Manlove .r�tc;EIVED
MAY 01 2014
NQTICE OF CLAIM FORM to the City of Saint Paul, Min�� CLERK
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 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 additionai sheets. Please note that you will not be contacted by telephone to clarify answers,so provide as
much information as necessary to egplain 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 '�O: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
First Name �Q��� Middle Initial�Last Name �G(V� ((J 1�.p
Company or Business Name
Are You an Insurance Company? Yes; Nc If Yes,Claim Number?
Street Address
City s} , P State /�/�/(� Zip Code sS �� i
Daytime Phone (OS ��%b-�Cell Phone(���-(,bSL Evening Telephone�� ;�� �
Date of Accidentl Injury or Date Discovered l�-�-1l,� Time ,'C� pm
Please state,a�d�tai�,what occurred(happened),and why yau are submitting a claim.Please indicate or�how you I
feel the City of a' t aul or its mployees are involved and/or responsible for our dama es. � �v,�,
W wlL 1�� `�' �.�
Please check the box(es)that most closely represent the reason for completing this form:
❑ My vehicle was dama.ged in an accident ❑ My vehicle�vas damaged during a tow
{d�My vehicle was damaged by a pothole or condition of the street ❑ My vehicle was damaged by a plow
❑ My vehicle v�ras 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 youu 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.
• Properry damage claims to a vehicle: two estimates for the repairs to your vehicle if the damage excee
$500.00; or the actual bills and/or receipts for the repairs � ��vt�
O Towing claims: legible copies of any ticket issued and a copy of the impound lot receipt 1 �(M!�
O Other property damage claims: two repair estimates if the damage exceeds$500.00; or the actual bills �S/�
andlor receipts for the repairs; detailed list of damaged items �
O Injury claims: medical bills,receipts
O Photographs are always welcome to document and support your claim but will not be returned.
Page 1 of 2—Please complete and return both pages of Claim Form
Failure to complete and return both pages will result in delay in the handling of your claim
All Claims-nlease comulete this section
Were there witnesses to the incident? Yes No Unknown (circle)
Provide their names, addresses and telephone numbers:
Were the police or law enforcement called? Yes No Ux�lrnown (circle)
If yes,what department or agency? ase#or report#
Where did the accident or injury take place? Provide street address,cross street,intersectic�,name of par or facility,
close t 1 dmark, tc. Please be as detailed possible. If neces�ary,attach a dia am. f y � �'
T � v - u�
S�.
Please in icate the a unt yQu� are seeking in c pensation or what you would like the City o do to esolve�his claim
to your satisfaction. I�MII v✓ 5 � ��' �
(/�/ -' D
, VPhicle Clai�ns- asQ co� letethis s 'an - -G' �eck bo�if-#�is sect�on does�at a 1
Your Vehicle: Year ZUO Make Model Z$
License Plate Number QS tate M A� Color Gt�� �
Registered Owner W
Driver of Vehicle
Area Damaged �, Y ` 1.G' V G /
City Vehicle: Year Make odel ✓
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 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 Telephone
Did you miss work as a result of your injury? Yes No
i _ _ . 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 L.
By signing this form,you are stating that all information you have provided is true and correct to the best
of your knowledge. rinsigned forms will not be processed
Submitting a false claim can result in prosecution. Date form was completed � b- 1
Print the Name of the Person who Com leted tlus Form: ��wU�-�\ �V N�`
P
Signature of Person Making the Claim: �W�
Revised February 2011
�
� '�` Parkway Auto Care
� �` � �� � '� 1581 Ford Parkway PAGE �
�� � _ � � 4 ¢ ���-�
Saint PauI,MN 55116
(651)698-3208
Create Date: 04/28/14 15:36:37
Customer ID: 1581044934 Year: 03 Date/Time: 04/29/14 17:12:31
Name: DEB MANLOVE Make: BMW Workorder#: 99040
Address: 1746 HARTFORD Model: 325XI Invoice#: 87453
Address 2: Lic No: 605JDD
City,State,Zip Code: SAINT PAUL,MN,55116 VIN: WBAEU33413PM52560 Email Address:
Home Phone: (651)233-0052 Color PO Number.
Work Phone: (651)- Engine: L6-2494cc 2.5L FleetMrholesale: N
Other Phone: Q- Mileage In: 144372
Tax Exempt#: Mileage Out: 144372
Service comments:
CHECK L.F.TIRE&RIM(POTHOLE)
Qty. Part# RFR Loc Description Parts Labor Total
FRONT WHEEL ALIGNMENT
1 @FWA FRONT WHEELALIGNMENT 0.00 0.00 0.00
1 ALL LABOR 0.00 69.95 69.95
FRONT WHEEL THRUSTANGLE ALIGNMENT
TOTAL FRONT WHEEL ALIGNMENT: 69.95
HAZMAT DISPOSAL
1 HAZMAT HAZARDOUS MATERIALS 2.50 0.00 2.50
TOTAL HAZMAT DISPOSAL: 2.50
OTHER PARTS/SERVICES �L
1 *31126758533 L.F. LOWER CONTROLAF�M 357.96 228.00 585.96
01-05
i *31129063163 L.F. LOWER CONTROLARM BUSHING 131.63 0.00 131.63
1 "'98465164 L.F. USED RIM 21U.00 0.00 210.00
1 TD TIRE DISPOSAL 0.00 2.50 2.50
1 TB TIRE BALANCE 0.00 9.95 9.95
1 VS VAIVE STEM 2.50 0.00 2.50
1 '118000357 DUNLOP SIGNATURE II 120.13 0.00 120.13
TOTAL OTHER PARTS/S�RVICES: 1,062.67
*"`Customer Wishes To Discard Old Parts "*
I HEREBY AUTHORIZE THE WORK TO BE DONE AS DESCRIBED ABOVE. I AGREE TO PAY ON DELNERY OF THE VEHICLE,
AND UNTIL PAID IN FULL YOU SHALL HAVE A LIEN ON THE VEHICLE FOR THE AMOUNT OWING. I FURTHER AGREE THAT YOU WILL NOT BE HELD
RESPONSIBLE FOR THE VEHICLE OR ARTICLES LEFT IN THE VEHICLE IN CASE OF FIRE,THEFTACCIDENTS OR OTHER CAUSES BEYOND YOUR
CONTROL. MY VEHICLE MAY BE DRIVEN BY YOUR EMPIOYEES FOR ROAD TESTAT MY RISK I AUTHORIZE SERVICE TO BE PERFORMED
INCLUDING SUBLET WORK. I HAVE READ AND UNDERSTAND THE ABOVE TERMS.
SIGNATURE DATE
THANK YOU FOR PAY AMOUNT ShopSupplies 30.79
YOUR BUSINESS AMEX 1,228.60 PARTS TOTAL 824.72
SALES TAX 62.69
12 MONTH/12,000 MILE TECH:OOOGLJ-0.00 J�M LABOR TOTAL 310.40
PARTS&LABOR WARRANTY GRAND TOTAL 1,228.60
THIS IS A HISTORY REPRINT (Reprinted:04l29l14 17:13:24)
�
Auto Rescue
feedbc►ckC�inmansautorescue.com
Date�-_.: r> � - `t� I.C. Motor Club �' � t` 5
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P.O.Number (;,•r�� �w:' � (r' ; , � , ��,' Name
Member Number Phone
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Address ! ' ,' ,) f, r!,-. +, ti J�'. ; ✓v` �r C�ry ,
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` . ocatlon S�Utotmation . :
Apt./Business I Building# Apt.# Gate Code
Location Notes
Call Time AM ETA Sta AM Finish AM
PM PM PM
l,
❑ Lock Out ❑ Jump Start ❑ Fuel -� Tire Change ❑ Tire Air ❑ GOA/NSR
Ve ide ; tion
Year,Make,Model Color LP# State
` ar., � !' � � � f� � � � ���`� � � S � � ;���.1� � �
�� , � � �j � 6.� � ! �>- � odometer , ,�.r,,>�
Lodcout Release Sectan-Cond'�ion of s artivaF
Passenger poor
❑ Previously attempted opening by another party—Damage to Door/ Doorframe Driver poor
Passengerpoor �
❑ Worn/ Damaged weather stripping—Window Broken/Scratched— Tint Scratched Driver poor
Passengerpoor
❑ Non Functioning Door handle/Door lock—Missing Door Handle/Lock Driver poor
Notes
I have requested that my vehicle be unlocked using lockout tools and/orkeys. 1 undersfan3`°t�ia�there is a possi��o'fi`" -�
damage to the door, door frame, weather stripping, lockingl mechanism, glass,or air bags when using these tools and thereby
release the person(s)and/or company of all responsibility, both civil and criminal, in a court of law. I wili accept full responsibility
should an dama e occur. InitiaL-
Generat Vehicle Condifian
Jump Start: ❑ Battery cracked /Broken ❑ Cables and/or Clamps/Loose/Corroded/ Broken/Missing
Tire Change: ❑ Vehicle/Rim Damaged ❑ Missing/Damaged Lug Nuts ❑ Missing /Damaged Studs �
Customer understands that the spare tire is designed to get the vehicle to a tire repair facility,as soo a .�=f
ossible,and the wheel fasteners lu s should be retor ued before drivin more than 40 miles,lnitia{. �
Fuel Delivery: ❑ Fuel Door Missing/Broken ❑ Fuel Cap Missing/Damaged
Notes
GOAlNSR
GOA/NSR Authorized by: Reason:
Method 0f Pa menY for Retait Non Motor Ctutr calls
Cash Visa MC AMEX Discover !'� DL#: ST
� :
CC#: f � Exp: Approval#
�4�+arized 5lsrnat�rs' f
I have had the opportunity to inspect my vehicle and have found it to be in good working order, Gas(+)
and that no damage has occurred to the vehicle including doors, door frames, paint,glass, Sub Total(_)
window tint, rims, lug nuts/studs, body or underbody as a result of the service.
I also acknowled that all equipment such as jacks, lug wrenches, lug nut keys,and special
toots�ebn ,f e or the vehicle have been returned in good working order. Customer Pay(-)
lnitial::'� ��
' fIQ/I�C y0U f0/' US%J'I Auto Rescue �nvoice Amount(_)
2744774 ��.: -=_ ,