Wirtzfeld NOTICE OF CLAIM F�RM to the City of Saint Paul, Minnesota
;t•fi�trrese�lrr Sra1e Stattrle�/66.!1 i,sratcs th�r� "._.e��er i ner;so�r...ti•/ro clairt+.s drrnzngc�s f'am mti'»tttilicipalily...shttN ctrtrs'e to bc pf•eser�ter!tn!he
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circumstrv�ces 7lrereo�nnd tlre cuztnttn!nf�co�+tpeersclliu�l ar otlter relief clenaai�rlerL°
P�ease complete this form in its entirety b� clearl��typing or printing}�our ansr��cr ta eacl�question. If more space is
needed,attach additional sl�eets. Pleasc note tliat t�ou may or may nat be contacted by telephone to discuss your claim
circumstances,so provide as mucli information as necessary to explain your claim,nud the amount oi compensation being
reyucstcd. This[orm must be signcd,and both pages compicted. If samething does not apply,�Frite`n/A'.
SEnD CO�IPLETED FORNI AND OTHER DOCUIlLENTS TO:
CITY CLERK, 15 VVEST KELLOGG BLVD, 310 CITY HALL, SAIVT PAtiL, NIn 551U2
First Name ������ Middle Initial� Last Name ���l 7���-��
C�mpan or B�siness Name, if�pplicable ,,��—��r�--��-�--�';ET���.•�, 1
Street Address 3/G i�,����'�� ��; h,� ��--� � S-./�"/��i�/4�� s i 1f'�.{�i���'
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City �T f�C�it _ State !/�7✓l� Zip Code S��lJ�
Da��time Telephone(�� ) ��� � � �� Evening Telephone(��
Date ofAecidenV Injury or Date Diseovered �'t Z � Time � �U am;�circle)
Piease state, in detail, what occurred, and why you are submitting a ciaim. Please indicate why or how you
fecl tf�e City of�Saint Paul ar its cmployees are involvecl andlor responsible.
( n� � ��w �37 T f' )
f (' �'b U/1 J ra� i t�vu � r � �N �a �1 l � S ���
Please check the box(es) that most closely represent the reason for completin�this fornz: ,
❑ Vehicle was damaged in an accident ,$�iicle was damaged during a tow
❑ Vehicle was damaged by a pothole or condition of the street ❑ Vehicle was damaged by a plo« I
� Veliicle wa,s wrongfuily towed andlor ticketed ❑ Injured on City property ;
D Other type c�f property damage-please spccify
❑ Other type of injury--please specify
❑ Qther type not listed—please sQecify '
In order to process your claim vau need to include copies of all applicable documents. This is a general
�uideline of�what should be submitted �vith a claim form, but it is not aIi inclusive. You may be asked to
provide additional information depending on your claim.
� Property damage clairns to a r•ehicle: at least twv estimates far the repairs to your vehicle;�r the ,
actual bills and/or receipts for the re�sairs
O Towing claims: legible copies of any tickets issued and capies of the impound lot receipts
4 Othcr property dama�;e:repair estimates,detailed Jist of datna�ed items R�C E I VE C�
O Injury claims: medical bills, receipts
O Photographs can be provided but will not be returned. �AN 03 2Q�4
Page 1 of Z—Please complete and return both pages of Claim Form ,�TY CLERK
Faiiure to providc a completed claim form will result in delays in processi
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ABRA Auto Body & Glass - East Workfile ID: c456e620
FederalID: 41-1942823
; - J 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: WIRTZFELD, GREG 7ob Number:
Written By: Mike Campion
Insured: WIRTZFELD,GREG Policy#: Claim#:
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact: 12 Front
Owner: Inspection Location: Insurance Company:
WIRIZFELD,GREG ABRA Auto Body&Glass- East
Bloomington
319 WINNIFRED ST E 1000 AMERICAN BLVD.W
ST PAU�, MN 55107 BLOOMINGTON, MN 55420
(651)757-6607 Cell Repair Facility
(952)888-0333 Business !,
VEHICLE 'I
I
Year: 2007 Body Style: 4D SED VIN: JTDBT923271156931 Mileage In: 109967 �,
Make: TOYO Engine: 4-1.5L-FI License: 421JTW Mileage Out: ���
Model: YARIS Production Date: 4/2007 State: MN Vehicle Out: '
Color: GREEN Int: Condition: Job#:
TRANSMISSION Dual Mirrors SAFETY WHEELS
Overdrive Console/Storage Drivers Side Air Bag Wheel Covers
5 Speed Transmission CONVENIENCE Passenger Air Bag PAINT
POWER Air Conditioning SEATS Clear Coat Paint
Power Steering Intermittent Wipers Cloth Seats
Power Brakes Tilt Wheel Bucket Seats
DECOR Rear Defogger Reclining/Lounge Seats
12/26/2013 3:44:41 PM 014565 Page 1
Preliminary Estimate
'CUstomer: WIRTZFELD, GREG 7ob Number:
Vehicle: 2007 TOYO YARIS 4D SED 4-1.5L-FI GREEN
Line Oper Description Part Number Qty Extended Labor Paint
Price;
1 FRONT BUMPER&GRILLE
2 ** <> Repl A/M Bumper cover 5211952934 1 198.00 1.9 3.0
3 Add for Clear Coat 1•Z
4 Repl Bumper cover clip 904670707122 8 7.84
5 FRONT LAMPS
6 ** Repl A/M CAPA RT Headlamp 8113052750 1 160.00 0.5
7 Aim headlamps 0.5
8 # **Possible Hidden Damage** 1
$UBTOTALS 365.84 2.9 4.2
�
ESTIMATE TOTALS
Category Basis Rate Cost$
Parts 365.84
Body Labor 2.9 hrs @ $52.00/hr 150.80
Paint Labor 4.2 hrs @ $52.00/hr 218.40
Paint Supplies 4.2 hrs @ $32.00/hr 134.40 �
Subtotal 869.44 I,
Sales Tax $500.24 @ 7.2750% 36.39 !
Grand Total 905.83
Deductible 0.00 �I
CUSTOMER PAY 0.00 ',
INSURANCE PAY 905.83 �I
"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.
12/26/2013 3:44:41 PM 014565 Page 2
Preliminary Estimate
`Customer: WIRTZFELD, GREG 7ob Number:
Vehicle: 2007 TOYO YARIS 4D SED 4-1.5L-FI GREEN
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
ARM8327, 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 Num!bers 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 j
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 �I
be repaired or replaced:
SYMBOLS FOLLOWING PART PRICE: I
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 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.
12/26/2013 3:44:41 PM 014565 Page 3
Preliminary Estimate
� Customer: WIRTZFELD, GREG 7ob Number:
Vehicle: 2007 TOYO YARIS 4D SED 4-1.5L-FI GREEN
ALTERNATE PARTS SUPPLIERS
Supplier: Wheelers Auto Body Supply
Location(s): 6150 CLAUDE WAY, INVER GROVE HEIGHTS MN 55076 (866)435-7015 (651)379-0808
Line Description Item# Price
2 A/M Bumper cover T01000321E $ 198.00
Supplier: Keystone-Complete-Minneapolis
Location(s): 3615 MARSHALL STREET NE, MINNEAPOLIS MN 55418 (800)328-1845 (612)789-1919
Line Description Item# Price
6 A/M CAPA RT Headlamp T02519108C $ 160.00
1
1
12/26/2013 3:44:41 PM 014565 Page 4
MAACO COLLISION REPAIR&AUTO PAINTING
81 WENT WORTH AVE E
WEST ST. PAUL, MN 5518
OFFICE 651-455-0003 FAX 651-455-0014
***PRELIMINARY ESTIMATE**"
12/31/2013 10:34 AM
Owner �
Owner: GREG WIRTZFELD
Address: 319 WINNEFRED ST E Work/Day: (651)757-6607
City State Zip: West Saint Paul, MN 55107 FAX:
,_ ._____._____�__..�
� Inspection
Inspection Date: 12/31/2013 10:36 AM Inspection Type:
i Repairer
Repairer: MAACO COLLISION REPAIR Contact: RICK TOBOZ
Address: 81 WENTWORTH AVE EAST Work/Day: (651)455-0003
Ciry State Zip: WEST ST PAUL, MN 55118 FAX: (651)455-0014
Email: aaron.maacostpaul@gmail.com
' Vehicle
2007 Toyota Yaris STD 4 DR Sedan
4cyl Gasoline 1.5
4 Speed Automatic
Lic Expire: VIN: JTDBT923271156931
Veh Insp#: Mileage Type: Actual
Condition: Code: Y1453A
Ext. Refinish: Two-Stage Int.Refinish: Two-Stage
Options
Air Conditioning Bucket Seats Center Console
Dual Airbags Intermittent Wipers Lighted Entry System
Mud/Splash Guards Power Brakes Power Steering
Rem Trunk-L/Gate Release Tachometer Tilt Steering Wheel
Tinted Glass Velour/Cloth Seats
_____.__.___ �.. _..._ .._..._._ _.._.� _ .w.,... _.,W_..__. u�,
!; Damages
Line Op Guide MC Description MFR.Part No. Price ADJ% B% Hours R
Front Bumpgl
1 EC 6 Cover,Front Bumper Replace Economy $198.00' 1.5 SM
2 L 6 13 Cover,Front Bumper Refinish 3.8 RF
3 RI 32 Grille,Frt Bumper Lwr R&I Assembly INC SM
4 RI 30 Emblem,Frt Bmpr Cover R&I Assembly 0.2 SM
5 RI 9 Filler,Front Bumper LT R&I Assembly 0.2 SM
12/31/2013 1038 AM Page 1 of 3
2007 Toyota Yans STD 4 DR Sedan
Claim#: ' 12/31/2013 10:34 AM
6 RI 10 Filler,Front Bumper RT R&I Assembly 0.2 SM
Front End Panel And Lamos
7 N 973 Headlamps Aim Additional Labor 0.4 SM
8 EC 42 Lens,Headlamp RT Replace Economy $160.00" 0.2 SM
8 Items
MC Message
13 INCLUDES 0.6 HOURS FIRST PANEL TWO-STAGE ALLOWANCE
-- --------__.�__��___________.___�_�_.____.
' Estimate Total&Entries
Other Parts $358.00
Paint Materials $121.60
Parts&Material Total $479.60
Tax On Parts Only @ 7.125% $25.51
Labor Rate Replace Repair Hrs Total Hrs
H rs
Sheet Metal(SM) $54.00 2.3 0.4 2.7 $145.80
MechlElec(ME) $75.00
Frame(FR) $75.00
Refinish (RF) $54.00 3.8 3.8 $205.20
Paint Materials $32.00
Labor Total 6.5 Hours $351.00
Gross Total $856.77
Net Total $856.11
Altemate Parts Y/00/00/00/00/00 CUM 00/00/00/00/00 Zip Code:00000 Default '
SPPL Yes Zip Code:55118 Default
I
Audatex Estimating 7.0.123 ES 12/31/2013 10:38 AM REL 7.0.123 DT 11/01/2013
Copyright(C)2013 Audatex North America, Inc.
1.7 HRS WERE ADDED TO THIS ESTIMATE BASED ON AUDATEX'S TWO-STAGE REFINISH FORMULA. �
THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF ONE OR MORE CRASH PARTS
SUPPLIED BY A SOURCE OTHER THAN THE MANUFACTURER OF YOUR MOTOR VEHICLE.
WARRANTIES APPLICABLE TO THESE REPLACEMENT PARTS ARE PROVIDED BY THE PARTS
MANUFACTURER OR DISTRIBUTOR RATHER THAN BY THE MANUFACTURER OF YOUR VEHICLE.
A PERSON WHO FILES A CLAIM WITH INTENT TO DEFRAUD OR HELPS COMMIT A FRAUD
AGAINST AN INSURER IS GUILTY OF A CRIME.
Op Codes
` = User-Entered Value E = Replace OEM NG= Replace NAGS
EC= Replace Economy OE= Replace PXN OE Srpls UE= Replace OE Surplus
12/31/2013 10:38 AM Page 2 of 3
2007 Toyota Yans STD d DR Sedan
C�yu�+=� � 12/31/2013 1034 AM
ET = Partial Replace Labor EP= Replace PXN EU= Replace Recycled
TE = Partial Replace Price PM= Replace PXN Reman/Reblt UM= Replace Reman/Rebuilt
L = Refinish PC= Replace PXN Reconditioned UC= Replace Reconditioned
TT = Two-Tone SB= Sublet Repair N = Additional Labor
BR= Blend Refinish I = Repair IT = Partial Repair
CG= Ch�pguard RI = R&I Assembly P = Check
AA= Appearance Allowance RP= Related Prior Damage
This report contains proprietary information of Audatex and may not be disclosed to any third party(other than
the insured,claimant and others on a need to know basis in order to effectuate the claims process)without
�udatex Audatex's priorwritten consent.
.�,�����
Copyright(C)2013 Audatex North America, Inc.
Audatex Estimating is a trademark of Audatex North America, Inc.
12/31/2073 10:38 AM Page 3 of 3