Reed (2) RECEl��ED
s RECEIVED
� MAY 12 2014
NOTIC� OI' CLAIM T�RM to the City of Sa�t���,��ne�12 21�14
Minnesntn Slute Stutrite 466.05 stntes thn� "...every persnn...wlin clninrs dunutges from ar�v mur�icipaliry...slrril!cm�se ro 1Q��c�t�fe�t d�RK
�ut�erning hut(y q/'t/le»�ur�icipa(ity wid�i�t 180 daps ctfter the ci/le�etl loss or injury is discovered n notice.rtntiitg the tinre,p ac•e,anrl
cii-cumsta�rces tl�ereof,and ilre nmount of cnirtpe�7satinn or other relie`deinnnded."
Please complete this ti�rm in its entirety by dearly 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 cl�im,and the amount of compensation being requested. Yoi�will receive a►
written acknowled�;ement once your form is received. The process can talce up to ten weelcs or longer depending on the
nature oCyour daim. This 1'orm must be signed,and both pages completed. If somelhing does not apply,write`N/A'.
SEND COMPLET�D I+'ORM AND OTHER DOCUM�NTS TO: CITY CL�RK,
15 W�ST K�LLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
Firs�Name m��C�l�� "r Middle Initial �� Last Name � � ���
Company or Business Name �
Are You an Insurance Company? Yes/� If Yes, Claim Number?
Street Address �� 6 O ,(��L �A/Q(� C ��
City��'�1 t��1Q G R d t/� j�rS- State '� ►'� Zi�Code 5 j�77
Daytime Phone (�)'� 0-,s�3 Cell Phone (G S( )?� .3�`ZS Evening Telephone ( ) -
Date of�Accident/Injury or Date Discovered I�1����— � U, a01� Time b.'3G am/ m
Please state, in detail, what occun•ed (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 damages.
� .. �"�a,r,k.CZ (',t'�,vr,.� •
Please check the box(es) [hat 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 1nd/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 copies of all annlicable documents.
For the claims types listed below, please be sure to include the documents indicateci 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
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 pa�;es of Claim Form
Failure to complete and return both pages will result in dclay in the handling of your claim.
All Claims—please complete this section .
Were there witnesses to the incident`? Yes No nknown (circle)
Provide their names, addresses and telephone numbers:
Were the police or law enforcement called? Yes � Unknown (circle)
If yes, whal 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 diagram. �,�%f�Y��fl�C �RONj,�'�
�d 5� �F -���0 .i- f'�6�2T�r � � 1.D�Qt�7p sf
Please in�icate the amount you are seeking in compensation or what you would lihe the City to do to resolve this claim
to your satisfaction. ,�.¢. o�����/ '��^'��>'►'v'
V�hicle Claims �le�se comeete this section ❑ check box if this section does not apnlv
Your Vehicle: Year �?0 �/ Make � 1 SS Model S�N'fRA
License Plate Nwnber cS�/D G GT State Color I��/�
Registered Owner �AMt-S A• .� rn�ReQ,e�fi E. ���1�
Driver of Vehicle .'f'�11'I.LS /q- � � fl'J
Area Damaged��dr�T•,�/Q�AR Lt/ EEL� — DRlU�2� S� oE
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle (City Employee's Name)
�nY►/T .�?� . . ,�yr�. i7�� u�A "'u P
w w i-�
Area Damaged , ..r--,-.
Iniurv Claims—please complete this section �check box if this section docs not annlv
How were you injured?
What part(s)of your body were injured?
Have you sought �nedical treatment? Yes No Planning to Seek Treatment (circle)
When did you receive treatment? (provide date(s))
� Name oP Medica] Provider(s):
� Address Telephone
Dicl you miss work as a result of your injury? Yes No
When did you miss work? (provid��s)j----
Name of your Employer:
Address Telephone
�Check here if you are attaching moc•e pages to this claim form. Number of additional pages p�.
I3y signifzg t/iis form,yoct are staling lltat ull information you liave provided is true and correct to the best
of your krtowledge. Unsig�ied forms will not be processed.
Siebmittiiig a false claim can result ifi prosecactio�z. Date f'orm was completed .���` a 4/ �
Yrint the Name of the Person who Completed this rorm: �R �A R�r E . I��CD
Signature of'Person Making the Claim:
Revised February 201 1
��in�
We had just returned from our winter in Florida and were not aware of the poor
conditions of the road as we turned off of Plato Blvd onto the access road to
�-!igh�,r���y 52 ��uth. �ur :«hicle s�med�ately !-:it sev�ral pct holes and stas-ted
vibrating. We pulled to the side of the road to view the damage. Both tires on
the passenger side of the car were blown and it was necessary to call a flat bed
tow truck to haul our vehicle to be repaired. Our insurance covered the cost of
t�e t�wing an�! afl �ut oUr $50Q �eduetible �f the r2pair cc�sts af$1,4��.65 (Copy
af bill attached}.
According to several people we talked to at the scene of the accident and with
our daughter who has traveled that route during the winter, those pot holes,
w�ich were huge, had been there for severai weeks if not months and the City�
had not done anything about repairing them.
I believe that the City should not only reimburse us for the $500 we had to pay
k��t a��n reirr!►�t�rse r���r ins�rance corn�ar�y, Amer�rise A!�to anc� Home lnsur�nce
Co. for their payment since, as you are aware, our insurance premium will
probably be increased because of the accident.
� ������ AAain Line 651-457-5757
�� � Fax 651-457-5009 N155AN , �
Toil Free 800-377-4125 �
1470 50th Street East • Inver Grove Heights,MN 55077 www.lutherauto.com
. • •
Szrvice Dept.Hours .•� •
Monday-Thursday:7:00 am-Midnight �hedule
Friday:7:00 am-6:00 pm • • ' ' �
Omline swrlca acheMM7n[N Lu�r,rrA�,to.�ron�
Saturday:9:00 am-4:00 pm • • � _ 5
CUSTOMER N0. AONISOR . 7AG NO.. �M/OICE DATE IM/OICE N0.
12415 5 MIKE WAGNER 727 403 04 17 14 NICS357776
�pBpp qRTE LICENSE NO. MiLEPGE �� ��.
Q40GGY 23 819 RED 34833
JAMES ADELBERT REED Y�,,,,,,�E,� �,�E��� �����5
7060 BALLARD CT 11/NISSAN/SENTRA/4DR SDN I4 CVT 2.0 04 29 11 65
INVER GROVE HEIGHTS, MN 55077-444 VEHICLEI.QNO. ��'��R�' �������
3 N 1 A B 6 A P 6 6 � 7 0 5 9 4 2
F.T.E.NO.. � P.O.NO. . R.O.OATE
JIM-PEG@Q.COM - 04 10 14
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RESIDENCE PHONE BUSINESS PFIONE CAMMINTS/E-mad MO� 2�U 19
651-450 1543 '
_._ .__ .. _. fcactory �a�an�;nt} ^onst�tutes all af il a
� �, ��,���°� �x. _ ' � � ,���a� �� a �?.�r�"����_-� �� ��, ���� � .. wa�antie� with res�e�t to tne sale o ti s
r. .; �:: �:.�'�tlk�-�;�I._�°;�... �..._��.. �:..� � � �M 1 ����
CUSTOMER STATES HIT A HUC� POT HOLE AND SEEMED TO HAVE BLOMM irem%r'tems rhe se(1er hE�reby ex��ress�y di.,clam�s
OUT BOTH DRIVER SIDE TIRES PLEASE CHECK AND ADVISE. a11 warrantes.eithar express or implied.indudin,�
any implie�l�var'ranty o1 merchr:�ntahility or!(fie�s
for a particular purpose ancf the seil�r neiN���;
qRT$------QTY-•-FP-NUMBER--•--•----•--•-DESCRIPTION------------•-------UNIT PRICE- assumes no� auti+orrzes ary otf�er person c,
� � 1 1 5123F�S NJB 119.99 119.99 assume far it any liabi�iry in connection ia�rth t+,e
# 1 1 513297 HUB 106.99 106.99 sa/e of fhis iterrvkems.
#f 1 2 20555R16 TIRE 146.00 292.00
BRID�ESTONE EL400 TURANZA
# 1 2 WHEELKEY RECON I�AiEEL � # 1 TOTAL PARTS� 896.98 '�' '
JOB # 1 TOTAL LABOR & PARTS 1312.98
. . .
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PERFORM ALIfNMENT. . � ��
COMPLETED ALIGNMENT.
.
ARTS------QTY---FP-NUMBER---•--•--------�SCRIPTION•-•-•--""�"#' 2 TOTAL PARTS 0.00 � �
. . .
� .. . .
JOB # 2 TOTAL LABOR & PARTS 101.76 • ' = '' •
. . : .
•--•-•----•- + �
------- -----•- ----•-•---------•----
STiMATE------------------•------------- - -
USTOMER HEREBY ACKNOWLEDGES RECEIVIN6
ORIGINAL ESTIMATE OF Si479.95 ( TAX) � How satisfied are you with
OTALS-----....--•--------••----._...--•--•--- --•------------------------------- LUTHER NISSAN-KIA?
� �q�{ [ ] CHECK # [ � VISA/MC TOTAL LABOR.... 517.76
TOTAL PARTS.... 896.98 Fxc�i.�erar � �
] ACCOUNTS RECEIVABLE C 7 �RICAN EXPRESS TOTAL SUBLET... 0.00
TOTAL G.0.6.... 0.00 ❑ ❑
] DISCOVEic C 1 OTMcn TOTAL MIS�, CN6. �-��
TOTAI MISC DISC 0.00
TOTAL TAX...... 63.91 If you're not completely satisfied...
WE WANTTO KNOW ABOU7 IT'.
TOTAL INVOICE$ 1478.65
HANKS FOR VISITING WITH US TODAY. PLEASE STOP IN AGAIN! ALL PARTS N�W�F31GlNFaI_
EQUIPMEPJT UNLESS
OTHERWISE SPECIFIEL�
THANK-YOU
� t�, ac�� � u 5�--�-,�� �'s
G��/J ' U CASH FOR YOUR USED VENICLE
� � Your car couid be worth more
�� "1 �� i �� than you think!And we'll buy it � t� ',�
.r,� � � �' (even if you don't buy from us)! �
F We'll quote ANY vehicle,
f • regardiess ot r,o�di8an.!f ycu
�_ accept,you'll walk away with the cash.You'll
�� never find a faster,simpier or safer way to sel�
your car.Visit our Saies Department for your
no-obligation appraisal or learn more at
Iutherauto.com
PAGE 1 OF 1 CUSTOMER COPY [ END OF INVOICE ] 09:32am �FXCLUDES SALVAGED VEHICLES