Benedek NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
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 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 �� Middle Initial F Last Name ���C��
Company or Business Name �(P� RECEIVED
Are You an Insurance Company? Yes/�o If Yes,Claim Number? IN�� �..�� z�1�
scr�c Aaa�ess 31 ro�r a �v e �,:�t �-l ERK
c�cy �i n h'eGKJ���5 State � � Zip Code J —
Daytime Phone( )�� Cell Phone(�)�-_j°�vening Telephone(��!'�-
Date of Accident/injury or Date Discovered�1� �� Time ���3� am/�
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 o its employees e in lved and/or responsible for your damages. � lr.t(,� kvlrn��
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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 you need to include couies of all apulicable documents.
For the claims types listed below,please be sure to include the documents indicated o�it will delay the handling of
your claim. Documents WII..L 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 Fhotographs are alw�ys welcome to document and support your el�im but wil�not be re�urned.
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�omDle�e�hi_s�e�ion
Were there witnesses to the incident? Yes o Nf�nknown (circle)
Provide their names,addresses and telephone numbers: �
Were the police or law enforcement called? Yes `� Unknown _ ,( ir�)
If yes,what derartment or a�ency? � � Case#or rerort# ���
Where did the accident or injury take place? Provide street address,cross street,intersection,name of park or facility,
closest landmark,etc. Piease be as detailed as possibie. if necessary, attach a diagram. C1dct�d� PN'�vi v�-e
a� �cl mn,�1� Q d •
Please indicate the amount you are seeking in compensation or what you would like the City to do o resolve this claim
to your satisf�ction. �.��tv�bl�c�'S� r�n�e � �F'2�,�o �n �a►� C��c��s � �v!- e✓t
fL�, h�W �"e c5`n �nn�l [°���
Vehicle Claims— lease com lete this section ❑ check box if this section does not a 1
Your Vehicle: Year Make v� Model C C
License Plate Numb State 1��Color ����
Registered Owner V�1 �—
Driver of Vehicle �
Area Dama ed C 1 -1-
City Vehicle: Year—�1VIake ��� Model '�l
License Plate Number S te Color
Driver of Vehicle(City Employee )
Area Damaged
Iniurv Claims—nlease complete this section �heck box if this section does not annlv
How were you injured?
What part(s)of your body were injured?
Have you sought medical treatment? 3�es 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.
Submitiing a false claim can result in prosecution. Date form was completed�I.��I���C
Print the Name of the Person who Complet this Form• ��'��� h�a'e��
�
Signature of Person Making the Claim:
Revised February 2011.
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317 GROVELAND AVE UNIT 714 `�'�?/VOL+KSWAGEN/CC/4DR SDN 2.0 LUX AT � OS���l/09 �
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a�_,�Y�`-��`��-1097 ����.�v51�`�-6281 �.,::�„��.,---- --- --- MO: 24893�
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M�A$at----------------------------------•---------......---.._._...._....---•------- ';,,;� .
J# 1 36VWZZROL OUTSIDE BULB TECH(5):884 22.49 � ' t =:,�:,�' r
BUL$ WARNING LIGiiT IS ON. �-,< < c. r t;�
REPLACED LEFT REAR INNER BRAKE LIGHT BULB �� .��h r s c roee ��c-�
�PARTS••----QTY---FP-NUMBER•-•----------•-DESCRIPTION--------••--•-------UNIT PRICE- ` 4 *J ii t-or�J�c�a+o .�veao�
� r c_, er cvr�
� 2 N-105-915-01 BULB 4.94 9.88 , , i
TOTAL • PARTS 9.88
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�J08# 1 TOTALS---•----•----•--•---•---•--•-------------•--......----•---• ' ; ,�:
LABOR 22.49 ��
PARTS 9.88 ,ar�e*�ev m na i�."'
i �_ �,�We ara tui�or�ition ��s2rv ro,i;r�us om rc,
� J06# 1 JOURNAL PREFIX VWLS JOB# 1 TOTAL 32.37 �,�,� �; �' � , ,, t""�
JOB#���CHARGES- ••--•-- ------•---- � _,..� u.��.
-----------------•--------------------•----•-•-•------------ �,
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��..__...---•------...--•............................. �
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3# 2 03VWZZIRT REPLACE 1 TIRE TECHtS):884 29.00 � ' ` ` ` �"�`
C/S: CUSTOMER STATES THAT THE TIRE BLEW OUT AND NEEDS TO BE ' • k' ' , ^ "'a`
REPLACED. PLEASE CHECK AND ADVISE MOUNT AND BALANCE ONE TIRE � ;.` �, ��� �� ��J �^ �J� �{��
I
PER CUSTOMER REQUEST. I
PREVENTIVE MAINTENANCE. _;-� ,;;a i;=•ear :tun�,C:cing i
MOUNTED AND BALA1fCED ONE TIRE. ° `�� ��'�`•�.` ' ���"` '�°'
DOT NUMBER: LM$P3VR2713 X 1.
PARTS----•-QTY---FP-NUMBER•--•---•--•--••DESCRIPTION-----------------•--UNIT PRICE- :,;.�;°��_��7f.<:,�-!�,ti��.�l4�ER
1 DTI-547-096 EXTREMEC�N 0.00 0.00
235/45Rll 94W ,� ` ` : ,� ;��r�.rtas ait c�tne
TOTAL - PARTS 0.00 � �� �' `:` r� �,,.��� r�e sain oi tn�s
� � � � -., •'i-� ., .,, ��_ei�oy sxpi�ss!y
J0� 2 TOTAL$---------------------------•••-•-•----•---•--------•-------- � c-; s � � c;`�e ex�ress or;
LABOR 29.00 �. . ,,.! , ;'� ,�:„d;varranty otl
JE� 2 JOURNAL PREFIX VWLS JOB� 2 TOTAL 29.OD `' `` ' `' '' � i°r a �ariicu�ar�
r.- ,ic �� -^ . �cci�(71P t OI"!
JOB# 3 CHARGES•-------•--•-----•-•---------------------•-•-----._.._._....-----......-- --••-_ � ,},o� �; ,,�r
au� ° p c� :o a ��.r�iel
���"""'.. ."""""'"'"""'""""".""'"""'_"""""""'"..."'^""'"" JI' i f i�- � 1 C,: �l C�CJ'i 1V7��'' t!1c^I
�,3# 3+D5VWZZBRK6 .. BRAICE WEAR•C�OOD TECH(S):884 0.00 ' ' '"' `�'" �
INSPECTED BRAKES AND FOUND MEASUREMENT TO BE ABOVE 7MM. ,�,�; ;,f,TS.��_�f}���,;. ��i_�r����✓;Er�T;�
BRAKES ARE GOOD AT THIS TIME. R,,'=titi 7Ti-�-F�'1?SE�'�i �`;��E�
JOB# 3 TOTALS-----•-•••--------------------------•-----•--••---•--•---•-- , I
JOB# 3 JQURNAL PREFIX VWLS JOB# 3 TOTAL 0.00 ,
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.JO� 4 CHARCES---------•••----•---•----------------------•-----.._.•--•----•-•-•---------•---•-
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' LA80R-�--•---•••--------•••-----•--••-----------------•-----•-------•--•-•--------• 1
'J# 4+03VWZZTIREG TIRE CONOITION-C�OOD TECH(S};g84 0.00 !
CHECKED TIRE CONDITION AND FOUND TREAD DEPTH AT 7/32" OR i
GREATER. � �
TIRE CONDITION IS GOOD AT THIS TIME.
PAGE t OF 3 CUSTOMER COPY [CONTINUED ON NEXT PAGE] 04:OSpm I