Lach c ° � l �� �
NOTICE OF CLAIM F� o the City f Saint Pau�,, n�n�� a
�.._
Minnesota Stafe Statute 466.05 states that "...every person...who claims damages from any municipality...shall cause�to.¢ ,�rgsented to the
governing body of the municzpality tivithin 180 days after the alleged loss or injury is discovered a notice�s��t�ng djte�tl�'rt�ti�3'lace,¢nd
circumstances thereof,and the amount of compensation or ofher relief demanded."
Plea'se 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 ezplain your claim,and the amount of compensation�ieing 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 I)OCUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL, SAI�TT PAUL, l��N 55102
rirst Name _ e f eY'r' � Middle Initial�Last Name �('�, , REGE!���
Cotnpany or Business Name `� ����� � � 2��2
Are You an Insurance Company? Yes�o If Yes, Claim Number? E;IT�; i�I_t��+'.
Street Address �� �P �0 �'IV�� �� i `
City Cj�, ��,V.,� State �i hYl(``1� (� Zip Code � "
Daytime Phone ���-�,�Cell Phone( .)�f_�Evening Telephone([�5� )�_��
Date of Accident/Injury or Date Discovered j'�0��( rj. a(�j�� Time���am/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 Pau or rts employees are involved and/or responsible for your damages. � �Gt Dr�
� •� �:- S�7.�► o�,,-� � �ro,rS o r i�o,�'�c'r,� r.ue,. v,r �e r re o.�rr .
p,�A �o jz,� rer a GQ�(' �2 v.Y' e h���b� � �2
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or � �• '
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- � a � e �� a n p.�1ne r ��a �t� �Q r e r � S� �rn�e r .��c`�S
Please check the box(es�that most close y represent the reason for completing this form: t�
❑ My vehicle was damaged in an accident ❑ My vehicle was damaged during a tow
LJ iV1y 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 prope �
L�Other type of properiy damage—please specify�Q ���C�c�'u1f� G1�� °4 �-�C� •
❑ Other type of injury—please speeify �
In order to process your claim you need to include copies of all apulicable 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 encouragec�to keep a
copy for yourself before submitting your claim form. .
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 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
O 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—please complete this section
Were there wiinesses to the incident? Yes No Unlrnown (circle)
Provide their names, addresses and telephone numbers:
Were the police or law enforcement called� Yes ,No 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, me of ark r�facility,
closest landmark, etc. Please be as detailed s possible.�f necess , attach a dia am.A Y� �C' �� �f`(1,
rr� ° �.e�- ��,1e�, V n � �
c��n +h� y _
Please indicate the amount you are se�king in compensation or what you would like the City to do to resolve this claim
to your satisfaction.
Vehicle Claims— lease com lete this section ❑ check box if this section does not a 1
Your Vehicle: Year a Make " Model����('2 h-�}'
License Plate Number State'� Color
Registered Owner �. � �Y`� `.
Driver of Vehicle C,' CJ Q Ic' Q��,
Area Damaged
City Vehicle: Year Make Model
___ _ _ ,__ _ . _
-_ .
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
In'ur Claims— lease com lete this section Q 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))
I�Tame of Medical Provider(s):
Address �Telephone
Di�i vou rr�ss work as a result of your inju�y? ,. Y�s . '_1��., - .
When did you miss work? ' ..-,. _ _ _ _ � :-. .._.' �_' , . � (provide date(s))
_...
Name of your Employer: _ - � .
Address ,. , .__ Telephe�� ; . ::.'
. _ . _
❑ Check here if yon are attaching more pages to tlus 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 processea� ,
Submitting a false claim can result in prosecution. Date form was compl ed
i
Print the Name of the Person who Completed this Eorm: ' ':
Signature of Person Making the Claim: �l
Revised February 2011
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986 Avon St.N,
Saint Paul,JMIY 55]03-1302
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eturn both pages will result in delay in the handling of your claim.
— .non ,�,r,��k,�l ��,�#.
Yes No Unknown ircle) �
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�� 1n 6\ ,,, ephon mbers: � tv �
� �`!� \�� � , �-�s s _ .-���--
-- bc�wr 3�r�e� Gro�� i�1�,�� �o5t -`'�p�� ��g�ta
Vesta Lach illed? es No Unknown (circle) �
986 Avon St. N � � Case#or report#
Saint Paui, MN 55103
�lace? Provide street address,cross street,intersection,name�f park or facility,
:ailed as possible. If necessary,attach a diagram`.'
, � . C -- F
d
�n SE, a
ricasC inuica�e uzc amoun� ou are seeking in compensation or what you would like the City t do to resolve is claim
to your sa �sfa tion. OrU �.�•���•= R (� � �O a � '� 3
_ +���r+�s� Q- �n ���-�"��- ---` e�e�,Q� - . . ��
��,�,�or, ' �4tt•Q,�C�e n Se s [.�t�') ��.{`m-�—�C��..T.�JI C�4 � c �
Vehicle Cl ' s- lease com lete this s tio ' � ❑ check box if t�is sectio� n does not a 1
Your Vehicle: Year � ('1 Make C�'r1-t'j U,C Model��2�(1.�'
License Plate Num�b�j�' State Color ChC �A
Registered Owner �I e, E� "' e. �C-
Driver of Vehicle ' C Q ' t �' OU���.
_ Area Damaged - � � C�
City Vehicle: Year� M k Model _
License Plate Numbe State Color ,
Driver of Vehicle(Ci E ployee' a ) d
Area Damaged
Iniurv Claims�lease complete this section [�'check box if this section does not avplv
How were you injured?
What part(s)of your body were injured?
Have you sought medical treatment? Yes No Planning to Seek Treatment(circle)
`JVhen did you receive treatment? (provide date(s))
Name of Meciical Provider(s):
Address Telephone
Did you miss work as a result of your injury? Yes No _____.,._____ __ .
._ __
4Vhen did you miss work? (provide date(s))
Name of your Employer:
Address Telephone ��f
�Check here if you are attaching more pages to this clazm form. Number of addihonal pages�. ,
Pf,�+n�
i��
By signing this form,you are stating that all information you have provided is true and correct to th� est
of your knowledge. -Unsigned forms will not be processea�
Submitting a false claim can result in prosecution. Date form was completed�(�' "I "E7U 1��_
Print the Name of the Person who Complefed this Form:
Signature of Person Making the Claim:
Revised February 2011
�� FORM to the City of Saint Paul, Minnesota
�� O�
� `,�� ry person...who claims damages fro.m any municipality...shall cause to be presented to the
'� � Q � 'days after the alleged loss or injury is discovered a notice stating the time,place,and
f,and the amount of compensation or other relief demanded."
���—�� 1 �y clearly typing or printing your answer to each question. If more space is
i �� te that you will not be contacted by telephone to clarify answers,so provide as
T
P R O � �ur claim,and the amount of compensation being requested. You will receive a
U
� D
,��,`i j�� is received. The process can take up to ten weeks or longer depending on the
signed,and both pages completed. If something does not apply,write`N/A'.
VI AND OTHER DOCUMENTS TO: CITY CLERK,
�VD, 310 CITY HALL, SAINT PAUL, MN 55102
FirsY Name_� � �, Middle Initial�Last Name 1.—�..G�
Company or Business Name
Are You an Insurance Company? Yes/� If Yes, Claim Number? '(U� �
Street Address�� (3� ��Q� j�,�QQ.�
City�ej'�, '�(U.�Q State � I �e Q Zip Code� `�
Daytime Phone(�)�_��Cell Phone.( )��" Evening Telepho�e(_���-_ � ���
Date of Accident/Injury or Date Discovered }�� '�j,�D��o� Time 3,� am pm
Please state,in detail,what occurred(happened), and why you are submitting a claim. Please 'nd'cate why or how3�ou�,
feel the City of Saint Paul or its employ es are invol�ed and/or responsible for your damages.��C1�f`n C�1
S,�i v.�Qr'i.?rij 0-wv�cl •�`�.� � •
C`�s.�y � ^c� �; ' � �Y� � . c e 0�
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'�� e,� �! �. � �, c v.::rn rc� °w o.� ot� e. � c�
o,c-� � � c- c� �uY-� �^ SU�v' . �C`n erZ CYp� v�� `e�:� �=`c�e c��y �i S hesq�n--
Please check the box(es)that most closely represent the reason for comple�ing�his form: $�b 1 e �ot- -Eh e da�'�►n°p�e
❑ My vehicle was damaged in an accident ❑ My vehicle was damaged during a tow-4f� 0�1k
G My vehicle was damaged by a potnaie or coriuition oi the s�ee� ❑ iv�y�z-ehicle v��as�arnage��;�a p.c��zi Ca'('<
❑ My vehicle was wrongfully towed and/or ticketed ❑ I was injured on City prope
L9fOther type of property damage–please specify ('�1' �eVJ -�- e'2 U� '�e, C,Ca,'('o
.� a vr ► -
In order to process your claim you need to include conies 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 WII,L NOT be returned and become the property of the City. You are encouraged to keep a
copy for y urself 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 far the repairs
O Towing claims: iegible copies af 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�f damaged items
O Injury claims: medical bills,receipts
Q�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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5 J � .j l, cu►tN tro 23-1�6W-019
PAYMENT NO �I��� � :'� �pgS DATE 05-05-2012
PAYMENt IIMaJqT ��•� � <<�n, �t�y � 1560-407-23A
. issue oatE tl���'�Z '� � �.� � iNSUReu LACH. JEROME C
AUTHORIZED BT ��1�.TORIE �
PHONE (�i `�f'6046 "
��
JEROME C. LAdi
986 AVON ST N
SAINT PAUL MN ��73Q2 �
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REMARKS 2 LTRS
COVERAGE DESCRIPTtQN ON BEFIALF OF AMOUNT
COMPREHENS[VE - YI1� LACH, JEROME C 6,842.20
RETAIN STUB F4R REC4RDS
�f r ����'�„�.n�i*�'�1 r �,���:- A� .,r� �t.wr.syj gta:^s;Y i � .��� a �. ,.. �_' i r `:. .s,c� ��yt��t � J,;.,r ���T/� ...
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•""�*��EXAC`t'`LY:SIX THOt�SAND EIGHT HUNDREDFORTIf-TWO AND 20/100 D'CJ�LAI� �`;.::,... ... ..:::.:....::.:. ..... :
Pdy t�du ,
O�rler�• JEROME C. LACH & CtTIZENS BANK , �
,,,,� ��q����
_ . '/ / . _ _.���...�\r.`.
MAY 24, 2012
VESTA LACH
JEROME LACH
986 AVON ST .
N
ST PAUL, MN 55103
RE: Account Number 00002726786003
Dear Customer,
Congratulations! We are pleased to inform you that the above referenced
account is now 'PAID IN FULL' . If your loan was secured bv collateral,
the collateral referenced below will be released and mailed within 14 davs.
2006 PONTIAC TORRENT-V6 2CKDL73F766040523
If you have questions about your paid loan, please call a representative in
our Customer Service Department at 1-877-265-3278.
If you have purchased Credit Life and/or Accident � Health Insurance, you
may be entitled to a refund of premium due to a pre-pavment of your loan.
Please contact your originating dealer and/or insurance company to confirm.
Thank you again for your business.
y�t Citizens
�� Automobile Finance,Inc.
Sta�Fa� � ,
Providing Insivance and Fin�cial Sennces
Hame Office,Bloom�gton.Ulirrois 61710 ��`�"�
May 11, 2012
I,
Jerome C Lach State Fann Claims
986 Avon St N PO Box 52267
Saint Paul MN 55103-1302 Phoenix AZ 85072-2267
RE: Claim Number. 23-126W-019
Date of Loss: May 05, 2012
Vehicle Owner: Jerome C Lach
Dear Jerome C Lach:
This letter is in reference to the settlement on your 2006 Pont TORRENT 4X4, bearing vehicle
identification number 2CKDL73F766040523.We have verified that this vehicle is cucren�y ti�ed
and/or registered in the State of Minnesota.
Your vehicle has been declared a total loss and you have voluntarily chosen to retain ownership
of the above described vehicle in its current damaged condition. We have agreed that the
salvage value of this vehicle is$2800.00, and your settlement amount will be$6842.20.
State Farm Mutual Automobile Insurance Company, its subsidiaries and affiliates will not be
responsible for storage charges afte�N/A.
State Farm Mutual Automobile Insurance Company, its subsidiaries and affiliates, make no
representation as to the condition, safety, reparability, and/or the ability of this vehicle to be
legally titled for operation on public roads. You also understand and adcnowledge that you may
- - be responsible for securing an appropria�eiy b�randed title to this vehicle anci it is your obligation
to comply with all state laws as required by the tiHing state.
If you have any questions, please contact us directly at 1-866-207-6046 ext. 9.
�.o.d..a...
Providing Ins�ance and Fir�ncial Senrices ��..�
Home pffi�.81c�ornington.Iliinois 61710 -
May 11, 2012'
I
Stabe Farm Claims
Jerome C Lach p0 Box 52267 i
986 Avon St N phoenoc AZ 85072-2267
Saint Paul MN 55103-1302 �
�: Claim Number. 23-126W-019
Date of Loss: May 05, 2012
Our Ins�ed: Jerome C Lach
Dear Jerome C Lach:
�for the total loss af your v�hide•As����y
We are providin9 Yo��h our daim payme ��,�ss any
discussed,our pot�cy provides fa paYmer�of the actuai cash value�'y�o� a����on
ap���qble ciedudible.Adual cash value is determined by the market value,�.
of your vehicle at the time the loss o�d•
To assist us in determining actual casbvaluu,�����o�e ces����S�s. �{
represen t a t i v e s,�r�f o rr n a ti o n p ro v i d e d Y Y a
now or later,you have additional informatiolue ofNOUr veiiide, PI���CO���iat th e number
not c�rre c t l Y d e t e rr n i n e d t h e a d u a l c a s h v a Y
indicated below.
The amour�payable to you was defiermined as follows:
$92Q3.OQ
Base Price +$�8.20
?ius:i axes(if appucabie j +$61.25 :
Lic:ense(if applicable) +�29.75
Title Fees(if aPPlicabie) _��
Ac�uai Cash Value _�50.pp;
Less: Deducable �a hcable) -�2�-�
Owner Retained Salvage C PP �p
Ovved to Lienholder(if appiicable) _��
Net Amount Payabie to You
� older,you can enjoy the benefits of online�e9�•
genefds induc�
As a State Farm po�icyh ur insuranc�e�r�fa��aOOO��;
chedcing the status of your daim online: managing yo ��to�t�.q�l you need
and staying conneded to State Farm. Just go to orst��n�nb�,Y'���addr�ess,and
to comPlete the process is Your State Farm poI�CY
about five minutes. If you are aUeady re9istered,thank y�ou!
If you have questions piease contact us.
,,��
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APPUCANTS/BUYER'S SIGNATURE(Sj Alt Must Sign
91PORTAMT-PLHl9E REAR ML BiIXiWT10N COLtECiID ON A 1p70R vBif,LE APPLICATION i5 HEQAflED BY tAW AND 45155UH1 AJ 10EfrtFV TOUt YOTOR �
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'� VEHICLE IDENT)FICATION NUMBER YEAR MAKE MODEUBODY TITLE NUMBER �'�
2CKDL73F766040523 06 PONT 4W TOR F2580Z168
DATE ISSUED ODOMETER TAX BASE CODE PLATE NUMBER CENTRAL OFFICE USE ONIY
�9/15/10 92598 024890 09 38bDZN .�
�
EXP 01
� FIRST SE�URED PARTY DOB 1ST OWNER
06/29/10 N0341 LACH VESTA MAE �
81635 LACH JEROME CHARLES �`
CITIZENS AUTO FINANCE INC
986 N AVON ST �
� PO BOX 255587 SAINT PAUL MN 55103-1302 �
SACRAMENTO �A 95865-5587 �'�
� TOTAL LIE�tS 1 dIII1i�I1NN1II11IIaIIr NIII�I��IIeIII�IIiIIIIlI1IIIlIIII�
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� STATE OF MINNESOTA �
CERTIFICATE OF LIEN RELEASE �
� _ _ TO A MOTOR VEHICLE i
� �.*....; � �
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� This security interest is hereby released on � ZS 1 L �
� � Date �
� X i l�t;�e /� •� ;
� Signature of Aut ed Agent � Titie � �I
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� �
; IMPORTANT — DO NOT DESTROY �
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�� This Cert�cate of Lien Re/ease must be attached to the i
original Cert�cate of Title to establish clear ownership. y
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�ii��,y,.v.n��r�.,,.re r��i,�i�m i,�t�m����r r�r�.,��,�,s�m��..a v.v�,o r�m.,.y.v s�.��
Thank ;� for your business!
Your continued patronage is �
sincerely appreciated! i �uaR�■e� _ �
�°- .�.:..,, Customer Invoice RV 1411a2
�,
Date: 05/30/2012 �
Invoice Date:05/21/2012
WHITE BEAR LAKE BRANCH LACH,JEROME
1803 BUERKLE ROAD SUITE 106 986 N.AVON
MAPLEWOOD,MN 55110 SAINT PAUL,MN 55103
PH: (651)766-7807 !
LACH,JEROME License Information: i
986 N.AVON 6742087026013
SAINT PAUL, MN 55103 MN 08/16/2013
PO Number:
Agreement Number: RV-141182
Vehicle Number Vehicle Tvpe Vehicle Plate Date Rented Date Returned
212246 2012 TOYOTA RAV4 519 HYB 05/07/2012 08:00 AM 05/21/2012 0328 PM
4 Day(s)@36.99,6 Day(s)@49.99,5 Day(s)@29.58 Charged 15 Day(s)
Description Amount
RATE CHARGE 278.04
Swap A/R -47.99
STATE TAX 19.11
LOCAL TAX 17.24
MN REG TAX 13.90
TRANSIT TAX 0.70
Total Charges 281.00
Driver Total : 281.00
Driver Payments: 0.00
Tax ID : 41-1770414 Net Due From Driver: 281.00
Include Rental Agreement Number with Payment: DUE UPON RECEIPT
Please Make Check Payable To and Remit To: Agreement Number: RV-141182
CHOICE AUTO RENTAL INC LACH, JEROME
1803 BUERKLE ROAD SUITE 106 p��Pay This Amount: 281.00
MAPLEWOOD,MN 55110
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White Bear L - 1)766-7807 '
�` ~ Brook,yn Park-�,s3 - � REPLACEMENT CONTRACT
A������ Richfield -(612)861-�GS6 �NSURANCE PROTECTION FOR THE DR/VER OF A TEMPORARV SUBST/TUTE
REPLACEMENT VEHICLE TO BE PROVIDED BY RENTER'S POLICY OF INSURANCE.
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- www.choiceautorentaLcom
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Mon.7:00 a.m.-5:30 p.m.•Tues.-Fri.730 a.m.-5:30 p.m.•Sat.9:00 a.m.-t 1:00 a.m.
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DATE/TIME OF RENTAL �j l �l �C� X.� AM/ (Circle one) �� '
'� �� OFFICE LOCATIO �' I
DA7E/TIME OF RETURN / / . AM/PM(Circle one)
REPLACEMENT VEHICLE ORIGINAL VEHICLE
• • • .
Rente (La q (First) Unit No.: Unit No.: � /' ,
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}°" � Lic.No.: Lic.No.: " - /; �` ,.!%
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Cu ddress
i � ` �'� Make: Switch Date: Make: i
Ciry Stat �,z�p Code �_ r
�S i j�i� Mileage Mileage Mileage ileage
f � �r Out: In: Out: �:
0 4 one /. te irth Social Securiry No. �
. /,� ;jf �' / / � �J u OUT E 1/8 1�) ;3/8 I/2 5/8 3/4 7/8 F
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ADDITIONAL LICENSED DRIVE none Qermitted with¢ut Choice' approval. �
� ( ! �'1 �- � r�arr ''/ `r�ac
� I request Choice's permission Io allow -� � � �
AGE LICENSE N0. TATE EXP.� �'�� ", ���. �` ' F`'
ustpfher' itial _ ``�
who is untler my control and di ction drne the rented vehicle for me my behaN. I am ,�
responsible for t, ir acts while ih y're dri ing and tor fulfilling terms and cond'o this agr ent.
AU . Y- ' �� �
X RENTEF �° C 1 'S R .
AIM INFORMATION RATE INFORMATION
� �� � INSURED ' CLAIMANT (circle one) � • �'' ''
� . � / A t�� . Rental Days @ %� G;1�
/ // ( l
Credil Card k: � �� EXp' PO#,ROq or CL#
Misc Charges
ORIG AMOUNT TYPE DATE PD. AUTH#
DEP. 2nd Payer �:.;;'_,,�?, �!',{ � � � � �
ADDT'L . { 'j` Refueling ServicelConvenience �
�?"`" DEP. Par.Roa o�c�u Charge(DO not retuel upon retum)
,�w; `
Cash Check Credit Card all ta�ces
LOSS THEFT ACCIDENT Fee imposed by State of MN tor t
DATE theregistrationofrentalcar5.0%
PHONE NAME
State Car Rental Tax 6.2%
REPPIR S �P:� Sales Tax 6.875%
� ���(��� �� Stadium Tax 15%
TYPE A i `
`�' ;�� j 8 Transit Tax 25% j : 't`i..
, :r;.r
THE RENTER AG S THAT THEI VALID 8 COLLECTIBLE IIABILITY AND
PEFiSONAI INJURY CT ON I RA CE COVERAGE IS MAINTAINED WITH � � � • � • � •
� CO. '� � � � � � • � • • :•
_ - • • � � •
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Agent's Name � � � � � ••� � � � .�•
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Agent's Phone No. �` ' r �' • � � • � �
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Policy No. ration Date
Vechicie cannot be used for commercial purposes. � � = ��'�r �
RE T R ���
Charges due to damage of vehicle may be processed through Renter's Credit card f=
Minimum assistance fee of$25.00 is assessed tor key retrieval. _
WE SELL QUALITY USED CARS FOR REP �
BUYING A CAR? �ESS!!!
Ask for details or check our showroom�choiceauto.com
ADDITIONAL STIPULATIONS ON REVERSE SIDE
TERMS AND CONDITIONS OF TEMPORARY SUBSTITIJTE REN'1'AL AGREEMENT
^� �
Choice Auto Rental,Inc.(hereinafter"Choice")agrees to rent to the renter identificd on the reverse side(hereinafter the"Renter"or"Dr:��er,°as the con�ext may
require),the vehicle described,subject to the following terms and provisions:
L AUTHORIZED DRIVERS. The vehicle shall be driven only by the Renter and dricers listed on the reverse side as Additional Licensed Drivers. Renter
represents that Renter and each Additional licensed Driver are 2l years of age or older and insured under one or more valid,coilectible,automobile liability
, insurance policies which meet the requirements of the Minnesota No Fauit Insurance Act.
2. NO WARRANTIES. Choice is not a guarantor of anyone's safery. Choice is renting the vehicle"as is." Ren[er agrees that Choice is not making any wananties
�, of inerchantability or fimess for a particular purpose as to the vehicle.
, 3. PROHIBITED L'SE. The vehide shall IVOT be used:(a)by any person not specified in Paragraph 1,above;(b)in any race,test or competitive event or in any
off-road use;(c)for the transportation of persons or properry for compensation;(d)in violapon of any federal,state or local law or for any illegal purpose;(e)
while under the influenee of intoxicants or drugs;(fl outside of[he continental United States,without the advance written permission of Choice;(g)to push or �
�ow any vehicle or trai]er;(h)to transport any hazardous matenals or explosives;(i)by anyone if Renter misrepresen[s facts to Choice pertaining ro rental,use or
operation of the car.
4. ACCIDENTS. If the vehicle is in��ol�ed in an�ccident,is stolen or is vandalized,the Renter shall immediately notify Choice and the police and deliver to Choice
every process,pleading,notice or paper oT any kind received relating ro any claim,suit or proceeding. The Ren�er shall cooperate fully with Choice and its
insurer in their investigating and shall do nothing after loss to pre.judice their rights.
5. REPAIRS. Renter shall NOT permit any repairs to hc made ii�the��ehicle or any liens to be placed upon the vehicle without Choice's express writt�n permission.
Renter is liahle for the cost,of.inti�unauthorized repairs.
6. PROPER"CY DAMAGE'1'O VEHICLE AND LOSS OF USE. Renter is responsible for all damage to tbe vehicle,regardless of fault,including its loss of use by
Choice. If the Rentcr has personal automobile insurance policy issued in Minnesota,the properry damage coverage of the Renter's personal automobilc
insurance policy must provi�le$�j,000 of coverage against damnge to the vehicle and its loss of use by Choice. Payme�t by Renter's insurer for su�h damages
���ithin the time required under viinn.Stat. $72A.021 is acccptable to Choice and paymeot by Renter prior to that time is not requirecl. In the event Renter's
insurer fails tu pay within thc time mquired by Minn.Stat. §72A.021,Renter shall owe such amount immediately on demand by Choice.
7. LIABIL[TY FOR BODILY INJURY AND PROPERTY DAMAGE TO OTHERS. The vehicle is insured by a liabiliry insurance policy issued ro Choice which,
subject to its terms and conditions,protects Choice against claims of bodily iqjury,death or property damage arising out of the maintenance of use of the vehicle.
The liability protection afforded by this policy does NOT protect drivers N�ho have available insuranec(whether written as primary,excess or contingen[)which
equals or exceeds thc MINIMUM LIMITS required by the financial responsibility laws of thc state of Minnesota.
Drivers who do not have insurance(w�hether primm�y,excess or contingent)which equals or exceeds the MINIMUM LIMITS reyuired by the state�,f Minnesota
are,subject to�he terms and conditions of Choice's policy,prot�cted by Choice's policy to the extent set lorth below�:
A. lf the driver has available insur�nce(�+-helher primary,excess or contiugent)which is Iess[han[he MINIMUM LIMITS reqt�ired by the s[ate of Minnesota,
Choice's policy will supplemcnt the insmance available to the driver,but onlv t�or the amount by which the limits required by the state of Minnesota exceed the
limits of insurancc that is available to the driver.
B. If the driver has��o other available insurance(�a�hether primary,e.�cess or contingent),Choice's policy will protect the driver,but only up to the MINIMUM
LIMITS rcquired hy the state of Minnesota.
il Choicc's i��surer is reyuircd b��law to protect ihe driver.Ch��ices's policy will,subjec[to i[s terms and conditions,afford such pro[ection,but onl�� up to Ihe
MINIMUM LIMITS reyuircd by thc sta�e ol�Minncsot�i.
The driver shall indemnify and hold Choice harmless from and against any and all claims of bodily injury,death or property damage arising ou[of the
mainte�ance or use of the vehicle which exceed the MINIMCTM LIMITS required by the state of Minnesota.
8. UNINSURED/UNDERIh'SURED AND PF_RSONAL ItiJURY PROTECTION. Choice is not providine any uninsured or underinsured motoris[co��er.»e��r
any personal injury protectiun���no-iauli�j cover,i�c tu the�ri��er ur other occupant of the vehide. 1b the exten�such insurance is reyuired by�he state of
Minnesota, Choice's insurance policy���ill,subjea to its tenns and conditions,provide such protection,but only if there is no other available insurance(whether
primary,excess or contingent)and then only up ro the MINIMUM LIMITS reyuired by the financial responsibility laws of the state of Minnesota.
9. RESPONSIBILITY FOR PERSONAL PROPERTY. Renter releases and holds Choice and its agents and employees harmless from anv and all claims t��r luss
or damage to any properry of the Renter or any other person which is left in,un,or about the vehicle,either before or after its return to Choice or while on
Choice's premises,withou[regm�d to H�hether Choice or any of its a�ents or emplo��ees�vere negligent.
10. POWER OF ATTORNEY. Renter hereby grants Choice a power of attorney i��present am�claims to Renter's insurer arisin��out of the usc uf the car.
1 I. RETURN OF VEHICLE.Renter agrees to return thc vehicle in its present condition-normal wear and tear exce�xed--on or beiore the due date and time shown
on the front of this agreement or sooner if demanded by Choice. In no event is tt�is rental for more than 30 days. Failure to retw n the vchirie at thc datc and time
due,or within 2�1 hours of oral or u�ritten demand.���hiche��er is enrlier,will tennina[e permis5ion to use the��chicle and will authorizc the issunnce�>f,i warrant
for the��rest of anyone in possession. If the��ehicle is returned to Choice at�my place other than the Office Location listed on the rcverse side of this A�,recment,
Renter agrees to pny all expenses a�d costs incurred by Choice to have the vehide returned. Choice may peacefully repossess the vehicle,without demand,
wherever fou�d if the vehicle is illegally parked,is used in viola[ion of 13w or the Agreement,is apparendy�ibandoncd.or H�as obtained as the result of um�
miss�atement or fraud. Choice shall not in any�•ay be liable to Renter for damages resulting from such repossession nor shall it be responsible for the loss or
damage lo any property of Renter in the vehide.
l2. AMOUNTS DUE UPON RETURN OF VEHICLE. Renter shall pay choice on demand;(a)all time and mileage charges an�taxes as computed on the front ol`
this AgreemenC(b)refueling charges if the vehicle is returned with less fucl than when it was rented;(c)all fines,penalties,forfeiwres,court costs and out-of-
pocket espenses incurred by Choice u��ith respect to the use of the vehicle including parking,traffic,or other viola[ions assessed against Choice,the vehicle or
Renter;(d)Choice's costs and expenses including reasonable attorney's fees(unless prohibited by law)incurred in collecting any payments due hereunder or
in re�ossessing the vehicle:(e�compensation for d.unage caused to the vehicle,including loss of use by Choice,other than through normal wear and te��r;(f)thc
full value of uoy loss or damage to the��ehicle,re�ardless of fault,including Choice's loss of use;however,if the damage to the vehiele is covered h��the Renter's
personal automobi(e insurance policy,payment by the Renter's insurer�-ithin the time limits specified by Minnesota statute§72.A?OL shall he acc��F�tuhle and no
prior payment by the Renter for sueh damage or loss of use is required.
Choice may charge Renter$25 f'or any dishonored checks. Choice may charge a b25 a,si,ian�e tce tur kcy,lust c�r luckcd in vehicles. Choice ma��apE,ly and
deposit to pay mnounts due Choice under the Agreement.
1i. CREDIT CHARGES. In the even[Renter direc[s Choice to bill charges hereunder to uny other person or org�mizalion,such person or orcanization shall bc
joinUy and separately liable for all such charges. Renter expressly authorizes Choice to proce.ss a credit card voucher,if any,in his/her namc for ch;u��e�m��dc
hereunder.
14. NO AGENCY. The vehicle is the pro�crty ui Choice. This is.m A�recment for temporary use,not a transfer of ownership rights. Renter has no rights as tu thc
car except those granted in this Agrecment,No person driving the vehicle shall be deemed ro be the agent,servant,or employee of Choice for any masun or
pwpose. Dw�ing the tenn of this Agreement,Rentcr shall assumc complete responsibiliry to any regulatory body having jurisdiction.
15. NO ASSIGNMENT. Renter cannot and ti�ill not as,ign this A�rcenunt or the��chicle.
t6. WAIVER/MODIFICATION OF'I'ERMS. This Agreement is�he entire a�reement between Choice and the Renter. Any change to lhis A�recment must he in
wri[ing and signe�by Choicc. No Choicc representntive other than a corpornte officer has the authority to add tenns�u vary the tcrms on this side�,I thc
Agreement or to add terms or vury any of the terms on the odrer sidc of the Agreemen[excep[those where a hlank exi�ts tu fil(in specificd inform.nion. Any such
addition or variatio��of aoy terms by a Choice officer is i�cifective unless it is in a writing signed hy�both Uie Renter and the Chuice officer and�pe�ificall��
relerences this agreement by contract number.
RO: 0047007.00 Detailed Customer Invoice Page: 1
6/08/12 3:48PM
Raymond Auto Body, Inc.
1075 Pierce Butler Route
St.Paul,MN 55104-1593
651-488-0588 FAX: 651-488-4794 '
JEROME LACH Date of Loss: 5/OS/12 CUSTOMER PAY
986 AVON STREET NORTH Year: 06
ST PAUL,MN 55103 Make: PONTIAC
Model: TORRENT
Home: 651-489-6617 Type: 4 DOOR Phone:
Work: Style: 6/7 Fax:
Est.: SLJNDERLAND Engine: Adjuster:
Received: 5/07/12 Color: TEAL Claim#: 23-126W-019
Del. Date: License: MN 388-DZN Policy:
Date Paid: 6/08/12 Mileage: 120,103 Betterment:
VIN: 2CKDL73F766040523 Deductible: 250.00
Ln. Description Parts Labor Units Refin Units Other
rocker clip's 19.86
1 REAR BUMPER
2 Overhaul O/H bumper assy 2.60 '
3 Rem/Repl RECOND Bumper cover 390.00 2.40
4 Refinish Add for Cleaz Coat 1.00
5 Rem/Repl RT Lower cover 72.56
6 Repair Skid plate 0.50 1.20
7 Rem/Repl Step pad 68.47
8 REAR LAMPS
9 Rem/Repl RT Tail lamp assy 185.90
10 Rem/Inst High mount lamp 0.40
11 Rem/Inst LT Tail lamp assy 0.30
12 LIFT GATE
13 Rem/Repl LKQ lift gate+25% 750.00 1.60 3.60
14 Refinish Overlap Minor Panel -0.20
15 R&R lift gate add for trnsfr g 0.90
16 Refn molding license panel 1.00
17 R&I Electrical wiring and comp 0.50
18 Remove stripes,decals,and ad 030
19 Rem/Inst Molding 0.30
20 Rem/Inst License panel 0.70
21 Rem/Repl Nameplate"TORRENT" 19.49 0.20
22 Rem/Repl Nameplate"AWD" 19.49 0.20
23 Rem/Inst RT Side trim 0.10
24 Rem/Inst LT Side trim 0.10
25 Rem/Inst Wiper arm 0.20
26 Rem/Inst Wiper motor lst design 0.50
27 Rem/Inst R&I spoiler 0.30
28 Repair Spoiler 0.50 1.20
29 Refinish Overlap Major Non-Adj.Panel -0.20
30 Urethane kit 25.00
31 Rem/Inst Weatherstrip 0.40
32 Rem/Inst RT Lift cylinder 0.20
33 Rem/Inst RT Wedge lift gate side 0.10
34 Rem/Inst LT Wedge lift gate side 0.10
RO: 0047007.00 Detailed Customer Invoice Page: 2
6/08/12 3:48PM
35 Rem/Inst Latch assy 030
36 Rem/Inst Upper trim 0.20
37 Blend Molding 0.50
38 Rem/Repl Emblem 19.49 0.20
39 REAR BODY&FLOOR
40 Blend Reaz body panel 0.60
41 Repair RT Comer pillar(HSS) 3.00 1.00
42 Blend RT Reinf panel(HSS) 0.20
43 Blend RT Inner pillaz 0.40
44 Refinish RT Reaz extn(HSS) 030
45 QUARTER PANEL
46 Blend Fuel door 0.20
47 Rem/Inst Fuel pocket 0.30
48 Rem/Repl RT Quarter glass Pontiac w/dee 228.09
49 Urethane kit 24.46
50 Rem/Inst Mud guard 0.20
51 Rem/Inst Mud guazd 0.20
52 Repair RT Upper panel(HSS) 3.00 0.40
53 Blend RT Outer wheelhouse 0.40
54 WHEELS
55 Rem/Inst RT/Rear R&I wheel 0.10
56 REAR DOOR
57 Rem/Inst RT R&I door assy I.00
58 Blend RT Outer panel 1.00
59 Repair Rem old stripes/tapes/adh reaz 0.50
60 RT Outer panel 125.00
61 Rem/Inst RT Rear w'strip 030
62 Rem/Inst RT Belt w'strip 0.20
63 Rem/Inst RT Side molding 0.30
64 Rem/Repl Retape door side mdlg 0.20 2.00
65 Rem/Inst RT Handle,outside 0.20
66 Rem/Repl RT Stone guard 16.41 0.30
67 Rem/Inst RT R&I trim panel 0.40
68 PILLARS,ROCKER&FLOOR
69 Rep Part.RT Uniside panei quarter panel 252.49 15.50 2.40
70 Refinish Overlap Major Non-Adj.Panel -0.20
71 Repair Deduct for Rear Bumper R&I -0.80
72 Refinish Clear Coat 2.50
73 Rem/Inst RT Rocker molding 0.70
74 Rem/Inst LT Rocker molding 0.70
75 Refinish RT Outer rocker pnl 0.90 �
76 Blend RT Inner rocker(HSS) 0,3p I
77 ROOF I
78 Rem/Inst RT Side rail lst design 0.50 I
79 Rem/Inst RT Carrier bar 1 st design 030
80 FENDER
81 Rem/Inst Mud guard 0,2p I
82 Rem/[nst Mud guazd p.2p i
83 MISCELLANEOUS OPERATIONS
84 Repair Frame time pull right rear 2.50
85 Repair Set up for pull 1.00
86 Rem/Repl Two tone tape stripes 0.40
87 Repa'u Glass Clean Up 1.00
88 Rem/f2epl Cover caz/bag 0.20
RO: 0047007.00 Detailed Customer Invoice Page: 3
6/08/12 3:48PM
89 Flex Additive 8.00
90 Refinish Conosion protection primer 030
91 Hazardous waste removal 3.00
92 Repair Right Rocker Pinchwelds 0.30
93 Repair Left Rocker Pinchwelds 0.30 0.30
94 Rem/Repl Seam sealer 15.00
914 Paint Materials 468.00
920 Clear Coat Paint Materials 75.00
926 Paint Blend Materials 108.00
Totals 2,167.25 44.70 21.70 728.46
Total Category Est.Cost Rate Units Est. Suppl. Total
PARTS 1,429.58 2,058.64 -16.39 2,042.25
BODY LABOR 844.00 50.00 42.20 2,110.00 2,110.00
FRAME LABOR 52.50 70.00 2.50 175.00 175.00
PAINT LABOR 434.00 50.00 21.70 1,085.00 1,085.00
MISCELLANEOUS 202.46 202.46
PAINT MATERIAL 390.60 30.00 651.00 651.00
Subtotals 3,150.68 66.40 6,282.10 -16.39 6,265.71
SALES TAX 156.97 -1.25 155.72
Grand Total: 3,150.68 66.40 6,439.07 -17.64 6,421.43
RO: 0047007.00 Detailed Customer Invoice Page: 4
6/08/12 3:48PM
Date Payment Received By Method Charge Type Amount
6/08/12 PERSONAL CK#5720 LEIBEL Check 6,421.03
Total Payments: 6,421.03
Balance Due: 0.40
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986 Avon St. N
Saint Paul, M1V 55103
Ia Lovi�g Memory Of
ARLAINE O. FRANZMEIER
� soru
June 12, 1944-Augusta,Geargia
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May 19,2012-Farmington,Minr►esota
And we know that all Fanera�service
Shepherd of�e Valley Luti�eran Church
things work together �e vatt ,tKinneso�a
T'hutsday,May 24,ZO12 at 10:30 A.M.
for good to them _,....�����
�at love God, �,,.�„t�;ngton
to them who are the called
Paub�arers
according to His purpose �Spcute C.J.Maines Todd Maines
Jim Hansoa Matt Gores Chris Gores
Romans 8�8 Aonorary Pallbesrers
Gene Olson Ken Ducios
Interment
S't.John's Cemetery-Rich Valley
Rosemowrt,Minnesota
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Caturia-Smidt Ftimeral Home
Hastings,Mmnesota
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