Duclos `�`��°v�ea
N0� ? �2412 Sota
,��.p.�ul�Niinne
,_ � , gNi to the Cl�' ��� resented to the
�,INI F4 municipaliry•••shall cause to be p lace,and
` oTICE �F CL , a notice stating the time,p
who claims damaSeS from anY
N erson..• ed loss or inju►'Y is discovereddemanded."
` ..everY P other relief If more space is
� S after the a11eS�ompe�ation or
Qiity within 18�d�' to ea�h question. So provide as
o the municip f and che amount of our answer answers,
Nfinnesota Stat body uf 466.OSrcums�an es thereo, hone to c►ar�fY YoU�,��►receive a
governing � �ng or printing Y telep requested.
clearly h'P ending on the
�n its entirety by ou�,���not be contacted byensation bVee�oT�onger dep �N�A,,
lete this form ount of comp Write
p1ease comp please note that y and the am take up to ten
needed,attach additional sheet�o eXp,ain your claim, ,rhe process can If something does not applY�
our form is received. a es comp�eted.
much information as ement once y ned,and both p g CITY �LE��
written ac oU��agm. This form must be sig ENTS TO:
nature ot y QTHER DOCUM � 55102
SEND COMPLETED FO��310 CITY HALL, SAINT PAU��
15 WEST K�I'LOGG BL �
Middle Initial
M Last Name D u� 10 5
First Name N� � �G
Company or Business Name
h o�
Are You an Insurance Company? Yes No If Yes,
Claim Number?
a�l E U'^i� 77
Street Address ��� � v� �Q o
State M N Zip Code 5 5 1
city M 1� w o oc�
Daytime Phone(bt2)S10 - b�12 Cell Phone(�
��.G Evening Telephone(_� S°4"`'�'
�o io t2. Time l=am/�
Date of Accident/Injury or Date Discovered � '
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. 2 �1004- t'�►t 5'nel��ti+o�
Rv�e e x�
} �� o� L 9� a+ 1�-' 3t� v rn oh Saturdaw o� {�o yer (9+" �o1Z• i�+.�r�. �
a s 14 ve 1n i c ta i w -t�.� rti t�t- ti a n�- 'h��n !��.e.. S n�2 a �t vV cars a I+s
v h I�s ot r ca �t k�. s l � v�lktcle
.z k b t r n�.,er a n s� a! -1'G.c f= wd s o'K io vk 4�K�.r2 't'�t l a� v1��ei�
7ke ra wa 4 fiY�-h-cc c4.. b a i K.2 t�«�s a wa- -h -t� F F. S. �.� w on'r.. � u e t a w u F•Q.
t� S'f'�11!� G1�GCG. S�o Z bt A Q.K o�,D Sp. �T3'�l l7 F'C'�l�iG�G. M�OV��L ��A� '�i�K
--�oK� 4 S was �v� �,r�u -�_ stxtl,ac� Gt� ti� 't'Kty rA.h iN�+s N�G C4'�'L4t M�
q t
Please c t r�ck the box(es)that mos closely represent the reason for completing this form: fil2 ; f,�.vKP�Zc p -� �
'�My vehicle was damaged in an accident ❑ My vehicle was damaged during a tow p f.-f{,
❑ My vehicle was damaged by a pothole or condition of the street ❑ My vehicle was damaged by a plow ��
❑ My vehicie was wrongfully towed and/or ticketed O I�ti•as injured o�
❑ Other type of property damage-please specify ��
❑ Other type of injury-please specify " 1�e {7'�i
In order to process your claim ou need to include co ies w�s dhy�.�
For the claims � �a licable doCAIIICIIts. ��0��1
typ s listed below,please be sure to include the documents indicated or it will delay the handlin of 4
your claim. Documents WII.,L NpT be returned and become the property of the City, yoU�e encoura �
copy for yourself before submitting your claim form. g
(�Pro e ged to keep a S{, �
p rty damage claims to a vehicle:two estimates for the repairs to your vehicle if the dama e excee
$500.00; or the actual bills and/or receipts for the repairs g ds �Y �a
O Towing claims: legible copies of any ticket issued and a co
O Other ro e g py of the impound lot receipt q kei.�,
P P rty dama e claims: two repair estimates if the damage exceeds$500.00; or the
and/or receipts for the repairs; detailed list of damaged items � � l u
� �jury claims:medical bills,receipts a��ai bills
O Photographs are always welcome to document and su d� �
�, PPo�t your claim bUt Wl] �u d��uN
Y° Page 1 °f2-Please complete and return both n�...,.. ,.r.., . 1 nOt�e re�li�ed.
K ean eoh�ec�. - 50 -� �k� Aa
La M e t�t,,.,! � .
• �i' Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims—nlease complete this section
Were there witnesses to the incident? Yes No Unknown (circle)
Provide their names, addresses and telephone numbers: 'Ch e o�{1�r -�;r e rre rn tN -t4�e �
�i� fi�uc f� . 'Ck.e y d�d ho�} q�� w�e -t-k e i r h a w�..� s. S�t- wa s (u s c kc s�
W e r e t h e p o l i c e o r l a w e n f o r c e m e n t c a l l e d? Y e s N o Un k nown (circ le) �"'°. � fi�
If yes,what department or agency? Case#or �� °f �•
P4u(
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,attach a diagram.
2v► -t 1►o r q k t k a a� -ltit r h t�t k.G. o� t4-e S+�a 11 i K o� Ptve- �h"�} o{�f � S 9 y W
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. A a 11 rt a�►5 �t�.l,�h °I O 3 • $t (re G¢i a k-�..
e5�'i w.a s Ipo d w�. a
Vehicle Claims—�lease complete this section ❑ check box if this section does not annlv
Your Vehicle: Year 2o Make K-I A Model S po r-(—A.q�¢,.
License Plate Number State M►J Color g(a�f`
Registered Owner F,rrd.o� G la. gt,c�k,�r = Ni�ol,e �{Q G�b S -
Driver of Vehicle N i �•o l.� �tc l,os
Area Damaged '�r� S i nt ti� � 1 e � bo o -{-l.,� �-
City Vehicle: Year Make Model 'r� -1-nccG,.�
License Plate Number h 0. State MN Color
Driver of Vehicle(City Emp oyee's Name)
Area Damaged t�o I1.c.
Iniurv Claims—alease complete this section �check box if this section does not annlv
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)) ii
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 !a. �. 1 Z.
Print the Name of the Person who Completed this Form: f.J i Go( e /lil• p l�t C�0 5
Signature of Person Making the Claim: Q� .
Revised February 2011
± ' ■ / ■
CUSTOMER #: 8106745 74152 �
� : Wb/ta Bssi
.. � *INV�ICE* Ch�ys/sr J��p Ood o
FREDERICK BEST BEECHER
1667 VILLAGE TRAIL EAST L7NIT $#3 3430 Highway 61 N • White Bear Lake, MN 55110
Phone: (651) 482-6100 • Service: (651) 482-0881
MAPLEWOOD, MN 55109 PAGE 1 www.barnettauto.com
HOME: 612-810-6745 CONT: 612-810-6745
BUS: 612-677-0640 CELL: SERVICE ADVISOR: 99 THOMAS C NELSON
CQLO; YEAR AI��iMQC?EL Vl ' ;L(C�hkSE 1LEAGE EN9 QU7 > TAG '?
BLK CHERR 11 KIA SPORTAGE KNDPB3A22B7054369 145GKD 25000 25000 T6166
#��L RA'T'E PROp,DAT� 1lVARR.£XP �iOMfSEA PO NQ. €iAT� ; PRYMEI�T IIdV.E1ATE
lOMARll D 18 : 00 090CT12 0 . 00 CASH 160CT12
�.O.OP�NE� ;R��a[a�r ' >� oPriorvs: STK:K11192 DLR:61909 ENG:2 .4 Liter DOHC
090CT12 160CT12 '
LINE OPCODE TECH TYPE HOURS LIST NET TOTAL '
A REPLACE LFT FRT TIRE � ,
SS MOUNT AND BALANCE TIRE �
285 CBK 0 .40 19 .20 19 .20
1 2115343 KUMHO SOLUS 171. 90 171. 90 171. 90 '
PO#8015 �
PARTS: 171. 90 LABOR: 19.20 OTHER: , 0 . 00 TOTAL LINE A: 191 . 10
25000 TECHNICIAN MOUNTED ONE NEW TIRE AND BALANCED THE WHEEL ON I
LEFT FR�3NT,� QF �EH����t,,� � ��..
.,,, � *******,t**�le***�t�ir�Ir�F�k�Y*�k*�r*�k****�t**�k�sk�k**:**��t��** �t�t*�t., .�s,, . '
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I
Thank you for your business STATEMENT OF DISCLAIMER (}�$C�{p710(� >TQTRLS'
The factory warrenty co�stitutes all of the
warrenties with respect to<he sale of this LABOR AMOUNT 19 .2 O
Your complete satisfaction is our #1 concem. ��em��temg. The sener nerenv eXoressH
disclaims all warrenties either express or PARTS AMOUNT 1�]1. 9 Q
If you are not completely satisfied or if you mo��,including any implied warranq of GAS,OIL,LUBE Q . Q Q
merchantability or fifiess for a particular
have any questions, comments, or if we P��oo�. SB��e� neimer assumes nor SUBLETAMOUNT Q . Q Q
� authorizes any other person to assume for
can be of further assistance please contact us. R����eb��m� �n connecuon w�u,me sme MISC.CHARGES Q . Q�
of this item/items.
� � ALL PARTS NEW ORIGINAL EQUIPMENT TOTAL CHARGES 191 . 1 O
SERVICE HOURS PARTS HOURS �N�E�oT,;ERW�sE�EC�F�EO �ess,ao�usTnnErvT
U-USED R-REBUILT O . O O �
V RECVCLED C-RECONDITIONED . SALES TAX
MONDAY - FRIDAY MONDAY - FRIDAY � 12 .25
7:�Dam - 6:OQpm 7:3�am - 5:3�pm� CUSTOMER SIGNATURE P�EA$E PAY '.
THIS AMOUNT 2(}3 .3'5
CUSTOMER COPY
- BARNETTS WHITE BEAR
3430 HIGHWAY 61
WHITE BEAR LAKE, MINNESOTA 55110
OFFICE:651-429-3391 FAX:651-429-5133
FEDERAL ID#41-0853814
***PRELIMINARY ESTIMATE"*"
10/08/2012 03:59 PM
Owner
Owner: NICOLE DUCLOS
Address: 1667 VILLAGE TRL EAST#3 Work/Day: (612)810-6712
City State Zip: Maplewood,MN 55109 F��
Inspection
Inspection Date: 10/08/2012 03:59 PM Inspection Type:
Primary Impact: Left Front Corner Secondary Impact:
Company: BARNETT CHRYSLER Appraiser License#:
Contact: THOMAS NELSON
Address: 3430 HWY 61 Work/Day: (651�182-6100
City State Zip: White Bear Lake, MN 55110 Work/Day: (651�186-3710
Repairer
Repairer: BARNETT CHRYSLER Contact: THOMAS NELSON 3430 HWY 61
Address: Work/Day: (651�182-6100
City State Zip: White Bear Lake, MN 55110 Work/Day:
Vehicle
2011 Kia Sportage LX 4 DR Wagon
4cyl Gasoline 2.4
6-Speed Automatic
Lic.Plate: Lic State: MN
Lic Expire: VIN: KNDP63A22B7054369
Veh Insp#: Mileage Type: Actual
Condition: Code: KA824B
Ext.Color: BLACK Int.Color:
Ext.Refinish: Two-Stage Int.Refinish: TwaStage
Options
AM/FM CD Player Air Conditioning Alarm System
Aluminum/Alioy Wheels Anti-Lock Brakes Auto Headlamp Control
Bucket Seats Center Console Cruise Control
Dual Airbags Flip-Up Liftgate Window Halogen Headlights
Head Airbags Intermittent Wipers Keyless Entry System
Lighted Entry System MP3 Piayer Overhead Console
Power Brakes Power poor Locks Power Mirrors
Power Steering Power Windows Privacy Glass
Rear Step Bumper Rear Window Defroster Rear Window Wiper/Washer
Side Airbags Sirius Satellite Radio Skid Plates
Split Folding Rear Seat Stability Cntrl Suspensn Strg Wheel Radio Control
Tachometer Theft Deterrent System Tilt Steering Wheel
Page 1 of 3
10/16/2012 03:59 PM
2011 Kia Sportage lX 4 DR Wagon
Claim#: 10/08/2012 03:59 PM
Tinied Glass Traction Control System Trip Computer
Velour/Cloth Seats
Damages
Line Op Guide MC Desc�ption MFR.Part No. Price ADJ% B% Hours R
1 N 18 Frt Bumper Cvr Overhau Additional Labor 1.6 SM
2 I 30 Cvr,Front Bumper Upr Repair 1.0' SM
3 L 30 13 Cvr,Front Bumper Upr Refinish 4.1 RF
4 E 6 Cvr,Front Bumper Lwr 865123W000 $147.18 0.8 SM
5 E REPLACE TIRE Replace OEM $171.90* 0.4* SM*
6 SB MOUNT&BALANCE Sublet Repair $20.00* SM'
6 Items
MC Message '
13 INCLUDES 0.6 HOURS FIRST PANEL TWO-STAGE ALLOWANCE '
Estimate Total 8�Entries
Gross Parts $319.08
Paint Materials $131.20
Parts&Material Total $450.28
Tax On Parts Only @ 7.125% $22.73
Labor Rate Replace Repair Hrs Total Hrs
Hrs
Sheet Metal(SM) $52.00 1.2 2.6 3.8 $197.60
Mech/Elec(ME) $121.00
Frame(FR) $72.00
Refinish(RF) $52.00 4.1 4.1 $213.20
Paint Materials $32.00
Labor Total 7.9 Hours $410.
Sublet Repairs $20.00
Gross Total E903.81
Net Total a903.81
Alternate Parts Y/00/00/00/00/00 CUM 00/00/00/00/00 Zip Code: 55110 Default
Audatex Estimating 6.0.726 ES 10/16/2012 03:59 PM RE�6.0.726 DT 09/01/2012
Copyright(C)2011 Audatex North America,Inc.
1.2 HRS WERE ADDED TO THIS ESTIMATE BASED ON AUDATEX'S TWO-STAGE REFINISH FORMULA.
Op Codes
10/76/2012 03:59 PM Page 2 of 3
� � LAMETTRY'S COLLISION - Workfile ID: ce89f656
,
MAPLEWOOD Federal ID: 411393089
"Every Customer Leaves With A Smile"
2923 MAPLEWOOD DR, SAINT PAUL, MN 55109
Phone: (651) 766-9770
FAX: (651) 766-8660
Preliminary Estimate
Customer: DUCLOS, NICOLE Job Number:
Written By:ANDY TIHANYI
Insured: DUCLOS, NICOLE Policy#: Claim #:
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact:
Owner: Inspection Location: Insurance Company:
DUCLOS, NICOLE LAMETTRY'S COLLISION- MAPLEWOOD
1667 VILLAGE TRAIL EAST#3 2923 MAPLEWOOD DR
MAPLEWOOD, MN 55109 SAINT PAUL, MN 55109
(612)810-6712 Evening Repair Facility
(651)766-9770 Business
VEHICLE
Year: 2011 Body Style: 4D UN VIN: KNDPB3A2267054369 Mileage In:
Make: KIA Engine: 4-2.4L-FI License: 145GKD Mileage Out:
Model: SPORTAGE 4X2 LX Production Date: State: MN Vehicle Out:
Color: BLK Int: Condition: Job#:
TRANSMISSION Overhead Console FM Radio Traction Control
Automatic Transmission CONVENIENCE Stereo Stability Control
POWER Air Conditioning Search/Seek SEATS
Power Steering Rear Defogger CD Player Cloth Seats
Power Brakes Tilt Wheel Auxiliary Audio Connection Bucket Seats
Power Windows Cruise Control Satellite Radio WHEELS
Power Locks Intermittent Wipers SAFET'Y Aluminum/Alloy Wheels
Power Mirrors Keyless Entry Anti-Lock Brakes(4) PAINT
DECOR Alarm Driver Air Bag Clear Coat Paint
Body Side Moldings Rear Window Wiper Passenger Air Bag OTHER
Dual Mirrors Steering Wheel Controls Head/Curtain Air Bags Signal Integrated Mirrors
Privacy Glass RADIO Front Side Impact Air Bags
Console/Storage AM Radio 4 Wheel Disc Brakes
11/17/2012 11:29:17 AM 053108 Page 1
. Preliminary Estimate
Customer: DUCLOS, NICOLE 7ob Number:
Vehicle: 2011 KIA SPORTAGE 4X2 LX 4D UN 4-2.4L-FI BLK
Line Oper Description Part Number Qty Extended Labor Paint
Price$
1 FRONT BUMPER
2 O/H bumper assy 2.0
3 R8cI R&I bumper cover Incl.
4 * Rpr Bumper cover � 3.6
5 Add for Clear Coat 1.4
6 Repl Valance panel 865123W000 1 147.18 Incl.
7 R&I License bracket 0.2
8 # Flex Additive 1 6.00 X
9 ** Repl A/M Clips and Fasteners 1 10.00 T
10 # Subl Hazardous Waste Disposal Fee 1 5.00 X
SUBTOTALS 168.18 3.7 5.0
ESTIMATE TOTALS
Category Basis Rate Cost$
Parts 147.18
Body Labor 3.7 hrs @ $54.00/hr 199.80
Paint Labor 5.0 hrs @ $ 54.00/hr 270.00
Paint Supplies 5.0 hrs @ $38.00/hr 190.00
Body Supplies 3.5 hrs @ $2.00/hr 7.00
Miscellaneous 21.00
Subtotal 834.98
Sales Tax $ 157.18 @ 7.1250% 11.20
Grand Total 846.18
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 846.18
THIS REPORT IS AND ESTIMATE ONLY, BASED ON OUR INITIAL INSPECTION AND DOES NOT COVER ADDITIONAL
PARTS OR LABOR WHICH MAY BE REQUIRED AFfER THE WORK IS OPENED UP. PART PRICES SUBJECT TO
CHANGE PER THE MANUFACTURER AND AVAILABILITY.
WARRANTY: LIFEfIME AGAINST DEFECTS IN WORKMANSHIP. WARRANTY REPAIRS DONE BY LAMETTRY'S
COLLISION ONLY. NO WARRANTY ON RUST, CORROSION RESISTANCE OR REPLACEMENT RENTAL CARS.
OUR ESTIMATED COMPLETION TIME DOES NOT INCLUDE INSURANCE OR PARTS DELAYS THAT WE MAY
EXPERIENCE.
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.
11/17/2012 11:29:17 AM 053108 Page 2
I
` �
, . Preliminary Estimate ;
�
Customer: DUCLOS, NICOLE Job Number: �
Vehicle: 2011 KIA SPORTAGE 4X2 LX 4D UN 4-2.4L-FI BLK �
�
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
ARY2303, CCC Data Date 11/8/2012, 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 (�) 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. �
I
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: I
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=Afhermarket part. BInd=Blend. 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. O/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=Bureau of Automotive Repair. EPA=Environmental Protection Agency. NHTSA= National Highway
Transportation and Safety Administration. PDR=Paintless Dent Repair. VIN=Vehicle Identification Number.
11/17/2012 11:29:17 AM 053108 Page 3
. , Preliminary Estimate
Cu'stomer: DUCLOS, NICOLE Job Number:
Vehicle: 2011 KIA SPORTAGE 4X2 LX 4D UN 4-2.4L-FI BLK
ALTERNATE PARTS SUPPLIERS
11/17/2012 11:29:17 AM 053108 Page 4