Kaufenberg, Robert R�����:���
S�P �8 ����+
NOTIC� OF CLAIM I+'ORM to the City of Saint Paul, Min��p���L��
Nli��nesou�Siate Sttttrtte 466.05 stntes drm " ...everv persoi�...�vliu rlt�inr.e dumages./i-unr arTV�rttu�icipa/ih�....shrrll crrir.se tn 6e presrnter!to�ke
�u��ernirtg hurly of'd�e m��riicipality witiiift l80 days af�er the alleged loss or injtuy is dise•overed a notice stati�tg tl�e linre,place,cutct
circumstances tlrereo/;niid tlre amoiu�t o/�contpensation nr uther relic,f clemnnde�L,.
Please complete this f'orm in its entirety by clearly typin�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 rec�uested. You wi0 receive a
written acknowledgement once your f'orm is received. The process can take up to ten weeks or longer depending on the
nature ot'your daim. This f'orm must be signed,and both pages completed. If something does not apply,wrile`N/A'.
SEND COMPLETED I'ORM AND OTHER DOCUM�NTS TO: CITY CLERK,
15 WEST K�LLOGG BLVD, 310 CITY HALL, SAINT�'AUL, MN 55102
� � �
First Name �a���� Middle Initial� Last Name ��� �� �
Company or Business Name � " �� _ ` _
Are You an Insurance Company? Yes No Ii'Yes, Claim Number?
Street Address � / � �E���� ��E C.¢S7'�
e�ry -�T� ��y � State �� � Zi� Code ��5���
Daytime Phone (�� )7�7-���a Cell Phone (bs�)y�-S798' Evening Telephone (6�� )��Z- ��`�D
o°
Date of Accident/lnjury or Date Discovered �/7/� � Time �d � �/pm
--r
Please state, in detail, what occurred (happenedj, and why you are submitting a claim. Please indicate why or how you
f�l the ity of�S aint Paul or its employees ar involved and/or responsible or your damages.
/-� .S"�/�t t r�� /1�E't/'AOA �ilG`� E� �j/� //✓/✓Eli✓�P/�ziJf�r�I/El.�JA �p/b!7 c� 5 6jA �7^C'��
,Q�D /✓�D R�.s C• s ! u y�a i� p �'e r�r� ro � e n � ra/ r� A r
/N ,0�i v'C t�<► o ti�v S d a a /i't �N�u� ,y r� GcJ � S a� /�tS.. t (
� �C/.S !�1 ^C Ij.9�t. SC�A7� L',.p v� G?(� l,�E'd c�` .�i OC` GcJ/�?/S' O � ��`C,S' ��lc°d�
L'�►►�/1 lS' d c /� .,�,ohA/1� v /aCv J'e. �i*q .4 r Gcs r� s o� •�`cs
w�r t ,D P� e c �,, A U� GcJ�� n� SS p A A c r
I
Please check the box(es) that most closely represent the re�ison for completing this form: j
❑ My vehicle was damaged in an accident ❑ My vehicle was damaged during a tow
�I 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 ❑ 1 was injured on City property
❑ Other type of property damage—please specify
❑ Other type of injury—please specify
In order to process your claim you need to include copies of all annlicable documents.
For the claims types listed below, please be sure to include the documents indicatecl 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
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.
Pa�e 1 of 2—Please complete and return both pages��f Claim Form
I?ailure to completc and return both pagcs will result in delay in the handting of your daim.
All Cl�ims—please complete this section
Were there witnesses to the incident? Yes No Unknown (circle)
Provide their names, addresses and telephone numbers: ��''�'' ��u�"�`'r� ' b��- ��a —6 �d �
7 9 9 �c=v�o.� A�'�' , S'r. Pau i n-��� .s si o �
Were the police or law enforcement called'? Yes No '` Unknown (circle)
If ycs, 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. Ple se be as detailed as ossible. If r►ecesst�ry, attach a diagram. �rl�� W� � �"
.S'f�ce�f �'.�an� A�7�9NFVAoa �vt �, ,S-r����./ /r�iv, .�'s'ioG
Please indicate the amo mt you are seeking in compensation or what you would like the City to do to resolve thi• laim
to your satisfaction. ��p%�t� T✓��e ls d` �/r� S A�m'�►6 r^U �eL�1�S e ��
M /'c� ��'^ S�`�P e 7� %C'vt
Vehicic Claims--lease com tete fhis sectior� check box iftfiris secticjn does not a 1
Your Vehicle: Year '�2°d� Make /�� F � Model � � S � �✓ 6
� License Plate Number N������tate /�►h/ Color �d
Registered Owner v�•'��� d'���f`� �� �`� b�—s
Driver of Vehicle �� "� �'` 5
Area Damaged LJ�P"�s °� �
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle (City Employee's Name)
Area Damaged
In,�ur�Claims—piease complete this section �check box if this section docs not apply
How were you injured?
What p�u-t(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))
I Naiuc of your Employer; - -- —
Address Telephone
�Check here if you are attaching more pages to this claim form. Number of additional pages � .
�' P<<t�rR E s
I3y signing this form,yoce are stating tliat c�ll information you lzave provided is true arzd correct to tlze best
of your k�towledge. U�zsigned forms will not be processed.
Submitting a false claim can reszclt in prosecutiort. Date f'orm was completed �/ ` �/!�
Yrint the Name of'the Person who Completed this Form:
��P�-� �c�nde�`1
Signature of'Person Making the Claim: � a��
Revised February 201 I
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2767 LONG LAKE ROAD
ROSEVILLE, MN 55113
(651)483-4591 048222 289887
�� Fax(651)483-8418 •'' ' '' • ''
www.normstire.com 0 9/12/14 0 9/12/14
w
BOB KAUFENBERG
7 9 9 NEVADA AVE EAST TIME: 13 : 19 TIME PROMISED:
. L
S T PAUL, MN 5 510 6 ����������N " �- �c,���
48222
FORD MUSTANG 2007
l�,�, �ER °'t"�1lf�'�, �r;.''
HOME: 651/772-6200
CASH OR CR CARD 1
WORK: EXT.:
• • • � � • • •• �
ESTIMATE ONLY
20"AMERICAN RACING TOURQE THRUST M WHEELS/CHRO E
299 . 00 EA
255/35R20 GENERAL TIRES 179 . 00 EA
BALANCE--LUG NUTS--TOTAL 2100 . 00
RETORQU L G NUTS AFTER 100 MILES
e '� MISC. �� - �XC19E'�AX '���� � L`14�1�R� � ��tT _-;.;: ,, .: � L
� � . �� � . 0� � . �� � . �0 � . �� � . �� � . �� � . 0�
SUB—TOTAL: O . O O
PRODUCTS / SERVICES SALES TAx: o . o 0
TIRES - NEW/USED ALIGNMENT TOTAL SALE : 0 . 00
CUSTOM WHEELS BALANCING
&ACCESSORIES OIL CHANGES � ' � � o . o 0
BRAKES SUSPENSION WORK
STRUTS/SHOCKS TIRE REPAIR TENDERED: 0 . 00 CHANGE: 0 . 00
BATTERIES TIRE TRUING
VIBRATION ANALYSIS
Signature
FRED'S MINNESOTA WHOLESALE,TIRE,WHEELS & REPAIR
3955 HIGHWAY 61
WHITE BEAR LAKE, MN 55110
(651)426-4518
SAFTEY INSPECTION ARE REQUIRED ON ALL VEHICLES
9/15/2014 3:52 PM page 1
Estimate#48996
KAUFENBERG, BOB
Vehicle : 2007 Ford Mustang 5.4 L 330 CID V8 DOHC 32 Valve
Last Mileage : 0
Created : 9/15/2014 3:49:59 PM Odometer In : 0
Srv Writer: TM Odometer Out: 0
Parts
Qty Code/Tech' Description Condition Unit Price Price
4 20"TORQUE THRUST M $269.00 $1,076.00
4 2553520 GENEREL GMAX $177.00 $708.00
1 INSTALL KIT $49.99 $49.99
Labor ....................................................... $0.00
Parts ....................................................... $1,833.99
SubleUMisc. ....................................................... $0.00
Shop Supplies/EPA ....................................................... $0.00
Charges ....................................................... $0.00
Sales Tax Tax @$1,833.99*7.1250°/a $130.67
Estimate $1,964.66
I hereby authorize the repair work herein set forth to be done along with the necessary material and
agree that you are not responsible for loss or damage to vehicle or articles left in vehicle in case of fire,
theft or any other cause beyond your control. I hereby grant you and/or your employees permission to
operate the vehicle herein described on streets, highways or elsewhere for the purpose of testing and/or
Inspection. An express garagekeeper's lien is hereby acknowledged on above vehicle to secure the
amount or repairs thereto. All Vehicles left over 48 hrs. after repairs are completed WILL INCUR A
$5.00 PER DAY STORAGE FEE. 12 Month or 12,000 Mile Warranty On Repairs.
Customer Signature
Estimates are valid for 30 days.
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