Shorein 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 municipaliry...shall cause to be presented to the
governing body of the municipality within 180 days after the alleged[oss 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 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�or►,�,�.5 Middle Initial --� Last Name v�v`�in �►��\ ,G�
—� V C
Company or Business Name nG � r V
� �3 _ ���g��� 6 2013
Are You an Insurance Company? es No If Yes,Claim Number?
StreetAddress������ �"- Nw� �k.�`� 3�d c�TY CL���
City �av�S'�G� State I�.� Zip Code_ � �
Daytime Phone(,`�D��Z�v- R� Cell Phone( ) - Evening Telephone( ) -
Date of Accident/Injury or Date Discovered��� G�9— �d� Time /'�s am/�
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 em loyees are involved and/or responsible for your dama es. 5� „
t � �l9lv
S L
. � +-
�v�Q.
LL �
P ease 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 vou need to include copies of all aaulicable documents.
For 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.
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-nlease comulete this section
Were there witnesses to the incident? Yes � Unknown (circle)
Provide their names,addresses and telephone numbers:
Were the police or law enforcement c�tled. e No Unknown (circle
If yes,what department or agency? �f� �� Case#or report# l 3 —a'��D�(a
Where did the accident or injury take place? Provide street address,cross street,intersection,name of park or facility,
closest landmark,etc. Ple�ase be as detail d as ossible. If necessary,attach a diagram.
�.�I�za�l a� 4 (�mo�. �
_--, ,
Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction.
Vehicle Claims- lease com lete this section ❑ check box if this section does not a 1
Your Vehicle: Year�Make Model V,1"c�
License Plate Numbe State�A�l 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)
Area Damaged
Iniurv Claims-nlease complete this section ❑ check box if this section does not apply
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): I
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
`�7,Check here if you are attaching more pages to this claim form. Number of additional pages�.
/ ..
By signing this fornz,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 prosecutian. Date form was completed �� y 3
Print the Name of the Person who Completed this�orm: �-� l�� '
Signature of Person Making the Claim:
Revised February 2011
Date: 10/24/2013 11:38 AM
Estimate ID: 13-4148454-01
Estimate Version: 0
Committed
Profile ID: Metro 7.125 All Part
Heppners Auto Body Inver Grove
6042 Claude Way East,Inver Grove Heights,MN 55075
(651)455-7920
Fax: (651)455-0140
Damage Assessed By: Tony Knops Appraised For: PROGRESSIVE
Type of Loss: Auto
Date of Loss: 10/20/2013 Arrival Date: 10/21/2013
Payer: Insurance Deductible: 500.00
Claim Paid: N
Claim Number: 13-4148454-01
Insured: JEFFREY BAILEY
Owner: JEFFREY BAILEY
Address: 1234 ROSE VISTA CT.APT.8,ROSEVILLE,MN 55113
Telephone: Work Phone: (612)292-0205 Home Phone: (651)398-0346
Contact Phone: (651)398-0346
Mitchell Service: 910607
Description: 2009 Honda Civic LX Vehicle Production Date: 8/09
Body Style: 4D Sed Drive Train: 1.SL Inj 4 Cyl 5A FWD
VIN: 19XFA16599E047791 License: 796-BLY MN
Mileage: 49,931
OEM/ALT: A Search Code: ARDENHILL1
Color: GRAY
Options: PASSENGERAIRBAG,DRIVERAIRBAG,POWER LOCK,POWER WINDOW,REAR WINDOW DEFOGGER
MANUAL AIR CONDITION,CRUISE CONTROL,TILT STEERING COLUMN
TELESCOPIC STEERING COLUMN,ANTI-LOCK BRAKE SYS.,FOG LIGHTS,AUXILIARY INPUT
FRONT AIR DAM,VARIABLE ASSISTED STEERING,SIDE AIRBAGS,ANTI-THEFT SYSTEM
SIDE HEAD CURTAIN AIRBAGS,DAYTIME RUNNING LIGHTS,AM/FM STEREO CD/MP3 PLAYER
FRONT BUCKET SEATS,INTERIOR AIR FILTER,KEYLESS ENTRY SYSTEM
STEERING WHEEL MOUNTED CONTROLS
Line Entry Labor Line Item Part Type/ Dollar Labor
Item Number Type Operation Description Part Number Amount Units
Infor ation Labels
1 000002 BDY REMOVE/REPLACE Inform Label Air Bag ution 77871-SDA-A90 4.65
2 000211 BDY REMOVE/REPLACE Inform Label A/C Refrigerant 80050-SNA-H00 1.55
Front Bumper
3 BDY OVERHAUL Frt Bumper Cover Assy 1.5 #
4 004745 BDY REMOVE/REPLACE Frt Bumper Cover "Non-OEM CAPA 223.00 INC #
5 REF REFINISH Frt Bumper Cover C 2 6 �
6 005109 BDY REMOVE/REPLACE R Frt Otr Bumper Grille 71106-SNA-A50 55.02 INC
7 005110 BDY REMOVE/INSTALL L Frt Otr Bumper Grille Existing INC r
8 005077 BDY REMOVE/INSTALL Frt Bumper License Plate Bracket Existing INC r
9 005078 BDY REMOVE/REPLACE R Frt Upr Bumper BraCket "Non-OEM 31.00 INC #
10 BDY REMOVE/INSTALL FrtBumperAssy INC #
11 005083 BDY REMOVE/REPLACE Frt Bumper Impact Ab�orber 71170-SNA-A50 72.78 WC
12 005084 BDY REMOVE/REPLACE Frt Bumper Reinforce�nent Bar(Alum) 71131-SNA-A00 117.10 0.4 #
13 005070 BDY REMOVE/REPLACE R Frt Bumper Bracket� 71135-SNA-AOOZZ 53.65 0.2 #
�q RAIL END '
15 005071 BDY REMOVE/REPLACE L Frt Bumper Bracket 71185-SNA-AOOZZ 53.65 0.2 #
16 RAIL END
Grille
17 005191 BDY REMOVE/REPLACE Grille Trim *"Non-OEM 114.00 INC #
18 005190 BDY REMOVE/REPLACE Grille "Non-OEM CAPA 106.00 0.2 #
19 005001 BDY REMOVE/REPLACE Grille Emblem 75700-TFO-000 19.48 0.1 #
20 BDY REMOVE/INSTALL Grille Assy INC #
ESTIMATE RECALL NUMBER: 10/24/201 3 11 38:19 13-414845401
Mitchell Data Version: OEM: SEP 13_V1023
MAPP:SEP_13_V1020 Copyright(C)1994-2013 Mitchell International Page 1 of 6
Software Version: 7.0.487 All Rights Reserved
Date: 10/24/2013 11:38 AM
Estimate ID: 13-4148454-01
Estimate Version: 0
Committed
Profile ID: Metro 7.125 All Part
21 005002 BDY REMOVE/REPLACE Grille Emblem Clip 2@1.60 90301-STO-003 3.20
Front Lamas
22 002315 BDY CHECK/ADJUST Headlamps 0.4
23 005015 BDY REMOVE/REPLACE R Front Combination Lamp Assembly "Non-OEM 202.00 INC #
24 005016 BDY REMOVE/REPLACE L Front Combination Lamp Assembly "*Non-OEM 202.00 INC #
Hood
25 000078 BDY REMOVE/REPLACE Hood Panel "Non-OEM CAPA 340.00 0.5
26 REF REFINISH Hood Outside C 2.6
27 REF REFINISH Add For Hood Underside C 1.3
28 000081 BDY REMOVE/REPLACE R Hood Hinge "Non-OEM 18.00 0.2 #
29 REF REFINISH R Hinge C 0.5
30 BDY REMOVE/INSTALL Hood Assy INC
31 BDY REMOVE/INSTALL Cowl Top Panel 0.3
32 BDY REMOVE/INSTALL R Cowl Top Panel Extension Assy 0.2 #
33 005123 BDY REMOVE/REPLACE Hood Latch 74120-SNA-A21 73.77 INC
Coolina
34 007016 BDY REMOVE/REPLACE Coeling Radiator '*Non-OEM 15�_20 - _1N1�-#
35 000135 BDY REMOVE/REPLACE Cooling RecoveryTank `*Non-OEM 6.00 INC
AIC/HeaterNentilation
36 006212 MCH REMOVE/REPLACE Air Cond Condenser Assy -M "Non-OEM 139.00 0.4 #
37 MCH REMOVE/REPLACE Evacuate 8�Recharge A/C -M 1.4
38 003320 MCH REMOVE/REPLACE Air Cond Condenser Pipe -M 80341-SNE-A01 148.72 0.8
Front Fender
39 000244 BDY REMOVE/REPLACE R Fender Panel "Non-OEM CAPA 153.00 1.5 #
40 REF REFINISH R Fender Outside C 1.6
41 REF REFINISH R Add To Edge Fender C 0.5
42 000245 BDY REMOVE/REPLACE L Fender Panel "Non-OEM CAPA 153.00 1.5 #
43 REF REFINISH L Fender Outside C 1.6
44 REF REFINISH L Add To Edge Fender C 0.5
45 003963 BDY REMOVE/REPLACE R Upr Fender Garnish 74206-SNA-A01 24.05 INC #
46 000262 BDY REMOVE/REPLACE R Fender Liner 74101-SNA-A00 49.14 INC #
47 000263 BDY REMOVE/INSTALL L Fender Liner Existing INC #r
Front Inner Structure
48 002345 REF REFINISH Radiator Support Complete �•5
49 000275 BDY REMOVE/REPLACE Front Body Radiator Support -S 60400-SNE-A01ZZ 268.12 8.7 #
50 000045 BDY REMOVE/REPLACE Front Body Closing Panel 71125-SNA-A00 57.68 INC
51 000048 BDY REMOVE/REPLACE R Front Body Clip 91505-S9A-003 2.42
52 000049 BDY REMOVE/REPLACE L Front Body Clip 91505-S9A-003 2.42
53 002357 REF REFINISH R Apron/Sidemember Complete �•5
54 002358 REF REFINISH L ApronlSidemember Complete �,5 i
55 000284 BDY REMOVE/REPLACE R Front Body Apron Agsy(HSS) -S 60650-SNA-305ZZ 429.95 7.5
56 000285 BDY REPAIR L Front Body Apron A�sy(HSS) -S Existing 3.0*#
57 000294 BDY REMOVElREPLACE R Front Body Sideme ber Assy(HSS)-S 60810-SNA-A02ZZ 332.75 4.0 # �
58 000297 BDY REMOVE/REPLACE L Front Body Sidemember Assy(HSS)-S 60910-SNE-AOOZZ 302.25 7.0 #
59 007085 MCH REMOVE/INSTALL Fuse Box -M Existing 0.3' �
60 007412 BDY REMOVE/INSTALL Engine Wiring Hamess Existing 0.7•
Air Baa Svstem
61 000328 MCH REMOVE/REPLACE Air Bag Module-Driver Front -M 77810-SNA-A82ZA 690.11 0.3
62 000333 MCH REMOVE/REPLACE R Frt Air Bag Impact Sensor -M 77930-SNA-632 57.11 0.2 #
63 000337 MCH REMOVE/REPLACE Air Bag Control Unit -M 77960-SNA-A23 171.30 0.4 #
64 BDY REMOVE/INSTALL Console 0•5 '
Enaine i
65 002387 MCH REMOVE/INSTALL Engine&Trans Assy -M 8.0 #
Enqine/Bodv Under Covers f�
66 005102 BDY REMOVE/INSTALL Engine UnderCover Existing 0.3 r I
Rocke r/P illars/Floor
67 001067 BDY REPAIR L Door Opening Frame Existing 1.0"#
68 REF REFINISH/REPAIR L Door Opening Frame C 1.5*
gg MODIFIED REFINISH W ITH FULL CLEAR COAT
Front Door
70 002403 REF BLEND R Frt Door Outside C 0.9
71 002404 REF BLEND L Frt Door Outside C 0.9
ESTIMATE RECALL NUMBER: 10/24/2013 11:38:19 13-4148454-01
Mitchell Data Version: OEM: SEP_13_V1023
MAPP:SEP_13_V1020 Copyright(C)1994-2013 Mitchell Intemational Page 2 of 6
Software Version: 7.0.487 All Rights Reserved
Date: 10/24/2013 11:38 AM
Estimate ID: 13-4148454-01
Estimate Version: 0
Committed
Profile ID: Metro 7.125 All Part
72 002695 BDY REMOVE/INSTALL R Frt Otr Belt Moulding 0.6 #
73 002696 BDY REMOVE/INSTALL L Frt Otr Belt Moulding 0.6 #
74 002697 BDY REMOVE/INSTALL R Frt Rear View Mirror INC
75 002698 BDY REMOVE/INSTALL L Frt Rear View Mirror INC
76 001515 BDY REMOVE/INSTALL R Frt Door Adhesive Moulding Existing 0.4*#
77 BDY REMOVElINSTALL R Frt Door Trim Panel INC
78 Includes Clean&Retape
79 001523 BDY REMOVE/INSTALL L Frt Door Adhesive Mojulding Existing 0.4'#
80 BDY REMOVE/INSTALL L Frt Door Trim Panel INC
81 Includes Clean&Retape
82 002707 BDY REMOVE/INSTALL R Frt Otr poor Handle 0.7 #
83 002708 BDY REMOVE/INSTALL L Frt Otr poor Handle 0.7 #
Roof
84 002735 BDY REMOVE/INSTALL L Roof Drip Moulding 0.3
85 936012 ADD'L COST HAZARDOUS WASTE DISPOSAL 3.50 *
ADDITIONAL OPERATIONS
86 REF ADD't OPR Ctear Coat 3.8
Additional Costs&Materials
87 ADD'L COST PainUMaterials 620.00 '
MANUAL ENTRIES
88 900500 BDY * ADD'L LABOR OP SET UP&MEASURE UNIBODY/FULL FRAME Existing 2.0*
89 Includes all necessary operations except pull time
90 900500 FRM* REPAIR PULUSQUARE UNIBODY/FRAME Existing 4.0*
91 Document Control Points
92 900500 REF ' REMOVE/REPLACE FLEX ADDITIVE *•Non-OEM 2.50 ' 0.0`
93 900500 BDY * ADD'L LABOR OP COVER CAR FOR OVERSPRAY •*Non-OEM 5.00 ' 0.2*
94 900500 BDY " REMOVE/REPLACE TOW BILL-TAXABLE 1 TIME ONLY Sublet 75.00 ' 0.0'
95 900500 BDY • REMOVE/REPLACE CLEAR PROTECTIVE TAPE Sublet 125.00 ' 0.0`
*-Judgment Item
#-Labor Note Applies
"*Non-OEM CAPA- Non-Original Equipment Manufacturer Replacement Part, CAPA Certified
*"Non-OEM-Non-Original Equipment Manufacturer Replacement Part
C-Included in Clear Coat Calc
r-CEG R&R Time Used For This Labor Operation
NAPA AUTO PARTS KEYSTONE AUTOMOTIVE KEYSTONE AUTOMOTIVE PP
CALL YOUR LOCAL STORE 3615 MARSHALL ST.NE 3615 MARSHALL ST.NE
OR CALL 1-800-LET-NAPA MINNEAPOLIS i MINNEAPOLIS
MN 55418 MN 55418
(800)328-1845 �612)789-1886 (800)328-1845 (612)789-1886
(800)538-6272
34 �'CU2922 151.20 9 **H01067108N 31.00 4 "H01000266PP 223.00
23 "H02503127 202.00 17 **H01210127PP 114.00
24 *'H02502127 202.00 18 "H01200198PP 106.00 �
28 *"H01236115 18.00 25 *'H01230148PP 340.00
35 '*H03014115 6.00
36 "CNDDPI3525 139.00
39 "H01241168C 153.00
42 "H01240168C 153.00
Prior Damage: i
SEE UPD PHOTOS
ESTIMATE RECALL NUMBER: 10/24/2013 1138:19 13-414845401
Mitchell Data Version: OEM: SEP 13 V1023
MAPP:SEP 13_V1020 Copyright(C)1994-2013 Mitchell International Page 3 of 6
Software Version: 7.0.487 All Rights Reserved
Date: 10/24/201311:38 AM
Estimate ID: 13-4148454-01
Estimate Version: 0
Committed
Profile ID: Metro 7.125 All Part
All manufacturers requirements regarding seat belt and supplemental
restraint system replacement must be adhered to. If additional parts
or operations are necessary to properly accomplish this, please
contact the estimating claims rep.
Estimate Totals
Add'I
Labor Sublet
I. Labor Subtotals Units Rate Amount Amount Totals II. Part Replacement Summary Amount
Body 45.8 52.00 0:80 Q.00 2,387.60 Taxable Parts -- 4,911.57
Refinish 22.8 52.00 0.00 0.00 1,185.60 Sales Tax @ 7.125% 349.95
Frame 4.0 70.00 0.00 0.00 280.00
Mechanical 11.8 80.00 0.00 0.00 944.00 Non-Taxable Parts 125.00
Non-Taxable Labor 4,791.20 Total Replacement Parts Amount 5,386.52
Labor Summary 84.4 4,791.20
III. Additional Costs Amount IV. Adjustments Amount
Taxable Costs 620.00 Insurance Deductible 500.00-
Sales Tax @ 7.125% 44.18
Customer Responsibility 500.00-
Non-Taxable Costs 3.50
Total Additional Costs 667.68
Paint Material Method:Rates
Init Rate=32.00
I. Total Labor: 4,791.20
II. Total Replacement Parts: 5,386.52
III. Total Additional Costs: 667.68
Gross Total: 10,845.40 ,
I IV. Total Adjustments: 500.00- �
Net Total: 10,345.40
Point(s)of Impact i
1 Right Front Corner(P) �
Insurance Co: PROGRESSIVE f
I
Inspection Site: Burnsville Service Center I
Address: 12450 River Ridge Ct
Bumsville,MN 55337
ESTIMATE RECALL NUMBER: 10/24/2013 11:38:19 13-4148454-01
Mitchell Data Version: OEM: SEP_13_V1023
MAPP:SEP_13_V1020 Copyright(C)1994-2013 Mitchell Intemational Page 4 of 6
Software Version: 7.0.487 All Rights Reserved
Date: 10/24/201311:38 AM
Estimate ID: 13-4148454-01
Estimate Version: 0
Committed
Profile ID: Metro 7.125 All Part
THIS IS A DAMAGE ASSESSMENT ONLY - NOT AN AUTHORIZATION TO REPAIR -
BASED ON DPM�IGE VISIBLE OR CERTAIN AT THE TIME IT WAS WRITTEN.
IF FRAME OR UNIBODY REPAIR IS INCLUDED ON THIS ESTIMATE, THE AMOUNT
SHOWN INCLUDES TIME OR ALLOWANCE FOR MEASURING BEFORE, DURING AND
AFTER THOSE REPAIRS.
THE OWNER OF THE VEHICLE MAY SELECT THE REPAIR FACILITY OF HIS/HER
CHOICE.
TO ENSURE PROPER AND PROMPT PAYMENT FOR ADDITIONAL DAMAGE DISCOVERED
DURING THE COURSE OF REPAIRS, CONTACT PROGRESSIVE FOR SUPPLEMENT
HANDLING PROCEDURES.
PROGRESSIVE HONORS THE PREVAILING LA�OR MARKET R.ATE IN YOUR AREA FOR
YOUR PROPERTY. IF YOU CHOOSE A SHOP THAT CHARGES IN EXCESS OF
PREVAILING LABOR MARKET RATES, YOU WILL BE RESPONSIBLE FOR THE
DIFFERENCE.
LIFETIME GUARANTEE FOR SHEET METAL AND PLASTIC BODY PARTS
The replacement parts written on the estimate are intended to return
your vehicle to its pre-loss condition with proper installation.
After repair, if any sheet metal or plastic body part included in the
estimate fails to return your vehicle to its pre-loss condition
(assuming proper installation) , in terms of form, fit, finish,
durability or functionality, Progressive will arrange and pay for the
replacement of the part, to the extent not covered by a
manufacturer's or other warranty. This service will be performed at
no cost to you (including associated repair and rental car costs) . To
obtain service under this Guarantee, call Progressive at
1-800-274-4641. This Guarantee applies as long as you own or lease
the vehicle. This Guarantee is not transferable and terminates if you
sell or otherwise transfer your vehi�le.
THIS GUARANTEE DOES NOT COVER NORMAL WEAR AND TEAR OR D�IMAGE CAUSED
BY IMPROPER MAINTENANCE, NEGLECT, ABUSE OR SUBSEQUENT ACCIDENT. THIS
GUARANTEE IS LIMITED TO AR.RANGING FOR THE SELECTION OF REPAIR PARTS
THAT WILL RETURN YOUR VEHICLE TO ITS PRE-LOSS CONDITION. ACCORDINGLY,
PROGRESSIVE WILL NOT BE LIABLE FOR ANY INDIRECT, INCIDENTAL OR
CONSEQUENTIAL DAMAGES THAT RESULT FROM THE INSTALLATION OR USE OF
THESE PARTS.
Part Type Terms and Abbreviations
NEW and OEM or part number displayed - These refer to a new, original
equipment manufacturer part.
NON-OEM and A/M and Qual REPL - These refer to an after-market part,
which is a new, non-original equipment manufacturer part.
USED/RECYCLED and LKQ - These refer to a used OEM part.
REMANUFACTURED and RECOND. and RECORE - These refer to used/recycled
OEM parts that have been refurbished.
REPAIR SHOP'S AUTHORIZED REPRESENTATIVE'S SIGNATURE INDICATING
AGREEMENT ON COST TO RETURN THE VEHICLE TO PRE-LOSS CONDITION
ESTIMATE RECALL NUMBER: 10/24/2013 1138:19 13-4148454-01
Mitchell Data Version: OEM: SEP_13_V1023 Page 5 of 6
MAPP:SEP_13_V1020 Copyright(C)1994-2013 Mitchell International
Software Version: 7.0.487 All Rights Reserved
Date: 10/24/2013 11:38 AM
Estimate ID: 13-4148454-01
Estimate Version: 0
Committed
Profile ID: Metro 7.125 All Part
INCLUDING TOW/STORAGE CHARGES:
SHOP SIGNATURE: EST. COMPLETION DATE:
ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE/SHE IS
FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION OR
FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF
INSURANCE FRAUD.
Event Log
File Created: 10/22/2013 08:48:17 AM
Estimate Started: 10/22/2013 08:51:46 AM
FstimateFnnfed: 1D/241ZUT3 10:i1:41 AM
Estimate Committed: 10/24/2013 11:3�8:19 AM
Estimate Uploaded: Estimate not uplbaded
I
I
ESTIMATE RECALL NUMBER: 10/24/2013 11:38:19 13-4148454-01 i,
Mitchell Data Version: OEM: SEP_13_V1023 i
MAPP:SEP_13 V1020 Copyright(C)1�94-2013 Mitchell Intemational Page 6 of 6
Software Version: 7.0.487 All Rights Reserved