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= F�EC�ie,ED
N1AR 2 5 2�1�+
NOTICE OF CLAIM FORM to the City of Saint Paul, Mig�q���a�E�K
Minnesota State Statute 466.05 states that "...every person...who claims damages from arry municipality...shall cause to be presented to the
governing body of the municipality 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 PAiTL, MN 55102
�,.,
First Name �._,,���C ►`�^�_� Middle Initial�Last Name "�' , ��
Company or Business Name /,;"'�� �15rj'7f (,�(�j t'�is (��7'�"�'1 1(;�/'��
Are You an Insurance Company? Yes V N� If Yes, Ciaim Number? -
StreetAddress ����/�,���� Jr��(�,(?
City `y`�, C�� � State � Zip Code `� �
Daytime Phone(�[)�� .��Cell Phone ,(�}�-�� • Evening Telephone(����
Date of Accidenb Injury or Date Discovered �-,� Time a /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 Sai t Paul or its emplQyees are involved and/or responsible for our damages. ��,��;y,,
- � ' E' , C�.�.� _ ' ) � �
� � ;• ,. C�� ,` .
�- - �'_ � ��,��;;r
� G� 3 .
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�1�
�` r� �� �'� � �i� ;��_ f� �, j � i
Please c�eck��box(es)that most clos�ly represent the reason for completing this form:
�'My vehicle was damaged in an accident ❑My vehicle was damaged during a tow
C My vehicle was damaged by a pothale or condition of the street ❑M_y vehicle was damaged by a plow
❑My vehicle was wrongfully towed and/or ticketed . ❑ I as injur,d on.City properly.
�Other type of property damage—please specify�'li'/rJ (��"�t2f['f� 7j7 '/'t��J,l�,��/��r, ���� .
❑Other type of injury—please specify �.�je/a���/ t/, �
/�
In order to process your claim you need to include coAies of all anplicable documentsC'��
For the claims types listed below,please be sure to include the documents indicated or it will delay the handling of
your claim. Documents WII.,L NOT be reiumed and become the property of the City. You are encouraged to keep a
copy for yourself before submitting your claim form.
O Properly 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 properly 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 resnit in delay in the handling of your claim.
All Claims-nlease complete this section ,�_.
Were there witnesses to the incident? Yes No � Unlmown (circle)
Provide their names, addresses and telephone numbers: �"`
_-,�--
Were the police or law enforcement ca11e ? �.. Yes No Unlmown (circle)
If yes,what deparlment or agency? � � Case#or report# ��-L>,�� -- ��(.t�
Where did the accident or injury take place? Provide street address,cross street,intersection,na.me of park or facility,
closest landmark,etc. Please be as detailed as possible.��neces attach a diagram.
��t�� �Gr/'7F�"L,j r(L`ia., �.C�.��t. ���./"'l�{.� ���i��
J
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.� � J��,�������f�C�, f r ' � ���/ ' ' -r' _��
� ° l'�- 7 � ��>.1�r� .����Zl� = �c ---
� �i
Vehicle Claims-please cetnr�lete this section ❑ check box if this section does not a 1
Your Vehicle: Year 2CD�_Make�,� Model
License Plate Number , '' Sta.te /�Color
Registered Owner . ' GV
Driver of Vehicle �'� i ' � �� �- �/�' c' "C� `� - �-a ,
Area Damaged C' �c G�"' c�i S/ .le�`` � '��S /!Q �Q/jG/t
City Vehicle: Year ake Model �����,�-, ✓
License Plate Number State Color � �` ����� �
� �- ��ll`t i's
Driver of Vehicle(City Employee's Name) , . ��?C'ic��`'S f/1
Area Damaged /��/��
Injury Claims-please complete this section � check box if this section does not apply
How were you injured?
What part(s)of your body were injured?
Have you sought medical treatment? Yes No Planning to Seek Treatrnent(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
Vti'h�n�id you miss work? _(provide cate(s)j
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 fonrz,you are stating that all information you haveprovided is true and correct to the best
of your knowledge. Unsigned foPms will not be processed
Submitting a false claim can result in prosecutiort. Date form was completed : �
Print the Name of the Person who Completed this Form: � ( �
Signature of Person Making the Claim:_ ��'
Revised February 2011
LATUFF BROS., INC.
880 UNIVERSITY AVENUE
ST. PAUL, MINNESOTA 55104
(651)224-2828 FAX:(651)291-0677
FEDERAL ID#41-0777034
**"PRELIMINARY ESTIMATE'**
03/2412014 04:14 PM
Owner J
Owner: SELINA GANT
Address: 72 MAYWOOD PLACE Work/Day:
Cell: (651)208-6256
City State Zip: Saint Paul, MN 55117 F��
Llnspection -- ----J
Inspection Date: 03/24/2014 04:13 PM Inspection Type: Drive In
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: Left Front Side Secondary impact:
Driveable: Yes Rental Assisted:
Appraiser Name: ROBERT LATUFF Appraiser License#:
Repairer I
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
Target Complete Date/Time: Days To Repair: 3
Remarks ----- - J
�*'******`*PRELIMINARY ESTIMATE""""""""""�
POSSiBLE ADDITIONAL DAMAGE MAY BE FOUND AFTER TE/#R DOWN
Vehicle
�----- -
2001 Saab 9-3 SE 4 DR Hatchback
4cyl Gasoline Turbo 2.0
4 Speed Automatic
Lic.Plate: 322LJW Lic State: MN
Lic Expire: VIN: YS3DF58K612023462
Prod Date: 10/2000 Mileage:
Veh Insp#: Mileage Type: Actual
Condition: Code: L2163B
Ext.Color: BLACK Int.Color:
Ext.Refinish: Two-Stage Int. Refinish: Two-Stage
Options Page 1 of 3
03124/2014 04:33 PM
2001 Saab 93 SE 4 DR Hatchback
Claim#: 03/24/2014 04:14 PM
AM/FM Stereo Tape Air Conditioning Air Dam
Alarm System Aluminum/Alloy Wheels Anti-Lock Brakes
Automatic Trans Center Console Climate Control For A/C
Cruise Control Digital Clock Driver Information Sys
Dual Airbags Dual Power Seats Fog Lights
Headlight Washers Heated Power Mirrors Intermittent Wipers
Leather Seats Leather Steering Wheel OnStar System
Power Antenna Power Brakes Power poor Locks
Power Moonroof Power Steering Power Windows
Rear Spoiler Rear Window Defroster Rear Window Wiper/Washer
Side Airbags Split Folding Rear Seat Sport Suspension
Strg Wheel Radio Control Tachometer Telescopic Steering Whl
Tilt Steering Wheel Tinted Glass Traction Control System
Trip Computer
Damages �
Line Op Guide MC Description MFR.Part No. Price ADJ% B% Hours R
Strines And Mouldinas
1 RI 136 MIdg,Fender Side LT R&I Assembly 0.3 SM
Front End Panel And Lam�s
2 E 1398 Harness,Frt Lamp Wirin LT 4468245 $57.50 0.3 ME
3 E 54 Lamp,Side Marker LT 467645$ $147.90 INC SM
4 RI 58 Lamp,Side Marker LT R& I Assembly INC SM
Front Body And Windshield
5 E 103 Fender,Front LT 4922332 $416.:i0 3.6 SM
6 L 103 13 Fender,Front LT Refinish 3.6 RF �
2.0 Surface �
0.5 �dge I
0.6 wo-stage setup �
0.5 Two-stage
7 E 255 Nameplate,Fender LT 4958153 $40.80 0.2 SM i
Manual Entries
8 SB M60 Hazardous Waste Removal Sublet Repair $5.00* SM
8 Items
MC Message f
13 tNCLUDES 0.6 HOURS FIRST PANEL TWO-STAGE ALLOWANCE
Estimate Total&Entries '
_�
Gross Parts � $662.70
Paint Materials $115.20
Parts&Material Total $777•90
Tax on Parts&Material @ 7.625% $59.31
Labor Rate Replace Repair Hrs Total Hrs
Hrs
Sheet Metal (SM) $52.00 4.1 4.1 $213.20
Mech/Elec(ME) $85.00 0.3 0.3 $25.50
Frame(FR) $75.00
Refinish(RF) $52.00 3.6 3.6 $187.20
03/24/2014 04:33 PM Page 2 of 3
2001 Saab 9-3 SE 4 DR Hatchback
Claim#: 03/24/2014 04:14 PM
Paint Materials $32.00
Labor Total 8.0 Hours $425.90
Sublet Repairs $5.00
Gross Total $1,268.11
Net Total $1,268.11
Alternate Parts No
SPPL Yes Zip Code:55104 Default
Audatex Estimating 7.0.123 ES 03/24/2014 04:33 PM REL 7.0.123 DT 02101/2014 DB 0 311 5/2 0 1 4
Copyright(C)2013 Audatex North America, Inc.
1.1 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= Replace Recycled
TE = Partial Replace Price PM= Replace PXN Reman/Reblt UM= Replace RemanlRebuilt
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
A�,t^#���Y Audatex's prior written consent.
4f /1
�} titt:�t.)�:;Ilal�w::1i(Y
-- Copyright(C)2013 Audatex North America, Inc.
Audatex Estimating is a trademark of Audatex North America, Inc.
03/24/2014 04:33 PM Page 3 of 3
. Collision
0���� AUTO SERVICE ��.
8 &BODY REPAIR 651-222-4458 5854e2e6
36p West SeveMh St. � Workfile ID:
St.Paui MN 55102 E S COLLISION CENTER Federal ID: 410986303
' ....: �••••. Mechanical �ARE BY PEOPLE WHO CARE
..... . :::::......:::..
....... ....... .:�i11114.
�''��`' ��� ST W, SAINT PAUL, MN 55102
651-22M7571
Mike FritzKapps a��west sevemn s�. Phone: (651) 222-4458
,�d,�o„+�no.� St.Paul MN 55102 F�: (651) 224-8640
Preliminary Estimate
,:ustomer: Gant, Selina
Written By: MICHAEL FRITZKAPPS
Gant, Selina Policy #:
Claim #:
I,�swed: Days to Repair: 0
Date of Loss:
���pe of Loss:
i �int of Impact: 11 Left Front
Inspection Location: Insurance Company:
.,wner:
c,ant, Selina BONFE'S COLLISION CENTER
77 Maywood Place
380 7TH ST W
�t. Paul, MN 55117 SAINT PAUL,MN 55102
(�;51)488-2466 Evening Repair Facility
(651) 208-6256 Cell (651)222-4458 Business
VEHICLE
Body Style: 4D H/B VIN: YS3DF58K612023462 Mileage In:
��'r�ar: 2001 Mileage Out:
Engine: 4-2.OL-T License: 322UW
�iake: SAAB State: MN Vehicle Out:
Model: 9-3 SE Production Date: 10/2000
�oior: Black Int:
Condition: Job#:
RADIO Electric Glass Sunroof
TRANSMISSION Body Side Moldings SEATS
Console/Storage AM Radio
Overdrive FM Radio Bucket Seats
5 Speed Transmission CONVENIENCE Leather Seats
Air Conditioning Stereo
POW ER Search/Seek W HEEIS
Power Steering Intermittent Wipers Aluminum/Alloy Wheels
Tilt Wheel Cassette
Power Brakes gAFETY PAINT
Cruise Control Clear Coat Paint
Power Windows Drivers Side Air Bag
Power Locks Rear Defogger OTHER
Alarm Passenger Air Bag
Power Mirrors Anti-l.ock Brakes(4) Fog Lamps
Heated Mirrors Message Center Traction Control
Steering Wheel Touch Controis 4 Wheel Disc Brakes
Power Driver Seat Rear Spoiler
Rear Window Wiper Head/Curtain Air Bags
Power Passenger Seat Communications System
DECOR Telescopic Wheel
Dual Mirrors
Climate Control , ROOF
I
Pa���> 1
013793
'25/2014 10:46:57 AM
COL- MECHANICA,� •
Preliminary Estimate
i:ustomer: Gant, Selina
Vehicle: 2001 SAAB 9-3 SE 4D H/B 4-2.OL-T Black
_ine Oper Description Part Number Qty Extended Labor Paint
Price$
1 FRONT BUMPER
Z * R&I Bumper assy-drop left side p.g
3 FRONT LAMPS
4 Repl LT Signal lamp 4676458 1 147.90 Incl.
5 R&I LT Repeater lamp white Incl.
6 FENDER
? Repl LT Fender 4922332 1 416.50 2.8 2.p
8 Add for Clear Coat ��8
9 Add for Edging ��5
10 Repl LT Fender liner 4959417 1 93.50 Incl.
li R&I LT Body side mldg w/o Viggen 0,2
12 Repl LT Nameplate"SE" 4958153 1 40.80 0.2
13 R&I LT Mud guard w/o Viggen 0.3
14 FRONT DOOR �
15 Blnd LT Outer panel ?.1
16 R&I LT Weatherstrip belt 0.3
l7 R&I LT Body side mldg w/o Viggen 0.3
18 R&I LT Mirror housing 0.4 �
19 R&I LT Handle, outside p 3 ;
20 R&I LT R&I trim panel 0.4
21 # Repl COVER CAR COMPLETE(2 1 14.00 T 0.2
TIMES)
22 # Repl CORROSION PROTECTION 1 15.00 T 0.5
23 # Repl HAZARDOUS WASTE REMOVAL 1 7.00 T
24 # Refn MASK&TAPE JAMBS �3
25 # Refn COLOR, SAND&BUFF PAINT �.5
7_f # PART PRICES SUBJECT TO 1
INVOICE i
27 # **** POSSIBLE HIDDEN DAMAGE 1
*****
SUBTOTALS 734,70 6.8 �.2
!25/2014 10:46:57 AM 013793 Paqe 2
Preliminary Estimate
Customer: Gant, Selina
Vehicle: 2001 SAAB 9-3 SE 4D H/B 4-2.OL-T Black
ESTIMATE TOTALS
Category Basis Rate Cost$
Parts 698.70
Body Labor 6.8 hrs @ $56.00/hr 380.i30
Paint Labor 5.2 hrs @ $ 56.00/hr 291.:'0
Paint Supplies 5.2 hrs @ $35.00/hr 1H2�i0
Body Supplies 3J hrs @ $3.00/hr i1.i0
Miscellaneous 36��,�
Subtotal 1,599.�_��!
Sales Tax $927.80 @ 7.6250% 7C.'�
Grand Total 1,670.54
Deductible O.UO
CUSTOMER PAY 0.00
INSURANCE PAY 1,670.54
I
::r:**************************************************************************
T�IS IS A VISUAL ESTIMATE ONLY.
r��DITIONAL DAMAGE MAY BE FOUND AFTER TEAR DOWN OF VEHICLE.
�"O GUARANTEE ON RUST WORK.
F.K****************************************************************************
MINNESOTA FRAUD WARNING '
;'; n�rson who submits an application or files a claim w�th intent to defraud or helps commit a fraud against an '
ir�urer is guilty of a crime. ;
'"''"�a have the right to choose any repair facility to have your vehicle repaired* ;
� �� IS NOT AN AUTHORIZATION TO REPAIR ALTHOUGH IT IS AGREED BETWEEN THE REPAIR FACILITY AND '
E=�_'RANCE THAT THE ABOVE VEHICLE CAN BE REPAIRED BY THE REPAIR FACILI7Y FOR THE AMOUNT STATED I(�! �
-I; ;�_ GROSS TOTAL SECTION. ONLY THE VEHICLE OV1I'NER CAN AUTHORIZE THE REPAIR OF THE VEHICLE AND AI �
C���STS OF REPAIR ARE THE SOLE RESPONSIBILITY OF THE VEHICLE OWNER.
THIS APPRAISAL WAS BASED ON VISIBLE OR CERTAIN DAMAGES AT THE TIME OF INSPECTION. TO REQUEST A
`=UPPLEMENT, PLEASE CALL (866) 514 4788. PLEASE FAX THE SUPPLEMENT AND ALL SUPPORTING DOCUMENTS
U',�TTH CLAIM NUMBER TO (866) 454 0890. THE REPAIR FACILITY AND ESURANCE WILL REACH AN AGREED PRICE
F''.:OR TO BEGINNING ANY OF THE SUPPLEMENTAL REPAIRS. THE REPAIR FACILITY WILL THEN SEEK
l�.� 'i HORIZATION FROM THE VEHICLE OWNER FOR THE ADDITIONAL REPAIRS. NO SUPPLEMENTS WILL BE
f �ORED UNLESS APPROVED IN ADVANCE BY ESURANCE.
1- qIR FACILITY MUST BE PROVIDED A COPY OF THIS ESTIMATE PRIOR TO COMMENCEMENT OF REPAIR.
I URE TO DO SO MAY SUBJECT THE VEHICLE OWNER TO ADDITIONAL EXPENSE.
��'�i� 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.
%2014 10:46:57 AM 013793 Pa���3
Preliminary Estimate
C:;�tomer: Gant, Selina
Vehicle: Z001 SAAB 9-3 SE 4D H/B 4-2.OL-T Black
t_��imate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guidc.
f_=K7315, CCC Data Date 3/17/2014, 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
(,�+Iternative 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.
A,sterisk (*) or poubte Asterisk (**) indicates that the parts and/or labor information provided by MOTOR may have
h�en modified or may have come from an alternate data source. Tilde sign (�) items indicate MOTOR Not-Included
� ,bor operations. The symbol (<>) indicates the refinish operation WILL NOT be performed as a separate procedure
f"��m the other panels in the estimate. Non-Original Equipment Manufacturer aftermarket parts are described as Non
! -i�l or A/M. Used parts are described as LKQ, RCY, or USED. Reconditioned parts are described as Recond.
I �cored parts are described as Recore. NAGS Part Numbers and Benchmark Prices are provided by National Auto
��ass Specifications. Labor operation times listed on the line with the NAGS information are MOTOR suggested labo�-
o�eration times. NAGS labor operation times are not included. Pound sign (#) items indicate manual entries.
S��me 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
d�alership.
i �:� following is a list of additional abbreviations or symbols that may be used to describe work to be done or parts to
I-.� repaired or replaced:
`�(i�BOLS FOLLOWING PART PRICE:
r: -MOTOR Mechanical component. s=MOTOR Structural component. T=Miscellaneous Taxed charge category.
;:=Miscellaneous Non-Taxed charge category.
�'MBOLS FOLLOWING LABOR: �
D=Diagnostic labor category. E=Electrical labor category. F=Frame labor category. G=Glass labor category.
��-=Mechanical labor category. S=Structural labor category. (numbers) 1 through 4=User Defined Labor Categories.
C;THER SYMBOLS AND ABBREVIATIONS:
,^ ij.=Adjacent. Algn.=Align. ALU=Aluminum. A/M=Aft rmarket part. BInd=Blend. BOR=6oron steel.
c ?PA=Certified Automotive Parts Association. D&R=Dis�onnect and Reconnect. HSS=High Strength Steel.
i "D=Hydroformed Steel. Inc1.=Included. LKQ=Like Ki�id and Quality. LT=Left. MAG=Magnesium. Non-Adj.=Non
/-�iacent. NSF=NSF International Certified Part. O/H=Overhaul. Qty=Quantity. Refn=Refinish. Repl=Replace.
1-._�I=Remove and Install. R&R=Remove and Replace. Rpr=Repair. RT=Right. SAS=Sandwiched Steel.
� �ct=Section. Subl=Sublet. UHS=UItra High Strength Steel. N=Note(s) associated with the estimate tine.
C�C ONE Estimating - A product of CCC Information Services Inc.
� �e following is a list of abbreviations that may be used in CCC ONE Estimating that are not part of the MOTOR
C�'.ASH ESTIMATING GUIDE:
E-..,R=Bureau of Automotive Repair. EPA=Environmental Protection Agency. NHTSA= National Highway
� ,nsportation and Safety Administration. PDR=Paintless Dent Repair. VIN=Vehicle Identification Number.
:� 'S/2014 10:46:57 AM 013793 Page 4
OFFICE OF HUMAN RESOURCES
Angela S.Nalezny,Drrector
RISK MANAGEMENT
CITY OF SAINT PAUL 200CrryHa!lAnnex Telephone: 65l-266-6500
C'hristopher B.Colen7an,Mayor ?5 West Fourth Stree! Facsimrle: 6SI-266-8886
Sarnt Pau!MN 55102-1631
�
March 20, 2014
Ms. Selina B. Gant
72 Maywood Place
Saint Paui, MN 55117
RE: File Number C-140124
Dear Ms. Gant:
I received your claim filed with the City of Saint Paul and have begun my investigation.
Please send me two (2) estimates and photos of your vehicle. Please refer to the above file
number in any correspondence with me.
I will notify you of my decision on your claim when I have completed my investigation.
Sincerely,
Sandra Bodensteiner
Claims Manager
SB
AA-ADA-EEO Employer
� _ RECEIVED
' NOTICE OF CLAIM FORM to the City of Saint Paul, M1MAR S 4 2014
C� ���RK
Minnesota State Statute 466.05 states that "...every person...who claims damages from arry municipality...shall cause to be presented to the
governing body of the municipality within 180 days after the alleged loss or injury is discovered a notice staring 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 �._����� ►'�(;�. Middle Initial�Last Name "�' �_
p Y /� �mp G����S �15fE�C� �U�f _ __ _ _
Com an or Business Name
Are You an Insurance Company? Yes f(,N� If Yes,Claim Number?
Street Address �� �✓U JQ�G' �i�C�
City���j„�„� Staite � Zip Code��i11LL
Daytime Phone(���- .�Cell Phone(���-�Evening Telephone(����
Date of Accidenb Injury or Date Discovered �� Time _�/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 Sai t Paul or its emplpyees are involved and/or responsible for our damages. ,,z ;'
- E - , D�.�; - ' ��n " � r/�'1��
7 c � � � � � '
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Please c eck ox(es)that most clos�ly repres�the reason for completing this form:
�y vehicle was damaged in an accident ❑My vehicle was damaged during a tow
My vehicle was damage�by a pothole or condition of the street ❑My vehicle was damaged by a plow
�My vehicle was wrongfully towed and/or ticketed I as inj rd on.City property.
�Other type of property damage—please specify_ i'' CL
C�!�I�Gi.
❑ Other type of injury—please specify ��f��
G�'��
In order to process your claim vou need to include conies of all anplicable documen s.
For the claims types listed below,please be sure to include the documents indicated or it will delay the handling of
your claim. Documents WII.,L 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 da.mage 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
. o com lete and retarn both pages will r��t in delay in the handling of yonr claim•
. Failnre t p
All Claims— lease com lete this section YeS No U�o� (circle)
Were there witnesses to the incident.
Provide their names,addresses and telephone numbers: '
No cu'cle
� Yes Unknown � �
VJere the police or law enforcement call � C�e#or report# ��'������
If yes,what department or agencY? �
take place? Provide atreet address,cross street,inteTSection,name of park or facility,
Where did the accident or injury ssible. neces attach a diagram•
closest landma�'k,etc. Please be as detailed as po
�n compensatio or what you would like the City to do to r�lve this cl '
Please indicate the amount you are seeki.ng � � � • �/ i' � '
O
to your satisfaction. -----
.� . .._C!a
�check box if this sect►on does not a 1
Vehicle Claims—olease�em jlete this section M�el
M�e �� /1�(_Color
your Vehicle: Year ,
License Plate Number
State
Registered Owner � - �- �' � -`-
Driver of Vehicle '�` �S /�
� r�' e s - C'i.c.+�' �d�c,e
Area Damaged Model
City Vehicle: Y�_-- �e Color � �s
License Plate Number
State /�G�r�S �
Driver of Vehicle(City Employee's Name) /�Q�.�_
Area Damaged _ `
In'n Claims— lease com lete this section
check box if this section does not a 1
How were you injured?
What part(s)of your body were injured?
planning to Seek Treatment(circle)
Have you sought medical treatment? YeS NO (provide date(s))
When did you receive treatment?
Name of Medical Provider(s): Telephone
Address No
Did you miss work as a result of your injury? YeS (provide ciate(s)}
When did you miss work?
Name of your Employer: Telephone
Address
❑ 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 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 Completed this Form: I �
Signatnre of Person Making the Claim:
Revised February 2011
RECEIVED
Pro ert Dama e Release APR �4 2�14
F le Number C-140124 CITY CLERK
For the sole consideration of one thousand three hundred eighty eight dollars
and eleven cents ($1388.11), the receipt and sufficiency whereof is hereby
acknowledged, the undersigned hereby releases and forever discharges the City of
Saint Paul, the Saint Paul Fire Department, Bob Bonne, their heirs, executors,
administrators, agents, and assigns, and all other persons, firms or corporations liable,
or who might be liable, none of whom admit any liability, from any and all claims,
demands, damages, actions, causes of Iaction or suits of any kind or nature whatsoever,
to property which has resulted, or may �evelop in the future from an incident which
occurred on or about the 25th day of February, 2014, at or near, Saint Paul, MN.
The undersigned hereby declares that the terms of this settlement are fully
understood and voluntarily accepted for the purpose of making a full and final
compromise adjustment and settlement of any and all claims, disputed or otherwise, on
account of the property damage mentioned above.
I hereby state that I have read this release, know the contents thereof, and have
signed the same, relying on my own jud ent and on no r presentations of o ers, and
of my own free will and accord this � day of �� , 20�
I t presence of:
i ess , elina A. Gant
� �
_l'-�.-- ,
i ness
Subscribed and sworn to before me on
this /y� day of �►^,`( , 20/�{.
,��-/-��1 ���-�% /��o-e�
Notary Public
� 'h� NlKOLAUS DAVID BOESE
�� ` NOTARYPUBLIC-MINNESOTA
''a:7e" MYCOMMISSIONEi�IRESOtl31l1a