Pettersen, Elizabeth ��������D
.�UL 0 9 Z014
NOTICE OF CLAIM FORM to the City of Saint Paul, lV��i��$.�p�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 municipality within 180 days after the aUeged loss 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 typing or printing your answer to each question. 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 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 � ST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
First Name� ���../� � Middle Initial 1� � Last Name � � �� �
Company or Business Name /�,1'I
Are You an Insurance Company? Yes/� If Yes,Claim Number?/�1��
StreetAddress � _) ��1�1G'�14�� �1 ��.��
City �,-���� � S�� �I���L ( State � t� Zip Code 1�ZS
Daytime Phone (��y���_Cell Phone(� �/�-� �� Evening Telephone(�t]�)�C�_ �� 1-�3
Date of Accident/Injury or Date Discovered /' �' r���'�/ Time �:J� a pm
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 r your damages.
lt S I G� I� �Z'� GL , � x' �713 �' /Pc /�
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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
�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 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 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 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—alease complete this section
Were there witnesses to the incident? Yes No Unknown (circle)
Provide their names, addresses and telephone numbers: Il,�/
Were the police or law enforcement called? Yes � Unknown (circle)
If yes, what department or agency? R��/� Case#or report#�%/�
Where did the accident or injury take place? Provide street address,cross street, intersection,name of park or facility,
closest land rk, etc. Please be as detailed as possible. If necessary, attach a diagram.
�p ll_� �- i.c1�-lY�h�c, r�? ��tv �nr�l�y � y= C.`�:c,��r-�� l�zr-�
Please indicate the amount you are seekin in compensation or what you wo ld lik�the City to do to resolve this claim
to your atisfaction. '� �' � ��
, ,
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Vehicle Claims— lease com lete this section ❑ check box if this section does not a 1
Your Vehicle: Year :�G I � Make Model � /
License Plate Number � C - State�Color I.,t
Registered Owner � � f' �
Driver of Vehicle � � � ��� E S�'
Area Dama ed +-��' � �' _I' �' - �
City Vehicle: Year l�� Make ,�! /� Model �
License Plate Number �-�/�_ State i� Color
Driver of Vehicle (Cit Employee's Name) /tI
Area Damaged �Lt-� ��
Iniurv Claims—nlease complete this section 4p check box if this section does not apnlv
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
O Check here if you are attaching more pages to this claim form. Number of additional pages
By signing this fornz,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 �� / /�
Print the Name of the Person who Completed this Form:
� �tzcz y�`�/l �� �'�S'�°�
Signature of Person Making the Claim• / L -�" - � �2��j��
Revised February 2011
v�scouNt�
DUP T 1 R E J�J��;�
discounttire.001'Y1 REF�RIh1T DRIG IIUV #5��3��49
�RIG DATE �7-�7-��14
DATE: �7-�7-c014 T I1�1E: 4:c�, PM
• •- . •- • •- • • �
CNF:L �'ETTERSEN ��1� HONDG Mhlht cf
ELIZA�ETH FIT 1540 RCIPERT 5T S
9L5 MAIVOM I N HG'E 1 b"BASE SGORT WEST ST F'AUL MIV JJ�1�
SAINT F'AUL MN 55118 MILEflGE: 1,964 RHONE: 651-��E,-9�1�
��LA`('E # IUTA4CFE
tWt !H} CiJl-4J1�11J..S ��t`c R�HERT J GIEBLER
DL# TORGUE SF'ECS: �8� WORIi ORDER#
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4�8`5 h1Rh1 1 ISJlJJR1E� �i�H E�W YQK AVTU ��CEhlD .�4� 11�. �� i 1.:.�0
WARRA{VTY: hiILEH�E- �S,��t� 5EE �E�JEFSE �IDE FOR bJHRRANTY UETaILS
COMMENT: ROLT F'ATTERN: 4-i�k
COMI+IENT: I NFLA'T I ON F:�� R.3�'
80�17 IVRM 4 CERTIFICATES FOR REFUIVI7, REF�LACEI�ENT . �� 15.�7� E�.��
8u�;��4 NFth1 1 WASTE T I RE U 1 SF'O�aL FEE .��1 3. �� �..�►0
e�►�19 NRM 1 IIVSTALLAI"IGN g. �IFETIME 5F'IN PALANCIIVG . 0� 1E.�� IE_.0�
A�E�Gt, NRhI 1 L I FET I ME ROTAT I 1�hd L i FET I h1E REF'�t I RS I IV�LUDEU .�� .�� .�0
9b5�7 N Rt*1 1 #�0�1`� TG-4� RED TF'MS REBU I LD K I T . �� .0� .��
CO�II�Eh1T: r�eplace tire in back, r�f to spare
C�I�MEIVT: GRRO I NTMENT: �7-Q►7-��14 4:�� F'M
Since yo�_i ha��e purchased fewer• than foi_tr tir,es tor wheels) , we will mount the new tir�es on tt�e
r�ear� af yo�.�r ��ehicie for best safEty and handling.
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113•{3a- +
3•00 +
16•00 +
8•05 + SUATOTAL: i��_'.��
15•00 + TAx: �3.►��
1'��5•05 * TCtTAL: ���%�. �5
XXJ(}:XXXi(X}:XX 4�6� ViSA: ���.�5
TENDERED: 2��.�5
Signat�.ir�e on file
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recydable paper
�,�.�, ..;f .� -�... :� � � y� .,,;,;�:�.,_-" _ '' ";�= -- LIMI'I'ED WARRAnT'I'IES
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�;���„ � ' Discount Tire and America's Tire Stores
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��r --:� ELIGIBILITY-These Limited Warranties apply to all owners of the tice using
� CERT/F/CATE �t in noncommercial service,except tbr the Mileage Warranty which is limited
to[he original purchaser.
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��;;;, FO R R E PAI R, R E FU N D O R R E PLAC E M E NT •�, To�ucE n e�M- P�esent y��������e<5>aaa ong;�a�5a�es�,�o��e�anY
�� ;;� Discounc Tire or America's Tire Store.To locate a store you may call 1{888)774-
�'l.'•'� For a fee wllected at the thne of the original tire purchase or for a fee collected to subject a' 6560,or visit the Discount Tire web site at www.discountare.com.The vehicle
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other tires to[he terms of this certificate, Discount Tire or America's Tire stores will ? on which the tire was used must be availabfe for inspection.You will be asked
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:� refund the purchase price and the sales t�,if any,on any tire covered in the event of a to complete the cuscomer pottion of the adjustment claim form.
��"~-� failure due to workmanship and materials or a non-repairable road hazard for the service - .
o,:;°° � WARRANfY COVERAGE
��,.. of the odginal tread down ro 3/32 inch remaining, or 3 years from date of purchase, �
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�'v,ti..:.__ whichever occurs first.Upon refund or credit of sales tax,customer hereby acknowledges New Tires-Workmanship and Materials-[f our examination shows
j�r y--� by actual signature or electronic sigaamre capmre such credit or refund.This additional 'i that a passenger,SW,or light truck tire covered by this warranty has bewme
(a��.;;'< < aeknowledgement satisHes a teehnical requirement in the sales ta�c stamtes and/or ,� imservieeabte 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 wID be replaced on a pro rata tread wear basis.
or credit of sales ta�ces.At the election of the purchaser,we will sell a replacement tire s New Tires-Road Hazard(if applicable)-If our examination shows that
4�J;
' to the purchaser at the original price paid for the damaged tire,plus the required sales ' ,�,
' taac.In the event the covered tire is discontinued or unavailable,a tire of similar value will "'�'+' �p�senger,SiJV,or light truek tire covered by this warranty has become
'"j� unseroiceable due to a normal road hazazd<i.e.,non-repairable puncture,cut,
;� be substimted. tir snag bn�ise,oc impact break)during the service dow�to 3/3�of an inch,it
If in our opinion,the tire can be safety repaired,we will do so hee of charge.The cost of w�11 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 appiicable) - In addition to the
This certificate will be honored at any Discount Tire orAmerici's Tire stores.This certificate warran[ies.ahoye, every mile�ge watranted passenger, SW or light truck
�<_. � tire is warranted co the original parchase�for the speeified number of milr's -
��vr�:"A does not cover dama e caused b wllision,vandaGsm,chain dama e,mechanical defects ^'A
�� B Y g o;;l� of tread wear and against normal road hazards for the same mileage (if
��;�� of the vehicle or willful abuse.No other properry damage or consequential damage of any ��=�`'.gi; dpp�icable).If our examination shows that the tire eovered by this wazranty
�r��_ kind is covered by this certificate. ,��y has worn down to its tread indicarors before giving the specified number
�,��s;_ ,� of miles of no�commercial sen�ice on the passenger,SUV or light truck o0
, r�t� There will be addltlonal charges to purchase a new certificate for a replacement tire and which it was ic�stalled,it will be replaced on a pro-rata mileage basis.
�l��'`,? to balance a replacement tlre. '+�
��i� � '` ATV/Trailer Tires - If our examination shows that a trailer or ATV tire
�� B redeemin this certificate,the customer relin uishes the ri ht to an manufacmrer's «
;��� Y S 4 B Y o � covered by this warranty has become unserviceable,other than by a road
�},; warranry that may apply,and lliscount Tire or Amenca's Tire may claim for its own benefit � hazard,during the three year period following its date of purchase,it will
' any such manufacturer's waaanty. be replaced based on a charge of i3%per yeu or part thereof of the origie�al
' ' s purchase price.
�`'�-- � • � • � 'v�
� CAI.CULATION OF REPLACEMENT CHARGES - Tires are replaced
- under these limited warranties with a comparably priced new tire a[a pro-rata
���ui, ' �O�� cost to the customec Tread wear is pro-rared on the basis that the tire is wom
D � �� out when the tread is wom down to i/32 of an inch remaining tread groove
depth or to the tread wear indicators on tires containing them.Tire replacement
i�.' �� cost is determioed by multiplying the origina(cost of the tire by the percentage
T ' � � of tread used For example,if the original[read was ll/32 of an inch,and the
���� tire has 5/32 of a� inch of tread remaining at the time of replacement, the
�=� �� replacement cost will be 75%of the original cost((11/3�-5/32)/CI1/3�3/32)
�r,j;� � �� x 100).The replacement cost for mileage warranted tires is prorated at a set
ti+�,,r � :�' charge per 1,000 miles dm�en.F.E.T.and state tanes are added to the replacement
� � �� � ;�� wst.Addidonal chazges for mounNng and balancing apply.
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�tiM..J���n��� 1 0'n ..+«i'!�!��,.w � � � a e�4 .� +ti �Jr �i ' {o�j��a,�'y.•�'.
a'YX '��''�* '-`-?��;�Y� --`'�2•sS��a =:- gx-�-':`�<s �'��`^'. �'�4�,! IT'EMS NOT COVERED-These warran[ies do not cover:
_ �. _ � � , � `�
The wst 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 sercice(however
, commercial service does not include use by the owner as transpor[ation in
his/her regular trade or business);
TI PS TO I M PROVE TI RE ' llamage,destruction,or failure due to accident,fire,orvandalism;
• Irregular or premature tread wear caused by improper inHa[io�,
. misalignment.imbala�ce of u�heels,or wom out shock absorbers or brakes;
M1 LEAC-�E AN D SA���Y- � ____ _
• Damage or faiti�re due to non-tire causes such as being run Hat,mechanical
condition of the vehicle,cuts from rims or chains,or any willfiil abuse;
• Problems related to the appearancr of the tire after the first LO%of wear.
�ROTATE TIRES � REPLACE
every 6,000 to 8,000 miles or when worn-out tires when built-in wear bars OWNER'S Di1TIES-It is the owner's responsibiliry ta
necessary to equalize treadwear. appear across the tread surface. • see�nac cne cires are operacea at proper�nt�ac�on,pressure and loads;
�REBALANCE � REMEMBER TO RETURN ' Pay applicable taxes and dealer services such as mou�ting a�d balancing;
every other rotation to promote even to any Discount Tire/America's Tire store • aea�rn cne aaj��5c�t�ie�r�:�nd�ompiece cne�uscomer port�o�of che
tire wear and a smooth ride. for a tire inspection. d�i��scmrm c1a;m eorm.
DURATION OF COVERAGE-These warranties expire three(3)years from
�MAINTAIN AIR PRESSURE � che dace oepurchase.
as recommended by the vehide or tire
manufaeturer.Check your air pressure at least �""" 1 � � CONDITIONS AND EXCLUSIONS - These ��m�rea warranc�es are the
� exdusive warcanties of Discount Tire or America's Tire stores,are in lieu of the
0l1C0 08Ch fnOrlth When tlles afe COOI. warr.�nties of the manufacturer,and set forth the exclusive remedies available to
the tire usec In[he event that the terms of an applicable maoufacturer's warraury
�MAINTAIN ALIGNMENT exceed the protection given under these wananties,Discount Tire or America's
. Tire srores wdl honor those rerms.Discount Tire or America's Tire may claim
(Front&Rear)replace worn suspension parts. I���(�t for its own benefit any such manufacturer's warranty These limited warranties
A�� �H P �� do not provide wmpensation for any consequential, special, incide�tal or
�PLEASE DO NOT USE i contingent damages. some states do not auow the exclusion or timitation of
' incidental or consequential damages,so the above limitation or exclusio�may
any"Fix-a-Flat"type produets. f ���' not appiy to you.Tirrs presented for a claim remain the properry of Uiscount
S.����� � Tire or America's Tire titores.No representahve or employee of Discount Tire or
��NSPEL•T . ,.,. America's Tire S[ores may e�large or alter these warranties.
tires occasionally for excessive wear,tf28CJ CONSiJMER RIGHTS - These limited warcanties give you specific legal
Of SIdBWall CutS,Of othe�d8md90. rights,and you may also have other rights which vary from State ro State.
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