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NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Lfrnnesota S�crle S�ntute=166.0�slaies thaf " ...c i•ery person...�alro c/uim,r dmna�es fi•om nny naunicipaliry...slrnl/c�nrse to he presented�u thc
�,ni�erning ho�/j;qf the miu�rcipnlit7,�vi!lrin /80 days uftei•r/te a!le;ed lo.rs or ir jury is discovei-ed a nolrce stntin�the lime./�lace. nnd
circirm�tnnce.c ther-eof,and tlre nm�i�nt�fcompensa[ion or other relief derna��ded...
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 may or may not be contacted by telephone to discuss your claim
circumstances,so provide as much information as necessary to explain your claim,and the amount of compensation being
requested. This form must be signed,and both pages completed. If something does not apply,write`NiA'.
SEND COMPLETED FORM AND OTHER DOCUMENTS TO:
CITY CLERK, 15 WEST KELLOGG BLVD,310 CITY HALL, SAINT PAUL, MN 55102
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First Nan�e �(�'�, C,� l� Middle Initial �Last Name �C��,1 ��������
Company or Business Name, if applicable JAN 22 2014
Street Address _ �+�TY�.� FRK
C � Ap
City J , 'Pt1�1� State Iv`Qj(�,n�PrSc�`�� Zip Code 5511�
Daytime Telephone (�oS � ) a.3� — (•�� �� Evening Telephone ( C��VV� �
Date of Accident/ Injury or Date Discovered ��-"'�� '"�� Time J�:O�_am /pm (circle)
Please state, in detail, what occurred, and why you are submitting a claim. Please indicate why or how you
feel the City of Saint Paul or its employees are involved and/or responsible.
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Please check the box(es) that most closely represent the reason for completing this foim:
❑ Vehicle was damaged in an accident � Vehicle was damaged during a tow
❑ Vehicle was damaged by a pothole or condition of the street ❑ Vehicle was damaged by a plow
(� Vehicle was wrongfully towed and/or ticketed ❑ Injured on City property
❑ Other type of property damage—please specify
❑ Other type of injury—please specify
❑ Other type not listed—please specify
In order to process your claim youu need to include copies of all applicable documents. This is a general
guideline of what should be submitted with a claim form, but it is not all inclusive. You inay be asked to
provide additional infonnation depending on your cl�im.
O Property damage claims to a vehicle: at le�st two estimates for the repairs to your vehicle, or the
actual bills and/or receipts for the repairs
O Towing claims: legible copies of any tickets issued and copies of the iinpound lot receipts
O Other property dainage: repair estimates, detailed list of damaged iteins
O Injury claims: medical bills, receipts
O Photo�-aphs can be provided but will not be returned.
Page 1 of 2 — Please complete and return both pages of Claim Form
Failure to provide a completed claim form will result in delays in processing.
Notice of Claim Form, City of Saint Paul, page two
All Claims — please complete this section�y
Were there witnesses to the incident? es No Unknown (circle)
If yes, please provide their names, addresses and telephone nuinbers:
'�'o r a P, 1�_�c4 �_�r �3 S S�(G m c�t� �,�1- P.cn�� 5� 'PaJ i J"��I�
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Were the police or law enforcement called? Yes No 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 e as de ailed as possible. If helpful, attac a diagram. `
1n, Fr � c1F � S u s r s
� � tir ��t SS' l 1
Please indicate e amount you are seeking in c mpensation froin this claim or what you would like the City
to do to resolve this claim to our satisfaction. l,�•S r}�1
F� �1 G�
Vehicle Claims— alease complete this section ❑ check box if this section does not apply
Your Vehicle: Year 1 �l Make 44 Utievva it� Model l�,�,����V
License Plate Number T State �lN Color Q �4,c. k,
Registered Owner ' t�.c;S G �Uvt„� 6
Driver of Vehicle C`cv L� o , p�,� S .
Area Damaged (.C U,VLC —Y6(n- btJv✓�,1��i/�
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle (City Employee's Name)
Area Damaged
In'ur Claims — lease com lete is section ❑ heck box if this section does ot a lv
How w you i ure . f be �� (�
�e .� r,.
What part s o ou bo y re i jur d?
H ve yo s u ht ed� al treati nt? es No Pla nin to S k T e e t (cir 1
Wh n id recei e trea m t? ( r vid date(s
Nanz f M dical ro -ider .
d res el h ne
�d you i ss ork as a r ul o our in'ur � es o
hen did y niss work;. (p o i e dat s)
� ame of ui mployer� i
A dress � Telephon
❑ Check here if you are attaching more pages to this claim form. Number of additional pages
Bt'si�nin�;this form,you are stating thut all infornratian you hnve provided is true and co�•rect to the besr of yOUY ICJ70N�ledge. Unsigned
fi��•ms tivil! irnt he processed. Suhmitti�rg u fu/se claim cun result i�r prosecutiar.
Print the 1\Tame of the Person who Completed this Form:
Signature of Person Making the Claim:
Date form was completed R��;Sed A�,-;i;���
' GREGG'S AUTO BODY Workfile ID: 17b0a5de
` FederalID: 411353442
HONEST AND CONSISTENT QUALITY
581 E. 7th Street, St. Paul, MN 55130
Phone: (651) 774-8211
FAX: (651) 774-0174
Preliminary Estimate
Customer: SOLIS REYES, FRANCISCO
Written By:Gregg Rosenberger
Insured: SOLIS REYES,FRANCISCO Policy#: Claim#:
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact: 12 Front
Owner: Inspection Location: Insurance Company:
SOLIS REYES, FRANCISCO GREGG'S AUTO BODY
139 E SYCAMORE ST# 1 581 E.7th Street
ST PAUL, MN 55117 St. Paul, MN 55130
(651)230-4155 Cell Repair Facility
(651)774-8211 Business
VEHICLE
Year: 1999 Body Style: 4D SED VIN: 1G1NE52M6X6262688 Mileage In:
Make: CHEV Engine: 6-3.iL-FI License: Miieage Out:
Model: MALIBU LS Production Date: State: Vehicle Out:
Color: Int: Condition: Fair Job#:
TRANSMISSION Dual Mirrors AM Radio Bucket Seats
Automatic Transmission Body Side Moldings FM Radio WHEELS
Overdrive Console/Storage Stereo Aluminum/Alloy Wheels ;
POWER CONVENIENCE Search/Seek PAINT ',
Power Steering Air Conditioning Cassette Clear Coat Paint �
Power Brakes Intermittent Wipers SAFETY OTHER
Power Windows Tilt Wheel Drivers Side Air Bag Fog Lamps
Power Locks Cruise Control Passenger Air Bag Power Trunk/Gate Release
Power Mirrors Rear Defogger Anti-Lock Brakes(4)
Power Driver Seat Keyless Entry SEATS
DECOR RADIO Cloth Seats
1/2/2014 9:41:50 AM 034178 Page 1
� •
' Preliminary Estimate
Customer: SOLIS REYES, FRANCISCO
Vehicle: 1999 CHEV MALIBU LS 4D SED 6-3.iL-FI
Line Oper Description Part Number Qty Extended Labor Paint
Price$
1 FRONT BUMPER
2 Repl Bumpercover 12463112 1 302.27 1.4 3.0
3 Add for Clear Coat 1•2
4 Add for fog lamps 0.4
5 REAR BUMPER
6 Repl Bumper cover 12463199 1 333.82 2.0 3.0
7 Add for Clear Coat _ 1.2
8 QUARTER PANEL _ __
9 Repl LT Quarter panel 89024827 1 596.67 14.5 3.4
10 Add for Clear Coat 1.4
11 Deduct for Rear Bumper R&I -1.6
12 # Car Cover 1 0.2
13 # Refn Corrosion Protection 0.5
14 # Subl Hazardous Waste 1 5.00 X
SUBTOTALS 1,237.76 16.7 13.9
ESTIMATE TOTALS
Category Basis Rate Cost�
Parts 1,232J6
Body Labor 16.7 hrs @ $55.00/hr 918.50
Paint Labor 13.9 hrs @ $55.00/hr 764.50
Paint Supplies 13.9 hrs @ $35.00/hr 486.50
Miscellaneous 5.00
Subtotal 3,407.26
Sales Tax $ 1,719.26 @ 7.6250% 131.09
Grand Total 3,538.35
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 3,538.35
GREGG'S AUTO BODY takes great care to ensure that every repair meets our standards for quality. GREGG'S AUTO
BODY guarantees labor performed for as long as you own your vehicle on workmanship and wiil, at our expense
repair or correct all defects which are attributable to defective or faulty workmanship in the repairs stated on the
repair invoice. This guarantee covers labor only and does not apply to parts, materials or equipment which may be
covered by and subject to terms of manufacturer or vendors warranty. This guarantee does not include damage
caused by or resulting from rust or corrosion, unreasonable use, improper maintenance or care of the vehicle.The
above is an estimate based on our inspection and does not cover additional parts or labor which may be required
after the work has been opened up.Parts price subject to change without notice. YOU HAVE A RIGHT TO CHOOSE A
REPAIR FACILITI'OF YOUR CHOICE. WE GREATLY APPRECIATE YOUR BUSINESS.
1/2/2014 9:41:50 AM 034178 Page 2
' . Preliminary Estimate
Customer: SOLIS REYES, FRANCISCO
Vehicle: 1999 CHEV MALIBU LS 4D SED 6-3.1L-FI
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.
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
DE1CP97, 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 (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.
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 clescribe 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=6oron 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.
1/2/2014 9:41:50 AM 034178 Page 3
AA Auto Repair LLC INVOICE
102 E Acker St
St.Paul MN 55117
651-797-9006
www.aaautorepairmn.com INVOICE#565
aaautorepairmn@gmaii.com DATE:i/8/2014
TO:FRANCISCO SOLIS REYES
139 E SYCAMORE 5T#1
ST.PAUL MN 55117
6512304155
1999 CHEVY MALIBU
DESCRIPTION HOURS RATE AMOUNT
Front Bumper Cover 302.27
Rear Bumper Cover 333.82
L Quarter Panel 596.67
Body Labor 16.5 50 825.00
Paint Labor 14 50 700.00
Paint Supplies 425.00
Total 3182.76
Tax 125.99
TOTAL $3308.75
Make all checks payable to AA Auto Repair LLC
Total due in 15 days.Overdue accounts subject to a service charge of 19'a per month.
THANK YOU FOR YOUR BUSINE55!
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