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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. n ltX�S 1� Y' �CO3 � c�S U � {" � •n o.�' �+ � � `�h.e. u �J i i� �k Y2Cfi�C riJQ.1f b1� �3U1'riI9�.1�Of�,YY1►,1 C�l�• 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: . ,�, ���'� ��-'" ( Revised February 2011 y J ��.�c�-e,�, Accident Report ' Page 1 of 1 ' � �,xx��F� ,�.� s"'�','.sru�o�"�'Ir��'�utia��Ijr.oP�o�ri" 1�"""'"'-�,rr"""�; ��, .:� � a� ,...... 14161053 �t��•a:;'��'' fE�..I�����'�.. 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O1 7259 LAVERNE AVE S I3 O1 -; 74 MICHAEL ST N O1 11 pryMy GTY,SIAfL[� •UIV,Sfl11f fm yMYYl O1 COTTAGE GROVE 55016 ST PAUL 55119 O1 0 �¢"" �M �4 `tt'�04 04 OS' N >°°Q"., �E �4 �e09 04 u��5 �N� p1� KG�I 1me oai�G �vrE ru��oa� �wtMSV:�r sMxwANCF4�F+rs IIIR.V�ern i.�wt nnt onue rr=u ToMw -wusroni,wr,xw1waxmKii awMwrn � 98 t�" 98 N o,"�„ :°lt1 98 l�" 98 N p�� p�(.W pY[RYWE � fMC �4�NRMNMIF �II� payp O1 City of St Paul N , TORRES LOYDA N 01 �E��rvn �ravlFCa -ovTn ,AM�ees mHFD �sMrr 38 N `. 74 MICHAEL ST , N O1 KnI18f J*�.9f�lELi NM.WII pNECi Cl'Yl"A�k.!/ WtYN4 pMCCT �FMWF 11 St Paul, Mn "IC` 05 ST PAUL MN 55119 "'M O1 O1 tl�('lOC W.R! �M�OFL YEAP COIM WME YWI�. YkM :J{pll y/�IOG 06 FORD FXS 00 red " 06 OM({NFV R��FI S�'!G YCMRC2 ` �iY{M4•1 MW�.WIYI�lMt•'lAiC1 S1(IEV Y�.WIV�G .i �.fM101*�11 �YIYIN ONGLCv 02 Medic6 MN O1 O1 , 831MYG MN 14 02 n'� O1 � 02 �a�awc� c�aicr�uuac� Nwuwu.mw�n +aw wu�wr� city of St Paul � State Farm 2088394c2523 ,� , ����� �� �'�� �'���� �ACCIDENTNIVOI.VEDACOYMERCULMOTORVEX�C�E,$CNOOLBUS,ORME/1DSTARTBU9 �n r�ue�T t� ,� " qEMEMBER TO NOTIFlI TII!ETATE PA7ROl(nqWM un0er M81lf.7!]�nd 169AS11�. :xlMllMW4RI�GiMq6FF1 M�'liNfXiPIFfl14W CO'NIW9Li CdMMR('J4V[�ypyCNYPW3 WIOIIUMalXIW1L MiMIYKM MdWOlM•MI'Nk5Sk5 lMi v�pIMIMItU01R�1 8l4 �YPL Wt AMY6 fFR, MIR: 77lqfiP fIVNSP(MI � � ONM NlSFAJICk IIIMYII�BC� � aA�h• \ . Owy 11u11!L1M,'t M1MNVIMlN � � �VIYL� O� YR91RVIfl MMM11111f11 O ''__—_ OM4l, � TvMFNf✓��rfR��YNC0i1qICN�'aN0[fM/'��W4iWWQUNOMIMY�MtM111Yf�tTYIAUMINkN'S) M�MC.FOM�IRR'VrrLLIOWIM.M�W�II. (�� �� ac��w 7Y �j'+• uwnn�ni. _ — ' txwc: �1 � � �1 ucaww tif � Veh {2 r+as stopped in parking lot facinq North , �3 �t' �K bound at Shepard and Chestnut waiting to pull tIXIIN O�' �'� � Q� out Veh Y1 was Medic 6 responding to a medical �6 �O call Veh kl was pulling into parking lot south �^�+ S• N « � bound and stzuck Veh f2 tlriver side rear bumper �iM� N with their driver side reai bumper while pulling �,.Ea wr`. � t� 'into the full parkinq lot ��4 9 8 G ��', fMIWM J� � � � �� �� � �; YTArAE�1 �y 1��Y x= x� QZ i1t�k�`hw�l y� � t4 .j� WUM.X 1 N_ 7; x• .r:•�. � R� ._. � 08 � t � - .�"" � .,w�. ri �r na 9�.sc ;�' O1 - A O 1 � � �,r �s . ky ia N �i � �'� au.w, w c�.n X{ .� �1 2 �t 0 9 - Oli�CERIW�CMiYEYO�WOF --__f• • MC'K'�' MfNO tTa'KW �61I1lMIMQ ICYJI � officer Amy Rahlf 323 St Paul PD CN p„�„„ po,�w I , . .� https.//dvscrash.x.state.mn.us/dvsinfo/accidentrecords 2008/Includes_LE/PnntReportIndiv 8/25/2014 � y � � : � � � � - � • �� •-�- �� •• • . . , ( ��� � � -.. 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