Campbell ���c�ivEp
�jUG 0 �' 20 i2
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NOTICE OF CLAIM FORM to the City of Saint Paul, Mi�rl'e�s�t�
Minnesota State Statute 466.05 states that"...every person...who claims damages from any municipaliry...shall cause to be presented to the
governing body of the municipaliry within 180 days after the alleged loss or injury is discovered a notice stating rhe 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 prceess can take up to ten weeks or longer depending on the
nature of your claim Tlvs 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 ��^R'r Middle Initial `� Last Name �A^`Q�F ��
Company or Business Name
Are You an Insurance Company? Yes/� If Yes,Claim Number?
Street Address �S�� � � • �
City ��• ��� State /�l�t/ Zip Code ��°2-
Daytime Phone( ) - Cell Phone(G5� )� Z 6 t y Evening Telephone(_) -
Date of Accidend Injury or Date Discovered `9' �`(�t2- Time � 3`y am/�
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 az involved and/or responsible for your damages. w.: d c:v��
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Please check the l�ox(es)that m�st closely represent the reason for completing this form: � ,
�y vehicle was damaged in an accident ❑ 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 vou need to include copies of all anplicable documents.
For the claims types listed below,please be sure to include the documents indicated or it will delay the handling of I
your claim. Documents WILL NOT be returned and become the property of the City. You aze encouraged 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-nlease comnlete this section
Were there witnesses to the incident? es No Unknown (circle) r
Provide their1}ames,addresses and telephone numbers: ��+��'+N� �M -i I l.�b� �+�� ' �`��
�°S'�'I /`�'' �`�- l�• �f+ ��-�tr J� � �c�'� '-- �
r- r
Were the police or law enforcement called? Yes C� 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,name of park or faci "ty,
closest landmark,etc. Please be as detailed as possible. If necessary,attach a diagram. E• ?�'` S-�, r�(r^'D �•
k:�onJ �C.
Please indicate the amount you are seeking in compensation or what you w uld like the City to do to resolve this claim
to your satisfaction.CC-� 1�(�- � G ttFZ f-� T-�� � j'�Cj Cy�� �n,� r�t c,..;� t� ��
t��CctD Z� N� 5�;��S��y��-,C°� .
Vehicle Claims- lease com lete this section ❑check box if this section does not a 1
Your Vehicle: Year Z•°� Make r°�-� Model h'°`'`'
License Plate Number State�Color �v�
Registered Owner S{�A�� C«-�l,i��
Driver of Vehicle S-�a�+ CaMe�F��
Area Damaged �R-N� R:)`�*� TtR t=
City Vehicle: Year Make � Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Injury Claims-ulease comolete this section , check box if this section does not applv
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: i
Address Telephone ',
�Check here if you are attaching more pages to tlus claim form. Number of additional pages�. j
By signing this fornt,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 � �Z
Print the Name of the Person who Completed t ' ,c��sRT �'\M���- (f
Signature of Person Making the Claim:
Revised February 2011 /
Bobby And Steves Auto World Mpls
"The Best Auto World In the World"
Bill To Stewart Campbell Plate 256ALW
1589 7th St W Description Blue 2001
St Paul Mn 55102 Make Ford Focus
Engine 4-121 2.OL DOHC
Odometer 117,016
Phone (651) 278-2696 VIN 3FAFP31391R201192
PO # N/A
Work Order # 0000266316
Invoice Date ]un 20 2012 Invoice # N/A
Appointment Jun 18 2012 10:52 am Svc Advisor Laughlin, Brady
Promised Jun 18 2012 12:52 pm Technician Lee, Chris
Estimated Work
* Install New Tire 1
h1ount tire, instali new vaive stem where applicable, clean and seal tire to wheel seat, set tire pressure to proper inflation.
Computer spin balance tire and wheel. Mount and torque wheel lug nuts to manufacturers torque specifications. Perform
final road test where applicable.
P205r`50r2.6 Fu:�ion Hr� 87h 1.00 Units $99.90 / Unit $99.90 RST
Mount & Balance 1 Tire $20.00 E*
Piease Note
Some wheels require lug nut re-torque. Ask your Service Consultant for details.
Keeping your tires properly inflated and rotated will assist in maximizing tire wear life and vehicle handling. _
Sub $119.90
Estimate Totals —.__...
Total Labor $20.00
Total Parts �99•90
Total Before Taxes &Miscellaneous Charges $119.90
(*) Shop Supplies $1.60 S
(E) Environmental Charge MPLS 6 % $1.20
(R) Lifetime Tire Protection $10.00
(5) State Sales Tax �•775 % ��•89
(T) Tire Disposal Charge $2.99 Each $2.99
Totals $143.58
Estimate Comments
This Estimate is valid for 30 days.
1221 Washing[on Ave 5 Minneapolis,Mn 55415-1247
Phone:612.333.8900 Fax:612.333.2145 Email:service.mpls@bsaw.com
www.fourstarauto.com
Four St�r 3324 University Ave. S.E.
,,, • • . Minneapolis, MN 55414 We Employ
AUtO S¢rtiiC¢ I11C 612 378-9561 �Certitted Technicians.
, � )
STEWART CAMPBELL 2001 eng: L4 2.OL 121ci 1 plate# 256 ALW mileage
15897TH ST W FORD ' vin#3FAFP31391 R201192
STPAUL,MN 55102 FOCUS ZX3
C#651 278 2696
•
ESTIMATE ON TIRE AND RIM.
• •
TlRES NEW TIRE PURCHASE 276.05 Group Total
STEM 1@ 1.95 1.95 VALVE STEM . I LABOR 14 .0 0
TDF 1@ 2.15 2.15 TIRE DISPOSAL FEE �LABOR MOUNT AND BALANCE TIRE (S>
2055016 1@ 107:95 107.95 FUZION HRI �
USED WHEEL 1@ 150.00 150.00 16"6 SPOKE PAINTED SIL �
Parts Sub-Total 262.05 '
INFORMATION IS `INTENDED FOR ESTIMATING PURPOSES ONLY'e
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� � � � I.the Registeretl Owner,authorize you to perform the above repairs � ��� � �
and furnish all materials and include any necessary sublet work in the
above estimate.I understand any cost quoted heretofore is an estimate
only. Your employees may operate vehide for inspection, testing,
delivery at my risk.You will not be responsible for loss or damage to C
vehicle lett more than 46 hours after notification that repairs are PART S 2 6 2 . �J
completetl. An express mechanic's lien is acknowledged on above
Estimate vehicle to secure the amount of repairs thereto,induding those irom LABOR 14 . 0�
any prior work or repair contract on this vehicle.In the event an atlorney
is retained to foreclose this lien or to bring suit for coliection ot any T a X 2� . 3 7
sums due,I agree to pay costs of collection and reasonable attorney �T w.�f
fees.Receipt of a copy of this order is hereby acknowledged. TOTeaaa WORK ORDER 2 9 6. 7 G
Signed ...........--
...._------ _.----._ ....----------.....
Customer Signature