Verhulst R���IV�D
JUN 05 2013
NOTICE OF CLAIM FORM to the City of Saint I�'a�l�����ita
Minnesota State Stantte 466.05 states that"...every person...who claims damages from any municipality...shall cause to be presented to the
gaverning body of the municipaliry within I80 days after the alleged loss or injury is discovered a notice stating the time,place,and
circumstances thereof,and the amount of compensation or other relief demanded."
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 will not be contacted by telephone to clarify answers,so pmvide as
much information as necessary to explain your claim,and the amount of compensation being requested. You will receive a
written acknowledgement once your form is received. The process can take up to ten weel�s or longer depending on the
nature of your claim. This form must be signed,and both pages completed. If something dces 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 f��r��-�� Middle Initial � Last Name V Pi�'I'LGL l5-�
� �_
Company or Business Name A
Are You an Insurance Company? Yes/ o If Yes,Claim Number?
Street Address �O� M� [—�L 2
City I�'C'l�xC��('1� Stat�e MIV Zip Code r�
Daytime Phone(6�/)7� - '�Cell Phone (�)�- �5�J Evening Telephone(�)�-�7�3
Date of Accidend Injury or Date Discovered � � Time�am pm
Please state,in detail,what occurred(happened),and why you are submitting a claim.Please indicate why gr how you
feel the City of Saint Paul or�ts mployees are involved andlo res nsible for you dama es. �if. /�.�t l /r'�o/i�e.
V���c/E ` " Gr �+. cCC. � n . C�.
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Please check the box(es)that most closely represent the#eason for completing this form:
�My vehicle was damaged in an accident ' ❑My vehicle was damaged during a tow
❑My vehicle was damaged by a pothole ar condition of the street ❑My vehicle was damaged by a plow
❑My vehicle was wrongfully towed and/ar ticketed ❑I was injured on City property
O Other type of property damage—please specify
O Other type of injury—please specify
In order to process your claim vou need to include copies of all applicable documents.
For the claims types listed below,please be sure to include the documents indicated or it will delay the handling of
your claim. Documents WILL NOT be returned and become the property of the City. You are encouraged to keep a
copy for yourself before submitting your claim form.
O Property damage claims to a vehicle: two estimates for the repairs to your vehicle if the damage exceeds
$500.00;or the actual bills and/or receipts for the repairs
O Towing claims: legible copies of any ticket issued and a copy of the impound lot receipt
O Other property damage claims: two repair estimates if the damage exceeds$500.00; or the actual bills
and/or receipts for the repairs;detailed list of damaged items
O Injury claims: medical bills,receipts
O Photographs aze always welcome to document and support your clairn but will not be returned.
Page 1 of 2—Please complete and return both pages of Claim Form
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims-qlease comulete this section
Were there witnesses to the incident? es No Unknow (circle)
Provide their names,addresses and telephone numbers: f�nknnMUlt. ���°Ifi`5 �'%/�Q
Were the police or law enforcement called? Yes No Unknown (circle)
If yes,what department or agency? 5'f l�tU,1 Case#or report#_/� -��'7°37�
Where did the accident or injury take place? Provide street address,cross street,intersection,name o�park facility,
closest landmark,etc. Please be as detailed as possible. ff necessary, attach di gram. f� Siol v / �p7'+�,
�u, �C b a.� � s�� l '� �, a,c�
Please indicate the amount you are s king in compensation or what ou ou d 1' e e City to esolve is claim
J� to your satisfaction. o�'tWo S /4PA q- � ` c! 2 S .�!'�,
�S��.`�1 s �.. _� C�.4p �. � �� .50
------ _ T� �?�• 8' -- -- -
Vehicle Claims- lease com lete this section ❑check box if this section does not a 1
Your Vehicle: Year GY�� Make Model
License Plate Number � l- State Color
Registered Owner . q- cx,111,r�
Driver of Vehicle /:S'� �
Area Damaged �e ' % �t, N/ P� �
City Vehicle: Year rjc�0� Make Model C/'Cl� " , f c�,
License Plate Number_�/ State�/�Colar
Driver of Vehicle(City mplo,�ee's N e) rY�,
Area Damaged Lf_�� �/`f�/l�
I�iurv Claims-nlease complete this section �check bo�,if this section does not applv
How were you mjured?
�
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 ef�eur Ernployer: _ _ _ -- _
Address Telephone
�Check here if you are attaching more pages to this claim form. Number of additional pages,�.
By signing this forrn,you are stating that all information you have provided is true and correct to the best
of your knowledge. Unsigned forms will not be processed.
Submitting a false claim can result in prosecution. Date form was completed�/ /,�
Print the Name of the Person who Completed this For : /- � ��,/�� �!''/+'� s
Signature of Person Makin the Claim: %���/�r/�U
�
Revised February 2011
` Accident Repart Page 1 of 2
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2005 Saturn Ion Sedan 4D ION-2 Prices, Values &Ion Sedan 4D ION-2 Price Specs � NA,,. Page 1 of 2
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2005 Satum lon
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�'....:�:: Mileaqe:103000 �
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USE'd Ca�PI'IC25
Suggested Retai!
Excellent
$6,661 �`�
Yehicle HighGghts
MPG:City 23/Hwy 32 Max Seating:5
Doors:4 Engine:4-Cyl,2.2 Liter
Drivetrein:FWD Transmission:Manual,5-Spd
EPA Class:Sub Compact Cars Body Style:Sedan
CountryotOrigin:United States CountryofAssembly:United States
YourConfigured Options
http:i�www.kbh.cami�aturn/ior�/2005-saturn-ionl2-sedan-4d/?condition=excellent&vehicle._. 5i17/2013
Date: 5l S/201311:41 AM
Estimafe ID: FRE60939—2
Estimate Version: 0
Preliminary
Profile ID: MPLS,ST PAUL
METLIFE AUTQ & H4ME
Fieid Appraisal Unit P 0 Box 410200,CHARLOTTE,NC 28241-0200
(800)854-6011
Ema�: palverman@rc�etlife.com
Damage Assessed By: PATTI ALVERMAN File Handier. Timothy Curran
(800)854-6011 ext 6323
Contact Appraiser 800-854-6011 Ext 4776
Fax 866-743-4935
Corxfit+on Code: Moderafe Wear Type of Loss: CoAision
Date of Loss: 5f 412013
Gusbn Contct: 5/712013 Assgn Date: 5/7/2013
Deductibie: 500.00
Ciaim Paid: N
Policy No: 141239562-0 Claim Number: FRE60939—2
insured: dAMIE VERHULST PATRICK VERHULST-TL
Owner. PATRICK VERHULST—TL
Address: 400 ME1#DOW LN,WOODBURY,MN 55125
Telephor�e: Home Phone: {651)731-9773 Contact Phone: (651)731-9773
Mitcheii Service: 910422
Description: 2005 Satum ION 2 Vehide Production Date: 5/05
Body Style: 4D Sed Drive Train: 2.2L Inj 4 Cyl 5M fWD
VIN: 1G8AZ52F95Z176101 License: 495JLJ MN
Mileage: 103,074
OEM/ALT: A Search Code: MEMSP
Coloc Red
Options: PASSEN�ER AIRBAG,DRiVER AIRBAG,POWfR LOCK,REAR WlNDOW DEFOGGER
MANUAL AIR CONDITION,TILT STEERING COLUMN,FRONT AIR DAM,TINTED GLASS
VARIABLE ASSISTED STEERING,ANTI-THEFT SYSTEM,AUTOMATIC HEADLIGHTS
DAYTIME RUNNING LIGHTS,AM/FM STEREO CQ,FRONT BUCKEf SEATS,INTERIOR AIR FILTER
POWER UFTGATEITRUNK,REAR AC�HEATER
Line Entry Labor Line Item Part Type! Dollar Labor
IYem Number Type Operation Descriptlon Part Number Amount Units
FroM Bur�er
1 BDY OVERHAUL Fd Bumper Cover Assy 2•2 #
2 001850 BDY REMOVEIREPLACE Frt Bumper Cover i Remanufactured 221.00 INC #
3 REF REFiNISH F+f Bumper Cover C 2.6
d 001860 BDY REMOVElREPLACE Frt Lwr Bumper Panel "QUAL REPL PART 41.00 INC
Fror�f Lamos
5 �478 BDY CHECK/ADJUST Headlamps �•4
6 000461 BDY REMOVE/REPLACE L Front Combination Lamp Assembly "QUAL REPL PART 148.00 � ING
—�.--
7 000639 BDY REMOVElINSTALL Hood Assy �•'�
Front Famler
8 006371 BDY REMOVE/REPLACE L Fender Par�el Qu�Recyded Part 200.00 ' 2.0 #r
9 REF REFiNiSH L Fender Outside C 2.0
ESTIMATE RECALL NUMBER: 05/08/201311:41:21 FRE60939—2
Mitcheli Data Version: OEM: FEB_13_V
MAPP:fEB_13_V Copyright(C)1994-2013 MftcfieN Intemational Page 1 of 5
Software Version: 7.0.485 Atl RigMs Reserved
Oate: 5I8/201311:41 AM
Estimate ID: FRE60939-2
EsGmate Versioo: 0
P�eliminary
Profli e i�: MPLS,ST PAUL
�p REF REFINISH L Add To Edge Fender C 0.5
�� A AAA Auto(Mu�phy)651-023-2432 Ref#15028&1
�2 Lir�e Markup%25.00 50.00
13 000373 BDY REMOVEtREPLACE L Fe�der Em�em 22710102 20.27 INC #
1q 00036i BDY REMOVE1REPlACE L Fender Reinforcement Qual Recycied Part !NC' 0.3 #
�5 BDY REMOVE/fNSTALL LFenderAssy INC #
16 000363 BDY REMOVE/REPLACE L Fender Liner Qual Recycled Part INC" INC r
Frortt inner Structure
t? 00041& BDY REMOVE/REPLACE L Upr Front Bafy Side Rail -S 226864&3 557.2(} 3.5
�$ REF REFINISH L Upr 5ide Raii Q�5
Wheel
19 001917 BDY REMdVEiREPIACE Ailoy Wheel 3@50.00 Quai Recycied Pa�t 150.00 ' 0.9 r
Front Susaension
20 002527 MCH REMOVEIREPLACE L Lwr FR Susp Control Arm Assy -M 19207819 156.90 1.9 #
Instrument Panei
21 000706 MGH REMOVE/INSTALL Ir�strument Panel Assy -M 4�
Front Door
22 000332 REF REFiNISH L F�t Door Frarr�e 1.5
23 000322 REF REFINISH L Frt Door Outs+de C 1.6
24 000330 BDY REMOVEIINSTALL L Frt Door Outer Panel ��� #
25 000318 BDY REMOVE/REPLACE L Frt Door Shell Quai Rec}+cied Pazt 200.00 ` 5.2 #r
2g Line Markup°Ao25.00 50.00
27 000261 BDY REMOVE/1NSTALL l Frt Rear View Mirtor INC
28 000263 BdY REMOVE/INSTALI L frt Otr Belt Moulding lNC #
29 000316 BDY REMQVEJINSTALL L Frt Door Trim Panei INC
30 000243 BDY REMOVE/INSTALL l Frt Qtr poar Handle INC
Rear poor
31 0009Q1 REF BLEND L Rear poor Outside C 0.8
32 000903 BDY REMOVElINSTALL L Rear poor Assembly �•d
33 000905 BDY REMOVElINSTALL L Rear poor Outer Panel 1•2 #
34 001449 BDY REMOVElINSTALL L Rear Otr Belt Moulding iNC #
35 000837 BDY REMOVE/INSTALL L Rear Otr poor Handle iNC
Side Bodv
3S OQ1171 BDY REMOVE1ftEPLACE L Section Hinge Pillar '•� #
37 REF REF�NISH L Hinge Pitlar T•�
38 001139 BDY REMdVElREPLACE L Side Body Panel Assembiy -S Qual Recyded Part 200.00 * INC #
3g line Ma�CUp°�25.00 �.�
4Q 001037 REF REFINISH L Frt Applique C 0.5'
41 001039 BDY REMOVEIINSTALL L Frt Side Body Appiique INC
42 001022 BDY REMOVE/REPLACE L Ftocker Motdding Qual Recycled Part 60.00 * INC r
43 Line Markup°h25.00 15.00
44 001768 BDY REPAIR L FR Side Body Apptique Existing 0.3'
RearSuspensian
45 QQ0930 MCH REMOVEiREPLACE Rear Susp Axie Assembly -M Qual Recycled Part 350.00 " 4.2 #
4g Line Markup%25.00 87.50
47 936012 ADD'L COST HAZARDOUS WASTE DESPOSAI 3•� '
48 900500 REF ` ADD'L LABOR OP FLEX ADDITIVE Sublet 5.00 ' 0.0'
49 900500 MCH ' ALIGN 4-WHEEL ALIGNMENT Sublet 99.99 ' 0.0'
ADDRIONAL OPERATIdNS
50 REF ADQ'L OPR C{ear Coat 2•2
51 900500 MCH ` ADD'L LABOR OP MdUNT&BALANCE Sublet 60.00 ' 0.0'
52 3 @$20 EA
53 933025 BDY ADD'L OPR Transfer LKQ Fart Trim 3.0"
Additional Costs&Materia{s
54 ADD'L COST PainUMateriais 422•`a �
ESTIMATE RECALL NUMBER: 05/0&l201311:41:21 fRE60939-2
RAitchell Data Version: OEM: FEB_13_V
MAPP:FEB_13_V Copyright{C)1994-2013 Mitcheil IMemational Page 2 of 5
Software Version: 7.0.485 Ail Rights Reserved
Date: 5/8/2013 t 1:41 AM
Estimate ID: FRE60939—2
Estimate Version: 0
Preliminary
Profile ID: MPLS,ST PAUL
*-Judgment Item
#-Labor Note Applies
"`QUAL REPL PART-Quality Repiacement Parts
C-Included in Clear Coat Cafc
r-CEG R&R Time Used For This Labor Operation
KEYSTONE AUTOMOTiVE
2021 W.DiVISION ST.
ST.CLOUD
MN 56301
(800}247-0861 �612)251-8494
2 "GM1000754R 221.00
4 "GM1041109 41.00
Recycler i�fortnation Se.ction:
AAA Auto Salvage-ARAPro
2871 160th 5t.W.
Rosemount MN 55068
800-238�664;651-d23-2808
25 2005 Satum ION LEFT FRON7 DOOR 1N6003 VA 200.0p
Description:U815K,OUAD,LEV2,BLUE,PW,PL,000„CPE,ELECTRIC,l,
Economy Auto Saivage
24350 P►easant Ridge Rd
Winona MN 55987
800-743-5639;507�d54-8615
19 2005 Satum ION WHEEL 010136 VA 50.00
Description:15X6,ALUMINUM(�T PF7},15X6,AIUMINUM(OPT PF7),
Automotive Recyders
5323 Hwy-52 South
Rochester MN 55904
800-657-4403;507-289-0109
A2 2005 Satum ION LEFT ROCKER MOULDING 112400 VA 60.Q0
Description:-LH-LIV-WA817K,
Disdaimer.The price indications on recyded paris are real�composfte
va4ues�based on the pric�g op�On selected wifh(�RP. Prices are the
latest avadable at time of imentory dowMoad and are subjed to cha�x,�e
ar�ava�abdity. ,
To detertnine actual repairer net or whoresale price,call the automo6ve
recyder of your choice.
Certain pads located for this quote are interchargeable but are not an exact
match. Call the automotive recycier of yaur choice.
ESTIMATE RECALL NUMBER: 05/08f201311:41.21 FRE60939—2
M�chell Data Ve�sion: OEM: FEB_13_V
MAPP:FEB_13_V Copyright(C)1994-2013 Mitchell Intemational Page 3 of 5
Software Version: 7.0.485 All Rights Reserved
Date: 5(8I201311:41 AM
Estimate ID: FRE60939—2
Es6mate Version: 0
Preliminary
profile ID: MPLS,ST PAUL
Estimate Totals
Add'I
Labor Subiet
!. Laba Subtotals UniGs Rate Amount Amour� Totals II. Part Repiacement Summary _ Amount
g�y 25.5 52.OQ 0.00 O.OU 1,326.00 Taxable Parts 2,304.37
Refinish 13.2 52.00 0.00 5.Q0 691.40 Parts Adjustments 252.50
Mechanicai 10.8 72.60 0.00 159.99 937.59 Sales Tax @ 7.125% 182.18
Non-Taxab{e La6or 2,954.99 Tota�Repiacement Parts Amount 2,739.Q5
Labor Summary 49.5 2,9��99
itl. Additional Costs Amount N. Adjustrnents Amour�
Ta�ble Costs 3.00 Insurance Deductible 50(?.00-
Sales Tax @ 7.125°h 0.21
Customer Responsib�ity 500.00-
Non-TaxaWe Costs 422.40
Totai Additionai Costs 425.61
Pain#Matenai Method:Rates
Init Rate=32.Q0 ,Init M�Hours=99.9,Addl Rate=O.DO
L Tota!labor. 2.954.93
11. Total Replacement Parts: 2,735.05
IA. Total Additional Casts: 425.61
Gross Tatal: 6,119.65
!V. Total Adjustments: 500.00-
Net Total: 5,619.55
TOTALLOSS
This is a preliminary estimate.
Additional chanaes to the estimate may be required for the actuaf repair.
Point{s)of impact
15 Totat Loss(P),19 Leit fron3 Comet(S),12 Front Cerder{S)
cv
CImnC ins Ca: MetLife � �^�'•`�""'o
u, �o�'��°o°
� �
�
trispection Site: abra auto body �W o "" �
Address: 8230 hudson rd Q(,J,,; �v
WOODBURY,MN 55125-9111 (1 H� � a
(651)738-2272 CD
'.!c., �
(651)738-2272 'O.=
l�spection Date: 5/8/2013 �a� �
�
,.`h ax*a F-"'-
,� o� w ^
... ... O Z 2 U p Q W
ESTlMATE RECALL NUMBER: 05l0&t201311:49:21 FRE6Q939—2 Q'`�c-a
Mitchell Data Version: OEM: FEB_13_V - - _
MAPP:FEB_13_V Copyright(C)1994-2013 MitcheU intemational Page a u� 5
Soflware Version: 7.0.485 Aii Rights Reserved