Klimisch �i��k:`� `�:e�.:�3
�2
NOTICE OF CLA�� �O1Z to the City of Saint Paul, Minnesota
-� .�
Minnesota State Statute 466.05 states that'�.�Ue' °e�i�1�.�'�w�io claims dama es om an munici ali shaU cause to be resented to the
n'P S .�' Y P rY... p
governing body of the municipality within]80 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 sometlring 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�CS`S�LG� Middle Initial�Last Name �����S��
Company or Business Name
Are You an Insurance Company? Yes/ Vo If Yes,Claim Number?
Street Address��l� � l/���(�'� �'('��� 1����` t'r f��
City `c l�i � �'`�� State �N Zip Code 5`J ��
Daytime Phone( ) - Cell Phone��)�-,L�Evening Telephone(_) -
-}'�� L
Date of Accidend Injury or Date Discovered��✓A• �'r Z.� �.� Time Z� �7 a /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.
� . P:� ,41-Eat�r�(Yt2�/l��-
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 annlicable 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 aze encouraged to keep a
copy for yo elf before submitting your claim form.
roperty 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 properiy 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 J�ury claims:medical bills,receipts
PfPhotographs 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 comnlete this section —�����
Were there witnesses to the incident? Yes No Unknown y� (circle)
Provide their names,addresses and telephone numbers: f�c 1.�. SC��Z,.�?.
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 ark or facility,
closest landmark,etc. Please be as detailed as pos ble. If necessary,attac a d�agram. �, �r: e�: ,
'�.ty4- P�S� '��✓� sf ►-,z\aw .l�c. L�y��e.. bnr.�i.e,. �n'c�c,►-C -}b� �� ✓`e-�c,-ts /�'���-wJ-S l�l•z�.
�� °
Please indicate the amount you e seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction.��;�,`.��• '1'�n o i5 �2� D.,vt,�cl�.rqe, oSr �-�, �-t�o �S�-+�MN� 1���vi�
Vehicle Claims- lease com lete this section ❑ check box if this section does not a 1
Your Vehicle: Year Z.����' Make �a� Model f 4
License Plate Number�/� �A� State�Color
Registered Owner ��5+c.� /�-� � 'w���
Driver of Vehicle ' -e�S1 c.� � 1.�1 i vwisc-
Area Damaged�f►'►Dz.�-C'�'e-�,J iCev�S� b�C���. �.►n[d v Ic'v����-�cs-c���{�
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Injurv Claims-please complete this section laJ check box if this section does not applv
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
I�t:'heck here if you are attaching more pages to this claim form. Number of additional page3���
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 i I�-3 I 1�a
Print the Name of the Person who Completed this Form: '.�55�<<A���►'M�Sc-�
Signature of Person Making the Claim: " �^c- - � �
Revised February 2011
I was driving home from work, east on Kellogg Blvd at 12:15AM. I went past the
last stoplight,just under the Lafayette Bridge (lights were all green; speed limit had just
changed to 40mph). Suddenly, I noticed large ice chunks blocking the entire right lane of
traffic. I did not have time to slow down and there was another vehicle in the left lane so I
could not switch lanes. After hitting the ice I then observed city workers removing these
ice/snow walls from the side of the bridge. There were no caution signs or cones blocking
the right lane of traffic from drivers. If there had been,this would have been easily
avoided. When an entire lane is compromised, such as this, I do feel it is the cities
responsibility to block off that lane of traffic. Because the city failed to block off the
lanes of traffic and give warning of the hazard caused by the ice removal, I believe it is
the cities responsibility to reimburse me for the cost of repairing my vehicle. Attached
you will find 2 estimates.
HEPPNER'S WOODBURY AUTO BODY Workfile ID: dd70da04
1807 WOODLANE DR, WOODBURY, MN 55125
Phone: (651) 735-5055
FAX: (651) 735-5057
Preliminary Estimate
Customer: KLIMISCH,]ESSICA 7ob Number:
Written By:)ON MARTENS
Insured: KLIMISCH,JESSICA Policy#: Claim #:
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact: 12 Front
Owner: Inspection Location: Insurance Company:
KLIMISCH,JESSICA HEPPNER'S WOODBURY AUTO BODY OTHER PARTY
400 WELLA ST NORTH # 100 1807 WOODLANE DR
ST PAUL, MN 55119 WOODBURY,MN 55125
(507)581-1581 Evening Repair Facility
(651)735-5055 Day
VEHICLE
Year: 2007 Body Style: 4D SED VIN: 3FAHP08Z87R177316 Mileage In:
Make: FORD Engine: 4-2.3L-FI License: 975JA6 Mileage Out:
Model: FUSION SEL Production Date: State: MN Vehicle Out:
Color: MAROON Int: Condition: lob#:
TRANSMISSION Body Side Moldings Message Center 4 Wheel Disc Brakes
5 Speed Transmission Dual Mirrors RADIO SEATS
POWER Overhead Console AM Radio Cloth Seats
Power Steering CONVENIENCE FM Radio Bucket Seats
Power Brakes Air Conditioning Stereo WHEELS
Power Windows Rear Defogger Search/Seek Aluminum/Alloy Wheels
Power Locks Tilt Wheel CD Changer/Stacker PAINT
Power Driver Seat Cruise Control SAFETY Clear Coat Paint
Power Mirrors Telescopic Wheel Driver Air Bag OTHER
Heated Mirrors Intermittent Wipers Passenger Air Bag Fog Lamps
Power Trunk/Tailgate Alarm Head/Curtain Air Bags
DECOR Steering Wheel Controls Front Side Impact Air Bags
1/22/2013 11:19:08 AM 018571 Page 1
,
i
Preliminary Estimate �
Customer: KLIMISCH,JESSICA 7ob Number:
Vehicle: 2007 FORD FUSION SEL 4D SED 4-2.3L-FI MAROON
Line Oper Description Part Number Qty Extended Labor Paint
Price$
1 FRONT BUMPER
2 Repl Bumper cover 6E5Z17D957CAPTM 1 344.40 2.3 2.6
3 Add for Clear Coat 1.0
4 Add for fog iamps 0.4
5 Repl LT Bumper cover side reinf 6E5Z17C9476 1 35.50
6 R&I License bracket 0•2
_.... _.. .... ,_ _.._... . .
7 RADIATOR SUPPORT
8 Repl Lower deflector AE5Z8327A 1 91.45 0.3
__ __ . . ....... _ _.._ __ __ .._ _ ___ _ _
9 FENDER
10 Repl LT Fender liner 6E5Z16103A 1 70.53 0.4
11 # LOWER ENGIN SHELD 1 105.03 0.5
12 # Repl 'Hazardous Waste Disposal Fee 1 5.00 X
13 # Repl 'Flex Additive 1 3.00 X
SUBTOTALS 654.91 4.1 3.6
ESTIMATE TOTALS
Category Basis Rate Cost$
Pa� 646.91
Body Labor 4.1 hrs @ $52.00/hr 213.20
Paint Labor 3.6 hrs @ $52.00/hr 187.20
Paint Supplies 3.6 hrs @ $32.00/hr 115.20
Body Supplies 3.0 hrs @ $2.00/hr 6.00
Miscellaneous 8.00
Subtotal 1,176.51
Sales Tax $646.91 @ 7.1250% 46.09
Grand Total 1,222.60
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 1,222.60
THIS REPORT IS BASED ON OUR INSPECTION AND DOES NOT COVER ANY ADDITIONAL PARTS OR LABOR WHICH
MAY BE REQUIRED AFTER THE WORK IS OPENED UP. OCCASIONALLY AFfER THE WORK HAS STARTED,WORN OR
DAMAGED PARTS ARE DISCOVERED WHICH ARE NOT EVIDENT FIRST INSPECTION.
MN 5T 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.
1/22/2013 11:19:08 AM 018571 Page 2
Preliminary Estimate
Customer: KLIMISCH,]ESSICA Job Number:
Vehicle: 2007 FORD FUSION SEL 4D SED 4-2.3L-FI MAROON
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide '
DR2JP06, CCC Data Date 1/17/2013, 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 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=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=Lefit. 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=6ureau of Automotive Repair. EPA=Environmental Protection Agency. NHTSA= National Highway
Transportation and Safety Administration. PDR=Paintless Dent Repair. VIN=Vehicle Identification Number.
1/22/2013 11:19:08 AM 018571 Page 3
i
HEPPNER'S WOODBURY AUTO BODY
1807 WOODLANE DR,WOODBURY, MN 55125
Phone: (651) 735-5055, Fax: (651) 735-5057
. . - - . .
Owner: KLIMISCH,JESSICA Insurance: OTHER PARTY Estimator: JON MARTENS Vehicle Out:
Job Number: Claim Number:
Year: 2007 Color: MAROON License Plate: 975JA6 Production Date:
Make: FORD Body Style: 4D SED State: MN Mileage In:
Model: FUSION SEL Engine: 4-2.3L-FI VIN: 3FAHP08Z87R177316 Condition:
x +"y"; Y�16 I'^R 9 � rd�. r 7w I °` tl�a v, pwp e o 1,
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Comments:
1/22/2013 11:19:06 AM Page 1
ABRA Auto Body & Glass - Woodbury Workfile ID: deaa689c
FederalID: 47197.6323 ,
ABRA...AMERICA'S MO5T RECOMMENDED! I
8230 Hudson Rd Suite 100, Woodbury, MN 55125
Phone: (651) 738-2272 '
FAX: (651) 73$-9795
Preliminary Estimate
Customer: KLIMISCH, JESSICA Job Number;
Written ey: Rich Rick
Tnsured: KLIMISCH,7ESSiCf1 Policy#: Claim #: .
rype of l.oss: Date of Loss: i./27/2013 12:00:00 PM Days to Repair: 0
I�oint of Impact:
Owner: Inspection Location: Insurance Company:
KLTMISCH,JESSICA AE3RA Auto Qody&Glass-Woodbury ALLIED INSURANCE
h00 LU[LL./�STREET N NUMBER 100 8730 Hudson Rd Suite 100
ST. P�l1L, MN 55119 Woodbury, MN 55].25
(50/) 581�]580 [3usiness Repair Facility
(651)738-2272 Day
VEHICLE
Year: 2007 Body Style: 4D SED VIN: 3FAHPOSZ87R177316 Mileage In:
Make: FORD Engine: 4-7_.3L-FI License: Mileage Out:
Model: FUSTON SFL Production Date: State: Vehicle Out:
C:olor: RFD Int: Condition: Job #:
TRANSMISSION E3ody Side Moldings Message Center 4 Wheel Disc E3rakes
5 Speed Transmission Dual Mirrors RADIO SEATS
POWER Overhead Console AM Radio Cloth Seais
Power Steering CONVENIENCE FM Radio Bucket Seats
Power I3rakes Air Conditioning Stereo WHEELS
Rear Uefo er Search/Seek Aluminum/Alloy Whcels
Power Windows 99
Power Locks
Tilt Wheel CD Changer/Stacker PAINT
Power Driver Seat
Cruise Control SAFETY Clear Coat Paint
Telesco ic Wheel Driver Air Bag OTHER
Power Mirrors p
Ffeated Mirrors
Intermittent Wipers Passenger Air Bag Fog Lamps
Power Trunk/Tailgate Alarm Head/Curtain Air Bags
DECQR Steering Wheel Controls Front Side Impac.t Air E3ags
1/7_2/?Ol3 1L'43:58 AM
057558 E��9c` �
i
�
Preliminary Estimate ,
Customer: KLIMISCH,]ESSICA
)ob Number: II
Vehicle: 2007 FORD FUSION SEL 4D SED�}-2.3L-FI RED '
Line Oper Description Part Number Qty Extended Labar Paint
Price$
^ 1 FRONT BUMPER
? ** <> Repl R[COND Qumper cover 6E5Z17D957CAPTM 1 293.00 2.3 7•6
3 Add for Clear Coat � �
q Add for fog lamps �'�
5 R&I License bracket �'?
6 R&I RT Cover w/fog lamps chrome Incl.
� R&I LT Cover w/fog lamps chrome Incl.
8 FENDER
9 Repl LT Fender liner 6E5Z16103A ]. 70.53 0•h
10 RADIATOR SUPPORT
11 Repl Lower deflector AE5Z8327A 1 91.45 0.3
17. # Rep) �Flex Additive/Adhesion Promoter 1 8.50 X
13 # Hazardous Waste 1 5.00 X _
SUBTOTALS 468.48 3.6 _ 3.6
ESTIMATE TOTALS --.—
Basis Rate Cost$
Category �y�'98
Parts
Body Labor 3.6 hrs @ $53.00/hr 190.80
Painl Labor 3.6 hrs @ $53.00/hr 190.80
Painl Supplies 3.6 hrs @ $33.00/hr 1 18.80
13.�0
Miscellaneous ---- —
9fi8.88
Subtotal ---- -
Sales Tax $454.98 @ 7.1250% 37.�+�.
Grand Total 1,001.30
�___ __
0.00
Deductible 0.00
CUSTOMER PAY ---
INSURANCE PAY 1,001.30
WARRANTY VALID ONLY WITH ORIGINAL COPY OF YOUR RECEIPT.
PARTS PRICES ARE SUBJECT TO INVOICE. NO GUARANTEE ON RUST REPAIRS. DELAYS DUE TO PARTS
AVAILABILIlY AND INSURANCE COMPANY REINSPECTS CAN AND DO OCCUR, PLEASE UNDERSTAND THAT WE
HAVE LITTLE CONTROL OVER SUCH SITUATIONS, BUT, WE WILL MAKE EVERY EFFORT TO REPAIR YOUR CAR AS
QUICKLY AS POSSIBLE. REPAIR TIMES ARE BASED ON FLAT RATE GUIDELINES AND MAY OR MAY NOT COINCIDE
WITH ACTUAL REPAIR TIME.
*****PAYMENT IS REQUIRED IN FULL FOR VEHICLE TO BE RELEASED!******
*****UNLESS OTHER PRIOR ARANGEMENTS ARE MAQE*****
MN ST 60A.955 - A PERSON WHO FILES A CLAIM W1TH INTENT TO DEFRAUD OR HELPS COMMIT A FRAUD
AGAINST AN INSURER IS GUILTY OF A CRIME.
]/7_�/2013 11:�F3:58 AM
057558 �a9c �
I
Preliminary Estimate I'
Customer: KLIMISCH,7ESSICA Job Number:
Vehicle: 2007 FORD FUSiON SEL 4D SED 42.3L-FI RED
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless ofiherwise noted all items are derived from the Guide
DR2JP06, CCC Data Date 1/17/2013, 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 O�M
(Alternative OEM) parts are OEM parts thal 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=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-�1dj. �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.
)./?_7/2013 t].:�F3:58 AM
057558 I��q� '
I
Preliminary Estimate
Customer: KLIMISCH,JESSICA ]ob Number:
Vehicle: 2007 fQRD FUSION SEL 4D SED 4-2.3L-FI RED
ALTERNATE PARTS SUPPI.IERS
Supplier: Keystone- NWPP-A
Location(s): 3615 MARSHALL STREET NE, MINNF�IPOLIS MN 55418 (800)328-1845 (612)/89�1.91.9
Line Description Item# Price
2 RECOND Bumper cover F01000596R $ �93.00
�
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