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Czapiewski . �3��.i,a�="��'"'�' �RN 2� 20�3 �, � � � � � � � ` ,a � Natianal Docurnent Centex � � ��'�! �� P. a. �a�2�s��z o��orn� c��, a� ��ia�-s��z claimsdocuments a�hpcs.cam Fax: 877-217-1�89 Toll Fxee: S00-HelpPoint 01/25/2013 Self Insured Attn: City Of Saint Paul- City Clerk 15 West Kellogg Blvd- 310 City Hall Saint Paul,MN 55102 Our Insured: Piotr Czapiewski Our Claim#: 099 SUB 1022908319-1 Date of Loss: 10/31/2012 Your Insured: City Of Saint Paul Driver:Rudy Burgos Your Claim#: Deductible Amount: $240.00 Loss of Use Amount: $0.00 Rental Amount: $0.00 Total Amount Owed: $2,641.89 Dear City Of Saint Paul- City Clerk: We have made payment to our insured for damages resulting from this accident. Our investigation has established that the above loss was caused by the negligence of your insured. By virtue of our subrogation rights this letter is to advise you that we expect payment from you for the amount of damages within 14 days of the receipt of this letter. Be advised that no partial payment,which is less than the full amount claimed herein,will be considered in any way an acceptance of benefits,a novation or an accord and satisfaction of this claim without the express written release of our claim executed by an individual who identifies himself/herself as a member of our subrogation department.Therefore,our legal rights to enforce collection on the remaining amount of the claim shall not be waived or estopped due to a partial payment by you or someone acting on your behalf. If you need additional support for our claim or require further information,please call me at 630-907-6913 with your FAX number so that the requested information can be sent to you. Sincerely, Illinois Farmers Insurance Company � � Kristin Jones Auto Subrogation Representative kristin.j ones@hpcs.com PO Box 268992 Oklahoma Ciry,Ok 73126 NOTICE OF CLAIM FORM to the City of Saint Paul, 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 municipaliry within 180 days af7er the alleged loss or injury is discovered a notice staring 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 P��r�- Middle Initial Last Name C Z�P t�u=s k'�' Company or Business Name �llin G tS F��5 lrlSv►ek+�iC� LbM PA-f11,+ Are You an Insurance Company?�No If Yes,Claim Number? �� d—�b g 3�� Street Address �3 33 E P E e�M g�e �D City S��*��" p A u L State �''�^� Zip Code 5 S l l 1� Daytime Phone(b5� )�a`��- g`��Cell Phone(!c 51)Z�-7- `��? Evening Telephone( ) - Date of Accidend Injury or Date Discovered 1�_�3 1) �'G 1 � Time �D � �d �/pm Please state,in detail,what occurred(happened),and why you are submitting a claim.Please indicate why or how you feel the City of Saint Paul or its employees are involved and/or responsible for your damages. O f�-�� R k d� B u�c�.S Lo n s �v�e U:w;� N�B �.N i�t�c��Le� A�P P��4-e N l inl� t��-ut��Lp�, � �,�,++�n� e! s-�k.� ��peGacK�-v u.i �a ��t R��oci�� F31�cEA1J -rb ru�n� S1� �FtL e� B u��s Ba-�� twtn s� «u�Siau /;-*�D c_o t<< arv �i - c�Lt I� e nt g-�,�c.-ez-p 1��z?E.'. e z k p t ti bv S K—+- Pl se 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 property damage—please specify ❑ Other type of injury—please specify In order to process your claim��ou 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 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 witnesses to the incident? � s No Unknown (circle) Provide their names,addresses and telephone numbers: ��Kl N k-IuLp,�2T �e 51— �`�Ej— �`�� Were the police or law enforcement called? � No Unknown a�(circle) If yes,what department ar agency? S t P�i.ul �`D Case#or report# � 58 7b7 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. I n t�rS�etlD n �f R ah da1 p h o' U,+A-�+,G cl:� � s t' I��t.K,L �N 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. � a� �e '-t1c 89 Vehicle Claims—please comnlete this section ❑ check box if this section does not applv Your Vehicle: Year a�e'� Make �� Model M�Q�N� License Plate Number ��-►�% ��'� State �''� N Color StLV� Registered Owner F i c T� e2A-P i Ew s K 1 Driver of Vehicle �AM� AS !�&:vE Area Damaged FRLw 7 g u+�� H�D City Vehicle: Year Make F��D Model ��w�► ��tk License Plate Number sqNA D �5 3(a State i"�N Color Driver of Vehicle(City Employee's Name) R�D�/ ��E�� AreaDamaged R��- ��►�v�-- Injurv Claims nlease complete this section �heck box if this section does not apnlv 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)) Name of your Employer: Address Telephone ❑ Check here if you are attaching more pages to this claim form. Number of additional pages By signing this form,you are stating that all information you have provided is true and correct to the best of your knowledge. Unsigned forms will not be proeessed. Submitting a false claim can result in prosecution. Date form was completed �E � Z 5�2 C� 3 Print the Name of the Person who Completed this Form: 1'��5�"�u �°^!�' Signature of Person Making the Claim;_ ° . SC'�� r�� ,�,r� /sj� u�ncts F�++��s ��ts ecn.tpa►�,� Revised February 2011 /' s National L}ocument Centex '"�. �`+ � � � �+ � '�, P. �. Box 2G8992 Dklahama City, �K 7312G-$992 claimsdocurnents a�pcs.com Fax: 877-217-1389 Toll Fxee: S00-HelpPoint 01/25/2013 Payment Log Account Number: EEE882197 Date of Loss: 10/31/2012 Insured's Name: Piotr Czapiewski Claim Number 099 SUB 1022908319-1 Your Claim Number Loss Type Proof of Payment Date: 01/24/2013 Payee: RAYMOND AUTO BODY 1075 PIERCE BUTT,ER RTE ST PAUL,MN,55104 Payment Descriprion: Material Damage Amount: $2,401.89 Sub Total: $2,401.89 Deductible Amount: $240.00 Salvage $0.00 Total Amount: $2,641.89 Illinois Farmers Insurance Company Jan 2413 06:04p p.1 ��'l � �'� L 2�� '� p�e 1 of 1 Accident Report� fl � ,.�••�,,;�� "'�°�° ,�} � 12259707 � � '� ` �.,�+� �.�no• � � ...� IO 3). OI2°'i(�ed Og51 � hj 'j• (�2 OD �10 5�' ' ny.�r M �flr r PGUhcvAE� �dU�w.meaeaflfEf,YiE � �• E ��,� « _.____. �{R e� �~ � � [tandol. h � ' � iQ . .,m. .��.� �� ..� a...,�. �'6�^° ��+rv +�• �7ar�rick TM � MY ANwM �Qv�� .�. � o..�-.�..M...'-' � D O1 t�j. w�oc� �°�"••�`•+ '� �` OL E715017971.213 -�1 `" U 1 e�.crcw�.wn o�o.�n. ..ec. �r �"'0i°'"""$URGOS a� QYQY'R CZA�I S I �B lI 60 �� RUDY . �� ql O1 .,,�,�. ,�.« • N: 1333 EAC�UNIBE RD ],7 367 GROVE STRE�'r � s � 6522A79921 01 a „�, arr. a ST @AOf. 55116 Ol ST. PA[TL 55101 °°�* °04 Og OS � a� � '�"° � �.. g� 0� m �q fl 4 �4 45 N .> M 4 ,� � �.,�`�' ...�..�..� �.... ,�. ,..� � *... ,�o� .,vrc owo ,r.� .wa� wr."'asw�+a` '�. 98 �i' 98 N= �� ,: '� g8 �" 98 i�l.� Da�n� om. � ,,.�.� . 23� 02 OZ CITY OF ST. PAtJL tt CZAPIEwsKI PIOTR � . .�, '�i�' 03� ,�,r, � 1333 EDGCtIMBE � � �, ,�,,,,.� . 03 367 GROVB STREET � � ��,�,r,,, +� Ol 41 "w� °+"TQ`•� 55I01 "l�. O1 S'P pAUL AIN 55116 �+� U7 ST. PAUL, MN MOR da �L D� � �" °0'O" NISS o,.o,� �c C� yl "w 03�°' - 05 Ford "'°" n'e` ww 01 .o. "°°` '°^ . wu,e. woa� ••o •w��e0 °° °••• •� KLW649 MN 3 02 S uad1536 �'1T1• �l wwr+�eae•�a '°'��" � °0"�'""�" Fa rmers Z 920 99836 � �� • ,�o�ne�v��a.�.�cKOO�.eas,ae H��r nus �++� '"E � na wn� .n�t+n+• .�s,oae. ��n,vma�(��rislao.raa�a�� _ qK �BiR 7p 1iOtiPY 7)fE S� aoer.+� mt , �.�w+c�erra�_rm"a�r,rw++� ��„�„�sn�.umda�ondw+� oorh� -+-. � eo� ms ac ,ue.a Rser www ro �"'ro" .�ea� """�°` �,y �`"`""�° 04 04 04 OS N N' p� ' naozxlzA4 tioxAl�o NaxzN O1 03 ,� ,M.,eu�o� •�•�•° � AOBLN NARIE H�LH�.CL �6�16l8096i1 02 03 in'� E' 09 04 0� 05 N N? Om•°' .�,..... CO . � ""�arnoE J . ' �� ar�n�raae�+aawv�aw�+� � v�uewa,�,a,uam,woreirthooma�ewnFONwaa"'o�r°:�aa,�antien�re�, N/A � N/A w�wK �4 ACCiM . - •°- ' ' � ' O1 -IInit ii,(EF]0 Bucgos) vas drivia9 S9u�d 1536 lae o r�s�,s �•. Qazviek apii=oachiaq RandolPh- �nft #�.e1oi+Iy � „a„o„ 03 �`� yegan +enterfnq i.ntexsCCtiDn.when.ahla��aa co � 9B �°w" ^: � � quickly apprearlied. lsora NB RandolP ._ - wr� N tu=n sH on warMiek. p20 Burqaa•safd aemi.-was � ��- :' . es ao he 3.��ately put his 44 a+a.� �.' � ! • 20 from his buup co 1 l Y.s ioa=YHO' � ' ��- '' 1 sq�ad itt reve� to'avoi�i a sea�i., 1+e ' mew.a~t= saYd as t�e foevaed hia atteation a�x tt� , , w� eniEed up backim4 uP into oait �fT: No injuries. . g g �- �- +�rs�� -• . ..MndeXatt da�ma8� to-hotti vebicles..Bhoto�.tsk�1- �,q w�� -^� -~� �� . . ... .._._.. � .,,�,,, '� �� . - .--_,. .. . . . � ' � .... . . . . . . . . . , Q2 q�Equ+b F'• �ht+le�I� . � .. . • 1TrB : s::; 1 T �„ ... .. . ; �. i'% . � ai _ .. . ... � - �� _=. ' . � - � . ,�� ; i � _ - ;;, e _. . . • - Y ,' �1. ,7: k DMGnlM Y,. . , . _... . g0 . ��.. ;'. E � .�.,�.�,,,,, �.�.a.a .� 01 :.:- S-S-p St Paul PD Yv �e�s �� ,�,Y.,��,.o..�. 18 2 � Sergeant GaY�e pQrter htt�;lldvslesupport.arg/dvsinfolacx identceco�ds 2008/Includes L�JPriatRel�'�v_LE.asp?ACCN=123... �If312412 RAYMOND AUTO BODY� INC. Workfile ID: 2b3ba9c8 Federal ID: 41-0888257 1075 PIERCE BUTLER RTE, SAINT PAUL, MN 55104 Phone: (651)488-0588 FAX: (651)488-4794 Supplement of Record 1 with Summary Customer: CZAPIEWSKI, PIOTR Job Number: Written By: DAMON SLAIKEU,1/22/2013 7:58:55 AM Insured: CZAPIEWSKI,PIOTR Policy#: 0192099836 Claim#: 1022908319-1-2 Type of Loss: COLLl-Collision Date of Loss: 10/31/2012 12:00:00 AM Days to Repair: 4 Point of Impact: 12 Front Owner: Inspection Location: Insurance Company: CZAPIEWSKI,PIOTR raymond auto body FARMERS 1333 EDGCUMBE RD Other MINNESOTA SAINT PAUL,MN 55116 PO BOX 268994 (651)698-8961 Evening OKLAHOMA CITY,OK 73126 (651)247-9827 Business (800)445-7911 Business VEHICLE Year: 2007 Body Style: 4D UN VIN: JN8AZ08W27W633839 Mileage In: 87416 Make: NISS Engine: 6-3.5L-FI License: XLW649 Mileage Out: Model: MURANO 4X4 S Production Date: 12/2006 State: MN Vehicle Out: Color: silver Int: black Condition: Job#: TRANSMISSION Privacy Glass AM Radio SEATS Automatic Transmission Console/Storage FM Radio Cloth Seats 4 Wheel Drive CONVENIENCE Stereo Bucket Seats POWER Air Conditioning Search/Seek WHEELS Power Steering Rear Defogger CD Player Aluminum/Alloy Wheels Power Brakes Tilt Wheel SAFEi'Y PAINT Power Windows Cruise Control Anti-Lock Brakes(4) Clear Coat Paint Power Locks Intermittent Wipers Driver Air Bag OTHER Power Driver Seat Keyless Entry Passenger Air Bag Rear Spoiler Power Mirrors Rear Window Wiper Head/Curtain Air Bags TRUCK DECOR Steering Wheel Controls Front Side Impact Air Bags Rear Step Bumper Dual Mirrors RADIO 4 Wheel Disc Brakes 1/22/2013 7:58:55 AM 019495 Page 1 Supplement of Record 1 with Summary Customer: CZAPIEWSKI, PIOTR 7ob Number: Vehicle: 2007 NISS MURANO 4X4 S 4D UN 6-3.5L-FI silver Line Oper Description Part Number Qty Extended Labor Paint Price$ 1 FRONT BUMPER 2 Repl Bumper cover FBM22CC20H 1 358.57 1.8 2.8 NOTE:Jennean @ keystone 612-789-1919 no recon/Ikq AAA Ryan 651-423-2432 no recon/Ikq Action Ken 65-227-8996 no Ikq 3 Add for Clear Coat 1.1 4 Repl License bracket 96210CC20A 1 59.53 0.2 5 Repl Energy absorber 62090CA000 1 73.95 0.1 6 Repl LT Stay 62211CA000 1 71.57 0.2 7 R&I RT Stay �•Z 8 Repl Chrome strip 62072CC20A 1 57J0 9 Repl Prep unprimed bumper 1 0.7 SO SO1 Repl LT Underbody shield 62065CAOOA 1 74.27 Incl. 11 SO1 Repl LT Louver 62087CC20A 1 5.98 Incl. 12 � RADIATOR SUPPORT � 13 Repl Lower tie bar 62530CC406 1 281.23 1.0 14 GRILLE � 15 S01 Repl Grille 62310CC206 1 224.97 Incl. NOTE:AAA-Don 651-423-2432 not insurance quality on the grille.Other vendors did not have. __ .. __.� �_._ -- —___. _ 16 AIR CONDITIONER&HEATER 17 SO1 Repl Condenser 92110CN000 1 414.55 m 2.4 lg Repl Refrigerant recovery 1 m 0.4 M 19 Repl Evacuate&recharge 1 m 1.4 M Zp * Repl LT Side seal 92185CA100 1 5.22 0_2 Zl Repl Lower absorber 92183CA000 1 5.22 0.1 ZZ * R&I RT Side seal 0—z z3 # Hazardous Waste 1 3.00 24 # Flex Additive 1 2.00 X SUBTOTALS 1,637.76 8.2 4.6 NOTES Estimate Notes: Date Vehicle In: 1-15-13 How&When the customer wants to be contacted: 3 days (Cell) Target Delivery Date Based on 4 Hours Per Day:3 Explained Farmers COD Benefits and Procedures:yes Damage consistent with facts of loss:yes Explained Repair Process and Estimated Completion Date to Customer:yes Explained Benefits and Warranty of Aftermarket Parts to the Customer:yes �*Aftermarket Sheetmetal and Plastic Parts:Customer: Declines ❑*Aftermarket Mechanical Parts—Customer: Declines Prior or Unrelated Damages: NoOWhere? LKQ,Aftermarket,and Reconditioned Parts Search Includes: 1/22/2013 7:58:55 AM 019495 Page 2 Supplement of Record 1 with Summary Customer: CZAPIEWSKI, PIOTR Job Number: Vehicle: 2007 NISS MURANO 4X4 5 4D UN 6-3.5L-FI silver keystone no parts jennean AAA-Pete no Ikq Johns auto quote# 1097316 AC AAA-Pete better bumper no covers Action Ken no Ikq Ran RPS on Demand:yes-keystone no stock or core Customer Authorize Repairs:yes ESTIMATE TOTALS Category Basis Rate Cost$ pa� 1,635.76 Body Labor 6.4 hrs @ $52.00/hr 332.80 Paint Labor 4.6 hrs @ $52.00/hr 239.20 Mechanical Labor 1.8 hrs @ $89.00/hr 160.20 Paint Supplies 4.6 hrs @ $32.00/hr 147.20 Miscellaneous 2.00 Subtotal 2,517.16 Sales Tax $ 1,635.76 @ 7.6250% 124.73 Grand Total 2�641•89 Deductible 240.00 CUSTOMER PAY 240.00 INSURANCE PAY 2,401.89 1/22/2013 7:58:55 AM 019495 Page 3 Supplement of Record 1 with Summary Customer: CZAPIEWSKI, PIOTR )ob Number: Vehicle: 2007 NISS MURANO 4X4 S 4D UN 6-3.5L-FI silver SUPPLEMENT SUMMARY Line Oper Description Part Number Qty Extended Labor Paint Price$ � � � �:: -.,�m -� �, ��`;� � � � 8 �� '�a' � � � '� � �,'°� � �,. . -...,.�� .,. ��: , . n a i'Y,c k, �.� .a'I+�n`�'��'" ..,.. .�,_'s� +t�;�;�H�...'x.��i i.-, ,�,,..��'-�'�`-'g»��.,.:;�.��,a� �:��:'�. ,!h.��M�" s ,�. d�.�_:7h� a v �� 2 Repl Bumper cover FBM22CC20H 1 -358.57 Incl. -2.8 NOTE:Jennean @ keystone 612-789-1919 no recon/Ikq AAA Ryan 651-423-2432 no recon/Ikq Action Ken 65-227-8996 no Ikq 2 SO1 Repl Bumper cover FBM22CC20H 1 358.57 1.8 2.8 NOTE:Jennean @ keystone 612-789-1919 no recon/Ikq AAA Ryan 651-423-2432 no recon/Ikq Action Ken 65-227-8996 no Ikq 5 Repl Energy absorber 62090CA000 1 -73.95 Incl. 5 SO1 Repl Energy absorber 62090CA000 1 73.95 0.1 19 Repl Lower absorber 92183CA000 1 -5.22 Incl. 21 SO1 Repl Lower absorber 92183CA000 1 5.22 0 1 �„��f��=�� ,�a�° ��'�.� � r,� �`�- __ ,� �.��'� � � � .,,.."� � a . w,,i.�,.� .� ,..,� �� , _ a,i.N� . �...�... ° � � � a �:..s ,. ,��a,�z.��.a = � _ �,< �n^,��a�a ,.�..-�a� �^r.�>-M, 2 0/H front bumper "Z•Z 11 GRILLE 12 * Repl LKQ Grille+25% 62310CC20B 1 -93.75 Incl. 16 * Repl LKQ Condenser+25% 92110CN000 1 -75.00 m -2.4 � r �� , , + � ..,, � ��_� � �° ,Q_�� .�� , �.'� „�.��_ - .. �r��._�. . .a� . .,s .`�. �P.�=�� ur ��. �.�`�-, �.� _ _�,a..�-. . �. 10 SOl Repl LT Underbody shield 62065CAOOA 1 74.27 Incl. 11 SO1 Repl LT Louver 62087CC20A 1 5.98 Incl. a, . �.._m_...m m , 14 GRILLE 15 S01 Repl Grille 62310CC20B 1 224.97 Incl. NOTE:AAA-Don 651-423-2432 not insurance quality on the grille.Other vendors did not have. 17 SO1 Repl Condenser 92110CN000 1 414.55 m 2.4 SUBTOTALS 551.02 -0.2 0.0 TOTALS SUMMARY Category Basis Rate Cost$ Pa� 551.02 Body Labor -0.2 hrs @ $52.00/hr -10.40 Subtotal 540.62 Sales Tax $551.02 @ 7.6250% 42.04 Additional Supplement Taxes -0.02 Total Supplement Amount 582'64 NET COST OF SUPPLEMENT 582'64 1/22/2013 7:58:55 AM 019495 Page 4 Supplement of Record 1 with Summary Customer: CZAPIEWSKI, PIOTR Job Number: Vehicle: 2007 NISS MURANO 4X4 S 4D UTV 6-3.5L-FI silver CUMULATIVE EFFECTS OF SUPPLEMENT(S) Estimate 2,059.25 CRAIG AMUNDSON Supplement SOl 582.64 DAMON SLAIKEU Job Total: $ 2,641.89 CUSTOMER PAY: $ 240.00 INSURANCE PAY: $ 2,401.89 QUALITY REPLACEMENT PARTS WARRANTY OUR REPAIR ESTIMATE MAY SPECIFY THE USE OF QUALITY REPLACEMENT PARTS. QUALITY REPIACEMENT PARTS ARE PARTS NOT MANUFACfURED BY OR FOR THE ORIGINAL EQUIPMENT MANUFACTURER. WE WILL STAND BEHIND THE QUALITY REPLACEMENT PARTS THAT ARE SPECIFIED ON THIS ESTIMATE AND USED IN THE REPAIR OF YOUR VEHICLE, FOR AS LONG AS YOU OWN/LEASE THE VEHICLE. WE WARRANT THESE PARTS ARE OF LIKE KIND, QUALITY, SAFETY, FIT AND PERFORMANCE TO PARTS MANUFACTURED BY OR FOR THE ORIGINAL EQUIPMENT MANUFACTURER. THIS WARRANTY EXCLUSIVELY COVERS LOSS OR DAMAGE THAT IS RELATED TO DEFECTS IN THE QUALITY REPLACEMENT PART. THIS WARRANTY DOES NOT COVER DAMAGE OR PART FAILURE DUE TO IMPROPER INSTALLATION, MISUSE, NEGLECT, ABUSE, IMPROPER MAINTENANCE, ABNORMAL OPERATION, OR NORMAL WEAR &TEAR. SHOULD A SUPPLIER OF A PART SPECIFIED IN OUR REPAIR ESTIMATE, OR THE REPAIR FACILITY THAT PERFORMS THE REPAIR ON YOUR VEHICLE, BE UNABLE TO RESOLVE A LEGITIMATE COMPLAINT ABOUT THE QUALITY REPLACEMENT PART USED IN THE REPAIR, WE WILL MAKE EVERY EFFORT TO SEE THAT THE PROBLEM IS CORRECTED. THIS WARRANTY AND ANY REPRESENTATIONS MADE HEREIN ARE NON-TRANSFERABLE AND EXTEND ONLY TO THE PARTY OWNING/LEASING THE VEHICLE AT THE TIME OF THE REPAIR. ❑ FOR ASSISTANCE, PLEASE CONTACT THE NEAREST HELPPOINT CLAIM SERVICES OFFICE. DISCLAIMER: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT INSURANCE CLAIM FOR THE PAYMENT OF A LOSS MAY BE GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN STATE PRISON. THE LABOR AND TAX RATES USED WERE DETERMINED BY THE VEHICLE INSPECTION LOCATION UNLESS THE REPAIR FACILITY WAS KNOWN AT THE TIME OF THE INSPECTION OR ANOTHER LOCATION WAS SPECIFIED BEFORE THE ESTIMATE WAS PREPARED 1/22/2013 7:58:55 AM 019495 Page 5 Supplement of Record 1 with Summary Customer: CZAPIEWSKI, PIOTR 7ob Number: Vehicle:2007 NISS MURANO 4X4 S 4D UN 6-3.5L-FI silver "MN LAW GIVES YOU THE RIGHT TO CHOOSE ANY RENTAL VEHICLE COMPANY,AND PROHIBITS ME FROM REQUIRING YOU TO CHOOSE A PARTICULAR VENDOR" THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF ONE OR MORE REPLACEMENT PARTS SUPPLIED BY A SOURCE OTHER THAN THE MANUFACTURER OF YOUR MOTOR VEHICLE. WARRANTIES APPLICABLE TO THESE REPLACEMENT PARTS ARE PROVIDED BY THE MANUFACTURER OR DISTRIBUTOR OF THE REPLACEMENT PARTS RATHER THAN BY THE MANUFACTURER OF YOUR MOTOR VEHICLE. 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. Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide ARF3620, CCC Data Date 1/17/2013, and the parts selected are OEM-parts manufactured by the vehicles Original Equipment Manufacturer. OEM parts are available at OE/Vehicle dealerships. OPT OEM (Optional OEM) or ALT OEM (Alternative OEM) parts are OEM parts that may be provided by or through alternate sources other than the OEM vehicle dealerships. OPT OEM or ALT OEM parts may reflect some specific, special, or unique pricing or discount. OPT OEM or ALT OEM parts may include "Blemished" parts provided by OEM's through OEM vehicle dealerships. Asterisk(*) or pouble Asterisk(**) indicates that the parts and/or labor information provided by MOTOR may have been modified or may have come from an alternate data source. Tilde sign (�) items indicate MOTOR Not-Included Labor operations. The symbol (<>) indicates the refinish operation WILL NOT be performed as a separate procedure from the other panels in the estimate. Non-Original Equipment Manufacturer aftermarket parts are described as AM. Used parts are described as LKQ, RCY, or USED. Reconditioned parts are described as Recond. Recored parts are described as Recore. NAGS Part Numbers and Benchmark Prices are provided by National Auto Glass Specifications. Labor operation times listed on the line with the NAGS information are MOTOR suggested labor operation times. NAGS labor operation times are not included. Pound sign (#) items indicate manual entries. Some 2012 vehicles contain minor changes from the previous year. For those vehicles, prior to receiving updated data from the vehicle manufacturer, labor and parts data from the previous year may be used. The CCC ONE estimator has a compfete 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=6oron steel. CAPA=Certified Automotive Parts Association. D&R=Disconnect and Reconnect. HSS=High Strength Steel. HYD=Hydroformed Steel. Inc1.=Included. LKQ=Like Kind and Quality. LT=Left. MAG=Magnesium. Non-Adj.=Non Adjacent. NSF=NSF International Certified Part. O/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. 1/22/2013 7:58:55 AM 019495 Page 6 Supplement of Record 1 with Summary Customer: CZAPIEWSKI, PIOTR Job Number: Vehicle: 2007 NISS MURANO 4X4 5 4D UN 6-3.5L-FI silver CCC ONE Estimating -A product of CCC Information Services Inc. The following is a list of abbreviations that may be used in CCC ONE Estimating that are not part of the MOTOR CRASH ESTIMATING GUIDE: BAR=6ureau of Automotive Repair. EPA=Environmental Protection Agency. NHTSA= National Highway Transportation and Safety Administration. PDR=Paintless Dent Repair. VIN=Vehicle Identification Number. 1/22/2013 7:58:55 AM 019495 Page 7 Claim Reference Id 1 02290831 9-7-2 File Name PHOT027 File Date 01/17/2013 -�.--__ _, Labei side of condensor Note Owner:PIOTR,CZAPIEWSKI� Style:2007,NISS,MURANO 4X4 S� Insured:PIOTR,CZAPIEWSKI�LossDate:10/31/2012� PolicyNumber:0192099836�ShopName:RAYMO Photo Location RAYMOND AUTO BODY,INC. Photo Taken By CRAIG AMUNDSON side of condensor Estimate Indicator S01 Claim Reference Id 1022908319-1-2 File Name PHOT026 File Date 01/77/2073 Label condesor more Note Owner:P10TR,CZAPIEWSKI� Style:2007,NISS,MURANO 4X4 S� Insured:PIOTR,CZAPIEWSKI�LossDate:10/31/2012� PolicyNumber:0192099836�ShopName:RAYMO Photo Location RAYMOND AUTO BODY,INC. Photo Taken By CRAIG AMUNDSON condesor more Estimate Indicator S07 Claim Reference Id 1022908319-1-2 File Name PHOT025 File Date 01/17/2013 Label Ikq condensor Note Owner:PIOTR,CZAPIEWSKI� , I Style:2007,NISS,MURANO 4X4 S� � Insured:PIOTR,CZAPIEWSKI�LossDate:10/31/2012� !" ' PolicyNumber:0192099836�ShopName:RAYMO � Photo Location RAYMOND AUTO BODY,INC. I' Photo Taken By CRAIG AMUNDSON Ikq condensor Estimate Indicator S01 Claim Reference Id 1022908319-1-2 File Name PHOT024 File Date 01117/2013 Label lots of miles on this one Note Owner:PIOTR,CZAPIEWSKI� Style:2007,NISS,MURANO 4X4 S� Insured:PIOTR,CZAPIEWSKI�LossDate:10/31/2012� PolicyNumber:0192099836�ShopName:RAYMO Photo Location RAYMOND AUTO BODY,INC. Photo Taken By CRAIG AMUNDSON lots of miles on this one Estimate Indicator S01 Claim Reference Id 1022908319-1-2 File Name PHOT023 File Date 01/15/2073 Label STYRO UPPER Note Owner:PIOTR,CZAPIEWSKI� Style:2007,NISS,MURANO 4X4 S� ;�-.>. Insured:PIOTR,CZAPIEWSKI�LossDate:1 0/3 112 01 2� ShopName:RAYMOND AUTO BODY,INC.�Claim Photo Location RAYMOND AUTO BODY,INC. �..— Photo Taken By CRAIG AMUNDSON STYRO UPPER Estimate Indicator E01 Claim Reference Id 1022908319-1-2 Flle Name PHOT022 File Date 01/15/2073 Label AC PUNCHED Note Owner:PIOTR,CZAPIEWSKI� Style:2007,NISS,MURANO 4X4 S� Insured:PIOTR,CZAPIEWSKI�LossDate:70/31/2012� �'-t ShopName:RAYMOND AUTO BODY,INC.�Claim Photo Location RAYMOND AUTO BODY,INC. Photo Taken By CRAIG AMUNDSON AC PUNCHED Estimate Indicator E01 Claim Reference Id 1022908319-7-2 File Name PHOT021 File Date 01/15/2013 Label CRUSHED LEFT SIDE RAD SUPPORT Note Owner:PIOTR,CZAPIEWSKI� Style:2007,NISS,MURANO 4X4 S� Insured:PIOTR,CZAPIEWSKI�LossDate:70/31/2012� ShopName:RAYMOND AUTO BODY,INC.�Claim Photo Location RAYMOND AUTO BODY,INC. A�'� �#:�.. PhotoTakenBy CRAIGAMUNDSON CRUSHED LEFT SIDE RAD SUPPORT Estimate Indicator E01 Claim Reference Id 1022908319-1-2 File Name PHOT020 File Date 01/15/2073 — Label right rear � Note Owner:PiOTR,CZAPIEWSKI� y , Style:2007,NISS,MURAN04X4S� Insured:PIOTR,CZAPIEWSKI�LossDate:10/31/2012� ShopName:RAYMOND AUTO BODY,INC.�Claim Photo Location RAYMOND AUTO BODY,INC. Photo Taken By CRAIG AMUNDSON right rear Estimate Indicator E01 Claim Reference Id 7 0 2290831 9-1-2 File Name PHOT019 File Date 01/15/2013 ^ � Label tear in bumper mount holes Note Owner:PIOTR,CZAPIEWSKI� �� Style:2007,NISS,MURANO 4X4 S� `� �}i�� Insured:P10TR,CZAPIEWSKI�LossDate:10/31I2012� ShopName:RAYMOND AUTO BODY,INC.�Claim Photo Location RAYMOND AUTO BODY,INC. Photo Taken By CRAIG AMUNDSON tear in bumper mount holes Estimate Indicator E01 Claim Referenceld 1022908319-1-2 File Name PHOT018 File Date 01/15/2013 — Label Left front Note Owner:PiOTR,CZAPIEWSKI� Style:2007,NISS,MURANO 4X4 S� Insured:PIOTR,CZAPIEWSKI�LossDate:10/31/2012� ShopName:RAYMOND AUTO BODY,INC.�Claim Photo Location RAYMOND AUTO BODY,INC. Photo Taken By CRAIG AMUNDSON Left front Estimate Indicator E01 Claim Reference Id 1022908319-1-2 File Name PHOT017 File Date 01/15/2013 x�- �?,_-= Label odometer i,;; �� „��' Note Owner:PIOTR,CZAPIEWSKI� V' Style:2007,NISS,MURANO 4X4 S� Insured:PIOTR,CZAPIEWSKI�LossDate:10/31/2012� ShopName:RAYMOND AUTO BODY,INC.�Claim Photo Location RAYMOND AUTO BODY,INC. Photo Taken By CRAIG AMUNDSON odometer Estimate Indicator E01 Claim Reference Id 1022908319-1-2 File Name PHOT016 File Date 01/15/2013 - Label lic plate Note Owner:PIOTR,CZAPIEWSKI� Style:2007,NISS,MURANO 4X4 S� Insured:PIOTR,CZAPIEWSKI�LossDate:10/31/2012� ShopName:RAYMOND AUTO BODY,INC.�Claim Photo Location RAYMOND AUTO BODY,INC. Photo Taken By CRAIG AMUNDSON lic plate Estimate Indicator E01 Claim Reference Id 1022908319-1-2 File Name PHOT015 File Date 01/15/2013 - Label BUMPER CHROME Note Owner:PIOTR,CZAPIEWSKI� Style:2007,NISS,MURANO 4X4 S� � ' Insured:PiOTR,CZAPIEWSKI�LossDate:10/31/2012� � ShopName:RAYMOND AUTO BODY,INC.�Claim Photo Location RAYMOND AUTO BODY,INC. Photo Taken By CRAIG AMUNDSON BUMPER CHROME Estimate Indicator E01 Claim Reference Id 1022908319-1-2 File Name PHOT074 File Date 01/15/2013 � Label damage to front bumper Note Owner:PIOTR,CZAPIEWSKI� Style:2007,NISS,MURANO 4X4 S� _� Insured:PIOTR,CZAPIEWSKi�LossDate:10/31/2012� ShopName:RAYMOND AUTO BODY,INC.�Claim Photo Location RAYMOND AUTO BODY,INC. Photo Taken By CRAIG AMUNDSON damage to front bumper Estimate Indicator E01 Claim Reference Id 1022908319-1-2 File Name PHOT013 File Date 01/15/2013 Label BACKSIDE COVER LOOK Note Owner:PIOTR,CZAPIEWSKI� Style:2007,NISS,MURANO 4X4 S� Insured:PIOTR,CZAPIEWSKI�LossDate:10/31/2012� ShopName:RAYMOND AUTO BODY,INC.�Claim Photo Location RAYMOND AUTO BODY,INC. Photo Taken By CRAIG AMUNDSON BACKSIDE COVER LOOK Estimate Indicator E01 Claim Reference Id 1022908319-1-2 File Name PHOT072 File Date 01/15/2013 �� ; � Label vin �. °� Note Owner:PIOTR,CZAPIEWSKI� �� Style:2007,NISS,MURANO 4X4 S� �� f Insured:PIOTR,CZAPIEWSKI�LossDate:1 0/3112 01 2� i ShopName:RAYMOND AUTO BODY,INC.�Claim �"""''�' Photo Location RAYMOND AUTO BODY,INC. Photo Taken By CRAIG AMUNDSON �i� Estimate Indicator E01 Claim Reference Id 1022908319-1-2 File Name PHOT011 File Date 01/15/2073 Label LT SIDE RAD SUPPORT Note Owner:PIOTR,CZAPiEWSKI� Style:2007,NISS,MURANO 4X4 S� Insured:PIOTR,CZAPIEWSKI�LossDate:10/31/2012� � :,,�` ShopName:RAYMOND AUTO BODY,INC.�Claim - Photo Location RAYMOND AUTO BODY,INC. I � Photo Taken By CRAIG AMUNDSON LT SIDE RAD SUPPORT Estimate indicator E01 Ciaim Reference Id 1022908319-1-2 File Name PH0T010 File Date 01/15/2013 - T�� Label center dash Note Owner:PIOTR,CZAPIEWSKI� � � � Style:2007,NISS,MURANO 4X4 S� Insured:PIOTR,CZAPIEWSKI�LossDate:10/31/2072� ShopName:RAYMOND AUTO BODY,INC.�Claim Photo Location RAYMOND AUTO BODY,INC. Photo Taken By CRAIG AMUNDSON center dash Estimate indicator E01 Claim Reference Id 7022908379-1-2 File Name PHOT09 File Date 07/15/2013 y��i ■ Label LT BAFFLE �! Note Owner:PIOTR,CZAPIEWSKI� Style:2007,NISS,MURANO 4X4 S� Insured:PIOTR,CZAPIEWSKI�LossDate:10/37/2012� �i , ShopName:RAYMOND AUTO BODY,INC.�Claim �"�'� Photo Location RAYMOND AUTO BODY,INC. -_ _ Photo Taken By CRAIG AMUNDSON LT BAFFLE Estimate Indicator E01 Claim Reference Id 1 02290831 9-7-2 File Name PHOTOS File Date 01/15/2013 ��-��. �„� �� Labei interior , _..,f..�i� � �� Note Owner:PIOTR,CZAPIEWSKI� � ��•�^� Style:2007,NISS,MURANO 4X4 S� Insured:PIOTR,CZAPIEWSKI�LossDate:10/31/2012� ShopName:RAYMOND AUTO BODY,INC.�Claim Photo Location RAYMOND AUTO BODY,INC. Photo Taken By CRAIG AMUNDSON interior Estimate Indicator E01 Claim Reference Id 7 02290831 9-1-2 File Name PHOT07 File Date 01/75/2073 �� :�i� Label lic plate frame damage `� T " � Note Owner:PIOTR,CZAPIEWSKI� Style:2007,NISS,MURANO 4X4 S� Insured:PIOTR,CZAPIEWSKI�LossDate:10/31/2012� ShopName:RAYMOND AUTO BODY,INC.�Claim Photo Location RAYMOND AUTO BODY,INC. Photo Taken By CRAIG AMUNDSON lic plate frame damage Estimate Indicator E01 Claim Reference Id 7022908319-1-2 File Name PHOT06 File Date 01/15/2013 -- ��, „ ;. �;�,�„ �;:;- Label left rear � �t� Note Owner:PIOTR,CZAPIEWSKI� Style:2007,NISS,MURANO 4X4 S� = Insured:PIOTR,CZAPIEWSKI�LossDate:10/31/2072� ShopName:RAYMOND AUTO BODY,INC.�Claim Photo Location RAYMOND AUTO BODY,INC. Photo Taken By CRAIG AMUNDSON left rear Estimate Indicator E01 Claim Reference Id 1022908319-1-2 File Name PHOT05 File Date 01/15/2013 Label GRILLE HIT UPPER ONE ON COVER Note Owner:PIOTR,CZAPIEWSKI� � Style:2007,NISS,MURANO 4X4 S� Insured:PIOTR,CZAPIEWSKI�LossDate:1 0/3112 01 2� ShopName:RAYMOND AUTO BODY,INC.�Claim Photo Location RAYMOND AUTO BODY,INC. Photo Taken By CRAIG AMUNDSON GRILLE HIT UPPER ONE ON COVER Estimate Indicator E01 Claim Reference Id 1022908319-1-2 File Name PHOT04 File Date 01/15/2013 -- - , Label right front � Note Owner:PIOTR,CZAPIEWSKI� I I Style:2007,NISS,MURANO 4X4 S� = Insured:P10TR,CZAPIEWSKI�LossDate:70/31/2012� � ShopName:RAYMOND AUTO BODY,INC.�Claim Photo Location RAYMOND AUTO BODY,INC. Photo Taken By CRAIG AMUNDSON right front Estimate Indicator E01 Claim Reference Id 1022908319-1-2 File Name PHOT03 File Date 01/75/2073 I� �r �?' Label LOWER LEFT VALANCE �v�,� ,�� _� x� Note Owner:PIOTR,CZAPIEWSKI� "t�:r�= ��,au, Style:2007,NISS,MURANO 4X4 S� Insured:PIOTR,CZAPIEWSKI�LossDate:1013112012� ShopName:RAYMOND AUTO BODY,INC.�Claim Photo Location RAYMOND AUTO BODY,INC. Photo Taken By CRAIG AMUNDSON LOWER LEFT VALANCE Estimate Indicator E01 Claim Reference Id 1022908319-1-2 File Name PHOT02 File Date 01/75/2013 � � Label crack in lower front bumper Note Owner:PIOTR,CZAPIEWSKI� Style:2007,NISS,MURANO 4X4 S� Insured:PIOTR,CZAPIEWSKI�LossDate:10/31/2012� ShopName:RAYMOND AUTO BODY,INC.�Claim Photo Location RAYMOND AUTO BODY,INC. Photo Taken By CRAIG AMUNDSON crack in lower front bumper Estimate Indicator E01 Claim Reference Id 1022908319-1-2 File Name PHOT01 File Date 0111 5/2 0 7 3 Label lic plate bracket ripped out of fro Note Owner:PIOTR,CZAPIEWSKI� g Style:2007,NISS,MURANO 4X4 S� �° Insured:PIOTR,CZAPIEWSKI�LossDate:10/31@072� ShopName:RAYMOND AUTO BODY,INC.�Claim Photo Location RAYMOND AUTO BODY,INC. Photo Taken By CRAIG AMUNDSON lic plate bracket ripp Estimate Indicator E07 �