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Speckel P-i��:�:`.`��.�' _ ._ _ _. .. .. ......_. FEB 2 � 2413 � ti q -�:. :. �.,� _ NOTICE OF CLAIM FORM to the City. of Sain��'a�;�nnesota Minnesota State Statr�te 466.03 states that"...every ptrson...who claims damages from any mwiicipaliry...shall caust to be presented to thc governing body of the municipaliry within 180 days aft�r the alleged toss or injury is discovered a notic�stating the time,place,and circumstances thereof,and the mnount of compensation or other relief demanded" Please complete this form in its entirety by cleady 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,290 CITY HALL,SAINT�AUL,MN 55102 ; First Name 1�P,� I ��G Middle Initial� Last Name ��P C k P_ � � � �.--= �.,�ompa�ny or Busi�e�s.i��i£aanl��' .�, - - - - �"�� Street Address Z � 7 � � I 1 C�r/1 �V�� City 1� 11�11�1 e C�.�C7(�� ( C State Y�V� 1� Zip Code�� Daytime Telephone �� Z�SO — �S� 11� � Evening Telephone (_� � 3 Date of Accidend Injury or Date Discovered 2-�4 � � � Time I Z: �7�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 andlor responsible. v S - ac.,c. ( � Y �� -F'� u v�-� c�-�` YYl t a C � I� � Please check the box(es) that most closely represent the reason for completing this form: I� Vehicle was damaged in an accident � Vehicle was damaged during a tow � ❑ Vehicle was damaged by a pothole or condition of the screet i$�Velucle-was darnaged by a plow ❑ Vehicle was wrongfully towed andlor 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. • Property damage claims to a vehicle: at least two estimates for the repairs to your vehicle, or the actual bills andJor 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 Notice of Claim Form, City of Saint Paul,page two All Claims-please comnlete this section Were there witnesses to the incident? Yes No Unlaiown (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? � t�.� Case or report# �� - O Z�- �cj� 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. _ ZU O F r�1 �P_c,. � r.+ v R� I � r_.�t - �-1 � P(1 c � t � Please indicate the amount you are seeking in compensation from this claim or what you would like the City ��_ � �, I..�- M�KG Snelling►ae""" 22g North 55�04 St.Pau��►��^nesota phone 651-6a6'7389 Fax 651-646•5384 ��e �oaners FREEWAY AUTO BODY � INC. Workfile ID: 84ea0ff9 - FederalID: 411476560 229 SNELLING AVE N, SAINT PAUL, MN 55104 State ID: 7298792 Phone: (651) 646-7389 FAX: (651) 646-5384 Preliminary Estimate Customer: SPECKEL, MELISSA Job Number: Written By: MIKE OSTERMAN Insured: SPECKEL, MELISSA Policy#: Claim #: Type of Loss: Date of Loss: Days to Repair: 0 Point of Impact: � Owner• Inspection Location: Insurance Company: SPECKEL, MELISSA FREEWAY AUTO BOpY,INC. __ , � --.�,;._�,� 2002 GARFIELD AVE APT 22 229 SNELLING AVE N MINNEAPOLIS, MN 55405-3206 SAINT PAUL, MN 55104 (651)280-8365 Evening Repair Facility (651)646-7389 Day VEHICLE Year: 2012 Body Style: 4D SED VIN: KNAGM4A7XC5295229 Mileage In: Make: KIA Engine: 4-2.4L-FI License: Mileage Out: Model: OPTIMA LX Production Date: State: Vehicle Out: Color: Int: Condition: Job#: TRANSMISSION Console/Storage FM Radio Cloth Seats 6 Speed Transmission Overhead Console Stereo Bucket Seats Overdrive CONVENIENCE Search/Seek WHEELS POWER Air Conditioning CD Player Full Wheel Covers Power Steering Rear Defogger Auxiliary Audio Connection PAINT Power Brakes Tilt Wheel Satellite Radio Clear Coat Paint Power Windows Telescopic Wheel SAFETY ` OTHER ` � Power Locks Intermittent Wipers Anti-Lock Brakes(4) Traction Control Power Mirrors Keyless Entry Driver Air Bag Stability Control � Heated Mirrors Alarm Passenger Air Bag Fog Lamps DECOR Steering Wheel Controls Head/Curtain Air Bags Signal Integrated Mirrors Tinted Glass Message Center Front Side Impad Air Bags Body Side Moldings RADIO 4 Wheel Disc Brakes Dual Mirrors AM Radio SEATS , I 2/11/2013 1:03:16 PM 030101 Page 1 Preliminary Estimate Customer: SPECKEL, MELISSA Job Number: Vehicle: 2012 KIA OPTIMA LX 4D SED 4-2.4L-FI Line Oper Description Part Number Qty Extended Labor Paint Price$ 1 FRONT BUMPER&GRILLE 2 0/H bumper assy 2•8 3 Repl Bumper cover w/o SX 865114C000 1 523.15 Incl. 3.0 4 Add for Clear Coat 1•Z 5 Add for fog lamps 0.3 6 Repl Absorber 865202T010 1 61.70 0.1 7 Repl Upper grille 2.4 liter 863504C000 1 488.90 Incl. 8 Repl Prep unprimed bumper 1 0.8 9 Repl LT Cover reinf 865832T000 1 9.35 ��`-� 10 * R&I Lower deflector w/o SX Incl. 11 * R&I Lower grille Incl. 12 R&I Emblem Incl. 13 Repl LT Side retainer 865134C000 1 14.93 0.1 14 R&I LT Hole cover w/o fog lamps Incl. 15 R&I LT Side molding Incl. 16 FRONT LAMPS 17 Repl LT Headlamp from 12/06/10 921014C000 1 380.63 0.3 lg Aim headlamps 0.5 19 RADIATOR SUPPORT zp * Rpr Radiator support 2.4 liter 1_0 0_5 21 FENDER ZZ * Rpr LT Fender 0.5 1.8 z3 Add for Clear Coat �•� 24 R&I LT Vent grille 0�2 25 R&I LT Fender liner 16"&17"wheels 0.4 26 # HAZARDOUS WASTE 1 5.00 X 27 # CAR COVER 1 0.2 28 # FLEX ADDITIVE 1 5.00 X 29 # RESTORE CORROSION 1 5.00 X 0.3 PROTECTION SUBTOTALS 1,493.66 6.5 8•2 2/11/2013 1:03:16 PM 030101 Page 2 , Preliminary Estimate Customer: SPECKEL, MELISSA ]ob Number: Vehicle: 2012 KIA OPTIMA LX 4D SED 4-2.4L-FI ESTIMATE TOTALS Category Basis Rate Cost$ pa� 1,478.66 Body Labor 6.5 hrs @ $50.00/hr 3Z5.00 Paint Labor 8.2 hrs @ $50.00/hr 410.00 Paint Supplies 8.2 hrs @ $30.00/hr 246.00 Miscellaneous 15.00 Subtotal 2,474.66 Sales Tax $ 1,478.66 @ 7.6250% 112.75 Grand Total 2,587.41 <:.�.��._ Dedudible `*°1 CUSTOMER PAY 0.00 INSURANCE PAY 2,587.41 THIS IS A VISUAL ESTIMATE ONLY. ADDITIONAL PARTS AND LABOR MAY BE REQUIRED UPON VEHICLE TEAR DOWN. PARTS PRICES SUBJECT TO INVOICE. FREEWAY AUTO BODY OFFERS A LIMITED LIFE TIME WARRANTY ON REPAIR WORKMANSHIP AND REFINISHING FOR AS LONG AS YOU OWN YOUR VEHICLE. NO WARRANTY FOR RUST REPAIRS WILL APPLY. PLEASE FEEL FREE TO CONTACT THE MANAGEMENT OF FREEWAY AUTO BODY WITH ANY QUESTIONS. 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. 2/11/2013 1:03:16 PM 030101 Page 3 Preliminary Estimate Customer: SPECKEL, MELISSA 7ob Number: Vehicle: 2012 KIA OPTIMA LX 4D SED 4-2.4L-FI Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide ARY2433, 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 Benchmairk 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=6lend. BOR=6oron steel. CAPA=Certified Automotive Parts Association. D&R=Disoonnect and Reconnect. MSS=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. SA5=5andwiched 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. 2/11/2013 1:03:16 PM 030101 Page 4 ,E'S BODYWORKS &GLASS Workfile ID: 984f2219 B U Y H A P P YTM MORRIE�$ Federal ID: 41-0949742 L O N G �A K E .X IT RIGHT THE FIRST TIME�� 'OD�'""�••�u,oa�,�., JVayzata Blvd, Long Lake, MN 55356 Phone: (952) 543-7830 FAX: (952) 543-7839 Preliminary Estimate Customer: Speckel, Melissa WrittRn By:Tim Hornig Insured: Speckel, Melissa Policy#: Claim#: Type of Loss: Collision Date of Loss: Days to Repair: 5 Point of Impact: 12 Front - -- -__� Owner: - - o�: Insurance Company: , Speckel,Melissa MORRIE'S BODYWORKS&GLA55 STATE FARM INSURANCE COMPANIES ' 2121 Ilion Ave N 2605 W Wayzata Blvd i Mpls, MN 55411 Long Lake,MN 55356 (651)280-8368 Cell Repair Facility ' (952)543-7830 Business VEHICLE Year: 2012 Body Style: 4D SED VIN: KNAGM4A7XC5295229 Mileage In: 13292 Make: KIA Engine: 4-2.4L-FI License: 5AY680 Mileage Out: , Model: OPTIMA LX Production Date: State: MN Vehicle Out: � Color: White Int: Condition: Excellent Job#: TRANSMISSION Steering Wheel Controls AM Radio Intermittent Wipers 6 Speed Transmission BRAKES FM Radio EXTERIOR Overdrive Power Brakes Stereo Power Mirrors Traction Control 4 Wheel Disc Brakes Search/Seek Dual Mirrors SEATS Anti-Lock Brakes(4) CD Player Body Side Moldings Bucket Seats GLASS INTERIOR Alarm ! Cloth Seats Tinted Glass Power Locks Fog Lamps Lumbar Adjustment Rear Defogger Air Condidoning Keyless Entry STEERING Power Windows Driver Air Bag PAINT � Power Steering WHEELS Passenger Air Bag Three Stage Paint Tilt Wheel Full Wheel Covers Front Side Impact Air Bags ' Telescopic Wheel RADIO Console/Storage li � �icnn�� •��•�n onn f1S7'��Q Paae 1 Preliminary Estimate Customer: Speckel, Melissa Vehicle: 2012 IQA OP'TIMA LX 4D SED 4-2.4L-FI White Line Oper Description Part Number Qty Extended Labor Paint Price; 1 # ***Needs Disassembly*** 1 2 FRONT BUMPER&GRILLE 3 0/H front bumper 2.8 4 Repl Bumper cover w/o SX 865114C000 1 523.15 Incl. 3.0 5 Add for Three Stage 2.1 6 Add for fog lamps 0.3 7 Repl Upper grille 2.4 liter 863504C000 1 488.90 Ind. 8 FRONT LAMPS ----— ___ -- � 9 Repl LT Headlamp from 12/06/10 921014C000 1 380.63 0.3 � 10 Aim headlamps 0.5 SUBTOTALS 1,392.68 3.9 5.1 ESTIMATE TOTALS Category Basis Rate Cost$ Parts 1,392.68 Body Labor 3.9 hrs @ $54.00/hr 210.60 Paint Labor 5.1 hrs @ $54.00/hr 275.40 Paint Supplies 5.1 hrs @ $34.00/hr 173.40 Body Supplies 0.3 hrs @ $7.00/hr 2.10 Subtotal 2,054.18 Sales Tax $ 1,392.68 @ 7.2750% 101.32 , Grand Total 2,155.50 , Deductible 0.00 CUSTOMER PAY 0.00 INSURANCE PAY 2,155.50 This is an estimate for repair only. This estimate is not a final bill or invoice for a completed repair. ' Estimates are subject to change at any time and will vary based on parts usage, parts availability and method of ; repair used. ' Parts prices may vary based on current manufacture list price at time of estimate. �, Morries does not warranty any rust or corrosion repairs unless a new replcement part has been used. Ask about our optional free loaner/rental program and limited lifetime warranty. And remember to drive carefully and always wear your seatbelt... Thank you from all of us at Morrie's Bodyworks&Autoglass 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. 2/6/2013 2:32:30 PM 057329 Page 2