Moenck (2) Attorneys
m KENNETH L.WILBER(CO,IL) 'i Phone: 800-313-5169
� CHRISTINE CHANCE(FL,GA,IL) Fax: 800-3i3-5i79
" PATRICK LIGHT(IL) Tax ID: 4z-16z8ozs
° RACHAEL PERRY QL� �XTILBER
F,�i'rnrt��,i.�� Si:�k��in�c:
F����6�.���
ST PAUL CITY CLERK' S OFC ��� �9 ��13
RON GUIFOILE �ITY CL�RK
15 W KELLOGG BLVD RM 310
ST PAUL, MN 55102
December 5, 2013
RE: Our Client: USAA
Our Client ' s Insured: BRUCE J MOENCK
Our File Number: 1042607 - 28
Your Insured: MICHAEL ALLEN JELINEK
Your Claim/Poliry Number: LIC PLATE 175337
Date of Accident : 08-26-13
Amount Claimed: $1, 418 . 38
Please be advised that we represent USAA
for a claim they paid to their policyholder. We have been
informed that there is possible coverage through your company.
Enclosed please find the supporting documents for your review.
After your review, please contact this office to discuss settlement
proceedings . If you have further questions, please contact
Kristi Loyer, who we have assigned to handle this claim.
Please note that all payments for this claim will need to be made
payable to USAA
and remitted to our office for proper handling.
Tnank you for your irnmediate attention to this matter.
�� �;
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i
� ER A D AS
KLW/ps
Enclosure
Wilber&Associates,P.C.Attomeys at Law €: Wilber Insurance Services � Wilber Consulting
y ��,� ����. ����� � zio Landmark Dr�� Normal,IL � 6176i-z19c,
R�C�IVED
NOTICE OF CLAIM FORM to the City of Saint Paul, MinnesotaGEC 0 9 2013
Minnesota Srcite Stcitute 466.05.rtute.r that "...every person...who cluim,s damages from uny municipnlit}�...shc�ll cuu,xe tn be pre.+�l�d to�theCL E RK
gorerning bncl}�of d�e nt«nicipu[it��within 180 dcey.r after the ulleged loss nr injur��is discovered n notice.rtuting the time,pluce,and
circumstances�thereof,nnd the amount of compensation or other relief demnnded."
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 Nan1e
Company or Business Name(,l�►�' '1r(�Yl��'' ��C.��iCL�J ��K'�` �,��L1 �ll(.�/�'- �������'����k
Are You an Insurance Company? es No If Yes,Claim Number? �(�� L�� l
Street Address �,� L'a��Y' �rf� c!1 � :
City 'v����� State �� Zip Code���
Daytime Phone(3�)�lr ' -��e�Phone�--�� - —�vening Telephone -
Date of AccidenU Injury or Date Discovered �'� �� � � � Time ��- � �pm
Plcasc statc, in dctail, what occurrcd (happcncd), and why you are submitting a claim. Plcasc indicatc why or how you
feel the City of Saint Paul or its employee are i�n,volved and/or responsib(e for your damages.
��v�e
' � � C� I� �' )tiS1.K X.L t�l CYV(C� i:2-i'-(C c2-�►�
� ,�� � , r
.�. �.'�`/ �L�'�(C'�• �/�'L`lCl� , �
Please check the box(es)that most closely represent the reason for completing this form:
��y 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
❑ M}� 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 conies of all annlicable 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.
O 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 receip[s 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 comalete this section
Were there witnesses to the incident? Yes No nknown (circle)
Provide their names, addresses and telephone numbers:
�
Were the police or law enforcement alle�? " No Unknown (circle) /.,��f
If yes, what department or agency2 �_ Case#or report# 1� °l�� 'W`"`I
Where did the accident or injury take place? Provide street address,cross street,intersection,name of park or,facility,
clQsest land ark,etc. Please be as detailed as possible. If necessary, attach a diagram.�.r�L � �l f . _�
���'1 c�
Please indicate the a�ount you are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction.� l�{� � �
Vehicle Claims— lease com lete this section ❑check box if this section does not a 1
Your Vehicle: Year 7 nb�Make _Model'✓�� ` rCY?
License Plate Numb r State_�Color
Registered Owner �
Driver of Vehicle '
Area Dama ed � �`� � �
City Vehicle: Year.��_Make �'�L�� _Model
License Plate Number�'��j �7%_7 State� Color l,l)l�-�
Driver of Vehicle(C�ty, mplo ee's Name)
Area Damaged ' � 1��� -'
Iniurv Claims nlease complete this section '�heck box i.f this section does not applv
How were you inj 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 of your injury? Yes No
When did vou 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 this form,you are statifzg that all inforrrcation you have provided is trtce ancl correct to the best
of your k►zowledge. Unsigned fortns will not be processed.
Submitting a false claim can result in prosecution. Date form was completed 1� � �� �
Print the Name of the Person who Completed t ' orm: ''� t 5� �—`C �''�
i
Signature of Person Making the Claim:
C� -
Revised Febmary 2011 � __.� �
ABRA Auto Body & Glass - West St Workfile ID: f13fa381
Federal I D: 41-1942823
Paul
Right the First Time...On Time
130 THOMPSON AVE E, West Saint Paul, MN
55118
Phone: (651) 552-7744
FAX: (651) 552-8176
Estimate of Record
Customer: MOENCK, CW4 BRUCE lob Number:
Written By:Craig Scheffler, 8/26/2013 1:12:37 PM
Adjuster: Billingsley,Thomasina,(800)531-8722 Business
Insured: MOENCK,CW4 BRUCE Policy#: 004235244 Claim#: 004235244000000030001
Type of Loss: Collision Date of Loss: 8/26/2013 12:00:00 PM Days to Repair: 4
Point of Impact: 05 Right Rear
Owner: Inspection Location: Insurance Company:
MOENCK,CW4 BRUCE UNKNOWN USAA
481 SIDNEY ST E Other Colorado Springs--8187
SAINT PAUL, MN 55107 Visit"USAA.com"or call
(651)228-0509 Evening (800)531-8722 Business
(651)245-4825 Cell
VEHICLE
Year: 2000 Body Style: 2D CPE VIN: KMH]G35F3YU203107 Mileage In: 141079
Make: HYUN Engine: 4-2.OL-FI License: IZZER Mileage Out:
Model: TIBURON Production Date: 4/2000 State: MN Vehicle Out:
Color: Red Int: Condition: Job#:
TRANSMISSION DECOR RADIO 4 Wheel Disc Brakes
Overdrive Dual Mirrors AM Radio SEATS
5 Speed Transmission Console/Storage FM Radio Cloth Seats
POWER CONVENIENCE Stereo Bucket Seats
Power Steering Air Conditioning Search/Seek WHEELS
Power Brakes Intermittent Wipers Cassette Aluminum/Alloy Wheels
Power Windows Tilt Wheel SAFETY PAINT
Power Locks Cruise Control Drivers Side Air Bag Clear Coat Paint
Power Mirrors Rear Defogger Passenger Air Bag
8/26/2013 1:12:37 PM 029893 Page 1
USAA Confidential
0901119c8d24641c
Estimate of Record
Customer: MOENCK, CW4 BRUCE Job Number:
Vehicle: 2000 HYUN TIBURON 2D CPE 4-2.OL-FI Red
Line Oper Description Part Number Qty Extended Labor Paint
Price$
1 QUARTER PANEL
2 * Rpr RT Quarter panel 8_0 2.4
3 Add for Clear Coat 1.0
4 R&I RT Quarter glass Hyundai 1.5
5 # Repl �Urethane Kit 1 20.00 T
6 REAR LAMPS
7 R&I RT Combo lamp assy Incl.
8 REAR BUMPER
9 ** <> Repl RECOND Bumper cover 8661027510 1 232.00 1.8 2.8
10 Overlap Major Non-Adj. Panel -�•Z
il Add for Clear Coat 0.5
SUBTOTALS 252.00 11.3 6.5
NOTES
Estimate Notes:
1)DR(8-26 ),DC(8-26 ), DI(8-26 )Schd( ),Drivable(YES),ACV(%60).
2)ECD O,Pay-Code O,ERT(4 DAYS).
3)Signed Direction to pay is on file. NO
4)Discussed repairs,provide estimate and QRP brochure to(OWNER)by(AND)on(8-26).
5)Prior Damage: (RT QUARTER IS RUSTED WJOULD NEED TO REPLACE DUE TO RUST ).
6)LKQ/Aftermarket:(KEYSTONE ).
7)Aftermarket Parts Approval(NO ).
8)Appearance Allowance Offered;(NO )
Prior Damage Notes:
ABOVE TAILPIPE
ESTIMATE TOTALS
Category Basis Rate Cost$
Parts 232.00
Body Labor 11.3 hrs @ $52.00/hr 587.60
Paint Labor 6.5 hrs @ $52.00/hr 338.00
Paint Supplies 6.5 hrs @ $32.00/hr 208.00
Miscellaneous 20.00
Subtotal 1,385.60
Sales Tax $460.00 @ 7.1250% 32J8
Grand Total 1,418.38 ',
Deductible 1,000.00 I
CUSTOMER PAY 1,000.00
INSURANCE PAY 418.38
8/26/2013 1:12:37 PM 029893 Page 2
USAA Confidential
0901119c8d24641c
Estimate of Record
Customer: MOENCK, CW4 BRUCE Job Number:
Vehicle: 2000 HYUN TIBURON 2D CPE 4-2.OL-FI Red
THIS IS A VISUAL INSPECTION ONLY. THERE MAY BE ADDITIONAL DAMAGE AFTER DISASSEMBLY. PARTS ARE
SUBJECT TO INVOICE. THERE ARE NO GUARANTEES ON RUST REPAIRS.
"Minnesota law gives you the right to choose any rental vehicle company, and prohibits me from requiring you to
choose a particular vendor."
Please Present A Copy Of This Estimate To A Repair Facility Of Your Choice
*USAA Subsidiaries include: United Services Automobile Association(USAA), USAA Casualty Insurance Company(CIC),
USAA General Indemnity Company(GIC) USAA County Mutual Insurance(CMI) and Garrison Property Casualty
Insurance Company. Garrison Property and Casualty Insurance Company, a subsidiary of USAA Casualty Insurance
Company, is authorized to use the USAA logo, a registered trademark of United Services Automobile Association.
This is not an authorization to repair. Failing to present this estimate to the repairing garage before repair may result
in additional expenses to you. A USAA appraiser must authorize any supplement to this estimate. Repairs to this
vehicle may require specific welding equipment as recommended by the manufacturer.
If alternative quality replacement parts have been included in this appraisal, the source for these parts has also been
disclosed. If alternative quality replacement parts as�isted on the appraisal are ultimately used in the repair of your
vehicle, the warranty on such parts will be equal to, or greater than, the parts being replaced, as stated in USAA's
limited parts warranty. USAA warrants that the parts used on your vehicle will be of like kind and quality, function, fit,
safety and corrosion protection as the part or parts they replace. USAA identifies certified and validated parts for
sheet metal replacement parts.
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.
8/26/2013 1:12:37 PM 029893 Page 3
0 9 01119 c 8 d2 4 6 41 c USAA Confidertial
Estimate of Record
Customer: MOENCK, CW4 BRUCE ]ob Number:
Vehicle: 2000 HYUN TIBURON 2D CPE 4-2.OL-FI Red
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
AER1032, CCC Data Date 8/16/2013, 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 (�) 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 category. (numbers) 1 through 4=User Defined Labor Categories.
OTHER SYMBOLS AND ABBREVIATIONS:
Adj.=Adjacent. Algn.=Align. ALU=Aluminum. A/M=Aftermarket part. BInd=Blend. BOR=6oron 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. 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. 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.
8/26/2013 1:12:37 PM 029893 Page 4
0 9 01119 c 8 d2 4 6 41 c USAA Confidential
Estimate of Record
Customer: MOENCK, CW4 BRUCE ]ob Number:
Vehicle: 2000 HYUN TIBURON 2D CPE 4-2.OL-FI Red
ALTERNATE PARTS SUPPLIERS
Supplier: Keystone-Complete-Minneapolis
Location(s): 3615 MARSHALL STREET NE,MINNEAPOLIS MN 55418 (800)328-1845 (612)789-1919
Line Description Item# Price
9 RECOND Bumper cover HY1100128R $232.00
8/26/2013 1:12:37 PM 029893 Page 5
0 9 O 1119 C 8 d2 4 6 41 C us�v►confidential
MOENCK, BRUCE J. - 004235244 - Loss Summary Page 1 of 1
oolbars� �r#tef�'esh �EXit; TO
ottom
he deductible for Collision has already been waived.
Payments Payment Settings
Payments ► CLR Helq
Review Payments
Reauested Date Amount Pavees Issued Date Method Status I
10/31/2013 $1,000.00 ABRA AUTO BODY AND Printed check Scheduled for
GLASS 11/15/2013
08/26/2013 $418.38 ABRA AUTO BODY AND 09/11/2013 Printed check Not Cleared
GLASS
'�iRefresh �Ex'tt
To ToD
0901119c4����ipt.usaa.com/inet/gas_pc_claim IVN�f`_"��g. ' Ptfifl�rv 11/8/2013
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