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. NOTICE OF CLAIM FORM to the City of Saint Paul,`�inne�� !�
Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipality...shall�e��rls�tb���ted to the
governing body of the municipaliry within 180 days after the alleged loss or injury is discovered a notice stating the 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 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�Gt. �_ Middle Initial � Last Name �(�c�fi�--
Company or Business Name
Are You an Insurance Company? Yes o� If Yes, Claim Number? �1��j y ��-�—�' ��,.1�+ 3e,,,c(WI.;,�i�.�L-t�,;
Street Address �� C�S f� � � C���
N n�l 1��.� v�i >
City ����, v,( le. State /11 Q� Zip Code S�l��
Daytime Phone(_) - Cell Phone c�a )�1� - 3��3"Evening Telephone(_� S"'�=`
Date of Accidenb Injury ar Date Discovered � g Time �� � am 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. � ��tsh l�►ru,,�
M� r` '�'TJ ; �
> CL �J
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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
^ P.1�-vc:nic;e was da.-naged'u-y a ro�i.oie ar coc�ditiun uf i1►e 5treei u iviy vehicle was damaged ny 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 eopies of all apnlicable 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
�Property damage claims to a vehicle tw stimates 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 eYCeeds $500.00;or the actual bills
andlor receipts for the repairs; detailed list of damaged items
�njury claims: medical bills,receipts �.�t�n� ,�.�„�vin>
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 comalete this section
Were there wimesses to the incident? Yes No nknown (circle)
Provide their names, addresses and telephone numbers:
Were the police or law enforcement called? es No Unknown (circle) ��>
If yes,what department or agency? �-�� ��.-fi�a � Case#or report# I Z�p��-Y(Q L�
Where did the accident or injury take place? Provide street address,cross street, intersection Jna��f park or facility,
closest landmark, etc. Please be s detailed as possible. If necessary,attach a diagram.
� k� ������ �n
Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction. (' �� �.,x� p,.,v�d ,nnLeli r,r.,C '6i I�s C�c>v�e�e.�tt�.laxc-cl_ � c�;.,m.b..�.
Vehicle Claims-alease complete this section r ❑ check box if this section does not applv
Your Vehicle: Year��Make /'o�, h•,c �• Model (�-(�,
License Plate Number �,q_ ,Q�- State "W� Color ��,�v�
Registered Owner _�C.��„�
Driver of Vehicle f i-t-;K,ti �C. (T _,+.�_.
Area Damaged
City Vehicle: Year ' Make S-{- odel � S-{-�
�
License Plate Number � ��, 3 a.u State�Colo I�i,�..
Driver of Vehicle(City Employee's Name) �b �,�.1�,(:����,.���,,,,�
Area Damaged ��„�
Iqjury Claims-please comalete this section ❑ check box if this section does not�ply
How were you injured? c� � � �,,,y� - �
G v� � � �'l l�a.lo et- .✓
What part(s)of your bo y were injured? [J.,�c �✓ � l�o-(,,u v���o,,.� �.� . w� �, hc�� i-t�► o�-�����,;,�
I�a � � ., -� �
Have you sought dical treatment? �s No Planning to Seek Treatment(circle)
When did you receive treatment? _ (,,T ] �� (provide date(s))
Name of Medical Provider(s): vi �c �
Address ,�.33 I`�� ; �f . m N �lephone (;,� / -��}� _�y,j,,
Did you miss work as a result of your inj ry? es No ��
W nen dici you miss work? (�• 1 g /� (provide date(s))
Name of your Employer: �—f,«( �h�_,
Address 3gb T�r_K s�►-. S�S ;}t 3�7 S-f-. ��I�Telephone (p S 1-��3- 3D3��
�� ` ss rol
0'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 �'l L�12
Print the Name of the Person who Completed t 's Form: �i�" �� 1`C (St.c���"'�--
Signature of Person Making the Cla
Revised February 2011
' ' LATUFF BROS. , INC. l.i' �5��'Y`°'�'`°-:-�
, � $80 UNIVERSITY AVENUE `�`�+s �s o�►4.� �a.:n
ST. PAUL, MINNESOTA 55104 ,2yF-,r„�
( 651) 224-2828 FAX: (651) 291-0677 �,C:x�.�-2 p�—,«�`�
FEDERAL ID# 41-0777034 �,��� e
CD LOG NO 48656-1 DATE 06/21/12
SHOP: LATUFF BROTHERS AUTO BODY INSP DATE: 06/21/12
ADDRESS : 880 UNIVERSITY AVE. CONTACT: ROBERT LATUFF
CITY STATE: ST. PAUL, MN PHONE l : (651) 224-2828
ZIP: 55104— FAX: (651) 291-0677
OWNER: GUPTA, RITIKA WORK1PHONE: (651) 223-3011
ADDRESS: 2265 N SNELLING AVE 109 CELL PHONE: (612) 310-3965
CITY STATE: ROSEVILLE, MN
ZIP: 55113
POINT OF IMPACT: 9
DAYS TO REPAIR: 6
LIC# : 609RJJ STATE: WI VIN: 1G2ZH57NX84203579
BODY COLOR: RED MILEAGE:
CONDITION: ACCTNG CTL# :
DRIVEABLE: YES VEH. INSP# :
*=USER—ENTERED VALUE E=REPLACE OEM NG=REPLACE NAGS '
EC=REPLACE ECONOMY UE=REPLACE OE SURPLUS UC=RECONDITIONED PRT
UM=REMAN/REBUILT PRT EU=REPLACE SALVAGE EP=REPLACE PXN
OE=REPLACE PXN OE SRPLS PC=PXN RECONDITIONED PM=PXN REMAN/REBUILT
TE=PARTL REPL PRICE ET=PARTL REPL LABOR IT=PARTIAL REPAIR
I=REPAIR L=REFINISH BR=BLEND REFINISH �
TT=TWO—TONE CG=CHIPGUARD SB=SUBLET '
N=ADDITIONAL LABOR RI=R&I ASSEMBLY P=CHECK
AA=APPEAR ALLOWANCE RP=RELATED PRIOR UP=UNRELATED PRIOR
�
POSSIBLE ADDITIONAL DAMAGE AFTER TEAR DOWN
***************PRELIMINARY ESTIMATE**********************
6 DAY REPAIR TIME
2008 PONTIAC G6 GT 4DOOR SEDAN 6CYL GASOLINE 3 . 5
CODE: W3503C/D OPTNS I/24DGAKMNO
OPTIONS :
TWO—STAGE — EXTERIOR SURFACES TWO—STAGE — INTERIOR SURFACES
BUMPER COVER MOUNTED FOG LAMPS ANTI—LOCK BRAKE SYSTEM
AUTOMATIC TRANS FRONT SIDE IMPACT AIRBAGS
STRG WHEEL MTD RADIO CONTROLS ROOF MOUNTED AIRBAGS
CRUISE CONTROL
`OP GDE MC DESCRIPTION MFG. PART N0. PRICE AJ% Bo HOURS R
-- --- -- ----------- ------------ ----- --- -- ----- —
PAGE 1
06/21/12
�2008� F'�!UTIAC G6 GT 4DOOR SEDAN
CD-LOG '10 48656-1
I 0479 LID, REAR DECK REPAIR 3 . 0*1
L 0479 13 LID, REAR DECK REFINISH 3 . 6 4
2 . 5 SURFACE
0 . 6 TWO STAGE SETUP
0 . 5 TWO STAGE
E 0416 EMBLEM, DECK LID 15880158 GM PART 41 . 36 0 . 2 1
E 0423 DECAL, DECK LID 22689392 GM PART 34 . 90 0 . 4 1
E 0424 DECAL, DECK LID 22689394 GM PART 32 . 68 0 . 4 1
RI0483 CYL, DECK LID LOCK R&I ASSEMBLY 0 . 2 1
I 0509 PANEL, REAR BODY REPAIR 4 . 0*1
L 0509 PANEL, REAR BODY REFINISH 1 . 8 4
1 . 5 SURFACE
0 . 3 TWO STAGE
RI0418 PLATE, REAR BODY SILL R&I ASSEMBLY 0 . 2 1
RI0533 TAILLAMP ASSEMBLY LT R&I ASSEMBLY 0 . 6 1
RI0534 TAILLAMP ASSEMBLY RT R&I ASSEMBLY 0 . 6 1
RI0550 LAMP, HIGH MOUNTED STOP R&I ASSEMBLY 0 . 3 1
E 0565 BUMPER, REAR 25960707 GM PART 218 . 90 p , g 4
L 0565 BUMPER, REAR REFINISH
0 . 7 SURFACE
0 . 1 TWO STAGE
E 0566 COVER, REAR BUMPER 19121114 GM PART 433 . 37 � . 9 4
L 0566 COVER, REAR BUMPER REFINISH
2 . 4 SURFACE
0 . 5 TWO STAGE
E 0576 COVER, RR BUMPER LOWER 22712777 GM PART 106. 76 INC 1
E 0567 ABSORBER, REAR BUMPER 20851989 GM PART 234 : 5��6* p . 3*1*
L M14 CORROSION PROTECTION REFINISH *4*
N M17 COVER CAR EXTERIOR ADDNL LABOR OPERA 7 . 00* 1 . 0*1*
I M18 SET-UP & MEASURE REPAIR *1*
SBM60 HAZARD. WSTE. REM. SUBLET REPAIR 5 . 00* 2 . 0*3*
I PULL REAR UNIBODY LENG REPAIR
23 ITEMS
MC MESSAGE (S)
13 INCLUDES 0 . 6 HOURS FIRST PANEL TWO-STAGE ALLOWANCE
FINAL CALCULATIONS & ENTRIES 1, 102 . 53
GROSS PARTS 14 . 00
OTHER PARTS 291 . 20
PAINT MATERIAL 1, 407 . 73
PARTS & MATERIAL TOTAL 7 , 6250 85 . 14
TAX ON PARTS @
LABOR RATE REPLACE HRS REPAIR HRS
1-SHEET METAL 52 . 00 5 . 7 8 . 0 712 . 40
2-MECH/ELEC 85 . 00
3-FRAME 75 . 00 2 . 0 150 . 00
4-REFINISH 52 . 00 9. 1 473 . 20
5-PAINT MATERIAL 32 . 00 1, 335 . 60
LABOR TOTAL
PAGE 2
06/21/12
?b08� P�NTIAC G6 GT 4DOOR SEDAN
�D LDG ?;0 48656-1
SUBLET REPAIRS 5 . 00
TOWING
STORAGE
�ROSS TOTAL 2, 833 . 47
JET TOTAL 2, 833 . 47
3HOPLINK U0231 ES CD LOG 48656-1 DATE 06/21/12 05: 42 : 06PM R6. 37 CD 06/12
PXN: NO GEOCODE
�OST LOG
(C) 1998 - 2008 AUDATEX NORTH AMERICA, INC.
2 . 0 HRS WERE ADDED TO THIS EST. BASED ON AUDATEX TWO-STAGE REFINISH FORP�IULA.
--------------------------------------------------------------------------
******************************NOTE********************�*****
ALL WORK MUST BE PAID IN FULL AT DELIVERY UNLESS DIRECT
BILLING IS PRE ARRANGED! ! ! ! ! !
WE ACCEPT PERSONAL CHECKS UP TO $500 . 00
VISA, MASTERCARD AND DISCOVER AND ALL INSURANCE DRAFTS
IF YOUR LOAN COMPANY IS NAMED ON CHECK THEY MUST SIGN THE
CHECK BEFORE WE CAN RELEASE YOUR CAR.
ALL WORK IS WARRANTIED WITH A LIMITED LIFETIME WARRANTY
THANK YOU FOR DOING BUSINESS WITH LATUFF BROTHERS
PAGE 3
06/21/12
�— _ -
� Workfile ID: be8b6846
� HEPPNER'S AUTO BODY
395 E. 7TH ST•, SAINT PAUL, MN 55101
Phone: (651) 224-5644
FAX: (651) 224-6042
Preliminary Estimate
Customer: Gri''rA, RT��►R.
�Jl, Written By:Wayne Ehrmantraut
Policy#: Claim #:
Insured: �I�TA���R' Days to Repair: 0
Type of Loss: Liability Date of Loss:
Point of Impact: 06 Rear
I���qon Wcation: Insurance Company:
Owner. WEST BEND
�A���R HEPPNER'S AUTO BODY
2265 N.SNELLING#109 395 E.7TH ST•
ROSEVILLE,MN 55113 SAINT PAUL,MN 55101
(612)310-3965 Evening Repair Facility
(612)310-3965 Cellular (651)224-5644 B�siness
VEHICLE
Body Style: 4D SED VIN: 1G2ZH57NX84203579 Mileage In:
Year: 2008 Mileage Out:
Make: PONT Engine: 6-3.5L-FI License: 6��� Vehicle Out:
Producaon Date: State: MN
Model: G6 GT )ob#:
Color: MET RED Int: Condition:
4 Wheel Disc&akes Goth Seats
Intermittent Wipers Power Windows
Ke less Entry Rear Defog9er
Air Conditioning Communications System Y Satellite Radio
Console/Storage Message Center
Aluminum/Alloy Wheels 5earch/Seek
Cruise Control Overdrive
AM Radio Steering Wheel Controls
Driver Air Bag Passenger Air Bag
Anti-Lock&akes(4) power Brakes Stereo
Automatic Transmission Dual Mirrors
Auxiliary Audio Connecaon FM Radio
Power Locks Telescopic Wheel
Bucket Seats Fog Lamps
Power Mirrors Tilt Wheel
CD Player Front Side Impact Air Bags
Power Steering Traction Control
qear Coat Paint Head/Curtain Air Bags Power Trunk/Tailgate
Page 1
6/30/2012 11:36:42 AM 070412
Y '
Preliminary Estimate
Customer: GIPTA, RITIKA R.
Vehicle: 2008 PONT G6 GT 4D SED 6-3.5L-FI MET RED
Estimate based on MOTOR CRASH EST'IMATING GUIDE. Unless otherwise noted ail items are derived from the Guide
DRiFQ05, CCC Data Date 6/22/2012, 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 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=6oron 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. 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=6ureau of Automotive Repair. EPA=Environmental Protection Agency. NHTSA= National Highway Transportation
and Safety Administration. PDR=Paintless Dent Repair. VIN=Vehicle Identification Number.
6/30/2012 11:36:42 AM 070412 Page 4
MyChart-AccQUnt Details https://www.mychartweb.com/MyChartlinside.asp?mode=hbacco�mtd...
'�"��� 1 S y�o�cth�1�
.-�a��.���-° ,
Name: Ritika R Gupta � DOB: 3/16/1979 � MRN: 1006964056 � PCP: Kimberly A Fischer, MD
Account Details
Account Type: Hospital Billing
Guarantor Demographics
Guarantor: GUPTA,RITIKA R
Account Number: 100186171
Address: APT 109
2265 SNELLING AVE N
ROSEVILLE MN 55113-4232
Home Phone: 612-310-3965
Work Phone: 612-349-3051
Amount Due
0-30 days 31-60 days 61-90 days 91-120 days Over 120 days Total
$0.00 $0.00 $0.00 $0.00 $0.00 $0.00
Outstanding Accounts
Date Description Charges Payments / Insurance Patient
Adjustments Balance Balance
06/18/2012 Acct #7957259 GUPTA,RITIKA R
Outpatient
UNITED
HOSPITAL
D87348
Total 1,751.10 0.00 1,751.10 0.00
Outstanding Balance: $0.00
Statements �-� �� '"S�`�'�`�����s
� , ,�,� ��/
No statements are avai/ab/e for this account. � �
c'� �lfi��
Payments Since Last Statement �-����-r
w��I h�-��.J
No payments have been made since last statement. �S �ra��
1 of 2 6/29/2012 9:24 AM