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Phan i � =--. - , _ ; � Providing Insurance and Financia/Services �StateFarm� � Home 0f6ce Bloomington IL ' August 20, 2013 City Of Saint Paul State Farm Claims 15 West Keliogg Blvd W P.O.Box 2371 310 City Ha ll Bloomington IL 61702-237R E C E I V E D Saint Paul MN 55102-1635 AUG 2 6 2013 CITY CLERK Certified Mail -Return Receipt Requested RE: Claim Number. 23-17S5-279 Our Insured: Huong Ngoc Phan Date of Loss: March 29, 2013 Your Insured: City Of Saint Paul Your Insured Driver: Lawrence Langlois Loss Location: Intersection Of University& Raymond, Saint 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 $45,747.30 501 - Rental/Loss of Use $ 600-050- Med Pay/PIP $ Other $ Salvage Recovery $minus salvage amount of$8,069.49 Amount State Farm Paid $37,677.81 Insured Deductible $500.00 Total Claim Amount $38,177.81 Based on the assessment of liability between the parties, State Farm Mutual Automobile Insurance Company is seeking 100% of the Total Claim Amount listed above. The amourit payable to State Farm Mutual Automobile Insurance Company for this loss is $38,177.81. 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, � ' 23-17S5-279 � Page 2 i ; August 20, 2013 I ou are neither authorized nor ermitted to: 1 use the customer information we rovided for Y P � ) p 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� �' " 1 �7/a " ' Natalia Ryan Claim Representative (877)457-8276 Ext. 60 Fax: (866)231-9276 State Farm Mutual Automobile Insurance Company Enclosure CC: LEAGUE OF MINNESOTA CITIES 145 UNIVERSITY AVE W SAINT PAUL, MN,55103-2044 a.3 - 1 � s � � . sa � . NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota Minnesota State Statute 466.05.states that"...euery person...who claims dcurrages fi�om any municipaliry...shalf couse en be presented ro rhe governing body of the municipality wiihin t80 duys after the alleged loss or injury is discovered a notice stating the time,place,and circumstances thereof,a�u!the amount of com{�ensation or other refief demancled." Please complete lhis form in its entirety by clearly typing or printing your answer to each question. If more space is needed,attach additional sheeks. Please note that you may or may not be coatacted by telephone to discuss your c2aim circumstances,so provide as much information as aecessary to explain your claim,and the amount of compensation being requested. This form must be signed,and both pages completed. If something does not appty,write`N/A'. SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK,15 WFST KELLOGG BLVD,310 CITY HALL,SA1NT PAUL,MN SS102 First Name�vn� Middle Inirial Last Name PhA,y�, Company or Business Name,if applicable �,�.� Street Address I � ,3�1�,! �, �� N � City � ��-�k. State_�, � Zip Code . ^C L� � e.f Daytime Telephone(?� � �0 1- �.I �(A Evening Telephone(__) Date of Accidend Injury or Date Discovered 3 'a�1 -a (1 ► � Time S .' � ar�i !pm(circle) Please state,in detail,what occurred,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. � � `��.1 1�(1SL,l�f�Q_ • .��1��, �'� 1 - --- — P�le�a check the box(es)that most closely represent the reason for completing this form: Cfi"Vehicle was damaged in an accident ❑Vehicle was damaged during a tow O Vehicle was damaged by a pothole or condition of the street ❑ Vetiicle was damaged by a plow ❑ Vehicle was wrongfully towed and/or ticketed ❑ Injured on City property � Other type of property damage-please specify_ ❑ Other type of injury-please specify ❑ Other type not listed-please specify`_ In order to process your claim you need to inelu�e eopies of all apalicable documents. This is a general. guideline of what should be submitted with a claim form,but it is not all inclusive. You may be asked to provide additional information depending on your claim. O Property damage claims to a vehicle: �t least two estimates for the repairs to your vehicle,or the actual bills and/or receipts for the repairs ' O Towing claims: legible copies of any Cickets issued and copies of the impound lot receipts O Other property damage: repair estimates,detailed list of damaged items � Injury claims: medical bills,receipts O Photagraphs can be provided but will not be returned. Page 1 of 2-Please complete and return both pages of Claim Form Failure to provide a completed ciaim form will resutt in delays in prceessing. I ; Notice of Claim Form,City of Saint Paul,page two All Claims— lease com lete this section Were there witnesses to the incident? Ye\ No Unknown (circle) If es, please provide their names, adciress and telephone numbers: _�-�_�lti�.,L.O_�. (o l}� "I t) �-�(��a'� Were the police or law enforcement ca3led? es� No Unknown (circle) If yes,what department or agency? � i Case#or report# 1 "�1� l_.�—� '� Z Where did the accident or injury take place? Provide street address,cross street,intersection,name of park or facility,elosest landmazk,etc. Please be as detailed as possible. If helpful, attach a diagram. ,�--��-• —a�- U��Ua„rs d- �(�.a�ry,v�nd Please indicate the amount you are seeking in compensatic�n from this claim or what you would like the Ciry to do to resalve this c aim to your satisfactio QS - �A- � 0 Vehicle Claims—please complete this seetion ❑ check box if this section does not applv Your Vehicle: Yearav�..,_�_.Make U v l J �� Model '�',�� L License Plate Number �a ti �1m State M-,�Color R i Registered Owner I�� b Driver of Vehicle Area Damaged �v P City Vehicle: Year avU I N1ake I� �S �'Model License Plate Number i.�-�K. State Color Driver of Vehicle (City Employee's Name) LA�u�f�tn,! 1 Area Damaged In'u Ctaims— lease com lete this section ❑ check box if this section does not a l How were you injured? What part(s}of your body were injured? J ` h+�Q,c„rr . Have you sought medical treatment? �Yes_ No Planning to Seek Treatment (circle) When did you receive treatment7 (provide date(s)) Name of Medical Provider(s): Addsess Telephone Did you miss work as a result of your injury? Yes No When did you miss work? (p�ovide date(s)) Name af y�ur Employer: Address Telephone ❑Check here if you are attaching more pages to this claim form. Number of additional pages By signing thrs forin,you nre su►ting that aU infornur[ion you have provided is true and correct to the bcst of your knowtedge. Unsigned forms will not be processed Submi#ireg a false claim can resuU in prosecuaon. Print the Name of the Person who Completed this Form: �P m �r.��n� �ct�' N L�,'�t-j�a� L��-1 l�.y� -°s��-w--d-«�C. a�.sl��S P�,,. Signature of Person Making the Claim: Date form was eompleted � "� �a U� � Revised Apri120(l7 �-• , i `Total Resource Auctions c,,.u�w�,o,�tie 8,069.49 TRA Minneapolis 80�1 Jefferson Hiqhway ��Ah B�a: 8,400.00 Maple Grove MN 55369 noa ce�.s State Farm Insurance - Heartland Zone Paol Fee 65.00 6215 Ranch Drive Paol Tow o.o0 �ittle Rock AR 72223 Yard to Yard Transport o.o0 Tax ID# 58-1620001 Pool Storage o.00 Resale Cert# Enhancements 55.o0 Title Fees o.o0 s''"°'''�"�,°" DMV Fees 20.�5 Tt�#/Lot# : 474859! 737778 0.o0 Branch: Maple Grove Bond Fees o �� Insured: HUONG PHAN Taxes �,o0 Owner: HUONG PHAN K ysnspection o.o0 Claim#: 23-17S5-279 Re-Run o.o0 Year: 2013 Mail Personals o.o0 Make/Model: VOLV XC60 AWD 3.OL ViR o.o0 VIN: YV4902DZXD2372562 T �� iao.�5 ACV: 43,193.00 wer.ne.cn.�.s Plekuo 1.oaatlen In�onn�llon T�W 54.50 Impound Lot as.o0 Saint Paul MN 551a7 Storage Administrative Fees eo.o0 s«i ob.�e►su�..��e�o� Tea�down o.o 0 UAB SAGUNE Estimate Fee o.o0 KLAIPEDA 5810 Lien Fees o.o0 Taxes io.26 °ati°��"''"�' Clean Up a.o0 Loss Date 03/29/13 EPA Clean-Up o.o0 Assigned 04/04/13 parts Shop o.o0 Released 04/04/13 preservation 4.flo PECk Up 04/04/13 �� 189.76 Titfe Received 05/16/13 �,ao Sale Doc Received 05I28/13 Late Pick Up Credit Auction Dats 07/�6/13 T��i��, 330.5� Buyer Payment Date 07/19/13 Reported to N1CB REC'D 1N CSU SUL 2 $ 2013 �E�RTLAN� ZflNE i C ' d ` . . �r��.►�� w�a . . .• .�� r�w •�r��-� ��• Sainf Paul Police fmpound lot,830 Barge Cha��el Raad,Vehic�e Rel�ase Form t rf�ake;13 VOLVO lice�e�027HYM CN;134�D13Z Irnwic�#143T� E}atelTime Rel�ase�:04104�t01313:59 Tow Cfrarge; � �4.�0 Ol� ' �eleased to:TRA Staage Charge: $ 4�.04 � �� 1'� oDo gaid by:CRE�IT CARD Rdmi�Charge; $ 8 . Re�ased by;CHERI Taz;{7.62��) $ 10.26 �,�he u�ders�ned,have recover�d the veh�c�desc�bed above, Subto�f: $ 189.16 !u�11 c�eck�e uehic�for dama�e�any othe�pro�ems that may have accUrretl while�his vehicle was i��e a,stady of�he Servi�e Charge; S Q,� Sai�t Pau(Palice Departm�l. I ac�Crio�ul�ge I wifl repart damage a�dlor a�y a�er pr�lems to�e Impau�d Lo�sta� To�l Charges; $ 189.16 ��is fa�m p�a to leaving�impou��1ot Dam�e a�1or a�her pro�lem: Police Repo�made:Yes�No_I�Yes,C��,li N0,Why? TO PROTECT YOUR RIGHYS REPORT ANY PROBIEMSIDAMA�E BEFORE LEAVI�IG TH�lOT �i��ore ��o .j _ � � I J•r„� � �T� I�"t�RJt� t{7T 83� B�� #fAiVI�E�. iRD S�I� P�. h�N. �5�.07-2�5� 6a1-2�6�-56�� I'''lerchant �D: $�380�4� Tera� �Ci: 0�1��4�6��80�S38�I��IB P��r�� rc��r� �a�cxxx�c�cx�xxg�$� �T�� nt�� Me#��: l��u�� ; � f$�.7� Tax; � �� ._____� ��=__ , _�__�.� �ota�: � 1�{�� 4�1� �4:0�; 0� �� #; �� r ��e: �i��"� ��r��: �n 1 i�e �� e: ��P h1p��1 � ��f� �o�e: �I��C� �l * �:� � � � � � �ustQn,��' Gan�r THA1�1� �fflt�* t x ;;. -. .� -'YS�id'�.` 3� "} � .'_ �.'. µ _ .�_ ,,� # � ' � .e �,.- u �. _ �'v+� � z CA� " , 'd� � ' � w_.D f'�3F� r .5,�'� � �' '@'� � ..'. , °:y� t�"}k•'�'.�.�� . ._..� � �'�: .,.t� . �� ,�� ..o-4"+'y (`l�. t . �� .�. �c �`�� r . �� x R ( '��' I G�\�r �::�� -��,�1 X�'� . ; � q � �� . _ : �,, . . �, t�. � ?�, y.�"' , . .��,4s' ��` 4�n.-� �, �. � � ° :s�'= �. _ - =` ��, .,,y . ,�t J� ��,. _�--';;� - --- ^,,� i` {� _ _ � �,`� '` ��-- � 9 �, .._� . � `,� °> _ .ea,.;,rx-.su_�"4�'a.Ye�.'2: +* :Y, `�' ,. . . . . -i _ �"S3""` , � S� � . _ � ° . . . ..... . . . . 3 . -��' �� ...."�a. . �, �_ . � ` , r . +# ,. ., „ . ;, . ... � . .. .. .. t � � .��— .. .�`� _. .. � _ x„t �,._� � .. �s �°' �� - 's ;,'�, . ,�. w .,' .�, 1 �� :� ��. r a��Ae�:, � ---° r -�� "; s :�+� w'��3i�:��,s�s. i �:: '..: �.`.�::' . �:R- . � .;.c .,.. ....: "A 4.-„ ..,.. .� .. �� . � ~ --�� _ . � _� � }; _ .: .. .._ ... ..�.�.z '_ _ .. 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N «.._. �,�✓��--°-.__._ .._r.�-, .. ... ._ :�� . �� - •. s. r . �, -�--�,.._,rv � ` .,a, . . . _ . , �,_� .... ..., .^. �_ d.. . .... . :.—.,,,,._,-�:. . ..... . . ,1� .� �. ,� � .. .;�.. �� . `��. . . . .... .� ` , �� _.. .�_�� . K�� 4 -� r � _� � ;� _._ � :=� A{� _�, , � 04/05/13 11:43 AUTOSOURCE Page 1 � Via: Multiple AS Request: 32420558 Version: 1 ADMINISTRATIVE DATA 2013 VOLVO XC60 T6 TURBO 4WD 4D WAGON Joe Erickson Claimant: State Farm Insurance Insured:Phan, Huong Plymouth Branch Claim:23-1755-27901 1285 Northland Drive Loss Date: 03/29/2013 Mendota Heights MN 55120 Loss Type:Collision Policy: Other: Estimator Name: . Estimator Phone: . Vehicle Location: . License Number: . License State: . License Expiration: . Specialty Plate Type: _ ' Prior Damage AmountS : . . Prior Damage Desc: . Supplement Amount S : . Supplement Desc: . Tow / Other Charges: . Other Remarks : _ '. i VALUATION DETAIL 2013 VOLVO XC60 T6 TURBO 4WD 4D WAGON I 1 . 2013 VOLVO XC60 T6 TURBO 4WD 4D WAGON Comparable 1 Your Vehicle PRICE South Kansas City, Mo 537 , 985 Odometer 6 , 450 Mi(Actual ) 10 , 585 Mi(Actual ) -350 Equipment Reverse Sensing 735 Packages Climate Package 840 Tailgate Package 1 , 215 Technology Package 1 , 965 Comparable 1 Adjusted Price 542 , 390 2 . 2013 VOLVO XC60 T6 TURBO 4WD 4D WAGON Comparable 2 Your Vehicle PRICE Louisville , Ky 543 , 710 Odometer 6 , 348 Mi(Actual ) 10 , 585 Mi(Actual ) -360 Reverse Sensing 735 Packages Climate Package 840 Tailgate Package 1 , 215 Comparable 2 Adjusted Price 546 , 140 3 . 2013 VOLVO XC60 T6 TURBO 4WD 4D WAGON Comparable 3 Your Vehicle PRICE Salt Lake - Ut 539 , 805 Odometer 6 , 259 Mi(Actual ) 10 , 585 Mi(Actual ) -370 04/05/13 11: 43 AUTOSOURCE Page 2 Via: Multiple AS Request: 32420558 Version: 1 VALUATION DETAIL (continued) 2013 VOLVO XC60 T6 TURBO 4WD Reverse Sensing 735 Packages Climate Package 840 Tailgate Package 1 , 215 Technology Package 1 , 965 Comparable 3 Adjusted Price 544 , 190 4 . 2013 VOLVO XC60 T6 TURBO 4WD 4D WAGON Comparable 4 Your Vehicle PRICE Salt Lake , Ut 537 , 038 Odometer 6 , 606 Mi(Actual ) 10 , 585 Mi(Actual ) -340 Reverse Sensing 735 Packages Climate Package 840 Tailgate Package 1 , 215 Technology Package 1 - 965 � -� Comparable 4 Adjusted Price 541 , 453 Final Market Value Calculation 1 _ 2013 Volvo XC60 T6 Turbo 4WD 4D Wagon 542 , 390 2 . 2013 Volvo XC60 T6 Turbo 4WD 4D Wagon 546 , 140 3 . 2013 Volvo XC60 T6 Turbo 4WD 4D Wagon 544 , 190 4 . 2013 Volvo XC60 T6 Turbo 4WD 4D Wagon 541 , 453 Average Price 543 , 543 Total Condition Adjusted Market Value 543 , 543 Deductible -500 . 00 Net Adjusted Value 543 , 043 . 00 The selling price may be substantially less than the asking price. In the case of this 2013 Volvo XC60 T6 Turbo 4WD 4D Wagon, the difference between the asking price and selling price is generally 5a. This selling price adjustment has been applied to the advertised price . VEHICLE DESCRIPTION 2013 VOLVO XC60 T6 TURBO 4WD 4D WAGON VIN: YV4902DZXD2372562 VOLVO 2013 Volvo XC60 T6 Turbo 4WD 4D Wagon 10 , 585 Miles Standard Automatic Dimming Auto Headlamp Air Conditioning Dual Airbags Alarm System Amplifier Anti-Lock Brakes Dual Zone Auto A/C Bodyside Cladding Rear Step Bumper Cruise Control Center Console Rear Window Daytime Running Driver Seat Memory Floor Mats Bucket Seats Head Airbags High Definition Halogen Headlights Intermittent Wipers Illuminated Visor Keyless Entry LED Brakelights Lighted Entry Mirror(s) Memory Heated Power MP3 Player Power Brakes Power poor Locks 04/05/13 11:43 AUTOSOURCE Page 3 Via: Multiple AS Request: 32420558 Version: 1 VEHICLE DESCRIPTION (continued) 2013 VOLVa XC60 T6 TURBO 4WD Power Steering Power Windows Dual Power Seats � Roof/Luggage Rack AM/FM CD Player Rear Fog Lamp 2nd Row Head Split Folding Rear Rain-Sensing W/S Rem Trunk-L/Gate Rear Window Side Airbags Stability Cntrl Leather Seats Rear Spoiler Sirius Satellite Dual Sunroof Strg Wheel Radio _ Leather Steering Tachometer Trip Computer � Traction Control Tinted Glass Tire Pressure Tilt & Telescopic Aluminum/Alloy Wireless Phone Wireless Audio Optional Adaptive Cruise Heated Frnt & Rear Heated W/S Wiper Power Liftgate Reverse Sensing Rear View Camera Packages Climate Package : Heated Frnt & Rear Seats : Heated W/S Wiper Washers; Tailgate Package: Power Liftgate: Rear View Camera; Technology Package: Adaptive Cruise Control Trim Levels *T6 , T6 Platinum, T6 Premier Plus . T6 * Indicates your R-Design, T6 R-Design Plat , T6 R-Dsgn trim level Premr+ A detailed description of your vehicle was provided to Autosource by a trained appraiser. Contact State Farm Insurance if revisions are necessary. VEHICLE CONDITION 2013 VOLVO XC60 T6 TURBO 4WD 4D WAGON SEATS Good CARPETS Good INT TRIM Good GLASS Good HEADLINER Good BODY Good PAINT Good EXT TRIM Good ENGINE Well Maintained TRANSMISSION Well Maintained FRONT TIRES New REAR TIRES New COMPARABLE VEHICLE DETAILS 2013 VOLVO XC60 T6 TURBO 4WD 4D WAGON The following information provides the details for the vehicles used to calculate the Autosource Value . 1 2013 VOLVO XC60 T6 TURBO Adjusted 537 � 985 04/05/13 11:43 AUTOSOURCE Page 4 Via: Multiple AS Request: 32420558 Version: 1 COMPARABLE VEHICLE DETAILS (continued) 2013 VOLVO XC60 T6 TURBO 4WD Stock# L13087 . 6450 Miles . 6 Cylinder Turbo 3 . 0 Engine � 6-Speed Automatic , Anti-Lock Brakes , Air Conditioning- Automatic Dimming Mirror- Auto Headlamp v� i,: Control , Alarm System, Aluminum/Alloy Wheels , Amplifier, Bodyside Cladding, Bucket Seats , Cruise Control , AM/FM CD Player- Center Console, Dual Airbags , Rear Window Defroster, Heated Power Mirrors , Daytime Running Lights , Driver Seat Memory- Dual Sunroof , Dual Zone Auto A/C, Dual Power Seats , Floor Mats , Head Airbags , Halogen Headlights , High Definition Radio, Intermittent Wipers , Illuminated Visor Mirror, Keyless Entry System, LED Brakelights , Lighted Entry System, Leather Steering Wheel , Leather Seats , Mirror(s) Memory, MP3 Player, Power Brakes , Power poor Locks , Power Steering, Power Windows , Roof/Luggage Rack. Rear Fog Lamp, 2nd Row Head Airbags , Rear Step Bumper, Rain-Sensing W/S Wipers , Rem Trunk-L/Gate Release , Rear Window Wiper/Washer, Side Airbags , Stability Cntrl Suspensn. Split Folding Rear Seat - Rear Spoiler, Sirius Satellite Radio, Strg Wheel Radio Control , Tachometer, Trip Computer, Traction Control System, Tinted Glass , Tire Pressure Monitor. Tilt & Telescopic Steer, Wireless Phone Connect , Wireless Audio Streaming, Floor Mats , Blue Tooth Communications . Center Armrest . Q��ered for sale by Superior Volvo in South Kansas City, MO, ( 816 )501-2818 . Advertised 03/10/13 . VIN Not Advertised.The advertised price of 539 , 984 was adjusted to account for typical negotiation. 2 2013 VOLVO XC60 T6 TURBO Adjusted 543 , 710 Stock# V380190 . 6348 Miles . 6 Cylinder Turbo 3 . 0 Engine , 6-Speed Automatic , Technology Package , Anti-Lock Brakes , Air Conditioning� Adaptive Cruise Control , Automatic Dimming Mirror, Auto Headlamp Control , Alarm System, Aluminum/Alloy Wheels , Amplifier, Bodyside Cladding, Bucket Seats - Cruise Control , AM/FM CD Player, Center Console , Dual Airbags , Rear Window Defroster. Heated Power Mirrors , Daytime Running Lights , Driver Seat Memory, Dual Sunroof , Dual Zone Auto A/C, Dual Power Seats , Floor Mats , Head Airbags , Halogen Headlights , High Definition Radio. Intermittent Wipers , Illuminated Visor Mirror, Keyless Entry System, LED Brakelights , Lighted Entry System, Leather Steering Wheel - Leather Seats , Mirror(s) Memory, MP3 Player, Power Brakes , Power poor Locks , Power Steering, Power Windows , Roof/Luggage Rack, Rear Fog Lamp, 2nd Row Head Airbags , Rear Step Bumper, Ftain-Sensing W/S Wipers , Rem Trunk-L/Gate Release , Rear Window Wiper/Washer, Side Airbags , Stability Cntrl Suspensn, Split Folding Rear Seat , Rear Spoiler, Sirius Satellite Radio, Strg Wheel Radio Control - Tachometer, Trip Computer, Traction Control System, Tinted Glass , Tire Pressure Monitor, Tilt & Telescopic Steer, Wireless Phone Connect , Wireless Audio Streaming. Offered for sale by Volvo Of Louisville in Louisville , KY- (502 )493-3333 . Advertised 03/10/13 . VIN Not Advertised.The advertised price of 546 , 500 was adjusted to account for typical negotiation. 3 2013 VOLVO XC60 T6 TURBO Adjusted 539 , 805 04/05/13 11:43 AUTOSOURCE Page 5 Via: Multiple AS Request: 32420558 Version: 1 COMPARABLE VEHICLE DETAILS (continued) 2013 VOLVO XC60 T6 TURBO 4WD 6259 Miles . 6 Cylinder Turbo 3 . 0 Engine - 6-Speed Automatic , Anti-Lock Brakes , Air Conditioning, Automatic Dimming Mirror, Auto Headlamp Control , Alarm System, Aluminum/Al1oy Wheels , Amplifier, Bodyside Cladding, Bucket Seats , Cruise Control , AM/FM CD Player, Center Console , Dual Airbags , Rear Window Defroster, Heated Power Mirrors , Daytime Running Lights , Driver Seat � Memory, Dual Sunroof , Dual Zone Auto A/C, Dual Power Seats , Floor Mats , Head Airbags , Halogen Headlights , High Definition Radio, Intermittent Wipers , Illuminated Visor Mirror, Keyless Entry System, LED Brakelights , Lighted Entry System, Leather Steering Wheel , Leather Seats , Mirror(s) Memory. MP3 Player, Power Brakes , Power poor Locks , Power Steering, Power Windows , �oof/Luggage Rack, Rear Fog Lamp, 2nd Row Head Airbags , Rear Step Bumper, Rain-Sensing W/S Wipers , Rem Trunk-L/Gate Release , Rear Window Wiper/Washer, Side Airbags , Stability Cntrl Suspensn, Split Folding Rear Seat, Rear Spoiler� Sirius Satellite Radio, Strg Wheel Radio Control , Tachometer, Trip Computer, Traction Control System, Tinted Glass , Tire Pressure Monitor, Tilt & Telescopic Steer, Wireless Phone Connect , Wireless Audio Streaming. Offered for sale by Ken Garff Jaguar in Salt Lake , UT, ( 801)257-3600 . Advertised 03/11/13 . VIN Not Advertised.The advertised price of 541 , 900 was adjusted to account for typical negotiation. 4 2013 VOLVO XC60 T6 TURBO Adjusted 537 . 038 Stock# 1VU1221 . 6606 Miles . 6 Cylinder Turbo 3 . 0 Engine , 6-Speed Automatic , Anti-Lock Brakes , Air Conditioning, Automatic Dimming Mirror, Auto Headlamp Control , Alarm System, Aluminum/Alloy Wheels , Amplifier. Bodyside Cladding, Bucket Seats , Cruise Control , AM/FM CD Player, Center Console- Dual Airbags, Rear Window Defroster, Heated Power Mirrors , Daytime Running Lights , Driver ��-at Memory, Dual Sunroof , Dual Zone Auto A/C, Dual Power Seats , Floor Mats , Head Airbags , Halogen Headlights , High Definition Radio, Intermittent Wipers , Illuminated Visor Mirror, Keyless Entry System, LED Brakelights , Lighted Entry System, Leather Steering Wheel , Leather Seats , Mirror(s) Memory, MP3 Player, Power Brakes , Power poor Locks , Power Steering, Power Windows , Roof/Luggage Rack. Rear Fog Lamp. 2nd Row Head Airbags , Rear Step Bumper , Rain-Sensing W/S Wipers , Rem Trunk-L/Gate Release , Rear Window Wiper/Washer, Side Airbags , Stability Cntrl Suspensn- Split Folding Rear Seat , Rear Spoiler , Sirius 5atellite Radio, Strg Wheel Radio Control , Tachometer, Trip Computer, Traction Control System, Tinted Glass , Tire Pressure Monitor- Tilt & Telescopic Steer, Wireless Phone Connect , Wireless Audio Streaming. Offered for sale by Ken Garff Volvo in Salt Lake , UT, (801 )257-3500 . Advertised 04/02/13 . The advertised price of 538 � 987 was adjusted to account for typical negotiation. VINSaURCE ANALYSIS 2013 VOLVO XC60 T6 TURBO 4WD 4D WAGON 04/OS/13 11:43 AUTOSOURCE Page 6 Via: Multiple AS Request: 32420558 Version: 1 VINSOURCE ANALYSIS (continued) 2013 VOLVO XC60 T6 TURBO 4WD VIN: YV4902DZXD2372562 Decodes as: 2013 Volvo XC60 T6 Turbo 4WD 4D Wagon Accuracy: Decodes Correctly History: Activity was reported o AUTOSOURCE ACTIVITY: (NONE? . o AUTOTRAK ACTIVITY: (NONE) . o AUDATEX/ESTIMATING ACTIVITY: (NONE) o SALES HISTORY ACTIVITY: (NONE) REPORTED PHONE NUMBER ANALYSIS 2013 VOLVO XC60 T6 TURBO 4WD 4D WAGON No Vehicles Advertised at (651 ) 641-4763 No Vehicles Advertised at (763 ) 767-1186 VALUATION NOTES 2013 VOLVO XC60 T6 TURBO 4WD 4D WAGON o Adjustments of Special Note - The requested Exception valuation has been processed using one or more Comparables in order to meet state regulatory requirements . - A mileage adjustment of 8 . 50 cents per mile/kilometer has been applied. This adjustment is based on the vehicle year, vehicle category and market area. Mileage adjustments are capped at 40% of the vehicle ' s starting value . - No special adjustments were made for this vehicle. o Information provided by State Farm Insurance - Loss vehicle description was provided by State Farm Insurance - All values are in U. S . dollars _ o Autosource Valuation Process - Over 3 , 800 - 000 vehicles are entered weekly into the database used for researching this value . This database includes dealer inspected- dealer inventory, dealer advertised- phone verified and advertised private party vehicles . - The originating search area for this valuation was Blaine , Minnesota. - The market area expansion was authorized by Autosource Guidelines . 04/05/13 11:43 AUTOSOURCE Page 7 Via: Multiple AS Request: 32420558 Version: 1 VALUATION NOTES (continued) 2013 VOLVO XC60 T6 TURBO 4WD t� �. The VIN decoded correctly. o Other Adjustments or Comments - Inspection Location: TRA - Estimate Left With: No one - Possible Supp Amt & Desc: Large Add likly - Prior Damage Amt & Desc: S - Remarks: Rt rear wheel hit . Rolled over, damageing lt side and roof . Side air bags and seat bags . - Valuation or VIR Submitted: Yes - Estimate Amount: 531 , 916 . 96 - Option/Accessory Notes : Condition Notes: Like new - Odometer Accurate: Yes Keys Available: Yes - License & State: 022 HYM, Mn Expiration Date: Jun 13 Specialty Plate: - Storage per day: S Towing and Other Charges : S - Engine 5erial #: - This valuation does not include condition adjustments as the loss vehicle was reported in typical condition NICB REPORT 2013 VOLVO XC60 T6 TURBO 4WD 4D WAGON NICB/ISO Member: 5037 STATE FARM MUTUAL AUTOMOBILE Claim: 2317S5279 Loss Date: 03/29/13 Type of Loss: PROPERTY/CASUALTY Phone: RECALL BULLETINS 2013 VOLVO XC60 T6 TURBO 4WD 4D WAGON Nat � l . Highway Traffic Safety Admin (US) has issued a total of 2 recall bulletins that may apply to this vehicle . NHTSA ID Number: 12V439000 Date Issued: 09/10/12 Quantity Affected: 9 04/05/13 11:43 AUTOSOURCE Page 8 Via: Multiple AS Request: 32420558 Version: 1 RECALL BULLETINS (continued) 2013 VOLVO XC60 T6 TURBO 4WD Defect: Volvo is recalling certain model year 2013 S60 and XC60 vehicles _ A manufacturing defect within the Supplemental Restraint System (SRS) control unit may lead to an inadvertent deployment of the seat belt pretensioner and/or inflatable curtain. If the seat belt pretensioner and/or inflatable side curtain deploy without cause , the driver could be distracted and the driver ' s visibility could be reduced. increasing the risk of a crash. ' Remedy: These vehicles have not been sold and the SRS control unit will be replaced prior to the cars being sold. Owners may contact Volvo at 1-800-458-1552 _ The Volvo recall campaign number is 257 . Consumers may also contact the National Highway Traffic Safety Administration� s vehicle safety hotline at 1-888-327-4236 (TTY 1-800-424-9153 ) , or go to www. safercar.gov. NHTSA ID Number: 13V084000 Date Issued: 03/05/13 Quantity Affected: 7 Defect: Volvo is recalling certain model year 2013 S60 and XC60 vehicles � manufactured on January 7 , 2013 . The product identification labels were printed with the incorrect manufacture year. Thus , these vehicles fail to comply with the requirements of 49 CFR Part 567 , °Certification Regulation. " With an incorrect date of manufacture on the certification label , the vehicle owner may not be to determine if they are affected by future vehicle recalls , increasing their risk of a crash of injury. Remedy: Volvo has quarantined the affected vehicles and will install correct labels prior to sale. The recall began during March 2013 . Owner notification letters will not be sent . Owners may also contact the National Highway Traffic Safety Administration� s vehicle safety hotline at 1-888-327-4236 (TTY 1-800-424-9153 ) , or go to www. safercar.gov. ORIGINAL EQUIPMENT GUIDE 2013 VOLVO XC60 T6 TURBO 4WD 4D WAGON ----------Engine Options----------- -------Transmission Options-------- * 6 Cylinder Turbo 3 . 0 STD * 6-Speed Automatic STD -----Other Optional Equipment------ --------Convenience Options-------- 04/05/13 11 : 43 AUTOSOURCE Page 9 Via: Multiple AS Request: 32420558 Version: 1 ORIGINAL EQUIPMENT GUIDE (continued) 2013 VOLVO XC60 T6 TURBO 4WD * Anti-Lock Brakes STD * Air Conditioning STD * Amplifier STD * Adaptive Cruise Control * Bodyside Cladding STD * Automatic Dimming Mirror STD * Center Console STD * Auto Headlamp Control STD * Dual Airbags STD * Cruise Control STD * Head Airbags STD * Rear Window Defroster STD * Halogen Headlights STD * Daytime Running Lights STD * Intermittent Wipers STD * Dual Zone Auto A/C STD * Keyless Entry System STD * Floor Mats STD * LED Brakelights STD * Heated W/S Wiper Washers * Lighted Entry System STD * Illuminated Visor Mirror STD * Leather Steering Wheel STD Mud/Splash Guards * Mirror(s? Memory STD * Reverse Sensing System 5785 Metallic Paint 5550 * Rain-Sensing W/S Wipers STD * Roof/Luggage Rack STD * Rem Trunk-L/Gate Release STD Rear Entertainment Systm 51 , 800 * Rear View Camera * Rear Fog Lamp STD * Strg Wheel Radio Control STD * 2nd Row Head Airbags STD * Tire Pressure Monitor STD Running Boards * Tilt & Telescopic Steer STD * Rear Step Bumper STD ---------Power Accessories--------- * Rear Window Wiper/Washer STD * Heated Power Mirrors STD * Side Airbags STD * Dual Power Seats STD * Stability Cntrl Suspensn STD * Power Brakes STD Skid Plates 5415 * Power poor Locks STD * Rear Spoiler STD * Power Liftgate * Tachometer STD * Power Steering STD * Trip Computer STD * Power Windows STD * Traction Control System STD -----------Seat Options------------ Tonneau/Cargo Cover 5215 * Bucket Seats STD * Tinted Glass STD Child Seats (2 ) 5500 Wood Interior Trim 5650 * Driver Seat Memory STD * Wireless Phone Connect STD * Heated Frnt & Rear Seats * Wireless Audio Streaming STD * Leather Seats STD -----Radio/Phone/Alarm Options----- * Split Folding Rear Seat STD * Alarm System STD -----------Wheel Options----------- * AM/FM CD Player STD 19 Inch Al1oy Wheels 5750 * High Definition Radio STD * Aluminum/Alloy Wheels STD * MP3 Player STD -----------Roof Options------------ * Sirius Satellite Radio STD * Dual Sunroof STD ------------------------------Option Packages------------------------------- Blind Spot Info System 5700 Includes Power Retractable Rearview Mirrors Camera Package 5795 Includes Front Blind View Camera * Climate Package 5900 Includes Heated Frnt & Rear Seats , Heated W/S Wiper Washers � Interior Air Quality System 04/05/13 11 : 43 AUTOSOURCE Page 10 Via: Multiple AS Request: 32420558 Version: 1 ORIGINAL EQUIPMENT GUIDE (continued) 2013 VOLVO XC60 T6 TURBO 4WD Exterior Styling Kit 51 , 575 Package #1 51 , 095 Includes Mud/Splash Guards , Running Boards Polestar 51 , 495 Portable Navigation 5795 Scuff Plates 5755 * Tailgate Package 51 , 300 Includes Power Liftgate , Rear View Camera * Technology Package 52 , 100 Includes Adaptive Cruise Control , Lane Departure Warning, Pedestrian Detection , Base retail price: 541 , 545 -,��., Loss Vehicle manufacturer� s suggested retail price as reported: 546 , 630 Editions available for the same body style (in order of original cost , increasing) : *T6 , T6 Premier Plus , T6 R-Design, T6 Platinum, T6 R-Dsgn Premr+ , T6 R-Design Plat * Indicates loss vehicle equipment . ABOUT YOUR VALUATION 2013 VOLVO XC60 T6 TURBO 4WD 4D WAGON This report contains proprietary information of Audatex and shall not be disclosed to any third party (other than the insured or claimant) without Audatex� s prior written consent . If you are the insured or claimant and have questions regarding the description of your vehicle , please contact the insurance company that is handling your claim. Information within VINsource/NICB is provided solely to identify potential duplicative claims activity. User agrees to use such information solely for lawful purposes . Tax rates contained herein are based on general sales tax data provided by Vertex Inc . Excise , use - registration, licensing and other taxes and fees that may be applicable are not included. Audatex makes no representations or warranties concerning the applicability or accuracy of such tax data. 04/05/13 11 : 43 AUTOSOURCE Page 11 Via: Multiple AS Request: 32420558 Version: 1 Report Generated by Audatex� a Solera Company US Pat _ No 7912740B2 US Pat_ No 8200513B2 (C) 2013 Audatex North America, Inc . All Rights Reserved. STATE FARM INSURANCE COMPANIES 500 SOUTH 84TH STREET LINCOLN, NE 68510-2611 SUPPLEMENT FAX:(MN,WI)800-230-1949 SUPPLEMENT FAX:(IA,NE,ND,SD)800-455-9697 """PRIOR DAMAGE ESTIMATE"*'' 04/05/2013 12:45 PM Owner Owner: HUONG N PHAN Address: 12324 3RD ST NE Work/Day: (651)641-4763 Home/Day: (763)767-1186 City State Zip: BLAINE, MN 55434-1982 Cell: (763)259-0153 Control Information Claim#: 23-17S5-27901 Insured Policy#: Loss Date/Time: 03/29/2013 07:00 AM Loss Type: Collision Insured: HUONG N PHAN Address: Work/Day: (651)641-4763 Home/Day: (763)767-1186 City State Zip: Cell: (763)259-0153 Claim Rep: TEAM R3 ACC CP Address: Work/Day: (866)207-6046 Inspection Inspection Date: 04/05/2013 12:37 PM Inspection Type: Field Inspection Location: TRA-MINNEAPOLIS Contact: Address: 8001 JEFFERSON HWY City State Zip: MAPLE GROVE, MN 55369-4902 Primary Impact: Rollover Secondary Impact: Driveable: No Rental Assisted: Assigned Date/Time: Received Date/Time: 04/05/2013 12:22 PM ��`'-�' First Contact DateRime: Appointment Date/Time: 04/08/2013 08:00 AM Appraiser Name: JOE ERICKSON Appraiser License#: Vehicle 2013 Volvo XC60 T6 4 DR Wagon 6cyl Gasoline Turbo 3.0 6-Speed Automatic Lic.Plate: 022 HYM Lic State: MN Lic Expire: 06/2013 VIN: YV4902DZXD2372562 Prod Date: Mileage: 10,585 Veh Insp#: Mileage Type: Actual Condition: Code: K2704D Ext. Color: BLACK Int.Color: Ext.Refinish: Two-Stage Int.Refi�ish: Options 04/052013 01:08 PM Page 1 of 4 2013 Volvo XC60 T6 4 DR Wagon �laim#: 23-1755-27901 04/OS/2013 12:45 PM 2nd Row Head Airbags 4-Wheel Drive AM/FM CD Player Adaptive Cruise Control Air Conditioning Alarm System Aluminum/Alloy Wheels Amplifier Anti-Lock Brakes Auto Headlamp Control Automatic Dimming Mirror Bodyside Cladding Bucket Seats Center Console Cruise Control Daytime Running Lights Driver Seat Memory Dual Airbags Dual Power Seats Dual Sunroof Dual Zone Auto A/C Floor Mats Halogen Headlights Head Airbags Heated Frnt&Rear Seats Heated Power Mirrors Heated W/S Wiper Washers High Definition Radio Illuminated Visor Mirror Intermittent Wipers �e�ss Entry System LED Brakelights Leather Seats Leather Steering Wheel Lighted Entry System MP3 Player Mirror(s)Memory Power Brakes Power poor Locks Power Liftgate Power Steering Power Windows Rain-Sensing W/S Wipers Rear Fog Lamp Rear Spoiler Rear Step Bumper Rear View Camera Rear Window Defroster Rear Window Wiper/Washer Rem Trunk-L/Gate Release Reverse Sensing System Roof/Luggage Rack Side Airbags Sirius Satellite Radio Split Folding Rear Seat Stability Cntrl Suspensn Strg Wheel Radio Control Tachometer Tilt&Telescopic Steer Tinted Glass Tire Pressure Monitor Traction Control System Trip Computer Wireless Audio Streaming Wireless Phone Connect Damages Line Op Guide MC Description MFR.Part No. Price ADJ% Hours R Front Bumper 1 RI 8 Front Bumper Cover R&I R 8� I Assembly 1.0 SM 2 I 8 Cover,Front Bumper Repair 1.0" SM »Rt Ft, Rt of center 3 L 8 # Cover,Front Bumper Refinish 3.6'` RF 2.5 Surface 0.6 Two-stage setup 0.5 Two-stage #= 10, 13 »*'REFINISH WITHIN DAMAGED PANEL** 4 E 92 01 Spoiler,Lower Front 307634121 $138.14 0.2 SM 5 E 363 Defl,Front Bumper Lwr 312908635 $69.07 0.3 SM Front End Panel And Lam�s 6 RI 28 Grille Assembly R&I Assembly 0.3 SM Manual Entries 7 SB Flex Additive Sublet Repair $2.00" SM 8 SB Hazardous Waste Removal Sublet Repair $3.00* SM 8 Items MC Message 01 CALL DEALER FOR EXACT PART#/PRICE 10 INCLUDES AUDATEX 71ME TO CLEAR ENTIRE PANEL 13 INCLUDES 0.6 HOURS FIRST PANEL TWO-STAGE ALLOWANCE Estimate Total&Entries Gross Parts $207.21 Paint Materials $115.20 Page 2 of 4 04/052013 01:08 PM 2013 Volvo XC60 T6 4 DR Wagon Geim#: 2317S5-27901 04/OS/2013 12:45 PM �g,$Material Total $322.41 Labor Rate Replace Repair Total Hrs Hrs Hrs Sheet Metal(SM) $52.00 1.8 1.0 2.8 $145.60 Mech/Elec(ME) $75.00 Frame(FR) $75.00 Refinish(RF) $52.00 3.6 3.6 $187.20 Paint Materials $32.00 Labor Total 6.4 Hours $332.80 Gross Total $674.46 Alternate Parts Y/00/00/00/00/00 CUM 00/00/00/00/00 Zip Code: 55430 METRO AREA RecyGed Parts NOT APPLICABLE .,.._ =.�;_ A�ifex Estimating 6.0.925 ES 04/05/2013 01:08 PM REL 6.0.925 DT 02/01/2013 Copyright(C)2011 Audatex North America, Inc. *"THIS IS AN AUDATEX"FAST START"VEHICLE. PLEASE CALL YOUR LOCAL DEALER TO CONFIRM PART NUMBERS AND PRICES.'* 1.1 HRS WERE ADDED TO THIS ESTIMATE BASED ON AUDATEX'S TWO-STAGE REFINISH FORMULA. ANY PERSON WHO SUBMITS AN APPLICATION OR FILES A CLAIM WITH INTENT TO DEFRAUD OR HELPS COMMIT A FRAUD AGAINST AN INSURER IS GUILTY OF A CRIME. THIS IS AN ESTIMATE. REPAIR FACILITES MUST INSPECT THE VEHICLE TO DETERMINE IF ANY REPAIRS NOT LISTED ARE REQUIRED,AND TO CONTACT STATE FARM BEFORE MAKING SUCH REPAIRS. REPAIRER ALSO IS RESPONSIBLE FOR CONDUCTING ANY NECESSARY INSPECTION AND SAFETY CHECKS PRIOR TO AND AFTER COMPLETING REPAIRS. THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF ONE OR MORE CRASH PARTS SUPPLIED BY A SOURCE OTHER THAN THE MANUFACTURER OF YOUR MOTOR VEHICLE. WARRANTIES APPLICABLE TO THESE REPLACEMENT PARTS ARE PROVIDED BY THE PARTS MANiJFACTURER OR DISTRIBUTOR RATHER THAN BY THE MANUFACTURER OF YOUR VEHICLE. A PERSON WHO FILES A CLAIM WITH INTENT TO DEFRAUD OR HELPS COMMIT A FRAUD AGAINST AN INSURER IS GUILTY OF A CRIME. Op Codes * = User-Entered Value E = NEW PART NG= Replace NAGS EC= *" NON-OEM PART ET= Partial Replace Labor EP= *"NON-OEM PART EU= RECYCLED PART TE = Partial Replace Price PM= REMAN/REBUILT PART UM= REMAN/REBUILT PART L = Refinish PC= RECOND PART UC= RECOND PART TT = Two-Tone SB= Sublet Repair N = ADDITIONAL OPERATION BR= Blend Refinish I = Repair IT = Partial Repair CG= Chipguard RI = R& I Assembly P = Check �-�:,.� 04/052013 01:08 PM Page 3 of 4 2013 Volvo XC60 T6 4 DR Wagon Claim#: 23-1755-27901 04/OS/2013 12:45 PM This report contains proprietary information of Audatex and may not be disclosed to any third party(other than the insured, Gaimant and others on a need to know basis in order to effectuate the claims process)without ��1�� Audatex's prior written consent. Y a S�lert canpanp Copyright(C)2011 Audatex North America, Inc. Audatex Estimating is a trademark of Audatex North America, Inc. "4,e s Page 4 of 4 04/052013 01:08 PM 04/05/13 11:28 AUTOSOURCE Page 1 ' Via: Multiple AS Request: 32420554 Vehicle Inspection Report ---------------------------------------------------------------------------- Claim No: 23-1755-27901 Rep: Claim Unit: Owner: PHAN Rep Phone: Rep Fax: Insured: PHAN, HUONG Loss Code: Date of Loss : 03/29/13 Date Report . : 04/05/13 Location Address : Phone: Storage: S /day N/A- Towing : S Cause of Loss: Stock # *Collision Theft Flood Vandalism Hail Fire Other: ---------------------------------------------------------------------------- VEHICLE DESCRIPTION ---------------------------------------------------------------------------- 2013 Volvo XC60 T6 Turbo 4WD 4D Wagon Lic . Plt: . Exp. : VIN: YV4902DZXD2372562 Color: Ext . Black Int. St: . Engine Disp. 3 . 0 No. Cyl _ 6 *Gas Diesel *Turbo/Supercharged _Electric Trans: *Auto Manual Speeds: _3 _4 _5 *6 _7 _8 9 10 Mileage• Tires Mfg: oWear: LF 15o LR 15% SP _o 10 , 585 Size: RF 15o RR 15% ---------------------------------------------------------------------------- Cab Type:_Reg Cab _Ext .Cab Crew Cab Load/Rating: _1/2 Ton _3/4 Ton _1 Ton Box Size: Box Type: _Styleside Stepside Van Type _Passenger _Cargo _Regular _Extended Conversion Name: ---------------------------------------------------------------------------- VEHICLE EQUIPMENT ---------------------------------------------------------------------------- ACCESSORIES OTHER ACC. SEATS ROOF BUMPERS OTHER *Pwr Steer AM Radio Power Seat Vinyl Top *Rear Step Grille Grd *Pwr Brakes *AM/FM Stro *Du Pwr Seat *Luggage Rck Tube Fog Lights *Pwr Windows AM/FM Cass *Heated Seat Roll/LteBar Chrome Winch *Pwr Locks AM/FM CS/CD Lumbar Adj _ Convertible _Chr. Step Camp. Shell *Pwr Mirrors *CD Player _Splt 60/40 *Sun-Power WHEELS Bed Liner *Cruise Ctrl CD Changer *Bucket Sun-Manual Cust. Whl _Sp-in Bed *Tilt Wheel Equalizer Cloth/Velr Sun-Pop-Up Whl Cvr Liner *Air Cond. *Alarm Sys . *Leather TRUCKS/VANS *Alum./Alloy Tool Box Dual Air Rem. Startr Vinyl Television Chrome Aux Tank *AntiLck Brk *Keyless Cpt �n Chair Sliding Rr _Sty. Stl _Hyd.Lft Gt 4WH Dsc Brk Navigation 2 4 _6 Window _Dual Rear Lift Kit 4 Wh Str�g DVD Player GLASS Power Rear Wheels Gr Eff Pkg *Air Bg Drvr GPS _HeadsUp Dsp Window SUSPENSION Trlr Hitch *Air Bg Pass VCR Heated W/S DRIVETRAIN Trl Tow Pkg _Run.Boards *Air Bg Othr *Center Cons *Heated B/G1 2 WD Off . Rd Pkg PAINT Pwr Antenna Overhd Cons *Tinted Gls *4 WD Cmp. Spl 2-Tone *Rear Wiper Privacy Gls AutoLckHubs _Custom *Rear Spoilr _ManuLckHubs _Graphics *Remote Trunk ---------------------------------------------------------------------- Use this space to explain or describe Equipment/Accessories listed above and/or list and describe additional Equipment/Accessories Climate Package Tailgate Package Technology Package Adaptive Cruise Control , Automatic Dimming Mirror, Auto Headlamp Control , Du al Airbags , Amplifier- Dual Zone Auto A/C, Bodyside Cladding, Daytime Runnin . g Lights , Driver Seat Memory, Floor Mats , Bucket Seats , High Definition Radi o, Halogen Headlights , Heated W/S Wiper Washers , Intermittent Wipers , Illumi nated Visor Mirror, LED Brakelights , Lighted Entry System, Mirror(s) Memory, Heated Power Mirrors , MP3 Player, Power Liftgate , Dual Power Seats , Rear Fo g Lamp, 2nd Row Head Airbags , Split Folding Rear Seat , Reverse Sensing Syste m, Rain-Sensing W/S Wipers , Rear View Camera, Stability Cntrl Suspensn, Leat her Seats , Sirius Satellite Radio, Strg Wheel Radio Control , Leather Steerin g Wheel , Tachometer, Trip Computer, Traction Control System, Tire Pressure M onitor, Wireless Phone Connect , Wireless Audio Streaming RADIO: *OEM Non-OEM Brand: Model No. �ELLULAR PHONE: OEM Non-OEM Brand: Model No. CB: OEM Non-OEM Brand: Model No. PAINT: *Orig. _Repaint(+/- S ---------------------------------------------------------------------------- PRE-LOSS CONDITION ---------------------------------------------------------------------------- Explain if other than average condition for year, make and model vehicle: + Avg - INTERIOR: ________ Seats: Good _ X _ Carpet: Good _ X _ Glass: Good _ X _ Dash: Good _ X _ Headln: Good _ X _ EXTERIOR: Sht.Mt: Good _ X _ Paint: Good _ X _ Trim: Good _ X _ A4ECHANI CAL: Engine: Well Maintained _ X _ Trans . : Well Maintained _ X _ PRIOR DAMAGE: Yes No Est . Written: Yes No Amount: S OVERALL CONDITION: Above Avg. Avg. _Below Avg. OVERALL CONDITION DESCRIPTION: Inspection Location: TRA Estimate Left With: No one Possible supp Amt & Desc: Large Add likly Prior Damage Amt & Desc: S Remarks : Rt rear wheel hit. Rolled over , damageing lt side and roof . Side airbags and seat bags . Valuation or VIR Submitted: Yes Estimate Amount: 531 , 916 . 96 Option/Accessory Notes:Condition Notes : Like new Odometer Accurate: YesKeys Available: Yes License & State: 022 HYM. MnExpiration Date: Jun 13Specialty Plate: Storage per day: STowing and Other Charges : S Engine Serial # : J Inspected by: Date: --------------------------------------------------------------------------- Report Generated by Audatex, a Solera Company , � • (C) 2013 Audatex North America, Inc . All Rights Reserved. Hi Corey, Attached is the police report per your request. Thanks. 763-767-1186 --- On Mon,4/1/13,Huong Phan<huongnphan@yahoo.com>wrote: From: Huong Phan<huongnphan@yahoo.com> Subject: Police Report for claim#231755279 To: "Jessie Wieden" <jessie.wieden.j8p4@statefarm.com>, robin.anderson.nnau@ statefarm.com Cc: "Robin Anderson" <robin.anderson.nnau@statefarm.com> Date: Monday, April 1,2013, 10:05 AM Hi Jessie and Robin, I called talking to Roxe to report the auto accident on the 2013 Volvo XC64 on Friday. Huong Phan was the drive and got hit in the accident. Attached is a copy of the police report. Please forwazd this to Roxe because I do not have her email address. I called and left a voice message this morning for Roxe and will call her back if don't hear from her today. In the mean time, I want to send the police report and info that Roxe needs. United Hospital located in St Paul,Reference number: HAR#9415768(this was the hospital that Huong was in on Friday 03/29/13,ambulance took him here) United Hospital located in Fridley, Reference number: HAR#9422088 (this was the hospital that Huong was in on Saturday 03/30/13,refered to this hospital from urgent care at Fairview clinics due to his pain increased and nurse said he had to go to the hospital that she cannot check him in at the urgent care.) Thanks. Huong Phan Thuy Pham 763-412-3963 . • Accideni Report Page 1 af 1 .��.��. _.� — � 13060732 N � wr.AworoM .mmo' +T+o�+� au� M,wm .w, we .aw °�'ri "` N Y 02 (?0 D2 X 3 29 2013 0531 � 1101[�E81'Ritll NOYIfMYYtAORSfRmiNIAR 4GO�WYDIRL'�IDM �� ..�_,.�ft �A �M�� 10 Universit Ave � � r awnno �n•nn� �rru�ro�er +ewless nwrt►meecm�.�wr..an�n� �� 62 �,� St. Paui +_• 10 Raymond r�er�w� romon oawRaceKtvru+�i nue wse wa�•nr roo+w ow��ooE.ur�n.t rwE ai+e axttn� �rn� �� O1 v50225465560'1 MN D O1 02 k411123383306 MN D pl Uz ,.tran: wacRwcxroar.wn a aw+u wws�aVr.wau.w� asca.wm .craw: OS LRWRENCE EMIL LANGLOiS 0� 02 4i HUO[3G NGOC PHAN 09 18 63 O1 r�wxn o.�na, ,senuc. .00nes. oxuoe �rnw wr� O1 590 NE 7TN AVS N,. 02 12324 3RD ST NE N O1 O1 'ensa a .aW4 rm.{nNEM� amn OI PTNE CETY 55fl63 651-771-7356 g�AiNE 55434 763-?67-1186 O1 NCV�a Sk]i q�HYT YNEEqPe YNW 6/C{i �UIE� pY EV1 f11F5l� �: G[R WSlY RGpMG O1 � M . 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Y �'<" oaw.r .�� f` � OS O1 �^ ��,�,��.�, 1�3 ._�, w�nea,rc� �mue.�aaa. �aa O£�icer Ilya Tereshko 842 St Paul PD � ❑,� p�« https://dvstesupport.org/dvsinfo/accidentrecords 2008/Includes_LE/�'rintReportIndiv_LE.... 3/29/2413 ' r RBZ0006Z �� State Farm Mutual Automobile Insurance Company � Auto Payments by COL � Route To: Demetria King BASIC CLAIM INFORMATION Claim Number: 23-17S5-279 Date of Loss: 03-29-2013 Policy Number: 3148-329-23Q Named Insured: PHAN, HUONG N 400 -COLL C denotes consolidated payment E denotes EFT payment P previously converted payment from CAT/CMR Payment Payable Pay Rsn Number Issued Date Particiqant COL Cd Status Amount Auth ID Cd 105607499J 04-09-2013 Named Insured(s) 400 2 Paid $41,791.66 BQK7 105607505J 04-09-2013 Named Insured(s) 400 1 Paid $3,955.64 BQK7 Total: $45,747.30 Date: 08-20-2013 Page 1 FOR INTERNAL STATE FARM USE ONLY Contains CONFIDENTIAL information which may not be disclosed without express written authorization.