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Deegan (Paqe 1 of 3) NOTICE OF CLAIM FORM to the City of Sai�nt Paul,Minnesota Minneaota State S�re�66.OS states tl�"...evcry person...wlw claims damagas¢om any mwricipaliry...shall cause w de prerenud to tke govErning body of the m�nieipaltry witAin 180 days ajter the alleged lass or tryury ts discove►ed n notice stati�d�e time,p/ace,and - �ctrcumstances ihereof,mrd tTn onrowit ofc6mpensatlort or other rrlisf demonded" Please romplete this tarm in iu entlrety by ctearly lyping or printiqg your answer to esch questton. If more space iv needed,attae6 additional sheets. Please note that you wili not be cnptacted by telephone to clarity answers,so provide as_ mach informsdon as necessary to ezplain qour claim,and:the amount of compenestion bein�reqnested. You will receive a _ written aeknowledgemen#ona yoar focm is received. The process ean take up to tea waeks or louger dependiag on the natnre oi yopr claim. This form mast be afgned,apd bqth pag�,wmpletad. If�met6ing does not apply,write'N/A'. ��':�•_��iC��,;s SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CTTY CLERK, �t� � 6 ZO�2 15 WE�T KELLOGG BLVD,314 CITY HAI.L,SAINT PAUL,MN SS102 Pirst Name�Fi`.Z F��-- Middle Inifial^!�-Last Name�t�� ✓v ��`��` C��_�;�'i�r � Company or Business Name C� , I Are You an Insurance Comp. Yes/ If Yes,Claim Number? �/ � " � � � 7 sr�c naar� f'� J. ��yc {� L1� City ►�"�� "� t ' J T.Staie �^'� 1� Zip Code�—5. Y �., � - e hone(—)� S'� ' �C�a f �t��C' _ Date of Accid�U Tnjury or Date Discoverad S /. % // �--Time �/p� ?� `e � � 1'/ � Plaase state,in detail,what occutred(happened),and why you are submit3ing a claim.Please indicate why or how you feel the City of Saint Paul or zts�mployees are involved and/ar responsibte for your damages. �° ! ./ - , , Please ch�k the box(es)that most closely represeni the reason for eompleting this form: C1 My vehiclo was damaged in an accident 0 My vehicle was damaged during a tow ❑My vehicle was damaga,d by a pothole or condition of the street C1 My vehicle was damaged by a plow .I,a My vehicle was wi�ongfully towed and/or ticketed 0 I was injured on City properry �b Other rype of property damage—please specify_ �'�_,.,��. . ��(� ❑Other type of injury-please specify . In order to process your claim vou need to include conies of all apnlicable doctcments For the.claims types listed 1seIow,pleasa be sura m include the doeuments indicated or it will delay�e haqdling of Yow'claim• Documents WII.I�NOT be returned aed beoome the propert�+of the City. You are encoutagad to keep a copy for qourself befora submitting your cleun form. O Property damage claims to e vehicle:lwo estimetes far the repairs to your vehicle if the damage exceeds 5500.00;or tfie actusl bills aad/or roceipts for the repairs O Towing claims:legible copies of any ticket issued and a copy of the impound lot receipt O Ofher property damage claims:two repair estirnates if the damage exceeds$500.06;or the actual biJls and/or receipts Cor the repairs;dctailed Iist of damaged items O Injury claims:medical bills,raceipts 0 Photographs aro atways walcome to document and support your ctaim but will not be refurned. � Page 1 of 2–Please complete and return bot6 pages of Claim Form (Page 2 of 3) Failare to complete and return both pages wi0 resplf iu delsy in the handiing of yoar c1Aim. Atl CIAi m lete th' ' n Were thera witnessas to the incident? - No Unknown (circle} Provide the'v names,addresses and telephone numbers: - - Were the police or iaw enforeement called? Yes � Unl�own - (circle) If yes,what depanment or ageney? Case#or report# Where did the accident or ic►jury taka place? Provide street addnass,cross street,interse�tion,name of park or facility, cIosest laudmark,ate. Please be as detai�as possible. Lf necessary,attach a diagram. ' .a� � `T�-'� t��•�._ 1.n I �. fl�k, Q,� �� 1 Please indicata t�he amount you are seeking ie cowpensation r what you would liice the City to do ta resolve this claim to your satisfaction. � �'7 '7 Le . �1� Yeh�cle f'laima—u[e�nlete thia eeEli9n p check box if this saction does not anplv Your Vehicle: Year Make Madel License Plate I�lumber Sta�e Color Regiistered Owner Driver of Vehicle � Area Damaged � City Vehicle: Year Make Model License Plate Numba 5tate � Color Driver of Vehicle(City Fanplo}+ee's Name) Area Damaged Ineurv Claims—nlease comulete thia section ❑check box if this section does aot apulv How were you injured? What part(s)of your body were injured? Have you sought medical treatment? Yes No Planning to Seek'I'reatment(circle) When did you receive treahnent7 (provide date(s)) Name of Medical Provider(s): ' - Addcess __ Telephone Did you miss work as a resuIt of your injury? . Yes No When did you miss work7 (provide date(s)) Name of your Employer: Address Teiephone Check here if you are attaching more,pages to this clafm form. Number of additional pages_, By signing tliis farm,you are stating that all infarmatlo�you haue prnvrded is true a�rd correct to tlee best ; of your knowledge. U�rsig�red jorncs will not be processed Submitd�g a faJse ctatm can rtsult in prosecrdion Date form was compteted � Ptint fhe 1Vame of the Person wLo C eted this_F�►rni:; �fz�f?�a �'+r� • ��,C�� /�, Signature o[Petsoa Making the � �,.¢.�.�r-,�� 5 Revised February 2011 - AMERICAN FAMILY � 6131 Blue Circle Drive I Eden Prairie MN 55343-9130 I amfam.com Mailing Address:PO Box 1246 � Minneapolis,MN 55440-1246 I Phone:(952)933-4884 September 20, 2012 39-JMD058 CITY OF ST PAUL LIZ QUICKSELL - DISTRIBUTION DIVISION -WATER 1900 RICE ST SAINT PAUL MN 551 1 3-681 0 RE: Your Insured Name: City of St. Paul Your File Number: Unknown Our Claim Number: 00-815-000887 3958 Our Insured: John G Horner- 2290 Timber Trl E Maplewood Date of Accident: August 9, 2012 Total Claim: $5,776.40 Company Portion: $4,776.40 Insured's Deductible: $1,000.00 Dear City Of St Paul: We are notifying you that American Family Mutual Insurance Company has now made payment on the above referenced claim and our supporting documentation and proof of payment is enclosed. The facts support that this incident was caused by your insured's negligence. Please forward the total claim , amount indicated. We will reimburse our insured their deductible. ', We look forward to concluding this matter soon. Thank you for your attention to this matter. When sending correspondence, please include 'Attn: Subrogation Dept'. Respectfully, ��' �--� Jared M Deegan, AIC, AINS, SCLA Subrogation Senior Adjuster American Family Mutual Insurance Company 1-800-MYAMFAM (1-800-692-6326) X 66172 � jdeegan C�amfam.com � Fax: (866) 833-5588 www.amfam.com/claims Enc: (Paqe 3 of 3) DisMbution Division '.:�, 190o Hice St Saint Paul MN 55113 : --�_�-r_ � �rt s`L "' � � Liz Quicksell TECHNICIAN Phone•857-266�6875 FaM•G5�-2668878 E-+nell•liz.qu�kveq�ci.sipaul.mn.us � I II S.A.T.R.N. Subro Potential Page 1 of 1 Jared �� Insured: HORNER.JOHN G Policy: 22-DE1711-01 Claim: 00-815-040887 Loss Date: 08-09-2012 Go Back Save and Go Back Subrogation Potential SelecUDeselect Claimant Peril Draft P mt Pa ment Select Deductible Amount ID Code Key Type Date Draft Applied Paid Payee Name 00 R64 0000649727 01 08-23-2012 � 0.00 $71.53 HORNER,JOHN G 00 R64 0081001161 01 09-20-2012 r 1,000.00 $4,704.87 SERVPRO INDUSTRIES INC I � � i https://satrn.amfam.com/satrn/SubroActivity?subroId=00815000887 9/20/2012 Jared ICS: Print Notes 00-815-000887 Page 1 of 1 Jared Print Notes for 00-815-000887 Note(s) have been individually selected. Cancel Print Entered Party Name(s) Type(s) Note For Entered By 08/23/2012 (02:06 PM CDT) HORNER,JOHN G (00} Property Damages WCE003 Reached agreement on repairs with Serv Pro. Issued payment 081 0000649727 $71.53, applied deductible. No depreciation taken, repairs only and added sales tax due to no repairs needed as we are only laying the carpet and cleaning it. Called 651-739-8352 spoke with John. Explained this portion of the claim and payment. Mailed payment and estimate to him. He said they already installed the carpet. _ _ _ _ _ _ _ _ ,II i � http://ics/ics/claimnotes/printNotes.do 9/20/2012 Jared AMERIC� American Family Insurance Group Attn: Scanning Center 6000 American Parkway Madison,WI 53783 Office: 800-692-6326 Fax:877-381-3926 August 17,2012 HORNER,JOHN G Claim Number: 00815000887 2290 TIMBER TRL E Date of Loss: 8/9/2012 MAPLEWOOD,MN 55119-5818 The attached estimate of damages has been prepared for your property. The estimate has used common prices for labor and material from your area. Enclosed is our draft for the actual cash value(today's replacement cost less depreciation)of your damaged properiy. For Dwelling and Structure damages,we may ha�e included your mortgage company,U.S.BANK NATIONAL ASSOCIATION ,on the draft as required by your policy. Summary For Dwelling Replacement Cost Value Less Recoverable Less Non Recoverable Actual Cash Value(ACV) Depreciation Depreciation $3,109.95 $3,109.95 Less Deductible ($1,000.00) Total ACV Settlement $2,109.95 See the enclosed estimate for details of your settlement which may include other itemized details not shown above. If you wish to make a claim for the recoverable depreciation amount,you must do TWO things: 1. You must have the item(s)replaced or repaired within one year from your date of loss. *Exception:Georgia and Washington policies ONLY-Please refer to your policy language as well as the section of this estimate titled Claiming Recoverable Depreciation following the Estimate Recap or Coverage Limit Details sections. 2. You must submit a final repair bill or purchase receipt showing the item(s)has been repaired or repiaced. The attached estimate is what we espect to be the reasonable cost to repair or replace the property. This estimate may not include permit fees. If total chazges for repair/replacement plus permits exceed the amount shown here for that repair/replacement,prior to any deductible,then additional amounts may be payable. If the actual cost is more or less,the final pay�ment will be adjusted accordingly. If you wish,you may repair or replace with higher qualiry items,however,you will be responsible for any increase in cost. Please refer to your policy under either CONDITIONS-SECTION I or HOW WE SETTLE LOSSES-SECTION I for further details on determining your loss settlement. Please present this estimate to a contractor or repair facility of your choice BEFORE you authorize the start of repairs. If any additional damage or costs are identified,for which you believe we should be responsible,they must be approved by a representative of American Family Insurance prior to having the additional work done. If you,your contractor,ar repair facility have any questions,please contact us at. AMERICAN FAMILY American Family Insurance Group American Family Insurance appreciates your business. Thank You, Unknown HORNER,JOHN G 00815000887 8/17/2012 Page:2 AMERICAN FAMILY American Family Insurance Group Insured: HORNER,JOHN G Phone: (651)739-8352 2290 TIMBER TRAIL MAPLEWOOD,MN 55119-5818 Claim Rep.: Unknown Estimator: Melissa Company: Servpro of Cottage Grove/Woodbury Claim Number: 00815000887 Policy Number: 22DE171101 Type of Loss: Water Coverage Deductible Policy Limit Dwel ling $1,000.00 $266,700.00 Contents $0.00 $213,400.00 Date Contacted: 8/9/2012 3:00 PM Date of Loss: 8/9/2012 Date Est.Completed: 8/ll/2012 8:17 AM Price List: MNMNSB AUG12 Restoration/Serv ice/Remode I Sales TaYes: Matl Sales Ta�c Reimb @ 7.125% Manuf.I-�ome TaY @ 7.125% Cleaning Sales TaY @ 7.125% ', Clothing Acc Ta� @ 7.125% , i � � HORNER,JOHN G 00815000887 8/17/2012 Page:3 AMERICAN FAMILY American Family Insurance Group Estimate Recap For Dwelling Recoverable Non-recoverabie Description RCV Depreciation Depreciation ACV Main Level 436.49 0.00 0.00 436.49 Main Level - Foyer 320.7'7 0.00 0.00 310.77 Main I.evel - Bedroom 248.62 0.00 0.00 248.62 Main Level - Office 248.61 0.00 0.00 248.61 Main Level - Bathroom 386.83 0.00 0.00 386.83 Main Level - Family Room 801.48 0.00 0.00 801.48 Main I.evel - Stair closet 428.53 0.00 0.00 428.53 Main L.evel - Utility Room 248.62 0.00 0.00 248.62 3,109.95 0.00 0.00 3,109.95 ' I IMPORTANT-Please read the definitions below ' What is replacement cost(RCV)? Replacement cost is the cost to repair the damaged item with an item of like kind and quality,without deduction for depreciation. What is depreciation? Depreciation is the amount deducted from the replacement cost based upon the age and condition of the item being replaced. What is actual cash value(AC�? Actual cash value is based on the cost to repair or replace the damaged item with an item of like kind and quality, less depreciation. If your home is older than 1978 it may contain lead painted materials. The EPA may require contractors to follow special procedures to contain and/or remediate lead from the damaged area. If a lead test is taken and your home was found to contain lead, American Family Insurance requires you to notify us before beginning any repairs. Please be aware that the EPA regulations consider lead to be a pollutant. Your policy limits the testing, cleaning, containment and removal of a pollutant to $10,000.00 for covered losses. '�*Should you elect to participate in the Emergency Water Removal Program, a Preferred Contractor Discount to American Family Insurance Company applies and will reflect on payments for covered losses. �� Physical mail you submit: American Family Insurance appreciates your assistance in the handling of your HORNER,JOHN G 00815000887 8/17/2012 Page:4 AMERICAN FAMILY American Family Insurance Group claim. Any documentation you submit will be scanned and electronically retained in your claim file. Please include the claim number on the items submitted. The original documentation will be destroyed after 30 days. 1,f'you would like your documents returned,please indicate this on the documents and provide the address where you want the documents sent. HORNER,JOHN G 0081500088'7 8/17/2012 Page:5 AMERICAN FAMILY American Family Insurance Group HORNER_JOHN_G Main Level Main Level Description Replacement Actual Cash Qty Unit Price Taxes Cost Total Deprecia6on Value Equipment setup,take down,and monitoring(hourly charge) 6.00 HR $45.26 $19.35 $290.91 -$0.00 $290.91 Equip.setup,take down&monitoring-after hrs 2.00 HR $67.95 $9.68 $145.58 -$0.00 $145.58 Totals $29.03 $436.49 -50.00 $436.49 Foyer Height:8' Missing Wall 4' 11 3/16"X 8' Opens into FAMILY_ROOM Missing Wall 3'X 8' Opens into STAIR2 308.14 SF Walls 109.27 SF Ceiling 417.41 SF Walls&Ceiling 109.27 SF Floor 12.14 SY Flooring 38.52 LF Floor Perimeter 38.52 LF Ceil.Perimeter Description Replacement Actual Cash Qty Unit Price Taxes Cost Total Depreciadon Value Air mover�ial fan(per 24 hour period)-No monitoring 10.00 EA $29.01 $20.67 $310.77 -$0.00 $310.77 ', Totals 520.67 5310.77 -50.00 $310.'77 Bedroom Height:8' 324.00 SF Walls 100.85 SF Ceiling 424.85 SF Walls&Ceiling I 100.85 SF Floor 11.21 SY Flooring 40.50 LF Floor Perimeter 40.50 LF Ceil.Perimeter Description Replacement Actuat Cash Qty Unit Price T$xes Cost Total Depreciation Value Air mover axial fan(per 24 hour period)-No monitoring 8.40 EA $29A1 $16.54 $248.62 -$0.00 $248.62 Totals 516.54 5248.62 -50.00 $248.62 ' Office Height: 8' 326.62 SF Walls 104.14 SF Ceiling 430.76 SF Walls&Ceiling 104.14 SF Floor 11.57 SY Flooring 40.83 LF Floor Perimeter 40.83 LF Ceil.Perimeter Description Replacement Actual Cash Qty Unit Price Taxes Cost Total Depreciation Value HORNER,JOHN G 00815000887 8/17/2012 Page:6 AMERICAM FAMILY American Family Insurance Group Office continued... Description Replacement Actual Cash Qty Unit Price Taxes Cost Total Depreciation Vaiue Air mover axial fan(per 24 hour period)-No monitoring 8.00 EA $29.01 $16.53 $248.61 -$0.00 $248.61 Totals $16.53 $248.61 -$0.00 $2A8.61 Bathroom Height:8' 340.04 SF Walls 112.15 SF Ceiling 452.19 SF Walls&Ceiling 112.1 S SF Floor 12.46 SY Flooring 42.51 LF Floor Perimeter 42.51 LF Ceil.Perimeter Description Replacement Actu�l Cash Qtv Unit Price Taxes Cost Total Depreciafion Value Au mover axial fan(per 24 hour period)-No monitoring 10.00 EA $29.01 $20.67 $310.77 -$0.00 $310.77 Dehumidifier(per 24 hour period)-Large-No monitoring 1.00 EA $71.00 $5.06 $76.06 -$0.00 $76.06 Totals 525.73 $386.83 -$0.00 $386.83 Family Room Height:8' Missing Wall 4'9 3/16"X 8' Opens into FOYER 792.32 SF Walls 404.93 SF Ceiling 1,197.25 SF Walls&Ceiling 404.93 SF Floor 44.99 SY Flooring 98.70 LF Floor Perimeter 98.70 LF Ceil.Perimeter Description Replacement Actual Cash Qty Unit Price Taxes Cost Total Depreciadon Value Air mover axial fan(per 24 hour period)-No monitoring 16.00 EA $29A1 $33.08 $497.24 -$0.00 $497.24 Dehumidifier(per 24 hour period)-Large-No monitoring 4.00 EA $71.00 $20.24 $304.24 -$0.00 $34424 Totals $53.32 5801.48 -$0.00 �801.48 ' HORNER,JOHN G 0081500088'7 8/17/2012 Page:7 AMERICAN FAMILY American Family Insurance Group Stair closet Height: 12'S" Subroom: Stairl(1) Height: 12' 1" Missing Wall 3'X 12' 1" Opens into FOYER Subroom: Stairl(2) Height:8' Missing Wall 3'X 8' Opens into STAIR CLOSET 300.31 SF Walls 68.34 SF Ceiling 368.65 SF Walls&Ceiling I 14.24 SF Floor 12.69 SY Flooring 37.90 LF Floor Perimeter 37.50 LF Ceil.Perimeter Description Replacement Actual Cash Qty Unit Price Taxes Cost Total Depreciation Value Air mover axial fan(per 24 hour period)-No monitoring 4.00 EA $29.01 $8.26 $124.30 -$0.00 $124.30 Dehumidifier(per 24 hour period)-Lazge-No monitoring 4.00 EA $71.00 $20.23 $304.23 -$0.00 $304.23 Totals 528.49 $428.53 -50.00 $428.53 Utility Room Height:8' 872.00 SF Walis 456.45 SF Ceiling 1,328.45 SF Walls&Ceiling 456.45 SF Floor 50.72 SY Flooring 109.00 LF Floor Perimeter 109.00 LF Ceil.Perimeter Description Replacement Actual Cash Qty IJnit Price Taxes Cost Total Depreciation Value Air mover axial fan(per 24 hour period)-No monitoring 8.00 EA $29A1 $16.54 $248.62 -$0.00 $248.62 Totals 516.54 $248.62 -$0.00 $248.62 Replacement Cost Taxes Totai Depreciation Actual Cash Value Estimate Totals $206.85 $3,109.95 -$0.00 $3,109.95 HORNER,JOHN G 00815000887 8/17/2012 Page:8 AMERICAN PAMILY American Family Insurance Group Attn:Scanning Center 6000 American Parkway Madison,WI 53783 Office:800-692-6326 Fax: 87?-3 81-3926 September 11,2012 HORNER,JOHN G Claim Number: 00815000887 2290 TIMBER TRL E Date of Loss: 8/9/2012 MAPLEWOOD,MN 55119-5818 The attached estimate of damages has been prepared for your properiy. The estimate has used common prices for labor and material from your area. Enclosed is our draft for the actual cash value(today's replacement cost less depreciation)of your damaged property. For Dwelling and Structure damages,we may have included your mortgage company,U.S.BANK NATIONAL ASSOCIATION ,on the draft as required by your policy. Summary For Dwelling Replacement Cost Value Less Recoverable Less Non Recoverable Actual Cash Value(ACV) Depreciation Depreciation $3,330.59 $3,330.59 Less Deductible ($1,000.00) Total ACV Settlement $2,330.59 See the enclosed estimate for details of your settlement which may include other itemized details not shown above. If you wish to make a claim for the recoverabie depreciation amount,you must do TWO things: l. You must have the item(s)replaced or repaired within one year from your date of loss. *Exception:Georgia and Washington policies ONLY-Please refer to your policy language as well as the section of this estimate titled Claiming Recoverable Depreciation following the Estimate Recap or Coverage Limit Details sections. 2. You must submit a final repair bili or purchase receipt showing the item(s)has been repaired or replaced. The attached estimate is what we expect to be the reasonable cost to repair or replace the property. This estimate may not include permit fees. If total charges for repair/replacement plus permits exceed the amount shown here for that repair/replacement,prior to any deductible,then additional amounts may be payable. If the actual cost is more or less,the final payment will be adjusted accordingly. If you wish,you may repair or replace with higher qualiry items,however,you will be responsible for any increase in cost. Please refer to your policy under either CONDITIONS-SECTION I or HOW WE SETTLE LOSSES-SECTION 1 for further � details on determining your loss settlement. Please present this estimate to a contractor or repair facility of your choice BEFORE you authorize the start of repairs. If any additional damage ar costs are identified,for which you believe we should be responsible,they must be approved by a representative of American Family Insurance prior to having the additional work done. If you,your contractor,or repair facility have any questions,please contact us at. AMERICAN FAMILY American Family Insurance Group American Family Insurance appreciates your business. Thank You, Unlrnown HORNER,JOHN G 00815000887 9/1 U2012 Page:2 AMERICAN FAMILV American Family Insurance Group Insured: HORNER,JOHN G Phone: (651)739-8352 2290 TIMBER TRAIL MAPLEWOOD,MN 55119-5818 Claim Rep.: Unknown Estimator: Melissa Company: Servpro of Cottage Grove/Woodbury Claim Number: 00815000887 Policy Number: 22DE171101 Type of Loss: Water Coverage Deductible Policy Limit Dwelling $1,000.00 $266,700.00 Contents $0.00 $213,400.00 Date Contacted: 8/9/2012 3:00 PM Date of Loss: 8/9/2012 Date Est.Completed: 9/I 1/2012 2:43 PM Price List: MNMNSB AUG12 Restoration/Serv ice/Remodel Sales TaYes: Matl Sales TaY Reimb @ 7.125% Manuf.Home Ta� @ 7.125% ' Cleaning Sales Tax @ 7.125% Clothing Acc TaY @ 7.125% I ,'I �I � � HORNER,JOHN G 00815000887 9/11/2012 Page:3 AMERICAN FAMILY American Family Insurance Group Estimate Recap For Dwelling Recoverable Non-recoverable Description RCV Depreciation Depreciation ACV 11�in I.evel 388.00 0.00 0.00 388.00 Main Level - Foyer 329.19 0.00 0.00 329.19 Main Level - Bedroom 285.73 0.00 0.00 285.73 Main Level - Office 230.80 0.00 0.00 230.80 Main Level - Bathroom 386.83 0.00 0.00 386.83 Main Levet - Family Room 1,078.49 0.00 0.00 1,078.49 Main I.evel - Stair closet 491.96 0.00 0.00 491.96 Main Level - Utility Room 312.95 0.00 0.00 312.95 Main Level - Closetl 1.93 0.00 0.00 1.93 General -175.29 0.00 0.00 -175.29 3,330.59 0.00 0.00 3,330.59 IMPORTANT-Please read the de5nitions below What is replacement cost(RCV)? , Replacement cost is the cost to repair the damaged item with an item of like kind ' and quality,without deduction for depreciation. What is depreciation? Depreciation is the amount deducted from the replacement cost based upon the � age and condition of the item being replaced. ' What is actual cash value(AC�? Actual cash value is based on the cost to repair or replace the damaged item I with an item of like kind and quality,less depreciation. If your home is older than 1978 it may contain lead painted materials. The EPA may require contractors to ollow special procedures to contain and/or remediate lead from the damaged area. If a lead test is taken and your home was found to contain lead, American Family Insurance requires you to notify us before beginning any repairs. Please be aware that the EPA regulations consider lead to be a pollutant. Your policy limits the testing, cleaning, containment and removal of a pollutant to $10,000.00 for covered losses. �"Should you elect to participate in the Emergerccy Water Removal Program, a Preferred Contractor HORNER,JOHN G 0081500088'7 9/1 l/2012 Page:4 AMERICAN FAMILY American Family Insurance Group Discount to American Family Insurance Company applies and will reflect on payments for covered losses. �� Physical mail you submit: American Family Insurance appreciates your assistance in the handling of your claim. Any documentation you submit will be scanned and electronically retained in your claim file. Please include the claim number on the items submitted. The original documentation will be destroyed after 30 days. If you would like your documents returned,please indicate this on the documents and provide the address where you want the documents sent. � HORNER,JOHN G 00815000887 9l11/2012 Page:5 AMERICAN FAMILY American Family Insurance Group HORNER_JOHN_G Main Level Main Level Description Replacement Actual Cash Qty Unit Price Taxes Cost Total Depreciation Value 1.Equipment setup,take down,and monitoring(howly chazge) 5.00 HR $45.26 $16.12 $242.42 -$0.00 $242.42 8/9-1.5 hours equipment and monitoring 8/10- 1 hour equipment monitoring 8/13- 1 hour equipment monitoring 8/14-1.5 hours equipment monitoring and take down total:5 American Family adjuster Warren Ellinger,notified of additional drying time requued. 2.Equip.setup,take down&monitoring-after hrs 2.00 HR $67.95 $9.68 $145.58 -$0.00 $145.58 8/11- 1 hour equipment monitoring 8/12- 1 hour equipment monitoring total:Z Totals $25.80 $388.00 -$0.00 $388.00 Foyer Height:8' Missing Wall 4' 11 3/16"X 8' Opens into FAMILY_ROOM Missing Wall 3'X 8' Opens into STAIR2 308.14 SF Walls 109.27 SF Ceiling 417.41 SF Walls&Ceiling 109.27 SF Floor 12.14 SY Flooring 38.52 LF Floor Perimeter 38.52 LF CeiL Perimeter Description Replacement Actual Cash Qty Unit Price Taxes Cost Total Deprecia6on Value 3.Air mover aYial fan(per 24 hour period)-No monitoring 10.00 EA $29.01 $20.67 $310.77 -$0.00 $310.77 2 air movers at 4 days=8 1 air movers at 2 days=2 total: 10 American Family adjuster Warren Ellinger,notified of additional drying time required. 13.Lift carpet for drying 59.27 SF $0.29 $1.23 $18.42 -$0.00 $18.42 Totals $21.90 5324.19 -$0.00 �329.19 Bedroom Height:8' 324.00 SF Walls 100.85 SF Ceiling 424.85 SF Walls&Ceiling 100.85 SF Floor 11.21 SY Flooring 40.50 LF Floor Perimeter 40.50 LF Ceil.Perimeter HORNER,JOHN G 00815000887 9/11/2012 Page:6 AMERICAN FAMILY American Family Insurance Group Bedroom continued... Description Replacement Actual Cash Qty Unit Price Taxes Cost Total Depreciation Value 4.Air mover axial fan(per 24 how period)-No monitoring 8.00 EA $29.01 $16.54 $248.62 -$0.00 $248.62 2 air movers at 4 days=8 American Family adjuster Warren Ellinger,notified of additional drying time required. 36.Contents-move out then reset-Small room 1.00 EA $37.11 $0.00 $37.11 -$0.00 $37.11 Totals $16.54 $285.73 -$0.00 $285.73 Office Height:8' 326.62 SF Walls 104.14 SF Ceiling 430.76 SF Walls&Ceiling 104.14 SF Floor 11.57 SY Flooring 40.83 LF Floor Perimeter 40.83 LF Ceil.Perimeter Description Replacement Actual Cash Qty Unit Price Taxes Cost Total Depreciation Value 5.Air mover aYial fan(per 24 hour period)-No monitoring 4.00 EA $29.01 $8.26 $124.30 -$0.00 $124.30 1 air movers at 4 days=4 American Family adjuster Warren Ellinger,notified of additional drying time required. 14.Lift carpet for drying 104.14 SF $0.29 $2.15 $32.35 -$0.00 $32.35 37.Contents-move out then reset-Lazge room 1.00 EA $74.15 $0.00 $74.15 -$0.00 $74.I S Totals $10.41 5230.80 -$0.00 $230.80 Bathroom Height:8' 340.04 SF Walls 112.15 SF Ceiling 452.19 SF Walls&Ceiling 112.15 SF Floor 12.46 SY Flooring 42.51 LF Floor Perimeter 42.51 LF Ceil.Perimeter Description Replacement Actual Cash Qty Unit Price Taxes Cost Total Depreciation Value 6.Au mover axial fan(per 24 hour period)-No monitoring 10.00 EA $29.01 $20.67 $310.77 -$0.00 $310.77 2 air movers at 5 days=]0 American Family adjuster Warren Ellinger,notified of additional drying time required. HORNER,JOHN G 00815000887 9/l l/2012 Page:7 AMERICAN FAMILY American Family Insurance Group Bathroom continued... Description Replacement Actual Cash Qty Unit Price Taxes Cost Total Depreciation Va1ue 33.Dehumidifier(per 24 hour period)-Large-No inonitoring 1.00 EA $71.00 $5.06 $76.06 -$0.00 $76.06 1 Dehu at 1 day= 1 Took this dehu from the closet to finish drying the bathroom on the Sth day. American Family adjuster Warren Ellinger,notified of additional drying time required. Totals 525.73 $386.83 -$0.00 $386.83 Family Room Height: 8' Missing Wall 4'9 3/16"X 8' Opens into FOYER 792.32 SF Walls 404.93 SF Ceiling 1,197.25 SF Walls&Ceiling 404.93 SF Floor 44.99 SY Flooring 98.70 LF Floor Perimeter 98.70 LF Ceil.Perimeter Description Replacement Actual Cash Qtv Unit Price Taxes Cost Total Depreciation Value 7.Air mover axial fan(per 24 hour period)-No monitoring 16.00 EA $29A1 $33.08 $497.24 -$0.00 $497.24 4 au movers at 4 days= 16 American Family adjuster Warren Ellinger,notified of additional drying time requued. 10.Dehumidifier(per 24 hour period)-Large-No monitoring 4.00 EA $71.00 $20.24 $304.24 -$0.00 $304.24 1 Dehu at 4 days=4 American Family adjuster Warren Ellinger,notified of additional drying time required. 18.Lift carpet for drying 404.93 SF $0.29 $8.37 $125.80 -$0.00 $125.80 22.Baseboard-Detach 3.34 LF $0.82 $0.19 $2.93 -$0.00 $2.93 38.Contents-move out then reset-Extra large room 1.00 EA $148.28 $0.00 $148.28 -$0.00 $148.28 Totals $61.88 $1,078.49 �-$0.00 $1,078.49 HORNER,JOHN G 00815000887 9/I 1/2012 Page:8 AMERICAN FAMILY American Family Insurance Group Stair closet Height: 12'8" Subroom: Stairl(1) Height• 12' 1" Missing Wall 3'X 12' 1" Opens into FOYER Subroom: Stairl (2) Height: 8' Missing Wall 3'X 8' Opens into STAIR_CLOSET 30031 SF Walls 68.34 SF Ceiling 368.65 SF Walls&Ceiling 114.24 SF Floor 12.69 SY Flooring 37.90 LF Floor Perimeter 37.50 LF Ceil.Perimeter Description Replacement Actual Cash Qty Unit Price Taxes Cost Total Depreciallon Value 8.Air mover axial fan(per 24 hour period)-No monitoring 4.00 EA $29.01 $8.26 $124.30 -$0.00 $124.30 1 air mover at 4 days=4 American Family adjuster Warren Ellinger,notified of additional drying time required. 11.Dehumidifier(per 24 hour period)-Large-No monitoring 4.00 EA $71.00 $20.23 $304.23 -$0.00 $304.23 1 Dehu at 4 days=4 On Sth day moved this dehu to the Bathroom,see Bathroom notes. American Family adjuster Warren Ellinger,notified of additional drying time required. 20.Lift carpet for drying 28.25 SF $0.29 $0.58 $8.77 -$0.00 $8.77 21.Baseboazd-Detach 14.70 LF $0.82 $0.86 $12.91 -$0.00 $12.91 23.Interior door slab oniy-Detach 1.00 EA $4.33 $0.31 $4.64 -$0.00 $4.64 39.Contents-move out then reset-Small room II 1.00 EA $37.1I $0.00 $37.11 -$0.00 $37.11 ' ' Totals $30.24 $491.96 -$0.00 $491.96 i Utility Room Height:8' 872.00 SF Walls 456.45 SF Ceiling 1,328.45 SF Walls&Ceiling 456.45 SF Floor 50.72 SY Flooring 109.00 LF Floor Perimeter 109.00 LF CeiL Perimeter Description Repiacement Actual Cash Qty Unit Price Taxes Cost Total Depreciallon Value 9.Air mover axial fan(per 24 how period)-No monitoring 8.00 EA $29.01 $16.54 $248.62 -$0.00 $248.62 HORNER,JOHN G 00815000887 9/11/2012 Page:9 AMERICAN FAMILY American Family Insurance Group Utility Room continued... Description Replacement Actual Cash Qty Unit Price Taxes Cost Total Depreciation Value 2 air movers at 4 days=8 American Family adjuster Warren Ellinger,notified of additional drying time required. 24.Replace Washing machine-Remove&reset 1.00 EA $29.48 $0.00 $29.48 -$0.00 $29.48 25.Replace Dryer-Remove&reset 1.00 EA $34.85 $0.00 $34.85 -$0.00 $34.85 Totals $16.54 $312.95 -50.00 5312.95 Closetl Height:8' 101.19 SF Walls 7.78 SF Ceiling 108.97 SF Walls&Ceiling 7.78 SF Floor 0.86 SY Flooring 12.65 LF Floor Perimeter 12.65 LF Ceil.Perimeter Description Replacement Actual Cash Qty Unit Price Taxes Cost Total Depreciallon Value 32.Lift carpet for drying 622 SF $0.29 $0.13 $1.93 -$0.00 $1.93 Totals $0.13 �1.93 -50.00 $1.93 General Description Replacement Cost Qty Unit Price Total Depreciation Actual Cash Value 34.Replace 5%Equipment Discount 1.00 EA $175.29 -$175.29 -$0.00 -$175.29 Totals -$175.29 -50.00 -$175.29 Replacement Cost Taxes Total Depreciation Actual Cash Value Estimate Totals $209.17 $3,330.59 -$0.00 53,330.59 HORNER,JOHN G 00815000887 9/11/2012 Page: 10 . .____._. ..__..____. __-----. .. —____. .._.._.___.._.... .._--... --� ; Dat� ! isivoice Nn- �� g 1�. , ---_ - -�l�-{-�201� _—�._..._. _-1 John Horncr 2290 Timher Trail 2290'Timher Trail i Mxrlcwix�d. 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