Thomas, McArthur �
� � ? RECEI�I,Ep
� NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesot�L 31 2014
. ,
Minnesota State Statute 466.05 states that " ...every person...who claims damages from any municipality...shall cause to be p�Ir��the
governing body of the municipality within 180 days after the alleged loss or injury is discovered a notice stating the time, qe�a d C L���
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 may or may not be contacted by telephone to discuss your claim
circumstances,so provide as much information as necessary to explain your claim,and the amount of compensation being
requested. This form must be signed,and both page�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 ���`' �h�'I�' Middle Initial � Last Name r/�a��...5
Company or Business Name, if applicable ,
Street Address � �3 7 � ��� S �
_ �-_ _
City S �r /�/'�L1� � � State ��-� �J�/ Zip Code S / _
Daytime Telephone (� S�) 7�3-�7�� Evening Telephone L_)
Date of Accident/Injury or Date Discovered Time am/pm (circle)
Please state, in detail, what occurred, 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.
'�,�'�iG .=1/�6� �vR%y �OL��?r/�`c�/li/�0���� S�7/4�/7 ��/l�G' >G iyli?�('/; � i9i6l�i
7'4�Srv G�1/�Z� `'�� 7��/� /'/�/ 7�`1�c�i'��GLLF,�' Li/� 7�i/�'f ��rhrJ�'� 7H�= S�r7r%
7�1�4� Y-��,�� ���S'N��,° IYLia lylr
Please check the box(es)that most closely represent the reason for completing this form:
�Vehicle was damaged in an accident ❑ Vehicle was damaged during a tow
❑ Vehicle was damaged by a pothole or condition of the street ❑ Vehicle was damaged by a plow
❑ �ehicle was wrongfully towed and/or ticketed ❑ Injured on City property
❑ Otner ty�e of�operty damage-please specify
❑ Qther type of injury-please specify
❑ Other type not listed-please specify
In order to process your claim you need to include copies of all applicable documents. This is a general
guideline of what should be submitted with a claim form, but it is not all inclusive. You may be asked to
provide additional information depending on your claim. �
O Property damage claims to a vehicle: at least two estimates for the repairs to your vehicle, or the
actual bills and/or receipts for the repairs
O Towing claims: legible copies of any tickets issued and copies of the impound lot receipts
O Other property damage: repair estimates, detailed list of damaged items
O Injury claims: medical bills, receipts -
O Photographs can be provided but will not be returned.
Page 1 of 2-Please complete and return both pages of Claim Form
Failure to provide a completed claim form will result in delays in processing.
Notice of Claim Form, City of Saint Paul, page two
Atl Claims—please complete this section �
Were there witnesses to the incident? Yes No Unknown (circle)
If yes, please rovide th 'r names, addre�es and telephone numbers:
c� 1y o� s� r/�i�� ������ ti`��,�r����r� �
Were the police or law enforcement called? Y No Unknown (circle)
If yes, what department or agency? l�o L �C� � Case # or report# f Lf%�7d 6�J
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 helpful, attach a diagram.
��rr��r �!= /'r�S/� r �-q,�,s7
Please indicate the amount you are seeking in c�mpensation from this claim or what you would like the City
to do to resolve this claim to your satisfaction. //��^,�� i� 6��r �r Y �'�k
Vehicle Claims—please comulete this section ❑ check box if this section does not applv
Your Vehicle: Year ' � Make �jC�X'?/-� Model C C'rt'�c:L f�
License Plate Number Ck = State /y]yi Color /j1 G�r
Registered Owner pJc_ _ r�`J UY" �J��J�'1�S __
Driver of Vehicle��c{�i"7�i ti✓ �f�GrYl�95� - -
Area Damaged ,�'i3���F, /� �)�°.r ✓-/QG�v�
City Vehicle: Year �CG,� Make ,J��r_'y� Model L69L�
License Plate Number F/Rf 7/��IC�t' State ✓h�?i Color ��F_.�;�'
Driver of Vehicle (City Employee's Name)/1�,q e�m t LX{�w iVc;/7jF13
Area Damaged �r/�U�l/ % /°i4S5'F/1�r-rl� S�L l
Injurv Claims—nlease complete this section �check box if this section does not applv
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))
____�{am�of Medi�at 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 al[injormalion you have provided is true and correct to the best of your knowledge. Unsigned
forms wi!/ not be processed Submitting aJalse claim can result in prosecution.
Print the Name of the Person who Completed this Form: yJ�c/�r 7/���r �f7�����
Signature of Person Making the Claim: �J�l� L.�1',�i�T/l %�G��
Date form was completed 7�a I /I�'I Revised April 2007
Accident Report Page 1 of 1
,�x..�.� —• ,�.� - Ysrp��±�nr�or�r';�� �""'��'�`��., , ,.. . - -a
;h } A,.,,�� j�. „: � �� �. �g ;. r.¢,�'�:...� �; '��, �
14129260 � ,��. .��'�:y?�,"-c't�•.3� �p�! �L,.;+T!;!i`.E?..:#�;�ce:�•���,q�!1�,,..s��1+»'r r o
ri.v.oaEin ruo.nnw VFNi41F! rairo �nu�cu ��w �ji,t�i{T.L;_���"''�' �� bwam� wri reN+ ny�,hu u�unmrac c
w u �;
N Y 02 00 00 Y ,��ga;��y;','; ,o�y,�, 6 26 2014 1117 �,
GOYfC9Y91CY N0.1kM/1Nkltf%ISiPilIM4F w p.RG1NJH p I
�,„ 10 ROBERT STREET u aSa � w ��`�T�"� `" - - S'T B� CJw�`y $
cd,rmrq rraru nrrtnc.rcrw� NWIFWtf MOltE15TRFEfCp1/UMR,d1fG�Wk
62 �. ST PAUL +_ 10 9TH STREET
'� n1" �M' :'F•/' R. Y.'��r�'
�u�C(`y�•'Pl�BI110A �NIVFNIII'iMYM.Y��NI••^•' S'�1C,R.Al3 ULSI�NY' 10&TI�V 'dWfRIICLVlEW1NOM � 4 � RT�If C.��O,''ROIAIW �IIVt�
1`� O1 A501086136206 MN D O1 . O1 K231155880106 MN D O1 V1
FK^Ot2 �MMLI��fYNXIL Wi) G�ttClY+111 �MNAL�1W1.uI1M��lallT� ;L1fdMM u.l[Mt
90 MCARTHUR THOMAS 08 24 60 � NAOMI LYNN NUTTER 07 05 62 O1
ww�k ucnsu - �— p�Na-n n em�er=�mrcu wvcai �eanucr rrv.r�
O1 1837 E 3RD ST N O1 : 25 4th Street West N� O1 - OS
�kl CIfY.J1Afl�Y �GI V.SUIf IP PNY�fl
O1 ST PAUL 55119 651-783-6717 � ST PAUL 55101 65i-zz�-�eii O1
0 �"" uM '��9 ��99 6 �05 N `°�"� F �9 � �"�99 06 ���5 ��N� 01�
�ICNL M�F MUG 1Y1'f. IL�qS✓ IIMIkW(d! M'x.NANCFkFMJ�('i A.NWYVR )KGl I�PY OIIVG Mk f0110.�1` 'NN�L>05f WINNM%titllYlCT MNMWW.R
'�' 98 t�." 98 N• o�„ °I� 98 t�" 98 N oµ�a
JCCW UMCRWNE �MU ••.4MlfMN4i 'W t%XW
pl THOMAS MCARTHUR N ` City of St Paul PIre Department N O1
�Oln 837 E 3RD ST Tt3 �25 4th Street West N� 31ry�
Ycni�N .A•r.a��nu. nA,s.l dacc� a�vY�n�k.rn �uuw. dnrct �f+�wr
O1 ST PAUL MN 55119 `td' O1 ; ST Paul MN 55102 "t� 02 09
�wn�a wv.a wrxi ieu� .xarn `wrr wi.a_ � r.v c� rninc
07 TOYT UCC 199 BLU , Pier LAD 00 RED 03
uw:aw ��if• - s•oEO r..�na.. ��Kk�tM�.^� wa�wwuE�ix��fY�iC1 siiru r�w�aa ���•+���s��� � wx..w+...�.i rrccr�
02 270KME MN 5 O1 � O1 ' FIRETRUCK MN 019 O1 ' dl 02
w�r...HCC IYMY;YW`�BEl1 . MO���NR'1.iWdIA �UK.vMIYIiR
�ALLIED 918622722 � City St Paul City St Paul _ ,�
��'°C"��� w� ���'� Ky dµ�� IF ACCIDENT INVOLVED�CONMEqCIAL MOTOR VEHIGIE,9CHOOL BUS,OR MFAU START BUS w'��� �� �nK
irn nx
AEMEMBER TO NOTIF�TNE STATE PATROL(naulnd under MS 16i.7t3�nd 169.ISt1�.
;:UWItNtSNK1�.1iN11Y1FPlu'TYtI.�MM�FNruuF ' W'HU4DLi (Y1W��CWHHCLC4I,YD[P]NVIVII�JNM�LNNM! fX)TMYCA
�5������� W(hAIN WIIU W111�11lE,{ /VIL U.i! iU1YKi fJFCf WJSCI T01qSV INANY�YLII
��, �W91kNJil2 �WWCR �
❑nlh/ �
a�W NW•LNN{.L NlN/1V4YFN � )
T+
Q N Y.� 1�
�i
��' '� —"� �� W JFINY.F PoN NIVIIfR �
— �OMIM �
f.M+1iPff�'�fRnuMfCO�OKN'vu�00[W.niinWH�XJU.uGtUNNM'lX'/�MMlfivi�i�lw'Iw1a1M11F�y IfNMC.f0�11MfR'Y�VCUOY+'MYMiW.M O
�.('rl�+` .GI '�� NVLU'M1L � �� � � � _� ..L .S KNC�
T
' `�
� ' QL
I � � �
oi :� (� �I � J .
�`'"�"" ` Both vehicles were NB on Robect Street }�
Q3 ;�' `~�s� approaching�9th Street to make rlqht turns ��, ��
""�^"' ,� r Vehicle M2 was a FiXe I.adder Truck requirinq a � O1
O1 - - - ^� �^ — � wide [urn and was not aware that Vehicletll was ,#
aown.� � driving up on the right side ir� right lane ^*"r'
N �j � The two vehicles collided as they attempted to j� 04
;,,��,w�� — _ make the right turns � „f�¢
98 �� _ _ _ '�i },J��. VehY2, Fire Ladder Trucki08
� �,, did have a crew inside the truck Q
�4`„�w. �'� No injuries ��"*""'""'
wwo-k� � � '� �1
FWkUFNI � � �i WlAlliM f
I �� � ' •.
.�„-, l I �� ; � � O 1
OS � ��
�„�� .,� � � ' O1
O 1 � :�c,•v sr� � � � ^ "•ON't
�, ,f� � �
,��,� N r. ,�
02 � r � 02
CffIGLARU.KIMYCNlD�VG[• Y /�'� MfIW 5TA'R"1 �NA'LMM0. L(YN
Police Officer Lori Hayne 937 St Paul PD p„w.��, p��,.a �
https.//dvscrash.x.state.mn.us/dvsinfo/accidentrecords_2008/Includes_LE/PrintReportIndiv 6/29/2014
WINDY'S COLLISION CENTE, INC.
767 BUSH AVENUE
ST. PAUL MN 55106
PHONE: (651)774-4426 FAX: (651)772-0368
***PRELIMINARY ESTIMATE*"*
07/22/2014 03:40 PM
Owner �
Owner: MCARTHER THOMAS
Address: 1837 EAST 3RD Work/Day: (651)783-6717
City State 2ip: Saint Paul, MN 55119 FAX:
Inspection �
Inspection Date: 07/22/2014 03:40 PM Inspection Type:
Appraiser Name: JON PHILMALEE Appraiser License#:
Address: 767 BUSH AVE Work/Day: (651)774-4426
Cell: (612)237-6526
City State Zip: Saint Paul, MN 55106 � FAX: (651)772-0368
Email: THEFUMS@MSN.COM ,
,
Repairer j
Repairer: WINDY'S COLLISION CENTER Contact: JON PHILMALEE
Address: 767 BUSH AVE Work/Day: (651)774-4426
ST PAUL HomelEvening:
City State Zip: ST PAUL, MN 55106 FAX: (651)772-0368
Email: THEFUMS@MSN.COM
Vehicle a
1997 Toyota Corolla STD 4 DR Sedan
4cyl Gasoline 1.6
3 Speed Automatic
Lic.Plate: 270 KME Lic State:
Lic Expire: VIN: 1 NXBA02E6VZ632303
Veh Insp#: Mileage Type: Actual
Condition: Code: Y1164A
Ext. Refinish: Two-Stage Int. Refinish: Two-Stage
Options
Bucket Seats Dual Airbags Power Brakes
Rem Trunk-L/Gate Release Tinted Glass U.S.A. Built Vehicle
Velour/Cloth Seats
Damages �
Line Op Guide MC Description MFR.Part No. Price ADJ% B% Hours R
07/22/2014 03:48 PM Page 1 of 3
1997 Toyota Corolla STD 4 DR Sedan
Claim#: 07/22/2014 03:40 PM
Front Bumper
1 N 6 Front Bumper Cover R&I Additional Labor 1.6 SM
2 I 6 Cover,Front Bumper Repair 1.0* SM
3 L 6 13 Cover,Front Bumper Refinish 3.6 RF
2.5 Surface
0.6 Two-stage setup
0.5 Two-stage
Front End Panel And Lamos
4 EC 57 Lamp,Side Marker LT Replace Economy $25.00` INC SM
Front Bo y And Windshield
5 I 103 Fender,Front LT Repair 4.0' SM
6 L 103 Fender,Front LT Refinish 2.9 RF
2.4 Surface
0.5 Two-stage
Front Doors
7 EU 229 Mirror,0uter Standard LT Replace Recycled $35.00" +30.00 0.3 SM
8 L 229 Mirror,0uter Standard LT Refinish 0.5 RF
0.4 Surface
0.1 Two-stage
Manual Entries
9 SB M03 Flex Additive Sublet R�pair $3.50" RF
10 SB M17 Cover Car Exterior Sublet R�pair $3.50" RF
11 SB M60 Hazardous Waste Removal Sublet Repair $3.50` SM
11 Items
MC Message
13 INCLUDES 0.6 HOURS FIRST PANEL TWO-STAGE ALLOWANCE
_. _____ __. _ .__. _ _. _._ .___._.�.___..___, ._. ._��_.M._� ______
; Estimate Total&Entries
Other Parts $60.00
Paint Materials $238.00
Line Item Markup $10.50
Parts 8�Material Total $308.50
Tax on Parts&Material @ 7.625% $23.52
Labor Rate Replace Repair Hrs Total Hrs
H rs
Sheet Metal (SM) $54.00 0.3 6.6 6.9 $372.60
Mech/Elec(ME) $85.00
Frame(FR) $75.00
Refinish(RF) $54.00 7.0 7.0 $378.00
Paint Materials $34.00
Labor Total 13.9 Hours $750.60
Sublet Repairs $10.50
Gross Total $1,093.12
Net Total $7,093.72
Alternate Parts Y/00/00/00/00/00 CUM 00/00/00/00/00 Zip Code: 55106 Audatex Host
07/22/2014 03:48 PM Page 2 of 3
1997 Toyota Corol�a STO 4 DR Sedan
Claim#: 07/22/2014 03:40 PM
Audatex Estimating 7.0.226 ES 07/22/2014 03:48 PM REL 7.0.226 DT 07/01/2074 DB 07/75/2014
Copyright(C)2013 Audatex North America, Inc.
1.7 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 = Partial Replace Labor EP= Replace PXN EU = Replace Recycled
TE = Partial Replace Price PM= Replace PXN Reman/Reblt UM= Replace Reman/Rebuilt
L = Refinish PC= Replace PXN Reconditioned UC= Replase 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
�Audarex Audatex's priorwritten consent.
a Sn�rra tom�np
. Copyright(C)2013 Audatex North America, Inc.
Audatex Estimating is a trademark of Audatex North America, Inc.
07/22/2014 03:48 PM Page 3 of 3
__ _ � _F_
�I��t�"�G' ���� __.� .. -. . ,������d�
(�/����� DATE y[�_�����WORK PHONE HOME PH�IE ��� ��� �
NAME��
ADDRESS /�� � g������ � CITY ����`! .D.:
STATE �}ZIP �•�1�.
YEAR�MAKE MODEL �/�'Z./f-y�///� � I.D.NO.
PAINT CODE ' PR .DATE TRllu�' MILEAGE LICENSE NO. DATE OF LOSS
_ ,
r!r,' _
WRITTEN BY tNS.CO. FILE NO. CLAIM NO. P.O.NO.
ADJUSTER IIC.NO. PHONE Dedudible/Betterment
�`„` y� a�'i`AUt�QF "[�'.� ? €' .Pl�N�E7� = "> - . . ,
�:P�ICE �i� t���e k=A�rma�icet t�f�pM�C PI � LJ18€1R � '�t.�l`CMIS�':'
- u r -
U�Used��e1�11# � :=� "
_ X`�C1tlf � _ . � °_ :°
1 -
2
3 . a�_: _,: . - ...
. ,
� ... . ._ ._ � -
� _ � . _�
� . � ,. ,. , . �
r � r . , , _
;
; -�� � . _
�k
5
�.; ..�-�. � � -
7
� =._ ,.- , :�
-� � -
9 ` .
_ , �, _= v
� , . � ,
1i
12 �K�.,_ : . A , .�: u�; -
13
'�--^-' 15
u�� ` �" �`' x '� ,� � � �'" -
� �
<
-ri . <� ' ..� w �
x
� -'. -. r . ._.. .:. _ . '_ S�
. -.-�' .. .-
� 7. 4
�e
, 17
F_., , � _ , ,
" ' �_ �.
19 '
� �
� i � r, � �,...
2U � .�� n� �
21
'�' � �< `
23 � _ I
- �
� ��,�
25 -
� "�
��� ��°� � � �� _ �s �. � ��
-
:� �_
27 _
1 hereby authorize the above work and:adcnov�edge receipt of cop . ' TOTALS -►
P P ices subject to inwice�
Signed X D te �q�j�,�nrs.��
� Shop ies �$ -
"� � �y � � �°� PAl�i�rs.�e?��$ -
t J ;,
�� � � ��' �j �� Paint SuppRes $ �
���:�
f �.} ,. Towing/Storage $ _
�'y��l`' �'==� �.'� ry! � Sublet/MisceOaneous $
. {
j F�ene F'ben5 $
;:'%��?' ���"�E€.� ����'f��'�. �. susro�rn� $
����•, �`���� p��� ��� �t� $
; � '�����o �Va1'Y� �°'7r��a�� T� -,F�� -.............._. ........$ -/!�'�%/
�,_F 7? ,� F���F ���,'�� EPA/Waste Disposal Charge $ ��_
I � � TOTi�/�
_
UD/E/A inc.,One I/D/E/A Way,Caldwell.ID 83605-6900•CALL TOLL FREE 1-800-835-8281•ttem Vo.FR 1002
This Repc�rt is based on our inspectian and does not cover any additional parts ar labar wh:ch may be required
after ihe vvork �s opened up. Occasionally after the �+ork has started, worn or clamaged parts�re discovered which
are not evider�t or� �irst inspection.
Procuremert and deiivery charges may be added for special service on items not avaiiable locally.
Report Deposit (�Jate --_—} to be appiied to tatal cost............................,...........$ _
Photos......................................................................................................................................$
Car Rental {$ per day since -- ---)...:............................................:..$
7emporary Repair (Date _�.__Area Performed ) ..............$
___ t �,�. :�.:_� : s_ , . _:
The follawing items were inciuded in this Re�c�rt��but wer� ��;nie��by 1�ns��ance �r�in�an}� R�r�sent�tiv�*.f � - �
�
To4al Change to f�eport�----- - —{Carry This Amaunt ta Froni- * )
��WER t�F ATT�RN�Y
oat�-___ --
------�.��1�1_�4�_�tt�N_SY_THE��: 1='�c�ENTS:
__ __ _ .�._ �._ _
.�__. -
---
That the undersigned does hereby constitute and appoint _ ` �`�`
my (or our} true and i�wf�{ attorney to sign name, place and stead of the �nd�rsigned on any Insurance
Checks or Drafts issued by___� _�_ _ s {insurance Compa��y) cc�vering any repairs to
my (or our) automabile �uthorized by myseif (�r ourselv�s) in �vh�tever marner is necessary to place
check or draft in a cashable position.
I (or wej I�ereby ratify �nd confirm v�rhatever action said �it�.���r;ey sh�ll or may take by virtu� hereaf
in the premises.
�fVitness--- ---,_--- ---Assured_-- _ ___
Witness-__ _— _____..--Assurec! __ _. .___--____--------------- -----
,,�._ -
_. , g--, � . ,T _
' _ _ �l��/IAF�K���.�.�.�.,__. w;
. .: � .