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Lorenz-Meyer t�C�,CIVCU MAY 2 91013 NOTICE OF CLAIM FORM to the Cit�b����l, Minnesota Minnesota State Stati�te 466.05 states that "...every person...who claims damages from any mt�nicipality...shall cause to be presented to the governing body of the m��nicipality 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 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 Middle Initial Last Name � ••_= ; Company or Business Name Are You an Insurance Company? Yes/1� If Yes,Claim Number?_�'�/� Street Address "� � City State Zip Code Daytime Phone(6�j) EJC Os(J Cell Phone(65I )Z/� -3�� Evening Telephone( ) - Date of Accident/Injury or Date Discovered � � - }� - 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 andlor responsible for your damages. ar- ,�f � _ ��, � t,� r - . , . , i — I ' �E:i' ii� ks.-' �t :t :�i � ��. ._� Zi � ;�?' : _.,:. , 's.:..� � � m" I��.�-: i i `E�i'.- r � j. , , .. ,i� il _ .� . -. � �'.l`-' � � ...- .. . ,f._ ... _ ' , �i t )> - . �. . _.+r, .. .— � <._�.E �iiE'� _ „ ., ,. , ,—.iu° lir�.. .� � . .. _. ., =T:: ,. .. I . _ ._ .. . ... �, -.i.:�,��r} i,-ti .. � €.;?�.t ., fi i�., �. i. 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 copies of all anqlicable documents. For the claims types listed below, please be sure to include the documents indicated or it vvill 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 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 comulete this section --� Were there witnesses to the incident? Y� No Unknown (circle) Provide their names, addresses and telephon numbers: Were the police or law enforcement called? Yes Y� 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. Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim to your satisfaction.�� Vehicle Claims—please complete this section ❑ check box if this section does not annlv Your Vehicle: Year =��� Make Model � � License Plate Number � State Color Registered Owner Driver of Vehicle - ' - � - Area Damaged City Vehicle: Year Make Model License Plate Number State Color Driver of Vehicle(City Employee's Name) Area Damaged Iniury Claims—ulease comulete this section �check box if this section does not annlv 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 statirtg 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. 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Please, complete the survey at TIRES•SBRVICE•BRAKES•8ATf6RIE5 �.ntbCares.com Use password 68200513 00005 MN NATL TIRE & BAT # 875 * FINAL BILL -INVOICE** Page 1 2185 �'ORD PKWY Invoice# 68200513 - RI ST PAUL MN 55116-1816 Order Num 41955599 - WI (651) 690-5007 Date/Time In. . . . . . . . 05/21/13 09 :51 :25 Date/Time Promised. . 05/21/13 14 :26 : 07 2006 MERCEDES-BENZ E500 Tag: RGA979 St: MN Mileage: 38323 Engine: VIN# WDBUH83J86X204556 ------------------------------------------------------------------------------- Customer: 26387858 PO#: Ship To: LORENZ-MEYER, MARTIN 3S3 5��;� �! SAINT PAUL NII�T 5510� �. Opening Salesperson 12965207 �Home# 651-695-0303 Work# Email : ! ------------------------------------------------------------------------------- Item Number Item Description Qty Price Each Extended ------------------------------------------------------------------------------- XPTR BRIDGESTONE SERENTY 1 218 . 06 218 . 06 DOT #: 1V91 DBA 1812 1 235 /50 17 96V New SCRHWxp ServiceCentralRoadHazard 1 32 . 70 32 . 70 New REC30K RECOMMEND 30, 000 MILE SERVICE 1 AMX Am. Express Card 269 .88- CARD NUMBER 2006 APPR 582980 IF YOU HAVE A QUESTION OR CONCERN PLEASE SPEAK TO OUR STORE MANAGER, WILLIAM PUNCHES AT (651) 690-5007 I ����� � �� � � �� 1�� �ii� I Special Credit : `�n��.���.��'a"�!�'� New Tire Limited Warranty "What is covered and for how long: Every new tire purchased at a Tire Kingdom,Merchanu Tire,NTB or Big O Tires store(collecdvely"TBC Retail')is warranted by the manufacturer against defects in workmanship or maferials down to 2/32nds of an inch remaining tread grove depth.Additional warranties may apply to some tires.TBC Retail will honor the manufacturer's warranty on any such tires,and any such tires which fail under the terms of the manufacNre s warranry will be repaired or replaced in accordance with the manufacturer's warranty program.You must comply with the conditions of the manufacturer's warranty program to receive this warranty coverage. *How credit is determined: If a tire covered by this warranty becomes unserviceable due to a defect in workmanship or materials(tire separation,etc.)during the usable tread life of the tire(usable tread depth is original Vead depth minus 2/32nd of an inch),you will receive a credit for the amount of usable tread remaining on the unserviceable tire times the current selling price(example 60%usable remaining tread times the current selling price of$80 equals a credit of$48).This credit will be applied to the invoice of the replacement Ure. *What is not covered: This warranty does not cover tires which become unserviceable due to: I. Conditions resulting from road hazards such as cuts,snags impact breaks or punctures. 2. Conditions resulting from improper installadon,wheel misalignment or tire/wheel assembly imbalance. 3. Conditions resulting from consumer damage such as improper Ure and vehicle maintenance,misuse,abuse or accident. 4. Tire uniformity complaint after the first 2/32nds inch of tread wear. 5. Use in any commercial application. *See Other General Terms and Conditions below. Limited Mileage Warranty *What is covered and for how long: If a mileage warranty is noted on the front of the documentation attached hereto,such tire whosc remaining tread depth grove is reduced to 2/32nds of an inch or less prior to receiving the specified mileage,will be replaced with the same or an equivalent new tire at the then wrrent retail price,including applicable taxes,less an allowance based on the actual mileage received at the time presented to a TBC Retail store compazed ro the specified mileage.Mileage warranty daims will onty be honored within 6 years of the date of original tire purchase and before the tire delivers the warranted mileage.The following tires are excluded from the limited mileage warranry:commercial use tires,tires worn from excessively aggressive driving conditions such as racing and tires worn from improper maintenance such as lack of rotation,improper air pressure,alignment or mechanical wear. *Owner ObligsNons: Proper tire care is necessary ro obtain the maximum mileage and wear from a tire.It is your obligation to see that your tire/wheel assemblies are in balance and properly aligned,that your tires are operated at vehicle manufacturer's recommended cold inflation pressure and that your vehicle is well maintained.Your tires must be inspected by us a minimum of every 6,000 to 10,000 miles.Check air pressure in each of your tires including the spare,at least monthly when the tires aze cool.TBC Retail will check alignment,treadwear,tire pressure and the mechanical condition of the vehicle anytime at no charge at any TBC Retail location. *What is not covered'! 1. Defects in workmanship and/or materials(covered by separate new tire limited warranty). 2. Failures caused by road hazards. 3. Tires used on special applications such as light trucks(unless specifically covered),vans,recreational vehicles or commercial vehicles including taxi,police,etc. 4. Tires with premature or irregular wear or damage due to improper inflation,misalignment of wheels,mechanical defects of vehicle or tires on vehicles where necessary vehicle repair or maintenance has not been performed. 5. Tires damaged by fire,wrecks,obsdvctions on the vehicle or willful and malicious damage. 6. Repairable puncmres or tires run flat. 7. Sidewall damage from scuffing wrbs or other cosmetic damage. 8. Tires transferred from the vehicle on which they were originally installed. 9. Use in any commercial application. *See Other General Warranty Terms and Conditions below. Road Huard Warranty *What is covered and for how long: This waaanty covers all tires for which this warranty has been purchased that has become unserviceable as a result of normal road hazards(i.e.cut,snag,bruise,impact breaks or irreparable punctures).This limited warranry terminates when the covered unserviceable tire is adjusted or when the tire is worn to a level of 2/32nds of an inch,the minimum tread depth required for safe vehicular operation. •What is not covered: Tires removed from service due to being ovedoaded,intentional abuse or tires used in other than normal passenger vehicle service.Tires that can be safety fixed will be repaired FREE OF CHARGE.Road service,towing costs and other incidental damages or costs are not covered. *How is replacement price determined? Normal Road Hazards,Run Flats and Workmanship/Material Defects In the event a tire covered under the warranry becomes unserviceable due to normal road hazard(example:cuts,snags,impact breaks or non-repairable punctures),(usable tread life is the original tread depth minus 2/32nds of an inch),in the first 12months or 12,000 miles,whichever comes first,you will receive full credit of the original purchase price of the tire towards the cost of replacement.ARer the FREE REPLACEMENT period of 12 mon[hs or 12,000 miles,whichever comes first,you will receive a credit for the amount of usable[read remaining on the damaged tire based upon your original purchase price.(example:�0%usable Vead remaining times the original purchase price of S50 equals a credit of S25).This credit will be deducted from the cost of the replacement tire.When the tire is wom down to 2/32nd of an inch or less,the Gre is worn out and the warranry ends,regardless of the age of the tire. *This warranty must be purchased tor this coverage to apply. *See Other General Terms and Conditions below. Ot6er General Warranty Terms and Conditions *Who gets the warranty? All warranties apply to the original purchaser and may not be assigned to a subsequent purchaser or owner of the motor vehicle on which the tire(s)covered by our warranties are installed.A tire (s)mounted on any vehicle other than the vehicle on which it was first mounted is also not covered by these warranties. *Where to go for warranty replacement and/or service? All TBC Retail warranties will be honored at all TBC Retail locations,including any Big O,Tire Kingdom,MerchanPs or NTB store naponwide.For warranry service,you must present your sales invoice and service records,along with the unserviceable tire(s).TBC Retail store locations can be obtained by calling 1-800-NEW-TIRE,or in PA or N.J.1-888-TIRES NTB or in the white pages or yellow pages under Tire Dealers Retail.In the event you are unable to locate a TBC Retail store or require further assistance,you may contact our CUSTOMER SERVICE OFFICE at 800-926-8473 anywhere in the Condnental United States. *Consumer Rights: This warranty gives you specific legal rights and you may have other rights,which vary from state to state. Some states do not allow limitation on how long an implied warranty lasts,so the warranty limitations may not apply[o you. *Conditions and Exclusions: Nothing in this wartanty is intended to be a misrepresentation that tire failure cannot occuc To the extent permitted by law,liabiliry for consequential damages is disclaimed.To the extent that a manufacturer's warranty applies,such warranry shall be primary and the TBC Retail warranty shall not appty to the extent of the manufacturer s wananty. *Owners Obligations: Proper tire care and vehicle maintenance are necessary to obtain maximum treadwear and service from a tire.It is your obligation to properly maintain your tires and the vehicle,upon which they are installed,including;operating your tires at the vehicle manufacturer s recommended cold inflation pressures,insuring your tire and wheel assemblies are in balance,tires rotated on a cegular basis(every 6,000 miles is recommended),vehicle in proper wheel alignment and vehicle steering,suspension and driveline components are well maintained.TBC Retail will check and inspect tire condition,wheel alignment and vehicle condition at any time without charge.