Hernandez, Rosa (2)Underwritten By:
American Family Insurance Company
Tel: 1-800-MY AMFAM (1-800-692-6326)
Fax: 1-866-935-2858
Claim Number:
Date Of Loss:
01-006-330565
06/18/2023
Policy Number:410352406037
Policyholder:Delmi Martinez
6000 AMERICAN PARKWAY
MADISON, WI 53783-0001
ST PAUL FIRE DEPARTMENT
1675 ENERGY PARK DR
SAINT PAUL, MN 55108-2703
November 17, 2023
Page 1 of 2
Your Insured Name: St Paul Fire Department
Your Claim Number: #REQUIRED - Double Click Here to Enter Adverse Carrier's Claim Number
Dear St Paul Fire Department,
This correspondence is regarding the claim for Delmi Martinez.
We are notifying you that we have made payment on the above referenced claim and our supporting documentationand proof of payment are enclosed.
The following breakdown shows the damages that were incurred by our insured:
DAMAGE AMOUNT
Total Damages:$4,095.62
American Family Insurance Company Damage Payment(s):$3,595.62
Damage Deductible:$500.00
Rental Expense Payments:$n/a
Demand Total (Payments + Deductible):$4,095.62
Our investigation and the facts of this claim support that this incident was caused by your insured’s negligence.Please forward the total claim amount indicated to the address listed below. We will reimburse our insured theirdeductible.
American Family Insurance Company
Attn: Claim Number 01-006-330565
6000 American Parkway
Madison, WI 53783-0001
Page 2 of 2
We are committed to providing excellent customer service and are here to assist you. Please contact us with any
questions you may have.
Sincerely,
Stacy MacKenzie
Stacy MacKenzie
Claim Senior Adjuster
AFICS on behalf of American Family Insurance Company
Stacy.MacKenzie.1@afics.com
Phone: 1-920-330-5262 | Fax: 1-866-935-2858
Mail: 6000 American Parkway, Madison, WI 53783-0001
Revised March 2023
NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minnesota State Statute 466.05 states that “…every person…who claims damages from any municipality…shall cause to be presented to the governing body of the
municipality within 180 days after the alleged loss or injury is discovered a notice stating the time, place, and circumstances thereof, and the amount of compensation
or other relief demanded.”
Please complete this form in its entirety by clearly typing or printing your answers to each question. If you have additional documentation, you may add those
documents to your submission. You will not be contacted by telephone unless clarification is needed. The claim process for investigations can take upwards of four (4)
weeks. This form must be signed, dated with all applicable sections completed. Submission this completed form to the Saint Paul City Clerk’s Office by email
(cityclerk@ci.stpaul.mn.us), fax (651-266-8574) or mail addressed to “Saint Paul City Clerk, 15 West Kellogg Blvd., Suite 310, Saint Paul, MN 55102”.
Claimant: First Name: _______Rosa ______________________ Last Name:
_______________________________Hernandez________________
Please Indicate Your Pronouns: ☒ She/Her/Hers, ☐ He/Him/His, ☐ They/ Them/Theirs
Company or Business Name: ______American Family Insurance
______________________________________________________________________________
Is this claim being made by an Insurance Company? YES If yes, what is your Claim/File Number?
__01006330565_______________________
Is this claim being made by an Attorney? NO If yes, what is your File Number? _______________________________________
If yes, provide your Insured’s/ Client’s Name: ____Delmi Martinez and Rosa
Hernanadez___________________________________________________________________
Street Address: ___ 5239 Greenfield
Ave____________________________________________________________________________________________
City: ____________Saint Paul__________________________________ State: MN Zip Code: 55112
Daytime/Work Phone: ________ 612-743-3826__________________________ Cell Phone: _____________ 612-743-
3826________________________________
Date of Incident or Date Discovered (Must Complete): 6/18/2023 Time: 7:15 pm_____________________________
Please state, in detail, what happened that prompted you to file a Notice of Claim Form: _ ambulance sideswiped insured’s vehicle
as insured was waiting to turn left___________________________________
Please state why or how you feel the City of Saint Paul is responsible for your Damages? _____city ambulance caused damages
_______________________________
Please check the reason that most closely describes the reason for your submitting a claim. Please note the documents that will
need to be provided with your completed form. Photographs will be accepted. All documents submitted become the property of
the City of Saint Paul and shall not be returned.
☒ Automobile damage from a motor vehicle accident: please provide two estimates for repairs or actual bill that has been paid.
☐ Automobile damage from a street defect or pothole: please provide two estimates for repairs or actual bill that has been paid.
☐ Automobile was towed and may or may not have sustained damage: please provide copy of towing ticket (if available), receipt
from Impound Lot, and two estimates for repairs or actual bill that has been paid.
☐ Snow Emergency: please provide copy of towing ticket (if available), receipt from Impound Lot, and two estimates for repairs or
actual bill that has been paid.
Revised March 2023
☐ Property damage: please provide two estimates for repairs or actual bill that has been paid.
☐ You were injured during a motor vehicle accident: please provide police report number, details about injury.
☐ You were injured in the City of Saint Paul: please provide police report number, witnesses, and details about injury.
Continue to page 2 of Notice of Claim Form. Failure to complete and return both pages will result in delays.
This section must be completed for all claims.
Is there a police report for this incident? YES
If yes, please provide the police report case number: ____ 23107320_______________________
If yes, what law enforcement agency responded? ________ St Paul
PD____________________________________________________
Where did the incident take place? Please provide a street address, intersection or name of city park or facility:
___ Maryland Ave E AT Payne Ave, St Paul, MN
55130_________________________________________________________________________________________________________
What would you like to see happen to resolve this claim to your satisfaction?
__Repayment for repairs
__________________________________________________________________________________________________________
Were there witnesses to this incident? Please provide names and contact phone numbers:
____________________________________________________________________________________________________________
For property damage claims, including vehicle accidents.
Your vehicle’s information: Year: ____2009_____ Make: _____Honda____________ Model: Pilot Color: silver
License Plate #: ____KCV111_____________________ State vehicle is registered in: Minnesota
Registered owner of vehicle: ____ Delmi Martinez_________________________ Driver: Rosa
Hernandez__________________________________________
Area(s) damaged:_____ entire passenger side is scratched, front door makes noise when
opening_________________________________________________________________________________
If a City vehicle was involved, License Plate #: _________________________________ Color: ambulance
Was there City insignia on the vehicle? YES Driver’s Name: ______ Frank
Daly________________________________________________
Other property damaged: _______________________________________________________________________________________
For injury claims of any type.
What part of your body was injured? _____________________________________________________________________________
Did you go to the emergency room or urgent care? YES / NO Where? ___________________________________________________
Was medical treatment received? YES / NO Where? ________________________________________________________________
First day of medical treatment? _____________ Are you still receiving medical treatment? YES / NO
Did you miss any work as result of this incident? YES / NO
Employer(s): _________________________________________________________________________________________________
Revised March 2023
How much time have you missed from work? _____________________________________________________________________
If you are submitting other documents, please state what you are attaching and how many pages: _________________________
By signing this form, you agree that all information provided is true and correct to the best of your knowledge.
Please NOTE that submitting a false or misleading claim can and will result in prosecution under Minnesota Statutes.
Name of Person completing form: ____Diane Gallagher_________________________________________________________
Signature of Person submitting this form: ____Diane Gallagher___________________________________________________
Relationship of person signing to Party making the claim: ____Claims Adjuster ______________________________________
Date document is being signed: 11/16/2023
LaMettry's Collision, Glass and More
New Brighton
Workfile ID:
PartsShare:
Federal ID:
35a27381
41-1393089
"Every Customer Leaves With A Smile"
1100 Silver Lake Road, New Brighton, MN 55112
Phone: (651) 925-5650
FAX: (651) 379-0079
Supplement of Record 1 with Summary
Customer: Martinez, Delmi
Written By: Sammy Ward, 10/5/2023 11:36:15 AM
Insured:Martinez, Delmi Policy #:410352406037 Claim #:01006330565-1
Type of Loss:Collision Date of Loss:6/18/2023 7:15 PM Days to Repair:25
Point of Impact:17 Left & Right Side
Owner:Inspection Location:Insurance Company:
Martinez, Delmi LaMettry's Collision, Glass and More New
Brighton
AMERICAN FAMILY INSURANCE COMPANY
5239 Greenfield Ave 1100 Silver Lake Road American Family Insurance
Saint Paul, MN 55112 New Brighton, MN 55112 American Family - AF3
(612) 743-3826 Cell Repair Facility MADISON
(651) 925-5650 Business
VEHICLE
2009 HOND Pilot EX-L 4WD 4D UTV 6-3.5L Gasoline MPFI Silver
VIN:5FNYF48579B009012 Interior Color:Mileage In:149,352 Vehicle Out:
License:KCV111 Exterior Color:Silver Mileage Out:
State:MN Production Date:5/2008 Condition:Job #:
TRANSMISSION CONVENIENCE FM Radio Electric Glass Sunroof
Automatic Transmission Air Conditioning Stereo SEATS
Overdrive Intermittent Wipers Search/Seek Bucket Seats
4 Wheel Drive Tilt Wheel Auxiliary Audio Connection Reclining/Lounge Seats
POWER Cruise Control Satellite Radio Leather Seats
Power Steering Rear Defogger CD Changer/Stacker Heated Seats
Power Brakes Keyless Entry SAFETY 3rd Row Seat
Power Windows Alarm Drivers Side Air Bag WHEELS
Power Locks Message Center Passenger Air Bag Aluminum/Alloy Wheels
Power Mirrors Steering Wheel Touch Controls Anti-Lock Brakes (4)PAINT
Heated Mirrors Rear Window Wiper 4 Wheel Disc Brakes Clear Coat Paint
Power Driver Seat Telescopic Wheel Traction Control OTHER
Power Passenger Seat Climate Control Stability Control Fog Lamps
DECOR Dual Air Condition Front Side Impact Air Bags TRUCK
Dual Mirrors Backup Camera Head/Curtain Air Bags Trailer Hitch
Body Side Moldings Home Link Positraction
Privacy Glass RADIO ROOF
10/5/2023 11:36:16 AM 308896 Page 1
7xkc2x7xkc2x
Supplement of Record 1 with Summary
Customer: Martinez, Delmi
2009 HOND Pilot EX-L 4WD 4D UTV 6-3.5L Gasoline MPFI Silver
Console/Storage AM Radio Luggage/Roof Rack
10/5/2023 11:36:16 AM 308896 Page 2
Supplement of Record 1 with Summary
Customer: Martinez, Delmi
2009 HOND Pilot EX-L 4WD 4D UTV 6-3.5L Gasoline MPFI Silver
Line Oper Description Part Number Qty Extended
Price $
Labor Paint
1 FRONT BUMPER
2 O/H bumper assy 2.2
3 *<>Repl LKQ bumper assy +30%04711SZAA91ZZ 1 275.60 Incl.2.8
4 Repl Add for fog lamps 1 0.5
5 R&I License frame 0.2
6 FRONT LAMPS
7 Repl Aim headlamps 1 0.5
8 R&I RT R&I headlamp assy 0.3
9 FENDER
10 R&I RT Fender liner 0.4
11 R&I LT Fender liner 0.4
12 *Rpr RT Fender 4.0 2.0
13 Overlap Major Non-Adj. Panel -0.2
14 R&I RT Reinforcement splash guard 0.1
15 R&I RT Deflector 0.1
16 #Refn Basecoat Reduction -0.2
17 ROOF
18 R&I RT Rail assy 0.6
19 PILLARS, ROCKER & FLOOR
20 *Blnd RT Aperture panel 1.3
21 FRONT DOOR
22 *Rpr RT Outer panel (HSS)1.0 2.4
23 Overlap Major Adj. Panel -0.4
24 R&I RT Water deflector 0.1
25 R&I RT Belt molding 0.3
26 R&I RT Applique 0.2
27 *Repl RT Body side mldg EX, EX-L, SE
nimbus gray
75302SZAA11ZD 1 209.65 0.4 0.0
28 *Repl RT Mirror assy w/heated black 76208SZAA11ZF 1 234.96 0.3 0.0
29 *Rpr RT Mirror cover EX, EX-L, SE
black
0.5 0.4
30 Overlap Minor Panel -0.2
31 R&I RT Handle, outside w/body-color
nimbus gray
0.7
32 R&I RT R&I trim panel 0.4
33 REAR DOOR
34 *Repl RT Body side mldg EX, EX-L, SE
nimbus gray
75303SZAA11ZD 1 207.65 0.4 0.0
35 QUARTER PANEL
36 R&I RT Wheelhouse liner 0.6
37 *Rpr RT Quarter panel 3.0 2.7
38 Overlap Major Non-Adj. Panel -0.2
39 S01 Clear Coat 2.5
10/5/2023 11:36:16 AM 308896 Page 3
Supplement of Record 1 with Summary
Customer: Martinez, Delmi
2009 HOND Pilot EX-L 4WD 4D UTV 6-3.5L Gasoline MPFI Silver
40 R&I RT Air vent 0.1
41 R&I RT Quarter glass Honda 1.1
42 REAR LAMPS
43 R&I RT Tail lamp assy 0.3
44 REAR BUMPER
45 S01 R&I R&I bumper cover 1.1
46 VEHICLE DIAGNOSTICS
47 #Rpr Pre Scan M
48 #Rpr Post Scan M
49 #Rpr Repair Cleanse
50 #Color Tint with test panels 1
51 #Corrosion Protection 1 5.00 0.2
52 #Cover Car 1 5.00 0.2
53 **Repl A/M Flex Additive BASF part
#522-111
1 5.00
54 #Subl Hazardous Waste 1 3.00 X
55 **Repl A/M Urethane Kit Quarter Glass 1 20.00
SUBTOTALS 965.86 20.2 12.9
NOTES
Prior Damage Notes:
left side front end is scratched
ESTIMATE TOTALS
Category Basis Rate Cost $
Parts 962.86
Body Labor 20.2 hrs @ $ 71.00 /hr 1,434.20
Paint Labor 12.9 hrs @ $ 71.00 /hr 915.90
Paint Supplies 12.9 hrs @ $ 50.00 /hr 645.00
Miscellaneous 3.00
Subtotal 3,960.96
Sales Tax $ 1,607.86 @ 8.3750 %134.66
Grand Total 4,095.62
Deductible 500.00
CUSTOMER PAY 500.00
INSURANCE PAY 3,595.62
10/5/2023 11:36:16 AM 308896 Page 4
Supplement of Record 1 with Summary
Customer: Martinez, Delmi
2009 HOND Pilot EX-L 4WD 4D UTV 6-3.5L Gasoline MPFI Silver
SUPPLEMENT SUMMARY
Line Oper Description Part Number Qty Extended
Price $
Labor Paint
Deleted Items
43 REAR BUMPER
44 *<>Rpr Bumper cover w/o Touring -1.0 -2.6
45 Overlap Major Non-Adj. Panel 0.2
46 Clear Coat -2.5
47 O/H bumper assy -1.8
48 R&I Step pad Incl.
Added Items
39 S01 Clear Coat 2.5
44 REAR BUMPER
45 S01 R&I R&I bumper cover 1.1
SUBTOTALS 0.00 -1.7 -2.4
TOTALS SUMMARY
Category Basis Rate Cost $
Parts 0.00
Body Labor -1.7 hrs @ $ 71.00 /hr -120.70
Paint Labor -2.4 hrs @ $ 71.00 /hr -170.40
Paint Supplies -2.4 hrs @ $ 50.00 /hr -120.00
Additional Supplement Materials/Supplies 115.00
Subtotal -296.10
Sales Tax $ -5.00 @ 8.3750 %-0.42
Total Supplement Amount -296.52
NET COST OF SUPPLEMENT -296.52
CUMULATIVE EFFECTS OF SUPPLEMENT(S)
Estimate 4,392.14 Sammy Ward
Supplement S01 -296.52 Sammy Ward
Job Total: $4,095.62
CUSTOMER PAY: $500.00
INSURANCE PAY: $3,595.62
10/5/2023 11:36:16 AM 308896 Page 5
Supplement of Record 1 with Summary
Customer: Martinez, Delmi
2009 HOND Pilot EX-L 4WD 4D UTV 6-3.5L Gasoline MPFI Silver
THIS REPORT IS AN ESTIMATE, BASED ON OUR INITIAL INSPECTION AND DOES NOT COVER ADDITIONAL PARTS
OR LABOR WHICH MAY BE REQUIRED AFTER THE WORK IS OPENED UP. PART PRICES SUBJECT TO CHANGE PER
THE MFGR.
LIFETIME WARRANTY ON WORKMANSHIP, 30 DAYS ON WHEEL ALIGNMENTS. WARRANTY WORK MUST BE
PERFORMED BY LAMETTRY'S COLLISION ONLY. PARTS WARRANTIED BY THE MANUFACTURER. ****NO
WARRANTY ON RUST RESTORATION, CORROSION RESISTANCE OR REPLACEMENT RENTAL CARS****** OUR
REPAIR ESTIMATED TIME DOES NOT INCLUDE INSURANCE OR PARTS DELAYS WE MAY EXPERIENCE.
A PERSON WHO SUBMITS AN APPLICATION OR FILES A CLAIM WITH INTENT TO DEFRAUD OR HELPS COMMIT A
FRAUD AGAINST AN INSURER IS GUILTY OF A CRIME IN MINNESOTA.
Minnesota Statutes 72A.201
"You have the legal right to choose a repair shop to fix your vehicle. Your policy will cover the reasonable
costs of repairing your vehicle to its pre-accident condition no matter where you have repairs made. Have you
selected a repair shop or would you like a referral?"
After an insured has indicated that the insured has selected a repair shop, the insurer must cease all
efforts to influence the insured's or claimant's choice of repair shop
Privacy Policy
LaMettry's is very sensitive to the importance of protecting the privacy of personally identifiable information regarding
our customers. PII refers to personal information that could be used to discover a person's identity or location.
LaMettry's endeavors to secure the privacy of PII obtained from our customers and limit disclosure of such
information to persons who need such information for the performance of services requested by our customers.
LaMettry's employees who are authorized to have access to customer PII are required to protect such information
from unauthorized disclosure and are only authorized to disclose such information to your insurer, our service
providers and others as needed to perform requested services. LaMettry's does not sell customer data or otherwise
distribute PII for any reason other than as needed to serve our customers. By sharing your PII with LaMettry's, you
consent to LaMettry's use of your PII in accordance with this Privacy Policy.
THE INSURANCE COMPANY PROVIDING THIS ESTIMATE DOES NOT AUTHORIZE REPAIRS. AUTHORIZATION MUST
COME FROM THE VEHICLE OWNER. ANY SUPPLEMENT(S) MUST HAVE PRIOR APPROVAL FROM A REPRESENTATIVE
OF THE INSURANCE COMPANY PROVIDING THIS ESTIMATE.
AMERICAN FAMILY INSURANCE GROUP AND ITS AFFILIATES (PERMANENT GENERAL COMPANIES) DO NOT
AUTHORIZE REPAIRS. AUTHORIZATION MUST COME FROM THE VEHICLE OWNER.
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.
10/5/2023 11:36:16 AM 308896 Page 6
Supplement of Record 1 with Summary
Customer: Martinez, Delmi
2009 HOND Pilot EX-L 4WD 4D UTV 6-3.5L Gasoline MPFI Silver
Estimate based on MOTOR CRASH ESTIMATING GUIDE and potentially other third party sources of data. Unless
otherwise noted, (a) all items are derived from the Guide ARG4456, CCC Data Date 09/18/2023, and potentially other
third party sources of data; and (b) the parts presented are OEM-parts. OEM parts are manufactured by or for the
vehicle's Original Equipment Manufacturer (OEM) according to OEM's specifications for U.S. distribution. OEM parts
are available at OE/Vehicle dealerships or the specified supplier. 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 with discounted pricing. Asterisk (*) or Double Asterisk (**) indicates that the parts and/or labor data
provided by third party sources of data 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, A/M or NAGS. 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 2023 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 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. Blnd=Blend. BOR=Boron steel.
CAPA=Certified Automotive Parts Association. D&R=Disconnect and Reconnect. HSS=High Strength Steel.
HYD=Hydroformed Steel. Incl.=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=Ultra High Strength Steel. N=Note(s) associated with the estimate line.
CCC ONE Estimating - A product of CCC Intelligent 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.
10/5/2023 11:36:16 AM 308896 Page 7
Supplement of Record 1 with Summary
Customer: Martinez, Delmi
2009 HOND Pilot EX-L 4WD 4D UTV 6-3.5L Gasoline MPFI Silver
PARTS SUPPLIER LIST
Line Supplier Description Price
3 LKQ Corp #~363946694 $ 212.00
26548 Chippendale Ave. West LKQ bumper assy +30%
Northfield MN 55057 Bumper Cover - Front EXL,5DR EX-L (LEATHER),S#$N0610
(651) 460-6166 Quote: 2206662092
Expires: 11/18/23
10/5/2023 11:36:16 AM 308896 Page 8
Bumper
Claim Reference Id:01006330565-1
File Name:PHOTO1
File Date:09/01/2023
Label:Bumper
Note:Owner:Delmi,Martinez|Style:2009,HOND,Pilot EX-L
4WD|Insured:Delmi,Martinez|LossDate:06/18/2023|Sho
pName:LaMettry's Collision, Glass and More
Photo Location:LaMettry's Collision, Glass and Mor
Photo Taken By:Sammy Ward
Estimate Indicator:E01
Front Bumper
Claim Reference Id:01006330565-1
File Name:PHOTO8
File Date:09/01/2023
Label:Front Bumper
Note:Owner:Delmi,Martinez|Style:2009,HOND,Pilot EX-L
4WD|Insured:Delmi,Martinez|LossDate:06/18/2023|Sho
pName:LaMettry's Collision, Glass and More
Photo Location:LaMettry's Collision, Glass and Mor
Photo Taken By:Sammy Ward
Estimate Indicator:E01
Front Bumper
Claim Reference Id:01006330565-1
File Name:PHOTO16
File Date:09/01/2023
Label:Front Bumper
Note:Owner:Delmi,Martinez|Style:2009,HOND,Pilot EX-L
4WD|Insured:Delmi,Martinez|LossDate:06/18/2023|Sho
pName:LaMettry's Collision, Glass and More
Photo Location:LaMettry's Collision, Glass and Mor
Photo Taken By:Sammy Ward
Estimate Indicator:E01
Front door
Claim Reference Id:01006330565-1
File Name:PHOTO14
File Date:09/01/2023
Label:Front door
Note:Owner:Delmi,Martinez|Style:2009,HOND,Pilot EX-L
4WD|Insured:Delmi,Martinez|LossDate:06/18/2023|Sho
pName:LaMettry's Collision, Glass and More
Photo Location:LaMettry's Collision, Glass and Mor
Photo Taken By:Sammy Ward
Estimate Indicator:E01
FT Body side molding
Claim Reference Id:01006330565-1
File Name:PHOTO3
File Date:09/01/2023
Label:FT Body side molding
Note:Owner:Delmi,Martinez|Style:2009,HOND,Pilot EX-L
4WD|Insured:Delmi,Martinez|LossDate:06/18/2023|Sho
pName:LaMettry's Collision, Glass and More
Photo Location:LaMettry's Collision, Glass and Mor
Photo Taken By:Sammy Ward
Estimate Indicator:E01
lf d martinez
Claim Reference Id:01006330565-1
File Name:PHOTO17
File Date:09/01/2023
Label:lf d martinez
Note:Owner:Delmi,Martinez|Style:2009,HOND,Pilot EX-L
4WD|Insured:Delmi,Martinez|LossDate:06/18/2023|Sho
pName:LaMettry's Collision, Glass and More
Photo Location:LaMettry's Collision, Glass and Mor
Photo Taken By:Sammy Ward
Estimate Indicator:E01
LT FT
Claim Reference Id:01006330565-1
File Name:PHOTO20
File Date:10/04/2023
Label:LT FT
Note:Heat Map
Photo Location:
Photo Taken By:Smart Review
Estimate Indicator:E01
LT FT
Claim Reference Id:01006330565-1
File Name:PHOTO20
File Date:09/01/2023
Label:LT FT
Note:Owner:Delmi,Martinez|Style:2009,HOND,Pilot EX-L
4WD|Insured:Delmi,Martinez|LossDate:06/18/2023|Sho
pName:LaMettry's Collision, Glass and More
Photo Location:LaMettry's Collision, Glass and Mor
Photo Taken By:Sammy Ward
Estimate Indicator:E01
LT R
Claim Reference Id:01006330565-1
File Name:PHOTO2
File Date:10/04/2023
Label:LT R
Note:Heat Map
Photo Location:
Photo Taken By:Smart Review
Estimate Indicator:E01
LT R
Claim Reference Id:01006330565-1
File Name:PHOTO2
File Date:09/01/2023
Label:LT R
Note:Owner:Delmi,Martinez|Style:2009,HOND,Pilot EX-L
4WD|Insured:Delmi,Martinez|LossDate:06/18/2023|Sho
pName:LaMettry's Collision, Glass and More
Photo Location:LaMettry's Collision, Glass and Mor
Photo Taken By:Sammy Ward
Estimate Indicator:E01
Mirror
Claim Reference Id:01006330565-1
File Name:PHOTO9
File Date:09/01/2023
Label:Mirror
Note:Owner:Delmi,Martinez|Style:2009,HOND,Pilot EX-L
4WD|Insured:Delmi,Martinez|LossDate:06/18/2023|Sho
pName:LaMettry's Collision, Glass and More
Photo Location:LaMettry's Collision, Glass and Mor
Photo Taken By:Sammy Ward
Estimate Indicator:E01
Mirror
Claim Reference Id:01006330565-1
File Name:PHOTO6
File Date:09/01/2023
Label:Mirror
Note:Owner:Delmi,Martinez|Style:2009,HOND,Pilot EX-L
4WD|Insured:Delmi,Martinez|LossDate:06/18/2023|Sho
pName:LaMettry's Collision, Glass and More
Photo Location:LaMettry's Collision, Glass and Mor
Photo Taken By:Sammy Ward
Estimate Indicator:E01
Mirror
Claim Reference Id:01006330565-1
File Name:PHOTO10
File Date:09/01/2023
Label:Mirror
Note:Owner:Delmi,Martinez|Style:2009,HOND,Pilot EX-L
4WD|Insured:Delmi,Martinez|LossDate:06/18/2023|Sho
pName:LaMettry's Collision, Glass and More
Photo Location:LaMettry's Collision, Glass and Mor
Photo Taken By:Sammy Ward
Estimate Indicator:E01
Molding
Claim Reference Id:01006330565-1
File Name:PHOTO18
File Date:09/01/2023
Label:Molding
Note:Owner:Delmi,Martinez|Style:2009,HOND,Pilot EX-L
4WD|Insured:Delmi,Martinez|LossDate:06/18/2023|Sho
pName:LaMettry's Collision, Glass and More
Photo Location:LaMettry's Collision, Glass and Mor
Photo Taken By:Sammy Ward
Estimate Indicator:E01
ODO
Claim Reference Id:01006330565-1
File Name:PHOTO15
File Date:09/01/2023
Label:ODO
Note:Owner:Delmi,Martinez|Style:2009,HOND,Pilot EX-L
4WD|Insured:Delmi,Martinez|LossDate:06/18/2023|Sho
pName:LaMettry's Collision, Glass and More
Photo Location:LaMettry's Collision, Glass and Mor
Photo Taken By:Sammy Ward
Estimate Indicator:E01
Rear Side Molding
Claim Reference Id:01006330565-1
File Name:PHOTO22
File Date:09/01/2023
Label:Rear Side Molding
Note:Owner:Delmi,Martinez|Style:2009,HOND,Pilot EX-L
4WD|Insured:Delmi,Martinez|LossDate:06/18/2023|Sho
pName:LaMettry's Collision, Glass and More
Photo Location:LaMettry's Collision, Glass and Mor
Photo Taken By:Sammy Ward
Estimate Indicator:E01
RT Fender
Claim Reference Id:01006330565-1
File Name:PHOTO21
File Date:09/01/2023
Label:RT Fender
Note:Owner:Delmi,Martinez|Style:2009,HOND,Pilot EX-L
4WD|Insured:Delmi,Martinez|LossDate:06/18/2023|Sho
pName:LaMettry's Collision, Glass and More
Photo Location:LaMettry's Collision, Glass and Mor
Photo Taken By:Sammy Ward
Estimate Indicator:E01
RT FT
Claim Reference Id:01006330565-1
File Name:PHOTO13
File Date:10/04/2023
Label:RT FT
Note:Heat Map
Photo Location:
Photo Taken By:Smart Review
Estimate Indicator:E01
RT FT
Claim Reference Id:01006330565-1
File Name:PHOTO13
File Date:09/01/2023
Label:RT FT
Note:Owner:Delmi,Martinez|Style:2009,HOND,Pilot EX-L
4WD|Insured:Delmi,Martinez|LossDate:06/18/2023|Sho
pName:LaMettry's Collision, Glass and More
Photo Location:LaMettry's Collision, Glass and Mor
Photo Taken By:Sammy Ward
Estimate Indicator:E01
RT FT Door
Claim Reference Id:01006330565-1
File Name:PHOTO5
File Date:09/01/2023
Label:RT FT Door
Note:Owner:Delmi,Martinez|Style:2009,HOND,Pilot EX-L
4WD|Insured:Delmi,Martinez|LossDate:06/18/2023|Sho
pName:LaMettry's Collision, Glass and More
Photo Location:LaMettry's Collision, Glass and Mor
Photo Taken By:Sammy Ward
Estimate Indicator:E01
RT Mirror
Claim Reference Id:01006330565-1
File Name:PHOTO23
File Date:09/01/2023
Label:RT Mirror
Note:Owner:Delmi,Martinez|Style:2009,HOND,Pilot EX-L
4WD|Insured:Delmi,Martinez|LossDate:06/18/2023|Sho
pName:LaMettry's Collision, Glass and More
Photo Location:LaMettry's Collision, Glass and Mor
Photo Taken By:Sammy Ward
Estimate Indicator:E01
RT Qtr panel
Claim Reference Id:01006330565-1
File Name:PHOTO11
File Date:09/01/2023
Label:RT Qtr panel
Note:Owner:Delmi,Martinez|Style:2009,HOND,Pilot EX-L
4WD|Insured:Delmi,Martinez|LossDate:06/18/2023|Sho
pName:LaMettry's Collision, Glass and More
Photo Location:LaMettry's Collision, Glass and Mor
Photo Taken By:Sammy Ward
Estimate Indicator:E01
RT Qtr Panel
Claim Reference Id:01006330565-1
File Name:PHOTO12
File Date:09/01/2023
Label:RT Qtr Panel
Note:Owner:Delmi,Martinez|Style:2009,HOND,Pilot EX-L
4WD|Insured:Delmi,Martinez|LossDate:06/18/2023|Sho
pName:LaMettry's Collision, Glass and More
Photo Location:LaMettry's Collision, Glass and Mor
Photo Taken By:Sammy Ward
Estimate Indicator:E01
RT Qtr Panel & Rear Bumper
Claim Reference Id:01006330565-1
File Name:PHOTO4
File Date:09/01/2023
Label:RT Qtr Panel & Rear Bumper
Note:Owner:Delmi,Martinez|Style:2009,HOND,Pilot EX-L
4WD|Insured:Delmi,Martinez|LossDate:06/18/2023|Sho
pName:LaMettry's Collision, Glass and More
Photo Location:LaMettry's Collision, Glass and Mor
Photo Taken By:Sammy Ward
Estimate Indicator:E01
RT R
Claim Reference Id:01006330565-1
File Name:PHOTO19
File Date:10/04/2023
Label:RT R
Note:Heat Map
Photo Location:
Photo Taken By:Smart Review
Estimate Indicator:E01
RT R
Claim Reference Id:01006330565-1
File Name:PHOTO19
File Date:09/01/2023
Label:RT R
Note:Owner:Delmi,Martinez|Style:2009,HOND,Pilot EX-L
4WD|Insured:Delmi,Martinez|LossDate:06/18/2023|Sho
pName:LaMettry's Collision, Glass and More
Photo Location:LaMettry's Collision, Glass and Mor
Photo Taken By:Sammy Ward
Estimate Indicator:E01
Vin
Claim Reference Id:01006330565-1
File Name:PHOTO7
File Date:09/01/2023
Label:Vin
Note:Owner:Delmi,Martinez|Style:2009,HOND,Pilot EX-L
4WD|Insured:Delmi,Martinez|LossDate:06/18/2023|Sho
pName:LaMettry's Collision, Glass and More
Photo Location:LaMettry's Collision, Glass and Mor
Photo Taken By:Sammy Ward
Estimate Indicator:E01
| | | Clm: 01-006-330565 MN | Ins: Delmi Martinez | DoL: 06/18/2023 | Pol: 410352406037 | St:
Open | Adj: Stacy MacKenzie (Subrogation Auto Team 1)
Financials (Total Incurred: $3,595.62): Transactions
Payments
Scheduled
Send Date
Issue Date Amount Exposure Coverage Cost Type Status Pmt Type Check
Number
Pay To
10/31/2023 11/06/2023 $3,595.62 1 Collision Loss Cost Submitted Supplement 0008484630 Delmi
Martinez
User: Stacy MacKenzie Page 1 11/17/2023 11:30 AM