Larrea �
_ 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 rrtunicipality...shall cause to be presented to the
governing body of the municipality within 180 days after the alleged loss or injury is discovered a norice stating the time,place,and
circumstances thereof,and the amount of compensation or other relief demanded."
Please complete this form in its entirety by cleariy 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 ciarify answers,so provide as
much information as necessary to explain your claim,and the a�mount 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 sometWng does not apply,write`N/A'.
SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK,
15 WE5T KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
First Name Middle Initial Last Natne
Company or Business Name
RECE1 r, ��.
Are You an Insurance Company? Yes/No If Yes,Claim Number? SEP 11 �413
Street Address - , �` i�� E RK
City ����=�� � ! State � Zip Code -
Daytime Phone(_) - Cell Phone(_) - Evening Telephone(_� -
Date of Accidend Injury or Date Discovered - Time am/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. -
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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 cooies of all aonlicable 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 Pronertv dama�e claims to a vehicle:two estimates for the renairs to vour vehicle if the dama�e 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 c�amaged items
O Injury claims: medical bills,receipts �
O Photo�ravhs aze alwavs welcome to docum�nt and sunnort 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 wimesses to the incident? Yes No Unknown (circle)
Provide their names,addresses and telephone numbers:
Were the police or law enforcement called? ,Y�e No Unknown (circle)
ff yes,what department or agency? �r t <� ' ='� � `�:����-�x����r�-�,? Case#or report# �vo �as� F+�t:�
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. '�n ��r����ato� �a�r.v2v�,���.JAer,
L����barr�A �_ ��n;i � �ei�r� � �r� ;-•�� �
Please indicate the amount you are seeking in compensation or what you would like the Ciry to do to resolve this claim
to your satisfaction. �����_ �%
Vehicle Claims-nlease comnlete tWs section ❑ check box if this section does not annlv
Your Vehicle: Year �'�?��� Make �� Model t� =7��
License Plate Number >1`� r�- " State Color �'�
Registered Owner '� ` ���-°
Driver of Vehicle -G.
Area Damaged s� ���t� ��,�
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniurv Claims-nlease comulete this section � check box if this section does not applv
How were you injured�
What part(s)of your body were injured?
- i
Have you sought medical treatment? Yes ' No 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 injury? Yes No
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
By signing this form,you are stating that all inforination 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 ? -
Print the Name of the Person who Completed this Form:
Signature of Person Making the Claim:
Revised Febroary 2011
'����1�0 Date: 04/19/13 Iuvoice#: 10210049895
=fl��MfR 1VI�MBL+'R PURCHASE INVOICE T�me Li: 19:22:56
Membersl�ip!l: 1 1 1 802254532
MI,MI3l+,K IN�ORMA'CION VLHICLI;IM�ORMA'I'ION
LUIS LARREA 2005 Lexus ES 330 Base
6443 REGENCY LN Color: WHITE Liceuse:
EDEN PRAIRIE, MN 55344-7838
Odometer:
Whcel 'Corquc: 76
Air Pressure: Front: 30 Rear: 30
ITENi# DESCKIPTION Qty SLIP PRINT
672864 TURANZA SERENITY PLUS 2
PERFORMANCE H/V
215/SSR17 94V BW
BAN 146-906
75,000 Mile Warranty
6850 Tire Installation 2
7023 Disposal Fee 2
IIII II)III I III)I II IIII III(II)II III II III III II
9200102100498952
D.�.T.}�: 1 VLMDBH4 912 1\7L�MDBH 4 912
NOTES:
X X
. ,
*Inflatiou and Toryue speci�catious are recommended by Manufacturer.
Bestto Spare
Static Dynamic JAKE
_Blackwall _Whitewall Sales Person
PagcN I
" Costco Koad Hazard Warrant
'1'O UALIFY I'OR'CIIIS �VARIZAN"CY:
I. You must bc the original ��urchascr of thc tires.
2. You must have rurchased the lires li�om Coslco Wholesale.
3. You must presenl tl�e original purchase receipt and tire to a Costco Wholesale Tire Center.
CONllI'1'IONS OF'1'HIS WARRAN'1'Y:
1. The Purchaser must rotate and balance their tires as oullincd by the vehicle manufacturer.
2. The Purchaser must operate their tires at inllaCion pressures outlinecl by the vehicic manufaeturer.
3. The Purchaser must keep all mechanical parts that effect tires in proper�vorking condition.
4. The Purchaser will be required to sign a"Costco Wholesale Tire ndjustment Forrn".
WHAT IS COVF,RED:
1. "Road Hazard Failure" is defined as a tire that becomes unserviceable due to cuts,non-repairable punctures or
impact damage. Costco Wholesale will repair tires with tread-facc injuries in accordance with established RMA
(Rubber Manufacturers Association)standards.
2. This warranty covers road hazard (ailures in Passenger, Performance and Light Truck tires purchased fi-om Costco
Wholesale.
3. Tliis warranty is valid for either sixty(60)monttis from tlie date of purchase or wheu the tire readies 2/32
of an inch or less in remainin�tread depth,(wllichever conies first).
4. This warranty provides credit based upon remaining usable tread at the time of failure due to road hazard.
5. "Usable Tread" is defincd as thc original tread depth of a tire less 2/32 of an inch(tread wear indicators).
6. Gedit is detennined by multiplying the useable remaining tread by the current pricc of the tirc.
7. This Warranty is a promise under certain concJitions to give credit on a pro-rated basis lowards the purchase of a
new tire. This warranty does not imply that tires sold by Costco Wholesale meet certain specificalions or cannot
fail."I'his Warranty does not replace or modify any original tire manufacturcrs warranty on material and
workmanship.
WHAT IS NOT COVEItEU:
1. A tire that is damaged/I�ailed due to vandalism.
2. A tire that is damaged/failed due to an accident.
3. A tire thal is damaged/failed due to commercial use. I
4. A tire that is damaged/failed due to racing. �
5. A tire that is damaged/Cailed due to Off-Road use.
6. A tire that is damaged/failed due to snow chains or studs.
7. A tire that is damagcd/failed duc to rapid or in-egular wcar.
8. A tirc that is damaged/failed due to wear from worn mcchanical components on the vehicle.
9. Tires transic�red fi�om the vel�icle on which thcy were originally installed.
10. Loss of time, inconvenience, loss of use oCvehicle or consequen�ial damage.Some states do not allow the
exclusion or limitation of incidental or consequential damages,so the above limitations or exclusions may not
apply. �
TIRE CARE RECOMMENDATIONS:
1. Have the air pi•essiere in your tires checked by a ti�•e��rofessionnl as least aice n nionth.Serioars injury n�av�'esult
from tire.failtu�e due to undc�-in/lahon. � �
2. Al�+�nvs�•eqirest lhal the in�latio��pressiu•e iy�your tires be set to the tire or vehicle n�nntifncturers specificalions. �
3. Do no!overload your vehicle. Serlous injwy may result�i•om overloading l�oiu�vehicle.
4. Regi,sle�•yotrr tires using the DOT(Deparbnent Of T�•ar��s/�a•tutio«)card p�•ovided at tlte tin:e ofpi�rc{tase.
5. Read nndfollow al/tire maintenai�ce requii•ements orrtlle7ed in the Tii�e Manufacturers War•ranty booklet provided
crl the tinte oJpiu•chase.
6. Al���ays insist oit ui7 RMA (Rubber��untrfc�cturers As:;i�cialionJ approved l�vo-piece lire�•epair tf required.
7. rix-a-flat p�-odi�cts shorrld no!be used These producrs void sane�r�a�zufactu��er warranties. Costco will not
pe�form tire repairs or�tires where Fix-a-Flnt has been u.red.
8. !J j�ou nre perrch�siirg less�hrn�four�ires, nJOiuN the ne�i�tires o�r the i•ecn•of the ve/iicle.
9. It is recon�nrended to Jtane your lug nuts re-1ig/�tened 25 nriles n�ter youi•tires are servlced o��replaced.
10. Requesl d�cit your lire and rim nsseniblies are ltand lor•��tred with a calibrated torgare wrench to tlte velt[cle
nurnufcrctui•er.c specifi�ntio��s.
/L Hrn�e vot�i•tiree i�t.ef�ected b��a tire/�i•o%es,rrona!«!/eust once a t•eirr.
�
Rev.(r08
1
�O Uatc: 4/19/13 Iuvoice#: 10210049895
=���R MEMBER FINAL INVOICE Ti�ue L�: 19:22:56 'Ti�ne Out: 19:43:49
Membership#/: 1 1 1 802254532
MEMBLR INI+OItMATION VCHICLL IIVFORMAT101�1
LUIS LARREA 2005 Lexus E5 330 Base
6443 REGENCY LN Color: WHITE Liccuse: 613KXW
EDEN PRAIRIE, MN 55344-7838
Odou�etcr: 125938
Wl�eel Torque: 76
Air I'ressui•e: rront: 30 Itear: 30
I1'EM# DESCRI I''TION Qty
672864 TURANZA SERENITY PLUS 2
PERFORMANCE H/V
215/SSR17 94V BW
I3AN 146-9UG
75,000 Mile Warranty
6850 Tire Installation 2
7023 Disposal Fee 2
D.O.T.II: 1VLMDBH4 912 1VLMDBH4 912
N01 ES:
See Additional Notes. . .
X X
*I��flatiou aud Toryue speciCcatious are recommended by Manufacturer.
I3est to Spare
Static _Dynamic ]AKE JACOBO
Blackwall Whitewall Sales Person 10-Point Vehicle Release
— — Pagc# I
� Costco Road Hazard Warrant
'I'U UALIFY I�OR'i'1115 �VAKIiAN'1'Y:
I. You musl bc thc original piirchascr oF thc tires.
2. You must have purchased the tires Ii�om Costco Wholesale.
3. You u�ust presenl tlie original purchase receipt and tire lo a Costco Wholesale"I'ire Center.
CONUI'170NS OF'1'NIS WARRAN'CY:
I. The Purchaser must rotate and balance their tires as outlincd by the vehicle manufacturer.
2. The Purchaser must operate thcir tires at intlation pressures outlincd by the vehicle manufacturer.
3. The Yurchaser must keeE�all mechanical parts that eflect tires in proper working condition.
4. The Purchaser will be required to sign a"Costco �Vholesale Tire�ldjustmenl Form".
WHA't' IS COVERED:
I. "Road Hazard Failure" is defined as a tire that becomes unserviceable due to cuts,non-repairable punctures or
impact damage.Costco Wholesale�vill repair tires with trcad-face injuries in accordance with cstablished RMA
(Rubber ManuFacturers Association)standards.
2. This warranty covers road hazard failures in Passenger, f'erformance and Light Truck tires purchased from Costco
Wholesale.
3. This warranty is valid for either sixty(60)montlis fiom tlie date of purchase or when the tire reaches 2/32
of an inch or less in remaining tread deptl�,(whichever comes first). •
4. This warranty provides credit based upon remaining usable tread at lhe time of failure due to road hazard.
5. "Usablc'I'read" is defined as the original trcad depth of a tii e less 2/32 of an inch(tread wear indicators).
G. Credit is determined by multiplying thc uscable reiliaining tread by the current price of the tire.
7. This Warranty is a promise under certain conditions to give credit on a pro-rated basis towards the purchase oCa
new tire. This warranty does not i►nply that tires sold l,y Costco Wholesale meet certain specifications or cannot
fail."I'his Warranty does not replace or modify any original tire manufacturcrs warranty on material and
workmanship.
WNAT IS NOT COVERED:
L A tire that is damaged/failed due to vandalism.
2. A tire that is damaged/failed due to an accident.
3. A tire that is damaged/failed due to commercial use.
4. A tirc that is damaged/failed due to racing.
5. A tire that is damaged/failed due to Oft=Road use.
6. A tire that is damaged/ failed due to snow ci�ains or studs.
7. A tiro U�at is damagcd/failcd duc to rapid vr irregular wcar.
8. A tire that is damaged/failed due to wear trom worn mechanical components on the vehicle.
9. Tires transferred ti�om the vehicle on which they were originally installeci. '
10. Loss of time, inconvenience, loss of use of vehicle or consequential da►nage.Some states do not allow the �
exclusion or limitation of incidcntal or conscquential damages,so the above limitalions or exclusions may not
apply.
TIRE CARE RECOMMENDATIONS:
1. Have!he ai�•��res,sure in you�•tires checkecl bv a l�re j�rofessionn!as least once u��rohth. Se�•ioars lnjur•y�nay result
fi•om tire failure c�ue to urrdei•infTnlion. ,
l. Alwnys regtres[Ihat N�e inJlalio��pressu�•e rn y�oin•lires be set to the lire or vehicle mana�facturers speciJicutions.
3. Do ftot overlond yoi�r vehicle.Serious injwy may result Jrom ove�•louding yotu•vehicle. '
4. Registe�•you��tires using the DOT(Deyurhrienl Of Transporta�ion)curd pi�ovided at the tinte ofpurcha.re.
5. Read nnd follow all tii•e maintenance requii•e��ae»ts outlined in t{te Ti�•e Manufacturers Waf•ranty booklet provided
at[he lime ofpu�•chase.
6. Al��vays if�sist on an R�L1A (Rubber Nlanufcic•turers Association)app�•uved two-piece lire�-epair if�reqciired.
7. F'ix-a.�lnt prod:�cts should not be used. Tlzese pr•oducts voicf some rnunzrfaclu�•er H�nrranties. Cosico will not
pe�form tire��epairs o��tires wl�ere Fix-n-Flat has been used. �
8. If voar are�urchasing less tha��four tires, rnou�rt the new tires on tlte renr of the vehicle.
9. It is recomnte��ded!o ha��e��otrr lug ritrts re-lightened 25 miles nf(er��oao•ti��es are se�viced or reploced.
/0. Keqtresl thc��your lire ci�rd rlm c�ssen�hlies cire hnnd lorc�trecl with u c�alihrnled tvrgc�e wrenclr !o the vehicle
manu,nclurej�s specr,ic:atio�is.
1/. Hnve youi�tii�es ii�spected 6��a tire/»•ofes:sional ul Ieast once n yenr.
Rev.6-08
'
�����0 Date: 4/19/13 Invoice�1: 10210049895
—�'fl��R ADDITIONAL NOTES Time In: 19:22:56 Time Out: 19:43:49
Membership�/: 1 1 1 802254532
* Follow the direction in your vehicle ' s owner ' s manual for rotation and ���
rebalance. In the absence of direction in your vehicle ' s owner' s manual, ,
rotate and rebalance your tires every 7, 500 MILES or 12 , 000 KM.
* Tires inflated with nitrogen. Nitrogen stabilizes a tires inflation �
pressure more efficiently than regular air. If needed, air and Nitrogen may
be mixed; return to any Costco afterward for purge and refill to the proper
Nitrogen purity level . ;
* Tire rotation patterns may be limited if a tread depth difference of more ,
than 2/32nds of an inch is present between the front and rear tires of a
vehicle.
* VEHICLE WAS TOWED TO OUR LOCATION. THE LF,LR TIRES WERE FLAT. MEMBER HIT A
POT HOLE AND DAMAGED THOSE TIRES . WHEELS TORQUED TO 76 FT/LBS . WHEELS
MOUNTED ON CLEAN DRY SURFACE. 25 MILE RE-TORQUE REQUIRED AFTER 25 MILES OF
DRIVING. LUG KEY PLACED BACK IN REAR OF VrHICLE. WDB VY,JO.
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