Kyllonen, Sarah RECEIVED ��������
MAI� 2 7 2014 MAY 0 9 2�'1�
CITY CL��CE OF CLAIM FORM to the City of Saint Paul, Minn`�s�t C CLE��C
Minnesota State Statute 466.05 states thnt °...every person...who clarms dnmages from nny municipalit��...shall cnuse to be presented to the
governing body nf the municipnlit��within I80 day.r after the nlleged loss or injury is discnvered n notice stnting the time,pl�ce,nnd
circumstnnces thereqf,nnd the amoirnt nf cnmpensntion 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 additionat 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 �G�-�'C�'� Middle Initial J Last Name �`-1 6 t G�e�
Company or Business Name
Are You an Insurance Company? Yes/ To j If Yes,Claim Number?
Street Address �3$� ��r{����.� *�VC�t'�U�
City �� �<�u. i State ��')1�,' Zip Code s S `G 5
Daytime Phone (��- 7� Cell Phone(��a)�- Jr3�a Evening Telephone(�05� ) �O90- I�Y-3
Date of Accidend Injury or Date Discovered 3/0`��I�y Time f�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 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'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 praperty 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 d�nage 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 � � �n14
O Other property damage claims: two repair estimates if the damage exceeds $500.00;��e t al i'�1s
andJor 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 wimesses to the incident? Yes ' No Unknown (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 ossible. If necessary,attach a diagram.
�av��1�h�, {�'�� '���t Sc.�c.i�t,.. ��� iY'1� �h c:�(t A u�
Please indicate the amount you are seekin in compensat�on or what you would like the City to do to resolve this claim
to your s isfaction: " ?' � ' �� l � c ��
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Vehicle Ciaims—alease complete this section ❑check box if this section does not aanlv
Your Vehicle: Year �i�i �,�Make f��Z�� Model�
License Plate Number� �;G��S State�1'I Color S� V�✓
RegisteredOwner ���� �2✓v�[,t.r��5 �r�.,rc�ln (�� �t�:�1zn
Driver of Vehicle �
Area Damaged��(�V���; �V; �-t- "'["�2_.
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 anvlv
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
�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'� �
Print the Name of the Person who Completed this Form:�;rr'n� '�y t �G Y'►� ���.�_
A� �
Signature of Person Making the Claim: �t��.�+i�y�y=��-- � '
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Revised Februazy 2011
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���° `�� �:�r.;s• '�=�`�:ti� �'� _ . :."'��.v����`��.�'�e;:�•�;,, ��� ��'s, LIMI'I'ED WARRAIV'I'IES
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� ELIGIBILII'T-These Limited Warcanties apply to all owners of the tire using
f'd,'���- ��, �� it in noncommercial service,except for the Mileage Warra�ty which is limired
���a' ��R���� ��� v�"� to the original purchaser.
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`r�;:. FO R R E PA1 R, R E F U N D O R R E P LAC E M E NT � •�;�% TO MAICE A CLAIM-Present your tire(s)and original sales invoice to any
.,.. -�-{'v8�
�:-6 >�4j,�� Discount Tire or America's Tire Store.To locate a store you may call 1{888)774-
�? For a fee collected at the time of the original tire purchase or for a fee collected to subject 65G0,or visit the Discount T'ue web site at www.discounttire.com.The vehicle
other tires to the terms of this cet[ificate, Discount Tire or America's Tire stores will •< on which the tire was used must be available 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 complete the customer portion of the adjustment claim form.
i'' failure due to workmanship and materials or a non-repaitable road hazazd for the service ""
�k' of the original tread down to 3/32 inch remaining,or 3 years from date of purchase, '..fvy� R'�'i'1 COVERAGE
�'�' whichever occurs first.U on refund or credit of sales tas,customer hereb acknowled es �
P y g z New Tires-Workmanship and Materials-If our examination shows
� ; by acmal signature or electronic signature capture such credit or refund.This additional � .���+.�'��,q� that a passenger,SW,or light truck tire covered by this warranry has become
�y�_ ` acknowledgement satisFies a [echnical requirement in the sales tax statures and/or . �'r� unserviceable due to a workmanship or materials defect during the service
�;.� regulations for many jurisdictions that a signed receipt must be obtained upon the refund — �:�, down to 3/32 of an inch,it will be replaced on a pro rata tread weaz basis.
�;:i_ or credit of sales tases.At the election of the purchaser,we will sell a replacement tire �,. s;`;+.'
to the purchaser at the original price paid for the damaged tire,plus the required sales �. New Tires-Road Hazard(if applicable)-If our examination shows that
� ti - �,� a passenger,SLJV,or light truck tire covered by this watranry has become
�v.`.` tax.In the event the covered tire is discontinued or unavailable,a tire of similaz value will r,�� unserviceable due to a norntal road hazazd(i.e.,non-repairable puncmre,cut,
be substimted.
�,��4.� ;:�y snag,bruise,or impact break)during the service down to 3/32 of an inch,it
�•`.<` ` ff in our opinion,che tire can be safely repaired,we will do so free of chazge.The cost of will be replaced on a pro-rata tread wear basis.
��' this certificate is set forth on the receipt issued for the purchase of tire(s). �,\� New Tires - Mileage Warranty (if applicable) - In addition to the
�. This certificate will be honored at any Discount Tire orAmerica's Tire stores.This certificate �'�'''�!�) warranties above, every mi:eage wan�auted passenger, SUV or light truck
��' dces noc cover damage caused bgeeHi�ion;vandalism,chain damage,mechanical defeccs �d,�;;; tire is wx�rante&te theoriginal p�rchaser For the specified number of mlles
of tread weaz and against �ormal road hazards for the same mileage (if
of the vehicle or willfiil abuse.No other property damage or consequential damage of any applicable).If our exaeninadon shows that the tire covered by this warranty
'� kind is eovered b this certificate.
� Y .��i� has worn down to its tread indlcators before giving[he speclfied number
There will be additional charges to purchase a new certificate for a replacement tire and � of miles of noncommercial service on the passenger,SUV or light uvck on
i crtiM_ which it was installed,it wID be replaced on a pro-rata mileage basis.
�i to balance a replacement tire. �,
, By redeeming this certifica[e,the customer relinquishes the right to any manufacmrer s „ ATV/Trailer Tires - If our examination shows that a trailer or ATV tire
11�5� warranty that may apply,and Discount Tire or America's Tire may claim for its own benefit �y','���� covered by this wananty has become unserviceable,other than by a road
�� �.�i..,, hazatd,during the three year period following its date of pucchase,it will
= any such manufacturer's wamanty. _�,_.-;v, be replaced based on a charge of 33%per year or part thereof of the original
�, � y.
•_ t v��,f{w Purchase price.
� • � � � •
��:'+', f�j�i CALCULATION OF REPI.ACEMEIVT CHARGES - Tires aze replaced
4'P L��''� under these limited warranties with a com azabi nced new tire at a ro-rata
'� _��. P Y P� P
'rr : ' >'' cost to the customer.Tread weaz is pro-rated on the basis that the tire is wom
� D'��Q���� €��y out when the tread is worn down to 3/32 of an inch remaining tread groove
=�ti� depth or ro the tread wear indicators on t'ues containing them.Tire replacement
�,.- y�'�'y cost is determined by multiptying the ariginal cost of the tire by the percentage
� � t � � _�ti of tread used.For example,if the original tread was 11/32 of an inch,and the
�t�t�,. ,'�,'�,+''r� t've has 5/32 of an inch of tread remaining at the time of replacement, the
''� replacement cost will be 75%of the original cost((11/3z-5/32)/(11/323/32)
�.>, f'>',l;�� x 100).The replacement cost for mileage warranted tires is prorated at a set
� ' �'%kr�fr charge per 1,000 miles driven.F.B.T.aad state taxes are added to ihe replacement
,�� � ��,,, cos4 Additional charges for mounting and balancing apply.
�6v��.Y�r�.. � .,�'��y,P�.� y7tiM.�„� ♦fs �... P�+�y4����y 3F},
d�3 �
J - /' ��.� v�:f .� e'< !
'`��/ �� }�✓/ ITEMS NOT COVERED-These wartanties 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 transpottation in
his/her regular 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;
• inegulaz or premature tread weaz caused by improper inHation,
M I L EAG E A N D SA F ETY misalignment,imbalance of wheels,or wom out shock absorbers or brakes;
• Damage or failure due to non-tire causes such as being run Hat,mechanical
condition of the vehicle,wts from rims or chains,or any willfiil abuse;
�ROTATE TIRES �� REPLACE • P�oblems related to the appearance of the tire after the first 10%of weu.
every 6,000 to 8,000 miles or when worn-out tires when built-in wear bars OWNER'S DU1'IES-I[is[he owner's responsibiliry[o:
necessary to equalize treadwear, appear across the tread surface. • See that[he tires are opera[ed at proper inflation,pressure and loads;
REBALANCE � REMEMBER TO RETURN ' Pay applicable taxes and dealer services such as mounting and balancing;
every other rotation to promote even � to any Discount Tire/America's Tire store ' Return the adjus[able tire and complere the customer portion of the
tire wear and a smooth ride. for a tire inspection. adjuscmenc cia�m form.
DURATION OF COVERAGE-These wananties expire three<3)years hom
�MAINTAIN AIR PRESSURE ttie dace otp�rchase.
as recommended by the vehicle or tire
manufacturer.Check your air pressure at least � � CONDITIONS nrm ExeLUSioxs - �rnese tim�ced wamdnc�es are che
� exdusive warra��ties of Discount T've or Aenerica's Tire stores,are in lieu of the
once each month when tires are cool. warraacies oe cne manueacmrer,and set forth the exclusive remedies available ro
the tire user.In the event that the terms of an applicable manufacturer's warranry
�MAINTAIN ALIGNMENT exceed the protection given under these warranties,Discount Tire or America's
Tire stores will honor those rerms.Discount Tire or America's Tire may claun
�(Front&Rear)re lace wom sus ension arts. � ���������
P P p for its own benefit any such manufacturer's warranty.These limited wamanties
A'II� F' do not provide compensation for any consequential, special, incidental or
�Ij PLEASE DO NOT USE i � I contingent damages. Some States do not allow the exclusion or limitation of
V incidental or consequential damages,so the above limitation or exclusion may
any"Fix-a-Flat°type products. ������ ���1, not apply to you.T'ues presented for a claim remain the property of Discount
� , � � Tire or America's Tire Stores.No representative or employee of Discount Tire or
�� � � America's Tire Stores may enlarge or altec these warranties.
INSPECT
tires occasionalty for excessive wear,tread
CONSUMER RIGHTS - These limited wamanties give you specific legal
Of SICI2wflll CUtS,or other damage. rigncs,and you may also have other rights which vary from State to State.
� s`�� � �
This claim form is being returned without having been set 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).
Other: � 7 �t1! ����e- �� ���
`�`�-— .
Please return the completed claim form to:
Office of the City Clerk
City of Saint Paul
15 W. Kellogg Blvd.
310 City Hall
S aint P aul, MN 5 5102
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
��VILL I�,TOT be done. In other vvords,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.