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NOTICE OF CLAIM FORM to the City of Saint Paul, Mi�k�b�'aLERK
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 municipality 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 wiR not be contacted by telephone to clarify answers,so pmvide as
mnch information as necessary to explain your claim,and the amount of compensation being requested. You will receive a
written acl�owledgement once your form is received. The proces.s can take up to ten weeks or longer depending on the
nature of your claim. Tlus 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
1 � �
First Name 6-.� ��Q, Middle Initial�Last Name�.i � I S�(
Company or Business Name
Are You an Insurance Company? Yes l�No� If Yes,Claim Number?
Street Address �D�T ��� � LI ����
City (l��� State �,� Zip Code—;,�k��.s�U.t
Daytime Phone(��-I I�1 Cell Phone(�)�-��Evening Telephone( ) -
Date of Accident/Injury or Date Discovered� �� Time ��� am/�
Please state,in detail,what occurred(happened),and why you aze 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 ges.
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Please cTiec the box(esj�that most c osely represent the ason for completing tlus form`T �
❑ 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
CI Other type of injury—please specify
In order to process your claim vou need to include couies of all aanlicable 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.
e 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 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—ulease comulete 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 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 p k or facility,
closest 1 dm k,etc. Pleaset�as detailed as possible. ff necessary,attach a diagram. �� ��f' ��
���� Q�'� Cti u��1
Please indicate the amount you are seeking in compensa�ion or what you wquld like the City to do to esolve this claim
to your satisfaction. � Ol{M 6S�° k� $'�a�" -�'�n.t czv►��uV1't" �Inr Ci r�
Vehicle Claims— lease com lete this section ❑check box if this section does not a 1
Your Vehicle: Year���_Make Model
License Plate Number �� State Color _
�
Registered Owner
Driver of Vehicle L^
Area Damaged �
Ciry Vehicle: Yeaz e Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniurv Claims please complete this section �check box if this section does not applv
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 I 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 pageslto this claim form. Number of additional pages � .
By signing this form,you are stating that a11 information you have provided is true and correct to the best
of your knowledge. Unsigned forms will not be processec�
Submitting a false claim can result in prosecution. Date form was completed J
Print the Name of the Person who Completed this Form: (--. ��
c
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Signature of Person Making the Claim:
;'
Revised Febmary 2011
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Chassis Parts Drive Shafts � E1LE.�OPY .
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Fifters Tire Repair �Lj������EL CO. �� � ,
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Exhaust Wheel Weights . ���W� s _; , _.. .. ..t:.
prums and Rotors Ride Control _._
Disc peds&Shoes Wheels
� . Wheel,Trailer Components . ..,:',�,:,;r`-_
Bearings&Seals Trailer Parts/Axies and Automotive Parts Speoia�ists. _ '. :'. .:'.' �` `'
Fluids Starters/Aftemators � irNO�ce No. ._ . - - _. _ ..
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lease Remit To:
PtONEER RIM&WHEEL CO.
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No merchandise returns or exchanges will be accepted without auihorization and origi�ai receipt;restocking charge may apply.
The Seller hereby e�cpressry disclaims all warcanties, either acpressed or implied, including any implied warranty of ' J r, ', r},:�� _ ��:�
merchantability or fitness tor a particu�ar purpose,and the Seqer neither assumes nor authorizes any other person to
assume for it any IiabNity in connection whh►he sale of this merchandise. ^�C/�C C �AV QY __ — -
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TO A�PAST DUE ACOCOUtNTS IOR7 HOENECaALLMAXIMUMED THI � INVOICE
WHICHEVER IS LESS). �
AutoZone 3Q86
846 ARCADE ST
St Paut. NM
(651) 176-4611
PIOMEER Loralty Card 910100XXX%XX6300
RIM & WHEEL *660177E� 20004 �_ � ��z�79 Z,?g_p
2500 KENNEQY STREET NE Stiae TR 425
HINNEAPOLIS, NN 55413 Tubeiess Fire Vetues, ? FK
�542362 2081-A Z.79 p
612-331-137 1 Sti�e iR 418
iubeless Tire Ualues, 2 PK
DATE 04/12J2014 SAT TIME 11:52 SUBtOiAI 0.00
TOTAL 0.00
RE6 iO3 CSR i07 RECEIPi i341618
INVOICE # ��9065 STR _ TRANS �9y s5oa
MERCHANDISE $81.60 D A T E E O 4!�3/2 O 1 4 20:12
TOTAL 581.60 # OF ITEMS SOLa 1
CREDIT CARD �81.60
_________________________._______ III{I�I��I���N��I�II�IIlIII���IIIIII�NII�lllliqll
SALE ag�,gp
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APP : 013726 Me�ber: DAUE JASIMSKI
REF : 0�1 As of Ob/13/2014 at 14:1G:25 Pq CST
REC NO : 1 Credits Ta�ards Next Re�ard: 0
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*.��..�*�������*���*����**�� THIS IS NOT A SALES INVOICE'.-LflYAi�iAAY DE�'GSIT *��*��t��*�*�*****#�*_.
3�►�64 h�FG -i ��5/��R-lE� ��V B5W G�i�DYEAR EAGLE GT _ _ _- .�!� --t�;Qt;�"".�—�1�s�.�DQ►
COMiMENT:_ $t}LT �ATTERh1: 5-11� _
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WGRRAh�T''J: I+tILEf�E�E- SQ�,��� SEE REVERSE SIDE FOR bJGRRf�I�iY L�ETHIL�
COMh1EhlT� I�fFLHT I ON F e 3V� Ft:3�►
8►��17 NPhf i CERTIFICATES F�R REFUNU, kEF�LACEi�E�Ei' .+�Q► 1,�.�Q� f.�•�t�
8i�4Q�� t�Ri� i ADJI�STh1ENT LIFETIME BALANCE t� VAL�tE .�� .��+ a�'�
I het,eby e�ttity I a� the ❑wner of t�-ie prod�sct pr�esented tor wart�anty claim and the p;oduct
desct^ibed ��as nat invalved in any accident, per,sr,r�al in.jiary, conseq�.tential damage,
or o�het� lass. I accept this �ci,justmer,t ,�redit ir� lie�_� af other� claims.
I agr^ee the �rod+act ret�ar�ned f,�r repl�cen�rrt becames the ��rope�~ty of the pr od�.�ct m�r��afact�irFf�
,
SURTOTAL: i,?�.@�C
TC�TflL QF ALL DEPCiSITS: 13.Q�� TAn: 7.b3
k�ALR�ICE I7L1E o .�� TAX t REFLfND: : -7.E�
TOTAL; 13��0
�lh1QUNT TNIS DEF'4SIT: 13.�Q�
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TENi}ERE�t: 13.�b�
�igrsat!me on file
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