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David Anderson i � � NOTICC OF CLAIl�i FORM to the City of S�int Paul, IViinnesot� A�lrr�nesola Slnte SYntule=/66.05 siales Ihal " ...e>>e��persnn...�rho clni�ns dnnuiges fi�on��...shnll cnuse lo be preseiiled to tfte goi�erriing boclv q/'11ae nuuuci��nlrh�u�it6iin lb0 dnys nfier Ihe nlleged loss o�-injwy is discovered a nolice stati��g N�e trnze,pince, nnd circunz.slnnces�hereof, n��d the n�nowal o/comper�salia�or��i� ��c�ieJ��lc��'`�Iecl.„ Please coroplete tl�is form in its entirety by clearly typing or printing you •� ��vGr;t �question. If more space is needed,attacl► additional sheets. Ple�se note that you will not be contacted��te�e�tS��to clarify answers,so provide as much information as necessary to ex��lain your claim,and the amount of compensation being requested. You will receive� ��ritten acl:nowledgement once your i'orm is received. TI►e process can talce up to ten weelcs or longer depencling on the nature of'yow•claim. This form must be signed, and both pages completed. If something does not�pply,H�rite `N/A'. S�ND COMPLETCD FORM ANn OTH�R DOCUIVIENTS TO: CITY CL�RI�, 15 W�ST K�LLOGG BLVD, 310 CITV I:IALL, SAINT PAUL, MN 55102 Tirsi Name �� Middle lnitial� L1st Name�.�'�G��:>„� Comp�ny or I3usiness Name� Are You an Insurance Comp�ny? Yes�lf Yes, Claim Number? Street Address 7/ f—t` -C'Gc=.cl4/�w /,'vr CitY�_/N � �.C.F�E"..r State�,s�i Zip Code f'"-��%Y Daytime I'hone (�r�)�;_-��'y�_Cell Phone (��_- Cvening Telephone(Gr/ 7d�o -(oi Date of Accident/ Injury or Uate Discovered /a1/L�l� Tlllle��Z_8111 � ll ��O�SE St2te, IIl C�Ot�I�, W�lc1t OCCIII'I'0CI �I71�)��011eCI�, i111C� W�ly)�011 al'e SUli171lttI11�T 8 CI�IIII. PI0c�S8 111CIIC�lYO Wlly OC Il0\��y011 feel the City of Saint Paul or its employees are involved and/or res��onsible for youc damages.��L�� fCs�I�c.�rTL� jy/J" C��'� /.( T1Y��-�u�<. ,��'�/�..,✓�Y To�,�/�r .�'.4't�efi�i'� �� v r.4'�'r+ /�a i�<r w� ,� „�c'.�'.�,—�L'� /`��it�� C✓c' , �,vc �c�C/l�',,S" cf f si/�' � � /�tt.c� L!�' �.L ��'� i: i5��?6 !�-/C`��c [✓�'isf�t '�cc�f/� �,,� ��! << <��! � �� E�-�,��',-l', r' /�,– ,�' �±/'t _ T — � � � _ _ � , � . « �- �- ' �� L✓�-�:�5 LiOT�,,�. , lease c�ecl: he �ox es th�t most c osely represent the reason for completin his form: � My vehicle was damaged in an accident ,��My vehicle was damaged durin�a tow ❑ My vehicle was damagecl by a pothole or condition of the street ❑ My vehicle was dama�;ed by a plow ❑ My vehicle was wrongfiilly to�ved and/or ticl:eted ❑ 1 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�ll applic�ble documents. For the claims types listed below, ple�se be sure to include the documents indic�ted or it will delay the handling of your claim. Documents WILL NOT be returned and become the propecty of the City. l'ou are encouraged to l:eep 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 ticl:et issued and a copy of ihe impound lot receipt O Other property dam�ge claims: two repair estimates if the damage exceeds $500.00; oc the actual bills and/or receipts for the repairs; detailecl list of damaged items O Injnry claims: medical bills, receipts O Photographs are always�velcome to docnment and support youc cl�im but will not be returned. Page 1 of 2—I'le�se complete and retw•n boih pages of Claim Form r�ilure to complete and rehu•n both pages��ill result in delay in tl�e handling of yow-claim. All Cl�ims—n�e<�se com��lete ihis section Were there witnesses to Ihe incident? Yes ��1'o Unl:nown (circle) Provide their n�mes, addresses and telephone numbers: Were the police or law enforcement called? Yes � UniCIION�R (circle) If yes, what cle��artment or agency? Case# or report# Where did the accident or injury tal;e place? Provide street address, cross street, intersection, name of parl:or facility, closest landmark, etc. Please be 1s detailed as possible. If necessary, attach a diagr�m. Please indicate the amount you are seel:ing in compensation or�-vhat you wou(d lil:e the City to do to resolve this cl�im to �our satisfaction. ` � ) S�' L 1V c-1 D i�/� �' J7,L9�f_�T Vehicle Claims—l�le�se com �lete this section ❑ checl: box if this section does not a»I Your Vehicle: Year �� Mal:e l�i c_ Model �fjr�� License Plate Number ��;J f�� State,��Color�� Rebistered Owner/,��,�,l, ��F,,_r::_, Driver of Vehicle ' Area Damaged -- ` v �.✓ t City Vehicle: Year Mal:e Mo el License Plate Number State Color Driver of Vehicle (City Tmplo}�ee's Name) Area D�maged Iniury Claims—please co�nplete this section , cl�ecl:box if this section does not au�ly 1-low were you injured? Wh�t part(s)of your body wece injured?_ Have you sought medical treatment? Yes No Pl�nning to Seel:"I'reatment(circle) When did you receive treatment? (provide date(s)) Name of Medical Provider(s): Address Telephone Did you miss worl:as a cesult of your injury? Yes No When did you miss worl:? (provide date(s)) Name ol�your Cmployer: Address Telephone ❑ Checic here if you are att�ching more pages to tl�is claim form. Number of�dditional p�ges By signi�tg tlris fnrnz,yorc «re statiirg t/�at a/l i�tfornzntio�i>>ou hrrne pronided is trire niid correct to the best nf yorrr InroivCerlge. Unsig��ed fornls �vi!l�int be processed. SI[Gili[t/Ill�!l flIISL� CIQIi91 Cl1yl /�esult iii prosecutin��. Date form was completed j�pr�l T''L'�' Print the N�me of t1�e Perso�i w�ho Compleled this Form: ,/>�6 ,,� �}/�y�� Signat�n•e of Person M�lcing the Clai�n:/��.-- C Revised l�'ebruary 201 I ��•�•�'�+�1� �� I �s�� f��` 1 i �, �� - _ � ��/ ' ' J � 1 • �, I � � � 1 i � �i �i �� i � � � � �� + � �� 1 . i' � :�, � �. � . � � � � ,:�►,��!�� , . ��► [' � ' � !!:� �� `� ( �, � ,. � � ��. + , ,�'� � � � .� �: � � �,,t :��"� � ' �'i��i G• � y '� i�' � I � 1��' �1 .� �� s �� . � � {,., �� _ - .�,r��' � � _ �� iA � � ,�t�1�� ,�� r � �� 1� � ,,• � � ��.,1� ,�► 1 • ,� 1� � ' � �� / �k �►/""'• �1' 1 , 1 1 A� . ►��/ �� ,� � � � ; 1'. � •� 1 � � ��,•�� , �,, ��: � ` � � ��'�' �, �� ; i: ' �� ' :� � �t+ �� 11 i� � �� ; �,;, . i�1 � 1�; �� "'��, 2� �t�� 7 � ' �� 1;`��i� � � �� ;� �� y� . �I' �� .; ��'�� `�:'� a K� 1 � �� i / ,t� � � �r'�� rt 1�� ,� � � � r , � , � � . �� ,,. � � •. � I � � r��jr � � .� _��..�:•�� '•'� �,� ��r �j ;; - �� ;� � � � _ � j� � j � .r � �► �� .r , � � � . , j� ji �. � � j�� , �► � , � � � ► i ► - . . . . � � 9�:rs �4 F �; . �� ,a �G,yT , ,� , `, � � �--- �—�----_.��,��.�!!ii�!i�� ,. . Saint Paul Police Impound Lot, 830 Barge Channel Road, Vehicle Release Form Make: 96 GMC License#: RGU103 CN: 11262442 Invoice#: 135059 DatelTime Released: 12/22/2011 18:19 Tow Charge: $ 54.50 Released to: TOTO Storage Charge: $ 90.00 Paid by: CREDIT CARD Admin Charge: $ 80.00 Released by: DEBORAH Tax: (7.625%) $ 10.26 I,the undersigned,have recovered the vehicle described above. Subtotal: $ 234.76 I will check the vehicle for damage or any other problems that may have occurred while this vehicle was in the custody of the Service Charge: $ 0.00 Saint Paul Police Department. I acknowledge I will report damage and/or any other problems to the Impound Lot staff Total Charges: $ 234.76 on this form prior to leaving the impound lot. Damage and/or other problem:� —,!'--�.�� /��, J��f�f � �� ✓ �.•�.��,�,--. ;<��,�"�`�� 5� �'rsf-�E- �'l�'�br��,v��!, �;,��,,��r� �,��r��7,�'.�f' /N ,''.��'.C��f .C��" �l'1s.t�i�,��'''�l'�<ErT C��v e�/'�/�,C_ Police Report hiade: Yes_No_IF Yes, CN , If NO, Why? TO PROTECT YOUR RIGHTS REPORT ANY PROBLEMS/DAMAGE BEFORE LEAVING THE LOT �d�� 5/2000 Signature�� .,�.,,� .a._ _ �, • - •_ FRIDLEY AUTO BODY 960 OSBORNE ROAD N.E. FRIDLEY, MN 55432 OFFICE: 763-784-4211 FAX:763-784-4233 TAX ID#26-3858666 WWW.FRIDLEYAUTOBODY.COM ***PRELIMINARY ESTIMATE`** 01/11/2012 03:28 PM --._ ---....._ __— --._--------- ----� Owner I Owner: dave andersen Address: 155 glenview ave Work/Day: (952)292-1241 City State Zip: Lino Lakes, MN 55014 FAX: ._ - --------------—..------_ _ __--__ _-- _-- ! Inspection Inspection Date: 01/11/2012 03:29 PM Inspection Type: Appraiser Name: Greg Estuesta Appraiser License#: Address: 960 OSBORNE RD NE Work/Day: (763)784-4211 City State Zip: Fridley, MN 55432 FAX: (763)784-4233 Email: greg@fridleyautobody.com ___ _— -------------- — � Re airer t--p-- ---- — ------- ___ _ _.__ _._.- — — Repairer: FRIDLEY AUTO BODY Contact: Address: 960 OSBORNE RD NE Work/Day: (763)784-4211 FAX: (763)784-4233 City State Zip: FRIDLEY, MN 55432 Work/Day: Email: info@fridleyautobody,com ,--....------ � Vehicle , __ --- -- --___---------- 1996 GMC K1500 SLT 2 DR Ext Cab Short Bed 8cyl Gasoline 5.7 4 Speed Automatic Lic.Plate: RGU-103 Lic State: MN Lic Expire: VIN: 2GTEK19R7T1519773 Veh Insp#: Mileage Type: Actual Condition: Code: U8023D Ext.Color: ARCTIC WHITE Int. Color: Ext.Refinish: Two-Stage Int. Refinish: Two-Stage Ext.Paint Code: 10 9567 Int.Trim Code: Options 4-Wheel Drive AM/FM Stereo Tape Air Conditioning Airbag Restraint Aluminum/Alloy Wheels Anti-lock Brakes Chrome Bumper(s) Cruise Control Intermittent Wipers Keyless Entry System Leather Seats Leather Steering Wheel Lighted Entry System Power Brakes Power�7oor Locks Power Drivers Seat Power Mirrors Power Steering Power Windows Tachometer Tilt Steering Wheel Tinted Glass 01/11/2012 03:35 PM Page 1 of 3 .-,�..�.� �.,.e 1996 GMC K1500 SLT 2 DR EM Cab Short Bed Claim#: 01/11/2012 03:28 PM r,----- ! Damages __ ___ Line Op Guide MC Description MFR.Part No. Price ADJ% B% Hours R 1 E 5 46 Bumper,Front 15680830 GM Part $341.49 1.8 SM 2 E 136 Strip,Front Impact 15574113 GM Part $79.31 INC SM 3 E 29 46 Grille Assembly 15986073 GM Part $157.63 0.4 SM 4 L 29 13 Grille Assembly Refinish 1.8 RF 1.0 Surface 0.6 Two-stage setup 0.2 Two-stage 5 RI 42 Headlamp Assy,Halogen RT R&I Assembly 0.3 SM 6 SB M60 Hazardous Waste Removal Sublet Repair $5.00' SM 6 Items MC Message 13 INCLUDES 0.6 HOURS FIRST PANEL TWO-STAGE ALLOWANCE 46 PRINTABLE ALTERNATE PARTS COMPARE __- --- - -_.. _ --- __...... --- ! Estimate Total&Entries Gross Parts $578.43 Paint Materials $57.60 Parts&Material Total $636.03 Tax On Parts Only @ 7.125% $41.21 Labor Rate Replace Repair Hrs Total Hrs Hrs Sheet Metal(SM) $52.00 2.5 2.5 $130.00 Mech/Elec(ME) $80.00 Frame(FR) $75.00 Refinish(RF) $52.00 1.8 1.8 $93.60 Paint Materials $32.00 Labor Total 4.3 Hours $223.60 Sublet Repairs $5.00 Gross Total $905.84 Net Total $905.84 Alternate Parts Y/02/00/00/02/02 CUM 02/00/00/02/02 Zip Code: 55432 Default Recycled Parts NOT REQUESTED Audatex Estimating 6.0.726 ES 01/11/2012 03:35 PM REL 6.0.726 DT 12/01/2011 DB 12/15/2011 Copyright(C)2011 Audatex North America, Inc. 0.8 HRS WERE ADDED TO THIS ESTIMATE BASED ON AUDATEX'S TWO-STAGE REFINISH FORMULA. THIS ESTIMATE HAS BEEN PREPARED BASED UPON THE USE OF ONE OR MORE AFTERMARKET CRASH PARTS SUPPLIED BY A SOURCE OTHER THAN THE MANUFACTURER OF YOUR MOTOR VEHICLE. WARRANTIES APPLICABLE TO THESE AFTERMARKET CRASH PARTS Otl11/2012 03:35 PM Page 2 of 3 � � � T 1996 GMC K1500 SLT 2 DR Ext Cab Short Bed Claim#: 01/11/2012 0328 PM ARE PROVIDED BY THE PARTS MANUFACTURER OR DISTRIBUTOR RATHER THAN BY YOUR OWN MOTOR VEHICLE M�INUFACTURER. BY MY SIGNATURE BELOW, I ACKNOWLEDGE RECEIPT AND APPROVAL OF THIS ESTIMATE. SIGNATURE ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE IS FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD. Op Codes * = User-Entered Value E = Replace OEM NG= Replace NAGS EC= Replace Economy OE= Replace PXN OE Srpis 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 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 ��"�1� Audatex's prior written consent. ,��:u,<<�:,��,�a��zz� °� Copyright(C)2011 Audatex North America, Inc. Audatex Estimating is a trademark of Audatex North America, Inc. 07/11/2012 03:35 PM Page 3 of 3 BECK NORTHWAY COLLISION, INC. 3721 FLOWERFIELD RD CIRCLE PINES, MN 55014 763 784 7154 FAX 763 784 7155 TAX ID 41-1752489 '"'PRELIMINARY ESTIMATE*** 01/16/2012 03:58 PM Owner Owner: Qave Anderson Address: 155 Glennview AVE Work/Day: (651)780-6015 City State Zip: Lino Lakes, R�N 55U14 FAX: Inspection Inspection Date: 01/16/2012 03:58 PM Inspection Type: Appraiser Name: John Brown Appraiser License#: Address: 3721 Flowerfield RD (763)784-7154 (763)784-8730 City State Zip: Circle Pines, NIN 55014 FAX: (763)784-7155 Email: becknorthway@aol.com _ _. _ __ Repairer __ __ __ Repairer: Beck Northway Collision Contact: John R Brown Address: 3721 Flowerfield RD Work/Day: (763)784-7154 Work/Day: (763)784-8730 City State ZYp: Circle Pines. MN 55014 FAX: (763)784-7155 Email: becknorthway@aol.com . . __ _.._._ . ..._ . ..._ Vehicle �_..._.. .._..__ _.. __..... _�_....... 1996 GMC K1500 SLT 2 DR Ext Cab Short Bed 8cyl Gasoline 5.7 4 Speed Automatic Lic Expire: VIN: 2GTEK19R7T1519773 Veh Insp# : Mileage Type: Actual Condition: Code: U8023D Ext. Refinish: Two-Stage Int. Refinish: Two-Stage Options 4-Wheel Drive AM/FM Stereo Tape Air Conditioning Airbag Restraint Aluminum/Alloy Wheels Anti-lock Brakes Chrome Bumper(s) Composi'.e!European Hdlmps Cruise Control Intermittent Wipers Keyless Entry System Leather Seats Leather Steering Wheel Lighted Entry System Power Brakes Power poor Locks Power G�r;vers Seat Power Mirrors Power Steering Power Windows Tachometer Tilt Steering Wheel Tinted Glass Damages _ 01/16I201�04-.01 PM ......... .. Page 1 of 3 1996 GMC K1500 SLT 2 DR Ext Ca6 Short Bed , Claim#: . 01/16/2012 03:58 PM Line Op Guide MC Description MFk.Part No. Price ADJ% B% Hours R 1 RI 5 Bumper Assembly.Front R� I Asseinbly 0.9 SM 2 E 136 46 Strip.Front impact 15574'113 GA4 Part $79.31 0.4 SM 3 E 29 46 Grille Assembiy 12388709 GM Part $384.66 0.6 SM 4 L 29 13 Grille Assembly Refinish 1.8 RF 1.0 Surface 0.6 Two-stage setup 0.2 Two-stage 5 SB M60 Hazardous Waste Removal Sublet Repair $5.00` SM 5 Items MC Mes>age 13 INCLUDES 0.6 HOURS FIRST PANEL TWO-STAGE ALLOWANCE 46 PR!NTA6LE ALTERNATE PARTS COMPARE Estimate Total&Entries __ _ Gross Parts $463.97 Paint Materials $57.60 Parts&Material Total $521.57 Tax On Parts Only @ 7.125% $33.06 Labor Rate Replace Repair Hrs Total Hrs �i rs Sheet Metal (SM) $52.00 1 9 1.9 $98.80 Mech/Elec(ME) $g7.pp Frame(FR) �?5.00 Refinish(RF) $52.00 1 8 1.8 $93.60 Paint Materials $32.00 Labor Total 3.7 Hours $192.40 Sublet Repairs $5.00 Gross Total $752.03 Net Total $752.03 Alternate Parts 1'/02/00/00/02/02 CiJM 02/00/00/02i02 Zip Code: 55014 Default Audatex Estimating 6.0.726 ES 01/16/2017.04:01 I�M RFL 6.0.726 DT 12/01/2011 DB 01/15/2012 Copyright(C)2011 Audatex Nurth America, Inc. 0.8 HRS WERE ADDED TO THIS ESTIMATE BASEL� �N AUDATEX'S TWO-STAGE REFINISH FORMULA. THIS ESTIMATE HAS BEEN PREPARED PASED ON THE USE OF ONE OR MORE CRASH PARTS SUPPLIED BY A SOURCE OTHER TI3�1 7'HE MAI�TliFAC'I'URER OF YOUR MOTOR VEHICLE. WARRANTIES APPLICABLE TO THESE REPLACEv1ENT PARTS ARE PROVIDED BY THE PARTS MAI�TUFACTURER OR DISTP.IBUTOR RATHE'.? 7'HAN 3Y THE MAIVUFACTURER OF YOUR VEHICLE. A PERSOI�T WHO FILES F: CLAIM TiVI'?'H INTENT TO DEFRAUD OR HELPS COMMIT A FRAUD AGAIIv'ST AN INSURER IS GUILTY OF �� CRIME. ovisizoizoa:oi�h� Page 2 ot 3 1996 GMC K1500 SLT 2 DR Ext Cab Shor!8..�. • Claim#: O1/16/2012 03:58 PM 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 LP= 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= Re!ated 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 ��`�`��"�� Audatex's prior�.vri:ten consent. .� s�.�� > „ , ��& _°=m�� Copyright(C)�:011 /�ludatex Nr,rth America, Inc. Audatex Estimating is a trademark of Auclatex North America, Inc. I 01/16I201204:0�PM Page 3 of 3