Vang, Lee (2) NOTICE OF CLAIM FORM to the City of Saint Panl,Minnesota
Minrtsmota Stats Staaae�OS states d�at"...every per�on...wia danna damagss,j►+om a�y mw�icipaJity...alwll cnuae w bs pnaentsd to t►u
8�'��8�!'of���lity withirt 1&0 days r�ttr the aAeged lata ar i�{jwry is dfacovend a eotia a�atotg du tane,Place.and
cirprn�atonces thertof,and tlu arrount of campa�ation or odrer nlief demonded"
Pknse compkts tlris form in i�e�nt7 by dearly t7Pn8�'P�'m�8 7�answer to a�eh qoation. II more ap�oe is
needea,att�ch additio�l sheets. Pleaee note tLat yon wal not be contacted by tdephone to darliy a�'ra,eo p�+ov�de sg
mmch finiormatbn as neoes�uy to ezptnin yoaT cl�im.And t�e amoant oi compensati�bdng nqoested. Yoa wlll reodve a
written aclmowledgewmt once yoar form is reoeived. The proce�s can take up to ien wee�s�lo�er dq►mdusg on the
natm�e oi yoar da�n. 'I1�fo�rm mast be signed,and bot6 pa�s coml�leted. If something does not aPP�Y��k`N/A'.
SEND COMPLETED FORM AND OTHER DOC;UMENTS TO: CITY CLERK,
15 WEST KELLo�BLVD,31 ITY HALL,SAINT PALTI.,MN 55102
.�eo9�e�tf�lr� PKC-tt�xtd�n�,t9f�0
First Name �'r. 1N'id�e Initial Last Name
Company oz Business Name � �
Are You an ivsurance Company `Y No If Yes,Claim Number? 7��
Strcet Address ������E�
�' S`� �p� AUG 2 5 �0��
Daytime Phone 'rvI Q��_" Cell Phone(� Evemng Telephone�� -
Date of Avcidend Injury or Date Discovered �,�,�3�/¢ � 3•"�/ �� �I TY C L E R K
please state,in de�i1,what occurned(haQpenefl},and why you are submitting a claim.Please indicate why or how you
feel the City of Saint Paul ar its employees are involved and/or responsible fa your damages.
� h
-�r�-a,-�I-I-r-� -
Please check the box(es)tbat most closely represent the reason for completing this form:
�My vehicle was damaged in an accident ❑My velricle was damaged during a tow
My velricle was damaged by a pothole or condition of the street ❑My vehicle was damaged by a plow
O My velricle was wrongfully towed and/or ticketed ❑I was injurefl on City property
p Other type of property damage—please speafy
❑Other type of injury—please spacify
In order to process your claim vou nced to include conaes of all annl�cable documents.
For the claims types listed below,Pkase be sure to include the documents indicated or it will delay the handling of
yow claim, Documents WII-L NOT be returned and become the property of the City. You are encouraged to ke�p a
copy far yourself before submitting your claim foim.
O Property damage claims to a vehicle:two estimate�s for the repairs w your velucle if the daznage e�ceeds
$500.00:ar the actual b�ls 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 da�nage 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 Injury claims:meclical t�ills,receipts
O Photographs are always welcome to document and support your claim but will not be returned.
Page 1 of 2—Please o�mplete mud rehun both pages of Claim Form
I
�
Fallure to complett and return both ps�ges wIll result in del�,y in the handling a[your c1Aim.
All CI�1118—D�18C OD1riD1�C�8 BEC�Oi1
Were there wimesses to the incident? Yes �Ng� Unlmown (circle}
Provide their names,addresses and telephone numbe�°
Were the police or law enforcement called? �� No Unlmown (circle}
If yes,what department or agency? Case#or report#
Where did the aocident or injury take place? Provide strcet address,cross st�et,intersecxion,name of park or faality,
cl/osesvl/,/�etct%Please be�ci�'led��ble. ff necessary,a�tach a ciiagcam.
Flease i�cate the amount you are seelang in compensation a�what you would like the 6ty to do to resolve this claim
to your satisfaction.
�
.�
V� �m ❑ heck box if this "on dces a 1
Your Vehicle: Year � Make Mode1
License�� Pla Ntunber State Color
Registered Ownea
Driver of Vebicle
Area
City Vehicl� Year O Model
I.iccnse Plate Number State Color
Driver of Vehick(City Fmployee's Name) �°1(j/� (�C
Area I)amaged
In;nry Cla�ms_Dlesse comgl�e thia seclion ❑chack boa if this saction does not avulv
How were you injured?
What part(s)of your body were injured?
Have you sought mer�ical treatment? Yes No Planning to Seek Treatment(circle} n���S))
When did you receive t�eatment? (P� �
Name of Mer�ical Provide,r(s):
Addmss Telephone
Did you miss work as a result of yaur injury? Yes No
rovide date(s})
When did you miss work? (P
Name of your F�ployer:
Address Telephone c}��
�Check h�e if you are attaching more gages to this claim form. Number of additionsl gsges �f �'��
BYY s+Br+�B'��.��J'oa are s�ating d�at all ir�'ormalion yoa have prmnided rs dree myd correct tv the best
of your krrowkdge. Unsigned forms will r�ot be processed
Srrbmitaing a jalse cJaam can result iri prosecua'on. Date form was campleted
PrInt the Nsme of the Person who Comgleted t1�is Fo �� � �
Signature of Person Maldng the Claim: ;
i
Rcvised FebruarY 2011
i
i
I
Description of Loss: Our named insured's 2005 Toyota Sienna was traveling southbound on
Johnson Pkwy approaching the intersection of 7`h St. A City of St Paul 2013 Ford Explorer was
traveling northbound on Johnson Pkwy approaching the intersection of 7u'St. As our insured
proceeded forward,the 2013 Ford attempted a left hand tum and strudc our insured's vehicle,
causing damage. The driver, Brian Nowicki, is the proximate cause of the accident for failure to
yield right of way.
F«� W�9 Request for Taxpayer Give Form to the
(Rev.December2011) Identification Number and Certification requester.Do not
Departrtrent of the Treasury send to the IRS.
Intemal Revenue Service
Name(as shown on your Income tax retum)
N Busineas name/disregarded entity name,if differeM irom above
� ��� 4 G-'�i 5 � V'7 �1 t� �U •�'�'LS C� �
�- Check appropriate box for federal tex lassificatbn:
c
� ❑ IndividueVsole ro rietor C Corporation
� p p ❑ S Corporation ❑ Partnership ❑TrusUestate
c
0
� � � LimRed ifability company.Enter the tax classfficatlon(C=C corporation,S=S corporation,P=partnership)► ❑�empt payee
o •
------------------------°------
M �
a� ❑ Other(see instructions)►
v
� Ad �s/s(number,street,end apt.or sufte no.) Requester's name and address(optionaq
a �t J� N��or� ���
m Cfty,state,and ZIP code
� � �+�-1�.. ► `
�
List axount num here(optionap
• Taxpayer ldent�cation Number(TIN)
Enter your TIN in the appropriate box.The TIN provided must match,the name given on the"Name"line ���Secu►KY rn+mbs�
to avoid backup withholding.For individuals,this is your social security number(SSN).However,for a � _m _�
resident alien,sole proprietor,or dfsregarded entity,see the Part I instructions on page 3.For other
entities,it is your employer identification number(EIN).ff you do not have a number,see How to get s
TIN on page 3.
Note.If the account is in more than one name,see the chart on page 4 for guidelines on whose �+P��r ide�rtlflcation number
number to enter.
3 �f - � � o -
Certification
Under penatties of pery'ury,I certify that:
1. The number shown on this form is my correct taxpayer identification number(or I am waiGng for a number to be issued to me},and
2. I am not subject to backup withholding because:(a)!am exempt from backup withholding,or(b)I have not been notffied by the Intemal Revenue
Service(IRS)that I am subject to backup withholding as a result of a failure to report all interest or dividends,or(c)the IRS has notified me that I am
no longer subject to backup withholding,and
3. I am a U.S.citizen or other U.S.person(defined below).
Certification instructions.You must cross out item 2 above if you have been notffied by the IRS that you are currently subject to backup withholding
because you have failed to report all interest and dividends on your tax retum.For real estate transactions,item 2 does not apply.For mortgage
interest paid,acquisition or abandonment of secured property,cancellation of debt,contributions to an individual retirement arrangement(IRA),and
generally,payments other than interest and divid ds,you are not required to sign the certification,but you must provide your correct TIN.See the
instructions on page 4.
Sign s��,�or
Here u.s.�reo�► o�► �—�?—%-lf'
General Instructions, Note.If a requester gives you a form other than Form W-9 to request
Section references are to th�ernal Revenue Code unless othervvise Your TIN,you must use the requester's form if ft is substantially similar
noted.
to this Form W-9.
Definition of a U.S.person.For federal tax purposes,you are
Purpose of Form considered a U.S.person if you are:
A person who is required to file an information return with the IRS must •��ndividual who is a U.S.citizen or U.S.resident alien,
obtain your correct texpayer identification number(TIN)to report,for •A partnership,corporation,company,or association created or
example,income paid to you,real estate transactfons,mortgage interest organized in the United States or under the laws of the United Stetes,
you paid,acquiskion or abandonment of secured property,cancellation .q���te(other than a foreign estate),or
of debt,or contributions you made to an IRA.
Use Form W-9 only if you are a U.S.person(including a resident •A domestic trust(as defined in Regulations section 301.7701-'�.
alien),to provide your correct TIN to the person requesting it(the Special rules for partnerships.Partnerships that conduct a trade or �
requester)and,when applicable,to: business in the United States are generalty required to pay a wfthholding
1.Certlfy that the TIN you are giving is correct(or you are waiting for a �x on any foreign partners'share of income from such business.
number to be issued), Further,in certain cases where a Form W-9 has not been received,a
partnership is required to presume that a partner is a foreign person,
2.Certify that you are not subject to backup withholding,or and pay the wfthholding tax.Therefore,ff you are a U.S.person that is a
3.Claim exemption from backup withholding if you are a U.S.exempt partner in a partnership conducting a trade or business in the United
payee.If applicable,you are also certifying that as a U.S.person,your States,provide Form W-9 to the partnership to establish your U.S.
allocable share of any partnership income from a U.S.trade or business status and avoid withholding on your share of partnership income.
is not subject to the withholding tax on foreign partners'share of
effectively connected incorne.
Cat.No.10231X Form�/-9(Rev.12-2011)
��������I'�a
Payment Address Document Address
24344 Network Place P.O.Box 512929
Chicago, IL 60673-1243 Los Angeles,Ca 90051
Phone:(877)818-0139
Fax:(888)781-6947
8/12J2014 9:18:00 AM
Certified Mail 91 7108 2133 3934 1980 2765 Retum Receipt Requested
CITY OF ST PAUL
CITY CLERK OFFICE
310 CITY HALL
15 WEST KELLOGG BLVD
ST PAUL,MN 55102
Your Glient: NOWICKI, BRIAN
Your Claim Number: N/A
Our insured: VANG, LEE
Our Claim Number:143fi13457
Amount Subject to Reimbursemerrt: 4,933.55
Amount of Insured's Deductible: 500.00
Please take this as formal notice of our subrogation rights relative to the above -captioned
claim. We have completed our investigation into the facts of the above-captioned loss and find
that your insured was the proximate cause of the accident.
Location of Loss: S ON JOHNSON PKWY/EB ON 7TH STREET in ST PAUL
Date and Time of Loss:03-15-14 @ 7:11 PM
Description of Loss: Our named insured's 2005 Toyota Sienna was traveling southbound on
Johnson Pkwy approaching the intersection of 7`h St. A City of St Paul 2013 Ford Explorer was
traveling northbound on Johnson Pkwy approaching the intersection of 7�'St. As our insured
proceeded forward,the 2013 Ford attempted a left hand tum and struck our insured's vehicle,
causing damage. The driver, Brian Nowicki, is the proximate cause of the aocident for failure to
yield right of way.
Please ma � u draft payable to Progressive Preferred Insurance Co as subrogee of
"VANG, , i the amount stated above and mail it to the attention of the undersigned at your
earlies n ience. All supporting documentation is endosed. I have diaried my file ahead
fiftee 5}, ays. Thank you for your anticipated, prompt attention to this matter.
�
sp E ba
Stfbrogat n Representative
Progres ve Preferred Insurance Co
Tel. 440 10-5567
Fax. 88 781-6947
Email: son_E_Saba@progressive.com
Ciaim Payment Detail Page 1 of 1
�t�irrt �ayrra�nt 9�etail ( 1��3613��7 )
PaymerrtInformation------------------------____-------------------------______--------------------------------------______----------_____-----------______,
� Ofsbursement Number: 481841883 Total Amount: a3,833.72
EFT Trace Number: Invoice Number:
Paid To: LAMETTRY'S ONLY
Mailing Addre�s: 2923 MAPLEWiDOD DRIVE
! MAPLEWi00D,MN 55109 USA
� In Payment Of: COLLA5 TOYOTA SIENNA/LESS 500DEDUCT
1__________________________________________-_--_-_--_--_______________--_--_________________-------________________________________----_______--_---___________________�
VendorInformation---------------------------------------------------____--------------------------------------------------____------------------------;
Name: LAMETTRY'S COLL... 1099 Required:
� Type: BODYSHOP
1_______________________________________________________________________________________________________________________-------------------_------------------_____________!
_.Reviewed Summa ------________________________________--____________________---_________-------______________________.
-------------_____ _
issuing Rep: A085668 Approved By:
Isaue Date: 04-1r14 Review Date:
Last Updated Rep: A085668 Reviewed By:
-------------------------
i--Bank Information----------------------------------------------------------------------------------------_______----------------------------------------;
! TYpe: Loss Bank Code: AS2
� Stop Reason: Cleared: 05-0�14
� Stop Date:
, �
i___---------------------------------------------------------------------------------------_-___--__----------------------------_____-------------------------------�
Ex ure Detail:COLL-----____________________________________________________________________________________________________________________________,
`__. �
� Party Name: VANG,LEE Amount Paid: $3,833.72
� Property Description: 05 TOYOTA SIENNA Deductible Taken: 5500.�
� Payment Type: FINAL PAYMENT Property Damage: $0.00
( Rer�tal: $0.00
(
http:l/claimspayments/Alpha/ClaimsPaymentsWeb/default.aspx?... 8/12/2014
Claim Payment Detail Page 1 of 1
�f�irn �ayment ��taE9 ( 14���13�4�7 )
--Paymerrt Information-----------------------------------------------------------------------------------------------------------------------------------------_
Disbursement Number: 768278937 Total Amount: a598.83
EFT Trace Number: Invoice Number:
Paid To: ENTERPRISE RENT-A�-CAR
Mailing Address: ENTERPRISE RENT-MCAR
� 1506 BUERKLE ROAD
E VADNAIS HEIGHTS,MN 55110�259
E In Payment Of: ENTERPRISE RENT MCAR RENTAL INVOICE#1901 D296755
•--------------------------------------------------------------------------------------------------_--_----------------------------------------------------------------�
--Vendor Information•---------------------------------------------------------------------------------------------------------------------------�
Name: ENTERPRISE RENT... 1099 Required:
Type: GI.ASS SHOP
,
��������������������������..�.�����'��������������������������������������������������������������������������������������������������������������������������������J
�--Reviewed Summary---------------------------------------------------------------------------------------------------------------------------------------;
Issuing Rep: A088101 Approved By:
Isaue Date: 0�01-14 Review Date:
Last Updated Rep: A089101 Reviewed By:
__ ___ ____________________________________.__--------_•---_-------.________________�
Bank Information
Type: Loss Bank Code: CTB
Stop Reason: Cleared: Or04-14
�
Stop Date:
�.... .._. _. .. _... ._.._.. .� .. .._. ........ . ... . . .............................. .. .. .... . ....._.. .. .. ......... ... .. .... ..... .. . . ..... ........ . .....�
;-•Exposure Detail:RENTAL--------------------_______________________-_------------------------------------.___-----________-----___-----_____-__-__-__;
j Parly Name: VANG,LEE Amount Paid: 5599.63
� Property Description: 05 TOYOTA SIENNA Deductible Taken: s0.00
PaymentType: FINALPAYMENT PropertyDamage: $0.�
! Rerrtal:
#599.83
II
�
(
http://claimspayments/Alpha/ClaimsPaymentsWeb/default.aspx?... 8/12/2014
ARMS RO-Automated Rental Manag�ent System Page 1 of 1
���C���y: ENTERPRISE RENT-M
CAR
Snvoice: D2�755-1901
� PROGRESSIVE Atiternate tnvo�ce 79CM9T
Number:
Bill To: PR01927 REN7AL QE7',4EL:
PROORESSNE
ATTN:KARA HERRERA Rerrtel Per'iOd: 4/11J74 to 4/25/14(1b days)
12450 RIVER RIDGE LANE STE 100 Bi��ed Period: 4111114 to 4125f14(15 days)
BURNSVILLE, MN 55337
itENTER INFt3RMAl1QN: i�ra�a�et�����rrfee� liabe Amount ;
Rer�': VANO,LEE : 15 DAYS� 32.96 5494.40 ;
3
RENTAL INFORMATION: � 15 DAYS DW� 19.60 �294.00 �
i
Rental BrdnCh Location: � 15 DAYS PAi� 3.39 $50.85 ;
ENTERPRISE RENT A CAR(1801) �
1567 COUNTY ROAD E E � 1f����a�
WHITE BEAR LAKE, MN 561105261 ; �urwt�arg�
{651)484-2911� � '
; 1 SURCHARGE96 14.2096 570.20 ;
�
AQQtTIQNA�CLAIM INFQRMATIQN: ; 1 SALES TAX 7.12% $35.23 ;
ClaimNumber:14-3813457 �.........................................._........._.........._...._...._...._..._...._......._._...._._......._.................;
Claim Type:Insur�ed ; Tofal Char+gss: �14.68 ;
vehlde CondiUon:Dfveable ; 1„ess Amount Received: 5344.85 :
Date Of Loss:
Insured Name: � Total Amount Dua: �88.88 �
Owner's Vehide:2005 TOYOTA SIENN
Add�on�Driver.
R6pair Facility:
IAMETTREY'S-MAPLEWOO D
MAPIEWOOD, MN 55109
{651)766-9770�.�
YEHICLES RENTEI3:
Effective StaNing Ending Rate
Datie and Y�ar Mala Model VIN M,�� Milea�e Mil�ag� Charyed
Time
4/11/14 2014 CHEV CAPT 3C3NAL4EK8ES551670 10178 10259 Si $32.96
8:53 AM
Rental Invc�i�e
Please Retium This Portion wilh Remittenoe
Make Payment TO: Total Charges: $944.88
ENTERPRI3E RENT-A-CAR Less Ampunt ReCeived: $344.85
P.O.BOX 840086 Total Amount Due.................... 5599.83
KANSAS CITY,MO 641840086
Fedd'al ID:43-0724835 pbase hc�de on your chedc:
Irn+oice:D296755-1901
https://www.armsweb.com/armsweb/closedcustomerfile.do 8/12/2014
Da[e: 4/15/2014 07:10 AM
Estkn�e ID: 14-3613457-01
Estknae Verslon: 0
CaniNtted
Prdlle ID: 'Metro al Parts
PROGRESSIVE
10220 Galdenrod 3[NW�100,Com Rapids,MN 55448
(612}7162845
Damage Assessed By: MIKE MCAAAFION 'Galm Rep: KARA HERRERA
(95�562-6920
'Product Type Au[o
'Date af Loss: 3/15/2014
`DeductWie: 500.00
'Clalm Number: 143613457-Ot
Insured: LEE YANG
Owner: LEE VANG
Address: 1120 BEECH S7 M1,SAINT PAUL,MN 55106
Telephane: Home Phone: (651)2334543 Corrtact Phone: (651)2334843
M Ifchell 3eMc e: 910147
Descrip[im: 2005 Tqra[a 3lenrra XLE
Body 9tyle: Van 119'WB Drlve TraYr 3.3L InJ 6 Cyl 2W D
YIN: 5TDZA22C255297573 Llcense! 880HW W MN
Mileage: 129,664
OEM/ALT: A S�Co�: ARDENHILLI
Options: PA33ENGER AIRBAG,DRIVER AIRBAG,POWER DRIVER SEAT,POW ER LOCK,POW ER W INDOW
REAR W INDOW DEFOGOER,CRU13E CONTROL,TILT 3TEERMIO CALUMN,POW ER PA39BJOER 9EAT
TELE9COPIC STEERMG COLUMN,LUGGAGE RACK,PREMIUM 90UND SY3TEM
ANTI-LOCIC BRAKE SYS.,FOG LIGHTS,ALUM/ALLOY WHEa3,LEATHER STEERING W HEEL
FRONT AIR DAM,TNTED OLA9S,AUTO AIR CONDITION,TRIP CAMPUTER
THIRD ROW 3PLR BENCH 9EAT,SUBWOOFER,UNIVER3AL GARAGE DOOR OPENER
VARIABLE A3SISTED 3TEERING,ANTI-THEFT SYSTEM,AUTOMATIC HEAaIGHT3
DUAL POW ER 9LIDNJG DOORS,AM/FM STEREO CA8SETTElCD,FRONT BUCKET SEAT8
INTERIOR AIR FILTER,KEYLES3 EiJTRY 3YSTEM,POW ER HEATED EXTERbR MIRROR3
REAR AC&MEATER,REAR AUDIO CONTROLB,REAR W INDOW DIVER3ITY ANTENNA
REARWINDOW WIPER,SECONDROW CAPTAfJSCHAIRS,STEERING WHEELAUDIOCONTROL3
Line En6y Laba Unekem PartType! DaNar Labor
ttem Number Type Operadon Desarfptim Part Number AmauM Untts
IMarmatlon Labals
1 002353 BDY REMOVE/REPLACE L Infam L�el Caifim Label 74541-AE030 1.96
2 000008 BDY REMOVE/REPLACE L Infam La�el Door Operdim 74528-08010 2.30
3 000012 BDY REMOVE/REPLACE hAorm Label Tke Pressure CaWon ORDER FROM DEALER 2.70
Frant 8umux
4 002083 BDY REMOVEIINSTALL Frt Bumper Assy 0•��#
5 Droprtoosen ONy
Front LamDs
6 002093 BDY REMOVE/IN3TALL L Front Canbinatlon Lamp 2•0�
FrontFender
7 �2105 RE F BLEND L Fenda Outslde C 0.8
6 004048 BDY REMOVE/IN3TALL L Fender Gamish �•Z
9 000225 BDY REMOVE/1N3TALL L Fender Liner E�AStlng 02'
10 Loosen Only far rAinish
11 000729 BDY REMOVElREPLACE L Fender Clip 2�3.94 47749-D8010 7.88
RockerlPlNars
12 000877 BDY REPAIR L Rackerw/Cerrter Plia -3 Existlng 11.0'
13 REF REFMISH L Ce�na Plllar&Radcer Canple[e C 2.5
14 Repalr Time Indudes Tle Down&Pull
15 004064 BDY REMOVE/INSTALL L Rocker Scuff Rate Existlng 02 r
16 004074 BDY REMOVE/IN9TALL L Ctr PillarTrim Panel Exisdng 0.3 r
17 004078 BDY REMOVE/INSTALL L Rocker 3cuff Plate Exlstlng 02 r
18 001403 BDY REMOVE/IN9TALL L Frt Door Opening W eatherstrip Existlng 0.4 r
Front Daw
19 002773 BDY REMOVElREPLACE L Frt Door 3hell 67002-AE022 781.20 5.0 M
ESTIMATE RECALL NUMBER: OM14J201414:59:53 14-3613457-01
Mitchell Data Versian: OEM: MAR_14_V0409
MAPP:MAR_14_V0406 Copyrigh[(C)1994-2014 Mi[chell in[ematlonal Page 1 d 4
SoRware Verslm: 7.1.163 All Wghts Reserved
Date: 4115l2014 07:10 AM
EstYna[eID: 14-3613457-Ot
Estlmae Ve►slon: 0
ComrNlted
Prar��e�o: •i,nevo a�Pares
20 RE F REFINI3H L Fr[Door Outakle C 1.8
21 RE F REFINI3H L Frt Add Fa Jatnba&IMerla C 1.0
22 Intru�on beam Is bent
23 001256 BDY REMOVElREPLACE L Frt Door Tape 75956-AE010 20J4 02#t
24 001264 BDY REMOVElREPLACE L Frt Door Adhesh^e Moulding 75732-AEOCi0�J1 1 S6.BS 0.1
25 Palnted
26 002167 REF REFNI3H L Fr[HanQe C 0.5
27 �1345 BDY REPAIR L FK Door Oulsfde Hande Existlrg 0.5'�
28 �1397 BDY REMOVE/REPLACE L Frt Doar Chedt 68620-AE011 102.46 INC#
29 BDY REMOVE/IN9TALL L Frt Door THm Panel INC
30 001405 BDY REMOVE/REPLACE L Frt Upr poar Blaokau[T�e 739�-AE010 41.60 02 y
31 001407 BDY REMOVE/REPLACE L Frt Doar Rear&aclmu[Tape 7596g-AE010 16.61 02#
9ds Daor
32 002196 BDY REMOVE/IN3TALL L Otr Belt Maulding 0.3
33 002188 BDY REMOVE/IN9TALL L 91de Door 1.3
34 NEED TO PUT ON BENCH FOR W EL.DING
3b �1452 BDY REPAIR L Side Door Repalr Panel E�Astlnp 11.0'�
36 REF REFNISH L31deDoaOutalde C 1.9
37 001456 BDY REMOVElIN9TALL L Frt Slde Door Mouldk�g Exl�irg 0.3 r
38 001458 BDY REMOYElINSTALL L Reev 91de Doar Maulding Existlrg 0.3 r
39 001464 BDY REMOVE/REPLACE L 31de Door AdhesNa Mautling TS7d2-AE030-J1 156.86 02
40 MIssING
41 00'2200 BDY REMOVE/1NSTALL L Door Trim Panel INC
42 OOQ204 BDY REMOVElIN3TALL L Otr Dov Handle 0.7 tl
43 002208 BDY REMOVE/IN9TALL L Rear poor Windav Regulata 0.9�
44 FOR ACCE39 TO REPAIR9
45 936012 ADDL C09T HAZARDOUS WASTE DI3P09AL 3.50 •
ADDITIONAL OPERATION3
46 RE F ADDL OPR G�r Cae� 22
Addkbnal Costs&MaMrfals
47 ADDL COST PaInUMatalals 342.40 •
IrANl1AL ENTRIES
48 �0500 BDY' REMOVE/REPLACE '9lenna'steppad New 16.15 ' 0.3'
49 900500 BOY' REMOVE/REPLACE CORR0310N PROTECTION ••Non-0EM 7.50 ' 0.3'
50 9Q0500 BDY' ADDL LABOR OP COVER CAR FOR OVERSPRAY '•Non-OEM 7.50 • OT
51 900500 BDY• REMOVE/REPLACE ORAVEL GUARD 1-PANEL ••Non-OEM 7.50 • 0.3'
52 900500 BDY' REMOVElREPLACE 3EAM 3EALER•PANEL REPLACEMENT PERTUBE '•Non-OEM 40.00 • INC'
'-Judgment Item
#-Labor Note Applies
C-Included in Clear Coat Calc
r-CEG R&R Time Used For Th's Labor Operation
All manufacturers requirements regarding seat belt and supplemental
restraint system replacement must be adhered to. If additional parta
or operations are necessary to properly accomplish this, please
contact the estimating claims rep.
Estimate Totals
Add'I
Laba' 9ubiet
I. Labor 9�totals UnRs Ra[e AmouM Amourrt Tda� II. Part Repixerr�ent 9ummary Amouni
Body 37.3 52.00 0.00 0.00 1,939.60 Taxable Parts 1,369.82
Refinish 10.7 52.00 0.00 0.00 556.44 Sales Tax @ 7.125% 97.60
Nm-Taxahle Lahor 2,496.00 Tdal Replxemerrt Parls Amount 1,467.42
Labor 9ummary 48.0 2,496.00 ,I
ESTIMATE RECALL NUMBER: 04l1 4/201 4 1 4:59:53 143613457-Ot '
Mi[chell Data Versim: OEM: MAR 14 V0409
MAPP:MAR_14_VO4D6 Copyright(C)1994-2014 Mitchell Intem�onal Page 2 d 4
3oftware Versim: 7.1.163 All Rlghts Reserved
Date: 4115/2014 07:10 AM
Estim�e ID: 1 4-361 3457-01
Estlmate Verslon: 0
Canmhted
Prdlle ID: •AAetro All Parts
III. AdOttional Costs Amou�[ IV. Ad�uatrnenta Nnount
Ta�ode Casis 342.40 hsurar�ce De�dlde !fW.DO-
9ales Tax � 7.725% 24.40
Cuatomer RespanslbNity 500.OD-
Nm-Taxable Cos[s 350
Talal Addtlan�Costs 370.30
Palnt Materlal Metliod:Rates
INt Rate=32.00
1. Tatal Labor: 2,496.00
II. Total Replaoemeit Parls: 1,467.42
111. Total Addtlonal Coets: 370.30
Gross Tdal: 4,333.72
IV. Tahal Ad)ustrnerns: 500.00-
N�Tdal: 3,833.72
Pdftt(s)d Impact
12 Frart Center(P)
Alt.Location: PROGRE981VE
k�spea[bn 3re: L4METTRY3 COLL1310N MAPLEWOOD
Address: 2923 MAPLEW OOD DR
MAPLEWOOD,MN 55109
(661)76G9770
Inspectlon Da�e: M14l2014
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 I5 INCLUDED ON TfiIS ESTIMATE, THE AMOUNT
SHOWN INCLUDES TIME OR ALI,UWANCE FOR MEASURING BEFORE, DURING AND
AFTER THOSE REPAIRS.
THE OWNER OF THE VEHICLE MAY SELECT THE REPAIR FACILITY OF H13/HER
CHOICE.
TO ENSURE PROPER AND PROMPT PAYMENT FOR ADDITIONAL DAMAGE DISCOVERED
DURING THE COURSE OF REPAIRS, CANTACT 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 HODY PARTS
The replacement parts mritten on the eatimate are intended to return
your vehicle to its pre-loss condition with proper installation.
After repair, if any sheet metal or plastic bady 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, Progreasive 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
ESTIMATE RECALL NUMBER: 04l14l201414:59:53 143613457-01
Mitohell Da[a Verslm: OEM: MAR 14 V0409
MAPP:MAR_t4_Y0406 Copyrigh[(C)1994-2014 Mitchell Intematlonal Page 3 d 4 �
3oftware Versim: 7.1.163 All Rlgh[s Reserved
Da�e: 4/1512014 07:10 AM
Eatknae ID: 14-3613457-01
Eetlma[e Verslon: 0
Cammltted
Praflle ID: •Metro al Parts
obtein service under this Guarantee, call Progressive at
1-800-274-4641. This Guarantee applies as long as you own or lease
the vehicle. This Guarantee is not transferable and terminates if you
sell or otherwise tranafer your vehicle.
THIS GUARANTEE DOES NOT COVER NORMAI, WEAR AND TEAR OR DAMAGE CAUSED
BY IMPROPER MAINTENANCE, NEGLECTi ABUSE OR SIIBSEQUENT ACCIDENT. THIS
G�TARANTEE 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 DAMAGES THAT RESULT FROM THE INSTALLATION OR USE OF
THESE PARTS.
Part Type Terms and Abbreviationa
NEW and OEM or part number di8played - 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/RECYCI.ED and LKQ - These refer to a used OEM part.
REMANUFACTURED and RECOND, and RECORE - These refer to used/recycled
OEM parts that have been refurbiahed.
REPAIR SHOP'S AUTHORIZED REPRESENTATIVE'S SIGNATURE INDICATING
AGREEMENT ON COST TO RETURN THE VEHICLE TO PRE-IASS CANDITION
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 GI,AIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF
INSURANCE FRAUD.
Event Log
FMe Crea[ed: 04/14/2014 01:10:16 PM
Estlm�e 9tated: 04l14l2014 0228:40 PM
Estlm�e PNnted: 04/14/2014 02:59:09 PM
Estlma[e Commtted: 04/14/2014 02:59:53 PM
Estlm�e Uploaded: 04/15/2014 07:09:16 AM
I',
E3TIMATE RECALL NUMBER: OM14l201414:59:53 14-3613457-01
Mftchell Data Versim: OEM: MAR 14 V0409
MAPP:MAR_14_V0406 CapyrigM(C)1994-2014 Mi[chell Intematlonal Page 4 d 4
9oftware Verslm; 7.1.163 All Rights Reserved
2�14-07-24 10:01 Progressive 9528829805 » Fax Server P 1/1
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