Otte, Johnathan ��-:�.�.;���_�
�=_�,,�9 �-
NOTICE OF CLAIM FORM to the City of Saint Paul, Mi�i��s�b����
��
Minnesota State Statute 466.05 states that"...every person...who claims damages from any municipality...shall cause to b�pr'eSercteed to�t►iet
governing body of the municipaliry within 180 days after the aUeged 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 aclznowledgement once your form is received. T�e process can take up to ten weel�s 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
.-� ^ I.JTC
First Name �bv��,�ah Middle Initial � Last Name e—
Company or Business Name
Are You an Insurance Company? Yes/��o If Yes,Cla�im Number?
Street Address �� I�L-l� e, �.
/� r � �
City ��6 t t-�,�'i.e c..S Stat�e � � Zip Code ��1
Daytime Phone��')�2-26Y8 Cell Phon�) - Evening Telephone(_) -
Date of Accidend Injury or Date Discovered J���\ �3� Z�� / Time % yS am/�m
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 i�volveda�/or responsible for your mages.
61:Le ` c/' �c.v�r �,e�il � e Si �
Ple e 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 condirion of the street ❑ My vehicle was damaged by a plow
❑ My vehicle was wrongfully towed and/or ticketed ❑I was injured on City properiy
� 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 aunlicable 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 o lf before submitting your claim form.
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 suppoR your claim but will not be returned.
Page 1 of 2—Please complete�nd return both pages of Claim Form
i
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims—alease comnlete this section
Were there wibnesses to the incident? Yes No Unknown (circle)
Provide their names,addresses and telephone numbers:
Were the police or law enforcement called? Yes No Unknown (circ )
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 landmar etc Please be as detailed as possible. If necessary, attach a diagram. �ci.�� St, l''�e�✓' _
t� v
Please indicate the amount you ar seeking in compensation or what you woul�l like the City to do to re olve this claim
to your satisfaction. d� � ,1�� a"`�- O"` �� �``°��
�, � Z ' �� o �� ✓a, f f � e. ak b o r.,��2
`�'��1�-� e�LDl.�n^�hK�'G`1 a{' ¢, r�a�t.��1 E.. �� ►My c. .
Vehic e Cl ' — lease co lete this section `•� ❑check box if this section does not a 1
Your Vehicle: Year 2, , Make c Model +^ '
License Plate Number 1 � � State�_Color �
Registered Owner
Driver of Vehicle
Area Damaged �' e fi � C
City Vehicle: Year ?�d 1 Make a( Model f
License Plate Number po I� � State M k Color � 2
Driver of Vehicle(City Employee's Name) n/t,'� �.�.el 1�ov�.�a-S �� � A
Area Damaged
Iniurv Claims nlease comnlete this section check box if this section does not applY
How were you injured?
What part(s)of your body were injured?
Have you sought medical treatrnent? 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�f 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.
' 'n a alse claim can result in prosecution. Date form was completed �- � � ���
Submitti g f �, —'
Print the Name of the Person who Completed s Fo J fl�d`�
Signature of Person Making the Claim:
Revised February 2011
Accident Report Page 1 of 1
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03 �� -""" " �I I I `I� attempted to make a u=turn Veh A2 was in the �, ��
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N i _ _ _ _ _� little to'make a tiqhter u-turn and made contact 01
mec-wr� � with Veh i2 � Dr 12 said he was'ok and the other�, ��
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https./ldvscrash.x.state.mn.us/dvsmfo/aceidentrecords_2008/Includes_LE/PrmtReportIndiv 7/14/2014
RAYMOND AUTO BODY� INC. Workfile ID: 154d7248
FederalID: 41-0888257
1075 PIERCE BUTLER RTE, SAINT PAUL, MN ' � ' '
55104
Phone: (651) 488-0588
FAX: (651) 4$8-4794
Preliminary Estimate
Customer: OTTE,)ONATHAN ]ob Number:
Written By:JAKE ERICKSON
Insured: OTfE,JONATHAN Policy#: Claim #:
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact: il Left Front
Owner: Inspection Locatidn: Insurance Company:
OTTE,JONATHAN RAYMOND AUTO BO�Y, INC. CUSTOMER PAY
2026 KEENE DRIVE 1075 PIERCE BUTLER RTE
COLUMBUS, NE SAINT PAUL, MN 55104
(402)942-2648 Day Repair Facility ,
(651)488-0588 Business
V�HICLE
Year: 2009 Body Style: 4D SED VIN: 1FAHP35N69W101001 Mi�eage In: 98085
Make: FORD Engine: 4-2.OL-FI License: 10-BJ1 Mileage Out:
Model: FOCUS SE Production Date: 7/2008 State: NE Vehicle Out:
Color: YELLOW Int: GREY Condition: Job#:
TRANSMISSION Dual Mirrors AM Radio Front Side Impact Air Bags
Overdrive Console/Storage FM Radio Head/Curtain Air Bags
5 Speed Transmission CONVENIENCE Stereo SEATS
POWER Air Conditioning Search/Seek Cloth Seats
Power Steering Intermittent Wipers CD Player Bucket Seats
Power Brakes Tilt Wheel Auxiliary Audio Connection WHEELS
Power Windows Rear Defogger Satellite Radio Aluminum/Alloy Wheels
Power Locks Keyless Entry SAFETY PAINT
Power Mirrors Message Center Drivers Side Air Bag Clear Coat Paint
DECOR RADIO Passenger Air Bag
7/21/2014 1:53:20 PM 019495 Page 1
Preliminary Estimate
Customer: OTTE,70NATHAN 7ob Number:
Vehicle: 2009 FORD FOCUS SE 4D SED 4-2.OL-FI YELLOW
Line Oper Description Part Number Qty E�ctended Labor Paint
Price#
1 FRONT BUMPER
2 0/H bumper assy 1.9
3 * Rpr Bumper cover �Q 2•6
4 Add for Clear Coat 1.0
5 FRONT LAMPS
6 Repl LT Headlamp assy 8S4Z13008F 1 249.33 Incl.
7 Repl Aim headlamps 1 0.5
8 FENDER
9 Repl LT Fender w/o grille 8S4Z16006A 1 190.38 1.9 1.8
10 Add for Clear Coat �•�
11 Add for Edging 0.5
12 Add for Clear Coat 0.1
13 R&I LT Fender liner Incl.
14 FRONT DOOR
15 Bind LT Outer panel 1.1
16 R&I LT Belt w'strip , 0.2
17 R&I LT Mirror assy w/power w/o 0.3
heated glass
18 R&I LT Door glass Ford 0.6
19 * R&I LT Run w'strip �
20 R&I LT Handle,outside black 0.4
21 R&I LT R&I trim panel 0.4
22 MISCELLANEOUS OPERATIONS I,
23 Repl Cover car/bag 1 0.2
24 # Hazardous waste removal 1 6.00 X
25 # Color tint/color match 1 0.5
26 # Repl Corrosion protection primer 1 0.4
27 # Repl Flex additive 1 8.00
Zg # ***OPEN TO HIDDEN OR 1
ADDITIONALDAMAGES***
SUBTOTALS 453.71 8.7 8•7
7/21/2014 1:53:20 PM 019495 Page 2
Preliminary Estimate
Customer: OTTE,70NATHAN 7ob Number:
Vehicle: 2009 FORD FOCUS SE 4D SED 4-2.0�-FI YELLOW
ESTIMATE TOTALS
Category Basis Rate Cost$
Parts 447.71
Body Labor 8.7 hrs @ $54.00/hr 469,80
Paint Labor 8.7 hrs @ $54.00/hr 469.80
Paint Suppiies 8.7 hrs @ $34.00/hr 295.80
Miscellaneous 6.00
Subtotal 1,689.11
Sales Tax $743.51 @ 7.6250% 56.69
Grand Total 1,745.80
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 1,745.80
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�fHE ACTUAL CO5T OF REPAIRS, INCLUDING BUT NOT
LIMITED TO HIDDEN DAMAGE, PARTS PRICE CHANGES, AND INSURANCE COMPANY INVOLVEMENT.
PLEASE CONSIDER THIS WHEN MAKING DECISIONS RE ARDING THE REPAIRS TO YOUR VEHICLE.
�
7/21/2014 1:53:20 PM 019495 Page 3
Preliminary Estimate
Customer: OTTE, 70NATHAN Job Number:
Vehicle: 2009 FORD FOCUS SE 4D SED 4-2.OL-FI YELLOW
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
DR2)K08, 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 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 2014 vehicles contain minor changes from the pre�ious 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. Part� numbers and prices should be confirmed with the local
dealership.
The following is a list of additional abbreviations or symb�ls 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 categor�. F=Frame labor category. G=Glass labor category.
M=Mechanical labor category. S=Structural labor categoly. (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 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.
7/21/2014 1:53:20 PM 019495 Page 4
LATUFF BROS., INC.
880 UNIVERSITY AVENUE
ST. PAUL, MINNESOTA 55104
(651)224-2828 FAX:(651)291-0677
FEDERAL ID#41-0777034
**"'PRELIMINARY ESTIMATE""'`
07/21/2014 02:22 PM
____.__ __ . __�_ __ , . _ __._._ � � __. �.
+ Owner
Owner: JOHN OTTE
Address: 9 WEST 7TH ST#244 Work/Day:
Home/Evening: (402)942-2648
City State Zip: Saint Paul, MN 55102 FAX:
, Inspection _ _. . . _ _.__. . _ __ __ �_ _._ _ _._ �._____ . __.___. . _-- _ _____. __ . .
Inspection Date: 07/21/2014 02:21 PM Inspection Type: ,
Inspection Location: Latuff Brothers Inc Contact:
Address: 880 University Ave Work/Day: (651)224-2828x
FAX: (651)291-0677x
City State Zip: Saint Paul, MN 55104 Work/Day:
Email: general@latuffbrothers.com
Primary Impact: Left Front Side , Secondary Impact:
Appraiser Name: MATTHEW HOWARD �' Appraiser License#:
' Repairer
�_. _... _._ _ __ . _... .. _ __ __ __ __._ .__ __ _ __ _ . _ _ ______ . ___ _ __. ,____. __ _—__
Repairer: Latuff Brothers Inc Contact:
Address: 880 University Ave Work/Day: (651)224-2828
FAX: (651)291-0677
City State Zip: Saint Paul,MN 55104 Work/Day:
Email: general@latuffbrothers.com
�_ __..._ .._
' Vehicle
'LU09 Ford Focus SE 4 DR Sedan
4cyl Gasoline 2.0 Dohc
4 Speed Automatic
lic.Plate: 10-BJ1 Lic State: NE
Lic Expire: VIN: 1FAHP35N69W101001
Prod Date: 01/2008 Mileage:
Veh Insp#: Mileage Type: Actual
Condition: Code: P1593C
Ext.Refinish: Two-Stage Int. Refinish: Two-Stage
Options �'�
AM/FM CD Player Air Conditioning Alarm System
Aluminum/Alloy Wheels Bucket Seats Center Console
Chrome Grille Dual Airbags Halogen Headlights
Head Airbags Intermittent Wipers Keyless Entry System
Lighted Entry System MP3 Player Power Brakes
Power poor Locks Power Mirrors Power Steering
Power Windows Rear Window Defroster Rem Trunk-UGate Release
07/21/2014 02:24 PM Page 1 of 3
2009 Ford Focus SE 4 DR Sedan
Claim#: 07/21/2014 02:22 PM
Side Airbags Sirius Satellite Radio Split Folding Rear Seat
Tachometer Theft Deterrent System Tilt Steering Wheel
Tinted Glass Trip Computer Velour/Cloth Seats
, -----.___ __.__ _ .____---- _._,_.. __�_.______�_ ____.__ __ _. ____ _..___--.._..
_ _. _e.___ _....t_ ___. _ ___
� Damages
Line Op Guide MC Description MFR.Part No. Price ADJ% B% Hours R
Front Body And Windshield
1 EU 103 Fender,Front LT Replace Recycled $125.00" +25.00 2.4 SM
2 L 103 13 Fender,Front LT Refinish 4.1 RF
2.4 Surface
0.5 Edge
0.6 Two-stage setup
0.6 Two-stage
Front Doors
3 BR 209 Pnl,Front Door Outer LT Blend ReFinish 1.2 RF
0.8 Blend
0.4 Two-stage
4 RI 25 W/Strip,Belt Outer LT R&I Assembly 0.2 SM
5 RI 243 Mirror,0uter R/C LT R&I Assembly 0.7 SM
- 6 RI 518 Channel,Front Glass Ru LT R&I Ass�embly 1.0 SM
7 RI 645 Handle,Front Door Otr LT R&I Ass�embly 0.3 SM
Manual Entries
8 SB Hazardous Waste Removal Sublet Repair $5.0�* SM'
8 Items
MC Message
13 INCLUDES 0.6 HOURS FIRST PANEL TWO-STAGE ALLOWANCE
r.._____._____________�_�_.____ .__..�.___._a..-------______�.__ ,_ �._.._ ____.._._. _.�.__ _.�._ ...____.__
j Estimate Total &Entries �
Other Parts $125.00
Paint Materials $185.50
Line Item Markup $31.25
Parts&Material Total $341.75
Tax on Parts&Material @ 7j625°/a $26.06
Labor Rate Replace Repair Hrs Total Hrs
H rs
Sheet Metal(SM) $55.00 4.6 4.6 $253.00
Mech/Elec(ME) $85.00
Frame(FR) $75.00
Refinish(RF) $55.00 5.3 5.3 $291.50
Paint Materials $35.00
Labor Total � 9.9 Hours $544.50
Sublet Repairs $5.00
Gross Total $917.31
Net Total ' $917.31
i
,
Alternate Parts No
SPPL Yes Zip Code:55104 Default
07/21/2014 0224 PM Page 2 of 3
� 2009 Ford Focus SE 4 DR Sedan
Claim#: 07/21/2014 02:22 PM
Audatex Estimating 7.0.226 ES 07/21/2014 02:24 PM REL 7.0.226 DT 06/01/2014 DB 07/15/2014
Copyright(C)2013 Audatex North America,Inc.
1.6 HRS WERE ADDED TO THIS ESTIMATE BASED ON AUDATEX'S TWO-STAGE REFINISH FORMULA.
THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF ONE OR MORE CRASH PARTS
SUPPLIED BY A SOURCE OTHER THAN THE MAI�TUFACTURER 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 �I 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
_� = Refinish PC= Replace PXN Reconditioned UC= Repiace Reconditioned
TT = Two-Tone SB= Subtet Repair N = Additional Labor
BP.= 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
''Acrda�ex Audatex's priorwritten consent.
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�Copyright(C)2013 Audatex No�th America,Inc.
Audatex Estimating is a trademark of Audatex North America, Inc.
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