Hasheider I
RECEIVED �
MAR 14 2�14
NOTICE OF CLAIM FORM to the City of Saint Paul, lv�i��(s�ERK
Minnesota State Statute 466.05 states that°...every person...who claims damages from any 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 arrwunt 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
FirstName 'Y,�r��S MiddleInitial I LastName NaSl�elder
Company or Business Name IV�A
Are You an Insurance Company? Yes//� If Yes,Claim Number? N ��
Street Address g 7� C 1 eve�q yt� �Ve. S �{ p-�' {�–(C�
City S'f�� �a�t� State M ihnc so�f�t. Zip Code 551 I 6
Daytime Phone(�)�� q 3 Cell Phone(60$)� qD8 Evening Telephone(LQ� 1577-°IO�N
Date of c �d �njttty�or Date Discovered�urSC�y, Jo�h�23� Time 3� 3� am 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.
— P/eo►s� see er� ose ih r or► Ja�d J � d c�d
Please check the box(es)that most closely represent the reason for completing this form:
❑ My vehicle was damaged in an accident ❑�Iy vehicle was damaged during a tow
❑ My vehicle was damaged by a pothole or condition of the street �qy 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
❑ Other type of injury—please specify
In order to process your claim vou need to include copies of all apqlicable 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.
F nclOS e d�roperty damage claims to a vehicle: two estimates for the repairs to your vehicle if the damage exceeds
�'—'�$5 0.00; 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
�r,�/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—ulease comnlete this section
Were there witnesses to the incident? Yes No Unknown (circle)
Provide their names,addresses and telephone numbers: n�/A
Were the police or law enforcement called? es No Unknown (circle)
If yes,what department or agency?�5+,Pa�l Poi ice De.��}- Case#or report# I y -- D 1 �}-- 6 5 7
Where did the accident or injury take place? Provide street address,cross street,intersection,name of park or facility,
closest lan��ark,etc. Please��as detailed as po ci`bl� If necessary,attach a diagram.
, r ioy� y�^ar iv�� -{�e a�c�deh�,
Please indicate the amou t you are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction. �l,qRS, q 7
Vehicle Claims—please comnlete this section ❑ check box if this section does not annlv
Your Vehicle: Year 2�0�l Make e c�n r Model Mo�tv►�-av�eer
License Plate Number 702 —l�l State��Color S��v e r
Registered Owner Ma�ry and /UdYC1As NnS�1ei de 1-
Driver of Vehicle r e' e r
Area Damaged__Q r�ver Side �oo r �to �ror�-l- tiv��er�
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniury Claims—please complete this section �/.a �sl check box if this section does not applv
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 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 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 M ANl�l ��f T���
Print the Name of the Person who Completed this Form: /I/� ArcuS �laShei��
Signature of Person Making the Claim:T�� ,
Revised February 2011
RECEIVED
March 10, 2014 MAR 14 2��q Marcus Hasheider
871 Cleveland Ave. S.Apt. P-10
C�TY CLERK St. Paul, MN 55116
City Clerk
15 West Kellogg Blvd, 310 City Hall
St. Paul, MN 55102
Dear City Clerk,
I would like to file a claim with the City of St. Paul for the amount of$1,995.97. This amount will
cover the cost of repairing all damage to my vehicle, caused by a City of St. Paul snow plow
truck. This letter contains more information on the incident.
On Jan. 23, 2014 at 3:30 a.m., I believe a City of St. Paul snow plow passing by my vehicle, a
2004 Mercury Mountaineer, removed my driver-side mirror and scratched the paint on the
driver-side door.
I filed a police report with the City of St. Paul Police Department, case number 14-014-657, and
confirmed I was legally parked overnight on the City of St. Paul street, 807 Cleveland Avenue
South. I then discussed the incident with the City of St. Paul Streets Division office and the
general manager, Doug Brusch. I received confirmation that a City of St. Paul snow plow truck
passed through the same street my vehicle was parked on overnight.
As I previously mentioned, I would like to file a claim with the City of St. Paul for the amount of
$1,995.97 to cover the cost of repairing all damage to my vehicle, caused by a City of St. Paul
snow plow truck.
I will be following up within a week to discuss this with you in further detail. My personal
information is listed below and included on the Claim Form enclosed with this letter.
Best regards,
Marcus Hasheider
Phone: (608) 577-9084
Email: marcushasheider(a�qmail.com
Enclosures: �
Notice of Claim Form to the City of St. Paul, MN I
Maps of Accident Location II
Estimate for Repair Work !
Maps of Accident Location
Below are photos to show the location of the accident that happened on Thursday, Jan. 23 at
3:30 a.m.
W Hillcrest Ave
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Photo above is an overhead view of the accident location.
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Photo above is a street view using Google Maps. Please note the "X" marks the accident
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Photo above is a street view using Google Maps. Please note the "X" marks the accident
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Showin the driver's side of the vehicle that was dama ed. The mirror and door were dama ed.
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Showing the driver's side of the vehicle that was damaged. The mirror and door were damaged.
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Showing the driver's side of the vehicle that was damaged. The mirror and door were damaged.
SUBURBAN AUTO BODY INC. W01*�jo: s�o�115
FederalID: 41-1443480
2989 COUNTRY DR, LTfTLE CANADA, MN 55117
Phone: (651)633-8900
FAX: (651)481-0700
Preliminary Estimate
Cusbomer: Hasheider, Marcus 7ob Number:
Written By:Jamie Whitwood
Inwred: Hasheider,Marcus Pdicy#: qaim#:
Type of Loss: Date of loss: Days to Repair: 0
Pant of Impact: 10 LeR Front Pillar(LeR
Side)
Owner: Inspectlon Locstion: Insurance Company:
Hasheider,Marrus SUBURBAN AUTO 60DY INC.
2989 CWNTRY DR
LITTLE CANADA,MN 55117
Repnir Faality
(651)633-8900 Business
VEHICLE
Year: 2004 Body Style: 4D UTV VIN: 4M2ZU86K44Z709138 Mikage In:
Make: MERC Engine: 6-4.OL-FI Llanse: Mika9e Out:
Madet: MOUNTAINEER AWD Productfon Date: State: Vehide Out:
Color: SIWER/GRAY IM: Cor�didon: Job�:
TRANSMISSION Dual Mirrors �r wr,dow wper SEATS ,
Automatic Trarumission Privacy GIasS RADIO qoth Seats
Overdrive Cor�sale/Storage AM Radio Dudcet Swts
4 WF�eel Drive O�nerhead Consde FM Radio 3rd Row Seat I
POWER CONVENIENCE Sberto WHEELS i
Power Steering Air Conditioning CD Player Altxnirxim/Alloy Wheels
Power Brakes IMermittmt Wipers SAFE7Y OAINT I
Power wndows Tilt YVhed Drivera Side Air Bag Clear Coat Paint
Power Lodcs Cruise Contrd P�er Air Bag OTHER
Power Mirrors Rear Defogger Mti-Lodc&akes(4) Fo9 L.�mPs
Heated MiROrs Kryle�EMry 4 Whc�el Disc 6rakes 7RUCK
Power Driver geat Alarm ROOF Traikr Hitch
DECOR Message Center Luggage/Roof Radc Trailering Padcage
2/6/2014 9:18:51 AM 019966 Page 1
Preliminary Estimate
Cusbomer: Hasheider,Marcus 7ob Number:
Vehicle:2004 MERC MOUIYTAINEER AWD 4D UTV 6�.O1-FI SILVER/6RAY
Line Optr Despiption Part Number Qty Extended Labor Psint
Priae#
1 FRONT dUMPER
2 R&I R&I��Y 1.4
__ _
_ _
3 FRONT LAMPS _ _
4 R&I LT Headlar►iP�Y 0.2
5 * R&I LT Rer�ater larrm in fender 0.2
_ __ __
6 FENDER _
7 R&I LT Fender liner 0.3
8 * Rpr LT Fender&Alian to door
2.S 2.2
9 Add for Qear Coat 0.9
10 Repl LT Claddirg primed 1L2Z16A039EA 1 71.78 0.3 0.4
11 Overlap Minor Panel -0.2
12 Add for Clear Coat 0.1
13 FRONT DOOR
14 R�I LT R&I trim panel 0.5
15 R&I LT Handle,outside 0.4
16 Repi LT Mirror assy w/o�ght,w/o heat 1L2217683AAA 1 115.60 0.4
17 Repl LT Qadding 1L2Z7820879FB 1 287.43 0.5 0.9
18 Add for Clear Coat p,2
19 R&I LT Belt w'striP 03
20 * Rpr LT Outer panel
5�4 2.4
21 W�rtap Major Adj.Panel -0.4
22 Add for qear Coat 0.4
_ _ _ _ __
23 MISCELLANEOUS OPERATIONS
24 * Repl 1 � �
25 # PrGr�FHler appbcation 1 0.5 '
26 # Cover/�ag Vehfde 1 0.2 �
27 # Tint to Match 1 0.5 I�
28 # Enivironmentai Fee 1 5.00 X ,
SUdTOTALS 479.s1 13.0 8.4 �
NOTES
Estimate Notes:
Estimate subjed M rcvfew after disassembly!Addftlonal or more exter�sive damage may be revealed. �
2/6/2014 9:18:51 AM 019966 Page 2
Preliminary Estimate
Customer: Hasheider,Marcus 7ob Number:
Vehide:2004 MERC MOUNTAiNEEIR AWD 4D UTV G�F.OI-FI SILVER/GRAY
ESTIMATE TOTALS
C�ateyory Basis Rate cost�
�s 474.81
Body Labor 13.0 hrs @ �54.00/hr 702.00
Paint Labor 8.4 hrs � ;54.00/hr 453.60
Pairrt Supplies 8.4 hrs � ;34.00/hr 285.60
BodY Supp�ies 9.7 hrs @ ;2.00/hr 19.40
Miscelianeous 5.00
Subtotal 1,940.41
Sales Tax ;779.81 @ 7.1250% 55.56
Grand Total 1,995.97
Deductlble 0.00
CUSTOMER PAY p,pp
INSURANCE PAY 1,995.97
ESTIMATE OPEN TO TEARDOWN, PART PRICES&INSPECTiON.
ADDITIONAL COST'S MAY ARISE DURING THE REPAIR PROCESS.
******THIS IS A VISUAL INSPECTION ESTIMATE ONLY******
MN ST 60A.955 - A PERSON WHO FILES A CLAIM WITH IIYfENT TO DEFRAUD OR HELPS COMMIT A FRAUD
AGAINST AN INSURER IS GUILTY OF A CRIME.
�
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2/6/2014 9:18:51 AM 019966 Page 3
Preliminary Estimate
Cusfiomer:Hashelder,Marcus 7ob Number:
Vehide:2004 MERC MOUNTAINEER AWD 4D UN 6-4AL-FI SIWER/GRAY
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
DR2MZ02, CCC Data Date i/17/2014, and the parts selected are OEM-parts manufactured by the vehicles Original
Equipment Manufacturer. OEM parts are available at OE/Vehide dealerships. OPT OEM (Optional OEM) or ALT OEM
(Altemative OEM) parts are OEM parts that may be provided by or through altemate sources other than the OEM
vehide dealerships. OPT OEM or ALT OEM parts may reflect some specific, special, or unique pricing or discount.
OPT OEM or ALT OEM parts may indude "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 mme from an altemate data source. Tilde sign (N) items indicate MOTOR Not-Included
Labor operations. The symbol (<>) indicates the refinish operation WILL NOT be perfa�med 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 informaGon are MOTOR suggested labor
operation times. NAGS labor operation times are not included. Pound sign (#) items indicate manual entries.
Some 2014 vehides 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 fdlowing 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 UBOR:
D=Diagnostic labor category. E=Electr�ical labor categary. FsFrame 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=6lend. 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 Intemational Certified Part. 0/H=Overhaul. �y=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 Steei. N=Note(s) assoaated with the estimate line.
CCC ONE Estimating-A product of CCC Information Services Inc.
The fdlowing 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 af Automotive Repair. EPA=Environmental Protection Agency. NHT'S�►= National Highway
Transportation and Safety Administration. PDR=Paintless Dent Repair. VIN=Vehide Identiflcation Number.
2/6/2014 9:18:51 AM �19966 Page 4