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Xiong (2) , -�,.... .�l�„--� �►�v�..i v i..�v . . _ __. �''Y . MAR 1� �0�3 �.., �.L:�. � NOTICE OF CLAIM FORM��kef Saint Paul, ll�i�[d'sb��RK 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 municipality 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 this 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 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,310 CITY HALL, SAINT PAUL, MN 55102 First Name �U�� Middle Initial i� Last Name X,�.(,r�� Company or Business Name, if applicable Street Address �(1�� ti��(11�Q��j�� City �Ct � � � �� State_ l V� I V � Zip Code �� Daytime Telephone( �� ) � � � Evening Telephone(��) �� Date of Accident/ Injury or Date Discovered Time am/pm (circle) Please state, in detail, w�at occurred, and why you are sub:nitting a claim. Please indicate why or how you feel the�ity of Saint Paul or its emnloyees are involved and/or responsible. , _. � �--� --T �-- -----. - _ � • <. . ` . ��' - - ^ . .,,r`. ��=�yy ' ::'" �'`''; / r '��_ � . �..% ° 2.T�, 1 �r r � � _ � }L-�' 4 Y-= -"� 1 ` i �.-,.�: � . �.__"_' _' — � n. �— �..��.._ ,. �� ` ///�///� �' � ��l� (`,i �.. �� #�s�� ,l� ` ._ �/r�� TE-<'_" ✓ i�* jI� i � �r ��_ i , „ � � '�•s — --_� l` -- __,,� � li �� Please check the box(es) that most closely represent the reason for completing this form: ❑ Vehicle was damaged in an accident �Vehicle was damaged during a tow ❑ Vehicle was damaged by a pothole or condition of the street ❑ Vehicle was damaged by a plow ❑ Vehicle was wrongfully towed and/or ticketed ❑ Injured on City property ❑ Other type of property damage—please specify ; ❑ Other type of injury—please specify ❑ Other type not listed—please specify I i 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 and/or receipts for the repairs • 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 • Photographs can be provided but will not be returned. Page 1 of 2—Please complete and return both pages of Claim 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—please comulete this section Were there witnesses to the incident? Yes No Unknown (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? Case#or report# 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. �� Please indicate the amount you are seeking in compensation from this claim or w at ou would like the City to do to resolve this claim to your satisfaction. t� S S d 11, (M-�/ UM��- • Vehicle Claims— lease com lete this section ❑ check box if this section does not a 1 Your Vehicle: Year 2- l Make � Model L License Plate Number 5 5� � State��Color Registered Owner f.l. Driver of Vehicle Area Damaged City Vehicle: Year Make Model License Plate Number State Color _ _ �_J nrivs!-of j✓�hicle (City Employce'�it3ame) Area Damaged ` Iniurv Claims—Qlease complete this section �check box if this section does not applv 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 I� When did ou miss wark? rovide date s Y �P � )) Name of your Employer: Address Telephone �s1 Check here if you are attaching more pages to this claim form. Number of additional pages�. By signing this form,you are stating that all information 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. Print the Name of the Person who Completed this Form: Signature of Person Making the Claim: Date form was completed ��Z� l I l Revised April 2007 I am very upset about the damage on my vehicle. When I went to pick up my vehicie at the pound lot, I looked around the car to see if there were any damages and then I discover under the back bumper it was damaged.When you look under the back bumper there was a weird lump like shape under the car. It looks as if the bumper caught on to something that damaged and broke the two latches holding the bumper in place. l feel that the City of St. Paul is responsible because they towed my car away and left damages. � I ABRA Auto Body &Glass - Midway Workfile ID: a87eced0 FederalID: 41-1852119 Right The First Time...On Time 1190 UNIVERSITY AVE W, SAINT PAUL, MN 55104 Phone: (651) 645-1563 FAX: (651) 641-6129 Preliminary Estimate Customer: XIONG, PAKOU 7ob Number: Written By: Pat Kearin Insured: XIONG, PAKOU Policy#: Claim#: INV# 17551 Type of Loss: Date of Loss: 12/9/2012 12:00:00 PM Days to Repair: 0 Point of Impact: 06 Rear Owner: Inspection Location: Insurance Company: XIONG,PAKOU ABRA Auto Body&Glass-Midway Unknown Insurance 761 COMO AVE#308 1190 UNIVERSITY AVE W ST PAUL, MN 55103 SAINT PAUL, MN 55104 (651)734-8132 Business Repair Facility (651)645-1563 Business V�HICLE Year: 2010 Body Style: 4D SED VIN: 1NXBU4EE8AZ167740 Mileage In: 5555555 Make: TOYO Engine: 4-1.8L-FI License: 558-CTl/ Mileage Out: Model: COROLLA LE Production Date: State: MN Vehicle Out: Color: RED Int: Condition: Job#: TRANSMISSION Dual Mirrors i Stereo Cloth Seats Automatic Transmission Console/Storage Search/Seek Bucket Seats Overdrive CONVENIENCE CD Player WHEELS POWER Air Conditioning Auxiliary Audio Connection Full Wheel Covers Power Steering Rear Defogger SAFETY PAINT Power Brakes Tilt Wheel Anti-Lock Brakes(4) Clear Coat Paint Power Windows Telescopic Wheel Driver Air Bag OTHER Power Locks Intermittent Wipers Passenger Air Bag Traction Control Power Mirrors RADIO Head/Curtain Air Bags Stability Control I, Power Trun � k/'failgate AM Radio Front Side Impact Air Bags DECOR FM Radio SEATS 2/26/2013 12:55:03 PM 011906 Page 1 � Preliminary Estimate Customer: XIONG, PAKOU 7ob Number: Vehicle: 2010 TOYO COROLLA LE 4D SED 4-1.8L-FI RED Line Oper Description Part Number Qty E�ctended Labor Paint Price$ 1 REAR BUMPER 2 <> Repl Bumper cover US built Base,LE, 5215902963 1 266.73 1.5 3.0 XLE 3 Add for Clear Coat 1,2 4 _ MISCELLANEOUS OPERATIONS _ , _ . . _ 5 # Repl 'Flex Additive/Adhesion Promoter 1 8.50 X 6 # �Hazardous Waste 1 5.00 X SUBTOTALS 280.23 1.5 4.2 NOTES Prior Damage Notes: 1 ESTIMATE TOTALS Category Basis Rate Cost; Parts 266.73 Body Labor 1.5 hrs @ $54.00/hr 81.00 Paint Labor 4.2 hrs @ $54.00/hr 226.80 Paint Supplies 4.2 hrs @ $34.00/hr 142.80 Miscellaneous 13.50 Subtotal 730.83 Sales Tax $266.73 @ 7.6250% 20.34 Grand Total 751.17 Deductible 0.00 CUSTOMER PAY 0.00 INSURANCE PAY 751.17 THIS IS A VISUAL INSPECTION ONLY. THERE MAY BE ADDITIONAL DAMAGE AFTER DISASSEMBLY. PARTS ARE SUBJECT TO INVOICE. THERE ARE NO GUARANTEES ON RUST REPAIRS. "Minnesota law gives you the right to choose any rental vehicle company, and prohibits me from requiring you to choose a particular vendor." I 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. 2/26/2013 12:55:03 PM 011906 Page 2 Preliminary Estimate Customer: XIONG, PAKOU 7ob Number: Vehicle: 2010 TOYO COROLLA LE 4D SED 4-1.8L-FI RED Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide ARM8428, 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 parks 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. i 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. 2/26/2013 12:55:03 PM 011906 Page 3 WINDY'S COLLISION CENTE, INC. 767 BUSH AVENUE ST. PAUL MN 55106 PHONE: (651)774-4426 FAX: (651)772-0368 ***PRELIMINARY ESTIMATE"' 02/26/2013 03:16 PM Owner Owner: PAKO XIONG Address: 761 COMO AVE#308 Work/Day: (651)734-8132 City State Zip: Saint Paul, MN 55106 F,qX; Inspection Inspection Date: 02/26/2013 03:16 PM Inspection Type: Appraiser Name: JON PHILMALEE Appraiser License#: Address: 767 BUSH AVE Work/Day: (651)774-4426 Cell: (612)237-6526 City State Zip: Saint Paul, MN 55106 FAX: (651)772-0368 Email: THEFUMS@MSN.COM Repairer Repairer: WINDY'S COLLISION CENTER Contact: JON PHILMALEE Address: 767 BUSH AVE Work/Day: (651)774-4426 ST PAUL Home/Evening: City State Zip: ST PAUL,MN 55106 FAX: (651)772-0368 Email: THEFUMS@MSN.COM Vehicle 2010 Toyota Corolla LE 4 DR Sedan 4cyl Gasoline 1.8 4 Speed Automatic Lic.Plate: 558 CN Lic State: Lic Expire: VIN: 1 NXBU4EE8AZ167740 Veh Insp#: Mileage Type: Actual � Condition: Code: Y21246 j Ext.Refinish: Two-Stage Int.Refinish: Two-Stage � Options � AM/FM CD Player Air Conditioning Alarm System Anti-Lock Brakes Bucket Seats Center Console Daytime Running Lights Digital Clock Digital Signal Processor Dual Airbags Halogen Headlights Head Airbags Intermittent Wipers Lighted Entry System MP3 Player Power Brakes Power poor Locks Power Mirrors Power Steering Power Windows Rear Side Airbags Rear Window Defroster Rem Trunk-L/Gate Release Side Airbags Split Folding Rear Seat Stability Cntrl Suspensn Steel Wheeis Tachometer Telescopic Steering Whl Theft Deterrent System Tilt Steering Wheel Tinted Glass Traction Control System Velour/Cloth Seats 02/26/2013 03:18 PM Page 1 of 3 2010 Toyota Cordla LE 4 DR Sedan Claim#: 02/26/2013 03:16 PM Damages Line Op Guide MC Description MFR.Part No. Price ADJ% B% Hours R 1 E 566 Cover,Rear Bumper 5215902963 $266.73 0.6 SM 2 L 566 13 Cover,Rear Bumper Refinish 3.7 RF 2.6 Surface 0.6 Two-stage setup 0.5 Two-stage 3 RI 535 Reflector,Rear Bumper LT R&I Assembly INC SM 4 RI 433 Spoiler,Lower Rear LT R&I Assembly 0.8 SM 5 SB M60 Hazardous Waste Removal Sublet Repair $3.50' SM 5 Items MC Message 13 INCLUDES 0.6 HOURS FIRST PANEL TWO-STAGE ALLOWANCE Estimate Total 8�Entries Gross Parts $266.73 Paint Materials $125.80 Parts&Material Total $392.53 Tax On Parts Only @ 7.625% $20.34 Labor Rate Replace Repair Hrs Total Hrs Hrs Sheet Metal(SM) $54.00 1.4 1.4 $75.60 Mech/Elec(ME) $85.00 Frame(FR) $75.00 Refinish(RF) $54.00 3.7 3.7 $199.80 Paint Materials $34.00 Labor Total 5.1 Hours $275.40 Sublet Repairs $3.50 Gross Total $691.77 Net Total a691.77 Alternate Parts Y/00/00/00/00/00 CUM 00/00/00/00/00 Zip Code:55106 Audatex Host � � � Audatex Estimating 6.0.925 ES 02/26/2013 03:18 PM REL 6.0.925 DT 01/01/2013 DB 02/15/2013 Copyright(C)2011 Audatex North America, Inc. 1.1 HRS WERE ADDED TO THIS ESTIMATE BASED ON AUDATEX'S TWO�STAGE REFINISH FORMULA. Op Codes 02/26/2013 03:18 PM Page 2 of 3 2010 Toyots Corolla LE 4 OR Sedan Claim#: 02/26/2013 03:16 PM " = User-Entered Value E = Replace OEM NG= Replace NAGS EC= Replace Economy OE= Replace PXN OE Srpls UE= Replace OE Surplus ET= Partial Replace Labor EP= Replace PXN EU= Replace Recycled TE = Partial Replace Price PM= Replace PXN Reman/Reblt UM= Replace Reman/Rebuilt L = Refinish PC= Replace PXN Reconditioned UC= Replace Reconditioned TT = Two-Tone SB= Sublet Repair N = Additional Labor BR= Blend Refinish I = Repair IT = Partial Repair CG= Chipguard RI = R&I Assembly P = Check AA= Appearance Allowance RP= Related Prior Damage This report contains proprietary information of Audatex and may not be disciosed to any third party(other than the insured,claimant and others on a need to know basis in order to effectuate the claims process)without rAudatex Audatex's prior written consent. a Solera compartr Copyright(C)2011 Audatex North America, Inc. Audatex Estimating is a trademark of Audatex North America, Inc. i ! 02/26/2013 03:18 PM Page 3 of 3 STATE��INNESOTA-RAMSEY DISTRICT COURT � I IIIIII(IIII IIIII IIIII IIIII IIIII IIIII IIIII IIIII IIII IIII The undersigned,being duiy swom,upon his/her oath deposes and says: � * 8 8 8 7 4 8 8 4 2 * ��;iate of Offense � � Time of Offense ' �r' Plate : �h.License No. " Year • � State Make Style�Cobr Loration of Offense: � VI�)LATION: SNOW EMERGENCY St.Paul Ordinance 161.03 FINE $53.�0 (Amount includes mandatory state surcharges of$13.00) CN ` Citing Otficer Citing � Officer Number Dept. ,. D Posted Night Plow O Day Plow ❑Plowed in(Windrow) OTagged Before Plow ❑Drove Off f OFFICER'S NOTES ; ❑NO PLATE VIN: Citatton can be paid at the Impound Lot.Please read the back of the citatfon for payment lnstructions. - CITATION - ake:06 TOYOTA License#:558CTV CN: 12288997 invoice#: 17551 � 1 D te/Time Refeased: 12/10/2012 16:26 Tow Charge: $ 123.95 ' �( 1 V eleased to:TOTO Storage Charge: $ 15.00 \� Paid by:CASH Admin Charge: $ 80.00 Released by:YOUA Tau:(7.625%) $ 15.55 i,the undersigned,have recovered the vehlcle described above. Subtotal: $ 234.50 I will check the vehicle for damage or any other problems that may have occurred while this vehicle was in the custody of the Service 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: $ 234.50 on this form prior to leaving the impound lot. � Damage and/or other problem: �Y`� ��Qr l�S C�' C�f�l� t �� 2,� -I��O�� c�-� � n� ia�i,� Police Report made:Yes_No_IF Yes,CN , If NO,Wh� TO PROTECT YOUR RIGHTS REPORT ANY PROBLEMS/DAMAGE BEFORE LEAVING THE LOT Signature sn000 i �. �� 4 � .��% ,�� . . x`" �4,g,}aq%.. ' �' . .�t3,i* �I�n� . � e �� . ��u,; ��' �� - 4t� � � � � � I I '�`�;: ��:��,�. �.�� -� ��. *xp�.��'y s �-.�,�a, � � a . y�:�`3�,� 3 . - r •- ,a':� F"b aR 4 .. . � ��T�� - .. �.�� . ,�".' _ . . ��=rv,, „�}� ► 2�z��3 . 4 . ��'. � t» � i � . V 6�alnw I'� 4 1': ` y.y i ��'�'� i}-0n �A _ ...1 ._,-4R,,,_ � . \ � �s�a�'� S�g�C �° '�� j�,� � � � � _ , �i� �� . � ?� �:�': _ X. � � � .� ..k._..,,,, v:.. �;:'. '�.. 1;. , _•, . �2,�?,�e163 ;.� - �, „ ;�}i'� (.y� .�.-.A 4UTY �: _.:LER:�IF--,.. '".. . � ' . ! �t. f g,;�,'F. � '.,..it.. , � . 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