Downing RECEIVED
JUL 25 2013 :
NOTICE UF CLAIM FORM to the City of�aint Pau�;M��nesota '
Minnesota State Statute 4b6.05 states rhat"...every person...who claims damagesfrom any municipality._.shall cause to be presented to the '
governing body of the ma�nicipaliry within 180 days nfter the aUeged lass or injury is discovered a notice stating the time,place,and
circumstances thereof,and rhe amount of compensatior�or orher relief demanded."
Ptease compieie this form in its entirety by clearly typing or printing yonr answer to each question. If more space is
needed,attach additional sheets. Please note that yoa will not be contacted by telephone to clarify answers,so provide as
much information as netessary to explain your claitn,and the amoant of compensation being requested. You will receive a '
written acknowtedgement 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 srgned,and boin gages completed. If something daes not apply,write`N/A'.
SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK,
15 WEST KEL OGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
(�,�a�e � �° �m�� Q��.�a �o� .
First Name � � M�tldie Initial L st Name �
Company or Business Name �
Are You an Insurance Company Yes No If Yes,Claim Number?l�'N"1� �� �� C�1
Street Address
� n ` _
Cit}��� T� ` State Zip Code��
Daytime Phane��{�Q-��Cell Phone ) - Evening Telephone(_) - '
Date of Accident/Injury or Date Discovered l Time�,�_am pm
PIease state,in detail,what occurred(happened),and why you are submitting a ciaim.Please i di ate why or how you
.�, r�:...,.�� • ,io... •�.. , ,a ,...�r •i., f � s
eel �,ae�.��y �� ;r���aal�r; z«,p��ye s���o ve.,u„ o~-es cns.��,: or�� �= a«.a^es.
�
Please check the box(es)that most closely represent the reason for complering this form:
❑My 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 wrongfutly towed and/oz ticke d ❑ I was injured on Cit pro erty
�Other type of properiy damage--please specif, l�r� Q(1 ,�_
❑ Other type of injury—please specify
In order to process youx claim you need to include copies of all apvlicable 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 WIL.I.,NOT be returned and become the property of the City. You are eneouraged to keep a
copy for yourself before submitting your claim form.
O Property damage ciaims 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 ar�y ticket issued and a coQy of the impound lot receipt :. ..
O Other property damage claims:two repair esti�ates if the damage exceeds$500.00;or the actual bills
and/or receipts for the repairs;detailed list of dan}aged items
O Tnjury claims:medicai bills,receipts
O Photographs are always welcome to document and support your clazm 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 resuit in delay in the handling of your claim.
All Claims—ulease comnlete this section
Were there wimesses to the incident? Yes CN�o Unknown (circle)
Provide their names,addresses and telephone numbers: ;
Were the police or law enforcement calied? Yes No Unknown (circle)
If yes,what department or agency? Case#or report#
Where did the acczdent or injury take glace? Provic�e street address,cross street,intersect�n, name of ark or faciiity, '
;1 sq est la}ndmark,etc. Please be as detailed as possible. If necessary,attach a diagram..�.�'�'k� �
.���
Please zndicate the ount you are seeking in compensatian or what you would like the City to do to resolve this claim '
to.your satisfaction���.t-1��C'j�, .
Vehicle CIaims— lease com iete this sectian �check box if this section does not a 1
Your Vehicle: Year�_Make ��Z(��3 Model '
License Plate Numb r State Color '
Registered Owner
Driver of Vehicie
Area Damaged ,
City Vehicle: Year Make Model
License Plate Number State Color
Dri�er of Vehicle(City Employee's Nanne)
Area Damaged ;
iniu�v iidim�—p�e.z�e corr,pirie this se..if�,-, �C1i2Ci{uvX ii i.kllS S2V^`i.ivii uv2S iivt avI'iiY '
How were you injured?
What part(s)of your body.were injured? � '
Have you sought medical treatment? Yes No Planning to Seek 2reatment(circte)
When did you receive treatment? (provide date(s))
Name of Medical Provider(s):
Address Telephone
Did you miss work as a resuit of your injury? Yes No ;
When did you miss work? (pravide 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 t�iat all information you have provided is true and cvrrect to the best
of your knowledge. Unsigned forms wald not be processed.
Submitting a farlse claim can result in prosecution. D form was completed l O/ U' J
� �
Print the Name of the Person who Com te this Form• `
Signature of Person Nlaking the Claim:
Revised February 20I i '
� A II statesROA1VOKEEVAR24018��rogation Claim Cntr
You're in good hands.
CITY OF ST. PAUL
200 CHA 25 W 4TH ST
ST PAUL MN 55102
July 22,2013
CLAIM NUMBER: 0290535202 F2E PHONE NUMBER: 800-776-2615
DATE OF LOSS:June 21,2013 FAX NUMBER: 540-725-6191
OUR INSURED:KATHRYN DOWNING OFFICE HOURS:Mon-Fri 8:00 am-7:00 pm
YOUR FILE NUMBER:
YOUR INSURED:
ADDRESS:
CITY STATE ZIP: , ,
LOSS LOCATION:Idaho Ave West,St Paul,,MN
AMOUNT OF LOSS: $7,847.58
Re: Subrogation Claim Notice
Dear CITY OF ST.PAUL,
Our investigation indicates your insured was responsible for the loss referenced above.
Please accept this letter as notice of ow subrogation claim. Enclosed,you will find copies of the supporting documents for
which we are seeking reimbursement. To assist you in your review,the following is a breakdown of our subrogation
demand:
Auto Dama e(Com an Paid): $7,597.58
Rental: $
Towin : $
Other: $
Deductible Customer Paid : $250.00
Salva e Recove : $
Insured Out of Pocket( lease send directly to our Insured): $
Please forward your payment with our claim number to:
Allstate Payment Processing Center
P.O. BOX 650271
Dallas,TX 75265 0271
0290535202 F2E
We ask that you direct any future correspondence to the address listed at the top of this letter.Thank you.
Sincerely,
GzSA Boo�E
LISA BOONE
800-776-2615 Ext. 7257079
Allstate Indemniry Company
SUBU033 0290535202 F2E
I
Report Date: 07/22/2013
Payment Ledger
Policy Holder: COLIN COOK KATHRYN Total Amount Paid $7,597.58
DOWNING
Partici ant: KATHRYN DOWNING Medical Deductible: $0.00
Date of Loss: 06/21/2013 Co- a ment Amount $0.00
Claim Number: 0290535202
Payment/Credit payee/Payor Check# Amount
Date
07/15/2013 aBRA ST PAUL 181278652 S 709.03
07/15/2013 ABRA ST PAUL 11985 S 6,411.84
07/16/2013 SAFELITE SOLUTIONS LLC 11986 $ 476.71
ABRA Auto Body &Glass - Midway Workfile ID: cd77043f
FederalID: 41-1852119
Right The First Time...On Time
1190 UNIVERSITY AVE W, SAINT PAUL, MN 55104
Phone: (651) 645-1563
FAX: (651) 641-6129
Estimate of Record
Customer: DOWNING, KATHRYN ]ob Number:
Written By: Pat Kearin,6/25/2013 11:18:58 AM
Insured: DOWNING, KATHRYN Polity#: ALLSTATE Claim#: 000290535202H01
Type of Loss: Comprehensive Date of Loss: 6/21/2013 12:00:00 PM Days to Repair: 9
Point of Impact: 16 Non-Collision
Owner: Inspection Location: Insurance Company:
DOWNING,KATHRYN 1190 UNIVERSITY AVE W -
758 IDAHO AVE W SAINT PAUL,MN 55104-4123 Allstate--4500
SAINT PAUL, MN 55117-3465 Repair Facility P.O. 187
(612)309-1308 Day Minneapolis,MN 55440
(612)975-0500 Business
VEHICLE
Year: 2010 Body Style: 4D SED VIN: JM1BL15F4A1259562 Mileage In: 40064
Make: MAZD Engine: 4-2.OL-FI License: 529DRJ Mileage Out:
Model: 3 Production Date: 12/2009 State: MN Vehicle Out:
Color: SILVER Int: Condition: ]ob#:
TRANSMISSION Console/Storege Stereo 4 Wheel Disc Brakes
5 Speed Transmission CONVENIENCE Search/Seek SEATS
Ove�drive Rear Defogger CD Player Cloth Seats
POWER Tilt Wheel Auxiliary Audio Connedion Bucket Seats
Power Steering Telescopic Wheel SAFETY Recline/Lounge Seats
Power Brakes Intermittent Wipers Anti-Lock Brakes(4) PAINT
Power Windows Steering Wheel Controls Driver Air Bag Clear Coat Paint
Power Mirrors RADIO Passenger Air Bag
DECOR AM Radio Head/Curtain Air Bags
Dual Mirrors FM Radio Front Side Impact Air Bags
6/25/2013 11:19:15 AM 011906 Page 1
Estimate o�Record
Customer: DOWNING, KATHRYN ]ob Number:
Vehicle: 2010 MAZD 3 4D SED 4-2.OL-FI SILVER
Line Oper Oescription Part Number Qty Extended Labor Paint
Price$
1 PILLARS,ROCKER&FLOOR
2 * Rpr RT Roof rail 4_0 1_0
3 * Rpr LT Roof rail �.0 1_0
4 ROOF
5 Repl RT Roof molding BBM5509H0 1 38.62 Incl.
6 R&I LT Roof molding Incl.
7 Repl Roof panel w/sunroof w/antenna BCY770600 1 645.99 17.5 3.0
hole
NOTE: LKQ roof$500 not cost effective with mark up and trim time considered
8 Repl Rear header BBM470700 1 45.11 1.3 0.4
9 # Rpr 'Deduct-Convert Labor to -2.0
Sublet r&i front glass
10 # Subl remove Windshield 1 52.00 X
11 # Subl reinstall Windshield 1 52.00 X
12 # Repl �Urethane Kit 1 20.00 T
13 R&I Headliner 2.OL w/o rain sensor Incl.
14 RESTRAINT SYSTEMS _
15 R&I RT Head air bag m 0.4 M
16 R&I LT Head air bag m 0.4 M
17 REAR DOOR
18 Blnd RT Outer panel 1.0
19 R&I RT Belt w'strip �•3
20 R&I RT Moveable glass Mazda 0.4
21 R&I RT Handle,outside to O1/12 �•$
gunmetal blue
22 R&I RT Trim panel assy cloth black 0.6
23 BACK GLASS
24 * Repl Glass Mazda BBM463930 1 Incl. Incl.
25 Deduct for Back Glass R8cI -2•5
26 # Repl 'Damage Glass Charges 1 35.00 G
27 # �Glass Claim Express-Bill Direct 1
28 QUARTER PANEL
29 Blnd LT Quarter panel 1.1
30 Repl RT Quarter panel BBY47041X 1 543.76 17.5 3.0
NOTE: LKQ qtr panel not cost effective with mark up and trim time considered
31 Overlap Major Adj. Panel -0.4
32 Deduct for Back Glass R&I -2•5
33 Dedud for Overlap -1.5
34 Repl RT Stone guard BBM4504P2A 1 43.32 0.2
35 Repl LT Stone guard BBM4504R2A 1 43.32 0.2
36 R&I Fuel door 0.3
37 Blnd Fuel doar 0.2
38 TRUNK LID
6/25/2013 11:19:15 AM 011906 Page 2
Estimate of Record
Customer: DOWNING, KATHRYN 7ob Number:
Vehicle: 2010 MAZD 3 4D SED 4-2.OL-FI SILVER
39 * Repl LKQ trunk lid assy+30% BBY45261XD 1 442.00 0.7 2.2
40 Overlap Major Adj. Panel -0.4
41 Refn trunk lid underside 1.1
42 Repl Emblem BBY451730 1 25.60 0.1
43 Repl Nameplate"3" BBY451721 1 11.68 0.2
44 Repl Nameplate"MAZDA" BBY451710 1 17.84 0.2
45 REAR BODY&FLOOR
46 R&I RT Trunk side trim Incl.
47 R&I Rear panei trim Incl.
48 R&I Pkg tray trim w/o 10 speakers Incl.
49 Repl RT Tail lamp pocket BBY470480 1 31.47 2.0 0.4
50 Overlap Minor Panel -0.2
51 Deduct for Overlap -0.7
52 Repl Pkg tray trim w/10 speakers BBN2683A00O2 1 211.14 Incl.
NOTE: Customer declined appearance allowance on package tray
53 REAR LAMPS _ _ _
54 * Repl LKQ RT Tail lamp assy w/o LED BBM451150F 1 97.50 Incl•
+30%
55 R&I LT Tail lamp assy w/o LED 0.4
56 R&I License lamp Incl.
57 REAR BUMPER __ _
58 <> Repl Bumper cover 2.OL BBM450221M66 1 317.07 1.9 3.0
NOTE: Customer declined a/m parts recond not avialable per john at keystone and Murphy at AAA
59 Overlap Major Non-Adj. Panel -0.2
60 Deduct for Rear Bumper R&I -1.5
61 Clear Coat 2.5
62 Repl RT Retainer BBM4502H1E 1 21.81 0.1
63 # 'Car Cover 1 5.00 X
64 # 'Corrosion Protection 1 8.00 X
65 # Repl 'Flex Additive 1 6.00 X
66 # 'Hazardous Waste 1 3.00 X
67 # Rpr Clean up Glass and Debri 1.5
NOTE:Trunk and Back seat wet from back glass being broken out
SUBTOTALS 2,717.23 45.3 18.7
NOTES
Estimate Notes:
Customer declined a/m parts
LKQ parts search:car-part.com aaa Ikq smart parts pams
6/25/2013 11:19:15 AM 011906 Page 3
Estimate of Record
Customer: DOWNING, KATHRYN 7ob Number:
Vehicle: 2010 MAZD 3 4D SED 4-2.OL-FI SILVER
ESTIMATE TOTALS
Category Basis Rate Cost$
Parts 2,571.23
Parts Discount $ 1,996.73 -2.0% -39.93
Body Labor 44.5 hrs @ $52.00/hr 2,314.00
Paint Labor 18.7 hrs @ $52.00/hr 972.40
Mechanical Labor 0.8 hrs @ $67.00/hr 53.60
Paint Supplies 450.00
Miscellaneous 146.00
Subtotal 6,467.30
Sales Tax $2,551.30 @ 7.6250% 194.54
Grand Total 6,661.84
Deductible 250.00
CUSTOMER PAY 250.00
INSURANCE PAY 6,411.84
THIS IS A VISUAL INSPECTION ONLY. THERE MAY BE ADDITIONAL DAMAGE AFTER 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."
IMPORTANT INFORMATION ABOUT ALLSTATE'S CHOICE OF PARTS POLICY
❑This estimate may list parts for use in the repair of your vehicle that are manufactured by a company other than the
original manufacturer of your vehicle. These parts are commonly referred to as aftermarket parts or competitive
parts, and would be designated on this estimate as "QUAL REPL PARTS", "A/M" or "COMP REPL PARTS". Such parts
may include cosmetic outer body crash parts such as hoods, fenders, bumper covers, etc. Allstate guarantees the fit
and corrosion resistance of any aftermarket/competitive outer body crash parts that are listed on this estimate and
actually used in the repair of your vehicle for as long as you own it. If a problem develops with the fit or corrosion
resistance of these parts, they will be repaired or replaced at Allstate's expense. This guarantee is limited to the
repair or replacement of the part.
However, if you choose not to use one or more of the aftermarket/competitive outer body crash parts that may be
listed on this estimate in the repair of your vehicle, Allstate will specify the use of original equipment manufacturer
parts, either new or recycled at Allstate's option, at no additional cost to you.no cost to you. will be used in place of
these parts to repair your vehicleAllstate does not separately guarantee the performance of original equipment
manufacturer parts, and makes no representation about the availability of any manufacturer's guarantee.
Suppliers listed in the repair estimate for Aftermarket or Recycled parts are used only as a reference as for the
availability and pricing of the Aftermarket or Recycled part. A repair facility is under no obiigation to purchase these
parts from the listed suppliers.
❑
6/25/2013 11:19:15 AM p11906 Page 4
Estimate of Record
Customer: DOWNING, KATHRYN 7ob Number:
Vehicle:2010 MAZD 3 4D SED 4-2.OL-FI SILVER
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 calculated using a preset user threshold amount for the paint and materiai cost.
IMPORTANT INFORMATION ABOUT ALLSTATE'S CHOICE OF PAfZTS POLICY
This estimate may list parts for use in the repair of your vehicle that are manufactured by a company other than the
original manufacturer of your vehicle. These parts are commonly referred to as aftermarket parts or competitive
parts, and would be designated on this estimate as "QUAL REPL PARTS", "A/M" or "COMP REPL PARTS". Such parts
may include cosmetic outer body crash parts such as hoods, fenders, bumper covers, etc. Allstate guarantees the fit
and corrosion resistance of any aftermarketJcompetitive outer body crash parts that are listed on this estimate and
actually used in the repair of your vehicle for as long as you own it. If a problem develops with the fit or corrosion
resistance of these parts, they will be repaired or replaced at Allstate's expense. This guarantee is limited to the
repair or replacement of the part.
However, if you choose not to use one or more of the aftermarket/competitive outer body crash parts that may be
listed on this estimate in the repair of your vehicle, Allstate will specify the use of original equipment manufacturer
parts, either new or recycled at Alistate's option, at no additional cost to you. Allstate does not separately guarantee
the performance of original equipment manufacturer parts, and makes no representation about the availability of any
manufacturer's guarantee.
6/25/2013 11:19:15 AM 011906 Page 5
Estimate of Record
Customer: DOWNING, KATHRYN 7ob Number:
Vehicle:2010 MAZD 3 4D SED 4-2.OL-FI SILVER
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
ARH5418, CCC Data Date 6/14/2013, 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 Non
OEM or A/M. 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=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.
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.
6/25/2013 11:19:15 AM D11906 Page 6
Estimate of Record
Customer: DOWNING, KATHRYN ]ob Number:
Vehicle:2010 MAZD 3 4D SED 4-2.OL-FI SILVER
IMPORTANT INFORMATION ABOUT THE NAMED INSURANCE COMPANY'S CHOICE OF PARTS POLICY.
THIS ESTIMATE MAY LIST PARTS FOR USE IN THE REPAIR OF YOUR VEHICLE THAT ARE MANUFACTURED BY A
COMPANY OTHER THAN THE ORIGINAL MANUFACTURER OF YOUR VEHICLE. THESE PARTS ARE COMMONLY
REFERRED TO AS AFfERMARKET PARTS OR COMPETITIVE PARTS, AND MAY INCLUDE COSMETIC OUTER BODY
CRASH PARTS SUCH AS HOODS, FENDERS, BUMPER COVERS, ETC. THE INSURANCE COMPANY GUARANTEES THE
FIT AND CORROSION RESISTANCE OF ANY AFTERMARKET/COMPETITIVE OUTER BODY CRASH PARTS THAT ARE
LISTED ON THIS ESTIMATE AND ACTUALLY USED IN THE REPAIR OF YOUR VEHICLE FOR AS LONG AS YOU OWN
IT. IF A PROBLEM DEVELOPS WITH THE FIT OR CORROSION RESISTANCE OF THESE PARTS, THEY WILL BE
REPAIRED OR REPLACED AT THE INSURANCE COMPANY'S EXPENSE. THIS GUARANTEE IS LIMITED TO THE REPAIR
OR REPLACEMENT OF THE PART. HOWEVER, IF YOU CHOOSE NOT TO USE ONE OR MORE OF THE
AFTERMARKET/COMPETITIVE OUTER BODY CRASH PARTS THAT MAY BE LISTED ON THIS ESTIMATE IN THE
REPAIR OF YOUR VEHICLE, THE INSURANCE COMPANY WILL SPECIFY THE USE OF ORIGINAL EQUIPMENT
MANUFACTURER PARTS, EITHER NEW OR RECYCLED AT THE INSURANCE COMPANY'S OPTION, AT NO ADDITIONAL
COST TO YOU. THE INSURANCE COMPANY DOES NOT SEPARATELY GUARANTEE THE PERFORMANCE OF ORIGINAL
EQUIPMENT MANUFACTURER PARTS,AND MAKES NO REPRESENTATION ABOUT THE AVAILABILITY OF ANY
MANUFACTURER'S GUARANTEE.
6/25/2013 11:19:15 AM 011906 Page 7
ABRA Auto Body &Glass - Midway Workfile ID: cd77043f
Federal ID: 41-1852119
Right The First Time...On Time
1190 UNIVERSITY AVE W, SAINT PAUL, MN 55104
Phone: (651) 645-1563
FAX: (651) 641-6129
Supplement of Record 1 with Summary
Customer: DOWNING, KATHRYN Job Number:
Written By: Pat Kearin,7/il/2013 10:38:10 AM
Insured: DOWNING, KATHRYN Policy#: ALLSTATE Claim#: 000290535202H01
Type of loss: Comprehensive Date of Loss: 6/21/2013 12:00:00 PM Days to Repair: 9
Point of Impad: 16 Non-Collision
Owner: Inspection Location: Insurance Company:
DOWNING,KATHRYN 1190 UNIVERSITY AVE W -
758 IDAHO AVE W SAINT PAUL, MN 55104-4123 Allstate--4500
SAINT PAUL, MN 55117-3465 Repair Faciliry P.O. 187
(612)309-1308 Day Minneapolis,MN 55440
(612)975-0500 Business
VEHICLE
Year: 2010 Body Sryle: 4D SED VIN: JMiBL15F4A1259562 Mileage In: 40064
Make: MAZD Engine: 4-2.OL-FI License: 529DR7 Mileage Out:
Model: 3 Production Date: 12/2009 State: MN Vehicle Out:
Color: SILVER Int: Condition: ]ob#:
TRANSMISSION Console/Storage Stereo Head/Curtain Air Bags
Overdrive CONVENIENCE Search/Seek SEATS
5 Speed Transmission Intermittent Wipers CD Player Cloth Seats
POWER Tilt Wheel Auxiliary Audio Connedion Bucket Seats
Power Steering Rear Defogger SAFETY Reclining/Lounge Seats
Power Brakes Steering Wheel Touch Controls Drivers Side Air Bag PAINT
Power Windows Telescopic Wheel Passenger Air Bag Clear Coat Paint
Power Mirrors RADIO Anti-Lock Brakes(4)
DECOR AM Radio 4 Wheel Disc Brakes
Dual Mirrors FM Radio Front Side Impact Air Bags
7/11/2013 10:38:18 AM 011906 Page 1
Supplement of Record 1 with Summary
Customer: DOWNING, KATHRYN ]ob Number:
Vehicle:2010 MAZD 3 4D SED 4-2.OL-FI SILVER
Line Oper Description Part Number Qty Extended Labor Paint
Price;
1 WHEELS
2 SO1 R&I RT/Rear R&I wheel m 0.1
3 WINDSHIELD
4 501 Repl Reveal molding BBM450601 1 56.43 Incl.
5 501 R&I Windshield Mazda w/o rain Incl.
sensor
6 PILLARS,ROCKER&FLOOR
7 * Rpr RT Roof rail 4_0 1_0
8 * Rpr LT Roof rail 5_0 1_0
9 ROOF
10 Repl RT Roof molding BBM5509H0 1 38.62 Incl.
il R&I LT Roof molding Incl.
12 * SO1 Repl Roof panel w/sunroof w/antenna BCY770600 1 655.73 17.5 3.0
hole
NOTE: LKQ roof$500 not cost effective with mark up and trim time considered
13 Repl Rear header BBM470700 1 45.11 1.3 0.4
14 # Rpr �Deduct-Convert Labor to -2.0
Sublet r&i front glass
15 # Subl remove Windshield 1 52.00 X
16 # Subl reinstall Windshield 1 52.00 X
17 # Repl 'Urethane Kit 1 20.00 T
18 R&I Headliner 2.OL w/o rain sensor Incl.
19 RESTRAINT SYSTEMS
20 R&I RT Head air bag m 0.4 M
21 R&I LT Head air bag m 0.4 M
22 SEATS&TRACKS
23 501 R&I R&I rear seat as an assy Incl.
24 REAR DOOR
25 Blnd RT Outer panel 1.0
26 R&I RT Belt w'strip 0.3
27 R&I RT Moveable glass Mazda 0.4
28 R&I RT Handle,outside to O1/12 0.8
gunmetal blue
29 R&I RT Trim panel assy cloth black 0.6
30 BACK GLASS
31 * Repl Glass Mazda BBM463930 1 Inc1• Incl.
32 Dedud for Back Glass R&I -2.5
33 # Repl 'Damage Glass Charges 1 35.00 G
34 # 'Glass Claim Express-Bill Direct 1
35 QUARTER PANEL
36 Blnd LT Quarter panel 1.1
37 Repl RT Quarter panel BBY47041X 1 543.76 17.5 3.0
NOTE: LKQ qtr panel not cost effective with mark up and trim time considered
7/11/2013 10:38:18 AM 011906 Page 2
Supplement of Record 1 with Summary
Customer: DOWNING, KATHRYN Job Number:
Vehicle: 2010 MAZD 3 4D SED 4-2.OL-FI SILVER
38 Overlap Major Adj. Panel -0.4
39 Deduct for Back Glass R&I -2.5
40 Dedud for Overlap -1.5
41 Repl RT Stone guard BBM4504P2A 1 43.32 0.2
42 Repl LT Stone guard BBM4504R2A 1 43.32 0.2
43 R&I Fuel door 0.3
44 Blnd Fuel door 0.2
45 SOl R&I RT Vent assy Incl.
46 TRUNK LID
47 * Repl LKQ trunk lid assy+30% BBY45261XD 1 442.00 0.7 2.2
48 Overlap Major Adj. Panel -0.4
49 Refn trunk lid underside 1.1
50 Repl Emblem BBY451730 1 25.60 0.1
51 Repl Nameplate"3" BBY451721 1 11.68 0.2
52 Repl Nameplate"MAZDA" BBY451710 1 17.84 0.2
53 501 Repl RT Hinge BBM4527106 1 33.07 0.4 0.5
54 501 Repl RT Lift cylinder w/o spoiler BBM456930A 1 3339 Incl.
55 INSTRUMENT PANEL
56 * 501 Repl LKQ RT Woofer+30% GS3M6696Z 1 130.00
57 * SO1 Repl LKQ RT Rear speaker w/SO G53N66960 1 32.50 0_2
speaker sys+30%
58 * 501 Repl LKQ LT Rear speaker w/10 G53N66960 1 32.50 �
speaker sys+30%
59 REAR BODY&FLOOR
60 R&I RT Trunk side trim Incl.
61 R&I Rear panel trim Incl.
62 R&I Pkg trey trim w/o 10 speakers Incl.
63 Repl RT Tail lamp pocket BBY470480 1 31.47 2.0 0.4
64 501 Overlap Minor Panel -�•Z
65 Dedud for Overlap -0•�
66 Repl Pkg tray trim w/10 speakers BBN2683A00O2 1 211.14 Incl.
NOTE: Customer declined appearance allowance on package tray
67 501 Repl RT Gutter BBM4704416 1 9439 2.0 0.3
68 REAR LAMPS
69 * Repl LKQ RT Tail lamp assy w/o LED BBM451150F 1 7.5 Inc1•
+30%
70 R&I LT Tail lamp assy w/o LED 0.4
71 R&I License lamp Incl.
72 SO1 R&I RT Backup lamp assy 0•2
73 SOl R&I LT Backup lamp assy 0•2
74 * 501 Repl LKQ High mount lamp w/o FOB BBM451580F 1 Inc1• Incl.
key
75 REAR BUMPER
76 <> Repl Bumper cover 2.OL BBM450221MB6 1 317.07 1.9 3.0
NOTE:Customer declined a/m parts recond not avialable per john at keystone and Murphy at AAA
77 Overlap Major Non-Adj. Panel -0•2
7/11/2013 10:38:18 AM D11906 Page 3
Supplement of Record 1 with Summary
Customer: DOWNING, KATHRYN 7ob Number:
Vehicle:2010 MAZD 3 4D SED 4-2.OL-FI SILVER
78 Deduct for Rear Bumper R&I -1.5
79 Clear Coat 2•5
80 Repl RT Retainer BBM4502H1E 1 21.81 0.1
81 ** 501 Repl A/M 'Seam Sealer 1 46.53 X Incl.
82 # �Car Cover 1 5.00 X
83 # �Corrosion Protection 1 8.00 X
84 # Repl �Flex Additive 1 6.00 X
85 # �Hazardous Waste 1 3.00 X
86 # Rpr Clean up Glass and Debri 1.5
NOTE:Trunk and Back seat wet from back glass being broken out
SUBTOTALS 3,185.78 48.6 19.5
NOTES
Estimate Notes:
Customer declined a/m parts
LKQ parts search:car-part.com aaa Ikq smart parts pams
ESTIMATE TOTALS
Category Basis Rate Cost$
Parts 2,993.25
Parts Discount $2,223.75 -2.0% -44.48
Body Labor 47.8 hrs @ $52.00/hr 2,485.60
Paint Labor 19.5 hrs @ $52.00/hr 1,014.00
Mechanical Labor 0.8 hrs @ $67.00/hr 53.60
Paint Supplies 450.00
Miscellaneous 192.53
Subtotal 7,144.50
Sales Tax $2,968.77 @ 7.6250% 226.37
Grand Total 7,370.87
Deductible 250.00
CUSTOMER PAY 250.00
INSURANCE PAY 7,120.87
7/11/2013 10:38:18 AM 011906 Page 4
Supplement of Record 1 with Summary
Customer: DOWNING, KATHRYN Job Number:
Vehicle: 2010 MAZD 3 4D SED 4-2.OL-FI SILVER
SUPPLEMENT SUMMARY
Line Oper Description Part Number Qty Extended Labor Paint
Price$
Changed Items
6 Repl Roof panel w/sunroof w/antenna BCY770600 1 -645.99 -ll.5 -3.0
hole
NOTE: LKQ roof$500 not cost effective with mark up and trim time considered
12 * SO1 Repl Roof panel w/sunroof w/antenna BCY770600 1 655.73 17.5 3.0
hole
NOTE: LKQ roof$500 not cost effective with mark up and trim time considered
Deleted Items i
50 Overlap Minor Panel �•2
Added Items
1 WHEELS
2 501 R&I RT/Rear R8cI wheel m 0.1
3 WINDSHIELD _
4 SO1 Repl Reveal molding BBM450601 1 56.43 Incl.
5 SOl R&I Windshield Mazda w/o rain Incl.
sensor
22 SEATS&TRACKS
23 SOl R&I R8cI rear seat as an assy Incl.
45 SOl R&I RT Vent assy Incl.
53 SOl Repl RT Hinge BBM452710B 1 33.07 0.4 0.5
54 SOl Repl RT Lift cylinder w/o spoiler BBM456930A 1 3339 Incl.
55 INSTRUMENT PANEL
56 * SO1 Repl LKQ RT Woofer+30% G53M6696Z 1 130.00
57 * 501 Repl LKQ RT Rear speaker w/10 G53N66960 1 32.50 0_2
speaker sys+30%
58 * SOl Repl LKQ LT Rear speaker w/SO G53N66960 1 32.50 0_2
speaker sys+30%
64 SO1 Overlap Minor Panel -0•2
67 SOl Repl RT Gutter BBM470441B 1 94.39 2.0 0.3
72 SO1 R&I RT Backup lamp assy �•2
73 501 R&I LT Backup lamp assy 0•2
74 * 501 Repl LKQ High mount lamp w/o FOB BBM451580F 1 Incl. Incl.
key
81 ** SO1 Repl A/M 'Seam Sealer 1 46.53 X Incl.
SUBTOTALS 468.55 3.3 0.8
7/11/2013 10:38:18 AM 011906 Page 5
Suppiement of Record 1 with Summary
Customer: DOWNING, KATHRYN ]ob Number:
Vehicle:2010 MAZD 3 4D SED 4-2.OL-FI SILVER
TOTALS SUMMARY
Category Basis Rate Cost$
Parts 422.02
Parts Discount $227.02 -2.0% -4.54
Additional Supplement Adjustments -0.01
Body Labor 3.3 hrs @ $52.00/hr 171.60
Paint Labor 0.8 hrs @ $52.00/hr 41.60
Paint Supplies 0.8 hrs @ $32.00/hr 25.60
Additional Supplement Materials/Supplies -25.60
Miscellaneous 46.53
Subtotal 677.20
Sales Tax $417.47 @ 7.6250% 31.85
Additional Supplement Taxes -0.02
Total Supplement Amount 709.03
NET COST OF SUPPLEMENT 709.03
CUMULATIVE EFFECTS OF SUPPLEMENT(S)
Estimate 6,661.84 Pat Kearin
Supplement 501 709.03 Pat Kearin
Job Total: $ 7,370.87
CUSTOMER PAY: $ 250.00
INSURANCE PAY: � 7,120.87
THIS IS A VISUAL INSPECTION ONLY. THERE MAY BE ADDITIONAL DAMAGE AFTER 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."
7/11/2013 10:38:18 AM 011906 Page 6
Supplement of Recorp 1 with Summary
Customer: DOWNING, KATHRYN Job Number:
Vehicle:2010 MAZD 3 4D SED 4-2.OL-FI SILVER
IMPORTANT INFORMATION ABOUT ALLSTATE'S CHOICE OF PARTS POLICY
❑This estimate may list parts for use in the repair of your vehicle that are manufactured by a company other than the
original manufacturer of your vehicle. These parts are commonly referred to as aftermarket parts or competitive
parts, and would be designated on this estimate as "QUAL REPL PARTS", "A/M" or "COMP REPL PARTS". Such parts
may include cosmetic outer body crash parts such as hoods, fenders, bumper covers, etc. Allstate guarantees the fit
and corrosion resistance of any aftermarket/competitive outer body crash parts that are listed on this estimate and
actually used in the repair of your vehicle for as long as you own it. If a problem develops with the fit or corrosion
resistance of these parts, they will be repaired or replaced at Allstate's expense. This guarantee is limited to the
repair or replacement of the part.
However, if you choose not to use one or more of the aftermarket/competitive outer body crash parts that may be
listed on this estimate in the repair of your vehicle, Allstate will specify the use of original equipment manufacturer
parts, either new or recycled at Allstate's option, at no additional cost to you.no cost to you. will be used in place of
these parts to repair your vehicleAllstate does not separately guarantee the performance of original equipment
manufacturer parts, and makes no representation about the availability of any manufacturer's guarantee.
Suppliers listed in the repair estimate for Aftermarket or Recycled parts are used only as a reference as for the
availability and pricing of the Aftermarket or Recycled part. A repair facility is under no obligation to purchase these
parts from the listed suppliers. •
❑
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 calculated using a preset user threshold amount for the paint and material cost.
IMPORTANT INFORMATION ABOUT ALLSTATE'S CHOICE OF PARTS POLICY
This estimate may list parts for use in the repair of your vehicle that are manufactured by a company other than the
original manufacturer of your vehicle. These parts are commonly referred to as aftermarket parts or competitive
parts, and would be designated on this estimate as "QUAL REPL PARTS", "A/M" or "COMP REPL PARTS". Such parts
may inctude cosmetic outer body crash parts such as hoods, fenders, bumper covers, etc. Allstate guarantees the fit
and corrosion resistance of any aftermarket/competitive outer body crash parts that are listed on this estimate and
actually used in the repair of your vehicle for as long as you own it. If a problem develops with the fit or corrosion
resistance of these parts, they will be repaired or replaced at Allstate's expense. This guarantee is limited to the
repair or replacement of the part.
However, if you choose not to use one or more of the aftermarket/competitive outer body crash parts that may be
listed on this estimate in the repair of your vehicle, Allstate will specify the use of original equipment manufacturer
parts, either new or recycled at Allstate's option, at no additional cost to you. Allstate does not separately guarantee
the performance of original equipment manufacturer parts, and makes no representation about the availability of any
manufacturer's guarantee.
7/11/2013 10:38:18 AM 011906 Page 7
Supplement of Record 1 with Summary
Customer: DOWNING, KATHRYN Job Number:
Vehicle: 2010 MAZD 3 4D SED 4-2.Ol-FI SILVER
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
ARH5418, CCC Data Date 7/10/2013, 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 Non
OEM or A/M. 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 Specifcations. 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 2014 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=6lend. BOR=6oron 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.
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 Safery Administration. PDR=Paintless Dent Repair. VIN=Vehicle Identification Number.
7/11/2013 10:38:18 AM 011906 Page 8
Supplement of Record 1 with Summary
Customer: DOWNING, KATHRYN 7ob Number:
Vehicle: 2010 MAZD 3 4D SED 4-2.OL-FI SILVER
IMPORTANT INFORMATION ABOUT THE NAMED INSURANCE COMPANY'S CHOICE OF PARTS POLICY.
THIS ESTIMATE MAY LIST PARTS FOR USE IN THE REPAIR OF YOUR VEHICLE THAT ARE MANUFACTURED BY A
COMPANY OTHER THAN THE ORIGINAL MANUFACTURER OF YOUR VEHICLE. THESE PARTS ARE COMMONLY
REFERRED TO AS AFTERMARKET PARTS OR COMPETITIVE PARTS, AND MAY INCLUDE COSMETIC OUTER BODY
CRASH PARTS SUCH AS HOODS, FENDERS, BUMPER COVERS, ETC. THE INSURANCE COMPANY GUARANTEES THE
FIT AND CORROSION RESISTANCE OF ANY AFTERMARKET/COMPETITIVE OUTER BODY CRASH PARTS THAT ARE
LISTED ON THIS ESTIMATE AND ACTUALLY USED IN THE REPAIR OF YOUR VEHICLE FOR AS LONG AS YOU OWN
IT. IF A PROBLEM DEVELOPS WITH THE FIT OR CORROSION RESISTANCE OF THESE PARTS, THEY WILL BE
REPAIRED OR REPLACED AT THE INSURANCE COMPANY'S EXPENSE. THIS GUARANTEE IS LIMITED TO THE REPAIR
OR REPLACEMENT OF THE PART. HOWEVER, IF YOU CHOOSE NOT TO USE ONE OR MORE OF THE
AFTERMARKET/COMPETITIVE OUTER BODY CRASH PARTS THAT MAY BE LISTED ON THIS ESTIMATE IN THE
REPAIR OF YOUR VEHICLE, THE INSURANCE COMPANY WILL SPECIFY THE USE OF ORIGINAL EQUIPMENT
MANUFACTURER PARTS, EITHER NEW OR RECYCLED AT THE INSURANCE COMPANY'S OPTION, AT NO ADDITIONAL
COST TO YOU. THE INSURANCE COMPANY DOES NOT SEPARATELY GUARANTEE THE PERFORMANCE OF ORIGINAL
EQUIPMENT MANUFACTURER PARTS, AND MAKES NO REPRESENTATION ABOUT THE AVAILABILITY OF ANY
MANUFACTURER'S GUARANTEE.
7/11/2013 10:38:18 AM 011906 Page 9