Enterprise (2) Entergrise Rent-A-Car � �f�
P4 BC?X 842442
DALLr^►S.TX 752842442
Tuesday,Marcv�5,2013
CITY CLERK OF ST PAUL
310 Cih'Hall RECEI�f ED
15 kellogg Bh�d.,Vt%est
ST.PAL7.,���v sslaz MAR 1 1 2013
�:;�_i_�` ��`�►��
Rc�: Balance Du� .�386.68
Bili�ng Irr�voice 61226308
Ctaim No. t133ti8354
Date of Loss ll/07/21112
Renter's Name ENTERPRISE LUT DAMAGE
Dear SirlMadam:
Our review indicates that you are respansible for the damages to our velucle.
Enclosed�lease find dociunentarion ta sfipport our claun. Please review tl�is iuformation and remit
payment iu fi►II to ttre address above. Please inchide our claixu number o�t your payment. If you =
�refer you may alsa pay the aznouut due using a debit card,credit card or directly from your l�anl: =
account at https:/lwww.velocitypa}nueut.cou�/client/bankofaanerica/erac/index.htm =
If yoti have reported this clavu to your insurance and�'or credit card company.please contact ocu
office witl�the claim inforivation.
If you have any qt�estions,please contact�is at the number below.
Si�eerely,
Erin 1�4�gee
Recovery Specialist
ERiI�i.L.MAGEE t�l EHI.COM
Damage Recovery Unit
DIltECT: 970-226-8352
OFFICE:866-30Q-3238
FAX:888-874-5937
2 of 9
I�'VOICE
Date: 03fOSf2Q I 3
CITY CLERK OF ST PAUL Claun#: 03308354
310 City Hall Unit#f: �GFLGQ
15 Kellogg Blvd.,West Billiug Iuvoice#: 61?2b308
ST. PAI1L,MN�4102
Vehicle Inforn�atia�
VIN: JN8AE2KP5�9039621
Year: 201?
Make: NISN
Model: QUES
Item Total Gost Amonnt Due
Dainages $280.70 $280.?0
qdmiaistrative Fees $SO.QtI $50,00
Loss of Use $5598 $55.98
i.aoo aays�s39_s9�4tay�2 loo^r.o��uRm�r
Diminislunent of Value $28.07 Rlaived
Total Amo�int D�te: $386.68*
*Remit payment in U_S. Dollars.
PAY L'PON REC`EIPT =
— — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — —
ALL P�YME:tiTS�li?ST INCLL?DE THIS RE?1�ITTANCE Tf)BE CREDIT'ED PROPERLY!
PAYABLE TO:
DAMAGE RECOVERY UNIT Claim#: 033d8354
PO BOX 842442 Uuit#: 7GFLGQ
DALLAS,T�7�2842A42 Billing Invaice#: 61226308
Toll Free#: 866-3�0-3238
Total Amauut Due: � 386.b8*
*Remit gayment ui U.S.Dollars.
Total Amount Remitted: S
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O��r daim uiunber: 03308354
Yonr Claim Information
Yaur instuance/credit card company:
Your claim numUer:
Name of claiins adjuster:
Adjuster!company email address:
Adjuster/company plioae uuinber:
Adjuster/compauy fax ntunber:
Adjuster/company mailing address:
Address
Citt�, State, Zip
Please rep11�to:
Damage Recovery Unit
Emait:DRUZ�ehi.com or
Fax: 888-874-8937
Phone: 866-3Q0-3238
Maii: PO BOX 842442 DAI..LAS.TX?52842442
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�of 9
�stimate Irtf�rmation R�epair Facility
Estimate tQ: REGDOT2tt4o5�a�a Claim: OX79061E5 Repeir FacitiEy Latuff Auto Bady
Esfimator WILLIAM LATL7FF Address- 8$0 lJniversity Ave
File ID: 5Q02
Platform: Audatex-Audatex Estimating Phone� fi51-2242828
Date Created: 11;0812012 Faz:
Federal Tax ID 4 1-0777 034
State Tax ID:
BAR:
��hi�le E)a#a
Unit#: 7GFLGQ Year 2012 Make: Nissan Madei: QllEST
VIN: JN8AE2KP5C9039621 Color: Grey Lic.State: IL License: N421685
Body Style- PASSENGER VAN Engine: 6CYL GA50LINE 3.5 (3dometer 29917 Prod_Qate: 01f2012
Points of Impact
Primary- Right Rear Comer
5econriary: Left Side
�ti�
Line Op Description Type Parf# Price Qty Labor Paint
OQ1' RPR COVER,REAR BUMPER 28
OQ2' RE� ' CaVER,REAR<BUMPER — 2_5R
003 R8�1 REFLECTOR,REAR BUMPER RT 0.68
Qfl4* REF FLEX ADDITIVE AC 5.00 1 OR
OU5* SUS HAZARDOUS WASTE SL �QD 9 - OB
- _-- - - - —
OQ6' RPFt SET BA�K REAR GQVEF�. 4-�B
T�ta1s
Parts =
Paris Toia!
{.��' ;
Type Additianallabor Rate Houn Totak
Labor-6ady 37.00 3.1 114.7t�
Lsbor-RefinESh 37.Ofl 2_5 92.5{t
Labor Total 207.20
1��.'Cl�tS
t�latenals-Paint �2�
Materials Total B2•5a
�tS�,�II!�i11JS '
Other-Rdditional Cos# �o�
Other-Sublet 5-�
Misceitaneous Tat�f 11.OU
�1t'�tlS�fil�.`tl�
Insurance Pay
280.7II
Totai C1aim gefore Taxes ` 280.70
7 of 9
Fina!7o#al 280.T0
Op Codes
R81 Operation-Remaveflnstall
REF Qperation-Refinish
RPR C�peratior�-Repair
SUB Operafion-Sublet
Part Type Codes
AC CYther-Additional Cost
SL Other-SubleQ
LaborCodes
8 Labor-Body
R �abor-Refinish
Paint Type Codes
R Labor-Refinish
8�f 9
N�TICE QF CL�IM F4RM to the City of Saint Paut,Minnesota
d?ir�rierofa SlRte Sfatrrm aG6.45 states rlmt"...evrnr persair...a�lio claurrs dntiragesfrorn rrr�y�niwrcipnfint.,sfrnN cnt�se to be presentarl to ahe
gqrertziag I�ady�J'the inu+ucipafiry ivithin 1&0 clatis afler dre alleged loss ar in%ury+.c ditcovered a nofice statu:g tke trme,place,and
r,irr.rnnstattm,s Fhere�(,anrl tJre afnouru ojcanpe�i,ratirnr or odeer rclief derna+tdttL'"
Please complete this form in its entirety by clearly typing or printin�your answer to each question, [€rnore space is
��eeded,aEtach addifio:ial sl�ecfs. Please note tlsat you wili not be contacted by telephone to clarffy aaswers,so provide as
mnch information ss necessary to ea�glain your ciaim,and tNe amount of compensatinn heing reqaested. You�rill recei�•e a
�r�ritten ackno�vEedgement once your t'orm is received. The process enn take up to ten weetss or longer depending on the
mature uf your claim. This form n►ust bc signecl,and 6uth pages cornpleted. If samething docs not appiy,writte`NIA.',
S�ND COMPLETED FORM AND OTHER DOGCJMENTS TO: CITY CLERK,
15��VEST I�ELLOGG BLVD,310 CITY HALL,SAINT PAUL,NIN 55102
First Name Middle Initial_�___Last Name
Cnmpany ar Business I�'ame �1T�='�P1�-�� 1��T- f�" �L-
�� t���.�
Are Y u an nsurin�e ompany? Yes/No If Yes,Clairn Number? D"�2C�rCz33�� .._._�
Sts�et Address � i�C�Y� ��1-U�2
City lJ�.rt��_ State T]C Zip Code�'�Z�t-�
Daytitne Phone�}�0-v3�-6elI Phane�,_,_,_).,�..� Evening Te[ephone( ) -
Date of Accident!Ittjury or[�ate Disco��ered I! �,�"�1��...- Time,�D am/�
Please stare,in detail,�+hat occurred(h�ppened),and why you are submitpng a ciaim.Please indicate w6y or hvw you
feel the City of Saint Paul or it•em�loyees are inv�lveii aod/or respansible for yovr d-�ges.
��� ti�c�i c.����.� N� S
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Please check ttie box{es}that most closely represent tGe re�son�or r.ompleting this form:
�'My vehicfe was damaged in an accident �My vehiele was damageci during a tow
�My vehicle was damaged by a pothole or condition of the street D bgy vehicle was ci�maged by a plaw
❑My vehicle w�s wrongfully towed andlor ticketed �I wAS injured on City prapercy
�Other type of property dama=e-please specify �
O Ocher type of injury-please specify
In ordeC to process yaur clain�y,ou need to incliide coAies of all anplicable doct�menfs.
Fe�r the claims types 1'ssted below,please be sure ta includa the documents indicated or it will delay the handling of
vour claim, Documents WILL NO"f be returned and beGOme the property of the Ciry. You are encouraged to keep a
copy for yourself before submitting your claim farm.
4 Property damage ctairtts to a vehicle:two esticnates for the repairs to your vehic[e if the damage exceeds
$500.�0;ar the aceual bills anrUor receipts for the repairs
O Towin�claims:legible copies of any ticket issued and a copy af the impound tot receipt
O�dier property dama�e clf►inis:rivo repair esti�nates if the damage exceeds$�00.00;or the actual bills
and/or receipts for the repairs;detailed tist�f damaged items
O Injury claims:�nedicgl bilis,receipts
�Photographs are always��elcome to document and sugport your clazm but will noY be retarned.
Page 1 of 2-Please complete and return both pages of Claim Form
��f 9
Failure ta co�nplefe and retarn both pages will result in deIay in the handling of y�ur ciaim.
All Clairos-olease comnlete this section
Were therr:witneyses to the inc'tc3ent? � Nn Unknown {circle)
Provide their narnes,addresses and teiephane nambers:��.Z�C.�, }C��pC��S
_ foSl - 7_ _�,-UU��
We�the police or law e�forcement called? es Nv Unknown (circle)
If yes,what deparEment or agency? �P�D Case#or report#��N ZS�
(��t C�2 C'A'l�r1Fi-�'(�}�q-t/C..�K-.
Where did the accident vr injury cake place? Provide sireet address,cross street,intersectinn,name of park or facility,
closest lnndmad:.etc. Please be s detailed as passible. If necessary,attach a diagram.
!t tp 1 t)Yt�v e.,r S t�-u �j-� �� ST p�ta t_ �(�,i SS�L-L) '
I'3ease indicate the amo�{nE vou are seeking in compensation ar what you would tike the City to da co resolve this claim
to your satisfaction. �b��. (r��
Vchicle Claims-[riease comulete this secti�n O check#x�x if this sectic�n daes not�plv
Your Veh�cle: Year C.�t�_Make 1SS Madel FS
License Plate�Iumber �v State J„(,�Color
Reoistered Owner 1 �- t�W S
Driver of Vehicle - I
Area Dflrnaged
City Vehicle: Ye�tr (,)t�J1�- Make I44c�de1
License Piate Number lV State�Q,�Golar N
Driver of Vehicle(City Err►ployee's Name) t }Vl c,�_ "C-t.X^
Area Damaged N i�' '
in4ar�C1ai�ns-nlease eem�lets t�►is seetiort {ch�bzfx�sftS�is s�ti�in 8��s noi ap�lv
�-I�w were you in�ured?
1�'hat part{s)vf yoar body were injured?.___--------..�..�____...____�._.�______.�.._.____�..__.___...�_.—��____ _ ,
Have you sought medical treacrnent? Yes No Planninb to Seek Treatrnent(circle) = I
When did you receive treatment? i (provide date(s)} _
Name of Medic�l Providee(s): —
Address 'I'elep(�one
Did you miss work as A result of your in}ury? Yes A`o
Whe�z did yuu miss work? (prc�vide date(s})
Name of yt�ur Employer:
Address TeIephone
'�I,Check here it'you are afitaching more pages to this clairn farm. Number oC additional pages ��,,..
B,y si��iir��this fvrm,yor�are stating that ald ittformatio�a you have provided is drtce and correct tn tl:e best
o f your knowledge. Ufzsignsd forms will nvt be processed.
5ubrniliin��u false ctaifn can result in prosecution. Dat�form was cornpleled . � ��2_C"71�
Pi•int ihe I�ame af the Person wh<y Completed �s Form:�-��__.�-�.,_/���-
Signature of Person i1�Iaking the Claitn:_�
Revised Febrvary 201[