Ahlers ����+�'E�i
��� � 2 2013
NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
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Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipality...shall cause to be presentec�t�o�e
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 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
First Name `..� ��`�G.� Middle Initial L. Last Name ����� �
Company or Business Name, if applicable �
Street Address ��� �-�. C'�c.;��_ � �,� �
City ��_ �r_ . 4� State�� Zip Code b
Daytime Telephone ( Sl ) �G�- l3�G Evening Telephone�_)
Date of Accident/ Injury or Date Discovered Z/(�Z.-I � � Time 16 : `�f am/�m (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 its employees are involved and/or responsible. ������
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Please check the box(es) that most closely represent the reason for completing this form: �� ��5
❑ Vehicle was damaged in an accident �! Vehicle 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
O 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 you 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 comqlete this section -��--
Were there witnesses to the incident? Yes No Unknown � (circle)
If yes, please provide their names, addresses and telephone num
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Were the police or law enforcement called? Yes � 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
�r facility, closest landmark, e�c. Please be as detailed as possible. If helpful, attach a diagram.
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Please indicate the amount you are seeking in compensation from this claim or what you would like the City
to do to resolve this claim to your satisfaction.
Vehicle Claims-alease complete this section ❑ check box if this section does not apnlv
Your Vehicle: Year 2��� Make Model S�l v��x'G c��
License Plate Number Z.Z. State�_Color_���c_K
Registered Owner 1�����cs..c�� ��[��S
Driver of Vehicle
Area Damaged -F'cd.,�� ���:xp�-�_ ��_e�cc.� �('
City Vehicle: Year Make Mod�
License Plate Number State Color
Driver of Vehicle (City Employee's Name)
Area Damaged
Iniurv Claims-please complete this section ❑ 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 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 ojyour knowledg� Unsigned
forms wi!! not be processed. Submitting a jalse claim can result in prosecution. t
Print the Name of the Person who Completed this Form: � � V�,��2v'�
Signature of Person Making the Claim:
Date form was completed� l7-,//�7 Revised April 2007
HAAS COLLISION &GLASS Workfile ID: 4e0eb5bf
FederalID: 33-1120284
WIZARDS OF HAAS License Number: 71709
1400 ST. CLAIR AVENUE, SAINT PAUL, MN 55105
Phone: (651) 699-1812
Preliminary Estimate
Customer: Ahlers, Bill
Written By: Bob Kreuger
Insured: Policy#: Claim #:
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact:
Owner: Inspection Location: Insurance Company:
Ahlers, Bill HAAS COLLISION&GLASS
1267 St.Clair Ave. 1400 ST.CLAIR AVENUE
St. Paul, MN 55105 SAINT PAUL, MN 55105
(651)403-1330 Cell Repair Facility
(651)699-1812 Day
VEHICLE
Year: 2009 Body Sryle: 4D SHORT VIN: 1GCEK29019Z152568 Mileage In:
Make: CHEV Engine: 8-5.3L-FI License: Mileage Out:
Model: K1500 4X4 SILVERADO Production Date: State: Vehicle Out:
EXT LT
Color: Int: Condition: Job#:
TRANSMISSION DECOR AM Radio Stability Control
Automatic Transmission Dual Mirrors FM Radio Communications System
4 Wheel Drive Privacy Glass Stereo SEATS
Overdrive CONVENIENCE Search/Seek Cloth Seats
POWER Air Conditioning CD Player WHEELS
Power Steering Tilt Wheel Satellite Radio Styled Steel Wheels
Power Brakes Cruise Control SAFETY PAINT
Power Windows Intermittent Wipers Anti-Lock Brakes(4) Clear Coat Paint
Power Locks Keyless Entry Driver Air Bag TRUCK
Power Mirrors Message Center Passenger Air Bag Rear Step Bumper
Heated Mirrors RADIO Traction Control
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2/19/2013 3:26:32 PM 071709 Page 1
Preliminary Estimate
Customer: Ahlers, Bill
Vehicle: 2009 CHEV K1500 4X4 SILVERADO DCf LT 4D SHORT 8-53L-FI
Line Oper Descriptio� Part Number Qty Extended Labor Paint
Price$
1 FRONT BUMPER
2 Repl Lower extn 25821880 1 67.12 0.3
3 ** Repl Opt OEM Bug Shield 1 99.45
SUBTOTALS 166.57 0.3 0.0
ESTIMATE TOTALS
Category Basis Rate Cost$
Pa� 166.57
Body Labor 0.3 hrs @ $56.00/hr 16.80
Body Supplies 0.3 hrs @ $3.00/hr 0.90
Subtotal 184.27
Sales Tax $ 166.57 @ 7.6250% 12.70
Grand Total 196.97
CUSTOMER PAY 0.00
INSURANCE PAY 196.97
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.
2/19/2013 3:26:32 PM 071709 Page 2
Preliminary Estimate
Customer: Ahlers, Bill
Vehicle: 2009 CHEV K1500 4X4 SILVERADO EXT LT 4D SHORT 8-5.3L-FI
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
DR1GH07, CCC Data Date 2/14/2013, 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 Benchma�k 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=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.
2/19/2013 3:26:32 PM 071709 Page 3