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Mueller kFCF4�I�D � MAY 02 7013 NOTICE OF CLAIM FORM to the City of Saint��l,�i�ota 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 municipaliry 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 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 Y ' 1��u"�/✓ Company or Business Name Are You an Insurance Company? Yes o If Yes,Claim Number? Street Address ��v � � �• �v v City �� l^' State�I�1 Zip Code �v� �� Daytime Phone��-��.�Cell Phone( ) - Evening Telephone(_) - Date of Accidend Injury or Date Discovered � 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 ity of S 'nt Pa 1 or its empl ees aze inv lv nd/ reC�s/pi�sibl��r your d S ages. , O l� �i V� �- -Y �,� G` ° `f/��13 w �, � -Q tt Please check the box(es)that most closely represent the reason for completing this form: �� 1 - ' ❑ My vehicle was damaged in an accident ❑ My vehicle was damaged dunng a tow �vehicle was damaged by a pothole or condition of the street ❑ My vehicle was damaged by a plow 'O My vehicle was wrongfully towed and/or ticketed ❑I was injured on City property ❑ Other type of property damage—please specify 0 Other type of injury—please specify - -- In order to process your claim vou need to include conies of all anplicable 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 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 comnlete this section �� Were there witnesses to the incident? Yes ��v9/ Unknown (circle) Provide their names,addresses and telephone numbers: Were the police or law enforcement called? Yes � Unknown (circle) If yes,what department or agency? Case#or report# Where did the accident or injury take place? Provide street address,cross street, intersectio}�,n1a of park or facili , closest landmark,et . Please be s etailed as p ssible. If necessary, attach a diagram. W ��"'��2.-� � �� Please indicate the amoun .yo are seeking in compensation or hat u wou d like the City to do to resolve this claim to your satisfaction. ��O�-vf �. Vehicle Claims— lease com lete this section ❑check box if this section does not a 1 Your Vehicle: Year Make Model � License Plate Number ��7rW1 State Color Registered Owner � Driver of Vehicle Area Damaged � -E'ir� '-��" �� ✓�'� �'2� City Vehicle: Year M e el License Plate Number State Color Driver of Vehicle(City Employee's Name) Area Damaged Iniurv Claims please complete this section �dheck box if this section does not avnlv How were you injured? What pazt(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. Submittin a alse claim can result in prosecution. Date fo was completed � `� �3 g f � I/�'1 �,-el (-�,r Print the Name of the Person who Completed t s Form: Signature of Person Making the Claim: Revised February 2011 LEHMAN'S GARAGE BLOOMINGTON Page 1 F I N A L B I L L MUELLER, AMY Printed 04/05/2013 3:44 PM 171 AMERICAN BLVD WEST Estimate:230125 Created04/03/2013 BLOOMINGTON, MN 55420 Repair Order: 230125 (952) 888-8700 ' Customer: Insured Vehicle: Insurance Com an : I MUELLER, AMY HYUN ELANTRA GLS 4D C - PAY I , 200 E 10TH. ST#300 YEAR: 2004 Claim Number: C-PAY ' � ST. PAUL, MN 55101 License: UNKNOWN 'i Work: (612) 729-3504 Mileage In: 1 � , Mileage Out: 1 '� Drivable: No ' Written by: LANGLAND, RANDY L Labor Paint Item Price Ext. Price Units Units PT BT * 1 REMOVE/REPLACE 15"STEEL WHEEL 77.18 77.18 CC" * 2 SU mount and balance * 0.2 M' " CC* - *-- 3 REN10V€JREPLACE valve stem 2.01 * 2.01 �__. ___A * CC" * 4 REMOVE/REPLACE tire 195/60R15 88H CAP 1A 69.10 69.10 A " CC* SPORT (vc827) I FINAL BILL SUMMARY , Regular Supp Total Regular Supp Total ', Other parts: $79.19 $69.10 $148.29 Parts Total: $79.19 $69.10 $148.29 � � Labor Total: $19.56 $0.00 $19.56 I I Reg Supp Tax: $5.76 $5.03 $10.79 ' Units Units Rate Amount I! Mechanical : 0.2 0.0 $97.80 $19.56 � Total: $178.64 ' SUBTOTAL SUPPLEMENTS TOTAL MUELLER, AMY PAYABLE REPAIR TOTAL $104.51 _ $74.13____. --_�_.___.�1ZH-64 I , Labor Dept Codes:B-Body D-PDR I-To Go E-Electrical F-Frame GGlass M-Mechanical P-PaiM S-.To Come In PT-Price Types: O-New(OEM);A-New(Non-OEM);V-Used Parts;R-Reconditioned;Space-No Type L-Labor,M'-Material;H-Hazardous;S-Storage;T-Towing;U-Sublet BT-Billing Types: No Code-Insurance Charge;CC-Customer Charge;BT-Betterment;AP-Appearance Allowance PD-Prior Damage;NC-No Charge CCC Pathways Data,Copyright 1995 CCC Information Services (")Indicates Estimator Judgement.Underline Indicates Supplement. The elements of data used to calculate this Estimate were obtainetl from a CCC Database. ` ` Calculations of the Estimate are performed by a computer program created by YADA Systems,Inc. 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