Buckman NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minnesota State Statute 466.05 states that"...every persort...who ctaims damages from any municipality...shall cause to be presented to the
governing body of the municipaliry within 180 days after the alleged loss or injury is discovered a nntice stating the time,place,and
circumstances thereof,and the amount of compensatinn or other redief demanded."
Please complete this form in its entirety by clearty 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. Yoa will receive a
written acknowledgement once your form is received. The process can take up to ten weeks or tonger depending on the
nature of your claim. This form must be signed,and both pages completed. If something dces not apply,write`N/A'.
SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN REC
, � �, !� EIVED
First Name ,����. � ' �,f Middle Initial�Last Name � �` ?� c�
� � � �_�,� EC 1'7 2013
Company or Business Name
Are You an Insurance Company? Yes/No If Yes, Claim Number? CITY CLERK
Street Address T-Ci� C� .� � cc Y'J`�`��'Yl UY z.lJ�
r
City �� � t?y, ���ct J I�I-i�.; State �%� � Zip Code ��/ �
Daytime Phone(F,,(�)�-G i 7�Cell Phone(�)�-�SEvening Telephone(�,�)��- /�/D
�
Date of Accident/Injury ar Date Discovered�:.,�'air /' �,�°%J � Time!���L� am�'pm
Please state,in detail,what occuned(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 res�onsible for your damages. � in/�`�L��'"�`�� I'1�
� � �` .�.�� i}t , � 7 '� f° :V�Y! f � t
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Please check the box(es)that most closely represent the reason for completing this form:
�VIy vehicle was damaged in an accident ❑My vehicle was damaged during a tow
❑My vehicle was damaged by a pothole or condition of the street ❑My vehicle was damaged by a plow
❑My vehicle was wrongfully towed andlar 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 conies of all apnlicable 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.
O Property damage claims to a vehicle: two estimates for the repairs to your vehicle if the damage exceeds
$SOO.QO;or the actual bills and/or receipts far 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 actual bills
and/or receipts for the repairs;detailed list of damaged items
O Injury claims: medical bills,receipts
O Photographs aze always welcome to document and support your claim but will not be retumed.
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—olease complete this section
Were there witnesses to the incident? ��Y�e�s+. No �, Unknown ,(circle) ,.,,
Provide their names,addresses and telephone riumbers: .,�� �irl�''�'t�.1 �iY ti/� � _�
�����-T✓�'� ��;€'-T���✓1 — �V I �''"Y1P���Z�� —�Z,Z���
Were the police ar law enforcement called? !Ye� No Unlrnown (circle)
If yes, what department or agency? �'-� Case#or report#J 1 t,4�--J i�;
�-Z-=-�.—,--
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. ; ��.!/�� �
,�
���i vr'v'w�c�/
Please indicate the amount you aze seekin in compensation or what you would like the City to do to resolve this claim
to your satisfaction. '� �-� 7- 1 �
,•, % y r
.,6�'�/t'�� �l'`�'� G��i.l:���"..��� f�'12�'�-� r'j'�� �%� `�✓r ��i✓O�-rz �c d-� � ` ,
Vehicle Clai lease com lete this section ❑check box if this section does not a 1
Your Vehicle: Year ' Make l C, •' Model
License Plate Number ' �� State Calor l i
Registered Owner '� �•:U
Driver of Vehicle y
Area Damaged "+ r' ` J -
City Vehicle: Year��Make �- � Model !` 'Y � �
License Plate Number��; ��_ State Color '
Driver of Vehicle,,(City Employe 's Name) �.,�Ir���,t r�g, �r)d �/i �
Area Damaged .�--�e N '�' ��..�.,i �--. ����C�7�
Iniurv Claims—please complete this section �eheck box if this section does not avplv
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 form,you are stating that aU information you have provided is true and correct to the best
of your knowledge. Unsigned forms will not be processed.
Submitting a false claim can result in prosecution. Date form was completed I��I�7/I ?,�
�
Print the Name of the Person who Completed this Form:/V��- Tt ��P �7��,�a�►� �
Signature of Person Making the Claim: / V '� /1 e0/'�t,l� � �� f a ���
Revised February 2011
LaMettry's Collision, Glass and More Workfile ID: 2447046c
FederalID: 411393089
�,-„-.���.r:_..:.-t�,.. Eden Prairie
b�'°'+"�" �`'� �'��" "Every Customer Leaves With A Smile"
11903 Valley Veiw Road, Eden Priarie, MN 55344
Phone: (952) 941-5586
FAX: (952) 941-2637
Preliminary Estimate
Customer: BUCKMAN, NATALIE
Written By: EP Team 1 BRANDON MEHDIZADEH
Insured: BUCKMAN, NATALIE Policy #: Claim #:
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact: 08 Left Qtr Post(Left
Side)
Owner: Inspection Location: Insurance Company:
BUCKMAN, NATALIE LaMettry's Collision, Glass and More Eden
Prairie
9945 GARRISON WAY 11903 Valley Veiw Road
EDEN PRAIRIE, MN 55347-3044 Eden Priarie, MN 55344
(952)426-1510 Cell Repair Facility
(952)941-5586 Business
VEHICLE
Year: 2008 Body Style: 4D VAN VIN: STDZK23C78S118915 Mileage In:
Make: TOYO Engine: 6-3.5L-FI License: S]Y 036 Mileage Out:
Model: SIENNA 4X2 LE Production Date: 9/2007 State: MN Vehicle Out:
Color: RED Int: GRAY Condition: Job #:
TRANSMISSION CONVENIENCE FM Radio SEATS
Automatic Transmission Air Conditioning Stereo Cloth Seats
Overdrive Intermittent Wipers Search/Seek 3rd Row Seat
POWER Tilt Wheel CD Changer/Stacker Captain Chairs(2)
Power Steering Cruise Control SAFETY WHEELS
Power Brakes Rear Defogger Drivers Side Air Bag Wheel Covers
Power Windows Keyless Entry Passenger Air Bag PAINT
Power Locks Steering Wheel Touch Controls Anti-Lock Brakes(4) Clear Coat Paint
Power Mirrors Rear Window Wiper 4 Wheel Disc Brakes TRUCK
DECOR Telescopic Wheel Traction Control Power Trunk/Gate Release
Dual Mirrors Dual Air Condition Front Side Impact Air Bags
Body Side Moldings RADIO ROOF
Privacy Glass AM Radio Luggage/Roof Rack
12/6/2013 9:53:10 AM 018584 Page 1
Preliminary Estimate
Customer: BUCKMAN, NATALIE
Vehicle: 2008 TOYO SIENNA 4X2 LE 4D VAN 6-3.5L-FI RED
Line Oper Description Part Number Qty Extended labor Paint
Price$
1 REAR BUMPER
2 0/H bumper assy 1.6
3 * Rpr Bumper cover w/o reverse sensor 1.Q 2.6
4 Add for Clear Coat 1.0
5 # BODY PULL 1 2.0
6 SIDE PANEL
7 Repl LT Protector 58742AE010 1 3.16 0.2
8 * Rpr LT Side panel 1�.5 2•7
NOTE: ENTIRE FRONT SECTION PUSHED IN, DAMAGES THROUGH STYLELINES
ATTEMPTING TO REPAIR, MAY NEED REPLACEMENT.
9 Add for Clear Coat 1.1
10 Add for Edging 0.3
11 Add for Lock Pillar 0.5
12 R&I Fuel door 0.3
13 Blnd Fuel door �•Z
14 R&I LT Molding center rail front 0.3
15 R&I LT Glass Toyota w/o antenna 1.0
green,w/o sunshade
16 * Rpr LT Outer wheelhouse 1�
17 R&I LT Trim panel assy LE, 7 0.6
passenger,w/6 spkr stone
18 SIDE LOADING DOOR
19 Repl LT Door shell w/o power slide 6700408075 1 741.72 5.5 3.3
w/o sunshade(HSS)
20 Overlap Major Adj. Panel -0.4
21 Add for Clear Coat 0.6
22 * Repl LT Body side mldg CE, �E&XLE 7574208030D0 1 133.23 0.3 �Q
dark red
23 FRONT DOOR
24 Blnd LT Door shell (HSS) 1.1
25 * R&I LT Body side mldg CE, LE&XLE �
dark red
26 R&I LT Mirror assy w/o heated 0.3
27 R&I LT Handle, outside dark red 0.5
28 # Repl Molding Clean and Retape 1 2.00 0.2
29 R&I LT R&I trim panel 0.4
30 PILLARS,ROCKER&FLOOR
31 Blnd LT Ctr plr&rocker s 1.0
32 WHEELS
33 ** Repl RECOND LT/Rear Wheel,alloy 42611AE031 1 189.00 m 0.3
16"
34 # Subl FOUR WHEEL ALIGNMENT& 1 89.95 X
SUSPENSION CHECK
35 REAR LAMPS
12/6/2013 9:53:10 AM 018584 Page 2
Preliminary Estimate
Customer: BUCKMAN, NATALIE
Vehicle: 2008 TOYO SIENNA 4X2 LE 4D VAN 6-3.5L-FI RED
36 R&I LT Combo lamp assy 0.4
37 # Refn Car Cover �•2
38 # Refn Corrosion Protection 0.3
39 # Subl Hazardous Waste Disposal Fee 1 5.00 X
40 # Flex Additive 1 6.00
41 # * ESTIMATE WRITTEN FOR 1
OWNER,
42 # POSSIBLE HIDDEN DAMAGES * 1
SUBTOTALS 1,170.06 33.7 14.5
ESTIMATE TOTALS
Category Basis Rate Cost$
pa� 1,075.11
Body Labor 33.7 hrs @ $56.00/hr 1,887.20
Paint labor 14.5 hrs @ $ 56.00/hr 812.00
Paint Supplies 14.5 hrs @ $38.00/hr 551.00
Body Supplies 26.0 hrs @ $2.00/hr 52.00
Miscellaneous 94.95
Subtotal 4,472.26
Sales Tax $ 1,678.11 @ 7.2750% 122.08
Grand Total 4,594.34
Dedudible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 4,594.34
THIS REPORT IS BASED ON OUR INITTAL INSPECTION AND DOES NOT COVER ADDITIONAL PARTS OR LABOR
WHICH MAY BE REQUIRED AFTER THE WORK IS OPENED UP. PART PRICES SUBJECT TO CHANGE PER THE
MANUFACTURER. WARRANTY: LIFEfIME AGAINST DEFECTS IN WORKMANSHIP. WARRANTY REPAIRS DONE BY
LAMETTRY'S COLLISION ONLY. PARTS/SUBLET WARRANTIED BY THE SUPPLIER. NO WARRANTY ON RUST,
CORROSION RESISTANCE OR REPLACEMENT RENTAL CARS. OUR ESTIMATED TIME DOES NOT INCLUDE
INSURANCE OR PARTS DELAYS THAT WE MAY EXPERIENCE.
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.
12/6/2013 9:53:10 AM 018584 Page 3
LUTHER COLLISION & GLASS - Workfile ID: 6ee511a1
Federal I D: 26-4607447
PLYMOUTH
9825 56th Ave North, PLYMOUTH, MN 55442
Phone: (763) 331-6000
FAX: (763) 331-6001
Preliminary Estimate
Customer: BUCKMAN, NATALIE 7ob Number:
Written By: David Haight
Insured: BUCKMAN, NATALIE Policy#: Claim#:
Type of Loss: Date of Loss: Days to Repair: `�.° �y QP`(S
Point of Impact: O8 Left Qtr Post(Left
Side)
Owner: Inspection Location: Insurance Company:
BUCKMAN, NATALIE LUTHER COLLISION&GLASS- CUSTOMER PAY
PLYMOUTH
9945 GARRISON WAY 9825 56th Ave North
EDEN PRARIE, MN 55347 PLYMOUTH, MN 55442
(612)710-7033 Cell Repair Facility
(763)331-6000 Business
VEHICLE
Year: 2008 Body Style: 4D VAN VIN: STDZK23C785118915 Mileage In: 85503
Make: TOYO Engine: 6-3.5L-FI License: SJY036 Mileage Out:
Model: SIENNA 4X2 LE Production Date: State: MN Vehicle Out:
Color: BURGANDY Int: Condition: Job#:
TRANSMISSION Overhead Console FM Radio ROOF
Automatic Transmission CONVENIENCE Stereo Luggage/Roof Rack
Overdrive Air Conditioning Search/Seek SEATS
POWER Intermittent Wipers Auxiliary Audio Connection Cloth Seats
Power Steering Tilt Wheel CD Changer/Stacker 3rd Row Seat
Power Brakes Cruise Control SAFET'Y Retractable Seats
Power Windows Rear Defogger Drivers Side Air Bag Captain Chairs(2}
Power Locks Keyless Entry Passenger Air Bag WHEELS
Power Mirrors Steering Wheel Touch Controls Anti-Lock Brakes(4) Wheel Covers
Heated Mirrors Rear Window Wiper 4 Wheel Disc Brakes PAINT
DECOR Telescopic Wheel Traction Control Clear Coat Paint
Dual Mirrors Duai Air Condition Stability Control TRUCK
Body Side Moldings RADIO Front Side Impact Air Bags Power Trunk/Gate Release
Privacy Glass AM Radio Head/Curtain Air Bags
12/12/2013 10:48:18 AM 100723 Page 1
Preliminary Estimate
Customer: BUCKMAN, NATALIE )ob Number:
Vehkle: 1_008 TOYO SIENNA 4X2 LE 4D VAN 6-3.5L-FI BURGANDY
Line Oper Description Part Number Qty Extended Labor Paint
Price$
1 FRONT DOOR
2 Blnd LT Outer panel 0 0.00 0.0 1.1
3 R&I LT Applique 0 0.00 0.3 0.0
4 * R&I LT Body side mldg CE, LE&XLE 0 0.00 0.� 0.0
dark red
5 # Rpr CLEAN/RE TAPE 0 0.00 0.5 0.0
6 R&I LT Mirror assy w/o heated 0 0.00 0.3 0.0
7 * R&I LT Handle, outside 0 0.00 0.5 0.0
8 R&I LT R&I trim panel 0 0.00 0.4 0.0
9 SIDE LOADING DOOR
10 Repl LT Door shell w/o power slide 6700408075 1 741.72 5.5 3.3
w/o sunshade(HSS)
11 Add for Clear Coat 0 0.00 0.0 1.3
12 Repl LT Black out tape 75932AE010 1 36.83 0.3 0.0
13 Repl LT Body side mldg CE, LE&XLE 7574208030D0 1 133.23 0.3 0.4
dark red
14 Add for Clear Coat 0 0.00 0.0 0.1
15 SIDE PANEL
16 Sect LT Side panel cut in window 61612AE010 1 916.40 17.0 3.5
opening
17 Overlap Major Adj. Panel 0 0.00 0.0 -0.4
18 Add for Clear Coat 0 0.00 0.0 0.6
19 Repl LT Protector 58742AE010 1 3.16 0.2 0.0
20 R&I LT Glass Toyota w/o antenna 0 0.00 Incl. 0.0
green,w/o sunshade
21 # GLASS INSTALL KIT 1 25.00 X 0.0 0.0
22 # Rpr TIE DOWN 0 0.00 1.0 0.0
23 # Rpr UNIBODY PULL 0 0.00 3.0 F 0.0
24 # LT PINCH WELD CLEAN-UP 1 0.00 0.6 0.6
25 # RT PINCH WELD CLEAN-UP 1 0.00 0.6 0.6
Z( Blnd Fuel door 0 0.00 0.0 0.2
__�._ _ __ .._ � _ _
27 PILLARS,ROCKER&FLOOR
2g Blnd LT Ctr plr&rocker 0 O.00 s 0.0 1.0
__
29 REAR LAMPS
30 R&I LT Combo lamp assy 0 0.00 Incl. 0.0
31 REAR BUMPER
32 R&I R&I bumper cover 0 0.00 Incl. 0.0
�.33 WHEELS _
34 Repl LT/Rear Wheel,alloy 17" 14 4261108040 1 445.79 m 03 0.0
spoke
35 * R&I TPMS sensor 0 0.00 m Q� M 0.0
36 # FOUR WHEEL ALIGNMENT 1 109.95 X 0.0 0.0
37 # CORROSION PROTECTION 1 0.00 0.0 0.3
38 # HAZARDOUS WASTE REMOVAL 1 8.00 X 0.0 0.0
12/12/2013 10:48:18 AM 100723 Page 2
Preliminary Estimate
Customer: BUCKMAN, NATALIE 7ob Number:
Vehicle: 2008 TOYO SIENNA 4X2 LE 4D VAN 6-3.51-FI BURGANDY
39 # CAR COVER PER TIMES USED 1 6.00 0.2 0.0
40 # MASK JAMBS PER OPENING 1 0.00 0.0 0.3
41 # DE-NIB&BUFF 0.5 REFINISH 1 0.00 1.0 0.0
PER PANEL
42 # **VISIBLE DAMAGE EST.ONLY** 1 0.00 0.0 0.0
SUBTOTALS 2,426.08 32.5 12.9
ESTIMATE TOTALS
Category Basis Rate Cost$
Parts 2,283.13
Body Labor 29.3 hrs @ $54.00/hr 1,582.20
Paint Labor 12.9 hrs @ $54.00/hr 696.60
Mechanical Labor 0.2 hrs @ $ 115.00/hr 23.00
Frame Labor 3.0 hrs @ $85.00/hr 255.00
Paint Supplies 12.9 hrs @ $34.00/hr 438.60
Miscellaneous 142.95
Subtotal 5,421.48
Sales Tax $2,721.73 @ 7.2750% 198.01
Grand Total 5,619.49
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 5,619.49
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.
12/12/2013 10:48:18 AM 100723 Page 3
Preliminary Estimate
Customer: BUCKMAN, NATALIE ]ob Number:
Vehicle: 2008 TOYO SIENNA 4X2 LE 4D VAN 6-3.5L-FI BURGANDY
Estimate based on MOTOR CRP,SH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
ARM8530, CCC Data Date 12/9/2013, 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 (�) items indicate MOTOR Not-Included
Labor operations. The symbol (<>) indicates the refinish operation WILL NOT be per�ormed 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 m+nor 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.
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=Sublet. UHS=UItra 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=Bureau of Automotive Repair. EPA=Environmental Protection Agency. NHTSA= National Highway
Transportation and Safety Administration. PDR=Paintless Dent Repair. VIN=Vehicle Identification Number.
12/12/2023 10:48:18 AM 100723 Page 4
Preliminary Estimate
Customer: BUCKMAN, NATALIE Job Number:
Vehicle: 2008 TOYO SIENNA 4X2 �E 4D VAN 6-3.5L-FI BURGANDY
ALTERNATE PARTS USAGE
Year: 2008 Body Style: 4D VAN VIN: STDZK23C785118915 Mileage In: 85503
Make: TOYO Engine: 6-3.5L-FI License: SJY036 Mileage Out:
Model: SIENNA 4X2 LE Production Date: State: MN Vehicle Out:
Color: BURGANDY Int: Condition: Job#:
Alternate Part Type Selection Method #Of Times Notified Of #Of Parts Selected
Available Parts
Aftermarket Automatically List 0 0
Optional OEM Automatically List 0 0
Reconditioned Automaticaily List 0 0
Recycled N/A 0 0
12/12/2013 10:48:18 AM 100723 Page 5