Abraham � R��E(�ED
MAY 14 2Q14
NOTICE OF CLAIM FORM to the City of Saint Paul, Mi�e�t�L E R K
Minnesota State Stanete 466.05 states that"...ei�ery person...who clainu damages from any murticipalin�...shall cause to be presented to the
Rovernin,q Gody of the rnunicipalin�withir:180 days after the alle,qed lass or inju�7�is discovered a notice statin,q the tirne,place>and
circurnstances thereqf,artd the urnouru nf cnmpen.catinn nr 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 exptain your ciaim,and the amount of compensation being requested. You will receive a
written acknowledgement once your farm 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'.
SF,ND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
First Name ��LL�,S Middle Initial�Last Ndme �r����
Company or Business Name N/�'
Are You an insurance Company? Yes! �10 If Yes,Claim Number?
Street Address ���2' �l2r'` �j✓e�� N•��
City ��A"��L� State �"�I n n-�5�� 7,ip Code �`��4`�
Daytime Phone(�122)79�.-ylvlo"L Ce11 Phone(�v5� )�7 - `11�9� Evening Telephone('�3)�'Z- y�L!t
Date of Accident/Injury or Date niscovered � g �� Time ' �� am/pm
Please state,in detail,what occurred(happened),and wt�y you are submitting a claim.Please indicate why or how you
feel the City of Saint Paul or its employees are invol��ed and/or responsible for your damages.
� (,�J . .ee.a
s � cc4fttCh e r
� p 1 p.t 4 a.f, tS2 ��
�C� Q
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 vehicte 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
Tn order to process your claim vou need to include copie.5 of all applicable documents.
For the claims types listed below,ptease be sure to inciude the documents indicated or it will delay the handling of
yovr claim. Documen[s WILL NOT be returned and become the property of the City. Yvu 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 esrimates if the damage exceeds$500.00;or the actual bills
and/or receipts for the repairs;detailed list of damaged items
' O Injury ciaims: medical bills,receipts
O Photographs are aiways welcome to document and support your ciaim but will not be returned.
V Page 1 of 2—Please complete and return both pages of Claim Form
�1�f hch,�cl �'s cz e�,,,l e�fhc�c�-l�r r'eee(Ft a�d Pst�TA�tr��ouru�e.el had�lo f��Cne 2sc�.�o�`79.94 Plus 1�►�tC�.
S�ic�sh sh�f ld i s brot��„a.�d�dr�O b� replo-�ed �,�"�16.pp ptc.cs�-rrx.
,
, �
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims—t�tease complete this section
Were there witnesses to tt��incide�it? Yes � Unknown (circle)
Provide their names, addresses an�telephone numbers���� a, �_car-�v�-I'fh2t�-('l�'1�C�_��i��� �n�-Q
3 c��N4r��.�t�ts �e.�,�-�-e.G�d �.���
Wer�the police or l�w enforeemesit calleci? �� No L�nlcnown (circle)
If yes,ivhat department or agency?3 c�_ IF rpn _. r Case#or report# �
See�{�ct�d et�r.
Where dici tne accident ar�njury take pia�e? Provide st��eet address,cross street,inte*-section,name of park or faciIity,
closest landmark,z�:;. Please be as d tailed as,Possible. If necessary, attach a diagrair►. "h'N�S hc�sPn-ed 2�
� � i � /d � - �°�'Y� �� � l� ,. r C/P �?i/
Pleas�indicate th�atnount you are seeking in compensation or vvhat vou would like the City tp do to resolve this ciairn
to yoar s tisfaction. r�m S�e in �� .9 ' �r�� a �d �b•a�
1 / � � c � �' t� � h �
��y �.�e��-- p usfi�.
Vehicie Claims—piease complete this section ❑check box if this section does not annlv
Your Vehicle: Year o'40/4 l�iake Mo�el Snre nr+o
License Pla±e Num�er o2a-M11C State Mj� Color �rio�K �her/t,t
Registered Owner 1,cv r s r V i c ic ri o �hrra�►4ry.
Driver of Vehicle � ' .A-b�'I'�Kd�rY�
Ar�aDamaged ren-�-��pr��a nF��PC�1I��C Ay► I.J IG�1'Yl2/� '
City Vehicle: Year N 1� Make N j p Model NLA ,
License Plate Number ,�►�� Sta�e ��- Color 1U�d
Drivzr af Vehicle(City�rrmployee's Name) N J�4
Area Damaged 1J.��F
ini ry Ciaims �lease camplete this section I t�check box if this section daes not a�niy
How were yc�u injured?
What part(s)c�f your body were injured?
Hav�you sought medical treatment? Yes No Planning to Seek Treatment(�ircle)
When did you receive treatment? (provide date(s))
Name of Medical Provider(s):
Address Telephone
Did you miss work as a result of y�ar injury? Yes No
When did y�u miss work? (provide dat�(s)}
Narne of your Empl�yer:
Address Telephone
!�I Check here if you are attaching more pages to this claim f€srm. 1*.Tumber of additiona�pages •� .
By signing this form,you are stating that all informati�r�you have provided is true and correct to the best
of yocsr knowledge. Ilnsigned forms wil�not be processed.
Submiiting r�false claim can result in prosecutian. Date form was completed ���I I�'
Print the Name of#he Person who Compieted thi F�rm: �u l.S ��_���
�
Signature of Person Making the Claim: G
Revised February 2011
In response to ?"Please state, in detail" My A-B-C
A). What occurred/happened. t incurred damage to my vehicle on Saturday, 1/18/14. (6:00—6:15
P.M.), as I was driving south down a very dark Childs Road to work at the Metro Waste water plant at
2400 Childs Road. This happened at approximately 1125 Childs Road(big building on right—terminat
#1). I hit a huge(6 x 20)—massive-dangerous-unsafe,water, ice,and pothole (6x5)filled formation on
Childs Road. I am lucky I did not kill myself or the person coming down the road towards me when it
happened.
B). Why I am submittin�a claim
1). Because there is damage to my vehicle.
2). Because this damage did not need to occur. If someone from weekend day shift, non-
emergency police, City St. Paul, City St Paul Public Wo�ks Department,would have acted when first
notified that there was an unsafe condition on Childs Road. (between 12:00—1:00 P.M.the day shift
manager at the Metro Plant called in unsafe condition on Childs Road).
3). To try to prevent something like this from happening again.
C). Why or how do I feel the Citv of St Paul or its�emqloyees are involved and/or responsible for these
dama�es.
1). Because Saturday, 1/18/14(between 12:00 and 1:00 P.M.)the manager on the day shift at
the Metro Plant called the City of St. Paul non-emergency number about a very dangerous unsafe
condition on Childs Road heading to the plant. The manager asked that someone respond as soon as
possible and get some barricades up at a minimum (nothing was done).
2). Saturday, 1/18/14, 6:15 P.M. (still nothing done i.e. no barricades nothing on this huge
unsafe section of a very dark Childs Road) I am the night shift manager on duty at the Metro Plant. I hit
this huge, (6x20) massive-dangerous-unsafe,water, ice,and pothole (6x5)filled formation on Childs
Road. I am lucky I did not kill myself or the person coming down the road towards me when it
happened.
So,yes I think(and I think most people would agree)that 6 hours to respond to an emergency request
for an unsafe road condition to 3 City Department is more than enough time to respond. (Actually
someone should have come out and inspected and put out lighted barricades ASAP). We are all lucky no
one got seriously hurt on that road in this time frame,and if the first emergency unsafe road conditions
request would have been handled in a reasonable amount of time this damage to my car would not
have happened.
P.S. Just so you know when I arrived into the plant at 6:30 P.M. t called St. Paul police(non-emergency)
and reported unsafe road conditions on Childs Road. They gave me the number to the City of Paul. I
called this City of St. Paul number, (operator#58)they gave me the number to the City of St. Paul Public
Works(Gregg 651-266-9700). (All this took about 5 minutes) A City of St, Paul Public Works employee,
(Steve) answered his cell phone immediately when I called him,and when I told him who I was and why I
was calling he said "I'm on my way with barricades to Childs Road right now". St Paul police non-
emergency or City Dispatch had called him. That's how this should have been handled on the first call
between 12:00 and 1:00 P.M., and if it had been this damage to mycar would not have occurred.
Thank You
Louis Abraham
1992 112`h Circle NE
Blaine MN 55449
763-792-4662
CUSTOMER #: 66267 112154
7911 Lakeland Ave N
*INVOICE* Brookfyn Park, MN 55445
LOUIS CHARLES ABR.AHAM Phone: (763) 424-9100
1992 112TH CIR NE Fax: (763} 424-5763
BLAINE, MN 55449-6112 PAGE 1 www.kiaofbrooklynpark.com
HOME:763-792-4662 CONT:651-402-7692
BUS: CELL: 651-402-7692 SERVICE ADVISOR: 998027 DANIEL RUDOLPH
COL.OR YERR ; MAKEfN117DEt. ' UIlU; LXCENS€ MILEAf�E�W/;OUT TRG
DARK CHE 14 KIA SORENTO 5XYKT4A78EG482852 7500 7500 150
QEL.;DATE >;.PRQD:"DRT� :1i�Fi�Ftf#::EX€� f'AC?TyEt$�� Pf3 E�tt3. ; `''RATE :. �'A�i4tEN7 ` IN�I. ElATE
27SEP13 D 18 : 00 08APR14 0 . �0 CASH 08APR14
#�;p �p�Ei} ; R�q€�'i' ; oPT10NS: SOLD-STK:LG0140 ENG:3 .3_Liter GDI
TRN:AUTOMA.TIC
12 :35 08APR14 13 :32 08APR14
LINE OPCODE TECH TYPE HOURS LIST NET TOTAL
A OIL i�NI3"FIIIT�R �HANGE<: AND ;?TIgE"RQTAT��3�7 '
6K OIL AND FILTER CHANGE AND TIRE ROTATION
�51� CFM ' _ 34>::;05 ,.: :34;: 05 ;? '
_, _ . ;
COUPP BUYERS LOYALTY -25. 00 -25.00
:eOUPS COUPUI� '.DIS COT3N'�' -10!.O f7 '' -1�. 0 0 ; >
1 26320-3CAA0 SERVICE KIT-OIL FILT 7.50 7.50 7.50
5 <:OI I�°'MOTOR O I I},. 2.5� : 2:.5 fl ;; . �.2:.5 0
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S C/S HT_� BI�; �'��'>::I-�QL�'�3�I's:€?�C`r*
150 INSFECT `�MAGE.FRONT SPLASH SHIELD
BRO < $316 0: ����c� >��us �� :� sIs*rr��� � ::
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WHE NMENT*
; 450. ..�g$. .;: °: ;: - . < . �:: >' ;:. _.... . �N' �) ,<
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C F�ULTIPQINT.UEHICLE I2�SPSCTIfl�.,
KCP2 MULTIPOINT VEHICLE INSPECTION
4 5 d '` G�'P _ a..0 0 `: O.fl 0 ;'`
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D** 4: i�3HEEL �IGNMEiSP� . _ _
CAUSE: 4 WHEEL ALIGNMENT
, P��G3�MEi�t`T 4 WHEBL :1�L�G��`�' � ;
450 CPM 79.99 " 7�_ 9 .99_r�
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CUSTOMER PAY SHOP CHARGE FOR REPAIR ORDER 4 . 09
e�ea�ed 2014-04-Q"� 03.2I.Qflptn i
taken by Dan Rudo lph
_ _ _ _
TERMS:STRIC7LY CASH OR CREDIT CARD 'D�SGftEE'Tltitd T�TALS
pny wa'rnnties on tM Woducta sold hercby arc those mede bY the mam+F�cturer. As between Mis relai�ceHer antl buyv.N+e �GMCPf' LABOR AMOUNT 114 . 0 4 �
proAUCt�6 to be soW"AS�S'md the enrin riak as m the Wality and pertom�a�e of the pioduct is with the 6uYa- The seNar
exO��Y dadaims a11 wartanties./ather exWeas or M++Wied,hcWdin9 anY ImP�d warraniV of machanpWitM ur fitr�ass far a 2 O .O O
p�w��p�q� �nd the$�11�r neiTher essuma no�wMo�i:es am�othu pason to ssetnm ror+t a,ry 1iaeSty in wnrection with �SECURITY PART$AMOUNT
- the sale of said Oroducts. This discianner trY thia Sdkr in iro waY offects Me terms ot the mamrfacturer'e wartanty. The hWm PLUS GAS,OIL,LUBE Q . ��
acknowledpas being so in/ormad prior to the ssk, NO710E:All parte new originai equipment unkss otherwfae sPecified.
^I hereby wtYiori:e the rapaL wonc hnreinsfta sat tmM to be Aone Non9 wiM the neeeasarv m�teAd end apres that yw m noc �OTHER SUSLET AMOUNT Q . Q�
rcsyomible fw ioss or damspe to vehicla or artieles kft M vehide in casa of flro.MeH w�ny aMr eswe beYOnO Yaw can/d a
ta any dNays eaused Dy unaradabHitr os osrts a ae�.ys M oa�+s�a�n M���*�m��•��+'e�YO1 MISC.CHARGES' —3 0 . 91
mdlor yaur employees 0��^to aperste Me vehi�ie haro+n deacAbed e^atraats,highwsys w elcewhere ta the pu'pose d
„�;,,8„,d,,�;,,,,,�„�,.�,��.meehmrc's fien is hereW eoknu++ladged on ebave vddde M secu�e tfm annuM o�� R�yTAL CAR TOTAL CHARGES 10 3 . 13
thereto.' Q . Q Q
❑YES SALES TAX 1. 7 6
X PLEASE PAY
CUSTOMER SIGNATURE ❑ NO THIS AMOUNT �.04.Hg >
wMISCELLANEOUS SUPPLIES AND MATERIALS:A charge is ineluded tor msteiisls a�lor hezerdous westt 6apoaai(if applicaWei uaed on your vMkle.Material items �� ��/�({�I{�'
arC:Nuca,bohs,waahers,tape.am.aero�prey,oaint a�mate+fals.shelix.whent.rsgs,carbwetor deaner�towele,coldar,battery cleanar.wire.window sealu,etc. � i
i
Cq�yiyht XqD AW.Inc.SEfMCE IMVOKE T'1'E 2�512C CIISTOMER COPY .