Cai 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 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� Middle Initial�Last Name C� ` 3 -��
Company or Business Name
� Di2
Are You an Insurance Company? Yes/No If Yes,Claim Number? �1�h
Street Address��D q� s iMQ..�P."�W�-�,�� �G�- � ��rf `����
City �UUGC�t.v�rta State �Y1 /i� Zip Code �S �29
Daytime Phone( Sl)�- 77 3 ell Phone( �()Z33-�79.�Evening Telephone(�5 )Z-3 3 �7
Date of Accidend Injury or Date Discovered 7�2�� 2O l Z Time :0� am/pm
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 aze involved and/or responsible for your damages.
�� ,kn,tt, ,
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 O I was injured on City property
❑ Other type of property damage—please specify
O 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 aze 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$500.00;or the actual bills '
and/or receipts for the repairs;detailed list of damaged items ',
O Injury claims: medical bills,receipts
O Photographs are always welcome to document and support your claim but will not be returned.
Page 1 of 2—Please complete and return both pages of Claim Form
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims—ulease comnlete this section
Were there witnesses to the incident? Yes No Unknown (circle)
Provide their names,addresses and telephone numbers: �D
Were the police or law enforcement called? es No Unknown (circle)
If yes, what department or agency?�'� Case#or report# I 2 I 7 7 D � �
Where did the accident or injury take pl� Provid�et aiTdress,cross street, intersection,n me of park or facilit ,
closest landmark,etc. Please be as etailed as possible. If necessary,attach a diagram. /QO� . S
� �o �$ e��'.o��'�rn,TSt� P���� � ��c,-n.�-v,,�m
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. � ��� -
, ��� �I'1 P�e� ,
Vehicle Claims— lease com lete this section ❑check box if this section does not a 1
Your Vehicle: Year��'�_Make Model
License Plate Number �TO�L State.��Co r Ti�s� �'Y��en
Registered Owner ' C �
Driver of Vehicle "T,e�n��i_
Area Damaged
City Vehicle: Year Zv0� Make ,e� Model��rG k _
License Plate Number�S'r! Z�� State QZiV Color_. _ _ ���PiV'
Driver of Vehicle(City Employee's Name) I���Pir't� 13_ �}G-�'Y'y`�_
Area Damaged l�i �+''
Iniurv Claims nlease complete this section ❑check box if this section does not avnlv
How were you injured? �le
What part(s)of your body were injured? A/r�
Have you sought medical treatment? Yes � Planning to Seek Treatment(circle)
When did you receive treatment? �/D (provide date(s))
Name of Medical Provider(s): /1/�—
Address /��D ,,,,.Teb p� �� Q��
Did you miss work as a result of your injury? Yes lv
When did you miss work? (provide date(s))
Name of your Employer: `
Address lephone ��'!—ZD 1-7� 34
�Check here if you are attaching more pages to this claim form. Number of additional pages g- .
By signing this forin,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 �1 3' ' �� �Z
Print the Name of the Person who Completed this Form: J -e-n n �� �Q�
Signature of Person Making the Claim: �� ��+
Revised February 2011
Accident Report Page 1 of t '
,���
12177059 � •
N.�w+u� n�.wao M.n„ �o�m � .w . ; ecl� � '.�
N' N $2 �0 . �Db 13 7 25 2012 0900 �Q
�� � 1� street� s w ���� a —'�B�T 8• ew�� <
CpM'/tq � � MB[M 11696116roM� 414 IIO�Ri4i116t�CaIVWRptIW1/i
62 8,w Saint Paul +�• 10 Robert Street
�,q„� wrnw ow�nuee�.ewre�-� .me we. san. .�w o�aeume�u,eeo-: .oa. wn o�m�,u. {�i
� O1 T180290990609 MN D O1 O1 W853233599316 MN D O1 y�
r�erait vwsx�cnawn aaevr�m wiy�u[�mc�ASrl afeawm meraAr
RIGOBERTO BUST}1MANTE AGUIRRE 12 22 79 JENNY GUILIANGAO CAF. OS 14 60
17 367 Grove Street N, O1 11090 SWEETWATER PATH N, O1 61
�
O1 � PAUL 55101 WOODBURY 55129 6512336795 Ol
am�n �n �g wrr �mrt �w.o uer wav sei cvr �waorr nww.a s�er wa[+r �ou�o
Ql � M . U9 04 04 05 N , F �4 04 09 05 N Ol
NOM lYR OiG HK MIIOlV t11111YOR Y�UAIIC[l�NK I�IIM��1 A101 lflf EI�O lY�i 10110A iMIIYAi AI�AMVYIMEF �MYa .
'� 98 � 98 13� o�, na '9� 98 1�' 98 t� o e1 N7°+
02 3S GENERAL CONTRACTING N CAI QINGSHENG � ��
03 �8 N DALE ST IJ,� 11090 SWEETWATER PATH � • �m
.e,�ue an:.o.e.a. w.w ona an:.uic.o. �uuO U I Ol�
O1 ST PAUL 1�I 55103 '1�Pr 03 WOODBURY MN 55129 "'�
ow�ne wa roon rEw wwx .wa ram .a+i mio� uo�ee
OS JEEP GCK 200 . °' PLYM VOF 99 GRN O1
�.N ,.. R� ..,�� ,�, ��, ... �.,�. R� ,�� "'"" 02�
02 586gz' 1�I 3 O1 � O1 970jx1 MN 3 � � U1
sawr�
City of Saint Paul �� Met I,'ife 0581019900
cwao wv wwm .�r�a�a+. w.�oo.. wxo xKw. .o.
rne EJ1GCmFMr91VOLV�ACOW1lRCIRLMOTORVlHIC1$lCN001.6US.ORNEADSTART9YB � m�
� ? N9i�lERTON071FYT1ESiA76MRROl/naYWrMttW1M.7�i�nd1MAN1}, �
toM6laiuvBlflcxlre�t.rma�Gllnutxn� ealwll�6e c0�WloKwo6xu�ep�7-�om�GM61wME �uofr/il ,
W�BI�tl/MI� � YNf WFp iJt 1Ki UIE W��O F�LT M/6@V 70 iWii01R ' � ��.
� II�OBM� RYN�lt A,
� � 0011lN !L�/
O Y�� A1110�1 '
Y� 1
J Opni'1 •��l`
O� AI��YC! AMA�1� y
C�■ �OIMIYGFOl1i1104UOfO�AlOOii'WIIOMOiM111i9mR1�11�N8011YYlOMLplYil�{) � MIMOb1Ow1Y/rilA00Mlli1
eoem a�*
�uw�u�:
�1 �1
saaw� N eer+oaws� ------•._..._....._._._.._..... ._...._......._..____.._...____._.----..._
03 On Jul�+ 25, 2012 at around 0900 houra, Unit 1 wa
� _ tiaveling in the�l.ePt�larie��iieat�oun�iitt6 SEieet �o
� � .E_apprcachinq_Rob.eri,.3traeL.....At.She.ir�tas,aecttA Ol
O1 � I � I Unit 1 encountered a pickup truck with a
°M"'0°' •nvr�hboead-tu��-�iqnal-wesEbaund—lOt3s Staeat-at— ��
rj' Rabert Street. The vehicle was stopped in the 04
rneor.a - —— � ,,,,�— — — rlt9'Y�af bmn�2ane�s�-�xr-wehiel�_lcaei..a..a2ffar.�.
98 1 op�sortunity to turn but_did not move. The �
� __ � __ _ ___ vehicle was ti�ocking both'ianes o�-£ravel:'"tYn3:£ "
— �a...a L.carefullg..x.ez�L.ar.RUAd..Y.h.0..b�nc.]c1n2.Jt9Ai,R�.�.oA.. .unei�
the left (south) side. Unit 1 crosaed into the O1
� � � oppasiLe.Lane•to get a�cound..b],ockiaq-.uahiale..- ���
.
'''"' the same time Unit 2 followed llnit 1. Light at
�I � `"A
� •�:
:-:� 'the�tnter'secti�n tarned�ys2lvw rthaa'red:'-•�Jnit..�.� 1
OS ,.�
� I „ was.,now partiallx,in.the left_lane_and partially u�xr
ww in the oncominq lane. In order to avoid blockin O1
Ol I I ..the zoad wag, .11nit_1 backed.nxay..from the_......._._.
:�:=
..�,
t�. I I _ ' •• intersection behind the blocking (continued ,
;..
..,,.- .._ . . • on-..atfiaehed-paqe)........................................_....._...----� Yr
ioow ..........................._�_"_---'.._.....'.-- -..�..........._..
arorr
.........._. �l
OZ
arrr�aw.ewuenoe�oac� �eoer eeinsw�w 0 seauwna ioea
Sergeant Craig Gromek 123 3t Paul PD p«... p�
Case#:12177064
Report Date:7/30/2072
Accident Narrative,contlnued:
vehide. Unit 1 collided with Unit 2. Unft 2 was also partially in oncoming traffic. No injuries. No Tows. Very minor damage/
No damage.
http://www.dvslesupport.org/dvsinfo/accidentrecords 2008/Includes LE/PrintReportIndiv... 8/16/2012
U ntitled
On 07/25/2012 around 9:00 am when I drove close to the road Robert Street from 10th Street
downtown St. Paul, the driver Rigoberto Bustamante Aguiree ahead of ine
pulled his vehicle to the left side of the lane since he was going to take a left turn on Robert
Street. I was driving right behind his vehicle since I was going
to take a left turn also. Then he realized the vehicle ahead of him stopped suddenly, he
immediately reversed his vehicle, but without looking back for anything
and bumped into the front of my vehicle. That is how he damaged my vehicle. This incidence
is completely his fault. He acknowledged his fault and apologized to me right after
the incidence.
Page 1
ABRA Auto Body &Glass - Woodbury Workfile ID: cc91�}e89
FederalID: 41192637_3
ABRA...AMERICA'S MOST RECOMMENDED!
8230 Hudson Rd Suite 100, Woodbury, MN 55125
Phone: (651) 738-2272
FAX: (651) 738-9795
Preliminary Estimate
Customer: CAI,7enny Job Number:
Insured: CAI,]enny Policy#: Claim #: .
Type of Loss: Date of Loss: 8/29/2012 I2:00:00 PM Days to Repair: 0
Point of Impact:
Owner: Inspection Location: Insurance Company:
CAI,Jenny ABRA Auto Body&Glass-Woodbury CUSTOMER PAY
11090 SWEETWATER PATH 8230 Hudson Rd Suite 100
WOODBURY,MN 55129 Woodbury,MN 55125
(651)201-7739 Business Repair Facility _
(651)738-2272 Day
VEHICLE
Year: 1998 Body Style: 4D VAN VIN: 2P4GP4534WR706368 Mileage In:
Make: PLYM Engine: 6-3.OL-FI License: Mileage Out:
Model: VOYAGER 4X2 SE Production Date: State: Vehicle Out:
Color: Int: Condition: Job#:
TRANSMISSION Body Side Moldings AM Radio Passenger Air Bag
Automatic Transmission Dual Mirrors FM Radio SEATS
Overdrive CONVENIENCE Stereo Cloth Seats
POWER Tilt Wheel Cassette 3rd Row Seat
Power Steering Cruise Control Search/Seek WHEELS
Power Brakes Intermittent Wipers SAFETY Full Wheel Covers
Power Mirrors Rear Window Wiper Anti-Lock Brakes(4) PAINT
DECOR RADIO Driver Air Bag Clear Coat Paint
8/30/2012 1:17:17 PM 057558 Paq� �
Preliminary Estimate
Customer: CAI,7enny 7ob Number:
Vehicle: 1998 PLYM VOYAGER 4X2 SE 4D VAN 6-3.OL-FI
Line Oper Description Part Number Qty Extended Labor Paint
Price$
1 FRONT BUMPER
2 Repl Bumper cover gray green 4883849AA 1 384.00 2.3 1.2
3 Add for Clear Coat 0.5
4 FRONT LAMPS _ _ _ __
5 Repl RT Headlamp assy w/o Quad 4857040AB 1 245.00 0.3
Lamps
6 # addtional damage upon tear 1
' down poss.
SUBTOTALS 629.00 2.6 1.7
ESTIMATE TOTALS
Category Basis Rate Cast$
Parts 629.00
Body Labor 2.6 hrs @ $53.00/hr 137.80
Paint Labor 1.7 hrs @ $53.00/hr 90.J.0
Paint Supplies 1J hrs @ $33.00/hr 56.J 0
Subtotal 913.00
Sales Tax $629.00 @ 7.1250% 44.87_
Grand Total 957.82
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 957.82
HEPPNER'S WOODBURY AUTO BODY Workfile ID: 7f963def
1807 WOODLANE DR, WOODBURY, MN 55125
Phone: (651) 735-5055
FAX: (651) 735-5057
Preliminary Estimate
Customer: CAI,7ENNY 7ob Number:
Written By:JON MARTENS
Insured: CAI,)ENNY Policy#: Claim#:
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact:
Owner: Inspection Location: Insurance Company:
CAI,]ENNY HEPPNER'S WOODBURY AUTO BODY OTHER PARTY
11090 SWEATWATER PATH 1807 WOODLANE DR
WOODBURY, MN 55129 WOODBURY,MN 55125
(651)233-6795 Evening Repair Facility
(651)735-5055 Day
VEHICLE
Year: 1998 Body Style: 4D VAN VIN: 2P4GP4534WR706368 Mileage In:
Make: PLYM Engine: 6-3.OL-FI License: 970JXL Mileage Out:
Model: VOYAGER 4X2 SE Production Date: State: MN Vehicle Out:
Color: GREEN Int: Condition: ]ob#:
TRANSMISSION Body Side Moldings AM Radio Passenger Air Bag
Automatic Transmission Dual Mirrors FM Radio SEATS
Overdrive CONVENIENCE Stereo Cloth Seats
POWER Tilt Wheel Cassette 3rd Row Seat
Power Steering Cruise Control Search/Seek WHEELS
Power Brakes Intermittent Wipers SAFETIf Full Wheel Covers
Power Mirrors Rear Window Wiper Anti-Lock Brakes(4) PAINT
DECOR RADIO Driver Air Bag Clear Coat Paint
8/31/2012 2:35:46 PM 018571 Page 1
Preliminary Estimate
Customer: CAI,7ENNY )ob Number:
Vehicle: 1998 PLYM VOYAGER 4X2 SE 4D VAN 6-3.OL-FI GREEN
Line Oper Description Part Number Qty Extended Labor Paint
Price#
1 FRONT BUMPER
2 Repl Bumper cover gray green 4883849AA 1 384.00 2.3 1.2
NOTE: PARTS: Order by description. LABOR:Time includes R&I/R&R grille.Time is after headlamps have been
removed. Refinish time is provided for those instances when required color is not available or for some repair
situations on the upper panel only.
3 Add for Clear Coat o•5
4 R&I License bracket 4676273 �•2
5 GRILLE
6 Repl Grille cool gray U694SS8AA 1 112.00 Incl.
NOTE: PARTS: Order by color and application. LABOR:Time is after bumper cover is removed.
_ __ _ __ _
7 FRONT LAMPS
g ** Repl A/M CAPA RT Headlamp assy w/o 4857040A6 1 186.00 0.3
Quad Lamps
g Aim headlamps 0.5
10 # Repl �Hazardous Waste Disposal Fee 1 5.00 X
11 # Repl �Flex Additive 1 3.00 X
SUBTOTALS 690.00 3.3 1.7
ESTIMATE TOTALS
Category Basis Rate Cost;
Parts 682.00
Body Labor 3.3 hrs @ $52.00/hr 171.60
Paint Labor 1.7 hrs @ $52.00/hr 88.40
Paint Supplies 1.7 hrs @ $32.00/hr 54.40
Body Supplies 2.6 hrs @ $2.00/hr 5.20
Miscellaneous 8.00
Subtotal 1,009.60
Sales Tax $682.00 @ 7.1250% 48.59
Grand Total 1,058.19
Dedudible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 1,058.19
THIS REPORT IS BASED ON OUR INSPECTION AND DOES NOT COVER ANY ADDITIONAL PARTS OR LABOR WHICH
MAY BE REQUIRED AFTER THE WORK IS OPENED UP. OCCASIONALLY AFfER THE WORK HAS STARTED,WORN OR
DAMAGED PARTS ARE DISCOVERED WHICH ARE NOT EVIDENT FIRST INSPECTION.
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.
8/31/2012 2:35:46 PM 018571 Page 2