Garcia (2) �
, i
. ;
;
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 municipality...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 tttis form in its entirety by ciearly 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 euplain 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 ���A-�� Middle Initial Last Name �A���.F� •••-••l
titt�t�vE�
Company or Business Name 20�
Are You an Insurance Company? Yes/N�o If Yes,Claim Number?
Street Address ��%� �.N 1��-LC S A � E ���{���
City �R� 1�1T �A��L- State M I� Zip Code � �
Daytime Phone�(Q.�L)��_Cell Phone( ) - Evening Telephone( ) -
Date of Accidend Injury or Date Discovered �� � � � ' �.� 1 �.. Time ��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. r W A�
�t�s_i�fa C�tJ `�N������-� C-�C3-t �1 C.. T�''�(„��,L �Y��rt" (�tiCl fl
�� ��-� �-�,e s� ry � fi � R� 5�rc�� �t �-c� -r�+��� +-� ��,�t�tY�xx�nt�
�l�i��. t-c���� r��.� -►� � _ . _
��.���-� �1. t� -��c�� �-t�r c� v -��, �r�N.-T "p 17�r v� �-�En� �
�..��� �, r�� �r-�� -re���..� ���- N -� �R���T A��a ac 1a r��.�
������� �-�.-'O tv c�T ���, v N fi�1 �r.�t-t-N.��S �i��l.'�
\d�1�1� �YI��b�C `�tN C� �.K � nt�Ae`b'`1 �U�-.�b±-i�L�-1 l��R�. M'� (}�'r1����
Please check the box(es)that most closely represent the reason for completing this form:
1�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 apulicable 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.
Pagc 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 complete this section
Were there witnesses to the incident? es No Unknown (circle)
, Provide their names,addresses and telephone numbers:�g�� �..(`;S� �t_A f�S°�F. �
� � a� - �� N ,5-� . �r���� r�N �� 1c��1 g� z. � y �y �f�z�8
Were the police or law enforcement called? Yes No Unknown (circle)
If yes,what department or agency? �(� lr LC E., Case#or report# 12 i°(y 5`I $
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 necessary,attach a diagram.
�A LE A I�IT> `_�HE_Y R(�N1VE -�N T� 1�S�C T�C�1�
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. L 1r.1��T' T�t.�,�]A M��F.�� My v E N-� c �� TC) �f F
e�� �z�
Vehicle Claims— lease com lete this section ❑check box if this section does not a 1
Your Vehicle: Year '��Make�.' N EVY c� LCT Model �1 C� I' I�
License Plate Number��,�i �X� State M�Color `_���V E�
Registered Owner .�"f��1�-t E G t�'�[' �P.
Driver of Vehicle �'R�P-LE �a ��L C-Lp�
Area Damaged '�F'�'� tVT ����1 E"'� �`L���.
City Vehicle: Year .'�G��Make `.�T�C�► Model �TE
License Plate Number q.��1 � (a(� State M n Color
Driver of Vehicle(City Employee's Name) TY1C�M A� SA MES 1t�1 t� -cr �
Area Damaged
In_iurv Claims—please comnlete this section (�check box if this section does not apvlv
How were you 3njured?
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 wark? (provide date(s))
Name of your Employer:
Address Telephone
�Check 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.
Submitling a false claim can result in prosecution. Date form was completed �L - O �. ' ��� 2.
Print the Name of the Person who Completed this Form: ,�—Z N �1'��LR '�CS
Signature of Person Making the Claim: `� t
Revised February 2011 "
09/11/2007 03:29 400 PAGE 02
.. .... �� .«,..�p (�.[
I'aile►rc to�ompletk'.and retU![I FJO'kFl�1��EC�L�il� resu�lt in de(ay in the harx3ling o�y��ur i3ai�n.
hill C'��d€, Cumvle�tt�is seciion
�lcre the.�e wim�se�co thi incident? �4'e.�3 y�� L'nkn4wn Ecircli;)
Pxov�de ttae�r n�unes,addresses and teleph�ne i�fiirb�rs: _����,� _ L�_�����,...�,�„.
R� .�thC i :�GC n^. ,Y. � rc�. . .. , � (�Y�► l�iC^ l:nKnoWt1 (r_�iCltl
' �,:.,deparu��nt u �.�.. -,." _�,�..�.����_Cas��.�c�►��?rrrt�.t_�zS����..`.a E�'°�i
wnere di�j the acrident or inl�ry tak�Pla�e'1 k'�•o�'�d�st�et ad:lress,crvss si.reet, i�l?er�ec-:tian,narne of park cir!'aciti�y,
rlusest lnndmark, ete, Plea�a��ie as def,�leci a�p�ssibls. I;'���cess�cy,att�eh a diagrair..M�___._ _..__._ ,_
P]easc indi�tttE EhE a�nouraE v�u�r.G Stekit]g Lt r,orr:pen�tio:i ur tivh�,t r�cu w��uici lil�.e the C�ty�to do tu resalr��thi�cl��:x�.
ro�ours�tiSfaclit��r.._.,-- --- - •�. .- --�_.�,.�, _,^.M..,.�.-..---•--•---__...._
�� icle C[uim�-ql��e cqn��1.4I�this�tiun�_.__._� __^,,_0�ck be� if tf�i�,sectio��does n�t a�,y�,,,rl�
xC]11X Vt=�9lC1C: ��CAT i4TSrL., �q,.�i,.�
L,ic:�r.;��►'!,:;.r h::i.�,1.,��;��.....�........�..._�.r.... 4�"::p....,,..�_��,•4::"__._.. ,_.�...T.---M _ _.,-...=
l2egister��O�ner__...._._.__..,_.�,_..r_.,..... r._.,,.,......�_ _ . ---.-.,__--
Urir�ea uf'�'�,iu��o - — - ._.__... ._. .-.__.,,..w..._.-----T.,......,,�..._.__—...,.__....
,�aze71'�arza�;aa_ ..... .�......, ._...�. �. _ ,,.. ..__.._..,__.._...--�.......`----�,--�---- '
�ity Vehicle; Ye.ar_----�-Mukc--------._._._....,�'T. .
. ._....__...._.__ ----- �-�-�---�--------
1.icCll.4e f'lalr 1�1l101beC •---•.._.r.-.:_._.,......,_ SiillC .,.. ..._.LUtUC..,w,--•--._...._.—.—_.r,...,
. r_,_�_... ,r.•. ,-. , , .
L7114'CrUf�i.��ur� �,�.u� i,::+}'1_!:F. :•`�;!'}t.�__......_...,..--- -- �
__...�,....,...------^.:..... ......--- j
Area Dar.w���?.---._..._._ . �
_._.. _ .,...,_.._ _.. ..._,...._..------..� _.......-�----- ,.._..._.. ...--- �
Ir� urv C�airns-- ka e c u�efe thic a�*rr�oi L'� ��-�,k b�x ;f thiti scct�r�n 1c�es n , '
,.�... ���4�,.._....._....^.__.... _- - - , _ �..__. Y.._.l^,_ . .�11?.k_Y.
Hc�w� wert�.you icljurcd'1_...._..._..,.........,�._....�.... .. .........._. _....__..__..,_.�__.--- ____.�-_._ �_.__..._ ,..
......._.__..____.__._,..._.r__�...w_..��:..._...._�------�-----_-�.__. - �----....w.._�----�-�-----��--- �
---..........
�ihat p;:.rt(s)uf yai�.*body �vere ini��re.a�..__.. ..._.._._.. .. . . .-.--.----._.._... ..
�
�aR��y�<��s4��ni►,�;a���i:.�:�;::;���--�-- ,� -------��- ..�—;�E:�,�-:W �t��k;�ti�;r��F�ar�►.,�;�<<����i�,---- � ,
V�nc�n�ifl y�au roceive trea����w��.t? ...__..._ �pi�o�.�icie date�s ii I
_� _. _ .. . .. _..-.__.��...,. __........--
�dit)C C►.:vfedic�l Pruvider�a;-_.,,.._... -�_�_--_��. . ._... ._ II
...._..._.----- � --- . _.__�-------.—,._
Acldrrss. _�_. .. _., -.. _.... --�---- .......----- �I'cle�+ii�n� �
f�id�'DU n17K5�►�or�,a8 ri tt�U�t Of VC�U:tA�u�r��'' � :��:� Nc� ',
When did yau n,iss•vork?„_,_._..�.._._,,.,..,....,........._..�......_..._.___ _ (,`.�![t��:�.t�• t'�.lel,+?)
Namc df;�atit r,rnp?oyer: .�__ .----�---- ._T. .._____-..._.._.�.._.�.... ^__�...� __....,.__�_._..---
.. .
Address---.,..._........ Tei u�}z.u:e_..----.-_...__.........---------
l$�Cherk he�'e if ycu�r�s�ltazt.i�.g�nc�rc pag++�it►tius clai��n tot�n. \umb�r of a�lditi��na] paRes„�„�,
II3�� signing this,farm,yr»�RrQ s[ctin� t/tat alI inform��livtt vOt� r.L>•::�r,:=:��;:s:�or��cs ans�c.,rr�c.':v l�.c vt�st
of xourk�awl�dge. Un::igned f"nrms witd tr�a ba y�ucESSe��.
Srcbnt�hlinga�`ulse cluin� can resuit i,t,�ro;;<-�'Eiti�rrr. I)ate t«rrn wa�conrpt.�tne! ..,_,,,�,,,�� t� �.. 1 ..__.
P�int thc N�me n[the Yes�xon wbo t'a�x�,-,'At,�!� �!�is Y r.r:�-. ••-�'�.-,-,° '�\..`�+c-�..:...�Z.���--- - _...._,,.._
�
��nt1�e of Petao�Atskin�!tie C'Ia� '''`" �.�;`� f"°: �`� �`.,
,:
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Kr,•,�d t�r.�,,;�r�au�� t F1s � T C��4r� �� � �
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08/31/2007 04:48 400 PAGE 01
Saint P�ul Police Departme�t Pa�� 1 °'�
�RICINAL OFFENSE / INCIDENT REPO�.T
Complalr#Nurf�ber l�eferanca CN date and 77me of Rapa?
'�2194548 08/15/2Q12 13:12:00
����:
TRAFFIC ACCIDENT-PR4PERTY DAMAGE AGCif��NT
Primary Reporting Otlroer. Bjo�kman, Todd J N&►►e allocstioNbusiness
Primerysqued: 128 Gxati�on orincident: pALE ST N& SFtERBURNE
S��'�'�+►���' ST PA U L, M N 55104
�av��r� Day, Daniel
n►Srr�ctWestern oer�an�otoccurrenoe: asr�sr�o�2 �2:19:04�
s+�; 08!15/2012 12:19:00
Arn9st made:
Seco1'�ctary oifanss:
��
Pdice OA9Cer Assecrlletl a•Irqurad: PWice dtficer Asslsted Suicide:
C�1me Scene Processad.�
� QFFEN8E DETAILS '
TRA�FIC ACCID�NT-PRQPERTY DAMAGE ACCIDENT
Att�mpt Pnly' Appe�rs to pe Gang Related.� i
i
� NAMES � i
�
Su�pect Garcia,Jamie ;
76U CMARLES AV W �
KN�WN ST PAUL, MN 55104 '
krrJv►s�ts ar.arraaea �
Nkk�kk Nar»e: �
AXes� i
AKA FJrat Neme: RKA Last Name:
GsERNd i
I
3ex� M��� Race: Qther ��g: 3/16/1964 1�esident Status: �� �
Hisparric: Y8S a98� 48 hom to
Pholres
�:651-224-5237 ceu: contact:
Wb+fc: Fax: Pager.
EmPloym�rtt
OCa�psNon: Empbyer.
SP341588�7$48pF
eeiaiizee� ea:ae aae Pac� ez
Saint Paul Police Department � 'a6
ORIGINAL OFFENSE/INCIDENT REPORT
cb�pr:i nw��nr Rs�.nc.cN o�u am rxn.wrreow
12194548 08/15/2012 13:12:00
R:+wronw..:
TRAFFIC ACCIDENT-PROPERlY DAMAGE ACCIDENT
� i,� .��
a�wr�wre�
� yyµ� tw�.rr a�OS.• L'oww srek:
PhYdW D�rpllon
UA MWIF
IINpI�f ro luld: FNiU/qM: MaNCObr
µry��. p SkN: FadvHrr HsirType.
T.M.� Cya Cokr. 91me ryPo' .
OIh1101IMNrnwMan
Ar��htl: PonWtenpeptl.' V�6r�R�wr�DOrtlM.
DUC Mfl�rp��noou�lr�d'
Car�fiqn:
talwrbl�IMewhoN' MstlioNlwMavobYNW�
�RI VIIBklPo�TMmM.I�I1109
891 DALE ST N
ST PAUI,MN 65104
Meb�w w�lhws
INUt IYrnr
A/sz
AKA Raf IV�M: A!(A L�Y IHiNIi:
O�YNf
� Snr:pyk A�a:WMI� �� 1Y31h985 Maid�MSlema:
w,pr.r� �w:47 � a
Pqonw
� Iknw: p�: CovN�d.'
Nbk Fu: Pqu:
�l�k
� �: �
1ernYludan
� ,:,. SSM. .. . Licaisar�n�: tiosnosSrero: ..
j Saint Paul Police Department '"� s ae
� ORIGINAL OFFENSE/INCIDENT REPORT
j cwro+rM M,1ro.. rr�em�w ta ar.„w rx�.arxnan
1219454g OS/15/2012 13:12:00
�wran��..
� TRAFFIC ACCIDENT-PROPERTY DAMAGE ACCIDENT ;
,I
I ��� �
�� TYM'InEh�dual Crrldwr7rO�wa�r. No w�OrovnsschmP+"Na
;� CaiO�tiw1: I
7Wnb1Malhcra�iorp:No �'y^�+u��� Na
� ViMim CITY OF 9T PAUL
881 DALE 3T N
3T PAUL,MN 55104 �
I
Mrlownp wAllrw (
j ��»: ;
; �; �
�uu ruat wm.: ,uu ux nems: �
I � i
� g�„ �0.. DoB: nure.nrsr.m.• �,
�k. AyY /rom M I
'I �Y I
d
� �: G� Cwxt ��
µyy: Fu: ��
�
:� pOCyqUm: EmPiolac
�
� SSPt: uwme a Ipr: Uwn.+a SWe:
Yktl»I Mb�tlen
T1a�:Govemment [�^�Mr�� No �rovrs»crwp�a.No
CanaM�en
7ra»ro�r.mmrabNl'0^No Mwk�nw.aeontsned.• No
�� qsauen.Kerti LW
607 DALE ST N
ST PAUL.MN 55104
Mdnrnu xMw�
I�NdrIVM�'
AMt'
AKA FMlf�lenle: AI(A Luf IVUIM:
sP30�3eene�eOG
�8I31/2@07 04:48 406 PAGE 63
Saint Paul Pol�ce Dep�rtment p�� � ofs
ORlCIIVAL OF��NSE 1 INCIDENT REppRT
comp�a�n�Nun�ber Rek►ence c,v
Date And Tin1e af Repprt
12194548 OS/15/2012 13:1�:00
PNr„ery,of�nsa:
TRA�FIG ACCIDENT-PROPERTY DAMAG� AGCID�NT
,� v�cdm!�lb,msnon
Ti�� Individuai Can ldenr►ryy o�er. No Wrlling to Pro3s Char�gs:
Gond►tion: NO
Tskan to h�alth cere fstx7r�j,. NO Medlca��e�eas�obtaln¢a:
Nb
Victim CITY pF ST PAUL
891 pAL�S7 N
5T PAUL, MN 55104 �
NICk»ameE Or'AN�a�s
NlCk Ner�:
ANes:
AKA F�lyerpe: AKA Last Neme:
Dqrdb
Ssx: Rat;e: DOB� Resirlent Status:
��� '4g�' hbm to
PHer►�s j
Nome: CaN; Contarx.� '
YWr�C; Fax: peyer. i
Eenploymvnt i
OccuAatbn, �mPloYer..
ldilntMcsBbn
SSN.� LlC9A99 Or!D� License State;
wetrm brlbrnrutlon
r�� GavemmenE �n�M+fi�OASnder. No Inr,�rrr�ro�sa Charges; Nb �
Condl�an:
TakBn!o ha8lth Cem fBCENtf�� NO 1Nadlcal release obtained: Np
Witness Klaassen, i(erri Lou
501 DAI.� ST N
ST PAUL, MN 55104
Nlclur�ms�or Allss�a
Nkk Nams:
nuaa:
AKR fNat Neme: AKA Gast Name�
SP301588F7Bd8UF
Saint Peul Police Qep�rtment Pg� a ofs
�F�IGINAL �FFENSE ! 1NCfbENT REP�RT 'r
Corpplarnt Number Refgrgnce CN Date�np Tirrt�o/R�pWt
12194548 Q$/15/2Q 12 13:9 2:00
�7�►8�O�RS9:
TRAFFlC ACCIDENT-PROPER�t�Y DAMA�� ACCIDENT
aem;� �
5ex: Female R�: White doe: 10/29/1967 Resident status:
HisPar►!c: A9e� 44 (rom to
f�Honoa
��: Ce!l: 952-454-8258 Corngct:
�' Pax: p��
�►p�=
occupation: ��o�
/derttfRcatlon
SSN: Lk.snse or IDl: License State;
SOLVq�lLITY FACTORS
Suspect can be lde+�tllred: �y,
Photos Taken: StO/en Prvpe�ty TraosaA�e:
Evldev�ae Tumed!n: Prope,d•Twned!n:
Ralpted►ncld�nt: ;
1-Ab
Biolog�calAnelysis: Fing��t8 7'aken� �
Nannti�An
��' It6ms Fingeiprint9d: f
Cpb Camments: 1
�
. �
PROPERTY �
l7�M�1
ryp�ot�oss; D�maged o�te oitoss.• g/��/2012 �.ocauon cosr: Dale/Sherburne !
owner.• Garcia, Jamie Dste ReCpvered.• Locstldn Recover�d. �
n�lode��: Quar�Gry: seriar#.�
Articde rype/Item: Other property / Vehicle Tore�ya�ue;
�escHaaoR:
Tumed in at- Codcer 1D#.� Lab exams:
SP301348F78de0F
Z0 3Jdd 00b Z5�b0 L00ZlTEl80
08/31I2007 04:56 400 PAGE 01
P�Be 5 oF6
Sair�t Paul Police Deparkment
�RIGINAL OFFENS� I INCIDENT R,EPQRT
Date and Time o/ReAart
� c��te��t M+�ber �e+��nce crv 08/15/2012 13:�2:00
12'I94548
Pdmary oR`errse:
TRAFFIC ACCIDENT-PRQ�'ERN �AMAGE ACCIDENT
VEHIGL� INFb1�MATION (Proparty)
Status Doscr7ptlan
Stetus: Dg111aged License no.: 285GXS y�r i 995
staro: MN T�� Pickup
Tow�ed: No co►or: $ilver
Lock stafus Y�
Uooro unJaaked: V.I.N.: Doors; 2
Ignitivn unlocked:
Meke: Chevrolet TrartsmisslDn:
Tiunk unloCked: Model.. r� 51fiR Pasifion;
resys in venk�s: No '����
Insnrance 6 owneYln�bmratlon VthrNe Coe�errts 8 drl�'or
lnsu�co.: Keys�n veh;de; No
LienAO�der. Ownor eNowed someone to
use vshicle:
Le�ss CompenY.
Arltount Owed; $Q SiO�en Mefllod:
Rsgfsksrsd awner. ���i�,Jamie Thett Coverage:
priwrs d�csnae no.: Psrsona!pr+op6rtY in vehiCl9' I
i
ven�a�e
dRIVER SIDE FRONT FEND�RIBUMPER AREA
I
�
i
�
Pa�ticipsnts: C
Person Type: Name: Address: Phone:
Suspect Ga�eia, Jsmie 760 CHARLES AV W 651-224-5237 1
ST PAUL, MN 551Q4 i
Victim Walt�rs,'fhamas James 891 DALE ST N ,
ST PAUL, MN 5510�4 '
� Victim CITY OF S�'PAUL 891 DAL�ST N
ST PAUL, MN 5510�
111r�tness Klaassen, Kerri Lou 501 DALE ST N
ST PAUL, MN 551�4
� NARRATIV�
On 08-15-12 at 1218 hours I, �ifiCer Bjor'kman-Sq 12$, was dispatched to Dale/Sherburne on an accident
involving a City of St Paui f'ublic Wo�ks truck_
� Upon arrival I found a 2 vehicle accident at the intersection,
SP3015e8F7e4eoF
08/31/2607 94:45 40B PAGE 02
Page 6 oi 6
Saint Paul Police Department
ORIGINAL OFFENSE 1 INCIDENT REPORT
Comp�anf Number Re�erence CN (Jsfe and Trme of Revort
1219454$ 08/15/2012 13:12:00
Primery oMBnse:
TRAFFIC ACC{QENT-PROPERTY DAMAGE ACCIDENT
The City ot St Paul dump truck involved was Mn Lic#939160. This was driven by a Thomas James Walters 01-
31-65. Walters siated he was S/B Dale 5t in the right lane and did not see the other vehicle puliing out from
Sherburne.
I spoke with the other driver who I identified as Jaime Garcia 03-16-64. Garcia stated he was partially pulled out
onto Dale St from Sherburne. He stated he was stopped in traffic. We stated the City truck came southbound
on Dale and struck the slde of his truck. He was driving Mn Lic#295CXB.
I looked at Garcia's vehicle and found damage to the front left fender and bumper area. His passenger was
ide�t�ed as Debra Desere-Ann Lee 08-09-72.
No one involved in the accident stated they were injured, i
i
Lee pointed me to a witness who stated she saw the accident from a 3rd stary window of 501 Dake St.
I went to that location and sppke with a Kerri Lou Klaassen. She stated she was sitting at her desk an the 3rd �
tloor whlch faced North. She stated she heard a horn,which she believed to be Garcia's, at whlch time the City �
truck struck the other vehicle. She stated she saw Garcia's vehicle partially pulled out on Dale from Sherbume �
and that it was stopped in trafFc.
Officer Mackintosh arrived and photographed the accident. See also the State Accident Report.
PUBLIC NARRATIVE �
A iwo vehicle accident and Dale and Sherburne. �
i
,
�
�
. SP30i568F7G460F
08/31/2007 05:01 400 PAGE 01
Saint Paul Police Department Peae , brz
SUPPL�M�NTA� OFF�NSE / lNCIDENT R�PORT
�►„a�u Nu►►,a� ,��,�o cn+
�2�f 94548 a8r�ana r„►,�o��a�,t
��►�r on�nse: 0$/1 fi/2012 'I 5:42:QO
' TRAFFIC ACClDENl`-PROP�RTY DAMAG� ACCIDENT
F�4'R°portN'B 0/f'+�`a� M�Ckir►tosh, 7h2odpl�E 8 Name o/IocatioNbu4ine�s;
��'►Ys4ued� ?20 tocationOfinci�enf:
Seco,x�ay,�,�„�,�;��. DALE ST N &SHEFiBUF�NE
�p►��' Ellison, Jeremy �r�'AUI�, MN 55104
Dlstrict:WBSter11 Date 8 timo oJoccurrence:
0�/15/2012 42:19:OU to
5ite:
fl$h$/2D12 12:19:00
Am�st made;
Seoond�a►Y oAf�nse:
Po�pcs OflxaerAssaultedorinjulgd: Polltae OlBOerpssJsted SpiCide.�
Cr�me Soene Processed�
� oF�eNSE aEr�i�.s
TRAF�IC ACCIpEMT-P
ROP�RTY DAMAGE ACGID�NT
A��"ty� Apaears to be Gang Related:
SQLVABILITY FAGTORS
s�ae�t�,�rdena�ea: gY.
Photvs Tsksn� Stabn PmPe+tY Tigcse4la;
Evld9r�ce Tinned!n: Properfy Tumed!n:
RBJ9fed fnCidertf.'
LeA
BlobgicelAnelysis: Fingorpnnts Taken:
Na�otic Analysls: Items Ffng�rprin(�d:
i
Lab Com»rents: �
I
� Participanta: ;
Persan Type: Name: Add�ess: Phone:
NARRATIVE
On 08/15/2012 at 1219 hours, Squad# 120 (Mackintosh, Theodore B) was dispatched tfl DALE ST N to take
photos of TRAF�IC ACCIDENT-PRdPERTY DAAAAGE ACCIDENT,
List of Photos for CN 12194548:
SP901�BOF7g48QF
� , ` � ��^�_�
�5` �J
�
� ��
!,
�
08/31f26�7 64:52 400 PAGE 01
Sain# Paul Police Department Pa� 2 �«
SUPPL,EMENTAL t�FF�NS� / I�VCIpENT REP�R1`
Complaint Nwrrber Referamae Cnr
bate end Time o€Repa}
1279454$ 08/16/20�2 15:42:OQ
��r�n�.�
T�A�'FIC ACCIDENT-PROPEFtTY DAMAGE AC�IDENT
�• 12194548-08152012 1�3$51-TRAFFICACCDNT-1.'
2. 12194546-OB152012 1139f 1-7RAF�ICACCDNT-2�� - Laptap scr�en af CAD call
3. 72194548-081�2072L113932-TR,qFFtCACCDNT-3.�� _ street signs Sherburne/Dale
a- 12194548-08152012�114003-TRAF�lCA�CDNT-4�� � �b Sherburne, west of Dale St
5. 12'f 94548-081520i 2_114015-TRA�FICACCDNT-5_,� _ $�b d��� 5t north af Sherburne
s• 1219454$-08152012 114042�7RAFFlCACCpNT-6,� _ NW comer Sherbume/Daie of scene
93'160 — 1Pg - Front pf(poir�t of impact) MN#295CXB�nd MN
7• 7Z1945�48-081520'12,�'f 14b48-TRAFFICACCDNT-7,jpg - Front right MN#295CXB
8. 12194548-08152012_114053-TRAFFICACCpNT-8.jpg - Front left MN 93f60
g� 12194548-08152092`114059-TRAFFICqCCDNT-9.jpg - Interior MN#295CXB
The labeted photos were TRANSFERRED to the Media Vault.
Pt1BLIC NARRATfVE
photds
�
�
�
SP301S68F784gpp
08/31/2007 65:01 400 PAGE 02
� Accideat�t,�port �e 1 of 1 �
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10102I2012 10:24 651--699-7@31 FEDEX OFFICE 6663 PAGE 01
BdNFE'$AUTO SERVICE $c BOD'1� Workf}le ID; 4db9ff45
REPAIR_CF
380 7TH ST W, SAINT PAUL, MN 55142
Phone, (651) ��z-4458
FAX: (651) 2Z4-864�
Prelimir�ary �sxim�te
Custumer: GARCIA,JAMIE
Written By:MAtTHEW BEBEL
insured: GARCIq,]AMIE Policy#: !:laim#:
Typc of Loss� Date of Loss: Uays to Rapair: 3
Point of Impact: 11 Left Frant �
Owner: Inspection Location: ;[nsur�nCe Corltpdny�
GARCIA,1/�1lWIE BaNFE'S AUTO SERV�CE&BODY
REPAIR_CF
7�0 CHARLES AVE 380 7TH ST W
ST PAUL,MN 55104 SAINT PAUL,MN 55102
(851}338-8521 Cellular Repair Facility
(651)222-4456 Business •
VEHICLE
Year: 1995 Body Styte: 2D LONG VIN: 1GCC51441582fi5D55 Mileage In; 231Z"L9
Make; CHEV Engine; 4-2,2L-F1 IJcense: 29SCX6 Mlteage Out;
Mod�l; S�0 4X2 PI'OduCtfOn Date: State: MN Vehicle Out:
Calor: 5ILVER Int; Condition: ExcPJlent 3ob#:
TEtANSMIS3iON CONVENiENCE Search/Seek Styled Stee{Wheels
5 S�d 7Yc�115rt1155i0i1 ,air Candittioning SAF�TY PAINT
Overdrjve Intermittent Wipers Anti-Lock Brakes(�1) Cle�r CoBt pairlt '
POWER Message Center Driver Alr Bag TRUCK
ppwer SCeering RADIO Passenger Air Bag ReBr Step Bumper i
Power Br�ke5 AWI R�diO S�ATS I
D�CaR FM Radlo Clotli 5eats �
Dual Mirtors Stereo WHEELS ,
�
I
10/2/2012 9:35:48 AM 013793 P�gF 1
10/02/2012 10:24 651--699-7031 FEDEX OFFICE 0603 PAGE 02
Pre#iminary�stimate
Customer: GARC�A,J,AM��
Vehicle_ 1995 CHEV 510 4X2 2D LQNG 4-�.1.�•FI S;LV�R
Line Oper Description Part Number Qt:y Extended Labor Paint
Price$
1 �ftUNT BUMPER �����
� 0/li fronC bumper l.g
3 Repl eumper S-x0 w/o decor pkg 15G4�597 1 267,47 Incl, 1.0
4 Add For dear Coat Q.q
5 Repl �T�xt�nsfon Chevrole[w/o decor 1238311i t 38.37 Incl. 0.5
pkq
6 Add fpr Clear C:oat 0.1
7 GRII.L,E
8 Repl Grllle gray Chevrolet 15647630 1 191,98 IncL 1.3
9 Add for Clear Coat a 3
IO HOOD
il " Rpr Hood Chevrolet �� 2 g
i2 Add f�ar Ciear Coat �.�
13 FENDER
J,4 �• Repl A/M LT Fender 2WD 1z377871 ]. ���_D_Q 7..p z.�
15 Overtap Mt�jor Adj,Pan�l _p..�
16 Add for Clear Coat a 4
17 Add for�dging 0.5
i9 Deduct for Overiap -0,5
19 FRONT DOOR
20 81nd �T Outer panel � 1
21 # Repl NAZ4RDOlJS WASTE REMOVAL 1 7,40 "f
�Z � R&I TRlM FOR BLENDING �,g
13 # x*r*PpS.S�BL�IIIDDEN DAMA6E �.
�.w•x**
Z4 � PART PRICES SUS]ECTTO 1
INVOICE
25 # Refn TINT COLOR TO SECURE PAINT 05
MATCH �
SUBTOTALS 7'43�82 6.6 ].1.8 �
i
�
I
1D/2/20i2 4:35:A8 AM 013793 Page 2
10/02/2012 10:24 651--699-7031 FEDEX OFFICE 0603 PAGE �3
P�relimin�ry Estimate
Customer: GARCTA,3AMIE
Vehicle: 1995 CHEV 510 4X2 7,�LONG 4Z.ZL•Fi SILVE:R
�STxMA7E TOTALS _
CatEgory _ . ._,8asis Rate Cost$
Parts G96,82
8ody Labor 6.6 hrs �) $5fi,00/hr 369.bfl
Palnt Labar 11,817rs C� $5G,00/Iir 660,80
Paint 5upplie5 7,1,.f3 hrs C� $35.00/hr 413.Q0
eody SqppHes 3•5 hrs �il $3,00/htr IQ.50
Mlscellaneous 7.00
Subtotal " � -- 2,1.;7.7z
Shces Tax �$703.82 C� 7,6250°/a 53.67
�rand'ro#a� .�� � z,zii.s�
Dedu�ble� � ����
CUSTOMER PAY fl•bfl
INSURANCE PAY �� 2,211.39
�K�*�k:f��k*�k�k**�k�ICaK��k�KW�k�k�k�k�Ic�K�}c�k�k*�C***�Y**�K�c�C�K�k�K�K�k*�k�k*7kyK��Y�*W�k!k?K�k�k��k***��*=K�W�k�k�Ic W.�c****
THT$IS A VISUAL ESTXMATE ONLY.
ADDITlONAL DAMAGE NiAY BE FOUND AFfER TEAR DOW�t OF VEfi�XCI,f.
NO GUARANTEE ON RUST WORK.
***�:****:�*************�*��xt****************t*t:�***************=r��:******�****�;*
MINN�SOTA FRAUD WAI�NZNG
A person who submits an application or files a claim with intent to d�fraud or hE:lps commit a fraud against an
insurer is guilty of a Crime.
MN ST 50A.955 -A PERSON WHO FILES A CI.JIIM WITH IIVT'ENT'T4 DEFRAUD ���t HELPS COMMIT A FRAUD
AGAINST AN ZNSURER IS GUILTY�F A CRXME. ;
�
. �
i
16/Z/��1�2 9:35:R8 AM 013793 p�9e�
10/02/2012 16:24 651--699-7931 FEDEX OFFICE 0603 PAGE 04
Preliminary Estimate
Customer GARCIA,aAMIE
Vehicie: �995 CHEV S10 4X2 2D LONG 4•2,7.L-fI SILVLR
C�timate based an MOTOR CRASH e5TlMA7ING GUIDE. Unless otherwise nated ail items are derived from the Guide
DE1Gp94, CCC Data Uate 10/1/2012, and the parts selected are �EM-par�s manufactured by th�vehicles Original
Equipment ManufacCurer. OEM parts are available al OE/Vel�icle dealerships. C►PT��M (Optional �EM) or ALT a�M
(Alternetive OEM) parl� are O�M pa�ts that may be provided by ar�hrough alternate sources ol•her than thc OEM
vehicle dealershlps. OPT OEM or ALT O�M parts may r�flect some speciFc, s�e�c.ial, or unique pricing or discount.
DPT QEM dr ALT O�M par�s may include "Blemished" parts provided by OEM's tlirouc�i� �EM veh'scle d�alerships.
AsCerisk(*) or pouble Asterisk (**) indicates diat the �arts and/or labor inform��tion provided by MOTOR may have
been modifi�d or may have come from an altcrnate data 5ource. Tilde sign (N) items indicate M�T4R Not-Intluded
Labor opera�ions. The symbol {<>) indicates the refinish operation WILI. NOT �e {�erformed as a separat� pr�cedure
from Che other panels in the esttmate. Non-Original Equipment Manufaeturer afl:��rmarket parts are described as AM.
Used parts are describEd as LKQ, RCYy or USED. Reconditianed parts ar� clescribed as R�cond. Recorcd parts are
described as Recdre. NAGS Part Numbers and Benchmark Pric�s are provided by National Auto Glass Specifscations.
�.abor operation tim�s listed an the line with the 1dAGS information are MOTOR suggested labor aperation times.
NAGS labar operatipn times are not includ�d. Pound sign (#) items indicate manual entries.
$ome 201� vehicles contain minor changes from the previ�us year. For tE,os� vehicle5, prior to receiving updatec!
data from the vehicle manufacturer, labor and par�s data frvm the previous year may be used. The CCC ON�
est�mator has a complete list of applicable vehicles. Parts numbers and prices should f�e confirmed with the locai
dealership,
The follawing is a list of additionaf abbreviatians or symbols that may be used t�o d�scribe work to be done or parts to
be repaired or replaced:
SYMB�LS FOLLOWING PART PRZCE:
m�MOTOR Mechanical compo�ent. s=MOTOR S�ructural componenL. T=Misc�;llaneous 7axed charge eategory,
X=Miscellaneous Non-Taxed charge categary.
SYMB�LS FOLLOWINC� LA�OR:
D=Diagnostic fabor category. E=Electrical labor category. F=Frame fabor category. G=Glass labor calegory.
M=Mechanical labor category. 5=5tructural labor category. (numbers) 1 through 4�User Defined l.abar Categories,
OTHER SYMBOLS AND ABBR�VZATIONS: j
Adj.=Adjacent. Algn.�Align. A�U=Aluminum. A/M=Aftermarket part, �Ind=Blend, B�R=Baron steel.
CAPA=Certified Automotive Parts Association. D&R=Discannect and Reeonnect. HSS=High Strength Steel.
HYD=Hydroformed Steel. Inc1.=Included, LKQ=Uke Kind and Quality. LT=Lett. MAG=Magnesium. Non-Adj.=Nan
Adj�cenC. NSF^NSF Internatlonal Certifred Part, Q/H-Overhaul. Qty=Quantity. Refn=ftefinish. Repl�Replace.
R&I=ftemoVe and Install. R&R=Remove and Replace. Rpr=Repair. RT�Right. SAS=Sandwiched Steel. '!
S�ct=Section. Subl=Subl�. UHS=Uitra High Strength Steel. N=Note(s) associated with Che estimate line.
CCC ONE �stimating -A product of CCC Information Servi�es Znc.
Th�following is a list of abbreviations that may be used in CCC c7NE �stimating that are not pa�t of�he MOTOR
CF�ASH ESTIMAI�NG GUIbE:
BAR=Bur�au of Autamotive Repair. EPA=Environmentai Protection Agency. NI-�TSA� Nalional Wighway
Transportation and Safety Administration, PDR=Pafnrless Dent Repair. VIN=Vehicle Jdentification Number.
IO/2/2012 9;35;48 AM d13�93 Page�
6911212�07 20:53 406 PAGE �1
HIGHLAND AUTOSTAR CO�LISION CENTER
2042 WES'f 7T#i ST.
ST. PAUL, MN 55116
OFFlCE:651-699•034p FAX; 651-699•�4953
FEp tAX ID#41-1828627
"'•PR�L�IAINARY ESTIMATE***
10/04/�py2 pg:26 AM
�wner . ..... . . .
Qwner: JAIM�GAt�C1A
Addro�s: 780 CHARLES AVE Work/pay; (651)338-8521
Clty Ste�te Zip: Saint Paul,MN 55104 FAX:
. . ..
Impeotlon
InapecHon Ds�t�: iNOdl2012 06:26 AM Inspectfon Type:
�+rtmary Impact: Left Front Com�r Secondery Im�act•
Appralser Name: JOHN RITTER_JR Appraiser License#:
Address: 2042 W7TH ST Wbrk/Day; (651}699-0340
FAX: {651)699-4953
City 8tats Zfp: Saint Paul,MN 551 i 6 FAX:
Email: JQMNJR�HIGHLANDAU7'OSTAR.CQM
Repairer .. . -
Re Irer: HIGHLAND AUTOSTAR Contact:
� COLLISION
Addveas: 2042 7TH ST W Wbrk/Day: (651)699-0340
City State�ip: ST PAUL, MN 551 f 6-3107 �AX: {651)699-4953
�maEl: HA2042�POPP.NET
VehiCld . ,
995 Chevrolet S10 S717 2 DR Standard Cab Short Bed
►Gasaline 2.2
Speed Autdmatic
Lic.Plate: 295 CX8 Llc Sfate: MN
Lic�xpire: VIN: 1 GCCSt 44158265055
Veh Insp#: Mlleage Type: Actual
Condltlon: Code: UB522A
Ext.Color: SILVER Int.Color:
Ext.ReA�lsh: Two•Stage Int.Refinish: 1'wo-Stage
ptfons
irbag Restrafnt Anti-Lack Rear Brakes Intermittent Wipers
ower Brakes power Steering Rear Step 8umper
inted Olass Velour/Cloth 5eats
Dpmagps
Line Op Guld� MC DescHptlon MFR.Part No. Prlc� ADJ°�6 B96 Hours R
f2012 p6:30 AM Paqe�D�3
09/12/2607 20:53 406 PAGE 02
,aes cno.rde�sio s.,Ko z op sewem car s�wrt 8eo
C�mN:
�oroa�zo+z oe:zs aM
� E 5 # Bumper,Front 15647597 GM Part $287,47 2.3 5M
#�01,46
2 L 6 13 Bumper,Front Refiinish 1.8 RF
1.0 Surface
0.6 Two-stage setup
D.2 Trv�-stage
3 E 90 Extn,Front Bumper p�r LT 12383111 GM PBrt $38.37 ING SM
4 E 117 01 Defi,Frpnt Bumper 88963098 GM Part $58.71 INC SM
5 E 11 Brace,Front Bumper LT 93382975 GM Part $28.70 SM
6 E 9 p1 Frame,License Plate 15672291 GM Part $22,09 p.2 SM
7 E 124 Brkt,FrnM Bumper Mtg�T 12548280 GM Pan $28.93 1.4 SM
$ � 27 Grill�Assembiy 15647630 GM Part $i91.98 !NC SM
9 E ai 02 Headlamp Assy,Halogen LT 16524809 GM Part $t47.38 0.3 SM
10 N 973 Headlamps Aim Additiona!labor 0.4 SM
11 E 63 �amp,Side Marker LT 5976405�M Part $27,37 INC SM
1� I 83 Panel,Hood Repair � p• �M
»LEFT EDGE ONLY DOES NOT lfVCLl1DE ANY PRIOR DAMAGE
13 L 83 Panel,Hood Refinish 3.5 RF
2,9 Suriace
0.8 Two-stage
14 EU 103 Fender,Front L7 Rep�ace Recycled $250.00' +25.00 1.8 5M
15 L 103 Fende►,Front LT Refinish 3.1 RF
i,6 Surface
1.0 Edge
0.5 Two-stage
16 56 HAZARO.WSTE.REM, Sublpt Repair $6.00" SM
17 S8 COVER CAR EXTERIOR Sublet Repair $7,00' RF
18 L CQRROSIpN PROTECTfON Refinish p.�+ �F
t 8 Item*
MC Messaqe
01 CALL DEALER FOR EXACT PART#/PRICE '!
02 PART NO.DISCQNTINUED,CALL DEALER FpR�XAGT PART NO.
13 INCLUDES 0.6 NOUFIS FIRST PAN�L i1N0-STAGE ALL�WANCE
46 PRINTABLE ALTERNATE PARTS GOM�'ARE
,E�timets Total d�Ent�fes
ross��rt¢ �e7�.0o
he�Pa�rts $250.00
alnt Materisls $311.50
ine Item Markup ��50
arts&Materlal Total $1,435.OQ
ax�n Parta Only � 7,6259�0 $8�.67
��� Rata Replsae Repalr Hrs Total Hrs
Hrs
heet Me1a1(3M) $56.00 6,0 1.4 7.4 $414.44
ech/E1sc(ME) $90.00
rarne(FR) $80.00
eHnish(RF) $58.00 8.9 8,9 $A98.4p
aln!MeEerlsis $39.00
�'��.�AM vege 2 of 3
09/12/2007 20:53 406 PAGE 63
�995 Chwol@I S70 W?D 2 017$tarq�rtl Gb Siw�t Bed
Cb�m K:-
10l0412472 08:�6 AM
�abor Total 16.3 liaurs $912.80
Sublet Repalrs $y3�
Gro$s Total
Net Total ����•`��
a2,446.47
Alternate Parts Y/p1J0(}/Ob/p1l01 CUM 01/00/UO/Oi/o1 Zip Code:55116 Default
Recycled Parts NOT REQUESTED
udatsx Estlmating B.O.a43 ES 10�04/2Qt2 08:30 AM REL 8.0.848 DT 09�0112012 p810/01/2012
opyrlght(C)2�11 Audetsx North America,Inc.
, -9 FlRS WER�ADf1Ep TO THIS ESTIMATE BqSED ON AUDATEX'5 TWO�.STA(��REFINISIi FOHMULA_
4U ARE AUTHORIZED TO MAKE THE ABOVE R�PAIRS,I UNDERSTAND TWAT pAYMENT!N FULL WILL BE DUE UPON RELEA$E
�
M�VEHICLE, pART'$pp�CES ARE SUBJECTO Tp INVOICE. I QRANT pERMIS510N TO OPERATE MY VEHICL�FOR TNE PURpOSE
F
ESTINQ/IMSWECT'►ON.HIGHLANd AU'CQSTAR IS NOt RESPOfVSBILE FOR L�SS pR DRMAGE FO THE VEHIGLE OR ITS
ONTENTSIN
ASE OF FlRE,1'HEFf OR ANY CAUSE BEYOND YOUR CONTFiOL,AU7HOR(2ED
Y: DATE:
HTS ESTIMATE I�SAS BEEN PREP,A,RED BASED ON �'H� USE OF ONE Ok� MORE CRASH �,A�TS
UFPLZED SY ,A. S�URCE OTHER THAN '�HE MANUFACTU�ER OF XOUR MOTOR V'EHIC�,E.
�.RANTZ�S APpLIGA�LE TO THESE REPLACEMEN�' PAR2'S ARE PROVIDEL] BY TI�� P�1RTS
�'ACTURE�t OR DTSTRIBUTqR RATHER TF�.A,�+i BY THE �LTFACTUR��t 0�' YpU� VEHICLE.
FERSON WHO FILES A CT.,.AIM W�TH �N'�ENT TO DEFRAUD OR HEL�S COMMIT A �'RAUD
GAINST AN INSURER �S GUZ��X OF ,A. CRII�E.
p Cades
= User-Entered Value E = Repiace OEM NG- Replace NAGS
C= Replace Economy OE= Replace PXiV OE Srpls UE= Replace OE 5urplus
= Parti'dl R6pl8ce Labor EP= Floplaca PXN EU= Replace Recycled
E� PaRiel Replace Price PM= Repl�Ce PXN Rsman/Reblt UM= Replace Reman/Rebu�4
- Refinish PC� Replace PXN Recanditioned UC- Replace Reconditipned
�.Two-Tone SB= Sublet Repair N = Additionaf l.abor
R= Blend Refinish I = Repait IT - Partial Repair
G= Chipguard RI = R&I Assembly P - Check
= Appearance Allowance HP= Fielated Prbr Dama9e
This repori COntains proprietflry Infom'�ation of AUdatex and may not he disclosed to any third party(other than
the insured,Claimant and others on�need to know basis in order to effectuate the claims process)without
Q��a��s� Audatex's prinrwrilten canseni.
!7 4
d SU�6'rJ COR�paHY
-,..-.-�Copy�ight(C)2011 Audatex North Amerlca,lnc.
Audatex�stimatin is a tradem�rk of Audatex North America, Inc.
Pape 3 of 3
IOa130�2 0l�30 AM