Johnson, Doris (2) Attorneys
� KENNETH L.WILBER(CO���� Phone: 800-3i3-5169
° CHRISTINE CHANCE(FL,GA,IL) Fax: 800-313-5179
� PATRICKLIGHT(IL� TaxID: c,z-16z8oz1
� RACHAEL PERRY(IL) WILBER
�,,������:�.J.,.,� S�:R4����, REC�I�,/ED
.iUN 16 2pi4
CITY OF ST PAUL C��Y CLERK
ATTN CITY CLERK
310 CITY HALL
15 KELLOGG BLVD WEST
SAINT PAUL, MN 55102
June 10, 2014 ,
RE : Our Client: USAA
Our Client ' s Insured: DORIS M JOHNSON
Our File Number: 1081500 - 40
Your Insured: JASON ORTAN
Your Claim/Policy Number:
Date of Accident : 01-31-14
Amount Claimed: $501 . 80
Please be advised that we represent USAA
for a claim they paid to their policyholder . We have been
informed that there is possible coverage through your company.
Enclosed please find the supporting documents for your review.
After your review, please contact this office to discuss settlement
proceedings . If you have further questions, please contact
Rachael Perry, who we have assigned to handle this claim.
Please note that all payments for this claim will need to be made
payable to USAA
and remitted to our office for proper handling.
Thank you for your immediate attention to this matter.
v\ V V� /� �
� �.
1
WILBER AND ASSOCIATES
KLW/ps
Enclosure
Wilber&Associates,P.C.Attorneys at Law� Wilber Insurance Services � Wilber Consulting
zioLandmarkDr � Normal,IL � 6176z-z194
RECEIVED
JUN 16 2014
NOTICE OF CLAIM FORM to the City of 5aint Paul, Mir,���'�LERK
Minnesota State Stutute 466.OS.rtate.r thut "...every person...rvho claim.r damages from uny mundcdpaliry...shull cuuse to be pre,sented to the
governing bod}•of the municipulit��within 180 duys after the alleged loss or injury�is discovered a notice stuting the time,place,und
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 _ Middle Initial Last Name
Company or Business Name WILBER&ASSOCIATES FOR USAA A/S/O DORIS JOHNSON
Are You an Insurance Company? Yes/No If Yes,Claim Number? 1081500
Street Address 210 LANDMARK DRIVE
Cit NORMAL State �� Zip Code 61761
Y
Daytime Phone( Rn9)�,3_-F�nn Cell Phone( ) - Evening Telephone( ) -
Date of Accident/Injury or Date Discovered 1/31/2014 Time U�K am/pm
Please state,in detail, what occurrcd(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.
USAA INSURED DRIVER DORIS JOHNSON WAS DRIVING TO A FUNERAL. SHE WAS STOPPED AT A
E
�nie�Q€pinGn Rv n rrrv�F �T P!l6�6 FIF�€TR� �� -Al�T I�€��nnininin Tn nni
EMERGENCY CALL AT THE TIME OF THE ACCIDENT.
Please check the box(es)that most closely represent the reason for completing this form:
�1 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 cicketed ❑ I was injured on City property
❑ Other type of property damage—please specify
� Other type of injury—please specify
In order to process your claim vou need to include conies of all annlicable 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.
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—please complete this section
Were there witnesses to the incident? �£�CX No XNn�"c�fr�v�CXXX (circle)
Provide their names, addresses and telephone numbers:
Were the police or law enforcement called? �� No ���f�i�X (circle)
If yes, what department or agency? Case#or report#
Where did the accident or inj ury 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.
INTERSECTION OF RANDOLF AND VICTORIA, ST. PAUL, MINNESOTA
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. $501.80
i
Vehicle Claims—ulease comnlete this section ❑ check box if this section does not annlv
Your Vehicle: Year 2009 Make TOYOTA Model CAMRY
License Plate Number za� an�e State n�ni_Color g���
Registered Owner
Driver of Vehicle DRIVER/OWNER DORIS JOHNSON
Area Damaged �AR RI I�APFR
City Vehicle: Year U/K Make U/K Model FIRE TRUCK
License Plate Number State Color
Driver of Vehicle(City Employee's Name) JASON ORTAN, 651-224-6896
Area Damaged
Iniurv Claims—Alease complete this section ❑check box if this section does not applv
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 6/10/2014
Print the Name of the Person who Completed s Form: RACHAEL PERRY, O/B/O USAA
Signature of Person Making the Claim: �,�j� iP �-
Revised February 2011
USAA
s1s�
Please visit us @ USAA.com
PO BOX 33490
San Antonio,TX 78265 Claim#: 006665918000000016001
Phone: (800) 531-8722 Workfile ID: f9b381ba
Estimate of Record
Written By:JOHN BRUMFIELD,License Number:981538,2/17/2014 11:47:40 AM
Adjuster: BRUMFIELD,JOHN,(612)965-0950 Cellular
Insured: DORIS JOHNSON Policy#: 006665918 Claim#: 006665918000000016001
Type of Loss: Collision Date of Loss: Ol/31/2014 12:00 AM Days to Repair: 2
Point of Impact: 06 Rear Deductible: 250.00
Owner: Inspection Location: Appr�iser Information: Repair Facility:
DORIS JOHNSON DORIS M JOHNSON (612)965-0950 OWNERS CHOICE
693 COUNTY ROAD C W 693 COUNTY ROAD C W
SAINT PAUL, MN 55113 SAINT PAUL, MN 55113
(651)482-0464 Evening Other
(651)482-0464 Day
VEHICLE
Year: 2009 Color: Blue Int: License: 365 BNA Produdion Date: 06/2008
Make: TOYO Body Style: 4D SED State: MN Odometer: 104347
Model: CAMRY LE Engine: 4-2.4L-FI VIN: 4T16E46K19U849100 Condition:
TRANSMISSION Tinted Glass RADIO Front Side Impact Air Bags
Overdrive Console/Storage AM Radio Head/Curtain Air Bags
5 Speed Transmission Overhead Console FM Radio SEATS
POWER CONVENIENCE Stereo Cloth Seats
Power Steering Air Conditioning Search/Seek Bucket Seats
Power Brakes Intermittent Wipers ' CD Player WHEELS
Power Windows Tilt Wheel Auxiliary Audio Connection Wheel Covers
Power Locks Cruise Control SAFETI( PAINT
Power Mirrors Rear Defogger Drivers Side Air Bag Clear Coat Paint
Power Driver Seat Keyless Entry Passenger Air Bag OTHER
DECOR Steering Wheel Touch Controls Anti-Lock Brakes(4) Power Trunk/Gate Release
Dual Mirrors Telescopic Wheel 4 Wheel Disc Brakes
2/17/2014 11:47:40 AM 005225 Page 1
0 9 01119 c 8 e 4 c c 7 6 0 USAA Confidential
Claim#: 006665918000000016001
Workfile ID: f9b381ba
Estimate of Record
2009 TOYO CAMRY LE 4D SED 4-2.4L-FI Blue
Line Oper Description Part Number Qty Extended Labor Paint
Price$
1 REAR BUMPER
2 R&I R&I bumper cover 5215906950 0 0.00 1.0 0.0
3 * Rpr Bumper cover US built 2.4 liter 5215906950 0 0.00 1_5 3.0
4 Add for Clear Coat 0 0.00 0.0 1.2
5 # Flex Additive 1 6.00 0.0 0.0
6 # Subl Hazardous Waste Remvl 1 3.00 X 0.0 0.0
SUBTOTALS 9.00 2.5 4.2
Nores
Estimate Notes:
SHOP TO CALL APPRAISER W1TH ANY ADDITIONAL DAMAGE.......
Prior Damage Notes:
SCRPAE ON LEFf SIDE OF REAR BUMPER COVER.VEHICLE INSPECTED IN GARAGE. DIRTY AND COVERED IN ROAD SPRAY/SALT AT TIME OF
INSPECTION.......
ESTIMATE TOTALS
Category Basis Rate Cost$
pa� 6.00
Body Labor 2.5 hrs @ $52.00/hr 130.00
Paint Labor 4.2 hrs @ $52.00/hr 218.40
Paint Supplies 4.2 hrs @ $32.00/hr 134.40
Miscellaneous 3.00
Subtotal 491.80
Sales Tax $ 140.40 @ 7.1250% 10.00
Total Cost of Repairs 501.80
Deductible 250.00
TotalAdjustrnents 250.00
Net Cost of Repairs 251.80
2/17/2014 11:47:40 AM 005225 Page 2
0 9 01119 c 8 e 4 c c 7 6 0 USAA Confidential
Claim#: 006665918000000016001
Workfile ID: f9b381ba
Estimate of Record
2009 TOYO CAMRY LE 4D SED 4-2.4L-FI Blue
Piease Present A Copy Of This Estimate To A Repair Facility Of Your Choice
*USAA Subsidiaries include: United Services Automobile Association(USAA), USAA Casualty Insurance Company(CIC),
USAA General Indemnity Company(GIC) USAA County Mutual Insurance(CMI)and Garrison Properly Casualty
Insurance Company. Garrison Property and Casualty Insurance Company, a subsidiary of USAA Casualty Insurance
Company, is authorized to use the USAA logo, a registered trademark of United Services Automobile Association.
This is not an authorization to repair. Failing to present this estimate to the repairing garage before repair may result
in additional expenses to you. A USAA appraiser must authorize any supplement to this estimate. Repairs to this
vehicle may require specific welding equipment as recommended by the manufacturer.
If alternative quality replacement parts have been included in this appraisal, the source for these parts has also been
disclosed. If alternative quality replacement parts as listed on the appraisal are ultimately used in the repair of your
vehicle, the warranty on such parts will be equal to, or greater than, the parts being replaced, as stated in USAA's
limited parts warranty. USAA warrants that the parts used on your vehicle will be of like kind and quality, function, fit,
safety and corrosion protection as the part or parts they replace. USAA identifies certified and validated parts for
sheet metal replacement parts.
PLEASE PRESENT A COPY OF THIS ESTIMATE TO A REPAIR FACILITY OF YOUR CHOICE.
THIS IS NOT A REPAIR AUTHORIZATION. FAILING TO PRESENT THIS ESTIMATE TO THE REPAIRING GARAGE
BEFORE REPAIR MAY RESULT IN ADDITIONAL EXPENSES TO YOU. A USAA APPRAISER MUST AUTHORIZE ANY
SUPPLEMENT TO THIS ESTIMATE. REPAIRS TO THIS VEHICLE MAY REQUIRE SPECIFIC WELDING EQUIPMENT AS
RECOMMENDED BY THE MANUFACTURER.
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.
2/17/2014 11:47:40 AM 005225 Page 3
0 9 O 1119 c 8 e4 c c 7 6 0 USAA Confidential
Claim#: 006665918000000016001
Workfile ID: f9b381ba
Estimate of Record
2009 TOYO CAMRY LE 4D SED 4-2.4L-FI Blue
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
ARM8522, CCC Data Date 2/14/2014, and the parts selected are OEM-parts manufactured by the vehicles Original
Equipment Manufacturer. OEM parts are available at OE/Vehicle dealerships. OPT OEM (Optional OEM) or ALT OEM
(Alternative OEM) parts are OEM parts that may be provided by or through alternate sources other than the OEM
vehicle dealerships. OPT OEM or ALT OEM parts may reflect some specific, special, or unique pricing or discount.
OPT OEM or ALT OEM parts may include "Blemished" parts provided by OEM's through OEM vehicle dealerships.
Asterisk(*) or pouble Asterisk(**) indicates that the parts and/or labor information provided by MOTOR may have
been modified or may have come from an alternate data source. Tilde sign (�) items indicate MOTOR Not-Included
Labor operations. The symbol (<>) indicates the refinish operation WILL NOT be performed as a separate procedure
from the other panels in the estimate. Non-Original Equipment Manufacturer aftermarket parts are described as Non
OEM or A/M. Used parts are described as LKQ, RCY, or USED. Reconditioned parts are described as Recond.
Recored parts are described as Recore. NAGS Part Numbers�nd 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=6lend. BOR=6oron steel.
CAPA=Certified Automotive Parts Association. D&R=Disconnect and Reconnect. HSS=High Strength Steel.
HYD=Hydroformed Steel. Inc1.=Included. LKQ=Like Kind and Quality. LT=Left. MAG=Magnesium. Non-Adj.=Non
Adjacent. NSF=NSF International Certified Part. 0/H=Overhaul. Qty=Quantity. Refn=Refinish. Repl=Replace.
R&I=Remove and Install. R&R=Remove and Replace. Rpr=Repair. RT=Right. SAS=Sandwiched Steel.
Sect=Section. Subl=Sublet. UHS=UItra High Strength Steel. N=Note(s) associated with the estimate line.
CCC ONE Estimating -A product of CCC Information Services Inc.
The following is a list of abbreviations that may be used in QCC ONE Estimating that are not part of the MOTOR
CRASH ESTIMATING GUIDE:
BAR=Bureau of Automotive Repair. EPA=Environmental Prdtection Agency. NHTSA= National Highway
Transportation and Safety Administration. PDR=Paintless D�nt Repair. VIN=Vehicle Identification Number.
2/17/2014 11:47:40 AM 005225 Page 4
0 9 01119 c 8 e 4 c c 7 6 0 USAA Confidential
Claim#: 006665918000000016001
Workfile ID: f9b381ba
Estimate of Record
2009 TOYO CAMRY LE 4D SED 4-2.4L-FI Blue
ALTERNATE PARTS USAGE
Year: 2009 Color: Blue Int: License: 365 BNA Production Date: 06/2008
Make: TOYO Body Style: 4D SED State: MN Odometer: 104347
Model: CAMRY LE Engine: 4-2.4L-FI VIN: 4T16E46K19U849100 Condition:
Alternate Part Type #Of Available Parts #Of Parts Selected
Aftermarket 0 0
Optional OEM 0 0
Reconditioned 0 0
Recycled 0 � 0
2/17/2014 11:47:40 AM 005225 Page 5
0 9 01119 c 8 e 4 c c 7 6 0 USAA Confidential
Claim#: 006665918000000016001
Workfile ID: f9b381ba
Estimate of Record
2009 TOYO CAMRY LE 4D SED 4-2.4L-FI Blue
RECALLINFO
Year: 2009 Color: Blue Int: License: 365 BNA Production Date: 06/2008
Make: TOYO Body Style: 4D SED State: MN Odometer: 104347
Model: CAMRY LE Engine: 4-2.4L-FI VIN: 4T1BE46K19U849100 Condition:
The National Highway Transportation and Safety Administration(NHTSA)has issued 5 safety-related recall notice(s)that may apply to the selected
vehicle.
NHTSA ID: 09V388000 Issued: Oct 8,09 Number of Vehicles: 03800000
Vehicle speed control:Accelerator pedal toyota is recalling certain model year`L004-2010 passenger Vehicles.The accelerator pedal can get stuck in
the wide open position due to its being trapped by an unsecured or incompatible Driver's floor mat.A stuck open accelerator pedal may result in
very high Vehicle speeds and make it difficult to stop the Vehicle,which could cause a crash,serious injury or death.Toyota will notify owners of
affected Vehicles to remove any Driver's floor mat and not replace it with any other floor mat pending the development of model-specific remedies.
Toyota will mail a second notification to owners of affected Vehicles notifying them of the free remedies when they are available.The first notice is
expected to be mailed during October 2009 and toyota will advise NHTSA of the estimated date when the remedies will be available.Owners may
contacttoyota at 1-800-331-4331,Lexus at 1-800-255-3987.
NHTSA ID: 13V014000 Issued: Number of Vehicles: 00003235
Seats Southeast toyota distributors,Ilc(set)is recalling certain models interspersed through model years 2009 through 2013 as follows: Model year
2009-2012 Tacoma,4Runner,Camry,Camry hybrid, Prius,and RAV4;model year 2009-2010 Avalon,F]Cruiser,and Highlander hybrid; model
year 2010-2013 model year Corolla,Sienna and Tundra;model year 2009-2013 Highlander and venza; model year 2012 Prius V;and model year
2010-2012 Sequoia.During modification by set to include accessories such as Leather seat covers,seat heaters or headrest dvd systems,these
Vehicles may not have had the passenger seat occupant sensing system calibration tested.Without passing the calibration test,the occupant
sensing system may not operate as designed.If the front passenger seat occupant sensing system is out of calibration,the front passenger airbags
may not deploy or they may deploy inappropriately for the passenger's size and position.This could increase the risk of personal injury during the
event of a Vehicle crash necessitating airbag deployment.Southeast toyota will notify owners,and Dealers will test the sensitivity of the occupant
detection sensors,and recalibrate them as necessary.The recall is expected to begin during January 2013.Owners may contact Southeast toyota
at 1-800-301-6859.
NHTSA ID: 12V491000 Issued: Number of Vehicles: 02519424
Visibitity:Power window devices and controls toyota is recalling certain model year 2007-2009 Camry,Camry hybrid,RAV4,Corolla,Corolla matrix,
Tundra,Sequoia, Highlander, Highlander hybrid,yaris,scion XB,scion XD and Pontiac vibe Vehicles.The power window master switch assemblies
in some of these Vehicles were built using a less precise process for lubricating the internal components of the switch assemblies.Irregularities in
this lubrication process may cause the power window master switch assemblies to malfunction and overheat.If the switch overheats,it may melt,
possibly resulting in a Fire.Toyota will notify its owners,and Dealers will inspect the switch and apply a special grease that inhibits heat build up or
replace any switch damaged by the defect,free of charge.Toyota owners that experience a problem with a switch should not attempt to make
repairs,but should contact their toyota Dealer or the toyota Customer experience center at 1-800-331-4331.General Motors will contact the
Pontiac vibe owners affected by this recall and GM Dealers will inspect and repair switches as necessary.Those owners may contact Pontiac
Customer care at 1-800-762-2737.
NHTSA ID: 12V091000 Issued: Number of Vehicles: 00186798
Exterior Iighting:Brake Iights:Switch toyota is recalling certain model year 2009 Camry Vehicles manufactured from July 1,2008,through February
28,2009,and model year 2009-2011 venza Vehicles manufactured from October 20,2008,through January 4,2011. During assembly of the
contact-type stop lamp switch,silicone grease may have come in contact with the surface of the switch which could cause contact resistance.If
this occurs,warning lamps could illuminate,a no start condition could result,the shift lever may not shift from the?Park?position,or the Vehicle?S
brake lights could become inoperative.Inoperative brake lights would not warn other Drivers that the Vehicle is slowing or stopping,increasing the
risk of a crash.Toyota will notify owners,and Dealers will replace the stop lamp switch,free of charge.The safety recall is expected to begin in
2/17/2014 11:47:40 AM 005225 Page 6
0 9 01119 c 8 e 4 c c 7 6 0 usaa coofiaeot�ai
Claim#: 006665918000000016001
Workfile ID: f9b381ba
Estimate of Record
2009 TOYO CAMRY LE 4D SED 4-2.4L-FI Blue
early April 2012.Owners may contact toyota at 1-800-331-4331.
NHTSA ID: 10V017000 Issued: Number of Vehicles: 00000000
Vehicle speed control:Accelerator pedal toyota is recalling certain model year 2005-2010 Avalon,model year 2007-2010 Camry,model year
2009-2010 Corolla,Corolla matrix, RAV4,model year 2010 Highlander,model year 2008-2010 Sequoia,and model year 2007-2010 Tundra
Vehicles.Due to the manner in which the friction lever interacts with the sliding surface of the accelerator pedal inside the pedal sensor assembly,
the sliding surface of the lever may become smooth during Vehicle operation.In this condition, if condensation occurs on the surface,as may
occur from heater operation(without a/C)when the pedal assembly is cold,the friction when the accelerator pedal is operated may increase,
which may result in the accelerator pedal becoming harder to depress,slower to return,or,in the worst case,mechanically stuck in a partially
depressed position.The accelerator pedal may become hard to depress,slow to return to idle,or,in the worst case,mechanically stuck in a
partially depressed position,increasing the risk of a crash.Toyota has not yet provided a remedy plan or an owner notification schedule.Owners
may contact toyota at 1-800-331-4331.
2/17/2014 11:47:40 AM 005225 Page 7
0 9 01119 c 8 e 4 c c 7 6 0 USAA Confidential
� � � �°� � —
-���� `� � � � ,..��;� _—� ,- ���� _
� �� r �e � � �
'�7�%�,� ����
�� , � _ �
���' ,� ��
�; __ � ,���r� ��
, - - ��, �
���� -
°�.�.��,
0 9 01119 c 8 e 4 c c 7 61 USAA Confidential
- . � ,� . �� : . . , .. _ .. .. •. _ . � .
... : P ' , _ �. . ' ' . . � . ,. .
� �k �t' -
� �$�� ��
�� ~� � ;
,, „• � ' � ,
z x' "''"�"`"�„� ' ��� �
� ���
�
� � ,
� �w L=�� � � ��€ � ;
�`',�—,.�.y�. � 5�� =.a �� n =� ' .
� ��1 � i" �"� �
a
'�,_ � , .
,� ��
i_._ t ; �;.: . .
f
-° � ,� � �- . .
` =i.° :`-r �� � `_" � "
tii
y
��
i
0 9 01119 c 8 e 4 c c 7 61 USAA Gonfidential
JOHNSON, DORIS M. - 006665918 - Loss Summary Page 1 of 1
oolbar �
�Refr�esF� �Exit ro
ottom
Payments `' Payment Settings
Payments ► CLR Heln
Review Payments
Requested Date Amount Payees Issued Date Method Status I
03/28/2014 $161.00 U MN MED CTR 03/28/2014 Printed check Not Cleared
FAIRVIEW
03/26/2014 $367.00 U MN MED CTR 03/26/2014 Printed check Not Cleared
FAIRVIEW
03/25/2014 $14,14 DORIS M lOHN50N 03/25/2014 Printed.check Not Cleared
03/23/2014 $161.00 U MN MED CTR 03/23/2014 Printed check Cleared
FAIRVIEW
03/20/2014 $161.00 U MN MED CTR 03/20/2014 Printed check Cleared
FAIRVIEW
02/17/2014 $251.80 DORIS M JOHNSON 02/17/2014 Printed check Cleared
G�;t���r�� �Exit',
To To�
'i
o9oiii9����i�'4int.usaa.com/inet/gas ���a LossSummary 3/31/2014