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Kretman NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota Minnesota State Statute 466.05 states that"...every person...who claims damages from any municipality...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 _��h� Middle Initial�Last Name �1�� Company or Business Name I i Are You an Insurance Company? Yes� If Yes,Claim Number? Street Address�q� 5 T�G��L S� s� R �- �Q City �'J �� CJ1�r State � � Zip Code SS� Daytime Phone(�) � i 330Ce11 Phone(�)5r -��pEvening Telephone( ) - Date of Accident/Injury or Date Discovered 3- I I-1 Z Time � -00 �/pm Please state,in detail, what occurred(happened),and why you are submitting a claim.Please indicate why r how you feel the City of Saint Paul or its em loyees are involved an or responsible for your da ges. � r � r , � � c +' r c�c� Please check the box es that most closel re resent the reas n f I � ) y p o ar completmg 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_�t�2� �►1C'�'1 �sp�� QYi �G�1� ❑ Other type of injury-please specify In order to process your claim you need to include conies of all aanlicable 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 WILL NOT be returned and become the property of the City. You are encouraged to keep a copy for�y�o rself before submitting your claim form. U 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 �hotographs 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 Claims—ulease complete this section Were there witnesses to the incident? Yes No Unknown (circle) Provide their names, addresses and telephone numbers: Were the police or law enforcement called? Yes No Unknown (circle) If yes, what department or agency? Case#or report# , Where did the accident or injury take place? Provide street address,cross street, intersection,name of park or facility, cl�oseC�st�and ark, t1�Pleass�be as detail�e-d` as ossii le. �n�essary, aiaOc�a diagram. � � � Please indicate the a ount you are seeking in compensation or what you would like the City to do to resolve this claim to your satisfaction. � 1�� C_c?✓�.r' GC��f C9Y � �,C1Q.°a f� Gc� ve� v�-.rf—„ ��C+ ► �1�, Vehicle Claims— lease com lete this section ❑ check box if this section does not applv Your Vehicle: Year Make_�O�' Model License Ylate Number T 3 C— State�`�1 Color �P Registered Owner Driver of Vehicle Area Damaged � 1� City Vehicle: Year Make Model License Plate Number ` State Color Driver of Vehicle(City Employee's Name) Area Damaged Iniurv Claims—please complete this section �check box if this section does not applv ! 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 addiNonal 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 3 ' �L� — �Z Print the Name of the Person who Completed this Form: �(��n �l��n Signature of Person Making the Claim: �y�2� ��—��--� Revised February 2011 RAYMOND AUTO BODY� INC. Workfile ID: 2f05af2b � FederalID: 41-0888257 1075 PIERCE BUTLER RTE, SAINT PAUL, MN 55104 Phone: (651) 488-0588 FAX: (651) 488-4794 Preliminary Estimate Customer: KRETMAN,JOHN Written By:JOHN JANASZAK Insured: KRETMAN,JOHN Policy#: Claim #: Type of Loss: Date of Loss: Days to Repair: 0 Point of Impact: Owner: Inspection Location: Insurance Company: �I KREfMAN,JOHN RAYMOND AUTO BODY,INC. I APT 10 1075 PIERCE BUTLER RTE I 2297 STANDISH STREET SAINT PAUL, MN 55104 '' ST PAUL, MN 55108 Repair Facility (651)689-1330 Evening (651)488-0588 Business VEHICLE Year: 2007 Body Style: 4D SED VIN: 1FAFP34N77W294880 Mileage In: Make: FORD Engine: 4-2.OL-FI License: Mileage Out: Model: FOCUS SE Production Date: State: Vehicle Out: I Color: Int: Condition: Job#: ' 5 Speed Transmission Console/Storage Overdrive Rear Defogger Air Conditioning Driver Air Bag Passenger Air Bag Recline/Lounge Seats AM Radio Dual Mirrors Power Brakes Search/Seek Bucket Seats FM Radio Power Locks Stereo CD Player Full Wheel Covers Power Mirrors Tinted Glass Clear Coat Paint Intermittent Wipers Power Steering Cloth Seats Keyless Entry Power Windows - "OUR QUALITY SHOWS WE CARE" _ ' a: •.;� ( _ �i Raymond Auto Body 1075 PIERCE BUTLER ROUTE • ST.PAUL,MN 55104 PHONE 651-488-0588 JOHN JANASZAK DIRECT 651-558-0118 E-mail:john@raymondautobody.com FAX 651-488-4794 3/12/2012 10:24:02 AM 019495 Page 1 Preliminary Estimate Customer: KRETMAN,70HN Vehicle: 2007 FORD FOCUS SE 4D SED 4-2.OL-FI Line Operation Description Qty Extended Labor Paint Price$ 1 FRONT BUMPER 2 R&I R&I bumper cover 1.2 3 GRILLE 4 R&I Grille w/o appearance pkg.chrome 0.2 5 FRONT LAMPS 6 R&I RT Headlamp assy w/o SVT 0.3 7 R&I LT Headlamp assy w/o SVT 0.3 8 HOOD 9 Repl Hood 1 520.02 1.0 2.6 10 Add for Clear Coat 1.0 11 Add for Underside(Complete) 1.3 12 Add for Clear Coat 0.3 13 FENDER 14 Blnd RT Fender 0.9 15 # R&I RT Fender Decal 0.2 16 # Rpr Clean and Retape Decal 0.2 17 Blnd LT Fender 0.9 18 # R8cI LT Fender Decal 0.2 19 # Rpr Clean and Retape Decal 0.2 20 MISCELLANEOUS OPERATIONS 21 * Repl Cover car/bag 1 Q2 22 # Subl Hazardous waste removal 1 6.00 X 23 # Color tint/color match 1 0.5 24 # Repl Corrosion protection primer 1 0.4 25 # ***open for hidden damages*** 1 SUBTOTALS 526.02 3.8 8.1 ESTIMATE TOTALS Category Basis Rate Cost$ Parts 520.02 Body Labor 3.8 hrs @ $52.00/hr 197.60 Paint Labor 8.1 hrs @ $52.00/hr 421.20 Paint Supplies 8.1 hrs @ $32.00/hr 259.20 Miscellaneous 6.00 Subtotal 1,404.02 Sales Tax $520.02 @ 7.6250% 39.65 Grand Total 1,443.67 Deductible 0.00 CUSTOMER PAY 0.00 INSURANCE PAY 1,443.67 3/12/2012 10:24:02 AM 019495 Page 2 Preliminary Estimate Customer: KRETMAN,70HN Vehicle: 2007 FORD FOCUS SE 4D SED 4-2.OL-FI WHILE WE HAVE MADE EVERY EFFORT TO WRITE A COMPREHENSIVE REPORT OF THE VISIBLE DAMAGE TO YOUR VEHICLE, IT IS IMPORTANT TO REMEMBER THAT THIS IS ONLY AN ESTIMATE. THERE ARE A NUMBER OF FACTORS THAT CAN AFFECT THE ACTUAL COST OF REPAIRS, INCLUDING BUT NOT LIMITED TO HIDDEN DAMAGE, PARTS PRICE CHANGES, AND INSURANCE COMPANY INVOLVEMENT. PLEASE CONSIDER THIS WHEN MAKING DECISIONS REGARDING THE REPAIRS TO YOUR VEHICLE. � AUTO CLUB INSURANCE ASSOCIATION, MEMBERSELECT INSURANCE COMPANY OR AUTO CLUB GROUP INSURANCE I� COMPANY (HEREIN INDIVIDUALLY AND COLLECTIVELY REFERRED TO AS ACIA) GUARANTEES THAT IT WILL REPLACE ' THE QUALITY REPLACEMENT PARTS (PARTS NOT MANUFACTURED BY THE ORIGINAL EQUIPMENT MANUFACTURER) ' IDENTIFIED ON THE VEHICLE ESTIMATE ASSOCIATED WITH THIS GUARANTEE REPAIR VEHICLE) IF A DEFECT IS � DISCOVERED. ACIA FURTHER GUARANTEES THAT TNE QUALITY REPLACEMENT PARTS, EXCLUDING GLASS AND MECHANICAL PARTS, ARE CERTIFIED OR VALIDATED TO BE OF OEM QUALITY IN ALL INSTANCES WHEN THIS CERTIFICATION OR VALIDATION IS AVAILABLE FOR THE PART. THIS GUARANTEE IS IN EFFECT FOR AS LONG AS YOU OWN THE REPAIR VEHICLE AND IS NOT TRANSFERABLE TO ANOTHER PARTY AT ANY TIME. THIS GUARANTEE COVERS THE COST OF THE PART, LABOR TO INSTALL, PAINT AND MATERIALS IF REQUIRED, AND REASONABLE RENTAL COST OF A SIMILAR TEMPORARY REPLACEMENT VEHICLE DURING THE REPAIRS. THIS GUARANTEE DOES NOT COVER CLAIMS FOR DIMINUTION IN VALUE OR CONSEQUENTIAL DAMAGES. j IF A DEFECT IN A QUALITY REPLACEMENT PART IS DISCOVERED, CONTACT YOUR LOCAL ACIA CLAIMS DEPARTMENT I IMMEDIATELY AND ACIA WILL REPLACE THE PART WITH A NEW ORIGINAL EQUIPMENT MANUFACTURER PART. IF AN ORIGINAL EQUIPMENT MANUFACTURER PART IS NOT REASONABLY COMMERCIALLY AVAILABLE, ACIA WILL REPLACE THE DEFECTIVE PART WITH ANOTHER QUALITY REPLACEMENT PART. I 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. � 3/12/2012 10:24:02 AM 019495 Page 3 Preliminary Estimate Customer: KRETMAN,JOHN Vehicle: 2007 FORD FOCUS SE 4D SED 4-2.OL-FI Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide DR2JK00, CCC Data Date 3/9/2012, 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 Pathways -A product of CCC Information Services Inc. 3/12/2012 10:24:02 AM 019495 Page 4 SUBURBAN AUTO BODY MINNESOTA'S COLLISION SPECIALIST 2989 COUNTRY DRIVE LITTLE CANADA, MN 55117 PHONE:651-633-8900 FAX:651-481-0700 ***PRELIMINARY ESTIMATE*** 03/14/2012 09:51 AM Owner Owner: John Kretman Inspection Inspection Date: 03/14/2012 09:51 AM Inspection Type: �Repairer � Repairer: TOM RAMLET Contact: Address: 2989 Country Drive Work/Day: (651)633-8900 City State Zip: Little Canada, MN 55117 FAX: (651�81-0700 Email: tr@suburbanautobody.net Vehicle 2007 Ford Focus SE 4 DR Sedan 4cyl Gasoline 2.0 5 Speed Manual Lic Expire: VIN: 1 FAFP34N77W294880 Veh Insp#: Mileage Type: Actual Condition: Code: P1583C Ext.Refinish: Two-Stage Int.Refinish: Two-Stage , Options AM/FM CD Player Air Conditioning Alarm System Center Console Dual Airbags Intermittent Wipers Keyless Entry System Lighted Entry System MP3 Piayer Overhead Console Power Brakes Power poor Locks Power Mirrors Power Steering Power Windows Rear Window Defroster Rem Trunk-UGate Release Split Folding Rear Seat Theft Deterrent System Tinted Glass VeloudCloth Seats Damages Line Op Guide MC Description MFR.Part No. Price ADJ% B% Hours R 1 N 5 Front Bumper Cover R&I Additional Labor 1.2 SM 2 RI 41 Headlamp Assy,Halogen LT R&I Assembly 0.9 SM 3 I 83 Panel,Hood Repair 6.0" SM 4 L 83 13 Panel,Hood Refinish 3.8 RF 2.7 Surface 0.6 Two-stage setup 0.5 Two-stage 03/14/2012 09:56 AM Page 1 of 3 , 2007 Ford Focus SE 4 DR Sedan Claim#: 03/14/2012 09:51 AM 5 RI 169 Pad,lnsulator Hood R& I Assembly 0.2 SM 6 BR 103 Fender,Front LT Blend Refinish 1.1 RF 0.7 Blend 0.4 Two-stage 7 RI 105 Skirt,lnner Fender LT R&I Assembly INC SM 8 L M14 Corrosion Protection Refinish 0.5" RF 9 L M15 Color Tint Refinish 0.5" RF 10 L M17 Cover Car Exterior Refinish 0.3" RF 11 SB M60 Hazardous Waste Removal Sublet Repair $5.00* SM 12 RI R&I It fender nmplt R&I Assembly 0.5' SM* »inc clean&retape. 12 Items MC Message 13 INCLUDES 0.6 HOURS FIRST PANEL TWO-STAGE ALLOWANCE Estimate Total&Entries Paint Materials $198.40 Parts&Material Total $198.40 Labor Rate Replace Repair Hrs Total Hrs Hrs Sheet Metal(SM) $52.00 1.6 7.2 8.8 $457.60 Mech/Elec(ME) $95.00 Frame(FR) $75.00 Refinish(RF) $52.00 6.2 6.2 $322.40 Paint Materials $32.00 Labor Total 15.0 Hours $780.00 Sublet Repairs $5.00 Gross Totai $983.40 Net Total 3983.40 Alternate Parts Y/00/00/00/00/00 CUM 00/00/00/00/00 Zip Code:55117 LOCAL SUPPLIERS Audatex Estimating 6.0.726 ES 03N4/2012 09:56 AM REL 6.0.726 DT 02/01/2012 DB 03/08/2012 Copyright(C)2011 Audatex North America, Inc. 1.5 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 MANTJFACTURER 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 03/14/2012 09:56 AM Page 2 of 3 2007 Ford Focus SE 4 DR Sedan ' Claim#: � 03/14/2012 09:51 AM * = User-Entered Value E = Replace 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= Partial Replace Price PM= Repiace 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 the insured,claimant and others on a need to know basis in order to effectuate the claims process)without ��'��` Audatex's prior written consent. d St��rrt G�drri Copyright(C)2011 Audatex North America, Inc. 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