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Halk RECEIVED FEB 19 Z��y� NOTICE OF CLAIM FORM to the City of Saint Paul, Min�e��t CLERK Minnesota State Statute 466.05 states that °...every person...who claims damages from any municipaliry...shaU cause to be presented to the governing body of the municipaliry within 180 days after the alleged 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 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 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��'I�`� Middle Initial � Last Name��/`� Company or Business Name Are You an Insurance Company? Yes��'' If Yes, Claim Number? Street Address �� Cit}� ��,/ / State /� Zip Code_�=J�' i �� Daytime Phone�) ��'� �� Cell Phone( ) - Evening Telephone( ) - I � Date of Accidentl Injury or Date Discovered C�i�. /��Z6/� Tim�3' �' a pm Please state,in detail, what occuned(happened), and why you are submitting a claim. Please indicate why or how you feel the City of Saint Paul or its emplo eus are involved and/or responsible for your damages. � � � �� • � . ,• � . � G:� '�` ✓� e� l_.�( t-1/�A U �L� G�.�. � �L✓� '��s� � .;�c�, � � _ -- ' � �- � _ - - � , �..�GZ m�Q � Please check the box(es)that most closely represent the reason for completing this form: ��'a �� ❑ My vehicle was damaged in an accident ❑ My vehicle was damaged during a tow ❑ My vehicle was damaged by a pothole or c�nc�ition of the street �]VIy v�hicle 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 you nleed 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. O 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 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 comnlete this section Were there witnesses to the incident? Yes No Unknown (circle) . Prov' ir na es, addresses nd tel ho e numbers: i� .� C�. /� �� ' � �� ---,- s Were the police or law enforcement c�11f d? Yes No Unknown (circle) If yes, what department or agency2�?•�f.�l /G'� Case#or report#�� ' �� a- � d�°� Where did the accident or injury take place? Provide street address,cross street, intersection, name of park or facility, c est landmark tc. Please e as detailed as possible. If necessary, att ch a diagram. �� a � Please indicate the amoynt you are seeking in compensation or what you would like the City to do to resol this cl�im to our satisfaction. �' � � � � �� 'X� , ry •� 7 � Vehicle Claims— lease co lete this section check box if this section does not a 1 Your Vehicle: Yea do Make Model �x .— License Plate Number / � L—,I�� State7`Z olor Registered Owner�'�olr�r �� Driver of Vehicle Area Damaged ; _ City Vehicle: Year Make Model License Plate Number State Color Driver of Vehicle(City Employee's Name) Area Damaged � Iniurv Claims—ulease comnlete this see.tion ❑ 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? 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 N� When did you mi�s:.��rk? (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 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 processed. Submitting a false claim can result in prosecution. Date form was completed 2 l� /� Print the Name of the Person who Completed t is Form: l ��C/ �%1 (�f�� Signature of Person Making the Claim: � Revised February 20]1 . 880vrolhers.com •651•224-2828• University q�e � "'"'�+'�atuffbrothers.com � � St. Paul, MN 55104 � � 9 ' LATUFF BROS:,INC. 880 UNIVERSITY AVENUE ST.PA�L,MINNES65 A291 0677 (651)224- 828 FAX:� � FEDERAL ID#41-0777034 ***PRELIMINARY ESTIMATE*"" ��127�2p14 01:45�PM _�----- ______------- Owner ! � i_._.----- Owner: ROBYN KIMAIGA WorklDay: Address: 836 CARROLL APT 2 Celi: (651)206-6576 City State Zip: Saint Paul, MN 55103 F�� -- ---- ---- — _— - ---_____, � Inspegtion , -- -- ----------- Inspection Date: 01/27/2014 01:44 PM Inspection Type: Drive In Inspection Location: Latuff Brothers Inc Contact: Address: 880 University Ave WorklDay: (651)2242828x FAX: (651)291-0677x City State Zip: Saint Paul, MN 55104 WorklDay: Email: general@latuffbrothers.com Primary Impact: Left Rear Corner Secondary Impact: Driveable: Yes Rental Assisted: Appraiser Name: ROBERT LATUFF Appraiser License#: i__._ __-- - � Repairer __-.- ----- --- ---- --- _P ------- Rp ai:er: Latuff Brothers Inc --- -------__ __ Address: 880 University Ave Contact: ------- Work/Day: (651)224-2828 City State Zip: Saint Paul, MN 55104 FAX: (651)291-0677 Email: general@latuffbrothers.com W��Day: ---- - ------__ Remarks ---------__.__---�_._— ___._-._-----__ ___._ ______, ---_..___. _____ ---- �"""`*"**PRELIMINARY ESTIMATE' �— I ,,..*�....�.�.�...., --_...__--- POSSIBLE ADDITIONAL DAMAGE MAY BE FOUND AFTER TEAR DOWN __ -------- -------------_- ; Vehicle ---- - ---__.___-_____-_-_ -_______----------_ __._.._--, 2004 Ford Explorer XLT 4 DR Wagon A -��"------�------- - ' 8cyl Gasoline 4.6 5 Speed Automatic Lic.Plate: 163GKR Lic Expire: Lic State: MN Prod Date: 08/2003 VIN: 1 FMZU73WX4UA13529 Veh Insp#: Mileage: Condition: Mileage Type: Actual Ext. Color: PUEBLO GOLD MET Code: P8453B Ext. Refnish: Two-Stage Int.Color: Ext. Paint Code: G3,M7113A Int. Refinish: Two-Stage Options Int.trim Code: � 01/27/2p7q 01:53 PM � ' Page 1 of 4 r � � i';�>, l 1 . 0112712014 01.45 PM 2004 Ford Explorer XLT 4 DR Wagon Air Conditioning Claim# AMIFM CD Player Anti-Lock Brakes AluminumlAlloy Wheels Automatic Trans 4_Wheel Drive erlTowing Package Alarm System Automatic Dimming Mirror Camp Auto Locking Hubs(4W�1 gucket Seats Dual Airbags Bodyside Cladding Cruise Control Fog Lights Center Console Fender Flares Leather Steering Wheel Electronic Transfer Case Keyless Entry System ppWer Brakes Intermittent Wipers Overhead Console ppWer MirrOrs Lighted Entry System Power Drivers Seat PrivaCy Glass Power poor Locks ppwer Windows Power Steering Rem Trunk-LlGate Release Rear Window Defroster Rear Window Wiper/Washer Tachometer e Rack Split Folding Rear Seat Trailer Hitch RooflLuggag Tinted Glass Tilt Steering Wheel Velour/Cloth Seats _ --- -- ----�I ----- — ----� ! Damages ---- - - — — Line Op Guide MC Description MFR.Part No. Price ADJ% B°/a Hours R Strioes And Mouldinas 1 RI 90 Guard,Stone LT R&I Assembly 0.2 SM Quarter And Rocker Panel .. 2 I 389 Panel,Quarter LT Repair 2.0' SM 3 L 389 Panel,Quarter LT Refinish 2.9 RF 2.4 Surface 0.5 Two-stage Tailgate � 4 I 479 SheIl,Taiigate Repair 3.0' SM 5 L 479 SheIl,Tailgate Refinish 2.8 RF 2.3 Surface 0.5 Two-stage 6 I 375 Applique,Tailgate Repair 2.0' SM 7 L 375 13 Applique,Tailgate Refinish 2.3 RF 1.4 Surface 0.6 Two-stage setup 0.3 Two-stage 8 RI 375 Appiique,Taiigate R&I Assembly 9 E 278 01 N/Plate,Tail ate 1.6 SM 9 4L2Z78425288A $28.63 0.2 SM 10 E 309 N/Plate,Tailgate 1 L2Z7842528GA $23.95 11 E 475 N/Plate,Tailgate 1L2Z7842528NA 0•2 SM 12 RI 496 Emblem,Tail ate $22'53 0•2 SM 9 R&I Assembly 0.2 SM 13 RI 492 Handle,Tailgate Outer R&I Assembly 0.9 SM Rear Bumoer 14 N 456 RR Bumper Cvr Overhaul Additional Labor 15 I 520 Cover,Rear Bumper Re air 2•� SM 16 L 520 Cover,Rear Bumper Refinish �•5` SM 2.6 Surface 3.1 RF I0.5 Two-stage Rear Bodv 1 amnc A11d FlOOr Pan 17 E 533 Taillamp Assembly LT 1 L2Z13405AA $71.44 INC SM Man�al ntrie� 18 N M03 Flex Additive Additional Labor 19 L M14 Corrosion Protection $6.00' RF Refinish 0.3' RF 01/27/2014 01:53 PM Page 2 of 4 0112712014 01:45 PM � RF $�.00• SM 2004 Ford Exp�orer XLT 4 DR Wagon qdditional Labor $5.00• �3* SM` Giaim# 20 N M17 Cover Car Exterior �3* SM" 21 SB M60 Hazardous Waste Removal R&I Assembly REAR LIC PLATE Repair 0,4* SM" 22 R� ROPE LT QTR GLASS $35.00' 23 � RESTRIPE TAPE 1 PNL Replace Economy 24 EC 2q Items MC Message 01 CALL DEALER FOR EXACT PART#1 PRICE 13 INCLUDES 0.6 HOURS FIRST PANEL TW�-STA-----GE A��WAN------CE-------- —_ � -- -__----------_ __ ,------ ----- --- - -- -- � Estimate Total&Entries ___ _____.____-------- ____.____ ------- $146.55 Gross Parts $48.00 Other Parts $364.80 Paint Materials $559.35 Parts&Material Totat @ �625��a $42.65 Tax on Parts&Material Labor Rate Replace Repair Hrs Total Hrs Hrs Sheet Metal(SM) $52.00 4.2 10.9 15.1 $785.20 Mech/Elec(ME) $85.00 Frame(FR) $75.00 Refinish(RF) $52.00 11.4 11.4 $592.80 Paint Materials $32.00 � _ Labor Total 26.5 Hours $1,378.00 Sublet Repairs $5.00 Gross Total $1,985.00 Net Total $1,985.00 Alternate Parts No SPPL Yes Zip Code: 55104 Default Audatex Estimating 7.0.123 ES 01127!2014 01:53 PM REL 7.0.123 DT 12101/2013 DB 01/1512014 Copyright(C)2013 Audatex North America, Inc. 2.4 HRS WERE ADDED TO THIS ESTIMATE BASED ON AUDATEX'S TWO-STAGE REFINISH FORMULA. THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF ONE OR MORE CRASH PARTS SUPPLIED BY A SOURCE OTHER THAN THE MANUFACTURER OF YOUR MOTOR VEHICLE. 6dARRANTIES 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 INTEI�fT TO DEFRAUD OR HELPS COMMIT A FRAUD AGAINST AN INSURER IS GUILTY OF A CRIME. Op Codes 01/27/2014 01:53 PM Page 3 of 4 . � . , . � 011271201401�.45PM 2004 Fora Explorer X�T 4 DR Wagon NG= Replace NAGS Claim#. E = Replace OEM �E= Replace OE Surplus * = User-Entered Value �E- Replace PXN OE Srpls E�- Replace Recycled EC= Replace Economy Ep- Rep�ace PXN �M= Replace RemanlRebuilt ET = Partial Replace Labor pM= Replace PXN RemanlReblt �C= Replace Reconditioned TE = Partial Replace Price pC= Replace PXN Reconditioned N - Additional Labor � = Refinish gg= Sublet Repair �T - Partial Repair TT = Two-Tone � = Repair p = Check gR= Blend Refinish RI = R&I Assembly CG= Chipguard Rp- Related Prior Damage qp,= Appearance Allowance 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 Aj j��y Audatex's prior written consent. �.J /i ,..Su;c�a;.u,nyNn�- Copyright(C)2013 Audatex North America, nc. Audatex Estimating is a trademark of Audatex North Arrerica, Inc. O V27/2014 01:53 PM Page 4 of 4