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Plageman _ __ _ __ _ � � � REC�IVED APR 16 2014 NOTICE OF CLAIM FORM to the City of Saint Paul, iVlinnesot CITY �LERK ,U9in�tesntn Sttrtc Stcrtrett�966.UJ atcrles tlrat "...ernry pe�son...u Ian elairns rJamngesJiv�Jr crny»rrrlrieipulitv...,chntl earrse to be presented to the �o+•errrrn�bodj�of tlae rrlrurrcipntitv 41'71Ift7!I(YO(f[i�:l(ff lE't"�IIE�crUeged In.��s a•i�jtu��rs disco��e,•ed n�TOticc stuti»u tlre ti�ne,place,a�1c� crrcurrrstr�ur.e�tlrerenJ.��uid the cvnoru�€+�/eontpenscxiorr nrotlrerrelic!'ctenaa�l<leEl.° Please con�plete thes forni in its entiret��bv clearl�typing ar printing yoi�r ans��•er to each qucstion. If more space is n��eded,attach additional sheets. Plcasc note that�-ou may ar ma��not be contacted by=telephonc t�discuss�our claint circumstances,so pror•idc as much information as necessar��to explain}°our claim,and the amoant of compensation bcing rcquested. "i'his form must be signcd,a�cl both pages completed. If something does not apply,�Frite`N/A'. SEVD COh1PLETED FORM AND aTHER DOCUI�IENTS TO: CITY CLERK, 1� �'�'EST KELL4GG BLVD, 310 CIT�' HALL, SAINT PAUL, l�ii'� 55102 First �Iame ... 4% 1`(1�'�-( Middle Initial � Last Name� � C:ompany or Business�Ia�ne, if applicable r Street Address � �� : � C' � c-� City _ State �� Zip C�dc �J� ��` i' Daytime Telephone S� ��C-'�� E�fenin�Telephone (__J � Date of Accident! Injury c�r Date Disco��ered � Time � . �� am i in circle) �L � Please state, in c�etail, ��hat occurred, anci why you are submitting a claim. Plcase inclicate why�r io��• fou'` i-ecl the City of Saint P ul or its employees are in�rolveci �ulci,`c�r responsi _ _ � � 1 ~ � ' ' ' ` � � 1 � ' �- � � � � r � � �r� - � � / � � , R f ,` o � U'c�G� v�� 'nC� �v-� `�( j o � � C� Please cheek the�iox(es) t a most c o�ely represent th�reason for cot le�in�tliis �: ��,i� ,' ❑ Vchicle was damageci in an accidcnt hicle«Tas damaged dunng a to�� ❑ Vehicle��-as damaged by a pothole or conditian of the street ❑ Vehiele was damaged by a p low ❑ Vchicle ��as wrongfully to��ed and/or ticketed ❑ Injured on City praperty ❑ Other typc of property damagc—please specify ❑ Other type of injury—please specify ❑ Othe�•ty�e not listed—�lease specify In order to process your claim vou need to include copies of ail apnlicable documents. This is a �eneral guidetinc oF cvhat should be submitted«�ith a clai�n fonn,but it is not all inclusive. Yau ma}�be asked to pr�vide additional infonnation depending on your clainl. � Froperty damage claims to a vehicle: at least two estimates for ihe repairs tc� your vct�icle;or the actu��l bills and/or receipts for the repairs 4 To�ifing clai�ns: legible copies af an5�tickets issued and copies of'thc impaund lot receipts O Other property da�nage: repair e5timates, detailed list of damaged items O Injury claiins: medical bilis, receipts O Photo�aphs can bc provided but�vill not be returned. Page 1 of 2— Plcase complete and return both pa�CS Uf C17111] FOP11� Failure to providc a completed claim fortri ►vijj!'eSli�t jn (]�j��r�1� I � prp�� , � � Notice vf Claim Form, �'ity of Saint Paul,page ri�ro All Cl3ims — pleasc camplete this scction �� 'ere there witnesses to the incidcni? Yes No !�Unknotr>n (circle) If yes, ��leasc�ravide their namcs, atidresses and tcicphone num . . Were the policc or law enfoY•cement called? Ycs No Unkna��n (circle) If ycs, «�hat department or a�ency`? Case=�or repart# ��here did the accicient or injury take pIace? Pravide stre�t address, cross street, inlersectian, name of park or facilitv, dosest landmark, etc. Pleasc be as etailcd as ossible. If helpful, attach a di ram. �� bC�- C�.,� � Q.r�.��-��. � �� , - �� Ylease indicate th' ount you are seeking in cai�nsation this claim or��hat you would like fi�1e City to do t� resahre this claim t� yaur sa isfaction. '� `� — � �. ��, �;�;� -- - � - ,� ; ' - ` _ -, � � ,��, � r _ � . l C'�Ci,r��u-�c., —�i�-- - `�� r�._ ��- � �� . � � �'ehicle Caainis — lca�e com lete tliis section � check box if this section does not a l�� Your Vehicie: Year ` �Ia1;e ` �� Q. Model '�� C�).�� License Plate�tumi��r State�'�N Color �P(�1�1� Registered O��ner .� ` c�� 1-' Dri��cr of��'ehicle L�O.A.�� 'L(� ' �� Arca I�amaged 1� ' 1 ,� t ' ' W�Mi �� City Vehicic: �'ear � ake Moc�el License Plate Number State Calor Drivcr oI�1�ehicle (City Employee's i�amc) Ai•ea Damaged In'ur�� Claims— lcase com lete this section _ k t�ox if this section does not a lv Ho�i� �y�ere you injured? �b'hat part(s) of your body«�ere injured`? Hac�e y0U SOU�ht inedical treattnent`? Ycs N� Playuling to Seck Treatn�ent (eircic} - 13%l�uliiic��rs�ur��i�� treatmeiit? (l�rovidc date(s)) N�ne of Medical I'ro��ider(s): -- _ _<lddress Telephone Did you miss ��ork as a result of your injury? Ycs N� «'hen dic� y��u miss �vork'? (provide date(s)) Narne of}�our Einployer: t'�ddress Telephone I�Check here if j-ou xre attachi�g more�agcs to rhis claun form. Number of additional u es � A g �. Bj•si�;nrrrg dlis fo�•nr,i�uu ari�stuti�r,�rliat a//iitjvrniatiou}•au lrave prnviEled is truc:a�rd correct r�i tfte t of:�•our knowler/,�e. U�tsigned _f��'nts��i/I no�Ge prnee,sser/. Srrhurinifrg er jahe elaim cun��esulr ii:pro.cecutia�t. Print tt�e Name of't�e I'ersan Fvha Completed rhis Form: Sign�ture of Pcrson 1�Iaking the Clai� : �`Y . � � Date form �vas completed ` � ( _ Rev��ed nrr�i�can; ----�— --- Attachment ..e tow report did state that there was damage to the left rear of the vehicle. Priar to being towed,the vehicie did have some peeling paint on the rear left bumper and aiso some rust near the rear left bumper.This damage had been evaluated previousiy and an estimate given. Upon leaving the tow lot, it was noted that the right rear bumper was cracked and smashed.This was not present prior to the tow. There were alsa three large scratches to the upper portion of the left rear of the vehicle. Those scratches were also not there prior to being towed by the city.The report does not specify what the damage looked fike and what portion of the left reaa�of the car had damage.The damage the tow truck driver noted prior to towing the vehicle was the peeling paint and rust.The other damage was caused by the tow. I immediately taok the vehicle to a body shop to have the new damage documented. ' ST. PAUL AUTO BODY SHOP W��e ID: 94723f79 FederalID: 56-2416759 388 FRONT AVENUE, SAINT PAUI, MN 55117 Phone: (651)488-5780 FAX: (651)489-8338 Preliminary Estimate Customer: BROWN, LAUREN )ob Number: Written By:Tom Mike Insured: BROWN,LAUREN Policy#: Claim#: Type of Loss: Date of Loss: Days to Repair: 0 Point of Impact: Owner: Inspec,�on Location: Insuranoe Company: BROWN,LAUREN ST.PAUL AUTO BODY SHOP 1613 WOODRIDGE ST 388 FRONT AVENUE ST PAUL,MN 55117 SAINT PAUL,MN 55117 (651)226-7514 Cell Repair Facility (651)488-5780 Day VEHICLE Year: 2004 Body Style: 4D WGN VIN: Mileage In: Make: CHRY Engine: 42.4L-FI License: Mileage Out: Model: PT CRUISER LIMIfED Production Date: State: Vehide Out: Color: Int: Condition: Job#: TRANSMISSION Privacy Glass AM Radio Electric Glass Sunroof Overdrive Overhead Cor�sole FM Radio SEATS 5 Speed Transmission CONVENIENCE Stereo Bucket S�ts POWER Air Conditioning Search/Seek Leatt�er Seats Power Steering Intermittent Wipers CD Player WHEELS Power Brakes Tilt Wheel Cassette Numinum/Alloy Wheels Power Windows Cruise Control SAFETY pAINT Power Locks Rear Defogger Drivers Side Air Bag Clear Coat Paint Power Mirrors Keyless Entry Passenger Air Bag OTHER DECOR Aldrm 4 Wheel Disc&'akes Fog Lamps Dual Mirrors Rear Window Wiper Front Side Impact Air Bags Body Side Moldings RADIO ROOF 1/3/2014 2:27:38 PM 079983 Page 1 Preliminary Estimate Customer: BROWN, LAUREN ]ob Number: Vehide: 2004 CHRY PT CRUISER LIMITED 4D WGN 42.4L-FI Line Oper Description Part Number Qty Extended Labor Paint Price; 1 REAR BUMPER 2 0/H rear bumper 1•7 3 ** Repl RECOND Bumper cover w/o turbo 5093642AA 1 445.00 Incl. 2.8 4 Add for Gear Coat 1.1 5 QUARTER PANEL 6 * Rpr LT Quarter panel from 2/1/Ol ?.� 2•6 7 Add for Gear Coat 1.0 SUBTOTALS 445.00 4.2 7.5 ESTIMATE TOTALS Category Basis Rate Cost; Parts 445.00 g�y�� 4.2 hrs @ $52.00/hr 218.40 Paint Labor 7.5 hrs @ $52.00/hr 390.00 Paint Supplies 7.5 hrs @ $32.00/hr 240.00 Subtotal 1,293.40 Sales Tax $445.00 @ 7.6250% 33.93 Grand Total 1,327.33 Deductible 0.00 CUSTOMER PAY 0.00 INSURANCE PAY 1,327.33 MN ST 6QA.955 - A PERSON WHO FILES A CLAIM WITH INTEf�fT'TO DEFRAUD OR HELPS COMMIT A FRAUD AGAINST AN INSURER IS GUILTY OF A CRIME. 1/3/2014 2:27:38 PM 079983 Page 2 • Preliminary Estimate Customer: BROWN, LAUREN )ob Number: Vehide: 2004 CHRY PT CRUISER LIMIfED 4D WGN 42.4L-FI Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide DR3NP01, CCC Data Date 12/16/2013, and the parts selected are OEM-parts manufactured by the vehicles Original Equipment Manufacturer. OEM parts are available at OE/Vehicle dealerships. OPT OEM (Optionai 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 Numb�rs and Benchmark Price.s 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 vehictes, 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. OTNER 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=Disco}�nect 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. O/H=Overhaul. Qty=Quantity. Refn=Refinish. Repl=Replace. R8cI=Remove and Install. R&R=Remove and Replace. Rpr=Repair. RT=Right. SAS=Sandwid�ed 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=Paintless Dent Repair. VIN=Vehicle Identification Number. 1/3/2014 2:27:38 PM 079983 Page 3 • Preliminary Estimabe Customer: BROWN, LAUREN 7ob Number: Vehide: 2004 CHRY PT CRUISER LIMII'ED 4D WGN 42.4L-FI ALTERNATE PARTS SUPPLiERS Suppiier: Keysbone-Complebe-Minneapolis Location(s): 3615 MARSHALL S7REET NE,MINNEAPOLIS MN 55418 (800)328-1845 (612)789-1919 Line Description Item# Price 3 RECOND Bumper cover w/o turbo CH1100288R $445.00 1/3/2014 227:38 PM 079983 Page 4 GREGG'S AUTO BODY wor�e m: od2c3ebd Federal ID: 411353442 HONEST AND CONSISTENT QUALITY 581 E. 7th Street, St. Paul, MN 55130 Phone: (651) 774-8211 FAX: (651)7740174 Pr�iminary Estimate RO Number: 6636 Written By:Gregg Rosenberger Insured: PLAGEMAN,JULIE PoNcy#�: Claim�: Type of Loss: Date of Loss: Days ta Repair: 0 Poirrt of Impact: 12 Front Owner: Inspedion Location: I�urance Canparry: PLAGEMAN,JULIE GREGGS AUTO BODY 72fi NEBRA.SKA AVE E 581 E.7th Street ST PAUL,MN 55106 St.Paul,MN 55130 (651}728-0858 Cell R�alr Faality �ssi)n4-s2ii s�s�r,�ss VEHICLE Year: 2012 Body Style: 4D WGN VIN: IQVDJT'2A65C7427308 Mileage Tn: Make: IQA Engine: 4-2AL-FI Licer�e: Mileage Out: Niodel: SOUL! Pra�dix.tion Date: State: Vehide Out: Color: Int: Conditlon: Good ]ob#: TRANSIyySSION Air Conditioning Search/Seek Electric Glass Sunroof Automadc Trar�smission Intexmi��pers CD Player SEATS POWER Tilt Whee1 Ainciliary Audio Connection Cloth Seats Pow�Steering Cruise Cor►trol Premium Raclio Bucket Seats Pow�Brakes Rear Defogger Satellite Radio WHEELS Pow�Wirrbws Keyless EMry SAFETY Numinum/Alloy Wheds Power Locks Ste�ing Whee)Touch Corrtrols Driv�s Side Alr Bag PAINT Power Mirrors Rear Window Wiper Passerger Air Bag Clear Coat Paint Heated Mirrors TeJescopic Whcei Mti-Lock&akes(4) OTHER DECOR BackuP Camera wlParldng Sensors 4 Wheel Disc Brakes Fo9 LamPs Dual Mirrors RADIO Frw�t Side Impact Air Bac,ys Traction Contrd Body Side Mddings AM Ra�o Head/Curtain Air Bags Stability Control Privacy Glass FM Radio Hands Free Device Signal Integrabed Mirrors CONVENIENCE St� ROOF 1/9/2014 4:52:40 PM 034178 P�1 Preliminary Estimate RO Number: 6636 v�rade:2oi2 iaa sou�!ao wcN a-z.o�-� Une Oper Dcscription Part Nund�er Qtp Ex6ended Labor PaiM Price� 1 FRONT BUMPER$GRILLE 2 O/H bumper assy 2.0 3 Re�) Bumper cover 865112K500 1 273.90 Incl. 2.8 4 Add for Clear Coat 1.1 5 Add for fog lamps 0.4 6 RB�I RT Moldir�g bladc Ind. 7 R&I LT Molding black Ind. 8 Repl Center cover pairrted 865122K540 1 138.49 Ind. 0.8 9 Add for Clear Coat 0.2 SO R&I Lower grille Ind• il R&I Center grille Ind• 12 R&I Frorrt deflector Ind. 13 � �'eP��P� 1 OJ 14 FRONT LAMPS 15 R&I RT Headlamp assy wJo lED �d• 16 HOOD 17 * Rpr Hood 9� �R NOTE:Hood ouk of alic,�rrrent 18 � Repl Fle�c Additive 1 5.00 19 # S�I Hazardous Waste 1 5.00 X SUgTOTALS 42239 2.9 5.6 ES'TiMATE TOTALS c��go,y �� cast; pa� 417.39 g�y�� 2.9 hrs � $55.00/hr 159.50 Pairrt Labor 5.6 hrs @� $55.00/hr 308.00 Pair�t Supplies 5.5 hrs � �35.00/hr 196.00 g�y��1e5 0.5 hrs @ $8.00/hr 4.00 MisceJlar�eo� 5.00 ��I 1.089.89 Sales Tax $617.39 � 7.6250% 47.08 Grand Total 1,136.97 ��e 0.00 4U5TOMER PAY • �� INSURANCE PAY 1,136.97 1/9/2014 4:52:40 PM 034178 �2 Preliminary Estimate RO Number: 5636 Vehide:2012 IQA SOUI!4D WGN 4-2.Ol-FI GREGG'S AUTO BODY takes great care to ensure that every repair meets our standards for quality. GREGG'S AUTO BODY guarantees labor perfiormed for as long as you own your vehide on workmanship and wili, at our expense repair or mrrect all defects which are attributable to defective or faulty workmanship in the repairs stated on the repair invoice.This guarantee covers labor oniy and does not apply to parts, materials or equipment which may be covered by and subject to terms of manufacturer or vendors warranty.This guarantee dces not indude damage caused by or resulting from rust or corrosion, unreasonabie use, improper maintenance or care of the vehide.The above is an estimate based on our inspecaon and does not cover additional parts or labor which may be required after the work has been opened up.Parts price subject to change without no�ce. YOU HAVE A RIGHT TO CHOOSE A REPAIR FACILTfY OF YOUR CHOICE.WE GREATLY APPRECIATE YOUR BUSINESS. MN ST 60A.955 -A PERSON WHO FILES A CLAIM WITH IfVTENT TO DEFRAUD OR HELPS COMMIT A FRAUD AGAINST AN INSURER LS GUILTY OF A CRIME. 1/9(2014 4:52:40 PM 034178 �3 Preliminary Estimate RO Number: 6636 Vehide:20121QA SOUL!4D WGN 42.OL-FT Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived fran the Guide ARY2455, CCC Data Date 1/2J2014, and the parts selected are OEM-parts manufactured by the vehides Original Equipment Manufacturer. OEM parts are avaitable 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 tf�e OEM vehide dealerships. OPT OEM or ALT OEM parts may reflect some spedfic, special, or unique pricing or discount. OPT OEM or ALT OEM parts may indude "Biemished" parts provided by OEM's through OEM vehide 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 altemate data source. Tilde sign (N) items indicate MOTOR Not-Induded Labor operations. The symbol (<>) indicates the refinish operation WIII NOT be pertormed as a separate praedure from the other panels in the estimate. Non-Originai Equipment Manufacturer aftermarket parts are described as Non OEM or A/M. Used parts are descxibed as LKQ, RCY,or USED. Reconditi�ed parts are described as Recond. Recored parts are deso�ibed as Recore. NAGS Part Numbers and Benchmark Prices are provided by National Auto Glass Spedficadons. Labor operation times listed on the line with tt�e NAGS informadon are MOTOR suggested labor operation times. NAGS labor operation times are not induded. Pound sign (#) items indicate manual entries. Some 2014 vehides oontain minor changes fr�n the previous year. For those vehides, prior to receiving updated data from the vehide manufacturer, laba�and parts data from the previous year may be used. The CCC ONE estimator has a complete list of applicable vehides. 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 worlc to be done or parts to be repaired or replaced: SYMBOLS FOLLOWING PART PRICE: m=MOTOR Mechanical component. s=MOTOR Structural oanponent. 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=6oron steei. CAPA=Certified Automotive Parts Association. D&R=Disconnect and Reconnect. HSS=High Strength Steel. HYD=Hydroformed Steel. Ind.=Induded. LKQ=Like IGnd and Quality. LT=Left. MAG=Magnesium. Non-Adj.=Non Adjacent. NSF=NSF Intemational Certified Part. O/H=Overhaul. Qry=Quantity. Refi=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 Infomiation Services Inc. The following is a tist 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=Vehide Identification Number. 1/9/2014 4:52:40 PM 034178 �4