Ahmed ' ���;�,��E�
JAN 3 i 2_n13 �
NOTICE OF CLAIM FORM to the City of Saint Paul, N,�j�ne�
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Minnesota State Statute 466.05 states that"...every persnn...whn claims damage.r.%mm any munici/�aliry...shall cause m be presented tn the
governing body qf the municipality within 180 days after the aUeged loss or injury is discovered a nntice stating the time,place,and
circumstances thereq f,and the amnunt qf compensadnrt nr 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 so�thing 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 �q �-E� Middle lnitial � Last Name �� M�
Company or Business Name � �
�
: Kaleel M. Ahmed `
Are You an Insurance Company? Yes/No If Yes,Ciaim Number? � : 10142 Bridgewater Pkwy. t
l O /�„ .L.. Q R.!l�s E(,J�-'/Ztf� �L<,(/J y � Woodbury MN 55129
Street Address �r. _-� _. � ,_-_ ,
City W����� State �`'�� Zip Code s�L
Daytime Phone(6�5��-`3�bCell Phone���3 3�3a Everung Telephone(�}3 R ^ `3��`�
Date of Accidend Injury or Date Discovered ��� � q�'�- °Z'��3 Time -�� �r �/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 andlor responsible for your damages.
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7�'Ft' ��Ot 1�1�FS .DIIM �$C= ()N �'fz t-f�a, �/rc�lc 1� r'�Oc.d• I
Please check the box(es)that most closely represent the reason for completing this form:
❑ My vehicle was damaged in an accsdent ❑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�u�
❑ lV1y vehicle was wrongfully towed and/or ticketed O I was injured on City property �
��j C�Other type of property damage—please specify G� �� -��kS4 � �' T° �-��/� `r���F
� Other type of injury—please specify �'`�' �
In order to process your claim vou need to include conies of all applicable documents.����'�'�"� �"�
M L',�/�-1�
For the claims types listed below,please be sure to include the documents indicated or it will delay the handling ofy
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
�� Property damage claims to a vehicle:iwo estimaies 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
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Failure to complete and return both pages will resWt in delay in the handling of your claim.
All Claims-alease comalete tlus secNon
Were there witnesses to the incident? Yes No nknow (circtej
Provide their names, addresses and telephone numbers: �t� 4r�' /.��l7 c-tA n✓ `r ���' � ���
�1' ��T JA1't-ic.t a� .�772-�L'1 , �
-77.� .r�ti./ '7�Nt�
Were the police or law enforcement called? Yes No Unknown (circle
If yes,what department or agency? Case#or report# D�'"1 E �vT' D t O �
F�c,c- .��.�r'o.c�
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' �7"h-�[c.0 a�./ J'?n-t�4� .�T~ i°�ti,. FL�v .
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. 4' /6 a 3 • �� _ -���•k /L�.la�•./�.' esG G.c�.. -
Vehicle Claims- lease com tete this section ❑check box if this section does not a 1
Your Vehicle: Year ! 9 q Make c/'0/ Model �'�
License Plate Number )C/1! R 9l�i State �� Color ��-�t�
RegisteredOwner /Cq-C�€-��L-- M • �(-M.�
Driver of Vehicle �'�At't.�L �`'t • A�-t�t'M�
Area Damaged �.'� P�E ��rJ !•�1 !� F'y+-�� �a 0 '� � M��-r�<
City Vehicle: Year Make - _Modei
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniurv Claims-nlease comalete this section Q�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
[�"Check here if you are attaclung 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 processed.
!/.�,G / � /.3
Submitting a false claim can result in prosecution. Date form was completed � �
Print the Name of the Person who Completed tlus Form: l'���-�Z-- � '�� �
Signature of Person Making the Claim:
Revised February 201]
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HEPPNER'S AUTO SERVICE CENTER Workfile ID: f0231384
Caring since 1956
624 COMMONS DR, WOODBURY, MN 55125
Phone: (651) 714-1471
FAX: (651) 578-1287
Preliminary Esfimate
Customer: AHMED, KALEEL Job Number:
Wriffien By:Bill Wiimes
Insured: AHMED,KALEEL Policy#: Claim#:
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact: 16 Non-Collision
Owner: Inspection Lacation: Insurance Company:
AHMED,KALEEL HEPPNER'S AUTO SERVICE CENTER
10142 BRIDGEWATER PARKWAY 624 COMMONS DR
WOODBURY,MN 55129 WOODBURY,NMl 55125
(651)503-3830 Cell Repair Facility
(651)733-1616 Day (651)7141471 Day
VEHICLE
Year: 1999 Body Style: 4D SED ViN: WAUCB28D7XAd39292 Mileage In: �
Make: AUDI Engine: 41.SL-T License: XNR914 Mileage Out:
Modd: A4 QUATTRO ProducGon Date: Sbte: MN Vehicle Out:
Color: BLACK Int:BIACK Condition: Jnb#:
TRAIVSMISSION Body Side Moldrx,�s Alarm 4 Wheel Disc Brakes
5 Speed Transmission Dual Mirrors RADIO Positraction
4 Wheel Drive Console/Storage AM Radio SEA75
Overdrive CONVENIENCE FM Radio Cloth Seats
POWER AirConditiormng Stereo Buck�Seats
Power Steering Rear Defogger Cassethe 1NHEELS
Power Brakes Tilt WheeJ Search/Seek Aluminum/Alloy Wheels
Power Windows Cruise Control SAFETY PAIM
Power Locks Telescopic Wheel Arrti-Lodc&akes(4) Clear Coat Paint
Power Mirrors Intermitherrt Wipers Driver Air Bag Metallic Paint
Heated Mirrors Climate Control Passenger Air Bag OTHER
DECOR Key�ess Fntry Frot�t Side Imp�act Air Bags Fog LamPs
1/24/2013 8:46:29 AM 060167 Page 1
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. �
_ Preliminary Estimate
Customer: AHMED, KALEEL 7ob Number:
Vehide: 1999 A�1DI A4 Ql1ATTR0 4i)S�i)41.8Z-T&RCK
Line Oper Desa�iption Part Number Qtp Extended Labor Paint
Price$
1 FRONT BUMPER
2 R&I R&I bump�assy 0.8
3 FRONT LAMPS
4 Rpl Both Head�nps 0.8 �
5 R&I RT He.adlamp assy Incl.
6 R&I LT Headlamp assy Incl.
7 R&I RT tesrs 0.2
8 R&I LT Lens 0.2
9 HOOD&GRILLE
10 * Rpr Hood 4_0 3.0
11 Add for Gear Coat 1•Z
12 R&I Insulator 0.3
13 FENDER
14 * Rpr RT Fes+der 1_0 1.8
15 Overlap Major Adj.Panel -0.4
16 Add for Clear Coat 0.3
17 * Rpr LT Fender 1_0 1.8
18 Overlap Major Adj.Panel '0•4
19 Add for Gear Coat 0.3
20 TRUNK LID
21 * Rpr Trunk lid 1_d 2.3
22 Overiap Major NorrAdj.Panel -0.2
23 Add for Clear Coat 0•4
24 Rept EmWem SD58537422ZZ I 70.00 0•2
25 Repl Nameplabe"A" 4D08537412ZZ 1 35.00 0.2
26 Repl Nameplabe"4" 8D0853741A2ZZ 1 35.00 0.2
27 ReQI Nameplat�e"1.8" 81A853743E27Z 1 35.00 0.2
28 R&I Lid trim 0.3
29 # Repl Hazardous Waste Removal 1 5.00 X
30 # Repl Car Cover 1 3.00 X
31 # Repl Cortosion protsction 1
SUBTOTALS 183.00 10.4 10.1
1/24/2013 8:46:29 AM 060167 Page 2
PDF created with pdfFactary trial version ,�v:°ti��v.pca�actorv.�.�����
Preliminary Estimate
Customer: AHMED, KALEEL 7ob Number:
Vehic�e: 1999 A21UT A4 Qt1AT'TRO 4D S�D 41.8Z-T BLACK
ESTIMATE TOTALS
category sasis Rate cost#
Parts 175.00
Body Labor 10.4 hrs @ $52.00/hr 540.80
Paint Labor 10.1 hrs @ $52.00/hr 525.20
Paint Supplies 10.1 hrs @ $32.00/hr 323.20
Body Supplies 9.6 hrs @ $2.00/hr 19.20
Miscellaneous 8.00
Subtotal 1,591.40
Sales Tax $175.00 @ 7.1250% 12.47
Grand Total 1,603.87
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 1,603.87
QUALITY REPLACEMENT PARTS WARRANTY
OUR REPAIR ESTIMATE MAY SPEQFY THE USE OF QUALITY REPLACEMENT PARTS. QUALITY REPLACEMENT PARTS
ARE PARTS NOT MANUFACTURED 8Y OR FOR THE ORIGINA� EQt1IPMENT MANlJFACTURER. WE WILL STAND
BEHIND THE QUALITY REPLACEMENT PARTS THAT ARE SPEQFIED ON THIS ESTIMATE AND USED IN THE REPAIR
OF YOUR VEHICLE, FOR AS LONG AS YOU OWN/LEASE THE VEHICLE. WE WARRANT THESE PARTS ARE OF LIKE
KIND, QUALITY, SAFEfY, F1T AND PERFORMANCE TO PARTS MANUFACTURED BY OR FOR THE ORIGINAL
EQUIPMENT MANUFACTURER.
THIS WARRANTY EXCLUSNELY COVERS LOSS OR DAMAGE THAT IS RELATED TO DEFECTS IN THE QUALITY
REPLACEMENT PART. THIS WARRANTY DOES N�T COVER DAMAGE OR PART FAILURE DUE TO IMPROPER
INSTALLATION, MISUSE, NEGLECT,ABUSE, IMPROPER MAINTENANCE, ABNORMAL OPERATION, OR NORMAL WEAR
&TEAR.
SHOULD A SUPPLIER OF A PART SPEQFIED IN OUR REPAIR ESTIMATE,OR THE REPAIR FAQLITY THAT PERFORMS
THE REPAIR ON YOUR VEHICLE, BE UNABLE TO RESOLVE A LEGITIMATE COMPLAINT ABOUT THE QUALITY
REPLACEMENT PART USED IN THE REPAIR, WE WILL MAKE EVERY EFFORT TO SEE THAT THE PROBLEM IS
CORRECTED.
THIS WARRANTY AND ANY REPRESENTATIONS MADE HEREIN ARE NON-TRANSFERABLE AND EXTEND ONLY TO
THE PARTY OWNING/LEASING THE VEHICLE AT THE TIME OF THE REPAIR.
FOR ASSISTANCE, PLEASE COfYTACT THE NEAREST HELPPOINT CLAIM SERVICES OFFICE.
DISCLAIMER:
ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT INSURANCE CLAIM FOR THE PAYMENT OF A
LOSS MAY BE GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN STATE PRISON.
THE LABOR AND TAX RATES USED WERE DETERMINED BY THE VEHICLE INSPECTION LOCATION UNLESS THE
REPAIR FACILITY WAS KNOWN AT THE TIME OF THE INSPECTION OR ANOTHER LOCATION WAS SPECIFIED
1/24/2013 8:46:29 AM 060167 Page 3
PDF created with pdfFactory trial version ,���,�.�v�-.�dttac�grv.��:r�
Preliminary Estimate
Customer:AHMED, KALEEL 7ob Number:
Vefiic{e:1999 AtlDI A4 Ql3ATfR0 4D SED 41.8t T SLACK
BEFORE THE ESTIMATE WAS PREPARED
MN ST 60A.955 -A PERSON WHO FILES A CLAIM WITH IIYTEIYT TO DEFRAUD OR HELPS COMMIT A FRAUD
AGAINST AN INSURER IS GUILTY OF A CRIME.
Estimate based on MOTOR CRASH ESIZMATING GUIDE. Unless otheiwise noted all items are derived from the Guide
EEA1396, 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 atternate 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 infortnation provided by MOTOR may have
been modified or may have come from an alternate data sousce. Titde sign(�) 9tems 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-0riginal 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 infomiation are MOTOR suggested labor operation times.
NAGS labor operation times are not incl�. 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 ptegory. F=Frame labor category. G=Glass labor category.
M=Mechanicat 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. D8cR=Disconnect and Reconnect. HSS=High Strength Steel.
HYD=Hydroformed Steel. Ir�cl.=Induded. ZKQ=Like Krrrd arrd Q�alrty. LT=Le�t. MAG=Magnesium. Non-Adj.=Non
Adjacent. NSF=NSF International Certified Part. 0/H=Overhaul. Qty=Quantity. Refn=Refinish. Repl=Replace.
RBcI=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.
1/24/2013 8:46:29 AM 060167 Page 4
PDF created with pdfFactory trial version vwvw.qafra„ _
Preliminary Estimate
Customer: AHMED, KALEEL Job Number:
Vetricle:1g99 AtlDI A4 QUaTTRO 4fl SED 41.8L-T 84.ACK
CCC ONE Estimating - A product of CCC Infortnation Services Inc.
The following is a list of abbreviations that may be useti in CCC ONE Estimating that are not part of the MOTOR
CRASH ESTIMATING GUIDE:
BAR=6ureau of Automotive Repair. EPA=Environmental Protection Agency. NHTSA= Nationa� Highway
Transportation and Safety Administration. PDR=Paintless Dent Repair. VIN=Vehicle Identification Number.
I
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1/24/2013 8:46:29 AM 060167 Page 5
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