Lasley _ �: ���+����
JUL � 0 2013
NOTICE OF CLAIM FORM to the �i�t�yY CLER�Paul, Minnesota
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
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 ezplain 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. Tlus form must be signed,and bqth pages completed. If something does not apply,write`N/A'.
SEND COMPLETED FORM AND OTHER DOCUMENTS TO: _ , , ��
- - - �AINT PAUL, MN 55102
First Name w C.� Middle Initial�Last Name ���5 �.
Company or Business Name � �
Are You an Insurance Company? Yes�No) If Yes, Claim Number?
�/
Street Address �� \� �,� C�t`.�\�Q C1 �.��Q
City State ��, Zip Code
Daytime Phone(��- Cell Phone �) - Evening Telephone(_) -
I ,`
Date of Accident/Injury or Date Discovered `9^ 1 � ^ ,� Time 4 am m
Please state,in detail,what occurred(happened), and why you are submitting a claim. Please indicate why or how you
- feel the City of S ' t Paul or its employees are involv�d and/or sponsible for your damages.
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ease check the box(es)that most closely represent the reason for completing this form:
y vehicle was damaged in an accident ❑My vehicle was da.maged 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 property
❑ Other type of property damage—please specify
❑ Other type of injury—please specify
In order to process your claim you need 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 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—nlease complete this section
Were there witnesses to the incident? Yes o Unlrnown (circle)
Provide their names, addresses and telephone numbers:
Were the police or law enforcement called? es 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,
osest lan ,etc �ease be as etailed as possible. If necessary, atta.ch a diagram.
� �S� ���
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Please indicate the �t'y^o,u are seeking in,compensationc�or what you would 1'ke the C'ty to do to resolve this claim
t your satisfaction� � � 6 � 0.�` �,�r-� �,
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Vehicle Claims— lease com lete this ction ❑ check box if this section does not a 1
Your Vehicle: Year�2�-`]—Make O Model
License Plate N V �—G L. Sta.te olor
Registered Owner C� `
Driver of Vehicle �i
Area Damaged � Y�C� �
City Vehicle: Year�_Make vf Model = '
� License Plate Number State�C�lo,r_ 6c�
Driver of Vehicle Ci Em loyee's Name) �' �
Area Damaged �
In'ur Claims— lease com lete this section ❑ check box if this section does not a 1
How were you injured? �
� What part(s)of your body were injured?
Have'you sought medical treatment? Yes No Planning to Seek Treatment(circle)
j When did you receive treatment? (provide date(s))
i Name of Medical Provider(s):
Address Telephone
� Did you miss work as a result of your injury? Yes
When did you miss work? (provide da.te(s))
Name of your Employer:
Address Telephone
'6�heck here if you are attaching more pages to this claim form. Number of additional pages
By signing this form,you are stating tliat all information you have provided is true and correct to fhe best
of your knowledge. Unsigned forms will not be processed.
Submitting a false claim can result in prosecution. Date form was completed
�
Print the Name of the Person who Completed this For -t��� °-t S
Signature of Person Making the Clai . a.-L_� �,
Revised February 2011
Accident Report Page 1 of 1
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https://www.dvslesupport.org/dvsinfo/accidentrecords_2008/Inc ludes_LE/P... 6/16/2413
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���`��� �-�t ��.� �;�� LONG'S AUTO PLACE, INC
� � � � �? G I �, � WHOLESALE D�PT PURCHASE/SALES AGREEMENT
1566 RICE STREET
� ��j l�3 SAINT PAUL, MN 55117
ph (651)488-8400 fax (651)389-9139
DLR20729
(DEPT 100 - STOCK# )
Date: 7-23-13
Dealer/Owner Name DAMIA LATRICE LASLEY
Address 2817 WIMBLEDON RIDGE
City, State, Zip Code WOODBURY, MN 55125
Business Phone # 651.283.0460 Fax Ph #
Dealer#
"( O� -� - LERS) '`'06TAIN"OQOMETER:STATEMENT
LAP -WHOLESALE DEPT IS BUY/NG THE FOLLOWING VEHICLE(S)
VEHICLE DESCRIPTION STOCK# MILEAGE AMOUNT
2007 PONTIAC G6 8862 1G2ZM187174179191 93,350 $6,500.00
Vehicle Identification#
TOTAL SALES AMOUNT $6,500.00
BUYER UNDERSTA A V H/CLES ARE SOLD AS/S
BUYER SIGNATURE DATE
printed name
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SELLER SIGNATURE °-" DATE
printed name
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Z�'`�� ���� ��: �;- �;, LONG'S AUTO PLACE, INC
� � � � I G i �� � WHOLESALE DEPT PURCHASE/SALES AGREEMENT
�J/�`� �J� 1566 RICE STREET
SAINT PAUL, MN 55117
ph (651)488-8400 fax (651)389-9139
DLR20729
(DEPT 100 - STOCK# )
Date: 7-23-13
Dealer/Owner Name DAMIA LATRICE LASLEY
Address 2817 WIMBLEDON RIDGE
City, State, Zip Code WOODBURY, MN 55125
Business Phone # 651.283.0460 Fax Ph #
Dealer#
(1�tON'�EA�.�RS) OBTA(N ODOMETER STATEMENT
LAP -WHOLESALE DEPT IS BUY/NG THE FOLLOWING VEHICLE(S)
VEHICLE DESCRIPTION STOCK# MILEAGE AMOUNT
2007 PONTIAC G6 8862 1G2ZM187174179191 93,350 $6,500.00
Vehicle Identification #
TOTAL SALES AMOUNT $6,500.00
BUYER UNDERSTA A I/ H/CLES ARE SOLD AS/S
BUYER SIGNATURE DATE
printed name
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SELLER SIGNATURE �" c� DATE
printed name
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�����7��J���� t'y . .."�,- WOrkfite ID: dd47�86$+�„ ,
Federal ID: 41135344�f'� ��
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Customer: LASLEY, DEMIA
� Written By:�Ric','-=t��,r: � � � �
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Insured: WSLEY, DEMIA !:y i ,� � �`...:
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Type of Loss � : :�; '_ -�. _ � Pair: p �i.
Point of Impact; ��
Owner: r.�.,,�_,.�i�r Location: _..,w.� ..r Company:
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LASLEY, DEMIA ��R'=�:aG'S AUTO BODY
2817 WIMBLEDON RIDGE _ E. '•:�:S�reet
W�ODBURY, MN 55125 �z�.�, "'�J 55130
(651) Z83-0463 Celi '�.:i',ry
-1?, Business
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Year: 200? � F,o � _. _-iC�E �: . �_�_ ���74�7�_?1 Mileage�In:�
Make: � PONT � _. ; :,.6'�FI . _� Mileage Out: � �
ModeL• G6 GTP � � ��; ;: Vehicle Out:
Color: Tr�t� _. . �
TRANSMISSIO� Boc; � �� :vio!�incs ;.::f ,,. Front Side ImpaCt Air Bags
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Automatic Transmission �c: ;c: , aa�e .. ., __ Head/Curtain Air Bags `
Overdrive . ...: . . SEATS '
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POWER _ _ - : . Cloth Seats ; ;�
Power Steerin; -� ; Bucket Seats
Power 6rakes WHEELS
Power Windo��,s � ' • Aluminum/Ailoy Wheels
Power Locks r�:.!� ,� �;" '! PAINT
Power Mirrors " ���..: ,, � �..ri = +� �<.:3 Clear Codt Paint
Power Driver Seat - _ OTHER
DECOR ; .ucn Controls '', Eo9 Lamps ._
Dual Mirrors - . ' s Power Trunk/Gdte RNeds� ��'_
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2 C/� <r; 2.2
3 Repl �u �:;;r,. 29.33 Incl. ; ' 3 0:�>.`
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8 Repl SP�'�' ;•: _ 82.35 Incl. �'`.'
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9 Repl �, _:e ,. ; �: ; 7.68 InCI. �=
10 Repl cr, � _ 54.80 IncL �
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11 FRONT lAMPS �
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12 Repl LT Iiea�la'- . _ Z10.9Q Ir1cL ��r:
13 Aim head.:� 4S �'
14 R2pl LT-r.c I;- i ?33.08 It1CL H°
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Customer: LASLLY, DEMT.� ��=•
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Par:s _ ..__ _ _ ._ ___- �3:� �`+
Body Labc 7.5 h~s @ $54.00/hr 405:00 , ;;
Pa ;t��bc- S.3 h;s @ � � $54.00/hr 47�20 5��;�
� Pa�nt`��a��.:� � s.b�:��; @ � $34.00/hr � 299y20d x-����
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Sa es-.�;: _ iG3.6u @ . 7.6250% 6&90r s`��:
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GREGG'S AUTO BCDY tak�� �;��� .: :. ,� ihat every r::i: :. � _ ��::� ��_<a :_ ;or quality. GREGG'S AUTO > �'� :.:
BODY guarantees labor performec;� fc ;, as you own your • ;c�,�anshi�: and wikl, at our e�cpense , ��!?'
repair or carrect all defects w�ic�� �t� � ;,�nle to defective o� � :� �a��shi� '�: �he repairs stated on the ' ;p ����,` ,
repair invoice. This guarant��� - , - �'���� and does not a�•�': �=:` .. ,a�:�ri�fs or equipment lnrhich may be �`
covered by and s�bject to r:r��-_� •� �:�r or vendors wa� �_ _;-u�t��= ;oes not include darnage �'
caused by or resulting from �� s� :: ,�:�-easonable use, , �� a�;c� ar care of the vehide.The
above is an est+mate basea ��� : :nd does not ccvE ! v�: which may be required
after the work has been or . -�� ;- su�ject to chane: : . -:,a\JEA RIGHT TO CH�SE;A
REPAIR FACILIT( OF YpUR C�-!��CE '•. '� ::f;?�Y APPRECIAT�. " . _ .. : `:. �
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MN ST 60A.955 - A PERSON 1��,/i�rJ T ;.-��iNi WITH INTENT�� ' :irZ H�.!��S COMMIT A FRAUD �"�'
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AGAINST AN INSURER IS GU�-��'' .' " �. � '
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: �,�le: �007 PONT G6 GT=' '. :� ; :; 'I_ _� , °` .°
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Estimate based on MOTOR C"A`�':� �'', GUIDE Unless ._:` ..; a�, .��:�s are derived from the Guid� ���-
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DRIFQ05, CCC Data_Date 7/.�7'�.^ " : ;�arts selected are ": ,a;� �d by the vehicles Original � ��
Equipment Manufacturer. OE� �, . , :!able at OE/Vehicie �=T L_;`1 (Optional OEM) or ALT OEM� �
(Aiternative OEM) parts are C�.�� ;! , . ,-,::y be provided by � . . _;���aL,_ �curces Other than the 0EM � '��
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vehicfe deaierships. OPT OL��� r. -���s may reflect su . �,u:a!, :� .�nique pricing or discount. : ��,,
OPT OEM or ALT OEM parts �� , ,� �ished" parts pro�� : � c= _:F �EM vehicle dealerships , � t�,
Asterisk(*) or pouble Astensk ;'`�; � _ �;�at the parts an�;' :cr �.�r�vided by MOTOR may have Y: ��,
been modified or ma y have ccm� 'r - ;:eYnate data source. -` • , :�ei. _ ��icate MOTQR Not-Included i�Y�,;
: .f� � .... ..
Labor operations. The symbo� ;;�. c. ;'�e refinish oper�; ; -�.� � �o-med as"a separate proeedu�� x��;
from the other panels in the �� �:� ! .'riginal Equipment °',. �:rm � parts are described as Non: �, ��:
OEM or A/M. Used parts ar� �F . , c,, RCY, or USED ;� . rrt� � described as Recond. ` � ���� „
Recored parts are described ._� . � Part Numbers anc� � �v�s ��� �rovided by National Auto
Glass Specifications. Labor �-�z ::. � s::��d on the line �rr�-' , . ,:-:�rrs�4 �:�r are MOTOR suggested labor
operation times. NAGS labcr ���:�:. _ -> :�r.� not included. ��':_.� _ ; :=er.�;� �r.dicate manual entries.
Some 2014 vehicles contain minor `- - � ;��rm the previous yet��� - i"��;� venici�s, �rior to receiving updated �..•,
data from the vehicle manufa�i�.�r_. r ,r:1 parts data fro�Y. i � . .- .r :-� , �a used. The CCC ONE �
estimator has a complete list orv �r: . ,::�:�cies. Parts nurrt;:: ; ��o�; . :.v confirmed with the local , : � ��
dealership. �,:
�.
The following is a list of add��.c� >:: . :s or symbols tha'= ; cie ; �e work to be dane or parts to ,��'
be repaired or r�:placed: � � � � � �� � � ' '�� '
,w:.
� �°
SYMBOLS FOLLOWING PAR+P[2::CF;
m=MtOTOR Mechanical comn�ne��t. �� ,��;�. Structural com�c��ti= --. -�.ei�an°ous Taxed charge category.
X=Miscellaneous Non-Taxed 4siC�fg�� . - y.
S`!MBOLS FnL!._OV!/�NG lABO�: E�'
�=Giagnoscic labar cvteg�;,;� -_ - - � , yaregory. F=�� :lass labor category. �
�1-Mechanica! I�bo� rateg�,,, ::., category. (�-,� . ;; -: :-r Defined Labor Categories_: ��_.
. . � .. . ��f'-����
YSP.�..
OTHER SYMBOLS AND ABBR�VIf,Ti��� . � "
Adj.=Adjacent. Algn.=Align. A�U=:, r�. A/M=Aftermarkei G; : r:.�-3iend. BOR=6oron steel. `�` �
CAPA=Certified Automotive Pa,�, i�:�. -. �: D8:R=Disconnec*. :�c � .��r!�.��t, HSS=High Strength SteeL �'`'
HYD=Hydroformed Steel. I�� =:`r�: � <<�=Like Kind and ��� � �' -a� �'1�,G=Magnesium. Non-Adj.=Non �
, �. �, _.�.,
Adjacent. �lSF=NSF Inte�nG���r��; . . '-a:t. 0/H=Overhau,. . _ . k ° �-l�efinish. Repl=Replace.
R&I=Remave and install. ��.� :: - : ':�piace. Rpr=:-.e��- :-�� .�dwiched SteeL
Sect=Section. Subi=Sub:et, _ ::rength Steel. h '� �_ ``: the estimate line,
�` :
CCC ON� Estimating - A pro�uct �` ' " . rraiion Services Inc ' : �`�:�
. , ,#.
+- - ; .ra�� be used in CCC �?�`'� ���.� : ; '���at a��,� not part of the MOTOR . �-,:
The following is a list of abbre�ia�i��, , '
CRASH ESTIMA,TI�'� GUIDE :
3AR=Bure�3u oF A,atomotive �',;,: . °c:nmental Protec:;_ "`'�S� - �:'ational Highway ` x,:
Transportation and Safety ;-'�c;,, , � '':=Paintless Dent ` . �,sc` . :`�nti�cation Number. �
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