Lucas RECEIVED
APR 2 3 2014
NOTICE OF CLAIM FORM to the City of Saint Paul, Minnes�6�Y C L E R K
Minnesota State Statute 466.05 states that"...every person...who claims damages from arry municipaliry...shall cause to be presented to the
governing body of the municipatity within 180 days after the aldeged dass or injury is drscmered a notice stating the time,place,and
circumstances rhereof,and the amount of compensation or other relief demanded"
Please complete Wis form in its entirety by clearly typiag or printing your answer to each qnestion. If more space is
needed,attach additionai sheets. Please note that you w�71 not be contaeted by telephone to clarify aaswers,so pmvide as
mnch information as necessary to esplain yonr claim,and the amoant of compensation beiog requested. You will receive a
written aclrnowiedgement once your form is recefve�. The process can take up to ten weeks or ionger depending on the
nature of your claim. This form mnst be�gned,and both pages completed, If something dces not apply,write`N/A'.
SEND COMFLETED FURM AND OTHER DOCIJMENTS TO: CITY CLERK,
15 WEST KELLQGG BLVD,310 CITY HALL,SAINT PAUL,MN 55102
First NameT\Y V 1 J'r Middle Initial�Last Name �'�li ,�C �C
Company or Susiness Name
Are You an Insurance Company? Yes� If Yes,Claim Number?
Street Address 1�"�� 1�, � � ���_—�.� �
City ��,�,�.�t �(� 1��-�—State I 1 J 1(11����t:�{�Zip Code��
Daytime Phone(��� ����ell Phone(��jj�-��.�Evening Telephone(�J -
Date of Accident/Injury or Date Discovered��IrGY l �� ��'�I'ime �v am��
Please state,in detail,wl�at occurred(happened),and why you are submitting a claim.Please indicate why or how you
feel the Ci of Saint P or�eqaployees aze inv ved and/or responsible for your dau�ages.
�
� �
� �
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Please check the box(es)that most closely represent the reason for completing this form:
❑My vehiGle was damaged in an accident [�My vehi.cle was damaged during a tow
"J�My vehicle was damaged by a pothole or condition of the street C]1VIy vehicle was damaged by a plow
❑My vehicle was wrongfully towed andlor ticic�ted ❑I was injured on City property
O Other type of Property dama$e–please specify
❑Other type of injury–please specify
In order zo process your claim vou need to inclnde cooies of all aunlicable documents.
For the claims types tisted below,please be sure to include the documents indicated or it will delay the handling of
your claim. Documents WII.L NOT be rettuned and become the properly 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 estixnates 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 retumed.
Page 1 of 2–Ple�se complete and return both pages of C1aim Form
Failure to complete and retnrn both pages will resnit in delay in the handling of your claim.
All Claim,,,c—qlease comalete this sectian
Were there witnesses to the incident? � No Unknown (circle) Q1
Provide their names,addresses and telephone numbers:�',�r�S�f�e �C`���,T 1 a-T vl�,��V 1
Were the police or law enforcement called? Yes No Unl�own (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 park ar facility,
close t dmazk,etc. Please be as detailed as ossible. If necessary,attach a diagram. . �_�j
. � 6 'tZ� - , o�.
SYI.�����(1� "� c�1•�-Y_
Please indicate the amount you are seekin m co nsation oz what you would like e City to do to resolve this clai�
to your satisfaction. � Z�
�., G�.�12, °°
V 'cle Cl ' — lease com lete this section check box if this sec 'on do not a 1
Your Vehicle: Year Make .�,_Model �,,.�_,
License Plate Number Z/ kS�x State Color � i�.Y
� Registered Owner
Driver of Vehicle
Area Damaged " CO�1'Kd t
City Vehicle: Year Make Model �'r M ,
License Plate Number State Color
Driver of Velucle(City Employee's Name)
Area Damaged
In.inrv Qaims—pleASe complete this sect�on O check box if tUis section dces not aoolv
How were you injured?
What part(s)of your body were injured? '
Have you sought medical treatment? Yes No Planning to Seek Treamient(circle)
When did you receive treatment? (provide date(s))
Name of Medical Provider(sj:
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 yon are attaching more pages to tl�is clatm form. Number of addittonal pages � .
By signing this form,you cue stating that all information you have p�ovrded is true and correct to the best
of your knowledge. Unsigned fornis will not be processed
5ubmitting a false daim can result in prosecution. Date rm was completed 'C��- v� C'��.��'�
Print the Name of the Person who Compl this orn►: C'"`-�
Signatare of Person Making the Claim: '
Revised February 2011
Praviding Insurance and Financia!Serviees ,s�e�Farm�
Horne�fftce, Btownington, IL
April 01, 2014
Amber R Lucas State Farm Claims
1350 7th St NW Apt 3 P.O.Box 52273
New Brighton MN 55112-2621 Phoenix AZ 85072-2273
RE: Claim Number: 23-432J-870
Date of Loss: March 28, 2014
Our Insured: Amber R Lucas
Dear Amber R Lucas
Our payment in the amount of$1,272.19 is en�closed. Our estimate is based on prices that are
competitive in your market area. In the event�dditional damage is identified by the repairer you
select, any amount previously paid will be taken into consideration as we determine any
additional amounts owed. We will review and consider any supplemental amounts requested by
you or the repairer you select, should additional loss-related damage become apparent. Any
additional payment will be based upon supplemental amounts agreed to by State Farm�. 'S ��
� l�'v
Your deductible of$500.00 has already been applied to the above payment. ��}�
Your vehicle estimate indicates a New Non-Original Equipment Manufacturer Part(s) and/or (J..�
Recycled Part(s)will be used in the repair of xour vehicle. The enclosed brochure should be V r,�,�
read carefully and retained for your records. I�contains State Farm's promise and other ��j 1`
consumer information about the repair of you vehicle while using these part(s). �� , �
The damage incurred in this loss will be considered prior damage unless and until you have the
��
damage repaired. If there is a subsequent loss to the insured vEh�cle and this prior damage has
not been repaired, the related prior damage will be considered in the settlement of any
subsequent loss. If you have the vehicle repaired, please notify your State Farm�agent.
Additionally, please keep a copy of your repair receipt.
If you should disagree with our decision and the amount in dispute is $10,000 or less, you have
the right to arbitrate your claim. To initiate the arbitration process, you need to contact the
American Arbitration Association at U.S. Bank Plaza, Suite 700, 200 South 6�' Street,
Minneapolis, Minnesota, 55402, telephone number 69 2-332-6545, for details regarding the
arbitration process. State Farm Insurance reserves the right to object to arbitration of coverage
questions or legal questions beyond the jurisdiction of an arbitrator.
If you have not selected a repair facility, we can assist you by identifying Select Service�and/or
Paintless Dent repairers who have agreements with State Farm�to provide quality repairs at
prices that are competitive in your market area. Conveniently located repairers can also be
found by going to www.statefarm.com.
STATE FARM INSURANCE COMPANIES
500 SOUTH 84TH STREET LINCOLN, NE 68510-2611
SUPPLEMENT FAX:(MN,WI)800-230-1949
SUPPLEMENT FAX:(IA,NE,ND,SD)800-455-9697
***ESTIMATE***
04/01/2014 08:26 AM
Owner
Owner: AMBER R LUCAS
Address: 1350 7TH ST NW APT 3 Home/Day: (612)203-9842
Home/Evening: (612)203-9842
Cit State Zi NEW BRIGHTON, MN pqX;
y p'S5112-2621
Control Information
Claim#: 23-432J-87001 Insured Policy#:
Loss Date/Time: 03/28/2014 07:00 AM Loss Type: Collision
Deductible: $500.00
Ins. Company: State Farm
Insured: AMBER R WCAS Home/Day: (612)203-9842
Address:
Home/Evening: (612)203-9842
Claim Rep: Team R3 ACC CP Team 33 yyork/Day: (866)207-6046
Address:
Inspection + .�.._
Inspection Date: 04/01/2014 08:26 AM Inspection Type: Field
inspection Location: Kennedy Transmission Contact:
Address: 19300 Minnesota 7 Home/Day: (952)474-2032
City State Zip: Deep Haven, MN 55331
Primary Impact: Right Front Side Secondary Impact:
Driveable: No Rental Assisted:
Assigned Date/Time: Received Date/Time: 03/31/2014 12:46 PM
First Contact Date/Time: Appointment Date/Time: 04/01/2014 08:00 AM
Appraiser Name: MILAN MOY Appraiser License#:
Repairer
Repairer: Shop unknown Contact: Shop unknown
City State Zip: MN F�'
,
Remarks ____ -
**SHOP TO CONTACT STATE FARM AFTER TEARDOWN WITH ADDITIONAL DAMAGE."'*
SHOP FAX ALL SUPPLS TO SUPPL UNIT 800-230-1949, PRIOR TO REPAIRS
Owner stated Rt front bumper and foglight prior condition dmged
Page 1 of 4
04/01 R014 09:47 AM
2003 Saturn L300 STD 4 DR Sedan
Claim#: 23-432J-87001 04/01/2014 08:26 AM
Vehicle
2003 Saturn L300 STD 4 DR Sedan
6cyl Gasoline 3.0
4 Speed Automatic
Lic.Plate: 425 KSX Lic State: MN
Lic Expire: 02/2015 VIN: 1G8JW54RX3Y510641
Prod Date: Mileage: 71,742
Veh Insp#: Mileage Type: Actual
Condition: Code: SN303C
Eut.Color: Silver met Int.Color:
Ext. Refinish: Two-Stage int. Reflnish: Two-Stage
Options
AM/FM CD Player Air Conditioning Alarm System
Aluminum/Alloy Wheels Anti-Lock Brakes Center Console
Cruise Control Digital Clock Dual Airbags
Fog Lights Head Airbags Heated Power Mirrors
Intermittent Wipers Keyless Entry System Leather Steering Wheel
Lighted Entry System Power Brakes Power poor Locks
Power Drivers Seat Power Steering Power Sunroof
Power Windows Rear Window Defrost�r Rem Trunk-UGate Release
Split Folding Rear Seat Sport Suspension , Tachometer
Tilt Steering Wheel Tinted Glass Traction Controi System
Velour/Cloth Seats
Damages ����
Line Op Guide MC Description MFR.Part No. Price ADJ% B% Hours R
Front Bodv And Windshield +30.00 2.4 SM
1 EU 104 Fender,Front RT RECYCLED PART $150.00'
»Certified Auto parts 1-800-791-5150
2 L 104 Fender,Front RT Refinish 3.1 RF
2.1 Surface
0.5 Edge
0.5 Two-stage
3 RI 122 Emblem,Front Fender RT R&I Assembly 0.2 SM
Front Bodv Interior Sheetmetal 0.3 SM
4 EU 168 Skirt,lnner Fender RT RECYCLED PART
»included with Qrp fender,Certi�ed Auto parts 1-800-791-5150
Wheels INC ME'
5 RI 400 Front Wheel R& I RT R&I Assembly
Front Suspension +30.00 0.4 ME
6 EU 673 46 Shaft Assembly,Axle R/F RECYCLED PART $50.00'
»LKQ Auto parts 1-800-950-4644 Qt�547412
Front Doors 1.2 RF
7 BR 210 Pnl,Front Door Outer RT Blend Refinish
0.8 Blend
0.4 Two-stage INC SM
8 RI 226 W/Strip,Belt Outer RT R&I Assembly 0.5 SM
9 RI 232 Pnl,lnner poor Trim RT R 8�I Assembly INC SM
10 RI 246 Mirror,Sport R/C RT R& I Assembly
Page 2 of 4
04/012014 09:47 AM
2003 Satum L300 STD 4 DR Sedan
Claim#: 23-432J•87001 04/01l2014 08:26 AM
11 RI 214 Cyl,Front Door Lock RT R&i Assembly 1.6 SM
12 RI 216 Handle,Front Door Otr RT R& I Assembly INC SM
Quarter And Rocker Panel
13 EU 93 MIdg,Rocker Panel RT RECYCLED PART $70.15* +30.00 INC SM
»LKQ Smart parts 1-800-349-5850 Qt 8545040
14 L 93 13 MIdg,Rocker Panel RT Refinish 1.4 RF
0.7 Surface
0.6 Two-stage setup
0.1 Two-stage
SP�*��� Replacement&Refinish
15 EU 800 Susp Assembly,Front RT RECYCLED PART $121.00" +30.00 1.7 ME
»LKQ Auto parts 1-800-950-4644 Quote 8547412 60,OOOmiles
Manual Entries
16 SB Four Wheel Align Sublet Repair $89.95* INC"' SM"
17 SB Hazardous waste Sublet Repair $3.00* INC" SM*
18 E Gar cover Replace OEM $4.00" INC` SM"
19 E Flex additive Replace OEM $3.00* INC" SM'
20 E Rt Front Tire Replace OEM $96.00" INC" ME*
»subject to invoice, Rt front tire cut up from suspension breaking
21 SB Mount&Balance Sublet Repair $16.00* INC" ME"
21 Items
MC Message
13 INCLUDES 0.6 HOURS FIRST PANEL TWO-STAGE ALLOWANCE
46 PRINTABLE ALTERNAT� PARTS COMPARE
�Estimate Total&Entries _ V�_�_� _ �_.._,�
Gross Parts $103.00
Other Parts $391.15
Paint Materials $193.80
Line Item Markup $117.35
Parts&Material Total $805.30
Tax on Parts 8�Material @ 7.275% $58.59
Labor Rate Replace Repair Hrs Total Hrs
Hrs
Sheet Metal(SM) $54.00 5.0 5.0 $270.00
Mech/Elec(ME) $105.50 2.1 2.1 $221.55
Frame(FR) $77.00
Refinish(RF) $54.00 5.7 5.7 $30?.80
Paint Materials $34.00
Labor Total 12.8 Hours $799.35
Sublet Repairs $108.95
Gross Total 51,772.19
Less: Deductible $500.00-
$1,272.19
Net Total
.* �
For more information regarding State Farm's promise of satisfaction relating to new non-original
equipment manufacturer(non-OEM)and recycled parts, please visit: htto:J/st8.fm/7X4 or QR code.
� . . �
�
Page 3 of 4
04/012014 09:47 AM �
2003 Satum L300 STD 4 DR Sedan
Ciaim#: 23-432J-87001 04/01/2014 0826 AM
Register online to check the status of your claim and stay connected with State Farm�.To register,go to statefarm.com and select Check the
Status of a Claim. If you are aiready registered,thank you! Not available in New Mexico.
Alternate Parts Y/01/00/00/01/00 CUM 01/00/00/01/00 Zip Code:55430 METRO AREA
Recycled Parts NOT REQUESTED
Audatex Estimating 7.0.226 ES 04/01/2014 09:47 AM REL 7.0.226 DT 03/01/2014
Copyright(C)2013 Audatex North America, Inc.
1.6 HRS WERE ADDED TO THIS ESTIMATE BASED ON AUDATEX'S TWO-STAGE REFINISH FORMULA.
ANY PERSON WHO SUBMITS AN APPLICATION OR FILES A CLAIM WITH INTENT TO DEFRAUD
OR HELPS COMMIT A FRAUD AGAINST AN INSURER IS GUILTY OF A CRIME.
THIS IS AN ESTIMATE. REPAIR FACILITES MUST INSPECT TH VEHICLE TO DETERMINE
IF ANY REPAIRS NOT LISTED ARE REQUIRED,AND TO CONT�CT STATE FARM BEFORE
MAKING SUCH REPAIRS. REPAIRER ALSO IS RESPONSIBLE FI�R CONDUCTING ANY NECESSARY
INSPECTION AND SAFETY CHECKS PRIOR TO AND AFTER COMPLETING REPAIRS.
THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF ONE OR MORE CRASH PARTS
SUPPLIED BY A SOURCE OTHER THAN THE MAN[JFACTURER OF YOUR MOTOR VEHICLE.
WARRANTIES APPLICABLF 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= ** NON-OEM PART OE= Replace PXN OE Srpis UE= Replace OE Surplus
ET = Partial Replace Labor EP= '"NON-OEM PART EU= RECYCLED PART
TE= Partial Replace Price PM= REMAN/REBUILT PART UM= REMAN/REBUILT PART
L = Refinish PC= RECOND PART UC= RECOND PART
TT = TwaTone SB= Sublet Repair N = ADDITIONAL OPERATION
BR= Blend Refinish I = Repair IT = Partial-Repair
CG= Chipguard RI = R&I Assembiy P = Check
RP= RP-RELATED PRIOR
This report contains proprietary information of Audatex and may not be disclosed to any third party(other than
� the insured, claimant and others dn a need to know basis in order to effectuate the claims process)without
��������Audatex's prior written consent.
a Sa,[er�eom�rnM �
-g�-. ....�.-d Copyright(C)2013 Audatex North America, Inc.
Audatex Estimating is a trademark of Audatex North America, Inc.
Page 4 of 4
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