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Ashmorth, Carolyn RECEI��ED MAY 2'7 2014 NOTICE OF CLAIM FORM to the City of Saint Paul, Minn�o�'� CLERK 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 municipality within 180 days after the alleged loss or injury i.c 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 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►orm 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 '`�J Middle Initial�.Last Name �� - — Company or Business ame N�'� Are You an Insurance Company? Yes� If Yes,Claim Number? Street Address ��'�� o< < '��''�� I � '��`�� City��I��-�� State � Zip Code� Daytime Phone(��Cell Phone(6�2)2�{�"-S4� Evening Telephone( ;--- Date of Accident/Injury or Date Discovered �ILvG�i 2,.20 J�ime��C7 am/� Please state,in detail,what occurred(happened), and why you are submitting a claim.Please indicate why or how you feel th Ciry of Saint Yaul or i s em yees are 'nvolv a and/or responsible ior your damages. , , C�-�' 2 , � � Please check the box(es)that most closely represent the reason for completing this form: �y vehicle was damaged in an accident ❑ My vehicle was damaged during a tow ❑ My vehicle was dar:!aged 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 applicab�e 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. O 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 Other property damage claims: two repair estimates if the damage exceeds $500.00; or the actual bills and/or receipts for the repairs;detailed list of damaged items O Injury claims: medical bills,re�eipts O Photographs are always welcome to document and support your claim but will not be returned. Page 1 of 2—Please complete and return both pages of Claim Form Failure to complete and return both pages will result in delay in the handling of your claim. All Claims—please complete this section Were there witnesses to the incident? Ye No Unknown (circle) Provide their names, addresses and tele hone numbers: r .c�,v�J � o — . �� I.a,�ev;.e�,.� �v�-. a2w�,\ � N �c r'� Were the police or law enforcement called? Yes No Unknown (circle) If yes, what department or agency? �' Case#or report# !�O�—l'a 2�-`-� Where did the accident or injary take place? Provide street address,cross s�reet, intersection,name of park or facility, closest landmark,etc. Please be as detailed as possible. If necessary, att ch a diagram. 1� J '� ,� i C�.Q. h.'� ��1.�� Ple�ase indi�Cate the amoun you are seeking in compens tion or what you would like the City to do to resolve this claim to your satisfaction. Vehicle Claims— lease com lete this section ❑check box if this section does not a 1 Your Vehicle: Year o��Make D o Model License Plate Number State�_Color /�rl t�l Registered Owner �� Driver of Vehicle � ,d Area Damaged � r City Vehicle: Year Make Model �� c �. License Plate Number�th State Color Driver of Vehicle(City Employee's Name)'�,i�� Q.�1i'�y'�P� �1p�2" N��'�3$� Area Damaged�,a Iniury �laims please comaiete this section ,�necic box ii this section does not aunlv 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 VVhen did you miss wo:k? (p*ovide date(s)) Name of your Employer: Address Telephone ( �►�.,4 Check here if you are attaching more pages to this claim form. Number of additional pages.� ��- By signing this form,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 form was completed �� ZO�� Print the Name of the Person who Completed this orm: � Signature of Person Making the Claim: Revised February 2011 °_.d : � ` ��`z-��nstructians for Filing Notice of Claim to City of �nt Paul I Minnesota State Statute 466.05 NOTICE OF CLA/M...(E1 very person...who claims damages fron��r�y � municipality...shall cause to be p�esented to the governing body of the municipa/ity within 180 days sfte� t�ie � a!leged loss or injury is discovered a notice stating the time,place, and circumstances thereof, and tite amount of � compensation"or other relief demanded. � , Piease complete this form m its entirety by�typing or printing your answer to each question in the space provided. If additionai spaae is'needed, please attach additional sheets. PLEASE RETURN THIS Office of City Clerk COMPLETED FQRM TO: 170 City Hail I 15 W Kellogg Blvd St Paul MN 55102 . ..�� c�,�z�.:,� . , , - - - _ .,..� - - - p = � _�:.� .�:� , Street Address: � City: State: Zip Code: Daytime Telephone: ( ) Evening Telephone: f 1 Date of Accident or Incident: �Z��v��Day of Week: rra� Time: /ll3d am �ircle onel _ ___ : _ �.��r _ _.__ ,..�_ __ Piease state, '�r'i„"w�iat cco urred and the circumstanc�� svrrounding the�event. Indica'te hcsw:�he� C'rty ofi Saint Paul is invalved, and why you feel the City is responsible. _; ; 4S �y � ,�, �' i' ri`�v/S c.�` w S�d� �nrY�''�" �`w �►f�_n!� 1-r ��a �y�`� .�-r�w��{� �a �SS _ � �.,w�.-��..,.�l�ase indicate vaur reasQn fQr �ar,q,Qletin�hiseform: . ❑ Vehicle accident ❑ Other property damage (please provide specifi�s below) ❑ Vehicfe was towed � Vehicle damaged ❑ Other injury to person (please provide specific� b�elow) ' ❑ Slipped and felt on City property Please provide the names and telephone numbers of any City employees involved in this , incident/accident and how they were involved: ' � �� t�,�.� ,��I c�-��l.,�k ��2_T� 0 3s� � � y ,�i <r:�:.^.. .� , . � . . � ;(over) �`�- � � ' �:� � ��d � ��„� � � � R:�.� _ �� . I i � �-,-�_:. I, If your vehicle was involved, please compiete the foliowing: � Year, make, and modeL• License Piate Number: Extent and area damaged: Was a City vehicle involved in this accident/incident? es No (circle one) � If yes, please compiete the foliowing: Type of �ehicle ��°�� Year, make, and model ; Color nf vehicle $11�� License Plate Number: �'�� Description of vehicle /�fQ�sGC Location of accident/incident (please provide specifics such as street eddress, intersection, eross streets, park name, facility name, etc.1: � > _ .. , __ ... . � � �-�,.- . ,: ..:=��,�a.�.:. ,�.; � ^,; _;.:_ " �� ic�4a.• . � - - - .. � ,.. .._. .�. _: Please draw or attach a diagram if applicable: � : . _ _ _ , __ �___ � -. - -- - __�. w ��.� �_ '� � Ptease sp8cify the nature and extent of the compensation or other relief you are requesting: �$ase attach`copies of any bills,:recsipts, tickets, or other documet�ts to support your<�laim. If you a��:, claiming damage to a vehicle, please submit two estimates. �� , , : _ _� _. ._ . �.�- _- _ :.; ,at'��-e��t°�-e :�;�itne�wes �ta tHis-�a��ic��;��s�'s��-?--- , ��__.. �s�eir-c'F�orrei ._.. : If ye please give the names, addresses, and telephone numbers of the witnesses: � � I� �a- -�aaa � �� ` �,.w�-�. �rnw S�i I� Were the police called?��No circle one) ff yes, what department or agency? ��c.�� Po{ice report number: �''�O`"1V�1y ' : � �,.; 1�. , Please print the name of the ` ` ' , " � � person completmg th�s form: ��, : �, � � , �s� =r Please sign your name: ��` � �� { � Date form signed: __ � � �k:� �` x � � � �;�i Risk Mgmt Division-Revised 1-30-01 ��: �• ,� � ' �'� � . J � ��:� �� - _� h-� Y ABRA Auto Body & Glass - Roseville Workfile ID: Ofdbe67d Federal ID: 41-1942823 Right the First Time...On time 1914 W. COUNTY ROAD C, ROSEVILLE, MN 55113 Phone: (651) 639-9848 FAX: (651) 639-9406 Preliminary Estimate Customer: ASHWORTH,CAROLINE Job Number: Written By: Bill Wearn Insured: ASHWORTH,CAROLINE Policy#: Claim #: Type of Loss: Date of Loss: ', Days to Repair: 2 Point of Impact: 11 Left Front Owner: Inspection Location: Insurance Company: ASHWORTH,CAROLINE ABRA Auto Body&Glass-Roseville CUSTOMER PAY 2583 DELLWOOD AVE 1914 W.COUNTY ROAD C ROSEVILLE, MN 55113 ROSEVILLE, MN 55113 (612)245-5989 Cell Repair Facility ' (651)639-9848 Business VEHICLE Year: 2007 Body Style: 4D SED VIN: JTNBE46K373023691 Mileage In: 177000 Make: TOYO Engine: 4-2.4L-FI License: 302MCL Mileage Out: Model: CAMRY LE Production Date: 5/Z006 State: MN Vehicle Out: Color: GREY Int: Condition: )ob#: TRANSMISSION Dual Mirrors Telescopic Wheel Anti-Lock Brakes(4) Overdrive Console/Storage RADIO 4 Wheel Disc Brakes 5 Speed Transmission CONVENIENCE AM Radio Front Side Impact Air Bags POWER Air Conditioning FM Radio Head/Curtain Air Bags Power Steering Intermittent Wipers Stereo SEATS Fow2r Brakes Tilt Wheel Search;Seel: Clcth Seats Power Windows Cruise Control CD Player Bucket Seats Power Locks Rear Defogger Auxiliary Audio Connection WHEELS Power Mirrors Keyless Entry SAFETY Wheel Covers Power Driver Seat Message Center Drivers Side Air Bag PAINT DECOR Steering Wheel Touch Controls Passenger Air Bag Clear Coat Paint 5/20/2014 4:38:41 PM 024206 Page 1 Preliminary Estimate Customer: ASHWORTH, CAROLINE )ob Number: Vehicle: 2007 TOYO CAMRY LE 4D SED 4-2.4L-FI GREY Line Oper Description Part Number Qty Extended Labor Paint Price; 1 FRONT BUMPER&GRILLE 2 R&I R&I bumper cover 1.4 3 * Rpr Bumper cover US built w/o SE � 2.6 4 Add for Clear Coat 1.0 5 FRONT LAMPS 6 R&I LT R&I headlamp assy ' 0.3 7 FENDER 8 * Rpr LT Fender 3.Q 1.8 9 Add for Clear Coat 0,7 10 FRONT DOOR 11 Repl LT Mirrorassy w/o heated, US 8794006190B1 1 170.83 0.4 0.6 built gray ' 12 Overlap Minor Panel _0.z 13 Add for Clear Coat 0.1 14 R&I LT R&I trim panel 0.6 15 MISCELLANEOUS OPERATIONS 16 # Refn �Corrosion Protection 0.3 17 # Repl �Flex Additive/Adhesion Promoter 1 8.50 T 18 # 'Hazardous Waste 1 5.00 X SU6TGTALS i84.33 6.7 6.9 ESTIMATE TOTALS Category Basis Rate Cost� Parts 170.83 Body Labor 6.7 hrs @ $56.00/hr 375.20 Paint Labor 6.9 hrs @ $56.00/hr 386.40 Paint Supplies 6.9 hrs @ $36.00/hr 248.40 Miscellaneous 13.50 Subtotal 1,194.33 Sales Tax $427.73 @ 7.1250% 30.48 Grand Total 1,224.81 Deductible 0.00 CUSTOMER PAY 0.00 INSURANCE PAY 1,224.81 THIS IS A VISUAL INSPECTION ONLY. THERE MAY BE ADDITIONAL DAMAGE AFTER DISASSEMBLY. PARTS ARE SUBJECT TO INVOICE. THERE 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." 5/20/2014 4:38:41 PM 024206 Page 2 LUTHER COLLISION & GLASS - workfile ID: a46fbf72 FederalID: 45-2947565 BLOOMINGTON 4801 American Bivd West, BLOOMINGTON, MN 55437 Phone: (952) 367-4500 FAX: (952) 367-4501 Preliminary Estimate Customer: Ashworth,Carolyn �ob Number: Written By: Ryon Brody Insured: Ashworth,Carolyn Policy#: Claim#: Type of Loss: Date of Loss: Days to Repair: 0 Point of Impact: Owner: Inspection Location: Insurance Company: Ashworth,Carolyn LUTHER COLLISION&GIJISS- BLOOMINGTON 2583 Dellwood Ave 4801 American Blvd West Roseville,MN 55113 BLOOMINGTON, MN 55437 (612)245-5989 Business Repair Faciliry (952)367-4500 Business VEHICLE Year: 2007 Body Style: 4D SED VIN: ]TNBE46K373023691 Mileage In: Make: TOYO Engine: 4-2.4L-FI License: Mileage Out: Model: CAMRY LE Production Date: State: Vehicle Out: Color: Grey Int: Condition: ]ob#: TRANSMISSION Dual Mirrors Telescopic Wheel Anti-Lock Brakes(4) Overdrive Console/Storage RADIO 4 Wheel Disc Brakes 5 Speed Transmission CONVENIENCE AM Radio Front Side Impact Air Bags POWER Air Conditioning FM Radio Head/Curtain Air Bags Power Steering Intermittent Wipers Stereo SEATS Power Brakes Tilt Wheel Search/Seek Cloth Seats Power Windows Cruise Control CD Player Bucket Seats Power Locks Rear Defogger Auxiliary Audio Connection WHEELS Power Mirrors Keyless Entry SAFETY Wheel Covers Power Driver Seat Message Center Drivers Side Air Bag PAINT DECOR Steering Wheel Touch Controls Passenger Air Bag Clear Coat Paint 5/22/2014 1:36:21 PM 304631 Page 1 ' Preliminary Estimate Customer: Ashworth,Carolyn ]ob Number: Vehicle: 2007 TOYO CAMRY LE 4D SED 4-2.4L-FI Grey Line Oper Description Part Number Qty Extended Labor Paint Price� 1 FRONT BUMPER 8�GRILLE 2 0/H bumper assy Z•3 3 * Rpr Bumper cover Japan built �,.4 Z•6 Note: Inc.tab repair 4 Add for Clear Coat 1.0 5 R&I License panel 0.1 6 FRONT LAMPS _ . 7 R&I LT R&I headlamp assy 0.3 8 FENDER 9 * Rpr LT Fender � 1•8 Note: Front of fender only SO Add for Clear Coat �� 11 R&I LT Fender liner 0.4 12 PILLARS,ROCKER�FLOOR 13 * R&I LT Rocker molding gray � Note: drop 14 FRONT DOOR . 15 Repl LT Mirror assy w/o heated,]apan 879403362061 1 170.83 0.4 0.6 built gray 16 Overlap Minor Panet '�•Z 17 Add for Clear Coat 0.1 18 R&I LT R&I trim panel 0.6 19 # Repl Flex Additive 1 8.00 X 20 # Subl Hazardous Waste Removal 1 8.00 X 21 # Refn Color Tint 0.5 22 # Refn Corrosion Protection 03 23 # Repl Car Cover-Paint 1 6.00 T 0.2 24 # Denib&Buff 1 0.5 25 # Subl Rental Car$32/day approx.5 1 160.00 X days SUBTOTALS 352.83 10.7 7.4 5/22/2014 1:36:21 PM 304631 Page 2 � � Preliminary Estimate Customer: Ashworth,Carolyn ]ob Number: Vehicle: 2007 TOYO CAMRY LE 4D SED 4-2.4L-FI Grey ESTIMATE TOTALS Category Basis Rate Cost$ Parts 170.83 Body Labor 10.7 hrs @ $54.00/hr 577.80 Paint Labor 7.4 hrs @ $54.00/hr 399.60 Paint Supplies 7.4 hrs @ $34.00/hr 251.60 Miscellaneous 182.00 Subtotal 1,581.83 Sales Tax $422.43 @ 7.2750% 30.73 Grand Total 1,612.56 Deductible 0.00 CUSTOMER PAY 0.00 INSURANCE PAY 1,612.56 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. 5/22/2014 1:36:21 PM 304631 Page 3 � � Preliminary Estimate Customer: Ashworth,Carolyn ]ob Number: Vehicle: 2007 TOYO CAMRY LE 4D SED 4-2.4L-FI Grey Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide ARM8522, CCC Data Date 5/14/2014, and the parts selected are OEM-parts manufactured by the vehicles Original Equipment Manufacturer. OEM parts are available at OE/Vehicle dealerships. OPT OEM (Optionat 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 afitermarket 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 inclwded. 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=Miscelfaneous 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=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. 0/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. 5/22/2014 1:36:21 PM 304631 Page 4 ��R� , q�s. , i �': � '. �i ' tl.� 1 . �',,, j ifj i f �� ♦ i�j °�. �'; i(.i � � i i i i d,� f ! f�'! � ! . � �� r; � e. V1��t R �^ 1�'� _ �� f '�� I �' �� ; I � ,��: -��_ 4� �- I � '' ; �. � �� , ' �� , i �, j : � � . 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