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Bergstrom (3) Providing Insurance and Frnancia!Services �State Farm� Home Office, Bloomington, IL November 19, 2013 RECEIVED City Clerk State Farm Claims ��C 0� 2��3 310 City Hall P.O.Box 2371 15 Kellogg Blvd West Bloomington IL 61702-2371 Saint Paul MN 55102 CITY CLERK Certifed Mail - Return Receipt Requested RE: Claim Number. 23-21X5-835 Our Insured: John Bergstrom Date of Loss: July 12, 2013 Your Insured: City Clerk Your Insured Driver: Andrew Justin Loss Location: 7th St& Douglas, St Paul, MN To Whom It May Concem: It is our understanding that you are self insured. Our investigation indicates you are responsible for this claim. Therefore, we are seeking recovery from you. This letter is to notify you of our subrogation claim and request your cooperation in settling this matter. To assist you in your review, here is a breakdown of the amounts State Farm�paid by Cause of Loss: 041/045- Uninsured Motorist BI $0 042- Uninsured Motorist PD $0 300 series/400- Comp/Collision $12,175.08 501 - Rental/Loss of Use $0 600-050- Med Pay/PIP $0 Other $� Salvage Recovery $2,257.85 Amount State Farm Paid $9,917.23 Insured Deductible $250.00 Total Claim Amount $10,167.23 Based on the assessment of liability befinreen the parties, State Farm Mutual Automobile Insurance Company is seeking 100% of the Total Claim Amount listed above. The amourrt payable to State Farm Mutual Automobile Insurance Company for this loss is $10,167.23. Please remit payment of this claim and include our claim number on the payment. If you have any questions or need additional information, please call me at the number listed below. If I am not available, any other member of my team may assist you. Thank you for your cooperation. In order to assist you in evaluating and processing the subrogation claim we are asserting, we may provide nonpublic personal information about our customer. We are sharing this information to effect, administer, or enforce a transaction authorized by the consumer. However, 23-21 X5-835 Page 2 November 19, 2013 you are neither authorized nor permitted to: (1) use the customer information we provided for any purpose other than to evaluate and process the subrogation claim, or(2)disclose or share the customer information we provide for any purpose other than to evaluate and process the subrogation claim. Sincerely, Ryan Perno Claim Representative (877)457-8276 Ext. 309-763-9150 Fax: (866)231-9276 State Farm Mutual Automobile Insurance Company Enclosure .• . -�"'3� � i x s-��s- NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota Minnesota State Statute 466.05 states that " ...every person...whn clainis darnages fi-mm�ny municipaliry...shall cause to be presented to the governing bodt�of the�nunicipaliry within /80 days nfter the alleged loss or injury is discovered a notice stating the time,place,and circumstances thereof, and the amount of contpensation 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 Middle Initial Last Name n��!� ��D ! Company or Business Name c��A,�,��l��-��✓a+n;�L ��n ��a'�E�- �- ^^�^ �U.�T� Are You an Insurance Company? Ye /No If Yes, Claim Number? ��XS Y��S � �� ,� �,�� ?l CITY CLERK Street Address �„ � �� Cit� l�`�lc'�-3mL hl�� State '�l( Zip Code �� "�� 7� Da}ti me Phone (�)�-� � 7� Ca� Phone (J7� 7��- ��S�Evening Telephone ( ) - Date of Accident/Injury or Date Discovered � �°�/'-� Time ��-�7 am/� Please state, in detail, what occurred (happened), and why you are submitting a claim. Please indicate why or how you fee the City of Saint Paul or its employees are involve and/or responsible for y r damage . /.1.�'.a /Lf�t � �t ��1.7�10l ,.... , Pl ase check the box(es) that most closely represent the reason for completing this form: L�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 copies of all applicable 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 complete this section Were there witnesses to the incident? Yes � Unknow n (circle) Provide their names, addresses and telephone numbers: Were the police or law enforcement called? es No linkno��n (circle) If yes, what department or agency?,�}� c��i� Case #or report # _1�c�c.��/� Where did the accident or injury take place? Provide street addre� oss treet, intersection, name of park or facility, closes landmark, etc. Please be as detailed as possible. If necessary, attach a diagram. 7c�/� ,(��- ��Otl,4PLtJ�_ �� Please indicate the amount ou are seeking in compensation or what you would like the City to do to resolve this claim to your satisfaction. ..Z�/�, %L/�/.-�3 Vehicle Claims- lease com tete this section ❑ check box if this section does not a 1 Your Vehicle: Year �? t� Make Model 1_(�C.e'.t�x-t_ License Plate Number - a// N L State��Color Tu,, Registered Owner�� _�i/.��;l�v :�lf.L�+��►_B'x.� Driver of Vehicle �r �� -� Area Damaged City Vehicle: Year �L��i Make ,L Model License Plate Number t C�L(�5�9 Sta �� ' Color . Driver of Vehicle (City Employee's Name)_1��ftL1l��:.v �,��-- Area Damaged C-��-�CnUc:c�-�- In'ur Claims- lease com lete this section ❑ check box if this section does not a 1 How were you injured? QP.,t/�f--��f,� What part(s) of your body were injured? 1(Zt�ZL_r/�� Have you sought medical treatment? e N Planning to Seek Treatment (circle) When did you receive treatmen � " / - ' � (provide date(s)) Name of Medical Provider(s): �T j ,c�L!�v �' ,} �,/'�� Address Telephone Did you miss work as a result of your injury? Yes tio When did you miss work? [�(��[.v-�• (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. Unsigned forms will not be processed. Submitting a false claim can result in prosecution. Date form was completed /�i`�ur�r /y� 0�0/� Print the Name of the Person who Completed this Form�UG�r•f�L r nv Signature of Person :Vlaking the Claim: ti �Qnt. Revised February 201 I Fam W'9 Request for Taxpayer Give Fortn to the `� °�^°�201' identification Number and Certification requester.Do not oewn.�a me r�;uy se�d to the IRS. i�tema�neverxx semce Name(as shown on your income tax return) State Farm Mutual Automobile Insurance Company Bus�ness name/disregarded entity name,it different from above N O O� � , a Check appropriate box fa federal tax classification: c � ❑ IndividuaVsole proprie[or �❑ C Corporation ❑S Corpaation ❑ Partnership ❑TrusVestate m c ao �� '� � Limited liability company.Enter the tau classification(C=C corporation,S=S corporation,P=partnership)► � �empt payee 0 -------------------------- C a a � ❑ Other(see instrudions)► u .v '; Address(number,street,and apt.or suite no.) Requester's name and address(optiona� a 1 State Farm Plaza m Ciry,state,and ZIP code N Bloomington,IL 61710 List account number(s)here(optional) Taxpayer ldenYrfication Number(TIN) Enter your TIN in the appropriate box.The TIN provided must match the name given on the"Name"line Social seeunty number to avoid backup withholding.For individuals,this is your social security number(SSf�.However,for a � _m -� resident alien,sole proprietor,or disregarded entity,see the Part I instructions on page 3.For other entities,it is your employer identification number(EIN).If you do not have a number,see How to get a TIN on page 3. Note.If the account is in more than one name,see the chart on page 4 for guidelines on whase Employer identifieation rnimber number to enter. 3 7 - 0 5 3 3 1 0 0 Certification Under penalties of perjury,I certify that: 1. The number shown on this form is my correct taxpayer identification number(or I am waiting for a number to be issued to me),and 2. I am not subject to backup withhofding because:(a)I am exempt from backup withholding,or(b)I have not been notified by the Intemal Revenue Service(IRS)that i am subject to backup withholding as a resuit of a failure to report all interest or dividends,or(c)the IRS has notified me that I am no longer subject to backup withholding,and 3. I am a U.S.citizen or other U.S.person(defined below). CeRification instructions.You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax retum.For real estate transactions,item 2 does not apply.For mortgage interest paid,acquisition or abandonment of secured property,cancella[ion of debt,contributions to an individual retirement arrangement(IRA),and generally,payments other than interest and dividends,you are not requlred to sign the ceRification,but you must provide your correct TIN.See the instructions on page 4. Sign S�9�t�.e� I � d'1 �1 a- Here U S person► /��}j�� Date► General Instructions Note.�f a requester gives you a form other than Form W-9 to request your TIN,you must use the requester's form if it is substantially similar Section references are to the Intemal Revenue Code unless otherwise to this Form W-9. noted. Detinition oi a U.S.person.For federal tax purposes,you are Purpose of Form considered a U.S.person if you are: A person who is required to file an information retum with the IRS must •An individual who is a U.S.citizen or U.S.reside�t alien, obtain your correct taxpayer identification number(11N)to report,for •A partnership,corporation,company,or association created or example,income paid to you,real estate transactlons,mortgage interest organized in the United States or under the laws of the United States, you paid,acquisition or abandonment of secured property,cancellation .q�estate(other than a foreign estate),or of debt,or contributions you made to an IRA. .A domestic trust(as defined in Regulations section 301.7701-�. Use Form W-9 only if you are a U.S.person(including a resident Special rules tor partnerships.Partnerships that conduct a trade or alien),to provide your correct TIN to the person requesting it(the business in the United States are generally required to pay a withholding requester)and,when applicable,to: tax on any foreign partners'share of income from such business. 1.Certlfy that the TIN you are giving is conect(or you are waiting for a Further,in certain cases where a Fortn W-9 has not been received,a number to be issued), partnership is required to presume that a partner is a foreign person, 2.Certify that you are not subject to backup withholding,or and pay the withholding tax.Therefore,if you are a U.S.person that is a 3.Claim exemption from backup withholding if you are a U.S.exempt Partner in a partnership conducting a trade or business in the United States,provide Form W-9 to the partnership to establish your U.S. payee.If applicable,you are also certifying that as a U.S.person,your S��us and avoid withholding on your share of partnership income. allocable share of any partnership income from a U.S.Vade w business is not subject to the withholding tax on foreign partners'share of effectively connected income. Cat.No.10231X Fam W-9(Rev.12-2011) RBZ00070 S�e�R11 State Farm Mutual Automobile Insurance Company � Auto Payments by Participant/COL s Route To: Stacey Vandegraft BASIC CLAIM INFORMATION Claim Number: 23-21X5-835 Date of Loss: 07-12-2013 Policy Number: 3325-429-23F Named Insured: BERGSTROM,JOHN Named Insured(s)/400 - COLL C denotes consolidated payment E denotes EFT payment P previously converted payment from CAT/CMR Payment Issued Payable Pay Auth Rsn Number Date Pavee COL Cd Status Amount ID Cd 105756445J 08-02-2013 JOHN BERGSTROM& 400 1 Paid $12,175.08 HGUL MARION BERGSTROM Total: $12,175.08 Date: 11-19-2013 Page 1 FOR INTERNAL STATE FARM USE ONLY Contains CONFIDENTIAL information which may not be disclosed without express written authorization. ��+. r'` «� r t' � ; � � � . �!� � ��>. = � " � �� ' � -z �:� _ �� j�`� . - �. � �; �, � - �< r � �. _. .. . - �� -, ;:,,�; .��: ,.:k.£ �,`f� � ,€.y ,.. , . � �� .. � � • �:� � ' ' k: � r{f �� ,.... ....�.... 7. � � �� }'', �4� 5 � i' ��a �'C � �1 � �� ° � � ,�� , � �" �� :� �. F ,� � ��' ::� � .,� ,�� :,:. ;� ��.�s ,. ; ,�,�; � .- . �;: ��, �� - r ,, .� ��: �; .� s:. . � �� A,., '.�� ;r 3`. , � ' � . . � `� �� —�-'_' � , . �.. r t _ ._��..._ .. ' �y., S� ♦ �,� � `�:::. y''• •:.3 , '�. a r� � y±`"��`"S^e.. �_'�� .2 �: � � � � �i�.} �. � 6 � �`. i� t �, � � _" � ...''tiy;� . � � � ,"'"� C7/22/13 09 : 17 AUToSOURCE Page 1 4_a: Direct AS Request: 32852462 Version: 1 P��ti=STRA�IVE DATA 2006 BUICK LUCERNE CX 4D SEDAN Pxrow Coll Claimant: �tate Farm Insurance Insured:Bergstrom, John Eurnsville Branch Claim: 23-21X5-83501 1265 Northland Drive Loss Date : 07/12/2013 N.e�dota Heights MN 55120 Loss Type:Collision Policy: Other: Estimator Name: TONY GERLACH Estimator Phone: 651-552-2222 Vehicle Location: ARROW COLLISION CENTER License Number: 2211HL License State: MN License Expiration: OCT 2013 Specialty Plate Type: HANICAP Prior Damage AmountS : N/A Prior Damage Desc: N/A Supplement Amount S : 2000 . 00 Supplement Desc: MISC HIDDEN DAMAGES Tow / Other Charges : 146 . 000 Other Remarks : HARD HIT REAR VALUATION DETAIL 2006 BUICK LUCERNE CX 4D SEDAN l . 2006 BUICK LUCERNE CX 4D SEDAN Comparable 1 Your Vehicle PRICE Hopkins � Mn 59 , 396 Odometer 86 , 677 Mi(Actual ) 63 , 084 Mi(Actual ) 650 Equipment XM Satellite Radio -�� Comparable 1 Adjusted Price 59 , 978 2 . 2006 BUICK LUCERNE CX 4D SEDAN Comparable 2 Your Vehicle PRICE Cokato, Mn 59 , 993 Odometer 71 , 614 Mi(Actual ) 63 , 084 Mi(Actual ) 235 Comparable 2 Adjusted Price 510 , 228 3 . 2006 BUICK LUCERNE CX 4D SEDAN Comparable 3 Your Vehicle PRICE Saint Cloud, Mn 59 , 391 Odometer 92 , 590 Mi(Actual ) 63 , 084 Mi�Actual ) 810 XM Satellite Radio -�� Comparable 3 Adjusted Price 510 , 131 4 . 2006 BUICK LUCERNE CX 4D SEDAN Comparable 4 Your Vehicle PRICE Rochester - Mn 58 , 455 07/22/13 09 : 17 AUTOSOURCE Page 2 Via: Direct AS Request: 32852462 Version: 1 VALL'ATIO�' DETA�L (continued) 2006 BUICK LUCERNE CX 4D SEDAN Odo�eter 127 , 120 Mi(Actual ) 63 , 084 Mi (Actual ) 1 - 760 Comparable 4 Adjusted Price 510 , 215 Final Market Value Calculation 1 . 2006 Buick Lucerne CX 4D Sedan 59 , 978 2 . 2006 Buick Lucerne CX 4D Sedan 510 . 228 3 . 2006 Buick Lucerne CX 4D Sedan 510 , 131 4 . 2006 Buick Lucerne CX 4D Sedan 510 , 215 Average Price 510 , 138 CONDITION Category Typical Condition Loss Vehicle Seats Condition Minor Wear Good 140 Carpets Condition Minor Wear Good 35 Int Trim Condition Minor Damage Good 55 Body Condition Minor Damage Good 225 Front Tires Good New 50 Rear Tires Condition Good New 50 Total Condition Adjusted Market Value 510 , 693 Deductible -250 . 00 Net Adjusted Value 510 , 443 . 00 The selling price may be substantially less than the asking price . In the case of this 2006 Buick Lucerne CX 4D Sedan- the difference between the asking price and selling price is generally 7a. This selling price adjustment has been applied to the advertised price . VEHICLE DESCRIPTION 2006 BUICK LUCERNE CX 4D SEDAN VIN: 1G4HP57276U211020 2006 Buick Lucerne CX 4D Sedan 63 - 084 Miles Standard Air Conditioning Dual Airbags Auto Load Leveling Alarm System Anti-Lock Brakes Cruise Control Center Console Rear Window Floor Mats Bucket Seats Head Airbags Intermittent Wipers Keyless Entry Lighted Entry Power Mirrors OnStar System Power Brakes Power poor Locks Power Steering Power Windows Power Drivers Seat AM/FM CD Player Rem Trunk-L/Gate Side Airbags Velour/Cloth Seats Strg Wheel Radio Tachometer Trip Computer Traction Control Theft Deterrent Tinted Glass Tilt Steering WheelAluminum/Alloy Wood Interior Trim 07/22/13 09 : 17 AUTOSOURCE Page 3 Via: Direct AS Request : 32852462 Version: 1 VEHICLE DESCRIPTION (continued? 2006 BUICK LUCERNE CX 4D SEDAN TriM Levels *CX, CXL V6 - CXL V8 , CXS * Indicates your trim level A detailed description of your vehicle was provided to Autosource by a traired appraiser. Contact State Farm Insurance if revisions are necessary. 4EHICLE CONDITION 2006 BUICK LUCERNE CX 4D SEDAN SEATS Good CARPETS Good INT TRIM Good GLASS Good HEADLINER Good BODY Good PAINT Minor Wear EXT TRIM Good ENGINE Minor Wear TRANSMISSION Minor Wear FRONT TIRES New REAR TIRES New COMPARABLE VEHICLE DETAILS 2006 BUICK LUCERNE CX 4D SEDAN The following information provides the details for the vehicles used to calculate the Autosource Value . 1 2006 BUICK LUCERNE CX 4D Adjusted 59 , 398 Stock# R012092 . 86677 Miles . 6 Cylinder 3 . 8 Engine , 4 Speed Automatic . Anti- Lock Brakes , Air Conditioning, Auto Load Leveling, Alarm System, Aluminum/Al1oy Wheels , Bucket Seats , Cruise Control , AM/FM CD Player, Center Console , Dual Airbags , Rear Window Defroster, Power Drivers Seat , Floor Mats , Head Airbags , Intermittent Wipers , Keyless Entry System, Lighted Entry System, OnStar System, Power Brakes , Power poor Locks , Power Mirrors , Power Steering, Power Windows , Rem Trunk-L/Gate Release , Side Airbags , Strg Wheel Radio Control , Tachometer, Trip Computer, Traction Control System- Theft Deterrent System, Tinted Glass , Tilt Steering Wheel , Velour/Cloth Seats , Wood Interior Trim, XM Satellite Radio. Offered for sale by Walser Chrysler Jeep Dodge in Hopkins , MN, (952)935-2400 . Advertised 04/28/13 . The advertised price of 59 � 998 was adjusted to account for typical negotiation. 2 2006 BUICK LUCERNE CX 4D Adjusted 59 - 993 Stock# 2411A. 71614 Miles . 6 Cylinder 3 . 8 Engine - 4 Speed Automatic , Anti- Lock Brakes - Air Conditioning, Auto Load Leveling, Alarm System, 07/22/13 09 : 17 AUTOSOURCE Page 4 Via: Direct AS Request: 32852462 Version: 1 COMPARABLE VEHICLE DETAILS (continued) 2006 BUICK LUCERNE CX 4D SEDAN Aluminum/Alloy Wheels � Bucket Seats , Cruise Control - AM/FM CD Player, Center Console - Dual Airbags � Rear Window Defroster , Power Drivers Seat, Floor N.ats - Head Airbags . Intermittent Wipers , Keyless Entry System, Lighted Entry Syste�- OnStar System, Power Brakes , Power poor Locks - Power Mirrors , Power Steer_�g- Power Windows , Rem Trunk-L/Gate Release , Side Airbags , Strg Wheel �ac�o Control , Tachometer, Trip Computer , Traction Control System, Theft Deterrent System, Tinted Glass , Tilt Steering Wheel , Velour/Cloth Seats , Hood =�terior Trim, Maintenance Records , Original Owner of Vehicle . Offered Lor sale by Cokato Motor Sales Inc in Cokato , MN, ( 320)286-2441 . Advertised C4/�4/13 . The advertised price of 510 , 745 was adjusted to account for typical negotiation. 3 2006 BUICK LUCERNE CX 4D Adjusted 59 , 391 Stock# 63113A. 92590 Miles . 6 Cylinder 3 . 8 Engine , 4 Speed Automatic , Anti- Lock Brakes , Air Conditioning, Auto Load Leveling, Alarm System, Aluminum/Alloy Wheels , Bucket Seats , Cruise Control , AM/FM CD Player, Center Console, Dual Airbags , Rear Window Defroster, Power Drivers Seat- Floor Mats , Head Airbags , Intermittent Wipers , Keyless Entry System, Lighted Entry System, OnStar System, Power Brakes � Power poor Locks , Power Mirrors , Power Steering, Power Windows , Rem Trunk-L/Gate Release , Side Airbags , Strg Wheel Radio Control - Tachometer, Trip Computer, Traction Control System, Theft Deterrent System, Tinted Glass , Tilt Steering Wheel - Velour/Cloth Seats - Wood Interior Trim, XM Satellite Radio . Offered for sale by Miller Auto Plaza in Saint Cloud - MN- ( 320 )251-8900 . Advertised 05/05/13 . The advertised price of 59 , 990 was adjusted to account for typical negotiation. 4 2006 BUICK LUCERNE CX 4D Adjusted 58 , 455 Stock# 27782A. 127120 Miles . 6 Cylinder 3 . 8 Engine - 4 Speed Automatic , Anti- Lock Brakes , Air Conditioning, Auto Load Leveling, Alarm System, Aluminum/Al1oy Wheels , Bucket Seats , Cruise Control , AM/FM CD Player, Center Console , Dual Airbags , Rear Window Defroster , Power Drivers Seat , Floor Kats - Head Airbags . Intermittent Wipers , Illuminated Visor Mirror , Keyless Entry System, Lighted Entry System, OnStar System, Power Brakes , Power poor Locks , Power Mirrors , Power 5teering, Power Windows , Rem Trunk-L/Gate Release , Side Airbags , Strg Wheel Radio Control , Tachometer, Trip Computer, Traction Control System, Theft Deterrent System, Tinted Glass , Tilt Steering h'heel . Velour/Cloth Seats , Wood Interior Trim- Floor Mats . Offered for sale by Kuehn Motor Company in Rochester � MN, ( 507 )536-9859 . Advertised 07/17/13 . The advertised price of 58 , 995 was adjusted to account for typical negotiation. 07/22/13 09 : 17 AUTOSOURCE Page 5 Via: Direct AS Request : 32852462 Version: 1 VINSOURCE ANALYSIS 2006 BUICK LUCERNE CX 4D SEDAN VIN: 1G4HP57276U211020 Decodes as : 2006 Buick Lucerne CX 4D Sedan Accuracy: Decodes Correctly History: No activity was reported REPORTED PHONE NUMBER ANALYSIS 2006 BUICK LUCERNE CX 4D SEDAN �o Vehicles Advertised at �651 ) 453-1779 VALUAiION NOTES 2006 BUICK LUCERNE CX 4D SEDAN o Loss vehicle description was provided by State Farm Insurance c Adjustments of Special Note - The requested Exception valuation has been processed using one or more Comparables in order to meet state regulatory requirements . - A mileage adjustment of 2 . 75 cents per mile/kilometer has been applied. This adjustment is based on the vehicle year , vehicle category and market area. Mileage adjustments are capped at 40% of the vehicle ' s starting value . - No special adjustments were made for this vehicle . - Al1 values are in U. S . dollars . o Autosource Valuation Process - Over 3 , 800 , 000 vehicles are entered weekly into the database used for researching this value . This database includes dealer inspected, dealer inventory, dealer advertised, phone verified and advertised private party vehicles . - The originating search area for this valuation was Inver Grove , Minnesota. - The market area expansion was authorized by Autosource Guidelines . o Other Adjustments or Comments - CLEAN CAR - There is no tax for the given zip code of 55077 . 07/22/13 09 :17 AUTOSOURCE Page 6 Via: Direct AS Request : 32852462 Version: 1 I�ICB REPORT 2006 BUICK LUCERNE CX 4D SEDAN NICB/ISO Member: 5037 STATE FARM MUTUAL AUTOMOBILE Claim: 2321X5835 Loss Date: 07/12/13 Type of Loss: PROPERTY/CASUALTY Phone: RECALL BULLETINS 2006 BUICK LUCERNE CX 4D SEDAN \at � l . Highway Traffic Safety Admin (US) has issued a total of 3 recall �ulletins that may apply to this vehicle . \HTSA ID Number: 06V105000 Date Issued: 04/04/O& Quantity Affected: 12 , 862 Defect: On certain vehicles equipped with a v8 engine , the power steering hose connectors may have been inadequately crimped which could result in a fluid leak. If this were to occur, power steering assist may be lost and increased steering effort would be required at low speeds . Also, if the power steering fluid were to contact hot engine parts - an engine compartment fire could occur. Remedy: Dealers will replace the power steering gear inlet hose_ The recall began on March 29 - 2006 . Owners may contact Buick at 1-866-608-8080 or Cadillac at 1-866-982-2339 . NHTSA ID Number: 08V441000 Date Issued: 08/27/08 Quantity Affected: 857 , 735 Defect: GM is recalling 857 , 735 MY 2006-2008 Buick Lucerne; Cadillac DTS; Hummer H21 ; MY 2007-2008 Cadillac Escalade , Escalade ESV, Escalade EXT; Chevrolet Avalanche , Silverado , Suburban, Tahoe; GMC Acadia, Sierra- Yukon, Yukon XL, Saturn Outlook; and MY 2008 Buick Enclave vehicles equipped with a heated wiper washer fluid system. A short circuit on the printed circuit board for the washer fluid heater may overheat the control-circuit ground wire . This may cause other electrical features to malfunction- create an odor , or cause smoke increasing the risk of a fire . Remedy: Dealers will install a wire harness with an in-line fuse free of charge. The manufacturer has not yet provided an owner notification schedule . Owners may contact Buick at 1-866-608-8800 ; Cadillac at 1-800-982-2339 or http://www. cadillac . com; Chevrolet at 1-800-630-2438 ; Saturn at 1-800-972-8876 or http://www_ saturn. com- GMC at 1-866-996-9436 ; or Hummer at 1-800-732-5493 ; or mygmlink at http://www-gm_ com/recall . GM Recall No. 08048 . Customers may contact the National Highway Traffic ***** CONT�D NEXT PAGE **** 07/22/13 09:17 AUTOSOURCE Page 7 Via: Direct AS Request: 32852462 Version: 1 RECALL BULLETINS (continued) 2006 BUICK LUCERNE CX 4D SEDAN Safety: 1-800-424-9153 ) ; or go to http://www_ safercar.gov. Customers May Contact: Customers may contact the National Highway Traffic Safety Administration' s Vehicle Safety Hotline at 1-888-327-4236 (TTY: 1-800-424-9153 ) ; or go to http://www. safercar.gov. NHTSA ID Number: 1OV240000 Date Issued: 06/04/10 Quantity Affected: 1 , 365 , 070 Defect: GM is recalling certain model year 2006-2009 Buick, Lucerne ; Cadillac DTS; Hummer H2 ; model year 2008-2009 Buick Enclave ; Cadillac CTS; model year 2007-209 Cadillac Escalade , Escalade ESV, Escalade EXT; Chevrolet Avalanche , Silverado, Suburban, Tahoe; GMC Acadia, Sierra, Yukon, Yukon XL; Saturn Outlook; and model year 2009 Chevrolet Traverse vehicles equipped with a heated washer flu id system (HWFS) . A recall was implemented in 2008 to add a fuse to the central circuit harness to address the potential consequences of a printed circuit board (PCB) electrical short_ However, there have been new reports of thermal incidents on HWFS modules after this improvement was installed- These incidents resulted from a new failure mode attributed to the device � s thermal protection feature_ The significance varies from minor distortion to considerable melting of the plastic around the HWFS fluid chamber. It is possible for the heated washer module to ignite and a fire may occur. Remedy: Dealers will permanently disable and remove the (CONTINUED NEXT PAGE) Heated Washer Fluid: heated washer fluid module_ An updated page for the owner manual will be provided and inserted in the owner manual to document that the feature has been permanently disabled and removed from the vehicle . The safety recall began on June 11 , 2010 . Owners may contact Buick at 1-866-608-8080 , Cadillac at 1-866-982-2339 , Chevrolet at 1-800-630-2438 , Saturn at 1-800-972-8876 , GMC at 1-866-996-9463 and Hummer at 1-800-732-5493 or at the Owner Center at www.gmownercenter . com. Owners may also contact the National Highway Traffic Safety Administration� s Vehicle Safety Hotline at 1-888-327-4236 (TTY 1-800-424-9153 , or go to http://www• safercar•gov. ORIGINAL EQUIPMENT GUIDE 2006 BUICK LUCERNE CX 4D SEDAN 07/22/13 09 : 17 AUTOSOURCE Page 8 Via: Direct AS Request: 32852462 Version: 1 ORIGINAL EQUIPMENT GUIDE (continued) 2006 BUICK LUCERNE CX 4D SEDAN ---- -—---Engine Options—--------- ---Transmission Options-------- *-6 Cylinder 3 . 8 Engine STD * 4 Speed Automatic STD --Other Optional Equipment------ --------Convenience Options-------- * Anti-Lock Brakes STD * Air Conditioning STD * Auto Load Leveling STD Automatic Dimming Mirror * Center Console STD * Cruise Control STD * Dual Airbags STD * Rear Window Defroster STD Engine Block Heater S50 * Floor Mats STD * Head Airbags STD Garage Door Opener * Intermittent Wipers STD Illuminated Visor Mirror * Keyless Entry System STD Reverse Sensing System * Lighted Entry System STD Rain-Sensing W/S Wipers * OnStar System STD * Rem Trunk-L/Gate Release STD Remote Starter * Strg Wheel Radio Control STD * Side Airbags STD * Tilt Steering Wheel STD * Tachometer STD ---------Power Accessories--------- * Trip Computer STD Heated Power Mirrors * Traction Control System STD * Power Drivers Seat STD * Tinted Glass STD Dual Power Seats 5350 * Wood Interior Trim STD * Power Brakes STD -----Radio/Phone/Alarm Options----- * Power poor Locks STD * Alarm System STD * Power Mirrors STD * AM/FM CD Player STD * Power Steering STD Harman Kardon Sound Sys 5470 * Power windows STD AM/FM In-dash CD Changer 5300 -----------Seat Options------------ MP3 Player 5150 * Bucket Seats STD * Theft Deterrent System STD Split Front Bench Seat 5250 XM Satellite Radio 5325 * Velour/Cloth Seats STD -----------Roof Options------------ ------- Wheel Options----------- Power Moonroof 5900 * Aluminum/Alloy Wheels STD ------------------------------Option Packages------------- -------------- Comfort & Convenience 5450 Includes Automatic Dimming Mirror, Heated Power Mirrors , Garage Door Opener, Illuminatd Visor Mirrors . Rain-Sensing W/S Wipers Driver Confidence 5595 Includes Remote Starter, Reverse Sensing System Entertainment Package 5795 Includes Harman Kardon Sound Sys , XM Satellite Radio Base retail price: 525 , 990 Loss Vehicle manufacturer� s suggested retail price as reported: 525 � 990 Editions available for the same body style (in order of original cost , increasing) : *CX, CXL V6 , CXL V8 , CXS 07/22/13 09 : 17 AUTOSOURCE Page 9 Via: Direct AS Request: 32852462 Version: 1 ORIGINAL EQUIPMENT GUIDE (continued) 2006 BUICK LUCERNE CX 4D SEDAN * Indicates loss vehicle equipment . ABOUT YOUR VALUATION 2006 BUICK LUCERNE CX 4D SEDAN This report contains proprietary information of Audatex and shall not be disclosed to any third party (other than the insured or claimant) without Audatex' s prior written consent . If you are the insured or claimant and have questions regarding the description of your vehicle , please contact the insurance company that is handling your claim. Information within � VINsource/NICB is provided solely to identify potential duplicative claims activity. User agrees to use such information solely for lawful purposes . Tax rates contained herein are based on general sales tax data provided by Vertex Inc . Excise , use , registration, licensing and other taxes and fees that may be applicable are not included. Audatex makes no representations or warranties concerning the applicability or accuracy of such tax data. Report Generated by Audatex- a Solera Company US Pat . No 7912740B2 US Pat . No 8200513B2 (C) 2013 Audatex North America , Inc . All Rights Reserved. . Acc:�ent Report � L:�� Page 1 of 1 ��-�-� ��' �� .o�:n .K.,,,b , � - 13144443 � • ' � a � �..�. � � �.� � ' '� a N Y i}2 04 �01 i' -- � '�' "a"� � "'� �.. . 7 12 2013�ri 1237 � 10 7th • � �r��sab"y °` •— �'* 8■ OK°'W � mwn�u ---- 62 B� M� �� 1°""m ��aeeccawwr,a��,�unt '"" +.._• 1D Douqlas � � ::..�•. .�, - i5� �aamn dNCn�care�arcwa aun�a.w � nrnws rmw pwd = t O1 E725041879019 1O�""°''� � � an�ws [� D O1 O1 F696069767616 I�T D OI � •wc+w: .w�c�.um o..wm r..�r.sc..oai.wn ANDREW 3AMES JUSTZN 05 19 94 JOiitJ 5 BERGSTROM 03�1�3 32 �: � O1 3Q5 PQPLAR bR �� " � N; DI 6865 BLACKHAWK TRAIL N, O1 O1 � . � �1 SHOREVIEW .55126 651-233-3596 ' INVER GROVE HT$ 5�JQ7� 65I-a53-1779 DI � O1 M �4 �04 06 d5 N � M �4 �04 D6 `�'S B 0"1"" � '�xaa rrr� Qnia r.n co�ov Omrnao nsu�a.n.�cr wrwaeeR � sn� ewa nrc ronov m�w.om �usanarwei 98 1�.°` 98 i�• n,� """"'°' � Do•� �: 98 �f`T 9$ Y�, 0� SPFD � • �� ,.. . .�-.._ .. . . _ � ,�� O1 CT OE UL MEJNICIPAL EQUIPT �i BERGSTROM JOAN S e} ��' HM M /pygs 10�NFD n�� 02 891 N DALE ST N.. . 6865 $LACKHAWK TRAIL ",y 02"" w�us an.sr+*Ea wuwo owee+ cm.snu�.a 15 ST PAUL MN 55103 '19'. 02 . INVER GROVE HTS NRl 55077 � °� 1°"J°` •� � O1 OI £ORD Rw 200 Ba2C UCX 00 � "°`°` �� r„a., n� +ti..� �° .�,.. OS 02 906659 MN 9 O1 � `�� ""�°° '° ry : 2221HL MII 3 O1 ' 03� W�YVti P011C�N�l9t �wUwqE Mn A ; Self insured '°""""'°' • State Earm 3325429B01236 oum wawv wu.w . n.e.,m�. .r.,eaE, itre w�e �ACCOEMfINVOWlDAOOMYERCW.MfOTCRYEHCtE,SCN00l8US,ORHEA06TARTeUB "�� waw7 eor ' ^ �70110i0Y 7Mfi BGTE MTROI(e.q�W endv Mi 1M.7t!�ntl tNA01fy. . � *w[ t�.ieaowv��r�n+.uo*aeo.n��..K �� vLVBYCEra�il7-bNIGMM�wE OOIMUMIe ._...�_..�_�_.iRwav—.`-..._. � �+ews�� ' wr ao�a ax � use �wc ertr .uaY m .__'--...— --._—. --��--- ° si.�fea 11nn 6srq�tron iesi-ss�-tne� 02 03 =/9/ E' 04 04 06 05 N Y; �� $p� ""'""'�" � � o� �� 5 o�- S�� ❑�. y a.�,�.��:a,,,��:��.�..�:,.�.�..�:�� F �.,o..,,,.,�.�..m, W •CCm �L'. � . D 1 '�=�.,""� � �� a...� �, ._ �; 9B �? / �:`.Unit 1 was ttaveling northeast on 7Ch. Unit 2 was� � ' / � •. makinq a lefC hend turn from 7Eh St noiEli on ;` O1 =` � I �'� � ''� Doug3as. Unit l rear .ended Oait 2. 'fhe .driver. oE ::, 98 �„� �% � t UniC 2 aas transported to United Hospital xith +: ° moderate injuries. r' „,,,a N ..< / > �...s� / _ ' 04 9 8 r� / a.'f `� !� *; / / ,_ .,. �� / , ;�ti ,:i � .�.� �,:: / , ��.g . OI o ?;: / / ''� N _ .�,�, Q i -/ / I I nr�r�v�c��'! O 1� � - -.. . . -..._. � w au� _ a' Y ?�� - � ?. o-wMr �1 � �:. . . . . .. `'. �1 wr+c9tµpl yv�Eao�nocE� �.. Officer Michael Fulton 408 ( ��.�� St �Paul PD �� 0�`�Ow�0� �_T � .a.. .� https://www.dvsiesupport.org/dvsinfolaccidentrecords_2008/Includes_LE/Pri ntReport.�ndi... 7/12/2013