The URL can be used to link to this page

Hoover, Meghan RECEIVED JUN �4 2014 NOTICE OF CLAIM FORM to the City of Saint Paul,��e�t��K Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipality...shall cause to be presented to the governing body of the municipaliry within 1SO days after the alleged lo,rs or injury is discovered a notice stating the time,place,and circumstances thereof,and the amount of compensation or other relief demanded." Please complete this form in its entirety by clearly typ�ng or printing your answer to each question. If more space is needed,attach additional sheets. Please note that you w 1 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 M�'��a n Middle Initial E Last Name t�o✓e r Company or Business Name Are You an Insurance Company? Yes/� If Yes,Claim Number? Street Address �� r" � City'��'� ��% �� State I�V Zip Code�� `� , Daytime Phone (�'�) 1 (v-T�tv Cell Phone( ) - Evening Telephone( ) - Date of Accident/Injury or Date Discovered d�' �� 2��' Time��am/� Please state,in detail, what occurred(happened), and why you are submitting a claim.Please indicate why or h�w you feel the Cit of Saint Paul or its employees e involved and/or responsibl for your damages. 0�, 0 � 1 � . V ' I� h C V�f�Vl 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 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 you need to include coUies of all apulicable 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 far 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 bil�s 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—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, address,e�and telephone numb rs: j,�:1 Y"1 1 t-iD1alP�1/ � SO"1 r `� 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 place? Provide street address,cross street,intersection,name of park or facility, close t landmark,etc. Please be as detailed as ossible. If necessary,attach a diagram. �1.. �--►�c! C�� '�j 52..�u � i Please indicate the amount you are see�ng in c�sati n or w at you would like the City to do to resolve this claim to your satisfaction. _r Vehicle Claims—please complete this section ❑ check box if this section does not avvlv Your Vehicle: Year Z--v t � Make C9�C�J1 Model N�A.,�.F�jl,l. License Plate Number o'2°�1 Ltar'b State�N Color �j1,UQ. RegisteredOwner M��I�GLY� �DOJ2--►" Driver of Vehicle 1��PJ1 �D�ti/P� . _ Area Damaged �YDY1� d+�i J2-✓St� � `��Y�� City Vehicle: Year Make Model License Plate Number State Color Driver of Vehicle(City Employee's Name) Area Damaged In'ur Claims— lease com lete this section heck box if this section does not a 1 How were vou iniured� � 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 1 . � 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 ��I �� Print the Name of the Person who Completed this Form: {�e�� e� Signature of Person Making the Claim:�. 0 � Revised February 2011 )LET - . ..- .. - - . .- -�---' 4/12/14 6074038/1 ��IAIIER CHEUROLET 14755 HIGHI�J�V 11� SERVICEDEPARTMENTHOURS � • " �' - • Itli1ER GROUE H• f•iPl 55G 7:o0a.m.tos:oop.m. 4�16�14 Pr'e-II1vOiC Monday-Friday _.�_ _.�_ � fERI'IIIIGL I6. ; 030422'[8 8:00 a.m.-12:00 p.m.Saturday h1ERCHNNi b� 316241509996 2 0 715 2 0 715 •. . .. • UISR Dale Coggin/1558 #��5229 ;ABETH . - . - - - .- . . .- SALE 1G11B5SA8DF157174 �piCH; OUOd64 [IiUOI�f: �641i1�iJ4 ;� � 55076 • - � • - �- - �- - - �- - �AiE� fiPr le. 14 iII�IE; 14;24 651-442-8920 2/G7/13 2/07/13 SEQ� 0022 AU I H:fi2fi94C ..- :.. .. .- fOTAL �477,54 M�I'IBU 4DR SDN LS ATLANTIS B 291T�AR DtiI�IEL NODUEk C�Si01�lER COPV ' � �� „_ _._..__. . _ CUSTOMER STATES THAT CUSTOMER NOTICED LOW TIRE LKI GHT COME ON ADVISE �aused by VERIFY TIRE PROBLEM NEED TO REPLACE TIRE AND RIM - RIM HAS A BEND IN IT Work performed by BILL MCCARTHY (BM ) 24 . 95 Installed 9598666 :N-WHEEL (05803-C) 1@295 . 00 295 . 00 Installed 19297176 :N-GY2156016 (05880-BOPCKT) 1@114 . 74 114 . 74 Installed 15263240 :SL-N-VALVE KIT (05875-BPCKT) 1@9 .26 9 .26 MOUNT AND BALANCE ONE TIRE Sub Total : 443 . 95 #2 - BODY: BODY CUSTOMER STATES THAT THERE IS A BODY MOLDING ON DR IVERS SIDE THAT FELL OFF ADVISE Caused by 2020220 .2 Work performed by BILL MCCARTHY (BM ) Warranty Installed 22944918 :N-MOLDING (10772-C) Qty: 1 Warranty INSTALL MOLDING ON DRIVER SIDE REAR DOOR - -------------------------------------------------------------------- #3 - MPI : MULTI POINT INSPECTION Work performed by Curtis Weaver (CW ) Sub Total : . 00 �'� - RLNT'�1�.T : RE�TTAL �JEHICLE RENTAL #14-247R 04/12/14 Work performed by Curtis Weaver (Cw ) Warranty TERMS:STRICTLY CASH UNLESS ARRANGEMENTS ARE MADE. 'I hereby authorize the repair LABOR 2 4 . 9 S woAc hereinafter to be done along with the necessary material and agree that you are not respons- pARTS 419 . 0� ible for loss or damage to vehicle or articles left in the vehicle in case of fire,theft,or any other . O O cause beyond your control or for any delays caused by unavailability of parts or delays in parts DEDUCTIBLE shipments by the supplier or transporter. i hereby grant you or your employees pertnission to . �� operale the vehicle herein described on streets,highways,or elsewhere for the purpose of testing SUBLET and/or inspection. An express mechanic's lien is hereby acknowledged on above vehicle to secure SHOP SUPPLIES 3 . 7 4 the amount of repairs thereto" . O Q HAZARDOUS MATERIALS DISCLAIMER OF WARRANTIES. Any wartanties on the products sold hereby are those made by 2 9 . 8 5 the manufacturer.The seller hereby expressly disclaims all wananties either express or implied,includ SALES TAX OR TAX I.D. ing any implied warranty of inerchantability or fitness for a particular puryose,and the seller neither SPECIAL ORDER DEPOSIT . �� assumes nor authorizes any other person to assume for it any liabiliry in connection with the sale of . O O said products. Any limitation contained herein does not apply where prohibited by law. DISCOUNTS TOTAL DUE 4 7 7 . 5 4 • • •- •- •-� X � ��