Anderson, Mary F�EC�I�/�D
Al1G �3 2014
NOTIC� Or CLAIM I'ORM to the City of Saint Paul, Mir�tt��t�� ��p�
Mi���resotn Sinte Stcuute 466.05 stnt�s Ihu� "...everv persnn...whn rininrs dcunnges,/'ro�n nriv�r�unicipality...shall c•nusr to be pre.se��rtcd tu the
�,�overning hody q/'dre�nuniciperlrry wi�l�i�i 180 dups qfter!he ci!le�ed loss or injury is cliscoi�ered a�iotice,statirrg tlre time,pine•e,arid
circ�unsicrnces lhereu/;arrd!he nmount of compef�satinn or other re(ief demnndect."
1'lease a�mplete this fi�rm in its entirety hy clf�arly typing or printing your answer to each question. IC more space is
needed,attach additional sheets. Ple�se note th.�t you will not be contacted by telephone to clarify answers,so provide as
much information as necessary to explain ynur claim,ancl the amoimt of compensation being requested. You will receive a
written acknowled�;ement once your form is received. The process can talce up to ten weeks or longer depenc�in�;on the
nature ot'yc�ur claim. This 1'orm must be signed,and both pages completed. If something does not apply,write `N/A'.
SEND COMPLET�D FORM AND OTHER DOCUM�NTS TO: CITY CLERK,
15 WEST K�LLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
First Name /��AR�� Middle Initial �• Last Name�f7�U���•S O/1�
_._.. _ _ _ _
Company or Business Name
Are You an Insurance Company? Yes/ I� If Yes, Claim Number?
Street Address o�� �a �d`-`�C� �au�
City ��C�,(��u�"Z Y State �1�1�1� Zip Code SS��S
Daytime Phone (�5/)�� o yy�Cell Phone�S/) Suu y�/��Evening Telephone (�'S/)7�_ 6�
J�-�j�,AoX.
D<<te oC Accident/ Injury or Date Discovered � V � �j� Time �• °v �im�
Please state, in detail, what occurred (happened), and why you are submitting a claim. Please indicate why or howyouu
feel the City of Saint Paul or its employees are involved and/or responsible for your dama es. 1���/'� L t
'�i /z r�� �,f c rn L o ���S �.��nt 7`H� S �eFE�s. il/E L v�s� �o�r
!.u/a S �c:�� ����� On[ ,�C.�� y /. C`{�a N- '7�/f�r� u�/�S No c/acc��o�V Si6�t�s
�Gc��� %�R � v 2 14�v`� i.�✓f��Zi�!i/y 6 !�o S f�.�_
c�v�Lu � �.S f�!J �S //l'1/��t i=u� �-/�L� C LL AN L(�J O� �K Y i✓� /L C .r
Please check the box(es) that most closely rePresent the reason far completing this form:
`❑ My vehicle was damaged in an accident ❑ My vehicle was dama ring�ta_tiv I
- � My �chicle was ciamaged 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
❑ Other type of injury—please specify
In order to process your claim you need to include conies of all annlicable 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 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 are always welcome to document and suppart your claim but will not be rewrned.
Page 1 of 2—Please complete and return both pages of Claim Form
� Failure to complete and return both pages will result in dclay in the handling of your cl�im.
AU Cl.�ims-plcasc completc this scction
Were there witnesses to the incident'? Yes No Unknown (circle)
Provide their names, addresses and telcphone numbers: ��I�
Wcre the police or law enforcement called? Yes � Unknown (circle)
If yes, what department or agency? Case#or report#
Where clid the accident or injury take place'? Provide street address,cross street, intersection, name of park or facility,
closest l�tndmark, ete Please be as detailed as possible. If necessary, attach a diagram.
��c� D �� `�� a /Y 1���c Y S7�•
Ple�ise indicate the amount you are seeking in compensation or what ou would like the City to do ro resolve this claim
to you satisfaction. !�/� � �d,� �--'v2� %� /.3� �o nl C � �'E t�2 � ,�v�
t/L�i L L c ,�1 c, c� �'fi�� U� �a��t- ���
_ - _ - -- _ _- -- — --- _ -- - - ,--—__-- -
Vehicle Claims- lease com iete this sectiori check box if this section does nc�t a 1
Your-Vehicle: Year ��/ Make �/V Model � �v �-'-�
License Plate Number Z Z _ State /�i.c�/ Color ^ '
Registered Owner
DriverofVehicle i�`,1 �-iLC�S�
Area Damaged �`Po/V f' � f�'���- CLc� ���E� o� G/3-�,
City Vehicle: Year ake _ Model
License Plate u er - State Color
Di-iver of Vehicle (City Employee's Name)
Area Damaged _
Injurv ClaimS please complete this section ❑ check box if lhis section docs not applv
How were you injured?
What part(s) of your body we injured?
Flave you sought medical tre� me ? Yes� No Planning to Seek Treatment (circle)
When did you receive treatrn nt? (provide date(s))
Name ol�Meclical Provider(s)
Address Telephone
Dicl you miss work as a res�il of your injury? Yes No
I When dicl vou mitis wo�-k?----_ „---- ----__ --(Prc�vide date(s))
Name of your Employer:
Address Telephone
�61,Check here if you are attaching moi•e pages to this claim form. Number of additional pages
�
I3y sigriirzg this forrn,yocc are stating ticat all informatio�z you )zave provided is true and correct to tlie best
of your krtowledge. U�zsigned forms will not be processed.
Srcbmitting a false clairn cara result iiz prosecutioiz. Date form was completed U'! �"' `
Yrint the Name of'the Person who Completed this Form: ��'1����/��t-l�.S�/�
Si�nature of Person Makin�;the Claim: '�--�
IZevised February 201 1
RAYMOND AUTO BODY, INC. �Norkfile ID: d33ae7d8
FederalID: 41-0888257
1075 PIERCE BUTLER RTE, SAINT PAUL, MN
55104
Phone: (651) 488-0588
FAX: (651) 488-4794
Preliminary Estimate
Customer: ANDERSON, MARY Job Number:
Written By: RACHELLE RODRIQUE
Insured: ANDERSON, MARY Policy#: Claim#:
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact:
Owner: Inspection Location: Insurance Company:
ANDERSON, MARY RAYMOND AUTO BODY,INC.
2212 TOWER COURT 1075 PIERCE BUTLER RTE
WOODBURY, MN 55125 SAINT PAUL, MN 55104
(651)731-0496 Business Repair Facility
(651)488-0588 Business
VEHICLE
Year: 2014 Body Style: 4D SED VIN: WDDGF8AB6EG230402 Mileage In:
Make: BENZ Engine: 6-3.5L-FI License: Mileage Out:
Model: C300 AWD Production Date: State: Vehicle Out:
Color: Int: Condition: Job#:
TRANSMISSION Console/Storage RADIO ROOF
Automatic Transmission Overhead Console AM Radio Electric Glass Sunroof
4 Wheel Drive Wood Interior Trim FM Radio SEATS
POWER CONVENIENCE Stereo Bucket Seats
Power Steering Air Conditioning Search/Seek Leather Seats
Power Brakes Intermittent Wipers CD Player WHEELS
Power Windows Tilt Wheel Auxiliary Audio Connection Aluminum/Alloy Wheels
Power Locks Cruise Control SAFETY PAINT
Power Mirrors Rear Defogger Drivers Side Air Bag Clear Coat Paint
Heated Mirrors Keyless Entry Passenger Air Bag OTHER
Power Driver Seat Alarm Anti-Lock Brakes(4) Traction Control
Power Passenger Seat Message Center 4 Wheet Disc Brakes Stability Control
DECOR Steering Wheel Touch Controls Front Side Impact Air Bags Signal Integrated Mirrors
Dual Mirrors Telescopic Wheel Head/Curtain Air Bags Power Trunk/Gate Release
Body Side Moldings Climate Control Communications System
Tinted Glass Home Link Hands Free Device
8/6/2014 9:25:47 AM 019495 Page 1
Preliminary Estimate
Customer: ANDERSON, MARY 7ob Number:
Vehicle: 2014 BENZ C300 AWD 4D SED 6-3.5L-FI
Line Oper Description Part Number Qty Extended Labor Paint
Price;
1 FENDER
2 Repl LT Fender liner front w/o C63 2046906030 1 72.00 0.3
3 Repl LT Fender liner rear w/o C63 2046904730 1 53.00 0.2
4 WHEELS
5 R&I RT/Front R&I wheel m 0.1
6 R&I RT/Rear R&I wheel m 0.1
7 QUARTER PANEL
8 Repl LT Wheelhouse liner 2046906130 1 105.00 0.5
9 MISCELLANEOUS OPERATIONS
10 * Repl Cover car/bag 1 Q�4
11 # Rpr Lift vehicle on hoist 1.0
12 # Rpr Remove tar 5.0
13 # Rpr Buff and detail as needed 5.0
14 # *This is not a final estimate* 1
SUBTOTALS 230.00 12.2 0.0
ESTIMATE TOTALS
Category Basis Rate Cost$
Parts 230.00
Body labor 12.2 hrs @ $54.00/hr 658.80
Body Supplies 12.0 hrs @ $4.00/hr 48.00
Subtotal 936.80
Sales Tax $278.00 @ 7.6250% 21.20
Grand Total 958.00
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 958.00
WHILE WE HAVE MADE EVERY EFFORT TO WRITE A COMPREHENSIVE REPORT OF THE VISIBLE DAMAGE TO YOUR
VEHICLE, IT IS IMPORTANT TO REMEMBER THAT THIS IS ONLY AN ESTIMATE.
THERE ARE A NUMBER OF FACTORS THAT CAN AFFECT THE ACTUAL COST OF REPAIRS, INCLUDING BUT NOT
LIMITED TO HIDDEN DAMAGE, PARTS PRICE CHANGES, AND INSURANCE COMPANY INVOLVEMENT.
PLEASE CONSIDER THIS WHEN MAKING DECISIONS REGARDING THE REPAIRS TO YOUR VEHICLE.
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.
8/6/2014 9:25:47 AM 019495 Page 2
Preliminary Estimate
Customer: ANDERSON, MARY 7ob Number:
Vehicle: 2014 BENZ C300 AWD 4D SED 6-3.5L-FI
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
ERI5777, CCC Data Date 7/17/2014, 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 �enchmark 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. 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=A�termarket part. BInd=6lend. 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. 0/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=Bureau of Automotive Repair. EPA=Environmental Protection Agency. NHTSA= National Highway
Transportation and Safety Administration. PDR=Paintless Dent Repair. VIN=Vehicle Identification Number.
8/6/2014 9:25:47 AM 019495 Page 3