Kessell RECEI�.�ED
MAY 0 5 2014
NOTICE OF CLAIM FORM to the City of Saint Paul, Mir���d��LERK
Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipality...shaU 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�Q,11�'_1 n L Middle Initial�Last Name �C���I
Company or Business Name
Are You an Insurance Company? es No If Yes,Claim Number?
Street Address � � �
City.� PQ1.�.1 State 1�iU Zip Code�.5�
Daytime Phone(bS� )�d-�Cell Phone(_��F Evening Telephone(�)� '��
Date of AccidenU Injury or Date Discovered 7'�7� �`f Time �'/� am 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/�— � Y� -
Please check the box(es)that most closely represent 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 ii�jured on City property
❑ Other type of property damage—please specify
❑ Other type of injury—please specify
In order to process your claim v��„ppd to include copies of all apnlicable 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$500.00;or the actual bills
and/or receipts for the repairs;detailed list of damaged items
O Injury claims: medical bills,receipts
O Photographs are always welcome to document and support your claim but will not be returned.
Page 1 of Z—Please complete and return both pages of Claim Form
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims—ulease complete this section
Were there witnesses to the incident? Yes No Unknown (circle)
Provide their names,addresses and telephone numbers:
Were the police or law enforcement called? Yes No Unknown (circle)
If yes,what department or agency? Case#or report#
Where did the accident or injury take place? Provide street address,cross street, intersection,name o P�ark or facility,
clo est landmark,etc. Please be as detailed as possible. If necessary, attach a dia ram. -�✓ t'OU'��
� J � �
Please indicate the a�nount you are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction�3(o5a 5�
Vehicle Claims—nlease complete this section ❑check box if this section does not applv
Your Vehicle: Year a v�a Make 1�0�un Model _
License Plate Number .Z3(o/�7A1� State (�"1 Color� /tY
Registered Owner -�Y�nc�r�e� ILt�$r)
Driver of Vehicle
Area Damaged Ot1T Q.SS[./7ut..r T1 Y -
City Vehicle: Year Make Model
� 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 auplv
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
�Check here if you are attaching more pages to this claim form. Number of additional pages �.
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 J�''o2"��T
Print the Name of the Person who Complete this Form: � �S�
Signature of Person Making the Claim:
Revised February 2011
- �•�' , = Parkway Auto Care pACE �
� � � ,�V� ������ "� ' 1581 Ford Parkway
������°�j } Saint Pau1,MN 55116
(651)698-3208
Create Date: 04/28/14 07:11:14 ..`
Year: 12 Date/Time: 04/30/14 09:59:0�
stomer ID: 1581044550 Make: VOLVO Workorder#: 99017
me: FRANCINE KESSEL Model: S60 T6 Invoice#: 87457
�ress: 1436 BAYARD AVE. Lic No: x
�ress 2: VIN: Email Address:
y,State,Zip Code: SAINT PAUL,MN,55116 Color: PO Number:
me Phone:(651)210-6785 Engine: L6-2953cc 3L FI FIeeUWholesale: N
�rk Phone: (651)-
ier Phone: ()- Mileage In: 18801
�Exempt#: Mileage Out: 18801
rvice comments:
Part#
RFR Loc Descri tion Parts Labor Total
�HER PARTSISERVICES TIRE DISPOSAL 0.00 2.50 2.50
TD TIRE BALANCE 0.00 9.95 9.95
TB 2.50 0.00 2.50
VS VALVE STEM 325.5q 0.00 325.54
"2354018 BRIDGESTONE TURANZA SERENITY+
TOTAL OTHER PARTSISERVICES: 340.49
•Customer Wishes To Discard Old Parts `�"
� \
'V
, V
�
�
�
HEREBY AUTHORIZE THE WORK TO BE DONE AS DESCRIBED ABOVE. I AGREE TO PAY ON DELIVERY OF THE VEHICLE,
4ND UNTIL PAID IN THE VEHICLE ORARTICLESNEOFT IN THE VIEHICLE�N CA E OF FIRE�,\THEFTACCIDENTS OREOTHER CAUSES BEYOOND YOUR
RESPONSIBLE FOR
CONTROL. SUBLET WORKA I HAVE READ AND�NDE STAND THE ABOVE TERMS.AT MY RISK I AUTHORIZE SERVICE TO BE PERFORME
INCLUDING
DATE
SIGNATURE
PARTS TOTAL 328.04
THANK YOU FOR PAY AMOUNT SALES TAX 25.01
YOUR BUSINESS VISA 365.50 �,o,gOR TOTAL 12.45
12 MONTH/12,000 MILE TECH:OOOALS-0.00 SPENCER
GRAND TOTAL 365.50
PARTS&LABOR WARRANTY
Thanks for your business.
INVOICE INVOICE Parkway Auto Care INVOICE INVOICE
� y Date: 04/19/14 Invoice#: 3770147614
�T�� MEMBER PURCHASE INVOICE Time In: 13:58:54
Membership#: 839205790000
MEMBER INFORMATION VEHICLE INFORMATI N
CYNTHIA SABAS 2012 Volvo S60 T-5
3214 46TH AVE N Color: SILVER License:
MINNEAPOLIS, MN 55422-1402 �`
Odometer:
(099)999-9999 Whee1 Torque: 103
(651)210-6785 Air Pressure: Front: 38 Rear: 38
ITEMff DESCRIPTION Qty SLIP PRIN'I'
673472 TURANZA SERENITY PLUS 4
HIGH PERFORMANCE
235/40R18 95W XL BW
BAN 106-106
50,000 Mile Warranty
6850 Tire Installation
4 " � -
7023 Disposal Fee 4 ` � '����� � " � �� �
,
��.�� ,
866632 TPMS SERVICE PACK GENERIC 4 � i '
. �. .r . .. . . . .
,4 �
\� 1 ... .. , ;� . .. , . .
�� \ � 1
� $„� �::.�.��:' .. .
,\x� �1 . � .. .. .. . , .
\ �
. .�� r.. ......,. , ,.,...
_ ;, � '''�
IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII ***SPECI�.O�ER***
9200037701476149
NOTES:
*Intlation and Torque specifications are recommended by Manufacturer.
Best to Spare
Static _Dynamic TOM
Blackwall Whitewall Sales Pe[sot► Page# 1