Poster RECEIVEC�
MAY 051014 ���EIVED
NOTICE OF CLAIM FORM to the City of�ha�►t��a���r�sA�i2014
Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipality...shall ca � rf� t
governing body of the municipality within 180 days after the alleged loss or injury is discovered a notice stating��ttm�pl�fi�
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 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'.
i
SEND COMPLETED FORM AND QTHER DOCUMENTS TO: CITY CLERK, I
15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
First Name 1"° ��1 �'' \ Middle Initial '�-Last Name � 1 C�.S���-�_
Company or Business Name n ��--L---
Are You an Insurance Company? Yes� If Yes,Claim Number? ,
C"�' � i" ~ '
Street Address �_� `�..__.� � `�. �V� �`
City �� �b— ��.\ St�te '" 1� Zip Code�S 1 C� �U
Daytime Phone(_) - Ce 1 Ph �g(�� :�� venin elephone(_� -
� Q��`t �� �
Date of Accident/Injury or Date Di ver � 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 Sa� t P�ul Qr its em loyees are volved andlor responsible for your d ges
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Pleas�c�eck tlie box��ohat most c e y represent the r�o� or completing this form:
❑My vehicle was dama�ed in an acc_ident ._._ _ ❑ My vehicle was damaged during a tow
�A'�Iy 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�roperty
❑ Other type of property damage—please specify
❑ Other type of injury—please specify
In order to process your claim you need to include copies of all applicable documents.
For the claims types listed below,please be sure to inclwcle the documents indicated or it will delay the handling of
your claim. Documents WILL NOT be retumed 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
� �''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 co plete and return both pages of Claim Form
�r > �aJ;(� +vt.c�� �, `; V� �u ���'�`'�
Failure to complete and retnrn 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 �� Unlrnown (circle)
Provide their names, addresses and telephone numbers:
�
Were the olice or law enforcement called. Yes Unlrnown circle
p C_� � )
, If yes,what department or agency? Case#ar report#
Where did the accident or injury take place? Provide street address,cross street, intersection,name of park or facility,
closest landmark, tc,. Pleas be a� detail d as ossible. ff ecessa�,y�ttach di�agram.
Gt,�i(��
Please indicate����o you eeking�mpensation or what yo would like the City to do to resolve this claim
i to your atisfaction.
' � , � _ Vvt � 'e 'P� Cd.
Vehicle Claims— lease com lete this section ❑ check box if this section does not a 1
Your Vehicle: Year 1VIa�_ _ Model � - _ _. _ _
License Plate Number 0 � State Color _ �
Registered Owner �
Driver of Vehicle �� ;
Area Damaged � `('� '�./r' � i Q,��`�
City Vehicle: Year Make 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 Treatrnent(circle)
When did you receive treatment? (provide date(s))
Name of Medical Provider(s):
Address Telephone
Did you miss wor���a result of your injury? ---- -- Y�s - No - ,,.._._�,_.�_
When did you miss work? �(provide date(s))
- - N�m�of ou�� �r: _ _ _ _ - _ _ _ ___ -- ---——
Y �1�taY --
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 processec�
Submitting a false claim can result in prosecution. Date form was completed 1 `-�'
Print the Name of the Person who Completed this Form: �-1.��`f � O �
n
Signature of Person Making the Claim: '
Revised February 2011
Marshall Cretin Service Center
2178 Marshall Ave
• St. Paul, MN 55104 �
� 651 644-3436 Lr i� �������ic���v��t��n�i_ 1 1�1F_
tg=�;�wi�,�i=+ at�i6, U611. �'i:lN;�t'�
* MARSHALLCRETINAUTO.COM * O -S
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4�4�'�6t1�'�'�d�
�`IHk�HtiL�-!_kEl i'!VE'i'it1�1.7'
Customer: POSTER, JUDITH Vehicle : 2009 LEXU ��,,�3 i�r;k��;r�Hi.� �iit�„
Address : 833 COTTAGE AVE E License : 202JHZ `-�i.r"Hil� �ir� ;S�fa4
City: SAINTPAUL, MN 55106- VIN : JTHCK262i �-hLU1'( `,;NLE
Home : 5 ) - xt: Engine : V6-2499 2. �Hl I:H $ i:�'I
!h�fii`I'',; � 6"t�b
Office : ( 651 ) - Ext: Mileage : 29038 H;iir; � i��r�:�;�
r��3.,..; . ..j # ,..,,,y �. r....
�}c t�V'I;I_,i fN i c,;.r IN�F
Op Tech Description X.;�X.�;i.}.;?',X,kk7;X�i`,1
Quan Part Number Part Description Reason for Replacement
,.:.: . ..
Service Requeats: =�H�_E Hi`i11UN l :G .t F..:� .. 4?!::'
put on spare � � i r��t f�i i��rV YHI-" rjF�ltur :,���}��,.�;,
TIR030 524 MOUNT SPARE TIRE ON VEHICLE: remove existing tire, install sparF rjl�l_;Ikl�lhdl� I�� rlhi.l 1 '
vehicle, ad'ust tire ressure to ro er level, and tor e wheel � �_�r_k'
7 P P P 4u ' r1�.iF',��"f�l`i 1
specification.
COM016 524 TECHNICIAN NOTES: Thank You! Please see attached estimate for on� I_il`;�!!�iF�.; I'iJF`y
' —�ecomme�dation OK Bad Recommendation
Dear Customer,
Please take a few minutes and visit our online
Web site to let_ r��qur thoughts about the
service you ju�ei5�d Ybur�p�it is key to helping
us improve our service.
Please visit ServiceSatisfaction.com and enter the
StudylD as shown below.
www.ServiceSatis�action.com
_ StudylD: ACGAAR necessary parts Labor: $'!5.00
:mission to Parts: $0.00
� Thank you in advance for completing our satisfaction Sublet: $0.00
� surve . We ho e ou will turn to us for our future elsewhere, at
y P y y �. � e�ress Other Fees: $0.00
� automotive needs. su I Char
�
� secure the pp Y 9 $1.05
s not responsible Subtot7l: $16.05
>arts shipments Sales Tax: $0.00
� left in car in
Paid ey: Total: $16.05
� C, UNLESS pay Ref: P81d: $O.00
Due: $16.05
x
Marshall Cretin Service Center Estimate#0014859
2178 Marshall Ave �ate : 4/5/14
- St. Paul, MN 55104 Page : 1
' 651 644-3436 Center :
* MARSHALLCRETINAUTO.COM * O-C-S
Customer: POSTER, JUDITH Vehicle : 2009 LEXU IS 250
Address : 833 COTTAGE AVE E License : 202JHZ Sub :
City: SAINT PAUL, MN 55106- VIN : JTHCK262092028246
Home : ( 651 ) - Ext: Engine : V6-2499 2.5L DOHC Trans :
Office : ( 651 ) - Ext: Mileage : 29038
Op Tech Description Labor Parts Subtotal
Quan PaR Number Part Description Reason for Replacement Price
TIR00_° MOUNT & BP,LANCE ONE TIRE 15.00 184.32 199.32
i.GO 20'v00X TYIs� SEP.VICE KrT � 9.95
1.00 TIRS FEE 3.00
2.00 WW WHEEL WEIGHTS 1.38
1.00 2259517 91V DONLOP SPORT SOOOM 169.99
SUB04C FREIGHT 30.00 30.00
OK Bad Recommendation OK Bad Recommendation OK Bad Recommendation
I hereby authorize the repair work to be done along with the necessary parts Labor: $15.00
and materials, and hereby grant you and/or your employees permission to Parts: $181.32
operate the vehicle herein described on streets, highways or elsewhere, at Sublet: $30.00
your descretion, for the purpose of testing and/or inspection. An express OtherFees: $3.00
mechanics lien is hereby acknowledged on the above vehicle to secure the Supply Charg $13.74
amount of repairs thereto. Z understand that dealer/owner is not responsible Subtotal: $243.06
for delay or other consequence due to the unavailability of parts shipments Sales Tax : $13.83
beyond theircontrol. Not responsible for damage or articles left in car in
case of fire, theft or any other cause beyond our control. TOtal: $256.89
WARRANTY IS 16 months OR 18,000 MILES WHICH EVER OCCURS FIRST, UNLESS Estimate Only
SPECIFIED OTHERWISE!
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s Collision, Glass and More Workfile ID: lb9ea89c
LAf1EIIkY'S CULLISION Maplewood
2923 Mqp��W����pkIVE
���� MAPLEW000, MN SSlpg
«s„ ;ss-sr;o Customer Leaves With A Smile"
_.......t..iawoW7�c M1L� t��}72f$290142389
ewood Drive, Maplewood, MN 55109
nr�,j,d�t iu: `�°:;`y"192j�qo6 Phone: (651) 766-9770
Sale FAX: (651) 766-8660
X,�XXXXXXXXXX81$1 Finai Biil
--- MpS1ERCqRD
RO Numh Entrv Methad: SwiAed
rotal: Adjuster: Express Team E Estimator: MW Team 1 ANDY
Customer: $ 5��1,�j� ,�p,NCE Phone: (855)341-8184 Create Date: 4/7/2014
PosrER,�� 04/14/14 �ay
In��b: 442013 16;49;�4 cia�m: z3-a�z9-565oi
833 COTTI Appr Code; 69813p Loss Date: 4/5/2014
SAINT PAI p�rud: Online Batcha: ppgSa9
(651)27E Deductible: 500.00
c�st`",F�c�py JTHCK262092028246 Mileage In: 2904�
Year: �HANK yo� 4D SED VIN:
Make:
SILVER Mileage Out:
Model: IS 25U Hv�� 202-JHZ Job Number: Vehicle Out: 4/14/2014
Descri tion Qty Extended Part Labor Type Paint
Line Ver Operation p price$ Type
1 E01 FRONT BUMPER&GRILLE
2 E01 Repair Bumper cover w/o headlamQ washers
6.0 Body 2.6
w/o park sensor '
1.0
3 E01 Add for Clear Coat
Base Coat Paint Reduction (0.3)
4 E01 Refinish �Z B�Y
� 5 - E01 Remove/Reptace� -` License bracket
_ 1 50.13T OEM
6 E01 Flex Additive 1 S.00T Other
7 SOl FENDER
0.4 Body
8 S01 Remove/Install RT Fender liner 1.5 Body
9 SOl Repair RT Fender liner-plastic repair
10 E01 WHEELS
11 E01 Remove/Replace Spare Wheel,spare
1 150.00T Used 0.2 Body
Wheel Re air Alloy 1 189.95 Other
12 E01 Sublet p
13 E01 Remove/Replace Dunlop tire SP Sport 5000-225/45R17 1 165.97T A/M
91V M+S
14 E01 Sublet Tire-Mount and Balance 1 25.00 Other
Ali nment-Thrust Angle 1 59.95 Other
15 E01 Sublet 9 1 5.00 Other
16 E01 Sublet Hazardous Waste Removal
17 E01 FRONT LAMPS
2.2 Body
18 E01 Overhaul 0/H bumper assy
19 E01 Remove/Replace RT Fog lamp
1 208.26T OEM 0.0 BodY
Marku Rate$ Total Hours Total$
Estimate Totals Discount$ P$ 658.35
78.99
Parts 279.90
Sublet/M iscellaneous
T=Taxable Item,RPD=Related Prior Damage,AA=Appearance Allowance,UPD=Unre�ated Prior Damage,PDR D aainUes�'a9 nt�cepai�A/EI'—�A�erm��a�t_M�an cael,�Ref Refin sh,Struc=
Remanufactured,OEM=New Ori9inal Equipment Manufacturer,Recor=Re-cored,LKQ=Like Kind Quality or Used, 9=
s���i Page 1
4/14/2014 4:44:15 PM
LAMETTRYS COLLISION
2951 MAPLEWOOD DR
MAPLEWOOD MN 55109
651-766-9770 y � �0 7 �
•A}11p
Address
Telephone
Vehicle (VIN)
License
Techaician
Mileage
Time Printed 4/15/14 11:08 A!!
I.oru¢ : IS (250/300/350) : 2009-13 : IS 250 All Ahool Driw
Froat : Left Front : Riqht
_---� r----�-
Actual Before Specified Ranqe Actual Hefore Specified Range
- - -1.2° 0.3° Camber -. .�° -. . � -1.2° 0.3°
R �° ^ ?" 3.9° 5.4° Caster ^..1` 4. - 3.9° 5.4°
` � o o p.�?" n i_%` -0.04° 0.12°
n,i2 ' �J.1� -0.04 0.12 T� � 10.5° 12.0°
� ... 10.5° 12.0° 3AI .... . ... ..
... . . ..... 9.4° 12.4° Included Anqle ..... ..... 9.4° 12.4°
..... ..... .. . .... Turninq Angle Diff. ..... ..... ..... . . ..
.t.
Front
Actual Before 3pecified Ranqe
Cross Camber G.2° :..2� -0.5° 0.5°
Cross Caster � .:� � � -0.5° 0.5°
Cross 3AI ..... ..... -0.5° 0.5°
Total T�e V.L4� V.LH �0.08� 0.24�
Croas Tnra Diff. ...•• • •••• • •• •• •• • •
Rear : Left Rear : Riqht
Actual Before 3pecified Raaqe Actual Before 3pecified Range
-G.6" -O.G° -1.5° 0.0° Camber -G. -G.�° -1.5° 0.0°
r_, 0.04° 0.20° Toe -- -- -.-- 0.04° 0.20°
C_1? ._.
Rear
Actual Before Specified Ranqe
Cross Camber �.4" i . .d° -0.5° 0.5°
Total Toe �.� �_� 0.08° 0.39°
• Thrust Aagle 0.03° 0.03° �I . .• •• • • •
.f Finai Bill
°��n Nrumber: 427073
Vehicle: 2009 LEXU IS 250 AWD 4D SED 6-2.5L-FI SILVER
Labor,Body 52.00 10.5 546.00
Labor,Refinish 52.00 3.3 171.60
Material,Paint 105.60
Subtotai 1,761.45
Sales Tax 54.43
Grand Total 1,815.88
Deductible (500.00)
Net Total ' 1,315.88
Estimate Version Totai$
Original 1,921.50
Supplement SOl (105.62)
Insurance Total$: 1,315.88
Received from Insurance$: 0.00
Balance due from Insurance$: 1,315.88
Customer Total $: 500.00
Received from Customer$: 0.00
Balance due from Customer$: 500.00
T=Taxable Item,RPD=Related Prior Damage,AA=Appea2nce Allowance,UPD=Unrela6ed Prior Damage,PDR=Paintless Dent Repair,A/M=Aftermarket,Rechr=Rechromed,Reman=
Remanufactured,OEM=New Original Equipment Manufacturer,Recor=Re-cored,LKQ=Liloe Kind Quality or Used,Diag=Diagnostic,Elec=ElecVical,Mech=Mechanica�,Ref=Refinish,Struc=
StNCtural
4/14/2014 4:44:15 PM Page 2