to assume
for it any liability in connection with the
sale of this item/items.
\ O ALL PARTS NEW ORIGINAL EQUIPMENT
o � � UNLESS OTHERWISE SPECIFIED.
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.. � Luthe W�stside �
«� Volkswagein
, � 2370 South Highway 100
St. Louis Park, MN 55416
Ph: (952) 377-4100 Fax: (952) 374-0755
www.westsidevw.com
CELL: 651-274-1403
CUSTOMERNO. '��S��B 663'��'A°�'°8586 '�""°�6�y�1/14 I��"$18540
LABOR RATE � E ,M1�AG� - '�— �I STOCK NO.
2854 OXFORD ST �AG���A�E , 68,446 �°��`�/ER/ �
KATRINA HAMILTON �
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ROSEVILLE, MN 55113-6102 _ —
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We belleve in foltowing certain pnnciples w en we
interact with other;.Our behavior should be a retlection
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,J# 4+OIVWZZ4WA 4 I�fliEEL ALIGNhfENT TEGH(S)s499 134.95 tai-�z�s n�ma� di9niry potential
PERFORM FOUR WHEEL ALIGNMENT PER CUSTOMER REQUEST. inte9riry serv�ce 9rowtn
PREVENTIVE MAINTENANCE. These princip:es can be translated into practices which
ALIGNED VEHICLE TO FACTORY SPECIFICATIONS. guide us m o�r inte�actions Witn otner peop�e.
`!We are fair.We clearly state our expectations.We do
��� 4 T�TA�$- not intentionally misrepresent ourselves or our
--------------------------••----------------------------•--
LABOR 134.95 P`°d�°ts.
❑ We keep promises and+ulfill expectations.
J�� 4 JOURNAL PREFIX �$ J�� 4 TOTAL 134.95 --"`�e treat everyone with respect and courtesy.we
acknow!edge and greet every pe�son.We answer
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company cr department name and our own name.
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,3# 5+02VWZZRBATT BATTERY TEST•RfD TECH(S):499 0.00 �omm��ities a�d ea�n otner. we we�oome tne
TESTED BATTERY AND FOUND TO BE IN POOR CONDITION. oPportunity to be ot ser�ice.
BATTERY FAILED QUICK TEST G we respect the ernironment.we do not litter,pollute
or inientlonally damage ihe environment.
J0� 5 TOTALS----•----------------"""""""""'""'""""""'""""""'�� 'r=�`/e be�ieve that every person has potential. We
provide each other with an environment that
JOB# 5 JOURNAL PREFIX VWLS JOB# 5 TOTAL 0.00 encoura9es 9row;h and devetoPment. we are
patient with others.
MISC------CODE---•----DESCRIPTION---•----------•--------•-------CONTROL NO--------- '`� Kecp a GreatThing Goiug
JOB # A SS S ENVIRONMENTAL DISPOSAL 20.37 �,,`��,� Genuine VW Parts&Service
j TOTAL - MISC 20.37
ESTIMATE------------------------•------------------•------------------•--------•--- STATEMENT OF DISCLAIMER
CUSTOMER NEREBY ACKNQWLEDfES RECEIVING The factory warranty constitutes all of the
ORIGINAL ESTIMATE OF E800.01 (+TAX) warranties with respect to the sale of this
GOMMENTS•------------------------•--...----------------•-------•------•------•--
GUSTOMER HAS BEEN SUPPLIED WITH A RENTAL VEHICLE CCC Appointment'cr item/items. The Seller hereby expressly
eated 2014-03-20 06:02:OOpm taken by Kevin Bednarek disclaims all warranties,either express or
implied, induding any implied warranty of
merchantability or fitness for a particular
purpose. Seller neither assumes nor
authorizes any other person to assume
for it any liability in connection with the
sale of this item/items.
� ALL PARTS NEW ORIGINAL EQUIPMENT
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.: � I.uthe Westside �
� Volkswagen
� 2370 South Highway 100
� St. Louis Park, MN 55416
� Ph: (952) 377-4100 Fax: (952) 374-0755
www.westsidevw.com
CELL: 651-274-1403
CUSTOMER NO. ��/��S 9���B 663 TAG N08586 I INV�� T�1 14 I
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KATRINA HAMILTON � '
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2854 OXFORD ST R � —�oEU�� ioeuveRVMi�es
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ROSEVILLE, MN 55113-6102 — -
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RE��E�9"�_1403 �'g'�S`�'�E 9 5 2 5 �aMMEN�5 Mo:
---------------------
""'"' We bsLeve In following certain principles w en we
interact�.vith others.Our behavior should be a reflection
��{Z---------------'---'- -----------'--------------- -•------------'------- oftheseprinciples:
54.U0 `
,3# 1 03VWZZpLUG TIRE REPAIR PLUG ' ' TECH��):499 fai�ness numan d�9niry Potent�a�
C/S: Customer states hit pot hole and hub cap fell off. Whee ;,,�eg�;ry service growfh
1 may be bent. Please check and advi se. Just left front hit These principles can be translated into practices which
pot hol e guide us in our interactions with other people.
THE RIGHT REAR AND LEFT FRONT WHEELS ARE BENT. `we arE tdir.�ve��ear�y state o�r eXPectatio�s.we do
TIRES LOOK ALRIGHT noi intentiona��y misrepresent ourselves or our
REPLACED BOTH THE LEFT FRONT AND RI6HT REAR WHEELS P`°d�°ts.
�We keep promises and fulfill expectations.
PARTS------QTY---FP-NUMBER---------------DESCRIPTION--------------•-----UNIT PRICE- ❑we treat e�eryone with resPect and courtesy.we
2 5K0-601-027-A-03C WHEEL 152.13 304.26 acknow�ed9e and 9reet e�e�y person.we answer
the telephone in a friendiy manner, giving the
2 1K0-998-275 REPAIR KIT � TOTAL - PARTS3 367.52 ccmPa�y or dePa�tmen,name and ou�own name.
❑We are unconditionally of service to our customers,
communities and each other. We welcome the
MISC------CODE-------•DESCRIPTION------------•----------'--•----CONTROL NO-----•--- oPPort��itytobeotservice.
I193 INTERNET LABOR DISC-NO CODE fOUND -25.00 � We respect the environment.We do not litter,polWte
I193A INTERNET PARTS DISC-NO CODE FOUND -25.00 or intc�uoca!�y damage tne P���i�onment.
TOTAL - MISC -50.00 r We be�ieve that every person has potential. We
provide each other wlth an environment that
encourages growth and development We are
�OR atient with others.
JOB# 1 TOTALS---------------•---------•------ 50.00 p
PARTS 367.52 "� Kcep a Grcat Thing Going
MISC -50.00 i,���/l� Gei�uine VW Parts&Service
JOB# 1 JOURNAL PREFIX VWLS JOB# 1 TOTAL 367.52
J0� 2 CHAR6ES------------•------------------------------•--•----------•----------------------- STATEMENTOFDISCLAIMER
LABOR------•---- -•---------------
_______________________ The factory warranty constitutes all of the
3# 2 45VWZZ(tENTAI... RENTAL-CUSF/EXT���WARR.�. ��= � �- T��HES?��99- � � � �� � �•��������'warranties with respect to the sale of this
CUSTOMER HAS BEEN SUPPLIED WITH A RENTAL VEHICLE item/items. The Seller hereby expressly
RENTAI VEHICLE. disdaims all warranties, either express or
implied, including any implied warranty of
JOB# 2 TOTALS-------•----------"-""'-""'-""'""��-���-� � merchantability or fitness for a particular
JOB# 2 JOURNAL PREFIX VWCS JOB# 2 TOTAL 0.00 purpose. Seifer neither assumes nor
authorizes any other person to assume
JOB# 3 CHARGES------------------"""""""'"""'"-������'' � � for it any liability in connection with the
------- sale of this item/items.
� u�oR---------------�----------------------------------------------------- -� ia.�a;
o ,}# 3 OIVWZZOF OIL & fILTER'CHANC-� ' "TECHfS):499 ALL PARTS NEW ORIGINAL EQUIPMENT
o PERFORM ENGINE OIL AND FILTER CHANGE PER CUSTOMERS REQUEST. UNLESS OTHERWISE SPECIFIED.
PREVENTIVE MAINTENANCE.
� OIL AND FILTER CHANGE HAS BEEN COMPLETED.
� PARTS------QTY---FP-NUMBER--•------------DESCRIPTION------------•-------UNIT P14C00 14.00 cusTOMERSi�NnruRe
� 1 06D-115-562 FILTERELEM �,62 43.40
� 70 G-052-167-SO ENGINE OIL TOTAL - PARTS 57.40
� JOB# 3 TOTALS---------------•---•----------------•------------------LABOR
18.70
- PARTS 57.40
9 JOB# 3 JOURNAL PREFI'X VWLS JOB# 3 TOTAL 76.10
� PAGE 1 OF 3 CUSTOMER COPY [CONTINUED ON NEXT PAGE] 04:51pm
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