Kyllonen �C�����V
M�Y 09 ZQ1�
NOTICE OF CLAIM FORM to the City of Saint Paul, Minn�s�aT�t CLE��C
Minnesota State Statute 466.05 states thnt "...every person...who claims dnmages.From nny municipalit��...shnll cnuse to be presented to the
governing hody qf the municipnlity withrn IRO dnys nfter the nlleged loss or injury is discovered n notice,statrng the time,pince,nnd
circ��m,stnnces thereqf,nnd the amount of compensntion or other relief demnnded."
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 �C�-rl�C�'� Middle Initial � Last Name �`/ � E C��
Company or Business Name
Are You an Insurance Company? Yes/ To� If Yes, Claim Number?
Street Address �3$� �e-►�����-`S '��� .�U2.
City �'• ���.u i State �'1 f�; _ Zip Code S S l�5
Daytime Phone(���-�Cell Phone(��a)�-�Evening Telephone(�5f ) �y�-�
Date of Accidend Injury or Date Discovered 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 damages_
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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
C�7'My vehicle was damaged by a pothole or condition o�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
In order to process your claim vou need to include copies of all apulicable documents.
For the claims types listed below,p]ease 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 aze 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 Unknown (circle)
Provide their names, addresses and telephone numbers:
Were the police or law enforcement called? Yes � 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 ar facility,
closest landmark,etc. Please be as detailed as possible. If necessary, attach a diagram.
�4a��►�r►z I�v�e �<<<�t s�,�.�-t,. ��� i���J-�h�.(� A��
Please indicate the amount you are seeking in compensatjon or what you would like the City to do to resolve this claim
to your satisfaction: � " � ' �� �l � - c ��
��o��n/ �� ,,� .
Vehicle Claims—please complete this section ❑ check box if this section does not anvlv
Your Vehicle: Year �i�j',.?� Make iY1�2.��_ Mode]
License Plate Number� �.i��.55 State i(h Color S� V�✓
RegisteredOwner ���1 �'V�v..r�tS ���.,�c�1� K� �(���zr�
Driver of Vehicle � �
Area Damaged�,�(t V�i'� �r'V% �-t� 't"��
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
IniurY Claims—please comalete this section check box if this section does not avvlv
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 Medica] 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
�heck 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.
Submitting a false claim can result in prosecution. Date form was completed��l�,l� �
Print the Name of the Person who Completed this Form: `�� Y°�� ��l �.�Y1�r�
-��S+r,�� � � �
Signature of Person Making the Claim:` �
Revised February 2011
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��,:�- -,��c�� >«� `�� .�� �� .�ti -��.�`�' ,,�,�``7'`•'� �"o�°. LIMITED WARRANTIES
�° �� � Discoant Tire and America's Tire Stores
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•� CERT/F/CATE w ELIGIBILITY-These Limited parranties apply tgo all own�of the tire using
i r� it in nontommercial service,exce t for the Milea e Warran which is limited
,�,,`� ' r to the original pu�chaser.
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�,� FO R R E PA I R, R E F U N D O R R E P LAC E M E NT R��� 'pp�E A CLAIM-Present your tire(s)and original sales invoice to any
;; �pti Discount Tire or America's Tire Store.To locate a store you may call 1{SSS)774-
y,.�F�....
e, For a fee collected at the time of the original tire purchase or for a fee collected to subject � �.�''.� 6560,or visit the Discount Tire web site at www.discounttire.com.The vehicle
other tires to the terms of this certificare, Discount Tire or America's Tire stores will � on which the tire was used must be avaiLzble for inspection.You will be asked
refund the purchase price and the sales taac,if any,on any tire covered in the event of a �,.�,'��".�� to complece the customer portion of the adjustment claim form.
� failure due to workmanship and materials or a non-repairable road hazard for the service - f�
�,.e•� of the original tread down to 3/32 inch remaining, or 3 years from date of purchase, b1,� WARRANI'T COVERAGE
'�"� whichever occurs first.Upon refund or credit of sales taac,customer hereby acknowledges s"� New Tires-Workmaaship and Materials-If our examination shows
' � by actual signature or electronic signature capture such credit or refund.This additional +�;� that a passenger,SiJV,or Gght truck tire covered by this warranty has become
�'�;��',�.i_`' acknowledgement satisfies a technical requirement in the sales taac statutes and/or __'°:`✓h� unserviceable due to a workcnanship or materials defect during the service
r; regulations for many jurisdictions that a signed receipt must be obtained upon the reCund , '�t down to 3/3z of an inch,it will be replaced on a pro nta tread weaz basis.
y'�v;s or credit of sales[ases.At the election of the purchaser,we will sell a replacement tire %'�'�
'`"' New Tlres-Road Hazard(if applicable)-If our examination shows that
�:" to the purchaser at the original price paid for the damaged tire,plus the required sales '.
r�Q�;� taac.In the event the covered tire is discontinued or unavailable,a tire of similar value will ' �2� a passenger,SW,or light truck[ire covered by this warranry has become
��„3 <;� unserviceable due to a normal road hazazd(i.e.,non-repairable puncture,cut,
r� be substimted. �,.� snag,bnrise,or impact break)during the service down to 3/32 of an inch,it
�' will be replaced on a pmrata uead wear basis.
if in our opinion,the tire can be safely repaired,we wID do so free of chazge.The cost of r¢
,✓�r,� this certificate is set forth on the receipt issued for the purchase of tire(s). �ti New Tires - Mileage Wartanty (if applicable) - In addition to the
���,� °'%qy;� warranties above, every mi:eage warranced passenger, SUV or light uvck
� �..-.- This certificate will be honored at any Discount Tir�or A�erica'�Tire stores.This certificate -v-'cti•< _�_��,�nte�ta t}re.arigin�-p�cf�asef.fer thc specified ttumber of mites--
does not cover damage cause�by eeHirirnr,van�sm;"chain damage,mechanical defeccs of uead weaz and against normal road hazards for the same mileage (if
of the vehicle or willful abuse.No other property damage or consequential dan�age of any applicable).If our exanunaUon shows that the tire covered by this warranty
kind is covered by this certificate. .�$ has wom down to its tread indicators before giving the specified number
' '�' of miles of noncommercial service on the passenger,SW or light truck on
�;� There will be additional charges to purchase a new certificate for a replacement tire and � 'a,l; which i[was installed,it will be replaced on a pro-rata mileage basis.
���!`'• [o balance a replacement tire. .�'�,,�>�'�
a'+,,'::��. � � A1'V/Tniler Tires - If our examination shows that a trailer or A7'V tire
' �y�� By redeeming this certificate,the customer relinquishes the right to any manufacturer's :��',`'r,.�;�� covered by this warranty has become unserviceable,other than by a road
'�;�r.-- wartanty that may apply,and Dixount Tire or America's Tire may claim for its own benefi[ �%Z±�� hazard,during the three year period following its date of purchase,it will
any such manufacturer's warranty. ;_;;,�,� be replaced based on a charge of 33�per yeaz or part thereof of the original
�� _ ,r�;�� purchase price.
� � • � • • -={:
�y�R -����i CAI.CUI.ATION OF REPI.ACEMENT CHARGES - Tires are replaced
4��.?� --• under these limited warranties with a comparably priced new tire at a pro-rata
�;y. d,��n'�'� cost to the customer.Tread weaz is pro-rated on the basis that the tire is worn
4 '�:•
. .
1��. Jr
�•.•.e out when the uead is worn down to 3/32 of an mch remaumi tread roove
, `�t,c � S S
,� D,�C O u N� -�'�r, dep[h or to the tread wear indicators on t'ues con[aining them.T�re replacemeat
�tg ; ��; cost is determined by multlplying the original cost of the eire by the percentage
��y�� ��
T 1 R E },;��, of tread used.For example,if the original aead was 11/32 of an inch,and the
i:{:'>- ..;�� tire has 5/32 of an inch of tread remaining at the time of replacement, the
r��� -"�'�'� replacemen[cost will be 75%of the original cost((11/32-5/32)/(11/323/32)
's- �1 x 100).The replacement cost for mileage warranted tires is prorated at a set
c. `.N�I
"�'.e . �%4�fjS} charge per 1,000 miles driven.F.E.T.and state taaces aze added to the replacement
"`: � cost Addidonal chazges for moundng and balaacing apply.
y ��"'���'�
�+ �i�i'���:, � 4 � ��'+� ��.P�I3�
��" �' ' �-3�+ `'''i�� ���� �� � ��`?s��� I1'EMS NOT CO�'ERED-These warranties do not cover:
�, � _ �}.._ , �
The cost of any tire includes any wheel weights used in the balancing of the tire. • Use in commercial service such as commercial truck racing,street
sweepers,off-the-highway taxi,limousine,or similar service(however
commercial service does not include use by the owner as transportation in
his/her reg[ilar trade or business);
T I PS TO I M P R O V E T I R E � Damage,destruction,or failure due to accident,fire,or vandalism;
• Irregular or premature tread wear caused by improper int]ation,
misalignment,imbalance of wheels,or wom out shock absorbers or brakes;
M1 L EAG E A N D SA F ETY • Damage or failure due to non-tire causes such as being run flat,mechanical
condiuon of the vehicle,cu[s from rims or chains,or any willful abuse;
• Problems related ro the appearance of the tire after the first 10%of weaz.
�ROTATE TIRES � REPLACE
every 6,000 to 8,000 miles or when worn-out tires when built•in wear bars OWNER'S DUTIES-It is the owner�s respons�biliry co:
necessary to equalize treadwear. appear aeross the tread surface. • See that the tires are operated at proper intlaUon,pressure ana ioaas;
�j�REBALANCE � REMEMBER TO RETURN ' Pay applicable taxes and dealer services such as mounting and balancing;
�I every other rotation to promote even � to any Discount Tire/America's Tire store ' Return the adjustable tire and complete the customer portion of the
tire wear and a smooth ride. for a tire inspection. ad�uscmenc cta�m torm.
DURA1'ION OF COVERAGE-These warranties expire three(3)years from
�MAINTAIN AIR PRESSURE � the date of purchase.
as recommended by the vehicle or tire
� CONDITTONS AND EXCLUSIONS - These limited warranties are the
manufacturer.Check your air pressure at least � � exclusive warranties of Discount Tire or America's T'ue stores,are in lieu of the
once each month when tires are cool. � warrannes oe ct,e man�acc�e�,and set foah the exclusive remedies available to
the Cve usev In the event that the cerms of an applicable manufacturer's wamanty
�MAINTAIN ALIGNMENT exceed the protection given under these warranaes,Discount Tire or America's
�� Tire stores will honor those terms.Discount Tire or America's Tire may claim
(Front&Rear)replace wom suspension parts. �'� I M � �' for its own benefit any such manufacturer's warrdnty.These limited wactanties
� � � ��,E�KS do nog provide�compensation for any consequential, special, incidental or
� PLEASE DO NOT USE � � contin ent dam es. Some States do not allow the exclusion or limitation of
incidental or consequential damages,so the above limitation or exclusion may
any"Fix-a-Flat°type produets. � � �'11 not apply to you.Tires presenced for a claim remain the properry of Discoun[
',AVES G,ps� Tire or America's Tire Stores.No representative or employee of Discount Tire or
�INSPECT S America's Tire Stores may enlazge or alter these warrai�ties.
� tires occasionalty for excessive wear,tfBBd CONSiJMER RIGHTS - These limited warranties
give you specific legal
or sidewall cuts,Of Othef ddm89B, rights,and you may also have other rights which vary from State to State.