Bergstrom RECEIVED
MEMORANDUM JUL 25 2013
TO CITY CLERK
THE ST. PAUL CITY COUNCIL
As you discuss the claim we have submitted to you, please
note we are senior citizens. I am 81 and my wife Marion is
76. The headaches and pain we experience are real and
disturbing. On the day of the accident we were on our way
to DeGigeos for lunch.
The accident was unfortunate. However the claim amount
would be significantly greater had I not followed the
guidelines specified in the 55 Alive Driving Course. I am
referring to the position of one's vehicles wheels when
preparing to make a turn. Until the turn is negotiated the
wheels should always be straight ahead. If my wheels had
been turned even sligh�ly we would have been propelled
into oncoming traf�ic and the results would have been
devastating. Possibly resulting in death, disfigurement and
expensive litigation.
�
Please consider the above when you judge this claim. ;
�
Sincerely �
�� � ,
� '%�a� �� -
Saint Paul City Council
August 9, 2013 AUG 0 6 2013
File Number C-130238 CITY CLERK
Madam President, Gentlemen;
At 12:3 7, July 12th my wife and I were abruptly changed
from normal senior citizens to angry, disgusting members
of society. We were anticipating a fine luncheon at
DeGidios on West 7� Street. Instead we were transported to
United Hospital.
i
While waiting to negotiate a' left turn onto Douglas Street
and into DeGideos parking lot, our vehicle was struck by a
large truck. The truck is owned by the City Of St. Paul. Our
vehicle, a 2006 Buick Lucerne was damaged beyond repair.
Our injuries were diagnosed as Cervical Sprain-Primary
and low back Strain. A common definition for whip lash.
We have experienced head aches, back aches, neck and
shoulder aches all related to the accident. I sent a claim to
the St. Paul City Clerk as directed by Mr. Guifoile. In our
claim I documented the daily aches and pains we were
suf�ering. I assigned a cost to the suffering anticipating a �
favorable result from you and your associates. Instead of a
satisfactory award, we received a letter from Sandra
Bodensteiner, Claims Manager for the City Of St. Paul.
Miss Bodensteiner said Minnesota Sta.te law prohibit's a
bodily injury claim [including a claim for pain and
suffering] from being presented unless certain requirements
are met. Miss Bodensteiner advised us to speak with our
insurance agent for clarification of the requirements. I
talked with the insurance agent and was appalled at what
she said. There is no way my wife and I can meet the
requirements necessary for an award to be granted.
My wife is 76 and I am 81. �Ve may be dead before such a
requirement could be satisfied. In the mean time we will
have the head aches and other pains because the City Of St.
Paul is protected by a law passed by the Minnesota.
Legislature. The truck that �aused our property loss and
pain is owned by the City of St. Paul. The driver was
looking over his shoulder j�st prior to the accident. The
driver of the truck was not issued a citation because he is a
municipal employee. Now you know why we are angry and
disgusted.
r%�� � `
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John Bergstrom Marion Bergstrom
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NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minnesota State Statute 466.05 states that"...every person...who claims damages from any municipaliry...shall cause to 6e presented to the
governing body of the municipaliry within 180 days after the alleged loss or injury is discovered a notice stating the time,place,and
circumstarrces thereof,and the amount of compensation or other relief demanded"
Please complete this form in its entirety by clearly typing or printing your answer to each quesbion. If more space is
needed,attach additional sheets. Please note that you will not be contacted by telephone to clariPy answers,so provide as
much information as necessary to e�lain your claim,and the auaunt 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 dces 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 �4 �'► N Middle Initial�Last Name��'R�7 S //� �M
Company or Business Name
Are You an Insurance Company? Yes 1� If Yes,Claim Number?
Street Address 6 c�b J �,(./�('�'�/7/q W�( �/Q��L
Ciry J'� G RO VE /�/G TS� sc�c� /J1%d�c/ESo TA zip Code .�a 7
Daytime Phone(��.3�7 7 q Cell Phone(_� - Evening Telephone(6 S/)�� /77�l
Date of Accidend Injury or Date Discovered 1��/�. �o /3 Time��r/pm
Please state,in detail,what occurred(happened),and why 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.
,� �EHiCL F o wN,�� �6 v T/e ci7y of.rr, p.��� ���r��.q �
�i c .r .�lv.n c 6 i4 �oRb .S' w� 1 S v�
� � iQea�Q o� /1''l,�l CAR wiT/� S`vc1 FoRre /�r Tor��Fa �v ca,t A-�
s v � E � EA os �L aN Cv '
/��W ' e �j`9,�/, Th e TR�ck W a s ,41 Ve�1 6 y A,t(�RE►n/ .i�/rlFs �'tes7i.✓
S <<sA�,�¢6�E'D .4T ��,/ N, 7��LF ST ST P/4v� /1'IiwJAI�'sa?A ,
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 pmperty
❑ Other type of property damage—please specify
❑ Other type of injury—please specify �
In order to process your claim vou need to include conies of all anplicable 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 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 repaiss
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;ar 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.
All Claims—ulease comnlete this section
Were there witnesses to the incident? Yes No Unknown (circle)
Provide their names,addresses and telephone numbers: �T/�e r� aS A d O C TG/t i/�eR ., 15�� To/�/
//I"112 ,�,�oT To /yl�Ve. � C'��c/ '7 � ine ber fi�s �/.a/ne .
Were the police or law enforcement called? es No Unknown c�rcle)
If yes,what department or agency? S��' P/��� PD Case#or report# ���'����.3
Where did the accident or injury take place? Provide street address,cross street,intersection,name of park or facility,
closest landmar etc. Please�be as detailed as possible. If necessary,attach a diagram. �i�/Tf/(SECT o�
1�('es? 7T� A�r� UoUGLAs STREET We GUeRe �o�,�s To �i ,1os- foR uNe�.
Please indicate the amount you are seeking in compensation or what you would like t�e City to do to resolye this claim
to your satisfaction. ,� /3. 3/7 76 /°�us ���R Reu T�� �3/, �o PQ/^ d a��'
o �t / � o /3
Velucle Claims—nlease rnmnlete this section ❑check box if this section dces not applv
Your Vehicle: Year o�o0 6 Make u Model L UC Ekii/E
License Plate Number > 1 State�Color_��/ s T o n�e.
RegisteredOwner �'o/�N a�b /yJ�/o�( ,BERG�7�I�La/17
Driver of Vehicle a
Area Damaged /QEAIQ of L'�R .�4itf?5 L�FT SI b�' eaR
CityVehicle: Year oD! Make fi�R� Model S
License Plate Number �6.5y q' State /�Y�Color s `
Driver of Vehicle(City Employee's Natne) A N DQ E y✓ .r�4M E S ,T U S 7'/N
Area Damaged u ni k'nl o r,�n/ —��?u�k �p A E�4 RS �o h Re.��IFoR�e c�-
Claims— lease com lete this section ❑check box i this section dces not a 1
How were you injured? �'F�f Vi CAL �S'PRA/ �IA9.4R y •.v;`T/� Ld u! f3��l� S"j`�' /N
What part(s)of your body were injured? C - ��J ' L a,r A� /� Ka�✓.a ri o�✓ a
a�e e e a�.v�e ��s�:S ii✓ La w e 6 a c k ov r
�al s r�t.c�,v
Have you sought medical treatment? es No Planning to Seek Treatment(circle)
When did you receive treatmentT ��� oZ ,�Nd 7 /� (provide date(s))
Name of Medical Provider(s): Uilli T'E�D hCospir�a� ,�N� �LL,/�il� C i�/i c n/e.s�T ST p.�u[ ,l1�I/, iSl-1�11•I�o
Address�33 �/ si►fiT Aue .S'i ('�vL�/rJ.v, SSiv� Telephone i
Did you miss work as a result of your injury? Yes vo
When did you miss work? (provide date(s))
Name of your Employer:
Address Telephone
�[Check here if you are attaching more pages to this claim form. Number of additional pages 9
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 wiU not be processed.
Submitting a false claim can result in prosecution. Date form was completed �U�� 07��r�o �.3
Print the Name of the Person who Completed this Form: �o ff l✓ � B F/Q G S ��A'! ,
Signature of Person Maldng the Claim: ,
Revisal February 2011 I�
I
i
Costs associated with accident on July 12, 2013
Car rental July 15th thru 31 St 17 days @ $31.30 $532.10
Aug. 1 St thru 31 St 31 days @ $31.30 $970.30
Towing & impound chgs. $189.76
Pain & Suffering $13,128.00
John Bergstrom Date
�- d� /.�
Marion Bergstrom
�
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� Impound Lot, 830 Barge Channel Road, Vehicle Release Form
�icense#: 2211 HL CN: 13144443 Invoice#: 145296
ST P11UL�:i1Fu�ND LUT
d5(! BRRGE CNANNEL RG
'H'"T "s5i'z"ss=ssai�T-245b : 07/15/2013 11:21 Tow Charge: $ 54.5Q
nr��na�� �t;: a�;e63er�ia�
Trrm I�: k3E17i34011[��5t��163kSU14�tk38
Storage Charge: $ 45.OQ
Sale
zzzzzzzzzzzz5127
RQ Admin Charge: $ 80.OQ
MRSIERCR�G Entr�Method; SWiped
Tax: (7.625%) $ 10.26
rotal, � 189,76
ie recovered the vehicle described above. Subtotal: $ 189.76
�ii15�13 li'��'�� e for damage or any other problems that
Inv�: ��3�3 RPar Code; G51331 �hfle this vehicle was in the custody of the Service Charge: $ 0.00
RPPn+d' Online �artment. I acknowfedge I will report
r,y��,,,- ���Y ther problems to the fmpound Lot staff Total Charges: $ 189.76
TE,aNti ro�, �aving #he impound lot.
Uamage andlor other problem:
Police Report made: Yes_No_IF Yes, CN , If NO, Why?
TO PROTECT YOUR RIGHTS REPORT ANY PROBLEMS/DAMAGE BEFORE LEAVING THE LOT
Signature 5i2000
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DESCRIPTION: RENTER:X __'Itli_: _"".'F:- '. i`.:i=�',
HAIL DAMAGE? YES NO PERMISSION GRANTED TO OPERATE VEHICLE ONLY IN THE STATE OF RENTAL AND THE FOLLOWING STATE(S):
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OPERATION IN ANY OTHER STATE OR COUNTRY WILL AFFECT YOUR LIABILIN AND RIGHTS UNDER THIS AGREEMENT.
RENTER DECLHIES OPIqN�L COWSqN RENTER ACCEPfS OPIpNAL COLL1510N DAMpGE WpNER �� �� � ����� � ��� ��
OAMAGE WPIVER(COW�AND ASStI1�ffS DAMAGE (CDW�AT FEE SHOWN IN COLUMN TO RIGHT.SEE
RESPONSI&LffY.SEE PARAGRAPH 6. NOTICE TO LEFf ANO PARAGR4PH i6.COLLISION RENTER;x
DAMAGE WANER IS NOT INSURANCE ---� � ---� �-- -- -
R N R:%
RENTER DECUNES OP710NAL PERSONRL ACdOEM RENTER ACCEPTS OPiIONAL PERSONAL ACCIDENT ����� � � ����� ����� �����
INSURANCE(PN�.SEE PARAGRAPH 9. MlSURANCE(VN�AT FEE SHOWN IN COLUMN TO
RIGHT.SEE PARAGRAPH 18. RENTER:X
NTER:X
RENTER DECl1NE5 OPTqNAL SUPPLEMEMAL LIABILlIY RENTER ACCEPTS OPfIONAL SUPPLEMEMAL LIABILIfY RENTER:X� � ���� � ���� -���� ���������
PROTECTION(SLP�.SEE PARAGRAPH 7. PROTEC710N(SI.P�AT FEE SHOWN IN COLUMN TO
RIGHT.SEE PARAGRAPH 17.
RENTER:A � .. .. .. .... . _._... ...
RENTER DECLINES OPIqNAL ROADSIDE ASSISfANCE RENTER ACCEPTS OP7NNL1�ROADSIOE ASSISTANCE
PROTEC710N(RAP�.SEE PROTEC1pN(RAP)AT FEE SHOWN IN COW MN T0 RENTER;X
PARAGR4PH 3.8.3. RIGHT.SEE OPTIONAL PRODUCTS NOTICE TO LEFf �� �� ��� �� �����
AND PARAGRAPH 79.
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DRNEN AUTOMOBILE WSURANCE POLICY MUST(1�COVER THE RENTAL OF THIS MOTOR VEHICLE AGAINST --- � -- -- � � ---- �
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O ____ OO W POLICY'S BASIC ECONOMIC LOSS BENEFITS, RESIDUAL LIABILffY INSURANCE,AND UNINSURED
� � � AND UNDERINSURED MOTORIST COVERAGES 1�0 THE OPERATION OR USE OF A RENTED MOTOR DEPOSITS
� O ��� VEHICLE.THEREFORE,PURCHASE OF ANY COI,LISION DAMAGE WANER OR SIMILAR INSURANCE
Z AFFECTED IN THIS RENTAL CONTRACT IS NOt NECESSARY. IN ADDmON, PURCHASE OF ANY REFUNDS
�OO OO ° ADDITIONAL LIABILITY INSURANCE IS NOT NECE$SARY IF YOUR POLICY WAS ISSUED IN MINNESOTA . � �
W INDSHIELD EOK?�Sc�yESM�����n,o UNLESS YOU WISH TO HAVE COVERAGE FOR LI,PBILITY THAT EXCEEDS THE AMOUNT SPECIFIED IN
oescR�PT�oN: YOUR PERSONAL AUTOMOBILE INSURANCE ICY.BY MY SIGNATURE BELOW,I ACKNOWLEDGE CLOSED BY
HAIL DAMAGE? ves No THAT I HAVE READ AND UNDERSTAND THEPA�OVE NOTICE INCLUDED IN THE SEPARATE FORM PAip Bv ���,. casH ���. cHECK . cHaR�E
F o�T E 1/8 ,�4 3/8 ,�2 5�8 3�4 ��e F qND REPEATED IN THE SEPARATE MINNESOT�CAWSION DAMAGE WANER FORM ON PAGE 3.
E �H��D DATE AMOUNT RECEIVED Bl
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IN E 1/8 1/4 3/8 1/2 5/8 3/4 7/8 F
OWNER IS AN AFFILIATE OF ENTERPRISE HOLDINGS INC.,WHICH OWNS ALL RIGHTS TO ENTERPRISE NAMES AND MARKS. �O EfltBfpflS2 L28SIt1g CORlpBfly Of Mltlfl@SOtB, LLC,ZO�
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ADDITIONAL TERMS AND CONDITIONS 199MNFALLI2 PAGE 2 of 4
��e�'e�agrees�b. R� . '-r P ;�R= ,� _ , .��_� a ���e,(�� �eo^sib� ', `������ ��� � � _- . ,�essones ��nc�dng all related costs Isee para-
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��� _�, � __ nts are x �;ted by Ren,e� t a �1�,
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r ����er,,.igns a �^� � � Ranter Ren�e� _ �+� _ �. , �� �a,���s cz ��� toiis tcvl�ng and storage atlaching to
' e�pressly zcK^owlEd 1 .. ��t��REntei ar��d Od,i er are tne oi�iy Naitie� �o.��s n� �a'�Agreer!�anl(Agreement) Jah�cle o��n�ui eri I . a�o�c,r�ng auring(ne Rental Period.Renteragrees Owner may provlde
nohrvlthstantling that� , ��ation for Vehicle may have been arranged b��a�i !aar�c th�..���nird party ma� � nte��s �.t or ,,,, ,�..;-e authorities and'or t4ird parties to process payment and!or transier
� ay fo�ali or part ef;I� � 2����1;and'or thaf a lhlyd par,y may negotiate cer!�:�,�, �i�r ,r�� �rcluqir�nu� � I^a� t � t;�.. . �-r(h����� -,t� �,�ay�_�ess a fee of up fo S2�per incidenf to apply
i���!e � �i��r= e�,tl a i�r,e �e�tai nn c � . , F�r r^aLa�� >� r �,[� ,��an :��Ils 2n �7ei a:m iis �.hon.
,, � ,� ���_ � t� ��e 7CC �� i ao-: c':�to S. ��,.er day o Renfa�Period for
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��,�,q� E ��r , - , - , �� �^�s� ��,ent�, _e ���_ -�?m�n,be,n�ee^ �7 ��� C„C �:� �R� d sn `leh�cle eperaror does not pay an appticable
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nen',er ar...�.,r�r�+i_" .� ;r ,.nPi ruc. �.��.or or_�ag�eF n���I unless��.i ::,ing and _�'�a ���_��arSc��.1 no�axceed S15 „F Ke�t-�aE��oa In additlon to the TCC Owner or a
! slgne�bv Prnter anr 0�.vner. tn�_;ua�t ��sep� tr �-c'r��srge Renters�redit oi debit card for the posfed cost of all such tolls
! 1. pefinitions �o�� �;�i��,os� ��A: � � �n��.� , ���s� if�_� ��d�:�,r �ed � , ��� �u:�, r � ud Junn � ;n�a' Fe�iod.A current IlsGng of TCC Covered
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i a 'Additional Authorized Driver�s) IAP���sl ' ' �.�- '-' sr',= .'= ,aermiLad b�,; ���'�ab�e ��-� re�a�.ie , af�!:wv.i ,I _�r,,�� ^rsF`or;8771 860-1258-Opera6on o(
_ , , �, � �T�rRiZED -� � ��r F �; � ,�ie apr ucab�e!o`rls are not paid may suojecf f�e
-� � . ��. . ,;- r E, ; � Fa,; � r3jra � � a ,�e-RENTER EXPRESSLY AUTHORIZES
� ��' ` � � � � v = �� r<tN?Ek, �J�C1= �DDRESa CRE�iT CARD INFORMATION AND ALL
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Optional lccessories � �. ����� .�ia scais y�,oba�pe�t�n�ng sys[ems ski F" ' ���NRY TO��A4LE 1HG ,�)LLECTION OF ALL TOLLS AND ASSOCIATED
� ra°k � �t,� ; a.cl o� r R� '-� � R; � JRRF�DURING THF REN�HL _RIO�
� Owner � '��:�_ �� c o��',�-;' re�i `� 1 2 r per mo�.'� t;o s< � .���,_ri,<�� ,um allowah!e by law,or all charges not
, Rental Period i . � ee _ �te� il Vehide is .�•I '_ e� r Roi �
�r-�i�. _ �E� � _ _ _ � _ ,.e O:mer uncer'his Ag�eem2r�or
�, ,
� "Renter _ _ _ �_ . - � i y,;.sses., � _ �r;n u.,a�ry��rm�.r c�rdiCion.inciud�ng attorneys�fees.
� � �'Vehicl2 i�eai �� �-`- r � �.�� �. ��'s,a . ac+� � er�osts o;exrenses rc�rred by Owner.
' 2.�OwnershiplVehicle�onditioniWan�anty Ex„�usion ,er, k ,, nt`,'el�� � ��i�i�iny Optional IF A GRf_QIT GARD ClR DEBIT CARD HAS BEEN PRESENTED AS A MEANS OF DEPOSIT OR
� o�_r-,�„,,s a�� c -�, �rL, . v�ai : even if� .nad,:egisteretl c� SECURITY. RENIER AUTNORIZES OWNER TO SUBMIT FOR PAYMENT ON SUCH CARD(S) ALL
���t•�I r�„��::;�, � �,�thorit�to omd Ow�er Renter agrees AMOUNTS OWED UNDER THIS AGREEMENT INCLUDING IF ANY THIRD PARTY TO WHOM A BILLING
�a��� r ��rc � � ;c',�.ar ca����i��tiea.RENTER WAS DIRECTED REFUSES TO MAKE PAYMENT. FOR A VEHICLE RENTED WITH A CASH,CHECK OR
� �j rq�i c �- ' . �G��0�21 � �A. I� HN��AS HAD AN MONEY ORDER DEPOSIT.ANY EXCESS DEPOSIT WIL�8E REFUNDED BY CHECK ISSUED WITHIN
�CE�.,r, _GpF _ � , . . ��G-S`� .� � A�D THE,R 15 BUSINESS DAYS OF THE END OF RENTAL PERIOD r��'��harges are su�ject to fmal audt by Owner
OPERATION 0'.". � _ „ , . . _.�T�� �r�t��� +vc �"d1P_IrJ �v`il H RESPECT 4. Limit_s_on U�e and_Te_min2tron of Right to Use,_
TO -`+ �F�r^ � �, Ahr � � '�,� LUDING ANV Ih�PLIED �NARRANTY OF a. ReMu ��eP fi�n fol o�in�hmits on use-
� f;1ERGr.+:'�r,'i -- - ��L= OSE Renter agrees to reWrn Vehicle and !1� , ' �le sr, rw�ue d �r �any oerson other than h���ter� ,�L_���.ri�hout O��vner�s prior�drf�er cocsen(
_ _
�
- _ - ; _ - -s -�� � �;;ne���s ��!e�� _._= _ �r 7ao;o�rting pe_ons`�r� �:s�hcol bus�,or for dri�rer(ralning.
�cT: _ . � e_ . s rc- � ���ll� �. . �_��`� �� _ _ �� , � - �. sao�t of pro�c�s`or n-F__�,�T�,�n can^�er.a contract carrieror
�� �,��� �� e�P �es,��enic e�r any C,pu �ai Accessories �.aie ��e�c�: �,�NLESS�
is ur�o, i-�.�,'r ��,_is , , ���n� '' �� �i '_�.__,��r ca�,,+ ,��o!if,v 0�,��mer � �?.,�,te � , , rerty nr � , i t���s,rance;equired of a moro�carr!er b},
,,,, . _,. , , ., . .
1 immtdiatery <<< :. � �e e' ci�is rented and/or oper�ted�.and
3. Payment by Renter � "� '� � ,� ns. �r fh� �u pose a�d comply�vith ali federal s!ate
, m �i���n Pa� �r��ni a a� s � ��ee F� .;i r
��-reof � ����,me of Ihe rental i� �eh e oe� e�i��� a �heqai pUrpo ir,a��r reckiess manner�,In a race or
�, _� . � r 24 h �� i y __«.t Lme of Ihe rental. spee r tc� �or push r �i�g.
. , � „ f f b I d
�, ;_ : � f�:l o �� ��� i�l � hi� � � s�n rr � �e n�r�ber o sea e�s provide by
' � ��, �� ��� ��r r�,^t
i i4 r Fk� � cc � 5 u ,�ni i� t�he �ar i:� E �a'. � ,
o�
i � i, rtc - �� �eito irom Veh�e
- i. ,ti, r trc rertai_
, � _,� � �re i a(t e�tar i ne
� - � ' !� �e�:° 3� �-?�e r�r�.�C�a� ersor�m�a .;v. r .� _" � ,oYcs aicohol �nfox�cants or
_ are ic � - ' y a �
� �Ren e �. . _ as se o�Pa e � �ua� � � ,. i�"
� � n��, - � rc � : e �e ertRaO � C` �1R�, hrl,���
� �� z i�a ��r:r 2 "�' � � � '��e� � ��i E r cr a or nIF ac�,m, cPerly,
� �ot x�e� s � � � �irle�i�re.r�ed�du n���n-7u iness hours or to ' �°°' ��� � ��N � �nidP manut��u e � ,�e ��at�o� and��rguidel res
� n�ula�r,�, � �� r_s,�� ���e 1 all E��tal chaine�i.�:i.•�er.hrouoh(he time an �9 �Ehic r ��I t be dr ie°or taKen outsitle the s�afe�authonzed on Page 1_ �
i
� ,.:E � res 11(` �'en�� ,, � _ i ,� :� � , '�i a
� � � � � � � �� � c ��� � a i ���u me ralse ad l�ess.o�a talse
- , r�ues s_. . � �r Pc��' �r��:itteJ fcr
� � �� � � ��` i n :II'dr.er� �c�i>e .,h �e dm r s 4c� �e _ �� a�J Ju ir� the Ranral Per�od�vho has
� _ r � � ,
�h e [ c by Rs�ter, ��'��r'�' _ rmics or nr J ��n rep�eaenls o�w��,�h �ds`acts fo'!rom
� � 4 � ,�: r e��v�rc,,- Jtiir F � ., �,(n,;r�
i t� I �s _ ��,aseo c,i�ttea�by Veh cle.O,�ner remits amounts � ` � �'ter; � ,�� : ,r , n,s�qr th�s�gre P a�n , '.iease�eh�cle
,�
rc�a -" . .r www,keystogreen.com for more mformation.The (13)Vehlcle shall not be usea to store or transport ex���ror s rnP�,,,�cah c�rros�ves or ofher hazardous
' � �� � _ ��,-;ad on the average mileage and(uel economy of materials or pollutants of any klnd or na�ure
�n����es i t ���f.� e�'acd�are r�' .a�c,rt�,�:ased on the emissions of a particular vehicle. b in the event of any viota(ion of the limits on use or , '�r r :s Aare me�; O�nner auto-
�����t ���.vhlch rovides for the dail rental of a toll collec- matically.withouf any further no6ce to Renter orAAC e ��h.Pi �q r�u=e��eh��e and O�roner
,�� , �t����� � � �:�ar�o�nitored toll collecti n services.In additlon retains any other righfs aed remedies provided by ia� �;r��r � n�,nah,Io�elze�ehide wifho�±legal
���e�i� ��;e '�lu„ _ � .�.� �.�.����:r or a thlyd party may separately charge Renter's p�ocess or notice fo Renter or AAD(s).Renfer and.,AD?s he e'�.�wai.e all clain s fo�aamages con-
c ��ad o �e�� ., _ ., a�,• �-.:e for cash rentals)for the Owner's cost of all tolls nected wlth such seizure.inclutling loss or damage�o�.��^en+s antl shall pay all expenses incurred by
'' Owner in returmno Vehicle fo Ihe original rental o(fice
I � ��ed usmy h �� �,ie�� ' �^_ � e�✓��e ��r�g the Re �al Perod wlfhln the Tolloass q � ,� �nr � rz Vehide f er ne rlgnt to do so is terminated.Owner has the right
4 -, � �,: ,e ,^a?^r �,t;�Re ,r s name ��:;e>s � , � r _„� �_; '�en Renter a d AFD�sj hereoy re�ease and discharge Owner from
c_'�'r,� , a����f. � � an�� � da! r e���sa^; e^,ace t�� � �ecdon c'a�J sucr to��ls and � ;� F�n ,.e�e�c� _ ��hannless agalnsf am�!iabilibi ansing from such notice Reeter
r ..,bi,C'e' . � S I . � 'n°.?B�'ai r-�'C � , 5 pfOV!'20 f�' 3�:>Ih2I;P <.,��i7Bl' ^
�� � � ����. �r � -- ,tc'axes fce�2nd c '���.t�c s�s_et°ori���n Paragraph s,
r�t�n i o Nd 5 e i�'�� � ��n;t�u e,�e ce cut o ine 5 Accidents.Dam3qa�o �oes ih�tt-.,t_hicie must ee-nmed�ately reporfed in wrifing to the office where
sei��ce �r� <,,�u��t<<U �Fr_ �� _na���� , � � �1,.ri a te5�et���a;raph„�� i3.1 Vehi,le was rented . �. � � ^t later than the following business day after the accident. Renter and
� i ,
A currer(litir o`T ' G_ ��+c� � , a�e��:��� Eq�est a� ,.�;vh,a le com' AAD�;r�usf�mr�,,,at_��y�� er!,�,�_;�.,,,.,here Vehicle�nras rented every orocess.pleading or paper
� ��' ' — elat r q� ai� �,i� in�� �c�a �den� h�f�e event of a claim,sui[or iega!
�. : ���rn� :� � � �ai_� - �retur �. �;�����ess°�;e'��tnan ���e_� e =r. .a� . f�. .�.r�r, �e , J �.s rePrese^fafives V2hicle mav be
:r rc-�� __ � �.sC,md „., 'er�,�, ,n fuei,ecc,sho���n on me tue, equi��Pd�:��'�a E ,�'D�' ��de�� DR s�s��^lar del.lce forthe purpose of recording data about fhe
i�,,�,,_ , ;re�u, ��:-iF� � e�_�r .e,,.
n���� � �- ,er re.� � . 't.� i . �,chasF_�:he=���- �er,�_�:;� �E�� "'� I - ��r- � ,c n�!er ccnsent;to O��vner or its represen,at�ves rehiev-
'� � � � ing anU u�iny su h oat rror �e uR.
), on r r F. iallon charge mulup ied by fhe luel tank capacdy of g Damaqe_to,Loss or Theft of Vehicle Optlonal Accessories and Related Costs,Excepl to the ex(ent
r,.reC c r�✓ur'use�fue�. restnc ed rrod��fie�l r ir�i ed 7;�ta�e lav Renter acrepta e,po�s L iiw for damage to loss or theft of Vehicle.
- _ �' � _atio !h„r tha.the Branch Add�ess on Page�1. � � _ .
" ��r ._r R_ !e , �ADlsi 3gc �ptic�a 4� rss i s� ��: , u c�rrrq�ur��g t e Rental Period regardless of fau!t or neg-
�� igerce R�rter �a� ,t^P cr 3c,�Gcd Rerte�sha .a:-Owrer the amount necPssary t-�repair
� T�t !^c .,nd ana>�n, �ci�ur _a�esi i�cluding b�,no_'��m�tetl to� Venicie or OF,tio��al r,���ssor s �2 � ;rsh li u h�ve Jeri��.c or Op:ioeal Accessories repaired withouf permis-
a ;,,� i„�r,P-ar� r�i ,Fa , CrargP iRAFC)�which is required to be paid by Owner or col- son ron �w�er f veh.cie� l��e i�ano � ier,evered or O,vner determines Vehicle is salvage.Renfer s��all
pay Owner thc fa ra kef va ur �ess any sale�roceeds For purposes of this Agreement,fair market value shall
lecte�fr;ii�?en�e r � �,� t c , !�t,�s ren(al for the construction flnancing,operation and;or be the retatl value of Vehicle rnmedlately ore,ediny the loss 'f Opfional Accessories are not retumed Renter
���alr te e of_ ��s�:l ,.��;ed renta �ar�arfify ner a',�pc 'a�ll;:ies� ,a.'c ��a�s��rfafion shall ay o�vne�th .��c2n��ent as(of �,�e Gptional�,��e,�;�ies Renter is responsible for all towing.srorage
�a�a a �.i�s�. ���m �!fces a ' �_r cc _u,•ed� � ��er tc r e �e.i le nd to establlsh damages Renter agrees
��- � �essior Recovery Fee(CONC REC�whlcr�s O��vner�s�narge fo recover the ;oncession �c pay a_��i fer los�er�se,re,�rdless o ie,.u;ilization _a . ��bilo�s:(i)If Owner determines Veh�de
�ee�a��c,b�;Owner to this airporfs owner or operata ��_ ccroec� ,n.�.�?��i,rei�,a��.and is repa r3.,��e�io.al aocr�c�rs"roci the repa,r esnma,e cia ._ o� � �,.,i!Iplied by the daily rate on Page 1�,(ii�if
s� The A1 inesofa R ��.1 ati^^ e ",;1'�R=_ —�r;hich �a!ee imposed by the s(ate of A41r,neso'2 Veh;de _ ,iclee and i��t r��:o.��.:;nr Ow cr re(crm nes��ehirre��s salvage_15 days at the dally rate on Page
fcr th�.regis'.ral� i �Na�.�..rs The�4inne�ofa RegisVation Fee�s not a tax and is not calcu- 1.Ren?er also aarees to pay ;a'�ar adminis(rative fee of SSQ00��hen ihe repair estlmate is less than$500 00
la'ed based on the cos's imposP .,per a �,nc�ular veh��,cie or S1�G�0�:vhen the repa!r-s[imate is bete�een So00 00�n;+51 5n GC or$150-00 if greater than$1.500.00�,(b)
� � ,�0 -� �t = - � , h��.!a�,; n . _�ali.r,Oc,^er. �,�f'T�es a�e�f�� a s.i^ _ �s�ie �. �hble� �c,:��rau c al���.��d��ec a_'D'��of(he repalr estimate if[he dam2ges
A spec�ai one ^:ay`e � _�o;� « �.�e gre�er;F:'n0 �0 or S��c m�c�bet ve?c t�e are o�ea�er�h����.^9�P2 i`.e���'�e�s ra,u re7 dur��,�ri ;�ness hours or[o any place other fnan Branch
�
� , ,, � �a[c�� _� �� ��� � � ___ ��(!or e enida ur O�r enal Accessories occurnn prior;c ar.
_� .. . � _,,, _ _ � : � r�� 9
,_ ,_� _-�r��� _ �, e,�; _�;,,, ���I ,,� � .. � � . , _ .^�I�.r Is RentEr;responsloility.SEE PARAGRAPH 16 FOR
ownerisanaffifateotEnteraiisfHC�oingslr�.wncno��nsa�i��y �stoBr°r"-- �< i ��� �;l{gCprSFP��@�SIIICJ COC?l�afl�/Of MIf1f12SOt8, LLC, 2��2
NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minnesota State Stalute 466.05 states that"...every person...who claims damages from any municipality...shall cause to be presented to the
governing body of the municipality 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 demanded."
Please complete this form in its entirety by cleady typing or printing your answer to each question. If more space is
needed,attach additional sheets. Please note that yon 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. Yon will receive a
written acicnowledgement once your form is received. The process can iake up to ten weel�s or longer depending on the
nature of your claim. This form must be signed,and both pages completed. If sometlung 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��R�� Middle Initial /`1 Last Name��7.5 �/�0�
Company or Business Name
Are You an Insurance Company? Yes� ff Yes,Claim Number?
Street Address 6��.� BL/3 C lC�1q InIK �R,q i L.
ty /�Ji,�/�✓ES o Tfl Zip Code.SSo 7 7 ^
Ci ,.�.� GR 0 V�' /Jf GTS� State
Daytime Phone(� .f3-��Cell Phone(_) - Everring Telephone(6fI)�- /779
Date of Accident/Injury or Date Discovered .TU�y fo�� �o�.3 Time oZ % J�7 �/pm
Please state,in detail,what occurred(happened),and why you are submitting a claim.Please indicate why or how you
feel the City of Saint Paul or its employees are i volved and/or respo ible for your damages,
�' r,� D �, . AUL L E�i v� in��✓;
L i C e - se. U .6 oR� .s• c � e n R
w fi uc c2 7oTAL�Eb wc.s TAKPit1 T�
v �e. o r`.0�s o a R.
GvAS • �J b .4N .�" MES � ��c/.
L E' e p - G �tl.
P—le�e 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 you need to include conies of all apvlicable documents.
For the claims types listed below,please be sure to include the documents indicated or it will delay the handling of
your claim. Doeuments WII.L 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 Uther 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.
All Claims-please comnlete 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)
ff yes,what department or agency?_�t' �1 U� Case#or report# l.3 i����3
Where did the accident or injury take place? Provide street address,cross street,intersection,name of pazk or facility,
closest landmark,etc. Ple�se be as detailed as possible. If necessary,attach a diagram. Il✓�,�SE�Tl 0/�/
sT T �tld �J�C� LG3 �T7' ee . We e. oin/ �e �,D
L�NC ,
Please indicate the amount you aze seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction. /f'e �L D eit! /�� 'L c� LQaI 6
v_��11ND ox s'7 edR-S'
Vehicle Claims- ease com lete this section O check box if this section dces not a 1
Your Vehicle: Year oo Make R v� c f( __Model u(�F RN�
License Plate Number aa�i ��. s���co�or SA Id� �7'�a�✓�
RegisteredOwner /r1/�R/o�l i4Nb �oN�! g�RGsTRo/►'1
Driver of Vehicle .7`o N�y/
Area Damaged R�A Q O� C'AR d N D ,C e�T S!d e /p e aR
City Vehicle: Year oo Make FoR D Model S
License Plate Number�'ob 6 5 9 State�i�J N Color 6n►"T /<'��,�
Driver of Vehicle(City Employee's Name) � ,T M 5 TUST�
Area Damaged v o W - �T v .4 s o a
I ' Claims- lease com lete this sec�on ❑check box if this section does not a 1
How were.you iniured�rTli e SQ FT T/rS.�J� c� /1'I y �CfC !�(1aS d���4� � �T �S
. �,� , �/ � t�s ead.�� 2s,
What part(s of your body were injured? N ec.=/�, �i.�a��.re ,�ti rk R�'c�T L�s a
Have you sought medical treatment? es No Planning to Seek Treatment(circle)
When did you receive treatment? tjv��TH (provide date(s))
Name of Medical Provider(s): �L�/NA CLi�/�� /S"o ��►'l ER S�n� •�ve• ct�e�T �T. P�vL�
Address /l��,i/,�tFSvTQ, SS//� Telephone 6.S/-ol�i�/-/�oo
Did you miss work as a result of your injury? Yes No
When did you miss work? (provide date(s))
Name of your Employer:
Address Telephone
L�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 wiU not be processed
Submitting a false claim can result in prosecution. Date form was completed � V 1� o�y �o l�
Print the Name of the Person who Comple tlus Form: J(�;! � ,C1���� T/e O/YJ
Signatare of Perr�s�on Mal�ng the Claim:
Revised February 201 I
RECOVERY
AUTO ACCIDENT JULY 12, 2013
July 13, 2013 Saturday
I woke up with aches and pains in both hips. My shoulders
hurt along with my back. There was a slight stif�ness in my
neck, but it was soon gone. My left leg is sore above the
knee when I press on it.
Marion has a headache and is taking Tylenol. She has a
bruise on the front and rear of her right leg.
July 14, 2013 Sunday
I woke up with a terrible back ache. Tylenol helped along
with B engay.
Marion woke up with a headache. Her lower back hurts this
morning.
July 15, 2013 Monday
Woke up at 5:15 with an aching back and sore shoulders.
Shoulders hurt in the joints.
Marion's headaches continue. We can't see our doctors
until Wednesday, July 17tn
July 16, 2013 Tuesday
Marion continues to have headaches. They are worse when
she moves her head.
Continued;
July 16, 2013 Tuesday
My back feels better today, but hurts terrible when I water
the flowers.
July 17, 2013 Wednesday
Mar�on's headaches continue. When we are in the car and
hit a bump she grimaces with pain. I try to avoid manholes
in streets. She has a doctors appointment at 11:15 A.M.
Marion's doctor told her she has tenderness in her neck.
My back is sore this morning. It is hurting a lot because I
watered the plants and put trash cans away for myself and
two neighbors. I will see my doctor at 1:00 P.M. My doctor
said I have Cervical Stress.
July 18, 2013 Thursday
Back ache, sore neck and aching shoulders kept me up
most of the night. Nothing seemed to help.
Marion continues to have headaches. Tylenol is helping.
She rests a lot.
July 19, 2013 Friday
I woke up at 4:00 A.M. My shoulders hurt in the joints. My
back hurt terribly and I had a cramp in my leg.
Continued;
July 19, 2013
Marion's headaches continue. Doctor said it may last for
sometime.
July 20, 2013
My headaches continue like Marion's. I got some
information on the internet about a clinic in Edina. I may
look into it. There is a tender spot in my right shoulder.
Marion is taking Advil per her doctors request.
July 21, 2013
My back is really sore today. The headache comes and
goes. Marion's continue. Riding in the car is stressful.
July 22, 2013
Tylenol is not helping my headache. I will have to use
Advil regardless of my kidneys. Marion seems to be
getting some relief from the Advil.
July 23, 2013
My aches are lessening. Marion's are ongoing. I hope it
won't be as long as the internet report said. Seven [7] years
is a long time to have headaches.
The following information is presented to the best of our
knowledge.
John S. Bergstrom Date
7-�5�-��
Marion A Bergstrom
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