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NOTICE OF CLAIM F�RM to the City of Saint Paul, Minnesota
;hlrm�esola Srule Statt�le�{66.!1?srurc.,nc�,� °...evert�per;cnit...trho clttints dant�rg�s fi•on�u��t�sunticipalrly...s1u111 ctnrse to be presented tn!hc
s;nrerrtiil,g hod����/�lltc•nrturicinrtlity u•r�hin 180 d�rys aJler r{re alle:gecl loss a•ii jtrn-is rliscvvcred a�roJice sla�iieL��/ie tinre,pluce,rrird
cfrctrnutmrces thereo%'ond!be an►niul!of c�nr�rrsnlion or ot/rer relicf demmuled."
P�ease eomplete this form in its entirety bv-clearl�=fyping or printing your ans�ver to eacl�question. If more space is
needed,attach additional sl�eets. Please note that you may or may not be cantacted by telephone to discuss your claim
circumstances,so pro�ide as much information as necessar,y to explain your claim,and the amount of compensation being
reyucsted. This form must be signcd,and both pages completed. If somcthing does not apply,write°n/r1'.
SEND COIIPLETED FORl1I A1VD OTHER DOCUNiE1V'TS TO:
'�CITY CLERK, 15 WEST KELLOGG BLVD,310 CIT'Y HALL, SAIyT PAliL, NIr SS1U2
� RECEIVED
First Name �l�l e Middle Initial Last Name Ya n�
Company or Bu.siness Name, if applicable f L� �`l`�' ����
Street Address 1�a-Gl U� ��'t� Si' _ N C CITY C LE RK
City �+�lS State_Nl� Zip Code yJ 5 �
Daytime Telephone �( ��}�aa-� " I�S�7 Evening Telep�Fi n�/(�� ,',��n �`���
Date of Accident/Injury or Date Discovered � �r ime �" a " circle)
Please state, in detail, what occurred, and why you�re submitting a claim. Please indicate why or how you
fecl the City of�Saint Paut or its cmployees are involvecl and/or res onsible.
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P ease c ec t e ox{es�t a most close y repr sent t e reason for completin�this form:
❑ Vehicle was damaged in an accident �Wehicle��as damaged during a tow
❑ Vehicle was damaged by a pothole or condition qf the street ❑ Vehicle was damaged by a plo�v
O Veliicle was wrongfully towed and/or ticketed ❑ Injured on City property
� Other type of property damage—please spccify
O Other type of injury--please specify
❑ Other type not listed—please specify
In order to process your claim vou need to include copies of all applieable documents. This is a general
guideline af what should be submitted with a claim form, but it is not aIl inclusive. You may be askcd to
provide additional information depending on your claim.
O Property damage claims to a vehicle: at least two estimates for the repairs to your vehicle;�r the
actual bills and/or reccipts for the repairs I
O Towing claims: legible capies of any tickets issued and copies of the impound lot receipts
� Other property damage:repair estimates, detailed list of damaged items
O Injury ciaims: medical bills, receipts
O Photographs 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�vill result in delays in processing.
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Saint Paul Police Impound Lot, 830 Barge Channel Road, Vehicle Release Form
Make: TOYOTA License#: 624AHZ CN: 14008439 Invoice#: 25077
Date/Time Released: 01/15/2014 11:11 Tow Charge: $ 123.95
Released to: TOTO Storage Charge: $ 15.00
Paid by: CASH Admin Charge: $ 80.00
�
Released by: ELISE Tax: (7.625%) $ 15.55 ,'�
x
I,the undersigned,have recovered the vehicle described above. Subtotal: $ 234.50 -
I will check the vehicle for damage or any other problems that
may have occurred while this vehicle was in the custody of the Service Charge: $ 0.00
Saint Paul Police Department. I acknowledge I will report
damage and/or any other problems to the Impound Lot staff Total Charges: $ 234.50
on this form prior to leaving the impound lot.
Damage and/or other problem:
Police Report made: Yes_No_IF Yes, CN , If NO,Why?
TO PROTECT YOUR RIGHTS. REPORT ANY PROBLEMS/DAMAGE BEFORE LEAVING THE LOT
Signature '� si2000
St. Paul Police Department for
Ram ey District Court
ECEIPT
Date/Time: 01/15/2014 11:11 Invoice #: 25077
Vehicle Plate: 624AHZ/
Payor: OWNER Location Paid: Impound Snow Lot
Citation: Amount:
0900642761 $ 56.00
Total Amount Paid: $ 56.00
Paid by: CASH
KEEP THIS COPY FOR YOUR RECORDS
�� ABRA Auto BOdy & Glass - Midway Workfile ID: 414d70db
Federal ID: 41-1852119
Right The First Time...On Time
1190 UNIVERSITY AVE W, SAINT PAUL, MN 55104
Phone: (651) 645-1563
FAX: (651) 641-612.9
Preliminary Estimate
Customer: VANG, BAO 7ob Number:
Written By:John Rucinski
Insured: VANG, BAO Policy#: Claim #: *
Type of Loss: Date of Loss: 1/14/2014 12:00:00 PM Days to Repair: 3
Point of Impact: O1 Right Front
Owner: Inspection Location: Insurance Company:
VANG, BAO ABRA Auto Body&Glass-Midway Unknown Insurance
629 VAN BUREN ST NE 1190 UNIVERSITY AVE W
MLPS, MN 55413 SAINT PAUL, MN 55104
(612)623-1857 xH Business Repair Facility
(612)246-5593 xPAO Business (651)645-1563 Business
VEHICLE
Year: 2007 Body Style: 4D SED VIN: 1NXBR32EX7Z910441 Mileage In: 98229
Make: TOYO Engine: 4-1.8L-FI License: 624-AHZ Mileage Out:
Model: COROLLA CE Production Date: 4/2007 State: MN Vehicle Out:
Color: WHITE Int: Condition: ]ob#:
TRANSMISSION Body Side Moldings FM Radio Cloth Seats
Overdrive Console/Storage Stereo Bucket Seats
5 Speed Transmission CONVENIENCE Search/Seek WHEELS
POWER Air Conditioning CD Player Wheel Covers
Power Steering Intermittent Wipers SAFETY PAINT
Power Brakes Tilt Wheel Drivers Side Air Bag Clear Coat Paint
Power Mirrors Rear Defogger Passenger Air Bag
DECOR RADIO 4 Wheel Disc Brakes
Dual Mirrors AM Radio SEATS
I
1/30/2014 1:41:00 PM 011906 Page 1
, Preliminary Estimate
Customer: VANG, BAO ]ob Number:
Vehicle: 2007 TOYO COROLLA CE 4D SED 4-1.8L-FI WHITE
Line Oper Description Part Number Qty Extended Labor Paint
Price$
1 FRONT BUMPER
2 R&I R&I bumper cover 1•Z
3 * Rpr Bumper cover CE&LE 2_5 2.6
4 Add for Clear Coat 1.0
5 Repl RT Side support 5211502061 1 24.85 0.1
6 FRONT LAMPS
7 R&I RT Headlamp assy CE&LE 03
8 * Rpr RT Headlamp assy CE&LE 1 0
„
9 FENDER
10 * Rpr RT Fender all � 2•0
11 Add for Clear Coat �•$
12 R&I RT Fender liner US built 0.3
13 MISCELLANEOUS OPERATIONS
14 # Refn �Car Cover 0.1
15 # Refn 'Corrosion Protection 0.3
16 # �Hazardous Waste 1 5.00 X
SUBTOTALS 29.85 8.4 6.8
NOTES
Prior Damage Notes:
1
ESTIMATE TOTALS j
Category ' Basis Rate Cost;
Parts 24.85
Body Labor i 8.4 hrs @ $54.00/hr 453.60
Paint Labor 6.8 hrs @ $54.00/hr 367.20
Paint Supplies 6.8 hrs @ $34.00/hr 231.20
Miscellaneous 5.00
Subtotal 1,081.85
Sales Tax $256.05 @ 7.6250% 19.52
Grand Total 1,101.37
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 1,101.37
THIS IS A VISUAL INSPECTION ONLY. THERE MAY BE ADDITIONAL DAMAGE AFfER 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."
1/30/2014 1:41:00 PM 011906 Page 2
. Preliminary Estimate
Customer: VANG, BAO 7ob Number:
Vehicle: 2007 TOYO COROLLA CE 4D SED 4-1.8L-FI WHITE
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
ARM8427, CCC Data Date 1/17/2014, 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 (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 �rom 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. O/H=Overhaul. Qty=Quantity. Refn=Re�nish. 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.
1/30/2014 1:41:00 PM 011906 Page 3