Corcoran, Michael i � �L�V`� V �..�4d
J�N 2 3 2014
NOTIC� OF CLAIM TORM to the City of Saint Paul,Nlinneso�"a��
Mirvresotn Stnte Stcltute 466.05.rtntes d�nt "...every pe��so�z...wFin e•lni�ns dcimnges,froni nny municipnliry...slrnll cnuse to be presented tn ll�e
��n��erning huctY��/'the municipaliry withift 180 daps r{/�ter t/te aRegecf loss or injurv is discovered ct notice stntirtg t/�e time,p/nce,cur�l
circ�nnstnnces tl�ereof,anc!tl�e amo�u�t of compensatinn or other relief demnnded."
Please complete this form in its entirety by clearly typing or printing your answer to each c�uestion. 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 u
written acknowledgement once your f'orm 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 DOCUM�NTS TO: CI�Y CLERK;
15 WEST KELLOGG73LVD, 310 CITY HALL, SAINT PAUL, MN 55102
First Name �/1 ��-f�Ll� Middle Initial fi Last Name__�C�Gl/j`�
Company or Business Name ��
Are You an Insurance Company? Yes/ io If Yes, Claim Number? �l�
Street Address �/ � -5v �i
City � �(�/f State / ��'� Zip Code ���"'
Daytime Phone �)1�`-��i` Cell Phone (�"Sr)�3S- o��oo�Evening Telephone (� -
/'`
Date of Accident/Injury or Date Discovered 1� o?� o�� Time ��� am/��
,_---p}���te,-irr-�et�it,�f"i�dc-u ecI (happened),and why you are submitting 1z:laim. Please inciicate why�-hw�r-�nu -�____�
feel the City of Saint.Pau .o�-its employees ar�inv lved an /o responsible for�y ur damages.� i�-� " �/'i L'� `?
�
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�} � .° a'N � $l ��� �; $ '�� ' •� ' �p;- ' �-r— � j,�—�" .1'--+� '
I� e c ec the box(es)that most closely represent the reason or completing this for :
❑ My vehicle was damaged in an accident ❑ My vehicle was damaged during a tow
�My vehie���r.�as damaged by- a�o±hele or condition of the �reet ❑ 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 copies of all anulicable 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; or 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 ro 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–please comnlete this section
Were there witnesses to the incident? Yes No � Unknown � (circle)
Provide their names, addresses and telephone numbers: �
Were the police or law enforcement cal ed? Yes No Unknown �ircle)
If yes, what departmcnt or agency? G�O Case#or rerort# '
Where did the accident or injury take place? Provide street address,cross street, intersection, name of park or facility,
closest land ark, etc. Please e as detailed as possible. If ngc ssar� attac a dia am. ��EC D�
fi� ��r S� re tX.t`t� a0� o� `� _ �
Please indicate ihe amo�nt you are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction. � Q'Q_ ��
Vehide Claims– lease com lete this s tion ❑ check box if this section does not a 1
Your Vehicle: Year � Make � Model G
License Plate Number �� "�—State �� Color ��1(��{>_
Registered Owner P3r '
Driver of Vehicle G�
Area Damaged /�4� �I`fi
City Vehicle: Year �2 Make � el
License Plate Number tate Color
Driver of Vehicle(City Employee's ame)
Area Damaged _
In'ur Claims– lease com lete this ction ❑ check box if this section does not a 1
How were you injured?
What part(s)of your body were injured? t �
Have you sought medical treatment? X s o, lanni o 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? ` Y�S'
�L'h�n �id yuu iiii�s work" _ _ _ %'--_-- -- - _ (Provide date(sJ)
Na�ne 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,yoic are stating tliat all information yore have provided is true and correct to the best
of your knowledge. Unsigned forms will�aot be processed.
Submitting a false claim can result in prosecution. Date f'orm was completed �� ot(1 �` L
� �jG �e �
Print the Name of the Person who Completed this Form: ,
Signature of Person Making the Claim: (kS/ (��
Revised February 201 I
Jim Coopers Tire&Auto Customer Quote Page 1 of 1
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r�. Jim Coopers Tire&Auto
" � �y 1340 Duckwood Drive, Ea an, MN 55123
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www.jimcoopers.com
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Customer Information: --"" '
Name: i/' �`� (�0��:=8�tr��','1`� Vehicle: ! �� � F�'���-
Address: /, , Phone: LicenseNin: /1� G�l�•-
�_�' �� � , �� C' �,� Email: Odometer: �'` �'�
Quote: � �G�'�'t �`�/��
Quote Effective Until 6/27/2014
Tire Description Add-
Tire Part Installed
Image Manufacturer Number UTQG Spd Warr Price FET On Tax price
Category Price
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��� � 185/65R14 T
�� SIGNATURE II BSW \
� Dunlop, 266004 2 620 A 8 T 65K $Y5.15 $0.00 $17.75 $5.5 $98.45 ' ,
� � SIGNATURE II Passenger Car below 20 � �
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dd-On Pr' c udes: 1 Tire: 98.4
Compufer Wheel Balance ' 2 Tires: $196.90 '
Tubeless Valve Stem 3 Tires: $295.35
Waste Tire Disposal Fee 4 Tires: $393.80
Grand T 1 Tire: 98A
2 Tires: $196.90 '
3 Tires: 5295.35 '
4 Tires: $393.80 '
Prices are good 20 days after the date of the quate.
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^� 6522 - Sears, Roebuck and Co. 450 MARION STREET ESTIMATE I
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��,�.;� �� St Paul, MN 55103 (651) 291-4228 �,
�' —�---— EPA Numbec Facilit er - �
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" �1�^H9EL TAG� INITIAL ESTIMATE RE D ESTIMATE PHONE AUTHORIZATION REF Ni i�? ~
_ YEAR/MAKE/MODEL PARTS 567.45 ES6'�'�3���
�,i��_���E 1998 HONDA CIVIC 4�1590 1 6L �
LICENSE k OLOR LABOR 515.50 APPROVED BY I CREATE9?'' �
OTHER S0 00 ' -
V.I.N. LOCATION ;
=d iWSTRUCT10NS TAX 55.14 CONTACTED BY � IN'JG�C=G 3�i ��
ODOMETER IN ODOMETER OUT TOTAL 588.09 I
TIME IN TIME OUT ATE'TIP�1E REVISED NUMBER CALLED LO u�L r
�� � ESTIMAT PUR„• NS�
_ - � 04'28/2014 01:53 PM PO NUr,1RFR�
I PROM_ISED TIME DATE TIME CALLED � -
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--- �
_R"c�F �'JHL TOR�UE SPECIFICATION See reverse for important warranty terms
� ��-�����^Ti�NS vLW'BO ALL 0 E APPLICATIONS and other information. �
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�"S OP;'_TERNATE CONTACTS
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`r;''`� " .--�-_� `"\ _ - — `-°- - �
ce.1= �ESCAIPSION OE tu1FBf-+d4r --�F —PRiC�ACt'- Ti?TAL — TE�R �SA ��i
_ ,;��� T,�ER PAW To R,N�HR S6,96 S6,96r 4,90„ This is an ESTI MATE ,
� !oc.a�TiaE�iSPOSa� 52 So sz ser a��go�� price for the goods and!or '�
VALVEAUB � 5299 52997 a19077
— , services you have requested. I
- `IREBALANCE PERFORCIANCE S'S50 5�550 4'9077
� These prices are good for �
- � ��Fa��°a:�c���c���2'u��2c me�char��se A'�5`-Cance'lat�on Fee may apply on Specal Ordered merchand'�se 21 dByS.@xCept Shce priCeS.whiCh 8re �
Sea Sa'espe�sen!or ceiaiis Vdlld fOf the dUf8ll0fl Of Ih0 S01e.
Thank you for shopping with us! J'�
. .'� NFORf�lATION LABOR DETAILS COPAMENTS ALL NE�V NON-0EM PARTS UNLESS OTHERVJISE SPECIFi�'I
� =.a�lac�e Ve�ifyTPMS- �
�� .._TiGER PA�'J TOURING HR 185 65Rt4 STD H 70.000 MILE
° _ _� .�e T��e !o add�ess an u�even or imbalanced tire.we wlll:adjusf tire pressure remove old weighls.computer spin balance Pnced EACH '
-- , �� grnt;t AND QL�OY 1^JHEELS PAUST BE R6TORpUED AFTER 25 MILES AND CHECKED PERIODICALLY i
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