Estrada ������'�!.�
JUN 1 5 2(�
NOTICE OF CLAIM FORM to the City of Saint Paul, Minneso
(' � �— y
Minnesota State Statute 466.05 states that"...everyperson...who claims damages fram any municipaliry...shallZ'�e'to�p esented to the
governing body of the municipality within 180 days after the adleged loss or injury is discovered a norice stating the time,place,and
circumstances thereof,and the amount of compensation or other relief demanded."
Please complete this form in its entirety by ciearly 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 necessxry to eacplain your claim,and the amount of compensation being requested. You will receive a
written acknowledgeaient once your form is received. The process can take up to ten weeks or longer depending on the
nature of your daim. TWs form must be signed,and boW pages rnmpleted. 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
y�,-._ �
First Name ���� Middle Initial�Last Name �S"1 Y ���
Company or Business Name
Are You an Insurance Company? Yes/� If Yes,Claim Number?
Street Address l�� �i�v +�.�,�1 �'N�- S ,
, �j
City �� • \ c'��� State � Zip Code � S U
Daytime Phone( ) - Cell Phone(�li ) S�b_�t�2 Evening Telephone( ) -
Date of AccidenU Injury or Date Discovered �I � J �� 0� Time 1 - 3� am/�
�
Please state,in detail,what occurred(happened),and why you aze 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. 'j' w�^S �f c>>►� �
�.J i�5�' v�l S l�lV�1M,-�' �),.Q, �''l t�I A�'(i( N�l�M�1►'�. PcJ�, i y,'��Vl .L �a v.1 Gl C�Y ��1 fi �rVri1
. , � ` � � �' t, 4"1'1 v � ' � ' �� t�� K , �1'� v �l �u��c ��ri�'�iFr�^�..�yh
��o.ti�� � r� fl���, �11 -��� � �i�1Y1�- I��ra t�le'c.� �1(� 'i 1'3Y�A�Q� S 3 1`. �v �iit�ri�t `t��k �1 (yar��
W(L'� ` v�y h ,.,�Q l�� � �1 ClI^ t- �4 �� ..
��, ,1,' �� �\v t;+� ��>J`t�' C.c; ✓) � 1' �� c'�c '� �
� , , fiL� !1.t��1..�.�
� � i � t � ,c ,� v� , i I,��i�J ' vi � in� � �' c�My..li-(V
1�., S it,?Go � �' �v!'�J ���� -k'G1���I'�:Y1-C[11NSC � wR.J �k 1��rG� 01( ; :::1 J -1'0 /1,:� h�1' f'1��"� ��iVic c,v�'� c1N �l��l�.lv��',
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 arder to process your claim vou need to include conies of all ap�licable 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 returned and become the property of the City. You are encouraged to keep a
copy for yourself before submitting your claim form.
'FfProperty damage claims to a vehicle:two estimates for the repairs to your vehicle if the damage ezceeds
$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 retiu�n both pages of Claim Form
Failure to complete and return botli pages will result in delay in the handling of your claim.
All Claims-please complete tlus section
Were there witnesses to the incident? � No Unknown circle) ,
Provide their names,addresses and telephone numbers: �, k��lY1 `���1 k. . �'2� ���-�1�� ,
��1� ���C�i���� ��- �. ".���°`�J����� -----I-'T'—'
Were the police or law enforcement called? es No Unknown (circle)
ff yes,what department or agency? �-. Qal.�,\T��C Q„ Case#or report# �Z'C)3��-��
Where did the accident or injury take place? Provide street address,cross street,intersection,name of park or facility,
closest land ark,etc. Please be as detailed as Rossible. If necessary,attach a diagram. �(li�,�1�t'(��. `� S�r�-
i����� -��,�lun� �c\� ������.��\)
Please indicate the amount you are seeking in comp nsation or what you would like the City to o to reso�claim
to your satisfaction. j_ Ca+M SQ1L�V�(?� �U� '��pU�`� ��(� ��,Y (�'(' �'�5'C �,M.Q�.�•
Vehicle Claims- lease com lete this section ❑check box if this section does not a 1
Your Vehicle: Year 7 fl�Make Model l,��V il . F X
License Plate Number ' tate g�Color � '
Registered Owner �1 Q`n'�'� S'FC�Gtc: (I�
Driver of Vehicle t, ' S
Area Damaged�JO���PY1q D� �:.�4 �M' h��rv1�,�'
City Vehicle: Year Make J" Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniurv Claims-please complete this section �.check box if this secUon does not app1Y
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 wark 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.
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 � �
Print the Name of the Person who Completed tlus Form:��-�.��� �,��h�{�
Signature of Person Making the Claim:�`" `� �
Revised February 2011
�h���c�. ��f-2�- e S'�u�-�-'�-�
ONLINE EVALUATION
NO.OP.description LEVEL LABOR PAII�T
1Front Bumper
2Repair- Refinish Bumper33.02.8
3-Add for Clear Coat1.2
4R&I- Remove and install components2.fi
Body Labor5.8 hrs@46.00/hr266.80
Paint Labor4.0 hrs@46.00/hr184.00
Paint Supplies4.0 hrs@28.00/hr112.00
Color Tint0.5 hrs@46.0023.00
Haz Waste DisposalSublet5.00
Color Sand and Buff0.5 hrs@46.0023.00
SUBTOTAL$ 613.80
TOTAL$ 613.80
Estimate based on the Instant Estimator damage level guide. Unlass otherwise noted all items are
derived from the Instant Estimator's damage level guide.
Database Date: 06/11/2012.
ESTIMATE OF REPAIR The Estimate of Repair includes labor and niaterial. If, on further inspection,
additional parts or repairs are needed,you will be contacted for��uthorization by one of our authorized
auto body repair facilities. We are not responsible for loss or darriage to your vehicle from fire,theft,
accidents or any cause beyond our control.
Prepared for: Renee 1ob Number : 1c:)14125
Email: reneenicole725@gmail.comZip Cade: 55105
Vehicle: 2002 Honda Civic
LAMETTRY'S COLLISION - RICHFIELD Workfile ID: 8f76317e
FederalID: 411393089
509 W 77TH ST, RICHFIELD, MN 55423
Phone: (612) 366-0016
f�AX: (612) 866-1158
Preliminary Estimate
Customer: ESTRADA, RENEE
Wri�ten By:CHRIS NORDQUIST
Insured: ESTRADA, RENEE Policy#: Claim #:
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact:
Owner: Inspection I.ocation: Insurance Company:
ESTRADA,RENEE LAMETTRY'S :.OLLiSION-RICHFIELD
100 FAIR`/IEW AVE S 509 W 77TH a'T
ST PAUL, MN 55105 RICHFIELD, PIN 55423
(480)516-8562 Evening Repair Facilir�
(612)866-0016 Business
VEHICLE
Year: 2002 Body Style: 2D�:PE VIN: 1HGI:M22952L079234 Mileage In:
Make: HOND Engine: 4-1,7L-FI License: MileageOut:
Model: CIVIC EX Produdion Date: State: Vehicle Out:
Color: Int: Condition: ]ob#:
Air Conditioning Cruise Control Keyless Entry Power Windows
AM Radio Driver Air Bag Overdrive Rear Defogger
Anti-Lock Lrakes(4) Dual Mirrors Passenger Air Bar Recline/Lounge Seats
Automatic Transmission Electric Glass Sunroof Power Brakes Search/Seek
Bucket Seats FM Radio Power Locks Stereo
CD Player Front Side Impact Air Bag�: Power Mirrors Tilt Wheel
Ciear Coat Paint Full Wheel Covers Power Steering Tinted Glass
Cloth Seats Intermittent Wipers PowerTrunk/Tailgate
�� �e5��1A�
._�-�
6/11/2012 7:05:02 AM 018585 Page 1
Preliminary Estimate
Customer: ESTRADA, RENEE
Vehicle: 2002 HOND CNIC EX 2D CPE 4-1.7L-FI
Line Operation Description Qty Extended Labor Paint
Price$
1 FRONT BUMPER
2 Repl Lower deflector 1 31.48 0.3
3 ** <> Repl RECOND Bumper cover 1 214.00 1.8 2.8
4 Add for Clear Coat 1.1
5 # HAZ WASTE 1 5.00
6 # FLEX 1 5.00
7 # TINT 1 0.5
8 # OPEN FOR HIDDEN DAMAGE 1
SUBTOTALS 255.48 2.1 4.4
ESTIMATE TOTALS
Category Basis Rate Cost$
Parts 255.48
Body Labor 2.1 hrs @ $54.00/hr 113.40
Paint Labor 4.4 hrs @ $54.00/hr 237.60
Paint Supplies 4.4 hrs @ $36.00/hr 158.40
Body Supplies 2.1 hrs @ $2.00/hr 4.20
Subtotal 769.08
Sales Tax $255.48 @ 7.2750% 18.59
Grand Total 78�•67
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 787.67
THIS REPORT IS AN ESTIMATE, BASED ON OUR INITIAL INSPECTION AND DOES NOT COVER ADDITIONAL PARTS OR
LABOR WHICH MAY BE REQUIRED AFTER THE WORK IS OPENED UP. PART PRICES SUBJECT TO CHANGE PER MFGR.
LIFETIME WARRANTY ON WORKMANSHIP, 30 DAYS ON WHEEL ALIGNME:NTS. WARRANTY WORK MUST BE
PERFORMED BY LAMETTRY'S COLLISION ONLY. PARTS WARRANTIED BY THE MANUFACTURER. NO
WARRANTY ON RUST RESTORATION, CORROSION RESISTANCE OR REPLACEMENT RENTAL CARS. OUR REPAIR
ESTIMATED TIME DOES NOT INCLUDE INSURANCE OR PARTS DELAYS WE MAY EXPERIENCE.
MN LAW-A PERSON WHO SUBMITS AN APPLICATlON OR FILES A CLAIM WITH INTENT TO DEFRAUD OR HELPS
COMMIT A FRAUD AGAINST AN INSURER IS GUILTY OF A CRIME IN MINNESOTA.
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.
6/11/2012 7:05:02 AM 018585 Page 2
" `�1�a�-e. ���.- �c�� -� \�S e v�Cs�. ��a�-e. Sr�:�►� �v� 1��y
C(,►��( ��`l1 � ���,�5 �S � �;�v�>,�vt � pwi^�Y:s ��ck:�'-s - -�— �uc,�
J'�S� ��V(,�G-� �1 � C`1�( �t�l (,l ��-v` �J- -�-(.�vl� ���� 2cV v���-
'� I
(JVL t�vt v1 ( uY . T� �c�l��- h� l�. t� � lC..�2..�� iZ.� �J Ca1-� J 4� �,i�h��
J
� �� c ��.��e C,� �t� �-�w ��l r,c{�S,
����� S.
�
���� �
�--e ��� � S���.1�,
i
f • - .
� . -
. I
. y
'��
� r ,�..,�,�.�w...�ti�.
�°` . � �•- . . i
. ;r :-� "."'::~.`�a'....
�.�w`��` �w � •�•
, ,. �� _ ,.
'�^, Y, ' _ ./I/� "w:� . ... ,�.�r
J� ♦
il� �
Xy�n
1�f�
.7+'�'�.�
,-• . �
-�., .-°�:. ;�,'�'��� �
� '
r� '
_,� � �����!E
�
` . y
.�
� ��
� z ..
� • . ` - „t rI ' ' _ .�..-�� , i.
`• � ♦.
1, \ �U ,�':�k
� � ri
' � ` r
A9
� , , � �
�' 1 1
I�
. ^�
. ��. .. �- +� `w':... � ..
�
"'�'+r„- �� {�, ��..,,_
�I� ��.q -,.. . . - ' �� ..
►'. yw.�, � � ' �..,``^._,... � �i�
� _� .1
�. .+ ' t��'Sj.
� �..w ,µ+ti�.: i . \� y+i
.. . J+�e "�' . .7/ , _
�c.a ��
" �w+�r.� --�+�'3. .. ti � . . .
, 1�7'.- T` ^��y� .
..,�:�. Fo N Z4 -�.. '�jF`., �`1�_. �"'. .+l�Y" �� ... ;�.:'�., .
. '7 � � qr, .. �'4�� . .�.'�1." .. � '
... . . '-�. .�. ��r'ti"�„_ " ""'
� ������:� ' A' ��7n? ��1'�it�",(�11+:* . .
.,/�'�, 'r, ' � •� � �'�"[��i . ' . . . . .
�
r'• n� � ,,,•. .
��`^ ✓��T , ;, ~•• �� r•-�b'�Fi
- _ ,:� .� '��,,,,'�'/� , , � ,� -
'�� � ��"-� }�. �t'
r "�i
.` „t L �"'�'',y,�y�,
,��'M...i . .. '�a�y'+r• . ' y Y,.+... .y� �"`�-�w.
��id �y►°
>_ ✓�' ` �;.�,m,�,,�� ,�, _ �' �
s.w7".'T: . .i' '� .�.-:.�tEt.i.=�
� . .,. , ' � ��,i.� . r ��•.� ._ .,r N�_ �
���
r• ,
�,,
�
�
`r . ,
� � � ' �
�'a ,�
��� � `
����'-�'� ' / �._ • � . ' `
� .� -
�. ' 1
��� � � a .
�
•� •
_ . M � _
l.- ---
I
��\ . .
° --._,.. �
. ! � II
. ~ ' I
. ' . ��� �
. 1 .
� � �.f, ,
�, �_ - _.__ �. �� � .
�
`�' � .T ,:y�ii� � .
..;1 �..F..l� . . .
'.� �� ' .
' ��
M �. �,,`' ' .
.r ,;�'.•�Yt,Y•+• �
•;�� � •_