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Ebertz ,:� �s; ...... a e�l:' .,.�a�'�:�'t�,� �`'��`� 1 � ��"�� .,_ , , �"`= �' R`�� '� NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota Minnesota State Statute 466.05 states thrtl "...every person...who claims damnges from any muificipaliry...shall cause to be presented to the governing hody of the municipnlity within l80 days after the alleged lass or injury is discovered a notice stating the time,place,and circumstance,r thereof,nnd the amounl of compen.rarion 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 Middle Initial�Last Name �c��IZ f � _ Company or Business Name "�''��— Are You an Insurance Company? Yes/� If Yes,Cl�im Number? Street Address '��'1�.��(,��"V� City r?i �lA L State J`-'�1�1 Zip Code C • C Daytime Phone(�)�_I L'i-1 Cell Phone( ) - Evening Telephone(ro5�)��8- �5� Date of Accident/Injury or Date Discovered � ( 3 Time�a�/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 and/or responsible for your damages. ��'D 21 V(1�{La ��.ST �ht,W t7 DA 1 �i ('�I Q �-VE R ETi,JEEl�i (-�L�W L1__�f-'�2t[YiZ I.�f-tGt� i !-t i i .��IA�spvr�,n�r�c�pr.L�r�� y o i t.��2 l��nu�r 7.D rn�� IT R��-� t�r.��y '�r��-ss ��r.E-��.��S�n i,�v �►y H�t��cEti-� i i�r�� aa-�-A� t�Aa.�aw�rl r�u �ny �r��"�L.�i �rsr nn�l ��bsm�►�T �i'a-t� c.��Ec� + 2 �+2s L��. rnic wb21c � wt�S 'F�F�['J[ nr� i HE " F}D i S ��`j'RF�T(��I-I (� nAD �R� �i�,E��.l °RF�n �ort �F�°� + C��'fT�-� ��SE � FEEL�'r-IE. G��`I 4,u-r9,ti� --i-qv� '��-(� /'� Sr� /� �j(�lS`I R�A17� i'r�'DHNG�KDU-S '�' 1� �QS �K.E raD�N� �i� UfR�"�IP31u5 THEN Y�� CAN 1� Pl'ease check the box(es)that most c osely represent the reason for completing this form: �,p {4�,�.N�D T�{E ZD � S� ❑My vehicte was damaged in an accident ❑My ve hic le was d amage d during a tow ��H��« �,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 property ❑ Other type of property damage–please specify ❑ Other type of injury–please specify In order to process your claim vou need to include copies of all applicable documents. For the claims types listed below,please be sure to include the documents indicated or it will delay the handling of your claim. Documents WILL NOT be returned and become the property of the City. You are encouraged to keep a copy for y urself before submitting your ciaim form. �roperty damage claims to a vehicle: two estimates for the repairs to your vehicle if the damage exceeds $500.00;ar 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;ar 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 daim but wili not be returned. Page 1 of 2–Please complete and return both pages of Claim Form Failure to complete and return both pages will result in delay in the handling of your claim. All Claims–please comulete this section Were there witnesses to the incident? es No Unknown (circle) Provide their names,addresses and telephone numbers: �R�C �RK��N 1Q�-S� �i �.LAI�C � �� t1Al.. � MtJ c.�cJl D�.� �o°.�1 L�'�� 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 ossible. If necessary,attach a diagram. I1N t5 f �.�(,�hSD ST C�A i�Z /�VE 3E��JE��.: �n��1.� -{ I�Q�ofZ Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim to your satisfaction. �� ' 'L FGYC �1-1�. � �1SES _I,A'�,'_/�-'/ !' R %ZG�E{tR. Vehicle Claims–ulease complete this section ❑ check box if this section does not applv Your Vehicle: Year 2°n�.Make M A�A � Model 3 License Plate Number b�L` F�T State_�I�Color ��K�=��' Registered Owner E � Driver of Vehicle �.(�.��tiE �?c2T� Area Damaged�RC��"�' T12� -�jl�Ll v�m�N°r City Vehicle: Year Make Model License Plate Number State Color Driver of Vehicle(City Employee's Name) Area Damaged Iniurv Claims please comnlete this section �check box if this section does not apqlv How were you injured? What part(s)of your body were injured? Have you sought medical treatment? Yes No Planning to Seek Treatment(circle) When did you receive treatment? (provide date(s)) Name of Medical Provider(s): Address Telephone Did you miss work as a result of your injury? Yes No When did you miss work? _ (provide date(s)) Name of your Employer: Address Telephone �Check here if you are attaching more pages to this claim form. Number of additional pages.�. By signing this form,you are stating that all information you have provided is true and correct to the best of your knowledge. Unsigned forms will not be processed. Submitting a false claim can result in prosecution. Date form was completed�?�1�i Print the Name of the Person who Completed t is Form: '� � Signature of Person Making the Claim: Revised February 201 1 - NTW, INC. ST PAUL MN STORE 2185 FORD PKWY ST PAUL MN 55116-1816 Telephone: 651 690-5007 Store #: 875 Merchant #: 0002 306625009875 001 , Invoice #: 66412588 RI 03/11/13 09:41 AM � Abcount #: 0737 Type: Visa Reference #: 00000!001 Batch #: 070001 Auth #: 763834 Sale Amount: $ 169.42 I agree to pay above total amount according to card issuer agreement. � . . / /�� How did we do? Receive a $10 off oil change coupon on ` your next visit. Please, complete the survey at nNES•S6FIYICE•BRARES•BATTERIES rvr77�'•ntbcares.com IIse password 66412588 oo0os MN NATL TIRE & BAT # 875 * FINAL BILL -INVOICE** Page 1 2185 FORD PKWY Invoice# 66412588 - RI ST PAUL MN 55116-1816 Order Num 39905008 - WI (651)690-5007 Date/Time In. . . . . . . . 03/11/13 08:30:13 Date/Time Promised. . 03/11/13 09:41:09 2004 MAZDA 3 Tag: 030HAT St: MN Mileage: 119735 Engine: VIN# JM1BK32F641183748 ------------------------------------------------------------------------------- Customer: 30551453 PO#: Ship To: EBERTZ, ANGIE 1978 ST CLAIRE AVE ST PAUL MN 55105 — Opening Salesperson 12965207 Home# 651-698-4578 Work# Email: ------------------------------------------------------------------------------- Item Number Item Description Qty Price Each Extended ------------------------------------------------------------------------------- SL00320556V Sailun Atrezzo SH402 1 97•99 97•99 DOT #:53LH RB85 2712 1 2000065 205/55R16 91V,2000065 50K-ECONOMY RADIAL ***replace R.F.*** ServiceCentralRoadHa ServiceCentralRoadHazard 16.00 16.00 Tire Disposal Charge Tire Disposal Charge 3.00 3.00 PTT SERVICE CENTRAI, NC INSTAL11 TP 1 � 1050K TPMS REPAIR KIT 1 1050K-TBC NCb WHEEL BALANCE NO CHARGE i 1 KMTSL MOUNT AND INSTALL ! 1 12960644 SKARDA, JEFFREY J. LTRF LIFETIME TIRE ROTATE SVC 1 LFFR LIFETIME FLAT REPAIR SERVICE 1 RHWCadj SL00320556V 1- 97.99 97.99- DOT #:53LH RB85 3211 1 LBu LIFETIME BAI�ANCE UPGRADE 1 10.00 10.00 WA1 1 YR WHEEL ALIGNMENT PROGRAM 1 124.99 124.99 12965205 JOHNSON, JEREMIAH REC120K RECOMMEND 120,000 MILE SVC 1 VISA Visa 169.42- CARD NUMBER 0737 APPR 763834 IF YOU HAVE A QUESTION OR CONCERN PLEASE SPEAK ', TO OUR STORE MANAGER, WILLIAM PUNCHES AT (651) 690-5007 � Special Credit: Total Charges. . 251.98 Total Credits. . 97•99- Sub-Total. . . . . . 153.99 New Tire Fees** .00 Shop Fees(*) 12.50 All Taxes. . . . . . 2.93 Payments. . . . . . . 169.42- Net Amount. . . . . .00 PLEASE PAY ABOVE AMOUNT. THANK YOU! Closer:12965207 I have received the goods and services as represented on this invoice. If this is a credit card purchase I agree to pay and comply with the cardholders agreement with the issuer. *This charge represents costs and profits to the vehicle repair facility for miscellaneous Shop Supply or waste Disposal. Customer Signature PLEASE SEE REVERSE SIDE FOR WARRANTY,TERMS,CONDITIONS AND OTHER IMPORTANT INFORMATION CUSTOMER COPY _ �.M...�.�� : .�„_�� New Tire IJmited Warranty *What is covered and for how long: ,� Every new tire purchased at a T've Kingdom,Merclunts Tsse,N7'B or Big O Tires storo(collectively'IBC Retail�is wazranted by the manufacNrer against defects in workmans6ip or marerials down to 2/32nds of an inch remaining tread grove depth.Addibonal warranfies may appty to some lires.TBC Retail will honor tLe manufacNrets warranty on any such Ures,and any such dres which fail under the[erms of the manufaclure s warrsnty will be repaired or replaced in accordance with the manufacNrer's wexranty progcam.You must comply with t6e conditions of the manufacturer's warranty program to receive this wartanry coverage. . *How credit is determincd: If a tire covered by this warranty becoma unserviceable due W a defect in workmanship or ma[erials(tire separafioq etc.)during the usable tread life of the tire(usable tread depth is original tread depth minus 2/32nd of an inch),you will receive a c=edit for Ne amount of usable tread remaining on the unserviceable tire 6mes the curtent setling price(example 60%usable remaining tread times the current selling price of S80 equals a credit of$48).This crcdit will be appGed to the invoice of the replacement tire. 'What is not covered: - This wartanry does mt wver Grzs which become unserviceable due to: l. Condidoos resulting from road harards such as cuts,soags impact breaks or punctures. 2. Condi600s rosulung&om improper installafioq wheel misaligcunent or ure/wheel assembly imbalanca . 3. Conditlons resulting from consumtt damage such as improper tirc and vehide maintenance,misuse,abuse or accident 4. Tire unifolmity complaint after the first 2/32nds inch of tread wear. 5. Use in any commercial appliwtion. 'See Other Ceoeral Terms and Conditiom below. Limited 11�leage Wsrrauty 'What ia covered and tor how loug: '' � If a mileage wartanry is noted on the front of the documentarion attached hereto,such tire whose remaining tread depth grove is reduced to 2/32nds of an inch or less prior to receiving the specified mileage,will be replaced wiM the same or an equivalent new tire at the then curtent retail price,including applicable taxes,less an allowance based on the acmal mileage receivW at Ne time presented to a TBC Remil store compared W Ihe specified mileage.Mileage warranry claims will only be honoreA within 6 years of the date of original bre purc6ase and before the tire deGvers the wazranted mileage.The following Gres are excluded from the limited mileage warrmty:commercial use bres,tires wom from excescively aggmssive driving conditioas sucA as racing and tires wom from improper maintenance such as lack of roqtlon,improper a'v pressure,alignment or mechanical wear.� 'Owner Obligatioas: � Proper tue care is necessary ro obain the mazimum mileage a¢d weaz from a tire.It is your obligafion to see that your tire/wheel assemblies are in balance and properly aligned,that your tires are operated at vehicle manufacNror's rocommended cold iaflation pressure and that your vehicle is well maintained.Your tlres must be inspected by us a minimum of every 6,000 ro]0,000 miles.Check a'v pressule in each of your tires including the spare,at Ieast monthty when tf�e tires are cool.TBC Retail will check alignment,treadwear,tlre pressure and the mechanical condition of the vehicle anyGme at no charge at any TBC Repil lowuon. •What is not wvered? l. DeFects in worl�anship and/or mamliak(covered by sepazate new lire limited wamanry). 2. Failures caused by road harerds. 3. Tires used on special applicabons mch as tight trucks(nnless speci6cally covercd),vans,recreabonal vehicles or compercial vehicla includivg taxi,police,etc. 4. Tires with premature or irtegulaz weaz or damage due to improper inflation,misaGgnment of wheels,mechanicat defeyts of vehicle or tires on vehicies whero necessary vehicle rcpair or mainrenance has not been perfocmed. � 5. T'ves damagW by fire,wrocks,obstrucfions on the vehicle or willful and malicious damage. . 6. Repa'vable punenires or tires'un flat � 7. Sidewall damage from scuffing curbs or o[6er cosmetic damage. 8. Tires transferted from the vehicle on which they were originally installed. 9. Use in any commercial applicarion. •See Other General Warrauty Terms aod Conditioos below. Road Hazard Warranty •What is covered and for how lavg: This warlanty covers alt tires for which this wamanty has been purchased tltat Las become unserviceable as a result of normal road hazards(i.e.cut,snag,bruise,impact breaks or'vreparable puncNres).This limited wazranty termioates when the wvered unserviceable tire is adjusted or when the tlre is wom ro a level of 2/32nds of an inch,the minimum tread depN requ'ved for safe vehicular operation. 'What is not covered: T'ves removed from service due to being overloaded,intenbonal abuse or tlres used in other thaa normal passenger vehicle service.Tires 8�at can be safety fixed will be repaircd FREE OF CHARGE.Road service,mwing costs and other incidental damages or costs aze not covercd. 'How ia replacemmt price determined? Normal Road Hazards,Run fian and Worlmaoship/Material DetMs In the event a tve covered under fhe wacranty becomes uuserviceable due W normal road hazard(ezample:cuts,snags,impact breaks or non-repa'vable puncNres),(usable tread life is the original Read depth minus 2/32nds of an inch),in the first 12movNs or 12,000 miies,whichever comes first,you wi(1 receive full credit of the original purchase price of the ere rowazds the wst of replacemenC After the FREE REPLACEMENT period of 12 months or 12,000 miles,whichever comes first,you will receive a ceedit for the amount of usable tread remawing on the damageA dre based upon your original purchase price.(example:50%usable tread remaining dmes Ne original purchase price of S50 equals a aedit of S25).1'his credit will be deducted from the cost of the replacement tire.When the tire is wom down to 2/32nd of an inch or less,the tire is wom out and the warranty ends,regardless of the age of the tire. •This warranty must be�purc6ased for thti rnverage to apply. •See Ot6er Geoeral Terms and Condidom below. - Other Ceneril Warranty Terms and Conditions •Who gets the warrauty? All wananfies apply to the original purchaser and may not be uaigned to a subsequrnt purchusr or owner of the motor ve6icie on which the fire(s)coverod by our warrandes are installed.A tire (s)mounted on any vehicle other than the vehicle on which it was fust mounted is also not covered by these warra¢fies. *Where to go[or warranty repiacement aod/ar aervice? All"CBC Retail warrznfies will be honored at all TBC Rnail locafions,including any Big O,Tire Kingdom,MerchanPs ar NfB store naGOnwide.For warranty service,you must present your saks invoice and service records,along with the unurviceable dce(s).TBC Retail sroro locations can be obtained by calling 1-800-NEW-771tE,or in PA or N.J.1-888-77RE5 N7'B or in the whire pages or yellow pages under Tire Dealexs Retail.In t6e eveat you are unable ro locate a TBC Retail store or require furtLer assistance,you may contact our CUSTOMER SERVICE OFFICE at 800-926-8473 anywhere in[he Conlinental United Stares. � •Consnmer RIY6d: This warranty gives you specific legal rights and you may 6ave other righis,which vary from staM W stah.Some states do not allow IimitaGOn on how long an implied wacranry lasts,so Ne warranty limitatlons may not apply to you. 'Covditioos and Exclusioos: Nothing in this wacranty is iatended to be a misrepresentation that tire faiture cannot cecur.To the extent pelmitted by law,liabiliry for consequential damages is disclaimed.i'o the exrent that a manufacturer's warranty applies,such warranry shall be primary and Ne TBC Retail wazianry shall not apply to the extent of the manufacturer s warlanty. 'Owners ObligaHoos: Proper tire care and vehicle maintenance are necessary W obmin maximum treadwear and service from a tve.It is youcobligaUOn to properly maintain your tires and the vehicle,upon which they are inshelled,including;operating your tires at the vehicle manufacturer s recommended cold inflarion pressures,insu�g your Gre and wheel asumblies are in balance,tim mmted on a regular basis(every 6,000 miles is recommended),ve6icle in proper wheel alignment and vehicle steering,suspension and driveline componenfs are well maintained.TBC Retail will check and inspect tire condition,wheel alignment and vehicle condifion at any 6me without charge. 'Replacement warranty: If you receive a replacemrnt tire under the teems of this wartanty(s)the replacement fire will be covered by the wacranty TBC Retail gives that tire.Road Elavard Coverage will need ro be purchased separately[o cover the replacement bre. Mechmical Servitt Terms&Conditiom Untess otherwise stated,all mecha¢ical service parts am wartanted for 12 montfis or 12,000 miles whichever comes fust All labor is warranted for 90 days or 4,000 miles whichever comes first, both[o the original purchaser during this period. TBC Refail will replace the par[s and redo the labor at no further cos[Warranfies do not apply ro vehicles used in commercial application. By execuuon of the repair autfior'vauon on the front of t6e invoice,customer authorius repair work ro be done as descnbed.GLstomec agrees ro pay cash on the delivery of the vehicle,and unel paid in full,TBC Retail shall 6ave a lien on the ve6icle for the amount owing.In the event of default by the wstomer in payment,TBC Retail is hereby specifically authoriud to rotain possession of the vehicle wittiout notice and withwt process of law,and said possession sLall inves[TBC Remil with all rights of possessory lien 6older under Ne law.Customer furfher agrees tha[TBC Retail will not be Meld rcsponsible for ihe articles left in vehicle in case of fire,the$accidents or any other causes bryond its conuol. Cusromers vehicle may be driven by TBC Retail employees at wstomers risk Storage will be charged at a rate of$15.00 per day beginning 3 days aRer noece to customer that repairs have been completed.If TBC Retail is forced ro take any acuon for wllection of any balance owing by cusromer to TBC Refail by tawsuit or otherwise,customer agrea ro pay inhrest on Ne amount owing until paid and the colleclion costs.The provisions hercin set forth s6a11 become part of any independent agreemen[for payment made between cusWmer and TBC Retail in connec[ion wi[h work authorized by this order.lf customer cancels tLis order,TBC Retail may charge for the cost of the teardown,the cost of parts and labor to replace items that were destroyed by reazdown and Ne wst ro reassemble the components of the vehicle. TBC Retail will not be responsible for damages to the vehicle due to cauus beyond iCs controi(ask about limits and exunt of insurance). Some states do not allow tkie exclusion or limitaUOn of incidentll damages,5o t6e above limitaROns may no[apply to you. Disdalmer of Warrauties Except as described herein,TBC Retail makes no express or implied warranty whatsoever with xespect to Ures,main[enance or repair work,including but no[limited lo the implied wartanUes of merchantabiliry and fimess for a partiwlar purpose.Any implied warranry is limited ro the same duraUOn as Ne written warranry. Some states do not allow limita[ion on how long an implied waeranty lasts,so[he above limita[ions may not apply[o you.TBC Retail disclaims any liability for incidental or consequential damages to the extent pem�itted by law.$ome sfa[es do no[allow Ihe exclusion or limitarion of incidental oc consequential damages,w the above limitafions or exclusions may not appIy to you. The customer's remedies described herein 5ha11 bC exclusive of any other remedies.Ttie wacranues described herein are for t6e ezclusive benefit of Ihe cusromer and are not assignabk ezcept as provided otherwise.7'he customer must present this document and cortesponding invoices to TBC Retail in order to resolve tk�e benefits of any wa=ranty contained herein. i �j�RN.TB� P�I NATL TIRE & BAT # 875 ***SCRA Document*** Page 1 2185 FORD PKWY Invoice# 66412588 - RI ST PAUL, MN 55116-1816 Order Num 39905008 - WI Date/Time In. . . . . . . . 03/11/13 08:30:13 Date/Time Out. . . . . . . 03/11/13 09:41:09 2004 MAZDA 3 Tag: 030HAT St: I�IId Mileage: 119735 Engine: VIN: JM1BK32F641183748 ------------------------------------------------------------------------=------ Customer: 30551453 Ship To: EBERTZ, ANGIE 1978 ST CLAIRE AVE ST PAUL, MN 55105 Opening Salesperson 12965207 Home# 651-698-4578 Work# Addl Repairs may be authorized by Phone# ------------------------------------------------------------------------------- ------------------------------------------------�------------------------------ i ' CUSTOMER COPY �} i ... . .� � ._. ., . ,,..�.�+wt`+'fN'�'e��+��