Preuss, Christine ����i`.���
au� , 4 2a��
CIT'� CLE�K
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 municipa[ity within 180 days after the alleged loss or injury is discovered a notice stating the time,place,and
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 yon will not be rnntacted by telephone to clarify answers,so pmvide as
much information as necessary to explain your claim,and the amount of compensation being requested. You will receive a
written aclmowledgement 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 rnmpleted. If sometLing 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
First Name � ' Middle Initial�Last Name �rpx���
Company or Business Name
Are You an Insurance Company? es No ! If Yes,Claim umber?
Street Address �, ��J�
City State M.1 � Zip Code � �
Daytime Phone(_) - Cell Phone(�,� Evening Telephone(_) -
��4(�b�l p�
Date of Accidend Injury or Date Discovered 7°�,3--� Time O'•1� am�
Please state,in detail,what occurred(happened),and why you are submitting a claim.Please indicate why or how you
feel City of Sai Paul r its employees aze involved and/or responsible for your ages. '
� `
� �
�
. e. � f � -�-
Pleas eck the box(es)that most closely represent the reason for completing this form:
;,0'1Giy vehicle was damaged in an accident O My 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
0 My vehicle was wrongfully towed and/or ticketed ❑I was injured on City property
❑ Other rype of propeity damage—please specify
❑Other type of injury—please specify
In order to process your claim vou need to include conies of all analicable 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 Other 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 aze 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 will resalt in delay in the handling of your claim.
All Claims-alease comnlete this section -.,,�
Were there witnesses to the incident? Yes No Unknow (circle)
Provide their names,addresses and telephone numbers:
Were the police or law enforcement called? Y,s � No Unknown (circle)
If yes,what department or agency? � '� Case#or report#�y - f��d�c�
Where did the accident or injury take place? Provide street address,cross street,in[ersection, ame of�,�p�k.�or faci�lit�'»,
close dmark,etc. Please be as de ' ed asp�?ssi_ble. If nece,�Y,attach a diagram. �„�(=`'�3"�(� Ot
�� �- � ��.�1 �'{�'/1 u j.
Please indicate the amo t you are seekin in compensation or what ou would like the Ci to do to reso e this claim
to your satisfaction. 3 '
Vehicle Claims- lease com lete t6is se tion ❑check box if this section does not a 1
Your Vehicle: Year Make Model
License Plate Number tate Yl C lor
Registered Owner
Driver of Vehicle \
Area Damaged � �.- �J
Ciry Vehicle: Year Make Model
License Plate Number j tate Color � ����
Driver of Vehicle(City Employee's Name (�
Area Damaged � �� �.•�,
Iniurv Claims-Ulease complete this section ❑check box if this section does not avalv �C�.�'
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 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.
Submittireg a false claim can result in prosecution. Date form was completed � � ' �
Print the Name of the Person who Completed t ' Form:
�
Signature of Person Making the Claim: �-
Revised February 2011
HIGHLAND AUTOSTAR COLLISION CENTER
2042 WEST 7TH ST.
ST. PAUL, MN 55116
OFFICE:651-699-0340 FAX: 651-699-4953
FED TAX ID#41-1828627
**`PRELIMINARY ESTIMATE*'*
08/12/2014 05:23 PM
Owner
Owner: CHRISTINE PREUSS
Address: 1609 WOODBRIDGE ST Work/Day: (651)592-4669
City State Zip: Saint Paul, MN 55117 FAX:
Email: PREUSSCHRISTINEII @GMAIL.COM
Inspection
Inspection Date: 08/12/2014 05:23 PM Inspection Type:
Primary Impact: Left Front Corner Secondary Impact:
Appraiser Name: LAWRENCE RITTER Appraiser License#:
Address: 2042 W 7TH ST Work/Day: (651)699-0340
City State Zip: Saint Paul, MN 551 1 6-31 07 FAX: (651)699-4953
Email: LARRY@HIGHLANDAUTOSTAR.COM
Repairer
HIGHLAND AUTOSTAR Contact: HIGHLAND AUTOSTAR
Repairer:COLLISION COLLISION
Address: 2042 7TH ST W Work/Day: (651)699-0340
City State Zip: ST PAUL, MN 55116-3107 FAX: (651)699-4953
Email: HA2042@HIGHLANDAUTOSTAR.COM
Vehicle ;
2004 Chevrolet Impala STD 4 DR Sedan
6cyl Gasoline 3.4
4 Speed Automatic
Lic.Plate: 860 AMP Lic State: MN
Lic Expire: VIN: 2G1 WF52E649167420
Prod Date: 09/2003 Mileage:
Veh Insp#: Mileage Type: Actual
Condition: Code: U4163A
Ext.Color: GREY Int.Color:
Ext. Refinish: Two-Stage Int.Refinish: Two-Stage
Options -AudaVIN Information Received
AM/FM Stereo Tape Air Conditioning Alarm System
Dual Airbags Intermittent Wipers Keyless Entry System
Lighted Entry System Power Brakes Power poor Locks
Power Mirrors Power Steering Power Windows
Rear Window Defroster Rem Trunk-UGate Release Split Front Bench Seat
Tachometer Tilt Steering Wheel Tinted Glass
Velour/Cloth Seats Wood Interior Trim
Page 1 of 3
08/12/2014 0526 PM
2004 Chevrolet Impala STD 4 DR Sedan
Claim#: 08/12/2074 0523 PM
AudaVIN options are listed in bold-italic fonts
Damages
Line Op Guide MC Description MFR.Part No. Price ADJ% B% Hours R
Strines And Mouldinas
1 RI 239 MIdg,Fender Side LT R& I Assembly 0.1 SM
Front Bum�er
2 E 6 46 Cover,Front Bumper 12335505 GM Part $293.30 2.6 SM
3 L 6 13 Cover,Front Bumper Refinish 3.7 RF
2.6 Surface
0.6 Two-stage setup
0.5 Two-stage
4 E 18 MIdg,Frt Bumper Cover 10308765 GM Part $104.88 INC SM
Front End Panel And Lamns
5 E 41 # Headlamp Assy,Halogen LT 10356097 GM Part $262.78 INC SM
#=01,46
6 N 973 Headlamps Aim Additional Labor 0.4 SM
Front Bodv And Windshield
7 I 103 Fender,Front LT Repair 1.5' SM
»EXCLUDES ANY RUST REPAIRS
8 L 103 Fender,Front LT Refinish 2.6 RF
22 Surface
0.4 Two-stage
Manual Entries
9 SB HAZARD.WSTE. REM. Sublet Repair $6.00' SM
10 EC COVER CAR EXTERIOR Replace Economy $7.00' SM'
11 L CORROSION PROTECTION Refinish 0.3' RF
12 EC FLEX ADDITIVE Replace Economy $6.00' SM*
13 L FEATHER, PRIME, BLOCK Refinish 0.5` RF
14 SB RENTAL 3 DAYS Sublet Repair $125.00' SM'
14 Items
MC Message
01 CALL DEALER FOR EXACT PART#/PRICE
13 INCLUDES 0.6 HOURS FIRST PANEL TWO-STAGE ALLOWANCE
46 PRINTABLE ALTERNATE PARTS COMPARE
Estimate Total &Entries __
Gross Parts $660.96
Other Parts $13.00
Paint Materials $248.50
Parts&Material Total $922.46
Tax on Parts&Material C� 7.625% $70.34
Labor Rate Replace Repair Hrs Total Hrs
Hrs
Sheet Metal(SM) $56.00 2.7 1.9 4.6 $257.60
Mech/Elec(ME) $90.00
Frame(FR) $80.00
Refinish(RF) $56.00 7.1 7.1 $397.60
Paint Materials $35.00
Page 2 of 3
08/12/2014 0526 PM
2004 Chevrolet Impala STD 4 DR Sedan
Claim#: OS/12/2014 05:23 PM
Labor Total 11.7 Hours $655.20
Sublet Repairs $131.00
Gross Total $��779•�
Net Total ���779•�
Alternate Parts Y/02/00/00/02/02 CUM 02/00/00/02/02 Zip Code:55116 Default
Recycled Parts NOT REQUESTED
Audatex Estimating 7.0.226 ES 08h2/2014 05:26 PM REL 7.0.226 DT 07/01/2014 DB 08/08/2014
Copyright(C)2013 Audatex North America,Inc.
1.5 HRS WERE ADDED TO THIS ESTIMATE BASED ON AUDATEX'S TWO-STAGE REFINISH FORMULA.
YOU ARE AUTHORIZED TO MAKE THE ABOVE REPAIRS. I UNDERSTAND THAT PAYMENT IN FULL WILL BE DUE UPON RELEASE
OF
THE VEHICLE. PARTS PRICES ARE SUBJECTO TO INVOICE. I GRANT PERMISSION TO OPERATE MY VEHICLE FOR THE PURPOSE
OF
TESTING/INSPECTION. HIGHLAND AUTOSTAR IS NOT RESPONSBILE FOR LOSS OR DAMAGE TO THE VEHICLE OR ITS
CONTENTSIN
CASE OF FIRE,THEFT OR ANY CAUSE BEYOND YOUR CONTROL.AUTHORIZED
gy; DATE:
THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF ONE OR MORE CRASH PARTS
SUPPLIED BY A SOURCE OTHER THAN THE MANUFACTURER OF YOUR MOTOR VEHICLE.
WARRANTIES APPLICABLE TO THESE REPLACEMENT PARTS ARE PROVIDED BY THE PARTS
MANUFACTURER OR DISTRIBUTOR RATHER THAN BY THE MANUFACTURER OF YOUR VEHICLE.
A PERSON WHO FILES A CLAIM WITH INTENT TO DEFRAUD OR HELPS COMMIT A FRAUD
AGAINST AN INSURER IS GUILTY OF A CRIME.
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= 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 Priw 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
�' j/���eY Audatex's prior written consent.
a,a a�a i�a
:1 1C:!t'i .��:i:i4
Copyright(C)2013 Audatex North America,Inc.
Audatex Estimating is a trademark of Audatex North America, Inc.
Page 3 of 3
08/12/2014 0526 PM
I
LaMettry's Coliision, Glass and More Workfile ID: 2c7ae8c4
FederalID: 411393089
�. Maplewood
��.�,»� "Every Customer Leaves With A Smile"
2951 Maplewood Drive, Maplewood, MN 55109
Phone: (651) 766-9770
FAX: (651) 766-8660
Preliminary Estimate
Customer: Preuss, Christine
Written By: Ben Kittel
Insured: Preuss,Christine Policy#: Claim #:
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact: 11 Left Front
Owner: Inspection locatio�: Insurance Company:
Preuss,Christine LaMettry's Collision,Glass and More
Maplewood
1609 Woodbridge St 2951 Maplewood Drive
St Paul,MN 55117 Maplewood,MN 55109
(651)592-4669 Cell Repair Facility
(651)766-9770 Business
VEHICLE
Year: 2004 Body Style: 4D SED VIN: 2G1WF52E649167420 Mileage In: 101976
Make: CHEV Engine: 6-3.4L-FI License: 860AMP Mileage Out:
Model: IMPALA Production Date: State: MN Vehicle Out:
Color: grey Int: Condition: Job#:
TRANSMISSION Dual Mirrors Climate Control 4 Wheel Disc Brakes
Automatic Transmission Body Side Moldings i RADIO SEATS
Overdrive Tinted Glass AM Radio Cloth Seats
POWER CONVENIENCE FM Radio WHEELS
Power Steering Air Conditioning Stereo Wheel Covers
Power Brakes Intermittent Wipers Search/Seek PAINT
Power Windows Tilt Wheel Cassette Clear Coat Paint
Power Locks Rear Defogger SAFETY OTHER
Power Mirrors Keyless Entry Drivers Side Air Bag Power Trunk/Gate Release
DECOR Message Center Passenger Air Bag
8/9/2014 11:18:45 AM 053108 Page 1
' � Preliminary Estimate
Customer: Preuss, Christine
Vehicle: 2004 CHEV IMPALA 4D SED 6-3.4L-FI grey
Line Oper Description Part Number Qty Extended Labor Paint
Price�
1 FRONT BUMPER
2 ** Repl RECOND Bumper cover Impala 12335505 1 237.00 1.7 2.8
3 Add for Clear Coat 1.1
4 Repl Molding 10308765 1 104.88
___ _ _.. _ _.. _ _
5 FRONT LAMPS
6 ** Repl RECOND LT Headlamp assy 10356097 1 223.00 Incl.
7 Aim headlamps 0.5
_... .._ ..__._.. _..._ � . .____ . _ .. ___._ ._. s ... __ ... ._ � .... ....��_. __�.
8 FENDER
9 * Rpr LT Fender �.S 2•�
10 Add for Clear Coat 0•8
11 R&I LT Fender liner 0.4
12 # Refn Car Cover �•2
13 # Refn Corrosion Protection 0.3
14 # Flex Additive 1 6.00
15 # Subl Hazardous Waste Disposal Fee 1 5.00 X
16 #
17 # Possible Hidden Damage May Be 1
Found After Disassembly
18 # Rental Car @$30 Per Day @ 3-4 1
Days
Note: Cost based on time in shop
SUBTOTALS 575.88 4.1 7.2
ESTIMATE TOTALS
Category Basis Rate Cost$
Parts 570.88
Body Labor 4.1 hrs @ $56.00/hr 229.60
Paint Labor 7.2 hrs @ $56.00/hr 403.20
Paint Supplies 7.2 hrs @ $38.00/hr 273.60
Body Supplies 3.7 hrs @ $2.00/hr 7.40
Miscellaneous 5.00
Subtotal 1,489.68
Sales Tax $851.88 @ 7.1250% 60.70
Grand Total 1,550.38
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 1,550.38
8/9/2014 11:18:45 AM 053108 Page 2
Preliminary Estimate
Customer: Preuss, Christine
Vehicle: 2004 CHEV IMPALA 4D SED 6-3.4L-FI grey
THIS REPORT IS AND ESTIMATE ONLY, 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 THE MANUFACTURER AND AVAILABILITY.
WARRANTY: LIFEfIME AGAINST DEFECTS IN WORKMANSHIP. WARRANTY REPAIRS DONE BY LAMETTRY'S
COLLISION ONLY. NO WARRANTY ON RUST, CORROSION RESISTANCE OR REPLACEMENT RENTAL CARS.
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 GUILIY OF A CRIME.
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
DE1CB00, CCC Data Date 8/8/2014, 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 with the NAGS information are MOTOR suggested labor
operation times. NAGS labor operation times are not included. Pound sign (#) items indicate manual entries.
Some 2015 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. ParCs numbers and prices should be confirmed with the local
dealership.
The following is a list of additional abbreviations or symdols 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=Aftermarket part. BInd=Blend. 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. 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.
8/9/2014 11:18:45 AM 053108 Page 3
� Preliminary Estimate
Customer: Preuss, Christine
Vehicle: 2004 CHEV IMPALA 4D SED 6-3.4L-FI grey
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.
i
8/9/2014 11:18:45 AM 053108 Page 4
� � � Preliminary Estimate
Customer: Preuss, Christine
Vehicle: 2004 CHEV IMPALA 4D SED 6-3.4L-FI grey
ALTERNATE PARTS SUPPLIERS
Line Supplier Description Price
2 Keystone-Insurance-A-Minneapolis #GM1000619R $237.00
3615 MARSHALL STREET NE RECOND Bumper cover Impala
MINNEAPOLIS MN 55418
(800)328-1845
(612)789-1919
6 Keystone-Insurance-A-Minneapolis #GM2502248R $223.00
3615 MARSHALL STREET NE RECOND LT Headlamp assy
MINNEAPOLIS MN 55418
(800)328-1845
(612)789-1919
I
�
8/9/2014 11:18:45 AM 053108 Page 5