Higgins �:
NC3TI�� aF CL.c�.��VI I'C3�ltlY� to the City of�aint Fau1, Minnesota
Minnesntu State Stati�te 46b.05 staees tfrat " ...erery pP+sun...wiio c•lai»+.s ciarnc�ge.s,Frr�ui cttz}�m��tnicipr.�liry...sitctlf cctu.s�tt�1ae pretserrzPCi tn the
gU��trning bc+tty t�f t/re municlpaliTr�ivltittn 1&0 du)�'s ctfier-trte ullegecl loss vr init��y is diSCVVered ci rer�lire S14�finf{the tiine,place,crnc�
circtin+stances thereoJ,nx:d t1�e nrnoia�t nf cn»�nensarior�ar cztfzer relief de+xnnded'
I'lease camplete this form in its entirety l�y clearly iyp�Yig or�rinting your answcr tc�each qEi�stit►n. IC rnore sr�ace iti
needed,aitACh additional sheets. 1'lease nate that yau wili n�t i�e coMactecl by telephone to ciarrify anssvers,so provide as
rreucxe infarrx�aiia�i as ne+cessary to expiain your clairn,and the amount of coinpensatiou being requested. You will receive a
writLer�acknutivledgement once your i'orn�is received. T'he process can tttke up to ien weeks or longer depending on the
nature oC yoar claim. This form must be signed,and both pages campleted. 1P something daes not app3y,�vrite`NtA'.
S�'_+.��3 COMFI,F.,�:'FD F{.)Rit�i �ND �THER D(JCUM�tiTS �'�: CITY CLERK,
15 WEST �LLOGG 1tLV�, 314 CI�T'i' HAT,T,, SATTiT FA�.LZ, MN 5�1.02
� RECEIVED
First�tame��U`� ..�. 1Vlic�dlc�I�ait.ial .....�__I..:ast Name __�_ic'��._!1�...._.........._ _._-..-..
�� . �aJ
� OCT 1_5 2013
Coir�p�ny or�usiness Name _.� �y��,nr�I�[ �c:��i.�i d�-- ___.............�.........____.........................................__-------------................_..........._
Are You an Tnsurance Company? Yes/.�c If Yes, C:l.�izn Nurnber? C`ITY �I F K
5treet�ddress�.�.,,�.I ��i :^ �1/?�-
City ..._....��'a �.;a l
__.___ Sta.te . l(l`� _.... .. _...._.....�_Zip Code�f�'�.
�-��'� ' ^q5� � ' Evenin�"1'ele hnne( )_�_._ .-....._.. .......
llaytime Phone i�(.-)�-��c.�-�-Cell Phone (C�L)_�___-�:�� P
Date of Accidentl Inj ury t�r D�te Discc�vered �' �7-��,.�.—.—Tirne °,�ab am/�i
�'lease state, in detail, wh�t accurred (happened), and why you are submittzng a claim. I'l�ase indieate why Un c��w yoYl
feel the City c�f Saint Paul c.�r its e�r��]<yyec� are ir�volvecl and/cyr re;s��c�risible:fc�r y�ur d�mages. ° e��
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Please cheek tl�c t:u�x(c:s)tt3at xxiast cl.�s�'lv r.t:��•e.sent il�ae re�cscara far c:c�rra��letin�;this form;
� �t�� vehicle ���as damaged in an accident ❑ My vel�icle �vas dama�ed c3urir�b a taw
❑ `1y venicle vfas damaged by a pothole or coadition of the street ❑ 1V,(y vehicle was damaged by a plow
❑ My vGhicle���as i��rt��x��;fully towed�tnd/vr tic�kc;cerl � ❑ I wa�injured on City property
(�Other type of property damage-please s�ecify � ��
❑ Ot.her type of injui}�-please s�ecify _._.,�._........................_.__..........................
In or�te,r tv prac�ss your clairri irau r�eed to i�clucle conies of ail xpnlicab�e dc�cu�nents.
For the cJlirns tyPes 1i�ted b�1ow, please b�sure to incIude the documents indicated or it will delay the handlina of
vour claim. 3Joc:u���ent:s WI�..I.._NC�T t,�e re:tura�d �d become tt�e pro}�erty nf the City. You r►re encour�i�ed to keep�
copy for yoursetf before submitting yaur claim form.
p Pr�r?erty il,�mage claims co a v�hicle: c.wc�e.stimaies fc�r the repairs tt�your vehzcle if the damage exceeds
�SC?O.C10; c�r th�acival l�i2ts ancUc7r rcc,c��IS f�r the rc,��airs
p'I,owin��Claims: legi.t�le copies of any ticket zssued ara� a copy of the impout�d lot receigc
;� :�^.� �Q n�' - r�„j�rty c�ama�e clairns: two repair c:stimsitet if thc:c3t�rn�de exceecls�SOOAO; oz'the aetual bills
�i,��� and/or receSpLS for tlae repaits; detailed list�Fciarns�;ed items
O Ir�j�k�y cl:iims: inedzc�I biIIs,re�:eipts
O Ylaotoaraptzs ar� alw�y5 welcosT�e to dc>cument and suZ��rt yuui-cl�im but will not tre returnecl.
]Pa�e ] af 2-Pte�se completc and return both pages+nf C:iairr� N�rrn
Faiiure tc�tomptete ar�d r+�turri bc�tb� �a�es will ccsult in delay in the handli�i�;of your claim.
A1l Cla'sms-t�lease cc�m�lete ihis sec tiun
Were there w-irne�ses to the incident? Yes N� Unkriown {circ]�.)
Provide their names, addresses anc�telephone numbers:� (i . � �MD��1��P__'S,
,� 1
Were the p�lice or iativ enfore�m�nt c�Iled? es Na L�nknown (circl�)
Tf yes, what department or�gency? � .�,'�Q� Gase#'nr report# ��, '7k� ���
��here did the accident c�r-injury taice plaue? Provide street address,cross streei, intersection,name of p�rk or facility,
closest lanclm�rk,r,ec. ���as�be as de�aile;t�as�c��si�1�. If necessary, attach a di�gra�m..,_,�.�..��'�--��l-��, �
. � �
1 t-�r�.�'.�1_.. ` � � .��_..
Please indicate the amount yau are seeking in cornpens<�tion or w�hat you would like the City to do to resalve this ctainz
tc�your satasfaction. �'���`��,c.�� -----
Vehicle Cl�irns- le�,se cc►m lete this section ❑ check box if this se�tion_does not appiv
Yc�ur Vehicie;: Ye�.r ��D Mak:e �� '.�Iodel_„_.,�,�[�. .
License Plate I�'utz�ber r,�'�.:�r,L..LI State�,,;,�Col�r S9/��//�
Rc�i�t�r�.cl(�wner /V�;�.L',ct.��...����2� �_
D�-iver q#Veliicle . .. �'t' _��. _ .,r/l,�_ _.... . �j_. �
a: ,�TG� Uc1IT7i1�Ct� �G^'—" � Gi7i- �: �� �✓ir���t 6(!/?r)�' � �lL^ ���L,....._
City Vehicle: Year_.�__.._....... .Ma�e....__. _...._ __1Vlodel ......._ �.
Lzcense Y1ate Numher ___.�.......�._... ._ State... Color
Uriver c�f Vehicte(City f?mp�oyee's Name) �_....... ..._
Area Damaged ._____��.____.
xniurv Clairns-ple�se comnlete this sectior� U check box if t��is Seciitsrz does not aUply
Hc�w tivere you injure�l? ._..._�._....._.__ ---
--._._..._..................................
What p�u�t(s} of your bocly���ere injnred?..._.........._ _._._._....._........_---
._---____..._ ......... _--
H�ve ycsu 5oubht mediGal Ire�tn�ent'? Yes ':�io Plannin,�to Seek Treatment(circle)
When did y�u recel��e t�.�.at�r�e.�it.? ..___....._.�............................................ ._.._ �Provide dute(s))
l�drz��f>Vled���a�P"rn�tiic�erfs). � _. � .�
--- ._ _........ m_._._
Telephone
Did �•ou miss work as a result of your injury? Yes No
t��:cn did ��u �iuss w•ork? (providc datc(s))
1'�'ame c�f your Empic>y�er: _ ...._
Address ,Teleptscrr�e
___..__.._._.....---
Q;�C:laecl; here i1.'��uu are at#�ch'tng mo�-c pages to ihis claim form. Ne�rriber��'addi�ional pages � .
By sigfazr�g tJzis forraf,�=vzc c�re stating that��ll informatiort yau have prnvir�ed is trrte and correct'ta tfie best
of your knarvleclge. L'nsig'ned,fvrms ►vill not be processed.
� -,
, � ..
Submitting a,f'aCse cla�nz cnri resutt in pr�+�ecutivn. Date furm was cam�leted ' - " ��_...___.__...._____
k'rint the Name of th� i'crst�n wiat� E;��nplet�d tk�is �+'ornr. __�C?���������5 - -___.�__.
,---'"�� _._ ,,�=� ---_
Signatuxe at Pexson t���l.ira;;the Clairn: �� ._.�- '� : �
fteviSC'd J^�f�ru�ry 2q1 I
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• Workfile ID: 9730d202
APPLE COLLISION &GLASS
Federal ID: 41-1717918
7125 151st St. W. #107, Apple Valley, MN 55124
Phone: (952) 432-2443
FAX: (952)432-2975
Preliminary Estimate
RO Number: 632494
Written By: Eric Bravo
Insured: HIGGINS, ROB Policy#: Claim#:
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact:
Owner: Inspection Location: Insurance Company:
HIGGINS, ROB APPLE COLLISION&GLASS CITY OF SAINT PAUL
301 HICKORY ST 7125 151st St.W. #107
FARMINGTON, MN 55024 Apple Valley, MN 55124
(651)399-5773 Day Repair Facility
(952)432-2443 Business
.
VEHICLE
Year: 2002 Body Style: 2D CPE VIN: 3FAFP11392R217947 Mileage In: 126915
Make: FORD Engine: 4-2.OL-FI License: 686CLU Mileage Out:
Model: ZX2 Production Date: 6/2002 State: MN Vehicle Out: 10/25/2013
Color: SILVER Int: Condition: Job#:
TRANSMISSION Body Side Moldings Stereo Bucket Seats
5 Speed Transmission Console/Storage Search/Seek Reclining/Lounge Seats
POWER CONVENIENCE Cassette WHEELS
Power Steering Intermittent Wipers SAFETIf Aluminum/Alloy Wheels
Power Brakes Rear Defogger Drivers Side Air Bag PAINT
Power Mirrors RADIO Passenger Air Bag Clear Coat Paint
DECOR AM Radio SEATS OTHER
a.a M,rras FM Radio Cloth Seats Rear Spoiler
10/8/2013 11:38:20 AM 052080 Page 1
Preliminary Estimate
RO Number: 632494
Vehicle: 2002 FORD ZX2 2D CPE 4-2.OL-FI SILVER
Line Oper Description Part Number Qty Extended Labor Paint
Price�
1 FRONT BUMPER
2 0/H front bumper 1.8
3 R&I R&I bumper assy Incl.
4 * Rpr Bumper cover w/o fog lamps 4,.Q 3.0
5 Add for Clear Coat 1.2
6 # Add for Flex Additive 1 2.00
7 Repl Emblem F8CZ8A223AA 1 18.60 Incl.
8 # R&I License plate 0.2
9 FRONT LAMPS _
10 R&I RT Headlamp assy from 8/25/97 0.3
11 R&I LT Headlamp assy from 8/25/97 0.3
12 R&I RT Turn signal lamp Incl.
13 R&I LT Turn signal lamp Incl.
14 FENDER .
15 Repl LT Fender liner F7CZ16103AA 1 19.88 Incl.
16 ** Repl A/M LT Fender F8CZ16006AA 1 134.00 1.8 2.0
17 Add for Clear Coat �•$
18 Add for Edging 0.5
19 WHEELS �
20 ' R&I LT/Front Wheel,spare 9�
21 * Repl LKQ LT/Front Wheel,alloy type 2, F8CZ1007BA 1 110.50 m Q�
swirl 15x5.5+30%
22 ** Repl A/M HYFLY HF201 185/60/15 84H 1 88.09
23 # 2 Whl alignment 1 69.99 X
24 # Mount&balance 1 20.00 X
25 DOOR
26 * Rpr LT Door shell � 2•0
27 Overlap Major Adj. Panel -0.4
Zg Add for Clear Coat 03
19 R&I LT Belt w'strip 0.3
30 * R&I LT Body�ide mlda silver �
3: = Gean&retape 1 2.00 0.3
32 ` Repl LKQ LT Mirror power+30% F8CZ17682DA 1 �7�.4 SL•�
33 Repl LT Mirror mount plate F8CZ176693CA 1 49.30
34 R&I LT Handle,outside silver frost 0.3
from 12/23/97
35 Repl LT Cover F8CZ17K7096A 1 8.87
36 R&I LT R&I trim panel 0.3
37 # Hazardous waste 1 5.00 X
38 # Carcover ' 1 0.2
39 # Corrosion protection 1 0.3
40 # Tint color 1 0.5
41 # *Hidden suspension damage 1
10/8/2013 11:38:20 AM 052080 Page 2
Preliminary Estimate
RO Number: 632494
Vehicle: 2002 FORD ZX2 2D CPE 4-2.OL-FI SILVER
probable*
42 OTHER CHARGES
43 # Towing 1 106.70
SUBTOTALS 732.43 15.1 10.4
ESTIMATE TOTALS
Category • Basis Rate Cost$
Parts 530.74
Body Labor 15.1 hrs @ $56.00/hr 845.60
Paint Labor 10.4 hrs @ $56.00/hr 582.40
Paint Supplies 10.4 hrs @ $34.00/hr 353.60
Miscellaneous �•99
OtherCharges 106.70
Subtotal 2,514.03
Sales Tax $991.04 @ 7.1250% 70.61
Grand Total 2,584.64
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 2�584•64
Preliminary estimate only. Additional damage may be found after tear down. Part prices subject to change per
invoice.
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.
10/8/2013 11:38:20 AM 052080 Page 3
Preliminary Estimate
RO Number: 632494
Vehicle: 2002 FORD ZX2 2D CPE 4-2.OL-FI SILVER
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
DE2JK98, CCC Data Date 10/1/2013, 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 listeci on the iine with the fvAGS 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 Structural 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=Blend. BOR=6oron steel.
CAPA=Certified Automotive Parts Association. D&R=Disconnect and Reconnect. HSS=High Strength Steel.
rYD=Hydroformed Steel. Inc1.=Included. LKQ=Like Kind and Quality. LT=Left. MAG=Magnesium. Non-Adj.=Non
Ad}acent. NSF=NSF International Certified Part. 0/H=Overhaul. Qty=Quantity. Refn=Refinish. Rept=Replace.
R&I=Remove and Install. R&R=Remove and Replace. Rpr=Re�Jair. RT=Right. SAS=Sandwiched Steel.
Sect=Section. Sub!=5ublet. UHS=Uttra High Strength Steel. N=Note(s) associated with the estimate line.
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=6ureau of Automotive Repair. EPA=Environmental Protection Agency. NHTSA= National Highway
Transportation and Safety Administration. PDR=Paintless Dent Repair. VIN=Vehicle Identification Number.
10/8/2013 11:38:20 AM 052080 Page 4