Mollner _ . NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipality...shall cause to be presented to the
governing body of the municipaliry within/80 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 n� Middle Initial�Y1 Last Name �(Ylp��Y1P�
Company or Business Name ��-���5'��
Are You an Insurance Company? Yes No If Yes,Claim Number? �-� �
Street Address ��'lal.o��'�� z►'�d �� , ,�,�,
��'��, ,���
City � State Zip Code
Daytime Phone(l-G�)��2��U Cell Phone�l�)�� ���ZSEvening Telephone(�)� ���
Date of AccidenU Injury or Date Discovered I Z —��J—12 Time l.D� S a /pm
Please state, in detail, what occuned(happened),and why you are submitting a claim. Please indicate why or how you
feel the City of Saint Paul or its employees are involved and/or responsible for your damages. _1_. l�C�_S
d,,,„�r ,, v�,�, � � +; �. � ;,,�.�
'V i r'� � o►. � — ✓
�-,r. ,. �rn S - \ n r, b r1
\ he ��� r �-ow-� la'•`as• S 0.-
ua-, z -1�- t ' c �r1C. -��' the lou��r, ot�
- ,, S ��1 0 � ��"�`'l
ea,,� oF -�� c�,.�,d� .
Please check the box(es)that most closely represent the reason for completing this form: �
0 My 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 propeRy
❑ Other type of property damage—please specify
❑ Other type of injury—please specify � ��'
In order to process your claim��ou need to include copies of all auplicable 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.
• 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 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,
closest landmark,etc. Please be as detailed as possible. If necessary, attach a dia ram.
YY��.� \�r,d 1Av� - �a�CL'so c1- l�,kh�r -���' �ac.c r:�
Please indicate the amount you are seeking in cQmpensation or what ou would like the City to do�to resolve this claim
to your satisfaction. —�-he �-rno��-�-T O�� -�'1r�e. -�i�.e V.�po.'l.r ���1--
� 1�8 (o
Vehicle Claims— lease com lete this s�rtion ❑check box if this section dces not a 1
Your Vehicle: Yeaz 2010 MakeTo o'�C�. Model
License Plate Numb r 1 'P� State IMN Color lr
Registered Owner � rr YY�oI\v�2�'
Driver of Vehicle r r n���n e�
Area Damaged �r'vo r�� �e �- `T��'e-
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniurv Claims—nlease complete this section ��check box if this section does not annlv
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 fornz,you are stating that all information you have provided is true and correct to the best
of your knowledge. Unsigned forms will not be proeessed.
Submitting a false claim can result in prosecution. Date form was completed �Z ��3��Z
Print the Name of the Person who Completed this F m: ��r'� w��``��
Signature of Person Making the Claim:
Revised February 2011
MR. TIRE SERVICE Repairorder#8039206
1201 RICE STREET Date : 12/13/12
ST PAU L, M i�! �r 1 ^7 Page : 1
- ' ' 651-487-2�S 1 Center: 1
Customer: PRISM PIGMENTS, PRtSM PIG�"'�n!T�' Vehicle : 2009 TOYO COROLLA
Address : 1251 ARUNDEL ST License : 181 DPW Unit :
City: SAINT PAUL, MN 55117 � VIN :
Phone 1 : ( 651 ) 488-4250 Ext: Engine : Trans :
Phone 2 : ( 651 ) 216-5645 Ext: Mileage : 63310 Colr :
Op Tech Description Labor Parts Subtotal
Quan Part Number Part Descri�,ci�n Reason for Replacement PNce
TI1001 JE MOUNT & BALANCB ONE TIRE 10.00 110.49 120.49
1.00 732674500 205/SSF.l' ".f: R:� 104.00
1.00 TIRE FP= 3.50
2.00 WFT WHEEL Y�=' ,'
1.00 SC1212 VALVE S`i_'.. 2.99
CO 001 Jfi SSRJICE MAIIAGSR NOTE: 0.00
-CAR CAMS IN WZTH A FLAT TIRE OP7 P^I'JER FF.ONT, NOT REPAIRABLE
Diacoun 0.00 -20.80 -20.80
OK Bad Recommendation dY. E�� �� Recommendatio� OK Bad Recommendation
I hereby authorize the repair work to be do:ie along with the necessary parts Labor: $10.00
and materials and hereby grant you and/or y�uc employees permission to operate Parts : $86.19
the vehicle herein described on streets, :�' : ,- 01 .=isewhere, at your des- SUbI@t: $O.00
cretion, for the purpose of testing and/or :c.- ,-..tior.. An express mechanics OtherFees : $3.50
lien is hereby acknowledged on the above ve:,i�i� to s�cure the amount of re- $Uppll@S $2.��
pairs thereto. I understand that dealer/ow.. •: is not responsible for delay or Subtotal : $101.69
other consequence due to the unavailability of parts shipments beyond their Sales Tax : $6.57
control. Not responsible for damage or arr. - . _-. tn car in case of fire,
theft or any other cauae beyond our contrc'. . Paid By: TOt81 : $'IO$.Z6
WARRANTY IS 90 DAYS OR 3000 MILSS WHICA E'':'' " � "RST, LJNLESS SPECIFIED On Account
Pay Ref: Paid : $0.�0
OTHERWISE! Due: $108.26
x
MR. TIRE SEfZVI�E Repairorder#$039206
1201 RICE SYI:E�T Date : 12/13/12
ST PAUL, Mt`J :�`s'I 17 Page : 1
651-487-2 8:i 1 Center : 1
Customer: PRISM PIGMENTS, PRISM PIGti1E�!TS Vehicle : 2009 TOYO COROLLA
Address : 1251 ARUNDEL ST License : 181 DPW Unit :
City: SAINT PAUL, MN 55117 VIN :
Phone 1 : ( 651 ) 488-4250 Ext: Engine : Trans :
Phone 2 : ( 651 ) 216-5645 Ext: Mileage : 63310 Colr :
Op Tech Description Labor Parts Subtotal
Quan Part Number Part Descri��tinn Reason for Replacement Price
TI1001 JL MOUNT & BALANCE ONE TIRE 10.00 110.49 120.49
1.00 732674500 205/SSR16 �I:CLE RS.� 104.00
1.00 TIRE FrE 3.50
2.00 WW WHEEL WEIGHI'S
1.00 SC1212 VALVE STF.;•i Z•99
CO 001 Jfi SERVIC$ MANAGER NOTE: 0.00
-CAR CAME IN WITB A FLAT TIRE ON DRIVER FRONT, NOT REPAIRABLfi
Discoun 0.00 -20.80 -20.80
OK Bad Recommendation OK E�a;: � Recommendation OK Bad Recommendation
2 hereby authorize the repair work to be done along with the necessary parts Labor: $10.00
and materials and hereby grant you and/or y�ur employees permission to operate Parts : $86.19
the vehicle herein described on streets, hi_i1:.:,;'s or elsewhere, at your des- Subl@t: �O.00
cretion, for the purpose of testing and/or in=,,-ction. An express mechanics OtherFees : $3.50
lien is hereby acknowledged on the above ve;7icle to sacure the amount of re- SUpplleS $2.��
pairs thereto. I understand that dealer/ow:�e�- is not responsible for delay or Subtotal : $101.69
other consequence due to the unavailability oE parts shipments beyond their Sales Tax : $6.57
control. Not responsible for damage or articl=.� 1°ft in car in case of fire,
theft or any other cause beyond our contro�. Pa�d By' TOt81 : $�OH.2G
On Account
WARRANTY IS 90 DAYS OR 3000 MILES WHICH EVE? OC"'!RS =iRST, UNLESS SPECIFIED Paid : $0.00
Pay Ref:
OTHERWISE: �Ue : Q��8.26
�v
X — _—
�uS-�- �r a d c1�,-�o r,�\ �-�e .. .
�h�� �... � �n;��z1�� C��\ed ��b\�e_ �o�1�,s z�a�.`.�'
k� �v�.c�d ev�.� -�- � t d �m-e.. �-h�-�- -�n�� 1n a c1
�
�pQ.�� do �.�n �Mz �ar� znd C`ear�ed �-{n-e. Stvee��-.
�
' -kh��� C�-c'`'�'-c.`"�
����,�,r..�. `� -�-1n1 S �1�p'��c-� c�-u�-`�`g
Z�n C� 1.��-S �-��� �-�•
�