Bronson _ � - >��� �`��'��'�
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' NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minnesota State Statute 466.05 states that " ...every persai..:who claims damages fron�any municipality...shall cat�se to be presented to the
governing body of the municipality within J80 days after the alleged loss or injurv 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 your 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�����5()� R F��i VE D
Company or Business Name
2�)4
Are You an Insurance Company? Yes/ 10 If Yes, Claim Number?
Street Address ��j� � �Y 1 (�S �j( v d E R K
City � State �� Zip Code ���,
Daytime Phone(� �� -���Cell Phone �(.�� - Evening Telephone(_) -
Date of Accident/Injury or Date Discovered Time 2,�� am/�
Please state, in detail, what occurred(happened), and why you are submitting a claim. Please indicate why or how you
fe,el the City of Saint Paul or its employees are involved and/or responsible for your damages.
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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 ❑ My vehicle was damaged by a plow
❑ My vehicle was wrongfully towed and/or ticketed
❑ Other type of property damage—please specify � I�'�'as injured on City property
❑ Other type of injury—please specify
In order to process your claim youu need to include conies of all applicable 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 WILL NpT be returned and become the property of the City. You are encouraged to keep a
copy for yourself before submitting your claim form.
�Property damage claims to a vehicle: two estimates for the repairs to your vehicle if the damage exceeds
$500.00; or the actual bills and/or receipts for the repairs
O Towing claims: legible copies of any ticket issued and a co
O Other property damage claims:two repair estimates if the damage x eed$SOOt00corpthe actual bills
and/or receipts for the repairs; detailed list of damaged items
O Injury claims: medical bills,receipts
O Photographs are always welcome to document and support your claim but will not be returned.
Page 1 of 2—piease 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 No nknown (circle)
Provide their names, addresses and telephone numbers:
I
Were the police or law enforcement called? Ye . No Unknown (circle) �
If yes,what department or agency? ' '"' ase#or report# � (`j '!`7�j�C./ '
Where did the accident or injury take place? Provide street address, cross street, intersection,name of park or facility, ,
closest landma k,etc. Pl ase be as detailed as ossib�. If necessary,attach a diagram.
► '�� � ►�1 - � � E �- � t_
Please indicate the am nt you are seeki in compensation or what you would like the City to do to resolve this claim
to your satisfaction. ,
Vehicle Claims— lease com lete this section � check box if this section does not a 1
Your Vehicle: Year Make Model
License Plate Number State�Color
Registered Owner
Driver of Vehicle �
Area Damaged ' � '
City Vehicle: Year�_ ake Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name) 1
Area Damaged �
v
Iniurv Claims please complete this secdon �,�check hox if this section does not applv
How were you injured?
What part(s)of your body were injured?
Have you sought medical treatment? Yes No 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
�heck 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��' ��-1
Print the Name of the Person who Completed this Form: '
Signature of Person Making the Claim: �
���z�°- r.�rrrnSt"'�
Revised February 2011
DRIVER EXCHANGE OF INFORMA710N
case#: 13015554
Cowity, RAMSEY � County Code: 62
City: MAPLEWOOD Date,'Time. 08/12/2013 n2;Z4 PM Agency Type: PD
.- - . -
Yr.Veh: 06 Make: FORD Style: EX Vehicle Plate#: 925305
Color: g�� Yr.Tag Expires: 14 State:MN
VI!��: 1 FTNJF30Y46ED85252
Ins ;;;rn;, ST.FHUL REGIONAL WATER SERVICES Policy#: NONE Est.Dmg:
First Name: JEFFERY Middle: CHARLES Last: aBBOTT DOB:0 911 2/1 9 7 7
Address. 10'��JICMENEMY CIR City. VADNAIS HEIGHTS State: MN Zip: 55127 Diff.Addr.on DL N
Race: Sex M Phone: DL#: Z966223798521 7L State: MN
. Ov;ner Infonnat�o i� -
PJama ST PAUL REGIONAL WATER SERVS
Address ?900 N RICE ST City: ST PAUL State: MN Zip: 55113
�- - �
`:� Veh 08 �
Make:STRN Style: PG icle Plate#: 262PC
:,c�`��i. r�iiJ -�-- -- 'ir.T�,y cX��ire5; 1� StBir.:-iv��J � . -._
✓IN: 1G8ZV57708F123101
Ins.�ornp UNKNOWN Policy#: UNKNOWN Est.Dmg:
First fJame: Middle Last: DOB:
Addres�;: City: State: Zip: Diff.Addr.on DL: N
Race: Sex: Phone: DL#: DL State:
O�mer Information �
' Pdarr�e BRONSON,DEREK TODD - _
Address: 4815 cRIKS BOULEVARD City: EAGAN State:MN Zip:55122 _
. . ' �
�- �
Yr.Veh Make: Style: Vehicle Plate#: ���('�.
Color. Yr.Tag Expires: State:
VIN:
ins Comp: � Policy#: Est.Dmg:
Fir�t PJame. Middle: Last: DOB:
Address. City: State: Zip; Diff.Addr.on DL: N
Race Sex. Phone: DL#: DL State:
O�:�mer In'ormai on.
Narr�e:
Address: City: State: 2ip:
First Name: Middle: Last: Phone: !
Address: City, State: Zip:
First Name: Middle: �:,st: F;ione:
Address: City: S!c,}� Zip: �
100 VIKING DRIVE E AND ENGLISH ST.
' � .`# �...
Property Demage othar than Vehicles
Est Amount
Signature of Officer.
Officer nam� BE�DE Badge No.: 446r Case number: 13075554 Misc`.
Agency Na�ra MAPLEN,'00�PO�ICE DEPT.
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ABRA Auto Body & Glass - Eagan Workfile ID: 262456d1
FederallD: 41-1942823
Right The First Time...On Time
1399 TOWN CENTRE DR, EAGAN, MN 55123
Phone: (651) 452-0717
FAX: (651) 454-6430
Preliminary Estimate
Customer BRONSON, DEREK 7ob Number:
Written By: Eric Mitre
Insured: BRONSON, DEREK Policy#: Claim#: 1
Type of Loss: Date of Loss: 10/21/2013 12:00:00 PM Days to Repair: 0
Point of Impa : 12 Front
Owner: Inspection Location: Insurance Company:
BRONSON, D EK ABRA Auto Body&Glass-Eagan CUSTOMER PAY
4815 ERICKS LVD 1399 TOWN CENTRE DR
EAGAN, MN 5 123 EAGAN, MN 55123
(612)702-69 1 Business Repair Faciliry
(651)452-0717 Business
VEHICLE '
Year: 2008 Body Style: 4D SED VIN: 1G8N57708F123101 Mileage In: 95204
Make: SATU Engine: 6-3.6L-FI License: 262PC Mileage Out:
Model: AURA XR Production Date: 8/2007 State: MN Vehicle Out:
Color: Blue Int: Condition: Job#: ,
TRANSMISSION Overhead Console AM Radio Communications System
Automatic Transmission CONVENIENCE FM Radio Hands Free Device
POWER Air Conditioning Stereo SEATS
Power Steering Intermittent Wipers Search/Seek Cloth Seats
Power Brakes Tilt Wheel Auxiliary Audio Connection Bucket Seats '
Power Windows Cruise Control Satellite Radio WHEELS '
Power Locks Rear Defogger CD Changer/Stacker Aluminum/Alloy Wheels
Power Mirrors Keytess Entry SAFETY PAINT �
Heated Mirrors Message Center Drivers Side Air Bag Clear Coat Paint
Power Driver Seat Steering Wheel Touch Controls Passenger Air Bag OTHER
DECOR Telescopic Wheel Anti-Lock Brakes(4) Fog Lamps
Dual Mirrors Remote Starter 4 Wheel Disc Brakes Traction Control
Body Side Moldings Home Link Front Side Impact Air eags Stability Control
Console/Storage RADIO Head/Curtain Air Bags Power Trunk/Gate Release
I
10/22/2013 5:16:53 PM 014556 Page 1
\/,8888s,9q���c�'f�hee��"%/`������0��
Preliminary Estimate
Customer: BRONSON, DEREK 7ob Number:
Vehicle: 2008 SATU AURA XR 4D SED 6-3.6L-FI Blue
Line Oper Description Part Number Qty Extended Labor Paint
Price�
1 FRONT BUMPER
2 0/H bumper assy 2•3
3 Repl Bumper cover 25851546 1 375.97 Incl. 2.8
4 Add for Clear Coat 1.1
5 Repl Energy absorber 20827683 1 102.32 IncL
6 R&I RT Outer grille XR Incl.
7 R&I LT Outer grille XR Incl.
g R&I Lower deflector IncL
9 GRILLE
10 R&I Center grille IncL
11 FRONT LAMPS
12 R&I RT Headlamp assy 0.3
13 R&I LT Headlamp assy 0.3
14 # �Hazardous Waste 1 5.00 X
SUBTOTALS 483•29 2•9 3•9
ESTIMATE TOTALS
Category Basis Rate Cost;
Parts 478.29
Body Labor 2.9 hrs @ $54.00/hr 156.60
Paint Labor 3.9 hrs @ $54.00/hr 210.60
Paint Supplies 3.9 hrs @ $34.00/hr 132.60
Miscellaneous 5.00
Subtotal 983.09
Sales Tax $610.89 @ 7.1250% 43.53
Grand Total 1,026.62
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 1,026.62
THIS IS A VISUAL INSPECTION ONLY. THERE MAY BE ADDITIONAL DAMAGE AFTER DISASSEMBLY. PARTS ARE
SUBJECT TO INVOICE. THERE ARE NO GUARANTEES ON RUST REPAIRS.
"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.
10/22/2013 5:16:53 PM 014556 Page 2
Preliminary Estimate
Customer: BRONSON, DEREK 7ob Number:
Vehicle: 2008 SATU AURA XR 4D SED 6-3.6L-FI Blue
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
DR8IK07, CCC Data Date 10/17/2013, 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 pa� and/or labor information provided by MOTOR may have
been modified or may have come from an alternate data ource. 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=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. 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=6ureau of Automotive Repair. EPA=Environmental Protection Agency. NHTSA= National Highway
Transportation and Safety Administration. PDR=Paintless Dent Repair. VIN=Vehicle Identification Number.
10/22/2013 5:16:53 PM 014556 Page 3
SUPERIOR SERVICE CENTER
3425 WASHINGTON DR
EAGAN, MN. 55122
PHONE:651-454-5522 FAX:651-454-9738
FEDERAL ID#41-1534523
"*PRELIMINARY ESTIMATE***
10/22/2013 04:42 PM
___ . . ._. __ .. _... _.__.
__ __ _ . _._.__.________... _._.__._._�._,.�....__,...__.
_,,.,...,..,. _......_____..�,,
Owner 3
___ _ ___ _. _ _ _.
__ , _ _....�__ _ .__ .
�
Owner: DEREK BRONSON
Address: 4815 ERICS BLVD Work/Day:
Home/Evening: (612)702-6961
City State Zip: Eagan, MN 55122 FAX:
� _ _.._... , _ _r_, ,. _
, _____�____ _____..__.��__�__�.,.�,_._ .i
Inspection }
_� ._ _._ ___..___ ._
Inspection Date: 10/22/2013 04:42 PM Inspection Type:
Appraiser Name: COLE M BEYER Appraiser License#:
Address: 3425 WASHINGTON DR Work/Day: (651)452-8555
City State Zip: Eagan, MN 55122 FAX: (651)452-3279
Email: ColeB@superior-mn.com
� ,,�__.,. � ,___..____„ ,.___.._.�_ ___,_,___.��., _._._
_.__.._._____��__ w�___ �...____.w__M_.m_�._
Repairer
; .�..._.___._ _ .._.._. .... ..... ..._�_ ._____.,., � _.____� .��_�. __-____ ___� .�,�, _.__._
Repairer SUPERIOR SUPERIOR Contact:
SERVICE CE
Address: 3425 Washington Dr. Work/Day: (651)452-8555
FAX: (651)452-3279
City State Zip: Eagan, MN 55122 Work/Day:
Email: admin@superiorcollisioncenter.com
___�_..� _...,�.___.. .... .. �____.. ._ _� —� _ .____ . _______ _________._ _._.___._______.__ _�___�__,
' Vehicle �
2008 Saturn Aura XR 4 DR Sedan
6cyl Gasoline 3.6
6-Speed Automatic
Lic Expire: VIN: 1G82V57708F123101
Veh Insp# : Mileage Type: Actual
Condition: Code: SN503D
Ext. Refinish: Two-Stage Int. Refinish: Two-Stage
Options
AM/FM In-dash CD Changer Air Conditioning Alarm System
Aluminum/Alloy Wheels Anti-Lock Brakes Automatic Dimming Mirror
Bucket Seats Cargo/Trunk Net Center Console
Climate Control For A/C Cruise Control Dual Airbags
Floor Mats Fog Lights Garage Door Opener
Halogen Headlights Head Airbags Heated Front Seats
Heated Power Mirrors Intermittent Wipers Keyless Entry System
Lighted Entry System MP3 Player OnStar System
Power Brakes Power poor Locks Power Drivers Seat
Power Steering Power Windows Rear Seat Audio Controls
Rear Spoiler Rear Window Defroster Rem Trunk-L/Gate Release
10122/2013 04:44 PM Page 1 of 3
2008 Saturn Aura XR 4 DR Sedan
Claim#: 10/22/2013 04:42 PM
Remote Starter Side Airbags Stability Cntrl Suspensn
Strg Wheel Radio Control Tachometer Theft Deterrent System
Tilt&Telescopic Steer Tinted Glass Tire Pressure Monitor
Traction Control System Trip Computer Velour/Cloth Seats
_��.,�_. ��w _m�w_�.�__ �..mm�__���. ..__�m�__�_a
_�..m� �a�._ mm�m_.__ a_w�_... ..
__...��� _���.
_�� e._�_�.m�_a__ __�
' Dama es �
_
�_�._�.�..__.__... _._._.__�.��_..�,_...__��_..____.,.___.______.._... _.._._ �. .__��_.�_. _..... ._.___..__,. _.,_..__..___._....� _._�__.___��__.__���.____�_<
Line Op Guide MC Description MFR.Part No. Price ADJ% B% Hours R
Front Bumner
1 E 6 Cover,Front Bumper 25851546 $375.97 3.4 SM
2 L 6 13 Cover,Front Bumper Refin;sh 4.�J RF
2.8 Surface
0.6 Two-stage setup
0.6 Two-stage
3 E 76 Panel,Frt Bmpr License 22725681 $32.63 0.2 SM
Manual Entries
4 E FLEX ADDITIVE Replace OEM $5.00' SM`
5 SB HAZARDOUS WASTE Sublet Repair $5.00'
SM*
6 L COLOR TINT Refinish 0.5' RF'
7 I ADDITIONAL DAMAGE Repair SM*
»ADDITIONAL bAMAGE IS POSSIBLE BEHIND BUMEPR COVER
7 Items
MC Message
' 13 INCLUDES 0.6 HOURS FIRST PANEL 7W0-STAGE ALLOWANCE
__ .._.. _._.—________.. ____ .__�____ __ .______.�
_.__._ _�_� ..__ _._� ._._._._ _..____...____
_..__ __� ._ �,,�_..
__.
' Estimate Total 8 Entries �� ����� � ���[
� ._....� ___..__...__. �_ �__. __��._...____._. ;
Gross Parts $413.60
Paint Materials $144.00
Parts 8 Material Total $557.60
Tax on Parts 8 Material @ 7.125% $39.73
Labor Rate Replace Repair Hrs Total Hrs
H rs
Street Metai(SM) $52.00 3.6 3.6 $187.20
Mech/Elec(ME) $110.00
Frame(FR) $80.00
Refinish(RF) $52.00 4.5 4.5 $234.00
Paint Materials $32.00
Labor Total 8.1 Hours $421.20
Sublet Repairs $5.00
Gross Total $1,023.53
Net Total
$1,023.53
Alternate Parts Y/00/00/00/00/00 CUM 00/00/00/00/00 Zip Code:55122 Default
Audatex Estimating 7.0.019 ES 10/22/2013 04:44 PM REL 7.0.019 DT 09/01/2013 DB 10/15/2013
10/22/2013 04:44 PM �
Page 2 of 3
2008 Salurn Aura XR 4 DR Sedan �
Claim#:
10/22/2013 04:42 PM
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
SUPPLIED BY A SOURCE OTHER THAN THE MANUFACTURER OF YOUR MOTOR VEHICLE.
WARRANTIES APPLICABLE TO THESE REPLACEMEI�T PARTS ARE PROVIDED BY THE PARTS
MANUFACTURER OR DISTRIBUTOR RATHER THAN �Y 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 = Partial Repiace Price PM= Replace PXN Reman/Reblt UM= Replace Reman/Rebuiit
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= Chipguard RI = R& I Assembly P = Check
AA= Appearance Ailowance 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
������t� Audatex's prior written consent.
��c�.�«�:cutr�zarFy
�°°°�°° Copyright(C)2013 Audatex North America,Inc.
Audatex Estimating is a trademark of Audatex North America, Inc.
10/22/2013 04:44 PM
Page 3 of 3