The URL can be used to link to this page

Untitled (3) RECEIVED MAR 312014 NOTICE OF CLAIlVI FORM to the City of Saint Paul, l�#��i�s�laERK Minnesota State Statute 466.05 states that"...every person...who ctaims damages from any municipality...shall cause to be presented to the governing body of the municipality within 180 days after the alleged loss ar injury is discovered a natice stating the time,place,and circumstances thereof,and the amount af compensation or other relief demanded." Please complete this form in its entirety by clearly typing or printing your answer to each question. If more space is needed,attach additional sheets. Please note that you will not be contacted by tetephone to clarify answers,so pmvide 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. 1�e process can take up to ten weel�s or longer depending on the nature of your claim. T'his form must be signed,and both pages compteted. If somettung does not apply,write`N/A'. SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK, 15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL,MN 55102 First Name��rYl Middle Initial�Last Name �-�N�1�� Company or Business Name Are You an Insurance Company? Yes/� If Yes, Claim Number? Street Address `�� " �-��'E N1�U IZ la-U� �1 ciry ST 'l�1'rU � state rV11� Zip Code ss l� 3 Daytime Phone( �3)�- 7�U Cell Phone 7( 63 )�- 7b0 Evening Telephone��) d/- �7�� Date of Accidend Injury or Date Discovered � � 2�l Time s• �s am� Please state,in detail,what occurred(happened),and why you are submitting a claim.Please indicate why or how you feel the Cit of Saint Paul or its employees are involved and/or responsible for your damages. PN 3 ��N r c.A t-��i� �-f� c 1�l 7a s AY �N� ��Q.�. �►"�.�.E Po�o� oN ��6`�l '�f�� D 21�Eo 7N�E`� SA i i� Tk F�r �avLD �Et �"N-�m � �X�I�m `Tf�{��1� D►u 3�► � R� � � �o-r}toz.,� `►- C� o P)G v�N�E/J N17 -fi��r�'l mY F�N� D2ti� 't"►2� BoTTl�or�� a�T C►�c.1�1n�G fhy �vm B� ��+-1U►� 0� i"f'1Y I�CN�`' BEND)N� M`� V'�HE�� i KNbClU��L�A(�1NL� G�f�* O�.f�� BUL6ING �1-2�� /S b � � tx� . T��.e.� H� ' �' E �t R�� !��a�l� / i/� S�Df T�'S7 Nol.� �iLL/N�Cl�M�S IOJ7" �N/�7 W��I�1 �1� tN/S W►�S 1GNa2.E y� Please check the box(es)that most closely represent the�eason for completing this form: ° ❑My vehicle was damaged in an accident ❑My vehicle was damaged during a tow �My vehicle was damaged by a pothole or condition of the street ❑My vehicle was damaged by a plow ❑My vehicle was wrongfully towed and/or ticketed ❑I was injured on City properiy ❑Other type of property damage-please specify ❑Other type of injury-please specify In order to process your claim vou need to include conies af all anvlicable 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 andlor 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 andJor receipts for the repairs;detailed list of damaged items O Injury claims: medical bills,receipts O Photographs are always welcome to document and support your claim but will not be returned. Page 1 of 2-Please complete and return both pages of Claim Form Failure to complete and return both pages will result in delay in the handling of your claim. All Claims-ulease complete this section Were there witnesses to the incident? Yes No Unknown (circle) Provide their names,addresses and telephone numbers: Were the police or law enfarcement called? Yes �No Unknown (circle) If yes,what department or agency? 1 C�=11-��D �� C)'f�f � Case#or report# ��X '�}tE �T Ho�-�S �H�U�� g��2� �l�^€y �`?" v�UR._S� Where did the accident or injury take place? Provide street address,cross street,intersection,name of park or facility, closest landmark etc. Please be as detailed as possible. ff necessary,attach a diagram.S�` �ftS T o� �N�2� �'A�K `D� ��/m��D A�uF v t3crrrl �►�sTS�vN'� L�'�--s Please indicate the mount you e seeking in compensation or what you would like the City to do to resolve this claim to your sarisfaction�,1��Z� ' Vehicle Claims- lease com lete this section ❑check box if this section does not a 1 Your Vehicle: Year Z�.S Make VUZKS W/-�GZ�' Model 'rT?� 29 S L- License Plate Number 1�1�2� iZG I�I State 1'�'I N Color GIZ `� Registered Owner ��1� �-lI`� 1�BE►2G Driver of Vehicle�Q��-YY� Z I N D��R� Area Damaged�RoN`t- RUmP�2 .X-vS��.1�1`�'�w1{'E�L,TI 12- -`D7Z1 u��'-S S I D� City Vehicle: Year Make Model License Plate Number State Color Driver of Vehicle(City Employee's Name) Area Damaged Iniurv Claims-ulease complete this section ❑check box if this secrion does not a�lv 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 �!Check here if you are attaching more pages to this claim form. Number of additional pages�. By signing this form,you are stating that all information you have provided is true and correct to the best of your knowledge. Unsigned forms will not be processed. Submitting a false claim can result in prosecution. Date form was completed � �--� �y Print the Name of the Person who Completed this Form: /T�� L 1 N �� 2� Signature of Person Maldng the Claim: ��?'� �� Revised Febmary 2011 � � � ; ��`��"�Iv,�i��'��.�z�k� �`�s% �� .�� -�. �s � � � - � ' 9 h ' ` � ��'�� '`� �'�"� ��'� � ,� � ��. �� "��..� x ;>a �. _ �� z. :,.�E��,�... � � �,,��'��I �. � � �� - y; _. °�i. y,�--- I � ' ° � 'i� `Y�� :;� - �E . i � 4 • i', ` r t„'Il� i f �. .� .t?.. � �.;...�..�'�v . `✓�-..• . . . � . ../ .. .. /...� �i�. f �1 � ;a: a a - aA � �;; . � ,�j � � �a k.,� �� N{�Y �� "�' �„ �'� - =;ss.' ��:� � ;:� :'� > 7:n ��.. . �� '� r� ,r, ��„ �,,.-�� ,r�,_.,� ,� � _ �� , s`t : ,�. ,, � s� ��-,��„x� �. #.� - ` r� ��-� ��;u�� ' F... _� , _ ��, --- �..� . +w� -.k ..... , F ` ' ....::k.�:" ;. •�.n �'�Y.� `;;�- � �- �� _sx :i �� . < O 5 � � f v �� W� � � ��+�*�� '�� }.:� .;^f L" J�r� P'H (�t. v`.. � �� -; �:': ' � �'.�. 4 I Y'.... , ' 4P.iar„�` gd � 1�+ II ��.'�} V.' � ,�,��► - .� "�: .�; � 4s ' . ,•�� .F� •. ' ��t�. r..� � 'L. t�Pa�• � . ...+�-�`.S1t. .. R , s " 's'�"' y� ' ��• .�� x,�, , �.,.. ,:a a"��.�, ;f�.. �'�� 1 a. � � �+,'r�� ,��'�s n:'^ a^- � �.k�` .�Jn7°a ,�c�+ n ' ��s ' Y'.r �. S.:'..� ��#7''� 5�y: aL� .� t e;�r�r: - ' �. -��,� ,� ya _- `?'�•��,� 3�,�s ,r.# y� .. F'�+� � :::'�k� �r'- ?:t'z<< .. �,„ � �� '. ,; _ , , -. ... � ., 'f, ... '�. �,�.�. "N'��_�� r�.•'.. . -.��'- ' �t'e+ � . � - .. � n¢9`!'e � wf^�'°:r.. _.. - �:. �,.� .T,� . .ht:ii.e!+^ , •.a .. -� _, _ ... , .,�� . ei,�.. �. "a'. . .. . ..�r.��. . � .,. ... R ., -� . .. - . . . - .. . . — y^T"' ,p.�'t �`-�`°`� n.-�,� „�,*,•,. � �� M N. ,.. ,y, ,.. � . <::�— � a.�.�; .�- � � � . - �.:1 ,�,. v;�r. � I C'NC�� oF '�aT t��ES . , _ _ � .. �.� ` � �. . ,� r � : `� s -' A•Aa. � � a �. ! .a�. ,.� � �"�.s�'" i .�� "�� - w..�� Q� � � � � � � , �-� � r.(►A:P�►-.�.�.��'�� e ,:i' 1 ��a�.a. . . �„ ��` � _-_ , ,. ,.. 'Nle.': .: , � , ,.��e°��p�,os,ai ',w�se,..�;��. ;�� a� ;�� r y,,� .�P.�<, � � � "�:; ^" -��'s`_ _-" ,ii t �,.,�� .} - �, r.t•{,, t, � y� i t:� a'" � 'g'" . � .. "- , "�� ..n�:,�` ��`..'��,'��_�`',�. � ,��'..��t'�"�,� 2 r ,g' �. -.0� A � -- .. ',�-'Fi�'" :7,>.,# � . . . Y"�� `�+I' ,��+5 Yn r �-�T y .P° ��_.�"1�'� _ )�.-�" • ` •`x .:S t 'D t''_. {L' r .. { .. ' *r . ..7 w ?�. � � , �1,'y��g .r �f. - • ' � �+ _ �'�, i. _ �,. ,� � � °- �� „ � � � �... , --- -� � .�s: � . ' . ._;�4 � A.i'..'F e.. �..�}. .. .. . f . .i.,.. � =t ¢ . � � �.�� f:�� . . � � � . . ' R"�'i�y � ..- -�::<. ..fs ':� - _ - , � . ,�'i^ � � ' ' ._. .. _ _ . _ . / . . . ,�-,..-:- , _ . - . - " . . � . f.— . ,.. . ' . � . ,^r _ ' - .' _ . _ .- �- { j.� ' . - . . ''�a�, 7_ � r h _ ." � ._ ' � �'' . . y AF J' - . ' _ . . � _ ' . ... 5�� ¢-ry :.. � �.. . . yF�,�F� � �J ' . � . . .. � . ,;�. .,.r rr.?:y'� ,.':a.. �-''�" N �8c�4t'S �RO� oTHEf� uP►RS RAYMOND AUTO BODY� INC. Workfile ID: 18d3787c FederalID: 41-0888257 1075 PIERCE BUTLER RTE, SAINT PAUL, MN 55104 Phone: (651) 488-0588 FAX: (651) 488-4794 Preliminary Estimate Customer: LINDBERG,ADAM Job Number: Written By:]ASON SLOMKOWSKI Insured: LINDBERG,ADAM Policy#: Claim #: Type of Loss: Date of Loss: i Days to Repair: 0 Point of Impact: 12 Front ' Owner: Inspection Location: Insurance Company: UNDBERG,ADAM RAYMOND AUTO BODY,INC. 994 LARPENTEUR AVENUE WEST 1075 PIERCE BUTIER RTE ST PAUL, MN 55113 SAINT PAUL, MN 551I04 (763)607-6760 Cell Repair Facility (651)488-0588 Business VEHICLE Year: 2005 Body Style: 4D SED VIN: 3VWPF71KK5M619292 Mileage In: Make: VW Engine: 5-2.5L-FI License: Mileage Out: Model: JETTA VALUE Production Date: State: Vehicle Out: Color: GREY Int: Condition: Job#: TRANSMISSION Dual Mirrors RADIO SEATS Overdrive Console/Storage AM Radio Cloth Seats 5 Speed Transmission CONVENIENCE FM Radio Bucket Seats POWER Air Conditioning Stereo WHEELS Power Steering Intermittent Wipers � CD Player Wheel Covers Power Brakes Tilt Wheel SAFETY PAINT Power Windows Cruise Control Drivers Side Air Bag Clear Coat Paint Power Locks Rear Defogger Passenger Air Bag OTHER Power Mirrors Keyless Entry Anti-Lock Brakes(4) Traction Control Heated Mirrors Alarm 4 Wheel Disc Brakes Signal Integrated Mirrors DECOR Telescopic Wheel Front Side Impact Air Bags 3/25/2014 5:25:50 PM 019495 Page 1 Preliminary Estimate Customer: LINDBERG,ADAM 7ob Number: Vehicle: 2005 VW JETTA VALUE 4D SED 5-2.5L-FI GREY Line Oper Description Part Number Qty Extended Labor Paint Price$ 1 FRONT BUMPER&GRILLE 2 0/H front bumper 2•9 3 Repl Bumper cover iK0807217AGRU 1 320.47 Incl. 2.6 4 Add for Clear Coat 1.0 5 Blnd RT Molding 0•2 6 Blnd LT Molding �•Z 7 Repl Lower grille iK0853677C969 1 77.25 Incl. 8 Repl LT Outer grille w/o fog lamps 1K0853665F969 1 50.40 Incl. 9 Repl LT Lower molding 1K08072432ZZ 1 87.10 Incl. 0.3 10 Add for Clear Coat 0.1 11 WHEELS i, 12 Repl LT/Front Wheel,steel 15x6 �, 5K0601027603C 1 146.28 m 0.3 0.5 13 Repl Valve stem 281601361 1 1.94 14 Repl LT/Front Wheel cover w/15" 1T0601147RGZ 1 71.02 wheel 15 TIRES 16 * Repl GDYR P195/65R15 Assurance GY03223 1 12 . 9 0.3 VSB 89H 17 # MOUNT AND BALANCE 1 25.00 18 MISCELLANEOUS OPERATIONS 19 * Repl Cover car/bag 1 � 20 # Hazardous waste removal 1 6.00 X 21 # Color tint/color match 1 0.5 22 # Repl Flex additive 1 8.00 23 # Rpr Color sand and buff 0.5 24 # Subl Four wheel alignment 1 99.95 X 25 # ***OPEN FOR HIDDEN 1 DAMAGES*** SUBTOTALS 1,023.40 3.5 5.9 3/25/2014 5:25:50 PM 019495 Page 2 Preliminary Estimate Customer: LINDBERG,ADAM 7ob Number: Vehicle: 2005 VW JETTA VALUE 4D SED 5-2.5L-FI GREY ESTIMATE TOTALS Category Basis Rate Cost$ pa� 917.45 Body Labor 3.5 hrs @ $54.00/hr 189.00 Paint Labor 5.9 hrs @ $54.00/hr 318.60 Paint Supplies 5.9 hrs @ $34.00/hr 200.60 Body Supplies 0.6 hrs @ $5.00/hr 3.00 Miscellaneous 105.95 Subtotal 1,734.60 Sales Tax $ 1,121.05 @ 7.6250% 85.48 Grand Total 1,820.08 Deductible 0.00 CUSTOMER PAY 0.00 INSURANCE PAY 1,820.08 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. This is not an authorization to repair. All GEICO customers have the right to have their vehicle repaired in the shop of their choice. No Supplement will be honored unless authorized by GEICO. NOTICE: Vehicles constructed of special metals may require the use of specialized welding and bonding equipment. Proper measuring and structural repair systems are required on today's vehicle to accurately accomplish vehicle repairs. Make sure your shop has the proper equipment to repair your vehicle. ALTERNATE PARTS DISCLAIMER: IF A QUALTTY REPLACEMENT PART (A/M, LKQ, RECOND OR OPT OEM) APPEARS ON THIS ESTIMATE, IT INDICATES THAT THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF ONE OR MORE CRASH PARTS SUPPLIED BY A SOURCE OTHER THAN THE MANUFACTURER OF YOUR MOTOR VEHICLE. GUARANTEES, IF ANY, APPLICABLE TO THESE REPLACEMENT CRASH PARTS ARE PROVIDED BY THE PART MANUFACTURER OR DISTRIBUTOR RATHER THAN BY THE MANUFACTURER OF YOUR VEHICLE. ***IN ADDITION TO ANY SUCH GUARANTEES, GEICO PROVIDES THE FOLLOWING: ****OWNER LIMITED GUARANTEE**** WE GUARANTEE THAT ALL QUALITY REPLACEMENT BODY PARTS (PARTS NOT MANUFACTURED BY THE MANUFACTURER) IDENTIFIED ON YOUR ESTIMATE, ARE FREE OF DEFECTS IN MATERIAL AND WORKMANSHIP AND MEET GENERALLY ACCEPTED INDUSTRY STANDARDS. THIS PARTS AND LABOR GUARANTEE WILL BE IN EFFECT FOR AS LONG AS YOU OWN THE VEHICLE DESCRIBED IN THE ESTIMATE. THIS GUARANTEE COVERS THE COST OF THE PART, LABOR TO INSTALL, AND INCIDENTALS SUCH AS PAINT AND MATERIALS AND IS SPECIFICALLY LIMITED TO THOSE ITEMS. THIS GUARANTEE DOES NOT COVER LOSS OR DAMAGE THAT IS UNRELATED TO DEFECTS IN THE QUALITY REPLACEMENT PARTS. THIS IS NOT TRANSFERABLE. 3/25/2014 5:25:50 PM 019495 Page 3 Preliminary Estimate Customer: LINDBERG,ADAM .7ob Number: Vehicle: 2005 VW]E"fTA VALUE 4D SED 5-2.5L-FI GREY IF ANY QUALITY REPLACEMENT PARTS ARE DEFECTIVE IN EITHER MATERIAL OR WORKMANSHIP, CONTACT YOUR LOCAL GEICO REPRESENTATIVE. MN ST 60A.955 - A PERSON WHO FILES A CLAIM WITH INTENT TO DEFRAUD OR HELPS COMMIT A FRAUD AGAINST AN INSURER IS GUILTY OF A CRIME. Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide ERA9278, CCC Data Date 3/17/2014, 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 dataIsource. Tilde sign (�) items indicate MOTOR Not-Included Labor operations. The symbol (<>) indicates the refinisfi 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. 3/25/2014 5:25:50 PM 019495 Page 4 Preliminary Estimate Customer: LINDBERG, ADAM ]ob Number: Vehicle: 2005 VW]ETTA VALUE 4D SED 5-2.5L-FI GREY 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. 3/25/2014 5:25:50 PM 019495 Page 5 ABRA Auto Body & Glass - Roseville Workfile ID: c561bcbb FederalID: 41-1942823 Right the First Time...On time 1914 W. COUNTY ROAD C, ROSEVILLE, MN 55113 Phone: (651) 639-9848 FAX: (651) 639-9406 Preliminary Estimate Customer: LINDBERG,ADAM Job Number: Written By: Bryan Worts Insured: LINDBERG,ADAM Policy#: Claim #: Type of Loss: Date of Loss: Days to Repair: 3 Point of Impact: 11 Left Front Owner: Inspection Location: Insurance Company: LINDBERG,ADAM ABRA Auto Body&Glass-Roseville CUSTOMER PAY 994 LARPENTUER AVE W 1914 W.COUNTY ROAD C ST PAUL, MN 55113 ROSEVILLE, MN 55113 (763)607-6760 Business Repair Facility (651)639-9848 Business VEHICLE Year: 2005 Body Style: 4D SED VIN: 3VWPF71KK5M619292 Mileage In: 80000 Make: VW Engine: 5-2.5L-FI License: MB28RGN Mileage Out: Model: JETTA VALUE Production Date: 3/2005 State: MN Vehicle Out: Color: GRAY Int: Condition: Job#: TRANSMISSION Dual Mirrors RADIO SEATS Overdrive Console/Storage AM Radio Cloth Seats 5 Speed Transmission CONVENIENCE FM Radio Bucket Seats POWER Air Conditioning Stereo WHEELS Power Steering Intermittent Wipers CD Player Wheel Covers Power Brakes Tilt Wheel SAFETY PAINT Power Windows Cruise Control Drivers Side Air Bag Clear Coat Paint Power Locks Rear Defogger Passenger Air Bag OTHER Power Mirrors Keyless Entry Anti-Lock Brakes(4) Traction Control Heated Mirrors Alarm 4 Wheel Disc Brakes Signal Integrated Mirrors DECOR Telescopic Wheel Front Side Impact Air Bags 3/27/2014 5:54:49 PM 024206 Page 1 Preliminary Estimate Customer: LINDBERG, ADAM Job Number: Vehicle: 2005 VW JETTA VALUE 4D SED 5-2.5L-FI GRAY Line Oper Description Part Number Qty Extended Labor Paint Price$ 1 FRONT BUMPER&GRILLE 2 0/H front bumper z.9 3 <> Repl Bumper cover 1K0807217AGRU 1 320.47 Incl. 2.6 4 Add for Clear Coat 1.0 5 Repl Spoiler 1K0805903CGRU 1 159.72 Incl. 6 Repl LT Outer grille w/o fog lamps 1K0853665F969 1 50.40 Incl. _ _ 7 WHEELS 8 * Repl LKQ LT/Front Wheel,steel 16x6.5 1K0601027K03C 1 81.25 m 0 3 +25% 9 Repl LT/Front Wheel cover w/16" 1K0601147GQLV 1 66.43 wheel 10 # Subl �2 Wheel Alignment 1 69.95 X 11 MISCELLANEOUS OPERATIONS 12 # �Hazardous Waste 1 5.00 X 13 # Repl �Flex Additive/Adhesion Promoter 1 8.50 T SUBTOTALS 761.72 3.2 3.6 NOTES Estimate Notes: TIRE IS SLOWLY LEAKING. LIKELY FROM DAMAGED WHEEL. POSSIBLE DAMAGE TO TIRE OR SUSPENSION PENDING ALIGNMENT ESTIMATE TOTALS Category Basis Rate Cost$ Parts 678.27 Body Labor 3.2 hrs @ $56.00/hr 179.20 Paint Labor 3.6 hrs @ $56.00/hr 201.60 Paint Supplies 3.6 hrs @ $36.00/hr 129.60 Miscellaneous 83.45 Subtotal 1,272.12 Sales Tax $81637 @ 7.1250% 58.17 Grand Total 1,330.29 Deductible 0.00 CUSTOMER PAY 0.00 INSURANCE PAY 1,330.29 THIS IS A VISUAL INSPECTION ONLY. THERE MAY BE ADDITIONAL DAMAGE AFTER DISASSEMBLY. PARTS ARE SUBJECT TO INVOICE. THERE ARE NO GUARANTEES ON RUST REPAIRS. "Minnesota law gives you the right to choose any rental vehicle company, and prohibits me from requiring you to choose a particular vendor." 3/27/2014 5:54:49 PM 024206 Page 2 Preliminary Estimate Customer: LINDBERG,ADAM Job Number: Vehicle: 2005 VW JETTA VALUE 4D SED 5-2.5�-FI GRAY MN ST 60A.955 - A PERSON WHO FILES A CLAIM WITH INTENT TO DEFRAUD OR HELPS COMMIT A FRAUD AGAINST AN INSURER IS GUILTY OF A CRIME. Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide ERA9278, CCC Data Date 3/17/2014, and the parts selected are OEM-parts manufactured by the vehicles Original Equipment Manufacturer. OEM parts are available at OE/yehicle dealerships. OPT OEM (Optional OEM) or ALT OEM (Alternative OEM) parts are OEM parts that may be providled 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. O/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. 3/27/2014 5:54:49 PM 024206 Page 3 Preliminary Estimate Customer: LINDBERG,ADAM 7ob Number: Vehicle: 2005 VW JETTA VALUE 4D SED 5-2.5L-FI GRAY CCC ONE Estimating - A product of CCC Information Services Inc. The following is a list of abbreviations that may be used in CCC ONE Estimating that are not part of the MOTOR CRASH ESTIMATING GUIDE: BAR=6ureau of Automotive Repair. EPA=Environmental P�rotection Agency. NHTSA= National Highway Transportation and Safety Administration. PDR=Paintless Dent Repair. VIN=Vehicle Identification Number. 3/27/2014 5:54:49 PM 024206 Page 4