Zamskaya � ' �=��..,��U '
� APR 0� 2013
NOTICE OF CLAIM FORM to the City of Saint P�1�'GI��a
Minnesotn S�nle Statnte 466.05 st�les thnt " ...eve�y person...wl{o c/nims damages fron�any rnunicipaliry...shal/cause to be presented to the
gover•ning body of the rni�nicipnlity ivithin l80 days after the a!legecf loss or injuiy is discovered a notice stati��g the time,p(ace,and
circ�unstances t/aereof, anc/die amou��t of con�pensation a�other relief cfernandecl."
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 Il ������� �.��1r����-�
� � Middle Initial Last Name
v
Company or Business Name, if applicable
Street Address ��� ���IG�1l/1G)' C�/�-�
nJ /� ? �/�, �
City �I�I' • ✓'��F State ��/ ' Zip Code`S�� ���
Daytime Telephone (���) 3�l .� ���7 Evening Telephone( ) �������
Date of Accident/ Injury or Date Discovered d � 3 �� Time am/pm (circle)
Please state, in detail, what occurred, and why yo�u are submitting a claim. Please indicate why or how you
feel th� ity of Saint Paul or its em loyees are in�olved and/or res onsible.
�/l� !�/ I � r� ,Y' % 9�%�'C� G�/'�-/Q-/ /�''�G/ L /�'/i����'7
G> �(�/l� 1/ �1 �
Please check the box(es) that most closely represent the reason for co pleting 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
In order to process your claim vou need to include copies of all anplicable 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.
O 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
O 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 �f Claim Form, City 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 numbe . __
Were the police or law enforcement called? Yes No Unknown (circle
If es, what de artment or agency? � s !� � Case#or ort,#� /� 0�� —�✓
Y p c G2 �� �� n`�1� Gu ��������
Where did the accident or injury take place? Provide st�e�dress, cross street, mtersection, na e o par
or facility, closest landinark, 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 what you would like the City
to do to resolve this claim to your satisfaction.�� ��
Vehicle Claims— lea e com lete this section ❑ check box if this sec ion does not a 1
Your Vehicle: Year 9 Make Model �'�� � m-�—
License Plate Number �-9� /� T State Color �Gf,A�( u-�
Registered Owner �/� � ����
Driver of Vehicle
Area Damaged �YI i /20��/� �s .-S"�> ��
City Vehicle: Year��� Make Model i S'.I'� �
License Plate Number State Color
Driver of Vehicle (City Employee's Name)
; Area Damaged
Iniurv Claims please 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))
i Name of Medical Provider(s):
Address Telephone
Did you miss work as a result of your injury? Yes No
When did you iniss work? (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
B��signing this for�n,you are staling that all inforuiation you have provided is true und correct to thc best of your knowledge. Unsigned
.fa�nrs wi/l not be processed. Subn:itti►ig a false c/aim can result in prosecution. L9�,f'v' �/I�1/GJ �_��7�/� L��
Print the Name of the Person who Completed this Form: ��
Signature of Person Making the Claim:
Date form was completed � ��3��-3 Reviscd Aprii 2007
HIGHLAND AUTOSTAR COLLISION CENTER
2042 WEST 7TH ST.
ST. PAUL, MN 55116
OFFICE: 651-699-0340 FAX: 651-699-4953
FED TAX ID#41-1828627
*`*PRELIMINARY ESTIMATE*"'
04/01/2013 01:44 PM
Owner
Owner: MILA ZAMSKAYA
Address: 1110 EDMUND AVE Work/Day: (651)329-6957
City State Zip: Saint Paul, MN 55104 FAX:
RF��
Inspection
Inspection Date: 04/01/2013 01:44 PM Inspection Type:
Primary Impact: Left Side Secondary Impact:
Appraiser Name: JOHN RITTER_JR Appraiser License# :
Address: 2042 W7TH ST Work/Day: (651)699-0340
FAX: (651)699-4953
City State Zip: Saint Paul, MN 55116 FAX:
Email: JOHNJRQHIGHLANDAUTOSTAR.COM
Repairer
Repairer: HIGHLAND AUTOSTAR Contact:
COLLISION
Address: 2042 7TH ST W Work/Day: (651)699-0340
City State Zip: ST PAUL, MN 551 1 6-31 07 FAX: (651)699-4953
Email: HA2042@POPP.NET
Vehicle
2009 Nissan Altima 2.5 4 DR Sedan
4cyl Gasoline 2.5
Continuously Variable Tr
Lic.Plate: 729 BWT Lic State: MN
Lic Expire: VIN: 1 N4AL21 E69N553789
Veh Insp#: Mileage Type: Actual
Condition: Code: Z1873A
Ext.Color: BLUE , Int.Color:
Ext. Refinish: Two-Stage Int. Refinish: Two-Stage
Options
Air Conditioning Alarm System Anti-Lock Brakes
Bodyside Moldings Bucket Seats Cargo/Trunk Mat
Center Console Cruise Control Dual Airbags
Floor Mats Halogen Headlights Head Airbags
Intermittent Wipers Keyless Access System Keyless Entry System
Overhead Console Power Brakes Power poor Locks
Power Mirrors Power Steering Power Windows
Rear Window Defroster Rem Trunk-UGate Release Side Airbags
Split Folding Rear Seat Tachometer Theft Deterrent System
04/01/2073 01:44 PM Page 7 of 3
2009 Nissan Altima 2.5 4 DR Sedan
Claim#: 04/01l2013 01:44 PM
7ilt&Telescopic Steer Tinted Glass Trip Computer
Velour/Cloth Seats
Damages
Line Op Guide MC Description MFR.Part No. Price ADJ% B% Hours R
Front Doors
1 E 275 Housing,Mirror Outer LT 96302JA04A $224.45 1.2 SM
1 Items
Estimate Total & Entries
1
Gross Parts $224.45
Parts& Material Total $224.45
Tax On Parts Only Q 7.625% $17.11
Labor Rate Replace Repair Hrs Total Hrs
H rs
Sheet Metal(SM) $56.00 1.2 1.2 $67.20
Mech/Elec(ME) $90.00
Frame(FR) $80.00
Refinish(RF) $56.00
Paint Materials $35.00
Labor Total 1.2 Hours $67.20
Gross Total $308.76
Net Total $308.76
Alternate Parts Y/00/00/00/00/00 CUM 00/00/00/00/00 Zip Code: 55116 Default
Recycled Parts NOT REQUESTED
Audatex Estimating 6.0.925 ES 04/01/2013 01:44 PM REL 6.0.925 DT 03/01/2013 DB 03M5/2013
Copyright(C)2011 Audatex North America, Inc.
YOU ARE AUTHORIZED TO MAKE THE ABOVE REPAIRS. I UNDERSTAND THAT PAYMENT IN FU�L WILL BE DUE UPON RELEASE
OF
THE VEHICLE. PARTS PRICES ARE SUBJECTO TO INVOICE. I GRANT PERMISSION TO OPERATE MY VEHICLE FOR THE PURPOSE
OF
TESTING/INSPECTION. HIGHLAND AUTOSTAR IS NOT RESPONSBILE FOR LOSS OR DAMAGE TO THE VEHICLE OR ITS
CONTENTSIN
CASE OF FIRE, THEFT OR ANY CAUSE BEYOND YOUR CONTROL. AUTHORIZED
gy: DATE:
THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF ONE OR MORE CRASH PARTS
SUPPLIED BY A SOURCE OTHER THAN THE MANUFACTURER OF YOUR MOTOR VEHICLE.
WARRANTIES APPLICABLE TO THESE REPLACEMENT PARTS ARE PROVIDED BY THE PARTS
MANUFACTURER OR DISTRIBUTOR RATHER THAN BY THE MANUFACTURER OF YOUR VEHICLE.
Page 2 of 3
04/01/2013 01:44 PM
2009 Nissan Altima 2.5 4 DR Sedan
Claim#: 04/01/2013 01:44 PM
A PERSON WHO FILES A CLAIM WITH INTENT TO DEFRAUD OR HELPS COMMIT A FRAUD
AGAINST AN INSURER IS GUILTY OF A CRIME.
Op Codes
' = 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 disclosed 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
�' �t ����e� Audatex's prior written consent.
4(
_,w��E,a �s� r:u;vv
Copyright(C)2011 Audatex North America, Inc.
Audatex Estimating is a trademark of Audatex North America, Inc.
Page 3 of 3
04/01/2013 01:4a PM
0
0
0
N
� �
L
O � f-'
W �
cn N J
(� � W �/�
N .
`n �°n o �°n. F-=-
Q) � a? o o �
fY o N o o � � p °� S Z
� C � � � N N �
() y� Efl 69 69 E!3 Efl d9 Q
.� � J
? � ^ � � W
� � � � �
� � � ° � � � �
� � -� � N t � j, �
� � U � � .. U L � w
U V �u u� V � m
� M U � � O V W
� � E X � � � �
� o � v� Q � cn v� f°- � Z �
� M � � o
�
ca ai �. a�
U Z � � � c�a �
U � � o .� N � W
� -a � >, o �, �
� j :-_"-� � � O �J O
> y O U - � ~ a.
a 3 �
M rn � , � � �? � oa � U Z
00 ti � � c '
U p . U � p � N Q
� y � � �i > (6 � 3 � � LL �
0 3 p +-' C �
1 C p _._- � �, � C p � a
� U � � � U U � a I W
� J 'D p�.0 � � E �
� `� °� �° °� — °� a� Z c�
Q � I
c� > cv N c � " � 2
SS o -os � o. rn �
� N � � � � N > � N Q'
� _
}
� L @ � �
U -v Q >- c'a .� 3 a°�i ° � a`' ai �
� .� -a >. o r
-- � O U � � � � � � � o c�o �
O Z cc � � Q � > � � � o � �
Q. � a°�i H �p � °' .��. � d � °- � o U
� c� � o � � � �c � � � � � FW- � �
a Z � � � � � a�i > ma� ° � � 0 �
N c .c co Q. v� � �
� � � a�i -� � a� U �� � � � � a �
� � 0 � a�. � y 3 E in � o � a � �