Baumeister Laux, Carol Ann Dear City Clerk's Office
Attention Claims Department
15 West Kellogg Blvd. RC�,C�VED
310 City Hall, Saint Paul, MN 55102 �UN 25 2014
C1TY C�E�K
Dear City Clerk,
On March 24, 2014 I was driving down Cretin Avenue to pick up some dinner at a local grocery store.
The time was about 7:50 p.m. and I was approaching the intersection of Cretin and Grand Avenue near
the St.Thomas University Campus driveway.There were cars on my left and I was in the right lane,
when I hit a huge series of pot holes. I immediately smelled smoke and was scared due to the fact I am
pregnant with my first child at the age of 40. The impact was so strong my passenger side airbags went
off. Please see the enclosed pictures I took with my cell phone.The noise of the impact was so severe, I
wasn't sure what I hit. I was able to pull the car into the driveway of Saint Thomas at the end of
Cleveland. The car shut off and the stench of smoke was strong. That is when I realized the air bags had
deployed on the passenger side of the car. This was extremely dangerous considering I was pregnant. If
they would have hit me on my side I could have lost the baby.
The cost of the damages was astronomical. I was able to start the car and get home to Marshall Avenue
near Montrose Place. The car was un-drivable since I couldn't see out of the entire right hand side. I
immediately called my insurance and they picked up my car the next day. 1 have a long commute every
day to Anoka from Saint Paul. As a result, I had to go to work two hours late while I waited for a rental
car a day later. My car repairs cost a total of$3256.81 dollars and I had to drive a rental for over three
weeks. (March 26, 2014—April 10, 2014)
Also, my deductible was$500.00 in order for me to pick up my car.As a result, my car insurance went
from $211.00 to$261.00 when I renewed in June. I went to my doctor's appointment and I was okay
that day, but soon after I had bleeding that sent me to the emergency room. I don't know if those
things are related, but the point is, it is dangerous.Airbags shouldn't be deployed from impact, but the
series of pot holes was unavoidable unless I wanted to swerve in the other person's lane and cause an
accident. I would like to file a claim with the city and receive at least my deductible back. I do look
forward to hearing from you. I love Saint Paul and I don't want anyone else to have to go through this.
If I don't hear anything I will seek out an attorney. My phone number is:Tel: 651-253-6430 and my email
is: Karolbaumeister@�mail.com.
est Regards,
� ���
� � �
Karol Ann Baumeister Laux
I
234 Montrose Place,Apartment 105
Saint Paul, MN 55104
. i , v . n � ,. t.��.:
. � �
NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minnesota State Stntute 466.05 states that °...every person...who clarms damnges from any mienicipality...sltall cnuse tn he presented to the
governing body of the municipality within 180 days nfter the alleged loss or injury is discovered a notice stnting the time,place,and
circumstances thereof,and the amount of compensatiott 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 wiR 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 F--t-1�G�-�� Middle Initial �� Last Name �-=� I�`��L''��5� ���`
Company or Business Name � 1 �"1
Are You an Insurance Company? Yes/ T� If Yes,Claim Number?
Street Address ��� �/ V(�►" I I I�%� �Vl ��v�
City���� � ""'1r'�-'l State I ' I'V Zip Code� f u
Daytime Phone � )���Cell Phone�^S� �-�-�3L� Evening Telephone( � �l ��
f i �Date of Accident/Injury or Date Discovered �/�41 �� Time �'S� am/ m
Please state,in detail,what occurred(happened), and why you are submitting a claim. Please indicate why or how you
�eel the City of Saint Paul or its employees are involved and/or responsible for your damages.
� ; .,
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P e��heck t e box(es)that mCo�sYcios'ely"represent t e reas n�or completing this form:
❑� M�'vehicle was damaged in an accident ❑ My vehicle was damaged during a tow
�1GIy 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 specify
❑ Other type of injury—please specify
In order to process your claim you need to include copies of all applicable documents.
Far 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.
�operty 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 far the repairs; detailed list of damaged items
O Iry}ury claims: medical bills,receipts
�hotographs are always welcome to document and support your claim but will not be returned.
Page 1 of 2—Please complete and return both pages of Claim Form
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims-ulease complete this section ,,.�,
Were there witnesses to the incident? Yes No Unknown (circle)
Provide their names, addresses and telephone numbers:
Were the police or law enforcement called? Yes No Unknown (circle)
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 ark or facility,
closest landmark,etc. Ple se be as detailed as ossible. If n essary, attach a diagram. ' ' �
j�ar C��c��c� ��,+•� i n-�rL��� , iJ,l c��� L�.� , 1 ���. �'�Uti'�1�'�
Please indicate the amount you are seekin in compensati�o"n�,o"r w t you would like the City to do to resolve this laim
to your satisfaction. �eCl ���� � �W��� lilJC�l,�- 1�'li'V ����C���
Vehicle Claims- lease com lete this se tion ❑ check box if this section does not a 1
Your Vehicle: Year�C�� Make Model �C�
License Plate Number C 'T� (nl� State�_Color ��
Registered Owner C�LU ^ �-'li'X
Driver of Vehicle �
Area Damaged ��1L L�''' 4'
City Vehicle: Year Make odel
License Plate Number State Color
Driver of Vehicle (City Employee's Name)
Area Damaged
Iniurv Claims-please 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 N
When did you miss work? (provide date(s))
Name of your Employer:
Address Telephone
L➢•eheck 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
���lj � �
Print the Name of the Person who Completed this Form: h-�+�� n � ��� ��
Signature of Person Making the Claim: ����� 1��� �'.�-��1+�.�--���
Revised February 2011
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PROGf�fll/!/��
KAROL ANN BAUMEISTER Company: Progressive Preferred Insurance Co ;
Claim number: 14-1813978-01
April 10,2014 I
Page 1 of 1 '
�ransaction Summary Questions
2 J08 Of�LVO C30 Please referto the business card in your
repair folder for the telephone number.
Your obiigations Thank you for allowing us to assist
Deductible ...... ......... ..... ... ..... . ... .... . . . .$500.00 you with the repair process.
Total . .. . ... ... ... .... . . . ........ ...............$500.00
Progressive's lifetime guarantee on
these repairs assures you that we
Payment summary stand behind the work completed.
Balance due ... . . . . . ........... . . . ............. . .. .$500.00
See your repair folder for details.
CREDIT CARD#XXXX-XXXX-XXXX-6669....................................$500.00
Total payments received . . . .. ............. . . .....$500.00
Received by:CODEY WITTIG,Claims Representative
In the event this payment fails for any reason or is insufficient to satisfy my obligation, I acknowledge and agree that I
remain obliyated to make immec'iate payment to the company designated above("�ompany")any amount due,that
Company may exercise any and all rights and remedies availabie to it at law in respect of such failure,and that I agree to
pay all reasonable colledion charges and costs, including attorney's fees and expenses of collection, in accordance with
applicable state law.
Initial
Credit car!! �aymant authorization
I hereby authorize Company to charge the credit card account indicated in payment of my vehicle repair expense
obligation set forth above. I represent and warrant that I am an authorized user of the account.
CREDIT�ARD #XXXX-XXXX-XXXX-6669 Authorization number:686486
Cardholder's Signature Date
X ............................................................................................................................................................................
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- ---- - .�- _ -- - �--_°-_._=. _ _ - - - �:=.
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Date: 4/8/2014 03:03 PM
Estimate ID: 14-1813978-01
Estimate Version: 2
Supplement: 1(F F) 4/8/2014 03:03:27 PM
Profile ID: Metro 7.125 All Part
ABRA Auto Body & Glass Apple Valley
15129 Foliage Ave.,Apple Valley,MN 55124
(952)4313500
Fax: (952)431-8880
Email: applevalley@abraauto.com
I
Damage Assessed By: JASON BREILAND Appraised For: JAY CONSING
(813)372-5471
Supptemented By: JASON BREILAND
.
Type of Loss: Property Damage
Date of Loss: 3/23/2014
Deductible: 500.00
Claim Number: 1 4-1 81 3978-01
Insured: KAROL ANN BAUMEISTER
Owner: KAROL ANN BAUMEISTER
Address: 234 MONTROSE PLACE,SAINT PAUL,MN 55104
Telephone: Work Phone: (763)506-8100 Home Phone: (651)253-6430
i
ContactPhone: (651)253-6430
Mitchell Service: 910885
Description: 2008 Volvo C30 T5 �
Body Style: 2D HB Drive Train: 2.SL Turbo Inj 5 Cyl SA FWD
VIN: YV1MK672482058399 License: 605CMH MN
Miteage: 102,294
OEM/ALT: A Search Code: ARDENHILLI
Color: SLUE
Options: PASSENGER AIRBAG,DRIVER AIRBAG,POWER LOCK,POWER WINDOW,REAR WINDOW DEFOGGER
MANUAL AIR CONDITION,TILT STEERING COLUMN,TELESCOPIC STEERING COLUMN
ANTI-LOCK BRAKE SYS.,TRACTION CONTROL,ALUMIALLOY WHEELS,AUXILIARY INPUT
LEATHER STEERING WHEEL,FRONT AIR DAM,TINTED GLASS,VARIABLE ASSISTED STEERING
SIDE AIRBAGS,ANTI-THEFT SYSTEM,AUTOMATIC HEADLIGHTS,SIDE HEAD CURTAIN AIRBAGS
DAYTIME RUNNING LIGHTS,AM/FM STEREO CD/MP3 PLAYER,ELECTRONIC STABILITY CONTROL
FRONT BUCKET SEATS,INTERIOR AIR FILTER,KEYLESS ENTRY SYSTEM,POWER DISC BRAKES
POWER HEATED EXTERIOR MIRRORS,POWER LIFTGATEITRUNK
STEERING WHEEL AUDIO CONTROLS
Line Entry Labor Line Item Part Type/ Dollar Labor
Item Number Type Operation Description Part Number Amount Units
Air Baa Svstem
1 000399 MCH REMOVE/REPLACE Air Bag Module-Passenger Seat -M 31271171-6 405.79 0.4 #
2 000403 MCH REMOVE/REPLACE R Air Bag Side Curtain Module -M 31271076-7 528.67 0.8 #
Front Susoension
3 001719 MCH ALIGN Four Wheel -M 1.3'
Enqine/Bodv Under Covers
4 000622 BDY REMOVElREPLACE Engine Under Cover 30793870-4 131.02 0.4
Front Seat
5 001740 BDY REMOVE/REPLACE Pass Side Seat Back Cover 39808538-1 315.26 ' 1.5 #
6 BDY REMOVE/INSTALL R Frt Seat Assy 0.5
Seat Belts
7 0010%4 BCY REMOVE/REPLACE L Frt Seat Belt 31320496-8 347.40 1.0 #
8 BGY REMOVE/INSTALL L Frt Seat Assy 0.5
9 001084 BDY REMOVE/REPLACE L Frt Seat Belt Buckle 6841697-3 77.11 0.4 #
Roof
10 001306 BDY REMOVE/REPLACE Roof Headtiner ORDER FROM DEALER 861.44 2.3
ESTIMATE RECALL NUMBER: 03/27/201413:73:39 14-1813978-07
Mitchell Data Version: OEM: FEB 14 V
MAPP:FEB 14_V Copyright(C)1994-2014 Mitchell International Page 1 of 4
Software Version: 7.0.487 All Rights Reserved
8 �
Date: 4/8/207 4 03:03 PM
Estimate ID: 14-1813978-01
Estimate Version: 2
Supplement: 1(F F) 4/8/2014 03:03:27 PM
Profile ID: Metro 7.125 All Part
S1 71 001330 BDY REMOVEIREPLACE R Roof Cover 30653885-1 �p,qg
S1 72 001734 BDY REMOVE/REPLACE R Roof Retainer Cover 30676480-4 7,q�
S1 73 001335 BDY REMOVE/REPLACE Roof Clip 30715923-6 �.�g
MANUAL ENTRIES
14 900500 MCH' ADD'L LABOR OP MOUNT 8 BALANCE INCLUDES STEM&WEIGHTS Sublet 18.50 ' 0.0*
15 900500 MCH* ADD'L LABOR OP MOUNT 8 BALANCE INCLUDES STEM 8�WEIGHTS Sublet 18.50 • 0.0"
16 900500 MCH' ADD'L LABOR OP MOUNT 8 BALANCE INCLUDES STEM 8 WEIGHTS Sublet 18.50 ` 0.0'
17 900500 MCH` ADD'L LABOR OP MOUNT 8 BALANCE INCLUDES STEM 8 WEIGHTS Sublet 18.50 ' 0.0*
S1 18 900500 MCH' ADD'L LABOR OP REPORGRAM SRS MODULE Sublet 180.00 ' 0.0`
'`-Judgment Item
#-Labor Note Applies
All manufacturers requirements regarding seat belt and supplemental
restraint system replacement must be adhered to. If additional parts
or operations are necessary to properly accomplish this, please
contact the estimating claims rep.
Estimate Totals
Add'I
Labor Sublet
i. labor Subtotals Units Rate Amount Amount Totals Ii. Part Replacement Summary Amount
Body 6.6 52.00 0.00 0.00 343.20 Taxable Parts 2,687.76
Mechanical 2.5 80.00 0.00 254.00 454.00 Sales Tax @ 7.125% 191.50
Non-Taxable Labor 797.20 Total Replacement Parts Amount 2,879.26
Labor Summary 9.1 797.20
III. Additional Costs Amount IV. Adjustments Amount
Total Additional Costs 0.00 Insurance Deductible 500.00-
Customer Responsibility 500.00-
I. Total Labor: 797.20
II. Total Replacement Parts: 2,879.26
III. Total Additional Costs: 0.00
Gross Total: 3,676.46
IV. Total Adjustments: 500.00-
Net Total: 3,176.46
Less Original Net Total: 2,973.89
Net Supplement Amount: 202.57
S1: JASON BREILAND 202.57
ESTIMATE RECALL NUMBER: 03/2712014 13:13:39 14-1813978-01
Mitchell Data Version: OEM: FEB 14 V
MAPP:FEB 14_V Copyright(C)1994-2014 Mitchell International Page 2 of 4
Software Version: 7.0.487 All Rights Reserved
a •
Date: 4/8/2014 03:03 PM
Estimate ID: 1 4-1 81 3 978-01
Estimate Version: 2
Supplement: 1(F F) 4/SI2014 03:03:27 PM
Profle ID: Metro 7.125 All Part
Point(s)of Impact
21 Undercarriage(P)
Insurance Co: PROGRESSIVE
Inspection Site: ABRA APPLE VALLEY(SCO)
Address: 15129 Foliage Ave
(SCO HOCHHALTER)
St Paul,MN 55124
Inspection Date: 3/27/2014
THIS IS A DAMAGE ASSESSMENT ONLY - NOT AN AUTHORIZATION TO REPAIR -
BASED ON DAMAGE VISIBLE OR CERTAIN AT THE TIME IT WAS WRITTEN.
IF FRAME OR UNIBODY REPAIR IS INCLUDED ON THIS ESTIMATE, THE AMOUNT
SHOWN INCLUDES TIME OR ALLOWANCE FOR MEASURING BEFORE, DURING AND
AFTER THOSE REPAIRS.
THE OWNER OF THE VEHICLE MAY SELECT THE REPAIR FACILITY OF HIS/HER
CHOICE.
TO ENSURE PROPER AND PROMPT PAYMENT FOR ADDITIONAL DAMAGE DISCOVERED
DURING THE COURSE OF REPAIRS, CONTACT PROGRESSIVE FOR SUPPLEMENT
HANDLING PROCEDURES.
PROGRESSIVE HONORS THE PREVAILING LABOR MARKET RATE IN YOUR AREA FOR
YOUR PROPERTY. IF YOU CHOOSE A SHOP THAT CHARGES IN EXCESS OF
PREVAILING LABOR MARKET RATES, YOU WILL BE RESPONSIBLE FOR THE
DIFFERENCE.
LIFETIME GUARANTEE FOR SHEET METAL AND PLASTIC BODY PARTS
The replacement parts written on the estimate are intended to return
your vehicle to its pre-loss condition with proper installation.
After repair, if any sheet metal or plastic body part included in the
estimate fails to return your vehicle to its pre-loss condition
(assuming proper installation) , in terms of form, fit, finish,
durability or functionality, Progressive will arrange and pay for the
replacement of the part, to the extent not covered by a
manufacturer's or other warranty. This service will be performed at
no cost to you (including associated repair and rental car costs) . To
obtain service under this Guarantee, call Progressive at
1-800-274-4641. This Guarantee applies as long as you own or lease
ESTIMATE RECALL NUMBER: 03127/2014 13:1339 74-1813978-01
Mitchell Data Version: OEM: FEB 14 V
MAPP:FEB_14_V Copyright(C)1994-2014 Mitchell International Page 3 of 4
Software Version: 7.0.487 All Rights Reserved
Date: 4/8/2014 03:03 PM
Estimate ID: 14-1 8 7 3978-01
Estimate Version: 2
Supplement: 1(F F) 4/8/207 4 03:03:27 PM
Profile ID: Metro 7.125 All Part
the vehicle. This Guarantee is not transferable and terminates if you
sell or otherwise transfer your vehicle.
THIS GUARANTEE DOES NOT COVER NORMAL WEAR AND TEAR OR D�MF�GE C,AUSED
BY IMPROPER MAINTENANCE, NEGLECT, ABUSE OR SUBSEQUENT ACCIDENT. THIS
GUAR7INTEE IS LIMITED TO ARRANGING FOR THE SELECTION OF REPAIR PARTS
THAT WILL RETURN YOUR VEHICLE TO ITS PRE-LOSS CONDITION. ACCORDINGLY,
PROGRESSIVE WILL NOT BE LIABLE FOR ANY INDIRECT, INCIDENTAL OR
CONSEQUENTIAL DAMF�GES THAT RESULT FROM THE INSTALLATION OR USE OF
THESE PARTS.
Part Type Terms and Abbreviations
NEW and OEM or part number displayed - These refer to a new, original
equipment manufacturer part.
NON-OEM and A/M and Qual REPL - These refer to an after-market part,
which is a new, non-original equipment manufacturer part.
USED/RECYCLED and LKQ - These re£er to a used OEM part.
REMANUFACTURED and RECOND. and RECORE - These refer to used/recycled
OEM parts that have been refurbished.
REPAIR SHOP'S AUTHORIZED REPRESENTATIVE'S SIGNATURE INDICATING
AGREEMENT ON COST TO RETURN THE VEHICLE TO PRE-LOSS CONDITION
INCLUDING TOW/STORAGE CHARGES:
SHOP SIGNATURE: EST. COMPLETION DATE:
ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE/SHE IS
FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION OR
FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF
INSURANCE FRAUD.
ESTIMATE RECALL NUMBER: 03/27/2014 13:13:39 14-1813978-01
Mitchell Data Version: OEM: FEB_14_V
MAPP:FEB_14_V Copyright(C)1994-2014 Mitchell International Page 4 of 4
Software Version: 7.0.487 All Rights Reserved
Date: 4!8/2014 03:03 PM
Estimate ID: 14-1813978-01
Estimate Version: 2
Supplement: 1 (F F) 4/8/2014 03:03:27 PM
Profile ID: Metro 7.125 All Part
ABRA Auto Body & Glass Apple Valley
15129 Foliage Ave.,Apple Valley,MN 55124
(952►431-3500
Fax: (952)437-8880
Email: applevalley@abraauto.com
Supplement Defta Report
Comparison of Estimate 1 4-1 81 3 978-01 Supplement 0 and Supplement 1
Damage Assessed By: JASON BREILAND
Supplemented By: JASON BREILAND
Insured: KAROL ANN BAUMEISTER
Owner: KAROL ANN BAUMEISTER
Vehicle Description: 2008 Volvo C30 T5
Date of Loss: 3/23/2014
Line Labor Line Item Dollar Labor CEG
Item Type Operation Description Part Type Amount Units Unit
Added Entries
S1 11 BDY REMOVEIREPLACE R Roof Cover 30653885-1 12.48 0.0 T
S1 12 BDY REMOVE/REPLACE R Roof Retainer Cover 30676480-4 7.41 0.0 T
S1 13 BDY REMOVEIREPLACE Roof Clip 30715923-6 1.18 0.0 T
S1 18 MCH ADD'L LABOR OP REPORGRAM SRS MODULE Sublet 180.00 ' 0.0`
Global Changes
No Deductible,Customer Responsibility,Labor Rate,or Part Adjustment changes were made.
Amount
Original Estimate: 2,973.89
Supplement 1 202.57
Orig Total Tax 190.00
Supp 1 Total Tax 191.50
Net Supplement Amount 202.57 �_
NetTotal 3,176. •��Z�f� I
Program Calc Versions Data Versio
Supp 0 7.0.487 FEB_14_V
Supp 1 7.0.487 FEB_14_V
I� �`A� V�
V ���''`� p'`�
� �
Pr� �� � � I ��
��'�-�j�� �[�
ESTIMATE RECALL NUMBER: 312712014 13:13:39 14-1813978-01 � �1—"�. �� '"`" ���
Software Version: 7.0.487 Copyright(C)1994-2014 Mitchell International Page 1 of 1
All Rights Reserved
PAOGRE.!'I/��p
KAROL ANN BAUMEISTER Company: Progressive Preferred Insurance Co
Claim number: 14-1813978-01
April 10,2014
Page t of 1
1'ransaction Summary Questions
2J08 V�LVO C30 Please referto the business card in your
repair folder for the telephone number.
Your obligations Thank you for allowing us to assist
Deductible . .. . . .... .. . ... . . . . . . ........ . . .. ...... .$500.00 you with the repair process.
Total . .. .. . . . . .. . . . . . ... . . ... .. ... . . . . . . .. ......$500.00 Progressive's lifetime guarantee on
these repairs assures you that we
Payment summary stand behind the work completed.
Balance due .. . . . . . . . .. .. . . ... . . ... . . . . ..... .. ... ..$500,00 See your repair folder for details.
CREDIT CARD#XXXX-XXXX-XXXX-6669....................................$500.00
Total payments received . . .... . ..... . ... . ........$500.00
Received by:CODEY WITTIG,Claims Representative
In the event this payment fails for any reason or is insufficient to satisfy my obligation,I acknowledge and agree that I
remain obligated to make immediate payment to the company designated above("Company")any amount due,that
Company may exercise any and all rights and remedies available to it at law in respect of such failure,and that I agree to
pay all reasonable collection charges and costs, including attorney's fees and expenses of collection, in accordance with
applicable state law.
Initial
Credit car�! paymr,nt authQrization
I hereby authorize Company to charge the credit card account indicated in payment of my vehide repair expense
obligation set forth above. I represent and warrant that I am an authorized user of the account.
CREDIT'�ARD #XXXX-XXXX-XXXX-6669 Authorization number:686486
Cardholder's Signature Date
X .... ... .................................................................... ..................................... ........................................................