Chase tiOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
llinn.�sora�:.::: �r.:�i�re�66���states that ° ...eveiy person...who claims damages from any municipality...sha[I cause to be presented to the
gorern�n�n�-,ir o/�the nu�nicipaliry within 180 days after the alleged loss or injury is discovered a notice stating the time,place, and
ciirunzstances t{:ereof, and the aniount 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
First Name �r10.Vt Middle Initial � Last Name 1.,�-�LS'� R�r�����p
Company or Business Name ner n n �n+3
N� LVI
Are You an Insurance Company? Yes No If Yes, Claim Number?
Street Address
2l l�l �h-i In,1.a�.vi d Pkw K
City �' �0.1M State �n Zip Code 55t1 lQ
Daytime Phone �)���Cell Phone(�)?JTT��Evening Telephone(���Q��2
Date of Accident/Injury or Date Discovered_���Z � 20 Time �� �S am/�
Please state, in detail, what occurred(happened), and why you are submitting a claim. Please indicate why or how you
feel th City o:Saint Paul or its employees are involved and/or responsible for your damages.
� ��L fii� �
Gcl s — � --1 0'�
rf� Z ��
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
❑ Other type of injury—please specify
In order to process your claim you need to include copies 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.
�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
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims-n�ease complete this section
Were there�ritnesses to the incident? es No Unknown (circle)
Provide their names addresses and telepho e numbers: �}� C S� sl 90 " 2
Z 1 w n� c- /HN
Were the police or law enforcement called? Yes Qo 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 necess , attach a diagram. 0/�/ CG '
,� ���'1` '� Z/ p/ l�/`l��/�,D �GN�fAi�+'T �¢k L �rti'V S SI l
Please indicate the amount you are seeking in compensation r what you would like the City to do to resolve this claim
to your satisfaction. s �/N6' f� /j't O/�
�'j y .�n�Su,�a.�.���u CT �c d� ¢�l,�l�C�
Vehicle Claims- lease com lete this section ❑ check box if this section does not a 1
Your Vehicle: Year ZQ�9 Make �/�1�/�f� Model I C Cr/YtJG:
License Plate Number yl - �- State Color S'/L �-Je
Registered Owner �'
Driver of Vehicle /l/f��I�1 C f
Area Damaged / ^�
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Injury Claims-please complete this section I�check box ifthis section does not applv
Ho�v 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 tlzis form,you are stating that all information you have provided is true and correct to the best
of yoi�r knowledge. Ilnsigned forms wi[l not be processed.
Submitting a false claim can result in prosecution. Date form was completed C �� ���
�.z �,� �- ('�.1 �
Print the Name of the Person who Complete i orm: . .
Signature of Person Making the Claim: �
Rcvised Februarv 2011
BUERKLE COLLISION CENTER Workfle ID: 84cad4e3
3350 HIGHWAY 61 N, SAINT PAUL, MN 55110
Phone: (651) 490-6606
FAX: (651) 490-6612
Final Bill
RO Number: 15925
Customer: Insurance: Adjuster. Estimator. TONY SIMONEAU/
CHASE, BRIAN PROGRESSIVE INSURANCE Phone: Create Date: 7/1/2013
2161 Highland Parkway Claim: 13-1628354-01
SAINT PAUL, MN 55116 Loss Date: 6/21/2013
(612) 363-5910 Dedudible: 500.00
Year: 2009 Sryle: 4D P/U VIN: SFPYK165296101276 Mileage In: 25254
Make: HOND Color: SILVER Mileage Out:
Model: RIDGELINE 4X4 RTL License: 841 BLY Job Number: 15925 TAG 347 Vehicle Out: 7/26/2013
Line Ver Operation Description Qty Extended Type Labor Type Paint
Price $
1 E01 Refnish Blend Right Roof Raii 0.6
2 501 Refinish Clear Left Roof Rail 0.6
3 E01 REAR DOOR
- ',S01 Blend RT Outer panel 1.0
5 E0: Remove/Install RT Belt molding 0.3 Body
6 E01 Remove/Instali RT R&I trim panel 0.0 Body
7 SO1 Remove/Install RT Door w'strip 0.2 Body
8 E01 Remove/Install RT Handie, outside painted billet silver 1.3 Body
9 E01 Remove/Install RT Door glass Honda w/tint 0.0 Body
10 E01 Remove/Install RT Run channel 0.2 Body
11 501 Remove/Install LT Door w'strip 0.2 Body
12 SO1 FRONT DOOR
13 501 Remove/Install RT Door w'strip 0.2 Body
14 501 Remove/Install LT Door w'str�p 0.2 Body
15 E01 ROOF
16 E01 Remove/Install RT Roof molding 0.3 Body
17 E01 Remove/Install LT Roof molding 0.3 Body
18 E01 REAR BODY&F100R
19 E01 Remove/Instail Back glass Honda w/privacy tint 0.0 Body
20 501 Remove!Install Rear Floor pan 4.0 Body
21 501 Repair Rear floor pan 8.0 Body 3.0
22 S02 Sedion Rear body panel (HSS) 1 275.85T OEM 3.0 Body 0.9
23 502 Overlap Major Non-Adj. Panel �0•2�
24 502 Dedud for Overlap (1.0) Body
25 502 SPECIAL ORDER FREIGHT 1 73.22T Other
26 E01 QUARTER PANEL
27 502 Remove/Replace RT Quarter panel 1 890J8T OEM 28.0 Body 3.0
T =Taxable Item,RPD=Related Prior Damage,AA=Appearance Allowance,UPD = Unreiated Pror Damage, �DR= �a�ncless Dent Repa�r,A,'r� =aRermarket,Rechr= Rechromed,Reman =
Remanufactured,OEM =New Original Equipment Manufacturer, Recor= Re-cored, LKQ =Like Kind Quaiity or Used, D��ag = DiagnosUC, Elec= Eiectncal,Mxh = Mechanical, Ref=Refinish,Struc=
Strudural
7/29/2013 2:08:47 PM Page 1
Final Bil►
RO Number: 15925
Vehicle: 2009 HOND RIDGELINE 4X4 RTL 4D P!U 6-3.SL-FI SILVER
,_ S�: Add for Clear Coat 1.6
;_ S�� Re^�ove;Replace RT Inner panel assy 1 1,068.95T OEM 10.0 Body 1.6
_= SG: i Add for Clear Coat 0.3
3: �SG2 I Remove;Replace RT Side trim panel 1 285.35T OEM 0.0 Body
�32 SO1 Removei Replace LT Upper molding 1 31.00T OEM 0.3 Body
33 SO1 Remove/Replace RT Upper molding 1 31.00T OEM 0.0 Body
34 SO1 Remove/Install Fuel door 0.3 Body
35 SO1 Repair LT Quarter panel 5.5 Body 2.8
36 501 Overlap Major Non-Adj. Panel (� z)
37 501 Add for Clear Coat
38 502 Removei Replace Splash/Mud guard 1 71.00T OEM 0.2 Body
39 E01 RESTRAINT SYSTEMS
40 E01 Remove;Install RT Head air bag 0.8 Mech
41 E01 Remove/Install RT Side impact sens rear 0.4 Mech
42 E01 TAIL GATE
43 501 Remove/Replace Tail gate 1 678.98T OEM 2.5 Body 3.0
44 E01 Overlap Major Non-Adj. Panel ��•Z�
45 SO1 Add for Ciear Coat 0.3
46 502 Remove/Replace Tail gate trim 1 336.18T OEM 0.0 Body
47 SO1 Remove/Replace Nameplate "HONDA" chrome 1 39.05T OEM 0.1 Body
48 SO1 Remove/Replace Nameplate"RIDGELINE" chrome 1 5710T OEM 0.1 Body
49 501 Remove/Replace Nameplate "4WD" 1 30.13T OEM 0.1 Body
50 SO1 Remove/Replace Upper molding 1 40.03T OEM 0.0 Body
51 SO1 Remove/Replace RT Upper latch 1 20.50T OEM 0.0 Body
52 501 Remove/Replace RT Striker 1 115.68T OEM 0.1 Body
53 501 Remove/ReplaCe RT Upper striker 1 3:J2T OEM 0.1 Body
54 E01 REAR LAMPS
55 S02 Remove/Replace RT Tail lamp assy 1 150.68T OEM 0.0 Body
56 E01 Remove/Install LT Tail lamp assy 0.0 Body
57 E01 REAR BUMPER
58 E01 0/H rear bumper 2.0 Body I
i
59 E01 Remove;Replace Bumper cover 1 408.73T OEM 0.0 Body 3.2
60 E01 Add for Clear Coat i.3
61 E01 Deduct for Rear Bumper R&I (1.4) Body
62 S01 Remove/Replace RT Spacer 1 13.17T OEM 0.0 Body
63 E01 glass kit 1 25.00T O±her
64 E01 Repair UNIBODY SETUP 2.0 Body
65 E01 Repair PULL AND SQUARE 4.5 Frame
66 E01 Remove;Replace RT REAR DOOR EDGE GUARD : 15.00T Other 0.2 Body
67 S02 ACCESS TONNEAU COVER 1 549.?3T OEh1 1.0 Body
68 502 Sublet Thrust Angle Atignment,(4) � 89.99 Other
Estimate Totals Discount$ Markup$ Rate S Total Hours Total ;
T=Tzxaole Item,RPD=Relat2d Prior Damage,AA=Appearance Allowance,UPD= Unrelated F'rior Damage, PCR = ?a�rness Den(Repa��r,A;�Pt =Ahermarket,R2Chr= RfChrom2d,Reman=
RemanufaRUred,OEM =New Original Eqwpment Manufacturer,Recor=Re-cored, LKQ =�ike Kind Quality or UseG,D�a9 = ���agnostic, E'�ec= `lectecal, Mech = Mechanical,Ref=Refinish,Struc=
Structural
7;29!2013 2:08:47 PM Page 2
Final Bill
RO Number: 15925
Vehicle: 2009 HOND RIDGELINE 4X4 RTL 4D P/U 6-3.5L-FI SILVER
��-L 5,238.23
S;�',e?i Miscellaneous 89•99
_abor, Body 52.00 68.3 3,551.60
Labor, Refnish 52.00 22.6 1,175.20
LzbCr, Frame 70.00 4.5 315.00
Labor, �lechanical 80.00 1.2 96.00
�,ater�al, Paint 723.20
Subtotal 11,189.22
Sa es Tax 373.22
Grand Total 11,562.44
Dedudible (500.00)
Net Total 11,062.44
Estimate Version Total $
Original 9,324.86
Supplement 501 1,355.17
Supplement 502 88Z.41
Insurance Total g: 11,062.44
Received from Insurance 5: 0.00
Balance due from Insurance 5: 11,062.44
Customer Totai S: 500.00
Received from Customer 5: 0.00
Balance due from Customer 5: 500.00
T=Taxable Item,RPD=Related Pnor Damage,AA=Appearance Allowance,U�D= Unrelated prior�amage, PDR= �a�nUess Dent Repair,A;h1 =4Rermarket,Rechr=Rechromed,Reman =
Remanufactured,OEFt =New Original Equipment Manu`acturer,Recor =Re-cored,I.KQ = Like k:intl Q�.:a'��ry o�UseC. D�ag = D�agnostic, �lec= Eied�kai, Mech = Mechanical,Re�= Refinish,S[ruc =
Strudurai
7/29/2013 2:08:47 PM Page 3
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