McInnis �' ��-�- 1�'c�� ��e ���gi�� ��
�� I'�,�`{��' .�� � �.I�,7_��3Q� N�Inn+s RECEIVED
__ _ -- —
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APR 112013
CITY CLERK
NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
rNtir�resota SIaIe Struu�e d66.OJ.ctute.c dtc�t "...c rerr��er.soa...�rho clainrs clnnxrges fi•os�un r inruiicipalitl•...shall caru'e ta be/�resrirtec!to Ihe
�n�•ernin,��(�n�l�•of the neunicipn(in�n•itlrin IRO�(tn•s cr%ter 1/re alle,�ed loss nr injirn�is discni�ere�/c��rotice statiirg the time,plrrce,nnd
circrunsra�tces 1lrereof tmd 16e cunoruv n�'compe�isntion or odrer�elieFde»uinded.••
Please complete this form in its entirety b� clearly t�ping or printing your answer to each question. If more space is
needed,attach additional sheets. Please note tt�at youi«-ill not be contacted by telephone to clarify answers,so provide as
much information as necessary to explain�our claim,*nd the amount of compensation being requested. You will receive a
written acknowledgement once ti�our 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,«�rite`N/A'.
SEND CO��IPLETED FORti1 AND OTHER DOCUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
First Name �;, '::�:11�°�:�'r� �iiddle Initial f s Last Name �`-'�� t.�- �-����� ��
� Company or Bu�ine�s\�am�
. Are You an Insurance Company? Y _��,,,./y�'�i�'����_�.��o�..�✓���}� If Yes,Claim Number?
Pi `-�'1.,;` � "� ��'4,E� � r7 ;(
Street Address _ ��,ar'z F�( h,��' ��,�"�;��" -�" �
� ' ; ,.r ,_�� , .` � �r,:�,." �°n � ��:,� � � .._, -_ �,
City ; � ,t_ ,,� ��.� ; , St�3te z I,���e',t ,t`,� �i.� Zip Code,... �_:> s ��`r
Davtirne Phone i 1 - CeiI Phon� +�J�� ce'a"�J j 7��i.EczninR Telephone( ) -
f,,. ' y ` ' ' �+'F'�� k ...,.....�..�.�
Date of Accident/Injury or Date Discovered_ �� %'" �=� � a :�� Time i � �-��" am�pm ,'
Please state,in detail, what occurred(happened),and why you are submitting a claim.Please in �cate�vhy or how you
feel he City of Saint Paul or it�emplo�ees are involved and/or responsible for your damages. ' 1 ' � r='
`�`�'_� c:�fific.'�c�..l'��� 1���Y'
Please check the box(es)that most closely represent the reason for completing this form:
❑My vehicle was damaged in an accident ❑ VIy�•ehicie was damaged during a tow
�My vehicle was damaged by a pothole or condition of the street ❑ M�� vehicle was damaged by a plow
❑ My vehicle was wrongfully to���ed and/or ticketed ❑ I�vas injured on City property
❑ Other type of propetty damage-please specif}�
❑ Other type of injury-please specify
In order to process your claim vou need to include couies of aIl applicable documents.
For the claims types listed beloev,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.
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.
n�..._ � _c.� .�. ' -
_ __
__ _ __
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims– lease com lete this secrion YeS No `Unf krioW��:� ��ircie)
Were there witnesses to the incident. t__,�---•'
Provide their names,addresses and telephone numbers:
...._,_� Unknown (circle)
Were the police or law enforcement called'? Yes �-NO�C1sz#�r report#
If yes,what department or agency`?
W her
e did the accident or injury take place? Provide street addrss��r�iLlch a diagramction,name of park or facility,
closest landn�lrk.etc. Please be as detailed as possible. If nec.e y.
J f #� „� � 7
ease indicate the am unt`�ou are seeking in compensation or what,y ou��,ould like.the Cit}�„to do to resolve this claim
� M
Pl )/ ] -�' -# �+,(' 'YC,�`}
( � �,
��`d/11..�i.✓�++�. �'� .
�„.... +.� � ,,,;Y .��,
t0)'Otl 51UStc1C(IOII. , ' �r a�' . -;;,;
� .r"""..�c'�' .-... �;�� l.J ,�� � t.7 r...,
R � r
` ❑check box if this section does not a I
Vehicle Claims– lease com lete this section M�el �
i '
Your Vehicle: Year �--��—Make P� ���� State�_Color y' �'
License Plate Numb�r � r"�� � � ;,
� ' ��� � ��-��' �� t�'
Registered Owner : ��
� �j `�i ��>�� t ,'! �',, � . .•., .� ;"�`t�..i�a'�s':.:y
Driver of Vehicle � ' - •� �;= r "� ��
� s r:.t�.�,.�. ;.:���� -� )� � �� ���."� >�� ��``' `� �� ' � /u z
Area Dama�ed_�;____— �Iodel -
\Iake__ — -
Ci«�Vehic:.: Year._----- State Color_
� License Plate Number ------
Driver of Vehicle(City Employee's Name>
Area Damaged
In'ur Claims– lease com lete this section
�check box if this section does not a 1
How were you injured'?
What part(ti)of your body were injured?
Planning to Seek Treatment(circle)
Have you sought meclical treatment? Ye5 No (provide date(s))
VVhen did��ou receive treahnent''
Name of Medical Pro��ider(s):_ Telephone
Addr'ess No
Did you miss work as a result of your injur}�'? I'eS (provide date(s))
When did you miss work?
Name of your Employer: Telephone_________�--
Address j .
�Check here if yyou are attaching more pages to this claim form. Number of additional pages
By siglti�ig tliis fornz,you are stati�ig tlzat all iiiforrncessed.�l� �tave provided is true«izcl correct to t):e best
of youicr kriowledge. Unsig�zed for�ns will not be pro
,��--�-C�-- 1�
Snb�nitting a false clainz can result in prosecutiai. Date form was completed �
��_ ; _...� h M� lnn;� -
a- i �r-.�� �
Fric�t the Name of the Person tivho Completed this Form: g
� �, ��� ,..�
�._..� �` ,�,�,`? ,�,
Signature of Person Making tlie Claim: _
Revised February 201 i
FINAL INVOICE
S�1ar� 6522 - Sears, Roebuck and Co. 450 MARION STREET INVOICEDATE 03!�8!20�3
v��,' St Paul, MN ���---(651)291-4228
AUTO CENTER EPANumber: FacilityNumber:
7AG� INITfAL ESTIM�ITE REVISED ESTIMATE PHONE A�ORiZATION N6402799
NAME:MCINNIS,ELIZABETH yFpq�AKFJMOD�L PARTS S13a.94 S286J0
ADD: 221 9TH AVE NE Zpp3 KIA RIO 4-15941.6L DOHC 5129.61 APPROVED BY: CREATED BY:
LqBOR S50.62
� MINNEAPOIIS,MN 55413 � N � MCINNIS.ELIZABETH 419077
!PRI. (6i2!267-7371 280338 G�RE�N OTHER SO.� �0.�
�� CA N TAX S1029 S21.96 CONTACTED BY: INVOICED BY
SEC: K pN p�1255362d1283 SHOP l0T FELDHUSEN,JUDI q�gp77
TIRE 1NSTALLAT�ON INSTHUCTIONS ODOMETER IN ODOMETER OUT TOTAL 5195.85 �����
xxx 86886 DAT6TtME OF OATE/�IME REVISED NUMBER CALLED: LOCAC
PURCHASE
TIMEIN TI T ESTI!�ATE (6�2)267-7371 pp NUMBE?
BLACK WALL 03I18I2013 i 1:34 AM 03�?6�2���G��?M 03li 8J2013 0333 PM 402799
gr 03116Y2013 01:50 PM ppjE/TIME CALLED:
PHOMISED TIME 03+t 812013 09'44 AM
� 03119Y2013 DROP-OFF
:a xxx Q4:00 PM
wN� TORQUE SPFCIFIGATION See reverse tor fmportant warra�tY terms�
AIR PHESSURE FAONT I REAR GR�6�— and Mher intormatio�.
REFER TO TIRE GUIDE 1 acknowledge notice and oral approval a!a� ;
incrase in ihe od inal eaNmeted ;ti�rRK AtlTHORI�
�rl�AAAAFNTS/REQUESTS�0 61 TFRNATF Ct�NTACTS: S X
l tdT BOTH ON FLAT RIMS. 80TH NEW TIAES ON REAfl
� TECH CS.a a�'„sN GCa CA�7PAFISON WITH MONfNLY
ITEM 1t DESCRIPTION OF MERCHANOISE PRICE EACH TOTAL ._;t_„c�, pa GpR PEiURN OR EXCHANGE
oTV So.00 So.ao sso�ia a;s.,, , _ _ .
� �g tgpq2pp2 UNDERCAR,COURTESYCK �� �� ���q q�gp77 y^`�=,:,� S286J0
1 LB 19042001 UNDERHOOD,COUR7ESY CK S6p.98 5121.9fiT 419077 ! y:_r,� �„•� 8129.61
C 2 PS 09533018 TIRE,P1756514TRSPNSTOURB 41g077 , ;,..,i`�_.._„ SOOC
2 AC 189027 LOCAL TIRE DtSPOSAL $2.`� $5�T �''`' -` 54 t6.3?
c,�.gg 57.98T 419077 c,:�-�.:; �.��,\
2 PS 09598734 VAWE,CHR SLV 1251N 419077 ';, 'c25`o
57.32 S14.64 _ S»3o'�
p �g 19019505 ROADHAZARD,PLUSAGREEMNT g14.99 529.98 860��4 d1907; .'.
2 LB 19012005 TIREBALANCE,PERFORMANCE S��y 584.99 8601 t4 419077
r t LB 19013011 ALIGN.SERVtCE Ap 419�77 H� `=�'_;;-;;�5�?-i657
$75.88 S151.76T .
R 2 LP 09595016 MISC.WHEEL $O.OD SD.00T 860114 �,_, =�='�_'�
Casr Te^�.°"
I k t PS 02801314 SU�GEST,BATTERY Cha�ge Due. "' "
x •This symbol indicates pans or labor changed or are addilional to lhe original estimale.�
� - A 15°a Restaking Fee may app�y on retumed merchandise. A t5°o Cance��ha'Fee may aP�N on Special O�de;ed mercnand;se
cancelled after 24 hpurs. SeE SafCSpC�so��a detaiis. _ � -
r'-'^ s 'r7�:�'=° '
SALGC� _ a -
SEARS VALUES YOUR FEEDBACK! i
We hope we lived up to your expectations.Please let us know at W�M(.SE
MrQfve�CCVVA(�I�r�''�� �
__ce�amos haber sobrepasado sus expectativas.Naganos saber e W1MN.SEARSFEEDBACK.CdM
i
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+�`I wN.�'Cw, t* �W�"�1"�W7(�'„`�'d6`V4RRA?d�`�'.115'K V�A':1���.LS A..*'L(,:t � �^ r' �
^F��d.a��A�"�W'���������„�,,��c;yym b3RanC8.PnCed EACH
�t'i1W.,:'� �+'�����.+'%t�'.�a5."�����a� w ;,-�rs*. ._=`.'-�
�^.,mKv r^c;i.3�P..J"M'�"�','IE.'N."�''`�'83�v' t'*4��",n"M�,"a"�°�r`�.i^yE,w'ro'iWSk'&"�%JY�4'M1.u+E Ga�'�. i^E""K.°m�C��.:
� � v �.�'v�H'^Lt�JAY�'�iF%�'?'E�� r^�MTS,+tt�`�s^�^'��"�7�? t3�°OY.ETc'+'v'�'�L�fifiN�.tES�"T��'RV'l+�,^E.t+��1DD.WORK WiIL BE PENFOflMED WITHOUT YC'.;�a
� � c a�� --'cp pp;"Y,ptfSS.STEERiNG35ttS�'EhSlON E'dALU�jlO�d.uaB�R ONLY.PARTS ADD.
r���.3E,G _5A-
;�e��31a:S�g3ested battery.Recommendat+on hased on co�dilians found durin9 a courtesy visual inspection ol tBe batlery anNor a test of Ihe starting and charging syste!^ See asscc�a'2'c"�e.'`
Ia��lUG NUrS ON CUSTOM AND ALLOY WHEELS MUST BE HE•TORQUED AFTER 25 MIIES AND CHECKED PERIODICALLY.
f
,
!
Date of occurrence: 03-I 5-2013
I was heading south bound on 35 E, on my way to work, when I was about to change
lanes to exit onto 94 I suddenly realized there was a large pothole that I was quickly
approaching. During this time there was a decent amount of traffic, the approximate time
1:20pm, I was unable to safely change lanes in time to avoid the pothole, also slowing down to
wait and go around was not an option due to the locatian of the pothole. The pothole was on the
right hand side near the University exit on 35E south. I would estimate the pothole to have been
at least b inches deep taking up nearly a third of the lane. When I hit the pothole it flattened both
the front and back tires as well as broke the wheels. I feel the city is responsible for the damages
to my vehicle due to the failure of not providing adequate road conditions and not promptly
fixing problems as they arise. I feel it is very important for the city to maintain the roads and
their condition to prevent injury and property damage. I am only requesting compensation for my
repair bill in the amount of$438.17 and ask that the city please in the future fix roads and
freeways quicker so we all can feel safer during our daily commutes.
Sincerely,
� ^
Elizabeth A. McInnis
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