Johnson, Angela . ,� RECEIVED
�� MaY 31 zo�3
,
NOTICE OF CLAIM FORM to the City of Sa�f��l��esota
Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipaliry...shall cause to be presented to the
governing body of the municipaliry within 180 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 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 �Cl G 2' Q Middle Initial � Last Name_ �C�h rl S C�1 Y�
,
Company or Business Name �f P�
Are You an Insurance Company? Yes/� If Yes, Claim Number?
Street Address � g 4� G rc��,o�rr. Q \! C . � � � I
City ��", �C�.�� State M /V Zip Code ��lD
Daytime Phone(�)�- ,$�17�Ce11 Phone(�)���Evening Telephone(�)3y�U`7 9�
Date of Accident/Inj ury or Date Discovered_�u� 2� 2013 Time 7= �� �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.0� $-����3 a�- �7 :�� a.�
wlvly dr���'�c, in le�- lanc o� Y�o��'1„bu4� 5„c,ll�n Qv�e. bv 14� S��ell�`�c, +v -}1� �eas� and S}u�c ��"r
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�;;►,�re nF��a.r �c1�t��.r�an �..� St. Gn-�4.�� �.�. �a� loca�c� �.� co�� «�-.c1 nusLzd �� I�a�.K: .'. �lace �s Pe a�u`de.,�-
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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 ondition of the stre ❑ 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 auplicable documents.
For the claims types listed below,please be sure to include the documents indicated or it will delay the handling of �I'
your claim. Documents WILL NOT be returned and become the property of the City. You are encouraged to keep a I
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-ulease comulete this section
Were there witnesses to the incident? Yes :�To nknown (circle)
Provide their names,addresses and telephone numbers:
Were the police or law enforcement called? es No Unknown (circle)
If yes, what department or agency? S+� '��-l�o���po��r e �e�'�Case#or report# I �C���-/� °7 3
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.
�..� � � 1�-I t� v.el ` c.v-c� s �i-�-k.
Fo-ir �ro::n S cx-b �ar�-�'ully Uper. v�r•1-,ole ccv�r
Please indicate the amount you are seeking m compensation or what you wo�4 ld like the City to do to resolve this claim
to your satisfaction. .� 9 '� (o '7') � S� t �� I1 f-�Z� �/ W Sc�me�z
,'
Vehicle Claims- lease com lete this section ❑ check box if this section does not a 1
YourVehicle: Yeaz �a�8 Make Vv�1<swc�4an Model Se a Mic,� -Io"^cz e :�'Qn
License Plate Number�5c� c R� ;_ State (`'�N Color S,'1 v�.r-
Registered Owner Ct�-.ue.la� K, �i, ��hnrc;n
Driver of Vehicle Q � t lo. .:
Area Damaged Winr c,l . -1-,'re q� '�,�v�,en-�-. r�'� c o r�-vu la�a�
City Vehicle: Year Make � Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
In_iurv Claims-please comnlete this section �eck box if this section does not applv
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
C'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 S' 2 t - ��J
Print the Name of the Person who Completed this Form: �� Y� G C. l �. K � �o �n SU(1
Signature of Person Making the Claim: � �_ \ {r.�l��c�-✓
Revised February 2011
Yncident Report 13004673 -MN0272000 Page 1 of 1
ST, ANTHONY POL/CE DEPARTMENT
/NC/DENT REPORT
ICR# 13004673 AGENCY ORI#MN0272000 JUVENILE:
Z Reported: 05-21-2013 1313 First Assigned:1310 First Arrived:1310 Last Cleared:1317
� Commited Start: 05-21-2013 0730 Commited End:
V Title: Traffic Accident, PD How Received: Radio
? Summary:
RO reported her vehicle struck a man hole cover that was partially sticking up. Damage to her
alignment, sensors and under carriage. Provided CN.
Location(s)
Address: 1400 Snelling Ave City: Falcon Heights State: MN Zip: 55108 Country: USA
� Officer Assigned: Schlingman,Jonathan Badge No: 146 Primary: Yes
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� MOC: SA9440 Literal: ACCIDENT PROPERTY DAMAGE Statute: UCR:
� Name(s)
Last Name: Johnson First: Angela Middle: Kay
W Involvement: Driver Name: Johnson,Angela Kay
Q Age:' Sex: F Race: W Height: 505 Weight: 140
Z Address: 1800 GRAHAM AVE APT City: ST PAUL State: MN Zip: 55116 Country:
Phone: (Home) (320�93-7193
Eye Color: BLU Hair Color:
W Accident State: MN Plate: 250CRZ VIN: 3VWRJ71K88M175325
v Make: VOLK Model: JETTA WOLFSBURG EDITION,4DR SEDAN Year: 08 Color: SIL
= Name(s)
> Driver/Owner
Last Name: Johnson First: Angela Middle: Kay
Suppl�mental Report
ICR: 13004673 Last Modified: 05-21-2013 1322
Title: PD Accident Created By: Jonathan Schlingman
I (Schlingman) spoke with Johnson by telephone re�arding damage to her vehicle (MN LIC/250CRZ). Johnson
advised she was traveling north on Snelling Ave (1300�1400 Block) in the left lane of traffic, when her vehicle
struck a man hole cover that was partially sticking up. Johnson advised it caused damage to her alignment, sensors
and under carriage. Johnson advised by the time she saw the cover, it was already to late to swerve as there were
other vehicles beside her. Provided CN.
It should also be noted at approximately 1030 hours, I was approached while parked on Hoyt Ave at Snelling
Avenue. The passing motorist advised the same man hole cover that Johnson struck was sticking up causing other
motorist to drive around it. I located the cover sticking up, approximately 7 to 12 inches off the road. I pushed the
cover back into place.
https://rvpdrms.metro-inet.us/letg/Applications/Incident/ReportControls/IncidentReport.aspx?Transform=... 5/29/2013
F, . ,
;� ' �1 ''��.L 1 180 East Highway 36
' � ; � 2
St: Paul, MN 55109
� �` � } COUNTRYSIDE 65�-484-844,
; �'�LKS�VTA GEN Fax: 651-484-8446
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- �: www.schmelzvw.com
SO#: 995205 . �I I'i1II�Il����l��, :�
Ta9#_ * Service Invoice Customer Copy * Au�n#: Pa9e ,
Customer No: 4937193 Advisor: MIKE HENDRICKSON Invoice Date: OS/24/2013 Term: CASH
ANGELA
JOHNSON License No Odometer In Odometer Out Delivery Date Stock No
1800 GRAHAM AVE APT 409 250CRZ 85341 85346 O6/25/2012 8D1071
� SAINT PAUL,MN 55116 Year Make Model Model No Color
Home: (651)340-0791 gus: (651)582-8478 2008 VOLKSWAGEN JETTA 2.OT SDN 1K2N3 R SILVER
' Cell: (320)493-7193 Today:(651)340-0791 Vehicle ID No Selling Dealer SO Date InServ Dabe Location
Email:angie:johnson@state.mn.us 3����K88M175325 COUNTRYSIDE VOLKS 05/21/2013 07/15/2008
Fleet#
Request/Complaint TYpe CSR#
Amount
1 0 CUSTOMER STATES HIT AN OPEN MANHOLE COVER VEHICLE
WOBBLY WNILE DRiVING,TRAGTION CONTROL WARNING
CAME ON,MIDAS FOUND DAMAGE WHEN iNSTALLING SPARE
- TIRE
� TECH INSPECTED THE VEHICLE ON THE HOIST,FOUND CPVW 456
THAT THE RIGHT REAR CONTROL ARM FLANGE HAS BEEN 113.40
> SHIFTED DUE TO THE�MPACT.TECH FOUNQ THAT THE
RIGHT REAR WHEEL AND TIRE ARE DAMAGED SEYOND
REPAIR,TECH RECOMMENdS REPlACING THE WHEEL
AND TIRE,ADJUSTING THE CONCTROL ARM FLANGE AND
ATTEMPTING TO PERFORM A WHEEL ALIGNMENT,TECH
STATES THAT ADDITIONAL DAMAGE MAY BE REVEALED •
AT/DURING ALiGNMENT.
PATCH TECH REMOVED AND REPLACED THE DAMAGED RIGHT CPVW 456
RE4R WHEEL AND TIRE, INSTALLED AND RESEALED THE �'99
TIRE PRESSURE MONITOR KIT,TORQUED WHEEL TO
- , VEHICLE SPECIFICATIONS AND VERIFIED PROPER
OPERATION.
s h AL TECH PERFORMED AND WHEEL ALIGNMENT TOVEHICLE CPVW 456
t p�: SPECIFICATIONS AND TEST DROVE TO VERIFY PROPER 89.95
£ OPERATION.
��. . � DURING INSPECTIONS THE TECH NOTED TNAT THE LEFf CPVW 456
INNER TAIL UGHT BULB IS INOP,TECH RECOMMENDS 0.00 .
REPLACEMENT AT THIS TIME(SEE LINE#5)
�`� n'C THANK YOU FOR CHOOSING SCHMELZ COUNTRYSIDE CPVW 456 �
VOLKSWAGEN;MIKE 8 YOUR VW SERVICE TEAM �•� '
� 1K0601025AN8Z8 WHEEL C
� DT10631 PILOT SPOR 385.00
� 207.99
� 1 K0998275 repair kit C
Technician 12 MIKE
26.88 .
� Techniclan 36 i
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-- ��:.ThBlIIC YOU StOt'@ HOUI'S STATEMENT OF DISCLAIMER
For Your Business! SERVICE The tactory wavanty constitutes all of the warranties
SALES PARTS With respect to the sale of this itemlrtems.The Seller
Yo�r eom lete satisfaction is our Monday-Thursd8 hereby expressly disclaims all warranties either
p Y Monday-Thursday Monday-Friday express or implied,including any implied wananty
#1 concern.(f you can't recommend ��00 am-7:00 pm 8:30 am-8:30 pm 8:00 am-6:00 pm of inerchantabiliry a fimess fa a particular purpose.
Frida Seller neither assumes nor authorizes an other
OUF$AfVjCB,Of I�YpU f1dV2 dfly 7:00 am-6:00 m Friday Saturday person to assume for it any liabiliry in connection
P 8:30 am-6:00 pm 8:00 am-4:00 pm with the sale of this ite�tems.
ques#ions,comments,or if we can Saturda y
Y Saturda ALL PARTS NEW ORIGINAL EQUIPMENT
be of�urther assistance please 8:00 am-4:00 pm 9:00 8R1-6:00 pRl UNLESS OTHEFWISE SPECIFIED
COfltdCt US. U-USED R-REBUILT
. - . . Y-RECYCLED C-RECONDITIONFD-
' Gl y��.L 1 1 80 East Highway 36
� � �, �+ � St. Paul, MN 55109
� ' �uOUNTRYSIDE 651-484-8441
VOLKSWAGEN Fax: 651-484-8446
www.schmelzvw.com . f
` SO#: 195205 Auth#: �I(I��I�IIIII�I'I���
Tag#: * Service Invoice Customer Copy * Page y
�
Customer No: 4937193 Advisor: MIKE HENDRICKSON Involce Date: 05/24/2013 Term: CASH
ANGELA
JOHNSON License No Odometer In Odometer Out Deltvery Date Stock No
1800 GRAHAM AVE APT 409 250CRZ � 85341 85346 06/25/2012 8D1071
SAINT PAUL,MN 55116 Year Make Model Model No Color
` Home:(651)340-0791 Bus: (651)582-8478 2008 VOLKSWAGEN JE7TA 2.OT SDN 1K2N3 R SILVER
� Vehicle ID No 3elUng Dealer SO Date InServ Date Location
Cell:` (320)493-7193 Today:(651)340-0791
3VWRJ71K88M175325 COUNTRYSIDE VOLKS 05/21/2013 07/15/2008
Email:angie.johnson@state.mn.us Fleet#
RequesUComplaint Type CSR# Amount
Requeat Totai 858.21
2 0 TOW IN
:: '.� . . � . . � .
. .. � . . . . . � . . . � � .. . � .. � t:_;.
I
Request Totai �^�_ O.OQ
,3 NO NO OPEN RECALLS FOUND AT THE TIME OF THE APPOINTMENT
;.;
�
Request TotaL 0.00
4 DECLINED CUSTOMER HAS DECLINED THE RECOMMENDED 80,000 MILE
_ SCHEDULED MAINTENANCE AT THIS TIME
1 N0177322 BULB C 3.65
Request Totai �3.65
Thank You StOr� HOUt'S STATEMENT OF DISCLAIMER
For Your Business! The factory warranty constitutes all ot the wairanties
SERVICE SALES PARTS with respect to the sale ot this item/items.rne Seller
�� �� hereby expressly disclaims all warranties either
Your'eomplete satisfaction is our Monday-Thursday Monday-Thursday Monday-Friday express or implied,including any implied warranty
7:00 am-7:00 pm 8:30 am-8:30 pm 8:00 am-6:00 pm of inerchantability or titness for a particular purpose.
#1 concern.If you can't recommend seller neitner assumes nor authorizes any otner
OUf SelVICB,or if ou have an Friday Friday Saturday person ro assume for it any liability in connection
Y Y 7:00 am-6:00 pm 8:30 am-6:00 pm 8:00 am-4:00 pm with the sale ot tnis item/items.
questions,comments,or if we can Saturday SetU�dey ALL PARTS NEW ORIGINAL EQUIPMENT "
be of#urther assistance please 8:00 am-4:00 pfll 9:00 afn-6:00 prtl UNLESS OTHERWISE SPEGFlED
CO(1t8Ct US. U-USED R-REBUILT .
Y-RECYCLED C-aFr.ntinirinnion
% ' C,�M�L 1 180 East Highway 36
� '� '� � St. Paul, MN 55109
' � ��U1VT11i S1�E 65 l-484-8441
' , ' Fax: 651-484-8446
� �VOLKSWAGEN �,,�„�,.5�hme�z,,,�,.�om �
SO#: 195205 ��III'�UII����II��
Tag#: * Service Invoice Customer Copy * A°�n#` Pe9e 3
Customer No: 4937193 Advisor: MIKE HENDRICKSON Invoice Date: 05/24/2013 Term: CASH
ANGELA
JOHNSON Ltcenae No Odometer In Odometer Out Delivery Dabe 3tock No
1800 GRAHAM AVEAPT 409 250CRZ 85341 85346 O6/25/2012 8D7071
SAINT PAUL,MN 55116 Year Make Model Model No` Color
Home: (651)340-0791 Bus: (651)582-8478 2008 VOLKSWAGEN JETTA 2.OT SDN 1K2N3 R SILVER
Vehlcle ID No Selling Dealer ` SO Date InServ Date LocaUon
CeIL• (320)493-7193 Today:(651)340-0791
3VWRJ71K88M175325 GOUNTRYSIDE VOLKS 05l21/2013 07l15/2008
Email:angie.johnson@state.mn.us Fleet#
Request/Compiaint TYPe CSR# Amount
•Rdded Operation
' ':5 ` BULB REPLACED ONE BURNED OUT BULB-LEFT INNER TAII LIGHT '
: BULB TECH REMOVED AND REPLACED THE LEFT INNER CPVW 458 t5.00`
- ° TAIUBRAKE UGHT BULB AND VERIFIED PROPER
OPERATION''
Technician 12 MIKE
�
; ; Request Total Y 15.00
; : LABOR 253.34
PARTS 623.52
SUPPLIES 24.13 .
� SUBTOTAL 900.99 �
{.;,
SALES TAX 44.43 '
TOTAL INVOICE 945.42
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;; �,.- :TI1aF1IC YOU- StOre HOUI'S STATEMENT OF DISCLAIMER
For Your Business! The factory warranry constkutes all of the wananties
SERVICE SALES PARTS with respect to the sale of this Rem/items.The Seller
� � hereby expressly disclaims all warranties either
Your complete satisfaction is our Monday-Thursday Monday-Thursday Monday-Friday express or impiied,including any impiied warranty
` 7:00 am-7:00 pm 8:30 am-8:30 pm 8:00 am-6:00 pm of inerchantability or fitness for a particular purpose.
#1 concem.If you can't recommend Seller neither assumes nor authorizes any other
OUf S2CVIC2y Of If ou have an Friday Fridey S2turday person to assume for it any liabiliry in connection
Y Y 7:00 am-6:00 pm 830 am-6:00 pm 8:00 am-4:00 pm with the sale ot this iteMitems.
questions,comments,or if we can SetUfdBy SBtufddy ALL PARTS NEW ORIGINAL EQUIPMENT
be of furthe�assistance please 8:00 em-4:00 pf11 9:00 am-6:00 pm UNLESS OTHERWISE SPECIFIED
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