Kemp ^c��n ,�`�� - S�/
- �i�=`��1���'
� - ��CEI�i��+
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NOTICE OF CLAIlV��'��`�o the City c���'����ul, Minnesota
Minnesota State Statiite�F66.05 srates tlaat °...every person...tivlao cdaims damages from any municipaliry...shall cause to be presented to the
governing body of t/ie inunicipaliry within 180 days after the alleged loss or•injury is discovered a notice stating tlie time,place,and
circumstnnees thereof,and the amount of compensa�ion or otlaer 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�(��t'��(a �� Middle Initial Last Name' �S� i�- �'�1CL(cf,��� 1�-e V�,�--
Company or Business Name
Are You an Insurance Company? Yes/No If Yes, Claim Number? ��� —v�/�.� -�s�
Street Address E.%• �L%1L ��'7�
City T�l'�iU�.�st . State � Zip Code(0�7U� o?,��//
%-e�m Gc 0
Daytime Phone (�)�,"j-�(�Cell Phone ( ) - Evening Telephone( ) -
Date of Accident/Injury or Date Discovered l� �'7 '�� Time �� ��U /pm
Please state, in detail, what occurred (happened), and why you are submitting a claim. Please indic te wh or how you
fe the City of Saint Paul or its employees are involved and/or responsible for your damages. � �/Z•
o Lc`c,c E/.8 ls��.— /f Gi r, n�i� .(/�'-�-,�; cl1!1�,r,(�,.,f:,.� Iirw L, i C%L r�Q LLt� l�
� —
Please check the box(es)that most closely represent the reason for completing this form:
t�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 you need to include copies of all apulicable 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 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—please complete this section
Were there wimesses to the incident? Yes �� Unknown (circle)
Provide their names, addresses and telephone numbers:
Were the police ar law enforcement called� � �re� No Unknown (circle)
If yes, what department or agency? �f.�� Case#or report# I�.��-r,'Q/
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.,�{ D.�•
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.,�1�1,. '7�(0 �1
Vehicle Claims—Alease complete this section ❑ check box if this section does not applv
Your Vehicle: Year c-�v�1 Make �Tb�y,��C� Model �u-r,u-�. _ � ?C L Z-
License Plate Numb r State�_Color (��i,t,+,Il
Registered Owner ./i � � '�� CE�i�
Driver of Vehicle��;,—,
Area Damaged �c� -��u�
City Vehicle: Year a�'� Make �n«, Model TS�
License Plate Number G'j//7 L/ State�_Color r,1,r l���
Driver of Vehicle (Ci�jy Employee's Name) �] �Q�-H /Vl�lr,e i�y
AreaDamaged P/5 ihU� d��-L��--
InjurV Claims—please complete this section �Vcheck box if this section does not apply
How were you injured? /YU
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 ,j--/-�n/�
Print the Name of the Person who Completed this Form: � L � -t
Signature of Person Making the Claim: ' �t�t��, C2 Q �TITU ��
� Sfv r�i�au�- �� �e�r� .
Revised February 20ll
Fam W�9 Request for Taxpayer Give Form to the
��,.�.�m��2°„� Identitication Number and Certification �`'��'°o"�
pepartmerrt of the Treasury send to the IRS.
Irrtemai Reverxie SefviCe
Name(as shown on your income tax retum)
State Farm Mutual Automobile I�surance Company
8usiness name/disreg�ded emity name,if different from above
N
m
�
W
a Chedc appropriate box fa federal tax dassification:
c
� ❑ IndividuaUsole proprie2or 0 C Corpordtion ❑S Corporation ❑ Partnership ❑TrusVestate
�a
e
o �Exempt payee
�� � Limited li�ility comparry.EMer the tax classification(C=C corporation,S=S corporation,P=parfie►shiP)►
0 -------------------------------
« a
a� ❑ Other(see instructions)►
� Address(n�xnber,street,and apt.or suite no.) Requester's name and address(optiona�
v
a 1 State Farm Plaza
m City,state,and ZIP code
N Bloomington,IL 61710
List accowrt number(s)here(optiona�
Taxpayer ldentrf'ication Number(TIN)
Enter your TIN in the appropriate box.The TIN provided must match the name given on the"Name"line Social securiqr m,mber
to avoid backup withholding.For individuals,this is your social security number{SSt�.However,for a � _m _��
resident alien,sole proprietor,or disregarded entiry,see the Part I instructions on page 3.For other
entities,it is your employer identification number(EII�.If you do not have a number,see How to get a
TIN on page 3.
Note.If the account is in more than one name,see the chart on page 4 for guidelines on whose Employer identifieation number
number to enter.
3 7 — 0 5 3 3 1 0 0
Certification
Under penalties of perjury,!certify that:
1. The number shown on this form is my correct taxpayer identification number(or I am waiting for a number to be issued to me),and
2. I am not subject to backup withholding because:(�I am exempt from backup withhold'+ng,or(b)I have not been notified by the Intemal Revenue
Service(IRS)that I am subject to backup withholding as a result of a failure to report all interest or dividends,or(c)the IRS has notified me that 1 am
no longer subje�t to backup withholding,and
3. I am a U.S.citizen or other U.S.person(defined below).
Certification inatnictions.You must cross out item 2 above if you have been notified by the IRS that you are curnently subject to backup withholding
because you have failed to report all interest and dividends on your tax retum.For real estate transactions,item 2 does not appy.For mortgage
irrterest paid,acquisition or abandonm�t of secured property,cancellation of debt,coMributions to an indlvidual retirement arrangement(IRA),and
generally,payments other than interest and dividends,you are not required to sign the certification,but you must provide your coRect TIN.See the
instructions on page 4.
_ S� �.'�� c �n,��x�t� ��� ►�► I �a� (�I a
_ ,
General Instructions Note.If a requester gives you a form other than Form W-9 to raquest
your TIN,you must use the requester's form if it is substantially similar
Section refe►ences are to the Intemal Revenue Code unless otherwise to this Form W-9.
noted. Deflnition oi a U.S.person.For federal tax purposes,you are
Purpose of Form considered a U.S.person if you are:
A person who is required to file an information retum with the IRS must •An Individual who is a U.S.citizen or U.S.resident alien,
obtain your correct taxpayer identification number(TIN)to report,fa •A partnership,corporation,company,or association created or
example,income paid to you,real estate transactions,mortgage interest organized in the United States or under the laws of the United States,
you paid,acquisttion or aba�donmerrt of secured property,cancellation .q���te(other than a foreign estate),or
of debt,or contr'ibutions you made to an IRA .A domestic trust(as defined in Reguiations section 301.7701-�.
Use Form W-9 onlY'rf yau are a U.S.person(fncluding a resident �������fa�����,p�nerships that conduct a trede or
alien),to provide your correct TIN to the person requesting it(the business in the United States are generally required to pay a withholding
requeste�and,when applicable,to: tax on any foreign partners'share of income from such business.
1.Certify that the TIN you are giving is correct(or you are waiting for a Further,in certain cases where a Form W-9 has not been recelved,a
number to be issue�, partnership is required to presume that a partner is a foreign person,
2.Certify that you are not subject to backup withholding,or and pay the withholding tax.Therefore,if you are a U.S.person that is a
3.Claim exemption from backup withholding if you are a U.S.exempt Pa*mer�n a partne.rship conducting a trade or business in the United
States,provide Form W-9 to the partnership to establish your U.S.
payee.If applicable,you are also certifying that as a U.S.person,Your status and awid withholding on your share of partnership income.
allxable share of any partnership income from a U.S.trade or business
is not subject to the withholding tax on foreign partners'share of
effectively connected income.
Cat.No.10231X Fam W-9(Rev.12-2011)
1hwc.i �..�...r. .� . _. �. �.. _ _ _ _ _ _ _ _ _ _ _ _. :w .
t StAt@ FAt'tt1� �r.t�ra�r
Providing Insurance and Financial Services
Home Office, Bloomington,Illinois 51710 �NfYLLANtffi
March 01, 2012
City Of St Paul State Farm Claims
Office Of City Clerk P.O. Box 2371
310 City Hall Bloomington IL 61702-2371
15 Kellogg Blvd., West
Saint Paul MN 55102
, Certified Mail-Return Receipt Requested ''
RE: Claim Number: 23-047S-551
Our Insured: Richard E Kemp
Date of Loss: 10/07/2011
Your Insured: St Paul Police Department
Your Insured Driver: Matt Morreim
Loss Location: 10th And St Peter, St Paul, MN
To Whom It May Concern:
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 $0
042 - Uninsured Motorist PD $0
300 series/400 - Comp/Collision $14,226.81
501 - Rental/Loss of Use $0
600-050 - Med Pay/PIP $0
Other $0
Salvage Recovery $0
Amount State Farm Paid $14,226.81
Insured Deductible $500.00
Total Claim Amount $14,726.81
Based on the assessment of liability between the parties, State Farm Mutual Automobile
Insurance Company is seeking 100% of the Total Claim Amount listed above. The amount
payable to State Farm Mutual Automobile Insurance Company for this loss is $14,726.81.
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.
23-047S-551
Page 2
March 01, 2012
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
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,
�
S cey L Vandegraft
Claim Processor
(877) 457-8276 Team 60 Ext. 55023
State Farm Mutual Automobile Insurance Company
Enclosure
_ �
**HEADER PAGE**
Casey Scheuer 23-0475-551
Printed: 15:53:16 March/06/2012
Product Line: Auto
Claim Number: 23-047S-551
Insured Name: KEMP, RICHARD
Requestor Name: Casey Scheuer
Alias: MBIU
Printer: CPCL2580
Comments:
I'
�
Luther Collision and Glass - Brooklyn Workfile ID: 24aa97a1
FederallD: 20-2714423
Park State ID: 7765216
8509 XYLON AVE N, BR0014YN PARK, MN 55445
Phone: (763) 493-2700
Supplement of Record
Customer: KEMP, RI CHARD E
Written By: HOWIE EMERY, 11/11/2011 4:37:57 PM
Adjuster: TEAM R2 ACC CR, (888)248-6961 Business
Insured: KEMP, RICHARD E Policy#: Claim#: 23-0475-55101
Type of Loss: OOLL-Collision Date of Loss: 10/7/2011 12:00:00 AM Days to Repair: 18
Point of Impact: 11 Left Front
Owner: I nspection Location: I nsurance Company:
KEMP, Po CHARD E Other STATE FARM I NSURANCF COMPANI ES
2801 87TH TRL N State Farm
BROOKLYN PARK, MN 55443-3746 PO BOX 82613
(763)424-6287 Evening LINCOLN, NE68501-2613
(612)296-4469 Day (888)248-6961 Business
Vehicle Drop Off Date: 10/07/2011 Promise Date: 11/02/2011 Repair Start Date: 10/10/2011
Repair Completion Date: 11/11/2011 Vehicle Pick Up/Return 11/11/2011
Date: I
I
VEHICLE
Year: 2011 Body Style: 4D SED VI N: 4T1 BK3EIOBU121690 Mileage I n: 27727
Make: TOYO Engine: 6-3.5L-FI License: 385NC Mileage Out:
Model: CAMRY XLE Production Date: State: MN Vehicle Out: I
Color: black Int: Condition: Job#: li
il
4 Wheel Disc Brakes Quise Control Overdrive Search/Seek i
Air Conditioning Digital qock Passenger Air Bag Steering Wheel Controls
AM Radio Driver Air Bag Power Brakes Stereo
Anti-Lock&akes(4) Dual Mirrors Power Driver Seat Telescopic Wheel
Automatic Transmission FM Radio Power Locks Tilt Wheel
Bucket Seats Front Side Impact Air Bags Power Mirrors Tinted Glass
CD Player Full Wheel Covers Power Steering Traction Control
CJear Coat Paint I ntermittent Wipers Power Trunk/Tailgate
Goth Seats Keyless Entry Power Windows
Console/Storage Lumbar Adjustment Rear Defogger
11/11/2011 4:37:57 PM 014557 Page 1
Supplement of Record
Customer: KEMP, RI CHARD E
Vehicle: 2011 TOYO CAMRY XLE 4D SED 6-3.5L-FI black
Line Operation Description Qty Extended Labor Paint
Price$
1 # Rpr SET UP&MEASURE 1.0
N 2 # Rpr PULL&SQUARE FRONT UNI BODY 7.0 F
3 # Rpr Pinch welds 0.5 0.5
4 PI LLARS, ROCKER&FLOOR
5 R&I RT Rocker molding black I nd.
6 R&I LT Rocker molding black Ind.
7 FRONT BUMPER&GW LLE
8 O/H front bumper 2.3
N 9 "' Repl REOOND Bumper cover US built w/o SE 1 226.00 I ncl. 2.6
10 Add for Qear Coat 1.0
11 Repl License bracket 1 68.27 0.2
12 Repl Upper seal US built 1 44.22 I nd.
13 Repl Upper retainer US built 1 55.71 I ncl.
14 Repl Emblem 1 41.09 Incl.
15 Repl RT Side support 1 33.50 0.1
16 Repl LT Side support 1 33.50 0.1
17 Repl Energy absorber US built 1 43.18 I nd.
18 Repl Reinf beam US Built 1 165.98 I ncl.
19 ' Repl Qille US built,XLE black 1 209.52 I nd.
20 Repl LT Hole cover US built w/XLE 1 28.19 I nd.
21 FRONT LAMPS
22 S01 Repl LT Headlamp assy Base, LE, XLE 1 355.20 0.5
23 S01 Aim headlamps 0.5
24 Repl RT Headlamp grommet 1 0.95
25 Repl LT Headlamp grommet 1 0.95
26 Repl LT Fog lamp assy US built 1 161.56 0.2
27 # Repl Fog lamp plug 1 15.00 0.4
N 28 S01 Repl RT Headlamp assy Base, LE,XLE 1 355.20 0.5 I
29 RADIATOR SUPPORT '
30 Repl Radiator support 1 495.52 s 8.4 1.8 �i
31 Evacuate&recharge m 1.4 M '
32 Refrigerant recovery m 0.4 M
33 Add for auto trans 2.4 liter m 0.2 M I
34 Repl LT Under cover US built 1 98.21 I ncl. I
35 Repi LT Deflector 1 56.78 0.1 I
36 COOLI NG
N 37 " Repl A/M Radiator assy w/o towing pkg US built 1 170.00 m I nG.
3g Add for auto trans m 0.2
39 # Repl Coolant 1 19.00
40 Repl Control module w/o towing pkg 1 320.02 m 0.2
41 Repl Fan shroud w/o towing pkg US built 1 72.32 m 0.8
42 AI R CONDITI ONER&HEATER
43 " Repl A/M Condenser assy 1 161.00 m I ncl.
11/11/2011 4:37:57 PM 014557 Pa9e 2
Supplement of Record
Customer: KEMP, RI CHARD E
Vehicle: 2011 TOYO CAMRY XLE 4D SED 6-3.5L-FI bladc
44 # Repl R134A&oil 1 14.95
45 HOO�
46 Repl Hood 1 497.51 1.8 2.8
47 Add for Underside(Complete) 1.4
48 Repl RT Hinge US built 1 33.39 0.7 0.3
49 Repl LT Hinge US built 1 33.39 0.7 0.3
50 Repl Latch assy Japan built XLE 1 72.09 Incl.
51 ENGINE/TRANSAXLE
52 Repl Engine cover US built 1 211.73 0.2
N 53 Repl Air deaner assy US built 1 609.41 m I ncl.
54 S01 Repl R&I engine/trans assy 1 m 12.0 M
55 # S01 deduct overlap front pipe 1 -0.8 M
56 FENDER
57 Repl RT Fender 1 227.82 2.2 1.8
58 Overlap Major Adj. Panel -0.4
59 Add for Edging 0.5
60 Deduct for Overlap -0.6
61 Deduct for Overlap -0.4
62 Repl LT Fender 1 227.82 2.2 1.8
63 Overlap Major Adj. Panel -0.4
64 Add for Edging 0.5
65 Deduct for Overlap -0.6
66 Dedud for Overlap -0.4
67 Repl LT Fender liner 1 85.31 I ncl.
68 Repl LT Opening extn 1 27.38 0.1
69 Repl LT Front extn 1 43.87 2.5 0.4
70 Repl LT Rate 1 19.39 0.8 0.2
71 ` Rpr LT Front panel s 2_0 0_5
72 Overlap Minor Panel -0.2
73 ' Rpr LT Upper rail s 2_0 0_4
74 Overlap Minor Panel -0.2
75 ' Rpr RT Upper rail s 2_0 0_4
76 Overlap Minor Panel -�•z
77 ' f�r RT Front panel s 1_0 0_5
78 Overlap Minor Panel -0•2
79 Repl LT Rail extn 1 57.81 s 1.5 0.4
N 80 "' Rpr LT I nner rail(HSS) 3_0 0_5
81 ' Repl LT Rail end(HSS) 1 58.15 1_0 0_2
N 82 "' Repl LT Outer rail(HSS) 1 153.92 2_0 0_4
83 Repl LT Front bradcet 1 15.29 0.3 0.2
84 FRONT DOOR
g5 * Rpr LT Outer panel 3_0 2.0
gg Overlap Major Adj. Panel -0.4
g7 R&I LT Beit molding 0.3
gg R&I LT R&I mirror 0.4
11/11/2011 4:37:57 PM 014557 Page 3
Supplement of Record
Customer: KEMP, RI CHARD E
Vehicle: 2011 TOYO CAMRY XLE 4D SED 6-3.5L-FI black
89 "' R&I LT Handie,outside US built,w/Smart Key bladc 0_3
90 R&I LT R&i trim panel 0.6
91 REAR DOOR
92 ' Rpr LT Outer panel 5_0 2.0
93 Overlap Major Adj. Panel -0.4
94 aear Coat 2.5
95 R&I LT Belt molding 0.3
96 R&I LT R&I outside handle 0.3
97 R&I LT R&I trim panel 0.5
98 MI SCELLANEOUS OPERATI ONS
99 * Repl Cover car/bag 1 0_2
100 # Refn OORROSION PROTECTI ON 0.6
101 # Repl FLIX ADDI TI VE 1 3.00 X
102 # Subl HAZARDOUS WASTE REMOVAL 1 3.00 X
103 # S01 Repl Seam sealer 1 43.20 I ncl.
104 # S01 Repl Retainers 1 35.28
105 STEERI NG GEAR&LI NKAGE
106 R&I Reservoir assy m 0.5
107 ELEGTRI CAL
108 R&I Battery 550 cca m I nd. �
N 109 ' R&I Junction blodc US built 3.5 liter 0:4
N 110 ' RB�I Actuator w/stability control Japan built m 0_5
111 WINDSHIELD
112 R&I Washer reservoir I ncl.
113 COWL
114 R&I Cowl vent panel 0.8
115 # Subl 4 wheel alignment 1 89.95 X
116 ' S01 Rpr Cowl top panel 1_5
117 S01 FRONT SUSPENSI ON
N 118 ' S01 Repl LKQ sub frame+30% 1 1.300.00 m 6.4 M
119 # S01 deduct overlap 1 -1.5 M
120 # S01 Subl Recalibrate yaw sensor 1 205.00 X
121 S01 EMISSION SYSTEM
122 ' S01 Repl Vacuum valve 1 55.37 0_5 M
123 S01 I NFORMATI ON LABELS
124 S01 Repl FJnission label 3.5 liter from 2/2010 1 1.03 0.2
125 S01 Rpl information labels 0.3
126 S01 Repl Plate cooling fan caution 1 1.47 Incl.
127 S01 Repl Caution label cooling fan 1 1.18 Incl.
128 S01 Repl AC label 1 0.58 I nd.
129 S01 Repl Eng info label 1 1.09 I ncl.
SUBTOTALS 7,360.25 80.5 24.3
NOTES
Line 2: HARD SWAY/ SAG BOTH RAI LS/ MASH AND BUCKLE LT RAI L
11/11/2011 4:37:57 PM 014557 Page 4
Supplement of Record
Customer: KEMP, RI CHARD E
Vehicle: 2011 TOYO CAMRY XLE 4D SED 6-3.5L-FI black
Line 9: THRU KEYSTONE 612-789-1919
Line 28: RECON HDLPS RET'URNED QUALI TY I SSUES
Line 37: 1 800 radiator
Line 53: CHECKED W AAA/ CERTI FI ED FOR LKQ
Line 80: after pull may require replacement
Line 82: TO FACI LI TATE RAI L REPAi RS
Line 109: loosen fron apron for aocess ,
Line 110: loosen from apron �
Line 118: certified recyclers 763-434-7000
LABOR Time includes R&R stabilizer bar,front pipe, and under covers.
ESTI MATE TOTALS
Category Basis Rate Cost $
Parts 7,059.30
Body Labor 54.9 hrs @ $50.00/hr 2,745.00
Paint Labor 24.3 hrs @ $50.00/hr 1,215.00
Mechanical Labor 18.6 hrs @ $90.00/hr 1,674.00
Frame Labor 7.0 hrs @ $70.00/hr 490.00
Paint Supplies 24.3 hrs @ $30.00/hr 729.00
Miscellaneous 300.95
Subtotal 14,213.25
Sales Tax $7,059.30 @ 7.2750% 513.56
Grand Total 14,726.81
Deductible 500.00
CUSTOMER PAY 500.00
I NSURANCE PAY 14,226.81
11/11/2011 4:37:57 PM 014557 Page 5
� Supplement of Record
Customer: KEMP, RI CHARD E
Vehicle: 2011 TOYO CAMRY XLE 4D SED 6-3.5L-FI black
SUPPLEMENT SUMMARY
Line Operation Description Qty 6ctended Labor Paint
Price $
Changed I tems
N 52 Repl Air cleaner assy US built 1 -609.41 m -0.5
N 53 S01 Repl Air cleaner assy US built 1 609.41 m I ncl.
Deleted I tems
4 # Rpr Loosen&realign cradle -1.0
N 23 " Repl REOOND RT Headlamp 1 -302.00 -0.5
N 24 ** Repl RECOND LT Headlamp 1 -302.00 -0.5
Added I tems
22 S01 Repl LT Headlamp assy Base, LE, XLE 1 355.20 0.5
23 S01 Aim headlamps 0.5
N 28 S01 Repl RT Headlamp assy Base, LE,XLE 1 355.20 0.5
54 S01 Repl R&I engine/trans assy 1 m 12.0 M
55 # S01 deduct overlap front pipe 1 -0.8 M
103 # S01 Repl Seam sealer 1 43.20 I ncl.
104 # S01 Repl Retainers 1 35.28
116 ' S01 Rpr Cowl top panel 1_5
117 S01 FRONT SUSPENSI ON
N 118 ' S01 Repl LKQ sub frame+30% 1 1.300.00 m 6.4 M
119 # S01 deduct overlap 1 -1.5 M
120 # S01 Subl Recalibrate yaw sensor 1 205.00 X
121 S01 EMI SSI ON SYSTEM
122 ' S01 Repl Vacuum valve 1 55.37 0_5 M
123 S01 INFORMATION LABELS
124 S01 Repl Emission label 3.5 liter from 2/2010 1 1.03 0.2
125 S01 Rpl information labels 0.3
126 S01 Repl Plate cooling fan caution 1 1.47 incl.
127 S01 Repl Caution label cooling fan 1 1.18 I ncl.
128 S01 Repl AC label 1 0.58 I ncl.
129 S01 Repl Eng info label 1 1.09 I ncl.
SUBTOTALS 1,750.60 17.6 0.0
11/11/2011 4:37:57 PM 014557 Page 6
Supplement of Record
Customer: KEMP, RI CHARD E
Vehide: 2011 TOYO CAMRY XLE 4D SED 6-3.5L-FI black
TOTALS SU M M ARY
Category Basis Rate Cost $
Parts 1,545.60
Body Labor 1.0 hrs @ $50.00/hr 50.00
Mechanical Labor 16.6 hrs @ $90.00/hr 1,494.00
Miscellaneous 205.00
Subtotal 3,294.60
Sales Tax $ 1,545.60 @ 7.2750% 112.52
Additional Supplement Taxes -0.08
Total Supplement Amount 3,407.04
NET COST OF SUPPLEMENT 3,407.04
CUMULATI VE EFFECTS OF SUPPLEMENT(S)
Estimate 11,319.77 HOWIEEMERY
Supplement S01 3,407.04 HOWI E EMERY
Job Total: $ 14,726.81
CUSTOMER PAY: $ 500.00
I NSURANCE PAY: $ 14,226.81
MN ST 60A.955 - A PERSON WHO FI LES A CLAI M WI TH I NTENT TO DEFRAUD OR HELPS COMMI T A FRAUD AGAI NST
AN I NSURER I S GUI LTY OF A CRI ME
11/11/2011 4:37:57 PM 014557 �9e�
�
Supplement of Record
Customer: KEMP, RI CHARD E
Vehicle: 2011 TOYO CAMRY XLE 4D SED 6-3.5L-FI black
Estimate based on MOTOR C�ASH ESTI MATI NG GUI DE. Unless otherwise noted all items are
derived from the Guide ARM8522, CCC Data Date 11/8/2011, 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-I ncluded Labor operations. The symbol (<>) indicates the
refinish operation WI LL NOT be performed as a separate procedure from the other panels in the
estimate. Non-Original Equipment Manufacturer aftermarket parts are described as AM, Qual Repl
Parts or Comp Repl Parts which stands for Competitive Replacement Parts. Used parts are
described as LKQ, Qual Recy Parts, 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. Pbund sign (#) items indicate manual entries.
Some 2010 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 Pathways estimator has a complete list of applicable vehicles. Parts numbers
and prices should be confirmed with the local dealership.
OCC Pathways - A product of CCC I nformation Services I nc.
11/11/2011 4:37:57 PM 014557 Page g
Luther Collision and Glass - Brooklyn Workfile ID: 24aa97a1
Federal i D: 20-2714423
Park State ID: 7765216
8509 XYLON AVE N, BROOI�YN PARK, MN 55445
Phone: (763) 493-2700
Estimate of Record
Customer: KEMP, RI CHARD E
Written By: HOWI E EMERY, 10/10/2011 4:37:55 PM
Adjuster: TEAM R2 ACC CR, (888)248-6961 Business
Insured: KEMP, RICHARD E Policy#: Claim#: 23-047S55101
Type of Loss: COLL-Collision Date of Loss: 10/7/2011 12:00:00 AM Days to Repair: 18
Point of I mpact: 11 Left Front
Owner: I nspection Location: I nsurance Company:
KE1�AP, Po CHARD E Other STATE FARM I NSURANCE OOMPANI ES
2801 87TH TRL N State Farm
BROOKLYN PARK, MN 55443-3746 PO BOX 82613
(763)424-6287 Evening LINOOLN, NE68501-2613
(612)296-4469 Day (888)248-6961 Business
Vehicle Drop Off Date: 10/07/2011 Repair Start Date: 10/10/2011
VEHI CLE
Year: 2011 Body Style: 4D SED VI N: 4T1 BK3EIOBU121690 Mileage I n: 27727
Make: TOYO Engine: 6-3.5L-FI License: 385NC Mileage Out:
Model: CAMRY XLE Production Date: State: MN Vehicle Out:
Color: black Int: Condition: ,bb#:
4 Wheel Disc Brakes Quise Control Overdrive Search/Seek
Air Conditioning Digital Qock Passenger Air Bag Steering Wheel Controls
AM Radio Driver Air Bag Rower Brakes Stereo
Anti-Lock&akes(4) Dual Mirrors Power Driver Seat Telescopic Wheel
Automatic Transmission FM Radio Power Locks Tilt Wheel
Budcet Seats Front Side I mpact Air Bags Power Mirrors Tinted C�ass
CD Player Full Wheel Covers Power Steering Traction Control
pear Coat Paint I ntermittent Wipers Power Trunk/Tailgate
CJoth Seats Keyless Entry Power Windows
Console/Storage Lumbar Adjustment Rear Defogger
10/10/2011 4:37:56 PM 014557 Page 1
�
Estimate of Record
Customer: KEMP, RI CHARD E
Vehicle: 2011 TOYO CAMRY XLE 4D SED 6-3.5L-FI black
Line Operation Description Qty F�ctended Labor Paint
Price$
1 # Rpr SET UP&MEASIJRE 1.0
N 2 # Rpr PULL&SQUARE FRONT UNI BODY 7.0 F
3 # Rpr �inch welds 0.5 0.5
4 # F�r Loosen&realign cradle 1.0
5 PI LLARS, ROCKER&FLOOR
6 R&I RT Rocker molding black Incl. I!
7 R&I LT Rocker molding black I nd. I
8 FRONT BUMPER&C�21 LLE
9 O/H front bumper 2.3
N 10 *' Repl RECOND Bumper cover US built w/o SE 1 226.00 I ncl. 2.6
11 Add for Clear Coat 1.0
12 Repl License bracket 1 68.27 0.2
13 Repl Upper seal US built 1 44.22 I ncl.
14 Repl Upper retainer US built 1 55.71 I ncl.
15 Repl Emblem 1 41.09 Incl.
16 Repl RT Side support 1 33.50 0.1
17 Repi LT Side support 1 33.50 0.1
18 Repl Energy absorber US built 1 43.18 I nd.
19 Repl Reinf beam US Built 1 165.98 Incl.
20 ' Repl C�ille US built,XLE black 1 209.52 I ncl.
21 Repl LT Hole cover US built w/XLE 1 28.19 I ncl.
22 FRONT LAMPS
N 23 *' Repl REOOND RT Headlamp 1 302.00 0.5
N 24 " Repl RECOND LT Headlamp 1 302.00 0.5
25 Repl RT Headlamp grommet 1 0.95
26 Repl LT Headlamp grommet 1 0.95
27 Repl LT Fog lamp assy US built 1 161.56 0.2
28 # Repl Fog lamp plug 1 15.00 0.4
29 RADI ATOR SUPPORT
30 Repl Radiator support 1 495.52 s 8.4 1.8
31 Evacuate&recharge m 1.4 M
32 Refrigerant recovery m 0.4 M
33 Add for auto trans 2.4 liter m 0.2 M
34 Repl LT Under cover US built 1 98.21 I ncl.
35 Repl LT Deflector 1 56.78 0.1
36 OOOLI NG
N 37 "" Repl A/M Radiator assy w/o towing pkg US built 1 170.00 m Ind.
38 Add for auto trans m 0.2
39 # Repl Coolant 1 19.00
40 Repl Control module w/o towing pkg 1 320.02 m 0.2
41 Repl Fan shroud w/o towing pkg US built 1 72.32 m 0.8
42 AI R CONDI TI ONER&HEATER
43 '" Repl A/M Condenser assy 1 161.00 m Ind.
10/10/2011 4:37:56 PM 014557 Page 2
Estimate of Record
Customer: KEMP, RI CHARD E
Vehide: 2011 TOYO CAMRY XLE 4D SED 6-3.5L-FI bladc
44 # Repl R134A&oil 1 14.95
45 HOOD
46 Repl Hood 1 497.51 1.8 2.8
47 Add for Underside(Complete) 1.4
48 Repl RT Hinge US buiit 1 33.39 0.7 0.3
49 Repl LT Hinge US built 1 33.39 0.7 0.3
50 Repl Latch assy Japan built XLE 1 72.09 I ncl.
51 ENGINE/ TRANSAXLE
52 Repl Engine cover US built 1 211.73 0.2
N 53 Repl Air cleaner assy US built 1 609.41 m 0.5
54 FENDER
55 Repl RT Fender 1 227.82 2.2 1.8
56 Overlap Major Adj. Panel -0.4
57 Add for Edging 0.5
58 Dedud for Overlap -0.6
59 Deduct for Overlap -0.4
60 Repl LT Fender 1 227.82 2.2 1.8
61 Overlap Major Adj. Panel -0.4
62 Add for Edging 0.5
63 Deduct for Overlap -0.6
64 Deduct for Overlap -0.4
65 Repl LT Fender liner 1 85.31 I ncl.
66 Repl LT Opening extn 1 27.38 0.1
67 Repl LT Front extn 1 43.87 2.5 0.4
68 Repl LT Rate 1 19.39 0.8 0.2
69 ' Rpr LT Front panel s 2.0 0.5
70 Overlap Minor Panel -p.2
71 ' Rpr LT Upper rail s 2.0 0.4
72 Overlap Minor Panel -p.2
73 ' F�r RT Upper rail s 2_0 0_4
74 Overlap Minor Panel -0.2
75 ' Rpr RT Front panel s 1_0 0_5
76 Overlap Minor Panel -0.2
77 Repl LT Rail extn 1 57.81 s 1.5 0.4
N 78 ' Rpr LT I nner rail(HSS) 3_0 0_5
79 ' Repl LT Rail end(HSS) 1 58.15 1_0 0_2
N 80 ' Repl LT Outer rail(HSS) 1 153.92 2_0 0_4
81 Repl LT Front bradcet 1 15.29 0.3 0.2
82 FRONT DOOR
83 ' Rpr LT Outer panel 3_0 2.0
84 Overlap Major Adj. Panel -0.4
85 R&I LT Belt molding 0.3
86 R&I LT R&I mirror 0.4
87 ' R&I LT Handle, outside US built,w/Smart Key black 0_3
88 R&I LT R&I trim panel 0.6
10/10/2011 4:37:56 PM 014557 Page 3
Estimate of Record
Customer: KEMP, RI CHARD E
Vehicle: 2011 TOYO CAMRY XLE 4D SED 6-3.5L-FI bladc
89 REAR DOOR
90 " Rpr LT Outer panel 5_0 2.0
91 Overlap Major Adj. Panel -0.4
92 CJear Coat 2.5
93 R&I LT Belt molding 0.3
94 R&I LT R&I outside handle 0.3
95 R&I LT R&I trim panel 0.5
96 MI SCELLANEOUS OPERATI ONS
97 ' Repl Cover car/bag 1 0_2
98 # Refn CORROSION PROTEGTI ON 0.6
99 # Repl FLIX ADDI TI VE 1 3.00 X
100 # Subl HAZARDOUS WASTE REMOVAL 1 3.00 X I
101 STEERI NG GEAR&LI NKAGE
102 R&I Reservoir assy m 0.5
103 ELECTPo CAL
104 R&I Battery 550 cca m Incl.
N 105 * R&I Junction block US built 3.5 liter 0.4
N 106 ' R&I Actuator w/stability control Japan built m 0_5
107 WINDSHIELD
108 R&I Washer reservoir Incl.
109 OOWL
110 R&I Cowl vent panel p.g
111 # Subl 4 wheel alignment 1 89.95 X
SUBTOTALS 5,609.65 62.9 24.3
N OTES
Line 2: HARD SWAY/ SAG BOTH RAI LS/ MASH AND BUCKLE LT RAI L
Line 10: THRU KEYSTONE 612-789-1919
Line 23: THRU KEYSTONE 612-789-1919
Line 24: THRU KEYSTONE 612-789-1919
Line 37: 1 800 radiator
Line 53: CHECKED W AAA/ CERTI FI ED FOR LKQ
Line 78: after pull may require replacement
Line 80: TO FACI LI TATE RAI L REPAI RS
Line 105: loosen fron apron for access
Line 106: loosen from apron
10/10/2011 4:37:56 PM 014557 Page 4
' Estimate of Record
Customer: KEMP, RI CHARD E
Vehicle: 2011 TOYO CAMRY XLE 4D SED 6-3.5L-FI black
ESTI MATE TOTALS
Category Basis Rate Cost$
Parts 5,513.70
Body Labor 53.9 hrs @ $50.00/hr 2,695.00
Paint Labor 24.3 hrs @ $50.00/hr 1,215.00
Mechanical Labor 2.0 hrs @ $90.00/hr 180.00
Frame Labor 7.0 hrs @ $70.00/hr 490.00
Paint Supplies 24.3 hrs @ $30.00/hr 729.00
Miscellaneous 95.95
Subtotal 10,918.65
Sales Tax $5,513.70 @ 7.2750% 401.12
Grand Total 11,319.77
Deductible 500.00
CUSTOMER PAY 500.00
I NSURANCE PAY 10,819.77
MN ST 60A.955 - A PERSON WHO FI LES A CLAI M WI TH I NTENT TO DEFRAUD OR HELPS COMMI T A FRAUD AGAI NST
AN I NSURER I S GUI LTY OF A CRI ME.
Estimate based on MOTOR CRASH ESTI MATI NG GUI DE. Unless otherwise noted all items are
derived from the Guide ARM8522, C�C Data Date 10/3/2011, 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-I ncluded Labor operations. The symbol (<>) indicates the
refinish operation WI LL NOT be performed as a separate procedure from the other panels in the
estimate. Non-Original Equipment Manufacturer aftermarket parts are described as AM, Qual Repl
Parts or Comp Repl Parts which stands for Competitive Replacement Parts. Used parts are
described as LKQ, Qual Recy Parts, 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 2010 vehicles contain minor changes from the previous year. For those vehicles, prior to
10/10/2011 4:37:56 PM 014557 Page 5
Estimate of Record
Customer: KEMP, RI CHARD E
Vehicle: 2011 TOYO CAMRY XLE 4D SED 6-3.5L-FI black
receiving updated data from the vehicle manufacturer, labor and parts data from the previous year
may be used. The Pathways estimator has a complete list of applicable vehicles. Parts numbers
and prices should be confirmed with the local dealership.
COC Pathways - A product of COC I nformation Services I nc.
I��
10/10/2011 4:37:56 PM 014557 Page 6
Estimate of Record
Customer: KEMP, RI CHARD E
Vehide: 2011 TOYO CAMRY XLE 4D SED 6-3.5L-FI bladc
ALTERNATE PARTS SUPPLI ERS
Supplier: RPW Headlamps
Location(s): PO BOX 125, I NDIANOLA IA 50125 (800) 336-4028
Line Description I tem# Price
23 RECOND RT Headlamp 8113033700 $302.00
24 REOOND LT Headlamp 8117033700 $302.00
10/10/2011 4:37:56 PM 014557 Page 7
**HEADER PAGE**
Casey Scheuer 23-0475-551
Printed: 15:55:14 March/06/2012
Product Line: Auto
Claim Number: 23-047S-551
Insured Name: KEMP, RICHARD
Requestor Name: Casey Scheuer
Alias: MBIU
Printer: CPCL2580
Comments:
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For Customer Support refer to the
L��� � ���I �� appropriate platForm below:
OrderPo�nt
800-934-9698
Orderpoint.support@lexisnexis.com
Accurint for Insurance
866-277-8407
Acc u ri nt.su pport@lexisnexis.com
Lexis.com
REPORT ATTACHED Law Firm accounts
800-543-6862
PAGE COUNT: 2
CLIEI�T : SF5215
DIVISI�ti : 10605993657
AD.TUSTER : MANTDYEI
CLAIM : 23-0475-551
TRANSACTI�\#: 376495441
DATE : 12/24/2011
DAT'E OF LOSS : 10/07/2011 TIME OF LOSS :
STRHET : 10T�I_AI�TD ST PETFiF
�;11 Y : 51 YAUL
COU?TT4' . R?,hi0�`,'
sTATE : M:v
INVESTIGATING AGENCY : ST.PAUL PD
RFP(�RT N[1MRRR : 11-209991
REPDRT TYPE : Auto Accident
r t11\1 1 1 . 1\ll.l1!]l\L 11.LilYli"
PARI'Y� : CITY UF SI'PAL'L
PARTY 3 :
CAR : CAMRY MAKE : TOYOTA YEAR : 20ll
TAG :
T�RTVF,R T T(�F.NSF, •
.�L�lli i iur:.�L iru c� :
POLICY�f:
POLICY STATE:
LU[;G lilf�ll.
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THANK YnLI FOR YC�I_IR (�RDER�
1 1 .
376495441
Accident Report � Page 1 of 1
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RBZ0006Z
STATE FARM State Farm Mutual Automobile Insurance Company
� Auto Payments by COL
INSURANCE
Route To: Casey Scheuer
BASIC CLAIM INFORMATION
Claim Number: 23-047S-551
Date of Loss: 10-07-2011
Policy Number: 1714-622-23A
Named Insured: KEMP, RICHARD E
400 - COLL
C denotes consolidated payment
E denotes EFT payment
P previously converted payment from CAT/CMR
Payment Payable Pay Rsn
Number Issued Date Participant COL Cd Status Amount Auth ID Cd
105022883K E 11-16-2011 Named Insured(s) 400 1 Paid $14,226.81 ECSAPY
Total: $14,226.81
Date: 03-06-2012 Page 1
This report includes only ECS Claims.
FOR INTERNAL STATE FARM USE ONLY
Contains CONFIDENTIAL information which may not be disclosed without express written authorization.