242291 02/17/15 CITY OF CARMEL, INDIANA VENDOR: 369111
® ONE CIVIC SQUARE RONALD HELLER CHECK AMOUNT: $ ...""304.43"
f.. _ CARMEL, INDIANA 46032 4556 E CR 850 NORTH CHECK NUMBER: 242291
PITTSBOROIN 46167 CHECK DATE: 02/17/15
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1120 4347500 304.43 GENERAL INSURANCE
Property Damage Release (FULL & FINAL)
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K (wro�, �»� K�/Fu� , in consideration of Three Hundred Four Dollars and Forty
Three Cenis, to me(us) in hand paid by City of Carmel, Indiana, have released and discharged,
and by these presents do for myself(ourselves), my (our) heirs, executors, administrators and
assigns, release and forever discharge the said City of Carmel, Indiana, other persons, firms or
corporations from all claims, demands, actions, or cauSes of action, resulting, or to result, from
an accident which occurred on or about the 6th day of February 2015 reason ()IAN
AUTOMOI3ILE ACCIDENT which occurred u( !'465 E at mile marker 30.2 Cannel, IN for all
property damage claims or demands whatsoever in law or in equity, which | (vme), my (our) heirs,
executors, administrators, or assigns can, shall or may have by reason of any rnutier, cause or
thing whatsoever prior to the date hereof.
It is Understood and Agreed that this is a full release for property damage and of every
property' damage claim in nature and kind whatsoever, and releases claims that are known and
unkiiown, suspected and unsuspected for properly damage only.
it is Further Understood and Agreed that any party hereby released admits no liability
to the undersigned or any others, shall not be estopped or otherwise barred froM asserting, and
expressly reserves the right to assert any claim or cause of action such party cuuybare against the
undersigned or any others.
In Witness Whereof, l (we) have hereunto set my(our) hand(s) and seal(s) this day
'
nf2�/�� 2015.
In The Presence 01'
• o ' l~ '"° ' ' citZ (Seal)
(X Street
Town-State
'
/
\.
/
M & M BODY SHOP Workfile ID: f7976851
Federal ID: 351612977
250 W MAIN ST, BROWNSBURG, IN 46112 State ID: 0002659450
Phone: (317) 852-6347
FAX: (317) 852-6398
Preliminary Estimate
Customer: Heller, Ron Job Number:
Written By: Drew Conner
Insured: Heller, Ron Policy#: Claim#:
Type of Loss: Date of Loss: Days to Repair: 0
Point of Impact:
Owner: Inspection Location: Insurance Company:
Heller,Ron M &M BODY SHOP
4556 E 850 N 250 W MAIN ST
Pittsboro,IN 46167 BROWNSBURG,IN 46112
(317)730-0636 Business Repair Facility
(317)852-6347 Business
VEHICLE
Year: 2011 Body Style: 4D SHORT VIN: 1FTEX1CM5BFB82607 Mileage In:
Make: FORD Engine: 6-3.7L-FI License: Mileage Out:
Model: F150 4X2 SUPERCAB STX Production Date: State: Vehicle Out:
Color: Int: Condition: Job#:
TRANSMISSION CONVENIENCE Auxiliary Audio Connection SEATS
Automatic Transmission Air Conditioning SAFETY Cloth Seats
Overdrive Intermittent Wipers Drivers Side Air Bag WHEELS
POWER Tilt Wheel Passenger Air Bag Aluminum/Alloy Wheels
Power Steering RADIO Anti-Lock Brakes(4) PAINT
Power Brakes AM Radio 4 Wheel Disc Brakes Clear Coat Paint
DECOR FM Radio Traction Control TRUCK
Dual Mirrors Stereo Stability Control Rear Step Bumper
Privacy Glass Search/Seek Front Side Impact Air Bags
Console/Storage CD Player Head/Curtain Air Bags
2/11/2015 3:51:55 PM 028503 Page 1
Preliminary Estimate
Customer: Heller, Ron Job Number:
Vehicle: 2011 FORD F150 4X2 SUPERCAB STX 4D SHORT 6-3.7L-FI
Line Oper Description Part Number Qty Extended Labor Paint
Price$
1 FRONT DOOR
2 * Repl LT Mirror black BL3Z17683BA 1 232.11 0_5
3 * R&.I LT R&I trim panel 0_6
SUBTOTALS 232.11 1.1 0.0
ESTIMATE TOTALS
Category Basis Rate Cost$
Parts 232.11
Body Labor 1.1 hrs @ $50.00/hr 55.00
Body Supplies 0.5 hrs @ $2.00/hr 1.00
Subtotal 288.11
Sales Tax $233.11 @ 7.0000% 16.32
Grand Total 304.43
Deductible 0.00
CUSTOMER PAY 0.00
INSURANCE PAY 304.43
A PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD AN INSURER FILES A STATEMENT OF CLAIM
CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION COMMITS A FELONY.
2/11/2015 3:51:55 PM 028503 Page 2
Preliminary Estimate
Customer: Heller, Ron Job Number:
Vehicle: 2011 FORD F150 02 SUPERCAB STX 4D SHORT 6-3.7L-FI
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
DR2MA09, CCC Data Date 2/9/2015, 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. The symbol (<>) indicates the refinish operation WILL NOT be performed as a separate procedure
from the other panels in the estimate. Non-Original Equipment Manufacturer aftermarket parts are described as Non
OEM or A/M. Used parts are described as LKQ, RCY, or USED. Reconditioned parts are described as Recond.
Recored parts are described as Recore. NAGS Part Numbers and Benchmark Prices are provided by National Auto
Glass Specifications. Labor operation times listed on the line with the NAGS information are MOTOR suggested labor
operation times. NAGS labor operation times are not included. Pound sign (#) items indicate manual entries.
Some 2015 vehicles contain minor changes from the previous year. For those vehicles, prior to receiving updated
data from the vehicle manufacturer, labor and parts data from the previous year may be used. The CCC ONE
estimator has a complete list of applicable vehicles. Parts numbers and prices should be confirmed with the local
dealership.
The following is a list of additional abbreviations or symbols that may be used to describe work to be done or parts to
be repaired or replaced:
SYMBOLS FOLLOWING PART PRICE:
m=MOTOR Mechanical component. s=MOTOR Structural component. T=Miscellaneous Taxed charge category.
X=Miscellaneous Non-Taxed charge category.
SYMBOLS FOLLOWING LABOR:
D=Diagnostic labor category. E=Electrical labor category. F=Frame labor category. G=Glass labor category.
M=Mechanical labor category. S=Structural labor category. (numbers) 1 through 4=User Defined Labor Categories.
OTHER SYMBOLS AND ABBREVIATIONS:
Adj.=Adjacent. Algn.=Align. ALU=Aluminum. A/M=Aftermarket part. Bind=Blend. BOR=Boron steel.
CAPA=Certified Automotive Parts Association. D&R=Disconnect and Reconnect. HSS=High Strength Steel.
HYD=Hydroformed Steel. Incl.=Included. LKQ=Like Kind and Quality. LT=Left. MAG=Magnesium. Non-Adj.=Non
Adjacent. NSF=NSF International Certified Part. 0/H=Overhaul. Qty=Quantity. Refn=Refinish. Repl=Replace.
R&I=Remove and Install. R&R=Remove and Replace. Rpr=Repair. RT=Right. SAS=Sandwiched Steel.
Sect=Section. Subl=Sublet. UHS=Ultra High Strength Steel. N=Note(s) associated with the estimate line.
CCC ONE Estimating -A product of CCC Information Services Inc.
The following is a list of abbreviations that may be used in CCC ONE Estimating that are not part of the MOTOR
CRASH ESTIMATING GUIDE:
BAR=Bureau of Automotive Repair. EPA=Environmental Protection Agency. NHTSA= National Highway
Transportation and Safety Administration. PDR=Paintless Dent Repair. VIN=Vehicle Identification Number.
2/11/2015 3:51:55 PM 028503 Page 3
Snyder, Denise W
From: Cromlich, Mark
Sent: Thursday, February 12, 2015 14:07
To: Snyder, Denise W
Subject: Fwd: Your Travelers Auto Claim #E3130481
Attachments: image001jpg;ATT00001.htm; E3130481 heller est.pdf, ATT00002.htm; Damage Release
City of Carmel 2.6.15.doc;ATT00003.htm
Do you take care of this? Or do I need to take something to the city? And I requested the release of liability
form if needed. I have talk to him on the phone and let him know that I would not be back in town until
Tuesday and I'm more than happy and willing to take care of whatever I can do.
Sent from my Whone
Begin forwarded message:
From: "Santos,Charisse" <C SANTO S42travelers.corn>
Date: February 12, 2015 at 1:50:44 PM EST
To: "Cromlich, Mark" <MCromlichgcarmel.in. og_v>
Subject: RE: Your Travelers Auto Claim #E3P0481
Hello Mr. Cromlich,
Attached is Mr. Ronald Heller's damage estimate for the mirror.Total is for$304.43. I've also attached
the property release you can send to him. Up to you if you require it to be notarized. It's a Word
document so feel free to edit as needed. He has agreed to receive payment directly from the City. His
mailing address is as follows.
RONALD HELLER
4556 E CR 850 N
PITTSBORO , IN 46167
1 will close down my file here, but please give me a call or email anytime for any other questions.
Best Regards,
Charisse Santos I Claim Professional
PO Box 3204
Naperville IL 60566
W:630.961.4221 F: 877.795.9975
1
Property Damage Release (FULL & FINAL,)
I (we), , in consideration of Three Hundred Four Dollars and Forty
Three Cents, to me(us) in hand paid by City of Carmel, Indiana, have released and discharged,
and by these presents do for myself(ourselves), my (our) heirs, executors, administrators and
assigns, release and forever discharge the said City of Carmel, Indiana, other persons, firms or
corporations from all claims, demands, actions, or causes of action, resulting, or to result, from
an accident which occurred on or about the 6`" day of February 2015 reason of AN
AUTOMOBILE ACCIDENT which occurred at I-465 E at mile marker 30.2 Carmel, IN for all
property damage claims or demands whatsoever in law or in equity, which I (we), my (our) heirs,
executors, administrators, or assigns can, shall or may have by reason of any matter, cause or
thing whatsoever prior to the date hereof.
It is Understood and Agreed that this is a full release for property damage and of every
property damage claim in nature and kind whatsoever, and releases claims that are known and
unknown, suspected and unsuspected for property damage only.
It is Further Understood and Agreed that any party hereby released admits no liability
to the undersigned or any others, shall not be estopped or otherwise barred from asserting, and
expressly reserves the right to assert any claim or cause of action such party may have against the
undersigned or any others.
In Witness Whereof, I (we) have hereunto set my (our) hand(s) and seal(s) this day
of 2014 .
In The Presence Of
(Seal)
(X) Street
Town-State
Prescribed by State Board of Accounts City Form No 201 (Rev.1995)
ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL
An invoice or bill to be properly itemized must show: kind of service,where performed, dates service rendered, by
whom, rates per day, number of hours, rate per hour, number of units, price per unit, etc.
Payee
Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
Damage to Personal Vehicle caused by CFD $304.43
I hereby certify that the attached invoice(s), or bill(s), is (are)true and correct and I have audited same in accordance
with IC 5-11-10-1.6
20
Clerk-Treasurer
VOUCHER NO. WARRANT NO.
ALLOWED 20
Ronald Heller
IN SUM OF $
4556 E. CR 850 North
Pittsboro, IN 46167
$304.43
ON ACCOUNT OF APPROPRIATION FOR
Carmel Fire Department
PO#/Dept. INVOICE NO. ACCT#/TITLE AMOUNT Board Members
1120 43-475.00 $304.43 1 hereby certify that the attached invoice(s), or
bill(s) is (are)true and correct and that the
materials or services itemized thereon for
which charge is made were ordered and
received except _ . 2011 -0 tB b 2l i0
Fire Chief
Title
I
Cost distribution ledger classification if
claim paid motor vehicle highway fund