Najmuddin, Ali REC�IVED
JUN 2� 2014
CITY CLERK
NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minnesota State Statute 466.05 states t3uit"...every persnn...wlu�claims damages from any municipality...shall cause tn be presented to the
governing body of the municipality within 180 days after the alleged loss or injury is discovered a norice stating rhe time,place,and
circumstances thereot;and the amount oj'compensation or other relief demanded."
Piease 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 pmvide as
much information as necessary to e�lain your claim,and the amount of compensation being requested. You will receive a
written acknowledgement once your form is received. The process can take np to ten weeks or longer depending on the
nature of your ciaim. This form must be signed,and both pages completed. If something dces 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
i I ,
First Name� Middle Initial Last Name � Q�1Y1
Company or Business Name —� j
Are You an Insurance Company? Yes/� If Yes,Claim Number?
Street Address��,-�i/� �. � �i'V
City � State_� Zip Code��l y
Daytime Phone(_) - Cell Phone(�]�Z-�Evening Telephone(_) -
Date of Accidend Injury or ate Discovere t��l �1� Time •_q'�i� am/p�i
Please state,in detail,what occuned(happened),and why you are submitting a claim.Please indicate why or how you
feel the ity of Saint Paul or its emplo ees ar involved and/or res nsible for your d ages.
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Please check the box(es)that most closely represent the reason for completin �s form:
❑My vehicle was damaged in an accident y 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
❑ My vehicle was wrongfully towed and/or ticketed ❑I was injured on City property
❑Other type of property damage—please specify
0 Other type of injury—please specify
In order to process your claim You 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 WII.L 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 Otl�er 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 documerit 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-ulease comulete this section
Were there witnesses to the incident? Yes No Unlrnow (circle)
Provide their names,addresses and telephone numbers:
Were the police or law enforcement called? Yes No Unl�ow (circle)
If yes,what department or agency? Case #
Where did the accident or injury take piace? Provide street address,cross street,intersectio�namG of park c�r facility>
closest landmark,etc. Please be as detailed as possible. Lf necessary,attach a diagram.�d �'t���
Please indicate the amount ou e s 'ng in compensatif�n or what yo would like the City to do to resolve this claim
to your sadsfac 'on. s , �S � �'l( .P' a���- � 4w` ��
�W�. � 1� W�^4. Zr
i
Vehicle Claims- lease com lete this section ❑check box if this section does not a I
Your Vehicle: Year�_Make o Model
License Plate Number Z - - tate�Color � _
Registered Owner � a d�`
Driver of Vehicle
Area Damaged ?1rv' �'n��-� v'
City Vehicle: Year Make —�Mode1
License Plate Number _ State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
In.iurv Claims please com�lete this section check box if this section dces not anvlv
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 of your Employer:
Address Telephone
❑Check here if you are attaching more pages to this claim form. Number of addifional pages
By signing this form,you are stating that all inforination you have provided is true and correct to the best
of your knowledge. Unsigned forms wiU not be processed.
Submitting a false claim can result in prosecution. Date form was completed �/2��
� �
Print the Name of the Person who Completed this o �
, �
Signature of Person Making the Claim: c
Revised Febmary 2011 /
FREEWAY AUTO BODY� INC. Workfile ID: 9f5683db
FederalID: 411476560
229 SNELLING AVE N, SAINT PAUL, MN 55104 State ID: 7298792
Phone: (651) 646-7389
FAX: (651) 646-5384
Preliminary Estimate
Customer: NA]MUDDIN,ALI )ob Number:
Written By: MIKE OSTERMAN
Insured: NAJMUDDIN,ALI Policy#: Claim #:
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact:
Owner: Inspection Location: Insurance Company:
NA]MUDDIN,ALI FREEWAY AUTO BODY,INC.
229 SNELLING AVE N
SAINT PAUL,MN 55104
Repair Facility
(651)646-7389 Day
VEHICLE
Year: 2009 Body Style: 4D SED VIN: Mileage In:
Make: VW Engine: 4-2.OL-TD License: Mileage Out:
Niodei: JFTTA TDI Production Date: State: Vehicle Out:
Color. Int: Condition: Jcb#:
TRANSMISSION CONVENIENCE FM Radio Head/Curtain Air Bags
Overdrive Air Conditioning Stereo SEATS
6 Speed Transmission Intermittent Wipers Search/Seek Bucket Seats
POWER Tilt Wheel Auxiliary Audio Connection Heated Seats
Power Steering Cruise Control Premium Radio WHEELS
Power Brakes Rear Defogger Satellite Radio Aluminum/Alloy Wheels
Power Windows Keyless Entry CD Changer/Stacker PAINT
Power Locks Alarm SAFETY Clear Coat Paint
Power Mirrors Message Center Drivers Side Air Bag OTHER
Heated Mirrors Steering Wheel Touch Controls Passenger Air Bag Traction Control
Power Driver Seat Telescopic Wheel Anti-Lock Brakes(4) Stability Control
DECOR RADIO 4 Wheel Disc Brakes Signal Integrated Mirrors
Dual Mirrors AM Radio Front Side Impact Air Bags Power Trunk/Gate Release
6/4/2014 5:19:18 PM 030101 Page 1
Preliminary Estimate
Customer: NA]MUDDIN,ALI ]ob Number:
Vehicle: 2009 VW]ETTA TDI 4D SED 4-2.OL-TD
Line Oper Description Part Number Qty E�ctended Labor Paint
Price$
1 REAR BUMPER
2 R&I R&I bumper cover 0.8
3 Repl Spoiler w/o GLI iK5807521GRU 1 257.40 0.6 1.0
4 Add for Clear Coat 0.4
5 # HAZARDOUS WASTE 1 5.00 X
6 # FLIX ADDITIVE 1 6.00 X
7 # TINT PAINT TO MATCH 1 0.5 0.5
SUBTOTALS 268.40 1.9 1.9
ESTIMATE TOTALS
Category Basis Rate Cost$
Parts 257.40
Body Labor 1.9 hrs @ $52.00/hr 98.80
Paint Labor 1.9 hrs @ $52.00/hr 98.80
Paint Supplies 1.9 hrs @ $32.00/hr 60.80
Miscellaneous 11.00
Subtotal 526.80
Sales Tax $318.20 @ 7.6250% 24.26
Grand Total 551.06
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 551.06
THIS IS A VISUAL ESTIMATE ONLY. ADDITIONAL PARTS AND LABOR MAY BE REQUIRED UPON VEHICLE TEAR
DOWN. PARTS PRICES SUBJECT TO INVOICE. FREEWAY AUTO BODY OFFERS A LIMITED LIFE TIME WARRANTY ON
REPAIR WORKMANSHIP AND REFINISHING FOR AS LONG AS YOU OWN YOUR VEHICLE. NO WARRAN7Y FOR RUST
REPAIRS WILL APPLY. PLEASE FEEL FREE TO CONTACT THE MANAGEMENT OF FREEWAY AUTO BODY WITH ANY
QUESTIONS.
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.
6/4/2014 5:19:18 PM 030101 Page 2
ABRA Auto Body &Glass - Midway W�file ID: 8b3bOcdf
FederalID: 41-1852119
Right The First Time...On Time
1190 UNIVERSITY AVE W, SAINT PAUL, MN 55104
Phone: (651)645-1563
FAX: (651) 641-6129
Preliminary Estimate
Customer: NA7MUDDIN,ALI )ob Number:
Written By:John Rucinski
Insured: NA]MUDDIN,ALi Policy#: Claim#: 1
Type of Loss: Date of Loss: 6/5/2014 12:00:00 PM Days to Repair: 2
Pant of Impact: 06 Rear
pyvner; Inspection Location: Insurance Company:
NA7MUDDIN,ALI ABRA Auto Body&Glass�-Midway CUSTOMER PAY
1419 GRAND AVE#1 1190 UNNERSITY AVE W
ST.PAUL,MN 55105 SAINT PAUL,MN 55104
(651)757-8419 Business Repair Facility
(651)645-1563 Business
VEHICLE
Year: 2009 Body Style: 4D SED VIN: 3VWRL71KK9Mi53791 Mileage In: 555555
Make: VW Engine: 42.OL-TD License: 279crz Mileage Out:
Model: JETTA TDI Production Date: 6/2009 State: MN Vehicte Out:
Color. silver Int: Condition: ]ob#:
TRANSMISSION COM/ENIEWCE FM Radio Head/Cur�in Air Bags
Overdrive Air Conditioning Stereo SEA7�
6 Speed Ttansmission Intermittent Wipers Search/Seek B�����
POWER Tilt Wheel Auxil"�ary Audio Connection Heated Seats
Power Steering Guise Control Premium Radio WHEELS
Power Brakes Rear Defogger Satellite Radio Aluminum/Alloy Wheels
Power wndows Keyless Entry CD Changer/Stadcer PAINT
Power Locks Alarm SAFETY q�ar Coat Paint
Power Mirrors Message Center Drivers Side Air Bag OTHER
Heated Mirrors Steering Wheel Touch Controls Passenger Air Bag Traction Control
Power Driver Seat Telescopic Wheel Anti-Lock Brakes(4) Stability Control
DECOR RADIO 4 Wheel Disc Brakes Signai Integrated Mirrors
Dual Mirrors AM Radio Front Side Impact Air Bags Power Trunk/Gate Release
6/5/2014 8:19:41 AM 011906 Page 1
Preliminary Estimate
Customer: NA7MUDDIN,ALI lob Number:
Vehicle:2009 VW]EfTA TDI 4D SED 42.OL-TD silver
Line Oper Descripdon Part Number Qty Extended Labor Paint
Price�
1 REAR BUMPER
2 O/H bumper assy Z•Z
3 ** Repl A/M CAPA Spoiler w/o GLI iK5807521GRU 1 209.00 Incl. 1.0
4 Add for Ciear Coat 0.4
5 # Rpr additional time to fit a/m part 1.0
6 Repl Tow eye cap w/o GlI 1K5807441GRU 1 28.46 Ind. 0.2
7 Add for Clear Coat 0.1
8 REAR LAMPS _ _
9 R&I RT Tail lamp assy 0.4
10 R&.I LT Tail lamp assy � 0.4
11 # R&I It&rt mud flaps 0.6
12 # Repl 'Flex Additive/Adhesion Pronwter 1 8.50 T
13 MISCELLANEOUS OPERATIONS . _
14 # �Hazardous Waste 1 5.00 X
SUBTOTALS 250.96 4.6 1.T
ESTIMATE TOTA4S
��jory Basis Rate Cost;
Parts 237.46
g�y��� 4.6 hrs @ $56.00/hr 257.60
Paint Labor 1.7 hrs @ $56.00/hr 95.20
Paint Supplies 1.7 hrs @ $36.00/hr 61.20
Miscellaneous 13.50
Subtotal C�r4.96
Sales Tax $307.16 @ 7.6250% 23.42
Grand Total �8•38
Deductible 0.00
CUSTOMER PAY �•�
INSURANCE PAY �8•38
THIS IS A VISUAL INSPECTTON ONLY. THERE MAY BE ADDITIONAL DAMAGE AFfER 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."
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
6/5/2014 8:19:41 AM 011906 Pa9e 2
Preliminary Estimate
Customer: NA]MUDDIN,ALI )ob Number:
Vehicle:2009 VW JETTA TDI 4D SED 4-2.OL-TD silver
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
ERA9278, CCC Data Date 6/2/2014, and the parts selected are OEM-parts manufactured by the vehicles Original
Equipment Manufacturer. OEM parts are avaiiabte at OE/Vehicle dealerships. OPT OEM (Optionai OEM) or ALT OEM
(Alternative OEM) parts are OEM parts that may be provided by or through altemate 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 altemate data source. Tilde sign (N) items indicate MOTOR Not-Induded
Labor operations. The symbol (<>) indicates the refinish operation WILL NOT be perfortned 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 Number�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 vehides 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=Afterm�rket part. BInd=6lend. BOR=Boron steel.
CAPA=Certified Automotive Parts Association. D&R=Disconrlect 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. O/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 Nighway
Transportation and Safety Administration. PDR=Paintless Dent Repair. VIN=Vehicle Identification Number.
6/5/2014 8:19:41 AM 011906 Page 3
Preliminary Estimate
Customer: NA3MUDDIN,AtI 3ob Number:
Vehicle:2009 VW JETTA TDI 4D SED 42.OL-TD silver
ALTERNATE PARTS SUPPLIERS
Suppiler: Keystone-Insuranoe-Minneapoils
location(s): 3615 MARSHALI STREET NE,MINNEAPOLIS MN 55418 (800)328-1845 (612)789-1919
Line Description Item# Prioe
3 A/M CAPA Spoiler w/o GLI VW1195102PP $209.00
I�
I
6/5/2014 8:19:41 AM 011906 Page 4