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Griepentrog , _ I NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota Minnesota State Statute 466.05 states tliat "...every person...wlio claims danaages from ar�y�nunici��ality...shal!cause to be presented to the gorerning body of the municipaliry witlarn 180 da�s afier the a/leged loss or injur��is discovered a notice s�atnig Ihe time,place,and circu�nstances tliereof,and dze ar��ourtt of compensation or o�lier re[ief 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 �'�I'��'v i�-� Middle Initial�Last Name ��''''��°�� Company or Business Name � RECEIVED Are You an Insurance Company? Yes/No If Yes,Claim Number? S�P 2� 2��3 Street Address �Z" � ��I��►re ,�v e. C�� LERK Ciry i,'�inr�'<- �SC�';� 1—t;,�'�. State �� ZipCode J�� (� Daytime Phone (�%�� ) 2%j- �� Cell Phone(E;� )2%� - g��f Evening Telephone ( �I )2t�3 -gc l �j Date of Accident/Injury or Date Discovered �� Z-� �� Time f��'�� 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 employees are involved and/or responsible for your damages. j�i�! vzl�i�l"r. bJc,S GGr kzc� G�, t , ' c�� 0 �l�.l y !��.n � �� t ec �a(c;nc,� �ztl �1 Y11V �2�i�.�� crc� � '��5,��e- SJStG�ntc� �Ryr�G�� . jl'�� 'i"(C.e. 15 c�,� �i�/ (Gir��' 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 specify ❑ Other type of injury—please specify In order to process your claim you need to include coqies of all applicable documents. Far 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 actua]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 complete this section Were there wimesses to the incident? Yes No Unknown (circle) C Provide their names, addresses and telephone numbers: J�^. U�i��1 c; , i C i H 0��c c a�`�- `' �T PG:�� G-I -� lD -- `�II(o Were the police or law enforcement called? Yes No Unknown (circle) If yes, what department or agency? Case#or report# Where did the accident ar 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. ��`1 ��arqr Av`e � Please indicate the amount you are seeking in compensation or what you would�hke th,e City to do to resolve this claim to your satisfaction. �G�v -��-� feCc�i�s ��' �I��e1 S�+�G 7�c;� rru�iG�etl �S��✓N�:1'�-. Vehicle Claims— lease com lete this section ❑ check box if this section does not a 1 Your Vehicle: Year LC'J"; Make �/� Model �Z License Plate Number �� %�1T Sta�e r�r Color 'vJh��'£ Registered Owner �1U, �v� G�: �,� r �C' Driver of Vehicle rn�: �1 i;� e�� rJ- Area Damaged 1 r�+ Fe,�c; e-� City Vehicle: Year Make Model License Plate Number State Color Driver of Vehicle (City Employee's Name) Area Damaged In_iurv Claims—please complete this section �check box if this section does not anply � 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 ❑ 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. Unsig�aed forms will not be processed. Submitting a false claim can result in prosecution. Date form was completed �I'� �� I 3 Print the Name of the Person who Completed this Form: ��'��'�z"`� �'�ZF't"'��'] �� `—� Signature of Person Making the Claim: �f-� Revised February 201 1 .� � _____-____,_--�, �.r \ . \, � r �� >>� I � � I , . ,� � , . �. ��1.(f�',N �i J �� N ��ta t�y1� ��! `�y! a � �A� ��' �� . ��1��A '�+ L �+��`�� '�i . �� JJiy �� v R i�`�11,1*��t�� r4+ • . t ♦ J�`�j;'�.a�.��( �� • aR . 'yi4�"��' j:�. x . �� ` ....;`'i��.��' ,}.� t��►a�+•y�*�. � + � Mr+ : }l ,�� '� ;` � V+}°•R' IYr 1 �� y�� y;'.��'4 �i � �.`- �• �x i� � �.�1'�' $�.��-' �� i r� .i ti '� � �, u_� t�/'� u`A ' ' #`y�, �, ��'�` t. �`► a ,! � s.,�. � ,I � i�� Y� 4 � J ! F �� ' �t�� . °R��g t'# � �_,�1 `�, �� a _ . x� �a.,., ' c ... �.. • � / WHITE BEAR BODY SHOP Workfile ID: 6e57368c FederalID: 20-050-3892 2218 4TH ST, WHITE BEAR LAKE, MN 55110 Phone: (651)429-7171 FAX: (651) 429-6069 Preliminary Estimate Customer: GRIEPENTROG, MATf 7ob Number: Written By: DENNIS GRAVEN Insured: GRIEPENTROG,MATf Policy#: Claim#: Type of Loss: Date of Loss: Days to Repair: 0 Point of Impact: il Left Front Owner: Inspection Location: Insurance Company: GRIEPENTROG,MATT WHITE BEAR BODY SHOP 4203 BELLAIRE AVE 2218 4TH ST WHITE BEAR LAKE,MN 55110 WHITE BEAR LAKE, MN 55110 (651)253-8515 Day Repair Facility � (651)429-7171 Business VEHICLE Year: 2007 Body Style: 4D WGN VIN: WBAVT73557FZ36486 Mileage In: Make: BMW Engine: 6-3.OL-FI License: 851BMT Mileage Out: Model: 328XI AWD Production Date: State: MN Vehicle Out: Cotor: Int:WHI'fE Condition: Job#: TRANSMISSION Console/Storage AM Radio Luggage/Roof Rack Overdrive Wood Interior Trim FM Radio Electric Glass Sunroof 6 Speed Transmission CONVENIENCE Stereo SEATS 4 Wheel Drive Air Conditioning Search/Seek Bucket Seats POWER Intermittent Wipers CD Player WHEELS Power Steering Tilt Wheei SAFETY Aluminum/Alloy Wheels Power Brakes Cruise Control Drivers Side Air Bag PAINT Power Windows Rear Defogger Passenger Air Bag Clear Coat Paint Power Locks Alarm Anti-Lock Brakes(4) OTHER Power Mirrors Steering Wheei Touch Controls 4 Wheel Disc Brakes Fog Lamps Heated Mirrors Rear Window Wiper Front Side Impact Air Bags Traction Control DECOR Telescopic Wheel Head/Curtain Air Bags Stability Control Dual Mirrors RADIO ROOF Headlamp Washers 9/17/2013 9:28:59 AM 090936 Page 1 Preliminary Estimate Customer: GRIEPENTROG, MATT 7ob Number: Vehicle: 2007 BMW 328XI AWD 4D WGN 6-3.OL-FI Line Oper Description Part Number Qty Fxtended Labor Paint Price; 1 FENDER 2 * Rpr LT Fender �Q � 3 Add for Clear Coat 0.7 4 FRONT LAMPS 5 R&I LT Repeater lamp 0.2 6 R&I LT R&I headlamp assy 0.3 � 7 HOOD 8 Blnd Hood 1.5 9 * R&I Emblem Q,� 10 FRONT BUMPER&GRILLE il R&I RT Finfsh molding outer 325,328 0.1 � 12 R8cI LT Finish molding outer 325,328 0.1 13 * R&I R&I front bump�r (pROP Q,$ DOWN LT SIDE FOR PAINTINGl 14 # SHOP SUPPLIES 1 5.00 15 # CORROSION PROTECTION 1 0.2 PRIMER 16 # MASK JAMBS,OPENINGS 1 0.3 17 # HAZARDOUS WASTE DISPOSAL 1 5.00 X SUBTOTALS 10.00 4.6 4.5 ESTIMATE TOTALS ��gory Basis Rate Cost� Parts 5.00 Body Labor 4.6 hrs @ $54.00/hr 248.40 Paint Labor 4.5 hrs @ $54.00/hr 243.00 Paint Supplies 4.5 hrs @ $32.00/hr 144.00 Miscellaneous 5.00 Subtotal 645.40 Sales Tax $5.00 @ 7.1250% 0.36 Grand Total 645.76 Deductible 0.00 CUSTOMER PAY 0.00 INSURANCE PAY 645.76 This is a visual estimate only. Additional parts and labor may be needed upon tear down. Part prices are subject to invoice. We do not warranty rust repair! We offer a national limited life time warranty on workmanship and labor for as long as you own your vehicle. MN ST 60A.955 - A PERSON WHO FILES A CLAIM WIT}i INTENT TO DEFRAUD OR HELPS COMMIT A FRAUD AGAINST AN INSURER IS GUILTY OF A CRIME. 9/17/2013 9:28:59 AM 090936 Page 2 Preliminary Estimate Customer: GRIEPENTROG, MATT 7ob Number: Vehide: 2007 BMW 328XI AWD 4D WGN 6-3.OL-FI Estimate based on MOTOR CRASH E5TIMATING GUIDE. Unless othervvise noted all items are derived from the Guide ERE1942, CCC Data Date 9/16/2013, 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 (A�ternative OEM) parts are OEM parts that may be provided by or through aiternate 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 panets 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=Blend. BOR=6oron 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=6ureau of Automotive Repair. EPA=Environmental Protection Agency. NHTSA= National Highway Transportation and Safety Administration. PDR=Paintless Dent Repair. VIN=Vehicle Identification Number. 9/17/2013 9:28:59 AM 090936 Page 3 BEARTOWN AUTO BODY� INC. Workfile ID: d85b9018 FederalID: 41-1642045 2034 FLORENCE ST., WHITE BEAR LAKE, MN State ID: 26-20756 55110 Phone: (651) 426-9368 FAX: (651) 426-6323 Preliminary Estimate Customer: Griepentrog, Matt ]ob Number• Written By:JODIE SAX Insured: Griepentrog, Matt Policy#: Claim #: Type of Loss: Date of Loss: Days to Repair: 0 Point of Impact: Owner: Insp�ction Location: Insurance Company: Griepentrog, Matt BEARTOWN AUTO BODY,INC. (651)253-8515 Business 2034 FLORENCE ST. WHITE BEAR LAKE, MN 55110 Repair Facility (651)426-9368 Business VEHICLE Year: 2007 Body Style: 40 WGN VIN: WBAVT73557FZ36486 Mileage In: Make: BMW Engine: 6-3.OL-FI License: Mileage Out: Model: 328XI AWD Production Date: State: Vehicle Out: Color: Int: Condition: Job#: TRANSMISSION Dual Mirrors AM Radio Luggage/Roof Rack 6 Speed Transmission Console/Storage FM Radio Electric Glass Sunroof 4 Wheel Drive CONVENIENCE Stereo SEATS � Overdrive Air Conditioning Search/Seek Bucket Seats POWER Rear Defogger CD Player WHEELS Power Steering Tilt Wheel SAFETY Aluminum/Alloy Wheels Power Brakes Cruise Control Anti-Lock Brakes(4) PAINT Power Windows Telescopic Wheel Driver Air Bag Clear Coat Paint Power Locks Intermittent Wipers Passenger Air Bag OTHER � Power Mirrors Rear Window Wiper Head/Curtain Air Bags Traction Control Heated Mirrors Alarm Front Side Impact Air Bags Stability Control DECOR Steering Wheel Controls 4 Wheel Disc Brakes Fog Lamps Wood Interior Trim RADIO ROOF Headlamp Washers � I / 6/26/2013 2:40:30 PM 073517 Page 1 Preliminary Estimate Customer: Griepentrog, Matt ]ob Number: Vehicle: 2007 BMW 328XI AWD 4D WGN 6-3.OL-FI Line Oper Description Part Number Qty Extended Labor Paint Price$ 1 FENDER 2 * Rpr LT Fender 3_0 2.0 3 Add for Clear Coat 0 g 4 R&I LT Fender liner front 0.3 5 FRONT BUMPER&GRILLE 6 R&I R&I front bumper 1.7 7 FRONT LAMPS 8 R&I LT Repeater lamp p,Z 9 R&I LT R&I headlamp assy 0.3 10 PILLARS, ROCKER&FLOOR 11 R&I LT Rocker molding 0.4 12 # HAZARDOUS WASTE 1 3.00 X 13 # OEM - RESTORE CORROSION 1 p,Z PROTECTION 14 # CAR COVER 1 5.00 X SUBTOTALS 8.00 5.9 3.0 ESTIMATE TOTALS Category Basis Rate Cost; Pa� 0.00 Body Labor 5.9 hrs @ $54.00/hr 318.60 Paint Labor 3.0 hrs @ $54.00/hr 162.00 Paint Supplies 3.0 hrs @ $32.00/hr 96.00 Miscellaneous 8.00 Subtotal 584.60 Grand Total 584.60 Deductible o.00 i CUSTOMER PAY 0.00 INSURANCE PAY 584.60 **WE ALSO DO MECHANICAL WORK** THIS REPORT IS AN ESTIMATE ONLY, BASED ON OUR INITIAL INSPECTION AND DOES NOT ACCOUNT FOR HIDDEN OR UNSEEN DAMAGE. PARTS PRICES MAY VARY AND ARE SUBJECT TO INVOICE FROM SUPPLIERS. WARRANTY: LIFETIME AGAINST DEFECTS IN WORKMANSHIP. WARRAN7Y REPAIRS DONE BY BEARTOWN AUTO BODY ONLY. NO GUARANTEE ON RUST REPAIR OR CORROSION RESISTANCE. OUR ESTIMATED COMPLETION TIME DOES NOT INCLUDE INSURANCE OR PARTS DELAYS THAT WE MAY EXPERIENCE. 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. 6/26/2013 2:40:30 PM 073517 Page 2 Preliminary Estimate Customer: Griepentrog, Matt Job Number: Vehicle: 2007 BMW 328XI AWD 4D WGN 6-3.OL-FI Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide ERE1942, CCC Data Date 6/14/2013, 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 Li(Q, 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 2012 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=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 ESfIMATING 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. 6/26/2013 2:40:30 PM 073517 Page 3 �