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Cooper 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 fhe governing body of fhe municipality within 180 days after the alleged loss or injury is discovered a nofice 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 ezplain 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 PALTL, MN 55102 First Name Sh e�r r. Middle Initial '�Last Name �- ooA�� Company or Business Name �" Are You an Insurance Company? Yes/�To If Yes, Claim Number? Street Address a\�tX �k �L�� City � k, 'Qo.sl State M� ZipCode 55�0 Daytime Phone U - �Cell hone ��i1 ��l`�- ��Evening Telephone U - Date of Accident/Injury or Date Discovered a��1\'��j Time p��5 Ca'�/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 employees are involved andlor responsible far your damages. 'S �,:�a5 v: �JO�-��bo�'n c� e�n �Gnaca�ti<a 4� .1�r'1.J�C S l�,_V�h d 4C'�2.�11f1 \�c'kC� , 4�� a��i.�.�c w q S '�o:YZ 4 e,��slbo�-�r,� o� �•-►;�¢.s�.�l:v c�a sz,�� g.�, �n o�d ��¢. �'�d ��4� �=e�p c�.r \:4 5 ��r� �er� crr, C�D c.�c r c�n �k+� c� �:�lr,t ��o.� �� -�- S.� w . c�-� � c��, d �-�a `�-�� 4CCi � ';'C�.cav-•-.v PS e a1.► � d`7. '� � Ci,C.c..; 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 vehicle was damaged by a pothole or condition of the street ❑ My vehicle was damaged by a plow U My vehicle was wrongiully 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 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 encouragec3 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 exeeeds$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- lease com lete this sectio Were there witnesses to the incident? Yes No Unknown (circle) Provide their names,addresses and telephone numbers: C�'1¢.�-��"�1 �hr�,�,n ,'n c� ��3�5�-X- `�qt� ��,r�� ^1�i��nc3\��> °��\ - �� S� C� A�c.4<b�►�r1q -k�a `a��cc�. �f'*t.�Jv��-- 1 Were the police or law enforcement called? �es No Unlrnown (circle) If yes,what department or agency? ��o.,l �o\:c.� Case#or report# i��`� � �"�� 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. 'S.��e.0 Se��7 O� J�av1�` � c�.nc1 ca��v�s 5:��i Av¢ � Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim ��yoursatisfaction. t'-orM,p��c�1r�'• C¢Qv"c' o�- �l�a�\�, d¢d:�c.�ab�e, �t'o� 'M.`�1 o n .•4'Oh C: �a A.l � 6 C*G�ct�; 1 c� `.� ¢e�ti c t31 �1��j � YobY {d�r �; t `,� 5� ��b�e� w��h ��-'S.�S o,�nd �all.00 V"ehicle��aims-please compiete this sec�ion u cnecic box ii this section dc�es not anniv Your Vehicle: Year ao�O Make �ocd Model {"S �. License Plate Number 3ti�(i�Cvu State M iV Color es�'¢� �c�,r� Registered Owner �e.�,� ++- ��ct: Gocz�¢� Driver of Vehicle 5�►�rc: C�pc�' Area Damaged�n+�5�n�� S:de, City Vehicle: Year a4o 5 Make ��d Model c:.v License Plate Number Sq,d i 5�'3 State�-1►� Color W1.�;�� Driver of Vehicle(City Employee's Name)�"c>�o,r� w�.�r!e.,,.� Area Damaged � d�c�,n�c+.,a�;a Injurv Claims-please complete this section ❑ check box if this seetion does not apply How were you injured? Z.n +�e co.-c' c��c,��c,;�-{ What part(s)of your body were injured? r:Y1�; �oot Have you sought medical treatrnent? es No Planning to Seek Treatment(circle) When did you receive treatment? a�� \1 � (provide date(s)) Name of Medical Provider(s): �e c�t-��,t'�- m��n�� P+:.��c s,cSrc �' e.1,�',r,,'c,, Address M 5 ti Telephone '1��,� #(1�5+ a�5 - Did you miss work as a result of your injury? �.� Yes No `� When did you miss work?`�j u� a��Mvn__,a ♦�C 1��. _.______ __(provide date(s)) � Name of your Employer: P�d.��ncrc3 C o�c� t.�n c�� 51�,'�� Address ��1�5 � � �e n'1 rn� 55�1v y Telephone l9 ta-��a I -t q 5� � C�c¢..�, ��e \ow�� 1a Qo�'!i� L G<'C��'�'lOr1 dqy �,�-��i �3�0 , �ty�cw tl A•�¢, �,��ca�l, M� S 51°`� �Check here if you are attaching more pages to t'his 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 3`��a141^J Print the Name of the Person who Completed this Form: S��.r�, C.apprtC Signature of Person Making the Claim: /�' Revised February 2011 ..► v � �CT��-�'n`i cd,��q�6"1 � — � ��sL°4S� �'c'1 C�:c,��2. `��'rl a2 c31,th OvEb�• y��.1 �- � es,s� �e��t'i��n� �� o�►Q$t1Sa,�ie� or `' �hat �a.a �.,�o� �d ��te {'he c;�y -�v d v - -�'o t'�G�o tv e �r�C►,`� Gl cx;�►1 �e� yo�s-�' , `J��:S�aGt-�"O� • ` , � (i►�e,:r a� uQh.'c,�rz. , - A�o�� -�o l�� }e�m��,C,( ' d J ��/ c a-c o Yl�v^m�r►� 1�c��..t a�ci\e ' - � 5 Q a . 04 �� M : s��d �os� al�z ll� �` '� �3.�5 " �� M;s��a .��c� a��li� , _ � .a t.o 0 ' S� e- u� C�t.�crtc3l � ` '�o brG c�2��.4'm i rL� , � (�L�dv'c.�t b:l\S , --�o b¢. c�.�-,c S co,�n Q d � , �� ,�1, c��sd-c��• �'c}c cv�c c�,�,�al � _ �° �c,�, Y� �� 1't�lt'�` �� 'li�zi� Riverside Internal Medicine RECE��'Ei� 2220 Riverside Avenue South MAR 0 4 2013 Minn 54 E1-1430 �ii i�` v��ii� 952-967-7175 � � I Ave � � � � � � � �-5030 iii p 000 r' C .� �cern: � — c '— � _ � �� een in clinic today, 3/1/2013 for follow up from 2/19/13. °' = ,- o r �r � �, �and 2/18/13. , � OD r— ca � co u� � � G � f1 r- ±� �v � / �� v 0 �� / �� i r � x � � % � �� , � i i a � �' � � � N ,� � � �� / / � � , , � i .r .� �' % � oa 3 / o � � � % °��'(� , � / � / � �` � y �� / ° �' � �ay Bank �e Community Bank ! 000 02 681 Page: 1 Date: 02/19/2013 I .` � 5Y � C Service Requested Account: XXXXXXXXXX07105 � � � D � 4 I � v C C O ry I�J��IIII��II� � � Z a **�**t******�,t�,t+�r r.�*,t*:*t�****+***t►x::**,t,t*:*** NOTICE OF OVERDRAFT ITEMS PAID ' AGAINST NSF * .�*..�.*�*...�*,.**.**,.*�..,...,*,..�,�..**�..,... OWING ITEMS HAVE BEEN PAID: ayee. . . . . . . . . . . . . . . . . Check # Amount 100.00 AFTER THIS ACTIVITY IS: 61 .88- � WITH ANY QUESTIONS 651 -523-7840 I � I I i_ _----_. _ ._ __ _ __.__.______.__.__---� _._�._ __�.____------ .._____..____.�__�__ -------- i '��.f�� .t��,��.r��r`� C)��.Y' _. ____._.____ _ ----_.__________.__---_....__. �_ .� z.�.� � '_ , , �, '�F1�;T6�)�d ;4�C<1_,i {�3!;". . . . '., t . _ .;. . rc�c�ce ,. , - ,. �„_ ,?!ie s;at��r,��„-�,-recei;�',, we must hear frem , , . _ ,_ . � _ _ <z;��;ear�-d. Caii us at+`�r �iumber I;sted below �� _ , : l+r`a.r,;-: ,- � ;.,:t� �..:� �..�. :.::�; ..�-.,._ ...t: ��c �q, . .-�•f;_ ..��.� �a.,�. . �!� s . . .. .. - . . . ...... �-_. ,� II �,. . '6 . _) .. � . . . . � � ... � _� . ., . . '.��i'.., , �.... 1:� a _ . �. � . � � _� ,.;:i� ��,� � , - �. . ,- . ��+.,n �;.: :>�}�as you can wl-�}- you believe it is an error `.��- � � �� a,�-�� ., _ , � ��r i� � _,�-,_��days`�do trus 15 business days if the �, , , ,�: :;� �� • ��' . r a c t f tt _ , , � . , . _ ,, ;; ., <<;�::a_int), we wilt credit ��ou ;: oun or �e � � � � � i h:�t _ �_,_,<: � - . _ � �e i� ,_. � ^o�n,.�iete our investigatic�. -.�"1'L'_��a€; u��:s` ;`3 J?��`ik'��!!��'ti; , rr��s�_ �iuV'It�} '...i�a.^;''4; 1'>,�,be`+...i�F"1�'`�a` Z,t!��Y .._:..�. ,.... ,». . �,x .�.a. ...., ,,.,. ..._�. �.,� .� I� ,� : _ � _ � , � _c; ��,�.. . .. , _ ._�:�.��nen*, write us on a separate sheet at ?f�P a:��ir��- ,' _ � � ,_ ,. . �� ;�;�r f "�� ,� _ r =, , � _. �� i�:-s�. + . ��e sent you the first statement on which the ! � � � 1_ _," � � _ �R'�:_1 "-`:::, C?.�i < .. ,_ . _ _ 7.i �t � II�Vr �`.!a=, �flCly�10081t;:1 P.rtCtS�Ild y0U (Tld�'hdV2 t0 f�a;+� �_ _ � .�� _ IN C�S� O� ERRUh; ;:.'.:: �:��1�STI�:�� '1�31"Y�.�?' YCJl3!=± �:';f..° WriYe.;:� i_;::> :s?• ;�- _ , � � : ,. . .:* F__ . '. _� � . VC�;��.- � - . .. �d'- :_o��.t .�,4�5_�vY"l�a idi'�f?3'fTir��64��i: - � _ _ . � .. . . . . ' � � - - �, - ._. ��:- 1 . _ . �; �: � ':NI!V VOL' t�@� �"� ;+ IS 2 � f1115�dK@. � � � While we investigate whether or not there has been an error,the fuilowing are true: � Y� � � � o� � � __ ,�t��e .",c�int � c,�U�esrion� �nihis� we are inve��r-r,ati�,g, but you are still oblioated to pay the parts of your statEmen? � � _ ,_ � � __. � __,:��_�r. ,,�c�� e�: �. �:�� , �e'�� „ --- -�� t�,,;�e an�action to colleci the am_nun' ; . _ - ,. , - _ _ � . _ _ � � � _ �i'��St Otl 1i19�c��'-��ilf,t. �Ut. If W2 Qe'EI'tTlll-!P. 't '. �- . ...�.. . . � .., , . . . . . . . . . . , . -�. ,. 'c;�= ._.'1 T.. i'l�f• ;•7?OUfI?. _ .i:'I� - � � � - � . ;'�c, Fli �ii_�, _ '1 _� _� ._ _. _. ._,. _ . _... . .. �t Ji i.7c11�. i-= -� . .. . . . . . .... . .. � - � . . _.ij � �i� .. t;t t_:�' �� -,. ,:�� .��..:�� '� '�;tc �ITar >i `=t��1�(� lr+1 iii��'��%a��ca��'�E C��P��PI��-FD t3Y tiPPI ��'�r.!��THE PER!ODI(� �� ,:.. �� .-, �w,�,��_ _ � _.- TG G�T ��7� �DA��Y BALP,NCE." WE {. , , ' ' � : t '_ ��J� �1��T'�H A�;Y J'VF'AID INTERLST � , �. � � � ��t .�:�-i ��:. f�+ �. _ � _� u� 1�� ,�i ANGE N te: !f±no �t3temo.,t f ii�„ iA t i 1?�r� '^i C� -i`i �`i f i �]; a y pflU �Ci i� ,, �; � nr "L �): r� 1�,�'0 � �r H DI��II1i� C;�CIe Vdl�i I'IC�JC�2 tlle SUrJS8C�U2flt� f�i rfi �, , ,i _ � ? f �2 � , , �� - � _ _ . � ��ai ��.��;;r aE �1-i�i �� i-;�_�� ..� ,;c,cr;�e. Ho�vev��_ ?ne number of da�s in r ,. . the i _ nex� ,,, �. , �. - � . ,�-�. �� . �, � ' fF Yc�p., t-- ,_ ,��. {-��,. .r _ r , ,. . .. ==;._^,�J '"��;"�:�tVFd'u`AL t%?.::e..r.r{,.i:x+� FiF:i s_ !•.;�L` r?f?'.G,�' .�r::�tilU[:J�it: RAi L M19AY VARY. ' !10'V�� .�, .. '�, ; �: �':�- _._s �.�:��d �.��r.��:. ._ , t�<, '� �E� < , , , � ��I;�ACGOU��T �3Y HPPLI'INU TNE „ �I �� ,. , _ �- , �. , � � _r ��, u�.�,� � . . . . � ��,a �:"�: �--i .'I '��a �:;�r"vLF 1 � :sr�i-i H� '`GAILY /� 'Ai�VP,N E�' R FFE„ AND 5'.�BTRACT � � � � � i�i �` t �'J�r � l� � 0 c i . r1i � �.;�'ES - - .. ` I' Ir-. , �. -.I� �� . . �.� FI.' I C.� �, I. . ' i }� hJC� "�o±e� f t��e statement � _ !ail � � - , . �� , � ,�. ,� � ;� . _ ,;� .. � ' ! �i��e �,!ur� � � E� � '�� I � ��cle 4v��. in,.lude the �� s�c : ,�,� �r - y� � � � � � � 'r � ��_- � --,n��ru�to a�c�u�� Howev�r 'he number ,e, , _ ,_ d� ��f jf i !-ii��L' .as ° i�t-','�::fs,., 1", r' ,'r,; a� D s � r _ _ r ��;t.�?�_ s_rtC°�- . _�. ,�;R��;� t;�.�.a �..1�,,�.`V i-'G��,'s��r�C RAT� MA�'�lAf�'4'. �-��H ' �r` . (�i�„ . „ . ,�_ � �.'_._ °.�1: �, _�_� r . .L(i - - � � �I i i� r n �5 � �J !�� S� JCSS J,�.Y. FAYP✓IENTS � A , _ . . � 5 :f=� -� E�, 5!,.1F5S HOURS ARE POS?EC IN . ,. , . � `� � t . . � . �'�_ ,�. ;�,� _ . '_;/,LLItiU "H� �AiJK NUMBER -- __ .... _.._ _. _. . _.--_. _.._ ___�___V_.r._.___.. � � ,:,, �_..� „ - r , _. �'` a ' University E3ank . ,. �_ � ��, �:� � � �vw��-v.�.�nivers�t)�ba:�k.con�� __._ _-- _ _ .. : :_.: ' , .. �___ �- 65 I-�65-5600 ____ ._ .__ ...� ._ �� - _....__�_ �r�9rBKRA�i20�-1 �'�•'�° c�nen� -,.. � terprise � �� .;�� _�� , y 199MNFALLI2 PAGE 1 of4 �'l � `-�P9 `��tii f•`ts T+� _: ' rit'� '" n l�ii �'��{ �?r .} ri�f .;{4j rpl Th' . �iil. . �y�x� ��__Fc{ �..n�.�? -��#-- F�.x_�:� �'P1 �i� �.t-'3 t�h! ].G,�ii:! F°�1 ! OWNEROFVEHICLE: c�I�.T�iF'�`�'i�E scf7`a�i�'tu #..�1�r�+�i`r` �F �'ilKd��'�sHq �r� �1.� ('LI��E�3 � ��.i71 ��-air...,3i C��,�t- i� . 7 ��•�t� y ; kc<-,y, a. ivJ� : _�i.�.''i)!�'_u j � BRANCH ADDRESS: c r�. _!-iI.F'I, L. at�s. ,. SL .. ��/ '.''. �� '._._�` ��i'_,��;� � N RENTAL SouRCE u � i.o.u . TYPE tId`:i!?";r`Y�l�{�� ,�t��i�f;� �' '..."„_'y�'�`..,__..�....._ � '�NP*��'r��+: RENTER t, i .�. . ..��tY� . __..�.___. �,y i.V:.A�.. _�.G i'l i � �L!t��F'�!�' uN �'F:i , START CHARGES IF DIFFERENT �-_--°.`--""- ..... ..----� ............ ..-.._.__ _.____,,...,. `'�f37��.� ' -�- --�'��r�� -_ _ _ �-- ORIGINAL VEHICLE _ _ _ COLOR LICENSE NO. ' �;E�° ;`� ��t��b'il. _ __ _ _ , MODEL ECAR# � t^'""� � �'��r� -,,j��.�`y�, ..... ...... __. ._._ ..... ..._; COMPANY [- n' �1 1� MILE- IN BILL �..i F�f.k�F'�'i.�y 4�J��n�C:: f��Y` ��i�ai{iL_�F �i. Ln`r'�i7:�7c t':L�tii7� AGE OUT .;7( =';`3,-' iOl�f�f'SEl�+� t''Hy'• {-�y''�y -,cryn_rRC;;,, ..._ ..... ........ ..,.. ...._ _, . �e � ATTN P E EXT. ... ��i DRIVEN - .._.-----. __._ ,__ _..__ � REFERENCE NUMBER: �� aa x � .ams�. 7"•�'s•t� -, �- !�.y �ti.:.,.i��t9�?t;.+;'i ^.� � _... . 0 W _. _ _ � o � � ,V ADDITIONAL AUTHORIZED DRIVER(S)-EXCEPT RE�UIR BY LAW,NONE PERMITTED WITH'Q�JT OWNER'S a wRin�n�ov,e,� �d� �'3'f� `�' IiRI'�tE�;S t='��'.MITTt:.� � �a I RE�UEST OWNER'S PERMISSION TO ALLOW _. ...... .. _ ... .. .. �� . 2 ... .. ..... ......... ........ _._.. . ..... °O - O WHO IS UNDER MY CONTROL AND DIRECTION TO DRIVE EHICLE FOR ME AND ON MY BEHALF.I AM RESPON- SIBLE FOR THEIR ACTS WHILE THEY ARE DRIVING,AND OR FULFILLING TERMS AND CONDITIONS OF THIS ..ovR �--eciu�c�x�o-.�earw RENTA�AGREEMENT(AGREEMEN1'�.USE OF VEHICLE B AN UNAUTHORRED DRIVER WILL APFECT MY LIABIL- ,,_ __ WINDSHIELDOK? �IYt�Y NO IN DRIGHTSUN THISAGREEME� �� 't✓ :X s. DESCRIPTION: ' --- _ ___ _ __.. HAIL DAMAGE? YES � PERMISSION G D TO OPERATE VEHIC ONIV IN T STATE OF RENTAL AND THE FOLLOWING STATE(S): �� F OUT E 1/8 1/4 3/8,1/2 5/8 3/4!7/$'; F � � �ei� �r��'�[iC? F?��ti°t�� Flt; l=lz i`i�� aC'fCP.c `.-'"E.i r �_ _ _. ___. __ _ .__ ____. L IN E 1!8 7/4 3/8 1/2 Sl8 3l4 7l8 F OPERATION IN ANY OTHER STATE OR CAUMRY WILL AFF T YOUR LIABILITY AND RIGHTS UNDER THIS AGREEMENT. � .,H ��,;tt,t�k� _ _ _ ___ r�r�o�avnoxKCaus� �a ornowu�o�waue� _.� DAMACE WANEt(CDWI AND A�UAES DAM�GE � (�)AT FEE S IN CALUMN TO RIGHT.SEE REBPOII�LIIY.SEE pARAGRAPH 6. NOTICE TO LE AND PARAGRAPH 16.CIXIISION �X DAMAGE W IS NOT INSURANCE. . ...._ .._�... .. __...... __. . ._----_. ..__.. f X DE.i.'�cS GG�Jd .;.:.. �`. RENTERDEWNESOPIIONkLPER50Nl�LACGDENT RENTERA6CEPfSOPIIONN.PERSONALACpOEM ... �Y�: �1...:'`I.��Fi'; ..... ... _. ...... _..... INSURANCE(PA1�.SEE PARAGRAPH 9. INSURANCE(PAI)AT FEE SHOWN IN COLUMN TO /} RIGHT.SEE PARAGRAPH 18. �R:X • T '. -._..__. —_ . _.._ .__._ ___'_ ___'__ . ____._ ___ _.... ..,__.� . . ._.. .._. _Y,� . . ___ . .�..,,..._ti.....�..,.�.-,.�,.-..-_-�._.a...�.: . . . ....._. - _... .. . - ��X i3ECL€NES�PA( �� : ... �. . ;�.,. �, -. ��.�. . ____. ., � .,y�... ,� .::m,4 = �! r�wrEao�cu�sor�wru�surxaeirawe�nr r�rrr�a�rrsarnauasu�r�rau�euir ,x �_�P ��'s;-95��Y _ .----..-�----`-�`�--- -�— __. ER �.SEE ARAGRAPH 7. PROlEC110N P�ARAGFRAPH 1HOWN IN COLUMN TO . x , S _ �- � - _ __ _ ____ . __. .t,.. ,��,� � RENTEROECl1NESOP1pN11LROW910EAS515fANCE REMERACCEPfSOPTIpULRQ�SI0EA3813�ANCE PR07EC7pH(RNP�.SEE PROTECiION�RM)AT FEE SHONM IN CALUMN TO $Ey�g:X �__��`�� _❑{'t+. � .. PARAG .8.3. � � RIC�Iif.SEE OP�IONAL PRODUCTS NOTICE TO LEFf �T[Pii- �":.7.�1` .. __ .._ .._. ... y AND PARAGRAPH 19. ,,.Y�� •X t,tt�P5 .�1i":t,EP'�Se��'.!' . ... ._. ... ..- • � � � .� . , ,C �c �� p • -��::�G�._��1'',Ei�{t7G--��.�_'�?-l�t7t71:�Vt'`� ..... ...... � • ._.. _.._. _... � , �.��i�,;'.(!�,i,. REPLACEMENT VEHICLE :x �..•- ; r o,aTe �r�^� �m7 ,..,.�;°.j . _ E � R PNER X EMPL E:i}��'i:.! i'I�� 4'i�..�ITFiL, t�kl !hY b G!1 # -E'��''�`�t�1?�'r++T�� ---- cO�oR uceNSe No. I WILI RETURN CAR BY: ' DATE TIME PAIDBY . ... .. __... ._.... .._. ...__. MODEL ECAR# t-ii + �S Je � - ,`'X�� d)�'��1;�f'dji�.� t_,--.✓.�....;.:�isf'1_� l�! tY7 . ................ ... J,:..�.� . MILE- IN � ...... __.. ___.. . . .___.. .___.___. ...__.. AGE OUT ___. .____.__.. _. . r oRiveN AUTOMOBILE INSURANCE POLJCY MUST�1)EOVER THE REMAL OF THIS MOTOR�VEHICLE AGAINST _____ ___.._.__ ��. _._.._ _ _.... __.. . �,�,�_� •��— DAMAGE TO THE VEHICLE AND AGAINST LOSS OF USE OF THE VEHICLE;AND(2�EXTEND THE TOTAL CHARGES O _._�. OO � POIJCY'S BASIC ECANOMIC LOSS BENEFffS;RESIDUAL LIABII.ITY INSURANCE,AND UNINSURED - - . � AND UNDEWNSURED MOTORIST CAVERAGES TO THE OPERATION�t USE OF A RENTED MOTOR DEPOSITS . � _— ._ _..._ �.� _ _ __ � �o VEHICLE.THEREFORE,PURCHASE OF AN`(COWSION DAMAGE WANER OR SIMILAR INSURANCE REFUNDS Z AFFECTED IN THIS RENTAL CONTRACT IS NOT NECESSARY. IN ADDmON, PURCHASE OF ANY �OO OO ° ADDf fIONAL LIABILIIY INSIlRANCE IS NOT NECESSARY IF YOUR POLICY WAS ISSIIED IN MINNESOTA • � � WINDSHIELD OK? YESM�NO UNLESS YOU WISH TO HAVE COVERA6E FOR LIABILITY THAT IX(�EDS THE AMOUNT SPECIFIED IN oescRiP-noN: YOUR PERSONAL AUTOMOBILE INSURANCE POLICY.BY MY SIGNATURE BELOW,I ACKNOWLEDGE �osE�sY HAIL DAMAGE? ves No T}�qT I HAVE READ AND UNDERSTAND T}�ABOVE NOTICE IN�.UDED IN THE SEPARATE FORM pAID BY CASH CHECK CHARGE F OUT E ,�8 ,�4 �8 ,�z 5�a 3�4 ��8 F D IN THE SEPARATE MINNESOTA COWSION DAMAGE WANER FORM ON PAGE 3. � �CeiproF DATE AMOUNT RECEIVED BY E S�C� t�ca�t�3l'�1��; Ii�'�S�C1G1C�� CASHREFUND � IN E 1/8 1/4 3/8 1/2 4 7/8 F , OWNER IS AN AFFiLIATE OF ENTERPRISE HOLDINGS INC.,WHICH OWNS ALL RIGHTS TO ENTERPRISE NAMES AND MARKS. �O Ellt@fPfIS2 L28SIf19 COfll�fly Of Mlllll@SO�,LLC,ZO'I: . .:,�C�.C� 7 . _- — --- ---.� ADDITIONAL TERMS AND CONDITIONS �9sMNFA��z PAGE2 ofa Renter agrees by Renter's signature on Page t that Renter has read,is aware of,accepts full responsibility for (2) For damage to,loss or theft of Vehicle or Optional Accessories,including all related costs(see para- and is bound by the terms and conditions contained in this Rental Agreement(Agreement),which consists of graph 6),to the extent CDW,as described in paragraph 16,or RAP,as described in paragraph 19,do Pages 1 through 4,hereof for the Rental Period whether or not subsequent Agreements are executed by Renter not apply. or if Owner assigns a new Agreement number during the Rental Period for the purpose of invoicing Rentec Renter (3) All fines,costs and attorneys'fees for legal violations,parking,tolis,towing and storage attaching to expressly acknowledges that Renter and Owner are the only parties to this Rental Agreement(Agreement), Vehicle or incurred by Owner occurring during the Rental Period.Renter agrees Owner may provide notwithstanding that a reservation for Vehicle may have been arranged by a third party;that a third party may Renter's information to applicable authorities andlor third parties to process payment and/or transfer pay for all or part of the rentai bill;and/or that a third party may negotiate certain terms of the rental,including but any such liability.In addition,Owner or third party may assess a fee of up to$25 per incident to apply not limited to the type of Vehicle,length of rentai,rental rate andlor selection of optional products.For matters towards all costs incurred in connection with any citations and tolls and their administration. arising from this Agreement Renter authorizes Owner to verify andlor obtain through credit agencies or other (4) A Tollpass Convenience Charge(TCC)(where available)of up to$5.00 per day of Rental Period for sources Renter's personal,credit andlor insurance information.This Agreement is the entire Agreement between each day Vehicle is operated on a TG�Covered Road and Vehicie operator does not pay an applicable Renter and Owner and cannot be altered by another document or oral agreement unless agreed to in writing and toll.Total TGC charges will not exceed.$15.00 per Rental Period.In addition to the TCC,Owner or a signed by Renter and Owner. third party may separately charge RentePs credit or debit card for the posted cost of all such tolis 1. Definitions:For the purposes of this Agreemenl,the following terms are specifiCally defined: not paid by Vehicle operator incurred during the Rental Period.A current listing of TCC Covered a."Additional Authorized Driver(s)"(AAD(s�)means any individual in addition to Renter who is permitted by Roads is available upon request,at"www.htalic.comlenterprise"or(877)860-1258.Operation of � Owner to operate Vehicle.This includes individuals identified on Page 1 as ADDITIONACAUTHORIZED Vehicle ona roadway or bridge not covered by TCC where applicable tolis are not paid may subject the DRIVER(S),and with the permission of Renter,includes Renter's spouse who meets the minimum rentat Renter to fines;costs and fees see Pacagraph 3.c.(3.)above.RENTER EXPRESSLY AUTHORIZES age and holds a valid license. OWNER TOTRANSFER RENTER'&NAME,ADDRESS,CREDIT CARD INFORMATION AND ALL b.°Optional Accessories"means but is not limited to optional child seats,giobal positioning systems,ski OTHER DATA NECESSARY TO ENABLE THE COLLECTION OF ALL TOLLS AND ASSOCIATED racks,toll transponders andlor other products accepted by Rentec CHARGES 1NCURRED DURING THE RENTAL PERIOD. c."Owne�'means"OWNER OF VEHICLE"shown on the top of Page 1; (5) A late charge of 1 112%per month,not to exceed the maximum allowable by law,on all charges not , d."Rental Period"means the period between the time Renter takes possession of Vehicle until Vehicle is paiQ within 30 days after the end of the Rental Period. retumed or recovered and in either case,checked in by Owner. (6) Ali expenses incurred by Owner in the collection of amounts due Owner under this Agreement or e.°Renter"means the person,or entity identified on Page 1 as'RENTER"; in regaining possession of Vehide or in enforcing any term or condition,including attorneys'fees, ' f. "Vehicle"means the"ORIGINAL VEHICLE"or any repiacement vehicle(s). Owner's administrative fees,and any other costs or expenses incurred by Owner. 2. OwnershiplVehicle ConditionlWarranty Exclusion.Renter acknowledges that Vehicle and any Optional IF A CREDIT CARD OR DEBIT CARD HAS BEEN PRESENTED AS A MEANS OF DEPOSIT OR Accessories are,by ownership,beneficial interest or lease,property of Owner,even if owned,registered or SECURITY, RENTER AUTHORIZES OWNER TO SUBMIT FOR PAYMENT ON SUCH CARD(S)ALL titled to a third party.Renter is not an agent of Owner and has no authority to bind Owner.Renter agrees AMOUNTS OWED UNDER THIS AGREEMENT INCLUDING IF ANY THIRO PARTY TO WHOM A BILLING Renter received Vehicle and any Optional Accessories in good physical and mechanical condition.RENTER WAS DIRECTED REFUSES TO MAKE PAVMENT. FOR A VEHICLE RENTED WITH A CASH,CHECK OR � IS TAKING POSSESSION OF VEHICLE AND ANY OPTIONAL ACCESSORIES"AS IS"AND HAS HAD AN MONEY ORDER DEPOSIT,ANY EXCESS DEPOSIT WILL BE REPUNDED BY CHECK ISSUED WITHIN ADEQUATE OPPORTUNITY TO INSPECT VEHICLE AND ANY OPTIONAL ACCESSORIES AND THEIR 75BUSINESS DAY�OF�fiHE END OF RENTAL PERIOD.All charges are subject to finataudit by Owner. OPERATION.OWNER EXCWDES ALL WARRANTIES,BOTH EXPRESS AND 1MPLIED,W{TH RESPECT 4. Limits on Use and Termination of Right to Use. TO THE VEHICLE AND ANY OPTIONAL ACCESSORIES, �NCLUDING ANY IMPLIED WARRANTY OF a. Renter agrees to the following limits on use: MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE.Renter agrees to return Vehicle and (1) Vehicle shall not be driven by any person other than Renter orAAD(s)without Owner's priorwritten consent. � any Optional Accessories to Owner on or before return date to the address stated on Page 1 or on Owner's (2) Vehicle shall not be used for transporting persons for hire;as a schooF bus;or for driver training. � demand and in same condition as received,ordinary wear and tear excepted.Renter agrees not to alter (3) Vehicle shall not be used for transport of products for hire as a common carrier,a contract carrier or , Vehicle or any Optional Accessories.If Renter or AAD(s)determines Vehicle or any Optional Accessories a private carrier of property UNLESS: is unsafe,Renter or AAD(s)shall stop operating Vehicle and any Optional Accessories and notify Owner i. Renter obtains bodily injury and property damage liability insurance required of a motor carrier by immediately. the state and/or federal government where Vehicle is rented and/or operated;and 3. Pavment by Renter. ii.Renter and any AAD(s)hold a valid dass license for that purpose and comply with all federal,state a. For items designated as either"Ihour","Iday',"Iweek"or"/month"on Page 1: or municipal laws,ordinances or regulations. (1) "Ihour"is 60 consecutive minutes or any portion thereof beginning at the start time of the rentaL (4) Vehicle shall not be used for:any illegal purposes;in any illegal or reckless manner,in a race or (2) If"day=24 hour period","Iday"is each consecutive 24 hours beginning at the start time of the rental. speed contest;or to tow or push anything. ( 3 If"da calendar da Ida is each consecutive full or artial da of the week. (5) Vehicle shall not be used to carry passengers in excess of the number of seat beits provided by ( � y y y p y manufacturer or outside of the assen er com artment. ! (4) "Iweek"is 7 consecutive 24 hour days beginning at the start time of the rental. P 9 P � (5) "Imonth"is 30 consecutive 24 hour tlays beginning at the start time of the rental. (6) Renter shall not remove any seats from Vehicle. (6) Unless expressly modified on Page 1,all charges are for a minimum of 1 tlay, (7) Vehicle shall not be driven by any person impairetl by the use of narcotics,alcohol,intoxicants,or b. Rent�r shall pay Owner.i!�a�filiates or agents amounts as set forth on Page 1 for: tlrugs.used with or�+/�,thout z pres�npt cn. (1) The hour day,week and month charges on Page 1 for the Rental Periqd.Th�.JhQ.ur_.Charge,if_- ` �_l8)_VehiGe shal�not be loaded in a�x cycfgf b'euicie�.GtassYehicte W�gh�RaEing.{Gy1�IF�which is, - -- p��t shall applyto2ach fuN or partia{heur m excess of a day.The hourly charges shail ��Pub oiVefiicle plus weight of load,as indicated on the driver side door jam,or wifh an improperly j '�'3"�"'"�r exceed fhe cost of one additional day.If Vehicle is returned during non-business hours or to or unevenly divided load as per Vehicle manufattarer's specifications and/or guidelines. any place other than the Branch Address on Page 1,all rental charges incurred through the time an (9) Vehicle shall not be driven or taken outside the states authorized on Page 1. � employee of Owner checks in Vehicle are Renters responsibility. (10)Vehicle shall not be driven on an unpaved road or off-road. (2) The mileage charge per mile for alt miles exceeding any free miles set forth on Page 1 permitted for (11)Vehicle shali not be operated by anyone:who has given a fictitious name,false address,or a false the Rental Period. or invalid driver's license;whose driver's license becomes invalid during the Rental Period;who has � (3) The Optional Accessories,services andlor products charges for those items accepted by Renter. obtained the keys without permission of Owner,or who misrepresents or withholds facts tolfrom (4) The optional Verified Carbon Offsets(CO2 OFFSET)accepted by Renter are an optional environ- Owner material to rental.use or operation of Vehicle. � mentai service designed to offset the greenhouse gases emitted by Vehicie.Owner remits amounts (�z)Renter shall not transfer or assign this Agreement andlor sublease Vehicle. � collected ro an independent 3rd party providec See www.keystogreen.com for more information.The (13)Vehicle shail not be used to store or transport explosives,chemicals,corrosives or other hazardous estimated emissions produced by Vehicle are based on the average mileage and fuel economy of materials or pollutants of any kind or nature. vehicles in the rental fleet and are not calculated based on the emissions of a particular vehicle. b. In the event of any vioiation of the limits on use or any other provision of this Agreement,Owner auto- (5) The optional Tolipass Service accepted by Renter,which provides for the daity rental of a toll colleo- matically,without anyfurther notice to Renter or AAD(s),terminates their right to use Vehicle and Owner tion transponder or,in some states,the use of video-monitored toll cotlection services.In addition retains any other rights.and remedies provided by(aw.Owner has the right to seize Vehicle without legal to the dairy charge for the Toilpass Service,Owner or a third party may separately charge Renter's Process or notice ttr Renter or AAD(s).Renter and AAD(s)hereby waive all claims for damages con- credit or debit card(or bill Renter,as applicable,for cash rentals)for the Owners cost of all tolls nected with such seizure,including loss or damage to contents,and shall pay ail expenses incurred by incurred using the transponder or video monitored service during the Rental Period within the Tollpass Owner in returning Vehicle to the original rental office. service area.Renter expressly authorizes Owner to transfer to a third party Renter's name,address, c. If Renter or AAD(s)continue to operate Vehicle after the right to:do.so is terminated,Owner has the right crediUdebit card information,and other data necessary to enable the collection of all such tolls and to notify police Vehide has been stolen.Renter and AAD(s)hereby.telease and discharge Owner from associated charges incurred during the Rental Period.No credit is provided for days the transponder and indemnify,defend and hold Owner harmless against any liability arising from such notice.Renter is not utilized.Tolipass Service has a limited service area;attempting to use the service outside the remains responsible for all charges,costs,taxes,fees and obligations as set forth in Paragraph 3. service area may subject the Renter andlor any AAD(s)to fines and penalties see Paragraph 3.(c.)(3.). 5. Accidents.Damage to,loss or theft of,Vehicle must be immediately reported inwriting to the office where A current listing of ToIlPass Service Area covered roads is available upon request,at"www.htallc.coml Vehicle was rented,and in no event later tlian the following business day after the accident.Renter and enterprise"or(877)860-1258. AAD(s)must immediatety deliver to the office where Vehide was rented every process,pleading or paper (6) The fuel charge at the rate shown.If based on consumption and Vehicle is returned with less fuel than relating to any claims,suits or proceedings arising from such accident.In the event of a claim,suit or legal I when rented,the charge shall be for the Owner's estimated difference in fuel level shown on the fuel proceeding,Renter and AAD(s)shall cooperate fully with Owner and its representatives.Vehicle may be � gauge from the time Vehicie is rented to the time it is returned.Renter shall not receive a refund or credit equipped with an Event Data Recorder(EDR)or similar device for the'purpose of recording data about the if VehiGe is returned with more fuel than when Renter received it.If Renter purchases the Fuei Service operation of Vehicle.To the extent permitted by law,Renter consents to Owner or its representatives retriev- Option,then Renter's fuel charge shall be the per gallon charge multiplied by the fuel tank capacity of ing and using such data from the EDR. Vehicle rented.Renter shall not receive a refund or credit for any unused fuel. 6. Damage to.Loss or Theft of Vehicle Optional Accessories and Related Costs Except to the extent (7) The one way fee(for reWrning to a predetermined location other than the Branch Address on Page 1), restricted,modified or limited by State law,Renter accepts responsibiliry for damage to,loss or theft of,Vehicie, fees for AAD(s)and/or fees based on Renter or AAD(s)age. Optional Accessories or any part or accessory occurring during the Rental Period regardtess of fault or neg- � (8) The taxes. ligence of Renter or any other person or act of God.Renter shall pay Owner the amount necessary to repair (9) The other fees and charges(none of which are taxes)induding but not limited to: Vehicle or Optional Accessones.ReMer shall not have Vehide or Optional Accessories repaired without permis- a An air ort Rental Auto Facilit Char e RAFC which is re wred to be aid b Owner or coi- sion from Ownec If Vehicle is stolen and not recovered or Owner determines Vehicle is salvage,Renter shall ( � y p Y 9 ( � q p y pay Owner the fair market value less any sale proceeds.For purposes of this Agreement,fair market value shall � lected from Renter in connection with this rental,for the construction,financing,operation and/or �the retail value of Vehicle immediately preceding the loss.If Optionai Accessories are not returned Renter maintenance of this consolidated rental car facility;other airport facilities;and/or transportation shall pay owner the replacement cost of the Optional Accessories.Renter is responsible for all towing,storage related facilities; or impound fees,and other costs incurred by Owner to recover Vehicle and to eslablish damages.Renter agrees (b) The Concession Recovery Fee(CONC REC)which is Owner's charge to recover the concession to pay a sum for loss of use,regardless of fleet utiGzation,calculated as follows:(i)rf Owner determines Vehicle fee paid by Owner to this airport's owner or operator in connection with this rental;and is repairable:total labor hours from the repair estimate divided by 4 multiplied by the daily rate on Page 1;(ii)if (c) The Minnesota Registration Fee(MNREGFEE)which is a fee imposed by the state of Minnesota Vehicle is stolen and not recovered or Owner determines Vehicle is salvage:15 days at the daily rate on Page for the registration of rental cars.The Minnesota Registration Fee is not a tax and is not calcu- 1.Renter also agrees to pay:(a)an administrative fee of$50.00 when the repair estimate is less than$500.00 lated based on the costs imposed upon a particular vehicle. or$100.00 when the repair estimate is belween$500.00 and$1,500.00 or$150.00'rf greater than$1,500.00;(b) c. Additional Obligations of Renter—Unless prohibited by law,Renter shall pay Owner,its affiliates or agents: a sum for diminishment of value if Vehicle is repairable calculated as 10%of the repair estimate if the damages � (1) A special one way fee or drop charge equal to the greater of$100.00 or$.50 per mile(between the are greater than$499.99.If Vehicle is returned during non-business hours or to any place other than Branch actual return location and originally agreed upon return location),if Renter or AAD(s)returns Vehicle Address on Page 1,any damage to,loss or theft of,Vehicle or Optional Accessories occurring prior to an to a location other than the originally agreed upon retum location. employee of Owner checking in and inspecting Vehicle is Renter's responsibility.SEE PARAGRAPH 16 POR wner is an atfiliate of Enterprise Holdings Inc,which owns all rights to Enterprise names and marks. - OO EfltefpflS@ LeaSIIICJ COI71PaC1�/Of MIC11leSOtB, LLC, 2��2 ADDITIONAL TERMS AND CONDITIONS 199MNFALL12 PAGE 3 of 4 INFORMATION ON OPTIONAL CDW.IF RENTER HAS AN AUTOMOBILE INSURANCE POLiCY ISSUED 11. Use in Mexico.Vehicle shall not be taken into Mexico without Owner's prior written consent.Even wit IN MINNESOTA,SEE NOTICE ON PAGE 1. Owner's prior written consent,CDW,PAI and SLP do not apply to accidents or events that occur in Mexicc 7. Responsibility to Third Parties.Owner complies with applicable motor vehicle financial responsibility laws Renter must maintain or purchase insurance which shall apply in Mexico,as specified and approved 6 as a state certified self-insurer,bondholder,or cash depositor.Except to the extent required by the motor Owner,prior to taking Vehicle into Mexico. vehicle financial responsibility laws of the applicable state or otherwise by law,Owner does not extend any 12.Third Party Proceeds. If a third party, including,without limitation, an insurance company, authorize ot its motor vehicle financial responsibility or provide insurance coverage to Renter,AAD(s),passengers or payment of any amount owed by Renter under this Agreement,Renter hereby assigns to Owner Renter third parties through this Agreement.If valid automobile liability insurance or self insurance is available on any right to receive such payment.Only those amounts actually paid by a third party to Owner shall reduce th basis to Renter,AAD(s)or any other driver and such insurance or self insurance satisfies the applicable state amount owed by Renter under this Agreement;provided however,certain third parties may have agreed t motor vehicle financial responsibility law,then Owner extends none of its motor vehicle financial responsibil- pay Owner a flat fee for this rental in lieu of Owner's"Iday"charges or the per diem benefits under the appl ity.However,if Renter and AAD(s)are in compliance with the terms and conditions of this Agreement and it cable insurance policy.In such event the flat fee might exceed or be less than:the normal"/day"charges a Owner is obligated to extend its motor vehicle financial responsibility to Renter,AAD(s)or third parties,then calculated under this Agreement;or the per diem benefits.Regardless of the amounts paid under such fl� Owner's obligation is limited to the applicable state minimum financial responsibility amounts.Unless required fee agreement,third party payments shall not be applied to:vehicle upgrades or optional products(beyon by law,Owner's financial responsibility shall not extend to any claim made by a passenger while riding in or on those provided by the third party�;or,rental days beyond those specified by the third party.Renter remain or getting in or out of Vehicle.Owner's financial responsibility shall not extend to liability imposed or assumed responsible for all charges not paid by the third parties,such as charges for vehicle upgrades,optional proc by anyone under any worker's compensation act,plan or contract.SEE CERTIFICATE SUMMARY OF SLP ucts,extra rental days,and all other charges. ON PAGE 3 FOR INFORMATION ON OPTIONAL SLP. 13. Power of AttorneK Renter hereby grants and appoints to Owner a Limited Power of Attorney: S. Indemnification by Renter. Renter shall defend, indemnify and hold Owner harmless from all losses, a. To present insurance claims of any type to Renter's insurance carrier andlor credit card company if: liabilities,damages,injuries,claims,demands,costs,attorney fees,and other expenses incurred by Owner i.Vehicle is damaged,lost or stolen during the Rental Period and if Renter fails to pay for any damages;c in any manner from this rental transaction,or from the use of Vehicle or Optional Accessories by any person, ii.Any liability claims against Owner arise in connection with this rental transaction and Renter fails t including claims of,or liabilities to,third parties.Renter may present a claim to Renter's insurance carrier for defend,indemnify and hold Owner harmless from such claims; such events or losses;but in any event,Renter shall have final responsibility to Owner for all such losses. b. To endorse Renter's name to entitle Owner to receive insurance,credit card and/or debit card paymenl This obligation may be limited if Renter purchases optional CDW and/or optional SLP.SEE PARAGRAPHS directly for any such claims,damages,liabilities or rental charges. 16 AND 17 FOR MORE INFORMATION ON OPTIONAL CDW AND OPTIONAL SLP. 14. Severabilitv.If any provision of this Agreement is determined to be unlawful,contrary to public policy,voi 9. Personal In'�Protection and UninsuredlUnderinsured Motorist Protection.Except as required by or unenforceable,all remaining provisions shall continue in full force and effect. law,Owner does not provide Personal Injury Protection,No Fault Benefits or Medical Payment Coverage 15. Limitation of RemedylNo Conseauential Damaaes.If Owner breaches any of its obligations under thi (collectively PIP)or UninsuredlUnderinsured Motorist Protection(UMIUIM)through this Agreement.If Owner Agreement and/or if Vehicle has any mechanical failure or other failure not caused by Renter or AAD(s)an is required by law to provide PIP andlor UMIUIM,Renter expressly selects such protection in the minimum if Owner is liable under applicable law for such breach or Vehicle failure,Owner's sole liability to Rentf limits with the maximum deductible and expressly waives and rejects PIP and/or UMIUIM limits in excess of and AAD(s)and Renter's and AAD(s)'sole remedy is limited to the substitution of another similar Vehicl the minimum limits required by law. by Owner to Renter and to recovery by Renter of the pro rata daily rental rate for the period in which Rentf 10. Personal Property.Owner is not responsible for any damage to,loss or theft of,any personal property, or AAD(s)did not have use of Vehicle or substitute Vehicle.RENTER AND AAD(S)WAIVE ALL CLAIM whether the damage or theft occurs during or after termination of the rental regardless of fault or negligence. FOR CONSEQUENTIAL, PUNITIVE, AND INCIDENTAL DAMAGES THAT MIGHT OTHERWISE B Renter acknowledges and agrees that no bailment is or shall be created upon Owner,whether actual,con- AVAILABLE TO RENTER OR AAD�S).SUCH DAMAGES ARE EXCLUDED AND NOT AVAIIABLE Ti structive or otherwise,for any personal property carried in or left in Vehicle or on Owner's premises. RENTER OR AAD�S). Certificate Summary of Supplemental Liability Protection THE PURCHASE OF SUPPLEMENTAL LIABILITY PROTECTION IS OPTIONAL AND NOT REQUIRED IN ORDER TO RENT A VEHICLE. THIS IS A SUMMARY ONLY AND IS SUBJECT TO ALL PROVISIONS,LIMITATIONS,EXCEPTIONS ANQ EXCLUSIONS OF THE SLP POLICY ISSUED BY EMPIRE FIRE 8 MARINE INSURANCE COMPANY.UPON RE�UEST A COPY OF THE POLICY IS AVAILABIE FOR REVIEW.SLP MAY PROVIDE A DUPLICATION OF COV�RAGE ALREADY FURNISHED UNDER A PERSONAL INSURANCE POLICY,OR SOME OTHER SOURCE.OWNER'f EMPLOYEES,AGENTS OR ENDORSEES ARE NOT QUALIFIED TO EVALUATE THE ADEQUACY OF RENTER'S EXISTING COVERAGE. SLP Benefits:Optional Supplemental Liability Protection(SLP)provides Renter with a waiver by Owner of ReMer's indemnification obligation to Owner(set forth in Paragraph 7)with respect to third party liability up to the minimum financia responsibility limits(at no charge to Renter)as outlined in the applicable motor vehicle financial responsibility laws of the state where Vehicle is operated AND excess insurance provided by Empire Fire 8 Marine Insurance Company(SLF charge as shown on Page 1 is for the excess insurance only),which supplies Renter and AAD(s)with third-party liability protection with a combined single limit per accident equal to the difference between the minimum fnancial responsibilit� limits referenced above and$1,000,000 Combined Single Limit per accident.SLP will respond to third party accident claims that result from bodily injury,induding death,and property damage that arise from the use or operation of Vehicle as permitted in this Agreement.The Empire Fire&Marine insurance policy dces not provide coverage for arry loss arising from the use or operation of Vehicle in Mexico.SLP is available for an additional charge as stipulated on Page 1, SLP Exclusions:For all exclusions,see the SLP policy issued by Empire Fire 8 Marine Insurance Company.Here are a few key exclusions: (a)Loss arising out of an accident which occurs while Renter or AAD(s)is under the influence of alcohol or drugs,or other substances unless prescribed by a phys�ian;(b)Loss arising out of bodily injury or property damage sustained by Rente or AAD(s)or any relative or family member of Renter or AAD(s)who resides in the same household;(c)Loss arising out of the operation of Vehicle by any driver who is not Renter or AAD(s);(d)Liability arising out of or benefits payable under an� uninsured or underinsured motorist law,in any state;(e)Liability arising out of or benefits payable under any first parry benefit law,medical payments,no-fault or any similar law to the foregoing,in any state;(�Bodily injury to an employee or thE spouse,child,parent,brother or sister of that employee,arising out of and in the course of employment by Renter or AAD(s);(g)Property damage to property transported or in the care,custody or control of Renter or AAD(s);(h)Damage to Vehicle (i)Liability arising out of the use of Vehicle,which was obtained based on false,misleading or fraudulent informa6on;(j)Loss arising out of the use of Vehide when such use is othenvise in violation of the tertns and conditions of the Rental Agreemenl Reoort SLP Claims to: ^Sedgwick CMS P.O.Box 94950 Cleveland,OH 44101-4950 Phone:l-888-515-3132 Fax:1-440-914-2903 Certificate Summ�of Personal Accident Insurance PURCHASE OF PERSONAL ACCIDENT INSURANCE(PA1)IS OPTIONAL AND NOT REQUIRED TO RENT A VEHICLE.THIS IS A SUMMARY ONLY AND IS SUBJECT TO ALL PROVISIONS,LIMITATIONS AND EXCEPTIONS OF THE PA POLICY ISSUED BY EMPIRE fIRE 8 MARINE INSURANCE COMPANY.UPON REQUEST,A COPY OF THE POLICY IS AVAILABLE FOR REVIEW.PAI MAY PROVIDE A DUPLICATION OF COVERA�E ALREADY FURNISHED BY A PERSONAI INSURANCE POLICY,COMPREHENSIVE HOMEOWNER'S OR TENANT'S POLICY OR SOME OTHER SOURCE.BENEFITS AVAILABLE UNDER THE PAI,HOWEVER,WILL BE PAID IN ADDITION TO THOSE RECEIVED FROM ANY OTHEI SOURCE.EMPLOYEES,AGENTS OR ENDORSEES OF VEHICLE OWNER(AS DEFINED IN THE RENTAL AGREEMENT)ARE NOT QUALIFIED TO EVALUATE THE ADEQUACY OF RENTER'S EXISTING COVERAGE. PAI provides Renter and Renter s passengers with Accidental Death,Accident Medical Expenses and Ambulance Expense benefits.PAI is available for an additional charge as stipulated on page 1 of the Rental Agreement."Renter"is th� person who signs the Rental Agreement as Renter. PAI Benefits: Renter Passenger Accidental Death,Not to exceed $100,000 $10,000 Accident Medical Expenses,Not to exceed $3,500 $3,500 Accident Ambulance Expense,Not to exceed $150 $�50 Accident Aggregate,not to exceed$130,000 per accident. The above PAI benefits for Renter apply to accidents during the Rental Period whether or not Renter is in Vehicle.Passengers are covered only for accidents occurring while they occupy Vehicle.Anyone other than Renter occupying c operating Vehicle shall be considered a"Passenge�'for the purposes of PAI benefts. PAI Exclusions: PAI shall not cover any death or injury caused wholly or pa�ly,direcUy or indirectly by suidde,attempted suicide,or self-inflicted injury;aircraft travel except as a passenger in a licensed aircraft on a regularty scheduled flight commilting or attempting to commil aiminal offense;an aceident which occurs while under the influence of alcohol or narcotics,unless prescribed by a physician;an accident which occurs while padicipating as a professional in a prearranged a organ¢ed race or testing of a vehicle;war or any a� of war,or engagement in an illegal occupation;nor shall this insurance be in effecl if Renter converts Vehide.Renter shall be deemed to have converted Vehide whenever Vehide is not retumed to ihe Owner by ihe retum date a by ihe extended retum date. To fle PAI claims,obtain a claim form from any rental office of Owner,complete it and return it with a copy of the Rental Agreement to: Sedgwick CMS P.O.Box 94950 Cleveland,OH 44101-4950 Phone:1-888-515-3132 Fax:t-440-914-2903 Minnesota Collision Damage Waiver Form: UNDER MINNESOTA LAW,A PERSONAL AUTOMOBILE INSURANCE POLICY MUST 11)COVER THE RENTAL OF THIS MOTOR VEHICL AGAINST DAMAGE TO THE VEHICLE AND AGAINST LOSS OF USE OF THE VEHICLE;AND(21 EXTEND THE POLICY'S BASIC ECONOMIC LOSS BENEFITS,RESIDUAL LIABILITY INSURANCE,AN UNINSURED AND UNDERINSURED MOTORIST COVERAGES TO THE OPERATION OR USE bF A RENTED MOTOR VEHtCLE.THEREFORE,PURCHASE OF ANY COLLISION DAMAGE WANER Oi SIMILAR INSURANCE AFFECTED IN THIS RENTAL CONTRACT IS NOT NECESSARY.IN ADDITION,PURCHASE OF ANY ADDITIONAL LIABILITY INSURANCE IS NOT NECESSARY IF YOUR POLIC WAS ISSUED IN MINNESOTA UNLESS YOU WISH TO HAVE COVERAGE FOR LIABILITY THAT EXCEEDS THE AMOUNT SPECIFIED iN YOUR PERSONAL AUTOMOBILE INSURANCE POLICY. Owner is an affiliate of Enterprise Holdings Inc.,which owns all rights to Enterprise names and marks. OO Ellt@fprlS@ L@BSlflg COIllp8ll�/Of Mlllll@SOta, LLC, 201 199MNFALLI2 PAGE 4 of 4 16. Optional Collision Damage Waiver. Renter may purchase optional RAP from Owner for an additional fee.If Renter purchases RAP,Owner agrees, COLLISION DAMAGE WAIVER IS NOT INSURANCE. THE PURCHASE OF DAMAGE WAIVER subject to the actions that invalidate DW listed in Paragraph 16,to contractually waive Renter's responsibility for IS OPTIONAL AND NOT REQUIRED IN ORDER TO RENT A VEHICLE. SEE NOTICE ON PAGE 1 the cost to provide 24/7 roadside assistance(where available)which includes replacement of lost keys(includ- REGARDING COLLISION DAMAGE WAIVER IF RENTER HAS AN INSURANCE POLICY ISSUED IN ing remote entry devices),Flat tire service(if no inflated spare is available,the vehicle will be towed-cost of a MINNESOTA. replacement tire is not covered by RAP),lockout service(if the keys are locked inside the vehicle),jumpstarts, Renter may purchase optional Collision Damage Waiver(CDW)from Owner for an additional fee.If Renter and fuel delivery service for up to 3 gallons(or equivalent liters)of fuel if Vehicle is out of fuel.RAP services purchases CDW,Owner agrees,subject to the actions that invalidate CDW listed below,to contractually waive are only available in the United States and Canada.If Renter does not purchase RAP,or RAP is invalidated as Renter's responsibility for all of the cost of damage to,loss or theft of,Vehicle or any part or accessory and set forth above,roadside assistance will be available,but standard charges will apply. RAP does not apply in related costs regardless of fault or negligence.Notwithstanding anything to the contrary and unless prohib- Mexico. ited by law,CDW does not apply to lost keys,key fobs,transponders,Optional Accessories,or any liability y0.Telematics Notice and Release.Vehicle may be equipped with OnStar or another telematics system.Renter imposed by law.CDW does not apply to damage occurring in Mexico. acknowledges that such systems utilize cellular telephone and/or radio signals to transmit data and com- When deciding whether or not to purchase CDW,you may wish to check with your insurance representative or munication and,therefore,privacy cannot be guaranteed.Renter authorizes use or disclosure of or access credit card company to determine whether,in the event of damage to,or theft of,Vehicle,you have coverage to call location information concerning Renter or other user of the service,automatic crash notification to or protection for such damage or theft and the amount of your deductible or out•of-pocket risk. any person for use in the operation of an automatic crash notification system and use of the vehicle location The following shall invalidate the CDW and accordingly damage and loss resulting or arising from system.Renter releases Owner,operator of the telematics system,wireless carrier(s)and other suppliers such actions are excluded from and not covered by the CDW: of components or services and their respective employees,officers,directors and agents from any dam- a. Damage or loss that results directly from the intentional,reckless,willful,or wanton misconduct of Renter age(including incidental and/or consequential damages)to persons(including without limitation Renter)or or AAD(s)in the operation of Vehicle; property caused by failure of the telematics system to operate properly.Third party service providers are not b. Damage or loss that results directly from Renter or AAD(s)operation of Vehicle while legally intoxicated agents,employees,or contractors of Owner.For limitations concerning warranty,privacy and performance of or under the influence of any illegal drugs,as defined or determined under the laws of the state in which the telematics system in Vehicle,contact the telematics provider. the damage or loss occurred; 21. Headinas.The headings of the numbered paragraphs of this Agreement are for convenience only, are c. Damage or loss that results directly from Renter or AAD(s)operalion of Vehicle to tow or push cargo or not part of this Agreement and do not in any way limit,modify or amplify the terms and conditions of this any other object; Agreement. d. Damage or loss arising out of the operation of Vehicle for any commercial purpose; yy,Release of Information to Third Parties.Renter agrees Owner may,and Renter expressly authorizes Owner, e. Damage or loss arising out of the use of Vehicle in the commission of a criminal activity that is classified to provide information in Owner's possession about Renter and AAD(s),including but not limited to such driver's as a felony under the laws of the state in which the criminal activity occurred; name,address,cellularlmobile and other phone numbers,driver's license andlor crediUdebit card information f. Damage or loss arising out of the operation of Vehicle in any speed test,speed contest,or driver training activity; to applicable authorities or other third parties,in connection with this Agreement including,without limitation, g: Damage or loss arising out of the operation of vehicle outside the United States or Canada; providing Renter's personal data to third parties which conduct services on Owner's behalf(such as consumer h. Damage or loss arising out of the operation of Vehicle by Renter or AAD(s)who submitted fraudulent or satisfaction surveys)and consent to Owner or Owner's representatives contacting Renter. false information to Owner; i. Damage or loss arising out of the operation of Vehicle by an unauthorized driver; 23. Choice of Law.All terms and conditions of this Agreement shall be interpreted,construed and enforced pur- j. Damage or loss that occurs as a result of continued operation of Vehicle when such operation would suant to the law of the State where this Agreement is executed by Renter without giving effect to the conflict cause damage to Vehicie. of laws provisions of such State. 17. Optional Supplemental Liability Protection. See the Certificate Summary of Supplemental Liability 24.Customer Privacv. Questions regarding privacy should be directed to: customerservice@erac.com; Protection on Page 3 for a summary of optional SLP. 1 (877)858-3884 or Enterprise Rent-A-Car,Privacy Questions,600 Corporate Park Drive,St.Louis,MO ,18.Ootional Personal Accident Insurance.See the Certificate Summary of Personal Accident Insurance(PAI) 63105. on Page 3 for a summary of optional PAI. 19. Roadside Assistance Protection. For roadside assistance call 1-800-307•6666. When deciding whether or not to purchase optional ROADSIDE ASSISTANCE PROTECTION(RAP),you may ' wish to check to determine whether you have other coverage or protection for such services. ROADSIDE ASSISTANCE PROTECTION IS NOT INSURANCE. THE PURCHASE OF ROADSIDE ASSISTANCE PROTECTION IS OPTIONAL AND NOT REQUIRED IN ORDER TO RENT A VEHICLE. . Earn VIP perks Click & save. � without renting Find ourlowestratesonlineand on our mobile site at enterprise.com. � like one. {, Earn points redeemable for free rental '_` days with the new Enterprise Plusr"' ; Join for free at enterpriseplus.com. � � Yourweekend We're alwa s �� y � starts here. on call. � Ask about our weekend specials, or 24-HOUR ROADSIDE ASSISTANCE* visit enterprise.com. 1 800 307-6666 Keys,flats,jumps,fuel or any other mechanical repair just call and we'll be there *Fees may apply. �n�r � . � �'_ We'll pick you up� OO 2012 Enterprise Rent-A-Car Pick-up subject to geographic and other restrictions. Page 1 of 1 ENTERPRISE LEASING COMPANY, 1161 UNIVERSITY AVE W,SAINT PAUL, MN 551044124 (651) 228-0088 RENTAL AGREEMENT REF# 463429 4KN6QR RENTER COOPER, SHERRI SUMMARY OF CHARGES DATE&TIME OUT 02/18/2013 02:18 PM Charge Description Date Quantity Per Rate Total DATE 8c TIME IN TIME&DISTANCE 02/18 -03/O1 12 DAY $20.86 $250.32 03/O1/2013 10:50 AM DW 02/18 - 03/O1 12 DAY $15.60 $187.20 PAI 02/18 -03/O1 12 DAY $3.39 $40.68 BILLING CYCLE REFUELING CHARGE 02/18 - 03/O1 $0.00 CALENDAR DAY Subtotal: ;478.20 VEH #1 2012 TOYO CORO LE Taxes&Surcharges VIN# 2TiBU4EE6CC772215 MINNESOTA REGISTRATION FEE 02/18 -03/O1 5% $12.51 LIC# 6UGG691 MINNESOTA RENTAL CAR TAX 02/18 -03/O1 6.2% $15.52 MILES DRIVEN 474 SALES TAX 02/18 -03/O1 7.625% $19.09 Total Charges: ;525.32 BILL TO ACCOUNT Bill-To/ Deposits .FARMERS CUSTOMER PAY DEPOSITS ($280.00) RENTALS** ATTN: CUSTOMER PAY Total Amount Due P.O. BOX 268994 ;0.00 OKLAHOMA CITY, OK 73126 PAYMENT INFORMATION AMOUNT PAID TYPE CREDIT CARD NUMBER CLAIM INFO $245.32 Mastercard xxxxxxxxxxxx8115 PENDING 1023064362-1-3 $180.00 CHECK LOSS DATE: 02/17/2013 $100.00 Mastercard xxxxxxxxxxxx5215 INSURED TYPE CAR: FOCUS SHOP: TOUSLEY FORD BODY SHOP PHONE: (651)484-7231 ATTN: UNKNOWN 3/1/2013 Accident Report Page 1 of 1 �� 13032849 � Nr+ranw �..,o. m.an irw ea. � N �N 02 00 '02 Y 2 1� 2013 Un 0815 � 10 Vandalia St . " �� '—•—8^ 8� 8w°�r �e mamw .rtaer �.orr .w ,owc�.n�coon...rt. 62 �� St Paul +,• 10 University Av W �s'� s.grQni �ruri awt.ur�rnre�•� iuu a�ss m owraucsrars.t "'� p O1N 3L O1 C383007856914 MN D O1 O1 P966152956621 � ' na*ai: �wce��mtwn �� Jason Whitney 11 8 73 SHERRI�MICHELLE COOPER 08 0762 O1 367 Grove St N. O1 2198 ST ANTHONY AVE N O1 0 wenr� • • ' 6516<59806 Q1 O1 St Paul 55101 ST PAUL 55109 xm.n .o� ��a.. .w.o uR w.EV E. wn �e.v* �s aae* �uC O1� O1 � M 4 OI 04 98 C F �9 04 06 OS �roa ma ma�e me mwr mM�►a.r riwau/xeE� wrrrea �aa ma owa �+c •e�ov ww�r rrarioir�uc� �wMrui � 98 � 98 N ��., '�' 1� N ��, ooa�. ooa. awe�w+� '"` O1"O`""E N• O1 01 City of St Paul N COOPER STEPHEN THOMAS ,�r. .�. '°„m '°""' 'Y O1'» 90 367 �rove N 2198 ST ANTHONY � ve„we �n;ma ar Ku,n o�.e. an:.r��t a Mur. a.ec. .w w 07 St. Paul MN 55101 '1tl' 03 ST PAUL MN 55109 "1C 05 O1 ania O1 ord CV 00 Whi FORD FSE O1 TAN 02 OWiN AAlE1 !fllO MMllfi �� bV+ 11AR• RPW YfMI[O �� O� O�� 2 S d1563 O1 O1 314DGU MN 13 O1 � soucr r.rw �«w.�cE iu..a rnrer...w City of St. Paul Self Ins. Farme=s 19168@454 ww�e w�tia �o. � � vw�c �rroc'w. w Meoe. IF AOCIOEMf NVW.V�1 A COYIIOICIAL YO1'01�Vi111CLi.�CIIOOL Nli�OR 1/Ap�TAIR fIM ruC *'°� � IIEY[Y/iR TO NOTIY TIK iTATE M1R0L M�unM il�10.1q rM 1M.411�. mr1[/xvavHru��.raroxuww�w� oo*� ow�ow�wru:�uoro�v+w�rwrE omna�oi a+nlwGw�wrtr�w wr. wnea - �ic nrf u�c �a�CJ. _ �r�e tww�r � _ ` �,...��_ � - � ,u� �r •�.,..._.,� Melvin Browninq l6121578/49171 W M �Uo*� 4 0,,,,, ""'°'"`s �"..r" W Vernon Marahal (612/961/11571 W z/z3� M Dd^�" �v Ow �rMrr� , ar�avmao.wwm.Aa�m.wwoeawra�an�r�w�orcn.rwa«.cuowuoMirwn a� aWam �va�armrr�n � � orNa kern � .wrw^K- O1 : �� N O1 ,�.. � I I nbr ro SGocr'. veh. Y2 S/B Vandalia at Oniversity with qreen � _..--- _ -----__ .. : iiqh:. "°""° LOGTI �YM�ty AV W O 1 O1 Veh.�l E/B University at Vandalia with red light. �� wwoa � _ N: ! � � Dziver of veh. fl was unable to see the semaphore 09 �d� do to the sun and struck the R/F' of Veh.12. � �� Driver Veh.#1 has a soar right shoulder. �� _ � . !. Driver Veh t2 has a soaz riqht foot. O1 � - —�� .�an�af �'a �: St. eaul Fire Medic Y23 arrived or. acene to check „oe«., �� w' � I both drivers. No medical attention was needed. I � 03 � I�.='� 02 ro.w. ;�:: ^� O1 81 I � I I5 Y b ( 1 � � �a«�. I.,; 05 O1 * F ��. I�II��Y1� �p1f IlUld IGCK °'a�a"""""`""E"°'"°°E' St Paul PD q�' 0°"'" SGT Wesley Slagle 248 �,,+,,,�.ii,�„��P�,,,,,,�,�r�Ta/cl��;nf�/accidentrecords 2008/Includes_LE/PrintReportIndiv LE.... 2/17/2013