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Bailey �ECE►vE� F�B 141�14 CITY CLEF�K NOTICE OF CLAIM FORM to the City of Saint Paul,Minnesota Minnesow Swte Statute 466.Q5 states that"...every person...who claims domogesfi+om ary nuuricipatity...shall cause to 6e preaented to the governing body of the»wnicipaliry within 180 days a,�kr the alleged Toss or injury is drscovered a norice statfng the trme,place,and crrcunutances thereof,ond the amo�nt of campensation ar othe�nlief demanded•• Ple,ase complete this form in its entirety by ckaiiy typing or prmting yonr answer to esch question. If more space is needed,attach additional sheefa. Please note that yoa wal not be contacted by telepiw�to darify answers,so provide as mach mformation as necessary to explain yonr cleim,end the amonnt of compens�tion being requested. Yon w�l receive a written ac�owledgement once yoar form is reoeived. The proceas can tahe ap to ten wee�s or longer depending on the natare of yoar daim. 'ILis form mavt be signed,snd both pages completed. If somethmg dces not apply,w�ite`N/A'. sExn co�LE�n Fo�axn o�R nocuMENTS To: crrY c�Rx, 15 WEST KELLOGG B�VD 3,�0 CITY HALL, SAINT PAUL,MN 55102 �,eo Rctr�vr p�,¢�ecr �nf �t�r-/o . First Name Middle Inilial Last Nazne — Company or Business Name — Are You an Insurance Company? No If Yes,Claim Number?� ' '��'f��'� Strcet Address Z�2 Q City �.o,s �'� .rS State /�iA' 7�p Code�'D 05/_D��q Daytime Phone( } - Cell Phone(_} - Evemng Telephone(IL'� ��y ��3� '�X t��V n� Date of Accident!Injury or Date Discovered 2 .3 Time /�/6 am/� � please State,in detail,a,hat occnrred(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�o i n 0 •\l l '16J�, r �. � -��r'_�� I { � Please check the boz(es)that most closely represent the reason for completing this form: O My velucle was damaged in an accident My vehicle was damaged during a tow p My vehicle was damaged by a pothole or condition of the sircet y vehicle was damaged by a plow O My vehicle was wrongfully towed and/or ticketed � I was injured n�Ci pr l�Other type of property damage–please specify �_ !�j Other type of injury–please spacify In order w prooess your claim von need to inclnde comes of all avnlicable docnments. For the claims types listed below,please be sune 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 tbe repairs to your vehicle if the damage e�cceeds $500.00;or the actual b�7ls and/or receipts for the repairs O Towing claims:legible copies of any ticket issued and a copy of tUe impound lot receipt O Other property damage claims:two repair estimates if the damage ezceeds$500.00;or the actual bills and/or receipts for the repairs;detailed list of damaged items O Injury claims:rnedical bills,receipts O Photographs are always welcorne to document and support your claim but will not be returned. Page 1 of 2–Please comglete and return both pages of Claim Form Failure to complete and return both psges will result in delay in the handling of your claim. All Clsims—ulease comnlete this sedion Were there witnesses to the incident7 Yes No Unlrnown (cincle) Provide their nacnes,addresses and telephone nutnbers: Were the polioe or law enforcement called? Y No Unlmown (circle If yes,what department or agency? Case#or report# 2 Where did the accident or injury take place? Provide st�eet addness,cross street,intersection,name of park or facility, closest landmark,etc. Pl be asa�ed�s ossible. If necessary,attach a diagam. �p/h�t I.n I�J��fM9 4�L�B.l�� P'lease indicate the amountyou are seeking in compensation or what you would like the(dty to do to resolve this claim to your satisfaction.�/A 4�A.5 + V hic Claims— m 1 n ❑c k a if ' tion not a 1 Your Vehicle: Year Make Model�_a V I G License Plate Number tate Color Registemd Owner Driver of Veducle City Vehicle: Year�_M Model License Plate Nwnber State Color Driver of Vehicle(City Fanployee's Name) Area I)atnaged In1urV Claims-Dlease complde this Section ❑check box if this secrion does not aovlv How were you injured? What part(s)of your body were injured? Have you sought rneclical U�eahnent? Yes No Planning to Seek Treatment(circle} When did you receive treatment7 (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? �P rovide date(s)} Name of your Employer: Acldness Telephone �Check here if you are attaching mo�e pages to this claim form. Number of additlonal pages By signiRg this forni,you are shati�g tha�ald information you have provided is hue and correct to the best of your knowledge. Urssig�ed forms will not be processed Submittang a false claim can result i�prosecution. Date form was complet � � ��l� Print the Name of the Penson who Completed ora� �'�� w°o �--� � Signature of Peison Making the Claim: Revised Pebrua�Y 2011 � i Description of Loss: Our named insured's 2009 Honda Civic was traveling on Woodbridge St approaching the intersection of Wheelock Pkwy. As our insured entered the intersection, our insured's vehicle came in contact with another vehicle, causing damage. The stop sign was lying face down, per the police report. We are seeking reimbursement from the City of St Paul for improper maintenance of the stop sign. I i ( �,/�i/f��1�� Payment Address Document Address 24344 Network Place P.O. Box 512929 Chicago, IL 60673-1243 Los Angeles,Ca 90051 Phone:(877)818-0139 Fax:(888)781-6947 2/7/2014 1:21:00 PM Certified Mail 91 7108 2133 3934 1951 0158 Return Receipt Requested CITY OF ST PAUL CITY CLERK OFFICE 310 CITY HALL 15 WEST KELLOGG BLVD ST PAUL,MN 55102 Your Client: CITY OF ST PAUL Your Claim Number:C-130320 Our Insured: BAILEY, JEFFREY Our Claim Number:l3-414$454 Amount Subject to Reimbursement:10,978.54 Amount of Insured's Deductible: 500.00 Please take this as formal notice of our subrogation rights relative to the above -captioned claim. We have completed our investigation into the facts of the above-captioned loss and find that your insured was the proximate cause of the accident. Location of Loss: WHEELOCK ST AND WOODBRIDGE ST in ST PAUL Date and Time of Loss:10-20-13 @ 1:15 PM Description of Loss: Our named insured's 2009 Honda Civic was traveling on Woodbridge St approaching the intersection of Wheelock Pkwy. As our insured entered the intersection, our insured's vehicle came in contact with another vehicle, causing damage. The stop sign was lying face down, per the police report. We are seeking reimbursement from the City of St Paul for improper maintenance of the stop sign. Please make your draft payabie to Progressive Direct Insurance Co as subrogee of "BAILEY, JEFFREY ", in the amount stated above and mail it to the attention of the undersigned at you rliest venience. All supporting documentation is enclosed. I have diaried my file ead fift days. you for you anticipated, prompt atterrtion to this matter. is o r Woolfolk Subrogation Represen tiv Progressive Direct Insuran o Tel. 877-818-0139 Ext 37806 Fax. 888-781-6947 Email: Christopher_Woolfolk@progressive.com _ _ _ � Claim Payment Detail Page 1 of 1 �PK�i�li"!'i ��'�ii'Et�.°R't# �k:?'�r"�N� � ��-�� ,� ;--Payment Information-----------------------------------------------------------------------------------------------------------------------------------------� i Disbursement Number: 480036064 Total Amount: $236.34 i EFT Trace Number: Invoice Number: � Paid To: HEPPNER'S AUTO BODY,INC.,ONLY i ! Mailing Address: 6042 CLAUDE WAY E � INVER GROVE HEIGHTS,MN 55076 USA ! In Payment Of: COLLISION,TOWING 8�TEARDOWN OF 2009 HONDA CIVIC � , �___.--------._.__. __________ _ ________ ____________ __._______._ ___ _.______ _ .________ ._._._.__ ------.__ _.___.___----__.___ �___._... _______._..� - --------__.___________________._____.--, ;--Vendor Information-----------------------___.__._-_----------_.______.__.___------------------------.__._------ -- , s i Name: HEPPNER'S AUTO... 1099 Required: ; Type: BODYSHOP , ; ;-•Review�ed5ummary ................ .__.___.-----___.._. _ .__.__.._ _.__.___ _.._.___ ._._____ __.._.___ __--.----•--.____ _,__.__.__..__, Issuing Rep: CJH0001 Approved By: i Issue Date: 10-2�13 Review Date: 4 Last Updated Rep: CJH0001 Reviewed By: � � �--------------------------------------------------------------------------------------------------------------------------------------------------------------------------� �-•Bank Information---____._._..-------------------------------�-------------------__-------�__�__.___.___------•---------�----------- -----�----_--------- � � Type: LOSS Bank Code: AS2 ! Stop Reason: Cleared: 11-12-13 � Stop Date: �_---_ . ----------- ___. ___ -----�- �--Exposure Detail:COLL_.._.. __.__._�__.__________________ _________________ ____.__. .._._ ____.__ _.__._.. _____.._.____._._.._...._.___._.....__, Party Name: BAILEY,JEFFREY C Amount Paid: $236•34 � Property Description: 09 HONDA CNIC Deductlble Taken: $0.00 Payment Type: SUPPLEMENTAL PAYMENT Property Damage: $0.00 Rental: $0.00 http://claimspayments/A1phalClaimsPaymentsWeb/default.aspx?p... 2/7/2014 Claim Payment Detail Page 1 of 1 �f��rr� �a�rne�€at I��ta�i � �.��.��8 } �--Payment Information---------------------------------------------..___------------____.-----------------------------------------------------------------------� � Disbursement Number: 479993565 Total Amount: $5,029.07 i EFT Trace Nurnber: Invoice Number, � � Paid To: JEFFREY C BAILEY,ON�Y i i Mailing Address: 1234 ROSE VISTA CT. 3 ' APT.8 � ROSEVILLE,MN 55113 USA i In Payment Of: -COLL-'09 HONDA CIVIC-LESS$500 DED-PROG OBTN SALV i ,—Vendor Information 3 � Name: 1099 Required: � Type: � r Reviewed Summary s Issuing Rep: A081379 Approved By: NDCF0084 i Issue Date: 1a2�13 Review Date: � Last Updated Rep: A081379 Reviewed By: ,..Bank Information_ . ...... ....... .. _...... ........_ ....... _..... .... ... .. ......, � Type: Loss Bank Code: AS2 ! Stop Reason: Cleared: 10-2&13 � Stop Date: ,_ Exposure Detal l:COLL .._._ .... .... _.._. __ .__..__.. . .. .._ _....._ _. _____ ___. _._._ _ _._..... _. s ; Party Name: BAILEY,JEFFREY C Amount Pa�d: $5,029.07 ' Property Description: 08 HONDA CNIC Deductible Taken: $500.00 ' Payment Type: FINAL PAYMENT Property Darnage: $0.00 Rental: $0.00 I http://claimspayments/Alpha/ClaimsPaymentsWeb/default.aspx?p... 2/7/2014 Claim Payment Detail Page 1 of 1 �l�irn 3��r��t P��ta€� � �.��.��1 ) s--Payment Information-----------------------------------------------------------------------------------------------------------------------------------------� ' Disbursement Number: 480185829 Total Amount: �140.00 i EFT Trace Number: Invoice Number: j Paid To: CROSS COUNTRY MOTOR CLUB(ONL`� ! Mailing Address: 1 CABOT RD s R MEDFORD,MA 02155 USA � In Payment Of: INV 362427;VM.�1310748510-2 � ;--Vendor Information --------- .__.__._- - ---------------------------_ _.-----------------. ._.__._-----------__.__.---_____ ---_.______------------; i � Name: CROSS COUNTRY M... 1099 Required: I Type: TOWING SERVICE � �--ReviewedSummary .__._______._-•------__.__.__._---------_.__.____ _._---- --------- --.____---------______.__----- __...____________._____. i Issuing Rep: JKA0005 Approved By: NDCF0084 i Issue Date: 11-1�13 Review Date: � Last Updated Rep: JKA0005 Reviewed By: , i ' , � � �---------------------------------------_________-----------------------------------------------------------------------___----------------------------------------------a ;-�Bank Information - -__._.._._.-------.�_._----------------•------------_�_.__------__ _____------ -------- ._..._�_------__._.._..-------------.____, s � Type: LOSS Bank Code: AS2 ; Stop Reason: Cleared: 12-ifr13 . Stop Date: �-•--------.._- --.______ -- -- ---- ----- ---- -----._.__. �-Exposure Detail:COLL _..------------- ____ _..._.___..__,---_____.____ _---.__._ -------_.__-----•--..._----------.__,__.--------.___.__, � Party Name: BAILEY,JEFFREY C Amount Paid: a140.00 1, Property Description: 09 HONDA CNIC Deductible Taken: $0.00 j Payment Type: SUPPLEMENTAL PAYMENT Property Damage: $0.00 ! Rental: 50.00 i http:/Iclaimspayments/AlphalClaimsPaymentsWeb/default.aspx?p... 2/7/2014 i Claim Payment Detail Page 1 of 1 �i�irr� �a�e�ae€�� a�� .�-��.��?it� � ;--Payment Informatfon---------------------------------------------------------------------------------------------------------------------------------------� ; Disbursement Number: 480332352 Total Arnount: a7,495.88 i EFT Trace Number: Invoice Number; � Paid To: HONDA FINANCIAL SERVICE,ONLY i ! AS LEIN HOLDER FOR JEFFREY BAILEY � Mailing Address: NPC PO BOX 165007 i IRVING,TX 75016 USA � In Payment Of: -COLL-'09 HONDA CIVIC-PROG OBTN SALV � �_.____.__ .__._..._ ._.__._.__._____. _ .------__ ____________ ______ _________ ____________________ _________ ________•---________ _.........__.__.________, ;--Vendor Information-------------------------------------------------..___------------_____________----------_____________----------_______________------------. � j Name: 1099 Required: i Type: � ;------------------------------�-----------______----------------________------------_____----------------_________-------°___________--------___________----------_______.; ;--Reviewed Summary--------------------------------------------------------------------------_________------------------------------_____--------------------� Issuing Rep: A081379 Approved By: NDCF0084 Issue Date: 11-22-13 Review Date: Last Updated Rep: A081379 Reviewed By: r-Bank Infortnation � Type: Loss Bank Code: AS2 j Stop Reason: Cleared: 12-0&13 i Stop Date: � � __.. ._ __........_..__..� � _ ._ ___.... .._.___. ....._ .._.___.... .._. . .. ... . .... .. ... ;Exposure Detail:COLL i Party Name: BAILEY,JEFFREY C Amount Paid: $7,495.88 s Property Description: 09 HONDA CNIC Deductibls Taken: $0.00 Payment Type: SUPPLEMENTAL PAYMENT Property Damage: $0.00 I Rental: $0.00 � ' � ' i_��_��__��_��_____�_��_��_��____�_��_��___��__��__��_��_�__'��_��3 http://claimspayments/AlphalClaimsPaymentsWeb/default.aspx?p... 2/7/2014 i _ . .. ... . �;. ; ; . . . � ��t�� . �'� `�s,� �r��s�k�'�H�� a .w� �a x�a� r x �.:��F'k'�� Fr_x' �m...-t d r' �- 'Y�s' �i ' ' : � , :`'Z Yk'��§�'`�.�^�F#A� � I � -: �. �rhy.:s �2� J}� .. ,��..�ic d ..�ati t •t�F � '" t� �� ' , r J :� .R+td'� '�".�� : ,�: :!c�1d''�. .:' ..: �.. 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'�.�'�I�i�S��i�'� � 8 .Oi' I.; � d �� ....i+(y+q, :�I '��}L t I t' ��€�Pf ft§ �� i � ��P ��'S ��,,, I .�r,. }S'. !4! §f RG 3 BSF�€�£4' € �� ¢��. �, �,,,�.�..""" . . .. � r : r r r 'y � A }��! 3s . �. ., J J }� r ��'� : � � ��M° � ) i �� - r' �+d f ,�f � s,rl ��r � f''�` �''. �� : r�;.� �r ;Ff�� a i,� '' r�h``�`�5,� ��, ,, x��, � , �r r� x � f sr �.'',s:f_+'�r �,�,r��i"` �," ' r �� Y f x ,r�� p.. � �� r �.f s��.r t "r �I'� y� '��'--z;'� � � �� .��i}'F`��`� � � �� t,,��f'�,.�r��' �' r.°'>�,-s?'��-�`,��' � t�.�.�,k� �. - 3 �,� f' � ��`��' } ,pr�� ,� ; �� ' � ��-�,9 �� '��r� '� -� r� �� a�H k,rar �ra��'� 5 � �x�r�`��' ��r� '� '�f '� � '� a m��t�'��"�3��i K '. ��"'��-�� e�i��.. � k � � �r �'x'-' _ �•`ha i� ��5�.��n��j�{,,� , f� � H �� ... � �� ,.y.'3,��',1r .Pt �� t� �.h� y91c 4rF 3�"�S�`.� +t�d�fi��f":2�^'w . . :a,, < E�.� �'F'fG.3�� . e �� p �:�F r# � � -�a-��h�. �e �>.,7� r�y3,�� . ��`'U ��,��'�� '��5�� # , p� �ry�-Ni��$� � �M��,k ��#1��P' �` '�" �' ,�r.. d,� �4 k x s a�, "'�'� ��+��'i'��`'�m� �� .{��r,��k" � k��#'�, �7r��i �, x -e6��- �c = �,F��r"- �;x�,�,k G `�:�'`,r��'r�(',i4``na ,�.� n � �L k . �.�� - r � �.. � �: Xr 4 i'-4..0'�` "�'y�"s�� .;�r � � � r �� f ,� ;,-��, �'t �i � " y��5w ,r��°,�,�:� ' r�4�' � � "? ,�� '' r�'' � r r� ,r��, ,� ,r,�}r'r r,�,�tr" �,, �` � �` .? �� . Jrf � 1' d r .�� Pr' ��t� r �� i�YS �u .Y?i � .tQ� . � � r.'�,�+ :; , � • .,?: .�� j ,,f;. � }�_r Jrr r�st'�-�-?'i��a*;� �-,"��'��,� „�'�._�Y .,....... _..... n,_. .:��, � . .� �. .... . , ..., - — .� �'- . , ��.�� , z r �� #�"�' ` `�'� ' °� "�'�' Vehicle Valuation Report l�vv�+er�r�fc�rn?�#iorr htc��rark' Prepared tor:Progressive Group oi Insurance Comparries (600�321-9843 �L1t1€lt1f1�1'��:: ..... . ......... :. ..... .... .., ...: : .,....:....... .. .. , :,-: Claim Information Gaim Number: 13�4748454-01 Version tt: 1 Policy Number: Coverage Type ot Loss: Collielon Owner: JEFFREY BAILEY Loss Date: 10/20/2013 Adtlress: 1234 ROSE VISTA CT. Reporteci Date: 10/2012013 pp-�,g Valuation Report Date: 10/24/2013 76:13:53 ROSEVILLE,MN 55113 Valuation Reporl ID: 1004007033 Owner Home Phone: (651)398•0346 � VehiCle Information Loss Vehicle: 2009 HONDA CIVIC LX 4D SDN 1.SL 4 Location: MN 55113 Cyl Gea A 2WD Exterior Color: Urben TRanlum Metallic VIN: 19XFA16599E047791 License Plate: 796 BLY,Minnesote,Exp,11I2013 Mtleage: 49,937 mlles Title History: No Yaluation Summary Base Value: 512,434.41 Loss Vehicle AdjuslmeMa Condition Adjustment: -$258.08 Prior Damage Adjustmertl: $0.00 Afler Market Parts Adjustment: $0.00 Returbishmem Adjustmern: $0.00 I Title Hislory Adjustment: $0.00 Market Value: 3Y2,176.33 SWtlamom AdJuaments Deductible: -$500.00 Settlemem Value: �'11,676.33 TMIe Fllelory Comments: Mitctx:ll w.�s�CL°a_et�s� TOtal IASS Claim A:13-4148454-01�CopyngM(c)2011-Mitchell Intemational.All Rights Reserved.�Page 1 �ass��h�l�..�etat[......... .....:.:: ....::.:. ........: ......::. ......;:. .....;. . ... .. .: Loss vehicle: 2009 HONDA GVIC LX 4D SDN 1.8L 4 Cyl Gas A 2W D Standard Equipment or xten h flaytime�tunnireg.Lxghfs..:='. . ......:: . ' ' ..... ...... .. .. ' ��ni{y�i�atn ...:: ,, Front and Rear Body Color 5-MPH Impact-Absorbing Bumpers Halogen Headlights St��2NSr�6:1n ;'. , :.:: ;. .: , i.. Interior ,Afu7/frt#�;1Ret§�1N�di'4�d-Vwatts Sp�ed$e�tsd�ve,�/oiemee artc#4 3peeke�s Tob�, Ruxi ,AEtdi�i .la�c ', . . . ; � a i GCyi�laj!+eF.MP3/V4�4A,f?�ayer. .. ._ ' � � Cloth Seats Cruise Corkrol ,: , []ual8ody Golor FddiFlg F'vwer i4djusta4le�iGac�ar FteafliiawA��io� . . .;: F`viced;lAbem3tt�ertE iAlndStneld VYpers; � ; ; Adjustab e Headre�ucket 5eats Wdh Driver Adjustable Seat H Frocit Ouai Sun , ' „ ' ,. eight and ��S Fmnt:Ekrai Yanity i�irrors '...... .. ;';.., . . ;:: .... .. ; :... ....... . .in�iass Radw,�4iitecum ._':; � Interior PartiGe.Pollen and Dust Air FiRer Manual Air Conditioning Pb4�er Y�tlOw-LodcpuE '. ; � ;:` � . ;; '�diNbf�t16W5'W+�4 61�tr��'(�i�TCf�lf�i�Jb�►1C)tNi�?'Qi�(�11�7dVr�1':: Rear Folding Bench Seat Wth Manually Adjustable HeadresLs Rear Heating Ducts Reav�(indow�efroster ..%_ . , i: ;I.. .. . ::: :, ... .. ..:i .Steertr+gl+Uheei hiounted�hols-ForC`wtiise�or�roE Mechanical 4�WheetAnb�LcxicBrakes , ; . . . !,Electrcuaie�rak�FarceDisMbutlon ;, , , __ _ Front Power 262-mm Verrtilated Disc and Rear Power 201-mm Drum Brakes Power Rack and Pinion Variable Assisted Steering 7�sq4P1�'r��M9 Cs4�F1?(4. ......::...... . ., .. .. .. .;: ......__`. ...... ..:.�� I�B�Ip�. , .....: .... ...:`_. .. .. .;;: .,i: ... .. ..:.....ii Safety ativ2nced C6mG�t�3ifitY E�fiirieefif�l:(�1�iTM�):Botly SViitture" >'' : ' �I�ld S�etY C3�koi-LoCk6 Lt�6Yatl fln R�Br potfCS ', ., Driver Airbag With Dual 7hreshold,Dual Stage Deployment Front Active Head Restraints _ .. .... . . _ _ _ Fr�and"Re�a�'AetomatiE`Loe[cin"Retrae�rs::,s .. . ` FsoieYarid fiear C�re�pl's 2oiies :�-.. .. .. .:. ... ... .: . 9 r ±.. Front and Rear Outboard 3Point Seatbelts Front and Rear Side Head Curtain Airbags Located In Headliner �rti�Prete�eioFle[s Vt�th fo�i��s -. ,, Froiit�Elie�f�lei M �siers , : ; .; _ _ _. __. .. __ _ .. _ . _ _ 9. �1.. Front Side Airbags Keyless Entry Operated Via Key Fob L A:T:�H. .. .: : ; ;. Mt�U�tutCU9n RQ!n44�.OR4�2t8S�k-rnC�4 �9Q��QCwU�4�GkaRd pa��C.:. , , ;_. . Ai�tr�i _.. .. . , , _ , . _ _ Occupant Position Detecdon System(OPDS)Passenger Airbag Cutoff Sensor Panic AIaRn Adivated By Weight ; ;; : , ov�e� : ' i�ro9rai��et�e'P�uv��lDOi:�oeks 5+��4atOrt?�i9�oek�n9;; .: - Pesser�e�A��i2g V�itla[�itaT 1ltres�t�u8tf�Depl . , , , , . , .,. Rear 3-Point Center Seatbelt Remote Fuel Door Release _ .. __ _ 5eleetive "' �a K' less � �eems ", ,.. : Unlodimg ej' �r .`°: � ;. . . '�e Giiart!Lk�; ', ;:,`' 7runk Anti-Trap Device VehiGe Anti-Lockout ldehidefln�-Tt�efl�l8l4iamTand�!s9melnitnol�ili�ef . ;; ....: ` M�chE:ll�+�e�rL�:s'L�s� TOtYI LOS6 Claim D:13-4148454-01�CopyngM(c)2D11-Mitchell Intemational.All Rights Reaerved.�Page 2 i � �a�s�t��t��u��r�...... : Loss vehicle: 2009 HONDA GVIC LX 4D SDN 1.8L 4 Cyl Gas A 2W D Comparable Vehicle Information Search Radius usad for ihis valuation: 75 miles Trom Iossvehicla ziplpostal code. Typc&I Mileage for this vehide: 58,000 mllea # Vehicle Description Mileage Location Distance From P�i� Adjusted Loss Vehicle Value ��os t�c�r�a�€w��Aa snr�!��sr�c�� ;; ' <,, , ��z,s��no.. .. �, 32:Sita 55423 11 rnif� $131�4 T2: GAS J��V�;. . . .: .. . !. .....: .. .. ....:..... ,:: .. .. . :, .. .. .:;.. . . ,,; . .Sra�tl'Pnce 2 20�9 HONDA CIVIC LX 40 SDN 4 1.SNORMAL 65,897 55433 13 mifes ��,5Q0.00 $12.269.32 GAS A 2WD Sold Pr�ce 2D09 HON�P,GNIC LX 4D SDN 4-1.8NORfJiAL ," ; ' $a�.898 00 3 GAS A 2WD , 4fs,Q37 . 55306 i .:2D rni�s. 5�12,fr89.5�4; , Sald Pnce 4 2009 HONDA CIVIC LX 4D SDN 4 1.8NORMAL �5,D87 55110 �Q miies $12'988�� $12,408.40 GAS A 2WD List Price , '2tl�5 F#C�1�1E]P,'CfVIC�X dE��Udd d 1$�Ik�t�lUlA�. , d��57& 55A23 i t1 rsu�s !. �#��5��0 $1 f 75Rt�a9 �' GftS R 2WD' ' :?.: r;. ;. , �ist:Pnce . .. 6 2009 HONDA CIVIC LX 4D SDN 4 1.SNORMAL a4.598 55077 13 mi!es $13,990.00 �,Z 790� GAS A ZWD List Price ,7,2�178 HONDA GMC�7C 4,Li S{SM:A t�NOftCJU#L ' i ' $�4;977 f3AS A 2WD" : &A;699 55At11 93 rtiifus 00 ; $`17&9�4.t19. , _ _ .. _. . . �13!AYiGE _,_ .. .. .,. _ . . .. .. . ...... ... _ 8 2009 HONDA CIVIC LX 4D SDN 4 1.8NORMAL 62,122 55344 17 mifes $12'9�''�� $�2,774-83 GAS A 2WD List Price s 200Q Hf�NE7A CtulC�4D 5DN 4 i 43NdRMAL ��?�98 00 Gli5 A 21M�. .. ., ; ?! ... 4'L;B�X 553IfG ."�Q r't�#ss �1�,632 1� Llst Prrce.......... . . . 2C09 HONDA CIVIC LX 40 SDN 4 1.SNORMAL q8��2 55379 25 miles $12�999.00 $12,Of6 78 �� GAS A 2WD List Price Base Value: E12,434.41 �,.OS8��11C�$�►L�jl�$tt'17Qf1�8 , Loss vehiCle: 2009 HONDA GVIC LX 4D SDN 1.8L 4 Cyl Ges A 2W0 Condition Adjustments Condition Adjustment: -E258.08 Overoll Condltfon: 2.83•Good Typical Vehicfe CondRion: 3.00 Mitch[;II tifF�:�C�°�::'WY' Totil Loss Claim A:73-4148454-01�CopyngM(c)2071-Mitchell�ntemational.All Rights Reserved.�Page 3 Gategory Condition Comments ;: ' ..: ; ,,; ; knte►� ;: ..:: ,, _ ,SEATS , ,, ;,,, ,ZF ,.,, . , , ,_., _ , , , _ _ air SEVERAL STAINS ON RlF,R/R SEATS i:I�A�tiJ�C1L� .:` ... ..-i . •:::. ...3:G'CC� ',: i ;: .. . .,:i..:fti�DE�4'�E-SOILC�G;$QIVSE{utAR�SS�1..,�"�cli1lTfi':i _ �x.QQQ� . . ! . : .. , „ ,: ; , . „ , , . DOORS/INTERIOR PANELS 3 Good SOME MARKS AND SOILING ;.. ��i�'f:€ ;„ .. ,. ,:,' . ;;�r; ��cx�si ,:: ,,' - A#QD��E��bl#.tN� ,: ,,,.., � ., ,,: ;. � GLASS 3 Good SOME PITTING ON WlS. �I�A[�l#1��►� �ve�i GQVd `` ��F�i.EEN'r'£DNp[rIEfN:� Exterior ,':f��+l.�' ,.; . ,:� ..,: :;:. ...�;�# ',:. ;: ::. :; SOyiA�'C�Ei�i��l�id��hlt�ib'��S`t:�'i�F�S.,. ' VINYUC„ ,,, ,.. " _ , -. _. _ _::. _ . _ ONVERTIBLE TOP Typical '}�21fii1. 'i ; '3;1?ood '.:: : ; :i: 5�F'�8' CiCt E�IHfS , ,., , ,,, ,�, ,, , _ ,,, ._: �. : ,; , . , _ �;, BODY 3 Good LG DENT ON TRUNK LID.MULTIPLE DINGS AAecheni�cel. .-;:, _ ;; , , ENGINE ,. „ ,, , . ,, „ ;; ; ; ,;; " , , ,:� , , ,, , . , ,., „ ,_.,,,,, ,, � _ 3 Goad MINIMAL DIRT AND GREASE ,'F{�1.�9UIISSffNil..:'_: .. .. ...: .. .. . .. . :. 3 C�opd .....'.i . .., .-, ; '; i�lfP�NNAG[3FRT A1VD GREASE ....:;: . Tire ,.. , 2 F : air A�L FOUR TIRES 4132 Tyqcal condition reflecls a vehicle that is in ready-tor-sale cond'Aion and rellecls normal wear and tear tor thal vehide type!age. Commem a: �+C,1t13��[l1�.�QF�tE:iA� " i '. ' Loss vehicle: 2009 HONDA GVIC LX 4D SDN 1.8L 4 Cyl Gae A 2WD Comparable Vehicles Mitr.htall�Fa.dcLa::t�s'" Tp��,p� Claim A:13-4148454-01�Copynght(c)2011-Mitchell Intemaiional.All Righis Reserved.�Page 4 '. 1 2008 HONDA CIVIC LX 4D SDN 41.6 NORMAL GAS A2WD Sold Price: $12,975.00 VIN: iSXFA16519EXXXXXX Adjustmerrts Loss VehiGe This Vehide Amount Stodc No: Mile2ge 49,931 52,501 $139 72 Lis6ng Date: 0911 4120 1 3 Total Adjustme�ts, $139.72 ZIPlPostal Code: 55423 Ad)usted Price: $93,114.72 Distance from 11 miles Loss Vehicle: 5ource: FRANCHISE SALE-J.D. POVYER AND ASSOCIATES 2 2009 HONDA C(VIC LX 4D SDN 4 1.8 NpRMAL GAS A2WD Sold Price: s11,600.00 VIN: 19XFA16559EXXXXXX Adjustments Loss VehiGe This Vehide Amount Stodc No: Mileage 49 931 65,897 $769.32 Listing Date: 0 812 4/20 1 3 Total Adjustmenfs: $769.32 ZIP/Postal Code: 55433 Adjusied Prica: 592,269.34 Distance from 13 miles Loss Vehicle: Source: FRANCHISE SALE-J.D. POWER AND ASSOCIATES 3 2009 HONDA CIVIC LX 4D SDN 41.8 NORMAL GAS A2WD Sold Price: 512,899.00 VIN: 19XFA16559EXXXXXX Adjustments Loss Vehicle This Vehide Arrwunt Mileage 49,931 46,037 � _ Siodc No: -$210.46 Lis6ng Date: OS1Q5/2013 Total Adjustmenls: -$210.46 ZIP/Postai Code: 55306 Adjustad Price: $92,688.54 Distance from 20 miles Loss Vehicle: Source FRANCHISE SALE-J.D. POWER AND ASSOCIATES MitcFt[:II irita.it��::tvs•' TOtil LOfe Claim A:13-4148454-01�CopyngM(c)2011-Mitchell Intemational.All Rights Reaerved.�Page 5 3 2009 HONDA CIVIC LX 4D SDN 4 1.8 NORMAL GAS A2YYD Sold Price: 512,899.00 4 2009 HONDA CIY�LX 4D SDN 4 1.8 NORMAL GAS A2WD List Price: 51Y,988.OQ VIN: iSXFA16599E048147 Adjustrnerrts Loss Vehicle This Vehide Amount Stodc No: 830995 projected Sold Adjustment -$842.00 Listing Date: 0 9/2 3120 1 3 MiTea4e ;% >` . 49,931 . ... b5i�� ,:: &262 40 ZIPlPostal Code: 55110 Total Adjustmer�ts: -$579.60 Distance from 10 miles Adjusted Price: 542,408.40 Loss Vehicle: Source: FRANCHISE WEB LISTING- CARS.COM BARNETT CHRYSLER JEEP KIA 3610 NORTH HIGHWAY 61 WHITE BEAR LAKE MN 55110 651 r129-3391 5 2D09 HONDA CIVIC LX 4D SDN 4 1.8 NORMAL GAS A2WD List PNce: 512,999.00 VIN: 19XFA16599E043417 Adjustmerrts Loss Vehicle This Vehide Amaunt Stodc No: 132954A . .,.,. ,,.. %5883:f10 Prtryerc�d�S�ild k�tr�T�, ,: . ; _ -,: _ . Lis6ng Date: 10f0912013 Mileage 49,931 42,576 -$351.41 ZIPlPostai Code: 55423 Total Adjustmenis -$7,244 41 Distance from 11 miles Adjusted Price: $11,754.59 Loss Vehicle Source: FRANCHISE WEB LISTING• CARS.COM RICHFIELD BLOOMINGTON HONDA 400 W.78TH ST. RICHFIELD MN 55423 612-866-6832 Mdchf:ll Wa:icL°�ast.�t• Toti1 Loss Claim A:13-4148454-01�CopyngM(c)2017-Mitchell Intemational.All Rights Reaerved.�Page 6 6 2009 HONDA CIVIC LX 4D SDN 4 1.8 NORMAL GAS A2WD List Price: 513,990.00 VIN: 2HGFA76599H526265 Adjustmerrts Loss Vehicle This Vehide Amount Stodc No: projected Sold Adjustment -$907.00 _ _ _ _ . __. . _ _... .. .. . . ._. _ _ _. . _ ._ _. . _ . .. _ _ _ _ _ _ _ Listing Date: 09l0912013 Mifeage . .. ..'.:.. . .....:49,9�i.::: ........ .:s{�F�$.;:s. ....:':. .... :�52.�4 21P/Postal Code: 55077 Total Adjustme�s: -51.199.34 Distance from 13 mlles Adjusted Price: S72,T90.66 Loss Vehicle Source: FRANCHISE DEALER WEB LISTING•VAST.COM INVER GROVE HONDA 4606 ROBERT TRAIL SOUTH INVER GROVE HEIGHTS MN 55077 651-30fi-8600 7 2009 NpNDA CIVIC LX 4D SDN 4 7.8 NORMAL GAS A2WD List PriCe: S�'1,977•00 VIN: 2HGFA16509H523786 Adjustments Loss Vehicle This Vehide Amount Stodc No: P8328 ` .._ _ P�oj�f�tl:'"a01d Afl�u�At, ..,;: `. .. ... ..:_. . .. .s. . .. ..::. .. ..,.$776.OQ Listing Date: 09/1812013 M�leage 49,931 64,699 $693 09 ZIP/Postal Code: 55441 Total Adjustments -$82.91 Distance from 13 miles Adjusted Price: Sf 1,894.08 Loss Vehicle: Source: FRANCHISE YYEB LISTING- CARS.COM CORNERSTONE AUTO RESOURCE OF PLYMOUTH 3901 VINEWOOD LN N PLYMOUTH MN 55447 763�59-5300 Mitchc;ll tnta±�CL°�nstvs• Tofall LOfs Claim A:13-4148454-01�CopyngM(c)2011 -Mitchell Intemational.All Righis Reserved.�Page 7 B 2009 HONDA CIVIC LX 4D SDN 41.8 NORMAL GAS A2WD List Price: 512,996.00 VIN: 19XFA16599E051338 Adjustments Loss VehiGe This Vehide Amount Stodc No: 130878A6 projected Sold Adjustment -$842.00 Listing Date: 08104/2013 sAUileage..`.... . ... ri9 9�i..: ...:;:.$2,127.::;. .. . ...:' S$3E1$3 ZIP/Postal Code: 55344 Total Adjustmerns: -5221.17 Distance from 17 miles Adjusted Price: i12,774.83 Loss Vehicle: Source: FRANCHISE WEB LISTING- CARS.COM METROPOLITAN FORD 12477 PLAZA DR EDEN PRAIRIE MN 55344 800-209-2934 9 2009 HONDA CfVIC LX 4D SDN 41.8 NORMAL GAS A2WD List Price: 512,998,00 VIN: 19XFA16559E002489 Adjustments Loss Vehicle This Vehide Amount Stodc No: AAH4200 ' ° R�O�Ec�#l::�bfd AtljuS�Rt. ..s .... ...,: , ....... ,�.W Listing Date: 10M212013 Mileage 49,931 42,877 -$365.82 ZIP/Postal Code: 55306 Total Adjustmerrts' -5365.82 Distance from 20 miles Adjusted Price: ST2,�32.18 Loss Vehicle: Source FRANCHISE WEB LISTING- CARS.COM WALSER BURNSVILLE HONDA 14800 BUGK H1LL RD. BURNSVILLE MN 55306 952-892-7100 Mitch[;II W�s�L°�_stvY TOt81 L010 Claim A:13-4148454-01�CopyrigM(c)2011-Mitchell Intemalional.All Righls Reserved.(Page 8 10 2009 HONDA CIVIC LX 4D SDN 41.8 NORMAL GAS A2WD List Price: 512,999.00 VIN: 18XFA16549E005464 Adjustments Loss Vehicle This Vehide Amount Stodc No: 18275Z projecied Sold Adjustment -$893.00 Lisdng Date: 10/12/2013 Nli �.. :; .. .. .. :: _49,9�i..:?. .. ....: A8172::' .....::`. ......=$89.� ZIP/Postal Code: 55379 Total Adjustmerds: -$982.22 Distance from 25 miles Adjusted Price: S12,Q16.78 Loss Vehicle: Source: FRANCHISE WEB LISTING- CARS.COM APP�E USED AllTOS SHAKOPEE 1400 iST AVE E SHAKOPEE MN 55379 952-987-5712 � �t�$�.�x'�F1'I ��t?hi ,, , �;, ' ' ' , � Sub-Model Description Configuration Original MSRP 2+�9°fiCil�$)i4:F�x1�71CF U4..,;i ..;;: .;. :;+. ': �RN:1;.$b 4 Cy�:Gas�1Alf7;: ...,: •a .. .. . ,:' 518;?55,�3 M11CrlE:ll�b3�Z�°s?.5i�isY" Tot91 LOSS Claim#:13-4148454-01�CopyngM(c)2011-Mitchell Intemalional.All Righis Reserved.�Page 9 Vehicle Valuation Methodology Explanation WorkCerrter Total Loss was buili through a joint partnership between J.D.Power and Assodates vehide valuation division Power Intormation Network (P.I.N.)and Mitchell Irnernational,a leading provider of daims processing solutions to private passenger insurers. WorkCen[er Total Loss produces accurale and easy-to-understarxl vehide valuations via this tive step proces s: Step 1-Locete Compara6le Vehicles Locate vehicles similar to the loss vehide in the same markel area.WorkCenter Total Loss Tincis these vehides in AutoTrader.com,Cars.com, Vast.com and directly from dealerships. Step 2-AdJust CompareMe Vehicles Make adjustments to the prices ot ihe comparade vehicles.The comparade vehi des are identical to the loss vehicle except where adjustments are itemized.There are several lypes oi comparable vehicle adjustmems . Projecled Sold Adjustmern-an adjustment to reflecl consumer purchasing behavior(negotiating a ditferent price than the lisied priceJ. . Mileage Adjustment-an adjustm ent tor ditterences in mileage between the comparable v ehide and the loss vehide. . Equipment-adjustments for d'+fferences in equipment between the comparable vehicle(e.g.equipment packages and options)arrd the los vehi de. Step 3-Calculate Bese Vehicle Value The base vehicle value is calculated by averaging the adjusted prices ot the comparable vehicles. Step 4-Calculate Loea Vehlcle AdJustmeMs There are iour types oi loss vehide adjustments: . Condition Adjustmem: Adjustmenis to accourn tor ihe candition ot the loss vehide prior to the loss. . Prior Damage AtliuslmeM: Adjusiments to accourn tor any prior damage presern on ihe loss vehide prior to tlie loss. . Atter Market Part Acfjustmertt: Adjustments to accourrl tor any atter market�preserrt on the loss vehicle prior 10 the loss. . Reiurbishment AdjuslmerTt: Adjustmerns to accourrl tor any refurbi shmem pertormed on ihe loss vehide prior to the loss. Step 5-Caiculete the Markei Value The Market Value is calculated by applying the loss vehide adjuslments to the base value. Mitch�ll i�f+�sicL�a::'L�s� TOiil Lo�s Claim ll:13-4148454-01�CopyngM(c)2011-Mitchell Imemational.All Righis Reserved.�Page 10 . � Date: 10l24/2013 11:38 AM Estimate ID: 13-4148454-01 Estimate Version: 0 Committed Profile ID: Metro 7.125 All Part Heppners Auto Body Inver Grove 6042 Claude Way East,Inver Grove Heights,MN 55075 (651 f 455-7920 Fax: (651)455-0140 Damage Assessed By: Tony Knops Appraiaed For: PROGRESSIVE Type ot Loas: Auto Date oi Loss: 10/20/2013 Arrival Date: 10/21/2013 Payer: Insurance Deductible: 500.00 Claim Paid: N Claim Number: 13-4148454-Ot Insured: JEFFREY BAILEY Owner: JEFFREY BAILEY Address: 1234 ROSE VISTA CT.APT.8,ROSEVILLE,MN 55113 Telephone: Work Phone: {612y 292-0205 Home Phone: (651)398-0346 Contact Phone: (651�398-0346 Mitchell Service: 910607 Descripdon: 2009 Honda Civic LX Vehicle Production Date: 8/09 Body S[yle: 4D Sed Drive Train: 1.8L Inj 4 Cyl 5A FW 0 VIN: 19XFA16599E047791 �icense: 796-BLY MN Mileage: 49,931 OEFNALT: A Search Code: ARDENHILLI Color: GRAY Options: PASSENGER AIRBAG,DRIVER AIRBAG,POWER LOCK,POWER WINDOW,REAR WINDOW DEFOGGER MANUAL AIR CONDITION,CRUISE CONTROL,TILT STEERING COLUMN TELESCOPIC STEERING COLUMN,ANTI-LOCK BRAKE SYS.,FOG LIGHTS,AUXILIARY INPUT FRONT AIR DAM,VARIABLE ASSISTED STEERING,SIDE AIRBAGS,ANTI-THEFT SYSTEM SIDE HEAD CURTAIN AIRBAGS,DAYTIME RUNNING LIGHTS,AM/FM STEREO CD/MP3 PLAYER FRONT BUCKET SEATS,INTERIOR AIR FILTER,KEYLESS ENTRY SYSTEM STEERING WHEEI MOUNTED CONTROLS Line Entry Labor Line Rem Part Type/ Dollar Labor ttem Number Type Operation Description Part Number Amount Units Inlormetion Lebels 1 000002 BDY REMOVE/REPLACE Infortn Label Air 8ag Caution 77871-SDA-A90 4.65 2 000211 BDY REMOVE/REPIACE Intorm Label NC Refrgerant 80050-SNA-H00 1.55 Front Bumoer 3 BDY OVERHAUL Frt Bumper Cover Assy 1.5 � 4 004745 BDY REMOVE/REPLACE Frt Bumper Cover "Non-OEM CAPA 223.00 INC ii 5 REF REFINISH Frt Bumper Cover C 2.6 6 005109 BDY REMOVE/REPLACE RFrtOtrBumperGdlle 71106-SNA-A50 55.02 INC 7 005110 BDY REMOVE/INSTALL L Frt Otr Bumper Grille Existing INC r 8 005077 BDY REMOVE/INSTALL Frt Bumper License Plate Bracket Existing INC r 9 005078 BDY REMOVE/REPLACE R Frt Upr Bumper Bracket "Non-OEM 31.D0 INC � 10 BDY REMOVE/INSTALL Frt Bumper Assy INC 8 11 005083 BDY REMOVE/REPLACE Frt Bumper Impact Absorber 71170-SNA-A50 72.78 INC 12 005084 BDY REMOVE/REPLACE Frt Bumper Reinforcement Bar(Alum) 71131-SNA-A00 117.10 0.4 # 13 005070 BDY REMOVE/REPLACE R Frt Bumper Bracket 71135-SNA-AOOZZ 53.65 02 # 14 RAIL END 15 005071 BDY REMOVE/REPLACE L Fr[Bumper Bracket 71185-SNA-AOOZZ 53.65 02 �r 16 RAIL END Griile 17 005191 BDY REMOVE/REPLACE Grille Trim '"Non-OEM 114.00 INC � 18 005190 BDY REMOYE/REPLACE Grille •`Non-OEM CAPA 106.00 02 N 19 005001 BDY REMOVElREPLACE Grille Emblem 75700-TFO-000 19.48 0.1 � 20 BDY REMOVE/INSTALL Grille Assy INC # ESTIMATE RECALL NUMBER: 10/24/2013 11:38:19 13-4148454-01 Mitchell Data Version: OEM: SEP 13 W023 MAPP:SEP_13_V1020 CopyrigM(C)1994-2013 Mftchell IMernational Page 1 ot 6 Sottware Version: 7.0.487 All Righ[s Reserved Date: 10l24/2013 11:38 AM Estimate ID: 13-4148454-01 Estimate Version: 0 Committed Profile ID: MeVo 7.125 All Part 21 005002 BDY REMOVE/REPLACE Grille Emblem Clip 2(�D1.60 90301-STO-D03 320 Front Lamps 22 002315 BDY CHECK/ADJUST Headlamps 0.4 23 005015 BDY REMOVE/REPLACE R Frorrt CombinaHon Lamp Assembly "Non-OEM 202.00 INC # 24 005016 BDY REMOVE/REPLACE L Front Combination Lamp Assembly "Non-OEM 202.00 INC # Hoad 25 000078 BDY REMOVE/REPLACE Hood Panel "Non-OEM CAPA 340.00 0.5 26 REF REFINISH Hood Outside C 2.6 27 REF REFINISH Add For Hood Underside C 1.3 28 000081 BDY REMOVElREPLACE R Hood Hinge "Non-OEM 18.00 02 & 29 REF REFINISH R Hinge C 0.5 30 BDY REMOVEIINSTALL Hood Assy INC 31 BDY REMOVE/INSTALL Cowl Top Panel 0.3 32 BDY REMOVE/INSTAIL R CovA Top Panel Extension Assy �•2 g 33 005123 BDY REMOVE/REPLACE Hood Latch 74120-SNA-A21 73.77 INC Coolina 34 007016 BDY REMOVE/REPIACE CoolingRadiator "Non-OEM 15120 INC # 35 000135 BDY REMOVE/REPLACE Cooling Recovery Tank '"Non-OEM 6.00 INC A!C lHeater/Ventiletion 36 006212 MCH REMOVE/REPLACE Air Cond Condenser Assy M `"Non-OEM 139.00 0.4 & 37 MCH REMOVE/REPLACE Evacuate&Recharge A/C M 1.4 38 003320 MCH REMOVE/REPLACE Air Cond Condenser Pipe -M 80341-SNE-A01 148.72 0.8 Front Fender 39 000244 BDY REMOVE/REPLACE R Fender Panel `*Non-OEM CAPA 153.U0 1.5 � 40 REF REFINISH R Fender Outside C 1.6 41 REF REFINISH R Add To Edge Fender C 0.5 42 OD0245 BDY REMOVE/REPLACE L Fender Panel "Non-OEM CAPA 153.00 1.5 � 43 REF REFINISH L Fender Outside C 1.6 44 REF REFINISH L Add To Edge Fender C 0.5 45 003963 BDY REMOVEJREPLACE R Upr Fender Garnieh 74206-SNA•A01 24.05 INC � 46 000262 BDY REMOVE/REPLACE R Fender Liner 74101-SNA A00 49.14 INC � 47 000263 BDY REMOVElINSTALL L Fender Liner Existing INC �r Frorit Inner Structure 48 002345 REF REFINISH Radiator Support Complete 1•5 49 000275 BDY REMOVE/REPLACE Front Body Radiator Support -S 60400-SNE-A012Z 268.12 8.7 # 50 000045 BDY REMOVE/REPLACE FroM Body Closing Panel 71125-SNA-A00 57.68 INC 51 000048 BDY REMOVE/REPLACE R Frorrt Body Clip 91505-S9A-OD3 2.42 52 000049 BDY REMOVE/REPLACE L Front Bady Clip 91505-S9A-003 2.42 53 OD2357 REF REFINISH R ApronlSidemember Compiete 1.5 54 002358 REF REFINISH L Apron/Sidemember Complete 1.5 55 000284 BDY REMOVE/REPLACE R Fror�t Body Apron Assy(HSS) -S 60650-SNA-305ZZ 429.95 7.5 56 000285 BDY REPAIR L Frori Body Apron Assy(HSS) S Existing 3.0'# 57 000294 BDY REMOVE/REPLACE R Frorrt Body Sidemember Assy(HSS)-S 60810-SNA-A02ZZ 332.75 4.0 � 58 000297 BDY REMOVE/REPLACE L Front Body Sidemember Assy(HSS) S 60910-SNEAOOZZ 30225 7.0 # 59 007085 MCH REMOVE/INSTALL Fuse Box -M Existing 0.3' 60 OD7412 BDY REMOVE/INSTALL Engine Wiring Harness Existing 0.7' Air Baa Svstem 61 000326 MCH REMOVE/REPLACE Air Bag ModulaDriver Front -M 77810-SNA-A82ZA 690.11 0.3 62 000333 MCH REMOYE/REPLACE R Frt Air Bag Impact Sensor M 77930 SNA-832 57.11 02 � 63 000337 MCH REMOVE/REPLACE Air Bag Control Unit -M 77960-SNA-A23 171.30 0.4 � 64 BDY REMOVEJINSTALL Console �•`� Endne 65 002387 MCH REMOVE/INSTALL Engine&Trans Assy -M 8•� � EnQne/Bodv Under Covsrs 66 005102 BDY REMOVE/INSTALL Engine Urxler Cover Existing 0.3 r Rocker/Pi I{arslFloor 67 001067 BDY REPAIR L Door Openirg Frame Existing 1.0'# 68 REF REFINISH/REPAIR L Door Ope�ing Frame C 1.5` gg MODIFIED REFINISH WITH FULL CLEAR COAT FroM Door 70 0024D3 REF BLEND R Frt Door Outside C 0.9 71 002404 REF BLEND L Frt Door Outside C 0.9 ESTIMATE RECALL NUMBER: 10l24/2013 11:38:19 13-4148454-01 Mitchell Data Version: OEM: SEP_t3_V1023 MAPP:SEP_73_V1020 Copyright(C)1994 2013 Mitchell Irrternational Page 2 ot 6 Sottware Version: 7.0.487 All Righls Reserved Date: 10l24/2013 11:38 AM Estimate ID: 13-4148454-01 Estimate Version: 0 Committed Profile ID: Metro 7.125 All Part 72 002695 BDY REMOVElINSTALL R Frt Otr BeR Moulding 0.6 � 73 002696 BDY REMOVE/INSTALL L Frt Otr Bek Moulding 0.6 x 74 OD2697 BDY REMOVE/INSTALL R Frt Rear View Mirror INC 75 002698 BDY REMOVE/INSTALL L Frt Rear View Mirror INC 76 001515 BDY REMOVElINSTALL R Frt Door Adhesive Moulding Existing 0.4"# 77 BDY REMOVE/INSTALL R Frt Door Trim Panel INC 78 includes Clean&Retape 79 001523 BDY REMOVE/INSTALL l Frt Door Adhesive Moulding E�asting 0.4'# BO BDY REMOVE/INSTALL L Frt Door Trim Panel INC 81 Includes Clean&Retape 82 002707 BDY REMOVE/INSTALL R Frt Otr Door Handle 0.7 � 83 002708 BDY REMOVE/INSTALL L Frt O[r poor Handle ' 0.7 � Root 84 002735 BDY REMOVE/INSTALL L Rooi Drip Mouldirg 0.3 85 936012 ADD'L COST HAZARDOUS WASTE DISPOSAL 3.50 ' ADDIIIONAL OPERA710NS 86 REF ADD'L OPR Clear Coat 3.8 Adddoral Costs&Meterials 87 ADD'L COST Paint/Materials 620.00 ' MANUAL ENTRIES 88 9D0500 BDY' ADD'L LABOR OP SET UP&MEASURE UNIBODYlFULL FRAME Existing 2.0` 89 Includes all necessary operations except pull[ime 90 9D0500 FRM' REPAIR PULUSQUARE UNIBODYlFRAME Existing 4.0' 91 DocumeM Control Poi�ts 92 900500 REF ' REMOVE/REPLACE FLEX ADDITIVE '"Non-OEM 2.50 ' 0.0' 93 900500 BDY" ADD'L LABOR OP COVER CAR FOR OVERSPRAY '"Non-OEM 5.00 ' 02" 94 900500 BDY' REMOVFJREPLACE TOW BILL-TAXABLE 1 TfME ONLY Sublet 75.00 ' 0.0' 95 900500 BDY ' REMOVE/REPLACE CLEAR PROTECTIVE TAPE Sublet 125.00 ` 0.0' '-Judgmem Item #-Labor Note Applies " Non-OEM CAPA-Non-Original Equipment Manufacturer Replacement Part,CAPA Cert'rfied '* Non-OEM-Non-Original Equipment Manufacturer Replacement Part G-Included in Clear Coat Calc r-CEG R&R Time Used For This Labor Operation NAPA AUTO PARTS KEYSTONE AUTOMOTIVE KEYSTONE AUTOMOTIVE PP CALL YOUR LOCAL STORE 3615 MARSHALL ST.NE 3615 MARSHALL ST.NE OR CALL 1-800-LET-NAPA MINNEAPOLIS MINNEAPOLIS MN 55416 MN 55418 (800)328-1845 (612)789-1886 (800}328-1845 {612)789-1866 (800}538-6272 34 "CU2922 75t20 9 "H01067108N 31.00 4 "H01000266PP 223.00 23 "H02503127 202.00 17 '"H01210127PP 114.00 24 "H02502127 202.00 18 "H01200198PP 106.00 28 "H01236115 18.00 25 "H01230148PP 340.00 35 "H03014115 6.00 36 ""CNDDPI3525 139.00 39 "H01241168C 153.00 42 "H01240168C 153.00 Prior Damage: SEE UPD PHOTOS ESTIMATE RECALL NUMBER: 10/24/2013 11:38:19 13-4148454-01 Mitchell Data Version: OEM: SEP 13 V1023 MAPP:SEP_73_V7020 CopyrigM(C)1994-2013 Mitchell Iriternational Page 3 oi 6 Soltware Version: 7.0.487 All Rgh[s Reserved Date: 10/24/2013 11:38 AM Estimate ID: 13-4148454-01 Estimate Version: 0 Committed Profile ID: Metro 7.125 All Pa�t All manufacturers requirements regarding seat belt and supplemental restraint system replacement must be adhered to. If additional parts or operations are necessary to properly accomplish this, please contact the estimating claims rep. Estimate Totals Add7 Labor Sublet I. Labor Subtotals Units Rate Amount Amount Totals II. Part Replacement Summary Amount Body 45.8 52.00 0.00 0.00 2,391.60 Taxable Parts 4,911.57 Refinish 22.8 52.00 0.00 0.00 1,185.60 SalesTax � 7.125% 349.95 Frame 4.0 70.00 0.00 0.00 280.00 Mechanical 11.8 80.00 0.00 0.00 944.00 Non-Taxable Parts 125.00 Non-Taxable Labor 4,79120 Total Replacement Parts Amount 5,386.52 Labor Summary 84.4 4,79120 III. Additional Costs Amount IV. Adjustmen[s Amount Taxable Costs 620.00 Insurance Deducfible 500.00- Sales Tax � 7.125Mo 44.18 Customer Responsibility 500.00- Non-Taxable Costs 3.50 Total Additional Costs 667.68 Paint Material Method:Rates Init Rate=32.00 I. Total Labor: 4,791.20 II. To[al Replacemen[Parts: 5,386.52 III. To[al Additional Costs: 667.68 Gross Total: 10,845.40 IV. Total Adjustmerrts: 500.00- Net Total: 10,345.40 Point(s)ot Impact 1 Rght Front Comer{P) Insurance Co: PROGRESSIVE InspecGon Si[e: Burnsville Service Cerrter Address: 12450 River Ridge Ct Burnsville,MN 55337 ESTIMATE RECALL NUMBER: 10/24/2013 11:38:19 13-4148454-01 Mitchell Data Version: OEM: SEP 13 V1023 MAPP:SEP_13_V1020 Copyright(C)1994-2013 MRchell Irrternational Page 4 ot 6 Soitware Version: 7.0.487 All Rghts Reserved Date: 10/24/2013 11:38 AM EstimatelD: 13-4148454-01 Estimate Version: 0 Committed Profile ID: Meho 7.125 All Part THIS IS A DAMAGE ASSESSMENT ONLY - NOT AN AUTHORIZATION TO REPAIR - BASED ON DAMAGE VISIBLE OR CERTAIN AT THE TIME IT WAS WRITTEN. IF FRAME OR UNIBODY REPAIR IS INCLUDED ON THIS ESTIMATE, THE AMOUNT SHOWN INCLUDES TIME OR ALLOWANCE FOR MEASURING BEFORE, DURING AND AFTER THOSE REPAIRS. THE OWNER OF THE VEHICLE MAY SELECT THE REPAIR FACILITY OF HIS/HER CHOICE. TO ENSURE PROPER AND PROMPT PAYMENT FOR ADDITIONAL DAMAGE DISCOVERED DURING THE COURSE OF REPAIRS, CONTACT PROGRESSIVE FOR SUPPLEMENT HANDLING PROCEDURES. PROGRESSIVE HONORS THE PREVAIZING LABOR MARKET RATE IN YOUR AREA FOR YOUR PROPERTY. IF YOU CHOOSE A SHOP THAT CHARGES IN EXCESS OF PREVAILING LABOR MARKET RATES, YOU WILL BE RESPONSIBLE FOR THE DIFFERENCE. LIFETIME GUARANTEE FOR SHEET METAL AND PLASTIC BODY PARTS The replacement parts written on the estimate are intended to return your vehicle to its pre-loss condition with proper installation. After repair, if any sheet metal or plastic body part included in the estimate fails to return your vehicle to its pre-loss condition (assuming proper installation) , in terms of form, fit, finish, durability or functionality, Progressive will arrange and pay for the replacement of the part, to the extent not covered by a manufacturer's or other warranty. This service will be performed at no cost to you (including associated repair and rental car costs) . To obtain service under this Guarantee, call Progressive at 1-B00-274-4641. This Guarantee applies as long as you own or lease the vehicle. This Guarantee is not transferable and terminates if you sell or otherwise transfer your vehicle. THIS GUARANTEE DOES NOT COVER NORMAL WEAR AND TEAR OR DAMAGE CAUSED BY IMPROPER MAINTENANCE, NEGLECT, ABUSE OR SUBSEQUENT ACCIDENT. THIS GUARANTEE IS LIMITED TO AARANGING FOR THE SELECTION OF REPAIR PARTS THAT VPILL RETURN YOUR VEHICLE TO ITS PRE-LOSS COND2TION. ACCORDINGLY, PROGRESSIVE VPILL NOT BE LIABLE FOR ANY INDIRECT, INCIDENTAL OR CONSEQUENTIAZ DAMAGES THAT RESULT FROM THE INSTALLATION OR USE OF THESE PARTS. Part Type Terms and Abbreviations NEW and OEM or part number displayed - These refer to a new, original equipment manufacturer part. NON-OEM and A/M and Qual REPL - These refer to an after-market part, which is a new, non-original equipment manufacturer part. USED/RECYCLED and LKQ - These refer to a used OEM part. REMANUFACTURED and RECOND, and RECORE - These refer to used/recycled OEM parts that have been refurbished. REPAIR SHOP'S AUTHORIZED REPRESENTATIVE'S SIGNATURE INDICATING AGREEMENT ON COST TO RETURN THE VEHICLE TO PRE-LOSS CONDITION ESTIMATE RECALL NUMBER: 10/24/2013 11:38:19 13-4148454-01 Mitchell Data Version: OEM: SEP 13 V1023 MAPP:SEP_13_V1020 CopyrigM(C)1994-2013 Mitchell Irrternadonal Page 5 oi 6 Sottware Version: 7.0.487 All Rghts Reserved , � Date: 10l24/2013 11:38 AM EstimatelD: 13-4148454-01 Estimate Version: 0 Committed Profile ID: Metro 7.125 All Part INCLUDING TOW/STORAGE CHARGES: SHOP SIGNATURE: EST. COMPLETION DATE: ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE/SHE IS FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD. Event Log File Created: 10122/2013 08:48:17 AM Estimate Started: 10l22/2013 08:51:46 AM Esbmate Printed: 10l24/201310:11�41 AM Esdmate Committed: 10/2412013 11:38:19 AM Esdmate Uploaded: Es6mate not uploaded ESTIMATE RECALL NUMBER: 10J24l2013 11:38:19 13-4148454-Ot Mitchell Data Version: OEM: SEP 13 V1023 MAPP:SEP_13_V1020 CopyrigM(C)1994-2013 Mitchell Irrternational Page 6 oi 6 Sot[ware Version: 7.0.487 All Rghts Reserved Page 1 of 4 ��►�,�..�,.��i�° Progressive Direct Insurance Co Total Loss Settlement Report 2900 43RD STREET NORTHWEST SUITE 300 ROCHESTER, MN 55901 (5�7) 226-9879 Date: 2/7/2014 Pr'ePared by: THOMAS SHOVEIN Owner: JEFFREY C BAILEY Claim Number: 134148454 Vehicle:09 HONDA CIVIC Date of Loss: 10/20/2013 VIN: 19XFA16599E047791 Adjuster License: Important information regarding your settlement offer and explanation of Actual Cash Value (AC1� We would like to inform you that we have made a determination regarding the total loss of your vehicle. Our settlement is based upon evaluation of your vehicle's actual cash value. If a lien holder is involved, the payment to you may change based upon the exact payoff amount of your loan. In order to determine your vehicle's actual cash value, we have pertormed a detailed evaluation of the vehicle's condition and probable value immediately prior to the loss. We will demonstrate how we arrived at this amount so you may be confident that our value is fair and reasonable in the current local market. We will include applicable taxes and fees when required by law. �ur settlement, less any applicable deductible amount, is contingent upon our receipt of a "clean" title with no liens attached. In most cases, we will also collect and arrange for the disposition of your damaged vehicle. We will need the actual title for the vehicle in order to complete this process. You may retain the vehicle salvage in some instances. Please note we make the appropriate deduction for the salvage amount when presenting our settlement offer to you. Additional titling requirements may also need to be completed. If you disagree with our valuation of your vehicle's actual cash value, we will consider your opinion and may revise our determination if credible information is presented to us. If you are insured with us and the amount of the vehicle's actual cash value remains in dispute, either party may request to proceed under the Appraisal section of your insurance policy contract. Please refer to your policy http://tlaweb/alphalT'LAWeb/default.aspx?page=PrintViewMenu... 2/7/2 0 l 4 Page 2 of 4 contract for more detailed information on the Appraisal process. I To determine the Actual Cash Value (AC� of your vehicle, we will: . Determine the baseline value . Make adjustments to account for any excessive wear and tear and/or prior damage The local market value does not take into consideration your particular vehicle's condition, unrepaired prior damage or excess wear and tear. We will itemize and estimate the cost of repairs and work that would make your vehicle comparable to the market value determined. We may add or subtract for generalized "dealer prep" or reconditioning charges if the vehicle requires adjustment. We may ask you to provide information about the vehicle that is not readily apparent by inspecting it, such as general maintenance and repair history, title history and title status (such as clean or rebuilt salvage). . Include the value of extraordinary refurbishments or repairs Vehicles in exceptionally clean condition may appraise higher than retail value. We also consider the cost and value of recent refurbishments. In general, though, refurbishment or recent replacement of maintenance type items does not increase the value of the vehicle, because those items are assumed in the value; they are expected to be in place and in good condition when a vehicle is sold. 1 Baseline Value $12,176.33 http://tlaweb/alphal'I'L,AWeb/default.aspx?page=PrintViewMenu... 2/7/2Q 14 Page 3 of 4 2 Preexisting Damage $0.00 �o.00 x o.00 ��o 3 Condition Adjustment $0.00 4 Refurbishment(s) $0.00 5 Custom Parts 8� Equipment $0.00 6 Actua! Cash Value $12,176.33 7 Fees $57.16 8 Taxes MN TAX $12,17fi.33X 6.50 % =$791.46 Taxes applied to settlement $791.46 9 Net Settlement $13,024.95 10 Deductible ($500.00) 11 Total Settlement $12,524.95 http://tlaweb/alpha/'TI.AWeb/default.aspx?page=PrintViewMenu... 2/7/2014 Page 4 of 4 Lien Holder Account Balance (Amount You Owe) HONDA FINANCIAL SERVICES Payoff as of 11/4/2013$7,495.88 $7,495.88 Net to Owner $5,�29.07 http://tlaweblalphaJ'I'LAWeb/default.aspx?page=PrintViewMenu... 2/7/2�]4 I , REMITTANCE: 42017262 i � DATE: 0'�109/2Q14 iNSU�nNCs AUIn AUCflONS Remittance Payable To: insurance Auto Auctions.Inc. Progress�ve Casualty Jnsurance-Corporate Attn:SetUement Gsoup 6055 Parklend 81vd. Box EM-3 Two Westbrook Corporate Center Suite 500 Attn: Natlonal Salvage Unit Westchester, Il. 60154 Mayfield Heights,OH 44124 Phone (7Q81492-7000 Attn:Salvage Qept Fax: 17Q8)492-7078 E-mail Total Salvape lnformation Account of Sale Acfivifv ACV IAA Stock#: 000-12157181 Sales $2,500.00 2d.53 IAA Branch: Minneapolis/St.Paul IAA Charges Fed.7ax I.D. 953790911 Consignmer�t Ffat Fee $85.00 0.70 Adjuster: Tttomas Shovein DMV Filing Fee $10.00 0.08 Insured: Jeffrey Bailey State/Local Transfer Fee $8.25 0.07 Owner. Jeffrey Bailey Claim#: 13-4146454 Policy#: Less IAA Charges ($103.25) (0.85) Vehicle: 2a09 HONDA CIVIC Net IAA Retum $2,396.75 19.68 Damage: Front end/ pa ment Amount o VIM: 19XFA16599E047791 y $2,386.75 19.68°� ACV: $12,176.00 NfC6 Date: 1l0912094 Buye[Information � A&P Auto,LLC 12515 Pennsvlvania Ave Suite 4 Savaae, MN 55378 Resale Certificate#: 8480085(MN) Efaosed Day,s Analysis Date of Evsnt: DaEe Davs Loss �0/20/2013 — Assigned 10/29l20l3 �D Releaser3 10l30l2013 2 Pickup 10130I2013 � i Title Rec'd �2/11/2013 43 Safe Doc.Rec'd 92f2312013 �3 Auction Date 1/8l2014 �� Buyer Payment N/A � Remittance 1/912014 2 i Elapsed Total Days: 82 IAA Doc.RP002.rp1 + � Received Date: 01/13/2014 e� Cross Country Motor Club VIMS lnvoice _ �OrOA ctve � ,u.;�7 ,�a�{ k � �� f , ��1��*�i•�� aS�9a �S 4��E� : :��.ti�� .�� I ti E��. w ti � ti h �' 44� : �.s i� sv��;�bzti� R�'�.si=��'{�:s'�F`i�1:t.;d�a��: 3.. ! s3.. :��il�t3 a'��7�4 s yS a S,�i�.t t:x9ar?pab'�7��4.-. �ss i�n� � I�7F��aF.�'! �i`I.� i�6��..�?z��9�..�'�.......8'z33 fl4i5?5.2s�i�..a@i..�%._3Eana:.ef..._..a.�83w38affF_e3?W..?:!i!?df�E?ce!@!t?.?ai@.e._�IPn33..s9u�..a9kPa.d3R4�..7.ri90ifi.3}5sF.iitE5..9i8t�..xP.l8.5..il.Fnv3�c.@E..�i Rn:xe BIII To: Claim Number 134148454 Progressive Insurance Case# VMJ-1310746510-2 Ar.count Progressive lnsucance Invace Date Od 30,2013 PaymenR Terms Net 7 Balance Due _ _ $14�{X} Remit Payment To: Cross Country Mator Club 1 Cabot Rd Medford,MA 02155 Contac�vimsbilling�crosscou�try-auto.cortt TIN:04-2530679 Please enter ihe Case number in fJre remarks section of the paymeM 8i�1 in�D�etai l ' � �; �� 4 � s � . ; '.:: .. ..._:F' . .. .....: . ...... .: ... ....'..ss.._s...FS�S 4�...axkfeF �as.e .,4��":x..e _.. ..e ._7,..9c...v....e_: vsras.s._.��t:e:...Fs R.�.u..e: Cusbomer Name SeN�ce Vehids Tow Advance Tow 8�Servlce Total D:be Class Mileage Charg� Charge Charges JEFFERY BAILEY 0�21'21113 Light Duty 3 50.00 ;140.00 5140.00 201:17 PM . ��11��#l�!`s" ' ' ;. :; . ...:..::: .... . .:::.:..�,::.... _ :,._.. _.__... .... : ... ..:. ._.. .::. . _: ......._ .. .......: :.:__.. __ ... . .. Year Make Model Plate VIN 2008 Honda CNIC NJA ASM � � . . .0 � f:: S � ' . - -.. . .. . i:h .'. S'�;�f��"�� uS� I� u��. �,�� sE � 1�� i��i 2 sf : � a E£ � 3° hs � �' t� � � � �i��-��?£r� � �r ` s: i�s{uL .i7..i.hx�.�LBer��.'�i��..xxiLR�6i•�IAS�nwn id.RiM�6+S��im�F. J.iiio�#&n.8� 'iii�xdin.YBS��i�. 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( ) Updated Medpay subrogation balance$ ( ) We have been awaiting payment on the above subrogation claim. Please forward payment immediately to: Sufxogatbn Payment Processing Center 24344 Neh�lc Plaoe Chicago, il 60673-l243 (G�� Other: ��s�. c�tiTO��-� u s R�� S��s o F �c.,�iw�-• `R+�tr.''f=s�: Sinc�+ely, � CSRISTOPSER WOOLFOLK ��S Subr�gation Repres�taf,ive - 440-603-7806 � ,4 ?-T� � oS u P�e �,�.� . , _ � . ��