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Safi ��; ,�; lnstruct�ons far Filinc� Notic� of elaim to City af Saint Paul� �� ;, Minnesota Sta`te Statute 466.05 NOTICE OF CLAIM...(E)veiy person...who claims d� tig�s' r�i municipality...shall cause to be presented to the governing body of the municipality within 180 days a ter the � alleged loss or inju�y is discovered a notice stating the time, place, and circumstances tA�oO��e amount of compensation or other relief demanded. CITY CLERK Please complete tl�is form in its entirety by typing or printing your answer to each question in tl�e space provided. If additional space is needed, please attach additional sheets. PLEASE RETURN THIS Office of City Clerk COMPLETED FORM TO: 170 City Hall 15 W I<eliogg Blvd St Paul MN 55102 Your Name: _T��l,�'� �G� � � -- -- - - — -_---- ------ -___-- -- ---- _ Street Address: __- !�-('� _�, ��-�1_ _�"�-r�- ------ - : City: ��GLC�'1/� �'� � VI�T S State: I/�� (/� Zip Code: ��3 Daytime Telephone: (�S �) ��O �-� �q � � Evening Telephone: ( ► Date of Accident or Incident: 2 13�Day of Weel<: �,�., Time: am or pm (circle one) , Please state, in detail, wl�at occurred and the circumstances surrounding the event. Indicate how the City of Saini Pauf is involved, and why you feel the City is responsible. � Go.,�( �,v f�-s � �.. c-o � C Cc�y w e -� � o�-v� Z t 2 I r. v� c..f e --�- �,.'� �� y u ' - 0 .^ow� - �� -,� �n—sZ- — \ �C T.,'�l\ � " Gwi �-S Gyv, k.¢. , C � ci C7 � . C�-. d�.� �;a.�. �fo � �-� o w �',� c;r.t�t-- • � �z/ia/Zo�3 � Please indicate your reason fo�completing this form: ❑ Vefiicle accident �:-1 Gther property damage (please provide specifics below) .,;�j: �' Vehicle was towed ��;'�I,� �'' Vehicle damaged ❑ Other injury to person (please provide specifics below) . '�i� ��. �,, ❑ Slipped and fell on City property :; ti Please provide the names and telephone numbers of any City employees involved in this ; s incident/accident and how they were involved: � ; `~ -� � O � C� O U �� ; _ , � � � a , '� s y�r (over) . If your vehicle was involved, please complete the follovving: / <� Year, mal:e, and model: �i'SS�,�,. �(N!�_�. �Ov License Plate Number: b Extent and area damaged: � Was a City vehicle involved in this accident/incident? Yes1 No (circle one) If yes, please complete the foilowing: Type of vehicle I��t `j ti.t� �-�'c� �n/�u��T y) Year, make, and model � � Color of vehicie License Plate Number: - Description of vehicle Location of accident/incident (please provide specifics such as street address, intersection, cross streets, park name, facility name, etc.): � i �Z�- C�La-rv�t o� /�c.� S 3�� 5'�/P `� __ __P.lease draw or_a_ttach a_ diagram if ap�lic_able:_ - - ____._______ � �� ' / �� Please specify the nature and extent of tlie compensation or other relief you are requesting. Please attach copies of any bills, receipts, tickets, or other documents to support your claim. If you are claiming damage to a veliicle, please submit two1estimates. �� ( �L G Lj)r�w��C e_- Were there witnesses to this accident/incident? Yes No (circie one) If yes, please give the n mes, addresses, and telephone numbers of the witnesses: � -�- � �-t- Yl ��/�j,.��L� � rnn.� ��c� n � �,f-�/ �€r.l .c Oi� Q h� ��}r 1� f.�fa�� „ r � � �_ , , .. _ (� � \ . i w ' Were the police called? Yes �Jo�(circle one) If yes, what department or agency? � Police report number: � Please print the name of the / person completing this form: � 1 j'°L.,� Please sign your naR�e: ` I Date form signed: � � � ��;;i Risk Mgmt Division - Fievised 1-30-01 ; �q�. ;��y.};:!,: ; a;;j'�. :k,t�l ,� __-- _ __ -------- - Saint Paul Pa)ice Im�ound Lot, �30 Sarqe Channel Road, Vehicle Release Form _,�_ Make: 00 NISSAN Licerse #: 596DK1. CN; 13027s44 lnvoice#: 18550 Date/Time Released: 02i12/20t3 2i;07 Tow Charge: $ 123.95 Released to: TOTO S±orage Charge: $ 15.00 Paid by: CASH Admin Charge: $ 80.00 Released by: ELISE Tax: (7.625°0) $ 15.55 I,the undersigned,have recovered the vehicle describ�� above. Subtotal: $ 234.50 I will check the vehicle for damage er any other probfems that � may have o�curred while this vehicle v��as in the custody�f the Ser�✓ice Charge: $ 0.00 Saint Paul Pnlice Department. I acknowledge I wi11 report damage and/or any other problems to the In?pouno Lot staff Total Charges: $ 234.50 on this form prior to leaving the impound loi. Damage and/or other probiem: _.��____�_c _��,�,�p-vN�� ;�,,�,�� - ti U�� _.E — � �--�5 ��s?t��M„ a c,��n�_o_ lv�� o � �- ��. g�-k � � ��G -c^ � �- o'( (L�� c +�1Z�c�s...r Police Report made: Yes^ Na_.._ IF Yts, CR�_______.____, If t�G, Why? � TO PROTECT YOUR RIG!--(TS REP�;�RT ANY PROB�I�UI�/DAMI�GE. BEFORE �EAVING THE LOT ;' Signature---- ' �.------------------------- 5i2000 �� R ' WALSER COLLISION &GLASS � Workfile ID: d18e7d06 FederalID: 75-3141113 BLOOMINGTON 9001 GRAND AVENUE S., BLOOMINGTON, MN 55420 Phone: (952) 884-8884 FAX: (952) 884-8898 Preliminary Estimate Customer: SAFI, MAHER Written By: Duane Houle Insured: Policy#: Claim#: Type of Loss: Other Date of Loss: Days to Repair: 0 Point of Impact: Owner: Inspection Locatbn: Insurance Company: i SAFI,MAHER WALSER COLLISION&GLASS- CUSTOMER PAY BLOOMINGTON 800 EAST 96TH STREET 9001 GRAND AVENUE S. BLOOMINGTON,MN 55420 BLOOMINGTON, MN 55420 (651)308-1981 Day Repair Facility (952)884-8884 Business �I� VEHICLE ', Year: 2000 Body Style: 4D VAN VIN: 4N2XN11T8YD827325 Mileage In: Make: NISS Engine: 6-3.3L-FI License: 596DKL Mileage Out: ; Model: QUEST SE Production Date: 4/2000 State: MN Vehicle Out: Color: GREEN/GOLD MET'. Int: Condition: Job#: GRAY TRANSMISSION Dual Mirrors Rear Window Wiper Passenger Air Bag Automatic Transmission Privacy Glass Steering Wheel Controls ROOF Overdrive Console/Storage RADIO Luggage/Roof Rack POWER CONVENIENCE AM Radio SEATS Power Steering Air Conditioning FM Radio Cloth Seats i Power Brakes Rear Defogger ' Stereo 3rd Row Seat Power Windows Tilt Wheel Cassette WHEELS Power Locks Cruise Control Search/Seek Aluminum/Alloy Wheels Power Mirrors Intermittent Wipers CD Player PAINT � Heated Mirrors Keyless Entry SAFETY Clear Coat Paint � DECOR Alarm Anti-Lock Brakes(4) Body Side Moldings Dual Air Condition Driver Air Bag 3/27/2013 30:02:45 AM 072704 Page 1 ` Preliminary Estimate Customer: SAFI, MAFiER Vehicle: 2000 NISS QUEST SE 4D VAN 6-3.3L-FI GREEN/GOLD MET. Line Oper Description Part Number Qty Extended Labor Paint Price# 1 FRONT BUMPER 2 * Rpr Bumoer cover(gouge lower � 2.6 center) 3 Add for Ciear Coat 1.0 4 R&I License bracket 0.2 5 GRILLE 6 0/H bumper assy 2.6 7 R&I R&I grille assy Incl. 8 FRONT LAMPS 9 R&I RT Headlamp assy Ind. 10 R&I LT Headlamp assy Incl. il COOLING 12 Repl Undercover 7589876000 1 36.93 0.3 13 # Repl Under cover clips(shop supplies) 1 5.00 14 # Subl HAZARDOUS WASTE REMOVAL 1 3.00 X 15 # Repl FLIX ADDITIVE 1 6.00 X 16 # 17 # PRICES SUBJECT TO VENDOR 1 INV. 18 # "POSSIBLE HIDDEN DAMAGE" 1 SUBTOTALS 50.93 4.6 3.6 NOTES Estimate Notes: POSSIBLE HIDDEN DAMAGES: FRONT BUMPER INTERNALLY UNDERSIDE OF VEHICLE. Prior Damage Notes: f.bumper license frame gouges ESTIMATE TOTALS � i Category Basis Rate Cost� Parts 41.93 Body Labor 4.6 hrs @ $52.00/hr 239.20 Paint Labor 3.6 hrs @ $52.00/hr 187.20 Paint Supplies 3.6 hrs @ $32.00/hr 115.20 Miscellaneous 9.00 Subtotal 592.53 Sales Tax $41.93 @ 7.2750% 3.05 Grand Total 595.58 3/27/2013 10:02:45 AM 072704 Page 2 ' ""@gr�ryAward �'•.esa 2070 Winner �— . `� Workfile ID: f5cbcf10 LEHMAN'S GARAGE, INC. - Federal ID: 410957340 BLOOMINGTON 171 AMERICAN BLVD WEST, BLOOMINGTON, MN 55420 Phone: (952) 888-8700 FAX: (952) 888-7229 Preliminary Estimate 7ob Number: Customer: MAHER SAFI,AHMED Written�y: Kevin Williams Insured: MAHER SAFI,AHMED Policy#: Claim#: Type of Loss: Date of Loss: Days to Repair: 0 Point of Impact: 12 Front Owner: Inspection Locatioh: Insurance Company: MAHER SAFI,AHMED LEHMAN'S GARAGE,INC.- BLOOMINGTON 800 E 96TH ST 171 AMERICAN BLVD WEST BLOOMINGTON,MN 55420 BLOOMINGTON,MN 55420 (651)308-1981 Cell Repair Facility (952)888-8700 Business VEHICLE Year: 2000 Body Style: 4D VAN VIN: 4N2XN11T8YD827325 Mileage In: Make: NISS Engine: 6-3.3L-FI License: 596DKL Mileage Out: Model: QUEST SE Production Date: 4/2000 State: MN Vehicle Out: Color: Int: Condition: Job#: TRANSMISSION Dual Mirrors Rear Window Wiper Passenger Air Bag Automatic Transmission Privacy Glass Steering Wheel Controls ROOF Overdrive Console/Storage RADIO Luggage/Roof Rack POWER CONVENIENCE AM Radio SEATS Power Steering Air Conditioning FM Radio Cloth Seats Power Brakes Rear Defogger ' Stereo 3rd Row Seat Power Windows Tilt Wheel Cassette WHEELS Power Locks Cruise Control Search/Seek Aluminum/Alloy Wheels Power Mirrors Intermittent Wipers CD Player PAINT Ke less Ent SAFETY Clear Coat Paint Heated Mirrors Y rY DECOR Alarm Anti-Lock Brakes(4) Two Tone Paint Body Side Moldings Dual Air Condition Driver Air Bag 3/27/2013 10:23:15 AM 016371 Page 1 AUTO Gl-ASS 95�-�e�omV ►�,,,10"""�s www.lehmansgara9 � I \ Preliminary Estimate Customer: MAHER SAFI,AHMED Job Number: Vehicle: 2000 NISS QUEST SE 4D VAN 6-3.3L-FI Line Oper Description Part Number Qty Extended Labor Paint Price$ 1 # PRELIMINARY ESTIMATE 1 2 FRONT BUMPER _ 3 R&I R&I bumper cover SJ 4 * Rpr Bumper cover �Q 2.6 5 Add for Clear Coat 1.0 6 Add for Two Tone 1.0 7 R&I License bracket 0.2 8 GRILLE _ _ _ 9 R&I R&I grille assy 0.3 _ _. 10 COOLING 11 Repl Undercover 7589876000 1 36.93 0.3 12 # Repl Flex additive 1 5.00 X 13 # Subl Hazardous waste removal 1 5.00 X SUBTOTALS 46.93 3.5 4.6 ESTIMATE TOTALS Category Basis Rate Cost# pa� 36.93 Body Labor 3.5 hrs @ $54.00/hr 189.00 Paint Labor 4.6 hrs @ $54.00/hr 248.40 Paint Supplies 4.6 hrs @ $35.00/hr 161.00 Body Supplies 1.3 hrs @ $1.00/hr 1.30 Miscellaneous 10.00 Subtotal 646.63 Sales Tax $36.93 @ 7.2750% 2.69 Grand Total 649•32 Deductible 0.00 CUSTOMER PAY 0.00 INSURANCE PAY �9•32 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. 3/27/2013 10:23:15 AM 016371 Page 2 - � Preliminary Estimate Customer: MAHER SAFI,AHMED ]ob Number: Vehide: 2000 NISS QUEST SE 4D VAN 6-3.3L-FI Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide AEF3793, 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 (�) 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 Non OEM or A/M. Used parts are described as LKQ, RCY, or USED. Reconditioned parts are described as Recond. Recored parts are described as Recore. NAGS Part Numb�rs 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=6lend. BOR=6oron steel. CAPA=Certified Automotive Parts Association. D&R=Disconnect and Reconnect. HSS=High Strength Steel. HYD=Hydroformed Steel. Inc1.=Inctuded. LKQ=Like Kind and Quality. LT=Left. MAG=Magnesium. Non-Adj.=Non Adjacent. NSF=NSF International Certified Part. 0/H=Os�erhaul. Qty=Quantity. Refn=Refinish. Repl=Reptace. 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=Bureau of Automotive Repair. EPA=Environmental Protection Agency. NHTSA= National Highway Transportation and Safety Administration. PDR=Paintless Dent Repair. VIN=Vehicle Identification Number. 3/27/2013 10:23:15 AM 016371 Page 3 Saint Paul Police Impound Lot, 830 Barge Cha�nel Road, Vehicle Release Form Make: 00 NISSAN License #: 596DKL CN: 13027844 Invoice#: 18550 DatelTime Released: 02/12/2013 21:07 Tow Charge: $ 123.95 Released to: TOTO Storage Charge: $ 15.00 Paid by: CASH Admin Charge: $ 80.00 Released by: ELISE Tax: (7.625%) $ 15.55 I,the undersigned,have recovered the vehicle described above. Subtotal: $ 234.50 I will check the vehicle for damage or any other prablems that may have occurred while this vehicle was in the custody of the Service Charge: $ 0.00 Saint Paul Police Department. I acknowledge I will report damage and/or any other problems to the Impound Lot staff Total Charges: $ 234.50 on this form prior to leaving the impound lot. Damage and/or other probTem: _____________-- --.-- — Police Report made: Yes_No___ IF Yes, CN______ , If NO,Why? TO PROTECT YOUR RIGHTS. REPORT ANY PROBL_EMS/DAMAGE BEFORE LEAVING THE LOT Signature _ __ 5i2000 St. Paul Police Department for Ramsey District Court RECEIPT Date/Time: 02/12/2013 21:07 Invoice #: 18550 I Vehicle Plate: 596DKUMN ' Payor: OWNER Location Paid: Impound Snow Lot Citation: Amount: 888753108 $ 53.00 Totaf Amount Paid: $ 53.00 � Paid by: CASH KEEP THIS COPY FOR YOUR RECORDS