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NOTICE OF CLAIM FORM to the City of Saint Paul, Minneso��C, 013
Minnesota State Statute 466.05 states that"...every person...who claims damages from any municipality...shall cause to be presented to tRb.-/Q
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 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 �Q` Middle Initial Last Name �� I a nL°-
Company or Business Name
Are You an Insurance Company? Yes No If Yes,Claim Number?
Street Address O�O J( �G�� C� ��
City � ""����- �t�Yl QS Stat�e �� Zip Code��I
Daytime Phone(���) 3O$'�J�O�Cell Phone�) �-�Evening Telephone(�O5 )� ��3(°
Date of Accident/Injury or Date Discovered ���-13 Time � am pm
Please state,in detail, what occurred(happened),and why you are submitting a claim.Please indicate why or how you
feel the City of Saint Paul or its emplo ees are involvgd and/or responsible for our damages. l �- �.1Q�
'.. p� �r a.v,e�a� ed� -�e�r `Fl� oc..J Sc�o -t�n r rt
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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 property
❑ Other type of property damage—please speciiy
�Other type of injury—please specify M-��A���C i.t�S /� �"t,t►'t GtS /'PcS'u/ d GCl'��-PK'�•
In order to process your claim vou 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 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;ar the actual bills and/or receipts for the repairs �'pc r 1S (�CT�- GQY'1��ILZ�oI .E?�
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-alease complete this section
Were there witnesses to the incident? Yes No 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? S , QU. Case#or report# /3/ �P� ��-1
Where did the accident or injury take place? Provide street address,cross street, intersection,name of park or facility,
closest landmark,etc. Please be as detailed as possible. If necessary attach a dia ram. �yt�e-►rS'eCl-t���'►
of M�'v�r�c� I�a I,.a- a+'.�i ba 1� ;� 5-fi. �aex.l (�s.e.� t���'e e r�r-���F�
Please indicate the amount you are seeking in compensation or what you would like the City to do tq resolve this claim
to your satisfaction. �-fi C' �y�t. a� y /i.-t� d a ��.,ci
�. �,1e .,;c� �� a�..-� r2._ a a r e �.�i 5 Q •
Vehicle Claims- lease com lete this section ❑ check box if this section does not a 1
Your Vehicle: Year .�[�Qf� Make trC nZModel � Z-0
License Plate Number I fX���/� State M 1l� Color C�e r►-� re
Registered Owner �/A 1 ,r'i f.3 P��+'��
Driver of Vehicle i
AreaDamaged P�odv/Fr�rn� � tr�Ar bt,�r►a�' -f-rt,cf.IC. c<,"l i4�'�� '�; 1"�a-►'�oo�'S
City Vehicle: Year aD�(ke Model
License Plate Number �`j l -�'i State �� Color n��Oi-°'�
Driver of Vehicle(City Emplo ee's Name) /'1?Ct n(,�e �1� bQ r ��r.
Area Damaged D �a
In'ur Claims- lease com lete this section ❑ check box if this section does not a 1
How were vou iniured� �2�tYendP N Q G�y4.P_— C �' v'C C
CILUSQ �K �
What part(s)of your body we e injured? PC � �du �{.�2�' ���
Have you sought medical treatment? Yes No Planning to Seek Treatment(circle)
When did you receive treatment? g' -�� (provide date(s))
Name of Medical Provider(s): /�On�
Address Telephone
Did you miss work as a result of your injury? � Yes No
When did you miss work? -� -�'/ ° �0 �r $- j2 . (provide date(s))
Name of your Employer: �h�2 Y �o'►Q A r'V�C e
Address �pl �(�`�'� �" � 3i� -� ` Telephone �7 �" c5�9 — /�5 �
22..
�1.Check here if you are attaching more pages to this claim form. Number of additional pages s .
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 $— ��' ���
Print the Name of the Person who Completed this F �L—a , v �
Signature of Person Making the Claim: -
Revised February 201 I
, Accident Report Page 1 of 1
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01" Vehiclea 1 and 2 aere eastbound Hinnehaha,
� ( � _
03 � waiting�to turn northbound Dale. Vehiclea were �p
L O1 ;,� �arrr�ww B I I I �� °i""� �.COpped i] traffic. .VehicLe 1 rear-e�ded vehicl O1
2. No in uries.
Nf MI
OIMIOGE .}�
N ��; _ _ _ • Vehicle 1 had no front damaqe. Vehicle 2 had 09
�a��d�- — � — ' �iltoderate rear damage. v�
� ...... :::.`
98 Driver ot vehicle 1 said vehicle 2 uae�in the
� �j _ intarsection, waiti�g to tuGn nqr.ChbQUqd. .The. ��
— — — � — semaphore chanqed to yellow snd the driver of 01
� _ _ ,_ �3 vehicle 2 stopped-suddenly in tha intersection._ . ���
— - - � The driver of vehicle 1 believed vehicle 2 vas
�,a, .�. # going to turn norttrbound and began to move
fosward in hi� Lane of traffic• Vehicle 1 struck �,oa
OS � 8 I I I 0 :;i vehicle 2 because i[ atopped auddenly. Driver of O1
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� ;;� vehlcle 1 aaid he was drivinq lU- mp . �
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Officer Baumhofer 567�''r��, � v—
Case#:13167704
Report�ate:8I8/2013
Accident Narrative,continued:
Driver of vehicte 2 said she stopped when the semaphore tumed to yellow and was then struck by vehicle 1. �
Vehide 1 is owned by the City of St.Paul. Photographs taken oE scene. Packetwriter report completed.
https://dvslesupport.org/dvsinfo/accidentrecords_2008/Includes_LE/PrintReportIndiv_LE.as... 8/8/2013
Va( ��c�e�
GOOK'S ONE STOP SHOPS LEXINGTON
9073 SOUTH HWY DRIVE
LEXINGTON,MN 55014-3936
BUS.(763)786-2646
FAX(763 786-8285
'"'*PRELIMINARY ESTIMATE*•*
08/12/2013 12:17 PM
.,__ . ._ _ . .. _.. _. .. �.. ,
4 Owner
Owner: bellome
.... ._ �__.__�_._. .
.___._______.____ _._..� ,
€.. _._ .. , _ _ . _ ._. . _ `
� Inspection '
......_.., ...,........ _. .�.�.>._..._ ��........� ,...e.....e_.�....._,.. . .._._._..,«_....�..... .,... . .._...- ........_....�..__�����., .... .._..,.....�..��...m�..���_�..�.�� f
Inspection Date: 08/12/2013 12:18 PM Inspection Type:
Primary Impact: Rear Secondary Impact:
Company: cooks one stop shop Appraiser License#:
Contact: pat j mevissen
Address: 9073 south highway dr Work/Day: (763)786-2646
Home/Evening: (763)227-2941
City State Zip: Lexington,MN 55014 FAX: (763)786-8285
Email: mevissenp@yahoo.com
_. ___ ... .__ ...- _._... .___..._ ... ...._..�_ _.... _�_.�_ .._.__..��,__ __..._.._._,._�._..._ _____. m.�__.. . .._.____._ _�._.�__,____.__..�.__._�__.._..__,_.._._.�_,______�
; Repairer �.....__.. _..__--._.___..�, ._..________.___ _.._i
. _ . . . _ _ __ .___ _ _,.. ��,. _.._ ___ ..._.�.__ _ ._____._ ..,_.._. . _____.__, __. _...�__,
Repairer: Pat Mevissen Contact:
Address: 9073 South Highway Dr Work/Day: (763)786-2646
FAX: (763)786�285
City State Zip: Lexington, MN 55014 Work/Day:
Email: davi21@peoplepc.com
,._._____.._____
_ ______..,. _.. . _..__. ._ _._.., .____._. �, ___._._ �._,_�_____..__.�,_ ._._._ _. ___.._�_ _...._..___..w_..___ _..__.__�.,_.______��., ---�
Vehicle }
�C_..__.__ _ . _�.__ _..�._. _. ._ ._.._ _.. ..._.... .. _..__.... ..,...___._�._.._..._,_. �.____.. .� _._. _ �«_ _.__ . _..._ ..,__...._ _._w._.�___�_ .____.___._______�
2000 Mercedes-Benz ML320 STD 4 DR Wagon
6cyl Gasoline 3.2
5 Speed Automatic
Lic Expire: VIN: 4JGAB54E7YA153879
Veh Insp#: Mileage Type: Actual
Condition: Code: 31803A
Ext.Color: red Int.Color:
Ext.Refinish: Two-Stage Int.Refinish: Two-Stage
Options
AM/FM Stereo Tape Air Conditioning Alarm System
Aluminum/Alloy Wheels Anti-Lock Brakes Center Console
Cruise Control Dual Airbags Fog Lights
Garage Door Opener Head Airbags Heated Power Mirrors
Intermittent Wipers Keyless Entry System Leather Steering Wheel
Lighted Entry System Overhead Console Power Brakes
Power poor Locks Power Steering Power Windows
Rear Side Airbags Rear Window Defroster Rear Window WipedWasher
Roof/Luggage Rack Side Airbags Tachometer
Tilt Steering Wheel Tinted Glass Traction Control System
Velour/Cloth Seats Wood Interior Trim
08l12/2013 1222 PM Page 7 of4
Ual �1ov�.
2000 Merc�des-Benz ML320 STD 4 DR Wagon
Claim#: 08/12/207312:17 PM
r___....,.� _ . _.... _.._-. __.... _..__._,.,. �._._... . ,�e,.___ ,...._ ._ _�..._ ___ , � _� �_�. . .__
_ ,
� Damages '
Line Op Guide MC Description MFR.Part No. Price ADJ% B% Hours R
Quarter And Rocker Panel
1 I 389 Panel,Quarter LT Repair 4.0' SM
2 L 389 13 Panel,Quarter LT Refinish 3.8 RF
2.7 Surface
0.6 Two-stage setup
0.5 Two-stage
3 I 390 Panel,Quarter RT Repair 3.0` SM
4 L 390 Panel,Quarter RT Refinish 3.0 RF
2.5 Surface
0.5 Two-stage
inner�uarter 8 Panels
5 E 354 01 Pnl,inner Qtr Trim LT 16369001258G63 $610.00 0.7 SM
Tailaa�te E 479 SheIl,Taiigate 1637401205 $1,490.00 6.3 SM
7 L 479 SheIl,Tailgate Refinish 3.7 RF
1.9 Surface
1.2 Edge
0.6 Two-stage
8 E 498 N/Plate,Tailgate 1638170915 $27.50 0.2 SM
9 E 491 Emblem,Tailgate 2107580158 $17.50 0.2 SM
Rear Bumoer
10 E 520 Cover,Rear Bumper 1638804771 $680.00 0.6 SM
11 L 520 Cover,Rear Bumper Refinish 2.8 RF
2.3 Surface
0.5 Two-stage
12 E 514 Reinf,Rear Bumper 1633100146 $570.00 5.7 FR
13 E 597 Brkt,Rear Bumper Mtg LT 1638852914 $27.50 INC SM
14 L 597 Brkt,Rear Bumper Mtg LT Refinish 0.2 RF
0.2 SurFace
15 E 598 Brkt,Rear Bumper Mtg RT 1638853014 $27.50 INC SM
16 L 598 Brkt,Rear Bumper Mtg RT Refinish 0.2 RF
0.2 Surface
17 E 629 Sensor,RR Bumper LT 0015427418 $81.00 0.1 SM
18 E 630 Sensor,RR Bumper RT 0015427418 $81.00 0.1 SM
19 E 631 Brkt,RR Bumper Sensor LT 0005420551 $3.90 0.1 SM
20 E 632 Brkt,RR Bumper Sensor RT 0005420551 $3.90 0.1 SM
21 E 585 01 Filler,Rear Bumper LT 16388001059040 $95.00 INC SM
22 E 586 01 Filler,Rear Bumper RT 16388002059040 $95.00 INC SM
Rear Body_Lames And Floor Pan
23 E 533 Taillamp Assembly LT 1638200364 $216.00 0.3 SM
Manual Entries
24 I M18 Set-Up And Measure Repair 2.0' FR
25 I M49 Frame Mash,Rear Repair 8.0"' FF2
25 Items
MC Message
01 CALL DEALER FOR EXACT PART#/PRICE
13 INCLUDES 0.6 HOURS FIRST PANEL TWO-STAGE ALLOWANCE
OB/12/20131222 PM Page 2 of 4
Val ���-
20D0 Mercedes-Benz ML320 STD 4 DR WaAon
.Claim#: 08/12/201312:17 PM
__�__�_..v.._._.. .., ..__,� ...�...._ __, ___. . _..__... _. _ ....._._ _.____ _..__..._ . . . ....__,_ . .______._._____._�._.�... ,_.__.�._.___.�v_._.._... _._..._ _,. ,.....__ _._....__._..
� Estimate Total 8�Entries �
Gross Parts $4,025.80
Paint Materials $411.00
Parts 8�Material Total $4,436.80
Tax on Parts 8 Material @ 7.125% $316.12
Labor Rate Replace Repair Hrs Total Hrs
Hrs
Sheet Metal(SM) $50.00 8.7 7.0 15.7 $785.00
Mech/Elec(ME) $80.00
Frame(FR) $75.00 5.7 10.0 15.7 $1,177.50
Refinish(RFi $50.00 13.7 13.7 $685.Q0
Paint Materials $30.00
Labor Total 45.1 Hours $2,647.50
Gross Total 57,400.42
Net Total i7,400.42
Alternate Parts Y/00/00/00i00/00 CUM 00/00/00/00/00 Zip Code:55014 Default
Audatex Estimating 7.0.019 ES 08/12/201312:22 PM REL 7.0.019 DT 07/01/2013
Copyright(C)2013 Audatex North America,Inc.
2.7 HRS WERE ADDED TO THIS ESTIMATE BASED ON AUDATEX'S 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.
WARRANTIES APPLICABLE TO THESE REPLACEMENT PARTS ARE PROVIDED BY THE PARTS
MANUFACTURER OR DISTRIBUTOR RATHER THAN BY THE MANUFACTURER OF YOUR VEHICLE.
A PERSON WHO FILES A CLAIM WITH INTENT TO DEFRAUD OR HELPS COMMIT A FRAUD
AGAINST AN INSURER IS GUILTY OF A CRIME. '
Op Codes
* = User-Entered Value E = Repiace OEM NG= Replace NAGS
EC= Replace 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/Rebft 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 Altowance RP= Related Prior Damage
OB/12/2013 12:71 PM Pege 3 of 4
V A,1 �(or�
20b0 Mercedes-Benz ML320 STD 4 DR Wagon
.Claim#: OB/1?J201312:17 PM
This report contains proprietary information of Audatex and may not be disclosed 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
'Audatex Audatex's priorwritten consent.
a Snlera cu�n�atrv
- Copyright(C)2013 Audatex North America, Inc.
Audatex Estimatin is a trademark of Audatex North America, Inc.
08l12/201312.22 PM P�qe 4 of 4
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