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Plocher � ��'E��F�� 0�� "i �� 2Q�2 , : � NOTICE OF CLAIM FORM to the City of Sai��'��E�nesota 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 V � N Middle Initial�Last Name ��n�^`�iir Company or Business Name�� Are You an Insurance Company? Yes No If Yes,Claim Number? �!�' Street Address � V ( ��i�e- �• � %�""1 City 5�� V 1 �✓ State l�i h'h��A Zip Code��- Daytime Phone( ) - Cell Phone(�oy))�- g6�j3 Evening Telephone( ) - Date of Accidend Injury or Date Discovered__�I��I I� Time��"'� am pm Please state,in detail,what occurred(happened),and why you are submitting a claim.Please indicate why or how you , feel th City of Saint Paul or its employ es are involverd` and/or responsible for your dama es. ;Y�� P,�J G. !'� u.c.t'�-8'►^ ovr r r � a I �J ' � o. P 1 r i ' I , P�l�e e check the box(es)that most closely represent the reason for completing this form: L1�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 O My vehicle was damaged by a plow ' ❑�Iy vehicle was wrongfully towed and/or ticketed ❑ I was inj red on City prope y C�Other type of property damage—please specify J i G��e s .1 ❑ Other type of injury—please specify In order to process your claim you 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 WILL NOT be returned and become the property of the City. You are encouraged to keep a copy for y rself before submitting your claim form. �roperty 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��jury claims: medical bills,receipts QJ 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 witnesses to the incident? Yes No Unkn (circle) Provide their names,addresses and telephone numbers: Were the police or law enforcement called? es No Unknown (circle) If yes, what department or agency? Savrvt�- p�� GP Case#or report# 1�.��,02-� Where did the accident or injury take place? Provide street address,cross street,intersection,name of park or acility, closest land ark,et�. Please be a detailed as possible. If nece sary,attach a dia ram. � �Kt.�. � u.�,<,� Please indicate the amount yo ar seeking in compensation or what you would like the City to do to resolve this claim to your satisfaction. C.o��- � �tpe.�•rt = $�350�.�2 Vehicle Claims— lease com lete this section ❑ check box if this section does not a 1 Your Vehicle: Year Z. Make W Model J�-{'-�-A License Plate Number °►Z•GJC� State�_Color 54 �w' Registered Owner �ia�,�' Driver of Vehicle � Area Damaged� ` u�,�l-h- 3N1�. �edL � _Q City��aicle: Year Make Model ��+"�''LPs''"�`��` � License Plate Number State Color Driver of Vehicle(City Employee's Name) Area Damaged In'ur Claims— lease com lete this section ❑ check box if this secti es not a 1 Ho re you injured? What part(s)of your were injured? Have you sought medical treatment? No Planning to Seek Treatment(circle) When did you receive treatment? (provide date(s)) Name of Medical Provider(s): Address elephone Did you miss work as a res your injury? Yes No When did you miss ? rovide date(s)) Name of yo mployer: Ad 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 ��/��6�� Print the Name of the Person who Completed this o � Signature of Person Making the Claim: /� � Revised February 2011 . .. a 4 : . h �� ' � .. � 11.?: . t�� .� S i�`'� � .,,�. �L''i=i i�1 ..�3'r.e�_. - "'t � �-.b;� - '��;.^ , • _-.. ...__. . } . �. ��:.�' _�� :, �� ,+ t� � �".'� - ,. _ . �'�c+.r"„� �� . . r'� +..,► � ; . � � , .f.r : i &k'' 4+�'ti �� . � s � � \ �" ,x � — � _ —�� .� ��_ ,��I�I � ( _ �' � 4 �._ . , • = _ � F_.. 3 ,_ i _ i"�3 ,'.�� Accident Report Page 1 of 1 d �t b s a �� iz2ozsoa � � nT� wevro► w.aea ww sw1 an � e N� � a} �0 �0 }� 8 2.4 2012 rl 0005 mC nwt�srsio' wirteM�onanusr�we M°�� efan� ae _ _8N 8N 8t .� . z . 10 Chestnut St • '" '""" � • w� i CQMi'IIIG ' M62Y 1�6VlCEf'0�? �WI[{Yf 11011Il�.[IiM1'l;WIVlMf.01�FlAiIR 62 8,. 5t Paul +_• 10 7th St W r/ifa�1 �o6nv/ oraVUlIm1ENl�ean ai+R6 aA» �uM rnlnoN dwetYCBaeMSIER-t salc dAO olea�ut xiC1011f O1 O1 H828093906318 NIN D O1 .nero�� wWeon.c�ois.wn .. o�,eo..m� ,w�rM.cwacu.n ovee.,wm rac�: JOSEPH NICHOLAS PLOCHER 11 09 86 �..�rex .aene+.._..�.� �- a� nmres. . . o�rwi. amue. www O1 101 E OLIVE ST.APT 4 I3� O1 ? pryyn R.SLILIY .�T'�� O1 STILLWATER 55082 6512109633 ■co.o ,ex w.r a�c.o.. w�uo cse. .u,cv aue �eovr �mor �a�w secr «,�ev �aa.o O1 �M �9 '°E 04 06 OS N � +we . aun iwe mNOS .iwe.arc .uww�a� wnrra� raa ma owie rr� mxoa mrw.oRr w�u.�r�m.a �ws.�a '� 98 �' 98 N, o� ,�. ,a* o.,� «a. wai .a[ o�w.E � we am,. O1 PLOCHER DAVID WAYNE N ' ' v�m +aow�r--"..__._..�.___...�.... ..��--- ia�o �men rawm re+m O1 101 E OI,IVE ST $4 Nl vo�ua tm.swtca ruu,o a�ser cm:�nnr.a nauo owcr �we O1 STILLWATER MN 55082 "[� 06 �"? ow�oc wKC wm¢ ww caa w.e roon rw� mw ouo�ae 11 VOLK JTD 200 SIL OMOlV .4TL• 7fR0 YIMllEO a4RLK.O w �wYl.iM PU1[I RIEO YF/MIFO � � IWY OIY�l1I 2 992CVG MN 3 26 � � 26 rauuxra .nn+N..a� .�aNra wwwru Earmer's Insurance 187146868 x�,w w+� .,.ccnor. n...aae. r""� � 'O1' i»[ ►ue F 11CGq�M MVdL�A C011NERd�L MOTOR VEMCLE.SCl100�&IS�OR HlAG iTART BW ,� f mt . RBIEM0FJ1T0 N071FY TN[�TAfE M7ROL(e�9uYb uW.r W 7M.7p�nA/NA571►. - � �va�euwre��.�orona�rwe omxiwf� � aau�rtwnot�u�t��•wm�[wMt�wwc omMra wwerber�wmesa� � u.r daEO td rrn ur •w�o e�ecr wscv w nwrro�� . ••� �,� �r� _ �wrMU }.! '• O� g! �� a.«�..s wu�rre� p O� g-' O� .�.�u wiMru � o� � awwe�wonm�a�r�am.wrERrv.aoosoa.,nnasww�.no.onr,uarnrE,.oxn.�e..e�te� wwan.e«arr,.ntow,wM..tn `� ..W Kern � wwwnc: °�� 26 O1 _ _ ...__ _.... . aa�u Unit 1 was travelling northwest on Chestnut St. . ... ........._._,. . . . 03 � There aas a storm epproecliing and high rinds �o �ourr o,�,�aar caused. a cnnstrnction...siqn..La.bley..nff_.4�.. .e.... O1 O1 \ 8 / �� sidewalk into the side of Unit 1, causinq damaqe a� to the-riqht side o! U+�it l. No.cStati,ons � � M"d N� ' /� issued. No photos taken. Oq TMFOR �N . . . . . ..... . . . .. .. . _..._. ...... .... ._...._.. �. 98 � � / . . . ._.... . ; '�" / � / . . . ......_.. .. _ .. . . ... "�"s�' � , ..�_---- _ . .._. _. ... . ....._ .... .._.._...__ . .._. ..... . i � / :nvr,o st-,:M.e� wa�u: �� / \ _ �..... .._ ... ...__-- _.__. . ... 08 OB o.i._ _. . . "°" \ __., _ �..• � 04 U1 _ .. . . ... . . ....._..:.. .. ,: _.,_. .. � � IOCIMR � . . . .. _. .. . ...... . . . . . . 02 90 orrr�u�cruwE,voaoa� ,��cr ..mnsr.,v� (]snwaaw �ax Officer Robert Lokhorst 664 c�.\ g St Paul PD O� O � https://dvslesupport.org/dvsinfo/accidentrecords 2008/Includes_LE/PrintReportIndiv_LE.... 8/24/2012 , � \ LAMEITRY'S COLLISION — Workfile ID: 812cd4c0 �� `� MAPLEWOOD FederalID: 411393089 ` � �+�e "Every Customer Leaves With A Smile° �s�co �� are� � satisfactio�Plete,a national 2923 MAPLEWOOD DR� SAINT PAUL� MN 55109 �a��about ed$��ement�o�ustomer � Phone: (651) 766-9770 Tha�ks fo��epa��ex epeny"'ay P YourcooPeratip�i e �t� FAX: (651) 766-8660 CSi ��°Smp�ete Preliminary Supplement 1 with Summary Pete.com Customer: PLOCHER,JOE 7ob Number: 420543 Written By:ANDY TIHANYI Insured: PLOCHER,JOE Policy#: Claim #: � Type of Loss Date of Loss: Days to Repair: 0 '`��'` Point of Impact: Owner: Inspection Location: Insurance Company: PLOCHER,JOE LAMETTRY'S COLLISION-MAPLEWOOD 101 OLIVE STREET EAST#4 2923 MAPLEWOOD DR STILLWATER, MN 55087 SAINT PAUL, MN 55109 �(651)210-8633 Evening Repair Facility (651)766-9770 Business - VEHICLE Year: 2009 Body Style: 4D SED VIN: 3VWRL71K09M129368 Mileage In: Make: VW Engine: 4-2.OL-TD License: 992CVG Mileage Out: Model: JETTA TDI Production Date: State: MN Vehicle Out: Color: SILVER Int: Condition: Job#: 420543 TRANSMISSION Dual Mirrors AM Radio Front Side Impact Air Bags 6 Speed Transmission CONVENIENCE FM Radio 4 Wheel Disc Brakes Overdrive Air Conditioning Stereo SEATS POWER Rear Defogger Search/Seek Bucket Seats Power Steering Tilt Wheel CD Changer/Stacker Heated Seats Power Brakes Cruise Control Premium Radio WHEELS Power Windows Telescopic Wheel Auxiliary Audio Connection Aluminum/Alloy Wheels Power Locks Intermittent Wipers Satellite Radio PAINT Power Driver Seat Keyless Entry SAFETY Clear Coat Paint Power Mirrors Alarm Anti-Lock Brakes(4) OTFIER ' Heated Mirrors Steering Wheel Controls Driver Air Bag Traction Control , Power Trunk/Tailgate Message Center Passenger Air Bag Stability Control ' DECOR RADIO Head/Curtain Air Bags Signal Integrated Mirrors ;� . � 10/1/2012 1:15:05 PM 053108 Page 1 - Preliminary Supplement 1 with Summary Customer: PLOCHER,70E 7ob Number: 420543 Vehicle: 2009 VW]ETTA TDI 4D SED 4-2.OL-TD SILVER Line Oper Description Part Number Qty Extended Labor Paint Price$ 1 FRONT BUMPER&GRILLE 2 R&I R&I bumper cover 1K0807217AGRU 1.5 3 FRONT LAMPS 4 R&I RT Headlamp assy 1K6941006S 0.3 5 HOOD . 6 * Rpr Hood 1K0823031J �,Q Z,6 7 Add for Clear Coat 1.0 8 * Add for Underside(Complete) � 9 FENDER 10 Repl RT Fender 1K5821022A 1 210.00 1.5 2.0 NOTE: MORE ECONOMICAL TO REPLACE THAN REPAIR il Overlap Major Adj. Panel -0.4 12 < Add for Clear Coat 0.3 13 Add for Edging 0.5 14 ' Add for Clear Coat 0.1 15 PILLARS, ROCKER&FLOOR 16 *`- Rpr RT Uniside assy 1K5809606 5 S.,Q 6.5 NOTE: INCL FRT AND REAR DAMAGES 17 Overlap Major Non-Adj. Panel _�,2 18 * Add for Clear Coat 1.3 19 FRONTDOOR 20 R&I RT Belt w'strip w/o chrome IK5837478E5AP p.Z 21 R&I RT R&I e�panel 1K5831106F 2.0 22 Blnd RT Exterior panel 1K5831106F 1.0 23 R&I RT R&I mirror 1K1857508BH969 Incl. 24 R&I RT Handle,outside 1K5837205GRU 0.3 25 SOl Repl RT Housing assy w/o memory 1K1857508CS969 1 243.00 0.7 , pkg w/heated mirror 26 SOl Repl RT Cover 1K0857538GRU 1 45.30 Incl. 0.5 27 SO1 Overlap Minor Panel _p,z 28 * SOl Add for Clear Coat 0.1 29 REAR DOOR 30 R&I RT R&I ext panel 1K5833106E 1.8 31 * Rpr RT E�erior panel 1K5833106E �,Q Z.p 32 Overlap Major Non-Adj. Panel -p,Z 33 * Add for Clear Coat p,4 � 34 R&I RT Belt w'strip w/o chrome 1K5839478F5AP 0.3 ' 35 R&I RT Handle,outside 1K5837205GRU 0.3 36 BACK GLASS 37 * Rpr Back glass Volkswagen 1K5845051AR Q,� NOTE:TIME IS TO ROPE 38 REAR LAMPS 39 R&I RT Tail lamp assy 1K5945096L Incl. 10/1/2012 1:15:05 PM 053108 Page 2 � Preliminary Supplement 1 with Summary Customer: PLOCHER,]OE 7ob Number: 420543 Vehicle: 2009 VW JETTA TDI 4D SED 4-2.OL-TD SILVER SUPPLEMENT SUMMARY Line Oper Description Part Number Qty Extended Labor Paint Price$ C' nged itertis , 22 R&I RT R&I mirror iK18575086H969 -0.4 23 SO1 R&I RT R&I mirror 1K18575086H9B9 Incl. Ac�Cl�tl Itep15 °� '�� 25 SOl Repl RT Housing assy w/o memory iK1857508CS969 1 243.00 0.7 4 � pkg w/heated mirror ' -a 26 SOl Repl RT Cover iK0857538GRU 1 45.30 Incl. 0.5 27 S01 Overlap Minor Panel _0,2 28 * SOl Add for Clear Coat 0.1 SUBTOTALS 288.30 0.3 0.4 TOTALS SUMMARY r Category Basis Rate Cost$ . Parts 288.30 Body Labor 0.3 hrs @ $54.00/hr 16.20 Paint Labor 0.4 hrs @ $54.00/hr 21.60 Body Supplies 0.7 hrs @ $2.00/hr 1.40 Paint Supplies 0.4 hrs @ $36.00/hr 14.40 Subtotal 341.90 Sales Tax $288.30 @ 7.1250% 20.56 Additional Supplement Taxes -0.02 Total Supplement Amount 362.44 NET COST OF SUPPLEMENT 362.44 CUMULATIVE EFFECTS OF SUPPLEMENT(S) Estimate ANDY TIHANYI Supplement 501 362.44 A HANYI � i Job Total: � 3,507.52 � INSURANCE PAY: $ 3,507.52 ! THIS REPORT IS AND ESTIMATE ONLY, BASED ON OUR INITlAL INSPECTION 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 AVAILABILITY. WARRANTY: LIFETIME AGAINST DEFECTS IN WORKMANSHIP. WARRANTY REPAIRS DONE BY LAMEi�i'RY'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 EXPERIENCE. 10/1/2012 1:15:05 PM 053108 Page 4 LAMEITRY'S COLLISION — Workfile ID: 812cd4c0 FederalID: 411393089 MAPLEWOOD 6 "Every Customer Leaves With A Smile" 2923 MAPLEWOOD DR, SAINT PAUL, MN 55109 Phone: (651) 766-9770 FAX: (651) 766-8660 Preliminary Estimate Customer: PLOCHER,]OE Written By: ANDY TIHANYI Insured: PLOCHER,JOE Policy#: Claim #: Type of Loss: Date of Loss: Days to Repair: 0 Point of Impact: Owner: Inspection Location: Insurance Company: PLOCHER,JOE LAMETTRY'S COLLISION-MAPLEWOOD 101 OLIVE STREET EAST#4 2923 MAPLEWOOD DR STILLWATER, MN 55087 SAINT PAUL, MN 55109 (651)210-8633 Evening Repair Facility (651)766-9770 Business VEHICLE Year: 2009 Body Style: 4D SED VIN: 3VWRL71K09M129368 Mileage In: Make: VW Engine: 4-2.OL-TD License: 992CVG Mileage Out: Model: ]E1TA TDI Production Date: State: MN Vehicle Out: Color: SILVER Int: Condition: ]ob#: 4 Wheel Disc Brakes Cruise Control Overdrive Satellite Radio 6 Speed Transmission Driver Air Bag Passenger Air Bag Search/Seek Air Conditioning Dual Mirrors Power Brakes Signal Integrated Mirrors Alarm FM Radio Power Driver Seat Stability Control Aluminum/Alloy Wheels Front Side Impact Air Bags Power Locks Steering Wheel Controls AM Radio Head/Curtain Air Bags Power Mirrors Stereo Anti-Lock Brakes(4) Heated Mirrors Power Steering Telescopic Wheel Auxiliary Audio Connection Heated Seats Power Trunk/Tailgate Tilt Wheel ! Bucket Seats Intermittent Wipers Power Windows Traction Control CD Changer/Stacker Keyless Entry Premium Radio Clear Coat Paint Message Center Rear Defogger 8/24/2012 3:26:07 PM 053108 Page 1 Preliminary Estimate Customer: PLOCHER,70E Vehicle: 2009 VW JETTA TDI 4D SED 4-2.OL-TD SILVER Line Operation Description Qty Extended Labor Paint Price$ 1 FRONT BUMPER&GRILLE 2 R&I R&I bumper cover 1.5 3 FRONT LAMPS 4 R&I RT Headlamp assy 0.3 5 HOOD 6 * Rpr Hood 'i.Q 2.6 � Add for Clear Coat 1.0 $ * Add for Underside(Complete) � 9 FENDER N 10 Repl RT Fender 1 210.00 1.5 2.0 11 Overlap Major Adj. Panel -0.4 12 Add for Clear Coat 0.3 13 Add for Edging 0.5 14 Add for Clear Coat 0.1 15 WINDSHIELD N 16 R&I Windshield Volkswagen,w/o rain sensor 2,g w/green shade band 17 # NON-CONDUCTlVE GLASS KIT 1 70.00 18 PILLARS, ROCKER&FLOOR N 19 * Rpr RT Uniside assy s �,.Q 6.5 20 Overlap Major Non-Adj. Panel _0,2 zl * Add for Clear Coat 1.3 22 FRONT DOOR Z3 R&I RT Belt w'strip w/o chrome 0,2 24 R&I RT R&I e�panel Z,p 25 Bind RT Exterior panel 1.0 26 R&I RT R&I mirror 0.4 27 R&I RT Handle,outside 0.3 z$ REAR DOOR 29 R&I RT R&I ext panel l,g 30 * Rpr RT Exterior panel �Q 2,0 31 Overlap Major Non-Adj. Panel -0.2 32 * Add for Clear Coat 0.4 33 R&I RT Belt w'strip w/o chrome 0.3 34 R&I RT Handle,outside 0.3 i 35 BACK GLASS I N 36 * Rpr Back glass Volkswagen Q,� �, 37 REAR LAMPS 38 R&I RT Tail lamp assy Incl. 39 REAR BUMPER N 40 * R&I R&I bumper cover Q,$ 41 # Refn Car Cover p.z 42 # Refn Corrosion Protection 0.3 8/24/2012 3:26:07 PM 053108 Page 2 � Preliminary Estimate Customer: PLOCHER,70E Vehicle: 2009 VW JEITA TDI 4D SED 4-2.OL-TD SILVER 43 # Flex Additive 1 6.00 X 44 # Subl Hazardous Waste Disposal Fee 1 5.00 X 45 ** Repl A/M Clips and Fasteners 1 10.00 T SUBTOTALS 301.00 26.5 17.7 NOTES Line 10: MORE ECONOMICAL TO REPLACE THAN REPAIR Line 16: MAY BREAK UPON REMOVAL Line 19: INCL FRT AND REAR DAMAGES Line 36:TIME IS TO ROPE Line 40: RT SIDE ONLY ESTIMATE TOTALS Category Basis Rate Cost$ Parts 280.00 Body Labor 26.5 hrs @ $54.00/hr 1,431.00 Paint Labor 17.7 hrs @ $54.00/hr 955.80 Paint Supplies 17.7 hrs @ $36.00/hr 637.20 Body Supplies 15.8 hrs @ $2.00/hr 31.60 Miscellaneous 21.00 Subtotal 3,356.60 Sales Tax $290.00 @ 7.1250% 20.66 Grand Total 3,377.26 Deductible 0.00 CUSTOMER PAY 0.00 INSURANCE PAY 3,377.26 THIS REPORT IS AND ESTIMATE ONLY, BASED ON OUR INITIAL INSPECTION AND DOES NOT COVER ADDITIONAL PARTS OR LABOR WHICH MAY BE REQUIRED AFfER THE WORK IS OPENED UP. PART PRICES SUBJECT TO CHANGE PER THE MANUFACTURER AND AVAILABILITY. WARRANTY: LIFETIME AGAINST DEFECTS IN WORKMANSHIP. WARRAMY REPAIRS DONE BY LAMETfRY'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 EXPERIENCE. 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. � 8/24/2012 3:26:07 PM 053108 Page 3 ' Preliminary Estimate Customer: PLOCHER,70E Vehicle: 2009 VW JETTA TDI 4D SED 4-2.OL-TD SILVER Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide ERA9278, CCC Data Date 7/2/2012, 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 Double 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 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. 8/24/2012 3:26:07 PM 053108 Page 4 � Y , ABRA Auto Body & Glass - Stillwater Workfile ID: e2a7132f • FederalID: 41-1942823 Right The First Time...On Time 14382 60TH ST N, STILLWATER, MN 55082 Phone: (651) 430-0800 FAX: (651) 430-0550 Preliminary Estimate Customer: Plocher,)oe )ob Number: Written By: Stacy Nelson Insured: Plocher,Joe Policy#: Claim#: unk Type of Loss: Date of Loss: 8/28/2012 12:00:00 PM Days to Repair: 0 Point of Impact: Ol Right Front Owner: Inspection Location: Insurance Company: Plocher,]oe ABRA Auto Body&Glass-Stillwater Unknown Insurance 101 Olive Street East#4 14382 60TH ST N stillwater, MN unk STILLWATER, MN 55082 (651)210-8633 Business Repair Facility (651)430-0800 Business VEHICLE Year: 2009 Body Style: 4D SED VIN: 3VWRL71K09M129368 Mileage In: 52247 Make: VW Engine: 4-2.OL-TD License: 992CVG Mileage Out: Model: JETTA TDI Production Date: State: MN Vehicle Out: Color: silver Int: Condition: Job#: TRANSMISSION Dual Mirrors AM Radio Front Side Impact Air Bags 6 Speed Transmission CONVENIENCE FM Radio 4 Wheel Disc Brakes Overdrive Air Conditioning Stereo SEATS POWER Rear Defogger Search/Seek Bucket Seats Power Steering Tilt Wheel CD Changer/Stacker Heated Seats Power Brakes Cruise Control Premium Radio WHEELS Power Windows Telescopic Wheel Auxiliary Audio Connection Aluminum/Alloy Wheels Power Locks Intermittent Wipers Satellite Radio PAINT Power Driver Seat Keyless Entry SAFETY Clear Coat Paint Power Mirrors Alarm Anti-Lock Brakes(4) OTHER ' Heated Mirrors Steering Wheel Controls Driver Air Bag Traction Control I Power Trunk/Tailgate Message Center Passenger Air Bag Stability Control � DECOR RADIO Head/Curtain Air Bags Signal Integrated Mirrors 8/31/2012 1:10:51 PM 019111 Page 1 ' Preliminary Estimate Customer: Plocher,)oe 7ob Number: Vehicle: 2009 VW)ETTA TDI 4D SED 4-2.OL-TD silver Line Oper Description Part Number Qty Extended Labor Paint Price$ 1 FRONT BUMPER&GRILLE 2 * R&I R&i bumner cover DROP RT SIDE 1K0807217AGRU 0_8 3 FRONT LAMPS 4 R&I RT Headlamp assy 1K69410065 0.3 5 R&I LT Headlamp assy 1K6941005S 0.3 6 HOOD 7 Repl Hood 1K0823031J 1 403.00 13 2.6 8 Add for Clear Coat 1.0 9 Add for Underside(Complete) 1.3 10 FENDER . _ 11 Repl RT Fender iK5821022A 1 210.00 1.5 2.0 12 Overlap Major Adj. Panel -0.4 13 Add for Clear Coat 0.3 14 Add for Edging 0.5 15 Blnd LT Fender 1K5821021A 1.0 16 PILLARS,ROCKER&FLOOR 17 * Rpr RT Windshield pillar iK5809606 s 2_5 2_0 18 Overlap Major Non-Adj. Panel �0•2 19 Add for Clear Coat 0.4 20 FRONT DOOR 21 R&I RT R&I ext panel 1K5831106F 2.0 22 Blnd RT Exterior panel iK5831106F 1.0 23 Repl RT Housing assy w/o memory 1K1857508CS969 1 243.00 0.7 pkg w/heated mirror 24 Repl RT Cover 1K0857538GRU 1 45.30 Incl. 0.5 z5 Overlap Minor Panel -0•2 26 Add for Clear Coat 0.1 27 REAR DOOR 28 R&I RT R&I ext panel iK5833106E 1•$ 29 * Rpr RT Exteriorpanel 1K5833106E 4_0 2.0 30 Overlap Major Non-Adj. Panel -0•2 31 Add for Clear Coat 0.4 32 R&I RT Belt w'strip w/chrome 1K5839476D2ZZ 0.3 33 QUARTER PANEL 34 * Rpr RT Quarter panel SEE FOOTNOTE 1_5 2.4 35 Overlap Major Adj. Panel -0.4 36 * Add for Clear Coat 0.4 37 REAR LAMPS 38 R&I RT Tail lamp assy 1K5945096L IncL 39 REAR BUMPER 40 * R&I R&I bumper cover DROP RT SIDE 1K5807417HGRU �—� 41 # Refn �Car Cover 0.1 42 # Refn �Corrosion Protection 03 8/31/2012 1:10:51 PM 019111 Page 2 ' Preliminary Estimate Customer: Plocher,Joe )ob Number: Vehicle: 2009 VW JETTA TDI 4D SED 4-2.OL-TD silver 43 # �Hazardous Waste 1 5.00 X SUBTOTALS 906.30 17.7 16.9 NOTES Prior Damage Notes: 1 ESTIMATE TOTALS Category Basis Rate Cost$ Parts 901.30 Body Labor 17.7 hrs @ $52.00/hr 920.40 Paint Labor 16.9 hrs @ $52.00/hr 878.80 Paint Supplies 16.9 hrs @ $32.00/hr 540.80 Miscellaneous 5.00 Subtotal 3,246.30 Sales Tax $901.30 @ 7.1250% 64.22 Grand Total 3,310.52 Deductible 0.00 CUSTOMER PAY 0.00 INSURANCE PAY 3,310.52 THIS IS A VISUAL INSPECTION ONLY. THERE MAY BE ADDITIONAL DAMAGE AFTER 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." 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. 8/31/2012 1:10:51 PM 019111 Page 3