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McIntosh �e��f��c�e��s fc�F� �i(��c��[atEC� o� C[aif�� a ��y o� �a�f�f Pa�� " , ' ll9rnnesota State Statute 466.05 NOTICE OF CLAIM...(E)ve�y person...who claims damages f�om any municipality...shall cause to be presented to the governing body of the municrpality ivithin >80 days after the alleged loss or in�ury is discovered a notice stating the time, place, and circumstances thereof, and the amount of compensation oi other ielief demanded � Please complete tl�is form in its enfirety by typing or printing your ans�Ner to each question in tl�e space provided. If additional space is needed, please attach additional sheets. PLEASE RETURN THIS Office of City Cler{c RECEIVED COMPLETED FORM T0: 170 City Hall APR �0 2013 15 W ICellogg Blvd St Paul MN 55102 C�-�-Y CLERK Your Name: .S G/�C�M C �e�,v l c�S L7 - -Street Address:- - -_��i� -- :s��"�_�u��. _ _ %�� ____. .._----.. . _ ____ - . --- City: _;�/ _P/�-�� State: m n� Zip Code:� � Daytime Tele�hone: _ IG �J� 7 �3 � gG �d, Evening Telephone: � � � l Date of Accident or Incident:v? � �� -/3�Day of Weelc ri-� �� Time: /� am r pm (circ�e one) . , , Please state, in detail, wl�at occurred and the circumstances surrounding the event. Indicate how the City of Saint Paul is involved, and why you feel the City is responsible. L G � �',� �r�� i � � �h`� .�2 -- A-T �-�'S�� Si c��/�1J ,� T�� aL i,.-,-, � �'o�C Sn'�� ,., � L'M cl� Q�-tJ C' �� i. Please indicate your reason for completing this form: � ;; f.=:1 Veliicle accident ' C7 Other property damage {piease provide specifics below) �;�;;j; � Vehicle was towed '�i�:' �Vehicle damaged ❑ Other injury to person (please provide specifics betow) �'��,I� ,�� :,i� ❑ Slipped and fell. on City property ��'� ,�:. � i;,_ i.�� 1 I: ! Please provide the names and telephone numbers of any City employees involved in this ( � •r ,. incident/accident and I�ow tliey were involved: �� P � � i� � � u � � l �- � � 7 -- g ? �3 w� �ss �i : , ! , �h��-1-1 n 6� c�=d Tf/c-' �4 - ; (ove�) I , .- . If your vehicle vvas involved, please complete the follo�Ning; ..7Sh c�G�� Year; mal.e, and model: Q � L.',.,r �,�(� (� �7h-?T��T�"� License Plate Number. Extent and area damaged: �Y+ Was a City vehicle involved in this accident/incident? Yes �� (circle one) If yes, please complete the following: Type of vehicle . Year, mal<e, and model - Color of vehicle License Plate Number: � Description of vel�icle Location of accident/incident (please provide specifics sucl� as street address, intersection, cross streets, park name, facility name; etc.): Gl �/� 5��2 ,B c�lT�7 �4 v�" S% � r.,� / r-�� S S/v � - -._..Plea.s.e_draw. or_attach a di_agram_.if.a.�plical�le;----------- .------. -- - ._------.----.----___ ---- -------...--•---.:------- -- � Please specify the nature and extent of tl�e compensation or other relief you are requesting. Please attach copies of any bills, receipts, tici<ets, or other documents to support your claim. If you are claiming damage to a vei�icle, please submit two estimates. , R cl�/,n � �—� L �2 /� � m!-�C'2 � � t�� Were there witnesses to this accident/incident? Yes No (circle one) If yes, please give the names, addresses, and telephone numbers of the witnesses: Were the police called? Yes No (circie one) If yes, what department or agency? • Police report number: Please print the name of the , ��S�-� S� person completing this form: T�l2.vMC � ��^-� ; � � � Please sign your name: �`� f Date form signed: -3 r l y� �� . 4;:, . Risk Mgmt Division - Revised 1-30-01 �"}{`�'?!:1. t:r:l;�};1't ..+'�,,F.21'',�' Saint Paul Police Impound Lot, 830 Barge Channel Road, Vehicle Release Form Make: 98 LINCOLN License#: 750HCW CN: 13027844 Invoice#: 19256 Date/Time Released: 03/01/2013 13:05 Tow Charge: $ 123.95 Released to: TOTO Storage Charge: $ 270.00 Paid by: CASH Admin Charge: $ 80.00 Released by: MARIANN Tax: (7.625%) $ 15.55 I,the undersigned,have recovered the vehicle described above. Subtotal: $ 489.50 I will check the vehicle for damage or any other problems 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: $ 489.50 on this form prior to leaving the impound lot. Damage and/or other problem: �?c f�k ��/.��=2- L'--O U�2 l��-�"�� Police Report made: Yes_No � IF Yes, CN , If NO, Why? TO PROTECT YOUR RIGHTS REPORT ANY'PROBLEMS/DAMAGE BEFORE LEAVING THE LOT Signature < i�� 1`� �1/�.,�--_ _ 5i2000 �/. (�� W � �� - �7 - �2�3 ��-� � SS � �� . � ABRA Auto Body & Glass - Midway Workfile ID: d4a23bOc FederalID: 41-1852119 Right The First Time...On Time 1190 UNIVERSITY AVE W, SAINT PAUL, MN 55104 Phone: (651) 645-1563 FAX: (651) 641-6129 Preliminary Estimate Customer: MCINIOSH,]EROME )ob Number: Written By:John Rucinski Insured: MCINIOSH,JEROME Policy#: Claim#: * Type of Loss: Date of Loss: 3/4/2013 12:00:00 PM Days to Repair: 2 Point of Impact: 06 Rear Owner: Inspection Location: Insurance Company: MCINIOSH,JEROME ABRA Auto Body&Glass-Midway Unknown Insurance 942 SHERBURNE AVE 1190 UNIVERSITY AVE W ST PAUL, MN 55104 SAINT PAUL, MN 55104 (612)743-8690 Business Repair Facility (651)645-1563 Business VEHICLE Year: 1998 Body Sryle: 4D SED VIN: 1LNFM9NOWY635925 Mileage In: 25 Make: LINC Engine: 8-4.6L-FI License: 750-HCW Mileage Out: Model: CONTINENTAL Production Date: State: MN Vehicle Out: Color: WHITE Int: Condition: Job#: TRANSMISSION DECOR Keyless Entry SEATS Automatic Transmission Body Side Moldings Alarm Leather Seats Overdrive Dual Mirrors RADIO Bucket Seats POWER Console/Storage AM Radio Recline/Lounge Seats Power Steering Overhead Console FM Radio WHEELS Power Brakes CONVENIENCE Stereo Aluminum/Alloy Wheels Power Windows Air Conditioning Cassette PAINT Power Locks Rear Defogger Search/Seek Clear Coat Paint Power Driver Seat Tilt Wheel SAFETIf OTHER Power Passenger Seat Cruise Control Anti-Lock Brakes(4) Traction Control Power Mirrors Intermittent Wipers Driver Air Bag Heated Mirrors Auto Level Passenger Air Bag Power Trunk/Tailgate Climate Control 4 Wheel Disc Brakes 4/2/2013 4:02:27 PM 011906 Page 1 Preliminary Estimate Customer: MCINIOSH,7EROME ]ob Number: Vehicle: 1998 LINC CONTINENTAL 4D SED 8-4.6L-FI WHITE Line Oper Description Part Number Qty Extended Labor Paint Price� 1 REAR BUMPER 2 ** Repl RECOND Bumper cover F80Z17K835AA 1 794.00 1.8 4_Q 3 MISCELLANEOUS OPERATIONS 4 # �Hazardous Waste 1 5.00 X SUBTOTALS 799.00 1.8 0.0 NOTES Prior Damage Notes: 1 ESTIMATE TOTALS Category Basis Rate Cost� Parts 794.00 Body Labor 1.8 hrs @ $54.00/hr 97.20 Miscellaneous 5.00 Subtotal 896.20 Sales Tax $794.00 @ 7.6250% 60.54 Grand Total 956.74 Deductible 0.00 CUSTOMER PAY 0.00 INSURANCE PAY 956.74 THIS IS A VISUAL INSPECTION ONLY. THERE MAY BE ADDITIONAL DAMAGE AFTER DISASSEMBLY. PARTS ARE SUBJECT TO INVOICE. THERE ARE NO GUARANTEES ON RUST REPAIRS. "Minnesota law gives you the right to choose any rental vehicle company, and prohibits me from requiring you to choose a particular vendor." 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. 4/2/2013 4:02:27 PM 011906 Page 2 Preliminary Estimate Customer: MCINIOSH,7EROME 7ob Number: Vehicle: 1998 LINC CONTINENTAL 4D SED 8-4.6L-FI WHITE Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide DE2KA98, CCC Data Date 4/1/2013, 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 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 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 tYom 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.=Included. LKQ=Like Kind and Quality. LT=Left. MAG=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. 4/2/2013 4:02:27 PM 011906 Page 3 Preliminary Estimate Customer: MCINIOSH,7EROME 7ob Number: Vehicle: 1998 LINC CONTINENTAL 4D SED 8-4.6L-FI WHITE ALTERNATE PARTS SUPPLIERS Supplier: Keystone-Complete-Minneapolis Location(s): 3615 MARSHALL STREEf NE, MINNEAPOLIS MN 55418 (800)328-1845 (612)789-1919 Line Description Item# Price 2 RECOND Bumper cover F01100275R $794.00 4/2/2013 4:02:27 PM 011906 Page 4 ' HEPPNERS AUTO BODY SAINT PAUL Workfile ID: c0a74ffd �� 400 SYNDICATE ST. N., SAINT PAUL, MN 55104 , � Phone: (651) 646-8615 FAX: (651) 645-3230 Preliminary Estimate Customer: McINIOSH,.7EROME Job Number: Written By: Marshall Mizuno Insured: McINIOSH,JEROME Policy#: Claim #: Type of Loss: Date of Loss: Days to Repair: 0 Point of Impact: 06 Rear Owner: Inspection Location: Insurance Company: McINIOSH,JEROME HEPPNERS AUTO BODY SAINT PAUL 942 SHERBURN AVE 400 SYNDICATE ST. N. ST PAUL, MN 55104 SAINT PAUL,MN 55104 (612)743-8690 Business Repair Facility (651)646-8615 Day VEHICLE Year: 1998 Body Sryle: 4D SED VIN: 1LNFM97VOWY635925 Mileage In: Make: LINC Engine: 8-4.6L-FI License: Mileage Out: Model: CONTINENTAL Production Date: 11/1997 State: Vehicle Out: Color: WHITE Int: Condition: Job#: � TRANSMISSION DECOR Keyless Entry SEATS Automatic Transmission Body Side Moldings Alarm Leather Seats Overdrive Dual Mirrors RADIO Bucket Seats POWER Console/Storage AM Radio Recline/Lounge Seats Power Steering Overhead Console FM Radio WHEELS Power Brakes CONVENIENCE Stereo Aluminum/Alloy Wheels Power Windows Air Conditioning Cassette PAINT Power Locks Rear Defogger Search/Seek Clear Coat Paint Power Driver Seat Tilt Wheel SAFETI( OTHER Power Passenger Seat Cruise Control Anti-Lock Brakes(4) Traction Control Power Mirrors Intermittent Wipers Driver Air Bag Heated Mirrors Auto Level Passenger Air Bag Power Trunk/Tailgate Climate Control 4 Wheel Disc Brakes 4/2/2013 3:37:32 PM 050503 Page 1 Preliminary Estimate Customer: McINIOSH,7EROME 7ob Number: Vehicle: 1998 LINC CONTINENTAL 4D SED 8-4.6L-FI WHITE Line Oper Description Part Number Qty Extended Labor Paint Price$ 1 REAR BUMPER 2 ** Repl RECOND Bumper cover F80Z17K835AA 1 794.00 1.8 Q.4 SUBTOTALS 794.00 1.8 0.0 ESTIMATE TOTALS Category Basis Rate Cost$ Parts 794.00 Body Labor 1.8 hrs @ $52.00/hr 93.60 Body Supplies 1.8 hrs @ $2.00/hr 3.60 Subtotal 891.20 Sales Tax $794.00 @ 7.6250% 60.54 Grand Total 951.74 Deductible 0.00 CUSTOMER PAY 0.00 INSURANCE PAY 951.74 THIS IS A VISUAL ESTIMATE ONLY. ADDITIONAL PARTS AND LABOR MAY BE EXTRA UPON TEARDOWN. PART PRICES SUBJECT TO INVOICE. NO GUARANTEE ON RUST REPAIR! QUALITY REPLACEMENT PARTS WARRANTY OUR REPAIR ESTIMATE MAY SPECIFY THE USE OF QUALITY REPLACEMENT PARTS. QUALITY REPLACEMENT PARTS ARE PARTS NOT MANUFACTURED BY OR FOR THE ORIGINAL EQUIPMENT MANUFACTURER. WE WILL STAND BEHIND THE QUALITY REPLACEMENT PARTS THAT ARE SPECIFIED ON THIS ESTIMATE AND USED IN THE REPAIR OF YOUR VEHICLE, FOR AS LONG AS YOU OWN/LEASE THE VEHICLE. WE WARRANT THESE PARTS ARE OF LIKE KIND, QUALITY, SAFETY, FIT AND PERFORMANCE TO PARTS MANUFACTURED BY OR FOR THE ORIGINAL EQUIPMENT MANUFACTURER. THIS WARRANTY EXCLUSIVELY COVERS LOSS OR DAMAGE THAT IS RELATED TO DEFECTS IN THE QUALITY REPLACEMENT PART. THIS WARRANTY DOES NOT COVER DAMAGE OR PART FAILURE DUE TO IMPROPER INSTALLATION, MISUSE, NEGLECT, ABUSE, IMPROPER MAINTENANCE, ABNORMAL OPERATION, OR NORMAL WEAR &TEAR. SHOULD A SUPPLIER OF A PART SPECIFIED IN OUR REPAIR ESTIMATE, OR THE REPAIR FACILITY THAT PERFORMS THE REPAIR ON YOUR VEHICLE, BE UNABLE TO RESOLVE A LEGITIMATE COMPLAINT ABOUT THE QUALITY REPLACEMENT PART USED IN THE REPAIR, WE WILL MAKE EVERY EFFORT TO SEE THAT THE PROBLEM IS CORRECTED. THIS WARRANTY AND ANY REPRESENTATIONS MADE HEREIN ARE NON-TRANSFERABLE AND EXTEND ONLY TO THE PARTY OWNING/LEASING THE VEHICLE AT THE TIME OF THE REPAIR. FOR ASSISTANCE, PLEASE CONTACT THE NEAREST HELPPOINT CLAIM SERVICES OFFICE. 4/2/2013 3:37:32 PM 050503 Page 2 Preliminary Estimate Customer: McINIOSH,7EROME )ob Number: Vehicle: 1998 LINC CONTINENTAL 4D SED 8-4.6L-FI WHITE DISCLAIMER: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT INSURANCE CLAIM FOR THE PAYMENT OF A LOSS MAY BE GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN STATE PRISON. THE LABOR AND TAX RATES USED WERE DETERMINED BY THE VEHICLE INSPECTION LOCATION UNLESS THE REPAIR FACILITY WAS KNOWN AT THE TIME OF THE INSPECTION OR ANOTHER LOCATION WAS SPECIFIED BEFORE THE ESTIMATE WAS PREPARED 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. Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide DE2KA98, 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 refllect 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 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. 5=5tructural 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. 4/2/2013 3:37:32 PM 050503 Page 3 Preliminary Estimate Customer: McINIOSH,7EROME Job Number: Vehicle: 1998 LINC CONTINENTAL 4D SED 8-4.6L-FI WHITE 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. 4/2/2013 3:37:32 PM 050503 Page 4 ALTERNATE PARTS SUPPLIERS Supplier: Keystone-Complete-Minneapolis Location(s): 3615 MARSHALL STREEf NE,MINNEAPOLIS MN 55418 (800)328-1845 (612)789-1919 Line Description Item# Price 2 RECOND Bumper cover F01100275R $794.00 4/2/2013 3:37:32 PM 050503 Page 5 Preliminary Estimate Customer: McINIOSH,7EROME 7ob Number: Vehicle: 1998 LINC CONTINENTAL 4D SED 8-4.6L-FI WHITE