Montana NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minnesota State Szatute 44b.Q5 states that",.,every p�rsan..,who claims damages jrom any muhicipaliry.,.shall cause to be presented to the
governing body of the municipality within 180 days after the alleged toss or injury is discovered a notice stating the time,place,and
circumstances thereof,and the amount of cornpensation 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 reque§ted. You will receive a
written acirnowledgement 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 DOCUMENT� TO: CITY CLERK,
15 WEST KELLOGG BLVD,310 CITY HALL, SAINT PAUL, MN 55102
First Name Christopher Middle Initial�j_Last Name Montana
Company or Business Name
Are You an Insurance Company? Yes!No If Yes,Claim Number? /��Gt.
Street Address 755 Davton Ave
City St. Paul State MN Zip Code 55104
Daytime Phone(�)�-2484 Cell Phone( saf1�16 - Evening Telephone(_) -
Date of Accidenb Injury or Date Discovered AUgust 27 Time �=30 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.
m right
• U-turn
0 0 ow ano er car. e o icer nving e squa car s a e a e rove ng m o . ere is no
reasonable a�estion of fa�lt. The front nanei �f the �ar is�ipntP�i an�i thp ririvPr���+o.+�..�r��o� ��+open
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Please check the box(es)that most closely represent the reason for completing this form:
6KMy 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 pmperty
❑Other type of property damage—please specify
❑Other type of injury—please specify
In order to process your claim vou need to include conies of all auulicable documents. ,�
For the claims types listed below,please be sure to include the documents indicated or it will delay the handling of I
your claim. Documents WII.L NOT be returned and become the property of the City. You ar�encourag�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-nlease comnlete this section
Were there witnesses to the incident? � No Unlmown (circle)
Provide their names,addresses and telephone numbers:
�A^ L•� n r OM j h.'16 l�,c_.
Were the police or law enforcement called? ei� No Unlmown (circle)
If yes,what department or agency? s7F'• pce� Pe��i� Case#or report# /�-��-,?B 1
Where did the accident or injury take place? Provide street address,cross street,intersection,name of pazk or facility,
closest landmazk,etc. Please be as detailed as possible. If necessary,attach a diagram.
_Dh Mih�tch��,��,oss -�,57`�-�crt �1 �G��,'.1..� �finc
Please indicate the amo nt ou are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction. � /��?� .I S�
Vehicle Claims- lease com lete this section ❑check box if this section dces not a 1
Your Vehicle: Year Make lW�i�'-c:rr' Model
License Plate Number 335-A-V� State�C r �"co
Registered Owner C f^ 1�e 0
Driver of Vehicle �n� � 7i� ti. a.0
Area Damaged wrt- c�L.v o�
City Vehicle: Year ake Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
In�iurv Claims-please com�lete this section .�check box if this section does not applv
How were you injuretl? h 0
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
f�Check here if you are attaching more pages to this claim form. Number of additional pages�. i
�,
By signing this form,you are stating that all infor►nation 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 ���3�Z '�,
/ i
Print the Name of the Person who Complet 's Fo ��"i r'S� �.,ri �'t�r�Q�c � ;
Signature of Person Making the Claim: �
�
Revised February 2011 '
LATUFF BROS., INC.
880 UNIVERSITY AVENUE
ST. PAUL, MINNESOTA 55104
(651)224-2828 FAX:(651)291-0677
FEDERAL ID#41-0777034
''**PRELIMINARY ESTIMATE***
09/05/2012 05:05 PM
. _. _. _ ..._.�.__ .,,.__.__...�
_....__. ... . _�. _.�.._,.,. .... ...__..,, _
Owner _ _
Owner: CHRIS MONTANA
Address: 755 DAYTON AVE Cell: (612)251-2484
City State Zip: Saint Paul, MN 55104 FAX:
____... __,.... . ._ _.. . .... _
' Inspection � �
Inspection Date: 09/05/2012 05:G4 PM Ir,specz;^n Type: Drive 1n
Inspection Location: Latuff Brothers Inc Contact:
Address: 880 University Ave Work/Day: (651)224-2828x
FAX: (651)291-0677x
City State Zip: Saint Paul, MN 55104 Work/Day:
Email: general@latuffbrothers.com
Primary Impact: Left Front Side Secondary Impact:
Driveable: Yes Rental Assisted:
Appraiser Name: ROBERT LATUFF Appraiser License#:
Repairer
_ _ _ _ _ _
Repairer: Latuff Brothers Inc Contact:
Address: 880UniversityAve Work/Day: (651)224-2828
FAX: (651)291-0677
City State Zip: Saint Paul, MN 55104 WorklDay:
Email: general@latuffbrothers.com i
I
Target Complete Date/Time: Days To Repair: 4
_ �. _
Remarks
"'"�****"PRELIMINARY ESTIMATE"""""""*'*"*"""
POSSIBLE ADDITIONAL DAMAGE MAY BE FOUND AFTER TEAR DOWN
_ ._._ _ . _ ._ .._.._. .., .,,
` Vehicle �
2002 Chevrolet Cavalier LS Sport 2 DR Coupe
4cyl Gasoline 2.2
4 Speed Automatic
Lic.Piate: 335AVZ Lic State: MN
Lic Expire: VIN: 1G1JH12F127273620
Veh Insp#: Mileage Type: Actual
Condition: Code: U2342C
� Ext. Color: RED Int.Color:
Ext. Refinish: Two-Stage Int. Refinish: Two-Stage
Options
Air CondiUonfng Alarm System Anti-Lock Brakes
Pago
09/052012 O5:t 0 PAA
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2002 Chevrolet Cavalier LS Sport 2 DR Coupe
Claim#: 09/OSI2012 05:05 PM
Center Console Chromed Alloy Wheels Compact Disc W/Tape
Cruise Control Dual Airbags Fog Lights
Intermittent Wipers Keyless Entry System Lighted Entry System
Power Brakes Power poor Locks Power Mirrors
Power Steering Power Windows Rear Spoiler
Rear Window Defroster Rem Trunk-UGate Release Sport Suspension
Tachometer Tilt Steering Wheel Tinted Glass
Velour/Cloth Seats
: _ _ ,_..,, �._.
...m ..... ,._ ___ �_______._ _.�.
Damages _. .
Line Op Guide MC Description MFR.Part No. �rice ADJ% B°/, Hours R
Striqes And Mouldinas
1 RI 268 MIdg,Front Door Side LT R&I Assembly 0.3 SM
Front Bumner
2 RI 100 Bumper Assembly,Front R&I Assembly 0.8 SM
3 I 100 Cover,Front Bumper Repair 1.0` SM
4 L 100 13 Cover,Front Bumper Refinish 3.7 RF
2.6 Surface
0.6 Two-stage setup
0.5 Two-stage
5 RI 9 Frame,License Plate R&I Assembly 0.2 SM
Front Bodv And Windshield
6 E 103 Fender,Front LT 88955574 GM Part $242.24 2.2 SM
7 L 103 Fender,Front LT Refinish 3.4 RF
2.3 Surface
0.5 Edge
0.6 Two-stage
Front Bodv Interior Sheetmetal
8 E 111 Shield,Front Splash LT 22605365 GM Part $49.71 INC SM
Front Doors
9 BR 209 Pnl,Front Door Outer LT Blend Refinish 1.1 RF
0.7 Blend
0.4 Two-stage
10 RI 259 W/Strip,Belt Outer LT R&I Assembly INC SM
11 RI 229 Mirror,Sport R/C LT R& I Assembly INC SM
12 RI 138 Channel,Front Glass Ru LT R&I Assembly 1.9 SM
13 RI 223 Cyl,Front Door Lock LT R&I Assembly 0.1 SM
14 RI 227 Handle,Front Door Otr LT R&I Assembly 0.4 SM
Manual Entries
15 SB M60 Hazardous Waste Removal Sublet Repair $5.00* SM
16 I CLEAN AND REBACK SD MLDG Sublet Repair $3.00' 0.3* SM'
17 SB THRUST ANG�E ALIGNMENT Sublet Repair $69.95" SM*
18 I BUFF LT FRT WHEEL Repair 0.5' SM'
18 Items
MC Message
13 INCLUDES 0.6 HOURS FIRST PANEL TWO-STAGE ALLOWANCE
I
_ _e _�_ _,.a ,_��_. _�. . .�_ _�._.e. �__ � ,�.._.,� � �,..� �. � ..... ___ ��
_._N� _ � .P __ ,... _ �. _
Estimate Total&Entries ` �
Gross Parts $291.95
Paint MatPrialc 7d�nn
09/05/2012 05:10 PM
Page 2 of 3
�
2002 Chevrolet Cavalier LS Sport 2 DR Coupe
Ciaim#: 09/OS/2012 05:05 PM
Parts&Material Total $537.95
Tax On Parts Only @ 7.625% $22.26
Labor Rate Replace Repair Hrs Total Hrs
H rs
Sheet Metal(SM) $50.00 5.9 1.8 7.7 $385.00
Mech/Elec(ME) $75.00
Frame(FR) $70.00
Refinish(RF) $50.00 8.2 8.2 $410.00
Paint Materials $30.00
Labor Total 15.9 Hours $795.00
Sublet Repairs �77•°�
Gross Total $1,433.16
Net Totai $1,433.16
Alternate Parts No
SPPL Yes Zip Code:55104 Default
Audatex Estimating 6.0.726 ES 09/05/2012 05:10 PM REL 6.0.726 DT 08/01/2012 DB 09/01/2012
Copyright(C)2011 Audatex North America,Inc.
2.1 HRS WERE ADDED TO THIS ESTIMATE BASED ON AUDATEX'S TWO-STAGE REFINISH FORMULA.
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/Reblt UM= F2eplace Reman/Rebuilt
L = Refinish PC= Replace PXN Reconditioned UC= Replace Reconditioned
TT = Two-Tone SB= Sublet Repair N = Additional Labor
BR= Blend Refinish ! = Repair !T = �a�tia! 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
������� Audatex's prior written consent.
a S�+J�ra a wr��r�trr�
- - Copyright(C)2011 Audatex North America, Inc.
Audatex Estimating is a trademark of Audatex North America, Inc.
09/OS/2012 05:�0 PM Page 3 of 3