Henquinet . RECEIV�'��
MAY 08 2013
NOTICE OF CLAIM FORM to the�ity o�a n�Paul, Minnesota
Minnesota State Statute 466.05 states that "...every person...who claims damages from m1}municipality...shall cause to be presented to the
governing body of[he municipality within I80 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 clemanded."
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 wiil 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 O�'HER DOCUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
First Name c--� Gl Y 1 �'� Middle Initial�Last Name�/� �`� � �< <r `� e �
Company or Business Name ���
Are You an Insurance Company? Yes No ;� If Yes,Claim I�iumber?
Street Address �l�? Cc t�"�rd�' ���p� � `� �p`�-�
City ����- J� ��'�' State �� Zip Code 5�
Daytime Phone(�.�/ )��=�0���Cell Phone ( ) - Evening Telephone(��/ )�- ����
Date of Accidend Injury or Date Discovered 5 I� ! 3 Time �• �3 am�
Please state,in detail, what occurred(happened),and wl�y you are submitting a claim.Please indicate why or how you
feel the C/�it of Saint Paul or i employees are involved and/or resp_onsible for your�amages � w�S �d�v�-��,.��
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c�i�c�r c�n� �a s d c u. <`o,�_ c��� /' Q c.a� �-�.. L�a <-�` S��/�3- �..�e. a s !n�.�
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Please check the box�es)that most closely represent the reasdn for completing this form: /����1 � L,�t p.r r1 c u� r t- `
❑ My vehicle was damaged in an accident j ❑ My vehicle was damaged during a tow�r����
�;,My vehicle was damaged by a pothole or condition di 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 you need to include copies 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 returned 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 es�imates for the repairs to,your�vehicle if the damage exceeds
$500.00;or the actual bills and/or receipts for the repairs AY�°'� ct
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 dramaged 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 No LJ"n rnown (circle)
Provide their names,addresses and telephone numbers:
Were the police or law enforcement called? Yes o Unknown (circle)
If yes,what department or agency? Case#or report#
Where did the accident ar injury take place? Provide street address,cross street,intersection,name of park or facility,
cl sest landmark,etc. P ase be a de,tfailed as possi e. If necessar ,attach a diagram. ary� �h��v`�l. t-���+ v�•~'"
��t�_ �iS'�'i S�Li�I d � Ll�lrY'+C e ���7 �- �f:'v1�'(�� � �j:r p �C/c'-s�•Z�c.�Ss
.
Please indicate the amo�t you are seeking in c�ensation or}�hat you w ld like the Ciry to do to solve this claim
to your satisfaction. 7�� �9 ��� V� �a t�u�l� w�� Y� '��` 'r «`r�s
Vehicle Claims— lease com lete this section ❑ check box if this section does not a 1
Your Vehicle: Year ��?( a-- Make �... 0.^��^- Model �^^ �''�"z�'� lc c�`°1�
License Plate Number `yc`�3 � � State Co ar �'% V += �'
Regi stered Owner c���►P`� e�n •v�� .ri r� �
Driver of Vehicle �(°-�^�-� �-� �"�"'��
Area Damaged ��c�� '.r��-°� s�; e-- � ��
City Vehicle: Year Make Model_
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
IniurV Claims—please complete this section �check box if this section does not apply
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? i 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 � � ��
Print the Name of the Person who Completed ' Fo ���� �� ��� `�� �l��
• � � � ,,,�_ %,
Signature of Person Malzing the Claim:_ `�'`" �r��
i
Revised February 2011
� White Bear +
�
r< � `������
.��' �,� .�'� ���
Acura Subaru +�
�CU�� suBa►Ru
3525 No. Hwy. 61 • WHITE BEAR LAKE, MN 551 10
651 .481 .7000 • Fax 651.251.0458
www.wbacura.com
CUSTOMERNO. ���^^^ ANDREW PARISSE �O�Q TAGNO���� INV05/03/13 uC533215
LLL o r
IABOR RPSE LICENSE MILEAGE COLOR STOCK NO.
ANET HENQUINET 23�Ex 6,764 ILVER/
1H7 COUNTY ROAD BZ W YEAR/MAKE/ ODEL DELIVERYDATE DELIVERYMIIES
OSEVILLE, MN 55113-3238 2�SUBARU/IMPREZA WAGON/5DR 2.OI SPT
VEHICLEI.D.NO. SELLWG DEALER NO. PRODUCTION DATE
� FIGPAS69CH233159 04/Ol/l�
F.T.E.NO. P.O.NO. A.O.DATE
ANETHENQUINET@COMCAST.NET 05/03/13
RESIDENGE PHONE BUSINESS PHONE E-MAIL ADDFiESS
651-483-3098 M0: 6�
-�---�-��--------------------------�------------•----------------..... Mywarrantiesontheproductssoldherebyare
of the manufacturec As between this retaii
MOUNT AND BALANCE ONE TIRE PER CUSTOMER REQUEST. wHire e�a acuRa,,susaRU,isuzu�
COMPLETED MOUNTIN6 AND BALANCIN6. the product�s to ne so�d°AS�s"and the entire i
TORQUE WHEELS AND TEST DRIVE. to the qua�ity and performance ot me product i
the buyer.The seller expressly disclaims all wam
either express or implied, including any ir
ART$------QTY---FP-NUMBER---------------DESCRIPTION---------LIST PRICE-UNIT PRICE- warrantyofinerchantabi�iryorftnessforaPar
B # 1 1 93217 P205/50R17 YOK 215.00 215.00 215.00 purpose,and the seller neither assumes nor auth
,706 # 1 TOTAL PARTS 215.00 any other person to assume for it any �iabi
connection with the saie of said products.
� # 1 TOTAL 111BOR & PARTS 235.00 disclaimer by this seller in no way effects the tei
the manufacturer's warranty.
----------------------------'-----...-------------------------....-•---•.....-------...--------
INSPECTED BRAKE LININGS AND FOUND CONDITION TO BE GOOD.
INSPECTION PERFORMED .� :;% -
f..-, --, -
�^� �
ARTS------QTY---FP-NUMBER---------------DESCRIPTION--•------LIST PRICE-UNIT PRICE- � „�,�,� ,� `k �..
JOB # 2 TOTAL PARTS 0.00 :�,� ,,,.,;,�$e..,,�S�y�d,..__,.__:��..,y:
JOB # 2 TOTAL LABOR & PARTS 0.00
--------------------------------•--------------•-----------------------------------------------
INSPECTED TIRE TREAD DEPTH AND FOUNO CONDITIONS TO BE GOOD.
INSPECTION PERFORMED -
M
ARTS------QTY---FP-NUMBER------•--------DESCRIPTION---------IIST PRICE-UNIT PRICE- �
JOB # 3 TOTAL PARTS 0.00
JOB # 3 TOTAL LABOR & PARTS 0.00 �
---------------------------------------------------------•-------------------------------------
`�
BATTERY HAS BEEN TESTED AND IS IN f00D CONDITION AT THIS �cs� �-'=�`z �`2.
TIME. You;car could be�vorth more tha�,
REPLACEMENT NOT NECESSARY. thin�!And�,ve'il b�y it;!�ven i�you d
buy frcm us;. VVe';; quot�,41�Y' :-e;;
ARTS-•----QTY---FP-NUMBER--------------•DESCRIPTION-----f---LIST PRICE-UNIT PRICE- regard!ess o� cone�:ior.. `r ,c�� acc.
JOB # 4 TOTAL PARTS 0.00 y,au il waik aw�ay �"�-i?" the cas!-. ':'
JOB # 4 TOTAL LABOR & PARTS 0.00 ;^ever�ind G�as:ar, si�;,p;er o�szfe,
TO SBE� j�4�!Ca�L �ViSi:vUf S81ZS �°'
- -- - - - - - men:I�r��O::r I'v.^.'�'iJ�i�'�i�?j:i,�'�„'�ISi
PERFORM hft1LTI-POINT VEHICLE INSPECTION. !earn more a��'��H�R,�u�C_��
SEE ATTACHED COPY. 'cXCi UD SA:_`::/_'-�u�C'�'�~�C'=S
ARTS------QTY---FP-NUMBER---------------DESCRIPTION-----•---LIST PRICE-UNIT PRICE-
JOB # 5 TOTAL PARTS 0.00
JOB # 5 TOTAL LABOR & PARTS 0.00
---------------------------------------------------------•----•---------•----•----------------- �����
.0.6. & SUPPLIES---------------------••---------------- - •---..
B # 1 1.0 WHEEL WEIGHTS @ 2.000 /UNIT 2'�� S U BA R L
TOTAL - GOG 2.00
ISC------CODE--------DESCRIPTION------------------------•-•----CONTROL NO••-------
# A .;�,l.L 3�o-�1r$':5S �E1N�11�1�:������'T a�1'�E��S� �'g�9��vm3��S�'��i�3c�18.52 �,� "t' a`, un;� � �';,
� ., t6�., �w . _ :��,��_
WE APPECIATE YOUR BUSINE�
PAGE 1 OF 2 CUSTOMER COPY [CONTINUED ON NEXT PAGEJ 03:05pm
+ ��.��� ��� Wh ite Bear +
�-++
Acura Subaru +�
�CU�� SUBARU
3525 No. Hwy. bl • WHITE BEAR LAKE, MN 551 10
651.481.7000 • Fax 651.251.0458
www.wbacura.com
CUSTOMERNO. ����^�� ANDREW PARISSE 1o�p TAGNOP.��� INV05%03/13 �uC533215:
[ 1 0
LABOR R4TE , LICENSE MILEAGE COLOR STOCK NO.
ANET HENQUINET ', 23�Ex 6,764 ILVER/
10 7 COU NTY ROAD BZ W Y�R/MAKE/fNODEL DELIVERY DATE DELIVERY MILES
2/SUBAiRU/IMPREZA WAGON/5DR 2.OI SPT
OS EV I L L E, MN 5 5113-3 2 3 8 VEHICLE I.D.NO. SELLINC�DEALER NO. PRODUC N D E_
7 F1GPA569CH233159 04��1�1�
FTE.NO. FO.NO. R.O.DATE
ANETHENQUINET@COMCAST.NET 05/03/13
RESIDENCE PHONE l3USINESS PHONE E-MAiL AD�RESS
651-483-3098 Mo: 6i
ISC------CODE--------DESCRIPTION-------------------------------CONTROL NO--------- ,4r�ywarrantiesontneproductsso�dnerebyare
OB # 1 ' ETDl ENVIRONMENTAL-TIRE DISPOSAL (1) 2.00 ot tne manufacturer. ias t�etween tros reta��
TOTAL - MISC 20.52 WHITE BEAR ACURA,SUBARU,ISUZU ar,a i
� � . the product is to be sold"AS IS°and the entire r
� � .. . to the quality and performance of the product i:
$�(I�T�`-------------`----�---�--------`-`-..------�-----•-----------------�---`-- thebuyecThesellerexpresslydisclaimsallwarr
USTOMER HEREBY ACKNOWLEDGES RECEIVING eitner exPress or implied, induding aoy tn
ORIGINAL ESTIMATE OF $272.99 (+TAX) warranty ot mercnantab��ity or trtness tor a Part
OTALS---�--�----------�-----------------------�-----�-----------------•---------------�-----��- Purpose,andthesellerneRherassumesnorauth�
any other person to assume for R any liabfi
x�*��rk****************** TOTAL LABOR.... ZQ.QQ �nnection with the sale of said products.
�rc ** TOTAL PARTS.... 215_00 disclaimer by this seller in no way effects the ter
[ ] CASH [ ] CHARGE [ ] VISA/MC � me manufacturer's warranty.
TOTAL SUBLET... 0.00
[ ] AMEX [ ] DISCOUER [ ] CHECK # ** TOTAL G.0.6.... 2.00
TOTAL MISC CH6. 20.52
TOTAL MISC DISC 0.00
ALSO DO PAINTLESS DENT REMOVAI HERE ON SITE, ASK YOUR TOTAL TAX...... 15.47 �,ri� �����j,�i-,�r`�'' ?
ERVICE CONSULTANT FOR DETAILS. ' """' :^",,.���V���' �' ='���' ''- -'
TOTAL INVO�CE$ 272.99 On�lme se.eicz schedulir;,ar�u�a�,,a�r:
K YOU fOR YOUR RECENT VISIT TO WHITE BEAR ACURA. SUBAi2U,. ___---:, .,--__ ...:__�_>--.:.-_ ,_�' �,._.._
D ISUZU. WE HOPE YOUR EXPERIENCE WAS EXCELLENT AND ALL
ERVICES WERE PERFORMED TO YOUR SATISFACTION. YOU MAY ALSO
ECENE A SURVEY FROM THE MANUFACTURER SOON, PLEASE TAKE A
�MENT TO fiLL IT OUT AND SEND IN. IF YOU HAVE ANY QUESTION WHITE BEAR ACURAiSUBAR
COMMENTS PLEASE CALL 651-481=7000. a52s N HIGHWRY 6i �,
SAINT PRUL, MN 55110 - '"` " '"
_ !
flzrchant ID: 6000900079660b2 i
Term ID: 82583786 � '''��
32906692;5994
I
i J C� �e �2S��'C('y0U`V2h?C:2.
Your car couid be worth more than
� �I SA think!And we'I!buy ii±(GVan ir you d
buy from us). We'if quote AivY ,teh
! XXXXXXXXXXXX�816 regardiess oi cqndttio^. If/ou acc
E11tfY M2thOd, Swiped you'i' waP�c away v✓itn t!�2 cas�?: '✓
rever fiind a`aste�:s�mpler o�sa��r
Apprvd; Online Batcha; 000Z99 To s�!� ���r���. ��5�� o�:�Saies ���
mer��cr your c,o�!�gation appr��s.
�5/03/13 15;0�;10 !earr,more at LUT�ERAUTO.GGi�n
"EXGLUDES SA.C',JF�G�D VEHf�!-S
Inv �; 332151 Aaar Code, 513�Z0
Total; � 2�2.99 �CU��
�� � � . � . � Customer CoPV SU�BARL
� . ,.°�,� �: ��� ?;
��L��.��� �c"�'�9����a���1�����P���d��, �9��, ����:��`�s`� �?��i'
WE APPECIATE YOUR BUSINE�
PAGE2 OF 2 CUSTOMER COPY [ END OF INVOICE ] ' 03�_05pm