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Rose, Tyler ��,�� NOTICE OF CLAIM FORM to the City of Saint Paul, Mi��i�es�b��j� Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipality...shal!caus!tb b'�p7t��Ae��t�� governing body of the municipaliry 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 you will not be contacted by telephone to clarify answers,so provide as much information as necessary to explain your claim,and the amount of compensation being requested. You will receive a written acknowledgement 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 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 ��( � Q'� Middle Initial � Last Name �U S Q� Company or Business Name Are You an Insurance Company? Yes No If Yes, Claim Number? Street Address �0 y g ��e,�c,�r-�p� � � t�.Ge, �.. City _ 5 h0 r�.V I�w Stafe �N Zip Code �.7`�� Z..�p Daytime Phone(b��)�� 1_D�� Cell Phone 5 � Z3�- QD�Q I Evening Telephone S� Z3`� (70ro� Date of Accidenb Injury or Date Discovered �Q��j(U GlC� 1��Time �� V a /pm 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 its employees are involved and/or responsible for your damages.� T I�,r v5{.'-� W�-S rJ�r i V +n jQ v v o� ' rno n C d� J �n n c�-} �� t: •" oW ��- bGcC � (�1 G� � , • • ,s ,�� a c P.�►�•� � - l i" u, � � 0 "�J c� GL 5 i G,n � , .� ,,� . Please check the box(es)that most closely represent the reason for completing this form: ❑ My vehicle was damaged in an accident ❑ 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 ❑ My vehicle was wrongfully towed and/or ticketed ❑ I was injured on City property ❑ Other type of property damage—please specify O Other type of injury—please specify In order to process your claim vou need tp include copies of all apalicable 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 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—nlease complete this section -� Were there wimesses to the incident? Yes No Unknown (circle) Provide their names, addresses and telephone numbers. Were the police or law enforcement called? Yes No Unknown (circle) If yes,what department or agency? Case#or report# 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 necessary, attach a diagram.j he 0.GC t CC�►�-� oC�u rrP� C� i n�-erSe.C.t�on o f 2�`lU 5 ��cer,(�r S f, We..S + 1250 Rayln�Y� ��e.� /l)or11,, 'i n St, '�u-� I , t�'1 S 10 5}�n on ao-k ne��j ba-t�a�) Please mdicate the amour�.you are seekmg in compensation or what you would like the�ity to do to resolve this claim to your satisfaction. �t, , � �¢�.y�u C ct cJ�yQ� (�y G.Ci.( . a . �,,( J WQ�� Sov►^e a.w�ovnf e�� -� c,� �.-+ . C�cr iS �-,�or-�.,� Vehicle Claims— lease com lete this section ❑ check box if this section does not a 1 Your Vehicle: Year I�_Make p h Model C,i v j cr LX License Plate Number lo �r�/ State��Color ¢.� Registered Owner � p 5 Driver of Vehicle ' e, , J �i��,+ Area Damaged +�-p✓� � '� � ` 1� + L(,LS�n r'� �. h oo� �� fer, City Vehicle: Year Make �pr� odel �- 1 SO d License Plate Number State��Color c.i-r k b 1 v 2, Driver of Vehicle City Employee's Name) � q,V e N a,�i�y " Area Damaged_�O f1C� Iniurv 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 I1dio Planning to Seek Treatment(circle) When did you receive treatment? 1 (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 wark? (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 Submitting a false claim can result in prosecution. Date form was completed ;�22 / "T' Print the Name of the Person who Completed this Form: / � e � � Signature of Person Making the Claim: '/ Revised February 2011 � �� BONFE'S COLLISION CENTER Workfile ID: 5156d416 *�� Federal ID: 410986303 ��iiii� ��,p��i�et��hii��uriir i��i�i��'eFM CAR CARE BY PEOPLE WHO CARE '��` ��` '"� 380 7TH ST W, SAINT PAUL, MN 55102 � � Phone: (651) 222-4458 FAX: (651) 224-8640 Preliminary Estimate Customer: ROSE,TYLER Written By: MATTHEW BEBEL Insured: ROSE,TYLER Policy#: Claim#: Type of Loss: Date of Loss: Days to Repair: f � —f- Point of Impact: Owner: Inspection Location: Insurance Company: ROSE,TYLER BONFE'S COLLISION CENTER (651)239-0061 Cell 380 7TH ST W SAINT PAUL, MN 55102 Repair Facility (651)222-4458 Business V�HICLE Year: 1995 Body Style: 4D SED VIN: 1HGEG8657SL033647 Mileage In: 169123 Make: HOND Engine: 4-1.5L-FI License: Mileage Out: Model: CIVIC LX Production Date: ' State: Vehicle Out: Color: RED Int: Condition: I Job#: ,� TRANSMISSION Dual Mirrors RADIO SEATS Automatic Transmission Body Side Moldings AM Radio Bucket Seats POWER Tinted Glass FM Radio Reclining/Lounge Seats Power Steering Console/Storage � Stereo WHEELS Power Brakes CONVENIENCE Search/Seek Wheel Covers Power Windows Intermittent Wipers Cassette PAINT Power Locics Tilt Wheel SAFETY Clear Coat Paint Power Mirrors Cruise Controi Drivers Side Air Bag DECOR Rear Defogger Passenger Air Bag 9/22/2014 4:03:52 PM 013793 Page 1 Preliminary Estimate Customer: ROSE,TYLER Vehicle: 1995 HOND CIVIC LX 4D SED 4-1.5L-FI RED Line Oper Description Part Number Qty Extended Labor Paint Price$ 1 FRONT BUMPER 2 Repl Bumper cover sedan 71101SR4000ZZ 1 558.10 1.6 2.6 3 Add for Clear Coat 1.0 4 FRONT LAMPS 5 Repl RT Headlamp assy 331005R3A01 1 251.00 0.6 6 Aim headlamps 0.5 7 Repl RT Signal lamp sedan 33300SR4A02 1 62.63 Incl. _ _ __ _ _ __ __ 8 HOOD 9 Repl Hood sedan 601005R4000ZZ 1 438.32 1.0 2.7 10 A�d for Clear Coat 1.1 11 Add for Underside(Complete) 1.4 12 Repl RT Hinge 60120SROAOOZZ 1 113.25 0.3 0.2 13 Add for Clear Coat 0.1 14 Repl LT Hinge 60170SROAOOZZ 1 113.25 0.3 0.2 15 Add for Clear Coat � 0.1 16 FENDER 17 * Rpr LT Fendersedan � 2�0 18 Overlap Major Adj. Panel -0.4 19 Add for Clear Coat 0.3 2p R&I LT Fender liner 0.4 21 Repl RT Fendersedan , 60211SR4507ZZ 1 276.03 2.0 2.0 2Z Overlap Major Adj. Panel �� -0.4 23 Add for Clear Coat ', 0.3 24 Add for Edging 0.5 25 Deduct for Overlap ' -0.5 26 FRONT DOOR ' 27 Blnd RT Outer panel ' 1.0 28 R&I RT Belt w'strip LX&IX 0.3 z9 R&I RT Mirror remote control 0.5 30 R&I RT R&:trim panel 0.3 31 # Repl HAZARDOUS WASTE REMOVAL 1 7.00 T 32 # ****POSSIBLE HIDDEN DAMAGE 1 ***** 33 # Refn TINT COLOR TO SECURE PAINT 1.0 MATCH $UBTOTALS 1,819.58 11.3 15J 9/22/2014 4:03:52 PM 013793 Page 2 Preliminary Estimate Customer: ROSE,TYLER Vehicle: 1995 HOND CIVIC LX 4D SED 4-1.5L-FI RED ESTIMATE TOTALS Category Basis Rate Cost; Parts 1,812.58 Body Labor 11.3 hrs @ $56.00/hr 632.80 Paint Labor 15.7 hrs @ $56.00/hr 879.20 Paint Supplies 15.7 hrs @ $35.00/hr 549.50 Body Supplies 9.8 hrs @ $3.00/hr 29.40 Miscellaneous 7.00 Subtotal 3,910.48 Sales Tax $2,398.48 @ 7.6250% 182.88 Grand Total 4,093.36 ****************************************************************************** THIS IS A VISUAL ESTIMATE ONLY. ADDITIONAL DAMAGE MAY BE FOUND AFfER TEAR DOWN OF VEHICLE. NO GUARANTEE ON RUST WORK. ****************************************************************************** MINNESOTA FRAUD WARNING A person who submits an application or files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime. 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. , I' 9/22/2014 4:03:52 PM 013793 Page 3 Preliminary Estimate Customer: ROSE,TYLER Vehicle: 1995 HOND CIVIC LX 4D SED 4-1.SL-FI RED Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide AEG4430, CCC Data Date 9/16/2014, and the parts selected are OEM-parts manufactured by the vehicies 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 (N) 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. 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: I' 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=Aft�rmarket 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 Serv�ces 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 Highway Transportation and Safety Administration. PDR=Paintless Dent Repair. VIN=Vehicle Identification Number. 9/22/2014 4:03:52 PM 013793 Page 4 �,�c � ��✓1-F oc�.�r t� , 1 e,,�" i�r�-�-��P.�.�`1 O ►1 (V � o � �.C� l� S t�u C� t.�� S�. t , � � g ��o �� , � � N --1,��- -�� ----� � -- --- -- - ---- --_�-� - . . �� << �� --- �- --- o -�-- -r�I e,r R�sE c�r�u rh ---�-- -- — ' o - -- -- � —� ` - �"��`"`� o n p� ; RA e. N , ��I�� -4-��k �,��, -- � - -- - , `��.�- � �-�b y .� ; � S�.��c��,r �fi. . � . , -� ,�,��- � . . -- � � � -----_-,�- -_ ------ _----- ��___ _ ___ _ -T ��_ _- -- _ _� - - _ ��=__--,___--_ - _. . � � _�,��_�-_ ___ � _ _ � _ __ _ �_______ ___ _��s��- - --- --- ` ---- - ---- -- � - a n 5��c� — ---t---- --------- -- �. �� _ � --- �.c,c.i c�,� � ---_ __--_--- — - - - --- ----- - ��r I -- ----- --�---- -- City of St. Paul, The car is totaled out. The estimate I received only gave the estimate for the new parts. Obviously the estimate would have been cheaper if they took the time to call around for used parts. The Kelly blue book value for selling to a private party is around $1,000 and I said it was in fair condition. I was looking to sell it to a private party, so I would prefer azound$1,000. So the estimate for azound$4,000 from Bonfe's Auto Repair is not what I expect. I'm looking to get rid of the car either way. -Thank you Tyler Rose