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Johnsen, Gary � � � RECEIVED APR 2 8 2014 NOTICE OF CLAIM FORM to the City of Saint Paul, Minne��.Y C L E�� Minnesota State Statute 466.05 states that"...every person...who claims damages from any municipaliry...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 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 �, I'' Middle Initial�Last Name .�/,�/�o�(.yt . Company or Business Name�`�// 1� Are You an Insurance Company? Yes/� If Yes,Claim Number? Street Address 2�7� f JGI�'t ) ��/✓�_ �%/P_l� /'J� / �1/ City ,/�l!?I�-c� .�i�lJ J//S State �f Zip Code s� T� Daytime Phone(d/L)i� - 5 /0 Cell Phone(6iL)��J�Evening Telephone(f>!L)�-� Date of Accident/Injury or Date Discovered `� -` - �� Time �/=O/� ar /pm Please state,in detail,what occurred(happened),and why you are submitting a claim. Please indicate why or how you feel the Cit of Saint Paul or its employees are involved and/or responsible for your damages. ? s-�`'�^�G�� !� ,-c�/� w�1� n�� r n��r �� /�tGr��cf��- � m�s�� i�' � � C � � � _ �f , � a , � - � � - h � � �r � � 7` �� . /r. -L � ' � Gt�� Ple�/��,�/'.errt� �.}6� �-/'v_/�a!� is� rt��'c /�t��tl` ��^ . heck the box(es'�thaf most closely repre�sent 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 coaies of all aaalicable 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. �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$500.00;or the actual bills and/or receipts for the repairs;detailed list of damaged items O Injury claims: medical bills,receipts �Photographs are always welcome to document and support your claim but will not be returned. Page 1 of 2-Please complete and return both pages of Claim Form Failure to complete and return both pages will result in delay in the handling of your claim. All Claims–please complete this section Were there witnesses to the incident? Yes No �Unlrno (circle) Provide their names, addresses and telephone numbers: Were the police or law enforcement called? Yes No Unknown (circle) If yes,what department or agency? Case#or report# Where did the accident or injury take place? Provide street address,cross street, intersection,name of park or facility, closest landmark,etc. Ple e be as detailed as possible. If�ecess�-y,attach a diagr / r. � l�G�CI� —/1?ti'i�'' �Yl i�5/S��D/�i 1��LtCiV �l�` �t' �KO �Y /CL�",_.,G_, � Please indicate the amount you aze seeking in compensation or what you would li the City to do to,resolve this claim to your sarisfaction. 7' G� ��/` L � e � Vehicle Claims–please comptete this section ❑check box if this section does not anply Your Vehicle: Year ��Make /�'1Gr�� Model �'6 DD License Plate Number �/'�( N) G k State n'!/J Color �/��i� Registered Owner �v�v'� n? - �!iJ r�� Driver of Vehicle Area Damag d f"i�L�7` t�Y� f 7� l� G City Vehicle: Year Make Model License Pl te Number State Color Driver of Vehicle(City Employee's Name) Area Damaged In'u Claims– lease com lete this section check box if this section dces not a 1 How were you injured? What part(s)of your body were injured? Have you sought medical treatment? Yes No Planning to Seek Treatment(circle) When did you receive treatment? (provide date(s)) Name of Medical Provider(s): Address Telephone Did you miss work as a result of your injury? Yes No When did you miss work? (provide date(s)) Name of your Employer: Address Telephone J$Check here if you are attaching more pages to this claim form. Number of additional pages r � 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 y'��'l T �J,, Print the Name of the Person who Completed t ' rm: �y � � �/�"� Signature of Person Mal�ing the Claim: Revised February 2011 � � , � i 9- � y � � � � 1 � � x � � C? � � D � � (tn;s+v�'mti P Z � � S,ttss`ss'S��.�8;vb N I �e � Summit Ave Summit Ave � 500ft +<��u� 200m AZ014 MapQuest - Portions C�2014 TomTom�Terms�Privac t �2ota Mapn�,est,�nc.use or arections arw maps is subjea to me Ma�pc]ues�Terms a use.we make no yuarantee or u,e aca,rac�a metr caneM,roed c«witions or rouce usebi�ity. 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' . _ .. � � a � �.. . . .. ri. �.., . . . . �� .. _ �4 ' = � . �/�`. � �- -r--._..� ; � `. . . • Mercedes-Benz of Maplewood CUSTOMER #: 6127885810 312507 Porsche of St. Paul � 2780 Maplewood Drive • Maplewood, MN 55109 Phone: 1651► 483-2681 • Fax: (651) 766-2323 *INVOICE* www.mercedesbenzofmaplewood.com GARY M JOHNSEN www.porscheofstpaul.com 2642 BENJAMIN STREET NE DUPLICATE 1 MINNEAPOLIS, MN 55418 PAGE 1 � HOME: 612-788-5810 CONT: 612-791-4359 BUS: 612-973-8059 CELL:612-791-4359 SERVICE ADVISOR: 24 ROBERT HOCHBERG QL > A � ! b :: <illl�l > i.ICENSE NULE,4GE Ehfl QtiT :; TAiC, BLUE 03 MERCEDES S600V WDBNG76J13A350728 35078 35079 5603 C��L bA�T� FROD. DaTE 1NARR. EXP. PRO(�{SED: PCI NO. `: RATE PAYM�N'i' INU.l�,4T� 15NOV13 D 17 : 00 15APR14 130 . 00 CC 18APR14 R.O.QPENED '< RfACJY 'I OPTIONS: SOLD-STK:P2893 DLR:42100 ENG: 5 . 5 Liter TRN:AUTO 15APR14 18APR14 LINE OPCODE TECH TYPE HOURS LIST NET TOTAL A MOUNT AND BALANCE ONE MERCEDES TIRE MMT1 MOUNT AND BALANCE ONE MERCEDES TIRE 438 CM 20 . 00 20 . 00 1 15494110000 2454019 242 .26 224 .39 224 .39 1 TD TIRE DISPOSAL FEE 2 .50 2 . 50 2 . 50 1 000-400-03-13 TIRE VALVE 3 . 50 3 . 50 3 . 50 5 000-990-53-07 SCREW 7 . 50 7. 50 37 . 50 PARTS: 267 . 89 LABOR: 20 . 00 OTHER: 0 . 00 TOTAL LINE A: 287 . 89 35078 mount and balance mounted and balanced 1 new tire, torqued all lugs on vehicle, test drove **************************************************** B SUBLET WHEEL FOR REPAIR S103 ROB TEAM REPAIRS 438 CM 0 . 00 0 . 00 SUBL REPAIR WHEEL PO#52623 CM 125 . 00 125. 00 PARTS: 0 . 00 LABOR: 0 . 00 OTHER: 125 . 00 TOTAL LINE B: 125. 00 � 35078 bent wheel sent wheel to be repaired *************************�************************** C SIGN AND DRIVE FLAT i CAUSE: FLAT TIRE ' 5103 ROB TEAM REPAIRS 438 WM ,.� (N/C) PARTS: 0. 0 0 LABOR s il. 0 0 OT ER: 0 . 0 0 'T(3'�'A�, L�� C: 0 . 0 0 �£ 35078 p.o. 1293276541 p..�. 1293276541 r ceived custome� pert�t�:��.on.f . signature, placed spare tire and new ugs on vehicle,.,:�3,gk�ten��1; It�gs, gave customer �opy of work order, left ***�x***********''*�*,t**********************�t�t*��*'�r�**�'* SUPPLIES/ENVIRONMENTAL FEES 2 . 04 COMPANY NAME STAl�t��tb ZURICH v"c�� COMPANY PHONE POLICY NUMBER TBD POLICY TERM 24 OUR REPORT CARD STATEMENT OF DISCLAIMER p��CREP710N Tp7ALS The factory warranty constitutes all LABOR AMOUNT Tiuly Exceptional = PASS, Anything else = FAIL tne`sa�e ofathss ie�m\it mse Tne Thank OU fOf OU( business. As a customer Of Seller hereby exp�essly disclaims all PARTS AMOUNT Y y warranties either express or GAS,OIL, LUBE Mercedes-Benz of Maplewood, Porsche of St. Paul you are implied, including any implied warranty of inerchantability or SUBLET AMOUNT entitled LO excellent service. It IS OUf mission to provide fitness for a particular purpose. that. If your experience was less than Truly Exceptional sene� neither assumes �o� MISC. CHARGES authorizes any other person to please notify your Service Advisor or the Service Manager. asg�me fo� �t any liability �� TOTAL CHARGES We WOUICI appreciate the OppOftUfllty to address y0uf connection with the sale of this item/items. LESS ADJUSTMENT concerns. ALL PARTS NEW � SALES TAX SERVICE HOURS: MONDAY - FRIDAY 7:00 am - 6:00 ►p ORIGINAL EQUIPMENT P UNLESS OTHERWISE PLEASE PAY SATURDAY 8:30 am - 12:30 pm SPECIFIED THIS AMOUNT I acknowledge that I have received a copy of this work order and the repairs performed by Mercedes-Benz of Maplewood, Porsche Customer of St. Paul. Signature X CUSTOMER COPY :-M�: . '_ . . . Mercedes-Benz of Maplewood CUSTOMER #: 6127885810 � 312507 Porsche of St. Paul , 2780 Maplewood Drive • Maplewood, MN 55109 � Phone: (651) 483-2681 • Fax: (651) 766-2323 *INVOICE* www.mercedesbenzofmaplewood.com GARY M JOHNSEN www.porscheofstpaul.com 2642 BENJAMIN STREET NE DUPLICATE 1 MINNEAPOLIS, MN 55418 PAGE 2 � HOME: 612-788-5810 CONT:612-791-4359 - BUS: 612-973-8059 CELL: 612-791-4359 SERVICE ADVISOR: 24 ROBERT HOCHBERG O < Y A MA �! . EL VIN LICEM1ISE Iv11LEA��;[M1II QtJT : TRG '. BLUE 03 MERCEDES S600V WDBNG76J13A350728 35078 35079 5603 _ ____ __ > b�L€JA7E RROCt. OATE :1NkRR.�XP. f+liOM[SED RQ [�€3. . RATE PA'1'M�N7' ;: INV.Ef�1TE 15NOV13 D 17 : 00 15APR14 130 . 00 CC 18APR14 _ __ __ _ __ ___ R:o.�PENF.�} ` R�A�Y i:' OPTIONS: SOLD-STK:P2893 DLR:42100 ENG:5 . 5 Liter TRN:AUTO 15APR14 18APR14 LINE OPCODE TECH TYPE HOURS LIST NET TOTAL EFFECTIVE DATE 16 NOV 2013 DEDUCTIBLE 100 . 00 MILEAGE LIMIT 24000 BEGIN MILES 30914 END MILES 54914 COMPONENTS Than]� you so much for your business. Please be sure to notify us if we did not meet or exceed your expectations. � �: ;, : :� � � � ; h , , �.. I ,,�, OUR REPORT CARD STATEMENT OF DISCLAIMER p�$C#{Ep71bN TQTALS The factory warrenty constitutes ali LABOR AMOUNT 2 Q . Q Q Trul Exce tional = PASS, An thin else = FAIL of tne warranties W�tn respect to y p y g the sale of this item\items. The pARTS AMOUNT 2 6 7. 8 9 Seller hereby expressly disclaims all Thank y0U fOf yoUf bUSIf12SS. AS a customer Of warrenties either express or GAS,OIL,LUBE � . �� Mercedes-Benz of Maplewood, Porsche of St. Paul you are i �mplied, including any implied warranty of inerchantability or SUBLET AMOUNT 12�j . �Q entitled to excellent service. It IS OUf f1lISS1011 t0 provide fitness for a particular purpose. that. If your experience was less than Truly Exceptional seue, neither assumes �o� MISC.CHARGES 2 . 04 lease notif authorizes any other person to p y your Service Advisor or the Service Manager. a��me for it any liability in TOTAL CHARGES 414 . 93 We would appreciate the opportunity to address your connection W�cn cne 5aie of cn�5 concerns. item�tems. LESS ADJUSTMENT O . O O ALL PARTS NEW SALES TAX 19. 0 9 SERVICE HOURS: MONDAY - FRIDAY 7:00 am - 6:00 fY) ORIGINAL EQUIPMENT p UNLESS OTHERWISE PLEASE PAY SATURDAY 8:30 am - 12:30 pm SPECIFIED THIS AMOUNT ��4.{�� _ ..__....... I acknowledge that I have received a copy of this work order and the repairs performed by Mercedes-Benz of Maplewood, Porsche Customer of St. Paul. Signature X CUSTOMER COPY