Eureka Recycling �����'���f��
`��N 2 � 2012
NOTICE OF CLAIM FORM to the City of Saint Paul, Minn,e�S.Qta, .
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Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipality...sha11 cause to be presented to the
, governing body of the municipality within 180 days after the alleged loss or injury is discovered a notice stating the time,place,and
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
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 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 Middle Initial�Last Name `'b �1
Company ar Business N me �e I �DY I'�D 0(,I �Q G � � � � � I
Are You an Insurance Company? Yes No If Yes,Claim mber?
Street Address � 1i V� ��1�� ��
City ` � � State � I VI Y1,e501'� Zip Code-�
Daytime Phone �� �p7 Cell Phone(��- �� Evening Telephone�) - �
Date of Accident/Injury or Date Discovered�/I 9�/�- Time //•'`/S am pm
Please state, in detail,what occurred(happened),and why you are submitting a claim.Please indicate why or how you
_eel the City of Saint Paul or its employees are involved and/or responsible for your damages.
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Please chec�the ox(e� st closely epresent he reason or c mpletmg t s form:
�My vehicle was da��aged in an acciden ❑ 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
❑ My vehicle was wrongfully towed and/or ticketed ❑ 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 you need to include copies of all apnlicable 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 WII..L NOT be returned and become the property of the City. You are encouraged to keep a
copy for yourself before submitting your claim form.
�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
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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 Unknown (circle)
� Prov'de their names,addresses and tele hone numbers:
D Gl � �a '
�Ti�ere the police or law enforcement called? Yes No Unknown (circle I
If yes,what deparhnent or agency? Case#ar report# � !.�- -(�
Where did the accident or injury take place? Provide street address, cross street, intersection,name of park or facility,
closes land ar etc. Plea e be as detailed as possible. necess ry,attach a diagram.
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Please'iridicate�� ur�yod �are se�ing in c' ori'ipensafioi�or wh�t you�ould like the City to do to resolve this claim
to our satisfactit6n.,
y � � � �
Vehicle Claims- lease com lete this s ction • ❑ check box if is section does not a 1
Your Vehicle: Year Z9 D� Make /)A� Q, Model
License Plate Numb /� State Color Q Piti'1 _I
Registered Owner � �1 U I✓I
Driver of Vehicle D�. 0 � �
Area Damagcd
City Vehicle: Year Make Model
�Q e pD��:��o,���- License Plate Number State Color �
�V�v�d�d n p f� Driver of Vehicle(City Employee's Name)
5���0 n a � a l( Area Damaged 0�
; �n'u 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))
Name 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 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 1Q�Z�'��
Print the Name of the Person who Completed is Form: I 1� �� �1'
Signature of Person Making the Claim:
Revised February 2011 ��t�,I�G� �C Vl�(�l �f"1 rQ(,1 �/1 �.Y O "� �-��'
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Astleford International Trucks
3000 BROADWAY ST N.E
MPLS,MN, 55413
Te1: 612-378-1660 Fax: 612-378-1872
prau@astleford.com
Estimate - Preliminary
Estimate Prepared by: Perry Rau Appraised for:
Accident Date:
Date of Loss: Date: 6/20/2012
Anival Date: Estimate#:
Type of Loss:
Policy Number:
Claim Number:
Insured:
Company: EUREKA RECYCLING •
Contact: BOBBY
Address: 2828 KENNEDY STREET NE
City, State,Zip Code: MINNEAPOLIS,MN 55413
Telephone,Fax: 651 222-7678, 612 623-3277
Year Make Model Color Trim
2008 INTERNATIONAL 4100/4200/4300/4400(DuraStar)
� Unit Number License Plate# Mileage Serial#/VIN#
2023 8J647139
Sup Seq Labor Labor Description Part Part Number pollar Labor
Type Op Type Amount Units
1 Ref Ref Refinish Front Bumper Exist 1.5
2 Body Rein/Rep Bumper,Front Gray New N.A. $641.50 T 1.5*
3 Body Ren�/Rep SHOP SUPPLIES New $45.00 T *
4 Paint Materials $56.25
* -Judgement Item
#-Labor Note Applies
Labor Parts
Body 1.5 Hrs @ $75.00 $112.50 Parts Subtotal $686.50
Refinish 1.5 Hrs @ $75.00 $112.50 Less Adjustments
Labor Total $225.00 Parts Total $686.50
Additional Costs and Operations
Addl. Costs/Ops Total $56.25
Tax
Parts Tax @ 7.00% $48.06
Addl. Costs Tax @ 7.00% $3.94
Tax Total $52.00
Totals
Sub Total: $1,019.75
Version 3.0 TruckEst is a Trademark of Mitchell International
Database Edition PHT 12-01 01998-2012 Mitchell Internarional,Inc. Page 1 of 2
All Rights Reserved.
Sup Seq Labor Labor Description Part Part Number pollar Labor
'�ype Op Type Amount Units
Customer Resp. $0.00
Net Total �1,019.75
The above is an estimate based on our inspection and does not cover any additional parts or labor which may be required after the work
has started. Occasionally,worn or damaged parts are discovered which may not be evident on the first inspection. Because of this,the
above prices are not guaranteed. Quotations on parts and labor are current and subject to change.
Tl�is is a prelimi�zary estimate. Additioiial changes to the estimate may be required for the actual�•epair.
TrucicEst does not automatically i�zclude items�•equi��ed by many business repair partne�•s. This application allows
tlie autl�or to nzanually ente�•line items such as ove��lap deductions.
2008 INTERNATIONAL 4100/4200/4300/4400(DuraStar)
Version 3.0 TruckEst is a Trademark of Mitchell International
Database Edition PHT 12-01 01998-2012 Mitchell Inteinational,Inc. Page 2 of 2
All Rights Reserved.
. AUTH�RIZA,`T10iV AN� REQUISlT10N �
. REC�R� 1N�OR�ATION � �
. � . � Claim# :` . .,
1 hereby authorize Western National Mutual�Insurance Company to receive from the Record �
� Department any information_allowed by law regarding fhe incident noted below. '
DRIVER'�101NNER'S IVAi1(IE: LOCATIOR� OF INCIDERI7': :
�I���s�-�� �.����r /��k.�.. . - oj� ��� i3�`�...,��',���
Please print( first, middle, last) � Name of street or highway
ADDRESS; . . � � �T �iq-,�L /�.5�-nst i� -
. � _ - City/County . ,
� �/3,�5 �►�n��aa, �� /o� . . . .
- �i QA-✓L /'v1 /� v�✓Sf/7 � . . . D/�TE OF INCIDEIIlT: lo /g /� . . .
. ACCIDEf�TlTHEFT/BURGLARYNANDALISM . �
- . (Please circle one) � : _
� . � � lIF AUTO ACCIDEftiT: � �
Full Narrie of lnvotved Driver Drivers License#
� �,��f.��;�,��/f����; Q 3� 7i 7��3 3S8i 9
. POLICE DEPARTiVIENT � � �CASE NUMBER: ' -
ST �� L �� . _ .r��-iy3_ � �� : . .
SIGiVATURE OF INVOLVED PARTY: � �-' �
` �PRIMT R�AME OF lN'�/OLVED PARTI(: ���s3�al�u �'�'/'�srcp/� /���� �
� [�]Driver �DOwner �Owner of Damaged Property ❑Passenger ❑Pedestrian .
�Nexfi of Kin: surviving.spouse,legal representative di the estate, truste under MS593.01. �
Requester hereby authorizes the Records Dept, to disclose accident information in accordance . � . .
� . : with Minnesofa Sfatutes, Secfion 169.09, Subd. 93. .
� PLEASE RETURN TO:, 1lVesfern-t�ational Niutual Insurance Company �
. � � � � PO Box 'I�463 � � � . � �
� . � I�linneapolis, fllii N 55440 � . .
Records Deparfinen#Only�- � . . . � � '
� if a copy of fihe police reporf is not enclosed, see reason checked below: • � ;
� 0 S.earch Made-- f�o Accident File Locafied� � � . .
. . ❑ Search tViade= No Police Report P�vailable , . . ' .
. . . . - 'i
A person who fi.les a claim with intent to defraud or helps commit a fraud against an insurer is guilty : �
of a crime (MN Statute 60A.955). - � � . .
YlESTERN NATIOHAL . � 2 �
IX9URANCE ' � � � � - '
�.�yr��n..��,,����anl STATEMEI�IT OF DRIVER � ��i .
. . Claim#� , � .
Driver's Name: � vR55�w Atc��� �0-���9-�� .� Owner's Name: /�� �r�,r�� - `o�.
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s7-�Oir.,L: i-►-f N � .S.S//� / •
Driv�rsAddress: /.35� �?2�q� J7 �/D� PhoneNo:. .GS/- yg9- 37`/ 3 Age: / o�� 7/
Driver's�License No: Q��? 717� 33��� "�I � � By whom employed? ��,ref="�- �'�yG��S
Describe car you were driving: Year �00$� Make ��a�i.L.�+��r`or�9�L Model �7 �a0
.. - . � )� � �,�-v� C�� ��J�.►#� 7�39
Vlmat was car being used for at 6me of accident? ���� `� ��Y u+�"`t ,
/� cl.,� e �e•� D A-'nn
LocationofAccident: D�� ��� I3�5T�I �no�-�Nor�ywr�tQ ) DateandHour: . CoJly�l� // �3
How fast,on what street and in what directibn.were you traveling: �o�c�60�' vN D��-�- �� r.�.s��'��
How�fast,on what street and in what direcfion.was othe�car traveling: /(�o�z9��a� �`r�"e - o'��in a� �
Describe condition of weather: �i.�-o.-•-�O w�e�.s Road: �fJ2Y � ��s�b����:.� � c l�n-
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How far away was other car when first noticed? �a b�Q*�'�'4^/ How many people were in your ca�? . � In other car? �� �
Distance from your car to right hand'edge of road? � ��- � � Other car? . /�7`y �
C��y►�� �9 / '�� �� ��/� � .
Area of damage to your vehicie: � ��s. S�'e b ,'3 �e.�..� �a�-� �. . .
�amaged area of other vehicle: �� �d-y�� .3���t'P SC��° o� 7`-�te �'�� . � . `. .
�i.'�/✓��
Ni,. authorities were notified of accident? . �e.5 � � � Date and Hour: /y ia-. Report# /�-/y3-� 51�
=ither driver cited or arrested? You? Other driver? Charges?
f faulty condition of either car caused accident;:explain: d� � - � � ,
�ame of owner.of other car or property: , � � � �. �. �n�ne: . � .
lddre'ss` ' . ' �
dame of driver of other car: � � ' . . Phone: ',
� . . qge: . ,
�ddress; � . •
)her driver's License No: � � Year and make of other.car. - �
:stimated damage to other car: . . . : Plate No: � .
lame and Policy#of Company insuring other car(s)? � � . � . . . �
AMES OF DISINTERESTED WITNESSES � � �
S��� ����.�.��KP � MITCHELL SCHUCK _
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Pan•olman
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��''� � ' �:" � . - POLICE DEPARTMENT �� -
'. � • 1 • � .� � CTTY OF SA1NT PAUL L
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�O�/I—�G —S�(y / � 367G�oieSrreet l�oiceMail:651-266-9000 .\�\\PdOLPOb��g,
, �/ /1 �1— Saint Paul,MN 55101 Mar!Box#:71420 `�� ,
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�v����_Q �e,}Z �L (,`O's�+i�/�s�� If you have questions regarding your report,call:
7�� -OVEf=
j � .Q ,D ../����� _ /1 Saint Paul Police Records Unit (651)266-5700
e G�'►i�� /f'ti`o c y�`2 �C i i q-r�r��� �
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1_,;_ D �r.[. ,J.;�..e sa.. T:.�� �o ,�e_ .
. ' Claim# � �
Did any person or persons sustain injuries? If so,explain in detail:
NAMES AND ADDRESSES OF OCCUPANTS IN YOUR CAR � �
i�IAMCS AND ADDRESSES OF ATTORNEYS REPRESENTING ANYONE INVOLVED ' � .
�lease describe in your own words how accident occurred. (Use separate sheet if necessary): � . � .
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'lease diagram the accident. Include any traffic control devices and indicate the�di ction of travel. � .
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� �n who files a claim with intent to defraud�or helps commit a fraud � gai t �n ins rer is guilty of a crime
lliv �tatute 60A;955): . : . .�
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