Ross (2) 9-dt�tlV�.L1
� ' MAR 19 2013
NaTICE OF CLAIM FORM to the City of Sai����nesota
Mi��rzesota S1nte Statute 46h.OS stafes Jhai "...every person...wlto clnlms damnges fi»nt mry mu�aicipality...sliall car�se to be preserued tn!hr
gni�erni��g bndy nJ�the nusnrcip�lily within 180 days arter the alleged loss a•injury is discovered a notice stating the time,place, ancl
crrcumstanees thereof,ar:d the amnunt�f en►�pe�isaliaz nr other r•eliejdemanded."
Please complete this form in its entirety by clearly typing or printing your answer to each questinn. If more space is
needed,attach additional sheets. Please note that you may or may not be contacted by telephone t�discuss,your ctaim
circunnstances,so provide as much information as necessary to explain your claim,and the amount of compensation heing
requested. This form must be signed,and both pages completed, if something does aot apply,write`N!A'.
SEND COMPLETED FORM AND OTHER DOCUMENTS TO:
CITY CLERK, 15 WEST KELLOGG BLVD,310 Cl'TY HALL, SAINT PAUL, MN 55102
First Name ��ic�n„i� Middle Inxtial,� Last Name �?�_ __
Company or Business Name, if applicable .______^.__ ^ _
Street A,ddress olUr .`J�'i ���-j P�' "`yr- Orr�,.�l,��'�j_ '
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City �v►\\� State ���_ ZipCode�5�13
Daytime Tel ephone (t�1� ) 'i�S-��y p Evening Telephone(l�l �) �t 5F-13�t�
Date of Accident/Inju�y or Date Discovered ,�� �D � 1 Time�_am /�im�(circie)
_._�,. ��
Please state, in detail, wliat occurred, and why you are submitting a claim. Please indicate why or how you
feel the Ciky of Saint Paui or its employees are involved and/or responsible.
—��Y�:.LL,�, c�. �Q��r�v���c��r��� �cn \ �.,� lQir�i�..1���c�.� -�w� �,�._.
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Please check the box{es) that most closely represent the reason foz eompleting this form:
❑ Vehicle was damaged it� an accident L�Vehzcle was damaged durizig a t�w
C] Vehicie w�s damage,d?�y��pct:�ole or c:�►yciition of the sc�eet ❑ Vehicle was damaged by a plow
I� Vehicle was wrongfulIy towed andJor ticketed ❑ Injured on City property
�'J Othe��type of property damage—piease specify
l� Other type of injury—�lease speczfy
❑ Other type not]isted—ptease specify
[n �rder to process your claim you need to include copies of all aanticable documents This is a general
guideline of wl�at shoUld l�e submitted with a claitn fQn�n,but it is a�ot all inelusive. You may be askec� to
��x-ovide additional 'zt�foz-�nation depending on your claim.
9 Property damage claims to a vehicle: at least two estimates for the repairs to'your vefiicle;oa•the
actual bills and/or z-eceipts for the repairs
� Towing claims: legible copies of any tiekets issued and copies of the impound�t��ec�er�t�a�3
O Other property damage: repair estimates, detailed list of datnaged items
U Injury claizns: a�nedical bills,receipts
O Photographs can be provided but will not be returned, _ _. .
Page l of 2—Please complete and return both pages of Clai�n Form
Failure to provide a completed claim form will result in delays in processing.
l�Totice of Claim Form, Cit,y of Saint Paul,page two
All Claims—please complete this section .-°°��--'�
Were there witnesses to the incident? Yes No � Unknown (circle)
If yes, please provide their names, addresses and telephone number's:
�.,_.__.___�
Were the police or law enfarcement called? Yes No �....,__I���kno (circle)
If yes, what department �r agency? Case#or report# �.
Where did the accident or injury take place? Provide street address,cross street, intersection, ttame of park
or facility, closest landmark, etc. Please be as detailed as possible. If helpful, attach a diagram.
- c�'- �'' �
Please indicate th.,a�;►a�ant y�u a�e seeking�n c�m�er�satlOiS iun�► �his ciaim or what you woul� lik� ih�City
to do to resolve this clairn to your satisfaction. -f w�v1 c� e�,�-mc��� ��. ������ `j
. , t --
Vehicle Claims please comQlete this section ❑ check box i�this section does not apply
Your Vehide: Year�� zX� Make <�_Model (',>�,�n �8
License Plate Number - State�.'LU Color �;-�p 1 �.
Registered Owner ���mbe��P��-±�� ��f�����
Driver of Vehicle �-,r t,. p��`�
� �
Area Damaged �nk�.� •�( tiMO�_C�Y1°Q `1� a�'�n�t o;� �k�:��-
City Vehicle: Year 1V�ake Model_
License Plate Number State Color —
Driver of Vehicle(City Employee's Name)
Area Damaged
in�urv Claims please complete this section �check box if this section does not apulv
How were you injured? ��
What part(s) of your body were injured?
Have you sought medical treatment? Yes No Planning to Seek Treatmeni {circle)
When did you recezve treatment? (provide date(s))
Name of Medzcal Pz'ovider(s): -
Address Telephone
Did you miss work as a result of your injury? Yes No
When did you miss work? (provide date(s))
Natne of your Employer:
Address T�lephone _
❑ Cl�eck l�ere if you are attaching more pages to this clainn form. Namber of additional pages
!3y sig�:ing this form,.you nre stati.r��that all injormatinn you have prnvided is true a�ed cnrrect tn ihe best ofyo��th�iwl�d�r. �i.��t'gned
.fnr»rs wiH not he prncecsed. Sub►xining a,ra[.ce claine can result i►e proseeution.
�'rint the lYame oi the Person who Completed this Form: � �1 .�2��
/'
Sigrnature of Person Making the Claim: -��'��
Date fornn was completed �9�/i�i� Revised April?_Q07
� HAMLINE AUTO BODY INC. Workfile ID: c7cff964
FederalID: 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#: Claim #:
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact:
Owner: Inspection Location: Insurance Company:
ROSS, NOAH HAMLINE AUTO BODY INC.
2659 GALTIER ST. 2520 BROADWAY DR
ROSEVILLE, MN 55113 LAUDERDALE, MN 55113
(612)745-1340 Cell Repair Facility
(651) 224-4717 Business
VEHICLE
Year: 2000 Body Style: 4D SED VIN: 2C3HD36]8YH199979 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: Job#:
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 Premfum Radio Ciear Coat Fai��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
; e,ry1'1
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3/il/2013 4:39:40 PM 099681 Page 1
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 -�•Z
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
22 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
28 Blnd LT Outer panel 1•Z
29 # Subl Hazardous waste removal 1 5.00 X
5UBTOTALS ' 1,586.20 5.8 11.6
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3/11/2013 4:39:40 PM 099681 Page 2
Preliminary Estimate
Customer: ROSS, NOAH
Vehicle: 2000 CHRY CONCORDE UCI 4D SED 6-3.2L-FI BLUE
ESTIMATE TOTALS
Category Basis Rate Cost$
pa� 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 @ 7.1Z50% 112.66
Grans!Tatai � 3,137.85
Deductible 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_J
*******************************************************************************
MN ST 60A.955 - A PERSON WHO FILES A CLAIM W1TH INTENT TO DEFRAUD OR HELPS COMMIT A FRAUD
AGAINST AN It�SURER IS G�1L fY UF A CRIME.
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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 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 LK�, RCY, or USED. Re�onditioned 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.
HY�=Hydr�formed S*ee!. In�1.=Included. LKQ=Like Kind an� Qualit��. LT=Left. M.AG=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.
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.
;� �
3/11/2013 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
Locatior.{s): 1710_,. 3Rl�;,DVV!•.Y, ROCH'":STEf:Mfv 55°04 (838)!�.r4-3450 {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 CH"1502119 $272.00
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3/11/2013 4:39:40 PM 099681 Page 5
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