Bergman �z���i��� '
MAY 05 201#
NOTICE OF CLAIM FORM to the City of Saint Paul, M��e,�o�ERK
Minnesota State Statute 466.05 states that"...every person...who claims damages from any municipality...shall cause to be presented to the
governing body of the municipaliry within I80 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 relief 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 e�cplain 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 CITY HALL, SAINT PAUL, MN 55102
First Name "1�0.r� Middle Initial�Last Name �t°-'�P 1nn-C� l/�
Company or Business Name
Are You an Insurance Company? Yes No If Yes,Claim Number? �
Street Address � Z--�O �q�r ��Q-� U� N 'S/!
City �J� �°k�'\ State MN Zip Code 5 g � "�
Daytime Phone(�j 3�Z 54q Cell Phone(��Z)�-��-Evening Telephone(6�Z)�'�U_OS 7Z
Date of Accidend Injury or Date Discovered �` L3� ly Time •��/ Z am/�
Please state,in detail,what occurred(happened),and why you are submitting a claim.Please indicate why or how you
fee the City of Saint P 1 or its employees are nv��ved an or respo sible��yo/ur�amages. �� `
.r.i J i IU��'�. b+^- �d Nr�!l k.r/t� K I �! t�li� W
�o u..L ��+-�.•`_ �Zt.G C� `! ��G`l. C•w
R �
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 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 andlor 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 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-please complete this section
Were there witnesses to the incident? Yes No Unknown (circle)
Pr vide their names,addresses and telephone numbers: �r-�d w 11'�--5
o(Z 5� ���-z�
Were the police or law enforcement called? /Yes � Unknown (circle)
If yes, what department or agency? �/t" Case#or report# /U/�'
Where did the accident or injury take place? Provide street address,cross street,intersection,name of park or facility,
c�gses landmar ,etc. Please be as d ailed s po sibia If necess , ttach a diagram.
.-I-�,�e�r5�v�11�ew ��,-�- �• l��ct t►d d- (9�a�46�w-
Please indicate the amou�n,.you are seeking in co pensation or what ou would like the City to do to resolve thi claim
to your satisff ction. �- �_'� L��t �G ; � v e <°s7• �
i G�I�j h a.- �.r (ti-� Q i .a
Vehicle Claims- lease com ete this secti ❑check box if this section does not a 1
Your Vehicle: Year 2 Make � � Model S
License Plate Number C�-QS C State�Color UV h i
Registered Owner oJ' r�-d 1/�
Driver of Vehicle �^-a►�/`�
Area Damaged f ra QG
City Vehicle: Year�Make Lf��r Model �
License Plate Number /V�- State /� olor
Driver of Vehicle(City Employee's Name) /v
Area Damaged �/4'
Iniurv Claims nlease complete this section �heck box if this section does not avvlv
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? (provide date(s))
Name of your Employer:
Address Telephone
L�`Check here if you are attaching more pages to this claim form. Number of additional pages�.
By signing this fornz,you are stating that all information you have provided is true and correct to the best
of your knowledge. Unsigned forms will not be processed.
Submitting a false claim can result in prosecution. Date forcn was completed ��z� ! /
Print the Name of the Person who Completed this Form• '�� �e rn 0. I/�-
Signature of Person Making the Claim:
Revised February 2011
RAYMOND AUTO BODY� INC. Workfile ID: cOb6194c
FederalID: 41-0888257
' 1075 PIERCE BUTLER RTE, SAINT PAUL, MN
55104
Phone: (651) 488-0588
FAX: (651) 488-4794
Preliminary Estimate
Customer: BERGMAN, MARK ]ob Number:
Written By:JOEL SLOMKOWSKI
Insured: BERGMAN, MARK Policy#: Claim #:
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact:
Owner: Inspection Location: Insurance Company:
BERGMAN, MARK RAYMOND AUTO BODY,INC.
2144 CATTAIL WAY 1075 PIERCE BUTLER RTE
HUDSON,WI 54016 SAINT PAUL, MN 55104
(612)790-0572 Cell Repair Facility
(651)488-0588 Business
VEHICLE
Year: 2008 Body Style: 4D SED VIN: iG6DD67V080179519 Mileage In:
Make: CADI Engine: 6-3.6L-FI License: Mileage Out:
Model: STS A�VD Production Date: State: Vehide Out:
Color: pearl white Int: Condition: Job#:
TRANSMISSION Dual Mirrors Parking Sensors Head/Curtain Air Bags
Automatic Transmission Privacy Glass RADIO Communications System
Overdrive Console/Storage AM Radio SEATS
4 Wheel Drive CONVENIENCE FM Radio Leather Seats
POWER Air Conditioning Stereo Heated Seats
Power Steering Intermittent Wipers Search/Seek WHEELS
Power Brakes Tilt Wheel Premium Radio Aluminum/Alloy Wheels
Power Windows Cruise Control Satellite Radio PAINT
Power Locks Rear Defogger CD Changer/Stacker Metallic Paint
Power Mirrors Keyless Entry SAFETY Three Stage Paint
Heated Mirrors Message Center Drivers Side Air Bag OTHER
Power Driver Seat Steering Wheel Touch Controls Passenger Air Bag Fog Lamps
Power Passenger Seat Climate Control Anti-Lock Brakes(4) Traction Control
Memory Package Navigation System 4 Wheel Disc Brakes Stability Control
DECOR Remote Starter Front Side Impact Air Bags Xenon Headlamps
4/Z8/2014 4:19:50 PM 019495 Page 1
� Preliminary Estimate
Customer: BERGMAN, MARK ]ob Number:
Vehicle: 2008 CADI STS AWD 4D SED 6-3.6L-FI pearl white
Line Oper Description Part Number Qty E�ctended Labor Paint
Price$
1 WHEELS
2 Repl RT/Front Wheel,alloy 17" 9596894 1 785.00 m 0.3
polished,front
3 Add for press sensor m 0.2
4 # Subl align suspension 1 99.95 X
5 # Subl mnt and balance 1 20.00 X
6 # Rpr reset tire pressure sensor 0.5 M
7 # Repl shop supplies 1 15.00
SUBTOTALS 919.95 1.0 0.0
ESTIMATE TOTALS
Category Basis Rate Cost$
pa� 800.00
Body Labor 0.5 hrs @ $55.00/hr 27.50
Mechanical Labor 0.5 hrs @ $99.00/hr 49.50
Miscellaneous 119.95
Subtotal 996.95
Sales Tax $800.00 @ 7.6250% 61.00
Grand Total 1,057.95
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 1,057.95
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.
4/28/2014 4:19:50 PM 019495 Page 2
� Preliminary Estimate
Customer: BERGMAN, MARK ]ob Number:
Vehicle: 2008 CADI STS AWD 4D SED 6-3.6L-FI pearl white
AUTO CLUB INSURANCE ASSOCIATION, MEMBERSELECT INSURANCE COMPANY OR AUTO CLUB GROUP INSURANCE
COMPANY (HEREIN INDIVIDUALLY AND COLLECTIVELY REFERRED TO AS ACIA) GUARANTEES THAT IT WILL
REPLACE THE QUALITY REPLACEMENT PARTS (PARTS NOT MANUFACTURED BY THE ORIGINAL EQUIPMENT
MANUFACTURER) IDENTIFIED ON THE VEHICLE ESTIMATE ASSOCIATED WITH THIS GUARANTEE IF A DEFECT IS
DISCOVERED.
ACIA FURTHER GUARANTEES THAT THE QUALITY REPLACEMENT PARTS, EXCLUDING GLASS AND MECHANICAL
PARTS, ARE CERTIFIED OR VALIDATED TO BE OF OEM QUALITY IN ALL INSTANCES WHEN THIS CERTIFICATION
OR VALIDATION IS AVAILABLE FOR THE PART. THIS GUARANTEE IS IN EFFECT FOR AS LONG AS YOU OWN THE
REPAIR VEHICLE AND IS NOT TRANSFERABLE TO ANOTHER PARTY AT ANY TIME. THIS GUARANTEE COVERS THE
COST OF THE PART, LABOR TO INSTALL, PAINT AND MATERIALS IF REQUIRED, AND REASONABLE RENTAL COST
OF A SIMILAR TEMPORARY REPLACEMENT VEHICLE DURING THE REPAIRS. THIS GUARANTEE DOES NOT COVER
CLAIMS FOR DIMINUTION IN VALUE OR CONSEQUENTIAL DAMAGES.
IF A DEFECT IN A QUALITY REPLACEMENT PART IS DISCOVERED, CONTACT YOUR LOCAL ACIA CLAIMS
DEPARTMENT IMMEDIATELY AND ACIA WILL REPLACE THE PART WITH A NEW ORIGINAL EQUIPMENT
MANUFACTURER PART. IF AN ORIGINAL EQUIPMENT MANUFACTURER PART IS NOT REASONABLY COMMERCIALLY
AVAILABLE, ACIA WILL REPLACE THE DEFECTIVE PART WITH ANOTHER QUALITY REPLACEMENT PART.
MOTOR VEHICLE REPAIR PRACTICES ARE REGULATED BY CHAPTER ATCP 132, WIS. ADM. CODE, ADMINISTERED
BY THE BUREAU OF CONSUMER PROTECTION, WISCONSIN DEPT. OF AGRICULTURE, TRADE AND CONSUMER
PROTECTION, P.O. BOX 8911, MADISON, WISCONSIN 53708-8911.
4/28/2014 4:19:50 PM 019495 Page 3
Preliminary Estimate
Customer: BERGMAN, MARK 7ob Number:
Vehicle: 2008 CADI STS AWD 4D SED 6-3.6L-FI pearl white
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
DR16C05, 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 (�) 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. 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=6ureau of Automotive Repair. EPA=Environmental Protection Agency. NHTSA= National Highway
Transportation and Safety Administration. PDR=Paintless Dent Repair. VIN=Vehicle Identification Number,
4/28/2014 4:19:50 PM 019495 Page 4
.
.
Maintenance Hours Labor Parts SS Tax Total
o.o $o.00 $o.00 $o.00 $o.00
o.o $o.00 $o.00 $o.00 $o.00
$o.00 $o.00 $o.00
$o.00 $o.00 $o.00
Brakes Hours Labor Parts SS Tax Total
o.o $o.00 $o.00 $o.00 $o.00 $o.00
o.o $o.00 $o.00 $o.00 $o.00 $o.00
$o.00 $o.00 $o.00 $o.00
Service Repairs Hours Labor Parts SS Tax Total
WHEEL 0.3 $39.00 $785.00 $4.68 $56.26 $885.24
ALIGNMENT 0.0 $99.99 $0.00 $12.00 $0.78 $112.77
PARTS INV#25118 0.0 $0.00 $0.00 $0.00 $0.00 $0.00
9596894 0.0 $0.00 $0.00 $0.00 $0.00 $0.00
T/RE PRESSURE SENSOR 0.0 ffi0.00 $115.16 $0.00 $7.49 $122.65
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
Totals 0.3 $138.99 $900.16 $16.68 $64.53 $1,120.66
APR 28, 20,14 VEHICLE INFORMATION Store 01 SERVCOI 784/5082 3030
----�—�----------------------------------------------------------------------
� CUSTOMER# 53060 CUSTOMER NAME MARK A BERGMAN �
I BUS. PHONE� 651-251-4700 RES. PHONE 612-790-0572 ACTVY DATE 05/20/2013 �
I ------=----------------------------------------------------------------------- �
I 1 SERIAL NUMBER/? 1G6DD67V080179519 18 DELIVERY MILEAGE 7180 �
I 2 yEAR 08 19 STOCK NUMBER �
� 3 MAKE CADILLAC 20 DEMO DATE �
I 4 LICENSE NiJMBER 21 --- DEMO MILEAGE �
� 5 MODEL NUMBER/? P PASSENGER 22 WARR EXP DATE �
I 6 --- CARLINE/MODEL STS AWD 23 --- WARR EXP MLG. �
I 7 --- DESCRIPTION 4DR SDN AWD 3.6 24 SERVICE CONTRACT (
I 8 EXTERIOR COLOR WHITE 25 NUNIBER �
� 9 TRIM 26 NAM �
I10 MODEL/MAINT CODE/? CDZA 27 EXP DATE MLG. �
� 11 PRODUCTION DATE HR 28 TYPE I
I12 TR.ANSMISSION A/M A 29 ENGINE NUMBER �
� 13 AIR COND Y/N Y PWR STEER Y/N Y 30 TOTAL SERV DAYS 2 �
� 14 TRIM LEVEL AWD W/1SA 31 KEY NUMBER (1) �
� 15 ENGINE CONFIG 3.6L V6 GAS 32 KEY NUMBER (2) �
�16 SELLING DEALER# 33 SALESMAN NUMBER 1348 �
I17 DEL/IN-SERV DATE 04/05/11 NAME MATTHEW E LOCKREM �
--------------------------------------------------------------------------------
(E=ENTER) (U=USR DEF) (N=NEXT) (M=MODIFY) (LINE#) �SC=SVC CONT) (D=DELETE) (TAB)
r
� � �. �,�c� -� v�l�
���,,,�.�.
WALLY McCARTHY �' ��
� ' � CADILLAC-OLDSMOBILE-HUMMER, INC. �4' _ ���
2325 PRIOR AVE. NORTH �+� — ►��
ROSEYILLE, MN 55113 \��� /��
PHONE (651) 636-6060 L
FAX (651) 636-6294 CADILLAC
U.S.A. 1-800-672-0914 TOLL FREE
www.mccarthyauto.com HUMN�R`
IT HAS BEEN A LONG,LONG COLD AND SNOWY WINTER
GIVE YOUR VEHICLE A OVER DUE CLEAN AND POLISH
CHECK OUT ALL OUR GREAT CLEAN AND WAX ITEMS
PARTS HOURS 7:00 -5:30 MON-FRI
PRICE QUOTES VALID 30 DAYS
53060 CASH RONALD D STUHR 04/28/14 PQ25118
CDR
651-251-4700
MARK A BERGMAN
2144 CATTAIL WAY
HUDSON, wI 54016
7� � �
1 0 9596894 WHEEL 5.803 N 785.00 785.00 785.00 ?�ou�c �ual�om
CORE PRICE 50.00 50.00
-1 0 GM9596894 CORE RETURN 50.00 -50.00
1 0 25758220 SENSOR 5.890 Y 47D 115.16 115.16 115.16
DISCWMEH OF WARRANT�S
THE ONLY WARRAN7IES APPLYING TO
THIS PART(S) IS iHAT OFFERED BY
THE MANUFACTURER. THE SELLING _
�
DEALER HEREBY EXPRESSLV DIS- o
� CL41MS ALL WARRANTIES EITHER g
E7(PRESSED OR IMPUED,INCLUDING �
ANY IMPLIED WARRpNTiES OF
, MERCHANTA8ILITV Oii FITNESS FOR A
PARTICUTAR PURPOSE,AND NERHER
ASSUMES NOR AUiHORIZES ANY LIA-
� BILITY IN CONNEC110N WITH THE SALE .
900.16 OF iHIS PART(S).BUYER SHALL NOT
TERMS
- BE ENT(11.E�TO RECOVER FROM THE
NO RETURNS ON SPECIAL ORDER PARTS. RESTOCK CHARGE 0.00 SEIUNG DFALER ANY CONSEQUEN-
NO RETURNS ON ELECTRICAL PARTS. T� 64.14 nn�onnu�es,DAMAGES TO PROP-
20%RESTOCKING CHARGE ON ALL ERTY.DAMAGES FOR LOSS OF USE,
MERCHANDISE RETURNED FOR CREDIT. �oss oF TiMe,�oss oF PROFRS,oR
NO RETURNS AFTER 30 DAYS. iricoMe,OR ANY OTHER INCIDENTAL
CU3TOMER'S SICaNATURE DAMAGES
� FREIGHT g64.30
16:49:07 CUSTOMER COPY "' PRICE QUOTE "' NET506 PAGE 1 OF 1