Lee, Song . . . � .y - .'a.��..
. af...,.... ...;� -,. .
�,�r � � zn�2
NOTICE OF CLAIM FORM to the City of Saint Paul, Mi��esota
:;- _
Minnesotu Stute Stutute 46h.05 stutes thut"...every person...whu cluims dumuges f�om uny municipuliry...sJutll cause to be presented to the
governing body of the municipaliry within I80 days ajter the alleged toss or injury is discovered a notice staling the lime,place,and
circumstances therenf,and the amounr of co»y�en.vation nr other relief dernanded."
Please complete this form in its entirety by cleariy 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
mnch 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 COMP'LETED FORM AND OTHER DOCUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
First Name s 0�lJ� Middle Initial x Last Name �L C=
Company or Business Name
Are You an Insurance Company? Yes� If Yes, Claim Number�
Street Address �5��� �cti�f��- �,5�
City �� �—G��-c.c � SCate �/J/�/ Zip Code �����d�
Daytime Phone(GS/)77.�- �2�I�"Cell Phone(���'j�i-�c''`�/7 Evening Telephot�e(�'S�)7�7,Z� •�Z���5"�
Date of Accident/Injury or Date Discovered :�'�3 G,�a'G/� Time �C'-�U am/�
Please state,in detail,what occurred(happened),and why you are submitting a claim.Please indicate why ar how you
feel the City of Saint Paul or its employees are involved and/or responsible for your damages.
ti
�
Ple se check the box(es)that most closely represent the reason for completing this form:
�My vehicle was damaged in an accident ❑My vehide 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 I
I
In order to process your claim vou need to include couies of all auplicable documents.
For the elaims types listed below,please be sure to include the documents indicated or it will delay the handling of �
your claim. Documents WII..L NOT be returned and become the property of the City. You are encouraged to keep a
copy for yourself before 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 claims: legible copies of any ticket issued and a eopy 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 aiways weicome to document and support your claim but will not be returned.
Pagc 1 of 2—Plcasc complctc and return both pagcs of Claim Form
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims-nlease comulete this section
Were there witnesses to the incident? Yes No Unk (circle)
Provide their names,addresses and telephone numbers:
Were the police or law enforcement called? / � No Unknown (circle)
If yes,what department or agency? �ST f� ��!� Case#or report# 1-�2 G� % 9�
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. %lu, �Lt.� ��.�e-�-,�
:�i1� ^..,r'�f't� ����.�,�i'1�r'��e2-G�'�-[_eh� , .t'4f� `�/O/`�i?Sd'`"� �I�GU'y�c�.<-,.� ��GL/���-r'C�7���f
J
Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim
to your sarisfaerion. p� -Ct�'��'�.�.�/-c-e-�C.-n2.c-�2c4_��/ ��c�2fc-r�-z-Ca1`�"� ��+-ea�—
�'-C-�-c.� ��c.�'�/��.����
--T
Vehicle Claims-nlease comnlete this section ❑check box if this section does not avulv
Your Vehicle: Year �,D/�2, Make �%UYC T�} Model /-f-���-/�s�-iv�E/°�
License Plate Number �i�r-f v T State ti7�V Color S�C-E/U
Registered Owner SC>✓v-�� Xior-u� /`.c=C�"
Driver of Vehicle SC�/v CC� �Ci v�t,� �C
Area Damaged R��� f3t fi��� -�
City Vehicle: Year �2���Make �C� Model �ti V
License Plate Number ti'G>/"�A-TC State MN Color ��/�
Driver of Vehicle(City Employee's Name) i/�C Tl�i/ G h��L-�S F/�-/Or,v i Cl�
Area Damaged �"�c�v T �;u�r pC�
Iniurv Claims-nlease comnlete this section ❑check box if this section does not avnlv
How were you injured? ti�l�
What part(s)of your body were injured?
Have you sought medical treatment? Yes TI�o 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 o `
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 carrect to the best !
of your knowledge. Unsigned forms will not be proeessed. �
I
Submitting a false claim can result dn prosecution. Date form was completed ��5�� � f ��"2 ,
Print the Name of the Person who Completed this Form: ��'N��'�'�'S`� ��'
Signature of Person Making the Claim:
����i�;��V
Revised Febmary 2011
� � . ... �.� p ' .
� O
�acK rws�aa ��� .
12208196 � *�•� `�
wn„ u,,h c
xrr.r,wwn we ra� vEwaEa �,Fn �n :un °�hu 2 2�0 m •
N y 03 00 ;,00 Y. 8 30 2012 0
. /� RO�QN�YD/iECT10M AT -_ Y M ❑! a r . .
ROUiE M1Ew N01ffE MABEN OR STREET W11IE � N E �.�.��.y q� 8� g 9 a�p � � < .
$ W V/IM
� 10 JOhI1SOri P�c ��� � � �S,,y �E�,��,�u�r.onc�nuE
`°"""'"° 10 E. Margaret Street
62 �„P 3425 +—'
swe cws asrnns 04a+�
F�emo�, vos�reou on�xueca�eaw�een_� suh evss o�srnn�a rosma: wuvtnucaa��«•z p�J D O1
os
O1 pl V742296812313 MN D O1 O1 Z186264645915
o�o►ewm r�c,w:
s�ctor:: wu+E�aur.w�oo�.usn wTeosoucix wwEtFnsr.MCO�.vsrt 07 15 68
SONG XIONG LEE 06 15 77 JAMES ROBERT WARRSN
oav�a. �sm�cr '°u�+
wa�x ,�ooa�ss onvia nEemicr ,mims N? pl O1
O1 1596 CHAMBER ST N, Ol 1931 KEI3WOOD DR E �
�� ��+�.� crtv,stetEZw 651-341-9892 Q.j �
Ol ST PAUL 55106 651-772-2955 Mp,pLSWOOD 55117
eovr s�� �w+or.c �tt w,sEV � � .
�w
acawo �oo� s�c EovT s�eECVT "nenc a�ct "'se' "mars M . "�¢ 'g 04 06 05 N OI
O1 wY� F �4 `� 04 d6 05 N �
,wE oau ,vv� ,owso ma�swm tiau�s� w".�wem . .
a�C�a rnE o1n1G rrvE roNOSG rwwsvo�+� w.BUwMCESOW�eE wr+MMBER �� O�
T� 98 �gT 98 N_, O� �, 98 �' 98 Y: 0�„�„
O�
ta� occvv
� �� c«� aw�rtaw� �, fl}
pi LEE SONG XIONG N WARREN JAMES ROBERT
.ow� vEn..n
vExTrr �ooaESS rowEO �sa q 1
ow o
03 1596 CHAMBSR ST N� 1931 KENWOOD DR E.'
nuwo on�rr �� .
w�use cm:sur�� ww�w ou�er an suh.m � 0 5 O l
O1 ST PAUL MN 55106 "1� 05 MAPLEWOOD MN 55117
� � � oMa�oc .
a.�cia .w� "°ce` 'r�v` co`°" ""a LCF 00 BLU 11
05 TOYT HIG 201 GRN BUIC
OYCSEV �LATE4 STREG YEARREG �MCEOFeVnOff3 .awM MarMNwE4H1f RAfES SfNEG YEMFEG war
�°�� „A,,, "�`""°' 02�
02 418HVT !�I 2 O1 O1 XMY616 NIId 12
a«�� ��rvM r °°`�c'�....eER
�E A052484691004018
21st Century Insura 310975 Liberty Mutual
.or
unc,o wawc vurvm wsr�n+o�s auve�ocf� �
�ra� xx IF ACGD£NT RNOWED A COMME"aC�1L MOTOR VElIICLP.SCMOOI BUS�OR HEAD START BUS � wMC
� REYEMBHt TO NOi1FY TNE STATE?ATRO�1��unWr A�'1q.763 and 189A511j. . ,
, ,paa�++cw.vencaera�ee+z-woTOnexa�ewwE ��'�� . ' � .
cow�unaKVts�etErawec�c,.wo+e�rueaenuwe ooTw�eai ..
I'
w�eE�loERbrwRNEbsES - wr rosn+a7EOieqRNSFx 7wE uaE NaasG EECr wsEV to T� rtuNw�eHt .N . .
�� r1�l9FRN(� , .
^' o°"°` �
�
.�.� ��
� V-7 •�, °°.�` ,
� ,,,,se�v�c� �w.rER <.
L
�� �
• Qderee
� n�uucmnaaoein'�vaaowr�c�tA�ea� � .
wme+oc on�t w+�1EO vrmrm�irrrro oEtaavTw/+aF aunoFV vwooenra+o�a+rsiavuc M�F�I�I .
DEV�GE ,
ACC7YP � I , NMWATIVE
01. :. � ... . .. . ..._. . ....... . . . . ..... _. ....._... ..
, 98
_ .__.._
�� �' AH unit
Unit 1 was driving south oa Johnons Pks+*Y
03 ' .___ . ._ .
.,... .._..._ . �
, .lOh(ISO PkW)/ 1 was approachiag the intersection of Johnson au 98
��*» �:: MazgareL. she .slow.ed .to stop..Ther.e wa�.a,vehi.cle..
O1 in froat of unit 1 making a left turn onto �� .
o„e„� ' � ' Margazet which-caused her to stop her uehicle. --
� 04
N. � � .. .
. •
_...._..
,�rneoFVrz ' I --UniC 2, who was behind un�.t 1: st • w�n .
tavr
i � . .. . _.. . ' �"
98 � At that time, unit 3 aras driviag soiith on Johnso
�� .;�� � � s, p}cwy., t7nit 3 rear-.ended unit.2. which..causea u??it, ���
�� f O1
-, o =� 2 to rear-end unit 1.
.
� ye . iL,: .. .._ . .. . . .... . . . ... . . . .. .... ..... . WFAl/1ER2 '
,
PRE�N� . .:__. .__.._ ... :._- ; 1�.: ,.
I' , I /�bT TO SC�L6, _._._.. . . ... -. .. .
. j �
�,., ..� __�...e.. �� �
, .
.r
vs: 1F.' . .._. ...... ... .._..._.....
. .. ........ . ..
. : ' . . . . . . .-'..
08 ,::_...._ 04
;r.'• :
wo w+s ,
E Margaret Street � "°�•
.; _.. .._ . _ . .
_
O1 �: _
Y_: — �. ..... ._ _ _ � .
: ;::
,:: , _.
,. ,� _.
_ � � .._ .
�s a+�n �e .. 0
O 1 � - �,. A�. °'' Q saoe� �"- - '
���MDe"0�' St Paul PD �-�i�' O� 0°"�" '�
Sergeant Todd Feroni 111 �' ����
�
�- :
:R .
- �ocKU�wa � � ' o � �
12208196 ' �
� p�y Artv7YE . C
MR-uoluN *usPaOP VBYLRFS KLLEO SwN , .W '
. .. .r .'Y . . Q .
nw�svshw aarte rAarex an s�T w�rt � . ��N°p�� a��� I ae �R g y �w�y • < � .
s w '� � �—
p+ •woure srs aane a.st�i awtwrt an�mwa
�,� 9 . ��. �� �
� +_
swE axis am�ne •s�c*a�+
v.e+a+� voarwe/ oavee��nn srwh wss asr•nn vom+w�+ ow�auee+s��R-z . .
O1 C763001880816 MN D O1 .
o.rE ac sw++� F�_
c.cron: wu�Fwsr.MCaF.twsrl w�ocamH .uurt6ascwoae.vsn �
TIMOTHY CHARLES FILIOWICH 11 16 77
w Na �� �
��arvcn �ooa¢u onv�o� r�s� +onnrss � .
O1 722 PAYNE AVE N; Ol ��
vHrsa
arnsa Urv.s�TE a Urr.5'v�7E ip . .
Ol ST. PAUL 55106 6512665565
�,.,p gx s�EOVr �carr u�c � «,sEV � �oc �� �c� � �• wa� �
Ol , M Q4 04 06 OS N •,
/LCHL T'PE OR{Ifi tYPE TO��06P 7RMISOOW� MBIAAMff6EpV�CE RRINIIBER AtOLL lvPE OAUC T'PE TON06� 7R�MBPOM ��E��� �� .
0�
� 98 � 98 13, o�„ �T � ��"
� �
OCdW OMRERIWE FwE O�NIEMM�� .
03 CITY OF ST.PAUL _ N : :,
,ovw � ve�rm
� v�+rn nooi�ss ravEn .�oor�a . . .
O1 367 GROVE STRSET � `
nwMO on�cr �u�
vtrva ertr,snae.a wuwa dnEer cm:su+E.m wr
p7 ST. PAUL, MN 55103 "1Q OS
� „� vcw wwn owc,�x .
wu1.00 wucE MaOE� rExt Cotoa
Ol FORD CRNV 200 WB
ou�sev wwts• sr�e r�ut� a�eaa� � wuwa�wrt vurss srr� r�wne� ,� �°+.�'°^�e iao �ww wogv
02 I30PLATE MN O1 O1
POIKY NUMBEM MURM+�11MT 2) POIIC�MMB9� '
Yi1MtA110E . . .
CITY OF ST. PAUL •
c�rsw w�zwv ,w� .�enoNS .o...noe. - +w� wzws � .
"a �ACCIDENT MVOLVED A COMNERCIAL iAOTOR VElNCLE.SCHOOL BUS.OR NEAD START BUS w!t
rnE a�g
� : REMEMSER TO NOTfFY TFIE STATE DATROI(nquirod undar MS 1N.7lS and 169A511} .
ea�r�aauvtre��w�aeai-rrnoneNU+Fnrw� . ooreaa,eea mr�u.ve.ntMweai:-wraae�n�nrwE omrue[n
���s � uar w�or soc r�ve � �,wa.w �.rter .usEV mnmv rnusvaer ��p �: • � �
0� uese�
. �or,�n � . .
D �� ' w�rt�� .� '. .
�us
��� � . .
�� �L6961VI�E RINMl�i9� .- .
Om� � _. .
p�µ�piROPE�1I�/'�BAOMObM�lW6t � - .
OwHEk OF 071ER OMMS�07POPENnMm0E9W V'fqNOF OMMfiEO vrtOrErtTr/VID/rn vRLOMV�[,MAlFA(S)
. ..r.. .. ,..... . �. « -. . ... � ,
OEM�t
ACCTYG ' ' . .. � . ' . . � NNMiATNF:
� ' ' � .-. . '. �._..' . -. .. . - . .. .... ....
YJILBUS � - ' . . . . .
' � ' . : . � � ... . . .. . ... . . . ...... .
... .. �.... :. ...__ ... .. . . . .._..,...._.... . .
- . . . . � �. . . . . .. . . MiONKMG
�outw ' � � � � � ...... ... ... . � . . ._.:_ ... . , ... . ._._..
, �. : ' . . .. . .; . _...
.. .._..... . - .. . . � . . . � . . - MNFI
'. �. '. . . . : �� . .. ... . .... .. . . �
_.
WKOOE �: ....... .' � ... .... . . . ..... ..... ._..
„y....:... . . ... .. , . . . -. .. . .... ._ .�. . �_ .._
. P : . . : . � . � ;•. ...._,._......... . ..�.,. �- . ,
. '+ . . . . . ..: . . .... ._. �. � � .. . ...
lYPEOCM2 .':. . .' '_ , ; ' . ., : . .. _...... .. .. .. . .. . . .. y�
.. . .. .. ._ .. _ l�Mf
�! � ' ... .. ... .. . .. .. ... : . � . . . .... " .. .
�f'qA6�y/L � � . �. � . ' � . ... ..:_........... ..'�� ......._....... ............. ... ..... . . . ........ .. ... ... ......... .... .. .
..._. y1FAT1ER1 .• .s
..r.; ' ... ...: ...'. . , . . ... .: ' . .. ... . .. .. ... .._.._... •
MOMKeRS ,.. . . : . - � . .. .. . ............ . .."'_.. .. " �_ . .
PRESFM ' . -. . . . . .. ' ._..._..... _._ _ . . . .
. . . . .. ... . . . :.
fY1ESOM s . .... .�. .:....... . . .. . . . . . . . .. . . . ... . . �� .
� . . . . - . . f-r . .._... ... . �
,: . . :..... ... ...... . ... . . . ...... .. .. ......... .. .
. .. . .... ..:.
_ .
� ' ' �. . � - . ' � _ �. . j .,.. .. .. . . . . . . . . .. .
' ' .
'! 7, .. ,
rmsws ._�_. �__._... . ..�. . :_ . . . . .. , . . ... . .
� : . . � .. .� �.. ... :. �.... ._.... ..,.. �. . . . . .A.�:. . . _.. .... . .. . . .. ....... .. . .. . . �
.. . .... . ' . . . . . . . . �%'� . . . . .�.... ... .. .. _ ' � �
�j`.. .... .... .. .. . . . .. . � :,5,." ... . . .. . . ..
. - . �. . . � . . . I%�
� i
. . . . . . .. . . . �iL% ... ... ... . . . ..
; �� -.. : � . ... . . . .. . . �� .. .. . . ... . ... _..._. ..
. . . � � .:_ .., .. . ,. - -....��tr��.. �y .� - v►mo.svmor �srNC►,�im� ❑�°�i'� " • ,
,x:,.:.. .�..,...,. . . .. .
orr�nwu�cw��e�• � St Paul PD O�" 0°'"et
Sergeant Todd Feroni 111
LAMEITRY'S COLLISION - Workfile ID: f55dafbl
FederalID: 411393089
MAPLEWOOD
"Every Customer Leaves With A Smile"
2923 MAPLEWOOD DR, SAINT PAUL, MN 55109
Phone: (651) 766-9770
FAX: (651) 766-8660
Preliminary Estimate
Customer: LEE,SONG XIONG 7ob Number:
Written By:CHRIS BRANT
Insured: LEE,SONG XIONG Policy#: Claim #:
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact: 06 Rear
Owner: Inspection Location: Insurance Company:
LEE, SONG XIONG LAMETTRY'S COLLISION-MAPLEWOOD
1596 CHAMBER ST 2923 MAPLEWOOD DR
ST PAUL, MN 55106 SAINT PAUL, MN 55109
,(651)231-2417 Day Repair Facility � -
' ' (651)766-9770 Business
VEHICLE
Year: 2012 Body Style: 4D UN VIN: STDBK3EH4CS117343 Mileage In: 7306
Make: TOYO Engine: 6-3.5L-FI License: Mileage Out:
Model: HIGHLANDER 4X4 Production Date: State: Vehicle Out:
Color: MET GREEN Int: Condition: ]ob#:
TRANSMISSION Overhead Console FM Radio Stability Control
Automatic Transmission CONVENIENCE Stereo SEATS
4 Wheel Drive Air Conditioning Search/Seek Cloth Seats
POWER Rear Defogger CD Player 3rd Row Seat
Power Steering Tilt Wheel Auxiliary Audio Connection Captain Chairs(2)
Power Brakes Cruise Control SAFETY Retractable Seats
Power Windows Telescopic Wheel Anti-Lock Brakes(4) WHEELS
Power Locks Intermittent Wipers Driver Air Bag Aluminum/Alloy Wheels
Power Mirrors Keyless Entry Passenger Air Bag PAINT
DECOR Dual Air Condition Head/Curtain Air Bags Clear Coat Paint
Dual Mirrors Rear Window Wiper Front Side Impact Air Bags OTHER
Privacy Glass RADIO 4 Wheel Disc Brakes Rear Spoiler
Console/Storage AM Radio Traction Control '
�� �
. G
�, " •Fa � •_
` -_,.T-� _ _ - i �
9/8/2012 10:21:09 AM 053108 Page 1
Preliminary Estimate
Customer: LEE, SONG XIONG 7ob Number:
Vehicle: 2012 TOYO HIGHLANDER 4X4 4D UN 6-3.5L-FI MET GREEN
Line Oper Description Part Number Qty Extended Labor Paint
Price$
1 REAR BUMPER
2 Repl Prep unprimed bumper 1 0.7
3 0/H bumper assy 2•0
4 <> Repl Bumper cover 521590E907 1 310.53 Incl. 2.6
5 Add for Clear Coat lA
6 * Repl Lower cover 521690E050 1 128.09 Incl.
7 EXHAUST SYSTEM
8 * Rpr Rear muffler all 174300P210 m Q.,�
NOTE: STRIGHTEN OUT TIP
9 # Flex Additive 1 6.00 X
10 # Subl Hazardous Waste Disposal Fee 1 5.00 X
SUBTOTALS 449.62 2.5 4.3
ESTIMATE TOTALS
Category Basis Rate Cost$
pa� 438.62
Body Labor 2.5 hrs @ $52.00/hr 130.00
Paint Labor 4.3 hrs @ $52.00/hr 223.60
Paint Supplies 4.3 hrs @ $32.00/hr 137.60
Miscellaneous 11.00
Subtotal 940.82
Sales Tax $438.62 @ 7.1250% 31.25
Grand Total 972•��
Deductible O:QO
CUSTOMER PAY 0.00
INSURANCE PAY 9�2•��
THIS REPORT IS AND ESTIMATE ONLY, BASED ON OUR INITIAL INSPECfION AND DOES NOT COVER ADDITIONAL
PARTS OR LABOR WHICH MAY BE REQUIRED AFTER THE WORK IS OPENED UP. PART PRICES SUBJECT TO
CHANGE PER THE MANUFACTURER AND AVAILABILIIY.
WARRANTY: LIFEfIME AGAINST DEFECTS IN WORKMANSHIP. WARRANTY REPAIRS DONE BY LAMETTRY'S
COLLISION ONLY. NO WARRANTY ON RUST, CORROSION RESISTANCE OR REPLACEMENT RENTAL CARS.
OUR ESTIMATED COMPLETION TIME DOES NOT INCLUDE INSURANCE OR PARTS DELAYS THAT WE MAY
fXPERIENCE.
MN ST 60A.955 - A PERSON WHO FILES A CLAIM WITH INTENT TO DEFRAUD OR HELPS COMMIT A FRAUD
AGAINST AN INSURER IS GUILTY OF A CRIME.
9/8/2012 10:21:09 AM 053108 Page 2
. ' � Preliminary Estimate
Customer: LEE, SONG XIONG 7ob Number:
Vehicle: 2012 TOYO HIGHLANDER 4X4 4D UN 6-3.5L-FI MEi'GREEN
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
ARM8438, CCC Data Date 9/4/2012, 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-Included
Labor operations. The symbol (<>) indicates the refinish operation WILL NOT be performed as a separate procedure
from the other panels in the estimate. Non-Original Equipment Manufacturer aftermarket parts are described as AM.
Used parts are described as LKQ, 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 2012 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 CCC ONE
estimator has a complete list of applicable vehicles. Parts numbers and prices should be confirmed with the loc�l
dealership.
The following is a list of additional abbreviations or symbols that may be used to describe work to be done or parts to
be repaired or replaced:
SYMBOLS FOLLOWING PART PRICE:
m=MOTOR Mechanical component. s=MOTOR Structural component. T=Miscellaneous Taxed charge category.
X=Miscellaneous Non-Taxed charge category.
SYMBOLS FOLLOWING LABOR:
D=Diagnostic labor category. E=Electrical labor category. F=Frame labor category. G=Glass labor category.
M=Mechanical labor category. S=Structural labor category. (numbers) 1 through 4=User Defined Labor Categories.
OTHER SYMBOLS AND ABBREVIATIONS:
Adj.=Adjacent. Algn.=Align. ALU=Aluminum. A/M=Aftermarket part. BInd=6lend. BOR=6oron steel.
CAPA=Certified Automotive Parts Association. D&R=Disconnect and Reconnect. HSS=High Strength Steel.
, ,
HYD=Hydroformed Steel. Inc1.=Included. LKQ=Like Kind and Quality. LT=Left. MAG=Magnesium. Non-Adj.=Non
Adjacent. NSF=NSF International Certified Part. 0/H=Overhaul. Qty=Quantity. Refn=Refinish. Repl=Replace.
R&I=Remove and Install. R&R=Remove and Replace. Rpr=Repair. RT=Right. SAS=Sandwiched Steel.
Sect=Section. Subl=Sublet. UHS=UItra High Strength Steel. N=Note(s) associated with the estimate line.
CCC ONE Estimating -A product of CCC Information Services Inc.
The following is a list of abbreviations that may be used in CCC ONE Estimating that are not part of the MOTOR
CRASH ESTIMATING GUIDE:
BAR=6ureau of Automotive Repair. EPA=Environmental Protection Agency. NHTSA= National Highway
Transportation and Safety Administration. PDR=Paintless Dent Repair. VIN=Vehicle Identification Number.
9/8/2012 10:21:09 AM 053108 Page 3
ABRA Auto Body & Glass - Workfile ID: b496c0e3
FederalID: 41-1942823
, - Maplewood
Right The First Time...On Time
2806 HIGHWAY 61, MAPLEWOOD, MN 55109
Phone: (651) 483-2145
FAX: (651) 483-2509
Preliminary Estimate
Customer: LEE, LAI/SONG )ob Number:
Written By:Jerry Price
Insured: LEE, LAI/SONG Policy#: Claim#:
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact: 06 Rear
Owner: Inspection Location: Insurance Company:
LEE, LAI/SONG ABRA Auto Body&Glass-Maplewood FARMERS
1596 CHAMBER 2806 HIGHWAY 61 COD PLUS--BS
ST PAUL, MN 55106 MAPLEWOOD,MN 55109 P.0 BOX 268994
(651)772-2955 Car Repair Facility OKLAHOMA CiTY,OK 73126
(651)216-3286 Evening (651)483-2145 Business (800)445-7911 Business
VEHICLE
Year: 2012 Body Sryle: 4D UTV VIN: STDBK3EH4CS117343 Mileage In: 99
Make: TOYO Engine: 6-3.5L-FI License: 418HVT Mileage Out:
Model: HIGHLANDER 4X4 Production Date: State: MN Vehicle Out:
Color: GREY Int: Condition: Job#:
TRANSMISSION Overhead Console FM Radio Stability Control
Automatic Transmission CONVENIENCE Stereo SEATS
4 Wheel Drive Air Conditioning Search/Seek Cloth Seats
POWER Rear Defogger CD Player 3rd Row Seat
Power Steering Tilt Wheel Auxiliary Audio Connection Captain Chairs(2)
Power Brakes Cruise Control SAFETY Retractable Seats
Power Windows Telescopic Wheel Anti-Lock Brakes(4) WHEELS
Power Locks Intermittent Wipers Driver Air Bag Aluminum/Alloy Wheels
Power Mirrors Keyless Entry Passenger Air Bag PAINT
DECOR Dual Air Condition Head/Curtain Air Bags Clear Coat Paint
Dual Mirrors Rear Window Wiper Front Side Impact Air Bags OTHER
Privacy Glass RADIO 4 Wheel Disc Brakes Rear Spoiler
Console/Storage AM Radio Traction Control
9/21/2012 10:23:32 AM 014563 Page 1
Preliminary Estimate
Customer: LEE, LAI/SONG 7ob Number:
Vehicle: 2012 TOYO HIGHLANDER 4X4 4D UN 6-3.5L-FI GREY
Line Oper Description Part Number Qty E�ctended Labor Paint
Price�
1 REAR BUMPER
2 <> Repl Bumper cover 521590E907 1 310.53 1.6 2.6
3 Add for Clear Coat 1.0
4 Repl Prep unprimed bumper 1 0.7
5 Repl Molding 527510E010 1 184.63 Incl.
6 <> Repl Lower cover 521690E050 1 128.09 Incl. 1.4
7 Overlap Major Non-Adj. Panel -0.2
8 Add for Clear Coat �•Z
._ _. _ . _.
. . _
9 MISCELLANEOUS OPERATIONS
10 # �Color Tint 1 0.5
11 # �Flex Additive 1 2.00 X
12 # �Hazardous Waste 1 3.00 X
SUBTOTALS 628.25 1.6 6.2
ESTIMATE TOTALS
Category Basis Rate Cost$
Parts 623.25
Body Labor 1.6 hrs @ $50.00/hr 80.00
Paint Labor 6.2 hrs @ $50.00/hr 310.00
Paint Supplies 6.2 hrs @ $31.00/hr 192.20
Miscellaneous 5.00
Subtotal 1,210.45
Sales Tax $623.25 @ 7.1250% 44.41
Grand Total 1,254.86
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 1,254.86
THIS IS A VISUAL INSPECTION ONLY. THERE MAY BE ADDITIONAL DAMAGE AFfER DISASSEMBLY. PARTS ARE
SUBJECT TO INVOICE. THERE ARE NO GUARANTEES ON RUST REPAIRS.
"Minnesota law gives you the right to choose any rental vehicle company, and prohibits me from requiring you to
choose a particular vendor."
9/21/2012 10:23:32 AM 014563 Page 2
Preliminary Estimate
Custbmer: LEE, LAI/SONG 7ob Number:
Vehicle: 2012 TOYO HIGHLANDER 4X4 4D UTV 6-3.5L-FI GREY
QUALITY REPLACEMENT PARTS WARRANTY
OUR REPAIR ESTIMATE MAY SPECIFY THE USE OF QUALITY REPLACEMENT PARTS. QUALITY REPLACEMENT PARTS
ARE PARTS NOT MANUFACTURED BY OR FOR THE ORIGINAL EQUIPMENT MANUFACTURER. WE WILL STAND
BEHIND THE QUALITY REPLACEMENT PARTS THAT ARE SPECIFIED ON THIS ESTIMATE AND USED IN THE REPAIR
OF YOUR VEHICLE, FOR AS LONG AS YOU OWN/LEASE THE VEHICLE. WE WARRANT THESE PARTS ARE OF LIKE
KIND, QUALITY, SAFETY, FIT AND PERFORMANCE TO PARTS MANUFACTURED BY OR FOR THE ORIGINAL
EQUIPMENT MANUFACTURER.
THIS WARRANTY EXCLUSIVELY COVERS LOSS OR DAMAGE THAT IS RELATED TO DEFECTS IN THE QUALITY
REPLACEMENT PART. THIS WARRANTY DOES NOT COVER DAMAGE OR PART FAILURE DUE TO IMPROPER
INSTALLATION, MISUSE, NEGLECT, ABUSE, IMPROPER MAINTENANCE, ABNORMAL OPERATION, OR NORMAL WEAR
&TEAR.
SHOULD A SUPPLIER OF A PART SPECIFIED IN OUR REPAIR ESTIMATE, OR THE REPAIR FACILITY THAT PERFORMS
THE REPAIR ON YOUR VEHICLE, BE UNABLE TO RESOLVE A LEGITiMATE COMPLAINT ABOUT THE QUALITY
REPLACEMENT PART USED IN THE REPAIR, WE WILL MAKE EVERY EFFORT TO SEE THAT THE PROBLEM IS
CORRECTED.
THIS WARRANTY AND ANY REPRESENTATIONS MADE HEREIN ARE NON-TRANSFERABLE AND EXTEND ONLY TO
THE PARTY OWNING/LEASING THE VEHICLE AT THE TIME OF THE REPAIR.
FOR ASSISTANCE, PLEASE CONTACT THE NEAREST HELPPOINT CLAIM SERVICES OFFICE.
DISCLAIMER:
ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT INSURANCE CLAIM FOR THE PAYMENT OF A
LOSS MAY BE GUILTI( OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN STATE PRISON.
THE LABOR AND TAX RATES USED WERE DETERMINED BY THE VEHICLE INSPECTION LOCATION UNLESS THE
REPAIR FACILITY WAS KNOWN AT THE TIME OF THE INSPECTION OR ANOTHER LOCATION WAS SPECIFIED
BEFORE THE ESTIMATE WAS PREPARED
MN ST 60A.955 - A PERSON WHO FILES A CLAIM WITH IIVTENT TO DEFRAUD OR HELPS COMMIT A FRAUD
AGAINST AN INSURER IS GUILTY OF A CRIME.
9/21/2012 10:23:32 AM 014563 Page 3
Preliminary Estimate
Custbmer: LEE, LAI/SONG 7ob Number:
Vehicle: 2012 TOYO HIGHLANDER 4X4 4D UTV 6-3.5L-FI GREY
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
ARM8438, CCC Data Date 9/17/2012, 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 (N) items indicate MOTOR Not-Included
Labor operations. The symbol (<>) indicates the refinish operation WILL NOT be performed as a separate procedure
from the other panels in the estimate. Non-Original Equipment Manufacturer aftermarket parts are described as AM.
Used parts are described as LKQ, 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 2012 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 CCC ONE
estimator has a complete list of applicable vehicles. Parts numbers and prices should be confirmed with the local
dealership.
The following is a list of additional abbreviations or symbols that may be used to describe work to be done or parts to
be repaired or replaced:
SYMBOLS FOLLOWING PART PRICE:
m=MOTOR Mechanical component. s=MOTOR Structural component. T=Miscellaneous Taxed charge category.
X=Miscellaneous Non-Taxed charge category.
SYMBOLS FOLLOWING LABOR:
D=Diagnostic labor category. E=Electrical labor category. F=Frame labor category. G=Glass labor category.
M=Mechanical labor category. S=Structural labor category. (numbers) 1 through 4=User Defined Labor Categories.
OTHER SYMBOLS AND ABBREVIATIONS:
Adj.=Adjacent. Algn.=Align. ALU=Aluminum. A/M=Aftermarket part. BInd=Blend. BOR=Boron steel.
CAPA=Certified Automotive Parts Association. D&R=Disconnect and Reconnect. HSS=High Strength Steel.
HYD=Hydroformed Steel. Inc1.=Included. LKQ=Like Kind and Quality. LT=Left. MAG=Magnesium. Non-Adj.=Non
Adjacent. NSF=NSF International Certified Part. 0/H=Overhaul. Qty=Quantity. Refn=Refinish. Repl=Replace.
R&I=Remove and Install. R&R=Remove and Replace. Rpr=Repair. RT=Right. SAS=Sandwiched Steel.
Sect=Section. Subl=Sublet. UHS=UItra High Strength Steel. N=Note(s) associated with the estimate line.
CCC ONE Estimating - A product of CCC Information Services Inc.
The following is a list of abbreviations that may be used in CCC ONE Estimating that are not part of the MOTOR
CRASH ESTIMATING GUIDE:
BAR=Bureau of Automotive Repair. EPA=Environmental Protection Agency. NHTSA= National Highway
Transportation and Safety Administration. PDR=Paintless Dent Repair. VIN=Vehicle Identification Number.
9/21/2012 10:23:32 AM 014563 Page 4