Bell (2) �"��t"�;:����
DE� i 1 2012
NOTICE OF CLAIM FORM to the City of Saint Paul, r ' � i .,�.�
� � ,
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 municipaliry within I80 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 or printing your answer to each question. If more space 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 explain your claim,and the amount of compensation being requested. You wili 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 most be signed,and both pages completed. If something dces not apply,write`N/A'.
SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
First Name ��'U Middle Initial M Last Name �� 1 �
Company or Business Name
Are You an Insurance Company? Yes/No If Yes, Claim Number?
Street Address ��03� `��1+1 T\v4• S •
City IY�1�1`(1S1(UP�`�S State I�N Zip Code ���cl
Daytime Phone( ) - Cell Phone( `�)�4�h-_�Evening Telephone( ) -
Date of Accidend Injury or Date Discovered N�Y� �� �U`L Time � '`�� ��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.Q 1`L '�
Q c\�, C . r � 1 11 � C,i k hl�c_
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�1�.� c1r�n�c;+�1e �t-� i'V�y v��ehkl� -
Please check thb 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
❑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
❑Other type of property damage–please specify
❑Other type of injury–please specify
In order to process your claim vou need to include conies of all anplicable 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 WILL NOT be returned and become the property of the City. You are encouraged to keep a
copy for yowself before submitting your claim form.
O 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
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 Injury claims: medical bills,receipts
O Photographs aze always welcome to document and support your claim but will not be returned.
Page 1 of 2–Please complete 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 No Unknow " (circle)
Provide their names,addresses and telephone numbers:
Were the police ar law enforcement called? Yes No Unknown (circle)
If yes,what department or agency?�y_r•Qt7ltil ���1 t�e Case#or report# �2-�3 �0��
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. �t �1'YZ 1 Ylte Y S�L��'1
;,-�- C�ev��anci ar�c� �-�,n������h �� fau�� eas��t�l�ci �n ��iciph �va���n�, n-t �-�s�.
e.7�o�!�� �� �
Please m�icate the amount you are seeking in compensation or what ou would like the City to do to resolve this claim
to your satisfaction. YY� St�'K.W1 k � �"ti C '��r S �
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Vehicle Claims-ulease comnlete this section ❑check box if this section does not apulv
Your Vehicle: Year C�O Make G�D i�L I�C, Model S
License Plate Number��1 ItP M State M Color Si IY�-�
Registered Owner � Y►
DriverofVehicle �'1Fi�C'� iMt;t►'1�' 1�
Area Damaged � Y Y1'� y f '� � �
City Vehicle: Year ake C �,=v� Mo el 351�0.� T � ��`�431
License Plate Number�=�State ►'�N' Colar C`1►'k�Yl
Driver of Vehicle(City Employee's Name)�-raY�taS �. ML���1an 11_
Area Damaged
Iniurv Claims ulease comnlete this section �check box if this section does not avplv
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
�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 infornaation 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 �'�I�.J �Z
} �i
Print the Name of the Person who Completerl this Form: ���1 ��1 t
"� ' � ` �
Signature of Person Making the Claim:
Revised February 2011
I mmy Bergen
Estimotor
tommy.berge�@�ehmansga ro ge,com
:� ��' Integrity Award
Workfile ID: 873f67b9
••.B-Q 2010Winner ,'S GARAGE, INC. SOUTH Federal ID: 410957340
MNPLS
5431 LYNDALE AVE S, MINNEAPOLIS, MN 55419
Phone: (612) 827-5431
FqX: (612) 827-0076
Preliminary Estimate
]ob Number:
Customer: BELL, SHEiLA
Written By:Tommy Bergen
Claim #:
Insured: BELL,SHEIIA Policy#:
Type of Loss:
Date of Loss: Days to Repair: 0
Point of Impact:
Inspection Location: Insurance Company:
Owner:
BELL,SHEILA LEHMAN'S GARAGE,INC.SOUTFi MNPLS
5639 PENN AVE S. 5431 LYNDALE AVE 5`
MPLS, MN 55419 MINNEAPOLIS,MN 55419
(612)865-3886 Other
Repair Facility
(612)827-5431 Business
VEHICLE
Body Style: 4D SED VIN: SG6DM577040158725 Mileage In: �
Year: 2004 Mileage Out:
Make: CADI Engine: 6-3.6L-FI License: 899-APM
Model: CTS Production Date:
State: MN Vehicle Out:
Color: SILVER Int:
Condition: Job#:
AM Radio SEATS
TRANSMISSION DECOR Leather Seats
Dual Mirrors FM Radio
Automatic Transmission Stereo Bucket Seats
Overdrive Console/Storage y�HEELS
CONVENIENCE CD Player
pOWER SAFETIf Aluminum/Alloy Wheels
Power Steering Air Conditioning ppINT
Rear Defogger Anti-Lock Brakes(4)
Power Brakes Driver Air Bag Gear Coat Paint
Power Windows Tilt Whee1 OTHER
Cruise Control Passenger Air Bag
Power Locks Traction Control
Intermittent Wipers Head/Curtain Air Bags
Power Driver Seat Front Side Impact Air Bags Fog Lamps
Power Mirrors Keyless Entry
Heated Mirrors Steering Wheel Controls
4 Wheel Disc Brakes
Power Trunk/Tailgate
RADIO Communications System
Page 1
016370
12/6/2012 12:25:32 PM
Downtown 1320 Crys1a��d�°
gloom�n9ton g19 South 71h Streel �haska,MN 55318
�71 American Blvd.�N Minneapo��s.MN 55415 952_361_q242
_:.,.,+nn.MN 55420 612_333-1339
_,,,_ Fax:361-5560
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Preliminary Estimate
Customer: BELL, SHEILA ]ob Number:
Vehicle: 2004 CADI C'fS 4D SED 6-3.6L-FI SILVER
Line Oper Description Part Number Qty Eutended Labor Paint
Price$
1 REAR BUMPER
2 R&I R&I bumper cover 1•�
3 * Rpr Bumper cover 3.6 liter ]�. 3.0
4 Add for Clear Coat 1•2
5 REAR LAMPS .
6 R8cI RT Tail lamp assy 0.4
7 QUARTER PANEL _
8 * Rpr RT Quarter panel �Q 2•7
9 Add for Clear Coat 1.1
10 Blnd Fuel door �•Z
t
li # Bind LT. UPPER RAIL 1.0
__ _.._ __
12 PILLARS,ROCKER&FLOOR . .
13 R&I RT Rocker molding front CTS 0.6
14 ** A/M Rope glass 1 4.00 0.4
15 # Subl Hazardous waste removal 1 5.00 X
16 # Refn Cover Car 0•2
17 # Color tint/color match 1
18 # Refn Corrosion protection primer 0.3
19 # Repl Flex additive 1 5.00 X
SUBTOTALS 14.00 7.6 9J
ESTIMATE TOTALS
Category Basis Rate Cost$
Parts 4.00
Body Labor 7.6 hrs @ $52.00/hr 395.20
Paint Labor 9.7 hrs @ $52.00/hr 504.40
Paint Supplies 9.7 hrs @ $52.00/hr 504.40
Miscellaneous 10.00
Subtotal 1,418.00
Sales Tax $4.00 @ 7.7750% 0.31
Grand Total 1,418.31
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 1,418.31
America First Insurance, Colorado Casualty, Golden Eagle Insurance, Indiana Insurance, Liberty Agency
Underwriters, Liberty Northwest, Montgomery Insurance, Ohio Casualty, Peerless Insurance and Safeco Insurance are
part of Liberty Mutual Agency Markets, a business unit of Liberty Mutual Group.
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.
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