Aden KtLEIVED
FEB 20 20�4 RECEIVEp
NOTICE 4F CLAIM F4RM to the City o#�����Vlinn�t�� 2���
:tlirrrres��trr Sru1e Slatule�F66.I1�slcrtes tlrcil "...c��cri�pciT011...it'ITO CI(llJliS(ICU17(?QCS�/'ORi CDlP At1[!l1Clp(JIN)�...shall cattse t �'�f'�r'�!�j tc�
��orernii;�borly�f dre�nru�ricirtrlily trr�lri�r/HU�lir}s a/ier rhe a!lt:Xerf loss or ii jun�is rliscvvered a�iolice srarr�r;11re�ile!p�trccl•e►kd��K
circirnrstances lhereoj n,�d die rrnrnrr�n oJ'caupe�rsarimr nr other reticf de���niiderL"
P�ease complete this form in its entirety by clearl��typing or printing your ans�►�cr to eacl�question. If more space is
needed,attach additional sl�eets. Please note tliat you ma,y or may not be contacted by telephone to discuss your claim
circurnstances,so provide as mucli information as necessae-��ta explain your claim,and the amount oi compensation bcing
reyucstcd. This forni must be signed,and bath pages complcted. If somcthing does not apply,write`n/A'.
SEND C���IPLETED FOR11I AND OTHER DOCtil��E1VTTS TO:
CITY CLERK, 15 VVEST KELLOGG BLVD,310 CITY I3ALL, SAIVT PAtiL, NIN SS1U2
First Name J� 4Z�� �Q Middle Initial� I,ast Name_ �1 �`P "1
Company or Bu.siness NaYne, if applicable L ' � v� � �C'� l/�e'�'-
Street Address I d SI �9`�h r���_ Sf v$�
City f� .� :� 1 ►'� �°S State��} Zip Code .�,l�
Daytitne Telephane r��j �'��2=q�g3 Evening Telephone(l�r�) � ��— `�3��
Date ofAccident/Injury or Date Discovered �/1 f��(1� Time ` �d0 �,�pm (circle)
Please state, in detail, �uhat occurred, and why you are submitting a claim. Please indicate whv or how you
fccl the City of'Saint Paul ar its c Zployees ar in oivecl and/or r sponsible. -
c� � � C � 1�Yt
f
Please check the box(es) that most closely represent the reason for o pleting this fomi:
O Vehicle was damaged in an accident Vehicle�i�as damaged durin�a tow
❑ Vehicle was damaged by a pothole or condition of the street � ehicle�ras dama�ed by a plo��v
O Vehicle wa,S wrongfully towed and/or ticketed O Injured on City property
❑ Other type of property damage—please spccify �
❑ Other type of injury--please specify
❑ Other tS�pe not listed—please specify�o �'�(� �;_.� � C.��/1
]n order to process your claim �ou need to include copies of all applicable documents. This is a generaI
�uideline af what should be submitted��ith a claim form, but it is not aIl inclusive. You may be asked to
provide additional inforn�ation depending on your claim.
� Property damage claims to a vehicle: at least two estimates far the repairs to youx vehicle;or the
actual bills andJor rcccipts for the repairs
O Towing claims: legible capies of any tickets issued and copies of the impaund lot receipts
� Other property damage:repair estimates, detailed list of damaged items
O injury claims: medical bills, receipts
O Photographs can be provided but will not be rehirned.
Page 1 of 2—Please complete and return both pages of Claim Form
Failure to providc a completed claim form will result in delays in processing.
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x.tEd�o atueu`uot��as.za�ui=�aa��s ssaa� `553II?�lE ��.I�S aplAO.itj �2�EId a3(Ll�5111[LIT.IO�UaPi��B at(� �lp a.Iai.�
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�,,,,�,..-
HEPPNER'S AUTO BODY (Downtown) Workfile ID: 22fffa61
� EPPNER�S 395 E. 7TH ST., SAINT PAUL, MN 55101
� � � � ' Phone: (651) 224-5644
FAX: (651) 224-6042
Preliminary Estimate
Customer: ADER, SADEYO ]ob Number:
Written By: Marshall Mizuno
Insured: ADER,SADEYO Policy#: Claim#:
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact: 12 Front
Owner• Inspection Location: Insurance Company:
ADER,SADEYO HEPPNER'S AUTO BO�Y(Downtown) TOWING COMPANY
1051 19TH ST APT#308 395 E.7TH ST.
DES MOINES,IA 50314 SAINT PAUL, MN 55101
(612)232-9393 Cell Repair Facility
(651)224-5644 Busin�ss
��
VE�IICLE
Year: 2002 Body Style: 4D SED VIN: 1N4ALi1DX2C193185 Mileage In:
Make: NISS Engine: 4-2.SL-FI License: 552-ZNQ Mileage Out:
Model: ALTIMA S Production Date: i/2002 State: IA Vehicle Out:
Color: SIIVER Int: Condition: ]ob#:
TRANSMISSION Body Side Moldings RADIO Cloth Seats
Overdrive Tinted Glass AM Radio Bucket Seats
5 Speed Transmission Console/Storage
FM Radio Reclining/Lounge Seats
POWER CONVENIENCE Stereo WHEELS
Power Steering Air Conditioning Search/Seek Wheel Covers
Power Brakes Intermittent Wipers CD Player PAINT
Power Windows Tilt Wheel SAFETY Clear Coat Paint
Power Locks Cruise Control Drivers Side Air Bag OTHER
Rear Def er Passenger Air Bag Power Trunk/Gate Release
Power Mirrors °99
DECOR Keyless Entry � 4 Wheel Disc Brakes
Dual Mirrors Telescopic Wheel SEATS
2/18/2014 2:43:02 PM
070412 Page 1
� '
Preliminary Estimate
R Customer: ADER, SADEYO Job Number:
Vehicle: 2002 NISS ALTIMA S 4D SED 4-2.5L-FI SILVER
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
ARF3745, CCC Data Date 2/14/2014, 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 Equipment Manufacturer aftermarket parts are described as Non
OEM or A/M. Used parts are described as LKQ, RCY, or U,SED. 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=Miscelfaneous 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=Discohnect 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.
Page 3
070412
2/18/2014 2:43:02 PM
' RAYMOND AUTO BODY� INC. Workfile ID: 3bcd9ad8
FederalID: 41-0888257
1075 PIERCE BUTLER RTE, SAINT PAUL, MN
55104
Phone: (651) 488-0588
FAX: (651) 488-4794
Preliminary Estimate
Customer: ADEN, SADIYO 7ob Number:
Written By:JERRY SLOMKOWSKI
Insured: ADEN, SADIYO Policy#: Claim #:
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact:
Owner: Inspection Location: Insurance Company:
ADEN,SADIYO RAYMOND AUTO BODY,INC.
(612)232-9393 Day 1075 PIERCE BUTLER RTE
SAINT PAUL, MN 55104
Repair Facility
(651)488-0588 Business
VEHICLE
Year: 2002 Body Style: 4D SED VIN: 1N4AL11DX2C193185 Mileage In:
Make: NISS Engine: 4-2.5L-FI License: Mileage Out:
Model: ALTIMA 5 Production Date: State: Vehicle Out:
Color: Int: Condition: Job#:
TRANSMISSION Body Side Moldings RADIO Cloth Seats
Overdrive Tinted Glass AM Radio Bucket Seats
5 Speed Transmission Console/Storage FM Radio Reclining/Lounge Seats
POWER CONVENIENCE Stereo WHEELS
Power Steering Air Conditioning Search/Seek Wheel Covers
Power Brakes Intermittent Wipers � CD Player PAINT
Power Windows Tilt Wheel SAFETY Clear Coat Paint
Power Locks Cruise Control Drivers Side Air Bag OTHER
Power Mirrors Rear Defogger Passenger Air Bag Power Trunk/Gate Release
DECOR Keyless Entry 4 Wheel Disc Brakes
Dual Mirrors Telescopic Wheel SEATS
2/18/2014 12:59:54 PM 019495 Page 1
Preliminary Estimate
Customer: ADEN, SADIYO )ob Number:
Vehicle: 2002 NISS ALTIMA S 4D SED 4-2.5L-FI
Line Oper Description Part Number Qty Extended Labor Paint
Price�
1 FRONT BUMPER
2 0/H bumper assy 2.1
3 * Rpr Bumper cover "i.Q 3.2
4 Add for Clear Coat 1.3
SUBTOTALS 0.00 5.1 4.5
ESTIMATE TOTALS
Category Basis Rate Cost;
pa� 0.00
Body Labor 5.1 hrs @ $59.00/hr 300.90
Paint Labor 4.5 hrs @ $59.00/hr 265.50
Paint Supplies 4.5 hrs @ $39.00/hr 175.50
Body Supplies 3.0 hrs @ $8.00/hr 24.00
Subtotal 765.90
Sales Tax $ 199.50 @ 7.6250% 15.21
Grand Total 781.11
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 781.11
WHILE WE HAVE MADE EVERY EFFORT TO WRITE A COMPREHENSIVE REPORT OF THE VISIBLE DAMAGE TO YOUR
VEHICLE, IT IS IMPORTANT TO REMEMBER THAT THIS IS ONLY AN ESTIMATE.
THERE ARE A NUMBER OF FACTORS THAT CAN AFFECT THE ACTUAL COST OF REPAIRS, INCLUDING BUT NOT
LIMITED TO HIDDEN DAMAGE, PARTS PRICE CHANGES, AND INSURANCE COMPANY INVOLVEMENT.
PLEASE CONSIDER THIS WHEN MAKING DECISIONS REGARDING THE REPAIRS TO YOUR VEHICLE.
2/18/2014 12:59:54 PM 019495 Page 2
� Preliminary Estimate
Customer: ADEN, SADIYO 7ob Number:
Vehicle: 2002 NISS ALTIMA S 4D SED 4-2.5L-FI
QUALITY REPLACEMENT PARTS WARRANTY
OUR REPAIR ESTIMATE MAY SPECIFY THE USE OF QUALITY REPLACEMENT PARTS. QUALITY REPLACEMENT PARTS
ARE PARTS NOT MANUFACTURED BY OR FOR THE ORIGINAL EQUIPMENT MANUFACTURER. WE WILL STAND
BEHIND THE QUALITY REPLACEMENT PARTS THAT ARE SPECIFIED ON THIS ESTIMATE AND USED IN THE REPAIR
OF YOUR VEHICLE, FOR AS LONG AS YOU OWN/LEASE THE VEHICLE. WE WARRANT THESE PARTS ARE OF LIKE
KIND, QUALITY, SAFET`(, FIT AND PERFORMANCE TO PARTS MANUFACTURED BY OR FOR THE ORIGINAL
EQUIPMENT MANUFACTURER.
THIS WARRANTY EXCLUSIVELY COVERS LOSS OR DAMAGE THAT IS RELATED TO DEFECTS IN THE QUALITY
REPLACEMENT PART. THIS WARRANTY DOES NOT COVER DAMAGE OR PART FAILURE DUE TO IMPROPER
INSTALLATION, MISUSE, NEGLECT, ABUSE, IMPROPER MAINTENANCE, ABNORMAL OPERATION, OR NORMAL WEAR
&TEAR.
SHOULD A SUPPLIER OF A PART SPECIFIED IN OUR REPAIR ESTIMATE, OR THE REPAIR FACILITY THAT PERFORMS
THE REPAIR ON YOUR VEHICLE, BE UNABLE TO RESOLVE A LEGITIMATE COMPLAINT ABOUT THE QUALITY
REPLACEMENT PART USED IN THE REPAIR, WE WILL MAKE EVERY EFFORT TO SEE THAT THE PROBLEM IS
CORRECTED.
THIS WARRANTY AND ANY REPRESENTATIONS MADE HEREIN ARE NON-TRANSFERABLE AND EXTEND ONLY TO
THE PARTY OWNING/LEASING THE VEHICLE AT THE TIME OF THE REPAIR.
FOR ASSISTANCE, PLEASE CONTACT THE NEAREST CLAIM DEPARTMENT OFFICE.
DISCLAIMER: __.
ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT INSURANCE CLAIM FOR THE PAYMENT OF A
LOSS MAY BE GUILTY OF A CRIME AND MAY BE SUB)ECT TO FINES AND CONFINEMENT IN STATE PRISON.
THE LABOR AND TAX RATES USED WERE DETERMINED BY THE VEHICLE INSPECTION LOCATION UNLESS THE
REPAIR FACILITY WAS KNOWN AT THE TIME OF THE INSPECTION OR ANOTHER LOCATION WAS SPECIFIED
BEFORE THE ESTIMATE WAS PREPARED
THIS IS NOT AN AUTHORIZATION TO REPAIR.
TO ENSURE REPAIRS WILL BE COMPLETED BASED ON THIS ESTIMATE; PLEASE PROVIDE A COPY TO THE REPAIR
FACILITY PRIOR TO AUTHORIZING REPAIRS. FAILURE t0 DO SO MAY RESULT IN YOU BECOMING RESPONSIBLE
FOR PAYING UNAPPROVED EXPENSES.
NO PAYMENT FOR A SUPPLEMENT WILL BE APPROVED OR ISSUED UNLESS THE REPAIRS WERE AUTHORIZED
PRIOR TO COMPLEfING THE SUPPLEMENTAL REPAIRS. TO EXPEDITE THE HANDLING OF ANY SUPPLEMENTAL
DAMAGES, PLEASE ACCESS HTTP://WWW.THESHOPOFCHOICE.COM/FARMERS. IF YOU NEED TECHNICAL
ASSISTANCE REGISTERING OR UPLOADING ATTACHMENTS, CONTACT NUGEN IT CUSTOMER SUPPORT AT
(855)-684-3648 BEfWEEN 7 AM AND 7 PM CENTRAL TIME. POTENTIALLY, A REINSPECTION MAY BE NECESSARY.
CIRCLE OF DEPENDABILITY SUPPLEMENTS: CIRCLE OF DEPENDABILITY PROGRAM SHOPS WILL CONTINUE TO
PROCESS SUPPLEMENTS THROUGH THE NORMAL SUPPLEMENT PROCESS. PLEASE CONTACT YOUR FIELD OR
OFFICE CONSULTANT IF YOU HAVE ANY QUESTIONS.
THIS PROCESS DOES NOT APPLY TO BRISTOL WEST.
2/18/2014 12:59:54 PM 019495 Page 3
- ' Preliminary Estimate
Customer: ADEN, SADIYO 7ob Number:
Vehicle: 2002 NISS ALTIMA S 4D SED 4-2.5L-FI
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
ARF3745, CCC Data Date 2/10/2014, 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 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 Structura! 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=Dis¢onnect 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=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=6ureau of Automotive Repair. EPA=Environmental Protection Agency. NHTSA= National Highway
Transportation and Safety Administration. PDR=Paintless Dent Repair. VIN=Vehicle Identification Number.
2/18/2014 12:59:54 PM 019495 Page 4