Chapman t'��i.;is;��#r;l�
AUG � � 201Z
NOTICE OF CLAIM FORM to the City of S��_�I'��l���Vlinnesota
Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipaliry...shall cause to be presented to the
governing body of the municipality 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
�b�(�J Middle Initial �- Last Name G�������
Company or Business Name
- --�-- -— - ----
Are You an Insurance�ompany? es/ 0 1 es, (: aim um er?
Street Address (1� ` ��� �V�
City ---'I . ����-- State �f�) Zip Code���
Daytime Phone(�I )�-.575�Cell Phone (��4-��Evening Telephone(�S�)�} �757
Date of Accident/Injury or Date Discovered � -(�- �Z Time 'U U 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. � (��E
��.C.N FJ�vM C [�AK- i(�c�., e�N '�Tl�+E �cU r..��1�t�b i t� f�I�rt T d F t�u 1�.
- G � � � � (��c,�.- N� � -
- ' jJ E�t� F -I M YJ 1-t f G I-� TH� �.l T y 5
St 1 L� C -' � �1 � 1-� �L-L
I�fS ISS � � ? . � _ - � r � - ks
- � i � 5 � �
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 V C1+1G�-E I��N ,+-Fl� F� ���� f��
� Other type of injury-please specify �U�v����T��'
In order to process your claim you need to include copies of all annlicable 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.
a 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
a 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
�a 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.
Nvr To T!-lE ��NC.� �LTU�u—� Fl�L���iCr
All Claims—please complete this section �-��.�� �j� pil��� �-Fi: �,�L!_�h(
Were there witnesses to the incident? Yes N U own (circle) k3j�+�1GH ON 1�G
Provide their names, addresses and telephone numbers: �UtILL�.
Were the police or law enforcement called? Yes N� Unknown (circle)
If yes,what deparhnent 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 po,s�ible. If necessary, attach a diagram. (hl j= (J T" ('jF �(�
1-It.�n'1E f}T �ll �i���—�— �v� ( Rr I'�..iolZ AV�� S'i"_ �'�i,�L, M
Please indicate the amount you are seeking in compensation or what you would like the City to do to r solve this claim
to your satisfaction. �7� �`� �� ty;a�� ��,� �;, /��;�,�� ��MR���
Vehicle Claims— lease com lete this section �' chec�C box if this section does not a 1
Your Vehicle: Year�_Make 'd{�� Model /� � --
License Plate Number ��!=; �x-f�(� State Color L(�I�
Registered Owner '— 1 1 L.���/ P A /'c �?'I{G V�l ( FL,�
Driver of Vehicle CI � �. 'P1�/4� � � �l S �-Lb �tT T1ML
Area Dama�ed �TY�P G�F' C./�B �3�1 W INL�-�4-�IG�—D 01= L�Mc�GtE
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
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
Subrnitting a false claim can result in prosecution. Date form was completed g' �O -- I L
Print the Name of the Person who Completed this Form: ' y�1��� LI�/��� I
Signature of Person Making the Claim: �
Revised February 2011
. RAYMOND AUTO BODY� INC. Workfile ID: f063af5f
FederalID: 41-0888257
1075 PIERCE BUTLER RTE, SAINT PAUL, MN
55104
Phone: (651) 488-0588
FAX: (651) 488-4794
Preliminary Estimate
Customer: CHAPMAN, ED
Written By:JASON SLOMKOWSKI
Insured: CHAPMAN, ED Policy#: Claim#:
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact: 13 Rollover
Owner: Inspection Location: Insurance Company:
CHAPMAN,ED RAYMOND AUTO BODY,INC.
1911 CARROLL AVENUE 1075 PIERCE BUTLER RTE
ST PAUL,MN 55104 SAINT PAUL,MN 55104
(651)644-5757 Evening Repair Faciliry
(651)488-0588 Business
VEHICLE
Year: 1997 Body Style: 2D P/U VIN: 1FTCR15XOVP609698 Mileage In:
Make: FORD Engine: 6-4.OL-FI License: Mileage Out:
Model: RANGER 4X4 SUPERCAB Production Date: State: Vehicle Out:
SPLASH
Color: BURGANDY Int: Condition: Job#:
TRANSMISSION DECOR FM Radio WHEELS
5 Speed Transmission Body Side Moldings Stereo Aluminum/Alloy Wheeis
4 Wheel Drive Dual Mirrors Search/Seek PAINT
Overdrive Console/Storage SAFETY Clear Coat Paint
POWER CONVENIENCE Anti-Lock Brakes(2) TRUCK
Power Steering Intermittent Wipers Driver Air Bag Rear Step Bumper
Power Brakes RADIO SEATS
Power Mirrors AM Radio Cloth Seats
8/6/2012 5:06:52 PM 019495 Page 1
Preliminary Estimate
Customer: CHAPMAN, ED
Vehicle: 1997 FORD RANGER 4X4 SUPERG46 SPLASH 2D P/U 6-4.OL-FI BURGANDY
Line Oper Description Part Number Qty Extended Labor Paint
Price;
1 CAB
2 * Rpr Roofpanel 5L5Z1350202AA 4.Q 3.5
3 Add for Clear Coat 1.4
4 * R&I RT Drip molding rear F37Z13517A72A Q.$
5 * R&I LT Drip molding rear F37Z13517A73A 4$
6 R&I Headliner F57Z1351944AAK 2.0
7 # Rope Glass 1 0.6
--.._— ._--------------_______._.----- ---------—___ ._ __.._ . .____.__--.__. __---.._ ._--_____ _._.__..----------
8 MISCELLANEOUS OPERATIONS
9 * Repl Cover car/bag 1 �
10 # Subl Hazardous waste removal 1 6.00 X
11 # Color tint/color match 1 0.5
12 # Rpr Color sand and buff 0.5
13 # Repl Corrosion protection primer 1 �•2
SUBTOTALS 6.00 8.2 6.3
ESTIMATE TOTALS
Category Basis Rate Cost;
pa� 0.00
Body Labor 8.2 hrs @ $53.00/hr 434.60
Paint Labor 6.3 hrs @ $53.00/hr 333.90
Paint Supplies 6.3 hrs @ $33.00/hr 207.90
Miscellaneous 6.00
Subtotal 982•40
Grand Total 982.40
Deductlble 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 982.40
8/6/2012 5:06:52 PM 019495 Pa9e Z
5 �
HAMLINE AUTO BODY, INC. Workfile ID: 258a3a8e
FederalID: 41-0918545
Done The Way It Should Be
2520 BROADWAY DR, SAINT PAUL, MN 55113
Phone: (651) 224-4717
FAX: (651) 224-3789
Preliminary Estimate
Customer: CHAPMAN, ED
Written By:Chad Remick
Insured: CHAPMAN,ED Policy#: Ciaim#:
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact:
Owner: Inspection Location: Insurance Company:
CIiAPMAN,Ed HANILINE Al)TO E3UDY,INC.
1911 CARROLL AVE 2520 BROADWAY DR
ST PAUL,MN 55104 SAINT PAUL,MN 55113
(651)644-5757 Evening Repair Facility
(651)224-4717 Business
VEHICLE
Year: 1997 Body Style: 2D P/U VIN: 1FTCR15XOVP609698 Mileage In:
Make: FORD Engine: 6-4.OL-FI License: Mileage Out:
Model: RANGER 4X4 SUPERCAB Production Date: State: Vehicle Out:
Color: Int: Condition: Job#:
4 Wheel Drive Dual Mirrors Power Brakes Tinted Glass
5 Speed Transmission Intermittent Wipers Power Steering
And-Lak Brakes(2) Overdrive Rear Step Bumper
8/1/2012 4:43:44 PM 099681 Page 1
;
Preliminary Estimate
Customer: CHAPMAN, ED
Vehicle: 1997 FORD RANGER 4X4 SUPERCAB 2D P/U 6-4.OL-FI
Line Operation Description Qty Extended Labor Paint
Price;
1 CAB
2 * Rpr Roof panet �,4 3.0
3 R&I RT Weatherstrip 0.3
4 R&I RT Weatherstrip 0.3
5 R&I Headliner w/o assist handle 1.0
6 # ROPE WINDSHEILD 1 0.6
7 # Subl Hazardous waste removal 1 5.00 X
8 # Repl Cover car 1 4.00
5 # Cclor tint/color r�atch 1
10 # Rpr Color sand and buff 0.5
li # Repl Corrosion protecfion primer 1
SUBTOTALS 9.00 7.7 3.0
ESTIMATE TOTALS
Category Basis Rate Cost;
pa� 4.00
Body Labor 7.7 hrs @ $52.00/hr 400.40
Paint Labor 3.0 hrs @ $52.00/hr 156.00
Paint Supplies 3.0 hrs @ $34.00/hr 102.00
Body Supplies 5.5 hrs @ $6.00/hr 33.00
Miscellaneous 5.00
Subtotal 700.40
Sales Tax $4.00 @ 7.1250% 0.29
Grand Total 700.69
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 700.69
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Thank You For Your Business.
This is an estimate only. This estimate does not account for hidden or unseen damage(s). Parts prices may vary and are
subject to invoice.
Payment method: VISA, MASTERCARD, AMERICAN EXPRESS, DISCOVER, CASH, CASHIERS CHECK.
Authorization of Repair
Customer Signature Date_J_�
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