Wilkinson Microsoft Word - Claim form 2.11.doc - 15774 http://wwv�jxa�Gl�jev�DocumentCenter/Home/View/...
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NUTICE OF CLAIM FURM to the City of Saint Paul, Minnesota
:Yli�uzesorer Sarte Sra�ure-156.05 sxrt�s rhar "...e��er�•person...���Iro claiins•danrctges{ronr ur.}�mu�rieiFxrli���...shcrll cause 10 be pre.senre�!ta tlre
,Sorerr.in,�t�a���of�Ire rnu�ririfxrlir�'�rirhitt/50 da��3 cr(}er rhe alleged lns.e or i��jurt is disco��rrecl u n.otrre stnriu�the rirne.place,und
cir�•urn.rtcrnces tlte�•�of,ur.d lhe nrnotnri nf cotttpen.salia:nr uthcr refie(denrauded...
Please cornplete this forrn in its enti ret,y b}•clearly t��itig or�rintin��oin•answer to each yuestion. If more space is
necYled,attach aclditional sheets. Plea�e note that�ou will not he contactecl b��tc�ephone to clarif��ans��•en.so prc»ide as
rnuch ii�t��rn�ation as necessar��to e.y�l.iin your clairn.and the arnount of ccxnpensation bein�requesteci. You w�ll recei��e a
�vritten ackno«•led�ernent onc�your forrn is received. The process can t�ke u��to ten rveeks or lon�er ciepcndin!;�n the
nature of��our ctairn. This for�n rnust be si�neci,and both E�a�es completed. If so�nething ck�es ncH appl��,«�rite °N/�1'.
SEND CONTPLETED FORM AND OTHER DOCL1n�1ENTS TO: CIT�' CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT P�4UL, IVIN 55102
Fi►�t N�u»e�_ l��liddle Initial � La�t N�in;�� �����nr-�
C'un]pan� c�r Bu�ine;:NttmC - -- �
Are You an In;ur,,nce Company'? Yes No If Yes,Cl�iim Nutttber?
s<<��.�� ..��,�i���.,; 1 r.. ve CITY ��.._��K
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c���� �. �c��ce �n1 z��c���� �SI ��
U�ivtirne Phone 1�5�)�10 -��Cetl Phone 1�) 10-��Evenin� Teleph��ne�s�- _;aa _ a.�t�
f)��Ce �,f Accid�nt/ Injury� ori�ate T)i�c;overed �C(�f�� �(�,. ��Tim� � �V am pm
/
Please :t�ite. in detail. �vhat occurred (happened), and���hy you are auhmit[ing a claim. Plea� indicate���hy or h�,« ve�u
tc��l th�:City uf Saint �'��ul r it�e_nip<,y s�u•c inval�'ed �nd/ r re.�p� tsib��: (� r�'c�ur da�t���g� _
f 1,�,� S � e U
�
•�
J � �r �� e
P(eau:check the box(es) that nx�,t clo�:l� repre�nt the n:a�on for completin�*thi;form:
0 1�9y �rhicle. �va: dama��ed in �in accident ❑ My vehicle �vas d�ima«ed ilurin�<i to«
❑ l��fiv ��e_hi�le���a, dan�a�;ed by zl pothule c,r�cc,ndition c�f the str•zet � h�1v �•��.hicle ���a: d��m<»eil l,� �, �lc•�;,
❑ h1v vehicle w,��s wrongfiully to���e� arid/or tickete I��as i�1jt red �t it}�,pro.erty� ,
,�the�r ty�pe of prope�ty damage—plea� specify �
� Ckh�r rype of injut�r— plea�e �pecify_ z_
In orcler to process your claim you n�eed to inclucle copies of all applicable dacuments.
Fur the cl.iims type� li5t�d bel�«�, pleuse be ;ure tu include the document� indi�ate.d or it w ill delay the hund(il���uf
vour•claim. DacuinenC:�W ILL N�T be returned anti b�eonx the prc;perCy of�th�Gity. You ace encour�,�ed to kee����
copy t���r your.:zlf bafore submitting ��our clairn for���.
O Prupe�ty dank�ee claims to:� vehicle: t�vo e�timate�fur thc repaii�to your vehicle if tf�e dama�e ex�ee�ti
�;>00.00; or th��ctual bill;��ndlc�a•t•ecei��ts for•the re�pair� �
O T'���ing claiins: legiEi(e eupies of any ticket i�uied �inJ u cu�y ot�che impound !ot ��eceipt
O Qther propenc �luma�e claims: t���o repair estimates if the damage excee���i>Ot�.(l(l; or the �ictual bills
�ind/or rece.ipts for thr� ce�ai��: dex�iiled li,t ot damag�:d item.
O Injury claim�: medical bills, receipts
O Photographs are al���uys�velcome to da:un�ent and suppu�t your claim l�ut w�ill not be returnecl.
Page 1 af 2—Please comp�ete and r�turn both pages of Claim Form
1 of 2 4/1/2013 10:07 AM
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Microsoft Word - Claim form 2.11.doc - 15774 http://www.stpaul.gov/DocumentCenter/Home/View/...
FaU�ire to complete and ret�irn both pages will result in clelay In the handling of��our claim.
All C'Ialms-please complete this section
�'4'ere there �vitne.:e�tu the incident'? Ye, No Unknc��{�n fcircle)
pr��•ide Cheir names, �icldre;ses and telephone n�ar7�ers:
�'�`ere the pc?lice or la�v enforcen�:nt c.illed�? Ye� No Unknown (�i►�:le)
lf}�e., what depu�tn�ent or a�enc}''.' Ca:e#or repoi-t #
�'�'here di�l the accident or injury take pl�x.e`? Provide street addre:s,cr�s� �treet, intenection, name c�f��ark or facility,
clo:ect landmark, ete. Ple�ise be�is detail�d a: pc�ssible. If nece„�iry�, att��ch a diaarani.
.(��,,� C�'�i(�
Ple�i�e indicate the ayc�unt you are,eehin� � co► n�atio� or p�+hat you ���ould Iihes,F�fe C'ity to da to�e:otve this claim
tc,your��ditir��,ction. ( �/�(��, 73 - �/ 7 �f� �1' �7.�(`c.� .� %c:�%� , :
� 1 �( ��r`f
�'ehicle Claims- leas� com lete this sectio ❑�heck b�x ifthis section does not a I
Your Vehiele: Year ` 6 Make 1�2odel
Lice��se Plate Number � State Color
Re�istered O«�ner
Driver c�f Vehicl�
Area Dank��;ed
C'it� Vehicle: Year � Make Moclel
L,irense Platt Numher State. Golor
Drivet-of Vehicle tCity E7iiployee'sName)
Area Dam<���zd
[n.iur�� Clalms-please complet�thls sectiun check box if this;c�tion do�� not a�l�-
H��« �vere you injured?
`'4'h��t partl�) of��our bc�dy �vere injure.d'?
i
— I
He�v� �ou sou��ht o�edical treatment'? Yes No Pl��nning t� Seeh Treatme.nt (ci�r�leJ '
1��'hc:n ilid you receive treat►nent? (pro��ide datet�l) I
Name of htedical Pro��iderl�): � ^ �
,lcldre:s Telephone_ li
C}icl �ou mi»���ork as a re;ult of your injury'? Ye> No ���
1'�'hen did }�c���� mic; u�orl:'' (pruvicic c�atc(:1)
Na►ne of your Emplo_yer•:_ _ �
�ddre.s Telephone _
p'Gheck here if you are attaching more�ages to tl�is claim form. N��ml�er of additional pages 5^
Rp sigiling this form, you are stctti�tg that all in for►natio�i yor� have provi�led is true and correct to t/re best
of yotrr krtox�ledgc�. G'�tsign�tl fornts wil/�rot he processed.
Suhmittin�rr f'rtlse clain� cafr result i�r prosecrrtion. Date form ���as completed �-�1 - ��
�'rint the Name of tlte Person«�ho Completed this Form: �� � � �,(�� ���y�, �d1
Signature afPerson 1�laking the Claim: ��
12c�isc�l Frhr�c�rv?O1 I
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MASTER COLLISION ROSEVILLE Workfile ID: 309d12d1
FederalID: 431916060
2325 N0. PRIOR AVENUE, ROSEVILLE, MN 55113
Phone: (651) 604-2929
FAX: (651) 604-2932
Preliminary Estimate
Customer: WILKINSON,JILL 7ob Number:
Written By: Husein Hassan
Insured: WILIQNSON,JILL Policy#: Claim#:
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact:
Owner: Inspection Location: Insurance Company:
WILIQNSON,JILL MASTER COLLISION ROSEVILLE UNKNOWN
1019 FREMONT AVE 2325 N0. PRIOR AVENUE
ST PAUL,MN 55106 ROSEVILLE,MN 55113
(651)288-9214 Business Repair Facility
(651)210-2546 Cell (651)604-2929 Brsiness
VEHICLE
Year: 2001 Body Style: 4D SED VIN: 1G6KD54YX1U139771 Mileage In: 246310
Make: CADI Engine: 8-4.6L-FI License: N/A Mileage Out:
Model: DEVILLE Produdion Date: State: MN Vehicie Out:
Color: PEARI WHTfE Int: Condition: Job#:
TRANSMISSION DECOR Alarm Passenger Air Bag
Automatic Transmission Dual Mirrors Steering Wheel Controls Front Side Impact Air Bags '
Overdrive Console/Storage Message Center 4 Wheel Disc Brakes �
POWER CONVENIENCE RADIO Communications System
Power Steering Air Conditioning AM Radio SEA7'S
Power Brakes Rear Defogger ; FM Radio Cloth Seats
Power Windows Tilt Wheel Stereo WHEELS
Power Locks Cruise Control Cassette Aluminum/Alloy Wheels
Po�ver Driver Seat Intermittent Wipers Search/Seek PAINT
Power Passenger Seat Auto Level CD Player Three Stage Paint
Power Mirrors Climate Control SAFETY OTHER
Heated Mirrors Elec.Instrumentation Anti-Lock Brakes(4) Traction Control
Power Trunk/Tailgate Keyless Entry Driver Air Bag
4/12/2013 2:13:40 PM 071463 Page 1
PDF created with pdfFactory trial version www.qdffactory.com
Preliminary Estimate
Customer: WILKINSON,)ILL Job Number:
Vehicle: 2001 CADI DEVILLE 4D SED 8-4.6L-FI PEARL WHITE
Line Oper Description Part Number Qty Extended Labor Paint
Price#
1 REAR BUMPER
2 O/H bumper assy 2.2
3 * Repl Bumper cover Deville 19151517 1 537.40 Incl. 2.6
4 Add for Three Stage 1.8
5 # Repl MISC CLIPS&FASTENERS 1 8.95 T
6 # FLIX ADDITNE '� 1 6.00 X
7 # HAZARDOUS WASTE REMOVAL i 1 3.00 X
SUBTOTALS 555.35 2.2 4.4
ESTIMATE TdTALS
Category Basis Rate Cost;
Parts 537.40
Body Labor � 2.2 hrs @ $55.00/hr 121.00
Paint Labor 4.4 hrs @ $55.00/hr 242.00
Paint Supplies 4.4 hrs @ $35.00/hr 154.00
Miscellaneous 17.95
Subtotal 1,072.35
Sales Tax $546.35 @ 7.1250% 38.93
Grand ToWI 1,311.28
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 1,111.28
***NO GUARANTEE ON RUST REPAIRS***
WARRANTY ONLY VALID WITH ORIGINAL PAPER WORK AND WARRANTY CERTIFICATE
PART PRICES SUBJECT TO INVOICE FROM DEALER '''
REPAIR TIMES ARE ESTIMATED AND DO NOT NECES�ARILY DICTATE ACTUAL REPAIR TIMES NEEDED
MASTER COLLISION GROUP DOES NOT ACCEPT PERSONAL CHECKS OVER$1000.00
A PERSON WHO SUBMITS AN APPLICATI�N OR FILES A CLAIM WITH INTENT TO DEFRAUD OR HELPS COMMIT A �
FRAUD AGAINST AN INSURER IS GUILTY OF A CRIME ,
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.
4/12/2013 2:13:40 PM 071463 Page 2
PDF created with pdfFactory trial version www.pdffactory.com
04/17/2013 14:33 8512210919 LISA Page 2/4
R�ERING AUTOBODY Wo�file ID: a870d058
Federai ID: 411827490
90 N. DALE ST., SAINT PAUL, MN 55102
Phone: (651) 221-0919
FAX: (651) 221-1946
Preliminary Estimate
Customer:WILIQNSSON,7ILL Job Number:
Wntten By: Lisa Roering i
Insured: WILKINSSON,JILL Policy#: Claim#:
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact:
Owner: Inspection Location: Insurance Company:
WILKINSSON,JILL ROERING AUTOBODY
1019 FREMONT AVE 90 N. DALE ST.
ST PAUL, MN 55106 SAINT PAUL,hiN 55102
(651)288-9214 Day Repair Facility
(651)210-2546 Cell (651)221-0919 Day
VEHICLE
Year: 2001 Body Style: 4D SED VIN: iG6KD54YX1U139771 Mileage In:
Make: CADI Engine: 8-4.6L-FI License: Mileage Out:
Model: DEVILLE Production Date: State: Vehicle Out:
Color: P WHITE Int: Condidon: Job#:
TRANSMISSION DECOR Alarm Passenger Air Bag
Automatic Transmission Dual Mirrors Steering Wheel Controls Front Side Impact Air Bags
Overdrive Console/Storage Message Center 41Nheel Disc Brakes
POWER CONVENIENCE RADIO Communications System
Power Steering Air Conditioning AM Radio SEATS
Power Brakes Rear Defogger FM Radio Cloth Seats
Power Windows Tilt Wheel Stereo WHEELS
Power Locks Cruise Control Cassette Aluminum/Alloy Wheels �
Power Driver Seat Intermittent Wipers Search/Seek PAINT
Power Pass�nger Seat Auto Level CD Player Three Stage Paint
Power Mirrors Climate Control SAFET1f OTHER
Heated Mirrors Elec.Instrumentation Anti-Lock Brakes(4) Traction Control
Power Trunk/Tailgate Keyless Endy Driver Air Bag
4/17/2013 2:32:05 PM 076657 Page 1
04/17/2013 14:33 6512210919 LISA Page 3/4
Preliminary Estimate
Customer:WILKINSSON,7ILL 7ob Number:
Vehicle:2001 CADI DEVILLE 4D SED 8-4.6L-FI P WHITE
Line Oper Description F1art Number Qty Extended Labor Paint
Price;
1 REAR BUMPER
2 O/H bumper assy Z,2
3 Repl Bumper cover Deville,w/o 19151517 1 537.40 Incl. 2.6
backup alarm w/o body colored
cover �
4 Add for Three Stage l.g
5 # Repl Flex additive 1 0.3
6 # Color tint/color match 1 0.5
7 # Subl Hazardous waste removal 1 5.00 X
SUBTOTALS 542.40 2.2 5.2
ESTIMATE TOTALS
Cateyory Basis Rate Cost$
Parts 537.40
Body Labor 2.2 hrs (c� $55.00/hr 121.00
Paint Labor 5.2 hrs (� $55.00/hr 286.00
Paint Supplies 5.2 hrs (c� $32.00/hr 166.40
Miscellaneous 5.00
Subtotal 1,115.80
Sales Tax $537.40 Cc� 7.6250% 40.98
Grand Total 1,156.78
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 1,156.78
Roering Auto Body,takes great care to ensure that every repair meets your satisfaction.
The labor perFormed by Roering Auto Body is guaranteed against any defect in workmanship for as long as you own
your car. '
Roering Auto Body guarantees that for as long as you own your vehicle, Roering will, at its expense, correct or repair
all defects which are attributable to defective or faulty workmanship in the repairs stated on the repair invoice, unless
caused by or damaged resuRing from unreasonable use, improper maintenance or care of vehicle, and rust and/or
corrision.
This guarantee covers labor only and does not apply to parts, materals or equipment which may be covered by
manfacturer's warranty.
MN ST 60A.955 -A PERSON WHO FILES A CLAIM WITH INTENT TO DEFRAUD OR HELPS COMMrf A FRAUD
AGAINST AN INSURER IS GUILTY OF A CRIME.
4/17/2013 2:32:05 PM 076657 Page 2