Burdick �C� 31 2012
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NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minnesota Stnte Statute 466.05 stntes thnt "...every person...who claims dnmages from nny mienicipalrty...shnll cnt�se to be presented to the
goverrirng body of the municipnliq�wi�hin 180 days after d1e alleged loss or injury is discovered a notice stating the time,place,nnd
circuinstances thereof,and the nmount of compensntion 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 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 J�eV C.Y1 Middle Initial�Last Name (JU.�.D i G�
Company or Business Name �+���
Are You an Insurance Company? Yes/� If Yes,Claim Number?
Street Address�9�7 �U/�A��� 5�
City M�LEGI 10OD State � �1.� Zip Code ���Oc/
Da time Phone r _
y (����Cell Phone( 6�� )�-(o�Evening Telephone( )
Date of Accident/Injury or Date Discovered iD a5/•� Time /��4 am/�
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.
S ►2 Go 5 . Gf l, F'/✓�� .i� ` �t1�45
u�i n� b l�P r tt� ���2� �ht 6���� A�' o �2A,�} i n1�ro r� 5��� aF m y
C�l-�_ e R��s���, D�m�1 b E rr� i H-� L�1�'T 5�.�� oF m� C�f2
P�le�e check the box(es)that most closely represent the reason for completing this form: '
�'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 '�
0 Other type of injury—please specify ��
I
In order to process your claim you need to include copies of all anulicable 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
�`�g,
C
Failure to complete 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? � No Unknown (circle)
Provide their names, addresses and telephone numbers:
S I� PA U L F��.� DEPA�2.--t�rr►�nl7' � �
Were the police or law enforcement called? es� No Unknown (circle)
If yes,what department or agency? J! l. ORICL t� UE�Case#or report# i�a 5 H-is b
Where did the accident or injury take place? Provide street address,cross street, intersection,name of park or faci�ity,
closest landmark,etc. Please be as detailed as possible. If necessary,attach a diagram. �i�O D �Ult.�t.l.�A Y �;
/yJA-�2/t� A�V�•
Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim
toyoursatisfaction. "rf-�'� �p�(.�.lT 3- RrY1 S��-'/�� �✓` C`,0�'v'►PE�U5A-7�G�tl 1S
� �. �loCi. op
Vehicle Claims- lease com lete this section ❑ check box if this section does not a 1
Your Vehicle: Year I99g Make Model_ SL-2
License Plate Number 8�19-��� State rr�Color (����1/
Registered Owner 5�V�� Q�GlZ�I�K,
Driver of Vehicle
Area Damaged � �-�F'r' S i t�� l�F C i4-�
City Vehicle: Year Make Model s 1-: PA'UL �/�2� 77�'UG
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Inlury Claims-please complete this section �heck box if this section does not avplv
How were you injured?
I
What part(s)of your body were injured? � I
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
[�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.
Submitting a false claim can result in prosecution. Date form was completed `D-�Gr f�-
Print the Name of the Person who Completed this Form: J��ilj � �/,{�2 Q!L/�
Signature of Person Making the Claim:�� �
Revised February 201 I
SUBURBAN AUTO BODY
MINNESOTA'S COLLISION SPECIALIST
2989 COUNTRY DRIVE
LITTLE CANADA, MN 55117
PHONE: 651-633-8900 FAX:651-481-0700
***PRELIMINARY ESTIMATE***
10/26/2012 04:05 PM
. __�_...__��.W�._...._ _........ .�......_...__..__.___
_...._..._... __.._�—.._�
Owner �� _ ��_
Owner: STEVEN BURDICK
Inspection ---._._._____...___._. _
Inspection Date: 10/26/2012 04:06 PM Inspection Type:
Appraiser Name: JOSH STORRS Appraiser License#:
Address: 2989 COUNTRY DR Work/Day: (651)633-8900
CeIL• (651)983-4438
City State Zip: Little Canada, MN 55117 FAX:
CRepairer ��
Repairer: Suburban Auto Body Contact: Suburban Auto Body
Address: 2989 Country Drive Work/Day: (651)633-8900
City State Zip: Little Canada, MN 55117 FAX: (651�81-0700
Email: tr@suburbanautobody.net
Vehicle � �
1998 Saturn SL2 STD 4 DR Sedan
4cyl Gasoline 1.9 Dohc
4 Speed Automatic
Lic Expire: VIN: 1 G8ZK5273WZ260853
Veh Insp#: Mileage Type: Actual
Condition: Code: SN213C
Ext. Refinish: Two-Stage Int.Refinish: Two-Stage i
Options
AM/FM Stereo Air Conditioning Center Console I
Dual Airbags Intermittent Wipers Power Brakes
Power Steering Rear Window Defroster Rem Trunk-UGate Release
Tachometer Tilt Steering Wheel Tinted Glass
Velour/Cloth Seats
Damages _.s_.�.__._..._ _._.___..... ....____.�_
Line Op Guide MC Description MFR.Part No. Price ADJ% B°/a Hours R
1 RI 6 Front Bumper Cover R&I R&I Assembly 0.8 SM
2 BR 103 13 Fender,Front LT Blend Refinish 1.9 RF
0.9 Blend
0.6 Two-stage setup
10/26/2012 04:35 PM Page 1 of 3
1998 Satum SL2 STD 4 DR Sedan � .
Claim#: 10/26/2012 04:05 PM
0.4 Two-stage
3 RI 121 Emblem,Front Fender LT R& I Assembly 0.2 SM
4 RI 32 Guard,Fender Mud LT R& I Assembly 0.2 SM
5 E 207 02 Door SheIl,Front LT 21172109 $575.93 7.4 SM
6 RI 231 Pnl,lnner poor Trim LT R&I Assembly INC SM
7 RI 217 Applique,Frt Door Fram LT R&I Assembly 0.2 SM
8 E 245 Mirror,0uter R/C LT 21170589 $165.40 INC SM
9 RI 213 Cyl,Front Door Lock LT R&I Assembly INC SM
10 RI 215 Handle,Front Door Otr LT R&I Assembly INC SM
11 E 287 02 Door SheIl,Rear LT 21171137 $384.12 4.7 SM
12 RI 315 Applique Assy,Rear Dr LT R& I Assembly 02 SM
13 RI 309 Pnl,lnner poor Trim LT R&�Assembly INC SM
14 RI 297 Glass,Rear poor T LT R&I Assembly INC SM
15 RI 333 Rear Vent Glass R& I LT R&I Assembly INC SM
16 RI 293 Handle,RR Door Outer LT R&I Assembly INC SM
17 I 389 Panel,Quarter LT Repair 6.0* SM
18 L 389 Panel,Quarter LT Refinish 2.3 • RF
1.9 Surface
0.4 Two-stage
19 E 533 Taillamp Assembly LT 21110953 $152.04 0.3 SM
20 RI 533 Taillamp Assembly LT R&I Assembly INC SM
21 RI 569 Rear Bumper Cover R&I R&I Assembly 1.0 SM
21 Items
MC Message
02 PART f�19. DISCONTINUED,CALL DEALER FOR EXACT PART NO.
13 INCLUDES 0.6 HOURS FIRST PANEL TWO-STAGE ALLOWANCE
Estimate Total&Entries
Gross Parts $1,277.49
Paint Materials $134.40
Parts&Material Total $1,411.89
Tax On Parts Only @ 7.125% $91.02
Labor Rate Replace Repair Hrs Total Hrs
H rs
Sheet Metal (SM) $52.00 15.0 6.0 21.0 $1,092.00
Mech/Elec(ME) $95.00
Frame(FR) $75.00
Refinish(RF) $52.00 4.2 4.2 $218.40
Paint Materials $32.00
Labor Total 25.2 Hours $1,310.40
Gross Total $2,813.31
Net Total a2,813.31
Alternate Parts Y/00/00/00/00/00 CUM 00/00/00/00/00 Zip Code: 55117 LOCAL SUPPLIERS
Audatex Estimating 6.0.843 ES 10/26/2012 0�:35 PM REL 6.0.843 DT 09/01/2012
Copyright(C)2011 Audatex North America, Inc.
1.4 HRS WERE ADDED TO THIS ESTIMATE BASED ON AUDATEX'S TWO-STAGE REFINISH FORMULA.
10/26/2012 04:35 PM � Page 2 of 3
1998 Saturn SL2 STD 4 DR Sedan �
Claim#: 10/26/2012 04:05 PM
THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF ONE OR MORE CRASH PARTS
SUPPLIED BY A SOURCE OTHER THAN THE M�ITTUFACTURER 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= Replace Reman/Rebuilt
L = Refinish PC= Replace PXN Reconditioned UC= Replace Reconditioned
TT = Two-Tone SB= Sublet Repair N = Additional Labor
BR= Blend Refinish I = Repair IT = Partial Repair
CG= Chipguard RI = R&I Assembty P = Check
AA= Appearance Allowance RP= Related Prior Damage
This report contains prqprietary 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
� �1 l�a�'e� Audatex's prior written consent.
�M�
d 513��'Jii t0t1t/3dlFY .. .- . .
Copyright(C)2011 Audatex North America, Inc.
Audatex Estimating is a trademark of Audatex North America, Inc.
10/26/2012 0435 PM - Page 3 of 3
. PROTECH AUTO BODY LLC Workfile ID: 75b631f0
FederalID: 45-1838127
� 3900 Highway 61 N, White Bear Lake, MN 55110
Phone: (651) 317-8020
FAX: (651) 317-8030
Estimate
RO Number:
Customer: Insurance: Adjuster: Estimator: Ron Begin
Burdick, Steve Phone: Create Date: 10/26/2012
2967 Furness St Claim:
Maplewood, MN 55109 Loss Date:
(651)788-6735 Deductible:
Year: 1998 Style: 4D SED VIN: 1G8ZK5273WZ260853 Mileage In:
Make: SATU Color: Green Mileage Out:
Model: SL2 License: Job Number: Vehicle Out:
Line Ver Operation Description Qty Extended Type Labor Type Paint
Price$
1 E01 FENDER
2 E01 Repair LT Fender 1.0 Body 2.1
3 E01 Add for Clear Coat p,g
4 E01 Remove/Install LT Emblem 0.2 Body
5 E01 FRONT DOOR
6 E01 Repair LT Door frame assy 2.0 Body 1.0
7 E01 Overlap Major Adj. Panel (0.4)
8 E01 Add for Clear Coat 0.1
9 E01 Remove/Replace LT Exterior panei 1 220.03T OEM 1.7 Body 0.0
10 E01 Remove/Replace LT Mirror remote 1 162.65T OEM 0.0 Body
11 E01 Remove/Replace LT Lock cylinder clip 1 0.64T OEM
12 E01 Remove/Replace LT Lock cylinder 1 45.00T OEM 0.3 Body
13 E01 REAR DOOR
14 E01 Remove/Replace LT Door frame assy 1 384.12T OEM 3.6 Body
15 E01 Remove/Replace LT Exterior panel 1 260.78T OEM 0.0 Body 0.0
16 E01 QUARTER PANEL
17 E01 Repair LT Quarter panel 2.0 Body 2.0
18 E01 Overlap Major Non-Adj. Panel �0.2�
19 E01 Add for Clear Coat 0.4
20 E01 Alignment LT Quarter panel 1.0 Body
21 E01 Sublet Hazardous waste 1 5.00 Other i
22 E01 Remove/Replace Car cover 1 10.00 Other 'i
Estimate Totals Discount$ Markup$ Rate$ Total Hours Total$
Parts
1,083.22
Sublet/Miscellaneous 5.00
Labor, Body 52.00 11.8 613.60
Labor, Refinish 52.00 5.8 301.60
T=Taxable Item,RPD=Related Prior Damage,AA=Appearance Allowance,UPD=Unrelated Prior Damage,PDR=Paintless Dent Repair,A/M=Aftermarket,Rechr=Rechromed,Reman=
Remanufactured,OEM=New Original Equipment Manufacturer,Recor=Re-cored,LKQ=Like Kind Quality or Used,Diag=Diagnostic,Elec=Electrical,Mech=Mechanical,Ref=Refinish,Struc=
Stru[tural
10/26/2012 4:15:36 PM Page 1
Estimate
R� Number:
Vehicle: 1998 SATU SL2 4D SED 4-1.9L-FI Green
Material, Paint 185.60
Subtotal 2,189.02
Sales Tax 76.47
Grand Total 2,265.49
Net Total 2,265.49
Estimate Version Total$
Original 2,265.49
Insurance Total$: 2,265.49
Received from Insurance$: 0.00
Balance due from Insurance$: 2,265.49
Customer Total$: 0.00
Received from Customer$: 0.00
Balance due from Customer$: 0.00
I
�
�
T=Taxable Item,RPD=Related Prior Damage,AA=Appearance Allowance,UPD=Unrelated Prior Damage,PDR=Paintless Dent Repair,A/M=Aftermarket,Rechr=Rechromed,Reman=
Remanufac[ured,OEM=New Original Equipment Manufacturer,Recor=Re-cored,LKQ=Like Kind Quality or Used,Diag=Diagnostic,Elec=Electrical,Mech=Mechanical,Ref=Refinish,Struc=
Structural
10/26/2012 4:15:36 PM Page 2
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