Alarcon (2) AMERICAN FAMILY
6131 Blue Circle Drive I Eden Prairie MN 55.'i43-9130 I amfam.com
r°e• �
Mailing Address: PO Box 1246 I Minneapolis,MN 55440-1246 I Phone:(952)933-4884 ����;+�
November 20, 2012 NOV 2 C 2012
�IT'�' �;��,c��;,
39-ESK001
CITY CLERK
15 WEST KELLOGG BLVD 310 CITY HALL
SAINT PAUL MN 55102
RE: Your Insured Name: City of St Paul Police Dept
Your File Number: unknown
Our Claim Number: 00-345-006685 3951
Our Insured: Maximino Goches Alarcon
Date of Accident: August 20, 2012
Total Claim: $1,228.88
Company Portion: $1,128.88
Insured's Deductible: $100.00
Dear City Clerk:
We are notifying you that American Family Mutual Insurance Company has now made payment on the
above referenced claim and our supporting documentation and proof of payment is enclosed.
The facts support that this incident was caused by your insured's negligence. Please forward the total claim
amount indicated. We will reimburse our insured their deductible.
Thank you for your attention to this matter. When sending correspondence, please include 'Attn:
Subrogation Dept'.
Respectfully,
� ���
Eileen S Kayfes
Subrogation Senior Adjuster
American Family Mutual Insurance Company
1-800-MYAMFAM (1-800-692-6326) X 66170
ekayfes @ amfam.com
www.amfam.com/claims
Enc:
S.A.T.R.N. Subro Potential Page 1 of 1 Eileen Kayfes
�����
Insured: GOCHES ALARCON, MAXIMINO Policy: 10-671135-06
Ciaim: 00-345-006685 Loss Date: 08-20-2012
Go Back Save and Go Back
Subrogation Potential
SelecUDeselect
Claimant Peril Draft P mt Pa ment Select Deductible Amount
ID Code Key Type Date Draft Applied Paid Payee Name
00 025 0000008147 01 11-05-2012 r 1��.�� $1,128.88 MAXIMINO GOCHF_S ALARCON
https://satrn.amfam.com/satrn/SubroActivity?subroId=00345006685 11/20/2012
(Page 2 of 2)
Accident Report Page 1 0£1
c�
� �.
�w.b. ,� �
� tars9a�4 �t �'. o�
N Nr+ro+un .wwro. vExoca w� iW wm� m. n � $.
�
� r� �r da �o �o � e zo zo�ia zsao �;
� ,ourt�,sm. a Maa�o. ' ( ❑ R ` o
� 10 Pa e a rr ��W � �'--j�rr �-+s 8w°�W <
�
N COIMiY�O � M6W PII �CW� 1WICM WOY7i45D�CWRIWiPIfiNWC I
W 62 �,w. St. Paui +_•_T_ 10 '7th St B
3 AC1011� .a.lilON M�Y�[ICf/RiM�tll..� L� Q#. W,b l�10, MKAi1�1��,..fA.: „�4L a.�, 0.di.,Ut f�.p�0a,
.�j I`' O1 T03Q287328103 hIl`1 I Ol Ol R2420980U9579 •I�IIt X 09
� nao+: 6wcronauxf attorewm w�awz.mwcum octnrar r.oiw:
0 15 ARN(7LF0 CURIEL JR� O6 20 43 BRIGIDO ROSAL�ES-PONCS 07 23 82 Ol
IV .�+wte warm • on.+a wsnan .00wse o� �w�+
0 O1 367 Grove N; O1 3312 CLINTON AvE 3 UNIT 2 N? 01 06
a 3t.�pau1 55106 651-391-1i11 MpLS 55408 651-434-5386 Ol
neaev �; an f�cv. �u eorr �wua amr wm � m ior �+rc�r .w urn �uxv �oouo
pl Y j M II4 04 06 05 It "Yy' . 4 04 06 OS iJ Ol
/1L16 ITPi OAq'111A 7p11Cl��1R�r1VG��'FWGM�GEYRY�i IrI1NOQll NCl M[ OR!<YIC �OIIOQl MNOMI M4iAaMaItlMCE N.f1M1Y101
`� 96 �" 98 1�? 0 y, •'�1,� 98 l�` 98 N� p�
oovs arsn.u� me ox�eaKVn °�
0� City ot St. Paul - N AI,AItCON MAXTMINO GOCHPsS N• 0�
�pl I� �821 PILL9HQRY AV S N 03TM
wrwt an.aurca 1uwo oweet emcswc.tv w� O Q��
a� �rt, os uxca�xsr� � ss42a ""s9
�� � � � � � � � � ��
01 FORD DRW 99 05
waser ruie� arru reMUO - � rwi� �r�o rbwxa a�� wr ouoacv
02 i�Il�T Ol Ol Ol Ol O1 837JKP IyAi 13 O1 Ol Ol O1 Ol 0�
�aMN10E AaJLY+wfA WuRWiP�A ralltrr�Yafrt
City o� St. Paul Sslf-Insured American Family 106711350462
� +wWr .a„w wve�.cn, w.swoc. �nceWerrturvotvFV�co►wetdu►mronvewc�.ac�wot.evs,oaxennst�areus •wr� �«xwr .� .
� T aeat�mgtioH07KVT►IS8saT6P�iaak.w6.dunaerlaStc9aea.nd�m��t�►. i a"•4
m+amvaneo.e�wxa�.�onc�uznx�ue ootnmem ta.vmawwM..a:.rarmawusawYe eof+��ew
nwubr�csr.�masus ' tan o�cer td irrc � �ou.o �tc'.ws�v ro �oas '
0� araee+a �aa�c++se� l
� O�
- �,w. �w�l+oc � n.raau � ..�
' QOUo
O„s waav�n �r++ra 1
' powa
amavwaow�merRae�n�voxiuenworwwseraaomN,oAamwruoru�qn awcmvnoournseuareaeu�ae
,�xm � �
Q 1 _.... _. __ Ol
�� Hoth vehicle N1 and N2 ae=e facing southboiwd
.,,,�_,_�_.._._- -
� t � � , �4;i' nttempting Co turn east onto ?Cfi St�S.� ��
�:e.:e-�:.�� :{'�;:'•:an .vehic]a JFZ xas�stopped:xaitinS.to.tcua..vehie2e . O1
O1 o I � fll fafled to etop nnd reaz-ended vehicle 92
e+w�. t �*� �causing�•afnor•danaqe•to•vehicle #i� - "r'°`
liT� �_y��� - _ --- 02
ff�aw� y � •••• �
98 �! ~� �.._. _._ .... �..... . ».�. ?
�'c�": � I � ~ . ._. . ..�,
� Q � j ..� - - ,��
,a,,, " _ _ o i
as _ ._ . ._._.._._..._ ,�
.�.� , 04
o� � - __. ._ _
. _ . �-- - �
..�
IIOOIM •••• •
O1 O1
mcunv�c�wrewoe.�m�r � • +�+ Q�wt�urn wrx
Sergeant Brad Hazelett 27.3 _n� `����_^ St Paul PD paw: po,�«
✓✓ �nP \
�
J"
http.//www.dvsiesupport.or�dvsinfo/accidentrecor�2008/Inclades LE/PrintReportlndiv.., 8/21/2012
�
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:
C� ontrol Information
Claim#: 00345006685-OC Insured Policy# : 1067113506
Loss Date/Time: 08/20l2012 07:00 AM Loss Type: Collision
Deductible: $100.00
Ins.Company: American Family Insurance
Insured: MAXIMINO GOCHES ALARCON
Address: Home/Day: (612)532-1208
�----Inspect�on ------------- -- -------------- — I
--�_________.__----
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 WorklDay:
License#: Regulation ID: 41-1942823
Target Complete Date/Time: Days To Repair: 3
� __.______.__._.___.�-.---.—___�.� —
�Remarks __ �
------------------- --
**ANY AND ALL SUPPLEMENTS MUST BE WRITTEN BY AND HAVE PRIOR
AUTH BY AMERICAN FAMILY**
FILE HANDLER YASMARY AT EXT 62254
11/02/2012 09:42 PM Page 1 of 3
1999 Ford F-450 X�T CabBChassis 4 DR Crew Cab
Claim#: 0034500668SOC 1'I/01/2012 01:43 PM
------ i
�� 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: 1 FDXW46FXXED65570
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 Hdlmps 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°/a 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
� Esti�mate Total&Entries � _ _ -- ___ ---- --- —----- _^ __ ---- --- - ----- __ .__�� _" �
Other Parts $300.00
Paint Materials $64.00
Line Item Markup $75.00
Parts 8�Material Total $439.00
Tax On Parts Only @ �•275% �27•2$
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
11/02l2012 09:42 PM Page 2 of 3
1999 Ford F-450 XLT Cab&Chassis 4 DR Crew Cab
Claim#: 00345006685-OC '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 $�,228•$$
Less: Deductible $100.00-
Net Total a1,128.88
Alternate Parts Y/00/00/00/00/00 CUM 00l00/00/00/00 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 10/01l2012 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 MANUFACTURER 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 CONII�IIT
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= RECYCLED PART
TE = Partial Replace Price PM= Replace PXN Reman/Reblt UM= Replace Reman/Rebuilt
L = Refinish PG= 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
'r Audatex Audatex's prior written consent.
a SuJrrd confµartY
Copyright(C)2011 Audatex North America,Inc.
Audatex Estimating is a trademark of Audatex North America, Inc.
Page 3 of 3 �
11l02/2012 09:42 PM �II
10103l2012 14:25 FAX 6512688574 SAINT PAUL CITY COUNCIL I�J002l003
NO'I'��E OF CLAY� FORM to the C�ty of Saint �' �j�l, :li�Rnnesota
�19in��esala State Stattrte 466.03 stafes that °.,.evr�y'person••-�b•ho r.laims dnmages jrom any municipnli' .._:•ha.'%c��se iv be presenterl to the
govnrni�rg botly orthe ntunicipaliry tivithiat 180 dcrys afte�•the alteged loss or i�jury is discoyered a n sia�st.rti�:F fhe[rrne,place,and
ctrcumslareces thereof,an�!the nrnoutrt ofco»�perrsation nr ot(�e�'�'eliejdem, zd��d.'
Please compiete tl�ts form in its enNrety hy clearty typ[�i�;or pri��tiFtg your anr�ver to e:� �I�qu,�sttc•n. If more space is
veeded,atYacli addirional sheets, Please note that you wili noE be contacted by telepltone• �cfar;fy::wswers,so provide as
mnc�informatio�i as necessR�y to expiain your claim,and fhe amount of com�ensanon bei ig rec ues ted, You Fvill reeei��e a
�sritten aclQrozvtedgement once tour form is received. Ttte process can take up to ten wc ks or lo�,er depending on the
nati�re of your claim. This form must be signed,and both pflges conipleted. If somethi. ;c.oe.not apply,write`i��/A'.
SEND C01�1'PLETED FOR�.ANA OTHER DOCUVIENTS � 'C�: C'�'CY CLERK,
1S WEST KELLOGG B.L'�,314 CITY HALL, SAI�T'T P' �17I,,1�9.�V 551Q2
First Name Middle Initial � Last Name �� ��_
Company or usiness Name Y'C �.` ��- ��C
Are You an Insiu�ance Companv? es No If Yes,Claim l�iumbe�•? ' �Ll�.,
Stxeet Address UZUV� 1`fi�(�E''V 1 C�� ��,� �l�`� - --------
City 1�'1(��,,,'� State W�- Zi �t:a��.'_�����
Daytime Phane���Cell Phone�� - Evening Telephon �__,)_�______
Date of AccidentJ Injtuy or Date Discover�d (�(��� Tuae�_a n! m
Please state,in detail,what occurred(happened),and why you are subn�itting a clazra.l ease ind�cate rvhy or how you
feel th i of Saint Pau2 or its employecs are invo4r�ed an or r s�onszble#'oz your dai• ages.T__
���c�e �.�t r�P� rec�� P n�� �..,�;Scrne�. -----
Please check the box(es�that most closely represent the reason for completiug this forn:
�My vehicle was damaged iza an accidei�t ❑My vehicic ;v�:s c.arna�ed dunin�a tow
❑My vehicle was damaged by a pothole or condirion of the sireet ❑vIy vehicle .w_s c.�n i�ed Uy a ptow
❑My vehicie was uTangfully toa ed aad/or ticketed � I v��as injur: 9 un i:i13 properiy
0 Other type of property damage-please specify --.T.-
❑Other rype of injury-pleasc specify _�.�
In order to process yaur claim��ou need W ineivde copies of al!av�l_ �abIf.doeuments.
For the ciaims types listed l�elow,ple�.se be swre to include the dacuinents indicated or: �vitl �el�,}�the handling of
yoirr claim. Documents l�7LL I�iOT be ret�un�d and become the praperty of the Cit�. ' 'ot�az��e:tcoui�aged to keep a
capy for yourself before subzniitin�your claim form_
O Propezy.q darnage claims�o a vehicle:nvo estimates for the repairs to yaur ve icle;.:`.t��:damage exceeds
�500.00; or the actual bills and,�or i�eceipts for tf�e repaixs
O Towing claims:legible copies of any ticket issued and a copy of the impaun�: lot rf;,ei,��
Q Othe�-property damage claims:two repair estamates if the damage exceeds$: OCAC;rn ehe actual bills
ai�d/or receipts foi-the repa�rs;detailed list of damaged ite2ns
0 Tz�jury claints:medicat b�lls,recei.pts
4 Phota�raphs are always welcome to docunlent and support your elaim but w: l r.ot be retumed.
Page 1 of 2-Please complete and return botlt pages of Clair. �or��
10/Q3/2012 14:26 �AX B5126B8574 SAINT FAUL CITY COUNCIL �003lOU3
Tailure to cnmplete and return both pages wXll resriit in tielxy in#he haudl�ig oi'3�o�Er cIaim.
All Clai�ms-please com�lete this section
�Vez�there��7tuesscs to thc isicident? YeS No I;cilmow3� (cirale: .
Provide thetr z►anies,addi-esses azid telephone z�un�,bers: - ----
�Vere the police or law enforcamezit catled7 Ye No Utiknown (����1
Lf yes,rkhat department or agency? Case#os report� 1?.���3�
�Vhere did the nccident ar injury take place? Pravide street address,cz�oss sta-eet,intersecc �n,n�zne af park or�acility,
closest iandmark,etc. Please Ue as dztailed as possible. If necessary, attach a diagrau�..__ _�_
- . ,�,,,�.� � . ,�.—_�
Please indicate the amount -ou are seekuig in co�ipensation or w�at you would like the ty to do i'a resolve this claim
.toyoursatisfaetian. � � Z P ���� tSC�-�. 1t��"�
Vei�icte Clai�ms- lease coai lete f.his sectlon ❑chec bo�; if:tu;,.s��;:,lion does not anplv •
Your Vehicie: Year Make Model� .1�..l�i�l.�
T.ieense Piate Number -1 State Coior _ `�
Registered 4ck-n.ez- � ��C'; 'n `�-
Driver of Vehicle �----
Area Damaged � --�—
City Velucle: Yeax iVlake . odel —�.._-.
License Plate Numbar State Color __..—.
Driver of Vehicle(City Employee's Name) • --—
Area Damaged -- J-
In'ui .iainas- lease com Iete thfs sectian �check bo? if rh.,s�ection does not appiv
How were you inJured? --.—.
What part(s�of your bad�r w�re injured? � ----
Have you sought raedical h-eatnient? Yes No Plannua$to Seek T� ,aan�_nt!�c:srcle}
_(provide date(s))
Wb,en did you receive freatment? ------
Name of Medical Provider(5): Telephot' _ _.�_
Address
Did you miss wark as a result of yoLU'injiuy? Y� �� ��o�de date(s)j
�Vhen did you miss work? . • —`- —
Name of your�mployer: Telepha e__._
Addr�ss '
�.Check here if you are affaching more pages to thLs claim form. Number of' Eddit+on:�.l pages�•
I3y signing this forls�,you are stating that rrll infarma#lon yvu hm�e prvvrded is+� u��a t:d :orrect to the best
of your lcnoyvledge. Unsigned forms wil!noi he processer�
Subrnittin�a false cdaine cnn result in pt•osecutiotz. Date form w�s completed_. �_.._..__ -
print the Name of the Person�vho Comgleted thfs�'orm: • -- --�-
Signattu'e of Person MQlcing the Claim: - --�'' �
Re�ised Februaxy 2011