Hinton RE��I�E� ��
NOTICE OF CLAIM FORM to the City o�ain�Pa�, Minnesota
, Mir�nesota State Statute 466.05 states that"...eve erson...who claims dama es om a�y��u`°ni�� �fy`.�y.'.'h
ry p g fr c3pa► s all cause to be presented to the
governing body of the municipality within 180 days after the alleged loss or injury is discovered a nortce stating the time,place,and
circumsCances thereof,and the amount of compensation or other relief detnanded."
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 egplain your claim,and the amount of compensation being requested. You w71 receive a
written aclmowledgement 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 Middle Initial�Last Name 'y"I I �1 ►�'/ �'
Company or Business Name
Are You an Insurance Company? Yes/I�fi If Yes,Claim Number?
Street Address � � Z�r �� �� �,�.��
City a'1 • ��'"ul State �'� Zip Code ��UY/
Daytime Phone(���-_�Cell Phone( ) - Evening Telephone(��-�0'a
Date of Accidend Injury or Date Discovered�'r) � ��� 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 S 'nt Paul or its emptoyees aze invo ed and/o responsible for your damages..
� �.
� � �. ��o�� �L�
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 roperty
❑ Other type of property damage—piease specify � �l�(��-
❑ Other type of injury—please specify
In order to process your claim youu need to include copies of all apnlicable 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 are encouraged to keep a
copy for y urself befare submitting your claim form.
�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
andlor receipts for[he repairs;detailed list of damaged items
O Injury claims: medical bills,receipts
O Photographs aze 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 Glaims-ulease comnlete this section
� Were there wimesses to the incident? Ye No Unknown (circle)
Provide their names,addresses and telephone n bers: V✓����-S S � i..(�' -f�-�.�.►✓' hQ:-Y,� GZr.s�
�„ � fi�
Were the police or law enforcement called? Yes � Unknown (circle) ����
If yes,wh'at depaztment or agency? Case#or report# C`�
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 possib e. If necessary attach a diagram.
t��a,�, � �'� � - �'�"� �aM�� h-,,,� ��( 0 � l,�-, �h �� � (���
Please indicate the amount you e seeking in compensation or what you would like the,City to o to resolve this claim
to your.satisfaction. - r ,r- �
Vehicle Claims—please complete this section !7 check box if rhis section does not a 1
Your Vehicle: Year�QQ�_Make °� Model �
License Plate Number '�- � �^. _ tate�_Color ('op �
Registered Owner o �-- ' "ne��
Driver of Vehicle �m �
Area Damaged i �
Ciry Vehicle: Year Make C'Vvvt�,.__Model 0...
License Plate Number L 89 i o 3c� State�t%Color_�����
Driver of Vehicle(City Employee's Name) '���i-�:�:r'" ` �
Area Damaged_�„����,rr»r�,e�t-,
Iqjury Claims—please complete this section ❑ check box if this section does not apply
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
�- ❑ Check here if you are attaching more pages to this claim form. Number of additional pages
By signing this forrn,you are stuting 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�-
Print the Name of the Person who Comple ' Fo �`""` �1���'
Signature of Person Maldng the Claim.
Revised February 2011
TOUSLEY COLLISION CENTER Workfile ID: bbb20d79
FederalID: 41-0609970
1493 COUNTY ROAD E E, WHITE BEAR LAKE, MN
55110
Phone: (651) 288-6262
Preliminary Estimate
Customer: HINTON, KIM M.
Written By: Cindy Tuttle
Insured: HINTON, KIM M. Policy#: Claim #:
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact: il Left Front ,
Owner: Inspection Location: Insurance Company:
HINTON, KIM M. TOUSLEY COLLISION CENTER
1722 E STH STREET 1493 COUNTY ROAD E E
ST PAUL, MN 55105 WHITE BEAR LAKE, MN 55110 ,4 .,,;j
(651)774-4785 Evening Repair Faciliry
(651)774-4785 Day (651)288-6262 Business
VEHICLE ,
Year: 2006 Body Style: 4D UTV VIN: 1FMEU73E36U674314 Mileage In: 55812
Make: FORD Engine: 6-4.OL-FI License: XCP753 Mileage Out:
Model: EXPLORER 4X4 XLT Production Date: 7/2006 State: MN Vehicle Out:
Color: TAN Int: Condition: Job#:
4 Wheel Disc Brakes CD Player Front Side Impact Air Bags Power Mirrors
4 Wheel Drive Clear Coat Paint Intermittent Wipers Power Windows
Air Conditioning Cloth Seats Keyless Entry Privacy Glass
Aluminum/Alloy Wheels Console/Storage Luggage/Roof Rack Rear Defogger
AM Radio Cruise Control Overdrive Rear Step Bumper -
Anti-Lock Brakes(4) Driver Air Bag Passenger Air Bag Search/Seek
Automatic Transmission Dual Mirrors Power Brakes Stability Control
Body Side Moldings FM Radio Power Driver Seat Stereo -- -
Bucket Seats Fog Lamps Power Locks Tilt Wheel
3/7/2012 9:49:31 AM 065151 Page 1
Preliminary Estimate
Customer: HINTON, KIM M.
� . Vehicle: 2006 FORD EXPLORER 4X4 XLT 4D UTV 6-4.OL-FI TAN
Line Operation Description Qty Extended Labor Paint
Price$
1 FRONT BUMPER
2 0/H bumper assy 2.6
3 Repl Bumper cover 1 466.27 Incl. 2.8
4 Add for Clear Coat 1.1
5 Add for fog lamps 0.4
6 Repl Valance 1 48.65 Incl.
7 R&I License bracket 0.2
8 # Repl Flex additive 1 5.00
9 * Repl RT Front molding primed 1 26.83 0.2
10 * Repl LT Front molding primed 1 26.83 0.2
11 Repl LT Bumper bracket 1 31.38
12 GRILLE
13 R&I Grille XLT, Limited 0.3
14 * Rpr Front panel �4 �
15 * Add for Clear Coat _�9�
16 FRONTLAMPS
__.
17 Repl LT Headlamp assy 1 207.09 IncL
18 Aim headlamps 0.5
19 FENDER �
20 * Rpr LT Fender w/wheel opng molding,w/side mldg � Z•2
21 Overlap Major Non-Adj. Panel -0.2
22 Add for Clear Coat 0.4
23 * Repl LT Wheel opng mldg XLT,XLT Sport primed 1 138•52 0.4
24 # Repl REMOVE AND REPLACE TAPE STRIPE 1 25.00 0.3
25 * R&I LT Fender liner/FOR PAINT 0.3
26 PILLARS, ROCKER&FLOOR
27 R&I LT Running board from 12/3/02 0.6
28 # Refn Corrosion protedion 0.3
29 # Refn Cover car �•2
30 # Subl HAZARDOUS WASTE FEE 1 3.50 X
SUBTOTALS 979.07 11A _7�.3
3/7/2012 9:49:31 AM 065151 Pa9Q 2
Preliminary Estimate
Customer: HINTON, KIM M.
� ` Vehicle: 2006 FORD EXPLORER 4X4 XLT 4D UlV 6-4.OL-FI TAN
ESTIMATE TOTALS
Category Basis Rate Cost$
Parts 975:57
Body Labor 11.0 hrs @ $52.00/hr 572.0�
Paint Labor 7.3 hrs @ $52.00/hr 379.60
Paint Supplies 7.3 hrs @ $32.00/hr 233.60
Miscellaneous 3.50
Subtotal 2,164.27
Sales Tax $975.57 @ 7.1250% 69.51
Grand Total 2,233.78
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 2,233;78
MN ST 60A.955 - A PERSON WHO FILES A CLAIM WITH INTENT TO DEFRAUD OR HELPS COMMIT A FRAUD AGAIN5T
AN INSURER IS GUILTY OF A CRIME. ��
�a��i:�
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide� �
DR2MF02, CCC Data Date 3/1/2012, 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 (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 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 ir�dicate 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 dat�"'".-`.
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. -�-
.t, ,
The following is a list of abbreviations that may be used in CCC ONE Estimating that are not part of the MOTOR CRASW
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.
3/7/2012 9:49:31 AM 065151 Page 3
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