Sherk RECEIVED
OCT 012013
CITY CLERK
NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Mrnnesow Slare Swiute 466 OS swlv lhul"...every person...n�iw clainu d�tmuges jrorn any mwticiyuliry...shaU cause!o be prescnted fo 1hr
grn�erning hodj�njthr mroticipaliry within!&1 da}•s ajler fhe alJeged lnrs nr injury is discoverrd a nntrce atuting tlu�ime,plact,aru/
trrcumstanc�a therrnf,and the ameunf ojcnmpenaatian o�ahrr rrlief de►nanded."
Please complete thls form in(ls eatirety by clearty typi�g or printIng your adswer to each qnesUon. If more space is
needed,attach additional sheets. Please note that you will not be coatacted by telephone to ciat3fy answers,so provide as
much In(ormatlon as necessary to explain yaur claim,and the aawuni o[com�tensation being requested. Yov will receive a
wrllten acknowledgemeal once your form is received. The proceu can take up to ttn wceks or Ioager depending on lhe
nature of yow daim. Thfs form mnst be�gned,and both paga completcd. U something does aot apply,wiitc`N/A'.
SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD,310 CITY HALL, SAINT PAUL,MN 55102
First Name � �t���'n Middle Tnitial �L.ast Name 5 I�erk
Company or Business Narne
Are You an Insurance Company? Yes/ 1�g If Yes,Claim Number?
Strcet Address 2 9 U 0 +n 4.�?eC. /1Y�. /V
City �ei�.i Y1�1� _ State ,M /V Zip Code S�y Z7
Daytime Phone(� ���'- 6�3 L Cell Phone(� - Evening Telephanc�} -
Date of Accidend injury or Date Discovertd�Z �3 Time � • y� am/ t�r
Pleasc sta[c,in detail,what occurred{happened),aad why you are submitting a claim.Please indicate why or how you
feeI ths Cit of Saint Paal or its employees arc invotved and/or responsibie for your damages. L 1�rA ark,'�
� f' f trt v t:.l� i.. r� � S �f 'c Scti, 1 7'' sr Was a.
wr z e �1� l On t e s• ewrt i✓a �t at;/ v� ' l� �� e a� at.�
w4� a.�t �cl r af t ; tr,.a/ Qf �:+ Sl� e � � a � r� '1' a
� ;.11el ark,'� a rece�tiP a� zn ,'1 s a r � Th 7tih� iJe< <�{ +,.s�[
� 02 r 4�1' / a�/ � �in �IiS o � �S�'v bztaul� GvAt ��e �li �e ,I_
�A/k i�1i �1ri�'jflw/4' �►Lew• On rl[ CHrb �J 0.nV A'tPcY/II: f.w.� 7+lif c�l�iwc��n dG� '�l
Pleasc check the box(es}that most closely represent the reason for completing this farm: �`�'�'��t.
(�My vehicle was damagcd in an accidcnt O My vchicle was damaged during a tow
❑My vehicie was @amaged by a pothole or condition of the street O My vehicle was damaged by a plow
❑My vchicle was wrongfutly towed andJor ticketcd ❑I was injured on City propeRy
❑Other type of property damage—please specify
❑Othcr type of injury—plcase specify
in order to process your claim you need to incEude caqies of all appiicable documents.
For the claims types lis[ed beiow,please be sure to include the documonts indicated or it will d�lay the handling of
your cfuim. Documents WILL NQT be retumed and become the property of the City. You art encouraged to keep a
copy for yourself before submitting your claim form.
C�Property damage claims to a vehicle:two esumatcs for the repairs to your vehicle if thc damage cxceeds
5500.00;ar thc actual bills and/or reccipts for the repairs
O Towing claims:legibic copies of any ticket issucd and a copy of the impound lot reccipt
O Other property damage claims:two repair esiimates if the damage excceds 5500.00;or the actual bills
and/or receipts for the repairs;detailed list of damaged items
O Injury claims: mcdical bills,receipts
�Photographs are always welcome to document and support your claim but will not bc retumed.
Page 1 of 2—Plesse completc and return both pagcs of Clalm Form
Faiturc to complete and tetnrn bath pages wW result in delay in thc handung of your daim.
All C[aims—please comalete this section
Wcre thcre witnesses to the incident? ,,se No Unknown {circic}
Prp vide their�,namcs,addresses and teEephor�e numbers: �or�a Ft��r �E ;� 3�U— 76 2 (
(, �10:. l��n;��•, La�e ,IV /�et i�3 /1/lao/e to+t, MN' S5 l/
Were ihe police o�law enfarcement called? Yes � Unknown (circle)
If ycs,what department or agency? Case#or repoR#
Where did the accident or injury take place? Provide street address,cross stree�intersection,name of park or facility,
closest landmark,etc. Plea�e be as detailed as possible. If neccssary,attach a diagram.Mc N�!ld 5�+►•'}�i
14 E �xctia.�a,; J f. �a,.l - 7he S,�de � N, S�/.ef nex� � f� nrvt,�.,d �i�n+t. �oIe fo
C�d a. St'.
Please indicate the a ount you are seekiag in compensation or what yau would like the City to do to resolve this claim
toyoursatisfaction.�ljoo✓ S� t. P����/ ;ah C� � ��,�. ct�,Y.( [cr�� Gno n�t ..�:/
{,,'r�d a ccrfs
Vehtcle Claims—nlease comnlete thi tI n ❑check box if this section docs not aaplv
, YourVehicle: Year '�QBti Ma1ce � evrc)ef Model 7'"�Zhoe
Liccnse Plate Number Z�9- M A� State MN Color R�aL
Registered Owner R�cha�d ShrrK
Drivcr of Vehicle S S/x
ArcaDamagcd,R[ar, bkck, r��.h+- S�'d� '� �'r%�
City Vehicle: Year Make Model
License Plate Number Statc Cotor
Driver of Vchicic(City Employcc's Namc)
Arca Damaged
Inlurv Claims—nlease comnlete this section �check boz if this section does not aaalv
How wcrc you injured?
What part(s)ot'your body were injured?
Have you sought medical treatment? Yes No Planniag to Seck Tmatment(circle)
Whcn did you rcceivc ucatment? {providc datc{s))
Name of Medical Providcr(s):
Address Telephone
Did you miss work as a result of your injury? Ycs Na
When did you miss work? (providc date(s})
�Iame of your Employcr:
Address Tcicphone
❑Check here i[you are attaching more pages to this claim form. Namber of additional pages 7 ���r
� �j
�
By signing tliis form,you are staling that all information you have provided is true and cvrrecl to the best
ojyour knowledge. Unsigned jorms will nol be processed
Submitling a false claim can resull in prosecution. Date totm was completed�9 r 3
Print the Name of the Persoa who Completed th�s Form: ��t c'�
Signature of Person Making the Cialm:
Revised February 2011
BOULEVARD COLlISION W«��to: idlib624
FederalID: 41-1633482
� . fi901 I.AUREL AVE, GOL.DEN VALLEY, MN 55426
Phone:{763) 595-0006
FAX: (763)595-0556
Prel�minary Estlmate
Customer.SHERK,STEVE 3ob Number:
WriEten By:JOE UNDERbAHL
Insured: SHERK,STEVE Policy�: Oaim�:
Type of L.o9s: Date of Loss: Days eo Repair. 0
Point of Impatt:
Ownen Inspectlon Locatbrf: Insurance Company:
SHERK,ST�YE BOULEVARO COLLISION
2900 QUEBEC AVE N 6901 LAUREL AVE
NEW HOPE,MN 55427 GOLDEN VAILEY,MN 55426
(763)400-6232 Day Repdir Fatility
(763)595-0006 Evening
VEHICLE
Year. 2006 Bady Style: 40 UTV VIN: 1GfVEK13T16J145280 Mileage In:
Make: QifV Engine: B-5.3L-FI license: 279MAE Mileage Out:
Model: TAhiOE 4X4 LT Producdon Date: State: MN Vehtde Our
C41or: BLIJE 1M: Condition: Job�:
TRANSMLSSION Console/Storage AM Radio SEATS
Automatlt Tr�nSmissi0n Overf�ead ConSde FM Radia Budcet Seats
pverdrive CONVEIrIENCE Stereo leather Seats
4 Wheei Orive Air CwxittioNng Seard�/5eek Heated Seats
POWER Intemattent Wipers CD Player 3rd Row Seat
power Steering Tllt Wheel Premium Radio Wi�lEELS
Power Brakes Cn�ise Contrnl tD Chan9a75tacker Aluminum/1Uloy Wheels
Panrer Windows Rear Defogger SAFETY PAINT
payye�Locks Keyle5.5 Entry Orirrers�de Air 8ag Clear Coat Paint
Power Mirrws Alartn Pa�enger Air Bag OTHER
Heated Ml�ra�5 Message Cenber Mti-Lak&akes(4) Fog Lamps
Power Driver Sea[ Steenng Wheel Touth Cantrds 4 Wheel DisC&ake5 Signal Integrated Mlrror5
Power Passet�ger Seat Rear Window Wiper Sbbility Control TRUCK
pECpR Ektal Air Condition Communicatlons Sy�em Rear Step Bumper
Dudl Mirtors Home Unk ROOF Trailer Hitth
Tinted Glass RADIO l�ggage/Roof Radc Traflering Padcage
9/23/2013 3:26:05 PM 019494 Page 1
Preilminary Estlmate
° Customer:SHERK,STEVE ]ob Number:
Vehide:2006 piEV TAF�OE 4X4 LT AD U7V 8-5.3L-Fl BtUE
Une Oper DescriptMn Part Number Qly Extended Labor Patnt
Price�
2 QUARTER PANEL
2 ' Rp� RT QuarM�pdnel ,Z,Q 27
3 Add for Uear Coat 2.1
4 R&1 RT Rare black gralned a•Q
5 # Clean&re-tape mol�ng 1 0.5
6 # Repl Gear th�guard mylar 1 50.00
7 R&I RT Applique panel ��
g R&I RT Glass GM dnted Z•fl
9 REAR LAMPS
10 R&I RT Canbo lamp assy Tahoe, ��
Yukon,Denali
il REAR BUMPER
12 R&I R&I bcunper assy 1.0
13 # Subl Flazardaus waste rertrovai 1 4.00 X
14 # Repl Cover tar 1 Q.2
15 # Repl Wmasion praLectlon prkner 1 0.3
15 # Repl Ur�tl�ane glass kit 1 20.00
SUBTOTALS 74.00 6.2 4.3
ESRMATE TOTALS
�g�y Ba�is Rate Cost;
Parts 70.08
gody labpr 6.2 hrs �1 #52.00/hr 322.40
Paint Labor 4.3 hrs @ �52.00/hr 223.60
P��pph� 4.3 hrs @ $32.00/hr 137.60
Misceilanea�s 4.00
�b� 757.60
Sales Tax S 207.60 � 7.2754 46 15.10
Grand Total 772•70
OeductiWe 0.00
CUSTOMER PI1Y 0.00
INSURANCE PAY T72.70
NO GUARANI'EE ON RUST REPAIRS!!
PARTS PRICES SUBJECT TO INVOICE!!
NOT RESPONSIBLE FOR ITEMS LEFf IN CARS!!
ESTIMATE DOES NOT INCLUDE HIDDEN DAMAGE!!
MN ST 60A.955 -A PER50N WHO FILES A CLAIM WITH IIVT'ENT TO DEFRAUD OR HELPS COMMIT A FRAUD
AGAiNST AW INSURER IS GUILTY OF A CRIME.
9/23/2013 3:26:05 PM 019494 Page 2
CRYSTAL C4LLISION CENTER & W01*���D: 2�as�o�
t ' CRYSTA! FLEET SERVICES
5108 W BROADWAY AVE, CRYSTAI, MN 55429
Phone: (763) 533-0412
FAX: (763) 533-8703
EsNmate
RO Number.
Customer: Insurance: Adluster: Esdmator: Kale Nemik
Sherk,Steve Phone: Create Oate: 9/23lZ013
2900 Quebec Ave N aaim:
New Hope,MN 55427 t.oss Oate:
(763)400-6232 Deductible:
Year. 2006 Style: 4D UTV VIN: 1GNEK13T26JF45280 Mileage In:
Make: GiEV Cotor: MNeage Out:
Model: TANOE 4X4 LS tJcense: 279MAF ]ob Number: Vehide Out:
Une Ver Operation Descriptton Qty Extended Type labor 7ype Paint
Pcice;
1 E01 REAR SUMPER
2 E01 Remave/InstaQ R&[bumper assy 1.0 Body
3 EDl REAR lAMPS
4 E01 RemoveiFn�afi RT Combo lamp assy Tahoe,Yulcon, 0.3 Body
Dena►i
5 E01 QUARTER PNVEL
6 E01 Repair RT Quarter panel 2.0 8ody 2.7
7 E01 Add for Gear Coat i.l
8 E01 RemovE/Ittstall RT Wheelhouse liner 03 Body
9 EOi Remove/Install RT Fiare primed 0.4 6ody
10 E01 RemoveJIr�stafl RT Applique pane! 0.0 Body
11 F01 Remove/Instatl RT Glass GM tinted 2•0 8ody
12 E01 RemoveJIr�all RT PlUar trim upper pewter OA Body
13 E01 Remuve/Iru�ll RT Qtr trlm panel pewter 0.0 Body
14 E01 ROOF
15 E01 Remove/Instatl RT Side rail 0.5 Body
16 E01 HAZARDOUS WASTE REMOVAL 1 SAO Other
17 EQl COVER CAR 0•�
!8 E01 CORROSION PROTECTION 0.5
19 E01 COlQR TINT a•5
26 E01 Remove/Replace 3-M Protector 1 75.00T Otl�er 0.4 Body
Estlmate Totals Discount; Markup� Rate$ Tota!Hours Total�
Par� sa.00
Labor,Body 54.00 6.9 372.60
Labor,Refinish 54.00 5.1 275.40
Material,Paint 173.A0
T�Ta�able Item.RPD�AetateC Prbr Oamage.M�Appearonce Allawana,U�D�Unrdated Pria Dartuge,POR=Pa!ntless Omt RM�.AIM'Aftermarket Redv a iiedvomed,Reman=
i2emanutacWrEd,OEM-New Orlykwl Equtpment ManufaRUrer.Reoor=Pe�cored,UcQ'llke�ind QuatitY or Used,Dag.Diagnostic.Elec°Electrfd.Hech�MeCwNCaI,Ref�RefiNSh,Struc•
StrutIIU21
9/23/2013 12:39:27 PM Page 1
Estimate
RO`IVuniber:
Vehide:2006 CHEV TAHOE 4X4 LS 40 UIV 8-5.3l-FI
��.� 2.00 2.4 4.$0
��� 906.20
��T� 18.42
Grand Total 924.62
Net Total 924.62
Estlmate Yersion ����
Orig3nai 924.62
Insurdnce Total g: 924.62
Rece�ved from Insura�ce$: 6.00
Balance due from Ir�surance$: 924.62
Ct�stomer Tota!$: Q.00
Rete,ved from Customer;: d.00
Balance due from Customer�: 0.00
T e Taxable(tem,RPP=Rdaced Pria Damage,M:nppearance nitownnce.UPD-Uruetatetl Pnar Damage,PDR.Paintless Oent Repa'u,A/M.AlEertnarket,ilechr r Rechromed,Raman=
ar�,a�,uracturee,OEM-uew o�s�ai�,ivme�c Manuracn,re.,ru�-arwred,ucQ a uke and Quaucy a usea,o�as-�wqwanc,�+ec�ekcc�sca�,M«h-Mec3,anKai,ae�•a�,,struc•
Stru�ural
9/23/2013 12:3927 PM p�z
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Naylor, Racquel (CI-StPaul)
From: Steve Sherk <sherksteve@gmail.com>
Sent: Tuesday, October O1, 2013 2:09 PM
To: Naylor, Racquel (CI-StPaul)
Subject: Stephen Sherk - Claim Form
Attachments: Stephen Sherk - St. Paul Claim.pdf
Here's my claim form
1