Egal, Mariam � � REC�I�J�D
NOTICE OF CLAIM FORM to the City of Saint Paul, Minneso�a 12 ����
Minnesota State Statute 466.05 states that"...every pe.rson...who claimr damages from any+nunicipaliry...sholl cause tob�brl�sehtedfU��' `
governing body o(the municipality within 180 days a(ter the aUeged loss or injury is discovered a notice stating the time,place,and
circurn,ttances thereof,and the amount of compensation or othet•re[ief demat�ded."
Please co,mplete this form in its entirety by cleariy typing or printing your answer to each questlon. 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 o[compensation being requested. You will receive a
written acknowledgement once yo�r fnrm is received. The process can take up to ten weeks or longer depending on the
nature of your claitn. Tlils form must be signed,and both pages completed. If something does not appty,write`N/A'.
SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERIi,
15 WEST KELLOGG BLVD,310 CITY HALL, SAINT PAUL,MN 55102
First Name � ��1�1"1 Middle Initial� Last lVame L I
Company or Business Name
Are You an Insurance Company? Yes/�If Yes,Claim Number?
Street Address �.��d ��:L i���'.1l� �Q-V� /`'� � � ,� ��
;.,.,�./� �
City _ 'L State �� 7,ip Code_��j' �
Daytime Phone(�����ell Phone(�)�-�Evening1 Tcicphone(�)���►�
Date of AccidenU Inj ury or Date Discovered � �� � Time �� am/ e�i �
C�
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 iis employees are involved and/or responsible for your damages.
t: ��, � �r �n�. 4tY�
.
v� ,� v r� � �, � vh y
: , ��
{ � � � �
Ple se check the Uox(es)that mosl closely represent the reason for complering this form: �"� �e��' � �en
�Iy vehicle was damaged in an accident � My vehicle was damaged during a tow
0 My vehicle was damaged by a pothole or condition of the street U My vehicle was damaged by a plow
U My vehicle was wror�gfully lowed and/or ticketed � I was injured on City property
0 Other type of property damage—please specify
� Other type of injury—please specify
In order to process your claim vou need to include coaies of all apalicable documents.
For the claims types listed below,plea�e he 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.
0 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
0 Towing claims:legible copies of any ticket issued and a copy of the irnpound lot receipt
0 Other pro�erty 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
� Injury claims: medical bills,receipts
� 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 will result in delay in the handling of your claim.
All Claims—olease comnlete this section
Were there witnesses to the incident? Yes No Unknown circle)
Provide their names,addresses and telephone numbers:
r
Were the police or law enforcement called? es No Unlrnown (ci rcle)
If yes,what department or agency? �. Case# r re rt �j,��3 �
� ; � , � av f . � .
Where did the accident or injury tak� lace? Provide stre�et�addres ,c�ss s�treet, intersection,name of park or facility,
closest andmark,etc. Please be as detailed as sible. . n ess� ,'a ac. a dia ram. �
Po �► B
, ,
Please indicate the amount you ar s ekin i compensat'on or what yo would like the C' to do to r olve this lai��
to your.,satisfaction. � ' � ��- ' ��
, � _
Vehicle Claims— lease com lete this section if this section does not a 1 �
Your Vehicle: Year Make� �_Model '
License Plate Number. � State�Color '
Registered Owner
Driver of Vehicle
Area Damaged i � ' �n � �
City Vehicle: Year Make Model �
License Plate Number State Color_ �'
Driver of Vehicle(City Employee's Name) �
Area Damaged
I
In'ur Ciaims— lease com lete this sectfon 0 check box if this section does not a 1 I
How were you injured? �'
What part(s)of your body were injured?
Have you sought medical treatment? Yes No Plannin o Seek Treat nt(circle)
When did you receive treatment? (provide date(s))
Name of Medical Provider(s): '
Address Telephone
Did you miss worlc as a result of your injury? Ycs 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 additionat pages
By signing this forin, you are siating that all information you have provided is true and correet to the best
o%your knowledge. Unsigned forms will not be proeessed.
Submitting a False claim can result in prosecution. Date form was completed
Print the Name of the Person who Completed this Furm: /\.�� `v' � �'
Signature of Person Making the Claim�
Revised February 2011
�Accident Report Yage 1 ot 1
,
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O1 EGAL MARIAM OSMAN N City of St Paul (Eire) N 01
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O1 2520 SILVER LN NE APT 207 N. ' 759 Randolph Ave � 90
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�ttps.//dvscrash.x.state.mn.us/dvsinfo/aecidentnecords_2008/Includes_LE/Pnn"tDVSReportl� 8/6/2014
ABRA Auto Body &Glass - Fridley �Norkfile[D: e5622da2
FederalID: 41-1942823
Right the First Time...On Time
7710 UNIVERSITY AVE NE, FRIDLEY, MN 55432
Phone: (763) 5741610
FAX: (763) 574-1502
Preliminary Estimate
Customer:EGAL, MARIAM 7ob Numtier:
Written 8y:RobeR Mahowald
Insured: EGAL,MARIAM Policy#: Claim#: 0
Type of Loss: Date of Loss: 8/11/2014 12:00:00 PM Days to Repair: 0
Polnt of Impact: Ol Rlght front
p��; Inspection Location: Insurance tompany:
EGAL,MARIAM ABRA Auto Body&Glass-Fridley CUSTOMER PAY
2520 SILVER LN NE 7710 UNNERSITY AVE NE '
CHANHASSEN,MN 55421 FRIDLEY, MN 55432
(404)514-3942 Busi�ess Repair Facility
(763)574-1610 Business
VEHICLE
Year: 2001 Body Style: 4D SEO VIN: 4T16G22K91U016086 Mileage In: 0
Make: TOYO Engine: 4-2.2L-FI License: 748KLE Mileage Out:
Model: CAMRY LE Production Date: 9/2Q00 State: MN Vehide Out: I
Color: BIACK Int: Condition: �ob��
TRANSMISSION Dual Mirrors AM Radio C�oth Seats
Automatic Transmission Body Side Moldings FM Radio Bucket Seats
Overdrive Console/Storage Stereo Redining/Lounge Seats
POWER CONVENIENCE Search/Seek WHEELS
Power Steering Air Condidoning CD Player Wheel Covers '
Power Brekes Intermittent Wipers Cassette P��'1�
Power Windows Tilt Wheel SAFETY Clear Coat Paint
Power Locks Guise Control Drivers Side Air Bag OTHER
Power Mirrors Rear Defogger Passenger Air Bag Power Trunk/Gate Release
DECOR RADIO SEATS
8/11/2014 3:15:55 PM 011413 Page 1
Preliminary Estimate
Customer: EGAL, MARIAM lob Number:
Vehide:2001 TOYO CAMRY LE 4D SED 4-2.2L-FI BLACK
Line Oper Description Part Number Qty Extended Labor Paint
Price;
1 FRONT BUMPER
2 ** Repl A/M CAPA Bumper cover 52119AA902 1 228.00 1.8 2.8
3 Add for Clear Coat 1.1
_.. .__-----------------------------___-__...----------------�-------..�__.._-----------.._...._._----------------- -- ---- ---------.-.__�___
4 FRONT LAMPS
S ** Repl A/M CAPA RT Signal lamp assy 81510AA020 1 81.00 Incl.
._,____._.-----------.----------------------------____._._._..___..___.._.._._.._.._____..._.__._....__..__--------._.._..__T---------.-------.___,_.__..__.,_....-
6 FENDER
7 ** Repl A/M CAPA RT Fender 53811AA020 1 168.00 2.0 2.0
8 Add for Clear Coat o.8
9 Add for Edging 0.5 '
10 Deduct for Overlap -0.4
il Repl RT Body side mldg US built 75623AA902 1 19.11 0.2 0.3
12 Add for Clear Coat 0.1
13 # Repl �Flex Additive/Adhesion Promoter 1 8.50 T
_�_..___�_�.-------._.._______.�.._____......__.._�__....____-°.__.._...._..__._..._..�.__._._.......,.._.�.______.__.._...___..__.__._,.,---_______....__._..._._M_.____.._.._...._�_....,_�_-----.
14 MISCELlANEOUS OPERATIONS
15 # �Hazardous Waste 1 5.00 X
SUBTOTALS 509.61 3.6 7.6
ESTIMATE TOTALS
Category Basis Rate Cost;
Parts 496.11
Body Labor 3.6 hrs @ y 56.00/hr 201.60
Paint Labor 7.6 hrs @ $56.00/hr 425.60
Paint Supplies 7.6 hrs @ $36.00/hr 273.60
Miscellaneous 13.50
Subtotal 1,410.41
Sales Tax $778.21 @ 7.1250% 55.45
Grand Total 1,465.86
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 1,465.86
�
THIS IS A VISUAL INSPECTION ONLY. THERE MAY BE ADDITIONAL DAMAGE AFTER DISASSEMBLY. PARTS ARE
SUB]ECT 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 Sf 60A.955 -A PERSON WHO FILES A CLAIM WIfH INTENT TO DEFRAUD OR HELPS COMMIT A FRAUD
AGAINST AN INSURER IS GUILTY OF A CRIME.
8/il/2014 3:15:55 PM 011413 Page 2
Preliminary Estimate
Customer: EGAL, MARIAM 7ob Number:
Vehicle:2001 TOYO CAMRY LE 4D SED 4-2.2L-FI BLACK
Estimate based on MOTOR CRASH ESTIMAIING GUIDE. Unless otherwise noted all items are derived from the Guide
AEM8509, CCC Data Date 7/10/2014, and the parts selected are OEM-parts manufactured by the vehides Original
Equipment Manufacturer. OEM parts are available at OE/Vehicle dealerships. OPT OEM (Optional OEM)or ALT OEM
(ARemative 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 same 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-Induded
Labor operations. The symbol (<>) indicates the refinish operation WILL NOT be performed as a separate procedure
frorn 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 p�ovided 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 (#) iterns indicate manual entries.
Some 2015 vehicles contain minor changes from the previous year. For those vehides, 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 conflrmed wlth 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 replaoed:
SYMBOLS FOLLOWING PART PRICE:
m=MOTOR Mechanical component. s=MOTOR Strudural 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=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 Intemational Certi�ed Part. 0/H-Overhaul. Qty=Quantity. Refn=Refinish. Repl=Replace.
R&I=Remove and Install. R&R=Remove and Replace. Rpr=Repair. RT=Right. SA5=5andwiched 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 rnay 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 Safery Administration. PDR=Paintless Dent Repair. VIN=Vehicle Identification Number.
8/11/2014 3:15:55 PM 011413 Page 3
�n •V
Preliminary Estimate
Customer:EGAL, MARIAM ]ob Number:
Vehicle: 2001 TOYO CAMRY LE 4D SED 4-2.2L-FI BLACK
ALTERNATE PARTS SUPPLIERS
Line Supplier Description Price
2 Keystone-Insurance-A-Minneapolis #T01000206C �228.00
3615 MARSHALL STREET NE A/M CAPA Bumper cover
MINNEAPOLIS MN 55418
(800)328-1845
(612)789-1919
5 Keystone-Insurance-A-Minneapolis #T02531136C �81.00
3615 MARSHALL STREET NE A/M CAPA RT$ignal lamp assy
MINNEAPOLIS MN 55418
(800)328-1845
(612)789-1919
7 Keystone- P+A-Minneapolis #T01241162C �168.00
3615 MARSHALL STREET NE A/M CAPA RT Fender
MINNEAPOLIS MN 55418
(800)328-1845
(612)789-1919
i
i
8/11/2014 3:15:55 PM 011413 Page 4
4 ,
BARAN►A AVTO CENTER �
100 5th St. NE Minneapolis, MN 55413
ESTIMATE ONLY
Name: Mariam Egal Mileage: Date: 8/11/14
Address: Make/Model: Toyota RO#
City,State,Zip: Camry LE Tirne Promised:
Phone Number:404-514- Year: 2001 Keep Old Parts:
3942 License: 748 KLE Payment Method:
Engine:
Vin #: 4�1BG22K91U016086
Customer Comments i
o- �
PARTS
Description Qty Labor Price
Front Bumper Cover 1 1.0 $185.69
Right Fender 1 .75 $115.35
Right Headlight 1 .50 $130.25
Right Signal Light 1 .50 $89.50
Front Bumper Rebar 1 .75 $125.69
Total 5 3.5 $646.48
LABOR HOU RS
Description Labor Price($69/hr)
Paint Front Bumper Cover and Fender 2.5 172.50
Replace Parts 3.5 241.50
Totals 6.0 414.00
r .
GRAND TOTAL
Description Price
Parts Total $646.48
Labor Total $414.00
PainUClear Coat and Supplies $475.00
Disposal Fee $25.00
Subtotal $1560.48
Tax(7.775% of Parts) $50.26
$1610.74
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