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Absey , Providing Insurence and Financial Services �StateFarmO Home Office, Bloomington, IL December 19, 2013 City Of St. Paul State Farm Claims 15 West Kellogg Blvd P.O.Box 2371 310 City Hall Bloomington IL 61702-2371 St. Paul MN 55102 ��C�.IVE� Certified Mail - Return Receipt Requested �p,N 06 2014 RE: Claim Number. 23-24L7-070 ��'Y �LERK Our Insured: David Absey Date of Loss: September 16, 2013 Your Insured: City Of St. Paul Your Insured Driver: Unknown Loss Location: 2299 Territorial Rd, St Paul, MN Insured's Out-of-pocket: $69.15 To Whom It May Concern: 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: i 041/045- Uninsured Motorist BI $ 042- Uninsured Motorist PD $ 300 series/400- Comp/Collision $4,932.34 501 - Rental/Loss of Use $276.59 600-050- Med Pay/PIP $ Other � Salvage Recovery $ Amount State Farm Paid $5,208.93 Insured Deductible $500.00 Total Claim Amount $5,708.93 Based on the assessment of liability between the parties, State Farm Mutual Automobile Insurance Company is seeking 100% of the Total Claim Amount listed above. The amourit payable to State Farm Mutual Automobile Insurance Company for this loss is $5,708.93. 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 � . i 23-24L7-070 Page 2 December 19, 2013 information to effect, administer, or enforce a transaction authorized by the consumer. However, 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, Natalia Ryan Claim Representative (877)457-8276 Ext. 60 Fax: (866) 231-9276 State Farm Mutual Automobile Insurance Company Enclosure . �� - � �l� NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota ' .�Llinnesoia State Statute 466.05 states that "...every person...who claims damages from any municipality...shall cause to be presented to the go�erning body of the municipality within 180 days after the alleged loss or injury is discovered a notice stating the time,place,and circumstances thereof,and the amount of compensation or other relief demanded.° Please complete this form in its entirety by clearly typing or printing your 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 Mritten acknowledgement once your form is received. The process can take up to ten weeks or longer depending on the nature of}�our claim. This form must be signed,and both pages completed. If something does not apply,write`N/A'. SE\D COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK, 1� �VEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN��1,Q�IVE� C�, Fir.t \ame (�1�� Middle Initial Last Name �1�-�-�- 2014 Company or Business Name � ITY CLERK Are You an Insurance Company?�e�s/No If Yes, Claim Number? ..� 3 - �-j �. �1-U�7 C-j Street Address � � u �-3 1 �' i��[)l,l� �-(J�-'� � � City��,.�1�,t �J 1 �� State 1�;1�. � Zip Code�.S 3/ �n Daytime Phone (��.�-�Cell Phone ( ) - Evening Telephone ( ) - Date of Accident/Injury or Date Discovered C��I(� ,_ 1► � Time 3 , � _am/pm 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. _��.,�� ' � -C.�-. L �- � � � � (� - r ' � � `L-' � Ple check the box(es) that most closely re resent the reason for completing this form: My vehicle was damaged in an accident �f�L C-� p`�� / �� 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 0 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 coAies 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. 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 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 �o Unknown (circle) Provide their names, addresses and telephone numbers: .� «'ere the police or law enforcement c ed� Y • No Unknown (circle� If�es, ��hat department or agency? �� . � �� ' ' '� Case#or report# �� - �Ut)-�G� � � «'here 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. � a �i i 1�Y,I'��-cN�c�� cC.?�( Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim to �our �atisfaction. " � � � ';i% � � �l t �� L � � t �� g�'� � �.l'� 3t �U � c�'\ Vehicle Claims- lease com lete this section ❑ check box if this section does not a 1 Your Vehicle: Year �U Make �" �4(� Model � License Plate Number �-�a- � State 1'� Color � Registered Owner � �� Driver of Vehicle C�(� ni lL� .--- Area Damaged�r �1 �r S�E f�1ti)J.-i� d �.��.+,'t:A � City Vehicle: Year � - Make Model License Plate Number State Color Driver of Vehicle (City Employee's Name) Area Damaged Iniur�Claims please complete this section 1� ❑ 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): 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 ❑ 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 � � � �t �� 3 Print the Name of the Person who Completed this Form: `�0 �� 1� c`- Signature of Person Making the Claim:�� `�' �`S"��'�� "'/'�� - Revised February 201 1 �1slL� ,�� %��y , � RAYMOND AUTO BODY, INC. Workfile ID: Of2649ad FederalID: 41-0888257 1075 PIERCE BUTLER RTE, SAINT PAUL, MN 55104 Phone: (651) 488-0588 FAX: (651) 488-4794 Supplement of Record 1 with Summary Ct�mer: ABSEY, DAVID 7ob Number: Written By:CHAD WYTTENBACH, 10/11/2013 11:25:38 AM Adjuster:TEAM R2 ACC CR, (866)207-6046 Day Insured: ABSEY, DAVID Policy#: Claim#: 23-24L7-07001 Type of Loss: COLL-Collision Date of Loss: 9/16/2013 3:15:00 PM Days to Repair: 9 Point of Impact: 11 Left Front p�; Inspection Location: Insurance Company: ABSEY, DAVID RAYMOND AUTO BODY,INC. STATE FARM INSURANCE COMPANIES 11033 FOX HOLLOW LN N 1075 PIERCE BUTLER RTE STATE FARM SELECT SERVICE CHAMPLIN, MN 55316-3036 SAINT PAUL, MN 55104 PO BOX 52272 (763)712-9438 Evening Repair Facility PHOENIX,AZ 85072-2272 (763)300-6216 Day (651)488-0588 Business (866)207-6046 Business Vehicle Drop Off Date: 09/17/2013 Promise Date: 09/27/2013 Repair Start Date: 09/19/2013 Repair Completion Date: 09/27/2013 Vehicle Pick Up/Return 09/27/2013 Date: VEHICLE Year: 2007 Body Style: 4D SED VIN: 19UUA66267A014761 Mileage In: 95656 Make: ACUR Engine: 6-3.2L-FI License: UED-626 Mileage Out: Model: TL Production Date: 12/2006 State: MN Vehicle Out: 9/27/2013 Color: CHARCOAL Int: GRAY Condition: Job#: TRANSMISSION Steering Wheel Controls AM Radio Front Side Impact Air Bags Automatic Transmission BRAKES FM Radio Console/Storage Traction Control Power Brakes Stereo Intermittent Wipers SEATS 4 Wheel Disc Brakes Cassette Wood Interior Trim Power Driver Seat Anti-Lock Brakes(4) Search/Seek EXTERIOR Power Passenger Seat ROOF CD Changer/Stacker Power Mirrors Bucket Seats Electric Glass Sunroof INTERIOR Dual Mirrors Leather Seats GLASS Power Locks Alarm Heated Seats Rear Defogger Power Trunk/Tailgate Fog Lamps STEERING Power Windows Air Conditioning Keyless Entry Power Steering WHEELS Cruise Control PAINT Tilt Wheel Aluminum/Alloy Wheels Driver Air Bag Clear Coat Paint Telescopic Wheel RADIO Passenger Air Bag 10/11/2013 11:25:38 AM 019495 Page 1 ,Supplement of Record 1 with Summary Cu�er: ABSEY, DAVID 7ob Number: Vehicle: 2007 ACUR TL 4D SED 6-3.2L-FI CHARCOAL l,ine Oper Description Part Number Qty Extended Labor Paint Price� . FROf�fT BUMPER 2 0/H bumper assy Z•4 3 <> Repl Bumper cover Base 04711SEPA80ZZ 1 309.03 Incl. 3.0 a Add for Clear Coat 1•2 5 Add for fog lamps 0.3 6 Repl LT Spacer 71198SEPA00 1 23.40 Incl. 7 Repl lT Cornersupport 711905EPAOOZZ 1 39.83 0.1 8 Repl LT Bumper grille Base 71107SEPAlOZA 1 28.87 0.2 9 Repl LT Lamp housing 71109SEPA00 1 40.33 10 Repl LT Chrome strip Base 71126SEPAlOZA 1 19.35 Incl. 11 Repl License frame 711455EPA00 1 16.93 0.2 12 Blnd Tow brkt cover alabaster slvr 0.1 13 GRILLE 14 Repl Grille standard 711205EPAlOZA 1 17.85 Incl. 15 Repl Center grille standard Base 75705SEPA10ZA 1 86.32 Incl. 16 Repl Molding Base 75125SEPAlOZA 1 34.47 Incl. 17 * R&I Cover 0=2 18 FRONT LAMPS 19 Repl LT Headlamp assy Base 33151SEPA22 1 600.37 0.7 2p R&I LT Side marker lamp 0•2 21 Repl Aim headlamps 1 0.5 22 FENDER 23 * Rpr LT Fender 3_0 2.0 24 Overlap Major Adj. Panel -0.4 25 Add for Clear Coat 0.3 Z6 Add for Edging 0.5 Z7 Add for Clear Coat 0.1 2g Repl LT Fenderliner 74150SEPA10 1 41.46 0.4 Z9 R&I RT Upper trim 0.1 30 R8cI LT Upper trim 0.1 31 * Rpr LT Upper extn bracket 0_5 32 ENGINE/TRANSAXLE 33 Repl Resonatorassy 06172RDA305 1 94.62 m 0.3 34 * R&I Lower case m 0_5 35 # Repl Airbox rivet(stock) 2 2.00 36 WHEELS 37 * R&I Spare Spare wheel 17x4 0_3 38 ** SO1 Repl RECOND LT/Front Wheel,alloy 42700SEPA53 1 199.00 m 0_i 17x8 Base 39 INSTRUMENT PANEL 40 SO1 R&I LT Front dr speaker �'z : 41 PILLARS,ROCKER&FLOOR , 42 R&I LT Rocker molding front alabaster 0.3 10/11/2013 11:25:38 AM 019495 Page 2 ,Supplement of Record 1 with Summary Customer: ABSEY, DAVID 7ob Number: Vehicle: 2007 ACUR TL 4D SED 6-3.2L-FI CHARCOAL siv <3 FRONfT DOOR aa • Repl LKQ LT doorassy+25% 67050SEPA9IZZ 1 843.75 1.8 3.0 NOTE: Pam's#874028 45 Overlap Major Adj. Panel -0.4 a6 Add for Clear Coat 0.5 47 R&I LT Belt w'strip 0.3 48 501 Repl LT Glass 76253SEPA11 1 51.18 0.2 49 • Repl LT Mirror housing alabaster sivr 76251SEPA1IZF 1 77.28 0_5 SO R&I LT Handle,outside alabaster slvr 0.4 51 R&I LT R8cI trim panel 0.6 52 R8cI LT Applique 0.3 53 Repl LT Upper molding 724655EPAOIZA 1 41.80 0.4 NOTE: One time use. 54 Repl LT Turn signal lamp 34351STX305 1 80.88 0.2 55 R&I LT Mirror assy white diamond 03 56 R&I LT Door check 0.3 57 * SO1 Repl LT Handle,outside gasket front 72180SEPA91 1 4 35 58 Repl LT Handle,outside cap alabaster 72184SEPAOIZK 1 13.87 slvr 59 R&I LT Door w'strip 0.5 60 SO1 R&I LT Door glass Acura �•� NOTE: LKQ GLA55 WAS TINTED HAD TO PUT IN ORIGINAL GLASS 61 SO1 R&I LT Upper hinge 0.3 62 SOl R&I LT Lower hinge 0.3 63 # 501 Repl Flat Bolt 90103S7S003 1 1.27 NOTE: Bolt did not come with LKQ door 64 * S01 Repl RT Regulator 72210SEP305 1 136.20 0.5 65 REAR DOOR 66 Blnd LT Outer panel (HSS) 1.0 67 R&I LT Belt w'strip 0.3 68 R&I LT Handle,outside alabaster slvr 0.4 69 R&I LT Lock assy 0.3 7p R&I LT R&I trim panel 0.5 71 Repl LT Handle,outside gasket front 72180SEPA91 1 2.52 72 Repl LT Handle base collar 72140SEPA81 1 0.48 73 MISCELLANEOUS OPERATIONS 74 * Repl Cover car/bag 1 0_0 0_2 75 # Repl Hazardous waste removal 1 3.00 76 # Repl Flex Additive 1 8.00 77 # Refn Corrosion protection primer 0�3 78 # SO1 Subl Align 4 Wheel Suspension 1 85.00 X 79 # SOl Refn Color tint/Color match 0.5 NOTE: Painters needed additional time to match overall refinish of paint 80 TIRES 10/li/2013 11:25:38 AM 019495 Page 3 ,Supplement of Record 1 with Summary Customer: ABSEY, DAVID ]ob Number: Vehicle: 2007 ACUR TL 4D SED 6-3.2L-FI CHARCOAL 8: • Repl YOKO 235/45R17 AS530 BW 97H Y07431 1 201.99 0.3 NOTE: Will need to order- YOKOHAMA YK520 235/45R17 97V 82 s Subl Mount&Balance 1 25.00 X 83 s Subl Tire Disposal 1 3.00 X SUBTOTALS 3,133.40 20.0 11.9 NOTES Esamate Notes: KeystOne-612 789 1919 Debt)ie No recon or LKQ available No QTE#M0276898 AAA-651 423 2432 Murphy No recon or LKQ available No QTE#1446674 Action-651 227 8996 Don No recon or LKQ available No QTE#Y134721 Car-part.com Randy @ Pam's auto-Found door ESTIMATE TOTALS Category Basis Rate Cost� Parts 3,020.40 Body Labor 20.0 hrs @ $52.00/hr 1,040.00 Paint Labor 11.9 hrs @ $52.00/hr 618.80 Paint Supplies 11.9 hrs @ $32.00/hr 380.80 Miscellaneous 113.00 Subtotal 5,173.00 Sales Tax $3,401.20 @ 7.6250% 259.34 Grand Total 5,432.34 Deductible 500.00 CUSTOMER PAY 500.00 INSURANCE PAY 4,932.34 10/il/2013 11:25:38 AM 019495 Page 4 ,Supplement of Record 1 with Summary Customer ABSEY, DAVID 7ob Number: Vehicle: 2007 ACUR TL 4D SED 6-3.2L-FI CHARCOAL � ' � For�,ore-+tor^tiaoon regarding State Farm's promise of satisfaction relating to new non-original equipment � man�fac*.lr�(non-OEM)and recycled parts, please visit:htto://st8.fm/7X4 or QR code. � � ■ � � Reg�sier onlme to check the status of your claim and stay connected with State FarmO.To register,go to http://www.statefarm.com/ and select Check the Status of a Claim. If you are already registered,thank you! Not available in New Mexico. 10/11/2013 11:25:38 AM 019495 Page 5 . Supplement of Record 1 with Summary Customer. ABSEY, DAVID 7ob Number: Vehicle: 2007 ACUR TL 4D SED 6-3.2L-FI CHARCOAL SUPPLEMENT SUMMARY line Oper Description Part Number Qty Extended Labor Paint Price$ �� 37 " Repl RECOND LT/Front Wheel,alloy 42700SEPA53 1 -189.00 m -0.1 17x8 Base 38 •• SO1 Repl RECOND LT/Front Wheel,alloy 42700SEPA53 1 199.00 m 0_1 17x8 Base 5a Repl lT Handle,outside gasket front 72180SEPA91 1 -2.52 57 ' S01 Repl LT Handle,outside gasket front 72180SEPA91 1 4.35 Oalebsd T�ems 4b ' R&I LT Glass -�•Z 71 # Sect Thrust angle wheel alignment 1 -65.00 X Added Items 39 INSTRUMENT PANEL 40 SOl R&I LT Front dr speaker �•Z 48 SO1 Repl LT Glass 762535EPA11 1 51.18 0.2 60 SOl R&I LT Door glass Acura 0•� NOTE: LKQ GLA55 WAS TINTED HAD TO PUT IN ORIGINAL GLASS 61 SO1 R&I LT Upper hinge 0.3 62 S01 R8cI LT Lower hinge 0.3 63 # SOl Repl Flat Bolt 90103S7S003 1 1.27 NOTE: Bolt did not come with LKQ door 64 * SO1 Repl RT Regulator 72210SEP305 1 136.20 0.5 78 # SOl Subl Align 4 Wheel Suspension 1 85.00 X 79 # S01 Refn Color tint/Color match 0.5 NOTE: Painters needed additional time to match overall refinish of paint SUBTOTALS 220.48 2.0 0.5 TOTALS SUMMARY Category Basis Rate Cost; Parts 200.48 Body Labor 2.0 hrs @ $52.00/hr 104.00 Paint Labor 0.5 hrs @ $52.00/hr 26.00 Paint Supplies 0.5 hrs @ $32.00/hr 16.00 Miscellaneous 20.00 Subtotal 366.48 Sales Tax $216.48 @ 7.6250% 16.52 Additional Supplement Taxes -0.01 Total Supplement Amount 382•99 NET COST OF SUPPLEMENT 382•99 10/11/2013 11:25:38 AM 019495 Page 6 Supplement of Record 1 with Summary Customer: ABSEY, DAVID 7ob Number: Vehicle: 2007 ACUR TL 4D SED 6-3.2L-FI CHARCOAL CUMULATIVE EFFECTS OF SUPPLEMENT(S) Estimate 5,049.35 CHAD WYTTENBACH Supplement S01 382.99 CHAD WYTTENBACH Job Total: $ 5,432.34 CUSTOMER PAY: � 500.00 INSURANCE PAY: $ 4,932.34 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. 10/11/2013 11:25:38 AM 019495 Page 7 . Supplement of Record 1 with Summary Customer: ABSEY, DAVID ]ob Number: Vehicle: 2007 ACUR TL 4D SED 6-3.2L-FI CHARCOAL Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide ART4817, CCC Data Date 10/9/2013, 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 (Altematrve 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. 10/11/2013 11:25:38 AM 019495 Page 8 Supplement of Record 1 with Summary Customer: ABSEY, DAVID ]ob Number: Vehicle: 2007 ACUR TL 4D SED 6-3.2L-FI CHARCOAL ALTERNATE PARTS SUPPLIERS Supplier: Keystone-Complete-Minneapolis Lotatia�(s): 3615 MARSHALL STREET NE,MINNEAPOLIS MN 55418 (800)328-1845 (612)789-1919 Line Description Item# Price 38 RECOND LT/Front Wheel,alloy 17x8 Base ALY71762U20 $199.00 10/11/2013 11:25:38 AM 019495 Page 9 , Supplement of Record 1 with Summary Customer: ABSEY, DAVID Job Number: Vehicle: 2007 ACUR TL 4D SED 6-3.2L-FI CHARCOAL TIRE PARTS SUPPLIERS Une Description Supplier Price 81 YOKO 235/45R17 A5530 BW 97H NTB $201.99 12751 CENTRAL AVE NE, BLAINE MN 55434-0 (763)755-4422 10/11/2013 11:25:38 AM 019495 Page 10 _ ___ . _ -- �a�=- , �� .,„��r ��,.,, . , �..... : ,. , . �, . `' � d' -a° .p. �' .I.. "``'� � ' .� ��II �I� I � �� _. � � t �"-y ° ' � a �. ,; �>, „� . .. . � _-. 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J�D►616 � 1� ¢;, . � - .� �: ="�. ��' ?�* ; , a .;x , �.: �� z��: ��`;w�wr a�� .��-�. ,�s�s.,."�.'��,►C,.'.�.,,, . � '�,� t � . .��' � , . � ' �'ES;1t�y� � . ._. ,� '�,... .:,f� .,. .,. . � _ � � ` � S� � . . ��n . ..�x-t:�.' � ,it:.�-�:'. �'r:,S. . � . s !R ,.'S . .'�1.'`� `'��' f .A:.,1' "�.v'� p�'��i Er,�.M ' . � � .:..f , � = �� I" ; � , �� r �° - �•, , � . � � RBZOOOMD S�e�flRil State Farm Mutual Automobile Insurance Company � Auto Rental Bills a Route To: Demetria King BASIC CLAIM INFORMATION Claim Number. 23-24L7-070 DaLe of Loss: 09-16-2013 Pdicy Number. 0584-845-236 Named Insured: ABSEY, DAVID ABSE, DAVID BILL SUMMARY Bill Information Invoice Number: 1906D468983 Claim Number: 23-24L7-070 Rental Vendor: ENTERPRISE RENT-A-CAR Date of Loss: 09-16-2013 Insured Name: ABSEY, DAVID Received From Renter: $69.15 Renter Name: ABSE, DAVID Billed To Others: Rental Start Date: 09-17-2013 Amount Due: $276.59 Renter End Date: 09-27-2013 Amount Paid To Date: $276.59 Current Bill Status Primarv Status Primary Reason(s) Reviewed Secondarv Status Secondarv Reason(s) Paid Vehicle Information Vehicle Rental Start Rental End Assnd Class Aapr Class Make Model 01 09-17-2013 09-27-2013 SC SC CHRY 200 Invoice Details Rate Percent Extended Vehicle Descriqtion Billed Partv uanti % Covered Amount 01 Daily Rental Rate State Farm 11 25.80 80.000 $227.04 01 Daily Rental Rate Renter 11 25.80 20.000 $56.76 Sales Tax State Farm 227.04 7.620 0.000 $17.31 Sales Tax Renter 56.76 7.620 0.000 $4.33 Government Surcharge State Farm 227.04 5.000 0.000 $11.35 Government Surcharge State Farm 227.04 9.200 0.000 $20.89 Government Surcharge Renter 56.76 5.000 0.000 $2.84 Government Surcharge Renter 56.76 9.200 0.000 $5.22 Subtotal Less Taxes : $283.80 Received From Renter: $69.15 Total Taxes : $61.94 Amount Due From State Farm : $276.59 Date: 12-19-2013 Page 1 FOR INTERNAL STATE FARM USE ONLY Contains CONFIDENTIAL information which may not be disclosed without express written authorization. , , RBZ0006Z 5�� State Farm Mutual Automobile Insurance Company � Auto Payments by COL . Route To: Demetria King BASIC CLAIM INFORMATION Claim Number: 23-24L7-070 Qate of Loss: 09-16-2013 Policy Number: 0584-845-23B Named Insured: ABSEY, DAVID 400 -COLL C denotes consolidated payment E denotes EFT payment P previously converted payment from CAT/CMR Payment Payable Pay Rsn Number Issued Date Participant COL Cd Status Amount Auth ID Cd 105857470K E 10-11-2013 Named Insured(s) 400 1 Paid $4,932.34 ECSAPY Total: $4,932.34 501 - RENT C denotes consolidated payment E denotes EFT payment P previously converted payment from CAT/CMR Payment Payable Pay Rsn Number Issued Date Participant COL Cd Status Amount Auth ID Cd 105846207K E 10-03-2013 Named Insured(s) 501 1 Paid $276.59 ECSAPY Total: $276.59 Page 1 Date: 12-19-2013 FOR INTERNAL STATE FARM USE ONLY Contains CONFIDENTIAL information which may not be disclosed without express written authorization.