Thill, Corinne ��c�iv�o �
MAY282014 �( a � � � �
CITY C� R
This claim form is being returned without havmg�b'�8�et up as a claim for the following
reasons:
Failure to provide a written description as to what happened and why a claim form
was being submitted(page one).
� Failure to provide the proper and required documentation (page one).
Failure to provide a date of accident or injury(page one).
Failure to indicate the amount of compensation being sought (page two).
Failure to provide information about the vehicle involved (page two).
Failure to provide information about the injury claimed(page two).
Failure to sign the claim form (page two).
Failure to print the name of the person who completed the claim form (page two). ,
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�Other:
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Please return the completed claim f to: II
Office of the City Clerk
City of Saint Paul
15 W. Kellogg Blvd.
310 City Hall
Saint Paul, MN 55102
If you do not return the completed claim form with the appropriate documentation or
information completed, then a claim file will NOT be established and an investigation
WILL NOT be done. In other words,NO FURTHER ACTION will be taken until the
information requested is provided by you.
Please remember that it is a crime to submit a claim form or to pursue compensation
falsely or under false circumstances.
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MAY 2810i� l����I�I�D
. C�TY CLERK �1AY 14 2014
' NOTICE OF CLAIM FORM to the City of Saint Paul, 1�i�5@��K
Minnesota State Stanue 466.05 states thal "...ei�ery person...wha claims darnages fi•om am�mtmicipality...shall cnuse to be presented to die
governing/�odv of the municipality within 180 days after the nlleged loss or injury_ is discovered�nolice stating the�ime,plac•e,nnd
circurnsta��ces thereof,and�he ai�iount of conapensatio�l 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 (�_��1�E''_ Middle Initial�Last Name����1
�ompany or�u�iness Itiame— __ _ - ,, a v �-TZVi�
Are You an Insurance Company? Yes/Qo If Yes,Claim Number?
Street Address (����' ,���„�
City�2 A tJ State Y"\t� Zip Cod�;,-�i�____I ��
Daytime Phone��33f 3�e11 Phone��-d�v� I Evening Telephone( ) -
Date of Accidend Injury or Date Discovered l ' � ��' 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/ r res onsible for your dama es. C n
OQC�'
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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 wac 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 you 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; ar 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—Plea complete and return both pages of Claim Form
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. 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 l�To Unknown (circle)
Provide their names, addresses and telephone numbers:
Were the police or law enforcement called? Yes No Unknown (circle)
If yes, what department or agency? Case#or report#
Where did the accident or injury take place7 Provide street address,cross street, intersection, name of park or facility,
� closest landmark,etc. Please be as deta�led� possible. If necess , attach a diagram.
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Please indicate the amount you e seeking i compens�ation or what you would like the City to do to resolve this claim
to your satisfaction. �,,'�j���
Vehicle Claims— lease com lete this section ❑ check box if this section does not a 1
Your Vehicle: Year,�_Make Model °..5
License Plate Number StateM Color V��
Registered Owner
Driver of Vehicl
Area Damaged "e--
Ciry Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name) ����� � � `1��t�±}
Area Damaged .
Iniurv Claims Qlease complete this section heck box if this section does not applv
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 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 ca�z result in prosecution. Date form was completed 5 �a � ��
Print the Name of the Person who Comple d t is �
Signature of Person Making the Clai •
Revised February 2011
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. J =M COOPERS T=RE � AUTO STORES �,'Q ''
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• OWNED AND OPERATED BY A PROUD GOODYEAR INDEPENDENT DEALER �r I �:
* AN INDEPENDENT DEALER *, 1340 DUCKWOOD DRIVE �'�'��tFtr`�r�f� 1 ;'
EAGAN, MN 55123 � ! �; �
(651)454-7100 GOOD�YEAR � ��
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FEDERAL TAX ID# 416282673 �DUNLOP �
NONE@NONE.COM ' � �
� KELLYI�STIRES '��'r''�,;
� =NVO =G E 04/23/14 04/23/14 '� �
�. : T— Z'1 7Z34 04 :56 PM 05:24 PM '�° �i
TERR: 7367 :!;;i';'�
PAGE: Ol NONSIG: 176747 i >� ��'"
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BILL TO: DAN & CORINNE THILL � •, I �: ; :
' 662 BRIDLE RIDGE RD ; ; �I !' '; ,
! � EAGAN, NIIJ 5 512 3 ` jl i� I � ,
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' � PHONE 1. . . . . . . (651)452-3407 EXT. VEH YEAR/MAKE. 03 LEXUS ' 'I�j ;;' =
PHONE 2 . . . . . . . (651) 231-2059 EXT. VEHICLE MODEL. ES 300 „ �
i DATE REQUESTED 04/23/14 VEHICLE COLOR. NAVY
r TIME REQUESTED LICENSE/STATE. UYU323 / MN . � :I'' �
RETURN :PARTS. . NO ODOMETR IN/OUT 131214 / 131214 ; !�''
SALESMI-1N. . . . . . 034 / 034 VEHICLE INFO. . 3 .0 i �'',�!
VEHICLE ID #. . JTHBF30G235040544 PRIOR INVOICE. 213875 j �� �l
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ACCOUNT # COB TC CUST# TYPE/STATE AUTHORIZATION CREDIT CARD N0. ','�. � .
736700053 R O1 01187 0 MN 02309Q NDC 8594 • ,, �
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SLSM TECH PRODUCT CODE BC QTY DESCRIPTION PARTS lBR/EXCISE IINE TOTAL!
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034 413-499-329-0 R 1 P215/60R16 94V SL ASSUR COMTRD TOURING 132.07 .DO 132��� ij"
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' 413-622-110-0 QTY. 1 N0. PJXBJ,l1R4913 ,,,� ;,
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' 034 025 041-263 R 1 NEW VALVE STEM 2.75 .DO 2f� ';i
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034 025 044-263 R 1 WHEEL BALANCE — COMPUTER SPIN .00 1Z.50 12:�s 'i.
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034 034 092-701 R 1 DECLINED ROAD HAZARD PROTECTION AUTO .00 .00 ' :d !�
I, . 034 034 093-101 R 1 WASTE TIRE DISPOSAL fEE .00 2.50 ��:�i ' '
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THANK YOU FOR YOUR BUSINESS, WE REALLY APPRECIATE IT! ED. PETE & JOE. ' i � `
WE RECOMMEND AN ALIGNMENT CHECK WITH [V[RY NEW TIRE PURCHASE DRIVE SAFELY & BUCKLE UP! � ;!; � i;
� WE ARE A FULL SERVICE REPAIR FACILITY. PLEASE V IS I T U S O N T H E W E B A T W W W.J I M C O O P E R S.C O M � ;� �+u� ,,
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I UNDERSTAND THAT ALL CUSTOM WHEEL LUG NUTS MUST BE RE-TORQUED AFTER 25 MIIES AND CFiECKED PERIODICALLV. !'li �
si gnature ';'� .�
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PARTS TOTAL. ....... 134.8�i� 'I
LABOR TOTAL. ....... 15.0�j�I� ; ; '
1 - CHARGED AMOUNT -159.43 SUB TOTAL. ......... 149;82�;�i !'I.
, X--------------------------------- TAXABLE AMOUNT 134.82 SALES TAX.. ......... 9 61 i �
CUSTOMER AUTHORIZATION FOR TOTAL =N V O =C E TOTA t_ =�'� S 9 - 4�S I i I�i�,l
:° �TREAD L/F... .. 11/32 TREAD R/F..... 7/32 TREAD R/R. .... 7/32 TREAD UR.. .. . : 7ifi2'i
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� HAVE A QUESTION OR PROBLEM� ' i�'
Pkase lell our store manager.W e vatue your opin'ron as much as your � i i .
business.Should you�eed additional assislance,eall our �
CUSTOMER ASSISTANCE LINE 1-800-321-2136 I��
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