Williams NOTICE OF CLAIM FORM to t6e City of Saint Paul, Minnesota
Minnesota State Statute 466.05 states that"...everyperson...who claems damages fron any municipality...shall cause to be presented to the
governing body of the municipality within 180 days after the alleged/oss or injury is discovered a not:ce staling the time,place,and
ciricumswnces thereof,and the amount of compensation or other reliejdemanded"
Please rnmplete this form in its entirety by cleady typing or printing your aaswer to each questlon. It more space is
needed,attach additional sheets. Please note that yoa vrill not be coataded by telephone to clariPy s�aswers,so provide as
much ioformation as necessary to eaplain yau claim,and t6e amaunt of compensation beiog requested. You will receive a
written xcknowledgement once your form ia reeeived. The proeess can take np to ten weeks or longer depending on tLe
natnre of your claim. This form must be stgned,and bot6 pages completed. If somet6ing 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
— / RECEII�ED
First Name J���'1�'►��- Middle Initial�Last Name �'�r�l i A-m S
-____.�_. ,
� � � c /I � �EB 0 201�
�°mpanY_9vBusiness Name � . '�� � �/�-1� '�i'�� � �-��r
Are You an Insurance Company? Yes/�Ny If Yes,Claim Number? Z �li� s-� �f"� /;�� C'Gk� .+-.�,;��%��.���
Screec Address L',', �G� �i 7rif L�� Sr�n�L >4 K � �c�� � (- t���, �-.. -�� i�Y ,�ti ��-�h��
1 �-
City-� 3���Y}'j�S/1��� �4'V�� State � �'l.� Zip Code��
Daycime Phone(���Cell Phone �(«-)���Evening Telephone�,�-�
Date of Accident/Injury or Date Discovered ;�—�'/� Time c�:3�✓ am pm
Please state,in detail,what occuired(happened),and why you ate submitting a claim.Please indicate why or how you
feel the Ciry of Saint Paul or its employees are involved�d/or responsible for your damages. Z u.' �.-�
' �-i U"i n C�n 1-� �Z C���h 'T� �' � 1-� , � `1�"�
� � y w �s ,; � . �
I l G ' r�'1 1.J ��1 l� ' r�r c:.F.c 'e�.�p ��
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I
�P ase check the box(es)that most closely represent the reason for completing this form: I
My vehicle was damaged in an accident �My vetricle was damaged during a tow
❑My vehicle was damaged by a pothole or condition of the str�et ❑My vehicle was damaged by a plow
❑My vehicle was wron�ully towed and/or ticketed 0 I was injured on City property �
❑Other type of property damage-please specify
❑ Other type of injury-please specify
In order to process yaur claim you nced to iucinde conies of all aoolicable documents.
For the claims types listed below,please be sure to include the docu�nts indicated or it will delay the handling of
your claim. Documents WII..L NOT be returned and become the property of the City. You are encouraged to keep a �
copy for yourself before submitting your claitn form. �
O Properiy 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 i
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 darnaged items
O Injury claimS:medical bills,receipts
O Photographs are always welcome to document and support your claim but will not be retumed.
Page 1 of 2-Please oomplete and return both pages ot Claim Form
Failnre to complete and return both pages witl resalt in delay in the handling of your claim.
All Claims-dease comdete this section / -_, i
Were there wimesses to the incident? Yes No (Unlcnow�� (circle) ;
Provide their names,addresses and telephone numbers: '
1
. t
Were the police or law enforcement called? Yes No Unl�own (circle) ;
If yes,what department or agency? Case#or report#j`��L� � ��(� �
Where did the accident or injury take place? Provide street address,cross street,intersection,name of park or f ty, �
cl st landmark etc. Please be as detailed as possible. ff necessary,attach a di l-� n � I
� -��r��e� �� �'- hc�h /�U� /-��!f C,
Please indicate the amo you are seekin in compensation or what you would like the City to,do to resolve this claim
to our satisfaction. ` � U '2 � ' ` ��- � " ��"''-� �� i
-�S C�(1, A I
, �
V ' e com etc this section ❑check box if this secti does not 1
Your Vehicle: Year�o�' � Make L 1-1 Model:�'/� � /'
License Plate Number ' State r� Color !��y
Registered Owner ✓1 /�. �1/ 'f� i j
Driver of Vehicle '� h n � , m " i
Area Damaged � :�/�t�1!c'r ��/ � ' >( �
City Vehicle: Year ! Make r�% C Model F �S(� �
License Plate Number �� ,�l(n�-'�. State�Color �hi-t�-c
Driver of Vehicle(Ciry Employee's Name)
Area Damaged!e•���- �' s� ��-�
Injury Clafrns-nlease comol�e this section check box if this section does nat annlv
How were you injured? '�
What part(s)of your body were injured? I
Have you sought medical treatment? Yes N Planning to Seek Treatment(circle) I�
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 o �
When did you miss work? (Pro����(S))
Name of your Employer. '
Address Telephone
❑Check hete if you are attacLing more pages to tLis daim form. Number of addittonat pages ,
By signing this form,you are stating that all information you have provided is true arid correct to tJee best
of your knowledge. Unsigned forms will not be processed
Submitbing a jalse c�re car�result in prosecution. Date form was cwmptc�ed � -�� - �a—
Print the Name of the Person who Completed this orm: .�d 1��► n i �- �� /vv/ ���� S
Signature of Petson Malang the Claim:
Revised Febrnary 2011
. `�
. �.�� �t l� Lr h � T�►, 1 �����''°a--.
�. �� � v �c.� �v,�� v ri � Y
THOMAS AUTO BODY AND COLL SION I� x►/�.�C �[.0 "
5170 WEST BROADWAY �
CRYSTAL, MN.55429
PHONE: 763-205-1187 FAX:763-205-1191
TAX�D:26-4076997
*"'`PRELIMINARY ESTIMATE'"""
02/10/2012 12:15 PM
_ _ �.. ,.__ ,
Owner
Owner: Johnnie Williams
Address: Work/Day: (612)859-5778
Inspection
Inspection Date: 02/10/2012 12:15 PM Inspection Type:
Appraiser Name: Kyle Perleberg Appraiser License#:
Address: 5710 West Broadway Work/Day: (763)205-1187
FAX: (763)205-1191
City State Zip: Crystal, MN 55429 FAX:
Email: ThomasAutobody@hotmail.com ;
__ _ _ __ �
_ _. __. _ _____ _._ ___ _ � __..
Repairer
_ _ _ _�__ �.. _ _.. _. ____.. _ w_.. _. _.�.w_�_---__. .._. ._.__ _.....�. _,�,..�
Repairer: Thomas Auto Body and Collision Contact Paul Neil I
Address: 5170 West Broadway Work/Day: (763)205-1187
FAX: (763)205-1191 I
City State Zip: Crystal, MN 55429 Work/Day:
Email: ThomasAutobody@hotmaiLcom
�
Vehicle
I
2001 Chrysler PT Cruiser STD 4 DR Wagon
4cyl Gasoline 2.4 �
4 Speed Automatic '
Lic Expire: WN: 3C8FY4BB91T592378 '
Veh Insp#: Mileage Type: Actual
Condition: Code: M7203A
Ext.Refinish: Two-Stage Int.Refinish:
Options
AM/FM Stereo Tape Air Conditioning Center Console
Dual Airbags Intermittent Wipers Power Brakes
Power Steering Power Windows Rear Window Defroster
Rear Window Wiper/Washer Split Folding Rear Seat Tachometer
Tilt Steering Wheel Tinted Glass Velour/Cloth Seats
Damages . __ _ __ '
...
Line Op Guide MC Description MFR.Part No. Price ADJ°/a B% Hours R
1 RI 74 Front Bumper Cover R&I R&I Assembly 1.4 SM
02I10/2012 12:23 PM Page 1 of 3
200�Chrysler PT Cruiser STD 4 DR Wagon
Claim#: 02/10/2012 12:15 PM
»"*RENTAL CAR REQUIRED*"`"`
2 I 74 Cover,Front Bumper Repair 1.0* SM
3 L 74 13 Cover,Front Bumper Refinish 3.8 RF
2.7 Surface
0.6 Two-stage setup
0.5 Two-stage
4 RI 1499 Bracket,License Mtg R&I Assembly 0.2 SM
5 RI 41 Headlamp Assy,Halogen LT R&I Assembly 0.6 SM
6 I 103 Fender,Front LT Repair 0.5* SM
7 L 103 Fender,Front LT Refinish 2.8 RF
2.3 Surface
0.5 Two-stage
8 RI 15 Guard,Fender Mud LT R&I Assembly 0.2 SM
9 I 209 Pnl,Front Door Outer LT Repair 7.5" SM
10 L 209 Pnl,Front Door Outer LT Refinish 2.4 RF
2.0 Surface
0.4 Two-stage
11 RI 130 W/Strip,Belt Outer LT R&I Assembly 0.2 SM
12 RI 493 MIdg,Front Door Belt LT R&I Assembly 0.3 SM
13 RI 299 N/Plate,Front Door LT R&I Assembly 0.2 SM
14 EC 381 46 Mirror,0uter R!C LT Replace Economy $104.00' 0.3 SM
15 E 223 Cyl,Front Door Lock LT 4864651 $21.45 0.5 SM
»Trim
16 E 227 Handle,Front Door Otr LT 4724913AD $84.35 0.2 SM
17 I 289 Pnl,Rear poor Outer LT Repair 5.0* SM
18 L 289 Pnl,Rear poor Outer LT Refinish 2.0 RF
1.7 Surface
0.3 Two-stage
19 RI 325 W/Strip,Belt Outer LT R&I Assembly 0.2 SM ;
20 RI 309 MIdg,Rear poor Side LT R&I Assembly 0.3 SM �
21 RI 305 Handle,RR Door Outer LT R&I Assembly 0.6 SM �
22 I 361 Panel,Quarter LT Repair 4.5" SM
23 L 361 Panel,Quarter LT Refinish 2.4 RF �
2.0 Surface
0.4 Two-stage
24 RI 26 Guard,Mud LT R&I Assembly 0.2 SM
25 RI 533 Lens,Taillamp LT R&I Assembly 0.3 SM i
26 RI 556 Rear Bumper Cover R&I R&I Assembly 1.4 SM
27 L M14 Corrosion Protection Refinish 0.3" RF I
28 EC M17 Cover Car Exterior Replace Economy $3.00' 0.2' SM
29 SB M60 Hazardous Waste Removai Sublet Repair $3.50" SM
30 N Clean 8�Re-tape Mldg Additional Labor $4.00' 0.4` SM*
30 Items
MC Message �
�
13 INCLUDES 0.6 HOURS FIRST PANEL TWO-STAGE ALLOWANCE
46 PRINTABLE ALTERNATE PARTS COMPARE
. _ _ _ __ . �.__ .. _ .._.. _._ .�. _..
Estimate Total 8�Entries '
Gross Parts $105.80
Other Parts $111.00
Paint Materials $465.80
Parts&Material Total $682.60
Tax On Parts Only @ 7.275% $15.77
Labor Rate Replace Repair Hrs Total Hrs
Hrs
Sheet Metal (SM) $54.00 7.3 18.9 26.2 $1,414.80
Mech/Elec(ME) $87.50
Frame(FR) $70.00
02/10/20�2 12:23 PM Page 2 of 3
2001 Chrysler PT Cruiser STD 4 DR Wagon
Claim#: 02/10/2012 12:15 PM
Refinish(RF) $54.00 13.7 13.7 $739.80
Paint Materials $34.00 '
Labor Total 39.9 Hours $2,154.60 II
Sublet Repairs $3.50 I
Gross Total $2,856.47
Net Total �2,856.47
Alternate Parts Y/01/00/00/01/00 CUM 01/00/00/01/00 Zip Code: 55429 Default ,
�
I
Audatex Estimating 6.0.626 ES 02/10/2012 12:23 PM REL 6.0.626 DT 06l01/2011 �
Copyright(C)2011 Audatex North America, Inc.
2.7 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 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 = Repiace 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 = Partiai Repiace Price PM= Replace PXN Reman/Rebit 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
�����'�� Audatex's priorwritten consent.
r "+fi3,'t`F-a ;.��'fb .
Copyright(C)2011 Audatex North America, Inc.
Audatex Estimating is a trademark of Audatex North America, Inc.
:
02/10/2012 12:23 PM Page 3 of 3
Gmail -PHOTOS Pa�e I of 3
` Johnnie Wiiliams<jbw1107�gmail.com>
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('�,�.,�.1�i�y�i�
PHOTOs
1 message
Cory Wyatt<cwyatt�abraauto.com> Fri, Feb 10,2012 at 12:OS PM
To: "JBW1107(83GMAIL.COM"<JBW1107(8�gmail.com>
HERE ARE YOUR PHOTOS.THANK YOU FOR YOUR TIME.
Cory Wyatt
Customer Serviae Manager
Abra Auto Body&G/ass
New Hope
Of�ice-763-535-0027
Fax-763-535-0232
cwvattL�abraautao,a�m
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• ABRA Auto Body & Glass - New Hope Workfile ID: fb20c33b
FederalID: 41-1942823
Right The First Time...On Time
7701 42ND AVE N, NEW HOPE, MN 55427
Phone: (763) 535-0027
Preliminary Estimate
Customer: WILLIAMS,70HNNIE
Written By: Cory Wyatt
Insured: WILLIAMS,JOHNNIE Policy#: Claim#:
Type of Loss: Date of Loss: Days to Repair: 5
Point of Impact: 09 Left T-Bone(Left Side)
Owner: Inspection Location: Insurance Company:
WILLIAMS,JOHNNIE ABRA Auto Body&Glass-New Hope CUSTOMER PAY
5318 HAMPSHIRE AVE N 7701 42ND AVE N
CRYSTAL,MN 55428 NEW HOPE, MN 55427
(612)859-5778 Day Repair Facility
(763)535-0027 Business
VEHICLE
Year: 2001 Body Style: 4D WGN VIN: 3C8FY46691T592378 Mileage In: 107904
Make: CHRY Engine: 4-2.4L-FI License: XN 330 Mileage Out: ,
Model: PT CRUISER Production Date: 12/2000 State: MN Vehicle Out: !
Color. SILVER Int: GREY Condition: Job#: '
5 Speed Transmission Cloth Seats Intermittent Wipers Rear Window Wiper I
Air Conditioning Console/Storage Overdrive Recline/Lounge Seats
AM Radio Driver Air Bag Passenger Air Bag Search/Seek
Body Side Moldings Dual Mirrors Power Brakes Stereo
Bucket Seats FM Radio Power Steering Tilt Wheel
Cassette Front Side Impact Air Bags Power Windows I
Clear Coat Paint Full Wheel Covers Rear Defogger
2/10/2012 11:54:54 AM 013794 Page 1
Preliminary Estimate
Customer: WILLIAMS,70HNNIE
Vehicle: 2001 CHRY PT CRUISER 4D WGN 4-2.4L-FI SILVER
Line Operation Description Qty Extended Labor Paint
Price�
1 FRONT BUMPER
2 R&I R&I bumper cover 1.6
3 * <> Rpr Bumper cover w/accent w/o chrome 1.� 2.4
4 Add for Clear Coat 1.0
5 # Refn 'Deduct-Partial Paint; Full Clear -0.5
6 FRONT LAMPS
7 R&I LT Headlamp assy 0.3
8 FENDER
9 * Rpr LT Fender � 2,(
10 Overlap Major Non-Adj. Panel -0.2
11 Add for Clear Coat 0.5
12 # Refn �Deduct-Partial Paint; Full Clear -0.5
13 FRONT DOOR
14 * Rpr LT Outer panel S.Q 2,0
15 Overlap Major Adj. Panel -0.4
16 Add for Clear Coat 0.3
17 R&I LT Belt w'strip 0.3
18 * R&I lT Lower molding bright silver Q.3
19 # �Clean&Retape Molding 1 2.00 0.3 '
20 Repl LT Nameplate"PT CRUISER" 1 53.25 0.2 '
21 Repl LT Mirror assy w/o power 1 164.00 0.5 I
22 R&I LT Handle,outside 0.3
23 R&I LT Lock cylinder 0.2 ;
24 R&I LT R&I trim panel 0.4
25 REAR DOOR
26 R&I LT Belt w'strip 0.3
N 27 * Rpr LT Outer panel �Q 2.p
28 Overlap Major Adj. Panel -0.4
29 Add for Clear Coat 0.3
30 Add for Edging 0.5
31 * R&I LT Lower molding paint to match Q� �
32 # 'Clean&Retape Molding 1 2.00 0.3
33 R&I LT Handle,outside 0.3
34 QUARTER PANEL
35 * Rpr LT Quarter panel to 2/1/O1 w/o rocker � 2.6
36 Overlap Major Adj. Panel -0.4
37 Add for Clear Coat 0.4
38 R&I LT Quarter glass Chrysler tinted 1.0
39 REAR LAMPS
40 R&I LT Combo lamp assy 0.3
41 REAR BUMPER
42 R&I R&I bumper cover 1.1
43 # Repl 'Flex Additive/Adhesion Promoter 1 8.50 X
2/10/2012 11:54:54 AM 013794 Page 2
. Preliminary Estimate
Customer: WILLIAMS,70HNNIE
Vehicle: 2001 CHRY PT CRUISER 4D WGN 4-2.4L-FI SILVER
44 MISCELLANEOUS OPERATIONS
45 # Refn 'Car Cover 0.1
46 # Refn �Corrosion Protection 0.3
47 # 'Hazardous Waste 1 5.00 X
48 # 8 DAYS TO REPAIR 1
SUBTOTALS 234.75 26.5 12.6
NOTES
Line 27: INCLUDES SHELL DAMAGE
ESTIMATE TOTALS
Category Basis Rate Cost�
Parts 221.25
Body Labor 26.5 hrs @ $52.00/hr 1,378.00
Paint Labor 12.6 hrs @ $52.00/hr 655.20
Paint Supplies 12.6 hrs @ $33.00/hr 415.80
Miscellaneous 13.50
Subtotal 2,683J5
Sales Tax $221.25 @ 7.2750% 16.10
Grand Total 2,699.85
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 2,699.85
I
THIS IS A VISUAL INSPECTION ONLY. THERE MAY BE ADDITIONAL DAMAGE AFTER DISASSEMBLY. PARTS ARE I
SUBJECT TO INVOICE. THERE ARE NO GUARANTEES ON RUST REPAIRS. ;
MINNESOTA FRAUD WARNING: '
A person who submits an application or files a claim with intent to defraud or helps commit a fraud against an insurer is �
guilty of a crime.
"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
2/10/2012 11:54:54 AM 013794 Page 3
, Preliminary Estimate
Customer: WILLIAMS,]OHNNIE
Vehicle: 2001 CHRY PT CRUISER 4D WGN 4-2.4L-FI SILVER
. Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
DR3NP01, CCC Data Date 2/8/2012, 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 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 i
and Safety Administration. PDR=Paintless Dent Repair. VIN=Vehicle Identification Number. ;
2/10/2012 11:54:54 AM 013794 Page 4
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