Farrell, Mike RECEIVE�
NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesbfa �4 2014
Minnesota State Statute 466.05 states that "...every person...who c[aims damages from any municipality...shall cause to be�r�s�nt�d ltltl�E R K
governing body of the municipality within 180 days after the alleged loss or injury is discovered a notice stating the time,place,and
circumstances thereof,and the amou t of compensation or other relief demanded."
Please complete this form in its entirety by clearly typi g or printing your answer to each question. If more space is
needed,attach additional sheets. Please note that you w' not be contacted by telephone to clarify answers,so provide as
much information as necessary to egplain 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 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
First Name M. � ��� Middle Initial 4J Last Name �a�'r�I �
Company or Business Name
-- --- -- -- _ ____
Are You an Insurance Company? Yes/ To If Yes,Claim Number?
Street Address i ��d� ���c�� /}-cr2 S a -
City � tn.�vt 5 v� ��P State /vL ,n/ 7ip Code 5��
Daytime Phone �1( SZ?Z�Z- ��� Cell Phone q5Z Z(z-(,d�� Evening Telephone `is2 2fZ_ b t'�
Date of Accidentl Injury or Date Discovered � `�l '��'f Time l a�= �� 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 Pau/l or its employees are involved and/or responsfible foIr your damages. Tk��.-'' i.v'u -c� v��'�/
u,r �D/�2. c:v� c r�' � .�►, - ��e�'G l c�in c� °� S b z � r � 2 t iv�.��
t t"� 2 1�n N � r �': ✓�c✓� -��'�- .+ }' c C a > c �¢i'j-�'
r�vY� Z �E�e� -��. �--1,e �'`�� L✓'� 1� o h- -�-1� �-��'2 ctv�c� rki n�e -f-�Q 1'L�n � Cct�D_
Tl� � �. �s � c„ :hi� r���,.� a �f�� a � �
r��e! t�✓ S �� n� h�c 1�/ ;.�s�T� c� 5 y��5 S �`b i� _ � c�„ ' ��„��( .�
,.�'� ��/ �o�rn '� +�Q CO S �- O � �"� V'�n.; h 2 L'�l ��('Q •. �ln Q, V'ti i n G 1�c�r¢ o�a� �l 1 p�-� 3�,+ �
_. ✓'e
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
�VIy vehicle was damaged by a pothole or condition of the street ❑ My vehicle was damaged by a plow
- - '� A'fy vehiclz was wmr�gfr�liy bwed��'w orti�e�d--J— — u I � � �' �ii�i� _ —
❑ Other type of property damage—please specify
❑ Other type of injury—please specify
In order to process your claim you need to include coUies 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 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 andlor 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
andlor 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—please complete this section
Were there witnesses to the incident? Yes No Unlrnown (circle)
Provide their names, addresses and telephone numbers:
Were the police or law enforcement called? Yes No Unlrnown (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 park or facility,
closest 1a�dmark,etc. Please be as detailed as possible. If necessary,attach a diagram.�1/�� ��-�1 �o�n c� �a.v�e
��- Gl e�e I�.h� 6 z�-ofe, �3 Q,,� l�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.� G � ., 3 '-�
Vehicle�laims—plea�e comgt�terthis-section - ❑ check bo�if this section does�ot apply
Your Vehicle: Year 1 C(� W Make r���� Model �j�-c�c e�-
License Plate Number � � State��Color G rQ�e�
Registered Owner /t'f:c�c��e( �a,,,��c. l l
Driver of Vehicle ���.� �=e ,�a �re t (
Area Damaged �.�o n-� D c�S�,�v�G.e r �F-�.r�
City Vehicle: Year Make �� Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name) �
Area Damaged
Injury Claims—please complete this section �check box if this section does not apply
How were you injured?
Wha.t 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 da.te(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 da.te(s))
ry Name o�`your Employer: """-f`
Address Telephone
$�Check here if you are attaching more pages to this claim form. Number of additional pages i .
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.
Subrnitting a false claim can result in prosecution. Date form was completed 3- l�-r-�`�
Print the Name of the Person who Completed this Form: /�,� ke �c,, v-✓-L l �
�
Signature of Person Making the Claim: • a � ����
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Revised February 2011
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recydable paper
>�;: 4.� �.�,.��,�q ;y ,. `�``� •�`�`�f � �� � \ LIMITED WAltRANTIES
.� "'��. .:�d NO t 1 4'FNY��YN Y� �f b� Vi �' f..y �Cj `� 1
r M i�Ah�"l��Pi�i9l�J���Cr�CJ64��yii�+�A��i!'Oi���er�AQ�'Pr�i�P f)
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��� �r �r�F;�,i� �(' ���I��v r�it�r ���r �� +�+����.,����f�� ����� �1SCOUIlt T1TC all[t Atllel'lCil S Tll'e StOTeS
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C���,�,���� __ ELIGIBILITY-These Limited Warranties apply to all owners of the tire using
�� it in non-commercial service,except for the Mileage Warranry which is limited
=�'_'<;';��'"� to the original purchaser.
: : FO R R E PAI R, R E FU N D O R R E PLAC E M E NT � '"� TO MAKE A CLAIM-Present your tire(s)and original sales invoice to any
Discount Tire or America's Tire Store.To locate a store you may call 1{888)774-
'� For a fee collected at the[ime of the origival tire purchase or for a fee collected to subject ��;:>;yl; 6560,or visit the Discount Tire web site at www.discounttire.com.The vehicle
other[ires ro the terms of this certificate, Discount Tire or America's Tire stores will =='�:;< on which the tire was used must be available for inspection.You will be asked
refund the purchase price and the sales tax,if any,on any tire covered in the event of a «:��;:'y�i� to complece the customer portion of the adjustment claim form.
'! failure due to workmanship and materials or a non-repairable road hazard for the service "=:
;, of the original tread down to 3/32 inch remaining, or 3 years from dace of purchase, �:��.;':?�j�; WARRANTY COVERAGE
whichever occurs first.Upon refund or credit of sales ta�c,cusromer hereby acknowledges ?_�:.�'�' New Tires-Workmanship and Materials-If our examination shows
�� by actual signature or eleetronic signature capture such credit or refund.Thls additional ='"�'��� that a assen er,SLJV,or li ht truck tire covered b this watratt has beeome
M '' '�;i�:;t+l, P 8 8 Y �3'
"�krs acknowledgement satisfies a technical requirement in the sales tax stamtes and/or _'..g;;� unserviceable due to a workmanship or materials defect during the service
regulations for many jurisdictions that a signed receipt must be obtained upon the refund T down to 3/32 of an inch,it will be replaced on a pro rata tread wear basis.
.�c• i�:::;;��
or credit of sales taxes.At the election of the purchaser,we will sell a replacement tire ' New Tires-Road Hazard(if a hcable)-If our examination shows that
>' to the purchaser at the original price paid for the damaged tire,plus the required sales =;:';;�;, PP
' ta�c.In the event the covered tire is discontinued or unavailable,a tire of similaz value will ��;:;ylj a passenger,SW,or Gght truck tire covered by this warranry has become
-.-.-:5;� unserviceable due to a normal road hazard(i.e.,non-repairable puncture;cut,
be substituted.
,�,..,�, -?''=:':;; snag,bruise,or impact break)durie�g the service down to i/32 of an inch,it
� ".�:::;�')/ will be replaced on a pro-rata tread wear basis.
If in our opinion,the tire can be safely repaired,we will do so free of charge.The cost of _.,�_,�,a,;�
this certificate is set forth on the receipt issued for the purchase of tire(s). ;��. � New Tires - Mileage Warranty (if applicable) - In addition to the
This certificate will be honored at any Discount Tire or America's Tire stores.This certificate : _ warrenties above, every mileage warranted passenger, SW or light truck
�" �S._=:;;; tire is warranted to the original purchaser for the specified number of miles
does not cover damage caused by collisio�,vandalism,chain damage,mechanlcal defects '��`;.y�,��� of tread wear and against normal road hazards for the same mileage (ff
�,� of the vehicle or willful abuse.No other property damage or consequential damage of any __-�:.��� applicable).If our examination shows that the tire covered by fltis warranty
kind is covered by this certificate. '=''��J°" has worn down to its tread indicators before rvin the s ecified number
. ♦ ij> 8 8 P
There will be additional chazges[o purchase a new certificate for a replacement tire and of miles of noncommercial service on the passenger,SUV or light truck on
\ which it was installed,it will be replaced on a pro-rata mileage basis.
�4� to balance a replacement tire. ,w:�� ,I�
"'','"'� �,:.:?"`° A1'V/Trailer Tires - If our examination shows that a trailer or ATV tire
By redeeming this certificate,the customer relinquishes the right to any manufacturer's === ` covered by this warranty has become unserviceable,other than by a road
< -�;;:y,;��
warrdnty that may apply,and Discount Tire or America's Tire may claim for its own benefit : .,,/ hazard,during the three year period following its date of purchase,it will
r�, any such manufacturer's warranry. ::c:'-;;� be replaced based on a charge of 33%per yeaz or part thereof of the original
���'�+i;!i) purchase price.
� • � • � � i=_�:';�i'
�' �;i�'';�;±} CALCUI.e11'ION OF REPI.ACEMENT CHARGES - Tires are replaced
�, ='=-`•'''f under these limited warrauties with a comparably priced oew tire at a pro-rata
'I D'��O��� �� cos�t to the customer.Tread wear is pro-rated on the gasis that the t'upe is worn
� out when the tread is wom down to 3/3z of an inch remaining tread groove
�' �? de th or to the tread wear indicators on tires containin them.Tire re lacement
�,� . ��! � cost is determined by multiplying the original cost of the tlre by the percentage
T ' � � of tread used For example,if the original tread was 11/32 of an inch,and the
� ��::,�j tire has 5/32 of an inch of tread remaining at the[ime of replacemen[, the
' replacement cost will be 75%of the original cost((ll/32-5/3z)/(11/3z3/32)
�;,�i�,,., ��� � x 100).The replacement cost for mileage warrented tires is prorated at a set
°w@,','�* :__:+��� charge per 1,000 miles driven.F.E.T.and state taxes are added to the replacement
��1� 1Vr� N��N r1�y�� �f�+� Nn�1 1u��� �irr wst AddiNonal c es for mountin and balancin l
�� tt ��1 �� a ��� �� �� a������ ���� � �������� ������E �t����F ���i�r �'$ S $aPP Y•
��� . : '. ° /� ' ; ���ll�l�`��qltl�l���1�11 R�1�1�11 f' 1�1�A,�1�1�1'1 ' 1 11, � ♦ 1)
' e ePys . r :4.,• .k .�J�` �,!� O�i ���s� �t0i ��ai�� pi�����p����ii 0♦ i
�S�_�4. ' i.. L' _ H M�'C i f1'W:. � ' '
�y ,� _, =_ �� �_ � ___ ITEMS NOT CO�'ERED-These warranues do not cover:
The cost of any tire includes any wheel weights used in the balancing of the tire. • Use in commeccial service such as commercial truck racing,street
sweepers,off-the•highway tani,Ilmousine,or similar service(however
commercial service does not include use by the owner as transportation in
his/her regular trade or business);
T I PS T O I M P R O V E T I R E � Damage,destmction,or failure due to accident,fire,or vandalism;
• Irregular or premature tread weaz caused by improper inflation,
M I L EAG E A N D SA F ETY �salignment,imbalance of wheels,or wom out shock absorbers or brakes;
• Damage or failure due to non-tire causes such as being run flat,mechanical
cbnditionofthevehictc;YCrtsfrom-iimsvrchaine;�rae��viltfuka�nee; --
' �ROTATE TIRES � REPLACE • Problems related to the appearance of the tire after the fust 10%of weaz.
, every 6,000 to 8,000 miles or when wom-out tires when built-in wear bars ownnx'S DI71'IES-Ic is[he owner's responsibility to:
neeessary to equalize treadwear. appear across the tread surface. • See that the tires are opera[ed at proper intlation,pressure and loads;
�REBALANCE � REMEMBER TO RETURN ' Pay applicable tazces and dealer services such as mounting and balancing;
every other rotation to promote even to any Discount Tire/America's Tire store • Return the adjustable tire and complete the customer portion of the
adjustment claim form.
tire wear and a smooth ride. for a tire inspection.
DURATION OF COVERAGE-These wacrandes expire three(3)years from
; �MAINTAIN AIR PRESSURE the date of putchase
as recommended by the vehicle or tire �! CONDITIONS AND EXCLUSIONS - These limited wa�anties are the
manufaeturer.Cheek your air pressure at least � � � �. exclusive warrancies of Discounc Tire or America's Tire stores,are in Iieu of the
onee each month when tires are cool, wanannes ot ct,e manutacmre�,and set forth the exclusive remedies available to
the tire user.In the event that the terms of an applicable manufacturer's warranty
� �MAINTAIN ALIGNMENT exceed the protection given under these warranaes Discount Tire or America's
Tire stores will honor those terms Discount Tire or America's Tire may claun
, (Front&R2ar)replaCe wol'n SuspenSion parts. '°; for its own benefit any such manufacturer's warranty.These limited warranties
�
A�R �H�E�K� �� do not provide compensauon for any consequential, special, inciden[al or
�PLEASE DO NOT USE i contingent damages. Some States do not allow the exclusion or limitation of
incidental or consequential damages,so the above limitauon or exclusion may
any"Fix-a-Flat"type products. ��p�ES GA��' not apply to you.Tires presented for a claim remain the property of Discount
�( � � Tire or America's T've Stores.No representative or employee of Discount Tire or
' �INSPECT nmerica's Tire Stores may enlarge or alter these warranties.
, tires occasionally for ezcessive wear,tread
CONSUMER RIGHTS - These limited warraaties give you specitic legal
Or Sld2wdll CutS,Of Oth2�d8md92. rights,and you may also have other rights which vary from State to State.
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