Dustin �tEG�l�E�
NOTICE OF CLAIM FORM to the City of Saint Pau �ta
Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipality...shall cause to be ented to the
governing body of the municipality within 180 days after the alleged loss or injury is discovered a notice�;i��t���ce,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 ezplain 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 FaRM AND OTHER DOCUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
First Name Middle Initial�Last Name ���%/�1 _
Companyo ur Business Name /L��T =_ -- - - -
Are You an Insurance Company? Yes/No If Yes,Claim Number?
Street Ad ess � i
City s �/ State ��/ Zip Code ��� /
, ,
Daytime Phone(��1�����e11 Phone,��'�c��Evening Telephone _
Date of Accident/Injury or Date Discovered `,�7v���o Time c��� pm
Please state,in detail,what occurred(happened), and why you are submitting a claim.Please indi te why or w you
feel the C' of S ir}t Paul or its employ es are involv d an r responsible f r yo amages. � � �
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(y��-u..r�s o� �o�-ne-S 7��'�-1' �p�� �/'C�' G I
Please check the box es t at most cl�sely re sent e reason fo comp ehng this fo
(aJ My vehicle was damaged in an accident�l`_CLm b�(.�CLMG'�� ❑ 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
C� My vehicle was wrongiully towed and/or ticketed C� 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��ou need to include copies of all applicable 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 encouragec�to keep a
copy�for yourself befare submitting your claim form.
� Property damage claims to a vehicle:two estimates for the repairs to your vehicle if the da.mage exceeds
$500.00; or the actual bills andlor 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 far the repairs; detailed list of ciamaged items
O Injury claims: medical bills,receipts
• Photographs are always welcome to docuxnent and support your claim but will not be returned.
.,% � Page 1 of 2-Please complete and return both pages of Claim Form
I ' ��"�'�h�-os
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Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims-please complete this section
Were there witnesses to the incident? Yes No Unlrnown � (circle)
Pro�de eir names ad�esses and t e ho e numb�rs: �- _
7 f�
Were the police ar law enforcem nt called? Yes" � No Unlrnown (circle
If yes,what department or agency? S'`� �G'1LG��Ti�� Cas �or�o�rt� a a' ��
GF
W here di d t he acci dent or injury take place? Provide street address,cro treet,intersecti��ame f park or facility,
closes landmark, etc. Please be as det �led as possible. �Ifnecessary, attach a diagram. � °c�l
s , ���
� o�n O y �'� � if Ur y��d`�f ke the��� to do to reu�th�c���
Please in icate the amount ou are eekin com nsatio w t u woul
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to your satisfaction.
. � � �
--- -- - - -- 1So 1��y �f-2 � i • c°- `s-
Vehicle Claims- lease com lete this section ❑ check box if this section does not a 1
Your Vehicle: Year ��JD Make Model /
License Plate Number State � Color s� ���
Registered Owner `
Driver of Vehicle �
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_ Area Damaged -� .r � - �_ ^ \
City Vehicle: Year Make Model /I'i�/�
_- _ _ _
�rn/_�� License Plate Number State Color �d-Dke� J
f� �� Driver of Vehicle(City Employee's�Tame) `
Area Damaged ' �'j
�
Injurv Claims-nlease 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
_ Wh�r_�i;d.vo�mi�s_v��rk? -- - _ (pmvide date(sl)
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 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 processec�
Submitting a false claim can result in prosecution. Date form was completed ����Bv�
Print the Name of the Person who Completed this Form: ���L���4� �.i��s��
�
Signature of Person Making the Claim: �
Revised February 2011
FAIRWAY COLLISION CENTER� INC. workf�e��: 31d9s45a �
FederalID: 41-1248355
125 E COUNTY ROAD F, VADNAIS HEIGHTS, MN
55127
Phone: (651) 483-4055
FAX: (651) 483-5324
Preliminary Estimate
Customer: DUSTIN, KATHLEEN
Written By:TROY HEIR
Insured: Policy#: Claim #:
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact: il Left Front
Owner: Inspection Location: Insurance Company:
DUSTIN, KATHLEEN FAIRWAY COLLISION CENTER,INC.
921 HERITAGE CT. 125 E COUNTY ROAD F
VADNAIS HEIGHTS,MN 55127 VADNAIS HEIGHTS,MN 55127
(651)483-8655 Evening Repair Facility
(651)249-2473 Business (651)483-4055 Day
VEHICLE
Year: 2010 Body Style: 4D SED VIN: JA32U2FUOAU031681 Mileage In: 1
Make: MITS Engine: 4-2.OL-FI License: 306 EBV Mileage Out: 1
Model: LANCER ES Production Date: 5/2010 State: MN Vehicle Out:
Color: RED Int: Condition: Good Job#:
Air Conditioning Cloth Seats Message Center Privacy Glass
Alarm Console/Storage Metallic Paint Rear Defogger
Aluminum/Alloy Wheels Cruise Control Overdrive Search/Seek
AM Radio Driver Air Bag Passenger Air Bag Stability Control
Anti-Lock Brakes(4) Dual Mirrors Power Brakes Steering Wheel Controls
Automatic Transmission FM Radio Power Locks Stereo
Auxiliary Audio Connection Front Side Impact Air Bags Power Mirrors Tilt Wheel
BuCket Seats Head/Curtain Air Bags Power Steering _ Traction Control
,�D Player Intermittent Wipers Power Trunk/Tailgate
Clear Coat Paint Keyless Entry Power Windows
4/20/2012 5:06:00 PM 016694 Page 1
. �,
• Preliminary Estimate
Customer: DUSTIN, KATHLEEN
Vehicle: 2010 MITS LANCER ES 4D SED 4-2.OL-FI RED
Line Operation Description Qty Extended Labor Paint
Price$
1 FRONT BUMPER&GRILLE
z Repl Bumper cover 1 365.38 1.9 3.0
3 Add for Clear Coat 1•2
4 Blnd Bumper cover cover 0.1
5 Repl LT Side bracket 1 13.67
( R&I RT Outer grille Incl.
7 R&I LT Outer grille Incl.
g R&I Grille Incl.
9 R&I Grille assy ES>S Incl.
10 Repi Prep unprimed bumper 1 0•8
11 FRONTLAMPS
12 R&I LT Headlamp assy 0.3
13 FENDER
14 Repl LT Fender 1 175.77 1.5 1.8
15 Add for Clear Coat �•�
16 Add for Edging 0.5
17 Add for Clear Coat 0.1
lg Repl LT Fender liner w/o 2.OL turbo 1 71.57 Incl.
ig WHEELS
zp ** Repl RECOND LT/Front Wheel,alloy 16" 10 spoke 1 184.00 m 0.3
Zl ** Repl RECOND LT/Rear Wheel,alloy 16" 10 spoke 1 184.0 m 0.3
22 # Subl MOUNT&BALANCE X 2 1 50.00 X
23 # Repl LF TIRE-YOKOHAMA AVID 534 1 144.00
24 # Rpr RESET TPMS SYSTEM 0.3 M
z5 FRONT SUSPENSION
26 Repl Align four wheels 1 m 1.8 M
27 PILLARS, ROCKER&FLOOR
28 R&I LT Pillar molding 0.1
29 R&I LT Rocker molding 0•8
30 * Rpr LT Rocker molding � 1•8
31 Add for Clear Coat 0.4
N 32 Blnd LT Center pillar sedan w/o sunroof s 0.9
33 FRONT DOOR
34 * Rpr LT Outer panel � 2.3
35 Overlap Major Adj. Panel -0.4
36 Add for Clear Coat 0.4
37 R&I LT Water shield w/o premium audio 0.1
38 R&I LT Belt molding w/bright 0•2
39 Repl LT Mirrorassy 1 235.00 0.5
40 Repl LT Mirror cover ES,GTS&Ralliart red 1 90.05 0.2 0.5
41 Overlap Minor Panel -�'Z
42 Add for Clear Coat 0.1
43 R&I LT Handle,outside w/body color,w/o fast key 0.3
4/20/2012 5:06:00 PM 016694 Page 2
Preliminary Estimate
Customer: DUSTIN, KATHLEEN
Vehicle: 2010 MITS LANCER ES 4D SED 4-2.OL-FI RED
red
44 R&I LT R&I trim panel 0.4
45 REAR DOOR
46 * Rpr LT Outer panel 2�. z•3
47 Overlap Major Adj. Panel -0.4
48 Add for Clear Coat 0.4
49 R&I LT Water shield w/o premium audio 0.1
50 R8cI LT Belt molding w/bright 0•2
51 R8cI LT Handle,outside w/body color red 0.3
5Z R&I LT R&I trim panel 0.4
53 # Refn ROPE BACK GLASS �•Z
54 ROOF �
55 R&I LT Drip molding 0.3
56 QUARTER PANEL
57 * Rpr LT Quarter panel w/o sunroof w/o spoiler 9.� 2•Z
58 Overlap Major Adj. Panel -0.4
59 Add for Clear Coat 0.4
60 Add for Lock Pillar 0.5
61 R&I Fuel door 0.3
gz Refn Fuel door 0•3
63 Add for Clear Coat 0.1
64 Repl LT Film 1 2237 0.2
65 * Rpr LT Outer wheelhouse S � �
66
* Add for Clear Coat 0.1
67 # Rpr SHEETMETAL PULL LT QUARTER/WHEELHOUSE 2•0
68 REAR LAMPS
69 R&I LT Combo lamp assy w/black/clear 0.3
70 REAR BUMPER
71 R&I R&I bumper cover 1•Z
72 * Rpr Bumper cover w/o Ralliart � 3•Z
73 Add for Clear Coat 1.3
74 # Repl Corrosion Protection Per Panel 1 0.3
75 # Refn EXTERIOR CAR COVER 0•2
76 # FLEX ADDITIVE 1 "'7.50 X
77 # Subl HAZARDOUS WASTE 1 4.00 X
SUBTOTALS 1,547.31 37.8 25.0
NOTES
Line 32: LT ROOF RAIL AREA
4/20/2012 5:06:00 PM 016694 Page 3
� ' � Preliminary Estimate
Customer: DUSTIN, KATHLEEN
Vehicle: 2010 MITS LANCER ES 4D SED 4-2.OL-FI RED
ESTIMATE TOTALS
Category Basis Rate Cost;
pa� 1,485.81
Body Labor 35.7 hrs @ $52.00/hr 1,856.40
Paint Labor 25.0 hrs @ $52.00/hr 1,300.00
Mechanical Labor 2.1 hrs @ $90.00/hr 189.00
Paint Supplies 25.0 hrs @ $32.00/hr 800.00
Miscellaneous 61.50
Subtotal 5,692.71
Sales Tax $ 1,485.81 @ 7.1250% 105.86
Grand Total 5,798.57
CUSTOMER PAY 0.00
INSURANCE PAY 5,798.57
THIS IS AN ESTIMATE ONLY. ADDITIONAL COSTS MAY ARISE DURING THE PROCESS OF REPAIRS.
The limit of your coverage is the actual cash value of your auto or its damaged parts at the time of loss. Fair market
value, age and condition of your damaged vehicle will be considered when determining the actual cash value of a loss.
Certain parts lose value or depreciate because of age, condition, and/or wear and tear. Betterment is the increase in
value of a vehicle or any of its parts as a result of replacing certain parts damaged in a loss. If the replacement of
certain parts results in an increase in value to your vehicle or any of its parts, a deduction for betterment may be made
to your loss payment to reflect the actual cash value you are owed under your policy.
NWCPP=Nationwide Crash Parts Program
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.
_-�.:,,.,:�...
4/20/2012 5:06:00 PM 016694 Page 4
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