Quinn � � RECE��'�Q
�R 14 2013
NOTICE OF CLAIM FORM to the City of Saint $�"�l��i�esota
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 municipaliry within 180 days after the alleged loss or injury is discovered a notice stating the time,place,and
circumstances thereof,and the amount of compensation or other relief demanded."
Please complete tius 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 will 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 acknowledgement 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 �' Last Name �v�� �✓)
Company or Business Name
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Are You an Insurance Company? Ye If Yes,Claim Number?
Street Address � �3 � �e� ��
City �in��l St�te �� Zip Code �J/�
Daytime Phone(fi51 16�y -�Cell Phone(���Evening Telephone(6�l�- ��39
Date of Accidend Injury or Date Discovered�.� ��� ��Time pm
Please state,in detail,what occurred(happened),and why you are submitting a claim:�Flease indicate wh or how you
feel the City of Saint Paul or its employees are invol d and/or responsible for your damages. � ����
�. � a�a k �: 1�� ;� ; �'-/��e
v 7' w�. �n - T�
�' ✓l. � a�� i �C • (�O
Iti,� �� i �- � -►.�
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 �J 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�o include copies of all applicable documents.
For the claims types listed below,please be sure to incl�lde the documents indicated or it will delay the handling of
your claim. Documents WILL NOT be returned and become the property of the City�ou 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�e repairs
O Towing claims: legible copies of any ticket i sued and a copy of the impound lot receipt
0 Other property damage claims:two repair estimates if the damage exceeds$500.00;or tife actual bills
� eip s or the repairs;detailed list of amage i
s: meaicai�uis,receip�s
0 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—ulease comnlete this section �
Were there witnesses to the incident? es No Unknown (circle) 1��� �
Provide their names,addresses and telephone numbers:T�.�� 0�6,�b��, ,, ��f�� � c�P����°�'
f�,��I , �5�a��-���y
Were the police or law enforcement called? Yes � 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 pazk or fa ility,
cl sest landm+ark,etc. Ple�se be as tailed as possible. If nec ssary,attach a diagra� {- �� �2.
�p -�,nca�L �i�e� �4' �-���:�. �� �. �,�.ti� a F �9�y���� �---
Please indicate the amount you e seeking i compens�tion or what you would like the City to do to resolve this claim
to your satisfaction. � �5/��� �
Vehicle Claims—nlease complete this section ❑ check box if ttus section does not avnly
Your Vehicle: Year �q 8 q Make Model �. w
License Plate Number State.�Color�
Registered Owner �n �
Driver of Vehicle .r
Area Damaged ' i
City Vehicle: Year Make � Model v�
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniurv Claims—nlease comulete this section f�check box if this section does not avvlv
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
Q� Check here if you are attaching more pages'to this claim form. Number of additional pages
By signing this fornz,you are stating that all infornzation you have provided is true and correct to the best
of your knowledge. Unsigned forms will not be processed.
Submitting a false claim can result in prosecution. Date form was completed ���O �I�
`' f� �
Print the Name of the Person who Complete ' + 't�r�-�C..-i�y►✓1
Signature of Person Making the Cl m:
Revised February 2011
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HAMLINE AUTO BODY INC. Woricfile ID: 40348388
Federal ID: 41-0918545
Done The Way It Should Be
2520 BROADWAY DR, LAUDERDALE, MN 55113
Phone: (651) 2244717
FAX: (651) 2243789
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Preliminary Estimate
Customer: quinn,peter
Written By:Tony Foss
Insured: quinn,peter Policy#: Claim#:
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact:
- Owner: Inspection Location: Insurance Company:
quinn,peter HAMLINE AUTO BODY INC.
2520 BROADWAY DR
LAUDERDALE,MN 55113
Repair Faciliry
(651)224-4717 Business
VEHICLE
_: �
Year: 1989 Body Style: 4D UTV VIN: 1GNEV16K9KF131022 Mileage In: 100020
Make: CHEV Engine: 8-5.7L-FI License: Mileage Out:
Model: V15 4X4 SUBURBAN Production Date: State: Vehide Out:
TAILGATE
Color. red Int: Condition: � Job#:
TRANSMISSION POWER DECOR PAINT
k 4 Speed Transmission Power Steering Tinted Glass � Gear Coat Paint
4 Wheel Drive Power&akes Dual Mirrors
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3/7/2013 4:30:58 PM 099681 Page 1
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Preliminary Estimate �
Customer: quinn, peter
Vehicle: 1989 CHEV V15 4X4 SUBURBAN TAILGATE 4D UTV 8-5.7L-FI red
Liae Oper Description Part Number Qty Extended Labor Paint
Price�
1 FRONT DOOR
open * Repl LT Mirror---soecial order part not 996225 1 110.00 0.3
retiumable �
open Repl LT Mount bracket 14007429 1 23.23
4 Repl LT Clamp I 14007430 1 21.01
open Repl LT Gasket 14008191 1 17.04
open Repl LT Cover 14007431 1 53.80
SUBTOTALS 325.08 0.3 0.0
ESTIMATE TOTALS
Category Basi¢�_ Rate Cost;
Parts I 325.08
Body Labor , 0.3 hrs @ $56.00/hr 16.80
Body Supplies I 0.3 hrs @ $6.00/hr 1.80
Subtotal 343.68
+ -
Sales Tax $325.08 @ 7.1250°h 23.16
Grand Total 366.84
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY �r�r+. 366.84
I
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Thank You For Your Business.
This is an estimate only. This estimate does not accou for hidden or unseen damage(s). Parts prices may vary and
are subject to invoice. ,,,�
Payment method: VISA, MASTER ERICAN DCPRESS, DISCOVER, CASH, CASHIERS CHECK.
Authorization of Re '
Customer Si ature ` Date�.J��
********** ***** *******************************************************
MN ST 60A.955 - A PERSON WHO FILES A CLAIM WITH INTENT TO DEFRAUD OR HF�S COMMIT A FRAUD
AGAINST AN INSURER IS GUILTY OF A CRIME.
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3/7/2013 4:30:58 PM 099681 Page 2
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Preliminary Estimate '�
Customer: quinn, peter
Vehicle: 1989 CHEV V15 4X4 SUBURBAN TAILGATE 4D UTV 8-5.7L-FI red
Estimate based on MOTOR CRASH ES"fIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
DO1GA84, CCC Data Date 3/1/2013, 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 dat source. Tilde sign (�) items indicate MOTOR Not-Included
Labor operations. The symbol (<>) indicates the refini�h 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 Numbe�s 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 enfies.
Some 2012 vehicles contain minor changes from the pr vious year. For those vehicles, prior to receiving updated
data from the vehicle manufacturer, labor and parts da from the previous year may be used. The CCC ONE
estimator has a complete list of applicable vehicles. Pa 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 cat ory. (numbers) 1 through 4=User Defined Labor Categories.
OTHER SYMBOLS AND ABBREVIATIONS:
Adj.=Adjacent. Algn.=Align. ALU=Aluminum. A/M=A ermarket part. BInd=6lend. BOR=6oron steel.
CAPA=Certified Automotive Parts Association. D&R=Disconnect and Reconnect. HS�iigh 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. 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=Environmen I Protection Agency. NHT'SA�'"IVational Highway
Transportation and Safety Administration. PDR=Paintl ss Dent Repair. VIN=Vehicle Identification Number.
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3/7/2013 4:30:58 PM 099681 Page 3
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