Anderson, Susan NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota .
Minnesota Stnte Stcrtirte 466.05 stcites that "...every person...who c(aims damages from uny m«nicipality...shaR cae�.re to be pre.sented to the
,�overning bocly oj'the municipality within 180 dm�s nfter the nReged loss or injury is discoverecl a notice stnting the tin�e,pluce,n�ici
circumstances therenf,and the amount qf compensntinn or other relieFdemanded."
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 S �'-S � � Middle Initial � Last Name�'^�p £-� S � !v
� EIVED
Company or Business Name �U��}-
Are You an Insurance Company? Yes No If Yes, Claim Number? OCT 1 O ZO�3
Street Address l S � g ��'Yl�S �- �� CITY CLERK
City Sfi ���-- State rn � Zip Code 5�� � �
Daytime Phone (��� )��-r77��'Cell Phone ( ) - Evening Telephone ( ) -
Date of AccidenU Inj ury or Date Discovered � '�-`�—�3 Time /o 'o o pm �`�X'
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. z w�� d 2 i��'y�'j
.v �^7 rs� m �v w,�i�r-� �,�r9'�2 ff u� 1 iv f_h� rz��h t h rr n�p l.rrn�f_ o v� 2 -�ti�
�3re�nU� Pg-S� rfim �S H-v� �`�t' 2� �a4s tr•V m �P ft-�v��. � iyiv �:v; T,� �t /i9��`
f�+l�t-r ��}-.s n o.�" J i f � R b l i�u+�i� .. S �v F v F 2 s+4� i7' .r fh,�n�� �'� �+ UsT h ���
b E��v -t � �ti f c� s i �� w n-�s b F e«�Hs� r"f �I�'�! rw�f— �e F-�1PC-f , T� d �-� A c�r•.� -fhL
oN� o m c v�2 c+4�� ,� 02 ►�,.� � ;cf �- a�-� �cf�, Stfv�
� .A-w�2 S K � 1'1•� r4 D � -It ►Z f Pc�vt i � I�— / 8 S-d'(o d
Please check the box(es)that most closely represent the reason for completing this form:
C�My vehicle was damaged in an accident f ❑ My vehicle was damaged during a tow
�^My vehicle was damaged by a pothole or condition of the street O 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 copies of all annlicable documents.
For the claims types listed below, please be sure to incluide 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.
�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-please 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? 5� �'A'�L. �D�C.r c� Case#or report# l 3 - � 8�- g��
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. � '� � h �`f� ��Af2.,
�'U� A-T '-f h e e rv � v th�. C�c'icD Cy� p►4ST -�1 v►� A-�g� S �S-1 ►'S E�-0 2� '�1
n 2�'v�, �., �� -�-o N�zF�- ��12�, �-rt t��N , �3 ���'U.F� �v ��s -� rnf)It�S�L�N,�
Please indicate the amount you are seeking in com ensation or what you would like the City to do to resolve this claim
to your satisfaction. T wo c�`r� t_� K� �h e � � T� � p t��r --�o� (Z� Ptr°�lu -t, d
w� � I 8 �4 , 4 �(- a---}- sr+a a o !a ca � � +2 r� � b v� c�, ��
Vehicle Claims-nlease comulete this section ❑ check box if this section does not a�plv
Your Vehicle: Year a-O � 1 Make T� J �T/q- Model �►21�-t.S
License Plate Number ��P y -� 8#-}- State r1� l� Color L'°li-�t-2Ci„p+qr� � 2�Y
Registered Owner 5 �S i'�F vv r- � 0 it1�}T,�l- t3-i.,1 �n� p �V�S o N
Driver of Vehicle 5�S i� � �}N D �{2S O �
Area Damaged IZ I�5�'l"�' � �0 ti1 �1"
City Vehicle: Year Make Model
� i �+�'� License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
In�urv Claims-please complete this section Fa"check box if this section does not ap�lv
How were you in�ured?
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 ofyouur 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 tlzis 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 i � — � � — i.3
Print the Name of the Person who Completed this Form• S ✓S �`l ^� �N ,� �-2 S o�
Signature of Person Making the Claim: �� "`�-+�--� �
�
Revised February 201 I
- � Schoonover Bodyworks &Glass Workfile ID: 622e8962
We Can Fix That!
1060 West County Road E, Shoreview, MN 55126
Phone: (651) 483-6756
FAX: (651) 483-3460
Preliminary Estimate
Customer: ANDERSON, SUSAN
Written By:Tom Nolan
Insured: ANDERSON,SUSAN Policy#: Claim #:
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact: O1 Right Front
Owner: Inspection Location: Insurance Company:
ANDERSON,SUSAN Schoonover Bodyworks&Glass
1858 AMES AVE 1060 West County Road E
ST PAUL, MN 55119 Shoreview, MN 55126
(651)735-7752 Evening Repair Facility
(651)483-6756 Business
VEHICLE
Year: 2011 Body Style: 4D H/B VIN: JTDKN3DU061409640 Mileage In: 32328
Make: TOYO Engine: 4-1.8L-G/E License: 664HBH Mileage Out:
Model: PRIUS Production Date: 8/2011 State: MN Vehicle Out:
Color: GREY Int: Condition: Job#:
TRANSMISSION Air Conditioning Stereo Cloth Seats
Automatic Transmission Intermittent Wipers Search/Seek Bucket Seats
POWER Tilt Wheel CD Player WHEELS
Power Steering Rear Defogger Auxiliary Audio Connection Aluminum/Alloy Wheels
Power Brakes Message Center SAFETI( PAINT
Power Windows Steering Wheel Touch Controls Drivers Side Air Bag Clear Coat Paint
Power Locks Telescopic Wheel Passenger Air Bag OTHER
Power Mirrors Climate Control Anti-Lock Brakes(4) Traction Control
DECOR Home Link 4 Wheel Disc Brakes Stability Control
Dual Mirrors RADIO Front Side Impact Air Bags Rear Spoiler
Console/Storage AM Radio Head/Curtain Air Bags
CONVENIENCE FM Radio SEATS
9/27/2013 1:58:50 PM i 013550 Page 1
, Preliminary Estimate
Customer: ANDERSON, SUSAN
Vehicle: 2011 TOYO PRIUS 4D H/B 4-1.8L-G/E GREY
Line Oper Description Part Number Qty Extended Labor Paint
Price$
1 FRONT BUMPER&GRILLE
2 Repl Bumper cover w/o fog lamp 5211947917 1 259.19 2.4 3.3
3 Add for Clear Coat 1.3
4 Blnd RT Tow eye cap 0.1
5 Blnd LT Tow eye cap 0.1
6 R&I License bracket 0.2
7 Repl RT Bezel w/o fog lamps 8148147010 1 43.18 Incl.
8 FRONT LAMPS __ __ _ _ _
__ _
9 R&I RT R&I headlamp assy 0.3
10 Repl RT Turn signal lamp 8151147020 1 26.72 Incl.
11 FENDER __ __ _
12 * Rpr RT Fender 4.4 2•�
13 Add for Clear Coat 0•8
14 R&I RT Fender liner 0.5
15 Repl RT Nameplate"HYBRID" 7537447051 1 29.08 0.2
16 # Subl CLEAR ADV.ON RT FENDER 1 62.50 X
17 PILLARS,ROCKER&FLOOR __ _ _
18 R&I RT Rocker molding 0•9
19 # Subl Hazardous waste removal 1 5.00 X
20 # Repl Cover car 1 0.2
21 # Corrosion Protection 1 0.3
22 # Tint Color 1 0.5
23 # Repl Mask interior 1 0.3
24 # Rope Glass-FENDER GLASS 1 0.4
25 # ADDITIONAL DAMAGE POSSIBLE 1 Itl��.
*******************:
SUBTOTALS 425.67 8.5 9.3
ESTIMATE TOTALS
Category Basis Rate Cost$
Parts 358.17
Body Labor 8.5 hrs @ $56.00/hr 476.00
Paint Labor 9.3 hrs @ $56.00/hr 520.80
Paint Supplies 9.3 hrs @ $36.00/hr 334.80
Body Supplies 6.6 hrs @ $3.00/hr 19.80
Miscellaneous 67.50
Subtotal 1,777.07
Sales Tax $692.97 @ 7.1250% 49.37
Grand Total 1,826.44
�
9/27/2013 1:58:50 PM 013550 Page 2
• � Preliminary Estimate
Customer: ANDERSON, SUSAN
Vehicle: 2011 TOYO PRIUS 4D H/B 4-1.8L-G/E GREY
LIMITED WARRANTY
Schoonover Bodyworks, Inc. takes great care to ensure that every repair meets our standards for quality.
The labor performed by Schoonover Bodyworks, Inc. is guaranteed against any defect in workmanship for as long as
you own your vehicle.
Schoonover guarantees that for as long as you own your vehicle, Schoonover will, at its expense, correct or repair all
defects which are attributable to defective or faulty workmanship in the repairs stated on the repair invoice, unless
caused by or damaged resulting from unreasonable use, improper maintenance or care of the vehicle, and rust
and/or corrosion.
This guarantee covers labor only and does not apply to parts, materials or equipment which may be covered by
manufacturer's warranty.
"Minnesota law gives you the right to choose any rental vehicle company, and prohibits me from requiring you to
choose a particular vendor."
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.
I
9/27/2013 1:58:50 PM 013550 Page 3
. . • Preliminary Estimate
Customer: ANDERSON, SUSAN
Vehicle: 2011 TOYO PRIUS 4D H/B 4-1.8L-G/E GREY
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
ARM8546, 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
(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 (N) 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 categ�ry. (numbers) 1 through 4=User Defined Labor Categories.
OTHER SYMBOLS AND ABBREVIATIONS: ,
Adj.=Adjacent. Algn.=Align. ALU=Aluminum. A/M=Aft�rmarket 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=6ureau of Automotive Repair. EPA=Environmental Protection Agency. NHTSA= National Highway
Transportation and Safety Administration. PDR=Paintless Dent Repair. VIN=Vehicle Identification Number.
9/27/2013 1:58:50 PM 013550 Page 4
\
LAMETTRYS COLLISION MAPLEWOOD
2923 MAPLEWOOD DR
MAPLEWOOD, MN 55109
PHON E: 651-766-9770
***PRELIMINARY ESTIMATE'**
09/18/2013 06:01 PM
Owner
Owner: SUSAN ANDERSON
Address: 1858 AMES AVE Work/Day: (651)735-7752
City State Zip: Saint Paul, MN 55119 FAX:
Control Information
Loss Date/Time: Loss Type: Collision
Deductible: $500.00
Ins.Company: Liberty Mutual Insurance
Address: 27201 Bella Vista Parkway Work/Day: (800)838-7103
City State Zip: Warrenville, IL 60555 FAX:
Inspection � � � �
Inspection Date: 09/18/2013 06:02 PM Inspection Type: Direct Repair Program
Primary Impact: Front Secondary Impact:
Company: Lamettry's Collision Appraiser License#:
Contact: ANDY TIHANYI
Address: 2923 Maplewood Drive Work/Day: (651)766-9770
FAX: (952)656-6093
City State Zip: Maplewood, MN 55109 FAX:
Email: ATIHANYI@LAMETTRYS.COM
' Repairer
Repairer: LaMettry's Collision, Inc. : Contact:
Address: 2951 Maplewood Drive Work/Day: (651)253-8050
City State Zip: Maplewood, MN 55109 Work/Day:
Email: ATIHANYI@LAMETTRYS.COM/Jwheeler@lamettrys.com
License#: Regulation ID: Tax ID#41-1393089
!� Remarks �
"`"`*""*"*"`""""**"`*All Supplements Require Prior Approval*****""""*****"'*"`"'
PLEASE submit all supplements to: Liberty0469@libertymutual.com or
FAX to: 603-334-8305
Include Customer Name, Claim Number, and all necessary invoices&photos
Vehicle IS scheduled,direction to pay LaMettry's Collision, pay shop direct
Vehicle �� ��
2011 Toyota Prius II 4 DR Hatchback
4cyl Hybrid 1.8
Continuously Variable Tr
09l18/2013 05:56 PM Page 1 of 5
2011 Toyota Prius II 4 DR Hatchback
Claim#: 09/18/2013 06:01 PM
Lic.Plate: 664-HBH Lic State: MN
Lic Expire: VIN: JTDKN3DUOB1409640
Prod Date: 08/2011 Mileage: 35,947
Veh Insp#: Mileage Type: Actual
Condition: Code: Y1923A
Ext.Color: GRAY int.Color:
Ext. Refinish: Two-Stage Int.Refinish:
Options
2nd Row Head Airbags AM/FM CD Player Air Conditioning
Aluminum/Alloy Wheels Anti-Lock Brakes Auto Headlamp Control
Bucket Seats Center Console Chrome Grille
Climate Control For A/C Cruise Control Digital Instrument Panel
Driver Knee Airbag Dual Airbags Halogen Headiights
Head Airbags Heated Power Mirrors Illuminated Visor Mirror
Intermittent Wipers Keyless Entry System LED Brakelights
Lighted Entry System MP3 Player Overhead Console
Power Brakes Power poor Locks Power Steering
Power Windows Rear Window Defroster Rear Window Wiper/Washer
Side Airbags Split Folding Rear Seat Stability Cntrl Suspensn
Strg Wheei Radio Control Theft Deterrent System Tilt&Telescopic Steer
Tinted Glass Tonneau/Cargo Cover Traction Control System
Trip Computer Velour/Cloth Seats
Damages
Line Op Guide MC Description MFR.Part No. Price ADJ°/a B% Hours R
1 E 6 01 Cover,Front Bumper 5211947921 $237.46 2.9 SM
2 L 6 13 Cover,Front Bumper Refinish 4.6 RF
3.3 Surface
0.6 Two-stage setup
0.7 Two-stage
3 RI 32 Grille,Frt Bumper Lwr R&I Assembly INC SM
4 E 23 Seal,Front Bumper 5339547020 $19.88 INC SM
5 L 125 Prep Raw Frt Bmpr Cvr Refini h 0.7 RF
OJ�Surface
6 RI 45 Spoiler,Lower Front R&i Assembly INC SM
7 E 15 46 Filler,Front Bumper LT 8148247010 $43.18 INC SM
8 BR 92 Cover,Tow Hook Access LT Blend Refinish 0.1 RF
0.1 Blend
9 RI 419 Brkt,Front Lic Plate R&i Assembly 0.2 SM
10 N 970 Fog Lamps Aim Additional Labor 0.3 SM
11 E 10 Lamp Assembly,Fog RT 812100D042 $163.08 INC SM
12 I 104 Fender,Front RT Repair 2.0* SM
13 L 104 Fender,Front RT Refinish 2.8 RF
2.3 Surface
0.5 Two-stage
14 E 1480 Nameplate,Fender RT 7537447051 $29.08 0.2 SM
15 L M14 Corrosion Protection Refinish 0.3" RF
16 SB M60 Hazardous Waste Removal Sublet Repair $4.00" SM
17 RI Lic Plate R&I Assembly 0.1* SM"'
18 SB Scotch Cal Sublet Repair $85.00' SM*
19 RI Rope vent glass R&I Assembly 0.4" SM"
19 Items
MC Message
01 CALL DEALER FOR EXACT PART#/PRICE
09/18/2013 05:56 PM Page 2 of 5
2011 Toyota Prius II 4 DR Hatchback
Claim#: 09/18/2013 06:01 PM
13 INCLUDES 0.6 HOUR�FIRST PANEL TWO-STAGE ALLOWANCE
46 PRINTABLE ALTERNA7E PARTS COMPARE
Estimate Total&Entries
Gross Parts $492.68
Paint Materiais $272.00
Parts 8�Material Total $764.68
Tax on Parts&Material @ 7.125% $54.48
Labor Rate Replace Repair Hrs Total Hrs
H rs
Sheet Metal(SM) $52.00 3.8 2.3 6.1 $317.20
Mech/Elec(ME) $75.00
Frame(FR) $70.00
Refinish (RF) $52.00 8.5 8.5 $442.00
Paint Materials $32.00
Labor Total 14.6 Hours $759.20
Sublet Repairs $89.00
Gross Total $1,667.36
Less: Deductible 00-
Net Total
$1,167.36
Alternate Parts Y/01/00/00/01/01 CUM 01/00/00/01/01 Zip Code:55109 LIBERTY MUTUAL
Recycled Parts Y/4/0 Zip Code:55109
Audatex Estimating 7.0.019 ES 09/18/2013 05:56 PM REL 7.0.019 DT 09/01/2013 DB 09/15/2013
Copyright(C)2013 Audatex North America,Inc.
1.8 HRS WERE ADDED TO THIS ESTIMATE BASED ON AUDATEX'S TWO-STAGE REFINISH FORMULA.
"THIS IS NOT AN AUTHORIZATION TO REPAIR. PRESENT THIS APPRAISAL TO THE
REPAIRING GARAGE BEFORE REPAIRS BEGIN.WE RESERVE THE RIGHT TO INSPECT ANY
ADDITIONAL DAMAGE BEFORE CONSIDERING PAYMENT OF SUPPLEMENTAL REPAIR CHARGES."
NUMBER OF DAY TO REPAIR.......
THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF CRASH PARTS SUPPLIED BY A
SOURCE OTHER THAN THE MANUFACTURER OF YOUR MOTOR VEHICLE. THE AFTERMARKET
CRASH PARTS USED IN THE PREPARATION OF THIS ESTIMATE ARE WARRANTED BY THE
MANUFACTURER OR DISTRIBUTOR OF SUCH PARTS RATHER THAN THE MANUFACTURER OF
YOUR VEHICLE.
DEAR LIBERTY MUTUAL CUSTOMER,
A LIBERTY MUTUAL APPRAISER OR APPROVED REPAIR FACILITY HAS COMPLETED AN
APPRAISAL OF THE DAMAGES TO YOUR VEHICLE. A COPY OF THE APPRAISAL WILL BE
MAILED IF ONE IS NOT ATTACHED.
WITH LIBERTY MUTUAL YOU MAY CHOOSE WHO W�LL COMPLETE REPAIRS TO YOUR VEHICLE.
09/18/2013 05:56 PM Page 3 of 5
�2011 Toyota Prius 11 4 DR Hatchback
Claim#: ' 09/18/2013 06:01 PM
YOU MAY CHOOSE A SHOP YOU ARE FAMILIAR WrTH OR ONE OF OUR TOTAL LIBERTY CARE
SHOPS. (IF YOU DESIRE WE WILL PROVIDE YOU WITH A LIST OF OUR TOTAL LIBERTY
CARE SHOPS. PLEASE PRESENT THE APPRAISAL TO THE SHOP OF YOUR CHOICE. )
THE SHOPS PARTICIPATING IN OUR TOTAL LIBERTY CARE PROGRAM OFFER YOU BOTH
A WRITTEN GUARANTEE AND QUALITY REPAIRS. LIBERTY MUTUAL, HOWEVER CAN ONLY
OFFER A GUARANTEE AT OUR APPROVED TOTAL LIBERTY CARE SHOPS.
SHOULD THE REPAIR SHOP FIND ADDITIONAL DAMAGE, THEY ARE REQUIRED TO CONTACT
LIBERTY MUTUAL PRIOR TO PERFORMING ADDITONAL REPAIRS. SUPPLEMENTAL CHARGES
SUBMITTED WITHOUT PRIOR AUTHORIZATION FROM LIBERTY MUTUAL WILL BE DENIED.
IF YOU WOULD LIKE LIBERTY MUTUAL TO ISSUE PAYMENT TO THE REPAIR SHOP YOU HAVE
SELECTED DIRECTLY, PLEASE SIGN AND DATE THE AUTHORIZATION BELOW.
------------------------------------------------------------------------------
. DIRECT PAYMENT AUTHORIZATION •
I AUTHORIZE LIBERTY MUTUAL TO PAY ON
MY BEHALF FOR THE REPAIR OF COVERED DAMAGES TO MY VEHICLE.
VEHICLE OWNER'S SIGNATURE DATE
**************************CAPA SHEET METAL OPTION*****************************
A CAPA CERTIFIED SHEETMETAL PART IS AVAILABLE FOR YOUR VEHICLE FOR THE
FOLLOWING PARTS.
LEFT FENDER OEM $ QRP $ DIFFERENCE $
RIGHT FENDER OEM $ QRP $ DIFFERENCE $
HOOD OEM $ QRP $ DIFFERENCE $
LEFT DOOR OEM $ QRP $ DIFFERENCE $
RIGHT DOOR OEM $ QRP $ DIFFERENCE $
DECK LID OEM $ QRP, $ DIFFERENCE $
YOUR TOTAL SAVINGS IF YOU CHOOSE CAPA PAR�I'S WOULD BE: $
AS THE OWNER YOU HAVE THE CHOICE ***TOTAL DIFFERENCE SUBJECT TO PART
AVAILABLILITY AND PRICE FLUCTUATION. USE OF CAPA CERTIFIED SUBSTITUTE SHEET
METAL DOES NOT AFFECT YOUR WARR�INTY.
I HEREBY GIVE THE SHOP PERMISSION TO USE 'Z'HE ABOVE CAPA PARTS
Op Codes
" = User-Entered Value E = Replace OEM NG= Replace NAGS
EC= QUALITY REPL. PART OE= OEM SURPLUS PART UE= OEM SURPLUS PART
ET = Partial Replace Labor EP= QUALITY REPL. PART EU= LIKE KIND&QUALITY
TE = Partial Replace Price PM= Replace PXN Reman/Rebit 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 Allowance RP= Related Prior Damage
Page 4 of 5
09/18/2013 05:56 PM
2011 Toyota Prius II 4 DR Hatchback
Claim#: 09/18/2013 06:01 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's prior written consent. '
�Str�ra e�m��
� -- Copyright(C)2013 Audatex North America,Inc.
Audatex Estimating is a trademark of Audatex North America, Inc.
I
I
I
�
09/18/2013 05:56 PM Page 5 of 5