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Edwards �- � JUI. 02 2013 NOTICE OF CLAIM FORM t�eYC�yEo��aint Paul, Minnesota Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipality...shal!cause to be presented to the ' governing body of the municipality within I80 days 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 additional sheets. Please note that you may or may not be contacted by telephone to discuss your claim circumstances,so provide as much information as necessary to explain your claim,and the amount of compensation being requested. 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 r-- First N e Middle Initial� Last Name� �.-fGy,�f � Company or Business Name, if applicable Street Address �c���- ��l.�,f/I i'/C!'� �+� City �� ��'ti.L(� �'l�J/� State�� Zip Code� Daytime Telephone (�,�/) ,� �� l��j� Evening Telephone �� Date of Accident/Injury or Date Discovered ✓�`� G 3 Time am�circle) Please state, in detail, what occurred, and why you are submitting a claim. Please indicate why or how you feel e City of Saint Paul or its employees are involved and/or responsible. C c�-� /�. �.r ucc � s�-� r� � 6 Q d�' .ee o I. .�c.r�I � o Q � ,,,� ��CP� c�c /'LC �'"`l U+C. �,J- • K � • '7` �r,�.b � �C' c e s �- � � �� rl 7�' o , � `�i � fG-�- {7f�. Please check the box(es)that most closely represent the reason for completing this form: �icle was damaged in an accident ❑ Vehicle was damaged during a tow ❑ Vehicle was damaged by a pothole or condition of the street ❑ Vehicle was damaged by a plow ❑ Vehicle was wrongfully towed and/or ticketed ❑ Injured on City property ❑ Other type of property damage—please specify ❑ Other type of injury—please specify ❑ Other type not listed—please specify In order to process your claim you need to include copies of all applicable documents. This is a general guideline of what should be submitted with a claim form, but it is not all inclusive. You may be asked to provide additional information depending on your claim. O Property damage claims to a vehicle: at least two estimates for the repairs to your vehicle, or the actual bills and/or receipts for the repairs O Towing claims: legible copies of any tickets issued and copies of the impound lot receipts O Other property damage: repair estimates, detailed list of damaged items O Injury claims: medical bills, receipts O Photographs can be provided but will not be returned. Page 1 of 2—Please complete and return both pages of Claim Form Failure to provide a completed claim form will result in delays in processing. , r Notice of Claim Form, City of Saint Paul, page two All Claims-please complete this section . Were there witnesses to the incident? es No Unknown (circle) If y s, please provide their na e , addresses an telephone numbers: G= r�.� ��� �- G��w•c� � �-C C� S/ �? � �� � Were the police or law enforcement call d? es No Unknown (circle) If yes, what department or agency? �4 Case# or report# L Where did the accident or injury take place? Provid �ee��ddress, cross street, intersection, name of park or facility, closest landmark etc. Please be as detailed as ossible. If helpful, attach a diagram. 0�02/ !r _ � 5- , .C�-� ,�I� Please indicate the amount you are seeking in compensation from is claim or what y u would like the City ' to do to resolve this laim t your s tisfaction. E � J , G �Zo � _-- i Vehicle Claims- lease com lete this secti n � check box if this section does not a 1 Your Vehicle: Year��Make Model y2�M C'�' License Plate Number State���j�Color Registered Owner i � Driver of Vehicle �" Area Damaged City Vehicle: Year �v� Make U Model G f-�d � License Plate Number - tate�Color ��d- w N i�� Driver of Vehicle (City Employee's ame) ��,NN�S Y���`'��"� Area Damaged ��{C� ! �i'T� C�c��(�'�'�,� i�4-�� ,� wK��-�-w�L� In'u Claims- lease com lete this section ❑ check box if this section does not a 1 How were you injured? What paxt(s) of your body were injured? /�/ 1�A- Have you sought medical treatment? Yes o Planning to Seek Treatment (circle) When did you receive treatment? (provide date(s)) Name of Medical Provider(s): Address Teiephone 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 L�Check here if you are attaching more pages to this claim form. Number of additional pages � . By signing fltis form,you are stating fhat all informafion you have provided is true rrect fo ihe est of your knowledg Unsigned forms will not be processed. Submitfing a false c[aim can result in prosecution. Print the Name of the Person who Comp t is For Signature of Person Maki Claim• ' Date form was compl ted ' r U Revised April 2007 HEPPNER'S AUTO BODY (Commons) Workfile ID: a4aec9f3 �E'P��V�E';R'� , � �, � Caring since 1956 624 COMMONS DR, WOODBURY, MN 55125 Phone: (551) 714-1471 FAX: (651) 578-1287 Prelimir�ary Estimate Customer: EDWARDS,]AMES ' Job Number: Written By: Doug Glaus Insured: EDWARDS,)AMES Policy#: Claim #: Type of Loss: Date of Loss: Days to Repair: 0 Point of Impact: Owner: Inspection Location: Insurance Company: EDWARDS,JAMES HEPPNER'S AUTO BODY(Commons) 2212 GLENRIDGE AVE 624 COMMONS DR ST PAUL, MN 55119 WOODBURY, MN 55125 ; (651)587-1547;Day Repair Facility (651)714-147I Day ',�_1•" __..__-.-- VEHICLE Year: 1999 Body Style: 2D CPE VIN: 2G1WW12M3X9262294 Mileage In: Make: CHEV Engine: --_6-3.1L-FI License: Mileage Out: Model: MONTE CARLO LS Production Date: State: Vehicle Out: Color: Int: Condition; ]ob#: TRANSMISSION Power Mirrors RADIO Driver Air Bag Automatic Transmission DECOR AM Radio Passenger Air Bag Overdrive Body Side Moldings FM Radio SEATS POWER Dual Mirrors Stereo Cloth Seats Power Steering CONVENIENCE Cassette WHEELS Power Brakes Air Conditioning Search/Seek Full Wheel Covers Power Windows Tilt Wheel SAFETY PAINT Power Locks Intermittent Wipers Anti-Lock Brakes(4) Clear Coat Paint 7/1/2013 3:11:18 PM 060167 Page 1 Preliminary Estimate Customer: EDWARDS,)AMES Job Number: Vehicle: 1999 CHEV MONTE CARLO LS 2D CPE 6-3.1L-FI + Line Oper Description Part Number Qty Extended Labor Paint Price$ 1 QUARTER PANEL open Repl LT quarter panel 10281317 1 995.53 16.5 3.4 3 Add for Clear Coat ! 1.4 4 Repl Nameplate"Monte Carlo"chrome 10189884 1 35.92 0.2 5 R&I Fuel door Incl. 6 * Rpr Fuel door 1�. 0.3 7 Add for Clear Coat 0.1 8 REAR LAMPS _ _ _ _ . 9 R&I LT Tail lamp assy Incl. _ _ __ ___ _ _ 10 REAR BUMPER li Repl Bumper cover 10184892 1 345.05 1.5 2.6 12 Add for Clear Coat - 1.0 13 Deduct for Rear Bumper R&I -1.0 14 # Repl Flex Additive 1 3.00 X 15 # Repl Car Cover 1 3.00 X 16 # Repl Hazardous Waste Removal 1 5.00 X SUBTOTALS 1,387.50 18.2 8.8 ESTIMATE TOTALS Category Basis Rate Cost$ Parts 1,376.50 Body Labor 18.2 hrs @ $52.00/hr 946.40 Paint Labor 8.8 hrs @ $ 52.00/hr 457.60 Paint Supplies 8.8 hrs @ $32.00/hr 281.60 Body Supplies 19.2 hrs @ $2.00/hr 38.40 Miscellaneous 11.00 Subtotal 3,111.50 Sales Tax $ 1,376.50 @ 7.1250% 98.08 Grand Total 3,209.58 Deductible 0.00 CUSTOMER PAY 0.00 INSURANCE PAY 3,209.58 l 7/1/2013 3:11:18 PM 060167 Page 2 Preliminary Estimate Customer: EDWARDS,7AMES 7ob Number: Vehicle: 1999 CHEV MONTE CARLO LS 2D CPE 6-3.1L-FI QUALITY REPLACEMENT PARTS WARRANTY OUR REPAIR ESTIMATE MAY SPECIFY THE USE OF QU REPLACEMENT PARTS. QUALITY REPLACEMENT PARTS ARE PARTS NOT MANUFACTURED BY OR FOR THE ORI INAL E UIPMENT MANUFACTURER. WE WILL STAND Q BEHIND THE QUALITY REPLACEMENT PARTS THAT ARE SPECIFIED ON THIS ESfIMATE AND USED IN THE REPAIR OF YOUR VEHICLE, FOR AS LONG AS YOU OWN/LEASE THE VEHICLE. WE WARRANT THESE PARTS ARE OF LIKE KIND, QUALITY, SAFEfY, FIT AND PERFORMANCE TO PARTS MANUFACTURED BY OR FOR THE ORIGINAL EQUIPMENT MANUFACTURER. THIS WARRANTY EXCLUSIVELY COVERS LOSS OR DAMAGE THAT IS RELATED TO DEFECTS IN THE QUALITY REPLACEMENT PART. THIS WARRANTY DOES NOT COVER DAMAGE OR PART FAILURE DUE TO IMPROPER INSTALLATION, MISUSE, NEGLECT, ABUSE, IMPROPER MAINTENANCE, ABNORMAL OPERATION, OR NORMAL WEAR &TEAR. SHOULD A SUPPLIER OF A PART SPECIFIED IN OUR REPAIR ESTIMATE, OR THE REPAIR FACILITY THAT PERFORMS THE REPAIR ON YOUR VEHICLE, BE UNABLE TO RESOLVE A LEGITIMATE COMPLAINT ABOUT THE QUALITY REPLACEMENT PART USED IN THE REPAIR, WE WILL MAKE EVERY EFFORT TO SEE THAT THE PROBLEM IS CORRECTED. THIS WARRANTY AND ANY REPRESENTATIONS MADE HEREIN ARE NON-TRANSFERABLE AND EXTEND ONLY TO THE PARTY OWNING/LEASING THE VEHICLE AT THE TIME OF THE REPAIR. FOR ASSISTANCE, PLEASE CONTACT THE NEAREST HELPPOINT CLAIM SERVICES OFFICE. DISCLAIMER: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT INSURANCE CLAIM FOR THE PAYMENT OF A LOSS MAY BE GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN STATE PRISON. THE LABOR AND TAX RATES USED WERE DETERMINED BY THE VEHICLE INSPECTION LOCATION UNLESS THE REPAIR FACILITY WAS KNOWN AT THE TIME OF THE INSPECTION OR ANOTHER LOCATION WAS SPECIFIED BEFORE THE ESTIMATE WAS PREPARED 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. i i 7/1/2013 3:11:18 PM 060167 Page 3 Preliminary Estimate Customer: EDWARDS,JAMES Job Number: Vehicle: 1999 CHEV MONTE CARLO LS 2D CPE 6-3.1L-FI Estimate based on MOTOR CRASH ESTIMATING GUIDE , Unless otherwise noted all items are derived from the Guide DE1CG95, CCC Data Date 6/14/2013, and the parts sele�ted are OEM-parts manufactured by the vehicles Original Equipment Manufacturer. OEM parts are available at OEyVehicle 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 Stee�. 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: I BAR=Bureau of Automotive Repair. EPA=Environmental Protection Agency. NHTSA= National Highway Transportation and Safety Administration. PDR=Paintless Dent Repair. VIN=Vehicle Identification Number. 7/1/2013 3:11:18 PM 060167 Page 4 � - 'Rich Rick Customer Service Manager 651.738.2272 Cell:651.2)0.5252 AUfO BODY 8 6LASS www.abraauto.com 8230 Hudson Road Woodbury,MN 55125 �.�� � Fax:651.738.9795 Emaii:richrick@abraauto.com I ABRA Auto Body & Glass - Woodbury Workfile ID: 2286f8b4 FederalID: 411926323 ABRA...AMERICA'� MOST RECOMMENDED! 8230 Hudson Rd Suit� 100, Woodbury, MN 55125 Phone: 651) 738-2272 FAX: (�51) 738-9795 Prelimihary Estimate Customer: Edwards,James 7ob Number: Written By: Rich Rick Insured: Edwards,]ames Policy#: Claim#: . Type of Loss: Date of Loss: 7/1/2013 12:00:00 PM Days to Repair: 0 Point of Impact: Owner: Inspection Location: Insurance Company: Edwards,James ABRA Auto Body&Glass-Woodbury CUSTOMER PAY 2212 Goodrich Ave 8230 Hudson Rd Suite 100 St Paul, MN 55109 Woodbury, MN 55125 (651)587-1547 Business Repair Facility (651)738-2272 Day VEHICLE Year: 1999 Body Style: 2D CPE VIN: 2G1WW12M3X9262294 Mileage In: Make: CHEV Engine: 6-3.iL-FI License: Mileage Out: Model: MONTE CARLO LS Production Date: State: Vehicle Out: Color: BLACK Int: Condition: Job#: TRANSMISSION Power Mirrors RADIO Driver Air Bag Automatic Transmission DECOR AM Radio Passenger Air Bag Overdrive Body Side Moldings FM Radio SEATS POWER Dual Mirrors Stereo Cloth Seats Power Steering CONVENIENCE Cassette WHEELS Power Brakes Air Conditioning Search/Seek Full Wheel Covers Power Windows Tilt Wheel SAFETIf PAINT Power Locks Intermittent Wipers Anti-Lock Brakes(4) Clear Coat Paint 7/1/2013 2:56:22 PM 057558 Page 1 Preliminary Estimate Customer: Edwards,)ames Job Number: Vehicle: 1999 CHEV MONTE�CARLO LS 2D CPE 6-3.1L-FI BLACK I I Line Oper Description , Part Number Qty Extended Labor Paint Price$ 1 REAR BUMPER ' 2 * Rpr Bumper cover � �,p 2,6 3 Add for Clear Coat 1.0 4 ** Repl A/M RT Molding LS 10176790 1 36.00 0.3 5 ** Repl A/M LT Molding LS 10176790 1 36.00 0.3 6 REAR LAMPS 7 ** Repl A/M LT Side marker lamp 5978477 1 9.00 0.2 8 QUARTER PANEL 9 * Repl LKQ LT quarter panel +30% 10281317 1 390.00 16.0 3.4 10 Add for Clear Coat 1.4 11 Repl LT Outer wheelhouse 12527765 1 220.75 2.5 12 # Rpr Cut and trim LKQ panel 3.0 13 BACK GLASS 14 R&I Back glass GM w/o heated 2.0 15 # Repl 'Urethane Kit 1 25.00 T 16 # Refn 'Corrosion Protection 0.3 17 # Repl �Flex Additive/Adhesion Promoter 1 8.50 X SUBTOTALS 725.25 27.3 8.7 ESTIMATE TOTALS Category Basis Rate Cost$ Parts 691.75 Body Labor 27.3 hrs @ $53.00/hr 1,446.90 Paint Labor 8.7 hrs @ $53.00/hr 461.10 Paint Supplies 8.7 hrs @ $33.00/hr 287.10 Miscellaneous 33.50 Subtotal 2,920.35 Sales Tax $ 1,003.85 @ 7.1250% 71.52 Grand Total 2,991.87 Deductible 0.00 CUSTOMER PAY 0.00 INSURANCE PAY 2,991.87 WARRANTY VALID ONLY WITH ORIGINAL COPY OF YOUR RECEIPT. PARTS PRICES ARE SUBJECT TO INVOICE. NO GUARANTEE ON RUST REPAIRS. DELAYS DUE TO PARTS AVAILABILITY AND INSURANCE COMPANY REINSPECTS CAN AND DO OCCUR, PLEASE UNDERSTAND THAT WE HAVE LITTLE CONTROL OVER SUCH SITUATIONS, BUT, WE WILL MAKE EVERY EFFORT TO REPAIR YOUR CAR AS QUICKLY AS POSSIBLE. REPAIR TIMES ARE BASED ON FLAT RATE GUIDELINES AND MAY OR MAY NOT COINCIDE WITH ACTUAL REPAIR TIME. *****PAYMENT IS REQUIRED IN FULL FOR VEHICLE TO BE RELEASED!****** *****UNLESS OTHER PRIOR ARANGEMENTS ARE MADE***** 7/1/2013 2:56:22 PM 057558 Page 2 Preliminary Estimate Customer: Edwards,)ames ' ]ob Number: Vehicle: 1999 CHEV MONTE'CARLO LS 2D CPE 6-3.1L-FI BLACK 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. I Unless otherwise noted all items are derived from the Guide DE1CG95, CCC Data Date 6/14/2013, and the parts sele¢ted 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. 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=6ureau of Automotive Repair. EPA=Environmental Protection Agency. NHTSA= National Highway Transportation and Safety Administration. PDR=Paintless Dent Repair. VIN=Vehicle Identification Number. 7/1/2013 2:56:22 PM 057558 Page 3 Preliminary Estimate Customer: Edwards,]ames 7ob Number: Vehicle: 1999 CHEV MONTE CARLO LS 2D CPE 6-3.iL-FI BLACK ALTERNATE �ARTS SUPPLIERS Supplier: Keystone-Complete-Minneapolis i Location(s): 3615 MARSHALL STREET NE, MINNEAPOLIS MN 55418 (800)328-1845 (612)789-1919 Line Description Item# Price 4 A/M RT Molding LS GM1158322 $36.00 5 A/M LT Molding LS GM1158322 $36.00 7 A/M LT Side marker lamp GM2860108 $9.00 7/1/2013 2:56:22 PM 057558 Page 4