Reichert RECEIVEp
NOTICE OF CLAIM FORM to the City of Saint Paul, Minne��aa18 2014
Minnesota State Statute 466.05 states that "...every person...who c[aims damages from any municipality...sha[l cause toYu��sY����R K
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 �o�c� Middle Initial�Last Name ��: C��.���
Company or Business Name
Are You an Insurance Company? Yes/� If Yes, Claim N;imber?
Street Address �1�1 O C_�.�n�-•.� R� -� L S
City �l Q p�r...,-�n- State Y1�1 Vl� Zip Code �S 35�1
Daytime Phone(��)g�� — �$�ell Phone((Ql�_)�g-S� t Q Evening Telephone(�S�) qSx �.+-1 Q 5
Date of Accident/Injury or Date Discovered y I s I ti� Time G C. 3O �/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 andlor responsible for your damages. �'`j�;k v.
r l � r ky �y�
Q
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 _
❑ �tiier type af injury—please specify
In order to process your claim vou need to include copies of all aunlicable 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. '
•PropeRy damage claims to a vehicle: two estimates for the repairs to your vehicle if the damage exceeds
$500.00; or the actual bills andlor 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 witnesses to the incident? Yes No Unknown (circle)
Provide their names, addresses and telephone numbers:
Were the police or law enforcement called? Yes N�, 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. �Uc�{k� ��►.,a.
Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction.
I
Vehicle Claims—nlease comnlete this section ❑ check box if this section does not applv
Your Vehic:�: Year OU"l 1VM�.ke G�v..t_ Model IIVti.�.; 10 c.,�
License Plate Number State�v �Color�L v�
Registered Owner fl.Q,���,,,�,,.. �,�;cJl,•�t�-
Driver of Vehicle �,�r.�c���..� �,e�c.�.o-t�
Area Damaged �CC���� �]�,.¢.�,\ 'h r,-;,,L,
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Injury Claims—ulease complete this section '�.check box if this section does not a�plv
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: f
Address Telephone �,
�.Check here if you are attaching more pages to this claim form. Number of additional pages�. I
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 �'I � ►�{ �I�
Print the Name of the Person who Completed this Form: ��Urr(G�� Q2;C'►^a-t k
Signature of Person Making the Claim: � __ ����
Revised February 2011
�, Page 1 of 1
,..w�°
Pro Tire and Service �nvoice
2415 W Industrial Blvd �— 25725
Long Lake, MN 55356 Estimate Ref#0
Shop Phone: (952)473-4261 Date Printed:04/14/2014
Printed Time: 2:28 pm
HaURef: More Than Just A Tire Store! Time Promised:
Reichert,Jay/Deb 2007 CHEVROLET MALIBU LTZ V6 3.5L 3490CC 213CID FI GAS N N
9190 County Rd 15 VIN: 1G1ZT57N27F297480
License:522DZT Milea e In: 164,755 Date Written: 04/14/2014
Maple Plain, MN 55359 g
Home: (952)955-2485 unit#: Mileage Out: 164,755 Written By: Michael Caldeen
Cell: (612)968-5718 Deb �oM: Save Old Parts: No
Job Name Description Technician Qty List Extended
HOIST FEE HOIST FEE
Labor Gen Work Requested-HOIST FEE 35.00
Work Performed-CUSTOMER GETTING SQUEAL WHEN DRIVING. INSPECTAND ADVISE.
Job Total: 35.00
HUB BRG WHEEL BEARING-Replace-Front
Suspension-...
Labor Gen Work Requested-WHEEL BEARING-Replace-Front 115.70
Suspension-Hub&Bearing-One Side
Part BR930317 Hub Bearing Assembly, Front 1.00 327.54 327.54
Job Total: 443.24
Parts: $327.54
Payment Date Type Method Amount Labor: $150.70
Sublet: $0.00
Misc: $0.00
Payment Totals:
Hazmat: $5.00
8upplies: $13.56
Tax Total: $24.82
Invoice Total: $521.62
THANK YOU FOR YOUR BUSINESS!
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