Osterman .�.:'i _i'� -'i!'.� t'I':�1`� ��'_i; 4!_' ,�,i�± F:... 2d��, � - - -
RECEIVED
NO'�'YCE OF CLAIM �'012M to thc Cit�y� of Sa�n:t Pau��I�n�n�l�ta
h117U1F501u•Slll€SflllxtlE�OO.US S1cTftS 2�)(Il ...E'VE.'i}�/)E1'SfJ>t.-.�Wlin clairns ciczrruzges fi•om�anv nuaratcipaliC,W�1Qi��i�Tt��b��diQEi�tU 1�7e
��ovErriir�g boctv nf the mundedpaliTV wirlcin 1 SO drn�s afi�r the allege�!l��ss o�2ri�ury�s`r-liscu;��red�x ravtice stating the iin:r•,PI;��'�n,7i:
circ:mi.rtanc�•s Yhc:reG�,Q�ri�d�tP-11l�tOiPtt nf;vmpensaliun or oth¢Y r�lief d�rnandact-"
Please Co:mE3lete tliis form in its entirety b;V clearl�y ty��fyig or pr9niing��our answer to each questir�n, If ruure space is
needed,attach additional st�eets. �'lease note tb.at yo� �ill uot b�contacfed�y telephone to claz-i�y ans�vers,au pruvide as
n�auch in�ormatiun�s necessar�'to esplaftl your clain�,snd t6e smount of coruf�erysAtiot�beir�tg requested. I'ou n�ll receive y
�-ritten scltnu�'lE:dge�uent once y�ur�orm is received. 'The process caz�talr.e up tu ten w�el:s ur Tonger depEUdirig on the
iiatnre of your claizr�. '�'k�is form must be s►�ned,and bot��ttges completed. If sorriet}1iYt�+doES nOt apply�,write�\!A'.
SEND CUlVIFY,ET��� �N"'OYtlVI AND OTHER DOCl�1Vl�.N'�'S TQ: CI'ITY CLERIi,
X5 WEST IiELLC7GG SLVD, 3].� CITY HALL, S�NT PAUL, l��N �5102
Fiz�t NanZe Nlidd.le Initial I sst Narne��,�f�ir it�
C;omp<�n_y<�r Business Name ��(�� . .
�1xe Y��u au Instu•a�lce Company'? 'Y"es l� If e�,Clz��m Numrer?
Street Address �/ � �GL� WO� V�-'
ciry d i�iqf�L� C���O state� J Zip C'oaz �S/ / �
Dayrime phone ccs r)G yG-°�329�e�1 p��n��' ---- Evening Telephone{��)�8��9
I7ate of AccidcntJ Injury or 1���1'e i]isco�•ered�_��� ' � Time am �,m
Please statc,in de:tail,rv11��t oce��r�red(happened),9nd why you are submiiting a claiin.Please indica.te��rh �or hnw you
fecl it�c Ciry of SainT 1?3uI or its e uyees 3r.involved and/or rtsponsiblc for�oYU-dama�e�. � T F� -',
�r � ��
� 1 Q �
_/?/t.Gc'
P1c3se cF?.ecl:.rhe ho:�.(esj that rnust closely represent the reason for c.om�leting tlzis fnrtn:
�M,v vehicle��as clam.sger3 in axi aeeident ❑1�Zy vehicle vcr�s c�m..a�ed�lurin�a ta��
❑ 1vly veh.icle rwas tiamage�i by:�p���c�le or condition of the str•eet ❑My vehicle rvas c�irn.ageei h��s plo�v
Q M�vchicle wa���'oz�gfulljr tawed and/or ticketed ❑ I��c>as injured on City�rape�y
❑ Uther ty'Pe�f pr.operty c�aznage—please specify -----.
❑ Uther type of iz�jury—please speeify �-�•-
In order to process y�ur cla.im vout need t�inelnde eopies of all applic�ble documents,
For the claims types listc�below,please be siire to i.r�cl:ude the docvments indicsted nr it wil�delay the han.dl.i.n:�of
;vr�ur claim_ Dacurnents WILL NOT be ret�7rneci anci l�coz�.e the propertv of the City. You are encoura�cd t�kee�+a
copv fc�r yc�uTSelf before submitting your claim form.
O Pr<��erty damage clai�i�s to a vehicle:tt���o esti.rr,�tes tor the repazrs to your vehicle if the da.ma�c cr�:ccds
$500_00; or the actu.31 bills andlor rcccipts far the repairs
O '�'��cvin�clairns: legible copies af any tioket zssued and a copy of-tYie impound Iot receipi
O C�ther propertv damabe i%lai.m,s_two rc�r�ir estimates if tlie dainage e:�ceeds�SUO_�U; or the acival bilts
an.cl/or receipts for the rcp3irs;detaiied list of dan�aged items
O Injur_y elsims:medical bi11s,receipts
O Phutog?aphs ar�alwa.ys wtichmc tc�ducument and support your claim but wi1..l n�t be ret�ur�ed.
�?���1 of 2—Please complete and return tioth pages of Claim Form
rl.�.� �!i ?iii_ p��_;�11 ii�: �ij rP�w� F..:'; rdo. r _�
Failure tu cum��lete��.d return�nuYh pa�es will i•esult i:n de)ay in the huntllitt�of your c11i.m.
FUI C:laim�-�A��$se c�malete tbis section
Were tl�ere witnesses to the u�cident? es Nu IJn�.�o�vr� (CiTC1e}
Prot�ide their z?alnes,adc�r�sses arxd teleplione numbers:� � � I F� G �� ��-
Were the police�r law entorcetnent called? RYes 1�To LTnirn�wn (circlej
Tt yes,w11at dep�iiZment ox agency�' '�r.�,v >> G��st#c�r.report# /_� --<�9�=���
ti�'tierc�iid the�c�iclent o.r ir�jiuy take place'' Prr�vi.de street address,eross street,intersect:ic:�n,n.ame of park or fa.cilit}�,
closcst laxidmark,etc. Flca�c t�e ss de� tsileei as possible. I.f zlecessary,:�tt:ich�i e�ia�ram- _
A?'h/ c�'�- ti �„� �C_� o�
I'leasz n�di�ate thz:�lount you are see_l:in�;in ci�ttlpensation or t�vt►�t you c��ould like the City t��do to resol�,-e this claiiz�
to votu�satisfactian. � ��`���? - 7� . - �-� -_--
�'ehicle C'lai��- �lesse com lete this sect:iou ❑check bol if tlus secti.on cloes not a �l -
XOL1T VZIIICIZ: �'ear���_Ma�.��' ��,�—Muael� R C�'� R tA
�,icens�;Ylate Nunlbez' /�i �7-�/'pL' S�ate � Color h� � —
R.egistered C)wner _ ' c
Driver of Ve`hicle
Axea Damaged J�P� �� � � `' � `�`'
City VZ}llClZ_ I�23I It�ake�aPl� Mo 1 " _ - �T vc/�
License Flate Ntunb�.�'fl/-9'� State Colc�r �- �L
Dri��er of Vehicle(t:ity�,mployee's Name)�f.f� , �' s.��J a�'"p�,
flrea T7amas;ed_,_. -_ �---
In'u �ClaimS- IeA��COk�l. lete tbiS section check bo�if this section d�ies not a� lv
How were yoii inj ured`!,_ _ --
What p�rt(sj of yotrr bc�cly��ere snjured? - —=-
Ha�c_q�u so'ught 7nedical tr-�a,tment? Ye: N�� Pl�nnulg to Seel��Yeatrrient{circlej
�Vhen d.i.ii,vutr receive treatment? �ru-�-idc dzte�s)1
[�Tamc�f Meclical Provider(s): _._, --
Address __ ,'7'elephone
i_�i.d you miss�vork as a restilt af you.r injurS'? Yes No
�Vhen did}'ou miss tivork? m __ (pr���'i.�3�date{5))
Natxte of yotu'Empl��yer: Tcl�hone
Address
�(Che�i�hexe xf yuu are attachin�more p:t�es tr�tlxis clsuu form. Ntimber of additianal pages�.
l�y sigtiitig tjars fnrm,you are sta:tin�tlxat all rnf'or�nation you haveproviil�d is tTUe an.d'eorre.ct to tlie best
of yc,a�r�kn.o�t�le.rlge_ Unsigr�ed form,s svil!l nat be pro�essed.
ST�brttlttLtEy�false.clair►i cart �'esY[Ct i�r prnsecution. Date farm nas cuulpleted �=r�� '/`�._
Frint the l�axx�e of the Person who C.ompleted th..3.s�' ---°
;
5;:�;natYxre of�'ersan Making t�he Cl:iim: -
RC��i:SC(3 Fet�rtiaty 2G1 I
FREEWAY AUTO BODY � INC. Workfile ID: cff7368f
FederalID: 411476560
229 SNELLING AVE N, SAINT PAUL, MN 55104 State ID: �298�9z
Phone: (651) 646-7389
FAX: (651) 646-5384
Preliminary Estimate
Customer: OSTERMAN, MICHAEL Job Number:
Written By: MIKE OSTERMAN
Insured: OSTERMAN, MICHAEL Policy #: Claim #:
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact: 12 Front
Owner: Inspection Location: Insurance Company:
OSTERMAN, MICHAEL FREEWAY AUTO BODY, INC.
(651) 646-7389 Business 229 SNELLING AVE N
SAINT PAUL, MN 55104
Repair Facility
(651)646-7389 Day
VEHICLE
Year: 2012 Body Style: 4D SED VIN: 1GiZA5EU3CF217369 Mileage In: 14801
Make: CHEV Engine: 4-2.4L-FI License: 197-JAC Mileage Out:
Model: MALIBU LS Produdion Date: State: MN Vehicle Out:
Color: WHITE Int: Condition: Job#:
TRANSMISSION Dual Mirrors Stereo Bucket Seats
Automatic Transmission Privacy Glass Search/Seek Recline/Lounge Seats
4 Wheel Drive CONVENIENCE CD Player Heated Seats
Overdrive Air Conditioning Premium Radio WHEELS
POWER Tilt Wheel Satellite Radio Aluminum/Alloy Wheels
Power Steering Cruise Control SAFETY PAINT
Power Brakes Intermittent Wipers Anti-Lock Brakes(4) Clear Coat Paint
Power Windows Climate Control Driver Air Bag OTHER
Power Locks Keyless Entry Passenger Air Bag Traction Control
Power Driver Seat Alarm Head/Curtain Air Bags Stability Control
Power Passenger Seat Steering Wheel Controls Front Side Impact Air Bags Fog Lamps
Power Mirrors Message Center Positraction Signal Integrated Mirrors
Heated Mirrors RADIO Communications System
DECOR AM Radio SEATS
Body Side Moldings FM Radio Leather Seats
5/20/2013 1:44:19 PM 030101 Page 1
Preliminary Estimate
Cust�mer: OSTERMAN, MICHAEL Job Number:
Vehicle: 2012 CHEV MALIBU LS 4D SED 4-2.4L-FI WHITE
Line Oper Description Part Number Qty Extended Labor Paint
Price$
1 FRONT BUMPER&GRILLE
2 Repl License bracket 15823714 1 31.50 0.2
3 O/H front bumper 2.5
4 Repl Bumper cover 20832808 1 374.43 Incl. 3.4
5 Add for Clear Coat i•�
6 * Add for fog lamps 0_0
7 Repl Upper grille chrome 15899022 1 105.17 Incl.
8 Repl Lower grille chrome 25784044 1 109.07 Incl.
9 Repl Grille surround lower grille 25784043 1 163.32 Incl.
10 Repl Em�lem 22909142 1 45.92 Incl.
11 FRONT LAMPS
12 Repl LT Headlamp assy 25984638 1 292.60 0.3
13 Aim headlamps 0.5
14 # HAZARDOUS WASTE 1 5.00 X
15 # FLEX ADDITIVE 1 5.00 X
SUBTOTALS 1,132.01 3.5 4.8
ESTIMATE TOTALS
Category Basis Rate Cost$
Parts 1,122.01
Body Labor 3.5 hrs @ $52.00/hr 182.00
Paint Labor 4.8 hrs @ $ 52.00/hr 249.60
Paint Supplies 4.8 hrs @ $32.00/hr 153.60
Miscellaneous 10.00
Subtotal 1,717.21
Sales Tax $ 1,122.01 @ 7.6250% 85.55
Grand Total 1,802.76
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 1,802.76
THIS IS A VISUAL ESTIMATE ONLY. ADDITIONAL PARTS AND LABOR MAY BE REQUIRED UPON VEHICLE TEAR
DOWN. PARTS PRICES SUBJECT TO INVOICE. FREEWAY AUTO BODY OFFERS A LIMITED LIFE TIME WARRANTY ON
REPAIR WORKMANSHIP AND REFINISHING FOR AS LONG AS YOU OWN YOUR VEHICLE. NO WARRANTY FOR RUST
REPAIRS WILL APPLY. PLEASE FEEL FREE TO CONTACT THE MANAGEMENT OF FREEWAY AUTO BODY WITH ANY
QUESTIONS.
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.
5/20/2013 1:44:19 PM 030101 Page 2