Phelps ������'�:���
� FEB 2 5 2013
NOTICE OF CLAIM FORM to the City of Saint Pa�q�����ota
Minnesota State Statute 4b6.05 states tlzat "...every person.,.who claim.r damcrges•finm any municipality.,.shall cause to be presented to the
governing bncTy nJthe municipality within/80 days after the alleged loss or injury is discovered a notice stating the time,pJace, and
circumsta�tces thereof,rmd the amourat orcompensation or other r-elief demanded."
Please comptete 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
circumstanees,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 somet6ing does not apply,write`N/A'.
SEND COMPLETED FORM AND OTHER DOCUMENTS TO:
CITY CLERK, 15 WEST KELLOGG BLVD,310 CITY HALL, SA.INT PAUL, MN 55102
First Name �-t,C,���,r� Middle Initial Last Name '�
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Company or Business Name, if applicable
Street Address.�i i L � ? ,,-,� • j-f�
City ' � ,� ,�
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�`� j '" State ;�`��. Zip Code<`�5 �
Daytime Telephone(!�,i}�'��'- �,� j ��c� � �
--L-T---� Evening Telephone�_)�;�--�;�rn��
Date of Accident/Injury or Date Discovered .�-�`� -� j 5'
Time am /pm (circle)
P lease state, in detail, what occurred, ax�d why you are submitting a claim. Flease indicate why or how you
feel the City of Saint P ul or its employees are involvefd and/or responsible.
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Ptease check the box(es) that most closely represent the reason for corn leting this form:
O Vehicle was damaged in an accident
ehicle was damaged during a tow
❑yehicle was damaged by a pothole or condition of the street O Vehicle was damaged by a piow
C7 Vehicle was wrongfiilly towed andlor ticketed ❑ Injured on City property
❑ Other type of property damage-please specify
❑ Other type of injury-please specify
❑ Other type not listed-ptease specify
1n order to process your claim you need to include copies of ali apolicable documents. This is a generaI
guideline of what should be submitted with a claim form,but it is not a11 inclusive. You may be asked to
provide additional infonnation depending on your cl�im.
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 P9u1, page two
All Claims-ulease complete this section
Were there witnesses to the incident? Yes No � Unknown ' (circle)
If yes,please provide their names, addresses and telephone numbers:
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 helpful, attach a diagram.
%� " ,S , -�-t�r � �
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-please complete this section ❑ check box if this section does not applv
Your Vehicle: Year �.��� � Make i=: r r,� Model ��,;�, ;
License Plate Number State'rvt r✓ Color C���
Registered Owner ti=��, p���:,s
Driver of Vehicle
Area Damaged F • +- r, �;, � r��,� �
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 Q'check box if this section does not annlv
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 signi�tg Fhis form,you are statuig that a/l information you have provided is true and correct to the best of your knowledge. Unsigned
forms will not he processed Submitting a false claim can result in prosecution.
Print the Name of the Person who Completed this Form:
Signature of Person Making the Claim: �C .1�_r�
�
Date form was completed -1 �� -�� Revised April 2007
LATUFF BROS., INC.
880 UNIVERSITY AVENUE
ST. PAUL, MINNESOTA 55104
(651)224-2828 FAX:(651)291-0677
FEDERAL ID#41-0777034
**'PRELIMINARY ESTIMATE*`*
02125/2013 10:26 AM
Owner
Owner: EUGENE PHELPS
Address: 1957 ROME AVE Work/Day:
Home/Evening: (763)274-4789
City State Zip: Saint Paul, MN 55116 FAX:
_ _ _ _ __ _. __
Inspection _
Inspection Date: 02/25/2013 10:25 AM Inspection Type: Drive In
Inspection Location: Latuff Brothers Inc Contact:
Address: 880 University Ave Work/Day: (651)224-2828x
FAX: (651)291-0677x
City State Zip: Saint Paul, MN 55104 Work/Day:
Email: general@latuffbrothers.com
Primary Impact: Right Front Corner Secondary Impact:
Driveable: Yes Rental Assisted:
Appraiser Name: ROBERT LATUFF Appraiser License#:
Repairer
Repairer: Latuff Brothers Inc Contact:
Address: 880 University Ave Work/Day: (651)224-2828
FAX: (651)291-0677
City State Zip: Saint Paul, MN 55104 Work/Day:
Email: general@latuffbrothers.com
Target Complete Date/Time: Days To Repair: 2
Remarks
2 DAY REPAIR
`*""""`PRELIMINARY ESTIMATE"'"'"""""'"""`
POSSIBLE ADDITIONAL DAMAGE MAY BE FOUND AFTER TEAR DOWN
Vehicle _
__
2001 Ford Taurus SES 4 DR Sedan
6cyl Gasoline 3.0 Flex
4 Speed Automatic
Lic.Plate: 7436VT Lic State: MN
Lic Expire: VIN: 1FAFP55221A251424
Prod Date: 05/2001 Mileage:
Veh Insp#: Mileage Type: Actual
Condition: Code: P3533D
Ext.Color: TOREADOR RED MET Int.Color:
Ext. Refinish: Two-Stage Int.Refinish: Two-Stage
Ext. Paint Code: M6758A,FL Int.Trim Code:
02!25/2013 1028 AM Page 1 of 3
2001 Ford Taurus SES 4 DR Sedan
Claim#-. 02/25/2013 1026 AM
Options
AM/FM CD Player Air Conditioning Alarm System
Aluminum/Alloy Wheels Anti-Lock Brakes Center Console
Cruise Control Duai Airbags Intermittent Wipers
Keyless Entry System Lighted Entry System Power Brakes
Power poor Locks Power Drivers Seat Power Mirrors
Power Steering Power Windows Rear Window Defroster
Rem Trunk-L/Gate Release Split Folding Rear Seat Split Front Bench Seat
Tachometer Tilt Steering Wheel Tinted Glass
Velour/Cloth Seats
Damages
Line Op Guide MC Description MFR.Part No. Price ADJ% B°/a Hours R
Front Bumper
1 UC 6 Cover,Front Bumper Replace Reconditioned $192.00' 2.8 SM
2 L 6 13 Cover,Front Bumper Refinish 3.7 RF
2.6 Surface
0.6 Two-stage setup
0.5 Two-stage
Front End Panel And Lamns
3 EU 42 Headlamp Assy,Halogen RT Replace Recycled $130.00* 0.2 SM
4 N 973 Headlamps Aim Additional Labor 0.4 SM
Manual Entries
5 SB M60 Hazardous Waste Removal Sublet Repair $5.00' SM
5 Items
MC Message
13 INCLUDES 0.6 HOURS FIRST PANEL TWO-STAGE ALLOWANCE
Estimate Total&Entries
_ _
Other Parts $322.00
Paint Materials $118.40
Parts&Material Total $440.40
Tax On Parts Only @ 7.625% $24.55
l.abor Rate Replace Repair Hrs Total Hrs
H rs
Sheet Metal (SM) $52.00 3.0 0.4 3.4 $176.80
Mech/Elec(ME) $85.00
Frame(FR) $75.00
Refinish (RF) $52.00 3.7 3.7 $192.40
Paint Materials $32.00
Labor Total 7.1 Hours $369.20
Sublet Repairs $5.00
Gross Total $839.15
Net Total $839.15
OZ25/2013 10�28 AM Page 2 of 3
� �
2001 Ford Taurus SES 4 DR Sedan
Claim#: 02/25I2013�0�26 AM
Alternate Parts No
SPPL Yes Zip Code: 55104 Default
Audatex Estimating 6.0.925 ES 02/25/2013 10:28 AM REL 6.0.925 DT 01/01/2013 DB 02/15/2013
Copyright(C)2011 Audatex North America,Inc.
1.1 HRS WERE ADDED TO THIS ESTIMATE BASED ON AUDATEX'S TWO-STAGE REFINISH FORMULA.
THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF ONE OR MORE CRASH PARTS
SUPPLIED BY A SOURCE OTHER THAN THE MANUFACTURER OF YOUR MOTOR VEHICLE.
WARRANTIES APPLICABLE TO THESE REPLACEMENT PARTS ARE PROVIDED BY THE PARTS
M7INUFACTURER OR DISTRIBUTOR RATHER THAN BY THE MANUFACTURER OF YOUR VEHICLE.
A PERSON WHO FILES A CLAIM WITH INTENT TO DEFRAUD OR HELPS COMMIT A FRAUD
AGAINST AN INSURER IS GUILTY OF A CRIME.
Op Codes
' = User-Entered Value E = Replace OEM NG= Replace NAGS
EC= Replace Economy OE= Replace PXN OE Srpis UE= Replace OE Surplus
ET = Partial Replace Labor EP= Replace PXN EU = Replace Recycled
TE = Partial Replace Price PM= Replace PXN Reman/Reblt UM= Replace Reman/Rebuilt
L = Refinish PC= Replace PXN Reconditioned UC= Replace Reconditioned
TT = Two-Tone SB= Sublet Repair N = Additional Labor
BR= Blend Refinish I = Repair IT = Partial Repair
CG= Chipguard RI = R& I Assembly P = Check
AA= Appearance Aliowance RP= Related Prior Damage
This report contains proprietary information of Audatex and may not be disclosed to any third party(other than
the insured,claimant and others on a need to know basis in order to effectuate the claims process)without
�f������ Audatex's prior written consent.
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-- Copyright(C)2011 Audatex North America, Inc.
Audatex Estimating is a trademark of Audatex North America, Inc.
Page 3 of 3
02125I2013 1028 AM