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Barnett (2) RECEIVED NOTIC� OF CLAIM FORM to the City of Saint Paul, Minnesota 014 CITY CL� Mirri�es•o[u Stnte Stn(ute 466.05 st�les thnt "...eve�ry pe�son...whn clnims damnge.r./�rom nnv municipnlity...slrall crru.ce to he presc�rted t��lr e go��erning bu�fy of Nre m��nicipnlity witl�iii l80 days after ihe rille��ed loss or injury i.r discovered a nolice stnting tl�e�ime,place,c��d circ�uristcmces tliereof,and�he amount of compensatinn or other relief demanded." Please complete this form in its entirety by clearly typing ur 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 informatiun 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 f � ��2�:�-�- First Name ��y1.X' Y , Middle Initial Last Name Company or Businetis Name Are You an Insurance Company? Yes No If Yes, Claim Number? � Street Address 1�� City��,F_X�'�� State (�(1� Zip Code �lG� Daytime Phone (�)�l ��Cell Phone (�l ��P-�`�'�Evening Telephone ��-�� .� l r� r Date of Accidend Injury or Date Discovered �- )" i ��'�L� �� 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 Cit of Saint or 'ts em 1 yees are invol�v�e� or res onsi le for your dam� es. c � n- � � Please check the box(es) that most closely represent the reason for completing this form: ❑ ehicle was damaged in an accident O My vehicle was damaged during a tow E�'�ehicle 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 apnlicable 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. ; �, r�=: - 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��,�{ �; .'(�i�{ 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 I'ailure to complete and return both pages will result in delay in the h�ndling of your claim. All Cl�ims-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 ' n, name of ark�or facility, c sest la dm •, etc.�'_Je�ase be a eta'led��p�ible� If necessary, attach a diagram. i `� �� Please indicate the • unt ou are seel:ing in co� pensatio or w at o w d like th Ci y to do to resolva,t is clai t c�satisfactio � C.J U ' ! ` ----i�£'�iSi'��'�f2ii�l:'S— siE�a,��if� �iOli ❑ �.i��:;�:bv� ',�i�:l:, �:i:Jii ti+ii:': ii:;[ �i^••7• Your Vehicle: Year Make Model License Plate Number S(�e Color � Registered Owner 1.) `�U� Driver of Vehicle � Area Damaged City Vehicle: Year Make Model License Plate Number State Color Driver of Vehicle (City Employee's Name) Area Damaged Iniury Claims-please complete this section ❑ check box if this section does not �pplv 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 `�'�'t When did you miss work? �'""' (provide da[e(s)) I�1ame of your Employer: . ____________ _ i�dcTress —---------- - —--- - 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. Siebmitting a false claim can result in prosecution. Date f'orm was completed � Print the Name of the Person who Comp ted thi orm: f � �(��-��-- Signature of'Person Making the Claim: Kevitied 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 (181 CI) Lic# : 545KAX-MN Odometer In: 97293 Unit# : VIN#: SAJEA51C94WD91729 .. � ._, . ;�� ..: i s;� wy : ,:. , g i� �Fi z E�, i,t.^� ��'a,�, �. : : .r ., �, � ' 4'� z,d�. - . - a, +'��-�rs-s:� �.�:.��----,�.^'._ ^-z.,°-s�;c'.aw-":x�.,�..'; . � �„ �-., ti.. ,d....> . ...'=.�� ,ree,�� _� Y Front Hub Assembly - emove ep ace- � 0.�' 513169 1.00 167.83 167.83 Front,One Side Shop Supplies 4.00 I �,'.';-� . �_'1;�i� 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 NKYK �- __ _ __ _ _ �scouN � D t T 1 R E ��1�,�, discounttire.com DATE c 03—�1—�Q�14 T I ME: 9.:,5 AM . .- . . • . .- . . TAJUAIVA RARI�ETT :Q�Q�4 JAGUAI� MNM �6 19�Q� FERQNIA f�VE X—TYGE 135Q� UNIVERSITY AVE WEST I7—INCH 3.Q� SF'ORT 5AINT RAUL MN 551Q�4 5A I NT F�GUL h1N 551 Q�4 M I LEAGE: �7, i 6b F�HDIVE: 651-641-891 E tH) �51—;�i�-54Q�8 �L1 DANIE� A W�ODS TORG�UE S��EC5: �75 WdF7�{ ORDER# •. . . • • �875:� NR�1 4 �3�I45ZR-17 XL 97W FALKEN ZIEX ZE-51� .�� 61.�6 �45.�4 WARRANTY: MILEAGE— 3Q�,000 SEE REVERSE SIDE FDR WARRANTY DETAILS COMMEIVTe ROLT PATTERht: 5-1Q�8 COMMENT: INFLATIOIV F:3� R:33 , 8��4 IVRM 1 WASTE TI RE DISF�OSAL FEE .Q�� 3.Q�Q� 3.�Q� BQ��1'� NRm 4 IIVSTALLAT I OhJ R L I FET I ME SF'I N RRLANC I IVG .Q�� 16.Q�0 64.00 8Q�40� NRM 4 VALVESIRDTATIONS/ LIFETIME REF�AIRS INCLUDED .0Q� .Q�0 .Q�@ 8Q�136 NR�i —3 TRADE—IN TIRES TRADE—IN TIRES .�4� �'S.fi� —7�.4�0 The tir�e and/ar^ wheel yo�_� have chosen is different from the original eqt�ipment provided with yot�r� vehicle �nd may ch�nge its handling or stability char��cteristics. Further information is available from yattr Disco�_►nt Tire salesperson. SUPTDTAL: �37.Q�4 TAX: 1`.96 �,�; � p�, TOTAL: ��0.�Q� CASH: �0+�.0Q� XXXXxXXXXXXX i�4Q� VISA: 5Q�. 4�Q� TENDERED: �'5�.Q�0 Signature on file ', ��(� i oo�ro recyclable paper �-�.,� . ., �� .,... - -�;�. , r.�i�n wauxarrriEs ': -;:� �t ,y••��"`��,+c.,.�� A y o.. � ..��yo Y��°�;� �*v: � o ", " , d "��% Discount Tire and Amerlca s Tire Stores ri , I — '`•'� ELI6IBILITY-These Limited Warrnnties apply to all owners of the tire using C��,�,�� ` � rt in noncommercial service,except for the Mileage Warrenty which is limlted °�::� to the original purchaser. <,y.�'.�w FO R R E PAI R, R E FU N D O R R E PLACE M E NT �::;;;,Mi TO MAKE A CLAIM-Present your tire(s)and original sales invoice to any >';:,, Discount Tire or America's Tire Store.To locate a store you may call 1{S88)77¢ For a fee collected at the time of the original tire purchase or for a fee collecced to subject `"� 6560,or visit the Discount Tire web site at www.discounttire.com.The vehicle > other tires to the terms of this certi&cate,Discount Tire or America's Tire stoces will on which the tire was used must be available for inspection.You will be askeo refund the purchase price and the sales tax,if any,on any tire covered in the event of a e'�4' to complete the customer portion of the adjustment claim form. failure due to workmanship and materials or a noo-repairable road hazard for the service _ of the original tread down to 3/32 inch remaining, or 3 years from date of purchase, '"�, WARRANI'1 COVERAGE whichever occucs first.Upon refund ot credit of sales tax,customer hereby acknowledges �C New Tires-Workmanship and Materials-If our exacninaflon shows ��;°r;E• , by actual signature or electronic signature capture such credit or refund.This additional ;��,\ that a passenger,SiIV,or light truck tire covered by this warranry has become r�� acknowled ement satisftes a technical re uirement in the sales ta�c statutes and/or �'.'�� v,�' $ Q �r�,../� unserviceable due to a workmanship or materials defect during the service �ff�, � regulations for many jurisdicuons that a signed receipt must be obtained upon the refund «',f�ti4p down co 3/32 of an inch,it will be replaced on a pro rata tread weaz basis. �t��;: _ ot credit of sales taxes.At the election of the purchaser,we will sell a replacement tae ��'ta to the purchaser at the original price paid for the damaged tire,plus the req�ired sales ?_ ti New Tires-Road Hazard(if applicable)-If our examination shows that r„o. .� .,v.� a passenger,SW,or light truck tire covered by this warranry has become t;M;r',� tax.In the event the covered are is dixontinued or unavailable,a tire of similaz value will ��.;5�, ��rviceable due to a normal coad hazard(i.e.,non-repairable puncture,cut, ��r_.._�_ be substimted. � - snag,bruise,or impact break)during the service down to 3/32 of an inch,it ��I r ` If in our opinion,the tire can be safely cepaired,we will do so free of chazge.The cost of _ q�'_i will be replaced on a pro-rata tread weaz basis. � T tltis certiflcate is set forth on the receipt issued for the purchase of tire(s). �==' ,;,;, New Tires - Mileage Warranty (if applicable) - In addition to the �,,p_..__ -_-'.M1��"u� warranties above, every mileage warranted passenger, SW or light truck -__� This cert�care will be honored at any Discount Tire or America's Tire stores.This certificate �'__ � tire is warranted to the original purchaser for the specified number of miles >.:- � � _ r, i„^'- �_ .. does not cover damage caused by collision,vandalism,chain damage,mechanical defects 7•r•'v i of tread wear and against norulal road ha�ards for the same mileage (if of the vehicle or willfiil abuse.No other properry damage or wnsequen[ial datnage of any '^'�' appdcable).If our examination shows tha[[fie tire covered by this watranry kind is covered by this certificate. _, � has worn down to its tread indicators before giving the specifled number There will be addiuonal chazges to purchase a new certificate for a replacement tire and �'{'�� of miles of noncommercial service on the passenger,SUV or light truck on �r, o:;;. which it was installed,it will be re laced on a ro-rata milea e basis. �'�+ to balance a replacement tire. ,5'� p p g ` \ —�;.° ATV/Trailer Tires -If our examination shows that a trailer or ATV tire �:; By redeeming this certificate,the customer relinquishes the right to any manufacturer's ,y,, . „ covered by this watrrnty has become unserviceable,other than by a road �i,� -� warranty that may apply,and Discount Tire or America's Tire may claim for its own benefit x'y.n; hazard,during the thtee year period following its date of purchase,it will �,� any such manufacmrer's warranty. _ £� be replaced based on a charge of 33�per yeaz or part thereof of the original r ! `�� purchase price. �. � • � • • • -�.� �,,ti" �q�h CALCIILATION OF REPLACSMEIVT CHARGES - Tites are replaced °'�f' ""�� under these limired warranties with a compazably priced new tire at a pro-rata / � .., cost to the customer.Tread wear is ro-rated on the basis that the tire is worn r., , ti4� .�� ' ,��O �� ' �'�� out when the tread is wom down o 3/32 of an inch remaining tread groove ��y '`rL,� depth or[o the tread wear indicators on tires containing them.Tire replacement �� cost is detetmined by multiplying the original cost of the tire by the percentage T , � � '''4{� of tread used For example,if the original tread was 11/32 of an inch,and the ��,,�,`�. ; .��y tire has 5/3z of an inch of tread remaining at the time of replacement, the '. ,,�' replacement cost will be 75%of the odginal cost«l l/3z-5/32)/(11/32-3/32) �'% i'+,�i x 100).The replacement cost for mileage warranted tires is prorated at a set �y:3� �'••'� C� ` *ti;,� charge per 1,000 miles driven.F.E.T.and state taices are added to the replacement ��• �� cos4 Addidonal c6arges for mounNng and balancing apply. r,g� , d �� Q�� F �t��+�'•.,;�� 19�yf'�f ��. . �. { � d�... � �' 4�i4%�`� � �.�'es�r�•'�'4�4-'`��,�4�p4�4,0��4�A d�i 0 A ,fI�i��Gy f , _ ``' .�y �� _� ��✓`�'ff+.'�s!"-'`�"i,�`'',� . � t� ITEMS NOT COVERED-These warcanties do not cover. The cost of any tire includes any wheel weights used in the balancing of the tire. • Use in commereial service such as commercial truck racing,street sweepers,off-the-highway taaci,limousine,or similar service(however commercial sen�ice does not include use by the owner as transportauon in his/her regular trade or business); TI PS TO I M PROV E TI R E � Damage,destruction,or failure due to accident,fire,or vandalism; • Irregular or premature tread wear caused by improper inIlation, M I L EAG E A N D SA F ETY �salignment,imbalance of wheets,or worn out shock absorbers or brakes; • Damage or failure due to non-tire causes such as being run fla[,mechanical condition of the vehicle,cuts hom rims or chains,or any willful abuse; / • Problems celated to the appearance of the tire after the fust 10%of wear. � ROTATE TIRES __ REPLACE -_- �._ - .._..- - - _.- _- every 6,000 to 8,000 miles or when worn-out tires when built-in wear bars owxLR�s n[Tr[ES-ic is cne owne�s responsibtury co: necessary to equalize treadwear. appear across the tread surface. • See that the tires are operated at proper inflauon,pressure and loads; �REBALANCE � REMEMBER TO RETURN ' Pay applicable[axes and dealer services such as mounting and balancing; every other rotation to promote even to any Discount Tire/America's Tire store • Return the adjustable tire and complete the customer portion of the tire wear and a smooth ride. for a tire inspection. aajusrmenc ciaim eorm. DURATION OF COVERAGE-These wartanties expire three(3)years from �l MAINTAIN AIR PRESSURE � the date of purchase. as recommended by the vehicle or tire � CONDITTONS A1HD EXCLUSIONS - These limited warranties are the manufacturer.Check your air pressure at least !!�! � exclusive warranties of Discount Tire or America's Tire stores,are in tieu ot cne once each month when tires are cool. warranties ot che manueaccurer,and set forth ttte exclusive remedies available to the tice user.in the event that the terms of an applicabte manufacturer's warranty �MAINTAIN ALIGNMENT exceed the protection given under these warranties,Discount Tire or America's Tire stores will honor those tertns.Discount Tire or America's Tire may claim (Front&Rear)replaee worn suspension parts. ��' for ics own neneflc any such manneaccurer's warrancy.These Wniced warrancies � �' do not provide compensation for any consequential, special, incidental or �PLEASE DO NOT USE p�R CHE�C � contingent damages. Some States do not allow the exclusion or IimitaUon of � incidental or consequenual damages,so the above limitauon or exclusion may any Fix-a-Flat"type products. � �, � �' ' ; not apply to you.Tires presented for a claim remain the property of Discount S�AVES Gps,� Tire or America's Tire Stores.No representative or employee of Discount Tire or ��NSPECT � America's Tire Stores may enlarge or alter these warranties. tires occasionally for excessive wear,tread CONSiJMER RIGHTS - These limired watntnties give you specific legal or sidewall euts,or other damage. rignc�,and you may also have other rights which vary hom State to Stace. y,,.,� .+►. �: � � � � � � � � � k � � � � I i i - �= € �, � � a'` � � _ _ _ -- - : _ - --y--- --- _ _ ., _ � _, _ � - --�--.._..-�;__._ - �`�- 4t-s� =�� _,.-