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Duresky RECEIVED NOTICE OF CLAIM FORM to the City o��aint Paul, Minnesota Minnesoda State Statute 466.05 states that"...every person...who daims damages frC I TYun�Ct�'h�hdll cause to be presented to the governing body of the municipality within 180 duys after the alleged loss or injury is discovered a notice stating the time,place,and circurxstances thereof,and the amount of compensation or other relief demanded." Please complete this form in its entirety by ciearly 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 provide 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 prceess can take up to ten weeks or longer depending on the nature of your claim. This form must be signed,and both pages completed. If something 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.� �� Middle Initial s Last Name �ure 5 K �./ Company or Business Name N f� Are You an Insurance Company? Yes/(�10 If Yes,Claim Number? Street Address �3 8 a. S �n e_r�j��y�o� A V 2 City S�. QC�lA 1 State M n/ Zip Code S I U Daytime Phone(7G3 )�IS -7�35 Cell Phone( '' ) " - '' Evening Telephone( `' ) � - � Date of Accidend Injury or Date Discovered 6.�� 1�� Time 6� 3 U pm Please state,in detail,what occurred(happened),and why you are submitting a claim.Please indicate why or how you feel the City of Saint Paul or its employees are involved and/or responsible for your damages. S P t_ �.�1�cx t,he�� 1 Please check the box(es)that most closely represent the reason 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 or condition of the street ❑ My vehicle was damaged by a plow ❑ My vehicle was wrongfully towed and/or ticketed ❑ I was injured on City property �Other type of property damage—please specify_ M v Gc�� w a s da M a a L a hv a ���.� �+r a G . ❑ Other type of injury—please specify In order to process your claim vou need to include copies of all auUlicable 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. �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 impoand lot receipt O Other property damage claims: two repair estimates if the damage exceeds$500.00;or the actual bills and/or receipts for the repairs;detailed list of damaged items O Injury claims: medical bills,receipts O Photographs are always welcome to document and support your claim but will not be returned. Page 1 of 2—Please complete and return both pages of Claim Form � - . _ . �: _ .t: . � , . � , . . . . . . Failure to complete and return both pages will result in delay in the handling of your claim. All Claims—please comnlete this section Were there witnesses to the incident? Yes No Unknown (circle) Provide their names,addresses and telephone numbers: Were the police or law enforcement called? es No Unknown (circle) If yes,what department or agency? �'n�i�� �eoa��t�'►e,n t Case#or report# Where did the accident or injury take place? Provide street address,cross street,intersection,name of park or facility, closest landmark,etc. Please be as detailed as possible. If necessary,attach a diagram. �3$a 51n�r�u�r►e Rv� S-F.es�.� .M�i/ 5 5 39R Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim to your satisfaction. SG6 A'4"EU�-�'1G� po`f1G o� d Vehicle Claims—please complete this section ❑ check box if this section does not apulv Your Vehicle: Year ►9 4� Make �o r-a Model Tuu r u s License Plate Number 9 y G • A P 1� State M/✓ Color S;1��.- Registered Owner �cF� nu*�s![�/ DriverofVehicle �cFF ��restcy Area Damaged R__c �r;,,<r s��, ra�- ��'rd��' w;�1v+.�s .�a dders� Pcisr.»a� f�o� �+'^d'"f`�°°r• City Vehicle: Year Make Model w�^d:�,�� License Plate Number State Color Driver of Vehicle(City Employee's Name) Area Damaged Iniurv Claims please comnlete this section .I�check box if this section dces not apvlv 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 �7 . By signing this form,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. Subinitting a false claim can result in prosecution. Date form was completed�/a l�/�3 Print the Name of the Person who Completed is orm: �e T �f 2 � S • V Ll �1.,°S �J Signature of Persoa Making the Claim: Revised February 2011 Jeff Duresky Notice of Claim Form Attachments 1 On Friday June 21, 2013, a city tree fell on my car(1996 Ford Taurus). The tree does not appear to be healthy. Although the storm that occurred this night had high wind speeds, it seems the health of the tree contributed to its unstable limbs. According to the City of St. Paul website the Forestry unit: Is responsible for the maintenance of all City-owned trees. Monitoring the health, trimming and removal of trees on public property is Forestry's primary objective to ensure the continued health of our urban forest.The Forestry unit maintains trees growing: • On boulevards • On park land • On easements behind sidewalks • In the public right of way of streets and alleys' The health of this tree is clearly questionable (see photos).While it was the wind that directly caused this unstable limb to fall,the city failed to monitor and maintain the health of the tree. Therefore,I am asking that the city compensate me for my loss. If the City of St. Paul Forestry unit had fulfilled its own stated purpose,then this tree would not have posed the threat that it did. I am not arguing that the City of St. Paul should have known the exact moment when this tree limb would fall,but only that the Forestry unit did not properly monitor the health of this tree. At some point in the early morning of Friday July 21,2013 an unstable limb fell from the tree during a storm and landed on my car. I usually park on the street, since my roommate parks his truck in our driveway. However,due to an increase in parked cars I was forced to park down the street from my house and under the tree that fell since there were no other available spots. The fallen limb severely damaged my car (see photos).Although the engine is still working, the body and windows have extensive damage.The roof of the car has been damaged severely. On the driver side both the front and rear windows were destroyed. Both driver side doors are damaged so that they cannot be opened.The windshield needs to be replaced due to damage.On the passenger side the rear window was destroyed,and both doors are damaged. In addition to this the interior was damaged by water during the storm. I am not asking for the City of St. Paul to compensate me for all of these repairs.This would be a much larger claim. Rather I am only asking to be compensated for the estimated cost of my car. S<< ��y s� 6 � "Public Tree Maintenance,"Accessed on July 24, 2013, http://www.stpauL�;o_v/index.aspx?N ID=2530 , Jeff Duresky Notice of Claim Form Attachments 2 I am not seeking compensation for all the repairs to my car as this would be a much larger claim. Rather I am only seeking compensation for the worth of my car. According to the Kelly Blue Book website the trade-in value of my car is $948.00 (see attached page 3). According to NADA Guides the trade-in value of my car is $475.00(see attached page 4). My car is in rough condition due to the city tree that fell on it. The trade-value without this extensive damage caused by the city tree was much more (Kelly Blue Book: $1,248.00,NADA Guides: $1,100). I am seeking compensation for no less than the lower estimate of$475.00, although my car was worth more than this before the city tree fell on it. I will use the money towards purchasing a used car. The City of St. Paul Forestay unit has caused me to be without a vehicle because they failed to monitor and maintain the health of the ciry tree that damaged my car. Therefore, I am seeking some compensation from the CiTy of St. Paul. I I ��,, � .� ,� ������ ���� ��►�k ,,����, ... �-s .,.:t,:. �� �, � �, � � �,n�� � ��r . .. #.. Y...�' � K`�,'; .��`�`��, , ; �' ����� ����� x�`';. ,.�:ts""� - . . . . � , �a, _; �.., .' ,. advertisement why ads? Your Blue Boolc�Value 1996 Ford Taurus „ Style:GL Sedan 4D •�''��. Mileage: 120000 �...�,.�..� , Trade-In Vatue Vehicle Hightights Excettent MPG:City 18/Hwy 26 Max Seating:6 $1,423 Doors:4 Engine:Vb,3.0 LRer Very Good �`1,3LF8 Drivetrain:FWD Transmissan:Automatic Good EPA Class: Midsize Cars ! Body Styte:Sedan =� Country of Origin:United States Country of Assembly:United States Fair � ...a., _ _. . . .,_. _ .._,,. _ �: �-.. ..., _ _... _,..�.. �. .,._,� $948 Your Configured Options Our pre-selected options,based on typical equipment for this car. ✓Options that you added while configuring this car. Engine Comfort and Convenience Safet�r and Security V6,3.0 Liter Air Conditioning Dua{Air Bags Transmission Power Windows Wheels and Tires Automatic Power poor Locks Steel Wheels Drivetrain Cruise Control � Steering Power Steerinq Tilt Wheel Entertainment and InstrumenWtion AM/FM Stereo Cassette New Cars You Might Like ,,�� ��� 2014 Ford Taurus �,;,� �*'`�"` 2014 Chevrolet Impala a«+��,w� • 1. R � �'"�.,��2014 Chrysier 300 Glossary of Terms Kelley Blue Book�Trode-in Value-This is the amount you can expect to receive ' when you trade in your car to a dealer.This value is determined based on the style, cond+tion,mileage and opkions indicated. Kelley Blue Bookp Private Party Value-This is the sbrting point for negotiation of a used-car sale between a private buyer and seller.This is an"as is"value that does not , include any warranties.The final price depends on the car's actual condition and local ! market factors. Excellent Condition:3%of all cars we value meet tliis criteria.This car looks new and is � in exceflent mechanicai condition.It has never had paint or bodyworic and has an interior and body free of wear and visible defects.The car is rust-free and dces not need reconditioning.Its clean engine compartment is free of fluid leaks.It aiso has a clean tide history,has complete and verifiable service records and will pass safety and smog inspection. Very Good Condition:23%of all cars we value meet this criteria.This car has minor wear or visibie defects on the body and interior but is in excellent mechanical condition, requiring only minimal reconditioning.It has little to no paint and bodywork and is free of rust.Its clean engine compartment is free of fluid leaks.The tires match and have 75%or more of tread.It aiso has a clean title history,with most service records available,and will pass safety and smog inspection. Good Condition:54�0 of all cars we value meet this cntena.This car is free of major mechanical problems but may need some reconditioning.Its paint and bodywork may require minor touch-ups,with repairable cosmetic defects,and its engine compartment may have minor leaks.There are minor body scratches or dings and minor interior blemishes,but no rust.The tires match and have 50%w more of tread.It also has a clean title history,with some service records available,and will pass safety and smog inspection. Fair Condition: 18%of all cars we value meet tt�is criteria.This car has some mechanical ' or cosmetic defects and needs servicing,but is still in safe running condition and has a cfean title history.The paint,body andJor interior may need professional servicing.The tires may need replacing and there may be some repairable rust damage. Qc 1995-2013 Kelley Blue Book Co.00,Inc.All rights reserved. ;�;2?1a Ktitev t3?ut 6c=�;� Cv., I�ae. rlI rrgitts reserved, 5/21j2t113-5,12i;�0i3 �'dit,'on ?`t�� ,tilinrresotr� 551:�9. Th�s�ecifrc irr�rm,ation reGuired to determine the v��ue f��ttis�articu,ar ve,'aide was �upp/ied by th.:per_�cn gene,�ating this;�po�7. Vehicle valuations are oprnfons and mey vary fram vehic;e ta vehicf�. Actual vatuations;ail!vary bac�d up�n market cc�nditians, specificaeions, vehic;e con�rtion or other particu!ar circumstances pertinent to this partici:tar-vehide�r the transaction or L` � �°���� �`� � ',� �"�E "i`�Pav�r�a���et� #�#�trn�i#� � ���e 1���sn��� .t,� ,. tei�fl��s��oic$e�_�a�, 6/24/2Q�3 1996 Ford Taurus-V6 �edan 4C G� ���� �� ��e4�ii■ i" ��1rr� ������ Rough ',, Average Clean Clean Trade-In '�rad�-In Trade-In Retail �,��,� ����� 1V/A ���5 $'��tD ���2�� �t��eage. (�20,000} m►�es $4�5 ���� �475 �4�� Totat Base Rrice $4�5 $1,10Q �1,4�5 $2,G75 � �, � � : }' . � � _ r�' �� � . �' �1 � '�+� ����� �� � 1�����°����n � � ������ �� ����� ���� . . � �. , ,.-.� ���������' y�� , - �a����'����'��,. �..��` . � ,._. ..... ..... ...... ..�... ... .,.. .,.. ., .._.M. , _.. .,�.., ,..m� . ._._ ._...� �,.....,_ ro.. ._.�__, r _..�. .... __.._,e,e . ._��,.... _..._�..._ ...,.�._ .fi�����.F�TT.�.�.�`!�1�t�.T.... ����.� ��� �:�� ���� ������ ���� �������� T���C� � ������� t��el� �� ��t�r���r s��p���� �s-�a��s� f° ��: ���� Y,����� ,.��� ���� ������r� �i� �r� i���d � �����n���r��� �:� ��pti��i�F�t 2 s�3 ���}��ra� ���r�is�t ���c��� inc. �11 ��g�t�s Res��-v��, C�'' �°"��`r?ght ?._�13 !�>���',����. A1! �2i�h�s ����t��°d, u � i , � COUNTRYSIDE COLLISION CENTER INC � PO BOX 247 25861 MAIN ST ZIMMERMAN, MN 55398 PHONE: (763)856-3630 *'*PRELIMINARY ESTIMATE*** 06/24/2013 10:51 AM Owner __ __ ___ __ __ _ _ _ _ _. _..._.. Owner: jeff duresky Address: 27846 104th st Work/Day: (763)218-7235 City State Zip: Zimmerman, MN 55398 F�� Inspection _ _ _ � Inspection Date: 06/24/2013 10:52 AM Inspection Type: Appraiser Name: chuck carlson Appraiser License# : Address: Work/Day: (763)856-3630 City State Zip: Zimmerman, MN 55398 F�� Email: autobody@izoom.net _.... .._.�.,,, _... . _ _„_...,,,, Repairer __ I _ __d. _n. �._ _ ___ Repairer: Countryside Collision Center Inc Contact: Chuck Carlson Address: po box 247 . 25861 main st Work/Day: (763)856-3630 FAX: (763)856-3456 City State Zip: Zimmerman, MN 55398 Work/Day: Email: autobody@izoom.net Vehicle 1996 Ford Taurus GL 4 DR Sedan 6cyl Gasoline 3.0 4 Speed Automatic Lic Expire: VIN: Inaccessible VIN Veh Insp#: Mileage Type: Actual Condition: Code: P3523C Ext.Refinish: Two-Stage Int. Refinish: Two-Stage Options AM/FM Stereo Air Conditioning Center Console Dual Airbags Intermittent Wipers Lighted Entry System Power Brakes Power Mirrors Power Steering Power Windows Rear Window Defroster Rem Trunk-L/Gate Release Tachometer Tilt Steering Wheel Tinted Glass Velour/Cloth Seats Damages _ __ __ _ . __ __ . '! Line Op Guide MC Description MFR.Part No. Price ADJ% B% Hours R Page 1 of 3 O6l24/2013 10:55 AM 1996 Ford Taurus GL 4 DR Sedan Claim#: 06/24/2013 10:51 AM Unibody/Frame 1 I M00 Unibody-Frame Incl Setup Repair 6.0' FR* Stripes And Mouldinas 2 RI 255 MIdg,Front Door Side LT R& I Assembly 0.3 SM 3 RI 259 MIdg,Rear poor Side LT R& I Assembly 0.3 SM Front Body And Windshield 4 BR 103 13 Fender,Front LT Biend Refinish 1.9 RF 0.9 Blend 0.6 Two-stage setup 0.4 Two-stage Roof 5 E 341 02 Panel,Roof F6DZ5450202D $1,023.17 19.0 SM 6 L 341 Panei,Roof Refinish 3.6 RF 3.0 Surface 0.6 Two-stage Front Doors 7 EU 207 Door Assembly,Front LT Replace Recycled $225.00* 3.6 SM 8 L 207 Door SheIl,Front LT Refinish 3.5 RF 1.9 Surface 1.0 Edge 0.6 Two-stage 9 RI 273 MIdg,Front Door Belt LT R& I Assembly INC SM 10 RI 267 MIdg,Front Door Upper LT R& I Assembly 1.1 SM 11 RI 455 Applique,Frt Door Fram LT R& I Assembly 0.2 SM 12 RI 443 Cyi,Front Door Lock LT R& I Assembiy INC SM 13 RI 227 Handle,Front Door Otr LT R& I Assembly INC SM Rear poors 14 EU 287 DoorAssembly,Rear LT Replace Recycled $225.00' 2.5 SM 15 L 287 Door SheIl,Rear LT Refinish 3.4 RF 1.8 Surface 1.0 Edge 0.6 Two-stage 16 RI 338 MIdg,Rear poor Belt LT R& I Assembly INC SM 17 RI 305 Handie,RR Door Outer LT R& I Assembly INC SM Quarter And Rocker Panel 18 BR 389 Panel,Quarter LT Blend Refinish 1.1 RF 1.0 Blend 0.1 Two-stage Manual Entries 19 I inner struture roof Repair 12.0' SM' 19 Items MC Message 02 PART NO. DISCONTINUED, CALL DEALER FOR EXACT PART NO. 13 INCLUDES 0.6 HOURS FIRST PANEL TWO-STAGE ALLOWANCE _. ... _... Estimate Total 8�Entries _ ___ __ Gross Parts $1,023.17 Other Parts $450.00 Paint Materials $432.00 Parts&Material Total $1,905.17 Tax On Parts Only @ 6.875% $101.28 06/24/2013 10:55 AM Page 2 of 3 1996 Ford Taurus GL 4 DR Sedan Claim#: O6/24/2013 10:51 AM Labor Rate Replace Repair Hrs Total Hrs H rs Sheet Metal (SM) $52.00 27.0 12.0 39.0 $2,028.00 Mech/Elec(ME) $70.00 Frame(FR) $70.00 6.0 6.0 $420.00 Refinish(RF) $52.00 13.5 13.5 $702.00 Paint Materials $32.00 I Labor Total 58.5 Hours $3,150.00 Gross Total $5,156.45 Net Total $5,156.45 Alternate Parts Y/00/00/00/00/00 CUM 00/00/00/00/00 Zip Code: 55398 Default � Recycled Parts NOT REQUESTED Audatex Estimating 7.0.019 ES 06/24/2013 10:55 AM REL 7.0.019 DT 05/01I2013 DB 06/15/2013 I Copyright(C)2013 Audatex North America, Inc. 2.9 HRS WERE ADDED TO THIS ESTIMATE BASED ON AUDATEX'S TWO-STAGE REFINISH FORMULA. ESTIMATE CALCULATED USING THE 2.5 HOUR MAXIMUM ALLOWANCE FOR TWO-STAGE REFINISH OF NON-FLEX, EXTERIOR SURFACES. � THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF ONE OR MORE CRASH PARTS SUPPLIED BY A SOURCE OTHER THAN THE MANUFACTURER OF YOUR MOTOR VEHICLE. WARRANTIES APPLICABLE TO THESE REPLACEMENT PARTS ARE PROVIDED BY THE PARTS MANUFACTURER OR DISTRIBUTOR RATHER THAN BY THE M1�NUFACTURER OF YOUR VEHICLE. A PERSON WHO FILES A CLAIM WITH INTENT TO DEFRAUD OR HELPS COMMIT A FRAUD AGAINST AN INSURER IS GUILTY OF A CRIME. Op Codes ' = User-Entered Value E = Replace OEM NG= Replace NAGS EC= Replace Economy OE= Replace PXN OE Srpls UE= Replace OE Surplus ET = Partial Replace Labor EP= Replace PXN EU = Replace Recycled TE = Partial Replace Price PM= Replace PXN Reman/Reblt UM= Replace Reman/Rebuilt L = Refinish PC= Replace PXN Reconditioned UC= Replace Reconditioned TT = Two-Tone SB = Sublet Repair N = Additional Labor BR= Blend Refinish I = Repair IT = Partial Repair CG= Chipguard RI = R& I Assembly P = Check AA= Appearance Allowance RP= Related Prior Damage This report contains proprietary information of Audatex and may not be disclosed to any third party(other than the insured, claimant and others on a need to know basis in order to effectuate the claims process)without ji• ������ Audatex's prior written consent. i a i� ct$cr3Y�y�.l�r7tf'r�tP� -- Copyright(C)2013 Audatex North America, Inc. Audatex Estimating is a trademark of Audatex North America, Inc. O6/24/2013 10:55 AM Page 3 of 3 763-856-5y'�� „" ZIMMERMAN COLLISION � 26069 2nd St West Zimmerman, MN 55398 phone: 763-856-5949/fax: 763-856-5969 CUSTOMER INVOICE# 115010 06/24/13 Page 1 JEFF DURESKY plate: DURE0002 V6 3L 182ci GAS mileage 1996 FORD TAURUS GL SEDAN Vin # ZIMMERMAN , MN 55398 Home:21&7235 Work: Cell: F�� Operation Description Qty Ext. Price Labor Paint FRONT DOOR SHEET METAL L.k.q. L Shell Assy, Door 250.00 4.0 body � Refinish L Refinish Door Outside 2.3 Refinish L +Clear Coat / 2 Stage Major Panel 0�9 � REAR DOOR SHEET METAL Shell Assy, Door � L.k.q. L Sable 300.00 3.5 body Refinish L Refinish Door Outside 2.2 -credit- L -Overlap Adjacent Major 0�4 � Refinish L +Clear Coat / 2 Stage Major Panel 0-9 � ROOF SEDAN Panel, Roof Taurus Replace w/o Sunroof 1023.17 22.5 body Refinish Refinish Roof Outside 3.1 Refinish +Clear Coat / 2 Stage Major Panel ��2 � The data elements used in this report were obtained trom Pfitchell International's RepairMate Product. Non OEM part information has been provided by their respective suppliers. Calculations of the report are performed by a computer program created by Crash-writeR (C) 1997-2013. (-) Portions of this report were enhanced to reflect the Operator's Judgement for current prices & times. **'` SEE NEXT PAGE '`'`'' New il ZIMMERMAN COLLISION 26069 2nd St West Zimmerman, MN 55398 phone: 763-856-5949/fax: 763-856-5969 CUSTOMER INVOICE # 115010 06/24/13 Page 2 JEFF DURESKY plate: DURE0002 V6 3L 182ci GAS mileage 1996 FORD TAURUS GL SEDAN Vin # ZIMMERMAN , MN 55398 Home:218-7235 Work: Cell: Fax: � COLLISION SUI�lARY COLLISION LABOR RATE Hrs ESTIMATE PAINT 52.00 10.20 530.40 BODY LABOR 52.00 30. 00 1560.00 LABOR TOTAL 40.20 2090.40 PAINT SUPPLIES 32.00 10.20 326.40 SHOP SUPPLIES 5.00 30.00 150.00 GLASS 0.00 $ASE 0.00 PARTS 1573. 1� BASE 1573.17 PART3 6 GLASS 1573.17 LABOR TOTAL 2090.40 SASE 2090.40 PARTS 1573 . 1� LABOR 2090 . 40 Supplies 476 . 40 TAX (6. 8750) 140 . 91 TOTAL 4280.88 New i � ^'� ' � `F �, �,i , r ��r ,, fi p� � ±"���� �,. �� . , � , � r i � �•�, •�'� ,f .� ,/,; �A-S� ,� " . i �%'y' 7 , :"; ����jt���''t� �� r l � ) 'r. �.�}1 ,�� .�' ~� \ l�1• _ �'f�►'�� �/.. .,1� •b) .lA:Y� � . 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