Seivert, Lauren • � 1 4���'E F .` ..�..,.n RpCJ
`�
NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesdr F 1� `�4�
�� ; � -,:
Minnesota Stare Statute 466.05 states that°...every person...who claims damages from any municipality...shall cause to be s nt�d t �--_ `` '`
governing body of�he municipality within 180 days after the alleged loss or injury rs discovered a notice stating the time,place,and
circumstances thereof,and the amount of compensation or other relief demanded."
Please complete t6is 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 proces.s can take up to ten weeks or longer depending on the
nature oP your claim. This form mast be s�gned,and both pages rnmpleted. If something dces not apply,wrtte`N/A'.
SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD,310 CITY HALL, SAINT PAUL, MN 55102
First Name L-�/t.�,� V� Middle Initial ��Last Name ��v�r�
Company or Business Name
Are You an Insurance Company? Yes No , ff Yes,Claim Number?
Street Address � �
City ���C'y�(:]Q� I Cl�"1�S State 1 v l Zip Code��
Daytime Phone(��-�Cell Phone(�� g��/787 Evening Telephone(_� -
Date of Accidend Injury or Date Discovered ��(DI U.CT �7� �a'�Time '�� am/�
Please state,in detail,what occurred(happened),and why you are submitting a claim.Please ind'cate w or how you
feel the Ci of S 'nt Paul or its emp oyees aze involved and/or responsible for your ages. '�k.
r � � � , r ll� I r
� � ��
�
r� ` � � i '�'1 �Cti1l�
v ` �
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
�11y vehicle was damaged by a pothole or condition of the street O My vehicle was damaged by a plow
❑My vehicle was wrongfully towed and/or dcketed O I was injured on City property
❑Other type of property damage—please specify
❑Other type of injury—please specify
In order to process your claim vou need to include covies of all aaplicable documents.
For the claims types listed below,please be sure to include the documents indicated or it will delay the handling of
yoeu�claim. Documents WII.L NOT be retumed and become the property of the City. You are encouraged to keep a
copy for yourself before submitting your claim fotm.
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 dcket issued and a copy of the impound lot receipt
O Other property damage claims:two repair esdmates 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 retumed.
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 comulete this secHon
Were there witnesses to the incident? Yes No nknown (circle)
Provide their names,addresses and telephone numbers:
Were the police or law enforcement called? Yes (,� 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 par or facility,
clo st landmark,e�Pl e be as d tail as possibl . If nece ,attach a di '"
` �j��
Please indicate the amou you are seeking in compensadon or what you would like the City to do to resolve this claim
t bS t s�d n. a:.3 C) �
,
o �
Vehicle Claims- esse lete tt� O check box if 's section does not 1
Your Vehicle: Year Make Model
License Plate Numbe - _ State��_Color�, '
Registered Owner �
Driver of Vehicle
Area Damaged 1 �„' � �•
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
In Claims- lease com lete this section check box if this section does not a 1
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))
Nazne of your Employer:
Address Telephone
�Check here if you are attaching more pages to this claim form. Number of additional pages
By signing this form, you are stating that all in forn:ation you have provided is true and correct to the best
of your knowledge. Unsigned forms will ieot be processed.
Submitting a false claim can result in prosecution. Date form was completed G ��
Print the Name of the Person who Completed this Form: ���ti1 /� �` � �'����
Siguature of Person Making the Claim•
Revised February 2011 •
� CLUB MRNAGER JENNIFER MERCIL
( 651 ) 406 - 0079
EAGAN, MN
08/18/14 08:53 6503 473g 042 1821
, MICHAEL SEIVERT
TMA ITEHS F�LLOW
� ORDER NUMBER 0098670091343
5 TIRE INSTAL 15.00 N
� 510526 206/60R16 93.22 T
TMA ITEMS GOMPLETE
• SUBTOTAL 108.22
TAX 1 7.125 X 6.64
- TOTAL 11�.86
' VISA TEND 114.86
ACCOUNT � �**+ �*�* �*�* 6689 S
. APPROUAL � 096697
TERMINAL � 281031616
CHANGE aUE 0.00
Vlslt sa�aclub.cop tn see your• savinss
# ITEMS SOLD 2
TC� 6280 6682 1430 9032 9400 5
- 1111111111111111111111111111111II11111111111111lillllllllllllllllllllilllllllllllillllilll
Please tell ue about your sF�opping eap�riencd
http:!lwwHR survey,sa maclub.oom
IN RETURN FOR YOUR TIME YOU COULD RECEIVE
ONE OF FIVE$1,000 SAM'S CLUB 3HOPPING CARD3
Must bu 18 or older and a lepal reaident d the 50 U3 or
� DC to enter.No purchase necessary to enter ar win.70
e�ter without purchase and for dficial rules viait:
ww�n.entry.survey.samacl ub.com
Sweepatakes period ends on the date ahown in tlie
�cial rules.8urvey muat be taken wittun
TYVO weaks of taday.
Eata encueata tambibn se encuentra en eapanol en la
, p5gina de Internet.
*** MEMBER COPY ��*
� � ��,�� �e �v�.�—
t ���- r� �� i �
,
� � -�-
�� �� c��.�,��
�,� o��-h�al �� � �d
M
1��� � �--1—.
7
�
CLUB#04738
3035 DENMARK AVE
EAGAN, MN 55121-0000 US
(651)405-0079
LIC#MN
See cashier for michelin re istration card or visit
www.michelin.com to re is�er our tires
DATE NAME i PHONE# � 485700 91343
08-18-2014 SEIVERT,MICHAEL , (651)698-7681 �
� YEAR MAKE MODEL COLOR
2006 CHRYSLER SEBRING Silver
I L[CENSE ODOMETER MEMBER ARRIVAL TIME SERVICE COMPLETED TIME �
� 874APC 102141 2014-08-18 08:53 AM 2014-08-18 12:05 PM i
� Service Description Ser�✓ice I
-- ,
TIRE INSTALL PACKAGE Whitewall-N/A 15.00
-Tire Pressure-Drv Rear-CHECKED,30 -Tire Pressure-Drv Front-CHECKED,30 i
'� -Tire Pressure-Pass Rear-CHECKED,30 -Tire Pressure-Pass Front-CHECKED,30
-Valve Stem-Dn Rear-COMPLETE -Balance.4ccepted-Drv Rear-COMPLETE , i
� -New Tire-Drv Rear-COMPLETE I
-DOT Number-Drv Rear-APXWAX310713
-Dispose Tire Accepted-Drv Rear-COMPLETE -SAMS Battery Check-DECLINED
Not Applicable
i
LUG TORQUE I
Drv Rear 100 FT-LB �
i TREAD DEPTH I
iDrv Rear-10,33 �
I
� I
I
I I
I I I
II I
I
�
�
Merchandise Description � Quantity Unit Price Merchandise
j 205!60R16 92H TRDT l 93.22 93.22
�
i, ' ; � I
�I i I I I
� � ;
I
i � I '�
IMember Comments Total (Excl::ding Tax& Govt.Fees) 108.22
� PLACE NEW TIRE ON DRIVERS REAR �
PUT ON SAME AXLE WITH BEST TIRE I pLEASE READ IMPORTANT INFORMATION BELO
PLACE SPARE IN THE TRUNK I AND ON REVERSE
651-894-4787 � DISCLAIMER&ACKNOWLEDGMENT
I�I Technician Comments 1 authorize the stared service completion and give pennission to operate the vehicle.
I.Sam's Club is not responsible for loss'damage ro!he vehicle ur items left in it.
I ?.W'hen perfonning tire services or non-tire related services such as battery.wiper.or any
� other services.Sam's Club dces not perfonn any tve inspections other than those indicated
on this Service Ordec Gnless indicated on the Service Order.Sam's Club associates do not
iinspect the spare t've,if any.
i 3.�lembers should follow vehicle and tire owner's manuals guidance and kequently check
i tves for proper inflation pressure,tread depth(more than 3'32"in all groovesl and
conditions like tire age.cuts,punctures,cracking,bulges and uneven vead wear. B.-�TTERl'TECHhIC1AN:BR.AVDON ZOSG
Driving wnditions and vehicle operation may affect the safery and perfonnance of my tires CO�I�fOti TECH\ICL�,N:BRAVDO!�'_03G
I have read,understand and accept all provisions of the disclaimer and acknowledgment
above and the warranty starement on the reverse coverine parts and service on this��ehicle. Ql.�:�LITI'CON'TROL TECH:DEBOR.-�H 1321
I � S.�LES ASSOCI.�TE:DEBORAH 1831
� TIRE TECH�lC1.-�\:BR.a�DON 208G
� 08-18-2014
� MENiBER SIGNATURE DATE �
HAVE YOUR LUG NUTS RETORQUED AFTER THE FIRST 50 MILES.
�
, o ��� ���� 'V
�
, � �- �
� i �1 �
S ( ,
\� �-
( I/l C
� ����� �
� ���
I � -
�
� ` /�! -
��� �
��S� �./
�,
2006 Chrysler Sebring 16x65-aluminum-alloy-Sxl00mrr►-bolt-patter... tritp://www.getallparts.com/Chrysler-Sebring-2006�-26462-premia..
�Call Us 800,5241461 1 Wekane.piease si�►�in� q My Yehicles Od 0 items-30(shoppin�artaspxl
(td:18Q0,52�146n
ra�sa�rmroact�
�— ' se�ect venicle
- 1 � CHfCKOUT(cAeckoutanon.aspx) VIEW CART(shoppingeart.aspx)
GET ALL PARTS
Search by keyword,make,madel,or part numbei q SEARCH
(defaulkasp�
Chrysler Sebring 2006(chrysler-sebring-2006-parts.aspx)/Wheels and Tires(/c-202-wheels-and-tires.aspx)/Premium SureFit�
16�.5 Alurrrinum Alloy 15 Spoke Wheel,Rim-2228
sHa�� ,.
(ernaiProduCte�spXtProduCtl�26462)
A�
2006 Chrysier Sebring Premium ��' '�8A"
�'" � '� SureFit�16x6.5 Aluminum Alloy 15
.� � �� �. Spoke Wheel,Rim-2228 Q�,�,:�
' ' 5123.56
� � ,;_.� ��
�, � � �� Add to C�rt
`�� _ Part f:ALY02228B10
t` MYnuhcturor Part#:
Reconnnendations
i a, Vfew laroer fmaae
Description
Wheel Dlartieter: 18
W hesl W Idth:6.5
W heel SF�e:16�6.5
Nurtiwr of Lugs:5
Bok CIrcN:100mn
Bok Pattern:5x100mm
Offset:42rtm
Msterial:Aluminum ANoy
Piece:O�e
Desfgn: 15 Spoke
Placert�eM on V�ehick:Universal
Featwes Incpided:Flat�ea to ceMe�cap area
HoNender Number:2228
Identiflcatbn Number:ONVF99�RAAAE
We are not aiftYa�ed with Chrysler CorPoraUon.Aq tradert�arks meMioned herein bebr�g 4o tl�eir respectiue
owners.
Center Cap(s),VaNe Stem(s►,ViiNe Stem Sensor(s►,and Lug Nut(s)as w�eN as Lug Nut Covers are
Not IncNWed
Vehicle Fitn�r�
. '�,��--
0
��� ��� - '
� a
/� 1 � �� 1 �
�
'l Vl�- l
. G�
f �� �I
;, � � �
G� � �
�� ' �� �� �
c� -
� ' ,
�� .
..
J
• � �-. -
y,,..
,
:�.:
- •T � ��'�♦ �� •t�� �� .
. J• ,r r�Y�,,
a - � r�� ��„� � ��• ��,.�_ • `,4t.t��" �`.,-
:, 1'' ' . . ' "Y 'I �" '- ' .
� i
� ��h� ��1- '
r se� �,,�-
� �� � 7 �-� r `�
U
1
� ������
�
t
1
� .
� �
�. >�` ;
, � _ :
, .,.:
`�����,�� � � .
.r-�.a' ��e
r:;
X 2.. - "�'�s .s<
� �
�
.�..
.�.:z t- �^''" ;y �'�3':"#;�`°`
_ �� _3
���Y
j{) �� .
X �� t ry `
' �'°f ° -
� 5
r� '-� -.
��: �
�. � " _.,'�� ; S '.�.-
:F;
f �
�';t si+-_
JS�y..
Y�;z� iJ� %�.
y�=K�:'ar.`
.c,_- 3
F-;�i.�'��-
:✓�_ '_ •.i-.
��-� � ,
��. W ��h�fr ry ^ti� y.
� , r��'i��--�*"�` �t r _. . ' �� �.
LY V� � �� c.X/i`�rC/�v
,I-� .�O
�(,�,q l.c.S}— ��, p�.U 1 � ;
u
�yl C i�G?��rf'
,�
�
�
'�`v
��. `
��� � �'4t
,. ,
�
- �;
s
�
1
i �'
�
, ,� ,
_ �� :;
;
,�£�` �
a
t
La,�� 1M - �e�ve�-
� �S�- �� ao� �
� �
�c���w�-
�
�
� �