Hawthorne '-�r;.,�e. . ��:+�
SEr' 2 � Z�12
NO'�ICE O�' CLAYM FOI21Vi to th� Cit�� of Saint Pa�������z�e�;ota
d�lirrrresotn Stnte Statute 466.0.5 sta�es thnt "...eveiyE�erson...��i�ho clainis damages fi-an nn��nuu�icrpalr���...shal!enuse lo be presentecl to the
go>>erning boc(v o/the nzunicipnlih�ri�ithrn I80 days nfier the alleged loss or ii�jur��rs cliscovered a��odice statirrg Nte tii�ae,place, nnd
circ�u�:stmrces�hereof, mzd the c�nzou�at o/'conlpei�sntia�a�oI{7er relief densandecL"
Please complete this form in its entirety by clearly ty�ing or printing yonr ans�ver to each question. [f more space is
needed,attacl� additional sheets. Please note that you rvill not be contacted by telephone to clarify answers,so provide as
much information as necess�iy to explain your claim, and the amowit of compensation being requested. You �vill receive a
written acl:nowledgement once J�ou►-form is received. The process can talce up to ten weel<s or longer clepending on the
nature of your claim. This form must be signecl, and both pages completed. If something does not apply,write `N/A'.
S�ND COMPL�T�D FORM AND OTH�R DOCUM�NTS TO: CITY CL�RK,
15 WEST K�LLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
Pirst Name r _ Middle Initial�Last Name �rn __
Comp�ny or Business Name � � �
Are You an [nsurance Company? Yes/No If Yes, Clai�n Number?
Street Adct. �s ��CJ ��K,��!'�� �/�%/��� / �,
City �[(i(�� State Zip Code
'r G�
(�� - ,.,�—��t,,'�
Daytime Phone (_) - Cell Phone �vening Telephone(_) -
Date of Accident/ Injury or D�te Discovered q�.z w ��' Time 1' �P an /pm
Plelse state, in detail, what occ��rred(happened), and why you are submitting a claim. Please indicate why or ho�v you
f el the City f Saint Paul or its emp(oyees are involved and/or re ponsible for y ur d �ages. (,�
_ � ,
o� .�'s, ' G
i
Please checl<the box(es)th�t 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 dama�ed by a plow I
❑ My vehicle was wrongfiil(y towed and/or ticketed ❑ I was injured on City property '
❑ Other type of property damage—please specify I
❑ Other t_ype of injury—ple�se specity
In order to process your claim you need to inchule conies of all �pnlicable documents !
I'or tlle claims types listed befow, please be sure to include the documents indicated or it will delay tlle handling of
your claim. Documents WILL NOT be returned and become the property of the City. You are encouraged to]:eep � �
copy for yourself before submitting your claim form.
i
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/oc receipts for the repairs
O Towing claims: legible copies oC any ticl:et issued and �copy of the impound lot receipt
O Other property damage elaims: two repair estimates if the dlmage exceeds $500.00; or the actual bills
and/or receipts for the repairs; detailed list of damaged items
O Injuiy claims: medical bills, receipts
O Photographs are always welcome to document and support your claim but will not be returned.
P�ge 1 of 2—Please complete and retnrn botl� pages of Claim �orm
Fail�u-e to complete and return both p�ges will i•esult in delay in tl�e handlinb ot'yoiu�claim.
All Claims—��lease complete this section
Were there witnesses to the incident? Yes N Unl:nown ( c�le�) Q
Provide th ir names, add►-esses � ul teleph n �mbers: � �y���Z'TCi` Cj,�' �,(-(�'�
I� ( C.l S� �� h� , C.�st- s�a- �4�
Were the police or law enforcement called? es No Unfcnown (circle)
If yes, what department or agency? � �� Case# or repoct# ia a�oa� 3
Where did tl�e accident or injtny tal:e place? Provide street address, cross stceet, intersect� n, name of parl:or fac ity
closest landmarlc, etc. Ple�s be as detail as possible. If necessar , attich a diagram. ��CC,({ �-t— I�, �
�LC�.�, l'�.r� ,S� �'Yl/�sS�lO�
Please indicate the amount you ace seel:ing in compensation or�vhat you would fil:e the City to do to resolve this claim
to your satisfaction.
Vehicle Cllims– le�se com lete tliis sec ion ❑ check Uox iPthis section does not a l
Your Vehicle: Ye�r�_M�I:e � Mode( G�,�Wv`
License Plate Numbec State Co r
Registered Owner CQ _ h/'�.f.��Q,Q. YYI-C
Dciver of Veliicle _ �j���n , ' '
Area Damaged
City Vehicle: Year Mal:e `� Model j
License Pl�te Number State Color �
Driver of Vehicle (City Cmployee's Name)
Area Damaged
Iniury Claims–nlease comnlete this section �1eck box if this section does not��t�lv
I-Iow were you in�ured?
What part(s)of your body were injured? i
I
Have you sought medical treatment? Yes No Planning to Seel:Treatment(circle) i
When did you receive treatment? (provide date(s))
Nai��e of Medical Provider(s):
Address Telephone �
Did you miss worl:as a result af your injury? Yes No
When did you miss worl:? (provide date(s))
Name of your Employer:
Address Telephone
L�E:hecic he►•e if yoi� �re attacliing more pages to this claim form. Number of�dditional pages�. I
/
By signing tlris form,��ou are st�din;tli�rt ril!information yoi� /tnne provirlerl is traie n�irl correct to tlre best
of yorrr hito�vledge. Unsigned forms rvi/1 not be p�•ocesserl.
Sr�bntitting a ft�lse claim ca�z resrilt in prosecutior�. Date form was completed � � ��� I�
Print the Name of the Person who Comple 1 this Form: �-�t,_ b'7����
Sibnature of Person Malcing the Claim:
Revised Pebru�ry 201 1
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Saint Paul Police Impound Lot, 830 Barge Channei Road, Vehicle Release Form
Make: 05 DODGE License #: 514JHU CN: 12210213 Invoice#: 139896
Date/Time Released: 09/04/2012 21:57 Tow Charge: $ 54.50
Released to: TOTO Storage Charge: $ 30.00
Paid by: CASH Admin Charge: $ 80.00
Released by: DORIS Tax: (7.625%) $ 10.26
i,the undersigned,have recovered the vehicle described above. Subtotal: $ 174.76
I will check the vehicle for damage or any other problems that
may have occurred while this vehicle was in the custody of the Service Charge: $ 0.00
Saint Paul Police Department. I acknowledge I will report
damage and/or any other problems to the Impound Lot staff Tota! Charges: $ 174.76
on this form prior to leaving the imp nd lot. �
� �
'�- �;��.�i� ; ,
Damage and/or other problem: ���_U��� � � � � ���,��.�' u. �
Police Report made: Yes_ No_ IF Yes, CN , If NO, Why?
��.
TO PROTEGT YOUR RIG. �ftEP ANY PROBLEMS/DAMAGE BEFORE LEAVING THE LOT
,
Signature � _ —"'�� 5i2000
a•
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� � � �
, �
ABRA Auto Body &Glass - Midway Workfile ID: ca253478
FederalID: 41-1852119
Right The First Time...On Time
1190 UNIVERSITY AVE W, SAINT PAUL, MN 55104
Phone: (651) 645-1563
FAX: (651) 641-6129
Preliminary Estimate
Customer: HAWTHORNE,TESA 7ob Number:
Written By:John Rucinski
Insured: HAWTHORNE,TESA Policy#: Claim#: 1
Type of Loss: Date of Loss: 9/3/2012 12:00:00 PM Days to Repair: 4
Point of Impact: 06 Rear
Owner: Inspection Location: Insurance Company:
HAWTHORNE,TESA ABRA Auto Body&Glass-Midway Unknown Insurance
2132 DNISON CRT 1190 UNNERSITY AVE W
W.BEAR LAKE,MN 55110 SAINT PAUL, MN 55104
(612)385-5008 Business Repair Facility
(651)645-1563 Business
VEHICLE
Year: 2005 Body Style: 4D WGN VIN: 2D8FV48V45H577623 Mileage In: 555555
Make: DODG Engine: 6-3.5L-FI License: NO PLATES Mileage Out:
Model: MAGNUM SXT Production Date: 9/2004 State: Vehicle Out:
Color: W PEARL Int: Condition: Job#:
TRANSMISSION Body Side Moldings Rear Window Wiper SEATS
Automatic Transmission Dual Mirrors RADIO Cloth Seats
Overdrive Privacy Glass AM Radio Bucket Seats
POWER Console/Storage FM Radio WHEELS
Power Steering CONVENIENCE Stereo Aluminum/Alloy Wheels
Power Brakes Air Conditioning Search/Seek PAINT
Power Windows Rear Defogger CD Player Ciear Coat Paint
Power Locks Tilt Wheel SAFETY OTHER '
Power Driver Seat Cruise Control Anti-Lock Brakes(4) Traction Control
Power Mirrors Telescopic Wheel Driver Air Bag Fog Lamps
Heated Mirrors Intermittent Wipers Passenger Air Bag Rear Spoiler
DECOR Keyless Entry 4 Wheel Disc Brakes
9/25/2012 12:59:12 PM 011906 Page 1
Preliminary Estimate
Customer: HAWTHORNE,TESA 7ob Number:
Vehicle: 2005 DODG MAGNUM SXT 4D WGN 6-3.5L-FI W PEARL
Line Oper Description Part Number Qty Eutended Labor Paint
Price$
1 LIFT GATE
2 * Repl LKQ lift gate+30% 5135234A6 1 650.00 1.0 3.2
3 Add for Clear Coat 1.3
4 R&I Handle vanilla UEI4XWGAF 0.4
5 Repl Medallion Ram head 4806013AA 1 44.75 0.2
6 Repl Nameplate"MAGNUM" 4806208AB 1 36.35 0.2
7 Repl Nameplate"SXT' 4806210AB 1 31.85 0.2
8 R&I Lower trim panel from 2-28-04 UM74BD5AI 0.4
medium gray
.. ... .__� . .�
9 REAR BODY&FLOOR _ _ __ .. .. _ ...
10 * Rpr Rearbody panel 5065745AF � 1.6
11 Overlap Major Non-Adj. Panel _p,Z
12 Add for Clear Coat 0.3
_. . . _ _
13 REAR LAMPS . _ . _. _._
14 Repl License lamp 4805846AB 1 17.60 Incl.
__ __ _
__ _ ___. .. __ _ _.._ __. .
15 REAR BUMPER
16 ** <> Repl RECOND Bumper cover w/o dual 4805776AC 1 247.00 1.6 2.8
exh
17 Overlap Major Non-Adj. Panel -0,2
18 Add for Clear Coat 0.5
19 Repl Energy absorber 4806257AA 1 199.00 Incl.
20 # Rpr �Body Pull 1.0
21_ MISCELLANEOUS OPERATIONS __ . . _ . . _.
22 # Refn �Car Cover 0.1 '
23 # Refn 'Corrosion Protection p.3
24 # �Hazardous Waste 1 5.00 X
SUBTOTALS 1,231.55 9.0 9.7 ,
NOTES
Prior Damage Notes:
1
9/25/2012 12:59:12 PM 011906 Page 2
Preliminary Estimate
Customer: HAWTHORNE,TESA )ob Number:
Vehicle: 2005 DODG MAGNUM SXT 4D WGN 6-3.5L-FI W PEARL
ESTIMATE TOTALS
Category Basis Rate Cost#
Pa� 1,226.55
Body Labor 9.0 hrs @ $54.00/hr 486.00
Paint Labor 9.7 hrs @ $54.00/hr 523.80
Paint Supplies 9.7 hrs @ $34.00/hr 329.80
Miscellaneous 5.00
Subtotal 2,571.15
Sales Tax $ 1,226.55 @ 7.6250% 93.52
Grand Total 2,664.67
Dedudible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 2,664.67
THIS IS A VISUAL INSPECTION ONLY. THERE MAY BE ADDITIONAL DAMAGE AFTER DISASSEMBLY. PARTS ARE
SUBJECT TO INVOICE. THERE ARE NO GUARANTEES ON RUST REPAIRS.
"Minnesota law gives you the right to choose any rental vehicle company, and prohibits me from requiring you to
choose a particular vendor."
;
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.
9/25/2012 12:59:12 PM 011906 Page 3
Preliminary Estimate
Customer: HAWTHORNE,TESA ]ob Number:
Vehicle: 2005 DODG MAGNUM SXT 4D WGN 6-3.5L-FI W PEARL
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted ali items are derived from the Guide
DR3PT05, CCC Data Date 9/17/2012, 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 pouble 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 De�ned Labor Categories.
OTHER SYMBOLS AND ABBREVIATIONS:
Adj.=Adjacent. Algn.=Align. ALU=Aluminum. A/M=Aftermarket part. BInd=6lend. BOR=Boron steel.
CAPA=Certified Automotive Parts Association. D&R=Disconnect and Reconnect. HSS=High Strength Steel.
HYD=Hydroformed Steet. Inc1.=Included. LKQ=Like Kind and Quality. LT=Left. MAG=Magnesium. Non-Adj.=Non
Adjacent. NSF=NSF International Certified Part. O/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=Bureau of Automotive Repair. EPA=Environmental Protection Agency. NHTSA= National Highway
Transportation and Safety Administration. PDR=Paintless Dent Repair. VIN=Vehicle Identification Number.
9/25/2012 12:59:12 PM 011906 Page 4
Preliminary Estimate
Customer: HAWTHORNE,TESA )ob Number:
Vehicle: 2005 DODG MAGNUM SXT 4D WGN 6-3.5L-FI W PEARL
ALTERNATE PARTS SUPPLIERS
Supplier: Keystone-Complete-Minneapolis
Location(s): 3615 MARSHALL STREEf NE, MINNEAPOLIS MN 55418 (800)328-1845 (612)789-1919
Line Description Item# Price
16 RECOND Bumper cover w/o dual exh CH1100312R $247.00
9/25/2012 12:59:12 PM 011906 Page 5
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