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_ FE� 1 1 2[�13
" NOTICE OF CLAIM FORM to th�,s�',�,t���.;,�aint Paul, Minnesota
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 municipality within 180 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 tetephone to clarify answers,so provide as
much information as necessary to ezplain 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 ��t55� Middle Initial�Last Name �
_Cmm�anv nr B�usiness Name-__----M___
t�re You an u�surance Company? Yes No If Yes, Claim Num'oer?
Street Address �� �QG55 ��G�.t
City �'� State ��� Zip Code���
Daytime Phone(p��-�Cell Phone(��- "L��Evening Telephone(_� -
Date of Accidend Injury or Date Discovered "j�k,�v (fi'�" ,Zi�l 2- Time :� am p�
Please state, in detail,what occurred(happened), and why you are submitting a claim. Please indicate wh or how you
feel the City of Saint Paul or its employees are involved and/or responsible for your damages. Z
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�lease aheck the box(es)that most closely represent the reason for completmg this form:
� Ivty 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
- - - -- --
-- t er iyp�oi propeny aairiag'�
Failure to complete and return both pages will result in delay in the handling of your claim. �
All Claims—please comulete this section
Were there witnesses to the incident? Yes No Unknown (circle)
Provide their names, addresses and telephon bers: �T" � V - "LI�- ,`�(�?I S r Sf. �'�n�ti-,�j�t�
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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,
closest landmark, etc. Please be as detailed as possible. If necessary, attach a diagram. '"' '" �fi �
T ,v � � � C�r i.��� � ; � `
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. ��c(� � CL.� � H� .-� �- 1_� •�� �-� � � ,�
ti ehicle Claims—please complete this section � check box if this section does not a�plv
Your Vehicle: Year �C,�;,� Make �1.;��Ic1 Model '�
License Plate Number��j 6-�c� State_�Color �
Registered Owner N1�l��,Sq 1�1�� �
Driver of Vehicle c�,���_
Area Damaged f'�� c��..:,l�c-� . v��;� Cc�� 5 ,,:• �� �
City Vehicle: Year ti � Make l�todel
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
In'u Claims— lease com lete this section check box if this section does not a 1
How were you injured? �1//�
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 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 _ � '"(.C� — � `
Print the Name of the Person who Completed this F �; e
Signature of Person Making the Claim:.
Revised February 2011
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RO: 0048117.00 Detailed Customer Invoice Page: 1
10/03/12 5:36PM
Raymond Auto Body, Inc.
1075 Pierce Butler Route
St. Paul,MN 55104-1593
651-488-0588 FAX: 651-488-4794
--- - --- ---= ---- =--_ __-__-_.:
-�'��;�-�(�� Date of Loss: 6/06/12 FARMERS
�;:������['{ Year: 08
�i``PXC3�;,71�'N �i� Make: MAZDA
Model: 3
Home: 651-249-4245 Type: 4 DOOR Phone:
Work: 612-349-0824 EX00000 Style: 10-2 Fax:
Est.: SLAIKEU Engine: Adjuster: �
Received: 8/23/12 Color: GRAY Claim#: 1021527155
Del. Date: 10/03/12 License: MN SAJ-070 Policy: _ _
�1a!P. �3ia: 1�/n^!1� �,T;��w�t: ��iG� � ��1....;1��:..
VIN: JM1BK343781814029 Deductible: 1000.00
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RO: 0048117.00 Detailed Customer Invoice Page: 2
10/03/12 5:36PM
28 Rem/Inst Rear header 1.00
29 Repair Rear header 1.00
30 Rem/Inst Center bow 1.00
31 Rem/Inst Reinforcement w/o sunroof 1.00
32 Roof Mouldning clips 23.22 ,
33 PILLARS,ROCKER&FLOOR
34 Rem/Inst RT Rocker molding 0.40
35 Rem/Inst LT Rocker molding 0.40
36 Repair RT Hinge pillar(HSS) 4.00 1.70 ,
37 Repair LT Hinge pillaz(HSS) 10.00 1.70
38 Refinish Overlap Major Non-Adj.Panel -0.20
39 Rem/Repl Retape Rocker Moulding RT/LT 0.50 17.13
40 FRONT DOOR I
41 Repair RT Door shell hatchback 2.50 2.00
42 Refinish Overlap Major Non-Adj.Panel -0.20
43 Repair LT Door shell hatchback I.50 2.00
44 Refinish Overlap Major Non-Adj.Panel -0.20
45 Rem/Inst RT Surround w'strip 0.50
46 Rem/Inst LT Surround w'strip 0.50
47 Rem/Repl RT Body side mldg w/body color 46.81 030
48 Rem/Repl LT Body side mldg w/body color 42.63 030
49 Rem/]nst RT Mirror assy electric w/o de 030
50 Rem/Inst LT Mirror assy electric w/o de 030
51 Rem/Inst RT Handle,outside w/keyless e 0.30
52 Rem/Inst LT Handle,outside w/keyless e 0.30
53 Rem/Inst RT Trim panel assy w/o leather 0.40
54 Rem/Inst LT Trim panel assy w/o leather 0.40
55 Rem/Repl RT Nameplate"23" 10.95 0.20
56 Rem/Repl LT Nameplate"23" 10.95 0.20
�7 Rem/Repl RT Belt w'strip 33.13 030
58 Rem/Repl LT Belt w'strip 45.75 030
59 REAR DOOR
60 Repair RT Door shell 2.00 1.90
61 Refinish Overlap Major Non-Adj.Panel -0.20
62 Rem/Repl RT Body side mldg w/body color 46.81 0.30
63 Rem/Inst RT Surround w'strip 0.50
64 Rem/Inst LT Surround w'strip 0.50
6�Blend i:L Doui sheli 1.00'
66 Rem/Repl LT Body side mldg w/body color 46.81 0.30
67 Rem/Inst LT Handle,outside galaxy gray 0.30
68 Rem/Inst RT Handle,outside black 030
69 Rem/Inst LT Trim panel assy cloth black 0.40
70 Rem/Inst RT Trim panel assy cloth black 0.40
71 Rem/Repl RT Belt w'strip 3923 0.30
72 Rem/Repl LT Belt w'strip 38.47 0.30
73 QUARTER PANEL
74 Repair RT Quarter panel 2.00 2.20
75 Refinish Overlap Major Adj.Panel -0.40
76 RT Quarter glass Mazda(OUT) 40.00
77 LT Quarter glass Mazda(OUT) 40.00
78 Repair LT Quarter panel 1.00 2.20
79 Refinish Overlap Major Adj.Panel -0.40
80 Refinish Clear Coat 4.00
81 Blend Fuel door 0.20
��, -
RO: 0048117.00 Detailed Customer Invoice Page: 3
10/03/12 5:36PM
82 Rem/Inst Fuel door 030
83 LIFT GATE
84 Rem/Inst R&1 liftgate assy
85 REAR LAMPS
86 Rem/[nst RT Tail lamp assy w/o LED
87 Rem/Inst LT Tail lamp assy w/o LED
88 REAR BUMPER
89 Rem/Inst R&1 bumper cover 1.50
90 MISCELLANEOUS OPERATIONS
91 Rem/Repl Cover car/bag 26.83
92 Rem/Repl Cover car/Interior 030 10.00
93 Rem/Repl Corrosion protection primer 0.30
94 Hazardous waste removal � 10.00.
95 Glass Kits 64.59
96 Panel Bonding Kit-Roof 142.44
9?Rem/Repl Self Leveling seam sealer-Ro 1.00 SS.p2
98 Rem/Repl NVH Foam-Roof 0.50 124.80
99 Clear Coat Cap -1.50 � �
914 Paint Materials 598.30
920 Clear Coat Paint Materials 124.00
926 Paint Blend Materials 37.20
Totals 1,958.00 65.60 24.50 1,210.31
-----_ --
Total Category Rate Units Est. Suppl. Total
_ -- - ----- --- - --___ ____ --- _ - -
PARTS 1,313.24 384.76 1,698.00
BODY LABOR 50.00 65.60 1,775.00 1,505.00 3,280.00
PAINT LABOR 50.00 24.50 465.00 760.00 1,225.00
SUBLET 260.00 260.00
MISCELLANEOUS 101.12 349.69 450.81
PAINT MATERIAL 31.00 759.50 759.50
Subtotals 90.10 3,914.36 3,758.95 7,67331
SALES TAX 113.56 22.78 13634
Grand Total: 90.10 4,027.92 3,781.73� 7,809.65
_ _ _�----
Date Payment Received By Method Charge Type; Amount
_ _ _ ------ _ -- _ _--- -- -
8/30/12 Farmers ck# ]013563121 ARIAS Check 3,133.69
9/17/12 F.ARMERS CK# 1013563720 VALENTO Check 799.99
9/25/l2 Farmers Ck# 1013564108 ARIAS Check 350.02
`I0103f1� �1�� i; r`��.: _ � >� ��; •<� , . `.�;`�.,_ ����. =,.��� .�._=� ±��� -. _ ;�
10/03/12 FARMERS CK#1453008615 LEIBEL Check 2,486.80
Total Payments: 7,770.50
Balance Due: 39.15