Nurnberg RECEIVED - -- '
MAY 06 2013
NOTICE OF CLAIM FORM to the City of Saint`Ya�ul, l�'nnesota
Minnesota State Statute 466.05 stares that"...every person...who claims damages from any municipaliry...shall cause to be presented to the
governing body of the municipality within 180 days after the alleged loss or injury is discovered a norice stating the time,place,and
circumstances thereof,and the amount of compensation or other redief demanded." I
I
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 sometbing 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 �e(1f11 �f� Middle Initial �l Last Name N u���"J��-�
Company or Business Name,if applicable
Street Address �`� �'�"�SOR /���° �
City J� I"�� ; State �� Zip Code 5� `�o
Daytime Telephone(�i 2 ) Z��� q (s`f Evening Telephone �( �?) 2��`��'�`"t
Date of Accidend Injury or Date Discovered ri R1�3 � �i 3 Time pm(circle)
Please state,in detail, what occurred, and why you are submitting a claim. Please indicate why or how you
feel the City of Saint Paul or its employee involved andlor resp nsi le.
fi �, 6ou��e�r�r��e�� o� ve��c�e dam�. i n �e �q�'
c � � r� w�h c��I—�
o � i t�.�T_. -It� s R.o o S
t n P c�tt�2eS tn � �
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i � u�, ' �S o � � �-•
Please check the box(es)that most closely represent the reason for completing 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 hl ' ❑,�nj�mrecd`o�n prope�j ,•,,,'
�Other type of property damage—please specifyVC L-� W� d ��� �"'��w"�` �e�—
❑ Other type of injury—please specify
❑ Other type not listed—please specify
In order to process your claun vou need to include copies of all applicable 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.
�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
O Towing claims: legible copies of any tick ts issued and copies of the impound lot receipts
O Other property damage: repair estimates,c�etailed list of damaged items
� O Injury claims: medical bills,receipts
�Photographs can be provided but will not be returned.
Page 1 of 2—Please complete auld return both pages of Claim Form
Failure to provide a completed claim form will result in delays in processing.
I
Notice of Claim Form,City of Saint Paul,page two �i
All Claims—please complete this section
Were there witnesses to the incident? Yes �,To Unknown (circle)
If yes,please provide their names, addresses and telephone numbers:
j
Were the police or law enforcement called? Yes Unknown (circle)
If yes, what department or agency? Case#or report# I
Where did the accident or injury take place? Provide street address,cross street,intersection,name of park I,
or facility,closest landmark,etc. Please b as detailed as possible. If hel ful,attach a diagram. '�
S La � S��v� n 130 t t o2n�2 o-f
�
Please indicate th amount you are seeking in compensatiQn from thi laim or what you would h'j�e the City i
to d to esolve this�laim to your satisfaction. I u�ou1�X I�ILe � ��� �o QQ.t,I �f-fl(Z ;
v�.�,t�, ��a��
Vehicle Claims—nlease complete this section ❑ check box if this section does not avulv '
Your Vehicle: Year 199 7 Make �O2D Model�'-k�D'tTi�P�
License Plate Number nOS C9-Z P State rn►'� Color ���<-
Registered Owner JzMI FCR- /�- NW2-N6CR-6'
Driver of Velucle J�M11=`CR l�1l�.(�-1�16�.2�r
Area Damaged S 2�F T Q� RA w��Sl�-e�
City Vehicle: Year Make odel
License Plate Number State Color
Driver of Vehicle (City Employee's Name)
Area Damaged
Iniurv Claims—please complete this section 1�check box if this section does not annlv ,
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))
Name of Medical Provider(s):
Address Telephone
Did you miss work as a result of your injury? Yes No
When did you miss 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 �� I
By signing this form,you are stating that all ireformation you have provided is bue and correct to the best of your knowledge. Unsigned
forms will not be processed. SrebmiUing a false claine can resuk in prosecution. �
Print the Name of the Person who Completed t ' Form: �. a
Signature of Person Making the Claim:
Date form was completed ���0/��3 Revised Apri12007
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OKEEFFES COLLISION �Nor�le ID: c423bab9
FederdlID: 274472577
860 PAYNE AVE, SAINT PAUL, MN 55130
Phone: (651) 493-9484
FAX: (651)493-9359
Preliminary Estimate
Customer: Nurnberg,)ennifer 7ob Number:
Written By: David O'Keeffe
Insured: Numberg,Jennifer Policy#: Qaim#:
Type of Loss: Date of Loss: Days to Repair. 0
Point of Impact:
Owner: Inspectlon Locatlon: Insurenoe Company:
Numberg,]ennifer OKEEFFES COLLISION
519 Lawson Avenue E. 860 PAYNE AVE
�
St.Paul,MN 55130 SAINT PAUL,MN 55130
(612)210-9154 Business Repair Fadlity
(651)493-9484 Busir�ss
VEHICLE
Year: 1997 Body Style: 4D UTV VIN: 1FMFU18L9VL691261 Miteage In:
Make: FORD Engine: 8-5.4L-FI License: Mileage Out:
Model: IXPEDTTION 4X4 EDDIE Producdon Date: State: Vehide Out:
BAUER
Color: Int: Condition: Job#:
TRANSMISSION Body Side Moldings Keyless Eniry 4 4Vheel Disc Brakes
Automatic Transmission Dual Mirrors � Rear Window Wiper SEATS
Overdrive Privacy Glass li RADIO L.eather Seats
POWER Console/Sta"age � AM Radio WHEELS
power Steering Overhead Console FM Radio Aluminum/Alloy Wheels
Power&akes CONVENIENCE Stereo PAIH7'
Power Windows Air Conditioning Cassette qear Coat Paint
Power Locks Rear Defogger SAFETY OTHER
Power Driver Seat Tilt Wheel Arrti-Lodc Brakes(4) Fog Lamps
Power Mirrors Guise Contrd Driver Air Bag
DECOR Intermittent Wipers Passenger tir Ba9
4/29/2013 6:2023 PM 303923 P�1
Preliminary Estimate
Customer: nurnberg,jennifer 7ob Number:
Vehide: 1997 FORD IXPEDIfION 4X4 EDDIE BAUER 4D UTV 8-5.4L-FI
Line Oper Description Part Number Qty Enter�ed Labor Paint
Price�
1 VYINDSHIELD
2 Repl Windshield FORD F65Z1503100AA 1 214.15 2.2
3 ROOF
4 * Rpr Roof panel w/o roof radc w/o ],Q,Q 4.0
sunroof
5 Add for Gear Coat 1.6
6 R&I Headliner w/o sunroof w/auxiliary 2.8
AC
open Repl RT Handte F75Z7831406AAC 1 33.58 Incl.
8 PILLARS,ROCKER 8�FLOOR
9 * Rpr RT Uniside assy w/o wheel s 7�Q 4.0
opening molding
10 Overlap Major Non-Adj. Panel i -0.2
11 Add for Gear Coat 0.8
open Repl RT Upper pillar to 4/1/99 F65Z1502500AM 1 99.50 s 2.0
13 FRONT DOOR
open Repl RT Doorshell F75Z7820124AA 1 411.85 4.5 3.3
15 Overlap Major Adj.Panel -0.4
16 * Add for Clear Coat 0.6
17 Add for mirror 0.4
18 Repi RT W'strip on body F75Z7820708A6 1 81.33 0.4
19 Repl RT Door w'strip 1L3Z1620530BA 1 121.95 Ind. I
20 R&i RT Applique Ind.
21 R&I RT Beft w'strip Ind.
22 * R&I RT Body side midg Eddie Bauer ; Q,}
p��
23 Repi RT Mirror w/o signal heated F85Z17682HAC 1 238.03 Incl. i
24 R&I RT Door glass Ford I� Ind.
25 * R&I RT Run channel �
26 R&I RT Handle,outside primed Ind. I
27 R&I RT Lodc cylinder Ind.
28 R&I RT Belt w'strip Incl.
29 R&I RT R&I trim panel Ind.
30 FENDER
31 * Rpr RT Fender w/o wheel lip �,Q 2.2 �
32 Overlap Major Adj. Panel -�•4 �
33 * Add for Clear Coat 0.4
34 R&I RT Fender liner 0.6
open Repl RT Namepiate"IXPEDIfION F75Z16720AA 1 43.33 OZ
EDDIE BAUER"
36 STRIPE TAPE
37 Repl RT Stripe tape prairie tan F75Z7820000AAA 1 102.78 1.0
38 REAR DOOR
4/29/2013 6:17:26 PM 303923 Page 2
, Preliminary Estirr�ate
Customer: nurnberg,jennifer 7ob Number:
Vehide: 1997 FORD IXPEDITION 4X4 EDDIE BAUER 4D UTV 8-5.4L-FI
39 * Rpr RT Door shell �,Q 2.2
40 Overlap Major Adj.Panel -0.4
41 * Add for Gear Coat 0.4
42 R&I RT W'strip on body 0.4
43 R&I RT Door w'sd'ip 0.4
44 R&I RT Lower w'strip 0.3
45 R&I RT Applique 0.3
46 * R&I RT Body side mtdg Eddie Bauer Q�
primed ,
47 R&I RT Door glass Ford 0.5
w/weathersdip solar
48 R&I RT Vent glass Ford one way from OJ
2/28/97 to 4/21/98
49 * R&I RT Run channel Q,�
50 R8�I RT Handle,outside primed 0.4
51 ELECTRICAL
52 Repl Mtenna mast AL.8Z18813A 1 30.00 0.1
53 Repl Cap F65Z18A927AA 1 6.00
54 Repl RT Base 3L3Z18936AA 1 18.14 0.3
55 # Possible Hidden Damamge 1
SUBTOTALS 1,400.64 41.3 18.1
ESTIMATE TOTALS ,
Cate9orY Basis Rate Cost; ,
Parts 1,400.64
Body Labor 41.3 hrs @ $50.00/hr 2,065.00
Paint Labor 18.1 hrs @ $50.00/hr 905.00
Paint Supplies j 18.1 hrs @ $30.00/hr 543.00
Subtotal 4,913.64 j
Sales Tax � $1,400.64 @ 7.6250% 106.80 �
Grend Total 5,020.44
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 5,020.44 �
4/29/2013 6:17:26 PM 303923 Page 3
LATUFF BROS., INC.
880 UNIVERSITY AVENUE
ST. PAUL, MINNESOTA 55104
(651)224-2828 FAX:(651)291-0677
FEDERAL ID#41-0777034
***PRELIMINARY ESTIMATE"**
04/30/2013 10:10 AM
Owner �
Owner: JENNIFER NURNBERG
Address: 519 LAWSON AVE E Cell: (612)210-9154
City State Zip: Saint Paul,MN 55130 FAX:
Email: JENNIFERNURNBERG@HOTMAIL.COM
-- - � - • —
�--Inspection
-- -----------.._------------------ -
inspection Date: 04/30/2013 09:59 AM Inspection Type:
Primary Impact: Roof ' Secondary Impact:
Driveable: No ' Rental Assisted:
Appraiser Name: WILLIAM LATUFF Appraiser License#:
�--- - ----- ----- - -- �
LRepairer
Repairer: Latuff Brothers Inc Contact:
Address: 880 University Ave Work/Day: (651)224-2828
FAX: (651)291-0677
City State Zip: Saint Paul, MN 55104 Work/Day:
Email: generalC�latuffbrothers.com
� Remarks � �___ _,_ _._..�
'***"*"**'PRELIMINARY ESTIMATE"**"""""'"""" '
POSSIBLE ADDITIONAL DAMAGE MAY BE FOUND AFTER TEI�R DOWN
E-ESTIMATES ARE SUBJECT TO PHYSICAL AUDIT PRIOR TO'REPAIRS
REPAIRS EXCEED VALUE
__�_�_____�__�._�._�,�._._._.
�_._...________ �__.._�. __�_____ .A ._._--,
Lvehicle� � � �� �
1997 Ford Expedition Eddie Bauer 4 DR Wagon
8cyl Gasoline 5.4
4 Speed Automatic
Lic.Plate: Lic State: MN
Lic Expire: VIN: 1 FMFU18L9VL691261
Prod Date: Mileage: 252,483
Veh Insp#: Mileage Type: Actual
Condition: Good Code: P85036
Ext.Color: EBONY Int.Color:
Ext.Refinish: Two-Stage Int.Refinish: Two-Stage
Ext.Paint Code: M6373A,UA Int.Trim Code:
Options
4-Wheel Drive AM/FM Stereo Tape Air Conditioning
Alarm System Aluminum/Alloy Wheels Anti-Lock Brakes
04/30/2013 05:16 PM Page 1 of 5
j 997 Ford Expedition Eddie Bauer 4 DR Wagon
Claim ri: 04/30/2013 10:10 AM
Auto Locking Hubs(4WD) CamperlTowing Package Center Console
Chrome Bumper(s) Cruise Control Dual Airbags
Fog Lights Intermittent Wipers Keyless Entry System
Leather Seats Leather Steering Wheel Lighted Entry System
Overhead Console Power Brakes Power poor Locks
Power Drivers Seat Power Mirrors Power Quarter Windows
Power Steering Power Windows Privacy Glass
Rear Window Defroster Rear Window Wiper/Washer Roof/Luggage Rack
Running Boards Tachometer Tilt Steering Wheel
Tow Hooks
Damages
Line Op Guide MC Description MFR.Part No. Price ADJ% B% Hours R
Strfues And Mouldinas
1 RI 123 MIdg,Qtr Whl Opening LT R&I Assembly 0.3 SM
2 RI 124 MIdg,Qtr Whl Opening RT R&I Assembly 0.3 SM
Front Body And Windshield
3 NG 143 Windshield,Shaded NAGS DW1256-GB $258.20 -30.00 0.6 SM
4 E 144 W/Strip,Windshield YL3Z1503110AA $29.87 INC SM
5 EC 159 Sealant Kit,W/Shield Replace Economy $25.00* INC SM
Roof
6 E 341 Panel,Roof F75Z7850202BJ $691.18 26.5 SM
7 L 341 Panel,Roof Refinish 5.0 RF
4.2 Surface
0.8 Two-stage
8 E 336 02 Reinf,Roof F75Z7850222AD $54.98 0.5 SM
9 L 336 Reinf,Roof Refinish 0.6 RF
0.5 Surface
0.1 Two-stage
10 E 342 02 Reinf,Roof YL3Z1503418AA $87.47 1.5 SM
11 L 342 Reinf,Roof Refinish 0.6 RF
Q.5 Surface
1 Two-stage
12 L 363 Reinf,Roof Re inish 0.6 RF
0.5 Surface
0.1 Two-stage
13 L 424 Rail,Roof Side LT Refinish 0.6 RF
0.5 Surface
0.1 Two-stage
14 E 425 02 Rail,Roof Side RT F75Z78513A38AE $115.85 1.5 SM
15 L 425 Rail,Roof Side RT Refinish 0.6 RF
0.5 Surface
0.1 Two-stage
Dashboard And Comoonents
16 E 897 # MIdg,W/S Garnish RT F65Z1503598AAD $53.53 INC SM
#=01,02
Front Doors
17 EU 208 Door Assembly,Front RT Replace Recycled $400.00' 3.3 SM
18 I 208 Door SheIl,Front RT Repair 2.0' SM
19 L 208 13 Door SheIl,Front RT Refinish 5.2 RF
2.8 Surface
1.0 Edge
0.6 Two-stage setup
04/30/2013 05:16 PM Page 2 of 5
i 997 Ford Expedition Eddie Bauar 4 DR Wagon
Claim#: 04/30/2013 10:10 AM
0.8 Two-stage
20 EU 230 Mirror,0uter R/C RT Replace Recycled $150.00" INC SM
�uarter And Rocker Panel
21 ET 648 Pillar,Hinge RT Partial Replace Labor 13.0 SM
22 L 648 Pillar,Hinge RT Refinish 1.2 RF
1.0 Surface
0.2 Two-stage
23 ET 626 Pillar,Windshield RT Partial Replace Labor 2.2 SM
24 L 626 Pillar,Windshield RT Refinish 0.6 RF
0.5 Surface
0.1 Two-stage
25 TE 158 02 Panel,Bodyside Front RT Partial Replace Price $1,203.25 SM
26 L 607 Pnl,Rckr&PIr,Center RT Refinish 2.5 RF
2.1 Surface
0.4 Two-stage
27 BR 389 Panel,Quarter LT Blend Refinish 1.6 RF
1.1 Biend
0.5 Two-stage
28 BR 390 Panel,Quarter RT Blend Refinish 1.3 RF
1.3 Biend
INC Two-stage
lnner�uarter&Panels
29 E 266 02 Reinf,W/S Pillar RT F65Z1502500AM $99.50 1.0 SM
30 L 266 Reinf,W/S Pillar RT Refinish 0.6 RF
0.5 Surface
0.1 Two-stage
31 I 268 Reinf,Hinge Pillar RT Repair 2.0" SM
32 L 268 Reinf,Hinge Pillar RT Refinish 0.6 RF
0.5 Surface
0.1 Two-stage
33 E 408 02 MIdg,Pillar Drip RT F65Z1551700A $52.93 INC SM
Rear Bumoer
34 RI 566 Bumper Assembly,Rear R&I Assembly 0.5 SM
Rear Body.Lamns And Floor Pan
35 RI 533 Taillamp Assembly LT R�I Assembly 0.3 SM
36 RI 534 Taillamp Assembly RT R I Assembly 0.3 SM
Manual Entries
37 L M14 Corrosion Protection Refinish 0.6* RF
38 I M18 Set-Up And Measure Repair 2.0* SM'
39 SB M60 Hazardous Waste Removal Sublet Repair $5.00* SM
40 I M64 Unibody-Frame Alignment Repair 4.0* FR
41 I M69 Glass Clean Up Repair 2.0' SM
42 EC M70 Cover Car Interior Replace Economy $7.00` 0.3' SM'
43 EC 8307 SEAM SEALER X2 TUBES Replace Economy $99.00" SM*
44 EC 8115 PNL BONDING ADHESIVE Replace Economy $62.63* SM*
45 EC ROF BOW ADHESIVE Replace Economy $45.00" SM'
45 Items
MC Message
01 CALL DEALER FOR EXACT PART#/PRICE
02 PART NO. DISCONTINUED,CALL DEALER FOR EXACT PART NO.
13 INCLUDES 0.6 HOURS FIRST PANEL TWO-STAGE ALLOWANCE
Estimate Total&Entries � � �
Gross Parts $2,388.56
04/30/2013 05:16 PM Page 3 of 5
�'1997 Ford Expedition Eddie Bauer 4 DR Wagon
Claim#: 04/30/2013 10:10 AM
Other Parts $1,046.83
Paint Materials $710.40
Line Item Discount $77.46-
Parts&Material Total $4,068.33
Tax On Parts Only � 7.625% $256.04
Labor Rate Replace Repair Hrs Total Hrs
Hrs
Sheet Metal(SM) $52.00 52.1 8.0 60.1 $3,125.20
Mech/Elec(ME) $85.00
Frame(FR) $75.00 4.0 4.0 $300.00
Refinish(RF) $52.00 22.2 22.2 $1,154.40
Paint Materials $32.00
Labor Total 86.3 Hours $4,579.60
Sublet Repairs $5.00
Towing $125.00
Tax On Towing � 7.625% $9.53
Gross Total $9,043.50
Net Total $9,043.50
Alternate Parts No
SPPL Yes Zip Code:55104 Default
Audatex Estimating 6.0.925 ES 04/30/2013 05:16 PM REL 6.0.925 DT 03/01/2013 DB 04/15/2013
Copyright(C)2011 Audatex North America,Inc.
4.1 HRS WERE ADDED TO THIS ESTIMATE BASED ON AUDATEX'S TWO-STAGE REFINISH FORMULA.
ESTIMATE CALCULATED USING THE 2.5 HOUR MAXIMUM ALLOWANCE FOR TWO-STAGE REFINISH OF NON-FLEX,EXTERIOR
SURFACES.
THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF ONE OR MORE CR.ASH PARTS
SUPPLIED BY A SOURCE OTHER THAN THE MANUFACTURER OF YOUR MOTOR VEHICLE.
WARRANTIES APPLICABLE TO THESE REPLACEMENT PARTS AFtE PROVIDED BY THE PARTS
MANUFACTURER OR DISTRIBUTOR RATHER THAN BY THE MANUFACTURER OF YOUR VEHICLE.
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 Recycted
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
04/302013 05:16 PM Page 4 of 5
�997 Ford Expedition Eddie Bauer 4 DR Wagon
Claim#: 04/30/207 3 10:10 AM
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
�' /�udat'�x Audatex's prior written consent.
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Copyright(C)2011 Audatex North America,Inc.
Audatex Estimating is a trademark of Audatex North America, Inc.
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