Reller RECEIVED
APR 16 2013
' CITY CLERK
NOTICE OF CLAI'VI FQRM to the City of Saint Paul, Minnesota
S�innesotu State Sralute 466.05 states that"...every prrson...�vho claims danutges frnm any municipality....chal!cau.re ro be presenlyd m thr
go��eming bndy of the municipality within/80 days ajter the a!leged loss or injury u drscavered o notice stnting the time,place,and
circanrsrances thereof,nnd the amount of compensatinn or orher reliej demanded."
Please complete this form in its entirety by ciearly typing or printing your answer fo each question. If more space is
needed,attach additional sheets. Ptease note that you may or may not be contacted by teiephone to discuss your claim
circumstances,so provide as much information as necessary to explain your claim,and the amount of rnmpensation being
requested. This form must be signed,and bath pages completed. If something does not apply,write:N/A'.
SEND COMPLETED FORIYI AND OTHER DOCUMENTS TO:
CITY CLERK, 15 WEST KELLOGG BLVD,310 CITY HALL,SAINT PAUL,M.V 55102
First Name__�.L t,!�i Middle Initial � Last Name f�t��(C��
Company or Business Name,if applicable !
Sueet Address C Ot,'; r�:;�i,�t I,��J {=I �
City `�t" f�,v�( State_ �'71�i; � f_ •
'Lip Code 7:.%'/� , ,
Daytime Telephone (i;l L ) L-/L - -'�/1=/ Evenin Tele hone
� p �.i� )_�/`G' `�fYy �
Date of Accidend Injury or Date Discovered v u/ i�= Time � �UC� ,
��/pm(circle} i
Please state, in detail, �vhat occuned,and why you are submiiting a cIaim. Please indicate why or how you r
feel the City of Saint Paul or�ts employees aze involved and/or respons'ble. �
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Please check ihe box(es)that most c�"osely represent the reason for completin�this form: !
�Vehicle was damaged in an accident O Vehicle was damaged during a tow
❑ Vehicle was damaged by a pothole or condition of the street ❑Vehicle was damaged by a plo�v
❑ Vehicle was wrongfully towed and/or ticketed ❑ lnjured on City property I
❑Other type of property damage—please specify I
❑Other type of injury—please specify ,
❑ Other type not listed—please specify �
I
In order to process your claim vou need to include copies of all annlicable documents This is a general I
guideiine of what should be submitted with a claim form,but it is not all inclusive. You may be asked to !
provide additional informarion depending on your claim. I �I
O Property damage claims to a vehicle: at least two estimates for the repairs to your vehicle,or ihe �
- actual bills and/cr receipts for the repairs
O Towing claims: legible copies of any tickets issued and copies of the impound ic�t receipts ;
O Other progerty damage:repair estimates,de�tailed list of damaged items
O Injury claims• medical biIls,receipts ' j
O Photograpfis can be provided but witl not b�returned.
Page 1 of 2—Please complete anc�return both pages of Claim Form
Failure to provide a completed claim form will result in delays in processing,
Notice of Ciaim Form,City of Saint Paul,page two
All Claims—"please complete this section
Were there witnesses to che incident? Yes No , Unknown (circle)
If yes,please provide their names,addresses and telephone numbers:
Were the golice or law enforcement called? Yes 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. Please be as detailed as possible. If helpful,attach a diagram. ,
�
�vi��'; riavniu;,v n'� `.��.iitit" t�:v�� iY1;s��TB-iUt'pl, r��/G
Please indicate the aznount you are seeking in comp.ensation frQm this claim or what you would like the City
to do to resolve this Flaim to your satisfaction. —{�- ��v I J , !4e "thP ��.�fr. �--d�
, icr � � --
Vehicte Claims—please complete this section ❑check box if this secaon does not anplv
Your Vehicle: Year 2����� Make `���bc•v� Model 'trn���?�ti
License Plate Number f ' 7`�_ State r�N Color :Sl�tic,)`
Registered Owner�t �� i�,(%y
Driverof Vehicle l�•�vi� /i�i%t� , , . ,
AreaDamaged ��,m,��✓� fN��:�l,� h'�c�. G����'i�;.,�, i?���r ��%�r.'G�i���lcl�
Ciry Vehicle: Year Make Model
License Plate Number State CoIor
Driver of Vehicle(City Employee's 1�'ame)
` ' Area Damaged
Iniurv Claims—please complete this section ❑ check 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 T:eatment (ci:cle)
When did you receive treatment? (provide date(s))
Name of Medicai Provider(s):
Address Telephone
Did yon miss work as a result of your injury? Yes No
When did you miss work? (provide d�te(s))
Name of your Employer:
Address Telephone
0 Check here if you are attaching more pages to this claim form. Number of additional pages
By signing this form,ynu are skUutg that all injormatron you Jiave provided is bue and eoneet to the but ojyour kno w Unsigned
fo`fnt.rtiwil! not be psocesred. Submitting a false c7aim ean rerull in pmsteution.
Print the Name of the Person who Completed this Fo .. �-�- .� ���°''-
Signature of Person Making the Claim:
Date form was completed �`f /v//j Revised Apri12007
�3r�c� I-�anso�'s PrU Finishers, Inc.
,,
16i 17 1�Iain Ave. S.r. t�,vO)�e
Prior Lakc, MN 55372 �
(952)447-440Q DATE DONE INVOICE#
Federal Tax ID: -�1-1928193
� 9i2$;2012 1 f?�t?�� �
BIL�TO
Reller.Dave
2003 Ramlow Placc �
St.Paul,1111 g5116
i
�,J �.�
YEAR ! COLOR ! MAKE l MODEL CUST LAST 6 V.I.N.#
Ol,iF3laclJSubaru Imprc-ra� �33187
DESCRIPTION QTY COST/RATE SUB TOTAL
l.,abor 13.1 �0.00 6�5.OQ
Refinishing I 5.� 50.00 77�.00
Parts R Materiais-Taxable 914.00 9(4.00T
Paint R Supplics Non-Ta�ablc I 5.5 30.00 465.00
body supplies I 1.5 ?.pp _ 3;.00
Minnesota Sales Tax 6.87i°io G.875% 62.84
Total �2,894.84
BRAD HANSON'S PRO FINISHERS� Workfile ID: 2d867fc3
INC.
1b217 MAIN AVE SE, PRIOR LAKE, MN 55372
Phone: (952)447-4400
FAX: (952)447-4414
Preliminary Estimate
Customer: Refler, Dave 7ob Number:
Wntten By: Brad kanson
Insured: Reller,Dave Policy#: Ciaim#:
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impad:
Owner: Inspection Location: Insurence Company:
Relier,Dave BRAD HANSON'S PRO FINISHERS,INC.
2003 Ramlow place 16117 MAIN AVE SE
ST Paul,MN 55116 PRIOR LAKE,MN 55372
(612)618-4194 Cellular Repair Facility
(952)447-4400 Business
VEHICLE
Year: 2006 Body Style: 4D SED VIN: JF1GD67616G522187 Mileage In:
Make: SUBA . Engine: 4-2.5L-Fl Ucense: Mileage Out:
Model: IMPREZA Production Date: State: Vehicle Out:
Color: Int: Condition: Job#:
TRANSMISSION Dual Mirrors Alarm Passenger Air Bag
5 Speed Transmiss�on Console/Storage RADIO Head/Curtain Air Bags
Overdrive CONVENIENCE AM Radio 4 Wheel Disc Brekes
POWER Air Condidoning FM Radio SEATS
Power Steering Rear Defogger Stereo qoth Seats
Power Brakes Tilt Wheel Search/Seek Bucket Seats
Power Windows Cruise Control CD Player WHEELS
Power Laks Intermittent Wipers SAFET1f Aluminum/Alloy Whee4s
Power Mirrors Keyless Entry Anti-Lock Brakes(4) PAINT
DECOR Rear Window Wiper Driver Air Bag Clear Coat Paint
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