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Mealey (2) o �� ���� �i °Z�/�/ REC�I ��- MAYT� �Na.i� form is being returned without having been set up as a claim for the following CIT1�e�����,�`;. Failure to provide a written description as to what happened and why a claim form was being submitted (page one). Failure to provide the proper and required documentation (page one). D'�Failure to provide a date of accident or injury(page one). Failure to indicate the amount of compensation being sought(page two). Failure to provide information about the vehicle involved (page two). Failure to provide information about the injury claimed (page two). Failure to sign the claim form(page two). Failure to print the name of the person who completed the claim form (page two). �Other: � G�C�� Please return the completed claim form to: Office of the City Clerk City of Saint Paul 15 W. Kellogg Blvd. 310 City Hall Saint Paul, MN 55102 If you do not return the completed claim form with the appropriate documentation or information completed, then a claim file will NOT be established and an investigation WILL NOT be done. In other words,NO FURTHER ACTION will be taken until the information requested is provided by you. Please remember that it is a crime to submit a claim form or to pursue compensation falsely or under false circumstances. �EC�r\��� ��c�oe��D MAY 14 20�4 APR �8 2014 CiTY ���E OF CLAIM FORM to the City of Saint Paul, Minn��, CL�,�� Minnesotu Slute Slutute 466.05,slutes that "...every persun...whr�cluims dumuges.(rom uny municipulity....chull cuuse to be preserued tn the Koverning body'u(�he municipuliq�wiihin 180 duy.r afier t{�e ulle,Ked ln.s.s or injury i.s di.scavered u notice.�•tating�he�ime,pluce,und circum.c/ances therenf,nnd dze amount nf compensation or nther 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 ''`AJr� Middle Initial r Last Name i.`��� -r--- _ _ _ _ Company or Business Name ------ Are You an Insurance Company? Yes/� If Yes,Claim Number? Street Address�n � � ��h����----r— G State I V \� Zip Code _5� 5 I �5 City v�• I Ol l� , Daytime Phone (�)!�//-�IL1s1.�-e�� Phone(���-L�!Evening Telephone( ) - l��-�- �' ���5 � Date of Accidend Injury or Date Discovered C� .�� 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 damage,,�. � -t I , ��O , ��� vJ ' �' ` � �o � ' �" � ��� �C I\jj � ' ° � � ' V j Please check the b�ox(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 injured on Ciry property � Other type of property damage–please specify 0 Other type of injury–please specify In order to process your claim you need to include conies 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 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 properry damage claims: two repair estimates if the damage exceeds$500.00;or the actual bills and/or receipts for the repairs; detailed list of d�maged items O injury claims: medical bills,receipts �'' `�� '`;!'.:.� O Photographs are always welcome to document and support your claim but will not 6e 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–ulease comnlete this section Were there wimesses to[he 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 of park or facility, closest landmark,etc. Please be as detailed as possible. If necessary,attach a diagr m. � _�Sp '''� Please indicate the amount y u ar seekin�compensation or what you would like the City to do to reso ve this cl im to your satisfaction. ' ' r V�i►icie Ciaims– lease com iete this sectioe� �check box if this section does not a 1 Your Vehicle: Year �O 13 Make �t� Model �1�i.a+ra - License Plate Number State Color Registered Owner Driver of Vehicle MA.rN hG� L�'1 Area Damaged �i./' City Vehicle: Year Make Model License Plate Number State Color Driver of Vehicle(City Employee's Name) Area Damaged In'ur Claims– lease com lete this section ❑ check box if this section does not a 1 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 � When did you miss work? (provide date(s)) Name of yom-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. �-��� � � ��t� � Submitting a false claim can result in prosecution. Date form was completed � Print the Name of the Person who Completed this Form: Ma�� P. �-'�-U Signature of Person Making the Claim:_ �� � ._ ':�2 Revised February 201 I i INVER GROVE HYUNDAi � � 1290 East 50th St. HYUI�ID�I INVER GROVE HEIGHTS, MN 55077 HYUI'1DA1 (651)204-4400 CUSTOMEFiNO. /� S�VO KENR 3844 TA6N0. O�� INVOIo�/��/�� 'HYC5145013 � LABOR RATE LICENSE NO. MILEAGE COLOR STOCK NO. JAMES HOWARD 805 B�ACK/ 2035 GOODRICH AVE YEAR/MAKE/MODEL DELIVERYDATE DELNERYMILES 13/HYUNDAIfELANTRA/4DR SDN GLS AT ST PAU L, MN 5 5105 VEHICLE I.D.NO. SELLING DEALER NO. PRODUCTION DATE 5 N P D H 4 A E 2 D H 4 1 6 0 0 6 FT.E.NO. PO.NO. R� O�/��/�� RESLDE�E 242-1951 BUSINESSPHONE COMMENTS 65 MO: 8Q ----•---------------------------------------------------------------------------• THANK YOU FOR THIS OPPORTUNITY TO SERVE YOU. IT IS OUR AIM TO --------------------------------------•----------•----------------•------ PERFORM ALL THE REPAIRS RE- CUSTOMER STATES THE RIGHT FRONT TIRE IS FLAT. SHE HIT A POT QUESTED ON THIS REPAIR ORDER TO HOLE AND THEN ONLY DROVE ON IT FOR A SHORT TIME. YouR COMPLETE SATISFACTION. IF FLAT TIRE NOT REPAIRABLE OUR SERVICE WAS SATISFACTORY REPLACED THE RIC�iT FRONT TIRE TELL YOUR FRIENDS, IF NOT, PLEASE TELL US IMMEDIATELY. PARTS---•--QTY---FP-NUMBER--•-•••---•----DESCRIPTION---------------•••--UNIT PRICE- 1 1011352 205/5�t16 HANKO 130.77 130.77 OPTIMO H426 TOKEN CHARGE TOTAL - PARTS 130.77 A TOKEN CHARGE EQUIVALENT TO A PERCENTAGE OF OUR LABOR CHARGE MISC--•---CODE--------DESCRIPTION-------------------------""--CONTROL NO-----•••- HAS BEEN ASSESSED FOR SHOP SUP- TDl TIRE RECYCLING FEE 2'50 PLIES.PLEASE SEE REVERSE SIDE FOR TOTAL - MISC Z.SO A LIST OF THESE SUPPLIES. JOB# 1 TOTALS--------------•-------------•--------------------•----'LABOR 16.25 PARTS 130.77 MISC 2.50 JOB# 1 JOURNAL PREFIX HYCS JOB# 1 TOTAL 149.52 MISC•-----CODE--•----•DESCRIPTION...-------•----•---------------CONTROL NO••----•-- JOB # A SS SUPPLIES/ENVIRONMENTAL FEES 1.66 TOTAL - MISC 1.66 TOTALS----------------------------------------•------------••-••---------••---•-----------•---•• Thank You! **,t,�,k,r***�**�rx***,�***�******************* TOTAL LABOR.... 16.25 WE APPRECIATE YOUR BUSINESS * * TOTAL PARTS.... 130.77 _ _ _ * c ; *-_ TOTRt St1�t£'f... _�:UO ---- * [ ] CA„H [ ] CHECK CK NQ. [ * TOTAL G.O.G.... 0.00 * [ ] VISA C 7 M��R� C ] DISCOVER * TOTAL MISC CHG. 4.16 * * TOTAL MISC DISC 0.00 * [ ] AMER XPRESS [ ] OTHER C ] CHARGE * TOTAL TAX...... 9•32 �***,�x*,r**�x**�r�r,�*,kx*,rkx�***,t*,�,�*,�x�t****** TOTAL INVOICE� 160.50 °THANK YOU FOR YOUR BUSINESS!! "Any warranties on the products sold hereby are ° those made by the manufacturer. The seller w (above named dealership)hereby expressly dis- ? claims all warranties, either express or implied, Qincluding any implied warranty of inerchantability w � or fitness for a particular purpose, and neither � • assumes nor authorizes any other person to assume for it any liability in connection with the sale of said products" V 2 " PAGE 1 OF 1 CUSTOMER COPY [ END OF INVOICE ] 01:11pm � sFSSien o�oeni> . ,, 1°o U� �uiSt0�1'ter � �r�._+± :t is not �ractical to itemize ?he m��r,y miscellaneous supp��es ,���c' :-���, �ach repair job. To do so �.�dd to cu;� costs and !at�or charges. �, s�anciard charge for s�;;�p:ies �r;d ��� ,���rials is made on each � � ��������it a� this charg� wii( t;e a per�ce��t�ge o1 tt��e tot,�� !abo,� rh�r�<-. ,I is �v����l !;e shown in the lower = �epair order in the space provideei. E_;cperience has si�c4vr; tE���;� ciur a��e�_iye charge covers the � � ,_ , t���ese item� resulting in savings to our cu�tomers. , . � _?__�PJEOUS MATERIAL R�GULAr��Y CONSUMED I�! OUR SN�P �A��� PROCUCTION -�:: i,ers, Chassis Grease � ;bc:er Protector Solution Acety�e,�e 5�'�_�s�:ir:u lape � � � . Wiping Gioths Sc�.r���. Piug C-��,r�,�pounds S, ,,.,_r:, _ �1,'a�:�11.�c::�ther Strip Cemen; ��u;,:s r�a�rs-,,-°Y � ia_,es V����e Gri��ding Compound - __ �� �;r�;n�;��urid i, �assis Srurris _ C�rk;u�etor:�olvent � ��� ,c��s D��or �=r��se �le^tric ar,':; ;ape Crr:tiSr.e:i .�bctie+ i.�viilEJOi.It1C� Tvi�Ch�ifliC�S��IfO ,�,rits Shim Stock ��nde� Protectors - Abrasive Stones Choke C!eaner Metalite Cloth Siiiccne Spray Perrr��iox Corrpoun�s �Tr�,i�. GEmer,t Cuu!k Cord {'ar'�:'J�.'t�eE;�s :-: �°'���t �eaes Into the �ost of Servicing Y�ur Automobile. . :oc=sn t "just happen"! Operali!;.� a dep�ndable service business !equires erranization, competent � s�.ibstantial rapitaf irn�estm� it. �� cron't judge ;ervicF charc�es s�iely by tne ±�me spent repairing [�r_-notch technician gne� to d��ork, many cosis have been inc�arred iust to yet him ready to do the . . .. . ��iY�ti�. � � � Stock, of Par�s C�pitai fnvestment Wage� 5�.���;rvisory Persor�nel � Buifdin;� Prlaterials C��,i��i�;rs �� �;.�<�;r�tu� I_iability Ir��urar�ce � Clerks :; Ctzsuaity li�surance �.r�al i��xt,s � Workers �ornpensation State�T����,s 'Jc^�C�tiOf1S �;:Ge f�ti �.r,XES � Si�k PaV _ _ _ _ : _ � , . .<e : ne� n.: _ HAZARDOUS WASTE c;: ,:rr��d about the env�ronment as you are Disposal of hazardous �vaste has hecome a major concern - ��;:c�ssa�y to dispose of them. A charge for hazardous waste removal might include batteries, tires, (_IMITED W;�RRANTY �<ai:;;�ment parts carry a 12 month 12,Gt)0 mile parts and lapor !imi±ed warranty, provided by the A. Call our Street Maintenance office at (651)-266-9700, or email your report to pothole@ci.stpaul.mn.us Q. What information should I have when I call to report a pothole? A. Be prepared to give us a precise location of the pothole, and a number where we can reach you during the day. Q. Will driving over the patches harm my car? A. No,the patch should not cause any damage to your car. Q. Why aren't all potholes fixed right away? A: The City cannot repair a pothole until it knows about a pothole. That is why reporting potholes to the city are very important. When a call comes in about a pothole, the city tries to prioritize pothole repairs based upon the type of street, the size of the pothole, and the availability of crews. r' q: If there is a pothole and 1 hit it,the city will pay for the repairs to my car, correct? A: Not necessarily. Before the city will make payment for your vehicle,the city had to have prior notice of the pothole, and the city had to have failed to make repairs within a reasonable amount of time with the available crews. Since potholes develop frequently and often in our cold climate, notice often does not occur, making it unlike�y that the city had prior notice of the pothole prior to you striking it. That means that the city will probably not be responsible be your damages. q. How do I file a claim if my car is damaged by a pothole? A. Cantact the City Clerk's cffice fer a c!aim form at (b51)-265-8688. q. Will the city fill the potholes in the alley? A. It depends, if you're alley has been designated an "improved alley," then yes. If you're uncertain about the status of your alley, contact Scott Brimer at (651)-266-6225. Potholes on improved alleys can be reported to our Street Maintenance division at (651)-266-9700. Q. There is pothole on the highway on/off ramp,who do I contact? Pothole FAQs Q. How do potholes form? A. Potholes begin to form when moisture penetrates the pavement surface and reaches the soil underneath the pavement. When that moisture freezes, it will expand and push the pavement upward. When the moisture thaws, the soil will re�urn to its previous level, but the pavement will remain heaved. As vehicles pass over the raised pavement, the road surface begins to crack and over time a cavity is created below the pavement. Q. How is a pothole repaired? A. The defect (or hole) is swept free of loose debris, coated with a thin layer of tack, filled with asphalt, and then smoothed flat using a roller. Q. What does the city mean when it says"hot-mix" or"cold-mix"? A. Cold-mix asphalt is generally used only during the colder months. It is considered only a temporary repair because the cold-mix asphalt does not adhere well to the pavement surface. A hot-mix patch does adhere well to the pavement and a patch made with it can last from one to several years. Q. Can potholes be filled in the winter? A. Yes, see previous question discussing hot and cold-mix asphalt. q. Why do so many potholes occur in the spring? A. Spring is the time of year when the freeze-thaw cycle is most active. As snow melts, the pavement sub base and sub soils can become very soft. This is why most units of local government impose weight restrictions on larger vehicles during the spring. Q. How many crews does the city have repairing potholes? A. The number of crews will depend on the time of year, and the weather on any given day. During the spring,we can dispatch as many as 13 three-person crews for this purpose. q. How do I report a pothole? � �,�� �ti� ;��� �.