Treacy RECEIVED
MAY 13 2013
NOTICE OF CLAIM FO�'�b�e�� of Saint Paul, Minnesota
Minnesou�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 I80 days after the alleged loss or injury is discovered a notice stating tl2e time,place,and
circurnsiances thereof,and the amount of compensation or other relief demandeci."
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�V��l___ ___ Middle Initial�Last Name 1 �e��l.t
Company or Business Name _
Are You an Insurance Company? Yes�T If Yes, Claim Number?
Street Address � b�� 1�.��1�o�v�,�' r'rv-�
City S� • ��,�� State �� Zip Code S S t O�
Daytime Phone (�lS�)��� -`��� ( Cell Phone (�$� )Z3�=y��� Evening Telephone(�O�S� )Z3 -�{S�j
Date of Accident/Injury or Date Discovered � ` 3 i ZU l?�_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 City of Saint Paul or its employees are involved and/or responsible for your damagest.
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Please check the box(es)that most closely represent tlie 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
O Other type of property damage—please specify
❑ Other type of injury—please specify
i
In order to process your claim youu need to include copies of all aqplicable 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 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, intersection, nam�of park or facility,
closest landmark,etcn. Ple�ase be as detailed as possible. If necessary,attach a diagram.
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Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim
to vour satisfaction. �G°l� ' -1 I �- Qw1.o--��.� °� t�a-�-4-P--�
Vehicle Claims-nlease comnlete this section ❑ check box if this section does not apply
Your Vehicle: Year ZOc) 1 Make �'a v.�� Model n�.rk �-cw�-c
License Plate Number�2t 'i'a� State �'ItN Color �4.'�-�
RegisteredOwner I���n �fe�,r.�
Driver of Vehicle �� T�'t��-u
Area Damaged�-Fc-v r.� cN�-��S
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
I� Area Damaged
Injurv Claims-ulease 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. Yes No
�
--
__ --- - .
When did you miss wark? � (provide date(s))
Name of your Employer:
Address Telephone
1� 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��' �13
Print the Name of the Person who Complet d this Form: � vl tn- � C CG�wl
,
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Signature of Person Making the Claim: _
Revised February 2011
�On Precision Tune Auto Care 030-07 Invoice Number 35437
360 South Snelling Ave. Manager:JeffA. EStl111at@ 114109
St. Paul,MN 55105 Local Family Owned 05/03/13
651-690-2740 E-mai�owner at:
��rA ptune@popp.net Ptune@popp.net Mileage In Out 127070 mi
■v
Year 2001
TRACY 8�PATRICK ODONNELL Home 651-699-5949 Make BUICK PO#
1841 FAIRMOUNTAVE Work 651-239-4581 Model PARKAVENUE 3.8 X Auto_Man
Cell 651-332-6884 Tag XRC777 Veh Id
ST PAUL,MN 55105 Email VIN 1G4CW54K614206546
Customer Comments ]�_ Technician Comments �
GUEST HIT A POT HOLE ON FAIRVIEW AND 94.CHECK OUT RIMS AND P�T HOLED O H WHEELS AND TIRES ERE COMPLETELOY BLOWN
TIRES. ; OUT,WE REPLACED THEM TODAY;THANK YOU FOR YOUR
BUSINESS;
R Date Part Description Quantity Each Labor Disc Total
----------- –
----------- ,
�----- —--- Recommended Services ________ _ _ _ -------J
R 03/15/13 FIX GAS GAUGE � 1.00 103.59 103.59
Services Performed ___
- — -- 1.00 39.98 39.98
-1 48/0 Mount2 Mount 2 Tires w/Balance,Disposal 1.00 79.95 (40.00) 39.95
2 Wheel AI' nment
0 48/0 AUGN2 :*� �9 " � `
,�.� .,. . ,: ;�: ���
�225/60R16 Uniroyal Tiger�`aw ounng�'� "� � �" � ���'� � • � 199'98
0 48/0 130000209 • 350.00
0 48/0 MD0078 •
USED 16"WHEELS 2.00 175.00 �=_-
Tax Details ——
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Sale9 Tax . MN�
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24 Month/24�i Mile WarrantY '
Servi�s/Parts lilis�;w; e, . _ 18.5�–Sal� ,�„ .38.9'1 Deposi � 0.00
6�W.8� �PP ��-,.�:-; -�.
� 119.93 Discount (40.00) Other fiax mi 0.00
Labor ' -: 693.71 , _ e 693.71
Haz.Waste Handli 6.OQ . Sub.-Total ; �.�,.�,, - : .
._ s _ .,
CASH CHECK
CREDIT CARD ON ACCT 693.71
We welcome your comments,visit:www.precisiontune.com/WeCaze
Chance to win free oil changes and promotional discounts!
page 1 of 1
32200030075064
Precision Tune Auto Care ?424 Precision Franchising LLC �O 2011
WARRANTY PROGRAMS;
LIMITED WARRANTY FOR ENGINE SERVICES: The Precision Tune Auto Care Center identified on the front of this service order (the "Center')
warrants the parts and tabor en engine performance services. onboard diagnostics systems,systems adjusUnents or repairs,and fuel injector repairs for
24 months or 24.000 miles I40.O�J0 kmj after the date of the service,whichever first occurs.During that time,we will repair or replace,at our option,any
faiied or defective part that�ve installed as part of the service.
LIMITED LIFETIME BRAKE WARRANTY: If indicaled on ti�e fron'of this serv;ce order,the Center warrants U,e disc brake pads and/or brake shoes for
as long as you own the vehicle. Lahor is r�ct�rciuded. You must retum your vehicie to the Cen?er every ?2 months,or 12,OOC miles, whichever first
occurs, For a free brake inspection to muii�taln this warranty �n force. Tnis�arra��ty does not cover the cost of instafiation of required additional brake
compenents or services, such as new rotors or drums. macliining rotors or drums, calipers, brake hoses, master cylinders and other hydraulic
compone�is required to restore :ne brake system to proper safe operating specifications. Ali brake components other than pads and/or shoes are
warrantacl�or 2� mon+.hs or 24,000 miies,whichever first occurs.
LIMITED BRAKE WARRANTY: If indicated on the front of th�s service crder. ihe Center warrants parts and labor far 24 months or 24,000 miles,
whichever firs�ocrn-s- �a�s�+nd,or shoe, �vi!I b���m�ide� c- ��s�nr , , :�ri c �',�=fiictio��matE u.'c`+h�.F,�.ds 1nd/or shoes has a n;inimum thickness of
�
;..:_ L.�.c��� :.-"UG__�c_::.cfiy5 _...� � .� iritt�iR.ul?1 ^/?d �-1;. ?F.Ckr1gSS Vt I�lE li;; ��t ����f5 _...:i-G�.�.;_' ��. L.'u�:�;y]thg±tl'ne,WE'.4'I�: (EpdIY OY fP-blfiCB 8T
our option any failed or defective parts that we originally instailed as part of the service.
TIRE WARRANTY:Subject to manufacturer warranty.
SOME PRECISION TUNE AUTO CARE CENTERS OFFER WARRANTIES ON OTHER PARTS AND SERVICES.See the Center Manager for details.
These warranties are good on�y at the Center where the service was originaily performed. There is no warranty on parts or labor for the foilowing
services carburetor repiacement (whether new o� rebuiltj, fuel injection deaning, air induction cleaning, all fluid exchanges or tlushes. throttie body
ir,take deaning,AC refrigeran?or a!ignments.
INFORMATION RELATING TO ALl WARRANTIES:
How ta Get V�larrantv Service: Yoi.i must save this service order as proof of the date/mileage of the originat service. If warranty service is required,take
your ca�:ana'his service order back to the Center. 'Y'ou can bring your vehicfe ta any Precision Tune Auto Care Center that offers the covered seroice;
however not��fi Centers provide aii services so it is best to cali first.
�UJ��a� is Cove;�ed: Refer tc� the specific warranty terms above for enyine services and brake services. Except as specifie� in ihis warranty. no ather
services are warranted and �arts ar� sold subject to the man�itacturers warranty oNy, if any. ALL WARRANTIES ARE FOR THE P_ARTICIJLAR
VcHiCLE SERI/iCEC AtiD ARF f�!O��?RANSFERABLE �
What is Not Covered: (A) Damages resulting from accident abuse, negligence or repairs, reptacemer�is andior adjustmeni performed by others (B)
reimbursement for parts, labor or work performed by others: (C) components purchased irom third parties anr{ brought to a Center for instailation; (D)
toeving or car rent�l.car fare inconvenience,loss of time or use ot vehicie (Ei cash refunds of any kind,except where warranted parts or labor continue
te be defective arter a reasonabie number of attempts to repair by any Center. All refunds are at the discretion of the Cer.ter where the work was
originatly perfo�med.
cxclusions frorn Warranty Coveraqe: P,I! warranties appiy on!y to passenger cars, light duty trucks, SUVs, and vans up to 3i4 ton. Certain modeis of
vehides, such as commerciai, racfng, off-raad and those used in sporting events, are exciuded. Your pa;tiasiar warranry will be VOID if you have any
repairs. replacements or adjustments performed by any perso�other than an authcrized P;ecision Tune Auto Care Ce��ter.
EX�EPT FGR W'ARRANTIES EXPRESSLY WRITTFN HEREIN. ANY iMPLIED WARRANTY OF MERCHANTABlUTY OR FITNESS FOA A
PARTICU!_P.R P�RPOSE IS L1��11?ED IN DURATION ?C 24 MONTHS/24 pp0 MIt.FS (40.000 KM) 4NHIC.HEVER OCCURS FIRST AFTER THE
'��E'� ir�.`� � :=E rr,C '?> ,. , i\/r_ r �ro�E_"E-S FOI�;Al! `:'ilyRRAr��.i'r ����_if��, �Af'iE i_1C,9iT�D TC REPA!R, nEP�ACEMENT OR 9EFUND(NO i
f0 EXe�EU 1Nt ORIUiNAL SER�iCE U�tL3€�AMt3tit�r�k3�;�i�ttY rR- . E1V-WA�RAi�ifiY.-fi�i�-C€�t�ER ANfT
PRECISION TUNE AUTO CARE EXPRESSLY DlSCLAIM ANY LfABILITY FOR ANY OTHER EXPENSE, LOSS OR DAMAGE, WHETHER DIRECT,
INCIDENTAL OR CONSEQUENTIAL.NO ONF 'S AUTHORiZED TO EXTEND OR ENLARGE THESE VJARRANTIES.
SOME STATES DO NOT A.��OI�; �iN1iTATICN ON HOVV LONG AN fMPUED WAP.RANTY WIL�LAST OR C7N T'riE EXCLUSfON OR LIM1,1ITATION OF
INCIDENTqL OF CONS�G�UEt�TL4L uAMAuE�. SO THE ABOVE i.{MITATIONS OR EXC�USfONS ��AAY NOT APPLY TO YpU. TH�SE
`fdARRAN?iE�GNE YOU SPECIFIC LEGA�RIGHTS,AND YpU MAY AL�O HAVE OTHE�RIGNTS?HAT\/ARY FROM STATE TO STATE.
1?y�,� ir� rc� ��E�f�ro zt:sf ed with ir�e products and servr�as �eceived at thfs Center, we urge you to return to the Center immediately and tell us
abou� t �,����1 ,r:� �� r_ �, ��,�ncerns yo�,may have in a�r��mr�t and professionai manner.
Each Center {s independentiv owned and opera;�d. For additional u�formation. contaci the Cente: at the add!ess and phone number shown on the
reverse side.
Should�ou hav2 any questioi�s regarding this war,anty,please ca(!or write the Center or Precision F�ar�chising LLC at:
1-t366 94=.,-8863,or
Customer 5ervice Depar[ment
Precision Franchising LLC
P.O. Box 5000
Leesburn,VA 20177 -