Liu F��CEIVED
MAR 2 9 2Q13
NOTICE OF CLAIM FORM to the City of Saint P�-�I���
Minn�so�u Stute S�attue 466.05 stntes Niai "...n��e�.r person...i�rho c�laims durnuges frnm curt•m�oiirrp�/in...shc�l/c�nusc�o be presented to the
,,orc rni��,�bodr of the nnuzicipnlh��iri�hin /80 dcn�r«/ter 1/zc rrNeged/o.rs or iaju�_� rs disc°orc red a nnticc�s�alrng i/ie trrne.p/ace,nnd
� rirt'tu�z.sicuuer Nte�'eof,an�l 1he«moturi of rompc��tsalion nr oll�er mli�/�rlernnadcd.,.
Please com�lete this form in its entirety by clearly typing or print�ing 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
�►�ritten 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___� .J Middle Initial Last Name_ t k . _
Compai;�� or}3usiness Nan�e
Are You an Insm�ance Company? Yes No�f Yes, Claim Number?_ �
Sh�eet Addre�s_�(�� �er11 D�P �g,�,�"�
City SI ' (AI State_�N . _Zip Code
D�iytime Phone(�S�)��ZCell Phone (�)�-�ZEvening Telephone (_ ) _ _
Date of Accident/Injury or Date Discovered Time_ _am/pm
� Please state, in detail, what occurred (happened), and why you are submittin�a claim. Please indicate why or how you
feel the Ciry of Saint Paul or its employees are involved and/or responsible for your damages.
—��i�vMU �� – —
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"�X.�c'�avt_��—��l�� _�L� -Ivi Inc( � 1�Y�_j%_.��2��T_—
..�� 7 �+k„c b�-r►�o -d��� s�k 1 cr�v ��G-��r_o1� r��czi�c�
Please check the box(es)that most closely represent th� reason for completing this form:
❑ My vehicle was damaged in an accident � ❑ My vehicle was da�naged during a tow
�My vehicle was damaged by a pothole or condition of the street ❑ My vehicle was dama�ed by a plow
❑ My vel��cle v��as wrongfully towed and/or ticketed ❑ I was injured on City propert��
❑ Other type of property damage—please specify
❑ Other type of injury—please specify_
In order to process your claim you 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 handlina of
your claim. Documents WILL NOT be returned and become the propei•ty of the City. You are encoura�ed to keep a
copy for yourself before submitting your claiin fonn.
O Property damage claims to a vehicle: two e.ytimates for the repairs to your vehicle if the dama�e 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 dama�e claims: two repair estimates if the d�lmage exceeds $500.00; or the actual bills
and/or r�ceipts for the repairs; detailed list of damaged items
O Injury claims: medical bills, receipts
O Photo�raphs 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 dela��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? Yes � Unknown (circle)
ifi yes, what department or agency? Case#or repoct#
Where did the accident or inju►y 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. ��'V'��11�1 AV� .
� V�.l CW �e��i�1 � _
Please indicate the a�nount you are seeking in compensati�on"or�w,h"at you would like the City to do to resolve this claim
to yotn�satisfaction. __p�/�.t.,K'( U�i/ISLl'�C� �11�� Li,i'Yl-- - l� �
- -���t<iY���{����ts�i�(:� �- �r,� -E-�YT_�i��l a�C i�2e✓f-f 1 � 5Z�{-, c��
Vehicle Claims— lease com lete this section ❑ check box if this section does not a 1 �
Your Vehicle: Year 2(�d�—Make Model �r��l�
License Plate Number State�_Color �`i �1lt�1' �
Registered Owner � � � � S � •
Driver of Vehicle U u -
Area Damaged
City Vehicle: Year_ Make _Model
License Plate Number _ State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniurv Claims please complete this section ❑ check box iti this section does not applv
How were you injured?_��,r� .
What part(s)of your body were injured?
Have you sought medical h�eatment? Yes No Pltinnin� to Seek Treatment(circle)
When did you receive treatment7 (provide date(s))
Name of Medical Provider(s):
Address Telephone
Did you mi�s work as a result of your injury? Yes No
When did ��ou miss w�ork•' (pr����ide date(sll
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 forrn,you are stati�ig that all informatio�i you have provided is tr�ie and eorrect to the best
of your knowledge. D�zsigned forms will not be processed.
Submittirzg a false claim cafz result ifi prosecutio�. Date form was completed ���3 �
Print the Name of the Person who Completed 's Form: c1�7l��
Signature of Person Making the Clai :
Re��ised February 201]
Latuff Brothers
A/R Payment History for RO# 28295
Date: Ref# Received From: Amount: Received By:
03/25/2013 LIU 762-LIU JING&SUSAN Q XU $524.06 BECKY L ANDREWS
�
Summary
#of Payments: i
$524.06
Lt�l"Ur�BR�S INC
880 UNIVERSIT'(AVE
5T PAUL, MN 551Q4
03�?5�201� 17:22:43
Merehank ID: OO�1000�OL27�399
TerminalID: 0338a181
3672896�9888
CREDIT CARD
VISA SALE
CARD# �(XXXi(X)CXXXXX6939
INVOICE �001
Batch#: 000397
ApprovalCode: 025766
Entry Methnd: 5wiped
Mnde, Online
SALE AMOUNT $524.06
CUSTOMER COF�(
Page #1
Latuff Brothers
. �' 880 UNIVERSITY AVE.
ST. PqUL MN 55104 Final Invoice
6si-z24-za2s RO #:28295
.- Unit #:TD 21.0.0
Estimator: MATTFiEW yy HOWARD Arrived: 3/11/2013
Ready;
- Customer Information
Vehicle Information
Name: LIU JING&SUSAN Q XU TY Vehicle: 2009 CLASSIC SILVER MET To , Insurance Information
Address: 2157 TEMPLE CT Y Ins Co: AMERICAN FAMILY INS.
SAINT PAUL MN 55104-503� Sh'le: LE 4 DR Sedan
Phone: 952-484-7762 License: 375ARU �ontact:
VIN: JTDBL40E099070660 Phone: 651-483-8271
Mileage: 24633 Claim #: 00345022489-OC
Mileage Out: Deduct: $500.00
� S#Operation Description T �
� i Remo�eiRepiace Tow� Yq� �g o oo��d� Price T� �br '; Adtll� Dept����� Paint Addi�����`
� � $80.00 `/
Remove/Replace Cover,Front Bumper - B
2 Refinish _ AM $181.00 ✓ 1.8 _
Cover,Front Bumper B
3 Remove/Replace Seal,Front Bumper
R 4.1
4 Remove/Install - Nw $z9.08 �
Frame,License Plate B
5 Remove/Replace Fender,Front � � g
RT AM $117.97
6 Refinish __ ✓ 1.9 B
Fender,Front R7
� Remove/Replace Seal,Front Fender R
RT NV1j 32
$ Remove/Re lace $43.18 � -
P Seal,Fender-Cowl RT Nw B
9 Remove/Re lace $11.18 _ � _ _
p Skirt,lnner Fender B
RT NW $95.08 _
10 1 Remove/Replace Wheel,Front � B
RT NW $138.62
11 Remove/Re lace _ $138.62 ✓ p.3 B
P Brkt,Tire Pressure Sns N�j -
RT $7.30 �
12 I M
Remove/Replace Cover,Front Wheel -
RT NW $77.92 `j _
13 B
Remove/Replace Hose,Front Brake
�q RT NW $68.61
Remove/Replace Ball Joint,Lower Arm RT � ✓ 0 4 M
15 NW �$57.13
Remove/Replace Arm,Lower Control R/F � ✓ �$ M
16 Remove/Re lace NW $191.03 ✓ 3.1
�p Absorber,Strut R�F M
�� 1 Remove/Re lace AM ��25 19 `� z �
P Seat,Front Spring R7- M
_�g NW $19.83 $14.48 �/
Remove/Replace Sensor,Anti-Lock Brake M
RT NW $225.63 �
19 M
Remove/Replace Reservoir W/g Washer
20 Remove/Re lace NW $61.60 ✓ 0.3
p Hose,W/S Washer . B
21 NW $19.14 � O-1
Remove/Replace Pump,INasher B
22 NW $54.10 �
Paint Materials B
22 PM $355.20
Repair Pillar,Hinge RT
23 Refinish 0.5 B
Pillar,Hinge RT
24 Remove/Replace MIdg,Rocker Panel R 0.4
RT NW $328.24 �
25 B
Refinish MIdg,Rocker Panel
RT
26 R 1.3
Refinish CORROSION
SS $7.00
25/20�_.1_.��42T3:9=PM= -,-_- _- - ,-_
R. =0� --. - -
Page # 1
Latuff Brothers
r 880 UNIVERSITY AVE. ���
ST. PAUL MN 55104 al Invoice
651-224-Z828
RO #:28295
" � Unit #:TD 21.0.0
Estimator: MATTHEW W Hp�yARD Arrived: 3/11/2013
Customer Information Ready:
Name: LIU JING&SUSAN Q X��, Vehicle Information
Address: 2157 TEMPLE CT
Vehicle. 2009 CLASSIC SILVER MET To � Insurance Information
SAINT PAUL MN 55104-503� S�YIe: LE 4 DR Sedan y Ins Co: AMERICqN FAMILY INS.
Phone: 952-484-7762 License: 375ARU Contact:
VIN: J7DBL40E099070660 Phone: 651-483-gz71
Mileage: 24633 Claim #: 00345022489-OC
Mileage Out: , Deduct: $500.00
26 Repair _
PROTECTION
Pnl,Front Door Outer -
RT _ _ ..
27 0.5 B
Refinish Pnl,Front Door Outer - -
RT _ _
28 Remove/install R 2.1
MIdg,Front Door Belt '
RT
29 0.3 B
Remove/Install Housing,Mirror Outer I
RT
30 _ _ 0.3 B
Remove/Install Handle,Front Door Otr
RT _
31 0.7 B __
Repair -
MOUNT AND BALANCE
TIRE $1.50 _ _ �.3 _
33 g _ _
HAZ. WASTE REMOVAL SL
34 Remove/Replace $5.00 . .
Eagle LS 2 Tire B
195-65-15 AM $120.30 �
35 Remove/Re lace B
P 9098011019 WASH.
PIGTAIL NW I $6.69 _ ✓
36 Remove/Re lace B
P 8299812440 REPAIR
WIRES X2 NW �$13.68 ✓_
37 Repair B
REPAIR CONNECTOR I
38 _
THRUST ANGLE_ i 0.3 _ B
AUGNMENT S� $69.95
3� Remove/Replace B
827113A540 WASH.
CONN. NW $1.32 ✓
40 Remove/Replace B
5361412040 WASH
CONN. NW $3.51 . �
41 Remove/Re lace B
P ABS BODYSIDE
_ PIGTAIL LK $65.00 � _
42 Repair _ B
INSTALL ABS PIGTAIL ` -
44
KT13603 CLIP X1 �3 B
45 SS $7.10 �
KT13602 PUSH PIN X2 SS B
46 $8.86 �
P91116 RETAINER X1 B
47 SS $3.96 �
P24252 RETAINER X9 SS B
48 $28.89 �
P27685 CLIP X3 B
48 1 Remove/Replace RF SS $3.27 � _ _
AXLE NUT NW B
49 1 Remove/Re lace $6.90 $6.90 ,/
P UPPR RCKR CLIP X1 B
Nw $4.91 $4.91 �/
B
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.�3.:1�:42:39 PM -- -:_ —
__ _
Page # 2
Latuff Brothers Final Invoice
880 UNIVERSITY AVE,
� ' ST. PAUL MN 55104 fZ0 #:28295
651-224-2828 Ulllt �#:TD 21.�.�
Arrived: 3/11/2013
Estimator: MATTHEW W HOWARD Ready:
Customer Information Vehicle Information Insurance Information
Name: LIU JING&SUSAN Q XU TY Vehicle: 2009 CLASSIC SILVER MET Toy� Ins Co: AMERICAN FAMILY INS.
Address: 2157 TEMPLE CT Style: LE 4 DR Sedan Contact:
SAINT PAUL MN 55104-503`_ License: 375ARU Phone: 651-483-8271
Phone: 952-484-7762 VIN: JTDBl.40E099070660 Claim #: 00345022489-OC
Mileage: 24633 Deduct: $500.00
Mileage Out:
50 Remove/Replace 7692402020 CLIP X1 NW ✓ B
$1.47 _ _ _
52 1 Remove/Replace 4738950020 LINE Nl�✓ $14.08 $14.08 ✓ B
WASHER
53 WASHER FLUID SS $3.34_ ✓ B
53 TOYOTA OCS RESET SL $75.00 B
F _
54 RESET VSC STAB. SL $75.00 B
CONTROL
�Totals�: �° `� �'�� � �ourS �� ���� Rat�: TotaL• �`
Final (Combined) Totals
Parts - New $1,474.88
Parts - Used/LKQ $65.00
Parts -Aftermarket $544.46
PARTS TOTAL $2,084.34
Body Labor 7.7 $52.00 $400.40
Refinish Labor 11.4 $52.00 $592.80
Mechanical Labor 6.4 $75.00 $480.00
LABOR TOTAL $1,473.20
i
�
Shop Supplies �62.42
Sublet $224.95
Paint Materials $355.20
Towing $80.00 ,
Miscellaneous ; $1.50
-------------------------
Sub Total $4,281.61
SALES TAX (7.625%) $169.26
GRAND TOTAL $4,450.87
Minus Deductible $500.00
3•/�5�2013 1�.4�:3� PM ,_. . .- -_- _. ,_::- -, : Page # 3 —