Strub �
������`��
� MAY 2 3 2012
NOTICE OF CLAIM FORM to the City of Sa�i�t��au��1'�innesota
Minnesota State Statute 466.OS 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 noace stating ihe 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 acl�owledgement 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 ��'��a� Middle Initial Last Name S�U B
Company or Business Name_ ��`S�A��
Are You an Insurance Company? Yes No If Yes,Claim Number? �������� 5�
Street Address �� ��/� �g�
City 1"�►I�I��Al7?��IS State �� Zip Code �5yyo
Daytime Phone (�Z� q7�- �Z�N Cell Phone( ) - Evening Telephone(��- �Z 1�
Date of Accidenb Injury or Date Discovered � 1 g 1� Time �Q �3� a /pm
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 responsible for your damages.
ST PA�'I,- C► v�iz. I g �l ��p� ��-�� 8 o D b tZASs�12.'f 5-I'�2 n o �J�-
FO1� N ca�Nt N D ACll2f� '� niD T Q�1Z SN���.
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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 '
❑ 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 ricketed ❑ 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 vou need to include couies 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 WII.L NOT be retumed 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 ricket 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 !,
O 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-please complete this section
Were there witnesses to the incident? Yes N� Unknown (circle)
Provide their names, addresses and telephone numbers:
Were the police or law enforcement called? Yes To Unlrnown (circle)
If yes,what depamnent or agency? Case#or report#
Where did the accident or injury take place? Provide street address,cross street,intersection,name of park or facility,
closest landmark,etc. Please be as detailed as possible. If necessary, attach a diagram.
gtblr.}., �►�b �.elta��
Please indicate the amount you aze seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction.
1 , Z
Vehicle Claims-nlease comnlete this section ❑ check box if this section does not applv
Your Vehicle: Year ZOb(s Make �W'R1°� Model N!b'�C
License Plate Number State M1�1 Color
Registered Owner C v��Ztv` �'12ub
Driver of Vehicle (�r�l�t�.� 5 i�u�
Area Damaged ���T
City Vehicle: Year j4 9�l Make FoQ.D Model 'f fL+.D�1L
License Plate Number (.�GiO Z�� State�i N Color
Driver of Vehicle(City Employee's Name) ;/SDD IZA55�T
Area Damaged 'N�R
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 page� �-. !
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.
5 2 l�- '
Submitting a false claim can result in prosecution. Date form was completed �
Print the Name of the Person who Complete tlus Fo : - � /� t�� I'I
Signature of Person Making the Claim:
Revised February 2011
�
KEY COLLISION AND PAINT CENTER Workfile ID: 511bf4b2
FederalID: 41-1112517
480 AMERICAN BLVD WEST, BLOOMINGTON, MN
55420
Phone: (952) 884-6272
FAX: (952) 703-0940
� Estimate of Record
Customer: STRUB, COLLEEN
Written By: DALE OLSON,5/21/2012 1:59:15 PM
Insured: STRUB,COLLEEN Policy#: ALLSTATE Claim#: 000245390158D01
Type of Loss: Collision Date of Loss: 5/18/2012 12:00:00 AM Days to Repair: 3
Point of Impact: 12 Front
Owner: Inspection Location: Insurance Company:
STRUB,COLLEEN 480 AMERICAN BLVD W -
6788 CHRISTIAN CURV BLOOMINGTON,MN 55420-1124 Allstate Insurance
WOODBURY,MN 55125-6740 Repair Facility P.O. BOX 187
(651)276-2562 Day MPLS, MN 55440
VEHICLE -
Year. 2006 Body Style: 4D UN VIN: 2HNYD18936H533622 Mileage In: 76975
Make: ACUR Engine: 6-3.5L-FI License: TUZ778 Mileage Out:
Model: MDX 4X4 TOURING Production Date: State: MN Vehide Out:
Color: BLACK Int: Condition: Good Job#:
4 Wheel Disc Brakes Cruise Control Keyless Entry Power Windows
4 Wheel Drive Driver Air Bag Leather Seats Premium Radio
Air Conditioning Dual Air Condition Luggage/Roof Rack Privacy Glass
Alarm Dual Mirrors Memory Package Rear Defogger
Aluminum/Alloy Wheels Electric Glass Sunroof Navigation System Rear Window Wiper
AM Radio Entertainment Center Parking Sensors w/Equip Search/Seek
Anti-Lock Brakes(4) FM Radio Passenger Air Bag Stability Control
Automatic Transmission Fog Lamps Power Brakes Steering Wheel Controls
Budcet Seats Front Side Impact Air Bags Power Driver Seat Stereo
CD Changer/Stacker Head/Curtain Air Bags Power Locks Tilt Wheel
Clear Coat Paint Heated Mirrors Power Mirrors Traction Control
Communications System Heated Seats Power Passenger Seat Wood Interior Trim
Console/Storage Intermittent Wipers Power Steering
�
II
5/21/2012 1:5923 PM 008850 Page 1
�
Estimate of Record
Customer: STRUB,COLLEEN
Vehicle: 2006 ACUR MDX 4X4 TOURING 4D UTV 6-3.5�-FI BLACK
Line Operation Description Qty Extended Labor Paint
Price$
1 # OWNER DOES NOT WANT A/M PARTS 1
2 FRONT BUMPER
3 O/H bumper assy 2,z
N 4 Repl Bumper cover 1 355.85 Incl. 3.0
5 Add for Clear Coat 1,2
6 Repl Center fiiler dark gray metallic 1 58.77 Incl.
7 Repl License bracket 1 19.28 0.2
$ FRONT LAMPS
9 * Repl LKQ RT Fog lamp assy+25% 1 125.00 Incl.
10 Aim fog lamps 0.3
1 i HOOD
12 * PDR Hood 1 75.00 X
13 R&I Insulator 0.4
14 # Repl Corrosion Protection(per panel) 1 0.3
15 # Rpr HOOD(wetsand&buff) 0.5
16 # Repl Flex Additive 1 3.00 X
SUBTOTALS 636.90 3.9 4.2
NOTES
Line 4: NO RECOND COVER AVAILABLE
ESTIMATE TOTALS
Category Basis Rate Cost$
Parts 558.90
Parts Discount $433.90 -5.0% -21.70
Body Labor 3.9 hrs @ $50.00/hr 195.00
Paint Labor 4.2 hrs @ $50.00/hr 210.00
Paint Supplies 4.2 hrs @ $30.00/hr 126.00
Miscellaneous 3.00
PDR 75.00
Subtotal 1,146.20
Sales Tax $537.20 @ 7.2750% 39.08
Grand Total 1,185.28
Deducdble 500.00
CUSTOMER PAY 500.00
INSURANCE PAY 685.28
I
5/21/2012 1:59:23 PM 008850 Page 2
Estimate of Record
Customer: STRUB, COLLEEN
Vehicle: 2006 ACUR MDX 4X4 TOURING 4D UTV 6-3.5L-FI BLACK
THIS ESTIMATE IS BASED ON A VISUAL INSPECTION AND DOES NOT INCLUDE ADDITIONAL PARTS OR LABOR THAT
MAY BE REQUIRED TO COMPLEfE REPAIRS. PART PRICES ARE CURRENT AND SUBJECT TO INVOICE.
IMPORTANT INFORMATION ABOUT ALLSTATE'S CHOICE OF PARTS POLICY.
THIS ESTIMATE MAY LIST PARTS FOR USE IN THE REPAIR OF YOUR VEHICLE THAT ARE MANUFACTURED BY A
COMPANY OTHER THAN THE ORIGINAL MANUFACTURER OF YOUR VEHICLE. THESE PARTS ARE COMMONLY
REFERRED TO AS AFTERMARKEf PARTS OR COMPETITIVE PARTS,AND MAY INCLUDE COSMETIC OUTER BODY CRASH
PARTS SUCH AS HOODS, FENDERS, BUMPER COVERS, ETC. ALLSTATE GUARANTEES THE FIT AND CORROSION
RESISTANCE OF ANY AFTERMARKET/COMPETI'rIVE OUTER BODY CRASH PARTS THAT ARE LISTED ON THIS ESTIMATE
AND ACTUALLY USED IN THE REPAIR OF YOUR VEHICLE FOR AS LONG AS YOU OWN IT. IF A PROBLEM DEVELOPS
WITH TNE FIT OR CORROSION RESISTANCE OF THESE PARTS,THEY WILL BE REPAIRED OR REPLACED AT
ALLSTATE'S EXPENSE. THIS GUARANTEE IS LIMITED TO THE REPAIR OR REPLACEMENT OF THE PART. HOWEVER, IF
YOU CHOOSE NOT TO USE ONE OR MORE OF THE AFTERMARKET/COMPEfITIVE OUTER BODY CRASH PARTS THAT
MAY BE LISTED ON THIS ESTIMATE IN THE REPAIR OF YOUR VEHICLE,ALLSTATE WILL SPECIFY THE USE OF
ORIGINAL EQUIPMENT MANUFACTURER PARTS AT NO ADDITIONAL COST TO YOU. GUARANTEES FROM THE
ORIGINAL MANUFACTURER MAY APPLY TO SUCH PARTS; HOWEVER, ALLSTATE DOES NOT SEPARATELY GUARANTEE
THEM.
IMPORTANT INFORMATION ABOUT ALLSTATE'S CHOICE OF PARTS POLICY
❑This estimate may list parts for use in the repair of your vehicle that are manufactured by a company other than the
original manufacturer of your vehicle. These parts are commonly referred to as aftermarket parts or competitive parts,
and would be designated on this estimate as "QUAL REPL PARTS", "A/M" or"COMP REPL PARTS". Such parts may
include cosmetic outer body crash parts such as hoods, fenders, bumper covers, etc. Allstate guarantees the fit and
corrosion resistance of any aftermarket/competitive outer body crash parts that are listed on this estimate and actuaily
used in the repair of your vehicle for as long as you own it. If a problem develops with the fit or corrosion resistance of
these parts, they will be repaired or replaced at Allstate's expense. This guarantee is limited to the repair or
replacement of the part.
However, if you choose not to use one or more of the aftermarket/competitive outer body crash parts that may be listed
on this estimate in the repair of your vehicle, Allstate will specify the use of original equipment manufacturer parts,
either new or recycled at Allstate's option, at no additional cost to you. Allstate does not separately guarantee the
performance of original equipment manufacturer parts, and makes no representation about the availability of any
manufacturer's guarantee. '
Suppliers listed in the repair estimate for Aftermarket or Recycled parts are used only as a reference as for the
availability and pricing of the Aftermarket or Recycled part. A repair facility is under no obligation to purchase these
parts from the listed suppliers.
❑
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. I
5/21/2012 1:59:23 PM 008850 Page 3
Estimate of Record
Customer: STRUB, COLLEEN�
Vehicle:2006 ACUR MDX 4X4 TOURING 4D UTV 6-3.5L-FI BLACK
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
ART4821, CCC Data Date 5/16/2012, 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 vehicfe deaferships. 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 (�) items indicate MOTOR Not-Included Labor operations.
The symbol (<>) indicates the refinish operation WILL IVOT be performed as a separate procedure from the other
panels in the estimate. Non-Original Equipment Manufacturer aftermarket parts are described as AM. Used parts are
described as LKQ, 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 2012 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 CCC ONE estimator has a
complete list of applicable vehicles. Parts numbers and prices should be confirmed with the local dealership.
The following is a list of additional abbreviations or symbols that may be used to describe work to be done or parts to be
repaired or replaced:
SYMBOLS FOLLOWING PART PRICE:
m=MOTOR Mechanical component. s=MOTOR Structural component. T=Miscellaneous Taxed charge category.
X=Miscellaneous Non-Taxed charge category.
SYMBOLS FOLLOWING LABOR:
D=Diagnostic labor category. E=Electrical labor category. F=Frame labor category. G=Glass labor category.
M=Mechanical labor category. S=Structural labor category. (numbers) 1 through 4=User Defined Labor Categories.
OTHER SYMBOLS AND ABBREVIATIONS:
Adj.=Adjacent. Algn.=Align. ALU=Aluminum. A/M=Aftermarket part. BInd=6lend. BOR=Boron steel. CAPA=Certified
Automotive Parts Association. D&R=Disconnect and Reconnect. HSS=High Strength Steel. HYD=Hydroformed Steel.
Inc1.=Included. LKQ=Like Kind and Quality. LT=Left. MAG=Magnesium. Non-Adj.=Non Adjacent. NSF=NSF
International Certified Part. O/H=Overhaul. Qty=Quantity. Refn=Refinish. Repl=Replace. R&I=Remove and Install.
R&R=Remove and Replace. Rpr=Repair. RT=Right. SAS=Sandwiched Steel. Sect=Section. Subl=Sublet. UHS=UItra
High Strength Steel. N=Note(s)associated with the estimate line.
CCC ONE Estimating -A product of CCC Information Services Inc.
The following is a list of abbreviations that may be used in CCC ONE Estimating that are not part of the MOTOR CRASH
ESTIMATING GUIDE:
BAR=6ureau of Automotive Repair. EPA=Environmental Protection Agency. NHTSA= National Highway Transportation
and Safety Administration. PDR=Paintless Dent Repair. VIN=Vehicle Identification Number.
5/21/2012 1:59:23 PM 008850 Page 4