Tefera, Netsanet REC�Il��:='�
�EP 2 9 201�
NOTICE OF CLAIM FORM to the��j.���S�i�Paul, Minnesota
Min�usota State Statute 466.05 states that "...every person...who claims da�nages from any municipality...shadl cause to be presented to the
gorerning body of the municipalit��tivithin 180 days after the alleged Zoss or injury is discovered a notice stating the time,place,and
circumstances thereof,and the amount of compensarion 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. Piease note fhat you w�t not be contarted by te[epbone fo ciarify 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 yonr 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 VVEST KELLOGG BLVD, 310 CITY HALL, 5AINT PAUL,MN 55102
First Name�,��"rS�1� �'r Middle Initial � Last Name � �r��-✓�
Company or Business Name IJ I �
Are You an Insurance Company? Yes, N� If Yes,Claim Number?
Street Address��9� �`T- �l�(�_�ve- - �� � ��
City �`� 5�� State �� Zip Code �l � �
Daytime Phone(��1�_�C��ell Phone(�p�)�(�`C �3 Evening Telephone(_) -
Date of Accident/Injury or Date Discovered `�.Z� / ����� Time�J�A am/pm
Please state,in detail,what occurred(happened),and why you are submitting a claim.Please indicate why or ow u
feel the City of Saint Paul or its employees are involved and/or responsible for your damages. f'1 � �p��
� � � ��
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Please check the�x�es)that most c sely represent the reason for c pleting this fo .
�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 i jured on City property
1�Other type of property damage—please specify ;� _�(�, o�wnne�7
❑ Other rype of injury—please specify
In order to process your claim you need to include copies of all aanlicable 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.
4� 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
�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 witnesses to the incident? Yes No Unknown (circle)
Provide their names,addresses and telephone numbers:
Were the police or law enforcement called? Ye� No Unknown (circle)
If yes,what department or agency?�t�-- l�1.: ��}- CL��-`�ase#or report#
Where did the accident or injury take place? Provide street address,cross street,intersection,name of park or faciliry,
closest landmark, e . Please be as deta' ed as possible. If necessary,attach a diagram. °� _
�
Please indicate the amount you are seeking in compensation or what you would like the City to do to resolv this claim
to your sausfacti n. ' '��`h y� � � L
. ,
� �
Vehicle Claims- lease com lete this section ❑check box if this section does not a l
Your Vehicle: Year 0 Make � k.Y Model �� `n-
License Plate N�mber State��Color
Registered Owner ���-
Driver of Vehicle �-r�
Area Damaged � � a tS '���►�'�-
City Vehicle: Year Make Mo el
License Plate Number State Color
Driver of Vehicle(City Employee's Name}
Area Damaged
Iniurv Claims-please complete 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 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. U�signed forms Will�rot he processed
Submitting a false claim can result in prosecution. Date form was completed � I
r-- ,r
i �� �'
Print the Name of the Person who Completed this Fo
5ignature of Person Making the Claim:
Revised February 2011
MAACO COLLISION REPAIR AND AUTO PAINTING
2005 EAST LAKE STREET
MINNEAPOLIS,MN 55407
PHON E:612-721-6448
***PRELIMINARY ESTIMATE***
09/25/2014 01:31 PM
_.�__._�.��____...�___m__ ._____________._..__
�wner _ � .�_.�m_�.�__,_�.�.��_.� .____ _.....�____�.�___ � �. � _ ��
�__,
Owner: NETSANET TEFERA
Address: Work/Day: (763)350-4723
Inspection __ _�_��__ __ �___ �._ ____.._..__ _._ _._� _._._
Inspection Date: 09/25/2014 01:32 PM Inspection Type:
Appraiser Name: Melissa lehman Appraiser License#:
4 R er_ _�_�_v�---------- ------_ .___-__�__� __.___ _ - _�_--- _�__ _� .�_____.�_�
Repairer: Collision Repair&Auto Painting Contact:
Address: 2005 E. Lake Street Work/Day: (612)721-6448
City State Zip: Minneapolis,MN 55407 Work/Day:
Email: maaco2400@hotmail.com
Vehicle _� ___��_�.�______�. _�__._ � _ ____ � � ��-__ _. �_�_�_ � �--�€
2003 Chrysler Sebring LX 4 DR Sedan
6cyl Gasoline 2.7 FLEX
4 Speed Automatic
Lic.Plate: 877LNE Lic State: MN
Lic Expire: VIN: 1C3EL46T43N516430
Veh Insp#: Mileage Type: Actual
Condition: Code: M2563A
Ext.Color: Inferno Red Tinted Pearl Coat Int.Color: Prem Cloth Bucket Seats w/Pad
Print
Ext.Refinish: Two-Stage Int.Refinish:
Ext.Paint Code: PEL Int.Trim Code: �P8
Options -AudaVIN Information Received
AM/FM CD Player Air Conditioning Center Console
Cruise Control Daytime Running Lights Digital Clock
Dual Airbags Intermittent Wipers Pearlescent Paint
Power Brakes Power poor Locks Power Mirrors
Power Steering Power Windows Rear Window Defroster
Rem Trunk-L/Gate Release Smokers Package Tachometer
Tilt Steering Wheel Tinted Glass Velour/Cloth Seats
Wood Interior Trim
AudaVIN options are listed in bold-italic fonts
��___�_ ____ �.____.__ __.�.�.__ _ ._______��..�.� __ �____�_�
Damages�____�_ _._..___._.�__.__.._ .. ________ ._._�___�� _____ � �--�
Line Op Guide MC Description MFR.Part No. Price ADJ% B°/a Hours R
09/25/2014 01:35 PM Page 1 ot 3
2003 Chrysler Sebring LX 4 DR Sedan O9/25/2014 01:31 PM
Claim#:
�Q�
1 I 341 Panel,Roof Repair 12.0' SM
2 L 341 Panei,Roof Refinish 3.4 RF
2.8 Surface
0.6 Two-stage
3 RI 883 Roof Headliner R&I R&I Assembly 2.3 SM
Front Doors
4 BR 210 13 Pnl,Front Door Outer RT Blend Refinish 2.1 RF
1.0 Blend
0.6 Two-stage setup
0.5 Two-stage
5 RI 226 MIdg,Front Door Belt RT R&I Assembly 0.2 SM
6 RI 230 Mirror,0uter R/C RT R&I Assembly 0.3 SM
7 RI 228 Handle,Front Door Otr RT R&I Assembly 0.6 SM
Rear poors
8 I 288 Door SheIl,Rear RT Repair 4.0"` SM
»UPPER NEAR ROOF
9 L 288 Door SheIl,Rear RT Refinish 2.3 RF
1.9 Surface
0.4 Two-stage
10 RI 269 W/Strip,RR Door Body RT R&I Assembly 0.7 SM
11 RI 316 MIdg,Rear poor Belt RT R&I Assembly 0.2 SM
12 RI 306 Handle,RR Door Outer RT R&I Assembly 0.6 SM
Quarter And Rocker Panel
13 L 192 Pillar,Center RT Refinish 1.0 RF
1.0 Surface
»BLEND UPPER FROM ROOF REPAIR
Manual Entries
14 I M14 Corrosion Protection Sublet Repair $3.00" 0.2* SM`
15 N M17 Cover Car Exterior Additional Labor $3.00" RF
16 SB M60 Hazardous Waste Removal Sublet Repair $4.00" SM
16 Items
MC Message
13 INCLUDES 0.6 HOURS FIRST PANEL TWO-STAGE ALLOWANCE
Estimate Total&Entries �4 W�� �-��- --- -°°-----~
Other Parts $3.00
Paint Materials $281.60
Parts&Material Total $284.60
Tax on Parts&Material @ 7.775% $22.13
Labor Rate Replace Repair Hrs Total Hrs
H rs
Sheet Metal(SM) $54.00 4.9 16.2 21.1 $1,139.40
Mech/Elec(ME) $90.00
Frame(FR) $75.00
Refinish(RF) $54.00 8.8 8.8 $475.20
Paint Materials $32.00
LaborTotal 29.9 Hours $1,614.60
Sublet Repairs $7.00
Tax on Sublet @ 7.775% $0.54
Page 2 oi 3
09/25/2014 0135 PM
I
2�3 Chrysler Sebring LX 4 DR Sedan
Claim#: 09/25/2014 01:31 PM
" Gross?otal $1,928.87
Net Total $1,928.87
Alternate Parts Y/00/00/00/00/00 CUM 00/00/00/00/00 Zip Code:55407 Default
Recycled Parts Y/0/0 Zip Code:55407
Audatex Estimating 7.0.334 ES 09/25/2014 01:35 PM REL 7.0.334 DT 09/01/2014 DB 09/15/2014
Copyright(C)2013 Audatex North America,Inc.
2.1 HRS WERE ADDED TO THIS ESTIMATE BASED ON AUDATEX'S TWO-STAGE REFINISH FORMULA.
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= Reiated 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
'� Lf#�/^����� Audatex's prior written consent.
!l a.a a��
a 3aapra canpanK
Copyright(C)2013 Audatex North America,Inc.
Audatex Estimating is a trademark of Audatex North America, Inc.
Page 3 of 3
09I25/2014 01:35 PM �
I
ABRA Auto Body & Glass - Midway Workfile ID: 7014e2c2
FederalID: 41-1852119 i
Right The First Time...On Time ,
1190 UNIVERSITY AVE W, SAINT PAUL, MN 55104 '
Phone: (651) 645-1563
FAX: (651) 641-6129
Preliminary Estimate
Customer: TEFERA, NETSANET 7ob Number:
Written By: Pat Kearin
Insured: TEFERA,NETSANET Policy#: Claim #: .
Type of Loss: Date of Loss: 9/20/2014 12:00:00 PM Days to Repair: 0
Point of Impact: 13 Rollover
Owner: Inspection Location: Insurance Company:
TEFERA, NETSANET ABRA Auto Body&Glass-Midway CUSTOMER PAY
1485 ST. PAUL AVE#8 1190 UNIVERSITY AVE W
ST. PAUL,MN 55116 SAINT PAUL, MN 55104
(763)350-4723 Business Repair Facility
(651)645-1563 Business
VEHICLE
Year: 2003 Body Style: 4D SED VIN: 1C3EL46T43N516430 Mileage In: 5555555
Make: CHRY Engine: 6-2.7L-FI License: 877LNE Mileage Out:
Model: SEBRING LX Produdion Date: State: MN Vehicle Out:
Color: RED Int: Condition: Job#:
TRANSMISSION Dual Mirrors RADIO SEATS
Automatic Transmission Body Side Moldings AM Radio Cloth Seats
Overdrive Console/Storage FM Radio Bucket Seats
POWER CONVENIENCE Stereo Reclining/Lounge Seats
Power Steering Air Conditioning Search/Seek WHEELS
Power Brakes Intermittent Wipers CD Player Wheel Covers
Power Windows Tilt Wheel SAFETIf PAINT
Power Locks Cruise Control Drivers Side Air Bag Clear Coat Paint
Power Mirrors Rear Defogger Passenger Air Bag OTHER
DECOR Keyless Entry 4 Wheel Disc Brakes Power Trunk/Gate Release
9/26/2014 9:01:10 AM 011906 Page 1
� Preliminary Estimate
Customer: TEFERA, NETSANET ]ob Number:
Vehicle: 2003 CHRY SEBRING LX 4D SED 6-2.7L-FI RED
Line Oper Description Part Number Qty Extended Labor Paint
Price$
1 ROOF
2 * Rpr Roof panel w/o sunroof 12.0 33
3 Add for Clear Coat 1.3
4 R&I Headliner w/o sunroof LX 1.4
5 PILLARS,ROCKER&FLOOR
6 R&I RT Body w'strip 0.5
7 # Rpr �Rope Windshield&Back Glass 0.5
8 FRONT DOOR _
9 * Rpr RT Outer panel 1�. 2•3
10 Overlap Major Non-Adj. Panel -0•2
11 Add for Clear Coat 0.4
12 R&I RT Belt molding 03
13 * R&I RT Body side mldg black 0_3
14 # Rpr Clean and Retape mldg 0.5
15 R&I RT Mirror w/power w/o foldaway 0.3
16 R&I RT Handle,outside black 0.4
17 R&I RT R&I trim panel 0.5
_. 18 REAR DOOR
19 * Rpr RT Outer panel � 2•Z
zp Overlap Major Adj. Panel -0.4
21 Add for Clear Coat 0.4
22 * Rpr RT Door shell 1_0 Incl.
23 Add for Edging 0.5
24 R&I RT Door w'strip taupe 0.4
25 R&I RT Belt molding 0.3
26 * R&I RT Corner molding �
27 R8cI RT Applique 0�2
Zg * R&I RT Body side mldg black �
29 # Rpr Clean and Retape midg 0.5
30 R&I RT Handle,outside black 0.4
31 R&I RT R&I trim panel 0.5
32 MISCELLANEOUS OPERATIONS
33 # Refn �Car Cover 0.1
34 # Refn 'Color Tint 0.5
35 # Refn 'Corrosion Protection 0.3
36 # �Hazardous Waste 1 5.00 X
SUBTOTALS 5.00 25.0 10.7
9/26/2014 9:01:10 AM 011906 Page 2
�
. ,
Preliminary Estimate '
Customer: TEFERA, NETSANET 7ob Number:
Vehicle: 2003 CHRY SEBRING LX 4D SED 6-2.7L-FI RED
ESTIMATE TOTALS
Category Basis Rate Cost$
pa� 0.00
Body Labor 25.0 hrs @ $56.00/hr 1,400.00
Paint Labor 10.7 hrs @ $56.00/hr 599.20
Paint Supplies 10.7 hrs @ $36.00/hr 385.20
Miscellaneous 5.00
Subtotal 2,389.40
Sales Tax $385.20 @ 7.6250% 29.37
Grand Total 2,418.77
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 2,418.77
THIS IS A VISUAL INSPECTION ONLY. THERE MAY BE ADDITIONAL DAMAGE AFTER DISASSEMBLY. PARTS ARE
SUBJECT 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 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.
9/26/2014 9:01:10 AM 011906 Page 3
Preliminary Estimate
Customer: TEFERA, NETSANET 7ob Number:
Vehicle: 2003 CHRY SEBRING LX 4D SED 6-2.7L-FI RED
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
DE3NM01, CCC Data Date 9/16/2014, 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. 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=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. 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.
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=6ureau of Automotive Repair. EPA=Environmental Protection Agency. NHTSA= National Highway
Transportation and Safety Administration. PDR=Paintless Dent Repair. VIN=Vehicle Identification Number.
9/26/2014 9:01:10 AM 011906 Page 4
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