Rathman - � RECEIVED
MAY 15 2013
NOTICE OF CLAIM FORM to theC��o���i�aul, Minnesota
Minnnsota Sluie Stun�te 466.05 states d�cu "...ei�ei�person...who claims dnnuiges fi�om um�municiper/it1�...slrcdl eciuse�o Ue presented to the
gorerning bocll'qF�he nnmrci�alih��i'ithin 180 dq�'s c�/ter the uAegec/loss or ittjan��rs discovered a no�ice stating the time,pince,m�d
circ�un2stnnccs thereqf,und dre cunoun!nf compe��sation or other relief dernanded."
Please complete this form in its entirety by clearly typing or printing your answer to each question. If more space is
needed,attach additional sbeets. Please note tbat you will not be contacted by telephone to clarify answers,so provide as
much information as necessary to explain�our claim,and the amount of compensation being requested. You will recei��e 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 4{!1IplL� Middle Initial�Last Name�{�,-��1rv�r',�
Company or Business Name
Are You an Insurance Company? Yes No f Yes,Claim Number?
Street Address j��95 ��(�, V�)���I� .
City �irv�GLVI E;��Gl�--.e S State �(� Zip Code U� �
Daytime Phone( ) - Cell Phone(��-�.-?Evening Telephone( ) -
Date of Accidend Injury or Date Discovered a-C�t�� � �� , �2U�� 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 damages.
p�QOl�2 S2Q_ �A�t�C 1/\S1C� 1 P-�-�4-.G C�
Please check the box(es)that most closely represent the reason far completing this form:
❑ My ��ehicle was damaged in an accident ❑ My vehicle was damaged during a tow
��Iy vehicle was damaged by a pothole or condition o�the street ❑ My vehicle was damaged by a plow
❑ My vehicle was wrongfully towed and/or ticketed ❑ I was injured on City property
❑ Other rype of property dama�e—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 rypes 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 Towina 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, name of park or facility,
closest landmark,etc. Please be as detailed as possible. If necessary, attach a diagram.
6
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. � ���,`'t q
�'ehide Claims— lease com lete this sect:on ❑ �heck box if this �ection does not a lv
Your Vehicle: Year � Make 1�i5SGL.V� Model \(��s�jo�
License Plate Number O State�Color W1/l��P
Registered Owner
Driver of Vehicle
Area Damaged ��►�-C�ln�I 2r"� S�e�..S2 W DQ 'rj 1/� , �'�Vl'��` O�'�; `�J �CJC�
Citv Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle (Ciry Employee's Name)
Area Damaged
Injurti� Claims qlease complete this section �check box if this section does not apply
How w�ere you injured?
R%hat part(sj 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 Telepho.^.e
�heck here if you are atfaching more pages to this claim form. Number of additional pages�.
By signing this for�n,you are stating that all information you have provided is true arzd eorrect to the best
of your knowledge. Unsigned forms will not be p�ocessed.
Submitting a false claim can result in prosecution. Date form was completed I�� �t,l � �y �l�
Print the Name of the Person who Completed is Form �1
Signature of Person Making the Claim:
Re��i�ed February 301 I
1465 Highland Blvd.
Hoffman Estates,IL 60169
May 11,2013
City Clerk
15 W.Kellogg Blvd.
310 City Hall
Saint Paul,MN 55102
To whom it may concern,
I am submitting a claim to the city of Saint Paul to request compensation for damage to my vehicle incurred as a
result of the cit�s improper pothole repair.
On the morning of April 19,2013,I left work at the Minneapolis-Saint Paul Airport for an apartment I rented in
Saint Paul for days I could not commute home.While driving on lexington Avenue,I hit a pothole.The incident
occurred just past Jefferson Avenue,in a construction area.I spotted the pothole before I hit it,but was unabie to
avoid it due to the location of construction horses.The coliision with the pothole resulted in a flat tire and bent tire
rim,as well as a bent control arm and stab bar,all located in the front drive►'s side of the car.
I have attached copies of receipts for the repairs to my car,totaling$359.49,which I paid for out of pocket.The
first receipt,from Discount Tire,is for the damage I initially noticed to my tire and rim.I am requesting$55 for the
new rim,$16 for the installation of the tire,$12 for the certificates on the new tire,and$7.50 for the rebuild kit,
totaling$90.50.The wheel itself was covered under a warranty.Despite my wheel and rim being replaced,my car's
steering was pulling to the left.1 brought it in for repairs at Merlin's.Here they discovered the control arm and stab
bar were both bent as a result of the pothole. I used a 15%off coupon at Merlin's which was applied to parts and
labor,resulting in a total of$268.99.The$359.49 I am requesting from the city of Saint Paul is a combined total of
parts and labor from Discount Tire and Merlin's.
The city of Saint Paul is at fault for the damage to my vehicle.I inspected the pothole after my collision,and it
appeared to have been filled with gravel that had settled after rain and snow.The work that had been done,but
not completed combined with the presence of construction horses indicated the city's acknowledgement of the
pothole as a p�oblem.However,the incompletion of the project and my resulting collision point to negligence on
the city's behalf.I also feel that since the city was aware of the problem,traffic should have been rerouted around
the pothole,or the construction horses should have been removed to give drivers the opportunity to drive around
the pothole.
I hope to hear back from the city of Saint Paul as soon�s possible on this matter,and expect you to honor the full
amount of my claim.I have been as cost effective as p ssible throughout this process:opting for steel rims rather
than aluminum,using coupons,and having work done at businesses where I knew my parts were under warranty.I
have tried to be as fair as possible,and expect the same respect in�eturn.
Please feel free to contact with any further questions.1 can be reached by phone at 847.732.7252,or by email at
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;` `�, MERLIN 200,000 MILE SHOPS INVOECE
������ i��� 795 W. Higgins Rd. #3�1 20 pa � PM
200,000 M1LE SHOPS \ Schaumburg, IL 60195 Estimate#130501007
�;,< /� 847-885-7922
ANNA RATHMAN HOME: 847-843-8795 2008 NISSAN VERSA
1465 HIGHIAND WORK: $47-5149284 A13 8401 (IL)
SCHAUMlHOFFMAN,IL 60195 ACCOUNT#: ODOM IWOUT:37959/37959
3N16C13E38L432189
1.8L 4 Cyl.
268.99 MASTER CARD Sales:96:D'ANDREA
Tech: 18:Ra'
Qty item Number Loc Description ST � Each Labor Misc Extended
ALIGNMENTJFRONT END
1 RK620567 CNT ARM AND BALL JNT ASSM/CO RO 105.99 169.00 294.99
Shop Supplies: 8�85
18 Sub-Totaf ALIGNMENT/FRONT END: 105.99 189.00 0.00 303.84
P2rtS �05 9^
Labor 189.00
Shop Supplies 8.85
mr coupon 15% -44.25
Sub-Total 259.59
STATE Tax 9.40
Graad Total 268.99
Estimate Total was 268.99
THANK YOU FOR YOUR BUSINESS
Be sure to"like"our Facebook page for weekly specials! Meriin-Schaumburg
items declined B Customer
1 CUSTOM REAR WIPER RO 20.99 20.99
Total Declined: 20.99 0.00 0.00 20.99
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