Czapiewski (2) {,A' • Natianal Document Centex
' . �`• � � � � � � .,.-- A � P. �. Box 2G8992
��r,;�.:����klahoma City, �YL 7312G-8992
� `� 2013 clairnsdocuments a[�} pcs.com
FEB F�: s��-ai�-1�s�
�,����� �� .�.�.�'��, Toll Free: 800-HelpPoint
02/14/2013
Self Insured
Attn: City Of Saint Paul- Ciry 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#:
Amount Owed: $2,641.89
Dear City Of Saint Paul- City Clerk:
Be advised that due to this accident,our insured incurred out of pocket expenses in the
amount of$191.32. Please contact our insured direcdy to discuss the amount owed for tl�ese
expenses.
Our support for the additional amount is attached.
Sincerely,
Illinois Farmers Insurance Company
�
Kristin Jones
Auto Subrogation Representative
630-907-6913
PO Bo�:268992
Oklahoma City,Ok 73126
Page 1 of 1
ENTERPRISE LEASING COMPANY,1i61 UNIVERSITY AVE W,SAINT PAUL,MN 551044124(651)228-0088
RENTAL AGREEMENT REF#
462574 4C3XG1
RENTER SUMMARY OF CHARGES
HULBERT,ROBIN
ADDITIONAL DRIVER Charge Description Date Quantity Per Rate Total
CZAPIEWSKI,PIOTR nME&DISTANCE Oi/14-01/21 1 WEEK $161.01 $161.01
REFUELING CHARGE Ol/14-01/21 $0:00
DATE&TIME OUT Subtotai: ;161.01
01/14/2013 05;03 PM Taxes&Surcharges
DATE&TIME IN MINNESOTA REGISTRATION 01/14-01121 5% $8.05
O1/21J2013 A4:45 PM FEE
MINNESOTA RENTAL CAR 01/14-01/21 6.2% $9.98
BILIING CYCLE TAX
24-HOUR SALES TAX 01/14-OS/21 7.625�i6 $12.28
Total Charges: $191.32
VEH#1 2012 CHEV MALI 2LT4
VIN#1G1ZD5EU1CF320913 Total Amount Due $0.00
LIC#S48JDC
MILES DRIVEN 480 ppYMENT INFORMATION
CLAIM INFO AMOUNT PAID TYPE CREDIT CARD NUMBER
7YPE CAR: MURANO $191.32 American Express xxxxxx�000cxx2015 PENDING
SHOP: RAYMOND AUTO BODY
PHONE: (651)488-0588
ATTN: UNKNOWN
1/21/2013
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