Wuollet-Anderson 04/2812014 14:11 �Af� P.001/007
� 308 PRINCE STREET
� ST. PAUL,�MN 55101 " •
PHONE 651-224-9644
FAX: 651-228-?048 � ' ' •
. � . • .
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REC�EIVED
APR 2 81014
��� � CITY CL�RK
Yo: C'( - � Fax: i' _ �
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Fax: 651-22&7048 Pages (including cover): �--
Phone; � 651-224-9fi�4 Date: I��,�_ ��
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Re: 1
❑ Urgent c�pr Review ❑please Comnnent �lease Itaply 0 Please Recycle
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CONFIp�NT1ALITY NOTIC�
The document(s)accompanying this fax may contain confldential information that is legally privileged.The
informaUon Is oniy for the use of the Intended recipient named above. If you are not the intended recfpient,you are
hereby no�fied that any dlsdosure,copying, dlst�ibuHon, or the taking of any action in rellance on the contents of .
this telecopled Information,except Its dlrect delivery to the Intended reapient named above is st�lctly prohib(ted. If
you have received this fax in eROr, please notify us fmmediately by telephone to aRange far the return of the �
original fax documents to us.Thank you: ,
EQUAL OPPORTUNITY EMPl.OYER
H:ISHARED1SateZonalFormslFAX SafeZone.DOC CroattetJ on 11/?J2010 227:OD PM
04/28/2014 14:12 �A}� P.002/007 �
NOT�CE OF CLAYM FORM to the City of Saint Paul, Minnesota �
Minnesota Stare Statu[e 466 OS states that "...every person...who claims darnages froin any muNclpallty...shal!cause to be presented to the
governin,g body of the munlclpallly wlthin 180 days ajter the alleged loss or inJury Is dlstoverect a notrce stating the rime,place,and
clrrumstances thereof,and the amount af compensarlon or olhet relief demanded"
please complete t6is fonm in its entirety by clearly typing or printing yoor saswer to eacli qaestlon. lt more space ls
nceded,attach addltlonel sheets. Please note that yon wlll not be contacted by telephone to clarlfy answers,so provide as �
mach tnformation as necessary to explain your claim,and the amount of compensatlon being requested Yoa will receive a
written acirnowledgement once your form is received. The process can take ap to ten weeks or longer depending on the
nature of your claim. This form must be s�gned,and both pages completed. If something docs not apply,writc'N/A'.
SEND COMPLETED FORN�AND OTHER DOCiTMENTS TO: CYTY CLERK,
15 WEST KELLOGG B�.,VD, 310 CYTY HALL, SAINT P.A.UL, MN 55102
First Name Middle Initial�Last Name��b�T�� �I�'S�_
Company or$usiness N e
Are You an Insurance Company? Yes/No Yes,Claim Number? S ee a�au�d �
Street Address `�' � � �
City (S'1, �Ol1tiQ State � Zip Code 'FJ��d I
Daytime Phone(��� IP�'I� Cell Phone(��5- 77°�Evening Telephone(�� �� �1�7°�
so
Date of Accidend Inj ury or Date Discovered �la�/i�I Time�_fun/�
Please state,in detail,what occurred(happened),snd why you are subx►�itting a claim.Please indicate why or how you
feel the City of Saint Paul or its employees are involved dlor responsible for your damages.
1 ' �. � d.�, ,
1,.► � ' � ` A
� e�e ' � , �1�. .
� r 1-G Y'a � .��- � � r�c. I W.�m,e�f►a��-�.1�
e/E I s w� ,�. . .�
Please check the box(es)that most closely represent the reason for completing this form:
�1VIy vehicle was damaged in an accident ❑My vehicle was damaged during a tow
�.My vehicle was damaged by a pvthole or condition of the street �My vetucle was damaged by a plow
O My vehicle was wirongfully towed and/or ticketed ❑I was injured on Ci properry
�Other type of property damage—please specify T e � .c v��t.
❑Other type of injury--please specify � d w���L.
� In order to process your claim vou need to include copies o�all a»pueable doeuments.
For che claims types listed below,please be sure to include the documents indicated or it will delay the handling of
your elaim. Documents WII,L NOT be returned and beeome the property of che City. You aze 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 yow vehicle if tho damage exceeds
$500.00;or the actual bills and/or receipts for the repairs
O Towing claims: legible copies of any�'icket 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 rcpairs;dctailed list of damaged items �
O Injury claims: medical bills,receipts � �
O Photographs are always welcome to document and support your claim buc will noc be retumed.
Page 1 of 2—Please complete and retarn both pages of Claim Form
�
04/28/2014 14:12 �A)!) P.003/007
Fatlure to complete and return both pages will resu�t in delay in the handling of your claim.
All Claiens—please comnIete th�s secdon
Were chere witnesses to the incident? � No U own (circle)
Provide their names,addresses and telephone nu�nbers: _ -., yu i �,.� C..►I�1 �
e.� �.rl-h�✓a ���1 d R,. ►n.e ��; c a �._,[� •
Were the police or law enforcement le¢7� •� � No Unlmown (circle)
If yes,what department or age�acy7��i-� �a�o 1 Case#or report#
Where did the accident or injury tfilce place7 Provide sveet address,cross street,interseMion,name�of,park or facility,
closest landmark,etc. Please be as detailed as possible. If necessary,attach a diagram. ` �51LY � �
�1�.►��
Please indicate the amount you are seeking in comp�ns tion or what you would like the City to do to resolve this claim
to your sadsfaction. � � . b a
h S w.r w�
Vehfcle Clnims-- lease com I ' ection ❑ box if this section das not a 1
Yoar Vehicle: Year�_Make Model c,�S
License Plate Num er State Color
Registered Ownet � �
Driver of Vehicle �L� .
Area Damaged ��¢.1.� S��S4 _ p�, 1,�.,��.1�C��c�,e_
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehiclo(City Employee's Name)
Area Dam�aged
In,1ury Claims—please eomalete this section �check box if this section does not auAlv
' How were you injured7
What part(s)�f your body were injured?
Have you sought medicel treatment? Yes . No Planning to Seek Treatment(circle)
When did you receive treatme�nt7 (provide date(s))
Name of Medical Provider(s):
Address Telephone
Did you miss work as a result of your injury7 Yes No
When did you miss work7 (provide date(s))
Name of your Employer:
Address Telephone
�heck here tf you are attaching more pages to this claim fo�. Nwnber o[additional pages�. �
By signing this fowrrt,you are stat�ng that all information you have provided is true and cotrect to the best
of your knowledge. Unsigned forms will not be processed.
'm can result irc rosecution. Date form was completed . � !- �'T .,
Submctt�ng a false cta: p
Print the Name of the�exso�a w�o Connpleted this Form:
I�1 Y�GI 0 �e, ' �
Signature oP Person Making the Claim:
Rcviscd Febivary 2011
04/28/2014 14:12 �A� P.0041007
DaEa: IIZSI2014 03:31 iM
' Estlmafa 10: 11S/18BI9.01 .
E6tl1nat6 Verelon: 0
Committed
ProfIN ID: 'Ma4o All Parf6T.1
Progressive Direct Insurance Co
Damage Aeseeeed By: CHRI$pRUBB 'qabn Rep: Clrie Orubb
(631)248-2830
'Pmduct Type Auto �
•Dafo of Loe6: 4fY1R014
•D�tluCtlblO: 300.OD ,
'CWn1 N1Nnber 1Cd716949�01
I�eurod: liNDSEY 4Vl1oLLeT-ANOeR9oN .
Own�r: LIt�SE1f WUOLLeT.ANDERBQN •
Addro6s: 2144TM STREET E UNfT 215,SAINT PAUL,MN 55101
Telephonr. WoNc phona: (651)274�9844 Call Phono: �as�)�as-noe
conma�,on.: �a9�1�es noe
���N s.rv�oe: e��ooe
Daerlpdon: 2009 Ford Foaus SE
Body 3tyls: 40 Sod Otivs TrAln: 2AL(tIJ 4 Cyl 4A FWD
VIN: 1FAFIP86N09W2AeT/9 Llcense: 841CMG MN
OEM/AI.T: A 9earch Code: AROENHM.L1
Cobr: RED
Opdons: PA99ENGER AMZBAG,DRrvER AIRBA�,PoVYER�.ocK,POwER WINDOW,POWER STEERINf3
REAR WINpOW DEFOGGEIt,MANUAL AIR CONDRIaN,T�T 9TEERWO CpI.�JMN
AIUM/ALLOY WHEEL3,AUXILIARY INPUT,SATEI.LfTE RADIO
POWER ADJU3TABLE EXT�RIOrt Mtl2ROR,FRONT AIFi DAM,TINTeD O1A99,91DE AIRBA03
ANT�TNEFT 9YSTEM,310E HEAD CUR7AIN AIRBAGS,AMIFM Sl"@REO CdMP3 PLAYER
FROMT BUCKET 9FAT9,itEYLE33 ENTRY SY3TEM.POYVER LIFTGATe1TRUNK
LNto 8nby Lebor Uns Ms�+ Pert Typel DoNar UlbOr
Item Numbor lypa Oparation Qaec►Iptlon Part Number Amount unlle
Frent Bumwr
1 102079 BDY REMOVEINJSfALL FR BumpK Cowr INC J�
2 BDY OVEFiMAUL Frt Bumper Cowr Asay 2.0 A
8 102082 BOY REGAOVEIREPLACE Frt Bumpar C�er Romanufaetured � 372.00 INC 1!
4 ReF REFm13H FR Bumper Cover C 2.8
�
6 101797 BOY REIYIOVe/INSTALL OANe Aaey �C
� Front l�moa
B 10208d 9DY REMOVE/REPLACE R Fn Combinallon Lamp Asaembly RanonufaCtund 212.00 0.8 g
7 BDY CMECK/ADJUST Fleedlernpa 0.4
Front F�nd�r
S 100104 BOY REPAIft R Pandor Penol Exlatk�g 4.0•#
9 REF fi�Pfl�116H R Fender O�te�de C 20
t0 100112 BOY REMQVElREPLACE R Fsndsr Sp4uh SnI�Itl Cnp 2�1.87 'w70s8�.S 8300 5.74
egs�e�
11 101098 MCH REMOVFJREVLACE Bleed�S 9yetem -M 0.6
Wh�N
12 100201 �DY REMOVFJREPLACE Moy Wheal 834Z 1007 E 184.30 0.3
19 102a73 BDY REMOVPJR2PLACE Wheel 9eneorinefapatbn Kit 8F2Z 1A199 D 53.60
14 Non-Rowablo Part
Front Slmnenalon
16 '100Z96 MCH ReMOVE1FtEPLACE RFrtSuepCellper -M "Nof1•OEM 108.89 0.5#
Reek�MP111a�slFlear
16 102049 ItEF REFiNISH R Conbr PiNer&Roaker Canplale C 1.3'
17 100T01 BDY REPAIR R DoorOpenl�Frart19 Eklstlflg 6.0'$
te rodc�r panol
r�s_
19 800SOD MCH REMOVE/REPLACE CooperC94Tour1�195/60R16T "NOn�OEM 9Z.9d
zo 9aso,x �oo�cosr w�za�ous wnsTe asPOSn� aso�
• aodrrrorr_a�oPmnnoNs
21 REF ADD'L OPR Glee►Coet 20
ESTIMATE RECAIL NUMBER: oil�'�1201G 15:30:49 /C-s718908�01
MKchsll Data Vorslon: oEM: MAF�11 V .
MAPP:MAfZ„14 V CopydgM(C)189a-2014 Mlhi�ell IntameUonal Paqo t of 4
9ollwa�Vsr81011: 7.1.183 AN Riphfs Rosarved
04/28/2014 14:12 ff AX} P.005/007
Dau: 4/26I2016 09:37 PM
ese�maw ro: ta.eT,e�oe.m
Estlmats Wralon: 0
Commltlotl
Pronb�o: •Movo a�P.ns7.1
AddM1en91 Cosla d�elaterlala
22 ADD'L COST PaInMMeterlele 282.20•
29 800600 REF• REMOVEIRP_PLACE F�p(AppfTryE "Non.OEM 6.00• OA•
2C BOOSOO BDY" ADD'L LABOR OP COVER CAR FOR OVER&PRAY *'NomO�M 7.�0• 0.2•
26 900600 BDY• REMOVBREPLACE CORROSION PROTECTION "'Non-OEAA 7,60 " 0.9"
2B 9D0500 9DY' ADD'L LABOR OP MOUI�fT d,BALANCE INCLWES S'fHM�VYEIOHTS 9ublet 18.60' O.0•
MMIIIAL!M'RIE9
z7 eoosoo BDY• AoD��u+BOR oP �Re o�sPOSn� sublot 2.00• o.a
28 800600 BDY• ReMOVPJREPIAC� TOW SILL•TAXABLE 17MulE ONLY 8ublet 1d2.60• 0.0•
ze eoosDO MCH• ADDL LABOR OP 7W0 WMEEL ALIGtiNENT SuWoe as.es• o.a•
*•Judgment kem
#-L�bor Note Applles
�Non•OEM •Non•Origlnal Equipment Manufacture�Replacement Pert
' C-Included in Clear Coat Calc
NAPA AUTO PART8 1ceY9TONE AUTOMOTIV�
CALL YOUR LOCAL 8TORE • 3815 MAR9HAlL 9T�NE
oR ca��.�.eooa.Er-��n MINNEAPOLJ9
MN 65418
(800)3T��1945 (612)769-1886
ceoo��se.�zr�
"1 S '"3E58Z0 108.68 3 "F01000634R 9M.00
8 "FOZ.!'D3244R 212,00
Al1 manuEacturers requ3.rem�ate xegarding eeat bolt and supplement,�l
restraiat 9ystem raplac�►wnt muet bo adhered to. If additional parts
or oporations are necessnsy to properly a000a[�lish this, pleas0
contacti the ostimating cleims rep.
. Estimate Totals
���
... . . .. . . . ��� �a�
L Laqor 9ubtotal� UMts Rsto Amount NnouM Totala a. Pert Replaosmo�t Summery Mwunt
8ody 19.6 54.00 a.00 Y0.90 7�8.90 Texabls Perte 1,1TO.Ut
Reflnlah 8.3 94.00 0.00 O.OD 418.20 S�las7ax � 7.6Z946 89.21
M9chaMCa1 1.1 80.00 O.OD B6.9S 1S7.B'J
Totel Replacement Parla Amoun! 1,259.2Z
. Non Taxable Labor 1,399.BS
Labor Summary 22.8 1,866.86
IM. AddR10hB1 COBtB M1oU�t N. Ad�6trt►e� �D��
Taxabie Coete 262.20 Insurenca Deductlble 600.00-
9e�ee Tax � 7,026°/. 21.6Z
Custnmor Reeponslbllity 600.00-
� Non•Taxeble Coefe 3.60
TOtal AddHlonal Costs �T��
Palnt Malsrlal AAathod:Retee
Init Reto�3d.00
I. Total�.abor: 1,3S�.8y
11. Tolal Repiacement Parts: �,2s9.22
III. Tofel Additlonel CoBi6: 307.2Z
Oroee Totel: Z,922.OB
E&17MATE RECA�L NUNIBER: OM2WZ01416:SO:A9 14b716949-01
MncnellDetaverelon: O�IYI: MAIZ14_V
MAPP:MAi�1A_V Copynght(C)1984-201A MHehaN Intornatlonal Pa¢e 2 oF 4
Sohware Voreion: 7_i.163 All Rlghto Rsasrved
04/2812014 14:12 �A� P.0061007
oaro: a�2sl201s 03:31 PAn
�atlmetelD: t0-a718949.01
Estlmato Voraton: o
Caw1tNE9d
ProHlo 10: •Metro AM PeRe7.1
IV. Tot�l Atqustmo�NS: 600.00-
Not Totil: 2,422A9
/Ut Locetlon: PRO(iRES91VE
InapACtlon&Ile: LAIVFF 9ROS A�1T0 BODY(NC
Addras6: 880 UNIV�SITY AVE W
ST PAUL,MN 6610d
(B'�1)2Y4.2828
THIS Z8 A DAMAGE ASSESSQ�NT ONLY � NQ'1' AN AOTHORTZATION TO REPAIR �
BASED ON DAMAGE VISIHI,Iy OR C�RTAIN AT TE�E TI� I�' pvA9 9oRIT7'SN.
as � o� ulaieODX �tEPi�iR zs ixczvcan or� �S ESTi�►xl�, a� �►rwvrrr
SAOWN INCLIIDES TIl� OR ALLOWI�NCE b'OR D�ASQt2IIAG BEFORE, DUAINO AND
AFTER '!'H09E REPAIRS.
TH� .OWNER OF TSE VEKICLS �AAY 3ELECT Tf� REP]►IIt FACII.ITY OF HIS/�
CHOICE,
TO EN9UR� PROPER AND FROMB'P BA�NT FOR ADDITIONAL � DISCOVERED
DURING T� COUR83's OF REPAIR3� CONTACT PROGRESSIVE FOR 9UPPLEE�IT
f�ANDLING PROCEDIIRES.
PROGRESSIVS HONORS TgE P'REVAILING I.ASOR MARI�T RATE IN YOZ1R AtiF.A SOR
yOUR pROPERTY. IF YOU CFi00SE A 9HOP �BAT CF�IRCSS ZN EXC�.SS OF
PREVAILING I.ABOR MARI�T RATE3, YOQ 1iI7.I� BE RESPONSIBLE L'OR THE
AIFB�RENCE.
LIETsTI� 6UARANT�E SOR SHffiET �ETAL AND PLA9TIC SODY BARTS
The repincement parte arrit�en on the a�timats are intended to raturn
xovr vohicla to its pre-loes Co�dition with proper install�ttion.
' APter xepair, if any sheet metal os pl�stic body psrt ineluded in the
•• osta.ma�e Eails to return Xour vohiclo to Lta pre-losa condl.tion
(aesuming proper installation) , !.� texms of form, fit, finis�,
durebility ox �ctionality, Progressiva pill azra�c�qe and pay for �ha
replaeoment o�' the part, to tl�e extent not covesed by a
manu�a►cturer'e or other warranty. Thia eervine will be porformed a�
no cost to you (inCludit�g aseooiated r�patr and sent�l c�z costs) . To •
obtain eervi.w under th3e Gtia►ra�tee, call Proqrassiva aC
i-B00�27a-4641. Thia Guarantae applies as ].or►g as you own or lease •
the vehicla. Thia Guar�nntee is 11ot tixanefarable and tarminates i� you
se11 ox ottteraiso transfer your vehicle.
T�IB C,UARANTEE DO�S NOT COVEIt NOR�AL 9PEAR AND TEAR OR D71�►GS CA�SED
BY IMPROPER DE�AtNTENANCE, NEGLECT, ABUSE OR SUHSEQ[JENT ACCIDENT. '�HI3
GUARAN'i'ET TS LIMITSD TO ARRANGT.NG F�t T� $EL$CTIQTI OF REPAIR BARTS
THAT WILL RETURN YOUR VEFIICZE TO TTS PR�—L099 CObIDI'.L'IOD1. ACCORDINGLY,
PROGRSSSIVS WILL NOT HE I.IABI.E FO�t ANY INDIRECT, INCTDENTAL OR
CONBEQUENTIAL DAI�91GE3 TAAT RESLJLT H'RObI TBE IN9TALLA�IO� OR IISE OF
THESE PARTS.
Eart Type Teans and Abbreviations
NE4P and OE� or paxt number displayed - These rePer to a new, oxiginal ,
E571MATC RECALL NUMBER: 0412W201416:90:49 14•S71BY49-01
Mltohall Date Varelon: OEM: MAF�14_V
MAPP:MAl�14_V Copyrlqht(L7189C•Y01�MltcheN I�ematlonal Papo 3 of 4
Sohwaro Verelon: 7.7.163 All Rlphts Reearvod
oaizsizoi a �a:�z ��c7 P.00�ioo�
DOto: 4/1512014 03:31 PM
E6W1t9te 1D: 11�718809-01
" Eatlmata V�aion: o
Comhtittetl
Profilo ID: •Motro NI Pa1ts7.1
equipment manufacturer part.
NON-� �d A/M and Qual REPL - These refer to an after-mark�t pa�ct,
whicb ie a new, non-oziglAnl equipment manufacturer part.
U9ED/RECY�D 3ud I�RQ - These reYes to a uaed OE� p�rt.
R�MANt)FACTIJRED aad RECOND. atid RECOIi& - Thasa refer to used/recycled
OEtd parts �ha� have bean refurbimhed.
RBPAIR SHOP'S Ai7THORZZED REPRE9ENTA'1'IVE'9 9IGNA'PORE INDIC7►TING
AGRE��''N'i' ON CO3T TO RET[1RN THS VEHICLE TO PRE--L09S CONDITION
INC.LUDING TOW/9TORAGE CHARGE3: � .
9HOp SxCa�IAT(JRE: SST. C�LETION DATE:
ANX PER90N WHO, WT'1'H INTENT TO DEFRAUD OR P�ODOING TflAT HE/9�3E I3
FACILITATIN(3 A FRAUD AGAIN9'Y' AN TN3IIRER� SOB�ITS AN APPLICATION OR
FILES A CLATM CONTA2NING A FAL9E aR DBCEPTIVE 9TATE�ENT T3 ,GQILTY OF
zNSV�rs �r,v�.
Event Loa
Flle Creetad: Ml23/2014 08�1:19 AM
Fadmate Sterted: oN2512014 0227:67 PM
Eetlmete Printad: Orl2SRD14 0330_53 PM
EeUmeEe Cammltled: Od12W2014 09:30:49 PM
eeflmale Uploeded: OCI25f2014 05-3�'0�PM
ESTIMATe RECALL NUMBER: OU26f201A 73_30:49 1d.67189�BA1
Mk¢ho11 Deta Ve►abn: aEM: MA1�14_V
' MAPP;MAi�14 V CopyriBht(C)1094•2014 Mlp;he111nE9matlonal PaBo 4 of 3
SoAvvaro VerMon: 7.1.183 All f�ghts RAeerved