Conley . ��`b,,��'�.'�:�.
NOTICE OF CLAIM FORM to the City of Saint��liYl,��nesota
Minnesota State Statute ti:56.OS�stc.�es that "...every person...who claims damages from any munici�a�'��:°:,�hz2�l ca�.cg 10 be presented to the
governing body of the municipaliry within I80 days after the alleged loss or injury is discovered a notice sfatin�tht 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 eacL question. If more space is
��_ecled, �ttach addition�:',s�z?ets. Please note that you���il! not be�ontacted by tele���hor�c�to c'�_rify answers,so pro��ide as
much information as necessary to explain yo�ir claim,and the amount of compensation being requested. You will receive a
written acknowledgement once your form is received. The process can talce up to ten�veeks or longer depending on the
nature of ya�e;etaim. T'h��:orm must t�e��;ned,a�zci���F� pages eo�:apls<ec3. �f so�itet��in:g does a=_o�apply,write`�:i�x'.
SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102°�-'�����,��b
First Name o 'f"f% Middle Initial � . Last Name L-'� ��y ����� ��
2013
Coinpany oT�Business Na�7�e � '���� � �
,a °`�l
,� f
Are Y��� an Jnsura.nce Company? Yes/ To; If Yes, Claim Number?
Street Address_���,� .�c? 5 5 cim�� l-�-v�e�n u+.� (�t�Q 5�". .S�`� I�CLU.� � �7/l� JS%/7- �(o/�j�-
City S t, f� State rn/1..� Lip Code �J 5 ���7- S�a/�-
Daytime Phone(�S�)�c��-�O1� Cell Phone�) - Evening Telephone�/)��- �Q/3
Date of Accident!Injury or Date Discovered ����� �ZU�� Time ��'-3� am'/pm
. � . ,
Plea.se 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 are involved and/or responsible for your damages.�n I�/ZS ii Z Z dr�r� ov�.r-�h,t c,.
bad hole cn St.�}nthcny A�vc,��us1'Wcs� �4-Cb��w:�.��-i,� Ctz.uSnny vny rtylit�►ro�rl' -Vl'f�c �D b�ou:c:�. Z'hcre.wc:.o c�Iv I driv��
�tvne.thc�OCy,�b�l,ty �a rv�.,re cvcr�t�.s th�� wcvo C�dSe.c.zr+ -Po wnc�� unxk Graw �.�j da�e cv�i-1� L�i 4 pwct�.,�t,^�c�,n cv�'p� s � u e'Efirr
I u.r,« w��t�s�:�. S�-tur„�,� i4+L,�- te�h�w dr�.�o tix.hol�i.vcv� �bcc�C b� �hzn +d- �1a.dl �Ote.v� �i I1e� 1l� Wt�h Ytx�"..S �i..,,,�
C��. �vzxa h�A b:�cr� �� recersF'wa{w m4m bre��{i�ter+e.. � bci�c.vcy-hc- c.i#y (S rr.s�rn��bi� bzca,,.�se-�heu ' 1� �cei(e&' -FD�pzrly I
V'e�C�l�" �'te �QY'C C�Y G'.���Y' '�'r'1 G W c;,-FlY 111 tLCY� �7�'Ca/z..�awlc��Z� Flt((-�.:1.f�C.1 ox '+�. ydrect' �-C 'fY��f c, c r �u� < <ti n g W c:.r n IYtcJ
pf `W�e. hG20.Y�.Ct�.S S�.f CcncQi�wri ,
�Th��-nly s�gn � 'RaES, u%c,rk c�L,c.,,�'� or �Yn�Iw. v�£;�� ►rci�c��-10`�vi�- evcr� �..ur►<� �b hc�.� bc.��, �1-ho-e. �;i�.,... S�t d.z-vcr, -tl�,�re.
Please check the box(es)that most closely represent the reason for completing this form: b��. �
❑ My vehicle was damaged in an accident ❑ My vehicle was damaged during a tow
�1 My vehicle was damaged by a pothole or condition of the street ❑ My vehicle was damaged by a plow ,
❑ My vehicle was wrongfully towed andlor ticketed ❑ I was injured on City property I
❑ 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 WII.,L 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 andlor 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: rt,Td �e,�n��n �(�SI-Ln`f�l-/s(v/�y W'crk n�.4 � (3P �
�I�rn�`'-y,4 � l���rli�'t�-n : s atic.Q a. �wri,b zr- of R�ap l� Nt��Q s:�-c� �.�'t_�,+z�✓�� cz�t�.�'- h av CVu,
prbb I�rn s �St: AYa�h w*�.
Were thc police or law enforcemeilt called? Yes ro 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 diagram.
�-; F�Y1•}I,c,�y rTtxinw�.�u.s'� w��'�" VF i7,�{-cr-st.c�tw,� ia�i`�'h �hct�st,vcP'N�
Please indicate the a ount you are seeking in compensation or what you would like the City to do to resolve this claim
to yout•satisfaction.��Z'`�C'. �� ( %7C7 � W� �j�, ✓�t'ca r�-.�-� �5f _
- _-- 6`�1`� .�'zy' ��nyr+!-.�t_°�-�,'f u�hcc/s�T� °� -�..�he�.ls fz�- � ,-»u�cc.�
Vehicle Cl�ims-please complete this section ❑ check box if this section does not at�ply
YourVehicle: Year ,�C�C�`f Make /`1G�Zc�c� Model .'`I�c.�� G�
License Plate Number;"']l�M 8v�/ �" State M/v Color �re�/ <r�:,y
Registered Owner ��-�y L Ce�n l e�/
Driver of Vehicle ft� � . G�n i�
Area Damaged�h t 7' fine (fc'i�r i7� Si cQ�w'�.�2) , C�2 G v�m�r+�
City Vehicle: Year Make Model �
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged ` ' `
Injurv Claims-please complete this section C�heck 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
L�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. Date form was completed qCLr� : 3, ZD/ 3
Print the Name of the Person who Completed this Form: ��ff�/ L • �J 1����
Signature of Person Making the Claim: ��
-it��"�lis �s my criy�re:k �I��. �L � ��fS wheL$ c�e.x(�e.rsh�p �u�' c5-, ►��cr.v�.crcQz�-- ,
Revised February 2011 M�/ �rrcr,+ �/�� f# �S G�/c� C,�}(,�
�:` . O�. °
� � 4 tv.�.> �
� � CMEVROLET (�DB Service Direct:(651)653-5555 N
� �E, 1801 EAST COUNTY ROAD F Toll Free Watts:(800)326-2145 �
WHITE BEAR LAKE,MN 55110 �
www.polarchevmazda.com O
�� (651)429-7791
�
Vk:FiICLE IDENTIFICATTON MII;EAGE .O DA`TE Oi7T IkNOS�E NO.
CONLEY;BETTY L lYVHP84D345N56400 46747 10/25/12 90428
628 W JESSAMINE AVENUE
SAINT PAUL MN 55117 ��r�' r�cE r�onEL> coLOx �A� rro.
04 MAZDA MAZDA6 5 D STEEL GRA 06063
CCT3T.NG1.,: UICEN:3Fs > FI�CIE PHONE WQRK PHONE STOCZC NO: QROD.DATE SEIL�i.ADV: TERMS
48568 MRM809 651-488-2013 - -- 00/00/00 338 CASH
CUS1'. 6 RATE AEL�'u.'17AT� i7EI�IFI:.M�LES MILEAOE IN DATE. IN IN-SERV PAZ'E
C�i�9/04 37 46747 10/25/12 00/00/00 3 . OL V6 FI NF
THANR YOU FOR SERVICING YOUR VEHICLE AT
POLAR CHEVROLET/MAZDA
LZi� tSP.;C�#A� ; �ATL-C� T�CH. HOUTzSI4T3t '�YPfi AMOt7h1`T'_.
A
om WHEELS; RIGHT FRONT TIRE IS FLAT AND IN THE TRUNK CHECK TIRE AND
ADVISEn��CHECK FOR OTHER DAMAGE VEHICLE HIT A HOLE IN THE ROAD PRETTY HARD
or tear in sidewall, replaced tire C 22 , 00
05WHL3 P�93 .� ..,�:�.�,�, y
19162218 D2155017 1 C 146 . 29
TD TIRE DISPOSAL 1 C 2 . 00
Line Total . . . . . 170 .29
Sales Tax 10 . 57
Labor 22 . 00
Coupon/Credit 10 . 00-
Parts-Other 148 .
TOTAL-CUST-CRCARD 170 . 8
CUSTOMER COPY - PAGE O1
� STATffi�1ffi�1T OF DISCLAIMER . On behalf of servicing dealer, I hereby certify that the infoxmation contained
The factory warranty constitutes all of the warranties with respect to the herformed atcnoachargeeto owneYrW.16There was norindicationlfrom therappearance of
sale of this item/iteme. '1'he Seller hereby expressly disclalms all P Y =t re aired or replaced under this claim
warrantiee either expresa or implied, including any implied warranty of the vehicle or other.+iee, that an Pa p� ne li ence or misuse. Records
merchantability or Eitness for a particular purpose. Seller neither
had been connected in any way with any accident, 4 9
assumee nor authorizee .anY other person to assume for it any liability in cappontat9thelservicitngrdealerlforeinspectioneby fmanufactureres reprYes�entative.l
connection with the sale of this item/items.
(SIGNHD) DEAL6R, GEN&RAL MANAGfiFt OR AUTHORIZ� P&RSON (DATS)
CUSTOMHR SIGNATUAH .
� :- Y. >.
'�`�'€: -�-.. ,�:� E ,, x:,•:
_ . _ z ___
, s,�.� :. r _ - �.�__��- - - — -
' �,1 �
�`�� �
_ 7 ' cMEVno�er R��� Servlce Direct:(651)653-5555 �
� � ��� � Toll Free Watts:(800)326-2145 �
�> 1801 EAST COUNTY ROAD F �
� WHITE BEAR LAKE,MN 55110 ^
� www.polarchevmazda.com ` 1
(651)429-7791 O
��_� �
VEHICLE IDENTIFICATION MILEAGE O 'AATE OU'i' INVOICE NO.
BETTY L CONLEY lYVHP84D345N56400 46914 11/09/12 91558
628 W JESSAMINE AVENUE
SAINT PAUL MN 55117 Y�� �K� Mob�L coLOx TAC rro.
04 MAZDA MAZDA6 5 STEEL GRA 08431
`CUST.NO. LICENSE HOME PHONE W9RK PHONE STOCR NO. PROD.DATE SERV:ADV; TERM3
48568 MRM809 651-488-2013 - - 00/00/00 338 CASH
CUST.LABOR RATE RELIV.pATE , DF�J�IV.MILF.S MILEAGE IN DATE IN IN-SERV DATE
04/09/04 37 46914 11/09/12 00/00/00 3 . OL V6 FI NF
THANK YOU FOR SERVICING YOUR UEHICLE AT
POLAR CHEVROLET/MAZDA
:L�I�t�s t�P:�bT7fi �`AIT.-CD T�CH. HOUR5�4�'Y TYPE AMOtIN'f.
A
om ALIGNMENT CHECK;CHECK ALIGNMENT AND ADVISE
au RIGHT FRONT WHEEL OUT ,,VERY LIKELY CAUSED WHEN THE TIRE HIT A HOLE AND
BLEW OUT
or COMPLETE 4 WHEEL ALIGNMENT
11ALIGNC A46 C 99 . 95
Line Total . . . . . 99 . 95
B
om FULL CIRCLE INSPEC; PERFORM MAZDA FULL CIRCLE INSPECTION
or REFER TO INSPECTION REPORT CARD
3399P A46
Line Total .
Labor 99 . 95
Coupon/Credit 10 . 00-
� TOTAL-CUST-CRCARD 89 . 95
;
CUSTOMER COPY - PAGE O1
� STATID�1ffiaT OF DISCLAIMSR � On behalf of servicing dealer, I hereby ceztify tha[ the information contained
The factory warranty conetitutee all of the�warranties with respect Co the hereon ie accurate unlesa otherwise ehown. warranty services described were
sale of this item/items. The Seller hereby expressly disclaims all � perfoxmed a[ no charge to owner. There was no indication from the appearance of
warrantiee either exprese or implied, including any implied warranty of the vehicle or�othern�ise, that any part repaired or replaced under this claim
merchantability.or fitnese for a partiCUlar purpose. Seller neither had been connected in any way with any accident, negligence or misuae. Records
aesumea�nor authorizes any other peraon to aesume for it any liability in supporting this claim are available for (1) year from the date of payment notifi-
connection with the eale of this item/items. cation at�the servicing dealer for inspection by manufacturer's representative.
CUSTOMSR SIGNAT[JRB (SIGN6D) DSALSR, GSNERAL� MANAG6R OR AUTHORIZED PHRSON (DATE)
Mlor!r Order: be668 ' �I I III I I III I H IIIII III II IIII II�III III
First Name. rtY III IIIIII III I II IIIIIIII
Last Nam�: coniey 1YVHP84D345N56400
VIN: 1YVHP84D346N66400
License: 814gau
Teahnlalan: 7�6
Miloage: 46814
Date 11/8/12 10:67 AM
Mazda 2003-07 Mazda6 Sedan/Hatchback 3.OL
Before Measurements
Left Front Right Front
.� t t��' �
Camber j.
i w' "� T�, �
� ��� T � �v Il lp� � ��� �� �'
� � Castsr
CasNr � r" froM � ±, ' �
i
� »m..l, � 1
Toe
Toe
Total Toe
� ' �
Steer Ahead
Left Rear RigM Rear
� � �MI Y �.
� �$� �,� Cembef
Camber
T � � �'�I"�
� ;� .� � t � Tce T�r
Tce
Total Toe
- � �
� � Thrust M01e
CuRerrt MeasuremeMs t c -�-` � �°5,�rr��-.�
Left Front RigM Frottt
� t �.�� ,t �
° F�
Camber Csmb�r
t �..i �I ir" T �
� � � � S
Caster Castsr
r,
►�fror� �° ♦
� t M<< t °'�'� T�� �
,,... ;a, 4. � '" s�
Toe I
Total Toe
T w �
Staer Ahead
l.eR Rear Right Rear
( t �'' t �(j
«� ��
� � H;�
Camber Camber
tRsar o, I
� � ,; . t � '��D� Tce �
Tce
Total Toe
T �
Thrust MO�a
� • One or more values are not within speciflcation. Tire wear,handling and safety probl�ms may result.
�---