Trowbridge KtCEIVED
MAR 2 91013
NOTICE OF CLAIM FORM to the City o��Ta�ii����Vlinnesota
Minnesota State Statute 466.05 states that"...every person...who claims darrutges from any municipaliry...shall cause to be presented to the
governing body of the municipaliry within 180 days a,fter the alleged lass or injury is discovered a notice stating the time,place,and
circumstances thereof,and the amount of compensation or other relief demanded."
Please complete this form in its entirety by clearly typing or printing your answer to each questioa 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 prceess 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 dces 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_��Z,U� Middle Initial L Last Name T�o� br i r,(s�
Company or Business Name
Are You an Insurance Company? Yes�If Yes,Claim Number?
Street Address �3 27 �9—�'r�U i\h �� �
City 1�5�""��� ��`�' State ��aa'�� Zip Code�
Daytime Phone(�)��1-�5�.�.Cell Phone(�L).�,�y14�►b Evening Telephone(�)�" �S(o S
. �
Date of Accidenb Injury or Date Discovered Y�v9��' �� ?-o►3 Time am 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 are1 involved annd/or responsible for your damages.
� J i (l�o o �,Q o C 1 e 'i O� �n i a� er �.(a �.fi � r e
w �� 4r a �rt �t� srt� �A • 1 �O �
a. s e w 3 �a. � 5t a n �e t�
--4-e�c�... c r4�l 4 �� �!.� or c. C R�+t S��� �-A«�o.r�. �v [�.��- V e.�:c l�t A v�d� w�.n 'i�N o w�
!Y� �{' .
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
❑ My vehicle was wrongfully towed and/or ticketed ❑ I was injured on City property
❑ Other type of property damage—please specify
O Other type of injury—please specify ,
In order to process your claim j�a::„eed to include conies af all aaulicable documents. I
For the claims types listed below,please be sure to include the documents indicated or it will delay the handling of
your claim. Documents WILL NOT be returned and become the property of the City. You are encouraged to keep a
copy for yourself before submitting your claim form.
�Properiy damage claims to a vehicle: two estimates for the repairs to your vehicle if the damage exceeds
$500.00;or the actual bills and/or receipts for the repairs
O Towing claims: legible copies of any ticket issued and a copy of the impound lot receipt
O Other property damage claims:two repair estimates if the damage exceeds $500.00; or the actual bills
and/or receipts for the repairs;detailed list of damaged items
O Injury claims: medical bills,receipts
p�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 claun.
All Claims-nlease complete this section
Were there wimesses to the incident? Yes No Unknown (circle)
Provide their names, addresses and telepho numbers: r d, wl�
U11n �V�-•wta-t-- t- u� 11xS 'i.J^ S�S 1 — 4`f(�
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. Pleasep�as detailed as possible. If necessary,attach a diagram. 1�`W� �dvrr.� a✓l
l'l-t�c�ul��c.t. �k� wf—��-s�►-• ,ti..,-t�v—s�c�l-�.�
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.�A-+�1 �'-c/�✓ �1. �k�+'��v �4 YU�,�of-'-��'-1-iYz-� d-IC.��-'ar-t�u�
�---`"o�� --
Vehicle Claims-ulease comnlete this section ❑check box if this section does not annlv
Your Vehicle: Year Zo l I Make Va c�. �-vovl� Model Y.�C,�A-t✓v� l� � Dr• lM�� -
License Plate Number Z3 $ (9-�w State IM1� Color��t.e�2r�
Registered Owner C9�J E-T�w�'��
Driver of Vehicle ��j E•T/'��°�AJL
Area Damaged Q�I���'�.�- �i'�'an#- -hY�.}- R•r'M- � v�� 13t��`�'�-
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
I�r jurv Claims-nlease complete this secNon ,�check box if this section does not auvlv
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 � "�2� — �3
_�
Print the Name of the Person who Complete this Form: A tL� ` ,r o�..�� r ��g <
Signature of Person Making the Claim:
Revised February 2011
DDB
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discounttire.com
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GARY TRDWBRIDGE ��11 KIA M�iM 21
i��C GALVIN SOUL 154� ROBERT ST S
18°H�SE EXCLflI�t WEST ST fAUL MP! 55118
SA I NT PAUL MN 551 i 8 M I LERGE: i pHONE: 651-3Q+E�—�'31 t�
tH? 651-453-95fi5 00�1 CURT DANSIE
TQRQUE SPECS: 080 WORK QRDER#
.. , . . •
10943 hiRM 1 �'��514�R18 91V KIA H NflIVK00K OPTIMO H4L6 .�� 175.0Q� 175.��
WARRAiVTY: MILEAGE— 62�,0�� SEE REUERSE SIDE Ft1R W�RRANTY DETAILS
COMMEh{T: BDLT F�ATTERtV: 5-114.3
COMMENT: INFLATION F:3� R:33
8���4 �{Rhl i WASTE T I RE D I SF'OSAL FEE •�� �•�� �'��
g0�i9 NRI� 1 IIUSTALLATIOIV � LIFETIME SRIhI PRLAiVCIidG .�+d 16.�0 16.Q�0
$E,6E,E, NRM 1 LIFETIME ROTATI�N LIFETIME RE�RIRS INCLUDED .�b� •0� •��
Bb59� NRM 1 #70�'0K TQ-7� I�t\LHS TRMS REaUILb KIT ��� 7•�0 7•50
COMMENT: BOLT �'ATTERN: 5-114.3
COMMENT: APPDINTMENT: k3—����13 �:Q�� �'M
5ince you have purchased fewer than faur tir�es {or wheels), we will �o�int the new tires on the
rear of your vehicle far best safety and handling.
SUBTOTAL: L�1.50
TflX: 14. I4
T�TAL: L 1�.64
XXXXXXXXXXXX �473 hSASTERCARD: �15.64
TENDERED: �15.b4
Signature on file
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recydable paper
H� �1�TC} 1NH EE L & TR11V1 a a������"�'�
����f H�6�a� D�s:ri��stors, ln�
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NEW UNIVERSAL FACTORY FACTQRY ALLOY WHEEL CHROME WHEEL CHROME CHROME TRIM
WHEELCOVERS ORIGINAL USED ORIGIIiAL WHEElS CENTER CA� SIl4ULATORS ACCESSORIES ACCESSORIES
HUBCAPS &RIMS
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Ci�ck for :.3�ska,�ia.:�:i a;e:cs.u�sier�c�'tsi:z�ti+�:�.�.�.�4�Y caii�o or�er
REVietiv
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hank you for your order.Please keep this invoic�for your records.
ShiP To: Bii(To:
Name: gary trowbridge Name: 9a�Y��9e
Email Address: gfrow1@q.com Email Addr�s: gtrow1�q.can
Phone Number. 651-45�9565 Pho�Number. 651-453-9565
Fax Number. Fax Number.
C���y; par aide produds Company:
p��; 6800 otter lake rd. Address: 1322 galvin ave.
lino lakes,MN 55038 west st paui,MN 55118
Code Product Quan6ty Price/Ea. Totai
ALY74618U20 KIA SOUL Wheel Silver PaiMed � $169.95$169.95
�2�i29102K450 I�� �I `M�
F� Shipping:Free Shipping to Corttinentai USA Onty: 3Q•00
SaJes Tax: $1 i.68
Totai: 5781•63
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https://www.hubcaphaven.com/mm5/merchan�mvc?Session_ID=e7ebal0ed2c76a2fae424... 3/20/2013
' Fax fi54-�4�-�0�9 � � �
:� , � Toil free 8Q0-377�i25 Ni55Aitit
1470 50th Street Esst • Inver Grove iieights:MN 55077 vrwrr.futheraUto,com ��
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SBNIC@�I.HOUB � .'
Mo�day-Thursday:7:00 am-Midnight
Frlday_7:00 artt-6:00 pm �. a ' * =e: r�s s 3 ch�dule
Saturday:9:00 am-4:00 pm �"`��"=_�R-=�-
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���� 1,Z�243 MIGHAEL`WAGi+IER 727 ��478 03/1$/13 K105326447
GARY EVERETT TROWBRIDGE �� 2 8 RU � 30,660 / 10430
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1322 GALVIN AVE 11/KIA/SOUL/5DR WGN AT ! 05/12/11 > 51
WEST ST PAU L, MN 5 5118-203 7 y�LQ��p, sa.►a+�o�v-�►+o. �ooucno"aa�
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65I-453-9565 651-429-4513 Mo: 3066
P -------•-----------------------------------------------------------�-- The factory warranty constitutes a!! of the
- ° warranties with respecf to the sale of ihis
*** 3.750 Mi 1 e Servi ce at 3750 'k*'ti iterrc�items.The seNer hereby expressly drsdaims
lqFS Oi 1 & Fi 1 ter Chdnge W! Lube 2.OL 10l13 a�++varranries,either express or impiied.�nduding
any implied warranty ol mercharrtabrlrry or fifiess
CUSTOMER REQUESTS A 3.751C MILE SERVICE. for a particular purpose and the set�er neither
PREVENTIVE MAINTENANCE. assumes nor aufhorizes any other person to
PERFORMED A 3.75K MILE SERYICE PER CUSTOI�R'S REQUEST. assume for it any liability in connechon�nth the
sale of this i[em/ttems.
ARTS------Q'fY•--FP-NI�ER---------------DESCRIPTION------------- UNIT PRICE-
# 1 1 26300-35503 FILTER ASSY-ENGI 6.50 6.50 �„ �� ', ���°
JOB # 1 TOTAL PARTS 6.50 ; :,r�F��� , �
JOB # 1 TOTAL LABOR & PARTS 17.45 - -
----•------- ---- ------------------ - - -
....---- , � - . . . __
�e,_� _ --�Y=� v �j������ ����_- ,: __ .
�.,_.��
CUSTOMER STATES TF�ERE IS A NOISE COMIN6 FROM 7HE FROF(T " - , `. � '"� �,
T
� PASSEN(iER SIOE Mk1EEL AREA SINCE NITTIN6 A POT HOLE. PLEASE ` "�' "
CHEpC AND ADVISE �»°s� .
RI(�iT FRONT MAiEEL BEA(tIW(i • .���'° � -
REPLACED THE R/F WiEEI BEARING ,��- �� _
_: �• �� r �: �
ARTS------Q1Y---FP-t�ER----•----------DESCRIPTION----------•---------UNIT PRICE- - >� ' I
� 2 1 51720-2K000 BEARING-FR WiEEL �•� �•00 `,:'; , ,,,
JOB # 2 TOTAL PARTS $5.00
JOB � 2 TOTAL LABOR 8 PARTS 254,00 t
----- ----- ------ ----- ---- ------------- ----- --- --- - --- -
---- Hc�r�fied are you w�th
,,� FF� �.�� � � , - :�� >. •
CUSTOMER STATES HE HIT A PQT HOLE AND TtE RIM IS SENT. WOl1LD ` Lt� ER NtSSAPI-KIA?
LIKE ESTIF4ATE ON REPAIRS. � - �
5417.43 TO REPLA�CE TFIE R/F YHEEL =��--'--°- _
ARTS------Q1Y---FP-I�IBER---------------DESCRIPTION--------------------UNIT PRICE- ,� �
JOB � 3 TOTAL PARTS 0.00
JOB # 3 TOTAL LABOR 8 PAttTS 0.00 r ��:. _d ,- t�: � ;'��e�...
--------------------------------------------------------------------------------•-------------- .�. ., , . , . .
�t= � x. �':.��"�..�-� ,�:3:'3:;i i;'
.0.6. & Si1PPLIES--------------------------•---------------------------------
� 1 1.0 OIL BY Tt� SERUICE @ 10.500 /UNIT TOTAL - (�G 10.50 �i�� f'�=+=1��='`•`L%'`.`ORlG1N�`iL
��ai.._.���+ 9�rT�JaVLESS
ISC----•-CODE--------DESCRIPTION-------------------------------CONTROL NO--------- C�'-?r;;.:';S��.::r�ClF�€D
#A $S SHOP SUPPLIES 1.75
# 1 I183 INTERNET 524.95 OIL CHANfE TpTp� _ MISC -1.25 �����������'
STIMATE---------------------------------------------------------------------------
CASH FOR YOUR USED YEHICLE
U$TDlER F€RE$Y qCKNOWl.ED(�S RECEIVIIi(i vour car cou�d be worth more
� than you think!Md we'0 buy it
ORI6INAL ESTIMATE OF 5290.97 (+TAX) (even if you don't buy from us)! �
OMMENTS---------------------------------------------------------------------------- �
CC APPOINTMENT CREATED 2013-03-18 08:07:OOAM TAKEN BY S we'll quote ANY veti�cle.
� �Y regardless of condition.If you
accept,you'il waik away with the cash_You'li
• never find a faster,simpler or safer way to sel!
� your car.Visit our Sales Department for your
no-0bligation appraisal or learn more at
. IutUerauto.00m
PAGE 1 OF 2 CUSTOMER COPY (CONTINUED ON NEXT PAGE] 1031 pm •�CLUDES SAtVAGED VEHJCLES
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