Vermeland _ -
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 this form in its entirety by clearly typing qr prinHng your answer to each question. If more spaee 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 egplain your claim,and the amo.unt 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 CIT'Y HALL, SAINT PAUL, MN 55102
First Name :JU�� Middle Initial � Last Name V�r��-�� h�
Company or Business Name N��
Are You an Insurance Company? Yes/ T� If Yes,Claim Number? �"
Street Address �J�'3 ��ir Tl►G�d �`V� S •
City�'('jjY1 Sta.te �`-� N Zip Code �.��
Daytime Phone(�)�(�U�IUI Cell Phone���-�J(�. Evening Telephone�f i QQ��q
Date of Accident/Injury or Date Discovered� � 2�j �� Time���m '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.
Please 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
` 0 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 i
I„�) Other type of property damage—please specify(�}Y'aL�l hSYCG� bt��j�/ b� � PL1U 1 �IGU( Ll�Y1Gt'2°_-4=.
❑ Other type of injury—please specify G�US� �hl�-�h�G l,tir - i� I l��r�G1CG1 G�n c'�t»!� Qdhcr'ed
.�v r�,y v�h c u-e • �
= In order to process your cla.im you need to include copies of all applicable 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 WII.,L NOT be returned and become the property of the City. You are encouraged to keep a ;
copy for yourself before submitting your claim form. ';
, . C�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 i
O Other property damage claims: two repair estimates if the damage exceeds $500.00; or the actual bills ;
and/or receipts for the�epairs;detailed list of damaged items i
O Injury claims: medical bills,receipts ��CE��ED �
O Photographs are always welcome to document and support your claim but will not be re
Page 1 of 2—Please complete and return both pages of Claim Form NOV 15 20� I
CITY G�.ERK
_ _ _ _
_ _ _ __
_ ___
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims—please complete tlus section
Were there witnesses to the incident? Ye No Unknown (circle)
P ovide the� names,addresses and telephone numbers:� hYY�l� u�ckh OAn 1�lG(Ka_P�bl�j ���7�
,.�,� (�al , hC � d -� r.e re q�an��Cc�v 5_� sxd ;�m„
Were the police or law enforcement called? Yes � Unknown (circle)
If 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 necessary a ch a dia am.�_h-4 �C 1r�C, l -
r fUYJ�bi C�k� �A►'l�iln�i �m►� - �6 4�" � . � u 1 �� �rc d)
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. ,� �j� � '"`�
Vehicle Claims— lease com lete this section ❑ check box if this section does not a 1
Your Vehicle: Year a� 1 Make �jA Model b
License Plate Number (S�I D PX Sta.te�_Color�1 Ir�i'� ,
Registered Owner �j 15Q Yl �3Q S�l hCS ��tr'��I a h Lt
• Driver of Vehicle �jP j�'
Area Damaged�[��Qq-y4fG� Gq'�!� A I Gf�-v5��CY'1�1'' �-f V'�hf .t.-G
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniury Claims—please complete this section �check box if this section does not applv
How were you injured?
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 work? (provide date(s))
Name of your Employer:
Address . Telephone �
C�Check here if you are attaching more pages to this claim form. Number of additional pages�.
By sigt�ing 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 ���m�X ����
Print the Name of the Person who Completed this Form: :�U� ��w� VGr�1G�l h�
Signature of Person Making the Claim: �� .�i���-��'
Revised February 2011
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Claim of: Susan Bownes Vermeland
On Monday, October 22, 2012,Thomas and Sons, a contractor hired by the City of St. Paul to
reconstruct 4th Street in St. Paul, blew massive amounts of concrete dust into the air. The concrete dust
storm settled on my parked vehicle and given it was a damp day it adhered to all the painted and glass
surfaces. My vehicle was parked on the first level of the Capitol City Parking Ramp which is located in
downtown St. Paul on 4th Street, between Cedar and Minnesota Streets.
On my way to work on Tuesday, October 23, 2012 (approximately 5:45 a.m.), I noticed a layer of what I
thought was dust on my windshield. I sprayed the windshield with washer fluid which activated the
wipers. I immediately noticed that there was a coating on the windshield that would not come off;the
wipers made a scraping noise on the windshield so I stopped using them immediately. Upon arriving at
the parking ramp I checked my windshield and other surfaces of my vehicle to find they were covered
with a rough,grainy finish with would not brush off.
On Thursday, October 25, 2012, I contacted Sherry at Thomas and Sons Contractors. She said I should
get a professional car wash and their company would cover the cost. I went to the Downtowner
carwash in St. Paul,they looked at my vehicle and said the damage would not come off with a car wash.
They explained that in order to remove the concrete that had adhered to the finish of the vehicle and
the glass an acid wash would be needed and then the entire vehicle would need to be buffed. The cost
would be about$600 and take two days. I called Sherry at Thomas and Sons to tell her this information,
her response was that the cost should be closer to$150 and that I would need to get three estimates of
the work needed.
My personal schedule did not allow me to pursue this issue again until Thursday, November 15L at which
time I secured two additional estimates(all copies attached). I called Sherry at Thomas and Sons to
update her on the estimates. During the phone call she questioned me as to where I got her phone
number, and then she denied that her company had any connection to the concrete dust storm on
10/22/12. This was the same person that offered to pay for my car wash a week earlier. She questioned
me as to where they were working in St. Paul and then said the foreman told her their company wasn't
responsible "for anything".
Due to the nature of the damage to my vehicle and the fact that I could not see through my windshield
during inclement weather or use my windshield wiper, I needed to move ahead with the repairs
required. I selected Schoonover Bodyworks&Glass—Stillwater to do the work. My car was in for
repair, and I did not have use of it for three days, November 8,9 and 12.
��'��� �����������,
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Schoonover Bodyworks & Workfile ID: 81f773ba
Federal ID:
Glass-Stillwater
We Can Fix That!
2000 Curve Crest Boulevard, Stillwater, MN 55082
Phone: (651) 351-0086
FAX: (651) 351-0863
Final Bill
RO Number: 542523
Customer: Insurance: Adjuster: Estimator: Olin Glick
VERMELAND,SUSAN SELF PAY Phone: Create Date: 11/1/2012
4343 PENFIELD AVE S Claim: SELFPAY
AFTON,MN 55001 Loss Date:
(651)503-5056 Deductible:
Year: 2011 Sryle: 4D WGN VIN: 4S46RCCC2B3315384 Mileage In:
Make: SUBA Color: Green Mileage Out:
Model: OUTBACK PREMIUM License: 159DPX Job Number: COLLIN Vehicle Out: il/12/2012
Line Ver Operation Descriptlon Qty Extended Type Labor Type Paint
Price$
1 E01 Repair Acid wash 4,0 g�y
2 E01 Sublet High Speed Buff and Polish 1 275.00T Sublet
3 E01 Sublet Hazardous waste removal 1 5.00 Other
Estimate Totals Discount$ Markup$ Rate$ Total Hours Total$
Sublet/Miscellaneous 280.00
Labor,Body 52.00 4.0 208.00
Material,Shop 3.00 4.0 12.00
Subtotal 500.00
Sales Tax 19.59
Grand Total 519.59
Net Total 519:b9
Estimate Version Total�
Original 519.59
Insurance Total$: 0.00
Received from Insurance$: 0.00
`"a � N e it p
J N m°' m� t+� � Balance due from Insurance$: 0.00
�=00 0�+:� �.�3•-, m`" r1 .
O� �"' mW N m
�m u�7�p m m� i j � Customer Total$: 519.59
t-
p� ■m m •• s� a Received from Customer$: 0.00
O W,i-�9 n' � � F-oo �°
m�� � � � � �� � Balance due from Customer$: 519.59
IY� °+i � x 1-i ¢°�^° � �° .
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N SfJ �E ��CJ]c�o m.--. � Q �S c,a
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=Mxhanical,Ref=Refinish,Struc=
Structural
11/12/2012 2:42:23 PM Paae 1
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�^:s2 �1a�n: ���' �af i� r^cr��: (��= j ��� _��:3c� �:a�.- � Schedul� D���� �
:�. � - �
:�.Ldm2r �ama• �( � ,r��� ��=_f,-���- q.-;� ��- ( �chedule Time:
.i_-?.-�55' �-�,:-.�- -�'� ����€ �7��'�Ct `�''�'Y� �� I Y�ar �a'�G' Y" 'i,� �
=:� :��a�e,Zi �� ��#r� t--�1� ��'>� � c j �1o�2i: Gci��r: �- �j �
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;��i� Services tc be Complet2 . � � Luba:Yes 1 ��o Gas: Y�s/ Nc � ' 'n �i1�2r:Yas/ �o
." � " ,
�ecia; tns#ructicns: ' ` r; � `G-�"� �' �' , . G�� Wriisr: r
•�� Date: `� Orop Time: � _Pick-Up Tirne: �
:eds Ride: Yes! No To: Needs Pick-Up: Yes o From:
. t . ,
�:ailer: � � Manager: t
� �Interior Dtlr Mngr . � Exterior � Dtlr Mn r .
. .
ar-petlSeats H.S./OrbJH.W.(circle one) �
�or Side Pockets � � . - Hood Cracks
aor Panels . . . Trunk Cracks(AA all
� rubber
ash/Steering Wheel . . : �.� Door Trim Cracks .
o�sole/Glove Box ' � . �rc��.R�ar �ump�rs
� _:_�:. :,_.. : :.. :.. .. . �Tarl:B.�tgRemoval,..., : .
ir Vents.
'indows/Mirrors All Chromel Embiems �
isorslHeadliner � � . Windaws/Wiper Arms
unroof/Cover � White Walls � '
shtrayslCup holders � . Rimsl V1�heets :
�oor Mats-Clean & Put Vinyl Top
ackiir � - .
�ot Pedals (No AA)� All Trim & Grill
acuum Trunk � Armor All
ioor Side.Panels . .' Mud Flaps--Clean &AA �
rmor All interior � � �� Front Spoiler �
oor Jams (AA rubber � . Gas Fill Area .
tri s � � �
omplete Detaiis Door Jams{AA rubber
stri s
egreaselDress Engine . �
Ols Stickers Off �
iter Bag/ Paper Floor. Liter Bag! Paper Floor � � �
latsl Reminder Window . Mats/ Reminder Window
tickers Stickers
***Look for & do little things—oil sqeakydoors, tighten loose dashboard, etc.***
ALL 17EMS BACK INTO VEHICLE !!!• �
]ERRY'S AUTO DETAIL & FRAME INC. Workfile ID: f392a71c
13601 60TH ST N, STILLWATER, MN 55082
Phone: (651) 439-9340
FAX: (651) 439-6913
Preliminary Estimate
Customer: VERMELAND, SUSAN 7ob Number:
Written By: Mike DeCorsey
Insured: VERMELAND,SUSAN Policy#: Claim#:
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact:
Owner: Inspection Location: Insurance Company:
VERMELAND,SUSAN JERRY'S AUTO DEfAIL&FRAME INC.
4343 PENFIELD AVE S 1360160TH ST N
AFfON,MN 55001 SIILLWATER, MN 55082
(651)503-5056 Evening Repair Facility
(651)439-9340 Day
VEHICLE
Year: 2011 Body Style: 4D WGN VIN: 4S46RCCC263315384 Mileage In:
Make: SUBA Engine: 4-2.5L-FI License: Mileage Out:
Model: OUTBACK PREMIUM Production Date: State: Vehicle Out:
Color: Int: Condition: Job#:
TRANSMISSION Console/Storage AM Radio Luggage/Roof Rack
6 Speed Transmission Overhead Console FM Radio SEATS
4 Wheel Drive CONVENIENCE Stereo Cloth Seats
Overdrive Air Conditioning Search/Seek Bucket Seats
POWER Rear Defogger CD Player WHEELS
Power Steering Tilt Wheel Auxiliary Audio Connection Aluminum/Alloy Wheels
Power Brakes Cruise Control SAFETY PAINT
Power Windows Telescopic Wheel Mti-Lodc Brakes(4) Clear Coat Paint
Power Locks Intermittent Wipers Driver Air Bag OTHER
Power Driver Seat Keyless Entry Passenger Air Bag Traction Control
Power Mirrors Rear Window Wiper Head/Curtain Air Bags Stability Control
DECOR Alarm Front Side Impact Air Bags Fog Lamps
Dual Mirrors Steering Wheel Controls 4 Wheel Disc&akes
Privacy Glass RADIO ROOF
II
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11/1/2012 1:13:04 PM 018946 Page 1 i
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Preliminary Estimate
Customer: VERMELAND,SUSAN )ob Number:
Vehicte: 2011 SUBA OUTBACK PREMIUM 4D WGN 4-2.5L-FI
Line Oper Description Part Number Qty Extended Labor Paint
Price$
1 # Rpr REMOVE CONCRETE DUST 0 0.00 5.0 0.0
NOTE: POSSIBLE MORE TIME NEEDED,NEED TO GEf INTO THE REMOVAL PROCESS TO SEE HOW IT ALl
COMES OFF.
2 # Rpr BUFF COMPLETE 0 0.00 6.5 0.0
SUBTOTALS 0.00 11.5 0.0
ESTIMATE TOTALS
Category Basis Rate Cost$
pa� 0.00
gpdy Labp� 11.5 hrs @ $52.00/hr 598.00
Subtotal 598.00
Grand Total 598.00
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 598.00
QUALITY REPLACEMENT PARTS WARRAMY
OUR REPAIR ESTIMATE MAY SPECIFY THE USE OF QUALIIY REPLACEMENT PARTS. QUALITY REPLACEMENT PARTS
ARE PARTS NOT MANUFACTURED BY OR FOR THE ORIGINAL EQUIPMENT MANUFACTURER. WE WILL STAND
BEHIND TNE 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 WARRAMY 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 FACILTfY THAT PERFORMS
THE REPAIR ON YOUR VEHICLE, BE UNABLE TO RESOLVE A LEGITIMATE COMPLAINT ABOUT THE QUALITY
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 TNE 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 SUBJECT TO FINES AND CONFINEMENT IN STATE PRISON.
il/1/2012 1:13:04 PM 018946 Pa9e 2