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Lor �.-��:�:G�a��:�; SE� 2 � 2�12 NOTICE OF CLAIM FORM to the City of ��(�=�'�u�, Minnesota Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipality...shall cause to be presented to the governing body of the municipality within 180 days after the alleged loss or injury is discovered a notice stating the time,place,and circumstances thereof,and the amount of compensation or other relief demanded." Please complete this form in its entirety by clearly 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 much 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 COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK, 15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102 First Name �u-t Middle Initial ! Last Name L V� Company or Business Name �fo5�t5S�(�z �r�.��,�rrr-��-G� Are You an Insurance Company?��e /No If Yes,Claim Number? j�`��1�� StreetAddress �66 ( �es �v�— � 3 City S� /"a 4� State �/" Zip Code ��l�6 Daytime Phone( ) - Cell Phone(�)�- g�30 Evening Telephone( ) - Date of Accident/Injury or Date Discovered ��'� �" Time 7• `�� /pm Please state,in detail,what occuned(happened), and why you are submitting a claim. Please indicate why or how you feel the City of Saint Paul or Lits emplo ees are i volved and/or responsible for your damages. p `ce t ol7` GC c�� ✓� �, , r► u C- !l ti��_ Please check the box(es)that most closely represent the reason for completing this form: �NIy vehicle was damaged in an accident ❑ 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 vehicle was wrongfully towed and/or ticketed ❑ I was injured on City property O Other type of property damage—please specify �Other type of injury—please specify /Ve-c��c C S�ow�s �vi So�� fi'sSY� S�/�G+ 5 �'� �� he��.e� In order to process your claim��u need to include copies of all applicable documents. For the claims 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. O 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 copy 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 always welcome to document and support your claim but will not be returned. Page 1 of 2—Please complete and return both pages of Claim Form Failure to complete and return both pages will result in delay in the handling of your claim. All Claims-please complete this section Were there wimesses to the incident? Yes No Unknown (circle) Provide their names, addresses and telephone numbers. Were the police or law enforcement called? Ye No Unknown (circle) If yes, what department or agency? ic.� Case#or report# I��l�3�� 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 s p ss'ble. If necessary, attach a diagram. � r�v�r>a� S'� �I�t� St .S� P�-I P � "'�4� Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim to your satisfaction. Vehicle Claims- lease com lete this section ❑ check box if this section does not a 1 Your Vehicle: Year DO�{ Make l9 a Model n.v License Plate Number � State j�i Color a,c � Registered Owner J�V1a� LeT Driver of Vehicle u.aK L Z Area Damaged S S �� 0�7/ � u.k,� Yr r�-,c.- City Vehicle: Year ��l� Make Model � License Plate Number State i4'�i'V Color� Driver of Vehicle(City Employee's Name) a� �t�,� �5 �_ Area Damaged Injurv Claims-please complete this section ❑ check box if this section does not apply How were you injured? C��,(ti Cucu`�(e„�,+- What part(s)of your body were injured? t.�, �d-wS �f '>� �� h i,o 3 � Have you sought medical treatment? e No Planning to Seek Treatment(circle) When did you receive treatment? (provide date(s)) Name of Medical Provider(s): Address Telephone Did you miss work as a result of your injury? Yes No When did you miss work? (provide date(s)) i Name of your Employer: i 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 correct to the best of your knowledge. Unsigned forms will not be processed. Submitting a false claim can result in prosecution. Date form was completed � �� l � �,,' H,� r � / Print the Name of the Person who Completed this Form: �K°� C S 1`�'` �yh� u'S l'� Signature of Person Making the Claim: Revised Febmary 20ll � � � u� �s�,�;.�� ,��l-� • �� es f� ' -u �°ti �-- �'sa - � � �� °�O`� 3 ( Accident Report p�� 1 0�� 222143I9 � o wwn+n�+ w.wa. vti+aee a,m ,fr, °"Te 01�'ri "e � N �i �2 �0 �l0 � $ 9 7 2022 Q753 �, ,�� _._._8 B 8 p� z # fi M N ( 10 • 12th s w wim ..__.. n s x ,i 0 J� awnMO �, • wsaw aarno�ccvoen wursara nouw�uaoecoawunoarcuu� ` 62 �,w. St.Paul .�_. 10 Wabasha �•� Lr" /�p1�. aMlFleueW5Ew�qFJtn aalE Ws� o�s7Ja�e romsw awritlt�llaeMA�BFA-r swe tua asr.tus r(�fpp� /� �S O1 A901035584310 MN D 02 O1 P236212298110 I.�7 D pl ut c..... n�erors: w.e��mo�e.wn arxa ww�omr,.eoaawv wreaawM ru�= 08 Ian Andrew I3ash 12 OS 60 BOiJNY IV LEE 02 1'I 89 Qi • rcwu � m �aer , asna. u ee y�p� 24 1926 Como Avenue I3, O1 760 COtJNTY RD 8 E � N7 01 01 ^^'�+ ""'�a' w,;sz�e.a OZ St.Pau1 557.08 651/64�/7930 p,�pp�,gyqpOD 55117 653/239/A301 �i� O1 � M �9 1°`d4 98 98 N 'Y�" F �A �09 98 98 wN O1� �wa .ne �oaaw ,r.e ,owos•muarom .�� wwtumoa aa�. +m oaua ,»e �oxoo► mvwan �eeuav�e �,,,�, � tYr No Q� �t � �.j bur D� oav► wa�wwa� nm ow.uara�a 0� City of St.Pau2 Me ic #23 i� I,OR MAI YER i3 p� �M � � � 14 �926 Como Avenue N� 23I DAYTON AVE AET 101 �1 03� w�u� ertr.ar�+Zm auno a+�er prcmu.a wu�a onstt vwvsi i2 st.Paul,i�7 ssios �, �o-t s� PA[iL MN 55102 �g o� ai �� 08 Fozd Ambn 201 lted TOYT RV4 409 BLK pq PM01lV / A�O 1TMI1� � P� �� f4{TF� 6TR66 TfMA[O � ymyp O/� qRr IMW pID6ElI fl2 FIRE MN 3 O1 01� O1 fl2 01 019EDB MN 2 O1 01 03 01 01 03 � MtR�N� iCUCYNaoB{ MBINMQMY1�l i01lCYNWBLR City of St.Paul Progressive �12016832 ______.. � � +�,. KnccweNr�nro�vEO�coxp�'iir.reos'osve+na.e.'s e►�,aRyenasrurreus .._...—..-._^ j 7 �T4N01IFY7lt86Ti«6cPATRd. BTi (e�qntr�dtatdwNB'I�.708aedl6Y.i37f} , °� �t� �1F�uv�lKiBauefll�.umonrwiwi0ewu�E onMU�o6� ooNe:ew.vaw.eMX�Ertt-wtoa G/tl1@eN�Y7 OOtqlqFA iAR�X(��WnT66ka ' ten Or eex irre YSe A�1�6 tacr �u6Br ro ma�a�rt n+y.a erstcaer��ie: cst�c<ans�o� Ol 03 1j�Y�� F 98 98 98 98 N N? Qe�"',,,�, �� Mai Yer {6S1/994/8930) 02 03 �o�L9� F 04 04 9B 98 N N' a�, �� . �� ' � �uraex.�a n�xMwm +` . �� `` w ow�eeamxe�awaeumaein�noa,samroraa�w�nroremrnarnr�uonnwwaam aw�etamenmriveu�wr.orwea� �• �ccrn � OEnCE �f .. �1 �ae.ws ..---_........ ..... ......_....... .. ..........._.......,......................,...... a3 f I � Baramedic driver of vehicle �1 told me he was , ._... . .. ............................._........_.........._ ,..._ � � �� dslving W/8 on 12Lh street.Drfver oP'vefi'a:cie"#'x� � t I .� .t:old.me..he..decl�lad...t.o...entsr...the..94..kV.B..sptxa?AC�... O1 O1 :�"�� not seeing vehicle #2 and stxikinq it. armmac . • �Friver•of•vehi�c3e•#2-told��e-she•aras•ahead•of•�• � M*� N� I f � vehicie $1 as she xas preparing to enter 35FJ� p� "''Ea`a / 'SrB':DriveY"o'f"'V�e1stCTe"�2 'told m6 veMcSg tl'-th�e�[t� QQ f � came over into her lane stciking her right reac j� ....._.... ....... ...._..,......_... . . ..... ...... . �s — ^ � —� d quarter panel.ko injuttes. " '�' ' a�i � ...,.._...._. . . ..... ... ... .. ....... ....._.... .... ..�_.... ... . nfnmen� `�a' u�.' N . . . ., . � ............_..._---._ _. ._...._....... . .... .._._... O 1 '. — — -- �5mra4 RPE10M _— tZA6SrM ~_ " a,� YM511M � . . .. ... . . .. ......... . ...f.. .. ......_..-._............_..... MBI/V \ .... ....."""..., .... ..�...... . . .... . . . .. .. , UbR �1 �\ ._..... . .. ...... .... ... . ....... ... ...... .. .......... .... �� ,; , ._... . ..._.... . .................... ..... ........ ...... N. �� " � ... .__.. ...._,........................ ............_... . .. . .. . 09 02 o�rxe�wurcwweaos�ocer . ncr�ac. w�nas�ao� p sweo�mo< <ou� Pataolman Bxuce Schmidt #352 St Paul PD . , O� p� . � � i https://dvsIesupport.arg/dvsinfo/accidentrecor�s 2008/Inc�udes LE/1'cintReportlndiv_LE.as... 9/7/20I2 , j _J Date: 9121/201212:06 PM Estimate ID: 12-3941485-01 Estimate Version: 1 Supplement: 1(F F) 9120l2012 04:2�:=;7 F': Profile ID: *Metro All Parts7.1 PROGRESSIVE Damage Assessed By: KEVIN MIER *Claim Rep: Kevin Mier (507)67fr0557 Supplemented By: MATT BOYD *Product Type Auto `Date of Loss: 9I 7/2012 "Deductible: 500.00 'Claim Number: 12-3941485-01 Insured: MAI LOR Claimant: MAI LOR Address: 6150 LAMAR AVE SOUTH,COTTAGE GROVE,MN 55016 Telephone: Home Phone: (657)4948930 Owner: MAI LOR Address: 6150 LAMAR AVE SOUTH,COTTAGE GROVE,MN 55016 Telephone: Home Phone: (651)494-8930 Mitchell Service: 917752 Description: 2004 Toyota RAV4 Vehicle Production Date: 00/00 Body Style: 4D Ut Drive Train: 2.4L Inj 4 Cyl 2WD VIN: JTEGD20V640011130 License: 019EDB MN OEM/ALT: A Search Code: ARDENHILLI Color: BLACK Options: PASSENGER AIRBAG,DRIVER AIRBAG,POWER LOCK,POWER WINDOW,REAR WINDOW DEFOGGER MANUAL AIR CONDITION,CRUISE CONTROL,TILT STEERING COLUMN,ANTI-LOCK BRAKE SYS. TRACTION CONTROL,FOG LIGHTS,FRONT AIR DAM,TINTED GLASS VARIABLE ASSISTED STEERING,AM/FM STEREO CD,ELECTRONIC STABILITY CONTROL FRONT BUCKET SEATS,INTERIOR AIR FILTER,POWER DISC BRAKES,REAR WINDOW WIPER STEERING WHEEL AUDIO CONTROLS Line Entry Labor Line Item Part Typel Dollar Labor Item Number Type Operation Description Part Number Amount Units 1 702480 BDY REMOVEIREPLACE Wheel Remanufactured 179.00 0.3 S1 2 702741 BDY REMOVEIINSTALL R Rear Inr Rocker Scuff Plate Existing 0.2 r S1 3 701002 BDY REMOVE/INSTALL R Rear Otr Rocker Scuff Plate Existing 0.2 r S1 4 702733 BDY REMOVE/INSTALL R Rear poor Opening Welt Existing INC r 5 701126 BDY REPAIR R Frt Door Repair Panel Existing 1.0*# , 6 AUTO REF REFINISH R Frt Door Outside C 2.0 7 701132 BDY REMOVE/INSTALL R Frt Belt Moulding 0.6 # � 8 701134 BDY REMOVE/INSTALL R Frt Door Mirror INC # 9 701138 BDY REMOVE/REPLACE R Frt Door Moulding 75731-42110-CO 234.02 0.4 10 701152 BDY REMOVEIREPLACE R Frt Upr poor Moulding Pad 75793-42040 5.98 11 701154 BDY REMOVEIREPLACE R FR Door Front Moulding Pad 75787-42020 4.08 12 701156 BDY REMOVE/REPLACE R Frt Door Rear Moulding Pad 75794-42010 4.08 13 702986 BDY REMOVEIREPLACE R Frt Lwr poor Moulding Pad 75793-42040 5.98 14 701194 BDY REMOVE/INSTALL 1;Frt Door Trim Panel INC 15 701234 BDY REMOVEIINSTALL R Frt Door Handle 0.7 # 16 701355 BDY REMOVE/REPLACE R Rear poor Shell Used/Recycled 350.00 * 4.7 17 AUTO REF REFINISH R Rear poor Outside C 1.6 18 AUTO REF REFINISH R Rear Add For Jambs&Interior C 1A 19 Line Markup%30.00 105.00 20 701361 REF REFINISH R Rear poor Moulding C 0.7 21 701383 BDY REMOVE/REPLACE R Rear Upr poor Moulding Pad 75797-42010 4.08 22 701385 BDY REMOVEIREPLACE R Rear poor Moulding Pad 75794-42010 4.08 23 701387 BDY REMOVEIREPLACE R Rear poor Moulding Pad 7569T-42040 4.08 24 702996 BDY REMOVE/REPLACE R Rear Lwr poor Moulding Pad 75767-42010 4.19 25 703152 BDY REMOVE/REPLACE R Rear Lwr poor Stone Guard 75996-42070 32.12 0.2 26 701729 BDY REMOVE/REPLACE R Quarter Outer Panel 61610-42220 780.13 15.5 # 27 AUTO REF REFINISH R Quarter Panel Outside C 1.6 28 AUTO REF REFINISH R Add For Pillar C 0.5 This estimate has been re-calculated with a modified profile. ESTIMATE RECALL NUMBER: 09N1/201212:12:15 72-3941485-01 Mitchell Data Version: OEM: JUL 12 V0814 MAPP:JUL_12_V Copyright(C)1994-2012 Mitchell International Page 1 of 5 Software Version: 7.0.443 All Rights Reserved Date: 9/21/201212:06 PM Estimate ID: 12-3941485-01 Estimate Version: 1 Supplement: 1(F F) 9120I2012 04:25•r:7:': Profile ID: 'Metro All Parts7.1 29 AUTO REF REFINISH R Quarter Panel Edge C 0.5 S1 30 703287 BDY REPAIR R Quarter Wheelhouse Panel -S Existing 4.0* 31 703446 BDY REMOVE/REPLACE R Quarter Stone Guard 75998-42010 16.18 INC S1 32 703299 BDY REMOVEIINSTALL R Lwr Quarter Trim Panel Existing INC #r 33 701818 GLS REMOVE/INSTALL R Quarter Glass 0.2 # 34 702136 BDY REMOVE/INSTALL R Rear Combination Lamp INC 35 702167 BDY REMOVEIREPLACE R Rear Bumper Cover 52161-42912 154.11 0.1 36 AUTO REF REFINISH R Rear Bumper Cover C 1.0 37 702169 BDY REMOVE/REPLACE R Rear Bumper Protector 52581-42010 18.76 38 702171 BDY REMOVE/REPLACE R Rear Bumper Seal 52591-42020 25.95 39 702783 BDY REMOVE/INSTALL R Rear Bumper Guard Existing INC r 40 702185 BDY REMOVE/INSTALL R Rear Bumper Reflector Existing INC r 41 936012 ADD'L COST HAZARDOUS WASTE DISPOSAL 3.50 * 42 AUTO REF ADD'L OPR Clear Coat 2.2 43 AUTO ADD'L COST Paint/Materials 355.20 • 44 900500 BDY* ADD'L LABOR OP MOUNT&BALANCE INCLUDES STEM$WEIGHTS Sublet 18.50 * 0.0* 45 900500 MCH* ADD'L LABOR OP FOUR WHEEL ALIGNMENT Sublet 85.00 * 0.0* 46 900500 MCH* REMOVEIREPLACE RIGHT REAR TIRE New 96.80 ' 0.0* 47 starfire sf510 215f10/16,simpletire.com' 48 900500 BDY* ADD'L LABOR OP TIRE DISPOSAL Sublet 2.00 ' 0.0' 49 900500 GLS * REMOVE/REPLACE QUARTER GLASS URETHANE KIT Sublet 12.00 ' 0.0' 50 900500 REF • REMOVE/REPLACE FLEX ADDITIVE '"Non-OEM 5.00 * 0.0' 51 900500 BDY* ADD'L LABOR OP COVER CAR FOR OVERSPRAY **Non-OEM 7.50 * 0.2` 52 900500 BDY` REMOVE/REPLACE CORROSION PROTECTION *"`Non-OEM 7.50 * 0.3' 53 900500 BDY• REMOVEIREPLACE UNDERCOATING *'Non-OEM 7.50 ' 0.3' S7 54 900500 BDY* ADD'L LABOR OP TIE-DOWN AND PULL Existing 2.0" 55 QUARTER S1 56 900500 BDY` ADD'L LABOR OP SET UP&MEASURE UNIBODY/FULL FRAME Existing 1.0` 57 Includes all necessary operations except pull time *-Judgment Item #- Labor Note Applies �"`Non-OEM-Non-Original Equipment Manufacturer Replacement Part C-Included in Clear Coat Calc r-CEG R8R Time Used For This Labor Operation PRECISION WHEEL SERVICE 10921 EXCELSIOR BL.#106 HOPKINS M N 55343 ' (800)255-6973 (952)881-3010 I 1 *•42611-42141 179.00 i Recycler Information Section: Pam's Auto-ARAPro 7505 Ridgewood Road St Cloud MN 56303 800-560-7336;320-363-9232 16 2004 Toyota RAV4 RIGHT REAR SIDE DOOR M0882 VA 350.00 Description:ASSY,GRY,PWR,5D1,SIDE DOOR,R,US MKT, Disclaimer:The price indications on recycled parts are real or composite values,based on the pricing option selected with QRP. Prices are the latest available at time of inventory download and are subject to change and availability. To determine actual repairer net or wholesale price,call the automotive recycler of your choice. Certain parts located for this quote are interchangeable but are not an exact match. Call the automotive recycler of your choice. This estimate has been re-calculated with a modified profile. ESTIMATE RECALL NUMBER: 09/11/201212:12:15 72-3941485-01 Mitchell Data Version: OEM: JUL 12 V0814 MAPP:JUL_12_V Copyright(C)1994-2012 Mitchell International Page 2 of 5 Software Version: 7.0.443 All Rights Reserved Date: 9/21/201212:06 PM Estimate ID: 12-3941485-01 Estimate Version: 1 Supplement: 1(F F) 9/20/2012 04:2v:'7:`i_: Profile ID: "Metro All Parts7.1 All manufacturers requirements regarding seat belt and supplemental restraint system replacement must be adhered to. If additional parts or operations are necessary to properly accomplish this, please contact the estimating claims rep. Estimate Totals Add'I Labor Sublet 1. Labor Subtotals Units Rate Amount Amount Totals II. Part Replacement Summary Amount Body 31.7 52.00 0.00 20.50 1,668.90 Tauable Parts 1,963.12 Refinish 11.1 52.00 0.00 0.00 577.20 Parts Adjustments 105.00 Glass 0.2 52.00 0.00 0.00 10.40 Sales Tax @ 7.625% 157.69 Mechanical 0.0 80.00 0.00 85.00 85.00 Total Replacement Parts Amount 2,225.81 Non-Taxable Labor 2,341.50 Labor Summary 43.0 2,347.50 III. Additional Costs Amount IV. Adjustments Amount Non-Taxable Costs 358.70 Insurance Deductible 500.00- Total Additional Costs 358.70 Customer Responsibility 500.00- Paint Material Method:Rates Init Rate=32.00 I. Total Labor: 2,341.50 II. Total Replacement Parts: 2,225.81 IIi. Total Additional Costs: 358.70 Gross Total: 4,926.01 IV. Total Adjustments: 500.00- Net Total: 4,426.01 Less Original Net Total: 4,134.87 Net Supplement Amount: 291.14 S7: MATT BOYD 291.14 Point(s)of Impact 4 Right Rear Side(P) This estimate has been re-calculated with a modified profile. ESTIMATE RECALL NUMBER: 09/11/2012 12:12:15 72-3941485-01 Mitchell Data Version: OEM: JUL_12_V0814 MAPP:JUL_12_V Copyright(C)1994-2012 Mitchell International Page 3 of 5 Software Version: 7.0.443 All Rights Reserved Date: 9/21/201212:06 PM Estimate ID: 12-3941485-01 Estimate Version: 1 Supplement: 1(F F) 9/20I2012 0425�7:'�7 Profle ID: *Metro All Parts7.1 THIS IS A DAMAGFs ASSF3SSM13NT ONLY - NOT AN AUTHORIZATION TO REPAIR - BASED ON DAMAGE VISIBLFs' OR CFsRTAIN AT THE TIME IT WAS WRITTSN. IF FRAM� OR UNIBODY RFsPAIR IS INCLUDfiD ON THIS FSTIMATE, THFs AMOUN'P SHOWN INCLUDLS TIMS OR ALLOWANCE FOR MEASURING B}3FORE, DURING AND AFTER THOSE R]3PAIRS. THL OWNL�R OF THS VEHICLE MAY S£sLFsCT THL REPAIR FACILITY OF HIS/HSR CHOICL. TO ENSURE PROPER AND PROMPT PAYMSNT FOR ADDITIONAL DAMAGS DISCOVERSD DURING THE COURSS OF RSPAIRS, CONTACT PROGRESSIVE FOR SUPPLEMENT HANDLING PROCEDURES. PROGRFsSS2VE HONORS THE PREVAILING LABOR MARKET RATB IN YOUR ARSA FOR YOUR PROPERTY. IF YOU CHOOSE A SHOP THAT CHARG$S IN EXCESS OF PREVAILING LABOR MARKET R.ATSS, YOU WILL BE RESPONSIBLE FOR THE DIFFSRENCE. LIFFs'TIME GUARAN'PEE FOR SH33ET MFsTAL AND PLASTIC BODY PARTS '' The replacement parts written on the estimate are intended to return your vehicle to its pre-loss condition with proper installation. After repair, if any sheet metal or plastic body part included in the estimate fails to return your vehicle to its pre-loss condition (assuming proper installation) , in terms of form, fit, finish, durability or functionality, Progressive will arrange and pay for the replacement of the part, to the extent not covered by a manufacturer�s or other warranty. This service will be performed at no cost to you (including associated repair and rental car costs) . To obtain service under this Guarantee, call Progressive at 1-800-274-4641. This Guarantee applies as long as you own or lease the vehicle. This Guarantee is not transferable and terminates if you sell or otherwise transfer your vehicle. THIS GUARANTEE DOES NOT COVER NORMAL WEAR AND TEAR OR DAMAGS CAUSFsD BY IMPROPER MAINTENANCE, NSGLECT, ABUS}3 OR SUBSEQUENT ACCIDENT. THIS GUAR.ANTF3S IS LIMITSD TO ARRANGING FOR TH}3 SSLgCTION OF RFsPAIR PARTS THAT WILL RBTURN YOUR VSHICL}3 TO ITS PRE-LOSS CONDITION. ACCORDINGLY, PROGRESSIVS WILL NOT BE LIABLE FOR ANY INDIRSCT, INCIDENTAL OR CONSEQUENTIAL DAMAGES THAT RESULT FROM THS INSTALLATION OR USS OF THESE PARTS. Part Type Terms aad Abbreviations NEW and OEM or part number displayed - These refer to a new, original equipment manufacturer part. NON-OEM and A/M and Qual REPL - These refer to an after-market part, which is a new, non-original equipment manufacturer part. USED/RECYCLED and LKQ - These refer to a used OEM part. REMANUFACTURSD and RECOND. and RECORE - These refer to used/recycled OEM parts that have been refurbished. REPAIR SHOP'S AUTHORIZFsD RFsPRESSNTATIVE'S SIGNATURE INDICATING AGREEMENT ON COST TO RETURN THS VEHICLE TO PRE-LOSS CONDITION INCLUDING TOW/STOR.AGE CHARGFsS: This estimate has been re-calculated with a modified profile. ESTIMATE RECALL NUMBER: 09/17/2012 12:72:75 12-3941485-01 Mitchell Data Version: OEM: JUL 12 V0814 MAPP:JUL_12_V Copyright(C)1994-2012 Mitchell International Page 4 of 5 Software Version: 7.0.443 All Rights Reserved Date: 9/21I201212:06 PM Estimate ID: 12-3941485-01 Estimate Version: 1 Supplement: 1(F F) 9/2012012 04:25:47?�,i Profile ID: *Metro All Parts7.1 SHOP SIGNATURFs: SST. COMPLE�TION DATE3: ANY PLRSON WHO, WITH INTSNT TO D}3FRAUD OR KNOWING THAT HB/SHS IS FACILITATING A FR.AUD AGAINST AN INSURSR, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DSCEPTIVE STATEMENT IS GUILTY OF INSUR.ANCS FRAUD. This estimate has been re-calculated with a modified profile. ESTIMATE RECALL NUMBER: 09/11/201212:12:15 12-3941485-01 Mitchell Data Version: OEM: JUL_12_V0814 MAPP:JUL_12_V Copyright(C)1994-2012 Mitchell International Page 5 of 5 Software Version: 7.0.443 All Rights Reserved