Lechner '� �'�.�'�`��.���,.
SEr� i � �
NOTICE OF CLAIM FORM to the City of Saint P�, Minnesota '
��-�-�� �.,,
ww ;� �,,; "'.�';f.�
Minnesota State Statute 466.05 states that"...every person...who claims damages from any munictp��y.3�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 e�cplain 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 dces 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 �—a��� Middle Initial M Last Name 1--Qc.���
Company or Business Name
Are You an Insurance Company? Yes/� If Yes,Claim Number? '
Street Address 3`� 0 S GS�i 0� �}v� - S� f�-D{'- � /��•1✓�e'a,�o �`s M iV $5�jt7� _ '
City /����✓�e�01�3 State M/'� Zip Code 5 5 �t° �
Daytime Phone(��Z )Z�s-a��Z Cell Phone(��Z ) 2�s R��2 Evening Telephone(_) -
Date of Accidenb Injury or Date Discovered ���2/� Z Time � am pm
Please state,in detail,what occurred(happened),and why you are submitting a claim.Please indicate why or how you i
feel the City of Saint Paul or its employees aze involved nd/or responsible for your damages. M h C� '�'"f
•�r �F � Ct�; ��,.� ,.� [,i ., I ��a�� .,� !�
;l ✓�f; (rr�e . - o�✓r✓i� e� rWkJ ✓e �[ e 2c .� � .� u+— '
' ;n �t,wt� � �� e �►� sr � A•riJ �e c
� 1 /t J' ,�i�� i! c a-,
� G �v► ! r
Please check the box(es)that most closely represent the reason for completing this form:
Cd�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 order to process your claim vou need to include copies of all applicable 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 yo�u'self before submitting your claim form.
Q�'�roperty 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 In'ury claims: medical bills,receipts
C�hotographs 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
a
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims-nlease comnlete this section
Were there witnesses to the incident? Ye' No Unknown (circle)
Pro���i�*H"�T 118TT1eS,addresses and telephone numbers:; _ �l�� S�e ��'{�c�„�,( ��t� �,�-
�^I l cati�c�F i�{�or.,-��.�;v� _ ;
� �
Were the police or law enforcement called? �Yg� No Unknown (circle) '
If yes,what de partment or a genc y? ��k� c F St- ��u�.� Case#or re port# �2 - �� � 'S$5
Where did the accident or injury take place? Provide street address,cross street,intersection,name of park or facility, II
closest landmark,etc. Please be as detailed as possible. If necessary,attach a diagram.� �•�I� �� �-g U
L1u.c.�e��� �. _5�-< �a�,�,\ M VV -a c,�vss Yk �'h�N �� C�t,� k� pc�r-1�
�
Please indicate the amount you are seeking in compensation or what you would like he City to do to resolve this claim
to your satisfaction. •�� �ts�h f �e C; „ "a �.r
o rv�a w, �/ %c C �tk r►�c. i � � ��`/
i5 ��'"�7 I'(Potl�li(.
Vehicle Claims-ulease comnlete this section ❑ check box if this section does not apply
Your Vehicle: Yeaz l�t�l�3' Make 'Ta cta Model �c.l o n
License Plate Number $z --C3�'�'� State Ni '�l Color G ��
Registered Owner l-�.+�r� (��l�.�z'-,�
Driver of Vehicle L�u.�v� Le�k�
Area Damaged � �,w� aMcl' c k�c� • /
City Vehicle: Year Ma e Model
License Plate Number I �-�' "' 3�r+Z State M Color �1�� ;
Driver of Vehicle(City Employee's Name) i�a�t e� �1'a�s�� I,
Area Damaged 1V ]/'}
Iniurv Claims-ulease comnlete this section Gd'check box if this section does not anvlv
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
�'C�eck here if you are attaching more pages to tlus claim form. Number of additional pages l .
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 �( `2
Print the Name of the Person who Completed his Form: ��'t" °C ��
Signature of Person Making the Cl ' G��-
Revised February 2011
Hailey Hanson�651) 592-4580 - DRIVER
12922 Keller Ave N
Hugo MN 55038
Jackie Dooley (612, 88�570
1148 Cumberland St
St Paul MN 55117
David Sparks �651) 468-4246
1525 Allen Ave
West St Paul MN 55118
► ' • �
—.,�, � • _'
.. f�;�:
6... �.�. . ��.
��+•�_ . . . � �, . .
� .y i . . v� ��
i �
� �%j '' � • - .,#
k.,,�. . _ � ��..
I
i ;,t
� i�-
�-
. '�'
. ��
x
�
!
,', 'f�fY, � ��` i ,. ,-.����'_ � � _
. • • ` •, . .
` � � ' ~ _
/ � Y ��:�i,;� �
� ' _ __� t - .,. ..... ,v..� :.-,•. �„ ' ` - -
— -.�_=�:,��s�,?,�►�,
/ � L -- �� ''►..+a
�r` � " - � *_ =�
_ `�
�' 't �1 �.
1
.�
�'
�- ''�.
t�
f�-
�
_�,�
�'� :� .
�.��=:
;;.:_
,�,,
MULROY'S BODY SHOP
3920 NICOLLET AVE SOUTH
MINNEAPOLIS, MN 55409-2032
PHONE: (612)823-7257 FAX: (612)823-1401
WWW.MULROYSBODYSHOP.COM EMAIL: MULROYS@PCLINK.COM
"'*PRELIMINARY ESTIMATE*"'
06/26/2012 04:02 PM
,�_�_ .__ ______� �.� _�_______....._____
— -___ _ _� ________
____ T�_�_..�
� Owner
�_�.____ _..____�_____�._..____ __�_ .________.� ______.� ___._ _�__. ___�_______.___�i
Owner: JAURA LECHNER
Address: 3405 ELLIOT AVE S APT1 Work/Day: (612)275-9112
City State Zip: Minneapolis, MN 55407 FAX:
r---�—_��T�..____�_ ___._.�_. _ __�___�
I Inspection m �� � �
�._..�.�w�_.._.�. �_..�.�.,�__��__.e.�____��_��_
__..�._v�.._�_ �_�� �.,
Inspection Date: 06/26/2012 04:02 PM Inspection Type:
,�_______��.__
; Repairer __�� .�_ .�..,�� ..._�_�_ �_ ___—____._�.�
.___ m__ �_.__.___ .__�_..__�_______W_ � � .____�_ __...____._��� _ _—__,____.��a
Repairer: Mulroy's Body Shop �Contact:
Address: 3920 Nicollet Ave Work/Day: (612)823-7257
FAX: (612)823-1401
City State Zip: Minneapolis, MN 55409 Work/Day:
Email: mulroys@pclink.com
,e.._ .��._.__._..._ ______.._. _� ��_._._ ._ � ___ �_._.__
Vehicle �
1998 Toyota Avalon XL 4 DR Sedan
6cyl Gasoline 3A
4 Speed Automatic
Lic.Plate: 823 BNV Lic State: MN
Lic Expire: VIN: 4T1BF18B8W2173301
Veh Insp#: Mileage Type: Actual
Condition: Code: Y1543A
Ext.Refinish: Two-Stage Int.Refinish: Two-Stage
Options
AM/FM Stereo Tape Air Conditioning Anti-lock Brakes '
Bucket Seats Center Console Cruise Control (
Dual Airbags Intermittent Wipers Lighted Entry System
Power Brakes Power poor Locks Power Mirrors
Power Steering Power Windows Rear Window Defroster
Rem Trunk-UGate Release Side Airbags Tachometer
Tilt Steering Wheel Tinted Glass VelouNCioth Seats �
,��_�.____ ___ ________ _ _______ ___._�____.__________ _��_._�---------- __e.__�_ ._.�_____�_��
'._Damages_ _ ___ _ _._._..__ �._ _.�._.____�.______ ______ __._ __ __�_ _ - -----:
Line Op Guide MC Description MFR.Part No. Price ADJ% B°/a Hours R
1 E 911 Cover,Rear Wheel LT 42621AC010 $97.12 SM
2 E 912 Cover,Rear Wheel RT 42621AC010 $97.12 SM
3 E 287 Door SheIl,Rear LT 6700407010 $717.79 4.5 SM
O6I26/2012 04:03 PM Page 1 of 3
1998 Toyota Avalon XL 4 DR Sedan
Claim#: O6/26Y2012 04:02 PM
4 L 287 13 Door SheIl,Rear LT Refinish 4.3 RF
2.1 Surface
1.0 Edge
0.6 Two-stage setup
0.6 Two-stage
5 E 323 01 MIdg,Rear poor Side LT 7574207011A0 $147.45 0.3 SM
6 RI 369 Back Giass R&I R&I Assembly 3.0 SM
7 SB 370 Sealant Kit,Back Glass Sublet Repair $20.00* SM
8 E 372 Mldg Assy,Back Glass 7557107010 $120.73 INC SM
9 E 471 Panel,Quarter LT 6160207902 $917.61 14.7 SM
10 L 471 Panel,Quarter LT Refinish 3.7 RF
2.1 Surface
1.0 Edge
0.6 Two-stage
11 SB 503 Sealant Kit,Qtr Glass LT Sublet Repair $10.00* SM
12 RI 479 Deck Lid R&I R&I Assembly 0.6 SM
13 RI 533 Taillamp Assembly LT R&I Assembly INC SM
14 SB M14 Corrosion Protection Sublet Repair $5.00" RF
15 SB M17 Cover Car Exterior Sublet Repair $5.00` RF
16 SB M60 Hazardous Waste Removal Sublet Repair $5.00' SM
16 Items
MC Message
01 CALL DEALER FOR EXACT PART#/PRICE
13 INCLUDES 0.6 HOURS FIRST PANEL TWO-STAGE ALLOWANCE
�._�_
� _______ __._� � ___ � __��_.� _____.________ ____ __.__ �____��
�Estimate Total&Entries J
Gross Parts $2,097.82
Paint Materials $256.00
Parts&Material Total $2,353.82
Tax On Parts Only @ 7.775% $163.11
Labor Rate Replace Repair Hrs Total Hrs
H rs
Sheet Metal(SM) $52.00 23.1 23.1 $1,201.20
Mech/Elec(ME) $85.00
Frame(FR) $75.00
Refinish(RF) $52.00 8.0 8.0 $416.00
Paint Materials $32.00
Labor Total 31.1 Hours $1,617.20
Sublet Repairs $45.00
Gross Total E4,179.13
Net Total 34,179.13
Alternate Parts Y/00/00/00/00/00 CUM 00/00/00/00/00 Zip Code:55409 Default
Audatex Estimating 6.0.726 ES 06/26/2012 04:03 PM REL 6.0.726 DT 05/01/2012 DB 06/15/2012
Copyright(C)2011 Audatex North America, Inc.
1.8 HRS WERE ADDED TO THIS ESTIMATE BASED ON AUDATEX'S TWO-STAGE REFINISH FORMULA.
06Y26/2012 04:03 PM Page 2 of 3
1998 Toyota Avalon XL 4 DR Sedan
Claim#: O6/26/2012 04:02 PM
THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF ONE OR MORE CRASH PARTS
SUPPLIED BY A SOURCE OTHER THAN THE MANUFACTURER OF YOUR MOTOR VEHICLE.
WARRANTIES APPLICABLE TO THESE REPLACEMENT PARTS ARE PROVIDED BY THE PARTS
MANUFACTURER OR DISTRIBUTOR RATHER THAN BY THE MANUFACTURER OF YOUR VEHICLE.
A PERSON WHO FILES A CLAIM WITH INTENT TO DEFRAUD OR HELPS COMMIT A FRAUD
AGAINST AN INSURER IS GUILTY OF A CRIME.
Op Codes
' = User-Entered Value E = Replace OEM NG= Replace NAGS
EC= Replace Economy OE= Replace PXN OE Srpls UE= Replace OE Surplus
ET= Partial Replace Labor EP= Replace PXN EU= Replace Recycled
TE = Partial Replace Price PM= Replace PXN Reman/Rebit UM= Replace Reman/Rebuilt
L = Refinish PC= Replace PXN Reconditioned UC= Replace Reconditioned
TT = Two-Tone SB= Sublet Repair N = Additional Labor
BR= Blend Refinish I = Repair IT = Partial Repair
CG= Chipguard RI = R&I Assembly P = Check
AA= Appearance Allowance RP= Related Prior Damage
This report contains proprietary information of Audatex and may not be disclosed to any third party(other than
the insured,claimant and others on a need to know basis in order to effectuate the claims process)without
���a��aX Audatex's prior written consent.
.r Sc,��rs;c�,•t�rnrr�.
- Copyright(C)2011 Audatex North America,Inc.
Audatex Estimating is a trademark of Audatex North America, Inc.
O6/26f2012 04:03 PM Page 3 of 3
HEPPNERS AUTO BODY SAINT PAUL WoHcfile ID: 93035848
400 SYNDICATE ST. N., SAINT PAUL, MN 55104
Phone: (651) 646-8615
FAX: (651) 645-3230
Preliminary Estimate
Customer: LECHNER, LAURA
Written By: Marwan Kawas
Insured: LECHNER,LAURA Policy#: Claim#:
Type of Loss: Date of loss: Days to Repair: 0
Point of Impact:
Owner: Inspection Location: Insurance Company:
LECHNER,LAURA HEPPNERS AUTO BODY SAINT PAUL CUSTOMER PAY
3405 ELLIOT AVE S#1 400 SYNDICATE ST.N.
MPLS,MN 55407 SAINT PAUL,MN 55104
(612)275-9112 Evening Repair Facility
(651)646-8615 Day
VEHICLE
Year: 1998 Body Style: 4D SED VIN: 4T16F1868WU217330 Mileage In:
Make: TOYO Engine: 6-3.OL-FI License: Mileage Out:
Model: AVALON XL Production Date: State: Vehide Out:
Color: Int: Condition: Job#:
Air Conditioning C�oth Seats Intermittent Wipers Power Windows
AM Radio Console/Storage Overdrive Rear Defogger
Anti-Lock&akes(4) Cruise Control Passenger Air Bag Recline/Lounge Seats
Automatic Transmission Driver Air Bag Power&akes Search/Seek
Body Side Moldings Dual Mirrors Power Locks Stereo
Bucket Seats FM Radio Power Mirrors Tilt Wheel
Cassette Front Side Impact Air Bags Power Steering
Clear Coat Paint Full Wheel Covers Power Trunk/Tailgate
6/18/2012 11:37:51 AM 050503 Page 1
PDF created with pdfFactory trial version www.pdffactorv.com
Preliminary Estimate
Customer: LECHNER, LAURA
Vehide: 1998 TOYO AVALON XL 4D SED 6-3.OL-FI
Line Operetion Description Qty Extended Labor Paint
Price;
1 REAR DOOR
2 * Rpr LT Outer panel �,.Q 2,3
3 Add for Clear Coat 0,9
4 R&I LT Beit w'strip 0.3
5 * R&I LT Body side mldg beige from 3/98 Q,,�
6 * R&I LT Handle,inside sandalwood Q,�
7 R&I LT R&I trim panel 0.4
8 QUARTER PANEL
N 9 * Rpr LT Quarter panel � 2,p
10 Overlap Major Adj.Panel -0.4
11 Add for Clear Coat 0.3
12 R&I Fuel door 0.3
13 REAR LAMPS
14 R&I LT Combo lamp assy 0.3
15 REAR BUMPER
N 16 R&I R&I bumper cover 1.0
17 # Rpr BODY PULL 2.0
18 # Refn BAG/CAR COVER 0.2
19 # Subl HAZARDOUS WASTE REMOVAL 1 5,00 X
20 # Refn TINT COLOR 0.5
SUBTOTALS 5.00 11.9 5.8
NOTES I
,
Line 9: THLS REPAIR DOES NOT INCLUDE THE RUST REPAIR ON THE QUARTER PANEL. i
Line 16: DROP LT SIDE
�
�
6/18/2012 11:37:51 AM 050503 Page 2
PDF created with pdfFactory trial version www.pdffactorv.com
Preliminary Esdmate
Customer: LECHNER, LAURA
Vehide: 1998 TOYO AVALON XL 4D SED 6-3.OL-FI
ESTIMATE TOTALS
Category Basis Rate Cost$
parts 0.00
Body Labor 11.9 hrs @ $52.00/hr 618.80
Paint Labor 5.8 hrs @ $52.00/hr 301.60
Paint Supplies 5.8 hrs @ $32.00/hr 185.60
Body Supplies 9.0 hrs @ $2.00/hr 18.00
Miscellaneous 5.00
Subtotal 1,129.00
Grand Total 1,129.00
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 1,129.00
THIS IS A VISUAL ESTIMATE ONLY. ADDITIONAL PARTS AND LABOR MAY BE EXTRA UPON TEARDOWN. PART PRICES
SUBJECT TO INVOICE.
NO GUARANTEE ON RUST REPAIR!
MN 5T 60A.955 -A PERSON WHO FILES A CLAIM WITH INTENT TO DEFRAUD OR HELPS COMMIT A FRAUD AGAIN5T
AN INSURER IS GUILTY OF A CRIME.
6/18/2012 11:37:51 AM 050503 Page 3
PDF created with pdfFactory trial version www.pdffactorv.com
Preliminary Estimate
Customer: LECHNER, LAURA
Vehide: 1998 TOYO AVALON XL 4D SED 6-3.OL-FI
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
AEM8410, CCC Data Date 6/15/2012, 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 (�) 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=Miscetlaneous 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
E5TIMATING GUIDE:
BAR=Bureau of Automotive Repair. EPA=Environmental Protection Agency. NHTSA= National Highway Transportation
and Safety Administration. PDR=Paintless Dent Repair. VIN=Vehicle Identification Number.
6/18/2012 11:37:51 AM 050503 �9e 4
PDF created with pdfFactory trial version www.qdffactorv.com