Hannasch, Jacqueline (2) REC�s�/;�p
NOTICE OF CLAIM FORM to the City of Saint Paul, Minnes��a�9 2014
Minnesota State Statute 466.05 states that"...every person...who claims damages from any municipality...shall cause Cd�6��e.si�n��RK
governing body of the municipulity within/80 duys after the alleged loss or injury is discovered u notice stating the�ime,pluce,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 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 Jacqueline Middle Initial M Last Name Hannasch
Company ar Business Name '
Are You an Insurance Company? Yes No If Yes,Claim Number?
Street Address 12992 Jay St. N.W.
City Coon Rapids State Minnesota Zip Code 55448
Daytime Phone ( 76� 75� 7521 Cell Phone (763) 360_2530 Evening Telephone(7��)755_7521 '
Date of Accident/Injury or Date Discovered May 12th Time 6:00 am/pm I
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 our darr�ages. I was parked across the ,
street from 827 W. Hoyt, St. Paul, MN, 55117. While visiting my�amily, the Van rom e i y o t. Paul
nicked �� m� sister Karen B�land ( an adaptive rec activit��for an evenina a .tivi � M� Gi�t _r I idv
Osterndorf witnessed the van backing up and hitting mkcar. The damage is on the left front side of my
Chevy Malibu (silver). I talked with Chaz, who was the driver of the Van. A police report was filed by
Officer Peng Lee of the St. Paul police department ( 651-266-5700). The file# is 14091828
Please check the box(es)that most closely represent the'reason for completing this form:
L�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 �
O 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 youu need to include copies of all applicable 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`�lamage 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,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
i
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims-please comqlete this section
Were there witnesses to the incident? Yes No Unknown (circle)
Provide their names,addresses and telephone numbers: Judy OSterndOrf, 11606 W. Sunset Lane, Greenfield
414-852-5996 Cell#414-852-5996 Wisconsin, 53228
Were the police or law enforcement called? Yes No Unknown (circle)
If yes, what department or agency? St. PBUI, Minnesota Case#or report# 14091828
Where did the accident or injury take place? Provide street address,cross street, intersection, name of park or facility,
closest landmark,etc. Please be as detailed as possible. If necessary, attach a diagram. $27 W• HO� aVetlUe
St. Paul MN., across the street. �S`jt �
Please indicate the amoun� ou are seeking in ompensation 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 7 Make Model 7
License Plate Number SLL- 31 State_�Color i ver
Registered Owner Jacqueline Mae Hannasch '
Driver of Vehicle Jacc�ueline
Area Damag�ed Front left side near tire
City Vehicle: Year 2�� Make Chevrolet Model an
License Plate Number 923839 State Color Gold
Driver of Vehicle(City Employee's Name) Chasity (Chaz) Jo Kabermusz
Area Damaged l Pft rPar humnPr -
Iniury Claims please complete this section f�check box if this section does not apply
How were you injured?
What part(s)of your body were injured?
Have you sought medical treatment? Yes o 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
[�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 inforxnation 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 06/04/2014
Print the Name of the Person who Completed this Form: �af G t� � � • rn U� �l�h/�aSL/1
Signature of Person Making the Claim: � • '`
Revised February 201 1
;� , "
ABRA Auto Body & Glass - Coon �Norkfile ID: 4fa4e33c
FederalID: 41-1942823
Rapids
Right The First Time...On Time
11585 ROBINSON DR NW, COON RAPIDS, MN
55433
Phone: (763) 755-3665
FAX: (763) 755-1990
Preliminary Estimate
Customer: HANNASCH,7ACKIE Job Number:
Written By: Dan Larson
Insured: HANNASCH,]ACKIE Policy#: Claim #: .
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact: 11 Left Front
Owner: Inspection Location: Insurance Company:
HANNASCH,JACKIE ABRA Auto Body&Glass-Coon Rapids CUSTOMER PAY
12992]AY ST NW 11585 ROBINSON DR NW
MPLS, MN 55448 COON RAPIDS, MN 55433
(763)755-7521 Business Repair Facility
(763)755-3665 Business
VEHICLE
Year: 2007 Body Style: 4D SED VIN: SG1Z558F97F222012 Mileage In: 139821
Make: CHEV Engine: 4-2.2L-FI License: SLL-831 Mileage Out:
Model: MAIIBU LS Production Date: 12/2006 I State: MN Vehicle Out: �
Color: gray Int: gray Condition: Job#:
TRANSMISSION Body Side Moldings RADIO Cloth Seats
Automatic Transmission Console/Storage AM Radio Bucket Seats
Overdrive CONVENIENCE FM Radio WHEELS I
POWER Air Conditioning Stereo Wheel Covers
Power Steering Intermittent Wipers Search/Seek PAINT i
Power Brakes Tilt Wheel CD Player Clear Coat Paint
Power Windows Cruise Control SAFETIf OTHER �
Power Locks Rear Defogger , Drivers Side Air Bag Power Trunk/Gate Release
Power Mirrors Keyless Entry Passenger Air Bag
DECOR Message Center Head/Curtain Air Bags
Dual Mirrors Telescopic Wheel SEATS
5/19/2014 2:30:22 PM 014560 Page 1
Preliminary Estimate
Customer: HANNASCH,7ACKIE )ob Number:
Vehicle: 2007 CHEV MALIBU LS 4D SED 4-2.2L-FI gray
Line Oper Description Part Number Qty Extended Labor Paint
Price$
1 FRONT BUMPER
2 R&I R&I bumper cover 1.3
3 R&I License bracket p.2
4 * Rpr Bumper cover w/o fog lamps � 2.6
5 Add for Clear Coat 1.0
6 R&I Lower grille w/o 55 0.3
. _
7 GRILLE
8 R&I R&I grille assy Incl.
9 * R&I Molding p_2
_
_
10 FRONT LAMPS
11 R&I LT Headlamp assy 03
12 FENDER
13 ** Repl A/M LT Fender 10398518 1 93.00 2.0 1.8
14 Add for Clear Coat p,7
15 Add for Edging 0.5
16 Deduct for Overlap -0.3 '
17 R&I LT Fender liner IncL
18_ PILLARS,ROCKER&FLOOR
19 R&I LT Rocker molding base&LS 05 '
_ _
20 MISCELLANEOUS OPERATIONS
21 # �Hazardous Waste 1 5.00 X �
22 # Refn �ColorTint � p.5 �
6UBTOTALS 98.00 6.0 7.1
NOTES
Estimate Notes:
There may have additional damages that are under the bumper and fender.
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5/19/2014 2:30:22 PM 014560 Page 2
Preliminary Estimate
Customer: HANNASCH,7ACKIE 7ob Number:
Vehicle: 2007 CHEV MALIBU LS 4D SED 4-2.2L-FI gray
ESTIMATE TOTALS
Category Basis Rate Cost;
Parts 93.00
Body Labor 6.0 hrs @ $56.00/hr 336.00
Paint Labor 7.1 hrs @ $56.00/hr 397.60
Paint Supplies 7.1 hrs @ $36.00/hr 255.60
Miscellaneous 5.00
Subtotal 1,087.20
Sales Tax $348.60 @ 7.1250% 24.84
Grand Total 1,112.04
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 1,112.04
THIS IS A VISUAL INSPECTION ONLY. THERE MAY BE ADDITIONAL DAMAGE AFTER DISASSEMBIY. 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."
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. '
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5/19/2014 2:30:22 PM 014560 Page 3
�
Preliminary Estimate
Customer: HANNASCH,7ACKIE )ob Number:
Vehicle: 2007 CHEV MALIBU LS 4D SED 4-2.2L-FI gray
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
DRiCP04, 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 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: '� i
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 i
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.
5/19/2014 2:30:22 PM 014560 Page 4
Preliminary Estimate
Customer: HANNASCH,7ACKIE 7ob Number:
Vehicle: 2007 CHEV MALIBU LS 4D SED 4-2.2L-FI gray
ALTERNATE PARTS SUPPLIERS
Supplier: Wheelers Auto Body Supply
Location(s): 6150 CLAUDE WAY,INVER GROVE HEIGHTS MN 55076 (866)435-7015 (651)379-0808
Line Description Item# Price
13 A/M LT Fender GM1240306E $93.00
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5/19/2014 2:30:22 PM 014560 Page 5
� . AMERICAN AUTO BODY Workfile ID: le7dfe0b
FederalID: 41-1536093
Working to be better today than we were State ID: 3463442
yesterday!
8208 LAKELAND AVE N, BROOKLYN PARK, MN
55445
Phone: (763) 424-2522
FAX: (763) 424-3543
Preliminary Estimate
Customer: HANNASCH,JACQUELINE
Written By:JUSTIN NEUMAN
Insured: HANNASCH,JACQUELINE Policy#: Claim #:
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact:
Owner: Inspection Location: Insurance Company:
HANNASCH,JACQUELINE AMERICAN AUTO BODY
12992 JAY ST NW 8208 LAKELAND AVE N
COON RAPIDS, MN 55448 BROOKLYN PARK, MN 55445
(763)755-7521 Evening Repair Facility
(763)360-2530 Day (763)424-2522 Business
VEHICLE
Year: 2007 Body Sryle: 4D SED VIN: 1G1ZS58F97F222012 Mileage In:
Make: CHEV Engine: 4-2.2L-FI License: SLL-831 Mileage Out:
Model: MALIBU LS Production Date: State: MN Vehicle Out:
Color: GRAY Int: Condition: Job#:
TRANSMISSION Body Side Moldings RADIO Cloth Seats
Automatic Transmission Console/Storage AM Radio Bucket Seats
Overdrive CONVENIENCE FM Radio WHEELS
POWER Air Conditioning Stereo Wheel Covers
Power Steering Intermittent Wipers Search/Seek PAINT
Power Brakes Tilt Wheel CD Player Clear Coat Paint
Power Windows Cruise Control SAFETY OTHER
Power Locks Rear Defogyer Drivers Side Air Bag Power Trunk/Gate Release
Power Mirrors Keyless Entry Passenger Air Bag
DECOR Message Center Head/Curtain Air Bags
Dual Mirrors Telescopic Wheel SEATS
5/28/2014 9:14:38 AM 028638 Page 1
Preliminary Estimate
Customer: HANNASCH,JACQUELINE
Vehicle: 2007 CHEV MALIBU LS 4D SED 4-2.2L-FI GRAY
Line Oper Description Part Number Qty Extended Labor Paint
Price#
1 FRONT BUMPER
2 0/H front bumper Z,p
3 R&I R&I bumper cover Incl.
4 * Rpr Bumper cover w/o fog lamps ?� z,6
5 Add for Clear Coat 1.0
6 # Refn Feather/Prime/Block
7 # Refn Deduct for Partial Paint -0,2
8 R&I Upper support Incl.
9 R&I Lower grille w/o SS Incl.
10 R&I Lower deflector L5, LT, LTZ Incl.
il R&I License bracket p,Z
12 GRILLE
13 R&I R&I grille assy Incl.
14 FRONT LAMPS
15 R&I LT Headlamp assy 0.3
16 Repl Aim headlamps 1 0.5
17 FENDER
18 * Repl LKQ LT fender assy+25% 10398518 1 29�.2� 1.4 1.8
Note: PART AVAILABLE PER MURPHY AT AAA WITH LINER.
19 Add for Clear Coat 0.7
20 LT Refn edges 0.5
21 Deduct for Overlap -0.3
22 * Repl LKQ LT Fender liner 15882054 1 Ips�, Iil�1.
23 PILLARS,ROCKER&FLOOR
24 R&I LT Rocker molding base&LS 0.5
25 FRONT DOOR
26 Blnd LT Outer panel 1.0
27 R&I LT Belt w'strip 0.2
28 * R&I LT Body side mldg paint to match Q.,�
LS&SS
29 # Repl Clean and Retape 1 5.00 0.2
30 R&I LT Mirror assy w/o heated black 0.3
31 R&I LT Handle,outside 0.4
32 R&I LT R&I trim panel 0.4
33 MISCELLANEOUS OPERATIONS
34 * Repl Cover car/ba9 1 4.4 4.2
35 # Refn Corrosion Protection 0.2
36 # Repl Hazardous Waste 1 5.00 X
SUBTOTALS 216.25 8.9 7.8
NOTES
Estimate Notes:
5/28/2014 9:14:38 AM 028638 Page 2
Preliminary Estimate
Customer: HANNASCH,JACQUELINE
Vehicle: 2007 CHEV MALIBU LS 4D SED 4-2.2L-FI GRAY
OWNER STATES THERE IS A RATTLE COMING FROM VEHICLE SINCE ACCIDENT. SHOP WILL NEED TO DIAGNOIS AT TIME OF REPAIRS.
ESTIMATE TOTALS
Category Basis Rate Cost$
Parts 211.25
Body Labor 8.9 hrs @ $52.00/hr 462.80
Paint Labor 7.8 hrs @ $52.00/hr 405.60
Paint Supplies 7.8 hrs @ $32.00/hr 249.60
Miscellaneous 5.00
Subtotal 1,334.25
Sales Tax $460.85 @ 7.2750% 33.53
Grand Total 1,367.78
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 1,367.78
PARTS PRICES SUBJECT TO CHANGE WITHOUT NOTICE. THIS ESTIMATE IS BASED ON OUR INSPECTION AND
DOESN'T COVER ADDITIONAL PARTS OR LABOR WHICH MAYBE REQUIRED AFTER THE WORK IS STARTED. OFTEN
AFTER THE WORK HAS STARTED, WORN PARTS ARE DISCOVERED WHICH ARE NOT EVIDENT ON FIRST
INSPECTION. THEREFORE THE ABOVE ARE NOT GUARANTEED.
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.
5/28/2014 9:14:38 AM 028638 Page 3
_ , . Preliminary Estimate
Customer: HANNASCH,JACQUELINE
Vehicle: 2007 CHEV MALIBU LS 4D SED 4-2.2L-FI GRAY
Estimate based on MOTOR CRASH ESl"IMATING GUIDE. Unless otherwise noted all items are derived from the Guide
DR1CP04, CCC Data Date 4/1/2014, 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 Z014 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 Replac2. 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.
5/28/2014 9:14:38 AM 028638 Page 4