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Jolliet, Josette JUN/24/2014/TUE 01 : 08 PM FAK No, RE(;E�\���2 JUN 2 4 2014 CITY CLERK �10T�CE OF CLAIM FORM to the Citq of Saint Paul,Minnesata Muenerota State Statute 466.05 states that°...every person..,who clalm.r�damages finm any mwriclpallty...shall cause to 6e presented ro tl+e governing body of the rnunici�wliry w�7hfn I80 days c{Jier rhe alleged loss or in�Lry Is discovered a notke stat�g rhe tbne,place,and crrcunurartces tf�er�o}and the anwwu ojcompensation or other r+elief demar�ded." Please completx tWs form In�bs eaHrexy M��Y�JT�uB ox P��S Your a�uswe.�M eacb�questlon. �anmre space is needed,attacb,additionn�sh�.. Pkpse note tbat you w�71 not be o��acted by telepLone tn cl�dr�'y aaswers,so provide es much information ae neccesear�to explain yoar clsfm,and the smoiunt of com�►ensation be4ng requested. Yon vn'il receive a v�rltte�u acb.-niowkdsextuemt o�ace youz foxnu is 1^e�ved. �he p�[ocess cen tske up to ten weeks or longer depe�ag om We nature of your claim. TLia form m�t be�ed,and both pages oom�deted. ff something does not a�P�Y,write`N/A'. SEND COMPI.ETED FORNI AND OTHER DOCUIV�NTS TO: C�TY CLERK, 1S WEST KELLOGG BLVD,310 CITY HALL,SAllVT PAUL,MN 55102 �ust Name Josette Middle Juitial��.ast Nam��e Jollief Coz�o�auy or Business Name Are You an Insurance Company? Yes/�o �f'�es,Qaim Number? S�eet Address 4833 ROy81 OakS Drive . cicy Minnetonka ssa�e MN z;�p coae 55343 Daytime�one 6( 1 .2j875_3502 C�l��hone 612 75�502 Evening Telephone(fi1�$Z,k,i,5.�,� Dato of Accident/Injury ar Daoe Discovered 3/20/2014 �7uoae 9:55 ;+foa/�ooi �lease state,iva detail,wlaat occurr�d(happened),and why you are submitting a claim.please indica�e why ox how you feeX the Ci�t�+o£Saim Panl rnc its employees are involved and/orresponsible for your d�mages. T�'1�S IS fl'1V SECOIId attempt m trying io submit a cla�m for the darnaqe done to mv vehicle Thursdav, March 20, 9014 at 9 55 m I�•�as dri��iaa Sn�th on (� Prio�ve a ,ac�nt to Fo�r�ea�onc A+ Flem achoal when i veered to miss onQs.g'�,r].t�thQl�#o end u r ng over another. Mv ftont L.EFT tire i_mr�ed"iat�l�[�,4p�Sim�l w►heel was damaged. In addition; mv steerina , „_ , ._ ____.�.�_ _,.:�,.E„ • � althoug � t 'f o - immediai�� �t.Paul. I have en�losed a�uote for rei�bursem�nt fo�r dA g�e�s incurred. lease check the bo�(es tha�t naost c osely ro�resent reason or c lehn �rm: ❑My vehi�c�e was damaged iva sn aceident O My vehicle was damaged duxin�a tow (�(My vebacle was damaged by a pothole or condition of the sh+eet O N�y vebdcXe was dama�ged by a��ow O My vebnic�e was wtna�gfully towed and/or t�eketed Q I was�uajw�ed om Gicy pxv�eriy [7 Othe�type of�ro�«ty dsmsge—please specify ❑Otb�ez ty�of injmy--please specify Xn ozder to pzocesa youz c�ai�oo y,�g,�eed to include copies of all a»ulicable doc.aments. For the claims types listed below,please be swre oo ivacl.nde t�docnnnents infficaud or it will delay rhe handling of your claim. Documents WJLL I�LQT be�etuz�d and beconne the Pr°pe�ty of tY►e Ciry. You are encouraged t,o keep a copy for yourself before submiqing your c�aiAa�o�om. O property damage claims bo a vebicle:two esdioo�ates�oz tb�e are�sirs to yonr ve6icle if tho damage exceeds $500.00:oz the actual b�,s aud/oz receiQts for thc repeirs O Towin�clai�oos:leg�bXe copites o�any ticktt issued snd a copY a�the iaopomid lot receipt O Other propezty da�oo�a8e clai000s-two repaiar esti�mates if the dsmage exceed�$500.00;or the actnal bills and/or receipts for the repairs;detailed�st o�danaaged ite�ons O Injary claims:�medi.cal bills,zeceiipts O Pb�4to�bs�e aXways weleome�o documeut and snpport yonr claim but wil��aot be zetiuned. Pa�e 1 of 2—Please c�omplete and rehirn both psges of Claim Form JUN/24/2014/TUE 01 : 08 PM FAX No. P, 003 Fa�urc to complete and return both pages wjll resnit in delay fin tb,e b►wadling o�yowr caai�oo. A11 C]��,nl�e complete this section Were there wimesses m ffie ineident7 Xes � U�uknow�a (cutcle) Pirovide ti�eir names,addresses and tele�b�rnoie uunabeXS, weze tb�e pouee oz law e�a£o�cenoent called? Yes I�6 Unlwown (circle) If yes,what department ar agency? Case#a�r report# Where did the accident ox ioajuty tak��lsoe? Provide street addcess,aross street,intersectiou,name of park or facility, elosest laadnnaxl,etc. Please be as de�taulcd as poss��ble. If ncccssary,$cr�a ai�►. Heading south on N, Prior AY��a�pnt to Four Seasons A+ Elem, Schoal �'lease iooid�icate the a�oaAUnt you axe seel�uug in compensation or what you would]ike the(:iry to do to resolve t�is c�aim co your saasfacaon Vehicle qafms please o��l�e t��,gn Q check box if this section does not apply Yonr Vehicle: Year 2010 Mak� Mazda 1VIode1 3 License Plate Number 5`t�te��1L Color Red Regisrered owmer Josette Jollief Driver of vehic�e Josette Jollief AlCea]7a�g�d�yP.,[�,�,�j�p frnnf firp�WI'1P_P_{,and �tPPring..�l�gl�ment_ City Vebdc�e: Yeaz Ma1:e Model License Plate Numb�,� State Color Drives of Vehicle(Gty Fmployee's Name) Area DaruagPcl, Tninrv� ' —plesse ea�pleic tL�s seetion [�check�ox i�f t�is section does not aonlv How wex-e yan ivajnzed? Wb,at part(s)o�your body were injured? Have you aought medical t[eat��at? Yes No Planning to Seek Treaanent(circle) When�d you rece,ive treaboae�at? (pzvv�de daLe(s)) Name af Mcdical P�mv�idex(s). Address Telephone Did you miss wozk as a zesn�t o�your injwry? Yes No Whea did yau miss work? (pro"ide da�(sp Name of your Employer: Address Te�PbO� �Check here if you are attacb,ing naome�ages to tbds�laim�mnm. N�ber of additional pages By sig�t�ng t3tis fornt,you rve stating that all i�tfor►nation you have provided ix hue atsd cori►ect to the best of your knowledge. Unsigned forms wiU not be processed. Submi[�ig a false claim ca►t result i�t prosecutiort. Date�orm was comple�ted r Print the Name oi the Pe�son w�o Completed thus Form: 0 Signatuce of Person Makiiiag the Claina• ' Rev�sed Feb�uaty 2011 1UN/24/2014/TUE 01 : 09 PM FAx No, P. 004 QUOTE TIR�S PWS SERVICE ADVISOR: 1345903 8453 JOINER WAY 01 SHE�BY 03/22/2014 EbEN PRAIRIE, MN. 55344-7636 952.944.0458 2010 MAZDA 3 I SpOR7 JOLLIEF, JOSETTE 4-1999 2.OL DOHC 4833 ROYAL OAKS DR LIC# 831 DBA MN VIN# HOPKINS, MN 55343-8755 IN 01/01/70 12:OOAM EST. MILEAGE 0 — ._.. ---�-� ---�- - -- . .... . Store# 24421 Q QUOTE —_...... _.._. . ___._ . .. . _.._.. __. ._...__.. . .—... ...— _. .. Article Extended Job DesCrlption______ _ _ ______ Number T# Qty _ Part Labor __ Price __ Total .. - ------- - -- BRIDGESTONE TIRE PACKAGE 166.95 144883 ECOPIA EP422 s�205/50R17 XL93V 65,000 144883 1 143.99 143.99 Mile Limited Warranty NEW TIRE WHEEL BALANCE PARTS 7018708 1 3.99 3_99 NEW TIRE WHEEt BALANCE LABOR 7018716 1 9.00 9.00 TI'MS VALVE SERVICE KIT LABOR 7008190 1 2.99 2.99 TPMS VALVE SERVICE KIT Generic 1 3.99 3.99 SCRAP TIRE RECYCLING CHARGE(1) 7075078 1 2.99 2.99 LOW PROFILE TIRE INSTALLATION 7006472 1 N/C N/C STANDARD ALIGNMENT 79•99 Symptom:- ALIGNMENT SERVICE 7004575 1 79.99 79.99 WHEELS 01 200.00 WHEEL USED WHEEL 7019852 1 200.00 200_00 Prices valid for30 days. Summary Parts 351.97 � Laboc 94.97 . . Shop Supplies 5.52 .. Sub . 452.:46 . ;. - Taz ` 25:83 , ; , , � ',. , �:, , . „,. . Total . , 47$.29 ,_ , . . ,� � . ... , - . THIS IS NOT„�I.�����0 NOT PAY � - �:,. . ., . . �K:Y r...._. . . �. . .. 1 � ' � � �. ..� ^.:: . � � Trc:PNiATDLP'11�70p833�-REVty1y -�. �- �� Pa e � OT `�. '` '� 9uvEst �,2�126 ", See reverse sid���r Warrantv Infnrmatinn JUN/24/2014/TUE 01 : 08 PM FAX No. P. 001 ' ` rairieCar � P e a � � PrairieCare Psychiatric Services Date: �a�� v Time: �� AM� Children and Adolescents Inpatient Hospiial/PHP Mople Grave,MN To: Name Partial Hospitai Programs(PHP) Company Edina,MN � Department - Woodbury,MN �` Clinic Appointments Ciry.State.Zip , Edina,MN Fax � � '� � Woodbury, MN Adults � From: Name PrairieCare—Edirta Clinic Intensive Outpatient Program(IOP) Woodbury,MN Phone 952-230-910Q Ed�no,�v►N o Hospital Administration Fax:763.383.5801 Clinic Appointments 0 eus�ness and Developmgnt Fax: 763.259-6450 Edlno,MN ❑ woodbury Adult IOP Fax:651,259.9770 WOOdbury,MN . o Woodbury CliniC Fax:651.259,9780 o �d�na Clinic Fax: 952.922.252 Edina: 6363 France Ave S G Edina PHP Fax: 952.922.8178 Edi�a,MN 55435 o Edina�du�L IOP fax:95z-9z2-z049 Woodbury: 7616 Currel!Blvd. c Maple Grove PHV Fax:763.383.5803 Woodbury,MN SS125 ❑ Maple Grove Main Reception Fax:763383.5802 Maple GroVe: 12915 63rd Ave.N. p Maple Grove Inpatient Fax:763.383.5804 Maple Grove,MN 55369 Business Lof�: �Z918 63"'Ave.N. Total pages Maple Grove,MN 55369 � To learn mare,please tall us: O Urgent O Please Reply 888-9-PRAIRIE � www.prairie-care.com Instructions or Comments: Patient: DOB: , � - � �.�� 0 �C �-12 �� � � � ��� � i w � � V V o 1���,��—� �.- �I .�.���. �k�-�- 7his fax is Intended only for named recipientls)and is covered by 18 U.S.C.Seccion 2510-25zi and a2 CFR Part2. Thls fax is confidencial and may contaln Information thac is privileged or exempt From dlsclosure under applicable law. If you have receWed this fax in error,please immediacely notlfy the sender by fax ar telephane and destroy Immedlaeely. The Federal ruies p�ohibit you from making further disclosure of Droceaed Health Informatlon unless fu�ther disclosure is expressly permitted by Ihe wriLLen consent of the petson to whom it pertai�s,or ds oLherWlse permitted by law.A general authorizdtion for felease of inedical or other informdti0n may NoT be sufficienc for thls purpose.Thank you. R�.�S.FU2 Fax Transmitta�Sheet Rev.03/11