DeVore �e��:a�tt�
DEC 2 i 2012
�✓I�� �J���1>.
NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minnesota State Statute 466.05 states that "...even�person...who claims damages from any municipa[ity...shall cause to be presented to the
governing hod��of�he municipaliry within 180 days after rhe alleged loss or injury is discovered a notice stating the time,place,und
circumstances thereof,and the amounl 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. Ptease 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 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 CITY HALL, SAINT PAUL, MN 55102
First Name �—�w'�r�r� Middle Initial �� Last Name ����"���'��
Company or Business Name
Are You an Insurance Company? Yes CN� If Yes,Claim Number?
Street Address �2 3�� �b C�C�-kF��r ��
City �:C(tv�� State �`�Ll�! ZipCode �5 `���
Daytime Phone( ) - Cell Phone(��5� �'�- �Z43 Evening Telephone( ) -
Date of Accident/Injury or Date Discovered �2��� � 2 Time �2'v� am/��
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 a e invo ved and/or r spopsible for your damages. r �v�'rs S�dc'
YCc�r � Vi�w �'�'��vro� �� S✓►�GtS�c-� u:�c e���c�-c. u(on Vv��t� hou5ii�t �t YYIEC �tv�lSrh .
�t��r1C ho f �v �rc�� C��`nl Sv �, �l5vt Gt ( f�i�'► � d ir� .
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
❑ My vehicle was damaged by a pothole or condition of the street �My vehicle was damaged by a plow v r �r��-k
❑ 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 you need to include copies of all apulicable 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 yourself before submitting your claim form.
f8(PropeRy 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 are 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–nlease comnlete this section - _ �
Were there witnesses to the incident? Yes No �Unknown ' (circle)
Provide their names, addresses and telephone numbers:
Were the police or law enforcement called? Yes No 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 fa ility,
closest landmark,etc. Please be as detailed as possible. If necessary,attach a diagram.�Ci0 (3 Co('K G�
C�c�>5 f���r-�
Please indicate the amo t you are seeking in compensati oz what you yvauld lik�e the City to do to resolve this claim
to your satisfaction.___�'_�2� � [�, �eSS�f � '�� �=S( I�i�Gt'� fS �
Vehicle Claims–please complete this section ❑ check box if this section does not applv
Your Vehicle: Year ZG��� Make �/��V� Model '�Zc� t_ �
License Plate Number Sta 1�1� Color �/J Vl+�—
Registered Owner L��'Y���I�E' J - � Ol`e
Driver of Vehicle �tw�`cv��e_ J . '�c:>i�t' — <r �'�
Area Damaged l VCJ�S Si �' PN�I�t�0�
City Vehicle: Year Make �C Model ZS�� � I�
License Plate Number I 2 State N1 N �olor
Driver of Vehicle(City Employee's Name) l�U+���{ �,� I{G'i�/'�
Area Damaged
Iniurv Claims–please complete this section �check box if this section does not apply
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 � Z
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 � Z � � � �
Print the Name of the Person who Completed this Form: ��w��="�C�� - '�`'�Ul�
Signature of Person Making the Claim:
���-��-� �� �� ��
Revised February 2011
ABRA Auto Body & Glass - Midway �Norkfile ID: 9789faa6
FederalID: 41-1852119
Right The First Time...On Time
1190 UNIVERSITY AVE W, SAINT PAUL, MN 55104
Phone: (651) 645-1563
FAX: (651) 641-6129
Preliminary Estimate
Customer: DEVORE, LARRY 7ob Number:
Written By:Taylor Jump
Insured: DEVORE,LARRY Policy#: Claim#: 1
Type of Loss: Date of Loss: 12/17/2012 12:00:00 PM Days to Repair: 0
Point of Impact: 10 Left Front Pillar(Left
Side)
Owner: Inspection Location: Insurance Company:
DEVORE, LARRY ABRA Auto Body&Glass-Midway CUSTOMER PAY
4239 CRACKER AVE 1190 UNIVERSITY AVE W
EDINA, MN 55416 SAINT PAUL, MN 55104
(952)261-5243 Business Repair Facility
(651)645-1563 Business
VEHICLE
Year: 2008 Body Style: 4D SED VIN: WBAVA33518FV67058 Mileage In: 63039
Make: BMW Engine: 6-3.OL-FI License: SLU041 Mileage Out:
Model: 328I Production Date: 4/2008 State: MN Vehicle Out:
Color: WHITE Int: Condition: Job#:
TRANSMISSION Console/Storage RADIO Electric Glass Sunroof
6 Speed Transmission CONVENIENCE AM Radio SEATS
Overdrive Air Conditioning FM Radio Cloth Seats
POWER Rear Defogger Stereo Bucket Seats
Power Steering Tilt Wheel Search/Seek WHEELS
Power Brakes Cruise Control CD Player Aluminum/Alloy Wheels
Power Windows Intelligent Cruise Auxiliary Audio Connection PAINT
Power Locks Telescopic Wheel SAFETY Clear Coat Paint
Power Mirrors Climate Control Anti-Lock Brakes(4) OTHER
Heated Mirrors Keyless Entry Driver Air Bag Traction Control
Power Trunk/Tailgate Alarm Passenger Air Bag Stability Control
DECOR Steering Wheel Controls Head/Curtain Air Bags Fog Lamps
Tinted Glass Remote Starter Front Side Impact Air Bags
Wood Interior Trim On Board Computer 4 Wheel Disc Brakes
Dual Mirrors Message Center ROOF
12/17/2012 2:25:32 PM 011906 Page 1
Preliminary Estimate
Customer: DEVORE, LARRY 7ob Number:
Vehicle: 2008 BMW 328I 4D SED 6-3.OL-FI WHITE
Line Oper Description Part Number Qty Extended Labor Paint
Price�
1 FRONT DOOR
2 * Rpr LT Door shell 1_5 2.0
3 Add for Clear Coat 0•8
4 R&I LT Surround w'strip 0.5
5 R&I LT Belt w'strip 0.3
6 * Rpr LT Mirror cover � 0.5
7 Overlap Minor Panel -0•2
8 Add for Clear Coat 0.1
9 R&I LT Applique w/high gloss 0.3
10 Repl LT Mirror assy w/o folding w/o 51167189945 1 223.84 0.7
memory
il R&I LT Handle,outside w/keyless entr 0.4
to 1-08
12 R&I LT R&I trim panel 0.6
13 FENDER . . _
14 Blnd LT Fender 1.0
15 R&I LT Fender liner front 0.3
16 R&I RT Fender liner rear 0•2
17 # R&I LT Signal lamp �•Z
_., _. � ,. _. . ..._.� __
18 FRONT LAMPS
19 R&I LT R&I headlamp assy 0.3
20 FRONT BUMPER 8c GRILLE ..
21 R&I R&I front bumper 1•7
22 # Rpr Deduct R&I to loosen FRNT Cover -�•�
_._............ __, ... . . .... _ _
23 MISCELLANEOUS OPERATIONS
24 # Refn �Car Cover 0.1
25 # Refn 'Corrosion Protection 0.3
SUBTOTALS 223.84 7.3 4.6
12/17/2012 2:25:32 PM 011906 Page 2
Preliminary Estimate
Customer: DEVORE, LARRY 7ob Number:
Vehicle: 2008 BMW 326I 4D SED 6-3.OL-FI WHITE
ESTIMATE TOTALS
Category Basis Rate Cost$
Parts 223.84
Body Labor 7.3 hrs @ $54.00/hr 394.20
Paint Labor 4.6 hrs @ $54.00/hr 248.40
Paint Supplies 4.6 hrs @ $34.00/hr 156.40
Subtotal 1,022.84
Sales Tax $223.84 @ 7.6250% 17.07
Grand Total 1,039.91
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 1,039.91
THIS IS A VISUAL INSPECTION ONLY. THERE MAY BE ADDITIONAL DAMAGE AFfER DISASSEMBLY. PARTS ARE
SUBJECT TO INVOICE. THERE ARE NO GUARANTEES ON RUST REPAIRS.
"Minnesota law gives you the right to choose any rental vehicle company, and prohibits me from requiring you to
choose a particular vendor."
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.
12/17/2012 2:25:32 PM 011906 Page 3
Preliminary Estimate
Customer: DEVORE, LARRY 7ob Number:
Vehicle: 2008 BMW 328I 4D SED 6-3.OL-FI WHITE
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
ERE1942, CCC Data Date 12/14/2012, 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.
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:
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=Aftermarket part. BInd=Blend. BOR=6oron 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. 0/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.
12/17/2012 2:25:32 PM 011906 Page 4
ROERING AUTOBODY Workfile ID: 577bdc2c
FederalID: 411827490
90 N. DALE ST., SAINT PAUL, MN 55102
Phone: (651) 221-0919
FAX: (651) 221-1946
Preliminary Estimate
Customer: DEVORE, LARRY 7ob Number:
Written By: Lisa Roering
I
Insured: DEVORE, LARRY Policy#: Claim#:
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact:
Owner• Inspection Location: Insurance Company:
DEVORE, LARRY ROERING AUTOBODY
4239 CROCKER AVENUE 90 N. DALE ST.
EDINA,55416 SAINT PAUL,MN 55102
(952)261-5243 Cell Repair Facility
(651)221-0919 Day
VEHICLE
Year: 2008 Body Style: 4D SED VIN: WBAVA33518FV67058 Mileage In:
+ Make: BMW Engine: 6-3.OL-FI License: Mileage Out:
Model: 328I Production Date: State: Vehicle Out:
Color: white Int: beigh Condition: Job#:
TRANSMISSION Console/Storage RADIO Electric Glass Sunroof
6 Speed Transmission CONVENIENCE AM Radio SEATS
Overdrive Air Conditioning FM Radio Cloth Seats
POWER Rear Defogger Stereo Bucket Seats
Power Steering Tilt Wheel Search/Seek WHEELS
Power Brakes Cruise Control CD Player Aluminum/Alloy Wheels
Power Windows Intelligent Cruise Auxiliary Audio Connection PAINT
Power Locks Telescopic Wheel SAFETY Clear Coat Paint
Power Mirrors Climate Control Anti-Lock Brakes(4) OTHER
Heated Mirrors Keyless Entry Driver Air Bag Traction Control
Power Trunk/Tailgate Alarm Passenger Air Bag Stability Control
DECOR Steering Wheel Controls Head/Curtain Air Bags Fog Lamps
� Tinted Glass Remote Starter Front Side Impact Air Bags
Wood Interior Trim On Board Computer 4 Wheel Disc Brakes
Dual Mirrors Message Center ROOF
12/14/2012 3:02:40 PM 076657 Page 1
Preliminary Estimate
Customer: DEVORE, LARRY ]ob Number:
i
Vehicle: 2008 BMW 328I 4D SED 6-3.OL-FI white
Line Oper Description Part Number Qty Extended Labor Paint
Price$
1 FRONT DOOR
2 * Rpr LT Door shell 1_0 2.0
3 Add for Clear Coat 0•8
4 R8cI LT Belt molding w/o high gloss 0.3
w/o chrome
5 R&I LT Handle,outside w/keyless entr 0•4
to 1-08
6 R&I LT R8cI trim panel 0.6
7 Repl LT Mirror assy w/o folding w/o 51167189945 1 223.84 0.7
memory
g * R&I LT Mirror cover Incl.
9 * Rpr LT Mirror cover � 0.5
� 10 Overlap Minor Panel -0•2
11 Add for Clear Coat 0.1
12 # Subl Hazardous waste removal 1 5.00 X
13 # Repl Corrosion protection primer 1 0.2
SUBTOTALS 228.84 3.5 3.4
ESTIMATE TOTALS
Category Basis Rate Cost;
Parts 223.84
Body Labor 3.5 hrs @ $55.00/hr 192.50
Paint Labor 3.4 hrs @ $55.00/hr 187.00
Paint Supplies 3.4 hrs @ $32.00/hr 108.80
Body Supplies 2.2 hrs @ $3.95/hr 8.69
Miscellaneous 5.00
Subtotal 725.83
� Sales Tax $223.84 @ 7.6250% 17.07
Grand Total 742.90
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 742.90
Roering Auto Body, takes great care to ensure that every repair meets your satisfaction.
The labor performed by Roering Auto Body is guaranteed against any defect in workmanship for as long as you own
your car.
Roering Auto Body guarantees that for as long as you own your vehicle, Roering will, at its expense, correct or repair
all defects which are attributable to defective or faulty workmanship in the repairs stated on the repair invoice, unless
caused by or damaged resulting from unreasonable use, improper maintenance or care of vehicle, and rust and/or
corrision.
12/14/2012 3:02:40 PM 076657 Page 2
Preliminary Estimate
Customer: DEVORE, LARRY 7ob Number:
Vehicle: 2008 BMW 328I 4D SED 6-3.OL-FI white
This guarantee covers labor only and does not apply to parts, materals or equipment which may be covered by
manfacturer's warranty.
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.
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
ERE1942, CCC Data Date 12/10/2012, 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.
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:
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=Aftermarket part. BInd=6lend. 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.
12/14/2012 3:02:40 PM 076657 Page 3
Preliminary Estimate
Customer: DEVORE, LARRY 7ob Number:
Vehicle: 2008 BMW 328I 4D SED 6-3.OL-FI white
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.
i
12/14/2012 3:02:40 PM 076657 Page 4
� ' Preliminary Estimate
Customer: DEVORE, LARRY 7ob Number:
Vehicle: 2008 BMW 328I 4D SED 6-3.OL-FI white
ALTERNATE PARTS SUPPLIERS
12/14/2012 3:02:40 PM 076657 Page 5
HOWARD "BUD" HARE
, Public Works Supervisor 1 ��
G �
CITY OF SAINT PAUL
DEPARTMENT OF PUBLIC WORKS
STREET MAINTENANCE
873 North Dale Sn�eet Tel:651-292-6600
Saint Paul,MN SS103 Fax:651-488-7847
i
Responsive Services•Qualiry Facilities•Employee Pride �
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