Meade � R�CEIVED
MAY 21 �013
NOTICE OF CLAIM FORM to the City of Saint P�u�..�Vi���s��
Minnea•ota Stcue Stahrte 466.05 stutes that "...eveiy perso�i...w/to cictiina�damages fi�om nny municipaliry...shall caue�e Io be presented tu the
governing�oc/y qf die�riunicipnliq��vithin 180 duys nfter the nl(ebed loss or injtny is cliscovered a notice siating the time,place,nnd
circum�7unces ther-eof,and the cimount of com�e�2sntion or other relief demc�r�ded."
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 clarif'y 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 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 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\,t���\C..C'� Middle Initial�Last Name�Q�'AG��
Company or Business Name�rYl�i ���Gt'rk 1�
Are You an Insurance Company? Yes� If Yes,Claim Number?_.
Street Address �D�� �'U��C�C7lK'Uf'C.t �V�
City�'��n� p�`�` St�te �� Zip CodeeJs����--
Daytime Phone( � Cell Phone ��-�G�vening Telephone( `� -
+�, ch�v�7�'��,
Date of Accident/Injury or Date Discovered.��Vl � �� 2D�2J Time���am/pm
Please state, in detail, ��hat occurred(happened;, and why you are submitting a claim. Please indicate why or how you
f�el the i:ity of Saint Faui or iis e�;��.oyecs ar�, involve�.nd/or re�n�nsible for yo��r damages. I _ V � �V�_�_
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Please check the box(es)that most closely represent the reason for completing this torm:
❑ 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 �A�Iy vehicle was damaged by a plow
❑ My vehicle was wrongfully towed and/or ticketed ❑ I was injured on City property
❑ Other rype of property damage—please specify
❑ Other type of injury—please specify
In order to process your claim you need to include copies of all anplizable 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 or urself before submitting your claim form.
��roperty 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 an}�ticket issued and a copy of the impound ]ot 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
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
i
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims-please complete this section
Were there witnesses to the incident? Yes �o �1��� (circle)
Provide their names, addresses and telephone numbers:
Were the police or law enforcement called? Yes No� Unknown (circle)
If yes, what department or agency? 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. YY�OY-Gc�..vl GL✓��� �ctv�F..4"v
��
S"j"'r� . ►'h�
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.�Q.� ('C�£�- '(� � �Y' �L���� � '�.�-��C1CC.I.VV�'\�1�
Vehicle Claims- lease com lete this section ❑ check box if this section does not a 1
Your Vehicle: Year Make Q Model
License Plate Number �=����State�l l�' Color� 1
Registered Owner.,C'S-s�� 1�? ��Q..
Driver of Vehicle '
Area Damaged
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
InLrv Claims-ule�se comuleie tliis sectic�►� ❑ check bo� �f tllic �ecti�n d�es not a�,olv
� �EIow 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 t)zat all information you /iave 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 �1'` ` 2�� 3
Print the Name of the Person who Completed this Form: .J�'`�5��'�l I��CC�C�U✓
Signature of Person Making the Claim: �`-��1Q-�� G� `��Q��-�
Revised February 201 I
H & M AUTO BODY SHOP
Federal Tax ID: 41-2023429
867 NORTH DALE ST Customer No: 592
Estimate St. Paul, MN 55103 Report No: 591
Phone#: (651)489-2932 Claim#:
4/22/2013 Fax#: (651�489-0448 Assign No:
E-Mail• hongnguyen5338(a�yahoo.com
Vehicle information Owner-Jessica Meade Accident Location
1998 Dodge Intrepid
Style: 4D SED St. Paul, MN 55103
Color: Home Phone: (651) -
Color Code: Work Phone: (651) - Phone#1: -
Production Date: /0 Fax#: (651) - Phone#2: -
License: State: MN Insured- Claimant-
VIN: 263HD46R3WH 117825
Miles In: 0
Miles Out: 0 Home Phone: (651) - Home Phone: (651) -
Condition: Work Phone: (651) - Work Phone: (651) -
Estimator: HONG NGUYEN Fax#: (651) - Fax#: (651) -
Date Assigned:4/22/2013 Date of Loss:4/22/2013 Date of Inspection: 4/22/2013
Options: Stealth,Ali Wheei Drive, Se, Le, Caravan
Descri tion of Work Part Number Price Labor Paint Other
FRONT DOOR-OUTSIDE MIRRORS
' Replace LKQ Left Front Door Mirror,folding, $175.00 ' 0.4 body
unheated
Sub Totals � �
WILL CONTACT IF THERE IS AN ADDITIONAL HIDDEN Hours Rate Total
DAMAGE THAT IS NOT LISTED IN THE ESTIMATE .
Body Labor 0.4hrs $52.00/hr $20.80
LKQ Parts $175.00 T
THANK YOU FOR LETTING US SERVE YOU Tax $175.00 @ 7.6250°,/0 $13.34
Grand Total $209.14
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide. 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. Guide used is(DE3PH98). 1/13
*Indicates Estimator's Judament
T Indicates Taxed Item
SHOP POLICY 1,No guarantee RUST work 2, Store charge daily: Not repaired [inside$50} {outside $30} Rpair After 3 days not
pick up $15 a day 3. Cash Account must be be deposite upon and parts amount . 4.Warrenty parts for 30 days from the invoice
date 5. MUST PAY IN FULL before the car is released including insurance job .
CCC Comp-Est - A product of CCC Information Services Inc.
Page 1 of 1 �
Page 1 of 1
Len's Automotive Service Estimate
1419 7th Street W. 6082
Saint Paul, MN 55102 Estimate Ref#6,082
Shop Phone: (651)221-0160 Date Printed:05/08/2013
Printed Time: 4:44 pm
Web Address: LENSAUTO@COMCAST.NET
HaURef: Lensauto@comcast.net Time Promised:
Meade,Jessica 1998 DODGE INTREPID V6 2.7L 2700CC 167CID FI GAS N R EER
VIN:
License:328 EDZ Mileage In:0 Date Written: 05/OSl2013
Home: Work: unic n: Mileage Out: 0 Written By:
Cell: ooM: Save Old Parts: No
Job Name Description Technician Qty List Extended
Job#1 MIRRORS-Replace-Exter�al Mirror
Labor Rate 1 Work Requested-MIRRORS-Replace- External 50.22
Mirror
Part mi Mirror 1.00 144.15 144.15
Parts: $144.15
Payment Date Type Method Amount Labor: $50.22
Sublet: $0.00
Payment Totals: Misc: $0.00
Hazmat: $2.50
Supplies: $4.96
Tax Total: $11.38
Invoice Total: $213.21
651-221-0160
hereby authorize the above repair work to be done along with the necessary materia�and hereby grant you and/or your employees permission to operate the
ar or truck herein described on streets, highways or elsewhere for the purpose of testing and/or inspection. An express mechanic's lien is hereby
cknowledged on above car or truck to secure the amount of repairs thereto.
Authorized By
Date 'r�...�