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Reinsberg � RECEIVED APR 02 2013 NOTICE OF CLAIM FORM to the City �,F�n���Iinnesota Minnesota State Statute 466.05 states that"...every person...who claims damages from any municipality...shall cause to be presented to the governing body of the municipality within 180 days after the alleged loss or injury is discovered a notice stating the time,place,and circumstances thereof,and the amount of compensation or other relief demanded." Please complete this form in its entirety by clearly typing or printing your answer to each question. If more space is needed,attach additional sheets. Please note that you will not be contacted by telephone to clarify answers,so provide as much information as necessary to explain your claim,and the amount of compensation being requested. You will receive a written acknowledgement once your form is received. The process can take up to ten weeks or longer depending on the nature of your claim. This form must be signed,and bqth pages completed. If something does not apply,write`N/A'. SEND COMPLETED FORM AND O�HER DOCUMENTS TO: CITY CLERK, 15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102 First Name �;-`�`�-� Middle Initial � Last Name�1"��'���-��'�`��- Company or Business Name Are You an Insurance Company? Yes No If Yes,Claim Number? � C`�{-%,� Street Address � � � ) � ' �� ,,. { � � ' �� U� City 1�)C� ��� � �`'^ State ���� Zip Code , (_` Daytime Phone(���� )�5�- �����Cell Phone( ) - Evening Telephone(���)�CG� �l°��"� t�,� 1,, � � Date of Accidend Injury or Date Discovered 1 �l Q'�C�"1 � Time �' am pm Please state,in detail,what occurred(happened),and why you are submitting a claim.Please indicate why or how you feeLthe City of Saint Paul or its emplo ees are involved and/or es nsible for your damages. . a = �v� � a° � ' � P • CQ� � i r� Gt b� a.u-� � Si /°L � 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 durine a tow � My vehicie was damaged by a pothole or condition of the street J 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 ❑ Qtrer ty�e of ir.ju:y—pl�ase specify - --- In order to process your claim��ou need to include couies 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 retumed and become the property of the City. You are encouraged to keep a copy for yourself before submitting your claim form. $�Property damage claims to a vehicle:two estimates for the repairs to your vehicle if the damage exceeds $500.00;or the actual bills and/or receipts for the repairs O Towing claims: legible copies of any ticket issued and a copy of the impound lot receipt O Other property damage claims:two repair estimates if the damage exceeds$500.00;or the actual bills and/or receipts for the repairs;detailed list of damaged items O Injury claims: medical bills,receipts O Photographs are always welcome to document and support your claim but will not be returned. Page 1 of 2—Please complete and return both pages of Claim Form i Failure to complete and return both pages�will result in delay in the handling of your claim. All Claims—please complete this section Were there witnesses to the incident? Yes No Unknown (circle) Provide their names,addresses and telephone numbers: Were the police or law enforcement called? Yes No Unlrnown (circle) If yes,what department or agency? Case#or report# Where did the accident or injury take place? Provide street address,cross street,intersection,name of,park or facility, closest landmark,etc. Please be as detailed as possible. If ne essary, att ch a diagram. �eh,vts6�-t i'a�k-�-k �:��� v��,�a� a.�� �� ; ►�� s��au d �q� —_ Nnr�,aF� �a,�1 fcac� �,� 9 e Please indicate the amour.t you are seeking i compensation o what you would like the Cit to do to resolve this claim to your satisfaction.� ��S �—" -�C� � ('cJ�-�- O� �iv2- �j�(P C�v� ��5fa L(afi Gv� Vehicle Claims— lease com lete this section ❑ check box if this section does not an 1 Your Vehicle: Year �.t�UFS Make U Model License Plate Number ' C State �' Color Registered Owner v�s `�l-�" �'`S '(' Driver of Vehicle a Area Damaged G i �rQ- City Vehicle: Year Make Model License Plate Number State Color Driver of Vehicle(City Employee's Name) Area Damaged Iniurv Claims please comqlete this section �check box if this section does not avvlv How were you injured? What part(s)of your body were injured? Have you sought medical treatment? Yes No Planning to Seek Treatment(circle) When did you receive treatment? ' (provide date(s)) Name of Medical Provider(s): Address Telephone Did you miss work as a result of your injury? Yes No When did you miss work? (provide date(s)) Name of your Employer: Address Telephone ❑ Check here if you are attaching more pages to this claim form. Number of additional pages By signing this fornz,you are stating that all information you have provided is true and correct to the best of your knowledge. Unsigned forms will not be processed. Submitting a false claim can result in prosecution. Date form was completed �^�� � � Print the Name of the Person who Completed is Form: � � ��n S�-e- Signature of Person Making the Claim: Revised February 2011 � . �.�_ � ' / � Savinjgs Made Simple CLUB MANAG�R CHAD BISSON ( 651 ) 702 - 797Q NOODBURY, MN., MN , 11/10/12 10i43t63a1s6312�042 26q1 V I�hIBER 101-�***�**x2778 THANK Y�U, DAWN REINSBERG TMA ITkMS FULLUI+f ORDER NUMBER O(k18�70015458 5 TIRE INSTAL 15.00 N�� 5 TIRE INSTAL 15.00 N 5 TIR� IIVSTAL 15.00 N 44720�tp205/5�216L 110.13 T� 4472Q8 P205/5!�R16 110.13 T �7� ���16 110.13 T q47�$ P��16 110.13 T TMA ITEINS COMPL�TE E 245291 $50 INST�SArT� 50.pp-N Sl1BTUTAL 450.52 TAX 1 7.125 X 31.39 TUTAI. 481.91 � ECA'CI-ECK TEI�I q�1.91 I CIiANGE [Xk: '0.00 When You Pay by'check, you authorize , us to use its infurmation to pracess an Electronlc F4rx�is Tr�nsfer (EFT) or a c�aft drawn cxl your accc�mt, or to process the paynent as a check. If paynent is returnad unpaid, you autF�i ze co)1 o�t i on of ycx���payment and the Return Fea below by EFT(s) or draft(s) c�aYm on your account. Call 888-905-3388 with any questions RETURN FEE AMOUNT 30.00 Visit samsclub.caA to see your savings # ITEMS S�LD $ TC# 3431 0414 0051 2244 8254 0 IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIwIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII ' WE VALUE YOUH OPINION WE WANT TO KNOW AF30UT YOUR SHOPPING EXPERIENCE TODAY AT SAM'S CLUB Please complete a survey about today's club visit at: hMp:f/wvwv.survey.aamsclub.cor� ONE OF FWE s1�,000uSRATMS CLUB SHOPPI�NG CARDS You must be 18 or older and a legal resident ol the Unifed States to enter. No purchase necessary to win. To enter without purchase and for o(licial rules visit: www.entry.s urvey.sam s club.com Sweepstakes period ends on the date shown in Me oNicial rules. Survey rtwst be taken wiMiin 7W0 weeks ot today. Esfa encuesta tambibn se encuentra en espaPSol en la pipina de Internef. CLUB# 06312 9925 HUDSON ROAD WOODBURY, MN 55125-0000 US (651)702-7970 See cashier for michelin re istration card or visit www.michelin.com to re is�er our tires DATE NAME 105 3 COUNTY ROAD F PHONE# 485700 15458 11-10-2012 REIIVSBERG,DAWN DANBURY,WI 54830 (715)656-4362 YEAR MAKE MODEL COLOR 2008 CHEVROLET COBALT Dark Blue LICENSE ODOMETER MEMBER ARRIVAL TIMIE SERVICE COMPLETED TIME 529EKC 142478 2012-11-10 10:44 AM 2012-11-10 02:21 PM Service Description Service TIRE INSTALL PACKAGE [4@ i5.00J Whitewall-N/A I 60.00 -Tire Pressure-Drv Front-CHECKED,30 -Tire Pressure-Drv Rear-CHECKED,30 -Tire Pressure-Pass Rear-CHECKED,30 -Tire Pressure-Pass Front-CHECKED,30 -Valve Stem-Pass Front-COMPLETE -Valve Stem-Drv Rear-COMPLETE -Valve Stem-Pass Rear-COMPLETE -Valve Stem-Drv Front-COMPLETE -Balance Accepted-Pass Rear-COMPLETE -Balance Accepted-Pass Front-COMPLETE -Balance Accepted-Drv Front-COMPLETE -Balance Accepted-Drv Rear-COMPLETE -New Tire-Pass Frent-COMPLETE-DOT:APOFAE3't t 712 -New Tire-Drv Rear-COMPLETE-DOT:APOFAE31 1712 -New Tire-brv Front-COMPLETE-DOT:APOFAE31391 I -New Tire-Pass Rear-COMPLETE-DOT:APOFAE31391 I -Dispose Tire Accepted-Pass Rear-COMPLETE -Dispose Tire Accepted-Drv Rear-COMPLETE -Dispose Tire Accepted-Pass Front-COMPLETE-Dispose Tire Accepted-Drv Front-COMPLET -SAMS Battery Check-TESTED GOOD � LUG TORQUE � Drv Front 100 FT-LB Drv Rear ! 100 FT-LB Pass Front l00 FT-LB Pass Rear 100 FT-LB TREAD DEPTH Drv Front-10/32 Drv Rear-10/32 Pass Front-10/32 Pass Rear-10/32 Merchandise Description Quantity Unit Price Merchandise P205/SSR16 91 V TRDT 1 1 10.13 I 10.13 P205/SSR16 91 V TRDT I 1 10.13 1 10.13 P205/SSRl6 91 V TRDT 1 110.13 110.13 P205/SSR16 91 V TRDT 1 110.13 1 10.I 3 I • Member Comments Total (Excluding Tax& Govt. Fees) 500.52 Technician Comments DISCLAIMER 1 hereby authorize the stated repair work to be done along with the necessary material and hereby grant Sam's Club perrnission to operate the vehicle�erein described on streets,higl�ways or elsewhere for the purpose of testing and/or inspection. An express mechanic's lien is hereby acknowledged on above `vehicle to secure the amount of re airs thereto. SAM'S CLUB IS NOT RESP�NSIBLE FOR LOSS OR DAMAGE TO VEHICLES OR ARTICLES LEFT IN VEHI�L�S IN CA$,E OF FIIZE,THEFT OR ANY OTHE AUSE BEYOND SAM'S CLUB CONTROL. BqTTERI'TECHNICIAN:Rl'AN 1924 i COMMON TECHNICIAN:Rl"AN 1924 QUALITI'CONTROL TECH:ERIC 1425 SALES ASSOCIATE:REGIS 2G41 TIRE TECHNICIAN:RYAN 1924 11-1�-2�12 MEMBER SIGNATURE DATE HAVE YOUR LUG NUTS RETORQUED AFTER THE FIRST 50 MILES.