Nay PLC Towing & Recovery
FLATBEO S WHEEL LIFf TOWING OFFice 651-247-9783
JUMP-STARTS,LacKOUrs& F�vc 651-641-1818
PRIVATE PROPERTY IMPOUNOS PLCRECOVERY@YAHOO.COM
PO Box 4025•ST.PAUL,MN 55104
. • a
N�TICE OF CLAIM FURM to the City of Saint Paul, Minnesota
:t-linneso�o Sru1e Statirte�66.(1;srare.s lkcrr "...e�'Cll`�JC7:�U/1...it'Itfl CIQ1117S CICIIIt(IQL'S�O/li(!7!l'NtIUl1Gf7(fIllfj...slr�r!!ctrtrse ra be prese�rted�n die
�Ol'e!'7tf17�Q(70(I)'Of 1IJE'Aittl7lCln(!I!I}'4t'lII1IlT I�Y�I CJ(!l'S!1'ItY/{1C QIIf:�CCI IOST U!'ll�lU:l°1S CIISCOL'C'PC'CJ CI!lOIICE'S!(IH11Lrlhe tinre,pIQCL',rr�rd
circtrnrsrauces lhereof,nnrl tlrc anrniurt of�cot+rpe�u�uion nr otlter retief clenia�arfed."
P�ease complete this form in its entirety by clearl�typing or printing your ans���er to eacl�question. If more space is
needed,attach additional sheets. Please note that}•o� may or may not be contacted by telephone to discuss your claim
circumstances,so prvvide as mucli information as necessary�to explain your claim,aud the amount of compensatinn bcing
reyucstcd. This form must be signc�,a�td both pages compteted. If something does not apply,�vrite`1�/A'.
SEnD C�ti'IPLETED FOR1�I A1�D OTHER DOCGII�ENTS TO:
CITY CLERK, 15 `'VEST KELLOGG BLVD,310 CITY HALL,SAIVT PAUL, NIA 551U2
First Name ��r1 Middle Initial �t Nam� REC E I VE D
Company or Bu.siness Name, i�applicable JAN 2 4 ZO��F
Street Address 396 �- C -�7�
Gity 6 - ��C�,,�,�, State�[]�1/� Zip Code , l�
Daytitne Telephone �( S�/ ) 233-39�� Evening Telephone{_�
Date ofAccident/Injury or Date Discol-ered 1�Iq�l� Time �.2� arn�,'pm (circle)
Please state, in detail, ��vhat occurred, and why you are submitting a ciaim. Please indicate why or ho«�you
feel thc City of'Saint Paul or its employees are invoivecl ancUor responsible_
� c.� � a qP
i
Please check the box(es) that most closeiy represent the reason for completin�this fomi:
❑ Vehicle was damaged in an accident j�Vehicle w�as damaged during a tow
❑ Vehicle was damaged by a pothole or condition of the street ❑ Vehicle was damaged by a plow
C7 Veliicle wa.s wrongfully towed andJor ticketed � ❑ Injured an City property
� Other type af property damage-please specify
O �ther type of injury--please specify
❑ Other type not listed-please specify
In arder to process your claim �ou need to include copies af all applicable documents. This is a general
�uideline of what should be submitted with a claim form, but it is not alI inclusive. You may be asked to
provide additional information depending on your claim.
� Property damage ciaims to a r•ehicle: at least two estimates for the repairs to your vehicle;ar the
actua]bills andJor reccipts for the repairs �
� Towing claims: legible copies of any tick�s issued and copies of the impound lot receipts
� Other property damage:repair estimates, detailed list of damaged items
�}�°� Injury claims: medical bills,receipts
� Photographs can be provided but wilI not be returned.
Pagc 1 of Z-Please complete and return both pages of Claim Form
Failure to providc a completed claim form tivill result in delays in processing.
LuUC��ur F�,�.,a� �� I 1 P�;aidutoa sehr w.�o� a��a
�I - :u�t�i�aQ�i�a��y� aos.cad;o a.cn��a�ts
1
1p i� :[u.to� s�� Pa�a�d�uo� o�,� vos.�od a[{;,�o aure�aql�ur.rd
' -um�naasold ur t)nsal ua�urmla a.r/nf n�rnurruq�rs passaao��ay lor� �Jiee sur,�uJ
paa°rsri� �$�a�niou�Jnut fo q�rf�o��alfoa pud anl/sr papt:tOJ(JJdDJ�JlO:C 1(01�17tYdUfl/T]�t1/p1�1�ll11r1I5 alD J70.�'wJnjsrr1t�i�ruars.C�
• sa�ed �guoprppe�o.taqwn� •u[.to;tuigia scq�o;saa�d aaoui�a�qae�g a.�g noli,��aaaq x�aq� �
auot{da�as ssas�pd
:�a�Coiduz�.�no�C3o auc��
((s}a�ep apU�o.�� ��.iom sscui no�t p�p uaqM
o� sa� �,�nfuz.�no,s�o��ns�i e se �.zonn ssctu no,t p�Q
auo�{ciaial, . . ssa.�Pp�'
:{s}.�aprno.id Ie�cpa�3o au��
{(s}a��p aprnold) ��uau►lea.��antaaai no.� prp u�c�,41
(ai�.���} �u�c.u��aiZ xaa� o���nuu��d a� sa� a�uatu��a.0 �p�ipauz at��nos norC a,tipH
�,paanfur asan��Cpoq.�no���0{S�j1ECI j�t�,M
ni�---p ,�„ �o �,pamCu� no� a�an1 h��H
-� ,.. op uoi��as s?�{��t xoq x��ua � �oc��as s�u}a�al �uoa asBa� —swr��� ,un,ui
p��r,�u�Q Ea.z�
(au�N s,aa�ColduF�,i�r�)ola�aA 30.�anuQ
soic� a�E�S .��qumh a����asua��-�
[�P°Y1I ��y�( .�a1� :�I�iva11��t�
Jt p�G�ureQ�azd
� ai�tqan�o.�ant.�Q
ty aaump pa�a�sr�a�
iQlo��W a���S , laq�unN a}c�d asua�i�
nJ [aP�Y�t _ ��y��,cea� :a��t�{an.�no�
I ��ou saop uot�aas su{��t xoq x��c{a p �o�;aas srq}a�a� tuoa aseai —sui«I� a�a�yaA
�� ` �/� . � -uot����st�es mo�C a� t.uiEi� stL��antosai ol op��
�C�i J au� axti p�noh�no�i�eu.M zn uc�E�a sr��ufo.g aoi��suaduto�ut �uT�aas a.�e no�C;unoure a�a���ipu� aseal�
b , �,�! � U,_� �,
•tu�.c��i � �e � ` n a � rssod s� a }e a se a ase� �� a ° l�u� ue saso � `iC I T�U' .�o �
.P u � I .� [ �l�I ' [Q. Pl � P Q Id ' � K P [a I 1.I. .�
�.�d�o auleu `uoi��as.za�ut=�aa.z�s ssoa� `ssaipp� �aai�s apino.tJ �a�eld axe�,£�nfut.�o�uapt��e au� p�p ala�
#�c�tia.t.�o��se� �,�taua��.ro�vaLUu�dap��q,�� `sa��I
, (�I�.�i�) unlouxufl � sa� LPati��luavuaa.zo3ua n���.�o a�c�od au�azaM
:s.caqumu auaqdala� pu� s�ssaipp� `sauc�u.�iaq�apuoad as�a�d�sa�C}i
(aj�ai�} unlouxun c�� sa� ��uapt�ar aql o�sassau�T���.���� aiaM
uaUaas sic��a�a� uio� asea� —smi�[� 1[b'
o:+U a�Ed'in�d�u�es,�o:5��� �ui.�o� urie���o aar�oN
, EPPNER'S
' e = s �
Collision Repair Experts Workfile ID: 36c51410
S AUTO BODY (Downtown)
www.HeppnersAutoBody.com
� TH ST., SAINT PAUL, MN 55101
♦�� GRANTALMEIDA Estimator � Phone: (651) 224-5644
grant.almeida@heppnersautobody.com BBB FAX: (651) 224-6042
395 East 7th Street Phone(651)224-5644
St.Paul,MN 55101 Fax(651)224-6042 Preliminary Estimate
Customer: NAY, HEH 7ob Number:
Written By: Grant Almeida
Insured: NAY,HEH Policy#: Claim#:
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact: 12 Front
Owner: Inspection Location: Insurance Company:
NAY,HEH HEPPNER'S AUTO BODY(Downtown) OTHER
390 COTTAGE AVE W.APT#8 395 E.7TH ST.
ST.PAUL, MN 65123-3397 SAINT PAUL,MN 55101
(651)233-3976 Cell Repair Facility
(651)224-5644 Business
VEHICLE
Year: 2012 Body Style: 4D SED VIN: SYFBU4EE7CP012259 Mileage In: 21698
Make: TOYO Engine: 4-1.8L-FI License: 225-HYX Mileage Out:
Model: COROLLA S Production Date: 2/2012 State: MN Vehicle Out:
Color: BLACK Int: Condition: Job#:
TRANSMISSION CONVENIENCE Stereo Bucket Seats
Overdrive Air Conditioning Search/Seek WHEELS
5 Speed Transmission Intermittent Wipers I CD Player Aluminum/Alloy Wheels
POWER Tilt Wheel Auxiliary Audio Connection PAINT
Power Steering Cruise Control SAFETY Clear Coat Paint
Power Brakes Rear Defogger Drivers Side Air Bag OTHER
Power Windows Keyless Entry Passenger Air Bag Fog Lamps
Power Locks Message Center Anti-Lock Brakes(4) Traction Control
Power Mirrors Steering Wheel Touch Corrtrols Front Side Impact Air Bags Stability Control
Heated Mirrors Telescopic Wheel Head/Curtain Air Bags Rear Spoiler
DECOR RADIO Hands Free Device Power Trunk/Gate Release
Dual Mirrors AM Radio SEATS
Console/Storage FM Radio Cloth Seats
i
1/20/2014 9:13:49 AM 070412 Page 1
Saint Paul Potice Impound Lot, 830 Barge Channel Road, Vehicle Relea�e Form
Make: TOYOTA License#:225HYX CN: 14Q91327 Invoice#:2664t}
DatelTime Released: 01/19/201411:28 Tow Charge: $ 123.95
Released to:TOTO � Storage Charge: $ 0.00
Paid by: CREDIT CARD Admin Charge: $ 80.00
Released by:ADAM Tax: (7.625%) $ 15.55
t,the undersigned,have recovered the vehicle described above. Subtotai: $ 219.50
1 will check the vehicle for damage or any other problems that
may i�ave occurred wttile this vehicte was in the custody of the Service Charge: $ Q.00
Saint Paul Police Departmenf. 1 acknowiedge i wi0 report
damage andlor any other problems to the Impound Lot staff Total Charges: $ 219.50
on this form prior to leaving#he impound lot.
Damage and/or other probiem: � '
Police Report made:Yes_No_IF Yes, CN , if NO,Why?
TO PROTECT YOUR RIGHTS REPORT ANY PROBLEMS/DAMAGE BEFORE LEAVING THE LOT
Signature en000
St. Paul Police Department for
Ramsey District Court
RECEIPT
Date/Time: 01/19/2014 11:28 Invoice #: 26640
Vehicle Piate: 225HYX/
Payor: OWNER Location Paid: Impound Snow Lot
Citation: Amount:
0900208490 $ 56.00
Total Amount Paid: $ 56.00
Paid by: CREDIT CARD
KEEP THIS COPY FOR YOUR RECORDS
n � � o � � � � �
_. � < � s z � �
a' � � �' � � � � Q'
a. � ca � � .. �
cp � � n :n 1F�'
v, � o -�
1 � � Q �
� � �
, � o- a
� � � T
� 3 ,
� � �� � �
1 �' �� � � -a
� ,�.�; i Q
� � � � � �
i � t � .A c � ,
j � '� c�o . CD V—
; i
� = o � � � o
� i � ,a � � � �
' i � ! o �
�` � ! � -j
� Q a
_ .p
I
i
�
�
� �
� m -� p c "�
o` � � � _ �
� n � � �
c�
o a�i �' �' � —� p �
�. -� c� y C) •� � r
su � � �. n ro � �
� � � � � o 0
� �' o o �
� � � Q
�' m C
o � � •
� � � �
a
0
I � � � � C
� �►�+
�
m
S �
•�
�
. !
^ Preliminary Estimate
Customer: NAY, HEH 7ob Number:
Vehicle: 2012 TOYO COROLLA S 4D SED 4-1.8L-FI BLACK
Line Oper Description Part Number Qty Extended Labor Paint
Price$
1 FRONT BUMPER
2 R&I R&I bumper cover 1.1
3 Repl LT Spoiler S 7685202908 1 57.49 0.3 0.6
4 Add for Clear Coat 0.1
5 Repl LT Side retainer 5211602170 1 30.89 0.1
6 Repl LT Spoiler clip 5216102020 1 2.30
7 # Repl �Flex Additive 1 5.00
8 # 'Hazardous Waste Disposal Fee 1 5.00
9 # P[OSSIBLE HIDDEN DAMAGE 1
SUBTOTALS 100.68 1.5 0.7
ESTIMATE TOTALS
Category Basis Rate Cost�
Parts 100.68
Body Labor 1.5 hrs @ $55.00/hr 82.50
Paint Labor 0.7 hrs @ $55.00/hr 38.50
Paint Supplies 0.7 hrs @ $35.00/hr 24.50
Body Supplies 0.4 hrs @ $3.00/hr 1.20
Subtotal 247.38
Sales Tax $ 125.18 @ 7.6250% 9.54
Grand Total 256.92
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 256.92
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.
1/20/2014 9:13:49 AM 070412 Page 2
��.4-.
�
��=r
a,
�g��
�� � � � ��
".v�
� � �
A }
S
�� � � �
��9t
Sv •
!
I'�3t��*=;_ -
�
��-
,���`
'�'-
`�».
"+asm
� , � . ��i�l
�� ,� �
�.��;.
. � _
� ,, � � ,. :.
� � :
�.
,�. * �" a
�
�`;� II�� <.��'��
�, #
;,.� -_ � . �
�. ��,, �
x �.
dr�„µ �.vl..�:.
!�'+�.3 l�. _;'��;,
�
� h4.
4
re
° i'e
I
'A';Y
��+o'� � �.�- I.
I
� �Y �
Ao�i � "r; ..
. .. . �.. � �"X`''.� :�:, .. �
.�
�'`�+�4�''�
� �
� � }��;�� ��' 4�
�:�.�
` � � ` � ��
�;F �,.,!:..
_ ,,;.,. s ...: i ..
_ _ ��k.0.�'� �" _
..�.,.:�..
�"� �". . . �.
� �
� � �
�: � E �
x �� �3 � . �. .
� , �����,�
z - : •
j { �
7 � � >
e� � } �
.�
�•� ��
+ ` .�
. /
� � � $u ` • � � f
�;;� � r` _ ,�',. �_
� � � »
.� r;;;,;
;�� � � �<�` �`
-� � `� � � �
.
..� ;
�_: .-��,,,,,,r,� � _
. �
�
� �
� ..
\-�e.��
� ��. ������
.� ��,��} ,� ����`��� � ,� ��
� �. ��t .�` r � �� � �t��x ��
�m �';� � ?��,,- i n
M1� n
t 4 3 +c:m,a ` �d f' ��'�,' �'�4�r �
`�.nti ��n�3��x'�"",�., ���ki����Yr�� f� Y
� ��
�� �,r
�� ������
r � �ey�w a
�n,kr� �. w �„a x ar3.
rs c
,a�
t ���:..
�w�.,
tl
��Y
. �, ..... . �.
:�'.. ��.. . . i �. . ..�� .
. :..: ..,.. , .��. '�:
� ; �..
�� �j�
�p
:'�,r ����i:,�e
dl,x
.�Y'
�,5a�i . ,�i�
5
M... �{
3}��1
��'
_.::L�'..t
ii? ..
�'�Y
, R+�4r. ,.�.... ���?:,
x �
�� {
n
�,
'ti
;�
�°:�t �
�' #�
�t
�� ,
��, � �
�, '�.
�;� u
�,r .
���
r=� ��,�,
�;
����.., �.
a . ���r� �� �
i���.,
y,��„s � ;.� f:
f..�z� , '
�,.,
,�I����� I��II I` i I �'
I�� il
"''i
,I�
�:,
,
� <,. .;
. �
— �
;.� I i;� �
,#
. ...
;
�, :