Hamilton (2) � � � � � � �
This claim form is being returned without having been set up as a claim for the following
reasons:
X Failure to provide a written description as to what happened and why a claim form
was being submitted (page one).
Failure to provide the proper and required documentation(page one).
_�Failure to provide a date of accident or injury(page one).
Failure to indicate the amount of compensation being sought(page two).
Failure to provide information about the vehicle involved(page two).
Fai]ure to provide information about the injury claimed (page two).
Failure to sign the claim form (page two).
Failure to print the name of the person who completed the claim form (page two).
Other:
Please return the completed claim form to:
Office of the City Clerk �
City of Saint Paul
15 W. Kellogg Blvd.
310 City Hall
Saint Paul, MN 55102
If you do not return the completed claim form with the appropriate documentation or ,
information completed, then a claim file will NOT be established and an investigation ,
WILL NOT be done. In other words, NO FURTHER ACTION will be taken until the
information requested is provided by you.
Please remember that it is a crime to submit a claim form or to pursue compensation
falsely or under false circumstances. i
� i
R�C�IVED
APR 18 2014
CITY CLERK
� �1.�VL1 V LV
APR 18 2014 �
CITY CLERK ��
NOTICE OF CLAIM FORM to the City of Saint Paul, Min ��°P ���i
�� j� ��
Mirrnesota State Statute 466.05 states rhat "...every person...who claims damages,from any municipaliry...shall cause to 6e pr en�to th(��!
governing body of the mainicinalit}�within 180 days after the alleged loss or rnjury is discovered a notice stating the time,plac� �
circumstances thereof,nnd the nmount 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��iel/U�' Middle Initial�Last Name�T�// i�LTL�.�
Company or Business Name
- - --�---
Are You an Insurance Company? Yes/�c If Yes, Claim Number?
Street Address ���� U x���v=�� �-�.
City 1C �1i��V/�L� State /v//� Zip Code-���_�
Daytime Phone(�,�-��Cell Phone( ) - Evening Telephone( ) -
Date of AccidenV Injury or Date Discovered�/L-�J � Time��am/�
Please state,in detail,what occurred(happened),and why you are submitting a clair�Please indicate why or how you
feel the City of Saint Paul or its employees are involved and/or responsible for your damages. �'�^��•
�, �,
,�..5'�� fY%9 G'�/('/ (/� l,l)- �7� � ���, /-P f'f �j�� /�,�� � ` ' sf.
� —�`---
_ , .
, _ �u�-
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�i�rG( iv��s tp�c-t �U ���� �e Caa��r� �'11Yrn ���<t ����r>r- ����1� �c3u.l� ��
Please check the box(es)t at most closely represent the reason for completing this form: ������J��/
❑ 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
❑ �tt?eI'C�?P p��rp(JPrty da�,age_p�eacP gYPrifv
� 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 b�come 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 bilis
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—please comqlete 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 �1Vo�� Unknown (circle)
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.
c�► � �m� s-�--�—��- � �sT��z.��� .�✓� , v i. ar'7lTL .
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. ' � � '� ✓� L
� id �h���f�
��� ���
. . � . . _��—_ — - --�,�--�,—cc�tsax-ifthis�ec�uoes itvt a�plv
Your Vehicle: Year :ZU��Make V W Model J�7T.4
License Plate Number State�Color _
Registered Owner L��,�/��3 �'�i� j/J iti �LI,{�!���%
Driver of Vehicle �f�"T',�!/Uf1 �/L�!Dhl
Area Damaged�tY��V�7(,E�?�i ,�!!/"��Ci JYD� F'2G��<"�,��:19'� j/lZt=�/I'U �-aL:�/b/Y"
City Vehicle: Year Make Model �'�'='`�%
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
In'ur Claims— lease com lete this section check box if this section does not a 1
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 I
�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 for»ts will not be processed.
Submitting a false claim can result in prosecution. Date form was completed �,��v�� /��
Print the Name of the Person who Completed this Form: ��� /��✓v� �%�����,���;. ..._.
Signature of Person Making the Claim: �,t
� e: �sz _ . . � . �� �_
Revised February 201 l APR 1 � Lll�
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. " I.uthe � W�stside
�.� 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� ��qCOg 663 TA�N�.8586 �N�����3�21/14 I vwC5418540
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LABOFi RATE L E N0. �P:1ILEAGF_ C�OLOR— I STOCK NO.
KATRINA HAMILTON '� ���AZE ; 68,446ISILVER/ i
28 54 OXFORD ST � � P.KE/MODEL I UELI'J Y D E �DELIVEFY M1ULES
���VOLKSWA�EN/JETTA/ , ���1/07 '
ROSEVILLE, MN 55113-6102 ______- ___._ �___—
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interact with others.Our behavior should be a reflec on
***********************************************************'x TOTAL LABOR.... 203.65 of�heseprinciples:
TOTAL PARTS.... 424.92 �airness human dignity potentia�
Thank you for selecting Luther Westside Volkswagen for your TOTAL SUBLET... 0.00 ��reg�;ry service growth
servi ce needs. You may be recei vi ng a survey from the TOTAL G.0.6... 0.00 Tnese P''�°'p'es°a�be'�a�s'ated�nt°P�a°t�°es W'��n
manufacturer in the near future. We would appreci ate you TOTAL MISC CHG. 20.37 9U'de�5''n°�"�'e'a°„°�S""jn ome�peoP�e.
taki ng a few moments to complete and return thi s survey. The TOTAL MISC DISC L We are fair.We dearly state our expectations.W do
not inteotionally misrepresent ourselves or �ur
information is very valuable in helping us to improve the TOTAL TAX...... 30.91 p�oa��ts.
service we provide to you. If you IlaV2 dfl,Y C�U@St10fi5 01' """"""' ❑Wekeeppromisesandfulfillexpectations.
concerns, please contact us at (952)377•4100. TOTAL INVOICE$ 62.9.8.5 i�yye ireat everyone with respect and courtesy.We
acknowledge and greet every person.We an �ver
****'h***'t******�F�k***'F'Hc'k*'r'F'ti**'t*********�F�k'r*'k*irk************ the telephone in a friendly manner, giving the
company or deparlmeN name and our own nar e.
Vi si t our web site at www.l utherauto.com or our Facebook �� We are unconditionally of service to our custor ers,
page at www.facebook.com/1 uther.auto.dealershi ps for speci al �om�n��;t�es a�d each other. We welcome me
offers, contests, V1d205 and more!! opportuniry to be ot service.
I�UVe respect the environment.We do not litter,p� lute .
or Intentionally 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.
C� Keep a Great Thing Goin;
�� �
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STATEMENT OF DISCLAIMER
The factory warranty constitutes all c the
.�ur��� ��„�, ��:�;��i iu the saie o this
item/items.��"fie`S�1F�r ft��by'°�xpr� ssly
disclaims all warranties, either expre:s or
implied, inciuding any implied warrar ry of
merchantability or fitness for a parti;ular
purpose. Seller neither assumes nor
authorizes any other person to as: ume
� � tor it any liabiiity in connection wit � the
sale of this item/items.
/�� O AL�PARTS NEW ORIGINAL EQUIPP IENT
� � w" � UNLESS OTHERWISE SPECIFIED.
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v PAGE 3 OF 3 CUSTOMER COPY [ END OF INVOICE ] 04:51pm
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:� Volkswagen
, � 2370 South Highway 100
St. Louis Park, MN 55416
Ph: (952) 377-410�J Fax: (952) 374-0755
www.westsidevw.com
CEL�: 651-274-1403
CUSTOMER NO. ��S��B 663�i TA�"°.8586 ;�"�°�6�y�1/14 �.VYn��s"$18540
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LABOR RATE U�����E 'I��'"�A(" 68,446 II��L�E1�/ STOCK NO.
KATRINA HAMILTON a
2854 OXFORD ST � � � DELI DELIVERVMILES
�'�/�%�L��iVAGEN/J ETTA/ , �`��Y/p7 �i
ROSEVILLE, MN 55113-6102 _._ _ _ ______�_
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--------------•----------------------------------------------------------•-------
We be!ieve in following certain principles when �ve
interact with others.Our behavior should be a reflec.on
��R------------------------•-•------------••--------------------•------------•--- oftheseprinciples:
.3# 4+OIVWZZ4WA 4 WFIEEL ALI6NMENT TEGN(S):499 134.95 fao-�ess numan dignity potenna�
PERFORM FOUR WHEEL ALIGNMENT PER CUSTOMER REQUEST. i�te9rity service qrowtn
PREVENTIVE MAINTENANCE. These princip�es can be trans�ated into practices w 'ch
ALIGNED VEHICLE TO FACTORY SPECIFICATIONS. guide us m our interactions wim otner Peop�e.
-�. We are faic We clearly state our expectations.W do
J�B# 4 TOTALS---------------------------•--•----------•------------------ �oc intentiona�ly misrepresent ourselves or our
LABOR 134.95 Products.
�'!We keep promises and fulfill expectations.
J� 4 JOURNAL PREFIX VWC$ .J�B# 4 TOTAL 134.95 -We treat everyone witn respect and courtesy we
°� � acknowiedge and greet every person.We an wer
J�o7� 5 CHARGES-----------------------------------------------------------------------•--------- me telephone in a friendly manner, giving the
company or department name and our own nai ie.
��R•---•--•-•-•---••-•-----•'-------•----•--------------------------------------- f. l Weareunconditionailyofservicetoourcustor ers,
,l# 5�►'02VWZZRBATT BATTERY TEST•RED ; TE�H(S):499 Q.00 �omm��icies a�d each other. We we��omE me
TESTED BATTERY AND FOUND TO BE IN POOR CONDITION. oPportunity to be ot ser�ice.
BATTERY FAILED QUICK TEST �we respect the environment.We do not lirier,p Ilute
or intentionally damage the ernironment.
J�o}� 5 TOTALS--------------------••-------------------------------------- r��We believe that every person has potentia' We ����
provide each other with an environment that ��,,
JOB# 5 JOURNAL PREFIX UWLS JOB# 5 TOTAL 0.00 e�coura9es 9rowth and development. We are I
patient with others. i
MISC""--CODE-'-"""•DESCRIPTION-"""""'-'-'--"-""""'"""CONTROL NO'"""""' �`w� KeepaGreatThingGoin;
JOB # A SS S ENVIRONMENTAL DISPOSAL 20.37 �`��/ Genuine VW Parts&Serv :e
TOTAL - MISC 20.37
ESTIMATE---------------------------------------------------------------------------
CUSTOMER HEREBY ACKNOWIEDGES RECEIVIN6 STATEMENT OF DISCLAIMER
ORIGINAL ESTIMATE OF 5800.01 (+TAX) The far,Torv warranty constitutes all c the
COMMENTS-------•------•--•--•----------------•----•--------•-•-----•--------------- wa�iant�eSVv�ihf s ec tothesaleo this
CUSTOMER HAS BEEN SUPPLIED-WITH A RENTAL VfNi�Lf GGE Appoirrtment Cr item%item`s°'1'�'ie el�reby ezpn ssiy
eated 2014•03-20 06:02:0�)pm taken by Kevin Bednarek disclaims all warranties, either expre�s or
implied, including any implied warrar ty of
merchantability or fitness for a parti:ular
purpose. Seller neither assumes nor
authorizes any other person to as; ume
for it any liability in connection wit the
sale ot this item/items.
�
ALL PARTS NEW ORIGINAL EQUIPP IENT
� UNLESS OTHERWISE SPECIFIED.
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, � luthe W�stside �
-� 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
CUSTOMERNO. ��/� � AqYISORB I GG�ITAGN�586 IIN��7 Ll 14
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LABOR RATE 1�4iLEAGE �,STOCK NO.
, $��b� 68,446 ��'vER
KATRINA HAMILTON I �
2854 OXFORD ST �$%`���I�'�AGEN/JETTA/ —�DEUY� oEUVERVMi�Es
ROSEVILLE, MN 55113-6102 __ _ _
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interact with others.Our behavior should be a reflec on
�OR-------------•-----'•-•-----•-•----------'----'----------'---'-----•-----•---- � oftheseprinciples�
,3# 1 03VWZZPW6 TIRE REPAIR PLU6 TEGH(S):499 5U.00 ' �airness n�man dignity potential
C/S: Customer states hit pot hole and hub cap fell off. Whee ;�,re9��ry service growth
1 may be bent. Please check and advi se. Just left front hit These p��n��p�zs�a�be«a�s�ated��to p�a�t��es W ��n
pot hol e guide us in our interactions with other people.
THE RIGHT REAR AND LEFT FRONT WHEELS ARE BENT. �we a�e tdir we c�ear�y state our expectations.w do
TIRES LOOK ALRIGHT not intentiona��y misrepresent ourselves or �ur
REPLACED BOTH THE LEFT FRONT AND RIGHT REAR WHEELS products.
—'..We keep promises and fulfill expectations.
PARTS------QTY---FP-NUMBER------------•--DESCRIPTION----------------•---UNIT PRICE- I�� we treat e�eryo�e Wim �espect and courtesy we
2 5K0-601-027-A-03C WHEEL 152.13 304.26 ��know�ed9e and greet every person.We an wer
the telephone in a iriendly manner, giving the
2 1K0-998-275 REPAIR KIT TOTAL - PARTS3 367.52 company or dePa�tmen,n�me and our oWn nai e
❑ We are unconditionally of service to our custor ers,
communities and each other. We welcome Ihe
MISC•---•-CODE--------DESCRIPTION--------------•------------•---CONTROL NO--------- oPPo�c�,��,ytobeofservice.
I193 INTERNET LABOR DISC-NO CODE FOUND -25.00 = we resPect ihe environment.we do not�itter,p� wte
I193A INTERNET PARTS DISC-NO CODE FOUND -25.00 0�mtentiona��y damage tne environment.
TOTAL - MISC -SO.00 -'We believe that every person has potentia� We
provide each other wlth an environment that
..
encourages growth and development. We are
JO 1 TOTAL ---------------------------------•----------•-------------
�OR 5�.Q0 Paiientwithothers.
PARTS 367.52 ����� Kcep a Great Thing Goin;
MISC -50.00 �` � '
� Genuine VW Parts&Serv :e
���
,�B# 1 JOURNAL PREFIX VWLS JOB# 1 TOTAL 367.52
JOB# 2 CHAft6ES•---------...-r----------------------•-•-----•------._...--•-------•-------------
STATEMENT OF DISCLAIMER
------------•------
----•--------•---•---• The factory warranty constitutes all c the
� � b.U�O�- �i,�i i� �J;t;i �z;�eci to the sale o this
3# 2 45VtviZRENTAL " RENTAL-CUST/EXT WARR A �F� TECH(S):499
CUSTOMER HAS BEEN SUPPLIEQ WI� 1lEdI�LE _ itew+#' �ssly
RENTAL VEHICLE'. '' disclaims all warranties, either expre;s or
implied, including any implied warrai ty of
JOB#' 2 TOTALS------•--------------•�---"""'-"""""'""""""-'""�"��� merchantability or fitness for a part �ular
JOB# 2 JOURNAL PREFIX VWCS JOB# 2 TOTAL 0.00 Purpose. Seller neither assume: nor
JOB# 3 CHAR6ES----------------•------""""""""""'"""""--'�'����-��� """"" authorizes any other person to as ume
for it any liability in connection wit i the
� LABOR-------------•----------------------------------------•------•---•----•------ _saleofthisitem/items.
� ,i#`3 OIVWZZOF OIL & FILTER CHANC�E ° TECH(S):499 �g'�� ALL PARTS NEW ORtGINAL EQUIPI 1ENT
o PERFORM ENGINE OIL AND FILTER CHANGE PER CUSTOMERS REQUEST. UNLESS OTHERWISE SPECIFIED.
� PREVENTIVE MAINTENANCE.
� OIL AND FILTER CHANGE HAS BEEN COMPLETED.
� �:?'_r"-r.'�. . "
--------UNIT PRICE- --� ,-, '
� PARTS------QTY---FP-NUMBER---------------DESCRIPTION----------•- s'roro�ASiGNATURe� =i
� 1 06D-115-562 FILTERELEM 14.00 t4'r'00 -
w 70 G-052-167-SO ENGINE OIL 0.62 43.40
TOTAL - PARTS 57.40
PR 1 � 2014
� JOB# 3 TOTALS----------------------•-----------------------•--------LABOR 18.70
- PARTS 57.40
° JOB# 3 JOURNAL PREFIX VWLS JOB# 3 TOTAL 76.10
� PAGE 1 OF 3 CUSTOMER COPY [CONTINUED ON NEXT PAGE] 04:51 pm
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