Petersen, Amanda ��������
NOTICE OF CLAIM FORM to the City of Saint Paul�1VriniTesota
Minnesota State Statute 466.05 states that°...every person...who claims damages from any municipa�.�sl'ra�c���e 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 compensatiors or other relief demanded°
Please complete this form in its entirety by ciearly typfng 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 pmvide as
much information as necessary to explain your claim,and the amount of compensation being requested. You will receive a
written acl�nowledgement once your form is received. The process cao take up to ten weeks or longer depending on the
nature of your claim. Tlvs form must be signed,and both pages completed. If something 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
First Name� t Middle Initial /� Last Name �'��rf`��
Company or Business Name
A.re You an Insurance Company? Yes/�� If Yes,Claim Number?
Street Address �`�, � � v ��� �1 � � e/
City�V(i `L'.����!�`��S State '� Zip Code �5 5! � �
Daytime Phone(��(����-�,���Cell Phone(��"�Y�� Evening Telephone(_ -
Date of AccidenU Injury or Date Discovered �� �� �( �� Time ��`�7 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 Sai t Paul or its e ployees are i volve an or responsible for y ur damages. �
?��1 � G 1-- I
v�- �
i
P�le/�'�e 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 vou need to include conies of�11 analicable 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 yowself before submitting your claim form.
�$(Property damage claims to a vehicle:two esdmates 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 properiy 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 comulete this section
Were there witnesses to the incident? Yes N� Unknown (circle)
Provide their names,addresses and telephone numbers:
Were the hce or law enforcement led� / Yes No Unknown c�rcle
Po' ( .
If yes,what department or agency? �- ��t 1 f� Case#or report#
Where did the accident or injury take place? Provide street address,cross street,intersection,na f o aci i
closest l�an�d,,�a,r�,etc. Please be as detailed as ssibl . If necessary,attach a dia am.
�fX,�,� C'�Y1 (�1�V�P;._;,�1��. S�i�l`�'t1 d� � .�
Please indicate the amo�t yo���seekin in compensation or what you would like the City to do to resolve this claim
to your satisfaction. .�(!,�'f, a . �
Vehi le Claims— 1 lete this 'on ❑check box if this section dces not a 1
Your Vehicle: Year Make � Model
License Plate Numbe �_ State Color_ �+-
Registered Owner f
Driver of Vehicle l
Area Damaged'
City Vehicle: Yeaz�c�11 Make M el � L
License Plate Number(AhKYI.(�►ArY� State Colo
Driver of Vehicle(City E ployee's Name) i
Area Damaged �0 �QA(�(Sl-.(i�.J I
Iniurv('laims—nlease complete this section �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 miss work as a result of your injury? Yes No I
When did you miss work? (provide date(s))
Name of your Employer:
Address Telephone
Check here if you are attacWng 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 �/ 6�� �
Print the Name of the Person who Comple this F rn��f���� ��
M Icin the CI `��.
Sigzature�f rers�� a g
.
Revised February 2011
' - ABRA Auto Body & Glass - Roseville Workfile ID: 57464f6e
FederalID: 41-1942823
Right the First Time...On time
� 1914 W. COUNTY ROAD C, ROSEVILLE, MN 55113
Phone: (651) 639-9848
FAX: (651) 639-9406
Preliminary Estimate
Customer: PETERSEN,AMANDA
Written By: Michael Brasher
Insured: PETERSEN,AMANDA Policy#: Claim#: UNK
Type of Loss: Date of Loss: 2/24/2012 12:00:00 PM Days to Repair: 0
Point of Impact: 12 Front
Owner: Inspection Location: Insurance Company:
PETERSEN,AMANDA ABRA Auto Body&Glass-Roseville CUSTOMER PAY
3926 GLENNVIEW AVE 1914 W.COUNTY ROAD C
ARDENHILLS,MN 55112 ROSEVILLE,MN 55113
(651)331-0764 Business Repair Facility
(651)639-9848 Business
VEHICLE
Year: 1998 Body Style: 4D SED VIN: 4T16G22KOWU302884 Mileage In: 147478
Make: TOYO Engine: 4-2.2L-FI License: 826D]M Mileage Out:
Modet: CAMRY LE Production Date: 3/1998 State: MN Vehicle Out:
Color: GOLD Int: Condition: Job#:
Air Conditioning Clear Coat Paint Full Wheel Covers Power Steenng
AM Radio Cloth Seats Intermittent Wipers Power Trunk/Tailgate
Anti-Lock Brakes(4) Console/Storage Overdrive Power Windows
Automatic Transmission Cruise Control Passenger Air Bag Rear Defogger
Body Side Moldings Driver Air Bag Power Brakes Recline/Lounge Seats ��
Bucket Seats Dual Mirrors Power Locks Stereo
Cassette FM Radio Power Mirrors Tilt Wheel
2/24/2012 11:50:38 AM 024206 Page 1
� _ Preliminary Estimate
Customer: PETERSEN,AMANDA
Vehicle: 1998 TOYO CAMRY LE 4D SED 4-2.2L-FI GOLD
Line Operation Description Qty Extended Labor Paint
Price�
1 FRONT BUMPER
2 ** Repl A/M CAPA Bumpercover 1 157.00 1.8 2.8
3 Add for Clear Coat 1.1
4 Repl Emblem factory installed 1 27.35 0.2
5 MISCELLANEOUS OPERATIONS
6 # Refn 'Color Tint 0.5
7 # Repl 'Flex Additive/Adhesion Promoter 1 8.50 X
8 # �Hazardous Waste 1 5.00 X
SUBTOTALS 197.85 2.0 4.4
ESTIMATE TOTALS
Category Basis Rate Cost#
Pa� 18435
Body Labor 2.0 hrs @ $52.00/hr 104.00
Paint Labor 4.4 hrs @ $52.00/hr 228.80
Paint Supp�ies 4.4 hrs @ $33.00/hr 145.20
Miscellaneous 13.50
Subtotal 675.85
Sales Tax $ 184.35 @ 7.1250% 13.13
Grand Total 688,gg
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 688,gg
THIS IS A VISUAL INSPECTION ONLY. THERE MAY BE ADDITIONAL DAMAGE AFTER DISASSEMBLY. PARTS ARE
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.
2/24/2012 11:50:38 AM 024206 Page 2
" " ` , Preliminary Estimate
�Customer: PETERSEN,AMANDA
Vehicle: 1998 TOYO CAMRY LE 4D SED 4-2.2L-FI GOLD
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
AEM8509, CCC Data Date 2/15/2012, 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
and Safety Administration. PDR=Paintless Dent Repair. VIN=Vehicle Identification Number.
2/24/2012 11:50:38 AM 024206 Page 3
�� Schoonover Bodyworks & Workfile ID: c836a359
Glass-Shoreview
We Can Fix That!
1060 County Road E W, Shoreview, MN 55126
Phone: (651) 483-6756
FAX: (651) 483-3460
Preliminary Estimate
Customer: PETERSEN,AMANDA
Written By: Dylan Sprague
Insured: Policy#: Claim #:
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact:
Owner: Inspection Location: Insurance Company:
PETERSEN,AMANDA Schoonover Bodyworks&Glass-Shoreview
3926 GLENVIEW AVE. 1060 County Road E W
ARDEN HILLS, MN 55112 Shoreview, MN 55126
(651)331-0764 Day Repair Facility
(651)483-6756 Business
VEHICLE
Year: 1998 Body Style: 4D SED VIN: 4TiBG22KOWU302884 Mileage In:
Make: TOYO Engine: 4-2.2L-FI License: Mileage Out:
Model: CAMRY CE Production Date: State: Vehicle Out:
Color: GRAY Int: Condition: Job#:
5 Speed Transmission Cloth Seats Intermittent Wipers Rear Defogger
AM Radio Console/Storage Overdrive Recline/Lounge Seats
Body Side Moldings Driver Air Bag Passenger Air Bag Stereo
Bucket Seats Dual Mirrors Power Brakes Tilt Wheel
Cassette FM Radio Power Mirrors
Clear Coat Paint FuII Wheel Covers Power Steering
2/24/2012 10:06:21 AM 013550 Page 1
Preliminary Estimate
Customer: PETERSEN,AMANDA
Vehicle: 1998 TOYO CAMRY CE 4D SED 4-2.2L-FI GRAY
Line Operation Description Qty Extended Labor Paint
Price$
1 FRONT BUMPER
2 ** Repl RECOND Bumper cover 1 273.00 1.8 2.8
3 Add for Clear Coat 1.1
4 Repl Emblem black pearl 1 54.16 0.2
5 # Subl Hazardous waste removal 1 5.00 X
6 # Tint Color 1 0.5
7 # *** POSSIBLE ADDITIONAL DAMAGE*** 1
SUBTOTALS 332.16 2.0 4.4
ESTIMATE TOTALS
Category Basis Rate Cost;
Parts 327.16
Body Labor 2.0 hrs @ $52.00/hr 104.00
Paint Labor 4.4 hrs @ $52.00/hr 228.80
Paint Supplies 4.4 hrs @ $35.00/hr 154.00
Body Supplies 2.0 hrs @ $3.00/hr 6.00
Miscellaneous 5.00
Subtotal 824.96
Sales Tax $327.16 @ 7.1250% 23.31
Grand Total 848.27
LIMITED WARRANTY
Schoonover Bodyworks, Inc. takes great care to ensure that every repair meets our standards for quality.
The labor performed by Schoonover Bodyworks, Inc. is guaranteed against any defect in workmanship for as long as you
own your vehicle.
Schoonover guarantees that for as long as you own your vehicle, Schoonover will, at its expense, correct or repair all
defects which are attributable to defective or faulty workmanship in the repairs stated on the repair invoice, unless
caused by or damaged resulting from unreasonable use, improper maintenance or care of the vehicle, and rust and/or
corrosion.
This guarantee covers labor only and does not apply to parts, materials or equipment which may be covered by
manufacturer's warranty.
"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.
2/24/2012 10:06:21 AM 013550 Page 2
Preliminary Estimate
Customer: PETERSEN,AMANDA
Vehicle: 1998 TOYO CAMRY CE 4D SED 4-2.2L-FI GRAY
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
AEM8509, CCC Data Date 2/15/2012, 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 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=6ureau of Automotive Repair. EPA=Environmental Protection Agency. NHTSA= National Highway Transportation
and Safety Administration. PDR=Paintless Dent Repair. VIN=Vehicle Identification Number.
2/24/2012 10:06:21 AM 013550 Page 3
� Preliminary Estimate
Customer: PETERSEN, AMANDA
Vehicle: 1998 TOYO CAMRY CE 4D SED 4-2.2L-FI GRAY
ALTERNATE PARTS SUPPLIERS
Supplier: Keystone-P+A-Minneapolis
Location(s): 3615 MARSHALL ST. N.E.,MINNEAPOLIS MN 55418 (800)328-1845 (612)789-1919
Line Description Item# Price
2 RECOND Bumper cover T01000187R $273.00
2/24/2012 10:06:21 AM 013550 Page 4