Friel . RECEIVED
APR 0 9 2014
NOTICE OF CLAIM FORM to the City of Saint Paul, Mi�tLaLERK
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 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 nqf 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
written acknowledgement once yo�r form is received. The process can take up to ten weeks or longer depending on the
nature of your claim. Tlvs.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 �°L G.v� _ Middle Initial I Last Name ��'�e I
Company or Business Name
Are You an Insurance Company? Yes No If Yes,Claim Number?
Street Address t��( Z d�'►0 0.Ue G•
City �- �u-�� � State �N Zip Code.SSIOb
Daytime Phone ((�I )855- `lao� Cell Phone (�r)3a9 - Obo Evening Telephone( ) -
Date of Accident/Injury or Date Discovered o 1 I�II� Time � �� am/�m
Please state, in detail, what occurred(happened),and why you are submitting a claim.Please indicate why or how you
feel the City of Sain/t PaulIor its employeesf are involved and/cr responsible for your damages.
� !.c)fA_S Stoo02c} t��ii1� T�0 Cc�rs c.J�t��'i� �o� u A a e
�P.�� #ufn � E1��91 �/Pn = ln)aS �e�.< e� b � D�rce f
h� npe�^s �, be l'e,o1a e � ee 1 .-�lre
r�icF� 0.S �o-� Ociv.nw G Fn�o'� �is -�'fv+-�r� L.�h�cp� f'PS�I-�Pc� tn_ -�2
q�C�G�'�� .RIS�_rl{1C(F � S l.t,[�[���dteAa.� �i.aM�,r.Y, '�► �tl.t. /Vtw�-}�Cr iu/1� -�'C��.��.
�Ple se 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 (.��`oi ar�, f ne c k. S�oK�d�'� SoFe ness
In order to process your claim vou 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 WII.,L NOT ix�reEnrned anc�become the propert}c of tl��ity._You are encournged to keep a
copy for yourself before subrrutting your claim form. � �
38(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 re�umed.
Page 1 of 2—Please complete and return both pages of Claim Form
Failure to eomplete and return both pages will result in delay in the handling of your claim.
All Claims-please complete this section
Were there wimesses to the incident? Yes No Unknow (circle)
Provide their names, addresses and telephone numbers:
Were the police or law enforcement called? Yes No Unknown (circle)
If yes,what department or agency? Ao I i�e Case#or report# Cu.S e #� l�/- Oo lOa9
Where did the accident or injury take place? Provide street address,cross street, intersection,name of park or facility,
closest�andmark etc. Please be as detailed as possible. If necessary, attach a diagranz �Cdn-� S� £ Cha�SWa�-u+ �Je
50 ee k -�ro n�► I'-{�(-� -k�MQ rc� b4r r
Please indicate the a ount you are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction.�����3• �'�
Vehicle Claims- lease com lete this section ❑ check box if this section does not a 1
Your Vehicle: Year 443 Make ���� Model �O1J �
License Plate Number �`�`l - �W k State�(�Color l�I�c�
Registered Owner ec� a ri� �`e �
Driver of Vehicle SPun a��-�%�1� r�e I
Area Damaged_��,ir►�oe� / N! ti���e-�
City Vehicle: Year Make r Model
License Plate Number _ State Color (���k e
Driver of Vehicle(City Em�loyee's Name) C I o me✓1 q va nu
Area Damaged ��r;11 E I-�eua (�9h�ts
In'ur Claims- lease com lete this section ❑ check box if this section does not a 1
How were you injured? vn u I�e c K Jold-ae� ba�K kn� � er e"n� fe � d e�'
What part(s)of your body were injured? ne c k E s I�o�{I�r
Have you sought medical treatment? Yes No Planning to Seek Treatment(circle)
When did you receive treatment?�}�o�/30�� (provide date(s))
Name of Medical Provider(s):��� �c+r 1l S-�ein�A�Ser
Address r -Ion d� l e w��� Mnl $5��9 Telephone 6.7 � �3`�" SO SO
Did you miss work as a sult of your injury? es No
When did you miss work? a 1/03�y (provide date(s))
Name of your Employer: G �de n rne�rt �11 u���e
Address �`r3a 2�e��� aa�Ic ��. ,$�-, Qa�.l, f1'W SSf�S Telephone 651- $55- 9a�
�Check here if you are attack�ing more pages to this claim form. Number of additional pages � .
By signing this forni,you are stating that all information you have provided is true and eorrect to the best
of your knowledge. Unsigned forms will not be proeessed. �
,
Submitting a false claim can result in prosecution. Date form was completed 3 I ab��'t
Print the Name of the Person who Complete this Fo ��� `' '� �
1
Signature of Person Making the Claim:
Revised February 20ll � �
ABRA Auto Body & Glass - Workfile ID: ef2d4f7c
Federal ID: 41-1942823
� Maplewood
Right The First Time...On Time
2806 HIGHWAY 61, MAPLEWOOD, MN 55109
Phone: (651) 483-2145
FAX: (651) 483-2509
Preliminary Estimate
Customer: FRIEL, SEAN 7ob Number:
Written By: Scott Pomeroy
Insured: FRIEL,SEAN Policy#: Claim #: 00
Type of Loss: Date of Loss: 3/21/2014 12:00:00 PM Days to Repair: 7
Point of Impact: 06 Rear
Owner: Inspection Location: Insurance Company:
FRIEL,SEAN ABRA Auto Body&Glass-Maplewood CUSTOMER PAY
1701 IDAHO AVE E 2806 HIGHWAY 61 '
ST PAUL, MN 55106 MAPLEWOOD, MN 55109
(651)329-0609 Business Repair Facility
(651)483-2145 Business
VEHICLE
Year: 2003 Body Style: 4D SED VIN: 1GSAG52F03Z140123 Mileage In: 122606
Make: SATU Engine: 4-2.2L-FI License: 799-BWK Mileage Out:
Model: ION 1 Production Date: 1/2003 State: MN Vehicle Out:
Color: Black Int: Condition: Job#:
TRANSMISSION Console/Storage AM Radio SEATS
Automatic Transmission CONVENIENCE FM Radio Cloth Seats
POWER Intermittent Wipers Stereo Bucket Seats
Power Steering Tilt Wheel Search/Seek WHEELS
Power Brakes Rear Defogger SAFETY Wheel Covers
DECOR Message Center Drivers Side Air Bag PAINT
Dual Mirrors RADIO Passenger Air Bag Clear Coat Paint
3/27/2014 4:43:16 PM 014563 Page 1
Preliminary Estimate
Customer: FRIEL, SEAN Job Number:
Vehicle: 2003 SATU ION 1 4D SED 4-2.2L-FI Black
Line Oper Description Part Number Qty Extended Labor Paint
Price$
1 REAR BUMPER
2 ** <> Repl RECOND Bumper cover 22698403 1 265.00 1.1 3.0
3 Add for Clear Coat 1.2
4 Repl Absorber 22734110 1 91.48 0.1
5 REAR BODY&FLOOR
6 * Rpr Rear body panel 4_5 1.5
7 Overlap Major Non-Adj. Panel -0.2
8 Add for Clear Coat �•3
9 EXHAUST SYSTEM
10 Repl MufFler 22728721 1 379.78 m 0.8
ll MISCELLANEOUS OPERATIONS
12 # Refn �Car Cover 0.1
13 # Refn 'Corrosion Protection 03
14 # Repl �Flex Additive/Adhesion Promoter 1 8.50 T
15 # �Hazardous Waste 1 5.00 X
SUBTOTALS 749.76 6.5 6.2
ESTIMATE TOTALS
Category Basis Rate Cost;
Parts 736.26
Body Labor 6.5 hrs @ $56.00/hr 364.00
Paint Labor 6.2 hrs @ $56.00/hr 347.20
Paint Supplies 6.2 hrs @ $36.00/hr 223.20
Miscellaneous 13.50
Subtotal 1,684.16
Sales Tax $967.96 @ 7.1250% 68.97
Grand Total 1,753.13
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 1,753.13
THIS IS A VISUAL INSPECTION ONLY. THERE MAY BE ADDITIONAL DAMAGE AFfER 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.
I�
3/27/2014 4:43:16 PM 014563 Page 2
Preliminary Estimate
Customer: FRIEL, SEAN ]ob Number:
Vehicle: 2003 SATU ION 1 4D SED 4-2.2L-FI Black
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
DR8IA03, 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
(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 PRI�E:
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=6lend. BOR=Boron steel.
CAPA=Certified Automotive Parts Association. D&R=Disconnect and Reconnect. HSS=High Strength Steel.
HYD=Hydroformed Steel. Inc1.=Included. LKQ=Like Kirid 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=Bureau of Automotive Repair. EPA=Environmental Protection Agency. NHTSA= National Highway
Transportation and Safety Administration. PDR=Paintless Dent Repair. VIN=Vehicle Identification Number.
,�
3/27/2014 4:43:16 PM 014563 Page 3
Preliminary Estimate
Customer: FRIEL, SEAN ]ob Number:
Vehicle: 2003 SATU ION 1 4D SED 4-2.2L-FI Black
ALTERNATE PARTS SUPPLIERS
Supplier: Keystone-P+A-Minneapolis
Location(s): 3615 MARSHALL STREEf NE,MINNEAPOLIS MN 55418 (800)328-1845 (612)789-1919
Line Description Item# Price
2 RECOND Bumper cover GM1100681R $265.00
3/27/2014 4:43:16 PM 014563 Page 4
LaMettry's Collision, Glass and More Workfile ID: db04c8a5
FederalID: 411393089
� ,� , � Maplewood
� ��� "Every Customer Leaves With A Smile"
2951 Maplewood Drive, Maplewood, MN 55109
Phone: (651) 766-9770
FAX: (651) 766-8660
Preliminary Estimate
Customer: FRIEL, SEAN
Insured: FRIEL,SEAN Policy#: Claim #:
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact: 06 Rear
Owner: Inspection Location: Insurance Company:
FRIEL,SEAN LaMettry's Collision,Glass and More SELF PAY
Maplewood
1701 IDAHO AVE E 2951 Maplewood Drive
ST. PAUL, MN 55106 Maplewood, MN 551p9
(651)329-0609 Day Repair Faciliry
(651)766-9770 Business
VEHICLE
Year: 2003 Body Style: 4D SED VIN: 1G8AG52F03Z140123 Mileage In:
Make: SATU Engine: 4-2.2L-FI License: 7996WK Mileage Out:
Model: ION 1 Production Date: 1/2003 State: MN Vehicle Out:
Color: BLACK Int: BLACK Condition: ]ob#:
TRANSMISSION Console/Storage AM Radio SEATS
Automatic Transmission CONVENIENCE FM Radio Cloth Seats
POWER Intermittent Wipers Stereo Bucket Seats
Power Steering Tilt Wheel Search/Seek WHEELS
Power Brakes Rear Defogger SAFETY Wheel Covers
DECOR Message Center Drivers Side Air Bag PAINT
Dual Mirrors RADIO Passenger Air Bag Clear Coat Paint
1/3/2014 1:42:22 PM 053108 Page 1
Preliminary Estimate
Customer: FRIEL, SEAN
Vehicle: 2003 SATU ION 1 4D SED 4-2.2L-FI BLACK
Line Oper Description Part Number Qty Extended Labor Paint
Price$
1 REAR BUMPER
2 ** Repl RECOND Bumper cover 22698403 1 282.00 1.1 3.0
3 Add for Clear Coat 1.2
4 # Flex Additive 1 6.00
5 # Subl Hazardous Waste Disposal Fee 1 5.00 X
SUBTOTALS 293.00 1.1 4.2
ESTIMATE TOTALS
Category Basis Rate Cost$
Parts 288.00
Body Labor 1.1 hrs @ $56.00/hr 61.60
Paint Labor 4.2 hrs @ $56.00/hr 235.20
Paint Supplies 4.2 hrs @ $38.00/hr 159.60
Body Supplies 1.1 hrs @ $2.00/hr 2.20
Miscellaneous 5.00
Subtotal 751.60
Sales Tax $449.80 @ 7.1250% 32.05
Grand Total 783.65
THIS REPORT IS AND ESTIMATE ONLY, BASED ON OUR INITIAL INSPECTION AND DOES NOT COVER ADDITIONAL
PARTS OR LABOR WHICH MAY BE REQUIRED AFfER THE WORK IS OPENED UP. PART PRICES SUBJECT TO
CHANGE PER THE MANUFACTURER AND AVAILABILITY.
WARRANTY: LIFEfIME AGAINST DEFECTS IN WORKMANSHIP. WARRANTY REPAIRS DONE BY LAMEfTRY'S
COLLISION ONLY. NO WARRANTY ON RUST, CORROSION RESISTANCE OR REPLACEMENT RENTAL CARS.
OUR ESTIMATED COMPLEfION TIME DOES NOT INCLUDE INSURANCE OR PARTS DELAYS THAT WE MAY
EXPERIENCE.
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.
1/3/2014 1:42:22 PM 053108 Page 2
Preliminary Estimate
Customer: FRIEL, SEAN
Vehicle: 2003 SATU ION 1 4D SED 4-2.2L-FI BLACK
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
DR8IA03, CCC Data Date 1/2/2014, 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 pahts and/or labor information provided by MOTOR may have
been modified or may have come from an alternate data source. Tilde sign (N) 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 inc�luded. 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=Bureau of Automotive Repair. EPA=Environmental Protection Agency. NHTSA= National Highway
Transportation and Safety Administration. PDR=Paintless Dent Repair. VIN=Vehicle Identification Number.
1/3/2014 1:42:22 PM 053108 Page 3
�- ,
Preliminary Estimate
Customer: FRIEL, SEAN
Vehicle: 2003 SATU ION 1 4D SED 4-2.2L-FI BLACK
ALTERNATE PARTS SUPPLIERS
Supplier: Keystone-Complete-Minneapolis
Location(s): 2400 KERPER BLVD, DUBUQUE IA 52001 (800)747-2500 (563)556-5030
3017 A HOOVER AVENUE,STEVENS POINT WI 54481 (800)218-4848 (715)342-0772
2700 29TH AVENUE N, ESCANABA MI 49829 ($00)833-2030 (906)789-2200
9532 W.CARMEN AVENUE, MILWAUKEE WI 53225 (800)924-8230 (414)463-1019
822 CENTRAL AVENUE,LINTHICUM MD 21090 (800)390-4600 (410)636-4600
3615 MARSHALL STREET NE, MINNEAPOLIS MN 55418 (800)328-1845 (612)789-1919
2021 WEST DIVISION STREET,ST.CLOUD MN 56301 (800)247-0861 (320)251-8494
5969 HAASE ROAD, DEFOREST WI 53532 (800)356-7252 (608) 249-4775
5085 WREN DRIVE,APPLETON WI 54913 (800)422-1995 (920)731-3030
Line Description Item# Price
2 RECOND Bumper cover GM1100666R $282.00
1/3/2014 1:42:22 PM 053108 Page 4