Einch Eckberg RECEIVED
APR �8 20i4
NOTIC� OF CLAIM FORM to the City of Saint Paul, Minne�,q�Y CLERK
Mirt�Tesota S�ate Stutute 466.05 stnte.r thnt " ...every persnn...whn e•/nims dcrmnges,from miy municipn/ity....nc�i/!cnuse!n he presentcd to the
�overning body oJ'tl�e municipnliry mithi�i 180 dnys after tlre nlleged lo.rs or injury is di.rcovered a notice stating the time,pince,n��d
� �ircumstances thereo/;and the amount of compensatinn or other relief dentanded."
I'lease 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 compieted. 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
.STor c� +� • E•N C K _ E-.l•a Sc :..� E.Fc� �v6i++f-W,FE,,
First Name �'�" '`� Middle Initial '"�• Last Name C�-K k3E.R ra - F+us,43a,�� �Q Q�ve.�e F�u`S
�
Company or Business Name
Are You an Insurance Company? Yes/� If Yes, Claim Number?
StreetAddress sOSS� �/ogrna►�dac.� �I�E•ru� �etT'-�
City -ST�c..,��t-r;rR State m.,�vES or.r Zip Code ��o��
AAv� -
Daytime Phone ( ) - Cell Phone (d s�)o?S3-3a19'� Evening Telephone( ) -
Date of Accident/Injury or Date Discovered 3����1 i� N •y-�T Time 9�oo am/� — ���Aex.
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. .�Q��i�v �Nsr
O S Q R.$�N �VJ�, /00 � v� S O� �\ �G � _ �f iT �
T' o '� � ..�c� �'V� '.t� :J S � ,��C i�l��D6 .
crt i .T '�'e ut. Le i — : ,' C\.
F�O,OT �K�4J1 vSC�1Co�R S��E O� ��'fsNT I�M�UI MJ+41 �COKf.t� �• SEE H04�. J
1S IS � T ST ee.T� � � W J 4.�E eT`1 o t�. ti V O� GE 8 ��
�..'� �T' T�T � KI O uI�-�M�
Please check the box(es) that mos[ closely represent th�reason for completing this form: �E.i.�- F�+�►e�mwe�e��ti�,�
❑ My vehicle was damaged in an accident ❑ My vehicle was damaged during a tow
6�1 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 apnlicable 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.
� 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 y�.
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 - �.NF •
O Injury claims: medical bills, receipts - v ev�
� 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-nlease comnlete this section
Were there witnesses to the incident'? Yes No Unknown (circle)
Provide their names, addresses and telephone numbers: Ko+T'y V ��{�.Sov • So I �lotr•� �y�,,,;,� Sfi.-.SuT� lo�
�i�cc.aJ+4lEe rr►N SSc�i. • �S1 -a�Go� o7�c,• S'i"�� Srr�%rN - Stvmc� �4 �c.sS • G�a-7� -
i S�1Co .
Were the police or law enforcement called? Yes �o 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 park or facility,
closest landmark, etc. Please be as detailed as possible. If necessary, attach a diagram. o••t Su&.e•eBYN
�rey��JG �1ST Tb ��I t'«�`L � � QOetT /0O orC So Gy�QS WELT aF $c.�E�wS — dE•�< Sy jyt�•r.--
4N O u�tNS �.. /)')ap P /w/ � . . i .9
Please indicate the amount you are seel:ing in compensation or what you would like the City to do to resolve this claim
to your satisfaction. /}QK�4 �.s-r�'v���'c- %� f1,E- !tio„�lES-� o� fil►E -�""W o � '��7�•.8S
Vehicle Claims-please complete this section ❑ check box if this section does not a�ply
Your Vehicle: Year �oi3 Make Ho���l Model �4ea�e� �.X -1-
License Plate Number K'r�i $'''' State�v Color ���yc
Registered Owner 5��+�-�� A• �•µ� � +a��-
Driver of Vehicle D�—�• E�Kg�� - yK Ba
AreaDamaged ��ovr P.,su�o�2 S:�C� F�ou-r 8ccn► *� �-e�e� onf,e��
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle (City Employee's Name)
Area Damaged
Injurv Claims-please complete this section l�check box if this section does not apply
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? _ __ __ __ (pr��vide date(sll
Name of your Employer:
Address Telephone
❑ Check here if you are attaching more pages to this claim form. Number of additional pages
By signing tliis form,you are stating tliat all information you have provided is true and correct to the best
of yor�r knowledge. Unsigned forms will not be processed.
Submitting a false claim can resiclt in proseciction. Date form was completed
Print the Name of the Person who Compieted this Form:
Signature of Person Making the Claim:
Revised Febru�iry 201 I
ABRA Auto Body &Glass - Stiliwater Workfile ID: 15caeda3
FederalID: 41-1942823
Right The First Time...On Time
2000 Curve Crest Bivd, Stillwater, MN 55082
Phone: (651)430-0800
FAX: (651) 430-0550
Preliminary Estimate
Customer: EINCH,STACY )ob Number:
Written By: Stacy Nelson
Insured: EINCH,STACY Policy#: Claim#: NONE
Type of Loss: Date of Loss: 4/18/2014 12:00:00 PM Days to Repair: 0
Point of Impact: Ol Right Front
Owner: Inspection Location: Insurance Company:
EINCH,STACY ABRA Auto Body&Glass-Stillwater CUSTOMER PAY
5055 NORMANDALE AVE N 2000 Curve Crest Bivd
STILLWATER,MN 55082 Stillwater,MN 55082
(651)253-3294 Business Repair Fadlity
(651)430-0800 Business
VEHICLE
Year. 2013 Body Style: 4D SED � VIN: 1HGCR2F88DA106256 Mileage In: 18700
Make: HOND Engine: 42.4L-FI License: 833KTN Mileage Out:
Model: ACCORD IXL Production Date: 1/2013 State: MN Vehide Out:
Color: BLACK Int: Condition: Job#:
TRANSMISSION Air Conditioning Stereo Electric Glass Sunroof
Automatic Transmission Intermittent Wipers Search/Seek SEATS
POWER Tilt Wheel CD Player Bucket Seats
Power Steering Cruise Control Auxiliary Audio Connection Leather Seats
Power Brakes Rear Defogger Satellite Radio Heated Seats
Power Windows Keyless Entry SAFETY WHEELS
Power Locks Alarm Drivers Side Air Bag Aluminum/Alloy Wheels
Power Mirrors Message Center Passenger Air Bag P��T
Heated Mirrors Steering Wheel Touch Controls Anti-Lock&akes(4) Clear Coat Paint
Power Driver Seat Telescopic Wheel 4 Wheel Disc Brakes OTHER
Power Passenger Seat Gimate Control Front Side Impact Air Bags Fog Lamps
DECOR Backup Camera w/Parking Sensors Head/Curtain Air Bags Traction Control
Dual Mirrors RADIO Hands Free Device Stability Control
Console/Storage AM Radio Lane Departure Waming Signal Integrated Mirrors
CONVENIENCE FM Radio ROOF Power Trunk/Gate Release
4/18/2014 2:36:02 PM 019111 Page 1
� Preliminary Estimate
Customer: EINCH,STACY ]ob Number:
Vehide: 2013 HOND ACCORD IXL 4D SED 4-2.4L-FI BLACK
Line Oper Description Part Number Qty Extended Labor Pairrt
Price$
1 FRONT BUMPER
2 0/H front bumper 1.6
3 <> Repl Bumper cover 04711T2AA90ZZ 1 308.33 Ind. 2.8
4 Add for Clear Coat 1.1
5 Add for fog lamps �•2
6 R&I Ucense frame 0•2
7 # Subl �4 Wheel Alignment 1 89.95 X
Note:Vehicle went in big pot hole.Need to check suspension
8 # Repl 'Flex Additive/Adhesion Promoter 1 8.50 T
9 # �Hazardous Waste 1 5.00 X
SUBTOTALS 411.78 2.0 3.9
ESTIMATE TOTALS
��ry Basis Rate Cost�
Pa� 308.33
gpdy��� 2.0 hrs @ $52.00/hr 104.00
Paint Labor 3.9 hrs @ $52.00/hr 202.80
Paint Supplies 3.9 hrs @ $32.00/hr 124.80
Miscellaneous 103.45
Subtotal 843.38
Sales Tax $441.63 @ 7.1250% 31.47
Grand Total $74.85
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 874.85
TNIS IS A VISUAL INSPECTION ONLY. THERE MAY BE ADDITlONAL DAMA6E AFfER DISASSEMBLY. PARTS ARE
SUBJECT TO INVOICE. TNERE 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 HE�PS COMMIT A FRAUD
AGAINST AN INSURER IS GUILTY OF A CRIME.
4/18/2014 2:36:02 PM 019111 Page 2
RAYMOND AUTO BODY� INC. Workfile ID: 909740f7
FederalID: 41-0888257
1075 PIERCE BUTLER RTE, SAINT PAUL, MN
55104
Phone: (651) 488-0588
FAX: (651) 488-4794
Preliminary Estimate
Customer: EINCK, STACY )ob Number:
Written By: DAMON SLAIKEU
Insured: EINCK,STACY Policy#: Claim#:
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact:
Owner: Inspection Location: Insurance Company:
EINCK,STACY RAYMOND AUTO BODY,INC.
5055 NORMANDALE AVENUE NORTH 1075 PIERCE BUTLER RTE
STILLWATER, MN 55082 SAINT PAUL, MN 55104
(651) 253-3294 Day Repair Facility
(651)488-0588 Business
VEHICLE
Year: 2013 Body Style: 4D SED VIN: 1HGCR2F88DA106256 Mileage In:
Make: HOND Engine: 4-2.4L-FI License: Mileage Out:
Model: ACCORD EXL Production�ate: State: Vehicle Out:
Color: Int: Condition: Job#:
TRANSMISSION Air Conditioning Stereo Electric Glass Sunroof
Automatic Transmission Intermittent Wipers � Search/Seek SEATS
POWER Tilt Wheel , CD Player Bucket Seats
Power Steering Cruise Control Auxiliary Audio Connection Leather Seats
Power Brakes Rear Defogger Satellite Radio Heated Seats
Power Windows Keyless Entry SAFETY WHEELS
Power Locks Alarm Drivers Side Air Bag Aluminum/Alloy Wheels
Power Mirrors Message Center Passenger Air Bag PAINT
Heated Mirrors Steering Wheel Touch Controls Anti-Lock Brakes(4) Clear Coat Paint
Power Driver Seat Telescopic Wheel 4 Wheel Disc Brakes OTHER
Power Passenger Seat Climate Control Front Side Impact Air Bags Fog Lamps
DECOR Backup Camera w/Parking Sensors Head/Curtain Air Bags Traction Control
Dual Mirrors RADIO Hands Free Device Stability Control
Console/Storage AM Radio Lane Departure Warning Signal Integrated Mirrors
CONVENIENCE FM Radio ROOF Power Trunk/Gate Release
4/18/2014 3:36:49 PM 019495 Page 1
� � Preliminary Estimate
Customer: EINCK, STACY 7ob Number:
Vehicle: 2013 HOND ACCORD EXL 4D SED 4-2.4L-FI
Line Oper Description Part Number Qty Extended Labor Paint
Price$
1 FRONT BUMPER
2 0/H bumper assy 1.6
3 Repl Bumper cover 04711T2AA90ZZ 1 308.33 Incl. 2.8
4 Add for Clear Coat 1.1
5 Add for fog lamps �•2
6 R&I License frame 0•2
7 FRONT LAMPS
8 R&I RT R&I headlamp assy 0.3
9 R&I LT R&I headlamp assy 0.3
10 FENDER
11 R&I RT Fender liner 0.4
12 R&I LT Fender liner 0.4
13 MISCELLANEOUS OPERATIONS
14 # Hazardous waste removal 1 6.00 X
15 * Repl Cover car/bag 1 �
16 # Color tint/color match 1 0.5
17 # Repl Fiex additive 1 8.00
$UBTOTALS 322.33 3.4 4.4
ESTIMATE TOTALS
Category Basis Rate Cost$
pa� 316.33
Body Labor 3.4 hrs @ $54.00/hr 183.60
Paint Labor 4.4 hrs @ $54.00/hr 237.60
Paint Supplies 4.4 hrs @ $34.00/hr 149.60
Miscellaneous 6.00
Subtotal 893.13
Sales Tax $465.93 @ 7.6250% 35.53
Grand Total 928.66
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 928.66
WHILE WE HAVE MADE EVERY EFFORT TO WRITE A COMPREHENSIVE REPORT OF THE VISIBLE DAMAGE TO YOUR
VEHICLE, IT IS IMPORTANT TO REMEMBER THAT THIS IS ONLY AN ESTIMATE.
THERE ARE A NUMBER OF FACTORS THAT CAN AFFECT THE ACTUAL COST OF REPAIRS, INCLUDING BUT NOT
LIMITED TO HIDDEN DAMAGE, PARTS PRICE CHANGES, AND INSURANCE COMPANY INVOLVEMENT.
PLEASE CONSIDER THIS WHEN MAKING DECISIONS REGARDING THE REPAIRS TO YOUR VEHICLE.
4/18/2014 3:36:49 PM 019495 Page 2
� � Preliminary Estimate
Customer: EINCK, STACY Job Number:
Vehicle: 2013 HOND ACCORD EXL 4D SED 4-2.4L-FI
QUALITY REPLACEMENT PARTS WARRANTY
OUR REPAIR ESTIMATE MAY SPECIFY THE USE OF QUALITY REPLACEMENT PARTS. QUALITY REPLACEMENT PARTS
ARE PARTS NOT MANUFACTURED BY OR FOR THE ORIGINAL EQUIPMENT MANUFACTURER. WE WILL STAND
BEHIND THE QUALTTY REPLACEMENT PARTS THAT ARE SPECIFIED ON THIS ESTIMATE AND USED IN THE REPAIR
OF YOUR VEHICLE, FOR AS LONG AS YOU OWN/LEASE THE VEHICLE. WE WARRANT THESE PARTS ARE OF LIKE
KIND, QUALITY, SAFEfY, FIT AND PERFORMANCE TO PARTS MANUFACTURED BY OR FOR THE ORIGINAL
EQUIPMENT MANUFACTURER.
THIS WARRANTY EXCLUSIVELY COVERS LOSS OR DAMAGE THAT IS RELATED TO DEFECTS IN THE QUALITY
REPLACEMENT PART. THIS WARRANTY DOES NOT COVER DAMAGE OR PART FAILURE DUE TO IMPROPER
INSTALLATION, MISUSE, NEGLECT, ABUSE, IMPROPER MAINTENANCE, ABNORMAL OPERATION, OR NORMAL WEAR
&TEAR.
SHOULD A SUPPLIER OF A PART SPECIFIED IN OUR REPAIR ESTIMATE, OR THE REPAIR FACILITY THAT PERFORMS
THE REPAIR ON YOUR VEHICLE, BE UNABLE TO RESOLVE A LEGITIMATE COMPLAINT ABOUT THE QUALITY
REPLACEMENT PART USED IN THE REPAIR, WE WILL MAKE EVERY EFFORT TO SEE THAT THE PROBLEM IS
CORRECTED.
THIS WARRANTY AND ANY REPRESENTATIONS MADE HEREIN ARE NON-TRANSFERABLE AND EXTEND ONLY TO
THE PARTY OWNING/LEASING THE VEHICLE AT THE TIME OF THE REPAIR.
FOR ASSISTANCE, PLEASE CONTACT THE NEAREST CLAIM DEPARTMENT OFFICE.
DISCLAIM ER:
ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDU�ENT INSURANCE CLAIM FOR THE PAYMENT OF A
LOSS MAY BE GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN STATE PRISON.
THE LABOR AND TAX RATES USED WERE DETERMINED BY THE VEHICLE INSPECTION LOCATION UNLESS THE
REPAIR FACILITY WAS KNOWN AT THE TIME OF THE INSPECTION OR ANOTHER LOCATION WAS SPECIFIED
BEFORE THE ESTIMATE WAS PREPARED
THIS IS NOT AN AUTHORIZATION TO REPAIR.
TO ENSURE REPAIRS WILL BE COMPLETED BASED ON THIS ESTIMATE; PLEASE PROVIDE A COPY TO THE REPAIR
FACILITY PRIOR TO AUTHORIZING REPAIRS. FAILURE TO DO SO MAY RESULT IN YOU BECOMING RESPONSIBLE
FOR PAYING UNAPPROVED EXPENSES.
NO PAYMENT FOR A SUPPLEMENT WILL BE APPROVED OR ISSUED UNLESS THE REPAIRS WERE AUTHORIZED
PRIOR TO COMPLETING THE SUPPLEMENTAL REPAIRS. TO EXPEDITE THE HANDLING OF ANY SUPPLEMENTAL
DAMAGES, PLEASE ACCESS HTTP://WWW.THESHOPOFCHOICE.COM/FARMERS. IF YOU NEED TECHNICAL
ASSISTANCE REGISTERING OR UPLOADING ATTACHMENTS, CONTACT NUGEN IT CUSTOMER SUPPORT AT
(855)-684-3648 BETWEEN 7 AM AND 7 PM CENTRAL TIME. POTENTIALLY, A REINSPECTION MAY BE NECESSARY.
CIRCLE OF DEPENDABILITY SUPPLEMENTS: CIRCLE OF DEPENDABILITY PROGRAM SHOPS WILL CONTINUE TO
PROCESS SUPPLEMENTS THROUGH THE NORMAL SUPPLEMENT PROCESS. PLEASE CONTACT YOUR FIELD OR
OFFICE CONSULTANT IF YOU HAVE ANY QUESTIONS.
THIS PROCESS DOES NOT APPLY TO BRISTOL WEST.
4/18/2014 3:36:49 PM 019495 Page 3
° " � Preliminary Estimate
Customer: EINCK, STACY ]ob Number:
Vehicle: 2013 HOND ACCORD EXL 4D SED 4-2.4L-FI
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.
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
ARG4439, CCC Data Date 4/16/2014, 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 (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 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 followina is a Iist of additional abbreviations �r 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=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 International Certified Part. O/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.
4/18/2014 3:36:49 PM 019495 Page 4
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