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Xiong, Shoua RECEiv�� APR �8 2014 RECEI�IED NOTICE OF CLAIM FORM totheCit��t��l, Minr�� 2014 M i nnesota 3ate Statute 466.05 states that ev�y p�son who d ai ms damages from any muni a pal ity st�al I ca�de�es�ot�ci�a�K governi ng body of the m�i a pal i ty wi thi n 180 days after the al I eged 1 oss or i nj ury i s di scovered a noti oe stati rx,�the ti me,pl aoe,and a rcurnstances thae�f,and the amount of oompaisati on or other re!i ef dananded. Pleaseoompletethisform in itsentirety by dearly typing or printing your answer to each question. If morespaoe is needed,attach additional sheets Ple�enotethat you will not beoontaded by telephonetodarify ananrers,so provideas much information asneoe�r'y to explain your daim, and theamount of oompensation being reque�ted. You will reoeivea written�Icnowledgement onoeya�r form isreoeived. Theprocesscan takeuptoten weeksor longer depending on the natureof your daim. Thisform must besgned, and both pagesoompleted. If som�thing doesnot apply,write N/A : SEND COMPLETED FORM AND OTHER DOCUMENTSTO: CITY CLERK, 15 WEST KELLOGG BLVD, 310 CITY HALL, SAI NT PAUL, M N 55102 Frst Nar�e Middlelnitial Last Name �--I Company or Bt,�i+�ess Name N Are You an Insuraioe Company? Yes o If Yes, Clam Number? Street Address l� �� /1 L� � � c�ty �"� ��.1 state � zi p Code JJ�l 0 D2�yti me Phone( Cel I Phone(��O3ZZEveni ng Telephone( D�te of Aocider�l I nj ury or Date Discovered � • o�r��`t' Ti me�am/� PI�e s#ate, i n deta I,wha�oocurred(ha�pened), and why you are submi tti ng a d a m. R�e i ndi cate why or how you f�ty o�Paul o�ployees ae i nvolved and/or respor�si ble f a your darr►�es. Pl�e dieck the box(es)that rr�dosely represent thereae�n for completing thisform: M y vehi cle was damaged i n an aocident My vehi d e was damaged duri ng a tow �/I�lly vehi de was danaged by a pothole or oondition of the street M y vehide was damaged by a pl ow M y vehi d e was wraigf ul I y towed andlor ti dc�ed I was i nj ured on Ci ty property OthertYPe� {x'oP�Yd� p��fY Other type of i njury pl�e speafy I n order to process your d ai m vou need to i nd ude oopi es of al I appl i c�bl e document s For the d ai ms types I isted below, pl ea9e be sure to i nd ude the documents i ndi cated or it wi I I del ay the haridl i ng of your claim. Docurnents WILL NOT be returnecl axi become the property of the City. You are enoouraged to keep a copy for yourself bef ore st.txnitti ng your d a m form. �Property darr�age d a ms to a vehide:two esti mates for the repa rs to your vehide if the damage e�coeeds $500.00;or the adual bi I Is�d/or reoei�s for the repai rs Towi ng cl ai ms: legi ble oopi es of any tidcet i ss�.�ed and a o�py of the i mpound lot recei pt Other property darr�age d a ms:two repai r esti m�tes if the darr�age exoeeds$500.00; or the adual bi I I s and/or recei pts for the repai rs;deta led I ist of damaged items I nj ury d a ms: medical bi I I s, reoei pts Photographs ae al ways wel come to document and support your d ai m but wi I I rbt be returneci. Page1 of 2 Pl�seo�mpleteand return both pages� Claim Form Failureto oompleteand return both pageswiii result in delay in the handling of your daim. AII Claims pleaseoomnletethissec4ion Weretherewitr�essestotheincider�t? Yes No Unknown (arde) Provide thei r narr�es, addresses and tel ephone numbers: Werethepolioeor law enforoeme�rt called? Yes No Unknown (arde) If yes, wh�depaitment or agency? C�e#or�eport# Where di d the aay dent or i nj ury take pl aoe? P1'ovi de street address, cross�reet, i ntersedi on, name of park or f aci I ity, d osest I andmark, dc. Pl�e be as deta I ed as possi bl e. If , attach a di�ram. E SS PI�i r�ii�e t�amou�t you are i ng i n oomper�sation r wfrat y u woul d I i ke the City to do to resol ve this d a m to your sati sf adi on. , �j� 1'� �1��+2� cs� Iro1e a�' r�-�l . VefiideClaims l�ecom letethissection chedc x if thissec�iondoesnot Your Vehide: Year Make �- Model Lioense Rate Number St�e /��j Color 'P.�1AC� Registered Owner Sl�llQ � 1bt�1Es Driver of Vehide A rea Dar�aged City Vehide: Yea�' M Model Lioense R2te Numt�' State Color Driver of Vehide(City Employee s Name) A r�Danaged Iniury Claims �lea9eoom�l�ethissec�tion Vchedc box if thissediondoesnot aaplv How were you i nj ured? What pat(s)of your body were i nj ured? Haveyou sougM medical treatment? Yes No Planning to Seek Treetment (drde) When did you reoeivetr�tment? (provided�e(s)) Nameof Medical Provider(s): A ddre� Tel eptane Di d you mi ss work as a result of your i nj ury? Y es No When did you miss work? (provide date(s)) Nameof your Employer: Address Telephone �hedc hereif youareattachingmorep�tothisdaimform. Number of �dditional pages�� By sgni ng thi sform, you are stati ng that al I i nformation you have provided istrue and correct to the be� of your knowledge Unsgnedformswill not beprocessed. i n. Dateform wascom leted �� Submitting afalseda�m can regult in prosecut o p Print the Nameof the Person who Complet is Form: � S�gnatureaf Person MakingtheClai � Revised February 2011 map of hwy 35E on maryland Ave-Google Maps https://www.google.com/maps/preview?ce=utf-8&client=firefo... _._ Slawirgallresuhsforhrry36EnwrMa�yW�dAV�.5awY41,M56... . .�... . . .- — M Maps 8 U'ivitg Directions-drivirg�direCtiqis.eas�a.co/ � - � .. ' �_{ ..�n...txre.h(Mfs. Fx.�r��.�).�i.a:nvr'T' .S�irrr . bf.xyi:»:f 4':F.;.f ... . �I�c�'el�;-+L�:nl _ _ `..�PP'pmnze e .. myqn6v .:at:.u�v::�:tr�.'�» • . . . . ..`� . ...�. .� - Nrw�nurCe:e.r.s t.v:1�.Wi � �� " IMnP^7ny"vr F'. ..i ..�....- �y .. _ i , ., .. �.,,.yx ,�a�; . . � L _. . ° ._ L.__ ' .._ � _ s�n. 1��C:kanrs — _ " � � ��e v�� Cide�� ! �' Mep0ete6Y01�boopk ZOON 1 of 1 3/12/1411:1OPM CU�TOP�E�2 #: 415885 200457 BUERKLE HYUNDAI *INVOICE* 3350 HIGHWAY 61 SHOUA XIONG VADNAIS HEIGHTS- ST. PAUL, MN 55110 870 SIMS AVENUE #2 (651) 490-6688 SAINT PAUL, MN 55106-3826 PAGE 1 HOME:651-347-5774 CONT:651-347-5774 BUS: CELL:651-347-5774 SERVICE ADVISOR: 13 LOGAN KEYES COlOR YEAR MAKF/MObEL VIN' UGENSE MItEAGE IN/OUT TAG BLACK 13 HYUNDAI VELOSTER KMHTC6AD5DU096131 WM4025 24525 24525 6833 DEL.DATE PROD.DATE 1NARR:'EXP. PROMt5E0 PO N0. AATE PAYWIENT INV. DATE 13AUG12 D 28JLJN12 13AUG201 WAIT 07MAR14 134 . 00 CC 11MAR14 R:O.t�PENEO : R�ADY OPTIONS: 11:22 07MAR14 10 :46 11MAR14 LINE OPCODE TECH TYPE HOURS LIST NET TOTAL A MOUNT AND BALANCE 2 TIRES SOP TIRES KUMHO KH FRONT TIRES 3M2 MOUNT AND BALANCE 2 TIRES 30 , CR .1.30 28.00 28.00 2 52905-2V250—EB WHEEL ASSY—ALUMINIUM 467.69 467. 69 935. 38 2 'PO#'24276 '215/4OR18 KLJMHO KH25 129.56 129.56 259.12 2 52936-2V000 STEM—TPMS 19 .45 19.45 38 . 90 24525 DISMOUN'T 2 OLD TIRES. REMOVED SENSORS. REPLACED TPMS VALVES. MOUNTED AND BALANCE 2 TIRES . INSTALLED 2 NEW RIMS *************�r*�r**,�********************************* B CAR WASH — $5. 95 — NO CHAR.GE WITH SERVICE WASH CAR WASH — $5.95 — NO CHP�� r��s�� 37 CR 0 . 00 0 . 00 0 . 00 ************�*****�r�***��+�:�******,r�rr��P��:************ �`�'�, � C FOUR WHEEL ALIGNMENT Y� ' 4A F�UR WHEEL ALIGNMENT �.�,,...,. �•s j��"'�� .; �� 37 CR 1.90 ` 119. 95 119. 95 ..... 24525 per€orm alignment found c��'< out s��,. ��> �ront may need new strut due to damage � "�� ' � �"� � *�**�******�******�******,�***�***********�*****�**** D PERFORM COMPLIMENTARY MU�TI PQTNT �NS�ECT�Q�1 ; ; ._. ,,,; ,.. .� �� INSP�� PERFORM� COMPLIM . ,�. 'Y �'1*;�-P��I' �'�-�"�.�'E4`��iN ;'�.. �.-< � � 3� cR o . no o. 00 o . 00 ************�*�********��;��*�**��,��•******;�********* E** DURING INSTALL OF TIRES TECH FOUND CONTROL ARM TO BE BENT BACK ABOUT 2 INCHES. . OK TO REPLACE CONTROL ARM. INFO INFORMATION ONLY 37 CR 1.20, 174 .00 174 : 0� 1 54501-3X000 ARM COMPLETE-FR LWR RH 264 . 94 264 .94 264 .94 2452;5 rep7.aee rt front: ct�ntrol 'a�n during aiignment 'found camber out of spec may need rt front strut it may be bent also car seems to drift lef t but has bent rims and poor tire� rec 'replace front rim�: and tires then drive if still has issue replace strut and realign note front toe wa**�**8(3*de:g***s***********' ************************** WARfiANTY I W HI:ALL PARTS AND ACCES80RIES ARE 801.0 AND ALL Ii�AlflB ARE PROVIOFD BY THE DEALENSMP :QES��tPTION TOTALS EREBY E%PRESBLY qSCWMB ALL WARRANTIE8.EXPRESS AND IMVI.IED,INCLUDIN(i ANY IMPLIED 9PARRANTIEB OF MERCHANTABILITY AND fITNE86 FOR A PARTICUTAR PURPOSE,AND N6THER ASBUM�NOR AUTNORIZES LABOR AMOUNT ANY OTHER PERSON TO ASSUME FOH IT ANV LIABIUTY IN CONNECTION WITN THE SALE OF PARTS OR PRODUCTS Op TNE R�AIR.THE ONLV WARRANTIEB ON PANTS AND ACCE8SORIEB OR R�NRS ARE THOSE WHICN MAV BE OFfERED BY THE PARTS AMOUNT VEFMCLE MANUFACTUR9i OR THE PAHTS MANUFACTURER OR DiST111BUTOR AND ONLY SUCH MANUFACTURER OR DISTRIBUTOR SHALL BE LIABIE FOR PERFOHMANCE UND9t SUCH WARRANTIES. CUSTOMEH SHAU.NOT BE EN'TITLED TO GAS,OIL,LUBE RECOVER FROM THE DEALERS►MP ANY CONSEW/BdT1AL DAMA6E8.DAMAOES TO PROPERTY,DAMA6ES FOR LOSS OF USE. SUBLET AMOUNT LOSS OF TIME.LOSS OF P(iOFlT OR INCOME,OR ANY OTH6t INCIDBdTAL DAMAfiEB. By signing below, you acknowfedge that you were notified of and authorized the Dealership to perform the H��uswnsreasrosn� servicasJrepairs itemized in this Invoice and that you received (or had the opportunity to i�spectl any replaced parts as requested by you. The vehicle is being returned to You in exchenge for your payment of the Amount TOTAI CHARGES Due. LESS INSURANCE I authorize the retrieval of on-board data as needed to facilitate vehicle repair,as well as sharing of that data with the manufacturer for diapnostic and research purposes. SALES TAX OA7E CUSTOMER SIGNATURE AUTHORRED DEALERSHIP REPFESENTATIVE SIGNATURE p�EpSE PAY � THIS AMOUNT ALL PARTS ARE NEW ORIGINAL EnU1PMENT PARTS UNLESS OTHERWISE iNDICATED. �fl2008 ADP 101/091 SERVICE INVOICE TYPE 2-2512C-'AS-IS'-MINNESOTA•9�§TOMER COPY [jrTOME� $�: 415885 200457 BUERKLE HYUNDAI *INVOICE* 3350 HIGHWAY 61 ��OUA XIONG VADNAIS HEIGHTS- ST. PAUL, MN 55110 70 SIMS AVENUE #2 1651) 490-6686 AINT PAUL, NIl�1 55106-3826 PAGE 2 OME: 651-347-5774 CONT:651-347-5774 �US: CELL:651-347-5774 SERVICE ADVISOR: 13 LOGAN KEYES CQLOR' YEAR 'MAKElMC}DEL - VIN UG£NSE MILEACE iN/OUT i'AG �LACK 13 HYUNDAI VELOSTER KMHTC6AD5DU096131 WM4025 24525 24525 6833 DEL DATE PROD. AATE WARR. EXP. PROMIISED 'i PO N0. RAT'E PAYMENT ; INV. DATE ' .3AUG12 D 28JUN12 13AUG201 WAIT 07MAR14 134 .00 CC 11MAR14 R.O:ORFM1fE� ' READY OPTIONS: .1:22 07MAR14 10 :46 11MAR14 ,INE OPCODE TECH TYPE HOURS LIST NET TOTAL `USTOMER PAY SHOP CHARGE FOR REPAIR ORDER 2Q•�� WAIT created 2014-03-05 ' 02:17:OOpm taken by Aro n Martin _ ?a�'�a'.�,;�.z�-'� ��.� w � ' � . .;. �.� .;. ,: . . :- ,� . .. � _ � � . . .. — . . � ;,r,:.".s �" . � �- �, s^, �.tt � .. � � : � . � �� . .. �ti � , ,�4 . } WARpANTY DISCWMER:ALl PARTS AND ACCESSORIES ARE SOLO AND All.REPAIRS ARE PROVIDED BY THE DEALERSMIP pESCRIPTION TOTALS EREBY EXPRESSLY DISCLAIMS A4L WAHRANTI�.EXPRE88 AND IMPLIED,INCLUDING ANY IMPLIED pN�Y OnTNj{TER pERSON TO AS8 M,E OR�ANY lJABiLlTYAN CONNECTION WI�TH TH�E�SALE OFEPA�OR�PROWC�OR TM�E LABOR AMOUNT 321..95 REPAIR.THE ONIY WARt1AlYT1ES ON PARTS AND ACCESSOHIES OR REPAIRS ARE TH08E WHICH MAY BE OFFERED BY THE PARTS AMOUNT 1498 .34 VEHICIE MANUFACTURER OR THE PARTS MANUFACTURER OR DISTRIBUTON AND ONLY SUCH MANUFACTURER OR DISTRIBUTOH SHALL BE UABLE FOR PERFORMANCE UNDER SUCH WARRANTIES. CUSTOMER SHALL NOT BE ENTITLED TO GAS,OIL,LUBE O . O O RECOYER FROM THE DEALERBFNP ANr CONBEQUENTIAL DAMAGES.DAMA(iE8 TO PROPERTY,DAMAOES FOR LOSS OP USE. SUBIET AMOUNT O. OO L038 OF TIME.IOSS OF PROflT OR INCOME,ON ANY OTHER INCIOENTAL DAMAGES. By signing below, yo� acknowledge that you were notified of and authorized the Dealership to perform the HA2ARDOUS WASiE WSPOSN. �2� .0� services/repairs itemized in this Invoice and that you received (or had the opportunity to inspect) any replaced parts as requested by you. The vehicle is being returned to you in exchange for your payment of the Amount TOTAI CHARGES 1 s 4� .2 9 Due. LESS INSURANCE O . O O I authorize the retrievai of on-board data as needad to facilhate vehicle repair,as well as sharing of that data SALES TAX 106 . 76 with the manufacturer for diagnostic and research purposes. DATE CUSTOMER SIGNATURE AUTHOPI2ED DEALERSHIP REPRESENTATIVE SIGNATURE p�EqSE PAY THIS AMOUNT ��;Q�; ALL PARTS ARE NEW ORIGINAL EQUIPMENT PARTS UNLESS OTHERWISE INUICATED. ,�Q(yY�2006 0.DP 101/091 SERVICE INVOICE TYPE 2•2&2C•"AS-IS"•MINNESOTA•9�§TOMER COPY _. .. .. . .._. __. .. ._... ...._. . .. .. . _ .. .. ... ._.. .. __.._' ..._ _.._ . Gmail-Progressive Claim 14-3613516 https://mail.google.comlmail/?ui=2&ik=d4fbebf177&view=pt&... �`� � � Lou T<loucworks�igmail.com> Progressive Ciaim 14-3613516 1 message Laura Sonkowsky <Laura_Sonkowsky@progressive.com> Wed, Mar 26, 2014 at 4:48 PM To: "LOUCWORKS@GMAIL.COM" <LOUCWORKS@gmail.com> Lou and Shoua, i just wanted to let you know that our adjuster went out to the shop and confirmed all the damages today. We will be able to issue payment for the repairs minus the deductible. Our estimate was slightly under the shop's estimate by about $17 because the shop charged for supplies, which we do not owe for. After the deductible, the check amount will be $1429.20. Please let me know if you have any questions or concerns about that. Thank you, Laura Sonkowsky Progressive Insurance 10220 Goldenrod St. NW Coon Rapids, MN 55448 Ph: 763-354-5228 Fax: 763-354-5249 All correspondence (including any e-mail)we receive from you may become part of your permanent claims file. If you request a reply to this e-mail, we may respond by e-mail or by phone. 1 of 2 4/16114 9:36 PM I Shoua Xiong is submitting a claim for damages done to my vehicle due to a large pot hole on city highway. Date of Incident February 20, 2014 at approximately around 7:30 PM My vehicle was traveling southbound on hwy 35E when it came in contact with pothole. Hwy 35E southbound when you pass under the Maryland Avenue bridge. -See attachment. My vehicle is a less then 2 years old, with no prior damages and is in excellent condition. I feel the city is responsible for the damages caused to my car due to their part not fixing the city hwy pot hole and should pay for the damages it has caused me and my car. I have made a claim with my car insurance(Progressive). They paid for most of the cost, minus the deductible of$500 and a $17 for supply. Total Repair Cost $1947.05 Car Insurance Paid $1429.20 My car insurance rate will be inclining due to this accident claim. I feel the least the city can do is pay for remaining balance that came out of my pocket due to their negligence for not fixing the pot hole. It is their responsibility to keep the hwy and street safe for drivers and they fail to do that which resulted in damages to my car. My car insurance did their part and paid for most of the repair already the least the city can do is pay for the remaining. Tota1 amount of claim I am asking is $517.85 I have attached copies of the where the incident took place, repair cost invoice and a copy of what my car insurance paid. If you have any questions about this case. Feel free to call Hyundai, my car insurance or me. Please take a look at it and get back to me. Thank You, ' � Shoua Xiong 651 788 0322