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Neal r .- ' � RECEIVED NOTICE OF CLAIM FORM to the City of Saint Paul, Minneso�EB 11 2J)4 Minnesota State S`tatute 4S6.OS states that"...every person...who claims damages from arry municipality...shall cause to be pr��iP t�L E R K gwerning body of the municipaliry within 180 days after the alleged loss or injury is discavered a notice stating the time,place,and circumstances thereof,and fhe amount of comperrsation or other relief demanded" Ptease complete this form in its entirety by clearly fyping or printing yonr answer to each qaestion. If more space is needed,attach additionaI sheets. Please note that you w�i nat be contacted by telephone to clarify answers,so provide as much information as necessary to e�plain yqnr claim,and the amonnt of compensation being reqnested. You will receive a written acl�owledgement once your form is received. The process can take np to ten weeks or longer depending on the - nature of your ciaim: This form-mast be signed,-and both pages completec� If something does not apply,write�N/A'. _ _ SEND COMPLETED FORM AND 4THER DOCITMENTS TO: CTTY CLERK, 15 WEST KELLOGG BLVD,310 CTTY HALL, SAINT PAUL,MN 55102 First Name �RRiV��-T�itJL' Middle Initial l�I�Last Name^��I� Company or Business Name /I�� 'J -V _� — . Are You an.Insurance Company? Yes No Tf Yes,Claim.Number? StreetAddress g�`f' ��Ra�A �}�ENII� � � City ��" �F}4��-. State M� Zip Code .`�'��/�� Da e Phone 5 22y�(�7 Cell Phone(� - Evening Telephone �( 51•')��`�- �� —? �r�--��_p �y. IN�s � Date of Accidentl Injury or Date Discovered��-N 2 Z,, z�' 1`�' Time �1 Q Nam.�pm ��,�� B��;�N r�a o PM y�ND f's30 �� Please state,in.detail,what occurred(happened),and why you are submitbng a claim.Please indicate why or how you feel th.e City of Sai.nt Paul or its employees are involved and/or responsible for your damages.�df �� . -TA*1 Z2� z�� rra-- /�o/re�tit��t egti�F --r� NY ��n2. �n� � r�%�:a :�, , �: �r��. C ��e A Q.K�{� O ll F�C"N'T V�V R� 1� I nl� . U Pe�; C a N �'�(z ►-t A�r t ��1 _ h��, 'T�d-�:lL� � �e.��_ ��P ac-�f �a��,s E-� �c� D M� ti T 1-+�-v �3� ti' �+�-r 13Y" a � c�Y" ti �H �� e �R�,/�` ��N K F2eNT Sib� �Zo �- v��5i4��.D lrv"Co C�L�ZF� SI.IOl,1153 ,..iY A�Kk� o F �-T Y V eN�C L � 17 i D N Q-c L E T M�= l<N 4 Inl N r !�l�-U H r'7 ��R e Nj`l ,�R H 5 OHR K�D �f'�5-r' w�S� o�' �� o�/ %H� o Q Please check the box(es)that most closely re resent the reason for completing this form: � �My velucle was damaged in an accident �fl�.� �i }�NN�R g'�- ❑My vehicle was damaged during a tow __ ' Y � _ � ❑My vehicle was damaged by a pothole or condition of e stree ..i-'.�i'�iy vehicle zvas dama.gea b a �c�v ❑My vehicle was wrongfully towed and/or ticketed. ❑T was injured on City property ❑Other type of properly damage-please specify ❑pthe�r type of injury-please specify In.order to process your claim vou need to include copies of all annlicable documents. For the claims types Iisted below,please be sure to in.clude the docum.ents indicated or it will.delay the handling of your clai.m. Documents WILL NOT be retumed and become the property of the City. You are encouraged to keep a copy for yourself before submitting your claim form. O Properly damage claims to a vehicle:two estima.tes for the repairs to your vehicle if the�amage exceeds �e C?-�'� $SOO.00;or the actual bills and/or receipts for the repairs P(�as� CoN-�a�� Q�'" �t"z�P�S..{.� �s-��ma� O Towing c1aims:legible copies of any ticket issued and a copy of the impound lot receipt O Other property darnage 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 Q Injury claims:medical bills,receipts O Photographs aze always welcome to docum.ent and support your claim but will not be retut�aed. Page 1 of 2-Please complete and return both pages of Claim Form � . . � Failnre to complete and return both pages will resnit in dela.y in the handling of yonr claim. All Claims—please comulete this section Were there witnesses to the incident? Yes No Unlrnown (circle) Provide their names,addresses and telephone numbers: � ��c�re �ur-�KUFD Were the police or law enforcement called? es No Unlaiown (circle) M� e F If yes,what department or agency? � F'�� c�1 i c� Case#or report#_��— O l 3 — q 1-I �e� �j�u�r Where did the accident or injury take place? Provide street address,cross street,infersection,na.me of park or facility, closest landmar etc. Pleas be as detailed as possible. If necessary,attach a diagram. LQ�T S�p�- R"D� �u RO,�� c�.- •�7 � [_ . � TaL r iC-�� A-�1�. Rr��+? cFF vcN ,4 rac D h�/7 �c�( S P o 7' f7 n�r� N�—z- M �" C A!e (,�i�o r..r Po<< c�►��.� #S Te L D 'i a i-!r� - C R�1° y✓!t5 Please indica.te the amount you are seeking in compensation or what you would like the City to do to resolve this claim PAR KE� to your satisfaction. .Tt� C as T c� R�►'p�►��N� ►�� C �R, Du-r of P�K�7 Nc o�vE y OdI Rf N i At— _ _ _ _ VehicIe Claims�lease complete this section ❑check box if this section does not annrv -- Your Vehicle: Year Z c c�-{ Make ��Y C�R Model G' o�e-�C� A License Plate Number �2� �j�X Sta.te M�( Color Tqnl Registered Owner�a�vFST�K� /1(��-- Driver of Vehicle 'Pg�h��-t� R-r t-f e�t� Area Damaged T�+�i w f.� S i D�; �'�o�v—r r c�.-�� i►� = City Vehicle: Year l�ti�lC;��e wN' Ma1ce U u k�ke�r ti' Model _r n�� S -- -5 N�F 7 �� ,��n License Plate Number�(,v K,vv w�r State Color tdu Kive w�l -'rn Driver of Vehicle C' Em lo ee's Name S��-�� N� E M�. �Pa�-6�i zi.�G (�Q�,��_p � rt5' P Y ) YPr I� M� AreaDamaged �(nr KNCw�( CG�a- 3as - i�itia Fg,e Fl,c7��✓� ,�y C�e ) In'n Claims— lease com lete this section �check box if this section does not a 1 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 da.te(s)) , Name of Medical Provider(s}: Address Telephone — T�id yc��miss work as s:es�.��t ef ve•ar u?;u.*;�? YP� -Ne 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. Nnmber of additional pages Q . By signing this form,you are stating that alC information you have provided is true and correct to the best of your Itnowledg� Unsigned fornrs will not be processed Submitting a false claim can result in prosecution. Date form was completed : ��.�D /02 U! � Print the Name of the Person who Completed this Form: /Q��S iV� ��L- Signatnre of Person Making the Claim: , � �e Revised February 2011 i -..��.�� i �'�� `�� atuff Brothers Auto Bodym I Robert Latuff �, Esn►�nnTOr� ��.k� `�' `7 -6 / � -"q�� rlatuH@Ia,uN6rothe,scare�651224-2828`«wwwlch,H6rolhers:co� 880 Universiiy Av� • St.Pau(, MN 55104 _ ___ � Pride,Profession As`ml PartI1C�Slllp ; If you have a comment or concern about the service you ' �� ,r��„� I have received,you may report it to the St. Paul Police � gpg WINSOR Department,the Civilian Intemal Affairs Review i Patrolman Commission,or one of tfie organizations listed below: � POLICE DEPARTMENT � Police Civilian Int.Affairs Review Comm. (651)266-5583 1 / ' � St. Paul Police Department Int.Affairs (65l)266-5760 i ;,, CITY OF SAINT PAUL ` 367 Grove Strett Uoice Mail:65l-266-9000 ezt 7�322 I NAACP (651)649-0520 '`�` Urban League (651)224-5771 `'?�,'?P � Sainr Paul.MN 55J0/ bob.winsor�a ci�st�aul.mn.us Council on Asian-Pacific Minnesotans (651)296-0538 �� N# I Y- �/3- Y-< < Council on Hearing Impaired (651)297-7305 1 If you have quesdons regard��B Yo��P°rt�� Indian Affairs Council (651)296-0132 t Saint Paul Police Records Unit (651)Z66-5700 � Human Rights (651)266-8964 � . _--- ' _ _ . _.– ------____.-- J __._... ,____-__—' —._.__ ._____- ---� ___ --___ _ i ---____.______._ __ , _ DINO GUERIN � � District Chief 'i FIR DII�10 GUERIN ; # " � District Chief 'I � F1Rf � � �� p ice: 651-228-6214 � oE� Saint Paul Fire Departn►ent Mobile: 612-366-3296 645 Randolph Avenue F�: 651-228-6255 i Saint Paul,Minnesota 55102 ` O ice: 651-228-6214 n;•��+!��i sroaul mn�. � l Saint Paul Fire Departcr►ent �uobile:612-366-3296 645 Randolph Avenue p�;651-228-6255 Saint Paul,Minnesota 55102 Dino. uerinna i stnaul mn.u� i d a�v be�� o� , �S re�c i .�� \o��h��R �� ' �e' \�` �p�i ryA�'� QOJ �:�.►-; •bh.��y St. . � `�� P.►e �j�� -��.,� �`ore�'e�sr� � �\O`� O,`�\ \Oi J �� V LATUFF BROS., INC. 880 UNIVERSITY AVENUE ST. PAUL, MINNESOTA 55104 (651)224-2828 FAX: (651)291-0677 FEDERAL ID#41-0777034 ***PRELIMINARY ESTIMATE*** 01/24/2014 04:26 PM �--- ! Owner ------.___.- , Owner: EARNESTINE NEAL Address: 804 AURORA AVE Work/Day: Home/Evening: (651)224-6677 City State Zip: Saint Paul, MN 55104 FAX: ___ _ -- -- - , _ _ _ _--------- -- — � � Inspection _ -- -- — — ------ ---------' Inspection Date: 01/24/2014 04:24 PM Inspection Type: Drive In Inspection Location: Latuff Brothers Inc Contact: Address: 880 University Ave Work/Day: (651)224-2828x FAX: (651)291-0677x City State Zip: Saint Paul, MN 55104 Work/Day: Email: general@latuffbrothers.com Primary Impact: Left Front Side Secondary Impact: Driveable: Yes Rental Assisted: Appraiser Name: ROBERT LATUFF Appraiser License#: ---- i Repairer �----- -—---------- - --------- -------- --- --- ---_ Repairer: Latuff Brothers Inc Contact: Address: 880 University Ave Work/Day: (651)224-2828 FAX: (651)291-0677 City State Zip: Saint Paul, MN 55104 � WorklDay: Email: general@latuffbrothers.com Target Complete DatelTime: Days To Repair: 8 ; Remarks **'*`**"'*PRELIMINARY ESTIMATE*'*"'*"""""" POSSIBLE ADDITIONAL DAMAGE MAY BE FOUND AFTER TEAR DOWN COULD NOT OPEN DOOR AT TIME OF ESTIMATE r-- -- ------� � Vehicle -- ---- ----- 2004 Toyota Corolla LE 4 DR Sedan 4cyl Gasoline 1.8 4 Speed Automatic Lic.Plate: 626JHX Lic State: MN Lic Expire: VIN: 1 NXBR32EX4Z283915 Prod Date: 03/2011 Mileage: Veh Insp#: Mileage Type: Actual Condition: Code: Y21146 Ext.Color: GOLD Int.Color: Ext.Refinish: Two-Stage Int. Refinish: Two-Stage -v� . � yf, Mj► /OfG/'f�iC/e s 'PPSfLlh� � '�F,O 6'�°f�f '`Qf�f '''� 9/,� ��f o� P�f, , J'J� Co �� '4�,G�h o�� , . � . . � # l`��Di3 ��a-( 2004 Toyota Corolla LE 4 DR Sedan Claim#: 01/24/2014 04:26 PM Options AM/FM CD Player Air Conditioning Alarm System Automatic Trans Bucket Seats Center Console Digital Clock Dual Airbags Intermittent Wipers Keyless Entry System Lighted Entry System Power Brakes Power poor Locks Power Mirrors Power Steering Power Windows Rear Window Defroster Rem Trunk-L/Gate Release Split Folding Rear Seat Tachometer Tilt Steering Wheel Tinted Glass Velour/Cloth Seats Wood Interior Trim �Damages '� --� Line Op Guide MC Description MFR.Part No. Price ADJ% B% Hours R StriQes And Mouldinas 1 E 254 01 MIdg,Front Door Side LT 757320223000 $115.33 0.4 SM 2 BR 323 MIdg,Rear poor Side LT Blend Refinish 0.3 RF 0.2 Biend 0.1 Two-stage 3 RI 323 MIdg,Rear poor Side LT R&I Assembly 0.4 SM Front Bumoer 4 E 6 Cover,Front Bumper 5211902915 $233.50 1.4 SM 5 L 6 13 Cover,Front Bumper Refinish 3.7 RF 2.6 Surface 0.6 Two-stage setup 0.5 Two-stage 6 L 16 Prep Raw Frt Bmpr Cvr Refinish 0.5 RF 0.5 Surface 7 E 86 Filler,Front Bumper LT 5212802060 $48.01 INC SM Front End Panel And Lamns 8 N 973 Headlamps Aim Additio al Labor 0.4 SM 9 E 90 Lens,Headlamp LT 811700 200 $185.17 INC SM Front Bodv And Windshield 10 BR 83 Panel,Hood Blend Refinish 1.6 RF 1.1 Blend 0.5 Two-stage 11 RI 1030 Nozzle,W/S Washer LT R&I Assembly 0 1 SM 12 RI 1031 Nozzle,W/S Washer RT R&I Assembly 0.1 SM 13 E 103 Fender,Front LT 5380202060 $247.78 2.2 SM 14 L 103 Fender,Front LT Refinish 2.8 RF 1.8 Surface 0.5 Edge 0.5 Two-stage 15 CG 103 Fender,Front LT Chipguard 0.3 RF Front Bodv Interior Sheetmetal 16 E 152 Skirt,lnner Fender LT 5387602090 $94.36 INC SM Wheels 17 E 727 Cover,Front Wheel LT 42621AB060 $102.55 SM Front Doors 18 E 207 Door SheIl,Front LT 6700202220 $539.74 4.7 SM 19 L 207 Door SheIl,Front LT Refinish 3.5 RF 1.9 Surface 01/25/2014 12:32 PM Page 2 of 4 ` ' R�-� � ��{-o �3-9a( 2004 Toyo�a Corolla LE 4 DR Sedan Claim#. Ot/24/2014 0426 PM 1.0 Edge 0.6 Two-stage 20 E 201 Tape,Front Door LT 7592202030 $3821 0.2 SM 21 E 229 01 Mirror,0uter R/C LT 8794002391B0 $231.22 INC SM 22 E 211 Hinge,Front Door Upr LT 6872002020 $45.66 0.2 SM 23 L 211 Hinge,Front Door Upr LT Refinish 0.4 RF 0.3 Surface 0.1 Two-stage 24 E 213 Hinge,Front Door Lwr LT 6874002030 $45.66 0.2 SM 25 L 213 Hinge,Front Door Lwr LT Refinish 0.4 RF 0.3 Surface 0.1 Two-stage Rear poors 26 I 289 Pnl,Rear poor Outer LT Repair 1.0' SM 27 L 289 Pnl,Rear poor Outer LT Refinish 1.9 RF 1.6 Surface 0.3 Two-stage 28 RI 327 MIdg,Rear poor Belt LT R&I Assembly 0.3 SM 29 RI 305 Handle,RR Door Outer LT R&I Assembiy 1.1 SM �uarter And Rocker Panel 30 I 163 07 Pillar,Hinge LT Repair 1.5' SM 31 L 163 Pillar,Hinge LT Refinish 1.2 RF 1.0 Surface 0.2 Two-stage 32 I 187 07 Panel,Rocker LT Repair 0.5' SM 33 L 187 Panel,Rocker LT Refinish 1.3 RF 1.1 Surface 0.2 Two-stage Manual Entries 34 L M14 Corrosion Protection Refinish 0.3' RF 35 N M17 Cover Car Exterior Additional Labor $7.00' RF 36 SB M60 Hazardous Waste Removal Sublet Repair $5.00* SM 37 RI FRT LIC PLATE R 8 I Agsembly 0.2' SM' 38 SB THRUST ANGLE ALIGNMENT Sublet Ftepair $69.95' SM' 38 Items MC Message 01 CALL DEALER FOR EXACT PART#/PRICE 07 STRUCTURAL PART AS IDENTIFIED BY I-CAR 13 iNCLUDES 0.6 HOURS FIRST PANEL TWO-STAGE ALLOWANCE Estimate Total&Entries _ _ ___ _i Gross Parts $1,927.19 Other Parts $7.00 Paint Materials $582.40 Parts&Material Total $2,516.59 Tax on Parts&Material @ 7.625% $191.89 Labor Rate Replace Repair Hrs Total Hrs H rs Sheet Metal(SM) $52.00 11.5 3.4 14.9 $774.80 Mech/Elec(ME) $85.00 Frame(FR) $75.00 Refinish (RF) $52.00 18.2 18.2 $946.40 Paint Materials $32.00 01/25/2014 12�.32 PM Page 3 of 4 ° ` � ��-- � 1�-0��-5�( 2004 Toyota Corolla LE 4 DR Sedan Claim#: 01/24/2014 0426 PM LaborTotal 33.1 Hours $1,721.20 Sublet Repairs $74.95 Gross Total $4,504.63 Net Total $4,504.63 Alternate Parts No SPPL Yes Zip Code:55104 Default Audatex Estimating 7.0.123 ES 01/25/2014 12:32 PM REL 7.0.123 DT 12/01/2013 DB 01/15/2014 Copyright(C)2013 Audatex North America, Inc. 3.7 HRS WERE ADDED TO THIS ESTIMATE BASED ON AUDATEX'S TWO-STAGE REFINISH FORMULA. ESTIMATE CALCULATED UStNG THE 2.5 iiOUi'.MAXIMUM f�LLOWkML�'�FQR'�'J!!O-STAGc F2EF1NtSH OF l�iG�l-FLEX,EXfERiOr`i , SURFACES. THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF ONE OR MORE CRASH PARTS SUPPLIED BY A SOURCE OTHER THAN THE MAI�TUFACTURER OF YOUR MOTOR VEHICLE. WARRANTIES APPLICABLE TO THESE REPLACEMENT PARTS ARE PROVIDED BY THE PARTS MANUFACTURER OR DISTRIBUTOR RATHER THAN BY 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 Replace Price PM= Replace PXN �eman/Reblt UM= Replace Reman/Rebuilt L = Refinish PC= Replace PXN econditioned 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 Allowarce �tP= F:elated 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 �1 /��"�� Audatex's prior written consent. c.r �. ��'<<�� ;,;z� Copyright(C)2013 Audatex Nortt�America, Inc. Audatex Estimating is a trademark of Audatex North America, Inc. 01/25/2014 12:32 PM Page 4 of 4 i ! I Accident Report Page 1 of 1 �� _.� � 19013921 I� � � Hn�wo+tu+ rue wwr vcwata num wuan t uw uwn� wt[ vc.w 'nc i ' N Y 62 tl0 �0 Y 1 22 2019 �ed 12A3 `�,+ ( 110U�ELV6IEY EMl1iEPOR yMl! . R" YOIRECt10N ,v a � 10 Aurora Ave. �{as0 � W ��E`�DN� °" •---8R 8• Ow°`� < carirvwo wrriw rxscc�r�narrc NNtl3Y8 rtwres.nacEr.caau�ar.oarunAc 62 �„ 3625 +_• 10 Avon St. N. i,�rtpi vwmon owucRUCe�[ww�[�n n�n anes aar•nw roann, au�n��sv.�w�eea.x surt uwu oesr�nn s�erm� 4e O1 N204147914206 MN I O1 f.cronx xre�elnne2woususn ur¢oveu+m rwiclrwsr.wme.uap ahosra.w mcrwa 61 JAMES STEVEN HEINICKE 10 29 59 uWNER IiO�RE OR`IIQTN AOOREC� . t1MV10L1M RESTR�CT MMNER 05 645 Randolph Nf O1 wrvna cm.ir�r[.Lr .au .xw r1H9Ct O1 Saint Paul 55102 IKOMO f 66 BEY �, falt �EOw! WMO EI�T iMJtlV Iro11t66 9E% 6NFFOVT �EE�T ��WO fKT IWSEV 4CO�W �1 �`T M 4 0 4 0 4 0 5 N �a�'ECr mF KCML i(Y�VF {OT,ErR.W lY/�1F T0�1110Y 1MNf►Oxi IiIlptllµCESERVifF qW�WUNq µpµ M�E n�u'3 rvrr iON09� 11uNppqT �4MkMICE�[PVCE 0.tMNW�FR '�\ �'.�. 78 `V�- J B l�; Q OTIEII iFfT TR.CT p OTMFN . OGQi �wwFnNM1E FlME W�'SIIIMYE � fMF OCGM 02 City of St. Paul Fire Dept. N NEAL EARNESTINE N• 0� YEfiTVP AOOIIESC TtlwB] 100qE8! IONEU vEMIYP 32 645 Randolph Ave. N.: 804 At3RORA AVENUE N O1 � �wu� : unerre.ar . .u�urw owen cm,auie.zr . � . �uuw..wrer v.�uv. p-9 Saint Paul, MN 55102 KO' 07 ST PAUL MN 55104 '�'19 03 O1 �� .� ,� �.� .N.f � .� �«� ��a 06 Sprt E1 red . TOYT UCS Q04 TAN pg owtev vurer rr.co vFM�e so�uccor�ae a..�� er�o v6w�a � � �rwwe auaHv 02" E5 02 '�� A2 626JHX MN 14 02 �� 02 �3 . WWIINI�E� idUCVYl1.iER. MMIYNCI(1IM11I1 POI.ILYWYCN . City of St. Paul Harleysville A10391282 61110(Iao MKwT wubEO� MYECrION� wcvuoGE• vrrvEO w�Lwr J�rawr '1:a[� �n.�c If ACCIDENT INVOWED ACOMIYERCIAL M070R VEMICLE,BCHOOl8U8,OR NGD iTMT Wi. nwF mmc ' REMEYB�t TO NOTiY TME 9TATE PATROL(rpulnd und�r ME 1�9.7��nd 1N.{l11�. � ' GYY.FR)ALYfNMIfMLwBERf.MGTORCMWi11N�MF OOTNUNBkA f.01/1�MyU.�iW[L8MUA66R]-MOTORGRMENIW� WTMMEN M1B[M(i.N!l�ME89fi4 UNT P061N MiE0F0YM�8Ei IVK W( NR�G EIEGT MU9EY iUMU9P TW�NBMIRi . 0115 N o� ,b��. �»� Z - pa^,u A � Parked� . . . �,,,,o ,�w�w� � .uw�.wrn .5G 0210 N om„„ � pN,� ueaurnce nw�.w1een .. . - puroc« � 4.,� � OW1iEMOFP�N9lONNQDPNOFGiV�M00FEG�PfIOIOfONMGlOwiOPEil1YAN�ORVELLOwAONUlAi;fll WYM[DMO'FNIY�IFILOWTAGNIIl9� '�" �� . � ,NM�T�E: OEY�LE 02 04 . __.. .. _ _.. xwrw � ; 03 Veh. 1 was turning to w/b Aurora from s/b Avon. Veh. 2 was parked on e/b Aurora. A1 sald tfie�beck' `�M � end.of_veh.. l slid on the-icy..pavement an.d. hit 8� O1 I veh. 2 as he passed it. '�� - MI1FL N �i( N' Q � � _.. 02 . _ ,�,��a�,. 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ORIGINAL VEHICLE � . , ' � � �'�,, u``� � � �.,••COLOR ; Ltp�.NSE NO. ... . . . �f . .. . .�:S.�v10DEL �C�AR# �'' -�r-9 � . . ,� � --,=r,�4 MILE- IN BILL � � coMP'!'�4h�.t��S'='i C.E !`'.J��`JHL��- i;-�1`��,:�'F.)i..��i�� : �.:; �.��,:. � ?.� �r.�� AGE OUT TO� ' . _ �- ' ' — ��, jry A��if�`.�'�'�i:..�. �.��.�I;J �7;;C� PNONE ri.�., ��,l�.l% EM. �'DRIVEN .,Y� � � ----�.,,,� `��ro'— Rs�H��{i�t'�;?i ;� 1i ;�� 4 Sf7 ;r;tt�`�:i . �, 1 a�..: O<:�� ADDITIONALAUTHORIZEDDRIVER(S)�-EXCEPTA$REj�IJI�jE�B`('�A,�3�F,.[#1NI�1'fP,�yVITH4fyiTOWNER'S � � . � ��¢ WRITTEN APPROVAL. . . . ... .. .. .. . .. . ... . ..... I REW EST OWNER'$PERMIS410N TO ALLOW � 7 �° -"' " WHO IS UNDER MY CONTROL ANO DIRECTION TO ORIVE VEHICLE FOR ME AND ON MY BEHALF.I AM RESPON- �� OO �O SIBLE FOR THEIR,9f�TS WHILE THEY ARE DRIVING AND FOR FULFILLING TERMS AND CONDITIONS OF THIS - RENTAI AGREEMHNT AGREEMEN USE OF VEH(CLE BY AN UNAUT,�IORIZED ORIVER WILL AFFECT MV LIABIL- ..oun .eaurcx uw�w � WINDSHIELD OK? 17v AND R!G T E THIS A ��IFJi�f.� �j� y / . :-„, �: � � �� ;YE9 NO � � L% 7 ,;.` _t 'ir+t';�i DESCRIPTION: ��.��i��/f�"�.-!1.,!.'?.{� , ,' � . �+1�, �; HAIL DAMAGE? YES NQ �-. PERMISSION GRANTED TO OPERATE VEHICLE ONLY IN THE STATE OF RENTAL AND THE FOLLOWING STATE(S): E.. �� "`�i � ! 5 j� F OUT E 1/8 tl4 3/8 1/2 5/8 314 7/81.w; �. -�i .. f?5 _ i �:... .3 ._ _.�'..,_ '.t..� !4,/ � ��%'�`� ; ! st 1,.�-.�1i 1 4.. �� u � L IN E 1/8 7/4 3/8 1/2 5/8 314��7/8 F � � � OPERATION IN ANY 07HER STATE OR COUNTRV WILL AFFECT YOUR LIABILIN AND RIGHTS UNDER THIS AGREEMENT. �";� � 'i`�4� � ' � :�� _,;�,� 1 ��i�. l�� RENTEROH7IHESOPIpNALCOWBqN RENTERACCfPTSOP710N�LWLLLSplIDAM�GEWANER DANAGE WANER�C0W�AND A88UAE9 DANAf� � (CDWj AT FEE SHOWN IN CALUMN TO RIGHT.SEE . RE9POII�l11Y.SEE PARAGRhPH 6. NOTICE TO LEFf AND PARAGRAPH 16.COLLISION X ' � - � OAMAGE WANER IS NOT INSURANCE. � . . .. .. . ..... X�; :�':;,.�,� � . �,. �1 . ,.', I.,,iet. . ; � RENTEROECLP&SOPIIOIULPERSON�IACCOBIf . RENTERACCEPBOYfpNALP�i80�MLACfMOENT .�:, .. . .. . .... INSUTANI�(PAQ.SEE PARA6RAPH 9. W&11UNCE IPAI)AT FEE SHONT�!IN COLUMN TO � � . RIGHT.SEE PARAGRAPH 78. . - � X . � - . . . . . f�� . . . .. ..... ... . .. . ....? :'� - •,�.� � -•: •X ti `::?�: . '. . RENTEROECIIESOPIIdM191i0.BBIfALWBl1fY RENfERACCB190PTI0NN.81iRHBIfALIUBIIIfY � RFI$g;X �i'`.t �. ., ,-11.... .._ .. ..... PR07ECIIOtl�,p.SEE H 7. . PROlEC110N plPl AT FEE SHONM IN CALUMN TO �74 RIGHT.SEE PARAGRAPH 17. XL�. .., , �� : . .. .... ... .. ... . . .. . _. _. , REMEROEQIFS A89d�MICE �� REMERACC�ISOPIION�LROADSIOEA9919TANCE .,,- PROIECINN�ftIp�.SEE . � RtOTEC1101! AT FEE SFiOWN IN COLUMN TO . "�'� �-e �.:?;' ..I.�`_"t'� . .... .. ...... . PARAGHIQilti8.8.3. . RIGHT.SEE�IONAL PRODUCTS NOTICE TO LEFT R �X �'�`fF' .7 � '�r : y„� AND PARAORAPH 19. . f�� x . �� . �_ F . . ! � ��• _ �'.'.�Ji t ..,.:-1!{1.7�" .•_.-1'71.{_ti-8_L._i':i. . �• � � � .._.- �1 ._. .... � � ,r,1r ��/,v- ; ,i .i3i::f.J�`� . .. REPLACEMENT VEHICLE � ' ��N (�T, TE '�� T.�M1 7 � 1 A u OWNER `� ::�t °� _ EMPL. y.11rt�.tJ �'�� *�i7.�!r� i `Ts ,-i� � =� y .: � E T REP XL.x. � ..t . : .._._ . # .i,:iti .?-3 .� a ..`F�'�.. . . . . _.. ..JSS�f. tl� i �� .. . . co�oR ucENSE No. I WILL RETURN CAR BY: DEPOSIT(S►: DATE TIME � AMOUNT I PND BY ..._.. ... . .. ._.. .... .. ..... . . ... MODEL ECAR#� "_ ;. .^�i�i ��?�1 .� .� T �.._ _ .. . __¢".. �.r'..,�; ._. ..._ MILE- W i� AGE OUT � � .. . . . .. ... .. -. .. oRiveN AUTOMOBILE INSt1RANCE POI.ICY MUST(1)COVER THE RENTAL OF�_T TOR VEHICLE AGAINST 1 S `' '' ' .: ', i``� �,E,a��x— ��— DAMAGE TO THE VEHICLE AND AGAINST L�6�$E�F�1E ICLE; (2)D(TEND THE TOTAL CHARGES OO _.� O W POLICY'S BASIC ECONOMIC LOSS BENEFITS,�R E SIDUAL LIABILIT'Y INSURANCF.fAND UNINSURED • (� Q AND UNDERINSURED MOTORIST CAVERAGES T��1dE.OP.EBATIODLAR-kl�'OF A RENTED MOTOR DEPOSITS I I I I ��a VEHICLE:THEREFORE,PURCHASE OF ANY CAWSION DAMAGE WAIVER OR SIMILAR INSURANCE REFUNDS ur �iy Z �p�N T H I S R E N T A L C O N T R A C T I S N O T N E C E S S A R Y. I N A D D f f I O N, P URCHASE OF ANY �OO OO ° ADDmONAL LIABILITY INSURANCE IS NOT NECESSARY IF YOUR POLICY WAS ISSUED IN MINNESOTA. . � � WINDSHIELD OK? ves�r,o UNLESS YOU WISH TO HAVE COVERAGE FOR LIABILIlY THAT IXCEEDS THE AMOUNT SPECIFIED IN oescR�Pr�or,: YOUR PERSONAL AUTOMOBILE INSURANCE POLICY.BY MY SIGNATURE BELOW,I ACIQ�IOWLEDGE CLOSED BY HAIL DAMAGE7 ves No h{qT I HAVE READ AND UNDERSTAND THE ABOVE NOTICE INCLUDED IN THE SEPARATE FORM PAio ev casH �, cHECK F OUT E ,�e ,�4 3�8 ,�2 5�8 3�4 ��e F qND�E SEPARATE MINNESOTA COWSION DAMAGE WANER FORM ON PAGE 3. ' ; .�.. u RECEiaroF i DATE ' AMOUNT REf p_ E � ` � �� R� CASH REFUNDI �� .�} � IN E t/8 7/4 3/8 1/2 5/8 3/4...7/8 F - � �� OWNER IS AN AFFILIATE OF ENTERPRISE HOLDINGS INC.,WHICH OWNS ALL RIGHTS TO ENTERPRISE NAMES AND MARKS. � (C�Eflt0�f1$0�„88SIflg COfTlP8t1�/Of MIf1f12S0�2, . � ��.--� ��--a r� -� � � —� terpr�se � #�� t� �� _ , 199MNFALLI3 PAGE1of4 k'�{1 i' • 7 �� - _}�1)1? P-�3�i T[� ' �• � f•. _ e � w T Ti�r-. L�' �:_ ,.� � r I-€ .wt r – �n_t�. r'�'; F�i .�`tJ – •i 1� A�l – i i it ie ;` �s� �o:_F , ,�� tiE ��i 5 �7 �1 �� (' (' r (+ y�I[j�pyk! i + ' ' ;;_ {'4t� � ::{_ �:yl S� ^° r Fl�; L?•�C��i-��iG ��H`Li�9'� ��lS�iC-�i9i'�t V� E�11Si�{��v"{.';�9 L�_t.:� ' r--`^_ ..........._....,,fif{ r'� fJ�.;'iL� ' OWNEROFVEHICLE: S`lba �4!�It'EF'S3,Y i�'JE i� S�IP�T FP.t�L, 3�Pa_ a5 f �" �:�� BRANCHADDRESS: ' �` `�� i' �-'��'��,�� q - I � 'T f.t�J3� � � RENTAL SO # i.o.a � " TvPe iltiStJ�tAPdu'E ,.�t.cY:��'iL 99� . `. � • o�4��; ;�lf'i�^�:I4 9:1;� A►1 � ��R iAfihl�aTi�a� . . �- _ .. ±RY-__. . `...._ _____ $,� H __ __.--- -..____. _ __. STARTCHARGESIFDIFFERENT qppgE$ �� p7�� YE�'{�Ci,� p � 'F F':LJ�'+:��i!� �VG 7 PM6�F�?N�t t t i`�� - __._.__- -____._ . . ___. . .- . ___ .. _..._._..�-.L�Qr7-�:�i.F.�"�}{-"..�_-_.....__.._...__._, ORIGINALVEHICLE �'�1I�T PAUL ST,��i� �'� t,';. t�S�F'c�p�o"�'�Y --- — -- _ -- -- _ _-- �_��`_�--+_----___. .___._..__ BLU�°LOFi 5��"o. �1�.',l i44� EMPLOYER � s~–_`_� -- -_ _ _ — _____ _ _.. _.__.__ ______ ._--.____.... _._ r�VEP ooe� 7155� R��, ,�Y��F� ST�Q{E ex sr, ,r-�� .U'1 E�, ?'!� ��.�t�ib � _ __ __..__.- ------_.____ MILE- IN BILL `{ CO"''P`14�RLE��VILLE �l;TJti�—I'tfp1�E'r?�'OLIS�� t�Q CNFt�i�� MIi.kR€i� � AGE � � �! TO �- 7� _ ___ ._.. - — ----- ---- DRIVEN � A=:V��`h��t ��n'.1� �C{�t`C sA�� ti-�;F' �' _ . ., ----- .._. �g� �p�- _-- L �an.e.oro'— "": �$tG7b'�`L`t'('t{'j'{ ��?if,1(lll�Y� �Ct,��' ! ()�''• __ . ._... . _ .._......... ........---� -__._... __ .,.�. ..... .._ ., � � ... ,. � %:'._+_ t�1, O �g �5�6 yy�yy '�7�QW�� ' ��p� y�n __ __� _.,. � . . (� o �s.._.. ¢ WRITTENAPPROVAL.REDDRNER(S)-EXCEPiVURUi(7C.�'+BVRI��E�R!':! ! SCii OWNER'S �'jlli✓ �.� ...._R^•L"�C/JLC . . .I'n �� I REQUEST OWNER'S PERMI3SION TOALLOW � '}-L � AGE DRNERS LICENSE NO. STATE� EXP. �� 7-'( �� i� i� O f � 1 � � ..._.�_�. ^ _._._...__..__._._.�......_.__ .._... . � �O -" " O WHO IS UNDER MY CONTROL AND DIRECTION TO DRIVE VEHICLE FOR ME AND ON MY BEHALF.1 AM RESPON- 7�-—L .�_.�._...�.._ SIBLE FOR THEIR TS WHILE THEY ARE DRIVING ND FOR FULFILLING TERMS AND CONDIT�ONS OF THIS J- �^a^ -�� a�q RENTAL A6 E (AGREEMEN .USE OF VEH LE B��UNAUTJ�10RIZE0 ORIVER WILL AFFECT MY LIABIL- W ITY AND R T ER THIS AG .--. _ . ....__. .._...__.._._..__. WINDSHIELD OK7 NO � � f . � :•n :a.!-• F � �, t':,1p(�r ..�- �t.�iJ1V�i L�� V�i F'fH1YL=� OESCRIPTION: BECI-TE@. ,o�f`f HAIL DAMAGE? YES PERMISSI N D TO OPERATE VEHICLE ONLY IN THE STATE Of RENTAL AND THE FOLLOWING STATE(S): ( F OUT E 1/8 1/4 3/B 1/2 5/8 3/4 7/8�F �'�� ... �J�I j � ��'l {x' "� F � ... � �:_.��I.t"i- 'C�i � ` F4= .. l. ... _ ... e v�� .a3�;�li��?� �ei!.r3r�-' �(�i �!I i`#1 5f�[t..=;, �:..:�: ��TA.t� : �E L IN : E 1/8 1/4 3/8 1/2 518 3/4 7/8 F � � OPERA110N IN ANY OTHER STATE OR COUNTRY WILL AFfECT YOUR LIABILRY AND RiGHTS UNDER THIS AGREEMENT. �;.�n ��. ��.�t��k� _ . _ REN7EROECLRESOPfqW1LCdL&ON RENTERAIXIX�ISOPfI0Ni1LCOLl15pNUAYAGEWNVF.R .... MWYGEWNVER(�M�AND A4SUIES WIM�GE T FEE SHOWN IN COLUMN TO RIGHT.SEE � RE.9POIl%l1iY.5EE PARAGRAPH 6. TO LEF'f AND PARAGRAPH 16.COLU$IQN� •X . n ... _.... . .. ._..,.. _.._" __. _.._. x � " °`"`r '/ ` E�I '��.;��'ti�'3'f_� � RENIEROECtIlES PE60NALACdOB7f RENTERACC�fSOPiqNRLiERSON�LACCIDFNf � -.'.'--.___._.'-_.._.-- MSURI{NCE(PAI�.SEE PARAGRAPFi 9. NSURANCE /�I�AT FEE SHOWN IN COLUMN TO -.18..-.z.._.._.�._._._� :X .. !` � ._.._ ... .... . ' X _.,,_a,.:,;��r•,� .._. �� Cy �'_`..i�l��S��.. _. � RENTEROEq.fESOPIpIMI.S11PPlH�BIfKW19LfiY RENTERMx@TSOP710W1L91RPlH61ULlJqBIIfY �;X� �'-.� i-'.• .._. . ._. . _. _ __. PROIECIpN�p SEE P 7. PIm1EC110N ISLP1 AT FEE SFpNM M CALUMN TO X RIGFii.SEE PAIiAGRAPH 77. � X Lt ".. : ... � ...,. ... .. .. _.. _..._.. ._._.. ....... ... .. _ � RENfEROECI�ES AS&S�ANCE RENTERACC�ISOPfqN�LRORD8�EA3SISfANCE . .. . P�710N�SEE PROTECIION AT FEE SHUNN IN COLUMN TO �;X � -" GG;T? . � ..a. wcrrr.s� a�ooucrs rmnce ro�eFr �4. ��..,. u�?Y. _....._ ....-----._ AND PARAGRAPH 19. . __._. •X llc °�:�;' ...... ,......._..... .._..__.__ ...___..,.__..�__._..____.._.._.__ � • i • . • • '� '• � r'� F -+ �t�+r �� _c.ItE�__l,li�.h,�_.�5��_51_�. ' 4 __..__ __ . .• � �� __. .__. _ � j — '� :;:i'�l:_`.;i`w REPLACEMENT VEHICLE �� -�-, o rE BALES ?�S}t 7,.��5t __.__ A u OWNER EMPL. E�.i�E:.V tR� REt�i AL Gfi� TA: ?,^{�r E 7 REP X # �,��. ��.I��S�Ti_{�?� ��.....� L'{'�e .._ _. CoLOR LICENSE No. I WILL RETURN CAR BY: DEPOSR�S�: DATE TIME AMOUNT ' PND BY --_---- --------- ., -, - •-., , � --- ---__ -._--._. .. ._....._.._'____ MODEL ECARft n r. r� � � i-ra r�•i �1i1��1I�c?1 ��;,:;}�-, .,-;rr�:. _.N�r- � �1'_ ��..�t�:.� ; MILE- IN _ , � AGE OUT . � �' . .. .... ....__...._'-_—_-__ _ . . __.._...__.__.. DRIVEN AUTpMOBILE INSURANG'E POI.ICY MUST(1)COVER THE RENTAL OF THIS MOTOR VEHICLE AGAINST -I-I��I t.y SV t.��. _.._....... _. ._.. �'��•� �°�— DAMAGE TO THE VEHI(�.E AND AGAINST LOSS HICLE; (2)EXfEND THE TOTAL CHARGES � -.. .. O W POIJCI"S BASIC ECONOMIC LOSS BENEFITS, SIDUAL LIABI(JTY INSU D UNINSURED __. _ ....__ �_.___ __. .__- __�.___ a AND UNDERINSURED MOTORIST COVERAGES T A REMED MOTOR DEPOSITS � 9V�o VEHICLE.THEREFORE,PURCHPSE�ANY COWSION DAMAGE WANER OR SIMILAR INSURANCE _ _ __ Z AFFECTED IN THIS RINfAL CONffRACT IS NOT NECESSARY. IN ADDmON, P U R C H A S E O F/�M' REFUNDS �O° Oo � ADDt110NAL LIABIIf TY INSURANCE IS NOT NECESSARY IF YOUR POLICY WAS ISSUED IN MINNESOTA . � � WINDSHIELD OK? ves�NO ��YOU WISH TO HAVE COVERAGE FOR LIABILITY THAT IXCEEDS THE AMOUNT SPEGFlED IN oescRiP-norv: YOUR PERSONAL AUTOMOBI�E INSURANCE POIJCY.BY MY SIGNATURE BELOW,I ACKNOVVI.EDGE ��ED BY HAIL DAb1AGE7 YES NO T�{qT I HAVE READ AI�UNDERSTAND THE ABOVE NOTICE INCLUDED IN THE SEPARATE FORM CASH CHECK CHA' PAID BY F WT E 1/B ,�< � ,n �e �< ��e F � IN THE SEPARATE MINNESOTA COWSION DAMAGE WANER FORM ON PAGE 3. E �1C1 t_�+�:�(�Ii;1P f'��itl�CfS �� DATE AMOUNT RECEIVE � in e v v �e �n s�e aa �re F cast+�FUrm OWNER IS AN AFFILIATE OF ENTERPRISE HOLDINGS INC.,WHICH OWNS ALL RIGHTS TO ENTERPRISE NAMES AND MARKS. � r O Enterprisei Leasing Company of Minnesota,LLC N•�n 4•ilai'� a...alY