The URL can be used to link to this page

Andersun RECEIVED APR 212Ut4 �C�,ITY CLERK NOTICE OF CLA�M F�RM to the City of Saint Paul, nnesota Mir�nesotu Slttte Stntute 465.05 states thal"...every persore...wiw clnims drunages frnm a»y municipaliry...shn(1 cause tn be presented to the goi�erning body of the municipnlity wiihirt I80 days after tlie alleged toss or injurv is discovered a notic•e stating the time,place,and circernrstances thereof,anc!tlie amount of cornpensation 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 tha#you will not be contacted by telephoue to clarify answers,so provide as much information as necessary to explain your claim,and the araount of compensation being reqoested. Yoee will rece4ve a written acknowledgement once yow['form is received- The process can take up to ten weeks or longer depending on the nature of your claim. This form mitst be signed,and both pages completed. If sornething does not apply,wri#e`N/A'. SEND CUMPLETED FORM AND OTHER D�CUMENTS TO: CITY CLERK, 15 WEST KELLOGG BLVD,310 CITY HALL, SAINT PAUL,NIN 55102 First N�me ��'E'��'�-^� Middle Initial_�v Last Name_ �N��-R S�r� Company or Business Name_ �' � � i"`� Are You an Tnsurance Company? Yes No� If Yes,Claim Number? Steeet Address 1�3 � �--t N�-��-1J !"Cv C N v� City ��ti 1 1!� V�-- State �"l�' Zip Code S� �� Daytime Phone �? �°Z- S t g° Cell Phone h ✓� - Evening TeIephone N '� - Date of AccidenV Inj ury or Date Diseovered � � �.�--`'�4" Time �� % °° �prn 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. 1�; „� `-tt-� 2vti;7 �'`�-.�.c% !� '`-=oiL i �S • - 2C-v�°v5 v �4; � r-� � .�j 3�C iv ��,D — C —a-C ---+- E-�lL- �:� S. vn-t L ,� �ON � �C�— J n! � L C- al I�1 I i . I`�Y S ,f� � � `` l/� �t ( �� G � �,• ,z a�C-y�. y M �,t��. v z i e C-y 2c-c c-� �� 9�-. C �-+��,�c� Z 3�, l S . Please check the box(es)that most ciosely represent the'reason for completing this form: ❑ My vehicle was damaged in an accident ❑ My vehicle was damlged cEuring a tow �My vehiele was damaged by a pothole or condition of the street ❑My vehicle was damaged by a plow ❑My vehicle was wrongfulIy t�wed and/or ticketed ❑ I was injured on City property � Other type of property damage—please specify ❑ �ther type of injury—please specify In order to process your claim s ou need to inciude copies of all applicable documents. For the claims types listed below,please be sure to incIude the documents indicated or it will delay the handling of your claim. Documents WILL NOT be retumed and become the property of the City. You are encouraged to keep a copy for yoursetf before submitting your ciaim form. O Property damage claims to a vehicle:two estimates for the repairs to your vehicle if the damage exceeds $500.00; or the actuaI bi1Ls and/or receipts for the repairs O Towing ciaims: legible copies of any ricket issuerl and a copy of the impound lot receipt �Other property ciamage 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 �Photographs�re always welcome to document and support your claim but wil]not be returned_ Page 1 of 2—Please complete and return both pages of Claim Form Failure to complete arid return both pages will result in delay in Ehe handling of your claim. All Claims�lease com.plete 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 faciliry, closest Iandmar3;,etc. please be as detaited as ossible. If necessary,attach diagram. IV C�vt- `�i. C�f�-�� e --� S. ��n�L�-i� S��2�—i Please indicate the amount you e seeking in compe sation or what you would like the City to do to resolve this cl•'m to your satisfaction. �3� • ► S �,_„ �'(1llZ- /�,�ss,•.F� �.� N�-� l 1��- C,s�i� Vehicle Claims- lease com Iete this section ❑check box if this section dces not a 1 Your Vehicle: Year Zo 14- Make �!'>�/Lu Model 1 � t��-C Z� License Plate Number Z3"� �G V State �% Color ��C'� Registered Owner S P�CE�-t- `��L�2 LaN Driver of Vehicle Sf�C-x��E>,•` lk��zt�,-� A.rea Damaged i-��,�;^ l�/�s�-y.l�� "1:t�Z-� City Vehicle: Year n� i� Make Model License Plate Number State Color Driver of Vehicle(City Emptoyee's Name) Area Damaged In iurv Claims-�Iease comgtete this section check box if this section does not applv How were you injured? What pan(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 MedicaI Provider(s): Address Telephone Did you miss work as a resuIt of your injury? Yes No When did you nniss work? (provide date(s)) Name of your Employer: Address Telephone L�Check here if you are attaching more pages to this claim form. Number of additional pages 3 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. Submi.tt�ng a false claim can resull in prosecution. Date form was completed �I � 3 I Zn I `� Print the Name of the Person whu Completed this Form: ��"��~L- ' t r"��S�/�:' Signature of Person Making the Claim: � �\1 �--- Revised February 201 1 - Luth¢ BLOOMINC�TON � - �CUt�� SUBARU � -� 7801 LYNDALE AVENUE SOUTH, BLQOMINGTON,MN 55420 � � (952}881-6200 SERVIC�DIRECT[952j 887-0650 FAX(952j 881-1787 � TPiAt+fK YY�3t�4�(�i�"�iS�3f'P�lRTUAl1l'Y?'O'SE�f 1'C3U. #T IS OUR A1M TO PERFORM AlL P/�RT'$&SER�/IGE HQURS THE REPAIRS REQUESTED ON THIS REPAIR ORDER TO YOUR`COMPLETE SATISFACTIC)N. �QNDAY 6:30 AM - 6:00 PM I IF OUR SERVICE WAS EXCELLENT TELL YQUR FRIENQS. IF NOT, PLEASE TELL US TUES�AY- FRIDAY 6:30 AM-7:30 PM iMnA�R!��►� � . � � � . �� :�1#M �0�;P� , � ,: ,.,,: , �Y, -. ,_ .... TUk�L�AY 8 -� � �,. 3, , _ -� . eus�aGVO. �' 2043 r"�"o. 57 �NVO�b8/14 ��'�98283 . . . � .... ��: :. � �� LABdRAA�E '1- .�v.�.. .. . . MILEAGE 396 '�I�ETI�lN RE �� SPENCER NEZARES ANDERSON 1938 LINCOLN AVE �'/��'/IMPREZA WAGON/5DR Z.OI SP DE"�`��/14 °�"'"�`�`� g SAI NT PAU L, MN 5 510 5 SEIUNG�EALEA N0. P�0�1GT10N�NTE v�"°�'`�."°GPA � 66E82 56030 N F.T.E.NO:�.- . . . P.O.NO. . �R.O.W4/OU/14 - theencer@gmail .com `� �� _ . , --- ': �'�2755 MO: 39 �� r — — REPLACE PASS SIDE FRONT TIRE PER CUSTOMER REQUEST. STATES HE HIT A POTHOLE AND I�Y�I THERE IS A BULfE IN SIDEWALL. �� YOKAHAMA AVID 205/50R17. IN STOCK IN PARTS. M(XJNTED & BALANCED TWO TIRES AND TEST DROVE VEHICLE. UNIT PRICE• PRECISION CRAfTED PERFORMANCE PARTS------QTY---FP-NUMBER------•--------DESCRIPTION------------- � 212.68 212.68 JOB # 1 1 93217 205/50R17 YOKO YOK AVID S34D ,Jpg � 1 TOTAL PARTS 212•66 ,m6 # 1 TOTAL LABOR 8 PARTS 212.68 -•-----•-----------•--------•---•------------- �� s INSPECTED TIRE TREM DEPTH AND FOIArD CON6ITION TO BE GOOD. � � TIRE REPLACEI�Kf NOT NEEDEO AT THIS TIME. QjJAL,ITY DRIVEN` -----•-UNIT PRICE- PARTS-•----Qn---FP-Nl1MBER-••------------DESCRIPTION--------"� # 2 TOTAL PARTS 0.00 S E R V I C E ,JOB # 2 TOTAL LABOR & PARTS 0.00 ---------------- ---------------- -•-- 4„ ..: . REPLACREMENT NOTNNEEDED AT�THIS TI� �ITION. ' DESCRIpSIpN____________________UNIT PRICE- Cash forYour used vehicie. PARTS------QTY---FP-NUM�ER-----------'''' �pg # 3 TOTAL PARTS 0.00 Your car could be worth more than you think!And we'I!buy it!(even if you don't JpB # 3 TOTAL LABOR 8 PARTS 0.00 buy from us).we'li quote ANY vehicle, -----------------------•-•----•--• •---- --•- ------------------------ regardless ot condition.if you accept.You'II _____________________________ walkawaywiththecash.You never �n .... - � a faster,simpier or safer way to se your PERFORM SERVICE $AFTEY CLINIC. car.Visit our Sales Department for your $EE AT�ACFIED INSPECTION SHEET. no obligation appraisal or learn more at ---UNIT PRICE- �uTHER=�Ta�oM PARTS------QTY---FP-NUMBER---------------DESCRIPTION--•-------• _"' 0.00 'sxc�uoessa�vncEOVeHic�es ,7p6 # 4 TOTAL PARTS ,� # 4 TOTAL LABOR 8 PARTS 0:00 W E AP p R E C I AT E -------------- -------------------------------------------------coN�ioi.-i�o-_:::::::---- z.00 YOUR BUSINESS - ------------------- MISC---•••CODE•--•----DESCRIPTION-----•--- JOB # A EOD ENVIRONMENTAL DISPOSAL TOTAL - MISC 2.00 � ALL PARTS NEW ORlGINAL � ESTIMATE-----------•-----------•--•-------•---- ----------------•--••- """�� EQUIPMENT UN�ESS � CUSTOMER HEREBY ACKNOWLEDCfS RECEIVING OTHERWISE SPECIFIED. o ORIGINAL ESTIMATE OF 5245.00 {+TAX) __ o """""""""'""""""' P COMMENTS------------- ----- -------- -- N -- � created 2014-04-07 01:45:OOpm taken by Ryan Rodriguez AnywarrantlesonN+e roduttssoldherebyarethoseoJthe menulacfuier.As befweert thrs relail seller a�0 buYe�,Me p�oduCt is to be sold'AS lS'and the entlre�sk as fo the � � qvality a�perlormaxe of the P��t is with the buyer The setler expressty disclaims a!!warrantles,eifher express or p )mplied,includng any imd��wananry o!merchanfability or U litness Iw a parNCUlar purpose,a�the se!!e�neitl�assumes V � � norauthaizes any other person tv assume�or if any Nabllity tn wrtneClion wNh the sale o/sald prvducts.This disc�aimer by � this selte�irt no way al(ects the ferms ot Me manufacture�s CONTINUED ON NEXT PAGE� 06:19{NTt wat,anty The buYe�a�^°��9�s�ing so lnlwmed P�br ro � PAGE 1 OF 2 CUSTOMER COPY I Sere. - - - Luth BLOOMINGTON ♦ ,�cur�� suB�►Ru � � 7801 LYNQALE AVENUE SOUTH,BLOOMINGTON,MN 55420 � � (952)881-6200 SERVICE DIRECT(952)887-0650 FAX[952J 881-1787 THAfVI�"�t7'��`!C'�`fNtS OPPf3FCi'UF�t'1'1'1`O SERYE YQU. IT 1S'OUR AIM'f0 PERFORM ALL pARTS 8c SERYICE HOURS THE REPAIRS REQUESTED ON THIS REPAIR ORDER TO YOUR COMPLETE SATISFACTION. MONDAY 6:30 AM - 6:00 PM IF OUR SERVICE WAS EXCELLENT TELL YOUR FRIENDS. IF NpT, P�Ea,SE TE�� uS TUESDAY- FRIDAY 6:3Q AM -7:30 PM IMMEDIATELY, , . . . :;.; .; ;. .. SA�URDAY 8:00 AM-4:00 PM �.,. �a.:. ...�. . „ . �� .. _. :. : , :usro�n�irr�o. : : � 204 T"�N�. S� iNVO�E��8/14 ��`��98283 SPENCER NEZARES ANDERSON `�� v M��_�GE 396 �T�AN RE �� 1938 LINCOLN AVE DELI o�ArM��s '�'j��/IMPREZA WAGON/SDR 2.OI SP ��2F6/14 8 SA I NT PAU L, MN 5 510 5 SELLING DEALER NO. PRODUCTION UATE ��"��`�"°G P A L 6 6 E 8 2 5 6 0 3 0 £T.E.NO.. . . . � � � P.O.NO. . . .� � RO.Q4Y/OH/14 - . .. . theencer@gmail.com �j �,�� '�- �°#""��2755 MO: 39 �: --f --------------------------------=---------------------------------------•---------•---... ***�x****,t*�xx�r,t��,t,�x*x**k�********************�`ar TOTAL LABOR.... 0.00 TOTAL PARTS.... 212'68 �C U�� Thank you for selecting Bloomington Acura Subaru for your TOTAL SUBLFT... 0.00 service needs. You may be receiving a survey from the TOTAL G.0.6.... 0.00 manufacturer in the near future. We would appreciate you TOTAL MISC DISC 0.00 PRECISION CRAFTEDPERFORMANCE taking a few.moments to complete and return this survey. The information is very valuable in helping us to improve TOTAL TAX...... 15:47 the service we provide to you. If you have any questions or TOTAL INVOICE s 230.15 concerns, please contact us at (952)881-6200. �tx�cir***,rx*�r,�r�rr,t**,r�tr�r,t� *�r,tir�+t,r*,r� Visit our web site at www.lutherauto.com or our Facebook � . � page at www.facebook.com/luther.auto.dealerships for special offers, contests, videos and more�! QUALITY DRIVEN s S E R V I C E . Cash forYour Used Vehicle. Your car could be worth more than you think!And we'll buy it!(eve�if you don't buy from us).We'll quote ANY vehicle, regardless of condition.It you accept,you'll walk away with the cash.You'll never find a faster,simpler or saier way to sell your car.Visit our Sales Department for your no obligation appraisai or learn more at LUTHERAUTO.COM 'EXCLUDES SALVAGED VEHICLES WE APPRECIATE YOUR BUSINESS ALL PARTS NEW OR1GlNAL � EQUIPMENT UNLESS � OTHERWISE SPECIFIED. o 4 N My warranLes on!Ae producfs sofd�ereby are lhase o/tire � menufacNrer As betweert thls refai!seUe�an0 buyer,tha product is to be sofd'AS IS"and the entire rrsk as to the � quality arrd peAwmance o/ff�e product is wilh the buyer.7'he selfe�exD�ass�y disc�aims al7 warranties,either express or Q imp�ied,b1cludiry eny implied warianry ol merchenfabiUty or Y linress lor a Psrticular purpose,and Nre seller rreitl�er assumes V nw auNwizes any oNrer pauon ro aswma bi�t arry llab�l'N« connecfion with tAe sale o/said prod�cts.Thls MsctiaNner by � lhis seller in no way aNec15 Ne terms ot the manulacturers � [ EPID �F INVOIGE ] 06:18PfT� wa'�^b 7he buyer ack�owledges bel�g so inlo�med p�ioi to Q PAGE 2 OF 2 CUSTOMER COPY �B_ ___ � - Subaru Multi-Point Vehicle Inspection ustomer Name: SPENCER NFJ�4RES ANDERS01 Vehicle Year/Model: 14 SUBARU IMPREZA WAG� Date/Time:04/08/2014 18:19:43 hone: (H) (612) 202-5180 VIN: JFIGPAL66E8256030 Odometer: 396 ervice Advisor: LUKE Technician: KYLE MARTIN HUMPHRIES RO: 398283 Tag: 57 ` �, : WILL REQUIRE FURTHER ATTENTION reen Yellow Red � � Washer fluid � LF � � Transmission fluid �.� Green � � Brake fluid � Y�i�,,, ��o„, ❑ � � Power steering fluid ■ R�a R� ■ � � Coolant � � Engine al RR � � GutCh�Uid LR ��e«, ��, � � Rear differential fluid ❑ Y��w di�„ ❑ � � � Engine air cleaner . R� R� � � � � Headlights (check low/high beam)/Tail iights/Brake lights/ Hazard I' hts Marker li hts Drivin li hts urn si nals � � Windshield wa5her spray/Wiper operation/Wiper blades/ Windshield � Inspection Not Taken condition � � � Horn operation 4��(pise)or 1-2mm(Drum) � � . Check engine idle speed � [] . Check for abnormal noise and/or vibration, in and out of gear � � Yerify operation of systems warning lights-VSA/ABS/MIU � � TPMS SRS Cluster bulb check � ■ Drive belts and coolant hoses- cracking or damage Grcen �" � Ydlow Yelbw � � [] ■ Brake lines/Brake hoses/Brake cables/Fuel lines ■ � ■ � ;■ � � Exhaust system - check for damage and leaks � � ■ Inspect suspension components and steering gear components for dama wear and or leaks �R , � RR � [] Inspect rubber dust seals for cracks or tears � Green �n � � � Inspect drive axie boots for cracks or tears � Y�� Y�� Inspect rear differential fluid condition � R� Red ■ ■ � � Check and adiu�tire pressure (including spare) � � � Install reminder sticker � � � Reset maintenance light(if applicable) 4/32"to 6/32" � [] � Multi-point vehicle inspection checklist has been completed Genera)Comment: RF TIRE REPIACED ALL TIRE TRfADS AT 9 32 ■�.� ❑Fair �Bad Actual Cold Crankiny Amps 455 Factory Cold Cranking Amps 40� I