Hicks ����IVED
JUL 05 2013
NOTICE OF CLAIM FORM to the City of Sa�'ri�t�a��esota
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 municipa[ity within 180 days after the al[eged 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 will not be contacted by telephone to clarify answers,so provide as
much information as necessary to explain your claim,and the amount of compensation being requested. You will receive a
written aclu�owledgement 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�V,-IJUY � Middle Initial Last Name� �
Company or Business Name 'P
Are You an Insurance Compan . Yes � o If Yes,Claim Number?
Street Address I�� ��'e •
City Statell�O Zip Code �5a �
:�x- , a ag
Daytime Phone( )333_aZ�Cell Phone ) - Evening Telephone( ) -
Date of Accident/Injury or Date Discovered a � Time 0��� am/��
Please state,in detail, what occurred(happened),and why you are submitting a claim.Please indicate why or how you
th City o aint P ul Rr_its ploy es e i volved and/or responsible f r your d ages.
-e.e ro
l�1 �T�Pla ' ( -(o � — C
Please check the box(es)that most closely represent the reason for completing this form:
❑ 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 ❑ My vehicle was damaged by a plow
❑ My vehicle was wrongfully towed and/or ticketed . I was injur d on City ropert �" !
�Other type of property damage—please specify���P.Q I���1_� �t�Q���.YI ��.�, '
� Other type of injury—please specify �
In order to process your claim vou need to include copies of all anulicable documents. I
For the claims types listed below,please be sure to include the documents indicated or it will delay the handling of
your claim. Documents WII.L NOT be returned and become the property of the City. You are 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 andlor 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—please comulete this section
Were there witnesses to the incident? Yes � Unknown (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,
cl sest landmark etc. Pleas e as detailed as ossible. If necessary, attach a diagram.
��� U� 11��.�r����c�lr�.�oCu ��J-, m/� �!I�z
Please indicate the amou you are eeking in comp�nsation or hat you would like the C'ty to do to resolve this claim
to ur satis action. �5�-
r �
Vehicle Claims— lease com lete this s c 'on ❑check box if this section does not a 1
Your Vehicle: Year Make Model
License Plate Number State�Ll Color �'}'1rY�6�
Registered Owner
Driver of Vehicle
Area Damaged `-P
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
In�urv Claims—Qlease complete this section ❑ check box if this section does not applv
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
�heck here if you are attaching more pages to this claim form. Number of additional pages �.
By signing this fornz,you are stating that all information you have 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 com leted � ����
Print the Name of the Person who Co p t d this Form: ��
Signature of Person Making the Cla'
Revised February 2011
Date: 6/17l2013 0358 PM
Estimate ID: 9933060184
Estimate Version: 0
Committed
Profile ID: PDA DEFAULT
Property Damage Appraisers
Box 16173,Minneapolis,MN 55416
(952)884-3334
Fax: (952)884-3725
Email: pdaminn�polls�pdaorg.net
Damage Assessed By: Chris Eschen Appraised for: DAWN STODDARD CCC
iFttiFikit,t**it*ikttikik*Rrt*iFitlFitikrtitrtrt*ltikitirikiFlF#�k*1FiFiF1F#*ititrt*ikrttFrtit*�rlkiFit4it�t�lrltrkrtit*+trtrt
**1k1k**it**1k**1k1k***'k**'k******'k****1k*********#****'k****ik**tk*ik****#1k******
All finals with invoices need to be faxed or emailed to 952-884-3125,
or pdaminneapolis@pdaorg.net. Also, please eraail supplement photos to
address above. Supplements wili not be processed
unless there are both photos and invoices.Please call me about
supplements, DO NOT FAX OR EMAIL THEM! !
****rt***,r**t*,r****,t***tr***,t,r**te*********,t*************rt****,r********w*
***rtie*#****rt*,t*ir*ir**iF*ir##itir**rtirir**#*,t***ie*it**ir***#*rtrt*,t*ir*1F,tit*it*rt#irrtit*
612-597-1833 (cell#)
Chris Eschen-Appraiser
pdaminneapolis@pdaorq.net
Condition Code: Good
Date of Loss: 6/9/2013
Deductible: 0.00
File Number: 9933060184
Policy No: 22-A-J72514 Claim Number: 22-A-2NN180-V1
Insured: ERIN ANEIIPA
Owner: ERIN ANETIPA
Address: 885 WILDER ST S,ST PAUL,MN 55116-2045
Telephone: Work Phone: (651)69&1120
Mitchell Service: 911357
Description: 2013 Honda Odyssey EX-L
Body Style: VanPass Drive Train: 3.51 InJ 6 Cyl 2WD
VIN: 5FNRL5H66DB0806B0 License: 470-KFH MN
OEM/ALT: A Search Code: 993
Color: MAROON
Options: PASSENGER AIRBAG,DRIVER AIRBAG,POWER DRIVER SEAT,POWER LOCK,POWER WINDOW
REAR WINDOW DEFOGGER,CRUISE CONTROL,TILT STEERING COLUMN,LEATHER SEAT
POWER PASSENGER SEAT,TELESCOPIC STEERING COLUMN,ANTI-LOCK BRAKE SYS.
TRAC110N CONTROL,ALUMIALLOY WIiEELS,REARVIEW CAMERA,AUXILIARY INPUT
IPOD ADAPTER,LEATHER STEERING WHEEL,SATELLRE RADIO,FRONT AIR DAM
TINTED GLASS,AUTO AIR CONDITION,TRIP COMPUTER,THIRD ROW SPLff BENCH SEAT
SUBWOOFER,UNIVERSAL GARAGE DOOR OPENER,VARIABLE ASSISTED STEERING
SIDE AIRBAGS,ANTI-THEFT SYSTEM,AUTOMATIC HEADLIGHTS
INTERIOR AUTOMATIC DAYMIGHT OR ELECTROCHROMATIC MIRROR
SIDE HEAD CURTAIN AIRBAGS,DUAL POWER SLIQING DOORS,DAYTIME RUNNING LIGH75
AM/FM STEREO CD/MP3 PLAYER,ELECTRONIC P/�RKING AID,ELECTRONIC STABILITY CONTROL
FRONT HEATED BUCKET SEATS,FRONT SEATS WffH POWER LUMBAR SUPPORT
INTERIOR AIR FILTER,KEYLESS ENTRY SYSTEM,POWER DISC BRAKES
POWER HEATED EXTERIOR MIRRORS,REAR SPOILER,REAR WINDOW WIPER
SECOND ROW SPLIT FOLDING BENCH SEAT,STEERING NMEEL AUDIO CONTROLS
SUNROOF/MOONROOF(POWER)
ESTIMATE RECALL NUMBER: 06/17/207 3 1 5:5820 9933060184
MRchell Data Version: OEM: MAY_13_V0612
MAPP:MAY_13_V0609 CopyrigM(C)1994-2013 Mitchell International Page 1 of 4
Date: 6/17l2013 03:58 PM
Estimate ID: 9933060164
Estimate Version: 0
CommiHed
Profile ID: PDA DEFAULT
ESTIMATE IS SUSJECT TO AN AUDIT BY THE INSURANCE COI�ANY.
IF YOU HAVE ANY QUE3TION3 REGARDING PAYMENT, PLEA3E CONTACT
TSE INSURANCE COI�ANY. THEIR INFO IS AT THE END OF THE ESTIMATE.
Line EMry l.abor Line Nem Part Type/ Dollar Labor
I►em Number Type Operatlon Descriptlon Part Number Amount Units
1 102320 REF BLEND R Roof Rail C O.B #
2 900500 BDY' REMOVE/REPLACE URE7HANE Kff-PRICE FROM SAFELITE AUTO GLAS "QUAL REPL PART Z0.00 ` INC'
3 877-800-2727
4 101851 BDY REMOVE/INSTALL R Rocker Moulding 0.4
5 102062 BDY REPAIR R Van Side Panel Existing 6.0'�!
6 AUTO REF REFINISH R Van Side Panel Outsid� C 2.8
7 100209 GLS REMOVElINSTALL R Quarter Glass INC #
8 101586 GLS REMOVE/REPLACE R Qtr Glass Stationary 73511-TK8-1�1 275.05 2.6 #
g MLDG ONLY COMES WITH GLASS ASSY
10 100199 BDY REMOVEJINSTALL R Resr Combination Lamp 0.3
11 100206 BDY REMOVE/INSTALL Rear Bumper Assy 0.8
12 AUTO REF ADD'L OPR Clear Coat �•3
13 AUTO ADD'L COST PaInUMaterials 150.40 "
"-Judgment Item
#-Labor Note Applies
C-Included in Clear Coat Calc
Estimate Totals
Add'I
Labor Sublet
I. Labor Subtotals UnNs Rate Amount Amoum Totals II. Part ReplacemeM Summary Amount
Body 7.5 52.00 0.00 0.00 390.00 Taxable Parts 295.05
Refinish 4.7 52.00 0.00 0.00 244.40 Sales Tax @ 7.12596 21.02
Glass 2.6 52.00 0.00 0.00 135.20
Total Replacemerrt Parts Amount 316.07
Non-Tazable Labor 769.60
Labor Summary 14.8 769.60
III. Additlonal Costs Amount N. Adjustments Amour»
Non-Taxable Costs 150.40 Insurance Deductible 0.00
Total Additional Costs 150.40 Customer Responsibility 0.00
Paint Material Method:Rates
Init Rate=32.00 ,InN Max Hourl=99.9,Addl Rate=0.00
I. Total Labor: 769.60
II. Total Replacement Parts: 316.07
III. Total Addflional Costs: 150.40
Gross Total: 1,238.07
ESTIMATE RECALL NUMBER: 06/17/201315:5820 9933060184
MRchell Data Version: OEM: MAY_13_V0612
MAPP:MAY_13_V0609 CopyrigM(C)1994-2013 MHchell International Page 2 of 4
Date: 6/17/2013 03:58 PM
Estimate ID: 9933060184
Estimate Version: 0
Committed
Protile ID: PDA DEFAULT
N. Total Adjustments: 0.00
Net Total: 1,236.07
Point(s)of Impact
4 Right Rear Side(P)
insurance Co: AMERICAN NATIONAL PROP-ANPAC
Address: 1949 E SUNSHINE
SPRINGFIELD,MO 6589&0782
Work Phone: (800)553-5270
Fax Phone: (417)887-1802
Inspection Site: OWNERS RESIDENCE
46
ST PAUL,MN
Inspection Date: 6/17/2013
BodyShop: UNDECIDED
ititltrtik,tit*itit*#*rtit*itit�r**it7trFlk�krtitiF#it�kik*rtit�tltitititrF*it�kitirikit#it�t#lt�FitititiritytiF##,titlFir*
TSIS I3 NOT AN AUTHORIZATION FOR REPAIR NOR A GUARANTEE OF PAYMENT.
PROVIDING A COPY OF THIS APPRAISAL IS NOT AN AUTHORIZATION TO REPAIR.
ALL COST OF REPAIRS ARE THE SOLE RE3PONSIBILITY OF THE OWNER.
PROVIDING A COPY OF THIS APPRAISAL IS NOT AN ACCEPTANCE OF COVERAGE
OR LIABILITY AND ALL ISSUE3 OF COVERAGE OR LIABILITY ARE TO SE
DETERMINED
BY THE INSURANCE CARRIER.
ALL SUPPLEMENT3 MUST BE IN3PECTED BY THE APPRAI3ER LISTED ABOVE.
THIS ESTIMATE MAY INCLWE REPLACEI�NT PARTS 3UPPLIED BY A SOURCE
OTHER THAN THE MANUFACTURER OF YOUR VEHICLE. WARRANTIES APPLICASLE TO
TAESE REPLACEMENT PARTS ARE PROVIDED 8Y THE 1�1N(JFACTURER OR
DISTRIBUTOR OF THESE PARTS RATHER THAN TFIE MANUFACTURER OF YOUR
VEHICLE.
l�i LAW
A PER30N WSO SUBMITS AN APPLICATION OR FILES A CLAIM WITA INTENT TO
DEFRAUD OR HELP3 CO�+lIT A FRAUD AGAIN3T AN INSURER IS GUILTY OF A
CRIME IN MINNESOTA
ESTIMATE RECALL NUMBER: 06l17/201315:5820 9933060764
MRchell Data Verslon: OEM: MAY_13_V0612
MAPP:MAY_13_V0609 CopyrigM(C)1994-2013 Miichell International Page 3 of 4
Date: 6/17/2013 0358 PM
Estlmate ID: 9933060184
Estimate Version: 0
CommtHed
Profile ID: PDA DEFAULT
rt****ikit*1F*rt****rF1FiF�t*iF#*rtlk***iFrt*1k**rt********irik**1k****#*�tlFitikit*#***ik*iFitit*
ESTIMATE flECALL NUMBER: 06117/2013 75:5870 9933060184
Mttchell Data Version: OEM: MAY_13_V0612
MAPP:MAY_13_V0609 Copyright(C)1994-2013 Mitchell International Page 4 of 4
Date: 6/17/2013 0358 PM
Estimate ID: 9933060184
Estimate Version: 0
Commiped
Protile ID: PDA DEFAULT
Itemized Totals
I. Labor Subtotals Units Rate Totals II. Part Replacement Summary Amount
gpdy 7.5 52.00 390.00 Taxable Parts 295.05
Repair 6.0 " 312.00 New 275.05
Remove/Insiall 1.5 " 78.00 '"Qual Repl Part 20.00
Refinish 4.7 52.00 244.40
Blend 0.6 " 31.20 Sales Tax @ 7.125% 21.02
Refinish Only 2.8 " 145.60
AdditionalOperation 1.3 " 67.60
Total Replacement Parts Amount 316.07
Glass 2.6 52.00 135.20
Remove/Replace 2.6 " 13520
Non-Taxable Labor 769.60
Labor Summary 14.8 769.60
III. Additional Costs Amount IV. AdjustmeMs Amount
Non-Taxable Costs 150.40 Insurance Deductible 0.00
Total AddRional Costs 150.40 Customer Responsibilityr 0.00
Paint AAaterial Method:Rates
InR Rate=32.00 ,Inft Max Hours=99.9,/Wdl Rate=0.00
I. Total Labor: 769.60
II. Total Replacement Parts: 316.07
III. Total Addkional Costs: 150.40
Gross Total: 1,236.07
N. Total Adjustments: 0.00
Net Total: 1,236.07
ESTiMATE RECALL NUMBER: 06/7 7/201 3 1 5:5820 9933060184
MRchell Data Version: OEM: MAY_13_V0612
MAPP:MAY_73_V0609 Copyright(C)1994-2013 Mitchell Intarnational �9e � � �
Claim Reference ID:22-A-2NN180-V1
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Claim Reference ID:22-A-2NN180-V1
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