Stejskal - � � RECEIVED
� F E8 0 3 2�14
�OTICE OF CLAI1Vi FORM to the City of Saint Paul, Mir�g���LERK
;4lirureso�n Sru1c Stanllr.F66.l1�s�cnes 1l�cu "••-e�rn��x•r;�on...►rho dainz�damngesT om uitti-»un2icip�rlity...slrall cattse�o benrerented tn�Ire
�orerni�rq bvrly o jtlrc neunicipelit}'1l7/J11R I$O[I[ll'S Q�ttr//1C flIICKC[f IOSS W'bJ!(t'1°JS[flSCU VBPP[I[!lTOl1Ct'Slt�lfJl�llte d►1)1C,place,tr�rcl
ciretr�rulances rGerEO�a+rc!�he ru�miuu ojc�nrperlsaliun nr otlter r�liejdenlmarterl."
P�ease compiete[iiis�farm in iis entiret}bc ctcarl�fyping or printiag your ans�.•cr ta each question. If more space is
ueeded,attach addition�l sl�eets. Piease note that you may or ma��not be contacted by telephonc to dis.;nss your claim
circnmstances,so provide as much intormation�s necessar�tv esplajn youT claim,�Ild ihe amoant of eomQensation beinb
requcsted. This torm must be signcd,and bath pages completed. If something daes not apply,write°n/��,
SEnD CQILPLETED FORI�� �D OTHER DOCUNLENTS TO:
CITY CLERK, 15`VEST KELLOGG BlLVD,310 CITY HALL,SAI�iT PAtiL,1bll� 551U2
First Name__�;;u,t�r i�� MiddIe Initial
_� Last Name_ �}� i S'K-�..P
Company or gus�ness l�iame, if applicable
Street Address ZC1 ta L �1 �►�S�.a(I � '
Gi ty— ���+. (�A�...Q �
, State N1N Zip Code 55`1 C y I
Dlytime Telephone t Z___��) Z 5(,- �Zy Z Evening Telephane r--- ;
Date of Aceident/Injury or Date Diseol=ered I- 3o -1y �
Time 9 . �� am/ circle) i
Please state= in detail,what occurred, and why you are submitting a claim. Please indicate why or ho«r you
i
fccl the City of Saint Paul ar its cnlployees are involved anci/or responsible.
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Pleasc check the box{es)that most closely represent the reason for completing this form:
❑ Vehicle was damaged in an accident l�Vehicle��as damageci during a tow
❑ �tehicle was damaged by a pothole or condition of the street ❑ Vehicle v�Tas damaged by a plo�v
❑ Vellicle wa,5 wrongfully towed and(or ticketed ❑ Injured on City property
0 Other type of property damage—please spccify
❑ Other type of injury--please specify
0 athcr type not listed–please specify
In order to process your claim vou need to include co ies of all annlicable dacuments Th;s is a general
guideline of wI�at should be submitted tivith a claixn form, but it is not atl incIusive_ Yau may be askcd to '
provide additional inforn�ation depending on your claim.
O Property damage cIaims to a vehicle: at least twfl estim.ates for the repairs to your vehicle;or the
actual bills andlor reccipts for the repairs
O Towing claims: Iegibte copies of any tickets issued and copies of the impound lot receipts
p Other proper[y damage:repair estimates,detailed]ist of damaged items
O Injury claims:medic�l bills, receipts
O Photo�aphs can be provided but�vilI n�t be returned.
Page 1 of Z—Ple�se complete and return both pages of Claim Form
Failure to provide a coiupleted claim form will result in delays in processing.
Notice of Claim Form, City of Saint Paul,pagc t►ro
AlI Claims—pleasc comuletc this secdan
Were therc�vitnesses to the incident? Yes �1 Unknoivn {circle)
lf yes,please provide their names, addresses and telephone numbers:
Were the police or la��er�forcement calied? Yes N Unknt�wn (circle)
If yes,�c�hat department or agency? Case 7 or re�ort#
Where did the accident ar injury take place? Pro 'de street address,cross sireet,intersection,name af park
or facility, closest landmark, etc. Plcase be as det�iled as possible. If he]pful,attach a diagram.
4 iS ��i- C'� - Pa�.I r-+v.l
Please indicaEe the amaunt you Are seeking in compensarion from this claim or what you 1�ould like the Gity
to do io resolve this elaim to your satisfaetion. �ce�c�rY ni aw,,a.q,-S
Vehicle Claims—nlease comnlete this section ❑ check box if this section does not annlv
Your Vehicle: Year i`i qk Make rovc�-a Model_ �a.+�rv
License Plate Number L�i o �zv State,�N Color v �ah
Registered Owner_�ah v�c I S it�S i�a,l
Driver of Vehicle �QC,►-,���+-e jS�c,.,{
—�
Area Damagcd F►-c��+- •
Cit���rehicle: I'ear Make �Iodel
License Ptate Number State Color
Driver of Vehicic(Cit}j Employee's Name}
l�rea Damagcd
Iniarv Claims—alease comnlete this section ❑ check box if this section does not apnlv
H��v were you �n�ured? �(
What pari(s}of your I�dy were injvred? �,l
JU
Have you sought medicai ireatment? Yes No Planning to Seek Trea#ment (circle)
��l�hcn did you receive treatmerit? � (provide date{s)}
Name of Medical Provider(s}:
Address Telephone
Did you miss wt�rk as a result af your injvr�? Yes Na
When did you miss work? (provide date(s))
Name of your Employer;_ ,
Aciciress Telephone '
Q"Check here if�ou are attaching rnore pages to this claim form. ?iumber of additienal pages 7i . �
B}�.cigning this form,J prr are stati�tg that all infornlariou you have provirled is lrrte aed rorrect to the best of vour knowle[!g� (�nsiened %
fnrms rvill noi he�rocessed Submittotg a jutse claim can resuh in prosecutiorr.
Print the l�ame of the Pcrson who Compieted this Form: ['�u,1�r��f S�e iS K c,P
Signature of Person 1lRaking the Clsim: '
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Date form�vas cornpleted 2�I�1`f Rev��:�d Ar•;��nn�
ROERING AUTOBODY Workfile ID: 52cfeflc
FederalID: 411827490
90 N. DALE ST., SAINT PAUL, MN 55102
Phone: (651) 221-0919
FAX: (651) 221-1946
Preliminary Estimate
Customer: Stekskal,Gabriel 7ob Number:
Written By:Chad Mear
Insured: Stekskal,Gabriel Policy#: Claim#:
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact:
Owner: Inspection Location: Insurance Company:
Stekskal,Gabriel ROERING AUTOBODY
(218)256-2242 Day 90 N. DALE ST.
SAINT PAUL, MN 55�02
Repair Facility
(651)221-0919 Day
VEHICLE
Year: 1998 Body Style: 4D SED VIN: 4T16G28KKWU378054 Mileage In:
Make: TOYO Engine: 4-2.2L-FI License: Mileage Out:
Model: CAMRY CE Produdion Date: State: Vehicle Out:
Color: Int: Condition: Job#:
TRANSMISSION Dual Mirrors AM Radio Cloth Seats
Overdrive Body Side Moldings i FM Radio Bucket Seats
5 Speed Transmission Console/Storage , Stereo Reciining/Lounge Seats
POWER CONVENIENCE Cassette WHEELS
Power Steering Intermittent Wipers SAFETY Wheel Covers
Power Brakes Tilt Wheel Drivers Side Air Bag PAINT
Power Mirrors Rear Defogger Passenger Air Bag Clear Coat Paint
DECOR RADIO SEATS
1/31/2014 4:42:18 PM 076657 Page 1
Preliminary Estimate
Customer: Stekskal, Gabriel ]ob Number:
Vehicle: 1998 TOYO CAMRY CE 4D SED 4-2.2L-FI
Line Oper Description Part Number Qty Extended Labor Paint
Price;
1 FRONT BUMPER
Z ** Repl RECOND Bumper cover 52119AA901 1 340.00 1.8 2.8
3 Add for Clear Coat 1.1
4 # Subl Hazardous waste removal � 1 5.00 X
5 # Repl Flex additive 1 0.3
SUBTOTALS 345.00 1.8 4.2
ESTIMATE TOTALS
Category Basis Rate Cost;
Pa� 340.00
Body Labor 1.8 hrs @ $55.00/hr 99.00
Paint Labor 4.2 hrs @ $55.00/hr 231.00
Paint Supplies 4.2 hrs @ $32.00/hr 134.40
Body Supplies 1.8 hrs @ $3.95/hr 7.11
Miscellaneous 5.00
Subtotal 816.51
Sales Tax $481.51 @ 7.6250% 36.72
Grand Total 853.23
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 853.23
Rcering Auto Body, takes great care to ensure that every repair meets your satisfaction.
The labor performed by Roering Auto Body is guarantee� against any defect in workmanship for as long as you own
your car.
Rcering Auto Body guarantees ±hat for as long as you own yaur vehicle, Roering will, at its expense, correct or repair
all defects which are attributable to defective or faulty workmanship in the repairs stated on the repair invoice, unless
caused by or damaged resutting from unreasonable use, improper maintenance or care of vehicle, and rust and/or
corrision.
This guarantee covers labor only and dces not apply to arts, materals or equipment which may be covered by
manfacturer's warranty.
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.
1/31/2014 4:42:18 PM 076657 Page 2
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