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Sparks, Dorothy .� . � Providing lnsurance and Financial Services �StateFarm� Home Office, 8loomington, IL August 28, 2014 ��C�� City of St. Paul State Farm Claims ��P 1 1 �Q��} Attention: City Clerk P.O.Box 2371 � 310 City Hall Bloomington IL61702-2371 ��-Y CLERK 15 Kellogg Blvd. West Saint Paul, MN 55102-1691 Certified Mail - Return Receipt Requested RE: Claim Number. 23-4J71-385 Our Insured: Dorothy Jean Sparks Date of Loss: May 16, 2014 Your Insured: City of St. Paul Your Insured Driver: Jeffrey Rothedcer Loss Location: George St. & Manomin Ave., Saint Paul, MN Insured's Out-of-pocket: $45.86 Sir/ Madame: It is our understanding that you are self insured. Our investigation indicates you are responsible for this claim. Therefore, we are seeking recovery from you. This letter is to notify you of our subrogation claim and request your cooperation in settling this matter. To assist you in your review, here is a breakdown of the amounts State Farm�paid by Cause of Loss: 041/045- Uninsured Motorist BI $n/a 042- Uninsured Motorist PD $n/a 300 series/400- Comp/Collision $2,608.08 501 - Rental/Loss of Use $183.45 600-050- Med Pay/PIP $n/a Other $n/a Salvage Recovery $n/a Amount State Farm Paid $2,791.53 Insured Deductible $500.00 Total Claim Amount $3,291.53 Based on the assessment of liability befinreen the parties, State Farm Mutual Automobile Insurance Company is seeking 100% of the Total Claim Amount listed above. The amour�t , payable to State Farm Mutual Automobile Insurance Company for this loss is $3,291.53. ! Please remit payment of this claim and include our claim number on the payment. If you have any questions or need additional information, please call me at the number listed below. If I am not available, any other member of my team may assist you. Thank you for your cooperation. In order to assist you in evaluating and processing the subrogation claim we are asserting, we , may provide nonpublic personal information about our customer. We are sharing this ' . � 23-4J71-385 Page 2 August 28, 2014 information to effect, administer, or enforce a transaction authorized by the consumer. However, you are neither authorized nor permitted to: (1) use the customer information we provided for any purpose other than to evaluate and process the subrogation claim, or(2)disclose or share the customer information we provide for any purpose other than to evaluate and process the subrogation claim. Sincerely, � Whitney Hill Claim Specialist (877)457-8276 Ext. 6156927716 Fax: (866)231-9276 State Farm Mutual Automobile Insurance Company Enclosure i . i ' 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 municipa[ity...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 First Name � �w Middle Initial � Last Name ✓��Qv Company or Business Name �fwrt, FCLI�IM �-11SUX�Qn'l(,(�� 0�l0� 1 �� Ll.� SDl I(�— Are You an Insurance Company? Yes o If Yes, Claim Number? ��-�,�1 �— �FS Street Address �• � gC7ti. 231 � City ��l7l�YY11�U�Y� State � �- • Zip Code� ��—'7i31 ( Daytime Phone(��)y'S�-�Zl� Cell Phone( VjL�� Evening Telephone( �w Date of Accidentl Injury or Date Discovered )S � I lD �?.(�� Time tl� .�30 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.�C�.�t 1�� e �` S � � a UK- �Y�s f�, i '1 r�' S �a � � �� )CV�i S O�.0 t(�,e.r/!�- �_ �� P�le�e check the box(es)that most closely represent the reason for completing this form: C�� C�-��°� �'My vehicle was damaged in an accident ❑ My vehicle was damaged during a tow ❑ My vehicle was damaged by a pothole or condition of the street ❑ My vehicle was damaged by a plow ❑ My vehicle was wrongfully towed and/or ticketed 0 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 anplicable 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 andlor 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 comnlete this secNon Were there witnesses to the incident? Yes �.D1� Unknown (circle) Provide their names, addresses and telephone numbers: Y1�A. Were the police or law enforcement called? �� No Unknown (circle) If yes, what department or agency?��IMitl�le. �u"'h� ase#or report#��(� — l�?� 0 ��G 0. -1� Where did the accident or injury take place? Provide street address,cross street, intersection, name of park or facility, closest landmark,etc. Please be as detailed as possible. If necessary, attach a diagram. �-4l� 16\-�P�S2[�-,�1 c �(XU�('nn� I�[��rviin vt, . 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. �+�mb��,Y"s� .S}U1�e F��{ �1/�p � O,�IYA�- b� �3,2�14 .53 , Vehicle Claims—please complete this section � check box if this section does not applv Your Vehicle: Year 2UG�7 Make $t�ur�l Model �Oh Z License Plate Number $.1 S—ZOS State YVIN Color '�j Registered Owner � S Driver of Vehicle f tCM'� r S Area Damaged I S 51 lk�' S " City Vehicle: Year 20 t� Make FD� Model G.Dri L�L. License Plate Number 11"11 State N�II�Color V�V11-4� Driver of Vehicle (City Employee's Name) �e-�P��C�ln�c ��X' Area Damaged �� l' bu�.�'le,�r '. �,f Iniury Claims—please complete this secNon ❑ check box if this section does not avvlv How were you injured? Cor�t,a�\ck, ) rri�n�x' <<�,�;-S ��Oc' c�l�c'c�siU'�S What part(s)of your body were injured? S-�� Have you sought medical treatment? Yes � Planning to Seek Treatment(circle) When did you receive treatment? h �w (provide date(s)) Name of Medical Provider(s): n��,., Address ,r,l .. Tele u� Did you miss work as a result of your injury? Yes No �'' When did you miss work? q 1 . (provide date(s)) � Name of your Employer: � 1 Address ,-,1 Telephone �� . L�!'l:heck here if you are attaching more pages to this claim form. Number of additional pages�z By signing this form,you are stating that all inforination 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 n��Z� I�� i Print the Name of the Person who Completed this Form: �a1�ll'�Y��1 �"1�1 Sk(� �ctiYw► �ST ��0�'1'�U ��'1 ! ��p��S � Signature of Person Making the Claim: ` � �1` ' S u '� � ,S�.ckS ' Revised February 2011 , �I ' RBZ00070 StafeFarm State Farm Mutual Automobile Insurance Company �� Auto Payments by ParticipantlCOL m Route To: Whitney Hill BASIC CLAIM INFORMATION Claim Number: 23-4J71-385 Date of Loss: 05-16-2014 Policy Number: 3029-306-231 Named Insured: SPARKS, DOROTHY J Named Insured(s)/400 -COLL C denotes consolidated payment E denotes EFT payment P previously converted payment from CAT/CMR Payment Issued Payable Pay Auth Rsn Number Date Payee COL Cd Status Amount ID Cd 105161092K E 05-28-2014 PARAMOUNT MASTER 400 1 Paid $2,608.08 U5KN COL�ISION CENTER Total: $2,608.08 Named Insured(s)/ 501 - RENT C denotes consolidated payment E denotes EFT payment P previously converted payment from CATlCMR Payment Issued Payable Pay Auth Rsn Number Date Pavee COL Cd Status Amount ID Cd 105162746K E 05-29-2014 ENTERPRISE RENT-A-CAR 501 1 Paid $183.45 ECSAPY Total: $183.45 Date: 08-28-2014 Page 1 FOR INTERNAL STATE FARM USE ONLY Contains CONFIDENTIAL information which may not be disclosed without express written authorization. RB'LOOOMD StateFarm State Farm Mutual Automobile Insurance Company • Auto Rental Bills • •� Route To: Whitney Hill BASIC CLAIM INFORMATION Claim Number: 23-4J71-385 Date of Loss: 05-16-2014 Policy Number: 3029-306-231 Named Insured: SPARKS, DOROTHY J SPARKS, DOROTHY BILL SUMMARY Bill Information Invoice Number: 1910D654184 Claim Number: 23-4J71-385 Rental Vendor: ENTERPRISE RENT-A-CAR Date of Loss: 05-16-2014 Insured Name: SPARKS, DOROTHY J Received From Renter: $45.86 Renter Name: SPARKS, DOROTHY Billed To Others: Rental Start Date: 05-20-2014 Amount Due: $183.45 Renter End Date: 05-27-2014 Amount Paid To Date: $183.45 Current Bill Status Primarv Status Primary Reason(s) Reviewed Secondarv Status Secondarv Reason(s) Paid Vehicle Information Vehicle Rental Start Rental End Assnd Class Appr Class Make Model 01 05-20-2014 05-27-2014 IC CHEV CRUZ Invoice Details Rate Percent Extended Vehicle Description Billed Partv Quanti % Covered Amount 01 Daily Rental Rate State Farm 8 23.50 80.000 $150.40 01 Daily Rental Rate Renter 8 23.50 20.000 $37.60 Sales Tax State Farm 150.40 7.780 0.000 $11.69 Sales Tax Renter 37.60 7.780 0.000 $2•92 Government Surcharge State Farm 150.40 5.000 0.000 $7.52 Government Surcharge State Farm 150.40 9.200 0.000 $13.84 Government Surcharge Renter 37.60 5.000 0.000 $1.88 Government Surcharge Renter 37.60 9.200 0.000 $3.46 Subtotal Less Taxes : $188.00 Received From Renter: $45.86 Total Taxes : $41.31 Amount Due From State Farm : $183.45 Date: 08-28-2014 Page 1 FOR INTERNAL STATE FARM USE ONLY Contains CONFIDENTIAL information which may not be disclosed without express written authorization. R�sk Solut�ons (A3) 6/4/2014 10: 42 :49 AM PAGE 1/002 Fax Server 478958583 ' For Customer Support refer to the Lex i s N ex i s� appropriate platForm below: OrderPoint 800-934-9698 Orderpoint.support@lexisnexis com Accurintforinsurance 866-277-8407 Accunnt.support@lexisnexis com Lexis.com REPORT ATTACHED Law Firm accounts 800-543-6862 PAGE COUNT 2 CLIENT SF5215 DIVISION 10605993657 ADT[JSTER BCLEVOI CLAIM 23-4J71-385 TRANSACTI�N# 478958583 DATE 06/04/2014 DATE OF LOSS 05/16/2014 TIME OF LOSS 10 30 PM STREET CITY SAINT PAUL COUNTY RAMSEY STATE MN INVESTIGATING AGENCY MN DVS DMV REP�RT NUMBER 14-095-062 REPORT TYPE Auto Accident PARTY 1 DOROTHY SPARKS PARTY 2 PARTY 3 CAR MAKE YEAR TAG DRIVER LICENSE ADDITIONAL INFO ST.PAUL PD POLICY# PaLICY STATE LOSS KIND NOTE THANK YOU FOR YOUR ORDER! 3c14755017674YPSDLH77 Received 8/412014 9 42 46 AM�CeMral Daylight Time] Risk Solut�ons (A3) 6/4/2014 10: 42 :49 AM PAGE 2/002 Fax Server 478958583 ' ti + ��. W� STA�fOfMINAIlSOfA='D�IMfNf.DF ' '; "�'r " ,� �f�}. •� .�J<a��e.w�a..aa.«3.»,wE�-..�- .. �Y t R� •�� 19 0 95 0 62 N r�R..M �.e.a� A�A��yE�� ,r1.�:R : �=='Wr,—}� ��'..4---`%*-�:. � ��RrvAw/w R6MM KMGl�O AI.F9 w�Mil� 3 Ifr��n•�� YOMIM 6V! RAfI L rl ARYII[ e N N 02 00 O1 Y '�y �,�4:r,�=. �a.�,� 5 16 2019 2219 rn •w�e5.sru. pouT[nwlocqOrssmcirrw,i ny�pr��rowcriow M I ❑ p` I O ,„ 10 Geor e Street West . . ��"�0"y °i — — 8R ❑5 p•,°'y < eawrv w ri s�w rarwcr�iwn nwn avs �wn..mnFl cuwawr mruru�[ 62 �n„ St Pau1 +_• IO Manomin Avenue an�ycn «i.+ rr. ��a, m � :� .. .. b,:rc �. wn+.Rwraa� •»n� ... r xrr r. ;a�aeaeh . � r �miiw wrv�K�a�wwie�e�i stnc W!! OLSGTII4�KdlTbl tll�rtx�i(xr�nC�a�ivn � • fi�*E {?AA MliAlUb OR� � O1 E985Q86039117 MN D O1 1 O1 T350253619706 MN D O1 �� .croa� wuen�e.�emicus� �..ror�uan� �w.�wacum�.un� r+cm+r Jeffrey Mzchael Rothecker 03 21 69 ' DOROTHY JEAN SPARKS 07�08 54 ^�71fK ptV10Ll M11�1Cr �Ili�a 01rULi 1651111C� YNIIVlH O1 367 Grove Street N, O1 3019 31ST AV S APT 5 N Ori O1 �y.� qn.�uTE LY �[m{��p� O1 St Paul 55101 653-291-1ll1 S MINNEA20LIS 55906 612-722-7831 O1 O c�'� � �"`E°°` �irrorr .w�a e+ec� w�ev E,�� eea w�iovr wccvr �unv� swr.r �uaev ecase - �4 03 09 05 tJ , F "�9 'g09 04 05 C O1 wc� rnT am�e mmr m�rw �wr WDUN10EiEW�tt wr:.a.r�e. �ua� me ww nr� ru�oo. wu�warc �...Ya.rn: n.�wweR �`N` 98 t�'� 98 N o MF s"fl 98 �S"' 98 N- fl�,.�„ .__.__......_.... .... _.._.... . ._..... ._........... .............__........._..:...,...._......_ .._.._.. .. _.__. . _. ._. _ .... ... . _ .. dOfU' tfvMIlluUJ s C i O�[91MYE �NE V OCM O1 City of St Paul N jSPRRKS DOROTHY JEAN N� O1 LrH nr imsn � w iancn vcv m Oi 36? Grove Street N F3019 31ST AV S APT 5 N O1 �uiu� unnv�_rr wuno nrKn ,an.au.c.z. wura 07 St Paul, MN 55301 '1V; O1 i MINNEAPOLIS MN 55406 �"tV 07 O1� auo.a: •.••c �..a. ...w a.w 'w+a .mn .t+a anae aa.« O1 Ford Capr 201 Whi iSTRN 512 007 GLD p7 ouoatv rutc� sr�ce �r.n�c a�nowa Mf �wY.e.twi i ri�he sraa reM�ce .�ooaur� ..�. wr.wuo�na wu+cv �2 1177 MN 019 O1 � O1 1SJS205 MN 15 O1 Q2 0 MiWLI rJlC�M1i1fILM MWqWCEt1JH�l) �'QICIMYWLP City of St Paul � State Farm 302-9306-012-231 � CAqR) � rV �wnm MYECIIPI/ M6P400E� �p6m w�tr�t• +fA,or irat rt.t IF A[CIGlNTlNVOWED A CONMFRCUL MUTOR VEMICIE,SCMOOL BUS,OR HEAO 87ARi BU� ruc -vr[ � � REMENBERTO N0T1fY T71!O7AR PATROL(nquM�d usWr MS I19.7!]�M t W.�511�. � � QM�ERGYVfJMFMJIRNI W1(TfMtA1M11E OOTN.YC Gtl�1f�1ONMM6tM1i1�N1)MOfOI1CANRl11WC OOTM!!!/l 'KSfMC16�NR1lS�CD V�T M1�IiYlrtMtf• I�'�i. V]C MIMO F1CCT 1WR.�' i0110!/'��YJ19V�1 O4O YeYR:L ipMU1Ei � OO�N[ �W ��lSf�MCf 'N1Ml�lfll � pO1W � ❑�O a6lIKICE I�Fr�lyfl� ❑aMe .,. �..�� .........._ .... . �� OW*f/10i OTEA W WOkO MIOYFF!!/�M OEYMIIIOM M GIJ46m rV411T�WGfM�'OlON�1�6KYF11Id1 IG�wfLD WOpiRiY I'IELL011 fA:MYFP _I.__.. .uyi .tcnv f42 aw�,rrve. oevrr Me O1 � , � 09 �� Vehlcle l (marked police squad) entered 03 � I Q , intersection north bound on Manornin. Veh Y1 ;{� �w �TM � P•) � stcuck Vehlcle A2, .which was west on Geoige � O1 0� � °iy�°r''' '� Stceet wlth the right of way �� l � M�: �' St Paul Police Repor[ completeC OQ mror�,n � � � �� p�p C�---�D � 98 � �er•�ve ,� .- � ° . CM/MYI! � .r� � � 8 .�.� �. ...�.� � .. . __... .. � , AFAf�EP' '' � 02 �'�e°"�iTe j,1 i �1� w¢wnhw: wcsw� t� � �J I i � 08 � l �� 'w" �■.. �i ., t? 0 9 O 1 � �' 4 ge �'�3� r� � Y �� woirw � '�� , a�u,w�r 01 � - - -- - `" a' 4�J R�C(A RN�w.NNL I.M MDD[� " _ —_ �Itt IYl11R 6 ut OM p 6Ulc W�IHIL�IOCLL Sgt. Steven Smith 232 St Paui pD ��.. p�� 3c7415501768WPSDLH77 Recelved 6J412014 9 42 46 AM[Central Dayllght Time] PARAMOUNT•MASTER COLLISION Workfile ID: 9aacf5b4 FederalID: 411916060 MINNEAPOLIS Quality Auto Body Repair 224 W LAKE ST, MINNEAPOLIS, MN 55408 Phone: (612) 827-4697 FAX: (612) 825-0765 Supplement of Record 1 with Summary Customer: SPARKS, DOROTHY 7ob Number: Written By:Todd Christensen,5/28/2014 8:47:11 AM Adjuster:Team R2 ACC CR(Team 22),(866)207-6046 Day Insured: SPARKS, DOROTHY Policy#: Claim#: 23-4J71-38501 Type of Loss: Collision Date of Loss: 5/16/2014 10:30:00 PM Days to Repair: 0 Point of Impact: 08 Left Quarter Post Owner: Inspection Location: Insurance Company: SPARKS,DOROTHY PARAMOUNT MASTER COLUSION STATE FARM INSURANCE COMPANIES MINNEAPOLIS 3014 315T AVE S APT 5 224 W LAKE ST MINNEAPOLIS, MN 55406-2060 MINNEAPOLiS,MN 55408 Repair Facility (612)827-4697 Business Vehicle Drop Off Date: 05/20/2014 Promise Date: 05/28/2014 Repair Start Date: 05/20/2014 Repair Completion Date: 05/27/2014 Vehicle Pick Up/Return 05/27/2014 Date: VEHICLE Year: 2007 Body Style: 4D SED VIN: 1G8A155F77Z155186 Mileage In: 54768 Make: SATU Engine: 4-2.2L-FI License: SJS-205 Mileage Out: Model: ION 2 Production Date: 10/2006 State: MN Vehide Out: 5/28/2014 Color: tan Int: Condition: Job#: TRANSMISSION Tilt Wheel AM Radio Passenger Air Bag Automatic Transmission BRAKES FM Radio Console/Storage Overdrive Power Brakes Stereo Digital Clock SEATS GLASS Search/Seek Intermittent Wipers Bucket Seats Rear Defogger CD Player EXTERIOR Cloth Seats WHEELS INTERIOR Dual Mirrors STEERING Full Wheel Covers Power Locks PAINT Power Steering RADIO Driver Air Bag Clear Coat Paint 5/28/2014 8:47:15 AM 018806 Page 1 Supplement of.Record 1 with Summary Customer: SPARKS, DOROTHY ]ob Number: Vehicle: 2007 SATU ION 2 4D SED 4-2.2L-FI tan Line Oper Description Part Number Qty Eutended Labor Paint Price$ 1 REAR BUMPER 2 * Rpr Bumper cover/BUFF OUT 0_5 0_0 3 REAR LAMPS 4 R&I LT Tail lamp assy Incl. 5 QUARTER PANEL 6 Repl LT Lower panel 22688475 1 75.88 0.6 0.9 7 Add for Clear Coat �•Z 8 * Repl LKQ LT Quarter panel+25% 22727971 1 275.00 1_6 2_4 9 SOl Overlap Minor Panel -0•2 10 Add for Clear Coat 0•9 11 Deduct for Overlap -0.3 12 Repl LT Wheelhouse liner 22630263 1 52.18 Incl. 13 * Rpr LT Lower panel � 0_5 Note: PARTL4L PAINT 14 REAR DOOR 15 R&I LT R8cI ext panel 1.0 16 R&I LT R&I door assy 0•9 17 R8cI LT Surround w'strip 0.4 18 R&I LT Front w'strip �•Z 19 R&I LT Belt w'strip Incl. 20 R&I LT Applique 0•2 21 R&I LT Door glass SATURN 0.5 22 * R&I LT Run channel w/vent glass 0-9 SATURN 23 R&I LT Handle,outside body color Incl. 24 * R&I LT Latch w/power locks 0=8 25 R&I LT R&I trim panel 0.4 26 R&I LT Regulator power w/motor 0.6 27 R&I LT Regulator manual 0.6 28 * R&I LT Crank handle 0_i 29 * R&I LT Handle,inside �=$ 30 * R&I LT Latch w/o power locks � 31 R&I LT Control rod outside handle 0•2 32 R&I LT Doorcheck 0.3 33 # R&I WIRING TRANSFER 0.5 Note:THE LKQ DOOR CAME NON-POWER 34 SOl Refinish Components Z�� 35 SOl Overlap Major Non-Adj. Panel '�•Z 36 SOl Add for Clear Coat 0.4 37 SO1 Refn LT Exterior panel Incl. 38 FRONT DOOR 39 Refinish Components 2'Z 40 Overlap Major Non-Adj. Panel -0•2 5/28/2014 8:47:15 AM 018806 Page 2 Supplement of,Record 1 with Summary Customer: SPARKS, DOROTHY 7ob Number: Vehicle: 2007 SATU ION 2 4D SED 4-2.2L-FI tan 41 Add for Clear Coat 0.4 42 * Repl LKQ LT Exterior panel +25% 15242058 1 250.00 1_6 Incl. 43 # R&I LT EXTERIOR PANEL 0.8 Note: LKQ VENDOR SENT SEND DOOR SHELL WITH OUTER PANEL STILL AITACHED TO IT 44 FENDER 45 R8cI LT R&I fender assy 1.6 46 Blnd LT Fender 0.9 47 Repl LT Emblem 22710102 1 22.72 0.2 48 WHEELS 49 * Repl LKQ LT/Rear Wheel,steel 15x6 9593549 1 100.00 m 0_3 +25% 50 * Repl LT/Rear Wheel cover 15"wheel 9595923 1 53.27 51 # SOl Subl thrust angle alignment 1 69.95 X Note: REAR END WAS WITH-IN SPECS 52 # SOl Repl VALVE STEM 1 3.75 53 # SOl Subl MNT&BALANCE 1 16.25 X 54 # Repl FLEX ADDITIVE 1 6.00 55 # Subl HAZARDOUS WASTE 1 3.00 X 56 # Repl LKQ Door-Assembly+25% 130 1 250.00 57 # SOl Repl BIG SHOT MIXING NOZZLE 1 4.18 58 # S01 Repl PANEL BOND 1 10.36 59 # SOl Repl RETAINERS 6 5.52 60 # SOl Repl SCREWS 2 0.40 SUBTOTALS 1,198.46 18.1 10.2 NOTES II Prior Damage Notes: scratches on whell well , I ESTIMATE TOTALS Category Basis Rate Cost$ Parts 1,109.26 !, Body Labor 18.1 hrs @ $52.00/hr 941.20 Paint Labor 10.2 hrs @ $52.00/hr 530.40 Paint Supplies 10.2 hrs @ $32.00/hr 326.40 �� Miscellaneous 89•20 Subtotal Z�996•� Sales Tax $1,435.66 @ 7.7750% 111.62 Grand Total 3,108.08 Deductible 500.00 CUSTOMER PAY 500.00 INSURANCE PAY 2,608.08 5/28/2014 8:47:15 AM 018806 Page 3 Supplement of.Record 1 with Summary Customer: SPARKS, DOROTHY ]ob Number: Vehicle: 2007 SATU ION 2 4D SED 4-2.2L-FI tan � I � For more information regarding State Farm's promise of satisfaction relating to new non-original equipment � manufacturer(non-OEM)and recycled parts,please visit: htto://st8.fm/7X4 or QR code. � � • � � Register online to check the status of your claim and stay connected with State Farmp.To register,go to htta://www.statefarm.com/ and select Check the Status of a Claim. If you are already registered,thank you! Not available in New Mexico. � � 5/28/2014 8:47:15 AM 018806 Page 4 Supplement of.Recorc� i with Summary Customer: SPARKS, DOROTHY �ob Number: Vehicle: 2007 SA7U ION 2 4D SED 4-2.2L-FI tan SUPPLEMENT SUMMARY Line Oper Description Part Number Qty Extended Labor Paint Price; Changed Items 46 # Subl 4 WHEEL ALIGNMENT 1 -99.95 X 51 # SOl Subl thrust angle alignment 1 69.95 X NOTE: REAR END WAS WITH-IN SPECS Deleted Items 9 Overlap Minor Panel 0.2 Added Items 9 SOl Overlap Minor Panel -0.2 34 SOl Refinish Components 2.0 35 SOl Overlap Major Non-Adj. Panel -0.2 36 SOl Add for Clear Coat 0.4 37 SOl Refn LT Exterior panel Incl. 52 # SOl Repl VALVE STEM 1 3.75 53 # SO1 Subl MNT&BALANCE 1 16.25 X 57 # SOl Repl BIG SHOT MIXING NOZZLE 1 4.18 58 # SOl Repl PANEL BOND 1 10.36 59 # SOl Repl RETAINERS 6 5.52 60 # SOl Repl SCREWS 2 0.40 SUBTOTALS 10.46 0.0 2.2 TOTALS SUMMARY Category Basis Rate Cost; Parts 24.21 Paint Labor 2.2 hrs @ $52.00/hr 114.40 Paint Supplies 2.2 hrs @ $32.00/hr 70.40 Miscellaneous -13.75 Subtotal 195.26 Sales Tax $94.61 @ 7.7750% 7.36 Additional Supplement Taxes -0.01 Total Supplement Amount 202.61 NET COST OF SUPPLEMENT 202.61 5/28/2014 8:47:15 AM 018806 Page S Supplement of,Record 1 with Summary Customer: SPARKS, DOROTHY 7ob Number: Vehicle: 2007 SATU ION 2 4D SED 4-2.2L-FI tan CUMULATIVE EFFECTS OF SUPPLEMENT(S) Estimate 2,905.47 Todd Christensen Supplement S01 202.61 Todd Christensen Job Total: $ 3,108.08 CUSTOMER PAY: � 500.00 INSURANCE PAY: $ 2,608.08 WARRANTY ONLY VALID WITH ORIGINAL PAPER WORK AND WARRANTY CERTIFICATE. NO GUARANTEE ON RUST REPAIRS. PARTS PRICES ARE SUBJECT TO INVOICE FROM DEALER. REPAIR TIMES ARE ESTIMATED AND DONT NECESSARILY DICTATE ACTUAL REPAIR TIMES NEEEDED. OUR COMPANY DOES NOT ACCEPT PERSONAL CHECKS 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. 5/28/2014 8:47:15 AM 018806 Page 6 Supplement of,Record 1 with Summary Customer: SPARKS, DOROTHY )ob Number: Vehicle: 2007 SATU ION 2 4D SED 4-2.2L-FI tan Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide DR8IA03, CCC Data Date 5/14/2014, 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 and Benchmark Prices are provided by National Auto Glass Specifications. Labor operation times listed on the line with the NAGS information are MOTOR suggested labor operation times. NAGS labor operation times are not included. Pound sign (#) items indicate manual entries. Some 2014 vehicles contain minor changes from the previous year. For those vehicles, prior to receiving updated data from the vehicle manufacturer, labor and parts data from the previous year may be used. The CCC ONE estimator has a complete list of applicable vehicles. Parts numbers and prices should be confirmed with the 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=Boron 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 CCC ONE Estimating that are not part of the MOTOR CRASH E5TIMATING GUIDE: BAR=6ureau of Automotive Repair. EPA=Environmental Protection Agency. NHTSA= National Highway Transportation and Safety Administration. PDR=Paintless Dent Repair. VIN=Vehicle Identification Number. 5/28/2014 8:47:15 AM 018806 Page 7 Supplement of.Recorci 1 with Summary Customer: SPARKS, DOROTHY 7ob Number: Vehic�e: 2007 SA7U ION 2 4D SED 4-2.2L-FI tan ALTERNATE PARTS SUPPLiERS Supplier: Friendly Chevrolet Location(s): 7501 Highway 65 Ne, Minneapolis MN 55432 (612)276-3882 Line Description Item# Price 6 LT Lower panel 22688475 $75.88 12 LT Wheelhouse liner 22630263 $52.18 47 LT Emblem 22710102 $22.72 50 LT/Rear Wheel cover 15"wheel 9595923 $53.27 Supplier: LKQ Keystone North Central Location(s): 2101 Beloit Ave.,Janesville WI 53546 (800)362-9451 Line Description Item# Price I 8 LKQ LT Quarter panel +25% 22727971 $275.00 Supplier: PAM's Auto,Inc Location(s): 7505 Ridgewood Rd,Saint Cloud MN 56303 (800)560-7336 Line Description Item# Price 42 LKQ LT Exterior panel+25°/o 15242058 $250.00 49 LKQ LT/Rear Wheel,steel 15x6+25% 9593549 $100.00 56 LKQ Door-Assembly+25% 130 $250.00 I 5/28/2014 8:47:15 AM 018806 Page 8 PARAMOUNT MAS'6"ER COLLISION Workfile ID: 9aacf5b4 FederalID: 411916060 MINNEAPOLIS Quality Auto Body Repair 224 W LAKE ST, MINNEAPOLIS, MN 55408 Phone: (612) 827-4697 FAX: (612) 825-0765 Estimate of Record Customer: SPARKS, DOROTHY 7ob Number: Written By:Todd Christensen,5/20/2014 2:09:08 PM Adjuster:Team R2 ACC CR(Team 22),(866)207-6046 Day Insured: SPARKS, DOROTHY Policy#: Claim#: 23-4J71-38501 Type of Loss: Collision Date of Loss: 5/16/2014 10:30:00 PM Days to Repair: 0 Point of Impact: 08 Lef�Quarter Post Owner: Inspection Location: Insurance Company: SPARKS, DOROTHY PARAMOUNT MASTER COLLISION STATE FARM INSURANCE COMPANIES MINNEAPOLIS 3014 31ST AVE S APT 5 224 W LAKE ST MINNEAPOLIS, MN 55406-2060 MINNEAPOLiS, MN 55408 Repair Fadlity (612)827-4697 Business Vehicle Drop Off Date: 05/20/2014 Promise Date: 05/28/2014 Repair Start Date: 05/20/2014 VEHICLE Year: 2007 Body Style: 4D SED VIN: iG8A155F77Z155186 Mileage In: 54768 Make: SATU Engine: 4-2.2L-FI License: SJS-205 Mileage Out: Model: ION 2 Production Date: 10/2006 State: MN Vehicle Out: 5/28/2014 Color: tan Int: Condition: Job#: TRANSMISSION Tilt Wheel AM Radio Passenger Air Bag Automatic Transmission BRAKES FM Radio Console/Storage Overdrive Power Brakes Stereo Digital Clock SEATS GLASS Search/Seek Intermittent Wipers Bucket Seats Rear Defogger CD Player EXTERIOR Cloth Seats WHEELS INTERIOR Dual Mirrors STEERING Full Wheel Covers Power Locks PAINT Power Steering RADIO Driver Air Bag Clear Coat Paint 5/20/2014 2:09:09 PM 018806 Page 1 Esti�nate of Record Customer: SPARKS, DOROTHY 7ob Number: Vehicle: 2007 SATU ION 2 4D SED 4-2.2L-FI tan Line Oper Description Part Number Qty Extended Labor Paint Price$ 1 REAR BUMPER 2 * Rpr Bumper cover/BUFF OUT 0_5 0_0 3 REAR LAMPS 4 R&I LT Tail lamp assy Incl. 5 QUARTER PANEL __ 6 Repl LT Lower panel 22688475 1 75.88 0.6 0.9 7 Add for Clear Coat 0.2 8 * Repl LKQ LT Quarter panel+25% 22727971 1 275.00 1_6 2_4 9 Overlap Minor Panel -0.2 10 Add for Clear Coat 0.9 il Deduct for Overlap -0.3 12 Repl LT Wheelhouse liner 22630263 1 52.18 Incl. 13 * Rpr LT Lower panel 2_0 0_5 Note: PARTIAL PAINT 14 REAR DOOR 15 R&I LT R&I ext panel 1.0 16 R&I LT R&I door assy 0.9 17 R&I LT Surround w'strip 0.4 � 18 R&I LT Front w'strip 0.2 ' 19 R&I LT Belt w'strip Incl. �I 20 R&I LT Applique 0•2 'i 21 R&I LT Door glass SATURN 0.5 � 22 * R&I LT Run channel w/vent glass 0_9 I SATURN � 23 R&I LT Handle,outside body color Incl. I 24 * R&I LT Latch w/power locks 0_8 i 25 R&I LT R&I trim panel 0.4 � 26 R&I LT Regulator power w/motor 0.6 � I 27 R&I LT Regulator manual 0.6 i 28 * R&I LT Crank handle 0_1 i 29 * R&I LT Handle,inside 0_8 I 30 * R&I LT Latch w/o power locks 0_8 ' 31 R&I LT Control rod outside handle 0.2 32 R&I LT Door check 0.3 33 # R&I WIRING TRANSFER 0.5 Note:THE LKQ DOOR CAME NON-POWER 34 FRONT DOOR 35 Refinish Components z•z 36 Overlap Major Non-Adj. Panel -0.2 37 Add for Clear Coat 0.4 38 * Repl LKQ LT Exterior panel +25% 15242058 1 2 .00 1_6 Incl. 39 # R&I LT DCfERIOR PANEL 0.8 Note: LKQ VENDOR SENT SEND DOOR SHELL WITH OUTER PANEL STILL AITACHED TO IT 5/20/2014 2:09:09 PM 018806 Page 2 Estirnate of,Record Customer: SPARKS, DOROTHY 7ob Number: Vehicle: 2007 SATU ION 2 4D SED 4-2.2L-FI tan 40 FENDER 41 R&I LT R&I fender assy 1.6 42 Blnd LT Fender 0.9 ' 43 Repl LT Emblem 22710102 1 22.72 0.2 44 WHEELS 45 * Repl LKQ LT/Rear Wheel,steel 15x6 9593549 1 100.00 m 0_3 +25% ' 46 * Repl LT/Rear Wheel cover 15"wheel 9595923 1 53.27 ' 47 # Subl 4 WHEEL ALIGNMENT 1 99.95 X 48 # Repl FLEX ADDI'fIVE 1 6.00 49 # Subl HAZARDOUS WASTE 1 3.00 X 50 # Repl LKQ Door-Assembly+25% 130 1 250.00 ' SUBTOTALS 1,188.00 18.1 8.0 i NOTES Prior Damage Notes: ii scratches on whell well �i ESTIMATE TOTALS '' Category Basis Rate Cost� I, Parts 1,085.05 I Body Labor 18.1 hrs @ $52.00/hr 941.20 Paint Labor 8.0 hrs @ $52.00/hr 416.00 Paint Supplies 8.0 hrs @ $32.00/hr 256.00 Miscellaneous 102.95 Subtotal 2,801.20 Sales Tax $1,341.05 @ 7.7750% 104.27 Grand Total 2,905.47 Deductible 500.00 CUSTOMER PAY 500.00 INSURANCE PAY 2,405.47 � ' � For more information regarding State Farm's promise of satisfaction relating to new non-original equipment � manufacturer(non-OEM)and recycled parts, please visit: httq://st8.fm/7X4 or QR code. � � � . Register online to check the status of your claim and stay connected with State FarmO.To register,go to htt�//www.statefarm.com/ and select Check the Status of a Claim. If you are already registered,tt�ank you! Not available in New Mexico. 5/20/2014 2:09:09 PM 018806 Page 3 Estimate of Record Customer: SPARKS, DOROTHY Job Number: Vehicle: 2007 SATU ION 2 4D SED 4-2.2L-FI tan WARRANTY ONLY VALID WITH ORIGINAL PAPER WORK AND WARRANTY CERTIFICATE. NO GUARANTEE ON RUST REPAIRS. PARTS PRICES ARE SUBJECT TO INVOICE FROM DEALER. REPAIR TIMES ARE ESTIMATED AND DONT NECESSARILY DICTATE ACTUAL REPAIR TIMES NEEEDED. OUR COMPANY DOES NOT ACCEPT PERSONAL CHECKS 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. Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide DR8IA03, CCC Data Date 5/14/2014, and the parts selected are OEM-parts manufactured by the vehicles Original �'i 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 and Benchmark Prices are provided by National Auto Glass Specifications. Labor operation times listed on the line with the NAGS information are MOTOR suggested labor operation times. NAGS labor operation times are not included. Pound sign (#) items indicate manual entries. Some 2014 vehicles contain minor changes from the previous year. For those vehicles, prior to receiving updated data from the vehicle manufacturer, labor and parts data from the previous year may be used. The CCC ONE estimator has a complete list of applicable vehicles. Parts numbers and prices should be confirmed with the 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=Blend. BOR=Boron 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=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. 5/20/2014 2:09:09 PM 018806 Page 4 Estimate of Record Customer: SPARKS, DOROTHY 7ob Number: Vehicle: 2007 SATU ION 2 4D SED 4-2.2L-FI tan CCC ONE Estimating - A product of CCC Information Services Inc. The following is a list of abbreviations that may be used in CCC ONE 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. I 5/20/2014 2:09:09 PM 018806 Page 5 Estimate of Record Customer: SPARKS, DOROTHY 7ob Number: Vehicle: 2007 SATU ION 2 4D SED 4-2.2L-FI tan � ALTERNATE PARTS SUPPLIERS Supplier: Friendiy Chevrolet Location(s): 7501 Highway 65 Ne,Minneapolis MN 55432 (612)276-3882 Line Descriptio� Item# Price 6 LT Lower panel 22688475 $75.88 12 LT Wheelhouse liner 22630263 $52.18 43 LT Emblem 22710102 $22.72 46 LT/Rear Wheel cover 15"wheel 9595923 $53.27 Supplier: LKQ Keystone North Central Location(s): 2101 Beloit Ave.,Janesville WI 53546 (800)362-9451 Line Description Item# Price 8 LKQ LT Quarter panel+25% 22727971 $275.00 Supplier: PAM's Auto,Inc Location(s): 7505 Ridgewood Rd,Saint Cloud MN 56303 (800)560-7336 Line Description Item# Price 38 LKQ LT Exterior panel+25% 15242058 $250.00 45 LKQ LT/Rear Wheel,steel 15x6+25% 9593549 $100.00 50 LKQ Door-Assembly+25% 130 $250.00 i � i i I � � � , i1 5/20/2014 2:09:09 PM 018806 Page 6 � �,=- �� `� Y'¢. �`�� % .#9 � y � l�`i`_ �z � � � La�� `� ��; . 4 � °. � -= s�`� � ��- � „��-�,. =�.�,�,K,:,_' �: '� ` �;, �� ;°`- ��r �, _ .��_ .�r � �� ` _�; ��,. - - ,� �° � �:� i �� ,�" - �w � � ��r,�t.��„ ,., Xc �. >� r .. � . 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" . �""_ _'"�'_ t� - ^' �,. _,,_ �,� ,�.. �._ .�,.� �� + �� i� �: � �. �t,. � ,. , � .,�. • �� .. _ � . �� L . �. �'` ..� -�`�'""'.�` / � .�...� � , �� ,,,, � � I � 7$ , ' � �� :�,. � . ,��„ � . �_ _,., .�=�: �� '__-_,. f ,� � -�...� � . �- ,.� -._. V / » ,, ,:,:-�-- .�� ,. � . � . .. a�..� ��,�'. � v6. i s ��ii ��, �M1 ,, �,w�� ,, : � � 4 ,� .� �� , �. , _� '"^�c �,.,.� .,I:. ��