Herrick � ��Es������:��@�� -r�r �€���� E��Q���� ��� ��a€���� �� ����r a�� ������ ��€�� " ' .
�r--,T"--r• . ""!"`y, �
ll�linnesota State Sratute 466.05 NOTICE OF CLAIM...(E)veiy,oerson..�.who c/aims damages fiom any
municipality...shall cause to be p�esented to the goveming body of the munic,�'�'t� �i��}180 days arte� rhe
alleged loss or iniury is discove�e.d a n�tice stating the time, place, an.d circumstances ihe�eof, and rthe amaunt or'
compensation or other relief demanded. CI�TY CLERK
Flease complete this fori�� in its entirety by typing or p�inting your answer to each q�estion ir�
tl�e space provided. If additional space is needed, please attach additional sheets.
, -=;,
r' � = PLEASE RETURfV THIS Office of City Clerlc
Y �� COMPLETED FORM T0; 170 City Hall
15 W ICellogg Bivd
St Paul MN 55�02
Your Name: ' � � }�`'�r��,�� __
- Street-Addiess: - --.---- --- -__--- --_..__ _ __ _ - — _ ___.. . .__.. __._.
1� I �-� --`)-���'Y�4Y�=�,'-_ �Y-a-r �--. .. �} . _
c�tv: S`�11���1� State: �� z�� code: `�Z
Daytime Telephone: __(�(,'�Zl �;5�( ?i�}"(p� Evening Telephone: �_�__Nl�c
Date of Accident or Incident: IZ�QS ZD��Day of Weel<: ���(�S� Time; �•�� am or pm (circie one) ,
Please state, in detail, wf�at occurred and tl�e circumstances surrounding the event. Indicate how the
City of Saint Paul, is involved, and why you feel the City is responsibie, , ,
1� �ti � C� � ,�, , �,
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� �JC '�� G� 1 ��
Please indicate your reason for completing this forrr�:
;�
L.:l Vefiicle accident � Other property damage (please provide specifics b21ow) ;:;�1;
� Vehicle was towed ����I(�-er bDG�y C� a�!�(�� tD �f��I��� �'�1�� ';�I;
` 1�1.R(7?�pp'►� i i�
❑ Vef�icle damaged ❑ Otf�er injury to person (please provide specifics below) Y`� , �i�
• i�.
� Slipped and fell on City property 'i' `
��
i: ;
Please provide the names and telephone numbers of any City employees involved in this i `
incident/accident and how they were involved: ;
�
�
(over) '
� .
�
If your vehicle �n�as involved, please complete �he follo�n�ing;
1'ear, mal<e, and model: ZOO I ����/���fi�1��D11� � r'� \o Licer�se Plate (Vumber: 5�..� Qs� '
Extent and area damaged: �(�Q�1� 1,�1Y���� � .C�V C�1�dU,� �Y�C'ih� �?\.(t'�'►�P�(
Was a City vehicle involved in this accident/incident? 1'e No (circle one)
If yes, please compiete the following: Type of vehicle � (�j� 1 r�/4,L1�'�
Year, make, and model N �/�t
Color of vehicle N f� License Plate Number: N �Ik-
Description of vehicle ��� ��' ,�li�� �C�I,L_I_
Location of accident/incident (please ��rovide specifics sucl� as street address, intersection, cross streets,
park name, facility name; etc.): , �
( '11 C� U^v�S �. 1'Y-E' 1 � I Y� �r'1 D� d Y�
�� '� �1' t � 1� Y�L T.n C i''1� ���2: o r'
���
_ Flease draw..or attach a diagram_.i_f a�plicable:
_. _�___. --- _ --- -- - -- - ---- -�_ ---- ___ _ _ — ---- - .---. _ _
.
� ������ ��� a�-acin-�d �n��c��� .
w fin� f��,+� � �m d.c e� ci�� �� �� 1� v����� hc� y
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�er�e ��� cra��s , o�,� .�s , ��►nt- ch,Ps � �� � .
�c����cne� .
� �
Please specify the nature and extent of tl�e compensation or other relief you are requesting. Please
attach copies of any bills, receipts, ticicets, or other documents to support your claim, If you are
claiming damage to a veliicle, please submit two esti ates.
��P:�� � ��e �t��ch� �����, ���Gi�.� �
VVere ther� �r�itnesses to this accident/incident% Yes �o icirc(e one)
If yes, please give the names, addresses, and telephone numbers of the witnesses:
\Nere the police called? Yes �o (circle one) If yes, what department or agency? �
Police report number: -
Please print the name of The
person completing this form: �jr��-� �t'}L-�-^(`��C�
,4
Plea�e sig,n ;�our name; �'���__���� I,
i
Daie form sigred: �� � 2� 2(�'� I
-- �
�
Risl< Mgmt Division - Revised 1-30-01 ������ii�:
; �.F.,�,:I:
;;a::�¢,.�..
-a�:1:�;;;1:
;�;
I
ABRA Auto Body & Glass - WOOC�bUI'y Workfile ID: 310469db
FederalID: 411926323
ABRA...AMERICA'S MOST RECOMMENDED!
8230 Hudson Rd Suite 100, Woodbury, MN 55125
Phone: (651) 738-2272
FAX: (651) 738-9795
Preliminary Estimate
Customer: Herrick, Brooke �ob Number:
Written By: Katie Sorensen
Insured: Herrick, Brooke Policy#: Claim#:
Type of Loss: Date of Loss: 1/7/2014 12:00:00 PM Days to Repair: 2
Point of Impact: 12 Front
Owner: Inspecl
Herrick, Brooke ABRA Ai � ��-�.r �� , '�� � 'l(C �, , ���
r�., C� � � ��
11117 Jasmine Trl. N. 8230 Hi - -�—
Stillwater, MN 55082 Woodbu t�'���(�, �� 1�� , t �a� '�'�'
(612)859-2767 Business Repair F
(651)7: I�L1 i."`- c� � �-1 ��(,'��� y� �C' ��
f�;� �'�-� �£' C���� cl ��1�rY� �
� �� � t� �n� ��� y s����
Year: 2001 Body Style: .p
Make: CHEV Engine: �) �� � l. � �L'�J�
Model: MONTE CARLO SS Production Date: �( 1
Color: SILVER Int: BLACK Condition: ` '���1� y�l%'t .
-�r���� -�t�rn� �
TRANSMISSION Console/Stora
Automatic Transmission Overhead Cor
Overdrive CONVENIEN eats
POWER Air Conditionir
Power Steering Intermittent V ieels
Power Brakes Tilt Wheel
Power Windows Cruise Control
Power Locks Rear Defogge
Power Mirrors Keyless Entry • --y--
DECOR Steering Whe�
Dual Mirrors RADIO
Body Side Moldings AM Radio Release
',
1/14/2014 9:59:21 AM 057558 Page 1
�
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i
Preliminary Estimate
Customer: Herrick, Brooke Job Number:
Vehicle: 2001 CHEV MONTE CARLO SS 2D CPE 6-3.8L-FI SILVER
Line Oper Description Part Number Qty Extended Labor Paint
Price$
1 FRONT BUMPER
2 0/H bumper assy 2.5
3 Repl Bumper cover w/o sport pkg. 12335836 1 364.28 Incl. 2.6
4 Add for Clear Coat 1.0
5 Repl Emblem 10289678 1 44.00 Incl.
6 # Repl �Flex Additive/Adhesion Promoter 1 8.50 T
7 # Hazardous Waste 1 5.00 X
SUBTOTALS 421.78 2.5 3.6
ESTIMATE TOTALS
Category Basis Rate Cost$
Pdrts 408.28
Body Labor 2.5 hrs @ $53.00/hr 132.50
Paint Labor 3.6 hrs @ $53.00/hr 190.80
Paint Supplies 3.6 hrs @ $33.00/hr 118.80
Miscellaneous 13.50
Subtotal 863.88
Sales Tax $535.58 @ 7.1250% 38.16
Grand Total 902.04
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 902.04
WARRANTY VALID ONLY WITH ORIGINAL COPY OF YOUR RECEIPT.
PARTS PRICES ARE SUBJECT TO INVOICE. NO GUARANTEE ON RUST REPAIRS. DELAYS DUE TO PARTS
AVAILABILITY AND INSURANCE COMPANY REINSPECTS CAN AND DO OCCUR, PLEASE UNDERSTAND THAT WE
HAVE LITTLE CONTROL OVER SUCH SITUATIONS, BUT, WE WILL MAKE EVERY EFFORT TO REPAIR YOUR CAR AS
QUICKLY AS POSSIBLE. REPAIR TIMES A°E SASF�J ON FLAT RATE �UIDELFNES AND MAY OR MAY NOT COINCIDE
WITH ACTUAL REPAIR TIME.
*****PAYMENT IS REQUIRED IN FULL FOR VEHICLE TO BE RELEASED!******
*****UNLESS OTHER PRIOR ARANGEMENTS ARE MADE*****
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.
1/14/2014 9:59:21 AM 057558 Page 2
� I
Preliminary Estimate
Customer: Herrick, Brooke Job Number: �
Vehicle: 2001 CHEV MONTE CARLO SS 2D CPE 6-3.8L-FI SILVER
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
DE1CG00, CCC Data Date 1/10/2014, 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=Blend. 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.
1/14/2014 9:59:21 AM 057558 Page 3
SUBURBAN AUTO BODY INC. �Norkfile ID: fe91f757
FederdlID: 41-1443480
2989 COUNTRY DR, LITTLE CANADA, MN 55117
' Phone: (651) 633-8900
FAX: (651)481-0700
Preliminary Estimate
Customer: HERRICK, BROOKE �ob Number:
Written By:Jamie Whitwood
Insured: HERRICK,BROOKE Policy#: Claim#:
Type of Loss: Date of loss: Days to Repair: 0
Point of Impact:
Owner: Inspection Locatiain: Insurance Company:
HERRICK,BROOKE SUBURBAN AUTO BODY INC.
11117 JASMINE TRL N 2989 COUNTRY DR
STILLWATER,MN 55082 LTf'TLE CANADA,MN 55117
Repair Facility
(651)633-8900 Business
VEHICLE
Year: 2001 Body Style: 2D CPE VTN: 2G1WX15K519342095 Mileage In:
Make: CHEV Engine: 6-3.$L-FI License: Mileage Out:
Model: MONTE CARLO SS Production Date: State: Vehide Out:
Color: SILVER Int: Condition: Job#:
TRANSMISSION Console/Storage FM Radio Cloth Seats
Automatic Transmission Overhead Console Stereo Bucket Seats
Overdrive CONVENIENCE Search/Seek Redining/Lounge Seats
POWER Air Conditioning Cassette WHEELS
Power Steering Interrnittent Wipers SAFEIY Aluminum/Alloy Wheels
Power Brakes Tiit Wheel Drivers Side Air Bag PAINT
Power Windows Cruise Control Passenger Air Bag Clear Coat Paint
Power Locks Rear Defogger Anti-Lock Brakes(4) OTHER
Power Mirrors Keyless Entry 4 Wheel Disc Brakes Fog Lamps
DECOR Steering Wheel Touch Controls Front Side Impact Air Bags Traction Control
Dual Mirrors ftADIO Communications System Rear Spoiler
Body Side Moidings AM Radio SEATS Power Trunk/Gate Release
12/27/2013 4:30:56 PM 019966 Page 1
� . - ., ,�. . , . .. �a,i... .r e?k'.' � . ... ..�.'�5�.�$+t��§���� -
= _,- .. .. . . _. - ' - -- - _- . . _ -- —
��� .. :.. ..'a... - .... .._..,� . « . � . �. . -. - .. _.
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.. ., ._ ,:' ..
,_ ��
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Preliminary Estimate
Customer: HERRICK, BROOKE )ob Number:
Vehicle: 2001 CHEV MONTE CARLO SS 2D CPE 6-3.8L-FI SILVER
Line Oper Desaiption Part Number Qty Extended Labor Paint
Prioe;
1 FRONT BUMPER
2 Repl Bumper cover w/o sport pkg. 12335836 1 364.28 2.0 2.6
3 Add for Clear Coat 1.0
4 # Tint to Match 1 0.5
5 # Enivironmental Fee 1 5.00 X
6 # FLIX PARTS PAINT ADDITIVE I 8.00
SUBTOTALS 377.28 2.0 4.1
ESTIMATE TOTALS
��9aY Basis Rate Cost;
�� 372.28
�dY��►' 2.0 hrs @ $54.00/hr 108.00
Paint Labor 4.1 hrs @ $54.00/hr 221.40
Paint Supplies 4.1 hrs @ $34.00/hr 139.40
Body Supplies 2.0 hrs @ $2.00/hr 4.00
Miscellaneous 5.00
Subtotal 850.08
Sales Tax $515.68 @ 7.1250% 36.74
Grand Total ggg,82
Deducdble 0.00
CUSTOMER PAY p,pp
INSURANCE PAY ggg,82
ESTIMATE OPEN TO TEARDOWN, PART PRICES&INSPECTION.
ADDITIONAL COSTS MAY ARISE DURING THE REPAIR PROCESS.
******THIS IS A VISUAL INSPECTION ESTIMATE ONLY******
MN ST 60A.955 - A PERSON WHO FILES A CI.AIM WITH INTENT TO DEFRAUD OR HELPS COMMIT A FRAUD
AGAINST AN INSURER IS GUILTY OF A CRIME.
I
12/27/2013 4:30:56 PM 019966 Page 2
_.. ,. _. :�:
, . , . ,�;:,� - . .
�. .,.. „ ,,..� , ,r._
�, _
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�
Prellminary Estimate
Cwstomer: HERRICK, BROOKE 7ob Number:
Vehide: 2001 CHEV MONTE CARLO SS 2D CPE 6-3.8L-FI SILVER
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
DE1CG00, CCC Data Date 12/16/2013, and the parts selected are OEM-parts manufactured by the vehicles Original
�quipment 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, speciai, 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.
Reeored 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 vehi�les. 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 Mechanicai component. s=MOTOR Structural component. T=Miscellaneous Taxed charge category.
X=Miscellaneous Non-Taxed charge category.
SYMBOIS 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. AIU=Aluminum. A/M=Af�ermarket part. BInd=6lend. BOR=6oron steel.
CAPA=Certified Automotive Parts Association. D&R=Disconnect and Reconnect. HSS=High 5trength Steel.
HYD=Hydroformed Steel. Inc1.=lncluded. LKQ=Like Kind and Quality. LT=Left. MAG=Magnesium. Non-Adj.=Non
Adjacent. NSF=NSF International Certified Part. O/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 ESfIMATING 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.
12/27/2013 4:30:56 PM 019966 Page 3
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