Pribbernow R�CEIVED
APR � � 2014
NOTICE OF CLAIM FORM to the City of Saint Paul, Mi���LERK
Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipality...shall cause to be presented to the
governing body of the municipaliry 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 compensadon 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 l���`S�-in e Middle Initial�Last Name ���bb e rn e�
Company or Business Name ���
Are You an Insurance Company? Yes/� If Yes, Claim Number? ��R
Street Address ���P�7� Sohnson �� I`�E
City �IQ►(1 C State �� Zip Code �5 `�
Daytime Phone( )�� Cell Phone�✓"� )�-��Evening Telephone( ) �"L_�
Date of Accident/Injury or Date Discovered ��lJ�' l�0/� Time ��� am pm
Please state,in detail, what occurred(happened),and why you are submitting a claim. Please indicate why or how ou
feel the City of Saint Paul or its emplo ees are inv lved and/or responsible for your damages. (1 �1i oJ[ �or�L
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- iai a t u � foGt�s.
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 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 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.
�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 Photographs are always welcome to document and support your claim but will not be retumed.
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—nlease complete this section (D5�-�01-71 y�
Were there witnesses to the incident? Yes No Unknown (ci cle)
Provide their mes,addresses and telephone numbers: 7 i �Z 00 �/�,I`�� 55►a�
1� S� � 8'a '�ir - 9
Were the police or law enfarcement called? Yes N� Unknown (circle)
If yes,what department or agency? I�� Case#or report# 1J/A
Where did the accident or injury take place? Provide street address, cross street,intersection,name of park or facility,
clo est landmark, etc. Please be as detailed as possible. If nece sary,attach a diagram. L{�jM��1 �v�nuc�
S�. �aw 1 lot�h�1� P 2r�Jr ��a �� �{n�
Please indicate the am nt you are seeking in com ensation or what ou would lik the City to do to resolve this claim
to your satisfaction. i �rs,crneM CbS� �� y� ( � �nC �t
y ` n � � n l / sf{ c i v�scn,c,r1-,
Vehicle Claims— lease com lete this section ❑ check box if this section does not a I
YourVehicle: Year�QJ�_Make(�,hLY�O�t�h' Model � � LT
License Plate Number ay0- FF�P State n'll� Color W�'l�t
Registered Owner t� tf o
Driver of Vehicle f�s '}�1� Pfcbb�.f�10 uJ
Area Damaged �'1(01'�'�t QDSi'�inn SQ115D�
City Vehicle: Year N/A Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Injurv Claims please complete this section .�check box if this section does not avply
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
�,Check here if you are attaching more pages to this claim form. Number of additional pages�.
By signing this fornt,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��7��/�
Print the Name of the Person who Comple ed this Form: h��s�n-c ���blaccno�,�
Signature of Person Making the Claim: � �,
Revised February 201 I
CUSTOMER #: WB797919 6H1EO7 ROSEVILLE �,,,,�
BUICK I GMC �
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JEREMY NICOLE PRIBBERNOW 2775 Long Lake Road • Roseville, MN 55113
10651 JOHNSON STREET NE DUPLICATE 1 Service Phone: 651-604-1700
BLAINE, MN 5 54 3 4 PAGE 1 Fax: 651-604-1708
HOME: 612-3 81-4 5 31 CONT: 6 51-2 7 0-12 3 7 www.rosevillebuickgmc.com
BUS : 651-375-1418 CELL:651-270-1237 SERVICE ADVISOR: 5996 CYRIL FASNACHT
C(}lQR YEAR MAK�IMODEL 1flN IIGEN$E >MIL�A�i�iN/OUT TAG > ;
WHITE EBO 11 CHEVROLET MALIBU 1G1ZE5E7XBF280191 240HVP 54768 54768 T1035
CIEL. bATE P.RQI].D;4TE Wi4Rf�.�?CP. PROMlS�b f��:lalb, RA�`E PP�I'MENI' INU. Di47E
280CT11 D 17 : 00 17APR14 VMC 16APR14
R.O:OREtv�D ''READY `< OPTiOrvS: SOLD-STK:BR006275 DLR: 3690
ENG: 3 . 6 LITER SFI TRN:A
06 : 55 16APR14 17 :20 16APR14
LINE OPCODE TECH TYPE HOURS LIST NET TOTAL
A >:THE eIf ENG LIGHT CAME (3N AND TF�ACTTON CQI*1TRt�L TURiVED QFF LI�HT CAM�;
ON AND THERE WAS A SHAKING IN ENGINE AND NO POWER. . . . .NOTE O K
>� :� �: . � .�n`r�...��!��`.�..�.:�?,��>�'-�FI�. �. ���. ���
� i�T HOLES
CAUSE: DTC P�13'S . Thrott�.� Ptifisition �TBa Sensor?1-2 ' Co�relation ;
DR10 DEFAULT
'' 3564 CP ;224 .;01 '>2Z4 .'O1
1 12615503 (S) BODY 207 . 99 207 . 99 207 . 99
; 1 �259336� (S}GASIC�T < 22 . Ob , 22 .i}f 22 . 06
„ „ 54768 DTC P2135 . Throttle Position (TP) Sensor?1-2 Correlation TEST
, ; , ,THROTTLE PO���'IC7N CI,RCUI'I`. REPLAC�D THROTTLE B(�DY. RELEARNED IL7i�,E �;;
, , , ,CQ MQ3T L���.Y ��±ATED Tfl F�X�ESSIV� VIBRATION CAUSF:D BY HITTING,:
�„�?�:.... , > 'i
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**************************�*************************
B NO CAMPAIGNS DUE AT THIS TIME
CAl DEFAULT
': 3564 CP _ D .DO 4 .Q0
_ ****************************************************
C** AUTOMATIC TRANSI�'lT�SION FLUID FLUSI3
ATl AUTOMATIC TRANSMISSION FLUID FLUSH
' 356'4 Cp ' 89.''40 ' 89.':40
1 6600 TRANS SERVICE 28 . 68 28 . 68 28 . 68
' i4 '' 192862�3 'D�X6: 3 .',50 3 .>,60 , 5fl .,40 _
, , , , 54768 Performed Automatic Transmission fluid flush.
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SHUTTLE CC created 2014-04-15 *********************************************
i2 :32:04pm tal�en by Ari�iflne�te ***C�SH '' VM� DTSC !' AE < CHK > CHG ***
King *********************************************
THANK YOU FOR YOUR BUSINESS
ALL PARTS NEW ORIGINAL EQUIPMENT, UNLESS OTHERWISE SPECIFIED o�SC�tptidN ' 7ara�s
Thank you for this opportunity to serve you. It is our aim to perform alI the repairs requested LABOR AMOUNT 313 .41
on this repair order to your complete satisfaction. If our service was satisfactory tell your PARTS AMOUNT 3 0 9 . 13
friends. If not please tell us immediately. DiSCOUNTS 0 . 0 0
"Any warranties on the products sold hereby are those made by the manufacturer. The SUBLET AMOUNT 0 . 0 0
seller Roseville Buick GMC hereby expressly disclaims all warranties, neither express or MISC.CHARGES 24 . 99
implied, including any implied warranty of inerchantability or fitness for a particular purpose, TOTAL CHARGES 647 . 53
and neither assumes nor authorizes any other person to assume for it any liability in
connection with the sa f Said produCts." LESS INSURANCE 0 . 0 0
P. SALES TAX 2 2 . 0 3
X ' PLEASEPAY '
CUSTOMER SIGNATURE THIS AMOUNT �' 6 6 g . �6
Coov��aht 200p ADF,Inc.SERVICE INVOICE TYPE 2-512L CUSTOMER COPY