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Mirick ��`�'�D 'ohnston martineau JUL 2 6 2012 � PLLP ��;� ��,��;�� attorneys at law , �, July 25, 2012 City Clerk 15 West Kellogg Blvd 310 City Hall Saint Paul, MN 55102 P"?: Gtir Ciicnt: Tasha-Rose Mirick Our File No.: 12012R-TS Claim No.: 12 331 6068 Date of Loss: April 10, 2012 To whom it may concern: Enclosed please find the Notice of Claim Form for my client, Tasha Rose Mirick. Please contact me upon review to discuss this claim. Thank you. Very truly yours, Johnston� Martin PLLP _ C s p er A. Johnston Attornev at Law Cc: 1'asha Rose Mirick (651)ANY.'TIME (651)269.8463 Broadway Place�tiest � 1300 Godward Street NE,Suite 6650 ( Minneapolis,MN�5413 �vw1��.jm-legal.com � Fax(612)379.0480 NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota , Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipality...shall cause to be presented to the � governing body of the municipality within/80 days after the alleged loss or injury is discovered a notice stating the time,place,and I circumstances thereof,and the amount of compensation or other relief demanded." I 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`N/Athe nature of your claim. This form must be signed,and both pages completed. If something does not apply,wr�te SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK, , 15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102 !, First Name�-1G,�f'�- Middle Initial J Last Name �Yl'Y1C�Y�G�1 Company or Business Name � v � ' ' �2.- �31��C�1c� �' Are You an Insurance Company Yes No If Yes, Claim Number? ' Street Address 7 �� -�� v� �� C��, �; �l � �-�� State� I V Zip Code � � Daytime Phone(��Cell Phone(��,- Evening Telephone(��- Date of Accident/Injury or Date Discovered 4• � � ' � L- Time �� 3� a /pm I 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 res onsible for your damages. (�l,l.lr 1Y1�5t.�i'�� r � � +� , � � �I � aL � r � Please check the box(es)that most closely represent the reason for completing this form: ��1VIy 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 ecify . �`� � �; ❑ Othcr type of injury—please specify • �� In order to process your claim vou need to include copies of all annlicable documents. ;I For the claims types listed below,please be sure to include the documents indicated or it will delay the handling of I 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 �i 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 i 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—nlease comalete this section_.-_.-_ Were there wifiesses to the incident. Yes No Unknown (circl�/) Provide their names, addresses and telep e numbers:�1nP,�'� l.C�1r� �Ll!1 (�,L�� u�� Were the police or law enforcement called? Ye No Unknown (circle) If yes,what department or agency? ` Case# or report# 17 ' V��2-g� 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.�-�PK'S ��l`Olrl �F I i� :�P � � .r�,tl� �i�Q 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. � � � g 3: - 1 (X Cln u i�1�Ci1 u.�,i� Vehicle Claims—please complete this section , ❑ check box if this section does not a 1 Your Vehicle: Year gg�_Make �V► X _', Model �(I �i1� License Plate Number��- �-}t}V State M�1 Color��I►�� Registered Owner '� - . E,' � Driver of Vehicle�� - fi��1 Yl C�-�� Area Damaged �� Y1(,y City Vehicle: Year Make ��('f� Model License Plate Number �1?�lOC{� State��Color Driver of Vehicle(City Employee's Name) .�_�a��, �n a ��'Q.i'��: Area Damaged � �Y1�' C� l�Yt ��1 In'u Claims— lease com lete this section ❑ check box if this section does not a 1 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? q-� �1 � I 2. _(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: A��:ess Telephone • � � ne� e �e Mors � � �eS'S z � �e5i• �� 2�1q �� Check here if you are attaching more pages to this claim form. Num er of additional pages By signing this form,you are stating that all information you have providecl 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 Print the Name of the Person who Completed this Form: �,�PP ��1.��Yl S�n Signature of Person Making the Claim I � Revised February 2011 I 3 1999 MERCURY VILLAGER ESTATE PSNGR VAN 6 3.3 NORMAL GAS A2WD List Price: $2,997.00 VIN: 4M2XV11T3XDJ40846 Adjustments Loss Vehicle This Vehicle Amount Stock No: BR11882 Projected Sold Adjustment $0.00 Listing Date: 02/07/2012 Mileage 213,446 ' 123,487 -$994.85 ZIP/Postal Code: 55901 Equipment Convenience Group Yes No $59.30 Distance from 69 miles Luxury Group Yes No $119.21 Loss Vehicle: Electronic Automatic No Yes -$21.57 Source: FRANCHISE DEALER WEB 7`emperature Control LISTING-AUTOTRADER.COM ROCHESTER FORD MAZDA Total Adjustments: -$837.91 4900 HIGHWAY 52 N Adjusted Price: $2,159.09 ROCHESTER MN 55901 507-288-7564 I Comparable Vehicle Option Details: i Electronic Automatic Temperature Control I i Sub-Modei Comparison . � i Sub-Model Description Configurafion Original MSRP 1999 MERCURY VILLAGER ESTATE PSNGR VAN 3.3L 6 Cyi Gas 2WD $25,015.00 I � I Mitchell War��ent�r Total�oas Claim t!•12-331 RORR-01 I Convriaht(r.12011-Mitchell InternaTional.All Riahis Recerved I Paae 6 Vehicle Valuation Methodology Explanation WorkCenter Total Loss was built through a joint partnership between J.D.Power and Associates vehicle vatuation division Power Information Network (P.I.N.)and Mitchell Intemational,a leading provider of claims processing solutions to private passenger insurers. WorkCenter Total Loss produces accurate and easy-to-understand vehicle valuations via this five step process: Step 1 -Locate Comparable Vehicles Locate vehicles similar to the loss vehicle in the same market area.WorkCenter Total Loss finds these vehicles in AutoTrader.com,Cars.com,and direcU from dealerships. Step 2-Adjust Comparable Vehicles Make adjustments to the prices of the comparable vehicles.The comparable vehicles are identical to the loss vehicle except where adjustments are itemized.There are several types of comparable vehicle adjustments . Projected Sold Adjustment-an adjustment to reflect consumer purchasing behavior(negotiating a different price than the listed price). . Mileage Adjustrnent-an adjustment for differences in mileage between the comparable vehicle and the loss vehicle. . Equipment-adjustments for differences in equipment between the comparable vehicle(e.g.equipment packages and options)and the los � vehicle. Step 3-�alcula.e Base Vehicle Value ' The base vehicle value is calculated by averaging the adjusted prices of the comparable vehiGes. Step 4-Calculate Loss Vehicle Adjustments There are four types of loss vehicle adjustments: • Condition Adjustment: Adjustments to account for the condition of the loss vehicle prior to the loss. . Prior Damage Adjustment: � Adjustments to account for any prior damage present on the loss vehicle prior to the loss. I . After Market Part Adjustment: Adjustments to account for any after market parts present on the loss vehicle prior to the loss. f . Refurbishment Adjustment: I Adjustments to account for any refurbishment performed on the loss vehicle prior to the loss. Step 5-Calculate the Market Value The Market Value is calculated by applying the loss vehicle adjustments to the base value. Mftcheli WorkC�nter Total Loss Claim#�12-33160fiR-01 I Convriahf/r.1 7011-Mitr.hell IntPrnational.All Riahts ResPrvPd I PaaP 7 ,�. Mitchel/ - " " I' " � 5 ° " " T� 5� Vehicle Valuation Re ort P"ower/nformation Network`v � Prepared for:Progressive Group of Insurance Companies (800)321-9843 Summary Claim Information Claim Number: 12-3316068-01 Version#: 1 Policy Number: Coverage Type of Loss: Collision Owner: TRAVIS HAAGE Loss Date: 04/10/2072 383 SAINT ALBANS ST N Reported Date: 04h0/2012 SAINT PAUL,MN 55104 Valuation Report Date: 04/11/2012 09:13:45 (651)335-0647 Valuation Report ID: 1003062526 Vehicle Information Loss Vehicle: 1999 MERCURY VILLAGER ESTATE Location: MN 55104 PSNGR VAN 3.3L 6 Cyl Gas A 2WD Exterior Color: VIN: 4M2XV11T7XDJ19787 License Plate: Mileage: 213,446 miles Valuation Summary Base Value: $2,074.46 ' Loss Vehicle Adjustments {� Condition Adjustment: -$276.14 Prior Damage Adjustment: $0.00 After Market Parts Adjustment: $0.00 Refurbishment Adjustment: $0.00 Market Value: $1,798.32 Settlement Adjustments Deductible: -$100.00 ' Settlement Value: $1,698.32 Loss Vehicle Detail Loss vehicle: 1999 MERCURY VILLAGER ESTATE PSNGR VAN 3.3L 6 Cyl Gas A 2WD Standard Equipment Mitchell a Cente� Total Loss Claim#�12-331 ROfiR-01 I Cnnvriaht(r.12011-MitchPll IntPmational All Riahis Reserveci I Paae 1 Convenience Group Fiip Open Lifkgate Window and Interval�perMlasher Front Overhead Storage Consale;(One Compartme�t Deleted 1#Ordered ` With Power Moonrocsf} Light Group,(Includes Overhead Front Seat Dual Maplights,Front Door Step Lamps,Under Instrument Panel Lamps�th Time Delay,2nd and 3rd Power Rear Vent Windows Seat Row Driver Side Maplights) Remote Keyless Entry System,(tncludes 111uminated interior Lights,2 Remote Keyless Entry Gontrollers and Panic Alarm) Luxury Group 4-Way Power Passenger Seat Driver's Memory Seat and Exterior Memory Mirrors(Heated)With Auto Exit Assist HomeLink(R}Universai Garage�oor Opener Leather Seating Surfaces Travelnote(R)Digital Memo Recorder Mounted To Driver Sunvisor,Can Record Up To Three Minutes Worth Of Messages Loss Veh�Gle B�se�/atu� ,,,,,,,, ',,, ;�, %, , Loss vehicle: 1999 MERCURY VILLAGER ESTATE PSNGR VAN 3.3L 6 Cyl Gas A 2WD Comparable Vehicle Information Search Radius used for this valuation: 75 miles from loss vehicle zip/postal code. Typical Mileage for this vehicle: 143,000 miles # Vehicle Descrip.tion Mileage Location Distance From price Adjusted Loss Vehicle Value 1999 MERCURY ViLLAGER ESTATE PSNGR VAN ` $2,789.00 1 145,113 55057 34 miles $1,910.34` 6 3.3NORMAL GAS A 2WD List Price 2 1999 MERCURY VILLAGER ESTATE PSNGR VAN 117,000 55963 59 miles $3,795.00 $2,153.95 6 3.3NORMAL GAS A 2WD List Price 1999 MERGURY UILIAGER ESTATE PSNGR VAN $2,997.00 � 6 3.3NORiv1AL GAS A 2VW 123,487 559a1 89 miles List Price ��,��9.09' Base Value: $2,074.46 �.Vehicle.Adjustments _ Loss vehicle: 1999 MERCURY VILLAGER ESTATE PSNGR VAN 3.3L 6 Cyl Gas A 2WD Condition Adjustments Condition Adjustment: -$276.14 Overall Condition: 2.62-Good Typical Vehicle Condition: 3.00 Mitchell WorkCenter Total Loss Claim#�1?-33160fiR-01 I Convriaht(r.12011-Mitr.hell InlernaTional All Riahis Reserved I Paoe 3 Category Condition Comments interior HEADLINER 3 Good DASH/CONSOLE 3 Good CARPET 3Good SEATS 2 Fair leather seats splitting DOORS/INTERIOR PANELS 3 Good GLASS 3 Good Exterior PAINT 3 Good ' BODY 2 Fair penetrating rust � TRIM 2 Fair Ift taillamp is cracked VINYUCONVERTIBLE TOP Typical n/a � Mechanical ENGINE Typical unable to determine i TRANSMISSION TYP�� Tire 3 Good 8,7,6,7 Typical condition reflects a vehicle that is in ready-for-sale condition and reflects normal wear and tear for that vehicle type/age. I Comments: After Market Part Adjustments Category Description Adjustment Type Purchase Date Amount Paid Adjustment Amount EXTERIOR HITCH-BALL MOUNT INSTANT $0.00 ' QUOTE Comparable Vehicies Loss vehide: 1999 MERCURY VILLAGER ESTATE PSNGR VAN 3.3L 6 Cyl Gas A 2WD , Comparable Vehicles MRchell WorkCenter TOtAI LOSS Claim#•19-331ROfiR-01 I Cnnvriahf/r.1 9011-Mitchall International_All Riahis ReservPd I Paae 4 1 1999 MERCURY VILLAGER ESTATE PSNGR VAN 6 3.3 NORMAL GAS A2WD List Price: $2,789.00 VIN: 4M2XV11T1XDJ38576 Adjustments Loss VehiGe This VehiGe Amount Stock No: 12085D Projected Sold Adjustment -$296.00 Listing Date: 01I23I2012 M+feage 213,446 145,i 13 -$614.05 Equipment ZIP/Postal Code: 55057 ; Convenience Group Yes No ,; $49s33 Distance from 34 miles Luxury Group Yes No $99.16 Loss Vehicle: ' Comfort Group No ` Yes -$99.16' Source: FRANCHISE DEALER WEB Electronic Automatic No Yes -$17.94 LISTING-AUTOTRADER.COM Temperature Control DOKMO FORD CHRYSLER JEEP RAM Total Adjustments: -$878.66 1201 HIGHWAY 3 SOUTH Adjusted Price: $1,910.34 NORTHFIELD MN 55057 507-645-4478 ' Comparable Vehicle Package Details: Comfort Group ((DIO)Rear Seat Rudio Con►.rols) � Comparable Vehicle Option Details: '� Electronic Automatic Temperature Control I 2 1999 MERCURY VILLAGER ESTATE PSNGR VAN 6 3.3 NORMAL GAS A2WD List Price: $3,795.00 VIN: 4M2XV11T3XDJ20368 Adjustments Loss Vehicle This Vehicle Amount Stock No: 9340A Projected Sold Adjustment -$403.00 Listing Date: 03/08/2012 Mileage 213,446 117,000 -$;1,213.10" Equipment ZIP/Postal Code: 55963 i Convenience Group , Yes No - $67.12 Distance from 59 miles Luxury Group Yes No $134.92 Loss Vehicie: Source: FRANCHISE DEALER WEB ��ear Seat Audia Plo Yes -$17.49 Controfs` LISTING-AUTOTRADER.COM -$105.09 Power Moonroof No Yes CJ AUTO SALES Electronic Automatic No Yes ,-$24.41 2877 520TH STREET NW Temperature Cont�ol PINE ISLAND MN 55963 Anti-Lock Braking System,4 No Yes -$80.00 507-356-6000 Wheel Total Adjustments: -$1,641.05 Adjusted Price: $2,153.95 Comparable Vehicle Option Details: (DIO)Rear Seat Audio Controls,Power Moonroof,Electronic Automatic Temperature Control,Anti-Lock Braking System,4 Wheel Mitchell ork enter TOtd��.OSS Claim#�12-331fi0RR-01 I Cnnvriaht(r.11011-Mitr.hell International_All Riahis Reserved I PanP fi