Williams ��U�i`���
NOTICE OF CLAIM FORM to tl����t�y �b�1�aint Paul, Minnesota
Minnesota State Statute 466.05 states that "...every person...who claimsWd�a�ge��n�municipaliry...shall cause to be presented to the
governircg 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 may or may not be contacted by telephone to discuss your claim
circumstances,so provide as much information as necessary to explain your claim,and the amount of compensation being
requested. 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
�• � 1 ` '�' �M �
First Name `���C3` Middle Initial rn Last Name UV��I�Q�Y 1 �S •
Company or Business Name, if applicable�J �
Street Address,,���Y�N �V�— l�1/�, � � 7'
City �� -���� State Y 1 `� Zip Code����
Daytime Telephone (_��_�C� Evening Telephone( )
Date of Accident/ Injury or Date Discovered � � � Time , am ,pm(circle)
, —
Please state, in detail, what occurred, and why you are submitting a claim. Please indicate why or how you
feel the City of Saint Paul or i s emplo ees are involved and/or respo sib e. �
�(�t/ (�$_��J� fi0 I �� 1�1s� �O � ��e,V �1�1�
..
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✓�
Please check the box(es) that most closely represent the reason for com leting this form:
❑ Vehicle was damaged in an accident �ehicle was damaged during a tow
❑ Vehicle was damaged by a pothole or condition of the street ❑ Vehicle was damaged by a plow
❑ Vehicle was wrongfully towed and/or ticketed ❑ Injured on City property
❑ Other type of property damage—please specify '
❑ Other type of injury—please specify
❑ Other type not listed—please specify
In order to process your claim vou need to include copies of all applicable documents. This is a general
guideline of what should be submitted with a claim form,but it is not all inclusive. You may be asked to
provide additional information depending on your claim.
O Property damage claims to a vehicle: at least two estimates for the repairs to your vehicle, or the
actual bills and/or receipts for the repairs
O Towing claims: legible copies of any tickets issued and copies of the impound lot receipts
O Other property damage: repair estimates, detailed list of damaged items
O Injury claims: medical bills, receipts
O Photographs can be provided but will not be returned.
Page 1 of 2—Please complete and return both pages of Claim Form
Failure to provide a completed claim form will result in delays in processing.
Notice of Claim Form, City of Saint Paul, page two
All Claims-please complete this section _.-
Were there witnesses to the incident? Yes No '��Unkno� (circle)
If yes, please provide their names, addresses and telephone num ers:
Were the police or law enforcement called? Yes No Unkno (circle)
If yes, what department or agency? Cas Br report#
Where did the accident or injury take place? Provide street address, cross street, intersection, name of park
or facilitv, clQSest landmark, etc. Please be as detailed as possible. If helpful, attach a dia am.
rno� 5�.)rz_, 1 ��� y��.r-.�-- U�ln��l�' U.k��
Please indicate the amount you are seeking in �nensati,pn from thi claim or what you would like the City
to do to resolve this claim to your satisfaction��J
Vehicle Claims- lease com lete this section ❑ check box if this section does not a 1
Your Vehicle: Year Make Model
License Plate Number State�n Color
Registered Owner�V � `�(}NY1S
Driver of Vehicle
Area Damaged r��t'
City Vehicle: Year �' Make -- Model ^
License Plate Number � State � Color -'
Driver of Vehicle (City Employee's Name) '"
Area Damaged �
In'ur Claims- lease com lete this section check box if this section does not a 1
How were you injured?
What part(s) of your body were injured?
Have you sought medical treatment? �'es 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 injormation you have provided u true and correct to the best of your knowledge. Unsigned
forms wi[l not be processed. Submitting a false c[aim can resu[t in prosecution � � 1� `
Print the Name of the Person who Completed thi F �r��(�� )�� �1�,��5
� �
Signature of Person Making the Claim:
Date form was completed � Revised April 2007
Citation# $8$ �5�°���
' ST. PAUL
STATE OF MINNESOTA-RAMSEY DISTRICT COURT I IIIIII IIIII IIIII(III)IIIII I`III(IIiI IIIII IIIII IIII IIII
The undersigned,bemg duly sworn,upon his/her oath deposes and says:
* 8 8 8 7 5 2 7 0 7 *
Date of Offense � °:i.-' � � '. Time of Offense � ' .. , ..;;. ;: � '. `; _, �_.,., ` . , 1�I_X �;\
-, ._
Plate �,� '��` _:_ �'����' � '`��� V'�'�-
Veh.License Na Year�State ' Make Style � Color
Location of Offense: �
VIOLATION: �A SNOW EMERGENCY St. Paul Ordinance 161.03 FINE $53.0
• (Amount includes mandatory state surcharges of$13.0
CN :,
Citing s'.+ � _..., . Number x�'`�'` CitPg �";
Officer 'i Je t
❑Posted Night Plow ❑Day Plow �Plowed in(Windrow) ❑Tagged Before Plow ❑Drove(
OFFICER'S NOTES
❑NO PLATE VIN:
Citation can be paid at the Impound Lot.Please read the back of the citation for payment instructions.
CITATION
Saint Paul Police Impound Lot, 830 Barge Channei Road, Vehicle Release Form
ST PAUL. If1P0UND LOT
Make: 08 DODGE License#: 870DHU CN: 13027844 s�I�aa�x�.. I'�j.�5.5107-�295
651-266-5642
Date/Time Released:02/11/2013 09:24 Tow Charge: $ �rmhIDt I001734000081�38014406
Released to:TOTO " Storage Charge: $ Sale
zzzXXZZ�aaczzl�4
Paid by: CREDIT CARD Admin Charge: $ Uj� En�'Y Metho
Released by: ELISE Tax; (7,g25o�o� $ Total: S
6v11i13
I,the undersigned,have recovered the vehicle described above. Subtotal: $ I�y q; � �r Cod
I will check the vehicle for damage or any o�ther problems that �; Q�ji�
may have occurred while this vehicle was in the custody of the Service Charge: $ ...��
Saint Paul Police Department. I acknowledge I will report
damage and/or any other problems to the Impound Lot staff Total Charges: $ 219.50
on this form prior to leaving the im ound lot.
Damage and/or other problem:
�� r `�° �
A
� � �
Police Report made: Yes_No_IF Yes, CN , If NO, Why?
TO PROTECT YOUR RIGHTS REPORT ANY PROBLEMS/DAMAGE BEFORE LEAVING THE LOT
5/2000
Signature
MAIN MOTOR CHEVROLET & Workfile ID: 8734f2c5
CADILLAC BODY SHOP
435 W MAIN ST, ANOKA, MN 55303
Phone: (763) 506-9158
FAX: (763) 421-4385
Preliminary Estimate
Customer: WILLIAMS,TRICIA 7ob Number:
Written By: STEVE TARNOWSKI
InSUred: WILLIAMS,TRICIA Policy#: Claim #:
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact:
Owner: Inspection Location: Insurance Company:
WILLIAMS,TRICIA MAIN MOTOR CHEVROLET&CADILLAC
BODY SHOP
1635 SHERBURNE AVE 435 W MAIN ST
ST PAUL, MN 55104 ANOKA,MN 55303
(763)412-8123 Evening Repair Facility
(763)506-9158 Business
VEHICLE
Year: 2008 Body Sryle: 4D SED VIN: 263KA43R88H259920 Mileage In:
Make: DODG
Engine: 6-2.7L-FI License: Mileage Out:
Model: CHARGER
Production Date: State: Vehicle Out:
Color: Int: Condition: ]ob#:
TRANSMISSION Body Side Moldings Keyless Entry SEATS ,
Automatic Transmission Dual Mirrors
RADIO Cloth Seats
Overdrive
Console/Storage AM Radio Bucket Seats
POWER Overhead Console FM Radio WHEELS
Power Steering CONVENIENCE
Stereo Full Wheel Covers
Power Brakes
Air Conditioning Search/Seek PAINT
CD Pla er Clear Coat Paint
Power Windows Rear Defogger Y
Power Locks
Tilt Wheel SAFETY OTHER
Power Mirrors
Cruise Control Driver Air Bag Stability Control
Power Trunk/Tailgate Telescopic Wheel Passenger Air Bag
DECOR Intermittent Wipers 4 Wheel Disc Brakes
2/11/2013 5:59:41 PM
018750 Page 1
Time n�ent.
_,�:s�mable to keep ap�
,
I
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Preliminary Estimate
Customer: WILLIAMS,TRICIA 7ob Number:
Vehicle: 2008 DODG CHARGER 4D SED 6-2.7L-FI
Line Oper Description Part Number Qty Extended Labor Paint
Price$
1 FRONT BUMPER
2 0/H bumper assy 2.0
3 Repl Bumper cover w/o SRT8 4806179AE 1 514.00 Incl. 3.2
4 Add for Clear Coat 1.3
5 FRONT LAMPS
6 R&I RT Side marker lamp Incl.
7 R&I RT Headlamp assy w/o HID 0.3 �
8 FENDER
9 * Rpr RT Fender � 2.0
10 Add for Clear Coat 0.8
11 Repl RT Fender liner 5065502AD 1 88J0 0.3
12 HOOD ,
13 Blnd Hood w/o SRT8 1.4 '
14 # CORROSION PROTECTION 1 0.5
15 # CAR COVER FOR REFINISH 1 X 0.2 �!
16 # FLEX FINISH ADDIIIVE 1 4.00 X I�,
17 # HAZARDOUS WASTE 1 5.00 X I�
SUBTOTALS 611.70 5.1 9.4 i
I
NOTES �
Estimate Notes:
PRELIMINARY ESTIMATE ONLY.SUB]ECT TO DISASSEMBLY AND PARTS PRICES
PRELIMINARY ESTIMATE.SUBJECT TO WASHING VEHICLE FOR CLOSER INSPECTION
ESTIMATE TOTALS '
�
Category Basis Rate Cost#
Parts 602.70
Body Labor 5.1 hrs @ $55.00/hr 280.50
Paint Labor 9.4 hrs @ $55.00/hr 517.00
Paint Supplies 9.4 hrs @ $32.00/hr 300.80
Miscellaneous 9.00
Subtotal 1,710.00
Sales Tax $602.70 @ 7.1250% 42.94
Grand Total 1,752.94
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 1,752.94
2/11/2013 5:59:41 PM 018750 Page 2
Preliminary Estimate
Customer: WILLIAMS,TRICIA 7ob Number:
Vehicle: 2008 DODG CHARGER 4D SED 6-2.7L-FI
This is a VISUAL estimate only! Additional parts and labor may be extra upon dissasembly. Parts prices are subject to
invoice.
Main Motors Body Shop
FAX (763) 421-4385
TRICIA HEDBERG (763)506-9150
STEVE TARNOWSKI [763]506-9152
A person who submits an application or files a claim with intent to defraud or helps commit a fraud against an insurer
is guilty of a crime.
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.
I
2/11/2013 5:59:41 PM 018750 Page 3
Preliminary Estimate
Customer: WILLIAMS,TRICIA Job Number:
Vehicle: 2008 DODG CHARGER 4D SED 6-2.7L-FI
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
DR3PB06, CCC Data Date 2/8/2013, 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 (�) 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 Z012 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 I
be repaired or replaced: I
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. 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.
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