Brazier \
RECEIVED
�u� 1 s Za�3
NOTICE OF CLAIM FORM to the City of Saii����u���esota
Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipality...shall cause to be presented to the
governing body of the municipality within 180 days after the alleged loss or injury is discovered a notice stating the time,place,and
circumstarsces 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 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 �r�.vlG�..C( Middle Initial S Last Name �YUZi�%�
Company or Business Name
Are You an Insurance Company? Yes/� If Yes, Claim Number?
Street Address ��DO ��✓i ���5 t�'�/`� ����
City ��/YI.�C ��t r �!�- � , State fVl l� Zip Code-�
Daytime Phone (�)�-�4�Cell Phone�_���-�Evening Telephone(?l) -
Date of Acc�dent/In�ury or Date Discovered � J V` y T�me � m arp'/prp�
��
Please state,in detail, what occurred (happened), and why you are submitting a claim. Please indicate w y or how ou
feel the Cit of Saint Pau r its em 1 yees e inv ved�y�d/or re nsibl for your ma es.
Cl �2 l��C
� r m `
� � -____
,� v� S'� -
v ,� G
o r � ��,--
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 injured on City pro e
❑ Other type of property damage—please sp cif G✓G� PGt� �
❑ Otlier type of injury—please specify � /L r-� ��
In order to process your claim vou negd to include copies of all applicable 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 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 and/or 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
andlor 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—nlease complete this section
Were there witnesses to the incident? es N Unknow (circle)
Provid�heir a es addre ses and te phone r�umb s: ' h'1 OI? Ya�wN Oo ta�
L.l p
Were the police or law enforcement calle ? Yes No Unknown (circle)
If yes, what department or agency? � 2 D i� ase#or report#�I3 7 5�
Where did the accident or injury take place? Provide street address,cross street,intersectio ame f park o faci 't,y,
close landmark, etc. Please be as detailed as possible. If necessary, attach a diagram. �. G�SPi
�� /�� , � /1�
Please indicate the am�tt yqu a_ re,�eekin in compensation or what you would liky the Cit�to do to resolve this claim
to your satisfaction. >� '7h ''�-- �-h'1 Gc � �'+ ��
Vehicle Claims— le com lete this sec ion O heck box if this section does not a 1
Your Vehicle: Year Make % Model �h
License Plate Number State,��/ Color
Registered Owner Z i'�r
Driver of Vehicle r r z� e�
Area Damaged Q G �e.�c i'►'� ��' I
City Vehicle: Year Make Model 0 Cl/�
License Plate Number _ Sta J��! Color _
Driver of Vehicle(City Employee's Name) `
Area Damaged
In'ur Claims— lease com lete this section ❑check box if this section does not a 1
How were vou iniured? (9 h �_.
What part(s)of your body were injured?_T/(i?l'l/�Q.�
Have you sought medical treatment? Yes 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 o
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 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 completed ����
e
Print the Name of the Person who Completed this Form•
�
Signature of Person Making the Cla m:
Revised February 2011
� �J����� BIGHLEY AUTO BODY INC Workfile ID: dOc2d53e
FederalID: 41-1566731
� www.bighleyautobody.com
2409 N. MARGARET ST., N. ST. PAUL, MN 55109
Phone: (651) 777-3535
FAX: (651) 777-6079
Preliminary Estimate
Customer: ., .
Written By: Bill Bighley
Insured: ., . Policy#: Claim #:
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact:
Owner: Inspection Location: Insurance Company:
,, , BIGHLEY AUTO BODY INC
2409 N. MARGARET ST.
N.ST. PAUL, MN 55109
Repair Facility
(651)777-3535 Business
VEHICLE
Year: 2005 Body Sryle: 4D SED VIN: KMHWF35H55A115683 Mileage In:
Make: HYUN Engine: 6-2.7L-FI License: Mileage Out:
Model: SONATA GLS Productlon Date: State: Vehicle Out:
Color: Int: Condition: Job#:
TRANSMISSION Dual Mirrors RADIO Front Side Impact Air Bags �
Automatic Transmission Body Side Moldings AM Radio SEATS
Overdrive Console/Storage FM Radio Cloth Seats
POWER CONVENIENCE Stereo Bucket Seats
Power Steering Air Conditioning Search/Seek WHEELS
Power Brakes Intermittent Wipers CD Player Aluminum/Alloy Wheels
Power Windows Tilt Wheel Cassette PAINT
Power Locks Cruise Control SAFET1f Clear Coat Paint
Power Mirrors Rear Defogger Dnvers Side Air Bag OTHER I
Heated Mirrors Keyless Entry Passenger Air Bag Fog Lamps '
DECOR Alarm 4 Wheel Disc Brakes
7/9/2013 1:26:11 PM 305410 Page 1
Preliminary Estimate
Customer: ., .
Vehicle: 2005 HYUN SONATA GLS 4D SED 6-2.7L-FI
Line Oper Description Part Number Qty Extended Labor Paint
Price�
1 REAR BUMPER
2 * Repl LT Molding w/o bright 866713D021 1 136.39 0.4 4,4
3 Refn Bumper cover Z•6
4 Add for Clear Coat 1.0
SUBTOTALS 136.39 0.4 3.6
ESTIMATE TOTALS
�tEyary Basis Rate Cost#
pa� 136.39
Body Labor 0.4 hrs @ $54.00/hr 21.60
Paint Labor 3.6 hrs @ $54.00/hr 194.40
Paint Supplies 3.6 hrs @ $34.00/hr 122.40
Subtotal 474•79
Sales Tax $258.79 @ 7.1250% 18.44
Grand Total 493.23
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 493.23
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.
7/9/2013 1:26:11 PM 305410 Page 2
' � Preliminary Estimate
Customer: ., .
Vehicle: 2005 HYUN SONATA GLS 4D SED 6-2.7L-FI
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
AER1022, CCC Data Date 7/1/2013, 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 perfiormed 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 2014 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=6oron steel.
CAPA=Certified Automotive Parts Association. D&R=Diswnnect 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. 0/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.
7/9/2013 1:26:11 PM 305410 Page 3
CENTURY AVENUE COLLISION CENTER
WHERE QUALITY & SERVICE COMES FIRST
2501 CE�TURY AVENUE
2 BLOCKS SaUTH OF HWY 36
PHONE: 651-777-6055 FAX: 651-779-9417
CD LOG NO 21476-1 DATE 07/09/13
SHOP: CENTURY AVENUE COLLISION INSP DATE: 07/09/13
ADDRESS : 2501 N0. DIVISION ST CONTACT: GARRY
CITY STATE: NORTH ST PAUL, MN PHONE 1 : (651) 777-6055
ZIP: 55109- FAX: (651) 779-9417
OWNER: BRAZIER, BRENDA HOME PHONE: (651) 214-8703
ADDRESS : 3100 GLEN OAKS
CITY STATE: WHITE BEAR LAKE, MN
ZIP: 55110
POINT OF IMPACT: 8 TYPE OF LOSS : /DRV
LIC#: 264 KDJ STATE: MN VIN: KMHWF35H55A115683
BODY COLOR: BLUE MILEAGE: 208 , 021
CONDITION: ACCTNG CTL# :
DRIVEABLE: YES VEH. INSP# :
PROD.DATE: 07/04 PAINT CODE:
*=USER-ENTERED VALUE E=REPLACE O�EM NG=REPLACE NAGS
EC=REPLACE ECONOMY UE=REPLACE OE SURPLUS UC=RECONDITIONED PRT
UM=REM�1N/REBUILT PRT EU=REPLACE SALVAGE EP=REPLACE PXN
OE=REPLACE PXN OE SRPLS PC=PXN RECONDITIONED PM=PXN REMAN/REBUILT
TE=PARTL REPL PRICE ET=PARTL REPL LABOR IT=PARTIAL REPAIR
I=REPAIR L=REFINISH BR=BLEND REFINISH
TT=TWO-TONE CG=CHIPGUARD SB=SUBLET
N=ADDITIONAL LABOR RI=R&I ASSEMBLY P=CHECK
AA=APPEAR ALLOWANCE RP=RELATED PRIOR UP=UNRELATED PRIOR
ORIGINAL ESTIMATE
CHECK INNERS AT TEARDOWN
ESTIMATOR WILL NOT APPEAR IN COURT TO TESTIFY ON THIS ESTIMATE WITHOUT A FEE
PAID FOR HIS SERVICES AND TIME.
2005 HYUNDAI SONATA GLS 4DOOR SEDAN 6CYL GASOLINE 2 . 7
CODE: E3144B/D OPTNS B/24SDEJN
OPTIONS :
TWO-STAGE - EXTERIOR SURFACES TWO-STAGE - INTERIOR SURFACES
HEATED FRONT SEATS HEATED REMOTE CONTROL MIRRORS
REMOTE KEYLESS ENTRY SYSTEM CLIMATE CONTROLLED A/C
FRONT SIDE IMPACT AIRBAGS
OP GDE MC DESCRIPTION MFG. PART NO. PRICE AJ$ B$ HOURS R
-- --- -- -,---------- ------------ ----- --- -- ----- -
N 0587 REAR BUMPER OVERHAUL ADDNL LABOR OPERA 2 . 0 1
PAGE 1
07/09/13
2005 HYUNDAI SONATA GLS 4DOOR SEDAN
CD LOG NO 21476-1
I 0584 COVER, REAR BUMPER REPAIR 2 . 0*1
L 0584 COVER, REAR BUMPER REFINISH 3 . 1 4
2 . 6 SURFACE
0 . 5 TWO STAGE
E 0502 MLDG, REAR BUMPER CO LT 866713D001 136 . 39 INC 1
L 0502 13 MLDG, REAR BUMPER CO LT REFINISH 1 . 1 4
0 . 4 SURFACE
0 . 6 TWO STAGE SETUP
0 . 1 TWO STAGE
ECM03 FLEX ADDITIVE ECONOMY PART 4 . 00* *4*
SBM60 HAZARD. WSTE. REM. SUBLET REPAIR 3 . 00* *1*
7 ITEMS
MC MESSAGE (S)
13 INCLUDES 0 . 6 HOURS FIRST PANEL TWO-STAGE ALLOWANCE
FINAL CALCULATIONS & ENTRIES
GROSS PARTS 136 . 39
OTHER PARTS 4 . 00
PAINT MATERIAL 142 . 80
PARTS & MATERIAL TOTAL 283 . 19
TAX ON PARTS & MATERIAL @ 7 . 125� 20 . 18
LABOR RATE REPLACE HRS REPAIR HRS
1-SHEET METAL 54 . 00 4 . 0 216 . 00
2-MECH/ELEC 80 . 00
3-FRAME 80 . 00
4-REFINISH 54 . 00 4 . 2 226 . 80
5-PAINT MATERIAL 34 . 00
LABOR TOTAL 442 . 80
SUBLET REPAIRS 3 . 00
TOWING
STORAGE
GROSS TOTAL 749 . 17
NET TOTAL 749 . 17
SHOPLINK U8264 ES CD LOG 21476-1 DATE 07/09/13 01 : 45 : 13PM R6 . 37 CD 05/13
PXN: Y/00/00/00/00/00 CLTM 00/00/00/00/00 GEOCODE 55109
HOST LOG
(C) 1998 - 2008 AUDATEX NORTH AMERICA, INC.
1 .2 HRS WERE ADDED TO THIS EST. BASED ON AUDATEX TWO-STAGE REFINISH FORMULA.
--------------------------------------------------------------------------
THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF ONE OR MORE CRASH PARTS
SUPPLIED BY A SOURCE OTHER THAN THE MANUFACTURER OF YOUR MOTOR VEHICLE.
WARR.ANTIES APPLICABLE TO THESE REPLACEMENT PARTS ARE PROVIDED BY THE PARTS
MANUFACTURER OR DISTRIBUTOR RATHER THAN BY THE MANUFACTURER OF YOUR VEHICLE. A
PAGE 2
07/09/13
2005 HYUNDAI SONATA GLS 4DOOR SEDAN
CD LOG NO 21476-1
PERSON WHO FILES A CLAIM WITH INTENT TO DEFR.AUD OR HELPS COMMIT A FR.AUD
AGAINST AN INSURER IS GUILTY OF A CRIME.
PAGE 3
07/09/13
Accident Report Page 1 of 1
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{��JP OWNERNMIE FIRE ��pWNERNMIE FINE OCCUP
03 City of St. Paul N BRAZIER BRENDA SUE N O1
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g� N. 3100 GLEN OAKS AVE APT 311 N O1
VEM USE Citt,STATE,ZIP M1NC UIRECT C�IV,STAT�21P YULLING MNf-f.T VEM USF.
15 St. Paul, [rIIJ, 55103 `TO` 05 WHITE BEAR LAKE l�IN 55110 "'iq 07 01
UM6lOC Mu(E MOOEL YENi COIOR ANXE MOOH YEM GIXOR OMA lOC
98 golf cart grn HYUN SGX 005 BLU 06
or.w sEV a✓�res sr nec rEnn aEC �nce oc�s � �roarwaw e�rt.vure� s.nec vEw rtec �s��a�,�,�,rmj ,a,TM uoar wa� ouc sev
O1 02 � 02 264KDJ MN 14 02 02 02
�� n�VRN10E POLiClNUI.�EF � IN9UW�NGEN1R2) FOLICYNU�6EIi '
city of St. Paul State Farm unknown
GM30 BD NAZ WT WANED INSPECiqN I N6P BM('£• W�NFD MAi MAT POY
rrre auc IF ACCIDENT WVOIVED A COMMERCWL MOTOR VEHICIE,SCHOOL BU9,OR HEAD START BUS ai.wc rvP[
, �- � REMEMBER TO NOTIFY TNE STATE PATROL(requlred under MS 169.7E1 and 769.�511�. � -
LONAERCIALVEI4CLEMWBERI-MOTCMtUJtRIERNA�IE DOTNUTABER CdiMFRCW.VEHI0.ENM�ERI-MOTORCARRiERN.ME 007M1A6FR
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pWNER OF U'NER DPMAGED PROPERn'AND DESCfiIPtiON OF OMNGEO MiJPEHiYANPOR YELLOW TAG IWA.BERfS) P�MME�PftOPERl1'I VELIOW MG NUEBF31
.... .. . _ .....�.... .:..:..........r ,...... . „-......., ..»,r.
M.CIYP /� � . 1MRRATIVE. ��k OEVICE
; \ �+. 90 I
0 2 �y��\\ , ; _
srw xiro �� C� • .�.
p City of St. Paul employee Tracy Smith told me he ,;
03 N � < was driving city property golf cart / maintenance
� NtlRqNG
.oc,�+ �. olf c t r' cart when he.rear ended tttr LP#.26aKDJ., a 2005 a gg
Unit 1 9 °
06 � ` ? Hyundai Sonata, which was parked legally in i
p+e� / ', parking lot near East Shore-Dri,ve and .E, Wheelock��;� wrRF�
N � Parkway. MbI LP# 264KDJ was unoccupied when rear �.
T.,oEOF�n , � ended by maintenance cart driven by Smith. Smit'h ': 90
srEa,
98 / ` ', reported no injuries. �`, ""'
`` :
�-x I gave R.O. of NIN LP# 264KDJ , Brenda Brazier, :,# 10
�+�z � 5' my business card containing the.CN# and told her 'iiwe.*�eA�
/ ��e < how to get a copy of the accident report. No O1
WJIMERS p � citations were-issued-related�to this..accident
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OffICCR�MIN.WVAEMICBAOGE♦.. .. .... .. .. .. �. . l.l3El�V.. . . .. . . ' MTN0.9TATKK: �STATEPATROI LOGAL
officer Robert Howell 472 St Paul PD �SryEPiFF p���
http://dvslesupport.org/dvsinfo/accidentrecords_200 8/Includes_LE/PrintReportIndiv_LE.as... 7/4/2013