Mclaughlin K�L�IVED
MAY 2 0 2013
NOTICE OF CLAIM FORl�t��.'h��I�f Saint Paul, Minnesota
Minnesota State Statule 466.05 states that "...every persorT...who clalms danaages,�rom any nxunicipnliry...shaU cnuse to be presenled to the
governing hocl,y r�f the municipality within 180 day.s uf'ter the alleged ln,rs or injury is di.scovered u notic•e.ctating the time,pluce,uncl
circ��i��stcnu-es�hereof,und the amowit of corripensntion or otlter-relief clemanded."
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 uf 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
r �/
First Name�i�TQ,f G�C.. Middle Initial�Last Name �C �� JC�I-�s-�/�'
Company or Business Name �/�
Are You an Insurance Company? Yes�i'No� If Yes, Claim Number?
Street Address� ��� �tO�a,��,�� .���'
City j T 1���' W State ��/" Zip Code ��1's
Daytime Phone (�)�"��Cell Phone (fo� d )�-o r Evening Telephone(�)�`��- �3��
. �� � P
Date of Accident/Injury or Date Discovered �'�� �,���� Time «�.5 m/ m
Please state, in detail, what occurred(happened), and why you are submitting a claim.Please indicate why or how you
feel he rty of Saint aul or its employees-azy^e involved and/or r ponsible for our damages.���✓i/��Y�14i�rTN��
� �t f��/►� � 55�l+l a� t�N��R .J�.'"CJ f� � �0 i��L� ��.�.�C,(� �1�f7'� '1,1�T'Crh? !V
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2' �la - . c:,� 71+c. �'�Q � a O c`NOS'_Ar✓C � in/ �ie i� �O�iU�✓"S CR..�' �" c��,D..
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"i![is j�-ptl� f�r N�tP � -.
Please check the box(es)that most closely represent the reason fior completing this form:
❑ lyty vehicle was damaged in an accident ❑ My vehicle was damaged during a tow
@'S��iy 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 you need to include copies of all apulicable 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.
C�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$500.00; or the actual bills
and/or receipts for the repairs;detailed list of damaged items
O Injury claims: medical bills,receipts
O Photographs are always welcome to document and support your claim but will not be returned.
Page 1 of 2—Please complete and return both pages of Claim Form
Failure to complete and return both pages will result in delay in the handling of your claim.
Hii �laims—please complete this section
Were there witnesses to the incident? Yes No Unknown (circle)
Provide their names, addresses and telephone numbers:
Were the police or law enforcement called? Yes No' Unknown (circle)
If yes, what department or agency? Case#or report#
Where did the accident or injury take place? Provide street address,cross street, intersection,name of park or facility,
closest landmark,etc. ^P�ase be as detailed as possible. If necessary,attach a diagram. II�oRTI�����ND �a i RV7�
/�T ��� u�J D�K.!`'.�SS
Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction. �'7� 1. `7$
Vehicle Claims— lease com lete this section ❑ check box if this section does not a 1
Your Vehicle: Year 2�G9�� Make ck�Y Model .�'/�t ,��,a!
License Plate Num r C1 p�= Statel�! Color LJ�� ��
Registered Owner � ��K � � !k's !�J/� �
Driver of Vehicle /1.�� �' P t� L!
Area Damaged �'� ���'�-�, /Z►M, Tr�% �'� `
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniurv Claims—please comnlete this section l�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 work? (provide date(s))
Name of youur Employer:
Address Telephone
Q1'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 /� ��
Print the Name of the Person who Completed s o �C� � � N�'�^�
Signature of Person Making the Claim:
Revised February 2011
5/6/13 Prirrt
Subject: Damages
From: Pat McLaughlin (patmacsr@yahoo.com)
To: ward4@ci.stpaul.mn.us; ward3.@ci.stpaul.mn.us; potholes@ci.stpaul.mn.us;
Bcc: btreacy@�isi.com;
Date: Monday, May 6, 2013 3:07 PM
TO WHOM IT MAY CONCERN:
On Wedn�day, P�lay i�t I �vas �rii°ir�� "Ja��bour�d on Fairview.
As I passed under I-94 My car hit a pothole which was filled with water and, therefore,
invisible.
It was raining/snowing and there is no lighting under the bridge.
My left front tire and rim were damaged beyond repair and cost $420 to repair.
As the repairs were being complzt2d the garage was unable to do the wheel alignment
because
the force of the impact destroyed the left inner tie rod end. Only three days before this I had
replaced the
outer tie rods and the inner tie rods were soiid.
Now I am faced with another $315 to replace that tie rod and have the wheel alignment done.
Over $700 in a po'tt�ole!
I am a resident of Ward 3 and the pothole is in Ward 4. What is my recourse for getting some
of my money back?
This should not happen.
Pat McLaughlin
1821 Goodrich Ave.
St. Paul, Mn
651-699-4364
about:blank
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PLEASE REMIT TO:
� �. � ,�' . ��" ROYAL TIRE INC
� NW7828
� " PO BOX 1450
MINNEAPOLIS MN 55485-7828
www.royaltire.com
Order Number: N060075620
N06 St Paul Invoice Number: N060057993
1695 Universiry Ave Invoice Date: May 06,2013
Salesperson: F77
St. Paul MN 55104 Customer PO Number:
651/644-4905 Page 1 of 2
• � • •
Make: CHEVROLET
MCGLAUGHLIN � PAT " Model: IMPALA •
1821 GOODRICH ST Year. 2006
Color:
License: UEP521
Saint Paul MN 55105 � :� Unit�
(651)699-4364 Cust ID:� 00235131 Mileage: � 113,461
Comment:
• � ' ' • • " � '"
FLAT REPAIR IN THE TRUNK
008603 2255517 FUZION TOUR 101H BLK 2.00 80.99 0.00 0.00 161.98
225/55R17XL
OPWHEELS 17"REBUILT WHEEL 1.00 189.00 0.00 0.00 189.00
p1 N/A BASIC INSTALL PKG F92 2.00 0.00 O.QO 0.00 0.00
A30 N/q PASS COMPUTER SPIN BALANCE F92 2.00 11.00 0.00 0.00 22.00
C_3315 N/q 40,000_MILE WARRANTY F92 2.00 0.00 0.00 0.00 0.00
C_3342 N/q FREE 2 WEEKS OR 1,000 MILES F92 2.00 0.00 0.00 0.00 0.00
TRIAL OFFER
C_3343 N/q TORQUED TO SPECIFICATION F92 2.00 0.00 0.00 0.00 0.00
C_3395 N/q FREE TIRE MOUNTiNG F92 2.00 0.00 0.00 0.00 0.00
W/PURCHASE
C_3421 (�/q FREE!!LIFETIME TIRE ROTATION F92 2.00 0.00 0.00 0.00 0.00
FA (v/q FREE-ALIGNMENT CHECK F92 2.00 0.00 0.00 0.00 0.00
C_3030 N/q RUBBER VALVE STEMS 2.00 3.50 0.00 0.00 7.00
DISPA N/q PASS TIRES DISPOSAL ONLY 2.00 4.00 0.00 0.00 8.00
RHWCOMMEN N/q 1ST 25%OF TREAD 2.00 0.00 �; 0.00 0.00 0.00
T FREE-PRO=RATED AF7ER THAT ; .: :
RHWDECLINEDN/q CUST DECUNED TIRE PROTECTION 2.00 0.00 0.00 0.00 0.00
PLAN
PASS FRONT TIRES PRESURE SENSOR IS NOT
READING
LEFT INNER TIE ROD IS LOOSE CANNOT ALIGN.
$314.86 PARTS LABOR&ALIGNMENT.
SHOPSRTL N/q ENVIRO FEE/SUPPLIES-CONS'R 1.00 1.65 0.00 0.00 1.65
c�l�•1a
31�. �'G
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, ��'�g 7'b�A
RcP��R-�
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PLEASE REMIT TO:
� � � � ROYAL TIRE WC
N W7828
' PO BOX 1450
MINNEAPOLIS MN 55485-7828
www.royaltire.com
Order Number: N060075847
N06 St Paul Invoice Number. N060058101
1695 University Ave Invoice Date: May 14,2013
Salesperson: F77
St. Paul MN 55104 Customer PO Number:
651/644-4905 Page 1 of 1
� � • •
MCGLAUGHLIN , PAT Make: CHEVROLET
Model: IMPALA
1821 GOODRICH ST Year. 2006
Color.
Saint Paul- MN 55105 License: UEP521
'., � ' ;, , Unit:
(651)699-4364 Cust ID: 00235131 Mileage: 113,698
Comment:
� � . . � � .. � ..
ALIGN N/q ALIGNMENT SERVICE F98 1.00 74.99 0.00 0.00 74.99
DISCLBR N/q DISCOUNT LABOR 1.00 -20.00 0.00 0.00 -20A�
SHOPSRTL N/q ENVIRO FEE/SUPPUES-CONS'R 1.00 5.62 0.00 0.00 5.62
PAYMENT 7YPE:Cash $ 60.61
By providing a check as payment,you authorize us to either use infortnation
tiom your check to make a one-time electronic funds transfer from your CUSTOMER SIGNATURE•
account or to process the payment as a check transfer.For inquiries please call
320-257-3042.
A FINANCE CHARGE OF 1.5%/MONTH(18°.�a/ANNUAL RATE)
WILL BGCHARGED ON ALL PAST DUE ACCOUNTS.
'. . •i�' � • '. C • • � � •
$0.00 $OAO $74.99 ($14.38) 7.63 $0.00 $60.61 $ 0.00 $ 0.00 $ 60.61 ,
.��.._,...,,,„�+..
+,
' PLEASE REMIT TO:
4..
'� � ,( � ROYAL TIRE INC
NW7828
PO BOX 1450
MINNEAPOLIS MN 55485-7828
www.royaltire.com
Order Number: N060075620
N06 St Paul Invoice Number: N060057993
1695 University Ave Invoice Date: May 06, 2013
Salesperson: F77
St. Paul MN 55104 Customer PO Number:
651/644-4905 Page 2 of 2
� � • �
MCGLAUGHLIN , PAT Make: CHEVROLET
Model: IMPALA
1821 GOODRICH ST Year: 2006
Color.
Saint Paul _ MN_ 55105 License: UEP521
:.... . ,..,:. .,.„.. � 1. ._
. . . s . , . , _,. ;
_ . .. Uni� :. .,__..
, . , .. -.
(651)699-4364 Cust ID: 00235131 Mileage: 113,461
Comment:
• � � ' • � •� �
PAYMENT TYPE:Cash $416.92
By providing a check as payment,you authorize us to either use information
from your check to make a one-time electronic funds transfer from your CUSTOMER SIGNATURE:
account or to process the payment as a check transfer.For inquiries please call
320-257-3042.
A F[NANCE CHARGE OF L�%/MONTH(18%/ANNUAL RATE)
WILL BECHARGED ON ALL PAST DUE ACCOUNTS.
. .. . .;�. � . � . . . � . • � • •
$ 161.98 $0.00 $22.00 $205.65 7.63 $27.29 $389.63 $0.00 $0.00 $416.92
-; � -
RO�AL TIRE NO. G
169�i�'IZ'ERSITI':���E.
ST.P_�,LZ,�I\S$IO�I
Phone�Iumber: 651-6�1�--{905
FAS'�umber:
�Customer: ���PAT1�iCGLALTGHI.�T iDate: �Sf1412�1_��:4�_35PM ��� �'
�C'ompany: ��'Il� 2G1V�USS1069?9�U21 '
�Licen�e No: L.?EPS?1 �Technician: 9�+
'Oaomzter: 11�C99 ;Urder No.: C-7�8�7
_. _ _ ,. . _ _..,... . ____ _ _. ..._ __A. _.. ___ ,_._____ __ --- __._._______._ . ___ _ _ __ .._. _
____ _--- -- - - -__-- ---
VEHICLE �ALIGNMENT REP4RT ;
i
? CHE�•'R(aLET_. 2UOG, �SI'ALA RPO FE 1
-- -- ------------------ ----------.._ ----------___-----------
Pr�mary Angles � Initial i Specitication.: � Final
I -_____----.._._�Iin. _.__ A��.�. ' �
._....._�._�__._.. _ ___._.�_._.____._ _,.. . _,_.___
__
r Lzft ��� ( ,�o ��o..____ __._.. _��� _ �
1 C 1SICI�� _�_____� RI�t" �.'° ( ?'�° 3.�° 1 ? �� t
� ; _ _ . . _ __ --. _ _ _ __ � .__._ _ _ _ _ _ _ __ _._ __ 1
_
; _ Left i -1.9° ; -l.;° -0.;° _ q•,
� . �
9Frc�nt �C'•uuber Ri�ht � -1?°,---!--- -l.�° -------�-�='�-----!-----j���---.
�-------------------- ,
; ' L2ft ! 1.U;�� ; O.U�" t1.0;.� ; O.U(.1"
; `
! Toz Ri7ht i 0.0�,� j t►.00^ 0.0;,� � 0.0�" ;
Totnl i l.l(1 i 0(?�,. 0.15.� � 0 Oi„ ;
_____..,_�__.._._..___. _. ,_...._._. . ____._ ...___.... ..__..� .._�� i__.. . ___�.. ...__.__ _.._._ _ ___. .__.- -- ____. .. __
__. _. :
' Lefi -0.9" � -1.?° -t).?° 0.`)" ;
!C amber ' '
Ri�ht -Q.9° -1.?° -t1.�. 0.9�
(-}__. �..__ _. __._ _.._---_. __ . .. ,__. . _ __.__.. _ _ _ _____ _ _� __ __ _._. ;
t Left �.00" , [►_0�" i►.0;,� � O.Op�� �
Rrar ;T�e Ri�ht -�A�.. ! O.UO" • u.0;,, -O.U>„ `
� Toial -0.0;.. -U.U��� 0.1� ' -0 U;,,
: ;.��_-______ _- ----------___ - --- -------- __ __ ----- -- ------- -----_ __- -- - --—
� ;Thrust An�le ; -4.1° ' -0_?° U?° -0.1' �
______---,___..__.�_..__...__.. ..,.__ .._.. __�.,.._._,�.__.______._...K_..�.�....�.-- ---........__.�_�__.._ _ _ ____----_._,_
�Secondarti'Ai1gIpS ' Inicial tipe�itic�ui��n• Finat
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_._ _ . _ _ _ __ __._ _ . _ _ _ _ . __ _ __ _ _
Leit _ 1-�.�° _ l�U° i
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� _ ___ 1;_�?° _._�:—____�� -- ---------.__.._.. 1' �� ;
------ __ .__ --- ._ __-
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E ''�
f Inrluaei!�uvle Ri_ht ; 11.S° ------ 11.?:°
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v - ----
'-----_ . _�__._.... _.__ _. ...__ __ Left __ _ . . _,._ _ _ _ _ _ _ __ . _. __ . _._. ------- ,
' �_ ` t�.�o. �).�)" r
Toe Chrt On rurns ��t ' p.0° O.t}° ------
Left ----- ------- ------- ,
; _�__
'h1<11inn�m Turus �,zht ;
� ----- - -- ----- - -------
_ ,
�__------ --�_____..-----__.__.----__ -____ _ _ .. . _. ______u .._._ ..___._ _.._.___-- -.----�____ .---- --��____�.__
�TC12 C LlI4°e ChanRe Le1t
i ---- j ------ ----- ! ------- �
R.i�t --- � �____ _�_ i _-_--- i
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3
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Track�1'idth DitF. --- � (�.�" �-- -------- <t.ti" f
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--_._ _
. ______ ____ __ ____ _ _____--.__�.__ ___--__ __ .__._._ . __ _ ___ _ _ __ ___�
L�n � ----- — - ----- - ---
Front Ridz Heivht ��i � __
---- - - -----
�____._._ _ __... . _. . . ...--- ._______ .___.--- .. ___.._ __.4_ _ _ _ . _ ._..._-----._ . _. __._ -------_ _._ . _-------__.
,
Left � ----- . _ M
�Ftear Ride E�ri�ht Iti�t ' ,
� ---- ------- ---- -
-------____________.�_.-- ----�__._._.,___._r_ __ ,---_��.__ __.____. _ . _ -- --
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"Our Family Serving Your Family Since 1948."
�U ������ REPAIR ORDER# `�J 5�� Z `�
ENGINE SIZE
4�' � ODOMETER ll> `'�� �
4x4
TECHNICIAN VIN#
. � � ,:�r��,.
� : � . �• WIltiREOUIRE FUTURE ATTENTION " " � � � ' � '� F�
. � .
, o � , 6 �
__.._ ___.___ ..___..____ � ❑ Visually inspect front suspension.
� � � ❑ � Visually inspect rear suspension.
LF � � RF
� ❑ Visually inspect steering systems and components.
.` �.
,� _
� � � ❑ ` Inspect wheel bearings
� � � Rear(if applicable) � � � Visually inspect exhaust system for leaks,damaged 8loose parts.
k�
Visually inspect transmission,drive shaft,u-joints,CV joints,and
❑ ''�'',� Windshield condition � � , �:�+ transmission shift linka e if e uipped.
Cracks Chips
e . � � � � �
RESET MAINTENANCE REMINDER SYSTEM Y wA
� ❑ ,, ,� Check all vehicle dashboard waming lights.
� ❑ � Check interior lights,exterior lamps,brake lamps,turn signals, � �
y- and hazard warning lights. J
� ❑ ; Inspect power windows � /K�(�.�I��� �r ���� `�`S � �
� ❑ Visually inspect engine coolant level and brake fluid level. j 1j L . O �-�
�i-!��e_
� � Inspect power steering fluid and transmission fluid level. �L` . cl ,.�
� ❑ � �. � �.�.��.-i�r
y.:. Check windshield washer fiuid levels.Add fluid as needed.
Z, �, , �,�"v
� ❑ � Inspect for fluid leaks. 5 S
� ❑ ',,� Visually inspect engine air cleaner filter. � � �) •• �r"'
� ❑ 4�� Inspect cabin air fiiter.
� ❑ � Inspect fuel fiiter.
❑ �K.�."..
Inspect Battery condition.All cables and connections.
� � � Check Belts and hoses.
�.,-�
b � . ' v.r'h �l.f... �
.
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LF _ _ . _ � .. _ _ _ - RF
�� �Brake Lining mm �❑ �'� B�ake Lining mm
�❑ �Tire Tread 32nds
�❑ '•�a` Tire Tread 32nds
�❑ a Tire Pressure PS� �❑ �Tire Pressure Psi
Rotor Thickness
Rotor Thickness
Rear
Front
RR
LR
�� �Brake Lining mm
�❑ `�Brake Lining mm
� � �Tire Tread 32nds
�❑ �Tire Tread 32nds
� ❑ �Tire Pressure psi � ❑ �Tire Pressure psi
� Rotation needed � Ali9nment needed
� Rotation performed � Alignment performed
Tire size Perf.Rating_