The URL can be used to link to this page

Bednar _ . RECEIVED � JUN 18 2013 NOTICE OF CLAIM FORM ��Saint Paul, Minnesota Minnesota State Statute 466.05 states that "...every person...who clai�ns damages from any niunicipality...shall cause to be presented to the governing body of the municipality 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 clearl�typing or prinfing 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 COMPLFTED �ORM AND OTHER DOCU1ViENTS TO: CITY CLERK, 15 WEST KELLOGG BLVD, 310 CITY HALL, S�INT PAUL, MN 55102 . First Name �� J�� Middle Initial�Last Name �� IZ.-a�' _ � C'mm�anv nr R � � ��" �Q n d�s , -'-:... _ _ Are You an Insurance Company? Yes/�T If Yes, Claim Number? Street Address r r r�� c��' IV -�� 1-d LL� l/��• •5�� ' ' 1a CitY.��Q[1 � 3ta�e� �U Zip Code�_ � - ! �/ ��4� Daytime Phone �� ell Phone�.--��Evening Telephone Date of Accident/Injury or Date Discovered �j ^.� '" �`7 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 r�ponsible for your damag s. . n er • ee p e , ��- 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 , � a pothole or condition of the street ❑ My vehicle was damaged by a�low L� My vehicle was wrongfully towe an or c - ��` —' ❑ 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 anplicable 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. ,A�Property damage slaims to a vehicle: two estimates for the repairs to your vehicle if the damage exceeds $500.00; or the actual bills andlor 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 camplete and return both pages of Claim Form __ _ _ _ _ _ _ : . , __ . . _ _ _ _ __ _ _ _ _ _ . _ , I ' ; i ,. 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 No Unlrnown (circl ) Provide their names, addresses and telephone numbers: �e Q 0.�" � SL� � ____. � Were the police or law enforcement called? Yes O Unlrnown (circle) If yes,what department or agency? Case#or report# Where did the accident or injury take place? Provide street address,cross stxeet, intersection,name of paxk or facil'ty, closest landmark,etc. Please be as deta.' e as possible. If necessary, ch a diagram. i'f� � CW'� P�,►' Please indicate the amount ou are seekin in compensati or what you would like the City to do tp resolve this claim to your satisfaction. �� (�.,2� ,. �1 u��7.�`' .�'�e,r �K _j u vo�.# ' Z rrtcc�' �-�-- Vehicle Claims— lease com lete tlus section :� check box if this section does not a 1 Your Vehicle: Year�t Make j-�p�,�Ci Model e C L, License Plate Nurnber 3 � State�Color �q r-k G rce� Registered Owner L��i S G 6 c ti ��d r��r Driver of Vehicle E[i�c�b r�-�,, ��a,p- Area Damaged �A S S e n a e►r �ca r� GJ h P...e Z City Ve 'cle: Year Make Model � `" � License Plate Number State Color Driver of Vehicle(City Employee's Name) Area Damaged �/�Iniury Claims—please complete this section �heck box if this section does not applv � Ii 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 woi�k� �" „ Name of your Employer: Address Telephone ,I�Check here if you are attaching more pages to this claim form. Number of additional pages��5°� B�l� B,y signing this form,you are stating tlzat 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 ca�z result in prosecution. Date form was completed �j — ��j/ "' �,� Print the Name of the Person who Completed this Form: �L l S4lp e�1j �E�d/?Q�' , IO !� � Signature of Person Making the Claim: �L l S a E� Revised February 2011 " � Page 1 of 1 . Discount Auto Sales � Service �nvoice 1047 Raymond Ave 5515 Saint Paul, MN 55108 Estimate Ref#0 Shop Phone: (651)917-2288 Date Printed: 06/04/2013 Printed Time: 1:42 pm Web Address: DISCOUNTAUTOSERVICE.NET HaURef: ASE CERTIFIED TECHNICIANS Time Promised: Bednar, Elizabeth 2004 HONDA ACCORD EX L4 2.4L 2354CC FI GAS N K24A4 1105 Oxford St N VIN: Saint Paul, MN 55103 �icense: Mileage In: 113,880 Date Written: O6I04/2013 Home: (651)488-5048 un�t#: Mileage Out: 113,880 Written By: Cell: �oM: Save Old Parts: No Job Name Description Technician Qty List Extended Diagnose r Rear Wheel was told was George Augst wobbling Labor 1 o uested-Passenger Rear Wheel was told 0.50 95.00 47.50 - -— ---,nra�we�li�g_ _ -_ --- - —_ __---- —--- — � Job TotaC 47.50 - ------------------- -------r ----------- -------------------------- - alignment alignment George Augst Labor 1 sted-alignment 1.00 95.00 95.00 Work PerFormed-alignment �•�+� Job Total: 95.00 -------------------- mass CLEAN T BODY AND REPLACE AIR George Augst FILTER Labor 1 Work Requested-clean mass air check air filter . • • Work Performed-clean mass air check air filter Part FILTER Air Filter Element • • 3 • ------- ----------- -- Wheel Remove and Replace Wheel eorge Augst Part 21545 Wheel 1.00 300.00 300.00 Labor 1 Work Requested- Remove and Replace Wheel 0.25 95.00 23.75 Work Performed-Remove and Rep eel Job Tofal: 323.75 ----------------------------------------------- y7`�o _ _ _ --- - - _ _ �r . ,�x3: 7s I � 5' Parts: $319.73 Payment Date Type Method Amount Labor: $213.75 Sublet: $0.00 6/4/2013 Cash 570•� Misc: $0.00 Payment Totals: $570.54 �—' � Hazmat: $6.30 , � - �� j f �� Supplies: $6.30 �i a g n6 s �9 h rn e n j,�ti e e Z --- L� ' _ _---_ Tax Total: $24.46 � �� , j16 Invoice Total: $570.54 � Less Paid: 570.54 6 � �� 3'�� d6 Balance Due: $0.00 6 • 3v THANK YOU!WE APPRECIATE YOUR BUSINESS! I hereby authorize the above repair work to be done along with the necess�ry material and hereby grant you and/or your employees permission to operate the car or truck herein described on streets, highways or elsewhere for the purpose of testing and/or inspection. An express mechanic's lien is hereby acknowledged on above car or truck to secure the amount of repairs thereto. Authorized By Date Time