Breininger RECEIVED
�IAY �7 2013
NOTICE OF CLAIM FORM to the City o Saint P�i, Minnesota
Minnesota State Statute 466.05 states that° CITY CLERK
...every person...who claims damages from any munictpality...slutll cause to be presented to the
governing body of the municipality within 180 days after the aUeged 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 questioa If more space is
needed,attach additional sheets. Please note that yoa will not be contacted by telephone to clarify answers,so provide as
much information as necessary to e�cplain your claim,and the amount of compensation being requested. You will receive a
written acknowledgement once your form is received. The proc.�ess can take up to ten weeks or longer depending on the
nature of your claim This form most 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 � I'1 S�� Middle Initial S�R°Last Name '� I Yl 1 Y�
Company or Business Name N I�
Are You an Insurance Company? Yes No If Yes,Claim Number? �
Street Address �� CJ �f�'�5C�1Q� 5��� �
City ����,l.f�.l State � Iv Zip Code 5� D
Daytime Phone(_) - Cell Phone((o!�) l 70_58'1�1 Evening Telephone(� -
Date of Accidend Injury or Date Discovered N1a91�� Time '- �5 /pm
Please state,in detail, what occurred(happened),and why you aze submitting a claim.Please indicate why or how you
feel the City of Saint Paul or its employees are involved and/or responsible for your damages.
z rArnve o n �,�r✓;e� �o�-h b�u,nc{ s,�..�,A-��4i�.e. b��, ��-w�e.e n Mr��sh�i� �c,+�
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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
�Other type of injury—please specify
In order to process your claim vou need to include coaies of all aaulicable 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 aze 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—nlease comulete this section
Were there wimesses to the incident? Yes No Unlrnown (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 straet address,cross street,intersection,name of park or,facility,
closest landmark,etc. Please be as detailed as possible. If necessary,attach a diagram. �c�4hhoc�`�d -t�ifvieul i�'�t,
��.c�f o�ren�r�ass . hr`-�w,elt,v� (Yla�h.ct Q �� •�ve,vfsi��F-C-i _
Please indicate the amount you aze seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction. � �4-�.- l� —54vY�ou,in,� c�,, he 1,�� �Y'2,
I
Velucle Claims— lease com lete this secNon ❑check box if this section does not a 1
Your Vehicle: Year a 0 0 Make N D� Model F�t
License Plate Number a�C7 �R�i" I State 1J2�Color ii�a V�� ul v��
Registered Owner t�Il1 sa n * �c ct,v� �,i��,�n�n A e-Y
Driver of Vehicle iH i Y
Area Damaged -l-�t v t�-� t e� e
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
In'u Claims— lease com lete this section check box if this section does not a 1
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? iYes No
When did you miss work? (provide date(s))
Name of your Employer:
Address Telephone
L�.�Check here if you are attaching more pages to this claim form. Number of additional pages 2- .
(
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 S �� ��
Print the Name of the Person who Completed this Form: I l � �—�-� �} �
Signature of Person Making the Claim: "� 1
Revised February 2011
---.._. ..�. ....
��� � •�� Vi(1Cl rii.uu �ls.syy�.s - wl
(651) 646-0035 Date/Time In. . . . . . . . 04/29/13 13 :49:24
Date/Time Promised. . 04/29/13 18:42 :57
2010 HONDA FIT
Tag: 270GAT St: NIl�T Mileage: 19920
Engine: VIN# Jffi�IGE8�4�A��37654
-------------------------------------------------------
Customer: 30721929 PO#: Ship To:
BREININGER, ALLISON, SEAN
376 HERSCHEL ST
ST PAUL NIN 55104
Opening Salesperson 12982577 Home# 612-7?0-5879 Wark# 612-770-58?8
Email: breiningallison�gmail.com
- �.. ----------------------- _ __.as_-�-�-__,_�---r-<
Item Number Item Description Qty Price Each Extended
--------------------------------------------------------------------
MSG MESSAGE �
DP06518556H Dunlop SP Sport 7000 A/S 1 228.99 =2u.;�
DOT #:EU7V 3M7R 4012 1
265004140 185/55R16 83H,265004Z40
WORRMANSHIP
Tire Disposal Charge Tire Disposal Charge 3 .00 3.�u
PTT SERVICL CENTR.AL NC INSTALL TP 1
2040K TPMS REPAIR KIT 1
2040R-TBC '
NCb WHEEL BALANCE NO CHARGE 1
KMTSL MOUNT AND INSTALL 1
12996386 PRITSCHET, JAMES
LTRF LIFETIME TIRE ROTATE SVC 1
LFFR LIFETINIE FLAT REPAIR SERVICE 1
RHWD CIISTOMER WAS ADVISED AND 1
DECLINED ROAD HAZARD WARRANTY
VISA Visa 141. 18-
CARD NUMBER 0403 APPR 361652
IF YOU HAVE A QUESTION OR CONCERN PLFsASF SPEAK
TO OUR STORE MANAGER, SCOTT D. KEY
AT (651) 646-0035 '
Special Credit•
Total Charges. . 131.99
Total Credits. . .00
Sub-Total ._..:,_._Y _ 131 . 99
New Tire Fees** .00
--- Shop Fees (*) _0 u
Al1 Taxes. . . _ _ . _ .__
Pa�en�s. . . . . - - -��.__-
�f e� �ic�3:ia�.. . . . . . � _
�T.�,�i � � �ti� ."''1�'�'i�t� ��`..�'_`"+F- •
�'�Zi �i.IIS. �i.!'�.r���T:�L��..^,._.___
I have received the goods and services as sepreser.�ea ;_ *_�'s �...:�e. __ _:'_s := a :=��_ ��_
purchase I agree to pay and comply with tlse card�o��s a,r�-P-� ;�=w �:e _..s::�-. *_=_s �z��
represents costs and profits to the vehicle repair £aci�«y =,._ �s��==��4::s �:_ � :--___� �_
waste Disposal.
Customer Signature
PLEASE SEE REVERSE SIDE FOR WARRANTY,TERMS,CONDTTIONS AND�OTE�R Il�SPORTA.\T A"FOR�S�ITIO� �t ST01TIIt COP�
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