Skoog -. � RECEIVED
NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota� 13 2013
CITY �.ERK
Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipaliry...shall cause to be presented to
governing body of the municipa[ity 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
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First Name ��� ,�'<`- � Middle Initial 1�� Last Name ���'��)
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Company or Business Name �/��
Are You an Insurance Company? Yes No/ If Yes,Claim Number?
Street Address `' ���'�- .''yi�'f�=�-'r�%� i�y,"
City ��; /, � ���:���. Lr�/� � State �'/���� Zip Code `�" %"r ``
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Daytime Phone(; �J ) �>' � Cell Phone( � - Evening Telephone( } -
Date of Accidend Injury or Date Discovered /�?��-i Time /�.�« am�m.
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.
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Please check the box(es)that most closely represent thelreason 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 di 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 coqies 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.
;C�`Property damage claims to a vehicle: two esthmates for the repairs to your vehicle if the damage exceeds
$500.00; or the actual bills and/or receipts for tlhe 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 actual 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.
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: �1 : .-.• -, �;�� -�- ,��' -��� ✓���^��
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Were the police or law enforcement called? �Ye No Unknown (circle)
If yes,what department or agency? ��t;i 5� ,��Case#or report# � -��c� - 2'�i. �-� -��� �-/�
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:�� SF=I/ '� =-
�� /�.�� / ���:
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Please indicate the amount you are seeking in compensation or what you,would like the City to do to resolve this clai
, � , � .
to your satisfaction. :l l� �< .� ��- .cJ._/.-' - ,�; �y:��;�-��r t/ I��� �1� f'�-lJ -�� �'�T � �i��: -
J.i/�I � Yi��.- E`� � —�c-� L-:y; �s�,�Y� �
Vehicle Claims-nlease complete this section ❑ check box if this section does not applv
Your Vehicle: Year :��i�' Make � : -��� Model � / -��,
License Plate Number G�-��� �=��L%� � State�Color �i,¢« - '��`a,�
Registered Owner � �-J,���— sk��•�� �
Driver of Vehicle <� ���� S��"���"
Area Damaged ..��i✓c�y /��� ��.� ��/.✓,����.c
Ciry Vehicle: Year ---- Make — Model �F�,-. J���.� ���,.�jj #����J
License Plate Number �%�`��-.�� State/iii�` Color
Driver of Vehicle(City Employee's Name) �����f ✓, /2�Fr�'�-�/�c �i✓
Area Damaged f����
Iniurv Claims-please complete this section ,�1 check box if this section does not anplv
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 fornz,you are stating that all information you have provided is true and correct to the best
of your knowledge. Unsigned forms will not be prncessed.
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Submitting a false claim can result in prosecution. Date form was completed �=J��%� _'i
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Print the Name of the Person who Completed this Form: ���r-�� -�./�"�";
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Signature of Person Making the Claim: , �/ .
Revised February 2011 /
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Pride, Professionalism & Partnership
. CARY LEE
� Police O�cer �
���� POLICE DEPARTMENT
CITY OF SAINT PAUL
3E 367 Grave Street
',�i Saint Paut.MN 55101 car}.lee@ stpau/.mn.us
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If you have questions regarding youc report,call:
Saint Paul Police Records Unit (651)266-5700
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� RAYMOND AUTO BODY, INC. �Norkfile ID: 766aa004
FederaiID: 41-0888257
1075 PIERCE BUTLER RTE, SAINT PAUL, MN
55104
Phone: (651) 488-0588
FAX: (651) 488-4794
Preliminary Estimate
Customer: SKOOG, ROD 7ob Number:
Written By: STEVE SUNDERLAND
Insured: SKOOG, ROD Policy#: Claim#:
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact: °
Owner: Inspection Location: Insurance Company:
SKOOG, ROD RAYMOND AUTO BODY,INC.
488� MOREHEAD AVENUE 1075 PIERCE BUTLER RTE
WHITE BEAR LAKE, MN 55110 SAINT PAUL, MN 5510�1
(612)810-7501 Cell Repair Facility
(651)488-0588 Business
�
VEHICLE
Year: 2010 Body Style: 4D SHORT VIN: 1FTFWiEV3AFA93178 Mileage In:
Make: FORD Engine: 8-5.4L-FI License: Mileage Out:
Model: F150 4X4 SUPERCREW Production Date: State: Vehicle Out:
XLT
Color: Int: Condition: Job#:
TRANSMISSION Dual Mirrors FM Radio Stability Controi
Automatic Transmission Privacy Glass Stereo Front Side Impact Air Bags
Overdrive Overhead Console Search/Seek Head/Curtain Air Bags
4 Wheel Drive CONVENIENCE CD Player SEATS
POWER Air Conditioning Auxiliary Audio Connedion Cloth Seats
Power Steering Intermittent Wipers SAFETY WHEELS
Power Brakes Tilt Wheel ' Drivers Side Air Bag Aluminum/Alloy Wheels
Power Windows Cruise Control Passenger Air Bag PAINT
Power Locks Keyless Entry Anti-Lock Brakes(4) Clear Coat Paint
Power Mirrors RADIO 4 Wheel Disc Brakes TRUCK
DECOR AM Radio Traction Control Rear Step Bumper
12/9/2013 11:49:18 AM " 019495 Page 1
� Preliminary Estimate
Customer: SKOOG, ROD )ob Number:
Vehicle: 2010 FORD F150 4X4 SUPERCREW XLT 4D SHORT 8-5.4L-FI
Line Oper Description Part Number Qty Extended Labor Paint
Price;
1 FRONT DOOR
2 Repl LT Mirror chrome 9L3Z17683GA 1 477.97 0.3
3 R&I LT R&I trim panel 0.5
4 * Rpr LT Outer panel ( I�o ish) � �
SUBTOTALS 477.97 1.8 0.0
NOTES
Estimate Notes:
estimate to polish the left front door,scratch in door may not polish,may need to refinish left door.
ESTIMATE TOTALS
Category Basis Rate Cost�
Parts 477.97
Body Labor 1.8 hrs @ $54.00/hr 97.20
Subtotal � 575.17
Sales Tax $477.97 @ 7.6250% 36.45
{ Grand Total 611.62
1 Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 611.62
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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.
12/9/2013 11:49:18 AM 019495 Page Z
' Preliminary Estimate
Customer: SKOOG, ROD )ob Number:
Vehicle: 2010 FORD F150 4X4 SUPERCREW XLT 4D SHORT 8-5.4L-FI
AUTO CLUB INSURANCE ASSOCIATION, MEMBERSELECT INSURANCE COMPANY OR AUTO CLUB GROUP INSURANCE
COMPANY (HEREIN INDIVIDUALLY AND COLLECTIVELY REFERRED TO AS ACIA) GUARANTEES THAT IT WILL
REPLACE THE QUALTTY REPLACEMENT PARTS (PARTS NOT MANUFACTURED BY THE ORIGINAL EQUIPMENT
MANUFACTURER) IDENTIFIED ON THE VEHICLE ESTIMATE ASSOCIATED WITH THIS GUARANTEE IF A DEFECT IS
DISCOVERED. °
ACIA FURTHER GUARANTEES THAT THE QUALITY REPLACEMENT PARTS, EXCLUDING GLASS AND MECHANICAL
PARTS, ARE CERTIFIED OR VALIDATED TO BE OF OEM QUALITY IN ALL INSTANCES WHEN THIS CERTIFICATION
OR VALIDATION IS AVAILABLE FOR THE PART. THIS GUARANTEE IS IN EFFECT FOR AS LONG AS YOU OWN THE
REPAIR VEHICLE AND IS NOT TRANSFERABLE TO ANOTHER PARTY AT ANY TIME. THIS GUARANTEE COVERS THE
COST OF THE PART, LABOR TO INSTALL, PAINT AND MATERIALS IF REQUIRED, AND REASONABLE RENTAL COST
OF A SIMILAR TEMPORARY REPLACEMENT VEHICLE DURING THE REPAIRS. THIS GUARANTEE DOES NOT COVER
CLAIMS FOR DIMINUTION IN VALUE OR CONSEQUENTIAL DAMAGES.
IF A DEFECT IN A QUALITY REPLACEMENT PART IS DISCOVERED, C,ONTACT YOUR LOCAL ACIA CLAIMS
DEPARTMENT IMMEDIATELY AND ACIA WILL REPLACE THE PART WITH A NEW ORIGINAL EQUIPMENT
MANUFACTURER PART. IF AN ORIGINAL EQUIPMENT MANUFACTURER PART IS NOT REASONABLY COMMERCIALLY
AVAILABLE, ACIA WILL REPLACE THE DEFECTIVE PART WITH ANOTHER QUALITY REPLACEMENT PART.
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.
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' Preliminary Estimate
Customer: SKOOG, ROD Job Number:
Vehicle: 2010 FORD F150 4X4 SUPERCREW XLT 4D SHORT 8-5.4L-FI
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Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
DR2MA09, CCC Data Date 12/2/2013, 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
(Alt�rnative 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 manuaf 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=Aft�rmarket part. BInd=Blend. BOR=Boron steel.
CAPA=Certified Automotive Parts Association. D&R=Dis�onnect and Reconnect. HSS=High Strength Steel.
HYD=Hydroformed Steel. Inc1.=Included. LKQ=Like Kirid and quality. LT=Left. MAG=Magnesium. Non-Adj.=Non
Adjacent. NSF=NSF International Certified Part. O/H=Overhaul. Qty=Quantiry. 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,
CCC ONE Estimating - A product of CCC Information Ser�ices Inc.
The following is a list of abbreviations that may be used in CCC ONE Estimating that are not part of the MOTOR
CR/�SH ESfIMATING 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.
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