Zabinski NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipa[ity...shall cause to be presented to the
governing body of the municipality within 180 days after the alleged loss or injury is discovered a notice stating the time,place,and
circumstances thereof,and the amount 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 yonr 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 ��.�( Middle Initial � Last Name L-��.., ��i R Ff F /�
Company or Business Name i e�i �� �ML
� �.., �
Are You an Insurance Company? Yes/� If Yes,Claim Number?
� �
Street Address �1�'u ������ �,;z �#��� [�� T
City�k �-: �I State ���^J Zip Code `�S � G
Daytime Phone(�)��- � �hGj� Cell Phone(�L)` U_-v'?�� Evening Telephone(_) -
Date of Accident/Injury or Date Discovered ������ Time � ��� /pm
Please state,in detail, what occurred(happened), and why you are submittin.g a claim.Please indicate why or how you
feel the City of Saint Paul or its employees are involved and/or responsible for your damages. '' ti���- �r✓� _
' '� z ,,.,, ,c . � 1 ,-' is- s�., v.c� '.�rr� � �d z
t 0� G,� �+t i,.1 H c.� ' ' •� �d.�.0 f.� ✓�- M ��i C i c+�C r n� rJtu�
'1 t� f 5 �.b�✓� �'!i 0�' li� !� 1+�- Ll�L✓n 0' �iv�� ti�^L�/� � L 1� ' i n h_ 1.� � �'�.L l k S I l L.
i. r � � �.,�a �.�.� ,. �.#'� �'4 �.'�r�. M UHS �
� �
, I I
J i ��'un n� i 5�- Su✓�- � '� /d�.rl� �JL 6n '�- EH�} S�/!�t �� �•�t rU��•
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 I�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 vou need to include copies of all auulicable 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 WII..L NfST be returned and become the property of the City. You are encouraged to keep a
copy for yourself before submitting your claim form.
S.�'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
-�hotographs 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-please complete this section
Were there witnesses to the incident? Yes T� Unknown (circle)
Provide their names,addresses and telephone numbers:
Were the police or law enforcement called? Yes (�' 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,
� , n Sk r st,�F S o
closest landmark,etc. Please be as detailed as possible. ff necessary, attach a diagram. � A��L�c �
;,, SF ('�.�� bzk�«� i����l� A�� � G��d A�c
Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction. I ,� �1 �c �� �. �a� i.v U L f t,� �- �X ��'�
.M� w�; � I sg�:3�1
Vehicle Claims- lease com lete tlus section ❑ check box if this section does not a 1
Your Vehicle: Year 200� Make M :zdti Model yd4�c � 5
License Plate Number 5�`� 17 VX State 'r��l _Color (�cJ� -
Registered Owner ��'c,l ZH� �����
Driver of Vehicle i-Js.��'� �l�`v'.�h �.l- -� �'iMc
AreaDamaged�.v��- ����trs s���,�� dou� �Lh��V�tW /���I
City Vehicle: Year Make Model
�n����� License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniurv Claims please complete this section �check box if this section does not anulv
How were you injured?
What part(s)of your body were injured?
Have you sought medical treatment? Yes 1�10 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 this form,you are stating that all information you have provided is true and correct to the best
of your knowledge. Unsigned forms will not be processed.
Submitting a false claim can result in prosecution. Date form was completed �"Z S-��
Print the Name of the Person who Completed this Form: !���_�� S Z��O�n sl.�;
,,�-� �—' � '
Signature of Person Making the Claim: ll� .
Revised February 2011
LATUFF BROS., INC.
880 UNIV RSITY AVENUE
ST. PAUL, �INNESOTA 55104
(651)224-2828 FAX: (651)291-0677
FEDERAL ID#41-0777034
�'*PRELIMINARY ESTIMATE**"`
12/31/2013 02:41 PM
Owner ----------:
Owner: DAN ZABINSKI
Address: 908 GRAND AVE Work/Day:
CeIL (612)968-0563
City State Zip: Saint Paul, MN 55105 FAX:
� Inspection
Inspection Date: 12/31/2013 02:39 PM Inspection Type: Drive In
Inspection Location: Latuff Brothers Inc Contact:
Address: 880 University Ave Work/Day: (651)224-2828x
FAX: (651)291-0677x
City State Zip: Saint Paul, MN 55104 Work/Day:
Email: general@latuffbrothers.com
Driveable: Yes Rental Assisted:
Appraiser Name: ROBERT LATUFF Appraiser License#:
,__ —-- -,
Repairer
�-- ------- ------- ---- -------------- ----------_ _-----------...-----
Repairer: Latuff Brothers Inc Contact:
Address: 880 University Ave Work/Day: (651)224-2828
FAX: (651)291-0677
City State Zip: Saint Paul, MN 55104 WorklDay:
Email: general@latuffbrothers.com
Target Complete Date/Time: Days To Repair: 3
----
' Remarks ----------- --'
�-.- — ---..— -_ -------- ---
"***""'***PRELIMINARY ESTIMATE""""'��"""`�"
POSSIBLE ADDITIONAL DAMAGE MAY BE FOUND AFTER TEAR DOWN
— -- ----
r Vehicle -----_-''
2002 Mazda Protege5 STD 4 DR Hatchback
4cyl Gasoline 2.0
4 Speed Automatic
Lic.Plate: 584DUX Lic State: MN
Lic Expire: VIN: JM1BJ246X21485325
Prod Date: 06/2001 Mileage:
Veh Insp#: Mileage Type: Actual
Condition: Code: D1174F
Ext.Color: CLASSIC RED Int.Color:
Ext. Refinish: Two-Stage Int. Refinish: Two-Stage
Ext.Paint Code: A3E Int.Trim Code:
Options
Page 1 of 3
12/31/2013 02:44 P M
2002 Maztla Protege5 STD 4 DR HalchDack
Claim#: 12/31/2013 02�.41 PM
AM/FM CD Player Air Conditioning Aluminum/Alloy Wheels
Center Console Cruise Control Dual Airbags
Fog Lights Intermittent Wipers Keyless Entry System
Leather Steering Wheel l.ighted Entry System Power Brakes
Power poor Locks Power Mirrors Power Steering
Power Windows Rear Spoiler Rear Window Defroster
Rear Window Wiper/Washer Rem Trunk-L/Gate Release Roof/Luggage Rack
Split Folding Rear Seat Tachometer Tilt Steering Wheel
Tinted Giass Velour/Cloth Seats
Damages
Line Op Guide MC Description MFR.Part No. Price ADJ% B% Hours R
Stripes And Mouldings
1 RI 241 MIdg,Front Door Side LT R& I Assembly INC SM
Front Doors
2 L 207 13 Door Assembly,Front LT Refinish 4.4 RF
2.2 Surface
1.0 Edge
0.6 Two-stage setup
0.6 Two-stage
3 E 207 Door SheIl,Front LT BJOG59020D $641.57 4.7 SM
4 E 239 Tape,Front Door LT BL2C508W100 $23.52 0.2 SM
5 E 257 Tape,Front Door LT BL2C508W300 $10.66 0.1 SM
6 E 438 Tape,Front Door LT BL2C�508W500 $15.94 0.2 SM
7 E 467 Tape,Front Door LT BL2C508W700 $4.23 0.1 SM
8 E 469 Tape,Front Door LT BL2C5088100 $9.10 0.1 SM
9 E 402 01 Mirror,0uter R/C LT BN6B6918008 $129.71 INC SM
Manual Entries
10 SB M60 Hazardous Waste Removal Sublet Repair $5.00* SM
11 EC CLEAN AND REBACK SD MLDG Replace Economy $3.00` 0.3* SM*
11 Items
MC Message
01 CALL DEALER FOR EXACT PART#/PRICE
13 INCLUDES 0.6 HOURS FIRST PANEL TWO-STAGE ALLOWANCE
------ - ------------- - -------------------.-..____--.._..--------- _---------------..._ ___ _
' Estimate Total 8�Entries '
Gross Parts $834.73
Other Parts $3.00
Paint Materials $140.80
Parts &Material Total $978.53
Tax on Parts 8 Material @ 7.625°/o $74.61
Labor Rate Replace Repair Hrs Total Hrs
H rs
Sheet Metal (SM) $52.00 5.7 5.7 $296.40
Mech/Elec(ME) $85.00
Frame(FR) $75.00
Refinish (RF) $52.00 4.4 4.4 $228.80
Paint Materials $32.00
12/3'I/2013 02:44 PM Page 2 of 3
2002 MazCa Protege5 STD 4 DR Halchback
Claim tl�. 12l31/2013 02:41 PM
Labor Total 10.1 Hours $525.20
Sublet Repairs $5.00
Gross Total $1,583.34
Net Total $1,583.34
Alternate Parts No
SPPL Yes Zip Code: 55104 Default
Audatex Estimating 7.0.123 ES 12/31/2013 02:44 PM REL 7.0.123 DT 11/01/2013 DB 12/15/2013
Copyright(C)2013 Audatex North America, Inc.
1.2 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
SUFPLIED BY A SOURCE OTHER THAN THE MANUFP_CTURER 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
ET = Partial Replace Labor EP= Replace PXN EU = Replace Recycled
TE = Partiat Replace Price PM= Replace PXN Reman/Reblt UM= Replace Reman/Rebuilt
L = Reflnish 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= Chipguard 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
,��a- the insured, claimant and others on a need to know basis in order to effectuate the claims process)without
��t ����'�3� Audatex's prior written consent.
��
,,.���;� ,:,t
���� Copyright{C)2013 Audatex North America, Inc.
Audatex Estimating is a trademark of Audatex North America, Inc.
12/31/20�3 02.44 PM Page 3 0(3
HEPPNERS AUTO BODY (Midway) Workfile ID: 2b86143b
�w� 400 SYNDICATE ST. N., SAINT PAUL, MN 55104
. •
Phone: (651) 646-8615
FAX: (651) 645-3230
Preliminary Estimate
Customer: ZABINSKI, DANIEL 7ob Number:
Written By:JON MARTENS
Insured: ZABINSKI, DANIEL Policy#: Claim#:
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact:
Owner: Inspection Location: Insurance Company:
ZABINSKI, DANIEL HEPPNERS AUTO BODY(Midway) OTHER PARTY
908 GRAND AVE # Bl 400 SYNDICATE ST. N.
ST PAUL, MN 55105 SAINT PAUL, MN 55104
(612)968-0563 Business Repair Facility
(651)646-8615 Day
VEHICLE
Year: 2002 Body Style: 4D H/B VIN: JM1B]246X21485325 Mileage In:
Make: MAZD Engine: 4-2.OL-FI ! License: 584DUX Mileage Out:
Model: PROTEGE 5 Production Date: State: MN Vehicle Out:
Color: RED Int: Condition: Job#:
TRANSMISSION Console/Storage FM Radio SEATS
5 Speed Transmission CONVENIENCE Stereo Cloth Seats
POWER Air Conditioning CD Player Bucket Seats
Power Steering Intermittent Wipers SAFETY Reclining/Lounge Seats
Power Brakes Tilt Wheel Drivers Side Air Bag WHEELS
Power Windows Cruise Control Passenger Air Bag Aluminum/Alloy Wheels
Power Locks Rear Defogger Anti-Lock Brakes(4) PAINT
Power Mirrors Keyless Entry 4 Wheel Disc Brakes Clear Coat Paint
DECOR Rear Window Wiper Front Side Impact Air Bags OTHER
Dual Mirrors RADIO ROOF Fog Lamps
Body Side Moldings AM Radio Luggage/Roof Rack Rear Spoiler
12/31/2013 3:29:43 PM 050503 Page 1
Preliminary Estimate
Customer: ZABINSKI, DANI�L )ob Number:
Vehicle: 2002 MAZD PROTEGE 5 4D H(B 4-2.OL-FI RED
Line Oper Description Part Number Qty Extended Labor Paint
Price$
1 FRONT DOOR
2 Repl LT Door sheil BJOG59020D 1 641.57 4.0 3.0
3 Add for Clear Coat 1.2
4 Add for mirror power 0.4
5 Add for power units 0.4
6 Repl LT Mirror assy w/power w/o body B)OG69180A 1 184.23 Incl.
color
7 # Subl HAZARDOUS WASTE REMOVAL 1 5.00 X
8 # RESTORE CORROSION 1 0.2
PROTECTION
9 R&I LT Body side mldg w/o DX sedan 0.4
classic red
10 # Refn BAG/CAR COVER 0.2
SUBTOTALS 830.80 5.2 4.6
ESTIMATE TOTALS
Category Basis Rate Cost$
Parts 825.80
Body Labor 5.2 hrs @ $55.00/hr 286.00
Paint Labor 4.6 hrs @ $55.00/hr 253.00
Paint Supplies 4.6 hrs @ $35.00/hr i61.00
Body Supplies 4.0 hrs @ $3.00/hr 12.00
Miscelianeous 5.00
Subtotal 1,542.80
Sales Tax $986.80 @ 7.6250% 75.24
Grand Total 1,618.04
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 1,618.04
THIS IS A VISUAL ESTIMATE ONLY. ADDITIONAL PARTS AND LABOR MAY BE EXTRA UPON TEARDOWN. PART
PRICES SUBJECT TO INVOICE.
NO GUARANTEE ON RUST REPAIR!
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.
12/31/2013 3:29:43 PM 050503 Page 2
Preliminary Estimate
Customer: ZABINSKI, DANEEL Job Number:
Vehicie: 2002 MAZD PROTEGE 5 4D H/B 4-2.OL-FI RED
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
AEH5416, CCC Data Date 1Z/16/2013, and the p?rts selected are OEM-�arts 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 OENi or ALT vEPs parts rri�y inciude 'Blemisned" parts provided by OEM`s through OEM vehicie 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 Quatity. LT=Left. MAG=Magnesium. Non-Adj.=Non
Adjacent. NSF=NSF Internationa) 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 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.
12/31/2013 3:29:43 PM 050503 Page 3
`���``c��,1��,�
���
,
�:� � ' "
��.
M � � �- �
�� �
�� �t
� t��
� . ,,,�'�"�'�,
�� ,
�
� � �� �
v:�
�`�a
.-
. .�. _�. N
'g �� . .�_x
� ` „- �; v
m� �,
x � ��
!� "� �� '.-` .
��` �t
�� � �,
r
'�' JM"'%�,
� �
§;4�
� : � . ,��. : `= ��
:.�,.So; ., . £ _ ,� . ,
` _'r y�e�,� �
� &� e� ��
+�t� �
—— ,x�� � ' ;`�, — - �.
. 3
�'��
� �a: .� _.
._=�rt�,,.w,s.-__.:�..__.�-:......, :
.
ZC�c.�V'c1`���
��
�
\
�
��X
��;� 4� ;
��
��'���5 ��.���'-
�:�� a�
�
� � �r � �� �'
� ���
� ,���i �
�,�;�-
�� ��:
� ,� �
- �� ����
r�
.
� �
��� � �
: � �� , .
, � �°� � ��
HI�� ���, � �
�.
°}.
�
�
� �� ���� �
����� �-�
:�
'" �,.
�
.'��''�k�..
��av2
�, .
¢ Ps..
5� f•
����. ��� �, ,
� L��
Yy