The URL can be used to link to this page

Smith Pughm, Quashingm RECEI�IED NOTIC� OI' CLAIM TORM to the City of Saint Paul, Minneso�05 ��,� iLfirurr.sota Slule Statr�te 466.05.clntes!ha( "...evPrv persnit...x�l�n r/nims damn�e.c.%roin mrv nrunicipn/ity...shr�ll ccruse In �i,T.Y ttZ�l�7RP `� �oi�errring body u/'tl�e nrurticipciliry x�i[l+r�i 180 d�n�s after dre a/Ie,Setl loss or i�tjirrv is clisco��ered a notice stnti�rg lJ�e 1i��re,pluc•e:,cur�l cii-cum.stairces thereo%crrtrl tlte antneutt r f contpensatiun or ot{�er re/ic}'demnncled." Please complele this f��rm in its entirety by clearly typing or printing your answer to each question. If more space is needed,att�ch additional sheets. Please note that you will not be contacted by telephone to clarify answers,so provide�s much information as necessary to explain your cl�im,and the amounl of cc�rri�ehsation bein�requested. You will receive a wriUen acknowled�;ement once your fi�rm is received. The process can take up to ten weeks or longer depending on the � nature o['your claim. This 1'orm must be signed,and both pages completed. If somethin�does not apply,write `N/A'. SEND COMPLETED FORM AND OTHER DOCUM�N�'�� TO�: �CITY CLERK, 15 WEST K�LLOGG BLVD, 310 CITY HALL, SA�1T PAUL, IV�N 55102 First Name /��wr �'1�., "i,�}�r Middle Initial 1'�C Last Name - �r.�.-,��.-r'-`�,�: ,�':� <. b � � �,� � , � ., . Company or Business Name Are You an Insurance Company? Yes/�1y� If Yes, Claim Number? .'�� . 1 Street Address �l/`i .�� L , i, City ;�j:'- . i�:{ c,.c_1 State �� Zi�Code __S�i I`O�� Daytime Phone ( �) - � � Cell Phone (�;�_)��-:�� l��i�Evening Telephone ( ) - � Date of Accident/Injury or Date Discovered � ��!,�� 1 ;' %�, �i�� Time ) %�� ` am/� � Please state, in detail, what occurred (happened), and why you are submitting a claim. Please indicate whly.yir how you feel the City f Saint Paul or its etnployees are involved a/nd/or respQnsible for your damages. �� -J� �' � / i'� LL P ��,`f �i�./' ,,e.�� •l; ;h�,/`� \ ,.�i(f�'�; ![ G _/' � a l v '.C,- � �t � � /F � �<� l.c,;�R f �, �• r i�� 1 = ' .:f — :,� :�� % . i' 1 'e�'' � i�►• '-t L,-r:t �� .�' i � �� `i/..�' �' ./ Please check the box(es) that most closely represent[he reason for completing this form: ' (�`1VIy vehicle was damaged in an accident ❑ My vehicle was damaged duiing 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 pro�erty damabe—please specify ! ❑ Other type of injury—please specify � In order to process your claim yoti need td include conies of all annlic�ble 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 i 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 aqd/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 actu�il bills and/or receipts for the repairs; detailed ]ist of damaged items � O Injury claims: medical bills, receipts - �� O Photographs are always welcome to document and supPoR your claim but will not be returned. Page 1 of 2—Please complete and return both pages of Claim Form �� Failurc to complete and return both pages will result in dclay in the handling of your claim. All Claims-P�case complete this section � Were therc witnesses to the incident? Y� No Unknown (circle) �__ Provide their names, addresses and telephone numbers: f��t k/�� r/�� Were the police or law enforcement called? �1�'� No Unknown (circle� � � � �, ;:� ,j�.��.,�.� Case#or report# �L� -� -3 - G If yes, wh<<t department or agency. ____�__ Where did the accident or injury [ake place'? Provide street address,cross street, intersection, name of park c�r facility, closest landmark, etc. Please be as detailed as possible. If necessary, attach a diagram. -�C-�'rS7F' �t�'��+.�f��'! G.. - Please indicate ihe amount you are seeking in compensation or what ou would ike the City to dc to ry°��olve this claim `'' �~-C��-�:� ' •t�•�°, 'V�-��.r c3� y''�•+- i!�'��r�,.*/, < . to your satisfaction. �.� 1 -� � .{--�J "'�'{;� �k..n '1�"� � : Q Y�'e •- " � ' c�rtinn ❑ check box if thiti �ection doeti not apnlv Vcl�icic �laims<nleasL�cuuR1�-�-� — - — _ -- ' Your Vehicle: Year '�� Make.�-�.� � �;�=_ Model �''il�: i �.!%%x License Plate NumUer�� State I",�Color T�` Registerecl Owner ��t�-� �� .��,� ; ��' *' Driver of Vehicle ti�'.�� -' a� - �"� Area Damaged �- .� ' D � �e �'I �[ �� r•� Lk ?� City Vehicle: Year Make Model License Plate Number State > >.� Color - �c- Driver of Vehicle(Cit Employee's Name) w� dn+-� S�t-C��Cu''" / Area Damaged �''��-��r � �, �f�� ln�urv U��ims PleaSC compl�,tt this S�c.tion �check box if thi5 section docs not ap�lY How were you injured? What part(s) of your body were injured? Have you sought medical treatment? Yes No Planni��g to Seek Treatment (circle) When did you receive treat�nent? (provide date(s)) Name of Medical Provider(s): Address Telephone Dicl you miss work as a result of your injury? Yes No ' Wh�.n did you nuss w�rk?_ _ _ _ (provicle datc(s)) _ _ - - - -, _ �' Name of your Employer: ��idre� . __ _ -'�'.^,l�.pk�on� _ --- � Check here if you are attaching more pages to this claim form. Number uf additional pages � . I3y sigfiing this form,you are stating tltat ull information you )zave provided is true ai:d correct to the best ' of your kriowledge. Unsig�zed forms will not be processed. ' Secbmitti►tg a fnlse clainz can resr[[t i�t prosectctioit. Date form was completed ��" � ��'-�� Print the Name of the I'erson who Completed this F �: �-��'��='� ^��'�:�� '� ��'�" ' �' "` Si�;nature of'Person Making the Claim: � / , -��"""�' Itevisc�Fcbruary 201 I GREGG'S AUTO BODY Workfile ID: 272971d6 FederalID: 411353442 HONEST AND CONSISTENT QUALITY 581 E. 7th Street, St. Paul, MN 55130 Phone: (651) 774-8211 FAX: (651) 774-0174 Preliminary Estimate Customer: Smith-Pugh,Quashingm Written By:Justin Wilwert Insured: Smith-Pugh,Quashingm Policy#: Claim#: Type of Loss: Date of Loss: Days to Repair: 0 Point of Impact: Owner: Inspection Location: Insurance Company: Smith-Pugh,Quashingm GREGG'S AUTO BODY 919 3rd St 581 E.7th Street St Paul,MN 55106 St. Paul, MN 55130 (651)500-4749 Cell Repair Facility (651)774-8211 Business V�HICLE Year: 1999 Body Style: 4D SED VIN: iG2WJ52M9XF319123 Mileage In: Make: PONT Engine: 6-3.1L-FI License: Mileage Out: Model: GRAND PRIX SE Production Date: State: Vehicle Out: Color: Int: Condition: Job#: TRANSMISSION DECOR RADIO 4 Wheel Disc Brakes Automatic Transmission Dual Mirrors AM Radio SEATS Overdrive Console/Storage FM Radio Cloth Seats POWER CONVENIENCE Stereo Bucket Seats Power Steering Air Conditioning Cassette PAINT Power Brakes Intermittent Wipers SAFETIf Clear Coat Paint Power Windows Tilt Wheel Drivers Side Air Bag OTHER Power Locks Rear Defogger Passenger Air Bag Fog Lamps Power Mirrors Message Center Anti-Lock Brakes(4) Traction Control 5/23/2014 10:20:16 AM 034178 Page 1 Preliminary Estimate Customer: Smith-Pugh, Quashingm Vehicle: 1999 PONT GRAND PRIX SE 4D SED 6-3.iL-FI Line Oper Description Part Number Qty E�ctended Labor Paint Price$ 1 FRONT BUMPER 2 0/H bumper assy 2.4 3 Repl Bumper cover w/o custom bpr 88893301 1 278.33 Incl. 3.2 4 Add for Clear Coat 1.3 5 Repl Support 10433271 1 53.07 Incl. 6 FRONT LAMPS _ 7 Repl LT Headlamp assy 19149891 1 156.77 Incl. 8 Aim headlamps 0.5 9 HOOD . 10 Repl Hood w/o air vents 12369173 1 295.00 1.0 3.0 11 Add for Clear Coat 1•Z 12 Add for Underside(Complete) 1.5 13 R&I Insulator w/o pace car Incl. 14 Repl Weatherstrip 10250195 1 33.75 Incl. 15 Repl Latch 10423015 1 67.58 0.3 open Repl Center support SEE FOOTNOTE 1 0.3 17 Add for Clear Coat 0.1 18 * R&I RT Support strut � 19 * R&I LT Support strut � 20 FENDER 21 Blnd RT Fender 1.0 22 Blnd LT Fender 1.0 23 # Car Cover 1 0.2 24 # Refn Corrosion Protection 0.5 25 # Repl Flex Additive 1 5.00 26 # Subl Hazardous Waste 1 5.00 X SUBTOTALS 894.50 4.6 13.3 5/23/2014 10:20:16 AM 034178 Page 2 Preliminary Estimate Customer: Smith-Pugh, Quashingm Vehicle: 1999 PONT GRAND PRIX SE 4D SED 6-3.1L-FI ESTIMATE TOTALS Category Basis Rate Cost$ Parts 889.50 Body Labor 4.6 hrs @ $55.00/hr 253.00 Paint Labor 13.3 hrs @ $55.00/hr 731.50 Paint Supplies 13.3 hrs @ $35.00/hr 465.50 Miscellaneous 5.00 Subtotal 2,344.50 Sales Tax $ 1,355.00 @ 7.6250% 103.32 Grand Total 2,447.82 Deductible 0.00 CUSTOMER PAY 0.00 INSURANCE PAY 2,447.82 GREGG'S AUTO BODY takes great care to ensure that every repair meets our standards for quality. GREGG'S AUTO BODY guarantees labor performed for as long as you own your vehicle on workmanship and will, at our expense repair or correct all defects which are attributable to defective or faulty workmanship in the repairs stated on the repair invoice. This guarantee covers labor only and does not apply to parts, materials or equipment which may be covered by and subject to terms of manufacturer or vendors warranty. This guarantee does not include damage caused by or resulting from rust or corrosion, unreasonable use, improper maintenance or care of the vehicle.The above is an estimate based on our inspection and does not cover additional parts or labor which may be required after the work has been opened up.Parts price subject to change without notice. YOU HAVE A RIGHT TO CHOOSE A REPAIR FACILITY OF YOUR CHOICE. WE GREATLY APPRECIATE YOUR BUSINESS. 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. 5/23/2014 10:20:16 AM 034178 Page 3 o ' • Preliminary Estimate Customer: Smith-Pugh, Quashingm Vehicle: 1999 PONT GRAND PRIX SE 4D SED 6-3.1L-FI Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide DE1FD97, 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 (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 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=Blend. 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. 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. 5/23/2014 10:20:16 AM 034178 Page 4 • HEPPNER'S AUTO BODY (Downtown) Workfile ID: ea0db0a0 EPPNERi�'► 395 E. 7TH ST., SAINT PAUL, MN 55101 � • : ai Phone: (651) 224-5644 FAX: (651) 224-6042 Preliminary Estimate Customer: SMITH-PUSH, QUASHINSM 7ob Number: Written By: Scott Paloma Insured: SMITH-PUSH, Policy#: Claim#: 14073363 QUASHINSM Type of Loss: Collision Date of Loss: Days to Repair: 0 Point of Impact: 12 Front Owner: Inspection Location: Insurance Company: SMIfH-PUSH,QUASHINSM HEPPNER'S AUTO BODY(Downtown) GIECO 919 3RD ST 395 E.7TH ST. ST PAUL,MN 55106 SAINT PAUL, MN 55101 (651)500-4745 Day Repair Facility (651)224-5644 Business VEHICLE Year: 1999 Body Style: 4D SED VIN: iG2WJ52M9XF319123 Mileage In: 212896 Make: PONT Engine: 6-3.1L-FI License: 224NLX Mileage Out: Model: GRAND PRIX SE Production Date: 4/1999 State: MN Vehicle Out: Color: GRAY Int: GRAY Condition: ]ob#: TRANSMISSION DECOR RADIO 4 Wheel Disc Brakes Automatic Transmission Dual Mirrors AM Radio SEATS Overdrive Console/Storage FM Radio Cloth Seats POWER CONVENIENCE Stereo Bucket Seats Power Steering Air Conditioning Cassette PAINT Power Brakes Intermittent Wipers SAFETY Clear Coat Paint Power Windows Tilt Wheel Drivers Side Air Bag OTHER Power Locks Rear Defogger Passenger Air Bag Fog Lamps Power Mirrors Message Center Anti-Lock Brakes(4) Traction Control 5/23/2014 10:39:24 AM 070412 Page 1 . Preliminary Estimate Customer: SMITH-PUSH, QUASHINSM ]ob Number: Vehicle: 1999 PONT GRAND PRIX SE 4D SED 6-3.1L-FI GRAY Line Oper Description Part Number Qty Extended Labor Paint Price$ 1 INFORMATION LABELS 2 Repl Emission label 3.1 fiter Federal 24507059 1 21.83 0.2 _.. . __...�...__ ........ . ... ........ ....__. .. _..__._�.._. _._.....,.. _ _.. .._...., .._ . . .,,....,. _ _...,. .,. _ 3 FRONT BUMPER 4 * Rpr Bumper cover w/o custom bpr 2_0 3.2 5 Add for Clear Coat 1.3 6 0/H bumper assy 2•4 7 Repl Emblem 20696860 1 74.00 Incl. 8 Repl Support 10433271 1 53.07 Incl. �� . . _.._ . .� _. __._____...___ _ ..__ _. __.___ . _ 9 GRILLE __ ___ ___ 10 Repl LT Grille SE 10285342 1 20.97 Incl. ...,...._ _.___._. . ___... ,.,.�.,.,_... ___.__.__. __ �..._...,._,..._..�� ,..�..,,..�.._....._ . _.,,,,,.,. ...�__ .,.._. __. _ ._�_�.��, . 11 FRONT LAMPS 12 * Repl LKQ LT Headlamp assy+25% 19149891 1 106.25 Incl• 13 Aim headlamps 0.5 ___ _ .__ _ .._ .._._. __. .. __._ ._... .. _ _ 14 HOOD 15 Repl Hood w/o air vents 12369173 1 295.00 1.0 3.0 16 Add for Clear Coat 1•2 17 Add for Underside(Complete) 1.5 18 Repl Latch 10423015 1 67.58 0.3 19 # Repl �Flex Additive 1 5.00 20 # �Hazardous Waste Disposal Fee 1 5.00 SUBTOTALS 648J0 6.4 10.2 ESTIMATE TOTALS Category Basis Rate Cost$ Parts 648.70 Body Labor 6.4 hrs @ $52.00/hr 332.80 Paint Labor 10.2 hrs @ $52.00/hr 530.40 Paint Supplies 10.2 hrs @ $32.00/hr 326.40 Subtotal 1,838.30 Sales Tax $975.10 �� 7.6250% 74.35 Grand Total 1,912.65 Deductible 0.00 CUSTOMER PAY 0.00 INSURANCE PAY 1,912.65 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. 5/23/2014 10:39:24 AM 070412 Page 2 , Preliminary Estimate Customer: SMITH-PUSH,QUASHINSM 7ob Number: Vehicle: 1999 PONT GRAND PRIX SE 4D SED 6-3.1L-FI GRAY Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide DE1FD97, 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 (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 symbof (<>) 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=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=Bureau of Automotive Repair. EPA=Environmental Protection Agency. NHTSA= National Highway Transportation and Safety Administration. PDR=Paintless Dent Repair. VIN=Vehicle Identification Number. 5/23/2014 10:39:24 AM 070412 Page 3