Sjerven RECEIVED
F�B 07 2�14
NOTICE OF CLAIM FORM to the City of Saint Paul, MinnQ�� CLERK
Minnesota State Statute 466.05 stutes that"...every person...who claims damages from any municipulity...shaQ 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
circtemstartces 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 dces not apply,write`N/A'.
SEND COMPLETED FORM AND OT1HER DOCUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 C:ITY HALL, SAINT PAUL, MN 55102
First Name Brenda Middle Initial KI Last Name s�erven
Company or Business Name Northern Air Corp dba NAC Mechanical&Electrical
Are You an Insurance Company? Yes/No If Yes,Claim Number?
Street Address 1001 Labore Industrial Court,su�te a
City Vadnais Heights State MN Zip Code 55110
Daytime Phone( s5� �255 _3555 Cell Phone( ) - Evening Telephone(_) -
January 30,2o�a Time � �5 am/ m
Date of Accidend Injury or Date Discovered ' �— ��
Please state,in detail, what occurred(happened),and why you are submitting 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.
My driver,Scott Sedivy,was leaving a project in the Payne/Maryland area was stopped in the drive waiting for Vaffic to clear so he could enter the
street,a city worker(Sheila Warner)plowing snow with a bobcat on the sidewalk backed up and into our vehicle. She had just driven past the
drive at the construction site about 20 yards and then just started backing up and never looked back. My driver,Scott,could not move fast enough
to get out of the way,he blew his horn but she did not hear it and backed into the front bumper. The police were called and a case number created,
CN#14-019-345
Please check the box(es)that most closely represent the�eason for completing this form:
❑ My vehicle was damaged in an accident ❑ My vehicle was damaged during a tow
0 My vehicle was damaged by a pothole or condition of the street O 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��ou need to include copies 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 NOT 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 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
0 Photographs 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—alease comnlete this section
Were there witnesses to the incident? Yes No nknown (circle)
Provide their names,addresses and telephone numbers:
Were the police or law enforcement called? es No Unknown (circle)
If yes,what department or agency? St Paul Police Case#or report# 14-019-345
Where did the accident or injury take place? Provide street address,cross street,intersection,name of park or facility,
closest landmark,etc. Please be as detailed as possible. If necessary,attach a diagram.
Payne/Maryland construction site
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. $�,391.93
Vehicle Claims—please complete this section ❑check box if this section does not anvlv
Your Vehicle: Year 20�3 M�e Ford Mp�jel Edge
License Plate Number 338 LHT State MN Color White
Registered Owner Nortnern Air Corp dba NAC Mechanical&Electrical
Driver of Vehicle scott Sedivy
Area Damaged hont driver bumper
City Vehicle: Year Make Model bobcat
License Plate Number State Color
Driver of Vehicle(City Employee's Name) Sheila Wamer
Area Damaged unknown
Iniurv Claims—please complete this section 0 check box 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
� Check here if you are attaching more pages to this claim Form. Number of additional pages�.
By signrng this form,you are stating that all information you have proviried 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 February 6,2o�a
Print the Name of the Person who Completed this Form: Brenda Sjerven
�
Signature of Person Making the Claim:
Revised Februazy 2011
Brenda Sjerven
From: Scott Sedivy
Sent: Thursday, February 06, 2014 1:10 PM
To: Brenda Sjerven
Subject: Fwd: Scott's accident
Brenda,
Below are the phone numbers and yes you can call and get the accident report.
Scott Sedivy
Begin forwarded message:
From:Scott Sedivy<ssedivv@nac-hvac.com>
Date:January 31, 2014 at 6:33:55 AM CST
To: Brenda Sjerven<bsierven@nac-hvac.com>
Subject: Scott's accident
Brenda,
Well not again! We were working on some projects yesterday in the cities and as
we were leaving the Payne Maryland project in St. Paul, a city worker plowing
snow with a bobcat on the sidewalk backup up and into my vehicle. She had just
driven past the driveway at the construction site so I pulled up to leave and was
waiting for the traffic on the street to go by. She had gone down the sidewalk
maybe 20 yards then just started backing up and never looked. I couldn't go
forward or put the car in reverse fast enough. I blew my horn but she just backed
up into the front bumper. The damage isn't too bad. The city's policy is to call
the police and they do a report. I have the information below. What else do I
need to do?
Sheila Warner
St. Paul Parks & Rec
1100 N. Hamline Ave
St. Paul, MN 55108
Matt Arntzen
St. Paul Police Department
367 Grove street
St. Paul, MN 55101
CN# 14-019-345
1
CHUCK'S BODY SHOP, INC.
` 800 PARKWAY AVE.
EAGLE LAKE, MN 56024
OFFICE: 507-625-2910 FAX: 507-625-2131
FED. ID# 06-1253054
CD LOG NO 4274-1 DATE 02/05/14
SHOP: INSP DATE: 02/05/14
OWNER: NAC
POINT OF IMPACT: 0
LIC#: STATE: VIN: 2FMDK4GCODBB95925
BODY COLOR: WHITE MILEAGE:
CONDITION: ACCTNG CTL#:
*=USER-ENTERED VALUE E=REPLACE OEM NG=REPLACE NAGS
EC=REPLACE ECONOMY UE=REPLACE OE SURPLUS UC=RECONDITIONED PRT
UM=REMAN/REBUILT PRT EU=REPLACE �ALVAGE EP=REPLACE PXN
OE=REPLACE PXN OE SRPLS PC=PXN RECO DITIONED PM=PXN REMAN/REBUILT
TE=PARTL REPL PRICE ET=PARTL REPL LABOR IT=PARTIAL REPAIR
I=REPRIR L=REFINISH BR=BLEND REFINISH
TT=TWO-TONE CG=CHIPGUARD SB=SUBLET
N=ADDITIONAL LABOR RI=R&I ASSEMBLY P=CHECK
AA=APPEAR ALLOWANCE RP=RELATED �RIOR UP=UNRELATED PRIOR
PRELIMARY ESTIMATE ! ! ! ! � � � ' � � � � � �
MAY HAVE HIDDEN DAMAGE BEHIND FRT BUMPER COVER ! ! ! ! !
TRUCK # 299
338 LHT LICENSE PLATE NUMBER
2013 FORD EDGE SE 4DOOR WAGON 6CYL GASOLINE 3. 5
CODE: P7403C/G OPTNS C/24U
OPTIONS:
�WO-SfiAGE - EXTERIOR SURFACES TWO-STAGE - IN�ERIOR SUR�ACES
4-WHEEL DRIVE
OP GDE MC DESCRIPTION -MFG_PART_N0. PRICE AJo B$ HOURS R
E 0006 CVR, FRONT BUMPER UPR BT4Z17D957BPTM 289. 93 3. 1 1
L 0006 13 CVR, FRONT BUMPER UPR REFINISH 2. 9 4
1. 9 SURFACE
0. 6 TWO STAGE SETUP
0. 4 TWO STAGE
E 0114 Ol CVR, FRONT BUMPER LWR BT9Z17D957APTM 130. 63 INC 1
E 0096 RET, FRT BUMPER COVE LT BT4Z17C947B 11. 68 INC 1
E 0041 HEADLAMP ASSY, HALOG LT BT9Z13008H 432. 82 0. 3 1
N 0973 HEADLAMPS AIM ADDNL LABOR OPERA 0. 4 1
SBM03 FLEX ADDITIVE SUBLET REPAIR 5. 00* 4
SBM60 HAZARD. WSTE. REM. SIIBLET REPAIR 2.00* 1
�AGE 1
02/05/14
2013 FORD EDGE SE 4DOOR WAGON
� LOG NO 4274-1
8 ITEMS
MC MESSAGE (S)
O1 CALL DEALER FOR EXACT PART NUMBER / PRICE
13 INCLUDES 0. 6 HOURS FIRST PANEL TWO-STAGE ALLOWANCE
FINAL CALCULATIONS & ENTRIES
GROSS PARTS 865. 06
PAINT MATERIAL 98 . 60
PARTS & MATERIAL TOTAL 963. 66
TAX ON PARTS @ 6.875$ 59. 47
LABOR RATE REPLACE HRS REPAIR HRS
1-SHEET METAL 54. 00 3. 4 0.4 205.20
2-MECH/ELEC 75. 00
3-FRAME 65. 00
4-REFINISH 54 .00 2. 9 156. 60
5-PAINT MATERIAL 34 .00
LABOR TOTAL 361.80
SUBLET REPAIRS 7.00
TOWING ;�
STORAGE
GROSS TOTAL 1, 391.93
NET TOTAL 1, 391 . 93
SHOPLINK U2870 ES CD LOG 4274-1 DATE 02/OS/14 03: 57: 36PM R6. 37 CD 12/13
PXN: Y/00/00/00/00/00 CUM 00/00/00/00/00 GEOCODE 56024
HOST LOG
(C) 1998 - 2008 AUDATEX NORTH AMERICA, INC.
1. 0 HRS WERE ADDED TO THIS EST. BASED ON AUDATEX TWO-STAGE REFINISH FORMULA.
--------------------------------�-----------------------------------
�
PAGE 2
02/05/14
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