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Miller, Sarah NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota 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 is discovered a notice stating the time,place, and I circ:�mstances 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 �C r(,(�in Middle Initial I�f Last Name �i �L�� Company or Business Name Are You an Insuranc�Company? Yes No If Yes, Claim Number? Street Address �� J}i�'Y��11'1 I� �,�� City �F�l S' �I State M 1,�11� .S�� _Zip Code ��I�� Daytime Phone( ��_ - Cell Phone �'�Z �-��Evening Telephone(�'"— Date of Accident/Injury or Date Discovered ,��1 � Time � '1 15 �pm Please state, in detail,what occurred(hapnene��,and why ycu a;e subm;�ting a ciairn. Please indicate why or how you feei ii�e��rty oi Saint Paul�or its employees are involved and/or responsible f r your da ages. S �, ✓P c�.s , � � na ` -� �-, � - � c 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 0 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 You need to inciuc�e �opies 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�yo}�rself before submitting your claim form. a'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 properiy 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 wiil 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 their names,addresses and telephone umbers: v ' a, f1'�,�- S �Tt _ • Were the police or law enforcement called? Yes No Unknown (circle) If yes, what department or agency? Case#or report# Where did the accident or injury take place? Provide street address,cross street, intersection,name of ark or facility, closest landmark,etc. Please be as detailed as possible. If necgssary,attach a diagram.�Z-1� j� � pP�rn (.�o � 0�1 �L � vL 1 (.�� i�tii �IZe �rOS � �2� �a �lUc�. Please indicate the amount you are seeking in compensat'on or what you would like the City to do to resolve this claim to your satisfaction. G �- � se ' � ,� o� -�v � e�c�l I �� Vehicle Claims— lease com lete this section . ❑ check box if this section does not a 1 l�'`�j�; Your Vehicle: Year,�Z�!C� Make p� =e Model C�� License Plate Number State f�N Colo Q ,� Registered Owner p� ' Driver of Vehicle , Gl Y6i,� Area Damaged � City Vehicle: Year �04 Make ��Model License Plate Number�'�3—��"]/ State�I]�Color Driver of Vehicle(City Employee's Name)_,�r[�n ��,I I e- � ArPa Damaged I�f�_ Injury Claims—please complete this section �check box if this section does not�-,�;�v 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 csf your E�np�oyer: _ 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 information you have provided is true and correct to the best of your knowledge. Unsigned forms will not be processed. Submitting a jalse claim can result in prosecution. Date form was completed CU�/��i-�I�{ Print the Name of the Person who Completed i Form: (Sa-1�� -�,n � 1�l er- � Signature of Person Making the Claim: Revised February 201 I 1`n�1\��' �s ��7; �� .. � � • i s��. :y �° � � �. .� ;�:. � �� L . y:. {,. A's, {��4�i:, '� .,I II I I �4 'i�iX il� �I I I �� I'li i� ^�IP I I F. VVV �� _ @ gi y�'�i. � `:� `�� ' a `�I �_ �: �,�,_ �� j i � +, � '� �� P I � �� '�li III. ...� � � � ��,. ., ?�� J� �...�»� �"�; �. . � � . � � � - �� '` � � � �� z . _ ��-�� '� � ; ,. a �,. °� ��,. �,��.. �t � _ � �- � f �} �,$ � s�s ��' �.�.�� — ��: . � �,:: _ �'�� ,. � yr ��ti � � . . BEARTOWN AUTO BODY� INC. Workfile ID: 5ca55e9c FederalID: 41-1642045 2034 FLORENCE ST., WHITE BEAR LAKE, MN State ID: 26-20756 55110 Phone: (651) 426-9368 FAX: (651) 426-6323 Preliminary Estimate Customer: Miller, Sarah Job Number: Written By:JODIE SAX Insured: Miller,Sarah Policy#: Claim #: Type of Loss: Date of Loss: Days to Repair: 0 Point of Impact: Owner: Inspection Location: Insurance Company: Miller,Sarah BEARTOWN AUTO E30DY, INC. , (612)239-3052 Business 2034 FLORENCE ST.I WHifE BEAR LAKE, MN 55110 Repair Facility (651)426-9368 Business VEHICLE , Year: 2010 Body Style: 4D SED VIN: 163CC4F69AN193145 Mileage In: ', Make: DODG Engine: 4-2.4L-FI License: Mileage Out: Model: AVENGER SXT Production Date: State: Vehicle Out: Color: Int: Condition: Job#: TRANSMISSION Console/Storage AM Radio Front Side Impact Air Bags , Automatic Transmission CONVENIENCE FM Radio Head/Curtain Air Bags �� Overdrive Air Conditioning Stereo SEATS ', POWER Intermittent Wipers Search/Seek Cloth Seats Power Steering Tilt Wheel CD Player Bucket Seats Power Brakes Cruise Control Auxiliary Audio Connection WHEELS Power Windows Rear Defogger Satellite Radio Wheel Covers Power Locks Keyless Entry SAFETIf PAIN7 Power Mirrors Alarm Drivers Side Air Bag Clear Coat Paint DECOR Message Center Passenger Air Bag OTHER Dual Mirrors Telescopic Wheel Anti-Lock Brakes(4) Power Trunk/Gate Release Tinted Glass RADIO 4 Wheel Disc Brakes 6/9/2014 9:24:26 AM 073517 Page 1 Preliminary Estimate Customer: Miller, Sarah Job Number: Vehicle: 2010 DODG AVENGER SXT 4D SED 4-2.4L-FI Line Oper Description Part Number Qty Extended Labor Paint Price$ 1 FRONT BUMPER 2 ** Repl RECOND Bumper cover w/o fog 68004703AA 1 364.00 1.6 2.4 lamps 3 Add for Clear Coat 1.0 4 FRONT LAMPS 5 Repl LT Headlamp assy w/o optics 5116343AD 1 284.00 0.4 6 Aim headlamps 0.5 7 FENDER 8 Repl LT Fender 5008903AG 1 189.00 2.5 2.0 9 Add for Clear Coat p,g 10 Add for Edging i 0.5 il Deduct for Overlap -0.4 12 HOOD _ 13 Blnd Hood 1.4 14 WINDSHIELD 15 R&I RT Washer nozzle 0.2 16 R&I LT Washer nozzle 0.2 _ _ _ _ , 17 FRONT DOOR 18 Blnd LT Outer panel 1.2 19 R&I LT Belt w'strip 0.2 � 20 * R&I LT Body side mldg Q� ' 21 R&I LT Power mirror w/o foldaway 0.5 w/o heat 22 R&I LT Handle,outside w/o 0.3 'THATCHUM SECURITY"black I 23 R&I LT R&I trim panel 0.3 24 # HAZARDOUS WASTE 1 3.00 X 25 # OEM- RESTORE CORROSION 1 0.2 PROTECTION 26 # CAR COVER 1 5.00 T ' 27 # RENTAL CAR 4 days= $:27.00 1 28 # Possible hidden damage behind 1 bumper cover SUBTOTALS 845.00 6.6 9.5 6/9/2014 9:24:26 AM 073517 Page 2 � , Preliminary Estimate Customer: Miller, Sarah Job Number: Vehicle: 2010 DODG AVENGER SXT 4D SED 4-2.4L-FI ESTIMATE TOTALS Category Basis Rate Cost; Parts 837.00 Body Labor 6.6 hrs @ $52.00/hr 343.20 Paint Labor 9.5 hrs @ $52.00/hr 494.00 Paint Supplies 9.5 hrs @ $32.00/hr 304.00 Miscellaneous 8.00 Subtotal 1,986.20 Sales Tax $ 1,146.00 @ 7.1250% 81.65 Grand Total 2,067.85 Deductible 0.00 CUSTOMER PAY 0.00 INSURANCE PAY i 2,067.85 i **WE ALSO DO MECHANICAL WORK** THIS REPORT IS AN ESTIMATE ONLY, BASED ON OUR INITIAL INSPECTION AND DOES NOT ACCOUNT FOR HIDDEN OR UNSEEN DAMAGE. PARTS PRICES MAY VARY AND ARE SUBJECT TO INVOICE FROM SUPPLIERS. WARRANTY: LIFEi"IME AGAINST DEFECTS IN WORKMANSHIP. WARRANTY REPAIRS DONE BY BEARTOWN AUTO BODY ONLY. NO GUARANTEE ON RUST REPAIR OR CORROSION RESISTANCE. OUR ESTIMATED COMPLETION TIME DOES NOT INCLUDE INSURANCE OR PARTS DELAYS THAT WE MAY EXPERIENCE. 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. 6/9/2014 9:24:26 AM 073517 Page 3 • Preliminary Estimate � Customer: Miller,Sarah 7ob Number: Vehicle: 2010 DODG AVENGER SXT 4D SED 4-2.4L-FI Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide DR3PM08, 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 (�) 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 v��ith the fvAGS information are MOTOR suggested labor operation times. NAGS labor operation times are not inc�uded. 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=Efectrical 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=�uantity. 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. 6/9/2014 9:24:26 AM 073517 Page 4 y ' Preliminary Estimate Customer: Miller, Sarah ]ob Number: Vehicle: 2010 DODG AVENGER SXT 4D SED 4-2.4L-FI ALTERNATE PARTS SUPPLIERS Line Supplier Description Price 2 Keystone-Insurance-Minneapolis #CH1000919R $364.00 3615 MARSHALL STREET NE RECOND Bumper cover w/o fog lamps MINNEAPOLIS MN 55418 (800)328-1845 (612)789-1919 6/9/2014 9:24:26 AM 073517 Page 5 CLASSIC COLLISION CENTER 4061 HiGHWAY 61 WHITE BEAR LAKE, MN 55110 OFFICE:651-426-8082 FAX:651-426-0036 FEDERAL ID#41-1730876 '�"`PRELIMINARY ESTIMATE"'"` RO# 3127 06/09/2014 08:53 AM � _ _. _ _ - - - -- ------ Owner Owner: SARAH MILLER Address: 4191 SUMMIT LANE Work/Day: (612)239-3052 Home/Evening: (651)287-5078 City State Zip: White Bear Lake, MN 55110 FAX: Email: saranwrap21@yahoo.com �-------� � _. - __ _—_ — --------__.��---- Inspection Inspection Date: 06/09/2014 08:54 AM Inspection Type: Primary Impact: Left Front Comer Secondary Impact: Repairer __ _ _ _ Repairer: CLASSIC COLLISION CENTER Contact: PETER A HENLY Address: 4061 hiway 61 Work/Day: (651�26-8082 City State Zip: WHITE BEAR LAKE,MN 55110 FAX: (651�126-0036 Email: ARSCLASSIC@AOL.COM -------- -____�_..___ Vehicle 2010 Dodge Avenger Express 4 DR Sedan 4cyi Gasoline 2.4 4 Speed Automatic Lic Expire: VIN: 1B3CC4FB9AN193145 Prod Date: Mileage: 41,000 Veh Insp#: Mileage Type: Actual Condition: Code: N1563D Ext.Color: WHITE GOLD MET Int.Color: Ext.ReFnish: Two-Stage Int.Refinish: Two-Stage Ext.Paint Code: PWL Int.Trim Code: Options AM/FM CD Player Air Conditioning Alarm System Aluminum/Alloy Wheels Anti-Lock Brakes Automatic Dimming Mirror Bucket Seats Cargo/Trunk Mat Center Console Chrome Grille Cruise Control DVD Player Dual Airbags Floor Mats Fog Lights Halogen Headlights Head Airbags Heated Front Seats Heated Power Mirrors Illuminated Visor Mirror Intermittent Wipers Keyless Entry System Leather Steering Wh�el Lighted Entry System MP3 Player Power Brakes Power poor Locks Power Drivers Seat Power Steering Power Windows Rear Window Defroster Rem Trunk-UGate Release Side Airbags Sirius Satellite Radio Split Folding Rear Seat Strg Wheel Radio Control O6/09/2014 09:09 AM Page 1 of 3 2070 Dodge AvengerEupress 4 DR Sedan Claim#: O6/09/2014 08:53 AM Tachometer Tilt&Telescopic Steer Tinted Glass Velour/Cloth Seats I Da g___�.�----.___. Line Op Guide MC Description MFR.Part No. Price ADJ% B% Hours R Strines And Mouldinas 1 RI 425 MIdg,Front Door Side LT R&I Assembly 0.1 SM Front Bumoer 2 I 74 Cover,Front Bumper Repair 1.5` SM 3 L 74 13 Cover,Front Bumper Refinish 4.3 RF 3.1 SurFace 0.6 Two-stage setup 0.6 Twastage 4 RI 70 Panel,Frt Bmpr License R&I Assembly 0.1 SM �ront End Panel And Lam�s 5 E 41 01 Headlamp Assy,Halogen LT 5116203AE $270.00 0.3 SM 6 N 973 Headlamps Aim Additional Labor 0.4 SM Front Bodv And Windshield 7 BR 83 Panel,Hood Blend Refinish 1.8 RF Aluminum 1.2 Blend 0.6 Two-stage 8 RI 1052 Nozzle,W/S Washer LT R&I Assembly 0.1 SM 9 RI 1053 No�le,W/S Washer RT R 8�I Assembly 0.1 SM 10 E 103 Fender,Front LT 5008903AG $189.00 3.5 SM 11 L 103 Fender,Front LT Refinish 2.9 RF 1.9 Surface 0.5 Edge 0.5 Two-stage 12 RI 342 Guard,Fender Mud LT R&I Assembly INC SM Front Doors 13 BR 209 Pnl,Front Door Outer LT Blend Refinish 1.3 RF 0.9 Blend 0.4 Twastage 14 RI 130 MIdg,Front Door Belt LT R 8�I Assembly 1.1 SM 15 RI 229 Mirror,0uter R/C LT R&I Assembly INC SM 16 RI 237 Handle,Front Door Otr LT R&I Assembly 0.2 SM Manual Entries 17 EC M03 Flex Additive Replace Economy $5.00` RF 18 L M14 CoROSion Protection Refinish 0.3' RF 19 SB M60 Hazardous Waste Removal Sublet Repair SM 19 Items MC Message 01 CALL DEALER FOR EXACT PART#/PRICE 13 INCLUDES 0.6 HOURS FIRST PANEL TWO-STAGE ALLOWANCE Estimate Total&Entries _� _— Gross Parts $459.00 Other Parts $5.00 Page 2 of 3 O6/09/2014 09:09 AM •2010 Dodge Avenger 6cpress 4 DR Sedan Claim#: 06/09/'1014 08:53 AM Paint Materials $371.00 Parts&Material Total $835.00 Tax on Parts 8 Material @ 7.125% $59.49 Labor Rate Replace Repair Hrs Total Hrs Hrs Sheet Metal(SM) $54.00 5.5 1.9 7.4 $399.60 MechlElec(ME) $85.00 Frame(FR) $85.00 Refinish(RF) $54.00 10.6 10.6 $572.40 Paint Materials $35.00 Labor Total 18.0 Hours $972.00 Gross Total 51,866.49 Net Total E1,866.49 Alternate Parts Y/00/00/00/00/00 CUM 00/00/00/00/00 Zip Code:55110 Audatex Host Audatex Estimating 7.0.226 ES 06/09/2014 09:09 AM REL 7.0.226 DT OS/01/2014 DB 06/08/2014 Copyright(C)2013 Audatex North America,Inc. 2.7 HRS WERE ADDED TO THIS ESTIMATE BASED ON AUDATEX'S TWO�STAGE REFINISH FORMULA. Op Codes ' = User-Entered Value E = Replace OEM NG= Replace NAGS EC= Replace Economy OE= Replace PXN OE Srpls UE= Replace OE Surplus ET= Partiai Replace Labor EP= Replace PXN EU= Replace Recycled TE = Partiai Replace Price PM= Replace PXN Reman/Reblt UM= Replace Reman/Rebuilt L = Refinish PC= Replace PXN Reconditioned UC= Replace Reconditioned TT = Two-Tone SB= Sublet Repair N = Additional Labor BR= Blend Refinish I = Repair IT = Partial Repair CG= Chipguard RI = R&I Assembly P = Check AA= Appearance Allowance RP= Related Prior Damage This report contains proprietary information of Audatex and may not be disclosed to any third party(other than the insured,claimant and others on a need to know basis in order to effectuate the claims process)without 'rAudatex Audatex's prior written consent. a Solr�d cumpdny Copyright(C)2013 Audatex North America, Inc. Audatex Estimating is a trademark of Audatex North America, Inc. O6/p9/2014 09:09 AM Page 3 of 3 , � ,� , r� _ ,� ��.. ., r, _ : . - t T : ,�, n�., , . ,�'°�, , ��f � u�` q . � , n �,- � ,,_ _ �. — �� V � �� ,� � ,. � � � �. , , : �r . y�:.. ". _.. . ,.j .�: .:. � �1f �� ... :�� - .d " - �. . . � ... .... .. 't.,. .�,` . ._: . ".;.,,�-�. . � ``�"'y- '��`�.Yr . r � � �,,.-_' �\� � E � � � ` �-�`�_e z�.. � u �, � r�a�� °r�" ;'�`°� "�"� �* '"�„�.; `} s -- � �a�Y , - ,r.�� fst41E3 .. �jTt: .� �j�,,„��z ��'�"�d•,w�- �� b ";S m