Vang, Ricky_ �
Nat[onwide Insuranee
Allied Inwrance R E C E i�/E D
Natbmnride Agribusiness
Titan Inaurance F��� 14 2�14
On Your Side Victoria lnsurance
CITY CL�RK
Certified Mail Return Receipt
Date prepared February 10, 2014
City Clerk City of St Paul Claim number 72 22 20 100509
310 City Hall 10162013 01
15 Kellogg Blvd., West
St. Paul, MN 55102 Questions? Contact Claims Associate
Jill Augustine
Augustj2@Nationwide.com
Phone (515)508-3014
Claim details
Insurer: Nationwide Insurance Company of America
Policyholder: Ricky Vang
Claimant: St. Paul Police Department
Claim number: 72 22 20 100509 10162013 01
Loss date: 10-16-2013
Marion Street, St. Paul, MN
TORT CLAIM NOTIFICATION
Dear Clerk,
Enclosed for filing is the original Notice of Claim Form to the City of St Paul and supporting documents
including the police report, PIP log, estimate, audit, photographs of damage to vehicle of Ricky Vang. The
claim arose when a City of St Paul police officer rear-ended a vehicle operated by Ricky Vang while he was
traveling on Marion Street located in St. Paul, Minnesota. The impact damaged Vang's vehicle. Vang also
sustained a personal injury.
At the time of this collision Nationwide Insurance Company of America was the automobile carrier for Vang.
Nationwide compensated Vang for a portion of the damage to his vehicle. Nationwide also made PIP �
payments on behalf of Vang for the personal injuries sustained in the collision. Nationwide has a right of
subrogation to the extent of payments made as a result of this incident. The subrogation claim totals
$9942.26.
Please send you check in the amount of$9942.26 and payable to Nationwide Insurance Company of
America in full and final resolution of this matter. The tax identification number for Nationwide is 95-
2130882. Please mail your check to
Nationwide
1100 Locust, Dept 2019
Des Moines, IA 50391-2019
For more information
If you have any questions or concerns, please contact me at(515)508-3014 or Augustj2@Nationwide.com.
Si
�
`
ill u ine
ationwideTnsurance Company of America
� Nationwide Insurance
A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a
crime.
NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minnesota State Statute 466.05 states that"...every person...who claims damages from any municipality...shall cause to be presented to the
governing body of the mur�icipaliry within 1 SO days after the nlleged loss or injury 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 ooce your form is received. The process can take up to ten weeks or longer depeoding 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 IniUal Last Name
` i �
Company or Business Name�1�A-��c'v c�i-�E ..jti- s u.'q�,c��� � � :� .� q� i � � .�� cl� � i� -�
Are You an Insurance Company`��/No If Yes,Claim Number? �U��a `l
`
7 �.
Slreel Address %�G G �/c l��i S�'f � �f �`L"/ � �
_ ICity,' �z.i �%�C-i ti.�.l State ��� Zip Code �C. �/_���
Daytime Phone(��5�� - 'X•T Cell Phone ( )__- Evening Telephone(_) -
Date of Accident/Injury or Date Discovered/L� /�� �4� 3 Time_"3.'.�Z am/ �m�
Please state,in detail,what occurred(happened), and why you are submitting a claim. Please indicate why or how you
feel the Cpity of Saint Yaul or its employees are involved and/or responsible for' Jyour damages.
l,i�V l-'�.YG�P�— �� �L l � "V!'�l' �L.(� �`� J ` G�1N �an � lM1�� ...]l.G.i�ti: L% '' ��� -E'��lE� /j"7P-��
' � �,� d '� r E/ti' ^u lY t�ac: � tti {. .tuL �,�ti'tSu/��r1
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'I 4 — i , �EV
, ,,, �c Ir r ^� -�
� `f�'�s L�ct�i,1lC�% . '
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 da�naged by a pothole or condition of the street ❑ My vehicle was damaged by a plow
❑ My vehicle was wrongfully towed and/or ticketed ❑ I was injured on City property
I�Other type of property damage—please specify _ - �� 4� d - � , �` ' �"'y'
�] Other type of injury—please specify� �` �s
In order to process your claim v��: n°°d to include copies of all applicable documents.
For the claims types listed below,please be sure to include the documents indica�ed or i�will delay the handling of
your claim. Documents WILL NOT be returned and become the property of the City. You aze encouraged to keep a
copy for yourself before submitting your claim form.
O Property damage claims to a vehicle: two estimates for tbe 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;delailed lisl 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—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-please complete this section
Were�tiere witnesses to the incident? Yes No Unknown (circle)
Provide their names, addresses and telephone numbers:
Were the police or law enforcement calle ? Yes No Unknown (circle)
If yes,what department or agency? �I-- �S �I �����FP �-, Case#or report#�3�2 �L`�6
Where did the accident or injury take place? Provide street address,cross street,intersection,name of park or facility,
closest landmja�rk,etc. Please be as detaile�as possible. If necessary,attach a diagram. NI�,c��� •-S 1�t �-
" I�' f�4S�c � �ti �ti '� CC 7t� + (�b �)F �,.i uL IY�i i M'�/P.l�'�l�
Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim
toy,oursatisfaction. �Y%l � •b� ; r�c�d .y =� ��� �Le.. t�c.<<y i(��,�� c A�� �J's��i�.us S.ab,-c:•�s�t-�
�° .
cl����i �� �1P f�ti,E;l�-
Vehicle Claims please complete this section ❑ check box if this section does not anqlv
Your Vehicle: Year `l y�`� Make l c�y c�l 4- Model U 6�
License Plale Number N �2c State�l v�Color %,+-v
Registered Owner z_ 4 a�
Driver of Vehicle �� M
Area Damaged 'tZ�a�
City Vehicle: Year Make Model
License Plate Number (�Z�Z-�' State:h1N' Color Y��Lc��
Driver of Vehicle(City Employee's Name)�+ ' ��ee w` ���4 » Sa,�d-�r� � ���c.
Area Damaged -� � � � -
Injury Claims please complete this section ❑ check box if this section does not annlv
How were you injured?
What part(s)of your body were injured?
Have you sought medical treatment? �Y�e No Ylanning to Seek Treatment(circle)
When did you receive treatment? ,�z- �-�-�u�<<� �1�P �-�'`� (provide date(s))
Name of Meciical 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: I
Address Telephone
�] Check 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 correet to the best
of your knowledge. Unsigned forms will not be proeessed.
Subrrcitting a false clairn can result in prosecution. Date form was completed�l-'/�U�'��
Print the Name of the Person who Comp his Form: �.�i I f ' �t 1�5�1�
Signature of Person Making the Claim:
�
Revised Februazy 2011
NOV, 27. 2013 4; 02PM RATGEN PERSONAL I�JURY �AW FIRM N0. 278 P. 2
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SC? LU T E t� N �
ExperCis�•Tet:hnok�qy • Ft�sults
� Expense �
� Summary Medical Wage�
Tota I $
Charges 9575.78
Carrier Claim
Date Patient VANG,
Name: Nationwide Number: 7222201005091016201301 of 10/16/2013 Name: RICKY Total PBid g443.26 �
Loss
Applied to �0.00
Deductible
Applied to �p.00
Copay _ �
Expense First Last Billed Recom
Doc ID Type Service Provider/Payee DOS DOS Amount Reim Deductible �op
NF0106096 Medical Cole, David J 2013- 2013- 1820.00 0.00 0.00 0
10-29 11-13
2013- 2013- 1820.00 0.00 0
NF0106096 Medical Cole, David J 10-29 11-13
2013- 2013-
NF0106441 Medical JOHNSON, STEVEN 11-20 11-20 630.00 0.00 0.00 0
2013- 2013- 630.00 0.00 0
NF0106441 Medical JOHNSON, STEVEN 11-20 11-20
2013- 2013- 555.00 555.00 0.00 0
NF0108062 Medical Cole, David) 11-18 11-20
2013- 2013- 310.00 310.00 0.00 0
NF0110282 Medical Cole, David J 11-26 11-27
2013- 2013- 1040.00 1040.00 0.00 0
NF0113914 Medical Cole, David J 12-02 12-11
2013- 2013- 475.00 475.00 0.00 0
NF0116622 Medical Cole, David J 12-16 12-23
2013- 2014- 320.00 320.00 0.00 0
NF0120118 Medical Cole, David J 12-30 O1-08
2013- 2013- 714.00 714.00 0.00 0
NI0329114 Medical MURRAY, SUSAN ANN 12-06 12-06 I
NI0330741 Medical IN)URED WORKERS 2013- 2013- 66.26 0.00 0.00 0
PHARMACY L L C 12-06 12-06
2013- 2013- 3513.00 3513.00 0.00 0
NM1048286 Medical Hatti,Vikram 12-11 12-11
NW1178972 Medical INJURED WORKERS 2013- 2013- 66.26 66.26 0.00 0
PHARMACY 12-06 12-06
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Expense First Last Billed Recom
Doc ID Type Service Provider/Payee DOS DOS Amount Reim Deductible Cop
NW1185723 Medical INJURED WORKERS 2013- 2013- 66.26 0.00 0.00 0
PHARMACY L L C 12-06 12-06
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NATIONWIDE ENTERPRISE
Central Plains Claims Zone-NWIDE
One Nationwide Gateway
DES MOINES, IA 50391
Phone: (763) 267-8656 Claim#: 72222010050910161301R/Vl
FdX: (855) 803-2484 Workfile ID: 9e58157b
Estimate of Record
Written By:JEREMY CHAPMAN,License Number: 116179, 10/22/2013 9:56:51 AM
Adjuster: Chapman,Jeremy,(763)267-8656 Evening
Insured: Ricky Vang Policy#: NATIONWIDE INS COMP Claim #: 72222010050910161301R/Vl
OF
Type of Loss: Collision Date of Loss: 10/16/2013 04:00 PM Days to Repair: 0
Point of Impact: 06 Rear Deductible: 250.00
Owner: Inspection Location: Appraiser Information: Repair Facility:
Ricky Vang Vang,Ricky chapmj2@nationwide.com
375 Farrington St Apt F 375 Farrington St Apt F (763)267-8656
Saint Paul,MN 55103-2354 Saint Paul,MN 55103-2354
(651)202-1495 Evening Home
(651)202-1495 Cellular (651)202-1495 Evening
VEHICLE
Year: 1998 Color: Int: License: Production Date:
Make: TOYO Body Style: 4D SED State: Odometer:
Model: CAMRY LE Engine: 42.2L-FI VIN: 4T16G22K5WU285144 Condition:
TRANSMISSION Dual Mirrors AM Radio Bucket Seats
Automatic Transmission Body Side Moldings FM Radio Reclining/Lounge Seats �
Overdrive Console/Storage Stereo WHEELS
POWER CONVENIENCE Cassette Wheel Covers
Power Steering Air Conditioning SAFETY PAINT
Power Brakes Intermittent Wipers Drivers Side Air Bag Clear Coat Paint
Power Windows Tilt Wheel Passenger Air Bag OTHER
Power Locks Cruise Control Anti-Lock Brakes(4) Power Trunk/Gate Release
Power Mirrors Rear Defogger SEATS
DECOR RADIO Cloth Seats
10/22/2013 9:56:51 AM 116179 Page 1
Claim#: 72222010050910161301R/V1
Workfile ID: 9e58157b
Estimate of Record
1998 TOYO CAMRY l_E 4D SED 4-2.2L-FI
Line Oper Description Part Numbe� Qty Extended Labor Paint
Price$
1 REAR BUMPER
2 R&I R&I bumper cover 1.0
3 * <> Rpr Bumper cover 2_5 2.6
4 Add for Clear Coat 1.0
5 # Repl Flex 1 3.00 T
6 # Repl Hazardous Waste 1 3.00 X
SUBTOTALS 6.00 3.5 3.6
NOTES
Estimate Notes:
NO SUPPLEMENTS WITHOUT AUTHORIZATION.
LKQ SEARCH APS
//////APU CONSENT DECLINED BY OWNER//////
Prior Damage Notes:
RR COVER HAS UPD,MINOR DINGS SCRATCHES
ESTIMATE TOTALS
Category Basis Rate Cost$
Pa� 0.00
Body Labor 3.5 hrs @ $52.00/hr 182.00
Paint Labor 3.6 hrs @ $52.00/hr 187.20
Paint Supplies 3.6 hrs @ $32.00/hr 115.20
Miscellaneous 6.00
Subtotal 490.40
Sales Tax $ 118.20 @ 7.2750% 8.60
Total Cost of Repairs 499.00
Deductible 250.00
Total Adjustments 250.00
Net Cost of Repairs 249.00
The limit of your coverage is the actual cash value of your auto or its damaged parts at the time of loss. Fair market
value, age and condition of your damaged vehicle will be considered when determining the actual cash value of a
loss. Certain parts lose value or depreciate because of age,condition, and/or wear and tear. Betterment is the
increase in value of a vehicle or any of its parts as a result of replacing certain parts damaged in a loss. If the
replacement of certain parts results in an increase in value to your vehicle or any of its parts,a deduction for
betterment may be made to your loss payment to reflect the actual cash value you are owed under your policy.
NWCPP=Nationwide Crash Parts Program
10/22/2013 9:56:51 AM 116179 Page 2
Claim#: 72222010050910161301R/V1
Workfile ID: 9e58157b
Estimate of Record
1998 TOYO CAMRY LE 4D SED 4-2.2L-FI
This is an estimate only and is not an authorization to repair. Additional payment will be made only with the approval
prior to repair.
IMPORTANT! ALL SERVICE PROVIDERS MUST COMPLY WITH STATE AND FEDERAL PRIVACY LAWS, INCLUDING
THE PRIVACY PROVISIONS OF THE GRAMM-LEACH-BLILEY ACT AND WITH ALLIED'S PRIVACY STATEMENT AND
PROVISIONS. ACCORDINGLY,YOU ARE HEREBY NOTIFIEDTHAT CUSTOMER INFORMATION SHARED WITH OR
OBTAINED BY SERVICE PROVIDERS SHALL BE USED SOLELY FOR THE PURPOSE FOR WHICH IT WAS PROVIDED
AND FOR NO OTHER PURPOSE WHATSOEVER.
Nationwide will replace any defective like kind and quality(used), reconditioned, recyclable,and any quality
replacement aftermarket(non-OEM) parts for as long as you own or lease the vehicle.
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 9:56:51 AM 116179 Page 3
Claim#: 72222010050910161301R/V1
Workfile ID: 9e58157b
Estimate of Record
1998 TOYO CAMRY LE 4D SED 4-2.2L-FI
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
AEM8509, 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 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 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=6lend. 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. 0/H=Overhaul. Qty=Quanaty. Refn=Refinish. Repl=Replace. M
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 ES"TIMATING 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 9:56:51 AM 116179 Page 4
10/22/2013 at 14:57
CCC Accumark T"' Audit Report
NATIONWIDE ENTERPRISE
Central Plains Claims Zone-NWIDE
One Nationwide Gateway
DES MOINES,IA,50391
Written By:JEREMY CHAPMAN Appraisal Totals: Claim#:72222010050910161301 RN1
Daytime Contact:(763)267-8656 Last Appraised:$0.00 Policy#:NATIONWIDE INS
COMP OF
Adjuster:Jeremy Chapman Total Appraised:$499.00 Date of Loss:10/16/2013
Daytime Contact: Total Score:25 Type of Loss:Collision
Total Labor Hours:7.1
Total Variance:.00
. ,
Rule Description Line Number Actual Rule Variance Score
BR9:Mileage Unknown 25
'indicates rules with parts detail information
#Rule uses median part price and includes parts detail information
• .. . .
Appraisal Source: Inspection Location:
Addressl : Addressl :
Address2: Address2:375 Farrington St Apt F
City/State2ip: , City/State2ip:Saint Paul,MN 55103
Daytime Contact: Daytime Contact:(651)202-1495
Evening Contact: Evening Contact:(651)202-1495
Appraisal Platform:CCC ONE Inspection Type:HOME
Vehicle Owner:Ricky Vang Vehicle Information: 1998 TOYO CAMRY LE
Addressl : VIN:4T1 BG22KSWU285144
Address2:375 Farrington St Apt F License:
City/State2ip:Saint Paul MN 55103 Odometer:
Daytime Contact:(651)202-1495 Days to Repair:
Evening Contact:(651)202-1495 Driveable:YES
Production Date:
Point of Impact:6.Rear
Page 1 of 1
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