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NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota � �
Minnesota State Statute 466.05 sta[es that "...every person...who claims damages,/rom any municipaliry...shall ca�ise�o be presented to the
governing bodp qFthe municipaliry wi[hin 180 days after the alleged loss or injury is discovered a nolice stating the time,place,and
circumstances therenf,and the amount of compensatdon 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 expiain 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 Middle Initial�Last Name �����
Company or Business Name_�Q, 1 //�
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Are You an Insurance Company? Yes/�Vo� If Yes,Claim Number? Y �.1�
Street Address_ ���� I I'�.�� �� � r� F�� �
City� V I � ���(��S State ��� Zip Code�
Daytime Phone( 0� )�-(v0 � Cell Phone( DI )��j�(��Evening Telephone("7D1 )�Z- (00{�
Date of Accident/Injury or Date Discovered l5��y�2��� Time `7'>b am/�
Piease state,in detail, what occurred(happened), and why you are submitting a claim. Please indicate why or how you
feel the Cit of Saint Paul or its employees are i volved and/or res onsible for your damages.
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Please check the box(es)that most closely represent th�reason for completing this form:
�l My vehicle was damaged in an accident � ❑ My vehicle was damaged during a tow
❑ My vehicle was damaged by a pothole ar condition of the street ❑ My vehicle was damaged by a plow
❑ My vehicle was wrongfully towed and/ar 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 copies of all anulicable 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.
�1 Property damage claims to a vehicle: [wo 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 comnlete this section
Were there witnesses to the incident? Yes N� Unknown (circle)
Provide their names, addresses and telephone numbers:
Were the police or law enforcement called? Yes �Vo� 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,
clo e t landmark, etc. Please be as detailed as p ssible. If necessary, attach a diagram.�-�-/,(y,U' A71 ;x �
tllr�r���5s � �,�10 W��Pc�� ,1t Sr ��u� MN � Io�
Please indicate the amount you re seeking in ompensation or what you would like the City to do to resolve this c aim
to our satisfaction. Y � C5 �G�-Ir Gt.Y.2 I D�
� ' CL S � `�� �i �%
Vehicle Claims— lease com lete this section ❑ check box if this section does not a 1
Your Vehicle: Year �Zf�l�1 Make Model '
License Plate Numbe S State V L Color fi70[Ci '
Registered Owner � � /� ;
Driver of Vehicle GU'1
Area Damaged "
City Vehicle: Year ���S U(� Make Ci�`l�V y Model t' ' �
License Plate Number �lD,'�'i LdJl��i State��/ Co or YI I ,
Driver of Vehicle City Employee's Name) �!
Area Damaged � �
In_iurv Claims—olease comnlete this section I�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 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 for►n,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 �/���Z d��
Print the Name of the Person who Completed this Form: � ��VI
Signature of Person Making the Claim: ��. �(��/
Rcviscd Fcbruary 201 1 �
.�
; � �+ PARAMOUNT MASTER COLLISION Workfile ID: 5c4c2ff6
� , � FederalID: 411916060
, � . . .
MINNEAPOLIS
�
� x Quality Auto Body Repair
� � 224 W LAKE ST, MINNEAPOLIS, MN 55408
'� � ' a Phone: (612) 827-4697
,,
s FAX: (612) 825-0765
! �:!.
3
; Preliminary Estimate
"i ,
Customer: CAMPBELL, MEGAN 7ob Number:
�� Written By:Wayne Hagford
' � Insured: CAMPBELL,MEGAN Policy#: Claim#:
� y Type of Loss: Date of loss: Days to Repair: 0
Point of Impact: 12 Front
t; _,� Owner: Inspection Location: Insurance Company:
�� `� CdMPBELL,MEGAN PARAMOUNT MASTER COLLISION
MINNEAPOLIS
gi � 3300 GIRARD AVE S 224 W IAKE ST
j� � MPLS,MN 55408 MINNEAPOLIS,MN I55408
, (701)330-6014 Cell Repair Facility
; s (612)827-4697 Business
f 'r`r
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�
�> � VEHICLE �
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�; Year: 2001 Body Style: 4D UTV VIN: JN8DR09Y51W604176 Mileage In: 999
� Make: NISS Engine: 6-3.5L-FI License: 833-VLS Mileage Out:
s � Model: PATHFINDER 4X4 LE Production Date: State: WI Vehicle Out:
Color. TAN Int: Condition: Good Job#:
'' TRANSMISSION Console/Storage AM Radio SEATS
�
'� Automatic Transmission CONVENIENCE FM Radio Cioth Seats
�� Overdrive Air Conditioning Stereo Bucket Seats
4 Wheel Drive Intermittent Wipers Search/Seek Reclining/Lounge Seats
� 4 POWER Tilt Wheel Cassette WHEELS
�
Power Steering Cruise Control Premium Radio Aluminum/Alloy Wheels
. Power Brakes Rear Defogger CD Changer/Stacker PAINT
Power Windows Keyless Entry SAFETY Clear Coat Paint -
Power Locks Alarm Drivers Side Air Bag OTHER
Power Mirrors Steering Wheel Touch Controls Passenger Air Bag Fog Lamps
, Heated Mirrors Rear Window Wiper Anti-Lock Brakes(4) TRUCK
� DECOR Climate Control ROOF Running Boards/Side Steps
� Dual Mirrors Home Link luggage/Roof Rack
Privacy Glass RADIO Electric Glass Sunroof
9/19/2014 4:51:31 PM 018806 Page 1
Preliminary Estimate
` Customer: CAMPBELL, MEGAN 7ob Number:
Vehicle: 2001 NISS PATNFINDER 4X4 LE 4D UTV 6-3.5L-FI TAN
Line Oper Description Part Number Qty Extended Labor Paint
Price�
1 FRONT BUMPER
2 0/H front bumper 1.5
3 Repl Bumper cover F20222W140 1 181.97 Incl. 2.8
4 Add for Clear Coat 1.1
5 Add for fog lamps 0.3
6 Repi Bumper cover clip upper 015532DR9A 6 1.38
7 Repl RT Bumper cover grommet 0128100111 1 1.25 Incl.
8 Repl Bumper cover clip lower 0155309241 6 9.78
9 Repl LT Bumper cover grommet 0128100111 1 1.25 Incl.
10 Repl RT Bumper mver bolt 085666202A 1 0.98
11 Repl LT Bumper cover bolt 085666202A 1 0.98
� 12 Repl RT Bumper cover finisher inner 622562W100 1 61.87 Incl.
13 Repl LT Bumper cover finisher inner i 622572W100 1 59.63 Incl.
14 Repl RT Bumper cover finisher outer 622562W500 1 61.87 Incl.
15 Repl LT Bumper cover finisher outer 622572W500 1 59.63 Incl.
16 Repl Reinforcement 620302W100 1 302.98 Incl.
17 # LICENSE BRKT 1 53.38 0.2
18 FRONT LAMPS _
19 Repl RT Fog lamp assy 261502W125 1 231.75 Incl.
20 Repl LT Fog lamp assy 261552W125 1 220.72 Incl.
21 # Rpr WIRING REPAIR 1.0
22 # HAZARDOUS WASTE 1 5.00 X
23 # Repl FLIX ADDITIVE 1 5.00 X
� SUBTOTALS 1,259.42 3.0 3.9
ESTIMATE TOTALS ,
Category � Basis Rate Cost�
Parts ! 1,249.42
Body Labor 3.0 hrs @ $55.00/hr 165.00
Paint Labor 3.9 hrs @ $55.00/hr 214.50
Paint Supplies 3.9 hrs @ $35.00/hr 136.50
Body Suppiies 1.0 hrs @ $5.00/hr 5.00 _
Miscellaneous 10.00
Subtotal 1,780.42
58125 Tax $ 1,390.92 @ 7.7750% 108.14
Grand Total 1,888.56
Dedudible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 1,888.56
9/19/2014 4:51:31 PM 018806 Page 2
HAGEN'S AUTO BODY Workfile ID: 4b287444
FederalID: 41-0858119
� 2800 Lyndale Ave S, Minneapolis, MN 55408 State ID: 9227721
Phone: (612) 872-6671
FAX: (612) 872-1738
Preliminary Estimate
Customer: CAMPBELL, MEGAN
Written By: Paul Hagen
Insured: CAMPBELL, MEGAN Policy#: Claim#:
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact:
Owner: Inspection Location: Insurance Company:
CAMPBELL, MEGAN HAGEN'S AUTO BODY
2800 Lyndale Ave S
Minneapolis, MN 55408
Repair Facility
(612)872-6671 Business } .°- -.. - .--_. .__
VEHICLE
Year: 2001 Body Style: 4D UN VIN: )N8DR09Y51VJ604176 Mileage In:
Make: NISS Engine: 6-3.5L-FI License: Mileage Out:
Model: PATHFINDER 4X4 LE Production Date: State: Vehicle Out:
Color: Int: Condition: Job#:
TRANSMISSION Console/Storage AM Radio SEATS
Automatic Transmission CONVENIENCE FM Radio Cloth Seats - �-
Overdrive Air Conditioning Stereo Bucket Seats
4 Wheel Drive Intermittent Wipers Search/Seek Reclining/tounge Seats
POWER Tilt Wheel Cassette WHEELS
Power Steering Cruise Control Premium Radio Aluminum/Alloy Wheels
Power Brakes Rear Defogger CD Changer/Stacker PAINT
Power Windo4vs Keyless Entry SAFETY Clear Coat Paint
Power Locks Alarm Drivers Side Air Bag OTHER
Power Mirrors Steering Wheel Touch Controls Passenger Air Bag Fog Lamps
Heated Mirrors Rear Window Wiper Anti-Lock Brakes(4) TRUCK
DECOR Climate Control ROOF Running Boards/Side Steps
Dual Mirrors Home Link Luggage/Roof Rack
Privacy Glass RADIO Electric Glass Sunroof `
9/29/2014 3:59:35 PM 309542 Page 1
' Preliminary Estimate
wustomer: CAMPBELL, MEGAN
Vehicle: 2001 NISS PATHFINDER 4X4 LE 4D UTV 6-3.5L-FI
Line Oper Description Part Number Qty Extended Labor Paint
Price$
1 FRONT BUMPER
2 0/H front bumper 1.5
3 Repl Bumper cover F20222W140 1 181.97 Incl. 2.8
4 Add for Clear Coat 1.1
5 Add for fog lamps 0.3
6 Repl Reinforcement 620302W100 1 302.98 Incl.
7 Repl RT Bumper cover finisher inner 622562W100 1 61.87 Incl.
8 Repl LT Bumper cover finisher inner 622572W100 1 59.63 Incl.
9 Repl RT Bumper cover finisher outer 622562W500 1 61.87 Incl.
10 Repl LT Bumper cover finisher outer 622572W500 1 59.63 Incl.
._.._ _ . __...
11 RADIATOR SUPPORT :. .._ . ` ,,
12 Repl Under cover 758924W000 1 134.02 0.3
_ _ __ __ _ _ _ __ _ __._ _ _
_ __ _ _
13 FENDER
14 Repl RT Liner extension from 12/98 638442W100 1 50.12 0.6
15 Repl LT Liner extension from 12/98 638452W100 1 53.45 0.6
16 # Subl Hazardous waste removal 1 4.00 X
17 # Repl FASTENERS 1 40.00
18 # Repl Flex additive 1 4.00 T
SUBTOTALS 1,013.54 3.3 3.9
ESTIMATE TOTALS
Category Basis Rate' Cost$
Parts 1,005.54
Body Labor , 3.3 hrs @ $56.00/hi� 184.80
Paint Labor 3.9 hrs @ $56.00/hr 218.40
Paint Supplies 3.9 hrs @ $34.00/h�' 132.60
Miscellaneous 8.00
, _ _
Subtotal j 1,549.34
Sales Tax $ 1,142.14 @ 7.7750% 88.80
Grand Total 1,638.14
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 1,638.14
9/29/2014 3:59:35 PM 309542 Page 2