Postier • . . , ,i'
� �r�str��ctians for Fi(inc� Notice of Claim to City af Saint Paul� � � ;�
Minhesota State Statu�e 466.05 NOTICE OF CLAIM...(Elvery person...who claims damages from any f � I
municipality...sha/l cause to be presenred to the goveming body of t f �ty hin 180 days after the � �
alleged loss or injury is discovered a notice stating the time, place, a��b���ll�e�eof, and the amount of
compensation or other ielief demanded MAY 0 I
1 2D13
1'lease compiete this form in its entirety by typing or pri�'E;r1gYy�� r to each question in
the space provided. If additional space is needed, please at ach'�ditional sheets.
PLEASE RETURN THIS Office of City Clerk
COMPLETED FORM TO: 170 City Hall
15 W i<eilogg Blvd
St Paui MN 55102 ,
Your Name: ����`������� ,�����
- �----- -_ -- _ _ � _
_Street Rddress: � _ __ __ __ ___
_ _ _ _ --. _ _.--
`�T �.
City: � p1U1,1 , State: �� Zi� Code: ��
Daytime Telephone: {1�I�1 ,�� I- � O�� �
� Evening Telephone: _j � ) ( I
Date of Accident or Incident: J4��►� Da of Weelc `
y ��� Time: �� am o pr� (circle one) ,
�_i
Please state, in detail, wl�at occurred and the circumstances surrounding the event. Indicate how the
ity of Saint Paul is involv d, and why you feel the City is responsible.
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l,,..sP i. a.e yc i� �nr fcr :.cr�pl.,#ing �hi� forrr:
f-.1 Veiiicle ar.cident �.J Other property damage (please provide specifics below) ;';;�I;
�.;�.� ;
❑ Vehicle was towed `��
�,��,
�, Vehicle ciamaged 0 Other injury to person (please provide specifics below) ,,��4
;;
❑ Slipped and f�ll on City property �''i' `
'�i'�
Please provide the names and telephone numbers of any City employees involved in this � '
in ident/accident and how they were involved: ' ;
,
! i
(over)
II If your vehicle was involve please co plete the foilowing:
Year, mai<e, and model: � � � icense Plate Number:
Extent and area damaged: �- �
- - ;
� Was a City vehicle involved in this accident/incident? Yes N� (circle one)
If yes, please compiete the following: Type of vehicle
Year, make, and model ,
� Color of vehicle 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.):
� � _ _ ,
: __ Please_dra_w or attach a _d_ia�ram_ if applicable:
Please specify the nature and extent of the compensation or other relief you are requesting. Please
attach copies of any bills, receipts, ticl<ets, or other documents to support your claim. If you are
claiming dama to a v I�icle, ple e b it two estimat s.
,, �.
�
Were th e witnesses to this accident!i:-�cident? Ye ��o (circle one)
If yes, please give the names, addresses, nd t ephone numbers of the witnes s:
, �
Were the police called? Yes No (circle one) If yes, what department or agency? •
Police report number: -
Please print the name of the
person completinc� this form: ��rjS� P���Q,�
Please sign your name: � � � �I�� '�
f
Date form signed:
� II_�� �:
;:.
Risk Mgmt Division - Revised 1-30-01 ' �1,�:�
�t� �F1
'�.�tF�i)!�:
� a -R��1� �:
. GREGG'$ AUTO BODY Wor�le ID: a9a674a2
' FederalID: 411353442
HONEST AND CONSISTENT QUALTTY
581 E. 7th Street, St. Paul, MN 55130
Phone: (651) 774-8211
FAX: (651) 774-0174
Prelimirlary Estimate
Customer: POSTIER, MARISHA
Written By: Gregg Rosenberger
Insured: POSTIER, MARISHA Policy#: Claim #:
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact: 06 Rear
Owner: Inspection Location: Insurance Company:
POSTIER, MARISHA GREGG'S AUTO BODY
1509 RANDOLPH AVE#4 581 E. 7th Street I ,�
ST PAUL, MN 55105 St. Paul, MN 55130 ''
(612)247-5869 Cell Repair Facility
(651)774-8211 Business
�EHICLE
Year: 2005 Body Style: 4D H/B , VIN: 9BWGR61J454005853 Mileage In:
Make: VW Engine: 4-1.9L-TD License: Mileage Out:
Model: GOLF GLS TDI Production Date: State: Vehicle Out:
Color: SILVER Int: Condition: Good Job#:
� TRANSMISSION Dual Mirrors AM Radio 4 Wheel Disc Brakes
5 Speed Transmission CONVENIENCE FM Radio ROOF
Overdrive Air Conditioning Stereo Electric Glass Sunroof
POWER Rear Defogger ' Cassette SEATS
Power Steering Tilt Wheel I Search/Seek Cloth Seats
Power Brakes Cruise Control CD Player Bucket Seats
Power Windows Telescopic Wheel f SAFETY WHEELS
Power Locks Intermittent Wipers Anti-Lock Brakes(4) Aluminum/Alloy Wheels
Power Mirrors Keyless Entry � Driver Air Bag PAINT
Heated Mirrors Rear Windqyv Wiper Passenger Air Bag Clear Coat Paint
DECOR Alarm ` Head/Curtain Air Bags
Body Side Moldings RAD�O Front Side Impact Air Bags
�
4/25/2013 12:13:51 PM 034178 Page 1
, Prelimi�ary Estimate
Customer: POSTIER, MARISHA
Vehicle: 2005 VW GOLF GLS TDI 4D H/B 4-1.9L-TD SILVER
Line Oper Description Part Number Qty Extended Labor Paint
� Price$
1 FRONT BUMPER
2 * Repl Spoiler black 1J0805903AB41 1 84J0 0.3 1.0
3 Add for Clear Coat 0,2
4 REAR BUMPER _ _ _ _ _
S 0/H rear bumper 2.4
6 Repl Bumper cover w/o R32 1]6807421EGRU 1 328.25 Incl. 2.4
7 Add for Clear Coat l,p �
8 Repl RT Moiding 1)6807792AGRU 1 68.10 Incl. 0.5 �
9 Add for Clear Coat 0.1
10 Repl LT Molding 1]6807791AGRU 1 68.10 Inci. 0.5
11 Overlap Minor Panel �� -0.2
12 Add for Clear Coat 0.1
13 * Repl Spoiler w/o GTI w/o dual exhaust 1J6807521841 1 107.80 Incl. �,Q
14 Add for Clear Coat 0,2 �
15 # Repl Flex Additive 1 5.00 �
16 # Subl Hazardous Waste � 1 5.00 X �
SUBTOTALS 666.95 2J 6.8
ESTIMATE TOTALS I
Category Basis Rate Cost� '
Pa� 661.95
Body Labor 2.7 hrs @ $54.00/hr 145.80
Paint Labor 6.8 hrs @ $54.00/hr 367.20
Paint Supplies 6.8 hrs @ $34.00/hr 231.20 I
Miscellaneous 5.00
Subtotal 1,411.15
Sales Tax � $661.95 @ 7.6250% 50.47
Grand Total 1,461.62
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 1,461.62 i
4/25/2013 12:13:51 PM 034178 Page 2
, Preliminary Estimate
Customer: POSTIER, MARISHA
Vehicle: 2005 VW GOLF GLS TDI 4D H/B 4-1.9L-TD SILVER
GREGG'S AUTO BODY takes great care to ensure that ev ry repair meets our standards for quality. GREGG'S AUTO
BODY guarantees labor performed for as long as you ow�i your vehicle on workmanship and will, at our expense
repair or correct all defects which are attributable to def�ctive or faulty workmanship in the repairs stated on the
repair invoice. This guarantee covers labor only and does not apply to parts, materials or equipment which may be
covered by and subject to terms of manufacturer or vendors warranty. This guarantee does not include damage
caused by or resulting from rust or corrosion, unreasonable use, improper maintenance or care of the vehicle.The
above is an estimate based on our inspection and does not cover additional parts or labor which may be required
after the work has been opened up.Parts price subject to change without notice. YOU HAVE A RIGHT TO CHOOSE A
REPAIR FACILITY OF YOUR CHOICE. WE GREATLY APPRECIATE YOUR BUSINESS.
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.
i
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I I
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4/25/2013 12:13:51 PM 034178 Page 3
• Preliminary Estimate
Customer: POSTIER, MARISHA
Vehicle: 2005 VW GOLF GLS TDI 4D N/B 4-1.9L-TD SILVER
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
ERA9276, CCC Data Date 4/16/2013, 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 deaterships.
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. S=Structural labor category. (numbers) 1 through 4=User Defined Labor Categories.
OTHER SYMBOLS AND ABBREVIATIONS:
Adj.=Adjacent. Algn.=Align. ALU=Aluminum. A/M=Af�ermarket part. BInd=Blend. 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. 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, i
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.
4/25/2013 12:13:51 PM 034178 Page 4
� i
BONFE'S AUTO SERVICE & BODY Workfile ID: c03971df
REPAIR_CF
380 7TH ST W, SAINT PAUL, MN 55102
Phone: (651) 222-4458
FAX: (651) 224-8640
Preliminary Estimate
Customer: POSTIER, MARISHA
Written By: MATTHEW BEBEL
Insured: POSTIER, MARISHA Policy#: Claim #:
Type of Loss: Date of Loss: Days to Repair: 2
Point of Impact:
Owner: Inspection Location: Insurance Company:
POSTIER, MARISHA BONFE'S AUTO SERVICE&BODY
REPAIR CF �
1509 RANDOLPH #4 380 7TH ST W
ST PAUL, MN 55105 SAINT PAUL, MN 55102
(612)247-5869 Cell Repair Facility
(651)222-4458 Business
VEHICLE
Year: 2005 Body Style: 4D H/B VIN: 9BWGR61J454005853 Mileage In: 137491
Make: VW Engine: 4-1.9L-TD License: 617EDA Mileage Out:
Model: GOLF GLS TDI Production Date: State: Vehicle Out:
Color: SILVER Int: Condition: Job#:
TRANSMISSION Dual Mirrors AM Radio 4 Wheel Disc Brakes
5 Speed Transmission CONVENIENCE FM Radio ROOF
Overdrive Air Conditioning Stereo Electric Glass Sunroof
POWER Rear Defogger I Cassette SEATS
Power Steering Tilt Wheel Search/Seek Cloth Seats
Power Brakes Cruise Control CD Player Bucket Seats
Power Windows Tele=copic Wheel SAFETY WHEELS
Power Locks Intermittent Wipers Anti-Lock Brakes(4) Aluminum/Alloy Wheels
Power Mirrors Keyless Entry Driver Air Bag PAINT
Heated Mirrors Rear Window Wiper ' Passenger Air Bag Clear Coat Paint
DECOR Alarm Head/Curtain Air Bags
Body Side Moldings RADIO Front Side Impact Air Bags
4/25/2013 12:36:04 PM 013793 Page 1
• i
Preliminary Estimate
Customer: POSTIER, MARISHA
Vehicle: 2005 VW GOLF GLS TDI 4D H/B 4-1.9L-TD SILVER
Line Oper Description Part Number Qty Extended Labor Paint
Price$
1 FRONT BUMPER
2 0/H bumper assy Z•3
3 R&I R&I bumper cover Incl.
4 * Repl Spoiler black iJ0805903AB41 1 84.70 Incl. �
_. _
. _ _ _
5 REAR BUMPER
6 0/H rear bumper 2•`+
7 Repl Bumper cover w/o R32 1J6807421EGRU 1 328.25 Incl. 2.4
8 Add for Clear Coat 1.0
9 * Repl Spoiler w/o GTI w/o dual exhaust iJ6807521641 1 107.80 Incl. 1,2
10 # Repl FLEX ADDITIVE 1 7.00 T
11 # Repl HAZARDOUS WASTE REMOVAL � 1 7.00 T
12 # **** POSSIBLE HIDDEN DAMAGE 1
*****
13 # PART PRICES SUB]ECT TO 1
INVOICE
14 # Refn TINT COLOR TO SECURE PAINT � 0.5
MATCH
SUBTOTALS 534.75 4.7 6.3
ESTIMATE TOTALS
Category Basis Rate Cost$
Parts 520.75
Body Labor 4.7 hrs @ $52.00/hr 244.40
Paint Labor 6.3 hrs @ $52.00/hr 327.60
Paint Supplies 6.3 hrs @ $32.00/hr 201.60
Miscellaneous 14.00
Subtotal 1,308.35
Sales Tax $534.75 @ 7.6250% 40.77
Grand Total 1,349.12
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 1,349.12 �
******************************************************************************
THIS IS A VISUAL ESTIMATE ONLY.
ADDITIONAL DAMAGE MAY BE FOUND AFTER TEAR DOWN OF VEHICLE.
NO GUARANTEE ON RUST WORK.
******************************************************************************
MINNESOTA FRAUD WARNING
A person who submits an application or files a claim with intent to defraud or helps commit a fraud against an
insurer is guilty of a crime.
4/25/2013 12:36:04 PM 013793 Page 2
I
n � �
Preliminary Estimate
Customer: POSTIER, MARISHA
Vehicle: 2005 VW GOLF GLS TDI 4D H/B 4-1.9L-TD SILVER
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
ERA9276, CCC Data Date 4/16/2013, 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 sigr (�) 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. 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=Boron steel.
CAPA=Certified Automotive Parts Association. D&R=D�sca�nECt ar�d 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.
Sect=Section. Subl=Sublet. UHS=UItra High Strengtfi 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= Nationa) Highway
Transportation and Safety Administration. PDR=Paintless Dent Repair. VIN=Vehicle Identification Number.
4/25/2013 12:36:04 PM 013793 Page 3