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Cobb �� S�Ate�AI'lll� �r�r��rr Providing Insurance and Financial Services � APR 3 0 2012 ' Hbme Office,Bloomington, Illinois 61710 �NfYtAMt �� April 11, 2012 City of St Paul State Farm Claims Office of the City Clerk P.O. Box 2371 15 W Kellogg Blvd Bloomington IL 61702-2371 310 City Hall St Paul, MN 55102 , � Certified Mail-Return Receipt Requested RE: Claim Number: 23-04V3-500 Our Insured: Hinda R Cobb Date of Loss: January 30, 2012 ! Your Insured: City of St Paul Your Insured Driver: ', Loss Location: Intersection Of W 7th Ave And Ranken, St Paul, MN I, Sir or Madam '� Facts of Loss: I' Insured was making a left turn to go s/b on Ranken when she hit something in the road. Insured ', pulled over and noticed that it was a piece a Sewer Compressor fan. Area was not marked with ' cones or warnings of any kind. She could not see it while turning due to the slope in the road i and how low it sat. � � 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. ' As a courtesy to our insured, we are forwarding out-of-pocket expenses they incurred as a result of this loss. These are expenses that are not covered under our insured's policy. Please remit payment for the out-of-pocket expenses directly to our insured and confirm when you have done so. 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 $ 042 - Uninsured Motorist PD $ 300 series/400 - Comp/Collision $1,435.85 501 - Rental/Loss of Use $52.38 (plus $13.09 out of pocket expenses) 600-050 - Med Pay/PIP $ Other $ Salvage Recovery $ Amount State Farm Paid $1,488.23 23-04V3-500 Page 2 , April 11, 2012 S- Insured Deductible $250.00 Total Claim Amount $1,738.23 ' i i between the arties State Farm Mutual Automobile d on the assessment of liab I t , Base P Y Insurance Company is seeking 100% of the Total Claim Amount listed above. The amount I to State Farm Mutual Automobile Insurance Com an for this loss is $1,738.23. a ab e P Y P Y I Please remit payment of this claim and include our claim number on the payment. If you have any questions or need additional information, please call me at the number listed below. If I am not available, any other member of my team may assist you. Thank you for your cooperation. In order to assist you in evaluating and processing the subrogation claim we are asserting, we may provide nonpublic personal information about our customer. We are sharing this 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, � 1.��_ Kay Edgcomb Claim Processor (877) 457-8276 Ext. 52957 Fax: (866) 231-9276 I State Farm Mutual Automobile Insurance Company Enclosure a3- U�Iv 3- soo NOTICE OF CLAIM FQRM to the City of Saint Paul, Minnesota Minnesotu Siate Statute 466.�5 states rhut "...every E�ersan...whn claims dmm�ges from any munici�aliry...shall cause�n be�resented to the ,.�ove�+�it1g body of the nurnicipaliry within 180 days afier the alleged loss or injury is discoverect a notice stating the time>place,and " circumstances rhereof,and the amount of compensation or other�elief demanded." P►ease complete this form in its entirety by clearly typing or printing your answer to each question. If more space is needed,attach additional sheets. Flease note that yoa may or may not be cantacted by tclephone to discuss your claim circumstances,so provide as much iaformation as necessary to explain your claim,and the amount of compensation being requested. This form must be signed,and both pages completed. If something does not apply,write`N/A'. i SENU COMPLETED F4RM AND QTHER DOCUMENTS TO: CITY CLERK, 15 WEST KELLOGG BLVD,310 CITY HALL,SAINT PAUL,MN 55142 5� �a.trn 1 n�u,r�2_ ac-5 s c.c.lb ro�e l.° o�r First Name �i r��„ Middle Inirial Last Name _nb Company or Business Name, if applicable ��2 �'-r►'n � n su r�.�. ,I Street Address I�" � �'� °�-3 � ( Cit k� � DOYn � t��-�'l.. State � �— Zip Code �0�7 �v 3 7 � Y ; Daytime Telephone�� ) S � �a7(�X sa'as� Evening Telephone ( ) � �3� ��-- Time � am! cn eircle Date of Accidend Injury or Date Discovered �.�� P � � Please state,in detail, what occurred, and why you are submitting a claim. Please indicate why or how you feel the City of Saint Paul or its employees are involved and/or responsi le. in s�,�. r e d e GL. 1 e�� ,�'r� d V 2. �c� ! S�.e ' + (;�. S r res o r ��- � e orlt' w� f� We.►^� e F�— I 0. i r I � — — I Please check the box(es) that rnost claseiy represent the reason for completinb this farm: C7 Vehicle was damaged in an accident ❑ Vehicle was damaged during a tow �,Vehicle was damaged by a pothoie or condition of the street ❑ Vehicle was damaged by a plow Cl �ehiele was wrangfully towed and/or ticketed ❑ Injured on City property � Othex type of property damage—please specify_ _ ❑ Other type of injury—please specify _____ - ❑ Uther type not listed—please specify ._. In order to process your claim you need to include copies of all applicable documents. This is a general guideline of what shauld be submitted with a claim f.orm, but it is not all inclusive. You may be asked to provide additional information depending on your. claim. O Property darnage claims to a vehicle: at least two estimates for the repairs to your vehicle, or the I aetual bills and/or receipts f.or the repairs '', O Towing claims: legible copies of any tickets issued and copies of the impound lot receipts ! 0 Other property damage: repair estimates, detailed list of damaged items 4 Injury claims: medicat bil.ls,receipts O Photographs can be provided but will not be returned. Page 1 of 2—Piease complete and return both pages of Claim Form Failure to provi�de a completed claim form wiU result in delays in processing. i Notice of Claim Form, City of Saint Paul, page two j All Claims-Alease comalete this section Wer� th��e�witnesses to the incident? Yes No Unknown (circle) If yes, please provide their names, addresses and telephone numbers: �;�-•� wor ke r so..�� .rSor� rC,m.ove �_ Con�s Were the police or law enforcement called? Yes No Unknown (circle) If yes, what department or agency? C�� o� Case#or report# I�o aaa 3� Where did the accident or injury take place? Provide street address, cross street, intersection, name of park or facility, closest landmark, etc. ease be as detailed as possi�e. If helpful, attach a diagram. �J �d` �J'L'- °1- ��n S -E, at,c..� Please indicate the amount you are seeking in com ensation from this claim or what you would like the City to do to resolve this claim to your satisfaction. �l 13 �3,a3 Vehicle Claims-piease complete this section ❑ check box if this section does not applv Your Vehicle: Year a0 1� Make For Model �S i �n ! License Plate Number 5'(�0 H$/J State � Color Wh��e 5c�cdgr Registered Owner t�'�hdo� Co b4� Driver of Vehicle So�rn-a- ' Area Damaged i e,+�ler �►- � City Vehicle: Yeaz ake Model License Plate Number State Color Driver of Vehicle(City Employee's Name) f�rea Damaged � Iniurv Ctaims-please comQlete this section ❑ check box if this section does not apnlv i How were you injured? What part(s) of your body were injured? ��, Have you sought medical treatment? Yes No Planning to Seek Treatment (circle) �' When did you receive treatment? (provide date(s)) Name of Medical Provider(s): Address Telephone Did you miss work as a result of your injury? Yes No When did you miss work? (provide date(s)) Name of your Employer: Address Telephone — ' ❑ Check here if you are attaching more pages to this claim form. Number of additional pages By signing this form,you are statirtg that all informatiore you have prnvrded u bue and correct co the best of your knowledge. Unsigned forms will not be processed. Submitting a false claim can resutt in p�osecution. � ) C Q rn` Print the Name of the Person who Completed this Form: K � Signature of Person Making the Claim: _ • ' `�U `J.c,r•cRr�.�� Date form was completed � l � ��---- Revised April 200� RBZ0006Z STATE FARM State Farm Mutual Automobile Insurance Company Auto Payments by COL INSUlANC! a Route To: Stephanie Peters BASIC CLAIM INFORMATION Claim Number: 23-04V3-500 Date of Loss: 01-30-2012 Policy Number: 3755-626-23H Named Insured: COBB, HINDA R 403 -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 105064522K E 02-07-2012 Named Insured(s) 403 1 Paid $1,435.85 ECSAPY Total: $1,435.85 501 - RENT 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 105068118K E 02-13-2012 Named Insured(s) 501 1 Paid $52.38 ECSAPY Total: $52.38 � Date: 04-18-2012 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. RBZOOOMD STATE FARM State Farm Mutual Automobile Insurance Company Auto Rental Bills INSUlANCE Route To: Stephanie Peters BASIC CLAIM INFORMATION Claim Number: 23-04V3-500 Date of Loss: 01-30-2012 Policy Number: 3755-626-23H Named Insured: COBB, HINDA R COBB, HINDA BILL SUMMARY Bill Information Invoice Number: 1906D454793 Claim Number: 23-04V3-500 Rental Vendor: ENTERPRISE RENT-A-CAR Date of Loss: 01-30-2012 Insured Name: COBB, HINDA R Received From Renter: $13.09 Renter Name: COBB, HINDA Billed To Others: $0.00 Rental Start Date: 02-06-2012 Amount Due: $52.38 Renter End Date: 02-07-2012 Amount Paid To Date: $52.38 Current Bill Status Primarv Status Primary Reason(s) Reviewed Secondarv Status Secondarv Reason(s) Paid Vehicle Information Vehicle Rental Start Rental End Assnd Class Appr Class Make Model 01 02-06-2012 02-07-2012 FC SC MAZD 6 Invoice Details Rate Percent Extended Vehicle Description Billed Partv Quanti °/( o)($) Covered Amount 01 Daily Rental Rate State Farm 2 27.55 80.000 $44.08 01 Daily Rental Rate Renter 2 27.55 20.000 $11.02 ' Sales Tax State Farm 44.08 7.620 0.000 $3.36 � Sales Tax Renter 11.02 7.620 0.000 $0.84 i Government Surcharge State Farm 44.08 5.000 0.000 $2.21 ' Government Surcharge State Farm 44.08 6.200 0.000 $2.73 Government Surcharge Renter 11.02 5.000 0.000 $0.55 Government Surcharge Renter 11.02 6.200 0.000 $0.68 � Subtotal Less Taxes : $55.10 Received From Renter: $13.09 Total Taxes : $10.37 Amount Due From State Farm : $52.38 Date: 04-18-2012 Page 1 I This report includes only ECS Claims. FOR INTERNAL STATE FARM USE ONLY Contains CONFIDENTIAL information which may not be disclosed without express written authorization. � **HEADER PAGE** Stephanie Peters 23-04V3-500 Printed: 13:12:32 April/18/2012 Product Line: Auto Claim Number: 23-04V3-500 Insured Name: COBB, HINDA Requestor Name: Stephanie Peters Alias: NROS Printer: CPCL2580 Comments: � i � 1 1 . 3$3117771 � For Customer Support refer to the �� appropriate platForm below: OrderPoint 800-934-9698 Orderpoint support@lexisnexis com Accurint for Insurance 866-277-8407 Accunnt support@lexisnexis com Lexis.com REPORT ATTACHED Law Fum accounts 800-543-6862 PAGE COUNT: 2 CLIENT : SF5215 DIVISION : 10605993657 AD.1L'STER : MANDYEI CLAIM : 23-04V3-500 TRANSACTION#: 383117771 DATE : 03/04/2012 DATE OF L�SS : O1/30/2012 TIME�F LOSS : STREET : W 7TH AND RANKEN CITY : ST PAUL COUNTY : RAMSEY STATE : MN INVESTIGATING AGENCY : ST.PAUL PD REPORT NUMBER : 12022239 REPORT TYPE : Auto Accident PARTY 1 : HINDA COBB PARTY 2 : PARTY 3 : CAR : FUSION MAKE : FORD YEAR : 2011 TAG : ! DRIVER LICENSE : ADDITIONAL INFO : POLICY#: POLICY STATE: � L�SS KIND: ' i NOTE : THANK YOU FOR YOUR ORDERi 18ch1206400125 1 1 . 383117771 Accident R'eport I . . � :�,:�E� .�o � S a 12022239 � � � � iY1.NID�lIUM AMIqkY� Vill'4[i LLtl� IIIW )MM M OM[ rM 0 WW�lT� � N N dl �10 tb0 � I� , 1 30 2012 �on 1205 � �,�, ,��E�.��„� �,o,�� ;,�.��,� � ., S�8a B��J�� io • �tn st. w. 40 5b � w �M -- G7JlIT•» M6PU pllb701�Rflf 110YTF8�'b TYffY.Sff�F.fi,fLM/1M'6lfE4N�[ b2 gn. 3G25 +�• 10 Rankin ` fACldlf YI13110a AMlAtKEMMMJ'�CM-1 iT�T! Gib] 0.eUTUS'�CO��OM d11VkI1lCWfFi11MYEA-] S�iE Cu56 d.TAl1:9 FKFpI 01 O1 V282235418312 MN D O1 l\Cl[A7 MW1!!�WfM�lllCV41i7 OYlO�lNIN W�C�fT.t�l.tMTl R1RO��iM �AG'!0012 HINDA RUTH COBB 10 U3 48 wrvrn ,00ms. ow�a �e.�wn wo�a m Na r�� r. D6 2285 STEWAR'F #2212 N; O1 • �� vxt a!1;cuiG21 an.fvilS.H� O1 ST PAUL 55116 651-70?-3967 �wrr�w F:+ ,<.y eorr vsEr� .�o uocr w�ev .00nes� a�a a�EOn �raT wa.o � wi�v towo O1 � F �9 "" 09 06 OS N ""�' Krx nr� vun rne *o�asr nwvom +n�euu+caonN�n �wKwe� rau +w� owxi r+e �ower �nNera� .r�aM+za� nwru.�e�n rcn r[ar �J f�," N• °o�„ • ' ❑�n � �,�..� _ � �.r,� � �. 03 CAS WEST LLC N � � �fk7Yf �CNIEf! lO+RO r00�] ,oW� .�01..P p� PO BX 105704 � ' �O.VBE m�.it�*F.tP rutno o� cm.Nwtl.2P nw�q npVr `u.uQ O1 ATI,ANTA MN 303985704 "l�, �� o.c�cc rxu wucc. ,w. wwa w�a� yaa�. vr�v� m�w o.w.« O1 FORD F/E 2�1 WHT WGlfV RNif dfl� TMKD �n O�t i�:IWM Mlf• H�ImO �EMIIlO � Vl» Al�fw�d OYG�V RA �3 560HBr3 MN 2 21 � 21 , 11i/1W[F iOlr't�11 �4n�/1�N��I dOIC'/M��R '�. wma• wzwr �vwa wrrccroir nsr��oaes �°0`�� I +.►� w►: iF ACCIDENT IMVOLYEDACONN9tC1AL YOTOR VENtCIl.SGHOOL HUS�OR itEAtr BTART BIiS � n,� .. • • RAAEN$ER 7D NOTIFY T11E iTA7!PATROL IACUYOO�An MS 1 e9.7la�nd 70PAS11). �. WV141R'MtNM0.{wlrf��.Y0+0AfJ�tlNfwL! 00/MNlR COM61LM1MEMGL7�l�QRf-W7011G�ROINIWE �� . �xvu�tRSiwmesx� uar d su nec us[ �wo c,ecr w�xv m �x� •T Q„� w.�� } Ddve Bougie (651-231-6126) W i`1 � pm�. p Q,,,� „eg„u ��..� N � om.� N o "'°"",,,� '°""�„ N ,� ... oo,.� W a+�'a"o+xcaow.iiv.FOrcim�iooaw.:.waw....�'.co:�orew+vwmoare�wwrraw.i�er!s� c1w.anracrnerv�vRUn+v�wM*ea� � rxt» :4 wwrtne °� ' 21 ' .- ----•------• .... _ ._ _ .. - - - - _ 9 6 bO1°'� t V1 x/b 7th St. w. made left turn pnto Rank�n. 03 , �COnstzuction cones previously set up�to blo�k �� '°GTM '? 98 equiprtient prot=uding,from menhole_had been_�aoved. O1 ,, by an unknoxn citizen. vl then atruck equipmeat anwf %'• �� causing soderate-damage.-•�Person-vho moced �ones- �� N� � could not be loCatad, but city vorker saw the �2 �o,�'� per3on-Cd it."'SeparaCe re'port ffted-vith-St.' 02 :,�;� nnsi w Paui ro reqardinq the unknoNn party vho moved the W � } � conea... . _ ; _ _. . . . ., _ ,. ��rar. �p� --� '--�-- . _ . .. .. ,. . . . _ .... .. .___. ---— roEU�srt� `'�• �1 �Z �I .� a;• � ? • -- - � • - -- - - - ----- - -- . _ �., � � . ..._. ... .. . _. - -•�--- . .--- --- - �a: k� N �•-- - - _ . .. - - - -- - - 7� � ;ro�n � - --• QI �2 �; I . . _ _ . _... ._.._ .._ . . .. ._. .._... "i`„� �'`� N :-, .no•u� 'x:< .� _ . ... . . . . - --�-� - - - - - �{ �, 62 �t'• L. 0 3 � o:�,�.��.��,.�. -- - -°--— -- - •- - ,,�, �:�..,a: p s.,RM-� �.. Officer Eri.c Skog 661 ��(e St Paul PD � p� p e-� �„ http:Udvslesuppoct.org/dvsinfoJaccidentrecords 2008/Includes_LE/PrintReportIndiv_LE.asp?ACCN=12Q3... 2/4/2012 18ch1206400126 �' �li�as��?�''"�. I HIGHLAND AUTOSTAR COLLISION CENTER 2042 WEST 7TH ST. ST. PAUL, MN 55116 OFFICE: 651-699-0340 FAX: 651-699-4953 � FED TAX ID# 41-1828627 *** SUPPLEMENT 1 *** RO# 17165 O1/31/2012 02:28 PM S1 02/07/2012 05:36 PM Owner Owner: HINDA R COBB Address: 2285 STEWART AVE APT 2212 City State Zip: SAINT PAUL, MN 55116-4112 Home/Day: (651)307-3967 Work/Day: (612) 726-1127 Control Information Claim # : 23-04V3-50001 Loss Date/Time: O1/30/2012 06:00 AM Loss Type: Collision Deductible: $250.00 Accounting # . . Ins. Company: State Farm I!, Company Contact: STATE FARM INSURANCE , Address: PO BOX 82613 City State Zip: LINCOLN, NE 68501-2613 Work/Day: (888)248-6961 FAX: (800)423-0474 Insured: HINDA R COBB Work/Day: (612) 726-1127 Home/Day: (651) 307-3967 i Claim Rep: TEAM R3 ACC CP ' Work/Day: (866)207-6046 Inspection Inspection Date: O1/31/2012 02:28 PM Inspection Type: Select Service Primary Impact: Right Front Corner Driveable: Yes Rental Assisted: Yes Received Date/Time: 02/Ol/2012 11:29 AM Appointment Date/Time: 02/02/2012 06:00 AM Appraiser Name: LAWRENCE RITTER Address: 2042 W 7TH ST I City State Zip: Saint Paul, MN 55116-3107 I Work/Day: (651) 699-0340 FAX: (651) 699-4953 Email: LARRY@HIGHLANDAUTOSTAR.COM Orig Appraiser Name: LAWRENCE RITTER Address: 2042 W 7TH ST I City State Zip: Saint Paul, MN 55116-3107 � Work/Day: (651) 699-0340 Home/Evening: (651) 699-4953 FAX: (651) 699-4953 Email: LARRY@HIGHLANDAUTOSTAR.COM 2011 Ford Fusion SE 4 DR Sedan 02/07/2012 05:37 PM Page 1 of 4 Lldlm $ : LS-U4V3-SUUU1 Ul/Sl/LU1L UL/U�//L�1L Repairer Repairer HIGHLAND AUTOSTAR COLLISION Address: 2042 W 7TH ST City State Zip: ST PAUL, MN 55116-3107 Work/Day: (651) 699-0340 FAX: (651) 699-4953 Email: HA2042@POPP.NET Repair Start Date/Time: 02/06/2012 02:32 PM Vehicle Drop Off Date/Time: 02/06/2012 08:13 AM Repair Complete Date/Time: 02/07/2012 03:36 PM Vehicle Pick Up Date/Time: 02/07/2012 05:36 PM Target Complete Date/Time: 02/OS/2012 05:00 PM Days To Repair: 3 Remarks THANK YOU FOR COMING TO HIGHLAND AUTOSTAR COLLISION CENTER COPY OF ESTIMATE TO CUSTOMER Vehicle 2011 Ford Fusion SE 4 DR Sedan 4cy1 Gasoline 2.5 6-Speed Automatic Lic.Plate: 560 HBN Lic State: MN 'i Lic Expire: VIN: 3FAHPOHA9BR329378 Prod Date: Mileage: 5,394 Veh Insp# : Mileage Type: Actual �, Condition: Code: P3453C � Ext. Refinish: Two-Stage Ext. Color: WHITE SUEDE � Ext. Paint Code: WS ' Int. Refinish: Two-Stage Options AM/FM CD Player Air Conditioning Alarm System Anti-lock Brakes Auto Headlamp Control Bucket Seats Center Console Cruise Control Dual Airbags Floor Mats Fog Lights Halogen Headlights Head Airbags Illuminatd Visor Mirrors Intermittent Wipers Keyless Entry System Lighted Entry System MP3 Player Overhead Console Power Brakes Power poor Locks Power Drivers Seat Power Mirrors Power Steering Power Windows Pwr Accessory Outlet(s) Rear Window Defroster Rem Trunk-L/Gate Release Side Airbags Sirius Satellite Radio Split Folding Rear Seat Stability Cntrl Suspensn Steel Wheels Strg Wheel Radio Control Tachometer Telescopic Steering Whl Theft Deterrent System Tilt & Telescopic Steer Tinted Glass Traction Control System Trip Computer velour/Cloth Seats Damages Ln# Op GDE Description MFR.Part No. Price AJ% B°s HRS R --- -- ---- -------------------- ---------------- -------- -------- ---- -- 1 UC 20 Cover,Front Bumper RECOND PART 384 .00* 3 .0 SM 2 L 20 Cover,Front Bumper Refinish 3 .8 RF MC 13 2.7 Surface 0.6 Two-stage setup 0.5 Two-stage 2011 Ford Fusion SE 4 DR Sedan 02/07/2012 05:37 PM Page 2 of 4 �laim $ : L�-U4V3-5UUU1 Ul/31/LUlL UL/U7/LU1L 3 E 99 Reinf,Frt Bmpr Co RT AE5Z17C947C 6.23 0.2 SM 4 E 120 Gri1le,Frt Bumper Lw AE5Z8200DA 79.83 INC SM 5 E 121 M1dg,Frt Bmpr Cvr Lw AE5Z17K945A 165.92 INC SM 6 RI 10 Panel,Frt Bmpr Licen R & I Assembly 0.2 SM 7 Rt 42 Headlamp Assy,Hal RT R & I Assembly 0.2 SM 8 E 97 Bu1b,Front Fog La RT 2C5Z13N021AA 16.08* INC SM 9 E 49 Defl,Radiator Lwr Ai AE5Z8327B 67.90 0.1 SM 10 I 104 Fender,Front RT Repair 1.5* SM 11 L 104 Fender,Front RT Refinish 2.8 RF 2.3 Surface 0.5 Two-stage 12 SB HAZARD. WSTE. REM. Sublet Repair 3 .00* SM 13 SB COVER CAR EXTERIOR Sublet Repair 7.00* RF 14 SB FLEX ADDITIVE Sublet Repair 3 .00* RF 15 SB THRUST ANGLE ALIGNME Sublet Repair 84.99* SM 16 I FEATHER. PRIME, BLOC Repair 0.5* SM* 16 Items MC Message 13 INCLUDES 0.6 HOURS FIRST PANEL TWO-STAGE ALLOWANCE Estimate Total & Entries Gross Parts $335.96 Other Parts $384 .00 Paint Materials $198.00 Parts & Material Total $917.96 Tax On Parts Only @ 7.625% $54 .90 Labor Rate Replace Hrs Repair Hrs Total Hrs Sheet Metal (SM) $50.00 3.7 2.0 5.7 $285.00 Mech/Elec (ME) $85.00 Frame (FR) $70.00 Refinish (RF) $50.00 6.6 6.6 $330.00 Paint Materials $30.00 Labor Total 12.3 Hours $615.00 Sublet Repairs $g�,99 Gross Total $1,685.85 Less: Deductible $250.00- Net Total $1,435.85 Rates / Taxes Adjustment Deductible Adjustment Less: Previous Net Total $1,435.85- ', Net Supplement Total (Final Bill) $0.00 �i Alternate Parts No � Audatex Estimating 6.0.726 Sl 02/07/2012 05:37 PM REL 6.0.726 DT ' oi/ol/aoia DB oa/oi/aoia � Copyright (C) 2011 Audatex North America, Inc. 1.6 HRS WERE ADDED TO THIS ESTIMATE BASED ON AUDATEX'S TWO-STAGE � REFINISH FORMULA. YOU ARE AUTHORIZED TO MAKE THE ABOVE REPAIRS. I UNDERSTAND THAT PAYMENT IN FULL WILL BE DUE UPON RELEASE OF THE VEHICLE. PARTS PRICES ARE SUBJECTO TO INVOICE. I GRANT PERMISSION TO OPERATE MY VEHICLE FOR THE PURPOSE OF TESTING/ INSPECTION. HIGHLAND AUTOSTAR IS NOT RESPONSBILE FOR LOSS OR DAMAGE TO THE VEHICLE OR ITS CONTENTS IN CASE OF FIRE, THEFT OR ANY CAUSE BEYOND YOUR CONTROL. AUTHORIZED BY: DATE: THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF ONE OR MORE CRASH PARTS 2011 Ford Fusion SE 4 DR Sedan 02/07/2012 05:37 PM Page 3 of 4 L131m � : L3-U4V�-5UUU1 Ul/Sl/LUlL UL/U7/LUlL SUPPLIED BY A SOURCE OTHER THAN THE MANUFACTURER OF YOUR MOTOR VEHICLE. WARRANTIES APPLICABLE TO THESE REPLACEMENT PARTS ARE PROVIDED BY THE PARTS MANUFACTURER OR DISTRIBUTOR RATHER THAN BY THE MANUFACTURER OF YOUR VEHICLE. A PERSON WHO FILES A CLAIM WITH INTENT TO DEFRAUD OR HELPS COMMIT A FRAUD AGAINST AN INSURER IS GUILTY OF A CRIME. Op Codes * = User-Entered Value E = NEW PART NG = Replace NAGS EC = ** NON-OEM PART ET = Partial Replace Labo EP = ** NON-OEM PART EU = RECYCLED PART TE = Partial Replace Pric PM = REMAN/REBUILT PART UM = REMAN/REBUILT PART L = Refinish PC = RECOND PART UC = RECOND PART TT = Two-Tone SB = Sublet Repair N = ADDITIONAL OPERATION BR = Blend Refinish I = Repair IT = Partial Repair CG = Chipguard RI = R & I Assembly P = Check RP = RP-RELATED PRIOR This report contains proprietary information of Audatex and may not be disclosed to any third party (other than the insured, claimant and others on a need to know basis in order to effectuate the claims process) without Audatex' s prior written consent. Copyright (C) 2011 Audatex North America, Inc. � I �'� 2011 Ford Fusion SE 4 DR Sedan 02/07/2012 05:37 PM Page 4 of 4 *** SUPPLEMENT RECONCILIATION *** Supplement S1 Claim # : 23-04V3-50001 Claim Rep: TEAM R3 ACC CP Insured: HINDA R COBB Inspection Date/Time: O1/31/2012 02:28 PM Owner Name: HINDA R COBB Appraiser Name: LAWRENCE RITTER Vehicle: 2011 Ford Fusion SE 4 DR Sedan Actual Supplement 1 Net Total $0.00+ Summary Net Total Date Time Appraiser -------------------- ---------- ---------- ---------- ---------- Original Estimate $1,435.85 O1/31/2012 02:16 PM LAWRENCE RITTER Supplement 1 $1,435.85 02/07/2012 05:36 PM LAWRENCE RITTER This report contains proprietary information of Audatex and may not be disclosed to any third party (other than the insured, claimant and others on a need to know basis in order to ' effectuate the claims process) without Audatex' s prior written consent. Copyright (C) 2011 Audatex North America, Inc. 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