Nelson, Lea RECEIVED
FEB 2 0 201�
NOTICE OF CLAIM FORM to the City of Saint Paul, Mi�p���.ERK
Minnesota Stnte Stntute 466.05 stntes thnt "...eve,ry person...who cinims cfamages fro►n nny municipaliry...shall cnuse to l�e presented to the
governing I�ody of the municipality within 180 days after the n!leged loss or injury is discovered a notice statrng the time,pince,nnd
circcunstances thereof,and dze amount of compensntion or other relief demnnded."
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�` Middle Initial�Last Name N �.15 V ��
Company or Business Name � �`� � � �` " " ��-
Are You an Insurance Company? Yes No If Yes,Claim Number? '
Street Address "1 �5 � C a r' �--��- G'��`f�
City ��`� ���f ��.�P State_fi „ (� Zip Code S�����
Daytime Phone ((�!) 23b 2-°�`'Cell Phone (�05�� )� �3�' Evening Telephone( ) -
Date of Accidend Injury or Date Discovered�_�� 2-� ��� Time�9� n�pm
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. � ��.�> o.�-
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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 damaged by a pothole or condition of the street .��y 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
0 Other type of injury-please specify
In order to process your claim you need t�include copies of all anplicable documents.
For the claims types listed below,please be sure to inclu�e 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 esti�nates 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- lease com lete this section _�
Were there witnesses to the incident? Ye� No Unknown (circle)
Provide their names, addresses and telephone numbers: �� ? � ? �
Were the police or law enforcement called? Yes'� No Unknown (circle)
If yes, what depaRment or agency. �\ - ��. �--- Case#or report# I� 1 (_3 3 �
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.S�-a� � �-
��-u'�Z � ��-'C '�.� C,.(�C� S ��c��l�c���� o�vL �� S�,�r���cd ., S �L�- S��\L,
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:- � � —
E, �Vehicle Claims- lease com lete this section ❑ check box if this section does not a 1
Your Vehicle: Year 2�b� Make � a�c� Model ��w.�`b.� G.� �,
� License Plate Number '- - �l. State��Color ��.s e�
Registered Owner �i e��. o.
Driver of Vehicle S ��: c� '— ��
Area Damaged �c'� � �
City Vehicle: Year ? Make r` Model �
License Plate Number 4 5�4s�° State Color ? v��"��'
��1�rn4,pl
Driver of Vehicle(City Employee's Name) �hN • o ��3
Area Damaged _
Iniurv Claims-please complete this section l�check box if this section does not apnlv
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 ot�your Employer:
Address Telephone
`�heck here if you are attaching more pages to this claim form. Number of additional pages�. �Z
Pu-�'��
By signing this form,you are stating that all information you have provided 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 �-� ,�� ��
�` ` � `
Print the Name of the Person who Complete, this Form: Jc<,��/`C�c�,�C \��.
�z � 1
�° �
Signature of Person Making the ClaimE � �i' �;�:L'
Revised February 201 1 Iv
RS COLLISION &CUSTOM Workfile ID: 8c67324b
2382 LEIBEL ST, WHITEBEAR LAKE, MN 55110
Phone: (651) 653-3625
Preliminary Estimate
Customer: NELSON, LEA
Written By: RON SMITH
Insured: NELSON, LEA Policy#: Claim#:
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact:
Owner: Inspection Location: Insurence Company:
NELSON, LEA RS COLLISION&CUSTOM
4351 CIRCLE DR 2382 LEIBEL ST II
WHIfE BEAR LAKE,MN 55110 WHITEBEAR LAKE,MN 55110
(651)278-2030 Cell Repair Facility
(651)653-3625 Business
VEHICLE
Year: 2004 Body Style: 4D H/B VIN: 1GiZT64894F209234 Mileage In:
Make: CHEV Engine: 6-3.SL-FI License: 403HVL Mileage Out:
Model: MALIBU MNO(LS Production Date: State: Vehide Out:
Color: Int: Condition: Job#:
TRANSMISSION Dual Mirrors Telescopic Wheel ROOF
Automatic Transmission Body Side Moldings RADIO Skyview Roof
Overdrive Console/Storage AM Radio SEI►TS
POWER CONVENIENCE FM Radio Cloth Seats
Power Steering Air Conditioning Stereo Bucket Seats
Power Brakes Intermittent Wipers CD Player WHEELS
Power Windows Tilt Wheel SAFETY Aluminum/Alloy Wheels
Power Laks Cruise Control Drivers Side Air Bag PAINT
Power Mirrors Rear Defogger Passenger Air Bag Clear Coat Paint
Power Adjustable Pedals Keyless EnUy Anti-Lock Brakes(4) OTHER
DECOR Message Center 4 Wheel Disc Brakes Traction Control
2/6/2014 1:32:14 PM 307800 Page 1
Preliminary Estimate
Customer: NELSON, LEA
Vehicle: 2004 CHEV MALIBU M�W(LS 4D H/B 6-3.5L-FI
Line Oper Description Part Number Qty Eutended Labor Paint
Price$
1 FRONT BUMPER
2 * Rpr Bumper cover �Q 2.6
3 Add for Ciear Coat 1.0
4 0/H bumper assy ! 2.0
5 GRILLE
6 Repl Molding 22686449 1 179.33 0.5
7 FRONT LAMPS
8 ** Repl A/M CAPA RT Headlamp assy I 15851372 1 178.96 0.3
9 Aim headlamps 0.5
10 HOOD
11 ** Repl A/M CAPA Hood 22730964 1 327.00 1.0 3.0
12 Add for Clear Coat 1.2
13 Add for Underside(Complete) 1.5
14 FENDER
15 Blnd RT Fender 0.9
16 Blnd LT Fender 0.9
17 # Subl Hazardous waste removal 1 8.00 T
18 # Repi Cover Car 1 6.00 T 0.2
19 # Repl Flex additive 1 8.00 T
SUBTOTALS 707.29 7.5 il.i
ESTIMATE TOTALS
Category Basis Rate Cost$
Parts 685.29
Body Labor 7.5 hrs @ $54.00/hr 405.00
Paint Labor 11.1 hrs @ $54.00/hr 599.40
Paint Supplies il.l hrs @ $34.00/hr 377.40
Miscellaneous 22.00
Subtotal 2,089.09
Sales Tax $ 1,084.69 @ 7.1250% 77Z8
-
Grand Total 2,166.37
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 2,166.37
THIS IS A VISUAL ESTIMATE ONLY. PARTS AND LABOR MAY BE MORE APON TEAR DOWN AND INVOICES. NO
WARANTY ON RUST REPAIR
MN ST 60A.955 - A PERSON WHO FILES A CLAIM WITH INTENT TO DEFRAUD OR HELPS COMMIT A FRAUD
AGAINST AN INSURER IS GUILIY OF A CRIME.
2/6/2014 1:32:14 PM 307800 Page 2
Preliminary Estimate
Customer: NELSON, LEA
Vehicle: 2004 CHEV MALIBU MA)OC LS 4D H/B 6-3.5L-FI
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
DRiCP04, CCC Data Date 2/3/2014, 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 (�) 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 Equiprfnent Manufacturer aftermarket parts are described as Non
OEM or A/M. Used parts are described as LKQ, RCY, or U�ED. 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=Blend. BOR=6oron 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. O/H=Overhaul. Qty=Quantity. Refn=Refinish. Repl=Replace.
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 ESTIMATING GUIDE:
BAR=Bureau of Automotive Repair. EPA=Environmental Protection Agency. NHTSA= National Highway
Transportation and Safety Administration. PDR=Paintless Dent Repair. VIN=Vehicle Identification Number.
2/6/2014 1:32:14 PM 307800 Page 3
Preliminary Estimate
Customer: NELSON, LEA
Vehide: 2004 CHEV MALIBU MNOC LS 4D H/B 6-3.5L-FI
ALTERNATE PARTS SUPPLiERS
Supplier: Pams Auto INC
Location(s): 7505 RIDGEWOOD ROAD,ST CLOUD MN 56303 (800)9842359
Line Desaiption Item# Price
8 A/M CAPA RT Headlamp assy 114007791585137 $ 178.96
2
Supplier: Keystone-P+A-Minneapolis
Location(s): 3615 MARSHALL STREET NE,MINNEAPOLIS MN 55418 (800)328-1845 (612)789-1919
Line Description Item# Price
11 A/M CAPA Hood GM1230320PP $327.00
2/6/2014 1:32:14 PM 307800 Page 4
LATUFF BROS., INC.
880 UNIVERSITY AVENUE
ST. PAUL, MINNESOTA 55104
(651)224-2828 FAX:(651)291-0677
FEDERAL ID#41-0777034
***PRELIMINARY ESTIMATE'**
01/29/2014 02:13 PM
Owner
Owner: LEAH NELSON
Address: 4351 CIRCLE DRIVE Work/Day:
Home/Evening: (651)278-2030
City State Zip: White Bear Lake, MN 55110 FAX:
Inspection
Inspection Date: 01/29/2014 02:11 PM Inspection Type:
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: Front Secondary Impact:
Appraiser Name: MATTHEW HOWARD Appraiser License#:
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 Work/Day:
Email: general@latuffbrothers.com
Vehicle
2004 Chevrolet Malibu MAXX LS 4 DR Hatchback ,
6cyl Gasoline 3.5
4 Speed Automatic
Lic Expire: VIN: 1G1ZT64894F209234
Veh Insp#: Mileage Type: Actual
Condition: Code: U2653B
Ext.Refnish: Two-Stage Int.Refinish: Two-Stage
Options
AM/FM CD Player Air Conditioning Alarm System
Aluminum/Alloy Wheels Anti-Lock Brakes Center Console
Cruise Control Dual Airbags Intermittent Wipers
Keyless Entry System Lighted Entry System Power Adjustable Pedals
Power Brakes Power poor Locks Power Mirrors
Power Steering Power Windows Rear Window Defroster
Rem Trunk-L/Gate Release Second Row Fixed Sunroof Tachometer
Telescopic Steering Whl Tilt Steering Wheel Tinted Glass
Tonneau/Cargo Cover Traction Control System Velour/Cloth Seats
Ot/29/2014 02:15 PM Page 1 of 3
2004 Chevrolet Malibu MAXX LS 4 DR Hatchback
Claim#:
01/29/2014 02:13 PM
Damages
Line Op Guide MC Description MFR.Part No. Price ADJ% B% Hours R
Front Bumner
1 N 34 Frt Bumper Cvr Overhau Additional Labor 3.1 SM
2 I 6 Cover,Front Bumper Repair 4.0* SM
3 L 6 13 Cover,Front Bumper Refinish 3.7 RF
2.6 Surface
0.6 Two-stage setup
0.5 Two-stage
4 RI 76 Brkt,Front Lic Plate R&I Assembly 0.2 SM
Front End Panel And Lamps
5 E 158 MIdg,Grille Upper 22686449 GM Part $179.33 INC SM
6 E 42 Headlamp Assy,Halogen RT 15851372 GM Part $210.90 INC SM
7 N 973 Headlamps Aim Additional Labor 0.4 SM
Front Body And Windshield
8 EU 83 Panel,Hood Replace Recycled $225.00" +25.00 1.1 SM
9 L 83 Panel,Hood Refinish 5.0 RF
3.0 Surface
1.2 Edge
0.8 Two-stage
10 RI 86 Pad,lnsulator Hood R&I Assembly 0.3 SM
Manual Entries
11 SB Hazardous Waste Removal Sublet Repair $5.00* SM*
12 L Corrosion Protection Refinish 0.3' RF*
12 Items
MC Message
13 INCLUDES 0.6 HOURS FIRST PANEL TWO-STAGE ALLOWANCE
Estimate Total 8 Entries
Gross Parts $390.23
Other Parts $225.00
Paint Materials $288.00
Line Item Markup $56.25
Parts 8 Material Total $959.48
Tax on Parts 8�Material @ 7.625% $73.16
Labor Rate Replace Repair Hrs Total Hrs
Hrs
Sheet Metal(SM) $52.00 1.6 7.5 9.1 $473.20
Mech/Elec(ME) $85.00
Frame(FR) $75.00
Refinish(RF) $52.00 9.0 9.0 $468.00
Paint Materials $32.00
Labor Total 18.1 Hours $941.20
Sublet Repairs $5.00
Gross Total $1,978.84
Net Total $1,978.84
Ot/29/2014 02:15 PM Page 2 of 3
2004 Chevrolet Malibu MAXX LS 4 DR Halchback
Claim#: 01I29I2014 02:13 PM
Alternate Parts No
SPPL Yes Zip Code:55104 Default
Audatex Estimating 7.0.123 ES 01/29/2014 02:15 PM REL 7.0.123 DT 12/01/2013 DB 01/15/2014
Copyright(C)2013 Audatex North America,Inc.
1.9 HRS WERE ADDED TO THIS ESTIMATE BASED ON AUDATEX'S TWO-STAGE REFINISH FORMULA.
THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF ONE OR MORE CRASH PARTS
SUPPLIED BY A SOURCE OTHER THAN THE MANUFACTURER OF YOUR MOTOR VEHICLE.
WARRANTIES APPLICABLE TO THESE REPLACEMENT PARTS ARE PROVIDED BY THE PARTS
MANUFACTURER OR DISTRIBUTOR RATHER THAN BY THE MANUFACTURER OF YOUR VEHICLE.
A PERSON WHO FILES A CLAIM WITH INTENT TO DEFRAUD OR HELPS COMMIT A FRAUD
AGAINST AN INSURER IS GUILTY OF A CRIME.
Op Codes
* = User-Entered Value E = Replace OEM NG= Replace NAGS
EC= Replace Economy OE= Replace PXN OE Srpls UE= Replace OE Surplus
ET= Partial Replace Labor EP= Replace PXN EU= Repiace Recycled
TE = Partial Replace Price PM= Replace PXN Reman/Reblt UM= Replace Reman/Rebuilt
L = Refinish PC= Replace PXN Reconditioned UC= Replace Reconditioned
TT = Two-Tone SB= Sublet Repair N = Additional Labor
BR= Blend Refinish I = Repair IT = Partial Repair
CG= Chipguard RI = R&I Assembly P = Check
AA= Appearance Allowance RP= Related Prior Damage
This report contains proprietary information of Audatex and may not be disclosed to any third party(other than
the insured,claimant and others on a need to know basis in order to effectuate the claims process)without
�f���t�� Audatex's prior written consent.
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�+$u��id�tlrFijrd7ijr
- Copyright(C)2013 Audatex No�th America,Inc.
Audatex Estimating is a trademark of Audatex North America, Inc.
Page 3 of 3
Ot/29/2014 02:15 PM