Bonilla, Silvia F�E�EI�/��
1�10TICE O� CI.AIIVI FO�11VI t� the Ci�y of S���t �a�l, I�i�a��st��� 1� 2�1�
Nlin��esota.State Statute 466.05 states thnt "...eveiy persai...tivl�o claims�Inr��ages,fro»2 any ni�uxfcipa.lrry...slinll ca�ase to b�i�►��sbntF.cl yd'f/����
gover�2hlg body of the»�au�ieipality tivitlai�2 780 dm�s after the allegect loss or injury is discovered a notiee sinting the tinle,E�lnce,cmd
circu»zstcnzces thereof, m�d tlie an��our�t of comperzsation or other reGief demn�ided."
Ptease complete this foc•m in its entirety by clearly iyping or printing your answer to each question. If more space is
needed,attach additional shcets. Please note that you will not be contacted by telephone to ciarify answers,so provide as
mucli 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 cie�ending on the
natu:e of your claim. This form must be sigr.ecl,and both pages completed. If something does not apply,write`N/A'.
SEND COMPLETEI) FORM AND OTHER DOCUMENTS TO: CI�Y CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
o � �p Yl���(1�
First Name � ► �j,f t'a Middle Initial I,ast Name
Company or Business Name
Are You an Insurance Company? Yes/ lo If Yes, Claim Number?
Street Address �{�1 .us�
Ciry��j� 5� ��` State�_ Zip Code SSU��
Daytime Phone (��)�-�Cell Phone (��) � '�- �13 Evening Telephone( ) - �
i� � � �
Date of Accident/Injury or Date Discovered� Z.�? �� � Time� rf�i pm �
Please state, in detail, what occurred(happened), and why you are submitting a claim. Please indicate why or how y lu '
teel me Lity oT Saint Yaul or its employees are involved and/or responsibie ior your damaRes.�_�._
-the, t� �u a �r�' ; m �, t -�o e n -ee her► ' d� -
�. ., er � v►�+�e�
� � , � � cl Yan����
C��_�zS (�� . � � e e
QF'� J G.�ruy. �rl�` ��-CCti111 1'�(`I\lE L�ttYL�V�"TY'�C� LS� � V�C1•1•
�� S , ' .0 1l.e t�l
��ven a���-�• u� 5�''oc:`d 1�, juS� (ec�.;2 -W�G.ct i5 nvt �l��y av►b '�r�► v4� n�y� .l-��.
ease check the box(es) that most closely represent the r@ason Tor completing this form: �,d;n} .e,Jtr� c.�,s� � � ���
�1�.1VIy vehicle was damaged in an accident ❑ My vehicle was damaged during a tow v�
❑ My vehicle was dama�ed 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 injuiy—please specify
In order to process your claim you need to include copies of all applicable documents.
For the claims [ypes listed below, please be sure to include [he documents indicated or it will delay the handling of
vour clai-�. Do�:uments WILL NOT be returned and become the properxy o€the City. You are encouraged to keep a
copy for yourself before submitting your claim Torm.
O Properry damage claims to a vehicle: two estimates for the repairs to your vehicle if the damage exceeds
$500.00; ar 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 rep�iss; 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 retumed.
Page 1 of 2—Please complete and return both pages of Claim Form
Failure to complete and return both pages �vill 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)
Provide [heir names, addresses and telephone numbers.
Were the police or law enforcement called? Yes No Unknown (circle)
If ycs, what dcpartment or agency? Case#or rerort# - � �� - �
Where did the accident or injury take place? Pcovide street address, cross street, intersection, name of park or facility,
closest landmark, etc. Please be as detailed as possible. If necessary, attach a diagram. i n ,�'
Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction.T woc�ld I�K2 ��(o0U -4c: �« rmu Tt� cl< �d Z�vUU`` -�.� c� r-nr�nsa�.a1 �r►
. �: , . _ � e �
* U.«:ta r,c)-� i'3�t c��CLI, w�t1n +�;s s.hc.�C�tCYI ��. _��I d G�s� l,K.t +,� � 5�.,�►�e �t�c1t i�i .
Vehicle Claims please compl�e this section � check box if this section does not apply �"4.c.�l�y�c,
Your Vehicle: Year ZvU� Make C_L�eV�2:Le+ _Model�F�uGrSS�
License Plate Number _ State Color
Registered Owner
� Driver of Vehicle �� �
Area Damaged k \Z� '"'
City Vehicle: Year Make Mod 1
License Plate Number State Color
Driver of Vehicle (City Employee's Name)
Area Damaged
Injurv Claims please complete this section ❑ check box if this section does not app(v
How �vere you injured? �k
Wha[part(s) of your body were injured?
Have you sought medical treatment? Yes Planning to Seek Treatment(circle)
`Vhen 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 �
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 tlzis for�n,yoze are stating that all information you have provided is trice and correct to the best
of your knowledge. U�zsigned forms will not be processed.
Submitting a false claim can result in prosecaction. Date form was completed�Zq � ���
Print the Name of the Person who Completed this Form:
Signature of Person Making the Claim:
�� 1� ��'�' �� � � ��
Revised February 201 1
City of St. Paul, 1VIl�� - Official Website - Claims �abe 1 oi 1
< ;
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You are here:Home>Government>CIN Clerk>ClaimS
Appeats _. .. _ . ... _
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Clalins vYEfVI��N �
Data Practices Requests To file a daim against the City,fll out the Notice of Claim Form(PDF).Indude all proof necessary to show neg�igence on the
part of the City.
Domasllc Par�ner Regisiretlon
eieaions P.eturn your claim form to:
City Clerk
Nleelings 310 Ci[y H211
. � Vacahons of Public Lantl 15 Kellogg Blvd.,West . , . .
Saint Paul,MN 55102
The Ciry may deny any claim where the claimant cannot prove negligence.
�
Towiny Camaga
�` If you believe the towing company damaged your vehicle,call the Impound Lot at(651)266-5642 to find out which towing
`- r ` -'- company is responsible for your vehicle.
,.c.rr�'a!i� . .
., ;.. � . . ,. . � :���� '-.. , .. _ - ,
http://wtivw.stpaul.gov/index.aspx?nid=186 5/29/2014
� LaMettry's Collision, Glass and More Workfile ID: 7ac47ac5
FederalID: 41-1393089
InverGrove
"Every Customer Leaves With A Smile"
10 Mendota Road W, Inver Grove Heights, MN
55077
Phone: (651) 286-3921
FAX: (651) 286-3926
Preliminary Estimate
Customer: BONILLA, SILVIA
Written By:Team IGH LUKE THOMPSON
Insured: BONILLA,SILVIA Policy#: Claim#:
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact:
Owner: Inspection Location: Insurance Company:
BONILLA,SILVIA LaMettry's Collision,Glass and More Inver
Grove
(651)800-8642 Cell 10 Mendota Road W
Inver Grove Heights, MN 55077
Repair Facility
(651) 286-3921 Business
VEHICLE
Year: 2009 Body Style: 4D UTV VIN: iGNEV33D195108918 Mileage In:
Make: CHEV Engine: 6-3.6L-FI License: 742LGH Mileage Out:
Model: TRAVERSE 4X4 LTZ Production Date: State: MN Vehicle Out:
Color: Int: Condition: Job#:
TRANSMISSION Air Conditioning Search/Seek Bucket Seats
Automatic Transmission Intermittent Wipers Auxiliary Audio Connection Reclining/Lounge Seats
Overdrive Tilt Wheel Premium Radio Leather Seats
4 Wheel Drive Cruise Control CD Changer/Stacker Heated Seats
POWER Rear Defogger SAFETY Rear Heated Seats
Power Steering Keyless Entry Drivers Side Air Bag Ventilated Seats
Power Brakes Message Center Passenger Air Bag 3rd Row Seat
Power Windows Steering Wheel Touch Controls Anti-Lock Brakes(4) WHEELS
Power Locks Rear Window Wiper 4 Wheel Disc Brakes Aluminum/Alloy Wheels
Power Mirrors Telescopic Wheel Traction Control PAINT
Heated Mirrors Dual Air Condition Stability Control Clear Coat Paint
Power Driver Seat Navigation System Front Side Impact Air Bags ��R
Power Passenger Seat Backup Camera w/Parking Sensors Head/Curtain Air Bags Rear Spoiler
Memory Package Remote Starter Communications System Signal Integrated Mirrors
DECOR Home Link Hands Free Device Headlamp Washer
Body Side Moldings RADIO Blind Spot Detection TRUCK
Privacy Glass
AM Radio ROOF Power Trunk/Gate Release
6/11/2014 3:07:34 PM 305622 Page 1
. Preliminary Estimate
Customer: BONILLA,SILVIA
Vehicle: 2009 CHEV TRAVERSE 4X4 LTZ 4D UN 6-3.61-FI
Console/Storage FM Radio Luggage/Roof Rack
CONVENIENCE Stereo SEATS
6/11/2014 3:07:34 PM 305622 Page 2
� Preliminary Estimate
Customer: BONILLA, SILVIA
Vehicle: 2009 CHEV TRAVERSE 4X4 LTZ 4D UN 6-3.6L-FI
Line Oper Description Part Number Qty Extended Labor Paint
Price�
1 FRONT BUMPER&GRILLE
2 * <> Rpr Bumper cover 4�. 2•6
3 Add for Clear Coat 1.0
4 R&I License bracket 0•Z
5 0/H bumper assy Z•�
6 # Flex Additive 1 6.00
7 # Subl Hazardous Waste Disposal Fee 1 5.00 X
8 FRONT LAMPS
9 Repl RT Signal lamp assy 20794798 1 153.10 0.2
10 # Refn Tint Color 0.5
SUBTOTALS 164.10 6.4 4.1
ESTIMATE TOTALS
Category Basis Rate Cost�
Pa� 159.10
Body Labor 6.4 hrs @ $56.00/hr 358.40
Paint Labor 4.1 hrs @ $56.00/hr 229.60
Paint Supplies 4.1 hrs @ $38.00/hr 155.80
Body Supplies 4.2 hrs @ $2.00/hr_ 8.40
Miscellaneous 5.00
Subtotal 916.30
Sales Tax $323.30 @ 7.1250% 23.04
Grand Total 939.34
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 939.34
THIS REPORT IS AN ESTIMATE, BASED ON OUR INITIAL INSPECTION AND DOES NOT COVER ADDITIONAL PARTS
OR LABOR WHICH MAY BE REQUIRED AFTER THE WORK IS OPENED UP. PART PRICES SUBJECT TO CHANGE PER
MFGR. LIFETIME WARRANTY ON WORKMANSHIP, 30 DAYS ON WHEEL ALIGNMENTS. WARRANTY WORK MUST BE
PERFORMED BY LAMETTRY'S COLLISION ONLY. PARTS WARRANTIED BY THE MANUFACTURER. NO
WARRANTY ON RUST RESTORATION, CORROSION RESISTANCE OR REPLACEMENT RENTAL CARS. OUR REPAIR
ESTIMATED TIME DOES NOT INCLUDE INSURANCE OR PARTS DELAYS WE MAY EXPERIENCE.
MN LAW- A PERSON WHO SUBMITS AN APPLICATION O� FILES A CLAIM WITH INTENT TO DEFRAUD OR HELPS
COMMIT A FRAUD AGATI�iST AN INSIJFtER I� GUILTY OF A CRIME IN MINNESOTA.
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.
6/li/2014 3:07:34 PM 305622 Page 3
� Preliminary Estimate
Customer: BONILLA, SILVIA
Vehicle: 2009 CHEV TRAVERSE 4X4 LTZ 4D UTY 6-3.6L-FI
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
DR1GM09, CCC Data Date 6/6/2014, 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 (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:
�l'M86t�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.
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
Cf2�S+i{�'sTiM��EPtfr Gtf�fjE:
BAR=Bureau of Automotive Repair. EPA=Environmental Protection Agency. NHTSA= National Highway
Transportation and Safety Administration. PDR=Paintless Dent Repair. VIN=Vehicle Identification Number.
6/11/2014 3:07:34 PM 305622 Page 4
' ��
CASTRO'S COLLISION CENTER INC. Workfile ID: 1a6c0775
FederalID: 41-1720033
786 ROBERT ST S, SAINT PAUL, MN 55107 State ID: 16132285
Phone: (651) 291-2965 State EPA: MND98 0683429
FAX: (651) 224-0112 ucense Number: 75348
Preliminary Estimate
Customer: Bonilla,Silvia 7ob Number:
Written By:Tony Castro
Insured: Bonilla,Silvia Policy#: Claim#:
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact:
Owner: Inspection Location: Insurance Company:
Bonilla,Silvia CASTRO'S COLLISION CENTER INC.
417 l lth Ave So 786 ROBERT ST S
So St Paul, MN 55075 SAINT PAUL,MN 55307 -- �
(651)800-8643 Business Repair Facility
(651)291-2965 Day
VEHICLE
Year: 2009 Body Style: 4D UTY VIN: 1GNEV33D19S108918 Mileage In:
Make: CHEV Engine: 6-3.6L-FI License: Mileage Out:
Model: TRAVERSE 4X4 LTZ Production Date: State: Vehicle Out:
Color: Int: Condition: Job#:
TRANSMISSION Air Conditioning Search/Seek Bucket Seats
Automatic Transmission Intermittent Wipers Auxiliary Audio Connection Redining/Lounge Seats
Overdrive Tilt Wheel Premium Radio Leather Seats
4 Wheel Dnve Cruise Controi CD Changer/Stacker Heated Seats
POWER Rear Defogger SAFETY Rear Heated Seats
Power Steering Keyless Entry Drivers Side Air Bag Ventilated Seats
Power Brakes Message Center Passenger Air Bag 3rd Row Seat
Power Windows Steering Wheel Touch Controls Mti-Lock&akes(4) WHEELS
Power Laks Rear Window Wiper 4 Wheel Disc Brakes Aluminum/Alloy Wheels
Power Mirrors Telescopic Wheel Traction Control PAINT
Heated Mirrors Dual Air Condition Stability Control Clear Coat Paint
Power Driver Seat Navigation System Front Side Impact Air Bags OTHER
Power Passenger Seat Backup Camera w/Parking Sensors Head/Curtain Air Bags Rear Spoiler
Memory Package Remote Starter Communications System Signal Integrated Mirrors
DECOR Home Link Hands Free Device Headlamp Washer
Body Side Moldings RADIO Blind Spot Detection TRUCK
Privacy Glass AM Radio ROOF Power Trunk/Gate Release
Console/Storage FM Radio Luggage/Roof Rack
CONVENIENCE Stereo SEATS
6/5/2014 11:16:16 AM 011444 Page 1
Preliminary Estimate
Customer: Bonilla,Silvia 7ob Number:
Vehicle: 2009 CHEV TRAVERSE 4X4 LlZ 4D UTV 6-3.6L-FI
Line Oper Description Part Number Qty Ertended Labor Paint
Price;
1 FRONT BUMPER 8�GRILLE
2 * Rpr Bumper cover � 2.6
3 Add for Clear Coat 1.0
4 0/H bumper assy 2.0
5 Repl Air deflector 25973905 1 49.68 Incl.
6 Repi Lower cover 25912430 1 304.92 Incl.
7 FRONT LAMPS
8 Repl RT Signal lamp assy 20794798 1 153.10 0.2
9 R&I RT Headlamp assy w/o projector 0.5
tYpe
Note: For Bumper R&I '
10 R&I LT Headlamp assy w/o projector 0.5
type
11 R&I LT Signal lamp assy 0.2
12 FENDER
13 Repl RT Fender liner screw 11570637 2 7.02
Note: Due to the Accident liner is missing screws
14 Repl RT Fender liner retainer 21030249 2 2.68
15 # Hazard Waste 1 4.00 X
16 # Flex 1 5.00
17 #
18 # *Possible hidden Damage after 1
tear down
SUBTOTALS 526.40 6.4 3.6
ESTIMATE TOTALS
Category Basis Rate Cost�
Parts 522.40
Body Labor 6.4 hrs @ $54.00/hr 345.60
Paint Labor 3.6 hrs @ $54.00/hr 194.40
p�t�pp�i� '3.6 hrs @ $32.00/hr 115.20
Miscellaneous 4.00
Subtotal 1,181.60
Sales Tax $637.60 @ 7.6250% 48.62
Grand Total 1,230.22
MN 5T 60A.955 - A PERSON WHO FILES A CLAIM WITH INTEIVT TO DEFRAUD OR HELPS COMMIT A FRAUD
AGAINST AN INSURER IS GUILTY OF A CRIME.
6/5/2014 11:16:16 AM 011444 Page 2