Gjelten, Daniel NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipality...shall cause to be presented to the
governing body of the municipality within 180 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
F irst Name i a b1� e � Middle Initial�Last Name�re �T P V1 R�r�n�
'`�ELJ
Company or Business Name M_�
-- 1��4
Are You an Insurance Company? Yes o If Yes, Claim Number?
Street Address � � �OV��YO �2 �(QCQ ER�
City �fi �� State �� Zip Code fi S10�
Daytime Phone(�I )� 0�S Cell Phone((g�)S��=8 y�Eq Evening Telephone tb S�� �Fq 3 '��"Z°I
Date of Accident/Injury ar Date Discovered � — (�—�� Time � am/pm
Please state, in detail,what occurred(happened),and why you are submitting a claim. Please indicate why or how you
feel the City of Saint Paul or its employees are involved and/or responsible for your damages.
'�-e� 6 V+�!/In `� Fv►►� �Ww(�V-a� � tn� Can vv�
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�f the street � My��ehicle was damaged by a plow
� My vehicle was wrongfully towed and/ar ticketed � I was injured on City propgrty
�`�� O her type of property damage—please specify U 2�ti C(� �0✓w��a,�.a �v, �t�t/�f'��/►� V b'l 4v►n f/�.�
Other type of injury—please specify
In order to process your 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 befare submitting your claim form.
t3 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/ar receipts for the repairs
t1 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
a Injury claims: medical bills, receipts
t� 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? Yes No Unkr�wno (circle)
Provide their names, addresses and telephone numbers:
Were the police or law enforcement called? Yes No,� Unknown (circle)
If yes,what deparhnent 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 ossible. If necessary, attach a diagram.
�41 Z U�n✓��� �GC �'�"�i1M� S� D`f'
Please indicate the amount ou are se king in compen ation or what you would like the City to do to resolve this claim
to your satisfaction.��c�.e c�W f1�-v��
Vehicle Claims— lease com lete this section check box if this section does not a 1
Your Vehicle: Year �Z� �'�-- Make 1�V Model � S�1 �L C
License Plate Number State Color ��J P�/'
Registered Owner �QV� [.,-;e�}f v�
Driver of Vehicle �� ��
Area Damaged �,� . � �S
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniurv Claims—please comp�ete tfiis secfion � c eck box if thi�section does not apqlv
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 wark as a result of your injury? � Yes No
W�hen did you miss work? (provicte date(sj)
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 �� ZS ^ ��'
Print the Name of the Person who Completed this Form: D a � �e t � �T►C �� �
Signature of Person Making the Claim: �i"�X� 1\t
Revised February 2011
_ _ _
_
HEPPNERS AUTO BODY (Midway) rNorkfile ID: fa8ebc7e
��� 400 SYNDICATE ST. N., SAINT PAUL, MN 55104
Phane: (651)646-8515
FAX: (651)645-3230
Preliminary Estimate
Customer: G�ELTEN, DAN 7ob Number•
Written By:JON MARTENS
Insured: G)ELTEN,DAN Policy#: Claim#:
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact: 16 Non-Coilision
��: Inspection location:
Insurance Company:
�
GJELTEN,DAN ����� HEPPNERS AUTO BODY(Midway) STATE FARM INSURANCE COMPANIES
192 MONTROSE PMNAI�WitY 400 SYNDICATE ST.N.
ST PAUL,MN 55104 SAINT PAUL,MN 55104
(651)493-4729 Celi Repair Facility
(651)646-8615 Day
VEHICLE
Year. 2002 Body Style: 4D WGN VIN: VWWWH63632E4U6184 Mileage In:
Make: VW Engine: 6-2.8L-FI license: 6b76DN Mileage Out:
Modei: PASSAT GlX Production Date: State: MN Vehicle Out:
Color: SILVER GREEN Int: Condition: ��#:
TRANSMISSION BRAKES FM Radio Intermittent Wipecs
5 Speed Transrnission Power&akes Stereo Wood Interior Trim
Overdrive 4 Wheel Disc Brakes Ca�ette EXTERIOR
Traction Control Anti-t.odc Brakes(4) SearchJSeek Power Mirrors
�� ROOF ' INTERIOR Dual Mirrors
Porver Driver Seat Electric Glass Sunroof Power Locks Body Side Moldings
Power Passenger Seat GLASS Air Conditioning Alarm
Budcet Seats Rear Defo99er Guise Control Fog Lamps i
Leatt�er Seahs Pow�Windows Driver Air Bag Keyless Entry
Heated Seat�s WNEELS Passenger Air Bag PAINT
STEERING Aluminum/Alioy Wheeis Front Side Impact Air Bags Gear Coat Paint
Power Steering RADIO CAnsotej$torage
Steering Wheei Controls APN Radio "Digital Ciodc
!
6/17/2014 11:28:36 AM 050503 Page 1
Prefiminary Estimate
Customer: G7ELTEN, DAN ]ob Number:
Vehide:2002 VW PASSAT GLX 4D WGN 6-2.8L-FI SILVER GREEN
Une Oper Description Part Number Qty Extended Labor Paint
Price�
1 FRONT BUMPER
2 R&I R&I bumper cover 0.8
Note: FOR PAINIING
_ ...: _ __ _ __._._ _ _ _ __. . __ - -_.._ _ _ ._. _ _
3 FRONT LAMPS
4 R&I RT R&I headlamp assy 0.3
5 R&I LT R&I headlamp assy 0.3
_.� ,...._:.. . ....... _._....__ . .._.... .. � _ __...... . .. _
_ __...� ._._ ... . . ....., .__ ._ . _._
6 HOOD
7 Repi Hood 3B0823031K 1 280.80 1.2 2.6
8 Add for qear Coat 1.0
9 Add for Underside(Complete) 1.3
� :. ...,__..�. ... ,x... ... ........... �... . .... .. . _. ........__ ....._ . _ _ �
10 FENDER
11 * Rpr RT Fender to VIN 3B4P152545 1� 2•�
12 Overlap Major Adj.Panel -0.4
13 Add for Clear Coat 0.3
14 Bind LT Fender to VIN 364P152545 1-�
15 RScI RT Fender liner 1.8,2.0&2.8 liter 0.3
16 R&I LT Fender liner 1.8,2.0&2.8 liter 0.3
�- _ ____ ...— -.___.._._._,__. __. _ _. _-,---.---_____ __. _. . ____ . .
17 ROOF
18 Repi LT Drip molding aluminum 369854701C7Z7 1 168.48 0.6
19 R&I LT Drip channel 0.3
20 # Rpr LEFT ROOF PILIER 4.0 2.4
21 Repl LT Rail biadc 389860025B03C 1 329.62
�__ _ .__ ---- . __ __ _. _ . _..
.�22 FRONT DOOR
23 Repl LT Applique 380837901F041 1 76.97
24 Repl LT Door w'strip black/beige 380867365MMGU 1 144.83 0.6
._..�_,.......x �_ ......_, _ _.._..._. .. ..._. ... _ . _._.._. . .. __.. _ . . .._ . . .__ .
25 MISCELLANEOlfS OPERATIONS
26 Repl Cover car/bag 1 0.2
27 # RESTORE CORROSION 1 0.2
PROTECTION
28 # Subl HAZARDOUS WASTE REMOVAL 1 5.00 X
SUBTOTALS 1,005J0 10.4 10A
/
6/17/2014 11:28:36 AM 050503 Page 2
_ _
Preliminary Estimate
Customer: G7ELTEN, DAN 7ob Number:
Vehicie: 2002 VW PASSAT GLX 4D WGN 6-2.8L-FI SILVER GREEN
ESTIMATE TOTALS
��j�y Basis Rate Cost�
Pa� 1,000.70
g�y��r 10.4 hrs @ $32.00/hr 332.80
Paint Labor 10.4 hrs @ $32.00/hr 332.80
pa�nt Supp��s 10.4 hrs @ $32.00 Jhr 332.80
Misceilaneo� 5.00
Subtota� 2,004.10
c�j�-(� $1,333.50 @ 7.6250% 101.68
Grand Total 2,105.78
Deductible 0.00
CUSTOMER PAY 0.00
YNSURANCE PAY 2,105.78
THIS IS A VISUAL ESTIMATE ONLY. ADDITIONAL PARTS AND LABOR MAY BE EXTRA UPON TEARDOWN. PART
PRICES SUBJECT TO INVOICE.
NO GUARANTEE ON RUST REPAIR!
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.
s
6/17/2014 1128:36 AM 050503 Page 3
Preilminary Estimate
Customer: G]ELTEN, DAN 7ob Number:
Vehicle:2002 VW PASSAT GLX 4D WGN 6-2.8L-FI SILVER GREEN
Estimate based on MOTOR CRASH ESTIMATiNG GUIDE. Unless otherwise noted ail items are derived from the Guide
EEA9255, CCC Data Date 6/16/2014, 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 aiternate 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 inciude "Biemished" parts provided by OEM's through OEM vehicie 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 aiternate data source. Tiide sign (N) items indicate MOTOR Not-Included
Labor operations. The symbol (<>) indicates the refinish operation WILL NOT be pertormed 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 Reoore. 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, �abor 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 symtmis 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 categoty. S=Structural labor category. (numbers) 1 through 4=User Defined Labor Categories.
OTHER SYMBOLS AND ABBREVIATIONS:
Adj.=Adjacent. Algn.=Align. ALU=Aluminum. A/M=Af�ermarket 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. O/H=Overhaul. Qty=Quantity. Refn=Refinish. Repl=Repiace.
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 CCC DME Estimating that are not part of the MOTOR
CRASH ESTIMATING GUIDE:
BAR=Bureau of Automotive Repair. EPA=Environmental Protection Agency. NHTSA= National Highway
Transportation and Safety Administration. PDR=Paintless Dent Repair. VIN=Vehicle Identification Number.
f
6/17/2014 11:28:36 AM 050503 Page 4
STATE FARM INSURANCE COMPANIES
500 SOUTH 84TH STREET LINCOLN, NE 68510-2611
SUPPLEMENT FAX: (MN,WI)800-230-1949
SUPPLEMENT FAX:(IA,NE,ND,SD)800-455-9697
'""`PRELIMINARY ESTIMATE***
06/23/2014 12:40 PM
Owner
Owner: DAN GJELTEN
Address: 192 MONTROSE PL Home/Day: (651�93-4729
Work/Day: (651)962-5005
City State 2ip: SAINT PAUL, MN 55104-5625 Home/Evening: (651)962-5005
Corrtrol Information
Claim#: 23-4N20-88501 Insured Policy#:
Loss DatelTime: 06/16/2014 07:00 AM Loss Type: Comprehensive
Deductible: $500.00
Ins.Company: State Farm
Agent: v
Insured: DAN GJELTEN
Address: Home/Day: (651}493-4729
Worlc/Day: (651)962-5005
City State 2ip: Home/Evening: (651)962-5005
Claim Rep: Express Team E
Address: Work/Day: (855)341-8184
Inspection
Inspection Date: 06/23/2014 12:24 PM Inspection Type: Field
Inspection Location: RESIDENCE-Dan Gjelten Contact:
Address: 192 MONTROSE PL Home/Day: (651)962-5005x
City State 2ip: SAINT PAUL, MN 55104
Primary Impact: Non-Collision Secondary Impact:
Driveable: Yes Rental Assisted:
Assigned Date/Time: Received Date/Time: 06/22/2014 06:10 PM
First Contact Date/Time: Appointment DatelTime: O6/23/2014 08:00 AM
Appraiser Name: Mike CAV2 Appraiser License#:
Repairer _ _
Address: 400 N SYNDCATE ST Work/Day: (651)646-8615
City State Zip: ST PAUL, MN 55104 FAX: (651)645-3230
Remarks
ANY ADDITIONAL PLEASE CONTACT SUPP. UNIT FAX#800-230-1949
O6/23/2014 12:49 PM Page 1 of 4
��e..�-��,c�
2002 Vdkswagen Passat GLX 4 DR Wagon
Cleim#: 23-4N20-88501 O6l23l2014 12:40 PM
. Vehicle
2002 Volkswagen Passat GLX 4 DR Wagon
6cyl Gasoline 2.8
5 Speed Manual
Lic.Plate: 6676DN Lic State: MN
Lic Explre: 03/2015 VIN: WVWWH63B32E406184
Prod Date: Mileage: 135,175
Veh Insp#: Mileage Type: Actual
Condition: Code: 61364B
E�.Color: SILVER Int.Color:
Ext.Reflnish: Two-Stage Int.Refinish: TwaStage
Options
Air Conditioning Alarm System Aluminum/Alloy Wheels
Anti-Lock Brakes Automatic Dimming Mirror Center Console
Climate Control For A/C Compact Disc W/Tape Cruise Control
Dual Airbags Dual Power Seats Fog Lights
Garage Door Opener Head Airbags Heated Front Seats
Heated Power Mirrors Heated W/S Wiper Washers Intermittent Wipers
Keyless Entry System Leather Seats Leather Steering Wheel
Lighted Entry System Metallic Paint Monsoon Sound System
Power Brakes Power poor Locks Power Moonroof
Power Steering Power Windows Rain-Sensing W/S Wipers
Rear Window Defroster Rear Window WipedWasher Roof/Luggage Rack
Side Airbags Split Folding Rear Seat Strg Wheel Radio Control
Tachometer Telescopic Steering Whl Tilt Steering Wheel
Tinted Glass Traction Control System Trip Computer
Wood Interior Trim
Damages
Line Op Guide MC Description MFR.Part No. Price ADJ% B% Hours R
Striues And Mouldinas
1 RI 415 Cover,Rocker Panel LT R&1 Assembly 0.2" SM
2 RI 416 Cover,Rocker Panel RT R 8�I A�sembly 0.2* SM
Front Bumner
3 RI 6 Front Bumper Cover R&I R&I Assembly 0.8 SM
Front End Panel And Lamns
4 RI 41 Headlamp Assy,Halogen LT R 8�I Assembly 0.2 SM
5 RI 42 Headlamp Assy,Halogen RT R 8�I Assembly 0.2 SM
6 RI 168 Lens,Side Marker LT R 8�I Assembly 0.1 SM
7 RI 169 Lens,Side Marker RT R 8 I Assembly 0.1 SM
Front Bodv Md Windshield
8 E 83 01 Panel,Hood 3B0823031K $280.80 0.8 SM
9 L 83 13 Panel,Hood Refinish 5.2 RF
2.8 Surface
1.0 Edge
0.6 Two-stage setup
0.8 Two-stage
10 BR 103 Fender,Front LT Blend Refinish 1.1 RF
0.7 Blend
0.4 Two-stage
Ofi2312014 12:49 PM Page 2 of 4
G�e.��e�
2002 Volkswagen Passat GLX 4 DR Wagon
Gaim#: 23dN20$8501 O6/2312014 12:40 PM
11 I 104 Fender,Front RT Repair 2.0" SM
12 L 104 Fender,Front RT Refinish 2.2 RF
1.8 Surtace
0.4 Two-stage
Front Bodv Interior Sheetmetal
13 RI 111 Skirt,lnner Fender LT R&I Assembly 0.5 SM
14 RI 112 Skirt,inner Fender RT R 8�I Assembly 0.3 SM
844�
15 I 122 Panel,Bodyside Otr Upr LT Repair 3.5* SM
16 L 122 Panel,Bodyside Otr Upr LT Refinish 1.2 RF
1.0 Surface
0.2 Twastage
17 E 413 01 MIdg,Roof Drip LT 369854701C7Z7 $168.48 3.4 SM
18 RI 265 Channel,Roof Drip LT R&I Assembly 0.3 SM
Front Doors
19 E 233 01 W/Strip,Frt Door Body LT 3B0867365MMGT $144.83 0.5 SM
20 E 184 Applique,Frt Door Fram LT 360837901F041 $76.97 0.3 SM
Manual Entries
21 L M14 Corrosion Protection Refinish 0.3' RF
22 SB haz waste Sublet Repair $3.00' SM'
23 E car cover Replace OEM $3.00* SM'
23 Items
MC Message
01 CALL DEALER FOR EXACT PART#/PRICE
13 INCLUDES 0.6 HOURS FIRST PANEL TWO-STAGE ALLOWANCE
r_�.-------
__._...----
! Estimate Total 8�Ent�ies
Gross Parts $674.08
Paint Materials $320.00
Parts 8�Material Total $9�•08
Tax on Parts&Material @ 7.625% $75.80
��r Rate Replace Repair Hrs Total Hrs
Hrs
Sheet Metal(SM) $52.00 7.9 5.5 13.4 $696.80
Mech/Elec(ME) $72.00
Frame(FR) $65.00
Refinish(RF) $52.00 10.0 10.0 $520.00
Paint Materials $32.00
LaborTotal 23.4 Hours $1,216.80
Subiet Repairs $3.00
Gross Total s2'289.68
Less:Deductible $500.00-
Net Total 51,789.68
Register online to check the status of your claim and stay connected with State Fartn�.To register,go to statefarm.com and select Check the
Status of a Claim. If you are already registered,thank you!Not available in New Mexico.
Altemate PaRs Y/00/00/00/00/00 CUM 00/00/00/00/00 Zip Code:55109 METRO
Page 3 of 4
O6/23/2014 12:49 PM
� G,����e�.
2002 Volkswagen Passat GLX 4 DR Wagon
Claim#: 23-4N20�8507 06/23/2014 12:40 PM
Recycled Parts Y/1/0 Zip Code:55110 INV DATE:06/23/2014
Audatex Estimating 7.0.226 ES 06I23/201412:49 PM REL 7.0.226 DT 06/01/2014
Copyright(C)2013 Audatex North America, Inc.
2.4 HRS WERE ADDED TO THIS ESTIMATE BASED ON AUDATEX'S TWO-STAGE REFINISH FORMULA.
ANY PERSON WHO SUBMITS AN APPLICATION OR FILES A CLAIM WITH INTENT TO DEFRAUD
OR HELPS COMMIT A FRAUD AGAINST AN INSURER IS GUILTY OF A CRIME.
THIS IS AN ESTIMATE. REPAIR FACILITES MUST INSPECT THE VEHICLE TO DETERMINE
IF ANY REPAIRS NOT LISTED ARE REQUIRED,AND TO CONTACT STATE FARM BEFORE
MAKING SUCH REPAIRS. REPAIRER ALSO IS RESPONSIBLE FOR CONDUCTING ANY NECESSARY
INSPECTION AND SAFETY CHECKS PRIOR TO AND AFTER COMPLETING REPAIRS.
THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF ONE OR MORE CRASH PARTS
SUPPLIED BY A SOURCE OTHER THAN THE MANUFACTURER OF YOUR MOTOR VEHICLE.
WARRANTIES APPLICABLE TO THESE REPLACEMENT PARTS ARE PROVIDED BY THE PARTS
MANUFACTURER OR DISTRIBUTOR RATHER THAN BY THE MANUFACTURER OF YOUR VEHICLE.
A PERSON WHO FILES A CLAIM WITH INTENT TO DEFRAUD OR HELPS CONII�IIT A FR.AUD
AGAINST AN INSURER IS GUILTY OF A CRIME.
Op Codes
' = User-Entered Value E = Replace OEM NG= Replace NAGS
EC= *'NON-OEM PART OE= Replace PXN OE Srpls UE= Replace OE Surplus
ET= Partial Replace Labor EP= *"NON-OEM PART EU= RECYCLED PART
TE = Partial Replace Price PM= REMAN/REBUILT PART UM= REMAN/REBUILT PART
L = Refinish PC= RECOND PART UC= RECOND PART
TT = Two-Tone SB= Sublet Repair N = ADDITIONAL OPERATION
BR= Blend Refinish I = Repair IT = Partial Repair
CG= Chipguard RI = R 8�I Assembly P = Check
RP= RP-RELATED PRIOR
This report contains proprietary information of Audatex and may not be disclosed to any third party(other than
the insured,claimant and others on a need to know basis in order to effectuate the claims process)without
�A u da tex Audatex's prior written consent.
d SU!ete cv�npd:iy
— Copyright(C)2013 Audatex North America, Inc.
Audatex Estimating is a trademark of Audatex North America, Inc.
Page 4 of 4
06/23/2014 12:49 PM
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