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Peterson, EricMinnesoto State Stotute 466.05 stotes thot,,. ,every person. municipolity within 780 doys ofter the olleged loss or injury is Please complete this form in its entirety by clearly typing documents to yoursubmission. You will not be contacted by weeks. This form must be signed, dated with all (cityclerk@ci.stpaul.mn.us), fax (651--266-8574) or Claimant: First Name: ERIC Last Name: pETER Please Indicate Your Pronouns: ! She/Her/Hers, Company or Business Name: ls this claim being made by an Insuranr:e ls this claim being made by an Attorney? yES / lf yes, provide your Insured's/ Client's Name: Street Address:297 LAUREL AVE city: sT PAUL State: MN Zip code: 55102 Daytime/Work Phone: 651-353-6390 Ctell phone: Date of Incident or Date Discovered (Nlust Please state, in detail, what happened that p TIRE WHEN I WENT TO DRIVE VEHICLE NEXT MOR Please state why or how you feel the City of Saint UNFILLED POT HOLES Please check the reason that most closely need to be provided with your completed form. the City of Saint Paul and shall not be returned. n Automobile damage from a motor vehicle a X Automobile damage from a street defect or E Automobile was towed and may or may not from lmpound Lot, and two estimates For repairs ! Snow Emergency: please provide copy of towi actual bill that has been paid. n Property damage: please provide two estimate ! You were injured during a motor vehicle ! You were injured in the City of Saint Paul: plea Nlorch 2023 NOTICE OF FORM to the City of Saint paul, Minnesota who cloims damoges from ony municipolity...sholl couse to be bctdy ofthe a notice stating the time, ploce, ond circumstances of cornpensotion or other relief demonded," printing your answers to each question. lfyou have additional you add those unless clarification is needed. The claim orocess for i can take of four (4) sections completed. Submission this comoleted form to the by email addressed to "Saint Paul City Clerh 15 West Kellogg Blvd., Suite 55102" He/Him/His, ! They/ Them/Theirs 1-353-5390 e): 5 / lO / 2023 Ti me: 5 :00PM you to file a Notice of Claim Form: HtT A LARGE pO oLE oN IT. FLAT ING. TIRE REPAIR SHOP SAID SPLIT SIDEWALL TYPICAL POTH r\GE. I is responsible for your Damages? SUMMIT AVE lS Dl!iASTER..i LED WITH the reason for your submitting a claim. Please not the ts that will roperty ofotographs will be accepted. All documents submitted t: please provide two estimates for repairs or actual ill that has paid. : please provide two estimates for repairs or actua bill that ha$paid. sustained damage: please provide copy of towing actual bill that has been oaid. (if availa$), rer:eipt ticket (if available), receipt from lmpound Lot, and estimates reparrs or for repairs or actual bill that has been paid. t: please provide police report number, details about i provide police report number, witnesses, and details ? YES / NO lf yes, what is your Claim/File Number? N lf yes, what is your File Number? NO I claims. ls there a police report for this incident? NO lf yes, please provide the police report case number: lf yes, what law enforcement agency responded? Where did the incident take place? Plelase provide a street address, intersection or name of ,city Orr;. or t SUMMIT AVE WEST BOUND, BETWEEN FAIRVIEW AND CLEVELAND. What would you like to see happen to resolve this claim to your satisfaction? PAY MY REPAIR BILL. FIX THE STREET PI-EASE!! Were there witnesses to this incidenti' Please provide names and contact phone numbers: NO, BUT THE ENTIRE NEIGHBORHOOD IS DEALING WITH THIS STRETCH OF ROAD. For propertv damage claims, including vehicle acr;idents. Your vehicle's information: Year: 2015 Make: BMW Model: 4351 Color: WHITE License Plate #: G25--WVG State vehicle is registered in: MN Registered owner of vehicle: ERIC PETERSON Driver: ERIC PETERSON Area(s) damaged:Rl(iHT REAR TIRE lf a City vehicle was involved, License Plate #:Color: Was there City insignia on the vehicle? YES / NO Driver's Name: Other property damaged : For iniurv claims of anv tvpe,, What part of your body was injured? Did you go to the emergency room or urgent care? YES / NO Where? Was medical treatment received? YES; / NO Where? First day of medical treatment?Are you still receiving medical treatment? \'ES / NO Did you miss any work as result of this, incident? YES / NO Employer(s): How much time have you mi:;sed frorn work? lf you are submitting other documenlts, please state what you are attaching and how many pages: By signing this form, you agree that all information provided is true and correct to the best of your Please NOTE that submitting a false or misleading claim can and will result in prosecution under Name of Person completing form: ERIIC Signature of Person submitting this form: Relationship of person signing to Party making the claim: Statutes. nluisea vrorcn zozs Date document is being signerd:r-\7"r,3 Retail Invoice 202355 Emailed on0511712023 Emailed to ericjp.rcm@gmail.com Cust Status: Drop Off Appt:Yes MIDWAY - 3OO SN Service Advisor: 1 SHANE Customer Details: PETERSON, ERIC 1245 LAUREL AVE SAINT PAUL, MN 55104-6928 651.353.6390 x1 Description COURTESY CHECK Battery Test ResultsYour battery is measuring manufacturer's specification for required CCA. BRIDGESTONE TIRE WITH RUN FLAT. PACKAGE 019772 DRIVEGUARD BL 255/40R18 XL99W 50, Warranty DOT# EJ3ACJA132O WARRANTY FOR DRIVEGUARD 255/4ORF1 8 ORIGINAL ARTICLE ffi19772 PRICE 286.99 REMAINING TREAD DEPTH 7/32 SERIAL # NEW TIRE WHEEL BALANCE LABOR TPMS VALVE SERVICE KIT LABOR 6-231C TPMS KIT VSTO 7040215 ROAD HAZARD WARRANTY SCRAP TIRE RECYCLING FEE LOW PROFILE TIRE INSTALLATION BRIDGESTONE TIRE WITH RUN FLAT. PACKAGE 019772 DRIVEGUARD BL 255/40R18 XL99W 50 Warranty DOT# EJ3ACJA132O WARRANTY FOR DRIVEGUARD 255/4ORF18 ORIGINAL ARTICLE ffi19772 PRICE 286.99 REMAINING TREAD DEPTH 8/32 SERIAL # NEW TIRE WHEEL BALANCE LABOR TPMS VALVE SERVICE KIT LABOR 6-231C TPMS KIT VSTO 7040215 ROAD HAZARD WARRANTY SCRAP TIRE RECYCLING FEE LOW PROFILE TIRE INSTALLATION Donation BOYSAND GIRLS CLUBS OFAMERICA (! www.TiresPlus.com FINAL INVOICE Store# 24'4226 16123 07:2LtAM 7723 08:06AM COUPI: 195.47 n the our battery vehicle. 7046930 2 MilerLimited 019772 99VY BL 44% 1720 Miler L.imited 99W BL 7013632 70081 90 7012743 7040215 7075078 7006472 2 019772 7013632 70081 90 7012743 7040215 7075078 7006472 7013276 arct new unless otherwise witrranty, maintenance, and Rev Hist /Article # lD 5 5 otv has sufficient power and should reliably start You're recommended to have your battery after90 oays. COURTESY CHECK N/C 126.28 11 99 3.15 7.00 43.05 4.00 N/C 94.71 11.99 3.15 7n.n 43.05 4.00 N/C 1.00 1.99 3.15 700 .05 4.00 N/C 1.99 315 7.00 .05 4.00 N/C 1ri3.90 1.00 A\/E N, SAINT PAUL, MN.0rr-5330 - 651.644.19'75 Vllheel Lock: Alt. Auth. Name & Phone: Technician 52,JOSE Vehicle Details: 2015 BMW435IXDRIVEI BASE 3.OL L6 FI GAS VIN #: WBA4B3C52F LIG #: G25WVG MN MfLEAGE: 114.310 Fage '1 of 2 .crom/auto-repai 01 be located art 1.00 14 2022 002 Retail lnvoice 202355 Emailed onO5l1712023 Emailed to ericjp.rcm@gmail.com Cust Status: Drop Off A1 Yes ln: Out: $tore# 244226 16123 07:21AM 12123 08:06AM MIDWAY - 300SNELL|NGAVE N, SATNTPAUL, MN. 55104-5330 - 651.644.1975 Payment History: Visa 2973 MID:222220327972 Term: 0003 Card Inserted AID:40000000031010 Total Tendered I acknowledge notice and oral app a change in the original estimated Signature or Initials 388.71 807160 Sale PIN NOI VERIFIED 388.71 ;; Labc Shol Sub- Tiax I T,ota ,alof Revce. Revision History: Amt r Supl Totarl 322.09 38.28 es 2.42 362.79 | 25.92 $388.71 .U' J 1) 05t16t2023 2) 05t16t2O23 11:22AM 01:28PM -342-7CI PETERSON, ERIC IN PEI 387.71PETERSON, ERIC IN PEI 'mation on tire warranty, maintenance, and safety' can be located at https://www.ti respl us. com/ti res/wa rra nty-opti o ns/ or by caff ing toll free 800-847-3272 to obtain a free priinted copy I have recerived the above goods ancUor services;. lf lthis is a credit card purchase, I agree to pay and comply with my cardholder agreement with the issuer. Customer Signature tSON iSON ^4/r! Fl TORIST U ]I/\NCE )GRAM UST T S'TANDARDS Comple Visi HOW ARE WE DOING? Tell us about your experience today! -' a 4-minute suruey for a chance to win one of ten $50 gift cards each month www.TiresPlusllurvey.com within 4 days and enter Code 244226-202355 Page 2 of 2 formation on service warranty, maintenance, and safety can be located at https://www.tirersplus.com/auto-repair-services/repair-service-warranty/'l ,lP 11 14 2022 002