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Wolf � RECEIV�D �IAY 0 5 2014 NOTICE OF CLAIM FORM to the City of Saint Paul, N i��qh�E R K Minnesota State Statute 466.05 states that"...every person...who claims damages`rom any municipaLity...shaU 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 relie/'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 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 completed. If something does not apply,write`N/A'. SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK, 15 WEST KELLOGG BLVD, 310 CI1'Y HALL, SAINT PAUL, MN 55102 First Name r�1�'"'� Middle Initial �� Last Name v"�� Company or Business Name Are You an Insurance Company? Yes/ o If Yes,Claim Number? Street Address ��g .��sa�1 r'I�� City 71 • n� State M� Zip Code?�� Daytime Phone(�) �!1- /u� Cell Phone( ) - Evening Telephone( ) - Date of Accidend Injury or Date Discovered ?� ' � !� Time "/• �U am/pm 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.� CA.1� �� . . _ � �c�� Please 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 In order to process your claim vou need to include copies of all anulicable 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 be returned and become the property of the City. You are encouraged to keep a copy for yourself before submitting your claim form. 0 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 0 Towing claims: legible copies of any ticket issued and a copy of the impound lot receipt � 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 � Injury claims: medical bills,receipts � 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 Wolf, Anne From: JOEL WOLF (joelwolf 181 @msn.comJ Sent: Tuesday, April 29, 2014 11:43 AM To: Wolf, Anne Subject: Fwd: Claim Sent from my iPhone Begin forwarded message: From: Troy Beckman<troy.beckman.mdkk(�a,statefarm.com> Date: Apri128, 2014 at 12:37:04 PM CDT To: JOEL WOLF <ioelwolf 181(a�msn.com> Subject: Claim Hi Joel, hope all is well. I wanted to reach out to you regarding the rental car and having State Farm go after reimbursement for you. I apologize for the confusion, as I was thinking you had rental car reimbursement on your policy. Being State Farm has not paid you for the use of a rental car they cannot legally subrogate against the city as they have not actually incurred that loss. I hope that makes sense and again apologize for the mix up. If there is anything else I can assist you with in regards to this claim please let me know. Have a great week. �0� �P.GI�CQiC State Farm Agent 3841 St Francis Blvd Ste 102 Anoka,MN 55303 � (763)421-0955 �' (763)421-1863 Find us on the Web or Facebook! Refer vour family and friends to us bv clickin�here<--- ��t'��'��I�`�`. . �. _ , �. ,..�_ � . . .� . � ��"�� BONFE'S COLLISION CENTER Workfile ID: e4f77fce ��°°"'"�` Federai ID: 410986303 � CAR CARE BY PEOPLE WHO CARE � � � ��'�� 380 7TH ST W, SAINT PAUL, MN 55102 Phone: (651) 222-4458 FAX: (651) 224-8640 Preliminary Estimate �h� 1 L-�2.-- — �js/, ��i� Customer: WOLF,70EL C�� Written By: DAN DREELAN // Adjuster:Team R3 ACC CP(Team 33),(866)207-6046 Day �� G'� _ Insured: WOLF,JOEL Policy#: C�aim#: 23-29N5-91301 /fn�j/ / �/ if i Type of Loss: Collision Date of Loss: 2/22/2014 9:00:00 AM Days to Repair: 0 Point of Impact: 10 Left Front Pillar Owner: Inspection Location: Insurance Company: WOLF,JOEL RESIDENCE-ANNE WOLF STATE FARM INSURANCE COMP NIE� 1958JEFFERSON AVE 1958JEFFERSON AVE � �� ' �/ SAINT PAUL, MN 55105-1603 SAINT PAUL, MN 55105-1603 � (651)208-6613 Cell Other (612)667-6426 Day ,/ VEHICLE Year: 2006 Body Style: 4D UTV VIN: 2HNYD18896H534166 Mileage In: Make: ACUR Engine: 6-3.5L-FI License: 216DPW Mileage Out: Model: MDX 4X4 TOURING Production Date: 3/2006 State: MN Vehicle Out: Color: Silver Int: Condition: Job#: TRANSMISSION BRAKES AM Radio Intermittent Wipers Automatic Transmission Power Brakes FM Radio Navigation System 4 Wheel Drive 4 Wheel Disc Brakes Stereo Wood Interior Trim Traction Control Anti-Lock Brakes(4) Search/Seek EXTERIOR SEATS ROOF CD Changer/Stacker Power Mirrors Power Driver Seat Electric Glass Sunroof INTERIOR Dual Mirrors Power Passenger Seat GLASS Power Locks Alarm Bucket Seats Privacy Glass Air Conditioning Keyless Entry Leather Seats Rear Defogger Dual Air Conditioning Luggage/Roof Rack Heated Seats Power Windows Cruise Control PICKUP/VAN EQUIPMENT STEERING Rear Window Wiper Driver Air Bag Fog Lamps Power Steering WHEELS Passenger Air Bag PAINT Tilt Wheel Aluminum/Alloy Wheels Front Side Impact Air Bags Clear Coat Paint Steering Wheel Controls RADIO Console/Storage 3/7/2014 7:43:46 AM 013793 Page 1 Preliminary Estimate Customer: WOLF,]OEL Vehicle: 2006 ACUR MDX 4X4 TOURING 4D UN 6-3.5L-FI Silver Line Oper Description Part Number Qty Extended Labor Paint Price� 1 FRONT BUMPER 2 R&I R&I bumper cover 1,2 3 FRONT LAMPS 4 R&I LT R&I headlamp assy 0.3 Note: LABOR:Time is after bumper cover is removed.Time includes side upper beam. 5 FENDER 6 * Rpr LT Fender assy � 1.8 7 Add for Clear Coat 0.7 8 R&I LT Fender liner 0.4 9 R&I LT Mud guard 0.2 10 FRONT DOOR li * Rpr LT Outer panel � 2.p 12 Overlap Major Adj. Panel -0.4 13 Add for Clear Coat 0.3 14 R&I LT Belt w'strip 03 15 R&I LT Applique rear 0.2 16 * Repl LT Mirror assy w/touring pkg 7625053VA14Z5 1 277.57 0.3 �Q billet silver 17 R&I LT Handle,outside 0.3 18 R&I LT R&I trim panel 0.4 19 REAR DOOR 20 * Rpr LT Outer panel �Q 2.0 21 Overlap Major Adj. Panel -0.4 22 Add for Clear Coat 0.3 23 R&I LT Belt w'strip 0.3 24 R&I LT Handle, outside 03 25 R&I LT R&I trim panel 0.4 26 # Repl COVER CAR COMPLETE(2 1 5.00 T 0.2 TIMES) 27 # Repl CORROSION PROTECTION 1 5.00 T 0.3 28 # Repl HAZARDOUS WASTE REMOVAL 1 5.00 X SUBTOTALS 292.57 23.1 6.3 3/7/2014 7:43:46 AM 013793 Page 2 Preliminary Estimate Customer: WOLF,70EL Vehicle: 2006 ACUR MDX 4X4 TOURING 4D UN 6-3.5L-FI Silver ESTIMATE TOTALS Category Basis Rate Cost; Parts 277.57 Body Labor 23.1 hrs @ $52.00/hr 1,201.20 Paint Labor 6.3 hrs @ $52.00/hr 327.60 Paint Supplies 6.3 hrs @ $32.00/hr 201.60 Miscellaneous 15.00 Subtotal 2�p2Z,g7 Sales Tax $489.17 @ 7.6250% 37.30 Grand Total 2,060.27 Deductible 500.00 CUSTOMER PAY 500.00 INSURANCE PAY 1,560.27 Register online to check the status of your claim and stay connected with State Farmp.To register,go to htt�//www.statefarm.com[ and select Check the Status of a Claim. If you are already registered,thank you! Not available in New Mexico. ****************************************************************************** THIS IS A VISUAL ESTIMATE ONLI(. ADDITIONAL DAMAGE MAY BE FOUND AFTER TEAR DOWN OF VEHICLE. NO GUARANTEE ON RUST WORK. ****************************************************************************** MINNESOTA FRAUD WARNING A 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. MN ST 60A.955 - A PERSON WHO FILES A CLAIM WITH INTENT TO DEFRAUD OR HELPS COMMTT A FRAUD AGAINST AN INSURER IS GUILTY OF A CRIME. 3/7/2014 7:43:46 AM 013793 Page 3 Preliminary Estimate Customer: WOLF,70EL Vehicie: 2006 ACUR MDX 4X4 TOURING 4D UTV 6-3.5L-FI Silver Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide ART4821, CCC Data Date 3/6/2014, 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 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=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 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. R8cI=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. 3/7/2014 7:43:46 AM 013793 Page 4 _ � ;�r �� ,�; , ��1�'L�'�1;'��' Customer InvQic� �- ��tu l3eaiui ,� � =A�'°"jY*-y�' �`t 1 w �,f�! �$"�" Date: 04/17i?.014 Invoice Date: U4;16�'lO14 WHi TE BEAR LAKE BRANCi-i WOl F.JOEL 1E�03 BUERKLE ROAD SUITF t06 �958 JEFFERSON AVE. WNITE BEAR LAKE, MN 55110 SAINT PAUL, MN 55105 PH: (Ei51)76Ei-78U7 PN:(651)208-6613 WULF,JOEL License lnformation: 1958 JEFFERSON AVE. P513180094312 SAINT PAUL, MN 55105 MN 03/05J2018 PO Number. Agrecrnent Number: WF3-14 T7G8 Vehicie Number Venicle Ty�e VIN# Vehicle Plate Date Rented L?ate Retunieci MA13591 2012 JE�P COMPASS 1CANJCf3A9CD518664 806 L.MW 04/01/2014 07:00 AM 04r1fi/2014 0.:34 PM 16 Day(s)@39.99 Charged 16 Uay(s) Description Amount RATE CHARGF 639.84 [�UEL�,tit��l3E- 34.Uti MN SALES TAX 46.33 MN REN TAL TnX 58.87 MN R�G fAX 3i.99 TRnNSI"T IMPf-2VMT 1.68 Total Charyes 812.71 Driver TotaL 812/1 Driver Payments: O.OL Tax I�: 46-1467215 Net Due From Driver: 812.71 Include F2ental�greement Number with Pay�ment: Please lriake Check Payable To and Rerr:it To: DUE UPON RECEIPT CHOICE AUTO RENTAL INC �yreement Number: VVB-1�i708 1803 BUERKLE ROAD SUITE 106 WOl_F. JOEL WHITE BEAR LAKE, MN 55110 I�leasi�P��y 7his AmounL` S1`L.;fi ' --•, (� �—' . �l.(� �' � � �.�.s�C i i t? Y� 1 c.\ � ,1 t �..� t _ ` . � � � ��- ,� �� .� (�� t�`'��\ � b�1�� .� ,��,� �.� � ( �'�� " � � � � ��.� `� � ' � Wolf, Anne From: Bodensteiner, Sandra(CI-StPaul) [sandra.bodensteiner@ci.stpaul.mn.us] Sent: Tuesday, April 29, 2014 8:20 AM To: Wolf, Anne Cc: Nalezny, Angie(CI-StPaul) Subject: RE: St Paul Fire Department-Accident Ms. Wolf, Please submit a claim form for just the rental expense. This is the link to the claim form: http://www.stpaul.�ov/index.aspx?nid=186 In order to reimburse you for the rental directly I will need you to also include the following information with the claim form: A copy of the rental agreement, � Something in writing, either from your insurance company or insurance agent that verifies that 1. You do not have rental coverage and 2.They will not be subrogating against us for the rental cost � A copy of the repair estimate �The police report CN number where indicated Please send all information to the address on the claim form—15 West Kellogg Blvd., 310 City Hall, Saint Paul, MN 55102. As previously mentioned, claims are handled in the order they are received. If everything is received with the claim form,your claim should be able to be processed rather quickly. If you have any other questions, please let me know. Thank you, Sandra Bodensteiner From: Wolf, Anne [mailto:Anne.Wolf@merrillcorp.com] Sent: Monday, April 28, 2014 12:18 PM To: Bodensteiner, Sandra (CI-StPaul) Cc: Nalezny, Angie (CI-StPaul) Subject: RE: St Paul Fire Department-Accident Sa nd ra, We took my vehicle in to have it fixed and will be running the claim through my insurance company as you suggested that would be the easiest and quickest way to get it fixed. I do not have rental covered through my insurance so I had to pay out of pocket for that during the time my car was being fixed. Attached is the receipt for the rental car expenses. What is the best way to get this cost reimbursed? My insurance company will not submit this with the claim from the auto body shop so this has to be done by me. Thanks! Anne Wolf Marketing Program Manager Merrill Corporation M1r�,n iil C rntt. .... .1S�b. f):��..C)��.��l)f�lC!-' www.DataSite.com 1