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Freed RECEIVED h1AY 0 2 2014 NOTICE OF CLAIM FORM to the City of Saint Paul, Minn�s� C L E R K Minnesota State Statute 466.05 states that"...every person...who claims damages from any municipaliry...shall cause to be presented to the goveming 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 cleariy 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 daim,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 OT TY�i U SAINT A LCMN 55102�� 15 WEST KELLOGG BLVD, 310 C , � First Name 3�1�aN Middle Initial� Last Name �� Company or Business Name Are You an Insurance Company? Yes/� If Yes,Claim Number? Street Address �"� � �� City �UI.C�hn 1 Y�'�� State�*[ Zip Code S�C�. Daytime Phone(�oJ�)� �� Cell Phone(�b12��r- ��vening Telephone(��-J� ��7 Date of Accidenb Injury or Date Discovered pP 2�L �� y Time �'i'20 �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. �l�mS o2au��,r� o �-1 �p �cxrcx " L 1d��- 1� Ao�- iJc�L.� W `1 - AA ' � iY, `4– � � "r' tL' 2 i0 ,,,t �,• O vi � �^ # . � `� �� rt- ON h� 5 �OFCA�— --, �,t�, �0 1-ia�S O d� � • - Please check the box(es)that most closely represent the reason for comple�nlg�ehicle•was damaged during a tow ❑My vehicle was damaged in an accident �p'3GIy vehicle was damaged by a pothole or condition of the street �MW s iri ured on Ci yapr pey-ty plow ❑ My vehicle was wrongfully towed and/or ticketed ❑ Other type of property damage–please specify ❑ Other type of injury–please specify In order to process your claim vou 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 aze 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 your vehicle if the damage exceeds $$00.00; 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 p 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 comnlete this section Were there witnesses to the incident? Yes � Unlrnown (circle) Provide their names,addresses and telephone numbers: Were the police or law enforcement called? Yes � Unlmown (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. Please be�s detailed as possible. ff necessary,attach a diagram. t..1�, � �°c Please indicate the amount you e eeking in compensation or what you would like the City to do to resolve this claim to your satisfaction. � Vehicle Claims– lease com lete this section ❑check box if this section does not a 1 Your Vehicle: Year�2�—M�e '�� Model uC�.�U License Plate Number T�I 1+�p+-t I L State ('�t.s Color �U� Registered Owner �" Driver of Vehicl +� Area Damaged � ��h�" �O1 n`t- �n-�� City Vehicle: Year Make Model License Plate Number State Color Driver of Vehicle(City Employee's Name) Area Damaged Inturv Ciauns ulease complete this section ❑check box if this section does not anulv How were you injured? What part(s)of your body were injured? Have you sought medical treatment? Yes No Planning to Seek Treatment(circle) (provide date(s)) When did you receive treatment? Name of Medical Provider(s): Telephone Address Did you miss work as a result of your injury? Yes No (provide date(s)) When did you miss work? Name of your Employer: Telephone Address Check here if you are attaching more pages to this claim form. Number of additional pag 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 �-�° I� Print the Name of the Person who Co plete this �� Signature of Person Making the Claim: �� Revised February 2011 TIRES PLUS Service Hav��• Customer Invoice 01 RAY 132920 SOUTHDALE 6�2 7gg.57gg 04/17/2014 3020 W 66TH ST RICHFIELD, M20095BU CK �UCERNE CX Vg-279 4.6L DOHC FREED, BRIAN Lic#: TY HANK MN Vin#: PO BOX 20065 �n; 04/17/14 5:27PM Mileage: 8,360 BLOOMINGTON, MN 55420 Out: 04/17/14 6:39PM 612.961.6572 RETAIL SALE Store#2,44222 Rev Hist Unit Extended �ob � IArticle# ID___QtY_——Price __ Price_ __Total Description------------------------ �� N/C COURTESY CHECK 7046930 16NS 1 N/C 447,g0 COURTESY CHECK �,2 20 BRIDGESTONE TIRE PACKAGE 147093 16TN 2 203.99 407.98 147093 TURANZA W�SERENITY PLUS BL 245/50R18 100V 75,000 MILE LIMITED WARRANTY DOT# 1 VL7DBA4613 DOT# 1VL7DBA4613 _ _ ' 7090�J84 16TN -1 50.00 -50.00 TIRE-DISC DISCOUNT 7018708 16TN 2 3•99 7'98 NEW TIRE WHEEL BALANCE PARTS 7018716 16NS 2 9.00 18.00 NEW TIRE WHEEL BALANCE LABOR 7008190 16NS 2 2•99 5'98 TPMS VALVE SERVICE KIT LABOR 7009357 16TN 2 5.99 11.98 VS950 TPMS VALVE 6-207A 7075078 16TN 2 2'99 N/C SCRAR TIRE RECYCLING CHARGE(1) J006472 16NS 2 N/C LOW PFtOFtLE TIRE INSTALLATION 7040215 16TN 2 20.00 40.00 7040215 ROAD HAZARD WARRANTY FLAT/POSSIBLE TIRE(S) Technician(s): 16 JOEL PERSAUD Summarv� Payment History: Parts 417.94 480.17 01768B Labor 29'96 MasterCard $642 Shop Supplies 1.44 Total Tendered 480.17 449.34 Sub-Total Tax(7.275%) 30.83 Total $480.17 I have received the above gooand compiy with mylcardholderredit card purchase, I agree to pay agreement with the issuer. Rev Init Revision Histo : Amt 1) 04/17/201� 06:39PM 413.16 FREED, BRIAN N PERSON2 ' Customer Signature 2) 04/17/201 Initial here to indicate you have received the Tire Warranty Maintenance and Safety ManuaL All parts are new unless otherwise specified. � acknowledge notice and oral approval of Declined Work: an increase in the original estimated price. BRIDGESTONE TIRE PACKAGE BRIDGESTONE TIRE PACKAGE Signature or Initials www.TiresPlus.com �. � "�res Pl,s STD L:� '�t �..,%:��9�F�c'�;�,/�'.2 Inv1 130731.402114 D��e, �f, �,,,, ro„oY;P C�r�P f�r NJarrantv Information WORK ORDER# TIRES PLUS SERVICE ADVISOR 132920 3020 W 66TH ST 01 RAY 04/17/14 06:39PM RICHFIELD, MN. 55423-1942 612.798.5789 FREED, BRIAN 2009 BUICK LUCERNE CX PO BOX 20065 V8-279 4.6L DOHC BLOOMINGTON, MN 55420 LIC# TY HANK MN VIN# 612.961.6572 IN 04/17/14 5:27PM EST. MILEAGE 8,300 store# 244222 Recommended Services not Authorized by Customer i ;� Unit Price Extended Price �' Status Description Qty Parts Labor Job Total Cat. Total Total Recmd BRIDGESTONE TIRE PACKAGE 234.80 : 033108 TURANZA EL400 H BL 245/50R18 99H No 1 178.99 0.00 ' Mileage Warranty LIFETIME NEW TIRE WHEEL BAL-PARTS � 1 3.99 0.00 LIFETIIVIE NEW TIRE VVHEEL BAL-LABOR 1 0.00 13.00 TPMS VALVE SERVICE KIT LABOR 1 0.00 2.99 VS950 TPMS VALVE 6-207A 1 5.99 0.00 7040215 ROAD HAZARD WARRANTY 1 26.85 0.00 SCRAP TIRE RECYCLING CHARGE (1) 1 0.00 2.99 LOW PROFILE TIRE INSTALLATION 1 0.00 0.00 Recmd BRIDGESTONE TIRE PACKAGE 163.56 122273 TURANZA W/SERENITY BL 245/50R18 1 138.60 0.00 100V 50,000 Mile Limited Warranty, � Promotional pricing, original selling price is$251.99 0 0.00 0.00 you saved $113.39 per tire NEW TIRE WHEEL BALANCE PARTS 1 3.99 0.00 NEW TIRE WHEEL BALANCE LABOR 1 0.00 9.00 � TPMS VALVE SERVICE KIT LABOR 1 0.00 2.99 VS950 TPMS VALVE 6-207A 1 5.99 0.00 SCRAP TIRE RECYCLING CHARGE(1) 1 0.00 2.99 LOW PROFILE TIRE INSTALLATION 1 0.00 0.00 System Failure-Required > 398.36 398.36 Recommended Parts: 364.40 Labor: 33.96 Subtotal: 398.36 Shop Supplies: 1.68 Tax(7.275%): 26.94 Total: 426.98 THESE PRICES ARE VALID FOR 30 DAYS Labor charges are based on'Menu Items'of a predetermined amount or the flat rate charged per the Mitchell Labor Manual @$106.00/hr. � ALL PARTS ARE NEW UNLESS NOTED OTHERWISE www.TiresPlus.com � - 1 ,<t�,�,< '��°�PagQ � bf� Recommendations 090409 , , — I � - • • • �soHC ❑oHV ❑DIESEL Trans. I�Auto Year Make Model Eng.Size ❑�oHC ❑HYBRID Type ❑Manu � Hubcap Missing Y N Windshield Cracked Y N Scratches/Dents Y � I N �M I LEAG E' Lic.# State Inspection Due Month Year _ . • ' visua� I scned. � Why ReCOmmended + Tire Size: t Rp�� Run Flat Y Inspect OK SUG REO Maini. � � J �� /1 M1 � b � < <•� TPMS Y Wiper Blades ❑Front ❑Rear � J Head Lights Visual Tread Depth Turn License InspeCt sznds ❑FWD ❑RWD ❑4WD/AW Mini Lights ❑Brake ❑Si nal �Plate ��rking oK sUG E Oucer Inner Left Front ❑ Etl9ewear ❑ Cracking_ Air Filter PSI In: PSI Out: ❑ Cupping ❑ Nails Cabin ❑ c�cs ❑ Flepaira6le Air Filter ❑ Irtegulariry ❑ �rable PCV Valve Right Front . � ❑ eagewear ❑ creck�og_ PSlln: PSIOut: O Cupping ❑ Nails Washer Fluid ,� c��s ❑ Repairablc ❑ Irregularity ai[ahle_ Oil Level Power Str. Right Rear ❑ Edyewear ❑ crack�ng__ Fluid Level PSI In: PSI Out: ❑ Cupping ❑ Nails o c��s � Repairable Master Cyl.Fluid ❑ Brake Inspection _ Level ❑ Irregulariry rable Brake Fluid Flush O 'I O 30 7 OO Co er arts er million Left Rear �� ❑ Edgewear ❑ Creckir,y___ Trans.Service ❑ Flush psi m: asi out: ❑ Cupping ❑ Ne+i� Auto/Manual ❑ Pan Service ❑ Cuts ❑ Repairable Coolant TYPe - o �Re9��a.uY t❑ N��.aeoa�cie_— Level/Flush - ❑Upper ❑Lower ❑Bypass ❑Heater g�; ❑ Etlgewear ❑ c�ack��y _ Coolant Hoses ❑ Cupping ❑ Naiis ' ❑ v PSI In: PSIOut: ❑ALT ❑PS BeItS ❑ Cuts �❑ Repairabie Belts ❑Ser ❑A/C ❑AP 1 2 3 4 C ❑ iRe9U18f1�y p��pa. b� Battery ❑ Good ❑Marginal ❑ Replace J ED-18 Test ❑Rotation ❑Balance Battery ❑ Cable Ends/Cables �Nes ❑Hold Downs T�re Maintenance Accessories ❑Tire Wear � eattery Gard ❑CorroSion ❑PrBVentive Alignment Check ❑Maintenance � � - � - � + • • • • � •• �. • . � ' Why Recommended + M� Pads greater than 6mm(Disc)or Shoes greater than 2.4mm(Drum) Visual � Sched. � oe � Inspect oK SUG R Maint. ih��n�na��&�(p'isc)orSFaesg�ertl�anl.srtv^alesstl�24mn(atm Start/Charge c Document vehicle specitic measurements&minimum s cifications below est � "in(Disc)or Shoes less�h e � c imeasurements&mini a�� Beli Tensioner $ RF Pa� LF Pad Spark Plugs Actual Adual - Meas. Meas. Fuel Filter �� Fuel System �p,�p�y Machine Machine To To Service Ignition Wires Discarci Discard q� At MM Spec. MM 6pec. - -` �� Valve Cover � "�� " * RR Pad/: Gasket '�. LR Pad/Shoe ��'�� ' � Power Steering ❑ Pressure ❑ Retum A��a� Actual Hose Meas. Meas. Timing Belt Machine MMPrAial MM Achial MachiTe� To � Discard A�S�� MM S Exhaust System ❑Intermediate Pipe ❑ Muffler ❑Tailpipe MM Spec. At � _ � , � � - t Rear Clean/Adj U-Joint ❑Front ❑Rear Brake Hose(s) Idler/Pitman Arm ❑Idler ❑Pitman Parking Cables Other Brake Hardware Caliper V i nder Repa� Center Link , Services ❑Sway Bar ❑Front Bushings ❑ControlArtn ❑Rear �� Notes: � ❑Front ❑Left ❑Right ��. ''�f Link Pins ❑Rear' ❑Left ❑Ri ht � �P�n r �j � Y��Q��✓` ❑L Out� ❑L In ❑R In ❑R Out ❑Sleeve(s) "`�� Tie Rod Ends ( j � ❑L Upper ❑R Upper �� / � BaIlJoints ❑L Lower ��R Lower S ec — Actual— v ` , ,� n � � � W l/l. Radc&Pinion Assembl CV Boots ❑L Out ❑L In ❑R In ❑R Out � � �� CV Joints ❑L Out ❑L In ❑R In ❑R Out N Front ❑Left ❑Right Struts �Rear ❑Left ❑Ri M ❑Front ❑LeR ❑Right Shocks Rear � ❑Left pK pe�air I Aeo�acement Sua9ested 'Checi�ed 8 1) Close to end of usetul lite accepta6le 2)Address customer request/need I convenience STEP 5 STEP 7 3)Comply wtth manutacturer recommendation INSPECTED BY RE-INSPECTED BY 4)Technician recommendation from experience