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Rubens NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota Minnesota State Statute 466.05 states that "..,every person...who claims darnages from an munici ali governing body of the municipaliry within 180 days afrer the alleged loss or injury is discovered a noh'c�at�ng the�ime placet a�the circumstances thereof,and the amount of compensation or other relief demunded." 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 yaur claim. This form must be signed,and both pages completed. If something does not apply,write`N/A'. SEND COMPLETED FORM A1VD OTHER DOCUMENTS TO: CITY CLERK 15 WEST KEI,LOGG BLVD, 310 CITY H�jLL, SAINT PAUL, MN 55102 � First Name,��I�A Middle Initial � Last Name Company or Business Name� R�� Are You an Insurance Company? Yes No If Yes, Claim Number� MAY � ' 2 p�2 Street Address � C1tY_sJl . T A�ll �%��,�r �i��f State Zip Code� Daytime Phone(��_�Cell Phone(�)?�}_� Evening Telephone(��_� Date of Accidend injury or Date Discovered � Time?: 3° am/,� D(�O�C. Please state,in detail, what occurred(happened),and wh l�� feel the City of SaintPaul or its employees aze involved and/or espons ble fo your damlages.�dicate why or how you ; � 6 I�( � � � �Please 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 E ❑My vehicle was damaged by a pothole or condition of the street 0 My vehicle was damaged by a plow i ❑My vehicle was wrongfully towed and/or ticketed ❑ Other type of property damage—please specify �I�'�'as injured on City property � ❑ Other type of injury—please specify � In order to process your claim ou need to include couies of all annlicable documents ' For the claims types listed below,please be sure to include the documents indicated or it will delay the handling of �1 your claim. Documents WII,L NOT be returned and become the property of the City. You are encouraged to keep a . copy for yourself before submitting your claim form. O 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 i O Photographs 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 ' I ' i Failure to complete and return both pages will result in delay in the handling of your claim. All Claims—nlease complete this section Were there witnesses to the incident? Yes No nknown (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,intersec�i�n,name of ark or f ility, clo est landm k, et . Please e as det ' a ossib e. If ecessary,attach a diagram.-i(��t In Q �� Please indicate the unt you are s eking in mp nsa 'on or what yo would like the Ci to do tQ r s ve this claim to your satisfaction. •�a Vehicle Claims— lease com lete this se ti n ❑ check box if this section does not a 1 Your Vehicle: Year �D I i _Make Model v License Plate Num er Sta.te olo �� Registered Owner [,, Driver of Vehic �1 - Area Damaged � �'C'�t��lA.�) City Vehicle: _ Year�Make Mode 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 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 � Z 1 Z— Print the Name of the Person who Complet this F rm: Signature of Person Making the Claim: Revised February 2011 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 it's employees are involved andlor responsible for your damages. At approximately 2:30 p.m.on Thursday,April 12,2012,I was driving northbound on Hamline Ave.N.in the leftmost lane. As I approached the intersection at the entrance to Ayd Mill Rd. (Ashland Ave.),I slowed to stop behind a number of other vehicles stopped at the stoplight. I was perhaps as many as a half dozen cars back from the intersection/stoplight. On the opposite [southbound] side of the street,there were two city employees (they wore orange vests identifying them as being from City of St.Paul Public Works)mowing and weed whacking the green strip between the street and the frontage road. When the light changed to green and I began to accelerate,a rock was thrown from the mower,flew across the road,and struck my vehicle on the upper right corner of the driver's side door. I saw the rock coming toward me in my peripheral vision. The sound of impact caused me to duck and brake hard. Because there was no immediate place to pull over,I proceeded across the bridge over Ayd Mill Rd.and pulled into a parking lot at the next intersecrion(northwest corner at Hamline Ave.N. and Selby Ave.)to inspect my car for damage. Upon finding damage,I drove back over the bridge turning onto and then parking on the frontage road. I spoke to the worker who'd been weed whacking and asked for information about who I should contact regarding the damage to my vehicle. He briefly ran across the street to where their city truck was parked and came back talking on his cell phone. I assumed he was speaking with a superior. I was told to contact Sandra Bondensteiner about filing a claim with the city. In addition,I was asked for my name,telephone number,and license plate number,presumably so � the worker could report the incident. I neglected to get the name of the Public Works employee I spoke with. When I called the Public Works Department the following morning(Friday,April 13,2012)to try and find out the employee's name.,I was referred to the Pazks and Recreation Department after being told that it was one of their crews that I'd encountered. When I called Parks and Recreation,I was forwarded to the voicemail of Operations Manager,Gary Korum. I left a message requesring information but my phone call has not been returned. Please indicate the_amount you are seeking in compensation or what you would like the City to do to resolve this claim. I am seeking reimbursement for all costs associated with having my vehicle repaired.This includes the repairs themselves and the cost of a rental car for the 3 days my vehicle was in the shop being repaired. The totat amount I am seeking compensarion for is $939.33. Heppner's Auto Body $882.36 Enterprise Rent-A-Car $ 56.97 Total $939.33 1 hamline ave and ayd mill yd.-Google Maps 4/13/12 11:31 AM To see all the details that are visible on the screen, use the"Print" link next to the map. �� _ �,� � Dhn�no \ � ��n, U��,�re C��" w�r� U�� 1^s.��J i � ��J��d� ��.� � � � . _ � � - ��c�e� � ra�C t w�.�c � ��a�i�, W 1�.�, l�" t�lcz� ��-- � -�� .L= http://maps.google.com/maps?client=safari&rls=en&q=hamline+ave...KcT30gGMsqHDCQ&sa=X&oi=mode_link&ct=mode&cd=3&ved=OCAwQAUoAg Page 1 of 1 Driver's side door, window, trim Closeup of driver's side window and roof � .. � _� _ r ��, , .{.� '','n •;� �; �" y ��.: ,;�^: �;�'k��' "��i_Y",._ � Open driver's side door ' ` HEPPNERS AUTO BODY SAINT PAUL �Norkfile ID: 85bOc9b3 400 SYNDICATE ST. N., SAINT PAUL, MN 55104 �--`—_--- Phone: (651) 646-8615 � FAX: (651) 645-3230 �V�� Preliminary Supplement 1 with Summary Customer: Rubens,Sarah Written By: Sean Olivier Insured: Rubens,Sarah Policy#: Claim#: Type of Loss: Date of Loss: Days to Repair: 0 Point of Impact: 09 Left T-Bone(Left Side) Owner: Inspection Location: Insurance Company: Rubens,Sarah HEPPNERS AUTO BODY SAINT PAUL 1556 Jeefferson Ave 400 SYNDIG4TE ST. N. St. Paul,MN 55105 SAINT PAUL,MN 55104 (651)698-1730 Evening Repair Facility (651)646-8615 Day VEHICLE Year: 2011 Body Style: 4D WGN VIN: 4S46RGCC1B3365273 Mileage In: Make: SUBA Engine: 4-2.5L-FI License: Mileage Out: Model: OUTBACK PREMIUM Production Date: State: Vehicle Out: Color: Grey Int: Condition: Job#: 4 Wheel Disc Brakes Clear Coat Paint Keyless Entry Privacy Glass 4 Wheel Drive Cloth Seats Luggage/Roof Rack Rear Defogger 6 Speed Transmission Console/Storage Overdrive Rear Window Wiper Air Conditioning Cruise Control Overhead Console Search/Seek Alarm Driver Air Bag Passenger Air Bag Stability Control Aluminum/Alloy Wheels Dual Mirrors Power Brakes Steering Wheel Controls AM Radio FM Radio Power Driver Seat Stereo Mti-Lock Brakes(4) Fog Lamps Power Locks Telescopic Wheel Auxiliary Audio Connection Front Side Impact Air Bags Power Mirrors Tilt Wheel Bucket Seats Head/Curtain Air Bags Power Steering Traction Control CD Player Intermittent Wipers Power Windows 4/24/2012 1:45:40 PM 050503 Page 1 � • Preliminary Suppiement 1 with Summary Customer: Rubens,Sarah Vehicle: 2011 SUBA OUTBACK PREMIUM 4D WGN 4-2.5L-FI Grey Line Operation Description Qty Extended Labor Paint Price� 1 # Rental Car for 3 days @$30.00-Enterprise 3 90.00 2 FRONT DOOR 3 * Rpr LT Door shell Outback � 0_5 4 * Add for Clear Coat 5 Repl LT Upper molding 1 64.65 0.3 6 Repl LT Applique 1 32.63 0.2 7 * R&I LT Mirror w/o heated Q� 8 * R&I LT Glass run Q,� 9 PILLARS,ROCKER&FLOOR 10 * Rpr LT Center pillar s �,Q 1.5 11 ROOF 12 R&I LT Roof w'strip 0.1 13 R8cI LT Roof rail 0.3 N 14 * SOl R&I Headiiner w/o sunroof �Q � 15 QUARTER PANEL 16 * Refn LT Quarter giass Subaru pri�-tape off � 17 # RESTORE CORROSION PROTECTION 1 0.2 18 # Refn BAG/CAR COVER 0.2 19 # Subl HAZARDOUS WASTE REMOVAL 1 5.00 X 20 S01 RESTRAINT SYSTEMS 21 SOl R&I LT Head air bag Outback w/o sunroof m 0.8 SUBTOTALS 192.28 8.5 2.7 NOTES Line 14: DROP LT SIDE 4/24/2012 1:45:40 PM 050503 Page 2 - � Preliminary Supplement 1 with Summary Customer: Rubens,Sarah Vehicle: 2011 SUBA OUTBACK PREMIUM 4D WGN 42.5L-FI Grey ESTIMATE TOTALS Category Basis Rate Cost$ Parts 187.28 Body Labor 8.5 hrs @ $52.00/hr 442.00 Paint Labor 2.7 hrs @ $52.00/hr 140.40 Paint Suppiies 2.7 hrs @ $32.00/hr 86.40 Body Supplies 3.5 hrs @ $2.00/hr 7.00 Miscellaneous 5.00 Subtotal 868.08 Sales Tax $187.28 @ 7.6250% 14.28 Grand Total 882.36 Deductible 0.00 CUSTOMER PAY 0.00 INSURANCE PAY 882.36 4/24/2012 1:45:40 PM 050503 Page 3 � Work Order No. Page 1 � �C � 220412004 Order Date: 04/12/lz os :03 pm AUTOMOTIVE � y j�� a • �4 • 12-721-4210 , r �� v�056 .2nd Ave.So. Mpls., MN 5., 06 6 , /�� )�0� 4224 E.41 st Street•Mpis., MN 55406•612-721-i 357 �� randrautomotiveoniine.com RRAutomotive422�1@yahoo.com Complete Automotive Service • ASE Certifieci Bond,Daniel/Sarah 13 89��a OUTBA3 R2o12 1556 Jefferson Ave Lic: 731ETX Cyl Eng St.Paul 1yII�1 55105 Vin: 4S4BRCCC1B3365273 Ce11 Phone: 651-247-3805 Eq: AT AC PS FI 4W TB DS DC Sarah Cell: 651-247-4106 Profile: Labor: $684 . 0 Job01 Bod dama e 1.0 @ 70.47 =$ 70.47 63531AJ03A Chrome door mldg-S 39.16 10 9 . 63 63563AJOlA B piller mldg-S 1.0 @ 39.16 =$ Dent on roof above door. Damage on door top � side mldgs. Replace door mldgs. Remove roof rack for painting. Repair damage on roof. Paint & clearcoat repaired area of roof. _._ _ ___ Sublet: $14 0 . 0 Job02 Paint materials Recommendations: Needs rf fog light. Est $124 L.3 Da snts to _ _ motive �ost �ale" 68� . 00 Status: New 109. 63 �- e 140 .00 Payments: � _ � � 8 .52 �� T �a $942 .15 ':��" 0 .0 0 � ` � 942 .15 � AlL PARTS ARE NEW UNLESS SPECIFIED OTHERWISE PARTS REMOVED WILL BE DISCARDED UNLESS INSTRUCTED OTHERWISE 0 SAVE 0 DISCARD CREDIT CARDS �I� ' By signing below,I hereby authorize the repair work!o oe donz yong with th°necessary mffierial,and hereby grant your employces permission to operate � � Y/SA �� ; �� - the vehicle herein described on�treets,highways or elsewhere for ihe purpose of testing,and/or inspection.If automobile is retumed to customer before ACCEPTED ��'�� authonzetl service is perfortned,a diagnostic and handling charge will be made.I have read and understand ihe statemeots and estimates made on this side WE RESERVE THE RIGHT TO REFUSE ANY�eP,SOVAL CNECKS and the reverse of this/ihese pages(conneded with this vehicle).I aufiorize service to be performed.lncluding sublet work,and acknowledge receipt of this estimate.Customer is hereby notified that the said property is not insured w protected agains!loss occasioned by theft,fire or vandalism while the property remains with the Repair Garage. Customer SignaNre X I ACKNOWLEDGE RECEIPT OF AND AGREE TO THE TERMS AND CONDITIONS OF THIS CONTRACT. � � •�' •' • • � . �� ! Date: 4/26/2012 Midway Heppner's Auto Body INVOICE 400 Syndicate RO #: 23896 Saint Paul, MN 55104 Opportunity#: 13397 651 646-8615, 651 645-3230 fax) Est: Sean Olivier Sarah Rubens 11 SUBA OUTBACK PREMIUM 1556 Jeefferson Ave Color: Grey CUSTOMER PAY St. Paul, MN 55105 Type: PC 4D WGN Adjustor: Home: 651-698-1730 VIN: 4S4BRCCCI B3365273 Phone: Work: Prod Date: Plate: Claim#: Deductible: 0 F�: Mileage: Loss Type: En ine: 4-2.5L-FI P=Who Pa ? I=Insurance,C=Customer Qty Type Description Part# Amount S�p Labor Op �bor Paint P # Units Units 3 Rental car Rental Car for 3 days @$30.00- 90.00 Body I Enterpri FRONT DOOR � Parts Other FRONT DOOR LT Door shell Outback Body Rpr 1.0 0.5 I User FRONT DOOR Add for Clear Coat Define I d 1 Parts New FRONT DOOR LT Upper molding 63531AJ03A 64.65 Body Repl 0.3 I 1 Parts New FRONT DOOR LT Applique 63563AJO1A 32.63 Body Repl 0.2 I Parts Other FRONT DOOR LT Mirror w/o heated Body R&I 0.6 I Parts Other FRONT DOOR LT Glass run Body R&I 0.2 I FRONT DOOR PILIARS, ROCKER& � FLOOR Parts Other PILLARS, ROCKER&FLOOR LT Body Rpr 2.0 1.5 I Center pillar PILLARS,ROCKER&FLOOR ROOF � Body R&I 0.1 I Parts Othe� ROOF LT Roof�x'strip Parts Other ROOF LT Roof rail Body R&I 0.3 I Parts Other ROOF Headliner w/o sunroof 1 Body R&I 3.0 I ROOF QUARTER PANEL � Parts Glass QUARTER PANEL LT Quarter glass Refn 0.3 I Subaru privacy-tape o QUARTER PANEL RESTORE 0 2 � CORROSION PROTECTION QUARTER PANEL BAG/CAR COVER Refn 0.2 I Haz QUARTER PANEL HAZARDOUS 5.00 Body Subl I WASTE REMOVAL QUARTER PANEL RESTRAINT 1 I SYSTEMS Parts Other RESTRAINT SYSTEMS LT Head air 1 Body R&I 0.8 I bag Outback w/o sunroof Bdy/Sup MISC Body Supplies 7.00 3.5 I PnUMat MISC Paint&Materials 86.40 2•7 � Parts 187.28 Labor 582.40 Additional Costs 98.40 SubTotal 868.08 Taxes 14.28 Grand Total 882.36 Due from Insurance Due from Customer Sub-Total 868.08 Sub-Total 0.00 Tax 14.28 Tax 0.00 Total 882.36 Total 0.00 INVOICE #22 4/26/2012 2:32:33 PM RO#23896 Midway Heppner's Auto Body Page 1 Enterprise Rent-A-Car:Rental Cars at Everyday Low Rates 5/7/12 10:39 AM � �� _...,�u. �.� �` ..� . � � � Rental Receipt-Thank you for your business SARAH RUBENS Contract Number: L�5((52 Receipt Date: Apr 26, 2012 Enterprise Location: 900 UNIVERSI7Y AVE. Driver: SARAH RUBENS SAINT PAUL, MN 55104-4701 US Tel.: (651) 228-0088 Start Date: End Date: Make/Model Start Miles End Miles Miles Driven Apr 24,2012 @ 8:52 am Apr 26,2012 @ 3:02 pm NISN VERS 14,021 14,110 89 Total Miles g9 Charge Description Quantity Per Rate Total Rate 3 Day 23.00 69.00 CDW 3 Day 15.60 46.80 PAI 3 y 3.39 10.17 Subtotal: USD 125.97 Taxes and Surcharges SALES TAX 5.26 MINNESOTA REGISTRATION FEE 3.45 MINNESOTA RENTAL CAR TAX 4,28 Subtotal: USD 138.96 Total Charges: USD 138.96 Payment Information DEPOSIT 56.97 Subtotal: USD 56.97 CUSTOMER NUMBER:N2uxxx HEPPNER'S AUTO BODY-MIDWAY USD 81.99 Attn:UNKNOWN P0:23896 Total Payment Amount: USD 138.96 If you have any questions about this receipt please contact our support staff at(651) 228-0088 or Klasse F 5tandardwaqen. https://www.enterprise.com/car_rental/ticketReceiptDetail.do?ticket=456652&transactionld=WebTransaction8 Page 1 of 1