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Riveramedina � ` ��i��;� � JUN 1 4 2012 NOTICE OF CLAIM FORM to the Ci� ' ��Paul, Minnesota Minnesota State Stat�ue 4h6.05 stutes that"...every person...who claims damages froni any inunicipalitv...shall caatse to be presented to the governing body of the municipalitv withiri 180 days after the alleged loss or inju��is discovered a notice stating the tirne,place,and circumstnnces thereqf;and the nmount n/�compensatior�or other relzef clemanded." 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�1�1 G l Middle Initial � Last Name ��e�rer mec�)VI�.; Company ar Business Name Are You an Insurance Company? Yes No If Yes,Claim Number? Street Address 7�� riJ�� cS �/� l y City /vidl NG�^ State ��i►��E�SD� Zip Code $��'135� Daytime Phone( ) - Cell Phone (�)��Evening Telephone( ) - Date of Accidend Injury or Date Discovered�,,�n'� ;7 �a ,�Time ��m� 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 Sai t Paul ar its employees are involved and/or responsible for our damages. Mti �i.r t.�x�._�_ , o v, � Gae D U �,i .� N r, � ,� N-� � Y11 I P M�. �v...!aP v _ �__ 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 ticketed ❑ 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 copies of all anplicable 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 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 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 No Unknow (circle) Provide their names, addresses and telephone numbers: Sume � c,ey- �r.o�, t ��icG Te�3r Were the police or law enforcement called? Yes N� Unknown (circle) If yes,what department or agency? 6�)A- Case#or report# /,�`��l�,. 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 ossible. If necessary, attach a diagram. Gh �,�e �h��G� �2�.n� A�� SLm� I�Ve- � ��d�- �9aS �ynE �5T�� Please indicate the amount you are seeking in co�mPensation or what you would like the City to do to resolve this ciaim to your satisfaction.,�� —n.�� ./o G'�er' ��x,e.r re,�Cr,re,�►rh� ,i��u�1�� q i h�- IVl �CCIX uhc� �S�7Y��f3_ Vehicle Claims-Alease comnlete this section ❑ check box if this section does not a�plv Your Vehicle: Year�D,�Make �U�55c1�„ Model 3S�Z License Plate Number 7�U�6-�}� State�Color�uer Registered Owner nie/ � ��ero.m?c�i vi c� Driver of Vehicl^ J�;,�,�( � i,� yy.e�,�v�� tw�-- a� � uf 1�� ,� r�r�c Area Damaged__/-r►n¢- �.m,ncr� City Vehide: Year Un1L Make �,i(� Model f—/S� License Plate Number VMP- F��- State Ml� Color )��• Driver of Vehicle(Ciry Employee's Name) 0�1� �arrc 1 (Soer��, Area Damaged �� Iniurv Claims-please comAlete 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 6�� Print the Name of the Person who Completed this Form: e� � I�� Signature of Person Making the Revised February 201 1 OKEEFFES COLLISION W��e ID: 8c26576b FederalID: 274472577 860 PAYNE AVE, SAINT PAUL, MN 55130 Phone: (651)493-9484 FAX: (651)493-9359 Prelirr�inary Estimate Customer: Riveramedina, Daniel Written By: David 0'Keeffe Insured: Riveramedina,Daniel Policy#: Gaim#: Type of Loss: Date of Loss: Days to Repair: 0 Point of Impact: Owner: Inspection Location: Insurance Company: � Riveremedina,Daniel OKEEFFES COILISION 7201 York Ave S 860 PAYNE AVE #1219 SAINT PAUL,MN 55130 Edina,MN 55435 Repair Fadlity (612)237-2508 Evening (651)493-9484 Business i VEHICLE ' Year: 2003 8ody Style: 2D CPE VIN: JN1A234E73T002982 MileageIn: Make: NISS Engine: 6-3.5L-FI Lioense: Mileage Out: � Model: 350Z TOURING Production Date: State: Vehicle Out: Color: Int: Condition: lob#: 4 Wheel Disc Brakes Clear Coat Paint Keyless Endy Power Steering 6 Speed Transmission Gimate Control Leather Seats Power Windows Air Conditioning Console/Storage Overfiead Console Premium Radio Alarm Gvise Control Passenger Air Bag Rear Defogger Aluminum/Alloy Wheels Driver Air Bag Positraction Rear Window Wiper AM Radio Dual Mirrors Power Brakes Search/Seek Mti-lock&akes(4) FM Radio Power Driver Seat Stereo i Budcet Seats Heated Mirrors Power Locks Tilt Wheel I Cassette Heated Seats Power Mirrors Traction Control � CD ChangeryStadcer Intermittent Wipers Power Passenger Seat Xenon Headlamps 5/25/2012 9:48:25 AM 303923 Page 1 Preliminary Estimate Customer: Riveramedina, Daniel Vehide: 2003 NISS 350Z TOURING 2D CPE 6-3.SL-FI Line Operatlon Description Qty Extended L.abor Paint Price$ 1 # Repl Veiiside Version 3 Front Bumper Nissan 350Z 1 1,000.00 2.0 4.0 Z33 03-08 2 FENDER 3 Bind RT Fender p.g ' 4 Bind LT Fender 0.9 5 HOOD 6 Blnd Hood 1.5 7 # May Have Hidden Damage 1 SUBTOTALS 1,000.00 2.0 7.3 ' i I ESTIMATE TOTALS Category Basis Rabe Cost; ; Parts 1,000.00 � Body Labor 2.0 hrs @ $50.00/hr 100.00 Paint labor 7.3 hrs @ $50.00/hr 365.00 I Paint Supplies 7.3 hrs @ $30.00/hr 219.00 � Subtotal 1,684.00 � Sales Tax $1,000.00 @ 7.6250% 76.25 � Grand Total 1,760.25 Deductibie 0.00 CUSTOMER PAY 0.00 INSURANCE PAY 1,760.25 OKeeffes Collision takes great care to ensure every repair we perform meets your satisfaction. The labor performed by OKeeffes Collision is guaranteed against any defec# in workmanship for as long as you own your car. OKeeffes Collision guarantees that for as long as you own your vehicle, OKeeffes Collision will, at its expense, correct or repair all defects which are attributable to defective or faulty workmanship in the repairs stated on the repair invoice, unless caused by or damaged resulting from unreasonable use, improper maintenance or care of vehicle, and rust and/or corrosion. ! This guarantee covers labor only and does not apply to parts, materials or equipment which may be covered by manufacturer's warranry. 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, AND MAY BE PROSECUTED UNDER STATE LAW. MN ST 60A.955 - A PERSON WHO FILES A CLAIM WTfH INTENT TO DEFRAUD OR HELPS COMMIT A FRAUD AGAINST AN INSURER IS GUILTY OF A CRIME. 5/25/2012 9:48:25 AM 303923 Page 2 Preliminary Estimate Customer: Riveramedina, Daniel Vehide:2003 NISS 350Z TOURING 2D CPE 6-3.SL-FI Estimate based on MOTOR CRASH E5TIMATING GUIDE. Unless otherwise noted all items are derived from the Guide ARF3714, 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 aiternate sources other than the OEM vehicle dealerships. OPT OEM or ALT OEM parts may reflect some specific, special, or unique pricing or discaunt. OPT OEM or ALT OEM parts may include"Blemished" parts provided by OEM's through OEM vehicle deale�ships. 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 altemate 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 Rernnd. Recored parts are described as Reoore. 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. I � 5/25/2012 9:48:25 AM 303923 Page 3 ' HEPPNER'S AUTO BODY Workfile ID: c9eceee8 395 E. 7TH ST., SAINT PAUL, MN 55101 Phone: (651) 224-5644 FAX: (651) 224-6042 Preliminary Estimate Customer: RIVERAMEDINA, DANIEL Written By: Lan Krost Insured: Policy#: Claim #: Type of Loss: Date of Loss: Days to Repair: 0 Point of Impact: 12 Front Owner: Inspection Location: Insurance Company: RNERAMEDINA,DANIEL HEPPNER'S AUTO BODY OTHER 7201 YORK AVE 395 E. 7TH ST. EDINA, MN 55435 SAINT PAUL,MN 55101 (612)237-2508 Evening Repair Facility (651)224-5644 Business VEHICLE ; , Year: 2003 Body Style: 2D CPE VIN: JN1AZ34E73T002982 Mileage In: 161188 I Make: NISS Engine: 6-3.5L-FI License: 708-AH Mileage Out: Model: 350Z Production Date: 8/2002 State: MN Vehicle Out: Color: SILVER Int: Condition: Job#: 4 Wheel Disc Brakes CD Player Intermittent Wipers Power Windows 6 Speed Transmission Ciear Coat Paint Keyless Entry Rear Defogger Air Conditioning Climate Control Overhead Console Rear Window Wiper Alarm Cloth Seats Passenger Air Bag Recline/Lounge Seats Aluminum/Alloy Wheels Console/Storage Power Brakes Search/Seek AM Radio Driver Air Bag Power Locks Stereo Anti-Lock Brakes(4) Dual Mirrors Power MiROrs Tilt Wheel Bucket Seats FM Radio Power Steering 6/13/2012 11:44:09 AM 070412 Page 1 � Preliminary Estimate Customer: RIVERAMEDINA, DANIEL Vehicle: 2003 NISS 350Z 2D CPE 6-3.5L-FI SILVER Line Operation Description Qty Extended Labor Paint Price� 1 FRONT BUMPER 2 * O/H bumper assy 3.4 N 3 ** Repi A/M Bumper cover KIT PER INVOICE 1 1,293.50 Incl. 2.8 4 Add for Clear Coat 1.1 5 Repi Prep unprimed bumper 1 0.7 6 Repl Emblem 1 39.37 Incl. N 7 # Refn TINT COLOR 1.0 8 # Repl 'Flex Additive 1 5.00 9 # 'Hazardous Waste Disposal Fee 1 5.00 10 # POSSIBLE ADD DAMAGE 1 SUBTOTALS 1,342.87 3.0 5.6 '� NOTES ', Line 3: FRONT COVER A/M IQT PRICE IS PER INVOICE Line 7: LIGHT SILVER MET COLOR WILL NEED TINT TIME FOR COLOR MATCH ESTIMATE TOTALS Category Basis Rate Cost; Parts 1,342.87 � Body Labor 3.0 hrs @ $52.00/hr 156.00 Paint Labor 5.6 hrs @ $52.00/hr 291.20 Paint Supplies 5.6 hrs @ $32.00/hr 179.20 Subtotal 1,969.27 � Sales Tax $ 1,342.87 @ 7.6250% 102.39 6rand Total 2,071.66 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. ! 6/13/2012 11:44:09 AM 070412 Page 2 ` � Preliminary Estimate Customer: RIVERAMEDINA, DANIEL Vehicle: 2003 NISS 350Z 2D CPE 6-3.5L-FI SILVER Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide ARF3714, CCC Data Date 6/8/2012, 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. 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 Gtass 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: I D=Diagnostic labor category. E=Electrical labor category. F=Frame labor category. G=Glass labor category. I M=Mechanical labor category. S=Structural labor category. (numbers) 1 through 4=User Defined Labor Categories. I, OTHER SYMBOLS AND ABBREVIATIONS: Adj.=Adjacent. Algn.=Align. ALU=Aluminum. A/M=Aftermarket part. BInd=Blend. BOR=6oron steel. CAPA=Certified II 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. 0/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=Bureau of Automotive Repair. EPA=Environmental Protection Agency. NHTSA= National Highway Transportation and Safety Administration. PDR=Paintless Dent Repair. VIN=Vehicle Identification Number. 6/13/2012 11:44:09 AM 070412 Page 3 " Preliminary Estimate Customer: RIVERAMEDINA, DANIEL Vehicle: 2003 NISS 350Z 2D CPE 6-3.5L-FI SILVER ALTERNATE PARTS SUPPLIERS Supplier: Keystone-Complete-Dubuque Location(s): 2400 KERPER BLVD, DUBUQUE IA 52001 (800)747-2500 (563)556-5030 3017 A HOOVER AVENUE,STEVENS POINT WI 54481 (800)218-4848 (715)342-0772 2700 29TH AVENUE N,ESCANABA MI 49829 (800)833-2030 (906)789-2200 3615 MARSHALL STREET NE,MINNEAPOLIS MN 55418 (800)328-1845 (612)789-1919 5969 HAASE ROAD, DEFOREST WI 53532 (800)356-7252 (608)249-4775 5085 WREN DRIVE,APPLETON WI 54913 (800)422-1995 (920)731-3030 Line Description Item# Price 3 A/M Bumper cover IQT PER INVOICE NI1000201 $ 1,293.50 6/13/2012 11:44:09 AM 070412 Page 4 ' . \� �� `� € .: _ � � ��-,.�,. ;. �-�� , y� <.�,� i � � .� � `�'� ,_�. � y�� "��. � �� K:.� j�c � , �-- �.`��., - �.� Q� �. � � sn � "`� ia r � �z� : �- �'�' �� \ �� ' �r �` 3. �� :� � �,� �,s. �i ..:� �� ' �ry�'�' �� ? r,� �� i y� �� r� � Y � �� , ��' u � z � � � � � . ._� � � �//2 r`_ �a4 �' �� (�.� Y�� .�. . �� .. . z � � �� '� `� '��'` a � � a e` � �; � ,., 3�x�� 9� . 3''� Niiy/�,k �„ �,E� , Y� �//vi,�' '�: i��• . �I�� .. - Wei . �,., �q�y . . „�:��, r�^ � �. � �� . ._ .ti��r aT \ � ..�r.✓ ��... 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