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• '� ILlirtnesota State Sttttute 4b6.05 stafes lhat "..;every�ersort who claims ifamages from any munictpalzry..,shtt�'1 cau'se td be p�esented to the ;
governing body af th�tt�utitc:�ulit,�t t�ithin':180 da�aj3�r the ull�;�vss�a `r� a�p1i�s�t�t3ng th��T�e'pfa��u#td
, , circr`itrr�tan�es thea`ep�;tt�id the tr�rvun��eo»spevis��i��i�r r d�Grtdad"
P1Ease cnmp�ete tlus f�zt�in its�u#[�ety by�Iearly�ivn i►�'px#ru�arig your answer to ea€�:q�uestion If m�re s�a��fs
needed,atta�h addifaona�::sheefs. �lease:not+e that ou will�ot be coutac�ed b tele ho�le�tQ ctatri�:ansxvers ro�id�as n
Y u Y P .; 3� �3�,�
much informa#�ou a�necessary to explairi ynur c���m,aiid t}�e amount pf+compensation being;�r�c�uested Yoi��ii�rece�ve a ,
�ritten ae.lsauowledgement onc�yoar foriti�s rec���Yed. Th�process caln#ake up�o feu we+��'fl�laitger depeud�n��n the,: -
na�of;�nur,cla�m. �'Iufs fQrm amu�be�sigrie�,a�td bo p��com�eik�tl.;�'€s�ethtng,do�s�ot�pp�Y;��°<1���1,i ;=�,,: �
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1� '1�S'�K��.LO�.�L�'D�,��� ���.,�,��1�TT�'A�a� 551�� : .
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�'�rst Name':�{,�(��'"(� � l�ddle Ti�atial L�st.Naine .�������: _
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Compariy or Business Narne ,
A�e You an,Insurance Coxnpany�_ Yes� If Yes Clairn Number? I
...� ;. ` . � m +��'��.�rvc. � $ '.�i �� %f �r -.� �+ ,i
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Daytime�'ho���(��`����Gell:Fhoz��'����Eveni.ti�Telephone�}�� � ��
' .Date of Accidentl Injury or Date Disco�vered ���` ���"�»Tir�t1�_���� /p�ni
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Please state,.in�detail,wh�t o�ciured(happened),and why you are subrrntfing a claiii� Pl��s�;ndie�te wh�or ho.v�yau . ;
feel the City of Saint Paul.or its e�ploy�es ar involv�d arid/or responsi,ble�'or your:�lamages, -
�� .:���:�,� �� �
'. Please cl�k t�e box(es)tliat�nost closcs�y��e�en��i� on for�onm►pl�tuig�i�is fo�m �
C]My ve�cie was clamaged�n au'acc��,ent ' _ C!M�v,e��ie w�.c��e�dt���to�
,
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�l l�y�eh�cle Was�axnageii by a„�tk��Ie c�r e,oni��on of t1�C.�1r+eet C}Ivly vehicl��t!a�d�nag�d by,��lpw ;
, Cl 11r1y velucle was�viong�ly'tov�e�d:�cllor tict��ted ' LL�I wa$'inj�red Q���ty.ptt�ge� , ;: , '� �
- '���V1�V'������'��i l�4M�M*�.� �:f �7.,.�.. F .
�{��1'�4�lTi��li'��-'p�'�8�,�)� ' �`
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In orc�er�to process y�r��la�m'�rit��eec�t��lu+d�coufes of a �r� y � ��
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�c�r�he a�a�typcs I�si���c��+v;=�IEas�1�sure;tti u�cli���t1�e documen�s�c�ca#ed�r�t w�����t����i�ng o#'
yoi�r elaim:I)oeunien�s �� L N T be reluineci�ad�ie�na��e piap�.of�e�CiLji.''�oii�erico�ge�.tt�'#�ee��
copy for yoi��laefc�zz��suhnu�g Youz cla�m�'orm : : ': � � ' ;
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#�'rc��erty d�mage claur�tio a v+�I�cl��t�v�v��txrn��"for,�t��regaaa�s`�o�ai�v��a�.�I���h������ee,c� : '
' $�Q0.00;or.the actu�l biils ar�d/cir�eeei�S for�i'repaus . -
�Towing claims:legible eap�es�f any,�i��el�t 3' an�t a copy cr�ttie impvund�t����gt
O 0!ther property clamage`elaims.;two repair es „ fes xf.the damage:exceeds$�00,�(�,o�the act�ai hills '
and/or receipts for the rep�i�'s,;cteta.iled list of da` . ged`items�'
� O Inaury cl��m,s.,r�esiical b�ils,recaipts; � ` �� � �� � '
<. i'i�hotagraphs aTe alr�ys vvelcome tfl do�um� t aiirl�support�►our elaim but wili not b�ret�ci��l:
, , � ,
Page 1 of Z—Please�otnple�e�nd retur�both pages of Claim Form
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Failure to c�r��ete�nd�r�i�t�iu,�otl�pages wil���stdt iu dela�in th�I��t►c�ir�g-�f��ur-.clai�:
All Claims—u�ease coi��t►►plete this sectiou
Were ther�v�it��sses to th��ciderit? .' � ' No �. I7iaknawn. (c���ej . " �
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Were=th police or aw enforcemenf calle . Y � o . nknown ��cucle �
If yes,v�ha#departrrient or age�cy?., �i'C�se#or report# '
Where did�he accident or i�j�ry take piac$� �t'ovide str�et address,eross str��,�inters�ctit�z�;�arri�of.p k or f�cili �
closest��:�' tc. Piease he as d� sd as p ii�le. If ecess�,a�tach a dia azn. ' '
;� �, �
` Please in cate e a�own�y u are � in cumpensation ior you woul ' �?ry o �to re��lve kius claim
to your s�tisfaction. �` � ��� ���
Ve�►icle Claims— lease`com lete this section ❑check box'if this section�oes not a 1 '
i Your Vehicle: Year � Make Model -
� ����,,�- Lice�se�'�ate Nurnber : - :! Sta#�'� 'Co�l�
� �� �'�'eg�st�red Owner
Driv�r.of V,ehicle , - � :
Area Damaged
� City:V�hicle: Year , I1�alce odel
I �.License P1ate Numb'er State�� . Color
� Driver of�ehicle.(City.�ia�pioyee's Name) ,.
Axea l�arnaged : , � • , � , � t {
I
i . � Iqjnry_Claims—ptease comglete this section �� ❑check box�;t#'this�sectidn�c�oes"no#aptil�%� � �� � � �
' How.were you injured? !
What partt�s)of your body;were inj��cl?
Have you,sought rri��ic�l lreatmer,nt? �es � �To. :. ° Planni�g,ta Seek Tteatm�nt(ci�+cle}, �
When did you receive treatinent2 �provide date(�))
Name o�Medical.P�avide�(s�: � '
. , ;
_; .... .
, : .,
Address -_ Te��p�one
Did you Yniss work as a result ofyour injwty2.: Yes . ''No � `
� ` When did you miss work? � (provi�ie date(s)) �
Name of your Erriployer;
_ .�1�d�es� - - -- �fi�T�pTir�e� �
�heck here�f you�re�tt�ching mar�pages to this clai�form:: l�wmb�r c�f adt�4on�1 p��
. . �
By stgning this form,you are�latir�g that all tnf�vr�na#�ot�you,have pr�vitl�d i����an��Qr�ect�t1e�hest `
of your lcnowledg� FJ�signed forms wail�t�ot be p�oces�e� -
Subm�t#tng u�`att�e c�a�m ca�result ir;pr�r�s�cution: �l►ate fozm�vas cam�lete;d � � '.:LL� ��
P�nt the Name r�f the Pers��vwho Gomp�eted:. .' ' ��� - �����`. ,
Signature af Person Making the Claim:
,' .,;
. ,-: ..
` Revised�'ebiiiaty 2U 1 l :; . , `? � , . _ . , _! -;
At about 8:OOam on Thursday October 25, 2012 I was driving down St.Anthony ST.going westbound. On
the corner of St.Anthony and Chatsworth a new cross/walk bridge is being built across highway 94.The
equipment to build the bridge was lined up along the street causing half of the street to be blocked off
so there where road signs to signal to move to the right. While driving down the right side I hit a pothole
that I didn't see until I had already hit it(it was still dark outside and raining). Immediately after hitting it
my front passenger side tire blew and I slowly pulled over to the side. I called Enterprise since I was in
there rental car and they informed me that I had to put the spare tire on the vehicle and bring the
vehicle back to them. Since I do not know how to change a tire, I called my dad to come help me change
my tire. Shortly after AAA arrived and pulled up iM front of ine. Since I didn't call them, I got out of the
car to see if they came to help me but they were �ctually there to help a woman who was parked a few
feet in front of ine who also blew her front passenger tire on the same potholes.While waiting for my
dad to arrive multiple City of St. Paul vehicles pulled up to look at the potholes and one vehicle actually
drove over the potholes multiple times and then pulled over to the side and made a call. Shortly after
while I was getting my tire changed, another City of St. Paul truck came and tried to fill the hole with
gravel of something and then placed an A-frame construction sign up over the holes (shown in the
pictures). Once I got my spare tire on I returned the car to Enterprise and they informed me that I will
be receiving a bill in the mail for the total damage cost of the rental vehicle. Once I got to work I called
the City of St. Paul pothole number and the guy(named Sean I believe) informed me that there has been
multiple calls for that area and they have determined that it is actually not a pothole claim it is actually a
water claim and they referred me to the water company(266-6868)to file a claim.
� �'�`�
Ente�rise Rent-A-Car
P{�BO�i 8�24�2
DALLAS.TX 75'84�44�
VJednesciay,Navecnl�er 14,20I2
I30:\DRA ROLLINS
28 GEORGE STREET E
ST P�UL,hI`55107
Re: Clain�1'�0. 0326,1�lSO
�, ._,�.�'= �—��_� ... ,�� -.,�..a,.�,,,���. __,___...��---�_�•-K- _���*.�.:, _
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Balanc�Pr�e 5192.'3
Dear Sirti4ladam:
Ot�r r�vi�w indicates that yc�u are responsible for t1�e daii�a¢es to at�r vehicle.
Enclosed please fmd dacumentatiou to support our claun. Pl�ase review tlus iufoi�nation aud reniit
payment in full t�the address above. Please include c�ur claim munber ofi your�ayment. If you
prefer yot�may also pay the amount due usuig a debit card.credit card or directly frotn your bank
accotmt at https:/.'wi�v.velocitypayment.co�ifciient/bankofamerica/ei�acliudex.hm�
If}�ou have re�orteci fhis claim ta yo�n�insurance and!o;-credit carci company.please cavtact o�u =
office�vit12 the clauu uiformation. °
If yau have any que5tious,please contact us at tl�e nu�ber below. =
Siucer�ly,
Ente�•piise Rent.�-Car
Damage Rec�very Unit
866-300-�?38
Fax: 888-874-8437
DRL`2�,';eLi.com
_ �=. _,. _,
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:'af�
I�1'OICE
Date: illl�i2�12
DONDRA ROLLINS Claun#: 03?64450
28 GE�RGE STREET E Uuit#: 7FF1BN
Billin�uivoice#: 6080b011
ST PAUL..i��IN 5510?
Velucle Iufot7natiou
ti'IN: 1�'VHZ8DH8C5�419139
Year: 2Qi?
Make: MAZD
Mo�l: 6 �
��;�,N = ., � - - ----- - —_ -- _ - -- --
, - - __ _ -- --.�_._ � _: _ L_=. ,�__.__--
Ite1n 7otal Cost Amonnt Due
Damages $142.?; $142.''3
Adiniiustrative Fees $50.0� $SO.OQ
Dunuushment of�'alue $14.�7 Waived
Total�mount Due: $ 192.73�'
*Remit pa3�uent in U.S.Dollars.
PAY I'FO�REC'EIPT
— — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — —
ALL PAY�4IE�Tfi��IUST INCLi"1)E TAIS RE:�7ITTANCE TO BE CREDITED PROPERLY! —
PA�`�►BLE TO:
DA141AGE RECO��RY UNIT Clauu#: fl32G4450
PO BOX 842�42 tlnit#1: 7FF1BN
DALL�S,TX i52842442 Billing Invaice#: 60ROb011
Toll Free#: 866-�00-3238 �
Total Amount Due: S 192.73*
*Remit paytnent iu U.S. Dollars.
Total Amouut Re�nitted: $
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