Driscoll �
, NOTICE OF CLAIM FORM to the City of Saint Paul, Min����a���
Minnesota State Statute 466.05 states that "...every person...who claims iiamages from any municipality...shall cause td b'e'�re�en�ed�'t)!s ' -
governing body of the municipality within 180 days aJter the alleged loss or injury is discovered a notice stating the time, lace a
circumstances thereof,arui the amount of compensation or other relief demanded" (,���� 't,'{��.��+�
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 nole 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 �(Y� Middle Initial � Last Name � r IS[.�� t
Company or Business ame
Are You an Insuranc�Gfimpanq� �es�N�v If Y�s,e�a�r�tunt�-- - _--
Street Address 1 �-�"3� ���'1 °�s ��
City c�+ . � M�� State �-� Zip Code cS S)o�-
Daytime Phone �(�,51)�� OI(0( Cell Phone���8i-514 3 Evening Telephone(___) -
Date of Accidentl Injury or Date Discovered Q{� r� I 2� . 20�2 T'une ��`S m�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 responsibie for your damages.
�o S l l � �m s
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wG� s ��{-t-u �Ic rn a W A,-1--G.� h o x ��b�f'.- TI-�.c ��e.�'
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Please check the box(es)that most closely represent th�reason for completing this form: j�,� J�,x- �� ��,�y .��
�My vehicle was damaged in an accident ❑ My vehicle was da.maged 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 andlor ticketed ❑ I was injured on City property �+�ba�n • _
�Other type of property damage-please specify �
❑�Other type of injury-please specify ` '
In order to process your claim vou need to include coaies of all aanlicable documents.
For the clai.ms types listed below,please be sure to include the documents indicated or it will delay the handling of
your 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 form.
�j 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 properry damage claims:two repair estimates if the damage exceeds$500.00;or the actual bills
and/or receipts for the repairs;deta.iled 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 yonr claim.
All Claims-ulease complete this section --
Were there witnesses to the incident? Yes o Unknown (circle)
Provide their names,addresses and telephone numbers: N o �� s-��on�� 'h/l�k�
�'�-u i n C i ��.,a. v �L-�.�r� �I
Were the police or law enforcement called? Yes No Unknown (circle)
If yes,what department or agency? -}- Case#or report# 1 a - o�-, ^ �3(o
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 dia . 5-�-. �,{c�.;r .a-
� �; n� C�v�e.� �o�,,..-t-�.(�o I c,..r�,e.
�
Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction. � 3 2-L� • 2� -For �v;nzC_s�t;,,�t� . r'POaa r'
Vehicle Claims-please complete this section ❑ check box if this section does not annlv
Your Vehicle: Year �-��i Make �1 w z.d.e�_ Model M,(�v
License Plate Number �S S L��31� Sta.te M-� Color !�,' q�
Registered Owner ����
Driver of Vehicle � ,r-"� (
Area Damaged �
City Vehicle: Year Ma.ke Model �
License Plate Number State Color
Driver of Vehicle(City Employee's Name) �
Area Damaged • ' � '
Iniurv Claims-nlease complete this section �check box if this section does not a,pplv
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 treabnent? (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 Telephone �
�Check here if you are attaching more pages to this claim form. Nnmber of additional pages�:
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 ����(�--
Print the Name of the Person who Completed this Form: � �t-"1 S�f r
Signature ofPerson Maldng the Claim: ��L-�'L�_`e�._
Revised February 2011
� Work Order
� Date: 04126/2012
Work Order#: 2709744
Store: Al1-3699
All Auto Glass -Minneapolis
1179 -73 1/2 Ave NE
Phone: (763) 784-5922 Minneapolis, MN 55432
Fax: (763) 786-5198 TAX ID#: 411697166
Customer: Insurance-Fleet-Broker:
Amy Driscoll STATE FARM INSURANCE CO
1438 Thomas Avenue SUITE 18 6351 BAYSHORE ROAD
SAINT PAUL, MN 55104 FT MYERS FL 339173172
Phone: (651)641-0161 Fax: Phone: 2394796000
Phone2:65164�0161 !Vlobile: -- --
Job Scheduled For: April 26, 2012 9:00 am
Written By: Amy Gabler Sales Rep: Dan Webster
Technician:
Automobile tnformation Fleet Information Insurance Information
Year: 2001 Unit# : Policy#: 3351466A2523H
Make: Mazda Card# : Claim#: 2306Z0999
Model: MPV Exp Date: Loss Date: 04/26/2012
Style: Mini Van Driver Name: Cause:
VIN#: JM3LW284210204809 Driver Lic.: Authorization#:
Color: Fleet PO#: Agent/Broker:
Mileage:
License� State�
MFG Part Description (�ty Unit List O&A Discount Net
0 14 BN Windshield BN 1 Each 220.40 Y 25% 165. 0
FW02149 BNN Windshield Labor 2.8 Hrs 35.00 Y 98.00
HAH000 04 Adhesive 2. Urethane,Dam,Primer 1 Each 28.00 Y lat 20.00
F F2149 Filler Windshield 1 Each 26•�� N 26'��
Service Address Work Order Notes Owner Insurance
at home above address Sub Total o.o0 310.07
there rest of today, until 5 Tax o.00 �s.»
ADD ON Gross Total .00 .
SAINT PAUL, MN 55104 Deductible 0.00 . o
Primary Phone: (651)641-0161
Net Total 0.00 26.24
Secondary Phone: AMOUNT TO COLLECT $0.00
Mobile Phone:
*there will be lots of glass clean up.Sewer cap went thru w/s.`
Amy : '
Vehicle Notes:
PAYMENT AUTHORIZATION 8 PROCEEDS ASSIGNMENT
The work noted above has been completed to my satisfaction.I authorize my insurance company to release policy,coverage and other information related to this glass claim to All Auto Glass.I assign all policy
proceeds due me for this glass claim under the terms of my insurance policy to All Auto Glass and I direct my insurance company to pay those amounts diredly to All Auto Glass.If my insurer should ignore this
assignment and issue payment directly to me,I agree that I will immediately forward payment to All Auto Glass by either endorsing the check that 1 received over to All Auto Glass or paying All Auto Glass an amount
equal to what I receive.I agree to pay my dedudible,if any,myself.I also agree that if I do not have insurance coverage,I will pay for the work myself.
Signature
� _ _ .�-,Y . . � .. . _ , _._ . _
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� �� � �,� � ; F .� .M_-. � AIl Auto G/ass
�. REPLAGEMENT RECORD
` (763) 784-592�� Fax (763) 786-5�98
�
'E Technician: Year: Make: f�� _ Model:
� VIN: License plate number and state: �j/� �Q�� �, )
C r,� � ,J ,ti
€ Inspectionstickernumber. �� N/1 Mileage:
, �V
�
i
i
❑Passenger Side Air Bag ❑Side-Impact Air Bag Pre-Inspection NOteS
� S=Scratched
r
i D=Dented
C C=Chipped
�
� M=Missing
---------
�- --..
��__-� �` R=Rust
// � - -- -- '- ------- ---
F /
�� Post Inspection �
� ❑Vacuum
€ 0 B ❑Trim secure �
� I
� ❑Glass clean I
�' � � m ❑Wipers OK '
{ � � 0 Stickers/tags ;
l � ❑Check radio �
C
( Vehicle Type
_� ❑2-door
'��_-____------��\ ❑4-door
� \\
� ❑Hatchback
i ❑Station wagon
� . ;A 8 ❑Sport utility
', ❑Mini-van
� �� ❑Van/truck
► ❑Mini-pickup
� ❑Full-size pickup
�
f Installation Information
` Time glass was set: Vehicle release time:
ITemperature at start of curing(degrees F►: �- Relative humidity at start of curing(percentl:
k ,
�k
f Product Material Used Lot Number' �R��f��"���'��
i
E Urethane Adhesive I �
IGlass/FritPrep I �
� Glass/FritPrimer I .�.�`?� � ���� �
��
� Pinchweld Primer I LJ�� � .--j,��,�c-� g
k ,7
Specialty Primer I �
�
{ / P" � 4
� Moldings or parts used: / ,' � /• %�
D.O.T.numberlon glass—identifies brand and plantlocatio�l: �'j
���� ��
� Signature �-`� L ` -_.�._-_..�--... Date � ,�
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