Krukow To�. Sandy Pag�2 0�7 2013-12-'1 B 19 Op 02(GMT) From: Pefer Lee
NOTICE ()F CLAIIVI FOR1wI to the City of Saint Paul, Minnesota
MinrittSU1C1.��IGFi.'SflUZlft'-jC)h.GS SfGIPS Ihrat °._et�er�pnrsnn,..�i°hn cfatin:r darniege.r.jrnrn anp nuuricipafity...,rhat!cattse!n br prexente�f to Ihe
Savernrn.,q body c,ftke mrini�ipc�(iiy wirhin IRO d�ii�.s�rfter the nl�eged l��ss«r injun is ctrscovered c�naric�e stuling r{te frrne,plac�e.nnd
circurnstuncc?s the�reuJ;und tlze umaunt njcvrrti��c+nsalion ur vti�er rerflef[lenumderL"
Please cnm��lete this frirm in its cntirety hy clearly typing or pri�tting your answerto�euch qt►estion. If more spare i�
needed,attach additionul sheels. Pleast�nute that ruu will not lae contacted by telephctne to clarifr answers,sa provide as
n�uch informati�yn as necessHry tcs explain your ct:um,and the amount of compensation heing reqiiested. Ynu wilt receive a
written acknowledgement once your fUrm is received. Tl�e process can take up tu ten wE�eks or Icmger dependin�on the
nature of your claim. This forit�must be signed,and both pages completed. If sumething does nnt ap�ly,write`l�'/A'.
SEND COMPLETED FQRM AND CITHER DOGUMENTS T17: CITY CLERK,
15 WEST KELLCIGG BLVD, 31(� CITY HALL, SAINT PAiJL,MN 55102
Firs[Name��_��jc�N iWtiddle Initi:it �� Last?�ame��u 1�d�� -- r-+r�G i V E�
Corrtpany or Business Name ��','�c5`t' `� /J ��r f_t� �. ��E�.e.. 2013
Are You�ui Insurance Company? Yes/ 1i' Lf Yes, Cl�im NurY�ber'?_____
Street Address�� ' �4�� '� '� /�4 CITY CLERK
.� t Stace ,i _�"� "Lip Coc�e..
City_�v�_�-�--
. , .. „..
L?aytirne Phone{��)�-���',i`_Cell F'hone(��7 j`'�-��F_.vening TelePhone{_�""–
Dace of�cti�le;r7d(njury or Date Discovereci � l� (� Time,�__ a /pnt
Pi�:ase stacz,in det�iil, wh.it c�ccurred(happenedj, and why y�u are sub�n.itEin�a cl�i�n.Please indicate why or how you
feel he City�c�f Saint Paul c�r its emPloyees are i volvecl.ind/ar re/^spon�hle f r your dama�es.
� :.. 'f_I'�t���tyC'��,�r' �,`,'�t .�y �.,:� i.�'C . "t �u.A�--��rt.cci( dvJ' __��
�JL`E�C. �,� C�f'�j �1{ti .�"�+.L r_�"}"f'��,f-. —..__._..-- —.. _
PI <ts�check the t�ox(es)thal most closely represent the ceason for c�m�leti»g this{�orm:
j�l�!fy veh'rcle was dam�tged in an aecicient ❑ My vehicle was ctamaged during a tow
❑M��vehicle was dania�ed by a}�nti�ale nr ec�nditic�n of the street ❑My vehicle was damagecl by a plow
❑My vehicle was wron�fully towed ancV��r ticketed Q I w�as inj��reci on City�rciperty
CI ()ther type of prc�perty aan�age–plcase speci ly --
❑Uther type af'i:nju.ry–pleas�spec:if�y _ —..------- -
ln�rder tc�prc�c;ess your claim vou need to inciude c�pies of all apolicabte dacument�*;.
Pc�r the claiaa�s lYpes irsted below,C�lcase bc;sure tc�inclucie the documents ii��iicated��i'it will d�lay the han�f3i«g of'
your cluim. Dacurncnts�'�Il,t_NOT be returned and becnm�the���mP�i�ty of the City. Xc�n�re e�couraged to kt;eA tt
copy Ibr yoursi tf be�fore submitting your claim fonn.
O Pro�xrty d�ma�;e claims to a vehicle: two csiimates for ihe repairs to yuur vehicle if the damage exceeds
$SQ�.f)();or the actual bills�mcllor rec�ipt.s for the repairw
O Towiug claims: legible cc�pies o1��my 1:icket issued�ntl u copp af the in��c�und lot recuipt
O Other prope�-tv cia►rzage claims.two repaii•estimates if the dania�e exccecis$SC�.ixl;or the actual bitls
ancUc�r reeeipt�for the r�pairs;detaile�!list a�'�la.maged items
O Injury cl�im�: medical bills,recei�ts
O Photograph5 are always welecrme t�doc:ument and supp�rt your claim but will not be returned. �
Page 1 of 2–Please comptete and return bs�th pages of Claim rarm ��
��
U��'
�'�
__ .
To: Sandy Pag�3 of 7 20t3-'12-'1B '19.00:02 (GMT) From: Pei�r Lee
Failure to compteti and return both pages will resnit in delay in the ltandlin�of your claim.
All Claims-Alease comptete this sc�tion r""'-�'�
Were there wimesses to the incident? Yes t�'o nkno� (circlej
Provide their names, addresses anc}tc�lephone nun►bers: _
Were the police c�r law enf'orce►nent callt�d'I �' .' n'o Unki�own fcirclej �i��
lf yes, what department or agency?_��,.�. "e��+�-t.- Case#c�r re�rt#��_�=9�-, �
W'here did the accident ur injury take Place? Prc�vide 5treet sidclress,cross street,intersection.name of park or facility,
elose•t 1�ndm�u-:,etc.. Please h�as detail as p�S�ibl I�necc,�sai•y, attach��diagram.
_ �ti�,�_.''�_�- .�����__. -
Please indicate the ai��c�ynk y�xF are see.king iir�omErensation c�r what,y�u wot�Iti like the City to da ta resolve this ctaim
to your satisfactic�rt.�_�S �'�I. �Y ( C:S�r���►�.I1 �:a n-„r� )
Vehicle Clai�ns- lease com lete this section �check t�ox if this sectiar�does not a 1
Yc7ur Vehicle: Year �€' Make_ � t Mc�Eiel u 4��
Lic�:i�se Plate Nan�ber_ '-I ^ �t State jt_�s`_CoIor �_+�___
Registered Owi�er��1_ r `�% �
Driver c>t Vehlcle � �f� ak�
Area Damaged__�^��ttr 't d.c. �.�.fi ..;��,�-
City Vehicle: Ye�u•� _Make_,--.---.. Model St•r�.�-t- : �c.c-I'f�
F�'_.______
License Ptate Numher State___Calar� �
Driver�f Vehicie(City�mplc�yee'w I�ame�� �
Area Dainaged ._. —._ _ .
Tniurv Clt�ims please cornp{ete this section [�check t�ox i€this section does nat apply
How were you injurecJ? ---.._.---.-.-- ---
Wh.�t part(s)01'yaur bcxly were inj�red? --__,.--
- -- --— --- ..
Have yc�u sc>ught medicai Crea[ment7 Yes No Planning to Seek Treatment(circle)
When did yrn�receiv�treatment? __ (provide date(;sj)
Nurnc c�f i4�icdioul Prc�viclmr(e}: -_-
Acldres� _ TelePho�e
r�ltl yuu it�is� wuik ns a i�su1C vf yvur injury^: �'�-� �'�
Wlien did you n�iss wark'r _ (prtivicl�dateE�))
1�Lame c�l���i.iAic Fni����.�v�•� ........—.........—_.._.. _
' _ I r:{r,��honr,_.
.�durc,�;� ._..,,
❑Check here if}�ou are attaching mare ija�es tu this claim form. Number oi"adctitianul pages
BX signing t�iis jorm,you �re statiitg[hat all inf'ormation you have provide�'is lrue and carre.c#tv the best
of your knowtedge. Unsigned forms will nnt be proeesse�I
.SuGmitting a false claim can res►tlt in�ro.secution. Date form was completed�:�� / �����'�-�
Prinl the N�me of ttzc Person who Com�leted this b'c�rm: _ ��S t�N ' � ��u�cc�
�--�.._.-�---r''�
Signateire of Person Alakin�the(;ldim: ���_.__
i
f
Rr.aised Hebruary 2(l Li `---.f
To: Sandy Pag�4 of 7 20'13-12-1t3 19'.00'02(GMT) From: Peter Lee
^j '�.,� ���t ���j � �qte: 47l 9a�Qt 3 U4:57 f'M
G�.� L�t � E�te�o: �
� �„��(J� E!�t.t� r.BW+ie1Pl�iE}: 5lv�t R�
�1�.�� ���
ilUayn�-lfal Aut� �ody
97 S.aw�sso,Littk Gar,as#t,NIN 551�7
(651�4g3-�44�w
Er.saii-ww,��act.c�v;yfl3�ao�mrn
Tepc IR: At17�7T74
f?a�s�Ar�d Bjt: F�Ck�'np
QedU4tihle: t1HKNQWN
tnew'ed: !-tC�ldESr 1
!atlt�?er±seFV�ee: ?t�E2g
p�n: 1�Fad Fnax�s 2�rs SE:S
g�Y�- `4p� pr��Trafn: x.01.in(4 Cy{4A FtiND
V3N; 3 fAHi�3diV'�'74iV'1g140fi
rJENY4�T: F. S�Ctt Gode: Ei592.7;P
C}pt�xiS: PASSENC���t.AtRHPaC3,aF�.!ittER REFC9�[i,FOVV�R LOCK�POV`JER WINDUW,P4WER STE�RI►�G
R�A�W{NDC1M!'[JEPC;�.3�EP=_IttUtNt6AL AlF�C<JNDITION,�RUl8E�Q°J?Rt?!.,TlLT�TEEfi{NCi CS7l.UNlh
T�LE�CgPIG STE�RfNG CQLUfAN,F�JG!.lGHTS.AIUNUAI€.PY iNHEEI.S
L.�ATH�R gT�£RINC3 WNEEL.,PC)YJER A�.1t15TABL�EX'i�.Ft,l4�2l+UFtRt)R.FRQNT A1R DAM
TINTE�S GtABo,�`,1�tT!-Tt;€F°'8VS t w.�R Ativf�ilA bTcK£0 G�fAfi?3 p1RY�R,fR�YT aiiGl{ET SF.a+�S
Y.ETYCl�E(�S�S,�/-��yt�iiyT�RyfY�cSY�S■^T1E,`M{,Pt3Y/Y�'�R�Up�('T�yr'aNTEtTRIJNK,RFAR$�'O!#„E�
. �}1�'l�la-J c�i+L.i..�I11VMl�I�W M����Y'MO�Y
Line Erttry Lsbpb' L.O�iR� ReR Type! D�Iba" f.abor
ttem Numlxx Typp ��'�30!� •-'�.r'�tx: � Fert Nvmb�er - - �+mount Un+',�
RockertFillarslf lapr
1 � B�'( RE�A1R r,j F�.�c�R�t� .S =xtatfn9 2.fl'�F
Sf�Y�_
2 [,}t)T595 BDY •°.EhAblJ�ffi.EPLi�CE. L:]ua�OlRvrPdr�el YSAZ5427�S4t Ct1 1 508.78 46..4I �
3 REF REFINl3ti L Qu�rtel'Pane!4t�t5ide � �-;
q REF REFIt�fgW 1_C,2tt�te►P�nm{EtiX �; Q 5
5 REF R,EFtN15H L A�Ftx PfiidY e' �'�
Fr 0ot 927` B17� REIVFOVEfREPWCE L Uua�Air Wen#Penel ZU5Z 5428QB52 AR 14.42 0.1 # �
7 BDY REMOYEIlN57ALl f2axP Burs�p�w Ccxer ���
L�qage Lid
8 (1p�3�1 8DY REtvSt7YF1ftEPl.AGE l��ga Lid Pane! Quai Rec�cA�cd t'ait 2.50_40 ' 1-1
q REF REFlNt�H Lt�e liQ Qutside C 2.Q
16 REF REFINISFt l.tiggage Lid Underside G t•2
71 E�hrsa�tan it�clte�sl
92 (1a7769 BQY kEdn`f)iIElREFtAG� �U�C'tti ddh��iarr�'dt,� 4S4Z 5�42528lu� 34.0T U.1
t3 f307Trf BDY REAAGYElR�PEACE Lu49e�e Lid AdheSive Hart�piate �SdZ 544�528 CA 3Q,52 t3.1
Rex 6oc}�
14 Wt352 HC3Y f�EMdVE1REPI.�CE Reat Body PaneE 8S4Z 5440320 A. 144.48 �.3 �
'�:i '�FF �er1;lfSFi R,,*"a(dOrJ�i'alYci G S_S
16 REF ftEFIREi3H Ad�I�tarl� 4'8
RC�f lr3irElt�
17 008418 BpY ftEMOVEfREPtACE R Fte�aU Combkrra8on tamp As2em� ""Q�1A4 REPL PART 23•0�+ flrC
t8 O6�E019 9�v RFMOVFIRF171�CE L RearGorrcMna"c+r:'.�mP'�� 5347 53405AA 26-9F: 'At�:
Rear&xr�aeF
19 B6Y �J�fEftH.AU! ReaK BumP�A�7 E1.7
24 Qf�5048 6DY REMC3VE1FtEPLAGE Rear Bumpp.t GoYer S.S42 iTK835 DA 7�4.Bfi !#4C
2t REF REFlN15H Reef Bum¢er Cf�er � �2
22 068A43 BPY RcMOVF1REPl,ACE t2eer 8+cr�per FiNer Pnr�i 45421:7'$7 AR �1 S,S,T IPIC
ESTIMATE RF�Al.?RlU4lEEf�: 4��!1�'•3 35:S7:2d1 fl�3
AAitchdl�ata 1{e�siort. O�M: SEP�l3 V
[�p.PP`;&�R 13 V ��+f�19994-20i3 MitccheN teiterrraHattef Pe�(;�@ i 01 $
SoRwan�Y�r�k�n: 1,Q.4b7 Ari►�Ights Re�erved
To�. SanrJy Pag�5 of 7 20'13-'12-1l3 l9 00�02(GMT) From' Peter Lee
I�e: 42/£Y2093 i34:S7 P�A
FslJrm�fD; 3�
�'ft5�8�fCtSWti' ii
Pretkr»r►ary
Pro�;s!R� �Mp Rates
�# OOiflO� B�Y RENkQil�.��iJ4�� Ftsar Bum{�ea�}mpad Bar 4S�179Q6AA 77,15 {NG �i
24 REF R�FiFlfSH �r kr�c3 3s� 1,2
AddlllonatCosfs&Nfa�rfaRs
25 599006 AA�'L�DST Ru�Coatt� 20.QtJ �
Adtlitionaf O�vaXku►a
2� 53�006 FRRA AOD'L OPR PrdmelReck SeT Up 1,0'
7'7 S'33036 FRiW ACtO'L,UPR Unibtady Putl 2.(7'
28 REF AQD'E.Q1�R Cfeer Caet ,2.6
AfluKlonat coats a.f44ffireE�s
29 ADD'L G4ST Palc�th�#t�+1ak� �85.tQ '
30 �Ci�`t COi9T iia�xarc�CSUS Waate C,�16�c�a; S.OQ "
'-.1ud�ment ttem
�r!atx�r ridote Apoti�
'"QUAL REPL PART-Qu�fity Replac�merrt i'aris
C-Ir�cl!.�d�c!�n Gle�r�aa!��Sc
r�vsroNe au�cu�tar:vE
3615 MARSfiAt,L 5l".N�
r�n�tn��POt�s
MN 5�518
(BL�)32&!8a5 ,�'!2}�9-4 H£�6
17 '`"F02801188 23,IX1
Es�imate To��s
� ,
� ��
i: Wh4r Sul�dka Ut� R�e Arrronu�d Amncmt Tot.�is 11. Pert Replscen�et►t Summary Alrrount
$p�iy '�3.4 SZO�E G_�Q C'.dQ 1,97?$0 T��l4:�2:r!s �.448.7�
Refintsh 74.7 52AU fl_c}Q Q.Q� 794,� FartsAdju9lments �2.50
FieRte 3_D iSAQ p_iM1 U.UO 22S.OL� Salns ten (�n T.1�596 S7tl.7U�
Non-Taxable Lahor 2.3fi2.24 Toaa�k�placemertt Part�Anwunt 2,888,f13
t.dRxtl'SUnt�7�trY 4$,! 2,362.'LQ
itl. Aciditional G�.+ts Amase! #V_ As�ustmerts Amourtt
r�,�c.�ca `�ss,ta eus�mar�a�v a,rx�
sa{e�Ta� � t.��s§6 3a.s6 .
.._....+--.
Non Tar�die C4srs 2s.do '
Totsll Ad�CoStS 544.8dr
�aStY2liAa�ris�i M�thpti`Raf�s
lr�;t Rete s 33.QQ ,!nd Max tiQUfS=93.3,Addi Rate=U-OQ
ESTIRib1?F R�GAlL��JMBER: '.2.fi.l��113 4�:�?:2� 5.5P9.3
NGtcfteN Ils�Vars+ar�: O�MM' S�P_13 �!
I�APF:£;EP t3 iF Cnpyriig�M�C?i994-2tlt3M(4oheFtfntemational Pc�e 2 of 3
Saftw�e V�s�vr►: 7.4.-087 Aq F?IC,�r ReBetYed
_ _
To: Sandy Page 6 of� 20�3-�2-�t3 19 00-02(GMT) From: Peter Lee
, .,4
i. Ta[ail Lai�or. 2,3G2.20-
ii. i'�al Repia�cetneM Fafts: 2.6&8A3
�{!. T�t A�itians!i,es:s: ���
Gm&S 7ntal: 5.594,3Q•.
�i.L.i:
i�l. Tol�at AdJ�istrrrerKs: �.QO
fr`4:TGt6�: 5,38q.54
��llB�S�pCE1t1l1i1tFA BStiCE1Q�
Addit�onati chan�e�t4 the es'ti►nate rna�b�r��s�fnrt�a actast rat�ir.
; _
4
ESTlA�ITE RECALL P!!JMlBER' 121�'1�1'!3 485724 9S9'33
Ntgr,hep paf�VPrslon: ��t�l; S�P t�V
lM�P:&E,P.13�f �a�pyftghR(Ca i�s4•2Lt3Mlfch�fi iru�amatkon2f Fage 3 of 3
SotRv,rate il�t9bn: 7.lJ.98T All Rlghts R�earved
__ _
To: Sandy Pag��of 7 20t3-t2-'1Et '19 00'.02(GMT) From' Pet�r Lee
�.��,,. .....�
DOIJGLAS �1. DRUSCH Pride, Professionafism &Partnershi�
-; ; , ,f;> 1 -,
Public Wnrks Superz�i.cnr It! �- '- ° � . C. LESEIII
�, Ac�lice D,t�irer J�— �.{ `�� �__
,�,,f,`_ _ ,; --- �
CITY Or SAINT P�UL � :'• '�° �aLICE DEPARTMENT'
CIT'Y t)F:iA1IVT I'AUL
DEPrtft'fMENT C}�p4TIlL[C WC)RKS -
S1'REE"f&BRIfKE MA[NT1:N,4NCE i'11VfSJQ1� _ �G7���tr,Srrert 4bire M�til.63�-2hfi-4(XK)czt 7I7�i13
Sui,v Pmd.hlfi's_)UI uflren.c.rrrl(at i,ict�twf.mn.u.c
Tei:6ij.a66_FTOS CN��,�����__
8?3 North Uu1r Strerr Celd:ti51-Z55-1l811 [f pou huva questiix�ti rr,ganling ypur rr�rnr�,call:
3arnr Putrl„tifN 55fU3 Fux:6,5)_?i5/�.y7}� Stuof Paul Putice Rceords[Jpit (651}?b6-5J9fJ
� �
,��' � �����' ���� ���
�
` `�'� `.��j^�% ���-��
�
...�:�.; ���'..�- �������
, .
�� � c�;��J
.�. �� :�.�.�'�__..__._.
F(�'1y.� ���-"'�' �"1�}�?.:C� � .�-
� �� (�/ �f
(��'�- ��V.Q-rC_ f f-t'r.-�"T ; ��L�=___
W�£`. G��(f�"C_�
_..._._ ..._...
_� MINNESQTA lN�URANCE CARD
����
'- Mutual.
� PQLlCY"tRfFORMA710N �VEHlCt.E fNFQR�qATION �"suR""ce
P�Nwnbar ,• vw 2f)05 � CONTACT US
Ad2-248-2t7�6d"-�4A 2 7 Te�.y�,
P��v[-tt�rsr�u,,,, nt+k. FtYtJNUA f ��800-2C1A(MS
1 1 I t 7l20 t 2 i l•B00-225-246 71
Pa�ry EYpir.pnn Dw ,..,�MadN �TEICSON Cuican�tarriv ..
1 S/i ll2013 Y�q.rarv�cW,,,�p� �'320-253-dSpQ
KMe:��2Da�ua4a�es t`$Ob-53S-6639
�� IYe�,,.of�n.�r.A R°°°'°°'A"L'*'e° .� . . . .
- 1-aoo-a 2s-g898
SRfiAH F�ARELE.
FERI�lANDO fERRELL
The irtsurance company displayed belrnr,cerYifies that it.tia3� '��~.__
issued a liabiiity insurance policy with c3mpuisory covsrage '., cere��„��
as raqu"rred by the Minnasata financief res - ��»�t2bt2
the pali4YF}UJdet na�sted F�efow with resvect�o5theit tlhi�e�� .��f�•'�mn.k
dascribed_ 2Q 13
c�ronranmc LIBEt?TY Ml}TUl.l,l FIRE IlVSUAANCE C0.
xnrc nr,,,r,.:23035
� �'Isp(T 6f17 1D t0 . . . .
t
To� Sandy Paga'1 of 7 20'13-�2-�8 19-00-02(GMT) From: P�tcr Lee
FAX COVER SHEET
TO Sandy
COMPANY City of St. Paui
FAX NUMBER 16512668574
FROM Peter Lee
DATE 2013-12-1818:59:42 GMT
RE insurance claim on 2007 Ford Focus
COVER MESSAGE
here is the claim form for the damage cause by street sweeper on our 2007 Ford Focus.
It includes an estimate from an autobody repair shop.
I
I
WWW EFAX.COM