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F�B 24 2��4
_ �CITY CLEi�K
NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
M7T711QS0!(1 S!Q!C'SIC(!(!/P���.OS S!(1IPS/I1Ci! "...even•person...ii�ho clairns dnrna;es fromi an}�raianiripalir}�_..shal/cause�n be presented ta the
governin,�bnd��njdie m�o�icip�liry wirhin 1�0 dcr�•s cijter the nlleged loss or injurJ�is discovered n nolice stnting[he time,plc�ce,anc!
�irccnnsinnces therrof;nnd Ihe ctmotml u�compensntion or o!lter 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 expiain your claim,and the amount of compensation being requested. You will receive a
�vritten acl:nowledgement 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,
X15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
First Name 1 Middle Initial�Last Name �Q��
Company or Business Name_ ��%�
Are You an Insurance Company? Yes No If Yes, Claim Nuulber? N/1�
Street Address=�� S-('• G(�p(X �Q.��L /�0��
c�cy_ Sr�c,��„Ar �,
State_M N Zip Code �✓_ �g Z,
Daytime Phone(_) - Cell Phone ((�5!)y3�_ 333 Evening Telephone(_)
Date of Accident/Injury or Date Discovered G/Z/ �+..�
Time 2'��U � Pm
Please state, in detail, what occurred(happened),and why you are submitting a claim.Please indicate why or how you
feel the Ciry of S�int Paul or its employees are involved and/or responsible for your damages. �(,�a��:' C�'�
f�TT G
Please check the box(es)that most closely represent thz Ireason for completing this form:
❑ My vehicle was dama�ed in an accident
❑ My vehicle was dama�ed by a pothole or condition c�f the street �My vehicle was damaged dunn�a tow
❑ My vehicle was wron�fully towed and/or ticketed � My vehicle was damaged by a plow .
❑ Other type of proper[y dama�e—ple�e specify �I�'�injured on City property
❑ Other type of injury—please specify
In order to process your claim ou need t include co ies of all a licable docu
ments.
For the claims types listed below,please be sure to include the documents indicated or it will delay the handlintr of
your claim. Documents WILL NpT be returned and becqme the property of the City. You are encouraged to keep a
copy for yourself before submittin;your claim form. �
�Property damage claims to a vehicle: two estimates for the repairs to your vehicle if the damage exceeds
�$500.00; oi-the actua] bills and/or receipts for the repairs (��G�S�D)
Towin�claims: ]egible copies of any ticket issued and a copy of the impound lot receipt rh/
O Otherproperty damaQe claims:two repair estimates if the damage exceeds$500.00; or the actua] bills
and/or receipts for the repairs; detailed list of damaged items � �S�D,
O Injury claims: medical bi]]s,receipts
O Photographs are a]ways welcome to document and support your claim but will not be retumed.
Page 1 of 2—Please complete and return both pages of Claim Form
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Detail for submitting a claim:
My vehicle was towed by the City of St. Paul (or the tow company that handles their towing). Upon
arrival at the impound lot, I was advised by the impound lot employee to look the vehicle over for any
damage. I discovered that the front feft(driver's) side of the bumper had sustained what appeared to be
a puncture or crack, and the hood in approximately the same location right above the crack had a large
paint chip. This damage did not exist prior to the tow. Per instruction by the lot empioyee, I went back
inside and was given the notice of claim form. I have since acquired and enclosed the two copies of
repair estimates done by two independent, reputable St. Paul auto body shops.
�I
ABRA Auto Body & Glass - Midway Wor�le ID: aa865f44
FederalID: 41-1852119
Right The First Time...On Time
1190 UNIVERSITY AVE W, SAINT PAUL, MN 55104
Phone: (651) 645-1563
FAX: (651) 641-6129
Preliminary Estimate
Customer: RYAN, PATIN 7ob Number:
Written By: Steven Hanson
Insured: RYAN, PATIN Policy#: Claim#:
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact: 12 Front
Owner: Inspection Location: Insurance Company:
RYAN, PATIN ABRA Auto Body&Glass-Midway
11440 ST CROIX TR N 1190 UNNERSITY AVE W
STILLWATER, MN 55082 SAINT PAUL, MN 55104
(651)439-9333 Cell Repair Faciliry
(651)645-1563 Business
VEHICLE
Year: 2003 Body Style: 4D SED VIN: 1G8JU54F03Y509526 MileageIn: 103000
Make: SATU Engine: 4-2.2L-FI License: SMT019 Mileage Out:
Model: L200 Production Date: State: Vehicle Out:
Color: SILVER Int: Condition: Job#:
TRANSMISSION Dual Mirrors Alarm Passenger Air Bag
Automatic Transmission Console/Storage RADIO SEATS
Overdrive CONVENIENCE AM Radio Cloth Seats
POWER Air Conditioning FM Radio Bucket Seats
Power Steering Intermittent Wipers Stereo WHEELS
Power Brakes Tilt Wheel Search/Seek Wheel Covers
Power Windows Cruise Control CD Player PAINT
Power Locks Rear Defogger SAFETY Clear Coat Paint
DECOR Keyless Entry Drivers Side Air Bag
I
2/15/2014 11:09:41 AM 011906 Page 1
Preliminary Estimate
Customer: RYAN, PATIN )ob Number:
Vehicle: 2003 SATU L200 4D SED 4-2.2L-FI SILVER
Line Oper Description Part Number Qty Extended Labor Paint
Price�
1 FRONT BUMPER
2 ** <> Repl A/M CAPA Bumper cover 22707916 1 298.00 0.9 2.6
3 Add for Clear Coat 1.0
4 R8cI License bracket 0.2
_
5 HOOD
6 * Rpr Hood 2_5 3.0
7 Overlap Major Non-Adj. Panel -0.2
8 Add for Clear Coat 0.6
9 # Refn Dedud for partial paint -03
_ _ _ _ __ _ _ _
10 MISCELLANEOUS OPERATIONS
11 # Refn 'Car Cover 0.1
12 # Refn �Corrosion Protection 0.3
13 # Repl �Flex Additive/Adhesion Promoter 1 8.50 T ,
14 # 'Hazardous Waste 1 5.00 X
15 # POSSIBLE HIDDEN DAMAGE 1
BEHIND BUMPER COVER
SUBTOTALS 311.50 3.6 7.1
ESTIMATE TOTALS
Category Basis Rate Cost¢
Parts 298.00
Body Labor 3.6 hrs @ $ 56.00/hr 201.60
Paint Labor 7.1 hrs @ $56.00/hr 397.60
Paint Supplies 7.1 hrs @ $36.00/hr 255.60
Miscellaneous 13.50
Subtotal 1,16630
Sales Tax $562.10 @ 7.6250% 42.86
Grand Total 1,209.16
Dedudible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 1,209.16
THIS IS A VISUAL INSPECTION ONLY. THERE MAY BE ADDITIONAL DAMAGE AFTER DISASSEMBLY. PARTS ARE
SUBJECT TO INVOICE. THERE ARE NO GUARANTEES ON RUST REPAIRS.
"Minnesota law gives you the right to choose any rental vehicle company, and prohibits me from requiring you to
choose a particular vendor."
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.
2/15/2014 11:09:41 AM 011906 Page 2
Preliminary Estimate
Customer: RYAN, PATIN 7ob Number:
Vehicle: 2003 SATU L200 4D SED 4-2.2L-FI SILVER
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
DE8IC00, 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 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=Blend. 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=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=Paintlessl Dent Repair. VIN=Vehicle Identification Number.
2/15/2014 11:09:41 AM 011906 Page 3
Preliminary Estimate
Customer: RYAN, PATIN Job Number:
Vehicle: 2003 SATU L200 4D SED 4-2.2L-FI SILVER
ALTERNATE PARTS SUPPLIERS
Supplier: Keystone-Complete-Minneapolis
Location(s): 3615 MARSHALL STREET NE, MINNEAPOLIS MN 55418 (800)328-1845 (612)789-1919
Line Description Item# Price
2 A/M CAPA Bumper cover GM1000667C $298.00
2/15/2014 11:09:41 AM 011906 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***
02/15/2014 11:27 AM
Owner
Owner: RYAN PATIN
Address: 11440 ST CRIOX TRAIL N Cell: (651)439-9333
City State Zip: Stillwater, MN 55082 F��
Control Information
Claim#: TOW DAMAGE Insured Policy#:
Ins. Company: CUSTOMER PAY
Inspection
Inspection Date: 02/15/2014 11:26 AM 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:
Driveable: Yes Rental Assisted:
Appraiser Name: WILLIAM LATUFF 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
Remarks
*•*`**"'**"PRELIMINARY ESTIMATE***"*"**'**""""'�
POSSIBLE ADDITIONAL DAMAGE MAY BE FOUND AFTER TEAR DOWN
PRIOR DAMAGE:HOOD CRUSHED, HOOD FULL OF MUD, HOOD NEEDED REPLACING BEFORE TOW
Vehicle
2003 Saturn L200 STD 4 DR Sedan
4cyl Gasoline 2.2
4 Speed Automatic
Lic.Plate: SMT019 Lic State: MN
Lic Expire: VIN: 1G8JU54103Y509526
Prod Date: 08/2002 Mileage:
. 02/15I2014 11:29 AM Page 1 of 3
2003 Satum L200 STD 4 DR Sedan
Claim#: TOW DAMAGE 02I15/2014 1127 AM
Veh Insp#: Mileage Type: Actual
Condition: Fair Code: SN303B
Ext.Color: SILVER Int.Color:
Ext.Refinish: Two-Stage Int.Refinish: Two-Stage
Options
AM/FM CD Player Air Conditioning Alarm System
Automatic Trans Center Console Cruise Control
Digital Clock Dual Airbags Head 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 Giass Velour/Cloth Seats
Damages
Line Op Guide MC Description MFR.Part No. Price ADJ% B% Hours R
Front Bum�er
1 EC 6 Cover,Front Bumper Replace Economy $298.00` 1.8 SM
2 L 6 13 Cover,Front Bumper Refinish 3.7 RF
2.6 Surface
0.6 Two-stage setup
0.5 Two-stage
3 E 19 Brkt,Front Lic Plate 90584247 $25.08 0.2 SM
Front Body And Windshield
4 I 83 Panel,Hood Repair 2.0* SM
»@BROKEN MISSING MUD@LT OF CENTER ONLY. NO WARRANTY
»HOOD NEEDED REPLACING BEFORE LOSS
5 L 83 Panel,Hood Refinish 3.5 RF
2.9 Surface
0.6 Two-stage
»NO WARRANTY DUE TO PRIOR REPAIRS
Manual Entries
6 EC M03 Flex Additive Replace Economy $5.00` RF
7 SB M60 Hazardous Waste Removal Sublet Repair $5.00' SM
7 Items
MC Message
13 INCLUDES 0.6 HOURS FIRST PANEL TWO-STAGE ALLOWANCE
Estimate Total&Entries
Gross Parts $25.08
Other Parts $303.00
Paint Materials $230.40
Parts&Material Total $558.48
Tax on Parts&Material @ 7.625% $42.58
Labor Rate Replace Repair Hrs Total Hrs
Hrs
Sheet Metal(SM) $52.00 2.0 2.0 4.0 $208.00
Mech/Elec(ME) $85.00
02/15/2014 1129 AM Page 2 of 3
2003 Satum L200 STD 4 DR Sedan
Claim#: TOW DAMAGE 02/15/2014 11:27 AM
Frame(FR) $75.00
Refinish(RF) $52.00 7.2 7.2 $374.40
Paint Materials $32.00
Labor Total 11.2 Hours $582.40
Subiet Repairs $5.00
Gross Total $1,188.46
Net Total $7,188.46
Alternate Parts No
SPPL Yes Zip Code:55104 Default
Audatex Estimating 7.0.123 ES 02/15/201411:29 AM REL 7.0.123 DT 01/01/2014 DB 02/08/2014
Copyright(C)2013 Audatex North America, Inc.
1.7 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= Repiace PXN OE Srpls UE= Replace OE Surplus
ET = Partial Replace Labor EP= Replace PXN EU= Replace Recycled
TE = Partiai Replace Price PM= Replace PXN Reman/Rebit UM= Replace Reman/Rebuilt
L = Refinish PC= Replace PXN Reconditioned UC= Replace Reconditioned
TT = Two-Tone SB= Sublet Repair N = Additional Labor
BR= Blend Refuvsh I = Repair IT = Partiai 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
������Gf� Audatex's priorwritten consent.
a�utc�r,r cur.h�rar��
Copyright(C)2013 Audatex North America, Inc.
Audatex Estimating is a trademark of Audatex North America, Inc.
02/15/2014 11:29 AM Page 3 of 3
Saint Paul Police Impound �ot, 830 Barge Channel Road, Vehicle Release Form
Make: 03 SATURN License#: SMT019 CN: 14019188 Invoice#: 28011
Date/Time Released: 02/02/201413:56 Tow Charge: $ 123.95
Released to: TOTO Storage Charge: $ 15.00
Paid by: CASH Admin Charge: $ 80.00
Released by: RYAN Tax: (7.625%) $ 15.55
I,the undersigned,have recovered the vehicle described above. Subtotal: $ 234.50
I will check the vehicle for damage or any other problems that
may have occurred while this vehicle was in the custody of the Service Charge: $ 0.00
Saint Paul Police Department. I acknowledge I will report
damage and/or any other problems to the Impound Lot staff Total Charges: $ 234.50
on this form prior to leaving the impound lot.
Damage and/or other problem:
Police Report made: Yes_No_IF Yes, CN , If NO, Why?
TO PROTECT YOUR RIGHTS REPORT ANY PROBLEMS/DAMAGE BEFORE LEAVING THE LOT
5/2000
Signature
St. Paul Police Department for
Ramsey District Court
RECEIPT
Date/Time: 02/02/2014 13:56 Invoice #: 28011
VeMicle Plate: SMT019/MN
Payor: OWNER Location Paid: Impound Snow Lot
Citation: Amount:
0900217880 $ 56.00
Total Amount Paid: $ 56.00
Paid by: CASH
KEEP THIS COPY FOR YOUR RECORDS