Steward (American Family Ins) AMERICAN FAMILY
0
6131 Blue Circle Drive I Eden Prairie MN 55343-9130 I amfam.com
Mailing Address:PO Box 1246 I Minneapolis, MN 55440-1246 I Phone:(952)933-4884
March 06, 20�3 RECEIV'Ep
MAR 0 8 ��r3
�i i'�'LL��ii�
39-J EK002
CITY CLERK
15 W KELLOGG BLVD
310 CITY HALL
SAINT PAUL MN 55102
RE: Your Insured Name: City of St Paul
Your File Number: Unknown
Our Claim Number: 00-345-018544 3907
Our Insured: Laura A Steward
Date of Accident: January 29, 2013
Total Claim: $2,420.27
Company Portion: $1,920.27
Insured's Deductible: $500.00
Dear City Clerk:
We are notifying you that American Family Mutual Insurance Company has now made payment on the
above referenced claim and our supporting documentation and proof of payment is enclosed.
The facts support that this incident was caused by your insured's negligence. We would appreciate your
offer of settlement or your theory of liability.
We look forward to concluding this matter soon.
Thank you for your attention to this matter. When sending correspondence, please include 'Attn:
Subrogation DepY.
Respectfully,
Gwen M Ersbo
Claim Technician
American Family Mutual Insurance Company
1-800-MYAMFAM (1-800-692-6326) X 66224
gersbo @ amfam.com
Fax: (866) 833-5588
www.amfam.com/claims
Enc:
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 municipaliry...shall cause to be presented to the
governing body of the municipality within/80 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 Middle Initial Last Name
Company or Business Name� (�er.c � ��i+�'��a__F.�h��i�►,r�
� - -
Are You an Insurance Company? Yes/No If Yes,Claim Number? (JX� _��.S — (`�� u.��I y
Street Address���3 ( �s•.s_�.•�'c���- �r
City � �,g,�Q�',�,,r:e State �,�(1� Zip Code_�>S�3`I-3
�x+- c��aav
Daytime Phone (�)�-Q?4-� Cell Phone( ) - Evening Telephone( ) -
Date of Accidentl Injury or Date Discovered ���%1� Time am/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.
� w S"E'r '
^ 'rY� � �0
Please check the box(es)that most closely represent the teason for completing this form:
❑ My vehicle was damaged in an accident ❑�Iy vehicle was damaged during a tow
❑ My vehicle was damaged by a pothole or condition of the street (I�d'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 tp include copies of all aunlicable 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 WII,L 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$500.00; or the actual bills
and/or receipts for the repairs;detailed list of damaged items
O Injury claims: medical bills,receipts
O Photographs are always welcome to document and support your claim but will not be returned.
Page 1 of 2—Please complete and return both pages of Claim Form
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims—please comnlete this section
Were there witnesses to the incident? Yes No Unknown (circle)
Provide their names,addresses and telephone numbers:
Were the police or law enforcement called? Y No Unknown (circle)
If yes,what department or agency? S'�- ��,U� . � Case#or report# /.� ��q o�7
Where did the accident or injury take place? Provide street address,cross street, intersection,name of park or facility,
closest landmark,etc. Please be as detailed as possible. If necessary,attach a diagram.
Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction. � ;J��Q' y� `�s �i ncl.�•��� ��y ar.��`� �5���' �er�u�'�.�e1�
Vehicle Claims—please complete this section ❑check box if this section does not apply
Your Vehicle: Year�C� Make To��k Model C'_Q�et� L�
License Plate Number gSo �� State�U�Coloi S�,�t�
Registered Owner i.-d,.r x �} 1'�p.��f t�,
Driver of Vehicle a.r P�
Area Damaged r,„�.�c� s;{l�
City Vehicle: Year�Make ��!;�. Model .S't'�.
License Plate Number W�'��$_� State ''1�Color 0:�
Driver of Vehicle(City Employee's Name) (:1 di� �br-t ���y�('prk
Area Damaged p�ne e r cl U;v
Iniurv Claims—please comnlete this section ❑ check box if this section does not anvlv
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
Gd Check here if you are attaching more pages to this claim form. Number of additional pages�C .
By signing this form,you are stating that all inforrnation 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��y�I�
Print the Name of the Person who Comple ed is Form:�TU.l.2�L �C.Y��
Signature of Person Making the Claim:
Revised Februazy 2011
(Page 2 of, 2)
Accident Report Page 1 of 1
n
n � �
° i3oisoo� �
� �
pm.w+xe ... �sws� ouo �rw 10Mq1 °"Ti °'°�'ue �
� i z9 2ais oioo �
�' Y 6z ao �ba _ Y �7 ['f o
' traa� rowsN+aa�wsnmNUC x�i� �7pit�� a� �.�1.i� 8A Mw s� �
0 10 HAGUE AV � `+ " �''
.�.ne. .owr aom�rs asm�coo�rw.ca
� 62� �„�� ST 2AUL +_,.,.• 10 SAEtATOGA
3
V q�p� f0lIIW OiM![{isnF1M�R.1 R�R til6f 0. i00� CN�6NU[BSE1411k1.T tLIIE 6Ati RbiAM IK�G1
61 O1 Z946210461819 MN B U1 19
Oacmnz iwta�s�eonawn wzao.nn� v�.••oos.uvn artarem eeroae
c � CHAD ROBERT SOHN30N 11 17 ?3
N u,Ma u u�
� 05 191 126TH LANE NW K: QI
� � � ' n' "�..a
QZ COON RAEIDS 55448 651-266-910Q
�� �. � �4 �4 06 OS NN �"` � E0"` 5a rm� �.wn ewer � emuo
O 1 -Y 7 M •
Ha.. mE aaua ,..8 ioMDW tR�uerom wraaNUmMCS. .NrfNLt � ,w.� � ,..r nwo. �craa�oAi o.narY.oMa KINMWu
`� ' 96 �` 98 N: Q�,'E„ � o�
w
om
ow.r amsxwaee - � w.sRwuc ne aw
Oi GITY OE ST PAOL� N STEWARD LAORA ANN N• Ok
�wm �°"m �°°°m 1� Olm
3g 1 N DALE ST N; 1522 HAGUE AVE
,wu. arcswc� ""�H°°�eer °"K.°"`.'. '„'a° 07 98�
�,3 5`C PApL MN 55103 't4': '07 ST EAUL MN 55104 '"�
ow.a
98 STftG STE 200 � TOYT I�.7CS 00 SIL 08
wo euier sr� nwaw �,,,�+o�aff� ,�,�, npa� nnu wn+aa ,,. �,,, 02 a2�'
O1 939183 l�l 9 02 02 • 850HGK MN 3 02
�� ��
C�TY OF ST PAUL �� UNiCN WN
ewoo euzu.r �ww reaoenw. ,«„wm. "••�PO "�•� •�
� � IfACC�HirYNOUl�ACO�HI£RCAiMOTORVEH1ClE,SCNOCLBU8.ORXE�D3TARTBf76� w�c no[
RFatFA16ERT01i0Y1FY7HE BTA7E PATROtI�Wfrod u�d�t N61t9.783 W 160.{if1J.
eow�eou�n.aewu�R�.wm+wmenwu� oatw..+ed o�etuvenaeN�a-umaacw�rnx.u[ ovt�aaem
..�u+�larwt�csf�s ' wr or an sm �we rsya uxr wxv:o Teuaron � �
q,.�, "° �� �
a�
Dy,� ,...rxnu nww�eo� �
Q� ��
, �a�y ese�AY�D� �wwaen' �
doaw
an�tecane�ow+lftDOnore7�nNro a�aVNOeoMaertrrumartYaswvnra�+C�ISI nua�emwaYex�wwwoalMafA _ �`
V
ISIf'I � 98
. O� �, .w
�� OtiIT E 3TRUCK VNIT 2 NHILE HAKING A RIGFtT TURN
p� � I oerro ttacoe �bi�s s�ian�bc�+, � a
O1 9"w`T°°+� - THB ROADS WERE COt/ERED IR iCE AS THBRE kTA3
wwoae . � ' FR&E&IHG itAlt+. �eu�
N� � _ 04
�� 'OHZ1` T NAS A ST PAIIL CITY SNOWPLON RRtlCK. „�
98 �� (jNi'f 2 frTAS LISTED 't0 1522 BAGUE, 801' THERB WAS �
� ._.--. —� — �� 8liSNER A4 THE A£SIDENCB,. �"�1°"
0$
� � � ND�CITATi0K5 WERE•ISSITBD, • �,i„�i
� � _. . _.
OS ' pq
OS -� ( . _ __ _.... „�
;� Y
1. ',� - oxoam
'�°"" �'i 06
Ol `�• ;
nmc. p.�nnwn� cax
arnuwxr.�xaaaueei � St Paul PD �iJ Q aasr Q m�cn�
OFFICER John Lacska 763 `A
� ��
httns:l/dvslesutmort.or�Idvsinfo/aceidentrecords 20Q8/lnclndes_LE/�'rintDVSReportTndiv... 1/29/2013
Gwen Ersbo 11:44:02 Tue Mar 05, 2013
CLAIM RECORD OF PAYN�NT DISPLAY
CLAIM: 00-345-018544 ST: 22 POLICY: 22-134774-01 INCURRED: 01/29/2013
INSURED: STEWARD, LAURA A BENEFITS/LOSSES PAID TO DATE: 1920.57
LEGAL EXPENSE: 0.00
MEDICAL EXPENSE: 0.00
OTHER EXPENSE: 0.50
LOSS PAYN�NTS CREDITS EXPENSE PAYMENTS
NO DATE PAYMT# TYPE ID PER AMOUNT AMOUNT AMOUNT
01 02/26/2013 0000275970 01 00 025 1920.57
IN PAYMENT OF: SEE ICS FOR PAYMENT DETAILS
PAYEE/PAYOR: HEPPNERS AUTO BODY
RECONCILED: 00 03052013 TIN: 411522313-1 WITH TAKEN: N
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
02 02/01/2013 0000208375 05 00 025 .50
IN PAYMENT OF: SEE ICS FOR PAYMENT DETAILS
PAYEE/PAYOR: ST PAUL POLICE DEPT
RECONCILED: 00 02202013 TIN: * NONE * WITH TAKEN: N
NEXT --
OPT -- POL -- ------ -- CLM -- --- ------ DRFT ----------
ALL PAYMENTS FOR THIS CLAIM HAVE BEEN DISPLAYED. PF3=COPS MENU PA2=COMPANY
ti '
HEPPNERS AUTO BODY DOWNTOWN
395 EAST 7TH ST
ST PAUL, MN 55101
PHONE:651-224-5644
*"*SUPPLEMENT 1 ***
RO# 14558 01/29/2013 12:14 PM
S1 02/04/2013 08:20 AM
,_.____
' Owner '
Owner: LAURA A STEWARD
Address: 1522 HAGUE AVE (651)747-3197
(651)647-9218
City State Zip: SAINT PAUL, MN 55104-6757 F��
-- — — -- -- — --- ----
� Control Information
Claim#: 00345018544-OC Insured Policy#: 2213477401
Loss Date/Time: 01/29/2013 06:00 AM Loss Type: Collision
Deductible: $500.00
Address: 6131 BLUE CIRCLE DRIE Work/Day:
City State Zip: Eden Prairie, MN 55344 F��
Insured: LAURA A STEWARD
Address: (651)747-3197
(651)647-9218
-- ___.__ . _.__ _ _ .________._.�^__�___�.
' Inspection __....._ _._ ..--.__� __.._..._ .�_---------_.�
Inspection Date: 01/29/2013 12:13 PM Inspection Type: Direct Repair Program
Inspection Location: residence Contact:
Address: 1522 HAGUE AVE (651)747-3197
City State Zip: SAINT PAUL, MN 55104-6757
Primary impact: Left Front Corner Secondary Impact:
Driveable: Yes Rental Assisted:
Assigned DatelTime: Received Date/Time: 01/29/2013 07:27 AM
First Contact Date/Time: Appointment Date/Time: 01/30/2013 06:00 AM
Appraiser Name: Bob Claudon Appraiser License#:
Adtlress: 395 East lth Street Work/Day: (651)224-5644
City State Zip: Saint Paul,MN 55101 FAX: (651)224-9451
Email: downtown@heppnersautobody.com
Orig Appraiser Name: Bob Ciaudon Appraiser License#:
Address: 395 East 7th Street Work/Day: (651)224-5644
City State Zip: Saint Paul, MN 55101 FAX: (651)224-9451
Email: downtown@heppnersautobody.com
_. _ _ _
_.___ __ _____ .____ .. ____ _
___ _--- _ _�...._. ,
_---- _._.._ __ _ ,
. Repairer �__ -----.,�_ ��------------'
__ __._�_._._,.._ _---
-
_. -------.
_._ _____----------- --- __ _
Repairer: Heppners Auto Body Contact: Heppners 7th tree
Address: 395 E.7th st Work/Day: (651)224-5644
Work/Day: (651)224-6042
City State Zip: Saint Paul, MN 55101 Work/Day:
Email: downtown@heppnersautobody.com
Repair Start Date/Time: 02/04/2013 08:20 AM Vehicle Drop Off DatelTime: 02/04/2013 07:30 AM
Repair Complete DatelTime: 02/06/2013 02:00 PM Vehicle Pick Up DateITime: 02/06/2013 04:30 PM
Target Complete Date/Time: 02/08/2013 05:00 PM Days To Repair: 5
Page 1 of 4
02/OS/2013 08:17 AM
2002 Toyota Camry LE V6 4 DR Sedan 01/29/2013 12:14 PM
Claim#: 00345018544-OC 02/04/2013 08:20 AM
�. _.._ _ ___ __ _.__.__ . _.__ _�..___.._... .._,.... __. _ _..___ ___._� .._..._____.._...__�
; Remarks i
Field Inspection
_.._____ _.__.___ ._� __._ _ . ___. _.----
_____ _-----__. . __ _ . _.-----____.
_ _.__ . _._ ___�.
_.. _---- _..__.__..__. __,
Vehicle '
2002 Toyota Camry LE V6 4 DR Sedan
6cyl Gasoline 3.0
4 Speed Automatic
Lic.Plate: 850-BGK Lic State: MN
Lic Expire: 08/2013 VIN: 4T1BF30K62U541457
Prod Date: 08/2002 Mileage: 77,986
Veh Insp#: Mileage Type: Actual
Condition: Good Code: Y17436
Ext.Color: Silver Int.Color:
Ext. Refinish: Two-Stage Int. Refinish:
Options
Air Conditioning AluminumJAlloy Wheeis Anti-Lock Brakes
Bucket Seats Center Console Compact Disc W/Tape
Cruise Control Dual Airbags Intermittent Wipers
Lighted Entry System Overhead Console Power Brakes
Power poor Locks Power Mirrors Power Steering
Power Windows Rear Window Defroster Rem Trunk-UGate Release
Split Folding Rear Seat Tachometer Tilt Steering Wheel
Tinted Glass U.S.A. Built Vehicle VelourlCloth Seats
_ __ . _ _.__ . __. _ ._---- _._.___
___ ___. ___. _____...__._..... ......... �
�_�_.. _..
Damages _ _ __ ;
Line Op Guide MC Description MFR.Part No. Price ADJ% B% Hours R
1 N 4 Frt Bumper Cvr Overhau Additional Labor 2.4 SM
2 E 6 46 Cover,Front Bumper 52119AA904 $293.73 INC SM
»PER DEBBIE @ KEYSTONE NO RECON AVAILBLE
3 L 6 13 Cover,Front Bumper Refinish 3.7 RF
2.6 Surface
0.6 Twastage setup
0.5 Twastage
4 E 561 46 Reinf,Frt Bumper Upr LT 52126AA020 $31.26 0.1 SM
5 L 561 Reinf,Frt Bumper Upr LT Refinish 0.3 RF
0.3 Surface
6 RI 38 Panel,Frt Bmpr License R 8�I Assembly 0.2 SM
7 RI 28 Griile Assembly R&I Assembly S1 0.3 SM
8 E 41 46 Headlamp Assy,Halogen LT 81150AA060 $302.11 INC SM
»APU SEARCH FOUND NOTHING-ACTION AUTO NONE
9 N 973 Headlamps Aim Additional Labor 0.4 SM
10 I 83 Panel,Hood Repair 3.0"` SM
11 L 83 10 Panel,Hood Refinish 3.2" RF
2.6 Surface
0.6 Two-stage
»PARTIAL PAINT FULL CLEAR
12 RI 1030 Nozzle,W/S Washer LT R&I Assembly S1 0.1 SM
13 RI 1031 Nozzle,W/S Washer RT R&I Assembly S1 0.1 SM
14 E 103 Fender,Front LT 53802AA020 $264.49 1.6 SM
»APU SEARCH NOTHING-ACTION AUTO NOTHING
15 L 103 Fender,Front LT Refinish 2.7 RF
02/08/2013 08:17 AM
Page 2 of 4
I
2002 Toyota Camry LE V6 4 DR Sedan 01/29/2013 12:14 PM
Claim#: 00345018544-OC 02/04/2013 08:20 AM
1.8 Surface
0.5 Edge
0.4 Two-stage
16 RI 313 Guard,Fender Mud LT R&I Assembly INC SM
17 RI 152 Skirt,lnner Fender LT R&I Assembly INC SM
18 BR 209 Pnl,Front Door Outer LT Blend Refinish 1.2 RF
0.8 Blend
0.4 Two-stage
19 RI 231 Pnl,lnner poor Trim LT R&I Assembly INC SM
20 RI 258 MIdg,Front Door Belt LT R&I Assembly 0.3 SM
21 RI 254 MIdg,Front Door Side LT R&I Assembly 0.4 SM
22 RI 229 Mirror,0uter R/C LT R&I Assembly 0.3 SM
23 RI 215 Glass,Front Door T LT R&I Assembly 1.1 SM
24 RI 227 Handle,Front Door Otr LT R&i Assembly 0.3 SM
25 L M08 Stoneguard Refinish S1 0.2* RF
»gravel guard fender bottom
26 L M14 Corrosion Protection Refinish 0.3' RF
27 SB M60 Hazardous Waste Removal Sublet Repair $3.00" SM
27 items
MC Message
10 INCLUDES AUDATEX TIME TO CLEAR ENTIRE PANEL
13 INCLUDES 0.6 HOURS FIRST PANEL TWO-STAGE ALLOWANCE
46 PRINTABLE ALTERNATE PARTS COMPARE
_ _...------__. _--- - -
' Estimate Total 8�Entries
Gross Parts $891.59
Paint Materials $348.00
Parts&Material Total $1,239.59
Tax On Parts Only @ 7.625% $67.98
Labor Rate Replace Repair Hrs Total Hrs
Hrs
Sheet Metal (SM) $50.00 4.8 5.8 10.6 $530.00
Mech/Elec(ME) $72.00
Frame(FR) $65.00
Refinish(RF) $50.00 11.6 11.6 $580.00
Paint Materials $30.00
Labor Total 22.2 Hours $1,110.00
Sublet Repairs $3.00
Gross Totai 52,420.57
Less: Deductible $500.00-
Net Total 51,920.57
Actual Supplement Total $33.32
Less: Previous Net Total $1,887.25-
Net Supplement Total (Final Bill) 533.32
Alternate Parts Y/03/00l00/03/03 CUM 03/00l00/03/03 Zip Code:55101 AmFamCAPA
Recycled Parts Y/0/0 Zip Code:55101 INV DATE:02/08/2013
Requested Review On: 02/07/2013 08:33 AM
Audatex Estimating 6.0.626 S1 02/08/2013 08:17 AM REL 6.0.626 DT 01/01/2013 DB 02/01/2013
Copyright(C)2011 Audatex North America,Inc.
OZl08/2013 08:17 AM Page 3 of 4
2002 Toyota Camry LE V6 4 DR Sedan 0112912013 12:14 PM
Claim�!: 00345018544-0C 02/04/2013 0820 AM
2.5 HRS WERE ADDED TO THIS ESTIMATE BASED ON AUDATEX'S TWO-STAGE REFINISH FORMULA.
THIS ESTIMATE MAY INCLUDE AFTER-MARKET OR CRASH PARTS SUPPLIED BY A SOURCE
OTHER THAN THE MANUFACTURER OF YOUR VEHICLE. THESE PARTS CAN BE IDENTIFIED
BY THE DESIGNATION "**QRP/QUALITY REPLACEMENT PARTS" ON THE ESTIMATE.
WARRANTIES APPLICABLE TO THESE REPLACEMENT PARTS ARE PROVIDED BY THE
MANUFACTURER OR DISTRIBUTOR OF THESE PARTS, RATHER THAN THE MANUFACTURER OF
YOUR VEHICLE.
FOR YOUR PROTECTION, MINNESOTA LAW REQUIRES US TO INFORM YOU: A PERSON WHO
SUBMITS AN APPLICATION OR FILES A CLAIM WITH INTENT TO DEFRAUD OR HELP CONIl�4IT
A FRAUD AGAINST AN INS.URER IS GUILTY OF A CRIME. ,
Op Codes
* = User-Entered Value E = Replace OEM NG= Replace NAGS
EC= Replace Economy OE= Replace PXN OE Srpls UE= Replace OE Surplus
ET= Partial Replace Labor EP= Replace PXN EU= RECYCLED PART
TE = Partial Replace Price PM= Replace PXN Reman/Reblt UM= Replace Reman/Rebuilt
L = Refinish PC= Replace PXN Reconditioned UC= Replace Reconditioned
TT = Two-Tone SB= Sublet Repair N = Additional Labor
BR= Blend Refinish I = Repair IT = Partial Repair
CG= Chipguard RI = R&I Assembly P = Check
AA= Appearance Allowance RP= Related Prior Damage
This report contains proprietary information of Audatex and may not be disclosed to any third party(other than
the insured,claimant and others on a need to know basis in order to effectuate the claims process)without
�Audatex Audatex's prior written consent.
d Su!e�n�V�npar�y
Copyright(C)2011 Audatex North America,Inc.
Audatex Estimating is a trademark of Audatex North America, Inc.
02l08/2013 08:17 AM Page 4 of 4
**"SUPPLEMENT RECONCILIATION"`**
Supplement S1
Claim#: 00345018544-0C Insured Policy#: 2213477401
File#: Claim Rep:
Insured: LAURA A STEWARD Inspection Date/Time: 01/29/2013 12:13 PM
Owner Name: LAURA A STEWARD
Appraiser Name: Bob Claudon
Vehicle: 2002 Toyota Camry LE V6 4 DR Sedan
__ _.. ___ _. _ __ _. __.. ______ _.__ __ ___ ._______. __ --- __..._ ____.__._.___._------_. --------_.,
Deleted Lines I
__..____ ----_ . _ __. _____. ----_.--_____. _._ __ _ __._ ______ _ ._._____ o_._..__..o_ _..-.—_— --____ _ .____
Line Guide Part Operation Price ADJ/o B/o Labor Rate
1 131 Brace,Front Fender LT Replace OEM $7.13 INC SM
_.. _ . _ .._.._. _ _ . .. .__.____.___._ __._..__----___
_. _ _ . ___._...--
�Added Lines _ _ � �
Line Guide Part Operation Price ADJ% B% Labor Rate
2 28 Grille Assembfy R&I Assembly S1 0.3 SM
3 1030 Nozzle,W/S Washer LT R&I Assembly S1 0.1 SM
4 1031 Nozzle,W/S Washer RT R 8�I Assembly S1 0.1 SM
5 M08 Stoneguard Refinish S1 0.2" RF
___-- ----__. __. _ _.. _--__----__...-----.._.__...__.� .__._.. . .._.-- - ------
� _,_._ _ _.__
--.
Calculation Changes___._
_.. _... _ ----__------------.__._. __...._.__.___ ._ ...___.._��_�__._ �..._ __._ _.�_ �_--.---____1
From To Difference
Gross PaRs $898.72 $891.59 $7.13-
Paint Materials $30.00 $342.00 $30.00 $348.00 $6.00+
Tax On Parts Only 7.625% $68.53 7.625% $67.98 $0.55-
SM-Sheet Metal $50.00 $505.00 $50.00 $530.00 $25.00+
RF-Refinish $50.00 $570.00 $50.00 $580.00 $10.00+
Actual Supplement 1 Net Total $33.32+
,_---__._.._._..._._....--......__.._.._..__...—_____._ __----- --.—.----__-____..__,.-----._._.__-----------------------�
SummarRi__._.. --. ___.------ ---------- ---- -----------------------_. -------- --�
--._._ _. _ ._
Net Total Date Time Appraiser
Original Estimate $1,887.25 01/29/2013 07:28 AM Bob Claudon
Supplement 1 $1,920.57 02/04/2013 08:20 AM Bob Claudon
This report contains proprietary information of Audatex and may not be disclosed to any third party(other than the
insured,claimant and others on a need to know basis in order to effectuate the claims process)without Audatex's
�A uda rex Prior written consent.
e 5��!e�e iV�npa:�t�
Copyright(C)2011 Audatex North America,Inc.
Audakex Estimating is a trademark of Audatex North America,Inc.
02/OSI2013 08:17 AM Page 1 of t
"'REVIEW*"
Claim#: 00345018544-0C insured Policy#: 2213477401
File#: Claim Rep:
Insured: LAURA A STEWARD Inspection DatelTime: 01/29/2013 12:13 PM
Owner Name: LAURA A STEWARD
Appraiser Name: Bob Claudon
Vehicle: 2002 Toyota Camry LE V6 4 DR Sedan
_
_ . _.. _ _ __. __ _ _.._ _. . _ _ _._ --.._..__ ..,
Summary _ _ _ _ _ _ _ '
_ _ -- -- .._ ------'
Date Time Net Total Updated By Type
02/07/2013 08:33 AM $1,920.57 Bob Claudon Supplement 1
01/30/2013 08:00 AM $1,887.25 Bob Claudon Original Estimate(before review)
__
__ __ . __....._.
_._ _.__... ___...... __ _ _ ._____ _.._....�.. _ ___._. -------,----
rDeleted Damages _.��_ __,_�� _____.__._ —J
Type Guide Part Operation Price ADJ°fo B% Labor Rate
SUP 131 Brace,Front Fender LT Replace OEM S1 $7.13 INC SM
_ _ _ ____ _ __._
Added Dama�es __ _._..._.
Type Guide Part Operation Price ADJ°/a B°/a Labor Rate
SUP 28 Grille Assembly R&I Assembly S1 0.3 SM
SUP 1030 Nozzle,W/S Washer LT R 8 I Assembly S1 0.1 SM
SUP 1031 Nozzle,W/S Washer RT R&I Assembly S1 0.1 SM
SUP M08 Stoneguard Refinish S1 0.2' RF
»gravel guard fender bottom
CalculationChanges_ ---- ___._ _— _.._.. - - _ _ _...__.__.�_----.---. J
From To Difference
Gross Parts $898.72 $891.59 $7.13-
Paint Materials $30.00 $342.00 $30.00 $348.00 $6.00+
Tax O�Parts Only 7.625% $68.53 7.625% $67.98 $0.55-
SM-Sheet Metal $50.00 $505.00 $50.00 $530.00 $25.00+
RF-Refinish $50.00 $570.00 $50.00 $580.00 $10.00+
-------------------_ ----------- ---_—°_---
Actual Supplement 1 Net Total $33.32+
Admin Changes From To
SUP Repair Start-Date: 02/04/2013
SUP Repair Start-Time: 08:20 AM
SUP Vehicle Pick Up-Date: 02/06/2013
SUP Vehicle Pick Up-Time: 0430 PM
SUP Repair Complete-Date: 02/06/2013
SUP Repair Complete-Time: 02:00 PM
Notes Added
This report contains proprietary information of Audatex and may not be disclosed to any third party(other than the
insured,claimant and others on a need to know basis in order to effectuate the claims process)without Audatex's
�Audatex Prior written consent.
d Solrie cu�r�pe;�v
— Copyright(C)2011 Audatex North America,Inc.
Audatex Estimating is a trademark of Audatex North America,Inc.
02/07/2013 0833 AM Page 1 of t
"'*REINSPECTION""
Claim#: 00345018544-OC insured Policy#: 2213477401
File#: Claim Rep:
Insured: LAURA A STEWARD Inspection DatelTime: 01l29/2013 12:13 PM
Owner Name: LAURA A STEWARD
Appraiser Name: Bob Claudon
Vehicle: 2002 Toyota Camry LE V6 4 DR Sedan
_ _ _ _ __ __ _
Summary _ _ _ _ _ _ -- __._ __.
Net Total Date Time Appraiser
Supplement 1 $1,920.57 02/04/2013 08:20 AM Bob Claudon
Reinspection $1,920.57 Bob Claudon
Difference $0.00
Percent Impact: 0.00%
Gross Total Date Time Appraiser
Supplement 1 $2,420.57 02l04/2013 08:20 AM Bob Claudon
Reinspection $2,420.57 Bob Claudon
Difference $0.00
Percent Impact: 0.00%
Counts: Admin 1
Vehicle 0
Rates/Repair Facility 0
Deleted Damages 0
Added Damages 0
Changed Damages 0
Damage Reasons Difference °/a Impact
Actual Reinspection Net Total $0.00+
Admin Changes From To
Owner-Type: F�
Number of Lines Changed: 1
Report Remarks Changes
From
To
Field inspection
Reason 15: -No changes made.
Comments:
This report contains proprietary information of Audatex and may not be disclosed to any third party(other than the
insured,claimant and others on a need to know basis in order to effectuate the claims process)without Audatex's
�'A uda tex Prior written consent.
e So�r���v���yd:�y
- Copyright(C)2011 Audatex North America,Inc.
Audatex Estimating is a trademark of Audatex North America,Inc.
02/08/2013 08:17 AM Page 1 of t
F e
� � . .. � C. . . . . .
'Y.�-!"��,,,j.�.
ti � �;
_ � ��
��
� ' t .d;:
�
�_,.
,.�-�'.
�..
;,s.
�?�
.. . � r--� � �� - - . . .
L
<...:��;.-..
ti�`
�
� �
�
r A���.
�,,;,r
,�_'
.. .. . .. . . � - +_... ..
.,. .— ._. - � �r^' _ .
�.�_ . ;:.y . . .
_ /% 1'
......�.._ -!
'
,+ %,
:+�
.. 'Jfj,,t�/]y f;;.� r �� .
�'.� �fl 'l.r�� ...�'^ /
�� _� /
� � •�'�y d�
--•---t
,A � __
.,� �t�_;.
� � ��
* -.:.,.r
.. � "'� ��,�
.._ - T �f � �r
�_
' � -
�
�
�
, .. _ ... .. �r}�¢.
� - - .. �\ ��� '�{t"° .
�:: -�a .�c.� ��, �, .
�°5 _r
@ ;�, ..�+, � , "•4. . . ' � . . . � . .- .._ _. .
yg ��� .
„ .,.: . _
ra
��„� ,
. . n� � . . . .y...,R�. � =.v..
r�n� ...
� � . �' �
; -.r i6��3,_.. � ,
�- - � ,, . _ . _. .,
. .,� . .
,.
..,,,� _ -
, � � ,.; ,.;�,, 'r
— .-., ..
.,. , .� , -- y �
^'�,� ,�_ _:�• �.� � ��ew�
� � -��-���,�°�� ��5
---, ' '" w..�h ��\
_ ._, a� M�',�;�-.�L-= -
-- �"s��,,;;*
� � �� �
�t. �K� `
,r ��
�y„� °
�I�����
�. ., ,..n � , f�� �
�'.
' t ;�-F � _ _ � � i��y��,�;y'�-��� ..
. -'�i '.. # ,
�^ _.._ . .�- :... ..`"
�i .a.
t ��
. � _._. ... , ..
_ -. ' _ . . _..— � �.ra,a,.y,.,._.,
'+ny
�_
� ... ;:�:.�.� �.
- ` -_ ��
t �- �;
,y, , ����I €
� �,
�
,�,�..
�: �
`" >���
�':� ��. �"i
_,. . , ,
. e�;:- »�:. �.
� � �
-x:.,' .. ,,f�, .
� �,yb
� �
- �` �3 ,.�,/�. ..J7"p�"
�k .. _ . �,'. ...s� 3� J� �"
r'�i"� N,,...,�
:' ..
,. „ 's
. J , .,..
� �
-w,+-