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NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipaliry...shall cause to 6e presented to the
governing body of the municipality 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 typfng 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
First Name.( (rtR-I ST�P I-��jZ Middle Initial�Last Name SYl V ES T-E� ` ��n
V tU
Company or Business Name
18 2013
- Are You an Insurance Company? Yes� If Yes,Claim Number?
Street Address S� +�l ff �T �ft s� CITY CLERK
City S�f - �PrV L State �"'�ti Zip Code �5 �u j
Daytime Phone(32A)23Z-�Cell Phone(�)L3L- Qila�l Evening Telephone( ) -
Date of Accidentl Injury or Date Discovered II 3�'3 Time 2=� am/�
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. M Y V�►+�C.�
bvAr� i�l}I�I:ED [�N i3�Z.L�A-DWA`r STK.E'�" OC)IZIN1.� TI-F� IVA<T`f Eri�NI�STZf1LN�1
� N e, P�c,�.p
PFLV�E';2�Y AfvD �,I-f'E�ZErvi E i�E� �r 2c��4wtE� �� (= 2c�,Apa (JvF iU
rK� �va►v�r•�c.� S i CaN ►�n�' c� �Z i� �"��RF-•�*EE7l �r (1�4rL(-tE� v►.�
TN� D IZ t V�IL S S�rJ E-. Z� TF-f L ti�CaIV t't/`�(��i�?P12L�'�lZ L'� PLAL.c.:D�
�i1�s=+°E� � �vt `t' C-f�EZ (�4-r�t9-v� �vo�i.-�� tivT i3�-' Tr(�,2 c—:
Please check the box(es)that most closely represent the reason 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 of 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��S]!�P�c�PE '�iY ��UQ.i-`'� M��►�'T�1 N(%l�
❑ Other type of injury—please specify
In order to process your claim vou need to include copies of all anulicable 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
$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 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
i
Failure to complete and return both pages will result in delay in the handling of your claim. ,
All Claims–please comvlete this section
Were there witnesses to the incident? Yes No Unknown (circle
Provide their names, addresses and telephone numbers: A�L�►� L K v� ��Pk G IZ A-� VJ �N'bE�Lj '
�H' �3�9t� ��v/aOWA�c' ST _ A-PT Zu2 Sr_ ('A-u� �Jl� Clos�� .3�� c �`I�'�l
`�� 3�:�o w a��, 5-r'_ A-P T 5�v3 Sr. pr�u� w��•, . C lc 1 ln�r I 129
Were the police or law enforcement called? Yes � Unknown (circle)
If yes,what department or agency? Case#or report#
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.
t3Ru�owA`l STKE� �h►Zfi�-F�CKusS tr'�E� � �1 ST �AST / Pi2�Nt-E �i , V�A (. ST �i .
Please indicate the amount you are seeking in compensaUOn or what you would like the City to do to resolve this claim
to your satisfaction. P/a � ��- �i�( �N��, T H� �L��T(=H M!t r�KS l�v�q Je S Y 5►(,�ti'
Vehicle Claims–�lease complete this section ❑ check box if this section does not apnlv
Your Vehicle: Year =Z��v S'� Make S EEP Model (�rZAn�D C-ttE r2[a K�E
License Plate Number S�G -��3 State�N Color �� �U e�
Registered Owner C lt R�S R3 P ty E IZ 5 i' V v�5 TF iZ
Driver of Vehicle ( t+tZ 1 S TU c�N IZ- S`(w�S 7 r�Z
AreaDamaged�U�tiN�w N 'ST �'�4�>L
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniurv Claims please comelete this section �check 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 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 all information you have provided is true and correct to the best
of your knowledge. i�nsigned forms will not be processed.
5ubmitting a false claim can result in prosecution. Date form was completed��� �3
Print the Name of the Person who Completed this Form: Ctt�-�Sro�H E�z I�' . S Y L V G S TE2
-�— � _ �
Signature of Person Making the Claim: �
Revised February 2011
G
HEPPNER'S AUTO BODY (Downtown) Workfile ID: a1ff10f5
EPPNER�J� 395 E. 7TH ST., SAINT PAUL, MN 55101
• • : • �
Phone: (651) 224-5644
FAX: (651) 224-6042
Preliminary Estimate
Customer: SYLVESTER, CHRIS 7ob Number:
Written By:Grant Almeida
Insured: SYLVESTER,CHRIS Policy#: Claim#:
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact: 10 Left Front Pillar
Owner: Inspection Location: Insurance Company:
SYLVESTER,CHRIS HEPPNER'S AUTO BODY(Downtown) USAA
300 4TH ST. E. 395 E.7TN ST.
ST.PAUL,MN 55101 SAINT PAUL,MN 55101
(320)232-8671 Cell Repair Faciliry
(651)224-5644 Business
VEHICLE
Year: 2008 Body Style: 4D UTV VIN: 1]8HR58N08C209327 Mileage In: 143209
Make: ]EEP Engine: 8-4.7L-FI License: SLG-463 Mileage Out:
Model: GRAND CHEROKEE 4X4 Produdion Date: 3/2008 State: MN Vehicle Out:
LIMITED
Color: SILVER Int: Condition: Job#:
TRANSMISSION Body Side Moldings Remote Starter Stability Control
Automatic Transmission Privacy Glass Home Link Head/Curtain Air Bags
Overdrive Console/Storage RADIO ROOF
4 Wheel Drive Overhead Console AM Radio Luggage/Roof Rack
POWER CONVENIENCE FM Radio Electric Glass Sunroof
Power Steering Air Conditioning Stereo SEATS
Power Brakes Intermittent Wipers Search/Seek Bucket Seats
Power Windows Tilt Wheel CD Player Leather Seats
Power Locks Cruise Control Auxiliary Audio Connection Heated Seats
Power Mirrors Rear Defogger Premium Radio Rear Heated Seats
Heated Mirrors Keyless Entry Satellite Radio WHEELS
Power Driver Seat Alarm SAFETIf Aluminum/Alloy Wheels
Power Passenger Seat Message Center Drivers Side Air Bag PAINT
Memory Package Steering Wheel Touch Controls Passenger Air Bag Clear Coat Paint
Power Adjustable Pedals Rear Window Wiper Anti-Lock Brakes(4) OTHER
DECOR Telescopic Wheel 4 Wheel Disc Brakes Fog Lamps
Dual Mirrors Backup Camera w/Parking Sensors Traction Control
12/17/2013 8:54:08 AM 070412 Page 1
_ _ _ _ _
Cus�mer. SYLVESTER,CHRIS 7ob Number: I
Vehide:2008 JEEP GRAND CHEROI�E 4X4 LIMITED 4D UTV 8-4.7L-FI SILVER
Une Oper DescHption Part Number Qty Extended Labor Paint
Priae#
1 FRONT BUMPER
2 O/H bumper assy 2.4
NOTE: LABOR:Time indudes R&IJR&R grille and fiog lamps.
3 * Rpr Bumper cov� �,Q 2.6
4 Add for Clear Coat 1.0
5 # DEDUCT FOR PARI'IAL PAINT 1 -0.7
6 R&I License bradcet 0.2
_._�a 7 FRONT LAMPS __.___�_ __..._._�._.�.�_____.�._.._
8 R&I LT Headiamp assy w/o HID 0.4
�_ ��_� ___.._._v__.�_.---. _ .
9 FENDER
10 * Rpr LT Fender � 2_2
11 Add for dear Coat �•9
12 R&I LT Fend�li�r 0.4
13 PILLARS,ROCKER 8�FLOOR — -_ J
14 R&I LT Siil molding Limited,Overl 0.4
15 FRONT DOOR __._..__e____y__ --___....__�
16 * Rpr LT Outer panel ].:i 2•2
17 Overiap Major Adj.Panei -0.4
18 Add fior dear Coat 0.4
19 # DEDUCf FOR PARTIAL PAINT 1 -0.5
20 R&I LT Belt rrwlding Limited,chrome 0.3
21 R&I LT Lower molding Limited chrome 0.4
22 R&I LT Power mirror w/o memory 0.3
(GUK)silver
23 * Rpr LT Power mimor w/o memory 9� 0.6
(GUIn silver
24 OveHap Minor Panel -0�z
25 Add for Clear Coat 0-1
26 R8�I LT Handle,outside Laredo, 1.1
Limited,Overland&SRT8 btadc
27 R&I LT R8�I trim panel 0.4
28 # Repl 'Corrosion Protection 1 0.3
29 # �Cover Vehicle 1 0.2
30 # Repl 'Flex Additive 1 5.00
31 # 'Hazardous Waste Dis�osal Fee 1 3.50
32 # �Glass-Rope Wintlshield 1 0.5
33 # POSSIBLE HIDDEN DAMAGE 1
SUBTOTALS 8.50 11.3 8.2
12/17/2013 8:54:0$AM 070412 Pa9e 2
Preliminary Estimate
Customer: SYLVESTER, CHRIS 7ob Number:
Vehicle: 2008]EEP GRAND CHEROKEE 4X4 LIMITED 4D UTV 8-4.7L-FI SILVER
ESTIMATE TOTALS
Category Basis Rate Cost$
Parts 8.50
Body Labor 11.3 hrs @ $52.00/hr 587.60
Paint Labor 8.2 hrs @ $52.00/hr 426.40
Paint Supplies 8.2 hrs @ $32.00/hr 262.40
Subtotal 1,284.90
Sales Tax $270.90 @ 7.6250% 20.66
Grand Total 1,305.56
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 1,305.56
MN 5T 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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12/17/2013 8:54:08 AM 070412 Page 3
GREGG'S AUTO BODY Workfile ID: 44077604
FederalID: 411353442
HONEST AND CONSISTENT QUALITY
581 E. 7th Street, St. Paul, MN 55130
Phone: (651) 774-8211
FAX: (651) 774-0174
Preliminary Estimate
Customer: SYLVESTER, CHRIS
Written By; Gregg Rosenberger
Insured: Policy#: Claim#:
Type of Loss: Liabiliry Date of Loss: Days to Repair: 0
Point of Impact: 10 Left Front Pillar(Left
Side)
Owner: Inspection Location: Insurance Company:
SYLVESTER,CHRIS GREGG'S AUTO BODY
2445 119TH CT 581 E.7th Street
BLAINE,MN 55441 St. Paul, MN 55130
(320)232-8671 Cell Repair Facility
(651)774-8211 Bu�ness
VEHICLE
Year: 2008 Body Style: 4D UN VIN: 1]8HR58N08C209327 Mileage In:
Make: ]EEP Engine: 8-4.7L-FI License: Mileage Out:
Model: GRAND CHEROKEE 4X4 Production Date: State: Vehicle Out:
LIMITED
Color: SILVER Int: Condition: Good Job#:
TRANSMISSION Body Side Moldings Remote Starter Stability Control
Automatic Transmission Privacy Glass Home Link Head/Curtain Air Bags
Overdrive Console/Storage I RADIO ROOF .
4 Wheel Drive Overhead Console AM Radio Luggage/Roof Rack
POWER CONVENIENCE FM Radio Electric Glass Sunroof
Power Steering Air Conditioning Stereo SEATS
Power Brakes Intermittent Wipers Search/Seek Bucket Seats
Power Windows Tilt Wheel CD Player Leather Seats
Power Locks Cruise Control Auxiliary Audio Connection Heated Seats
Power MiROrs Rear Defogger Premium Radio Rear Heated Seats
Heated Mirrors Keyless Entry Satellite Radio WHEELS
Power Driver Seat Alarm SAFETI( Aluminum/Alloy Wheels
Power Passenger Seat Message Center Drivers Side Air Bag PAINT
Memory Package Steering Wheel Touch Controls Passenger Air Bag Clear Coat Paint
Power Adjustable Pedals Rear Window Wiper Anti-Lock Brakes(4) OTHER
DECOR Telescopic Wheel 4 Wheel Disc Brakes Fog Lamps
Dual Mirrors Backup Camera w/Parking Sensors Traction Control
12/17/2013 9:27:10 AM 034178 Page 1
Preliminary Estimate
Customer: SYLVESTER, CHRIS
Vehicle: 2008 JEEP GRAND CHEROKEE 4X4 LIMITED 4D UN 8-4.7L-FI SILVER
Line Oper Description Part Number Qty Extended Labor Paint
Price$
1 FRONT BUMPER
2 R&I R&I bumper cover 1.5
3 FRONT LAMPS _ _ _.
4 R&I LT Headlamp assy w/o HID 0.4
5 FENDER
6 * Rpr LT Fender � 2.2
7 Add for Clear Coat 0.9
8 R&I LT Fender liner 0.4
9 PILLARS,ROCKER&FLOOR
10 R&I LT Sill molding Limited,Overl 0.4
11 FRONT DOOR _ _ . _
12 * Rpr LT Outer panel �,Q 2.2
13 Overlap Major Adj. Panel -0.4
14 Add for Clear Coat 0.4
15 R&I LT Belt molding Limited,chrome 0.3
16 R&I LT Lower molding Limited chrome 0.4
17 # Retape molding 1 10.00 0.5
18 R&I LT Power mirror w/o heat(GTN) 0.3 I
19 R&I LT Door glass Jeep laminated IncL
20 * R&I LT Glass run �
21 * R&I LT Run channel Q,2 ,
22 R&I LT Handle,outside Laredo, 1.1 !i
Limited,Overland&SRT8 black ',
23 * Rpr LT Handle,oukside Laredo, Q,2 Q.4
Limited,Overland&SRT8 black ,
24 R&I LT R&I trim panel 0.4
25 * R&I LT Water shield IpCI.
26 # Car Cover I 1 0.2
27 # Refn Corrosion Protection 0.2
28 # Refn Feather Prime&Block Sand 1.0
29 # Subl Hazardous Waste 1 5.00 X '
SUBTOTALS 15.00 8.8 6J '
NOTES
Estimate Notes:
May need to blend hood to match paint
I -
12/17/2013 9:27:10 AM 034178 Page 2
, Preliminary Estimate
Customer: SYLVESTER, CHRIS
Vehicle: 2008 JEEP GRAND CHEROKEE 4X4 LIMITED 4D UN 8-4.7L-FI SILVER
ESTIMATE TOTALS
Category Basis Rate Cost$
Parts 10.00
Body Labor 8.8 hrs @ $55.00/hr 484.00
Paint Labor 6.7 hrs @ $55.00/hr 368.50
Paint Supplies 6.7 hrs @ $35.00/hr 234.50
Body Supplies 2.7 hrs @ $8.00/hr 21.60
Miscellaneous 5.00
Subtotal 1,123.60
Sales Tax $266.10 @ 7.6250°/o 20.29
Grand Total 1,143.89
CUSTOMER PAY 0.00
INSURANCE PAY 1,143.89
I
GREGG'S AUTO BODY takes great care to ensure that every repair meets our standards for quality. GREGGS AUTO '
BODY guarantees labor performed for as long as you own your vehicle on workmanship and will, at our expense I
repair or correct all defects which are attributable to defective or faulty workmanship in the repairs stated on the
repair invoice. This guarantee covers labor only and does not apply to parts, materials or equipment which may be
covered by and subject to terms of manufacturer or vendors warranty. This guarantee does not include damage
caused by or resulting from rust or corrosion, unreasonable use, improper maintenance or care of the vehicle.The
above is an estimate based on our inspection and does not cover additional parts or labor which may be required
after the work has been opened up.Parts price subject to change without notice. YOU HAVE A RIGHT TO CHOOSE A
REPAIR FACILITY OF YOUR CHOICE. WE GREATLY APPRECIATE YOUR BUSINESS.
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.
12/17/2013 9:27:10 AM 034178 Page 3
.
Preliminary Estimate
Customer: SYLVESTER,CHRIS
Vehicle: 2008]EEP GRAND CHEROKEE 4X4 LIMITED 4D UN 8-4.7L-FI SILVER
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
DR3WA05, 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 (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 �I
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. i
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=Afdermarket 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. 0/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=6ureau of Automotive Repair. EPA=Environmental Protection Agency. NHTSA= National Highway
Transportation and Safety Administration. PDR=Paintless Dent Repair. VIN=Vehicle Identification Number.
12/17/2013 9:27:10 AM 034178 Page 4