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Aura ��'���'?��F�`��i NOTICE OF CLAIM FORM to the City of Saint Paul, Min��o�a�� 2!l12 �, _..;, .,, ._ Minnesota State Statute 466.OS.rtates thnt "...every person...who claims damages from any m�un�cipality...shall cnuse to�-b��r�se��t�,d,.2;rrt�ae goi�erning body of the municipality within 180 days after the alleged loss or injurv is discovered a notice stating the lime,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 ���L���� j� Middle Initial :J Last Name �,( ,}�t( Co�npany or Business Name Are You an Insurance Company? Yes/ 1�� If Yes, Claim Number? Street Address ��,' �� ��� �`t (�ti �� �� `, _, � City G'`��' �� �-F- ��,(,1�•� State�j�"v Zip Code��i � �� Daytime Phone (t%) `'�`' %?I� Cell Phone �( I�)2� ��j� vening Telephone�) - Date of Accident/Injury or Date Discovered �t - i_3 - i � 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 Paul or,its emplo ees are involved and/or responsible for your damages. i � ��l'�Q `�CG {� �; t r. � � � � • r _ , � : � •,,�'� �� � �� Y, � � , , ., � J , � j. , ✓,. o .C� � '�� �, �.-,, �, ; C�. �r� , �f,�l -�'� ���� { .S ���. ��-. ��,.%�,_ _ � � 1 Please check the box(es) that most closely represent the reason for completing this form: ❑ My vehicle was damaged in an accident ❑ My vehicle was damaged during a tow �"My��ehicle 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 injared 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 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. 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 witnesses to the incident? Yes No ' Unknown (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, name of park or facility, . y ' b e. If necessary, attach a dia ram. :�t �G � � � � r,t!=�- , closest landmark, etc. Please be as detailed�s ossi � ��%� ����, � , , .�� �� � � � .� ,� �� ,��, .� Ir�i �,������ �i`j��.�_ �--r-"�:�.���c�x- '� �-�' +�' �' :-��_t- y �) Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claiin c �"�i=� � + � •�:, r �� . -� - toyoursatisfaction. 1.�-�_'� � ,� _.� r�1 �{lx.��� ���'� �-�k' �1��L�, � �� � (__�i= Vehicle Claims- lease com lete this section ❑ check box if this section does not a 1 Your V ehicle: Year •¢a"_�f�,'�� '� Make L��'�y�(,1.� ���� Model �` �S !-��" License Plate Number 1 I L State Color (`f`;l I l,�`1� / f��( Registered Owner � Driver of Vehicle "�� �1- 1 Y Area Damaged '.`�'� S. % City Vehicle: Year Make ' Model License Plate Number State Color Driver of Vehicle(City Employee's Name) Area Damaged Injury Claims-please complete 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: 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. 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Receive a $10 off oil change coupon on your next visit. Please, complete the survey at TIRES•SERVICE•BRAKES•BATTERIEB �•tkcares.com Use password 32656206 00001 MN NATL TIRE & BAT # 876 *** INVOICE REPRINT *** Page 1 1973 S ROBERT ST Invoice# 60475826 - RI WEST ST PAUL NIl�T 55118-3942 Order Num 32656206 - WI (651) 455-0002 Date/Time In. . . . . . . . 07/14/12 10 : 09 : 51 Date/Time Out . . . . . . . 07/14/12 11 : 18 : 59 2008 CHRYSLER ASPEN Tag: 114GVL St : MN Mileage: 65621 Engine: VIN# 1A8HW58N68F147116 ------------------------------------------------------------------------------- Customer: 29446388 PO# : Ship To: AUR.A, DUSTIN 90 WEST ARION ST WEST ST PAUL MN 55118 Opening Salesperson 12982047 Home# 715-220-3184 Work# Email : ------------------------------------------------------------------------------- Item Number Item Description Qty Price Each Extended ------------------------------------------------------------------------------- BF04926608TOL BFG Long Trail T/A 1 181 . 99 181 . 99 91173 P265/60R18 109T, 91173 US 50, 000 SCT Service Central Tire Install 1 16 . 99 16 . 99 SCB LIFETIME WHEEL BAL 1 KMTSL MOUNT AND INSTALL 1 12992142 TORGUSON, JACOB LTRF LIFETIME TIRE ROTATE SVC 1 TPMSKITS Tire Pressure Mon System 1 PA Price Adjustment 1- cctc TIRE CONCESSION CREDIT 1- 20 . 00 20 . 00- REC60K RECOMMEND 60, 000 MILE SERVICE 1 VISA Visa 193 . 55- CARD NUMBER 9143 APPR 071418 IF YOU HAVE A QUESTION OR CONCERN PLEASE SPEAK TO OUR STORE MANAGER, MATTHEW J. FLORY AT (651) 455-0002 -- --- — - -- � Total Charges . . 198 . 98 Total Credits . . 20 . 00- Sub-Total . . . . . . 178 . 98 New Tire Fees** . 00 Shop Fees (*) 1 . 70 Al1 Taxes . . . . . . 12 . 87 Payments . . . . . . . 193 . 55- � Net Amount . . . . . . 00 PLEASE PAY ABOVE AMOUN'I'. THANK YOU! Closer: 12965050 I have received the goods and services as represented on this invoice. If this is a credit card purchase z agree to pay and comply with the cardholders agreement with the issuer. *This charge represents costs and profits to the vehicle repair facility for miscellaneous Shop Supply or Waste Disposal. Customer Signature PLF.ASE SEE REVERSE SIDE FOR WARRANTY,TERMS,CONDITIONS AND OTHER IMPORTANT INFORMATION CUSTOMER COPY �,�rrt�r�x��r�QOM���'�'�;�"-'.` ,��.�� .... ttlrK�•q4MM•Mfl�yM•ONM �.�a . . . New Tire Limi[ed Warranty *What is covered and for how long: Every new tire purohased at a Tire Kingdom,Merchants Tire,NTB or Big O Tires store(collectively'TBC Retail')is warranted by the manufacturer against defects in workmanship or materials down to 2 32nds of an inch remaining tread grove depth.Additional warranties may apply to some tires.TBC Retail will honor the manufacturer's warranry on any such tires,and any such tires which fail under the terms of the manufacture's warranty will be repaired or replaced in accordance with the manufacturer's warranry program.You must comply with the conditions of the manufac[urer's warranry program ro receive this warranty coverage. *How credit is determined: If a tire covered by this warranry becomes unserviceable due to a defect in workmanship or materials(tire separation,etcJ during the usable tread life of the tire(usable tread depth is original tread depth minus 2%32nd of an inch),you will receive a credit for the amount of usable tread remaining on[he unserviceable tire times the curren[selling price(example 60%usable remaining tread times Uie current selling price of$80 equals a credit of$48).This credit will be applied to the invoice of the replacement tire. *What is not covered: This warranry does noi cover tires which become unserviceable due[o: I. Conditions resulting from road hazards such as cuts,snags impact breaks or punctures. 2. Conditions resulting from improper installation,wheel misalignment or tire/wheel assembly imbalance. 3. Conditions resulting from consumer damage such as improper tire and vehicle maintenance,misuse,abuse or accident. 4. Tire uniformity complaint atter the tirst 2i32nds inch of tread wear. 5. Use in any commercial application. *See Other General Terms and Conditions below. Limited Mileage Warranty *What is covered and for how long: If a mileage warranry is noted on the front of the docwnentation attached hereto,such tire whose remaining tread depth grove is reduced to 2/32nds of an inch or less prior to receiving the specitied mileage.will be replaced witl�the same or an equivalent new tire at the then current retail price,including applicable taxes,less an allowance based on the actual mileage received at the time presented ro a TBC Retail store compared to the specified mileage.Mileage warranty claims will only be honored within 6 years of the date of original tire purchase and before the tire delivers the warranted mileage.The following tires are excluded from the limited roileage wartanry:commercial use tires,tires worn from excessively aggressive driving conditions such as racing and tires worn from improper maintenance such as lack of rotation,improper air pressure,alignment or mechanical wear. *Owner Obligations: Proper tire care is necessary to obtain the maximum mileage and wear from a tire.It is your obligation to see that your tire/wheel assemblies are in balance and properly aligned,that your tires are operated at vehicle manufacturer's recommended cold inflation pressure and that your vehicle is well maintained.Your tires mus[be inspected by us a minimwn of every 6,000 to]0,000 miles.Check air pressure in eacl�of your tires including the spare,at least monthly when the tires are cool.TBC Retail will check alignment,treadwear,tire pressure and ihe mechanical condition of the vehicle anytime at no charge a[any TBC Retail location. *What is not cavered? l. Defects in workmanship and'or materials(covered by separate new tire limited warranty). 2. Failures caused by road hazards. 3. Tires used on special applications such as light trucks(unless specifically covered),vans,recreational vehicles or commercial vehicles including taxi,police,etc. 4. Tires with premature or irregular wear or damage due to improper inflation,misalignment of wheels,mechanical defects of vehicle or tires on vehictes where necessary vehicle repair or maintenance has not been performed. 5. Tires damaged by fire,wrecks,obstructions on the vehicle or wiliful and malicious damage. 6. Repairable punctures or tires run flat. 7. Sidewall damage from scuf'fing curbs or oNier cosmetic damage. 8. Tires transferred from the vehicle on which they were originally ins[alled. 9. Use in any commercial application. *See Other General Warranty Terms and Conditions belaw. Road Hazard Warranty *What is covered and for how long: This warranty covers aIl tires for which this warranry has been purchased that has become unserviceable as a result of nonnal road hazarAs(i.e.cut,snag,bruise,impac[breaks or irreparable punctures).i his limited warranty terminates when the covered unserviceable tire is adjusted or when the tire is worn to a level of 2/32nds of an inch,the minimum tread depth required for safe vehicular operation. *What is not covered: Tires removed from service due to being overloaded.intentional abuse or tires used in other than normal passenger vehicle service.Tires that can be safety fixed will be repaired FREE OF CI IARGE.Road service,rowing costs and other incidental damages or costs are not covered. *How is replacement price determined'? Normal Road Hazards,Run Flats and Workmanship/Material Defects hi the event a tire covered under the warranty becomes unserviceable due to nonnal road hazard(example:cuts,snags,impact breaks or non-repairable punctures),(usable tread life is the original tread depth minus 2/32nds of an inch),in the first 12months or 12,000 miles,whichever comes first,you will receive full credit of the original purchase price of the tire towards the cost of replacement.After the FREE REPLACEMENT period of 12 months or 12,000 miles,whichever comes first,you will receive a credit for the amount of usable tread remaining on the damaged tire based upon your original purchase price.(example:50%usable tread remaining times the original purchase price of$50 equals a credit of$25).This credit will be deducted from the cost of the replacement tire.When Uie tire is worn down to 2i32nd of an inch or less,the tire is worn out and the warranty ends,regardless of the age of the tire. *This warranty must be purchased for this coverage ta apply. *See Other General7'erms and Conditions below. Other General Warrantv Terms and Conditions *Who gets the warranty'? All warranties apply ro the original purchaser aud may not be assigned to a subsequent purchaser or owner of the motor vehicle on which the tire(s)covered by our warranties are installed.A tire (s)mounted on any vehicle other than the vehicle on which it was first mounted is also not covered by these warranties. *Where to go for warranty replacement and/or service? All TBC Retail warranties will be honored at all TBC Retail locations,including any Big Q Tire Kingdom,MerchanPs or NTB store nationwide.For warranty service,you must present your sales invoice and service records,along with the unserviceable tire(s).TBC Retail store locations can be obtained by calling 1-800-NEW-TIRE,or in PA or NJ.1-888-TIRES NTB or in the white pages or yellow pages under Tire Dealers Retail.In the event you are unable to locate a TBC Retail store or require further assisiance,you may contact our CUSTOMER SERVICE OFFICE at 800-926-8473 anywhere in die Continental United States. *Consumer Rights: This warranty gives you specitic legal rights and you may have other rights,which vary from state to state. Some states do not allow limi[ation on how bng an implied warranty lasts,so[he warranry limitations may not apply to you. *Conditions and Exclusions: Nothing in this warranty is intended to be a misrepresentation that tire failure cannot occur.To the exten[permitted by law,liability for consequential damages is disclaimed.To the extent that a manufacturer's warranty applies,such warranry shall be primary and the TBC Retail warranty shall not apply to the extent of the manufacturer's warranty. *Owners Obligations: Proper tire care and vehicle maintenance are necessary to obtain maximum treadwear and service from a tire.It is your obligation to properly maintain your tires and the vehicle,upon which they are installed,including;operating your tires at the vel�icle manufacturer's recommended cold inFlation pressures,insuring your tire and wheel assemblies are in balance,tires rotated on a regular basis(every 6,000 miles is recommended),vehicle in proper wheel alignment and vehicle steering,suspension and driveline components are well maintained.TBC Retail will check and inspect tire condition,wheel alignment and vehicle condition at any time without charge. xReplacement warranty: If you receive a replacement tire under the terms of this warranty(s)the replacement tire will be covered by the warranty TBC Retail gives that tire.Road Hazard Coverage will need to be purchased separately to cover the replacement tire. Mechanical Service Terms&Conditions Unless othenvise stated,all mechanical service parts are warranted for 12 months or 12,000 miles whichever comes first All labor is warranted for 90 days or 4,000 miles whichever comes first, Iboth to ihe original purchaser during[his period. \ "fBC Retail will replace the parts and redo the labor at no furtlier cosL Warranties do not apply to vehicles used in commercial application. By execution of the repair authorization on the front of die invoice,wstomer authorizes repair work to be done as described.Customer agrees ro pay cash on the delivery of the vehicle,and until \ paid in full,TBC Retail shall have a lien on the vehicle for the amount owing.hi the event of'default by the customer in payment,TBC Retail is hereby specifically authorized to retain possession of the vehicle without notice and without process of law,and said possession shall imest TBC Retail with alI rights of possessory lien holder under the Iaw.Customer fur[her agrees[hat TBC Retail will not be held responsible for the articles left in vehicle in case of t5re,thefL accidents or any other causes beyond its control. Customer's cehi,l�ma�be dri��en by TBC Retail employees at customei s risk.Storageµ�ill be charged at a rate of S I5.00 per day beginning 3 days after notice to cusromer that repairs have been completed.If TBC Retail is forced ro take any action for collection of any balance owing by cusromer to TBC Retail by lawsuit or otherwise,customer agrees[o pay interest on the amount owing � until paid and the collection costs.The provisions herein set forth shall become part oF any independent agreement for payment made between customer and TBC Retail in connection with work authorized by this order.If customer cancels this order,TBC Retail may charge for the cost of the teardown,the cost of parts and labor to replace items that were deshoyed by teardown and the cost to reassemble the components of the vehicle. TBC Retail will not be responsible for damages to the vehicle due to causes beyond iPs control(ask about limits and extent of insurance). Some states do not allow tl�e exclusion or limitation of incidental damages,so the above limitations may not appty to you. Disclaimer of Warranties Except as described herein,TBC Retail makes no express or implied warranty whatsoever with respect to tires,maintenance or repair work,including but not limited to the implied warranties of nterchantabtlity and fitness fot a particular putpose. Any implied warranty is limited to the same duration as die written warranry. Some states do not allow limitation on how long an implied warranty lasts,so the above limitations may no[apply to you. TBC Retail disclaims any liability for incidental or consequential damages to the extent permitted by law. Some states do not allow the exclusion or limitation of incidental or consequential damages,so the above limitations or exclusions may not apply to you. The customer's remedies described herein shall be exclusive of any o[her remedies.The warranties described herein are for the exclusive benefit of the customer and are not assignable except as provided otherwise.The customer must present this document and correspmiding invoices to TRC Retail in order to resolve the benefits of any warranry contained herein.