Blanda 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 6ody of the municipaliry 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 I.A�—L�L Middle Initial�Last Name�i-.f�N�H �..r.�,�:� ���
Company or Business Name
��Ai� �013
Are You an Insurance Company? Yes/� If Yes,Claim Number?
Street Address �7q�{ �f���d�� �v� � � � ����
City Sf�I:N I �'AtJ L State !"�/J Zip Code S S/o�
Daytime Phone(�S �)jj�- 2��7 Cell Phone(CoSI )�- 28�-lEvening Telephone(��)33� -Z�C�7
Date of Accidend Injury or Date Discovered �Z��/20! Z Time /Z�d am!�
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.z �i'A-l�cK- 1��.•a��h-�
Wl�'S hi�5i/✓dJn.t.� O^' CV1�4R�(L-f4�.-�17 A-Il� GJN-�,•� �1 5 Y �A-t�C. 1(Ll9C'K 7R-�V��J ►3�-1 Tc:Y�I 3 Wf�t-1'��
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T1-+� ►¢.�c.� -r�`�`t� r� �r �-a��, -ro s r�P z t-�N� w��l ��' t���r �� v r
W PU�-T� NO� �V(�1•���1�fL �f F�ti/ttrL� `��`CT�-P P�L, � ���z/�%{-t�O�N �1�1GW R�L(s�1}1 Pc`)L-��-f f�.R!`�1�"-�
A-n�i'� � �di�C� 'R-�1�0�� LJ�4S 't�ki�'tJ
Please check the box(es)that most closely represent the reason for completing this form:
f�Vly 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 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 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-alease comnlete this section
Were there witnesses to the incident? Yes No nknown (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? '� p�L. Case#or report# 1�.Z.�1`{ l 3�
Where did the accident or injury take place? Provide street address,cross street, intersection,name of park or facility,
closest landmazk,etc. Please be as detailed as possible. If necessazy,attach a diagram. ZH t�z5f�c t-c�!� �L
m�.���� ���. �- r��5�M�sr� . 5 r p�U� w►,�
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� 3:� (n��,S 7
���
Vehicle Claims-alease comnlete this section ❑check box if this section does not apnlv
YourVehicle: Year�`� Make C�E�"l Model �.�i't�.�--�--�"Z
License Plate Number SZ c �I G,�Z State h�1�Color (%� i�:-i�E,
Registered Owner __t��t�2��IL 174M�:5 (�.�.�--�`J�-
Driver of Vehicle �!-�YzyC.IL �,4i►'t�S (�...Aa D�'�-
Area Damaged L�F i �2 �2U1�.2i'��Ar'�� � ;-yq-t���:, + r
City Vehicle: Year�_Make S T�(9, Model 5 7�
License Plate Number `139/(oC� State l�n/ Color
Driver of Vehicle(City Employee's Name) {�l1�Li�L . ��.-N'1F-5 ���5
Area Damaged
Iniurv Claims-nlease comalete this section ❑ check box if this section does not apvlv
How were you mjured?
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
GYCheck 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 I���j�1 �
Print the Name of the Person who Complet this Form: ��� (�- ��5
Signature of Person Making the Claim: ��,��
Revised February 201 I
Accident Report Page 1 of 1
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https://www.dvslesupport.org/dvsinfo/accidentrecords_2008/Includes_LE/PrintReportlndi... 12/3/2012
Page � of 4
Saint Paul Police Department
ORIGINAL OFFENSE / INCIDENT REPORT
Complaint Number Reference CN Date and Time of Reporf
12284135 12/03/2012 14:32:00
Primary offense:
TRAFFIC ACCIDENT-PROPERTY DAMAGE ACCIDENT
Primary Reporting Officer: �aCObSS011, Jeffrey R Name of/ocatioNbusiness:
Primarysquad: 321 location oiincident: MARYLAND AV E &WESTMINSTER
Secondary reporting o�cer. M N 55106
Approver.- H8Z21ett, Brad
District: Eastern Date&time of occurrence: 12/03/2012 14:33:00 to
site: 12/03/2012 14:33:00
Arrest made:
Secondary offense:
Police O�cer Assaulted or Injured: Police O�cer Assisted Suicide:
Crime Scene Processed:
OFFENSE DETAILS
TRAFFIC ACCIDENT-PROPERTY DAMAGE ACCIDENT
Attempt Only. Appears to be Gang Re/ated:
Crime Scene Method 8 Point of Entry
Type: Gov/public property Foroe used: Hid/nside:
Description: Other public Pointofentry:
Method:
NAMES
Driver Blanda, Patrick James
994 HAWTHORNE E
MN �
Nicknames or Aliases
Nick Name:
Alias:
AKA First Name: AKA Last Name:
Details
sex: Male Race: DOe: 6/7/1981 Resident Status:
Hispanic: Age: 31 from to
Phones
Home: Ceu: Contact: 651-334-2867
Work: Fax: Pager.
SP98AF85587C9A1
Page 2 of 4
Saint Paul Police Department
ORIGINAL OFFENSE / INCIDENT REPORT
Complaint Number Reference CN Date and Time of Report
12284135 12/03/2012 14:32:00
Primary offense:
TRAFFIC ACCIDENT-PROPERTY DAMAGE ACCIDENT
Employment
Occupation: Employer.
Identification
SSN: License or ID#: License State:
Driver Walter, James Thomas
1564 47TH
SOMERSET, WI 54025
Nicknames or A/iases
Nick Name:
Alias:
AKA First Name: AKA Lasf Name:
Details
Sex: Race: DOB: 12/31/1965 Resident Status:
Hispanic: Age: 46 from to
Phones
Home: Cell: Contact:
Work: Fax: Pager.
Employment
Occupation: STREET MAINTANANCE Employer.�
Identification
SSN: License or ID#: License State:
Suspect
UNKNOWN
Nicknames or Aliases
Nick Name:
Alias:
AKA First Name: AKA Last Name:
Details
Sex: Race: DOB: Resident Status:
Hispanic: Age: from to
SP98AF85587C9A1
Page 3 of 4
� Saint Paul Police Department
ORIGINAL OFFENSE / INCIDENT REPORT
Comp/aint Number Reference CN Date and Time of Report
12284135 12/03/2012 14:32:00
Primary offense:
TRAFFIC ACCIDENT-PROPERTY DAMAGE ACCIDENT
Phones
Home: Cell: Contact
Work: Fax: Pager.
Emp/oyment
Occupation: Emp/oyer:
Identification
SSN: License or ID#: License State:
Physical Description
US: Metric:
Height: to Build: Hair Length: Hair Co/or.
Weight: to Skin: Facia/Hair.• Hair Type:
Teeth: Eye Color: B/ood Type:
Offender Information
Arrested: Pursuit engaged: Violated Restraining Order.�
DUI: Resistance encountered:
Condition:
Taken to hea/th care facility: Medical re/ease obtained:
SOLVABILITY FACTORS
Suspect can be Identified: gy;
Photos Taken: Stolen Property Traceab/e.•
Evidence Tumed In: Property Tumed In:
Re/ated/ncident.�
Lab
Bio/ogical Analysis: Fingerprints Taken:
Narcotic Analysis: /tems Fingerprinted:
Lab Comments:
Participants:
Person Type: Name: Address: Phone:
Driver Blanda, Patrick James 994 HAWTHORNE E
MN
Driver Walter, James Thomas 1564 47TH
SOMERSET, WI 54025
SP98AF85587C9A1
Page 4 of 4
Saint Paul Police Department
ORIGINAL OFFENSE / INCIDENT REPORT
Complaint Number Reference CN Date and Time of Report
12284135 12/03/2012 14:32:00
Primary offense:
TRAFFIC ACCIDENT-PROPERTY DAMAGE ACCIDENT
Suspect
NARRATIVE
Driver of vehicie#2 Blanda, Patrick James of 994 E. Hawthorne phone 651-334-2867 stated that he was west
bound on Maryland at Westminster when he observed a city Dump truck license# 939160 north bound on
Westminster proceed through the intersection and strike his vehicle in the left rear corner panel causing his
vehicle to slide sideways. The dump truck continued north bound on Westminster. Blanda stated that he
followed the truck honking his horn in a attempt to get the driver to stop. The vehicle eventually stopped at
Arlington and Arkwright. I talked to the driver of the dump truck who was driving city vehicle while working for
street maintenance. The driver Walter, Thomas James 1564 47th st. Somerset Wi. stated that he did not
realize that he struck another vehicle or why blanda was following him.
I compared the paint scrapings on the front of the dump truck with the damage on Blanda's vehicle. The color
was the same and the height of the damage also matched. Street maintenance supervisor Schwabel, Linda
phone 651-755-1118 arrived at the scene.
There was no damage to the dump truck. There was about $800.00 damage to Blanda's vehicle.
Squad 390 took photos of the damage
PUBLIC NARRATIVE
Accident at Westminster and Maryland involving a city vehicle.
SP98AF85587C9A1
Page � of 2
Saint Paul Police Department
SUPPLEMENTAL OFFENSE / INCIDENT REPORT
Complaint Number Reference CN Date and Time of Report
12284135 12/03/2012 13:10:00
Primary offense:
TRAFFIC ACCIDENT-PROPERTY DAMAGE ACCIDENT
Primary Reporting O�cer. Alb@fg, Mary B Name of location/business:
Primarysquad: 390 �ocationofincident:ARKWRIGHT ST & MARYLAND
Secondary reporting officer. MN 51506
Approver.� HBZeI@tt, Brad
oisr�cr: Eastern Date&time of occurrence: 12/03/2012 12:00:00 to
Site: 12/03/2012 12:00:00
Arrest made:
Secondary offense:
Police O�cer Assaulted or Injured: Police O�cer Assisted Suicide:
Crime Scene Processed:
OFFENSE DETAILS
TRAFFIC ACCIDENT-PROPERTY DAMAGE ACCIDENT
Attempt Only: Appears to be Gang Related:
SOLVABILITY FACTORS
Suspect can be/dentified.� gy:
Photos Taken: YeS Sto/en Property Traceable:
Evidence Tumed In: Property Tumed In:
Related lncident:
Lab
Biological Analysis: Fingeiprints Taken:
Narcotic Ana/ysis: Items Fingerprinted:
Lab Comments:
Participants:
Person Type: Name: Address: Phone:
NARRATIVE
On 11-3-2012 at 1200 hours, Squad# 390 (Alberg, Mary B) was dispatched to Arlington and Arkwright to take
photos of an APD.
List of Photos for CN 12284135:
SP98AF85587C9A1
Page 2 of 2
Saint Paul Police Department
SUPPLEMENTAL OFFENSE / INCIDENT REPORT
Complaint Number Reference CN Date and Time of Report
12284135 12/03/2012 13:10:00
Primary offense:
TRAFFIC ACCIDENT-PROPERTY DAMAGE ACCIDENT
1. 12284135-12032012 133241-APD-1.jpg - front of vehicle
2. 12284135-12032012_133248-APD-2.jpg - passenger side
3. 12284135-12032012 133255-APD-3.jpg - rear of vehicle
4. 12284135-12032012_133304-APD-4.jpg - drivers side
5. 12284135-12032012_133309-APD-5.jpg - dent on vehicle
6. 12284135-12032012_133321-APD-6.jpg - front of vehicle
7. 12284135-12032012_133332-APD-7.jpg - passenger side of vehicle
8. 12284135-12032012_133346-APD-8.jpg - rear of vehicle
9. 12284135-12032012_133357-APD-9.jpg - drivers side of vehicle
10. 12284135-12032012_133408-APD-10.jpg - front bumper
The labeled photos were TRANSFERRED to the Media Vault.
PUBLIC NARRATIVE
SP98AF85587C9A1
ABRA Auto Body & Glass - Workfile ID: 7a8d361d
FederalID: 41-1942823
Maplewood
Right The First Time...On Time
2806 HIGHWAY 61, MAPLEWOOD, MN 55109
Phone: (651)483-2145
FAX: (651) 483-2509
Preliminary Estimate
Customer: Blanda, Patrick 7ob Number:
Written By: Heather Larson
Insured: Blanda, Patrick Policy#: Claim#: 0
Type of Loss: Date of Loss: 12/3/2012 12:00:00 PM Days to Repair: 0
Point of Impact: 07 Left Rear
Owner: Inspection Location: Insurance Company:
Bianda, Patrick ABRA Auto Body&Glass-Maplewood CUSTOMER PAY
994 Hawthorne Avenue 2806 HIGHWAY 61
St. Paul, MN 55106 MAPLEWOOD,MN 55109
(651)334-2867 Business Repair Facility
(651)483-2145 Business
VEHICLE
Year: 1997 Body Style: 2D CPE VIN: 1GiJC1249VM146939 Mileage In: 1
Make: CHEV Engine: 4-2.2L-FI License: 500-HGR Mileage Out:
Model: CAVALIER Production Date: State: MN Vehicle Out:
Color: WH1TE Int: Condition: Job#:
TRANSMISSION DECOR SAFETY Bucket Seats
5 Speed Transmission Tinted Glass Anti-Lock Brakes(4) Recline/Lounge Seats
Overdrive Dual Mirrors Driver Air Bag WHEELS
POWER Console/Storage Passenger Air Bag Full Wheel Covers
Power Steering CONVENIENCE SEATS PAINT
Power Brakes Intermittent Wipers Cloth Seats Clear Coat Paint
1/18/2013 12:05:00 PM 014563 Page 1
Preliminary Estimate
Customer: Blanda, Patrick Job Number:
Vehicle: 1997 CHEV CAVALIER 2D CPE 4-2.2L-FI WHITE
Line Oper Description Part Number Qty Extended Labor Paint
Price#
1 REAR BUMPER
2 R&I R&I bumper cover 1.3
3 * <> Rpr Bumper cover painted 2_0 2.6
4 Add for Ciear Coat 1.0
5 # Refn 'Deduct-Partial Paint; Full Clear -0.3
6 _REAR LAMPS _ _ __ _ __ _ _ __
7 * Repl LKQ LT Tail lamp assy outer 5978319 1 ¢,SQQ Q�
+30%
NOTE: SHARP AUTO
8 * R&I LT Lower filler Q�
9 __ QUARTER PANEL . _ __ __ __ _ _ __ __ _ _
10 * Rpr LT Quarter panel 7_Q 2.2
11 Overlap Major Non-Adj. Panel -0.2
12 Add for Ciear Coat 0.4
13 R&I LT Applique 0.3
14 * R&I LT Body side mldg w/o Z24,w/o 4.7
RS primed
15 # �Clean&Retape Molding 1 2.00 X 0.3
16 # Rpr �Rope Quarter Glass 0.3
17 MISCELLANEOUS OPERATIONS _ _. _.
18 # Refn �Car Cover 0.1
19 # Refn �Corrosion Protection 0.3
20 # Repl 'Flex Additive/Adhesion Promoter 1 8.50 X
21 # �Hazardous Waste 1 5.00 X
SUBTOTALS 80.50 12.0 6.1
ESTIMATE TOTALS
Category Basis Rate Cost; I
Parts 65.00 '
Body Labor 12.0 hrs @ $54.00/hr 648.00 i
Paint Labor 6.1 hrs @ $54.00/hr 329.40 �'
Paint Suppties 6.1 hrs @ $34.00/hr 207.40
Miscellaneous 15.50 ,
Subtotal 1,265.30 �'
Sales Tax $65.00 @ 7.1250% 4.63 '
Grand Total 1,269.93
Deductible 0.00 '
CUSTOMER PAY 0.00 i
INSURANCE PAY 1,269.93
1/18/2013 12:05:00 PM 014563 Page 2
Preliminary Estimate
Customer: Blanda, Patrick 7ob Number:
Vehicle: 1997 CHEV CAVALIER 2D CPE 4-2.2L-FI WHITE
THIS IS A VISUAL INSPECTION ONLY. THERE MAY BE ADDITIONAL DAMAGE AFfER 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.
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
DE1CL95, 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 (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 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.
i
OTHER SYMBOLS AND ABBREVIATIONS:
Adj.=Adjacent. Algn.=Align. ALU=Aluminum. A/M=Aftermarket part. BInd=6lend. 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=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.
1/18/2013 12:05:00 PM 014563 Page 3
Preliminary Estimate
Customer: Blanda, Patrick �ob Number:
Vehicle: 1997 CHEV CAVALIER 2D CPE 4-2.2L-FI WHITE
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.
1/18/2013 12:05:00 PM 014563 Page 4
LAMEITRY'S COLLISION - Workfile ID: b2b7f0e8
FederalID: 411393089
MAPLEWOOD
"Every Customer Leaves With A Smile"
2951 MAPLEWOOD DR, SAINT PAUL, MN 55109
Phone: (651) 766-9770
FAX: (651) 766-8660
Preliminary Estimate
Customer: BLANDA, PATRICK
Written By:]ason Wheeler
Insured: BLANDA, PATRICK Policy#: Claim #:
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact: 07 Left Rear
Owne:: � Insp2ction Locatian: Insurance�ompany:
BLANDA,PATRICK LAMETTRY'S COLLISION-MAPLEWOOD CUSTOMER PAY
994 HAWTHORNE AVE E 2951 MAPLEWOOD DR
ST. PAUL, MN 55106 SAINT PAUL,MN 55109
(651)534-2867 Day Repair Facility
(651)766-9770 Business
VEHICLE
Year: 1997 Body Style: 2D CPE VIN: 1G1JC1249VM146939 Mileage In: 224736
Make: CHEV Engine: 4-2.2L-FI License: 500HGR Mileage Out:
Model: CAVALIER Production Date: 6/1997 State: MN Vehicle Out:
Color: WHITE Int: GRAY Condition: ]ob#:
TRANSMISSION DECOR SAFETY Bucket Seats
5 Speed Transmission Tinted Glass Anti-Lock Brakes(4) Recline/Lounge Seats
Overdrive Dual Mirrors Driver Air Bag WHEELS
POWER Console/Storage Passenger Air Bag Fuil Wheel Covers
Power Steering CONVENIENCE SEATS PAINT
Power Brakes Intermittent Wipers Cloth Seats Clear Coat Paint
1/18/2013 12:37:55 PM 053108 Page 1
Preliminary Estimate
Customer: BLANDA, PATRICK
Vehicle: 1997 CHEV CAVALIER 2D CPE 4-2.2L-FI WHITE
Line Oper Description Part Number Qty Extended Labor Paint
Price$
1 REAR BUMPER
2 0/H bumper assy 2.0
3 Repl Bumper cover painted 22597562 1 186.27 Incl. 2.6
4 Add for Clear Coat 1.0
�,. __.___._ _._�... _.,___ ____.__. ..__ __._ __. ..___ __ ...__._._.__ . ._. __...... _.__,__.
_ _--_._. ----._ ___.____ _. _.___
5 REAR LAMPS
6 ** Repl A/M LT Tail lamp assy outer 5978319 1 75.00 0.3
_ ._.. __._�_ __._.___ -----____ _.__..
_ __ ....__ _._�..____ _ ._.__�.__ .____.__ .__ ._. _____---- --.___�__.�_______________.____ ---
7 QUARTER PANEL -- ---Y - �V
8 Repl LT Quarter panel 22638037 1 1,15835 11.5 3.0
9 Add for Clear Coat 1.2
10 Deduct for Rear Bumper R&I -1.3
11 * R&I LT Upper qtr panel �,.Q
� ______� ._�__.___ ._._ ...__...__�__ _.___._� .______�.__-.__..____�_�_.-�_.____
_..__.__.-- -_._....__..��____�---_.__ ._____..__------- ..�__.__.__...____....__._._
12 WHEELS
13 R&I LT/Rear R&I wheel m 0.1
14 # Refn Car Cover 0.2
15 # Refn Corrosion Protection 03
16 ** Repl A/M Seam Sealer-Per Welded on 1 50.00 X
Panel
17 # Flex Additive 1 6.00 X
18 # Subl Hazardous Waste Disposal Fee 1 5.00 X
SUBTOTALS 1,440.62 14.6 8.3
ESTIMATE TOTALS
Category Basis Rate Cost$
Parts 1,419.62
Body Labor 14.6 hrs @ $56.00/hr 817.60
Paint Labor 8.3 hrs @ $56.00/hr 464.80
Paint Supplies 8.3 hrs @ $38.00/hr 315.40
Body Supplies 12.5 hrs @ $2.00/hr 25.00
Miscellaneous 21.00
Subtotal 3,063.42
Sales Tax $ 1,419.62 @ 7.1250% 101.15
Grand Total 3,164.57
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 3,164.57
1/18/2013 12:37:55 PM 053108 Page 2
Preliminary Estimate
Customer: BLANDA, PATRICK
Vehicle: 1997 CHEV CAVALIER 2D CPE 4-2.2L-FI WHITE
THIS REPORT IS AND ESTIMATE ONLY, BASED ON OUR INITIAL 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 LAMETTRY'S
COLLISION ONLY. NO WARRANTY ON RUST, CORROSION RESISTANCE OR REPLACEMENT RENTAL CARS.
OUR ESTIMATED COMPLEfION 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.
Estimate based on MOTOR CRASH ESRMATING GUIDE. Unless otherwise noted all items are derived from the Guide
DE1CL95, CCC Data Date 12/14/2012, 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 modified 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 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. 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.
1/18/2013 12:37:55 PM 053108 Page 3
Preliminary Estimate
Customer: BLANDA, PATRICK
Vehicle: 1997 CHEV CAVALIER 2D CPE 4-2.2L-FI WHITE
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.
1/18/2013 12:37:55 PM 053108 Page 4
Preliminary Estimate
Customer: BLANDA, PATRICK
Vehicle: 1997 CHEV CAVALIER 2D CPE 4-2.2L-FI WHITE
ALTERNATE PARTS SUPPLIERS
Supplier: Keystone-Comptete-Dubuque
Location(s): 2400 KERPER BLVD,DUBUQUE IA 52001 (800)747-2500 (563)556-5030
3017 A HOOVER AVENUE,STEVENS POINT WI 54481 (800)218-4848 (715)342-0772
2700 29TH AVENUE N, ESCANABA MI 49829 (800)833-2030 (906)789-2200
9532 W.CARMEN AVENUE, MILWAUKEE WI 53225 (800)924-8230 (414)463-1019
822 CENTRAL AVENUE, LINTHICUM MD 21090 (800)390-4600 (410)636-4600
3615 MARSHALL STREET NE, MINNEAPOLIS MN 55418 (800)328-1845 (612)789-1919
2021 WEST DIVISION STREEf,ST.CLOUD MN 56301 (800)247-0861 (320)251-8494
5969 HAASE ROAD, DEFOREST WI 53532 (800)356-7252 (608)249-4775
5085 WREN DRIVE,APPLETON WI 54913 (800)422-1995 (920)731-3030
Line Description Item# Price
6 A/M LT Tail lamp assy outer GM2800129 $75.00
1/18/2013 12:37:55 PM 053108 Page S