Speckel (2) �
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JUN 11 2013
Providing lnsurance and Finer►cial Services C I TY C L E R K �S�e��'�
Home Ofice, Bloomington,IL
June 05, 2013
City Clerk Of Saint Paul State Farm Claims
Attn: Sandra Bodensteiner P.O. Box 2371
15 Kellogg Blvd W Ste 310 Bloomington IL 61702-2371
Saint Paul MN 55102-1615
Certified Mail - Return Receipt Requested
RE: Claim Number. 23-17C5-205
Our Insured: Jeremiah Speckel
Date of Loss: February 04, 2013
Your Insured: City Snow Plow
Your Insured Driver: Unknown
Loss Location: Unknown , St. Paul, MN
To Whom It May Concem:
It is our understanding that you are self insured. Our investigation indicates you are responsible
for this claim. Therefore, we are seeking recovery from you. This letter is to notify you of our
subrogation claim and request your cooperation in settling this matter.
To assist you in your review, here is a breakdown of the amounts State Farm�paid by Cause of
Loss:
041/045- Uninsured Motorist BI $
042- Uninsured Motorist PD $
300 series/400- Comp/Collision $2,135.29
501 - Rental/Loss of Use $
600-050- Med Pay/PIP $
Other $
Salvage Recovery $
Amount State Farm Paid $2,135.29
Insured Deductible $250.00
Total Claim Amount $2,385.29
Based on the assessment of liability befinreen the parties, State Farm Mutual Automobile
Insurance Company is seeking 100% of the Total Claim Amount listed above. The amour�t
payable to State Farm Mutual Automobile Insurance Company for this loss is $2,385.29.
Please remit payment of this claim and include our claim number on the payment. If you have
any questions or need additional information, please call me at the number listed below. If I am
not available, any other member of my team may assist you. Thank you for your cooperation.
In order to assist you in evaluating and processing the subrogation claim we are asserting, we
may provide nonpublic personal information about our customer. We are sharing this
information to effect, administer, or enforce a transaction authorized by the consumer. However,
23-17C5-205
Page 2
June 05, 2013
you are neither authorized nor permitted to: (1) use the customer information we provided for
any purpose other than to evaluate and process the subrogation claim, or(2)disclose or share
the customer information we provide for any purpose other than to evaluate and process the
subrogation claim.
Sincerely,
I f� ��
J ck Pitts
Claim Representative
(877)457-8276 Ext. 60
Fax: (866)231-9276
State Farm Mutual Automobile Insurance Company
Enclosure
a �jl �CS-��S'
_ 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 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 1'�- ��� �c.,l � J e r� e C���/
Are You an Insurance Company. Yes/ o If Yes, Claim Number? � -3� � ��S��J
Street Address �� ��n � 3 ��
City��D v 1'� I I'� � State r L Zip Code �0 �� '0?3 7�
7 Tv�(�(�
Daytime Phone (�)�/-t�a76 Cell Phone ( ) - Evening Telephone( ) -
Date of Accident/Injury or Date Discovered ���/ .3 Time u��� 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.
�� hsu✓ v %� �cc t r- �t o r u o►.col ►� .�a� ��f-�� S�t�aw Ol a�
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Please 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
O 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 you need to include copies of all annlicable 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.
,�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
� Other property damage claims: two repair estimates if the damage exceeds $500.00; or the actual bills
andlor 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 o Unknown (circle)
Provide their names, addresses and telephone numbers:
Were the police or law enforcement called? Yes N� Unknown (circle)
If yes, what department or agency? Case#or report#
Where did the accident or injury take place? Provide street address,cross street, intersection, name of park or facility,
closest�� ar� Please be as detailed as possible. If necessary, attach a diagram.
Please indicate the amount y u are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction.�����.��I
Vehicle Claims—please complete this section ❑ check box if this section does not applv
Your Vehicle: Year �o I� Make ���G Model �1'k�i
License Plate Number 0 State Color�.u�/l i f�-
Registered Owner �r2
Driver of Vehicle
Area Damaged � �- P f� 2�✓S i
City Vehicle; Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
In_iury Claims—please comnlete this section .J�Ccheck box if this section does not applv
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 processed.
Submitting a false claim can result in prosecution. Date form was completed �9 �S � / �
Print the Name of the Person who Completed this Form: / � 1 ! 'C
Signature of Person Making the Claim: J � f •
J .� rQ nn ��,t�. �o e c�lc,�e�
Revised February 201 1
LUPIENT COLLISION CENTER Workfile ID: ddefdb90
Federal ID: 41-1922146
BROOKLYN PARK
7910 LAKELAND AVE N, BROOKLYN PARK, MN
55445
Phone: (763) 425-4499
FAX: (763) 315-4621
Supplement of Record 1 with Summary
Customer: SPECKEL, MELISSA Job Number:
Written By: Marty Celusnak,3/21/2013 8:52:18 AM
Adjuster:TEAM R2 ACC CR, ., (866)207-6046 Day
Insured: SPECKEL, MELISSA Policy#: Claim #: 23-17C5-20501
Type of Loss: COLL-Collision Date of Loss: 2/4/2013 12:00:00 PM Days to Repair: 0
Point of Impact: 12 Front
Owner: Inspection Location: Insurance Company:
SPECKEL,MELISSA LUPIENT COLLISION CENTER STATE FARM INSURANCE COMPANIES
2121 IILON AVE N 7910 LAKELAND AVE N AUTO CLAIMS CENTRAL
MPLS, MN 55411 BROOKLYN PARK, MN 55445 STATE FARM
(651)280-8368 Cell Other PO BOX 52272
(763)425-4499 Day PHEONIX,AZ 85072-2272
(888)248-6961 Business
Vehicle Drop Off Date: 03/15/2013 Promise Date: 03/22/2013 Repair Start Date: 03/15/2013
Repair Completion Date: 03/21/2013 Vehicle Pick Up/Return 03/21/2013
Date:
VEHICLE
Year: 2012 Body Style: 4D SED VIN: KNAGM4A7XC5295229 Mileage In: 15593
Make: KIA Engine: 4-2.4L-FI License: 5AY680 Mileage Out:
Model: OPTIMA LX Production Date: State: MN Vehicle Out: 3/22/2013
Color: WHITE Int: Condition: Job#:
TRANSMISSION Steering Wheel Controls AM Radio Intermittent Wipers
6 Speed Transmission BRAKES FM Radio EXTERIOR
Overdrive Power Brakes Stereo Power Mirrors
Traction Control 4 Wheel Disc Brakes Search/Seek Dual Mirrors
SEATS Anti-Lock Brakes(4) CD Player Body Side Moldings
Bucket Seats GLASS INTERIOR Alarm
Cloth Seats Tinted Glass Power Locks Fog Lamps
Lumbar Adjustment Rear Defogger Air Conditioning Keyless Entry
STEERING Power Windows Driver Air Bag PAINT
Power Steering WHEELS Passenger Air Bag Three Stage Paint
Tilt Wheel Full Wheel Covers Front Side Impact Air Bags
Telescopic Wheel RADIO Console/Storage
3/21/2013 8:52:19 AM 050005 Page 1
Supplement of Recond 1 with Summary
Customer: SPECKEL, MELISSA I Job Number:
Vehicle: 2012 KIA OPTIMA LX 4D SED 4-2.4L-FI WHITE
Line Oper Description Part Number Qty Extended Labor Paint
Price$
1 FRONT BUMPER Sc GRILLE
2 0/H front bumper 2•8
3 Repl Bumper cover w/o SX 865114C000 1 523.15 Incl. 3.0
4 Add for Three Stage 2•1
5 Add for fog lamps 0.3
6 Repl Emblem 863182G000 1 44.00 Incl.
7 R&I License bracket �•Z
8 * SOl Repl RT Side retainer 865144C000 1 6.08 0.1
9 * SOl Repl LT Side retainer 865134C000 1 6.08 0.1
10 Repl LT Cover reinf 865832T000 1 9.35
11 * 501 Repl Upper grille 2.4 liter 863504C000 1 144.77 Incl.
12 # HAZARDOUS WASTE FEE 1 2.00 X
13 FRONT LAMPS
14 * SOl Repl LT Headlamp from 12/06/10 921014C000 1 365.07 0.3
15 Aim headlamps 0.5
16 * S01 Repl LT Headlamp bracket 865814C000 1 12.15
17 Repl LT Headlamp clip 9219135000 1 1.07
18 R&I RT R&I headlamp assy 0.3
19 AIR CONDITIONER&HEATER
20 Repl LT Air guide 2.4 liter 291362T000 1 18.13 0.1
21 FENDER
22 # Refn BASE COAT REDUCTION -0.3
23 # Car Cover 1 0.2
24 * Rpr LT Fender 0_5 1.8
25 Add for Three Stage 1.3
26 Blnd RT Fender 1.3
27 # Rpr pull rad suppt Z•�
28 # Refn mask fender vent grilles 0.4
29 # Repl It headlamp clip 921912T100 1 3.43
30 # Refn Corrosion Protection first panel 0.3
31 # Flex additive 1 5.00
SUBTOTALS 1,140.28 7.2 10.1
NOTES
Estimate Notes:
OPEN FOR ADDITIONAL DAMAGE AFfER WASHED AND TORN DOWN
3/21/2013 8:52:19 AM 050005 Page 2
Supplement of Record 1 with Summary
Customer: SPECKEL, MELISSA .7ob Number:
Vehicle: 2012 KIA OP'TIMA LX 4D SED 4-2.4L-FI WHITE
ESTIMATE TOTALS
Category Basis Rate Cost�
Parts 1,138.28
Parts Discount $ 1,129.85 -5.0% -56.49
Body Labor 7.2 hrs @ $52.00/hr 374.40
Paint Labor 10.1 hrs @ $52.00/hr 525.20
Paint Supplies 10.1 hrs @ $32.00/hr 323.20
Miscellaneous 2.00
Subtotal 2,306.59
Sales Tax $ 1,081.79 @ 7.2750% 78.70
Grand Total 2,385.29
Dedudible 250.00
CUSTOMER PAY 250.00
INSURANCE PAY 2,135.29
Register online to check the status of your claim and stay connected with State Farm�.To register,go to http://www.statefarm.com/
and select Check the Status of a Claim. If you are already registered,thank you! Not available in New Mexico.
3/21/2013 8:52:19 AM 050005 Page 3
Supplement of Record 1 with Summary
Customer: SPECKEL, MELISSA Job Number:
Vehicle: 2012 KIA OPTIMA LX 4D SED 4-2.4L-FI WHITE
SUPPLEMENT SUMMARY
Line Oper Description Part Number Qty E�ctended Labor Paint
Price�
Changed Items
7 Repl RT Side retainer 865144C000 1 -14.93 -0.1
8 * 501 Repl RT Side retainer 865144C000 1 6.08 0.1
8 Repl LT Side retainer 865134C000 1 -14.93 -0.1
9 * SOl Repl LT Side retainer 865134C000 1 6.08 0.1
10 Repl Upper grille 2.4 liter 863504C000 1 -488.90 Incl.
11 * SOl Repl Upper grille 2.4 liter 863504C000 1 144.77 Incl.
13 Repl LT Headlamp from 12/06/10 921014C000 1 -380.63 -0.3
14 * 501 Repl LT Headlamp from 12/06/10 921014C000 1 365.07 0.3
15 Repl LT Headlamp bracket 865814C000 1 -32.65
16 * SOl Repl LT Headlamp bracket 865814C000 1 12.15
SUBTOTALS -397.89 0.0 0.0
TOTALS SUMMARY
Category Basis Rate Cost;
Parts -397.89
Parts Discount $-397.89 -5.0% 19.89
Additional Supplement Adjustments 0.01
Subtotal -377•99
Sales Tax $-377.99 @ 7.2750% -27.52
Additional Supplement Taxes 0.02
Totai Supplement Amount -405.49
NET COST OF SUPPLEMENT -405.49
CUMULATIVE EFFECTS OF SUPPLEMENT(S)
Estimate 2,790.78 Marty Celusnak
Supplement 501 -405.49 Marty Celusnak
Job Total: ; 2,385.29
CUSTOMER PAY: $ 250.00
INSURANCE PAY: $ 2,135.29
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.
3/21/2013 8:52:19 AM 050005 Page 4
Supplement of Record 1 with Summary
Customer: SPECKEL, MELISSA 7ob Number:
Vehicle: 2012 KIA OPTIMA LX 4D SED 4-2.4L-FI WHITE
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
ARY2433, CCC Data Date 3/15/2013, 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 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. 0/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.
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.
3/21/2013 8:52:19 AM 050005 Page 5
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���� State Farm Mutual Automobile Insurance Company
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Auto Payments by Participant/COL
Route To: Mary Holmes
BASIC CLAIM INFORMATION
Claim Number: 23-17C5-205
Date of Loss: 02-04-2013
Policy Number: 1632-218-23D
Named Insured: SPECKEL,JEREMIAH
Named Insured(s)/400 -COLL
C denotes consolidated payment
E denotes EFT payment
P previously converted payment from CAT/CMR
Payment Issued Payable Pay Auth Rsn
Number Date Pavee COL Cd Status Amount ID Cd
105585640K E 03-21-2013 LUPIENT COLLISION 400 1 Paid $2,13529 ECSAPY
CENTER DBA BROOKLYN
PARKIMPORTS
Total: $2,135.29
Date: 06-05-2013 Page 1
FOR INTERNAL STATE FARM USE ONLY
Contains CONFIDENTIAL information which may not be disclosed without express written authorization.