Cusick : ����ivE�
MAY 02 2013
NOTICE OF CLAIM FORM to the City of�� �i�,�i�finnesota
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 municipnliry 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 aITY HALL, SAINT PAUL, MN 55102
First Name � 1 Middle Initial�Last Name �u�� LI� —
Company or Business Name —
Are You an Insurance Company? Yes� If Yes, Claim Number?
Street Address ( U('� �S C�l�I C1 7'11���
i �p �,t / J D �
City �� ���I State t�l;V Zip Code��
Daytime Phone(���)�-�1j�i�.Cell Phone( ) - Evening Telephone(�)�_-�
Date of Accident/Injury or Date Discovered �'��" ��Ti��e�4t1�� � 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 P ul or its employees are involved and/or responsible for your d mages.
�t1L e Cl 'H1 , `�
S
S � '
5
. �
c -
S � r. ,
Please check the box(es)that most closely represent the r�ason for completing this form: �C��l aY1 G1[�I��
❑ My vehicle was damaged in an accident ❑ My vehicle was damaged during a tow ���
�J 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 ticke[ed ❑ 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 tQinclude copies of all applicable documents.
For the claims types listed below,please be sure to inclu�e the documents indicated or it will delay the handling of
your claim. Documen[s WILL NOT be returned and bec}�me 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—ulease 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 Unknown (circle)
If yes, what department or agency? Case#or report#
Where did the accident or injury take place? Provide street address,cross street, intersect n, name of park ar facility,
c osest�landm rk, etc. Please be as detailed as possible. If necessary, attach a diagram. �'�_`'L`� �.L`�'t
� ���
Please indicate the amount you are seeking in compensat on or what you would like the City to do to resolve this claim
�
to your satisfaction. �t UI 1-�,�'�
Vehicle Claims— lease com lete this section � c.heck box if this section does not applv
Your Vehicle: Year�nDa Make Model
License Plate Numb State��Color�IdGlt
Registered Owner � C S� �
Driver of Vehicle `
Area Damaged L
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Injury Claims please comqlete 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 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 n�-� � � ���
Print the Name of the Person who Completed this Form: J��'�l�-�'� l.,U sl C l�
5ignature of Person Making the Claim: »��f-�� -
� Revised February 201 I
�, ,� ��� �-L�e, , �c� �►�r�m�, �- �� �,�, �Ci- �-,
u� � , l
r'� r����l a l % ��n�� �le,e�e� '� b� ('e a ���c�l, �Jl�ic,� u�5
� �
� b �n� e u��t l�ec;����, , .
�un-�l��mc� arr U� ��%
�, ��{-�,� Z �i� '�'1C, �JC 1����� f��'�� � � C� U� r
�h � �� r -
�ubli�, l��r �CS, S�� �F,�' ���►�e�a� ���a�v� 1���; a�
� ��� ` � 1�i� �i a�► ��t, �,�P�l � U�5 �.�1� 'l�J�/1�►�V
b �n -�-o ��,�1��� � \ � ,� � �
. � ` �' �ln�s �t h�� t�Jas � ��a� �v SQ `' c�1v �e
�-��, l�ca�-ivn � �
�; �,,�� �� � � 9 - ' ,�-y
� �'t�� !�l��� �`� Q l^i� f��� .��;�`�l,)y� � i.�f�5 s.�� 1�� G�
� . �� � ,� �, . � �, ,,
� Y�n�1c� i��l Sa ic�, 1�,� 5 s`��e� ��r u�� �1 ��i'e.�} 7
�h�in � a icl e5, shc, �ic� ►��. `�-�+c�'' �-�►�irs h� �1re�I
< < < < y
Ca l l ecP '�l��5 l bc� c�n � �-�e��r �e��v� , � s�-r�(� su e��
. , �
��-hufi 5��� bc�r� �cc�d� nr �l�s���t 5 �� �la� A r� v�as
su r.��t s�$ ��t �-I,�i 5 1�1�!�`-� A.��e� b� � �I�, � Li1�5 �v��
��hc�� 5�►m�b�!� ��u�� � r�� �� � � l��k,
y �
�L �ea��iZ,�, �l�t� �Ue��o� � �5 �� �►� i5 �'�1� �a( 's�"� �t� �
� �
w��s� ev�,�< b� l�ta v"� � sa id ��cr�-, `� d u `�' ' '�l�a�' �
n l t c��c-�, �as ���r�Vt�l� �i� �t h`t�-i ti `�rs vf� nol� a��1�
� , g . ,� P
n�e.�.r�� `t� r c�►�Se � �►�e� �-�;� a�� v� i,�h� a.l i in�� �
� � g �
� ���tes W �,1�� ��� r�i�e�w� ��r� �1� G� � �J�s �vfi �
� �
� < < < � � ,
s c;cd � c�- `�te �-1�e ��- `�1� �s r�nc��Eu�- S o� �-� � c��F
� � �
�lr�.s�hc3,r si�n�.l c� I�c�v��, �ne�� lc�cc� �r� �� i�c�`�ein�' �Dr��
�e� hav z 1�Q �:p�c�,. � b�, �e�I�� Crk� sl��u Ic� Q
p
-��� �� dc��a��5 � un� ��r , ����1 � � � 1 ��4 �� �fiJlnc�n �
�
�-F'v� ��u� r„�ns i d��a�i vvt i � �1�i S m��-�;r,
���� How did we do? Receive a $10 off oil change coupon on
y0ur next visit. Please, complete the survey at
' TIRES•SERYICE�BRAKES•BATTERIES �•ntbcares.com Use password 67522139 00005
MN NATL TIRE & BAT # 984 * FINAL BILL -INVOICE** Page 1
1671 UNIVERSITY AVE Invoice# 67522139 - RI
ST PAUL MN 55104-3726 Order Num 41182913 - WI
(651) 646-0035 Date/Time In. . . . . . . . 04/24/13 08 :26 : 51
Date/Time Promised. . 04/24/13 09 : 31 : 32
2002 HONDA ACCORD
Tag: 512GPV St : MN Mileage: 61105
Engirle: VIN# 1HGCG56772A129541
-------------------------------------------------------------------------------
Customer: 31884887 PO# : Ship To:
CUSICK, CATHY
1003 OSEOLA
S T PAUL NIl�T 5 510 4
Opening Salesperson 12982577 Home## 651-224-3717 Work##
Email :
Item Number Item Description Qty Price• Each Extended
-------------------------------------------------------------------------------
GY17719655VB Gdyr Eagle LS-2 1 103 . 99 103 . 99
DOT ## :M6C6 O lFF 1812 1
706648163 P195/65R15 895, 706648163
WORKMANSHIP
Tire Disposal Charge Tire Disposal Charge 3 . 00 3 . 00
PTS SERVICE CENTR.AL NC INSTALL 1 �
VSR RUBBER VALVE STEM 1
NCb WHEEL BALANCE NO CHARGE 1
KMTSL MOUNT AND INSTALL 1
1299�2951 CHRISTOPHERS, DANYELL '
LTRF LIFETIME TIRE ROTATE SVC 1
LFFR LIFETIME FLAT REPAIR SERVICE 1
ACA ALIGNMENT CHECK & ADVISE 1 �
ALIGNMENT IS OUT OF SPECS, CUSTOMER DECLINED � I,
**
MSG MESSAGE 1 i
REPLACE TIRE IN THE TRUNK AND MOUNT ONTO THE D/F
***
RECBATT RECONIl�IEND NEW BATTERY 1
RECALIGN RECONII�IEND WHEEL ALIGNMENT 1
RHWD CUSTOMER WAS ADVISED AND 1
DECLINED ROAD HAZARD WARR.ANTY
CHECK Check Payment 114.40-
APPROVAL CODE 184664
IF YOU HAVE A QUESTION OR CONCERN PLEASE SPEAK
TO OUR STORE MANAGER, SCOTT D. KEY
AT (651) 646-0035
Special Credit :
- � . � • • �
� .�� � ��,,�� ;i� �;
_� .N. _. .� ".�' �. � �
Bill To Cathy Cusick Plate 512GPV
1003 Osceola Av Description Black 2002
St. Paul, MN 55105 MaC�e Honda Accord
U 5 A Engine 4-2254 2.3L SOHC
Odometer 61,131
Home (651) 224-3717 VIN 1HGCG56772A129541
Second Phone (651) 266-6162
PO #' N/A
Work Order# 0000031149
Invoice Date Apr 26 2013 i Invoice# 0000025947
Appointment Apr 26 2013 9:04 am Svc Advisor Jacobs, Scott
`Fromised Apr 26 2013 11:04 am' Technician Yemberg, ]acob
. °
Problerr►s Reso/ved �
Check Battery
Customer was told the battery had tested bad at another shop when having tires replaced. Battery tested bad and should
be replaced. '
Inspections Performed
Alignment Inspection
Customer had hit a pot hole and had a tire replaced. After initial inspection, found both the front and rear toe is in need of
adjustment.
Complimentary Service Inspection
Lubricate door hinges, air filter and wiper biades checked ok. battery was replaced and the tires have about 10(32's of
tread in the front and 7/32's of tread in the rear. Fluids were at the proper levels, coolant is dirty but tested to -34. Nated
the right rear sway bar link is broken and the left front is loose, recommend replacing',ai! four links.
,.,.. ,
Services Performed
Milage In' Mileage Out
�
Sub 50.00
Wheel I[7ignment
Includes alignment and reference on front and rear wheels. Extra charges may apply for shimming rear wheels if
appiicable;and on some front end adjustments.
Labor �79.95 *
Wark Performed By: Yernberg, ]acob �
Svb $7`9.95
Batt ry- Replac
Includ s cleaning nd servicing of battery cables and battery hoid down. nlcudes removal of components required r
access.
MT35 INT RSTATE BATTERY 1.00 Units $111.36 / Unit $ 1.36:. 1N
Top Po attery Termi�als 1.00 Units $3.33 / Unit �3.33 M
Labor $41.09 *
Work P rmed By: Yernberg,Jacob
ub $155J8
5w20- ube Oi &Filter
Check ii level an color first.
5 ZO - Oil 4.50 Units $ ., 7 / Unit $11.57 ME
334 - Oil Filter 1.00 Units 7�.95 / Unit 37.95 ME
abor �12.81 *
Work Performed By: ernberg, Jacob � ;
Sub $3 . 3
910 Randolph Avenue St Paui Minnesota 55102
Phone: (651) 298-0956 Fax: (651) 298-0886 Email: scott@stpaulauto.net