Johnson, Margaret RECEi���
MAY 12 �8��
NOTICE OF CLAIM FORM to the City of Saint Paul, Mi�p�� I Y C
Minnesota State Stancte 466.05 states t{uit"...every person...who claims damages from any mL�nicipality...shall caus`o be presented�t�Ae" `
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 l���r'�� Middle Initial�Last Name�t1;S�J�
Company or Business Name
Are You an Insurance Company? Yes/� If Yes,Claim Number?
Street Address S7� �2�� �T /V
City � t/ .i/' State ��V Zip Code��
Daytime Phone(�)��Cell Phone�)yy2- �g�v Evening Telephone( ) -
Date of Accidend Injury or Date Discovered�/ T/�� Time .J� .�i D am/�
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 res onsible for our damages.
, �� � �' c � e ,
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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 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
0 Other type of property damage—please specify
❑ Other type of injury—please specify
In order to process your claim Vou need to include copies 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.
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 pages of Claim Form
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims-nlease comulete this section
Were there witnesses to the incident? Yes No Unkno (circle)
Provide their names, addresses and telephone numbers:
Were the police or law enforcement called? Yes �N 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 diagram.
Please indicate the amo nt you are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction. ��� .�b
Vehicle Claims- lease com lete this section ❑ check box if this section does not a 1
Your Vehicle: Year�_Make 0� � Model � i�
License Plate Number� / � State rY� Color )�oc�i��i f[ �Ow n
Registered Owner < n
Driver of Vehicle Y`w. k r e t- �vk n5d r�
Area Damaged�� aKSt� �ont -��I��
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 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�.
l
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.
Submitting a false claim can result in prosecution. Date form was completed s/��/`f
Print the Name of the Person who Completed this Form: �V� !1r ��h
Signature of Person Making the Claim: �
Revised February 2011
Auto Rescue
, .,
feedback�inmansoutorescue,com
Date '. � I.C. �'� ;r , Motor Club
R ' i✓
P.O.Number ,r� , Name
t C
Member Number Phone . ' -. `� �'. :�"'�
� �.� ._ _-
Address - ����_�r C�h, - �`�`
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Locatlon Setvice ir�rr�af(on
Apt.I Business Building# Apt.# Gate Code
location Notes . ` �" f t
--....__ _. —_.__._.__ .' __...__
Call Time AM ETA Start AM Finish AM
PM PM PM
❑ Lock Out ❑ Jump Start ❑ Fuel ;;�Tire Change ❑ Tire Air ❑ GOA/NSR
v im4�, —_.___ --�
Year,Ivtake.Mod�ts � 3'`���' � i�_--;,��. Color LP# '�'��,� � ; State
, . , �' .
-- , � _. _
f , <- _
� � f y ! � ' dometer
, .
4
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,
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� y�,.�� y �__. i�� �� � i .. �
LOCkout R61Oaee SeCtion-Condili0n of Doa a u
Passenger poor
❑ Previously attempted opening by another party—Damage to Door/Doorframe Driver poor
Passengerpoor
❑ Worn/Damaged weather stripping —Window Broken !Scratched— T+nt Scratched Driver poor
Passenger poor
❑ Non Functioning Door handle/Door lock—Missing Door Handle/Lock Driver poor
. ` 'Nates
`�t t►�ve requested that my vehide be unlocked using lockout tools and/or keys. I understand that there is a possibility of
damage to the door,door frame, weather stripping, locking mechanism,glass,or air bags when using these tools and thereby
release the person(sj and/or company of all responsibility,both civil and eriminal, in a court of law. I will accept full responsibility I
should an damage occur. Initial: __—
Genernl VaMcla Con�tion -----
---._,. . ___ ___------ _... `
!
Jump Start: ❑ Battery cracked /Broken ❑ Cables and/or Clamps! Loose/Corroded/Broken/ Missing !
— ---
��.,
Tire Change: � Vehicle/ Rim Damaged ❑ Missing/Damaged Lug Nuts ❑_Missing J Dam�d Studs ,
- ----.... _ --- �-
— ___._ .. -- -- -- ,
Customer understands that the spare tire is designed to get the vehicle to a tire repair facility,a�soon as
ossible, and�the wheel fasteners(lugs)should be ieiorqued before driving more than 40 mile�s. /nitial:
�';?�:�� �
--- ---- — _„t�
Fuel Delivery: ❑ Fuel Door Missing/Broken ❑ Fue1 Cap Missing / Damaged ,,
Notes
�_�__� GOA/NSR
t G� OA/NSR Authorized by: Reason: I
__._ . _... ___. __....__....
Method Of Pa mertt for Retail Non Motor Club)calls �
Cash Visa MC AMEX Discover DL#: ST
_ _
—--
GG#� _ Exp� APProval# �
---•--v=—�. ---_.__--- i
�` Authorized S�anafure .. I�1 F`�.u�F,�?•�v�'� , _T,� ` ;%' t _....- —,� i
, .. __ ,� --- �
- I��'�"adthe opportunity to itTSp�ct my vehicie and have fczund-it"fo be in good working order, Gas(+) _�
� and tfiaf�no dam2ge-has occurred td`th�v�hicl�inciuding doors, door frames, paint,glass, � Sub Total(_) !
window tint, rims, lug nuts/studs, body,or underbody as a result of the sernce. — --a
! also ar,knewledge that a!I sq�ipment such�s;acks, I«g vv�enches, lug nut k.eys; and sper,iai �— �
� tools belonging tv me or the vehicle h9ve been returned '+n good working order. � Customer Pay(-) ;
�� Inirial:. r¢1 --- ---- --- �
, k �-� ------=- --- -- ---- -1
� Thank ou for usin Auto Reseue i �r,�aice Amount{_) _ J
;
- -------------- �-- —�--------- -----------
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�. �.� �; �_ � � �
6 03280n 236704 AutoNationO=
AN FORD WHITE BERR LAKE
1493 EAST COUNTY ROAD E
WNITEBEAR LAKE� MN 55110 *I�j�ICE* AutoNation Ford White Bear Lake
651-984-7231 ;pN 1 493 EAST CO U NTY ROAD E
WWW.AUTONATION.COM
DUPLICATE 1 WHITE BEAR LAKE, MN 55110
Tenn IU: 008 Ref u: 023 PAGE 1 PHONE (651) 484-7231
�NT: 651-730-9484
5�1� LL: 651-442-8086 SERVICE ADVISOR: 2363 TIMOTHY NIPP
MAKFIMOD�L: ,:: V1N : ; LECEf�SE MILERG�!N/::L}UT ;: TAG::: :::
XXaXXXXXXXXX5109
VISR EntrY Method; Swi�ed ESCAPE 1FMCU9J92DUD38724 724KFJ 13774/13774 1TRGW
�RR.EXP.. PRt�1VItS€D ::: P(?Nf3. >:RATE ; PAYMENT? . fNV.:DA7E
;
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05/06/14 13,29.4i
Inv#; 000023 Rppr Code; 466962 2 0. o0 06MAY14 Q CASH 06MAY14
iER�Y: OPTIONS: SOLD-STK:DUD38724 DLR:44A121
Rpprvd; Online Batch�� iZ�0�1 ENG:2 . 0_Liter TRN:A
Cust Ref p:236704 06MAY14
lotal;
$ 271,46 HOURS LIST NET TOTAL
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Customer Copv ; ' ' <:. .. ,:
>_
" � :`.� , Q
IOR: 0 . 00 OTHER: 0 . 00 TOTAL LINE A: 0 . 00
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,; _.. ;..
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�, �-,����i r,�v,� tsr�..,r�1v�... TIRE-RETIGHTEN AFTERMARKET WHEELS AFTER 100 MILES
,
90:�2 154�4��Q�Q�: C�3NTIPR�;�C3NTA��' H: 1�T;ED
MBV1 MOUNT AND BALANCE 1 TIRE-RETIGHTEN
AFT��Z�RK.ET WHEET�S >A�'TER �43� 11��L�5 ' ;; ;
-. ,.. ; ,.
2153 CFQ 17. 50 17.50
� 90{J�'*:1548<94�*�:QF�� �235j:45�2�.€3 <:2Q� :�� ' :�$4 �5 1$4 9�
1 DISP*FEE* TIRE DISPOSAL 2 . 50 2 .50 2 . 50
P�T�: ��7 �:� �;1�BOR :> �,7 5:�... ��'HER :: � 9fl Tt�TAL; LIN� B, �C1$ �5
, , , , 13774 MOUNTED AND BALANCED 1 NEW RF TIRE "
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_.;:: ... ; ,.
C ENTER DOT CODES 1. 2 . 3 ._�_4
DE�T� �'NTER DOT Cf�DES �. ::
2 . 3 . 4 .
' ' �15:3 : `: . . .:.:: . {3; [S 0 0.:0 0
>:
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PARTS: 0. 00 LABOR;: 0,. 00 OTHER: 0 . 00 TOTAL LINE C 0 . 00
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i��:i i s 3-�::��� :i�����::�T-R�'�{)�.� :: , . �: �� '�� � � �� � ` ' �� .. .. ... .. ... ..
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. . . . . . . :. �:
Ct3STUMER 1?A� SH�3P �'uUPPLI:ES F'ak�. RE.P�IR QRDER � ;��
SERVICE HOURS QUICKLANE HOURS STATEMENT OF DISCLAIMER ��SCREpTION TDTkES ;
The factory warranty constitutes all of the LABOR AMOUNT 17 rj�
MON.-THUR. MON.-THUR. warrenties with respecc to the sale of this
7:00 A.M. -7:00 P.M. 7:00 A.M. -7:00 P.M. item�items. The Seller hereby expressly PARTS AMOUNT 1 7 .45
FRIDAY FRIDAY disclaims all warranties either express or
implied, including any implied warranty of GAS,OIL,LUBE Q . ��
7:00 A.M. -6:00 P.M. 7:00 A.M. -6:00 P.M. merchantability or fitness for a particular
SATURDAY purpose.Seller neither assumes nor authorizes SUBLET AMOUNT Q . �Q
7:00 A.M.-4'OO P.M. any oTher person to assume for it any liability MISC.CHARGES 3 . 15
• in connection with the sale of this item/items.
BODY SHOP HOURS PARTS HOURS ALL PARTS NEW ORIGINAL EQUIPMENT TOTAL CHARGES ZOH . ZO
. UNLESS OTHERWISE SPECIFIED LESS INSURANCE O .O O
MON. -FRI. MON. -FRI. u-usEO R-REBUILT
7:30 A.M. -6:00 P.M. 7:00 A.M.-6:00 P.M. v-Recvc�EO C-RECONDITIONED SALES TAX
SATURDAY CUSTOMER SIGNATURE PLEASE PAY
7:30 A.M. -4:00 P.M. X THIS AMOUNT ��� ��; ,;
CUSTOMER COPY ���G�(�lf�i Zld(GI