Vavoulis NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Miniiesotu S[uie Stulu�e=F66.0�.��trite.s thut " ...erer��j�er.snn...u�hn clarms dcunu,�es fronA mn�naiu�iri��alih�...shall<�u�ise to ve presen�ed to rhe
go��ei-nin,Y bndv o/'the nrtmrci/�ctlit���rit/�in I80 du�'s ujer�he ulle;�e�d/oss nr inju�_�'is di.scm°c�red o notice.slc�lin�!he tinae,pluce.ond
rircuntsictnres�hcvcu/.and Ihc ci�nnurN n/'cani��eusu�iun ur nthc r rc�li<�f�Ic�n�ai�ded."
Please complete this form in its entirety b��cle�rly�typin�;or printin�y��ur answer to each question. If more space is
�, needed,attach additional sl�eets. Ple�se note Chat��ou �sill not he contacted by telephone to clarify answers,so provide as
�� much informatiou as necessary to explaiu your daim,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 for�n must be signed,and bnth pages completed. If something does not apply,write`N/A'.
SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 �ITY HALL, SAINT PAUL, MN 55102
First Name ���i0✓`H Middle Initial � Last NameU�v 4 U L�S . �
_T--
Company or Busine�s Name__ _ -- —�Q�-'�-� 2��2
Are You an Insurance Company? Yes No If Yes>Claim Number?
Street Address�_�-��W OOd �-� CI� �����
Citv �- �� __State M� Zip Code S����
� Daytime Phone (�S1 �Z�{U-_OSO'l Cell Phone (6'S� )3�6 -aa� Evening Telepl�one (b5� )��1 -�0��
� Date of Accident/Inj�uy or Date Discoverecl d�"� �'_����-- Time�-���� ai�� pi
Please state, in detail, what occurred (happened), 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 for your damages.
�- -4� � 11n �In;c�.L c�.t -�t�-� S-� 0 S'► `�-fi 1.¢a.�, L
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Please check the box(es) that most closely 1-epresent the reason for completing this form:
�My vehicle was damaged in an accident ❑ My vehicle was dumaged d��ring a tow
❑ My vehicle was damaged by a pothole or conclition of the street ❑ My vehicle was damaged by a plow
❑ My vehicle was �vrongfully towed and/or Cicl<eted ❑ I was ii�jured on City property
❑ Other type of property damage-please specif��
� ❑ Other ty�e of itljw�y-please specify _ -
� In order to process your claim vo« need to include copies of all applicable documents.
For the claims types listed below, �lease be sure to include the documents indicated or it will delny the hanclling 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 yow-claim form.
�Property damage claims to a vehicle: two estimates for the repairs to your vehicle ifi 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 Inj�u�y� claii��s: medical bills. receipts
O Photographs are always welcome to document �u�d suppo��t your claim but will not be returned.
Page 1 of 2-Please complet�and return both pages of Claim Form
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? Yes � Unknown (circle)
Provide their names, addresses and telephone numbers:
Were the police or law enforcement called'?, Ye� No Unknown (circle)
If yes. what department or�igency? ���Ck _ Case#or report#�� ~��j�� � b�-
Where did the accident or injury tal<e place'? Provide street address.cross street, intersection, name of park ar faciliry,
closest landmarl:,etc. Please be as detailed as po�sible. If necessa�y, attach a diagram. ��� c�fon °
�.PI�e�Sa-��- �� � S-t� �I��✓ �e a� �,-�e p 5� sa u-t�.-�a��� � P bas _A.�-� �
Please indicate the amount u are seel�� in compens��tion or what you would lil<e the Ciry to do to resolve this claim
to your satisfaction. _��0�_, _ —
r, < <
Vehicle Claims please complete this section ❑ checl< box if[his srction does not apply
Your Vehicle: Year_��1�_Make�0 R-�0 Model �-P�N 1�Y1-
License Plate Number "�'C,hi 33 S State N�Al Color a 1-P'��K-
Registered Owner -�no oJ �'
Driver of Vehicle �1✓�-�� ��a��'S
Area Damaged 2 J� ��
Citv Vehicle: Year Make Model �O1--1 CX 5�1.���
License Plate N��mber State Color
Driver of Vehicle (City Employee's Name) D-F-�� � 0 � SANp(L���'T
Area Damaged_ M ���+W�'�1 -�o -�v�v.'�" 1��1.�_�l
Inlurv Claims please complete tliis section �'�.check box if this section does not apply
How were you injured?
Wllat part(sj of your body were injured? _ —.—
� Have you sought medical treatment'? Yes No Planni���to Seel< Treatment (circle)
�� When did you receive treatment'? _ _ (provide date(s))
Name of Medical Provicler(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 f'orm,you are stating that all information you have provided is true and correct to the best
of yozer kftowledge. U►isigned forms wi.11 siot be�rocessed.
Submitting a false claim cai� result i►i prosecutio�z. Date f'orm was completed � � �� ►a�� ��
Print the Name of the Person who Completed tliis F rm: '��'� ��`� ����
Signature of Person Making the C'laim:
Rcvisc�i Fcbruary 201 I
7�
ABC AUTO BODY INC. Workfile ID: 5ldbeb85
federalID: 41-1864301
598 SMITH AVE S, SAIIVT PAUL, MN 55107
Phone: (651) 222-5872
FAX: (651) 225-8627
Preliminary Estimate
Customer: VAVOULIS,TONY )ob Number:
Written By:Joel Williams
Insured: VAVOULIS,TONY Policy#: Claim#:
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact:
Owner: Inspection Location: Insurance Company:
VAVOULIS,TONY ABC AUTO BODY INC.
(651)290-0507 Day 598 SMITH AVE S
SAINT PAUL,MN 55107
Repair Faality
(651)222-5872 Business
VEHICLE
Year: 1999 Body Style: 2D P/U VIN: iFTZR15V8XP621612 Mileage In:
Make: FORD Engine: 6-3.OL-FI License: Mileage Out:
Model: RANGER 4X4 SUPERCAB Production Date: State: Vehicle Out:
XL
Color: Int: Condition: Job#:
TRANSMISSION Dual Mirrors SearchJSeek Styled Steel Wheels
5 Speed Transmission Console/Storage SAFETY P��
4 Wheel Drive CONVENIENCE Mti-Lodc Brakes(2) Gear Coat Paint
Overdrive Intermittent Wipers Driver Air Bag TRUCK
POWER RADIO Passenger Air Bag Rear Step Bumper
Power Steering AM Radio SEATS
Power Brakes FM Radio Goti�Seats
DECOR Stereo WHEELS
11/12/2012 11:07:28 AM 050139 Page 1
+ Preliminary Estimate
Customer: VAVOULIS,TONY 7ob Number:
Vehicle: 1999 FORD RAN6ER 4X4 SUPERCAB XL 2D P/U 6-3.OL-FI
Line Oper Description Part Number Qty Extended Labor Paint
Price;
1 REAR BUMPER
2 0/H rear bumper 1.2
3 Repl Bumper assy flareside painted YLSZ17906KA 1 326.70 Incl. 1.8
4 Add for Clear Coat 0.7
SUBTOTALS 326.70 1.2 2.5
ESTIMATE TOTALS ,
Category Basis Rate Cost�
Parts 326.70
Body Labor 1.2 hrs @ $50.00/hr 60.00
Paint Labor 2.5 hrs @ $50.00/hr 125.00
Paint Supplies 2.5 hrs @ $30.00/hr 75.00
Subtotal 586.70
Sales Tax $326.70 @ 7.1250% 23.28
Grand Total �•98
Deductible
CUSTOMER PAY 0.00 Ii
�
INSURANCE PAY 609.98
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.
11/12/2012 11:07:28 AM 050139 Page 2
HIGHLAND AUTOSTAR COLLISION CENTER
2042 WEST 7TH ST.
ST. PAUL, MN 55116
OFFICE: 651-699-0340 FAX: 651-699-4953
FED TAX ID#41-1828627
*** PRELIMINARY ESTIMATE"*
11/12/2012 01:03 PM
Owner
Owner: TONY VAVOULIS
Address: 740 LINWOOD AVE Work/Day: (651)290-0507
Home/Evening: (651)227-6573
City State Zip: Saint Paul, MN 55105 FAX:
Inspection _
Inspection Date: 11/12/2012 01:03 PM Inspection Type:
Primary Impact: Rear Secondary Impact:
Appraiser Name: LAWRENCE RITTER Appraiser License# :
Address: 2042 W 7TH ST Work/Day: (651)699-0340
City State Zip: Saint Paul, MN 551 1 6-31 07 FAX: (651)699-4953
Email: LARRY@HIGHLANDAUTOSTAR.COM
_ _
Repairer
HIGHLAND AUTOSTAR Contact:
Repairer:COLLISION
Address: 2042 7TH ST W Work/Day: (651)699-0340
City State Zip: ST PAUL, MN 55116-3107 FAX: (651)699-4953
Email: HA2042@POPP.NET
Vehicle _
1999 Ford Ranger XLT 2 DR Ext Cab Stepside Short Bed
6cyl Gasoline 3.0
4 Speed Automatic
Lic.Plate: TCG 335 Lic State: MI
Lic Expire: VIN: 1FTZR15V8XP621612
Veh Insp#: Mileage Type: Actual
Condition: Code: P83366
Ext.Color: EBONY Int.Color:
Ext.Refinish: Two-Stage Int. Refinish: Two-Stage
Ext. Paint Code: UA,12,6373 Int.Trim Code:
Options
4-Wheel Drive AM/FM Stereo Tape Aluminum/Alloy Wheels
Anti-Lock Brakes Auto Locking Hubs(4WD) Chrome Step Bumper
Dual Airbags Intermittent Wipers Lighted Entry System
Power Brakes Power Steering Rear Jump Seat(s)
Split Front Bench Seat Stepside Bed Tachometer
Tinted Glass Velour/Cloth Seats
Page 1 of 3
11/12/2012 01:04 PM
1999 Ford Ranger XLT 2 DR Ext Cab Stepside Short Bed
Claim#: 11/12/2012 01:03 PM
Damages
Line Op Guide MC Description MFR.Part No. Price ADJ% B% Hours R
Rear Bum�er •
1 E 565 46 Bumper,Rear Step YL5Z17906HA $405.28 1.6 SM
2 E 573 Supt,RR Bumper Inner LT F37Z17788A $21.48 INC SM
3 E 574 Supt,RR Bumper Inner RT F37Z17787A $21.48 INC SM
4 E 570 01 Pad,Rear Bumper Step 4L5Z1768076AB $112.68 INC SM
4 Items
MC Message
01 CALL DEALER FOR EXA�T PART#/PRICE
46 PRINTABLE ALTERNAT�PARTS COMPARE
Estimate Total & Entries
Gross Parts $560.92
Parts&Material Total $560.92
Tax On Parts Only (� 7.625% $42.77
Labor Rate Replace Repair Hrs Total Hrs
Hrs
Sheet Metal(SM) $56.00 1.6 1.6 $89.60
Mech/Elec(ME) $90.00
Frame(FR) $80.00
Refinish(RF) $56.00
Paint Materials $35.00
Labor Total 1.6 Hours $89.60
Gross Total $693.29
Net Total $693.29
Alternate Parts Y/01/00/00/01/01 CUM 01/00/00/01/01 Zip Code: 55116 Default
Recycled Parts NOT REQUESTED
Audatex Estimating 6.0.843 ES 11/12/2012 01:04 PM REL 6.0.843 DT 11/01/2012 DB 11/08/2012
Copyright(C)2011 Audatex North America, Inc.
YOU ARE AUTHORIZED TO MAKE THE ABOVE REPAIRS. I UNDERSTAND THAT PAYMENT IN FULL WILL BE DUE UPON RELEASE
OF
THE VEHICLE. PARTS PRICES ARE SUBJECTO TO INVOICE. I GRANT PERMISSION TO OPERATE MY VEHICLE FOR THE PURPOSE
OF
TESTING/INSPECTION. HIGHLAND AUTOSTAR IS NOT RESPONSBILE FOR LOSS OR DAMAGE TO THE VEHICLE OR ITS
CONTENTS IN
CASE OF FIRE,THEFT OR ANY CAUSE BEYOND YOUR CONTROL.AUTHORIZED
gy; DATE:
THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF ONE OR MORE CRASH PARTS
Page 2 of 3
1 V12/2072 01:04 PM
1999 Ford Ranger XLT 2 DR Ext Cab Stepside Short Bed
Claim It: 11/12/2012 01:03 PM
SUPPLIED BY A SOURCE OTHER THAN THE MANUFACTURER 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= Reptace PXN EU = Replace Recycled
TE = Partial Replace Price PM= Replace PXN R�eman/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 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,claimant and others on a need to know basis in order to effectuate the claims process)without
Audatex Audatex's prior written consent.
ct�('?�M�d tl'�?I}=j;+1'
T - Copyright(C)2011 Audatex North America, Inc.
Audatex Estimating is a trademark of Audatex North America, Inc.
Page 3 of 3
11/12/2012 01:04 PM