Stillings �l�sfr��c�-�a��� �far Fi[in� t�otic� o� Claim ta CE�y af $��'��I� �
Mi��nesota State Statute 466.05 NOTICE OF CLAIM...(Elvery person...who claims damages/�"��gy2013
munrcipality..,shall cause to be presented to the goveming body of ihe municipality withi��day�fter the ,
alleged loss or injury is discove�ed a notice stating the time, place, and circumstances th nd�, ��nt of
compensation oi other relief demanded,
Please co�npiete this form in its entirety by typing or printing your answer to each q�estion in
tf�e space provided. If additional space is needed, please attach additional sheets.
_��, PLEASE RETURN THIS Office of City Clerk
COMPLETED FORM T0: 170 City Hall
15 W i<ellogg Blvd
St Paul MN 55102 ,
Your Name: , '
Street Address: - v� 17 v _ _ �Sj' _ _
City: J�,,�O�I` State: � � Zip Code: SSIOI
Daytime Telephone: (�� ��3 29(�. Evening Telephone: (c�y�1'�,P
Date of Accident or Incident: � Z(.P �Day of Week: Time; � •U2 m�r pm (circle onel
Please state, in detaii, wl�at occurred and the circumstances surrounding the event. Indicate how the
City of Saint Paul is invoived, and why you feel the City is responsible.
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Please indicate ��our reason for completing this form:
L::l Veliicle acrident 1--1 Other property damage (please provide specifics below) `� �
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❑ Vehicle was towed �
C� Vef�icle ciamaged ❑ Other injury to person (please provide specifics below) '
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❑ Slipped and fell on City property ''��
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Please provide tf�e names and telephone numbers of any City employees involved in this
incident/accident and I�ow tf�ey were involved:
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Ir your vehicle was involved, please complete the follo�n�ing;
Year, mal.e, and model: ����� {;�,�„� 'T'� �License Plate Number.
Extent and area damaged; ��,K�- '��:,,��,._t k1.,�- �r �-�= ���sse,����� �.��.,<�\:�-.�..l-
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1Nas a City vehicle involved in this accident/incident? Yes � (circle one)
If yes, please complete tl�e following: Type of vehicle
Year, ma!<e, and model
Color of vehicle License Plate Number: -
Description of vehicle
Location of accident/incident (please provide specifics such as street address, intersection, cross streets,
park name, facility name, etc.):
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Please draw or attacti a diagram if a�plical3le: �' - � -
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Please specify the nature and extent of tl�e compensation or other relief you are requesting. Please
attach copies of any bills, receipts, tici<ets, or other documents to support your claim. If you are
claiming damage to a veliicle, p,lease submit two estimates. ��
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�/Vere there witnesses to this accident/incident? Yes ��.�cle one)
If yes, please give the names, addresses, and telephone numbers of the witnesses:
JVere the police called? Yes No (�'ircle one) If yes, what department or agency? � .
�olice report number:
Please print the name of tf�e I
person completing this form: `'�� �t~ �. �
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P{ease sign yo«r name: � � ' � �
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Date form signed:
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�isl: Mgmt Division - Revised 1-30-01 ��i�ii`�'
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PETERS BODY SHOP INC. Workfi�e ID: c9451856
FederalID: 41-1328306
205 OSSEO AVENUE NORTH, ST CLOUD, MN License Number: 25987
56303
Phone: (320) 252-2993
FAX: (320) 252-0137
Preliminary Estimate
Customer: CHICOINE, BRANDY Job Number:
Written By: CHAD HANRATfY
Insured: CHICOINE, BRANDY Policy#: Claim#:
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact: 12 Front
Owner• Inspection Location: Insurence Company:
CHICOINE, BRANDY PETERS BODY SHOP INC.
99 CALIFORNIA AVE W 205 OSSEO AVENUE NORTH
ST.PAUL,MN 55117 ST CLOUD, MN 56303
(320)980-0755 Day Repair Facility
(320)252-2993 Day
VEHICLE
Year: 2009 Body Style: 3D H/B VIN: ]TKDE167190288694 Mileage In:
Make: SCIO Engine: 4-2.4L-FI License: 907KMA Mileage Out:
Model: TC Production Date: 8/2008 State: MN Vehicle Out:
Color: WHI'fE Int: Condition: Job#:
TRANSMISSION CONVENIENCE ! CD Player SEATS
5 Speed Transmission Air CondiUoning Premium Radio Cloth Seats
Overdrive Rear Defogger Auxiliary Audio Connection Bucket Seats
POWER Tilt Wheel SAFETY Recline/Lounge Seats
Power Steering Cruise Control Anti-Lock Brakes(4) WHEELS
Power Brakes Intermittent Wipers Driver Air Bag Aluminum/Alloy Wheels
Power Windows Keyless Entry Passenger Air Bag PAINT
Power Locks Steering Wheel Controls Head/Curtain Air Bags Clear Coat Paint
Power Mirrors RADIO Front Side Impact Air Bags OTHER
Power Trunk/Tailgate AM Radio 4 Wheel Disc Brakes Signal Integrated Mirrors
DECOR FM Radio ROOF
Dual MiROrs Stereo Electric Glass Sunroof
Console/Storage Search/Seek Skyview Roof
2/20/2013 2:53:24 PM 025987 Page 1
Preliminary Estimate
Customer: CHICOINE, BRANDY 7ob Number:
Vehicle: 2009 SCIO TC 3D H/B 4-2.4L-FI WHITE
Line Oper Description Part Number Qty Extended Labor Paint
Price�
1 FRONT BUMPER
2 Repl Bumpercover 5211921906 1 278.91 1.7 2.8
3 Add for Clear Coat 1.1
4 Repl RT Bumper cover side support 5211521020 1 27.61
5 Repl RT Bumper cover mount bracket 5214721010 1 2.76
6 Repl Lower grille w/o RS 1.0 5311221040 1 51.39 Incl.
7 # R&I LIC. PLATE 0.2 _
8 FRONT LAMPS
9 R&I RT Headlamp assy all 0.4
10 * Rpr RT Headlamo�all-SAND& �
BUFF
11 Repl Aim headlamps 1 _ OS _ _
12 FENDER
13 * Rpr RT Fender �,4 2'4
14 Add for Clear Coat 1.0
15 # Refn TINT COLOR 0.5
16 # Refn CORROSION PROTECTION 0�2
17 MISCELLANEOUS OPERATIONS
18 * Repl Cover car/bag 1 10.00 0.2
ig OTHER CHARGES
20 # E.P.C. 1 9.00
SUBTOTALS 379.67 4.5 8.0
ESTIMATE TOTALS
Category Basis Rate Cost$
Parts 370.67
Body Labor 4.5 hrs @ $54.00/hr 243.00
Paint Labor 8.0 hrs @ $54.00/hr 432.00
Paint Supplies 8.0 hrs @ $35.00/hr 280.00
Body Supplies 1.5 hrs @ $8.00/hr 12.00
Other Charges 9.00
Subtota� 1,346.67
Sales Tax $370.67 @ 7.3750% 2734
Grand Total 1,374.01
Deductible
0.00
CUSTOMER PAY 0.00
INSURANCE PAY 1,374.01
ASK ABOUT OUR LIFETIME WARRANTY ON COLLISION REPAIRS
PARTS PRICES SUBJECT TO INVOICE
2/20/2013 2:53:24 PM 025987 Page 2
Preliminary Estimate
Customer: CHICOINE, BRANDY 7ob Number:
Vehicle: 2009 SCIO TC 3D H/B 4-2.4L-FI WHITE
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.
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Uniess otherwise noted all items are derived from the Guide
ARM8560, CCC Data Date 2/14/2013, 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 AM.
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=6lend. 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. O/H=Overhaul. Qty=Quantity. Refn=Refinish. Repl=Replace.
R&I=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.
2/20/2013 2:53:24 PM . 025987 Page 3
ST.CLOUD COLLISION CENTER
1801 8TH STREET SOUTH
ST.CLOUD, MN 56301
OFFICE:320-240-1214 FAX: 320-240-1571
FEDERAL ID#41-156-1062
`"'*PRELIMINARY ESTIMATE'**
02/20/2013 02:57 PM
_ __ _ _ _ _.__ _
Owner �
_ _ _ ... _. ._.__. . .. _
Owner: BRANDY CHICOINE
Address: 99 CALIFORNIA AVE W Work/Day: (320)980-0755
City State Zip: Saint Paul, MN 55117 FAX:
. � _ ._ _ �
' Inspection .. �_ _�
_... . . _ _ _
Inspecfion Date: 02/20/2013 0?:.t8 F�M Inspection Type:
�
Appraiser Name: CURT M FILSMYER Appraiser License#:
Address: 1801 8th Street South Work/Day: (320)240-1214
City State Zip: Saint Cloud, MN 56301 FAX: (320)240-1571
Email: curtfilsmyer@yahoo.com
_ __ _ ... . __ __ _._�
' Repairer _ _ �
__ __ ._ _ _ . ....._. _. _ __. .. _
Repairer: ST CLOUD COLLISION CENTER Contact: MIKE HARMSEN
Address: 1801 8TH ST S Work/Day: (320)240-1214
City State Zip: ST CLOUD, MN 56301 FAX:
Email: m_harmsen@hotmail.com
. �.._ _ . . _ _ __ _ �
Vehicle
2009 Scion tC STD 2 DR Coupe
4cyl Gasoline 2.4
4 Speed Automatic
Lic.Plate: 907KMA Lic State:
Lic Expire: VIN: JTKDE167190288694
Veh Insp#: Mileage Type: Actual
Condition: Code: SC304B
Ext. Refinish: Two-Stage Int. Refinish: Two-Stage
Options
AM/FM CD Player Air Conditioning Alarm System
Aluminum/Alloy Wheels Anti-Lock Brakes Center Console
Cruise Control Digital Clock Digital Signal Processor
Dual Airbags Dual Sunroof Head Airbags
IPOD Control Intermittent Wipers Keyless Entry System
Knee Air Bags Lighted Entry System MP3 Player
Power Brakes Power poor Locks Power Mirrors
Power Steering Power Windows Rear Window Defroster
Rem Trunk-L/Gate Release Side Airbags Sport Seats
Strg Wheel Radio Control Tachometer Theft Deterrent System
Tilt Steering Wheel Tinted Glass Tire Pressure Monitor
Tonneau/Cargo Cover Velour/Cloth Seats
Page 1 of 3
02120/2013 03:00 PM
2009 Scion!C STD 2 DR Coupe
Claim#:
02/20/2013 02:57 PM
. . ..- - -.. . . .. . . .. . ...._. _.. __._.._.._.......___.._.._..... .. .
._._..._.-_._.___._.. _..... .,.. ,... ..... .. _ . _ . .
Damages __ �
Line Op Guide MC Description MFR.Part No. Price ADJ% B% Hours R
1 E 30 46 Cover,Front Bumper 5211921906 $199.00' 0.7 SM
2 L 30 13 Cover,Front Bumper Refinish 3.7 RF
2.6 Surface
0.6 Two-stage setup
0.5 Two-stage
3 E 14 Supt,Front Bumper Mtg RT 5211521020 $27.61 0.9 SM
4 I 42 Headlamp Assy,Halogen RT Repair 0.5" SM
»SAND AND BUFF OUT SCUFFS
5 N 973 Headlamps Aim Additional Labor 0.4 SM
6 SB HAZZ WASTE Sublet Repair $3.00* SM*
7 EC FLEX ADD Replace Economy $5.00' 0.2' SM'
7 Items
MC llAessa�e
13 INCLUDES 0.6 HOURS FIRST PANEL TWO-STAGE ALLOWANCE
46 PRINTABLE ALTERNATE PARTS COMPARE
. _ � .� _ _..._ �
' Estimate Total& Entries
_ _ . __ __. � _ _
Gross Parts $226.61
Other Parts $5.00
Paint Materials $125.80
Parts 8�Material Total $357.41
Tax On Parts Only @ 7.375% $17.08
Labor Rate Replace Repair Hrs Total Hrs
H rs
Sheet Metal (SM) $54.00 1.8 0.9 2.7 $145.80
Mech/Elec(ME) $80.00
Frame(FR) $78.00
Refinish(RF) $54.00 3.7 3.7 $199.80
Paint Materials $34.00
Labor Total 6.4 Hours $345.60
Sublet Repairs $3.00
Gross Totai $723.09
Net Total $723.09
Alternate Parts Y/01/00/OOI01/01 CUM 01/00/00/01/01 Zip Code: 56301 Default
Audatex Estimating 6.0.925 ES 02/20/2013 03:00 PM REL 6.0.925 DT 01/01/2013 DB 02/15/2013
Copyright(C)2011 Audatex North America, Inc.
1.1 HRS WERE ADDED TO THIS ESTIMATE BASED ON AUDATEX'S TWO-STAGE REFINISH FORMULA.
0220/2013 03:00 PM Page 2 of 3
2009 Scion IC STD 2 DR Coupe
Claim#: 02/20/2013 02:57 PM
A PERSON WHO KNOWINGLY AND VdITH INTENT TO DEFRAUD AN INSURER FILES A
STATEMENT OF CLAIM CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING
INFORMATION COMMITS A FELONY.
Op Codes
� = User-Entered Value E = Replace OEM NG= Replace NAGS
EC= Repiace 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 contair.s proprietar;infcrmation of Audatex and may not be discicsed 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
!�4��a C`�X Audatex's prior written consent.
ce 5a'c'�y tv�r���d%ir.
- - Copyright(C)2011 Audatex North America, Inc.
Audatex Estimating is a trademark of Audatex North America, Inc.
Page 3 ot 3
02/2012013 03:00 PM