Chang _ RECEIV�D
MAR 2 5 2013
NOTICE OF CLAIM FORM to the City of Saint P���Rta
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 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��Z-���� Middle Initial�Last Name�}��� —�
Company or Business Name��iCc��`k rC'
Are You an Insurance Company? �e /No If Yes,Claim Number?
Street Address���� �S'��C ��-.�C,
City��)�j ��c State `�,��_ Zip Code���
Daytime Phone (���a-r'J �b7�e11 Phone( ) - Evening Telephone( ) -
Date of Accident/Injury or Date Discovered ' — � — 2.b 1� Time � Nr1 am�
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 employees are involved and/or responsible for your damages.
.
�f2 ',c��'S�� c'��ec� 'p.� �V� ' ��
Please check the box(es)that most closely represent the reason for completing this form:
lSCl��y 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
❑ 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•�ou need to include copies of all applicable 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 propefty of the City. You 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 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-please complete this section
Were there witnesses to the incident? Yes No Unknown (circle)
Provide their names, addresses and telephone numbers:
Were the police or law enforcement called? �� No Unknown (circle)
If yes, what department or agency? C'�� (�ln) Q�_Case#or report# A�c.�1E.o1 - � 3����l�5
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 necessary, attach a diagram.
1 � S� �'�I t�t�� ta�'f�'t�1 c.� �����-�
Please indicate the amount you��ek��ing inCJco�ensation or what you would like the City to do to resolve this claim
to your satisfaction. � � .1 , •
Vehicle Claims- lease com lete this section ❑ check box if this section does not a 1
Your Vehicle: Year Zo0 1 Make T��1� Model `I�
License Plate Number� �- P State�t _Color S�1\f�(2
Registered Owner � l
Driver of Vehicle �M.'Pt � h��?'l `f�V -� __--
Area Damaged
City Vehicle: Year Z4��-1� Make M(��1� Model�,QOO
License Plate Number �'1 1 5�'Z~1 State��Color
Driver of Vehicle(City Employee's Name)�Pv i ��=-�ftee� f"(�5C�1C-'
Area Damaged
Injury Claims please complete this section ❑ check box if this section does not applv
How were you injured? I�1 �-t!
What part(s) of your body were injured?
Have you sought medical treatment? Yes 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? es �
When did you miss wark? (provide date(s))
Name of your Employer:
Address Telephone
❑ 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. Date form was complete
�
Print the Name of the Person who Completed this Form:� 1��
�
Signature of Person Making the Claim:
Revised February 2011
~` �"������RO.�NOKE VAR2401g�ubrogation Claim Cntr
You're in good hands.
�����n�l��l����i�����������������l�l�t��'��I��I��'�����������il�
CITY OF ST PAUL Minnesota
15 KELLOGG BLVD W
SAINT PAUL MN 551021635
March 21,2013
CLAIM NLTMBER: 0272023276 F2E PHONE NUMBER: 800-776-2615
DATE OF LOSS:January 02,2013 FAX NUMBER: 540-725-619 L
OUR INSURED: MAICHOU CHANG OFFICE HOURS: Mon-Fri 8:00 am-7:00 pm
YOUR FILE NUMBER:
YOUR INSURED:KEVIN FRASCONE
ADDRESS: 1283 EARL ST
CITY STATE ZIP: SAINT PAUL,MN, 55106-2024
LOSS LOCATION:jackson &maryland, st paul, ,MN
AMOUNT OF LOSS: $1,702.55
Re: Subrogation Claim Notice
Dear CITY OF ST PAUL Minnesota;
Our investigation indicates your insured was responsible for the loss referenced above.
Please accept this letter as notice of our subrogation claim. Enclosed,you will find copies of the supporting documents for
which we are seeking reimbursement. To assist you in your review,the following is a breakdown of our subrogation
demand:
Auto Damage(Com an Paid): $1,202.55
Rental: $
Towin : $
Other: $
Deductible(Customer Paid): $500.00
Salva e Recove : $
Insured Out of Pocket(please send directly to our Insured): $
Please forward your payment with our claim number to:
Allstate Payment Processing Center
P.O. BOX 650271
Dallas, TX 75265 0271
0272023276 F2E
We ask that you direct any future correspondence to the address listed at the top of this letter.Thank you.
Sincerely,
LIS�L BOOJ1��
LISA BOONE
800-776-2615 Ext. 7257079
Allstate Property and Casualty Insurance Company
SUBU033 0272023276 F2E
Accident Report Page i of 1
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htms:!/dvslesuon�rt:ar¢(dvsinfo/accidentrecords 2008/Includes LEJPrintRenortlndiv LE.as... 1/3/2013
Report Date: 03/21/2013 I�
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Payment Ledger �
�
Policy Holder: MAICHOU C&ZA Y VANG Total Amount Paid $1,202.55 I
Partici ant: MAICHOU CHANG Medical Deductible: $0.00
Date of Loss: Ol/02/2013 Co-payment Amount $0.00
Claim Number: 0272023276
Payment/Credit payee/Payor Check# Amount
Date
Ol/04/2013 MAICHOU C & zA Y vANG 548829499 $ 1,202.55
Allstate Property &Casualty Ins.
Minnesota
3601 MINNESOTA DRIVE STE 700,
BLOOMINGTON, MN 55435 Claim#: o0ov2023276DO1
Phone: (800) 869-0510 Workfile ID: Obfb9d7f
Estimate of Record
Written By:TERRY LUDWIG, 1/4/2013 2:44:48 PM
Insured: MAICHOU CHANG Policy#: 000911281694 Claim#: 000272023276D01
Type of Loss: Collision Date of Loss: O1/02/2013 12:00 PM Days to Repair: 6
Point of Impact: 09 Left T-Bone(Left Deductible: 500.00
Side)
Owner: Inspection Location: Appraiser Infortnation: Repair Facility:
MAICHOU CHANG Drive-in cklqc@allstate.com
1677 DIETER ST (952)270-0690
SAINT PAUL, MN 55106-1208
(651)771-3803 Other
VEHICLE
Year: 2001 Color: silver Int: License: 933 gpz Production Date:
Make: TOYO Body Style: 4D SED State: MN Odometer: 152496
Model: CAMRY LE Engine: 4-2.2L-FI VIN: 4T16G22K31U870202 Condition:
TRANSMISSION DECOR RADIO SEATS
Automatic Transmission Body Side Moldings AM Radio Cloth Seats
Overdrive Dual Mirrors FM Radio Bucket Seats
POWER Console/Storage Stereo Redine/Lounge Seats
Power Steering CONVENIENCE Cassette WHEELS
Power Brakes Air Conditioning Search/Seek Full Wheel Covers
Power Windows Rear Defogger CD Player PAINT
Power Locks Tilt Wheel SAFETY Clear Coat Paint
Power Mirrors Cruise Control Driver Air Bag
Power Trunk/Tailgate Intermittent Wipers Passenger Air Bag
1/4/2013 2:44:49 PM 110318 Page 1
Claim#: 000272023276D01
Workfile ID: Obfb9d7f
Estimate of Record i
2001 TOYO CAMRY LE 4D SED 4-2.2L-FI silver I�
Line Oper Description Part Number Qty Extended Labor Paint
Price�
1 FRONT LAMPS
2 R&I LT Signal lamp assy 0 0.00 0.2 OA
3 FENDER
4 Blnd LT Fender 0 0.00 0.0 1.0
5 * R&I LT Body side mldg US built 0 0.00 0_2 0.0
6 R&I LT Mud guard US built 0 0.00 0.3 0.0
7 FRONT DOOR
8 * Rpr LT Outer panel US built 0 0.00 � Z•2
9 Add for Clear Coat 0 0.00 0.0 0.9
10 * Repl RCY LT Mirror assy power w/o ST0706 1 56.25 0_4 0_6
heat, US built white+25%
11 Add for Clear Coat 0 0.00 0.0 0.1
12 R&I LT Belt w'strip 0 0.00 0.3 0.0
13 R&I LT Window molding 0 0.00 0.4 0.0
14 R&I LT Handle,outside US built silver 0 0.00 0.5 0.0
15 * Rpr LT Handle,outside US built silver 0 0.00 0_5 0.4
16 Add for Clear Coat 0 0.00 0.0 0.1
17 RScI LT R&I trim panel 0 0.00 0.4 0.0
lg * R&I LT Body side midg US built 0 0.00 0_3 0.0
19 * Rpr LT Body side midg US built 0 0.00 0_5 0.5
2p Add for Clear Coat 0 0.00 0.0 0.1
Zl ** Repl A/M Clean and Retape Mouldings 3 6.00 X 0.6 0.0
22 REAR DOOR
23 * Rpr LT Outer panel US built 0 0.00 6_5 Z•Z
24 Overlap Major Adj. Panel 0 0.00 0.0 -0.4
25 Add for Clear Coat 0 0.00 0.0 0.4
Z6 R&I LT Belt w'strip 0 0.00 03 0.0
27 R&I LT Window molding 0 0.00 0.4 0.0
2g * R&I LT Body side midg US built 0 0.00 0_3 0.0
29 * Rpr LT Body side mldg US built 0 0.00 Q.5 0.4
30 Add for Clear Coat 0 0.00 0.0 0.1
31 R&I LT Handle,outside US built silver 0 0.00 0.4 0.0
32 R&I LT R&.I trim panel 0 0.00 0.4 0.0
33 # Rpr Drop bumper end 0 0.00 0.5 0.0
NOTE: It front for paint.
34 ** Repl A/M door edge guard 1 50.00 1.0 0.0
35 # Color Tint-minor 1 0.00 X 0.0 0.0
SUBTOTALS 112.25 17•9 $•6
1/4/2013 2:44:49 PM 110318 Page 2
Claim#: 000272023276D01
Workfile ID: Obfb9d7f
Estimate of Record
2001 TOYO CAMRY LE 4D SED 4-2.2L-FI silver
ESTIMATE TOTALS
Category Basis Rate Cost$
pa� 106.25
Body Labor 17.9 hrs @ $50.00/hr 895.00
Paint Labor 8.6 hrs @ $50.00/hr 430.00
Paint Supplies 8.6 hrs @ $30.00/hr 258.00
Miscellaneous 6.00
Subtotal 1,695.25
Sales Tax $106.25 @ 6.8750% 7.30
Total Cost of Repairs 1,702.55
Deductible 500.00
Total Adjustments 500.00
Net Cost of Repairs 1,202.55
IMPORTANT INFORMATION ABOUT THE NAMED INSURANCE COMPANY'S CHOICE OF PARTS POLICY.
THIS ESTIMATE MAY LIST PARTS FOR USE IN THE REPAIR OF YOUR VEHICLE THAT ARE MANUFACTURED BY A
COMPANY OTHER THAN THE ORIGINAL MANUFACTURER OF YOUR VEHICLE. THESE PARTS ARE COMMONLY
REFERRED TO AS AFTERMARKET PARTS OR COMPETITIVE PARTS, AND MAY INCLUDE COSMETIC OUTER BODY
CRASH PARTS SUCH AS HOODS, FENDERS, BUMPER COVERS, ETC. THE INSURANCE COMPANY GUARANTEES THE
FIT AND CORROSION RESISTANCE OF ANY AFTERMARKET/COMPETITIVE OUTER BODY CRASH PARTS THAT ARE
LISTED ON THIS ESTIMATE AND ACTUALLY USED IN THE REPAIR OF YOUR VEHICLE FOR AS LONG AS YOU OWN
IT. IF A PROBLEM DEVELOPS WITH THE FIT OR CORROSION RESISTANCE OF THESE PARTS, THEY WILL BE
REPAIRED OR REPLACED AT THE INSURANCE COMPANY'S EXPENSE. THIS GUARANTEE IS LIMITED TO THE REPAIR
OR REPLACEMENT OF THE PART. HOWEVER, IF YOU CHOOSE NOT TO USE ONE OR MORE OF THE
AFTERMARKET/COMPETITIVE OUTER BODY CRASH PARTS THAT MAY BE LISTED ON THIS ESTIMATE IN THE
REPAIR OF YOUR VEHICLE,THE INSURANCE COMPANY WILL SPECIFY THE USE OF ORIGINAL EQUIPMENT
MANUFACTURER PARTS, EITHER NEW OR RECYCLED AT THE INSURANCE COMPANY'S OPTION, AT NO ADDITIONAL
COST TO YOU. THE INSURANCE COMPANY DOES NOT SEPARATELY GUARANTEE THE PERFORMANCE OF ORIGINAL
EQUIPMENT MANUFACTURER PARTS, AND MAKES NO REPRESENTATION ABOUT THE AVAILABILITY OF ANY
MANUFACTURER'S GUARANTEE.
******************************************************************************************
******************************************************************************************
SUPPLEMENT REQUEST PROCESS INSTRUCTIONS:
ANY ADDITIONAL DAMAGES MUST BE INSPECTED BY AN ALLSTATE TECHNICIAN
WHILE THE VEHICLE IS AT THE SHOP AND TORN DOWN PRIOR TO THE REPAIRS
BEING COMPLETED. PLEASE E-MAIL OR FAX ANY SUPPLEMENT REQUESTS TO ALLSTATE
USING THE FORM ATTACHED TO THE BACK OF THIS ESTIMATE. PLEASE E-MAIL
YOUR REQUEST TO : Supplementrequest@allstate.com OR FAX TO 1-866-655-0968.
FAILURE TO NOTIFY ALLSTATE OF ANY SUPPLEMENTAL DAMAGES MAY RESULT IN DENIAL OF
PAYMENT FOR THESE DAMAGES. REVIEW OF ALL INVOICES WILL BE REQUESTED
1/4/2013 2:44:49 PM 110318 Page 3
Claim#: 000272023276D01
Workfile ID: Obfb9d7f
Estimate of Record
2001 TOYO CAMRY LE 4D SED 4-2.2L-FI silver
FOR SUPPLEMENTS EMAIL: SUPPLEMENTREQUEST@ALLSTATE.COM OR FAX TO 866-655-0968
******************************************************************************************
******************************************************************************************
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.
Recycled Part Costs based on information provided by Car-Part.com. For assistance, call CCC at 800-637-8511.
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
AEM8509, CCC Data Date 11/1/2012, 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 (�) 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=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. 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.
1/4/2013 2:44:49 PM 110318 Page 4
Claim#: 000272023276D01
Workfile ID: Obfb9d7f
Estimate of Record
2001 TOYO CAMRY LE 4D SED 4-2.2L-FI silver
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.
1/4/2013 2:44:49 PM 110318 Page 5
Claim#: 000272023276D01
Workfile ID: Obfb9d7f
Estimate of Record
2001 TOYO CAMRY LE 4D SED 4-2.2L-FI silver
ALTERNATE PARTS SUPPLIERS
Line Description Supplier Item# Price
10 RCY LT Mirror assy power w/o heat,US built Bud Jones and Sons Auto Salvag ST0706 $45.00
white+25%
Bill Jones (320)532-3552
31787 US Hwy 169,Onamia MN 56359
1/4/2013 2:44:49 PM 110318 Page 6
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