Zhang RECE11�Ep
1�10�CE O� CLA�M FORIYI to the_City of Saint Paul, Minneso�a2� ��14
Minnesota State Statute 466.05 states that"...every person...who claims damages from any municipaliry...shall cause toSe pfespnte?l't��RK
governing body of the municipaliry 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 PAUL, MN 55102
First Name C'IL�Q11a11 Middle Initial Last Name Zhan
l��iVQry,`d� o� � '
Company or Business Name ����P SO�I't
Are You an Insurance Company? Yes No If Yes,Claim Number?
Street Address (�� �ril`U I �aC�
City �� �al�l State � I�1 Zip Code 5 5 I o�
Daytime Phone(_) - Cell Phone(��2)Z�6- 1� O Evening Telephone( ) -
Date of Accidenb Injury or Date Discovered �'e� ��, ZJ��f' Time '�l� am/pm
Please state,in detail,what occurred(happened),and why you aze submitting a claim. Please indi ate or how you
fee the City f Saint Pay1 o its e plo ees,are involve an��d/pr responsible f r your dama es. Q �
road�� e uelC,rv� �'#¢t� nml 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 �My 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 you need to include copies of all applicable 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.
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 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
�a�lt�e te e�p�ete and return both pages will result in delay in the handling of your claim.
All Cla�lms-t�l�eas�eomt�lete�his section
Were there witnesses to the incident? Yes N Unknown (circle)
Provide their names,addresses and telephone numbers:
Were the police or law enforcement called? Yes �l� Unknown (circle)
If yes,what department or agency? Case#or report#
Where did the accident or injury take place? Provide street address,cross street, intersection,name of ar�C or fa ility,
close?Ilandmark,etc. Please �a,s de�N d as po sible. �necessary at ch a diagram._ '�i '►n rk,�
l
Please indicate the amount you are s eking in com nsation o what you would like the City to do to res lve this claim
to your satisfaction. ' � ` �
,
Vehicle Claims— lease com lete this section ❑ check box if this section does not a 1
Your Vehicle: Year z40 Make Model S
License Plate Number $ State L�Color
Registered Owner
Driver of Vehicle
Area Damaged u 8 m �2r
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniurv Claims—nlease complete this section �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 2- .
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 � �� Z�'�
Print the Name of the Person who Completed this Form: N u l�I�I la I� z N/�I��
Signature of Person Making the Claim:
Revised February 2011
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ABRA MN Roseviile INVOICE
���� �� 1914 W. County Road C R� #: 31946
Roseville, MN 55113
(651) 639-9848�651�_639-9406 (fax) _ Est: TaylorJump
HUANAN ZHANG 07 VOLV S80 Geico
1219 RAY PL Color: SILVER A ' Adjustor:
SAINT PAUL, MN 55108-1155 I Type: PC 4D SED Phone:
Home: 612-206-7690 ' VIN: YV1AS982471019562 . Claim #: 0412983120101018-
Work: 612-206-7690 Prod Date: 0107 Plate: MN SGD050 01 Deductible: 500
Mileage: 77795 ' Loss T e: Com rehensive
Fax: 612-206-7690 Yp P
Engine: 6-3.2L-FI
-- _----____ —
------------ ------- —
P=Who Pays?(�=Insurance,C=Customer_
-- ------------- ----- -- -- - -- -- --
Qty ' Type Description Part# Amount' S�p Labor ' Op Labor Paint P
# ____ Units Units
Parts Other FRONT BUMPER&GRILLE License Body R81 0.2 �
bracket
' Parts Other FRONT BUMPER 8 GRILLE Bumper Body Rpr 3.0 2.4' I
cover painted w/lamp washer elec. , ,
' FRONT BUMPER&GRILLE Add for 1.0 I
Clear Coat '
' Parts New FRONT BUMPER&GRILLE O/H Body Ovrh 2.5 �
bumper assy
' Parts Other FRONT BUMPER&GRILLE RT Cap Body , Rpr 0.2 0.2 i
lamp washer
FRONT BUMPER 8 GRILLE Add for 0.1 I
C�ear Coat A
Parts Other FRONT BUMPER&GRILLE LT Cap Blnd �•� �
lamp washer
Parts New FRONT BUMPER 8 GRILLE Add for Body Repl 0.4 �
h'lamp washer
Parts Other FRONT BUMPER&GRILLE Spoiler Body Rpr 1.0 1•6 I
! Parts Other FRONT LAMPS LT R81 headlamp assy Body R81 0.2 �
Parts Other FENDER LT Fender to CH#79949 Body Rpr 0.5 2.2 I
FENDER Overlap Major Non-Adj.Pane► �0'2 �
' FENDER Add for Clear Coat B 0.4 I
Parts Other FENDER LT Fender liner Loosen Body R&1 0.2 �
I Parts Other ' HOOD Hood{ALU} Body Rpr 2.5 2.6 1
' HOOD Overlap Major Non-Adj.Panel A -0'2 �
HOOD Add for Clear Coat C , , 0.5 I
' ' Parts Other 'wINDSHIELD RT Washer nozzle w/o , ' Body R&I 0.2 ►
heating to CH#1427 ,
Parts Other WINDSHIELD LT Washer noule w/o Body R&I 02 �
heating to CH#1427 :
' 'Car Cover ' Refn 0.1 I
' 'Corrosion Protection ' Refn 0.3 I
Haz MISC Hazardous Waste 4•o� �
PnUMat MISC Paint&Materials 355.20 ' >>•� �
------_--- -- —
- —
_ ____ __— 1.513.60
-----------------
---- ----- SubTotal
' Taxes 25.31
Grand Totai 1.538.91
--- - ___ ---—
— ---- ---
-- ----
- -- --__
Due from Insurance Due from ustomer
Sub Total 1,013.60 Sub-Total 500.00
Tax 25.31 Tax 0.00
' Total ' 1,038.91 Total 500.00
---- ---------- —
— — -- - --— Total Amount 1,538.91
INVOICE #22 03/13I2014 07:10:13 AM RO#31946 ABRA MN Roseville
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