Youso, Andrew ������/�Ca
JUN 16 2014
NOTICJC UF CLAIM FORM to the City of Saint Paul��rx�����
Minnesotu State Stattrte 4�6b.�5 states that "_..every persvn._.wFw clain�s dttmages fran:m�y municipalitv...shall eause ta be presented tc�the
goi�erning body of Zhe muxieipctlity within J8D dcrys after tfre alleged loss or injttrv is discovered a notice stntrng tl�e time,place,and
circu��rstances thereof,and the arnnunt of compensation or other relief demanded"
Please complete this form in its entirety by clearly typing or printing your answer to each question. Yf more space is
needed,attach additionai sheets. Please note that you wilt not be contacted by telephane to clarify answers,so provide as
much infoz-mation as necessary to explain your etaim,and the amount of compensation being requesied. You will receive a
written acknawledgement once yowr form is received. The process can take up to ten weeks or longer depending on the
nature of your ciaim. This form must be signed,and both pages completed. If something daes not apply,wr'tte`N/A'.
SEND COMPLET�D FORM AND OTHER D4CUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVA, 314 CITY HALL, SAINT PAUL, MN 55102
\ �
First Name ��C�`(���_ Midd�e Tnitial�Last Name �U_S b
Company or Business Name
Are You an Insurance Company? Yes/(�a� If Yes,CIaiEZn Number?
U
5treet Address �'��� � ��'��/1 �i C,11,.9 �;"� ,
Czty ��,Q��'li�11i`�� State�� .�Zip Code sS�l 2
Daytime Phone (� 3�- St�T3 Cell Phone(��J ��Evening TeIephone( ) -
Date of AccidentJ Injury or Date Discovered � Time��am/�m
Please state, in detail, what occurred (happened),and why you are submitting a claim.Please indicate why r how you
feel the C� of Saint Paul or iis ernployees e involved and/or res onsible for your damages_ W0.S
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Please check the box(es)that most closely regresent the reason for completing this form:
❑ My vehicle was damaged in an acczdent ❑ My vehicle was da�naged duiing a tow
�My vehiele was damaged by a pothole or condition'of the street ❑My vehicle was daxnaged by a plow
❑ My vehicle was wrongfuiIy towed and/or ticketed ❑ I was injured on City property
O Other type of property damage--ptease specify
❑ Other type of injury—ple�zse specify
In order to process your claim vmu need to include copies of all apnIicable documents.
For the claims types listed below, please be sure to incIUde the documents indicated or it will delay the handling of
your claim. Documents WILL NOT be retumed 1nd become the property of the City. You are encouraged to keep a
copy for yourself before submittzng 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 andlor recei�ts for the repairs
O Towing claims: legible copies of any ticket issued and a copy of the impound lot receipt
4 Other property damaae claims: two repair estirnates if the damage exceeds�500.00; or the actual bills
and/or receipts for the repairs; detaited list of damaged items
O Injury claims:medical bills,receipts
O Photographs are always welcome to document and support your ctaim but will not be returned_
Page 1 of 2—Please comptete and return both pages of CIaim Form
Failure to complete and return 6oth pages will result in delay im the handling of your claim.
AII Claims—please complete this section �
Were there witnesses to the incident? '��Ce�. No Unkn wn {cixcle)
Provide their narnes, addresses and telephone�i ers: � � � � �iC%W G'r
1 s � �S -
Were the police or law en�orcement called? Yes No Unknown (circte)
If yes, what department or agency? Case#or report#
Where did the accident or injury take place? Provide street address,cross street,intersection,narne of par or facility,
clasest Iandmarl:,etc. Ple se be as detailed as possible. If necessary,attach a diagram. �.A/ i n�Cl� �f'
� � ��W�1 � U�e-� A�v-e_ ja�� ,l ,.� �
Please indicate the amovnt you are seeking i o pe�sation or what yo woald like the City to do to resolve this claim
to youz satisfaction. 1 Jo ,�.a_ ��'kd,. ,�1�t�(�SA-��� �b/` c1iiV►'tt�tA�41 r -�-�Cr.��1�_
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Vehicle Claims— tease conn lete thas sectaon ❑check box if this section dces not a 1
Your Vehicle: Year �1 Make Model �l. �
License Plate Number State Ml1 Color v '�
Registered Owner �'�
Driver of Vehicle
Axea Damaged � (.�
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle (City Emptoyee's Name)
Area Daznaged
Tn�urv Claims--please complete this sectiont �check box if this section does nOt app1Y
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? (grovide date(s))
Name of MedicaI Provider(s):
Address Telephone
Di�i you miss wark as a resuIt of your injury? Yes No
When did you zniss work? (provide date(s)}
Name of your Eznployer:
Address Telephone
❑ Chect�here if you are attaching more pages to this ctaim form. Number of additionaI pages � �.j
By signing this fornz,you are stating that alt in,f�rmation you have provided is true and correct to the best
of your knowledge. U�xsigned forms will not be Jprocessed. �
Submitting a false claim can result in prosecution. Date form was complet�d �
Print the Name of the Person who Comp eted t Form: � �
Signature of Person Making the Claim:
Revised hebraary 201 1
5✓1/2014 Claim Surrxnary
r ��'�Oa�4� AAvService Center� Loa Out
� � Policy Period:01/04/2014-07/04/2014 � Policy Number:4314019128
� /�UtO�ICy Claim Number:0478500190101016 � Claim Date:04i26/2014 ( Claim Type:Pottiole
IClaims Home CE��rta lnfo I Vehicle Bnspectian& Repa's� I DocumenYs� Photos I Yo�r Injury Info I ��ntact Info I
Claim Summary
Your next step is to schedule a vehicle inspection so we can estimate the damage.
Claim Details � F�Q�
Claim Number: 0478500190101016 �`� How can I find out the status
`�. � of m�clai m.
Andrew M Youso � .n,�
Your Name: �,�'�"'U How do I cancel this claim?
Your Claim Role: Insured,Owner,Report�r � � � How do I find my coveraae
04/26/2014 ' �� �S`" " and deductible for my claim?
Incident Date: � ��
�( S�� See More FAQs
Incident Location: MN �
Re orted Date: 04/26/2014
P Resourcp Center
Reported by: Andrew M Youso
About the Claims Process
Type of Claim: Pothole
How an Accident Affects My
Your Reported Vehicle Damage Rate
Insurance Terms
Your Vehicle: Private Passenger Vehicle,2007 MERC
MONTEGO Reporting a Claim Online
Damage: On File ,
About GE�O Auto Repair
X�ress0 '
Schedule Inspectic � ^ I
Feedback
People Involved
2007 MERC MONTEGO ',
Insured,Owner,Reporter Andrew M Youso
Please send us a messaae if you need to make any corrections to this information.
You can�load documents and photos directly to your claim to share them with GEICO.
Leaal
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� ' Arden Hills Tire and Service II IIIIIIIIII�IIIIIIIII IIIIIIII
�� 3757 N Lexington Ave, Arden Hills, Mn 55126 RO#: 20045257
, Phone: 651-490-9271 Estimate
Email: ardenhillstireservice a�comcast.net Printed: 05/02/2014 5:28 pm
Page: 1
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CUStO�YI@�COnC@�fl: CUSTOMER REQUEST - REPAIR RIM AND REPLACE TIRE.
DIBgflOSIS: REPAIR WHEEI�
R@CO(IIIYI@11�I8tlOfl: REPLACE TIRE AND REPAIR TIRE
DOT#B9YR DYXX-1414-X1
Labor: Description Extended
MOUNT, BALANCE & INSTALL TIRE 28.60
Labor Sub Total: 28.60
Parts: Part Num Cond Description Price Ea. Qty Extended
2255518 N 255/SSR18 MICH BW DEFENDER 98T 90K - 194.08 1.00 194.08
060082313 - 82313
WHEEL REPAIR N WHEEL REPAIR 215.00 1.00 215.00
WHEEL WEIGHTS N WHEEL WEIGHTS 0.00 1.00 0.00
Parts Sub Total: 409.os
Misc: Description Sold Price Qty Extended
TIRE DISPOSAL 1 TIRE 3.75 1.00 3.75
SHOP SUPPLIES AND ENVIRONMENTAL FEES 5.50
Misc Sub Total: 9.2s
Job Sub Total: 446.9�
RO Not Yet Finalized
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