213181 09/25/2012 CITY OF CARMEL, INDIANA VENDOR: 366563 Page 1 of 1
ONE CIVIC SQUARE STATE FARM CLAIMS
=o CARMEL, INDIANA 46032 PO BOX 661011 CHECK AMOUNT: $61.25
.o� DALLAS TX 75266-1011 CHECK NUMBER: 213181
CHECK DATE: 9/25/2012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1110 4351000 14-175W-176 61 .25 AUTO REPAIR & MAINTEN
Providing Insurance and Financial Services ��� ���r1TM
Nome Office, Bloomington, I
September 11, 2012 � f
City Of Carmel State Farm Claims SEP 14 2012
Civic
46032-2584 Dallllass TX675266-1011 O'�RMEL ppLtCE®Epp
RE: Claim Number: 14-175W-176
Date of Loss: August 16, 2012
Our Insured: Stephanie Whealy
To Whom It May Concern:
State Farm°appreciates the opportunity to assist with the handling of your property damage
claim related to your recent loss.
Attached is our payment for the estimated repairs to your damaged vehicle. You have the right
to select the repair facility that will repair your vehicle. Please present this estimate to the repair
facility of your choice.
Our payment is based on a repair estimate using prices that are competitive in your market area.
In the event additional damage is identified by the repairer you select, any amount previously
paid will be taken into consideration as we determine any additional amounts owed. We will
review and consider any supplemental amounts requested by you or the repairer you select,
should additional loss-related damage become apparent. Any additional payment will be based
upon supplemental amounts agreed to by State Farm. You may be responsible for the
difference for any amounts not agreed to by State Farm.
If paintless dent repair is specified in whole or in part for your vehicle repairs, payment is based
on the price for those repairs from agreements we have with repair facilities for such repairs.
This price is competitive in the market area for paintless dent repair.
If you have not selected a repair facility, we can assist you by identifying Select Service°and/or
paintless dent repairers who have agreements with State Farm to provide quality repairs at
prices that are competitive in your market area. Conveniently located repairers can also be
found by going to statefarm.como.
You are free to select repairers who do not have Select Service or paintless dent repair
agreements with State Farm. These repairers may perform quality repairs on your vehicle, but
may charge more than the prices that are competitive in your market area, and/or prices for
paintless dent repair that are established through agreements we have with repair facilities.
We will assist you by working with these repairers as best we can.
Date: 9/11/2012 09:18 AM
Estimate ID: 14-175W-17602
Estimate Version: 0
Committed
Profile ID: Indpls-Hamilton,IN
State Farm Insurance
For your insurance and financial needs, please contact a
State Farm@ agent or visit www.statefarm.com.
For any questions regarding this estimate please contact the indicated
claims representative.
Supplemental repairs require prior approval before work is completed.
Please fax all supplement requests to: (866) 334-7468.
THIS IS NOT AN AUTHORIZATION TO REPAIR. OWNER PAYS TOTAL REPAIR COST.
Damage Assessed By: JIM WATKINS Appraised For: Al -Rep Team
(888)695-3265
Type of Loss: Property
Date of Loss: 8/16/2012
Deductible: 0.00
Claim Number: 14-175W-17602
Insured: State Farm Insured
Claimant: CITY OF CARMEL
Address: 3400 W 131ST ST,CARMEL,IN 46074-8267
Telephone: Work Phone: (317)571-2500
Owner: CITY OF CARMEL
Address: 3400 W 131ST ST,CARMEL,IN 46074-8267
Telephone: Work Phone: (317)571-2500
Mitchell Service: 910565
Description: 2009 Chevrolet Impala Police
Body Style: 4D Sed Drive Train: 3.91-Inj 6 Cyl 4A FWD
VIN: 2G1 WS57M491305666 License: 14213 IN
OEMIALT: A Search Code: R6YY
Color: BLUE
Line Entry Labor Line Item Part Type/ Dollar Labor
Item Number Type Operation Description Part Number Amount Units
1 001196 BDY REPAIR R Rear Door Repair Panel Existing 2.0*#
2 AUTO REF REFINISH R Rear Door Outside C 2.2
3 900500 REF * REFINISH/REPAIR BASECOAT REDUCTION/RR DOOR Existing -0.1*
4 001939 REF REFINISH R Rear Door Moulding C 0.5
5 001941 BDY REMOVE/INSTALL R Rear Otr Belt Moulding 0.7 #
6 001206 BDY REMOVE/INSTALL R Rear Door Adhesive Moulding Existing 0.2 r
7 001943 BDY REMOVE/INSTALL R Rear Door Trim Panel INC
8 001951 BDY REMOVE/INSTALL R Rear Otr Door Handle 0.6 #
9 900500 BDY * ADDT LABOR OP CLEAN&RETAPE MOULDINGS/EMBLEMS Existing 0.2*
10 900500 BDY * ADD'L LABOR OP ADHESIVE REMOVAL Existing 0.1*
11 900500 BDY * REPAIR PULL UPPER BODY Existing 1.5*
ESTIMATE RECALL NUMBER: 09/1112012 09:18:50 14-175W-17602
Mitchell Data Version: OEM: AUG_12_V
MAPP:AUG_12_V Copyright(C)1994-2012 Mitchell International Page 1 of 3
Software Version: 7.0.480 All Rights Reserved
Date: 911112012 09:18 AM
Estimate ID: 14-175W-17602
Estimate Version: 0
Committed
Profile ID: Indpis-Hamilton,IN
12 PULL RIGHT QUARTER
13 003342 BDY REMOVE/INSTALL R Roof Joint Mldg Existing 0.3 r
14 002168 REF REFINISH R Quarter Panel Outside C 2.0
15 900500 REF * REFINISH/REPAIR BASECOAT REDUCTION/R QUARTER Existing -0,1*
16 900500 BDY* REPAIR R QUARTER PANEL Existing 10.0*
17 REPAIR AFTER PULL
18 002326 REF REFINISH R Roof Rail C 0,8*
19 CLEAR COAT ONLY
20 001851 BDY REMOVE/INSTALL R Quarter Liner Existing 0.4 r
21 002229 BDY REMOVE/INSTALL R Rocker Moulding 1.0
22 003537 BDY REPAIR R Rocker Moulding Existing 0.5*
23 AUTO REF REFINISH R Rocker Moulding C 1.4
24 900500 REF * REFINISH/REPAIR BASECOAT REDUCTION/R ROCKER MLDG Existing -0.1*
25 001457 BDY REMOVE/REPLACE R Quarter Adhesive Emblem 10424490 GM PART 39.49 0.2
26 002219 GLS REMOVE/INSTALL R Quarter Glass 2.0 #
27 900500 BDY* REMOVE/REPLACE RIGHT QUARTER GLASS KIT New 30.40 * 0.0*
28 001764 BDY REMOVE/INSTALL R Rear Body Trim Panel Existing 0.3 r
29 -900500 BDY* ADD'L LABOR OP ROPE/BACK TAPE WINDSHIELD Existing 0.2*
30 900500 BDY * ADD'L LABOR OP ROPE/BACK TAPE REAR GLASS Existing 0.2*
31 002241 BDY REMOVE/INSTALL R Rear Combination Lamp 0.3
32 AUTO BDY OVERHAUL Rear Bumper Assy 1.9 #
33 001845 BDY REMOVE/REPLACE Rear Bumper Cover Remanufactured 455.00 INC #
34 AUTO REF REFINISH Rear Bumper Cover C 2,9
35 936012 ADD'L COST HAZARDOUS WASTE DISPOSAL 3.00 *
36 936014 ADD'L COST FLEX ADDITIVE 3.00 *
37 AUTO REF ADD'L OPR Clear Coat 2,6
38 933005 REF * ADD'L OPR RESTORE CORROSION PROTECTION 0.00 * 0.3*
39 AUTO ADD'L COST Paint/Materials 347.20 *
-Judgment Item
#- Labor Note Applies
** non-OEM - New non-Original Equipment Manufacturer parts
C-Included in Clear Coat Calc
r-CEG R&R Time Used For This Labor Operation
KEYSTONE AUTOMOTIVE
849 WHITAKER ROAD,STE C
PLAINFIELD
IN 46168
(317)895-0530 (800)525-4639
33 `*GM1100736R 455.00
ESTIMATE RECALL NUMBER: 09/11/2012 09:18:50 14-175W-17602
Mitchell Data Version: OEM: AUG-12_V
MAPP:AUG_12_V Copyright(C)1994-2012 Mitchell International Page 2 of 3
Software Version: 7.0.480 All Rights Reserved
Date: 9/11/2012 09:18 AM
Estimate ID: 14-175W-17602
Estimate Version: 0
Committed
Profile ID: Indpls-Hamilton,IN
Estimate Totals
Add'I
Labor Sublet
I. Labor Subtotals Units Rate Amount Amount Totals II. Part Replacement Summary Amount
Body 20.6 44.00 0.00 0.00 906.40 Taxable Parts 524.89
Refinish 12.4 44.00 0.00 0.00 545.60 Sales Tax @ 7.000% F2 36.74 '
Glass 2.0 44.00 0.00 0.00 88.00
Total Replacement Parts Amount 561.63
Non-Taxable Labor 1,540.00
Labor Summary 35.0 1,540.00
III. Additional Costs Amount IV. Adjustments Amount
Taxable Costs 350.20 Insurance Deductible 0.00
Sales Tax @ 7.000% 24.51
Customer Responsibility 0.00
Non-Taxable Costs 3.00
Total Additional Costs 377.71
Paint Material Method:Rates
Init Rate=28.00 ,[nit Max Hours=99.9,Addl Rate=0.00
I. Total Labor: 1,540.00
II. Total Replacement Parts: 561.63
III. Total Additional Costs: 377.71
Gross Total: 2,479.34
IV. Total Adjustments: 0.00
Net Total: 2,479.34
Point(s)of Impact
4 Right Rear Side(P) _
Insurance Co: State Farm Insurance
Inspection Site: CITY OF CARMEL Police Dept.
Address: 3 Civic Square
CARMEL,IN 46032
(317)571-2523
Inspection Date: 9/1112012
NOTE: For your protection, the law of your state requires the
following to appear on this form:
Any person who knowingly, and with the intent to injure, defraud,
or deceive any insurance company, files a statement of claim
containing any false, incomplete, or misleading information, may be
guilty of a felony and subject to criminal and civil penalties.
ESTIMATE RECALL NUMBER: 09/11/2012 09:18:50 14-175W-17602
Mitchell Data Version: OEM: AUG-12_V
MAPP:AUG_12_V Copyright(C)1994-2012 Mitchell International Page 3 of 3
Software Version: 7.0.480 All Rights Reserved
PAYMENT NO 1 18 337671 J CLAIM NO 14-175W-176
PAYMENT AMOUNT $2,479.34 LOSS DATE 08-16-2012
ISSUE DATE 09-11-2012 POLICY NO 1501-634-14A
AUTHORIZED BY CURRY, ANITA INSURED WHEALY, STEPHANIE
PHONE (888) 695-3265
CITY OF CARMEL
3 CIVIC SO
CARMEL IN 46032-2584
REMARKS property damage repair to 2009 Chevrolet impala from loss on
8/16/12. attn: vicky bailey
COVERAGE DESCRIPTION ON BEHALF OF AMOUNT
PROPERTY DAMAGE LIABILITY CITY OF CARMEL 2,479.34
RE
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`*'EXACTtY TWO,THOUSAND FOUR HUNDREQ'SEV NTY-NINE`.AND,,34/1.00 DOLLARS $*****2, 479 : 34 m
'qy to the c
Order.of. CITY OF CARMEL v
W
' AUTHORIZED SIGNATURE w
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SECURED DOCUMENT WATERMARK APPEARS ON BACK,HOLD AT 450 ANGLE FOR VIEWING AUTHOP D SIGNATURE
II° b817337671I1° 0:044IL5Is 431a62629023PO
VOUCHER NO. WARRANT NO.
ALLOWED 20
State Farm Claims
IN SUM OF $
P.O. Box 661011
Dallas, TX 75266-1011
$61.25
ON ACCOUNT OF APPROPRIATION FOR
Carmel Police Department
PO#/Dept. INVOICE NO. ACCT#/TITLE AMOUNT Board Members
1110 14-175W-176 43-510.00 $61.25_
I hereby certify that the attached invoice(s), or
I I I
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
Wednesday, September 19, 2012
Chief of Police
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund
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))
09/19/12 14-175W-176 tax reimbursement $61.25
1 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