DuBord, Paul ����g���ICE OF CLAIM FORM to the City of Saint Paul, Minnesota
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�nt�Srrt�fG{i�(yo/�tlie�nunicipc�lih��rithin 180 d�n�s a%ter the all�gcd lo.ss or injinv is drscuvered a�totrce stating dte time,place,and
C�'rY ��� 0�� c�ircuri�starzces�l�er�u/;und�he arnot�nt qf�c�ona���ens�uion or odie�-��elief den�anded.„
Please complete this form in its entirety by clearly typing or printing your answer to each question. If more space is
needed,attadi 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 oP yo�r claim. 'Chis form must be signed,and both pages completed. If something does not apply,write`N/A'.
SENll COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK,
15 WEST KEL�,OGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
First Name p��'l 1 Middle Initial �Last Name � � ��/ � r�
Company or Business Name V��7 j�-�"7��
Are You an Insurance Company? Yes No � If Yes,Claim IVumber?_
Street Address ��� � ��( I ��� I��-�' ���--
City � CX State N�� Zip Code ������
Daytime Phone(�) �q� ��Cell Phone C��) ����°�Evening Telephone( ) -
Date of Accidentl Injury or Date Discovered_ � � � S� �� Time � "3� am K�)
Please s[ate, in detail, what occurred(happeneil),and why you are submitting a claim. Please indicate why or how you
feel the City of Saint Paul or itti emnloyees are involved an��/or responsihle for yoi�r damages.
D 0 �. v.�, �.- __ o ►� 6-�l ►� - �u —
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Please check the box(es)that most closely represent tlle resson for completing this form:
❑�y vehicle was damabed in an accident ❑ My vehicle was damaged durinb a tow
p�My vehicle was damaged by a �othc�le 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 oti property dama��e—please specify — —
❑ Other type of injury—please specify —
In order to process your cl�iim vou 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. Docurnents WILL i`dOT be ret�irned and become the property of the City. You are encouraged to keep u
copy for yourself before submitting your claiin forin.
O PropelTy dama��e claims to a vehicle: two estim�tes for the repairs to your vehicle if the damage exceeds
$500.00; or tl�e actual bills and/or receipts for tl�e i-epaii�s
�O owin�claims: le�ble copies of any ticket issued and a copy of the impound lot receipt
ther property damabe claims: two repair esti«�tates if the damage exceeds$500.00; or the actua] bills
and/or receipts for the repairs; detailed list of dama7ed 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 residt in delay in the handling of your claim.
All Claims-p�ease complete this section '�
Were there wimesses to the incidant'? �'esl No Unkno n � (circle)
Pr�>vidr their names, ��ddresses and telephoi�e numbers: ��.M1'�� `J �'(��� _
Were �he police or law enforcement called'? Yes No Unknown (circle)
It yes, what department or agency? ______Case#or report#
Where clid the accident or injury take place`? Provide street address,cross street, intersection, name of park or facility,
closest landmark,etc. Please e as detailed as possible. If nec sar�j attach dia�ram.
--�d_N.��� �i� ��,l���'� � �'e �2 _ I�V ���
Please indicate the amount you are see � �in comp �a ion or what ou woiild like tl�e City to do to resolve this claim
to your satisfaction. �--�C�'� ��.�.L ��� —
Vehide Claims- lease com lete this section ❑ check box if this section does not a i
Your Vehicle: Year��c{� Make Model__ � ��
License Plate Nurnber G�.23��C C.,, State � Color _
Registered Owner��--l-��"-��-�(`���
Driver of Vehicle �L-- 4' ���
�rea Damaged���� }��/���:, _�l.l--� �� �1�-S� � �
City Vehicle: Year_ Make_ __Model
License Plate Number _ State Color
Driver of Vehicle (City Employee's Name)___
Area Dair�aged_ ___
Lijurv(�'laims-please complete this section __ ❑ c:heck box if this section does not apnlv
How were you injured? f�1 �'1 _
What part(s)of your body were injured'? __ _ _ _— —
Have you sought medical treatment? Ye� No Planning to Seek Treatment(circle)
When did you receive treahnent'?__ ��_ _ (provide date(s))
Name of Medical Provider(s): __ _ — --
nddress _ __ Telephone
Did yo�i tniss work as a result of your injury? Yes No
Wflen �id you iuiss work'' (provide date(s))
Namc of your Employer: —
�ddress _ _Telephone
NJ Cherk here if you are attaching more pages t��this claim form. Number of additional pages �
By signing tliis form,you are stati�ig that all i�iforinatioiz you have provided is true and eorrect to the best
of your knowledge. Unsig�zed forms will fiot be processe�l'.
Sz�bmitting a false claim cara result irz prosecutiore. Date form was completed � � � �
Print the Name of the Person who Completed this Forrn:��u ��� �'r�
Signature of Person Makin�the Claim: __ _._ —
flc��i,cd I�ebruary ?Ol I
GRAND WHEELER ENTERPRISES INC.
1200 WEST 7TH STREET ESTIMATE#
SAINT PAUL, MN. 55102 010275
Phone-651-330-2387
grandwheelerent@aol.com
ESTIMATE FOR SERVICES Estimate Date : 07/21/2014
1999 Mazda - Protege DX
DUBORD, PAUL Lic# : Odometer In: 132458
Unit# :
VIN # :
Cust Id: 1,241
Part Description/Number Qty Sale Extended Labor Description Extended
Strut-Gas-Rear INSTALL RGAR STRUTS 284.85
333276 1.00 174.88 174.88 INSTALL REAR STRUTS
Strut-Gas- Rear Hazardous Materials 14.24
333277 1.00 174.88 174.88
Strut Mount-Rear Suspension
SM5457 1.00 67.98 67.98
Strut Mounting Kit-Left Rear
904995 1.00 44J2 44.72
Strut Boot- Rear
SB 102 2.00 35.04 70.08
Shop Supplies 26.63
Parts : $ 559.t7 Labor: $ 299.09 Tax : $ 42.64 Total : $ 900.90
Current Estimate... $900.90 Revision Amount... $0.00 Revised Estimate... $900.90
I hereby authorize the above repair work to be done along with the necessary material and hereby grant you and/or your employees
permission to operate the vehicle described for testing and/or inspection. Express mechanic's lien is hereby acknowledged on above vehicle
to secure the amount of repairs thereto. SMOG: I understand that I can have emission service and/or adjustments done elsewhere. I hereby
waive this right.
TEARDOWN ESTIMATE: I understand that my vehicle will be reassembled within days of the date shown above if I choose not to
authorize the service recommended.All Parts removed will be discarded unless instructed otherwise: Save all Parts .NOT
RESPONSIBLE FOR LOSS OR DAMAGE TO CARS OR ARTICLES LEFT IN CARS IN CASE OF FIRE,THEFT OR ANY OTHER
CAUSE.
SIGNATURE...................................................................................;............. Date......................................... Time.........................
Kare�s,Jeft PBge 1 Of 1 es117.01.04
.:
QUOTE
+�?� "-, s � y r Invoice Date Cust No. Order No. Page Invoice No. �
"�" 07/21/2014 100 106 - 83288 1 / 1 �
�
License:445566 Mileage:0 �I
�-�"-[�',r^�.�i.i::.:`�a `' 1999 MAZADA PROTEGE I
-- _i
St Paul Retail REMIT PAYMENT TO: -
1695 University Ave Royal Tire Inc
St Paul,MN 55104 NW�82a
Phone:(651)644-4905 PO BOX 1450
MINNEAPOLIS,MN 55485-7828
Sold To: Ship To:
PAUL DUBORD
803 N FAIRVIEW
SAINT PAUL, MN 55104
� Purchase Sales i Terms:CASH SALES �
��_Ord.No. Person Main Phone Other Phone Ship Via
�I
100 (651)497-0088 I
aty Qty �
Item No. Description F.E.T. Price Net Extension i
I Ordered, Shipped
OPALIGNPRT REAR STRUTS AND MOUNTS 2 2 214.86 429.72 i
I OPALIGNPRT REAR SPRINGS 1 1 107.82� 107.82 I
�MNLABOR LABOR 2.40 2.40 115.00 276.00
I ALIGN TOTAL VEHICLE ALIGNMENT 1 1 74.99 74.99 II
•.SHOPSRTL ENVIRO FEES/SHOP S-CONS'R 1 1 71.08 71.08
DO NOT PAY. THIS IS A QUOTE.
Sub-Total Parts: 608.62
Sub-Totai Labor: 350.99
Non-Taxable Amount: 422.07
Taxable Amount: 537.54
Tax 7.625%: 40.99
Total: 1,000.60
CUSTOMER SIGNATURE
A FINANCE CHARGE OF 1.5%/MONTH(18%/ANNUAL RATE) �I
WILL BE CHARGED ON ALL PAST DUE ACCOUNTS. i I
IX
RE-CHECK TORQUE AFTER THE FIRST 50 TO 100 MILES OF SERVICE