Tisdle ,
NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minnesota State Statute 466.OS states that "...every person...who claims damages from arry 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 wilt 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 ��Y'1�"1�'I Middle Initial � Last Name S s1 �-{- C�C�c i� i c D ,
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Company or Business Name 13 I
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Are You an Insurance Company? Yes/I� If Yes, Claim Number? �
Street Address � � ,� ��r.-S�4 �� i9-✓-'` L E R K
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City S�� ��V � State �� Zip Code� �
Daytime Phone (�� `/ Cell Phone(�s`�''`=� Evening Telephone(_) s�`"4
Date of Accident/Injury or Date Discovered�� � I
� —
� � 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 ar its em loyees are involved and/or responsible for your damages.
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Pl�ease check the box(es)that most closely represent the r�ason for completing this form:
EI 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
^u �iy�zhic�e was wrongfully towed and/c�tickete� n I was injured on City prope:�ty
❑ Other type of property damage-please specify
❑ Other type of injury-please specify
In order to process your claim vou need to include copies of all applicable documents. : '
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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 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
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-ulease comqlete this section
Were there witnesses to the incident? Yes No nknown (circle)
Provide their names, addresses and telephone numbers:
Were the police or law enforcement called? Yes� No Unknown (circle) G
If yes,what department or agency? Case#or report# �—/��— ��' 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 diagram.
ar ��, i� • .� � • v �a(r �t/�S l��i!' s
Please indicate the amount yo are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction. � �,� / �/7 � c.7
..�-
Vehicle Claims-nlease complete this section ❑ check box if this section does not applv
Your Vehicle: Year Make Model
License Plate Number State Color
Registered Owner
Driver of Vehicle
Area Damaged
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name) I
Area Damaged
i
Iniury Claims-please complete this section �heck box if this section does not applv
How were you injured? �
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What part(s)of your body were injured? !
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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 j
When did you miss work? (provide date(s))
Name of your Employer: I
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 Izave provided is true and correct to the best �
of your knowledge. Unsigned fo�ms will not be processed. �
Submitting a false claim can result in prosecution. Date form was completed �- l0 -.L3
1� �-� I
Print the Name of the Person who Completed this Form: N r( `` � � I �S cl �L
���_ ;
Signature of Person Making the Claim: �
Revised February 2011 �
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. RAYMOND AUTO BODY, INC. Workfile ID: cfe6bff9
FederalID: 41-0888257
1075 PIERCE BUTLER RTE, SAINT PAUL, MN
55104
Phone: (651) 488-0588
FAX: (651) 488-4794
Preliminary Estimate
Customer: TISDLE, BRIAN ]ob Number:
Written By: STEVE SUNDERLAND
Insured: TISDLE, BRIAN Policy#: Claim #:
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact:
Owner: Inspection Location: Insurance Company:
TISDLE, BRIAN RAYMOND AUTO BODY, INC.
883 MARSHALL AVENUE 1075 PIERCE BUTLER RTE
ST PAUL, MN 55104 SAINT PAUL, MN 55104
(651)343-8413 Cell Repair Facility
(651)488-0588 Business
VEHICLE
Year: 2001 Body Style: 4D SED VIN: 4T1BG22K81V833064 Mileage In:
Make: TOYO Engine: 4-2.2L-FI License: Mileage Out:
Model: CAMRY LE Produdion Date: State: Vehicle Out:
Color: Int: Condition: Job#:
TRANSMISSION Dual Mirrors AM Radio Cloth Seats
Automatic Transmission Body Side Moldings FM Radio Bucket Seats
Overdrive Console/Storage Stereo Reclining/Lounge Seats
POWER CONVENIENCE Search/Seek WHEELS
Power Steering Air Conditioning CD Player Wheel Covers
Power Brakes Intermittent Wipers Cassette PAINT
Power Windows Tilt Wheel SAFETY Clear Coat Paint
Power Locks Cruise Control Drivers Side Air Bag OTHER
Power Mirrors Rear Defogger Passenger Air Bag Power Trunk/Gate Release
DECOR RADIO SEATS
9/9/2013 2:39:43 PM 019495 Page 1
Preliminary Estimate
Customer: TISDLE, BRIAN ]ob Number:
Vehicle: 2001 TOYO CAMRY LE 4D SED 4-2.2L-FI
Line Oper Description Part Number Qty Extended Labor Paint
Price$
1 REAR BUMPER
2 0/H bumper assy 1.8
3 REAR LAMPS
4 Repl LT Combo lamp assy NAL 81560AA030 1 152.19 0.4
5 REAR BODY&FLOOR
6 * Rpr Panel below lid US built 3.Q 1.5
7 Add for Clear Coat 0.6
8 R&I Rear panel trim center US built p.2
9 R&I LT Trunk side trim US built 0.3
10 QUARTER PANEL
11 * Rpr LT Quarter panel US built w/o �Q 2,4
antenna
12 Overlap Major Adj. Panel -0.4
13 Add for Clear Coat 0.4
14 R&I Fuel door US built 0.3
15 Blnd Fuel door US built 0,2
16 * R&I LT Body side mldg US built �
17 * Rpr LT Body side mldg US built � g�
18 BACK GLASS
19 * Rpr Back glass LE&XLE Toyota,type �,4
2
20 MISCELLANEOUS OPERATIONS _
21 # Blnd Blend left sail 1.0
22 # Rpr Unibody structural repair 2.0 F
23 # Setup time&measure 1 2.0
24 Repl Cover car/bag 1 0.2
25 # Repl Hazardous waste removal 1 6.00 X
26 # Color tint/color match 1 OS
27 # Repl Corrosion protection primer 1 0.4
28 # Repl Flex additive 1 8.00
SUBTOTALS 166.19 18.6 7.0 ,
�I
9/9/2013 2:39:43 PM 019495 Page 2
, Preliminary Estimate
Customer: TISDLE, BRIAN 7ob Number:
Vehicle: 2001 TOYO CAMRY LE 4D SED 4-2.2L-FI
ESTIMATE TOTALS
Category Basis Rate Cost$
Pa� 160.19
Body Labor 16.6 hrs @ $59.00/hr 979.40
Paint Labor 7.0 hrs @ $59.00/hr 413.00
Frame Labor 2.0 hrs @ $82.00/hr 164.00
Paint Supplies 7.0 hrs @ $39.00/hr 273.00
Body Supplies 13.8 hrs @ $8.00/hr 110.40
Miscellaneous 6.00
Subtotal 2,105.99
Sales Tax $543.59 @ 7.6250% 41.45
Grand Total 2,147.44
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 2,147.44
WHILE WE HAVE MADE EVERY EFFORT TO WRITE A COMPREHENSIVE REPORT OF THE VISIBLE DAMAGE TO YOUR
VEHICLE, IT IS IMPORTANT TO REMEMBER THAT THIS IS ONLY AN ESTIMATE. THERE ARE A NUMBER OF FACTORS
THAT CAN AFFECT THE ACTUAL COST OF REPAIRS, INCLUDING BUT NOT LIMITED TO HIDDEN DAMAGE, PARTS
PRICE CHANGES, AND INSURANCE COMPANY INVOLVEMENT. PLEASE CONSIDER THIS WHEN MAKING DECISIONS
REGARDING THE REPAIRS TO YOUR VEHICLE.
AUTO .CLUB INSURANCE ASSOCIATION, MEMBERSELECT INSURANCE COMPANY OR AUTO CLUB GROUP INSURANCE
COMPANY (HEREIN INDIVIDUALLY AND COLLECTIVELY!REFERRED TO AS ACIA) GUARANTEES THAT IT WILL
REPLACE THE QUALITY REPLACEMENT PARTS (PARTS I�OT MANUFACTURED BY THE ORIGINAL EQUIPMENT
MANUFACTURER) IDENTIFIED ON THE VEHICLE ESTIMATE ASSOCIATED WITH THIS GUARANTEE IF A DEFECT IS
DISCOVERED.
ACIA FURTHER GUARANTEES THAT THE QUALITY REPLACEMENT PARTS, EXCLUDING GLASS AND MECHANICAL ,
PARTS, ARE CERTIFIED OR VALIDATED TO BE OF OEM QUALITY IN ALL INSTANCES WHEN THIS CERTIFICATION
OR VALIDATION IS AVAILABLE FOR THE PART. THIS GUARANTEE IS IN EFFECT FOR AS LONG AS YOU OWN THE
REPAIR VEHICLE AND IS NOT TRANSFERABLE TO ANOTHER PARTY AT ANY TIME. THIS GUARANTEE COVERS THE ,
COST OF THE PART, LABOR TO INSTALL, PAINT AND MATERIALS IF REQUIRED, AND REASONABLE RENTAL COST
OF A SIMILAR TEMPORARY REPLACEMENT VEHICLE DURING THE REPAIRS. THIS GUARANTEE DOES NOT COVER
CLAIMS FOR DIMINUTION IN VALUE OR CONSEQUENTIAL DAMAGES.
IF A DEFECT IN A QUALITY REPLACEMENT PART IS DISCOVERED, CONTACT YOUR LOCAL ACIA CLAIMS
DEPARTMENT IMMEDIATELY AND ACIA WILL REPLACE THE PART WITH A NEW ORIGINAL EQUIPMENT
MANUFACTURER PART. IF AN ORIGINAL EQUIPMENT MANUFACTURER PART IS NOT REASONABLY COMMERCIALLY
AVAILABLE, ACIA WILL REPLACE THE DEFECTIVE PART WITH ANOTHER QUALITY REPLACEMENT PART.
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.
9/9/2013 2:39:43 PM 019495 Page 3
, Preliminary Estimate
Customer: TISDLE, BRIAN .7ob Number:
Vehicle: 2001 TOYO CAMRY LE 4D SED 4-2.2L-FI
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
AEM8509, CCC Data Date 9/3/2013, 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 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 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=AfCermarket 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. 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.
9/9/2013 2:39:43 PM 019495 Page 4
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No. 1009
STATE OF l��IINNESOT.�
...
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� ��� � � . . . .
De a�t�en�t a Co�nme�ce
�.
. . The IIndersigned
� CONIlVIISSIONER OF CONIlVIE.RCE •
� , for the State of 1VIinnesota hereby '
certifies that
CTTY OF SAIl1'T PAUL
. has made application,paid the fees required and'm all other respects complied with the laws of the State of �
NI'mnesota and is hereby authorized to tc�sact the business of a NaFault Reparation Obligor authorized to
self-insure pmsuant to Minnesota Statutes,Section 65B.48. :
a� 300 City Hall Affiex,25 W.4th Street, SL Paul,MN 55102
Unless tbis authoriiy be suspended,revoked,or otherwise legally terminated,this certificate sball be in effect until
May 31,2012. �
. � IN TES'TIl�IONY WI�REOF,I have hereunto set my hand at �
. my office m the City of St.Panl,Minnesota, '
. - May 31,2009
,�--/ �
�
. ��� .
� . Commissioner of Co�erce �
.� • .
� .: . .