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Moore, Jasmine
Revised March 2023 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 municipality 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 answers to each question. If you have additional documentation, you may add those documents to your submission. You will not be contacted by telephone unless clarification is needed. The claim process for investigations can take upwards of four (4) weeks. This form must be signed, dated with all applicable sections completed. Submission this completed form to the Saint Paul City Clerk’s Office by email (cityclerk@ci.stpaul.mn.us), fax (651-266-8574) or mail addressed to “Saint Paul City Clerk, 15 West Kellogg Blvd., Suite 310, Saint Paul, MN 55102”. Claimant: First Name: ________________________________ Last Name: _______________________________________________ Please Indicate Your Pronouns: ☐ She/Her/Hers, ☐ He/Him/His, ☐ They/ Them/Theirs Company or Business Name: ____________________________________________________________________________________ Is this claim being made by an Insurance Company? YES / NO If yes, what is your Claim/File Number? _________________________ Is this claim being made by an Attorney? YES / NO If yes, what is your File Number? _______________________________________ If yes, provide your Insured’s/ Client’s Name: _______________________________________________________________________ Street Address: _______________________________________________________________________________________________ City: ______________________________________________ State: ________________________ Zip Code: ___________________ Daytime/Work Phone: __________________________________ Cell Phone: _____________________________________________ Date of Incident or Date Discovered (Must Complete): _____________________________ Time: _____________________________ Please state, in detail, what happened that prompted you to file a Notice of Claim Form: ____________________________________ Please state why or how you feel the City of Saint Paul is responsible for your Damages? ____________________________________ Please check the reason that most closely describes the reason for your submitting a claim. Please note the documents that will need to be provided with your completed form. Photographs will be accepted. All documents submitted become the property of the City of Saint Paul and shall not be returned. ☐ Automobile damage from a motor vehicle accident: please provide two estimates for repairs or actual bill that has been paid. ☐ Automobile damage from a street defect or pothole: please provide two estimates for repairs or actual bill that has been paid. ☐ Automobile was towed and may or may not have sustained damage: please provide copy of towing ticket (if available), receipt from Impound Lot, and two estimates for repairs or actual bill that has been paid. ☐ Snow Emergency: please provide copy of towing ticket (if available), receipt from Impound Lot, and two estimates for repairs or actual bill that has been paid. ☐ Property damage: please provide two estimates for repairs or actual bill that has been paid. ☐ You were injured during a motor vehicle accident: please provide police report number, details about injury. ☐ You were injured in the City of Saint Paul: please provide police report number, witnesses, and details about injury. Continue to page 2 of Notice of Claim Form. Failure to complete and return both pages will result in delays. Revised March 2023 This section must be completed for all claims. Is there a police report for this incident? YES / NO If yes, please provide the police report case number: ___________________________ If yes, what law enforcement agency responded? ____________________________________________________________ Where did the incident take place? Please provide a street address, intersection or name of city park or facility: ____________________________________________________________________________________________________________ What would you like to see happen to resolve this claim to your satisfaction? ____________________________________________________________________________________________________________ Were there witnesses to this incident? Please provide names and contact phone numbers: ____________________________________________________________________________________________________________ For property damage claims, including vehicle accidents. Your vehicle’s information: Year: _________ Make: _________________ Model: __________________ Color: __________________ License Plate #: _________________________ State vehicle is registered in: ___________________________ Registered owner of vehicle: _____________________________ Driver: __________________________________________ Area(s) damaged:______________________________________________________________________________________ If a City vehicle was involved, License Plate #: _________________________________ Color: _______________________________ Was there City insignia on the vehicle? YES / NO Driver’s Name: ______________________________________________________ Other property damaged: _______________________________________________________________________________________ For injury claims of any type. What part of your body was injured? _____________________________________________________________________________ Did you go to the emergency room or urgent care? YES / NO Where? ___________________________________________________ Was medical treatment received? YES / NO Where? ________________________________________________________________ First day of medical treatment? _____________ Are you still receiving medical treatment? YES / NO Did you miss any work as result of this incident? YES / NO Employer(s): _________________________________________________________________________________________________ How much time have you missed from work? _____________________________________________________________________ If you are submitting other documents, please state what you are attaching and how many pages: _________________________ By signing this form, you agree that all information provided is true and correct to the best of your knowledge. Please NOTE that submitting a false or misleading claim can and will result in prosecution under Minnesota Statutes. Name of Person completing form: _____________________________________________________________ Signature of Person submitting this form: _______________________________________________________ Relationship of person signing to Party making the claim: __________________________________________ Date document is being signed: _____________________ 1 For more information about how the claim process works and where to find services to help you recover, visit travelers.com/claim. Customer:REGINA WHITFIELD ALVIN Home:(651) 592-1281 WHITFIELD Property:1797 SHERWOOD AVE SAINT PAUL, MN 55119 Home:1797 SHERWOOD AVE SAINT PAUL, MN 55119 Cell:(651) 283-7389 Claim Rep.:Jackson Hendricks Company:TRAVELERS PERSONAL INSURANCE COMPANY Business:PO BOX 650293 Business:(800) 348-6944 E-mail:jhendri4@travelers.comDallas, TX 75265 Claim Number:I5L8871001H Policy Number:0M4571609380048633 1 Type of Loss:Vandalism/Malicious Michief Date of Loss:12/13/2023 12:00 AM Date Completed:3/28/2024 12:21 PM Price List:MNMN8X_MAR24 Coverage Deductible Policy Limit Dwelling $1,000.00 $371,000.00 Other Structures $0.00 $37,100.00 Contents $0.00 $107,850.00 Dear REGINA WHITFIELD ALVIN WHITFIELD: We have prepared this estimate regarding your loss or damage. A letter that explains your coverage and benefits is being sent to you separately. Because the information in an estimate serves as the basis for a determination of your benefits, you (and if applicable, your contractor) should review this estimate carefully. Let us know immediately (and prior to beginning any work) if you have any questions regarding the estimate. Under most insurance policies, claim settlement begins with an initial payment for the actual cash value of the covered loss or damage. To determine actual cash value, we estimate the item’s replacement cost, and then, if appropriate, take a deduction for depreciation. Depreciation represents a loss in value that occurs over time. In determining the amount to deduct for depreciation, if any, to apply to an item, we consider not just the age of the item immediately prior to the loss or damage but also its condition at that time. For each line item included in this estimate, the estimate shows not only the estimated replacement cost value, but also the amount of depreciation (if any) applied to the item, the item age and item condition upon which the depreciation (if any) was based and the item’s actual cash value. Thank you for allowing us to be of service, and thank you for choosing TRAVELERS PERSONAL INSURANCE COMPANY for your insurance needs. You can check the status of your claim, view your policy and much more at www.mytravelers.com. Answers to commonly asked questions can be found at https://www.travelers.com/claims/manage-claim/property-claim-process You can also upload documents directly to your claim at www.travelers.com/claimuploadcenter. 2 YOUR ESTIMATE COVER SHEET Claim Professional: John DoeBusiness: One Tower Square Business: (860) 555-9876 Hartford, CT 06183 E-mail: jdoe@travelers.com Claim Number: ABC1234001H Policy Number: 123456789-633-1 Type of Loss: FireDate of Loss: 10/10/2011 3:00 PM Date Completed: 10/11/2011 11:50 AM Price List: CTHA7X_OCT11 Coverage Deductible Policy Limit Dwelling $500.00 $300,000.00 Other Structures $0.00 $300,000.00Contents $0.00 $210,000.00 *Money, Gift Cards, etc [S 3:1] $200.00/$200.00 A B C D YOUR ESTIMATE DETAIL GUIDE_EXAMPLEMain Level Living Room LxWxH 18’ x 14’ x 8’ 512.00 SF Walls 252.00 SF Ceiling 764.00 SF Walls & Ceiling 252.00 SF Floor 28.00 SY Flooring 64.00 LF Floor Perimeter 64.00 LF Ceil. Perimeter 112.00 SF Short Wall QUANTITY UNIT TAX RCV AGE/LIFE COND. DEP % DEPREC. ACV DWELLING 1. R&R 1/2” drywall - hung, taped, floated, ready for paint 32.00 SF 2.78 5.65 94.61 3/150 yrs. Avg. 2% (1.62) 92.99 2. Paint the walls – two coats 512.00 SF 0.84 27.31 457.39 3/15 yrs. Avg. 20% (91.48) 365.91 3. R&R Carpet 252.00 SF 3.61 57.77 967.49 2/10 yrs. Avg. 20% <179.03> 788.46 CONTENTS 4. Cash, currency, money, bank notes, bullion, and coins 1.00 EA 200.00 0.00 200.00 0/NA Avg. 0% (0.00) 200.00 5. TV - LCD / LED-LCD 35-39 in. 1.00 EA 500.00 31.75 531.75 1/10 yrs. Avg. 10% (53.18) 478.57 Dwelling Totals: 90.73 1,519.49 272.13 1,247.36 Contents Totals: 31.75 731.75 (53.18) 678.57 Totals: Living Room 122.48 2,251.24 325.31 1,925.93 Totals: Main Level 122.48 2,251.24 325.31 1,925.93 Labor Minimums Applied QUANTITY UNIT TAX RCV AGE/LIFE COND. DEP % DEPREC. ACV DWELLING 6. Drywall labor minimum* 1.00 EA 356.25 22.62 378.87 0/NA Avg. 0% (0.00) 378.87 Dwelling Totals: 90.73 1,519.49 272.13 1,247.36 Contents Totals: 31.75 731.75 (53.38) 678.57 Totals: Labor Minimums 22.62 378.87 0.00 378.87 Line Item Totals: GUIDE_EXAMPLE 145.10 2,630.11 325.31 2,304.80 [%] - Indicates that depreciate by percent was used for this item[M] - Indicates that the depreciation percentage was limited by the maximum allowable depreciation for this item YOUR ESTIMATE SUMMARY Summary for Dwelling Line Item Total 1,785.01Comm Repr/Remod Tax 113.35 Replacement Cost Value $1,898.36Less Depreciation (272.13) Actual Cash Value $1,626.23Less Deductible (1,000.00) Net Claim $626.23 Total Depreciation 272.13Less Non-Recoverable Depreciation <179.03> Total Recoverable Depreciation 93.10 Net Claim if Depreciation is Recovered $719.33 P Q R S T U F G KHIJE L M N O Your Estimate Cover Sheet The cover sheet of your estimate includes important information such as: • (A) Your Travelers claim professional’s contact information • (B) Your claim number • (C) The types of coverage under your policy, including the applicable deductibles and policy limits. • (D) Your estimate may include policy sublimits for specific items, such as money. Each sublimit has a unique ID tag. That ID tag will appear next to any line item subject to the sublimit. Your Estimate Detail This is where the details about your lost or damaged property can be found. • (E) Description – Details describing the activity or items being estimated. • (F) Quantity – The number of units (for example, square feet) for an item. • (G) Unit – The cost of a single unit. • (H) Replacement Cost Value (RCV) – The estimated cost of repairing a damaged item or replacing an item with a similar one. RCV is calculated by multiplying Quantity x Unit Cost. • (I) Age – The age of the item. • (J) Life – The item’s expected life assuming normal wear and tear and proper maintenance. • (K) Condition – The item’s condition relative to the expected condition of an item of that age. (New, Above Average, Average, Below Average, Replaced) • (L) Depreciation % – The percentage of the loss of value that has occurred over time based on factors such as age, life expectancy, condition, and obsolescence. • (M) Depreciation – Loss of value that has occurred over time based on factors such as age, life expectancy, condition, and obsolescence. If depreciation is recoverable, the amount is shown in ( ). If depreciation is not recoverable, the amount is shown in < >. • (N) Actual Cash Value (ACV) – The estimated value of the item or damage at the time of the loss. Generally, ACV is calculated as Replacement Cost Value (RCV) minus Depreciation. • (O) Labor Minimums – The cost of labor associated with drive time, setup time and applicable administrative tasks required to perform a minor repair. Your Estimate Summary For each type of coverage involved in your estimate there is a summary section that shows the total estimated costs (RCV and ACV) and net claim amount for the coverage type. The example to the right depicts a Dwelling coverage summary. • (P) Line Item Total – The sum of all the line items for that particular coverage. • (Q) Total Replacement Cost Value – The total RCV of all items for that coverage. • (R) Total Actual Cash Value – The total ACV of all items for that coverage. • (S) Deductible – The amount of the loss paid by you. A deductible is generally a specified dollar amount or a percentage of your policy limit. • (T) Net Claim – The amount payable to you after depreciation and deductible have been applied. This amount can never be greater than your coverage limit. • (U) Total Recoverable Depreciation – The total amount of depreciation you can potentially recover. Guide to Understanding Your Property Estimate travelers.com The Travelers Indemnity Company and its property casualty affiliates. One Tower Square, Hartford, CT 06183 This material is for informational purposes only. All statements herein are subject to the provisions, exclusions and conditions of the applicable policy. For an actual description of all coverages, terms and conditions, refer to the insurance policy. Coverages are subject to individual insureds meeting our underwriting qualifications and to state availability. © 2020 The Travelers Indemnity Company. All rights reserved. Travelers and the Travelers Umbrella logo are registered trademarks of The Travelers Indemnity Company in the U.S. and other countries. C-26501 Rev. 4-20 YOUR ESTIMATE COVER SHEET Claim Professional: John Doe Business: One Tower Square Business: (860) 555-9876 Hartford, CT 06183 E-mail: jdoe@travelers.com Claim Number: ABC1234001H Policy Number: 123456789-633-1 Type of Loss: FireDate of Loss: 10/10/2011 3:00 PM Date Completed: 10/11/2011 11:50 AM Price List: CTHA7X_OCT11 Coverage Deductible Policy Limit Dwelling $500.00 $300,000.00Other Structures $0.00 $300,000.00 Contents $0.00 $210,000.00 *Money, Gift Cards, etc [S 3:1] $200.00/$200.00 A B C D YOUR ESTIMATE DETAIL GUIDE_EXAMPLEMain Level Living Room LxWxH 18’ x 14’ x 8’ 512.00 SF Walls 252.00 SF Ceiling 764.00 SF Walls & Ceiling 252.00 SF Floor 28.00 SY Flooring 64.00 LF Floor Perimeter 64.00 LF Ceil. Perimeter 112.00 SF Short Wall QUANTITY UNIT TAX RCV AGE/LIFE COND. DEP % DEPREC. ACV DWELLING 1. R&R 1/2” drywall - hung, taped, floated, ready for paint 32.00 SF 2.78 5.65 94.61 3/150 yrs. Avg. 2% (1.62) 92.99 2. Paint the walls – two coats 512.00 SF 0.84 27.31 457.39 3/15 yrs. Avg. 20% (91.48) 365.91 3. R&R Carpet 252.00 SF 3.61 57.77 967.49 2/10 yrs. Avg. 20% <179.03> 788.46 CONTENTS 4. Cash, currency, money, bank notes, bullion, and coins 1.00 EA 200.00 0.00 200.00 0/NA Avg. 0% (0.00) 200.00 5. TV - LCD / LED-LCD 35-39 in. 1.00 EA 500.00 31.75 531.75 1/10 yrs. Avg. 10% (53.18) 478.57 Dwelling Totals: 90.73 1,519.49 272.13 1,247.36Contents Totals: 31.75 731.75 (53.18) 678.57 Totals: Living Room 122.48 2,251.24 325.31 1,925.93 Totals: Main Level 122.48 2,251.24 325.31 1,925.93 Labor Minimums Applied QUANTITY UNIT TAX RCV AGE/LIFE COND. DEP % DEPREC. ACV DWELLING 6. Drywall labor minimum* 1.00 EA 356.25 22.62 378.87 0/NA Avg. 0% (0.00) 378.87 Dwelling Totals: 90.73 1,519.49 272.13 1,247.36 Contents Totals: 31.75 731.75 (53.38) 678.57 Totals: Labor Minimums 22.62 378.87 0.00 378.87 Line Item Totals: GUIDE_EXAMPLE 145.10 2,630.11 325.31 2,304.80 [%] - Indicates that depreciate by percent was used for this item[M] - Indicates that the depreciation percentage was limited by the maximum allowable depreciation for this item YOUR ESTIMATE SUMMARY Summary for Dwelling Line Item Total 1,785.01Comm Repr/Remod Tax 113.35 Replacement Cost Value $1,898.36Less Depreciation (272.13) Actual Cash Value $1,626.23Less Deductible (1,000.00) Net Claim $626.23 Total Depreciation 272.13Less Non-Recoverable Depreciation <179.03> Total Recoverable Depreciation 93.10 Net Claim if Depreciation is Recovered $719.33 P Q R ST U F G KHIJE L M N O YOUR ESTIMATE COVER SHEET Claim Professional: John Doe Business: One Tower Square Business: (860) 555-9876 Hartford, CT 06183 E-mail: jdoe@travelers.com Claim Number: ABC1234001H Policy Number: 123456789-633-1 Type of Loss: FireDate of Loss: 10/10/2011 3:00 PM Date Completed: 10/11/2011 11:50 AM Price List: CTHA7X_OCT11 Coverage Deductible Policy Limit Dwelling $500.00 $300,000.00Other Structures $0.00 $300,000.00Contents $0.00 $210,000.00 *Money, Gift Cards, etc [S 3:1] $200.00/$200.00 A B C D YOUR ESTIMATE DETAIL GUIDE_EXAMPLEMain Level Living Room LxWxH 18’ x 14’ x 8’ 512.00 SF Walls 252.00 SF Ceiling 764.00 SF Walls & Ceiling 252.00 SF Floor 28.00 SY Flooring 64.00 LF Floor Perimeter 64.00 LF Ceil. Perimeter 112.00 SF Short Wall QUANTITY UNIT TAX RCV AGE/LIFE COND. DEP % DEPREC. ACV DWELLING 1. R&R 1/2” drywall - hung, taped, floated, ready for paint 32.00 SF 2.78 5.65 94.61 3/150 yrs. Avg. 2% (1.62) 92.99 2. Paint the walls – two coats 512.00 SF 0.84 27.31 457.39 3/15 yrs. Avg. 20% (91.48) 365.91 3. R&R Carpet 252.00 SF 3.61 57.77 967.49 2/10 yrs. Avg. 20% <179.03> 788.46 CONTENTS 4. Cash, currency, money, bank notes, bullion, and coins 1.00 EA 200.00 0.00 200.00 0/NA Avg. 0% (0.00) 200.00 5. TV - LCD / LED-LCD 35-39 in. 1.00 EA 500.00 31.75 531.75 1/10 yrs. Avg. 10% (53.18) 478.57 Dwelling Totals: 90.73 1,519.49 272.13 1,247.36Contents Totals: 31.75 731.75 (53.18) 678.57 Totals: Living Room 122.48 2,251.24 325.31 1,925.93 Totals: Main Level 122.48 2,251.24 325.31 1,925.93 Labor Minimums Applied QUANTITY UNIT TAX RCV AGE/LIFE COND. DEP % DEPREC. ACV DWELLING 6. Drywall labor minimum* 1.00 EA 356.25 22.62 378.87 0/NA Avg. 0% (0.00) 378.87 Dwelling Totals: 90.73 1,519.49 272.13 1,247.36 Contents Totals: 31.75 731.75 (53.38) 678.57 Totals: Labor Minimums 22.62 378.87 0.00 378.87 Line Item Totals: GUIDE_EXAMPLE 145.10 2,630.11 325.31 2,304.80 [%] - Indicates that depreciate by percent was used for this item[M] - Indicates that the depreciation percentage was limited by the maximum allowable depreciation for this item YOUR ESTIMATE SUMMARY Summary for Dwelling Line Item Total 1,785.01Comm Repr/Remod Tax 113.35 Replacement Cost Value $1,898.36Less Depreciation (272.13) Actual Cash Value $1,626.23Less Deductible (1,000.00) Net Claim $626.23 Total Depreciation 272.13Less Non-Recoverable Depreciation <179.03> Total Recoverable Depreciation 93.10 Net Claim if Depreciation is Recovered $719.33 P Q R ST U F G KHIJE L M N O EA – EachLF – Linear FootSF – Square FootSY – Square YardCF – Cubic Foot CY – Cubic YardSQ – SquareHR – HourDA – DayRM – Room Common Units of Measure We encourage you to contact us if you have additional questions regarding your claim or anything in this guide. For information about how the claim process works and where to find services to help you recover, visit travelers.com/claim. 3 3/28/2024 Page: 3 REGINA_WHITFIELD___2 REGINA_WHITFIELD___2 QUANTITY UNIT TAX RCV AGE/LIFE COND.DEP %DEPREC.ACV DEBRIS 1. Tandem axle dump trailer - per load - including dump fees 1.00 EA 313.53 0.00 313.53 0/NA Avg.NA (0.00)313.53 Line item for debris removal Total: REGINA_WHITFIELD___2 0.00 313.53 0.00 313.53 Garage QUANTITY UNIT TAX RCV AGE/LIFE COND.DEP %DEPREC.ACV 2. R&R Overhead door & hardware - 10' x 7' 1.00 EA 1,534.72 94.62 1,629.34 10/35 yrs Avg.28.57%(432.58)1,196.76 Line item for damaged garage door 3. Siding Installer - per hour 0.50 HR 162.45 0.00 81.23 0/NA Avg.0%(0.00)81.23 Line item to fix cast iron siding accessory. Totals: Garage 94.62 1,710.57 432.58 1,277.99 Exterior House QUANTITY UNIT TAX RCV AGE/LIFE COND.DEP %DEPREC.ACV 4. R&R Sheathing - plywood - 1/2" CDX 9.00 SF 3.08 0.81 28.53 0/150 yrs Avg.0%(0.00)28.53 Totals: Exterior House 0.81 28.53 0.00 28.53 Contents QUANTITY UNIT TAX RCV AGE/LIFE COND.DEP %DEPREC.ACV 5. TV - LCD / LED-LCD 40-49 in. 1.00 EA 335.00 29.73 364.73 0/10 yrs Avg.0%(0.00)364.73 6. TV - LCD / LED-LCD 50-59 in. 1.00 EA 659.00 58.49 717.49 1/10 yrs Avg.10%(71.75)645.74 Orig. Desc. - TV 50" 7. Lawn mower - Electric 1.00 EA 310.00 27.51 337.51 1/7 yrs Avg.14.29%(48.22)289.29 Orig. Desc. - Electric Lawn Mower 4 3/28/2024 Page: 4 CONTINUED - Contents QUANTITY UNIT RCV DEPREC.ACVTAXAGE/LIFE COND.DEP % 8. R&R Panana Wooden Storage Cabinet, Narrow Pantry Cabinets Free Standing Tall Storage Cabinet with 2 Doors and Shelves (White) 2.00 LF 174.99 31.06 381.04 2/50 yrs Avg.4%(15.24)365.80 Amazon on Amazon.com - 3/28/2024 Orig. Desc. - Full Size Cabinet 9. Bed frame - Queen 1.00 EA 140.00 12.43 152.43 1/20 yrs Avg.5%(7.62)144.81 Orig. Desc. - Queen Bed Frame 10. Mattress - Queen 1.00 EA 650.00 57.69 707.69 1/20 yrs Avg.5%(35.38)672.31 Orig. Desc. - Queen Bed Matress 11. Vacuum - Robotic - High grade 1.00 EA 450.00 39.94 489.94 2/10 yrs Avg.20%(97.99)391.95 Orig. Desc. - Robot Vacuum 12. Laptop/Notebook computer - Less than 15 inch 1.00 EA 707.00 62.75 769.75 4/4.5 yrs Avg.88.88%(684.15)85.60 Orig. Desc. - Laptop 13. iPad - 256GB 1.00 EA 599.00 53.16 652.16 0/4.5 yrs Avg.0%(0.00)652.16 Orig. Desc. - IPOD 14. Stereo system 1.00 EA 120.00 10.65 130.65 2/10 yrs Avg.20%(26.13)104.52 Orig. Desc. - Stereo 15. Plate - Dinner - Casual dinnerware 5.00 EA 17.00 7.54 92.54 5/20 yrs Avg.25%(23.14)69.40 Orig. Desc. - Plates 16. Lamp set - High grade 2.00 EA 190.00 33.73 413.73 3/10 yrs Avg.30%(124.12)289.61 Orig. Desc. - Lamps 17. Vase / Crystal vase 2.00 EA 50.00 8.88 108.88 0/10 yrs Avg.0%(0.00)108.88 Orig. Desc. - Vases 18. Floor mirror 2.00 EA 200.00 35.50 435.50 0/20 yrs Avg.0%(0.00)435.50 Orig. Desc. - full size mirror 19. Patio swing 1.00 EA 480.00 42.60 522.60 1/7 yrs Avg.14.29%(74.66)447.94 Orig. Desc. - Patio Swing Set 20. Cell phone - Premium grade 1.00 EA 965.00 85.64 1,050.64 1/5 yrs Avg.20%(210.13)840.51 5 3/28/2024 Page: 5 CONTINUED - Contents QUANTITY UNIT RCV DEPREC.ACVTAXAGE/LIFE COND.DEP % Orig. Desc. - Iphone 21. R&R Door knob - interior - High grade 3.00 EA 83.30 9.55 259.45 10/20 yrs Avg.50%(100.90)158.55 22. Table - Dining / Kitchen - High grade 1.00 EA 1,100.00 97.63 1,197.63 5/20 yrs Avg.25%(299.41)898.22 Orig. Desc. - Table - Dining / Kitchen 23. Table - Patio 3.00 EA 210.00 55.91 685.91 1/7 yrs Avg.14.29%(97.99)587.92 Orig. Desc. - cocktail table 24. Fan - Pedestal 1.00 EA 80.00 7.10 87.10 2/10 yrs Avg.20%(17.42)69.68 Orig. Desc. - Fan - Tower 25. Food* 1.00 EA 200.00 0.00 200.00 0/NA Avg.0%(0.00)200.00 Line item for food/ fridge items thrown out by the police department, no by choice. Totals: Contents 767.49 9,757.37 1,934.25 7,823.12 Interior QUANTITY UNIT TAX RCV AGE/LIFE COND.DEP %DEPREC.ACV BASEMENT 26. R&R Handrail - round / oval - softwood - wall mounted 13.00 LF 15.61 4.78 207.71 2/150 yrs Avg.1.33%(2.55)205.16 27. Content Manipulation charge - per hour 10.00 HR 27.08 0.00 270.80 0/NA Avg.0%(0.00)270.80 Line item for time homeowner took to clean up items in basement. UPSTAIRS 28. Content Manipulation charge - per hour 10.00 HR 27.08 0.00 270.80 0/NA Avg.0%(0.00)270.80 Line item for time that it will take to clean up the upstairs. 29. R&R 1/2" drywall - hung, taped, floated, ready for paint 11.00 SF 4.07 0.69 45.46 0/150 yrs Avg.0%(0.00)45.46 line item to fix broken drywall upstairs. 30. Seal the surface area w/PVA primer - one coat 11.00 SF 0.82 0.06 9.08 0/15 yrs Avg.0%(0.00)9.08 6 3/28/2024 Page: 6 CONTINUED - Interior QUANTITY UNIT RCV DEPREC.ACVTAXAGE/LIFE COND.DEP % 31. Paint the surface area - two coats 11.00 SF 1.35 0.29 15.14 10/15 yrs Avg.66.67%(10.09)5.05 paint new drywall going on the crawl space door. 32. R&R Batt insulation - 4" - R15 - paper / foil faced 11.00 SF 1.73 0.81 19.84 0/150 yrs Avg.0%(0.00)19.84 33. R&R Baseboard - 3 1/4" 10.33 LF 5.32 1.77 56.72 0/150 yrs Avg.0%(0.00)56.72 34. Stain & finish baseboard 10.33 LF 2.20 0.23 22.96 0/15 yrs Avg.0%(0.00)22.96 Line item to stain and finish baseboard around crawl space. 35. R&R Light fixture 1.00 EA 103.72 3.24 106.96 0/20 yrs Avg.0%(0.00)106.96 36. R&R Smoke detector 1.00 EA 94.09 2.49 96.58 0/10 yrs Avg.0%(0.00)96.58 MAIN 37. R&R Bypass (sliding) door set - lauan/mahogany 1.00 EA 313.02 17.67 330.69 0/100 yrs Avg.0%(0.00)330.69 38. Refrigerator - Reset 1.00 EA 31.71 0.00 31.71 0/NA Avg.0%(0.00)31.71 Totals: Interior 32.03 1,484.45 12.64 1,471.81 Labor Minimums Applied QUANTITY UNIT TAX RCV AGE/LIFE COND.DEP %DEPREC.ACV 39. Finish hardware labor minimum 1.00 EA 60.52 0.00 60.52 0/NA Avg.0%(0.00)60.52 40. Drywall labor minimum 1.00 EA 505.92 0.00 505.92 0/NA Avg.0%(0.00)505.92 41. Painting labor minimum 1.00 EA 253.64 0.00 253.64 0/NA Avg.0%(0.00)253.64 42. Electrical labor minimum 1.00 EA 224.14 0.00 224.14 0/NA Avg.0%(0.00)224.14 43. Siding labor minimum 1.00 EA 406.61 0.00 406.61 0/NA Avg.0%(0.00)406.61 Totals: Labor Minimums Applied 0.00 1,450.83 0.00 1,450.83 Line Item Totals: REGINA_894.95 14,745.28 2,379.47 12,365.81 7 3/28/2024 Page: 7 WHITFIELD___2 [%] - Indicates that depreciate by percent was used for this item [M] - Indicates that the depreciation percentage was limited by the maximum allowable depreciation for this item Coverage Item Total %ACV Total % Dwelling 3,330.18 22.58%3,216.64 26.01% Other Structures 2,117.18 14.36%1,684.60 13.62% Contents 9,297.92 63.06%7,464.57 60.36% Total 14,745.28 100.00%12,365.81 100.00% 8 3/28/2024 Page: 8 Summary for Dwelling Summary for All Items Line Item Total 3,287.79 Matl Sales Tax Reimb 42.39 Replacement Cost Value $3,330.18 Less Depreciation (113.54) Actual Cash Value $3,216.64 Less Deductible (1,000.00) Net Claim $2,216.64 Total Depreciation 113.54 Total Recoverable Depreciation 113.54 Net Claim if Depreciation is Recovered $2,330.18 Jackson Hendricks 9 3/28/2024 Page: 9 Summary for Other Structures Summary for All Items Line Item Total 2,022.56 Matl Sales Tax Reimb 94.62 Replacement Cost Value $2,117.18 Less Depreciation (432.58) Actual Cash Value $1,684.60 Net Claim $1,684.60 Total Depreciation 432.58 Total Recoverable Depreciation 432.58 Net Claim if Depreciation is Recovered $2,117.18 Jackson Hendricks 10 3/28/2024 Page: 10 Summary for Contents Summary for All Items Line Item Total 8,539.98 Matl Sales Tax Reimb 757.94 Replacement Cost Value $9,297.92 Less Depreciation (1,833.35) Actual Cash Value $7,464.57 Net Claim $7,464.57 Total Depreciation 1,833.35 Total Recoverable Depreciation 1,833.35 Net Claim if Depreciation is Recovered $9,297.92 Jackson Hendricks 11 3/28/2024 Page: 11 Recap of Taxes Matl Sales Tax Manuf. Home Tax Cleaning Sales Tax Clothing Acc Tax Total Tax (8.875%) Reimb (8.875%)(8.875%)(8.875%)(8.875%) Line Items 894.95 0.00 0.00 0.00 0.00 Total 894.95 0.00 0.00 0.00 0.00 12 3/28/2024 Page: 12 Recap by Room Estimate: REGINA_WHITFIELD___2 313.53 2.26% Coverage: Dwelling 100.00% =313.53 Garage 1,615.95 11.67% Coverage: Other Structures 100.00% =1,615.95 Exterior House 27.72 0.20% Coverage: Dwelling 100.00% =27.72 Contents 8,989.88 64.91% Coverage: Dwelling 5.00% =449.90 Coverage: Contents 95.00% =8,539.98 Interior 1,452.42 10.49% Coverage: Dwelling 100.00% =1,452.42 Labor Minimums Applied 1,450.83 10.48% Coverage: Dwelling 71.97% =1,044.22 Coverage: Other Structures 28.03% =406.61 Subtotal of Areas 100.00%13,850.33 Coverage: Dwelling 23.74% =3,287.79 Coverage: Other Structures 14.60% =2,022.56 Coverage: Contents 61.66% =8,539.98 Total 13,850.33 100.00% 13 3/28/2024 Page: 13 Recap by Category with Depreciation Items RCV Deprec.ACV APPLIANCES 231.71 231.71 Coverage: Dwelling @ 100.00% =231.71 APPLIANCES - SMALL 530.00 106.00 424.00 Coverage: Contents @ 100.00% =530.00 CABINETRY 349.98 14.00 335.98 Coverage: Contents @ 100.00% =349.98 COMPUTERS & RELATED GOODS 1,306.00 628.38 677.62 Coverage: Contents @ 100.00% =1,306.00 CONTENT MANIPULATION 541.60 541.60 Coverage: Dwelling @ 100.00% =541.60 GENERAL DEMOLITION 581.65 581.65 Coverage: Dwelling @ 80.18% =466.34 Coverage: Other Structures @ 19.82% =115.31 DOORS 1,709.36 405.55 1,303.81 Coverage: Dwelling @ 16.96% =289.95 Coverage: Other Structures @ 83.04% =1,419.41 DRYWALL 543.65 543.65 Coverage: Dwelling @ 100.00% =543.65 ELECTRONICS 2,079.00 282.90 1,796.10 Coverage: Contents @ 100.00% =2,079.00 ELECTRICAL 301.17 301.17 Coverage: Dwelling @ 100.00% =301.17 FINISH CARPENTRY / TRIMWORK 234.53 2.49 232.04 Coverage: Dwelling @ 100.00% =234.53 FINISH HARDWARE 252.76 96.12 156.64 Coverage: Dwelling @ 100.00% =252.76 FRAMING & ROUGH CARPENTRY 19.98 19.98 Coverage: Dwelling @ 100.00% =19.98 FURNITURE - HOME & OFFICE 1,890.00 314.50 1,575.50 Coverage: Contents @ 100.00% =1,890.00 HOUSEWARES - DINING & FLATWARE 85.00 21.25 63.75 Coverage: Contents @ 100.00% =85.00 HOUSEWARES - HOME DECOR 880.00 114.00 766.00 Coverage: Contents @ 100.00% =880.00 INSULATION 14.96 14.96 Coverage: Dwelling @ 100.00% =14.96 LAWN, GARDEN & PATIO 1,420.00 202.86 1,217.14 Coverage: Contents @ 100.00% =1,420.00 LIGHT FIXTURES 90.90 90.90 Coverage: Dwelling @ 100.00% =90.90 14 3/28/2024 Page: 14 Items RCV Deprec.ACV PAINTING 300.24 9.90 290.34 Coverage: Dwelling @ 100.00% =300.24 SIDING 487.84 487.84 Coverage: Other Structures @ 100.00% =487.84 Subtotal 13,850.33 2,197.95 11,652.38 Matl Sales Tax Reimb 894.95 181.52 713.43 Coverage: Dwelling @ 4.74% =42.39 Coverage: Other Structures @ 10.57% =94.62 Coverage: Contents @ 84.69% =757.94 Total 14,745.28 2,379.47 12,365.81 Insurance Claims For Residential Contracting Goods and Services - A residential contractor providing home repair or improvement services to be paid by an insured from the proceeds of a property or casualty insurance policy shall not, as an inducement to the sale or provision of goods or services to an insured, advertise or promise to pay, directly or indirectly, all or part of any applicable insurance deductible or offer to compensate an insured for providing any service to the insured. If a residential contractor violates this section, the insurer to whom the insured tendered the claim shall not be obligated to consider the estimate prepared by the residential contractor. See, Minnesota Statutes Annotated, Section 325E.66