Howell i
l'-1�4.a����!�� I
FEB 2 � 2C�13 '
NOTICE OF CLAIM FORM to the City of Saint Pau�,.-�1!I�n���a
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,plaee,and
circumstances thereof,and the amount of compensation or ather 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 wtll 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 aclu►owledgement 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 � � Middle Initial l:� Last Name���e/�
Company or Business Name
Are You an Insurance Company? Yes/� If Yes,Claim Number?
Street Address����Gi.r � �/d ����
City L T�r/� State /,[� Zip Code c��
Daytime Phone(�)�- 93��Ce11 Phone( ) - Evening Telephone(_) -
Date of Accidend Injury or Date Discovered Time 1 -4 O am/�
Please state,in detail, what occurred(happened),and why you are submitting a claim.Please indicate why ar how you
feel the City of Saint Paul ar its emplo�ees are involved and/ar res onsible for your damages. T (�t'-�S
�- A A r 2 c� l � , `' A ' �
�q �-�- Q � n� � J��
5 ���, � r� �l�' " __
� ,� a ° �- � s<�-_ v _ _
M �� �- � .
Please check the box(es)that most closely represent the reason for completing this form:
�My 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
❑ Other type of property damage—please specify
❑ Other type of injury—please specify
In order to process your claim vou need to include copies of all aqplicable documents.
For the claims types listed below,please be sure to include the documents indicated or it will delay the handling of
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.
O Property damage claims to a vehicle: two estimates for the repairs to your vehicle if the damage exceeds
$500.00; or the actual bills and/or receipts for the repairs
O Towing ciaims: 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
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims-nlease comulete this section
Were there witnesses to the incident? Yes No Unkno (circle)
Provide their names,addresses and telephone numbers:
Were the police or law enforcement calle ? Yes No Unknown (circle
If yes,what department or agency? 0 � Case#or report# � ' �
ia- a�fl - ���-
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 ossible. If necessary,attach a diagram. ��� 1
Q f r�� �e � a d- �� � ,. .� � X ' �,g'%
Please indicate the am unt you are ���pensation or what you would like the City to do to resolve this claim
to your satisfaction. � 3��� � at/�c_sf � � �, r� L� r �
�
� rj �a� ino Z '�o ,2 - e.G, �'e p
��i rs sti.oLc � na�- /(.�,�;e ha�o�oen ea% �i� � �ns f- �'/�c��..
Vehicle Claims- lease com lete this section ❑ check box if this section does not a 1
Your Vehicle: Year a(3D� Make Model '� U� � �5
License Plate Number State Color � LvGs
Registered Owner L�b
Driver of Vehicle ft �
Area Damaged �
City Vehicle: Year Make ��(��:Z-�1 Model ���1��1►J $� lL�� �`���
License Plate Number �'�S d L, State �(Color
Driver of Vehicle(City Employee's Narne) f��'�/�' T' 2F�`�
Area Damaged
Injurv Claims please complete this section LlYcheck box if this section does not avplv
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))
Namz 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.
Submitling a false claim can result in prosecution. Date form was completed l
Print the Name of the Person who Completed this Form: �'� ��vP��
Signature of Person Making the Claim: ������••; �� ��
Revised February 201 I
ABRA Auto Body & Glass - Roseville Workfile ID: 894cfd5a
FederalID: 41-1942823
Right the First Time...On time
1914 W. COUNTY ROAD C, ROSEVILLE, MN 55113
Phone: (651) 639-9848
FAX: (651) 639-9406
Preliminary Estimate
Customer: HOWELL, MATTHEW 7ob Number:
Written By:Todd Warren
Insured: HOWELL,MATTHEW Policy#: Claim#: UNK
Type of Loss: Collision Date of Loss: 1/14/2013 12:00:00 PM Days to Repair: 5
Point of Impact: 06 Rear
Owne�: Inspection Location: Insurance Company:
HOWELL, MATTHEW ABRA Auto Body&Glass-Roseville CUSTOMER PAY
8090 GARFIELD ST. NE 1914 W.COUNTY ROAD C
SPRING LAKE PARK,MN 55432 ROSEVILLE,MN 55113
(763)331-1244 Business Repair Facility
(651)639-9848 Business
VEHICLE
Year: 2000 Body Style: 4D SED VIN: 1FAFP55UXYG274961 Mileage In: 188486
Make: FORD Engine: 6-3.OL-FI License: 077DYA Mileage Out:
Model: TAURUS SES Production Date: 7/2000 State: MN Vehicle Out:
Color: blue Int: Condition: Job#:
TRANSMISSION DECOR Keyless Entry Passenger Air Bag
Automatic Transmission Body Side Moldings RADIO SEATS
Overdrive Dual Mirrors AM Radio Cioth Seats
POWER Console/Storage FM Radio Bucket Seats
Power Steering CONVENIENCE Stereo WHEELS
Power Brakes Air Conditioning Cassette Aluminum/Alloy Wheels
Power Windows Rear Defogger Search/Seek PAINT
Power Locks Tilt Wheel SAFETY Clear Coat Paint
Power Driver Seat Cruise Control Anti-Lock Brakes(4)
Power Mirrors Intermittent Wipers Driver Air Bag
1/14/2013 3:38:44 PM 024206 Page 1
Preliminary Estimate
Customer: HOWELL, MATTHEW �ob Number:
Vehicle: 2000 FORD TAURUS SES 4D SED 6-3.OL-FI blue
Line Oper Description Part Number Qty Extended Labor Paint
Price$
1 REAR LAMPS
2 ** Repl A/M CAPA LT Tail lamp assy 3F1Z13405DA 1 99.00 Incl.
3 R&I RT Tail lamp assy Incl.
_.... . . _. . ,. _ _
4 � REAR BUMPER
5 0/H rear bumper 2•�
6 R&I Bumper cover Incl.
7 * <> Rpr Bumper cover 5.Q 3.0
8 Add for Clear Coat 1•2
9 ** Repl A/M Impact bar YF1Z17906A6 1 84.00 Incl. 0.8
10 ** Repl A/M Isolator YF1Z17787AC 1 71.00 Incl.
_ _
11 REAR BODY 8�FLOOR
12 Repl Rearbody panel YF1Z5440320CA 1 215.23 6.5 1.2
13 Overlap Major Non-Adj. Panel �0•2
14 Add for Clear Coat 0•2
15 Add for Inside 0.6
16 TRUNK LID _ _
__ __
17 * Repl LKQ lift gate+30% 3F1Z5440110AA 1 260.00 2.8 3.3
18 Overlap Major Adj. Panel -0.4
19 Add for Clear Coat 0.6
open Repl Shield graphite blue YF1Z136482AAD 1 201.12 0.2
21_ QUARTER PANEL _
22 * Rpr LT Quarter panel � �
23 Overlap Major Adj. Panel -0.4
24 Add for Clear Coat 0.1
25 * Rpr RT Quarter panel 3.Q 1_0
26 Overlap Major Adj. Panel -�•4
27 * Add for Clear Coat 0.1
_
28 MISCELLANEOUS OPERATIONS
29 # Refn 'Car Cover 0.1
30 # Refn 'Corrosion Protection 0.3
31 # Repl �Flex Additive/Adhesion Promoter 1 8.50 X
32 # �Hazardous Waste 1 5.00 X
SUBTOTALS 943.85 22.5 12.1
1/14/2013 3:38:44 PM 024206 Page 2
Preliminary Estimate
Customer: HOWELL, MATTHEW 7ob Number:
Vehicle: 2000 FORD TAURUS SES 4D SED 6-3.OL-FI blue
ESTIMATE TOTALS
Category Basis Rate Cost$
pa� 930.35
Body Labor 22.5 hrs @ $54.00/hr 1,215.00
Paint Labor 12.1 hrs @ $54.00/hr 653.40
Paint Supplies 12.1 hrs @ $34.00/hr 411.40
Miscellaneous 13.50
Subtotal 3,223.65
Sales Tax $930.35 @ 7.1250% 66.29
Grand Total 3,289.94
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 3�289•94
THIS IS A VISUAL INSPECTION ONLY. THERE MAY BE ADDTTIONAL DAMAGE AFTER DISASSEMBLY. PARTS ARE
SUBJECT TO INVOICE. THERE ARE NO GUARANTEES ON RUST REPAIRS.
"Minnesota law gives you the right to choose any rental vehicle company, and prohibits me from requiring you to
choose a particular vendor."
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.
1/14/2013 3:38:44 PM 024206 Page 3
Preliminary Estimate
Customer: HOWELL, MATTHEW 7ob Number:
Vehicle: 2000 FORD TAURUS SES 4D SED 6-3.OL-FI blue
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
DR2JN00, CCC Data Date 1/10/2013, 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 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 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=Boron steel.
CAPA=Certified Automotive Parts Association. D&R=Discannect 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. 0/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=Bureau of Automotive Repair. EPA=Environmental Protection Agency. NHTSA= National Highway
Transportation and Safety Administration. PDR=Paintless Dent Repair. VIN=Vehicle Identification Number.
1/14/2013 3:38:44 PM 024206 Page 4
Preliminary Estimate
Customer: HOWELL, MATTHEW 7ob Number:
Vehicle: 2000 FORD TAURUS SES 4D SED 6-3.OL-FI biue
ALTERNATE PARTS SUPPLIERS
Supplier: Keystone-Complete-Minneapolis
Location(s): 3615 MARSHALL STREET NE,MINNEAPOLIS MN 55418 (800)328-1845 (612)789-1919
Line Description Item# Price
2 A/M CAPA LT Tail lamp assy F02800154C $99.00
9 A/M Impact bar F01006203DSN $84.00
10 A/M Isolator F01170114DSN $71.00
1/14/2013 3:38:44 PM 024206 Page 5
. .
BLAINE AUTO BODY Workfile ID: bf7710c0
FederalID: 41-2000300
email - bab1231@pop.net, 1321 89TH AVENUE State ID: 5268463
NE, BLAINE, MN 55434
Phone: (763) 784-8846
FAX: (763) 784-5087
Preliminary Estimate
Customer: Howell, Matthew 7ob Number:
Written By: Roxanne Johnson
Insured: Howell,Matthew Policy#: Claim#:
Type of Loss: Date of Loss; Days to Repair: 0
Point of Impact: 06 Rear
Owner: Inspection Location: Insurance Company:
Howell,Matthew BLAINE AUTO BODY
8090 Ga�eld St.Ne email-bab1231@pop.net
Spring Lake Park,MN 55432 1321 89T}i AVENUE NE
(763)331-1244 Cellular BLAINE,MN 55434
(763)786-9327 Evening Repair Facility
(763)7848846 Day
VEHICLE
Year; 2000 Body Style: 4D SED VIN: iFAFP55UXYG274961 Mileage In:
Make: FORD Engine: 6-3.OL-FI License: 077DYA Mileage Out:
Model: TAURUS SES Production Date: State: MN Vehicle Out:
Color: Blue Int: Condition: )ob#: '
TRANSMISSION DECOR Keyless Entry Passenger Air Bag 'I
Automatic Transmission Body Side Moldings RADIO SEATS '
Overdrive Dual Mirrors AM Radio Cloth Seats
i
POWER Console/Storage FM Radio Bucket Seats I
Power Steering CONVENIENCE Stereo WHEELS
Power Brakes Air Conditioning Cassette Aluminum/Alloy Wheels
Power Windows Rear Defogger Sear�h/Seek PAINT
Power Locks Tilt Wheel SAFETY Clear Coat Paint
Power Driver Seat Cruise Control Anti-Lock Brakes(4)
Power Mirrors Intermittent Wipers Driver Air Bag
10/10/2012 10:56:21 AM 079298 Page 1
,
Preliminary Estimate
Customer: Howell, Matthew 7ob Number:
Vehicle: 2000 FORD TAURUS SES 4D SED 6-3.OL-F! Blue
Line Oper Description Part Number Qty Extended Labor Paint
Price�
1 REAR BUMPER
2 * <> Repl LKQ bumper assy;Sedan+30% 2F1Z17K835CA 1 325.00 1.6 3.0
3 REAR LAMPS
4 ** Repl A/M CAPA RTTaiI lamp assy 3F1Z13404DA 1 99.00 0.4
5 ** Repl A/M CAPA LTTaiI lamp assy 3F1Z13405DA 1 99.00 0.4
__ _ _ __ __ __ _ __
__ __ _ _ _ ___
6 TRUNK LID
7 * Repl LKQ lift gate+30% 3F1Z5440110AA 1 292.50 2.8 3.3
8 Overlap Major Non-Adj.Panel -0.2
9 R&I Lock cylinder w/o anti theft 0.4
10 R&I Shield graphite blue �•2
11 R&I Trim panel 0.3
12 * Refn Shield graphite blue 4�2
13 QUARTER PANEL
14 R&I Fuel door 0.3
15 * Rpr LT Quarter panel 4.4 2•2
16 Overlap Major Adj.Panel -0.4
17 * Rpr RT Quarter panel �5 Z•2
18 Overlap Major Adj.Panel '�•4
19 Clear Coat 2•5
20 Bind Fuel door �•Z
21 R&I RT Qtr glass Ford 2•0
22 R&I LT Qtr glass Ford Z•�
23 R&I RT Upper qtr trim graphite Incl.
24 R&I LT Upper qtr trim graphite Incl.
_ 25 BACKGLASS _ _ _ ____ _ __ __ __ _
_ _ __ __ _ _
26 * R&I Back glass Ford(ro�e offl �
27 # Subl Hazardous waste removal 1 5.00 X
28 # Repl Cover car 1 0.2
29 # Repl Flex additive 1 5.00 X
SUBTOTALS 825.50 18.4 12.8
10/10/2012 10:56:21 AM 079298 Page 2
Preliminary Estimate
Customer: Howell, Matthew Job Number:
Vehicle: 2000 FORD TAURUS SES 4D SED 6-3.OL-FI Blue
ESTIMATE TOTALS
Category Basis Rate Cost�
Parts 815.50
Body Labor 18.4 hrs @ $52.00/hr 956.80
Paint Labor 12.8 hrs @ $52.00/hr 665.60
Paint Supplies 12.8 hrs @ $31.00/hr 396.80
Miscellaneous 10.00
Subtotal 2,844.70
Sales Tax $815.50 @ 7.1250% 58.10
Grand Total 2,902.80
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 2,902.80
This is a preliminary estimate only, additional changes to the estimate may be required for actual repair. **** PARTS
PRICES SUBJECT TO INVOICE **** **** Old parts junked unless otherwise instructed ! *****
****** NO GUARANTEES ON RUST REPAIRS ******
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.
10/10/2012 10:56:21 AM ' 079298 Page 3
Preliminary Estimate
Customer: Howell, Matthew 7ob Number:
Vehicle: 2000 FORD TAURUS SES 4D SED 6-3.OL-FI Blue
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
DR2JN00, CCC Data Date 10/1/2012, 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,
Qual Repl Parts or Comp Repl Parts which stands for Competitive Replacement Parts. Used parts are described as
LKQ, Qual Recy Parts, 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 IinE with the NAGS information are MOTOR suggested labor operation times. NAGS
labor operation times are not included. Pound sign (#) items indicate manual entries. Some 2010 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 Pathways estimator has a complete list
of applicable vehicles. Parts numbers and prices should be confirmed with the local dealership.
CCC Pathways -A product of CCC Information Services Inc.
10/30/2012 10:56:21 AM ' 079298 Page 4
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Dea�t�en�t o Co�n�ne,�ce
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� COMIVIISSIONER OF COMMERCE �
� for the State of Minnesota hereby '
certifies that
CITY OF SA1NT PAUL
has made application,paid the fees requaed and'm all other respects complied with the laws of the 5tate of �
Minnesota and is hereby authorized to ti�ansact the business of a No-Fault Reparation ObIigor authorized to
self-insure pursuant to NI'mnesota Statutes,Section 65B.48. �
a� 300 City Hall Annex,25 W.4th Street, St Paul,MN 55102
Unless this authority be suspended,revoked,or otherwise legally termi.nated,this certificate shall be m effect until
May 31,2012. .
. ]N TESTINIONY WHEREOF,I have hereunto set my hand at
. my office m the City of StPaul,Minnesota,
. � May 31,2009
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