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Lamoureux N(�TICE ()F CLAII�� FORM to the Cit�� of �aint Paul, Minnesota ;t�rl;�resuna Sttire Srcrr�re�(6.Oi sttr�e�r rfi«r °...erer7�per•rnr...tirlio c/cxirns derrrxrgc=s frnrn any rnt�f*ic�iCxrtin�..shcill cause ro f�e Erres�er�e=d to ihc� ,�n��err�i���ha1� of rhe rn���ierfxrfii��s4•ir/ii��1�t}clnrs caf'ter the allegPe!ir�ss or iirjur��rs disc�oi�c=reci a rtotire srnzrfia�tfee rinee„plf�rc=,�r�7ri ~ircums�ant:es therenf ctru��tir amnur�I��f i�otnf�c�ssatrort or nt7ter rclie�detnruaclecl." Ptease cornplete this f�>rrn in its t�ntiret��by clearl��ttipuig or printing ti�our ans�s�er to each quetitio►�. tf rnnre space is I10Ei�t'C�,attach adclifion��l sheets. Please note that�ou���ill ttot b�e€�ntactE�cl b��tdephone to clarift'�ttsu°ers,so prrfFi�e as rnik h infi�rniati�m as ne�essarti°to e�lain��o�ir elaii�t,4�u1 thc:a���nunt of e�xn��nsation l�eing��quest�d. j'c�u will rec.eiFFe a ��ritten ack�x���leci;ernet�t ance t•our�'��rnt[s rcrei�ec1. The prc�cess can takt�up t�t�i��°eeks c�r Icx�,er clepending cx�tl�e nature of c��r clairn. Thi�fc,nn rn��st be si��ecl,anci both pa�es c:o�npletecl. If sc�rnething de�es not applt�,write•N/A'. SEND C01��1PLETED FORNI ��1ND OTHER DO�CEINIENTS TO: GITY CLERI�, 1� WEST I�ELLOGG BLVD, 310 CITY HALL, SAINT P�►i�L, 1�IN 55102 Fi��t N,une� � Micl�lle Init�iaf �L�rst�Nan� Ld..W1�1.J'�'�d,�. C�,m�,��n� c,r Bu:ine..Nanie .-�r� ���,u an Insui����ce Comp�ui}��' }'�;I �a If Ye,. Clain�Nun�ber'? sr����� :���t���.; �{y22 t�L',-�1sr� A�tc.. �o �s _ c«, ;vune.�.��,Ts sc{�c�:��1 -r.��c����t_��y l9 Da��tin�e F'h��ne t_�--�_Cel( Vhone(�1���� Evenin� Teleph�ane(�--'- i3�ue i�t��ciclentl�nj��r1=nr Drit� L7i�c t���ei�c1 12����3 Ti���e : arY� /pm Pl�a�state. in dttsail,N�h��t occ��rred {hap�enetl). t�nci «•h��}��c,�a ��re�ubmittin� a elai�u. Plea� inclis at�«°I��°or hoti� }o�� i'eel th� Cit� ot Saint Paul or it•�r3�plo��ec;arc in�ol�e�i an�l/c�r re, umil�l– c f'c>^yo�ar ti<in�a��e�. - c�;na ��-t,� . �� �_��' �a�l ���.n`s���.�S��c.� 10 1 — T ��e��' � �rs�� vr s� cie�,�A..°�-�,� �.-�a,� �I-;�lo � � 1�rr� r�.6�t' c�--l�� . 4 13 �t�-o.r9 a—c.w1t'- Plea.�i heck the bc�x(��}that rr�o�t clo:el�� r�°E?re�nt th�n;a:�n Fc�r�or��pleCin2 this f�,�•m: ❑ h1� ��hic:le ��a. c��rt�>>��e� in zin ��ccielent � l�t�� ���l��cl� ����a� clan�a�ei dt�rin���� tt�w� ❑ 1�1�� ��ehicle«a, ci�ri���t�ec�l b� a��othe�lc ar ce�nditi�n «t'the street �h��� ��c�hECle����i�: cla��3<i�e,d l�v <�plcn�� ❑ I��1� ��ehicle_ ��a; ��=rc7n�f�ullv t�,�red rrudlor tic•kttecl � I w°as iujure-cl on C'it}r propei-t�. � Chher t��p� of p�-opett� cl�atii����e_plc���e specif'v_ — ❑ Chh�rt�E}e t>finjuryy–plea�e�.��c.citv– In ��rder to proc�ess ����ur cl�iir�vou nee�l to inclucle c�pies �f all applicable d�cuments. For the clain�s t��e�li,ted E�elc��-, plea.c be�ure to inclue�e t he docun�e��ts ir�di4ated �r it�+°ill �lela��the f�����df�in�*c��� ���ur clziim. Document;Vl'ILL NOT be retur��e�� �ind b�coi7� th� pro��ertyo uf�th�Cit�°. Y<,u ar� eneea�n�aged tc�l:�eE,e� c������ for�'oui�elf before �ubmittin���°c�urc(aim fortn. O }'rope�tt dama��e claim.tt�<i �ehicle: h�o���[im�ite:f'c�r tl�t:reE?aii:�t�, vour�ef�ii•le if the damz���c exceed� `+�Of)_Q(?; or the ��rtual hills anJ/c,r etceiE�t,f��r the repair� O To��`in�,cl<litr��: I�gil�le ct�p[e�t�t��n�'ticl:et i��ued �rnd a�c7�>�=c�l�the in�E�uund lot rei:eipt O (hhc r E,r•c�E�erh d.�m�i>>�clair».: t��c� repziir e5tin�,rtc: if tt�e clsirt�a�;t excee�l.tij()0.00:ar the <�ctut�f hill:: and/or r�c�eipt:for the re�sairs:elrt��ileci li•t c�Y cl�irnaged iter�l. O Ic7j�u�r cl�iii».: n�idieal hili;. rcreipt� O I�hoto,,�raph.are�I��zn���e14�,���e t�> do<��an��nt <ind;up�?o�t yt�tar claini but�+°ill nc�t be retu�7aed� Fage 1 of 2–Please complete and rehirn both pa�c�of Claim Form R�CEIVE� JAN 03 2014 CITY CLERK Failure to cc►nipletc�and rnturn both pa�es���ill result in dt�la�-in the handlin�*of��our clai►n. :111 Claims-please 4omplE�te this sectian �ir�cr�e th�re�vitne..cs t��tlae inc�cl�nC? Ye; Nc� C?nknc�wr tcircle) Prc,�i�e,their name�, .�dilre.�,��nd tzleE�hc�ue nun�bers: ��'�:re the E,alic�or la�� entorceiYx;nt c<�lleii`' Y'e� Nu tTnknc�t�•n (cirilel If ��c•, ��haI dcE�aRment at a�r�ttct'?���� �� C�i;e�`or r<�port# �3' Z.(i�'$(�g ���h�rr �ii�l the a<<i�ient or injur��t<ike placr�? E'ro��icle ,treet adc�r�.�,crc�,: ;t�-�et. inte«eetion, nan7e��t'��ark��r°t'acil�ih�°. cl�,�e�t l��n�inru�k. �tc. Plca,�be G��d �ailetl as pc�,sible. If nec�;:s�rv. ��tt�ieh <i dia�r�a�n. _ ��5,�u, � ����M PI<<�� in�iir��te thc anx,iint �°«u ar� ,�ekDin« ii�c��iupe�n:�tion or�vh:iE y4��u wc�cald like thc Cit��tt�dc� t�,res��1���thi,�[�iir�� tc,��,ur<<�ti;t�iction. FS�-�W►e..'�CGS `rD�S�� , ��ehicle Claims— lease com lete this section ❑�heck bax if thi��cti�n doe� i�ot a��I�� �'�,ur Vchicle: Yt�r�- Z,f,'f63 1�°l��ke � Muc�el L«�n�e �'I��t�:Nui7�l�e.r_ 33 "6zu St�ite-�_Colcar�.A� x���i,terecl()�tner�I�b,.•�„e�. L6.rn�b�r��.s�— Dri��er at Vet3icle .�rr:�i D��I7�����ci �• S:d,t� �.�t�l�� �-s�DvN.t�t�.f S:r�.r�(cYsf Cit� ��hirl�: �'ear 1�9<cE:e 1�9odel Li�:en� Plate Numher State Color Urit ee c�P�`ehicl<tCitv Eri�plo�ee'�N<rm�) �r�:�i I)<ir�7�i��ec1 Inlui��C'laim5 �lea�e cr�mulete thi5 section �k heck hc�x ii�thi.��:��tic,n dc�ts not �rG�r�fy, Hc»�� �+�ere-vr�u ir�jure�!? 1?�h.at �>�irti•) c>f��c�ur E�t�d�� �+ei-e injurecl'' Ha�c��nu :i�u��ht n�edical treatm�i�t'.' Ye. No Plannin�� t« SE�k Treatment tci►�l�) V4'hen�dici�t>�� �Y:ceivc. tre.t�tmt.r�t' {j,r��vicle dat�:i��) Nume oi lt�le�l�ca1 Pr�ti�idcrt�): — :�dclre.; TeIt:E�h��ne _ Diii �c�u i�ii;s����r�l:ati<i r�sult ��i'��our injur�'? Y'e; No til�hen did�oii mi•: �iorl:'> ;,F�rc»i�e d��te(�►) Nan�e�,t�our Fmpl�,ter:_ — <�t�iji.�\\ Tc�<'E7fl Ot7t — �('herk herc� If���►u are attaching more pages to this elaim forn►. Number af adclitic►nal pagc��. By signurg tl�is forYtt, �`��ti rrre statir�g tl�at all irt f�rittatzorr }tau have �rovided is trrie a�td correci to tl�e hest of your ki:ow�lec�ge. t'►zsigr�ed for�tts x�ill�tot be �trocesse�. Srrl►ntit�irrg a f�lse c�ai��a can resrilt ir�pros��critior�. Date farm was completed �� -.� Print the Namc of the Yerson�rho C'ompletecl this F'orm: �s��'ld►.K. �.�M,aur�11� Signatum ofPerson A�Iaking the C:laim: E2evis.d F::�iu<ir'� ?i}1 I Accident Report __ ,� ��� � � 13261809 � � rRf-�MRVM P.iev'ROO VEM10.E7 1(ILLF9 wAPFD 1MW 6�TE YEAR Ow�On �PYTILf N Y t19 00 '�0 Y 12 9 2013 �� 0039 � PpIIF fY6TF4 11difE MIIIBEP OR LTqFFTN�ME /� A4b�Y���� �1 f�1 f�7 1 QST s w �w�en9ecnai� oR __ __ l.L� M� Siw�� < 10 Dale v � �� u u �aMl�V,�p Mi1FY YCiqiEW:EPOMT NIXfIF9V4 �UTEt.lTllfEf.CONLI4iT.ORfFATJpE 62 �,w Saint Paul 147 +_• 10 Marshall I�01 . vw�rn� orav[air.�us[wuaen.i su.c u�ss asuiva aoanor 00.MER1.0.��45FNU1BEP.1 suic a.w axuna Far.rm� O1 w32326"]922808 MN B O1 O1 i r.cra t �.v�c 6rtcr.wwaE.usr, u.h or anm ruue lruur.woa.e.uarl wn or artm ritror+7 DAVID PAUL REINSBERG 11 05 58 a MOrtES4 ]RWOIT 0.ElTR�LT bORE98 pivKJLM FlSiA�R �MMhER O1 2957 HAMLET AVE N � �1 �.�y urv.sr��e.zr crtr.su*�ur vnrxi O1 OAKDALE 55128 651793C477 RCbYO bb11EE5 SEY WEEOP� �EFavi M1MG EJEGf INJSEV MDRE61 ti% SAFFiEOPT �EEOPT 4MI.O FXCI IW� RCMWO - O� ���' [Vj 1v�19 0 4 0 6 0 5 N COa� T�'�k K�CqNsI iVPE OMW T'�fE TO�.1�XI9P T(1N19PORT /31i11LANLEBERVICi. RUIINUNlf� LLC11L TM'E fMll(1 H'. �OMOBP TPIW9PORi IJrIkI�NC[�CRNCE M�MNUMBEq `. r�"��,��_'�.8 �� �" Lv'"' � TO�IIE9 IFiT iE6T ~ QOTMM OCCUP OwM1F.RH�w[ FMIE OWNFNMNIE . fllE OCCI� p� CITY OF ST PAUL I CREERON KERRY THOMAS � �Q �EhIT9 AOlME55 TOWEO AlY11iE!] N O�/VP 38 891 N DALE ST [3> 238 DALE ST N v��se� ciner�re.zw wurx� ou�ECr crtr.st�rr..zrv ruu�w anrc.r xn�u �3 uST PAUL MN`55103 � c�� "I�� 03 ST PAUL MN��5102 r� ca� K9 03 O1L� ° O10 WHT 11 98 MACK 700 201 TOYT VEN py(:$FV PUTEI aTRiG KAw9G:� YO�wCE�E�iS ��[�'FUi pulG/ 9TAQG YLMqEC a:w�� �yp ���vivM OIG9EV O1 939666 MN 4 O1 � y�01 483kad MN 14 O1 � O1 03 W9UFVHt1E' POLGY NUMBE0. WBUMNCE(UNA)I I+OI N:Y MWBCP �iCity of Saint Paul Unknown u G�qG(�00 XAZ GMT WNVED IASPECTqN�. NSP 6ADGE� WAN�G 1M2 WT GRGO BDY �y� �� IF ACCIDENT INVOWEO A CONMERCIAL NOTOR VElpCLE,SCMOOL YU3,OR NEAD sTART BUS n.c +�*� � - REMEMBER 70 NOTIFY TNE STATE PATROL(requlrad untler MS 169.7!]aad 1{9Al11i. Gp�KlMJN.'uF�N].ENU4tlEN1�M0iQtURWERIUIIE �OTf1N.OE11 C(FMMP(}N�F.'MKLENUMBFAI���OMGFRP4RMNIF OO1MIliEA � W>9fMUER9!'.N�NE89E4 UWT v0.",1HMlE0�flN SE� TvPE USE M�BI�G EJELT WfEY iU1K19P ii1N18P(WT � •" � wla6Mtf wM�n1�BPA V� •11B . � OOTN01 ,` Q �weaENVICE � �w�A 1'i� UI9 ` . ' �OTXER "� . . . Oµ .Wl9EIIVKE MIM141�1lFA � oa��� � (YryNFR�(J'NFR(]wM'aE0 PROP;ATV N�W DFSCflIPTiaM Oi D/�.MGEU�'M�VEifiY AMOrcM YFLLOw iAG NUURFRSf WMWEU O��pT�'IIIELLON'iM MX�1!P �� ' Cify of Salnf Paul Plow Truck 939666 k2549 ucvice ♦Cc rvv �:'�- wwwarve: 0 2 �' _ 98 �""'"1e ,'' +-. VEN N1 was a City of Saint Paul plow truck (MN .:. � 03 w� 939666-M2599)that was in service and was �� «^TM `� travelinq._E/B on Marshall.ftom.Dale., . 98 O1 � a,,.,,❑,� ' VEH 111 had -a larqe plow blade on the fsont and an n^��- N. '� � � P, the right side of the plow truck. 01 MEOi1K 3�:� /�r'ro�-c'�� N �'y .. 9 wi The street was narrow with parked vehiclee on the _ 98 r . , € north and south sldes of the street. LOC Oi � . . . . MEATNNI� GiNINYZ :k.': vF'� . . . . . . .. .. e {' As the driver of VEH M1 was attemptinq to plow QQ q,�� �� ? the street, he struck 8 veh.iclas.-All.vehiCles. }�^ 'A4ATMFJI] I were struck on their Left side by the plow blade � , „�w„ `•� that was on the riqht side of the pYow track. �� r �. uGNr 08 �r; s`�i'r� All vehicles reieved moderate damage�to their 04 "'"'"` �� �., left side but none requiced_to. be toH.ed. because. . �� R03 ;!% they were parked legally and not obstructing z�` (conCir.ued on attached paqe) Y �µt _ . ... ouc�ur e r . .. .. _ . .. .. . . Nuu�w ?' ?+� .. _ . _ ... . . �2 st._e �t%' Q 1. .. t� � �� . . .::, . . ...—.__.. ..._._....... . ......... .. ,H .. ... .... . ��y }� PLiROIl��TION iT�RMT1ql L f«[fiRANNNAMENA3�pOE� yt Paul QU ❑wewn �OTNFII � Officer Andrew Franklin 400 �' http://dvslesupport.org/dvsinfo/accidentrecords_2008/Includes_LE/PrintReportIndiv_LE.a... 12/9/2013 _ _ Accident Report Page 2 of 6i Case#: 13261809 Report Date: 12/9l2013 Accident Narrative,continued: traffic. All vehicles were legally parked and unoccupied. Business cards with the case number were left with ail vehiGes involved,no owners could be reached. W S 04 O S http://dvslesupport.org/dvsinfo/accidentrecords_2008/Includes_LE/PrintRepartindiv_LE.a... 12/9/2013 Accident Report . � --- � i ��� ��r � 13261809 ' � ' »..wer .w�nov ve�u.EC wum iww[o swr� uwm wh rcw av w*wrvnc C „ . �i NqI�EM� RJUifMUWEROA4fXEETNMtE pa��pA�TnN �T 1 W aM E ` N E QINTERSECTqN�1� OR _^,�� ^{ S�y�y t 8 W Mt1H W L.1 a uMrvru tire�c+a nerFnencerourt Routesrs aour[F.sracnooreu..r.wr�nnne c�r twv +-• sk`w� ppyllp,; �hFpl�fN5EN11mM.1 9T4tE M8$ U191�l1k1 YU]lildl DMNERLIfEN!/Nl►MFR.t $T�IE fAKY Otfr�ryb i.CIORI Q1 OL FILT(YI i M.WE RMSt.YORE.UEiI D��F Of MRM �NME lfY1DL M�ODIE.USTI WTE Of MRI�� RK10R t T IEiTOLI WIMA �uIMR �Od�FSE 011VI0L1N 9TRI�f .�OFE6S �f 1 L1 21 � �� rr.sur[:o �an.sr�r¢.nv I�� �pEfy �y 9KfCO�T �{'[OPT AIH6�G FJECI ilU9EV . CVMFCT � Slifk[OVT �COPi APWN FJFCT MU�' RCpR10 .dwFrt NvE *1 YYk l� lY pMp T�npSP 1iMI5h�RT �Y&II.ANf.E5F11NK NLWNUNBER �T� TYPF T�0 IVVE TONOfP TP�NiVONT AYYIRANLEtfIMGE I1UNM1MtlFA Q MMI F)' �;.al i� . �� � . � O OTHER Q UTI K:fl iWf OCCIi ,�.. o.K...� . F.E �„.,� [� O O ;� POINDEXTER MICHAEL JOHN DOBBINS N SHIGGS JASON BII.L rowEO v�n rvv w.n+ ,Qprpss TavEO �conESS �T 01 �' 240 DALE ST N N: 580 MARSHALL AV *` � pW{IMfi p�llCT VEMUK .�� �,..�a rui�+c owECr cm,sr.re nr Q 3 �1 ;;1 ST PAJL MN 55102 "l�f 03 ST PAUL MN 55102 `�1 � �� � �� a�a�oc s.z .mu rc..a ava+ I,I$$ PE'i �Q 11 ' :i KIA SPO 200 ���,,�„t�� O„�„E,�„ 03E„ �yr�� ST nE6 VEW REG ffOiEMCE:f E�HTS �1'MNL' 0.wT!I STNEG �AWIIF(+ �Y� 456k1p MN 4 O1 O1 174d1m MN 19 O1 c«wr Hu�,o�n i�u.wla:Nwr�� rouc�w�.w �, Unknown Unknown � � xu+��sn wswt ..arnaor r„vH;oen w�zranr wn�vro mscecnow�� "'�"BAOCiE" IF ACpDENT IINOLVEO A COMIAERCIAI MOTOR VEHICLE,SCHOOL BUB,OR HEAD START iU! a�c � rrre v�.o ' � �� REMEMBER TO NOTIfY THE STATE PATROL(r�dutr�d undu Yf 1�B.T6]aM 169AE11} GOAMFxt�KVE11ClFWJY�ER�.MOiO�f.VWE11rU,.M tYJtnUMIEq CC�w�F.RCNLVEIYIXLMlIHk0.l.MOTORCMPiEMNMF DOT�UWf0. W.SSFN!:EiS(VATNFSSES UN'�T POS�N WTCOlDIf3T11 SFJ tYR USE /JX6M EIE�T M��Y IUNtA1'TMNEf'CWi � \ O� /�YflG[111Kf RWM/��EN \T� �Oii1U1 , ^� M�BYRMCL � NlMMIWlA � �, r �OME� . �� NaB9FRVIC[ IWNNiwIKM M �V (]u�r�kw � . .. . ... .. .. , . . . � o�wr.aeon�ararv�rauw���cNw�w . ._ ._.... ._ . '�q/.Hf40F0�MPMM«OP1�O�O�T��'M��'�'XIF1qNOf0/JA�OE�R�O>EMY/J16W1vEll(YNI)LMM�EAI9� . r. . ......,r._. .... .. . OEViCE n_cive .,.... . ._ . �. . _ ...... ,-... .... .. . ' NMMn�f�. ' t .' . . .. . � ... .... . j� . ..... �` �..". . �� . ' �` . ..,..... ....... .. . .. . .,.. .... .. ' .. . '... .. ... . 8^.lhMls .`4M . . . . . � .. . .. . �S ... . . . ... . . ;['.. .' . . . .. .. � }k;� .. .... MOMkWO S: . .. �d .. . 1� l0(:A1M . `. . . ..: . . . . . . . .. '.'3, . . :7 . . a wr a� cr em�r � . . _ . .. .. . . , �� . .... . . .. q� . � .. ..._. . . " - . .. ... , . _ .. _. ._._... rmracw��a � . . . . . . . . . . � ._. . ' �.. . . . � . � . . MF iWe� �p� '� .,. � �, . . . . . . .... 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' p Oi11EN ❑OTHEN O(:CJP OMIER NM1E �. . i1PE OMER NM1E GpE OCQIY 00 LAMOUREUX NATHANIEL JOHN N MCRELL JOHN WALTER H' �� �Hm �ou�ss rov.co .bd1E55 N° 03"° O1 4422 NICOLLET AVE SO APT#5 N. 587 SUTHERLAND DR vcNUSE rnv.sr�ie.a u�wo onecr or.eun ar wura tw�:r :��ueF 01. MINNEAPOLIS MN 55809 "IC`. 03 WOODBURY MN 55129 `"19 �3 O1 °"°`x """ �� r�H w�� FORD E'MS OOe RF.D 11�� 11 VOLK JGS 200 RED DMG tlEV PIAT[Y � Si PE� "Fi1H AEC. it,diNCC Os¢V�9 Yi .WAIE a 9r�EG �'EM� VWy�p lY Yv�s row� O� � O�flV 03 633ezu MN 3 O1 �01 sju458 MN 19 O1 4:SU9�n(.t � oOIR%YINMBFR M6UIN�CE',WR]I ���M�� �' Unknown Onknown CM�'� p�f W�M14D WSPECIIDNM f+SpbY]6EI. � ' WNVR11 w�2u�T I�RGOBM IF AGCIDENT INVOLVE�A COMMERCIAL MOTOR VENICtE,�CNOOL BUS,OR MGD iTApT BUi pv:F TME � � REMEMBER TO NOTFY THE BTATE PATROI(npulrW unMr Nt 1i9.7��and 189.1511�. i:VNAEXCNLVElY0.ENWBEP'.IAD10NfMPIFAl1�Af IIATMI�lE9 CCNMERCMLVF.IPCiCH1YIk4Y.MOT0i1CJAWENW�VE .DOTM111fER fP55FMGEN3;'MfNESSES . . .Y��T FOSIw W?FpsMTN Sf% 'YI! 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S C P a u 1 P D Q aNean Q oom Officer Andrew Franklin 400 http://dvslesupport,arg/dvsinfo/accidentrecords_2008/Includes_LE/PrintReportIndiv_LE.a... 12/9/2013 LUTHER COLLISION &GLASS � �Norkfile ID: a1b76986 PLYMOUTH F�de�i r�: z6-a6o�a�� 9825 56th Ave North, PLYMOUTH, MN 55442 Phone: (763) 331-6000 FAX: (763) 331-6001 Preliminary Estimate Customer: LAMOUREUX, NATE 7ob Number: Written By: Rick Nelson Insured: LAMOUREUX, NATE Policy#: Claim#: Type of Loss: Date of Loss: Days to Repair: 0 Point of Impad: Owner: Inspection Location: Insurance Company: LAMOUREUX, NATE LUTHER COLLISION&GLASS- PLYMOUTH (612)267-7183 Business 9825 56th Ave North PLYMOUTH, MN 55442 Repair Facility (763)331-6000 Business VEHICLE Year: 2003 Body Sryle: 4D SED VIN: 3VWSK69M33M093073 Mileage In: Make: VW Engine: 4-2.OL-FI License: 633EZU Mileage Out: Model: JETTA GLS Production Date: State: Vehicle Out: Color: RED Int: Condition: Job#: TRANSMISSION Body Side Moldings AM Radio Head/Curtain Air Bags Overdrive Console/Storage FM Radio ROOF 5 Speed Transmission CONVENIENCE Stereo Electric Glass Sunroof POWER Air Conditioning Search/Seek SEATS Power Steering Intermittent Wipers CD Player Cioth Seats Power Brakes Tilt Wheel Cassette Bucket Seats Power Windows Cruise Control SAFETY Reclining/Lounge Seats Power Locks Rear Defogger Drivers Side Air Bag WHEELS Power Mirrors Key�ess Entry Passenger Air Bag Aluminum/Alloy Wheels Heated Mirrors Alarm Anti-Lock Brakes(4) PAINT DECOR Telescopic Wheel 4 Wheel Disc Brakes Clear Coat Paint Dual Mirrors RADIO Front Side Impact Air Bags i 12/27/2013 3:01:04 PM 100723 Page 1 Preliminary Estimate Customer. LAMOUREUX, NATE ]ob Number: Vehicle: 2003 VW]ETTA GLS 4D SED 4-2.OL-FI RED Llne Oper Description Part Number Qty Extended Labor Paint Price$ 1 FRONT BUMPER 2 R&I R&I bumper cover 0 0.00 1.0 0.0 .__._�__�____.__�.._ .�_�..___.. _._____.._ .,__.._�_ ____.___.___.�..___� __......._._._.._.�..... __._._..__ ._,.,.._.,�.__....�..__.___�_.__.�._..___..__,.u._.__.__..�._.,._..._. 3 FRONT LAMPS 4 R&I LT Headlamp assy GL&GLS from 0 0.00 0.4 0.0 2108642,w/o 1.SL auto trans 5 R&I LT Repeater lamp 0 0.00 0.3 0.0 _ _.._...,_. _.._...._. _. ..__ _�....... _. .._.�_.. __ ._............ .... ......�.. . .._ ... .._. ..__._.... _.._.._._. ......_ _. .._.._.,...�...._...�.._.__.�..._.___.__..__.�.__._.._. 6 FENDER 7 Blnd LT Fender sedan 0 0.00 0.0 1.1 � __ ._.�_ _ ._.��..._.__ .__. ..._ ... ....... .... . ..._..�..,__. . ._.______ _....__._.__ __._�_�__ _._�.._____ ... ,_. _��.....��___._._�.._�_.�...,.�._-__�___ 8 FRONT DOOR � � 9 * Rpr LT Outer panel 0 0.00 $,Q 2.0 10 Add for Clear Coat 0 0.00 0.0 0.8 11 * R&I LT Body side mldg w/o chrome 0 0.00 Q,$ 0.0 insert seda�/RETAPE 12 * Rpr LT Door shell 0 0.00 2.4 Incl. 13 Add for Edging 0 0.00 0.0 OS 14 Add for Inside 0 0.00 0.0 0.5 15 Repl LT Mirror housing w/power,w/o 1J1857507DO1C 1 157.00 0.5 0.0 memory 16 Repl LT Mirror cover 380857537BGRU 1 61.00 Incl. 0.5 17 Overlap Minor Panel 0 0.00 0.0 -OZ 18 Add for Clear Coat 0 0.00 0.0 0.1 19 Repl LT Mirror glass w/power 361857523A 1 55.00 0.3 0.0 20 Repl LT Power regulator 1J4837461H 1 167.48 0.6 0.0 21 * R&I LT Window guide 0 0.00 Q,� 0.0 22 R&I LT Handle,outside primed 0 0.00 0.3 0.0 23 R&I LT R&I trim panel 0 0.00 0.4 0.0 .._.___ ._._ .�...__ .. ... ____ _.__ _.�_. . ..,,._., .._._.__.._ ..___... ..� _..___... .,w........ . .... ....._.._ __._..._.__.._,�__� .�_._....._.____,..___ ._.___..__._...__.__.�. 24 REAR DOOR 25 Repl LT Door shell 1J5833055F 1 739.20 3S 3.0 26 Overlap Major Adj. Panel 0 0.00 0.0 -0.4 27 Add for Clear Coat 0 0.00 0.0 0.5 28 Add for power units 0 0.00 0.4 0.0 29 Repl LT Sound absorber 323863950A 1 65.00 0.0 0.0 30 * R&I LT Body side mldg w/o chrome 0 0.00 Q,$ 0.0 inse RETAPE 31 Repl LT Moveable glass Volkswagen 1J5845025G 1 130.00 Incl. 0.0 32 Repl LT Window guide 1J58394310641 1 290.00 Incl. 0.0 33 R&I LT Handle,outside primed 0 0.00 Incl. 0.0 34 R&I LT R&I trim panel 0 0.00 Incl. 0.0 .,�__..___._. ._. ..._.____.._. .�_._..m.._.,.., _�._��.�..___..___.. . ._._...__�__.. ... .... ._ ,�.__._- _ ___.�_._�_..,_�. �.w 35 BACK GLASS 36 * Rpr Back glass Volkswagen/ROPE 0 0.00 4,4 0.0 ___ _ _ __ _.._ __ __ _ _.... 37 QUARTER PANEL 38 * Rpr LT Quarter panel 0 0.00 �,Q 2.4 39 Overlap Major Adj. Panel 0 0.00 0.0 -0.4 12/27/2013 3:01:04 PM 100723 Page 2 Preliminary Estimate Customer: LAMOUREUX, NATE 7ob Number: Vehicle: 2003 VW JETfA GLS 4D SED 4-2.OL-FI RED 40 Add for Clear Coat 0 0.00 0.0 0.4 41 R&I LT Wheelhouse liner 0 0.00 0.4 0.0 _ _ _ __ __ _ _ __ __ _..._ __ _ _ 42 REAR LAMPS 43 Repl LT Tail lamp assy 1J5945111S 1 133.00 0.4 0.0 _____.__-------_.__.__._.._.__._.._ __..�..... .. ......... . ............ . .. .._- - --__.._._ _...__._.___.____._._._.,.. _.___�_� _..._.__.__�._.__..___._.._---_. 44 REAR BUMPER ._.___.._.__.._....__._____ 45 0/H bumper assy 0 0.00 2.0 0.0 46 * Rpr Bumper cover 0 0.00 �( 2.4 47 Add for Clear Coat 0 0.00 0.0 1.0 48 * Rpr Molding 0 0.00 �Q 0.7 49 Add for Clear Coat 0 0.00 0.0 0.1 50 # CORROSION PROTECTION 1 0.00 0.0 0.3 51 # FLIX ADDITIVE 1 8.00 0.0 0.0 52 # HAZARDOUS WASTE REMOVAL 1 8.00 X 0.0 0.0 53 # CAR COVER PER TIMES USED 1 6.00 0.2 0.0 54 # MASK JAMBS PER OPENING 1 0.00 0.0 0.3 SUBTOTALS 1,819.68 40.0 15.6 ESTIMATE TOTALS Category Basis Rate Cost� Parts 1,811.68 Body Labor 40.0 hrs @ $54.00/hr 2,160.00 Paint Labor 15.6 hrs @ $54.00/hr 842.40 Paint Supplies 15.6 hrs @ $34.00/hr 530.40 Miscellaneous 8.00 Subtotal 5,352.48 Sales Tax $2,342.08 @ 7.2750% 170.39 Grand Total 5,522.87 Deductible 0.00 CUSTOMER PAY 0.00 INSURANCE PAY 5,522.87 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. 12/27/2013 3:01:04 PM 100723 Page 3 Preliminary Estimate Customer: LAMOUREUX, NATE ]ob Number: Vehicle: 2003 VW JETTA GLS 4D SED 4-2.OL-FI RED Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide EEA9277, CCC Data Date 12/16/2013, and the parts selected are OEM-parts manufactured by the vehicles Original Equipment Manufacturer. OEM parts are available at OE/Vehicle dealerships. OPT OEM (Optional OEM) or ALT OEM (Alternative OEM) parts are OEM parts that may be provided by or through alternate sources other than the OEM vehicle dealerships. OPT OEM or ALT OEM parts may reflect some specific, special, or unique pricing or discount. OPT OEM or ALT OEM parts may include "Blemished" parts provided by OEM's through OEM vehicle dealerships. Asterisk (*) or pouble Asterisk (**) indicates that the parts and/or labor information provided by MOTOR may have been modified or may have come from an alternate data source. Tilde sign (N) items indicate MOTOR Not-Included Labor operations. The symbol (<>) indicates the refinish operation WILL NOT be performed as a separate procedure from the other panels in the estimate. Non-Original Equipment Manufacturer aftermarket parts are described as Non OEM or A/M. Used parts are described as LKQ, RCY, or USED. Reconditioned parts are described as Recond. Recored parts are described as Recore. NAGS Part Numbers and Benchmark Prices are provided by National Auto Glass Specifications. Labor operation times listed on the line with the NAGS information are MOTOR suggested labor operation times. NAGS labor operation times are not included. Pound sign (#) items indicate manual entries. Some 2014 vehicles contain minor changes from the previous year. For those vehicles, prior to receiving updated data from the vehicle manufacturer, labor and parts data from the previous year may be used. The CCC ONE estimator has a complete list of applicable vehicles. Parts numbers and prices should be confirmed with the local dealership. The following is a list of additional abbreviations or symbols that may be used to describe work to be done or parts to be repaired or replaced: SYMBOLS FOLLOWING PART PRICE: m=MOTOR Mechanical component. s=MOTOR Structural component. T=Miscellaneous Taxed charge category. X=Miscellaneous Non-Taxed charge category. SYMBOLS FOLLOWING LABOR: D=Diagnostic labor category. E=Electrical labor category. F=Frame tabor 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=6lend. 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. 0/H=Overhaul. Qty=Quantity. Refn=Refinish. Repl=Replace. R&I=Remove and Install. R&R=Remove and Replace. Rpr=Repair. RT=Right. SAS=Sandwiched Steel. Sect=Section. Subl=Sublet. UHS=UItra High Strength Steel. N=Note(s) associated with the estimate line. CCC ONE Estimating -A product of CCC Information Services Inc. The following is a list of abbreviations that may be used in CCC ONE Estimating that are not part of the MOTOR CRASH ESTIMATING GUIDE: BAR=6ureau of Automotive Repair. EPA=Environmental Protection Agency. NHTSA= National Highway Transportation and Safety Administration. PDR=Paintless Dent Repair. VIN=Vehicle Identification Number. 12/27/2013 3:01:04 PM 100723 Page 4 Preliminary Estimate C��swmer: LAMOUREUX, NATE 7ob Number: Vehicle: 2003 VW JETTA GLS 4D SED 4-2.OL-FI RED ALTERNATE PARTS USAGE Year: 2003 Body Sryle: 4D SED VIN: 3VWSK69M33M093073 Mileage In: htake: VW Engine: 4-2.OL-FI License: 633EZU Mileage Out: Model: ]ETTA GLS Production Date: State: Vehicle Out: Cdor: RED Int: Condition: ]ob#: Altemate Part Type Selection Method #Of Times Notified Of #Of Parts Selected Availabie Parts Aftermarket Automatically List 2 0 Opbonal OEM Automatically List 0 0 Recondiboned Automatically List 0 0 Recycled N/A 0 0 12/27/2013 3:01:04 PM 100723 Page 5 4 �� WALSER COLLISION & GLASS — Workfile ID: 6c4013fa FederalID: 75-3141113 BLOOMINGTON 9001 GRAND AVENUE S., BLOOMINGTON, MN 55420 Phone: (952) 884-8884 FAX: (952) 884-8898 Preliminary Estimate CusL�mer. LAMOUREAU, NATE Written By: Duane Houle Irrn,red: Policy#: Claim#: Type of Loss: Date of Loss: Days to Repair: 0 Point of Impact: Owner. Inspection Location: Insurance Company: LAMOUREAU, NATE WALSER COLLISION&GLASS- BLOOMINGTON 4422 NICOLLET AVE SOUTH #S 9001 GRAND AVENUE S. MPLS, MN 55419 BLOOMINGTON, MN 55420 (612) 267-7183 Day Repair Facility (952)884-8884 Business VEHICLE Year: 2003 Body Style: 4D SED VIN: 3VWSK69M33M093073 Mileage In: Make: VW Engine: 4-2.OL-FI License: 633-EZY Mileage Out: Model: JETTA GLS Production Date: 10/2002 State: MN Vehicle Out: Color: RED Int: BLACK Condition: Job#: TRANSMISSION Body Side Moldings AM Radio Head/Curtain Air Bags Overdrive Console/Storage FM Radio ROOF 5 Speed Transmission CONVENIENCE Stereo Electric Glass Sunroof POWER Air Conditioning Search/Seek SEATS Power Steering Intermittent Wipers CD Player Cloth Seats Power Brakes Tilt Wheel Cassette Bucket Seats Power Windows Cruise Control SAFETY Reclining/Lounge Seats Power Locks Rear Defogger Drivers Side Air Bag WHEELS Power Mirrors Keyless Entry Passenger Air Bag Aluminum/Alloy Wheels Heated Mirrors Alarm Anti-Lock Brakes(4) PAINT DECOR Telescopic Wheel 4 Wheel Disc Brakes Clear Coat Paint Dual Mirrors RADIO Front Side Impact Air Bags 1/2/2014 12:50:14 PM 072704 Page 1 . �. Preliminary Estimate Customer: LAMOUREAU, NATE Vehicle: 2003 VW JETTA GLS 4D SED 4-2.OL-FI RED Line Oper Description Part Number Qty E�ctended Labor Pai�t Price� 1 QUARTER PANEL 2 Repl LT Quarterpanel iJ5809843A 1 558.00 15.5 3.2 3 Add for Clear Coat 1.3 4 R&I LT Wheelhouse liner Incl. 5 R&I LT Upper qtr trim gray Incl. 6 R&I LT Lower qtr trim black Incl. - -- --- -- - -------____�--___.._.______--__-- ---�-- ---�------- -�-------- - 7 REAR LAMPS 8 * Repl LT Tail lam as (GOUGEDI 1J59451115 1 133.00 Incl. -- ----- ------�..___-----_.___...__..�______ _.__--- ----- 9 REAR BUMPER 10 R&I R&I bumper cover Incl. ----- ---- ----- - -- . ___._..a.___� _ ._._,_ ._.____..__- ----_.__�____�.._. __._._ 11 REAR DOOR 12 Repl LT Doorshell 1]5833055F 1 739.20 3.5 3.0 13 Overlap Major Adj. Panel -�•4 14 Add for Clear Coat 0.5 15 Add for power units 0•4 16 R&I LT Door w'strip Incl. 17 R&I LT W'strip on body gray �•� 18 * R&I LT Body side mldg w/o chrome 93 insert 19 # Repl retape It r.door side mldg 1 10.00 0.3 20 Repl LT Moveable glass Volkswagen 1J5845025G 1 130.00 Incl. 21 Repl LT Fixed glass NAGS FV20616GTN 1 171.80 Incl. 22 Repl LT Window guide 1J58394310641 1 290.00 Incl. ___�_--- ____._..�._._--v_ _ -----�_-----------�__�_--- ---_�___ 23 FRONT DOOR 24 Repl LT Doorshell 1J4831055H 1 716.80 3.5 3.0 25 Overlap Major Adj. Panel -0.4 z6 Add for Clear Coat 0.5 z7 Add for mirror 0.4 zg Add for power units 0.4 29 R&I LT W'strip on body black&gray 0.4 30 * R&I LT Body side mldg w/o chrome � insert sedan 31 # Repl retape It f.door side mldg 1 10.00 0.3 32 Repl LT Mirror cover 360857537BGRU 1 61.00 Incl. 0.5 33 Overlap Minor Panel -�•Z 34 Add for Clear Coat 0.1 35 * Repl LT Mirror housing w/power 1J1857507EO1C 1 298.00 Incl. ,w/heat 36 Repl lT Door glass Volkswagen 1J4845201G 1 139.00 Incl. 37 * R&I LT Window guide � _._ __._-----._..�._..�_--�-----___.....____.__- --_--- 38 FENDER 39 Blnd LT Fender sedan 1.1 40 R&I LT Fender liner 0.3 1/2/2014 12:50:14 PM 072704 Page 2 Preliminary Estimate Customer: LAMOUREAU, NATE Vehicle: 2003 VW JETTA GLS 4D SED 4-2.OL-FI RED - - ----- - —---.__-__.__..__��._____—__ _..�_�� _�m� 41 FRONT LAMPS 42 R&I LT Headlamp assy GL&GLS from 0.4 2108642,w/o 1.8L auto trans 43 Repl Aim headlamps 1 0.5 44 R&I LT Repeater lamp 0.3 ----- _ -- -----.________.�.__.�__�_._.�_._._..�_� _�. 45 FROPfT BUMPER 46 R&I R&I bumper cover 1.0 --— _.._.....------______....__._.___.___.._..___�_�.,.____.�____ �_____�. ____�� 47 ROOF 48 R&I LT Drip rail 0.5 - - -- - -----_- -- _..._._._ ____._- --___.�_ �.-.-------_ .___.___ �______ � .____.._________�_—e 49 BAQC GIASS 50 ' R&I Back glass(ENCAPSULATED Incl. / GLASS)-SEE NOTES � / NOTE: (ENCAPSULATED BACKGLASS) : Backglass is encapsulated, may not be reuseable once removed. ✓ Approximent cost,$302.50 if needed. DUANE HOULE 51 # Repl backglass install. kit 1 20.00 _ _ _ - --- -- _ _ - -- — __ — _ ___-..____ _ _— __ ._ __ _.._ __ ---- --- ----- 52 TRUNK LID 53 * R&I R&I trunk lid(to install It atr 1.0 nl 54 # Refn GRAVEL GUARD 0.5 55 # Subl HAZARDOUS WASTE REMOVAL 1 3.00 X 56 # COVER CAR COMPLETE 1 6.00 X 0.2 57 # Repl SEAM SEALER 1 20.00 X 1.0 58 # 59 # PRICES SUBJECT TO VENDOR 1 INV. �� 60 # "POSSIBLE HIDDEN DAMAGE" 1 SUBTOTALS 3,305.80 31.4 12.7 ESTIMATE TOTALS Category Basis Rate Cost� Parts 3,276.80 Body Labor 31.4 hrs @ $54.00/hr 1,695.60 Paint Labor 12.7 hrs @ $54.00/hr 685.80 Paint Supplies 12.7 hrs @ $34.00/hr 431.80 Miscellaneous 29.00 Subtotal 6,119.00 Sales Tax $3,708.60 @ 7.2750% 269.80 Grand Total 6,388.80 CUSTOMER PAY 0.00 INSURANCE PAY 6,388.80 **NO GUARANTY ON RUST REPAIRS** PART PRICING SUBJECT TO CHANGE PER FINAL INVOICE 1/2/2014 12:50:14 PM 072704 Page 3