Torres, Loyda NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipality...shall cause to be presented to the
governing body of t/Te municipality within 180 days after the alleged loss or injury is discovered a notice stating the time,place,and
circurnstances thereof,and the amount of compensation or other relief dernanded."
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
I ,�,'\,,- RECEIVED
First Name �✓�J�- Middle Initial Last Name ��r��S
c:ompany or Business Name OCT 13 2���
Are You an Insurance Company? Yes/No If Yes,Claim Number? ��� �� ERK
Street Address �'y "'�� �'��t�Z` S�"
City .:�� Pa�I State �� Zip Code 55� ��
Daytime Phone(�) - Cell Phone((oS 1) 2g3 -15Z}' Evening Telephone( ) -
,� r
Date of Accident/Injury or Date Discovered_���y Time t�`i S�-- 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 dama es.
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Please check the box(es)that most closely represent the 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 or condition of the street ❑ My vehicle was damaged by a plow
❑ My vehic�e was wrongfully towed and/ar ticketed ❑ I was injured ar,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 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 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 witnesses to the incident? es No Unknow (circle)
Provide their names, addresses and telephone numbers: �n C.v1 ��'Yt�i ��� � �5�-Z lv�a-`�'DOO 2,�'a13�-=1..
Were the police or law enforcement called? Ye No Unknown (circle)
If yes, what department or agency? Case#or report# �� ~�� � --053
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.
t��^�-�'`l�z��,r� i�.. �,u E�l�cu��' �c, ((�.u� Ct� C�,l.�t7{1.^u.;�--"
Please indicate the amount you are seeking in compen�ation or what you would like the City to do to resolve this claim
to your satisfaction. _����•��
Vehicle Claims- lease com lete this section ❑ check box if this section does not a 1
Your Vehicle: Year 2('(�3 Make Model c:.�S
License Plate Number � State� 1�Color
Registered Owner L.U�c��.`�or�re S
Driver of Vehicle C�r=i eA�.c_ T• F.�✓7St��
Area Damaged �Q,C�� C�rc J-� b u m 02�
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniurv Claims-please complete this section [�heck box if this section does not apvlv
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
f�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 �1 l 7-� �� �
Print the Name of the Person who Completed fhis Fo�m: � L-�%�C%C.� �c'�1�1/f' `�`
�
Signature of Person Making the Claim: . ,�, ���'� ��-'"
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OAKDALE COLLISION CENTER
1040 GERSHWIN AVENUE
ST. PAUL, MN.55128
PHONE:651-264-0909 FAX:651-264-0910
"**PRELIMINARY ESTIMATE***
09/29/2014 04:07 PM
_ ._..___ _______
Owner __ __ _
: __ _ __ _ _........ __...__ _ _ _
__.. _
Owner: Loyda Torres
Address: 74 Michael St Work/Day: (651)283-1527
City State Zip: Saint Paul, MN 55119 F��
_.. _
' Inspection
Inspection Date: 09/29/2014 04:07 PM Inspection Type:
inspection Location: OAKDALE COLLISION CENTER Contact: DON JUEN
Address: 1040 GERSHWIN AVE. Work/Day: (651)264-0909x
Oakdalecollision@msn.com FAX: (651)264-0910x
City State Zip: OAKDALE, MN 55128 F��
Email: Oakdalecollision@msn.com
Primary Impact: Left Rear Corner Secondary Impact:
Company: OAKDALE COLLISION Appraiser License#:
Contact: DON JUEN JR.
Address: 1040 GERSHWIN AVE N Work/Day: (651)264-0909
City State Zip: Oakdale,MN 55128 FAX: (651)264-0910
_ _._ _�.
Repairer ___.._ _
_ —._
--....�__. ____ __... _ _ _ _ ___ . __ _^__y _(._._ > . ._____.
Repairer: OAKDALE COLLISION CENTER Contact DON J
Address: 1040 GERSHWIN AVE. Work/Da . 651 264-0909
Oakdalecollision@msn.com FAX: (651)264-0910
City State Zip: OAKDALE,MN 55128 F��
Email: Oakdalecollision@msn.com
_ . �.
Vehicle
2003 Ford Focus ZX5 4 DR Hatchback
4cyl Gasoline 2.0 ZETEC
4 Speed Automatic
Lic.Plate: 831MYG LicState: MN
Lic Expire: VIN: 3FAFP37373R147305
Veh Insp#: Mileage Type: Actual
Condition: Code: P1575D
Ext.Color: Red Int.Color:
Ext.Refinish: Two-Stage Int.Refinish: Two-Stage
Ext.Paint Code: FI Int.Trim Code:
Options
AM/FM CD Player Air Conditioning Alarm System
Aluminum/Alloy Wheels Center Console Cruise Control
Dual Airbags Intermittent Wipers Keyless Entry System
Lighted Entry System MP3 Player Power Brakes
Power poor Locks Power Mirrors Power Steering
Page 1 of 3
09/29/2014 04:08 PM
�. _
1�_� t ;� y
2003 Ford Focus ZXS 4 DR Hatchback
Claim#: 09/29/2014 04:07 PM
Power Windows Rear Window Defroster Rear Window Wiper/Washer
Rem Trunk-L/Gate Release Split Folding Rear Seat Tachometer
Tinted Glass Velour/Cloth Seats
;�._._....._,,� _,.,.��..,..�..._.�. .�..�...__�.._...._.._ ._.__..._.....,�_.....___w.____.___..�..._..._.....��. , .�__....,._�.._�..._��.......,....�..�..__._..�..�..._._.._�w___.T__.. ____.�..�€
; Damages
Line Op Guide MC Description MFR.Par#No. Price ADJ% B°/a Hours R
�
Rear Bumaer
1 N 571 RR Bumper Cvr Overhaul Additional Labor 1.6 SM
2 I 565 Cover,Rear Bumper Repair 3.0* SM
3 L 565 13 Cover,Rear Bumper Refinish 3.4 RF
2.3 Surface
0.6 Two-stage setup
0.5 Two-stage
Manual Entries
4 SB HAZARD.WSTE. REM. Sublet Repair $4.00' SM
5 EC FLEX ADDITIVE Replace Economy $4.00" SM'
6 EC BUMPER REPAIR KIT Replace Economy $10.00` SM
6 Items
MC Message
13 INCLUDES 0.6 HOURS FIRST PANEL TWO-STAGE ALLOWANCE
�, rEstimate Total&Entries �� .... .__�.. �_.._.___.._. .._____.� __...� _�...________ w.,,_�-__......,_�
Other Parts $14.00
Paint Materials $115.60
Parts&Material Total $129.60
Tax on Parts&Material @ �•�25% $9•23
Labor Rate Repiace Repair Hrs Total Hrs
Hrs
Sheet Metal(SM) $54.00 4.6 4.6 $248.40
Mech/Elec(ME) $85.00
Frame(FR) $75.00
Refinish(RF) $54.00 3.4 3.4 $183.60
Paint Materials $34.00
Labor Total 8.0 Hours $432.00
Sublet Repairs $4.00
Gross Total �574.83
Net Total $574.83
Alternate Parts No
Audatex Estimating 7.0.334 ES 09129/2014 04:08 PM REL 7.0.334 DT 09/01/2014 DB 09/15/2014
Copyright(C)2013 Audatex North America, Inc.
1.1 HRS WERE ADDED TO THIS ESTIMATE BASED ON AUDATEX'S TWO-STAGE REFINISH FORMULA.
Page 2 of 3
09/29/2014 04:08 PM
_ -. , �i��,� ,.
2003 Ford Focus ZX5 4 DR Hatchback
Claim#: 09/29/2014 04:07 PM
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 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 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= Repiace 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 8�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
��f���"�� Audatex's prior written consent.
i��
:�Strdi�ra�t�n���r�r
-° Copyright(C)2013 Audatex North America, Inc.
Audatex Estimating is a trademark of Audatex North America, Inc.
,
Page 3 of 3
09/29/2014 04:08 PM
,.,. k ,...
� ��-,._ -_
n HEPPNER'S AUTO BODY (Woodlane) Workfile ID: 4cd4d681
1807 WOODLANE DR, WOODBURY, MN 55125
Phone: (651) 735-5055
FAX: (651) 735-5057
Preliminary Estimate
Customer: TORRES, LOYDA 7ob Number:
Written By: Melissa Thuringer
Insured: TORRES, LOYDA Policy#: Claim #:
Type of Loss: Date of Loss: ' Days to Repair: 0
Point of Impact:
Owner: Inspection Location: Insurance Company:
TORRES, LOYDA HEPPNER'S AUTO BODY(Woodlane)
74 MICHAEL ST 1807 WOODLANE DR
ST PAUL,MN 55119 WOODBURY, MN 55125
(651)283-1527 Business Repair Faciliry
(651)735-5055 Day
VEHICLE
Year: 2003 Body Style: 4D H/B VIN: 3FAFP37373R147305 Mileage In:
Make: FORD Engine: 4-2.3L-FI License: 831MYG Mileage Out:
Model: FOCUS ZX5 Production Date: State: MN Vehicle Out:
Color: RED Int: Condition: Job#:
TRANSMISSION Dual Mirrors AM Radio Bucket Seats
Overdrive Body Side Moldings FM Radio Reclining/Lounge Seats
5 Speed Transmission Console/Storage Stereo WHEELS
POWER CONVENIENCE Search/Seek Aluminum/Alloy Wheels
Power Steering Air Conditioning CD Player PAINT
Power Brakes Intermittent Wipers SAFETY Clear Coat Paint
Power Windows Rear Defogger Drivers Side Air Bag OTHER
Power Locks Keyless Entry Passenger Air Bag Fog Lamps
Power Mirrors Rear Window Wiper SEATS
DECOR RADIO Cloth Seats
9/27/2014 11:18:36 AM 018571 Page 1
.�. . . °k�. ... .." „P
Preliminary Estimate
Customer: TORRES, LOYDA 7ob Number:
Vehicle: 2003 FORD FOCUS ZX5 4D H/B 4-2.3L-FI RED
Line Oper Description Part Number Qty Extended Labor Paint
Price$
1 REAR BUMPER
2 R&I R&I bumper cover 1.0
3 * Rpr Bumper cover �.4 J..�
4 * Add for Clear Coat Ll
5 # partial paint full clear 1
6 # Repl �Flex Additive 1 3.00 T
7 # possible hidden damage 1
SUBTOTALS 3.00 4.0 3.6
ESTIMATE TOTALS
Category Basis Rate Cost;
pa� 0.00
Body Labor 4.0 hrs @ $55.00/hr 220.00
Paint Labor 3.6 hrs @ $55.00/hr 198.00
Paint Supplies 3.6 hrs @ $35.00/hr 126.00
Body Supplies 3.0 hrs @ $3.00/hr 9.00
Miscellaneous 3.00
Subtotal 556.00
Sales Tax $ 129.00 @ 7.1250% 9.19
Grand Total 565.19
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 565.19
THIS REPORT IS BASED ON OUR INSPECTION AND DOES NOT COVER ANY ADDITIONAL PARTS OR LABOR WHICH
MAY BE REQUIRED AFfER THE WORK IS OPENED UP. OCCASIONALLY AFfER THE WORK HAS STARTED,WORN OR
DAMAGED PARTS ARE DISCOVERED WHICH ARE NOT EVIDENT FIRST INSPECTION.
MN 5T 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.
9/27/2014 11:18:36 AM 018571 Page 2
j�.:>'�. 4 '�.._.
j Preliminary Estimate
Customer: TORRES, LOYDA 7ob Number:
Vehicle: 2003 FORD FOCUS ZX5 4D H/B 4-2.3L-FI RED
Estimate based on MOTOR CRASH E5TIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
DR2JK00, 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 r ect some specific, special, or unique pricing or discount.
OPT OEM or ALT OEM parts may include "Blemished" p rts 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 pr�vious 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=A�termarket 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.
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.
9/27/2014 11:18:36 AM 018571 Page 3