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NOTIC� OF CLAIM FORM to the City of Saint Pau�, Minnesota
Minnesola Stnte Stntute 466.05 stntes ihat "...every person..,who claim.r damn�es fi»rn any municipality...sl�all cause zo he presenled to lhr
�n��erning bndy n�1he m�<nicrpnlity within/80 days after the alleged/oss or injtuy is drscovered a notice stating the time,place, and
circumstances thereof,aad t{�e amnw�t of compensatinn nr otlaer relief demanded."
Please complete this form in its endrety by clearly typing or printing your answer to each quesNon. lf more space is
needed,attach additional sheets. Please note that you may or may not be contacted 6y telephone to discuss your ctaim
circumstanees,so provide as much information as necessary to explain your claim,and the amount of compensation heing
requested, This form must be signed,and both pages completed. If someth�ng does not apply,write`N/A'.
SEND COMPLETED FORM AND OTHER DOCUMENTS TO:
CITY CLERK, 1S WEST KELLOGG BLVD,314 CITY HALL, SAINT PAUL, MN SS102
First Name �H ��; �� Middle Inztial � I,ast Name. �i E N ��(���
�D
Company or Business Name, if applicable
-����.
Street A.ddress � I � M C� S i
City____�T '�ja (,'� State �-( J�� Zip Code ���� I
Daytime Telephone (�_�) ) ��Z—� ,�J- Z 7 Evening Telephone(6�5�1_�� C��" —�Z6 �j(-}
Date of Accident/Injury or Date Discovered Time am/pm (circle)
Please state, in detail, what occurred, and why you are subm�tting a claim. Please indicate why or how you
feel the City of Saint Paul or its em plo�yees are involved an d lor responsible.
.) a.�.` ' �a,,tic�.c� ti..� 3 i��tz w..M 1V�� t'
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Please h k t box es th�t most closely rep esent the reason for p etin his fozm: �,
O Vehicle was damaged in an accident �Vehzcle was damaged during a tow '
I7 Vehicte was da.maged by a pothole or condition of the stxeet Q �T�]�'cle u�as damaged by a piow
i� Vehicle was wrongfully towed and/or ticketed ❑ Injured on City property
�] Other type of property damage-please sgecify
❑ Other type of injury-please specify
❑ Other type not listed-please specify '
In order to process your claim youu need to inelude coaies of aIl aauiieabte documents This is a gene-ra1
guideline of what should he submrtted with a cla�m form,but it is ziot all inelusive. You may be asked tfl
provide additional ii�fonnation depending an your claim.
O Property damage claims to a vehicle: at least two estimates for the repairs to your vehicle;or th�
actual bills and/or receipts for the repairs
O Towing claims: legible copies of any tickets issued and copies of the impound lot receipts
O Other property damage: repair estimates, detailed list of damaged items
O Injury claims: anedical bills,receipts
O Photographs can be provided but will not be returned.
Page 1 of 2-Please complete and return both pages of Clai�n Form
Failure to provide a completed claim fortn will resuit in delays in processing.
., `, � •
Notice of Claim Form, CiLy of Saint Pau�,page two
All Claims=please comalete this section ,
Were there witnesses to the incident? "� e No Unknown {circle)
If yes, please provide their names, addresses d teleph e numbers:
Were the police or law enforcement calied? Xes 6 Unknown (circlej
If yes, what department or agency? Case#or repart# ____
Where did the accident or injury take place? Provide street address, cross street, intersection, name of park
or fa�ity, closest landinark, etc. Please be as detailed as possible. If helpful, attach a diagram.
��
Please indicate the amount you are seeking in compensation from this ciaim or what you would like the City
to do to resolve this claim to your satisfaction. ' �� _ � � ��y � ��s� '
�- �. ��9rL -- � _
Vehicle Claims—please com�lete this section ❑ check box if this section does not applv
Your Vehicie: Year_ 2-� t j_Make_��;T�a Model �'�►Q�f % � L-.�_
License Plate Number Q Gi.TG State 1`�►l;r Color �tC�vER,
Regi stered Owner 'F�j�1 F v �h E�'
Driver of Vehicle �'r�r NF� ��t F rV
Area Damaged �.�'u�-� �u,�,a.�.�
City Vek�icle: Year 1V�ake � Model_
License Plate Number State Color
Driver of Vehicle(City Employee's Name) /rj LS� l��M Vfz-Rfl Y
Area Damaged _
Injurv Claims ptease camplete this section L�che�k box if this section does not apulv
How were you injured?
What part(s) of your body were injured?
Have you sought medical treatment? Yes No Ptanning to Seek Treatment {circle)
When did you receive treatment? (provide date(s))
Name of Medical Pravider(s}:
Address Telephone
Did you miss work as a result of your injury? Yes No
When did you miss work? (pravide date(s))
Name of your Employer:
Address T�lephone _
E1 Check here it you are attaching more pages to this clainn form. Narnber of additional pages
By sig�ei�:g this form,.vou are stating that all informatioli you have provided is true a�ed correct to tJ�e best of your knnwledge. Unsigned
,rorms wi/! not he processed. Subrtiitting a false c(aim can result in prosecution.
Print the Name of the Person who Campleted this Form:
Signatura of PeXSOn Making the Clairrt: �
T
Date form was completed ��� �j� Revised April 2007
�
. ,
4�_g783 Workfile ID: 59c98377
OFF�651-641'1g18 ► Body &Glass - Midway Federal ID: 41-1852119
F�,p,TBED&WHEEL LIF'f TOWING
JUM�AR7S,LOCKIM� N�
pLCRECAVEPY@YAH�'COM �he First Time...On Time
PRIVpTE PR��RN Y AVE W, SAINT PAUL, MN 55104
PO BoX 4025�ST.PpUL,MN 55104 , ,,�ne: (651) 645-1563
FAX: (651) 641-6129
Preliminary Estimate
7ob Number:
Customer: CHEN, CHINFU
Written By:]ohn Rucinski
Insured: CHEN,CHINFU Policy#: Claim#: *
Type of Loss: Date of Loss: 1/15/2013 12:00:00 PM Days to Repair: 2
Point of Impact: 12 Front
Owner: Inspection Location: Insurance Company:
CHEN,CHINFU ABRA Auto Body&Glass-Midway Unknown Insurance
1164 MACKUBIN ST 1190 UNIVERSITY AVE W
ST PAUL, MN 55117 SAINT PAUL, MN 55104
(651)348-7644 xH Business Repair Facility
(651)645-1563 Business
VEHICLE
Year: 2011 Body Sryle: 4D SED VIN: 2T16U4EE16C611222 Mileage In: 111111
Make: TOYO
Engine: 4-1.8L-FI License: 978G.7C Mileage Out:
Model: COROLLA LE
Production Date: 3/2011 State: MN Vehicle Out:
Color: SILVER Int: Condition: Job#:
TRANSMISSION Console/Storage RADIO Head/Curtain Air Bags
Automatic Transmission CONVENIENCE
AM Radio SEATS
Overdrive
Air Conditioning FM Radio Cloth Seats
POWER Intermittent Wipers Stereo Bucket Seats
Power Steering
Tilt Wheel Search/Seek WHEELS
Power Brakes
Cruise Control CD Player Wheel Covers
Power Windows Rear Defogger Auxiliary Audio Connection PAINT
Power Locks
Key�ess Entry SAFETY Cfear Coat Paint
Power Mirrors
Alarm Drivers Side Air Bag OTHER
Heated Mirrors
Message Center Passenger Air Bag Tradion Control
DECOR Steering Wheel Touch Controls Anti-Lock Brakes(4) Stability Control
Telesco ic Wheel Front Side Impact Air Bags Power Trunk/Gate Release
Dual Mirrors p
10/3/2013 12:23:43 PM
011906 Page 1
� . ° Preliminary Estimate
Customer: CHEN, CHINFU .7ob Number:
Vehicle: 2011 TOYO COROLLA LE 4D SED 4-1.8L-FI SILVER
Line Oper Description Part Number Qty Extended Labor Paint
Price�
1 FRONT BUMPER
2 <> Repl Bumper cover US built Base, LE 5211903901 1 246.60 1.7 2.6
3 Add for Clear Coat 1.0
4 R8cI License bracket 0•2
5 * R&I Emblem Incl.
6 Repl Seal 5339502040 1 29.08 0.1
7 # Repl 'Flex Additive/Adhesion Promoter 1 8.50 X
__ _ _.
__
8 MISCELLANEOUS OPERATIONS
9 # 'Hazardous Waste 1 5.00 X
SUBTOTALS 289.18 2.0 3.6
NOTES
Prior Damage Notes:
1
ESTIMATE TOTALS
Category Basis Rate Cost$
Parts 275.68
Body Labor 2.0 hrs @ $52.00/hr 104.00
Paint Labor 3.6 hrs @ $52.00/hr 187.20
Paint Supplies 3.6 hrs @ $32.00/hr 115.20
Miscellaneous 13.50
Subtotal 695.58
Sales Tax $390.88 @ 7.6250% 29.80
Grand Total 725.38
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 725.38
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 vrehicle 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.
10/3/2013 12:23:43 PM 011906 Page 2
� ^ Preliminary Estimate
Customer: CHEN, CHINFU 7ob Number:
Vehicle: 2011 TOYO COROLLA LE 4D SED 4-1.SL-FI SILVER
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
ARM8428, 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 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 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=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. O/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=Subtet. UHS=UItra High Strength Steel. N=Note(s) associated with the estimate line.
CCC ONE Estimating -A product of CCC Information Serviaes 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.
10/3/2013 12:23:43 PM 011906 Page 3
2013-10-03 05:03 1906 6512280473 » P 1/1
Reservation Detail Page 1 of 1
chen, thinfu 10/07/2013 04:00 PM ECONOMY
Raservatlon:62MWHG D�to Takoe: By: Orlqln;BRANCH
VohIC10
C�r CIa66: ECONOMY AuthoMzalton
Rato Quotod: SWtus:
$21.49/DAY
CarC�ass:
S000lals: Auth Amount:
Mlloapo CharOo: NO CHARGE a of Days:
PrOfOrOnC06: � MaY Par pay;
ToWI Max Amouet:
%Aulh:
Produe!/SOrv�CO6
DAMAGE WAIVER $15.60/DAY
PAI ¢3.39/DAY
RAP s3.99/DAV
SUPPLEMENTAL LIABIUTY PROTECTlON 2 $13.95/DAY
�Autho�izatlon
Pkk up/Return
PICk Up DstO: 30/07/2013 R�tu�n Dala: 10/08/2013
Plek Up Tlme: 04;00 PM Roturn Tlme: 06:00 PM
Plek Up Group: A0019_MINNESOTA Rotu�n G�oup; A0019_MINNESOTA
Piek Up 8�aneh: ST PAUL MIOWAY 1906 Rotu�n Braneh: S7 PAUL MIDWAY 1906
1161 UNIVEttS1TY AVE W li6i UN1vER5riY Ave w
SAINT PAUL,MN 551044324 SAINT PAUL,MN 5510+4124
Plek Up Mothod; Rcturn Method:
Plek Up�oeaqon: Return Loeatlon:
DUaCtlon6:
Rentar informatlon
then,chinfu Nome: (651) 348-7644
work:
MN Otho�:
BIII-to
Rentel Typc: BOOY SHOP
Claim'ryrpo:
Cialm/POl/PO/rto:
tnsurod Namo:
ShOp
Ronto►s Vohicla:
Fllpht Informatlon
alrllno: Fliphto Yormi�al:
A�Nval Qato: anlva)1'Imc:
10/3/2013 � �Gt,l� �S'� � -iU��f'�.t � �'GJ,� ��e II�C��'^� �1a�C . '