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Weinbeck, Dan 9-15-20NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota Minnesota State Statute 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 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 explain 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, SAINT PAUL, MN 55102 First Name ______________________ Middle Initial ____ Last Name ________________________________ Company or Business Name ___________________________________________________________________ Are You an Insurance Company? Yes / No If Yes, Claim Number? __________________________________ Street Address ______________________________________________________________________________ City ______________________________________ State _____________________ Zip Code __________ Daytime Phone (____)____-______ Cell Phone (____)____-______ Evening Telephone (____)____-______ Date of Accident/ 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. ___________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ 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 you need to include copies of all applicable 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 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. 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 Towing claims: legible copies of any ticket issued and a copy of the impound lot receipt 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 Injury claims: medical bills, receipts 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 Daniel W Weinbeck filing on behalf of myself, not a business 172 6th st E apt 1808 St Paul MN 55101 617 699 6168 8/23/2020 1:00 While driving along Concordia Ave. between Dale and Western, in the span of a block I hit a deep pothole with my left tire and shortly thereafter a worse one with my right tire. The 2nd pothole immediately reduced my tire pressure to 0 and I had to nurse my car back home before getting it towed to the dealership the next day. While examining my vehicle they determined the pothole punctured my right tire and bent the wheel. The left tire had a bulge in it caused by impact that needed immediate repair, and the wheel was also bent. They assured me this was common from drivingon poorly maintained roads, especially this year in St. Paul. If this damage occured in March, I would understand as it takes time to repair the damage from the winter, but it was in August and the roads have been very poorly maintained this year. Failure to complete and return both 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 Unknown (circle) Provide their names, addresses and telephone numbers: ________________________________________________ _____________________________________________________________________________________________ Were the police or law enforcement called? Yes No 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 necessary, attach a diagram. _______________________ ______________________________________________________________________________________________ Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim to your satisfaction. ______________________________________________________________________________ ______________________________________________________________________________________________ Vehicle Claims – please complete this section ________ check box if this section does not apply Your Vehicle: Year __________ Make _______________ Model_________________________________ License Plate Number _______________ State _____ Color ________________________ Registered Owner __________________________________________________________ Driver of Vehicle ___________________________________________________________ Area Damaged______________________________________________________________ City Vehicle: Year __________ Make _______________ Model_________________________________ License Plate Number _______________ State _____ Color ________________________ Driver of Vehicle (City Employee’s Name)_______________________________________ Area Damaged______________________________________________________________ Injury Claims – please complete this section ________ check box if this section does not apply How were you injured? ____________________________________________________________________________ _______________________________________________________________________________________________ What part(s) of your body were injured? ______________________________________________________________ _______________________________________________________________________________________________ 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 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 ________________________ Print the Name of the Person who Completed this Form: ______________________________________________ Signature of Person Making the Claim: _____________________________________________________________ Revised February 2011 Concordia ave. between Dale and Western $809.82 - please reimburse me for the repair due to this damage - I have lived in St. Paul for 4 years and enjoy the city but the roads are in especially bad shape this year and this $809 damage was likely unavoidable with all of the miles i put on St Paul streets 2019 Mercedes-Benz CLA 250 BTS 496 MN White Daniel Weinbeck Daniel Weinbeck Front tires and wheels 4 9-15-2020 Daniel Weinbeck Customer Information DANIEL W YMAN WEINBECK 172 6TH ST E APT 1808 SAINT PAUL MN 551012914 Customer Number - 252489 Home Phone #: Cell Phone #: Business Phone #: 6176996168 6517365800 Vehicle Information 2019 MERCEDES-BENZ 2DR CLA250 CPE 4MATI VIN #: Color #: Mileage #: WDDSJ4GB0KN720897 POLAR WHT 14161 Job # 1 Labor Total:$ 0.00 CUSTOMER STATES FR TIRE IS FLAT. PLEASE CHECK AND REPORT FINDINGS. Cause: 2 front tires replaced and both front wheels repaired Correction: PERFORM TIRE PATCH/PLUG REPAIR AND VERIFY TIRE IS NO LONGER LOSING AIR Part Number Part Description Parts Total:$ 0.00 Job # 1 Total $0.00 Job # 2 Labor Total:$ 0.00 CUSTOMER REQUESTED A LOANER Cause: Correction: PROVIDE COMPLIMENTARY LOANER VEHICLE DURING SERVICE. LOANER VEHICLE IS DUE BACK WITHIN 24 HOURS OF SERVICE BEING COMPLETE OR ADDITIONAL FEES WILL APPLY. NO SMOKING OR PETS IN LOANER VEHICLE PER LOANER AGREEMENT Part Number Part Description Parts Total:$ 0.00 Job # 2 Total $0.00 Job # 3 Labor Total:$ 0.00 PERFORM PREPAID 20,000 MILE / 2 YEAR FACTORY SCHEDULED MAINTENANCE. NPPMS 2 OF 2 INCL W IPERS Cause: Correction: PERFORM COMPLETE PREPAID 20K SERVICE Part Number Part Description Parts Total:$ 0.00 2780 US-61 Maplewood 55109 Phone: 6514832681 MN MInnesota US United States Repair Order #: Tag #: Inv oice Date: Advisor: Adv isor No. #: Order Open Date : 781264 D209 08/25/2020 KIMBERLY A. SANCHEZ 8048 08/25/2020 08/25/2020 2:19 PM * OEM means Original Equipment Manufacturer (factory) Parts | ** All parts are New unless specified otherwise. ~~ Thank you for your business ~~ MB176-820-43-00 TS WIPER BLADE MB270-180-01-09 TS OIL FILTER MB007603-014106 SEAL RING,VLRU PKOOIL 5W40 BULK TANK ZL000-989-79-02-19-BIFU MB GENUINE ENGIN MB000-989-08-07-01 BRAKE FLUID MB246-830-00-18 COMBINATION FI Job # 3 Total $0.00 Job # 4 Labor Total:$ 0.00 CUSTOMER REQUESTS BUY HAPPY MULTI-POINT INSPECTION Cause: Correction: COMPLETED MULTI-POINT INSPECTION Part Number Part Description Parts Total:$ 0.00 Job # 4 Total $0.00 Job # 5 Labor Total:$ 0.00 CREATE VEHICLE HEALTH REPORT VIDEO USING TRUVIDEO APPLICATIO Cause: Correction: VEHICLE HEALTH REPORT VIDEO CREATED AND SENT TO CUSTOMER FOR VIEWING Part Number Part Description Parts Total:$ 0.00 Job # 5 Total $0.00 Job # 6 Labor Total:$ 0.00 CUSTOMER REQUESTS BUY HAPPY MULTI-POINT INSPECTION Cause: Correction: COMPLETED MULTI-POINT INSPECTION Part Number Part Description Parts Total:$ 0.00 Job # 6 Total $0.00 2780 US-61 Maplewood 55109 Phone: 6514832681 MN MInnesota US United States Repair Order #: Tag #: Inv oice Date: Advisor: Adv isor No. #: Order Open Date : 781264 D209 08/25/2020 KIMBERLY A. SANCHEZ 8048 08/25/2020 08/25/2020 2:19 PM * OEM means Original Equipment Manufacturer (factory) Parts | ** All parts are New unless specified otherwise. ~~ Thank you for your business ~~ Job # 7 Labor Total:$ 61.00 CUSTOMER STATES TO MOUNT AND BALANCE 2 TIRES (FRONT TWO) Cause: MOUNT AND BALANCE 2 TIRES AS REQUESTED Correction: MOUNTED AND BALANCED 2 TIRES. RESET TIRE PRESSURE MONITOR AND ROAD TEST 1.0 Part Number Part Description Parts Total:$ 438.88 MBQ-8-40-1792 PIRELLI 225/40 ZLTD TIRE DISPOSAL FE Job # 7 Total $499.88 Job # 8 Labor Total:$ 236.00 PERFORM WHEEL STRAIGHTENING DUE TO IMPACT DAMAGE (FRONT TWO WHEELS) Cause: Correction: Part Number Part Description Parts Total:$ 0.00 Job # 8 Total $236.00 Job # 9 Labor Total:$ 0.00 RAYMOND AUTO BODY TO PRICE OUT SCRATCH ON FRONT END OF VEHICLE. Cause: Correction: CUSTOMER DECLINED REPAIRS AT THIS TIME. RAYMOND PRICED OUT $1100 FOR BUMPER, $1300 INCLUDING SCRATCH ON FL FENDER. Part Number Part Description Parts Total:$ 0.00 Job # 9 Total $0.00 Sublets Job #PO #Description 2780 US-61 Maplewood 55109 Phone: 6514832681 MN MInnesota US United States Repair Order #: Tag #: Inv oice Date: Advisor: Adv isor No. #: Order Open Date : 781264 D209 08/25/2020 KIMBERLY A. SANCHEZ 8048 08/25/2020 08/25/2020 2:19 PM * OEM means Original Equipment Manufacturer (factory) Parts | ** All parts are New unless specified otherwise. ~~ Thank you for your business ~~ Terms and Acceptance Customer acknowledges approval of work des cribed in this Repair Order Summary. Any Warranties on the product sold herein are those made by the manufacturer. The seller hereby expressly disclaims all warranties , either express including any implied warranty of merchantability or fitness for a particular purpos e. and neither assumes nor authorizes any other person to assume for it any liability in connection with the sale of said products. Please look for a surv ey on your service experience. The manufac tures s urvey will be sent to you by email. If you are not sure if your current email address is on file please check with your service advisor. We're working hard to make customers for life! Sublet Total:$ 0.00 Amount Totals Total Labor:$ 297.00 Total Parts:$ 438.88 Total Sublet:$ 0.00 Total G.O.G.:$ 0.00 Misc:$ 0.00 Discounts:$ 41.58 Sales Tax:$ 32.36 Customer Total:$ 809.82 .SIGNHERENOW. 2780 US-61 Maplewood 55109 Phone: 6514832681 MN MInnesota US United States Repair Order #: Tag #: Inv oice Date: Advisor: Adv isor No. #: Order Open Date : 781264 D209 08/25/2020 KIMBERLY A. SANCHEZ 8048 08/25/2020 08/25/2020 2:19 PM * OEM means Original Equipment Manufacturer (factory) Parts | ** All parts are New unless specified otherwise. ~~ Thank you for your business ~~