Moen . �; ���-
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CITY,CL�r.o ,
NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minnesota State Stntute 466.05 stntes t/iat "...every yerson...who claims clnmages from any municipnlity...shall cnuse to be presented to the
governing bocly of the rnunicipnlity wid2in 180 days after the alleged loss or injury is discovered a notice stating the time,place,c�r�d
circunistances thereof,and the aniount of compensation or other relief demnncfed.°
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 � -l� Mi�dle Initial�Last Name ���C�� �
Company or Business Name !'� ��
Are You an Insurance Company? Yes/ T�, If Yes,Claim Number�
\ i � t j ,
Street Address �',�� V�14,��i�►�t1� c��'. V�,��� � (�6�
City ��� �"C.UJ�,� State ��1� Zip Code �� �G '�
Daytime Phone(�5� )��� -���-��'� Cell Phone(�L}��-�1 Evening Telephone(�c'J I )��_- ��1y�0
Date of Accident/Injury or Date Discovered 3 " ���'� lr� Time�'�� am/ m
Please state,in detail,what occurred(happened),and why you are submitting a claim.Please indicate why or how you
f�e]the City of Saint Paul or its employees�re involved a d/or res onsible for your damages. � 1�.1 G�.S
� Y��f �� �G`;\�'�.:-t C�� �ti V 1�:� .5 �J , ��� �t, v..►V�C.� �'C' Lnir�`2
r�o�' k�� ^ 4-�,r �^� a�Q. \ �^.c.c. Y�� � 0..���1 � 1
' . �;., �. ,
�L� '10\�^ (�.� � -�. ���e. CLU�:> ���1. t?1'�.� 1 t7- + C�.V'.oi L:�'i +ti����
� _Y lV\\ � 1'�.. �. �` �\C � �> > l ��4\�G {iY} ��� � 1��.�
;�r�. ��4�.��� r'�..\c�� e�� ��� a �et-� o�M ' l vv.��c� .
`�"� �>�� _ u%�;�.� ,��� w�° ���v av��� � 5';�tv� -��,�
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
C Y�y��h:c.e was w��n�;u;iy torved an�'o�ticketed ❑ I was injured ai3 City�prope<<y
❑ Other type of property damage—please specify
❑ Other type of injury—please specify
In order to process your claim youu need to include copies of all applicable 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
copy for yourself before submitting your claim form.
m 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 datnaged items
O Injury claims: medical bills,receipts
O Photographs are aiways 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? 'e �T Unknown (circle
Provide their names,addresses and tel�hone numbers: ��hv� ��'4��� -'�"��3 �1�Y�5�� ����y�i
5-� , p�.�ti��, 'M N �_> t� eo — -�o � �- 3-+ � - ��3 ai
Were the police or law enforcement called? Yes N�y Unknown ��ircle)
If yes,what department or agency? C�I� Case#or report# N ���
Where did the accident or injury take place? Provide street address,cross street,intersection,name of park or facility,
�losest landmark,etc. Please be as d�ailed as possible. If r�ecessary,a�ac�a� �d�iagram. I���V ��\i , `�
,'��?`�� �"�k'1n `J� .���E-;" C aC<C!� l'az,'ti.oc�-41 iLti�i;�.51'.� `.Jt� 11a.:r\�C'.'� ��:. u' '� ���n� L.cL�'
�l'Ck(�.id�q i�LV����1�� � -�
Please indicate the amount ou are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction. � �_`>��.s � — ��� Ql'`n���i\�` �II C C'.��c��+� ����r�
Vehicle Claims—please complete this section ❑check box if this section does not apply
Your Vehicle: Year ��`��} Make P�n�r�a C Model L��CU,�� p t\w
License Plate Number �,3`� �_ State ��_Color T��,r�
Registered Owner��\e�l �t`�\�C� ►�
Driver of Vehicle� S ��L �.-�
Area Damaged `�����'v��- '�;1.`._�� fi.d���' ��ti� r ��.�r tS c�S���c� ' e ' c�-�:-Y�-• c�'ec'�
City Vehicle: Year 6•1 j 1� Make 1� j(� Model N 11� ,
License Plate Number �1�k� State N il� Color �1 ���
Driver of Vehicle(Cit Employee's Name) N �t\
Area Damaged j�l���
Injurv Claims—please complete this section �I check box if this section does not apply
How were you injured? ��1�
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? N��1 (provide date(s))
Name of Medical Provider(s): ��+;�t�
Address � I\� Telephone
Did you miss work as a result of your injury? Yes No
When did you miss work? N� (provide date(s))
Name of your Employer: i��`�h
Address �;1;°�� Telephone
L�Check here if you are attaching more pages to this claim form. Number of additional pages 5 .
By signing this form,yoic are stating that all informalion you have provided is true and correct to tlze best
of yoz�r 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,this Form: ��v"���� ��%�t��
;1 , , : ���� �� _� \
Signature of Person Making the Claim: ���v'� 4 �v�'�-L \
�
Revised February 2011
.f - - --
$� Midas Auto System Experts #6
�^ 1450 S Robert Street PAGE 1
` ,�,�,��� SAINT PAUL,MN 55118
'��'M�,' �:•`s (651)457-4381
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:ustomer ID: 2597027285 Year: 07 Date/Time: 04/01/13 16:37:56
lame: ASHLEY MOEN Make: PONTIAC Estimate#: 151887
.ddress: 406 WACOUTA Model: GRAND PRIX Invoice#: 113186
.ddress 2: Lic No: 439ARU Key Tag:
ity,State,Zip/Postal Code: SAINT PAUL,MN,55101 VIN: 2G2WP552471175738 PO Number:
ome Phone: ()51)214-6444 Color: BEIGE Email Address: ashley684@hotmail.com
/ork Phone: � Engine: V6-3800 3.SL Fleet/Wholesale: N
�ther Phone: Q- Mileage In: 110329
ax Exempt#: -, Unit Number:
ervice comments:
Mileage Out: 110329
INSPECT FRONT END/FIND TIRE AND RIM WITH HUB CAP
ty. Part# RFR Loc Description List Labor Total Midas InYI Corp issues rvritten warranties on muf-
��(= flers,shocks,struts,strut cartridges,brake shoes
`921011 RA TPMS SENSOR &pads,catalytic converters&variable rate spr-
PBR930548K RA ' 0.00 0.00 0.00 ings.The warranty terms of these products are
HUB BEARING ASSEMBLY 245.00 105.00 350.00 stated on a seperate printed warranty certificate
OVERALL 350.00 issued to you upon purchase of the a ro riate
TOTAL BRAKE: 350.00 warranted product.The terms of ALL warranties are
tONT END in the warranty binder on display in each
*HUBCAP RA HUB CAP - Midas Shop.All other products or workmanship are
97•52 0.00 g7.52 warranted for(90)days from the date of instal-
TOTAL FRONT END: 97.52 lation.There are no other warranties issued by
.IGNMENT Midas InYI Corp.Warranty work will be performed
ALIGN at any Midas location in the USA or Canada offer-
� FRONT ALIGNMENT 0.00 69.99 6g.gg ing the warranted product. For the address of the
TOTAL ALIGNMENT: 69.99 nearest Midas Location,see the Yellow pages of
2ES - the local telephone directory or write Midas
TIRE INSTALL RA MOUNT, BALANCE,VALVE 0.00 18.00 18.00 t sca IL 601q3tions, 1300 Arlington Heights Road:
144-645 RA ECOPIA EP422 92.33 0.00 g2.33 LIMITED WARRANTY ON WORKMANSHIP&MAT'LS
Tire Size: P225/60R16 Speed Rating: H This Midas Shop warrantes to the original purchase
Ply:97 H Walls: BL Load Rating:97 for 6 months or 6,000 miles,whichever comes first,
'WHEEL Rq from the date of purchase,all materials 8 workman
USED WHEEL 79.99 0.00 7g,gg ship EXCEPT any Midas product which has its own
TOTAL TIRES: 190.32 warranty certificate through Midas InYI Corp. Dur
ing this period if such product or workmanship
BE OIL FILTER should fail,they will repaired/replaced free of
CC RA COURTESY CHECK 0.00 0.00 0.00 charge upon presentation of this invoice,at the
TOTAL LUBE OIL FILTER: 0.00 location listed on this invoice.This is NOT a
Midas InYI Corp warrantyand does not cover the
AD HAZARD cost of additional components&labor required to i
RHW RA ROAD HAZARD WARRANT 10.00 0.00 10.00 restore the related system to its proper operation
TOTP,L R�,^,D l�AZr1RD: 10.00 This warranty gives you specific legal rights,you '
may also have other rights which vary from state '
to state.Thank you for your patronage and have
�ustomer Wishes To Discard Oid Parts'"* a wonderFul day!!!IIIf!111
i
NECESSARY COMPONENT OF WORK
. MIDA$ 5'ERVICE GENTER q }
WE5148T pp�OBE'R�T 95118
iERMINAL ID: AA14319A5
MERCHANi �: 1A7218978998 � �
UISA �
AMOUNT SUB TOTAL 717.83 I �
VIS 754.51 SALES TAX 36.68 #xxxxxxxxxxxx1392 f ;
SALE
GRAND TOTAL 754.51 F BA1CH: 881539 IHVOICE; 8391538188
H:000693-1.82 J. KRUG DATE: APR B1� 13 TIrE: 16;37
6Q: 8A5 AUiH N0: 822958
' TOTAL �54.51 ;
INVOICE INVOICE MidasAuto System Experts #6 INVO CUSTOMER COPY
CUSTOMER COPY �-•-. _ .
` i'� �l � � 03 � 4
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�rmer: VIN�I� I� I� I,�, I.� I�(� �,� I7 � 1 I 1 �7 `.�(7 I3 I� I ��.
�
f License��� � EST or Miles:�{� � Year/Make/�� �71-ust the Midas touch�
Plate: � � CSR#: l Ni� Modei:
0 0 ° - a - o May Require . , , , � • �
� Future Attention
,
. . . .. •.
Inspection/�icense due date: ❑ dw pedal ❑ Hard pedal ❑�ulsation
�If applicable
Noise ❑ None at this time ❑ arning light
� � ■ Dash Indicator�ights Sae��tr:���� ❑ Full evaluation suggested n
�=� t3=
��❑ ■ Horn �noperabfe Poor Tone
Tire size oE / / nctuai�16d l.�t
d� ❑ � EXt2YlOf'L19NtS �noperable Damaged Lens 7�ead Depth
� ❑ ■ wipers Inoperable Torn Chatter/ ' �- �5�32"or Greater ❑3�32"to 4�32" �2�32"oY Le55
a Streaking (y� � F
�i� LF�].a ❑ � /3z o�0�/32 � O��
� ❑ ��Hood�Hatch Supports �noperable Missing Damaged
°' � . ��1� �R y�' ❑ e az � /3z �❑ � RR
L
= 0 ❑��Engine Air Filter M�ssing st� oE ce
� wear Pattern/ Air f�ressure rtre Check/OE
. o Darr�age �TPMS warning IntervAl
� � �.�Cabin Air Filter nnissing st� e►nt al ' SyStem qd�ustedto �iuggests:
v
,�„ �, ccn _ cca �F � � eefore oEn�spec(cold) '� ��' nment
v RaNng al � � O F nt 9
� �■ Battery/Cables � RF �F 3
�, outofspe orrode �� BA�AYIC2
6°J �, RF �
l�l ❑ ■ Hoses Cracked Leaking Spongy �.R � � � ❑ •tAtIOYI
v RR '�.R 3a Rear RepAIP
i�
6 � ❑ ■ BeitS (except timing belt) Missing Cracked Frayed ,� � � RR �j� � �rtepiacement
�
��� ■ Window Washer Fluid .����� Your next factory scheduled maintenance(FSM)
J -
�' ❑ ■ Engine Oil ��e� oE�n��a� interval is scheduled at: miles.
� �■ r�ower Steering Fluid Leve( Over 5oK miles on oE Int$rval �/
originai oEM�iuid T�C ician Note :
Q'❑ ■ Tr^ansmission Fluid �evet E�nterv � `Y✓6 � ,
� � COO�AYIt e� � OE lntervat
pH Freeze Point RA
� ❑ � BPAke Fluld �evei copper ppm oE interva�
PPm�O 10 57 � � � � �� .
� � 1
200 ppm or greater yZ
/ /
� �Fluid �eaks SreC1�r�
� �1, ■ Steering System eent TornBOOt obs Seized �—/ J// �
� � ■ Shocks £J Struts �eaking over oi i►es on , rechnician Signature Date
ori n units
� � ■ Exhaust System �ki g rtattle �oose Service Advisor Initiais
Worn�Blnding How'd it go... We want to know.. REALLY!
� � � DPIVeI.IflC(N/Drive Shaf�) Torn Boot �oint �'
www midas.com
_ _ _
The Midas Touch�Visual Courtery Check is a visual check only.This Courtery Check will not include the teardown,dismantling or removal of any ,
component part or rystem inspected.The resultr of this courtesy Check will be provided to you.Depending upon the results of this Courtery Check, �.. i�,�
if you desire additional inspection work and/or parts,it will be necessary for,you to autYiorize any additional inspection,work and/or parts. , �' : ��,,
_ , _ _>: ;. . . . ,:. , �..,.:�, „� . ,._ .�. _ ._. ..
(�J'!Ol 1 Midm Inlermlional Carporation. M7971 ENG ra.11/2011
�ireston¢ �
coMP�eTe auTO caRe- NE COMPLETE AUTO CARE SERVICE ADVISOR:
Cory Miller 491 JACKSON ST 01 CORY
General Mana
� T PAUL, MN. 55101-2319 651.224.5868
4s��ackso�st. 2007 PONTIAC GRAND PRIX
St.Paul,MN 55101
a:ss,.zza.sssa V6-3800 3.8L
F: 651.224.1387 L�C# V�N #
'} , � ,�-��} � ;��,
IN 01/01/70 12:OOAM EST. MILEAGE 0
�f i l �€G�, k�"'�+"1 - � � 1
� *,�y��� ;���y����www F,j. � e� e eA fo arie�m x4 -- - - _ _
w �y'*Y�_��r�"i t'�������Y"`f4l������R6�� R ' � ��5� ��� .- - -- --..._ . . .-- -..._ . _ .._ .
QUOTE
_,,��-�?�ti;��.,;�x�k�����:�,�._2�;��. .� y .. �:w��;��' .-. Article Extended Jo b
Description Number T# Qty Part Labor Price Total
- - _ _
BRIDGESTONE TIRE PACKAGE 141.48
144645 ECOPIA EP422 BL P225/60R16 97H 65,000 144645 1 114.99 114.99
Mile timited Warranty�
NEW TIRE WHE�L BALANCE PARTS 7018708 1 2.00 2.00
NEW TIRE WHEEL BALANCE LABOR 7018716 1 12.99 12.99
7097782 ROAD,HAZARD PROTECTION ,,� . 7097782 1 11.50 11.50
� �"~� ` `ifi ` �� �� . 7015016 1 N/C N/C
TIRE 1NSk} ��. a ON����',�� �, }� � �� '���x�
� �
>ALtGNMENbT�SER�ICE��� � u,� � , ���t ` 69.99
;�� Symptofn�� ,-�" , � ,.
ALIGNMENT'SERVICE , - � " �- . 7004578 1 84.99 84.99
LBR-DISC DISCOUNT ALIGNMENT SERVICE 7001681 -1 15.00 -15.00
WHEELS 01 293.99
STEEL WHEEL STEEL WHEEL 7017868 1 85.00 85.00
7007204 TPMS SENSOR 7007204 1 116.99 116.99
000 NEW HUBCAP 7003189 1 92.00 92.00
BEARING & SEALS (Front-Right) 367.99
BR930184 FRONT HUB ASSEMBLY 7001922 1 261.99 261.99
REMOVE & REPLACE WHEEL HUB- FRONT, ONE 7032158 1 106.00 106.00
SIDE
, �-
� f�_ �`���r t���°��`��-��;� , ��;'
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a: k�, . . � . . .
Prices valid for 30 days. Summary
Parts 684.47
Labor 188.98
Shop Supplies 11.34
Sub 884.79
Tax 52.19
Total 936.98
TH I S�v��Sr.I��O���AN��[J�1/41�,�F��,�.��;�,�9c�r�AY
� STDFCACLASP7-dg�3�l�f!��10392 REV11!11 � Quotet 121126
See reverse sid2 for Warraniy Information