Brown RECEi`���-
NOTIC� OF CLAIM I�'ORM to the City of Saint Paul, Minneso�a5 20�4
Mi�uTesntn S�ate Stnt�ue 466.05 stntes thn► "...everv persnn...wdin claims dn�nnge.r.frnm am�municipnliry....rlrall cni�.re n'�e p�e.�•elfe7�tTJ�he`�
go��erning bucly of tfre municipn/ity withr�t /80 duys after the u//exed/oss or injurv is discovered n notice stnting t/ie tinre,plcu•e,curd
circtu»stnnces tF�ereof,ancf the mrioentt of contpensatinn or other relief denrtrnded."
Please complete this form in its entirety by clearly typing or printing your answer to each question. [f 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 recYuested. You will receive a
written acknowledgement once your f'orm 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 bolh pa�es completed. If somethin�does not apply,write`N/A'.
SEND COMPLETED FORM AND OTHER DOCUM�NTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
, .
First Name �_� Middle Initial Last Nam��b�
Company or Business Name
Are You an lnsurance Company? Yes� If Yes, Claim N�ber?
Street Address 1 V� � � �
City �� ��a �C State �1 V Zip Code � �
Daytime Phone (������� Phone �1 ��4� I���Evening e �D�
Date of Accident/Injury or Date Discovered �`� � — c���f' Time��am pm
Please state, in detail, what occurred (happened), and why you are submitting a claim. Please indic�ite why how you
feel the City of Saint Paul or its employees are involved and/or responsible for your damages� MO�I e� U(`.�
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Pl� �y,',►s� i* �'�U -t'i �c, 'WS ' �i m • Ca st I
cl�eck tfie box(es) that most closely r present t e reaso or completing this form:
❑ y vehicle was damaged in an accident ❑ My vehicle was damaged during a tow
y 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 you need to include conies of all annlicable 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.
O 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]ist 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
railure to complete and return both pages will result in delay in the handling of your cl:�im.
All Claims- lease com Ietc this section �
Were there witnesses to the incident? Yes No, Unknown (circle� ,
Provide their na es, addresses a telephone bers: �`'� - � ► ' 1',
� � ��
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�ark or f� lity,
closest lan mark, etc. Please be as etailed as possi le. If necessary, a ta a diagram. � �"��
._--
' �p�t Fu�a �es f � `/a �.
Please md�cate the amount ou are see�ing in com}�ensati�n r whlt you would like the City to do to resolve t i�claim
o ��
to your satisfaction.^ — �
�e-�
_ - -- - __ .
Vehide Claims- lease com lete this section ❑ check box if this section does not a 1 ►�'
Your Vehicle: Yearo�D 1 �Make Model
License Plate Num r � �l�C�� Statehfli� Col r
2egistered Owner �Y'(�e�.1(�
Driver of Vehic
Area Damaged �
City Vehicle: Year e Model
License Plate umber' State Color
Driver of V ic�e �i y rri�toyee's Name)
_
Area Damag
Iniurv Claims- please complete this section check box if this section does not tlpply
How were you injured?
What part(s)of your body wer � jured?
Have you tiought medical treatment? Y . 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 njury'? ��.� Yes No
When did you miss work? (provide date(s))
- — -- -
— --___ _--
Name of your Employer:
Address Telephone
Check here if you are attaching mo►•e pages to this claim form. Number of additional pages�.
By signing this form,you are stating tliat ull informatio�z you have provided is triee and correct to tlze best
of your knowledge. Unsigned forms will not be processed.
Submitting a false claim can result in prosecution. m was com leted � �Ot r �V'�
Print the Name of the Person who Completed thi rm: � �
Signature of Person Making the Claim: � -�
Revised February 201 1 , �-�'C`���
� G.�� �f e.v sv.� ��,�� oF -tl-� {�cs�.c� Cor��h or�s l n �N, � Wo�s �1��,��
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�`n�� E o, -t�-r (� ss• S -�- -�'uV�el� ��. Sw� s� 1�. �l�-'
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� 15 i'1,'� ��-r1U c� 5 ���� i�� G15 � l'�'�a�ji� � �C�S OrC�,�.�ca�a�1-e.
Auto Rescue ��5�'
feedbackC�inmansautorescue,com
Date(j�: . .-�i''1 -� u�!' I.C. • �� � a.. ,� MotorClub•; . , l = ���r � ,,�I� ; {
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P.O.Number '.a, ��;; '� ,�c O � �' Name �,�,l�j�� Y b� �:
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Member Number Phone �{;� -.��/� , ��1`� _ ":}
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Address ' / U�J ;� � � 4�� 5 �`�.� t li l City S,{ �(i� :...
- Loeatlon '�In(on+udon ra ,:
Apt./Business Building# Apt.# Gate Code
Location Notes
Call Time AM ETA Start AM Finish A�
PM PM PM
❑ Lock Out ❑ Jump Start ❑ Fuel IJ Tire Change ❑ Tire Air ❑ GOA/NSR
a. .,q .:- �, .. ..:-:.,;�/ ?�f110(71101�011 ' , .l':.. "F ,"x;� ;§.:;k-.,�t. > "
, . . .4. .. . ;.:_^.�,_, .:. ..�.-..f- , ,�.. '���:..
Year,Make, Model � U�� � ��� �V�V ��..� Color -�� �� (��. LP# ���,� �����State�.': �
�.
� �, ✓V � � � � f �,�i' � 1' rJ .si {( �, � Odometer !'�Y�;��� �
�J,��.
, .y.. ... 1....,. . ..
,' : � LodcoutRNeaseSeclbn`c` Mbn'd e u �rtiv�`.:- : ... .:r.,.,: ._ ;.� ,.:,
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/or keys. 1 understand that there is a possibility of
damage to the door, door frame, weather stripping, locking 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 will accept full responsibility
should an dama e occur. Initial:� -
Generel Vehlde Conditlon
� Jump Start: ❑ Battery cracked/Broken ❑ Cables and/or Clamps/Loose/Corroded/Broken-/Missing
� Tir' e Change: ❑ Vehicle/ Rim Damaged ❑ Missing/Damaged Lug Nuts ❑ Missing/Damaged Studs
Customer understands fhat the spare tire is designed to get the vehicle to a tire repair facility,as soon
ossib/e, and the wheel fasteners lu s should be retor ued before drivin more than 40 miles.lnitial:
Fuel Delivery: ❑ Fuel Door Missing/Broken ❑ Fuel Cap Missing/ Damaged
Notes
G A/NSR -
GOA/NSR Authorized by: Reason:
Method Of Pa ent for Retail Non Motor Club calls
Cash Visa C AMEX Discover DL#: ST
CC#: Exp: Approval#
Authorized Sls�natur+� \ �: - '
�
I have had the opportu 'ty to inspec 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 acknowledge that all Q�pment such as jaclis, lug wre�ches, lug nut keys, and special
tools belonging to r tl� V�ti�le have been returned in good working order. Customer Pay(-)
Initial:. 1 � 1 J
Ti�unk ou for usin Auto Rescue .� �nvoice,4mount(_)
27 �7272 �" v,`,�,��. ,:-7,_�:�
(�J . . . . . � .
� � OLAR �
� �� CX[YROLET �� Service Direct:(651)653-5555 . �� � ��►"'
�� _ � 1801 EAST COUNTY ROAD F` TOiI Ffee W4ftS;(800)326-2145 " ` �
WHITE BEAR CAKE,MN 55110 ' �
www.polarchevmazda.com
(651)429-7791 �
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�/EHI.CIoE TAENT�F�GA,TION '.;:MTLEAfiE>.C3 ;: AE►`R8 :1DLIT .: :> �NVOS�k.N0;'
ROSE A BROWN 2G1WC5E39D1153190 33547 04/29/14 34190
179 N. MCNIGHT RD #208
SAINT PAUL MN 55119
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redroses@cinc_i .����__ __ ---- - �� CHEVRE?�E�' - IMPALA L�' 08343
CUST.NO. LICENSE ; HOME :PSpNE <:WOxK �HQN� 3TC3C]C::IdC?. <FRp13.AJA ;: SE i/�AT)V T S . .:.
oz9zz 594MGZ 651-242-1015 - - 401656 00/00/00 459 CASH
;; ,.: ..:..
LJST:I,ABOR RATx DELIY.AA1`� ;`! � ,< Y �f�' N �' , , ;
03/15/14 32201 33547 04/28/14 03/15/14
THANK YOU FOR SERVICING YOUR VEHICLE AT
POLAR CHEVROLET/MAZDA
; ; :>;:>.:......... .
INE: OP.GbDB' E'A'TTr- r�'D :: T�CH ;: ','ii ;EI��,�� .:'!'X��. ; ;;::: :<;<::;::'�kMO�i�i� ;>
�
�m WHEELS ;cYreck tire for leak, cust hit a pot hole & the inside of the rim is
bent .
3u RIGHT FRONT RIM BENT
�r DISMOUNTED TIRE AND RIM, SUBLET '�O STR.AIGHTEN, REMOUNTED AND BALANC�D.
SPARE PLACED BACK IN TRUNK
05WHL3 A81 C 22 . 00
SUBLET TWIN CITY WHEEL 32173 1 C 150 . 00
Line Total . . . . . 172 . 00
3
�m GM MULTI POINT VEHICLE INSPECTION
�r REFER TO INSPECTION REPORT CARD
B3MPVI A81 _ _
Line Total .
� +
�m TIRES AT 50�;TIRES HAVE 50� OR MORE �READ REMAINING
�r FRONT TIRE TREAD DEPTH AT 8/32" , TIR PRESSURE SET AT 35PSI
33TIRG A81
Line Total .
CUSTOMER COPY - PAGE O1
STaT�r OP DISCLAZt�t On behalf oE oervicing dealer, Z hereby certify that the�lntoxmation contained� �
.e factory varranty constitutea all of the warrantiea with respect to the hereon io accurate unleaa othexvlsa ehown. Warranty services deacribed vare �
.le of [his item/itema. The Seller hereby expreeely disclaima all perfosmed at no Charge to oumer. Thars wat no Sndlcation fran the appearance of
rraneies eicher exprese or implied, including any implied varranty of � ths whicle or otherwice, that any part r�pair�d or replaced.under.�thia claim "�
�rchancability or Eitnese for a particular purpose. Seller neither � had����been connected in any way with any accident, negligence or�mieuae. Records
sumes nor authorizes any other pereon to acsume for it any liab111ty� in� �suppmrting thia c1aLa are available for (1) yaar from Cha date ot.payment notifi-
�cu�eccion vith che sale of thia item/items.. � . , ,.. .. �� � chtion at the saxvlcing dealer�for�lnapectioa by manufacturer�a repreeentative�.
COS1'QMBR SZGNATURB . (SIC3N�) DHALSR. G@IBRAL MANA6BR OR AUTAORIZ� PHR80N (DATS)
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