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Mosher, Jason �� iUG �4 2�1� NOTICE OF CLAIM FORM to the City of Saint Paul, Minr�� C��K Mtnnesota State Statute 466.05 states that"...every person...who claims damages frorn any munzcipa�ity...shall cause to be presented to the governing body of the municipality withiri 180 days nfter the allegecl loss or injury is discoverecl a notice stating the ti»ie,place,ancl circumstances thereof,and tlie araoitint 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 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 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 Jacon _ Middle Initial M Last Name Mosher Company or Business Name Are You an Insurance Company? Yes/�io If Yes, Cla�m Number? - — _ Street Address 21168 Macon CT City Flk River State MN Zip Code 55330 Daytime Phone(7f� )244 -�32Z_Cell Phone( ) - Evening Telephone( ) - Date of Accidentl Injury or Date Discovered 1 AUG 2014 Time 11�45 �/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 your damages. I wac vi l.in��_mv uniforms from Ft SneLli�.g and returning to��ork in St PaLI While driving back. � . , � . Please check the box(es)that most closely represent the�eason for completing this form: ❑ 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 L� Other tyi:,e of property damage—please specify ❑ Other type of injury—please specify In order to process your claim vou need to include copies of all auplicable 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 WILL 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 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 comnlete this section Were there witnesses to the incident? Yes � Unknown (circle) Provide their names, addresses and telephone numbers: Were the police or law enforcement called? 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 landmark,etc. Please be as detailed as possible. If necessary, attach a diagram. On 7th St. W,between St. Paul Ave and Circus Juventas heading West. Please indicate the amo nt you are seeking in compensation or what you would like the City to do to resolve this claim to your satisfaction. ��,1G�I � a'q Vehicle Claims–please complete this section C7 check box if this section does not applv Your Vehicle: Year 2014 Make v�,�k�,,�,aoP., :�'Iode�passa±'TDI License Plate Number State MN Color Black Registered Owner Tason Mos er Driver of Vehicle Jason Mos er Area Damaged Drrver s si e ron ire 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 �7 check box if this section does not applv 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 __—_ _------- �'elonh� - - - � Check here if you are attaching more pages to this claim form. Number of additional pages L. 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 12 AUG 2014 Print the Name of the Person who Completed this Form: Jason Mosher Signature of Person Making the Claim: o-�" �� - Revised February 2011 PA RAMOUNT AUTO S E RV=C E OWNED AND OPERATED 3Y A PROUD GOODYEAR INDEPENDENT DEALER 7151 RIVERDALE DR ��,,,�'��'~ RAMSEY, MN 55303 (763)432-6847 GOOD�YEAR FEDERAL TAX ID# 411811560 �DlJNLOP R.AMSEYGOODYEAR@THELINNCO.COM =NVO =GE 08/O1/14 08/02/14 KELLYi�TIRES R- 04553Z o4 :46 PM 03 :11 PM `TERR: 7 6 2 3 : PAGE: O1 NONSIG: 155832 BILL TO: JASON & STACEY MOSHER 17138 MONROE ST NW ELK RIVER, MN 55330 PHONE 1. . . . . . . (763)244-5234 EXT. VEH YEAR/MAKE. 14 VOLKSWAGEN PHONE 2 . . . . . . . VEHICLE MODEL. PASSAT DATE REQUESTED 08/Ol/14 VEHICLE COLOR. BLACK TIME REQUESTED LICENSE/STATE. NONE / N1I�T RETURN PARTS. . NO ODOMETR IN/OUT 3362 / 3362 SALESMAN. . . . . . 066 / 022 VEHICL�E ID #. . 1VWBN7A36EC091452 PRIOP. TNS.'OI��. 044�43 _ _ .. ACCOUNT # COB TC CUST# TYPE/STATE AUTHORIZATION CREDIT CARD N0. 762300051 V Ol 04565 0 MN 194409 HDC 0651 SLSM TECH PRODUCT CODE BC QTY DESCRIPTION PARTS LBR/EXCISE LINE TOTAL 066 397-700-000-0 R 1 235/45R18 CONT PRO CONTACT 178.83 .00 178.83 066 676 040-103 R 1 TIRE INSTALLATION - WITH PURCH-IN STORE .00 .00 .00 066 676 093-108 R 1 ROAD HAZARD PROTECTION DECLINED .00 .00 .00 066 676 093-110 R 1 LIFETIME COMPUTER BALANCE AND ROTATION 3.00 - 4.00 7.00 WHEELWEI6HT 2.00 WHEEL WEIGHTS 066 676 093-901 R 1 *TIRES SHOULD BE ROTATED EVERY 6000 MILES* .00 .00 .00 066 OQ6-223 R 1 MISCELLANEOUS SHOP SUPPLIES .00 .00 .00 066 022 093-111 R 1 ENVIRONMENTAL FEES / HAZARDOUS WASTE 2.50 .00 2.50 066 022 097-100 R 1 DOT A3X66NH1414 .00 .00 .00 ** COMPLETE AUTOMOTIVE SERVICE BACKED BY THE BEST WARRANTY IN THE INDUSTRY 12 MONTHS OR 12,000 MILES ** *YOUR COMMENTS AND CONCERNS ARE IMPORTANT TO US, VISIT OUR WEB SITE AT WWW.PARAMOUNTAUTOSERVICE.COM******* ** THANK YOU FOR CHOOSIN6 PARAMOUNT AUTO SERVICE FOR YOUR SERVICE AND TIRE NEEDS **** ' PARTS TOTAL........ 184.33 LABOR TOTAL........ 4.00 , CHARGED AMOUNT 201.29 SUB TOTAL.......... 188.33 X____ ____________________________ TAXABLE AMOUNT 181.83 SALES TAX.......... 12.96 CU TOMER AUTHORIZATION FOR TOTAL =N V O=G E TO TA 1.._ $Z O�I - Z S7 TREAD L/F.. ... 11/32 TREAD R/F... .. 11/32 TREAD R/R... . . 11/32 TREAD L/R..... 11/32 S E E RE VE RS E S =�E F OR =MPORTANT SA F E TY WA RN =N G AN� WA RRA NTY =N F ORMAT=ON HAVE A QUESTION OR PROBLEM� Please tell our stora manager.W8 value your opinion as much as your business.Should you need additional assistance,cali our CUSTOMER ASSISTANCE LINE 1-800-321-2136