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Rep & Hinze _ RECEIVED NOTICE OF CLAIM FORM to the City of Saint Paul, Minnes��a4 �014 Minnesota State Statute 466.OS states[hat "...every person...who claims damages from arry municipality...shall cause to be'pr'eseM�ta�h�K governing body of the municipality within 180 days after the alleged loss or injury u discovered q notice stating the time,p[ace,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 addition�l sheets. Please note that you will not be contacted by telephone to clarify answers,so provide as much information as necessary to ezplain your claim,and the amount of compensation being requested. You will receive a written acla►owledgement 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�oth 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 2 U I/' ,—�D� �.Middle Initia��l�Last Name �P� �r CC��Z�` Cbmpany or Business Name Are You an Insurance Company? Yes/�o If Yes,Claim Number? Street Address I7Sq �}�(C�q/�� G� �►�� City �'f'� /' Gtt�L State �J� Zip Code�� 6� Daytime Phone��-�� Cell Phone(�� - Evening Telephone(_� JGti,� Date of Accidenb Injury or Date Discovered �-� �� «►- Time am/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 and/or responsible for your damages. s� azt 6.c°.u.es� �rraz eG n�ce�e�.1 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 E�Other type of�property damage-please specify -��„ �p pel,►w•.c.,v �-�� .�� -� F�.o�,, s�w�- _ ❑ Other type of injury—please specify i -- In order to process your claim ou need o include co ies of all a licable documents. For the claims types listed below,please be sure to incluide 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 yourself before submitting your claim form. � O Property damage claims to a vehicle:two estimates for the repairs to yout 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 C�Other property damage claims:two repa.ir e`stimates if the damage exceeds $5.00.00; or the actual bills and/or receipts for the repairs; deta.iled list of da�naged items ' O Injury claims:medical bills,receipts ' O Photographs are always welcome to documenft 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—nlease complete this section , . Were there witnesses to the incident? � es �� No Unlrnown (circle) Provide their names, addresses and telephone'3�mbers: Were the police or law enforcement called? Yes ,No, Unknown (circle) If yes,what depariment or agency? �� Case#or report# Where did the accident or injury talce place? Provide street address,cross street, intersection,name of pazk or facility, closest landmark, etc. Please be as detailed as possible. If necessary,attach a diagram. t"i�q cua.QS��ic L 4v� sr �Ew� 55iC5a--�cote 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. ��►3,°° Vehicle Claims—please complete this sectaon �check box if this section does not avnlv Your Vehicle: Year Make Model License Plate Number Sfa.te Color Registered Owner � Driver of Vehicle Area Damaged City Vehicle: Year Make Model License Plate Number State Color Driver of V�hicle(City Employee's Name) Area Damaged Injury Claims—please complete this section C�check box if this section does not avnlv 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 IIid yot�m�ss vvork as�result of your�nn�� -- -- _-Yes No - -- - When did you miss work? (provide date(s)) Name of your Employer: Address Telephone C�Check here if you are attaclung more pages to this claim form. Nnmber of additional pages 8 . By signing this form,you are stating that all information you have.provided is true and correct to the best of your knowledge. U�xsigned forms will not be processed Submitting a false claim can result in prosecution. Date form was completed ,d.r�,u_. �, zo« Print the Name of the Person who Completed this Form: �`P�a N�NZe � -rcre��r �p � � Signature of Person Malang the Claim: Revised February 2011 � ' a I � -----. - ;]��4��.`'��L'�A �i-'T?�—Ss�'�?�--�.'�--=',��__Cr�?c�__fA.�T��lae��)�L ii.e,-rE+-�.�1,.'�_--'►? _ �!4�'__-- _ --:_�P!?-�4► � ss�C.�e�_�-s`�AL�R. f�t:a�adl++��D--�-r-$t=�t�t__��F►4.�?E'--Q�?`�--�- �"06�--t'Rr'�,t' .� - ------_.__:�__e��►��a�s��c��_�_�.__��,rc'__u.<�� ,r_ ��►s��..��..�a�.rr.�_._c,=e_..r�trr� �-�.-�--s��v — ------ �`��.16�_�_ <rIUL•l..'�T' _�.`33�:�__��__��_D@�'TC�'fC�1l��--}.�L—L_�_��t----1�.___�`/ltil.---k1.�__..S?.C��.��.�.��IS..-_. ---- -�>_��"�311�-:7&t.i�3��'_�`8L.133+�.��S=�A—_SC��.��1:._T141r_ LAE%15��._"��7Y_�'=-__k�zh�pR.�''I.LA��°.---i'�1...__."i��L..___ -----—=—�'��.��?��'�...----�._.��,�*�z��..anu:�--c�`t�ls�4t�4�`?l�--t�!+�g�.--�a-�.��-=e�?J_.►�"--- ------,f�'!�--�ts��sr_r_�t��s�`t�__c�_?+as�__s�t�;��._____ ..___----------------___ ._____.___----- --__--- ______._ � _„____.�1.,,_�v_w�.._�;_��.�i�--�v�t�.�a,.�__S�tG_._v,LC�L..__��'�.._ts.�cx.rt�►�. �-<3._t�.�*fcf��__...ssa.�-ry�.._s�ic� ------'I�r�az �uuc��_ Du�_�_�_�.!�t�1�3"+�S'�--�_taP_�-_._9:;_4:�i,c%__*_3�t��_p�Bi�+7_._�rw�i.:_.��a. � 1u.a...+Se__ __ _—�_.___��4`_K�_?£.�__L�lte..�i�.L-T��a1?_��4-1��'L 4. .�4 .t ui--"--!�?R`d'-4�Cl-S�bf,at<�.?-�'�5�.'Tv�1.r_.'�C.e... ��S'-.Q').16Z--.`k�1�'-._. � POr,�t.3�"�.----�--_�n��--�A�Lta.."`:�'�6Q•��zC.iZ��'1t9,�_.tvi�,_�....6►i�1.__!�•.��-R�:3Y�__Ie'�-OPD�l�-9�_.c,uu?�S-__-- ; Qarr��Mla �rs ��S��'1451-_NF__�5.�3�R4_.!3 �T$�'�'_�._wit,6TU3_'_�.'S44_L._...�fl�'.SSAi�__3s.+7�._.aaJ,4.�s?�'�kb"'2�._:Tti4�1r3 t+_.:Aj--.,.. �i eglZ �.�.r�..�._e_1��41�5i1 �.�._�?�.��C�z_r __Sz.��1�,....a�_.sx�_.!��_P_2�td?'..1��.,��.�4��-iz�19a.�.._�_ i —_-- ---�--�<<� ex� 6.�_ ws.i_-oc��'��S�4e1Z�-�-_A.�ild�2_��G�1.L�4�S_.._!•1.��__.�t'il!,±%�_.w_ �..-4T_.u_r��i9.. i '�,E.Se�C c�•ce •,�eae�� c w�._,.��_�i:A+-"�_G' :..lStsrt�.. :L��:_�G.e�s'�p.�.W��L�:_.._�.�._..._,_...�.___.�..��_�..___�.�� t ` �:�.�' a�t;�� 2 s.oat��z,�°.��.i�JG�.�.'�'-�C��.�a.�Au��!�►'��d.�*�ec.u�_�i�._�1�P�`(stca� i w E'�6�w-n e��e5?' t—T�``s�-t` .a.._.�sF�y �.. �i CL.�,_:r$��=.>5��..�`��i.?��?�n,�:S�:�'y�_�Yl,:�4�i?g --�s e.._w..�. ---- ��. 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'c' �7��t-c� Zip �-- ..� � ,!' ReSidetltial Site (r1SpeCti017 & Estimate (See Binding Terms on Reverse) Customer Qtv/LocationlDescriation Labor Parts Discount Total Accept Decline � � i � �� _ _ , � � � � ;� �`' � � �* �"� a�'- i >�. . a � � �a �� - � ��z . � � � ,ee �,. m�. � -s� _- r. °•�.��e s � ��..� o .� � � � ,�...� ,. m " Lav-Faucet&Water Supplies ❑ ❑ C� I o Lavatory-Drain Lines � � C� � � Shower ❑ �—�-- ': ❑ ❑ � I R�� e�5-sna� '� ❑ C', m Toilet-Operation ❑ ��19�p,�$-��-�„�Q�,�...r'�--� • � ❑ C � Dramage ; � m� �� Tro- ,��,. � � _ __ _ ,� ,.� - �- , � � �� F � .,� �, =� � , �.� � -��.�.�� ; ; � a d- � m � � � � � � � ��_ � : , .� . � � ; a r � . . v� «< � � � �_. � , . . � � i .� , ., � s .�� - � �;� _��.�. ��_ m_a ��;��. . � _. _ �. _ _ � , Relief Valves ❑ ' ��;��El�l �-- � � ` Tankless(Water temperature) ❑ � � � :; = Tank ❑ °� � � ❑ m Boiler Drain ❑ � � � � Ball Valve/Shut-Offs ❑ � � ' Water Supply&Piping ❑ � � � a, �A- � � _ :t _. = w� ti�� .� - � `°�r� r�N� ��. ��, �..� � �� . ��f � P_ . , ��•,_- -" - � �° * � � �� '�a, � � � �� , ? i a m � ^ � " � � ''• 1 � P, a �_ r � , ��: s s s� - � __��m �., ��4,� ��, ,P�.� ��::� � � �� _ � r�� '�,` o Main Sewer Line ❑ �� ❑ ❑ � � Hose Bib �g X.� _ � ,� ❑ ❑ 'a' Downspouts ❑ `� ` � m �m � �. � , ��. � � � �� m a� �� ,. u � � � ' � �a�.� WO ORD AUT�IIIk�1�TI0N I a ' the servi s indisated and agree to pay the amounts specified.I have read `�1---------� an agr : t erms on yr ers 'd ' cludi its on Roto-Rooter's responsib''ty specified in tho term� Total estimate reflects customer (Si na �°'�� — � (Print Name) �'V `� � authorization of work as indicated above. ES ND DESCRIPTION OF WO K TO PERFORMED(The approximate starting date is ,and the Tax not induded in estimate. approximate completion date is — .Neither date is guaranteed.tlnexpected conditions or problems could cause delays. ___ A d fini completion date is not of the essence.) �, � _ � �^' � � \ '�-' Labor 5.--' - �'� - . � / _ , - � f= �r=; r�L= �L,�.�'�i Parts � � , .�, �� ". � � ) ' '�' C.y'r 'C/1 �� .l � G,G ,L` -1i�:�if / �� .,j.%�i _r.I , � i ^ /��3r�`,� ._., iGC, . �J �,J ��=' _ /+. �l,°:%: Discount � i�r�.� , , ` � ., �� - �� :� �G�- ; -% � �'G E? " �- .Product S ��,�� < � ?�';�C; �G�' 7 ,.°�� ' � Other � 0, TSIADJ ST T H�kyG,,E� OR� " � �� -:C�/i�,./_-lr'_� �i ,;r" �, f�t=.f ��>?� /1 ,''�/��.�"'�!% ,/ 7'�� TOTAL $��'_�, �-= ' � � _ ,�7Je�`,�= ;�_,�:� -� , %z;r" —y , :1 �'T'� %- t-t o ,�r `t ,f ❑Cash ❑Check ❑CreditCard it 'y� :J__� /-'��-�% �'" Ti�� C-'- � �l'�" �� Jr `��!"ll . COMP _N �ledge completi6n of e a, escn ed workwhich has been done to my complete satisfaction. Auth# (Sig atu �/ �� - `��``- � (Print Name) Control Na ` % �� 48-�12055 ( echnician's Signature) (PriM Service Technician's Name and Numbe�j CUSTOMER COPY Roto-Rooter Services Company + Terms and Conditions I `` . The following terms apply to all work performed by Roto-Rooter Services Company or i�s affi;ixt��s("us")for the customer indicated on 'j Cl�e front of this form(`you"j. � � l. Your Respensibi�itie�. You a�ree to(a)remove a��y Yi��zai�ds,c,bstructi�ns or danger«us conditions around the job site not caused by ou��,vork,(b)li;��it z�ecess to the jr,b�i*e so that peopte not�.vor�_ir��n cui•job are nct�xpased to danaerous conditions rciating to�ur job,(c) place appropriate�ti�a��r�in�s tc�s;��; of dangerous conditions �vi.e�i�•,�J�� are nct oi: the job site,and(d)provide�is ��.vith�dequa�e access. 2. Exceptions to Our Re�onsibilities. We are not responsible for(a)personal injury,property damage or other damage ar los�te you ar others arising out of our work,except to the extent caused by our negli�ence or failure to perform the work in accordance with the contract between us;(b)defective,damaged,or deteriorated lines,mold,lead piping,or other unexpected or u�Idisclosed conditions,and the con�equences of such conditions,includinb delays,broken fixrures or line�,and lodbed e�uipment(if we encounYer such a condition,we may stop work,and I xGii ��1'll��ty li"�u il;.i5lili:A[�:t;.,li:iib�i'vt"li.� ..;,iii(iel'f011iil;il�� t;j ii,�lililC?'t;CiUll'�i�iU CUfI:�jC;t�,OUI\VOl'�C�Vl�ll'iC�iSC)EIc1r';f.;CiilIbC13C,��Cl�L1llICSS �`---_-�._,, explicitly stated in writinb,any damage necessary fo complete oilr��ork,ircluding damage to landscaping,walls,pain6ng,ti�e or concrefe ar sinti�ar;rerils; (e)cl��nia�e caused by the removal of any clean out,drain cover o�•cap;or(�j tasks��e perform in accordance with your specific : instructions. 3.Release and Hold Harmless. You release us from(and if you are a con,mercial customer,you will defend and indemnify us and hold us harmless against)all damages,claims,demands,settlements,jud�ments,liabilities,�osts and expenses,including reasonable attorneys' fees, allegedly arising out of(a)breach of your responsibilities under paragraph 1,or(b)matters for which we disclaim responsibility under paragraph 2. 4. Our Guarantee. If we provide a parts or equipment guarantee,as your exclusive remedy,we will give you the benefit we receive,if any,itnder t?�e;nanufacturez•'s wart-anty. If we provide a service guarantee,it�c�ve�s only clrainage fail�ire in the lir�e serviced,�ind defective plumbin�wo;'�cn�aflship,during the�uarantee term. As your exclusive r�medy t�nder aiir servi�:e a�iar�mtee,we will,at our option,either do ihe wc�rk a��iz��Et;�:�1 z�_�f;r cost or refund your payme�?+.Guarantees��o not ap��ly to��•o�iems�rising ot;t c�f rnain sewer line hni;'�up ar improper, � abno3��r+.� or ur_antiii��atec�use or c<��iditioi�s. Fxce��t as explicitly stated in ��-;ti�a�,.«e are i�at giving ar.y guarantees or makin�any w��ranties. � WE TJ1�C�AEi`�ANY IM�'�,��;��VA�RANTIE,S OF MEI2�"�?��:�'TAB�,�,F�fY C?f2 Fi'['?V�:SS F�R Fo PARTIC'Ji,AR PURPOSr. You may � transier a��:��:�aiir�e of'piumbin��;;p�ir or replacement to a pers�;�. ��ho purch�s<<�tk.e�rflperty,but you may�lot trai,sfer a drain cleaning or toiict auger gua�-antee.Your trausferee must present the wa:�-anty claim to RotaRooter at tl�e time we perform our work.�e do not guarantee ::hai o�a.�s;i_.ir�5r��a.+,t2 �v;iz �a..,>;��all��ist�=;g o�poier�ttal prob.enls.�ny d�mage�s or necessary repa�rs arisin�fi•om�;l�zmbing problems, either ider�tified or uc�identified,�are the sole responsibility of tt�e customer. � 5. ��in�itation of Dania�es.Qur liabiliry to you for any c3aim arising out of our work on any job(other than a claim pern�itted bY these ter�7ls far personal or bodily i�jury)wiil iu no event exceeci three ti�ries the amount you actually pay us for the work on that job.EXCEPT FOR A � s_ � '�', :'6fFZi�,�TTT��BY THESE TERMS r0,��=,RS��:A;.!?�� R::.�'i.`�Ii�a:liR'�'�R�.�Ji'E;;-�i`;`DAi,'i�'��iE,Yt)��WAIVE�NY RIGHT �'��? ":�1 z s'4 ?T��.�' 31_ _�,<�"v[.-��rS,�'01�SFE�LlENTIAi�DA�`r1�?GF,S,OR i�ELAY Dl�M�t=JFS. 6. Pa�ment Terms.`vVhen you pz��vie{e.a check as payment,you authurize us either to use iriioimation from your check to inake a one-time electrori�fund transfer fro��your account or to process the payment as a check ti•ansaction. If you fail to pay us any amount when due, we'will charge you interest on the am�unt due�at the rate of 1.5%per month(but not exceeding the highest rate legally permissible). You will reimburse us for the reasonable attorneys' fees we incur in all stages of collection. 7. Gene��al. Thcse te:�ms as�e part of our contractual agreement and will prevail over any inconsistent terms in any other agreement bet��°e��i��,;, i�icluding t�.�terms of any r�urchase arder,and may be modified only in a written instiument signed by both of us which specifically refe�s to the provisions to be�nodified. If any nf these terms is held;i,��alid or unen`�nrce�ibie,tl�e remail�ina provisions�vill natbe affected and wIll continue to apply. _ __ _ ___._____ _.__ _.--_-._ _ __.____-----_�.___.__�____--____.--.._ -- I HOW TO I�SOL�'E fi P'�tUliLEi17 + Contact the manager at your Roto-Rooter office. Everythiug�vill be dane to resolve your problem at the local level. � • If your problem cannot be resolvec'��locally,please contact Pat Swauson,Customer Service Coordinator,in our national headqiiarters: I Rot�-Rooter Services Cornpan}� or emaii pswansonCrrsc.com 2500 First Financial Center 255 East Fifth Sh•eet � Cinciunati,OH 45202 RotG-i�P�l41iDS��'� I RO�o� �A<iok'�.s.4:58%2�iec�ibne�rt�DIiWf, �-�'i: � �efc�6c'8°�s�0-Q�T�I#O€��f9�-78�^ej•�(i�li�i�3�i�-8�"`� i ROO'fER� ��4F� DRA NsSERY10E Date � y ��'"` INVOICE N0. � � '� I��` ! 1�-8�0-GET-ROTO Customer '�r'"'"i �-° �4� � Technician�='��° "•'� (435-7686) Address � �� :g,,,�°s,r,�,;�� .F-�° Zip S.S%�";� R@Sid@t1ti81 Sit@ It1Sp@Cti011 & Estimate (See Binding Terms on Reverse) Customer ' Qtv/LocatioNDescriation Labor Parts Discount Total Acceat Decline ' ��t_ � � ��.. ��T�"a,c' r a „w�N � �.s� � m� �� ?� `.�c... = z -. �.,�`a�`m �r�. w+.�c.g..' �, �� '�� -,, � °� � K.�• ' - - � E� �,. . �r. �.�,-� v� r = - - � , . ' � . . .. � - _ . . �- _ ,.. _ .. . ��: —.. _ __. �. .� _w� .� __.:k _ ,._ -:�.__�: . . .._ . � .. _ Lav-Faucet&Water Supplies ❑ � � ' oLavatory-Drain Lines ❑ � � � , � Shower ❑ °� � � � � � Toilet-Operation ❑ �9�'�-��-�� 0° Drainage ❑ " ❑ ❑ ' A e .� �- � - �� m � a �m � � � � s � � ,� � e � � � � i ��s3� m ; ��` �"� �� . y � �, � �� t � � �� e. �.s.s��m�. a� � _� � �. � _ . � ,� a _ �� ,.<, �. � � � � � Relief Valves ❑ ��.-�-}�� w Tankless(Water temperature) ❑ =,� � � , � `� ❑ � ° Tank �" m Boiler Drain ❑ ' �--�-- � � 3 Ball ValvelShut-Offs ❑ j �� ' Water Supply&Piping ❑ _ _ � - -� = � _a m�,� ..��._ � ;�� `�. - a-s�, s�� :,�:. ,�, "�,.. °_::��- -- a�- .� v=: . - �, . 6 =i` . ..�,_ z �.�„�. 3� ..— �.,... �� .�_� �`�-� -�- . � �.�s � v��. . . � ,+�. , . � , .�a �.:-� . ��w„ � ,. ,.�:� �. e° - m ' � a �� r� �� '�� '�-'�-�'""�. :.;- _ ^ � . - '. '�. q . .. . ��. e �� - �� %��' � ,.�.._ ��, . .�..��a =,,.-�:.�.�. �_ �.--"e . '��_._ .;__. .��-�' - - - ._ . ._.. ... _ � ._. _ - � �� i o Main Sewer Line ❑ � � , WI Hose Bib ❑ ��` � -�..�� ❑ ❑ �. . . C�— " - ❑ ❑ Downspouts ❑ U `� e .�� , ___ ._ _ _ ,�, :.. � .. - � � ; � a � ��:� g t�m - � � �� ,. �� °�.�.�� ' � � �.�--� � �� WORK ORDER AUTHORIZATION I a or ze the seroices indicated and agree to pay the amounts specified.I have read and agree�.t�e��he r�v�rse ' ,includ�limits on RotaRooter's responsibility specified in those terms. ; Total estimate reflects customer (Signaturej� ��=�� (Print Name) authorization of work as indicated above. ESTIMATE AND DESGREPTION OF WORK TQ BE PERF�RMEL1(The approxirr�ate starting date is and me Tax not included in estimate. , approximate completion date is .Neither date is guaranteed.Unexpected conditions or problems could cause delays. A definite completion date is not of the essence.) �S � � Labor $ �° �yy,•,r,�_ i;��: t.:, �� _�° .�f-��-7-� .�7 ,S�¢;�'� i �— Parts $ �`, - �,r�.�� S'-�r'r' � Discount $ Product $ ', Other $ ' COMMENTSIADJUSTMENTSICHANGES IN WORK: TOTAL $ i��, ' ❑Cash ❑Check ❑Credit Card ' COMPLETIQbI I ackaa�vledge com�etion� f t bove�cribed work which has been done to my complete satisfaction. Auth# (Signature�=' .��-�-�"� � '' �—��"J (Print Name) Control No. � -�` ��-312205 � (Servlce Technician's Signature) (PrIM Servfce Tech�iclen's Name and Number) CUSTOMER COPY =°`"' Roto-Rooter Services Company � � � � � Terms and Conditions � - � � � � The follo�ving te:�m,apply to ali��r'K performecl by Rcto-Rooter Se�•��ices Comparly or its affiliates(`iis")for the`customer iu:licated on the front of this forin;"}��u"). �� 1. Your I2espousibilities. Yc,td agi•ee to(a) remove any ha�ards,obstruct't�ns or danberous conditions around the job site not caused by our work.(b)lim?r_acce5s to the joh si::� so thatpenpl� ,;ot�=�orkin�o�:o�ar job ai�e not exposed to clan�erous e�n�itions rela�:��,��to our job,(c) place appropriatc�„�.arttings t� ��.�:�n o��d�uige;ous c cr,.'titions��°i.en��e are not oi� ihe job site,and�(dj provide�,s �:��th adequate access, 2. Exceptions to Our Responsibilities. We are not responsible for(a)personal injury,propesly damage or other damage or loss to you or others arising out of our�vorl<,except to the extent caused by our negligence or failure to perform the work in accordance with the contract between us, (b)defecti��e,damaged,or deteriorated lines,mold,lead piping,or other unexpected or undisclosed conditions,and the consequences . . . of siich c.�; �.,�.�,�,� ,_.�.� � 'e�� '��-�u: _ =.`__�-3�7c li�es,and I�.:I��ed�ui�n��.t (if•.ve tnco�!nter such a condition,we may stop wor ,an you will pay us a reasonable charge for the work performed};(c)the time required to complete our work with reasonable diligenee;;:(d);unless expl.icitly stated in��riTing,ar�y c?amage�?e -<�ssary to�:^mr'��rc o;i� ��;;rk,incl�ading damage to landscaping,walis,painting,tile or concrete or si;��;a�item�; (e)dan��age caused by the removal of any clean out,drain cover or cap;or(� tasks �ve perform in accordance witl�your specific instiuctions. 3.Release and Hold Hannless. You release us from(and if you are a commercial customer,you will defend and indemnify us and hold us harn�less against) all damages,claims,demands,settlements,judgnients,liabilities,costs and expenses,including reasonable attorneys'fee�s, allegedly arising out of(a)breach of your responsibilities under paragraph l,or(b)matters for which we diselaim responsibiliry under paragraph 2. . 4. i�ur Guarantee. IS we provide a parts or equipment guarantee,as your exclusive remedy,we will give you the benefit we receive,if any,u;�c!er t?�e sla�iufacturei•'s �cva��a,�ty. If we provide a service guai-antee,ir covers only drainage failure in the line serviced,and defective plambing�voricnle3r„�up,during the guarantee te:m. As yonr exclusive remedy under our service •�ua.�autee,�v?.will,at our optian,either do the work agai�l at no iat��r��st or_•��efund�o;�r-payment.Guarantees do not apply to problems arisinQ out of main sevaer line�backlip or improper, � abnormal or unar�ticip�ated use r�r i:ondi?ia��s. Exce�r as explicitly stated in u�ritinQ,��e ar�e not givin�a�?y�uarautces e,c making any�varranties. �1rE�iSCLAIM�NV iMPLIED WARRANTIE•g OF MER�H.aNTABILITY��R TITNESS FOR A P��:RTICULAR I'LJRPOSE.�You may .?_!IS`er a�uarantee of plumbing repair or replacement to a person who purchases the property,but you may not transfer a drain cleaning or ,;'� . —_ " _-.LiIZ°_�'=',: , '�f r�'°'Y'U ti TC�2'�t tl�a lVc1Ci^n�`j._^��1t12�O RCrG�C^1°?'�tt��_'.' s`it11e li'�j)C.�O_�_'. J_.� Y�t.�„'�i'�.��GTG:1G`_�li^c��"�.i1�C�� that our site inspectiol� w��l idesit's_fy all existing or poiential probienls.Any damages or necessary repairs arising fi•o�n plumbi�i�problems, either identified or unidentified,are the sole responsibility of the customer. 3. Limitation of Damages.Our liability to you fo�any claim arising out of our�vork on any job(other than a claim permitted by these terms for personal or bodily injury)will in no event exceed three tinzes the amount you actually pay us for the work on that job.EXCEPT FOR A C.L.Alidi d'�IZN?�'.:i E ".' TH.F_,S��Y idPv"� �.<?� Pa'R�ON/�T�O:'��C��i,�'I.11�'�;F'��It PR`JPi�,F2�`:'L>P.IVif��,`s'Oli WAIVE ANY R1C'iHT TCREC'GV �. "d( �:, .�. ., i;Al��' � ,��c;"�T;��'1A�._DA�/:AG'-:�,i�?? �JET:�IYD�I!/�.��,ti,�:S. _ . .< � �_ 6. Pa��icnt Terms.When you provide a check as paymeni,you authorize us eitner to use information from y�ur check to make a one-time elec�anic fund trausfer from your account or to process the�ayment as�check transaction. If you fail to pay us any amount when due, we will ch�rge you it.ter;si,on the amount due at the rate of i.5%pe.month(but not exceeding the highest rate legally permissible). Xou will reimburse us for the reasonable attorneys' fees we incur in all stages ot coi�ecrion. '' �ercc= These terms a�-e part of our contractual agreement and will prevail over any inconsistent terms in any other agreem�nt between us �;1L1uci��°�il�ti:t �a�s of.xn} pur�chase order,and ma�be modified only in a written instiument signed by�both of us which specifically refers to the provisions to be�nouified. If any of tiiesc te��ls is held i�?;��ilid or unenforceable,the remaining provisions �vi]?not be affected and will continue to apply. - HOV6'a� I2ESOLVE A PROBLEM - Contact tl�e n�anager at your R��ro-Rooter office. Everything will be done to resolve your problem at the local leveL � � If y�ur probiem cannot h�resolved loeaily,please contact Pat Swanson,Customer Service � Coordinator.in our national headquarters � Roto-Rooter Se:ti�ices Company or email pswanson@rrsc.eom 2500 First Financial Center �SS East Fifth Street Cincinnati,OH 45202 � ,_:� ROTO- �CAVATION PROPOSAL ROOTER� �°`°-'��.�„'��°'"�„Y 14530 27th Aven�e Nath,Mirvieepol're.MN 55447 P L B M B 1 M B a Swvfr�i-s00-(iET-R070(A38-7686)•Gc+neral(T6�519-3977 OBAIN SERYICE Ticket No. � /7� ��q�� M�"fB8O��"�'�1PN1 ', I Pro osal Submitted To Work To Be Performed At Name Name Street „j �j .� Street City City State ZIP /d State ZIP � Telephone Number Telephone Number ; Roto-Rooter hereby proposes to furnish all the materials nd to perform all the labor necessary for the completion of: � (Include make and model of materials and necessary labor,and state an cipated contingencies that would materially alter the estimated completion date.) I o, �e � , - �.. �t-{_°' i �' �. °-� �. � a✓' r i vr- j �' r.� �- vri G� . rt � '� a �j ' I .? o. °a I � � a - S<v- �7 i i i oY ' 1. Roto-Rooter will perform the work described above and supply all required materials for the sum of$ /�, ddp. , Customer will make payment as follows • %of the cost($ )upon execution of this Agreement. • %of the cost($ )upon the start of the work. ' Balance of the cost upon completion of the job. 2. The approximate starting date is �'7�/`� ,and the approximate substantial completion date is � �� . Neither date is guaranteed.Unexpected conditions or problems could cause delays.A definite completion date is not of the essence. 3. Roto-Rooter guarantees that all materials will be as specified above and that all work will be completed according to standard ' practice and in a good,workmanlike mannec 4. Customer will provide a�l necessary easements and rights of way. Unless specifically stated otherwise above, (a) Roto-Rooter , is not responsible for the removal of trees,sprinkler systems, underground and above ground fencing, rocks,sidewalks or ', driveways,or the repair of streets,sidewalks and the like,(b)Roto-Rooter will back fill and grade the excavated area to ground level and mound it to allow for settlement,and(c)Customer is responsible for all landscaping repairs or replacements ' Customer required following completion of the job.Roto-Rooter is not responsible for damage resulting from poor weather. Initials 5. If we cannot video or inspect the complete sewer line,we will give you a price to repair the section that we believe is causing the restriction.After we have uncovered that area,we will attempt to inspect the rest of the sewer line. If additional work needs to be done,or a complete sewer line replacement is required,we will propose a price to properly complete the work.The price for the additional work may be significantly higher than the original proposal. If you decide not to proceed with additional work , we propose,you will permit us to complete our work and back fill any excavation. 6. If deviation from the work described above is required or customer requests additional or different work be performed,the parties will agree on an additional charge and sign a new written work description before Roto-Rooter begins the new work. 7. THE TERMS AND CONDITIONS ON THE REVERSE SIDE OF THIS PROPOSAL WILL BE BINDING ON THE PARTIES. ' 8. This proposal may be withdrawn by Roto-Rooter if not accepted within�days.This proposal constitutes the entire agreement between the parties,and no modifications will be valid unless in writing and signed by both parties. Respea�fully subynitted: ,�.�' ;�' ; � I, � / � /( �� ,��/ LZ-!'�pi/r.�� 3 !� �I ec,nician Signature Printed Name/Technician Number Date ACCEPTANCE OF PROPOSAL I authorize the services indicated and agree to pay the amounts specified. I have read and agree to the terms, including the limits of Roto-Rooters responsibility specified in those terms. Customer Signature Printed Name Date C�ISTOMEs� E:€��?T PF-031-EXCA(Rev.7/13) Roto-Rooter Services Company � � � � � � Terms and Conditions - The following terms apply to all work performed by Roto-Rooter Services Company or its affiliates�"us")for the� � � � customer indicated on Che front of this proposal ("you"). �' I. Your Res�onsibilities. You agree to(a)removc any hazards,obstructions or dangerous conditions around the job site not cnused by our work,(b)limit access to the job site so that people not warking on our job are not exposed to dangerous conditions relating to our job,(c) place appropriate warninbs to warn of dangerous conditions when we are not on the job site,and(d)provide us with adequate access. 2. Exce�tion5 to Our Responsibilities. Wc are not responsible for(a)persona!injury,property damage or other damage or loss to you or others��rising out of our work,except to the extent caused by our ne�ligence or failure to perform the work in accordance with the contract between us;(b)defective,�ian�aged,or deterio�ated lines,mold,lead piping,or other unexpected or uudisclosed conditions,and the consequences of such conditions,including delays,broken fixtures or lines,and lodged equipment (if we encounte:r such a condition,��e may stop work,and you will pay us a reasonable charge for the work performed);(c)the time reqaired to complete our work with reasonable diligence;(d)unless explicitly stated in writing,any damage necessary to complete our work,including damage to landscaping,�valls,pai�ting,tile or concrete or similar items,(e)damage caused by the removal of any clean out,drain cover or cap; or(�tasks we perform in accordance with your specific instructions. 3. Release and Hold Harmless. You release us from (and if you are a commercial customer,you will defend and indemnify us and hold us harmless abainst) all damaaes,claims,demands,settlements,judgments,liabilities,costs and expenses,including reasonable attorneys'fees,allegedly arising out of(a)breach of your responsibilities under paragraph 1, or(b)matters for which we disclxim responsibility under paragraph 2. �4. Our Guurantee. If�ve pro��ide a parts or equipmcnt�=uarantee,as your exclusive remedy,we will Rive you the benefit we receive,if any,undcr the m<<nufacturer's�varranty.If w�e provide a service��uarantee,it covers only drainage failure in the line serviced,and defective plumbing workmanship,durinb the �uarantee term. As your exclusi�e remedy under our � se�-��ice �uarantee,we will,at our option,either do the work again at no labor cost or ref�md your payment. Guarantees do not apply to problems arisin�,out oi�main sewer line backup or improper,abnorm�l or unanticipated use or conditions. Except as explicitly stated in writing,we are not givin�any guarantees or making any warranties. WE DISCLAIM ANY IMPLIED WARR�NTIES OF MERCHANTf1BILtTY OR FITNESS FOR A PAR"CICULAR PURPOSE. You may transfer a guarantee of plumbing repair or replace��lent to a person w�ho purchases the property,but you may not transfer a diain cleaning or toIlet auger guaratitee. Your transferee mu5t pre,ent the warranty claim to Roto-Rooter at the time we perform our work. 5. Lin�itation of Dama«es. Our liability to you for any clain� arising out of our work on any job(other than a claim permitted by these terms for persunal or boclily� injury�) will in no e�ent exceed three times the amount you actually pay u� for the«ork on that job. EXCEPT FOR A CLa1M YERMITTED BY THESE TERMS FOR PERSONAL OR BODILY 1NJliRY OR PROPERTY DAMAGE.YOU WANE ANY RIGHT TO RECOVER INCIDENTAL DAMAGES, CONSEQUENTIAL DAMAGES.OR DELAY D.AMAGES. 6. Pa��nent Ter-ms �Vhen you pro�°ide a check as payment,you authorize us either to use information from your check to make a one-time eleca-onic fund transfer f'rom your account or to process the payment as a check u-ansaction. If you fail to pay us any amount when due,we�vill char�e you interest on the amount due at the rate of 1.5%per month(but not excaeding the highest rate tegally permissible). You will reimburse us for the reasonable attorneys'fees we incur in all stages of collection. %. GeneraL The�e term5 are part of uur conn-actual agreement and will prcvail over any inconsistent terms in any otl�er a�reeinent bet��een us,includinb the terms of any purchase order,and may be moditied only in a written instrument signed by both of us which specifically refers to the provisions to be modified. If any of these tenns is held invalid or unenforceable,the remaining provisions will not be affected and will continue to apply. HOW TO RESOL�'E A PROBLEM • Contact the manager at your Roto-Rooter office.Everything will be done to resolve your problem at the local level. • If your problem cannot be resolved locally,please contact Pat Swanson,Customer Service Coordinator,in our national headquarters: Roto-Rooter Services Company or email pswanson@rrsc.com 2500 Fiist Financial CenCer 255 East Fifth Street Cincinnati,OH 45202 � ROTO— VIDEO INSPECTION OF ' ROOTER� SEWER LINE AND RECOMMENDED �ate �r-�-i" � oswlMSSERricE SERVICE OR REPAIR Ticket No. /�°.�/�•L7ig � � I R�Yo-Rooter Servfce�Campeny I �rralt�tor Addross:5872 C.o�Cent�D►ive.q�icago tL 6t189.9 � 3ervios 1�804�QET-ROTO(438-768Eij•C3enet�(783}519�77 I naw,eeo�a t��ai� � � � Customer '�� '�y� Address /7.�"�� i%�_ ,.f�,._ 'L�'%�,� ; �,�•`,.,�^ �., ,' �_._-..=-s--�.=� � " � Roto-Rooter has conducted a video inspection of your sewer line,which shows one or more of the following problems: � i i REVIEW ' � Complete Collapse-The pipe has collapsed and cannot be cleaned or opened through mechanical methods. � � Broken, Cracked or Corroded-The pipe has deteriorated and/or broken, causing partial collapse(s)in the line and ! restricting flow. � � � Bellied Pipe-A section of pipe has sunk due to ground or soil conditions, creating a valley or dip in the pipe that ; restricts flow and collects paper and waste. i � Leaking Joints-The seals between pipes have broken, disconnected or corroded, allowing waste water to escape � into the areas surrounding the pipe. I � Blockages-Grease buildup or a foreign object is restricting or prohibiting proper flow and/or performance of the line. j i � Punctured Pipe-A foreign object has perforated th�sewer line. I Root Infiltration-Tree or shrub roots have invaded the sewer line. � ❑ � SOLUTION � Customer l~ ' Cable or J�t Sewer Line-Roto-Rooter will clean the line either with a mechanical blade and cable or a high-pressure ; Initials '—'"�"��' � (One Only) Water jet. PLEASE NOTE: This is a temporary s�olution and will not address the underlying problem with the pipe. There is high likelihood that the line will back up'again in the future.When that will happen cannot be determined at ! this time. i �--------�_�. ' c��ot�Repair;�2oto-Rooter will repair or replace a section of the sewer line. We will jet clean (when appropriate)and video-�f"ie�emainder of the line. If we discover problems in other parts of the line during this work,we will notify you, and at your request, provide a proposal and cost estimate for any additional required work. i Full Line Replacement-Roto-Rooter will replace the sewer line between two(2)agreed-upon points using one of the i following methods: � METHOD j �'��Open Trench-The existing line will be excavated, removed and replaced with new pipe and clean-out.The ; trench will be backfilled above grade to allow for settling. j � Pipe Lining (if permitted by local authority)-A new pipe sleeve will be installed inside the problem line. ' , Minimal excavation may be required for this method. � � Pipe Bursting (if permitted by local authoriry)-A new pipe will be pulled through the existing pipe. Some ! excavation may be necessary for this method. ,1 i' � i � I Comments: ��.� .,rr �,�-}��:� �� f rr! �;•..� ,;_�— !�-��n,�-- f-r- �r�,� . �,�"'� .-� �r,--f�-T-�+'�� '" .�, ?_ (:- ,- • / �$� . __--7 �,+, ;% �' ,3'/� � r :' _ % • 'j ,,ti- ,��,�� ,r��.�±...3.�a-1'' TeCfinician�yfiat e Phnted Name echrncian Number Date I have discussed all solution �tioPrs with Roto-Rooter. 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