Pierre ��'.`��';,E��oF#=�..�
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NOTI�E OF CLAIM FORM to the City �"�������u1, 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 demar2ded."
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 EST KELLOGG BLVD, 310 CITY HALL, INT PAUL, MN 55102
i
First Name �L Middle Initial Last Name � ����
Company or Business Name
Are You an Insurance Company?Yes/� If Yes,Claim Number?
�, ' � /�/
Street Address�� !1V ��'�rl i<�� _ , �� �vl�
�/ ' / � ' `,��/�
City�Y �,��L� State�^�l �/ Zip Code
Daytime Phone(�)����Cell Phone( ) - Evening Telephone ( ) -
Date of Accidentl Injury or Date Discovered �/�/�� Time , � am/�m
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/ r responsible for your damages.
Cz u1 � �- 7� ' ic� �tc:�' u� �
�• ' ' D � rL
P—lej�se check the box(es)that most closely represent the reason for completing this form:
L�l 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 you need to include copies of all apqlicable 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.
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
R2853-2
5
� A I I state:
�ai�ure�°o°comp-I�ete and return both pages will result in delay in the handling of your claim.
All Claims-please complete this section
Were there witnesses to the incident? Yes No nkno (circle)
Provide their names, addresses and telephone numbers:
-�
Were the police or law enforcement called? � �� No Unknown (circle)
If yes, what department or agency?� � Case#or report# f��- / �y7�t
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 nec�ssary, attach a diagram.
�_ cv�r�c c.i�� �`//C� �C%e�t.�1�^
Please indicate the amount you are seeking 'n compensation or what you would like the City to do to resolve this claim
to your satisfaction. �7��•�.�
Vehicle Claims- lease com lete this section ❑ check box if this section does not a 1
Your Vehicle: Year Make ' Model �/�Yl/L
License Plate Number � `J State�Color ��.
Registered Owner ' �� t✓��.
Driver of Vehicle-.
Area Dam`� ed I V`Q✓ ^
City Vehicle: Year %� Make Model
License Plate Number � State.�(4 Color
Driver of Vehicle(City Employee's Name) �JCt%YLQ(� 1 ��;��/���1
Area Damaged i.l�Y�11UWV�
Iniutv Claims-nlease comulete this section �eck 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) 'I
When did you receive treatment? (provide date(s)) ,
Name of Medical Provider(s):
Address Telephone I
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 I
,�heck 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.
Submitting a false claim can result in prosecution. Date form was completed ��/���`
Print the Name of the Person who Co let d this For . ���� �-t� ����'���--
Signature of Person Making the Claim:
Revised February 2011
R2853 2
, Page 1 of 1
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SEP-29-2012 05:20 From:HePpners Woodlane 6517355057 To:7302018 Paee:2�3
HEPPNEiL'S WQpDBURY A11T0 BODY ���I�� as5d4�o
18p7 WOODLANE DR,WOODBURY, MN 55125
Phone; (b51)735-5055
FAX; (651) 735-5057
Preliminary Estimate
Custiomer: pIERRE,PAT IA 7ob Number:
Writ�m e�r: RON IQNDE
Insured: PIERRE',PA7RI Poticy#�; ��m�:
Type of Loss: Colliston Detr2 of Loss' 9/il/2012 12:9Q:00 AM Oays to Repair. 0
fbint of Impact:
Owner: Inspection Location: insurance Comparry:
PIERRE,PATRICIA HEPPIdER'S WOODBURY AUTO BODY ALlSTATE A$SURANCE QOMPANY
183 N MCKNIGHT ROqD 1807 WOOOI,qNE DR
5T PAUI,MN 551�,9 WOOQBURY,MN 55125
(651j 731-9639 Day Repair F�ility
(651)735-5055 Day
YEHICLE
Year: 1996 8ody Style� 2D CPE VIN: 4TiCG12K5fU747423 Mileage 3n�
Make: TOYO Engine' 4-2.2L-FI Litense: 31576R Mileage Out:
Model: CqMRY LE ProOuttion Date: State: MN VehiCle Out:
CdOr; GREEN Int: Conditlon: 7ob#�;
TRANSML�iSYON Power Mirrors InCermittent WiperS SEATS
AutomatiC Trdnsmission DECOR RADlO Ctoth Seats
Overd►ive Tinted Glass AM Radio Bucket Seats
OOWER Dual MirrorS FM Radio Recline/LOunge Seats
Power Sbeering CONVENLENCE Stereo WMEELS
Power Brakes Air C�nditioning Cassette F�I Wheel Covers
Power Windows Rear Defpgger SAFE7II PAiNT
Pow�LoCks Tilt Wheel Driver Air Bag Clear Coat Paint
POw2r Mtenna Cnmse Contrd Passenger Air Bag
9/28/2012 4:15:52 DM 018571 Page 1
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SEP-29-2012 05:20 From:HePPners Woodlane 6517355057 To:73e2018 Paae:3�3
,. �
Preliminary Estimate
Cusl+omer:PIERRE,PA CIA �ob Number.
Vehicle: 1996 TOYO CAMRY LE 2D CPE 4-2.2L-Fl GREEN
u^� ��� ���+ Part Number Qty Extended I.abor Paint
PriCe;
1 FRON7 sUMPER
2 • Rpr Bu perCOVer 52119AA900
a.Q 2.S
3 Ad for Clear Coat �.0
4 R&I Lic nse bracket 5271133020 0.3
5 # Refi Pa 'a1 paint
_,._.,.......-.�. -0.2
�...�.,.,_ -_...,.._��_._......_.�_._...._......,._....__...,,.....,.._...�.__..w....,...----._.�.._.....---•-..,,.�...,......---,-�-• �--
6 FRONT U1MPS
� �/ bump�assy 2•8
� a _ " ` __ V�Repl A/ CAPA lT P�k lamp US built 8162006020 1 39.00 tncl.
. _.. _ . . ._..----•�-_�_._...---� ••----�----•-•-----•--._.....------...---••-••--•- ••---....------� --•�-- •---• •_--.•-----�
9 FENDER
10 = Rpr LT nder 5380206011
b.Sl 2.3
11 * Ad for Clear Coat �
�2 R$I LT ender liner 53$7633W0 Incl.
13 # Refn Pa 'al pai� -0 Z
14 R&I LT ud guaM 7662239225 03
15 # 'S 'pe-Tape-per panel 1 12.00 X 0.3
I6 # Repl 'C rrusian Protection
1 0.3
17 # Reh► ' r Vehicle 0.2
16 9t Repl 'H ardous Waste Disposal Fee 1 5.00 X
SUBTOTALS 56.00 8.7 6.3
ESTIMATE TOTALS
���Y dasi5 RaEe [ost s
P�ts 39.00
�y�� 6.7 hrs @ ;50.00/hr 335_00
P�iM Labo► 5.3 hr5 � �50.00/hr 315.00
Paint Supplies 6.3 hrs �1 $30.00/hr 189.00
M;scellaneous 17.00
Subtotal 895.00
S�es Tax ;39.OU � 7.1�50% 2.78
Gnnd Toql 897.78
Deductible 0.00
CUSTOMER PAY 0.00
iNSURANCE PAY 897.78
THIS REPORT IS BASED ON UR INSP�tTION AND DOES NOT COVER ANY ADDITIONAI, PARTS OR IABOR WHICH
MAY BE REQUIRED AFTER TH WORK IS OPENED UP. OCCASIONALLy AFTER THE WORK MAS STARTEp,WORN OR
DAMAGEb PARTS ARE DISCO ERED WHICH ARE NOT EVIDENT FIRST INSPECTION.
MN ST 60A.955 - A PERSON HO FILES A CIAIM Vi/trFi INTENT TO DEFRAUD OR HELPS COMMIf A FRAUD
AGAINST A�t INSURER IS GUI OF A CRtME,
9/28/2012 4:15:52 PM 0185�1 Page 2
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ABRA Auto Body &Glass - Woodbury Workfile ID: fbe5c069
FederallD: 411926323
ABRA...AMERICA'S MOST RECOMMENDED!
8230 Hudson Rd Suite 100, Woodbury, MN 55125
Phone: (651) 738-2272
FAX: (651) 738-9795
Preliminary Estimate
Customer: PIERRE, PATRICIA 7ob Number:
Written By: Rich Rick
Insured: PIERRE,PATRICIA Policy#: Qaim#: .
Type of Loss: Date of l.oss: 9J17/2012 12:00:00 PM Days to Repair: 0
Point of Impact:
Owner: Inspection Locafion: Insurance Company:
PIERRE,PATRIQA ABRA Aubo Body&Glass-Woodbury ALLSTATE INSURANCE COMPANY
183 N MCKNIGHT ROAD 8230 Hudson Rd Suite 100
ST. PAUL,MN 55119 Woodbury,MN 55125
(651)731-9639 Busin�s Repair Faatity �°
(651)738-2272 Day
VEHICLE
Year: 1996 Body Style: 2D CPE VIN: 4TiCG12K5TU747423 Mileage In:
Make: TOYO Engine: 42.2L-FI Licer�se: 315-JBR Mileage Out:
Model: CAMRY LE Production Date: Sbbe: MN Vehide Qut:
Color: green.Int: Condition: Job#:
TRANSMISSION Power Mirrors Intermittent Wipers SEATS
Automatic Transmission DECOR RADIO Clotli Seats
Overdrive Tinted Glass AM Radio ����
POWER Dual Mirrors FM Radio Redine/Lounge Seats
Power Steering CONVENIENCE Stereo WHEELS
Power Brakes Air Conditioning Cassette Full Wheel Covers
Power Windows Rear Defogger SI►FETY PAINT
Power Laks Titt Wheel Driver Air Bag Clear Coat Paint
Power Mtenna Cruise Control Passenger Air Bag
9/17/2012 1:00:29 PM 057558 Page 1
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Preliminary Estimate
Customer: PIERRE, PATRICIA 7ob Number:
Vehide: 1996 TOYO CAMRY LE 2D CPE 42.2L-FI green
Line Oper Description Part Number Qty Fxtended Labor Paint
Prtce�
1 FRONT BUMPER
2 ' R&I License bradcet 03
3 * <> Rpr Bumper cover 3_Q Z•5
4 Add for Clear Coat 1�Q
5 # Refn 'Deduct-Partial Paint;Full Gear -0.9
_ _ __ _ _ _ _
6 FRONT U4MPS
� , . ! ... . . .__ p/H bumper assy 2.8. � :�::_;sr: ,,::
8 ** Repl A/M CAPA LT Park lamp US buiit 8162006020 1 39.00 Inci.
_ __ _ .
9 FENDER
10 * Rpr LT Fender 1s4 2•3
il Ove�lap Major Non-Adj.Panei -�•z
12 Add for Clear Coat p�4
13 # � Refn 'Deduct-Paraal Paint; Full Clear -0.6
14 R&I LT Fender liner Ind.
15 R&I LT Mud guard 0.3
16 # Refn �Corrosion Protection 03
17 # Repl 'Tape Stripe 1 12.00 X 0.3
5UBTOTALS 51.00 6J 4.8
ESTIMATE TOTALS
� - Category Basis Rate Cost$
Parts 39.00
Bpdy Labor 6.7 hrs @ $50.00/hr 335.OQ
Paint Labor 4.8 hrs @ $50.00/hr 240.00
Paint Supplies 4.8 hrs @ $30.00/hr 144.00
Miscellaneous 12.00
Subtotal 770.00
Sales Tax $39.00 @ 7.1250% 2.78
Grand Total ��Z•78
• Deducable 0:00
CUSTOMER PAY 0.00
INSURANCE PAY 772.78
WARRANTY VALID ONLY WITH ORIGINAL COPY OF YOUR RECEIPT.
PARTS PRICES ARE SUBJECT TO INVOICE. NO GUARANTEE ON RUST REPAIRS. DELAYS DUE TO PARTS
AVAILABILITY AND INSURANCE COMPANY RQNSPECTS CAN AND DO OCCUR, PLEASE UNDERSi"AND THAT WE
HAVE LITTLE CONTROL OVER SUCH SITUATIONS, BUT, WE WILL MAKE EVERY EFFORT TO REPAIR YOUR CAR AS
QUICKLY AS POSSIBLE. REPAIR TIMES ARE BASED ON FLAT RATE GUIDELINES AND MAY OR MAY NOT COINCIDE
WITH ACTUAL REPAIR TIME.
*****PAYMENT IS REQUIRED IN FULL FOR VEHICLE TO BE RELEASED!******
,
*****UNLESS OTHER PRIOR ARANGEMENTS ARE MADE***** , :
9/17/2012 1:00:29 PM 057558 Page 2
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Preliminary Estimate
Customer: PIERRE;-PATRICIA �ob Number:
Vehide: 1996 TOYO CAMRY LE 2D CPE 42.2L-FI gre.en
ALTERNATE PARTS SUPPLIERS
Suppiier. Wheelers Auto Body Suppiy
Location(s): 6150 Q.AUDE WAY,INVER GROVE HQGHT'S MN 55076 (866)435-7015 (651)379-0808
Line Desaipdon Item# Price
' 8 ' � A/M CAPA LT Park(amp US built T02520139C $39.00
�
9/17/2012 1:00:29 PM 057558 Page 4
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