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Lautz American Family Ins . 8/8/2012 11 : 51 : 27 AM PAGE 1/015 Fax Server American Family Insurance Group MERICAN FAM1 Scanning Center 6000 American Pkwy � Madison, WI 53783-0001 Facsimile Cover Sheet To: Shari Moore Company: City Of St Paul City/State: St Paul MN Phone: Fax: 6512668574 From: Jamie D. Lautz Company: American Family Insurance Group Phone: Fax: 555-555-5555 Comments: Shari, I was advised by Sandra Bodensteiner to fax this information to you. Attached is the completed St. Paul Water claim form, along with a copy of our estimate, photos of the damage 8t rental bill. Thanks, ]amie Lautz American Family Insurance 804-692-6326 x 72262 jlau�@amfam.com The information contained in this facsimile message is attorney privileged and/or confidential informa6on intended only for the use of the individual or entity named above. If the reader of this message is not the intended recipient, or the employee or agent responsible to deliver it to the intended recipient, you are hereby notified that any dissemina6on,distribution, or copying of this communica6on is strictly prohibited if you have received this communication in error please notify us immediately by telephone using our toll free number 1-800-374-1111 at the extension iderrtified in the American Family phone number provided above so we may arrange for the return of this material at our e�ense. Thank you. Date&Time of Transmission: 8/8/2012 11:50:56 AM Number of pages including this cover sheet: 15 American Family Ins . 8/8/2012 11 : 51 : 27 AM PAGE 13/015 Fax Server NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota Minne.rntu Srcue S►u�ute 466.OS srures rlru� "...everp per.�n��...whn duims dan�a�,�e,c jrum un>>mu+�icipalit��...shu!!cau,sr.lo he presenled to�he gaverr►i�r�,�b�xl}'r�f rhe rn�nrlciperlrry withi�� /80 du�•s afler Ihr ulle�ed luss nr injury i.r cliccuvrred c��ru/icc s�crlirrg flre time.>>Ictce.u�id circuutslrntces ll►erer�f,and d�e amnttri�nf c�nmpe�i.culinn or ollrer�tli<<j�cmundc:d," Please comptete this form in its entirety by clearty typing or printing your answer to each question. If more space is needed,attuch additional sheets. Ptease nofe that you will not be contacted by telephone to clarify answers,so provide as much information as necessary to explain your claim,und the amount of compensution being requested. Yvu will receive a written acknowtedgement once yoar form is received. The process cun take up to ten weeks or longer depending on the nature of your claim. This form must be signed,an�!both pages completed. If something does not apply,write�NIA'. SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK, IS WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, M ��2� R C � First Name .lAMIE Middle lnitial � Last Name 1l1�Cf�ZZ Company oc Business Name AMER�CAN FAMILY (NS[JRAtJCE � Are You an Insurance Company? es No If Yes,Claim Number? ,��-7()'J�(o(o �f��'�"��L Street Address Io�O aMERtC'AN PKwY City MADISOtS State �l Zip Code 53?$ x�22l02 Daytime Phone(��pQ)�-b32 Cell Phone(�) - Evening Telephone( } - Date of Accident/lnjury or Date Discovered��12_____ Time 4� am/�m� Please state, in de[ai1,what occurred{happened),�nd why yau are submitting u claim. Please indicate why or how you feel the City of SainE Paul or its employees are in�olved and/or i�esponsible for yvur damages. JN$11KED 5'�AT'�A �j�9�Rr2�/['►f Atl f1AJSF1'11��f� MAI�HOI� COYE2 LYIt� Ji� �E �11 bD1E (I� MARYlAND ��E7S�lEE�1 SRl/1i.Sr2E�'C5 0� FERrIDAt��iL�f'�� N �IF►�J��b Mnf ��' RmJ�GD Ta SL'E�� T17 PHort�- ��d��tiL�� E��l.(IYEF SFrUR�u, oVEe. Ptease check the box(es)that most closely represent the reason for completing this form: O My vehicle was damaged in an accident O 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 vehicte was wrongfully towed andlor ticketed ❑ I was injured on City property �Other type of property damage-please specify ❑Other type of injury-please specify In arder to process your claim you need to include copies of aIl annlicable documents. Far the claims types iisted below,please be sure to include the documents indicated or it wi{i delay the hand;ing af your claim. Documents WILL NOT be returned and become the property of the City. You are encouraged to keep a copy for yourself befo�submitting your claim form. �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 etaims: legible copies of any ticket issued and a copy of the impound lot receipt O Other praperty damage clairns: twa repair estimates if the damuge exceeds$500.00;or the actual bills andlor receipts for the repairs;detailed list of damaged items O Injury claims: medical bilIs,receipts � Phatographs are always welcome to document and support your claim but wili not be retumed. Page 2 of 2-Please complete and return both pages of Claim Form American Family Ins . 8/8/2012 11 : 51 : 27 AM PAGE 14/015 Fax Server Failure to complete and return both pages will result in delay in the handling of your claim. Ali Claims—please comolete this section Were there wi[nesses to the incident? Yes No Unknown (circle) Provide their names,addresses and telephane numbers: _Q�Q �K�uRED� (}'17�IfR VEN IL'I.�S St1zcJC,� Co1f£� AU-�O� 11Ur NAVF E� FOR�IATt�rl. Were the potice or law enforcement called'? Yes Q Unknown (circle) If yes, what department or agency'? Case#or report# Where did the accident or injury take place? Provide street address,cross street, intersection, name of park or facility, closest landmark,etc. Please be as det�liled as possible, If necessary, attaeh a diagram. MA�((j11�D�({�`t1n1�F�( �erJoat� � MCurl�r4r MAY1fv�1DOn M�L Please indicate the amount yau are seeking in compensation ar what you would like the City to do to resolve this c1Aim t�your satisfaction. �f!1'1•q,� �pnMA(;� oF f�05�•Q4 + R�AL �to0�) Vehicle Claims—nlease comolete this section O check box if this section does nat aavlv Your Vehicle; Year � Z�iO Make�NRY51.�Q Model 3A� 'f'�t.bZ11J6 License Plate Number Siate Color BIAC�C Registered Owner L15/4 S1�11B Driver of Vehicle LISA �$ Area Damaged �r Q�R WN��L.-�_�„�i_tlSPFt�tOtJ T— City Vehicle: Year Make Mode! License Plate Number State Color Driver of Vehicle(City Employee's Name} Area Damaged Iniurv Claims—�lease complete this section C,��gck box if this section daes not annly How were you injured? Wh1t part{s)of your body were injured? _ _ _ ..... Have yau sought medical treatment'? Yes No Planning ta Seek Treatment(circle) When did you receive tr�atment? (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 Bmployer: Address Telephone �Check here if you are attaching more pages to this claim form. Number of additional pages.�. By signing thrs form,you are stating that oll tnfarmation you lrave provided is true and correct to the best of your knowledge. Unsigned fornts will not be processed Submittirtg a false clai.rn can result in prosecution. Dete form was completed 8��}2 Print the Name of the Person who Completed this Form: .�.JAM►�,.�tn� Signature of Person Maldng the Claim: Revised February 20t 7 Ame��g�E��jat��en�ir�a�i��n��te�7 � PAGE 4/015 Fax Serv�ge 1 of 1 � ?�?, �� AMERICAN Rental Company:ENTERPRISE RENT-A-CAR `• � Invoice: D537048-1929 FAMILY CRD ................................................................................................................................................................................................................................ Bill To: AMF44RU ��:5;:�;, ;r�;;,:�;�; AMERICAN FAMILY CRD ATTN: .*'CRD Rental Period: 7/11/12 to 7/13/12 (3 days) 302 N. WALBRIDGE Billed Period: 7/11/12 to 7/13/12(3 days) MADISON , WI 53783 ;�;:�'�i��€�?��;�3?si'�';i.�� '�'::�c;;.,�:�.:�:...:�.r�::::�> Rate Amount Renter. STRUB, LISA ; 3 DAYS @ 17.49 :: $52.47 : r �?'�3 ZZ�Z.itivt'�Cit�.�lr�i�2��' .�:\:�i��::i`.:3 Rental Branch Location: �"'�"'"''��'•`�' ENTERPRISE RENT-A-CAR(1929) > 1 SURCHARGE% 11.20% :: $5.88 : 8230 HUDSON RD WOODBURY, MN 551259111 ; 1 SALES TAX 7.12% € $3.74 � (651) 772-2995�v ;..............................................::.......................;.:........................: Total Charges: $62.09 : ;t:�:'��'�ti:?�=�?..�:.t_s,;�: ;��=:;��•t::i��: Less Amount Received: $2.09 Claim Number:00241707966 Total Amount Due: $60.00 : Claim Type: Insured Vehicle Condition: Non-Driveable Date Of Loss: 7/9/12 Insured Name: LISA STRUB Owner's Vehicle:2010 CHRYSLER 300 Additional Driver. Repair Facility: CENTURY AVE COLLISION N ST PAUL, MN 55109 (651) 777-6055�� ':::.,��::i.:::��::�il_..'t;: Effective Starting Ending Rate Date and Year Make Model VIN Mileage Mileage Mileage Charged Time 7/11/12 2012 CHEV IMPA 2G1WC5E36C1151475 22973 23127 154 $17.49 3:08 PM .'�'��a`�`a��3 �a3��a��.� ................................................................................................................................................................................................................................ Please Return This Portion with Remittance Make Payment To: Total Charges: $62.09 ENTERPRISE RENT-A-CAR Less Amount Received: $2.09 P.O. BOX 840086 Total Amount Due.................... $60.00 KANSAS CITY, MO 64184-0086 Federal ID:43-0724835 Please include on your check: Invoice: D537048-1929 https://www.armsweb.com/armsweb/approveinvoice 7/14/2012 American Family Ins . 8/8/2012 11 : 51 : 27 AM PAGE 5/015 Fax Server CENTURY AVENUE COLLISION CENTER WHERE QUALITY&SERVICE COMES FIRST 2501 CENTURY AVENUE 2 BLOCKS SOUTH OF HWY 36 PHONE:651-777-6055 FAX:651-779-9417 **4 SUPPLEMENT 1 *** 07/10/2012 03:21 PM S1 07/16/2012 04:49 PM ............................................................................................................................................................................................................................................................................: : Owner � ,,.,»...............................................».,.»......,....,....»,....,.,...,,.,..,.....,».......»,.»........,.,,.....»,.,,......»»,....,.,,,,,,.,,,,......»»,.......,,,....,»»..,....,,,...........»,....»..,.........»,.......,,.,.....,....,..., Owner: LISA STRUB Address: 2585 IVY AVE E APT 106 Work/Evening: (651)777-7091 Home/Day: (651)307-2460 City State Z.ip: MAPLEWOOD, MN 55119-7153 FAX: ............................................................................................................................................................................................................................................................................: ; Control Information � ...........................................................................................................................................................................................................................................................................: Claim#: 00241707966-OC Insured Policy#: 1861212201 Loss Date/Time: 07/09/2012 07:00 AM Loss Type: Collision Deductible: $500.00 Ins. Company: American Family Insurance Insured: LISA STRUB Address: (651)777-7091 (651)307-2460 ............................................................................................................................................................................................................................................................................: ; inspection ' ...........................................................................................................................................................................................................................................................................? Inspection Date: 07/1 0/201 2 03:19 PM Inspection Type: Direct Repair Program Inspection Location: Century Avenue Collision Contact: Garry Olson Address: 2501 Division Street North Work/Day: (651)777-6055x City State Zip: North Saint Paul, MN 551 09-31 1 1 Work/Day: Primary Impact: Left Rear Side Secondary Impact: Driveable: No Rental Assisted: No Assigned Date/Time: Received DateTme: 07/10/2012 09:55 AM Frst Contact Date/Time: Appointment Date/Time: 07/1 1/201 2 07:00 AM Appraiser Name: MIKE MATTESON Appraiser License#: Address: Work/Day: (651)777-6055 City State T.ip: N. ST. PAUL, MN 55109 FAX: Orig Appraiser Name: Garry Olson Appraiser License#: ......................................................................................................................................................................................................................... ; �...RePa i rer......................... ................... .......................... ............................................................................. ...........:.. ........... ................................................. . ..... . .... ..... ... ..... • Repairer: Century Avenue Collision Contact: Garry Olson Address: 2501 Division Street North Work/Day: (651)777-6055 City State Zip: North Saint Paul, MN 551 09-31 1 1 Work/Day: Repair Start Date/Time: Vehicle Drop Off Date/Time: 07/10/2012 03:20 PM Target Complete Date/Time: Days To Repair: 1 ,..........................................................................................................................................................................................................................................................................: : Remarks ' :...........................................................................................................................................................................................................................................................................: CHECK INNERS AT TEARDOWN 07/16/2012 OSA1 PM Paqe 1 ot 3 American Family Ins . 8/8/2012 11 : 51 : 27 AM PAGE 6/015 Fax Server 2010 Chrysler 300 Touring Plus 4 DR Sedan o7/10/2012 03:21 PM Claim#- 00241707966-OC 07/16/2012 04:49 PM ..Vehicle.................................................................................................................................... ..... ;..........................................................................................................................................................................................................................................................................a 2010 Chrysler 300 Touring Plus 4 DR Sedan 6cyl Gasoline 3.5 HO 4 Speed Automatic Lic.Plate: 254 HVK Lic State: MN Lic Expire: 12/2012 VIN: 2C3CA5CV9AH241670 Prod Date: 05/2010 Mileage: 51,219 Veh Insp#: Mileage Type: Actual Condition: Good Code: M2613B Ext.Color: BRILLIANT BLACK PRL Int.Cdor: Ext. Refinish: Two-Stage Int.Refinish: Two-Stage Ext. Paint Code: PXR Int.Trim Code: Options 2nd Row Head Airbags AM/FM CD Player Air Conditioning Alarm System Aluminum/Alloy Wheels Anti-Lock Brakes Auto Headlamp Control Bucket Seats Center Console Cruise Control Dual Airbags Floor Mats Fog Lights Halogen Headlights Head Airbags Heated Power Mirrors Illuminatd Visor Mirrors Intermittent Wipers Keyless Entry System Leather Steering Wheel Lighted Entry System MP3 Player Overhead Console Power Brakes Power poor Locks Power Drivers Seat Power Steering Power Windows Rear Window Defroster Rem Trunk-UGate Release Split Folding Rear Seat Stability Cntrl Suspensn Tachometer Telescopic Steering Whl Theft Deterrent System Tilt Steering Wheel Tinted Glass Traction Control System Velour/Cloth Seats ,..Damages................................................................................................................................................................................................................................................... Line Op Guide MC Description MFR.Part No. Price ADJ°� B°k Hours R 1 EC 1998 Wheel,Rear LT Replace Economy $431.25' 02 SM »VCT SCARFACE6 22X9.5 CH ROME 2 E 866 Link,Rear Suspension LT 68051639AA $143.00 � 22 ME 3 SB 4 WHEEL ALIGNMENT Sublet Repair $79.95' SM 4 EC LEFT REAR TIRE Replace Economy $135.14' SM* Betterment 30 »DURUN F-1 265/35R22 102V XL 4 Items ............................................................................................................................................................................................................................................................................: : Estimate Total&Entries ; :............................................................................................................................................................................................................................................................................ Gross Parts $143.00 Other Parts $566.39 Parts& Material Total $709.39 Tax On Parts Only @ 7.125% $50.54 Labor Rate Replace Repair Hrs Total Hrs Hrs Sheet Metal(SM) $50.00 02 02 $10.00 Mech/Elec(ME) $75.00 2.2 2.2 $165.00 Frame(FR) $68.00 Refinish(RF) $50.00 Paint Materials $30.00 07/16/2012 05-A 1 PM Page 2 ot 3 American Family Ins . 8/8/2012 11 : 51 : 27 AM PAGE 7/015 Fax Server 2010 Chrysler 300 Touring PIus4 DR Sedan 07/70/2012 0327 PM Claim k: 0 02 41 70796 6-OC 07/16/2012 04:49 PM Labor Total 2.4 Hours $175.00 Sublet Repairs $79.95 Towing $78.00 Tax On Towing @ 7.125% $5.56 Gross Total $1,098.44 Less: Deductible $500.00- Less: Betterment $40.54- Net Total $557.90 Less: Previous Net Total $557.90- Net Supplement Total (Final Bill) $0.00 Alternate Parts Y/00/00/00/00/00 CUM 00/00/00/00/00 Zip Code: 55109 AmFamCAPA Recycled Parts Y/0/0 Zip Code:55109 INV DATE:07/13/2012 Requested Review On:07/16/2012 05:01 PM Audatex Estimating 6.0.726 S1 07/16/2012 05:01 PM REL 6.0.726 DT 06/01/2012 DB 07/15/2012 Copyright(C)2011 Audatex North America,Inc. THIS ESTIMATE MAY INCLUDE AFTER—MARKET OR CRASH PARTS SUPPLIED BY A SOURCE OTHER THAN THE MANUFACTURER OF YOUR VEHICLE. THESE PARTS CAN BE IDENTIFIED BY THE DESIGNATION "**QRP/QUALITY REPLACEMENT PARTS" ON THE ESTIMATE. WARRANTIES APPLICABLE TO THESE REPLACEMENT PARTS ARE PROVIDED BY THE MANUFACTURER OR DISTRIBUTOR OF THESE PARTS, RATHER THAN THE MANUFACTURER OF YOUR VEHICLE. FOR YOUR PROTECTION, MINNESOTA LAW REQUIRES US TO INFORM YOU: A PERSON WHO SUBMITS AN APPLICATION OR FILES A CLAIM WITH INTENT TO DEFRAUD OR HELP COMMIT A FRAUD AGAINST AN INSURER IS GUILTY OF A CRIME. Op Codes ' = User-Entered Value E = Replace OEM NG= Replace NAGS EC= Replace Economy OE= Replace PXN OE Srpls UE= Replace OE Surplus ET= Partial Replace Labor EP= Replace PXN EU= RECYCLED PART TE = Partial Replace Price PM= Replace PXN Reman/Reblt UM= Replace Reman/Rebuilt L = Refinish PC= Replace PXN Reconditioned UC= Replace Reconditioned TT = Two-Tone SB= Sublet Repair N = Additional Labor BR= Blend Refinish I = Repair IT = Partial Repair CG= Chipguard RI = R& I Assembly P = Check AA= Appearance Allowance RP= Related Prior Damage This report contains proprietary information of Audatex and may not be disclosed to any third party(other than \��o��>�•• the insured,claimant and others on a need to know basis in order to effectuate the claims process)without ��"��' AudateXs prior written consent. �;,,,:;;;.••:r�,�,:.s::�, � �� Copyright(C)2011 Audatex North America,Ina Audatex Estimating is a trademark of Audatex North America, Inc. 07/16/2012 05�.01 PM Page 3 01 3 American Family Ins . 8/8/2012 11 : 51 : 27 AM PAGE 8/015 Fax Server ***SUPPLEMENT RECONCILIATION«.« Supplement S1 Claim#: 00241707966-OC Insured Policy#: 1 861 21 2201 Flle#: Claim Rep: Insured: LISA STRUB Inspectlon Date/Time: 07/10/2012 03:19 PM Owner Name: LISA STRUB Appraiser Name: MIKE MATTESON Vehicle: 2010 Chrysler 300 Touring Plus 4 DR Sedan Actual Supplement 1 Net Total �0.00+ :.............................................................................................................................................................................................................................................................: ;SummarY............................................................................................................................................................................................................................................: Net Total Date Time Appraiser Origina) Estimate $557.90 07/10/2012 09:59 AM Garry Olson Supplement 1 $557.90 07/16/2012 04:49 PM MIKE MATTESON This report contains proprietary information of Audafex 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 �� priorwrittenconsent. d 3c:+e,.r.r;�<�r:::a��Q�\\\�� Py 9 � ) ... Co ri ht C 2011 Audatex North America,Inc. Audatex Estimatin is atrademark of Audatex North America,Inc. 07/16/2012 05:01 PM Page 1 ot 1 American Family Ins . 8/8/2012 11 : 51 : 27 AM PAGE 9/015 Fax Server "'REVIEW'�' Claim#: 00241707966-OC Insured Policy#: 1 861 21 2201 Flle#: Clalm Rep: Insured: LISA STRUB Inspection Date/Time: 07/1 0/201 2 03:19 PM Owner Name: LISA STRUB Appraiser Name: MIKE MATTESON Vehicle: 2010 Chrysler 300 Touring Plus 4 DR Sedan ...............................................................................................................................................................................................................................................................: ?Summary ' ..........................................................................................................................................................................................................................................................: Date Time Net Total Updated By Type 07/16/2012 05:01 PM $557.90 Century Ave Collision Supplement 1 07/13/2012 09:58 AM $557.90 Century Ave Collision Original Estimate(before review) Admin Changes From To SUP Supplement Appraiser-First Name: Garry MIKE SUP Supplement Appraiser-Last Name: Olson MATTESON SUP Supplement Appraiser-City: N.ST. PAUL SUP Supplement Appraser-State: MN SUP Supplement Appraiser-Zip: 55109- SUP Supplement Appraiser-Phone 1: (651)777-6055x Notes Added This report contains proprietary information of Audatex and may not be disclosed to any third party(other than the \��""" insured,daimant and others on a need to know basis in order to effectuate the claims process)without Audatex's ��1��i'y�" prior written consent. LrF 4�.+� .�r�w.;��s st`e�,;...��Q\\\\�� Copyrlght(C)2011 Audatex North AmeNca,Inc. Audatex Estimatin is a trademark of Audatex North America,Inc. 07/16/2012 05:01 PM Page 1 ot 1 American Family Ins . 8/8/2012 11 : 51 : 27 AM PAGE 10/015 Fax Server r+� AMERfCAN FIk1YE1LY ;� A�v�€:�:k.Ye;.�.�v� �.�:[v��:�� r��s�r�z��r:� G�zt:��:a�� ----------------------------------------------------------_..._.---_-------------------------------------------------------------------------------------____--------------------------------------------------------------- 5C.,hN�!\t3 t'13N'C�:it•6f?Cftf r1A4.F:32.[Cr1\3'K\VX•;�t!�pIS[)N tv)�3;F?-(?C?(lF• d-i3t?U•A�Y.A:h'E]'A9•�(E-3tl()-G�J2••Cr33ti� July 10, 2012 71-JDL003 ST PAUL WATER COMPANY 1900 RICE ST SAINT PAUL MN 55113-6810 RE: Claim Number: 00-241-707966-0325 Our Insured Name: Lisa Strub Date of Loss: July 9,2012 Our Company Name: American Family Mutual Insurance Company Dear St Paul Water Company: We ha�e received notice of the above claim from our insured. Our preliminary investigation indicates you were the cause of our insured's damages. We anticipate making payment(s)to our insured. Once payment is made,our Subrogation Department will send supporting documentation to you or your insurance company to reimburse our claim payment(s)and our insured's deductible, if applicable. If you have a liability insurance policy, please complete the enclosed form and return it to us, marked"Attn:Subrogation Dept". We can then handle this matter directly with your insurance company. If you have any questions, please contact me at the number below. Sincerely, . � Jamie D Lautz Customer Care Center Auto Senior Representative American Family Mutual Insurance Company 1-800-MYAM FAM (1-800-692-6326)X 72262 jlautz@amfam.corn Fax:(866)912-5328 www.amfam.com/claims Enc: American Family Ins . 8/8/2012 11 : 51 : 27 AM PAGE 11/015 Fax Server INSURANCE INFORMATION FORM July 9, 2012 Date of Loss: American Family Claim Number: 00-241-707966-0325 American Family Insured's Name; LisaStrub My Name: Name of My Insurance Company: Address; Phone Number: My Policy Number is: Insured's Name on my Policy: My Agent's Name: Address; Phone Number: I ha�e reported this loss to my insurance company. Yes ❑No ❑ Check Here�if you do not have a liability insurance policy. 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