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APR 05 2013
NOTICE OF CLAIM FORM to the City of Sai CITY�L��esota
Mlnnesota State Stat:ete 466.05 states that "...every person...wl:o claims damages from any municipality...shall cause to be presented to the
governing body of the municipality within 180 days after t/Te 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 both pages completed. If something does not apply,write`N/A'.
SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK,
15 ST LLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
,� � �
First Name Middle Initial�Last Name��'1'3 � ''�'�
Company or Business Name_
Are You an Insurance Company? Yes No If Yes, Claim Number?' �
Street Address
City State Zip Code
Daytime Phone (_� - Cell Phone (_) - Evening Telep�one���-���
Date of Accident/Injury or Date Discovered � � � � / � Time �J �� m/�
-��,��
Please state,in detail, what occurred(happened), and why you are submitting a claim.Please in 'cate v�y or how you
feel th ' of S 'nt P 1 or its employees ar involved and/or resp nsible for ur damages. +/� 1J
t'i �i'''- 9"' � -
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Ple se che� �box es tT�fa��ost closely r r�"s'ent the reaso or com letin is'�o . d ,ff !''�
❑ My vehicle was damaged in an accident ❑ My vehicle was damaged during a tow �a��j�,
'�,'My vehicle was damaged by a pothole or condition of the street ❑ My vehicle was damaged by a plow ,��
u Iviy vehicie was wrongfully toweci and/or ticketed � ❑ 1 was in�ured on City property �
❑ Other type of property damage—please specify "(f�j�
❑ Other type of injury—please specify ��� p
on/lc•
In order to process your claim vou need to include copies of all anplicable documents. r�r"`�
7
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.
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 exceeds$500.00; or the actual bills
and/or receipts for the repairs; detailed list of damaged items
O Injury claims: medical bills,receipts
O Photographs are always welcome to document and support your claim but will not be returned.
Page 1 of 2—Please complete and return both pages of Claim Form
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims—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#ar report#
Where did the accident or injury take place? Provide street address,cross street, intersection,n park�r facility,
closest landmark, etc. Ple se be as detaile as possible. If necessary, attach a diagram.�`� d��
a. •*C 11/'�i �. �.� Cl...
Please indicate the amoun you are seeking i ompe s ion or w a u would like the City to do to so�ve this claim
to,�jour tis�action. � �.
T l��.
�Vehicle�laims— lease com le this sec ' n � check b x if this section, es not a l�
Your Vehicle: Year ` i ake Model
License Plate Numbe n State Color �
Registered Owner � "
Driver of Vehicle �
Area Damaged - / � .�'�
City Vehicle: Year Ma e odel
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Injury Claims—please complete this section �check box if this section does not applv
How were you injured?
What part(s)of your body were injured?
Have you sought medical treatment? Yes No Planning to Seek Treatment(circle)
When did you receive treatrnent? (provide date(s))
Name of Medical Provider(s):
Address Telephone
Did you miss work as a result of your injury? Yes No
—_ _ When did y�u 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 � '" � l � ` �
Print the Name of the Person who Completed this Form: �.. � ..�
� �
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Signature of Person Making the Claim:
Revised February 201 1
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TIRE
discounttire.com
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�,�;. ':•4;^;�;.::�.A,,,,�-� :�� `.�;r ;;.ti,.�'-;.� � LIMITED WARRANTIES
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�N�e,Arai�rP�� �'������ �` �C�r �jir�{'��S 1�.���i�'�r��J.4 •� t : �
�,.;>�� �. `�% � „ '� ,� � Discount Tire and Ameriea s Tire Stores
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���� CERT/F/CATE � ELIGIBILITY-These Limited WP rranties apply g all own�s of die cire using
.�s'
�✓P'a it in non-commercial service,exce t for d�e Milea e Warran which is limited
�?:�- ��>_; ro the original purchaser.
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��r� FOR REPAIR REFUND OR REPLACEMENT ����t�
'y,. + `�°��';. TO MAKE A CLAIM- Present your tire(s)and original sates invoice[o any
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-„ Discount Tire or America's Tire Store.To Locate a store you may call 1{888)774-
:;�.,.n For a fee collected at the time of the onginal tire purchase or for a fee collected to subject �'� 6560,or visit the Discount Tire web site at www.discounttire.com.The vehicle
%� ' other tires to the terms of this certificate, Discount Tire or America's Tire stores will on which the tire was used must be available for inspection.You will be asked
� refund the purchase price and the sales tax,if any,on any tire covered in the event of a to complete the customer portion of die adjustment claim form.
:-� failure due to workmanship and materials or a non-repairable road hazard for the service ti�
�;'r�:� of the original tread down to 3/32 inch remaining or 3 years from date of purchase �.L�� WARRANI'Y COVERAGE
:'a�'.->'- whichever occurs first.Upon refund or credit of sales tax,customer hereby acknowledges ___.:W,'
�•.. �-.;>� New Tires-Workmanship and Materiats-If our rxamination shows
��jy,y,,,,_ by actual signamre or electronic signature capture such credit or refund.This additional that a pas.senger,SUV,or light truck tire covered by tliis warranty has become
?� acknowledgement satisfies a technical requirement in the sales tax stamtes and/or imserviceable due to a workmanship or materials defect during the service
���.;=-, regulations for many jurisdictions that a signed receipt must be obtained upon the refund �a,�.\�� down to 3/32 of an inch,it will be replaced on a pro rata mead wear basis.
yk:._�._ or credit of sales taxes.At die election of Hie purchaser,we will sell a reptacement tire .*L„�,�.�
��`'.:=.,_ °- New Tires-Road Hazard(if a �IicaUlc)-If our exami�ation shows tliat
to the purchaser at the original price paid fer the dar,rrged cire,ph�:thP rPquircd sales =.: ��
, � tax.In the event the covered tire is discontinued or unavailable,a tire of similar value will d passenger,SUV,or light tnick tir�cav�r�ctbp this warranty has become
unserviceable due to a normal road hazard(i.e.,non-repainble puncture,cut,
> be substimted. snag,bruise,or impact break)during the service down to 3/32 of an inch,it
� � ` ''" will be re laced on a ro-rata tread wear basis.
If in our opinion,the[ire can be safely repaired,we will do so free of charge.The cost of P p
this certificate is set forth on the receipt issued for the purchase of tire<s). +.\ New Tires - Milea Wanan <if a hcable) - [n addition to the
o - 4�t^ Se h' PP ..
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�`�.� ..'�ti;:;�� warran[ies above, every mileage wananted passenger, SW or light truck
:;�= This cettificate will be honored at any Discount Tire or America's Tire stores.This certificate %r�` tire is warranted to the original purchaser for the specitied number of miles
��.:. �-- does not cover damage caused by collision,vandalism,chai�damage,mechanlcal defects �.��.�� ��F�read wear and a�ainst normal road hazards for the same miteage (if
w�� of the vehicle or willful abuse.No other property damage or consequential damage of any s✓� �p�iicable).If our examination shuws chat the tire covered by this warranty
�y, kind is covered by this certificate. " .,�`�.''A�a has wom down to its tread indicators before giving the specified number
�r' ..,�`f7f
-`' There will be additional charges to purchase a new certiticate for a replacement tire and >�i` of miles of nontommcrcial scrv�cc on the passcnger,SCR�or fight truch on
.r,;�� � �;� which it was installed,rt will bc replaced on a pro-rata milea�e basis.
to balance a replacement tire. �,.,7
��-�- - '4r'%'��� A1'V/Tniler Tires - [f our examinatiun shows that a trailer or ATI�'tire
� s By redeeming this certificate,the cusromer relinquishes the right to any manufacturer s
�;� : -��.y5yi� covered b}�this warranty has become unserviceable, odier than by a road
s"�•. = wairanry that may apply,and Discount Tire or America's Tire may claim for its own benefit - %:;.f�y� ��17ard, during the three year period following its date of purchase,it wil]
� ' an such manufacturer's warran
��r� 7 �Y �Q:� be replaced based on a charge of 33%per year or part thereof of the original
• �'�! purchase price.
� • � - • • -3�
S�n� CALCULATION OF REPLACEMENT CItARGES - Tires are replaced
� -��� under these limited wananties with a comparably priced new tire at a pro-rata
����` cost to the customer.Tread wear is pro rated on the basis that the tire is wom
��,',}��_ D'��0���� °ut when the tread is worn down to 3/32 of an inch remaining[read groove
depdi or to the tread wear indicators on ures containing them.Tire replacement
�,*a►% '� cost is determined by muluptymg the original cost of the tire by the percentage
�I TIRE , f
� �� of vead used.For example,if the original tread was 11/32 of an inch,and the
��'= tire has 5/i2 of an inch of tread remaining at the time of reptacement, the
replacement cost will be 75%of the originaL cost(Q 1/32-5/32)/(I1/3�3/32)
y��,� ,�;��� x 100). The replaceme��t cost For mileage warranted tires is prorated at a set
1�a*� �',,�;: charge per 1,000 miles driven.F.E.T.and state tares are added to the replacement
_'� � � t � [� f�1 1 1 �h<. cost.Additional charges for moundng and balancing apply.
�(��� �����t I�l� �1 1�1 �1�1� If�1 IN II�A HF 11 �� 1 14
r'_,��� , � 1 ��' � � R , a d, ,,R�,� ,,�,, „ ,( ,,��.a
1� O� e t i �i ti �i PJY• I! � ��♦ r��SYJ��� ��Jlr�� ..,��., � �'e��a �i� ,�7' rp�y°S�%
_ =� } +.•- ,: ::- = __ :_ ti=,r ��s,� :ak�'.� I NOT C VE c+e warranhes o nat cover
' ��; = - _-- _� ' � �<�",; � � � � �_�� TEMS O RED-Th•: d
The cost of any tire includes any wheel weights used in the balancing of the tire. • Use in commercial service such as commereial tnick racing,streec
sweepers,off-the-highway tar.i,limousine,or similar service(however
cummere�i:d service does not indude use by the owaer as transporta[ion in
- - . _ ._. .._ - . hisi he:'r:.�uia..:adc or i,usir�;;s): — - . - --,-- --—
TI PS TO I M PROVE TI RE • ndmage,destrucuon or failure diie to accident,fire,or vandalism;
• Irregul:�r or premature trrad wear caused by improper inflation,
M I L EAG E A N D SA F ETY misalignment,imbalai�ce of wheels or worn out shock absorbers or bcakes;
• Damage or failure due tu non-tire causes such as being mn ftat,mechanical
conditiun oF[he vehicle,cuts frum rims or chains,or any wi(Iful abuse;
/ • Prublems rel:ucd[o die appear,mce of[he tire after the firs[10%ofwear.
ROTATE TIRES REPLACE
every 6,000 to 5,000 miles or when worn-out tires when built-in wear bars OWNER'S DUTIES-It is the owner,rrspo�s;b�i�ry«�:
necessary to equalize treadwear. appear across the tread surface. • See tn,,<<i,e r�res�re oprrared ac prope���nnac,�n,press«re a�a iodds;
�REBALANCE �� REMEMBER TO RETURN ' PaY�PPlicable taxes and dealer services such as mounting and balancing;
every other rotation to promote even to any Discount Tire/America's Tire store • Ren�rn�ne adj��scabte hrr��d�ompiece me��scomer pomon ot che
adjustment claim form.
tire wear and a smooth ride. for a tire inspection.
DURATION OF COVERAGE-"Chese warran[ies expire three(3)years from
�MAINTAIN AIR PRESSURE � e�e date of p��r�t�dse. �
as recommended by the vehicle or tire �'" CONDITIONS AND EXCLUSIONS - These limited warranties are die
manufaeturer.Check your air pressure at least �' � � exclusive warranties of Discoimt Tire or America's Tire srores,are in lieu of the
once eaeh month when tires are eooL � � warranties of the manufacturer,and sec forth the exclusive remedies avallable to
� � the tire user In the event that the trrms of an applicab(e manufac[urer's wa�ranty
�MAINTAIN ALIGNMEN7 exceed the protection given under these wananties,Discount Tire or America's
�+.w Tire stores w�ll honor thosc tcrms ll�scount Tirc or Amcrica's Tirc may ctaim
(Front&Rear)replace worn suspension parts. '' fo�,cs own beneec�np sue h m:mufacturer's warranry.These limited warranties
� �'i1R l.� �ECK��1� do not provide compensation for any consequentiat, special, incidental or
� PLEASE DO NOT USE ���� contingent damages. Some States do noc allow the exch�sion or limitation of
_�..��:�����.�..........,.a,.�.� —� w=w�A��
incidental or consequential damages,so the above limitation or exclusion may
�aded a�qepd�ai
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Auto Rescue` �
feedbockC�inmanscrutorestue.com
Date �_ �—f L C. � f ,r Motor Club
"�.,__
P.O.Number �� � �' �' Name r ��
�. . .-�-� ,� // °i�
Member Number Phone l �/a`
Address ���(// ✓ City �'
�
L c�tion&Service Information
Apt./Business Building# Apt.# Gate Code
Location Notes
Call Time AM ETA Start AM Finish AM
PM PM PM
❑ Lock Out ❑ Jump Start ❑ Fuel �µTire Change ❑ Tire Air ❑ GOA/ NSR
en e��- � �
Year,Make,Model �-� �" �� Color ,� LP# State
� �
� � ' ``�' � � ��` Odometer
� l RAtea�e Section- ar�of s upon artivaf
Passenger poor
❑ Previously attempted opening by another party-Damage to Door/ Doorframe Driver poor
Passenger poor
� ❑ Worn/Damaged weather stripping-Window Broken/Scratched- Tint Scratched Driver poor
Passenger poor
❑ Non Functioning Door handle/Door lock-Missing Door Handle/ Lock Driver poor
Notes
I have requested that my vehicle be unlocked using lockout tools and/or keys. I understand that there is a possibility of
damage to the door,door frame, weather stripping, locking mechanism,glass,or air bags when using these tools and thereby
release the person(s)and/or company of all responsibility, both civil and criminal, in a court of law. I will accept full responsibility
; should an dama e occur. InitiaL•
General Vehide Conditlon°
. Jump Start: ❑ Battery cracked/Broken ❑ Cables and/or Clamps/Loose/Corroded/Broken/Missing
Tire Change: ❑ Vehicle/Rim Damaged ❑ M�ssing/Damaged Lug Nuts ❑ Missing/Damage, uds ;
Customer understands that the spare tire is design d to get the vehicle to a tire repair facility,as soori.as
ossible,and the wheel fasteners lu s should be retor ued before drivin mare than 40 miles.Initiia. �' - -
�..
Fuel Delivery: ❑ Fuel Door Missing/Broken ❑ Fuel Cap Missing/ Damaged
Notes I
F �OAlNSR
GOA/NSR Authorized by: Reason:
w Method Of,Pa ment forRetail Non Motor Glub calls ��
; Cash Visa MC AMEX Discover DL#: ST
ti
CC#: Exp: Approval#
� Autharized'Sls�nature °
I have had the opportunity to inspect my vehicle and have ound it to be in good working order, Gas(+)
and that no damage has occurred to the vehicle including doors,door frames, paint,glass, Sub Total(_)
,; window ti rims, lug nuts/studs, body or underbody as a result of the service.
I also know ge that all equipment such as jacks, lug wrenches, lug nut keys, and special
, tools longing t e or the vehicle have been returned in good working order. Customer Pay(-)
Initial:
� l?Q/IIf ou fo� usin Auto Rescue �nvoice,4mount(_)
Z 3 5�2 g 2 CUSTOMER