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Haatvedt Providing Insurance and Financia!Services StateFarm� Home Office, 8foomington, 1L . February 05, 2014 RECE�V�p City Clerk State Farm��aims FEB 10 2�14 15 West Kellogg Blvd 310 P.O.Box 2371 St. Paul MN 55102 BloomingtonlL61702-2371 CITY C�ERK Certified Mail - Return Receipt Requested RE: Claim Number. 49-26Z7-546 � Our Insured: Michael Haatvedt ! Date of Loss: December 05, 2013 � Your Insured: City Clerk ' Your Insured Driver. City Of St Paul-Public Works ; Loss Location: St Paul Avenue, St Paul, MN i I Sir/Madam : I � Facts of Loss: I Our insureds vehicle was parked and unoccupied and strudc by a city snow plow. ` Your file#C-130347 � i It is our understanding that you are seff 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 $ 042- Uninsured Motorist PD $ 300 series/400- Comp/Collision $2,643.58 501 - Rental/Loss of Use $ 600-050- Med Pay/PIP $ Other $ Salvage Recovery $ '; Amount State Farm Paid $2,643.58 Insured Deductible $500.00 Total Claim Amount $3,143.58 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 amount payable to State Farm Mutual Automobile Insurance Company for this loss is $3,143.58. 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. 49-26Z7-546 Page 2 February 05, 2014 ., 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, 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 cc: Risk Management Division 320 Centennial Office Bldg 658 Cedar St St. Paul. MN 55155 � ! RECEIVED - FEB 10 2�14 `�� " �� Z- � � �`��f' NOTICE OF CLAIM FORM to �e��i��h�nt Paul, Minnesota Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipaliry...shall cause to be presented to the governing body of the municipality within 180 days after the alleged loss or injury is discovered a notice stating the time,place,and Y circumstances thereof,and the amount of compensation or other relief demanded." Please complete this form in its entirety by clearly typing or printing your answer to each question. If more space is needed,attach additional sheets. Please note that you will not be contacted by telephone to clarify answers,so provide as much information as necessary to explain your claim,and the amount of compensation being requested. You will receive a written acknowledgement once your form is received. The process can take up to ten weeks or longer depending on the nature of your claim. This form must be signed,and both pages completed. If something does not apply,write`N/A'. SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK, 15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102 First Name 1� � �-�'► 4 �- � Middle Initial Last Name C'� ��'l,`� 1� 'L c� � Company or Business Name ��`��e-- ��VI/�.}-�<S l��S�� E..- h cti-e_- � ��tc.�c; �' tl Q�.l, r Are You an Insurance Company? es o If Yes, Claim Number? ' r � - a.(�? Z, � - �� Street Address �b p �( a 3 Z t City � ��d � �� -+-0 State �--� Zip Code � � �� ' Daytime Phone (�'?�j`��b'�`t Cell Phone( T� Evening Telephone( �— , Date of Accident/Injury or Date Discovered � � �� " � 3 Time a %�� am/� Please state, in detail, what occurred (happened), and why you are submitting a claim. Please indicate why or how you , feel the City of aint Paul or its employees are involved and/or responsible for your damages. O utl ' f <- L �t �. !-e,�' v!.�. G G � V ��,c.�12. �� l � - 1 3 0 3 '-f'7 i � i Please check the box(es)that most closely represent the reason for completing this form: � � My vehicle was damaged in an accident ❑ My vehicle was damaged during a tow � ❑ My vehicle was damaged by a pothole or condition of the street �My vehicle was damaged by a plow � ❑ My vehicle was wrongfully towed and/or ticketed ❑ I was injured on City property ❑ Other type of property damage-please specify ❑ Other type of injury-please specify In order to process your claim vou need to include copies of all 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. A�1 Claims-please comvlete this section Were there witnesses to the incident? Yes No Unknown (circle) -• Provide their names, addrresses and tIelephoneI numbers: C l�:L�l.0. �. � �t G ' � V e.( [� � ' �..D o I'C:,dL.c C� "C (-l� i C.��D,.e� �.Q S l — ` C'�U - �r�� Were the police or law enforcement called? �s No Unknown (circle) If yes, what department or agency?;��, � ��C.-�- Case#or report# 1 � � "Ql. S� � " U 7 y Where did the accident or injury take place? Provide street address,cross street, intersection, name of park or facility, clos�k ndrr�,ar�k,Je�tcJ./Plea�b��as-detailed as possible. If necessary, attach a diagram. �J � Please indicate the amount you are seekin,�in compensation or what you would like the City to do to resolve this claim to your satisfaction. 3 � � 3 � � d� Vehicle Claims-please complete this section ❑ check box if this section does not applv Your Vehicle: Year �o o 3 Make �'��l�t l ��.� Model (J e.. � t�-� License Plate Number l State Color W h��-� Registered Owner M ti ..►-L u, � � l--E��i/��. �I- Driver of Vehicle P�.ti.r lt� ; Area Damaged �r'�� n �� +� u C City Vehi e: Year Make Model License Plate Number ; State Color w a� -� �� Driver of Vehicle(City Employee's Name) �� (� Area Damaged � O ��,� IC.��v(L f' n ur Claims- lease com lete this section 0 check box if this section does not a 1 How were you iniured� _Ty 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 d�-�� Print the Name of the Person who Completed this Form: /V �T ��UQ,✓l Signature of Person Making the Claim:�� a^- �v��'�'`"' .S D Revised February 201 1 `�,�C� l�c�Q� ��'�-�C�`Q—"`'�v RBZ00070 StateFarm State Farm Mutual Automobile Insurance Company � Auto Payments by Participant/COL � � Route To: Jean Newmister '. BASIC CLAIM INFORMATION Claim Number: 49-26Z7-546 Date of Loss: 12-05-2013 Policy Number: 1111-405-496 Named Insured: HAANEDT, MICHAEL 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 105960180K E 01-04-2014 KEY COLLISION& PAINT 400 1 Paid $2,320.55 TJCY CENTER 105972863K E 01-14-2014 KEY COLLISION &PAINT 400 3 Paid $323.03 TCPJ CENTER Total: $2,643.58 ; Date: 02-05-2014 Page 1 FOR INTERNAL STATE FARM USE ONLY Contains CONFIDENTIAL information which may not be disclosed without express written authorization. STATE FARM INSURANCE COMPANIES ' 500 SOUTH 84TH STREET LINCOLN, NE 68510-2611 . SUPPLEMENT FAX:(MN,WI)800-230-1949 SUPPLEMENT FAX: (IA,NE,ND,SD)800-455-9697 ***SUPPLEMENT 2"*" 12/30/2013 S2 01/14/201410:36AM Owner � Owner: MICHAEL HAATVEDT Address: 2046 COUNTY ROAD C B Work/Day: (651)698-6111 Home/Day: (651)900-9236 City State Zip: SOMERSET,WI 54025-7506 Cell: (651)210-2112 Control Information Claim#: 49-26Z7-54601 Insured Policy#: Loss Date/Time: 12/05/2013 06:00 AM Loss Type: Collision Deductible: $500.00 Insured: MICHAEL HAATVEDT Address: Work/Day: (651)698-6111 Home/Day: (651)900-9236 City State Zip: CeIL• (651)210-2112 Claim Rep: TEAM R3 ACC CP Address: i Work/Day: (866)207-6046 --T � Inspection ; Inspection Date: 12/30/2013 07:33 AM Inspection Type: Field Inspection Location: KEY COLLISION 8�PAINT Contact: CENTER Address: 480 AMERICAN BLVD W City State Zip: BLOOMINGTON, MN 55420-1124 Primary Impact: Rear Secondary Impact: Driveable: Yes Rental Assisted: Assigned Date/Time: Received Date/Time: 12/27/2013 05:52 PM First Contact Date/Time: Appointment Date/Time: 12/30/2013 08:00 AM Appraiser Name: JOE POA9 Appraiser License#: Orig Appraiser Name: MARK W FELDKAMP Appraiser License#: Address: 1285 NORTHLAND DRIVE Work/Day: City State Zip: Mendota Heights, MN 55120 FAX: Repairer Repairer: KEY COLLISION&PAINT Contact: CENTER Address: 480 AMERICAN BLVD W Work/Day: (952)884-6272 City State Zip: BLOOMINGTON, MN 55420 FAX: (952)703-0940 License#: 009 Regulation ID: 411112517 01/142014 10:37 AM Page 1 of 5 2003 Cadillac De vlle DHS 4 DR Sedan 12/30/2013 Claim#: 49-26Z7-54601 01/14/2014 10:36 AM x Remarks SHOP TO DO DIAGNOSTICS ON STABILITY CONROL SYSTEM **•SHOP TO CONTACT STATE FARM IF ANY ADDITIONAL DAMAGE IS FOUND '�"SUPPLEMENT CHARGES MUST BE APPROVED PRIOR TO REPAIRS **"*FOR SUPPLEMENTS FAX#800-230-1949 WITH CLAIM NUMBER**'`" S-1 BY MARK F.AT KEY COLLISION BLOOMINGTON *****MORE DAMAGE POSSIBLE AFTER TORN DOWN FOR REPAIRS.""""' Vehicle � } 2003 Cadillac De Ville DHS 4 DR Sedan 8cyl 4.6 Northstar 4 Speed Automatic Lic.Plate: 138SW Lic State: WI Lic Expire: 05/2014 VIN: 1G6KE57Y03U281249 Prod Date: 06/2003 Mileage: 145,516 Veh Insp#: Mileage Type: Actual Condition: Code: T53436 Ext. Color: WHITE int.Color: E�ct. Refinish: Thre�Stage UserDefined Int. Refinish: Two-Stage Options Alarm System Analog Gauges Anti-Lock Brakes Auto Load Leveling Automatic Dimming Mirror Bose Sound System Chromed Alloy Wheels Climate Control For A/C Compact Disc W/Tape Cruise Control Digital Signal Processor Driver Information Sys Dual Air Conditioning Dual Airbags Dual Power Seats Heated Frnt&Rear Seats Heated Power Mirrors Intermittent Wipers Keyless Entry System Leather Seats Leather/Wood Steer Wheel Lighted Entry System OnStar System Overhead Console Power Brakes Power poor Locks Power Rear Sunshade Power Steering Power Windows Rain-Sensing W/S Wipers Rear Window Defroster Rem Trunk-UGate Release Side Airbags Side Mirror Lighting Strg Wheel Radio Control Tachometer Telescopic Steering Whl Tilt Steering Wheel Tinted Glass Traction Control System Trip Computer Wood Interior Trim Damages _ Line Op Guide MC Description MFR.Part No. Price ADJ% B% Hours R Front Doors 1 E 229 01 Mirror,0uter R/C LT 10381043 GM Part $593.63* S2 0.7 SM 2 L 229 14 Mirror,0uter R/C LT Refinish 2.0 RF 0.7 Surface 1.0 Three-stage setup 0.3 Three-stage Deck Lid And Back Glass 3 EU 479 Deck Lid Assembly RECYCLED PART $225.00" +30.00 0.9 SM »**AAA AUTO 651-423-2432/MURPHY REF#1974154 4 L 479 Lid,Rear Deck Refinish 4.9 RF 2.7 Surface 1.0 Edge 1.0 Three-stage 0.2 Two-stage 01/14/2014 1037 AM Page 2 of 5 2003 Cadillac De Vlle DHS 4 DR Sedan 12/30/2013 Claim#: 49-26Z7-54601 01/14/2014 10:36 AM 5 RI 175 Pnl,Lid Inner Trim R& I Assembly 0.2 SM 6 � 532 N/Plate,Deck Lid 25661451 GM Part $16.23 0.2 SM 7 E 539 N/Plate,Deck Lid 3538464 GM Part $46.33 0.2 SM ; 8 E 515 Emblem,Deck Lid 25722725 GM Part $35.57 0.2 SM 9 E 517 Emblem,Deck Lid 25722726 GM Part $46.75 S1 0.2 SM Rear Bum�er 10 N 31 RR Bumper Cvr Overhaul ADDITIONAL OPERATION 2.1 SM 11 I 566 Cover,Rear Bumper Repair S1 4.0* SM »RR BUMPER COVER AND SUPPORT BRACE 12 L 566 10 Cover,Rear Bumper Refinish 3.3* RF 2.8 Surface 0.5 Three-stage »"*"PARTIAL PAINT&FULL CLEAR 13 E 567 Abs,Rear Energy 25659777 GM Part $186.88 S1 INC SM 14 RI 404 Sensor,RR Bumper LT R& I Assembly INC SM 15 E 408 Sensor,RR Bumper RT 89046909 GM Part $343.03 S1 INC SM 16 RI 408 Sensor,RR Bumper RT R 8� I Assembly INC SM 17 RI 409 Sensor,RR Bumper LT R& I Assembly INC SM 18 RI 410 Sensor,RR Bumper RT R& I Assembly INC SM Rear Body. Lamus And Floor Pan 19 RI 533 Taillamp Assembly LT R& I Assembly 0.3 SM 20 RI 534 Taillamp Assembly RT R 8� I Assembly 0.3 SM 21 RI 543 Lamp,High Mounted Stop R& I Assembly 0.3 SM Manual Entries 22 E 12482327 NEW PART $19.19" S1 SM" »LR SENSOR HOUSING 23 E Flex Additive NEW PART $4.00* SM 24 SB HAZARDOUS WASTE DISPOSAL Sublet Repair $3.00" SM 24 Items MC Message 01 CALL DEALER FOR EXACT PART#/PRICE 10 INCLUDES AUDATEX TIME TO CLEAR ENTIRE PANEL 14 INCLUDES 1.0 HOURS FIRST PANEL THREE-STAGE ALLOWANCE Estimate Total &Entries � Gross Parts $1,291.61 Other Parts $225.00 Paint Materials $346.80 Line Item Markup $67.50 Parts&Material Total $1,930.91 Tax on Parts&Material @ 7.27 /o $140.47 Labor Rate Replace Repair Hrs Total Hrs H rs Sheet Metal(SM) $54.00 3.5 6.1 9.6 $518.40 Mech/Elec(ME) $75.00 Frame(FR) $77.00 Refinish(RF) $54.00 10.2 10.2 $550.80 Paint Materials $34.00 Labor Total 19.8 Hours $1,069.20 Sublet Repairs $3.00 Gross Total $3,143.58 Less: Deductible $500.00- Net Total $2,643.58 01/142014 10:37 AM Page 3 of 5 2003 Cadillac De Ville DHS 4 DR Sedan 12/30/2013 Claim#: 49-26Z7-54601 01/14/2014 1036 AM Actual Supplement Total $323.03 Less: Ri�evious Net Total $2,320.55- Net Supplement Total $323.03 . ❑. ,i + ❑■ t i For more information regarding State Farm's promise of satisfaction relating to new non-original : equipment manufacturer(non-OEM)and recycled parts, please visit: htto://st8.fm/7X4 or QR code. � � .,r. ❑� . _ . Register online to check the status of your claim and stay connected with State FarmO.To register,go to statefarm.com and select Check the Status of a Claim. If you are already registered,thank you! Not available in New Mexico. Alternate Parts Y/00/00/00/00/00 CUM 00/00/00/00/00 Zip Code: 55407 Default Recycled Parts NOT REQUESTED Audatex Estimating 7.0.123 S2 01/14/2014 10:37 AM REL 7.0.123 DT 12/01/2013 Copyright(C)2013 Audatex North America,Inc. 0.2 HRS WERE ADDED TO THIS ESTIMATE BASED ON AUDATEX'S TWO-STAGE REFINISH FORMULA. 2.8 HRS WERE ADDED TO THIS ESTIMATE BASED ON AUDATEX'S THREE-STAGE REFINISH FORMULA. THIS IS AN ESTIMATE. REPAIR FACILITES MUST INSPECT THE VEHICLE TO DETERMINE IF ANY REPAIRS NOT LISTED ARE REQUIRED,AND TO CONTACT STATE FARM BEFORE MAKING SUCH REPAIRS. REPAIRER ALSO IS RESPONSIBLE FOR CONDUCTING ANY NECESSARY INSPECTION AND SAFETY CHECKS PRIOR TO AND AFTER COMPLETING REPAIRS. THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF ONE OR MORE CRASH PARTS SUPPLIED BY A SOURCE OTHER THAN THE MANUFACTURER OF YOUR MOTOR VEHICLE. WARRANTIES APPLICABLE TO THESE REPLACEMENT PARTS ARE PROVIDED BY THE PARTS MANUFACTURER OR DISTRIBUTOR RATHER THAN BY THE MANUFACTURER OF YOUR VEHICLE. A PERSON WHO FILES A CLAIM WITH INTENT TO DEFRAUD OR HELPS COMMIT A FRAUD AGAINST AN INSURER IS GUILTY OF A CRIME. Op Codes ` = User-Entered Value E = NEW PART NG= Replace NAGS EC= "NON-OEM PART ET = Partial Replace Labor EP= "*NON-OEM PART EU= RECYCLED PART TE = Partial Replace Price PM= REMAN/REBUILT PART UM= REMAN/REBUILT PART L = Refinish PC= RECOND PART UC= RECOND PART TT = Two-Tone SB= Sublet Repair N = ADDITIONAL OPERATION BR= Blend Refinish I = Repair IT = Partial Repair CG= Chipguard RI = R 8 I Assembly P = Check RP= RP-RELATED PRIOR Ot/142014 1037 AM Page 4 of 5 2003 Cadillac De Ylle DHS 4 DR Sedan 12/30/2013 Claim#: 49-26Z7-54601 Ot/14/201410:36 AM This report contains proprietary information of Audatex and may not be disclosed to any third party(other than r A� the insured, claimant and others on a need to know basis in order to effectuate the claims process)without udatex Audatex's prior written consent. � a 5alera compan� Copyright(C)2073 Audatex North America, Inc. Audatex Estimating is a trademark of Audatex North America, Inc. ,I Ot/142014 10:37 AM Page 5 of 5 ***SUPPLEMENT RECONCILIATION"* Supplement S2 Claim#: 49-26Z7-54601 Insured Policy#: � File#: Claim Rep: TEAM R3 ACC CP Insured: MICHAEL HAATVEDT Inspection Date/Time: 12/30/2013 07:33 AM Owner Name: MICHAEL HAANEDT Appraiser Name: JOE POA9 Vehicle: 2003 Cadillac De�Ile DHS 4 DR Sedan Deleted Lines � Line Guide Part Operation Price ADJ°/a B% Labor Rate 1 229 Mirror,0uter R/C LT RECYCLED PART $225.00' +30.00 0.7 SM Added Lines Line Guide Part Operation Price ADJ% B% Labor Rate 2 229 Mirror,0uter R/C LT NEW PART S2 $593.63' 0.7 SM Calculation Changes From To Difference Gross Parts $697.98 $1,291.61 $593.63+ Other Parts $450.00 $225.00 $225.00- Line Item Markup $135.00 $67.50 $67.50- Tax on Parts&Material 7.275% $118.57 7.275% $140.47 $21.90+ Actual Supplement 2 Net Total $323.03+ umma � Net Total Date Time Appraiser Supplement 1 $2,320.55 01/03/2014 08:14 AM MARK W FELDKAMP Supplement 2 $2,643.58 01/14/2014 10:36 AM JOE POA9 This report contains proprietary information of Audatex and may not be disclosed to any third party(other than the insured,claimant and others on a need to know basis in order to effectuate the claims process)without Audatex's �/l��V Prior written consent. {„�f /1 d 50lerd Cpnpdhk Copyright(C)2013 Audatex North America,Inc. Audatex Estimating is a trademark of Audatex North America,Inc. 01/14/2014 10:37 AM Page 1 of 1 From: "19527030940"@FAX.kcs.statefarm.com ' Sent: Monday, ]anuary 13, 2414 9:32 AM To: HTLD CLMS-SUPP-TCOC subject: 4926z7546 ; � Ap r, 10� 2012 5;41 PM - . . � No. 5170 P. i/1 � � �ENDTOa � �STIMATIC9 UNiT- ,�'�n G��QQ"�°y01"Con�or•��An�Supplvm�nt Un�s Fax Phana: t�57}�6f�S7D M�tro.ar(BOO�Z�•194Y Tou I�ro. - � -- - � �tJPPi.EMENT REQU,E9T pftbe phone: . �sa��.as�•ozaa RE�iLI�BTf i� SHGP iN�ORMATECN Y�HICf.E MFQAMATION � shop Name: a !� oh/ .Cielm IVum�er. �,� ~ °�,�� i—�y�°0� -- .. 5hop Addr�salLocatlon: ��D »�er��F!+ I}'�` (Jq p IJ� L_ n� Dwner Name:, cn �� (T d;�f!�e�l/ --- f vr�. tJ �Loa m�++t�� n+'�✓ f . , �� y ,� Vehbl� sv: �°� MB�+9: C/�9i� �Mvdei: evt Phane�: ��-��'��7�.. 7re µ ��- �� hl��- Ft�l��°� Fax#; � b OrI nal Eat�matnr: Contact Pareon: � Date af Or��lnel E�timate: J-3'"� � . [a vehlcl�roady for�lnspeCtfort7 ❑Yes ❑ No . supg�eM�Nr�H�a��nrror� REPAIR REPLACE DE6q31P'nON 1'�C� FA�ORHlIB 11EftlRB PA1HT4 NIATL . • REPAIR fIEPl.ACE �D� - IquCE R � � AEPMpS �i T� commems/Approva�:�� r,� �r Y.rd r �� <,�� G� � � Q��- - '�C , NOTtC�:PfiIVAT�aND CON�IDEMfU1L,. Trre Enformatlan c.ontalnad In thlB f aaslmlla�T19889na co11W11�p�iv�pnd oolfiltlentla)mater 1�1 Intsnded fot tha eole uea b y tho St�la " Fazm{nsuranoa Companlo�. !!you arn n4i tho inlended r�eolplaM Aatad abova yvu ero hvr�by rwt[t�ed that any dlaalo4uie,dupl�etlori, � ar distr�bu�lon of this mfamatlon or the 1�lclnp oi any�In rallenoa�tho oonlerrt�oi.thta uan�bn,w�hout 1he expreas wr{tien consane of�he 5tate F arm insurance Companiea,la 9TRICTLY PROHE�I'f�b. li yau have reaeived thle tratl�mis9lan In erior,plssse notlfy us immedlate}y by tele�hone so that we can ar[d[1gs tor the roturn ot thb materla��t no cdst to you. 104842.1 Rev.iR•13�2oD9 • � � �� «<6 ��N �,dc� �o� ti�oz �� p� K�1(COlLISIQN AND PAIPIT CEi�TER Warkflle ID: 49304649 Federdl ID: 41-1112517 � 480 AMERICAN BLVD WEST,BLOOMINGTON, MN , >� � : 55420 M. . . " �, :,�ti. � Ph�ne: (952)884-6272 FAK: (952) 703-b940 Prellminary�Stimate Customer; HAATYEDT, MICWAEL ]ob Number: Written By:SHdP�STTMATOR Insured; ttAATV�DT,MICHAEL Policy#: Clalm#: 49-2dz7-54eoi Type of I�ss: babe of Loss: Days to Repalr: 0 Point of Impact: Owner: Inapqction Locatlan: Insurance Company; ruwN�OT,M[CHa�t KeY CO�us�ON arop PA[NT CEM'ER STATE FARM[N5uwwcE COMPaN[FS 1578 MINN�HAHA AVE 484 AMERICAN eLVD W�ST 57 PAUL,MN 55l06 BLOOMINGTON,MN 5542Q (651)940-9236 Day RepBir FaCiflty (952)684-6272 Business VEHIGLE Year; 2003 Body 5tyle: aD SCD ViN� 1G6KE57YU3uz&1249 Mlleage In: Make; CADI Engine: 8-4.6L-F! license: 138SW Mileage Out: MOd@I: �EV[LLE pNS PrOduCtl4p D8C8: Si2iC: MN VQtIIdC OUt� ColUr: WH[TE Int: Condition: bb#: TRAN3MLSSION Dua!Mirrors RAOIO Communicakions Sys[em Automatic Transmissian Rear Power S�I�ShaQe AM Radlo SEATS Overdrive CONVENIENCE Frt Radio Leatf�er Seats POWER wr Condltlor�ng 5[ereo Heabed 5eats POYVEr S6eerinp Intermittent Wlpers Se�thJseek Rear Heebed Seats Powcr Brakes T11t Vuheel W Player WHEELS Pow�4Vndows Crulse Control ca�ett� Cnrome wheels Power�ocks Rear Defogger Premium Radlo PAINT Power Mlrrors KeViess Entry SAFETY Three Skage Paint Heabed Mlrrors Alarm Drlvers 51de Air Bag d77iER PDwer Driver Seat Message Center Passenger Air Bag TracGon Contrnl Power Passenger Sea# S�emg lryhael Toudi Cantrol5 AnthLAtk Brakes(4) Power Trunk/Gate R�ease Memory Package TeleSCOpic Whecl 4 Wheel disc Brakes DECOR qirnate Cantral Frq�t 5fde Imp2C[Air eags 1/13/2014 10:25;35 AM 008850 Page 1 z �� c�6 ��N U�ds� �o� ti�oz �� u�� Preliminary Estimate = Gt�sMmer: NAANEDT,MIC�IAEL Job Numper: Vehkle:2�03 CAp[DEViLLE DHS 4D Sm 6•4.6L-FI WHITE Line oper desfxxiption Part Num6er Qty b�ndad �abor tsain# Pr1ce$ 1 # Repl ucQ MIRRoR(AAA)vn original 1 -292.54 NOTE:jaCk SCrEws busted In beck mirrpr no good 2 # ReAf cem mirrpr#103$1053 1 593.63 SUBTOTAIS 301.13 O.0 0.0 E57IMATE TOTA1,5 �g°� �a&g Rate Cost$ PartS 301.13 SUbtotal 301.13 Seles Taoc $301.13 � 7.2750% 21,91 GYand Tdtal 323.04 Deductible 4,00 CUSTOMER PAY �.� INSURAN(�PAY ��.� THIS ESTTMATE IS SASED ON A VISUAL INSPECTION AND DOES NOT INC�UDE ADDIIIONP,L PARTS OR LABOR THAT MAY BE REQUIRED TO COMPLE�E REPAIRS. PART PRIC�S ARE CIJRRENT ANb SUB7ECT TO INVOICE. MN ST 60A,955 -q PERSON WHO FIL�S A CLAIM W�'T'H INTENT TO DEFRqUD OR HELp5 COMMIT A FRAUD AGAINST AN INSURER IS GUILIY Q�A CRIME. i/13/2014 10:25:35 AM 008850 paye 2 � �� t�6 ��N U,d�� o� ti�oz �� p� Preliminary E9timate * Cusbamer: HAANFDT,MICHAEL aob Number: Vehicle:2D03 UIDI DEViI.I.E DHS 4D 5Eb B•4.6L-FI WHIfE Estimate based on MOTOR CRASH ESTIMATING GUID�. Unless otherwise noted all items are derived from the Guide QE1BA00, CCC Data p�te 1/10/2014, and the parts selected are OEM-parts manufactur�d by the vehicles prfginal �qu'spment Manufacturer, OEM parts are available dt OE/Vehiele dealerships_ OPT O�M (dpti�nal OEM)or ALT OEM (Alternative OEM)parts are OEM parts that may be pravided by or through alternate sources other than the OEM voehicle dealerships. OPT O�M or ALT OEM parts may reflec.t some spec�fic, special, or unique pricing or discount. OPT OEM or ALT OEM parts may inClude "Blemished" parts prov�ded �y dEM's through OEM vehicte dealershlps. Asterlsk(*)or pouble Astarlsk(**) indicates that the parts and/or labor Inforrnation provided by MOTOR may have been modifiecl or may have come from an alternate daka source. Tilde sign (�) it�ms Indicate MOTOR Not-Included Labor operations. The syrnbol (�>) indicates the refinish operation WILL NOT be performed a5 3 S�parate procedure from the OCher panels In the estlmabe. Non-Original Equipment M�nufacturer afterm�rket parts are described as Non oEM or A/M, Used parls are described as LKQ, RCY, ar USED. Reeonditidned paits are described as Recond. Repored parts are described �5 Recore. NAGS Part Numbers and Benchmark Prices are provlded by Nataanal Auto G1ass Spe�ificatlans. Labar operation times Ilsted on the line with the NAGS information are MOTOR suggested fabor nperadon times. NAGS labor operation tRnes are not included. Pound sign(#) iGems indlcate manua!entries. Sorne 2014 veniCles contaln minor changes from the previous year. For thase vehlcles, prior bo receiving updoted data from the vehicle manufacturer, labar and pa�ts dat�from the preevious year may be used. The CCC OfdE estlmator has a complete list of applicabl�vehlcles. Parts numbers and pr+tes should be cor�firmed with the loeal dealership. The following is a list of addidonal abbreviat�ons or symbols that may be used to describe work ta be done or parts to be repaired or replaced: SYM80LS FDI.LOWYNG PART PRICE: m=MOTOR Me�haniGal component. s=MOTOR StruCtural �amponent. T=Miscellaneous Taxed charge category. X=Mlscellaneoas Mon-Taxed�harge categary. SYMBOIS FOLLOWI�lG LAB�R: p=piagnostic labor category. E=Electri�l labor category. F=Frame labar category. G=Glass labor category. M=Mechanical labor category. S=Structural labar category. (numbers) 1 tfirough 4=User Deflned Labor Categwi85. OTHER SYMBOLS AND ABBREVIATIONS: Adj.=Adjacent, Algn,=Align. ALU=Aluminum, A/M=Aftermaricet part. BInd=Blend, BOR=Boron steel. CAPA-Certified Aui�pmative Parts Assoc+ation. D&R=Disconnect and Reconnect. H55^High Strength 5teel. 1-IYD=Hydrofarmed Steel. InC1.=Induded. I.KQ^Llke Ktnd and Quality. L7=Left, MAG=Magnesiurri. Non-Adj.=NOn Adjacent, NSF=NSF International Cerrtified Part. O/H=Overhaul. Qty=Quantity. Refn=Refinish. Repl=Replaoe, R&I=Remove and Install. R&R=Remove and Replace. Rpr=Repalr. RT�Right. SAS=Sandwlched Steel. Sect=Section. Subl�Sublet. UH5=UIkra Hfgh Strength Steel. N=Note(s)associated with the estlmabe line. CCC ONE EstimaGng�A product of CCC Informatlon Services Inc, The following is a list of abhreviations ifiat may be used in CCC OtdE Estlmating that are nat par�of the MOTOR CRASH ESTIMATING GUIDE: BAR=Bur�au of Automative Repair. EPA=Environmental ProteCtipn Agency. NHTSA= Nationdl Highway Transportation �nd Safety Administration, PDR—Palntless Dent Repair. VIN=Vehlcle Identificatian Number. i/13/2014 10:25:35 AM 008850 Page 3 � � �t�6 �N U�d�� 'OG ti��l �� 'u7� .... . ... . ..... .. . .::: .... . .. .......:.. ... .: ::� �„ �,,, .„• � F��:, ...... _ _ I. �r _ � 4uote: 268?5 �,,a��,�, ;, Salesman: 000050 ' .: . • :' Printed: 01/7.3 f 20�4 �82'S y'�,.t�'��1��tt� � Ed3�yR'Il� '�&�� :' Page: 1 10:28 ,. � - - ��..�. .',:�1�85 �9�2� 9�� Q� ....`, Account: PCPR ......................... . .. :. ...:........ ........... ..... . ..... .............. �N1T�CHAEL HPATV�DT x5�s r�z�H�� av SAINT AAUL MN 55106 Phone: 551-9�0-9236/651-698�6111 Qty Part N'umber Locatian On Fiand List Price Sale Price Ta�.al --- ------------------ -------- ------- ---------- - 1 103$1053 Sd 0 593 .63 593 .6� 593.�3 MTR-OS/RV 10 . 185 Any warsaatica on the producta aold hereby aze tho9e made by 1�he �oanuPacturer. 7he aeller ne=eby exDresaxy diaexalma a11 warrantiea, either e�cpreas or impliep, including s.ny t,�rr8nty of inerchant�ility or Eitnesa Ear a particular purpoae, and neither aaewnee nor QuChorisea eny other pereon to assume for it any lienility in;connectfon wieh Cke 96id 9&1G o£ e�i.d prodxcta. nT"T. HETORNS NUSS BY M(�8 WITH2D1 10 DAY3 ANL7 9USJECT TO 35� HAtlIDLING [tiARGE. NO RSPUNDS OA SS,ECTRICAL PARTS DE �PEC2AL ORDER PA&T8� ALL RETORNE� PAATS MUST HE IN ORI6INAL S�aRLE PAGKAt7INd, This is a quote. QuoteB priC�� ubjeet to change. ToCal Parts: 593 .63 Tax: 43 .18 Quote Total: 636.81 S �� LLl6 '�N U�dBI �Ol ti101 ��l �upr OFFICE OE HUMAN RESOURCBS Angela S Naleary,Drrecror ' RISK MANAGEMENT , CITY OF SAINT PAUL zoo c,�H�rr�,�z Telephone: 65L-2b6-63(J010 Ci+rutopher B,Coleman,Mayor 25 WestFourth Street Facsimrle: 651-166-8886 Saint Pae�!MN SS101-1631 Wr December 31, 2013 S#ate Farm Insurance Company Attn: Claim Representative PO Box 52273 Phoenix, AZ 85072-2273 RE: Our File Number: C-13034T � Your File Number: 49-26z7-546 Your Client: Michael Haatvedt Dear Claim Representative: i received your claim frled with the City of Saint Paul on behalf o#Mr. Haatvedt and have begun � my investigation. Please provide your detailed subrogation documents to my office and refer to the above file number in any corresponde�ce with me. I will notify you of my decision on your claim when I have completed my investigation. Sincerely, . � �G'!'�'J Sandra Boder�steiner Claims Manager SB AA-ADA-EEO Emptoyer � � �i �, `� p 1 � i �, ��:—°- ;-�a � � � ,� � �;-" � �� . �'� �,: ; ,I�i� ,`� ��1�I �� ,��V� I i „�,.�, : 'k' ',,�';; �.�' �' - � '+� .- �� - �, �` ,�� ' �, � . ��.° . n� r �3iR�� , < µ � . � "�` j..� � ' . k" � �" �. ,. �' • , � _as'` � _ �<°'y �� V �: #�;� ; � � � �� . �- � _ �.. � � ��4��£� � � �� ; , �,�._�; £ �� , � , °ti� ,�. �� .� � F 3, � � ��'�� ` � � t � � �w�; � l� � � �' �, � �, Y�� # r =. ,�. � '� t � �,;} � � ��,x � . '� � � �, � � ,.a STATE FARM INSURANCE COMPANIES � 500 SOUTH 84TH STREET LINCOLN, NE 68510-2611 . SUPPLEMENT FAX: (MN,WI)800-230-1949 SUPPLEMENT FAX: (IA,NE,ND,SD)800-455-9697 *'"'SUPPLEMENT 7 **" 12/30/2013 S 1 01/03/2014 08:14 AM Owner � Owner: MICHAEL HAATVEDT Address: 2046 COUNTY ROAD C B Work/Day: (651)698-6111 Home/Day: (651)900-9236 City State Zip: SOMERSET,WI 54025-7506 Cell: (651)210-2112 Control Information � Claim#: 49-26Z7-54601 Insured Policy#: Loss Date/Time: 12/05/2013 06:00 AM Loss Type: Collision Deductible: $500.00 Insured: MICHAEL HAATVEDT Address: Work/Day: (651)698-6111 Home/Day: (651)900-9236 City State Zip: Cell: (651)210-2112 Claim Rep: TEAM R3 ACC CP Address: Work/Day: (866)207-6046 Inspection � Inspection Date: 12/30/2013 07:33 AM Inspection Type: Field Inspection Location: KEY COLLISION&PAINT Contact: CENTER Address: 480 AMERICAN BLVD W City State Zip: BLOOMINGTON, MN 55420-1124 Primary impact: Rear Secondary Impact: Driveable: Yes Rental Assisted: Assigned Date/Time: Received Date/Time: 12/27/2013 05:52 PM First Contact Date/Time: Appointment Date/Time: 12/30/2013 08:00 AM Appraiser Name: MARK W FELDKAMP Appraiser License#: Address: 1285 NORTHLAND DRIVE Work/Day: City State Zip: Mendota Heights, MN 55120 F�� Orig Appraiser Name: MARK W FELDKAMP Appraiser License#: Address: 1285 NORTHLAND DRIVE Work/Day: City State Zip: Mendota Heights, MN 55120 FAX: Repairer Repairer: KEY COLLISION&PAINT Contact: CENTER Address: 480 AMERICAN BLVD W Work/Day: (952)884-6272 City State Zip: BLOOMINGTON, MN 55420 FAX: (952)703-0940 License#: 009 Regulation ID: 411112517 01N32014 09:03 AM Page 1 of 5 2003 Cadillac De Ville DHS 4 DR Sedan 12/30/2013 Claim#: 49-26Z7-54601 01/03/2014 08:14 AM Remarks v � SHOP TO DO DIAGNOSTICS ON STABILITY CONROL SYSTEM *"""SHOP TO CONTACT STATE FARM IF ANY ADDITIONAL DAMAGE IS FOUND *"*"SUPPLEMENT CHARGES MUST BE APPROVED PRIOR TO REPAIRS ****FOR SUPPLEMENTS FAX#800-230-1949 WITH CLAIM NUMBER***" S-1 BY MARK F.AT KEY COLLISION BLOOMINGTON *"***MORE DAMAGE POSSIBLE AFTER TORN DOWN FOR REPAIRS.'**** Vehicle i 2003 Cadillac De Ville DHS 4 DR Sedan 8cyl 4.6 Northstar 4 Speed Automatic Lic.Plate: 138SW Lic State: WI Lic Expire: 05/2014 VIN: 1 G6KE57Y03U281249 Prod Date: 06/2003 Mileage: 145,516 Veh Insp#: Mileage Type: Actual Condition: Code: T5343B Ext. Color: WHITE Int.Color: Ext. Refinish: Three-Stage UserDefined Int. Refinish: Two-Stage Options Alarm System Analog Gauges Anti-Lock Brakes Auto Load Leveling Automatic Dimming Mirror Bose Sound System Chromed Alloy Wheels Climate Control For A/C Compact Disc W/Tape Cruise Control Digital Signal Processor Driver Information Sys Dual Air Conditioning Dual Airbags Dual Power Seats Heated Frnt&Rear Seats Heated Power Mirrors Intermittent Wipers Keyless Entry System Leather Seats Leather/Wood Steer Wheel Lighted Entry System OnStar System Overhead Console Power Brakes Power poor Locks Power Rear Sunshade Power Steering Power Windows Rain-Sensing W/S Wipers Rear Window Defroster Rem Trunk-L/Gate Release Side Airbags Side Mirror Lighting Strg Wheel Radio Control Tachometer Telescopic Steering Whl Tilt Steering Wheel Tinted Glass Traction Control System Trip Computer Wood Interior Trim E Damages j Line Op Guide MC Description MFR.Part No. Price ADJ% B% Hours R Front Doors 1 EU 229 Mirror,0uter R/C LT RECYCLED PART $225.00" +30.00 0.7 SM »"*AAA AUTO 651-423-2432/MURPHY REF#1974154 LF LAMP WITH SIGNAL 2 L 229 14 Mirror,0uter R/C LT Refinish 2.0 RF 0.7 Surface 1.0 Three-stage setup 0.3 Three-stage Deck Lid And Back Glass 3 EU 479 Deck Lid Assembly RE CLED PART $225.00'` +30.00 0.9 SM »"*AAA AUTO 651-423-2432/MURPH�REF#1974154 4 L 479 Lid,Rear Deck Refinish 4.9 RF 2.7 Surface 01/03/2014 09:03 AM Page 2 of 5 2003 Cadillac De Ville DHS 4 DR Sedan 12/30/2013 Claim#: 49-26Z7-54601 01/03/2014 OS:t4 AM 1.0 Edge • 1.0 Three-stage 0.2 Two-stage . 5 RI 175 Pnl,Lid Inner Trim R& I Assembly 0.2 SM 6 E 532 N/Plate,Deck Lid 25661451 GM Part $16.23 0.2 SM 7 E 539 N/Plate,Deck Lid 3538464 GM Part $46.33 0.2 SM 8 E 515 Emblem,Deck Lid 25722725 GM Part $35.57 0.2 SM 9 E 517 Emblem,Deck Lid 25722726 GM Part $46.75 S1 0.2 SM Rear Bumuer 10 N 31 RR Bumper Cvr Overhaul ADDITIONAL OPERATION 2.1 SM 11 I 566 Cover,Rear Bumper Repair S1 4.0" SM » RR BUMPER COVER AND SUPPORT BRACE 12 L 566 10 Cover,Rear Bumper Refinish 3.3" RF 2.8 Surface 0.5 Three-stage »"**'`PARTIAL PAINT&FULL CLEAR 13 E 567 Abs,Rear Energy 25659777 GM Part $186.88 S1 INC SM 14 RI 404 Sensor,RR Bumper LT R&I Assembly INC SM 15 E 408 Sensor,RR Bumper RT 89046909 GM Part $343.03 S1 INC SM 16 RI 408 Sensor,RR Bumper RT R& I Assembly INC SM 17 RI 409 Sensor,RR Bumper LT R& I Assembly INC SM 18 RI 410 Sensor,RR Bumper RT R& I Assembly INC SM Rear Bodv. Lamps And Floor Pan 19 RI 533 Taillamp Assembly LT R& I Assembly 0.3 SM 20 RI 534 Taillamp Assembly RT R& I Assembly 0.3 SM 21 RI 543 Lamp,High Mounted Stop R&I Assembly 0.3 SM Manual Entries 22 E Flex Additive NEW PART $4.00* SM 23 SB HAZARDOUS WASTE DISPOSAL Sublet Repair $3.00* SM 24 E 12482327 NEW PART $19.19" S1 SM" » LR SENSOR HOUSING 24 Items MC Message 10 INCLUDES AUDATEX TIME TO CLEAR ENTIRE PANEL 14 INCLUDES 1.0 HOURS FIRST PANEL THREE-STAGE ALLOWANCE Estimate Total&Entries Gross Parts $697.98 Other Parts $450.00 Paint Materials $346.80 Line Item Markup $135.00 Parts 8�Material Total $1,629.78 Tax on Parts 8�Material @ 7.275% $118.57 Labor Rate Replace Repair Hrs Total Hrs H rs Sheet Metal(SM) $54.00 3.5 6.1 9.6 $518.40 Mech/Elec(ME) $75.00 Frame(FR) $77.00 Refinish(RF) $54.00 10.2 10.2 $550.80 Paint Materials $34.00 Labor Total 19.8 Hours $1,069.20 Sublet Repairs $3.00 Gross Total $2,820.55 01/03/2014 09:03 AM Page 3 of 5 2003 Cadillac De Ville DHS 4 DR Sedan 12/30/2013 Claim#: 49-26Z7-54601 01/03/2014 08:14 AM Less: Deductible $500.00- Net Totaa $2,320.55 Actual Supplement Total $812.00 �ess: Previous Net Total $1,508.55- Net Supplement Total $812.00 o�i . + a t � For more information regarding State Farm's promise of satisfaction elating to new non-original - _ equipment manufacturer(non-OEM)and recycled parts, please visit: ht :// 8.fm 7X4 or QR code. M � � ! .,�. 0 . . , Register online to check the status of your claim and stay connected with State FarmO. To register,go to statefarm.com and select Check the Status of a Claim. If you are already registered,thank you! Not avail�ble in New Mexico. Alternate Parts Y/00/00/00/00/00 CUM 00/00/00/00/00 Zip Code: 55125 MN METRO Recycled Parts Y/4/0 Zip Code:55120 INV DATE: 01/02/2014 Audatex Estimating 7.0.123 S7 01/03/2014 09:03 AM REL 7.0.123 DT 12/01/2013 Copyright(C)2013 Audatex North America, Inc. 0.2 HRS WERE ADDED TO THIS ESTIMATE BASED ON AUDATEX'S TWO-STAGE REFINISH FORMULA. 2.8 HRS WERE ADDED TO THIS ESTIMATE BASED ON AUDATEX'S THREE-STAGE REFINISH FORMULA. ANY PERSON WHO SUBMITS AN APPLICATION OR FILES A CLAIM WITH INTENT TO DEFRAUD OR HELPS COMMIT A FRAUD AGAINST AN INSURER IS GUILTY OF A CRIME. THIS IS AN ESTIMATE. REPAIR FACILITES MUST INSPECT THE VEHICLE TO DETERMINE IF ANY REPAIRS NOT LISTED ARE REQUIRED,AND TO CONTACT STATE FARM BEFORE MAKING SUCH REPAIRS. REPAIRER ALSO IS RESPONSIBLE FOR CONDUCTING ANY NECESSARY INSPECTION AND SAFETY CHECKS PRIOR TO AND AFTER COMPLETING REPAIRS. THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF ONE OR MORE CRASH PARTS SUPPLIED BY A SOURCE OTHER THAN THE MANUFACTURER OF YOUR MOTOR VEHICLE. WARRANTIES APPLICABLE TO THESE REPLACEMENT PARTS ARE PROVIDED BY THE PARTS MANUFACTURER OR DISTRIBUTOR RATHER THAN BY THE MANiJFACTURER OF YOUR VEHICLE. A PERSON WHO FILES A CLAIM WITH INTENT TO DEFRAUD OR HELPS COMMIT A FRAUD AGAINST AN INSURER IS GUILTY OF A CRIME. Op Codes * = User-Entered Value E = NEW PART NG= Replace NAGS EC= *"NON-OEM PART ET = Partial Replace Labor EP= *�NON-OEM PART EU = RECYCLED PART TE = Partial Replace Price PM= REMAN/REBUILT PART UM= REMAN/REBUILT PART L = Refinish PC= RECOND PART UC= RECOND PART TT = Two-Tone SB= Sublet Repair N = ADDITIONAL OPERATION BR= Blend Refinish I = Repair IT = Partial Repair CG= Chipguard RI = R 8� I Assembly P = Check RP= RP-RELATED PRIOR 01/032014 09:03 AM Page 4 of 5 2003 Cadillac De Ville DHS 4 DR Sedan 12/30/2013 Claim#: 49-26Z7-54601 01/03/2014 08:14 AM This report contains proprietary information of Audatex and may not be disclosed to any third party(other than the insured, claimant and others on a need to know basis in order to effectuate the claims process)without �.1��x Audatex's prior written consent. W a So�rra cam pan y Copyright(C)2013 Audatex North America, Inc. Audatex Estimating is a trademark of Audatex North America, Inc. 01/032014 09:03 AM Page 5 of 5 "*"SUPPLEMENT RECONCILIATION*"'k , Supplement S1 ' Claim#: 49-26Z7-54601 Insured Policy#: ' File#: Claim Rep: TEAM R3 ACC CP Insured: MICHAEL HAATVEDT Inspection Date/Time: 12/30/2013 07:33 AM Owner Name: MICHAEL HAATVEDT Appraiser Name: MARK W FELDKAMP Vehicle: 2003 Cadillac De Ville DHS 4 DR Sedan Added Lines P Trt �� € Line Guide Part Operation Price ADJ% B% Labor Rate 1 408 Sensor,RR Bumper RT NEW PART S1 $343.03 INC SM 2 517 Emblem,Deck Lid NEW PART S1 $46.75 0.2 SM 3 567 Abs,Rear Energy NEW PART S1 $186.88 INC SM 4 12482327 NEW PART I S1 $19.19' SM* Changed Lines Line Guide Part Operation Price ADJ% B% Labor Rate 5 566 Cover,Rear Bumper Repair S1 4.0' SM Cover,Rear Bumper 1.0' SM Calculation Changes � From To Difference Gross Parts $102.13 $697.98 $595.85+ Tax on Parts&Material 7.275% $75.22 7.275% $118.57 $43.35+ SM-Sheet Metal $54.00 $345.60 $54.00 $518.40 $172.80+ Actual Supplement 1 Net Total $812.00+ ummary g I Net Total Date Time Appraiser Original Estimate $1,508.55 12/27/2013 05:52 PM MARK W FELDKAMP Supplement 1 $2,320.55 01/03/2014 08:14 AM MARK W FELDKAMP This report contains proprietary information of Audatex and may not be disclosed to any third party(other than the insured,claimant and others on a need to know basis in order to effectuate the claims process)without Audatex's �� priorwritten consent. a so�era cempank �Copyright(C)2013 Audatex North America,Inc. ' Audatex Estimating is a trademark of Audatex North America,Inc. 01/03/2014 09:03 AM Page 1 of 1 F aF A� ...�..�I`i � � I I i � � i � ,. �- ��'�'G-� �� .�: � � ,�r � � ��a 4 � �� r � � �� *�� wk�� y� � n � ��a;.� . .. .. � '� � .. . .. . .. . . �� . `�.�.. . � . . . .. �=.^= i, �� ,a� �� X�; � ° ' ,� � i. �� , �� ,� �' �� '� ,, . � � � ��' � �� tx� �_ �� ,�� ,.: � �; �� :�,�,�; .,�� , �,' � �, " '� ��'"„�e� � i � � ��,i, q�j I * ��_, ��I �s �.� `"� ./� ��`:: ../ � � �� . � ; = N;,' ,,'; �:,' �� 1� �� . ..,, ,.�► `"�r ,�.. � ��j � � . � . . . .. � . . , -, ��,w""'�.�----� ..� �� - ��„ '� . . �' . . . � , :�=.. . . .� .. ... ... . �� v - � r . �.%�..' . . � . .,� � . _ . . . .. . � . /`�.a�"'��..." ..�i r � / r � tR r ;� r �� . . 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