Diederich 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 cle�rly 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, NIN 55102
First Name ��A�-�S Middle Initial � Last Name �i���R I�H
Company or Business Name ��C'����G
Are You an Insurance Company?_Yes No If Yes,Claim Number? _ APR � 3 2��2
street Address ayya bQ oa Kv��-�r 7�2. E• C:i�i'� CL�F3K
City ST• /ALl L State /�'1/1� Zip Code .5���Q
Daytime Phone(6 S/ )�-0 oZb Cell Phone(6 td)�-30�16 Evening Telephone( .�5�)��-�9�6
Date of Accidend Injury or Date Discovered 03�o?�I�oZ G/oZ , Time S� 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 Saint Paul or its employees are involved and/or res�onsible for vour dama�es. _
We were driving home on I-94 eastbound through"spaghetti junction"in St.Paul under the 7th Street bridge
on Tuesday,3/27 at 5:25 p.m.when something fell out of the sky,hit the hood of our vehic�e and bounced off the roof!
My wife thought someone had thrown something off the bridge but I recognized it as a street light globe.I went
back on Wednesday to confirm.Sure enough,the second light pole from the West end,on south side,of the 7th
street bridge is missing the top globe.It is the larger one(�12"-15")with two globes below it.I reported this
incident to Sandra Bodensteiner in case Public Works was not aware of the missing globe;or in case it is still
bouncing around under the bridge on the highway.In any event I feel the City is responsible for the damage to
Pleas� our vehicte.We're just glad it didn't hit the windshield or cause�s to have an accident with another car.
Liability:Public Works/Street Maintenance responsibility for faulty installetion/maintenance of light pole. T
❑ My YlillllilV ..u�u,.,....b.,..�.....__________ ,a tow
�[My vehicle was damaged by a�hc�l�es 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 sp��ify
In order to process your claim vou need to include conies of all applicable documents.
For the claims types listed below,please be swe to include the documents indicated or it will delay the handling of
your claim. Documents WILL NOT be retumed and become the property of the City. You are encouraged to keep a
copy for yourself before 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
and/or receipts for the repairs;detailed list of damaged items
O Injury claims: medical bills,receipts
• 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 complete this section
Were there witnesses to the incident? Yes No Unknown (circte)
Provide their names,addresses and telephone numbers:
Were the police or law enforcement called? Yes No Unknown (circle)
If yes, what department or agency? S'�' Pft t�,L Po t-�eE Case#or report# � •w�a-�'a
�P,�:w�.!
Where did the accident or injury take place? Provide street address,cross street,intersection,name of ark or facihty,
closest landmazk,etc. Please be as detailed as possible. If necessary, attach a diagram. W H�RE �9y EAsTBouN�
C'R oSSES U nI�ER THE �rN SrR EeT BQ��G�'
Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction. „�'/� �5�4 � DO
Velucle Clairus— lease com lete this section ❑ check box if this section does not a 1
Your Vehicle: Year aa�Make G'/►'�C Model
License Plate Number SAN 9.xS State� I�Color /1?ERLoT �EWEL Rt.�
RegisteredOwner eHARt.ES' �(E.��k1CN
Driver of Vehicle SRME 9`
Area Damaged /foa..D
(� City Vehicle: Year Make Model
���
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Intjury 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 additional pages 3 t P��u�e�S
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 d 3'30'a 0/a
Print the Name of the Person who Completed this Form: ��RRLFS' � ��F�E��Cf�
Signature of Person Making the Claim: � }/�•,�.���'�v
Revised February 2011
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OAKDALE CO.LLISION CENTER
1040 GERSFiWIN AVENUE
ST. PAUL, MN.55128
PHONE:651-264-0909 FAX:651-264-0910
***PRELIMINARY ESTIMATE***
03/30/2012 11:37 AM
_. _ . . ._ __._ _...__..,.
�....._,. _ . „� .�..._
_ .._.__r...._,. . ,. ._�._.�_...,.
Owner . _ .... _ . __, _:
Owner: Charles Diederich
Address: 2442 Brookview Dr E Work/Day: (651)738-0926
City State Zip: Maplewood, MN 55119 FAX:
___ _,,�._��_.... ,. .. __.....___�_..,,� ,,,,� _..._.. ._��.�._�,, ,.., ,
......_., ._„,,,,..... . _.�_.__......_ �___
_..... _ .. __..._ __,.,.�._ . . ..._.._ �..._
Inspection
Inspection Date: 03/30/2012 11:38 AM Inspection Type:
Company: OAKDALE COLLISION Appraiser License#:
Contact: DON JUEN JR.
Address: 1040 GERSHWIN AVE N Work/Day: (651)264-0909
City State Zip: Oakdale, MN 55128 FAX: (651)264-0910
___ __ .... . �
_ .... �_ � � .. _._. _
_. _. .._. . ..�. . _.___
__. ... ..._.�.. _____ .. ....
Repairer
_ ..___ __.__._ .p ..________......_...__._. _...... ..._.__� ��__.,.,.. _..W____W_�... __ _.____._.,_,,,,,,�__._. _.._..._. ,.,,_,... � ___... .._ _� ,,_,,,,,
Re airer: OAKDALE COLLISION CENTER Contact. DON JUEN
Address: 1040 GERSHWIN AVE. Work/Day: (651)264-0909
Oakdalecollision@msn.com FAX: (651)264-0910
City State Zip: OAKDALE, MN 55128 FAX:
Email: Oakdalecollision@msn.com
i
_ �_ _. _ _ ___ _ __. �
�_ _ __ __ _ .__.__ . . _ _ __._._ .
Vehicle
2011 GMC Terrain SLT2 4 DR Wagon
6cyl Gasoline 3.0
6-Speed Automatic
Lic Expire: VIN: 2CTFLXE5766293893
Veh Insp#: Mileage Type: Actual
Condition: Code: U7614C
Ext.Color: Red met Int.Color: �
Ext. Refinish: Two-Stage Int.Refinish: Two-Stage
Options
2nd Row Head Airbags 4-Wheel Drive AM/FM CD Player
Air Conditioning Alarm System Aluminum/Alloy Wheels
Amplifier Anti-lock Brakes Auto Headlamp Control
Automatic Dimming Mirror Bucket Seats Center Console
Chrome Grille Climate Control For A/C Cruise Control
Daytime Running Lights Driver Seat Memory Dual Airbags
Emergency S.O.S. System Floor Mats Fog Lights
Halogen Headlights Head Airbags Heated Front Seats
Heated Power Mirrors Heated W/S Wiper Washers Illuminatd Visor Mirrors
Intermittent Wipers Keyless Entry System Leather Seats
Leather Steering Wheel Lighted Entry System MP3 Player
Mirror(s)Memory OnStar System Power Brakes
Power poor Locks Power Drivers Seat Power Liftgate
03/30/2012 11:42 AM Page 1 of 3
ti, .
2011 GMC Terrain SLT2 4 DR Wagon
Claim#� 03130/2012 1137 AM
Power Moonroof Power Steering Power Windows
Pwr Driver Lumbar Supp Rear Spoiler Rear Step Bumper
Rear View Camera Rear Window Defroster Rear Window Wiper/Washer
Remote Starter Reverse Sensing System Roof/Luggage Rack
Side Airbags Skid Piates Split Folding Rear Seat
Stability Cntrl Suspensn Strg Wheel Radio Control Tachometer �
Theft Deterrent System Tilt&Telescopic Steer Tinted Glass
Tire Pressure Monitor Traction Control System Trip Computer
XM Satellite Radio
Damages
Line Op Guide MC Description MFR.Part No. Price ADJ°/a B% Hours R
1 N 15 Front Bumper Cover R&I Additional Labor 1.6 SM
2 RI 41 Headlamp Assy,Halogen LT R& I Assembly 0.3 SM
3 RI 42 Headlamp Assy,Halogen RT R& I Assembly 0.3 SM
4 E 83 Panel,Hood 25942546 GM Part $888.38 0.9 SM
5 L 83 13 Panel,Hood Refinish 5.6 RF
3.0 Surface
1.2 Edge
0.6 Two-stage setup
0.8 Two-stage
6 RI 40 MIdg,Hood Front R& I Assembly 0.2 SM
7 RI 82 Pad,lnsulator Hood R& I Assembly 0.3 SM
8 E 95 Label,Hood 19257194 GM Part $27.88 0.1 SM
9 BR 103 Fender,Front LT Blend Refinish 1.2 RF
0.8 Blend
0.4 Two-stage
10 BR 104 Fender,Front RT Blend Refinish 1.2 RF
0.8 Blend
0.4 Two-stage
i 11 RI 34 MIdg,Fender Lower L/F R& I Assembly 0.1 SM
12 RI 35 MIdg,Fender Lower R/F R& I Assembly 0.1 SM
13 RI 167 Skirt,lnner Fender LT R& I Assembly INC SM
14 RI 168 Skirt,inner Fender RT R& I Assembly INC SM
15 SB HAZARD. WSTE. REM. Sublet Repair $4.00' SM
16 SB COVER CAR EXTERIOR Sublet Repair $4.00' SM
17 E Caution label Replace OEM $5.00' 0.1' SM'
17 Items
MC Message
i 13 INCLUDES 0.6 HOURS FIRST PANEL TWO-STAGE ALLOWANCE
__ _.... __ . _._
Estimate Total 8� Entries
� Gross Parts $921.26
I Paint Materials $240.00
� Parts & Material Total $1,161.26
Tax On Parts Only @ 7.125% $65.64
Labor Rate Replace Repair Hrs Total Hrs
Hr
s
Sheet Metal(SM) $50.00 2.4 1.6 4.0 $200.00
Mech/Elec (ME) $80.00
Frame(FR) $71.00
Refinish (RF) $50.00 8.0 8.0 $400.00
Paint Materials $30.00
03/30l2012 11:42 AM Page 2 of 3
2011 GMC Terrain SLT2 4 DR Wagon
Claim#: 03/30/2012 11:37 AM
Labor Total 12.0 Hours $600.00
Sublet Repairs $8.00
Gross Total $1,834.90
Net Total $1,834.90
Alternate Parts No
Audatex Estimating 6.0.626 ES 03/30/2012 11:42 AM REL 6.0.626 DT 03/01/2012 DB 03/1512012
Copyright(C)2011 Audatex North America, Inc.
2.2 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
MAI�TUFACTURER OR DISTRIBUTOR RATHER TH1�N 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 = 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= 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
the insured,claimant and others on a need to know basis in order to effectuate the claims process)without
�����"�1� Audatex's prior written consent. ,
�I:e�f3;'Ia �:1i�:4. �
- Copyright(C)2011 Audatex North America, Inc. i
Audatex Estimating is a trademark of Audatex North America, Inc.
03l30/2012 1�:42 AM Page 3 oi 3
HEPPNER'S WOODBURY AUTO BODY Workfile ID: 7d38c19b
1807 WOODLANE DR, WOODBURY, MN 55125
Phone: (651) 735-5055
FAX: (651) 735-5057
Preliminary Estimate
Customer: DIEDERICH,CHARLES
Written By: RON KINDE
Insured: Policy#: Claim #:
Type of Loss: Liability Date of Loss: Days to Repair: 3
Point of Impact:
Owner: Inspection Location: Insurance Company:
DIEDERICH,CHARLES HEPPNER'S WOODBURY AUTO BODY CUSTOMER
2442 BROOKVIEW DR E 1807 WOODLANE DR
MAPLEWOOD, MN 55119 WOODBURY, MN 55125
(612)940-0926 Evening Repair Facility
(651)738-0926 Other - _ (651j 73�-�D�S Day -- - —--- .
VEHICLE
Year: 2011 Body Style: 4D UN VIN: 2CfFLXE5766293893 Mileage In:
Make: GMC Engine: 6-3.OL-FI License: 5AN925 Mileage Out:
Model: TERRAIN 4X4 SLT Production Date: State: MN Vehicle Out:
Color: RED Int: Condition: ]ob#:
4 Wheel Disc Brakes Cruise Control Luggage/Roof Rack Rear Defogger ;
4 Wheel Drive Driver Air Bag Message Center Rear Window Wiper I
Air Conditioning Dual Mirrors Parking Sensors w/Equip Remote Starter i
Aluminum/Alloy Wheels Electric Glass Sunroof Passenger Air Bag Satellite Radio ,
AM Radio FM Radio Power Brakes Search/Seek '.
Anti-Lock Brakes(4) Fog Lamps Power Driver Seat Stability Control �
Automatic Transmission Front Side Impact Air Bags Power Locks Steering Wheel Controls
Auxiliary Audio Connection Head/Curtain Air Bags Power Mirrors Stereo i
Bucket Seats Heated Mirrors Power Steering Telescopic Wheel
CD Player Heated Seats Power Trunk/Tailgate Three Stage Paint _ _
Ctimate Control Intermittent Wipers Power Windows Tilt Wheel
Communications System Keyless Entry Premium Radio Traction Control
Console/Storage Leather Seats Privacy Glass
3/30/2012 2:42:01 PM 018571 Page 1
Preliminary Estimate
Customer: DIEDERICH, CHARLE5
Vehicle: 2011 GMC TERRAIN 4X4 SLT 40 UN 6-3.OL-FI RED
Line Operation Description Qty Extended Labor Paint
Price$
1 FRONTLAMPS
2 R&I RT Headlamp assy 0.3
3 R&I LT Headlamp assy 0.3
q HOOD
5 Repl Hood 1 888.38 1.0 2•8
6 Add for Three Stage Z'�
� Add for Underside(Complete) 1.4
g R&I Insulator Incl.
g R&I RT Hood seal
10 R&I LT Hood seal
11 R&I Front seal Incl.
12
* R&I M I in 0.3
13 FENDER
14 Blnd RT Fender 1.5
15 Blnd LT Fender l.s
16 # Refn �Cover Vehicle 0'2
17 # Repl �Hazardous Waste Disposal Fee 1 5.00 X
SUBTOTALS 893.38 1.9 9.4
ESTIMATE TOTALS
Category Basis Rate Cost$
Parts 888.38
Body Labor 1.9 hrs @ $ 52.00/hr 98.80
Paint Labor 9.4 hrs @ $52.00/hr 488.80
Paint Supplies 9.4 hrs @ $ 32.00/hr 300.80
Body Supplies 1.0 hrs @ $2.00/hr 2.00
Miscellaneous 5.00
Subtotal 1,783J8
Sales Tax $888.38 @ 7.1250% 63.30
Grand Total 1,847.08
� CUSTOMER PAY 0.00
INSURANCE PAY 1,847.08
THIS REPORT IS BASED ON OUR INSPECTION AND DOES NOT COVER ANY ADDITIONAL PARTS OR LABOR WHICH
MAY BE REQUIRED AFTER THE WORK IS OPENED UP. OCCASIONALLY AFTER THE WORK HAS STARTED,WORN OR
DAMAGED PARTS ARE DISCOVERED WHICH ARE NOT EVIDENT FIRST INSPECTION.
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.
3/30/2012 2:41:13 PM 018571 Page 2