Hernandez, Yasmary 10/03/2012 14:25 FAX 6512668574 SAINT PAUL CITY COUNCIL f�002/003
\7�'I'ICE �F CLA��YZ FORM to the City of Saint F' i��i, i4�::Annesota
1LIi�u:esota State Stntute 466.�5 states tl2at " .,.evc�y�ne-rson...tivho claints damages fi•orn any utc�niciprrli' ...:�ha:�a7��se io be presenle�l to the
ooverning bodv o{tTxe�nttrticipaliry witltin 180 days a/ter tJre alleged loss or injarry rs discovered rz n 'ia�st:7i�:�the tirne,��lace,artd
circumsf.aitces tl2ereof,and the nmourrt ofconaperrsation or otlier•relief dern� id��d.
Please com�tete tl�is forni in its entirety by clearly typit�g or printing yonr answer to ea :1�qu��stii�n. If more space is
needed,attacl� additionai sheets. Please note tha#you will not be contacted by teleptione >clar ify:u�swers,so pro�•ide as
inucl�information as necessaiy to explain your elaim,and the amount of com�ensarion bei �g rec i�es Eed. You will receive a
written acica�o�vledgement once yaur form is received. Tt�e process can take up to ten�vr. ks or lozr;er depending on the
natiire of yoar claim. This form must be signed,and both pages completed. If somethi; ;c.oe;no t appl}�,write`;�F/A'.
SEND C�l��PI.ETED FORI�I.�ND OTHER DOCU1�El\TTS 'CI: C'='CY CLER.h',
1S WEST KEI;LOGG BLVID, 310 C�TY HALL, SAINT I'' �i7I,, 1�9:N 55102
First Name � �, ?�iiddle Initial � Last Name � ���_
Company or usiness Name ��tf L('�\��1(Y"\a�� �-d��'��'�C
Are You an Instu•ance Company? es No If Yes,Claim Nun3ber? , � �
Si�-eet Address V ���( \l�� ��� �1�1__���_
City 1"\(����\� State W� Zi �Coc�r.__�����
Daytime Phone �) C �-�Cell Phone�) - Evening Tetephon �_ �__
Date of Accident'Injiiry or Date Discovered �jr� +2. Ti1ne�Jl_s.1�-'_a n! �in
—�
Please state,iiZ detail, wl�at occurred{happened),and�n�hy you are subniittina a claizxz, 1 ease indicate�vhy or ho«-you
feel tli Cit of Saint Paul.or its employees are involved andlor responsible for your dar ages. �__
C� c��'►� P� �( ��v P n ,[� �t�Sv�P�, ------
___._ .__ ��••��•➢�p
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Please check the box(es)that inost closely represent the reason for conlpletin�this forn�
�My vehicle��ras danlaged zn an accident C7 My vehicle: sx��:s c.�a1�:z�ed during a tow
❑My vehicle was damaged by a pothole or condition of the street ❑My vehicle: ��v�.s c.ain a;cd by a plow
� My vehicle�jTas��-ongfully towed and/az-ticketed ❑ I was injur; i c�n �::;it} property
❑ t7thez•type of property dan�age-please specify . _�.�_
❑ Other type of injury-please specify __ ___�
I�i order ta process your claixn��ou need to iuctude copies of ai[ ap�l 'ablc: dc�c:uments.
For the claims rypes listed below,ple�,se Ue sure to include the documents indicated or-. �vill �lei�;}�the handling of
your claim. Documents V47LL NOT be retw.-ned and become the property of the City. ' oi�a�.+,e_tc,oiu•aged to keep a
copy for yc�urself before submitting your claim foi-�n.
C>Properiy darnage claims to a vehicle: rivo estimates for the repairs to your ve ic le;t frn�damage exceeds
a500.00; or the actual bills and(or receipts for the i-epairs
O Towing claims: legible copies of any ticket issued arid a copy of tl�e in�poun�: lot rf:cei;��
O Other property damage clai�ns: two repair estimates if the damage exceeds �: OC.�C; o� r,he actual bitls
and/oi•receipts for the repairs; detailed list of damaged ieems
O J,z�jury clainls: medical bills,receipts
O Photographs are aiways welcome to document and support your claim Uut w� 1 r ot be�eturned.
Page 1 of 2-Please complete and return botit pages of Ciait: Fo�-:�:�
10/03/2012 14:26 FAX 6512668574 SAINT PAUL CITY COUNCIL 1�003/003
Tailure ta conxplete and retu��zi both�ages will resnit in cielay in the handl.: zg of yo��r- cIaim.
All Claims-ulease complete this section
ti�'ere there u�itiiesses to the i�cidez�t? Yes '�To I:zlirno��eni (circle:
Provide their names,add.i•esses and telepl�one zxunit�ers: _�.__
�Vere the polzce or law enforcen�ezit called? Ye No liz�own (c.rc.l�:�}
If yes,«•hat depar�inent or agency? Case�ar raport#��2.1 a a'?��L�
�Vhere did thc accident oF•injury•take place? Frovide street address,cross street,intersect: �n,n.me ��f park or facility,
closest landmark, etc. Please Ue as detailed as possible. If necessary, attach a diagram._ __ __
��t��� �
Pleasz indicate the amol.mt�ou are seeking i.n co�npensation or�vhat you would like the C ty to da �o resolve this claim.
ta your satisfaction.�� � 2�o�4=�(l��'�UC�"S -L-�CI.i�( �C��_�C'�l�_�-�lnl-t-c.,
Vehicle Claizns- lease com lete thas section ❑ check bo�: :f:hi;..sc�;:t.ion does not apply
Your Vehicle: Year C Make ModeI � U �G�1�j!_i�
T.icense Plate'_Vumber � State Color
Regi stered O«,1ier � �� � �
Driver of Vehzcle � �� e _. _
Area Damaged � . _�.__
City Velucle: Year 1�ake . odel . ,� ___
License Plate Number State Co1or
Dri�c�er of Vel�icle(City Employee's Name) _�_�
�•ea Damaged _____
III1L11'y Ciaims-nlease complete this section �.check bo:� if th;s section does not aUph�
How were yati injured? . ___�_
Wl�at part(s)af your body wez-e injured? � �_._
Have you sought medical tr-eatnient? Yes No Planning to Seek T �am�:�nt s:c:ircle)
When did you receive treatment? __�___J(provide date{s))
Name of Medical Provider(s): ____,._
Address Telephor ;___�_
Did you zniss work as a result of your injiuy? Yes No
`�hen did you miss work? __.�__(provide date(s))
Name of your Employer: __ �_
Addre;s Telephc e__ ___
�LCl�eck here if yau are attaching more pages to this clain�form. Number of tddit ron:il pages � .
By sigfiirzg this forrn,ynu ure statifig tliat a1l info��mation yott kave provi�led is ►' u��a�ic�carrect to flae besi
of your Izir.o�vledb e. Unsigned fo�•nts will not ve processed.
i
Subtftittit�g a false clairri casz res�tlt in pf�osecrction. Pate form was completed_ __ ___ '
Print the Name of the Person svho ConiQleted this Form: , .__.�_
Signati�re of Pei•son NlAtang the Claizn: __.r._
Revised Februaiy 201 I
Accident Report Pege 1 of 1
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htt�:!/www.dvslesupport.org�dvsigfo/accidentrecords 2(308/Includes_LEIPcint�teportIndiv... 8/21/20 i 2
AMERICAN FAMILY INSURANCE
SCANNING CENTER
6000 AMERICAN PARKWAY
MADISON,WI 53783-0001
1-800-MYAMFAM (1-800-692-6326)
*"*ESTIMATE***
11/01/2012 01:43 PM
Owner
Owner: MAXIMINO GOCHES ALARCON
Address: 6821 PILLSBURY AVE S Home/Day: (612)532-1208
City State Zip: RICHFIELD, MN 55423-2347 FAX:
Control Information
Claim#: 00345006685-OC Insured Policy#: 1067113506
Loss Date/Time: 08/20/2012 07:00 AM Loss Type: Collision
Deductible: $100.00
Ins.Company: American Family Insurance
Insured: MAXIMINO GOCHES ALARCON
Address: Home/Day: (612)532-1208
Inspection
Inspection Date: 11/01/2012 01:41 PM Inspection Type: Field
Inspection Location: Owner's residence Contact:
Address: 6821 PILLSBURY AVE S Home/Day: (612)532-1208x
City State Zip: RICHFIELD, MN 55423-2347
Primary Impact: Rear Secondary Impact:
Driveable: Yes Rental Assisted:
Assigned Date/Time: Received Date/Time: 10/29/2012 04:16 PM
First Contact Date/Time: Appointment Date/Time: 10/30/2012 08:00 AM
Appraiser Name: JONATHAN LAMOTT Appraiser License#:
Address: Cell: (612)804-1791
FAX: (866)808-3544
Email: jlamott@amfam.com
Repairer
Repairer: ABRA AUTO BODY-BLGTN Contact:
Address: 1000 AMERICAN BLVD Work/Day: (952)885-9778
FAX: (952)885-9778
City State Zip: Bloomington, MN 55420 Work/Day:
License#: Regulation ID: 41-1942823
Target Complete Date/Time: Days To Repair: 3 i
Remarks
"'ANY AND ALL SUPPLEMENTS MUST BE WRITTEN BY AND HAVE PRIOR
AUTH BY AMERICAN FAMILY*"`
FiLE HANDLER YASMARY AT EXT 62254
11/022012 09:42 PM Page 1 of 3
1999 Ford F-450 XLT CabB.Chassis 4 DR Crew Cab
Claim#: 00345006685-0C 11/01/2012 01:43 PM
Vehicle
1999 Ford F-450 XLT Cab&Chassis 4 DR Crew Cab
8cyl Diesel Turbo 7.3L
4 Speed Automatic
Lic.Plate: 837JKP Lic State: MN
Lic Expire: 02/2013 VIN: 1FDXW46FXXED65570
Prod Date: Mileage: 278,367
Veh Insp#: Mileage Type: Actual
Condition: Code: P8196F
Ext.Color: TEAL Int.Color:
Ext.Refinish: Two-Stage Int.Refinish: Two-Stage
Options
176 Inch Wheelbase Airbag Restraint Automatic Trans
Composite/European Hdimps Dual Rear Wheels Intermittent Wipers
Power Brakes Power poor Locks Power Mirrors
Power Steering Rear Bench Seat Side Steps
Tachometer Tilt Steering Wheel Tinted Glass
Velour/Cloth Seats
Damages
Line Op Guide MC Description MFR.Part No. Price ADJ% B% Hours R
1 SB M14 Corrosion Protection Sublet Repair $3.00" 0.3* SM
2 I M18 Set-Up And Measure Repair 1.0* SM
3 SB M60 Hazardous Waste Removal Sublet Repair $3.00" SM
4 I M64 Unibody-Frame Alignment Repair 3.0' FR
5 EU Rear bumper assembly RECYCLED PART $300.00* +25.00 1.5' SM'
»Part avail from AAA 651-423-2432 qt#1840285
6 I Raer Gate Assembly Repair 1.0' SM*
»buff and adjust for fit...work truck had prior marks present
7 EU Rear Bumper Brackets RECYCLED PART INC* INC" SM'
8 I LH boxside Repair 2.0" SM'
9 L LH boxside Refinish 1.0* RF"
»spot in bottom of boxside
10 I RH Boxside Repair 3.0' SM"
11 L RH Boxside Refinish 1.0" RF"
»spot in bottom of boxside
12 SB Prior Damages Present Sublet Repair $0.00' 0.0" SM'
»repairs figured for spot refinish and repairs without remoavl of UPD
12 Items
E ist mate Total&Entries
Other Parts $300.00
Paint Materials $64.00
Line Item Markup $75.00
Parts 8�Material Total $439.00 '
Tax On Parts Only @ 7.275°/a $27.28
Labor Rate Replace Repair Hrs Total Hrs
Hrs
Sheet Metal(SM) $52.00 1.5 7.3 8.8 $457.60
Mech/Elec(ME) $70.00
Frame(FR) $65.00 3.0 3.0 $195.00
11/02/2012 09:42 PM Page 2 of 3 �
1999 Ford F-450 XLT Cab&Chassis 4 DR Crew Cab
Claim#: 0034500668SOC 11/01/2012 01:43 PM
Refinish(RF) $52.00 2.0 2.0 $104.00
Paint Materials $32.00
Labor Total 13.8 Hours $756.60
Sublet Repairs $6.00
Gross Total $��22g.gg
Less: Deductible $100.00-
Net Total $1,128.88
Alternate Parts Y/00/00/00/00/00 CUM 00/00/00/00/00 Zip Code: 55343 METRO OLD 0411
Recycled Parts Y/0/0 Zip Code: 55343 INV DATE: 11/01/2012
Audatex Estimating 6.0.626 ES 11/02/2012 09:42 PM REL 6.0.626 DT 10/01/2012 DB 11/01/2012
Copyright(C)2011 Audatex North America,Inc.
"`ANY AND ALL SUPPLEMENTS MUST BE WRITTEN BY AND HAVE
PRIOR APPROVAL FROM A REPRESENTATIVE OF THIS COMPANY. **
THIS ESTIMATE MAY INCLUDE AFTER-MARKET OR CRASH PARTS SUPPLIED BY A SOURCE
OTHER THAN THE MANUFACTURER OF YOUR VEHICLE. THESE PARTS CAN BE IDENTIFIED
BY THE DESIGNATION "**QRP/QUALITY REPLACEMENT PARTS" ON THE ESTIMATE.
WARRANTIES APPLICABLE TO THESE REPLACEMENT PARTS ARE PROVIDED BY THE
MANUFACTURER OR DISTRIBUTOR OF THESE PARTS, RATHER THAN THE MANLJFACTURER OF
YOUR VEHICLE.
FOR YOUR PROTECTION, MINNESOTA LAW REQUIRES US TO INFORM YOU: A PERSON WHO
SUBMITS AN APPLICATION OR FILES A CLAIM WITH INTENT TO DEFRAUD OR HELP 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 Srpis UE= Replace OE Surplus
ET = Partial Replace Labor EP= Replace PXN EU= RECYCLED PART
TE = Partial Replace Price PM= Replace PXN Reman/Reblt UM= Replace Reman/Rebuilt
L = Refinish PC= Replace PXN Reconditioned UC= Replace Reconditioned
TT = TwaTone SB= Sublet Repair N = Additional Labor
BR= Blend Refinish I = Repair IT = Partial 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, Gaimant and others on a need to know basis in order to effectuate the claims process)without
������l� Audatex's priorwritten consent.
a 5�era co�rp�r�y
Copyright(C)2011 Audatex North America,Inc.
Audatex Estimating is a trademark of Audatex North America, Inc.
11/02/2012 09:42 PM Page 3 of 3