Yang, Angela �
� NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minnesota State Statute 466.05 states that "...every person...who claims damages frorn any municipality...shal!cause to be presented to the
governing body of t/te municipality within 180 days afier the alleged loss or injury is discovered a notice stating the time,place,and
circumstances thereof,nnd the umoemt 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 ciaim,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, 31d CITY HALL, SAINT PAUL, MN 55102
First Name � �o- Middle Initial C. Last Name�'�� .-.•— �D
Company or Business Name N��
OCT 10 2013
Are You an Insurance Company? Yes� If Yes,Claim Number?
Street Address 532- �Vn� l��ht+�e CITY CLERK
City 5'�• P�-� State M N Zip Code 55(30
Daytime Phone(�.(_.)�OQ- 4� Cell Phone(6��)�- q�0 Evening Telephone(�_)(Li�.- y�
Date of Accidend Injury or Date Discovered ��ZJD13•9��Time am/pm
i
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. C�u� I31��L�V
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Please check the box(es)that most closely represent the reason for completing this form: ��
M vehicle was dama ed durin a tow J�'
❑ My vehicle was damaged in an accident � Y g g
C] My vehicle was damaged by a pothole or condition of the street ❑ My vehicle was damaged by a plew
�My vehicle was�vrongfully 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 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
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 ac[ual 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.�A�µ�`' �.
Po�;c.� ►�.s�i�- V..�".
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 complete this section
Were there witnesses to the incident? Yes No Unknown (circle)
Provide their names, addresses and telephone numbers: a 'n '1'Ne ' � 6Z�1 l.��s�` 3�•N� C•`�"�`!�
�►�:�SS�IZ-1 fM' �.istZ•L 3L- ��ca � � � �r w 12-- S
Were the police or law enforcement called? � No Unknown (circle)
If yes, what department or agency? 5�►� Q 0�.�. Case#or report# t31� �..��le � C—�3�2.$0
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. '� 5 's A�o
:�,�;J.�— Swc.w.� i...ac �3ap2 �.A'�r� St• N4- � Goiw�ba�- I�I�•:.�,�s , 1�+lN �1
Please indicate the amount you are seekin in compensation or what ou would like the City to do to resolve this claim
to your satisfaction. � 1JD0�.�•� � �'��l•�Q ��41��,t�es� t 4 2$3.QlS (,t.rJ-�sa) �� •Sd��•F�-�
�! 0 30 �'t L�nnr.�t�,x.�.� F,R.w, �ba. __�±•_3.is C�oel�c� E.�.a�t
Vehicle Claims please complete this section ❑check box if this section does not avplv
Your Vehicle: Year 2.00\ Make 1��QSar� Model Se�f�.o�-
License Plate Number q0 V State MN Color Go\�.
Registered Owner �� ��
Driver of Vehicle 1d►
Area Damaged �
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
In'ur Claims— lease com lete this section ❑check box if this section does not a 1
How were you injured? � ' � 'S t • • �► ~
�.�-- ����. �� c�F F�w► I�b�+�v � � �ti�s S�hs�F
What part(s)of your body were injured?
Have you sought medical treatment? Yes No lanning 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 �
When did you nuss work? (provide date(s))
Name of your Employer:
Address Telephone
�Check here if you are attaching more pages to this claim form. Number of additionat pagesl-Z.
By signing this form,you are stating that all infor�ation you have provided is true and correct to the best
of your knowledge. Unsigned forms will not be prbcessed.
Submitting a false claim can result in prosecution. Date form was completed ���S���3
Print the Name of the Person who Completed this orm: _ /'���,- C� ��'�1
� '�
Signature of Person Making the Claim:
Revised Fcbruary 201 1
532 Payne Avenue RECEIVED
Saint Paul, MN 55130 OCT 10 2p�3
CITY CLERK
October 7, 2013
City Clerk
City of Saint Paul
310 City Hall
Saint Paul, MN 55102
RE: File Number C-130280& Police Report/Case#13172676
Dear City Clerk:
Please find enclosed,the formal Notice of Claim Form along with receipts, estimates,and other
documentation for my request for reimburseme�t and punitive damages. I have also sent these copies
to Claim Manager Ms.Sandra Bodensteiner at 2�0 City Hall Annex, 25 West Fourth Street,Saint Paul,
MN 55102-1631, because she has reached out to me concerning this claim and incident.
I have provided two vehicle repair estimate quotes and live closer to Heppner's Auto Body in Downtown
out of the two repair locations where I obtained estimates. Also,while my vehicle is being repaired, I
am requesting for transportation,and am requesting for a rental car that will have to be returned next
day once my vehicle is ready for pickup because I will not be able to return the vehicle to the rental car
company before its closing time. In addition, I have enclosed receipts for costs of transportation while
my vehicle was impounded; costs for obtaining copies of the police report; and the cost meal the night
of my vehicle being impounded because my plans that evening were drastically changed when my
vehicle was wrongfully impounded.
If you have any questions or concerns about my requests, please feel free to contact directly at 651-600-
4940. '
Thank you.
_ Since y,
� �
Angela Chee Yang
Cc
Sandra Bodensteiner,Claims Manager
� HEPPNER'S AUTO BODY (Downtown) Workfile ID: 27766962
' EPPI1fER�J� 395 E. 7TH ST., SAINT PAUL, MN 55101
. : . .
Phone: (651) 224-5644
FAX: (651) 224-6042
Preliminary Estimate
Customer: YANG,ANGELA )ob Number:
Written By: Grant Almeida
Insured: YANG,ANGELA Policy#: Claim #:
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact: 06 Rear I
Owner: Inspection Location: Insurance Company:
YANG,ANGELA HEPPNER'S AUTO BODY(Downtown) OTHER
532 PAYNE AVE 395 E.7TH ST.
ST.PAUL, MN 55130 SAINT PAUL, MN 55101
(651)600-4940 Cell Repair Facility
(651)224-5644 Business
VEHICLE
Year: 2001 Body Style: 4D SED VIN: 3N1CB51D41L454748 Mileage In: 159983
Make: NISS Engine: 4-1.8L-FI License: 390-HWU Mileage Out:
Model: SENTRA GXE Production Date: 11/2000 State: MN Vehicle Out:
Color: TAN Int: Condition: Job#:
TRANSMISSION Dual Mirrors RADIO Cloth Seats
Overdrive Body Side Moldings AM Radio Bucket Seats
5 Speed Transmission Tinted Glass FM Radio Reclining/Lounge Seats
POWER Console/Storage Stereo WHEELS
Power Steering CONVENIENCE , Search/Seek Wheel Covers
Power Brakes Air Conditioning CD Player PAINT
Power Windows Intermittent Wipers SAFETY Clear Coat Paint
Power Locks Tilt Wheel Drivers Side Air Bag OTHER
Power Mirrors Cruise Control Passenger Air Bag Power Trunk/Gate Release
DECOR Rear Defogger SEATS
I
I
9/21/2013 9:52:08 AM 070412 Page 1
� Preliminary Estimate
Customer: YANG, ANGELA Job Number:
Vehicle: 2001 NISS SENTRA GXE 4D SED 4-1.8L-FI TAN
Line Oper Description Part Number Qty Extended Labor Paint
Price;
1 REAR BUMPER
2 0/H bumper assy 1.8
3 ** Repl RECOND Bumper cover H50225M025 1 207.00 Incl. 2.5
NOTE: PARTS: Component comes unprimed from OEM. Preparation is required. See ADD IF REQUIRED operation.
PART PRICE MATCH OEM
4 Add for Clear Coat 1.0
5 Repl Prep unprimed bumper 1 0.6
6 # Repl 'Flex Additive 1 5.00
7 # �Hazardous Waste Disposal Fee 1 5.00
8 # POSSIBLE HIDDEN DAMAGE 1
SUBTOTALS 217.00 1.8 4.1
NOTES
Prior Damage Notes: '
LT REAR TAILLAMP CREACKED RT QUARTER PANEL IS DENTED
ESTIMATE TOTALS
Category Basis Rate Cost;
Parts 217.00
Body Labor 1.8 hrs @ $54.00/hr 97.20
Paint Labor 4.1 hrs @ $ 54.00/hr 221.40
Paint Supplies 4.1 hrs @ $34.00/hr 139.40
Subtotal 675.00
Sales Tax $356.40 @ 7.6250% 27.18
Grand Total 702.18
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 702.18
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.
9/21/2013 9:52:08 AM 070412 Page 2
r
� - H�PPNER'S AUTO BODY (Downtown)
� 395 E. 7TH ST., SAINT PAUL, MN 55101
Phone: (651) 224-5644, Fax: (651) 224-6042
. � - - � .
Owner: YANG,ANGELA Insurance: OTHER Estimator: Grant Almeida Vehicle Out:
Job Number: Ciaim Number:
Year: 2001 Color: TAN License Plate: 390-HWU Production Date: il/i/2000
Make: NISS Body Style: 4D SED State: MN Mileage In: 159,983
Model: SENTRA GXE Engine: 4-1.8L-FI VIN: 3N1CBSiD41L454748 Condition:
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9/21;2013 9:50:57 AM Page 2
• � HEPPNER'S AUTO BODY (Downtown)
395 E. 7TH ST., SAINT PAUL, MN 55101
Phone: (651) 224-5644, Fax: (651) 224-6042
. . - • � .
Owner: YANG,ANGELA Insuranee: OTHER Estimator: Grant Almeida Vehicle Out:
Job Number: Ciaim Number:
Year: 2001 Color: TAN License Plate: 390-HWU Production Date: il/1/2000
Make: NI55 Body Style: 4D SED State: MN Mileage In: 159,983
Model: SENTRA GXE Engine: 4-1.8L-FI VIN: 3NiCB51D41L454748 Condition:
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9/21/2013 9:50:57 AM Page 1
' ABRA Auto Body & Glass - Midway Workfile ID: 12d7f83e
� FederalID: 41-1852119
� Right The First Time...On Time
1190 UNIVERSITY AVE W, SAINT PAllL, MN 55104
Phone: (651) 645-1563
FAX: (651) 641-6129
Preliminary Estimate
Customer: Yang, Angela 7ob Number:
Written By: Pat Kearin
Insured: Yang,Angela Policy#: Claim #: no
Type of Loss: Date of Loss: 9/16/2013 12:00:00 PM Days to Repair: 0
Point of Impact: 06 Rear
Owner: Inspection Location: Insurance Company:
Yang,Angela ABRA Auto Body&Glass-Midway CUSTOMER PAY
532 Payne Ave 1190 UNIVERSITY AVE W
St Paul,MN 55130 SAINT PAUL, MN 55104
(651)600-4940 Business Repair Facility
(651)645-1563 Busi�ess
I
VEHICLE
Year: 2001 Body Style: 4D SED VIN: 3N1C651D41L454748 Mileage In: 5555555
Make: NI55 Engine: 4-1.8L-FI License: 390HWU Mileage Out:
Model: SENTRA GXE Production Date: State: MN Vehicle Out:
Color: GOLD Int: Condifion: Job#:
TRANSMISSION Duai Mirrors RADIO Cloth Seats
Overdrive Body Side Moldings AM Radio Bucket Seats
5 Speed Transmission Tinted Glass FM Radio Reclining/Lounge Seats
POWER Console/Storage Stereo WHEELS
Power Steering CONVENIENCE Search/Seek Wheel Covers
Power Brakes Air Conditioning CD Player PAINT
Power Windows Intermittent Wipers SAFET1f Clear Coat Paint
Power Locks Tiit Wheel Drivers Side Air Bag OTHER
Power Mirrors Cruise Control Passenger Air Bag Power Trunk/Gate Release
DECOR Rear Defogger SEATS
10/S/2013 10:34:49 AM 011906 Page 1
� ' Preliminary Estimate
� Customer: Yang, Angela 7ob Number:
Vehicle: 2001 NI55 SENTRA GXE 4D SED 4-1.8L-FI GOLD
Line Oper Description Part Number Qty Extended Labor Paint
Price;
1 # May be hidden or additional 1
damage
2 REAR BUMPER
3 ** <> Repl RECOND Bumper cover H50225M025 1 207.00 1.4 2.5
4 Add for Clear Coat 1.0
S # Repl 'Flex Additive/Adhesion Promoter 1 8.50 X
6 MISCELLANEOUS OPERATIONS
7 # �Hazardous Waste 1 5.00 X
SUBTOTALS 220.50 1.4 3.5
ESTIMATE TOTALS
Category Basis Rate Cost�
Parts 207.00
Body Labor 1.4 hrs @ $54.00/hr 75.60
Paint Labor 3.5 hrs @ $54.00/hr 189.00
Paint Supplies 3.5 hrs @ $34.00/hr 119.00
Miscellaneous 13.50
Subtotal 604.10
Sales Tax $326.00 @ 7.6250% 24.86
Grand Total 628.96
Dedudibie 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 628.96
THIS IS A VISUAL INSPECTION ONLY. THERE MAY BE ADDITIONAL DAMAGE AFTER 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.
10/S/2013 10:34:49 AM 011906 Page 2
10/5/13 ANS Rent A Car:Malae a Reser�ation-Iriformation&ReHew-Step 4
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STEP � ? a =s : INFORMATION�REVIEW
(;ar�;�ntal�,urruziary 2a3.'35
� YOUR INFORMATION(k Required Feld) �� Base Rate for 1 day�a)5 hour(s) 105.98
Base Rate tU5.98
First Name:' Angela I hileage: Un6mted
t ._..__.._ .�._..--- -._..._ --------�
Laat Name:` ;Yang I Rental Options 12•98
___.______----------------.____— J Roadside SaferyNet 12 98
EmailAddreas:' �:kabzauj@gmad.com �
__-_-_ ..__.-.---- . _---......__._.---._J Protectioos 8 Coverages 98.18
,/J Send ire email promotions and offers.Uncheck to
op4ouL Loss Darrege Waiver{LDV� 55.�J8
___ ----- --------
Personai Accident Insurance(PA p 8.00
Contact Phone Num ber: 651-600-4940 Fx.11)xxx-xxx-xxxx R;rsonal Hfects Protection(PFP) 5 90
Your driver's�cense rt�y be subject to ver'dication from the state of issuance. Addilional liabiliry hsurance(Al.l) 28 30
Surcharges&Feea/Taxes 36.61
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Surcharges
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[nergy Recovery fee 1.20
Travel Agerrts Only: �0�05965L I �UB h�A# Rental tibtor Vehicle Tax(9.2°k)1 Reimbursement Fee(5%)
�_ 23.17
Taxes
Tax 12.44
Your Gedil Card is no[required to confirm this onGne reservation. � L ,
Cancel �StltTia�BC,� T�?��I (��s�) ���.��
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RBJiAL INFORMATION Modif
Pick-up Information
Location: St Paul Dow ntow n,St Paul,SOP
Date 8 7ime: Friday,October 11,2013 Q 07:30 AM
Return Information
Location: St P�ul Oow ntow n,St Paul,SOP
Date 8 7ime: Salurday,October 12,2013�a 12:00 PM
Renter IMormation
AWD: DUA Age: 25+
Rate Type: Lowest Residence: United States
Rate Code: 28
Wizard Number:WA
Coupon: WA
�CARDEfAILS M_o��
Car Class: Conpact
Ford Focus or simlar
�RBJTAL OPTIONS Modi��
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Equipment/ RoadsideSafetyNet(RSN) Selected
Servicas:
Protections I LUUJ Accepted
Coveragea: PAI Accepted
pFp Accepted
ALI Acceptetl
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rate($USD)
car 95.98 personal information •=required
optlons 109.16
_ __._ ... first name• last name•
fees &tazes 34.19 __ . _ .._._ _.. ............. ._.... __ _ _.__
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TOTAL(U5D) S 239.33 _ _. _. _ . _ . �
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AQ rate terms ''' � � . „ '
1 day,5 hour rental unlirtited free _ ' ' � �
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miles 14 day maximum rental
anowed (� I preferan HTML confirmation e-maii(deselectforte�d-only).
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location 'change ', [_; Yes,send me promotional email offers from Budget and its
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pick-up
166 EAST 7TH STREFf-SP4
'+� flight information !'�
ST.PA UL, NN 55101 US
Fri,11 Oct 2013 07:30 AM
airline flight#(4-number code ony)
__ _ _.
return __. ❑� ;
same as pick-up locatron � __ _ !
Sat.12 Oct 2013 12:00 PM
__._ _ . _ _._.
car cnar,9e �' use your credit card and secure your vehicle online
FORD FOCUS �
or similar
�`� pay at rental counter terms '�'? pay online terms
compact 2-or 4-door
automatic r'�:'g�t pt!
air conditioned
_ __..__................._................,..._........._..._....._....
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options 'change '':
_. . __
. Roadside SafetyNet �� '
PP . dY �'``�"TRUSTe' _�� �,,
. Su IPrnental Liabil' hsurance . _
. Loss Darru�ge V�laiver � ;ve�+s+qn
. Personai Accident and Effects
. smoke-free vehicle rates for rental period in U.S.dollars unless otherwise indicated
_..__......._........._._..._.._._.... .._............_......___....
offer codes 'change ''
. BCD none
. coupon code none I
_. _ ___ __..
personal info 'change '
RapidRez Number na�e ��
rosidency US ��
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10/2/13 Transactlon History-Metro Trar�sit Store
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Home > Metro Transit Store > Transaction History
__ _ _.. _ _ _..._ _._ _... _.. ......._ . _. _._ .
Transaction History
Serial#: 0160-0425-7566-8262
� N(ckname: Card 1
'; �� Current Pasa:
Curcent Stored Value: 3204.75
Last Used On: Sep 25 2013
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Register My Card
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Use in the Past 60 Days
Date Action i Vehicle Type 'i Stored Value Change
i
Sep 25 6:07 pm Ride Bus ; -$2.25
'I Sep 25 8:07 am Transfer Bus -$0.75
', Sep 25 7 49 am Ride Bus -$2.25
Sep 24 6:08 pm Ride Bus -$2.25
', Sep 24 7:53 am Transfer Bus ' -$OJS
Sep 24 7:45 am Ride Bus -$2.25
! Sep 18 6:07 pm Ride Bus -$2.25
. _ __ _ ___ . _ _ _ _ _ ,
j Sep 18 8:07 am Transfer Bus -$0.75 ;
_. _ i
Sep 18 7:49 am Ride Bus -$2.25
_ _ _ _ __ _ ,
! Sep 16 7:54 am Ride , Bus -$4.50
! Sep 15 2:36 pm Ride Bus -$2.50
_ _ _ . _ . ,
' Sep 15 11:25 am Ride Bus -$3.50
Sep 13 11:19 pm Ride Bus -$3.50
' Sep 13 10:27 pm Ride Bus -$3.50 '
: _ _ _
_. __
_ _
' Sep 13 10:27 pm Action Canceled Bus 51.75
_ _ ___,
Sep 13 10:27 pm Ride Bus -$1.75 ,
' Sep 10 6:37 pm Ride Bus -$1.75
Sep 10 8.08 am Transfer Bus -�OJS
Sep 10 7:46 am Ride Bus , -32.25
Sep 4 6:08 pm Ride Bus -32.25
Sep 4 8:07 am Transf�r Bus -SOJS
Sep 4 7:52 am Ride Bus -$2.25 i
Aug 27 6.13 pm Ride Bus -$2.25 I
Aug 27 7 41 am Transfer Bus S0.00
Aug 27 7 32 am Ride Bus -S2 25
https://store.metrotransit.orglFareCardTrar�sactionHistory.asp�l?farecard=0160042575668262 ��2
KIN��IDS KIPILAIDS
LAWSON CGMMUNS I.AVVSON C0�4MON:��
380 ST PETER S� '3t3U �T PETER ��
S-f. PAUL, MN �51u2 ST. PAUL, I�N 551u2
ii51.6t)2,9GU0 651 ,6U2.9000
BAR N!"�f AURAN T
Qate: Sep13'13 07:�5P��1
327U8 Patrir.k Card Type: M�.` �RCARD
---- -----------------.--...____... _ Acct #: XXXXXXXXXXXX��:;! �
Tbl 111/1 Chk 8382 Gst G Card Enf►�y: SWIPED
Sep 13'13 U r;ZuPM f i�ns (yi.�e: PUftCHA�:,E
-------------- --------- ._---- Auth l;oc�r:; ilH2'3aH
1 COCO PRI�N At' 12.95 Cher.k: 638?
1 UESCHUT SEAS 5./5 TaUle: lili�
1 MARG SL'RATCH �).55 �erver: 327i�9 Patrick
.;Ua�_IAL 2t3.25 Subkotal : 3C� , TJ
TAX 2.5y
iOTAL DUE 30 . 79 lip:... .._ __ __
Its a yreat time t� siyn uu for Total:
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our eat t'lrl an,� ;. ;� rewar s _
cluU. Ear�n l0U ����,,, . ��oinis I�,
Si�.lniny up taday, �:;h your Siynatiu�e
server for more detaiis.
• GUEST CUPY
-_-__-----_;--._:::_�_--- - .-_.----- P1ea5e keep for yi�ur rrcor�Js
� H04V U[D WE DO? � �
�CHR15 HAkiER, NKE5IUEN( & CEO �
► chris.harterar-u-i .com I
_ _ __ _
S'T . PAUL
POLICE
651-266-5700
DAtE 09/21/2U13 SAT �IME 10:12
NONAOD � 361225
NONAUD p 13172fi76
POL[CE $3.25
IOTAL �$3,25
CASH $4.OU
CNANGE $U./5
CLERK 1 U78157 Uu000