Fosburgh RECEI�/ED
AMERICAN FAMILY MAY 05 2p14
.
�
� 6131 Blue Circle Drive I Eden Prairie MN 55343-9130 I amfam.com CITY CLERK
Mailing Address: PO Box 1246 I Minneapolis,MN 55440-1246 I Phone:(952)933-4884
May 01, 2014
39-PMZ001
CITY CLERK
CITY OF ST PAUL
15 WEST KELLOGG BLVD
310 CITY HALL
ST PAUL MN 55102
RE: Our Claim Number: 00-815-024369-3905
Our Policy Number: 22PT3394-01
Our Insured: Marsha K Fosburgh
Date of Loss: January 13, 2014
Our Company Name: American Family Mutual Insurance Company
Dear City Clerk:
Attached is our completed claim for and supporting documents.
Sincerely,
�����
Pat Zoerb
Subrogation Senior Adjuster
American Family Mutual Insurance Company
1-800-MYAMFAM (1-800-692-6326) X 66303
pzoerb @ amfam.com
Fax: (866) 833-5599
www.amfam.com/claims
Enc:
RECEIe1ED
h9AY 0 5 201�r
. � � NOTICE OF CLAIM FORM to the City of Saint Paul, MinnesotaLERK
Mirtnesota State Statule 466.05 stutes t/rar "...every person...who rtaims damages from an)�munkipalrh�...shat!cause to be presenred to tAe
goti�erning 6ody ojthe municipalit�•within 180 days nfter the alleged loss or injun•is discovrred a notice statrng the time,place,and
circunutanees thereof,and the amnunr of compensation or other retiejdemanded."
Please complete this form in its entirety by ciearly typing or printing your answer to eac6 question. If aare space is
needed,attach addidona!sheets. Please note that you will not be contacted by telephone to clarify answers,so provide as
muc6 inforcnation as necessary to explain your claim,and the amount of compensation being requested. You will receive a
written acknowledgement oace your form is received. The process can take up to ten weeks or tonger dependiag on the
nature of your claim. T6is form must be signed,and boW pages completed. If something does not apply,write`N/A'.
SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
First Name Pat Middle Initial M Last Name Zoerb
Company or Business Name �erican Family Insurance
Are You an Insurance Company? Yes/No If Yes,Claim Number? 0 0 81 S-0 2 4�6 9
Street Address P 0 Box 12 4 6
City Minneapolis State MN ZipCode 55440
Daytime Phone( 8 0�6 9 2 6 3 2 f�ei1 pho��na � _ Evening Telephone( na � _
Date of Accidend Injury or Date Discovered 1-13-2 014 Time 1 : 0 0 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. Our insured is
Mar�h� FoGbLrc�h, 1078 Lonbard Ave, St. Paul, MN 55105 . The City of
� pa�,l waG re�airing the water main near our insured' s home. During the
er main cit workers allowed debris to enter the water
line and it traveled to our insured s home causing amages to our insured' s
water line•s and dwelling in the amount o �_ �� ,��
�
Please check the box(es)that most closely represent the reason for completing this form:
❑ My vehicle was damaged in an accident ❑ My vehicle was damaged during a tow
� My vehicle was damaged by a pothole or condition of the street ❑ My vehicle was damaged by a plow
❑ My vehicle was wrongfully towed and/or ticketed ❑ I was injured on City property
�Other type of propeRy damage-please specify Damaqe to our insured water line and home.
❑ Other type of injury-please specify
In order to process your claim you need to include copies of all auplicable documents.
For the claims types listed below, please be sure to inciude the documents indicated or it will delay the handling of
your claim. Documents WILL NOT be returned and become the property of the City. You are encouraged to keep a
copy for yourself before submitting your claim form.
O Property damage claims to a vehicle:two estimates for the repairs to your vehicle if the damage exceeds
$500.00;or the actual bills and/or receipts for the repairs
O Towing claims: legible copies of any ticket issued and a copy of the impound lot receipt
O Other property damage claims: two repair estimates if the damage exceeds$500.00; or the actual bills
and/or receipts for the repairs;detailed list of damaged items
O Injury claims: medical bills,receipts
O Photographs are always welcome to document and support your claim but will not be retumed.
Page 1 of 2—Please complete and return both pages of Claim Form
�
' ' Failure to complete and return bot6 pages will resuit in detay in the hsndling of your ctaim.
All Claims—ulease comalete this section
Were there witnesses to the incident? Yes No nknown (circle)
Provide their names,addresses and telephone numbers:
Were the police or law enforcement called? Yes No own (circle)
If yes, what department or agency? Case#or port#
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. If necessary,attach a diagram. City of St Paul was
working to repair the main water line near 1078 Lombard Ave and debris entered
into the line and entered our insueds ' water line damaging our insured' s water
Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim line &
to your satisfaction. home.
Vehicle Claims—please complete this section �check box if this section does not applv
Your Vehicle: Year Make Model
License Plate Number State Color
Registered Owner
Driver of Vehicle
Area Damaged
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniurv Claims—please comalete this section �check box if this section does not a 1
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))
IVame 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 �—�—'���
Print the Name of the Person who Comple d this Form: 'f� �Q`Cl��
Signature of Person Making the Claim:
. -���o w �
Revised February 201 1 �r� �
-�0 ��C 124�
�°, 'm� SS���
AMERICAN FAMILY
�
� 6131 Blue Circle Drive I Eden Prairie MN 55343-9130 I amfam.com
Mailing Address:PO Box 1246 I Minneapolis,MN 55440-1246 I Phone:(952)933-4884
May 01, 2014
39-PMZ001
ATTN: CITY CLERK
CITY OF ST PAUL
15 WEST KELLOGG BLVD
310 CITY HALL
ST PAUL MN 55102
RE: Your Insured Name: City of St Paul
Your File Number: Not set up/not known
Our Claim Number: 00-815-024369 3905
Our Insured: Marsha K Fosburgh
Date of Accident: January 13, 2014
Total Claim: $3,163.98
Company Portion: $2,163.98
Insured's Deductible: $1,000.00
Dear City Clerk:
We are notifying you that American Family Mutual Insurance Company has now made payment on the
above referenced claim and our supporting documentation and proof of payment is enclosed.
The facts support that this incident was caused by your insured's negligence. Please forward the total claim
amount indicated. We will reimburse our insured their deductible.
We look forward to concluding this matter soon.
Thank you for your attention to this matter. When sending correspondence, please include 'Attn:
Subrogation Dept'.
Respectfully,
�����
Pat Zoerb
Subrogation Senior Adjuster
American Family Mutual Insurance Company
1-800-MYAMFAM (1-800-692-6326) X 66303
pzoerbC�amfam.com
Fax: (866) 833-5599
www.amfam.com/claims
Enc:
AMERICAN FAMILY American Family Insurance Group
0
. ' 6000 American Parkway
Mailstop Q22T
Madison,WI 53783-0001
April 21,2014
FOSBURGH,MARSHA K Claim Number: 00815024369
1078 LOMBARD AVE Date of Loss: 1/13/2014
SAINT PAtIL,MN SS105-3255
The attached estimate of damages has been prepared for your property. The estimate has used common prices for
labor and material from your area.
Enclosed is our draft for the actual cash value(today's replacement cost less depreciation)of your damaged property. For
Dwelling and Structure damages,we may have included your mortgage company,WELLS FARGO BANK NA#936,on the
draft as required by your policy.
Summary For Dwelling
Replacement Cost Value Less Recoverable Less Non Recoverable Actual Cash Value(ACV)
Depreciation Depreciation
❑3,239.65 (�75.67) �3,163.98
Less Deductible (�1,000.00)
Total ACV Settlement a2,163.98
Less ACV Payments Made �°��92g•gg�
Total Outstanding ACV Settlement tt235.10
See the enciosed estimate for details of your settlement which may include other itemized details not shown above.
If you wish to make a claim for the recoverable depreciation amount,you must do TWO things:
L You must have the item(s)replaced or repaired within one year from your date of loss. *Exception: Georgia and
Washington policies ONLY-Please refer to your policy language as well as the section of this estimate titled
Claiming Recoverable Depreciation following the Estimate Recap or Coverage Limit Details sections.
2. You must submit a final repair bill or purchase receipt showing the item(s)has been repaired or replaced.
The attached estimate is what we expect to be the reasonable cost to repair or replace the property. This estimate may not
include permit fees. If total charges for repair/replacement plus permits exceed the amount shown here for that
repair/replacement,prior to any deductible,then additional amounts may be payable. If the actual cost is more or less,the final
payment will be adjusted accordingly. If you wish,you may repair or replace with higher quality items,however,you will be
responsible for any increase in cost.
Please refer to your policy under either CONDITIONS-SECTION I or HOW WE SETTLE LOSSES-SECTION I for further
details on determining your loss settlement.
Please present this estimate to a contractor or repair facility of your choice BEFORE you authorize the start of repairs. If any
additional damage or costs are identified,for which you believe we should be responsible,they must be approved by a
representative of American Family Insurance prior to having the additional work done. If you,your contractor,or repair
facility have any questions,please contact us at.
ARI�RICAN FAMILY American Family Insurance Group
0
American Family Insurance appreciates your business.
Thank You,
Allison Klein
FOSBURGH,MARSHA K 00815024369 4/21/2014 Page:2
i
I
AMERIC�AN`�►- American Family Insurance Group
.
Insured: FOSBURGH,MARSHA K Phone: (651)222-1977
1078 LOMBARD AVE
SAINT PAUL,MN 55105-3255
Claim Rep.: Allison Klein
Estimator: Allison Klein
Claim Number: 00815024369 Policy Number: 22PT339401 Type of Loss: Water/Plumbing
Coverage Deductible Policy Limit
Dwelling ❑1,000.00 ❑317,000.00
Contents
�0.00 �237,800.00
Date Contacted: 1/17/2014 4:45 PM
Date of Loss: 1/13/2014 1:00 PM
Date Est.Completed: 4/21/2014 11:59 AM
Price List: MNMN8X JAN14
Restoration/Service/Remodel
Overhead: ]0.0%
Profit: 10.0%
FOSBURGH,MARSHA K 00815024369 4/21/2014 Page:3
AMER�ICAN`FA�MILY American Family Insurance Group
0
Estimate Recap For Dwelling
Recoverable Non-recoverable
Description RCV Depreciation Depreciation ACV
Main Level - Stairs 495.64 53.34 0.00 442.30
Main Level - Kitchen 1,141.05 0.00 0.00 1,141.05
2nd floor - Hallway 167.50 22.33 0.00 145.17
Plumbing 1,100.10 0.00 0.00 1,100.10
Labor Mioimums Applied 335.36 0.00 0.00 335.36
3,239.65 75.67 0.00 3,163.98
IMPORTANT-Please read the definitions below
What is replacement cost(RCV)?
Replacement cost is the cost to repair the damaged item with an item of like kind
and quality,without deduction for depreciation.
What is depreciation?
Depreciation is the amount deducted from the replacement cost based upon the
age and condition of the item being replaced.
What is actual cash value(AC�?
Actual cash value is based on the cost to repair or replace the damaged item
with an item of like kind and quality,less depreciation.
The Actual Cash Value (ACV) is based on an item's:Age divided by normal Useful life, unless otherwise
noted. Deviation from Age divided by normal Ilseful life is common due to inspection evaluation, condition of
the item, obsolescence,product research, expert opinions, utility/functional value, market value and in some
cases all or some of the above. For further information on ACV and the depreciation applied,please contact
your claim representative.
Sales Tax- You are entitled to reimbursement of sales tax when incurred for items listed in this estimate upon
documentation submitted to American Family for the repair or replacement that item.
If your home is older than 1978 it may contain lead painted materials. The EPA may require contractors
to follow special procedures to contain and/or remediate lead from the damaged area. If a lead test is taken
and your home was found to contain lead, American Family Insurance requires you to notify us before
beginning any repairs. Please be aware that the EPA regulations consider lead to be a pollutant. Your policy
limits the testing, cleaning, containment and removal of a pollutant to $10,000.00 for covered losses.
Physical mail you submit: American Family Insurance appreciates your assistance in the handling of your
claim. Any documentation you submit will be scanned and electronically retained in your claim file. Please
FOSBURGI-�,MARSHA K 00815024369 4/21/2014 Page:4
i
AMERICAN PAMILY American Family Insurance Group ,
s
include the claim number on the items submitted. The original documentation will be destroyed after 30 days.
If you would like your documents returned,please indicate this on the documents and provide the address
where you want the documents sent.
Email: My goal is to provide outstanding customer service. If you will be using email to communicate with me
regarding your claim,please be sure to include your name and claim number on the subject line. Please
forward any email correspondence regarding your claim to the email address listed below. Thank you for
being our customer.
EMAIL: aklei2@amfam.com
BEFORE YOU RUN TO THE BANK.....
Enclosed may be a BANK DRAFT in payment of all or part of your loss. Your bank or credit union may put
a hold on this draft before you have access to these funds. If you have any questions about the draft or how it
will be credited to your account, please contact your financial institution regarding their procedures.
Before depositing this draft, make sure all parties who are named on the draft have endorsed it. The draft is
made payable to all parties that American Family Insurance has an interest in protecting. If a lien holder,
mortgage company, lease company or co-owner is involved, their names could appear on the draft. Please
make certain that every person or entity named on the draft has signed it to avoid delays.
FOSBURGH,MARSI-IA K 00815024369 4/21/2014 Page: 5
AMERICAN FAMII.Y American Family Insurance Group
FOSBURGH_MARSHA_K
Main Level
Stairs Height: l 7'
Missing Wall 2'8" X 17' Opens into Exterior
Subroom: Stairs2(l) Height: l7'
Missing Wall 3'2"X l7' Opens into LANDING
Subroom: Landing(2) Height: 17'
Missing Wall 3'2" X 17' Opens into STAIRS2
Missing Wall 3'4"X 17' Opens into STAIRS
Subroom: landing(3) Height:8'
Missing Wall 4" X 8' Opens into STAIRS
666.67 SF Walls 70J4 SF Ceiling 737.40 SF Walls&Ceiling
101.61 SF Floor 11.29 SY Flooring 54.20 LF Floor Perimeter
49.67 LF Ceil.Perimeter
Description Overhead& Replacement Actual Cash
Qty Unit Price Profit Cost Total Depreciation Value
1 a.Remove Two coat plaster over metal lath
10.00 SF �1.24 �2.48 ❑14.88 -g0.00 ❑14.88
lb.Replace Two coat plaster over metal lath
]0.00 SF �6.73 �13.46 �80.76 -�0.00 ❑80.76
Orig.Desc.- 1/2"drywall-hung,taped,floated,ready for paint
2.Seal the surface area w/]atex based stain blocker-one coat
10.00 SF �0.43 �0.86 �5.16 -�0.69(2/15yr) �4.47
3.Paint the walls-one coat
-�49.07 2/IS r �318.94
666.67 SF �0.46 �61.34 �368.01 ( Y )
4.Floor protection-plastic and tape- 10 mil
]01.61 SF �0.22 �4.48 �26.83 -�3.58(2/15yr) �23.25
Totals
❑g2.62 0495.64 -053.34 0442.30
Kitchen Height:8'
377.33 SF Walls 104.17 SF Ceiling 481.50 SF Walls&Ceiling
104.17 SF Floor 11.57 SY Flooring 47.17 LF Floor Perimeter
47.17 LF Ceil.Perimeter
Description Overhead& Replacement Actual Cash
Qty Unit Price Profit Cost Total Depreciation _ Value
5.Detach&Reset Paneling-Premium grade
377.33 SF �2.52 ❑190.18 �1,141.05 -�0.00 �1,141.05
FOSBURGH,MARSHA K 00815024369 4/21/2014 Page:6
AMERICAN FAMILY American Family Insurance Group
e
Kitchen continued...
Description Overhead& Replacement Actual Cash
Qty Unit Price Profit Cost Total Depreciation Value
Totals n190.18
01,141.05 -00.00 a1,141.05
2nd floor
Hallway Height: 8'
280.00 SF Walls 49.00 SF Ceiling 329.00 SF Walls&Ceiling
49.00 SF Floor 5.44 SY Flooring 35.00 LF Floor Perimeter
35.00 LF Ceil.Perimeter
Description Overhead& Replacement Actual Cash
Qty Unit Price Profit Cost Total Depreciation Value
6.Paint the walls-one coat
280.00 SF �0.46 �25.76
�154.56 -Q20.61 (2/15yr) s�133.95
7.Floor protection-plastic and tape- 10 mil
49.00 SF �0.22 �2.16 �12.94 -�1.72(2/15yr) �11.22
Totals
027.92 0167.50 -Q22.33 0145.17
Plumbing
Description Replacement Cost
Qty Unit Price Total Depreciation Actual Cash Value
8.Replace Bruce Nelson invoice
1.00 EA �340.00 �340.00 -a0.00 �340.00
9.Replace Bruce Nelson Estimate
1.00 EA �525.00 �525.00 -�0.00 �525.00
14.Replace Bruce Nelson Invoice
1.00 EA �235.10 �235.10 -�0.00 �235.10
Totals o1,100.10 -00.00 01,100.10
Labor Minimums Applied
Description Overhead& Replacement Actual Cash
Qty Unit Price Profit Cost Total Depreciation Value
10.Plaster labor minimum
1.00 EA �279.46 fl55.90 �335.36 -�0.00 +�335.36
Totals
055.90 a335.36 -00.00 n335.36
FOSBURGH,MARSHA K 00815024369 4/21/2014 Page: 7
AMERI�MILY American Family Insurance Group
0
Replacement Cost
Overhead&ProTit Total Depreciation Actual Cash Value
Estimate Totals o356.62 03,239.65 -075.67 03,163.98
American Family Insurance(as are all insurance companies in the State of Minnesota)is required by Section 65A.29,
Subdivision 11 of the Minnesota Statutes to make the following written statement when a claim is presented by you or a
claimant:If you have two or more paid losses during the three year experience period immediately preceding the next renewal
date,your policy may be subject to non renewal. However,the following type losses would not be
included:
a.losses caused by natural causes including but not limited to lightning,wind,or hail;
or
b.losses for which no payment was made by us;or
c.losses for which we recovered 80%or more of the payment through subrogation.
We try to settle all claims;however there may be times were an agreement cannot be reached.We may not be sued unless there
is full compliance with all the terms of this policy.Suit against us must be brought within two years after the loss or damage
occurs.
FOSBURGH,MARSHA K 00815024369 4/21/2014 Page: 8
AMERICAN FAMILY American Family Insurance Group
, � 6000 American Parkway
Mailstop Q22T
Madison,WI 53783-0001
January 28,2014
FOSBURGH,MARSHA K Claim Number: 00815024369
1078 LOMBARD AVE Date of Loss: 1/13/2014
SAINT PAUL,MN 55105-3255
The attached estimate of damages has been prepared for your property. The estimate has used common prices for
labor and material from your area.
Enclosed is our draft for the actual cash value(today's replacement cost less depreciation)of your damaged property. For
Dwelling and Structure damages,we may have included your mortgage company,WELLS FARGO BANK NA#936,on the
draft as required by your policy.
Summary For Dwelling
Replacement Cost Value Less Recoverable Less Non Recoverable Actual Cash Value(ACV)
Depreciation Depreciation
❑2,647.93 (�63.05) �2,584.88
Less Deductible (�s1,000.00)
Total ACV Settlement �1,584.88
See the enclosed estimate for details of your settlement wt►ich may include other itemized details not shown above.
If you wish to make a claim for the recoverable depreciation amouni,you must do T'WO tnings:
1. You must have the item(s)replaced or repaired within one year from your date of loss.*Exception:Georgia and
Washington policies ONLY-Please refer to your policy language as well as the section of this estimate titled
Claiming Recoverabie Depreciation following the Estimate Recap or Coverage Limit Details sections.
2. You must submit a final repair bill or purchase receipt showing the item(s)has been repaired or repiaced.
The attached estimate is what we expect to be the reasonable cost to repair or replace the property. This estimate may not
include permit fees. If total charges for repair/replacement plus permits exceed the amount shown here for that
repair/replacement,prior to any deductible,then additional amounts may be payable. If the actual cost is more or less,the final
payment will be adjusted accordingly. If you wish,you may repair or replace with higher quality items,however,you will be
responsible for any increase in cost.
Please refer to your policy under either CONDITIONS-SECTION I or HOW WE SETTLE LOSSES-SECTION I for further
details on determining your loss settlement.
Please present this estimate to a contractor or repair facility of your choice BEFORE you authorize the start of repairs. If any
additional damage or costs are identified,for which you believe we should be responsible,they must be approved by a
representative of American Family Insurance prior to having the additional work done. If you,your contractor,or repair
facility have any questions,please contact us at.
AMERICAN FAMILY American Family Insurance Group
American Family Insurance appreciates your business.
Thank You,
Allison Klein
FOSBURGH,MARSHA K 00815024369 1/28/2014 Page:2
AMERICAN FAMILY American Family Insurance Group
Insured: FOSBURGH,MARSHA K Phone: (651}222-1977
1078 LOMBARD AVE
SAINT PAUL,MN 55105-3255
Claim Rep.: Allison Klein
Estimator: Allison Klein
Ciaim Number: 00815024369 Policy Number: 22PT339401 Type of Loss: Water/Plumbing
Coverage Deductible Policy Limit
Dwelling ❑1,000.00 �317,000.00
Contents �0.00 �237,800.00
Date Contacted: 1/17/2014 4:45 PM
Date of Loss: 1/13/2014 1:00 PM
Date Est.Completed: 1/28/2014 9:41 PM
Price List: MNMN8X JAN14
Restoration/Service/Remodel
FOSBURGH,MARSHA K 00815024369 1/28/2014 Page:3
AMERICAN FAMILY American Family Insurance Group
Estimate Recap For Dwelling
Recoverable Non-recoverabie
Description RCV Depreciation Depreciation ACV
Main Level - Stairs 413.02 44.44 0.00 368.58
Main Level - Kitchen 950.87 0.00 0.00 950.87
2nd floor - Hallway 139.58 18.61 0.00 120.97
Plumbing 865.00 0.00 0.00 865.00
Labor Mi�imums Applied 279.46 0.00 0.00 279.46
2,647.93 63.05 0.00 2,584.88
IMPORTANT-Please read the definitions below
What is replacement cost(RCV)?
Replacement cost is the cost to repair the damaged item with an item of like kind
and quality,without deduction for depreciation.
What is depreciation?
Depreciation is the amount deducted from the replacement cost based upon the
age and condition of the item being replaced.
What is actual cash value(AC�?
Actual cash value is based on the cost to repair or replace the damaged item
with an item of like kind and quality,less depreciation.
The Actual Cash Yalue (ACV) is based on an item's:Age divided by normal Useful life, unless otherwise
noted. Deviation from Age divided by normal i�seful life is common due to inspection evaluation, condition of
the item, obsolescence,product research, expert opinions, utitiry/functional value, market value and in some
cases all or some of the above. For further information on ACV and the depreciation applied,please contact
your claim representative.
Sales Tax- You are entitled to reimbursement of sales tax when incurred for items listed in this estimate upon
documentation submitted to American Family for the repair or replacement that item.
If your home is older than 1978 it may contain lead painted materials. The EPA may require contractors
to follow special procedures to contain and/or remediate lead from the damaged area. If a lead test is taken
and your home was found to contain lead, American Family Insurance requires you to notify us before
beginning any repairs. Please be aware that the EPA regulations consider lead to be a pollutant Your policy
limits the testing,cleaning,containment and removal of a pollutant to $10,000.00 for covered losses.
Physical mail you submit: American Family Insurance appreciates your assistance in the handling of your
claim. Any documentation you submit will be scanned and electronically retained in your claim file. Please
FOSBURGH,MARSHA K 00815024369 1/28/2014 Page:4
AMERICAN iAMILY American Family Insurance Group
include the claim number on the items submitted. The original documentation will be destroyed after 30 days.
If you would like your documents returned,please indicate this on the documents and provide the address
where you want the documents sent.
Email: My goal is to provide outstanding customer service. If you will be using email to communicate with me
regarding your claim,please be sure to include your name and claim number on the subject line. Please
forward any email correspondence regarding your claim to the email address listed below. Thank you for
being our customer.
EMAIL: aklei2@amfam.com
BEFORE YOU RUN TO THE BANK.....
Enclosed may be a BANK DRAFT in payment of all or part of your loss. Your bank or credit union may put
a hold on this draft before you have access to these funds. If you have any questions about the draft or how it
will be credited to your account,please contact your financial institution regarding their procedures.
Before depositing this draft,make sure all parties who are named on the draft have endorsed it. The draft is
made payable to all parties that American Family Insurance has an interest in protecting. If a lien holder,
mortgage company, lease company or co-owner is involved,their names could appear on the draft. Please
make certain that every person or entity named on the draft has signed it to avoid delays.
FOSBURGH,MARSHA K 00815024369 1/28/2014 Page:5
AMERIC/1N FAMILY American Family Insurance Group
FOSBURGH_MARSHA_K
Main Level
Stairs Height: 17'
Missing Wall 2'8"X 17' Opens into Exterior
Subroom: Stairs2(1) Height: 17'
Missing Wall 3'2"X 17' Opens into LANDING
Subroom: Landing(2) Height: 17'
Missing Walt 3'2" X 1'1' Opens into STAIRS2
Missing Wall 3'4"X 17' Opens into STAIRS
Subroom: landing(3) Height: 8'
Missing Wall 4"X 8' Opens into STAIRS
666.67 SF Walls 70.74 SF Ceiling 737.40 SF Walls&Ceiling
101.61 SF Floor 11.29 SY Flooring 54.20 LF Floor Perimeter
49.67 LF Ceil.Perimeter
Description Replacement Cost
Qty Unit Price Total Depreciation Actual Cash Value
I a.Remove Two coat plaster over metal lath
10.00 SF �1.24 ❑12.40 -tt0.00 �12.40
lb.Replace Two coat plaster over metal lath
10.00 SF b6.73 �67.30 -�0.00 �67.30
Orig.Desc.- 1/2"drywall-hung,taped floated ready for paint
2.Seal the surface area w/latex based stain blocker-one coat
10.00 SF �0.43 �4.30 -n0.57(2/15yr) �3.73
3.Paint the wa11s-one coat
666.67 SF �0.46 �305.6? -r�40.89(2/1 Syr) �265:7�
4.Floor protection-plastic and tape-10 mil
101.61 SF �0.22 tt22.35 -�2.98(2/15yr) �19.37
Totals o413.02 -044.44 Q368.58
Kitchen Height:8'
37733 SP Walls 104.17 SF Ceiling 481.50 SF Walls&Ceiling
104.17 SF Floor 11.57 SY Flooring 47.17 LF Floor Perimeter
47.17 LF Ceil.Perimeter
Description Replacement Cost
Qty Unit Price Total Depreciation Actual Cash Value
5.Detach&Reset Paneling-Premium grade
377.33 SF �2.52 �950.87 -�0.00 �950.87
FOSBURGH,MARSHA K 00815024369 1/28/2014 Page:6
AMERICAN FAMILY American Family Insurance Group
Kitchen continued...
Description Replacement Cost
Qty Unit Price Total Depreciation Actual Cash Value
Totals II950.87 -�0.00 n950.87
lnd floor
Hallway Height:8'
280.00 SF Walls 49.00 SF Ceiling 329.00 SF Walls&Ceiling
49.00 SF Floor 5.44 SY Flooring 35.00 LF Floor Perimeter
35.00 LF Ceil.Perimeter
Description Replacement Cost
Qty Unit Price Total Depreciation Actual Cash Value
6.Paint the walls-one coat
280.00 SF �0.46 �128.80 -�17.17(2/15yr) �111.63
7.Floor protection-plastic and tape- 10 mil
49.00 SF �0.22 �10.78 -�1.44(2/ISyr) �934
Totals
�139.58 -a18.61 ❑120.97
Plumbing
Description Replacement Cost
Qty Unit Price Total Depreciation Actual Cash Value
8.Replace Bruce Nelson invoice
1.00 EA �340.00 �340.00 -�0.00 �340.00
9.Replace Bmce Nelson EsCimate
1.00 EA
❑525.00 �525.00 -n0.00 �525.00
Totals
ng65.00 -n0.00 Q865.00
Labor Minimums Applied
Description Replacement Cost
Qty Unit Price Total Depreciation Actual Cash Value
10.Plaster labor minimum
1.00 EA �279.46
❑279.46 -�0.00 �279.46
Totals
❑279.46 -00.00 a279.46
Replacement Cost
Total Depreciation Actua►Cash Value
FOSBURGH,MARSHA K 00815024369 1/28/2014 Page:7
AMERICAN FJIMILY American Family Insurance Group
Replacement Cost
Total Depreciation Actual Cash Value
Estimate Totals o2,647.93 -063.05 Q2,584.88
FOSBURGH,MARSHA K 00815024369 1/28/2014 Page:8
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