Steneroden, Eric � R���I`�/E�
� JU� 1� 2���
NOTICE OF CLAIM FORM to the City of Saint Paul, Minneso
CtTY ' ��
Minnesota State Statute 466.05 states that"..,every person...who claims damages from any municipaliry...shall cause to be pres�e�o'tli�
governing body of the municipality within 180 days after the alleged[oss or injury is discovered a notice stating the time,place,and
circumstances thereof,and the amount of compensation or other relief demancfed."
Please complete this form in its entirety by clearly typiag 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 yoar 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 �� I C. Middle Initial�Last Name �TG-N�/Qd��n/
Company or Business Name /��A
Are You an Insurance Company? Yes/ 10 If Yes,Claim Number?
Street Address �q�7 S W A�� L�� ��
City �'� �A UG state /7'I N Zip Code ���� �J
Daytime Phone(�Sn�- O d ell Phone( ) - Evening Telephone(�'S�) 3/- UD�(�
Date of Accidend Injury or Date Discovered �/�1 �Zd � `f Time�am/�
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 responsibl_e_for your d�mages,__
At about 3:25 PM, Friday, July 11, 2014, I was leaving the Phalen Park Golf Course
parking lot. I had just turned right on Phalen Drive toward the main entry so the
car speed was less than 5mph. A loud explosion shattered my front driver side
window. Some of the glass came into the car immediately, then glass fell inside
and out as the window began to disintegrate. I got out of the car, then noticing
the City worker on the (lakesidej curb with a weed whip about 25 feet from where
the explosion occurred. Without me saying anything he hurried over to see if I
was OK and appologized, saying that he didn't see me. (With his sound abating
headset I am sure he couldn't hear my car either.) The City worker, Tracy Smith
(parkworker#1), took full responsibility for the incident, helped extract the loose
glass to make the car drivable, cleaned up the area, reported the incident, got his
necessary paperwork to fill out, and gave me the card with the City Clerks Office #
so I could request this Notice of Claim form. I have no appearent injuries. I had
the window replaced at a dealership and have paid for it as the bill and receipt for
$482.13 indicates. So, pay me back and were even.
O Photographs are always welcome to document ana suppon yuu� ��a,,,�uu� w�u,�v���o�u„��u.
Page 1 of 2—Please complete and return both pages of Claim Form
.
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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? es No Unknown (circle)
Provide their names, addresses and telephone numbers:
�.i't'`l �i+rl i�l--4`t��f—�- '��A f.��1 S'�lyl� �
Were the police or law enforcement called? Yes � 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 pazk or facility,
closest landmark,etc. Please be as det 'led as possible. If necessary,attach a diagram. ��� GET�1 L S
s�'� wrti� C�E.� �r�
Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction. � 4��� . ��
Vehicle Claims- lease com lete this sectaon ❑ check box if thi section does not a 1
Your Vehicle: Year '?1�� 7 Make � C' Model �5 L
License Plate Number �/�f /�'�g`T' State Color��.� � T
Registered Owner 1 G '�'" �' L�E
Driver of Vehicle �'• ST� �a�
Area Damaged D�i L•��R.S S�1�� /N Od
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Injurv Claims-please complete this section �.�check box if this section does not auplv
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
�Check here if you are attaching more pages to this claim form. Number of additional pages 3 .
By signing ticis 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 7�tS��a��
Print the Name of the Person who Completed brm: ��� � ���'e D��/�
5ignature of Person Making the Claim: � ��
Revised Febmary 2011
�i�r .�QG�d
CUSTOMER #: 920168 421172 WHITE BEAR
*Irrvol�E* LINCOLN
ERIC STENERODEN �+
1975 WORBLER LN �N�+•
ST PAUL� MN 5 5119 PAGE 1. 3q25 N.HIGHWAY 61 • ST.PAUL,MINNESOTA 55110
HOME:651-731-0036 CONT: 651-731-0036 �ss�►asa-2ss�
BUS: CELL: SERVICE ADVISOR: 10 JEANNE DAUGHERTY
[. R YEA M �/ OUEL Vit3 CICENS£ MttEAGE tN/' UT TAC
WHITE 07 MERCURY MAR UIS 2MEFM75V07X602175 414MBT 107174 107174 256�
DEL�ATE PHOD.DATE WARR.�XP: Pf;ONkfSfD P1'7 N0. RATE PAYMfNT > INV. DATf
O1JAN07 D WAIT 14JUL14 131. 00 CASH 14JUL14
R.O.OPENED REr4flY ' OPTIONS: DLR:64A4 9 7
07:43 14JUL14 10: 09 14JUL14 LIST NET TOTAL
LINE OPCODE TECH TYPE HOURS
A DRIVERS FRONT WINDQW $HATTERED WHEN HIT BY FLYING IZOCR
SS REMOVED TRIM PANEL, RUN AND REGULATOR AND
REPLACE DRIVERS FRONT WINDOW 255.51 255.51
1361 CLM
1 FSAZ*5422411*A GT�PiSS - DOOR 188.�1 188.21 288.21
PARTS : 188 .21 LABOR: 255.51 OTHER: 0 . 00 TOTAL LINE A: 443 . 72
107174' REMOUED TRIM' PANEL CLEAN GLASS OUT OF RUN AND RECT3LATOR ,AS
GD AS POSS REPLACFD LFT FT DOOR GLASS PUT BACK TOGETHER
****�r*,�,**�r*,�******�*�*��*+****.*�r,��*****,�*�***t�****�
B CLEAN OUT ALL GLASS FROM BROKEN WINDOW
SS; SEE STORY ' 25 .00 25 . 00
1361 CLM
PARTS: 0.0 0 LABflR: 2 5.O t� flTHER: 0.0 0 TO'T`AL LINE B: ' 2 5. �0
1 0 7 174 CLEAN GLASS OUT OF DOOR AND CHANNEL ,REGULATOR AS GD AS POSS
****�*�********�**�*�*�**�r***�r���******�*�*:�r,�*,�**�**
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_ 13 .41 .
ANY wANRAH7iE5 ON 711E VMODUC75 SOIA ..�-OGSCRIf A���' TOTALS
� 1fE#!Y lWE TNSE OF T'F M�MUf�CTVNEltS. ....... .. .
•s e�r��++TMa^E*"��sE�"AND B1^'�". LABOR AMOUNT 2$O .S 1
nrt v+waxr�s ro ee soio•,�t a-�MO n�
`� "�" � � � �u�� � PARTS AMOUNT 18 H.2�.
� ansow�uHCe ov n�riroo�cr�s wm�n�
L I N C O L N �Ep' T�SEtlEN EXPRESSLY DISClA1M5 ALL
W�RMNTES. EITIER EXMESS OA ��..uEO. GAS�OIL,LUBE O . O O
�NCUJpNG ANY IAALIED WARMNTV OF
MfRCIMNTABILIT' OP FTNE55 WR A
IARTCVIAR RMPOSE, AN� T1E SELLfR SUBLET AMOUNT O .
NEITIER ASSUMES MOp �UTMOR12E5 �MY
'�� m"en .ensoN .o �ssu� wn n �rn MISC.CHARGES O. O O
�'�� � IJMt17M M CON1�CnON WITM 711E S�LF OF
/_�__6 SNO tnOCUCrS. �MS qStu�MEx sr n6
r� 5(LIFq�N Ip yypy ARECiS T1E 1F11�6 OF�E TOTAL CHARGES 4 6 8. 7
�MM/F►CTNIER'S W�IIMNTV. Trt M'EN
� �[KNpW�Ep(¢$9[iN($O INFORl.EO MiIOM 70 LESS iNSURANCE O . O O
� '� TME SAtE. . . .
11{.L P�R3 NEW OMGINAL E�U��EMT U10.E55
on�mmse sveciReo. SALES TAX �. .4
CUSTOMER SIGNATUAE p�EpSE PAY
Ttt�s AMOUNT 482'.13
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I fHANA Case No,___ Pa�e#16 of 16 j
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Damaged Window Opening Before Repair-Glass Shards
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Glass Shards in Casing
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