Yaritz �E�El�'EC�
�F� �? �, ?��12
NOTICE OF CLAIM FORM to the City of Saint Paul, �ne�ss.�t�
, �, � � .
Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipaliry...shall cause to be presented to the
governing body of the municipality within 180 days after the alleged loss or injury is discovered a notice stating the time,place,and
circumstances thereof,and the amount of compensation 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 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
First Name =i�//��- Middle Initial Last Name ����Z �
Company or Business Name �C�
Are You an Insurance Company? Yes/�If Yes,Claim Number?
Street Address .3��5 LoQt('/�'�I �1 vQ �
City �1� ���� State ��� Zip Code�
Daytime Phone(6fo��-� �i-�Cell Phone(6/1�-�Evening Telephone( ) -
Date of Accidend Injury or Date Discovered �/�o�/� Time .`'� �'� am/�
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.
�t= � �C (..(C_3 �
Please 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 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 WII,L NOT be returned and become the property of the City. You aze 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-ulease comnlete this section
Were there witnesses to the incident? `1 s! No Unknown (circle)
Provide their names,addresses and telephone numbers:
C.'n�'�r 1,���r�er l���.,Z�-���a�
Were the police or law enforcement called? es No Unknown (circle)
If yes, what department or agency? ' ��2 t� - GZE Case#or report# /� -�/�/- �/6�
Where did the accident or injury take place? Provide street address,cross street,intersection,name of park or facility,
c osest landmark,etc. Please be as detailed as p ssible. If necessary,attach a diagram. /JC�i�4��1' f�/''k �h
De������ec� C��: , ���ihv �Eri�i// C��rAo�^a,�s�n
Please indicate the amount you are seeking in compensation or what you woul�i like the City to do to resolve this claim
to your satisfaction. 3 �? ,5�/ S e c' �-1-,l,�C7G�a�c/ e-7S /nQf
�_o_��S /��i�ra/ �cr�� �x�ei�S�-��� �; ��c:r-hF�
Vehicle Claims- lease com lete this section ❑check box if this section does not a 1
Your Vehicle: Year_�Make - c�i/ Model ' /-
License Plate Number 6 ' G� State /yi'IjColar %3/�2c-
Registered Owner �,P�/l�' `/GT/�i f�
Driver of Vehicle �{R>U/Z �2Sc�h i�
Area Damaged �
City Vehicle: Year Make Model
License Plate Number State ]e�
Driver of Vehicle(City Employee's Name) � ��t/
Area Damaged
Iniurv Claims-ulease comqlete this section 1�check box if this section does not apnlv
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 rniss 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 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 �����/��
Print the Name of the Person who Completed this Form: � �yl G� 1'����
Signature of Person Making the Claim: 2 G��
Revised February 2011 �
At 3:02p.m. I, Artur Arseni, have gotten into the car, started it, and turned right onto
Energy ln. After proceeding straight and stopping at the stop sign at Energy ln and Energy Park ,
�
Dr. I then turned left onto Energy Park Dr. After proceeding forward, with no cars in sight in �
front, ar behind me. Going around a curve, I suddenly heard a loud"clashing" sound, the wheels
on the car lost traction to the road, because of the road being"slushy". Stepping on the break as
soon as possible, I have managed to stop the car on the far end on the intersection of Merrill
Circle and Energy Park Dr. I then pulled into Merrill Circle, and discovered that half of the car's
bumper was dragging against the ground. A woman came out of the Merrill Corporation rushed
out of the building, to ask me if I was okay. After comforting me, she brought me inside the
building and offered any assistance she could. She explained to me that she and two other
women were having a meeting in a room with a perfect vantage point to witness what had �
happened. The woman that saw every moment of it was Cindy Warner,that had described to me
how shocking it was for her to witness the incident taking place, witnessing city property falling
on the vehicle and seemed relieved that the cover of the street light, which she witnessed falling
onto the car, didn't fall even less than a half a second earlier, because it would have gone through
the windshield, possibly seriously injuring myself, the police was called to come and make the
report I thanked the ladies and went back to the vehicle. I called my mother and waited for the i
police officer to arrive. Eric Skog,the police officer arrived shortly later. With the chilly wind
touching down occasionally, the Officer invited me sit in his police car where it was warm, and
asked me about the incident, with my story, which I am writing at the moment, I gave him the
information Cindy Warner has given me along with the vehicle's insurance information and my
Driver's License. After he had written the information down in his laptop, he and I drove around
the road to inspect the area around the incident, whenever the Officer attempted to take a turn in
the car,the car slid making it difficult to drive in the harsh to go around a very slight turn, and
when the officer attempted to turn around the area of the incident, the sharper U-turn he
attempted to take left his All-Wheel-Drive vehicle swerving even when turning at low speeds.
The Officer then observed the street light pole and seeing the cover missing from the top of the
pole and the many shards on the road. In a few minutes my mother arrived on the scene,
distraught at the view she had of the bumper of the vehicle. The officer gave his information to
my mother, and my mother carefully drove away, finding a different road that had safer driving
conditions, to a reliable and close auto-mechanic.
ST. PAUL AUTO BODY SHOP Workfile ID: 7bfae680
FederalID: 56-2416759
388 FRONT AVENUE, SAINT PAUL, MN 55117
Phone: (651) 488-5780
FAX: (651) 489-8338
Preliminary Estimate
Customer: YARITZ,IRINA
Written By:Tom Mike
Insured: YARIfZ,IRINA Policy#: Ciaim#:
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact:
Owner: Inspection Location: Insurance Company:
YARIIZ,IRINA ST. PAUL AUTO BODY SHOP
308 LAWSON AVE 388 FRONT AVENUE
ST PAUL, MN 55117 SAINT PAUL,MN 55117
(612)282-7907 Cellular Repair Facility
(651)488-5780 Day
VEHICLE
Year: 2010 Body Style: 4D SED VIN: 1G1A65F50A7105556 Mileage In:
Make: CHEV Engine: 4-2.2L-FI License: Mileage Out:
Model: COBALT LS Production Date: State: Vehicie Out:
Color: Int: Condition: Job#:
Air Conditioning Cloth Seats Head/Curtain Air Bags Power Trunk/Tailgate
AM Radio Communications System Intermittent Wipers Rear Defogger
Automatic Transmission Console/Storage Message Center Satellite Radio
Auxiliary Audio Connection Driver Air Bag Overdrive Search/Seek
Bucket Seats Dual Mirrors Passenger Air Bag Stereo
CD Player FM Radio Power Brakes Tilt Wheel
Clear Coat Paint Full Wheel Covers Power Steering Tinted Glass
1/25/2012 4:08:09 PM 079983 Page 1
Preliminary Estimate
Customer: YARITZ, IRINA
VehicJe: 2010 CHEV COBALT LS 4D SED 4-2.2L-FI
Line Operation Description Qty Extended Labor Paint
Price�
1 # Frame/Unibody Repair&Set up 1 675.00 X
Z REAR BUMPER
3 O/H rear bumper 2.4
4 Repl Bumper cover base,LS,LT 1 489.85 Incl. 3.0
5 Add for aear Coat 1.2
6 Repl Center support 1 39.75 0.1
7 Repl Absorber 1 106.44 Incl.
8 Repl Impact bar 1 127.49 Incl.
9 Repl RT Side bracket 1 23.20 0.1
10 Repl LT Side bracket 1 22.80 0.1
11 REAR LAMPS
12 Repl RT Tail lamp assy 1 142.30 Incl.
13 Repi LT Tail lamp assy 1 135.27 Incl.
14 TRUNK LID
15 * Rpr Trunk lid 1_Q 2•3
16 Add for Ciear Coat 0.9
17 Repl Nameplate"COBALT LS" 1 33.37 0.2
18 QUARTER PANEL
19 0 Repl RT Quarter panel 1 �,Q 3.2
20 Overlap Major Adj. Panel -0.4
21 Add for Clear Coat 0.6
22 * Rpr LT Quarter panel �S2 2•4
23 Overlap Major Adj. Panel -0.4
24 Add for Clear Coat 0.4
SUBTOTALS 1,795.47 12.9 13.2
ESTIMATE TOTALS
Category Basis Rate Cost$
pa� 1,120.47
Body Labor 12.9 hrs @ $52.00/hr 670.80
Paint Labor 13.2 hrs @ $52.00/hr 686.40
Paint Supplies 13.2 hrs @ $32.00/hr 422.40
Misceilaneous 675.00
Subtotaf 3,575.07
Sales Tax $ 1,120.47 @ 7.6250% 85.44
Grand Total 3,660.51
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 3,660.51
1/25/2012 4:08:09 PM 079983 Page 2
Preliminary Estimate
Customer: YARI7Z,IRINA
Vehicle: 2010 CHEV COBALT LS 4D SED 42.2L-FI
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.
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
DR1CL05, CCC Data Date 1/17/2012, 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 reflect some specific, special, or unique pricing or discount. OPT OEM or
ALT OEM parts may include "Blemished" parts provided by OEM's through OEM vehicle dealerships. Asterisk (*) or
Double 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 AM, Qual Repl Parts or
Comp Repl Parts which stands for Competitive Replacement Parts. Used parts are described as LKQ, Qual Recy Parts,
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 2010 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 Pathways estimator has a complete list of applicable vehicles. Parts numbers
and prices should be confirmed with the local dealership.
CCC Pathways -A product of CCC Information Services Inc.
1/25/2012 4:08:09 PM 079983 Page 3
ALLIANCE CAR RENTAL �9512 83 5-0050 W Suburbs �952 892-6545 Suburbs
7200 France Ave. S. • SUitB 126 �St.Paul 8 NE Suburbs ❑Crystai 8 NW Suburbs RA # ,�,�, �Ll� ;")2
Minneapolis, MN 55435 • 952-835-0050 ssi-aas-aoss 763-533-7988
RENTER-FIRST MIDDLE u�sT , ORIGINAL VEHICLE REPLACEMENT VEHICLE
NUMBER STREET DATEAL � � ��» � � �, DATEAI � � � �
CITY . STATE 21P CODE DATE RN � � DATE RN / /
TELEPHONE NUMBERS - � MILES �. � 'f � . MILES � O O
� - OUT } S � OUT
HOME � � WORK MILES MILES
IICENSE NUMBER , STATE EXPIRATION DATE IN IN
� � � � � � � VEHICLE NUMBER ��._.; VEHICLE NUMBER � �
DATE OF IRTH
t � � LICENSE NUMBER LICENSE NUMBER
INSURANCE COMPANY/AGENT TELEPHONE -�` I ��; �.�,� � �
YEAR/MAKE °� YEAR/MAKE � /n y
�/C
UNDER MINNESOTA LAW, A PERSONAL AUTOMOBILE CREDITCARD exP�Ra,r�on,
TYPE t DATE ?....,. �. ��,
INSURANCE POLICY ISSUED IN MINNESOTA MUST c.aaoNO. �..� j '€
COVER THE RENTAL OF THIS MOTOR VEHICLE AGAINST
DAMAGE TO THE VEHICLE AND AGAINST LOSS OF USE
OF THE VEHICLE.THEREFORE, PURCHASE OF ANY
COLLISION (PHYSICAL) DAMAGE WAIVER OR OTHER I WILL RETURN CAR BV:
SIMILAR INSURANCE AFFECTED IN THIS RENTAL � �
CONTRACT IS NOT NECESSARY IF YOUR POLICY WAS EXTENDED EXTENDED
ISSUED IN MINNESOTA. IF YOU ARE COVERED BY SUCH To To
A POLICY, PAYMENT BY YOUR INSURER WITHIN THE TIME EOXTENDED TOTENDED
FRAME SET BY MINNESOTA LAW IS PERMITTED, AND EXTENDED exTEr,oEo
YOU ARE NOT REQUIRED TO MAKE A PRIOR PAYMENT. ro ro
BILLING INFORMATION
By initialing, I acknowledge reading and understanding the
foregoing. oAVS�$
Customer's Initials
SEE TERMS AND CONDITIONS ON BACK OFTHIS PAGE WEEKS�$ MONTH�$
By my initials, I accept or decline the following options as described in '�
paragraphs 2&5 of the Terms and Conditions on the back of this page. nni�es� ¢PER MILE
I DECLINE PHYSICAL DAMAGE WAIVER. FUEL LEVEL REFUELING OUT E 1/8 1/4 3/8 1/2 5/8 3/4 7/8
X RENTER X RENTER CHARGE �N E t/8 1/4 3/8 1/2 5/8 3/4 7/8 F
I WILL HAVE ADDITIONAL DRIVERS. I WILL NOT HAVE ADDITIONAL DRIVERS. MISC.CHARGESlCREDITS ACCOUNT NUMBER
X RENTER X RENTER
,.
SALES TAX %
ADDITIONAL DRIVER SIGNATURE DRIVER'S LICENSE NUMBER
z.
MN RENTAL TAX
ADDITIONAI ORNER SIGNATURE DRIVER'S LICENSE NUMBER
TOTAL CHARGES
1 have received,read,and agreed to the Terms and Conditions specified
on both sides of this Rentat Agreement,including the following: LESS DEPOSIT ( )
1. This Agreement automatically terminates after 30 days of rental.
2. The rental vehicle may not be removed from the state where rented TOTAL BALANCE DUE
without written permission from Alliance Car Rental.
3. Only 1 or an additional authorized driver,specified above,may drive g�LLED TO INSURANCE CO./OTHER
the vehicle.
4. If extensive cleaning is required before this vehicle is again
rentable, a cleaning charge may be imposed, at the discretion of FROM RENTER
Alliance Car Rental.This includes pet damage.
REFUND PAID BY CREDIT � `
5. I have inspected the rental vehicle as indicated below. �uE CHECK NO CARD J
TYPE
�;;�� VEHICLE INSPECTION PAYMENT GUARANTEE: If I have directed Alliance to bill charges to
Euterior Damage someone else who fails to make payment promptly when due, I will promptly
pay Alliance on demand.
Interior Damage INSUHANCE CO.OR OTHER
8
I ADDRESS
Glass Damage Spare&Tools —
L CITY STATE ZIP CODE
� � � � • L ADJUSTER-FIRST LAST
�
FRONT REAR LEFT SIDE RIGHT SIDE
� CLAIM NUMBER
I HAVE READ AND AGREE TO 3E BOUND BY THE TERMS AND R _
CONDITIONS CONTAINED ON BOTH SIDES OFTHIS AGREEMENT AND E TELEPHONE NUMBER DATE OF LOSS
AGREETO RETURN VEHICLETO ALLIANCE ON OR BEFORE RETURN C
DATE. T INSURED-FIRST LAST
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