Carlson, SamanthaRevised March 2023
NOTICE OF CLAIM FORM to the City of Saint 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 answers to each question. If you have additional documentation, you may add those
documents to your submission. You will not be contacted by telephone unless clarification is needed. The claim process for investigations can take upwards of four (4)
weeks. This form must be signed, dated with all applicable sections completed. Submission this completed form to the Saint Paul City Clerk’s Office by email
(cityclerk@ci.stpaul.mn.us), fax (651-266-8574) or mail addressed to “Saint Paul City Clerk, 15 West Kellogg Blvd., Suite 310, Saint Paul, MN 55102”.
Claimant: First Name: Samantha Last Name: Carlson
Please Indicate Your Pronouns: ☒ She/Her/Hers, ☐ He/Him/His, ☐ They/ Them/Theirs
Company or Business Name: ____________________________________________________________________________________
Is this claim being made by an Insurance Company? NO If yes, what is your Claim/File Number? _________________________
Is this claim being made by an Attorney? NO If yes, what is your File Number? _______________________________________
If yes, provide your Insured’s/ Client’s Name: _______________________________________________________________________
Street Address: 616 Summit Ave Apt 204
City: St. Paul State: MN Zip Code: 55104
Daytime/Work Phone: N/A Cell Phone: 651-324-9338_
Date of Incident or Date Discovered (Must Complete): 1/14/2026 Time: Discovereed 10:00 AM
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: Driver for Department of St. Paul Streets
division hit my parked car leaving a dent and scratches.
Please state why or how you feel the City of Saint Paul is responsible for your Damages? Driver for Department of St. Paul Streets
division hit my parked car leaving a dent and scratches – note was left accepting responsibility/acknowledging notification to police
department about the accident.
Please check the reason that most closely describes the reason for your submitting a claim. Please note the documents that will
need to be provided with your completed form. Photographs will be accepted. All documents submitted become the property of
the City of Saint Paul and shall not be returned.
☒ Automobile damage from a motor vehicle accident: please provide two estimates for repairs or actual bill that has been paid.
☐ Automobile damage from a street defect or pothole: please provide two estimates for repairs or actual bill that has been paid.
☐ Automobile was towed and may or may not have sustained damage: please provide copy of towing ticket (if available), receipt
from Impound Lot, and two estimates for repairs or actual bill that has been paid.
☐ Snow Emergency: please provide copy of towing ticket (if available), receipt from Impound Lot, and two estimates for repairs or
actual bill that has been paid.
☐ Property damage: please provide two estimates for repairs or actual bill that has been paid.
☐ You were injured during a motor vehicle accident: please provide police report number, details about injury.
☐ You were injured in the City of Saint Paul: please provide police report number, witnesses, and details about injury.
Revised March 2023
Continue to page 2 of Notice of Claim Form. Failure to complete and return both pages will result in delays.
This section must be completed for all claims.
Is there a police report for this incident? YES
If yes, please provide the police report case number: 26-005-998
If yes, what law enforcement agency responded? Saint Paul Police Department
Where did the incident take place? Please provide a street address, intersection or name of city park or facility:
Dale street near the intersection of Dale and Summit.
What would you like to see happen to resolve this claim to your satisfaction? Compensation/restitution to cover repair costs.
Were there witnesses to this incident? Please provide names and contact phone numbers:
Not that I know of.
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year: 2012 Make: Honda Model: Civic Color: Gray/Silver
License Plate #: KGM 024 State vehicle is registered in: Minnesota
Registered owner of vehicle: Samantha Carlson Driver: Samantha Carlson
Area(s) damaged: Above back left wheel
If a City vehicle was involved, License Plate #: #2365 License #965649_ Color: Make – Mack Granite Single Axle
Was there City insignia on the vehicle? YES / NO Driver’s Name: Brandon D Foster
Other property damaged: _______________________________________________________________________________________
For injury claims of any type.
What part of your body was injured? _____________________________________________________________________________
Did you go to the emergency room or urgent care? YES / NO Where? ___________________________________________________
Was medical treatment received? YES / NO Where? ________________________________________________________________
First day of medical treatment? _____________ Are you still receiving medical treatment? YES / NO
Did you miss any work as result of this incident? YES / NO
Employer(s): _________________________________________________________________________________________________
How much time have you missed from work? _____________________________________________________________________
If you are submitting other documents, please state what you are attaching and how many pages:
1. Estimate from Raymond Auto Body
2. Estimate from Classic Collision
By signing this form, you agree that all information provided is true and correct to the best of your knowledge.
Please NOTE that submitting a false or misleading claim can and will result in prosecution under Minnesota Statutes.
Name of Person completing form: Samantha Carlson
Signature of Person submitting this form: /s/ Samantha Carlson
Revised March 2023
Relationship of person signing to Party making the claim: Self
Date document is being signed: _____________________
RAYMOND AUTO BODY, INC.Workfile ID:
Federal ID:
State ID:
Federal EPA:
State EPA:
117bbd00
41-0888257
9407536
MND043164862
S-10620
1075 PIERCE BUTLER RTE, SAINT PAUL, MN
55104
Phone: (651) 488-0588
FAX: (651) 488-4794
Preliminary Estimate
Customer: CARLSON, SAMANTHA
Written By: RYAN THOMPSON
Insured: CARLSON, SAMANTHA Policy #: Claim #: N/A
Type of Loss: Date of Loss: Days to Repair:0
Point of Impact: 07 Left Rear
Owner: Inspection Location: Insurance Company:
CARLSON, SAMANTHA RAYMOND AUTO BODY, INC. CUSTOMER PAY
616 SUMMIT AVE 1075 PIERCE BUTLER RTE
APT 204 SAINT PAUL, MN 55104
ST PAUL, MN 55102 Repair Facility
(651) 324-9338 Cell (651) 488-0588 Business
VEHICLE
2013 HOND Civic Sedan EX Automatic PZEV 4D SED 4-1.8L Gasoline Electronic Fuel Injection GREY
VIN: 19XFB2F86DE045700 Interior Color: Mileage In:1 Vehicle Out:
License: KGM-024 Exterior Color: GREY Mileage Out:
State: MN Production Date: Condition: Excellent Job #:
TRANSMISSION Intermittent Wipers Stereo SEATS
Automatic Transmission Tilt Wheel Search/Seek Cloth Seats
Overdrive Cruise Control CD Player Bucket Seats
POWER Rear Defogger Auxiliary Audio Connection Reclining/Lounge Seats
Power Steering Keyless Entry SAFETY WHEELS
Power Brakes Alarm Drivers Side Air Bag Aluminum/Alloy Wheels
Power Windows Message Center Passenger Air Bag PAINT
Power Locks Steering Wheel Touch Controls Anti-Lock Brakes (4) Clear Coat Paint
Power Mirrors Telescopic Wheel 4 Wheel Disc Brakes OTHER
DECOR Climate Control Front Side Impact Air Bags Traction Control
Dual Mirrors Backup Camera Head/Curtain Air Bags Stability Control
Console/Storage RADIO Hands Free Device Power Trunk/Liftgate
CONVENIENCE AM Radio ROOF
Air Conditioning FM Radio Electric Glass Sunroof
1/30/2026 4:46:30 PM 019495 Page 1
Preliminary Estimate
Customer: CARLSON, SAMANTHA
2013 HOND Civic Sedan EX Automatic PZEV 4D SED 4-1.8L Gasoline Electronic Fuel Injection GREY
Line Oper Description Part Number Qty Extended
Price $
Labor Paint
1 WINDSHIELD
2*Rpr Windshield Honda - ROPE 0.3
3 ROOF
4 R&I LT Roof molding 0.4
5 PILLARS, ROCKER & FLOOR
6*Blnd LT Aperture panel s 1.2
7*Blnd LT Rocker panel s 1.0
8 REAR DOOR
9 R&I LT R&I door assy 1.1
10 *Blnd LT Outer panel 1.0
11 R&I LT Water shield Type 2 0.1
12 R&I LT Belt molding 0.3
13 R&I LT Handle, outside painted urban
titaniu
0.4
14 R&I LT R&I trim panel 0.4
15 BACK GLASS
16 *Rpr Back glass Honda-ROPE 0.3
17 QUARTER PANEL
18 *Rpr LT Quarter panel 22.0 2.2
19 Add for Clear Coat 0.9
20 R&I Fuel door 0.3
21 *Blnd Fuel door 0.2
22 R&I Fuel pocket US built 0.2
23 R&I LT Air outlet vent 0.1
24 R&I LT Inner liner 0.2
25 Repl LT Stone guard US built 74485TR0A00 1 18.30 0.2
26 *Rpr LT Inner panel US built (HSS)s 3.0 1.5
27 Add for Clear Coat 0.3
28 REAR BODY & FLOOR
29 R&I Rear panel trim 0.2
30 R&I LT Trunk side trim US built all 0.4
31 REAR LAMPS
32 R&I LT Tail lamp assy 0.2
33 REAR BUMPER
34 R&I R&I bumper cover 1.0
35 VEHICLE DIAGNOSTICS
36 *Subl Pre-repair scan 1 127.50 X m
37 *Rpr Post-repair scan m 0.5 M
38 MISCELLANEOUS OPERATIONS
39 *Repl Cover car/bag 1 0.0 0.2
40 #Hazardous waste removal 1 7.00 X
41 #Color tint / color match 1 0.5
42 #Rpr Color sand and buff 0.5
1/30/2026 4:46:30 PM 019495 Page 2
Preliminary Estimate
Customer: CARLSON, SAMANTHA
2013 HOND Civic Sedan EX Automatic PZEV 4D SED 4-1.8L Gasoline Electronic Fuel Injection GREY
43 #Repl Corrosion protection primer 1 0.5
44 #**OPEN FOR HIDDEN
DAMAGES**
1
SUBTOTALS 152.80 31.6 10.0
ESTIMATE TOTALS
Category Basis Rate Cost $
Parts 18.30
Body Labor 31.1 hrs @ $ 80.00 /hr 2,488.00
Paint Labor 10.0 hrs @ $ 80.00 /hr 800.00
Mechanical Labor 0.5 hrs @ $ 195.00 /hr 97.50
Paint Supplies 10.0 hrs @ $ 60.00 /hr 600.00
Miscellaneous 134.50
Subtotal 4,138.30
Sales Tax $ 618.30 @ 9.8750 % 61.06
Grand Total 4,199.36
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.
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.
1/30/2026 4:46:30 PM 019495 Page 3
Preliminary Estimate
Customer: CARLSON, SAMANTHA
2013 HOND Civic Sedan EX Automatic PZEV 4D SED 4-1.8L Gasoline Electronic Fuel Injection GREY
Estimate based on MOTOR CRASH ESTIMATING GUIDE and potentially other third party sources of data. Unless
otherwise noted, (a) all items are derived from the Guide ARG4449, CCC Data Date 01/16/2026, and potentially other
third party sources of data; and (b) the parts presented are OEM-parts. OEM parts are manufactured by or for the
vehicle's Original Equipment Manufacturer (OEM) according to OEM's specifications for U.S. distribution. OEM parts
are available at OE/Vehicle dealerships or the specified supplier. 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 with discounted pricing. Asterisk (*) or Double Asterisk (**) indicates that the parts and/or labor data
provided by third party sources of data 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, A/M or NAGS. 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 2024 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 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. Blnd=Blend. BOR=Boron steel.
CAPA=Certified Automotive Parts Association. CFC=Carbon Fiber.
D&R=Disconnect and Reconnect. HSS=High Strength Steel. HYD=Hydroformed Steel. Incl.=Included. LKQ=Like
Kind and Quality. LT=Left. MAG=Magnesium. Non-Adj.=Non Adjacent. NSF=NSF International Certified Part.
O/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. STS=Stainless Steel. Subl=Sublet.
UHS=Ultra High Strength Steel. N=Note(s) associated with the estimate line.
CCC ONE Estimating - A product of CCC Intelligent Solutions 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.
1/30/2026 4:46:30 PM 019495 Page 4
Classic Collision Summit Hill Workfile ID:
Federal ID:
Resale Number:
7dc96fda
99-2007661
8017444-00390 Dale Street North, Saint Paul, MN 55102
Phone: (651) 221-0919
FAX: (651) 372-4126
Estimate
RO Number:
Customer:Insurance:Adjuster:Estimator:Husein Hassan
Carlson, Samantha CUSTOMER PAY Phone:Create Date:1/21/2026
616 Summit Ave, Apt #204 Claim:
Saint Paul, MN 55102 Loss Date:
(651) 324-9338 Deductible:
2013 HOND Civic Sedan EX Automatic 4D SED 4-1.8L Gasoline Electronic Fuel Injection Grey
VIN:19XFB2F86DE045700 Interior Color:Mileage In:119,052 Vehicle Out:
License:KGM024 Exterior Color:Grey Mileage Out:
State:MN Production Date:5/2013 Condition:Job #:
Line Ver Operation Description Qty Extended
Price $
Part
Type
Labor Type Paint
1 E01 ESTIMATE WRITTEN FOR VISIBLE
DAMAGES ONLY
2 E01 ALL REPAIRS SUBJECT TO CHANGE FOR
PART PRICE INCREASES
3 E01 AND/OR POSSIBLE HIDDEN DAMAGES
4 E01 ROOF
5 E01 Remove/Install LT Roof molding 0.4 Body
6 E01 Blend LT Roof Rail 0.8
7 E01 PILLARS, ROCKER & FLOOR
8 E01 Remove/Install LT Pillar trim US built 0.2 Body
9 E01 Blend LT Rocker panel
10 E01 REAR DOOR
11 E01 Blend LT Door shell 1.0
12 E01 Remove/Install LT Belt molding 0.3 Body
13 E01 Remove/Install LT Water shield Type 2 0.1 Body
14 E01 Remove/Install LT Handle, outside painted urban titaniu 0.4 Body
15 E01 Remove/Install LT R&I trim panel 0.4 Body
16 E01 QUARTER PANEL
17 E01 Repair Pre-Pull on Quarter 2.0 Body
18 E01 Repair LT Quarter panel 13.0 Body 2.2
19 E01 Add for Clear Coat 0.9
20 E01 Refinish Feather Edge, Prime & Block 1.5
21 E01 Refinish Backside of Quarter 0.5
22 E01 Blend Fuel door 0.2
23 E01 Remove/Install Fuel door 0.3 Body
24 E01 Remove/Install LT Stone guard US built 0.2 Body
25 E01 Remove/Install LT Inner liner 0.2 Body
T = Taxable Item, RPD = Related Prior Damage, AA = Appearance Allowance, UPD = Unrelated Prior Damage, PDR = Paintless Dent Repair, A/M = Aftermarket, Rechr = Rechromed, Reman =
Remanufactured, OEM = New Original Equipment Manufacturer, Recor = Re-cored, RECOND = Reconditioned, LKQ = Like Kind Quality or Used, Diag = Diagnostic, Elec = Electrical, Mech =
Mechanical, Ref = Refinish, Struc = Structural
2/4/2026 9:53:49 AM Page 1
Estimate
RO Number:
2013 HOND Civic Sedan EX Automatic 4D SED 4-1.8L Gasoline Electronic Fuel Injection Grey
26 E01 REAR BODY & FLOOR
27 E01 Remove/Install LT Trunk side trim US built all 0.4 Body
28 E01 REAR LAMPS
29 E01 Remove/Install LT Tail lamp assy 0.2 Body
30 E01 REAR BUMPER
31 E01 Remove/Install R&I bumper cover 1.0 Body
32 E01 Remove/Install LT Side support 0.1 Body
33 E01 VEHICLE DIAGNOSTICS
34 E01 Repair Pre-repair scan 0.6 Mech
35 E01 Sublet Calibrate occupant classification system 1 175.00 Sublet
36 E01 Sublet Post-repair scan 1 75.00 Sublet
37 E01 MISCELLANEOUS OPERATIONS
38 E01 Remove/Replace Cover car/bag 1 10.00T OEM 0.2 Body
39 E01 Refinish Mask for Prime 0.5
40 E01 Color tint / color match 0.5
41 E01 Refinish Buff 0.5
42 E01 Remove/Replace Corrosion protection primer 1 12.00T Other 0.3 Body
43 E01 Sublet Hazardous waste removal 1 12.00T Other
Estimate Totals Discount $Markup $Rate $Total Hours Total $
Parts 10.00
Sublet/Miscellaneous 12.00
Labor, Body 82.00 19.7 1,615.40
Labor, Refinish 82.00 8.6 705.20
Labor, Mechanical 165.00 0.6 99.00
Material, Paint 62.00 8.6 533.20
Material, Shop 3.95 16.1 63.60
Miscellaneous 262.00
Subtotal 3,300.40
Sales Tax 62.29
Grand Total 3,362.69
Net Total 3,362.69
Estimate Version Total $
Original 3,362.69
Insurance Total $:0.00
Received from Insurance $:0.00
Balance due from Insurance $:0.00
Customer Total $:3,362.69
Received from Customer $:0.00
Balance due from Customer $:3,362.69
T = Taxable Item, RPD = Related Prior Damage, AA = Appearance Allowance, UPD = Unrelated Prior Damage, PDR = Paintless Dent Repair, A/M = Aftermarket, Rechr = Rechromed, Reman =
Remanufactured, OEM = New Original Equipment Manufacturer, Recor = Re-cored, RECOND = Reconditioned, LKQ = Like Kind Quality or Used, Diag = Diagnostic, Elec = Electrical, Mech =
Mechanical, Ref = Refinish, Struc = Structural
2/4/2026 9:53:49 AM Page 2