Vicars NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minnesota State Statute 466.OS states that "...every person...who daims 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 �` � l �n �!','f . Middle Initial�Last Name U i �� !�7
Company or Business Name �����'���
Are You an Insurance Company? Yes/1`�o If Yes, Claim Number? ��� � � 2��
Street Address � �`�.� '���'�' l. �(6�(� ��i�'P �-f�l-r'i��.�-a4a1�L o�i`t"� °��'a��1
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City � a( ! ���-� �'c-/( Vj L State � ! 1�1� �'SD'�!-� Zip Code S�� d
Daytime Phone(�� f ) a 7�,!- �S y Cell Phone(�S 1 )27Lj- L!>p 1 Evening Telephone( r S! )��-�-f Z 3�
Date of Accident/Injury or Date Discovered �� Z � � Z C' � Z Time ` '�3 t �i/pm
Plea�P �±ate,ir.d�tail, what�ccurred(happenedj, and why you are submitting a claim. �Iease indicate why or how you
feel the City of Saint Paul or its employees are involved and/or responsible for your damages. �- SU��t f �'c�I/1(, ;
'�r L���;( c��,�l (�('c��(��+ �, t�-�(�'r ��i ►�T�� ;n.� �� 1���c � !,✓l� ��r w1�1 K;��;� c1�� '
_� tl,P�i�:�� ;�i --T�t'.ti , �; . ��'��y !� � u/;�ttnf h� !' ,' `�t,•S � vl�' yrl';"t� � ;1�` �;G �'n���/;.
Please check the box(es)that most closely represent the reason for completing this form:
�,My 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
❑ Other type of properiy damage—please specify
❑ Other type of injury—please specify
In order to process your claim vou 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 V�ILL 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 ',�,�'���.-���F���
O Injury claims: medical bills,receipts
O Photographs are always welcome to document and support your claim but will not be ret��d.�J v 2��2
Page 1 of 2—Please complete and return both pages of Claim Form ,���;,r-�,? �:�.� ��R}°,��
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 witnesses to the incident? es` No Unknown (circle)
Provide their names, addresses and telephone numbers: ( ��, �� �y `C'�;-'�,�►r ���f� �c�l cj
� :�. s ��-��, ��Pnu�.S�1�+41 � SU� � a���u� vnn ss�r' � � 3L� �— �a �S
Were the police or law enforcement called? 'e No Unlrnown (circle)
If yes,what department or agency? �G� h-}- ��*,u� �'�r�i�� Case#or report#�Z� �� 7Z�/
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. �}�h'±�(,(���Y���C,:� (i�-
�U�Sh�L �vr''�1uf Ci41�( I"� Cll�� � n�' �V�PVI�.I�c%:
Please indicate the am unt ou a�e seekin in compensation or what you would like the C�to do to resolve this claim
to your satisfaction. , 5 P f' �t (G� � � �'�i� , v1� ��(�i�'S �"r �c( Wc~���( , i�
� I�4"�Vt.�.C ('c'Y ,h Y t� �•n i /'�1 � �! /�ip `j t�r,� -(' , E� -!(�r'C' U(, � "�,i tali"?�fh y
V�k;c(,� t sn .
Vehicle Claims-please complete this section ❑ check box if this section does not apnlv
Your Vehicle: Year �� � Make�;;1��� C( Model C± V.:= ( -- �Q X � 5 �
License Plate Number SL w - t?��' State .M� Color ° [
Registered Owner� •�("'i��+j�;( ���'/C�' V� � ��`Y�
Driver of Vehicle �� ( l� �; �1 c.� ✓ � [ C?�
Area Damaged �-t 1� � Pc-i/' Y u S �h�� i i^:
% CityVehicle: Year ?c�;=- Make �-c7(;, Model �'rc�W�1 r �(?'r !�i:(
License Plate Number G��+t 1 State tm r1 Color c.�J' �(,1 S�'u c�
Driver of Vehicle(City Employee's Name) 1(��i U �; � �ti vt �,�l�+ t'h
, Area T�amaged S C (-�:t �i � (!✓1 r'��•{�;;�� II�;� 7 rI f �E'-; i�
--
I
Injury Claims-please com_plete this section ❑ check box if this section does not apply
How were you injured?
What part(s) of your body were injured?
Have you sought medical treatment? Yes 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:
4 Address Telephone
I� 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
jof your knowledge. Unsigned forms will not be processed.
Submitting a false claim can result in prosecution. Date form was completed !�� ��Z u i�-
Print the Name of the Person who Completed this Form: � � c�I�K r�t ��YC P V l f u i"5
Signature of Person Making the Claim: �/''��/'��
,.7z.
Revised February 2011
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Saint Paul Police Department �'�
SUPPLEMENTAL OFFENSE / INCIDENT REPORT ' �
Complaint Number Reference CN Date and Time of Report
12199724 08/21/2012 11 :22:00 �
Primary offense: �
TRAFFIC ACCIDENT-SQUAD CAR
Primary Reporting Officer.• Nal'1'12t1, Valarie A Name of IocatioNbusiness:
Primary squad: 541 l.ocation of incident MARSHALL AV&HAMLINE
Secondary reporting officer. ST PAUL, MN 55104
Approver.• BUCk2, StUaI't
oisrrict:W estern Date&time of occurrence: 08/21/2012 09:30:00 to
Site: 08/21/201211:23:00
Arrest made: _ ._.
Secondary oHense:
Police Officer Assau/ted or Injured: Police Officer Assisted Suicide:
Crime Scene Processed:
OFFENSE DETAILS
TRAFFIC ACCIDENT-SGIUAD CAR
Attempt Only: Appears fo be Gang Related:
SOLVABILITY FACTORS
Suspect can be ldentNied: By; '
Photos Taken: Stolen Property Traceable: '
Evidence Tumed In: Property Tumed In:
Related Incident
Lab
Biological Analysis: Fingerprints Taken:
IVarcotic Analysis: ltems Fingerprinted:
Lab Comments:
Participants:
Person Type: Name: Address: Phone:
NARRATIVE
I, Sgt Namen, squad 541 was traveling east bound on Marshall Avenue approaching Hamline Avenue. The light ,�
was red and I was stopped in traffic. I saw a pickup truck with a w/m driver, gray hair, gray beard and
mustache, approximately 50+years old driving westbound on Marshall. The pickup truck drove through the red
light without stopping. A vehicle traveling southbound on Hamline had started to enter into the intersection
when the pickup drove through causing the southbound vehicle to stop in order to avoid hitting the pickup truck
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Saint Paul Police Department .,�
SUPPLEMENTAL OFFENSE / INCIDENT REPORT � �
; ��
Complaint Number Reference CN Date and Time of Report
12199724 08/21/2012 11:22:00 :
Primary offense:
TRAFFIC ACCIDENT-SQUAD CAR �
which continued westbound without stopping. `
I looked over my shoulder for traffic in the eastbound turn lane and didn't see any. I started to make a u-turn
using the turn lane and the Holiday Station drive way when my vehicle was struck on the left rear by a 1986
black Honda Civic, Lic #: SLW-020. I exited my vehicle and went to the driver of the Honda who stated he was
a little shaken up but said he was fine. I asked him if he wanted medics to come check him to be sure and he
said no. I told him to pull over to the side of the road and I would call it in.
I called Sgt Olson and notified him that I had a squad accident who notified Commander Mathison who called
me and stated he would be enroute.
I then spoke with CHRISTOPHER ANTHONY TAYKALO (DOB: 02/19/1972, 671 Smith Avenue South, St Paul,
MN 55107, C/P: 651-341-7275). Taykalo stated he was in the Holiday Station driveway when he saw me try to
make the u-turn and was struck by the Honda in the turn lane.
I spoke with the owner of the Honda who was identified by MN DL as RICHARD ROYCE VICARS (DOB: .
07/18/1990, 1895 Portland Avenue Lower, St Paul, MN 55104). He stated he was traveling eastbound on
Marshall Avenue. Vicars said as he pulled into the turn lane to go north on Hamline, the squad car turned in
front of him and he was not able to stop.
The right front bumper of the Honda struck the left rear tire on the squad. The right front turn light assembly
was broken, the front bumper was cracked and pushed out of alignment and the left front head light was �'�;
partially broke away from car frame. There was no damage to the squad. ,
Officer T. Macintosh arrived on scene and took photos. See his supplemental report. • �
PUBLIC NARRATIVE .� �
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' Saint Paul Police Department
SUPPLEMENTAL OFFENSE / INCIDENT REPORT •
Complaint Number Reference CN Date and Time of Report
12199724 08/21/2012 10:06:00
Primary offense:
TRAFFIC ACCIDENT-SQUAD CAR '�
Primary Reporting Officer: MaCkintoSh,Theodore B Name of location/business:
Primary squad: 120 l.ocation of incident:MARSHALL AV&HAMLINE
Secondary reporting officer.• ST PAUL, MN 55104
Approver.• D'cly, Daniel �
oisrr�cr. Western Date&time of occurrence: 08/21/2012 09:50:00 to
Site: 08/21/2012 09:50:00
Arresi made:
Secondary offense:
Police OfficerAssaulted or Injured: Police OfficerAssisted Suicide:
Crime Scene Processed:
OFFENSE DETAILS
TRAFFIC ACCIDENT-SGIUAD CAR
Aitempt Cnly: Appears to be Gang Related:
NAMES '
Owner Vicars, Richard Royce
MN 55104
N/cknames or A/lases
Nick Name:
Alias:
AKA First Name: AKA Lasf Name:
Deta/ls
Sex: Race: DOB: 07/18/1990 Resident Status:
Hispanic: Age: from to
Phones
Home: Cell: Contact
Work: Fax: Pager.•
Employment
Occupafion: Employer.• '
.:�
. ��
SP0000025A13661E • .
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Page 2 of 4
� Saint Paul Police Department
SUPPLEMENTAL OFFENSE / INCIDENT REPORT . �
Complaint Number Reference CN Date and Time of Report •
12199724 08/21/2012 10:06:00
Primary offense:
TRAFFIC ACCIDENT-SQUAD CAR � �
/dentiflcatlon
SSN: License or ID#: License Siate:
SOLVABILITY FACTORS ,
Suspect can be Identified: 8y: •
Photos Taken:YgS Stolen Property Traceable: ,
Evidence Tumed In: Property Tumed In:
Related lncident
Lab
Biological Analysis: Fingerprints Taken:
Narcotic Analysis: Items Fingerprinted:
Lab Comments: �
PROPERTY
ITEM#1
Type of Loss: Darpaggd Date of Loss: 08/21/2012 �ocarion�osr. Marshall/Hamline
Owner. VICa�S, Richard Royce Date Recovered: Location Recovered: •
Mode!#.• Quantity: Serial#: '
article Typeiltem: Other property / Vehicle Total value:
Description: rpOtO�V@hICl2
i
Turned in at• Locker ID#: Lab exams:
SP0000025A13661E
' Page 3 of 4 �
Saint Paul Police Department �
SUPPLEMENTAL OFFENSE / INCIDENT REPORT �
Complaint Number Reference CN Date and Time of Report
12199724 08/21/2012 10:06:00
Primary offense:
TRAFFIC ACCIDENT-SQUAD CAR
VEHICLE INFORMATION (Property)
Status Descriptlon
Status: License no.: SLW020 Yea►'. 1986
Towed: No State: MN Type:
Lock stafus Year. Color.•
Doors un�ocked.� V.I.N.: JHMAF5336GS036200 ��s�
Ignition unlocked: Make: Transmission:
Trunk unlocked: Model.• CIVIC 1500 CRX SI Shift Position:
Keys in vehicle: Np Mileage:
lnsurance&owner information Vehicle contents&drlver
Insurance co.: Keys in vehicle: NO
Lienholder.• Owner allowed someone to
Lease Company:
use vehicle:
Amount Owed: $Q Stolen Method:
Registered owner. Vicars, Richard Royce Thett Coverage:
Drivers license no.: Personal property in vehicle: �
Participants: '
Person Type: Name: Address: Phone: �
Owner Vicars, Richard Royce
MN 55104 �'
NARRATIVE
On 8/21/12 at 0950 hours, Squad# 120 (Mackintosh, Theodore B) was dispatched to Hamline/Marshall for a
squad accident.
List of Photos for CN 12199728: �
7
1. 12199728-08212012_090711-TRAFFICACCDNT-1.jpg - Laptop screen of CAD call .
2. 12199728-08212012_090717-TRAFFICACCDNT-2.jpg - Marshall/Hamline street signs
3. 12199728-08212012_090818-TRAFFICACCDNT-3.jpg - E/b Marshall west of Hamline '
4. 12199728-08212012_090852-TRAFFICACCDNT-4.jpg - Rear left Squad 1423 with tire damage
5. 12199728-08212012_090854-TRAFFICACCDNT-5.jpg - Closeup tire damage
6. 12199728-08212012_090859-TRAFFICACCDNT-6.jpg - Front MN# SLW020
7. 12199728-08212012_090911-TRAFFICACCDNT-7.jpg - Passenger MN# SLW020
8. 12199728-08212012_090917-TRAFFICACCDNT-8.jpg - MN# SLW020 rear
9. 12199728-08212012_090924-TRAFFICACCDNT-9.jpg - Driver side MN# SLW020
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� Pa98 4 of 4 ,,
� Saint Paul Police Department
SUPPLEMENTAL OFFENSE / INCIDENT REPORT
Comp/aint Number Reference CN Date and Time of Report
�
12199724 08/21/2012 10:06:00
Primary offense: ..
TRAFFIC ACCIDENT-SQUAD CAR � '
10. 12199728-08212012_090947-TRAFFICACCDNT-10.jpg - Front right corner MN# SLW020
11. 12199728-08212012_090958-TRAFFICACCDNT-11.jpg - Close up MN# SLW020
The labeled photos were TRANSFERRED to the Media Vault.
PUBLIC NARRATIVE
Photos APD Marshall/Hamline 8/21/12 at 0950 hours.
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SP0000025A13661E
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Accident Report Page 1 of 1
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03 � Driver of vehicle N2 (squad)was east bound on �
_. . . __. .
�„ I Marshall Avenue sloNing for red liqht aE H ne �p '
O1 �'�T T°�-E Avenue. ..A..Pickug..tr.uck tr3vsllnq..Neai.b.RUttd..oA_.._ Ol
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N' 1°""""°' ¢ approachin9 in center turn lane and proceeded to Ol
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�� Driver of vehicle �F1 Waa travelinq east`6ound on
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� Hamline Avenue. Driver pulled into turn lane to ,
.�w.rr make l-eft tusn.onto..nozth..bouad-Aamline...&venuQ. ��� �
� 0 vehicle #2 was making u-turn. Driver of vehicle
T Was'unable to stop-and strecie tha-7.eft°rear°
Ofi ,r•- I I tire of vehicle N2. uan
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O1 I I oamage-.YO..vehicle._N1..consia.ted..of.a.brokea.ziQhL_.
, ��� front turn liqht assembly, ftont bumper °�
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Commander David Mathison 12 St Paul PD p,�.. po�, '
Case#:12199724
Report Date:8/21/2012
Accident Narrative,cor�tinued: `
broken and shifted to the left. The leR front head light was partially broken off light frame. There was no damage to vehide
#2. ' .
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� HEPPNERS AUTO BODY SAINT PAUL Workfile ID: c42a8954
400 SYNDICATE ST. N., SAINT PAUL, MN 55104
Phone: (651) 646-8615
FAX: (651) 645-3230
Preliminary Estimate
Customer: VICARS, RICK 7ob Number:
Written By: Marshail Mizuno
Insured: VICARS,RICK Policy#: Claim#:
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact: 12 Front
Owner: Inspection Location: Insurance Company:
VICARS,RICK HEPPNERS AUTO BODY SAINT PAUL
1895 PORTLAND AVE 400 SYNDICATE ST. N.
ST PAUL,MN 55104 SAINT PAUL,MN 55104
(651)644-4237 Evening Repair Facility
(651)646-8615 Day
VEHICLE
Year: 1986 Body Style: 2D CPE VIN: JHMAF5336G5036200 Mileage In: 163681
Make: HOND Engine: 4-1.5L-FI License: SLW-020 Mileage Out:
Model: CRX SI Production Date: 2/1986 State: MN Vehicle Out:
Color: BLACK Int: Condition: )ob#:
TRANSMISSION Body Side Moldings RADIO SEATS
Automatic Transmission Dual Mirrors AM Radio Cloth Seats
Overdrive Console/Storage FM Radio Bucket Seats
POWER CONVENIENCE Stereo Recline/Lounge Seats
Power Steering Rear Defogger Search/Seek WHEELS
Power Brakes Tilt Wheel SAFETI( Deluxe Wheel Covers
DECOR Intermittent Wipers Driver Air Bag PAINT i
Tinted Glass Rear Window Wiper Passenger Air Bag Clear Coat Paint
10/2/2012 2:19:22 PM 050503 Page 1
Preliminary Estimate
Customer: VICARS, RICK 7ob Number:
Vehicle: 1986 HOND CRX SI 2D CPE 4-1.5L-FI BLACK
Line Oper Description Part Number Qty Extended Labor Paint
Price$
1 FRONT BUMPER
2 0/H front bumper 2,2
NOTE:CAN GET FROM DEALER BUT PRICE WILL BE DIFFERENT
3 <> Repl Cover CRX HF 625115B2950ZZ 1 230.45 Incl. 2.4
4 Add for Gear Coat 1.0
5 Repl RT Cover extension CRX HF 62517562660ZZ 1 59.15 0.3
NOTE: CANT GET FROM DEALER
6 Repl LT Cover e�ension CRX HF 62518562660ZZ 1 59.15 0.3
NOTE: CANT GET FROM DEALER
7� FRONT�LAMPS .____WW_ __.�_��__ .___ _______�__ _.�_ ___ �___._.__ ..___. �_____. _.___. _-._.._�_.__ _W___ _..�.. __� _,_ _�
open Repl RT Side marker lamp 34300S62683 1 76.97 0.3
NOTE:CANT GEf FROM DEALER
9 # Repl FLEX ADDIT'IVE 1 5.00 T
10 # Subl HAZARDOUS WA5TE REMOVAL 1 5.00 X
11 # Subl CHECK OUT REAR SUSPENSION 1 X
SUBTOTALS 415.72 3.1 3.4
ESTIMATE TOTALS
Category Basis Rate Cost;
Parts 405.72
Body Labor 3.1 hrs @ $52.00/hr 161.20
Paint Labor 3.4 hrs @ $52.00/hr 176.80
Paint Supplies 3.4 hrs @ $32.00/hr 108.80
Body Supplies 0.9 hrs @ $2.00/hr 1.80
Miscellaneous 10.00
Subtotal 864.32
Sales Tax $410.72 @ 7.6250% 31.32
Grand Total gg5,64
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 895.64
THIS IS A VISUAL ESTIMATE ONLY. ADDITIONAL PARTS AND LABOR MAY BE EXTRA UPON TEARDOWN. PART I
PRICES SUBJECT TO INVOICE.
NO GUARANTEE ON RUST REPAIR!
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.
10/2/2012 2:19:22 PM 050503 Page 2
�
, Preliminary Estimate
Customer: VICARS, RICK 7ob Number:
Vehicle: 1986 HOND CRX SI 2D CPE 4-1.5L-FI BLACK
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
AOG4415, 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 modi�ed 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 tocal
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. O/H=Overhaul. Qty=Quantity. Refn=Refinish. Repl=Repface.
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.
10/2/2012 2:19:22 PM 050503 Page 3
. ,
RAYMOND I�UTO BODY, INC. Workfile ID: ab6742ca
FederalID: 41-0888257
1075 PIERCE BUTI�R RTE, SAINT PAUL, MN
55104
Phone: �651) 488-0588
FAX: (�51) 488-4794
Prelimi�lary Estimate
Customer: VI�, RICK - 7ob Number:
Written By: ,�ASON SLOMKOWSKI
Insured: V(��� RICK Policy#: Claim #:
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact: 1���
Owner: Inspection Locat�n: Insurance Company:
VICARS, RICK RAYMOND AUTO B�pY, INC. PRIVATE PAY
1895 PORTLAND AV@ 1075 PIERCE BUTL�R RTE
SAINT PAUL,MN 55}Q�4•5976 SAINT PAUL, MN 5�a04
(651)644-4237 Eve� Repair Facility •
(651)274-4501 Cell� (651)488-0588 Bu�pess
�EHICLE
Year: 1986 Body Style: 2D CPE VIN: JHMAF5336GS036200 Mileage In:
Make: HOND Engine: 4-1.5L-FI License: Mileage Out:
Model: CRX SI Production Date: State: Vehicle Out:
Color: BLACK Int; Condition: Job#:
TRANSMISS� Body Side Moldings ROOF Full Wheel Covers ',
5 Speed Tran�ion Dual Mirrors Electric Steel Sunroof OTHER '
POWER Console/Storage SEATS Rear Spoiler
Power Brakes CONVENIENCE Bucket Seats
DECOR Rear Defogger Recline/Lounge Seats I
Tinted Glass Rear Window Wiper WHEELS II
10/2/2012 2:53:29(?� 019495 Page 1
Prelim�pary Estimate
Customer: VI�, RICK 7ob Number:
Vehicle: 1986 HOND G13X SI 2D CPE 4-1.5L-FI BLACK
Line pper Description • � Part Number Qty Extended Labor Paint
Price;
1 FRONT B�
2 0/H front bumper Z.Z
3 Repl Bumper cover CRX Si 62511562910ZZ 1 210.45 Incl. 2.4
4 Repl Molding 62580562000 1 35.65 Incl.
5 R&I License frame 62592SA5670 0.3
6 Repl Upper reinf CRX 62551S62000 1 33.92 Incl.
open Repl Reinforcement complete CRX 625505B2673 1 281.91 Incl.
open Repl RT Energy absorber manual trans 62595562681 1 87.18 0.3
9 Repl LT Extension CRX 62558S62660ZZ 1 45.03
open Repl LT Energy absorber manual trans 62595S62681 1 87.18 0.3
11 FRONT L�
12 R&I RT Headlamp assy 33100S62682 0.5
open Repl RT Park lamp assy HF 33300S62673 1 37.30 Incl.
open Repl RT Side marker lamp 34300S62683 1 76.97 Incl.
15 Repl Aim headlamps 1 0.6
16 FENDER _
open Repl RT Fender 61111S62662ZZ 1 237.83 2.0 2.2
18 Add for Edging 0.5
19 Deduct for Overlap -0.4
open Repl RT Molding 75811562972 1 13.48 0.2
21 MISCELL��US OPERATIONS
22 * Repl Cover car/bag 1 Q,�
23 # Subl Hazardous waste removal 1 6.00 X
24 # Repl Corrosion protection primer 1 0.4
25 # Repl Flex additive 1 8.00 X
26 # Subl Four wheel alignment-REAR 1 129.95 X
END SUSPENSION DIAGNOSE .
27 # ***OPEN FOR HIDDEN 1
DAMAGES*** '
`SUBTOTALS 1,290.85 6.0 5J ;
�
10/2/2012 2:53:29� 019495 Page 2
Prelim��ary Estimate
Customer: VIG� RICK ' 7ob Number:
Vehicle: 1986 HOND GRX SI 2D CPE 4-1.5L-FI BLACK
ESTIMATE TOTALS
Category Basis Rate Cost$
Parts F 1,146.90
Body Labor 6.0 hrs @ $52.00/hr 312.00
Paint Labor 5.7 hrs @ $52.00/hr 296.40
Paint Supplies 5.7 hrs @ $32.00/hr 182.40
Miscellaneous 143.95
Subtotal 2,081.65
Sales Tax $ 1,146.90 @ 7.6250% 87.45
Grand Total 2,169.10
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 2,169.10
WHILE WE HAV��pE EVERY EFFORT TO WRITE A C�MPREHENSIVE REPORT OF THE VISIBLE DAMAGE TO YOUR
VEHICLE, IT IS �RTANT TO REMEMBER THAT THI�IS ONLY AN ESTIMATE. THERE ARE A NUMBER OF FACTORS
THAT CAN AFFF�"�HE ACTUAL COST OF REPAIRS, II��LUDING BUT NOT LIMITED TO HIDDEN DAMAGE, PARTS
PRICE CHANGE�* �Vp INSURANCE COMPANY INVOLV��IENT. PLEASE CONSIDER THIS WHEN MAKING DECISIONS
REGARDING TH��PAIRS TO YOUR VEHICLE.
MN ST 60A.955 •� PERSON WHO FILES A CLAIM WITi� INTENT TO DEFRAUD OR HEIPS COMMIT A FRAUD
AGAINST AN IN�ER IS GUILTY OF A CRIME. 5
�_ '
I
i
10/2/2012 2:53:29 pp) 019495 Page 3
_ . , '
Prelim(�ary Estimate
Customer: VIC„�, RICK 7ob Number:
Vehicle: 1986 HOND�RX SI 2D CPE 4-1.5L-FI BLACK
Estimate based �[�QTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
AOG4415, CCC f���ate 10/1/2012, and the parts sele�ted are OEM-parts manufactured by the vehicles Original
Equipment Man���rer. OEM parts are available at O��Vehicle dealerships. OPT OEM (Optional OEM) or ALT OEM
(Alternative OEI���#s are OEM parts that may be pro�ided by or through alternate sources other than the OEM
vehicle dealersh�, �PT OEM or ALT OEM parts may r.�lect some specific, special, or unique pricing or discount.
OPT OEM or AL�'��N parts may include "Blemished" p,�rts provided by OEM's through OEM vehicle dealerships.
Asterisk (*) or q�le Asterisk (**) indicates that the �rts and/or labor information provided by MOTOR may have
been modified o��� have come from an alternate dat,� source. Tilde sign (N) items indicate MOTOR Not-Included
Labor operation�, '�i�e symbol (<>) indicates the refini�h operation WILL NOT be performed as a separate procedure
from the other �15 in the estimate. Non-Original Eqr��pment Manufacturer aftermarket parts are described as AM.
Used parts are �r±bed as LKQ, RCY, or USED. Recorl�litioned parts are described as Recond. Recored parts are
described as Re�. NAGS Part Numbers and Benchm�rk Prices are provided by National Auto Glass Specifications,
Labor operation�es listed on the line with the NAGS��formation are MOTOR suggested labor operation times.
NAGS labor oper�n times are not included. Pound si� (#) items indicate manual entries.
Some 2012 vehi� contain minor changes from the pr�vious year. For those vehicles, prior to receiving updated
data from the v�le manufacturer, labor and parts da� from the previous year may be used. The CCC ONE
estimator has a�plete list of applicable vehicles. P��s numbers and prices should be confirmed with the local
dealership. �
The following is��st of additional abbreviations or syr�tbols that may be used to describe work to be done or parts to
be repaired or r�ced:
SYMBOLS FOLL(��1�,G PART PRICE:
m=MOTOR Mec��l component. s=MOTOR Structu�al component. T=Miscellaneous Taxed charge category.
X=Miscellaneou��-Taxed charge category.
SYMBOLS FOLL('��l�G LABOR:
D=Diagnostic I�rategory. E=Electrical labor categQry. F=Frame labor category. G=Glass labor category.
M=Mechanical I��category. S=Structural labor cateQpry. (numbers) 1 through 4=User Defined Labor Categories.
OTHER SYMBO��p ABBREVIATIONS:
Adj.=Adjacent. �,=Align. ALU=Aluminum. A/M=A�ermarket part. BInd=6lend. BOR=6oron steel.
CAPA=Certified�notive Parts Association. D&R=Di�onnect and Reconnect. HSS=High Strength Steel.
HYD=Hydroforr��teei. Inc1.=Included. LKQ=Like KI�d and Quality. LT=Left. MAG=Magnesium. Non-Adj.=Non
Adjacent. NSF�� Znternational Certified Part. 0/H��verhaul. Qty=Quantity. Refn=Refinish. Repl=Replace.
R&I=Remove ar��all. R&R=Remove and Replace,, Rpr=Repair. RT=Right. SAS=Sandwiched Steel.
Sect=Section. ��Sublet. UHS=UItra High Strengtf��teel. N=Note(s) associated with the estimate line.
CCC ONE Estim�- A product of CCC Information S�pyices Inc.
The following is��of abbreviations that may be uset! in CCC ONE Estimating that are not part of the MOTOR
CRASH ESTIMA�"�GUIDE: `
BAR=Bureau of�otive Repair. EPA=Environmen��1 Protection Agency. NHTSA= National Highway
Transportation ��fety Administration. PDR=Paint{�s Dent Repair. VIN=Vehicle Identification Number.
10/2/2012 2:53:29,� 019495 Page 4