Cortez�_ _ __
NQTICE OF GLAIM FOR� to the City of Saint Paul, �Iinnesota
lfrirnc•.�ntn Stc7te Stcrtriti¢/�6.Gi,rtcuc.s thnt " ...e�•e,��pel;soi�...���h��clrri�rrc�(�nlages Ji•um uni�niunrcipalitv...shc�/I ccrtrse'10 be���ese�rtet�ta the
•�nrerrun,g hod�•ojtlrc nnuricip�rlrtv�eitlti�r T80 cfrtt's y/'te1•11tc alle�;ed lo.ss or i,rjruJ is c(iscu��ered n�rntice stati�r,,�the thxe,pJnce,and
cireunt.ctn�tees tkerc•nf, E�rrd lhcr arltnrurq oJeontpcxsa�icur or nther re�lref'def�rairdert.°
Please complete this form in its entiret�•by clearl��tr�pi�g or printi�a��aur�ns��-rr to each qucstion. If more space is
necded,attacti aciditivaat sheets. Ptrase note that�-oa mla�•or ma��not be contacied by telephone to discuss�our claim
circumstances,so providc as tnuch information as necessar�°to esplain}=our clxini,and the amount of compensation being
rcquested. `1'his form tnust be si�ncd, and both pages completed. If something does not applv,��rite`N/A'.
SEVD COI�IYLETED FpRI1�I AND UTHER DOCUIVIEN'TS TO;
CIT�' CLERk, 1� �'�'EST KELL�GG BLVD,310 CITY H�►LL, SAINT PAUL, ��iN 55102
First :�1ame �1 �t ,C���� Nliddle Initial� Last Name_ C�_Cti}-P �
Company or Business \1ame, if appiicable
Street Address 1�C%C� �- ���U. ' � � �, � C.
Cit�•�'L1�1� � ��.L �.
State_ ��r� Zip Codc S��
��
Da��timc Telephone (�) �a J�p�� Eirening Telephvne(�L} ;�,�� � g�j�
Date of Accident� Injuzy or Date Discovered 1t� �� 'Time `�'3O am r`�?ffi eircle)
Please �tate. in detail, ���hat c�ccui-red, and «�hy you are submitting a claim. Please indicate ��hy or I1o��� you
fec�e City of Saint Paul or its einptayees are ir�volved ancUor responsible.
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:':r.�� che::: the bo�(es) that mo�t closely�represcnt the reason for completing this fornl:
� ��ehicle a as damaaed iii an accident ❑ V�hicle���as damaged during a to�i�
❑ Vehicic «-as damaged by a pothole or candition of the street O Vchicle was damaged by a plow
❑ Vchicle was «�ron�fully to«-ed andr�r ticketed ❑ Injured on City property
�ther ty-pc of property datnagc—please specif_y �UV�1ci���1�,h,� �„��� 7 i C1-Zd- ��y o r
❑ Othcr type �f injur}%—please specif�� C�� 1 w��o�•,�c` .
❑ Other type not IiSted —piease specify
In ordcr to process ti��ur claim��ou need to include eonies of all znplicable documents. This is a general
guideline of�vhat sh�uld he sub�i�itted «�ith a clajm forin, but it is not alI inclusive. Y"ou may be asked to
prc�vide additional inforn�ation depending c�n yo�1r clainl.
O Property damage claims to a vehicle: at lcast t�vo estimates for the repairs t� your vchicic;or the
actual bills a�zd,�or receipts for t�ic repairs
O To��ring claims: legible copies ofi any tickets issued and capies af�thc impound ]at receipts
O Uther propertv dvnage: repair esti�nates, detailed list af damabed items R�C
O Ii�jury clai�ns: medical bills, receipts E�vE�,
O Photo�raphs cdn bc provid�ci but �viii not be rettu�ned. .IAN 03
2�?14
Page 1 of 2— Plcase complete and return both pages of Claim Fo
Failure ta pravide a completed claim form will result in del���s in pro��:CLFRK
Notice of Claim Form, Cih� of Saint Paul, page hvo
All Claims— pleasc complcte this scction
��'erc there ti��itnesses to the incident? �'e� '�o L`nkno���n (circle)
I' \�ea�c pro�•�f�e'their name , adciresses and tcicphone numben: �� �
�' �L ��c 1 GU 1. � � r ,( • � � ' 111►� �5 � � �
(� c� � — -r-�u51�,��a �ti.��� �. �-c> >�c l�� � �Y h,c li
Werc the police or Iaw enforeement ealled? Yes \o� Unkno�in (circle}
If ycs, ���hat de�artment or agency? Casc T or report�
��%hcre did the accident or injury take place? Provide street address, cross street, intersection, name of park
or facilit}�, closest landmark, etc. Please be as detailcd as possible. If helpful, attach a diagram.
N� .
I'lease indicate the amount you are seeking in compensation from lhis claim or what you w•ould like the Citv
to do to resolve this claim to youi•satisfaction. \, ��
S i;1.+Z— - V ; V-� � � ���. .
Vehicle Claims — lcase com lete this sectiun ❑ chec:k box if this section does not a lv
Your Vehicle: Year � �L V1ake vrc-� " Nlodel � U
License Plate�tumber �'>(��-i M LC State�Coto: i 1v �f
Rc�istered O�tner �'��� �c'�n��E . Lo:��
Driver of��'ehicle �� '�
Ay-ea llama�ec�_ '� t�.�} � �K,�°✓
City��'ehicle: �"ear ��akc vlodel
Licen�e F�late Number State Color
Drivcr ot�Vehicle (City Employee's I�aiTlc)
� Area Darna�eci
Injur-�- Claims— plcase complete this section �eck hor ii this section doc� no► annlv
Ho«� ���ere }�ou injured?
���'hat part(s) of your body�ver•e injurcd?
Have}F�ti sought medica� t��eatrnent`' Ycs No Planning to Seek Treatn�ent (circic)
�'4��ien did yc�u recci��e treatment`' (providc date(s))
�Iame af Medical I'rovid�;r(s}:
Address Telcphonc
Did }rou miss work as a result of your injury`' Ycs 'vo
��'l�en did you miss �vork? (provide date(s)j
\Tame of�rour Employer:
Address Telephone
� Check here if you are attaching more pagcs to this claim form. !�umber of additional pagcs
t1j•sirni�tg r/rr.c for•�u,,rau are s�uti�rR that rrll injornfatioa}'ou has�e pruvided is trur a►irl correcr[n Nre be.a uj�•our kno�vled��e. L��r�i,�ned
fnr•nts it�ilt n�t Le prncessed. Stthi�titting a julse claiin ran residt in prosectr�inn. .,
Print the Name af the Person �vho Completed this Form:�' �1 1 � i C��c1/� G ��/�� C-
Signature of Pci-son 1�Taking the C(aim: �- /n�L-�-z.E��c� � �
Date form tivas completed � � � � _ rz«;«�;���;, ,.,,,-
ABRA Auto Body & Glass - East Workfile ID: b4d65273
Federal ID: 41-1942823
' ' Bloomington
Right the First Time...On Time
1000 AMERICAN BLVD. W, BLOOMINGTON, MN
55420
Phone: (952) 888-0333
FAX: (952) 885-9778
Preliminary Estimate
Customer: CORTE2, MIRIAM )ob Number:
Written By:Todd Anderson
Insured: CORTEZ, MIRIAM Policy#: Claim #:
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact: 12 Front
Owner: Inspection Location: Insurance Company:
CORTEZ, MIRIAM ABRA Auto Body&Glass-East
Bloomington
1300 E MAYNARD DR# 379 1000 AMERICAN BLVD.W
ST PAUL, MN 55116 BLOOMINGTON, MN 55420
(651)280-8651 Business Repair Facility
(952)888-0333 Business
VEHICLE
Year: 2004 Body Style: 4D UN VIN: 1GNDT13S342315081 Mileage In: 113690
Make: CHEV Engine: 6-4.2L-FI License: TEMP Mileage Out:
Model: TRAILBLAZER 4X4 LT Production Date: 2/2004 State: Vehicle Out:
Color: SILVER Int: Condition: Job#:
TRANSMISSION Body Side Moldings Climate Control SEATS
Automatic Transmission Privacy Glass Home Link Cloth Seats
Overdrive Console/Storage RADIO Bucket Seats
4 Wheel Drive Overhead Console AM Radio WHEELS
POWER CONVENIENCE FM Radio Aluminum/Alloy Wheels
Power Steering Air Conditioning Stereo PAINT
Power Brakes Intermittent Wipers CD Player Clear Coat Paint
Power Windows Tilt Wheel SAFETY OTHER
Power Locks Cruise Control Drivers Side Air Bag Fog Lamps
Power Mirrors Rear Defogger Passenger Air Bag TRUCK
Heated Mirrors Keyless Entry Anti-Lock Brakes(4) Trailer Hitch
Power Driver Seat Alarm 4 Wheel Disc Brakes Trailering Package
DECOR Message Center ROOF Power Trunk/Gate Release
Dual Mirrors Rear Window Wiper Luggage/Roof Rack
12/19/2013 2:50:52 PM 014565 Page 1
Preliminary Estimate
Customer: CORTEZ, MIRIAM Job Number:
Vehicle: 2004 CHEV TRAILBLAZER 4X4 LT 4D UN 6-4.2L-FI SILVER
Line Oper Description Part Number Qty Extended Labor Paint
Price$
1 FRONT BUMPER
2 ** Repl RECOND Bumper cover w/o fog 88937008 1 288.00 1.5 2.6
lamp
3 Add for Clear Coat 1.0
4 Add for fog lamps 0.4
5 R&I License mount �•Z
6 # Repl �Flex Additive/Adhesion Promoter 1 8.50 X
7 MISCELLANEOUS OPERATIONS
8 # �Hazardous Waste 1 5.00 X
9 # POSSIBLE HIDDEN DAMAGE 1
SUBTOTALS 301.50 2.1 3.6
NOTES
Prior Damage Notes:
113690
ESTIMATE TOTALS
Category Basis Rate Cost$
Parts 288.00
Body Labor 2.1 hrs @ $54.00/hr 113.40
Paint Labor 3.6 hrs @ $54.00/hr 194.40
Paint Supplies 3.6 hrs @ $34.00/hr 122.40
Miscellaneous 13.50
Subtotal 731.70
Sales Tax $410.40 @ 7.2750% 29.86
Grand Total 761.56
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 761.56
"Minnesota law gives you the right to choose any rental vehicle company, and prohibits me from requiring you to
choose a particular vendor."
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.
12/19/2013 2:50:52 PM 014565 Page 2
,
Preliminary Estimate
Customer: CORTEZ, MIRIAM lob Number:
Vehicle: 2004 CHEV TRAILBLAZER 4X4 LT 4D UN 6-4.2L-FI SILVER
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
DR1GN02, CCC Data Date 12/16/2013, 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 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
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=6lend. BOR=Boron 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 �nd Replace. Rpr=Repair. RT=Right. SAS=Sandwiched Stee1.
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.
12/19/2013 2:50:52 PM 014565 Page 3
Preliminary Estimate
Customer: CORTEZ, MIRIAM )ob Number:
Vehicle: 2004 CHEV TRAILBLAZER 4X4 LT 4D UN 6-4.2L-FI SILVER
ALTERNATE PARTS SUPPLIERS
Supplier: Keystone-Complete-Minneapolis
Location(s): 3615 MARSHALL STREEf NE, MINNEAPOLIS MN 55418 (800)328-1845 (612)789-1919
Line Description Item# Price
2 RECOND Bumper cover w/o fog lamp GM1000640R $288.00
12/19/2013 2:50:52 PM 014565 Page 4