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Swenson RECEIVED MAY 2 2 2013 NOTICE OF CLAIM FORM to the City of Saint Pau��i��e� �K Minnesota State Statute 466.05.rtates that"...every person...w{w clnims damages from any municipality...shall 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 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 additionai sheets. Please note that you will not be contaMed by teSephone to ciarity answe�rs,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 process 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 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 � /� Middle Initial,,,�Last Name��f�/�� Company or Business Name Are You an Insurance Company? Yes� If Yes,Claim Number? Street Address /'�iJ"l�/�cZ- �/��?��f,�� /�� 6 �� City,�,��..�� `�^ ��`� State /L�l��/��/�� Zip Code�� yt' (�)� �ti 'Cell Phone(�)�1�Evening Telephone(_) Da �me Phone � �� - � Date of Accidend Injury or Date Discovered '� Time am/�� Please state,in detail,what occurred(happened),and why you are submitting a claim.Please indicate why or how you feel che City of Saint Paul or it em loyees are involved andlor responsihle for our damages. ��j ,�A�n� �' % ��-� — ' �_ �' `�'' _ - , / ' � T `" C�� ,� 9 J .� � � - �-- lr✓✓�/ =' ' �'- l 4'L� �/�� . ,f,' -� �� f � ._ ,r" �'' � �f �/ � �4 � �re rese �e aso�r co letin �ls�fo`rm��` �r r�� " "��/�J,, �S� `�a's8 c ecl�the box(es�t�iat fno�cTos y p P � �!G �Iy 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 ❑ Other type of injury—please specify In order to process your claim vou need to include conies of all apulicable dceuments. 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 aze 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 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 Failure to complete and return both pages will result in delay in the handling of your claim. All Claims—ulease complete this section Were there witnesses to the incident? es No Unknown� (circle) y, � Provide their names,addre ses and tele hone umbers: ��/�� /l�"U/ ��,T �7j�/Q,� ��.r�� > �i.� ..�- �'114L?t�:� l�'�/��" � T��,�I�/` - ' l � , Were the police or law enforcement called? Yes No Unknown (circle) � ,,� If yes,what department or a ency? ' Case#or report# f'�—�,Z'��'��// �%�C . �� ..5��' ,� 'T Where id the accident or m�U�y take place? Provide street address,cross street,intersection,name of park or facility, closest landmark,etc. Please be as detailed as possible. If neces�ary,attac�di�am.`T �'1� %L� U%��T �-°— ,,,�'��'j�JJ/l/ .�.9g/,�'-'�/1//� �t�` ./�.r` O� T. Please indicate the amount you are seeking in compensarion or w��u would like th�it ,t�o�do to resolve this claim to your satisfaction. ' � � i � � � �� Vehicle Claims— (ease com lete this section ❑check box if this section does not a 1 Your Vehicle: Year Make � Model License Plate Number G� � -�� State Color � � Registered Owner �� Driver of Vehicle � �i' ' �"" Area Damaged � � City Vehicle: Yeaz Make Model License Plate Number State Color Driver of Vehicle(City Employee's Name) Area Damaged Iniurv Claims nlease comnlete this section �l,check box if this secrion dces not aunlv 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�. By signing this form,you are stating that all information you have provided is true and carrect to the best of your knowledge. Unsigned fornts 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 Form: / � r Signature of Person Making the Claim: Revised February 2011 ' LEHMAN'S GARAGE� INC. SOUTH Workfile ID: 3f2afec4 M N PLS Federal ID: 410957340 5431 LYNDALE AVE S, MINNEAPOLIS, MN 55419 Phone: (612) 827-5431 FAX: (612) 827-0076 Preliminary Estimate Customer: SWENSON, BRIAN ]ob Number: Written By: Chad Ege Insured: SWENSON, BRIAN Policy#: Claim#: Type of Loss: Date of Loss: Days to Repair: 0 Point of Impact: 12 Front Owner: Inspection Location: Insurance Company: SWENSON, BRIAN LEHMAN'S GARAGE,INC.SOUTH MNPLS 15422 EMBLEM WAY 5431 LYNDALE AVE S APPLE VALLEY, MN 55124 MINNEAPOLIS, MN 55419 (612)987-8343 Business Repair Faci�ity (612)827-5431 Business VEHICLE Year: 1999 Body Style: 4D UN VIN: 1GNEK13R5XJ400731 Mileage In: Make: CHEV Engine: 8-5.7L-FI License: Mileage Out: Model: TAHOE 4X4 Production Date: State: Vehicle Out: Color: BLACK Int: Condition: Job#: TRANSMISSION DECOR Keyless Entry ROOF Automatic Transmission Tinted Glass RADIO Luggage/Roof Rack 4 Wheel Drive Body Side Moldings AM Radio SEATS Overdrive Dual Mirrors FM Radio Cloth Seats POWER Console/Storage Stereo Recline/Lounge Seats Power Steering CONVENIENCE Cassette WHEELS Power Brakes Air Conditioning Search/Seek Aluminum/Alloy Wheels Power Windows Rear Defogger SAFETY PAINT Power Locks Tilt Wheel Anti-Lock Brakes(4) Clear Coat Paint Power Driver Seat Cruise Control Driver Air Bag TRUCK Power Mirrors Intermittent Wipers Passenger Air Bag Rear Step Bumper 5/16/2013 3:32:30 PM 016370 Page 1 Preliminary Estimate Customer: SWENSON, BRIAN ]ob Number: Vehicle: 1999 CHEV TAHOE 4X4 4D UTV 8-5.7L-FI BLACK Line Oper Description Part Number Qty Extended Labor Paint Price$ 1 FRONT BUMPER 2 0/H front bumper 0.9 3 ** Repl A/M Face bar w/impact strip 15574111 1 263.00 Incl. chrome 4 Add for bumper strip 0.3 5 Repl Impact strip w/o Sport package 15574113 1 77.98 Incl. 6 Repl License bracket w/impact strip 15990674 1 21.28 0.3 7 Repl Filler center 12376285 1 60.27 0.3 0.8 8 Repl LT Filler side 12375170 1 23.40 0.3 0.3 9 Add for Clear Coat 0.1 10 Repl RT Face bar mount bracket 15686152 1 42.97 0.3 11 Repl LT Face bar mount bracket 15686151 1 42.97 03 12 Repl RT Face bar mount plate 15548810 1 7.79 13 Repl LT Face bar mount plate 15548810 1 7.79 14 Repl RT Face bar brace 15686150 1 33.48 0.2 15 Repl LT Face bar brace 15686149 1 33.48 0.2 16 GRILLE 17 ** Repl A/M Grille Blazer,Tahoe chrome 15981106 1 205.00 0.8 18 FRONT LAMPS 19 ** Repl A/M CAPA LT Park/turn lamp 5976838 1 57.00 Incl. 20 FENDER 21 ** Repl A/M CAPA LT Fender 15029229 1 165.00 2.8 2.6 22 Add for Clear Coat 1.0 23 Add for Edging 0.5 24 Add for Inside 0.5 25 R8cI LT Wheel opng mldg chrome 0.3 26 # Subl Hazardous waste removal 1 5.00 X 27 # Refn Cover Car 0•z 28 # Refn Corrosion protection primer 0.3 Z9 * R&I LT Body side mldg black � 30 # POSSIBLE HIDDEN DAMAGE 1 NOTE: WILL NEED TO INSPECT AFfER TEARDOWN SUBTOTALS 1,046.41 7.2 6.3 5/16/2013 3:32:30 PM 016370 Page 2 Preliminary Estimate Customer: SWENSON, BRIAN ]ob Number: Vehicle: 1999 CHEV TAHOE 4X4 4D UTV 8-5.7L-FI BLACK ESTIMATE TOTALS Category Basis Rate Cost$ Parts 1,041.41 Body Labor 7.2 hrs @ $54.00/hr 388.80 Paint Labor 6.3 hrs @ $54.00/hr 340.20 Paint Supplies 6.3 hrs @ $35.00/hr 220.50 Miscellaneous 5.00 Subtotal 1,995.91 Sales Tax $ 1,041.41 @ 7.7750% 80.97 Grand Total 2,076.88 Deductible 0.00 CUSTOMER PAY 0.00 INSURANCE PAY 2,076.88 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. 5/16/2013 3:32:30 PM 016370 Page 3 Preliminary Estimate Customer: SWENSON, BRIAN 7ob Number: Vehicle: 1999 CHEV TAHOE 4X4 4D UTV 8-5.7L-FI BLACK Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide DE1GC92, CCC Data Date 5/9/2013, 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 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=Aftermarket part. BInd=Blend. BOR=Boron 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. 0/H=Overhaul. Qty=Quantity. Refn=Refinish. Repl=Replace. R8cI=Remove and Install. R&R=Remove and Replace. Rpr=Repair. RT=Right. SAS=Sandwiched Steel. 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. 5/16/2013 3:32:30 PM . 016370 Page 4 Preliminary Estimate Customer: SWENSON, BRIAN ]ob Number: Vehicle: 1999 CHEV TAHOE 4X4 4D UN 8-5.7L-FI BLACK ALTERNATE PARTS SUPPLIERS Supplier: Keystone-Complete-Minneapolis Location(s): 3615 MARSHALL STREEf NE, MINNEAPOLIS MN 55418 (800)328-1845 (612)789-1919 Line Description Item# Price 3 A/M Face bar w/impact strip chrome GM1002802DSN $263.00 17 A/M Grille Blazer,Tahoe chrome GM1200238 $205.00 19 A/M CAPA LT Park/turn lamp GM2521128C $57.00 21 A/M CAPA LT Fender GM1240132PP $ 165.00 5/16/2013 3:32:30 PM 016370 Page 5 BONFE'S AUTO SERVICE & BODY Workfile ID: 08dda28c REPAIR CF 380 7TH ST W, SAINT PAUL, MN 55102 Phone: (651) 222-4458 FAX: (651) 224-8640 Preliminary Estimate Customer: Swenson, Brian Written By: MICHAEL FRTTZKAPPS Insured: Swenson, Brian Policy#: Claim #: Type of Loss: Date of Loss: Days to Repair: 0 Point of Impact: 12 Front Owner: Inspection Location: Insurance Company: Swenson, Brian BONFE'S AUTO SERVICE&BODY REPAIR_CF 15422 Emblem Way 380 7TH ST W Apple Valley, MN 55124 SAINT PAUL, MN 55102 (612) 987-8343 Celi Repair Facility (651) 222-4458 Business VEHICLE Year: 1999 Body Style: 4D UTV VIN: 1GNEK13R5XJ400731 Mileage In: Make: CHEV Engine: 8-5.7L-FI License: VCR949 Mileage Out: Model: TAHOE 4X4 Production Date: 10/1998 State: MN Vehicle Out: Color: Black Int: Condition: )ob#: TRANSMISSION Tinted Glass AM Radio Cloth Seats Automatic Transmission Body Side Moldings FM Radio Recline/Lounge Seats 4 Wheel Drive Dual Mirrors Stereo WHEELS Overdrive Console/Storage Cassette Aluminum/Alloy Wheels POW ER CONVENIENCE Search/Seek PAINT Power Steering Air Conditioning SAFETY Clear Coat Paint Power Brakes Rear Defogger Anti-Lock Brakes(4) Two Tone Paint Power Windows Tilt Wheel Driver Air Bag TRUCK Power Locks Cruise Control Passenger Air Bag Rear Step Bumper Power Driver Seat Intermittent Wipers ROOF Power Mirrors Keyless Entry Luggage/Roof Rack DECOR RADIO SEATS 5/17/2013 3:47:57 PM 013793 Page 1 Preliminary Estimate Customer: Swenson, Brian Vehicle: 1999 CHEV TAHOE 4X4 4D UN 8-SJL-FI Black Line Oper Description Part Number Qty Extended Labor Paint Price$ 1 FRONT BUMPER 2 Repl Add for bumper strip 1 0.3 ; 0/H bumper assy �•9 4 Repl Face bar w/impact strip chrome 15574111 1 335.80 Incl. 5 Repl Impact strip w/o Sport package 15574113 1 77.98 Incl. 6 Repl Air deflector w/o Sport package 15569430 1 54.17 Incl. 7 R&I License bracket w/impact strip 03 8 Repl Filler center 12376285 1 60.27 03 0.8 9 Repl LT Filler side 12375170 1 23.40 03 0.3 10 Add for Clear Coat 0.1 11 Add for Two Tone 0.1 12 FRONT LAMPS 13 Repl LT Park/turn lamp 5976838 1 67.48 Incl. 14 R&I LT Headlamp assy 0.5 15 GRILLE 16 Repl Grille Blazer,Tahoe chrome 15981106 1 366.38 0.8 17 FENDER 18 " R&I LT Edge guard 0_1 19 Repl LT Fender 15029229 1 601.78 2.8 2.6 zp Add for Clear Coat 1.0 21 Add for Two Tone 1.0 ZZ Add for Edging 0.5 Z3 Add for Inside 0.5 24 R&I LT Wheel opng mldg chrome 0.3 25 * R&I LT Body side mtdg black �=Z Z6 # R&I LT Mud Guard 0•2 27 FRONT DOOR Zg Blnd LT Outer panel 1.3 Z9 * R&I LT Body side mldg chrome � 30 R&I LT Power mirror w/o heat 0.4 31 R&I LT Handle,outside w/o Denali, 0.4 Escalade 32 R&I LT R&I trim panel 0.4 33 # Repl COVER CAR COMPLETE(2 1 14.00 T 0.2 TIMES) 34 # Repl CORROSION PROTECTION 1 15.00 T 0.5 35 # Repl HAZARDOUS WASTE REMOVAL 1 7.00 T 36 # Refn MASK&TAPE JAMBS 0.3 37 # Refn COLOR, SAND&BUFF PAINT 1.0 ;8 # Repl CLEAN &RE-TAPE MLDG 2 20.00 T 0.8 39 # PART PRICES SUBJECT TO 1 INVOICE 40 # **** POSSIBLE HIDDEN DAMAGE 1 5/17/2013 3:47:57 PM 013793 Page 2 Preliminary Estimate Customer: Swenson, Brian Vehicle: 1999 CHEV TAHOE 4X4 4D UN 8-5.7L-FI Black ****� SUBTOTALS 1,643.26 10.0 9.5 ESTIMATE TOTALS Category Basis Rate Cost$ Parts 1,587.26 Body Labor 10.0 hrs @ $ 56.00/hr 560.00 Paint Labor 9.5 hrs @ $ 56.00/hr 532.00 Paint Supplies 9.5 hrs @ $35.00/hr 332.50 Body Supplies 6.0 hrs @ $3.00/hr 18.00 Miscellaneous 56.00 Subtotal 3,085.76 Sales Tax $ 1,643.26 @ 7.6250% 125.30 Grand Total 3,211.06 Deductible 0.00 CUSTOMER PAY 0.00 INSURANCE PAY 3,211.06 ****************************************************************************** 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. MN ST 60A.955 - A PERSON WHO FILES A CLAIM WITH INTENT TO DEFRAUD OR HELPS COMMIT A FRAUD I AGAINST AN INSURER IS GUILTY OF A CRIME. I II 5/17/Z013 3:47:57 PM 013793 Pa9e 3 v �o �o �n p L ='" � � C �V� G�u�) C1 un7 N� �. O � Q a C N C.N mZ C V � mZ N � c �� ,p� N�� _(� � NNV1�2 .O L�p N �C N y N ftl U � `c �o V c�"o�a � ��a � � 0 0 C N a�0(� M(� N � c N ai :li�m co r� m o � � a �a Q � � a �, � � .. Q � � a o W° N � � �n�- .:� *- aa � ❑ � .� o 0 0 U � � �m y � °' a•tl .�t Z o �/�' � � � U w _ � w .:� �� o :�a i I, , ,