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NOTICE OF CLAIM FORM to the City of Sa�n���'��;�T�iinnesota
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��iunicipaliry 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 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 ��(�C:i Middle Initial (�Last Name���F�
Company or Business Name �'���1 ��CO� ����l��11��C�
Are You an Insurance Company? es No If Yes, Claim Number? 1���� �����
Street Address �lU� ��..l.l S�� � - ��- ����)
City ��4� State �� Zip Code��.�.
G�S �`��
Daytime Phone (��-_��Cell Phone(.�)�.-�_Evening Telephone��)�_-��
Date of Accident/Injury or Date Discovered ����.��r� Time��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 are involved and/ r responsible for your da ages.
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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
❑ 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 copies of all applicable 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.
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 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—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? 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 facility,
c sest landmark, etc. Please be as detail d as possible. If necessary, attach a diagram.
�,'��� ��-�,� C;�-�1 `��, t�c,��a���� l��
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. � ``'"�.51�,-`'I!
Vehicle Claims— lease com lete this section ❑ check box if this section does not a 1
Your Vehicle: Year C�c� Make � Mode1C\`�i-C�P�
License Plate Number " V State��Color �IZ�2
Registered Owner ���}����I� `�,.v,
Driver of Vehicle �U
Area Damaged � - - " �
City Vehicle: Year��1._Make Model (��Q
License Plate Number �� State�Color�
Driver of Vehicle (City Employee's Name)�\
Area Damaged n,�
Injurv 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 treatme ? 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 yo 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 proeessed.
Submitting a false claim can resc�lt in prosecution. Date form was completed I I� �'�
Print the Name of the Person who Completed this Form: ��a�I�
Signature of Person Making the Claim: ��
Revised February 2011
NATIONWIDE ENTERPRISE
Central Plains Claims Zone-NWIDE
One Nationwide Gateway, DES MOINES, IA
50391
Phone: (763) 691-3511 Claim#: 72222008120211071201K/HS
FdX: (866)902-3043 Workfile ID: d9925657
Estimate of Record
Written By: LISA CANADAY,License Number: 112242, il/19/2012 10:33:23 AM
Insured: Kendra Heifort Policy#: ALLIED P&C INSURANCE Claim#: 72222008120211071201K/H1
CO
Type of Loss: FTC-Fire,Theft Date of Loss: 31/07/2012 12:01 AM Days to Repair: 0
and Comprehensive
Point of Impact: 16 Non-Collision Deductible: 500.00
Owner: Inspection Location: Appraiser Information: Repair Facility:
Kendra Heifort Heifort,Kendra Email:
2041 Gresham Ave N 2041 Gresham Ave N canadli@nationwide.com
Saint Paul, MN 55128-4408 St.Paul,MN 55128 Phone: (763)691-3511
(651)890-6890 Evening Non Drive-in
VEHICLE
Year: 2009 Color: Blue Int:Gray License: 990 DVA Production Date: 04/2009
Make: DODG Body Style: 4D SED State: MN Odometer: 60783
Model: CHARGER SXT Engine: 6-3.5L-FI VIN: 263KA33V79H626587 Condition:
TRANSMISSION Tinted Glass AM Radio Bucket Seats
Automatic Transmission Body Side Moldings FM Radio WHEELS
Overdrive Dual Mirrors Stereo Aluminum/Alloy Wheels
POWER Console/Storage Search/Seek PAINT
Power Steering CONVENIENCE CD Player Clear Coat Paint
Power Brakes Air Conditioning Auxiliary Audio Connection Two Tone Paint
Power Windows Rear Defogger Satellite Radio Metallic Paint
Power Locks Tilt Wheel SAFETY OTHER
Power Driver Seat Cr�ise Control Anti-Lock Brakes(4) Traction Control
Power Mirrors Telescopic Wheel Driver Air Bag Stability Control
Heated Mirrors Intermittent Wipers Passenger Air Bag Fog Lamps
Power Trunk�ailgate Climate Control 4 Wheel Disc Brakes
Power Adjustable Pedals Keyless Entry SEATS
DECOR RADIO Cloth Seats
11/19/2012 10:33:24 AM 112242 Page 1
Claim#: 72222008120211071201K/H1
Workfile ID: d9925657
Estimate of Record
2009 DODG CHARGER SXT 4D SED 6-3.5L-FI Blue
Line Oper Description Part Number Qty Extended Labor Paint
Price$
1 FRONT BUMPER
2 R&I R&I bumper cover 1.4
3 HOOD
4 * Rpr Hood w/o SRT8 � 2•$
5 Add for Two Tone 1.1
6 FENDER
7 * Rpr LT Fender LS� Z•�
8 Overfap Major Adj. Panel -0.4
9 Add for Two Tone 0.5
10 Repl LT Nameplate"3.5L HIGH 4806330AA 1 31.00 0.2
OUTPUT'
11 FRONT DOOR
12 * Rpr LT Outer panel 1_0 2.4
13 Overlap Major Adj. Panel -0.4
14 R&I LT Handle,outside deep wtr blue �•4
15 * R&I LT Body side mldg all paint to 0_5
matc
NOTE:Incl clean and retape
16 R&I LT R&I trim panel 0.5
17 QUARTER PANEL
18 * Rpr RT Quarter panel 2.5 2.0
19 Overlap Major Non-Adj. Panel -0.2
20 Add for Two Tone 0.5
21 * Rpr LT Quarter panel 1_5 2.0
22 Overlap Major Non-Adj. Panel -0.2
23 Add for Two Tone 0.5
24 Clear Coat 2.5
25 REAR BUMPER
26 R&I R&I bumper cover 1.4
27 # Repl Corrosion protection 1 8.00 X
28 # Repl Hazardous Waste 1 3.00 X
SUBTOTALS 42.00 11.4 15.1
NOTES
Estimate Notes:
NO SUPPLEMENTS WITHOUT AUfHORIZATION.
LKQ SEARCH APS
11/19/2012 10:33:24 AM 112242 Page 2
Claim#: 72222008120211071201K/H1
Workfile ID: d9925657
Estimate of Record
2009 DODG CHARGER SXT 4D SED 6-3.5L-FI Blue
ESTIMATE TOTALS
Category Basis Rate Cost$
pa� 31.00
Body Labor 11.4 hrs @ $52.00/hr 592.80
Paint Labor 15.1 hrs @ $52.00/hr 785.20
Paint Supplies 15.1 hrs @ $32.00/hr 483.20
Miscellaneous 11.00
Subtotal 1,903.20
Sales Tax $31.00 @ 7.1250% 2.21
Total Cost of Repairs 1,905.41
Deductible 500.00
Total Adjustments 500.00
Net Cost of Repairs 1,405.41
The limit of your coverage is the actual cash value of your auto or its damaged parts at the time of loss. Fair market
value, age and condition of your damaged vehicle will be considered when determining the actual cash value of a
loss. Certain parts lose value or depreciate because of age, condition, and/or wear and tear. Betterment is the
increase in value of a vehicle or any of its parts as a result of replacing certain parts damaged in a loss. If the
replacement of certain parts results in an increase in value to your vehicle or any of its parts, a deduction for
betterment may be made to your loss payment to reflect the actual cash value you are owed under your policy.
NWCPP=Nationwide Crash Parts Program
This is an estimate only and is not an authorization to repair. Additional payment will be made only with the approval
prior to repair.
IMPORTANT! ALL SERVICE PROVIDERS MUST COMPLY WITH STATE AND FEDERAL PRNACY LAWS, INCLUDING
THE PRNACY PROVISIONS OF THE GRAMM-LEACH-BLILEY ACT AND WTTH ALLIED'S PRIVACY STATEMENT AND
PROVISIONS. ACCORDINGLY,YOU ARE HEREBY NOTIFIEDTHAT CUSTOMER INFORMATION SHARED WITH OR
OBTAINED BY SERVICE PROVIDERS SHALL BE USED SOLELY FORTHE PURPOSE FOR WHICH IT WAS PROVIDED
AND FOR NO OTHER PURPOSE WHATSOEVER.
Nationwide will replace any defective like kind and quality(used), reconditioned, recyclable, and any quality
replacement aftermarket(non-OEM) parts for as long as you own or lease the vehicle.
MN ST 60A.955 -A PERSON WHO FILES A CLAIM WIfH INTENT TO DEFRAUD OR HELPS COMMIT A FRAUD
AGAINST AN INSURER IS GUILTY OF A CRIME.
11/19/2012 10:33:24 AM 112242 Page 3
Claim#: 72222008120211071201K/H1
Workfile ID: d9925657
Estimate of Record
2009 DODG CHARGER SXT 4D SED 6-3.5L-FI Blue
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
DR3P606, CCC Data Date 11/14/2012, 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 (N) items indicate MOTOR Not-Included
Labor operations. The symbol (<>) indicates the refinish operation WILL NOT be pertormed 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 parks 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 laal
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. 0/H=Overhaul. Qty=Quantity. Refn=Refinish. Repl=Replace.
R8cI=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) assaiated 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=6ureau of Automotive Repair. EPA=Environmental Protection Agency. NHTSA= National Highway
Transportation and Safety Administration. PDR=Paintless Dent Repair. VIN=Vehicle Identification Number.
11/19/2012 10:33:24 AM 112242 Page 4
Nattonwide Insurance
Alliad Insurance
Nationvvfde Agribusiness
Titan Inaurance
On Your$ide' Victorfa Insurance
Jerome Kleekamp Paula Kleekamp
Page 1 of 1
Date prepared January 2, 2013
Jerome Kleekamp Paula Kieekamp Claim number 72 24 20 137093 11082012 01
806 Lost Creek Ln
Washington, MO 63090-5492 Questions? Contact Claims Associate
Andrea Irwin
irwina@nationwide.com
Phone (888)804-8595
We haven't been able Dear Jerome Kleekamp Paula Kleekamp,
to recover payments Our subrogation department has made several attempts to recover payments
related to your claim made on the collision claim against the at fault party. Despite our attempts, we
haven't been able to recover these c�aim payments or your deductible. We
anticipate forwarding this matter to an outside collection agency or attorney to
continue our recovery efforts against the at fault party, including the pursuit of your
deductible.
Claim details
Insurer: Allied Property and Casualty Insurance Company, a Nationwide
company
Policyholder: Jerome Kleekamp Paula Kleekamp
Claimant: Kodey Monzyk
Claim number: 72 24 20 137093 11082012 01
Loss date: 11-08-2012
Action requested
If you have any information that may assist us, please contact me at(888)804-
8595.
You can always count on us to be there
We want to continue meeting your insurance needs. If you have any questions or
concerns about your claim, please contact me at(888)804-8595 or
irwina@nationwide.com.
Sincerely,
Andrea Irwin
Allied Property and Casualty Insurance Company, a Nationwide company
One Nationwide Gateway
Des Moines, IA 50391-5595
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