Brown, Elizabeth NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
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 alleged 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 aaswers,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 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
�-- /�
First Name � � Middle Initial v -Last Name ��� � ^�E I V E Q
Company or Business Name "— �8 2�j4
Are You an Insurance Company? Yes No If Yes,Claim Number?
Street Address��� �"Y Gt.!�.. �—�—��-P , �'� CL���
City S7�' _ � State �,�,C� Zip Code y���
Daytime Phone(�`7 J� 5�11 Phone�)� I� Evening Telephone(�Z�� �` ��
Date of Accident/Injury or Date Discovered �G�Gc� �J"�,���T�me�am pm
Please state,in detail, what occuned(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 your damages.
..
Please check the box(es)that most closely represent the reason for completing this form:
O My vehicle was damaged in an accident ❑My vehicle was damaged during a tow
�vly vehicle was damaged by a pothole or condition of the street ❑ My vehicle was damaged by a plow
�My vehicle was ng u y towed and/or ticketed ❑ I was injured on City property
❑Other type of property damage—please specify ����
❑ Other type of injury—please specify �� ��-��+
GeJc�'._JCs �-- /�"1 '
In order to process your claim v��u°°d to include copies of all anplica e 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.
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
I 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 comnlete this section
Were there witnesses to the incident? Yes No Unknown (circle)
Provide their names, addresses and telephone numb rs: � �i�
�J o U °�' �-�C,Sz..
�-c� c..e,
Were th�e or law�enforc�e�alled? Yes No 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 park or facility,
closest landmazk, etc. Please be as detailed as possible. If necessary,attach a diagram. ,�[ �
/��� " Q�.:Q�,��o �L�_(,vm��n7� �" GO'st2m�✓�I
Please indicate the amount ou are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction. ��� f�"L� � c° �- !1 �,Q- r" � l� „ /l
.
� C� .
Vehicle Claims- lease com lete this section ❑ check box if this section does not a 1
Your Vehicle: Year Make Model
License Plate Number�`�� K.l�'1�- State Color �/c�e�'�_
Registered Owner�f i� �_�_�.�i ��,�-z.c.r.7
Driver of Vehicle S
Area Damaged
City Vehicle: Year Make odel
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
In'u Claims- lease com lete this section ❑ check box if this section does not a 1
How were you injured? �''"
What part(s)o your body were injure ?
Have you sought dical treat t? Yes No Planning to Seek Treatment(circle)
When did you receiv trea t? (provide date(s))
Name of Medical Prov s):
Address Telephone
Did you miss work a re t of your injury? Yes No
When did you mis work? (provide date(s))
Name of your E ployer:
Address Telephone
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: �P��-G""
�
Signature of Person Making the Claim:
� ��-�Zc-G-c�
Revised February 2011
Elizabeth G. Brown
NOTTICE OF CLAIM FORM—City of Saint Paul, Minnesota
Page 2
Reason for Claim: destruction of rim and tire
On July 15,while traveling down 7`h Street headed toward the airport from downtown Saint Paul, I hit a
crater that some would call a pothole. I was on 7th crossing Chestnut. Traffic was heavy but
manageable even though it was lunch time. Traffic was coming from the opposite direction and other
automobiles were in the right hand lane. There was no place to go except through the hole. Ironically I
was headed to get another tire and my car was full of gas. But due the extent of the damage, I then
needed to get a rim and a tire. I was able to find one at Crosstown Auto Parts on Marshall Avenue in St.
Paul. Because the incident happened after a payday,the car had to sit for 8 days. While I moved it
(inched it up or back a few feet into another spot on the same street) a couple of times during the week,
I removed my handicapped sticker and the next day I had a ticket. AAA replaced the rim and tire for me
but informed me that that was my last"no cost" call. I do not feel that call should be charged against
my account---it was the City's hole that caused it—not recklessness on my part. I learned when I called
to inquire about the ticket that there were "2"tickets issued to my car at the rate of $41 each during
that week. I do not have the tickets; however the Ramsey County Traffic Violations Office has record of
them. I have an envelop with instructions as to the cost of tickets...but no actual ticket. On July 23, I lost
three hours from work—trying to pick up the rim and tire only to learn that it"missed the truck" and
would not be available until the next day—more wasted bus fare at$2.25 a shot.
This pothole has cost me the following and I am asking to be reimbursed for the following in addition to
handling the AAA issue:
Rim and Tire $137.00
2 Parking Tickets $ 82.00
Bus fare for 8 days $ 41.00 (8 days at$2.25 during peak hours—to and from work only))
3 hours lost wages-- ($ 84.00) (3 hours at$28.00/hr.---no sure if reimbursement if allowed)
Total out of pocket lost 5260.00 +84.00 = $344.00
I also feel it is reasonable to ask that the City cover whatever AAA charged against my account
for this last AAA call. Attached are my AAA calls for this year. Please let me know what next
steps I should take. Thank you much for addressing this request.
��� ����� ��
�lizabeth G. Brown
651-230-1186
651-431-5956 (w)
July 31, 2014
u b, i• L V I T L � J I i�i
iuo. Ulyy r, �
,. M
August l, 201�
�lizabeth Brown
591 Blair Ave
St T'aul MN 55103
Dear Elizabetli Bro�rn,
This letter is to acknowledge your recent request for information regarc�ing yotu calls for
Bmer6ency Road Service. Club records reflect we received tlie follo�ing cails for
service tmder your membership:
Call # 187051
Address of Breakdown: 591 Blair Ave, St pau1, 1VIN�
llate : 2/20/14
Time ; 11 :13pitt
Trouble Code: Vehicle stuck needed extrication �,v ,Sno�J �3-c�a�"�
Vehicle: 2013 Nissan Altima (Taupe) �� �e �'c� �
Call # 60832
Address of Breakdown: Marshall Ave ��airvievv Ave N", St Paul MN
Date : S/10/14
Time : 3 :13pm
Trouble Code: Keys locked in tivnk needed loeksmith sezvice
'Vehicre: 99 73uick Itegal (�ilack)
Call # 9661'1
Address of Breakdown: Dale St&Blair Ave, St Paul,MN
Date : 6/1 S/14
Time ; 6 :41pm
Troqble Code: Flat t�re needed tire change
Vehiele: 99 Buick Regal (Black)
'W'e�value �oun�lnembership an� r9ok forwa��c� to ineeting your service needs in the future,
Yf furiher discussion is needed, please feel free to contact me at the toll fi•ee mimber listed
below. .
Sincerely,
a� .
ERS Member ltelations
ACGr Customer Cace
866-222-2273
Received Time Aug. 1. 2014 2: 38PM No, 0002
, �u l. 30, 2014 11 : 27AM No. 8780 P. 2
July 30,2014
Elizabeth Brown Th@, Au�O
591 Blair Avenue
Saint Pa�l, MI� 55103 Club Group
Dear Blizabeth,
Thrs letter is to acknowled�e your recent rec�uest for information regarding�ow call for
Brnergency Road Service. Cl�lb records reflect we received the following calls for service
under your rnembershi�:
CAII#, Date � Tlme
160$28 7/26/2014 11;37am
phone Service Required Statlon
(B51) 230-1186 7ire Change AAA M�N Fleet
Breakdown Y,ocation:
Sherman Street&7th Street W St. Paul MN
Destination:
Vehlcle Information:
1999 Buick Regal Black
'W'e hope t�at you will continue to call on AAA, and the next time you request sei�vice we
deliver the dependable road service you expect. 'We Value your Membership and look
forward to meeting your service needs in the future. Tf further discussion is needed,please
feel free to contact me at the toll free number listed below.
Since�-el�,
1`��`—�� `�„ "J�
- U
l7oreen McKnight ��
ERS Member Relations �1��
,� ��i 5
l��
Received Time Ju1, 30, 2014 11 : 14AM No. 9989
���/��(;E Invoice No. 136541
��ossro����r� ��c. � wEe�Y�ARs
us�nsUTO�ivRrs�`RUrt�sRt�s . Junkers, Repairables or Saleable
1440 Marshall Ave. • St. Paul, MN 55104 $100 - $10,000
Toll Free: 800-701-1102 • Phone: 651-645-7715 Order# 118196/3
Fax: 651-645-5183 Clairn Number Date 26 Jul 2014
mmur.�rosstamnl�irta.�tet Customer r�0# Time 11:34:46 CDT
Customer RO# Salesperson bob
Contac4 651 230 1186 Sales Type Cash
Invoice To Ship To
elizabeth elizabeth
MN MN
•
Delivery Customer Pickup I
I
Acct.Code
S:ack# Part Description Price
14F0455 (OAS)1999 REGAL Wheel 60.00
16x6-1/2, (9 siot),chrome 4031
Location:ROW 10 CAR 21
T;RE (CTA)2014 U.D.Tire 68.00
1 new 225 60 16"
Sub Total: 128.C�
Payment/Credits History , Tax1: 9.77
07/26114 Paymer,t:Cash 137.77 Tax2: 0.00
Total: 137.77 Total: 137.77
Amownt Due: 0.00
s
Invoice Terms
30 DAYV��[tP�����§F�$EoIR���!��I��I�I?��DP��DUM��P���ONS� NO REFUNDS.
HOURS OF OPERATION
MONDAY-FRIDAY 8:00 - 5:00
SATURDAY 9:00 - 3:00
CHECK# RECEIVED BY:
• . � �S .
•Hold or pull depo�lts not refundablr. •We assume nu labrx guarantec. •All claims and retumed goods MUST be acrompanled by thls bill. •No cash refund. •Merchandise sold"AS I5.""
•
BUYER READ:Insper�merchandua Il b cold'71S IS."We are no[re+ponsible�or damages o�any lo�s caused Gom labor,install�[ion,removal ur use ut�his merrhandue.We make no promise,
guarantee or warraNv other than what is shown on this form or displayed in this building.ReWmed mer<handisc acceptcd,and is limited to seller's option of replacement or oedit.
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