Barrett �
RECEIVED
APR 012013
CITY CLERK ��
NOTICE OF CLAIM FORM to the City of Saint Paul,Minnesots
Min+�esota Sura Smtate 466 OS states that"...tvery perton...who cTapns damagea from mry mwiicipaiity...alwll cauae to be pnacnted to the
gmerning baiY of dtt mrr�ticrpaluy wit7rin 180 days t�ler the aAegul lass or irykry rs dracouened o riotice sWtmg tbe time,Plac�.and
circwn�stances dtereof,and Nu a►r+o�nt af comptnsiotan or ot]ur relief denianded„
PleAee rnmpkte thi�form in its entaetY by clearl3'tyPmB or P��7oar answer to dkL question. Ii mort spnce is
needed,attadr additio�i sheets. Plea�e note that yon�►�1 not be rnntacted by telepho�to darify ans�re�s,so Provide as
mach miormation as neoeasarY b expla�Yon�'�and the amount of compmsation bdn�reqaested. Yoa�v�i reoeive a
written acknowkdgemem.once yoar form is re�xived. 'ILe proceua can talue ap to ten we�ks or longer depend'mg on the
natare oi yoar da�. '1Lis form�st be sip�ed,and boW pseea completed. If someth�g doe�not aPPI�',wri�e`N!A'.
SEND COMPLETED FORM AND OTHER DOCUMENTS TU: CITY CLERK,
15 WF�ST KELLOGG BLVD,310 CITY HALL,SAINT PAUL,MN 55102
p,�9rL�����. ►�re�t�.� A�st�
First Name �1� Middle Initial Last Name ��t�
Company or Business Name
Are You an lnsurance CamPanY? Yes/No If Yes,Claim Number? �° �io0� �"�`�I
Street Address `�
City
G State C'� tip Code fJ t�.5
Daytime Phone(_} - Cell P'hone U Evemng Telephone U
Date of Accide.nt/Injury or Date Discovered �� ���°
Please state,in detail,what occurre�(1�appened),and�'vhy you are submitting a claim.Please indicate why or how you
feel the City of Saint Pa C"1G��i����V����"• '��1b1�Cl.�x r�g�.
P'lease check the boa(es)t1�at most closely repnesent the reason far campleting this form: d�n a tow
�My vehicle was damag�ed in an accident ❑My vehicle was damagerl $
O My vehicle was damaged by a pothole or co�dition of the street �My vehicle was damaged by a plow
0 My velricle was wrongfully towed and/or ticketed ❑I was injured on City ProP�Y
O Other type of property damage—please specify
O Otber type of injury—please specify
In ordet to p�'ocess yout'Claim�nn npnil tn include covies oi all aoulicable docnments.
For the claims types listed below,please be sure to include the dnewnents indicated or it will delay the hancAing of
your cL�im. Documents QVILL NOT be returned and become the property of the City. You are encouraged W keep a
copy for youiself before submitting your claim form.
p property damage claims to a vehicle:two estunates foc the repairs to your vehicle if the damage eacceeds
$SOO.tlO;or the actual b�ls and/or receipts for the repaus
O Towing claims:legible copies of any ticket issued and a oopy of the impound lot receipt
O Other property damage claims:two repair estimates if the damage ezceeds$500.00;or the actual bills
and/ar receipts far the repairs;detailed list of damaged items
O Injury claims:nnedical bills,receipts
O Photographs are always welcome to docua�ent and support your claim but will not be retumed•
Page 1 of 2—Rease comglete and return both psges of Claim Form
Description of Loss: Our name insured's 2008 Chevrolet Silverado was stopped at a red light at
HWY 3fi EB. A 2001 Toyota Camry was stopped behind our insured's vehicle. A Saint Paul
Regional Water Service, 2009 Ford F250, license plate# 931650, was approaching our
insured's vehicle from behind. As our insured was waiting for the light to turn green, the 2009
Ford F25d was unable to slow down and strudc the 2001 Toyota Camry. The impact of the
collision pushed the Toyota Camry into our insured's vehicle. The driver, Peter Davis, is the
proximate cause of the accident for failing to maintain a safe distance and driver was inattentive.
�
Failure to camplete and return both pages wIll result in delay in the bandling of your claim.
All Cladms—ulease comulete thia section
Were there wimesses to the incident? Yes � Unlmown (circle}
Provide their names,addresses and telephone numbers:
Were the police or]aw enforcementc�e�d? Yes No Unl�own ircle}
If yes,what d�pariment ar agency? M N S'i7A.�•L Case#or report# E-� �
Where did the accident or injury take place? Provide street acldness,cross st�+eet,intersoction,narne of park ar facility,
closest landmark,etc. Please be as�eta_iled as p ble. If necessary,attach a diagam.
��.t`� `�l n Gt.�S K� 1 r� -
Please indicate the a�unt you are seeldng in c�t�'on�i hat you w+o�ild like the City to do t�resolve this claim
w your satisfaction. �' "1 ��D �° c-�
V���ms_ e�e co lete this on ❑check box if this secrion does not a 1
Yow Vehicle: Year Make Model G(
License Plate N State Color
Registered Owner
Driver of Vehick Y
Area Dama
City Vehicle: Year Make � Mode1 Z
License F1ate Number State Color
Driver of Vehicle(City F�nployee's Name)
Area Damaged
Iniurv Clsim$ ple�e eomvl�e this s�ian ❑check boa if this section dces not a�ulv
How were you injured?
What part(s)of your body were injured?
Have you sought medical treatment? Yes No P9anning to Seek Treatiment(circle)
vide date(s)}
When did you reveive treatment? �°
Name of Medical Pmvider(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 Fanployer:
Address Telephone
❑Check here if you are attaching mo�e pages to tliis cla�m form. Number of additional pages
By s+ignYrig d+is.form,you are stating dia�t all ir{�'ormahion you have�_' e and correct to tlre best
of your knowledge. Unsigned forms will not be process� /
5ubmitbirig a false cJarm can result in prosecution. Date form was ca�gleted �U '��-
Print the Name of the Person who Comple F f�l S �b 0
Signature of Person Making the C1sim. --
Revised Pebnzery 2011
�1�i��?��.r��i���
Payment Address Document Address
24344 Network Place P.O.Box 512929
Chicago, IL 60673-1243 Los Angeles,Ca 90051
Phone:(877)818-0139
Fax:(888)781-6947
3/16/2013 10:29:00 AM
Certified Mail 91 7108 2133 3934 2561 6684 Return Reoeipt Requested
CITY OF ST PAUL
CITY CLERK OFFICE
310 CITY HALL
15 WEST KELLOGG BLVD
ST PAUL MN 55102
Your Client: DAVIS, PETER
Your Ciaim Number: UNKNOWN
Our Insured: BARRETT, SCOTT
Our Claim Number: 13-3604804
Amount Subject to Reimbursemerrt: 7,365.28
Amount of Insured's Deductible: 500.00
Please take this as formal notice of our subrogation rights relative to the above -captioned
claim. We have completed our investigation into the facts of the above-captioned loss and find
that your insured was the proximate cause of the accident.
Location of Loss: HWY 36 EASTBOUND
Date and Time of Loss 02-01-13 @ 1:30 PM
Description of Loss: Our name insured's 2008 Chevrolet Silverado was stopped at a red light at
HWY 36 EB. A 2�1 Toyota Camry was stopped behind our insured's vehicle. A Saint Paul
Regional Water Service, 2009 Ford F250, license plate# 931650, was approaching our
insured's vehicle from behind. As our insured was waiting for the light to turn green,the 2009
Ford F250 was unable to slow down and strudc the 2001 Toyota Camry. The impact of the
collision pushed the Toyota Camry into our insured's vehicle. The driver, Peter Davis, is the
proximate cause of the accident for failing to maintain a safe distance and driver was inattentive.
Please make your draft payable to Progressive Preferred Insurance Co as subrogee of "
BARRETT, SCOTT
", in the amount stated above and mail it to the attention of the undersigned at your earliest
convenience. All supporting documentation is enclosed. I have diaried my file ahead fifteen (15)
days. Th k you f o antici ate , prompt attention to this matter.
`�
Chris op er Woolfolk
Subrogation Representative
Progressive Preferred Insurance Co
Tel. 877-818-0139 Ext 37806
Fax. 888-781-6947
Email: Christopher_Woolfolk@progressive.com
March 05, 2013, 13:17:28
CMSD2340 /CMSM2340 P A C M A N MAR 05 13 - 13:17
OPID: A088515 CLAIM PAYMENT INQUIRY TERMID: ?03N
INSD: BARRETT, SCOTT POL: 900129334-3
DOL : FEB O1 13 MN-ROSE W-GRP-A CLM: 133604804 OPEN REP: J BUCHANAN
PAY TO THE ORDER OF: TOTAL DRAFT AMOUNT: 5,795. 45
LINE 1• SCOTT BARRETT AND *****************************************
LINE 2 : HERITAGE AUTO BODY, INC. , ONLY *****************************
LINE 3:
ADDRESS: 6487 PHEASANT HILZS DR
CITY: LINO LAKES ST/PR* MN ZIP/CPC: 55038 CNTRY* USA
IN PAYMENT OF: COLLISION - 2006 CHEVROLET SIZVERADO - LESS $500 DED
1099 ? Y FEDERAI� TAX ID: 411582605 LAST UPDT REP: TCC0008
CDS CODE * 13 PCL EFT TRACE #: ISSUING REP: T CLARK
BANK CODE* AS2 ISSUE DATE : FEB 05 13 APPROVED BY:
STATE * MN AREA * REVIEW DATE: 00 00
STOP RSN * DRAFT # : 477101231 REVIEWED BY:
COMMAND:
March 05, 2013, 13:17:24
CMSD2340 /CMSM2340 P A C M A N MAR OS 13 - 13:17
OPID: A088515 CLAIM PAYMENT INQUIRY TERMID: ?03N
INSD: BARRETT, SCOTT POL: 900129334-3
DOL : FEB O1 13 MN-ROSE W-GRP-A CLM: 133604804 OPEN REP: J BUCHANAN
PAY TO THE ORDER OF: TOTAL DRAFT AMOUNT: 517. 30
LINE l: HERITAGE AUTO BODY, INC. , ONLY ****************************
LINE 2 :
LINE 3:
ADDRESS: 6487 PHEASANT HILZS DR
CITY: LINO LAKES ST/PR* MN ZIP/CPC: 55038 CNTRY* USA
IN PAYMENT OF: SUPPLEMENT - 2006 CHEVROLET SIZVERADO
1099 ? Y FEDERAL TAX ID: 411582605 LAST UPDT REP: TCC0008
CDS CODE * 13 PCL EFT TRACE #: ISSUING REP: T CLARK
BANK CODE* AS2 ISSUE DATE : FEB 14 13 APPROVED BY:
STATE * MN AREA * REVIEW DATE: 00 00
STOP RSN * DRAFT # : 477262453 REVIEWED BY:
COMMAND:
March 05, 2013, 13: 17:20
CMSD2340 /CMSM2340 P A C M A N MAR 05 13 - 13: 17
OPID: A088515 CLAIM PAYMENT INQUIRY TERMID: ?03N
INSD: BARRETT, SCOTT POL: 900129334-3
DOZ : FEB O1 13 MN-ROSE W-GRP-A CLM: 133604804 OPEN REP: J BUCHANAN
PAY TO THE ORDER OF; TOTAL DRAFT AMOUNT: 552. 53
LINE l: HERITAGE AUTO BODY AND SCOTT BARRETT, ONLY.****************
LINE 2:
LINE 3:
ADDRESS: 520 COON RAPIDS BLVD NW
CITY: COON RAPIDS ST/PR* MN ZIP/CPC: 55433 CNTRY* USA
IN PAYMENT OF: COZL-06 CHEV SILVERADO-SUPP#4
1099 ? Y FEDERAL TAX ID: 411582605 LAST UPDT REP: KXR0105
CDS CODE * 13 PCL EFT TRACE #: ISSUING REP: K REICH
BANK CODE* AS2 ISSUE DATE : FEB 20 13 APPROVED BY:
STATE * MN AREA * REVIEW DATE: 00 00
STOP RSN * DRAFT # : 477260172 REVIEWED BY:
COMMAND:
Date: 2/'L1/2013 03:39 PM
Esfim�e ID: 13-3604804-01 li
Estlmate Versim: 4 ,
Supplernent: 4(F F) 2/20/2013 03:48:04 PM
Protile ID: 'Metro AIIExcept7.1
l��6�ES�111E
Damape Assessed By: TREVOR CLARK 'Claim Rep: Trevor Clark
(763)286-20�
Supplemented By: KEVNV REICH
'Product Type Auto
`Date d Loss: 2/1/2013
'Deducd�: 500.00
'Claim Number: 13-36D4804-01
Irsured: SCOTT BARRETT
Claimard: SCOTT BARRETT
Address: 6487 PHEASANT HILLS DR,LINO LAKES,MN 55038
Telephaie: Home Phaie: (651)307-8594
Owner: SCOTT BARRETT
A�reea: 6487 PHEASANT HILLS DR,LNO LAKES,MN 55038
Telephone: Home Phane: (651)307•8594
Mi[chell Service: 915495
DescripUm: 2006 Chevrdet Pickup S�verado K1500 LT Vehic�Production Date: 12I05
Body Style: 4D PlaipCrw 6'Bed 144'W B Drive Tr.�: 5.3L hj 8 Cyl 4W D
V�I: 2GCEK13Z261254306 License: TME536 MN
Mileage: 112,805
OEM/ALT: A SearchCode: ARDENHILL2
Cda: SILVER
Opdons: PASSENGER AIRBAG,DRIVER AIRBAG,POW ER LOCK,POW ER W INDOW,POWER STEERING
REAR WINDOW DEFOGGER,MANUAL AIR CONDITION,CRUISE CONTROL,TILT STEERING COLUMJ
ANTI-LOCK BRAKE SVS.,LEATHER STEERING W HEEL,CHROME W HEELS,4W D OR AW D
FRONT AIR DAM,TINTEO GLASS,ANTI-THEFT SYSTEM,AUTOMATIC HEADLIGHTS
INTERIOR AUTOMATIC DAY/NIGHT OR ELECTROCHROMATIC MIRROR,DAYTIME RUNNING LIGHTS
AMlFM STEREO CD,ELECTRONIC SHIFf TRANSFER CASE,FRONT SPLIT BENCH SEAT
KEYLESS ENTRY SYSTEM,POWER HEATED EXTERIOR MIRRORS
line Entry Laba Line ftem Par[Type/ Ddlar Labor
Rem Number Type Opera[ion Description Part Number Amourit Units
- Air Baa Sv9tem
S4 1 500325 MCH REMOVE/REPLACE Air Bag System Diagnosis -M 0.5 U
S4 2 506931 MCH REMOVE/REPLACE L Frt Air Bag Sensor -M ORDER FROM DEALER 250.� 0.6
wne•i
3 500419 BDY REMOVE/INSTALL SpareTire/Wheel 0'2
Csb
4 502925 BDY REPAIR Otr Cab Back Panel Epsting �•5��
5 REF REFINISH Cab Back Panel Outside C 2.4
S3 6 502927 BDY REPAIR L Otr Cab Side Parrel Eristirg 8.0'g
7 REF REFlNISH l Cab Side Panei C 1.4
g - kicludes Pull As Needed
g 502939 BDY REMOVFJREPLACE L Cab Roof Moulding(Adhesive) 15045551 GM PART 22.87 02
10 502961 BDY REMOVElINSTALL L Rear Cab Pillar Trim Ebs[ing 0.3 r
11 502962 BDY REMOV EiINSTALL Lwr C�Rear W kdow Moulding E�dsting 02 r
Rear poor
12 503104 REF BLFND L Rear pou Ou[side C 1.0
13 505189 BDY REMOVE/INSTALL L Rear O[r Bel[Moulding �'2
14 503123 BDY REMOV E/INSTALL L Rear Dm Adhesive MoukJ�g E�asstirg 02 r
�5 - Added 2 ro Clean/RaTape
�g BDY ADD'L LABOR OP L Rear poor Adhesive Mouldk�6 0.2�
17 503163 BDY REMOVEJINSTALL L Rear poa H�dle 0.7 x
18 5D3198 BDY REMOVE/INSTALL L Rwr poor Glass Run Ebsting 0.2 #r
�9 - Drop For Retir�sh
Beck Wirdow
20 503212 GLS REMOVEIINSTALL Back Window 2'4 g
P'ickuo Bed
p� REF REFINISH T�Iga[eCampl�e � 2'�
EST IMAT E RECALL N Uu16ER: O7J05I2013 14:38:45 1�36D4804-01
Mi[chall Data Version: OEM: DEC_t2_V0206
MAPP:DEC_12_V0203 Copyri�t(C)1994-2012 MitcheA IMertiaGaial Page 1 of 5
Softwara Version: 7.0.463 All RigMs Reserved
Date: 2/212013 03:39 PM
Eatima[e ID: 1 3-36 0 4604-Ot
Estimate Version: 4
SupplemeM: 4(F F) 2l20l2013 03:48:04 PM
Prot�e I D: 'Metro AilExcept7.1
22 501494 REF B�END L Bed Fuel Door �� �
S4 23 501506 BDY REMOVE/REPLACE L Pickup Bed Side Panel Assy 88980680 1,116.38 ' 13.0 g
24 REF REFINISH L Bed Outer Side Paiel � Z•6
25 REF REFINISH L Bed Side Panel Inside C 1.4
26 501510 BDY REPAIR L Inr Rckup Bed Wheelhouse Panel Existing 2.0"
27 - Spot Relinieh
28 REF REFINISWREPAIR L Inr P'icla�p Bed Wt�eelhouae Panel C 0.3'
2g MODIFlED REFINiSH W ITH FULL CLEAR COAT
S3 30 501514 BDY REPAIR Pickup Bed Sill Par�l E�dstirg 5.0'�
3� - Includes Pull As Needed
32 REF REFINISWREPAIR Pickup Bed Sill Panel C 0.8'
33 MODIFlED REFINISH WITH FULL CLEAR COAT
34 501515 BDY REMOVEIINSTALL L Pickup 8ed Fuel Door Ebsting INC r
35 501519 BDY REMOVEIREPLACE L Rear Pick�Bed Brace 15072625 GM PART 40.58 02
36 501520 BDY REMOVE/REPLACE Taik�ateShell UsedlRecycled 325.00 ' 0.9
37 -PMA'S-324363-0000-JASON-�778730
38 Line Mark�%30.00 97.50
39 505369 BDY REMOVE/INSTALL L Upr Pickup Bed Wbuldiig 0.4
40 501562 BDY REMOVEIREPLACE Tailgate Adhesive Nameplate 15114063 GM PART 5622 0.1
q� - 51LVERADO'
42 505997 BDY REMOVEIINSTALL Taxieau Cover E�dsting 0.9 r
Rser Lemos
S1 43 506489 BDY REMOVE/REPLACE L Rear Combination Lamp AsaemWy Used/Recycled 8�.00 ' INC i
44 -A.A.A.-651-423-2432-RYAN x1871539
Si 45 Line Markup%30.00 25.50
Rasr Bunwa
46 BDY OVERHAUL Rear Bumper Aesy �•�
47 501885 BDY REMOYE/REPLACE Rear Bumper Face Bar 12496085 GM PART 525.13 INC
48 Rear Step Burtpc�Kd(Chrome)
TIR ES
49 900500 MCH REMOVE/REPLACE Frestaie Destir�ian LE 265�65R18 S "Non-OEM 162.07
50 936012 ADD'L COST HAZARDOUS WASTE DISPOSAL 3•� '
ADDRIONAi OPERATIONS
51 REF ADD'L OPR Clear Coat 2•9
'ionsl Costs&Neterids_
�2 ADD'L COST PainUMateri�s 4�'� '
53 90D500 GLS' REMOVElREPIACE URETHANE KIT-Back Glass Sublel 25.00 ' 0.0'
54 900500 BDY' ADD'L LABOR OP COVER CAR FOR OVERSPRAY "t�n-OEM 7.`.�0 ` �2'
55 900500 BDY` REMOVE/REPLACE CORROSION PROTECTI�J "Nm-OEM 7.`.�0 ' 0•3'
56 900500 BDY' ADD'L LABOR OP MOUNT&BALANCE II+�LUDES STEM&WEIGHTS Sublel 18.50 ' 0.0`
MANUAL ENTRIES
S2 57 900500 BDY' REMOVEJREPLACE TOW BILL-TAXABLE t TIME ONLY Sublet 514.96 ' 0.0"
S2 58 900500 BDY' ADD'L LABOR OP SET UP&MEASURE INJIBODY/FULL FRAME Epsting Z•0�
59 Includes all nwessary operadms except pull time
S2 60 900500 FRM' REPAIR PULUSQUARE UNIBODY/FRAME-4 Critrl P[s Ebsting 6.0'
61 - L Rear Rail-SAGO Upward
gp - Er�re Frartre-TW IST / Er�re F2me-DIAMOND
'-Judgmem Item
#-Labor Note Applles
C-Included In Clear Coat Calc
r-CEG R&R Time Used For This Labor Operatbn
Remarks
AIM PARTS DECLINED
All manufacturers requirements regarding seat belt and supplemental
restraint system replacement must be adherecl to. If additional parts
or operations are necessary to properly accomplish this, please
contact the estimating claims rep.
ESTIMATE RECALL NIMBER: 02/05/2013 14:38:45 1�3604804-Ot
MitcheA Da[a Veraion: OEM: DEC_12_V0206
MAPP:DEC_12_V02IXi Copyri�t(C)1994-2012 NY[chell Intematiaial Page 2 ot 5
Soflware Version: 7.0.483 All Ri�ts Reserved
Date: 2121/2013 03:39 PM
Esdma[e ID: 13-3604804-Ot
EsMnate Version: 4
Supplement: 4(F F) 2/20/2013 03:48:04 PM
Prot�e ID: 'Metro AIIExcepl7.1
�Tot�
,�,
Laba Sublet
L Labor Subtd�s Uni[s Rate Amount Amount Tohals II. Part Replacernert Summary Artaurrt
Body 37.6 52.00 0.00 18.50 1,973.70 Taxable Parts 2,62325
Refinish 15.1 52.00 0.00 0.00 785.20 Parle Adjustrnenls 123.00
Glass 2.4 52.00 0.00 0.00 124.80 Sales Tax � 7.125Wo 195.67
Frame 6.0 75.00 0.00 0.00 450.OD
Mecharical 1.1 80.00 0.00 0.00 88.00 Non-Taxable Parts 514.96
Non-Taxahie La6or 3,421.70 To[al Replacemeri Parts Amourd 3,456.88
Labor Summary 622 3,421.7D
III. Additimal Costs Amamt IV. Adjus6nerrts Amoun[
Non-Taxable Costs 486.70 kisurance Deductible `�•�
Tohal Additiorel Costs 486.70 Custamer Respmsibiliry `�.04
Pairrt Ma[erial Me[hod:R�es
krt Ra�e=32.00
I. Tdal Labor: 3,421.70
II. Tdal Rephacernait Par[s: 3,456.88
III. Total Addbor�l CosLs: 486.70
dross Tdal: 7,3&528
IV. Tdal Adjuetmerts: `�.�
r�c ra�: s,sssza
Less Original Net Tdal: 5,854.62
Net Supplerrcent Amaurt: 1,010.66
S1: TREVOR CLARK 59.17-
S2: TREVOR CLARK 517.30
S3: TREVOR CLARK 0.00
S4: KEVIN REICH 552.53
Poiri�s)01 Impact
7 Lett Rear Caner(P)
Inepec[iorn Site: HERITAGE AUTO BODY
Inspection Date: 2!5l2013
EST IMAT E RECALL N IMBER: 0?J05/2013 14:38:45 133604804-01
Mitchell Data Version: OEM: DEC_12_V0206
MAPP:DEC_12_V0203 CapyrigM(C)1994-2012 A�titchell Intemational Page 3 oi 5
Software Version: 7.0.483 All Rights Reserved
Date: 2/21/2013 03:39 PM
Estlmate ID: 13-360480401
Estimate Version: 4
Supplement: 4(F F) 2120/2013 03:48:04 PM
' Prot�e ID: 'Metro AIIExcept7.1
THIS IS A DAMAGE ASSESSMENT ONLY - NOT AN AIITHORIZATION TO REPAIR -
BASED ON DAMAGE VISIBLE OR CERTAIN AT THE TIME IT WAS WRITTEN.
IF FRAME OR UNIBODY REPAIR IS INCLUDED ON THIS ESTIMATE, THE AMOUNT
SHOWN INCLUDES TIME OR ALLOWANCE FOR MEASURING BEFORE, DURING AND
AFTER THOSE REPAIRS.
THE OWNER OF THE VEHICLE MAY SELECT THE REPAIR FACILITY OF HIS/HER
CHOICE.
TO ENSURE PROPER AND PROMPT PAYMENT FOR ADDITIONAL DAMAGE DISCOVERED
DURING THE COURSE OF REPAIRS, CONTACT PROGRESSIVE FOR SUPPLEMENT
HANDLING PR�EDURES.
PROGRESSIVE HONORS THE PREVAII�ING �BOR MARKET RATE IN YOUR AREA FOR
YOUR PROPERTY. IF YOU CHOOSE A SHOP THAT CHARGES IN EXCESS OF
PREVAIL2NG LABOR MARKET RATES, YOU WILL BE RESPONSIBLE FOR THE
DIFFERENCE.
LIFETIME GUARANTEE FOR SHEET METAL AND PLASTIC BODY PARTS
The replacement parts written on the estimate are intended to return
your vehicle to its pre-loss condition with proper installation.
After repair, if any sheet metal or plastic body part included in the
estimate fails to return your vehicle to its pre-loss condition
(assuming proper installation), in terms of form, fit, finish,
durability or functionality, Progressive will arranqe and pay for the
replacement of the part, to the extent not covered by a
manufacturer's or other warranty. This service will be performed at
no cost to you (including associated repair and rental car costs} . To
obtain service under this Guarantee, call Progressive at
1-800-274-4641. This Guarantee applies as long as you own or lease
the vehicle. This Guarantee is not transferable and terminates if you
sell or otherwise transfer your vehicle.
THIS GUARANTEE DOES NOT COVER NORMAL WEAR AND TEAR OR DAMAGE CAUSED
BY IMPROPER MAINTENANCE, NEGLECT, ABUSE OR SUBSEQOENT ACCIDENT. THIS
GUARANTEE IS LIMITED TO ARRANGING FOR THE SELECTION OF REPAIR PARTS
THAT WILL RETURN YOUR VEHICLE TO ITS PRE-LOSS CONDITION, ACCORDINGI�Y.
PROGRESSIVE WILL NOT BE LIABLE FOR ANY INDIRECT, INCIDENTAL OR
CONSEQUENTIAL DAMAGES THAT RESULT FROM THE INSTALLATION OR USE OF
THESE PARTS.
Part Type Terms and Abbreviations
NEW and OEM or part number displayed - These refer to a new, original
equipment manufacturer part.
NON-OEM and A/M and Qual REPL - These refer to an after-market part,
which is a new, non-oriqinal equipment manufacturer part.
USED/RECYCLED and LKQ - These refer to a used OEM part.
REMANUFACTURED and RECOND, and RECORE - These refer to used/recycled
OEM parts that have been refurbished.
REPAIR SHOP'S AUTHORIZED REPRESENTATIVE'S SIGNATURE INDICATING
AGREEMENT ON COST TO RETURN THE VEHICLE TO PRE-LOSS CONDITION
INCI,UDING TOW/STORAGE CHARGES:
SHOP SIGNATURE: EST. COMPLETION DATE:
ANY PERSON WHO. WITH INTENT TO DEFRAUD OR KNOWING THAT HE/SHE IS
FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION OR
FILES A C�.IM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUIZTY OF
EST IMAT E RECALL N Uu16ER: 07105/2013 1 d:38:45 1�3604804-01
MitcheA Data Veraim: OEM: DEC_12_V0206
MAPP:DEC_12_V0203 Copyri�t(C)1994-2012 MRchell Intematiorol Page 4 ot 5
Software Version: 7.0.483 All Rights Reserved
Date: 2/`21/2013 03:39 PM
Eslim�e ID: 1&360480401
Estimate Version: 4
S�plemerrt: 4(F F) 2/20/2013 03:48:04 PM
Prottle ID: 'Metro AIIExcept7.1
INSURANCE FRAUD,
Event Log
File Geated: 02l05/2013 12:14:01 PM
Es6mate Star[ed: 02l20/2013 03:39:19 PM
Estimate Printed: Estlm�e nd prirrted
Estimate Cortxnit[ed: 02l20/2013 03:54:06 PM
EsBmate Upl�d: 02P21l2013 03:38:54 PM
ESTIMATE RECALL NIMBER: O7J05/2013 14:38:45 133604804-01
MitcheA Daza Version: OEM: DEC_12_V0206
MAPP:DEC_12y0203 Capyri�t(C)1994-2012 Aktchell Intematiaial Page 5 ot 5
Sottvrare Version: 7.0.483 All Ri¢�ts Reserved
Dabe: 2/'21/2013 03:39 PM
Esfim�e ID: 13 3604804-01
Estirnate Version: 4
Supplemerrt: 4(F F) 2120/2013 03:48:04 PM
Proide ID: 'Metro AIIExcept7.1
�i,�,�
Supplanent Depa Repart
Corr�arison ot Estimate 13-3604804-01 Supplemert 0 and SupplemerN 4
Damage Assessed By: TREVOR CLARK
Supplemented By: KEVIN REICH
IrBUred: SCOTT BARRETT
Owner: SCOTT BARRETT
Vehicle Descrip6on: 2006 Chevrde[Pickup SiNerado K1500 LT
"Date ot Loss: 2!1l2013
Line Laba Line Item Ddlar Labor CEG
ftem Type Operatim Descripbon Par[Type Amount Uni[a Urit
Added Entries
S4 1 MCH REMOVElREPLACE Air Bag System Diapnosis -M 0.5 0.5
54 2 MCH REMOVE/REPLACE L Frt Air Bag Sensor -M OROER FROM DEALER250.W 0.6 0.6T
3 BDY REMOYEJINSTALL SpareTiraNV(hael 02 02
4 BDY REPAIR Otr Cab Back Pa�l Exishn9 ��`'� 9.5
5 REF REFINISH Cab Back Panel Outside C 2.4 2.4
S3 6 BDY REPAIR L Oh Cab Side Panel Ebsting 8.0' 8.5
7 REF REFINISH L Cab Side Panel C 1.4 1.8
g - Includes Pull As Needed 0.0
9 BDY REMOVElREPLACE L Cab Root Mouldirg(Adhesive) 15045551 GM PART 22.87 02 02T
10 BDY REMOVE/INSTALL L Rear Cab P�ar Trim Epsbrg 0.3 0.3
11 BDY REMOVElINSTALL LwrCabRearWindowMwldir� Epsting 02 02
12 REF BLEND L Rear poor Outs�e C 1.0 2.6
13 BDY REMOVEJINSTALL L Rear Otr Belt Mould'sg 02 02
14 BDY REMOVE/INSTALL L Rear poor Adhesive Moulding Existing 02 02
15 - Added 2 to Clean/Re•Tape 0.0
16 BDY ADD'L LABOR OP L Rear Door Adhesive Mwldirg 0�2'
17 BDY REMOVE/INSTALL L Rear poor Harde 0.7 0.7
18 BDY REMOVE/1NSTALL L Raar poar Cilass Run Ebsting 02 02
�g • Drop Fa Relirish 0.0
20 GLS REMOVE/INSTALL BackWfndaw 2.4 2.4
2t REF REFINISH Tailgate Complete C 2.1 2.5
22 REF BIEND L Bed Fuel Door INC 0.5
S4 23 BDV REMOVE/REPLACE L Picla�p Bed Side Pariel Assy 88980680 1,116.38 ' 13.0 13.OT
24 REF REFINISH L Bed Ou[a Side Panel C 2.8 32
25 REF REFINISH L Bed Side Panel Inside C 1.4 1.4
26 BDY REPAIR L In Pickup Bed Wheelhouse Panel Ebstirg 2.0' 2.0
p� - Spat Relinish 0.0
28 REF REFINISWREPAIR L Irr Pickup Bed Wheelhwse Panel C 0.3' 1.0
pg MODIFIED REFINISH WITH FULL CLEAR COAT 0.0
S3 30 BOY REPAIR Piclwp Bed Sill Panel Ezisting 5.0` 4.5
31 - Inck�des Pull As Needed 0.0
32 REF REFINISWREPAIR Piclap Bed SiN Panel C 0.8' 1.0
33 MODIFIED REFINISH W ITH FULL CLEAR COAT 0.0
34 BDY REMOVElINSTALL L Pickup Bed Fuel Door Epslirg INC 0.3
35 BDY REMOVE/REPLACE L Rear Pickup Bed&ace 15072625 GM PART 40.58 02 02T
36 BDY REMOVElREPLACE Tailg�e Shell U�d/Recycled 325.00 ' 0.9 12T
g� PAM'S-320-363-0000-JASON-5778730 0.0
38 Line Marlaip%30.00 97.50 0.0
39 BDY REMOVEJINSTALL L Upr Pickup Bed Mouklirg 0.4 0.4
40 BDV REMOVE/REPLACE Tailga[e Adhesive Namep�ate 15114063 OM PART 5622 0.1 02T
q� - •SILVERADO' 0.0
42 BDY REMOVE/INSTALL Tomeau Cwer E�°5��� 0'9 0'9
S1 43 BDY REMOVE/REPLACE L Rear Canbination Lamp Assembly Used/Recycled 85.(Hl ' INC 0.3T
44 -A.A.A.-651-473-2432-RYAN-N7871539 0.0
S1 45 Line Markup Wo30.00 25.50 0.0
ESTIMATE RECALL NUMBER: 2/5/2013 1 4:36:45 13-3604804-01
Saftware Version: 7.0.483 Copyri�t(C)1994-2012 MitcheN Intematiaial Page 1 of 2
All RigMs Reserved
Date: 2/21/2013 03:39 PM
Estim�e ID: 1&3604804-01
EstKnate Versian: 4
Supplanent: 4(F F) 2I20/2013 03:48:04 PM
Protde ID: 'Metro AIIExcepl7.1
46 BDY OVERHAUL Rear Burtp�Assy �•� ��2
47 BDY REMOVFJREPLACE R�r Bumper Face Bar 124�085 GM PART 525.13 INC 12T
48 - Rear Step Bumper Kit(Chrome) 0.0
49 MCH REMOVE/REPLACE Firestone Destination LE 265J65R18 S 090177 162.07 0.0 T
50 ADD'L COST HAZARDOUS WASTE DISPOSAL 3.50 ' 0.0
51 REF ADD'L OPR Gleaz Co� 2•9
52 ADD'L COST ParY/M�erials 48320 ' 0.0
53 GLS REMOVE/REPLACE URETHANE KIT-Back Glass Sudet 25.00 ' 0.0" T
54 BDY ADD'L LABOR OP COYER CAR FOROVERSPRAY "Non-OEM 7.50 ' 02' T
55 BDY REMOVEIREPLACE CORROSION PROTECTION "Nm-OEM 7.50 ' 0.3' T
56 BDY ADD'L LABOR OP MOUNT 8 BALANCE INCLUDES STEM 8 WEIGHTS Sublet 18.50 ' 0.0' T
S2 57 BDY REMOVE/REPLACE TOW BILL-TAXABLE 1 TIME ONLY Sudet 514.96 ' 0.0"
S2 58 BDY ADD'L LABOR OP SET UP 8 MEASURE UJIBODY/FULL FRAME Existing 2A'
59 Includes all necessary aperatiais except pull dme 0.0
S2 60 FRM REPAIR PULLlSQUARE UNIBODY/FRAME-4 Crirl Pts Ebs6ng 6.0'
g� - L Rear Raa-SAGG Upward ���
gp Errtire Frarne T W IST / Erii►e Frame-D IAMOND 0.0
Global Charc�es
Deductide From: To:
0.00 500.00
Laba Rates From: To: Adjustrnerts From:_ To:.
Bady 0.00 52.00
Relirish 0.00 52.00
Glass 0.00 52.00
Mechanical 0.00 80.00
Fr�ne 0.00 75.00
Bady-S 0.00 52.00
Estimate protile calculation settings(o[her than laba r�es and adjustmer�ts)have changed.
Amount
Origirral Estimate: 5,854.62
Supplemert 1 59.77-
Supplemeri 2 517.30
Suppemert 3 0.00
Suppletnert 4 552.53
Supp 4 Tot�Tax 195.67
Net Supplemerrt Amourt 1,010.66
Net Tatal 6,865.28
Prograrn C�Versims Data Versims
Supp 0 Pria to 5.0-400 Series
Supp 4 7.0.483 DEC_12_V0206
ESTIMATE RECALL NUMBER: 2/5/2013 14:38:45 13-3604804-01
Sottware Version: 7.0.483 Copyri�t(C)199A-2012 Mi[chell Intematimal Page 2 ot 2
All Ri�ts Reserved
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, �3 INDICA ING A,HIGH Fi?EED �AA38. VEAICIE 1 11� ��
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�6 I Q 2013
03J45/2U13 12:44 F�H 6314682641 PRDGkESSIVE (�003l047
Case�:13400905
Report Date:?1612013 �
Accfdant Narntive,coMfnued:
REAR END DAMAGE.
�CCUPANTS dF VEHICLE 2 WERE 7AKEN TO REGIONS MpSPITAL FOR P03318LE fNJUR1ES. NO OTHER
INJURIES REPORTED. CLEARIDRY ROADS_ NO WITIVE35ES ON SCENE.
0310b/2U13 12:44 FAx 6314682641 PRDERESSIVE T�0�4l007
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03/03/2U13 12:44 FAx 6314682641 PROBkESSIUE f�0�5i007
NOTYCE ()F CLAi11�i FURM�o the City of Ssint Pau�, Minne�ota
Min►ieaota Sfutc Stalwte 466.051lates Httrf"..,avery passan...wf�o c�aims don�ogts fram arp+mynicipaljty,..shal(cao�se ro 6s presanisd ro�he
gavernlr�g ba�y qf the mweicipaftty wfthtn 180 days a,�ter the a!leged la4s ar fnfnry fs didcover�ei!ct notlre statir�,►tke tlme,ptace,and
circmnstancts fhereof,and tJ�e anrouret ofco»�per�sation or other reliefdemanded"
Please conpiet�this form in its entiretl by dearly typioe ar prit�ting your anawec to esc6 qusfion. 1f more sp�ee is
needed,attsc6�ddltbn'1 sh�ets. �1e�se�ote tY�t y�will not be coetacted by telephoue to cl�ri[y answ�ors,so provide as
�ach infonoation�aece�sary W s:pl�m yoar cloim,and the anonnt o�'oompengation bcing req�ested. You will receive a
written ackne�rledgement onee your farm is rec�ived. The prnceas cen take qp to ten rveeks ar bnger�pending on the
�utare of your cixim. Thi�torm muat be sigqed,aad bath psges rnmpleted. iPsometluo�doe�not apply,wrile`N!A'.
SEND C41VIP�,ETED FURM AND UTHER D4CUMEN'rS TU: CITY CLERY�,
15 WES'���LOGG BLVD,310 CITY HAL�, SAYN�'PAUL,MN SSX02
First Name y� � M�ddlt Initial Last Name�]1(,LYl(�,1�1 Y�1
Company o�Business Name [
Are You en Instuencc Competty7 TVo If Yes,Cle.im Numbtr? �� ' ���'�O�
s��aa�s 2'�20 �-1'har � �l bo
c��y '�cr�v'�11� s�� �tt�J z�coe� ( i
� Daytime Phone����Celt Phone L� Evetiing Telephanc(� -
; Date of Axident/Injury or Aata Discovered �I 1 i �4�?� Time ���� am,�
Ploaso sta�e,in detail,what occwred(happened),and why you are submitting a clairn.Please indicate wtry or how you
feet the City af Saiat P 1 or its employeas are in�volved actd/or re9pons'ble or ur damages.
� r
, .
� t n
Ple�S�check the box(es)thet ma�t clasely represent the reason for cornpleting this form:
� B'6+Iy�ehicle was damaged in an secidsnt �My vehicle was damaged during a tow
! ❑My vertlictt was dama�ecf by a pothole or condition of the strat ❑My vehicie aas damaged by a plow
; ❑My vehicle was wron�'ully tov►�ed aad/or�iok�tEd �I waa injured on City Properiy
❑Othcr type of pmpe�ty damag�—plea�e specify
� �Other rype af injury—pleas�sPecify
i
! In order ta p�acess yotu claim vou a�ed to iaclude eonies of�11 apq�e�ble docaments.
IFor t�e claims types listed below,please be sure to include the documenrs iadicated or it will delay the handiing of
I your claim. Documents WILL NOT be return�end becorne tho propecty of the City. You are encouraged eo keep a
' copy for yow5elf befora submitting yo�claim fo�.
' Q Properiy damage ciaims to a vehicte:two estimat�for tho ropnirs to your vehicle if the damage exceods
5500-00;or t�e actual biIls andlor reoeipss for the repairs
O Towing claims: [egible copios of sny ticket issued end a copy of ifie impound lot receipt
O Other pmperty damage claims:two rcpair estimates if the dam�ge accecds�SOU.OQ;or the actua[bills
and/or rec�ipcs for the repairs;deta9lcd list af damaged items
O [njury alaims:medical bi11s,receipts
I O�otogr�hs are always welcome to document and suppoat your claim but wili not be returned.
Page 1 of x—Pleaae complete:ud retnrn botti�agea o�[Cl�f�Form
i
03/0512U13 12:44 FAx �314682641 PROGRESSIVE f�006l007
FsWure to comp�ete an�d ret�rn both psges�vilI resalt in delay in#he bandling oiyou�clai�-
All Clnims— na lete th' 'au�
Wene there witr�esses to the lncideM7 Yes � Unlmown (circle)
Provide their names,addresses and telephone numbers:� �
Were thc police or Iaw enforcennent ca11ed7 es Na Unlrnown circle)
If yes,what dtpartment or a�ency? IJ� Case#or report# �3 0 GtO�
Where did tf�c accidcnt or injury take place7 Provide s�zet address,cross street,in�r�ection,neme of perk or ficility,
closest I�dmark,etc. Please be as drxailed as possible. If necessazy,attaa�a iagram.
�Nla �D '�1a4bh S�'Qp,�' �W�.�Nl
pkease indicate tbe a,nount�ou are seeking in compeasat[on or what you would Iike the CI to da to resolve ihis claim
ta your s 'sf " (
Vehick Claims— e oom lete tWa se�i�on� ❑check x if t�is section does nat a 1
Your Vehicle: Yesr 7,oD�D Make Mode1
Licer�e plate Num�{ 'TMG 5��o State�1�1 Colar i1Vl.�
Rapstered Ovvner J�1'!�
Drivar of Vohicle
Area Damaged
City Vehicle: Yesr�_1Vleke f Mode1
C,icense ptate Number 5b �.1 Color
Driver of Vehicle(City Employee's Name)�� �aL��� _
Asea Dasnaged ��r't PXY.�
� Iaiurv Claima nle�e com»lete tLie eectiot� D e�cck box if this�ection does not aontv
How were you injaredT
What part{s)of your body were injured?
�ave you sought medica!t�+eatrnant'? es No Planning to Soek Treatmerit(cirele)
Whe�n did you receive�nent? (Provlde date(s))
Name of Modical Provider(5):
, Address Telephone
Did you miss work as a nsult of your injury7 Yes No
, Whan did you miss work? (providt date{s))
Namo of yow F�ployer: Telephos�e
Addre9s
�Che�k he�re i�yoa a�re s�ttac4uag more pages to thie claim fore►. Number of addition�l p�g�s�
By si8ning Ihis for�s,you are sta�ing flea�atl info�'nm�iore Yo�c kave provirled is true and correct to tke best
ojyour k►eowtedge, i'Insfgned forms wftl not 6e praGessed
Submil�ing a false claim ca�a nesalt in prasecutiae. Dat�form was complet�d � �� �
�rint the NAme of the�'erson aho Compl�ted thie �. �
Signatsre of Peraoa Making tbc Ctsim:
Revised Febn�ary 2011
03/05/2013 12:44 FAx 6314652641 PROERESSIVE (�0�7i007 �
i
� MINNESOTA DEQARTMEfdT OF PUSLiC SAFETY '
� � DRIVERAND VEHICLE SERVICES
Minnesata Crash Record Requ��t
Reports can be obtainad In person ar by mall at Driver and Vahfaic$erv�ss,44b Minnesota StrQSt,St.Paul,
Minnesots 65101-5167.For qurstions,cal)(65�i)216-7335.
Escrow accoum haldars may fax requo�to:(664}�82�551a or e-mafl to:dva.rsoasde�tste.mn.us.
• A S5 search fee is charged fiar all repork reqursts. ChecksJmcney arders should be made payabie to Driver and Vehicle
ServiceS,
. ReqUests will not be pro�essed without a signatur�from an author¢�requestor.An Authorized Requesbor is;
• a person invoived with the c.�aash�i.e.drlver,passenger, owner of damaged ptoperty,owner of vehicle, or pedestrian)
. a pe�sQn r�corded on the poiice report
• an insurance representative
. a legal represetttative
• Pleese note:!n the case of a fatalily, !he next of Idn, or lega!rapr�senfadve rnusf provide ptnot of dseth,such as a death
ca►fificate, ob�uary, or memorial card.
' Crash inforrn�tian ��ar oa�1� I.aw En�.Gase�
� person,$){nrolved (ftrst,mldd�,(ast name) Date of Birth Oriver LJcense Number LJrAnsa P1ate Numbee`
�. �'� �rre��- 31 b�l�q S 5Z�! 13� 2��
2
� 3. ���Ir..�
' 'Without listing licer►se plets numbers, the req�asted report may not be locsted.
Loc ' Grash Hi C' 1 u at+e a�t Crrsh m�
, �Nw a+o � I � N��wt�d �1� ���
Check the apProPriate box. jUllE BUCkiANAN
❑�riyer [�Owner of Damaged Property Name �oR rrr�ry
❑Passenper ❑Owner af Vehicle(if company owned,
❑Pedes�rian provide name af company} PROGRESSTVE IT�'SURANCE
❑ Lega! Repreaen�tive
�x Insurance Representa�ve Company Name
Next of Krct Ins, Ctaim# ��• �1daw,�D�!
❑ Escrow ount Number
� Mail to� PROGRE551VE ITiSl1kANCE CertiFication: I(we)certify that the infom�tion�nd statements o�
; this r+�quest are true and correct,and c,�mply with the provisions of
27?0 AR7HUR STREE'j#IDO �nn, 9tat§'169,�8, I (we)understa�d t�at d�closing any
� ir�fprmetion cantsintd ln any crash report,except as provided in
ROSEVILLE MN SS1I3 Minn. Stat§§ 1B9.09.Subd. 13, 13.82, Subd. 3 or 8,or ath�r
-__ statutes is a misdemeanar.
, X
� Sfgn of A horixed r
�
For oflice use oniy:
Comments: Search made� No File Located Search mack-Ne pni9ce report available�
I PS2503-06(05/1 Z)
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