Myers NOTICE OF CLAIM FORIVI to the City of Saint Paul, Minnesota
Minnesota Stnte Statute 466.05 stcues Ihnt "._ei er•�•person...tivho claims dai�aages frorn aiay m«nicipnlity...shall catcse to be presented to the
governing bod��of the�n�u�iicipalin�within L80 ci��vs after die alleged loss nr injrery is discoverect a notice stating the time,place,and
cr�-c�nnstnnc%�s t1Ter��oJ;nnd the anto«nt�J�conapensation or otlier relief demanded."
Please complete this form in its entirety by clearly t,yping 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 ackt�cw'�edg�m<�r.t on�e;ou�;'c-��i�re�•Ei�;e�l. The;�r•��ess ca►�takE u;to ten weel�s 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 Ct�MPL�T�� �'�T4i�� �I�TD O�HF,IZ D4CUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 �1TY HALL, SAINT PAUL, MN 55102
� First N�me �E 2 E M�./ �Vtidule Liit�al p Last PJarne ��5 _
�,_IV�l,�
Compar.y , 3��s :es:>I��a,.,.:,----------------------
Are You an Insurance Company? Ye� '�'�� Tf 1'es, Claim Number? �CT �4 �
Street Address___L2-��__S���^J���—�✓'�!�?_'_______--__ C'� CL��
City �Z• I�f�'U��. _;s.at:. 1�'L!� Zip Code J S I 0�-�
Daytime Phone (�0�2;��J�-��l'J�. �:'ell Phc�r.��v�J� 1���-�l 70 Lvening Telephone( C��-L--
Date of Accident/ �njury cr Dat� 1�1��,_�v°re:t__ ~ JZOl � I'ime $ '�� am pm
�t�---
Please state,in detail, wh�t�c�>>�rred �:��a;�;^e������1 and •��h�����u are st�bmir,ting a claim.Please indicate why or how you
feel the Citti� �f Saint i'aul or its ::mplo��ee� a;�e involved and�or responsible for your damages. = w�S OQ►�++�"V'
(3� �rE2cr g��"1'z�-s; P�+51 1��`�ZL. �A-e,z i�c �i7� ��45 rt�w�+�tS �YC C�+x iN
'T-�� PA��1 S NEA�2l� ""tr-FE rtvwc2 Hl? A 2oc� ��� i�-IC�I -r��E 2CGK N�'L__
��t�av�� a �Z_��s7 ,�.r� ���N►t�-�
P18aS8 C�if��t2� Z)OX�°_S� �'?�:3;iC;ST ���•-t 1 �•:r�i,cf;l:i tilC i�J3�:)I?J�OC i,01I1�_1�i1'1?t}I1S�OIITI:
❑ My veh�cle a�,�s d�ma��c�i:i�lr. a�:._d��.� C N�}�vehicle was damaged during a tow
� My vehicle was damaged�� �3 pothul� ur cc=;3�i��ioi: of th: s'seet ❑ My vehicle was damaged by a plow
� My vehicle was wronbfi��ly to�ed �d%c �eted ❑ I«�as injured on City property
�Other t E v+ ro ert��darna�e- f� s,�.: ;�� �:j' ��NiCI..E �l1tr'IArCri-� g-�l�1��� 1'ic�Z T+Qu..��.1 I�C��<.
y'l�' `� P P � b (` t�
❑ Other t}�Ne �f;r;}c�y- �;�1:as� �n��c��t:; ___—_—_
In order to pr��ce�� vuur ��;sz:i�ra ��aa i�k��i tu inclui�e c�► ies of all applicable documents.
For the cla.ms t��Ues listed bei��:�,. �;iea�t• ��'_ ���=''�to ;r��.'r,z�ie !�e �i��cuments ind��cated or it will delay the handling of
your claim. Documents W1L1,NO'!'be r:;turne� ar.d bec,ome the property of the City. You are encouraged to keep a
copy for yourself before sub�nittin<���our claim form.
�Property damage clain,� to <.ve!�,ici°: t�°o estimates for the rep�irs to your vehicle if the damage exceeds
$500.00; or the a�*nal hi�l� _n�1 ^� r,: ��'s T�r the regairs
O 'Tev�in�c?a�m>: I��gib':� ��^ � �` � ti�acet issueci ar.d a copy oi ti�e impound lot reeeipt
O O*her pronem� �!a^�a�e�,la�:��s� '�ti��^re^a�r.��t�m�te� if the �tarnage e�ceeds $500.00; or the actual bills
and/or rer.�eipts fo: tl�e ic t�a���r. ,.r�?,�; ;r; l:�t ��5�iiama,;�.cl �tems
O Iniw-v :laizn� ��.c".� ' ��,��'- c�� : -�-
O Phot�«�aT�hs a..: a1� ,;�'� '�-�• ,�.. :_� cic�����n►;i�t ar.d stapr�o�t�our cl�iEn but will not be retumed.
�a�� _� �#'�-��kn:��:���e►�ry���te and ret�ir�r k�4th F�ges of Claim Form �
Failure ta compiete anc� ret�arx�boti� pages wil�resu:t in delay in the handling of your claim.
All Claims-please cornt�iete tliis sec��a_+�
Were there witnesses to tr: incident`' f'es No Unknow (circle)
Provide their names, add:esses ai�d telcpllo-�� ._u;nber�:
Were the police or law enforcem�nt calle�`' Yes No Unknown (circle)
If es, what de artmen� or aQenc �? �'- ��v�________ Case#or re ort# � 1 q 21�S ��J" �H��v�
Y P" _ �� �--- -- - p �
Where did the accident or injury tak� ��lac��`' Pr�vide street address,cross street, intersection, name of park or facility,
� ,_ ,.�_ . ,__
closest la��U;�;u��., �tc. r��a�� c�� a, .:��a,i.;a a, possible. If necessary, attach a dia ram.
P�5 ,�(� _��z�._ P�K—aN__ (���ec.� ��src.c� ,v�,�++2 ����2 v'���.t_
Please indicate the amounT ye�� �i��� >�eeki���, in :;,mper,�at�on or���11at yoa would like the Ciry to do to resolve this claim
to your satisfaction. _ ' "`� T'- ' - _ -� - - �n r �,R' _`_,"�'
"�v� wci i"F:iK,i;i � ;. . :_ -�;-i y � �.-
-� ���� r � C7���. i,� l� � � �'1 1��� r ���'� �.�CN�
-�et� ?1-��C Ai'l�/�l 1��. U�,
�`�Nz��.�, l�i 4�'=Q5�4 �0.�ev �`�,6P��P .t �,�-,�aL
Vehicle Cla�ms_�lease c�jnplet�_th���_�c>ir�t______.�_____._.________ �_check box if this section does not avplv
Your Vel„ i�� '�;.:-�t!-����7_. '✓!,'�-:.' --`�'C?QiA-2U---_-Model__G�.3T+�/4C.IL
License F:��te Nun�b�r��]f[� �tate�`I1J Col�r C'�2��
I'c.,gistered l:wr.�:� S�'2- t''1�.��"�2S
D�Iv�r,-rti`--'�'` _��2-- —��
,?rea Dan�aged .__(ZA''.F �`-�-� - _�.�c_^r6_ W't�.i 0 Stti�2�
City Vehicte: Year__._-- -- ---- iV at:e _----------i�lodei--------
License I'1_�_�� �`�,�n�hr:r-- --- ��t ate Color
Drl��f•j•�l{��'�.�jij-�; !C���� �''�r�- 'Pe��i 1V�me�. . .-- '---------------'-
�r.,�.' �--�'�:�O-'j
1 �_s� _C�
In,Lurv Claim�r -_�►1e�se c�_�_r.��,i�_,•.� i';i�. >>._:�:��,.; � �heck box if this section does not applv
How wzre vou in�iared? --- -- - --------- -------------------
What puri; ? :;i y�:;ur bodti .;�t.�c �:i; :ec= -- -------------
----- -- ----- ------ --- ------- ------ -- --- ------
Have yon �;o���ht �e�iica'_ t��e^tm:nt" Y�s :�'o Plannin� to Seek Treatment(circle)
When did �:,;,,.i , �r��;ve t-°:�'n�er.,' (provide date(s))
Name of Medicai Prn�.�idc°�r��:------- --- ---- ----
?_ddress _ --- ---- -1'elephone
Did you miss �NC�rlc a� a resuit of��aar injlir�? Yes No
When did vou miss work`% _ _ . _ (provide date(s))
Name o���c��i. �;nnloy�.: ---- - -- -- - ------
Address----- _ - - _____ _ ----- Telephone
�Ct��i:�: 1►rre if���>�� aw�: 3�c�c:r�,��� :n��re �ages tu tii;s c�xirr►furin. �umber of additional pages
By sigr..in;*�ic,�'�r�►, ��re�r �.°n sts�*���; r% n'�Il ib�fz�rmation you have pr•vvided is true and correct to the best
of your krt��t�.1,��?Qe. �.Insif,>nec� f�rr,~,s •��ilt.not be processed.
Subrnittirt;� .:,f�'��� i:�G<i�r� �•�r:r ��•f�,��;'° �rr ;�rra�zvc�� '���. ���.�f�,w•m wa�completed� �� Z� �.�
Print the '�i�rr.�e ��f!}i:�Pe:.,. . „.� ;';,r�r-'c�:.ti th� Forr:►: _� _!"Y L�S
�E�--
Signatur: uf�'e�•sor� :�I:�f_=1s� �l�e �'a�,im: --- — -----
Ravised r'ei_..:.:; = -
ABRA Auto Body & Glass - Midway Workfile ID: 89ec6a3d
FederalID: 41-1852119
Right The First Time...On Time
1190 UNIVERSITY AVE W, SAINT PAUL, MN 55104
Phone: (651) 645-1563
FAX: (651) 641-6129
Preliminary Estimate
Customer: MYERS,TRACIE &7EREMY ]ob Number:
Written By:John Rucinski
Insured: MYERS,TRACIE& Policy#: Claim#: *
JEREMY
Type of Loss: Date of Loss: Days to Repair: 3
Point of Impact: 10 Left Front Pillar(Left
Side)
Owner: Inspection Location: Insurance Company:
MYERS,TRACIE&JEREMY ABRA Auto Body&Glass-Midway Unknown Insurance
1286 SEMINARY AVE 1190 UNIVERSITY AVE W
ST PAUL,MN 55104 SAINT PAUL, MN 55104
(651)500-1852 Business Repair Facility
(651)331-8170 Business (651)645-1563 Business
VEHICLE
Year: 1997 Body Style: 4D WGN VIN: 4S36G6853V7650348 Mileage In: 111111
Make: SUBA Engine: 4-2.5L-FI License: 575-HGP Mileage Out:
Model: LEGACY OUTBACK Production Date: 6/1997 State: MN Vehicle Out:
Color: GREEN Int: Condition: ]ob#:
TRANSMISSION DECOR Stereo Cloth Seats
Overdrive Dual Mirrors Cassette Bucket Seats
5 Speed Transmission Tinted Glass SAFETY Reclining/Lounge Seats
4 Wheel Drive CONVENIENCE Drivers Side Air Bag WHEELS
POWER Air Conditioning Passenger Air Bag Aluminum/Alloy Wheels
Power Steering Cruise Control Anti-Lock Brakes(4) PAINT
Power Brakes Rear Window Wiper 4 Wheel Disc Brakes Clear Coat Paint
Power Windows RADIO ROOF Two Tone Paint
Power Locks AM Radio Luggage/Roof Rack OTHER
Power Mirrors FM Radio SEATS Fog Lamps
9/20/2013 11:17:22 AM 011906 Page 1
Preliminary Estimate
Customer: MYERS,TRACIE &7EREMY 7ob Number:
Vehicle: 1997 SUBA LEGACY OUTBACK 4D WGN 4-2.5L-FI GREEN
Line Oper Description Part Number Qty Extended Labor Paint
Price;
1 WINDSHIELD
2 Repl Reveal molding upper 65023AC030 1 32.95 0.3
3 R&I RT Reveal molding side from 0.3
12/94
4 R&I LT Reveal molding side from 0.3
12/94
5 ROOF
6 * Rpr Roof panel w/o sunroof Outback � 3.5
w/o Limited
7 Add for Clear Coat 1.4
8 * Rpr RT Drip w'strip lift taoe for 9�
in in
9 * Rpr LT Drip w'str�lift tape for �
in i
10 R&I RT Rail assy 0.4
11 R&i LT Rail assy 0.4
12 # R&I center roof runners 1.0
13 MISCELLANEOUS OPERATIONS
14 # Refn �Car Cover 0.1
15 # Refn 'Corrosion Protection 0•3
16 # 'Hazardous Waste 1 5.00 X
SUBTOTALS 37.95 5.2 5.3
NOTES
Prior Damage Notes:
1
ESTIMATE TOTALS
Category Basis Rate Cost#
Parts 32.95
Body Labor 5.2 hrs @ $54.00/hr 280.80
Paint Labor 5.3 hrs @ $54.00/hr 286.20
Paint Supplies 5.3 hrs @ $34.00/hr 180.20
Miscellaneous 5.00
Subtotal 785.15
Sales Tax $213.15 @ 7.6250% 16.25
Grand Total 801.40
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 801.40
9/20/2013 11:17:22 AM 011906 Page 2
Preliminary Estimate
Customer: MYERS,TRACIE &7EREMY 7ob Number:
Vehicle: 1997 SUBA LEGACY OUTBACK 4D WGN 4-2.5L-FI GREEN
THIS IS A VISUAL INSPECTION ONLY. THERE MAY BE ADDITIONAL DAMAGE AFfER DISASSEMBLY. PARTS ARE
SUBJECT TO INVOICE. THERE ARE NO GUARANTEES ON RUST REPAIRS.
"Minnesota law gives you the right to choose any rental vehicle company, and prohibits me from requiring you to
choose a particular vendor."
MN ST 60A.955 - A PERSON WHO FILES A CLAIM WITH INTENT TO DEFRAUD OR HELPS COMMIT A FRAUD
AGAINST AN INSURER IS GUILTY OF A CRIME.
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
AEL7521, CCC Data Date 9/16/2013, and the parts selected are OEM-parts manufactured by the vehicles Original
Equipment Manufacturer. OEM parts are available at OE/Vehicle dealerships. OPT OEM (Optional OEM) or ALT OEM
(Alternative OEM) parts are OEM parts that may be provided by or through alternate sources other than the OEM
vehicle dealerships. OPT OEM or ALT OEM parts may reflect some specific, special, or unique pricing or discount.
OPT OEM or ALT OEM parts may include "Blemished" parts provided by OEM's through OEM vehicle dealerships.
Asterisk (*) or pouble Asterisk (**) indicates that the parts and/or labor information provided by MOTOR may have
been modified or may have come from an alternate data source. Tilde sign (N) items indicate MOTOR Not-Included
Labor operations. The symbol (<>) indicates the refinish operation WILL NOT be performed as a separate procedure
from the other panels in the estimate. Non-Original Equipment Manufacturer aftermarket parts are described as Non
OEM or A/M. Used parts are described as LKQ, RCY, or USED. Reconditioned parts are described as Recond.
Recored parts are described as Recore. NAGS Part Numbers and Benchmark Prices are provided by National Auto
Glass Specifications. Labor operation times listed on the line with the NAGS information are MOTOR suggested labor
operation times. NAGS labor operation times are not included. Pound sign (#) items indicate manual entries.
Some 2014 vehicles contain minor changes from the previous year. For those vehicles, prior to receiving updated
data from the vehicle manufacturer, labor and parts data from the previous year may be used. The CCC ONE
estimator has a complete list of applicable vehicles. Parts numbers and prices should be confirmed with the local
dealership.
The following is a list of additional abbreviations or symbols that may be used to describe work to be done or parts to
be repaired or replaced:
SYMBOLS FOLLOWING PART PRICE:
m=MOTOR Mechanical component. s=MOTOR Structurall component. T=Miscellaneous Taxed charge category.
X=Miscellaneous Non-Taxed charge category.
SYMBOLS FOLLOWING LABOR:
D=Diagnostic labor category. E=Electrical labor category. F=Frame labor category. G=Glass labor category.
M=Mechanical labor category. S=Structural labor category. (numbers) 1 through 4=User Defined Labor Categories.
OTHER SYMBOLS AND ABBREVIATIONS:
Adj.=Adjacent. Algn.=Align. ALU=Aluminum. A/M=Aftermarket part. BInd=6lend. BOR=Boron steel.
CAPA=Certified Automotive Parts Association. D&R=Disconnect and Reconnect. HSS=High Strength Steel.
HYD=Hydroformed Steel. Inc1.=Included. LKQ=Like Kind and Quality. LT=Left. MAG=Magnesium. Non-Adj.=Non
Adjacent. NSF=NSF International Certified Part. 0/H=Overhaul. Qty=Quantity. Refn=Refinish. Repl=Replace.
R&I=Remove and Install. R&R=Remove and Replace. Rpr=Repair. RT=Right. SAS=Sandwiched Steel.
Sect=Section. Subl=Sublet. UHS=UItra High Strength Steel. N=Note(s) associated with the estimate line.
9/20/2013 11:17:22 AM 011906 Page 3
Preliminary Estimate
Customer: MYERS,TRACIE &JEREMY 7ob Number:
Vehicle: 1997 SUBA LEGACY OUTBACK 4D WGN 4-2.5L-FI GREEN
CCC ONE Estimating -A product of CCC Information Services Inc.
The following is a list of abbreviations that may be used in CCC ONE Estimating that are not part of the MOTOR
CRASH ESTIMATING GUIDE:
BAR=Bureau of Automotive Repair. EPA=Environmental Protection Agency. NHTSA= National Highway
Transportation and Safety Administration. PDR=Paintless Dent Repair. VIN=Vehicle Identification Number.
9/20/2013 11:17:22 AM 011906 Page 4
r � �
' RAYMOND AUTO BODY� INC. Workfile ID: 41c69fb7
FederalID: 41-0888257
1075 PIERCE BUTLER RTE, SAINT PAUL, MN
55104
Phone: (651) 488-0588
FAX: (651) 488-4794
Preliminary Estimate
Customer: MYERS,]EREMY Job Number:
Written By: DAMON SLAIKEU
Insured: MYERS,JEREMY Policy#: Claim #:
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact:
Owner: Inspection Location: Insurance Company:
MYERS,JEREMY RAYMOND AUTO BODY, INC.
1286 SEMINARY AVENUE 1075 PIERCE BUTLER RTE
ST PAUL, MN 55104 SAINT PAUL, MN 55104
(651)331-8170 Cell Repair Facility
(651)488-0588 Business
VEHICLE
Year: 1997 Body Style: 4D WGN VIN: 4S3BG6853V7650348 Mileage In:
Make: SUBA Engine: 4-2.5L-FI License: Mileage Out:
Model: LEGACY OUTBACK Production Date: State: Vehicle Out:
Color: Int: Condition: Job#:
TRANSMISSION DECOR Stereo Cloth Seats
Overdrive Dual Mirrors Cassette Bucket Seats
5 Speed Transmission Tinted Glass SAFETY Reclining/Lounge Seats
4 Wheel Drive CONVENIENCE Drivers Side Air Bag WHEELS
POWER Air Conditioning Passenger Air Bag Aluminum/Alloy Wheels
Power Steering Cruise Control Anti-Lock Brakes(4) PAINT
Power Brakes Rear Window Wiper 4 Wheel Disc Brakes Clear Coat Paint
Power Windows RADIO ROOF Two Tone Paint
Power Locks AM Radio Luggage/Roof Rack OTHER
Power Mirrors FM Radio SEATS Fog Lamps
9/16/2013 4:20:22 PM 019495 Page 1
� �� Preliminary Estimate
Customer: MYERS,)EREMY ]ob Number:
Vehicle: 1997 SUBA LEGACY OUTBACK 4D WGN 4-2.5L-FI
Line Oper Description Part Number Qty Extended Labor Paint
Price$
1 ROOF
2 * Rpr Roof panel w/o sunroof Outback "i.Q 3.5
w/o Limited
3 Add for Clear Coat 1.4
4 R&I RT Drip molding 1.1
5 R&I LT Drip molding 1.1
6 R&I RT Rail assy 0.4
7 R&I LT Rail assy 0.4
8 R&I Headliner w/o sunroof Outback 3.0
open Repl LT Rail assy cushion center 91094AC030 1 5.18
10 Repl LT Rail assy cushion front 91094AC011 1 5.87
11 Repl RT Rail assy cushion rear 91094AC041 1 5.87
_
1Z MISCELLANEOUS OPERATIONS
13 Repl Cover car/bag 1 0.2
14 # Repl Hazardous waste removal 1 6.00 X
15 # Repl Corrosion protection primer 1 0.4
16 # Color tint/color match 1 0.5
SUBTOTALS 22.92 9.2 5.8
ESTIMATE TOTALS
Category Basis Rate Cost$
Parts 16.92
Body Labor 9.2 hrs @ $59.00/hr 542.80
Paint Labor 5.8 hrs @ $59.00/hr 342.20
Paint Supplies 5.8 hrs @ $39.00/hr 226.20
Body Supplies 3.2 hrs @ $8.00/hr 25.60
Miscellaneous 6.00
Subtotal 1,159.72
Sales Tax $268.72 @ 7.6250% 20.49
Grand Total 1,180.21
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 1,180.21
WHILE WE HAVE MADE EVERY EFFORT TO WRITE A COMPREHENSIVE REPORT OF THE VISIBLE DAMAGE TO YOUR
VEHICLE, IT IS IMPORTANT TO REMEMBER THAT THIS IS ONLY AN ESTIMATE. THERE ARE A NUMBER OF FACTORS
THAT CAN AFFECT THE ACTUAL COST OF REPAIRS, INCLUDING BUT NOT LIMITED TO HIDDEN DAMAGE, PARTS
PRICE CHANGES, AND INSURANCE COMPANY INVOLVEMENT. PLEASE CONSIDER THIS WHEN MAKING DECISIONS
REGARDING THE REPAIRS TO YOUR VEHICLE.
9/16/2013 4:20:22 PM 019495 Page 2
Reservation Detail Page 1 of 1
myers, jeremy 11/04/2013 09:00 AM INTERMEDIATE
Reservation: 61LB44 Date Taken: By: Origin: BRANCH
Vehicle
Car Class: INTERMEDIATE Authorization
Rate Quoted: Status:
$35.00/DAY
Car Class:
Specials: � Auth Amount:
Mileage Charge: NO CHARGE � �
�t� � #of Days:
Preferences: 1
Max Per Day:
np��`� Total Max Amount:
3 "" �
%Auth:
Product/Services
DAMAGE WAIVER $15.60/dAY
PAI $3.39/DAY
RAP $3.99/DAY
SUPPLEMENTAL LIABILITY PROTECTION 2 $13.95/DAY
r Authorization ,
Pick Up/Return
Pick Up Date: 11/04/2013 Return Date: 11/07/2013
Pick Up Time: 09:00 AM Return Time: 09:00 AM
Pick Up Group: A0019_MINNESOTA Return Group: A0019_MINNESOTA
Pick Up Branch: ST PAUL MIDWAY 1906 Return Branch: ST PAUL MIDWAY 1906
1161 UNIVERSITY AVE W 1161 UNIVERSITY AVE W
SAINT PAUL,MN 551044124 SAINT PAUL,MN 551044124
Pick Up Method: Return Method:
Pick Up Location: Return Location:
Directions:
Renter Information
myers,jeremy Home: (651) 333-18170
Work:
MN Other:
Bill-to
Rental Type: RETAIL
Claim Type:
Claim/Pol/PO/RO:
Insured Name:
Shop
Renters Vehicle:
Flight Information
Airline: Flight: Terminal:
Arrival Date: Arrival Time:
9/27/2013