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NOTICE UF CLAIM FORM to the City of Saint Pau�, Minnesota
Minnesota Stnte Statule 466.05 states that "...every person...wlto claims da►nages.T»m any municipality...shall cause tn he presented to!hr
grn�erni�ig bndy nrthe munrcipafity within 180 days after the alleged loss or injtuy is discovered a notice stating the time,place,nnd
circc�mstances thereoj,and the amnunt of cn►npenratinrz�r other��lief 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. Ptease note that you may or msy not be contacted by telephone to discuss your claim
circumstances,so provide as much information as necessary to explain your claim,and the smount of compensation being
requested. This form must be signed,and both pages completed. �f sometWng does not apply,write`N/A'.
SEND COMPLETED FORM AND OTHER DOCUMENTS TO:
CITY CLERK, 15 WEST KELLOGG BLVrD,310 CITY HALL, SAINT PAUL, MN 55102
First Name ��pn„1� Middle Inithal� Last Na.ma �
Company or Business Name, if applicable _ _
Street Address all,v'�J�I C���j P � �1r, p.-��r;\�� rn�} '
City �- v►\�� State �� Zip Code �Sj 13
Daytime Telephone (in13. ) -11�-�, �-10 Evening Telephone(��) �l t`�--I 3�-j t�
Date of Accident/Injury or Date Discovered .�� (D � �-013 Time�_am/ �m (circle)
Please state, in detail, what occurred, and why you ate submitting a claim. Please indicate why or how you
feel the City of Saint Paul or its employees are involved andlor responsibte.
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Please check the box{es} that most closely represent the reason for eompleting this form:
L7 Vehicle was da�naged in an aceident (�,Vehicle was damaged during a t�w
C] Vehicte was damaged by s pothole or condition of the street ❑ Vehicle was damaged by a plow
CI Vehicle was wrongfully towed andlor ticketed ❑ Injured on City property
C7 Other type of property damage—please specify
CI Other type of injury—please specify
C1 Other type not listed—please specify
In order to process your claim vou need to include coaies of aIl anulicable documents This is a general
guideline of what should be submitted with a claim form,but it is not alt inelusive. You may be asked to
��rovide additional infonnation depending on your claim.
� Property damage claims to a vehicle: at least two estimates for the repairs to your vehicte;or the
actual bilts and/or receipts for the repairs
� Towing claims: legible copies of any tickets issued and copies of the impound tot 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 retarn both pages of Claixn Form
Failure to provide a completed claim form will result in delays in processing.
Notice of Claim Form, City of Saint Paul, page two
All Claims–alease comalete this section .- - -�
Were there witnesses to the incident? Yes No � Unknown (circle}
If yes, please provide their names,addresses and telephone numbers-�����"
--,t'",
________
Were the police or law enforcement called? es No `�.__i�nkn� (circle)
If yes,what department or agency? Case#or repart#
Where did the accident or injury take place? Provide street address, cross street, intersection, iaame of park
or facility, closest landmark, etc. Please be as detailed as possible. If helpful, attach a diagram.
� �
Please indicate the amount you aze seeking in compensation from this ciaim or what you would like the City
to do to resolve this claim to your satisfaction. -T wovl c� �,�mc��,r� �1�. �,arn.�� �.� 1�c.
�-�k��� ����i „�.,� < i
Vehicle Claims–please comulete this section ❑ check box if this section does not applv
Yaur Vehicle: Year�2�� Make�,:; Model f',�n,�n r�6 e.
License Plate Number �W - ' �n State,��1 Color�-t�p�'�.t�t,�
Regi stered Owner K-�mbe rt�e ���_��i�¢-r�- �-�,�_.
Driver of Vehicle��-,��►,.� �� \
AreaDamaged �r�n�-�c�L��1����� n�� '/� �;.ia t o,� c;�;�-+-����_ L
City Vehicle: Year lv�ake Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
In,�ury Claims ptease camplete this seetion �check box if this section does not applv
How were you injured? t�►�
What}�art(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 Pravider(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 T�lephone _
❑ Check here it'you are attaching more pages to this claim form. Nurnber of additional pages
By si�►iruig this form,you are stating that afl informatioh you have provided is true and cnrrect to the best of your knnwledge. Unsigned
,fnrms will »ot be proce�sed. Submitting a fslse ciaim can result in prosecution.
Prynt the ATame of the Person who Campleted this Form:
Signature of Person Making the Claim:
Date form was completed Revised April 2007
°.,..�•uaie,ivlti'S;113 rnone: 651-224-4717
�'ww.hamlineautobod}�.com Fax: 651-224_3�89 �
� tonv�,hamlineautobod}�.com
HAMLINE AUTO BODY INC. Workfile ID: c7cff�364
FederelID: 41-0918545
Done The Way It Should Be
2520 BROADWAY DR, LAUDERDALE, MN 55113
Phone: (651) 224-4717
FAX: (651) 224-3789
Preliminary Estimate
Customer: ROSS, NOAH
Written By:Tony Foss
Insured: ROSS, NOAH Policy#: C►aim#:
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact:
Owner: Inspection Location: Insurance Company:
RO55,NOAH HAMLINE AUTO BODY INC.
2659 GALTIER ST. 2520 BROADWAY DR
ROSEVILLE, MN 55113 LAUDERDALE, MN 55�13
(612)745-1340 Cell Repair Facility
(651) 224-4717 Business
VEHICLE
Year: 2000 Body Style: 4D SED VIN: 2C3HD36J8YH199979 Mileage In: 202230
Make: CHRY Engine: 6-3.2L-FI License: Mileage Out:
Model: CONCORDE LXI Production Date: 10/1999 State: MN Vehicle Out:
Color: BLUE Int: Condition: ]ob#:
TRANSMISSION Dual Mirrors AM Radio SEATS
Automatic Transmission Console/Storage FM Radio Leather Seats
Overdrive CONVENIENCE , Stereo Bucket Seats
POWER Air Conditioning ' Cassette WHEELS
Power Steering Rear Defogger Search/Seek Aluminum/Alloy Wheels
Power Brakes Tilt Wheel CD Player PAINT
Power Windows Cruise Control Premium Radio Gear Coai Pai�t
Power Locks Intermittent Wipers SAFETY OTHER
Power Driver Seat Climate Control Anti-Lock Brakes(4) Traction Control
Power Passenger Seat Keyless Entry Driver Air Bag
Power Mirrors Alarm Passenger Air Bag
DECOR RADIO 4 Wheel Disc Brakes
3/11/2013 4:39:40 PM 099681 Page 1
._ �..� ���ev iT SHOULD BE" _
Preliminary Estimate
Customer: ROSS, NOAH
Vehicle: 2000 CHRY CONCORDE LXI 4D SED 6-3.2L-FI BLUE
Line Oper Description Part Number Qty Extended Labor Paint
Price;
1 FRONT BUMPER
2 0/H front bumper 1.6
3 ** <> Repl RECOND Bumper cover 4574848 1 410.00 Incl. 2.6
4 Add for Clear Coat 1.0
5 Repl LT Bumper cover brace 4805111 1 21.00 Incl.
6 Repl Medallion 5288940AA 1 67.75 Incl.
7 GRILLE
8 Repl Grille assy 4574849AB 1 294.00 Incl.
- 9 FRONT LAMPS
10 ** Repl A/M LT Headlamp assy 4780011AH 1 272.00 0.5
11 Aim headlamps 0.5
12 Repl LT Side marker lamp 4805269AA 1 96.45 Incl.
13 FENDER _
14 Repl LT Fender 5003061AD 1 210.00 2.0 2.0
15 Overlap Major Non-Adj. Panel �0•2
16 Add for Clear Coat 0.4
17 Add for Edging 0.5
18 Add for Clear Coat 0.1
19 Deduct for Overlap -0.4
20 Repl RT Fender 5003060AD 1 210.00 2.0 2.0
21 Overlap Major Non-Adj. Panel '0•2
ZZ Add for Clear Coat 0.4
23 Add for Edging 0.5
24 Add for Clear Coat 0.1
25 Deduct for Overlap -0.4
26 FRONT DOOR
27 Blnd RT Outer panel ', 1•Z
Zg Blnd LT Outer panel 1•2
29 # Subl Hazardous waste removal 1 5.00 X
SUBTOTALS 1,586.20 5.8 11.6
I'
�II
3/11/2013 4:39:40 PM 099681 Page 2
Preliminary Estimate
Customer: ROSS, NOAH
Vehicle: 2000 CHRY CONCORDE LXI 4D SED 6-3.2L-FI BLUE
ESTIMATE TOTALS
Category Basis Rate Cost�
Parts 1,581.20
Body Labor 5.8 hrs @ $56.00/hr 324.80
Paint Labor 11.6 hrs @ $56.00/hr 649.60
Paint Supplies 11.6 hrs @ $36.00/hr 417.60
Body Supplies 4.5 hrs @ $6.00/hr 27.00
Miscellaneous 5.00
Subtotal 3,005.20
Sales Tax $ 1,581.20 @ 7.1250% 112.66
Grand Total 3,117.86
� Deducdble 0.00
CUSTOMER PAY 0.00
INSURANCE PAY � 3,117.86
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Thank You For Your Business.
This is an estimate only. This estimate does not account for hidden or unseen damage(s). Parts prices may vary and
are subject to invoice.
Payment method: VISA, MASTERCARD, AMERICAN EXPRESS, DISCOVER, CASH, CASHIERS CHECK.
Authorization of Repair
Customer Signature Date_J�
***********************************************a�*******************************
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.
�
3/11/2013 4:39:40 PM 099681 Page 3
Preliminary Estimate
Customer: ROSS, NOAH
Vehicle: 2000 CHRY CONCORDE LXI 4D SED 6-3.2L-FI BLUE
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
DE3NH98, 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 refl�ct 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 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=Miscetlaneous 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=Afte�market part. BInd=Blend. BOR=6oron 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. 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 Servides 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.
3/11/2013 4:39:40 PM 099681 Page 4
Preliminary Estimate
Customer: ROSS, NOAH
Vehicle: 2000 CHRY CONCORDE LXI 4D SED 6-3.2L-FI BLUE
ALTERNATE PARTS SUPPLIERS
Supplier: Keystone-Complete-Minneapolis
Location(s): 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
Line Description Item# Price
3 RECOND Bumper cover CH1000249R $410.00
Supplier: Wheelers Auto Body Supply
Location(s): 1710 S.BROADWA'i,RJCHESTER MN 55904 (888)644-3450 (507)281-3450
6150 CLAUDE WAY,INVER GROVE HEIGHTS MN 55076 (866)435-7015 (651)379-0808
Line Description Item# Price
10 A/M LT Headlamp assy CH2502119 $272.00
3/11/2013 4:39:40 PM 099681 Page 5
Citation# $$$ 7�� 1�1
, � ST. PAUL
STATE OF MINNESOTA-RAMSEY DISTRICT COURT I IIIIII(�III III'I IIIII IIIII IIIII IIIII IIIII IIIII I�II n�
The undersigned,being duly sworn,upon his/her oath deposes and says: ��
* 8 8 8 7 6 4 1 0 1 *
Date of Offense / / Time of Offense ' __
Plate
Veh. License No. � Year State ' ? -'_�9a�a ___ _ ., * Style Color
Location of Offense: � - � �
VIOLATION: SNOW EMERGENCY St. Paul Ordinar�<��; ���.��3 FINE $53.0�
-—-.- - - (Amount includes mandatory state surcharges of$13.00)
CN
Citing Officer Citing _
Officer Number______._ _ _ Dept.
❑Posted Night Plow Rflay Plow C,1Plowed in�VVindre :) ❑Tagged Before Plow ❑Drove Off
OFFICER'S NOTES ________ _..
❑NO PLATE VIN: �-�' ��� O�
Citation can be paid at the Impound Lot. Please read ths bacic ot the citation for payment instructions.
CITATION
. To pay your citation online: 2ndwebpay.courts.state.mn.us
_..
. For additional information or to pay your fine by telephone using a credit card,call: 651-266-9202 � - ' _
Please have your citation number and credit card available.
. Mail payments to: Ramsey District Court Make Checks payable to: Ramsey District Court
Traffic Violations Bureau (A charge of up to$30.00 will be assessed on all returned checks) ,
15 West Kellogg Boulevard-Room 130
St. Paul, MN 55102-1613
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Violations Bureau Locations
St. Paul Court Suburban Court Law Enforcement Center
15 W. Kellogg Blvd., Rm 130 2050 White Bear Avenue 425 Grove Street
St. Paul, MN 55102 Maplewood,MN 55109 St.Paul,MN 55101
Office Hours:8:00 AM-4:30 PM Monday-Friday(Excluding Holidays)
Hearing Officers-By appointment only. Call(651-266-9202)
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Payment and Penalties
If you wish to plead guilty and submit payment for the offense on the reverse side of the citation,you must do so within 21 days from the date the citation
is filed with the Court.It is your responsibility to present your payment in a timely manner. Please allow 5 business days for proce§°sSng.A$S.QIIfate fee - -
is added to all unpaid fine balances.After 40 days from the date the citation is filed with the Court,an additional delinquent fee may be added to all unpaid
fine amounts and the case may be referred to a collections agency. If the offense is a petty misdemeanor,failure to appear will be considered a plea of
guilty and waiver of the right to trial unless the failure to appear is due to circumstances beyond the person's control(M.S. 169.91)and(M.S.609.491).
�------------------------------------------------------------------------------------------------------------------------------------�
Appeal
To plead not guilty,or to plead guilty and offer an explanation,take the following steps: 1)After 10 business days,call 651-266-9202 to confirm
that the citation has been fiied with the Court, and 2) request a hearing officer appointment.You must have a photo ID with you when meeting
with a Hearing Officer.
�-------------------------------------------------------------------------------------------------------------------------------------
I understand that by p�vina this fine I am enterin�c a olea of guiit�to this offense and voluntarily waive the following rights to:
1. The right to a trial by the Court in which I am presumed innocent until proven guilty beyond a reasonable doubt.
2. The right to confront and cross-examine all witnesses against me.
3. The right to remain silent or to testify on my own behalf.
4. The right to subpoena and present witnesses to testify on my behalf.
I also understand that this offense is a petty misdemeanor and the maximum penalty is a$300.00 fine.
Saint Paul Police Impound Lot, 830 Barge Channel Road, Vehicle Release Form
Make: CHRYSLER License#: VWN806 CN: 13044010 Invoice#: 21512
Date/Time Released: 03/06/2013 16:01 Tow Charge: $ 123.95
Released to: TSBE Storage Charge: $ 0.00
�i
Paid by: CREDIT CARD Admin Charge: $ 80.00
Released by: MINDY Tax: (7.625%) $ 15.55
I,the undersigned,have recovered the vehicle described above. Subtotal: $ 219.50
I will check the vehicle for damage or any other problems that
may have occurred while this vehicle was in the custody of the Senrice Charge: $ 0.00
Saint Paul Police Department. I acknowledge I will report
damage and/or any other problems to the Impound Lot staff Total Charges: $ 219.50
on this form prior to leaving the impound lot.
Damage and/or other problem: �r�n� ��,�r� �c I h;. . '�
Police Report made: Yes_No_IF Yes, C!V , If NO, Why?
TO PROTECT YOUR RIGHTS REPORT ANY PROBLEMS/DAMAGE BEFORE LEAVING THE LOT
Signature s�2000