Ray �
ZIMBRICK INC. BODY SHOP
AT FISH HATCHERY ROAD PH(608)273-2060/FAX(608)277-2223
AT STOUGHTON ROAD PH(608)241-5201 /FAX(608)241-4931
AT HIGH CROSSING BLVD.PH(608�41-3475/FAX(608)441-0502
"`PRELIMINARY ESTIMATE***
01/20/2014 11;35 AM
_____,__._.___________
-_.___._.____.__.__.�,�_._.��__
�.__.____________._. _...__ _ _,
; Owner `
Owner: CHERYL RAY
Address: N2959 TOMLINSON RD Work/Day: (608)334-9999
City State Zip: Poynette,WI 53955 FAX:
Email: jandcray@centurytel.net
Control Information �� �
Claim#: UNK Insured Policy#:
_._.__ _.___.__. _____. . ._.__.__....��.,�
---��_____r___._.____�__.._.__._.__. . __--__ ... ___ ____-__._ _�_ __�_ �.__._ _..____..____
__._ �___._. .
Inspection
Inspection Date: 01/20/2014 11:33 AM Inspection Type: Drive In
Primary Impact: Left Front Side Secondary Impact:
Driveable: Yes Rental Assisted:
Appraiser Name: Kyle J Griepentrog Appraiser License#: 39-0963195
Address: 5421 Wayne Terrace Work/0ay: (608)316-8883
FAX: (608�41-0502
City State Zip: Madison,WI 53718 Work/Day:
Email: kyle.griepentrog@zimbrick.com
_._._.____'�___.�_..___.�_�_.__..___.�.. . _,�.,._----,
; Repairer �
w._._....___-.---____�.�._.._.____._.______
_ � ..�-- ---___._---.._._._.___..
Repairer: ZIMBRICK BODY SHOP Contact:
Address: 5421 WAYNE TERRACE Work/Day: (608�41-3475
City State Zip; Madison,WI 53718 FAX: (608)441-0502
�._..._-------- - ____._ ____..___------------_�__.�------______.__.________._-------_�_.____._______._____ __----- ---.______V__- ------...._._.,
Remarks �
ORIGINAL ESTIMATE IS OPEN TO MORE HIDDEN DAMAGE
ESTIMATE IS OPEN TO PART PRICE DIFFERENCES
____v—.—_�_ __ ________.�.__
� _��..�_.�__�� ___.__.�._�__�.__._.___._ _
; Vehicle
2011 Buick Enciave CXL-1 4 DR Wagon
6cyi Gasoline 3.6 �
6-Speed Automatic
Lic.Plate: 485-NHU Lic State: WI
Lic Expire: 07/2014 VIN: SGAKVCED7BJ150015
Prod Date: 07/2010 Mileage: 53,102
Veh insp#: Mileage Type: Actual
Condition: Code: S7764B
Ext.Color: RED JEWEL TINTCOAT Int.Color:
Ext.Refinish: Three-Stage UserDefined Int.Refinish: Two-Stage
Ext.Paint Code: 301 N,GAQ int.Trim Code:
O7l20/2014 11:48 AM Page 1 of 3
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._ �_.�.._.�_ _ _<4
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Claimt�: UNn C;/202C14 Y,:3�.;t�t
, ��:.�!j$
2nd Row Head Airbags 3rd Row Head Airbags 4-Wheel prive
7 Passenger Seating AMlFM CD Player Alarm System
Hlui�lii�uiiiiAii�y'vvi�cc�a Ar�i�-i.G�n�;�6��� A;:.G��'�..�,.���r...,��.�,,,
Automatic Dimming Mirror Bodyside Cladding Bucket Seats
Center Console Chrome Grille Cniise Control
Daytime Running Lights Driver Seat Memory Dual Air Conditioning
.�.. _: :,:._.. -..._.:,_.. __::��iS r..._.: -...:• .....:.... ::,a�:pOr.S
u..���,��..��S ,.��� ......� ....,.,. .., �.........,
Duai Zone Auto A/C Emergency S.O.S.System Floor Mats
Fog Lights Garage Door Opener Head Airbags
Nea:ed Front Seats ��4:�d Pcwer Mirrors H;gh ln:�^sity Noadiamps
II�tR?1in2tR(i Vicnr hhirmr inta�r.;...�... _ .. _ �V., -_- — _ .
. "',,, �� . 'i ,:i:--..-
Leather Seats Leather/Wood Steer Wheel Lighted Entry System
MP3 Player Mirror(s}Memory OnStar System
Power Brakes Power poor Locks Power L+ftyate
Power Sieering rOWef VVIf1cjOW� �iiveCy viaSS
Rear Spoiler Rear View Camera Rear Window Defroster
Rear Window Wiper/Washer Rem Trunk-L/Gate Rel2ase Remote Startar
R�verse�ensing�ystem RooflLuggage Rack S?!'Q�!��^'.•'p'�^':^��^a'�
Side Airbags Stability Cntrl Suspensn StePring Linked Headlmps
Strg Wheel Radio Control Tachometer Theft Deterrent System
Third Seat(trucks) Tilt 8�Telescopic Steer Tinted Glass
T;.e D�nec�irp 11Annitnf Traction Control System Trip Computer
Tutone Paint Wood Interior Trim XM Satellite Radio
---_. ._. ---._____._.._. ____ __.._.__ __ __..._.__._.___.
_ ___ - __._.. � _.__.. .. _ -_. . __..._ _ __ _
___. __
Damages ;
Line Op Guide MC Description MFR.Part No. Price ADJ% B°/a Hours R
Front Doors
1 R► 231 Pnl,lnner poor Trim LT R&I Assembly 0.4 SM
2 E 245 Mirror,0uter R/C LT 25867122 GM Part $323.93 0.5 SM
3 L 245 14 Mirror,0uter R/C LT Refinish 1.7 RF
0.5 Surface
1.0 Three-stage setup
0.2 Three-stage
Manual Entries
4 SB M60 Hazardous Waste Removal Sublet Repair $3.00' SM
4 Items
MC Message
14 INCLUDES 1.0 HOURS FIRST PANEL THREE-STAGE ALLOWANCE
,�—.__ __.__ _____..--__ __ . _ _____-----_._-- -----_______ -------------_._�_--�___._.____ . _._.__
_ _.____�_. _.__..__. .. _..
Estimate Total 8�Entries
Gross Parts $323.93
Paint Materials $61.20
Parts&Material Total $385.13
Tax on Parts&Material @ 5.500% $21.18
Labor Rate Replace Repair Hrs Total Hrs
Hrs
Sheet Metal(SM) $65.00 0.9 0.9 $58.50
Mech/Elec(ME) $112.00
Frame(FR) $85.00
01/20/2014 11:48 AM Page 2 0�3
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Clailt#� UNK + 07QOI201411:35AM
Refinish(RF) $65.00 1.7 1.7 $110.50
Paint Materials $36.00
Labor Total 2.6 Hours $169.00
Tax on Labor @ 5.500% $9.30
Sublet Repairs $3.00
Tax on Sublet @ 5.500% $0.17
Gross Total $587.78
Net Total $587•78
Altemate Parts Y/00/00/00/00/00 CUM 00/00/00/00l00 Zip Code:53718 Defauit
Audatex Estimating 7.0.123 ES 01/20/201411:48 AM REL T.0.123 DT 01/01/2014 DB 01/15/2014
Copyright(C)2013 Audatex North America,Inc.
1.2 HRS WERE ADDED TO THIS ESTIMATE BASED ON AUDATEX'S THREE-STAGE REFINISH FORMULA.
THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF ONE OR MORE REPLACEMENT
PARTS SUPPLIED BY A SOURCE OTHER THAN THE MANUFACTURER OF YOUR MOTOR
VEHICLE. WARRANTIES APPLICASLE TO THESE REPLACEMENT PARTS ARE PROVIDED BY
THE MANUFACTURER OR DISTRIBUTOR OF THE REPLACEMENT PARTS RATHER THAN BY THE
MANiJFACTURER OF YOUR MOTOR VEAICLE.
Op Codes
' = User-Entered Value E = Replace OEM NG= Repiace NAGS
EC= Replace Economy OE= Replace PXN OE Srpls UE= Replace OE Surplus
ET= Partial Replace Labor EP= Replace PXN EU= Replace Recycled
TE= Partial Replace Price PM= Replace PXN Reman/Reblt UM= Replace RemanlRebuiit
L = Refinish PC= Replace PXN Reconditioned UC= Replace Reconditioned
TT = TwaTone SB= Sublet Repair N = Additional Labor
BR= Blend Refinish I = Repair IT = Partial Repair
CG= Chipguard RI = R&I Assembly P = Check
AA= Appearance Allowance RP= Related Prior Damage
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 u da�a.,x Audatex's prior written consent.
d C(t1L'!a CL�'�11j3+3(tV
- Copyright(C)2013 Audatex North America,Inc.
Audatex Estimating is a trademark of Audatex North America, Inc.
01120l2074 11:48 AM Page 3 of 3
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PO Box 4025
St Paul, MN 55104
Phone:651-247-9783 Fax:651-641-1818
February 11, 2014
Cheryl A. Ray �
N2959 Tomlinson Rd
Poynette,WI 53955
Dear Cheryl,
On the February 3, 2014 we were notified that you fited a damage claim on your 2011 Buick
Enciave.According to damage claim we were given the reason you stated for the claim was:
"housing unit cracked."
We are denying this referenced claim due to no components of a tow truck touch that location
that you are claiming was damaged.
Due to these facts listed above we are assuming no responsibility for the damages on the claim
you submitted.
If you have any questions or concems regarding this letter please feel free to contact our office.
Sincereiy,
Missy M. McMurray, General Manager �
�
PLC Recovery"PO Box 4025 St Paul, MN 55104"Phone 651-247-9783 * Fax:651-641-1818
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� ��B 27 2�'�t
CITY CLERK
NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minnesotu Stnte Statute 466.05 states�hat "...every person...who clai�ns damnges fro�n uny r�zunicipaliry...shnll cause to be presented to the
governing body of tlze�nunicipaliry within 180 da}�s after the alleged loss or injciry is discovered a notice stnting the time,place,und
circiunstances thereof,and the amoz�nt of compensation or other relief clemanded."
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 6e signed,and both pages completed. If something does not apply,write`N/A'.
SEND COMPLETED FORM AND OTHER DOCUMEIVTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
First Name h er � Middle Initia]� Last Name��
Company or Business Name -'�'
Are You an Insurance Company? Yes/� If Yes,Claim Number?
Street Address � 2�5`� T�rr���Son �
City�M��e-- State �� Zip Code S3���
Daytime Phone(�)J73��e11 Phone(�;I�- ��vening Telephone(�)33y- ��q�1
Date of Accident/Injury or Date Discovered �� � a � � Time (��3O am pm
Please state,in detail,what occurred(happened),and why you are submitting a claim.Please indicate why or how you
feel the City of Saint Paul or its employees are involved and/or responsible for your damages.
1�e..1�-���Ut. i�.-' Q S '!zi d S r o�r.i � Urr� �'o�-l-�. . C-l�+ ���lZa d
� u '. vs�J I b o d . ' �' �b�c1
. � e. � �v� �1 vu..r G.c� u
��✓ Gct� v J�Fa,J � � ��- ' If�ro-1�d �_
y��`��� v. .� ow ., �, � re}v�{� -4c)
L' n U.(�� �rM aC - Gv� -��o �-- � � G,��o
k-n o 1L a ��-kv;r�,. �f ovr �- �`� U�.a I �� c� . �.cv� i�.r(�s �n� V�wv,��d
Please check the box(es)that most closely rep sent the reason for completing this form: ��v„Y� (�Y�d� bY� 5�1'�,�-' �5
O My vehicle was damaged in an accident �'�My vehicle was damage�during a tow l, �—
❑ My vehicle was damaged by a pothole or condition of the street ❑ My vehicle was damaged by a plow �x�` .t3-
❑ My vehicle was wrongfully towed and/or ticketed ❑ I was injured on City property UJ�_� ��C�J
❑ Other type of property damage-please specify �,� ,
❑ Other type of injury-please specify
In order to process your claim you 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.
�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
andlor receipts far 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
;t I� :
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims-alease comulete this section , 1
Were there witnesses to the incident? Yes No Unknown (circle)
Provide their names,addresses and telephone numbers:
Were the police or law enforcement called? YesJ No Unknown (circle) •
If yes,what department or agency?�LbU.('c:l (o}� 51-0,'�� Case#or report# '� �' � '�.0�+`�
� 1 �
Where did the accident or injury take place? Provide street address,cross street,intersection,name of park o(��•,,f-acility,
close t land?�k,etc. Please be as de,tailed as possible. If ne essary,attach a diagram.l�U`�CMr�t}.1 1'W��/1
��� SQ_`�'.�.� �V`� O��f 4� ��ov�cl 1 f)'�" $3� �G��2 ���f�1�Cl 2aa�J
Please indicate the�ount you are eekin in compensation or what you would like the City to do to resolve this claim
to your satisfaction. �7�� ��- �DJ- -�S h,pr�n, i � l�r�� cA .
Vehicle Claims- lease com lete this section O check box if this section does not a 1
Your Vehicle: Year ���( Make����-lL Model �� I �!C._.
License Plate Number ��S NH 1/l. State�=Color E D
Registered Owner I 2a�
Driver of Vehicle C�M u ,1 y
Area Damaged�"�U'�tr �'�c�a— UJ���'�✓'
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name) �
Area Damaged
Iniurv Claims-please complete this section �check box if this section does not avnlv
How were you injured?
What part(s)of your body were injured?
Have you sought medical treatment? Yes No Planning to Seek Treatment(circle)
When did you receive treatment? (provide date(s))
Name of Medical Provider(s):
Address Telephone
Did you miss work as a result of your injury? Yes No
When did you miss work? (provide date(s))
Name of your Employer:
Address Telephone
gQ Check here if you are attaching more pages to this claim form. Number of additional pages��: Z P��h11'es
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 � �� I 7�I'-� � ��r �sr �
�v..w C�rrpaY��
Print the Name of the Person who Completed this Form: � j��-
Signature of Person Making the Claim: �•
Revised February 2011
' �
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� Sa;�t Paul Police Impound Lot, 830 Barge Channel Road, Vehicle Release Form
Make: 11 BUICK License#: 485NHU CN: 14011327 Invoice#: 26158
Date/Time Released: 01/19/2014 08:17 Tow Charge: $ 123.95
Released to: TOTO Storage Charge: $ 0.00
Paid by: CASH Admin Charge: $ 80.00
Released by: LARRY Tax: (7.625%) $ 15.55
I,the undersigned,have recovered the vehicle described above. Subtotal: $ 219.50 �
I will check the vehicle for damage or any other problems that
may have occurred while this vehicle was in the custody of the Service Charge: $ 0.00
Saint Paul Police Department. I acknowledge I will report
damage and/or any other problems to the Impound Lot staff Total Charges: $ 219.50
on this form prior to leaving the impound lot. �
��' `� ._ ��� �i� . . i i k�. ��.\1i 1�:�j� �'�.\s��� ✓t��`V�.. �M�-t�,,i� '_y` ,'� .
Damage and/or other probler�� G i��� -° `� � — �
��
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�2, ovi-c� �o ��,� c.o�^�ar
Police Report made: Yes_No�IF Yes, CN , If NO, Why? P �
�-�..v�S�r� � j�,-�` )�t;,s �Tsi���cke�i �-c, d a �� 1�o".v�cl l b�- S�v.Ff=
TO PROTECT YOUR RIGHTS REPORT ANY PRO�LEMS/DAMAGE BEFORE LEAVING THE LOT
� � . si2000
Signature `-
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