Alm� RECEIVED
MaY 12 zo��
NOTICE OF CLAIM FORM to the City of Saint Paul, Minne�Y CLERK
Minnesota State Statute 466.05 states that"...every person...who claims damages from any municipality...shall cause to be presented to the
governing body of the municipality 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 Middle Initial�Last Name ��
Company or Business Name
Are You an Insurance Company? Yes No If Yes,Claim Number?
Street Address
City `4C-Q��\ State �,� Zip Code ,`
Daytime Phone��-�Cell Phone�,�-��Evening Telephone���
Date of Accidend Injury or Date Discovered�, Time��15,L am/p�ii
�.�
Please state,in detail,what occurred(happened),and why you are submitting a claim.Please 'ndi t w + w yo
feel t e City of aint P u r i s emplo s ar ' vo d d/o re sible or our d es.
. ,
� �
�
lease c t e x es t c ose y r s t e r om et ng t is
❑M y v e h i c l e w a s dama ged in an accident ❑My vehicleva �ma n 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 City property
�Other type of property damage—please specify
❑ Uther type of injury—please specify
In order to process your claim vou need to include copies 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 list of damaged items
O Injury claims: medical bills,receipts
�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
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims—nlease complete this section ,_.---
Were there witnesses to the incident? Yes No ���rla� (circle)
Provide their names,addresses and telephone numbers:
Were the police or law enforcement called? Yes � j�::..J Unknown (circle)
If yes, what department or agency? Case#or report#
Where did the accident or injury take place? Provide street address,cross street, intersectionrnam of ark •
.clo��f"ntl�Xn��se e�as dgtailed� ossi�ble., neces ,��t�ch a diagram.
..�,,,�„L \Cly 1P r(�l
Please indicate th ou t ou are eeki i com sation r t o would 'ke the 'ty t o t 1 e ' aim
t your sati ctio .
Vehicle Claims— lease com lete this check box if this section does not a 1
Your Vehicle: Year Make Model
License Plate Nu b r ! State Color
Registered Owner
Driver of Veh' e
Area ge
City Vehicle: Year Make Mo e
License Plate Number S a Color
Driver of Vehicle(Cit loyee's Name)
Area Damaged
Iniurv Claims please complete this section ❑check box if this section dces not annlv
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 fornz,you are stating that all information you have provided is true and correct t the b st
of your knowledge. Unsigned forms will not be processed. �� �r�
n result in rosecution. Date form was completed � �7���� .' ���`� ��
Submctting a false claim ca p �
Print the Name of the Person who Completed thi orm:
, ��
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Signature of Person Making the Claim:
G (�,�`lv1• �
Revised February 2011 �\^�A�� �� ,
�V��
MIDAS AUTO SERVICE CENTER
1697 WEST SEVENTH STREET PAGE 1
, �� � � SAINT PAUL,MN 55116
^-�, (651)699-0220
��������
Customer ID: 2378026928 Year: 10 Datelfime: 04/09/14 16:57:18
Name: EMILY ALM Make: NISSAN-DATSUN Estimate#: 104085
Address: 1455 ALASKAAVE Model: SENTRA Invoice#: 207287
Address 2: Lic No: 656KCK Key Tag:
City,State,Zip/Postal Code: SAINT PAUL,MN,55116 VIN:3N1A66APOAL644005 PO Number:
Home Phone: (651)587-3099 Color: EmailAddress: na
Work Phone: (651)- Engine: 4-1998 2.OL DO Fleet/Wholesale: N
Other Phone: ()- Mileage In: 50349 Unit Number:
Tax Exempt#:
Mileage Out: 50349
Seroice comments:
Salesperson:R.KRAGNESS .
Qty Part# RFR Loc Description List Labor Total Schedule your next appointment
online at 1NWW.MIDAS.COM
� V To':�evr a!I yo:sr P:lid2s s°rvice
FINAL INVOICE APPROVl�L: records online please visit
VWVW.MYMIDAS.COM
See manager for details
Contact us via email at: -
MIDAS2378@GMAIL.COM
TIRES Thank you for your patronage.
1 OP/23757 RA ' 205/55R16 H TP TOURING 97.99 0.00 97.99 At Midas Auto Service Centers
Tire Size:2055516 our goal is 100%customer
Load Rating:91 satisfaction. If you have any
comments or concerns,please call
DOT Numbers: Y90FG95113 Franchise owner Joe Stranik
TOTAL TIRES: 97.99 **'651 224 2821 Ext. 11 *"
Thank You.
WHEEL SERVICE
1 BAL RA BALANCE WHEEL 2.00 0.00 2.00
1 TM RA TIRE MOUNTING 0.00 13.00 13.00
1 VS RA VALVE STEM 1.50 0.00 1.50
1 TD RA TIRE DISPOSAL 3.00 0.00 3.00
TOTAL WHEEL SERVICE: 19.50
**'Customer Wishes To Discard Old Parts"*
These Parts And/Or Services Were Declined by the Customee
� pLT RA THRUSTAUGNMENT 0.00 89.99 89.99
1 TPMSKIT RA A TPMS SERVICE KIT 6.99 ' 5.00 11.99
1 RHW RA 15.25 0.00 15.25
� RTW Rq 0.00 0.00 0.00
1 RHWD RA ROAD HAZARD WARR.(RH 0.00 0.00 0.00
Total Declined Service Recommendations: �•-,.>_ �. - _ .. -=�� '•-'�1,7•23
RA PART NO LONGER PERFORMS INTENDED PURPOSE
CREDIT CARD#: XXXX-XXXX-XXXX-9538
APPROVAL# :619065
TICKET# .
PAY AMOUNT SHOPSUPPLIES 5.87 W1NW.GOMIDAS.COM
VISA 131.78 PARTS TOTAL 104.49
SALES TAX $•42
TECH:000714-0.00 M.GALE LABOR TOTAL 13.00
GRAND TOTAL 131.78
INVOICE INVOICE MIDAS AUTO SERVICE CENTER INVOICE
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