Khitrykau RECEIVED
MAR 2 7 2013
CITY CLERK
NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minnesota State Statute 466.05 states tha� "...every person...w�claims damages from uny miaiicipaliry...shall cause to be presented to the
goverrting body of the rru�nicipaliry within 180 days after the lleged loss o;inja�r�rs discovered a nutice stating the time,place,and
circ�imstances thereof,and the amaet�t 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 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 bpth pages completed. If something dces 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
���`��1,_ Middle�nitial Last Name_.�1�1.(� �--
; _ _� _'
Company or Business Name
Are You an Insurance Company? Yes 1Vo If Yes,Claim Number`�
Street Address � �7 � �e af C�t S lc�l� ��F
City I"�,►�I I 1/i� �G1 �t G� State /"I/V Zip Code ��3 y�
Daytime Phone( ) - Cell Phone��fz) 366 8yI� Evening Telephone( ) -
Date of Accidend Injury or Date Discovered .��' ��1 /a ��3 Time�_a�ii /pm
Please state,in detail,what occurred(happened),and why you are submitting a claim.Please indicate why or how you
feel the City of Saint Paul or its e�loyees are involved nd/or responsible for your d ages.
Yc � c! � �r d M a � � �- �{ ��, � �
�e�„i de � s �o ✓ fn,� Q her- � ; e 3 a �
e�r �✓ �as hc�c� � � �'� p� � �
�, �� ��� �✓ S �v ��a V- dh
� ^ 0
� C d�- _ ' �vl�
�ec�'a� 4r�
P ase check the box(es)that most closely represent th�reason for compledng 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 ❑ My vehicle was damaged by a plow
O My vehicle was wrongfully towed and/or ticketed u 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 to include coaies of all auvlicable documents.
For the claims types listed below,please be sure to include the documents indicated or it will delay the handling of
your claim. Documents WILL NOT be returned and become the property of the City. You are encouraged to keep a
copy for urself before submitting your claim form.
�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 the repairs
O Towing claims: legible copies of any ticket issued and a copy of the impound lot receipt
O Other property damage claims: two repair estimates if the damage exceeds$500.00;or the actual bills
and/or receipts for the repairs;detailed list of damaged items
O Injury claims: medical bills,receipts
O 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—nlease comnlete this secrion
Were there wimesses to the incident? Yes o Unknown (circle)
Provide their names,addresses and telephone numbers:
Were the police or law enforcement called? es/ No Unknown (circle) �
If yes,what department or agency?�t fLr �-� S �OI U� Case#or report# � 3 — � �tJ " a 2 )
Where did the accident or injury take place? Provide street address,cross street,intersection,n me of park or facility, .
closest landmark,etc. Please be as detailed as possib e� If necessary,attach a diagram. �
� I..� �i Q l� - f '
Please indicate the amount you are seekinQ in co ensa 'on or what you would like the/�ity to do t resolve this claim
to your satisfaction. t 3� � • �� ��j �'-��� / ��'( ����
+
Vehicle Claims— lease com lete this section ❑ check box if this section dces not a I
Your Vehicle: Year �O!/ Make T Model � �
License Plate Number Z.v�)� G T State�j Color
Registered Owner P � L �
Driver of Vehicle oU� �
Area Damaged r-Q r r-�G ►,vt t�, w 2 � -2 �i / D c.�
City Vehicle: Yeaz Make Model
License Plate Number 3 State 1Z' Color �
Driver of Vehicle(City Employee's Name) j 0��r f k 0 t.�,a S �0�
Area Damaged f Q G�r
Injurv Claims please complete this section �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 Plannin�to Seek Treatment(circle)
� (provide date(s))
When did you receive treatment. �
Name of Medical Provider(s):
Address Telephone
Did you miss work as a result of your injury? Yes No �
�'hcn di�'y�u miss;��ork? _,_._ (provide date(s))
Name of your Employer:
Address Telephone
❑ Check here if you are attaching more page�to this claim form. Number of addirional pages�.
By signireg this form,you are stating that all information you have provided is true and correet to the best
of your knowledge. Unsigned forms will not be processed.
Submitting a false claim can result in prosecution. Date form was completed (� °2 3 /°2��3
Print the Name of the Person who Completed this Form: V ���, ��
Signature of Person Making the Claim:_ -
Revised February 2011
r 3� u�n3a��,-�µ. �c .z� ��� ,�"� v.�t� ,�'�.� .n �_. _.
� # A�, .� �
��°��r � ' � �:�' ��`^ � - r�.
�`a���� `�§�����• �'v� 4; =i� " �
>�", ° � � � ro�� '+� �i
� � � �� _�, � .�: � yc�t
h t ��y.
� ��x `F. ���'� W'.
�� � `n�'r° �'e ��� ���
��� g .�k
��� �<.
� �� s �c�..
��, =�3u,.
�4 x�'�:-�
�5 -F° 4N . 5., ��4�� .
y, 3r iy +w,
�.�a}��� �w� 'L��P�✓�s�� x t _ d� � �c��R�"�,
�
z� ��� .;•.;� � `� � � � •
r '
a`^� a ��
�� ��� �33
,��
tff
�
i K :
r�
� f � '
s > �.zt °�`� ���� '��,
;� � � �-� �b: �Q�t`s ,' x s��� °�
g�,e s
� r
R
•�,z�c
� �,.... .., .. . .. . .. . '- ... ,.,�_.. �1,... <,�,. ,.. ...,... .,. ..
, , , . - �sFa .� . „�.e. ,. �.
, .. .,.,...w, .
. , ., , ,. ,,,- � ��.. �
�
i1fiL5•99Z!TS9) iI�4`]cplo�ag axiMd I�d 1�4�5
qs��us�u mod�aip�xftv sucnsartk�ancy nad.l[
_...5 t"'t,....,• �..rt�i ��—�N?
srr�uurFxofiia..r,h�rzno�uuote fO;SS tiJ4�t+�p�f n*1nS
'. 4JS`iL ts�tRXk4'9!1Z-l59:i/°y4 a.rur� 7a:u1g a.:,n,�rJ 19£
'I�"lt'd.I.itiI4'S,�C1 X.I.L7
:z���zx�aaa �a1�zc�a ���:::
___—_—_ ,»��t��,t;«�
�a ��zio�:
diqsaau;xed?g uusx�r.uoissa,}cud�ap�ad
i
I
, . LUTHER COLLISION AND GLASS- Workfile ID: 70257301
' FederalID: 411300760
MOPKINS
250 5TH AVENUE SOUTH, HOPKINS, MN 55343
Phone: (952) 908-8600
FAX: (952) 908-8601
Preliminary Estimate
Customer: KHITRYLAV, PAVEL 7ob Number:
Written By:Todd Stadler
Insured: KHITRYLAV, PAVEL Policy#: Claim#: UNK
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact: 07 Left Rear
Owner: Inspection Location: Insurance Company:
KHITRYLAV, PAVEL LUTNER COLLISIOPI AND 6LA55- - CITY OF ST PAU6
HOPKINS
5275 BEACHSIDE DR 250 5TH AVENUE SOUTH
MINNETONKA, MN 55343 HOPKINS, MN 55343
(612)366-8413 Business Repair Facility
(952)908-8600 Business
VEHICLE
Year: 2011 Body Sryle: 4D H/B VIN: ]TDKN3DU765256506 Mileage In:
Make: TOYO Engine: 4-1.8L-G/E License: 751KGT Mileage Out:
Model: PRIUS Production Date: 12/2010 State: MN Vehicle Out:
Color: BLACK Int:TAN CLOTH Condition: Job#:
TRANSMISSION Air Conditioning Search/Seek Bucket Seats
Automatic Transmission Rear Defogger CD Player WHEELS
POWER Tilt Wheel , Auxiliary Audio Connection Aluminum/Alloy Wheels
Power Steering Telescopic Wheel SAFETY PAINT
Power Brakes Intermittent Wipers Anti-Lock Brakes(4) Clear Coat Paint
Power Windows Climate Control Driver Air Bag OTHER
Power Locks Steering Wheel Controls Passenger Air Bag Traction Control
Power Mirrors Message Center Head/Curtain Air Bags Stability Control
DECOR RADIO Front Side Impact Air Bags Rear Spoiler
Dual Mirrors AM Radio 4 Wheel Disc Brakes
Console/Storage FM Radio SEATS
CONVENIENCE Stereo Cloth Seats
3/16/2013 9:17:05 AM 023496 Page 1
, Preliminary Estimate
Customer: KHITRYLAV, PAVEL 7ob Number:
Vehicle: 2011 TOYO PRIUS 4D H/B 4-1.8L-G/E BLACK
Line Oper Description Part Number Qty Extended Labor Paint
Price$
1 REAR BUMPER
2 Repl Bumpercover 5215947905 1 253.77 1.8 2.8
3 Add for Clear Coat 1.1
4 Repl LT Retainer 5257647020 1 53.21 0.1
5 Repl Prep unprimed bumper 1 �•7
6 # Hazardouse Waste Removal 1 8.00 X
7 # Flex Additive 1 8.00 X
8 # Refn Color Tint 0.5
_ _ __ __ _ __ _ _.. ____ _ _
__ _ __._ _
9 PILLARS,ROCKER 8c FLOOR
10 Repl LT Closing plate 6563247041 1 32.24 0.2
.... _.. _. .,.. .,... . . �..._.,. _. �.. ... . .... .� .._. . _ ..__ ... . _ v. _
11 WHEELS
12 ** Repl RECOND LT/Rear Wheel,alloy 4261147110 1 189.00 m 0.3
15"
13 # Subl Mount&Balance 1 25.00 X
14 # Subl Alignment check 1 59.95 X
15 R&I Spare Wheei,spare 0.3
16 # Rpr Install spare to drive 0.3
17 Repl LT/Rear Wheei cover 4260247110 1 78.18
18 # Rpr Prewash for production 0.2
19 # Rpr Final Wash/Vacuum(Levei I) 0.2
20 # Refn Denib&Buff 0.3
SUBTOTALS 707.35 3.4 5.4
ESTIMATE TOTALS
Category Basis Rate Cost;
Parts 606.40
Body Labor 3.4 hrs @ $52.00/hr 176.80
Paint Labor 5.4 hrs @ $52.00/hr 280.80
Paint Supplies 5.4 hrs @ $32.00/hr 172.80
Miscellaneous 100.95
Subtotal 1,337.75
Sales Tax $606.40 @ 7.2750% 44.12
Grand Total 1,381.87
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 1,381.87
3/16/2013 9:17:05 AM 023496 Page 2
, ` Preliminary Estimate
Customer: KHITRYLAV, PAVEL 7ob Number:
Vehicle: 2011 TOYO PRIUS 4D H/B 4-1.8L-G/E BLACK
Luther's Limited Lifetime Collision Repair Warranty
Luther Collision & Glass guarantees all workmanship for as long as you own your vehicle. We will correct any repairs
listed on the repair invoice that are deemed to be defective as a result of our workmanship. This guarantee excludes
damage from rust, improper maintenance, use or care of the vehicle. This warranty applies to our labor only.
Materials, parts and equipment covered by the manufacture's warranty are not included in this limited warranty.
Part Prices are subject to invoice.
I understand that Luther Collision & Glass's final invoice for repairs of my vehicle may not match that of the insurance
company's estimate as to parts, labor or procedures used to repair my vehicle. The vehicle owner is responsible for
payment in full upon completion of repairs. If insurance is paying for repairs the vehicle owner is also responsible for
any charges necessary to correctly restore their vehicle back to prior to loss condition that the insurance may refuse
to pay. These charges will be discussed with vehicle owner in advance and are_usually paid for by the insurance
company.
Customer Pay Repairs:
When we repair your vehicle we enter a legal and binding contract for the repairs with you the vehicle owner. In
doing so, we can not accept check, credit card, cashiers check, or money order from the third parly. The only form
of payment we can accept form a third party is cash.
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.
3/16/2013 9:17:05 AM 023496 Page 3
. . , Preliminary Estimate
Customer: KHITRYLAV, PAVEL 7ob Number:
Vehicle: 2011 TOYO PRIUS 4D H/B 4-1.8L-G/E BLACK
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted ail items are derived from the Guide
ARM8546, CCC Data Date 3/15/2013, 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 Beneht�aric Prices are provtded-by Mationa! 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. Atgn.=Align. ALU=Aluminum. A/M=Aftermarket 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=Quantiry. 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 5teel. 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=6ureau of Automotive Repair. EPA=Environmental Protection Agency. NHTSA= National Highway
Transportation and Safety Administration. PDR=Paintless Dent Repair. VIN=Vehicle Identification Number.
3/16/2013 9:17:05 AM 023496 Page 4
, , Preliminary Estimate
Customer: KHITRYLAV, PAVEL 7ob Number:
Vehicle: 2011 TOYO PRIUS 4D H/B 4-1.8L-G/E BLACK
ALTERNATE PARTS SUPPLIERS
Supplier: Keystone-Complete-Minneapolis
Location(s): 3615 MARSHALL STREET NE,MINNEAPOLIS MN 55418 (800)328-1845 (612)789-1919
Line Description Item# Price
12 RECOND LT/Rear Wheel,ailoy 15" ALY69567U20 $ 189.00
I
3/16/2013 9:17:05 AM 023496 Page 5