Benegas, Ruben ��
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NOTICE OF CLAIM FORM to the City of Saint Paul, Minnes�a' �� '
Minnesota Stute Statute 466.05 stutes thut "...every person...who dnims damages from any municipulity...shull cause to be presented to the
governing body of the mttnicipuliry within 180 days ufier the alleged loss or injury is discovered u notice stating the time,place,und
circumstcmces thereof,und the mm�unt of compensntinn or other relief demunded.°
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 dces 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 A Last Name �e f�/ � 'a �
Company or Business Name /�� �
Are You an Insurance Company? Yes/ 10� If Yes,Claim I�Tumber?
Street Address � � �� � � �'� �-� i) /�'v�=
City �� I J �"v� State M � Zip Code�l� f
Daytime Phone(�2}�� ��Cell Phone( 6 (� ��S S�ef�ing Telephone( ���- a-'�S SS ��
Date of Accidend Injury or Date Discovered�_� � � I � Time ` � 3 6 am/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.
C' ' 7' ' � ( C � - i �-
i� . M (/w i 1� .
i�=� � I -
Ple 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
❑ Other type of injury-please specify
In order to process your claim vou need to include conies of all applicable 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'�roperty 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 ot Z—Ptease 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-please 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? es� No .- Unknown (circle)
If yes,what department or agency?��i��-t-' - ��� ��ase#or report# y
Where did the accident or injury take place? Provide street address,cross street,intersection,name of park or facility,
closest lapdmark,etc. Please be as detailed as possible. If necessary, attach a diagram. 1 �Z� �1�1'�~>>
�--t-r-- C 1 ��'`�L /�l�' S�/�' t/ /4 `j�2- �,c_,�}-S I?/�K=�L� / /1i )�7-e:�'�.�'� �;(--
y',l H t�� �-�_ .
Please indicate the amount u are se 'n in com ensation or what you would like the City to do to resolve this claim
to your satisfaction.
" � ' /L'Ltv /�'
' h y r� � 7� �''}-� r'�-°�=�� � -,�
Vehicle Claims-ulease complete this section , ❑ check box if this section does not annlv
Your Vehicle: Year z�� Make ��5�5��� Model ���f �1"`D�"-7Z-
License Plate Number G'� 3��F State 1�'1�'�Color �L��
Registered Owner �-` 3�-''� ������
Driver of Vehicle M `1 1s��t'� ��� �'��'-r �
Area Damaged Q I�� `���' S � D��
City Vehicle: Year �v I f Make l�'I��Z_Model � f'��
License Plate Number �3 � ���2 State M i"Color � �-�' �
Driver of Vehicle(City Employee's Name) �( i.i � i='H't�G,
Area Damaged U �� l�'�-'�� � � I�`
Iniurv Claims-nlease complete this section �check box if this section does not avnlv
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 fornz,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 ��/� ��
i �
Print the Name of the Person who Completed this Form: �`' �E� ���'��`�j
Signature of Person Making the Claim:
Revised February 2011
Accident Report Page 1 of 1
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PATROL Jeffrey Thissen 3 3 i�3 St Paul PD �� p.�,,. pe,.„
https.//dvscrash.x.state.mn.us/dvsmfo/accidentrecords_2008/Includes_LE/PrintRepoRlndiv 8/18/2014
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651-224.2828.w�N 55�p4
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�otu�10g�V��ve�s`ry P�e LATUFF BROS., INC.
a 880 UNIVERSITY AVENUE
ST. PAUL,MINNESOTA 55104
(651)224-2828 FAX:(651)291-0677
FEDERAL ID#41-0777034
*'*PRELIMIN RY ESTIMATE*""
09/0312014 12:56 PM
�
Owner
Owner: RUBEN BENEGAS H►ork/Day: (612)875-5531
Address: 1728 ASHLAND AVE Cell: (612)875-5531
City State Zip: Saint Paul, MN 55104
FAX:
i
�
Inspection
Inspection Type: Drive In
Inspection Date: 09/03/2014 12:54 PM Contact:
Inspection Location: Latuff Brothers Inc Work/Day: (651)224-2828x
Address: 880 University Ave FAX: (651)291-0677x
City State Zip: Saint Paul, MN 55104 WorklDay:
Email: general@latuffbrothers.com Secondary Impact:
Primary Impact: Left Front Corner Rental Assisted:
Driveable: Yes
Appraiser Name: ROBERT LATUFF Appraiser License#:
l
�_Repairer ____ Contact:
Repairer: Latuff Brothers Inc Work/Day: (651)224-2828
Address: 880 University Ave FAX: (651)291-0677
City State Zip: Saint Paul, MN 55104
Work/Day:
Email: general@latuffbrothers.com
Target Complete DatelTime:
Days To Repair: 2
J
Remarks
i
2 DAY REPAIR
***'*'"*"'*PRELIMINARY ESTIMATE"""'"""""'�"`�"'
POSSIBLE ADDITIONAL DAMAGE MAY BE FOUND AFTER TEAR DOWN �
Vehicle
2014 Nissan Pathfinder Platinum 4 DR Wagon
6cyl Gasoline 3.5
Continuously Variable Tr
Lic State: MN
Lic.Plate: 063LFF VIN: 5N1AR2MM2EC645415
Lic Expire: Mileage:
Prod Date: 10/2013 Mileage Type: Actual
Veh Insp#: Code: Z7144D
Condition: Int.Color:
Ext.Color: MEDIUM BLUE MET Int.Refinish: Two-Stage
Ext.Refinish: Two-Stage Int.Trim Code:
Ext.Paint Code: RBG Pa9e�or 4
09/03/2014 12:58 PM
Avr� �Et.ai�qbO�t •
our
I
2014 Nissan Pathfinder Platinum 4 DR Wagon
Claim#: 09/03/2014 12:56 PM
Options
1 st Row LCD Monitor 2nd Row Head Airbags 3rd Row Head Airbags
4-Wheel Drive AM/FM CD Player Aluminum/Alloy Wheels
Amplifier Anti-Lock Brakes Auto Headlamp Control
Auto Locking Hubs(4WD) Automatic Dimming Mirror Bodyside Moldings
Bose Sound System Bucket Seats Camper/Towing Package
Center Console Climate Cntrl Frnt Seats Cruise Control
Digital Signal Processor Driver Seat Memory Dual Air Conditioning
Dual Airbags Dual Power Seats Dual Zone Auto A/C
Electronic Transfer Case Fog Lights Full Size Spare Tire
Garage Door Opener Halogen Headlights Head Airbags
Heated Frnt&Rear Seats Heated Power Mirrors Heated Steering Wheel
IPOD Control Illuminated Visor Mirror Intermittent Wipers
Keyless Entry System Leather Seats Leather Shift Knob
Leather Steering Wheel Lighted Entry System MP3 Player
Mirror(s)Memory Navigation System Overhead Console
Perimeter Alarm System Power Brakes Power poor Locks
Power Liftgate Power Steering Power Windows
Privacy Glass Pwr Accessory Outlet(s) Pwr Driver Lumbar Supp
Pwr Tilt/Tele. Str Wheel Rear Heater Rear Spoiler
Rear Window Defroster Rear Window Wiper/Washer Rem Trunk-L/Gate Release
Reverse Sensing System Roof Rails Side Airbags
Split Folding Rear Seat Stability Cntrl Suspensn Strg Wheel Radio Control
Surround Cameras Tachometer Third Seat(trucks)
Tire Pressure Monitor Tow Hooks Traction Control System
Trailer Hitch Trip Computer USB Audio Input(s)
Wireless Audio Streaming Wireless Phone Connect Wood Interior Trim
XM Satellite Radio
Damages
Line Op Guide MC Description MFR.Part No. Price ADJ% B% Hours R
Front Bumner
1 N 22 Frt Bumper Cvr Overhau Additional Labor 4.4 SM
2 I 6 Cover,Front Bumper Repair 1.0* SM
3 L 6 # Cover,Front Bumper Refinish 3.4* RF
2.3 Surface
0.6 Two-stage setup
0.5 Two-stage
#=10, 13
»BLEND BASE FULL CLEAR COAT
Manual E tn ries
4 N M03 Flex Additive Additional Labor $6.00' RF
5 SB M60 Hazardous Waste Removal Sublet Repair $5.00" SM
5 items
MC Message
10 INCLUDES AUDATEX TIME TO CLEAR ENTIRE PANEL
13 INCLUDES 0.6 HOURS FIRST PANEL TWO-STAGE ALLOWANCE
Estimate Total&Entries �
Other Parts $6.00
Paint Materials $119.00
Page 2 oi 4
09l03I2014 12:58 PM
2014 Nissan Pathfinder Platinum 4 DR Wagon
Claim#: 09I03/2014 12:56 PM
Parts 8�Material Total $125.00
Tax on Parts&Material @ 7.625% $9.53
Labor Rate Replace Repair Hrs Total Hrs
Hrs
Sheet Metal(SM) $55.00 5.4 5.4 $297.00
MechlElec(ME) $85.00
Frame(FR) $75.00
Refinish(RF) $55.00 3.4 3.4 $187.00
Paint Materials $35.00
Labor Total 8.8 Hours $484.00
Sublet Repairs $5.00
Gross Total $623.53
Net Total 3623.53
Alternate Parts No
SPPL Yes Zip Code: 55104 Default
Audatex Estimating 7.0.226 ES 09/03/201412:58 PM REL 7.0.226 DT 07101/2014 DB 09/01/2014
Copyright(C)2013 Audatex North America, Inc.
1.1 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 MANUFACTURER OF YOUR MOTOR VEHICLE.
WARRANTIES APPLICABLE TO THESE REPLACEMENT PARTS ARE PROVIDED BY THE PARTS
MANUFACTURER OR DISTRIBUTOR RATHER THAN BY THE M�1I�TUFACTURER 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 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= Related Prior Damage
Page 3 of 4
09/03/2014 12:58 PM
2014 Nissan Palhfinder Plalinum 4 DR Wagon
Claim#: 09/03/2014 12:56 PM
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
�����"�s� Audatex's prior written consent.
�s�,,��=a�������.r,
Copyright(C)2013 Audatex North America, Inc.
Audatex Estimating is a trademark of Audatex North America, Inc.
Page 4 of 4
09/03/2014 12:58 PM
ABRA Auto Body & Glass - Eagan Workfile ID: e653b928
FederalID: 41-1942823
Right The First Time...On Time
1399 TOWN CENTRE DR, EAGAN, MN 55123
Phone: (651) 452-0717
FAX: (651) 454-6430
Preliminary Estimate
Customer: Benegas, Ruben 7ob Number:
Written By: MIKE ANDERSON
Insured: Benegas, Ruben Policy#: Claim #: ANONE
Type of Loss: Collision Date of Loss: 8/18/2014 12:00:00 PM Days to Repair: 0
Point of Impact: 11 Left Front
Owner: Inspection Location: Insurance Company:
Benegas,Ruben ABRA Auto Body&Glass-Eagan CUSTOMER PAY
1728 ASHLAND AVE 1399 TOWN CENTRE DR
ST PAUL, MN 55104 EAGAN, MN 55123
(612)875-5531 Business Repair Faciliry
(651)452-0717 Business
VEHICLE
Year: 2014 Body Style: 4D UTV VIN: 5N1AR2MM2EC645415 Mileage In: 7801
Make: NISS Engine: 6-3.5L-FI License: 063LFF Mileage Out:
Model: PATHFINDER 4X4 Production Date: 10/2013 State: Vehicle Out:
PLATINUM
Color: BLUE Int: Condition: ]ob#:
TRANSMISSION CONVENIENCE Stereo Leather Seats
Automatic Transmission Air Conditioning Search/Seek Heated Seats
4 Wheel Drive Intermittent Wipers CD Player Rear Heated Seats
POWER Tilt Wheel Auxiliary Audio Connection Ventilated Seats
Power Steering Cruise Control Premium Radio 3rd Row Seat
Power Brakes Rear Defogger Satellite Radio WHEELS
Power Windows Keyless Entry SAFETY 20"Or Larger Wheels
Power Locks Alarm Drivers Side Air Bag PAINT
Power Mirrors Steering Wheel Touch Controls Passenger Air Bag Clear Coat Paint
Heated Mirrors Rear Window Wiper Anti-Lock Brakes(4) OTHER
Power Driver Seat Telescopic Wheel 4 Wheel Disc Brakes Fog Lamps
Power Passenger Seat Climate Control Traction Control Rear Spoi�er
Memory Package Dual Air Condition Stability Control TRUCK
DECOR Navigation System Front Side Impact Air Bags Rear Step Bumper
Dual Mirrors Backup Camera w/Parking Sensors Head/Curtain Air Bags Trailer Hitch
Body Side Moldings Remote Starter Hands Free Device Trailering Package
Privacy Glass
Home Link Positraction Power Trunk/Gate Release
Console/Storage RADIO ROOF
Overhead Console AM Radio Luggage/Roof Rack
9/2/2014 2:48:37 PM 014556 Page 1
� Preliminary Estimate
Customer: Benegas, Ruben 7ob Number:
Vehicle: 2014 NISS PATHFINDER 4X4 PLATINUM 4D UN 6-3.SL-FI BLUE
Wood Interior Trim FM Radio SEATS
9/2/2014 2:48:37 PM 014556 Page 2
' Preliminary Estimate
Customer: Benegas, Ruben ]ob Number:
Vehicle: 2014 NISS PATHFINDER 4X4 PLATINUM 4D UTV 6-3.5L-FI BLUE
Line Oper Description Part Number Qty Extended Labor Paint
Price;
1 FRONT BUMPER
2 R&I R&I bumper cover 13
3 * <> Rpr Bumper cover � 3•2
4 Add for Clear Coat 13
5 R&I RT Trim cover w/fog lamps 0.1
6 R&I LT Trim cover w/fog lamps 0.1
7 R&I License bracket 0•2
8 R&I Lower molding �•Z
9 R&I Spoiler 0.3
10 R&I RT Lower deflector 0.1
11 # Rpr buff LT side doors for scratch 1.0
12 # Repl �Flex Additive/Adhesion Promoter 1 8.50 T
13 # �Hazardous Waste 1 5.00 X
SUBTOTALS 13.50 4.8 4.5
ESTIMATE TOTALS
Category Basis Rate Cost;
Pa� 0.00
g�y��r 4.8 hrs @ $52.00/hr 249.60
Paint Labor 4.5 hrs @ $52.00/hr 234.00
Paint Supplies 4.5 hrs @ $32.00/hr 144.00
Miscellaneous 13.50
Subtotal 641.10
Sales Tax $ 152.50 @ 7.1250% 10.87
Grand Total 651.97
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 651.97
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.
9/2/2014 2:48:37 PM 014556 Page 3
Preliminary Estimate
Customer: Benegas, Ruben 7ob Number:
Vehicle: 2014 NISS PATHFINDER 4X4 PLATINUM 4D UlV 6-3.5L-FI BLUE
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
ARF3638, CCC Data Date 8/15/2014, 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 refl�ct some specific, special, or unique pricing or discount.
OPT OEM or ALT OEM parts may include "Blemished" parts provided by OEM's through OEM vehicte 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=Blend. 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. I
The following is a list of abbreviations that may be used in CCC ONE Estimating that are not part of the MOTOR
CRASH ESfIMATING 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.
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