Renner RECEIVED - --- '
OC� 2 4 20]2
NOTICE OF CLAIM FORM to the City of Saint Pau�, Min�nes�ota
Minnesota Srate Statute;iu'6.05 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 reltef demanded."
Please complete this form in its entirety by clearly typing or printing your answer to each question. IP more space is
neesled,attach additional sheets. Please note that you may or may not be contacted by telephone to discuss your claim �'�
circumstances,so provide as much infortaation as necessary to egplain your claim,and the amount of compensation being
requ�ted. Tlus 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,31U CITY HALL,SAINT PAUL,MN 55102
First Name �Arn'<<K Middle Initial w Last Name �EN�'�
Company or Business Name,if applicable
Street Address l SS z 5�NFF F E�2 AYF
City .SA'�'T �A✓� State 1'yl N Zip Code r s��6
Daytime Telephone S�� ) �� 312� Evening Telephone(_)
Date of Accidend Injury or Date Discovered_ �a��'�� Z-01�- Time b�'�3 a�/pm(circle)
Please state,in detail, w�zat occurred, and why you are submitting a claim. Please indicate why or how you '
feel the Ciry of Saint Paul or its employees are involved and/or responsible. �',
a 6a�/cva�d fi'�c /�rt a oCc.�l /;�i,� dn fl�e �vch,�,� of' (�,cf���� 3 '
�n c�r� c anaf s 1af-��ed rny c�r pa�G�.�d �K fl,e sf,�eet v�r�iti�.�d
/� ��C1'Wtt TAI�J✓Qf 7''�?o�w� av� /o� Zb1 L �n/as &�Hf � �'�G CIfN iltiS�'Ytj
n�o,no�/{-mBN�': /1'f trlrai� J
,•C�t,� cvrO�Hf of' /e�3 Zo/z �✓�s Utfrrnr�/7 !i/%yl�y '
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 was 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 properry
�Other type of property damage—please specify vCl�i c/t �(avt�ASc� /•,H �`cG �n �pvlc va�a(
� Other type of injury—please specify
❑ Other type not listed—please specify
In order to process your claim vou need to include conies of all apnlicable 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 additional information depending on your claim.
f8(Properiy 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 clauns: legible copies of any tickets issued and copies of the impoupo lot receipts
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.
;f:
Page 1 of 2—Please complete and return both pages of Claim Form
Failure to provide a completed claim form will result in delays in processing.
I
,:,t<:
Notice of Claim Form,City of Saint Paul,page two '
All Claims—nlease complete this section �
Were there witnesses to the incident? Yes �N Unknown (circle) !
If yes,please provide their names, addresses and telephone numbers:
i
Were the police or law enforcement called? Yes Unknown (circle)
Tf yes,what department or agency? Case#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.
1 c'sZ s cl�e Ffc� A�lLn vc, fq�n t �i►„( ✓t�til i
Please indicate the amount you are seeking in compensation from this claim or what you would like the City i
to do to resolve this claim to your satisfaction. c� ✓ �ari, fi//!,✓Rfi�
- ib��! 1°''� I
I
Vehicle Claims— lease com lete this section ❑ check box if this section does not a 1 i
Your Vehicle: Year 1 p8?Make VoLKs Model � ;
License Plate Number Z � State 1k/l. Color ��IA�K
Registere�Owner P/NY�-��� �✓��2 I
Driver of Vehicle '` �
Area Damaged_ �,t-�v� Ft7✓fl E�2
City Vehicle: Year Make Model
Licez�se Plate Number State Color
Driver of Vehicle(City Employee's Name)
' Area Damaged
Iniur3t_.Claims—nlease comolete this section �Y9 check box if this section does not a�plv
How were you in�ured?
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)) j
Name of Medical Provider(s): � i
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
❑ Check here if you are attaching more pages to this claim form. Number of additional pages �
By signing thu form,you are stating that all i�formation you have provided is irue and correct to the best of your knowledge. Unsigned
forms will not be processed. Submitting a false clann can result in prosecution. �
Print the Name of the Person who Completed this Form:
Signature of Person Making the Claim: _
Date form was completed Revised Apri12007
�3TY.
7ERRY'S AUTO DETAIL & FRAME INC. �Norld�ile ID: 5f3308fb
13601 60TH ST N, STILLWATER, MN 55082
Phone: (651)439-9340
FAX: (651) 439-6913
Preliminary Estimate
Customer: RENNER, PATRICK Job Number:
Written By: Mike DeCorsey
Insured: RENNER, PATRICK Policy#: Claim#:
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact:
Owner: Inspection Location: Insurance Company:
RENNER,PATRICK JERRY'S AUTO DETAIL&FRAME INC.
1552 SCHEFFER AVE 13601 60TH ST N
ST.PAUL,MN 55116 STILLWATER,MN 55082
(651)321-3728 Evening Repair Fadliry
(651)439-9340 Day
VEFIICLE
Year: 2007 Body Style: 4D SED VIN: 3VWEF71KK7M147878 Mileage In:
Make: VW Engine: 5-2.5L-FI License: Mileage Out:
Model: JEl'TA WOLFSBURG Producaon Date: State: Vehicle Out:
Color: Int: Condition: ]ob#:
TRANSMISSION Console/Storage FM Radio Electric Glass Sunroof
5 Speed Transmission CONVENIENCE Stereo SEATS
Overdrive Air Conditioning Search/Seek Cloth Seats
POWER Rear Defogger CD Player Bucket Seats
Power Steering Tilt Wheel SAFETY Heated Seats
Power Brakes Cruise Control Anti-Lock Brakes(4) WHEELS
Power Windows Telescopic Wheel Dnver Air Bag Aluminum/Alloy Wheels
Power Laks Intermittent Wipers Passenger Air Bag PAINT
Power Mirrors Keyless Entry Head/Curtain Air Bags Clear Coat Paint
Heated Mirrors Alarm Front Side Impact Air Bags OTHER
DECOR RADIO 4 Wheel Disc Brakes Traction Control i
Dual Mirrors AM Radio ROOF Signal Integrated Mirrors I
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10/19/2012 4:04:46 PM 018946 Page 1
Preliminary Estimate
Customer: RENNER, PATRICK )ob Number:
Vehicle: 2007 VW JETTA WOLFSBURG 4D SED 5-2.5L-FI
Line Oper Description Part Number Qty Extended Labor Paint
Price�
1 FRONT BUMPER 8k GRILLE
2 R&I R&I bumper cover 0 0.00 1.5 0.0
3 FRONT LAMPS
4 R&I LT Headlamp assy 0 0.00 0.3 0.0
5 FENDER
6 Repl LT Fender 1K5821021A 1 210.00 1.5 2.0
7 Add for Clear Coat 0 0.00 0.0 0.8
8 Add for Edging 0 0.00 0.0 0.5
9 R&I LT Fender liner 0 0.00 Incl. 0.0
10 R&I LT Front extri w/6 speed manual 0 0.00 Incl. 0.0
11 # R&I MUD FLAP 0 0.00 0.2 0.0
12 # R&I NAMEPLATE-CLEAN AND 0 0.00 0.3 0.0
RETAPE
13 # Subl Hazardous waste removai 1 3.00 X 0.0 0.0
14 # Repl Cover car 1 0.00 X 0.0 0.2
15 # Color tint/color match 1 0.00 0.0 0.3
SUBTOTALS 213.00 3.8 3.8
ESTIMATE TOTALS
��9orY Basis Rate Cost#
Pa� 210.00
�Y��r 3.8 hrs @ $52.00/hr 197.60
Paint Labor 3.8 hrs @ $52.00/hr 197.60
Paint Supplies 3.8 hrs @ $32.00/hr 121.60
Miscellaneous 3.00
Subtotal 729.80
Sales Tax $210.00 @ 7.1250% 14.96
Grand Total 744,76
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY �44,76
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10/19/2012 4:04:46 PM 018946 Page 2
Preliminary Estimate
Customer: RENNER, PATRICK 7ob Number:
Vehicle: 2007 VW JEITA WOLFSBURG 4D SED 5-2.5L-FI
QUALITY REPLACEMENT PARTS WARRANTY
OUR REPAIR ESTIMATE MAY SPECIFY THE USE OF QUALITY REPLACEMENT PARTS. QUALITY REPLACEMENT PARTS
ARE PARTS NOT MANUFACTURED BY OR FOR THE ORIGINAL EQUIPMENT MANUFACTURER. WE WILL STAND
BEHIND THE QUALITY REPLACEMENT PARTS THAT ARE SPECIFIED ON THIS ESTIMATE AND USED IN THE REPAIR
OF YOUR VEHICLE, FOR AS LONG AS YOU OWN/LEASE THE VEHICLE. WE WARRANT THESE PARTS ARE OF LIKE
IQND, QUALITY, SAFETY, FIT AND PERFORMANCE TO PARTS MANUFACTURED BY OR FOR THE ORIGINAL
EQUIPMENT MANUFACTURER.
THIS WARRANTY EXCLUSIVELY COVERS LOSS OR DAMAGE THAT IS RELATED TO DEFECTS IN THE QUALITY
REPLACEMENT PART. THIS WARRANTY DOES NOT COVER DAMAGE OR PART FAILURE DUE TO IMPROPER
INSTALLATION, MISUSE, NEGLECT, ABUSE, IMPROPER MAINTENANCE, ABNORMAL OPERATION, OR NORMAL WEAR
&TEAR.
SHOULD A SUPPLIER OF A PART SPECIFIED IN OUR REPAIR ESTIMATE, OR THE REPAIR FACILITY THAT PERFORMS
THE REPAIR ON YOUR VEHICLE, BE UNABLE TO RESOLVE A LEGITIMATE COMPLAINT ABOUT THE QUAIITY
REPLACEMENT PART USED IN THE REPAIR, WE WILL MAKE EVERY EFFORT TO SEE THAT THE PROBLEM IS
CORRECTED.
THIS WARRANTY AND ANY REPRESENTATIONS MADE HEREIN ARE NON-TRANSFERABLE AND EXTEND ONLY TO
THE PARTY OWNING/LEASING THE VEHICLE AT THE TIME OF THE REPAIR.
FOR ASSISTANCE, PLEASE CONTACT THE NEAREST HELPPOINT CLAIM SERVICES OFFICE.
DISCLAIMER:
ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT INSURANCE CLAIM FOR THE PAYMENT OF A
LOSS MAY BE GUILTY OF A CRIME AND MAY BE SUB]ECT TO FINES AND CONFINEMENT IN STATE PRISON.
THE LABOR AND TAX RATES USED WERE DETERMINED BY THE VEHICLE INSPECTION LOCATION UNLESS THE
REPAIR FAQLITY WAS KNOWN AT THE TIME OF THE INSPECTION OR ANOTHER LOCATION WAS SPECIFIED
BEFORE THE ESTIMATE WAS PREPARED
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.
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10/19/2012 4:04:46 PM 018946 Page 3
Preliminary Estimate
Customer: RENNER, PATRICK 7ob Number:
Vehicle: 2007 VW JEfTA WOLFSBURG 4D SED 5-2.5L-FI
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
ERA9278, CCC Data Date 10/17/2012, 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 Defined 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 Steel. Inc1.=Included. LKQ=Like Kind and Quality. LT=Left. MAG=Magnesium. Non-Adj.=Non
Adjacent. NSF=NSF International Certified Part. 0/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=6ureau of Automotive Repair. EPA=Environmental Protection Agency. NHTSA= National Highway
Transportation and Safety Administration. PDR=Paintless Dent Repair. VIN=Vehicle Identification Number.
10/19/2012 4:04:46 PM 018946 Page 4
" � � Date: 10/8l201212:47 PM
Estimabe ID: 8017
Estimate Version: 0
Preliminary
Profile ID: Stillwater Collision
Stillwater Collision & Restoration
804 W.Laurel Street,Stillwater,MN 55082
(651)439-8771
Fax: (651)439-9322
Email: stillh2ocollision2�msn.com
TaxID: 4t-2100889
Damage Assessed By: Tony Grove
Deductible: UNKNOWN
Mitchell Service: 910115
Description: 2007 Volkswagen Jetta 2.OT
Body Style: 4D Sed Drive Train: 2.OL Turbo inj 4 Cyl 6A FWD
OEM/ALT: O Search Code: None
Options: PASSENGER AIRBAG,DRNER AIRBAG,POWER DRIVER SEAT,POWER LOCK,POWER WINDOW
REAR WINDOW DEFOGGER,MANUAL AIR CONDITION,CRUISE CONTROL,TILT STEERING COLUMN
TELESCOPIC STEERING COLUMN,ANTI-LOCK BRAKE SYS.,TftACTION CONTROL,FOG LIGHTS
ALUM/ALLOY WHEELS,AUXILIARY INPUT,SATELLITE RADIO,FRONT AIR DAM,TINTED GLASS
VARIABLE ASSISTED STEERING,SIDE AIRBAGS,ANTI-THEFT SYSTEM
SIDE HEAD CURTAIN AtRBAGS,DAYTIME RUNNING LIGHTS
AMlFM STEREO CqCHANGER WITH PREMIUM SOUND,ELECTRONIC STABILITY CONTROL
FRONT BUCKET SEATS,INTERIOR AIR FILTER,KEYLESS ENTRY SYSTEM,POWER DISC BRAKES
POWER HEATED EXTERIOR MIRRORS,POWER LIFTGATEITRUNK
REAR WINDOW DIVERSITY ANTENNA
Line Entry Labor Line Item PartType/ Dollar Labor
Item Number Type Operation Description Part Number Amount Units
1 002002 BDY REMOVEJINSTALL Frt Bumper Cover INC #
2 002248 BDY CHECK/ADJUST Headlamps 0.4
3 002006 BDY REMOVEIINSTALL L Front Combination Lamp 0.4 #
4 002053 BDY REMOVE/INSTALL L Fender Spiash Guard p.2
5 000161 BDY REMOVE/REPLACE L Fender Panel 1 K5 821 021 A 210.00 2.8 #
6 AUTO REF REFINISH L Fender Outside C 2.0
7 AUTO REF REFINISH L Add To Edge Fender C 0.5
8 AUTO REF ADD'L OPR Clear Coat 1.p'
9 933018 REF ADD'L OPR Mask For Overspray 5.00 • �'
10 AUTO ADD'L COST Paint/Materials 98.00 *
11 AUTO ADD'L COST Hazardous Waste Disposal 5.00 *
"-Judgment Item
#-Labor Note Applies
C-Included in Clear Coat Calc
ESTIMATE RECALL NUMBER: 10/08l20t2 12:44:11 8017
Mitchell Data Version: OEM: JUL 12 V
Copyright(C)1994-2012 Mitchell lntemational Page 1 of Z
Software Version: 7.0.443 All Rights Reserved
� ' � Date: 10/8/201212:47 PM
Estimate ID: 8017
Estimate Version: 0
Preliminary
Profile ID: Stillwater Collision
Estimate Totais
Add'I
Labor Sublet
i. Labor Subtotals Units Rate Amount Amount Totals II. Part Replacement Summary Amount
Body 3.8 50.00 0.00 0.00 190.00 Taxable Parts 210.00
Refinish 3.5 50.00 5.00 0.00 180.00 Sales Tax � 7.125% 14.96
Non-Taxable Labor 370.00 Total Replacement Parts Amount 224.96
Labor Summary 7.3 370.00
III. Additional Costs Amount IV. Adjustments Amount
Non-Taxable Costs 103.00 Customer Responsibility 0.00
Total Additional Costs 103.00
Paint Material Method:Rates
Init Rate=28.00 ,Init Max Hours=99.9,Addl Rate=0.00
I. Total Labor: 370.00
II. Total Replacement Parts: 224.96
III. Total Additional Costs: 103.00
Gross Total: 697.96
IV. Total Adjustments: 0.00
Net Total: 697.96
This is a preliminarv estimate.
Additional chanqes to the estimate mav be required for the actual repair.
At Stillwater Collision & Restoration �ve take great pride in our
commitment to our customers.
We stand by this commitment by offering a guarantee that will stand as
long as you own your vehicle.
ESTIMATE RECALL NUMBER: 10/08/2012 12:44:71 8017
Mitcheli Data Version: OEM: JUL 12 V
CopyNght(C)1994-2012 Mitchell Intemational Page 2 of 2
Software Version: 7.0.443 All Rights Reserved