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Alexander, Jason (Farmers) ,��`��C} (�IAY 0 �.� L012 �`��"t' ��kF�� '': �`' a Natroz,al Docurrient C;Psztei ��r. �.,;, . �:� �. � �. .�. � �...� r� ` P. Q.Fios Z6o992 � � �� klahoma Citp, �K 7312&-s992 cIaimsdotuments a�.pcs.cam Fax: 8�"f-217 1359 Toll F=ee: SQO-HelpPomt 05/09/201? rAX COvER SHC�'t' . �tm: Sandra Bodenstciner-Risk Mana�emc:nts C�f6ce Ciry of St�T'atil. ra.x#:G51-26C�-8574 Pages_ Otir Tnsured: )ason Alcsand�r C7ur Clai�xa#; 0<)9 SU13 102(')17167U-1 D;�te ot T�oss: 11 j3.1/2011 Xour Insured: C:ir.�(.-)f St 1'aul Yaur Claun #: URIV�I;: ��',n�DEI'.I(:Tti B1.L,�;S (Fircir�n) � S;ncereIy, 21st Cenn�ry Centc�uzi,sl Insucuace Co �'^� R ; .\ � ,. .'r 9�� ',��' ��.�� '�'.� `��,,.��.,;,;.: �°' ��a.3�..�' ..,.,.v�":. :.N,.r' JUCii Wai�.e�: Auto Subxogatio�i Representative G30-907-6971 jodi.wal�er@hpcs.com £ZO/ Z00'd 666L# ��'dl�'ItIS SNI 7��if1,LN�� sZZ OZZ6ZSZZ0£ OO �OZ ZZOZ'60 'f,'dI�I �,f . � � Nab.Onal Documerit�enter t'' �` P. �.Bax 2G8992 r :' ..�";.�.4. �.� � .a�.. l�... � � ''"� �kl.ahoma Citf; flK 7?�126-89�? ciaimsdocuments a�kpcs.com Fax: 87�-217-1389 �"oll Fsee: 800-�elpPoint 45/09/2012 St.Paul Czty Clerk Sa�idra�ode.nsr.eincr-Risk Mana�,n:rs Uffice 25 W.4th St.,S�e 2U(), C'-ity Hall�nne:c Sr_ Pacd,MN 55102 fte: Our Insured: Jason Alexander Our Claizz� #: 09)SUB 1020171670-1 Date of Lc�ss: 11/21/2011 Your Tnsured: City C�f St Paul Xou�-CI�n#; DRIVEh: HRLDERICI,'.�31_.r.rS lleductiblc Amoi;nt: �1,000.00 T�ss of Use 1�mount: $0.00 Tor�l A�noun[C�wed: $1,542.12 Dcar Saa�d��a.Bc>dc:�isteiu�er: We h1ti�tildC�e�dyllleRt tq OUI i115UrCCi fQr C��l.tl]c'L�'E'S L�St11t1l1g FLO�'I"1 t171$:iCC1C1f11L Ulli' invcstigation h�,5 established that tt�.c aUove tos�was caused by the ncgli�ex�ce of your driver. BY vlttUe Of Ulu SuUtO�dttOn rl�its ttus letter is to advrse you rh�t we e�ecr paymcnt frozr�you for ttie an�ount�f da�nages wirhin 14 days of the rcceipc of rhi5letter. Be advised that��o paL�is�I payme�zt,which is less than the fi:tll axnotlnt c:laimed hezein,w�ll bc r��nsidered in any waq aza acceprar�ce o:f benefin,a novadon or an accoXd and tiatisfacrion of this claim without ttie eQpress written rele%�e of our claim esecuted by an individual who xder�rif es hunseif/hersclf as a meml?er of our s�ibrogation deparm1ent.'ihexef'ore,our legai zight� tq enforce collecti�n oi�tlze remauung amou.nt of t�e claim shall not be waived or � estopped due r,<�a pardal payment by pou_ If you need addit�onal support for oui claam or require furtl-cer informaaon,pleasc cail nne at G30-�)U7-6971 �ri.rh yout FAX riumber s<>that the requested ulfozr��ation can be sent to you. Suiccrely, 21st Century Centeruiial Z�ZSUr<u�.ce Co �, t :� ;. ;":�.. ��! � y >s�� ``�`�,,��(,. / , V.MP�.�„,�:^ EfF�.:/f�Q;�^':..'�.�s F.�w�7. '.^. .. ih1 J n„i>•" •�... �:. ]odi.Walker Auto Sui�roga�ion R��resentati`E: jocli_�*ralkcr@hpcs.com Self Insured £ZO/ Z00 'd fi66L# ��l�'I'd5 SNI ��If1ZN�� sZZ OZZ6ZSZZ0� OO �OZ ZTOZ'60 'AtIYd NOTIC� OF CLA,�M FORN� to the CYty of 5aint Paul, Minnesota Minna.rota State Suztu�e 6hh.05 stases lhat "_..every peracirt,..wftn claims darrurgts frnrn any muraicipAlity....chal!ca[�sr tu bt pr�.eented tn ahr Fnvemirsg body nf the municipAlt{y within 180[lCtys afrC��e alle,�ed loss nr�njury is discnvCr'Cd R n�tice stating 1he'�ime,place,nnd circtain.PtanCP.e rherenf,arut dzC omnunt nf cornpensatinn nr ntlur�elief�emanded." PleASe complete this[oxm iF�its enxireiy hy clearly typiing or printing yu�tx ancwer to exuh question. If mute spftce is needed,attxcb addjtional sheets. Please iiote tbat ypu wiIl not be contacted by telepbone to dxrify et�s'wers,So provide As m��lch information as�ecessary to exp�a9n yoar claim,and the amount o�compensation be�i�ng requested. Yoi►w�11 receive a writLe�ae{niowledgemektt once your forbx 7s received. The prncess can take up to ten weeks oX tonger dependitag on the nature of�our claim. Thu folrm must be si��ned,and both pages completed. If Something does noi A�ply,write`N/A'. SEND CUIVIPLETED FORM ANA OT�IER DOCUMENTS TO: CITY CLE�tK, 15 VVEST KELLUCrG BLVD, 310 CITY I�A�.L, SAIN�' PAUL, N 55102 a,�� t t� Middle I�i.tial Last Namc � _ � � Fi.�st Name ��h� Coz�ipany or I3usit�ess Name S � � ��+ `-r �- � ' .Axe You an�tlsuraz�ce Compflny? Xes/No Tf Yes,Cl�im Numbe�. �D°� v/�J �C � `'� Street Address ��J O )C� ��' - City�!�4�h o vw � �u Stau: �� _7_ip Cocie_,,, 3 %��o c- ' `)�'- ��x a.-�- sa Day[imc Phone �� Cc1I Phone( ) - Evcnu�g Tele�honc( ) - Uace oF Accident/Injury or Date Aiscovered f l Time : Sa- am/� Please s�te,in detaal,wha�occurred(happened),and wh �ou are submining a clai�m_Plcase' icace why or how ou � fccl Che City o Saint Pflul�r x[s employees are involved arld/ox responsible f z' our da nages_ . � � \ ' ' �� ` ' ! p ase chc�k[h.e bcix(cti) l�itit nxost c]oscIy rep�'esen[thc rcttsoat for c�mplc;iitlg Ihis fonn_ vehicle wati dtun�ged in an accidet�t ❑T:VIy vchiCl�was claina��cd duz��a.t.ow ❑My vehic�e wa�dfunaged by x pothole o.r condirion of tt�e scrcu ❑v[y vchicle was damagcd by a plow ❑My veh.icic was wtongfully coweci and/or tieketed ❑1 was injv�ed on Ciry prope.tty l� Ochcr�ype of propcny damage-plcase specify ❑ Uther rype o�inj ury-please sFx-cify �order to proccss yow-clai�. c�u need to inclnde co ies of aIl a licable documents. roK the elauns types listcd below,Plea�e b�sure to incIude the docnmen�s ir�dicated or it will delay c��e handling of your claina. Docunients WTLL NU'r be lreturncd find becomc �hc prope�ty of thc Ciry. Xou arc cncourage�l u�kccp a capy for yaurself befon:�ubmiuing your claim fom�_ O Property dall7.a�e cldiriLS to�vehicic_IvVO esti�n�atcs for Lhe 1e�a�rs [o your've�.icle if thc dtima.ge excecds $SU0.00;or the acrual bil�s and/or reeeipts for nc�repairs O Towing cl aims:legible oopics of any ucket issued and a copy of the impound Iot reeeipt O Otk�er grc:>perty darzaagc clauns:two re�air es[irnates if Ehc damage exceecis�500.00;o��hc acmal bills and/ar receipts for ihe rep.�►irs;deCaiiLf��iSt O�d31ll3gcd iietriS O Tnjt�ry clai�TU: msdical b�llt,reCeipts O�'ho�ob aphs�,�re always welcome[o dvc:ument au�d Suppor[�'our claim but v�ill not be retumed. Page 1 of 2-Ple�se complete snd return both pages of Claim I'orm £ZO/ £00 'd $66L# �`atlll'ItIS SNI f,tillZN3� �stZ OZZ6ZSZZ0£ OO�OZ ZZOZ'60'f,tllnI F�i�ua�e to cornpiete and returm both pages will resalt in delay in ihe handlir►g of youx claim. All CEaims—nlease comnlete this section Wefe[here wiincsseS[o fhe iticildent? 'Y'es No LJnlrno�vvn (cz�c�e) Providc: ir ,1�t`l!eS,,�acidre. cs�nd tele ho mbers- ' / -----,��_��✓�r [� ��.�� \/ .d .��'��'-�l.t� __/L�`c� �(!V ,,� --- � We�e thc polic��ur 1�W e[7,fo.[cemcn�c�►lic �? Ye. Vo CiK�.4a�oWn (circicj If ye.s,wh:�t department o�agency? / Case#or zeix>r�# a' Where did ihe aceidetit or injur.y ta]cc plaec? Provide Stzeet addres�,eross sc�et,incersce�ic�n,name of park:o��acili�y, cios • landmark,ecc_ Plcasc be as deta�led�5 possiblo. Yf�essa,ry,�a�ac�h e clia�n. ��,/�%Ca�ax� Picds�;indicate the o m u are seeki �com�cnsacion or what you would like the Ciry to do Co zesc>ivc�his eiaun to yoU�SaticFaclion��_�� . �� Vehiele Clztinns— lea5e rnm lete thys Section ❑chcck box if thxc section docs noi t� 1 'Y�aur Vehxcle: Yc:ar 2� 0 4 NTakc G—'X Nxodel Lice�nse Plau;Number S 1/ S[ate Color • �' Regzste.�ed Owner �; � Dri vc.7 of Vehicle:� '� � � Area llainaged - Q''�-�-��-�" !'S CAty Vehicle: Year ��lake Model_ � Lice�se Plau:Number State Colc�r 1 � privcr of Vehicle(Cicy Employee's Name) Area Dauk�ed l�riurv CaairnS—olease eomnlete thi5 section 0 ch.eck l�px if[his scction does tt.ot a t �-T�w wcrc.you injvxed? _. . .. . ._.... . -.— pJhat�art(s)ol your body were injurcd7 Have you sou�hc mcdical ueatuient? Y�s No Planning to Seek Trea�mc:nt(eircle} When did you xeceive uc:atmenc? (provide datc(s)) Name of�Tedical Pro�vider(s): Address Tclephone Did you miss work as a result of yo��c injury? Xes No � (provit3e dflte(S)) When did you miss woXk. Namc of�our Employer Address '�'el cphonc; Chec�C here if yoa are att�aclung more pages to t�i,s ciaim form. Nambex o�additional pages�� By signing this form,you are stating th,pt all inforniativn you lrave provided i�Lrue and correct tu the best of your knnwleitge. rinsigned fnrrns will nvt be n�ocessed Submitt�ng a false cicum can result in prosecution. Aate form�omp�eted �� f . ` ) �'rint the Name of the Pe�son who Comp�eted tbis Form: �/ f� ��'� � Sig�zature o��'er,on Maicing the C�aim:__�a�1�� ' .-.-- �La"�'�'��- �"" .. a ✓• yN7�� ReviSed Fel,r�inry 2p]1 �ZO/ �00'd �66L# �`�7l�'I7S SNI 7,2iI1ZN�� stz OZZ6ZSZZ0£ ZO�OZ ZZOZ'60'T,tIAI /D�o««� �l Accidcnt KepoR , 11254759 � «.a.o..., ti. „u. A..� nw '°� • •"t�on "` � N� 1� �f3 t50 �30 7 �•11 2I 20I1 1652 � .aror . r.� �.w. • w.c.wvoacio� ��M� � f—�r n; �N a I . $ 10 UniversiL Q s � � �1• < ca�*fo� � �nca� w +v+ �ua�A�uswM�+n�.•c�.c fi2 �`. 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IwL .. . . .. . ....... � v,.cai.,.�w.uo.w;,, . a�c. �.�a.:..a. �,,.,.w�mQ�m.. � OffiCer 3amie Sipes 724 S= Paul PD p..ic,r Qiw;�k http:/lwww.dvslesup�ort.ocg�dvsin�o/accide�itreeords 2�08/Includes LE/L'rintReportIndi... 11/25/2al i £ZO/ 900'd �66L# 3`��Il1'I�tS SNI �xnsrta� �sZZ OZZ6ZSZZ0£ ZO �OZ ZZOZ'60 '�,tlI�i 21ST CENTURY CENTENNIAI. INS. CO. HELPPOINT SUPPLEMEIVTTEAM (SL) HELPPOINT CLAIM SERVlCES BY FARMERS Claim#: 1020171670•1-� FOR SUPPLEMENTS CALI S00-282-7033 workfile ID: lgcxop4g Supplement of Record 2 5ummary Written 6y:PAMFIA 0560RN,OS/07/2022 2:09:34 PM I Adjusber Osborn,PamE�a,(913)82b-8732 Business ' Insured: JASDN ALD(ANDER Pol�cy#: 0006425%1 C�aim�: SOZO1J16�0-1-1 Type of Loss= COLLS-MD Daie of Loss: f 1/Zl/2011 430:00 PM Days to Repair: 3 Point of Impact: 07 Left Rear Deductib�e: 1000.00 Owner: Inspection Location: Appraiser i�formaiiOtl: Repair Facility: JASON ALEXANDER Hcalth Specialty Center Sldg Phone:(913)SZ6-8732 MN 55000-55599 3b0 SPRING ST 435-4th APT 202 435 Phaien Blvd $T PAUI„MN 55102 Saint Pauf,MN 55130 (626)376-7370 Other O[her (510)502-22%Day VEHICLE Year: 2009 Color: Navy Blue Int: License: 395 CVA Product�ort Date: OS/2009 BEiGE Make: LEXU Body Sty1e: 4D SED State: MN Odometer: 44000 Model: IS 250 A1lVD Engine: 6-2.SL•FI VTN: JTHCK262592030798 CondiGon: Good 4 wheal�isc Brakes Console/Storage Keyless Ensry Rz3r Oefogger 4 Wheet Drive Cruise Control Leather Seats Search/Scek Air Conditioning Driver Air Bag Overdrive Signal Integl'ated Mir'�'a►s Alarm Dua]Mirrvr5 Passer�geY Ait'Sag Stability Contlrol Alumir1Ur11/Alby Wheefs dEt17'iC G1dSS Sunroaf POWeC B�kes S[ee�ng Whee!Controls Ari Radlo FM Radio Power Oriver Seat Stereo Md-Cak Brakes(4) Fog L.amps Power Locks Telescopic Wheel AutAmatic Transmission Frorrt Side Impact Air BagS Power Mirrors Thrce Stage Faint Auxifiary Audio COnneCtion Head/Curtain Air Bags PoWet PaSSenger Seat Tilt WheN BuckeL Se2ts I1eA2Cd Mfrrors Power Steering Tinted Glass CD Changer/Stacker Heated Seats Power TNnk/Ta1lgaLe Traction Con2rol Climate Control IrtteRnitCellt Wlpers PoWel'Wlndows 05/07/2012?:09_34 PM 024348 �ge� £ZO/ L00'd 466L# ��JFIl1'I�iS SNI T,Hf1ZN�� sZZ OZZ6ZSZZ0£ tO�OZ ZZOZ'60'f,ttAI �laim it: 1020171670-1-2 Woricfile ID: igcxOp4g Supplement of Record 2 Sammary Vehide2009 LDCU IS 250 AWD 4D SED 6-25C-FI Navy Bk,e Une Operation Description Qty Extended Labor Pairtt Price� 1 SOS PILLARS,ROCKER&ELOOR 2 501 R&I LT Rock�r molding qaint to match 0.5 3 * SOl R&I LT Door w'strip frortt Q� 4 � SOl R&I LT Door w'strip rear Q,2 5 SOS ROOF 6 501 Rc'hI LT Drip molding dark blue 0.3 7 SOl Repl LT Drip mol�ng clip 9 10.89 3 SOl RACK GtA55 9 * S01 Rpr Back nlass Lexus-Rope 03 , l0 501 WiNDSHIEID ' 11 SOl Repl LT Side molding 1 50.67 12 SOl Repl LTSide molding dip 5 26.60 ' 13 i� 501 Blnd upper sai[ O.S 'i 14 QUARTER PANEL � 15 ' Rpr LT Quarter panzl 2_0 2.4 ' Sb S02 Add for Three Stage 1•% 17 Blnd Fue[door 0_2 18 R3cT Fuel door 03 19 # 501 Repl Fuef door rivets 2 3.00 20 SO1 Repl LT Quarter panel protector 1 I3.76 0.2 21 S01 RFAR CAMPS 22 R&i L7 Lens 3�housing IS 250/350 p•2 ' z3 REAR BUMPER Z4 R8eI R&I bumper cover 1.2 25 ' <> Rpr Sumper caver w/reverze sensor 2_0 3.0 z6 pverlap Major Non-Adj.Panel -0.2 27 S02 Add for Three S�ge 1.1 Z$ R&I RT RcFlector 01 29 M R&I �Raverse sensor outer blue �-1 30 M R&I t7 Reverse sensar o�aer blue a-1 � 31 R&I RT Re�erse sensor inner dark blue 0.1 32 R&I LT Reverse sernor inner dark b�ue o_1 33 R&I LT Reftector �•� 34 # Hazardous Waste I 3.00 35 # FIexA6ditive 1 2.00 X 36 � C3r Cover 1 5.00 3� ;t Refn Corrosion Protection-a<+ 03 3g SUl R&I LT Suppori�1 4-1 39 SOI R&I lT SuPPort#2 0.1 40 # 501 Blnd Rt tow eye cap fl.l 41 # 501 81nd Lt Yow eye cap 0.1 OS/07/2012 2:09:34 PM 024348 Page 2 EZO/ 900 'd fi66L# �`�7l1'I7S SNI 7,2il1,LN3� �stz OZZ6ZSZZ0£ TO �OZ ZLOZ'60 'T,'dLd C(aim#: SOZ0171S70-1-1 Wo�le IQ: 1gGCOp4g Supplement of Record 2 Summary Vehide:2Q09 LIXU IS 250 AWD 4D SED 6-2.5L-Fi Navy Blue 42 S01 TRUNK LYD a3 501 R&i L7 Slde co�er upper 0.3 44 SOl R$3 LT Side cover IoWCP 0_i 45 # 501 De-Nib and PollSh 1 0.5 46 � S01 Mask Jambs 1 0.3 47 # S01 Rl1st ProOf ng 1 5.00 0.4 SUBTOTALS 119.g2 9.6 9.S ESTIMATE TO'rA�S Category Basis Rate Cost$ Parts 117.92 Sody LabO� 9.6 hrs �¢ $50.00/hr 4$0.40 Pafnt l.abor 9.5 hrs � $50.00/hr 475.00 Paint Supplies 9.5 hrs C� S 31•00/hr �94.50 Misceilaneous 2-� SUbtOtal 1,369.42 Sales Tax $117.92 C� 7.2750% 3.58 Tota)Cost of Repalrs 2.378.flo Oeciud�ae 1,000.00 7otal Adjustments 1,000.00 Net Cost of Repaet's 378.00 OS/07/2012 2:09:34 PM 024343 �9c 3 £ZO/ 600'd �66L# ��7l�'ItIS SNI �,2if1,LN�� stZ OZT6ZSZZ0£ ZO �OZ ZZOZ'60'T,KAI C�im#: 102017I670-1-1 Worl�ife ID: 1gcxOp4g Supplernent of Record 2 Summary VehlCIe2009 LEXU I$250 AWD 4D SED 6-2.SL-F! Navy Biue SUPPLEMENT SUMMARY Line Opera[ion Description Qty Extended tabor Paint Price S Deleied Iiems 16 Add far Clear Coat -1.0 27 Add for Clcar Coai •0.6 Added Itams 16 502 Add for Three Stage 1.7 27 502 Add for TF�ree S�ge i.i SUBTOTALS 0.00 0.0 1.2 TOTALS SUMMARY Category B$sfs Rate Cost¢ Parts U.00 Paint Labot 1.2 hrs � $50.00/hr 60_00 Paint Supplies 1_2 hrs � $3!_00/hr 37.20 5ubtoEa! 97.20 7oltal Suppleeneat Amount 97.20 NET C06T OF SUP?LEMEIYT 97.20 CUMULATIVE EFFECTS OF SUPPLEMEIVT(S) Esvmate 835.88 Co�by Vogt Suppkment SO! 444.9� ]ACLYN ZARIFA Supplement 502 97.29 PAMELA 0580RfJ Workfile Total: $ 1,378.00 TOTAL AD]USTMENTS: $ 1,000.00 NET COST OF REPAIRS: $ 378.Q0 OS(07/2012 2:09:34 PM 024348 Pagn 4 £ZO/ OZO'd 666L# ��7l1'I'dS SNI �,�if1,LN�� sZZ OZL6Z5ZZOE ZO�OZ ZZOZ'60'f,7Y�I Claim#: 1020171670-1-1 Wo�fe ID; SgcxOp4g Supplement of Record 2 Sumrs�ary Vehide:2049 I.E�CU IS 250 AWO 4D SED 6-?.SL-FI cva�y 61ue QUALIT�Y REPLACEMEfV7 PARTS WARRANTY OUR REPAIR ESTINfA7E MAY SPEGIFYTHE USE OF Ql1ALTfY REPLACEMENT PAR7S. QUALITY REPLACEMENT PARTS ARE PARTS NOT MANUFACTURED BY OR�ORTHE ORIGTIVAL EQUIPMENT MANUFACTURER.WE WiLL Sl'AND BEHIN�THE QUALTTY R�PLACEMElVT PARTS THA7 ARE SPECIFl�D ON THIS ES7IMATE AND IISED IN THE REPAYR OF YOUR VENZCLE, FOR AS IONG AS YOU OWN/LEASE 7HE VEHICLE, WE WARRANT TNESE PARTS ARE OF LIKE IC(ND, QUAIITI`, SAFETY, F1T AND PERFORMANCE TO PARTS MANUFACIURED SY OR FOR THE ORIGINAL EQIJIPMENT MANUFACI'URER. THIS WARRANTY IXCLUSNELY COVERS LOSS�R DAMAGE THAT IS RELA7ED TO DEFECfS IN THE QUALYI`( REPLACEMENT PART. THIS WARRANTY DOES NOT COVER DAMAGE OR PART FAILURE DllE TO IMPROPER INSTALLAT�ON, MISUSE, NEGLECT,ABUSE,IMPROPER MAINTENANCE,ABNORMAL OPERATION, OR NORMAL WEAR &TEAR. SFiOULD A SUPPLiER OF A PART SPECIFtED IN OUR REPAIR ESTIMATE, OR THE REPAIR FAQLITY'THAT PERFORMS THE REPAIR ON YOUR VEHICLE, �E UNASLE TO RESOLVE A LEGIi�IMATE COMPLAINT A60U7 THE QUAl1TY REPLACEMENT PART USED IN THE REPATR,WE WILL MAKE EVERY E�FORT TO SEE THAT�FNE PROBLEM IS CORRECTED. rHIS WARRANIY AND ANY REPRESENTATIONS MADE HEREIN ARE NON-'fRANSFERABLE AND EXTEND ONLYTO THE PARTY OWNING/LEASTNG THE VEHIC�E AT THE�fIME OF THE REPAIR. FORASSISTANCE, PLEASE COfVTACTTHE NEARE51-HELPPOINT CI.AIM SERVICES OFFICE, DISCIAIM ER: AIVY PERSON WNO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT INSURANCE CLAIM FOR THE PAYMENT OF A LOSS MAY BE GUiLTY OF A CRIME AND MAY BE SUBJECT TO FiNES AND CANFlNEMENT IN 5fA7E PRISON. THE LABOR AND TAX RATES USED WERE DET�RMINED 6Y THE VEHICLE INSPECTION LOCATION UNLESS THE REPAIR FACTIZTY WAS KNOWN AT THE"CIME OF TH�INSPECiION OR ANOTHER LOCATION WAS SPEQFFED BEFORE THE ESTIMATE WAS PREPARED 05/o7/zos.z z:o9:34� 024348 Paqe 5 £ZO/ ZZO'd fi66L# 3`a�'!1'I75 SI�II �,2if1ZN�� sZZ OZZ6ZSZZ0£ ZO �OZ ZZOZ'60'A71nI Claim#: 1020171670-1-1 Wor�le ID: ig�X4p4g Supplement of fLacord 2 Summary Vehide:2b09 IDCU IS 250 AWD 4D S�D 6-2.SL-FI Navy B1ue "IF THE ABOVE ESTIMATE INCIUDES A NAPA PAR7 PRZCE,THE REPAIR FACILITY MIIST COMPLEfE A ONE TIME SET UP WITH THEIR LOCAL NAPA RETAILER IN ORDERTO RECENE THE SPECIAL'�ARMERS PREFERRED PAR7S PROGRAM'PRICING. TO ACCOMPLISH SET UP, CONTACT Y011R LOCAI NAPA RErAILER AND ASK THEM TO INSERT BILLING COD�NllMBER 9066 INTO YOUR CUSTOMER BILLING PROFILE. TH�9066 CODE WILL ENABLE YOUR REPAIR FACILITY TO RECQVE SPECIAL PRICING ON AlL NARA PARTS AND/OR SUPPLIES PURCHASED. IF YOU DO NOT ALREADY HAVE A LOCAL NAPA REfAILER ACCOUNT, PLEASE CAIL 1-800-LET-NAPA FOR YOUR NFAREST NAPA LOCA�ON." 7HIS ESTIMATE HAS BEE�E PR�PARED 6ASEb ON THE USE OF A MOTOR VEHICIE CRASH PART NOT MADE BY i'HE ORIGINAL EQUYPMENT MANUFACTURER. THE llSE OF A MOTOR VEHICLE CRASH PAftT NOT MADE BY THE ORIGTNAL EQUIPMENT MANUFACTURER MAY INVAl.IDATE ANY REMAINING WARRANTfES OF TH�ORIGINAL �QUIPMENT MANl1FACfURER OfV TI-fAT MOTOR VEHiCLE. THE PERSON WHO P}2EPARED 7HIS ESTIMATE WILL PROVIDE A COPY OF THE PART WARRANTY FOR CRASH PARTS NOT MADE 6Y THE ORIGINAL EQUXPMENT MANI.fFACRJRER FOR COMPARESION PURPOSES. **"TO EXPE�ITE THE HANDLING OF ANY SUPPLEMENI'AL DAMAGES CLAIM, PLEASE HAVE THE APPROXIMATE AMOUNT OF ADD�'fIONAL DAMAGES AVAILABLE WHEN YOl!CALL 1-8�0-Z8Z-7033. POTENTIALLY,A REINSPECTION MAY 6E CONDUCTED WITHIN HOURS OF YOUR CALL.ALL SUPPLEMENTS MUST BE APPROVED BY A CLAIMS REPRE5ENTATIVE BEFORE REPAIRS ARE COMPLEFED**. 'THIS ESTIMAT�HAS BEEN PREPARED BASED ON THE 115�OF CRASH PARTS SUPPLIED BY A SOURCE OTFiER THAN THE MANUFACTEJRER OF YOUR MOTOR VEHZCLE. ANY WARRAM�IES APPLICABLE TO THESE REPLACEMENT PARTS ARE PROVIDED BY THE MANUFACTURER OR DIS712IBUTOR OF THE PARTS, R,4T1-1ER THAN BY THE ORIGTNAL MANL{FACTUR�R OF YOUR VEHICLE." MN ST 60A.955 -A PEi2SON�O FILES A CLAIM WITH INTENT TO DEFRAUD OR HELPS COMMIT A FRAUD AGAINST AN INSURER IS GUILTY OF A CRIME. OS/07/2Af2 2:09:34 PM 024348 Page 6 £ZO/ ZZO 'd �66L# '3�tt11'I�iS SNI I,�if1,LN�� sZZ OZZ6ZSZZ0£ ZO�OZ ZZOZ'60'T,�I�I Claim#: 102017167D-1-1 Woriffile ID: 19«�P99 Snppfement of Record 2 Summary Vehide:2009 LEXU IS 250 AWD 4B SED 6-Z.SL-FT Navy Blue Estimate based on M070R CRASH ESTIMATING GUIDE_ Unless otherwise noted a!f items are der�ved from ttte Guide ARBS916, CCC Data Date 05/01/2012,and the parts selected are oEM-parts manufactured by the vehicles Original Equipment Manufacturer. OEM parts are available at OE/Veh9tt�dealerships. OPT OEM (Optional OEM)or ALT OEM (Altemative O�M) pa�are OEM parts that may be provided by or through altemate sources other than the OEM vehicle dealerships. OPT OEM or ALT OEM parts may reflect some speCific, special, ar unique pricing or discount. OPT OEM Or ALT OEM parts may include "Blemished" parts provided by OEM's through OEM vehicle dealerships. Asterisk(x)or Oouble Asterisk(**) indicates that the parts and/or labor inFormation provided by MOTOR may have been mocfified or may have come frorrt an alternate data source. Tilde sign (�) items indicate MOTOR Not-included Labor operations. The symbol(<>) indicates the refinish operation WlLL NOT be performed as a separate procedure from Che other panels in the e5timate. Non-Original Equipment Manufatturer aftermarket parts are deSCribed as AM. Used pdrts are described as LKQ RCY, or USED. Reconditiorted parts are deSC�bed as ReCOnd. Recored parts are described as i�ecore. NAGS Part Numbers and Benchmark Priaes are pravided by National Auto Glass Specifications. Labor operation times IisCed on the line with the NAGS infomiation are MOtOR suggested labor operation tanes. NAGS labor operation times are nat included. Pound sign (#)items indicate manual entries. Some 2012 vehicles conrain minor changes from tf�e previous year. For those vehicfes,prior to receiving updated data from the vehicle manufattiurer, labor and parts datd from the previous year may be used. The CCC ONE estimator has a complete I'►sC of appiicable vehicles. Parts numbers and prices should bE con�irmed with the local deafersh ip. '1The following is a list of additional abbreviations or symbols that may be used to desa'ibe work to be done or parts to be repaired or replaced: SYMBOLS FOLLOWING PART PRICE: m=MOTOl2 Mechanical component s=MOTOR Structural component. T=MisCeltaneous 7axed charge category. X=Mistellaneous Non-Taxed charge category. SYMSOLS FOLIOWIWC� IABOR: D=Diagnostic labor category. E=Electrical labor category. F-Frame labor category. G=Glass labor category. M=MechaniCal labor category. S=Structura! {abor Ca[egory. (numbers} 1 through 4=lJser Pefined Labor Categories. OTHER SYMSOL5 AND ABBREVIA`fIONS� Adj•=Adjacent. Algn.=Align. ALU=A(uminum. A/Nt=Aftermarket parC. Bind=6lend. BOR=6oron sieel. CAPA=Certified Automotive Pdrts Associa�ion. D&R=DiSCOnnect and Reconnect. HSS=High Strer�gtl'� Steel. NYD=Hydroformed Steel. Inc1.=Included. LKQ=Like Kind and Quality. L7=Left. MAG=Magnesium. Non-Adj.=NOrt Adjacent. NSF=NSF Zntemational Certified Part. O/N=Overhaul. Qty=Quantity. Refn=Refinish. Repl=Replace_ R&I=Remove and Install_ R&R=Remova and Replace. Rpr�Repair. RT�RIght. SAS=Sandwiched Steef. Sett=Section. Subl=Sublet. UHS=UItra High Strength Stee1. N=NOte(s) assOCi2ted with tft2 estimate line. CCC ONE Estimating-A prod�ct of CCC Information Services Inc. The following is a list of abbreviations that may be�sed in CCC ONE Estima[ing that are not part of Che MOTOR CRASH ESTIMATYNG GUIDE: BAR=Bureau of Automotive Repair. EPA=�nvironmental Protection Agency. Nf-i'FSA= Nationdl Highway Transportatbn and Safety Administration_ PDR=Paintless Dent Repair. VIN=Vehicle Id2ntification Number. 05/07/�12 2:09:34 PM 024345 Page 7 £ZO/ £ZO 'd fi66L# '3`J711'ItIS SNI T�Hf1,LN�� sTZ OZZ6ZSZZ0£ ZO �OZ ZZOZ'60 '�,ttAI 21ST C�NTURY CENT�IVNIAL INS. CO. HELPPOINT SUPPL�MENTTEAM (SL) HELPPOINT CLATM SERVICFS BY FARMERS C7aim#: 3020171670-1-1 FOR SUPPLEMENTS CALL S00-232-7033 Wot'kfile ID: 1gcxOp4g Supplement of Retord 1 Summary Writtcn 6y:J�ICLYN ZARIFA,OS/04/20x2 10:20:37 AM Adjuster:Zarifa,Jadyn.(913)826-9648 Business Insured: JASON ALEXAWD�R Policy#: 0006425961 Claim#: 1020171670-1-1 7ype of Coss: COl.Li-MD Date of Lnss= 11/Zi/2011 4:30:00 PM Days Io Repair: 3 Paint of Impact: 07 LeR Rear Deductible: 1000.00 Owner: IltSpection Location: Appraiser Ynformation: Repair Fecility: ]ASON ALEXANDER HealCh Specialty Center Bldq Phonc:(913)826-9b48 MN 55000-55599 360 SPRING 5T 435-4[h APT 202 435 Phalen BNd ST PAUL,MN 55102 Saint Paul,MN 55130 (626)376-7370 Other Other (510)SOZ-22°1b Day . VEHICLE Ycar: 2009 Cobr: Navy B�ue Irtt Lioense: 395 C1/A Production Date: 01/2A09 BEtGE Make: LDCU BOdy Style: 4D SED State: MtJ Odometer: 44000 Model: IS 250 AWD Engine: 6•2.SL-FI VIN: JTNCK262592030798 Condition: Good 4 Wheel Disc Brakes ClimatC COnt�ol IMermittent WipeCS Power v✓�ndows 4 Whxl DrNe Console/Storage KCyless Entry Rear DefoggeY Ai�COndi[ioning Cruise Cor�trol Leather Seats SearCh/$zek Alam+ Driver Air Bag ��dri�� Slgnai Irrtegretcd Mirrors Aluminum/Afloy�Nheek Dual Mirrors Passenger tir Bag StabiUty Control AM Radio Electric Cslass SUnYOOf POwer Brakes Stee�ng Whee�Corrtrots Anti-Lock 6rakcs(4) FM Radio Power DriVel'Seat Ste�eo Aucomatic Transmission Foq Lamps Power LoCks Teiescopic Wheel Auxiliary Audio Connection Front Sidc ImpeCt Wr Bags Power Mirrors Tilt Whe�l BudceC Seats Head/Curtain Air Bags Power Passenger Seat TinEed Glass CD Changer/Stacker Hcated Mirrof's PowerSteePing TracGon ControE Clear Co3t Paint Heated SCatS Power Trunk/7d'llgaie O5/04/Z012 1Q-20:37 AM 1�2I Page 1 EZO/ �ZO 'd 466L# ��7l1'I'dS SNI �,?if1ZN�� sZZ OZZ6ZSZZ0£ ZO�OZ ZZOZ'60'��YI Claim #: 10201716%0-1.-1 Wo��e ID: 1gCxOp44 Supplernent of Record 1 Su�nmary Vehide_2A09 LDCU TS 250 AN/D 4D SED 6-2.5L-FI Navy Blue Line Oper-ation DesChption Q!y Extended Labor Pain! Pr[ce$ 1 SQi PILLARS,ROCKEFZ&ROOR 2 501 R&I LT Rocker molding paint tn match 0_5 3 " 501 R&I LT Door w strip(ront Q.2 4 �` SOl R&I LT Door w'strip rzar g.2 5 SOF ROOF 6 SOl R&Y LT Drip molding dark blue �-3 7 501 Rep1 LT Drip molding clip 9 I0.89 S 501 dACK GLASS 9 x SQ1 Rp� Back as - 03 10 501 WINDSHIELD li 501 Repl LTS�demofding 1 SD.67 12 S07. Repl LT Side molding clip 5 26.60 13 # 501 Blnd upper sail O.a 14 QUARTER PANEL 15 * P.pr LT Quarter pane! 2_0 2.4 16 Add for dear Coat i.o �7 61nd FUC!door 0.2 18 R&I Fuel door fl-3 19 # 501 Repl Fuel door►ivets z 3•0� 20 SOS Repl LT Quarber pand p'o[e�r 1 13.75 0_2 ?1 SOl REAR LAMPS 22 R&I LT Lens&housing IS 250/350 �•Z 23 REAR BiSMPER 24 R&Y R&I bumper cover 1-z 25 " <> Rpr Bumper cover w/reverse sensor z=o 3.0 Z6 Overlap Major Non-Adj.Panel '0-2 27 Add for Clear Coai 0_6 28 �&I RT Rcflector 0.1 2g x R&I 7 Revene sensor �i D�Z 3p Y R&I LT Reverse sensnr euter blue �•� 31 R�I RT ReverSC Sz�sor irener dark blue 0_1 gz R&L LT Revetse sensor inner dark blue d•1 33 R&I LT ReFlector fl.l 34 # Hazardous Waste 1 3.00 35 �? Flcx AdditivC 1 2.00 X 3G # Car Covef � 5•� 37 # Refn COt7osion Protcction-�`�`� 0.3 3S 501 R&I LTSuPPort#1 0.1 39 SOl R�I LTSupport#2 0.1 40 # SO1 Blnd Rt 6oW eye cap 0.1 41 # S01 Blnd Lt bow eye cap 0_1 05/04/2012 10_2(J37 AM 1o6S21 Pa9e Z £ZO/ SZO'd �66L# ��7l1'I75 5NI I,�If1ZN�� stZ OZZ6ZSZZ0£ ZO �OZ ZZOZ'60'�T'dYd Clal�n#; 1020171670.1-1 Wor3Sfile ID: 1gocOp4g Supplement of Record 1 Summary Vchicle:2U09 LEXU LS 250 AWD 4D SED 6•Z5L-F! Navy 61ue 4z S01 lRUNK LID 43 SOl R�I LT Sidc to�er upper 0.1 44 501 R&I L7 Side cover lower �-� 45 # 501 D�Nib and Polish 1 0.5 46 # 501 Mask Jambs 1 0.3 47 # 501 Rust Proofing S 5,00 0.4 SU670TAL5 ZI9•9Z 9•6 8'3 ESTIMATE TOTALS ��9ory Basis Ratc Cost$ Par�s 117.9? eody Ltibor 9.6 hrs � 3 50.00/hr 930.Oa Pain!1.1bor o.3 hrs � S�-00/hr 415.00 Paint SupP�� S.3 hrs @ ¢31.00/hr 257.3Q Miscellanrnus z'� Subtotai 1�272.22 Sa1es Tax $ii7.92 @ 7.7750% 8.58 Tartal Cost of Rtpalrs 1,280.80 Deductible 1,0OO.Oa Total AC�ustments 1,OOfl�00 Nee Gost of Repairs 2so.so O5/04/2�i2 10:2037 AM 106521 Page 3 EZO/ 9Z0'd i�66L# ��t1l1'I�S SNI h2if],lN�� sZZ OZZ6ZSZZ0£ £O�OZ ZTOZ'60 'f,�I1nI Claim �: 1020171670-2-1 Wos�le ID: 1gCXOp4g Supplement of Record 15um�nary Veh�<<e:2a09 LDCU TS 250 AWD 4D SED 6-2.5L-F! Navy Bfue StJPPLEMETIT SUMMARY Line Operation Description Qty Extended Labor Paint Price$ Deleted I�ems 4 # Refn Sase Coat Reduction 0.5 14 # Refn Base Coat Reduction 0.5 Added Flerns i 501 PlLLARS,ROCKER&FLOOR 2 SOl R&I L7 ROCker molding paint to matCh 0.5 3 '^" 501 R&I L7 Door�n/strip front � 4 * SOl R&T LT Door w'strip reaf � 5 SO1 ROOF 6 501 R&E LT Drip molding dark blue 0.3 7 SOl Repl LT Drip molding tlip 9 IO_39 8 SOS BACK GLA55 9 * 501 Rpr ��ck_glass Lexus�Rope �c' 10 501 WT1vDSHIELD il S01 Rcpl LTSide moldng 1 50_67 12 501 Rcpl LT Slde mofding clip 5 26.60 13 # 501 Blnd upper sail O.a 19 # SOS Repl Fuel door riveCs 2 3•00 • 20 SOl Repl LT Qudfler panef protector I 13.76 0.2 3S SOl R&I LTSupport tl O.I' 39 SOS FFcT LT Support#2 fl•� 40 # 501 Blnd Rt tow eye G7p 0.1 4i # 501 Blnd Lt tOW eye cap 0_i 42 SOl TRUNK LID 43 S01 R&I LT Sde cover upp� 0.1 44 S01 R&I LT Side tove�fower �•1 45 # SDi DcNib and Polish 1 0.5 4b # 50! Mask]ambs � 1 03 47 # SO1 R�st Proafing 1 5.00 Q-4 ' SU6T07AL5 1�9.92 3.3 �O OS/04/2012 10:20.37 AM 106821 page 4 EZO/ LZO'd fi56L# 3�J�l�'IFIS SNI xxnsNa� �sZZ OZZ6ZSZZOE £O �OZ ZZOZ'60 'T,7Yd Glairn#: 10201716�0-1-1 Wor�Jile ID: 1gacOp4g Supplemerst of Record I Summary Vehicle=2009 LfJCU TS 250 A�ND 4D SED b-Z.SL-FT Navy Blue TOTALS SUMMARY Category Basis Rate COS=� Parts 109.92 g�y�pjpr 3.3 hi5 � $50.00/hC 165.00 paint Labor 2.0 hrs @ $50.00/hr 500.00 paint Supplies 2.0 hrs p S 31.00/hr 62.00 Subtotal 436.92 Sales TIlx $104.92 C� 7.2750°i6 8-� Totlil SuPPlement pmOUn! 444.92 NEi'COST OF SUPPLEMENT 444.92 CUMULATNE EFFECTS OF SUPPLEMENT(S) EstimaEe 835.88. Colby Vogt Suppkment SOl 494.92 ]ACLYN ZAR3FA Workfile Total: $ 1,280.80 TOTAL AU7USTMENTS: S 1,000.00 NET COST O�REPAIRS; $ 280.80 QUAL1l�Y REPLACEMENT PAR7S WARRAMY OUR REPAIR ESTIMATE MAY SPEQFY THE US�OF QIJALiIY REPIACEMENT PARTS- QlJALTfY REPLACEMENT PARTS ARE PARTS NOT MANUFACTURED BY OR FORTr1E ORIGINAL EQUIPM�NT MANUFACTURER.WE WILL STAND BEHIRdD THE QUALITY REPLACEMENT PARTS THAT ARE SPEClFIED ON TFiIS ES1�MA�'E AND USED iN TNE REPATR OF YOUR VEHICLE, FOR AS LONG AS YOU OWN/LEASE THE VEHICLE. WE WARRANT"iliESE PARTS ARE 0� LIKE IQNB,QUALITY, SAFE7Y, FIT AND PERFORMANCE TO PARTS MANUFACTURED 6Y OR FOR THE ORIGINAL EQUIPMENT MANUFACTURER. THTS WARRAfVTY IXCLUSNELY COVERS L055 OR DAMAGE THAT IS RELATFD TO DEFECTS IN THE QUALITY REPLACEMENT PART. THIS WARRANTY DOES NOT COVER DAMAGE OR PART FAIUJRE DUE TO IMPROPER INSTALLATlON, MISUSE,NECzL�CT, ABUSE, EMPROPER MAIM-ENANCE, ABNOl2MAL OPERATiON,OR NORMAL WEAR &TEAR. SHOULD A SllPPLIER OF A PART SPECYFIED IN OUR REP/uR ESTIMAT�, ORTHE F2EPAIR FAQL1�'Y THAT PERFORMS 7HE REPAIR ON YOUR VEHICLE, BE UNABLE TO RESOLVE A LEGITIMATE COMPLAINT ABOUT T1-tE QUALIfY REPLACEMENT PART USED IN THE REPAIR,WE WIIL MAKE EV�RY EFFORTTO SEE THATTHE PROBLEM IS coaRECrEQ. THIS WARRAN'TV AND ANY REPRESENTATFONS MADE hiEREIN ARE NON-TRAIVSFERABLE AND EX'�END ONLY TO THE PARTY OWNING/I,EASING Tfi1E VEHiCLE l�TTH�TfME OFT}IE Rc�AiR. . FOR ASSISTANCE, PLEASE GONTACT THE NEARESf HELPPOINT CLAIM SERVYCES OFFiCE. DISCLAIMER: 05/04/20J.2 1020:37 AM I06821 Page 5 EZO/ 9Z0 'd i766L# �`a7l12tiS SNI T,2if1,LN3� �stZ OZZ6ZSZZ0£ £O �OZ ZZOZ'60 '��Int qaim#: 3020I71670-1-1 Workfi�e ID: lgcxOp4g Supplement of Record 1 Summary Vehicfe:2009 LDCU IS 250 AWD 4p SED 6•ZSL-FI Navy 81ue ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULEN7 INSURANCE CLAIM FOR 7HE PAYMEN7 OF A LOSS MAY 6E GUILTY OF A CR�ME AND MAY BE SUBJECTTO FINES AND CONFINEMENT IN STATE PRTSON. THE LASOR AND TAX RATES USED WERE DETERMIfVED BY THE VEHICL�INSPECTION LOCATION UNLESS TH� REPAIR FACIf_LTY WAS KNOWN AT Tf-{E 7IME OF THE INSPECTION OR ANOTHER LOCATION WAS SPEC7FIED BEFORE YHE ESTIMA7E WAS PREPA�ED "IF'fHE ABOV�ESTZMATE YNCLUDES A NAPA PART'PRIGE,THE l2EPAIR FACILIfY MUST COMPLEfE A ONE TIME SET UP WITN TNEIR LOCAL NAPA REfAILER IN 0l2DER TO R�CENE THE SPECIAL'�ARMERS PREFERIZED PARTS PROGRAM' PRICING. TO ACCOMPLiSH SET UP,CONTAC7 YOUR tOCAL NAPA RETAILER AND ASK THEM TO YNSERT BTLI.�NG CODE NUMBER 9066 INTO YOUR CUSTOM�R BILEING PROFILE. THE 9066 CODE WILL ENABLE YOUR REPAIR FAC�LiTY TO RECEIVE SPECZAL PRICENG ON ALL NAPA PARTS ANO/OR SUPPI.YES PURCFiASED. IF YOU QO NOT ALREADY HAVE A LOCAL NAPA RETATLER ACCOUNT, PLEASE CALL 1-800-1.ET-NAPA FOR YOUR NEAREST NAPA LOCATION." THIS ESTIMATE HAS BEEN PREPARED SASED ON 7HE ISSE OF A MOTOR V�HTCLE CRASN PART NOT MADE BY T11E ORIG�NAL EQUlPMENT MANUFACTURER. THE!!SE OF A MOTOR VEHICLE CRASN PART NOT MADE SY 7NE ORI6INAL EQUIPMENT MANUFACTEJRER MAY INVAl.IDATE ANY REMAINING WARRAN7IES OF THE ORI�INAL EQUIPMENT MANUFACTURER ON THAT MOTOR VEHICLE. THE PERSON WHO PREPARED THIS ESTIMATE iM1/�LL PROVIDE A COPY OF THE PART WARRAMY FOR CRASH PAR7S N�T MADE BY THE ORIGINAL EQUIPMENT MANUFACTLIRER FOR COMPARISION PURPOSES. �`�TO EXPEDITE THE HANDLING OF ANY SUPPLEMEM'AL DAMAGES CLAIM,PLEASE HAVE THE APPROXIMATE AMOUNT OF ADDITIONAL DAMAGES AVAILABLE WHEN YOU CALI 1�800-2$2-7033. POTEI�fIALLY,A RQNSPECT�ON MAY 8E CONDUCTED WITHIN HOEJRS OF YOUR CALL.ALl SUPPLEMENTS MUST BE APPROVEO BY A CLAIMS �EPRESENTATNE BEFORE REPAIRS ARE COMPL.ETED**. 'THIS E5TIMATE HAS BEEN PREPARED BASED ON THE USE OF CRASH PARTS SUPPLIED BY A SOURCE OTHER THAN THE MANUFACTURER OF YOUR MOTOR VEHZCLE. ANY WARRANTYES APPLICABIE TO THESE REPLAC�MENT PARTS ARE PROVIDED BY THE MANUFACTURER OR DISTRIBUTOR OF THE PAR7S, RATHER 7HAN 6Y THE ORIGINAL MANUFACTURER OF YOUR VEHICLE." MN Sf 60A.955 -A P�RSON.WHO F�LES A CLAIM WITH IfVTENTTO DEFRAUD OR HELPS COMMIT A FRAUD AGAINST AN INSURER IS GUIL'T�'OF A CRIME_ 05/04l�12 10:Z0:37 AM 106821 Paqe 6 £ZO/ 6Z0'd fi56L# 3`��Il1'I7S SNI �,2iflZN�� sZZ OZZ6ZSZZ0£ £O �OZ ZZOZ'60'I,7Yd Claim#: IaZ01�1670-1-i WO�Ie ID_ 19�P49 Supplement of Record i Summary Vehicle2009 E.EXU IS 250 AWD 4�SED 6�25L-FI Navy Blue Estimate based on MOTOR CRASH ES7IMATING GUIDE. Un(ess otherwise noted all items are derived from ttte Guide ARB8916,CCC Data Dabe 04/16/2012, and the parts selected are OEM-parts manufactured by the vehicles Original Equipment Manufatturer. O�M parts are available at OEN��deaierships. OPT OEM (Optional OEM)or ALT OEM (Altemative OEM) parfs are OEM par[s that may be provided by or through altemate sources other than the OEM vehicle dealerships. OPT O�M or ALT OEM pa�ts may reflect some specific,special, or un9que p�cing or discount. OPT OEM or ALT OEM parts may include"Blemished" parts provided by O�M's throuqh OEM vehicle dealerships. Asterisk(*)or pouble Asterisk(*°k)indicates tha[Uie parts and/or labor information provided by MOTOR may have been modified or may have come from an altemdte data source. Tilde sign (N)itemS indicate MOTOR Not-Included Labor operaYions_ The symbol(<>) indicates the refinish operation WILL NOT be performed as a separate procedure from the other panels in the estimate. Non-0r'�ginal Equipment Manufacturer dftermaNcet parts dre descxibed ds AM. Usec!partS are desa�ibed as LKQ, RGY, Or USED. ReCOnditioned parts are described as Recond. ReCOred parts are described as Recore. NAGS Part Numbers and Bet�Chmark Prices are pravided by National Auto Giass SpECifitations_ Labor operdtion times listed on the line wit�'1 tre NAGS information are MOTOR suggested labor operation times. NAGS labor operation tunes are not included. Pound sign (#) items indicate manual erttrie5. Some 2012 vehicles cvntain minor cfianges from the previous year. For those vehicies, prior to receiving updated data from the vehicle manufacturer, labor and partS data fran the previous yedr may be used. Ttle CCC OiVE �stimator has a camplete list of appl�able vehicles. Parts numbers and prices shauld be confirmed with the focal dealership_ �1'le following is a list of additional abbreviations or symbols that may be used to d�cribe work to be done or parts to be repdired or replaced: SYMBOIS FOLLOWIN6 PART PRICE: m�M01-OR Mect�anical component. s=MOTOR Shvchural component. T=MisceltaneousTaxed charge tategory. X=Miscellaneous Non-Taxed charge category. SYMBOLS FOLLOWING LABOR: D=Diagnostic labor category. E=Electr'ica! Id[�or category. F=Frame labor tategory. G=Glass kabor category. M=Mechanical labor category. 5=5tructural iabor category. (numbers) 1 tf�rough 4=USer Defined Labcx�Categories, OTHER SYM80L5 AND ABBREVIATIONS: Adj.=Adjacent. Algn.=Align. AtU=Aluminum. A/M=AfteRnarket part. BInd=Blend. 60R^Boron steel, CAPA=Certified AuComotive Pdrts Association. D&R=Discorl�3eCt and Reconne�[. HSS=Nigh Strength Steel. HYD=Hydroformed Steel, Znc1.=Included. LKQ=Like Kind and Qva1'rty_ LT=Left. MAG=Magnesiutll. IVon-Adj,=Non AdjdCent_ NSF=NSF Intemational Certified Part. O/H�Overhdul. Qty=Quantity. Refi=Refinish- Repl=Replace. R&I=Remove and Install. R&R=Remove and Replace. Rpr=Repair. RT=Right. SAS=Sandwiched Steel. Sect=Section. Subl=Subiet. UHS=UItra High Strength Steel. N=Note(s)associated with tfte est�mate line. CCC ONE Estimating - A product of CCC Informatian Services Inc_ '17�e foEiowing iS a list of abbreviati�ns that may be used in CCC ONE Estimating that dre not part of the MOTOR CRASH ESTIMATTNG GIJIDE: 6AR=6ureau of Autotl1otive Repair. EPA=Envirottmental ProteCtion Agency. NHTSA= Nativnai Highway Transportation and Safety Administration. PDR=Paintless Dent Repair. 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Pzoof of PayrnenF Date: U5/tk�/2012 Payee: JASON�ll,FXANDER.t�ND VILLIIG�Q3EVIZOT..ET CO 1755 W1�.Y7:ATA BLVI�L WAYZl�'1'A,�Lv,55391 , Paymcnt Descript}o�i; Iv�ateri�l I}ama�e Amounr. �444.92 17at.e: 05/t)7/?012 l:'ayec: Jn.50i�'A.LE7<.ANDER 1\i�i� v�i.�.g�E CHr�.VROLE'1' Cc� 17�5�%1�1'7�T�liLVll L WAYGATA,MN,55391 l?zyment Description, Mazerial Dazxiage Amnunr: $97.20 Sub Toral: $542.12 Dcducdble Amou��t: �1,OU�.�O Salvage $0_00 Total t�rraoun� �1,54?-12 £ZO/ £ZO'd 466L# �`�til�'I7S SNI ��il1,LN�� stZ OZZ6Z5ZZ0£ �O�OZ llaZ'60'�,tlYd