Jonas . REGE�V`�C;
� MaR 1 � 2012
�
NOTICE OF CLAIM FORM to the City of Saint Paul, M,i����t���
„ Minnesola Stnte S[nitue 466.05 slales lhnt "...evety person...irho claims damages jrom nrry municipality...shal!cmrse!o be presentec!to!he
'_ governing bafy�rthe municiExelity within 180 days af er 1he alleged(ars or injury is rliscovered a no[ice sJating the lime,place,and
� ciirums�ances lhereof,and the amount ojcompensntion o�other relief demnrtded."
`7 Please complete tl�is form in its entirery by clearly typing ar printing your answer to each quesfion. If more space is
needecl,attach aciditional sheets. Please note that you wip not be contacted by telephone to clarify answers,sa provide as
much information as necessary to expiAin your claim,and the amoant of compensation being requestecl. You will receive n
written acknowledgement once your form is received. The process cun take i�p to ten weeks or lon�er depencling on the
nuture of your claim. This torm m��st be signed,and both pages completed. tf something cloes not apply,write`N/A'.
SEND COMPLETED FORM AND OTHER DQCUMENTS TO: CITY CLERK,
15 W�ST KEL�OGG BLVD, 310 CITY HALL, SAINT PAUL,MN 55102
First Name �(`7s(l(,�GL Middle tnitial�Last Name ��Y1 r
Compnny or Business Name
Are You an Insurance Company? Yes/� If Yes,Claim Number?
Street Address '� � . �� ' '� Sj-�
City � St�te � �% Zip Code�y�
Daytime Phone( ell Phone(�)�37aaEvening Telephone(��- / 7/ 7— O �cc,�
� �'—,3 s'3 -���� —��
Date o f A c c i d e n n j u ry o r D a t e i s c o v e r e d �—o�= � �— Time C 7�'L�1 j �/p,��
Please state, in detail,what occurred(happened),and why you are submitting a claim. Please indic�te why or how you
feel the City of Saint Paul or its employees are involved and/or responsible for your damages.
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Please check the box(es)that most closely represent the reason for completing this form:
❑ My vehicle was damaged in an accident j�My vehicle was damaged during a tow
❑ My vehicle was damaged by a pothale 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 spebify
❑Other type of injury—please specify
In order to process your claim you need to include conies of aIl apnlicable documents
For the claims types listed below,please be sure to inclucle the documents indicated or it will delay the handling of
your claim. Docoments WILL NOT be returnecl and become the property ofthe City_ You are encoura�ed to keep a
copy for yourself before submitting your claim form.
O 1�roperty damage claims to a vehicle:two estimates for the repairs to your vehicle ifthe damage exceeds
5500.00;or the actual bills and/or receipts for the repairs
O Towing claims: le�;ible copies of any ticket issued and a copy of the impound lot receipt
O Other property damage claims:two renair estimates ifthe damage exceeds$500.00;or the actuat bills
and/or receipts for the repxirs;detailed list of dama�ed items
C7 (njury claims: medical biUs,receipts
O Photographs are always welcotne to document and support your claim but will not be returned.
Page 1 of 2—Please complete and return both pages of Claim Form
Tailure to complete and return both pages will resnit iu clelAy in the handling of your claim.
� All Claims—nlease comnlete this section
�'- Were there witnesses to the incident? Yes N�O Unknown (circle)
i Provide their names,addresses ancl telephone numbers:
A�
Were the police or law enforcement called? Yes � Unknown (circle)
If yes, what department or a�ency? Case#or report#
Where did tlie accident or injury take place? Provide street address,cross street, intetsection,name of park or f ility,
closest landmark,etc. Please be ras detaileci as possible. If necessary,�ttach a diagram. �#w����.0 p
\ 0./1�C /1 L�'w r I ty nt.� P�( .
Please indic�te the am unt you are seekin�in compensation ar what you wauld like the City to do to resolve this claim
to your sa isf ction. Gi � �. � � � �J
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Y i C'fl.�rt a-e,l'fl�'►�,�5 Gl}�t�c.�,
Vehicle Claims— lease com tete this secti n ❑check box if this section does not a 1
Your Vehicle: Year U Make L� Model (_a �Q ��t,�
License Plate Number CG- State�Color ,ct�e,•�
Registered Owner Q „ .� ;° ,� �,.,�
Driver of Vehicle •
Area Damaged 1,�, ,,.�
City Vehicle: Year Make Moclel -�p� -��_�
License Plate Number State Color
Driver of Vehicle{City Gmployee's Name) ',
Area Damaged '
In'u Claims— lease com lete this secti�n check box if this section does not a I I
How were you injured?
What part(s)ofyour body were injured?
Have you sought medical treatment? Yes No Planning to Seek'freatment(circle)
When did yoii receive treatment? (provide date(s})
Narne of Medical Provider(s): i
Address Telephone
Did you miss work as a result of your injury? Yes ]�o I
When did you miss work? (provide date(s)) ;
Name of your Employer: �
Address Telephone ''
`�Checic here if you are attacl�ing more pages to t6is claim form. Number of�dditional pages�
By signing tlris form,yon are stalifig Jlrat a1l information ynu hnve provideJ u trtte a�rd correct to t/�e best
of yorrr k�io►ule�lge. Unsignerl forms wi/I not be processed �
Submitting a fnlse claim cnn res��lt in prosecutio►�. Date form was completed�� - �a -/
Print the Name of the Person wl�o Completed this Form:� (,� �,/�-y� p n r�f V v Y1G.f
�
Signature of Person Making tl�e Claim:
Revised rebruary 201 I
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WHEELERS CHEVROLET-GMC
2701 S. MAPLE AVENUE P.O. BOX 527
MARSHFIELD,Wi.54449
PHONE : (715)387-1204 FAX: (715)3870727
E-MAIL: BODYSHOP@WHEELERGM.COM
*""PRELIMINARY ESTIMATE***
03/12/2012 08:58 AM
Owner
Owner: RAY JONAS
Address: 904 E.CLEVELAND Work/Day:
Home/Evening: (715)387-0202
City State Zip: Marshfield,WI 54449 Cell: (715)383-6569
Email: NONE
Inspection
Inspection Date: 03/12/2012 08:57 AM Inspection Type:
Primary Impact: Right Front Corner Secondary Impact:
Appraiser Name: DAVID BORES Appraiser License#:
Email: bodyshop@wheelergm.com
Repairer
Re airer: Wheelers Automotive Chevrolet
P ,GMC Contact: DAV�D D BORES
Address: 2701 South Maple Ave Work/Day: (715)387-1204
PO Box 527 Work/Day: (800)499-7830
City State Zip: Marshfield,WI 54449 FAX: (715)387-0727
Email: bodyshop@wheelergm.com !
Vehicle
ii
2004 Chevrolet Cavalier LS 4 DR Sedan j
4cyl Gasoline 2.2 ;
4 Speed Automatic '
Lic Expire: VIN: 1G1JF52F847191884
Veh Insp#: Mileage Type: Actual
Condition: Code: U23446
Ext.Color: MEDIUM GREEN EFFECT Int.Color:
Ext.Refinish: Two-Stage Int.Refinish: Two-Stage
Ext. Paint Code: 9539,47 Int.Trim Code: '
Options
AM/FM CD Player Air Conditioning Alarm System
Anti-lock Brakes Center Console Cruise Control
Dual Airbags Intermittent Wipers Keyless Entry System ,
Lighted Entry System Power Brakes Power poor Locks
Power Mirrors Power Steering Power Windows
Rear Window Defroster Rem Trunk-UGate Release Tachometer
Tilt Steering Wheel Tinted Glass Traction Control System
Velour/Cloth Seats
03/12/2012 09:01 AM Page 1 of 3
2004 Chevrolet Cavalier LS 4 DR Sedan
Claim#: 03/12/2012 08:58 AM
Damages
Line Op Guide MC Description MFR.Part No. Price ADJ°/a B% Hours R
1 EC 6 46 Cover,Front Bumper Replace Economy $269.00* 3.2 SM
2 L 6 13 Cover,Front Bumper Refinish 3.7 RF
2.6 Surface
0.6 Two-stage setup
0.5 Two-stage
2 Items
MC Message
13 INCLUDES 0.6 HOURS FIRST PANEL TWO-STAGE ALLOWANCE
46 PRINTABLE ALTERNATE PARTS COMPARE
Estimate Total 8�Entries
Othe�Parts $269.00
Paint Materials $125.80
Parts&Material Total $394.80
Tax on Parts&Material @ 5.500% $21.71
Labor Rate Replace Repair Hrs Total Hrs
Hrs
Sheet Metal(SM) $54.00 3.2 3.2 $172.80
Mech/Elec(ME) $73.00
Frame(FR) $62.00
Refinish(RF) $54.00 3J 3.7 $199.80
Paint Materials $34.00
Labor Total 6.9 Hours $372.60
Tax on Labor @ 5.500% $20.49
Gross Total $809.60 '
Net Total $809.60 ;
Alternate Parts Y/01/00/00/01/00 CUM 01/00/00/01/00 Zip Code:54449 Default
Audatex Estimating 6.0.726 ES 03/12/2012 09:01 AM REL 6.0.726 DT 02/01/2012 DB 03/08/2012
Copyright(C)2011 Audatex North America, Inc.
1.1 HRS WERE ADDED TO THIS ESTIMATE BASED ON AUDATEX'S TWO-STAGE REFINISH FORMULA. II
I
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
03/12/2012 09:01 AM Page 2 of 3
2004 Chevrolet Cavalier LS 4 DR Sedan
Claim#: 03/12/2012 08:58 AM
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
�M""�� the insured,claimant and others on a need to know basis in order to effectuate the claims process)without
'� ������� Audatex's prior written consent.
a�erleri�rw�P�Y
� Copyright(C)2011 Audatex North America, Inc.
Audatex Estimating is a trademark of Audatex North America, Inc.
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03/12/2012 09:01 AM Page 3 of 3
' Date .3 �1�—�a�.�
AUTO BODY SERVICE
OVER 25 YEARS EXPER/ENCE Customer Name
c°"'pt�c� Address �� � �'— �ione No. 3g3 -�.�G �
PAINTING �/I �'� �� �9-�_/7 j7
�� — �� !i BODY WORK CitylState_�" l
AMERICAN&FOREIGN
CARS 8 TRUCKS
Year d� �/ Make Model
609 S.Washington
Marshfield,WI 54449 VIN
Call 387-2262
PARTS AND
REPAIR REPLACE DETAILS OF REPAIRSIOR REPLACEMENT LABOR MATERIALS REFINISHING
,
C�� �� e� a
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c�uf �-/�' I bC7 do , O
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TOTALS
ESTIMATE VOID AFTER 90 DAYS s� � �
YOU AAE ENTITLED TO A PRICE ESTIMATE FOR THE REPAIRS YOU HAVE AUTHORIZED.THE REPAIR
PRICE MAY BE LESS THAN THE ESTIMATE, BUT WILL NOT EXCEED THE ESTIMATE WITHOUT YOUR
PERMISSION.YOUR SIGNATURE WILL INDICATE YOUR ESTIMATE SELECTION. L.3bof C� � �Q
t. I request an estimate in writing before you begin repairs. Parts �y��
2. Please proceed with repairs,but call me before continuing if the price wiil exceed S
Materials (�Q r �j D
3. I do not want an estimate. Sublet or Sandblasting
Our estimate charge ls SUB TOTAL � �
Do you want the parts you are entitled to? ❑ Yes ❑ No
EQUIRED AFTERB MSE WORK HASN EEN ST�ARTED.AFTER�THE WO KAHAS ST RTED,W RN OR DAMAGED PARBS T� �CJ
WMICM AAE NOT EVIDENT ON FIRST INSPECTION MAY BE DISCOVERED.NATURALLY TMIS ESTIMATE CANNOT COVER
5���NOENCIES.PARTS PRICES SUBJECT TO CHANGE WtTHOUT NOTiCE.TMIS ESTIMATE IS FOR IMMEDUTE TOTAL � � � ' �
THIS WORK AUTHORIZED BY TERMS:Net - 10 days;1 V2%after 30 days
Motor vehicle repair trade practices are regulated by Wis.Adm.Code Chapter Ag 132,administered by the Trade Division,Wis.Dept.of Agriculture,
P.O.Box 89�1, Madison,wisconsin 53�os-8s11. ESTIMATE SHEET AND REPAIR ORDER