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Cherre �:. �� _ REC�liiE� , APR i 3 2012 � � NOTICE OF CLAIM FORM to the City of Saint Paul, 1V.�� ! Minnesota State Statute 466.05 states that "...eve erson...who claims dama es rom an munici ali shall cause to be resented to the � ryP S .f Y P �J'... p , governing body of the municipality within 180 days after the alleged loss or injury is discovered a notice stating the time,place,and i 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 i 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 egplain 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 .'"1��l�- Middle Initial�' Last Name �.�1��1r 1r �i Company or Business Name �� —--_ __ - - - _ _ -- __- Are You an Insurance Co�p�ny? Yes �fo If Yes,Claim Number? � --- --- - ____ -- Street Address OV'� j2[� r l..Or. � °'� �i ��1 z City � �f�1,Ot�'/1r t�l State ry Zip Code . Wb Daytime Phone ��1�-03Z CeYI Phone(��)�- 7��Evening Telephone�)�'� 2,99LP Date of Accident/Injury or Date Discovered 7*��j�, Time��p�► Please state,in detail,what occurred(happened), and why you are submitting a claim. Please indicate why or how you feel the City of S 'nt Paul or its emplo ees are involved and/or responsible for your damages.01'1. ZI ZR �W L�, �v�v e1t,Z � o �e � y r��►�t, 33� r v M j u � fi� Z •Y � � ►�a,s rfl �y+�, •n evv rn- .� i ls r �l�e. �n a�-�H � r> Q r �� t � � � DW Y� IYVCY� 1 �� l� D �7 V � r r�ry � c,e an-o� �p �, `��'/-�L �t �evy C�. �� Yl-� �ocar',� oF � Z L'�� Sr►Uv� � easeecheck thb x(es)h t mo�st closely represent th n f com t is form: Ce,yyipVGt, j,. - c�q,,�.��,� ❑ My ve hic le w a s d a m a g e d i n a n a c c i d e n t ❑ 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 _ __ sarx wed and/or ticketed�_ �❑ I was injured on City property ❑ Other type of property damage�please speci ❑ Other type of injury-please specify In order to process your claim vou need to include copies of all applicable 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. `�S2 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 �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 complete this section , Were there witnesses to the incident? Yes No nlrno (circle) Provide their na�nes, addresses and telephone numbers: ' '� Were the police or law enforcement called? Yes N� Unlrnown (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,lan k,etc. Please be as de iled as possible. If ne essary atta.c a diagram. �'hz r�,c;� a C euS`s2�c� �-if�e.��► i c� e.��'.�-��.�l,v� s s Please indicat�the aeinount you are seelcing in co�n}ation or what you would like the City to do to resolve this claim to your satisfaction. � � . .Vehicle Claims—� Iease com'��Yete this'sec 'an ' ❑,chec �be��is section d�es not a 1 Your Vehicle: Year ' D Make C�1`� ' Model G✓ L�`f"� • License Plate Number State Color Registered Owner �� f� Driver of Vehicle Sa+y1 l� p�S Vyt1rL Area Damaged �fOn 1/V1'yl S ti City Vehicle: Yeaz Make Model N J�, License Plate Number State Color � Driver of Vehicle(City Employee's Name) Area Damaged In'ur Claims— lease com lete this section check box if this section does not a 1 How were you injured? 61.m What part(s)of your body were injured? Have�you sought medical treatment? Yes No Planning to Seek Treatment(circle) When di.d 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? ( rovide, te s �,_ R , _ �_. : , . ,P....�r,.�.� .�..� .,�.�. I�amg�q�your Emplo • _ _ ...- Address Telephone �Check here if you are attaching more pages to this claim form. Number of additional pages T . 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�iot be processec� Submitting a false claim can result in prosecution. Date form was completed_`��l�j� Print the Name of the Person who Completed this Form: /t(��Q ��//°e, Signature of Person Making the Claim: J Revised February 2011 �'' � � � � � ,� � ��r � '�. �� a $ . c,. � `a i ..� � � `� ` b� `�� . ,� ; � . � �; � �� x � � �� _ , .. � ` �.�� , , � ..: � :. � � � , � � ,_ . � .. � � � > � +: �� ,� �� _ � �'' � �r.,� _ �, r� � � � � f � ��" �'� � :�� a4 � `` �` � W,� �; E€�� ,� �„� ; � x , �` � t'�,� p � .. . tr ��z � � � ^ �' �F� �' �. � ��. � .. . .. . � k(� � . . ....,�..�. � �: a� ��€ � � � �� , ' " �. � � i� � �;, r � � � �� :� �.�>,�• ��-�.�> � � � � � � �! +a +�r�� ► �, � : � . �� ` � � +� ;�� e � � � �` �� , � � '�� '� , � :� � �� #� : � � �!� � f R � �� A . . �� .. � .. ... � � �� '� � � . , � . .. � � . ,� � � $ � � r� � . , '�` � ��:. �, ��. ,�, � � � , � �� _ � � �� : � � � , � � � � � ��"��. � �� , � �� ' �� : �°; � � � � � �� , _ � �` � ' ' � �` ' � �� < � �:" „ � ` � � � `, � -�> t fi �� "� �� s � �� `' $ z � ,E�� r � ... � � � ' r �z� i �. . .. - �a. �s S''�.� . .2. � �� F 4�� . . � � �:�. � � .: �� .�,`°= ... . . . 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F „ , . � �. . . � t�.. ... .. , .. . .. g . ... � . . . .. ¢� ... ... ... .Ki� .. a�x ,�:�a��: Ct�''Y AUTO GLASS - SO ST PAUL CUSTOMER COPY 116 CONCORD EXCHANGE SO SO ST PAUL, MN 55075-2446 PH:(651) 552-1000 FAX:(651) 552-1080 FederalTaxlD: 411652150 PIO#: Cust State Tax ID: WorkOrder: W001059707 Taken By: Erik H Cust Fed Tax ID: Installer: Ship Via: Date: 2/29/2012 SalesRep:Victor Hapka Adv. CodeAgt/Ins __ Bill To: CASH _ Sold To: CASH CHEVRE, ADELE CHEVRE, ADELE 1269 EASTER LANE 12:30PM EAGAN, MN 55123 SSP SHOP 55075, MN 00001 (651)248-3742 _ Vehicle Information Make: Chevrolet Model Style: Cavalier 2 Door Coupe Year: 2001 Odometer: VIN: License: _ Fleet Number: Unit Number. Color. BLUE __ Qty Part Number Description Sell Total 1 DW01191GTYN Windshield-(Encap) $123.90 $123.90 1 Hrly 45 Labor $103.50 $103.50 1 HAH000004 Adhesive-(2.O,Urethane,Dam,Primer) $25.00 $25.00 Add'I parts used Safe Drive Away Time Install Date: 02/29/12 12:30 PM,Required Time: 01:00 PM, In Shop Location: M Vehicle VIN: I_I—I_I—I_I_I_I—I_I—I—I—I_I—I—I—I_I Collect From Customer $263.97 Sub Total: $148.90 Labor: $103.50 Tax: $11.57 Customer's Signature: COD Total: $263.97