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Hannasch, Jacqueline �I �G �/ �rnh�r C - 1 �� J� � 2ndcl��C��✓E� ` �IUL o'7 2Q14 NOTICE OF CLAIM FORM to the City of Saint Paul, Minneso a Minnesota State Statute 466.05 siates that"...every person...who claims damages from any municipality...shal!cause to be p7g�e�ed toTJe��—�� governing body of the municipality within 180 days after the alleged loss or injury is discovered a norice stating the time,place,and circumstances thereof,and the amount of compensarion or other relief demanded." Please complete this form in its entirety by clearly typing or printing your answer to each quesdon 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 ea�plain 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 dces 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 �acqueline Middle Initial M Last Name Hannasch Company or Business Name Are You an Insurance Company? Yes/No If Yes,Claim Number? Street Address 12992 Jay St. N.W. City Coon Rapids state Minnesota �P��e 55448 Daytime Phone(� 755- 7521 Cell Phone(763)360_2530 Evening Telephone(763)�55-7521 Date of Accidend Injury or Date Discovered May 12th Time 6:00 � 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 for our damages. I was parked across the street from 827 W. Hoyt, St. Paul, MN, 55117. While visiting my�amily, the Van rom e � o t. Paul sterndorf witnessed the van backina up and hitting my car The damage is on the left front side of my Chevy Malibu (silver� I talked with Chaz who was the driver of the Van A police reaort was filed by Officer Penq Lee of the St Paul police department ( 651-266-5700). The file# is 14091828 Damage was done to the front left side of the vehicle There has been a rattlinq sound cominq from the damaged P�rea Rf t�i�v�hi leg�n�e the �cc�dent. Th�� has be�en add�ti�na�da�na�qe found to the vehicle. ease c ec e x�es)tha most c ose y represen e reason or comp e ng s o �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 vou need tp include conies of all apulicable dceuments. For the claims types listed below,please be sure to include the documents indicated or it will delay the handling of your claim. Documents WII,L NOT be returned and become the property of the City. You are encouraged to keep a copy for yourself before submitting your claim form. �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—nlease comulete this section Were there witnesses to the incident? Yes No Unlmown circle) Provide their names,addresses and telephone numbers: Judy Ostemdorf, 116 6 W. Sunset Lane, Greenfield 414-852-5996 Cell#414-852-5996 Wisconsin, 53228 Were the police or law enforcement called? Yes No Unknown (circle) If yes,what department or agency? St. Paul, Minnesota Case#or report# 14091828 Where did the accident or injury take place? Provide street address,cross street,intersection,name of park or facility, closest landmark,etc. Please be as detailed as possible. If necessary,attach a diagram. 827 W• Hoyt avenue St. Paul MN., across the street. Please indicate the amount You are seeking in compensarion or what you would like the City to do to resolve this claim to your satisfaction. 1,60U.00 — �;7 (j(�.U U Vehicle Claims— lease com lete this section ❑check box if this section dces not a 1 Your Vehicle: Year Make� Model License Plate Number SLL- 31 State��Color i ver xegistered Owner Jacaueline Mae Hannasch Driver of Vehicle Ja ueline Area Dama�ed ront left side near tire City Vehicle: Year 2 0 0 M�e Chevrolet Mode an License Plate Number 923839 State Color Gold Driver of Vehicle(City Employee's Name) Chasitv (Chaz) Jo Kabermusz Area Damaged ��** �^^��i�mnPr Iniurv Claims please comulete this section C�Ccheck box if this section dces not avalv 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 L�Check here if you are attaching more pages to this claim form. Number of additional pages�_. �d 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 06/04/2014 Print the Name of the Person who Completed this Form: Jacqueline Hannasch (�"� Signature of Person Making the Claim: n � � r �• d �� '�G l y Revised February 2011 Sandy's Auto Service Page 1 N O T E S HANNASCH, JACQUELINE Printed 06/23/2014 2:48 PM Estimate:23325 Created06/23/2014 Repair Order: 23325 Customer: Insured ____ �hicle: ______ Ins. Com an : HANNASCH, JACQUELINE � CHEV MALIBU CAR 12992 JAY ST NW YEAR: 2007 COON RAPIDS, MN 55448 Color: GREY Home: (763) 755-7521 License: SLL 831 MN Mobile: (763) 360-2530 Mileage In: 142457 Mileage Out: 142457 VI N: 1 G 1 ZS58F97F222012 Proj. Delivery Date: 06/23/2014 Delivery Date: 06/23/2014 � Drivable: Unknown [06/23/2014 12:38 PM/SANDY] [06/23/2014 12:34 PM/SANDY] [06/23/2014 09:07 AM/SANDY] �-RCI�ED SUSPENSION AT THE REQUEST OF CUSTOMER AFTER BEING HIT BY A ST. PAUL CtTY VEHICLE THE LEFT FRONT OUTER TIE ROD END IS LOOSE&THE LEFT FRONT OUTER CV BOOT IS LEAKING BOTH COULD HAVE BEEN CAUSED BY THE ACCIDENT AND EVENTUALLY COULD BECOME A SAFETY ISSUE (WHEN REPLACING A TIE ROD END,AN ALIGNMENT MUST ALSO BE DONE) BOTH ITEMS PASSED INSPECTION ON APR1L 29,2014 WHEN THE CUSTOMER WAS IN FOR AN OIL CHANGE AND 27-POINT INSPECTION ------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------- LEFT FRONT OUTER TIE ROD END (CAN TURN INTO SAFETY ISSUE IF NOT REPAIRED) PART-69.95 LABOR- 102.00 ALIGNMENT-69.95 TOTAL-256.88 ------------------------------------------------------------------ RIGHT FRONT CV SHAFT ASSEMBLY PART- 166.92 LABOR- 161.42 TOTAL-350.23 --------------------------------------------------------------------------------- ANY QUESTIONS CALL-SANDY PERALA 612-387-6515 ProfitNet[Ver.9.50.2022]�J 1989-2013 YADA Systems,Inc.All rights reserved.Licensed by Sandy's Auto Service