Bailey, Jeffrey � R�C!�1�I�D
SEP �6 20Z�+
� NOTICE OF CLAIM FORM to the City of Saint Paul, Mi��o� ���
Minnesota State Statute 466.05 states that"...every person...who claims damages fram any municipality...shall cause to be presented to the
governing body of the�nunicipaliry within 180 days after the alleged loss or injciry is discovered a notice stating the time,pince,and
circu�nstances 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 Jeffrey Middle Initial Last Name Bailey
Company or Business Name Mr. Bailey is insured by Progressive Direct
Are You an Insurance Company? Yes/No If Yes, Claim Number? 13-4148454
Street Address c/o James P. Young, Attorney, 900 American Boulevard East, Suite 212
City Bloomington State MN Zip Code 55420
Daytime Phone ( F1�1�5 7622 Cell Phone( ) - Evening Telephone( ) -
Date of Accidend Injury or Date Discovered 10/20/2013 Time�p�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.
Jeffrey Baileks vehicle was dama�ed in an accident due to a stop sign beina down in a road
St Paul police witnessed the siqn laying on the qround and 20 feet from the intersection.
P ase 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 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 vou 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.
Property damage claims to a vehicle: two estimates for the repairs to your vehicle if the damage exceeds
$500.00; or the actual bills and/or receipts for the repairs
O Towing claims: legible copies of any ticket issued and a copy of the impound lot receipt
O Other property damage claims: two repair estimates if the damage exceeds $500.00; or the actual bills
and/or receipts for the repairs; detailed list of damaged items
O Injury claims: medical bills,receipts
O Photographs are always welcome to document and support your claim but will not be returned.
Page 1 of 2—Please complete and return both pages of Claim Form
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims—ulease comnlete this section
Were there witnesses to the incident? �Yes No Unknown (circle)
Provide their names, addresses and telephone numbers: �t Pai iJ PDIICP�ffIrPi' �tE'Ven L�.Stt'ACtI,
Lindsay O-Brien (see police report)
Were the police or law enforcement called? �Yes No Unknown (circle)
If yes, what department or agency?������� Case#or report# 13227046
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.
of Wheelock and Woodbridqe in St. Paul, MN
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. _ reimburse Progressive $10,478.54 and Jeff Bailey's deductible of$500.00
Vehicle Claims—please complete this section ❑ check box if this section does not applv
Your Vehicle: Year�nnq Make Honda Model CIVIC
License Plate Number 796b1y State MN Color
Registered Owner Jeffrey Bailey
Driver of Vehicle �a
Area Damaged �hi�la tntalari
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Injur_y Claims—please complete this section 6�check box if this section does not applv
How were you injured?
What part(s)of your body were injured?
Have you sought medical treatment? Yes No Planning to Seek Treatment(circle)
When did you receive treatment? (provide date(s))
Name of Medical Provider(s):
Address Telephone
Did you miss work as a result of your injury? Yes No
When did you miss work? (provide date(s))
Name of your Employer:
Address Telephone
�Check here if you are attaching more pages to this claim form. Number of additional pages�.
By signing this form,you are stating that all information you have provided is true and correct to the best
of your knowledge. Unsigned forms will not be processed.
Submitting a false claim can result in prosecution. Date form was completed Se�tember 24, 2014
Print the Name of the Person who Completed this Form:
Signature of Person Making the Claim: `
Revised February 201 1
Young Law
900 American Boulevard East
Suite 212
Bloomington, MN 55420 (trina@younglawmn.com) (612-285-7622)
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Date: 10/24/2013 11:38 AM
� Estimate ID: 13-4148454-01
Estimate Version: 0
Committed
Profile ID: Metro 7.125 All Part
Heppners Auto Body Inver Grove
6042 Claude Way East,Inver Grove Heights,MN 55075
(651)455-7920
Fax: (651)455-0140
Damage Assessed By: Tony Knops Appraised For: PROGRESSIVE
Type of Loss: Auto
Date of Loss: 10(20/2013 Arrival Date: 10/21/2013
Payer: Insurance Deductible: 500.00
Claim Paid: N
Ciaim Number: 13-4148454-01
Insured: JEFFREY BAILEY
Owner: JEFFREY BAILEY
Address: 1234 ROSE VISTA CT.APT.8,ROSEVILLE,MN 55113
Telephone: Work Phone: (612)292-0205 Home Phone: (651)398-0346
Contact Phone: (651)398-0346
Mitchell Service: 910607
Description: 2009 Honda Civic LX Vehicle Production Date: 8/09
Body Style: 4D Sed Drive Train: 1.8L Inj 4 Cyi 5A FW D
VIN: 19XFA16599E047791 License: 796-BLY MN
Mileage: 49,931
OEM/ALT: A Search Code: ARDENHILLI
Color. GRAY
Options: PASSENGER AIRBAG,DRIVER AIRBAG,POWER LOCK,POWER WINDOW,REAR WINDOW DEFOGGER
MANUAL AIR CONDITION,CRUISE CONTROL,TILT STEERING COLUMN
TELESCOPIC STEERING COLUMN,ANTI-LOCK BRAKE SYS.,FOG LIGHTS,AUXILIARY INPUT
FRONT AIR DAM,VARIABLE ASSISTED STEERING,SIDE AIRBAGS,ANTI-THEFT SYSTEM
SIDE HEAD CURTAIN AIRBAGS,DAYTIME RUNNING LIGHTS,AM/FM STEREO CD/MP3 PLAYER
FRONT BUCKET SEATS,INTERIOR AIR FILTER,KEYLESS ENTRY SYSTEM
STEERING WHEEL MOUNTED CONTROLS
Line Entry Labor Line Item Part Type/ Dollar Labor
Item Number Type Operation Description Part Number Amount Units
Information Labels
1 000002 BDY REMOVE/REPLACE Inform Label Air Bag Caution 77871-SDA-A90 4.65
2 000211 BDY REMOVE/REPLACE Inform Label A/C Refrigerant 80050-SNA-H00 1.55
Front Bumaer
3 BDY OVERHAUL Frt Bumper Cover Assy 1.5 #
4 004745 BDY REMOVE/REPLACE Frt Bumper Cover "'Non-OEM CAPA 223.00 INC #
5 REF REFINISH Frt Bumper Cover C 2.6
6 005109 BDY REMOVE/REPLACE R Frt Otr Bumper Grille 71106-SNA-A50 55.02 INC
7 005110 BDY REMOVE/INSTALL L Frt Otr Bumper Grille Existing INC r
8 005077 BDY REMOVE/1NSTALL Frt Bumper License Plate Bracket Existing INC r
9 005078 BDY REMOVE/REPLACE R Frt Upr Bumper Bracket "Non-OEM 31.00 INC #
10 BDY REMOVE/1NSTALL FrtBumperAssy INC #
11 005083 BDY REMOVElREPLACE Frt Bumper Impact Absorber 71170-SNA-A50 72.78 INC
12 005084 BDY REMOVE/REPLACE Frt Bumper Reinforcement Bar(Alum) 71131-SNA-A00 117.10 0.4 #
13 005070 BDY REMOVElREPLACE R Frt Bumper Bracket 71135-SNA-AOOZZ 53.65 02 #
14 RAIL END
15 005071 BDY REMOVE/REPLACE L Frt Bumper Bracket 71185-SNA-AOOZZ 53.65 0.2 #
16 RAIL END
Grille
17 005191 BDY REMOVE/REPLACE Grille Trim "Non-OEM 114.00 INC #
18 005190 BDY REMOVE/REPLACE Grille '"Non-OEM CAPA 106.00 0.2 #
19 005001 BDY REMOVE/REPLACE Grille Emblem 75700-TFO-000 19.48 0.1 #
20 BDY REMOVE/INSTALL Grille Assy INC #
ESTIMATE RECALL NUMBER: 10l24/2013 11:38:19 13-4148454-01
Mitchell Data Version: OEM: SEP 13_V1023
MAPP:SEP_13_V1020 Copyright(C)1994-2013 Mitchell International Page 1 of 6
Software Version: 7.0.487 All Rights Reserved
Date: 10/24/2013 1138 AM
Estimate ID: 13-4148454-01
Estimate Version: 0
Committed
Profile ID: Metro 7.125 All Part
21 005002 BDY REMOVE/REPLACE Grille Emblem Clip 2@1.60 90301-STO-003 3.20
Front Lamps
22 002315 BDY CHECK/ADJUST Headlamps 0.4
23 005015 BDY REMOVE/REPLACE R Front Combination Lamp Assembly "Non-OEM 202.00 INC #
24 005016 BDY REMOVE/REPLACE L Front Combination Lamp Assembly "'Non-OEM 202.00 INC #
Hood
25 000078 BDY REMOVE/REPLACE Hood Panel "Non-OEM CAPA 340.00 0.5
26 REF REFINISH Hood Outside C 2.6
27 REF REFINISH Add For Hood Underside C 1.3
28 000081 BDY REMOVE/REPLACE R Hood Hinge *`Non-OEM 18.00 0.2 #
29 REF REFINISH R Hinge C 0.5
30 BDY REMOVE/INSTALL Hood Assy INC
31 BDY REMOVE/INSTALL Cowl Top Panel 0.3
32 BDY REMOVE/INSTALL R Cowl Top Panel Extension Assy 0.2 #
33 005123 BDY REMOVE/REPLACE Hood Latch 74120-SNA-A21 73.77 INC
Coolina
34 007016 BDY REMOVE/REPLACE Cooling Radiator "Non-OEM 151.20 INC #
35 000135 BDY REMOVE/REPLACE Cooling RecoveryTank ""Non-OEM 6.00 INC
A!C/HeaterNentilation
36 006212 MCH REMOVE/REPLACE Air Cond Condenser Assy -M "Non-OEM 139.00 0.4 #
37 MCH REMOVE/REPLACE Evacuate&Recharge A/C -M 1.4
38 003320 MCH REMOVE/REPLACE Air Cond Condenser Pipe -M 80341-SNE-A01 148.72 0.8
FrontFender
39 000244 BDY REMOVE/REPLACE R Fender Panel "'Non-OEM CAPA 153.00 1.5 #
40 REF REFINISH R Fender Outside C 1.6
41 REF REFINISH R Add To Edge Fender C 0.5
42 000245 BDY REMOVE/REPLACE L Fender Panel "Non-OEM CAPA 153.00 1.5 #
43 REF REFINISH L Fender Outside C 1.6
44 REF REFINISH L Add To Edge Fender C 0.5
45 003963 BDY REMOVE/REPLACE R Upr Fender Garnish 74206-SNA-A01 24.05 INC #
46 000262 BDY REMOVE/REPLACE R Fender Liner 74101-SNA-A00 49.14 INC #
47 000263 BDY REMOVE/INSTALL L Fender Liner Existing INC #r
Front Inner Structure
48 002345 REF REFINISH Radiator Support Complete �•5
49 000275 BDY REMOVE/REPLACE Front Body Radiator Support -S 60400-SNE-A01ZZ 268.12 8.7 #
50 000045 BDY REMOVE/REPLACE Front Body Closing Panel 71125-SNA-A00 57.68 INC
51 000048 BDY REMOVE/REPLACE R Front Body Clip 91505-S9A-003 2.42
52 000049 BDY REMOVE/REPLACE L Front Body Ciip 91505-S9A-003 2.42
53 002357 REF REFINISH R Apron/Sidemember Complete �•5
54 002358 REF REFINISH L Apron/Sidemember Complete ��5
55 000284 BDY REMOVE/REPLACE R Front Body Apron Assy(HSS) -S 60650-SNA-305ZZ 429.95 7.5
56 000285 BDY REPAIR L Front Body Apron Assy(HSS) -S Existing 3.0'#
57 000294 BDY REMOVE/REPIACE R Front Body Sidemember Assy(HSS)-S 60810-SNA-A02ZZ 332.75 4.0 #
58 000297 BDY REMOVE/REPLACE L Front Body Sidemember Assy(HSS)-S 60910-SNE-AOOZZ 302.25 7.0 #
59 007085 MCH REMOVE/INSTALL Fuse Box -M Existing 0.3`
60 007412 BDY REMOVE/INSTALL Engine Wiring Harness Existing 0.7'
Air Baq Svstem
61 000328 MCH REMOVElREPLACE Air Bag Module-Driver Front -M 77810-SNA-A82ZA 690.11 0.3
62 000333 MCH REMOVE/REPLACE R Frt Air Bag Impact Sensor -M 77930-SNA-632 57.11 0.2 #
63 000337 MCH REMOVE(REPLACE Air Bag Controi Unit -M 77960-SNA-A23 171.30 0.4 #
64 BDY REMOVE(INSTALL Console 0.5
Enaine
65 002387 MCH REMOVE/INSTALL Engine&Trans Assy -M 8.0 #
Enaine/Bodv Under Covers
66 005102 BDY REMOVE/INSTALL Engine Under Cover Existing 0.3 r
Roc ke r/P i I la rs/FI oor
67 001067 BDY REPAIR L Door Opening Frame Existing 1.0'#
68 REF REFINISH/REPAIR L Door Opening Frame C 1.5'
gg MODIFIED REFINISH WITH FULL CLEAR COAT
Front Door
70 002403 REF BLEND R Frt Door Outside C 0.9
71 002404 REF BLEND L Frt Door Outside C 0.9
ESTIMATE RECALL NUMBER: 10l24/2013 1138:19 13-4148454-01
Mitchell Data Version: OEM: SEP 13_V1023
MAPP:SEP_13_V1020 Copyright(C)1994-2013 Mitchell International Page 2 of 6
Software Version: 7.0.487 All Rights Reserved
Date: 10/24/2013 11:38 AM
� Estimate ID: 13-4148454-01
Estimate Version: 0
Committed
Profile ID: Metro 7.125 All Part
72 002695 BDY REMOVElINSTALL R Frt Otr Belt Moulding 0.6 #
73 002696 BDY REMOVE/INSTALL L Frt Otr Belt Moulding 0.6 #
74 002697 BDY REMOVE/INSTALL R Frt Rear View Mirror INC
75 002698 BDY REMOVE/INSTALL L Frt Rear View Mirror INC
76 001515 BDY REMOVE/INSTALL R Frt Door Adhesive Moulding Existing 0.4'#
77 BDY REMOVE/INSTALL R Frt Door Trim Panel INC
78 Includes Clean&Retape
79 001523 BDY REMOVE/INSTALL L Frt DoorAdhesive Moulding Existing 0.4'#
80 BDY REMOVE/INSTALL L Frt Door Trim Panel INC
81 Includes Clean&Retape
82 002707 BDY REMOVE/INSTALL R Frt Otr poor Handle 0.7 #
83 002708 BDY REMOVE/INSTAL� L Frt Otr poor Handle 0.7 #
Roof
84 002735 BDY REMOVE/INSTALL L Roof Drip Moulding 0.3
85 936012 ADD'L COST HAZARDOUS WASTE DISPOSAL 3.50 '
ADDITIONAL OPERATIONS
86 REF ADD'L OPR Clear Coat 3�8
Additional Costs&Materials
87 ADD'L COST PainUMaterials 620.00 *
MANUAL ENTRIES
88 900500 BDY ' ADD'L LABOR OP SET UP 8�MEASURE UNIBODY/FULL FRAME Existing 2.0"
89 Includes all necessary operations except pull time
90 900500 FRM' REPAIR PULL/SQUARE UNIBODY/FRAME Existing 4.0`
91 Document Control Points
92 900500 REF ' REMOVE/REPLACE FLEX ADDITIVE ""Non-OEM 2.50 ' 0.0*
93 900500 BDY ' ADD'L LABOR OP COVER CAR FOR OVERSPRAY "Non-OEM 5.00 ' 0.2*
94 900500 BDY ' REMOVE/REPLACE TOW BILL-TAXABLE 1 TIME ONLY Sublet 75.00 ' 0.0'
95 900500 BDY ' REMOVE/REPLACE CLEAR PROTECTIVE TAPE Sublet 125.00 ` 0.0'
"-Judgment Item
#-Labor Note Applies
'"` Non-OEM CAPA-Non-Original Equipment Manufacturer Replacement Part, CAPA Certified
"` Non-OEM-Non-Original Equipment Manufacturer Replacement Part
C- Included in Clear Coat Calc
r-CEG R&R Time Used For This Labor Operation
NAPA AUTO PARTS KEYSTONE AUTOMOTIVE KEYSTONE AUTOMOTIVE PP
CALL YOUR LOCAL STORE 3615 MARSHALL ST.NE 3615 MARSHALL ST.NE
OR CALL 1-800-LET-NAPA MINNEAPOLIS MINNEAPOLIS
MN 55418 MN 55418
(800)328-1845 (612)789-1886 (800)328-1845 {612)789-1886
(800)538-6272
34 'CU2922 151.20 9 "H01067108N 31.00 4 "H01000266PP 223.00
23 "H02503127 202.00 17 "H01210127PP 114.00
24 "H02502127 202.00 18 "H01200198PP 106.00
28 "H01236115 18.00 25 "H01230148PP 340.00
35 "H03014115 6.00
36 "CNDDPI3525 139.00
39 "H01241168C 153.00
42 "H01240168C 153.00
Prior Damage:
SEE UPD PHOTOS
ESTIMATE RECALL NUMBER: 10/24/2013 11:38:19 13-4148454-01
Mitchell Data Version: OEM: SEP_13_V1023
MAPP:SEP_13_V1020 Copyright(C)1994-2013 Mitchell International Page 3 of 6
Software Version: 7.0.487 All Rights Reserved
Date: 10/2412013 11:38 AM
Estimate ID: 13-4148454-01
Estimate Version: 0
Committed
Profile ID: Metro 7.125 All Part
All manufacturers requirements regar�ing 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 45.8 52.00 0.00 0.00 2,381.60 Taxable Parts 4,911.57
Refinish 22.8 52.00 0.00 0.00 1,185.60 Sales Tax @ 7.125% 349.95
Frame 4.0 70.00 0.00 0.00 280.00
Mechanical 11.8 80.00 0.00 0.00 944.00 Non-Taxable Parts 125.00
Non-Taxable Labor 4,791.20 Total Replacement Parts Amount 5,386.52
Labor Summary 84.4 4,791.20
III. Additional Costs Amount IV. Adjustments Amount
Taxable Costs 620.00 Insurance Deductible 500.00-
Sales Tax @ 7.125% 44.18
Customer Responsibility 500.00-
Non-Taxable Costs 3.50
Total Additional Costs 667.68
Paint Material Method:Rates
Init Rate=32.00
I. Total Labor: 4,791.20
II. Total Replacement Parts: 5,386.52
III. Total Additional Costs: 667.68
Gross Total: 10,845.40
IV. Total Adjustments: 500.00-
Net Total: 10,345.40
Point(s)of Impact
1 Right Front Corner(P) j
Insurance Co: PROGRESSIVE ,
Inspection Site: Bumsville Service Center '
Address: 12450 River Ridge Ct
Burnsville,MN 55337
ESTIMATE RECALL NUMBER: 10/24/2013 11:38:19 13-4148454-01
Mitchell Data Version: OEM: SEP 13 V1023
MAPP:SEP 13_V1020 Copyright(C)1994-2013 Mitchell Internationai Page 4 of 6
Software Version: 7.0.487 All Rights Reserved
, Date: 10/24/2013 11:38 AM
Estimate ID: 13-4148454-01
Estimate Version: 0
Committed
Profile ID: Metro 7.125 Ali Part
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 BEFOKE, 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
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 DAMAGE CAUSED
BY IMPROPER MAINTENANCE, NEGLECT, ABUSE OR SUBSEQUENT ACCIDENT. THIS
GUARANTEE 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 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 refer 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
AGR�EMENT ON COST TO RETURN THE VEHICLE TO PRE-LOSS CCNDITION
ESTIMATE RECALL NUMBER: 10/24/2013 1138:19 13-4148454-01
Mitcheil Data Version: OEM: SEP 13 V1023
MAPP:SEP 13_V1020 Copyright{C)1994-2013 Mitchell International Page 5 of 6
Software Version: 7.0.487 All Rights Reserved
Date: 10/24/2013 1138 AM
Estimate ID: 13-4148454-01
Estimate Version: 0
Committed
Profile ID: Metro 7.125 All Part
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.
Event Log
File Created: 10/22/2013 08:48:17 AM
Estimate Started: 10/22/2013 08:51:46 AM
Estimate Printed: 10/24/2013 10:11:41 AM
Estimate Committed: 10/24/2013 11:38:19 AM
Estimate Uploaded: Estimate not uploaded
ESTIMATE RECALL NUMBER: 10/24/2013 11:38:19 13-4148454-01
Mitcheil Data Version: OEM: SEP 13 V1023
MAPP:SEP 13_V1020 Copyright(C)1994-2013 Mitchell Internationai Page 6 of 6
Software Version: 7.0.487 Ali Rights Reserved
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�SD3011 /CMSM3011 P A C M A N AUG 27 14 - 14 : 34
?ID: A090277 SALVAGE INFORMATION REVISE TERMID: ?062
�SD: BAILEY, JEFFREY C POL# : 25088789 -11
�L : OCT 20 13 MN-SEMN -BRN- CLM: 134148454 ACTIVE REP : T SHOVEIN
�OP : 09, HONDA, CIVIC VIN: 19XFA16599E047791
�OP OWNER: BAILEY, JEFFREY C
�LVAGE STAT* C VEHICLE TYPE* 01 AUTOMOBILE
�LVAGE METHOD* A POOL POOL STOCK NUMBER: @12157181
�LVAGE VENDOR* I070 IAA - ST . PAUL, MN
�ITIAL STORAGE BEGAN: OCT 20 13 INITIAL STORAGE ENDED: OCT 20
�TE TITLE ORDERED: DEC 06 13 TITLE RECD/TYPE* A REBUILDABLE OR GENERAL TI
�E TAX ACV: 12 , 176 . 33 TAX, TAG, TITLE: TOTAL VALUE AMOUNT : 12, 176 .
�TE SOLD: JAN 08 14 SALE PRICE . 2, 500 .
�LVAGE END BUYER: A & P AUTO
�XT :
�COV DESC L/COV TOTAL FEES NET RECOVERY
�LL 2103 453 . 59 2 , 046 . 41
�MMAND: SALREV F4=RECADD F5=SALFEA F10=SALREC F13=SALFEE
� REMITTANCE: 920172fi2
� � DATE: 0'!/09/2014
INSUFtANCfi
AV�'0 AUGTC4NS
Remittance Payable To:
Insurance Auto Auctions,lnc. Progressive Casual#y lnsurance-Corporate
Attn; Settlemen�Group 6055 Parkland Blvd, Box EM-3
Two Westbrook Corpora#e Center Suite 500 Attn: NaUonal Salvage Unit
Westchester, IL. 6015�4 Mayfield Heights, OH 44124
Phone f7Q8)492-7000 Affn: Salvage Dept
Fax: l708)492-7D78
E-maii Total
Salvaae lnformatian
Account of Sale A iv' °IoACV
IAAStock#: OOQ-12957981 Safes $2,50D.00 20.53
lAA Branch: MinneapolislSt. Paul IAA Charges
Fed.Tax I.D. 953790191 Consignment Ffat Fee $85.00 0,70
Adjuster: Thomas Shovein DMV Filing Fee $90.Q0 0.08
Insured: Jeffrey Bailey State/Local Transfer Fee $8.25 0.07
Owner: Jeffrey$ailey
Claim#: 13-4148454
Policy#: Less IAA Charges ($103.25) {4.85}
Vehicle: 2009 HONDA CIVIC Net IAA Return $2,396.75 19.68
Damage: Front end/ Pa ment Amount %
VIN: 19X�A16599E047794 Y $2,396.75 19.68
ACV: $12,'!76.00
NICB Qate: 1/09/2014
Beye[Infarmation
A& P Auto, LLC
12515 Pennsvlvania A�e Suite 4 :
Savaae. MN 55378
Resale Certificate#: 8480085 (MN)
Elapsed Days Analysis
Date of Event: Date Davs '
�oss �a��aizo�a __
Assfgned 10/29I2093 1a
Released 10/30/2013 2
Pickup 10J30/2013 '1
Title Rec'd 12/11120'f 3 43
Sale Doc. Rec'd 12/23/2013 73 ,
Auction Date 1/8/2014 �7'
Buyer Payment N/A 0
Remittance 1/9/2014 2
Elapsed Tofal Days: 82
IAA Doc.RP002.rp1
�SD2340 /CMSM2340 P A C M A N AUG 27 14 - 14 : 35
?ID: A090277 CLAIM PAYMENT INQUIRY TERMID: ?062
JSD: BAILEY, JEFFREY C POL: 25088789 -11
�L : OCT 20 13 MN-SEMN -BRN- CLM: 134148454 ACTIVE REP: T SHOVEIN
?AY TO THE ORDER OF: TOTAL DRAFT AMOUNT : 7 , 495 . 88
LINE 1 • HONDA FINANCIAL SERVICE, ONLY*******************************
LINE 2 : AS LEIN HOLDER FOR JEFFREY BAILEY***************************
�INE 3 :
�DDRESS : NPC PO BOX 165007
ITY : IRVING ST/PR* TX ZIP/CPC: 75016 CNTRY* U
�1 PAYMENT OF: -COLL- ' 09 HONDA CIVIC-PROG OBTN SALV
)99 ? N FEDERAL TAX ID: LAST UPDT REP: A081379
�S CODE * 13 PCL EFT TRACE # : ISSUING REP: T SHOVEIN
�NK CODE* AS2 ISSUE DATE : NOV 22 13 APPROVED BY: M FIMMEN
PATE * MN AREA * 972 REVIEW DATE : 00 00
POP RSN * DRAFT # : 480332352 REVIEWED BY:
�MMAN D:
;
�
�SD2340 /CMSM2340 P A C M A N AUG 27 14 - 14 : 35
?ID: A090277 CLAIM PAYMENT INQUIRY TERMID: ?062
�SD: BAILEY, JEFFREY C POL: 25088789 -11
�L : OCT 20 13 MN-SEMN -BRN- CLM: 134148454 ACTIVE REP: T SHOVEIN
?AY TO THE ORDER OF: TOTAL DRAFT AMOUNT : 140 . 00
�INE 1 : CROSS COUNTRY MOTOR CLUB (ONLY)
LINE 2 :
LINE 3 :
�DDRESS : 1 CABOT RD
ITY: MEDFORD ST/PR* MA ZIP/CPC: 02155 CNTRY* U
�1 PAYMENT OF: INV 362427 ; VMJ-1310746510-2
)99 ? Y FEDERAL TAX ID: 42530679 LAST UPDT REP: JKA0005
�S CODE * 02 PCL EFT TRACE # : ISSUING REP: J WHALEY
�NK CODE* AS2 ISSUE DATE : NOV 13 13 APPROVED BY: M FIMMEN
PATE * MN AREA * 226 REVIEW DATE: 00 00
I'OP RSN * DRAFT # : 480185829 REVIEWED BY:
�MMAND:
f
�SD2340 /CMSM2340 P A C M A N AUG 27 14 - 14 : 35
'?ID: A090277 CLAIM PAYMENT INQUIRY TERMID: ?062
QSD: BAILEY, JEFFREY C POL: 25088789 -11
�L : OCT 20 13 MN-SEMN -BRN- CLM: 134148454 ACTIVE REP: T SHOVEIN
?AY TO THE ORDER OF: TOTAL DRAFT AMOUNT : 236 . 34
�INE l : HEPPNER' S AUTO BODY, INC . , ONLY*****************************
LINE 2 :
LINE 3 :
�DDRESS : 6042 CLAUDE WAY E
LTY: INVER GROVE HEIGHTS ST/PR* MN ZIP/CPC : 55076 CNTRY* U
�1 PAYMENT OF: COLLISION, TOWING & TEARDOWN OF 2009 HONDA CIVIC
�99 ? Y FEDERAL TAX ID: 411522313 LAST UPDT REP: CJH0001
�S CODE * 13 PCL EFT TRACE # : ISSUING REP: C HOCHHALTER
�NK CODE* AS2 ISSUE DATE : OCT 25 13 APPROVED BY:
PATE * MN AREA * REVIEW DATE: 00 00
POP RSN * DRAFT # : 480036064 REVIEWED BY:
�MMAN D:
I
�SD2340 /CMSM2340 P A C M A N AUG 27 14 - 14 : 35
�?ID: A090277 CLAIM PAYMENT INQUIRY TERMID: ?062
JSD: BAILEY, JEFFREY C POL: 25088789 -11
�L : OCT 20 13 MN-SEMN -BRN- CLM: 134148454 ACTIVE REP: T SHOVEIN
?AY TO THE ORDER OF: TOTAL DRAFT AMOUNT : 5, 029 . 07
�INE 1 • JEFFREY C BAILEY, ONLY**************************************
LINE 2 • ****�****�*�*******�************�*
�INE 3 :
�DDRESS : 1234 ROSE VISTA CT .
APT . 8
ITY: ROSEVILLE ST/PR* MN ZIP/CPC : 55113 CNTRY* U
�I PAYMENT OF: -COLL- ' 09 HONDA CIVIC-LESS $500 DED-PROG OBTN SALV
)99 ? N FEDERAL TAX ID: LAST UPDT REP: A081379
�S CODE * 13 PCL EFT TRACE # : ISSUING REP: T SHOVEIN
�NK CODE* AS2 ISSUE DATE : OCT 25 13 APPROVED BY: M FIMMEN
PATE * MN AREA * 972 REVIEW DATE: 00 00
POP RSN * DRAFT # : 479993565 REVIEWED BY:
�MMAN D:
Progressive Group of Insurance Companies
Settlement Summary
Claim Information
Claim Number: 13-4148454-01 Coverage Type of Loss: Collision
Policy Number: Loss Date: 10/20/2013
Owner: BAILEY,JEFFREY Reported Date: 10/20/2013
Valuation Report ID: 1004007033
Vehicle Information
Loss Vehicle: 2009 HONDA CIVIC LX 4D SDN 1.8L 4 Cyl Gas A Location: MN 55113
2WD
VIN: 19XFA16599E047791 Exterior Color: Urban Titanium Metallic
Mileage: 49,931 miles License Plate: 796 BLY, Minnesota, Exp,
11/2013
Title History: No Title History Comments:
Loan Information Payment Information
Lien Holder Payoff: $0.00 Lien Holder Payment(s): $0.00
Loan/Lease Payoff Coverage: $0.00 Net to Owner: $12,524.95
Settlement
Stated Amount: $0.00
Actual Cash Value: $12,176.33
Base Value: $12,434.41
Title History Adjustment: -$0.00
Refurbishment Adjustment: $0.00
After Market Parts Adjustment: $0.00
Condition Adjustment: -$258.08
Prior Damage Adjustment: -$0.00
Market Value: $12,176.33
Settlement Adjustment(Pre-Tax): $0.00
Fees: $57.16
Taxes: $791.46
Company Obtains: $0.00
Net Settlement: $13,024.95
Settlement Adjustment(Post-Tax): $0.00
Deductible: -$500.00
Other Adjustments: $0.00
Total Settlement: $12,524.95
Adjuster License#:
Comments: