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Kemp ^c��n ,�`�� - S�/ - �i�=`��1���' � - ��CEI�i��+ �1AK i> � �<+�� - �`1AR 0 !� 2�?1� -, ,- � ._ � ; 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: k, , .I ? �y/ / #' r j¢�`►.°, �.� t� :.a � - � ._ � . � �) � � �, � .� � � I �` �� � -:�: � . ; � & ;-, ���� �•:a�,i� ,t' f � , , � .. €.. � A�� � �. s •� . .,a ' ,�- � �,: � 1 1 . 3764954�1 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. ��� : THANK YnLI FOR YC�I_IR (�RDER� 1 1 . 376495441 Accident Report � Page 1 of 1 yr�.sn Q ���-. . _ .__.. _,.__ ,.�,� _ � , t�n[1DOO9 � •Sd • . I. =•. � � � al i1T�lo+Y1 MNO '�a1tS .- -- wL0 71�1 + rm . an . °�F'ri �. ri' "N tlz bu '�o �Y � 'za �r � zoii u�4� � � �c+mw AVtb�waont7tcr�wc - �u. �w+[rKCnon' { ❑ Q d 1� St.Peter . M ���1' °" --.�sr Bs {]w°`�r � < 62 � ��.. St:Paul � . +_• . 10. LOth Stzeet �O1� O1' G74?Q18647578 MN D�... '� O1 K641191208211 � �MN � . O1 r �� r.c�wi wKVac.cacwn . � rto..um�. �fwc*,�w.uan - wvrvom� .rcma� O1 RICHA.RD EARL KEMP 06 17 59 cKATTHEW MICHAEI.�.MORREZM 12 30 B1 05 W� p� ��� '�� ' ' Y4 Ri�KT W!�(R O1 2801 87TH TRAIi. N ' K, .' 1496'SHERWOOD WAY ,Y; O1 O1' un.eu�c.m . e„i.,..an, • ��p�ip ..�. .�� n�,rr.vr�1;� IiAr_IL�r Yf6J� � �llfllllf/111}! ,� U1 � � ,�� ��� V��n�Mp.�. � ' rar.[tl � r� �� � � ti��'°r iu[*� •�� rrg� .���� �.. 7 �u *..[ a.w .w� mwos nr.MO.. r.u.seaertas Rww�n � noa me a�o me mno� +wverorrt .wwawiv� +wM.sa� � t,'�", N; O". ' . . �e �i' N' Dnw � . aO^�" ' . Orn�a � ems t�o�..e . n[ or�arwe � oww �1 RF',MP RTf:NAAn RAAT. � � . r1 ' CT ADr=T.'!'TTY ('�F� . . � N� fIt .v�,,. .ow¢s� . - " — - -- — O1 2801 87'fH TRAIL N N,�� �p 891 N �ALE 5T� .• �1 • 01'�" .�wu+c a�....ma. . . . . � O1 BROOKLYN PARK I°43 5 5 4 9 3 � ��� � ��u�E� �� �� '�"' ��' ' -�. •"14'� 03_ ST.. PAUL MN 55103� "10 O5; 17_ ' ma�'- . .. . ' , tivu - . " ymR, ' •' •-�c.N tadl . Owcaa 08 TOYT ; XS 201 BLK' E'ORD • �, TSE � 00 .WHI • p2 wes�v nan. aT�a xwrea K�a�v�.e-. �..e. . rurti - . . arKa .vxqe . �eo�aaw �as�ww�ne wom C3 385NC MN. 2 41 Ol: O1 O1 O1 � . 911721 ' MN . 12�• � 41, 01., O1 O1. 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K , � �� �- ms.��� :,. �.�;� ;t. - . > � ��`� '�< �'° r ;��:� �� 3�z, o �,x.i, j �� ,� � , �� , � ' ` '''i ,, °° :�: . � � . i � ,� �� a �`� . f �I�� .� 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.