RPVCCA_CC_SR_2011_11_01_E_Claim_Against_CityCITY OF RANCHO PALOS VERDES
TO:
FROM:
DATE:
SUBJECT:
REVIEWED:
HONORABLE MAYOR &CITY cou~~EMBERS
CARLA MORREALE,CITY CLERK ~
NOVEMBER 1,2011
CLAIM AGAINST THE CITY BY SAFECO INSURANCE
COMPANY ON BEHALF OF INSURED KYOKO MINAMI
CAROLYN LEHR,CITY MANAGER ~
RECOMMENDATION
Reject the claim and direct staff to notify Safeco Insurance Company.
BACKGROUND
Safeco Insurance Company (Safeco),on behalf of their insured Kyoko Minami,has filed
a Subrogation Notice with the City of Rancho Palos Verdes.Safeco alleges that their
client has sustained damages to their property and is seeking reimbursement for
monies paid out on behalf of their insured.
The City's Claims Administrator,Carl Warren and Company,has reviewed the claim
and advised the City to reject the claim,as the incident occurred in the center median
area at 2222 Palos Verdes Drive North in the City of Rolling Hills Estates;therefore,the
City has no liability for the incident.
Attachments:
Subrogation Notice and Attachments
E-1
Safeco Insurance Company ofAmerica
PO Box 515097
Los Angeles,CA 90051-5097
Mailing Address:
PO Box 515097
Los Angeles,CA 90051-5097
Phone:(877)922-5020
Fax:(888)268-8840
October 6,2011
City Of Rancho Palos Verdes
30940 Hawthorne Blvd
Palos Verdes,CA 90275
Attn:carolyn 1ehr-city manager
SUBROGATION NOTICE
Our Insured Name:
Our Claim Number:
Loss Date:
Your Insured:
Your Claim Number:
Kyoko Minami
650522764033
June 12,2011
City Of Rancho Palos Verdes
To Whom It May Concern:
We have completed our investigation of the above loss.Our investigation indicates that your
insured is liable for the damages to our insured's property.Under our insured's policy,we have
become legally subrogated to the right of our insured to recover from your policyholder.As such,
we are seeking reimbursement from you for the damages we paid out on behalf of our insured.
Enclosed please find the documentation that will support the claim.
Collision:
Car Seat:
Out-of-pocket:
Deductible:
Salvage:
$3,384.34
$175.59
$1,000.00
Property Damage TOTAL:$4,559.93
CA2060 05108
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Page 2
Kyoko Minami
October 6,2011
Please issue your check payable to Safeco Insurance Company of America,Attn:
Subrogation Cashier,PO Box 461,St.Louis,MO 63166.
Please direct all future subrogation correspondence to the Subrogation Department at the mailing
address noted above.If you have any questions we can be reached at 877-622-5020 ext.7673100.
Sincerely,
Subrogation Department
Safeco Insurance Company of America
(877)922-5020 Ext:7673100
Fax:(888)268-8840
CA2060 05/0B
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Policy Number:A2234707
Date of Loss:June 12,2011
Claim Number:650522764033
Policy Holder Name:Kyoko Minami
Payment Recap for damages paid on behalf of our insured(s),Kyoko Minami as of
October 06,2011:
Transaction Claim Amount Date Start End Payee Name
Class Paid Date Date
Payment CPR $342.40 9/21/11 SCOTT ROBINSON
HONDA INC DBA
HONDA SERVICE
CENTER &KYOKO
MINAMI
Payment CPR $1,620.33 7/2/11 SCOTT ROBINSON
HONDA &KYOKO
MINAMI
Payment CPR $175.59 6/30/11 KYOKO MINAMI
Payment CPR $1,421.61 6/23/11 SCOTT ROBINSON
HONDA &KYOKO
MINAMI
Total Payments:$3,559.93
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SAFE CO INSURANCE COMPANY
OF AMERICA
EMAIL:EDWARD.MOISA@SAFECO.COM
P.O.BOX 515097
LOS ANGELES,CA 90051-5097
(562)292-7086 FAX:(888)268-8840
650522764033-201
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SUPPLEMENT OF RECORD 2 WITH SUMMARY
WRITTEN BY:EDWARD MOISA 07/01/2011 10:59 AM
ADJUSTER:DOMINIC MIZZONI (562)292-7086
INSURED:KYOKO MINAMI
OWNER:KYOKO MINAMI
ADDRESS:_._....~.
OTHER:
INSPECT 20340 HAWTHORNE BLVD
LOCATION:TORRANCE,CA 90503
REPAIR SCOOT ROBINSON HONDA
FACILITY:20340 HAWTHORNE BLVD
TORRANCE,CA 90503
CLAIM #650522764033-201
POLICY #A2234707
DATE OF LOSS:06/12/2011 AT 04:00 PM
TYPE OF LOSS:COMPREHENSIVE
POINT OF IMPACT:13.ROLLOVER
DAY:(310)833-1800
OTHER
6 DAYS TO REPAIR
LICENSE #
TILT WHEEL
INTERMITTENT WIPERS
STEERING WHEEL CONTROLS
CONSOLE/STORAGE
POWER STEERING
POWER LOCKS
AM RADIO
SEARCH/SEEK
DRIVER AIR BAG
4 WHEEL DISC BRAKES
RECLINE/LOUNGE SEATS
ALUMINUM/ALLOY WHEELS
REAR DEFOGGER
TELESCOPIC WHEEL
ALARM
DUAL MIRRORS
CLEAR COAT PAINT
POWER WINDOWS
POWER TRUNK/GATE RELEASE
STEREO
ANTI-LOCK BRAKES (4)
FRONT SIDE IMPACT AIR BAG
BUCKET SEATS
OVERDRIVE
2003 HOND ACCORD EX 4-2.4L-FI 4D SED TAN INT:TAN
VIN:JHMCM56623C084715 LIC:5BSV237 CA PROD DATE:03/2003
CONDITION:GOOD
AIR CONDITIONING
CRUISE CONTROL·
KEYLESS ENTRY
BODY SIDE MOLDINGS
ELECTRIC GLASS SUNROOF
POWER BRAKES
POWER MIRRORS
FM RADIO
CD CHANGER/STACKER
PASSENGER AIR BAG
CLOTH SEATS
AUTOMATIC TRANSMISSION
ODOMETER:62210
NO.OP.DESCRIPTION QTY EXT.PRICE LABOR PAINT
* 1 198.95*X
1 PILLARS,ROCKER &FLOOR
2 SOl REPL LT FRONT SILL PLATE OUTER
IVORY
3*SOl RPR LT APERTURE PANEL USA &MEX
BLT
4 REPL LT PILLAR TRIM W/O HEAD AIR
BAG IVORY
5*R&I FRONT CARPET 2.4L IVORY
6 WINDSHIELD
N 7*SUBL WINDSHIELD SAFELITE
1
1
1
15.62
8.97
0.2
S 7.5*3.2
0.2
0.6*
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SUPPLEMENT OF RECORD 2 WITH SUMMARY
2003 HOND ACCORD EX 4-2.4L-FI 4D SED TAN INT:TAN
NO.OP.DESCRIPTION QTY EXT.PRICE LABOR PAINT
8#
9#
10#.
11#
12 SOl
13 SOl
14 SOl
15
16
17#S02
18*SOl
19 SOl
20 SOl
21#S02
22 SOl
23 SOl
24 SOl
25 SOl
26 SOl
27 SOl
28 SOl
29 SOl
30 SOl
31 SOl
32 SOl
33 SOl
34 SOl
35 SOl
36 SOl
37 SOl
38 SOl
39 SOl
40 SOl
41 SOl
42 SOl
43 SOl
44 SOl
45 SOl
46#S02
47#S02
48#S02
49#S02
50#S02
51#S02
RPR COLOR MATCH
RPR CLEAN DASH AND VENTS
RPR CLEAN BROKEN FINE GLASS
INTERIOR
R&I RT AND LT FRONT SEATS
FRONT DOOR
R&I RT BELT W'STRIP LX,EX,SE
R&I LT BELT W'STRIP LX,EX,SE
ROOF
REPL LT ROOF MOLDING
HAZARDOUS WASTE
RPR ROOF PANEL W/SUNROOF
ADD FOR CLEAR COAT
R&I RT ROOF MOLDING
SUBL TINT RT AND LT DOOR PLUS 20%
REAR DOOR
R&I LT R&I DOOR ASSY
REAR LAMPS
R&I LT TURN &STOP LAMP
REAR BUMPER
R&I R&I BUMPER COVER
BACK GLASS
REPL SEAL KIT
R&I BACK GLASS HONDA USA &MEXICO
BUILT
HOOD
REFN HOOD
OVERLAP MAJOR ADJ.PANEL
ADD FOR CLEAR COAT
REPL FRONT SEAL
FENDER
BLND RT FENDER
BLND LT FENDER
R&I RT FENDER LINER
R&I LT FENDER LINER
FRONT BUMPER
R&I R&I BUMPER COVER
FRONT LAMPS
R&I RT HEADLAMP ASSY
R&I LT HEADLAMP ASSY
SUBL REPAIR DASH SCRATCHES
ALGN WINDSHILED
URETHANE GLASS KIT
SUBL INSTUMENT PANLE PLUS 20%
SUBL TOW
R&I SHIFTER
SUBTOTALS ==>
2
1
1
1
1
1
1
1
1
1
49.19
3.00
120.00
49.33
7.20
180.00
40.00
1140.00
340.00
2152.26
X
X
X
X
0.5
1.5
3.0
1.5
0.3
0.3
0.6
0.5
2.0*
0.6
1.0
0.3
1.0
2.3
0.2
0.4
0.4
1.3
0.4
0.4
3.5
0.3
30.8
3.2
1.3
2.6
-0.4
0.4
1.0
1.0
12.3
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LINE 7
SUPPLEMENT OF RECORD 2 WITH SUMMARY
2003 HOND ACCORD EX 4-2.4L-FI 4D SED TAN INT:TAN
SAFELITE 310-479-6369
PARTS
BODY LABOR
PAINT LABOR
PAINT SUPPLIES
SUBLET/MISC.
30.8 HRS
12.3 HRS
12.3 HRS
@$42.00/HR
@$42.00/HR
@$30.00/HR
372.26
1293.60
516.60
369.00
1780.00
SUBTOTAL
SALES TAX
TOTAL COST OF REPAIRS
ADJUSTMENTS:
DEDUCTIBLE
TOTAL ADJUSTMENTS
NET COST OF REPAIRS
$4331.46
$542.31 @ 9.7500%52.88
$4384.34
1000.00
$1000.00
$3384.34
AMERICA FIRST INSURANCE,COLORADO CASUALTY,GOLDEN EAGLE INSURANCE,INDIANA
INSURANCE,LIBERTY AGENCY UNDERWRITERS,LIBERTY NORTHWEST,MONTGOMERY
INSURANCE,OHIO CASUALTY,PEERLESS INSURANCE AND SAFE CO INSURANCE ARE PART OF
LIBERTY MUTUAL AGENCY MARKETS,A BUSINESS UNIT OF LIBERTY MUTUAL GROUP.
***COpy OF ESTIMATE PROVIDED TO CUSTOMER ***
****NO SUPPLEMENT WILL BE PAID WITHOUT PRIOR APPROVAL***
****SUPPLEMENTS WILL REQUIRE ALL INVOICES FOR THE ENTIRE REPAIR ****
THIS IS NOT AN AUTHORIZATION FOR REPAIRS.THE VEHICLE OWNER MUST AUTHORIZE
REPAIRS.NO SUPPLEMENT WILL BE HONORED WITHOUT APPROVAL BY A SAFE CO CLAIMS
REPRESENTATIVE.AGREED PRICE REACHED BY
OF AGREED DATE OF-=CO""'M:-:"P:::L:-:E=::T:::I::-:O~N=----.COPY OF AN ESTIMATE WAS GIVEN TO REPAIR A
FACILITY?WAS A COpy OF AN ESTIMATE GIVEN AND EXPLAINED TO
VEHICLE OWNER?CLAIMS REP THIS ESTIMATE MAY HAVE BEEN
PREPARED BASED ON THE USE OF LKQ PARTS.LKQ PARTS,ALSO KNOWN AS QUALITY
RECYCLED,OR USED PARTS,ARE OF LIKE,KIND,&QUALITY TO THE ORIGINAL PARTS ON
YOUR VEHICLE.WE SPECIFY ONLY QUALITY PARTS THAT MEET INDUSTRY STANDARDS WILL
BE USED.
I 'WE ARE PROHIBITED BY LAW FROM REQUIRING THAT REPAIRS BE DONE AT A SPECIFIC
AUTOMOTIVE REPAIR DEALER.YOU ARE ENTITLED TO SELECT THE AUTO BODY REPAIR SHOP
TO REPAIR DAMAGE COVERED BY US.WE HAVE RECOMMENDED AN AUTOMOTIVE REPAIR
DEALER THAT WILL REPAIR YOUR DAMAGED VEHICLE.IF YOU AGREE TO USE OUR
RECOMMENDED AUTOMOTIVE REPAIR DEALER,WE WILL CAUSE THE DAMAGED VEHICLE TO BE
RESTORED TO ITS CONDITION PRIOR TO THE LOSS AT NO ADDITIONAL COST TO YOU OTHER
THAN AS STATED IN THE INSURANCE POLICY OR AS OTHERWISE ALLOWED BY LAW.
3
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SUPPLEMENT OF RECORD 2 WITH SUMMARY
2003 HOND ACCORD EX 4-2.4L-FI 4D SED TAN INT:TAN
IF YOU EXPERIENCE A PROBLEM WITH THE REPAIR OF YOUR VEHICLE,PLEASE CONTACT US
IMMEDIATELY FOR ASSISTANCE.
AUTO BODY REPAIR CONSUMER BILL OF RIGHTS
A CONSQMER IS ENTITLED TO:
1.SELECT THE AUTO BODY REPAIR SHOP TO REPAIR AUTO BODY DAMAGE COVERED BY THE
INSURANCE COMPANY.AN INSURANCE COMPANY SHALL NOT REQUIRE THE REPAIRS TO BE
DONE AT A SPECIFIC AUTO BODY REPAIR SHOP.
2.AN ITEMIZED WRITTEN ESTIMATE FOR AUTO BODY REPAIRS AND,UPON COMPLETION OF
REPAIRS,A DETAILED INVOICE.THE ESTIMATE AND THE INVOICE MUST INCLUDE AN
ITEMIZED LIST OF PARTS AND LABOR ALONG WITH THE TOTAL PRICE FOR THE WORK
PERFORMED.THE ESTIMATE AND INVOICE MUST ALSO IDENTIFY ALL PARTS AS NEW,USED,
AFTERMARKET,RECONDITIONED,OR REBUILT.
3.BE INFORMED ABOUT COVERAGE FOR TOWING AND STORAGE SERVICES.
4.BE INFORMED ABOUT THE EXTENT OF COVERAGE,IF ANY,FOR A REPLACEMENT RENTAL
VEHICLE WHILE A DAMAGED VEHICLE IS BEING REPAIRED.
5.BE INFORMED OF WHERE TO REPORT SUSPECTED FRAUD OR OTHER COMPLAINTS AND
CONCERNS ABOUT AUTO BODY REPAIRS.
6.SEEK AND OBTAIN AN INDEPENDENT REPAIR ESTIMATE DIRECTLY FROM A REGISTERED
AUTO BODY REPAIR SHOP FOR REPAIR OF A DAMAGED VEHICLE,EVEN WHEN PURSUING AN
INSURANCE CLAIM FOR REPAIR OF THE VEHICLE.
COMPLAINTS WITHIN THE JURISDICTION OF THE BUREAU OF AUTOMOTIVE REPAIR
COMPLAINTS CONCERNING THE REPAIR OF A VEHICLE BY AN AUTO BODY REPAIR SHOP
SHOULD BE DIRECTED TO:
TOLL FREE (866)799-3811
CALIFORNIA DEPARTMENT OF CONSUMER AFFAIRS
BUREAU OF AUTOMOTIVE REPAIR
10240 SYSTEMS PARKWAY
SACRAMENTO,CA 95827
THE BUREAU OF AUTOMOTIVE REPAIR CAN ALSO ACCEPT COMPLAINTS OVER ITS WEB SITE
AT:WWW.AUTOREPAIR.CA.GOV
COMPLAINTS WITHIN THE JURISDICTION OF THE CALIFORNIA
INSURANCE COMMISSIONER
ANY CONCERNS REGARDING HOW AN AUTO INSURANCE CLAIM IS BEING HANDLED SHOULD BE
SUBMITTED TO THE CALIFORNIA DEPARTMENT OF INSURANCE AT:
(800)927-HELP OR (213)897-8921
4
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SUPPLEMENT OF RECORD 2 WITH SUMMARY
2003 HOND ACCORD EX 4-2.4L-FI 4D SED TAN INT:TAN
CALIFORNIA DEPARTMENT OF INSURANCE
CONSUMER SERVICES DIVISION
300 SOUTH SPRING STREET
LOS ANGELES,CA 90013
THE CALIFORNIA DEPARTMENT OF INSURANCE CAN ALSO ACCEPT COMPLAINTS OVER ITS WEB
SITE AT:WWW.INSURANCE.CA.GOV
FOR YOUR PROTECTION CALIFORNIA LAW REQUIRES THE FOLLOWING TO APPEAR ON THIS
FORM:
ANY PERSON WHO KNOWINGLY PRESENTS FALSE OR FRAUDULENT CLAIM FOR THE PAYMENT OF
A LOSS IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN
STATE PRISON.
5
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SUPPLEMENT OF RECORD 2 WITH SUMMARY
2003 HOND ACCORD EX 4-2.4L-FI 4D SED TAN INT:TAN
ESTIMATE BASED ON MOTOR CRASH ESTIMATING GUIDE.UNLESS OTHERWISE NOTED ALL
ITEMS ARE DERIVED FROM THE GUIDE ARG4437,CCC DATA DATE 06/01/2011,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
DOUBLE 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.NON-ORIGINAL EQUIPMENT MANUFACTURER AFTERMARKET PARTS ARE
DESCRIBED AS AM,QUAL REPL PARTS OR COMP REPL PARTS WHICH STANDS FOR
COMPETITIVE REPLACEMENT PARTS.USED PARTS ARE DESCRIBED AS LKQ,QUAL RECY
PARTS,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 2010 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 ABBREVIATIONS OR SYMBOLS THAT MAY BE USED TO DESCRIBE
WORK TO BE DONE OR PARTS TO BE REPAIRED OR REPLACED:MOTOR
ABBREVIATIONS/SYMBOLS:D=DISCONTINUED PART A=APPROXIMATE PRICE LABOR TYPES:
B=BODY LABOR D=DIAGNOSTIC E=ELECTRICAL F=FRAME G=GLASS M=MECHANICAL P=PAINT
LABOR S=STRUCTURAL T=TAXED MISCELLANEOUS X=NON TAXED MISCELLANEOUS PATHWAYS:
ADJ=ADJACENT ALGN=ALIGN A/M=AFTERMARKET BLND=BLEND CAPA=CERTIFIED AUTOMOTIVE
PARTS ASSOCIATION NSF=NSF INTERNATIONAL CERTIFIED PART D&R=DISCONNECT AND
RECONNECT EST=ESTIMATE EXT.PRICE=UNIT PRICE MULTIPLIED BY THE QUANTITY
INCL=INCLUDED MISC=MISCELLANEOUS NAGS=NATIONAL AUTO GLASS SPECIFICATIONS
NON-ADJ=NON ADJACENT O/H=OVERHAUL OP=OPERATION NO=LINE NUMBER QTY=QUANTITY
QUAL RECY=QUALITY RECYCLED PART QUAL REPL=QUALITY REPLACEMENT PART COMP REPL
PARTS=COMPETITIVE REPLACEMENT PARTS RECOND=RECONDITION REFN=REFINISH
REPL=REPLAC~R&I=REMOVE AND INSTALL R&R=REMOVE AND REPLACE RPR=REPAIR RT=RIGHT
SECT=SECTION SUBL=SUBLET LT=LEFT W/O=WITHOUT W/=WITH/SYMBOLS:#=MANUAL LINE
ENTRY *=OTHER [IE ..MOTORS DATABASE INFORMATION-WAS CHANGED]**=DATABASE LINE
WITH AFTERMARKET N=NOTES ATTACHED TO LINE.OPT OEM=ORIGINAL EQUIPMENT
MANUFACTURER PARTS EITHER OPTIONALLY SOURCED OR OTHERWISE PROVIDED WITH SOME
UNIQUE PRICING OR DISCOUNT.NWCPP=NATIONWIDE CRASH PARTS PROGRAM.
CCC PATHWAYS - A PRODUCT OF CCC INFORMATION SERVICES INC.
6
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SUPPLEMENT OF RECORD 2 WITH SUMMARY
2003 HOND ACCORD EX 4-2.4L-FI 4D SED TAN INT:TAN
-------------------------------------------------------------------------------
NO.OP.DESCRIPTION QTY EXT.PRICE LABOR PAINT
-----~-------------------------------------------------------------------------
-------CHANGED ITEMS-------
19#HAZARDOUS WASTE 1 -3.00
17#.S02 HAZARDOUS WASTE 1 3.00 0.5
23#SOl SUBL TINT RT AND LT DOOR PLUS 20%1 -102.00 X
21#S02 SUBL TINT RT AND LT DOOR PLUS 20%1 120.00 X
-------DELETED ITEMS-------
8 INSTRUMENT PANEL
9 R&I R&I INSTRUMENT PANEL -3.5
19 REPL ROOF PANEL DAMPER 1 -77.24
49 SOl CONSOLE
50 SOl R&I R&I CONSOLE ASSY -1.2
-------ADDED ITEMS -------
46#S02 SUBL REPAIR DASH SCRATCHES 1 180.00 X
47#S02 ALGN WINDSHILED 3.5
48#S02 URETHANE GLASS KIT 1 40.00
49#S02 SUBL INSTUMENT PANLE PLUS 20%1 1140.00 X
50#S02 SUBL TOW 1 340.00 X
51#S02 R&I SHIFTER 0.3
SUBTOTALS ==>
PARTS
BODY LABOR
SUBLET/MISC.
SUBTOTAL
SALES TAX
1640.76 -0.4 0.0
-37.24
-0.4 HRS @$42.00/HR -16.80
1678.00
$1623.96
$-37.24 @ 9.7500%-3.63
TOTAL SUPPLEMENT AMOUNT
NET COST OF SUPPLEMENT
$1620.33
$1620.33
WORKFILE TOTAL $4384.34
ESTIMATE
SUPPLEMENT SOl
SUPPLEMENT S02
1342.40 EDWARD MOISA
1421.61 EDWARD MOISA
1620.33 EDWARD MOISA
TOTAL ADJUSTMENTS $1000.00
NET COST OF REPAIRS $3384.34
AMERICA FIRST INSURANCE,COLORADO CASUALTY,GOLDEN EAGLE INSURANCE,INDIANA
INSURANCE,LIBERTY AGENCY UNDERWRITERS,LIBERTY NORTHWEST,MONTGOMERY
INSURANCE,OHIO CASUALTY,PEERLESS INSURANCE AND SAFE CO INSURANCE ARE PART OF
LIBERTY MUTUAL AGENCY MARKETS,A BUSINESS UNIT OF LIBERTY MUTUAL GROUP.
***COPY OF ESTIMATE PROVIDED TO CUSTOMER ***
****NO SUPPLEMENT WILL BE PAID WITHOUT PRIOR APPROVAL***
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****
SUPPLEMENT OF RECORD 2 WITH SUMMARY
2003 HOND ACCORD EX 4-2.4L-FI 4D SED TAN INT:TAN
SUPPLEMENTS WILL REQUIRE ALL INVOICES FOR THE ENTIRE REPAIR ****
THIS IS NOT AN AUTHORIZATION FOR REPAIRS.THE VEHICLE OWNER MUST AUTHORIZE
REPAIRS.NO SUPPLEMENT WILL BE HONORED WITHOUT APPROVAL BY A SAFE CO CLAIMS
REPRESENTATIVE.AGREED PRICE REACHED BY
OF AGREED DATE OF~C~O~M=P~L=E=T=IO=N~----.COPY OF AN ESTIMATE WAS GIVEN TO REPAIR A
FACILITY?WAS A COpy OF AN ESTIMATE GIVEN AND EXPLAINED TO
VEHICLE OWNER?CLAIMS REP THIS ESTIMATE MAY HAVE BEEN
PREPARED BASED ON THE USE OF LKQ PARTS.LKQ PARTS,ALSO KNOWN AS QUALITY
RECYCLED,OR USED PARTS,ARE OF LIKE,KIND,&QUALITY TO THE ORIGINAL PARTS ON
YOUR VEHICLE.WE SPECIFY ONLY QUALITY PARTS THAT MEET INDUSTRY STANDARDS WILL
BE USED.
I 'WE ARE PROHIBITED BY LAW FROM REQUIRING THAT REPAIRS BE DONE AT A SPECIFIC
AUTOMOTIVE REPAIR DEALER.YOU ARE ENTITLED TO SELECT THE AUTO BODY REPAIR SHOP
TO REPAIR DAMAGE COVERED BY US.WE HAVE RECOMMENDED AN AUTOMOTIVE REPAIR
DEALER THAT WILL REPAIR YOUR DAMAGED VEHICLE.IF YOU AGREE TO USE OUR
RECOMMENDED AUTOMOTIVE REPAIR DEALER,WE WILL CAUSE THE DAMAGED VEHICLE TO BE
RESTORED TO ITS CONDITION PRIOR TO THE LOSS AT NO ADDITIONAL COST TO YOU OTHER
THAN AS STATED IN THE INSURANCE POLICY OR AS OTHERWISE ALLOWED BY LAW.
IF YOU EXPERIENCE A PROBLEM WITH THE REPAIR OF YOUR VEHICLE,PLEASE CONTACT US
IMMEDIATELY FOR ASSISTANCE.
AUTO BODY REPAIR CONSUMER BILL OF RIGHTS
A CONSUMER IS ENTITLED TO:
1.SELECT THE AUTO BODY REPAIR SHOP TO REPAIR AUTO BODY DAMAGE COVERED BY THE
INSURANCE COMPANY.AN INSURANCE COMPANY SHALL NOT REQUIRE THE REPAIRS TO BE
DONE AT·A SPECIFIC AUTO BODY REPAIR SHOP.
2.AN ITEMIZED WRITTEN ESTIMATE FOR AUTO BODY REPAIRS AND,UPON COMPLETION OF
REPAIRS,A DETAILED INVOICE.THE ESTIMATE AND THE INVOICE MUST INCLUDE AN
ITEMIZED LIST OF PARTS AND LABOR ALONG WITH THE TOTAL PRICE FOR THE WORK
PERFORMED.THE ESTIMATE AND INVOICE MUST ALSO IDENTIFY ALL PARTS AS NEW,USED,
AFTERMARKET,RECONDITIONED,OR REBUILT.
3.BE INFORMED ABOUT COVERAGE FOR TOWING AND STORAGE SERVICES.
4.BE INFORMED ABOUT THE EXTENT OF COVERAGE,IF ANY,FOR A REPLACEMENT RENTAL
VEHICLE WHILE A DAMAGED VEHICLE IS BEING REPAIRED.
5.BE INFORMED OF WHERE TO REPORT SUSPECTED FRAUD OR OTHER COMPLAINTS AND
CONCERNS ABOUT AUTO BODY REPAIRS.
6.SEEK AND OBTAIN AN INDEPENDENT REPAIR ESTIMATE DIRECTLY FROM A REGISTERED
AUTO BODY REPAIR SHOP FOR REPAIR OF A DAMAGED VEHICLE,EVEN WHEN PURSUING AN
INSURANCE CLAIM FOR REPAIR OF THE VEHICLE.
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07/01/2011 AT 11:23 AM
102759
650522764033-201
27AFOAOH
SUPPLEMENT OF RECORD 2 WITH SUMMARY
2003 HOND ACCORD EX 4-2.4L-FI 4D SED TAN INT:TAN
COMPLAINTS WITHIN THE JURISDICTION OF THE BUREAU OF AUTOMOTIVE REPAIR
COMPLAINTS CONCERNING THE REPAIR OF A VEHICLE BY AN AUTO BODY REPAIR SHOP
SHOULD BE DIRECTED TO:
TOLL FREE (866)799-3811
CALIFORNIA DEPARTMENT OF CONSUMER AFFAIRS
BUREAU OF AUTOMOTIVE REPAIR
10240 SYSTEMS PARKWAY
SACRAMENTO,CA 95827
THE BUREAU OF AUTOMOTIVE REPAIR CAN ALSO ACCEPT COMPLAINTS OVER ITS WEB SITE
AT:WWW.AUTOREPAIR.CA.GOV
COMPLAINTS WITHIN THE JURISDICTION OF THE CALIFORNIA
INSURANCE COMMISSIONER
ANY CONCERNS REGARDING HOW AN AUTO INSURANCE CLAIM IS BEING HANDLED SHOULD BE
SUBMITTED TO THE CALIFORNIA DEPARTMENT OF INSURANCE AT:
(800)927-HELP OR (213)897-8921
CALIFORNIA DEPARTMENT OF INSURANCE
CONSUMER SERVICES DIVISION
300 SOUTH SPRING STREET
LOS ANGELES,CA 90013
THE CALIFORNIA DEPARTMENT OF INSURANCE CAN ALSO ACCEPT COMPLAINTS OVER ITS WEB
SITE AT:WWW.INSURANCE.CA.GOV
FOR YOUR PROTECTION CALIFORNIA LAW REQUIRES THE FOLLOWING TO APPEAR ON THIS
FORM:
ANY PERSON WHO KNOWINGLY PRESENTS FALSE OR FRAUDULENT CLAIM FOR THE PAYMENT OF
A LOSS IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN
STATE PRISON.
9
E-13
07/01/2011 AT 11:23 AM
102759
650522764033-201
27AFOAOH
SUPPLEMENT OF RECORD 2 WITH SUMMARY
2003 HOND ACCORD EX 4-2.4L-FI 4D SED TAN INT:TAN
ESTIMATE BASED ON MOTOR CRASH ESTIMATING GUIDE.UNLESS OTHERWISE NOTED ALL
ITEMS ARE DERIVED FROM THE GUIDE ARG4437,CCC DATA DATE 06/01/2011,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
DOUBLE 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.NON-ORIGINAL EQUIPMENT MANUFACTURER AFTERMARKET PARTS ARE
DESCRIBED AS AM,QUAL REPL PARTS OR COMP REPL PARTS WHICH STANDS FOR
COMPETITIVE REPLACEMENT PARTS.USED PARTS ARE DESCRIBED AS LKQ,QUAL RECY
PARTS,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 2010 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 ABBREVIATIONS OR SYMBOLS THAT MAY BE USED TO DESCRIBE
WORK TO BE DONE OR PARTS TO BE REPAIRED OR REPLACED:MOTOR
ABBREVIATIONS/SYMBOLS:D=DISCONTINUED PART A=APPROXIMATE PRICE LABOR TYPES:
B=BODY LABOR D=DIAGNOSTIC E=ELECTRICAL F=FRAME G=GLASS M=MECHANICAL P=PAINT
LABOR S=STRUCTURAL T=TAXED MISCELLANEOUS X=NON TAXED MISCELLANEOUS PATHWAYS:
ADJ=ADJACENT ALGN=ALIGN A/M=AFTERMARKET BLND=BLEND CAPA=CERTIFIED AUTOMOTIVE
PARTS ASSOCIATION NSF=NSF INTERNATIONAL CERTIFIED PART D&R=DISCONNECT AND
RECONNECT EST=ESTIMATE EXT.PRICE=UNIT PRICE MULTIPLIED BY THE QUANTITY
INCL=INCLUDED MISC=MISCELLANEOUS NAGS=NATIONAL AUTO GLASS SPECIFICATIONS
NON-ADJ=NON ADJACENT O/H=OVERHAUL OP=OPERATION NO=LINE NUMBER QTY=QUANTITY
QUAL RECY=QUALITY RECYCLED PART QUAL REPL=QUALITY REPLACEMENT PART COMP REPL
PARTS=COMPETITIVE REPLACEMENT PARTS RECOND=RECONDITION REFN=REFINISH
REPL=REPLACE R&I=REMOVE AND INSTALL R&R=REMOVE AND REPLACE RPR=REPAIR RT=RIGHT
SECT=SECTION SUBL=SUBLET LT=LEFT W/O=WITHOUT Wi =WITHI SYMBOLS:#=MANUAL LINE
ENTRY *=OTHER [IE ..MOTORS DATABASE INFORMATION-WAS CHANGED]**=DATABASE LINE
WITH AFTERMARKET N=NOTES ATTACHED TO LINE.OPT OEM=ORIGINAL EQUIPMENT
MANUFACTURER PARTS EITHER OPTIONALLY SOURCED OR OTHERWISE PROVIDED WITH SOME
UNIQUE PRICING OR DISCOUNT.NWCPP=NATIONWIDE CRASH PARTS PROGRAM.
CCC PATHWAYS - A PRODUCT OF CCC INFORMATION SERVICES INC.
10
E-14
07/01/2011 AT 11:23 AM
102759
650522764033-201
27AFOAOH
SUPPLEMENT OF RECORD 2 WITH SUMMARY
2003 HOND ACCORD EX 4-2.4L-FI 4D SED TAN INT:TAN
ALTERNATE PARTS USAGE
AFTERMARKET PARTS
AFTERMARKET SELECTION METHOD:AUTOMATICALLY LIST
NO.OF TIMES USER WAS NOTIFIED THAT AN AFTERMARKET PART WAS AVAILABLE:0
NO.OF AFTERMARKET PARTS THAT APPEAR IN THE FINAL ESTIMATE:0
OPTIONAL OEM PARTS
OPTIONAL OEM SELECTION METHOD:AUTOMATICALLY LIST
NO.OF TIMES USER WAS NOTIFIED THAT AN OPTIONAL OEM PART WAS AVAILABLE:0
NO.OF OPTIONAL OEM PARTS THAT APPEAR IN THE FINAL ESTIMATE:0
RECONDITIONED PARTS
RECONDITIONED SELECTION METHOD:AUTOMATICALLY LIST
NO.OF TIMES USER WAS NOTIFIED THAT A RECONDITIONED PART WAS AVAILABLE:0
NO.OF RECONDITIONED PARTS THAT APPEAR IN THE FINAL ESTIMATE:0
RECYCLED PARTS
NO.OF TIMES USER WAS NOTIFIED THAT A RECYCLED PART WAS AVAILABLE:0
NO.OF RECYCLED PARTS THAT APPEAR IN THE FINAL ESTIMATE:0
11
E-15
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E-17