Hellenbrand RECEIVED
MaR 2 s zoi�
NOTICE OF �LAIM FORM to the �ity of Saint Paul, 1M�3��s�$E R K
Minnesota State Statute 466.05 states that"...every person...who claims damages from any municipality...shall cause to be presented to the
governing body of the municipalily within 180 days after the alleged loss or injury is discovered a notice stating the time,plac�and
circumstances thereof,and the amount of compensation or other relief demanded."
Please complete thLs 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 clarit�answers,so provide as
muc6 information as necessary to ex;►lain your claim,and the amount of compeasation being requested. You will receive a
written acknowtedgement once your form is received. The process can take up to ten weelcs or longer depending on the
natare af yonr etaim. This form must be signed,aad both pages com�etal. If samething @aes nat aPP�Y�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�. C� �' � Middle Initial � Last Name �2 I I�V1�CJ�G!Vl GI
Company or Business Name I�'a I Y i�12vt1 �P1.t ��� SG Y'V iCC'�
Are You an Insurance Company? Yes/ To If Yes,Claim Number?
Street Address � �` ��rz ��"t E'v� S`�Y'2��
City �Ct t v1fi �Gt � � State /VI I ►1 v1 G5 O�G{ Zip Code.�L�
Daytime Phone(�j�7 R�D(:ell Phone(�)� � �u oEvening Telephone(5a rrJ�b�V i 6u s
Date of Accidend Injury or Date Discovered � �—oZ�``aZD I �{'Time °�� am/� q P�roX i w►at��y '
/
Please state,in detail,what occurred(happened),and why you aze submitting a claim.Please indicate why or how you
fe�l the�}'ry vf Sainc Paul or it�employus�re involvecl and/or responsible for your d�mag�s,
I T l� L� t`�-For►v�a+�o � �s St�fe� o �n ct
�
a e5 0
,� � �
Please check the box(es)that most closely represent the reason for completing ttus 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 ricketed O 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 you need to include couies vf all ar�nlicable dvcuments.
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 PropeRy damage claims to a vehicle: two estimates for the repairs to your vehicle if the damage exceeds
$50�.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
U Other property damage claims: two repair es�imates if the damage exceeds$500.(�; or the actual bills
and/or receipts for the repairs;detailed list of damaged items
O Injury claims: medical bills,receipts
O Photographs aze 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 pa�es will result in delay in the handling of your claim.
All�laims—ulease comvlete this section
Were there witnesses to the incident? es o Unknown � (c' clg)
Provide their names, addresses and telephone numbers: ��� v. �I 1� � e�_ �
Were the police or law enforcement called? Yes No Unknown (circle I!
If yes,what department or agency?Sct�N'I"' P�1 �01 t c� Case#arCreport#���– d��L�� �p !,
Where did the accident or injury take place? Provide street address,cross street,intersection,name of park or facility, '
cl�sest landmark,etc. Please be as detailed as possible. If necessary,attach a diagram.
� r2c o ` e ` S �Y�r -F � ' t n�-�-���,��
T b ��� � t oc:c�rrecf abJ�f.bD � �-t.e si- af- �v►qq o+� UnIY2v�S('� Ave ti ,
Please�`in�icate t�e amo nt you are seelc�n m compensanon or what you woutd l�e the City to do to re�lve this claim
ta yr,ur satisfacuan. �� OO ` � �I� � i�ke, w►v V e� i C�e to b c� � �'ke
i -t- w�, � ��rc, -1-I�� u�c�'�l p�+ +o ak �o c�r.�?.
Vehicle Claims— lease c m let his section ❑ch ck box if this section dces not a 1
,
Your Vehicle: Year Make Mc�del �
License Plate Number —G S State Color S��� vC'Y'
Registered Owner r v� �i h
Driver of Vehicle v� v' H ,
Area Damaged -S � ' � a f' ,•-l.d riveYs side�
City Vehicle: Yeaz Make odel
License Plate Number State Color �
Driver of Vehicle(City Employee's Name) �
Area Damaged e ' �
r
I Claims— 1 com lete his section ❑check x if this section does not a 1
How were you injured? r �
e l� ' v
What part(s)of your body were injured?
Have you sought medical treatment? Yes o Planning to Seek Treatment(circle)
When did you receive ueatment? (pmvide date(s))
Name of Medical Provider(s):
Address Telephone
Did you miss work as a result of your injury? Yes
When did you miss work? (provide date(s))
Name of your Employer: ,
Address Telephane
�h k here if you are attaclring more pages to this claim form. Number of additional pages�.
I s-f�a"�"�w�eh-f-, �j�°9s. reGei p'ts, I3�oqs� esfi���t-e..s]
By signing is��rm,you are stating that all inforfnation yo�i ytave provided is true and c�rrect tp the best
of your knowledge. Unsigned forms will not be processed.
Submitting a false claim can result in prosecution. Date form was completed �J � — �"1` �� � �
Print the Name of the Person who Completed this Form: D1i' ClG-' �
Signature of Person Mal�ng the Claim:
Revise�February 2011
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RAYMOND AUTO BODY� INC. Workfile ID: b51625dd
FederalID: 41-0888257
1075 PIERCE BUTLER RTE, SAINT PAUL, MN
55104
Phone: (651) 488-0588
FAX: (651) 488-4794
Preliminary Estimate
Customer: HELLENBRAND, GREGORY 7ob Number:
Written By:JOHN]ANASZAK
Insured: HELLENBRAND,GREGORY Policy#: Claim #:
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact: 06 Rear
Owner: Inspection Location: Insurance Company:
HELLENBRAND,GREGORY RAYMOND AUTO BODY,INC.
(651) 214-7908 Day 1075 PIERCE BUTLER RTE ,
SAINT PAUL, MN 55104 �
Repair Facility
(651)488-0588 Business '
�I
VEHICLE I
�
Year: 1997 Body Style: 4D SED VIN: 1HGE76526VL011401 Mileage In:
Make: HOND Engine: 4-1.6L-FI License: 374-CJR Mileage Out: �
Model: CIVIC DX Production Date: State: MN Vehicle Out:
Color: SILVER Int: Condition: )ob#: I
i
TRANSMISSION Body Side Moldings FM Radio Reclining/Lounge Seats ;
Overdrive Tinted Glass Stereo WHEELS
S Speed Transmission CONVENIENCE SAFETY Wheel Covers
POWER Intermittent Wipers Drivers Side Air Bag PAINT
Power Steering Tilt Wheel Passenger Air Bag Clear Coat Paint
Power Brakes Rear Defogger SEATS
DECOR RADIO Cloth Seats
Dual Mirrors AM Radio Bucket Seats I
3/3/2014 2:30:06 PM 019495 Page 1
Preliminary Estimate
Customer: HELLENBRAND, GREGORY ]ob Number:
Vehicle: 1997 HOND CIVIC DX 4D SED 4-1.6L-FI SILVER
Line Oper Description Part Number Qty Extended Labor Paint
Price$
1 FRONT BUMPER
2 Repl Bumper cover 04711SO1A00ZZ 1 210.12 1.6 2.6
3 Add for Clear Coat 1.0
4 ROOF
5 R&I LT Roof molding 0.5
6 PILLARS,ROCKER&FLOOR
7 Blnd LT Rocker panel s 0.8
8 Blnd LT Aperture panel DX, LX, EX,VP s 1.4
US/Canada blt
9 . REAR DOOR _
10 Blnd LT Outer panel 1.0
11 R&I LT Pillar molding US built 0.3
12 R&I LT Body side mldg DX, LX&GX 0.3
13 * R&I LT Run channel 0=2
14 R&I LT Fixed glass Honda 0•9
15 R&I LT Handle,outside DX, LX&GX 0.3
US built
16 R&I LT R&I trim panel 0.3
17 QUARTER PANEL
18 Repl LT Quarter panel w/o GX US, 04646SOlASOZZ 1 1,167.18 13.0 2.8
Canada bu
19 Add for Clear Coat 1.1
2p Blnd Fuel door �'Z
21 Repl Air outlet vent 75450510000 1 21.12
ZZ Repl LT Innerpanel w/o GX 64700504310ZZ 1 488.93 s 5.5
23 Repl LT Wheeihouse w/o GX US, 64730501AO1ZZ 1 260.00 s Incl.
Canada built
24 Repl LT Support plate 64715SO4000ZZ 1 7J2 __
25 BACK GLASS
26 R&I Back glass sedan, Honda Incl.
27 # Repl Glass kit 1 20.00
28 REAR BODY&FLOOR
29 Repl Rear body panel US built 66100SO1A02ZZ 1 319.05 Incl. 1.5
30 Overlap Major Adj. Panel -0.4
31 Add for Clear Coat 0'2
32 Add for Inside 0'8
33 Add for Clear Coat 0'2
34 Deduct for Overlap -1.0
35 Repl LT Filler panel below tail lamps 66230SO1A00ZZ 1 41.45 Incl. 0.4
US built
36 Add for Clear Coat 0.1
37 Repl Floor US built 04655SO1A01ZZ 1 810.97 22.0 1.5
3g Repl LT Railend 04654SR4AOOZZ 1 94.33 s 4.0 0.6
3/3/2014 2:30:06 PM 019495 Page 2
� Preliminary Estimate
Customer: HELLENBRAND, GREGORY Job Number:
Vehicle: 1997 HOND CIVIC DX 4D SED 4-1.6L-FI SILVER
39 Add for Clear Coat 0.1
40 Deduct for Overlap -Z•�
41 TRUNK LID
42 Repi Trunk lid sedan w/o GX 68500S01305ZZ 1 675.72 1.2 2.1
43 Overlap Major Adj. Panel -0.4
44 Add for Clear Coat 0.3
45 Add for Underside(Complete) 1.1
46 Add for Clear Coat 0•2
47 Repl Weatherstrip 74865504003 1 45.10 Incl.
48 Repl LT Hinge sedan US built 68660SV1AOOZZ 1 38.10 1.0 0.2
49 Add for Clear Coat 0.1
50 Repl RT Hinge sedan US built 68610SV1000ZZ 1 38.10 1.0 0.2
51 Add for Clear Coat 0.1
52 REAR LAMPS
53 Repl LT Lens&housing 33551SO4A02 1 131.62 Incl.
54 Repl LT Lens&housing 34156SO4A02 1 97.53 IncL
55 REAR BUMPER
56 0/H rear bumper 1.5
57 Repl Bumper cover sedan,coupe 04715SO1A00ZZ 1 233.52 Incl. 2.6
5g Add for Clear Coat 1.0
S9 Deduct for Rear Bumper R&I -0•8
60 Repl Energy absorber sedan US built 71570501A00 1 87.10 Incl.
61 Repl Reinf beam 71530SO1A00ZZ 1 194.90 IncL
62 MISCELLANEOUS OPERATIONS
63 Repl Cover car/bag 1 0.2
64 # Hazardous waste removal 1 6.00 X
65 # Color tint/color match 1 0.5
66 # Repl Corrosion protection primer 1 0.4
67 # Repl Flex additive 1 8.00
68 # Rpr Right Rocker Pinchwelds 0.5 0.5
69 # Rpr Left Rocker Pinchwelds 0.5 0.5
70 # Setup time&measure 1 2.0
71 # Rpr Unibody structural repair 6.0 F
72 # Subl Four wheel alignment 1 99.95 X
73 # Repl Panel bond adhesive 1 65.00 1.0
74 # Repl Seam sealer/caulking 1 35.00 1.0
SUBTOTALS 5,196.51 61.0 25.3
3/3/2014 2:30:06 PM 019495 Page 3
� Preliminary Estimate
Customer: HELLENBRAND, GREGORY ]ob Number:
Vehicle: 1997 HOND CIVIC DX 4D SED 4-1.6L-FI SILVER
ESTIMATE TOTALS
Category Basis Rate Cost$
pa� 5,090.56
Body Labor 55.0 hrs @ $59.00/hr 3,245.00
Paint Labor 25.3 hrs @ $59.00/hr 1,492.70
Frame Labor 6.0 hrs @ $82.00/hr 492.00
Paint Supplies 25.3 hrs @ $39.00/hr 986.70
Body Supplies 58.5 hrs @ $8.00/hr 468.00
Miscellaneous 105.95
Subtotal 11,880.91
Sales Tax $6,545.26 @ 7.6250% 499.08
Grand Total 12,379.99
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 12,379.99
WHILE WE HAVE MADE EVERY EFFORT TO WRITE A COMPREHENSIVE REPORT OF THE VISIBLE DAMAGE TO YOUR
VEHICLE, IT IS IMPORTANT TO REMEMBER THAT THIS IS ONLY AN ESTIMATE.
THERE ARE A NUMBER OF FACTORS THAT CAN AFFECT THE ACTUAL COST OF REPAIRS, INCLUDING BUT NOT
LIMITED TO HIDDEN DAMAGE, PARTS PRICE CHANGES, AND INSURANCE COMPANY INVOLVEMENT.
PLEASE CONSIDER THIS WHEN MAKING DECISIONS REGARDING THE REPAIRS TO YOUR VEHICLE.
3/3/2014 2:30:06 PM 019495 Page 4
� Preliminary Estimate
Customer: HELLENBRAND, GREGORY 7ob Number:
Vehicle: 1997 HOND CIVIC DX 4D SED 4-1.6L-FI SILVER
QUALITY REPLACEMENT PARTS WARRANTY
OUR REPAIR ESTIMATE MAY SPECIFY THE USE OF QUALITY REPLACEMENT PARTS. QUALITY REPLACEMENT PARTS
ARE PARTS NOT MANUFACTURED BY OR FOR THE ORIGINAL EQUIPMENT MANUFACTURER. WE WILL STAND
BEHIND THE QUALITY REPLACEMENT PARTS THAT ARE SPECIFIED ON THIS ESTIMATE AND USED IN THE REPAIR
OF YOUR VEHICLE, FOR AS LONG AS YOU OWN/LEASE THE VEHICLE. WE WARRANT THESE PARTS ARE OF LIKE
KIND, QUALITY, SAFETY, FIT AND PERFORMANCE TO PARTS MANUFACTURED BY OR FOR THE ORIGINAL
EQUIPMENT MANUFACTURER.
THIS WARRANTY EXCLUSIVELY COVERS LOSS OR DAMAGE THAT IS RELATED TO DEFECTS IN THE QUALITY
REPLACEMENT PART. THIS WARRANTY DOES NOT COVER DAMAGE OR PART FAILURE DUE TO IMPROPER
INSTALLATION, MISUSE, NEGLECT, ABUSE, IMPROPER MAINTENANCE, ABNORMAL OPERATION, OR NORMAL WEAR
&TEAR.
SHOULD A SUPPLIER OF A PART SPECIFIED IN OUR REPAIR ESTIMATE, OR THE REPAIR FACILITY THAT PERFORMS
THE REPAIR ON YOUR VEHICLE, BE UNABLE TO RESOLVE A LEGTTIMATE COMPLAINT ABOUT THE QUALITY
REPLACEMENT PART USED IN THE REPAIR, WE WILL MAKE EVERY EFFORT TO SEE THAT THE PROBLEM IS
CORRECTED.
THIS WARRANTY AND ANY REPRESENTATIONS MADE HEREIN ARE NON-TRANSFERABLE AND EXTEND ONLY TO
THE PARTY OWNING/LEASING THE VEHICLE AT THE TIME OF THE REPAIR.
FOR ASSISTANCE, PLEASE CONTACT THE NEAREST CLAIM DEPARTMENT OFFICE.
DISCLAIMER:
ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT INSURANCE CLAIM FOR THE PAYMENT OF A
LOSS MAY BE GUILIY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN STATE PRISON.
THE LABOR AND TAX RATES USED WERE DETERMINED BY THE VEHICLE INSPECTION LOCATION UNLESS THE
REPAIR FACILITY WAS KNOWN AT THE TIME OF THE INSPECTION OR ANOTHER LOCATION WAS SPECIFIED
BEFORE THE ESTIMATE WAS PREPARED
THIS IS NOT AN AUTHORIZATION TO REPAIR.
TO ENSURE REPAIRS WILL BE COMPLETED BASED ON THIS ESTIMATE; PLEASE PROVIDE A COPY TO THE REPAIR
FACILITY PRIOR TO AUTHORIZING REPAIRS. FAILURE TO DO SO MAY RESULT IN YOU BECOMING RESPONSIBLE
FOR PAYING UNAPPROVED EXPENSES.
NO PAYMENT FOR A SUPPLEMENT WILL BE APPROVED OR ISSUED UNLESS THE REPAIRS WERE AUTHORIZED
PRIOR TO COMPLETING THE SUPPLEMENTAL REPAIRS. TO EXPEDITE THE HANDLING OF ANY SUPPLEMENTAL
DAMAGES, PLEASE ACCESS HTfP://WWW.THESHOPOFCHOICE.COM/FARMERS. IF YOU NEED TECHNICAL
ASSISTANCE REGISTERING OR UPLOADING ATT'ACHMENTS, CONTACT NUGEN IT CUSTOMER SUPPORT AT
(855)-684-3648 BETWEEN 7 AM AND 7 PM CENTRAL TIME. POTENTIALLY, A REINSPECTION MAY BE NECESSARY.
CIRCLE OF DEPENDABILITY SUPPLEMENTS: CIRCLE OF DEPENDABILITY PROGRAM SHOPS WILL CONTINUE TO
PROCESS SUPPLEMENTS THROUGH THE NORMAL SUPPLEMENT PROCESS. PLEASE CONTACT YOUR FIELD OR
OFFICE CONSULTANT IF YOU HAVE ANY QUESTIONS.
THIS PROCESS DOES NOT APPLY TO BRISTOL WEST.
3/3/2014 2:30:06 PM 019495 Page 5
� Preliminary Estimate
Customer: HELLENBRAND, GREGORY )ob Number:
Vehicle: 1997 HOND CNIC DX 4D SED 4-1.6L-FI SILVER
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
AEG4431, CCC Data Date 2/14/2014, and the parts selected are OEM-parts manufactured by the vehicles Original
Equipment Manufacturer. OEM parts are available at OE/Vehicle dealerships. OPT OEM (Optional OEM) or ALT OEM
(Alternative OEM) parts are OEM parts that may be provided by or through alternate sources other than the OEM
vehicle dealerships. OPT OEM or ALT OEM parts may reflect some specific, special, or unique pricing or discount.
OPT OEM or ALT OEM parts may include "Blemished" parts provided by OEM's through OEM vehicle dealerships.
Asterisk (*) or pouble Asterisk (**) indicates that the parts and/or labor information provided by MOTOR may have
been modified or may have come from an alternate data source. Tilde sign (�) items indicate MOTOR Not-Included
Labor operations. The symbol (<>) indicates the refinish operation WILL NOT be performed as a separate procedure
from the other panels in the estimate. Non-Original Equipment Manufacturer aftermarket parts are described as Non
OEM or A/M. Used parts are described as LKQ, RCY, or USED. Reconditioned parts are described as Recond.
Recored parts are described as Recore. NAGS Part Numbers and Benchmark Prices are provided by National Auto
Glass Specifications. Labor operation times listed on the line with the NAGS information are MOTOR suggested labor
operation times. NAGS labor operation times are not included. Pound sign (#) items indicate manual entries.
Some 2014 vehicles contain minor changes from the previous year. For those vehicles, prior to receiving updated
data from the vehicle manufacturer, labor and parts data from the previous year may be used. The CCC ONE
estimator has a complete list of applicable vehicles. Parts numbers and prices should be confirmed with the local
dealership.
The following is a list of additional abbreviations or symbols that may be used to describe work to be done or parts to
be repaired or replaced:
SYMBOLS FOLLOWING PART PRICE:
m=MOTOR Mechanical component. s=MOTOR Structural component. T=Miscellaneous Taxed charge category.
X=Miscellaneous Non-Taxed charge category.
SYMBOLS FOLLOWING LABOR:
D=Diagnostic labor category. E=Electrical labor category. F=Frame labor category. G=Glass labor category.
M=Mechanical labor category. S=Structural labor category. (numbers) 1 through 4=User Defined Labor Categories.
OTHER SYMBOLS AND ABBREVIATIONS
Adj.=Adjacent. Algn.=Align. ALU=Aluminum. A/M=Aftermarket part. BInd=Blend. BOR=Boron steeL
CAPA=Certified Automotive Parts Association. D&R=Disconnect and Reconnect. HSS=High Strength Steel.
HYD=Hydroformed Steel. Inc1.=Included. LKQ=Like Kind and Quality. LT=Left. MAG=Magnesium. Non-Adj.=Non
Adjacent. NSF=NSF International Certified Part. 0/H=Overhaul. Qty=Quantity. Refn=Refinish. Repl=Replace.
R&I=Remove and Install. R&R=Remove and Replace. Rpr=Repair. RT=Right. SAS=Sandwiched Steel.
Sect=Section. Subl=Sublet. UHS=UItra High Strength Steel. N=Note(s) associated with the estimate line.
CCC ONE Estimating - A product of CCC Information Services Inc. �
The following is a list of abbreviations that may be used in CCC ONE Estimating that are not part of the MOTOR
CRASH ESTIMATING GUIDE:
BAR=Bureau of Automotive Repair. EPA=Environmental Protection Agency. NHTSA= National Highway
Transportation and Safety Administration. PDR=Paintless Dent Repair. VIN=Vehicle Identification Number.
3/3/2014 2:30:06 PM 019495 Page 6
HEPPNERS AUTO BODY (MldWdy) Workfile ID: 4bb42be3
� � ��� 400 SYNDICATE ST. N., SAINT PAUL, MN 55104
Phone: (651) 646-8615
FAX: (651) 645-3230
Preliminary Estimate
Customer: Hellenbrand,Gregory 7ob Number:
Written By:Jason Wengler
Insured: Hellenbrand,Gregory Policy#: Claim#:
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact: 06 Rear
Owner: Inspection Location: Insurance Company:
Hellenbrand,Gregory HEPPNERS AUTO BODY(Midway) CUSTOMER PAY
1412 Galtier St. 400 SYNDICATE ST. N.
St. Paul,MN SAINT PAUL,MN 55104
(651)214-7908 Day Repair Facility
(651)646-8615 Day
VEHICLE
Year: 1997 Body Style: 4D SED VIN: 1HGEJ6526VL011401 Mileage In: 236701
Make: HOND Engine: 4-1.6L-FI License: 374-CJR Mileage Out:
Model: CIVIC DX ProducGon Date: 11/1996 State: MN Vehicle Out:
Color: Silver Int: Condition: Job#:
TRANSMISSION Body Side Moldings FM Radio Reclining/Lounge Seats
Overdrive Tinted Glass Stereo WHEELS
5 Speed Transmission CONVENIENCE SAFETY Wheel Covers
POWER Intermittent Wipers Drivers Side Air Bag PAINT
Power Steering Tilt Wheei Passenger Air Bag Clear Coat Paint
Power Brakes Rear Defogger SEATS
DECOR RADIO Cloth Seats
Dual Mirrors AM Radio Bucket Seats
3/15/2014 11:45:47 AM 050503 Page 1
Preliminary Estimate
Customer: Hellenbrand,Gregory 7ob Number:
Vehicle: 1997 HOND CIVIC DX 4D SED 4-1.6L-FI Silver
Line Oper Description Part Number Qty Extended Labor Paint
Price�
1 REAR BUMPER
2 O/H rear bumper 1.5
3 ** Repl RECOND Bumper cover sedan, 04715SO1A00ZZ 1 198.00 Incl. 2.6
coupe
4 Add for Clear Coat 1.0
5 Repl Reinf beam 71530SO1A00ZZ 1 194.90 Incl.
6 Repl Energy absorber sedan US built 71570SO1A00 1 87.10 Incl.
7 Repl LT Side reinf coupe&sedan 71595501A00 1 5.75 Incl.
_ _e._. �_______ �_�..__.�..� ___�_._,.�...___w,,,__,.,,,..,.,,w,�.._.�.
_,.�,_ .__�_�,�,_,_.�..__ ,_.___..._.wm__.__�_ .__.._ ______._.....__.
8 REAR LAMPS
9 Repl RT Lens&housing 33501SO4A02 1 131.72 Incl.
10 Repl LT Lens&housing 33551SO4A02 1 131.62 Incl.
_..___...__ _ .� _.__,__..._..��_..._.__.,,,,,._,.�,� �.��_�.�_�_ �._�....�_
11 TRUNK LID �� �
12 * Repl LKQ trunk lid assy+35% 68500501305ZZ 1 0.5 2.1
13 Add for Clear Coat 0.8
14 Refn trunk lid underside 1.1
15 R8cI Lock sedan US built 0.4
16 Repl RT Hinge sedan US built 68610SV1000ZZ 1 38.10 1.0 0.2
17 Add for Clear Coat I 0.1
18 Repl LT Hinge sedan US built 68660SV1AOOZZ 1 38.10 1.0 0.2
19 Add for Clear Coat 0.1
20 Repl Weatherstrip 74865SO4003 1 45.10 Incl.
21 R&I License pocket sedan,DX,GX 0.3
22 Repl Nameplate"CIVIC"standard 75765SO4000 1 31.07 0.2
23 Repl Emblem sedan 75700SR3000 1 19.43 0.2
24 Repl Nameplate"DX"standard 75723SO1A00 1 20.73 0.2
_..__�_._..__ ___....___ _._._ _. ____.._.._..._�._..�. _.___ _ _.._ .__� _. _.._�__.,....._ ....
25 REAR BODY&FLOOR
26 Repl Rear body panel US built 66100SO1A02ZZ 1 319.05 6.0 1.5
27 Overlap Major Adj. Panel -�•4
28 Add for Clear Coat �•2
29 Add for Inside �•8
30 * Rpr Floor US built � 1.5
31 * Rpr LT Rail US built s �Q 1.0
32 Add for Clear Coat �•2
33 Repl Rear panel trim 84640SO4JOOZA 1 11.20 Incl.
___.__ _��� ___ _�... �__._����_.__��.. _�.�._.�_.__.._
34 QUARTER PANEL ���� �
35 * Repl LKQ LT qrtr&Iwr rear;4 door 04646501A1OZZ 1 202.50 16.0 3.9
+35%
36 Overlap Major Adj. Panel -0.4
37 Add for Ciear Coat �•�
38 Deduct for Overlap -1.0
39 Deduct for Rear Bumper R&I -0•8
40 R&I Fuel door 0.3
41 Blnd Fuel door 0•z
3/15/2014 11:45:47 AM 050503 Page 2
Preliminary Estimate
Customer: Hellenbrand,Gregory 7ob Number:
Vehicle: 1997 HOND CIVIC DX 4D SED 4-1.6L-FI Silver
42 # Blnd Lt Outer upper uniside 0.6
43 * Rpr RT Quarter panel w/o GX US, Q,� 2.0
Canada bu
44 Overlap Major Adj. Panel -0.4
45 Add for Clear Coat 0.3
46 # Blnd Rt outer upper uniside 0.3
_ _..._.___ � __ __..._.. __.� �_.�_�_.
___.�..__.___ __ __----..�._.____� ��._____�� _.w__�._._._. ..�_.�___
47 REAR DOOR
48 Btnd LT Outer panel 1.0
49 R&I LT Body side mldg DX, LX&GX 0.3
50 R&I LT Handle,outside DX,LX&GX 0.3
US built
51 R&I LT R&I trim panel 0.3
_�.� ._._. �_ _..� _____._..._._....__V_.___m_____�__...__......m.___._
52 PILLARS,ROCKER&FLOOR
53 R&I RT Rocker molding 0.3
54 R&I LT Rocker molding 0.3
_. �_..._._.._.__�.,_� �_.__� _� �.___.
_�_._ _e..ae _m�____.____ _______� _..__�
55 ROOF -- __.___ _.__.__._____ __._� _...__._.._._
56 R&I RT Roof moiding 0.5
57 R&I LT Roof molding 0.5
58 R&I RT Drip molding DX,VP US built 0.3
59 R&I LT Drip molding DX,VP US built 0.3
__._�. ._.. .....,__� _�. � _.e.m�� _______.. __.��_ _....._. .. ..___.�_.�__ �____._____ __. . �,. _� ._ ._
60 MISCELLANEOUS OPERATIONS �
61 Repl Cover car/bag 1 0.2
62 # RESTORE CORROSION 1 0.2
PROTECTION
63 # Repl FLEX ADDITIVE 1 5.00 T
64 # Subl HAZARDOUS WASTE REMOVAL 1 5.00 X
65 # Repl GLASS KIT 1 25.00 T
66 # Bonding Kit 1 55.00 X
67 # Subl FOUR WHEEL ALIGNMENT 1 89.95 X
68 # Rpr PINCH WELD CLAMP LT 0.3 0.2
69 # Rpr PINCH WELD CLAMP RT 0.3 0.2
70 # Refn ROPE GLASS 0.3
71 # SEAM SEALER 1 20.00 T
72 # Rpr SETUP AND MEASURE 2.0
73 # Rpr FRAME PULL AND SQUARE 3.0 F
SUBTOTALS 1,674.32 44.7 22.1
3/15/2014 11:45:47 AM 050503 Page 3
Preliminary Estimate
Customer: Hellenbrand, Gregory 7ob Number:
Vehicle: 1997 HOND CIVIC DX 4D SED 4-1.6L-FI Silver
ESTIMATE TOTALS
Category Basis Rate Cost;
Parts 1,474.37
Body Labor 41.7 hrs @ $55.00/hr 2,293.50
Paint Labor 22.1 hrs @ $55.00/hr 1,215.50
Frame Labor 3.0 hrs @ $75.00/hr 225.00
Paint Supplies 22.1 hrs @ $35.00/hr 773.50
Body Supplies 40.9 hrs @ $3.00/hr 122.70
Miscellaneous 199.95
Subtotal 6,304.52
Sales Tax $2,297.87 @ 7.6250% 175.21
Grand ToWI 6,479.73
THIS IS A VISUAL ESTIMATE ONLY. ADDITIONAL PARTS AND LABOR MAY BE EXTRA UPON TEARDOWN. PART
PRICES SUBJECT TO INVOICE.
NO GUARANTEE ON RUST REPAIR!
3/15/2014 11:45:47 AM 050503 Page 4
Preliminary Estimate
Customer: Hellenbrand, Gregory 7ob Number:
Vehicle: 1997 HOND CIVIC DX 4D SED 4-1.6L-FI Silver
QUALITY REPLACEMENT PARTS WARRANTY
OUR REPAIR ESTIMATE MAY SPECIFY THE USE OF QUALITY REPLACEMENT PARTS. QUALITY REPLACEMENT PARTS
ARE PARTS NOT MANUFACTURED BY OR FOR TNE ORIGINAL EQUIPMENT MANUFACTURER. WE WILL STAND
BEHIND THE QUALITY REPLACEMENT PARTS THAT ARE SPECIFIED ON THIS ESTIMATE AND USED IN THE REPAIR
OF YOUR VEHICLE, FOR AS LONG AS YOU OWN/LEASE TNE VEHICLE. WE WARRANT THESE PARTS ARE OF LIKE
KIND, QUALITY, SAFEfY, FIT AND PERFORMANCE TO PARTS MANUFACTURED BY OR FOR THE ORIGINAL
EQUIPMENT MANUFACTURER.
THIS WARRANTY EXCLUSIVELY COVERS LOSS OR DAMAGE THAT IS RELATED TO DEFECTS IN THE QUALITY
REPLACEMENT PART. THIS WARRANTY DOES NOT COVER DAMAGE OR PART FAILURE DUE TO IMPROPER
INSTALLATION, MISUSE, NEGLECT, ABUSE, IMPROPER MAINTENANCE, ABNORMAL OPERATION, OR NORMAL WEAR
&TEAR.
SHOULD A SUPPLIER OF A PART SPECIFIED IN OUR REPAIR ESTIMATE, OR THE REPAIR FACILITY THAT PERFORMS
THE REPAIR ON YOUR VEHICLE, BE UNABLE TO RESOLVE A LEGITIMATE COMPLAINT ABOUT THE QUALITY
REPLACEMENT PART USED IN THE REPAIR, WE WILL MAKE EVERY EFFORT TO SEE THAT THE PROBLEM IS
CORRECTED.
THIS WARRAMY AND ANY REPRESENTATIONS MADE HEREIN ARE NON-TRANSFERABLE AND EXTEND ONLY TO
THE PARTY OWNING/LEASING THE VEHICLE AT THE TIME OF THE REPAIR.
FOR ASSISTANCE, PLEASE CONTACT THE NEAREST CLAIM DEPARTMENT OFFICE.
DISCLAIMER:
ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT INSURANCE CLAIM FOR THE PAYMENT OF A
LOSS MAY BE GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN STATE PRISON.
THE LABOR AND TAX RATES USED WERE DETERMINED BY THE VEHICLE INSPECTION LOCATION UNLESS THE
REPAIR FACILITY WAS KNOWN AT THE TIME OF THE INSPECTION OR ANOTHER LOCATION WAS SPECIFIED
BEFORE THE ESTIMATE WAS PREPARED
THIS IS NOT AN AUTHORIZATION TO REPAIR.
TO ENSURE REPAIRS WILL BE COMPLETED BASED ON THIS ESTIMATE; PLEASE PROVIDE A COPY TO THE REPAIR
FACILITY PRIOR TO AUTHORIZING REPAIRS. FAILURE TO DO SO MAY RESULT IN YOU BECOMING RESPONSIBLE
FOR PAYING UNAPPROVED EXPENSES.
NO PAYMENT FOR A SUPPLEMENT WILL BE APPROVED OR ISSUED UNLESS THE REPAIRS WERE AUT}iORIZED
PRIOR TO COMPLEfING THE SUPPLEMENTAL REPAIRS. TO EXPEDITE THE HANDLING OF ANY SUPPLEMENTAL
DAMAGES, PLEASE ACCESS HTTP://W1NW.THESHOPOFCHOICE.COM/FARMERS. IF YOU NEED TECHNICAL
ASSISTANCE REGISTERING OR UPLOADING ATTACHMENTS, CONTACT NUGEN IT CUSTOMER SUPPORT AT
(855)-684-3648 BEIINEEN 7 AM AND 7 PM CENTRAL TIME. POTENTIALLY, A REINSPECTION MAY BE NECESSARY.
CIRCLE OF DEPENDABILITY SUPPLEMENTS: CIRCLE OF DEPENDABILITY PROGRAM SHOPS WILL CONTINUE TO
PROCESS SUPPLEMENTS THROUGH THE NORMAL SUPPLEMENT PROCESS. PLEASE CONTACT YOUR FIELD OR
OFFICE CONSULTANT IF YOU HAVE ANY QUESTIONS.
THIS PROCESS DOES NOT APPLY TO BRISTOL WEST.
3/15/2014 11:45:47 AM 050503 Page 5
Preliminary Estimate
Customer: Hellenbrand,Gregory 7ob Number:
Vehicle: 1997 HOND CNIC DX 4D SED 4-1.6L-FI Silver
MN ST 60A.955 - A PERSON WHO FILES A CLAIM W1TH INTENT TO DEFRAUD OR HELPS COMMIT A FRAUD
AGAINST AN INSURER IS GUILTY OF A CRIME.
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
AEG4431, CCC Data Date 3/10/2014, and the parts selected are OEM-parts manufactured by the vehicles Original
Equipment Manufacturer. OEM parts are available at OE/Vehicle dealerships. OPT OEM (Optional OEM) or ALT OEM
(Alternative OEM) parts are OEM parts that may be provided by or through alternate sources other than the OEM
vehicle dealerships. OPT OEM or ALT OEM parts may reflect some specific, special, or unique pricing or discount.
OPT OEM or ALT OEM parts may include "Blemished" parts provided by OEM's through OEM vehicle dealerships.
Asterisk (*) or pouble Asterisk (**) indicates that the parts and/or labor information provided by MOTOR may have
been modified or may have come from an alternate data source. Tilde sign (�) items indicate MOTOR Not-Included
Labor operations. The symbol (<>) indicates the refinish operation WILL NOT be performed as a separate procedure
from the other panels in the estimate. Non-Original Equipment Manufacturer aftermarket parts are described as Non
OEM or A/M. Used parts are described as LKQ, RCY, or USED. Reconditioned parts are described as Recond.
Recored parts are described as Recore. NAGS Part Numbers and Benchmark Prices are provided by National Auto
Glass Specifications. Labor operation times listed on the line with the NAGS information are MOTOR suggested labor
operation times. NAGS labor operation times are not included. Pound sign (#) items indicate manual entries.
Some 2014 vehicles contain minor changes from the previous year. For those vehicles, prior to receiving updated
data from the vehicle manufacturer, labor and parts data from the previous year may be used. The CCC ONE
estimator has a complete list of applicable vehicles. Parts numbers and prices should be confirmed with the local
dealership.
The following is a list of additional abbreviations or symbols that may be used to describe work to be done or parts to
be repaired or replaced:
SYMBOLS FOLLOWING PART PRICE:
m=MOTOR Mechanical component. s=MOTOR Structural component. T=Miscellaneous Taxed charge category.
X=Miscellaneous Non-Taxed charge category.
SYMBOLS FOLLOWING LABOR:
D=Diagnostic labor category. E=Electrical labor category.11 F=Frame labor category. G=Glass labor category.
M=Mechanical labor category. S=Structural labor categor�r. (numbers) 1 through 4=User Defined Labor Categories.
OTHER SYMBOLS AND ABBREVIATIONS:
Adj.=Adjacent. Algn.=Align. ALU=Aluminum. A/M=Aftermarket part. BInd=6lend. BOR=Boron steel.
CAPA=Certified Automotive Parts Association. D&R=Disconnect and Reconnect. HSS=High Strength Steel.
HYD=Hydroformed Steel. Inc1.=Included. LKQ=Like Kind and Quality. LT=Left. MAG=Magnesium. Non-Adj.=Non
Adjacent. NSF=NSF International Certified Part. 0/H=Overhaul. Qty=Quantity. Refn=Refinish. Repl=Replace.
R&I=Remove and Install. R&R=Remove and Replace. Rpr=Repair. RT=Right. SAS=Sandwiched Steel.
Sect=Section. Subl=Sublet. UHS=UItra High Strength Steel. N=Note(s) associated with the estimate line.
CCC ONE Estimating - A product of CCC Information Services Inc.
The following is a list of abbreviations that may be used in CCC ONE Estimating that are not part of the MOTOR
CRASH ESTIMATING GUIDE:
BAR=Bureau of Automotive Repair. EPA=Environmental Protection Agency. NHTSA= National Highway
Transportation and Safety Administration. PDR=Paintless Dent Repair. VIN=Vehicle Identification Number.
3/15/2014 11:45:47 AM 050503 Page 6
Preliminary Estimate
Customer: Hellenbrand,Gregory Job Number:
Vehicle: 1997 HOND CIVIC DX 4D SED 4-1.6L-FI Silver
ALTERNATE PARTS SUPPLIERS
Supplier: Keystone-Complete-Minneapolis
Location(s): 3615 MARSHALL STREET NE,MINNEAPOLIS MN 55418 (800)328-1845 (612)789-1919
Line Description Item# Price
3 RECOND Bumper cover sedan,coupe H01100178R $ 198.00
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