Robertson _-� _
. _ RECEIVED
� .�UL 1� 1Q1�
NOTICE OF CLAIM FORM to the Cit�������1, Minnesota
Minnesota State Statute 466.05 states that "...every person...who claims damagesJrom any municipality...shall cause to be presented to the
governing body of the municipqlity 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 de»2anded."
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 egplain 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, 5AINT PAUL, MN 55102
�n/y��n�-R i� '��,�
First Name Middle Initial� Last Name �0.�E R TSa�
_,._.�__ _
Company or Business Name �- ____ _
Are You an Insurance Company? Ye No If Yes,Claim Number?
Street Address t�7 ,E�'4 Z��G�-' �'e��� ��'��
City G� ��tiLL Sta e /�� Zip Code ��� !
_.
Daytime Phone(��73v-g�O�Cell Phone� - `3 Evening Teleph�(_�"`—"=
/.�
Date of Accidend Injury or Date Discovered ^" ,i�� 1` A _ Time�am pm
Please state,in detail,what occurred(happened), and w y you are submitting a claim. Please indicate why or how you
feel the City of Saint Paul or its employees are involved and/or responsible for your damages. lii�i�� AR�vi�/G�
/��oRy�-r3oc�N/� o�'�/ l3A7rGF C���- iP�A� /.�'�7/.:i�F Ln� /�
E2 �TO 6Po�LJ.S" 7'�`�'�' [/FfflC'G�' -S C/ /�v� r�'-r��c
/ ���
/30>i�/ /Pll'�-h�T �//!� ti'.O l ��'ic lf'.
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
❑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 vou 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 WII.L NOT be retumed 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 dama.ge 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 documtnt and support your claim but.will not be returned.
Page 1 of 2-Please complete and return both pages of Claim Form
I
__ _ _ __
Failure to complete and return�ioth pages will result in delay in the handling of your claim.
All Claims-please complete this section
Were there witnesses to the incident? Yes No Unnl�own (circle)
Provide their names, addresses and telephone numbers:
Were the police or law enforcement called? Yes No Unlmown (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 necessary, attach a diagram. 3J� ..,-r,,�:fr 5ou'� � �� ��
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� £'ie /}�7o.t/ /�099 � �7�GG' a it o� Gi.r/�'i2 �-��.�/ /c'p�y�-jJ
0�/ <3� T�7G F C���lc. f�p�y,0, D/�2� A7-?ffcit��,)
Please indicate the amount you are seelang m compens tion or what you would like the City to do to resolve this claim
to your satisfaction. � �Qa_ 9�3 -�`J�' ��S T�P 7 �'1 �i/i�Giy�� ��v� �3o'7sf�/s� TU6t/j�l/('r
-�'�G� � �lG.fi�►7�'�c? Cr����G-f�S�Si�v c E � /�riE /f�3 Cav�P2�frs-� � /��
�7c�r K clt�-S�r� ,� /��?<rr��' �¢-�-�G-.v�rl£.v7' COv'F��-,�9'� �nB�es,r�i�o c�v�.2s ro ur..r�
-�eTiicleZ,'Iaims-QIease comT�e this sec�"ion - — - -�ir�ck�oxirtnis se�iian-aves rrofaupiv--- -'=-
Your Vehicle: Year 2 d o S Make e h�v v�d�.c� Model__ �ha.�'� � 1Jod 2
License Plate Number iQHG 3 8(o State �v►a/Color �9
Registered Owner .Q�v�vF�n�ei� .q-rl� ,cg 2�-S
Driver of Vehicle O�iV�Vc�°t7A�lZl� � �P.03�'/? S
Area Damaged i�l6�T F2u� 2E ���-i �R� � �P£ !�/i��L T/�PE �2lm
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Injurv Claims-nlease 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 N 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 i�jury? Yes No
�. When did you miss work? (nrovide date(sl)
- -s,.--—
Name of your Employer:
Address Telephone
�Check here if you are attaching more pages to this claim form. Number of additional pages�. PLU.�
� P�oro9f-e�r,�js
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 7�l/��3
Print the Name of the Person who Completed t ' Form: �, �D 8 TSd�
Signature of Person Making the Claim:
Revised February 2011 ,r `
Customer Invoice FIRESTONE COMPLETE AUTO CARE Service Advisor:
109813 SUNRAY 04 JERRY
07/02/2013 2041 OLD HUDSON RD 651.739.3423 '
SAINT PAUL, MN. 55119-4403
2005 CHEVROLET COBALT[GREYJ
ROBERTSON, MARK 4-134 2.2L DOHC
17 BATTI.,�Crc'EEK RD Lic#: RHL386 MN Vin#: 1 G1AK52F957598108
SAINT PAUL, MN 55119-5078 In: 07/01/13 2:26PM Mileage: 125,440
651.730.8408 Or 651.730.8408 Out: 07/02/13 11:19AM
Store#020338 RETAIL SALE
Rev Hist Unit Extended Job
Description IArticle# ID Qty Price Price Total
COURTESY CHECK 04
COURTESY CHECK 7046930 11 NS 1 N/C N/C
FIRESTONE TIRE PACKAGE 04 458.32
117632 AFFINITY TOURING BL P195/60R15 87T 70,000 117632 11TN 2 91.99 183.98
Mile Limited Warranty
DOT# W2V9A1 C1313
DOT# W2V9A1C1313
LIFETIME NEW TIRE WHEEL BAL-PARTS 7025194 11TN 2 2.99 5•98
LIFETIME NEW TIRE WHEEL BAL-LABOR 7001725 11 NS 2 10.00 20.00
LIFETtME RUBBER VALVE 7024341 11TN 2 2.00 4.00
7097782 ROAD HAZARD PROTECTION 7097782 11 TN 2 9.20 18.40
SCRAP TIRE RECYCLING CHARGE (1) 7075078 11TN 2 2.99 5•98
TIRE INSTALLATION 7015016 11 NS 2 N/C N/C
7018228 FACTORY STEEL WHEEL 15" 7003030 11TN 2 109.99 219.98
LIFETIME ALIGNMENT RECHECK 04
Symptom:-
LIFETIME ALIGNMENT RECHECK 7022837 11 NS 1 N/C N/C
Technician(s):
11 TERENCE KEOHEN
Payment History: Summary:
CFNA 3508 492.93 09329 Parts 432.34
Labor 25.98
Total Tendered 492.93 Shop Supplies 1.20
Sub-Total 459.52
All CFNA purchase(s)through December 31, 2013 of$299 dr more Tax(7.625%) 33.41
receive 6 month deferred interest, see www.CFNA.com for more details.
Total $492.93
I have received the above goods and/or services. If this is a credit
card purchase, I agree to pay and comply with my cardholder
agreement with the issuer.
Customer Signature
Initial here to indicate you have received
the Tire Maintenance Warranty Book. I
All parts are new unless otherwise specified.
Declined Work:
AIR FILTER
IGNITION PARTS
COOLANT SYSTEM SERVICE WITH NEW ANTIFREEZE
FUEL SYSTEM CLEANING
av�n�w.Fi�•estoneCompleteAutoCare.com
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Page 1 of I irni i2ii26ao2ois
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�lMITED NA'TIONWIDE SE�i610E WA1212ANYY
��,�+= ti'�.��;fi��►� �5 er��artant to us:
� fl ���- r�es�° �*e,s�e At Firestone Complete Auto Care, our goai is complete c���stor��e�� satisfaction. if you have any questions
� �i�r � cr ;iou received or our natiom,�ide limited warranty, �iease contac# the Manag er of the�tore listed on the
�� �e � rnay al�o contact Brdgesione Retaii Operations. LLC Custemer Retentioi�toli free at i-800-36'-3872 or visrt�;c.website
S��urrry�6eteAutaCa�e.com.
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� � � ���� ���� � ��rt;�r �i vvill be `,ixed �ight tha frst time. if The automr�tive ,epair or servire was perf�rrn�d improperly, then
� ti ce .�t r,�o additional charge to ycu, during the established warranty pericd.
, , .,,::�r-�€�'tu�:
� �;)�� �rCrir;ie IS ^O� `ec7d)/ �T'h2 kllll8 W2 prOf`IISeCj, WE 'JJfI� Off2i' ? 1�°�� C�iSCOU[lt Oi'1 �/OUf fl�Xt pUfCili3S@ �C�ISCOUIIt
, ,r i:h i5 valid U', any company-owned Firesto;,e Compiete A�.iu C:are S,ore. The subsequant secord visit must
� � �,t I�:;' CfIC�I'ia� SefVIC�. T�11S (�;SCCU^t C%3flflOt�6` �lSB� IO f�QlJ�e OI�tS�dn�lf?C �E�1.
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� � � �;- ��� .sed er Firesto�.e Complete Auu:C�,��are co��ered by a miniiY�um c? t�s✓e!ve "21 months or 12000 miles. whichever
�s and service� �arrying a different,varrd�-���. Somr exciusiors m:ay apply; please see details below. Warranties apply
,. a;e,� ar � rr�;ce performec on private passenger vehicles. 7his warranty is valid at company-owned Fir2stone Complete Auto Care
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�n_:.�� �eab!e during tha w�:r:anty periocJ, �v�i 1��� rep�a��ea ?ree o;a:�y add tion��� c;��arge for parts or labor, except as
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c � cnEnta ��iudi��,,�master cylinders �ts,�s.orc�is a,�d al!additio�a!!abor are warrantied for a period of r�,�elve!?2)months �
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� ;�e ied i.�� � � _ . ,_. ��,�-i::��veh i; If,:��a�t, �a e reti_i �!ic�rFSiore ve _.<e�c�mar�facrcre�'s sper_'i��ti�ns then tnose parts �
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,-•. _ ,��,-�a„� �xaiusions kr p a n�a�,t of a�'�-�re �_,c,r;,e�n�,;,, ;���t i ��_iude, �n the�����arra�t;or belts,�radlator hoses.Ccst of refrigerant and recharging of
� � � � � '�� 1 �`�,� ii �;�' o� �: ��icne �,3rt,o a or��l � �r�-�or 'ost of additiona!brake system components,including,
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�� � � � ��'�E�: �Auto C a�e�ar�, ���� ;r=d �y a ;Vl�rsufa�turer's Lirs7ifed U�,rranty from U✓orkmanship and material related issues.
�� � � �. �v � �;��p�l�ment�f ri�i�iaare L��ities� �arranty v�Y ��", �l� �.s !;y '.ire brand and mode! Information about these tire
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�cNERAL°k0�;1� ��,'S(�,� ,i ca�;l� ���a-a �� i tiesi
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� � , -. H P J��G � 3��;�� �r,ic r ,� _ ��� � �,'_�,� ,�t,;Ga F to .�r � hP warr�ntied parta and.%or service work;or any
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� i �_ , i ,:_a�pl�to proau._h.�;r ,�el �es�s��d fc,r con�merc�al -a���ng.o�of°ru�� p�rr;eses. nr to �amage ca��ed by abuse or accident.
_ r F'v ��':DGt�r/�i�JF R�T1 _��P SiaTiC�� �. l. ��ND i S rIR�ST��'� �r P�FT�AUTO CAn� Sl(ikt S DISCLAIM LIABILITY
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