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Ozasky, Robert RECEIVED � � � NOTICE OF CLAIM FORM to the City of Saint Paul, M�i��so��14 Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipality...shall Ltii�s�td be��s�rtt�dY�e governing body of the municipality within I80 days after the alleged loss or injury is discovered a notice stating the time,place,and circumstances thereof,and the amount of 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 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 be signed,and both 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 Robert Middle Initial Last Name_Ozasky Company or Business Name Are You an Insurance Company? Yes If Yes,Claim Number?_416530-GA Street Address 1100 Locust Street Dept 2019 City Des Moines State IA Zip Code_50321 Daytime Phone(515)508-3044 Cell Phone ( ) - Evening Telephone( ) - Date of Accidend Injury or Date Discovered 03/19/2014 Time_08:00 am Please state,in detail, what occuned(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 andlor responsible for your damages. _Our insured was driving west on 7th Street towards Highway 5 when he hit a pothole,which caused damage to the front end of his vehicle. As a result of the damages from the accident,his vehicle was deemed a total loss. 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 property damage—please snecify ❑ Other type of injury—please specify In order to nrc,�P____c�n�„-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. 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 returned. Pa�e 1 of 2—Please comnlete and return both naEes of Claim Form 1 � Failure to complete and return both pages will result in delay in the handling of your claim. ' All Claims-please complete this section Were there witnesses to the incident? No Provide their names, addresses and telephone numbers: Were the police or law enforcement called? No If yes, what department or agency? Case#or report# 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._7th Street,west of South Davern Street and before the street turns into Highway 5. Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim to your satisfaction._$2849.42 Vehicle Claims-please complete this section ❑ check box if this section does not apply Your Vehicle: Year_1996 Make_Mercedes_Benz Model_E320 License Plate Number_220 DAN State_MN_Color_Smoke Silver Registered Owner_Robert Ozasky Driver of Vehicle_Robert Ozasky Area Damaged_Right front fender and front suspension. City Vehicle: Year Make Model License Plate Number State Color Driver of Vehicle(City Employee's Name) Area Damaged Injury Claims-please complete this section � check box if this section does not apply 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_27_. 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_06/03/2014 Print the Name of the Person who Completed this Form: �Q 2--t" -� � << c—� � �� ✓� - Signature of Person Making the Claim.��il./�I✓/ ��=�!�%�%`�--�'��`"`. Revised February 2011 : i � � � � m = L I� c w, o U � d � EN � ° r � � `� U � � Y O m y �+ � � !C L � � a () o m � m Q.. � d Z` t� � o > fl. � c � � �c n � GO o � c o � N � � y O �"' N r ` O y � � U 'a m � � �, � � � � o 0 N � d � � � y y N � M W � d � � � O N 0 C � d � � � � N � O ' 1 N M � v — O c0 . . ++ Cn0 O N � � o '� °o � �' a C� Q � a � N M o a° N t� �' 'a — G� � L' } L Y � ~ N V � � O — a � � � ,�, w F- � `. � ¢ N � s � � U � � o � tn •V � � = Y o � � � � � m � _ � � � .� � v M � U COPART AUTO AUCTIONS Date 5/22/14 I 3737 EAST RIVER ROAD FRIDLEY, MN 55421 Visit us at www.copart.com PHONE (763) 781-1025 All Amounts are in USD TAX ID# 942867490 ANTICIPATED SETTLEMENT STATEMENT Copart Lot# 17584314 37 MN - MINNEAPOLIS Loss Date 3/19/14 Called In 3/21/14 P/U Cleared 3/21/14 N337 PIP779A Pickup Date 3/21/14 CRYSTAL MUCK Original Title 4/03/14 ALLIED - CWESTVEC Trans Title 4/07/14 1100 LOCUST ST Sale Document 5/O1/14 DEPT 2018 Loss Type COLLISION DES MOINES, IA 50391 Description 96 MERZ E320 TAN Vehicle ID# WDBJF55F4TJ019810 Claim# 416530GA License#/ST Policy# PPDM0007366704 Mileage 234,430 Loss Code Pickup From SEARS IMPORTED AUTOS Reference# COLL 1 13500 WAYZATA BLVD Insured ROBERT OZASKY MINNETONKA, MN 55305 Owner ROBERT OZASKY (952) 546-5301 ADVANCE CHARGES PAID BY COPART ESTIMATE . . . . . . . . . . . . . . . 129.00 TOTAL ADVANCE CHARGES . . . . . . . . . 129.00 COPART SERVICE CHARGES TITLE PROCESSING. . . . . . . . . . . . 20.75 CLEAN TITLE PIP PROGRAM CHARGE. . . . . . . . . . . 75.00 TOTAL COPART SERVICE CHARGES. . . . . . 95.75 TOTAL DUE COPART . . . . . . . . . . . . . . 224.75 PROCEEDS FROM SALE . . . . . . . . . . . . . 350.00CR *Bid Raised By Internet* BALANCE DUE SELLER . . . . . . . . . . . . . 125.25CR SALE INFORMATION Lot# 17584314 Sold To 691725 RMS Sale Date 5/21/14 10751 89TH AVENUE N Sale Amount 350.00 MAPLE GROVE, MN 55369 ACV 2911.00 (763) 424-9819 Repair Est 6896.00 Return 12.0� Item# 70 Invoice Date 5/22/14 Cert# C115B2020 Invoice Amount 125.25CR USD Payment From Buyer REMIT TO: COPART 4610 WEST AMERICA DRIVE FAIRFIELD, CA 94534 DEPOSITORS INSURANCE COMPANY � Central Plains Claims Zone-NWIDE � Nationwied Is On Your Side i One Nationwide Gateway DES MOINES, IA 50391 PhOn2: (412) 417-9577 Claim #: 416530-GA-1 Fax: (866) 364-6086 Workfile ID: f6a&a�2 Estimate of Record Written By:JASON L WISOR,License Number: 217385,3/21/2014 10:58:40 AM Adjuster:Wisor,Jason,(412)417-9577 Business Insured: ROBERT OZASKY Policy#: PPDM0007366704 Claim #: 416530-GA-1 Type of Loss: Collision Date of Loss: 03/19/2014 08:00 AM Days to Repair: 0 Point of Impact: 21 Undercarriage Deductible: 500.00 Owner: Inspection Location: Appraiser Information: Repair Facility: ROBERT OZASKY Sears wisorj@nationwide.com 9350 COLLEGEVIEW RD APT 13500 Wayzata Blvd (412)417-9577 114 Minnetonka,MN 55305 BLOOMINGTON,MN 55437 Non Drive-in (952)831-7937 Evening (952)831-7937 Cellular VEHICLE Year: 1996 Color: Golc Int:Tan License: 220DAN Production Date: 03/1996 Make: BENZ Body Sryle: 4D SED State: MN Odometer: 234430 Model: E320 Engine: 6-3.2L-FI VIN: WDBJF55F4TJ019810 Condition: TRANSMISSION Dual Mirrors Telescopic Wheel SEATS Automatic Transmission Body Side Moldings Ciimate Control Bucket Seats Overdrive Tinted Glass RADIO Reclining/Lounge Seats POWER Console/Storage AM Radio Leather Seats Power Steering Wood Interior Trim FM Radio WHEELS Power Brakes CONVENIENCE Stereo Aluminum/Alloy Wheels Power Windows Air Conditioning Search/Seek PAINT Power Locks Intermittent Wipers Cassette Clear Coat Paint Power Mirrors Tilt Wheel Premium Radio Metallic Paint Heated Mirrors Cruise Control SAFETY OTHER Power Driver Seat Rear Defogger Drivers Side Air Bag Fog Lamps Power Passenger Seat Keyless Entry Passenger Air Bag Traction Control Memory Package Alarm Anti-Lock erakes(4) DECOR Message Center 4 Wheel Disc Brakes 3/21/2014 10:58:40 AM 038012 Page 1 i Claim #: 416530-GA-i Workfile ID: fGa8c442 Estimate of Record 1996 BENZ E320 4D SED 6-3.2L-FI GoIC Line Oper Description Part Number Qty Extended Labor Paint Price� 1 FENDER 2 Repl RT Apron assy 2106202261 1 4,700.00 s 13.0 1.5 3 FRONT SUSPENSION 4 Repl RT Lower cntrl arm 2103306207 1 328.00 m 1.5 M 5 Repl RT Knuckle 2103300120 1 336.00 m 2.2 M 6 Repl RT Shock E300,E320,E430 2103200930 1 115.00 m 0.6 M 7 Deduct for Overlap -0.3 M 8 Repl RT Spring 2103211204 1 99.00 m Incl. M SUBTOTALS 5,578.00 17.0 1.5 NOTES Prior Damage Notes: RUST ALL OVER ESTIMATE TOTALS Category Basis Rate Cost� Pa� 5,578.00 Body Labor 13.0 hrs @ $52.00/hr 676.00 Paint Labor 1.5 hrs @ $52.00/hr 78.00 Mechanical Labor 4.0 hrs @ $ 129.00/hr 516.00 Paint Supplies 1.5 hrs @ $32.00/hr 48.00 Subtotal 6,896.00 Sales Tax $ 5,626.00 @ 7.2750% 409.29 Total Cost of Repairs 7,305.29 Deductible 500.00 Total Adjustrnents �•� Net Cost of Repairs 6,805.29 The limit of your coverage is the actual cash value of your auto or its damaged parts at the time of loss. Fair market value,age and condition of your damaged vehicle will be considered when determining the actual cash value of a loss. Certain parts lose value or depreciate because of age, condition, and/or wear and tear. Betterment is the increase in value of a vehicle or any of its parts as a result of replacing certain parts damaged in a loss. If the replacement of certain parts results in an increase in value to your vehicle or any of its parts, a deduction for betterment may be made to your loss payment to reflect the actual cash value you are owed under your policy. NWCPP=Nationwide Crash Parts Program 3/21/2014 10:58:40 AM 038012 Page 2 Claim #: 416530-GA-1 Workfile ID: f6a&442 Estimate of Record 1996 BENZ E320 4D SED 6-3.2L-FI Golc This is an estimate only and is not an authorization to repair. Additional payment will be made only with the approval prior to repair. IMPORTANT! ALL SERVICE PROVIDERS MUST COMPLY WITH STATE AND FEDERAL PRNACY LAWS, INCLUDING THE PRNACY PROVISIONS OF THE GRAMM-LEACH-BLILEY ACT AND WITH ALLIED'S PRNACY STATEMENT AND PROVISIONS. ACCORDINGLY,YOU ARE HEREBY NOTIFIEDTHAT CUSTOMER INFORMATION SHARED WITH OR OBTAINED BY SERVICE PROVIDERS SHALL BE USED SOLELY FOR THE PURPOSE FOR WHICH IT WAS PROVIDED AND FOR NO OTHER PURPOSE WHATSOEVER. Nationwide will replace any defective like kind and quality (used), reconditioned, recyclable, and any quality replacement aftermarket (non-OEM) parts for as long as you own or lease the vehicle. 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. 3/21/2014 10:58:40 AM 038012 Page 3 Claim#: 416530-GA-1 Workfile ID: ffia8c442 Estimate of Record 1996 BENZ E320 4D SED 6-3.2L-FI Golc Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide EEI5716, 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 atternate data source. Tilde sign (N) items indicate MOTOR Not-Included Labor operations. The symbol (<>) indicates the refinish operation WILL NOT be performed as a separate praedure 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 laal 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=6oron steel. CAPA=Certified Automotive Parts Assaiation. 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) assaiated 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 Fstimating that are not part of the MOTOR CRASH ESTIMATING GUIDE: BAR=6ureau of Automotive Repair. EPA=Environmental Protection Agency. NHTSA= National Highway Transportation and Safety Administration. PDR=Paintless Dent Repair. VIN=Vehicle Identification Number. 3/21/2014 10:58:40 AM 038012 Page 4 CCC VALUESCOPE Depositors Insurance Company Claim Services Market Report Report Reference Number: 51783479 Adjuster: Wisor, Jason Claim reference: 416530-GA-1 Adjuster ID: 0366278 Loss Incident Date: 03/19/2014 Date Submitted: 03/21/2014 Insured: Robert Ozasky Owner: Ozasky, Robert Policy Number: PPDM0007366704 Appraiser: WISOR, JASON L Introduction Depositors Insurance Company has conducted an inspection of your 1996 Mercedes-Benz E320 4 door Sedan located in Minneapolis, MN. The inspection information was then used to conduct research in your local market to determine the market value of your vehicle. The local market value of your vehicle was defined by the Zip code 55437 -- Minneapolis, MN The recommended settlement amount based on the loss vehicle description provided by Depositors Insurance Company is $2,941.00 Section Title: Section Contents: Vehicle Valuation Summary Market Valuation with components VlNguard Vehicle Identification Vehicle configuration information VlNguard VIN Vehicle History Vehicle history research Local Market Definition Local market basis Valuation Methodology Method used to evaluate the vehicle Vehicle Condition Vehicle�s pre-accident condition Comparable Vehicles Detail Comparable vehicles located in market Vehicle Model Information Characteristics of the loss vehicle type NHTSA Vehicle Recall NHTSA recall notices Appraisal and Valuation Notes Log notes for this file __________________________ Vehicle Valuation Summary =_________________________ Local Market Value S 2,911.00 Pre-tax amount $ 2, 911.00 Vehicular Sales Tax 1.0306% + 30.00 License/fees (if applicable) Adjusted vehicle valuation amount S 2,941.00 Automated sales tax calculation based on applicable state, county and municipal tax rates. ________________________ Vehicle Valuation Allowances =_______________________ Valuation request: 51783479 (continued) 1996 BENZ E320 __________________ Vehicle Valuation Allowances (continued) __________________ Compared to the typical vehicle in the marketplace your vehicle's value was affected by these factors: Odometer 234,430 - 808.00 MM - Memory Package + 28 .00 MC - Message Center + 17 .00 These allowances illustrate factors that influence the settlement amount when compared to a typical vehicle. The typical vehicle is a vehicle of the same year, make, and model as the loss vehicle, including average mileage, and all standard and predominant equipment. In cases where a standard or predominant option is superceded by a replacement or upgrade, a corresponding addition will appear for the option to reflect this. The vehicle valuation allowances also reflect proper deductions for all standard or predominant equipment not present on the loss vehicle. These allowances are illustrative only. The actual Local Market Value is calculated entirely from comparable vehicles with adjustments to reflect the loss vehicle configuration. ____________________________ Vehicle Description =___________________________ DESCRIPTION OPTION Odometer 234,430 Vehicle equipment: Std AT - Automatic Transmission Rptd OD - Overdrive Std PS - Power Steering Std PB - Power Brakes Std PW - Power Windows Std PL - Power Locks Std PM - Power Mirrors Std SP - Power Driver Seat Std PC - Power Passenger Seat Std AC - Air Conditioning Std CL - Climate Control Std TW - Tilt Wheel Std CC - Cruise Control Std RD - Rear Defogger Std IW - Intermittent Wipers Std CN - Console/Storage Rptd MM - Memory Package Std KE - Keyless Entry Std TL - Telescopic Wheel Rptd MC - Message Center Rptd WT - Wood Interior Trim Valuation request: 51783479 (continued) 1996 BENZ E320 ______________________= Vehicle Description (continued) _______________________ Std BS - Bucket Seats Std RL - Reclining/LOUnge Seats Std LS - Leather Seats Std AM - AM Radio Std FM - FM Radio Std ST - Stereo Std SE - Search/Seek Std CA - Cassette Std UR - Premium Radio Std AW - Aluminum/Alloy Wheels Std AG - Drivers Side Air Bag Std RG - Passenger Air Bag Std AB - Anti-Lock Brakes (4) Std DB - 4-Wheel Disc Brakes Std TD - Alarm Std TX - Traction Control Std DM - Dual Mirrors Std HM - Heated Mirrors Rptd BN - Body Side Moldings Std TG - Tinted Glass Std FL - Fog Lamps Rptd IP - Clearcoat Paint Rnr� MP - MPtall ;n p�inr _______________________ VINguard Vehicle Identification =______________________ VIN: WDBJF55F4TJ019810 Insurer Description VlNguard Analysis --------------------------------- --------------------------------- Year 1996 1996 Make Mercedes-Benz Mercedes-Benz Model E320 E 320 JF55 JF55 Body style 4d Sed 4d Sed Engine 6-3 .21-Fi 6-3 .21-Fi Trans Automatic Transmission Overdrive Restraints AIR BAGS (DRIVER+PASS. ) Air Bags (Dr.+Pass.+Side) Curb Weight 3,545 Odometer 234430 This vehicle was assembled in RASTATT, GERMANY _________________________ VINguard VIN Vehicle History =_______________________ VlNguard has decoded this VIN without any errors. Valuation request: 51783479 (continued) 1996 BENZ E320 ----------------= VlNguard VIN Vehicle History (continued) ____________________ ******************************************************************************* * WARNING - VlNguard has detected prior event (s? in this vehicle's history. * * Please review the information detailed below. * *********+****************+**************************************************** ISO Vetiicle Hist�x•y: Number of times reported to ISO: 9 ISO' s file number: H0213364162 Activity reported: Property & Casualty 03/19/2014 Insurance company: Nationwide Mutual Insurance Company Phone: (800) 421-3535 Claim number: 416530GA Activity reported: Property & Casualty 11/13/2010 Insurance company: D023 Phone: (515) 280-4456 Claim number: 0187222E026237366707 Activity reported: Property & Casualty 11/13/2010 Insurance company: Nationwide Mutual Insurance Company Phone: (800) 421-3535 Claim number: 7222043948202010111301 Activity reported: Property & Casualty 12/17/2008 Insurance company: D023 Phone: (515) 280-4456 Claim number: 0187222D691437366707 Activity reported: Property & Casualty 12/17/2008 Insurance company: Nationwide Mutual Insurance Company Phone: (800) 421-3535 Claim number: 7222011373202008121701 Activity reported: Collision Estimate 10/15/2007 Insurance company: Allstate Insurance Company Phone: Unavailable Claim number: 4501416681B03 Coverage: Liability Point of impact: Left Side Mileage: 0164630 ISO notified: 08/30/2008 Activity reported: Property & Casualty 10/15/2007 Insurance company: D023 Phone: (515) 280-4456 Claim number: 0187222D486147366707 Activity reported: Property & Casualty 08/21/2007 Insurance company: D023 Phone: (515) 280-4456 Claim number: 0187222D450807366707 08/20/2001 Activity reported: Property & Casualty Insurance company: D023 Phone: (515) 280-4456 Claim number: 0187222C604727366707 Collision History Information: Collision incident reported by Allstate on 12/06/2007 Claim # 4501416681-03 in Minneapolis, MN Repair estimate: $182 Miles: 164,630 Damage Location: Rear Collision incident reported by Nationwide Enterprise on 09/10/2007 Claim # 22D45080/I003 in Rochester, MN Repair estimate: $1,291 Miles: UNKNOWN Damage Locatian: Left Front Collision incident reported by Nationwide Enterprise on 10/17/2007 Claim # 22D48614/I003 in Hastings, MN Valuation request: 51783479 (continued) 1996 SENZ E320 ----------------= VINguard VIN Vehicle History (continued) ____________________ Repair estimate: $1, 035 Miles: 164,574 Damage Location: Rear --------------------= AutoCheck Vehicle History Report =_______________________ AutoCheck Vehicle History Report Experian Automotive Report Run Date: 03/21/2014 ------------------------------------------------------------------------------- Key: � N = No Problem Found � Y = Problem Found � I = Information Found ------------------------------------------------------------------------------- TITLE CHECK THIS VEHICLE CHECKS OUT. AutoCheck database for this 1996 MERCEDES-BENZ E320 (WDBJF55F4TJ019810) shows no historical events that indicate a significant automotive problem. These problems can indicate past automotive damage or warnings associated with the vehicle title. Problems Checked Results Found Abandoned N No Abandoned Record(s) Found Damaged N No Damaged Record(s) Found Fire Damage N No Fire Damage Record Found Grey Market N No Grey Market Record Found Hail Damage N No Hail Damage Record Fot�nd Insurance Loss N No Insurance Loss Record Found Junk N No Junk Record(s) Found Rebuilt N No Rebuilt Record(s) Found Salvage N No Salvage Record(s) Found PROBLEM CHECK THIS VEHICLE CHECKS OUT. AutoCheck database for this 1996 MERCEDES-BENZ E320 (WDBJF55F4TJ019810) shows no historical events that indicate a significant automotive problem. These problems can indicate past automotive damage or warnings associated with the vehicle title. Problems Checked Results Found NHTSA Crash Test Vehicle N No NHTSA Crash Test Vehicle Record(s) Found Frame Damage N No Frame Damage Record(s) Found Major Damage Incident N No Major Damage Record(s) Found Manufacturer buyback/lemon N No Manufacturer Buyback/lemon Record(s) Found Aal nat i nn rPrnieGt , �'1 7R"�479 lrnnt i nna�31 l 99F RRN7 F."�2(1 _______________ AutoCheck Vehicle History Report (continued) __________________ Odometer Problem N No Odometer Problem Record(s) Found Recycled N No Recycled Record(s) Found Salvage Auction N No Salvage Auction Record(s) Found water Damage N No Water Damage Record(s) Found ODOMETER CHECK THIS VEHICLE CHECKS OUT. For this 1996 MERCEDES-BENZ E320 (WDBJF55F4TJ019810) no indication of odometer rollback or tampering was found. AutoCheck determines odometer rollbacks by searching for records that indicate odometer readings less than a previously reported value. Other odometer events can report events of tampering, or possible odometer breakage. Date Reported Odometer Reading 1996-05-08 10 1996-05-24 1997-05-15 1998-06-02 1999-06-16 2000-06-19 59,640 2000-08-17 2001-04-02 2002-03-27 2003-04-22 2004-04-27 2005-04-26 2006-04-28 2007-04-23 2008-03-25 2009-03-24 2010-03-23 2011-04-14 2012-04-13 2013-04-23 VEHICLE INFORMATION INFORMATION FOUND. AutoCheck found additional information on this vehicle. These records will provide more history for this 1996 MERCEDES-BENZ E320 (WDBJF55F4TJ019810) . Problems Checked Results Found Accident N No Accident Record(s) Found Corrected Title N No Corrected Title Record(s) Found Driver Edticati�n N No Driver Educati�n Record(s) Found Duplicate Title N No Duplicate Title Record(s) Found Emissions Safety Inspection N No Emissions Safety Inspection Record(s) Found Fire Damage N No Fire Damage Record(s) Found Lease Y Lease Record(s) Found Valuation request: 51783479 (continued) 1996 BENZ E320 --------------= AutoCheck Vehicle History Report (continued) __________________ Lien Y Lien ReCOrd(s) Found Livery Use N No Livery Use Record(s) Found Government Use N No Government Use Record(s) Found Police Use N No Police Use Record(s) Found Fleet N No Fleet Record(s) Found Rental N No Rental Record(s) Found Fleet and/or Lease N No Fleet and/or Lease Record(s) Found Fleet and/or Rental N No Fleet and/or Rental Record(s) Found Repossessed N No Repossessed Record(s) Found Taxi Use N No Taxi Use Record(s) Found ThPft N Nn Thaft Ra�nr�7 (al Frn�n�l FULL HISTORY Below are the historical events for this vehicle listed in chronological order. Report Run Date: 03/21/2014 Event Event Odometer Data Event Date Location Reading Source Detail 1996-05-08 MN 10 Motor Vehicle Dept TITLE 1996-05-24 MN 00000000 Motor Vehicle Dept REGISTRATION EVENT/RENEWAL 1997-05-15 MN 00000000 Motor Vehicle Dept REGISTRATION EVENT/RENEWAL 1998-06-02 MN 00000000 Motor Vehicle Dept TITLE 1999-06-16 MN 00000000 Motor Vehicle Dept TITLE 2000-06-19 MINNEAPOL, MN 59,640 Motor Vehicle Dept TITLE 2000-08-17 MINNEAPOL, MN 00000000 Motor Vehicle Dept REGISTRATION EVENT/RENEWAL 2001-04-02 MINNEAPOL, MN 00000000 Motor Vehicle Dept REGISTRATION EVENT/RENEWAL 2002-03-27 MINNEAPOL, MN 00000000 Motor Vehicle Dept REGISTRATION EVENT/RENEWAL 2003-04-22 MINNEAPOL, MN 00000000 Motor Vehicle Dept REGISTRATION EVENT/RENEWAL 2004-04-27 MINNEAPOL, MN 00000000 Motor Vehicle Dept REGISTRATION EVENT/RENEWAL 2005-04-26 MINNEAPOL, MN 00000000 Motor Vehicle Dept REGISTRATION EVENT/RENEWAL 2006-04-28 MINNEAPOL, MN 00000000 Motar Vehicle Dept REGISTRATION EVENT/RENEWAL 2007-04-23 MINNEAPOL, MN 00000000 Motor Vehicle Dept REGISTRATION EVENT/RENEWAL 2008-03-25 MINNEAPOL, MN 00000000 Motor Vehicle Dept REGISTRATION EVENT/RENEWAL 2009-03-24 MINNEAPOL, MN 00000000 Motor Vehicle Dept REGISTRATION EVENT/RENEWAL Valuation request: 51783479 (continued) 1996 BENZ E320 _______________ AutoCheck Vehicle History Report (continued) ___----------_____ 2010-03-23 MINNEAPOL, MN 00000000 Motor Vehicle Dept REGISTRATION EVENT/RENEWAL 2011-04-14 MINNEAPOL, MN 00000000 Motor Vehicle Dept REGISTRATION EVENT/RENEWAL 2012-04-13 MINNEAPOL, MN 00000000 Motor Vehicle Dept REGISTRATION EVENT/RENEWAL 2013-04-23 MINNEAPOL, MN 00000000 Motor Vehicle Dept REGISTRATION EVENT/RENEWAL AutoCheck Vehicle History Report Terms and Conditions: Experian's Reports are compiled from multiple sources. It is not always possible for Experian to obtain complete discrepancy information on all vehicles; therefore, there may be other title brands, odometer readings or discrepancies that apply to a vehicle that are not reflected on that vehicle's Report. Experian searches data from additional sources where possible, but all discrepancies may not be reflected on the Report. These Reports are based on information supplied to Experian by external sources believed to be reliable, BUT NO RESPONSIBILITY IS ASSUMED BY EXPERIAN OR ITS AGENTS FOR ERRORS, INACCURACIES OR OMISSIONS. THE REPORTS ARE PROVIDED STRICTLY ON AN 'AS IS WHERE IS' BASIS, AND EXPERIAN FURTHER EXPRESSLY DISCLAIMS ALL WARRANTIES, EXPRESS OR IMPLIED, INCLUDING ANY IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE REGARDING THIS REPORT. 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You and Experian agree to submit to the personal and exclusive jurisdiction of the courts located within the county of Cook, Illinois. ___________________________ Local Market Definition =__________________________ The local market value for your 1996 Mercedes-Benz E320 4 Door Sedan was defined by ZIP code 55437 -- Minneapolis, MN. Adjacent markets were also searched as secondary sources to locate comparable vehicles. Details of the specific markets searched follow. Valuation request: 51783479 (continued) 1996 BENZ E320 _____________________ Local Market Definition (continued) _____________________ The state of Minnesota is composed of 7 distinct local markets. The following 6 zones were used in the preparation of this CCC Valuescope Market Report. Minneapolis/St Paul, MN - Primary local market vehicle database. In this market, CCC maintains a database of 12,547 inspected dealer vehicles located at 36 dealerships, and 40,309 dealer advertised, and 943 privately advertised vehicles taken from 27 local papers or magazines. St. Cloud, MN - Secondary local market vehicle database. In this market, CCC maintains a database of 1,791 inspected dealer vehicles located at 8 dealerships, and 6,658 dealer advertised, and 157 privately advertised vehicles taken from 14 local papers or magazines. Sw. Minn/Mankato, MN - Third local market vehicle database. In this market, CCC maintains a database of 1,544 inspected dealer vehicles located at 7 dealerships, and 6,278 dealer advertised, and 166 privately advertised vehicles taken from 17 local papers or magazines. Other markets searched - Rochester, Eau Claire and Duluth. . In these markets, CCC maintains a database of 4, 917 inspected dealer vehicles located at 19 dealerships, and 14,274 advertised vehicles taken from 31 local newspapers or magazines. Search extended to locate additional comparable vehicles. In certain circumstances, the area searched may be further extended to locate additional comparable vehicles for use in the valuation of your vehicle. That was done in connection with this valuation, and CCC was able to locate comparable vehicles in Indianapolis, South Bend, St. Louis and Flint/Tri-Cities. Adjustments were made to the value of each comparable vehicle to account for differences, if any, in year, model, body style, engine configuration, packages, options, and mileage. Nationwide, CCC maintains a database of 706,264 inspected dealer vehicles lnratP� at � .�ti� �Pa� PYRhInR . an� 4 .��7 .ti�� a��TPrY�CP� �7Phlr�PG rakan fr�m 1, 071 local papers and magazines. For your vehicle' s CCC Valuescope Market Report, CCC identified 6 advertised vehicles as comparable to your vehicle, and used their values to determine the Local Market Value. Vehicles are determined to be comparable to the loss vehicle based on: * Nearness to the loss vehicle' s primary garage location * Similarity of model, equipment, and odometer * Precision of the data (inspected versus advertised) Valuation request: 51783479 (continued) 1996 BENZ E320 ___________________________ Valuation Methodology =__________________________ This CCC Valuescope Market Report was prepared for Depositors Insurance Company by CCC Information Services Inc. CCC has been preparing market reports for the insurance industry since 1981. CCC physically inspects vehicles for sale at vehicle dealerships in the local markets, and subscribes to local newspapers and automotive publications in these markets. CCC maintains vehicle databases containing these inspected dealership vehicles along with the dealer and private party advertised vehicle information. When Depositors Insurance Company requests a CCC Valuescope Market Report from CCC, they provide CCC the VIN (Vehicle Identification Number) of the loss vehicle. Decoding this VIN identifies the exact vehicle for which the local market value will be done. See the VINguard Vehicle Identification section. Depositors Insurance Company also provides CCC the vehicle owner's Zip code. This identifies the local market that will be used to determine the market value. See the Local Market Definition section. Finally, Depositors Insurance Company provides CCC with the configuration of the loss vehicle including equipment, odometer, condition, maintenance, etc. This information is the starting point for determining the local market value. Using this information, CCC searches its databases to find comparable vehicles in the local market. Each vehicle is compared to the loss vehicle, and adjustments are made for differences in model, equipment, and odometer. Those vehicles that are deemed most comparable to the loss vehicle are used to determine the local market value. See the Local Market Definition section. After the Adjusted Value for each comparable vehicle is calculated (see the L�cal Market Comparable Vehicles section) , CCC calc.ulates the Local Market Value. This calculation is a weighted average. Using a weighted average allows those vehicles most similar to the loss vehicle to contribute a greater percentage to the Local Market Value than less similar vehicles. Factors that determine similarity are: * Nearness to the loss vehicle's primary garage location * Equivalency of model, equipment, and odameter * Precision of the data (inspected versus advertised) Using a weighted average results in more accurate local market value as the vehicles most similar and closest to the loss vehicle contribute more to the market value than less similar, more distant vehicles . Valuation request: 51783479 (continued) 1996 BENZ E320 ______________________________ Vehicle Condition =_____________________________ Depositors Insurance Company uses Condition Inspection Guidelines to �PYPYmInP rhP rnn�itinn nf kPV rmm�nnant.G nf rhP �nRC VPhIr�P T�PCP guidelines are specific to geographic location, year, and vehicle type. The guidelines describe physical characteristics for each of the vehicle components. Based on these guidelines, Depositors Insurance Company determined the condition of the vehicle prior to the loss. Category Condition Adjustments ----------- --------- ----------- MECHANICAL Engine Average private $0 Transmission Average private $0 PAINT Average private $0 TIRES Front Tires Average private S� Rear Tires Average private $0 BODY/GLASS Average private SO INTERIOR Average private SD Total Adjustments: S� ------------------------------------------------------------------------------- * The Condition Inspection Guidelines provide information based on vehicle age, vehicle type, and geographic location. Your vehicle has been identified as being located in the North region as an older passenger car. * The Condition Inspection Guidelines, and all dollar adjustments, are determined by surveys, inspections, and interviews with dealerships across the United States. ------------------------------------------------------------------------------- Valuation request: 51783479 (continued) 1996 BENZ E320 _________________________ Comparable Vehicles Detail =_________________________ The local market comparable vehicles are compared to the loss vehicle, and adjustments are made for differences in equipment, odometer, model, etc. The Price, Asking Price, Take Price or List Price displayed below (as applicable) may differ from the advertised price where CCC obtains different price information from the seller. The Adjusted Value represents the price of the comparable configtired exactly as the loss vehic.le. Loss Vehicle � Dealer Vehicle Dealer Vehicle Private Advertised -------------------+------------------- ------------------- ------------------- 1996 Mercedes-Benz 1996 Mercedes-Benz 1996 Mercedes-Benz 1997 Mercedes-Benz E320 E320 E320 E320 4d Sed 4d Sed 4d Sed 4d Sed 6-3 .21-Fi 6 6 6 Auto Trans-OD Auto Trans Auto Trans Auto Trans-OD AM/FM Stereo Seek AM/FM Stereo Seek AM/FM Stereo Seek AM/FM Stereo Seek with Tape Cassette With Tape Cassette With Tape Cassette With Tape Cassette Premium Radio Premium Radio Premium Radio Anti-LOCk Brakes Anti-LOCk Brakes Anti-Lock Brakes Anti-LOCk Brakes �4) �4� �4� �4� Air Conditioning Air Conditioning Air Conditioning Air Conditioning Drivers Side Air Drivers Side Air Drivers Side Air Drivers Side Air Bag Bag Bag Bag Aluminum/Alloy Aluminum/Al1oy Aluminum/Alloy Aluminum/Alloy Wheels Wheels Wheels Wheels Cruise Control Cruise Control Cruise Control Cruise Control F�a T�amnc Fna T�am»a Fna T,amnc Fna T�amna Heated Mirrors Heated Mirrors Heated Mirrors Keyless Entry Keyless Entry Keyless Entry Keyless Entry Leather Seats Leather Seats Leather Seats Leather Seats Power Passenger Power Passenger Power Passenger Power Passenger Seat Seat Seat Seat Power Locks Power Locks Power Locks Power Locks Power Mirrors Power Mirrors Pawer Mirrors Power Mirrors Power Windows Power Windows Power Windows Power Windows Rear Defogger Rear Defogger Rear Defogger Rear Defogger Passenger Air Bag Passenger Air Bag Passenger Air Bag Passenger Air Bag Power Driver Seat Power Driver Seat Power Driver Seat Power Driver Seat Alarm Alarm Alarm Alarm Telescopic Wheel Telescopic Wheel Telescopic Wheel Telescopic Wheel Tilt Wheel Tilt Wheel Tilt Wheel Tilt Wheel Traction Control Traction Control Traction Control Traction Control Front Side Impact Memory Package* Air Bags Message Center* Electric Glass Roof* Miles: 234,430 196,000 162,000 146, 000 Pub Date 3/12/2014 Pub Date 3/11/2014 Pub Date 2/09/2014 Valuation request: 51783479 (continued) 1996 BENZ E320 ___________________ Comparable Vehicles Detail (continued) ____________________ Loss Vehicle � Dealer Vehicle Dealer Vehicle Private Advertised -------------------+------------------- ------------------- ------------------- Location: Sheridan Mishawaka Carmel Distance From:Minneapolis 487 421 497 Dealer/Publication: Dad' s Gates Chevy World Autotrader.com Phone Number: 317/758-1130 574/256-3000 317/292-3900 VIN: WDBJF55FXTJ022436 Stock# 32456p1 Plate# Wdbjf55f9v Price S 3,500 Price $ 4,133 Price $ 3,995 Adjustments ------------------- Model/Year + 25 Options + 45 + 45 - 156 Mileage - 298 - 965 - 1, 154 Baseline - 461 - 461 Adjusted Value $ 2,786 $ 2,752 S 2,710 * List Price is the sticker price �f. the vehic.le. Take Price is the amoiint f�r which the vehicle can be purchased as defined by the contact at each dealer. * Option adjustments are made in comparison to the typical vehicle. Typical vehicle options that are not present are enclosed in parentheses. * The baseline is defined as the condition of the typical vehicle on the road. Baseline adjustments are made when a comparable vehicle condition varies from that of a typical vehicle. * All dollar adjustments are determined by surveys, inspections, and interviews with dealerships across the United States. * Note that some comparable vehicles that were recently available in the local market may no longer be available. * The Price, Asking Price, Take Price or List Price displayed above (as applicable) may differ from the advertised price where CCC obtains different price information from the seller. _______________________ Additional Local Advertisements =______________________ Phone/ Compared Source/Location/Year Model/Vin Odometer Date Price To Loss --------------------------------------- -------------- ------- ------- Autotrader.com (866) 604-3602 $ 4,995 $ 2,836 Saint Charles, M0. 443 Miles From Minneapolis 1997 E320 125,000 O1/21/2014 Valuation request: 51783479 (continued) 1996 BENZ E320 _________________ Additional Local Advertisements (continued) _________________ Phone/ Compared Source/Location/Year Model/VIN Odometer Date Price to Loss --------------------------------------- -------------- ------- ------- WDBJF55F3VA378987 Autotrader.com (810) 714-1500 $ 4,495 S 3,445 Fenton, MI. 499 Miles From Minneapolis 1997 E320 166,201 Rec. Avail . WDBJF55F2VA302029 Autotrader.com (636) 441-4400 S 5,250 S 2, 934 Saint Peters, M0. 440 Miles From Minneapolis 1997 E320 105,920 02/14/2014 WDBJF55F6VA444500 * The PriCe, Asking PriCe, Take PriCe or List Price displayed above (as applicable) may differ from the advertised price where CCC obtains different price information from the seller. = Vetiicle History _______________________________ For 1996 the Mercedes Benz E-class has been totally redesigned. One of the more distinguishable features are the new oval-shaped headlamps. Also, the E-class is only offered as a 4-door sedan. The new sedan is offered in only two versions. The E320 will sport a V-6, 3 .2-liter, 24-valve power plant, while the E300D will utilize the 6-cylinder, 3 .0-liter, 24-valve diesel engine. Acceleration is very quick in both versions and ride quality is everything you would expect from Mercedes with an exceptionally smooth and quiet ride. Once again Mercedes has held nothing back in itsoffering of standard features. Both versions include: dual front air bags, anti-lock new side air bags, traction control, remote entry system, programmable garage door opener, tilt/telescopic wheel, and 16 inch wheels and tires. Interior space has been maximized especially in the rear seat area where leg room is now ample. The new E-class is a good value and is a strong strong contender among premium sedans. ____________________________ NHTSA Recall Notices =____________________________ The National Highway Traffic Safety Administration has issued 1 safety related recall notice that may apply to the above valued vehicle. For additional information or assistance, call CCC customer service at 1-800-621-8070 and follow the automated operator's instructions. Please use your valuation request number for reference. NHTSA ID: 96V058000 Issued: 03/29/1996 No. of vehicles: 149 The drive belt pulley on the Engine can develop fatigue cracks in the metal and break. If the drive pulley breaks, the car would not have Engine cooling, battery charging, and/or power steering. Valuation request: 51783479 (continued) 1996 BENZ E320 ______________________ NHTSA Recall Notices (Continued) _______________________ Loss of these systems can cause the car to over heat, lose power from the battery, and loss of control of the car increasing the potential for a Vehicle accident. Dealers will replace the Engine crankshaft damper-pulley on these Vehicles. System: Engine; pulley; crankshaft. Vehicle Description: Passenger Vehicles equipped with 6-cylinder Engines. Note: Owners who take their Vehicles to an authorized Dealer on an agreed upon service date and do not receive the free remedy within a reasonable time, should contact Mercedes-Benz at 1-800-367-6372 . Also contact the National highway traffic safety administration's auto safety hotline at 1-800-424-9393. -----------------------= Appraisal and Valuation Notes =_______________________ The loss vehicle has been valued as an older vehicle in the North region with 39°s more than average miles of 168, 100. USER COND CAT ME NOT FOUND; SET TO F FOR Engine USER COND CAT MT NOT FOUND; SET TO F FOR Transmission USER COND CAT P2 NOT FOUND; SET TO F FOR Paint USER COND CAT TF NOT FOUND; SET TO F FOR Front Tires USER COND CAT TR NOT FOUND; SET TO F FOR Rear Tires USER COND CAT B2 NOT FOUND; SET TO F FOR Body/Glass USER COND CAT I2 NOT FOUND; SET TO F FOR Interior Statutes concerning vehicle value include Minnesota Statute 72A.201. (C) Copyright 2014 CCC Information Services Inc. Al1 rights reserved. Various aspects of our Market Report are covered by one or more pending patent applications. The trade names and/or trademarks used herein are owned by their respective trademark owners. TER Complete this form when file is closed. Date valued: 03/21/2014 Date of loss: 03/19/2014 SEND T0: CCC INFORMATION SERVICES INC. ATTN: SETTLEMENT TRACKING 100 S. MAIN ST. SIOiJX FALLS, SD 57104 FAX: 1-800-621-7070 Settlement Data Request number: 51783479 User id: 22384 Code: NA Insured: ROSERT OZASKY Vehicle: 1996 BENZ E320 Claim reference: 416530-GA-1 Adjuster: 0366278 Settl Adj : CCC Values Settlement Values Base Valuation: 2911.00 Condition Adjustment Amount: (+/-) Additional Considerations: (+) Prior Damage: (-) Non-Factory Options: (+) Other Pre-Tax Adjustments: (+/-) Subtotal (ACV) : 2911.00 + 1.0306% Tax: 30.00 + s Deductible: (-) Rebates: (-) Other Post-Tax Adjustments: (+/-) Owner Retained Salvage: (-) Adjusted CCC Amount: 2941.00 + Final Settlement Amount: Settlement date: / / Insured report date: / / (mm/dd/yyyy) (mm/dd/yyyy) Claim Representative Settlement Notes: � ,�'�'� +`. t �,, q ,y ��^��b :.�.: � , ��,.-;� ... _ �� .r., _ - ' �,,,�,':;,., - � � � � � � � � , ,� °vV-.� ��>. �.`� t.� � } �. � � `3's � ��s` � �� z�� y III I � �t il! i,� I�I.I II 1 �.+e.e:_�. 4 �. ,� ,�� ' �. ,.K�... � � � � ,�y�`� � . .. g� §�. . _;,°"�-,�. a`#�� -,r�'"�"� .� � � �..� .� . �� ..?`..:."':=��:. 1 ,. t�;c �.> ,_�..... t � � �� . � . � - -p . , � � • � �', '�: �� . •1!��'� ��i� 'ip3' �� ` ��+� °�� ,� �`iRlh�- '�a.`: � ,,� �� _' ii � � , . � �s °- � �� 3 r .� '��' ,'%r '�' a • .p < �� °�� . sf,. ��.�� -; - , �,� i g,a ' z �� , � , . ,` � . � � „ . - � . x ��, .. ,. .. 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