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� � (nstruct�oi�s for Fiiing Notice of Claim ta City af Saint Paul� ' � ��
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lt�innesota State Statute 466.05 NOTICE OF CLAIM...(Elvery person...who claims damages from any
municipality...shall cause to be presented to the governing body of the municipality wirhin 180 days after ihe �
alleged loss or injury is discovered a notice stating the time, place, and circumstances thereof, and the amount of
compensatron or o�her relief demanded.
Please complete this form in its entirety by typing or printing your answer to each question in
the space provided. If additional space is needed, please attach ad��i't���ets.
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PLEASE RETURN THIS Office of City C��
COMPLETED FORM TO: 170 City Hall j ��'���i'irr(
15 W !<ellogg Blvd
St Paul MN 55102 .
Your Name: �,r(�l�e� '� ���,�,�
--- Street Rddress: --' - �V'�.hct�c; _ S�7�,-��-__ _ _ _ _ _ _ -- - -_ _ _ _- -- ---- --
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City: (����,���,MQ � t State; �1�1�� Zip Code: � 5 (I.5
Daytime Telephone: (6 s�l ) j`� `� " �v�'l Evening Telephone: _��s � ► .3 Y`� "�G��
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Date of Accident or Incident: �� .� ��°f 3 �Day of Weelc S���r�c� Time:���r� a� or pm (circle onel ,
rlease state, in detail, wl�at occurred and the circumstances surrounding the event. Indicate how the
City of Saint Paul is involved, and why you feel the City is responsible.
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Please indicate your reason for completing this form:
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C:l Veliicle accident (--1 Other property damage (please provide specifics below) ;;.,;1',
'L� Vehicle was towed '�'`' �
'�. Vehicle damaged ❑ Other iinjury to person (please provide specifics below) �1�
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❑ Slipped and fell on City property �"i �'
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Please provide the names and telephone numbers of any City employees involved in this r ,'
incident/accident and I�ow tf�ey were involved:
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If your vehicle was involved, please complete the following: � �
Year, mal<e, and model: �vli g�p,� � � -1�Ci � License Plate Number. QQ �- � U� � •
Extent and area damaged: C,��L d c�} ea lc h+ ;,�C � �-.' �'� hf ��� sGf e
v�h�e�.i w r 11 �f:i,��i S r c�2. ; v�:�le �nti�� w� � � ��� S�c+�.r.
Was a City vehicle involved in this accident/incident? es} No (circle one)
If yes, please complete the following: Type of vehicle "r6 � �Tt�-�'-�L
T �,�� �� } }:�,,�;� Year, make, and model
� �� S�� �.t Color of vehicle License Plate Number: �
Description of vehicle
Location of accident/incident (please provide specifics such as street address, intersection, cross streets,
park name, facility name; etc.):
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Please specify the nature and extent of the compensation or other relief you are requesting. Please
attach copies of any bills, receipts, tickets, or other documents to support your claim. If you are
claiming damage to a vehicle, please submi�wo estimate�
f�.�1 c���oa�s�:�c� ' Irr�h �tr.,�e,�. ti.r;,ts r.�t�_ �v��cr„ed v.�nfil �oa -��w'r..,� �LT• T v�,II
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Were there witnesses to this accident/incident. Yes No (circle one) �!li'L. �� g
If yes, please give the names, addresses, and telephone numbers of the witnesses:
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S�rv� �wbctiS: 715 � ��3 -�i;�`-1 • (��.nni� 1-�c�c�.K.` �jsl '}riS"- i�ya"
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Were the police called? Yes No (circle one) If yes, what department or agency? •
Police report number: _ 2 �„��S }�r� F;, ,,to{ C��� ��i:� c��.d. � ��1� �
Please print the name of the �'�} ��tS �`�( �`
person completing this form: Anate�,J � �o,�a,e�
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Please sig,n your name: ��
Date form signed:
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Risk Mgmt Division - Revised 1-30-01 : �9,�'��
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� LaMettry's Collision, Glass and More Workfile ID: 09alcece
FederalID: 411393089
�w��, � v Maplewood
��.,.���,,,�.�. "Every Customer Leaves With A Smile"
2951 Maplewood Drive, Maplewood, MN 55109
Phone: (651) 766-9770
FAX: (651) 766-8660
Prelimirtary Estimate
Customer: HOUDEK,ANDREW
Written By:Team 2 CHRIS BRANT
Insured: HOUDEK,ANDREW Policy#: Claim #:
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact:
Owner: Inspection Location: Insurance Company:
HOUDEK,ANDREW LaMettry's Collision,Glass and More
Maplewood
607 WARNER RD 2951 Maplewood Drive
MAHTOMEDI, MN 55115 Maplewood, MN 55109
(651)399-9088 Day Repair Facility
(651)766-9770 Business
VEHICLE
Year: 2011 Body Style: 4D SHORT VIN: 1FTFX1ET36KD62278 Mileage In: 23677
Make: FORD Engine: 6-3.5L-T License: 907GMZ Mileage Out:
Model: F150 4X4 SUPERCAB FX4 Produdion Date: State: Vehicle Out:
Color: BLACK Int: Condition: Job#:
TRANSMISSION Privacy Glass Stereo SEATS
Automatic Transmission Console/Storage CD Player Cloth Seats
4 Wheel Drive Overhead Console Auxiliary Audio Connection WHEELS
Overdrive CONVENIENCE Satellite Radio Aluminum/Alloy Wheels
POWER Air Conditioning SAFETY PAINT
Power Steering Rear Defogger Anti-Lock Brakes(4) Clear Coat Paint
Power Brakes Tilt Wheel Driver Air Bag OTHER
Power Windows Cruise Control Passenger Air Bag Fog Lamps
Power Locks Intermittent Wipers Head/Curtain Air Bags TRUCK
Power Driver Seat Keyless Entry Front Side Impact Air Bags Rear Step Bumper
Power Mirrors RADIO 4 Wheel Disc Brakes Trailering Package
DECOR AM Radio Traction Control
Dual Mirrors FM Radio Stability Control
3/1/2013 10:31:23 AM 053108 Page 1
� Preliminary Estimate
Customer: HOUDEK,ANDREW
Vehicle: 2011 FORD F150 4X4 SUPERCAB FX4 4D SHORT 6-3.5L-T BLACK
line Ope� Description Part Number Qty Extended Labor Paint
Price$
1 FRONT BUMPER
2 0/H bumper assy 1•9
3 ** Repl A/M NSF Bumper w/fog lamps 9L3Z177576 1 445.00 Incl.
chrome
4 Add for fog lamps 0.4
5 Repl Upper filler painted,w/o XL 9L3Z17D957BPTM 1 336.71 1.5 1.8
w/wheel lip
6 Add for Clear Coat _ 0•7
7 FRONT LAMPS
8 Repl LT Headlamp assy CL3Z130086 1 270.05 Incl.
9 Aim headlamps 0.5
10 FRONT DOOR
11 Repl LT Mirror black BL3Z176836A 1 291.92 03
12 ELECTRICAL
13 R&I RT Base �•3
14 FENDER
15 * Rpr RT Fender w/o wheel opng mldg ?� Z•6
(HSS)
16 Add for Clear Coat 1.0
17 * R&I RT Nameplate"F-150 XLT' �
18 # Rpr CLEAN AND RETAPE MOLDING 0•2
19 # Subl Hazardous Waste Disposal Fee 1 5.00 X
20 # Flex Additive 1 6.00 X
SUBTOTALS 1,354.68 7.8 6.1
ESTIMATE TOTALS
Category Basis Rate Cost$
Pa� 1,343.68
Body Labor 7.8 hrs @ $56.00/hr 436.80
Paint Labor 6.1 hrs @ $56.00/hr 341.60
Paint Supplies 6.1 hrs @ $38.00/hr 231.80
Body Supplies 7.3 hrs @ $2.00/hr 14.60
Miscellaneous 11.00
Subtotal 2,379.48
Sales Tax $1,343.68 @ 7.1250% 95.74
Grand Total 2,475.22
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 2,475.22
I
3/1/2013 10:31:23 AM 053108 Page 2
Preliminary Estimate
Customer: HOUDEK,ANDREW
Vehicle: 2011 FORD F150 4X4 SUPERCAB FX4 4D SHORT 6-3.5L-T BLACK
THIS REPORT IS AND ESTIMATE ONLY, BASED ON OUR INITIAL INSPECTION AND DOES NOT COVER ADDITIONAL
PARTS OR LABOR WHICH MAY BE REQUIRED AFTER THE WORK IS OPENED UP. PART PRICES SUBJECT TO
CHANGE PER THE MANUFACTURER AND AVAILABILITY.
WARRANTY: LIFETIME AGAINST DEFECTS IN WORKMANSHIP. WARRANTY REPAIRS DONE BY LAMETTRY'S
COLLISION ONLY. NO WARRANTY ON RUST, CORROSION RESISTANCE OR REPLACEMENT RENTA�CARS.
OUR ESTIMATED COMPLETION TIME DOES NOT INCLUDIE INSURANCE OR PARTS DELAYS THAT WE MAY
EXPERIENCE.
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.
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
DR2MA09, 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 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=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. 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.
3/1/2013 10:31:23 AM 053108 Page 3
- Preliminary Estimate
Customer: HOUDEK, ANDREW
Vehicle: 2011 FORD F150 4X4 SUPERCAB FX4 4D SHORT 6-3.5L-T BLACK
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.
3/1/2013 10:31:23 AM 053108 Page 4
Preliminary Estimate
Customer: HOUDEK,ANDREW
Vehicle: 2011 FORD F150 4X4 SUPERCAB FX4 4D SHORT 6-3.5L-T BLACK
ALTERNATE PARTS SUPPLIERS
Supplier: Keystone-Complete-Dubuque
Location(s): 2400 KERPER BLVD, DUBUQUE IA 52001 (800)747-2500 (563)556-5030
3017 A HOOVER AVENUE,STEVENS POINT WI 54481 (800)218-4848 (715)342-0772
2700 29TH AVENUE N, ESCANABA MI 49829 (800)833-2030 (906)789-2200
9532 W.CARMEN AVENUE, MILWAUKEE WI 53225 (800)924-8230 (414)463-1019
822 CENTRAL AVENUE, LINTHICUM MD 21090 (800)390-4600 (410)636-4600
3615 MARSHALL STREET NE, MINNEAPOLIS MN 55418 (800)328-1845 (612)789-1919
2021 WEST DIVISION STREET,ST.CLOUD MN 56301 (800)247-0861 (320)251-8494
5969 HAASE ROAD, DEFOREST WI 53532 (800)356-7252 (608)249-4775
5085 WREN DRIVE,APPLETON WI 54913 (800)422-1995 (920)731-3030
Line Description Item# Price
3 A/M NSF Bumper w/fog lamps chrome F01002411N $445.00
3/1/2013 10:31:23 AM 053108 Page 5
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