Vickers ��i��------ _
OCi 2 6 20�i2
NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesot�.a CLERIC
Minnesota State Statute 466.05 states`��at"...every person...who claims damages from any municipaliry...shall cause to be presented to the
governing body of the municipality within 180 days afYer the alleged loss or injury is discovered a notice stating ihe 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. Piease note that you may or may not be contacted by telephone to discuss your claim '�
circumstances,so provide as much information as necessary to ezplain your claim,and the amount of compensation being
requested. This form raast 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 PALIL,MN 55102
First Name �Y 1�� Middle Initial�"Last Name V i �VS
Company or Business Name,if applicable �/�_�tt
Street Address � Z`1� �„�,��� eV �-NGVi�a
City �►n}- �U,r,t,( State M.V� Zip Code SS I I�P
Daytime Telephone (�D S� � ,��� ' � 33 o Evening Telephone �z.)�.0 3 — 3�'�' �
Date of Accidentl Injury or Date Discovered L7� Time =00 am pm(circle)
Please state,in detail, what occurred,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.
�c Se-c- cc�kf�c.L�� � �.�—
�;
Please check the box(es)that most closely represent the reason for completing this form:
❑ Vehicle was damaged in an accident ❑ Vehicle was damaged during a tow '
❑ Vehicle v��s�damaged by a pothole or condition of the street ❑Vehicle was damaged by a plow
❑ Vehicle was wrongfully towed and/or ticketed �Injured on City property
�type of property damage—please specify �� � v
Other type of injury—please specify �
G Other type not listed—please specify
In orde:to process your claim vou need to include conies of all applicable documents. This is a general
guideline of what should be submitted with a claim form,but it is not all inclusive. You may be asked to
provide aciditional information depending on your claim.
�Property damage claims to a vehicle: at least two estimates for the repairs to your vehicle,or the
_ _ actual bills and/or receipts for the repairs
O Towing claims: legible copies of any tickets issued and copies of the impound lot�eceipts
O Other property damage:repair estimates,detailed list of damaged items
O Injury claims: medical bills,receipts
O Photographs can be provided but will not be returned.
Page 1 of 2—Please complete and return both pages of Claim Form
Failure to provi�te a completed claim form will result in delays in pro�cessing.
I
Notice of Claim Form,City of Saint Paul,page two -`'
All Claims-please comulete this section
Were there witnesses to the incident? Yes No Unknown (circle) I
If yes,please provide their names, addresses and telep numbers:
I
Were the polic�or law�nforcement called? Yes No Unknown (c�rcle) ,
If yes,what department or agency? ase#or report# '
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 helpful, attach a diagram.
G c� -�-t� fh �,e�. �.v o -{'�.c i -�'v
L c I
Please dicate the amount u are seelcing in compensat'on from this claim or what you would like the City
to do to resolve this claim to our satisfaction. h'l C. �w. � � oa
r d l c � � i
Vehicle Claims- lease com lete this section ❑ check box if this section does not a �
Your Vehicle: Yeaz Zn b"j Make Model r+
License Plate Number State�rlv�Color ��c� �
Registered Owner ;
Driver of Vehicle �
Area Damaged o v c, �
City Vehicle: Year M e Model �
License t;ate Number State Color
Driver of Vehicle (City Employee's Name)
Area Damaged
Iniurv Claims-please complete this section �check box if this section does not app�
How were vou iniured?
,..__
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): !
Addres� 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
�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 information you have provided is truc and conect to the best of your knowkdge. Unsigned
for�ns will not be processed Submitting a false claim can result in prosecution. _ � '
Print the Name of the Person who Complet this Fo L
Signature of Person Making the Claim: l.
Date form was comple4,�d D ,� Revised April?A07
Please state, in detail, what occurred, 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.
A City tree, located on the boulevard between the City sidewalk and the City
street at the residence adjacent to my home, dropped a large branch onto my
car which was parked on the street in front of my home. The City is
responsible because the tree causing the damage is located on property
owned by the City and is thus the City's tree. The branch did NOT drop due
to a storm or high wind because no such event occurred on or around
8/29/12. The branch dropped because the tree was not properly maintained
and had been allowed to become dangerously unsafe.
Latuff B��others
A/R Payment History for RO# 27�49
Date: Ref# Received From: Amount: Received By:
09/20/1012 VTCK330-PROGRESSIVE INS. $4,950.63 BECKY L ANDREWS
10/03/2012 VICK330-VICKERS KERRI $1,000.00 BECKY L ANDREWS
Summary
#of Payments: Z
Totai of Payments: $5,950.b3
Page #i
Latuffi Brothers Final Invoice
880 UNIVERSITY AVE.
ST. PAUL MN 55104 {ZD #:z7��9
6si-zza-ZSZS Unit #:TD25.O.a
Arrived: 9/18/2012
Ready: l0/1i201Z
Estimator:WILLIAM LATUFF
Customer Information Vehicie Information Insurance Information
Name: VICKERS KERRI Vehicle: 2007 BLACK Toyota Corolia lns Co: PROGRESSIVE INS.
Address: 1246 SCHEFFER AVE Style: 4D Sed Contact:
ST PAUL Mf�5511b Ucense: VTX821 Phone: 490-6823
Phone: (651)361-3330 VIN: 1NX8R32E07Z927247 Claim #: 12-3939919-01
Mileage: 79593 Deduct: $i,000.00
Mileage Out:
:� .'.',�"��p��za���a_. �.' .��,�c�p�t�on. . ... ; . .'�Yp�.. . R,ri�e A�clj pr�ce T `:I�br Addt t)�pt Paint Addl
1 Remove/#tepiace Inform Labei Air Cond NW $2.33 ✓ 0.1 8
Caution
_ . .._ _. . ... ... ..........__.._ _ _ . .. _. _
2 1 RemovelRepiace Inform Label Emission NW $1.98 $1.38 ✓ 0.1 e
Control
_ _. ._ .._ _
3 RemovelReptace Inform Label Vacuum NW $1.12 ✓ 0.1 B
Diaphragm
_
_ _ _ .... .... . _
q Remove/Replace Griile Bolt NW $9.86
_.. . . _
5 12emovellnstall R Frt Combination Lamp
1.4
_ ..
... P. .. ._...
_ _. _.... . __.. _ _ __....... .. .. .
6 Remove/Re lace L Front Combination NW $167.39 ✓ 6.3 B
Lamp Lens&Housing
_ _ _._.. . .... . ... _. .. _ .
__
7 ChecklAdJust Headlamps a•4 B
_._..
_.. __._ ... _ _ __ ... . .
8 RemoveiReplace Hood Panel NW $386•79 ✓ �•� B
_..,._,_..._.. ... . .. ...,....._. . ..._.. .. ... __ _. . ... _ .. _... ._ _ _
g Refrnish Hood Outside R 2.3
__.......... .......,.., ... ......._._.... ........_..,.. .........
....... _._......... __.. _....__ ._._._ .._ .... ._ . _. _
10 Refinish Add For Hood Underside R �•2
11 - -Remove/Repface _ Hood Insulator Retainer ._`.- NW __$11.92 _ _. � __ ___.__ _.
B
x8 x8 x8
_ .. ..
_ _
R 0.
12 Blend R Fender Oufside
. .__.. . . ... _...
__ _. .... _.
_ ... _ . R 0.5
13 Refinish L Add 7o Edge Fender
__.. p__ _. .. ..... _..._.._...
_ .
_- 5.0 B
14 Re air L Fender Panel
_ _ _
_ __ _ _ R t.6
15 Refinish L Fender Outside
__. .. _ .. _ _ . ........_.. __ _
.._ ._ .. . . _ _
16 Remove/lnstall R Fender Liner fl•4 B
_... _.._ _ _.. _ . _ _ _ _
_ .... ... _. 0.4 __ _ B.
17 Remove/lnstaii L Fender Liner
_. ......_.... _..._.... I
_ .. ......... . _.. ._ __ . . . __ B
1 S Remove/Replace L Fender Retainer x3 x3 NW $3.27 ✓
x3
_._ ... . . . _. �
�g 1 Remove/Replace W/Shield Glass AM $79.05 $79.05 ✓
_
_ _ .. .. . __. ____ _ __ .... . _
_2p _ @cost
_. _..... _.. ..... ._. . _. . ____ _ _ B
_
.... .. ...................__.
21 Remove/Repiace WlShield Reveal NW $74.39 ✓
Moulding __
_ . _........ . .__......__ _.. ..... ...
p ........._._ . ....�... .
... _ .__.__ .........__ ........ .... ..... __... B
22 RemovelRe lace R WlShield Visor NW $8.22 ✓
Retainer
_..._ _.. ... .
B
23 Remove/Replace L W/Shield Visor NW $8.22
Reiainer
_ _ _ .
_ _. ..... .
__ 0.
24 Removellnstall R Cowl/Dash Cover
_. _ . . _ 0.2 B
25 Remove/lnstall L CowUDash Cover
_ _
Zg Remove/Replace Roof Panel NW $454.43 ✓ 18 5 B
10/3/2012 4:57:05 AM Page# 1
Latuff Brothers F�nal Invoice
880 UNTVERSITY AVE.
ST. PAUL MN 55104 {ZQ #:�7�49
651-224-2828 Unit #:TD25.0.0
Arrived: 9/18/2012
Estimator:WILLIAM LAIUFF Ready: 10/1/2012
Customer Ynformation Vehicte Information Insurance Information
Name: VICKfRS KERRI Vehicfe: 2007 BLACK Toyota Corolla Ins Co: PROGRESSIVE IN5.
Address: 1246 SCHEFFER AVE Styie: 4D Sed Contact:
ST PAUL MN 55I16 License: VfX821 Phone: 490-6823
Phone: (651)361-3330 VIN: 1NX8R32E07Z927247 Claim #: 12-3939919-01
Mileage: 79593 Deduct: $1,0OO.Ofl
Mileage Out:
_.._ _ _ __. _ _ _ _ __
27 Refinish Roof Panel Outside _ _. _... __..... R 2,4
_ _
28 RemovelRepiace Frt Roof Header Panel NW $74.39 ✓ 1.5 B
........ __ _ .. . __.. ...
29 Remove/f2epiace Frt Roof Refnforcement NW $30.63 ✓ 1.5 B
Bow
_ .. _. _.. .. . .. _ _. ......_.
30 RemovelReplace Rear Roof f2einforcement NW $30.63 ✓ 1.5 S
_ _._ _ _ .
31 RemovelReplace Ctr Roof Reinforcement NW $42.61 ✓ 1.5 B
Bow
_ __. . _... . _._ __. .. _ __ . _ __ _
_ ____.
32 RemovelReplace Rear Roof Reinforcement NW $30.63 ✓ 1.5 B
Bow
_. ...,.._ ...... .. .._
_ ..
33 Remove/Replace R Roof Drip Finish Mldg NW $56.49 ✓ B
... __.._ _. ._ _. . ___ ___ __ .. .
34 RemovelReplace L Roof Drip Finish Mldg NW $56.49 ✓ $
__.. . .. __
35 Remove/Repiace R FR Roof Moulding Ciip NW $2.52 ✓ 8
x2 x2 x2
_ _. _ _._... .
36 Remove/Replace 4.Frt Roof Moulding Clip NW $2.52 ✓ B
x2 x2 x2
_. _. . . _ . . . _ _ _
37 RemovelReplace Roof Headliner NW $940.15 ✓ 0.5 B
_.. . _.__ .,. .. . _ .. . _ _ .
38 1 RemovelRepiace Back Window Glass AM $106.45 $106.A5 ✓ G
. _ __. _
. .. . _ ._
39 Remove/Replace Back Window Glass Seai NW $26.29 ✓ B
_ _..._...... .... . _ .
40 RemovelReplace Beck Window Moulding NW $56.49 ✓ �
__... . . .. _ . . ..._....... ... ........ .... ....... _ __ __.._ _. .. ... __...... . . __ . ..... .....
41 Addl Labor Clear Coat R 2.5
_ .. . .._.. ... . . .. . .._.. _..... .. ........... . . .. . . __.__ ......... .,_.__ _.
42 PaintlNlaferials PM $361.60
_ ... _ ... . _ _. . _... __.. _ _
_.. -- .
43 Addl Labor Hazardous Waste HW $3.50 B
Disposal
..._
__. . .. . .... _...__ _. ___. _. ......... _ _
44 Refinish CORROSION SS $7.50 ✓ R 0.3
PR07ECTION
.. .......... . .......... �.
_._... ___ _
45 Remove/Replace WINDSHIELD INSTALL SS $25.00 ✓ B
KIT
_ _ . . .__ _ _ B . ._
_. . ._.... .. P.. .. _
A6 Remove/Re lace BACKGLASS INSTALL SS $25.00 ✓
KIT
_ .. .. .. _ .. _
_ _ _ .. _
_.. B
47 RemovelReplace ROOF BOW ADHESIVE SS $25.00 ✓
_.. __
_.__..... ._. .. ....___ _.... _ . .
... _..... _ B
48 8308 HVY BDY SEAM SS $49.50 ✓
SEALER
._
_ ........ . ..._..... .... ._. ........ __ _ . _ .. _ .
...49_..... ..._.._.... .... _ . COVER FOR REFINISH . . SS $5.00 ✓ 0.2 B
_. ... ..... . .......... .. .
_ ... .. ....__... ..__...... __...... __. ..,..... _.
50 RemovelRepiace FR£IGHT WINDSHfELD AM $4.56
__..._ ___ .. _
. ............... ..____ _...
51 @COST
__ .. .
52 Addl Labor REZERO OCS SL $80.00 E
10/3/2012 9:57:05 AM Page# 2
Latuff Brothers Final Invoice
880 llNIVERSITY AVE.
ST. PAUL MN 55104 R� �#:z7d�9
651-2z4-2828 Unit #;TD25.0.0
Arrived: 9/18/2012
Ready: l0/1/2012
Estimator:WILLIAM LATUFF
Customer Informafiion Vehicle Information Insurance Information
Name: VICKERS KERRI Vehicle: 2007 BLACK Toyota Corolla Ins Co: PROGRESSIVE INS.
Address: 1246 SCHEFFER AVE Style: 40 Sed Contact;
ST PAUL MN 55116 License: VTX821 Phone: 490-6823
Phone: (651)361-3330 VIN: 1NXBR32E07Z927247 Claim #: 12-3939919-01
Mileage: 79593 Deduct: $1,000.00
Mileage Out;
_ ..
_._ _ _. . ... .. . ._
53 _ _ P27685 FENDER _...... SS .. .. .-$8.32 _ ✓ B
SHIELD CLIP x8 x8
T�o���d ,, Hc�.urs Ra�e: To#al:
; , ..:
R�-.+.,...':t >...��, e.., . �...::.. ". �... . :_ ;:.. . �, . > .. .,
..:.. . . , . .. . . . .
Fina{(Combined)Totals
Parts-New $2,489.76
Parts-Aftermarket $190.00
PARTS TOTAL $2,679.76
Body Labor 36.5 $52.00 $1,898.00
Refinish Labor 11.6 $52.00 $603.20
LA64R TOTAL $2,501.20
Shop Supplies $145.32
Sublet �90.00
Paint Materials $361.60
Nazardous Waste Removal $3.50
- ---------------
Sub Totai $5,781.38
SALES TAX{7.625°/a} $2ti5.�7
. GRAND TOTAL $5,996.45
Minus peductible $1,000.00
i
10/3/2012 9:57:05 AM Page# 3
Latuff Brothers Final Invoice
880 UNIVERSITY AVE.
ST. PAUL MN 55104 R� #:27�4}
651-224-2828 Unit #:TD25.0.0
Arrived: 9/18/2012
Ready: l0/1/2012
Estimator:WILl3AM WTUFF
Customer Information Vehicle Ynformation Insurance Information
Name: VICKERS KERRI Vehicle; 20Q7 BLACK 7oyota Corolla Ins Co: PROGRESSTVE INS,
Address: 1246 SCHEFFER AVE Style: 4D Sed Contact:
ST PAUL MN 551I6 License: ViX821 Phone: 490-68Z3
Phone: (b51)361-3330 VIN: 1NXBR32E07Z927247 ��dU�: �1,000 00 9-01
Mileage: 79593
Mileage out:
Thank you for bringing your vehiCle to our shop for repairs.
We appreciate your business.
Note: Please do not wax or polish the newly painted parts an your vehicle for at least 90 days. Also,
within this same tfine periad, do not pufi coverings such as car covers or bras oa your vehicle. This will
allow the finish to cure and harden completely.
Note:Aluminum wheels must be retorqued after the�rst 50-100 miles driven. Refer to owner's manua!
for proper torque specifications.
latuff Brothers provides a non-trans€erable lifetime warranty for the work performed on the above vehicEe for as long as the
customer listed above owns the vehicle. Subtet labor subject to the guarantee of each supplier. This warranty shall only apply if
the defects occurred under norrr�al driving conditions and not where any vehicle has been subjected to accidents, negligence,abuse
or misuse.
Our customers are imporCant to us. Since establishing our business, we have always been based on,QUALITY, HONESTY
and CUSTOMER SER1/IGE.
CUST�MER SATISFACTI�N SURV�Y�NSTRUCTIONS
1.You will receive a survey by mail.
2. Please fil[out and�efurn, as soon as possible, so the Automotive Customer Relations Sureau(ACRB)can process
your warranty.
3. We strive to provide you with a great customer experience. If you are hesitant to give us top marks, please let us know
so we can address any needs you may have.
I
I
10/3/2012 9:57:05 AM Page#4
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