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HomeMy WebLinkAbout02-08-2017 Haller, Dan and Lynnette - Claim for Damages (rec'd 2-14-2017)Pre§ecut©r.s Office FED 14 vZ0|7 Civil Divisionr.RasEEci"R `{#y`€ttt£`C;EORERSJi± I,,fA9m,+5anue..~ _u!!_uqucB_- ©2/@8/201711:56:49 flM 00 ims against Cc)unty/r`ls/misc ti`as County audit 11111111111"111111111111111111111!1 2© 17@2©88© 11 Page:1 of 10 K C0 PROSEC KITTITAS COUNTY CLAM FOR DAMAGES Return to : =o°5u#y5A|dv!::;uitel05 Ellensburg, WA 98926 509-962-7504 Instructions: Please read the entire form before completion. Fill out each question as completely as possible, to the best of your ability. Do not hesitate to use the back side of this form if you need more than the space provided. An incomplete response may delay the processing of your claim. 1. Name (Including spouse, if married): i c`n H```\\€' ;09?¥5`=r,.,:c 7L).`m+ a+ t\Lt`\\f-v Phone urome):i,-a ,;, - i; j' 5', >~q-a iOvork): ( ) Address (include fomer address if at present address for less than 6 months): I)hysical m#70 j'.-+hw€n~ f`7uo\cl, 5i|ah WA JU`9q-2~ DateofBirth: O®/o` I lJlz, Date and Time of hcident: C\?erT,`+ 11 O\.Tn. oi` -TLnun:) `13, 2cn =2¥°2n7°f]ne#ti±b___\__)G#o`.i\£___G||?"bv`ri±,W.A 1of3 Kittitas County claim for Dzimages Form Revised 9/2 012 7. Describe in detail the defect which caused the injury: lCa 4t v�h cLe G t a,d ;ll m�.,..CW In u.,a U 8. Describe in narrative form and in detail exactly°how the incident occurred: 1— W d, S CA -(0 JA, r � 8�„ S i � � J 5���' ; , , � } L.c� _n �1 -C'sz'.,t ._,. 1 Iyrt V1 9. List the names of all persons involved and contact information, if known. 10. 11. Was claim investigated by a police officer? Sheriff v' State Patrol Description of claimant's vehicle: Model: City Police Make ,2 �5 Year License No. \i 1 2, 18 4- 12. Describe what you did after the accident occurred: __rr cl C� c I vt 13. Describe the conversations you had, if any, with County personnel during or after the incident occurred: ((41. 2of3 Kinitas County Claim for Damages Form Revised 9/2012 14. Describe the damages or injuries which you sustained as a result of the incident: i0aYY1¢ 4, `!0 C O"'r, , MD Jul G a k , -- 15. What is the amount of damages claimed? (Include estimates and bills, if available): 16. How did you identify the County as the party responsible for your damage? 17. List the names and adds asses of all witnesses to the incident: .5 -ee ���� PS i,W► J 18. Are you covered by insurance? Yf s If yes, who is your insurance agent/carrier? ,54-c,,vn , Dated s Day of —J7O(iw ,', 2011 Signature of Claimant Subscribed and swom (affirmed) to before me this 1 day ofF` " 1 20 Seal n 0 r?-Mz Sri T:�Yl-b Public in and for the State of Washington ng at LJ -Pr Kittitas County Claim for Damages Form Revised 9/2012 Customer: Haller, Dan Insured: Haller, Dan Type of Loss: Point of Impact: 12 Front Owner: Haller, Dan 2770 s wenas rd selah, WA 98942 (509) 952-8607 Cell GREENWAY AUTO BODY CF 1600 E YAKIMA AVE, YAKIMA, WA 98901 Phone: (509) 453-7989 FAX: (509) 453-7956 Preliminary Estimate Written By: Hector Cardenas Policy #: Date of Loss: Inspection Location: GREENWAY AUTO BODY -CF 1600 E YAKIMA AVE YAKIMA, WA 98901 Repair Facility (509)453-7989 Day VEHICLE Workflle ID. 609c07d6 Claim #: 47-0621384 Days to Repair: 0 Insurance Company: 2015 CHEV Sonic LT Automatic 4D SED 4-1.8L Gasoline Electronic Fuel Injection silver VIN: 1G1JC5SH7F4181457 Interior Color: Mileage In: License: Exterior Color: silver Mileage Out: State: Production Date: Condition: TRANSMISSION Automatic Transmission POWER Power Steering Power Brakes Power Windows Power Locks Power Mirrors Heated Mirrors DECOR Dual Mirrors Tinted Glass Console/Storage CONVENIENCE Air Conditioning Intermittent Wipers Tilt Wheel Cruise Control Rear Defogger Keyless Entry Alarm Message Center Steering Wheel Touch Controls Telescopic Wheel Remote Starter RADIO AM Radio FM Radio Vehicle Out: Job #: Stereo SEATS Search/Seek Cloth Seats CD Player Bucket Seats Auxiliary Audio Connection Reclining/Lounge Seats Satellite Radio WHEELS SAFETY Aluminum/Alloy Wheels Drivers Side Air Bag PAINT Passenger Air Bag Clear Coat Paint Anti -Lock Brakes (4) OTHER Front Side Impact Air Bags Traction Control Head/Curtain Air Bags Stability Control Communications System Power Trunk/Gate Release Hands Free Device Rear Side Impact Air Bags 1/18/2017 4:25:40 PM 014595 Page 1 Preliminary Estimate Customer: Haller, Dan SUBTOTALS 307.60 3.4 3.6 ESTIMATE TOTALS 2015 CHEV Sonic LT Automatic 4D SED 4-1.81L Gasoline Electronic Fuel Injection silver Category Basis Rate Cost $ Parts 307.60 Line Oper Description Part Number Qty Extended Labor Paint 3.4 hrs @ $ 52.00 /hr 176.80 Price $ 3.6 hrs @ 1 FRONT BUMPER & GRILLE Paint Supplies 3.6 hrs @ $ 32.00 /hr 115.20 2 O/H front bumper 784.62 2.7 3 ** Repl RECOND Bumper cover w/o RS 95229055 1 253.00 Incl. 2.6 4 Add for Clear Coat Deductible 1.0 5 R&I Emblem w/o RS 0.00 Incl. 6 Repl LT Trim cover w/o fog lamps 96694768 1 43.60 Incl. 7 R&I License bracket IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE IMPRISONMENT, 0.2 8 # Tint 1 0.5 9 # flex additive 1 6.00 10 # hazardous waste removal 1 5.00 1/18/2017 4:25:40 PM 014595 Page 2 SUBTOTALS 307.60 3.4 3.6 ESTIMATE TOTALS Category Basis Rate Cost $ Parts 307.60 Parts Discount $ 43.60 -5.0 % -2.18 Body Labor 3.4 hrs @ $ 52.00 /hr 176.80 Paint Labor 3.6 hrs @ $ 52.00 /hr 187.20 Paint Supplies 3.6 hrs @ $ 32.00 /hr 115.20 Subtotal 784.62 Sales Tax $ 784.62 @ 8.2000% 64.34 Grand Total 848.96 Deductible 0.00 CUSTOMER PAY 0.00 INSURANCE PAY 848.96 MyPriceLink Estimate ID: 251138796379226112 IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE IMPRISONMENT, FINES, AND DENIAL OF INSURANCE BENEFITS. 1/18/2017 4:25:40 PM 014595 Page 2 Preliminary Estimate Customer: Haller, Dan 2015 CHEV Sonic LT Automatic 4D SED 4-1.8L Gasoline Electronic Fuel Injection silver Estimate based on MOTOR CRASH ESTIMATING GUIDE and potentially other third party sources of data. Unless otherwise noted, (a) all items are derived from the Guide DR1012, CCC Data Date 1/17/2017, and potentially other third party sources of data; and (b) the parts presented 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 data provided by third party sources of data 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, A/M or NAGS. 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 2017 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 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. O/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. 1/18/2017 4:25:40 PM 014595 Page 3 Preliminary Estimate Customer: Haller, Dan 2015 CHEV Sonic LT Automatic 4D SED 4-1.8L Gasoline Electronic Fuel Injection silver Line Supplier PARTS SUPPLIER LIST Description Keystone #GM 1000928R 16393 NE CAMERON BLVD RECOND Bumper cover w/o RS PORTLAND OR 97230 Quote: 106348563-450318250202163 (360) 260-8400 Expires: 03/04/17 Price $ 253.00 1/18/2017 4:25:40 PM 014595 Page 4 T ALTO ART & COLLISION REPAIR LLC Your Body Shop of Choice a3fr 4r AY 5 YuN r�CAn,re. info@mikesautoart.com 1718 S. 18TH STREET, YA IM , WA 8901 Phone: (509) 248-7874 FAX: (509) 576-7874 Preliminary Estimate Customer: Haller, Dan Insured: Haller, Clan Type of Lass: Point of Impact: 12 Front Owner: Haller, Dan (509) 952-8607 Cell Written By: Irma Philp Policy #: Date of Goss: Inspection Location: AUTO ART & COLLISION REPAIR LLC 1718 S. 18TH STREET YAKIMA, WA 98901 Repair Facility (509) 248-7874 Business VEHICLE workfile ID: 909f81b9 Federal ID: 80-0342924 Claim #: Days to Repair: 0 Insurance Company: 2015 CHEV Sonic LT Automatic 4D SED 4-1.8L Gasoline Electronic Fuel Injection Silver VIN: IGIJC5SH7F4181457 Interior Color: Mileage In: License: Exterior Color: Silver Mileage Out: State: Production Date: Condition: TRANSMISSION Air Conditioning Stereo Automatic Transmission Intermittent Wipers Search/Seek POWER Tilt wheel CD Player Power Steering Cruise Control Auxiliary Audio Connection Power Brakes Rear defogger Satellite Radio Power Windows Keyless Entry SAFETY Power Locks Alarm ©rivers Side Air Bag Power Mirrors Message Center Passenger Air Bag Heated Mirrors Steering wheel Touch Controls Anti -Lock Brakes (4) DECOR Telescopic Wheel Front Side Impact Air Bags Dual Mirrors Remote Starter Head/Curtain Air Bags Tinted Glass RADIO Communications System Console/Storage AM Radio Hands Free Device CONVENIENCE FM Radio Real" Side Impact Ail" Batts Vehicle Out: Job #: SEATS Cloth seats Bucket Seats Reclining/Lounge Seats WHEELS Aluminum/Alloy Wheels PAINT Clear 0"'at Paint OTHER Traction Control Stability Control Power Trunk/Gate Release Get live updates at www.ca.rwise.com/e/36nQ8N 1/18/2017 4:38:24 PM 401274 Page 1 Preliminary Estimate Customer: Haller, Dari 20151NHEV Soric LT Automatic 4D SED 4-1.81- Gasoline Electronic Fuel Injection Silver Line Oper Description Part Number Qty Extended Labor Paint Price 1 FRONT BUMPER & GRILLE 2 " Rpr Bumper cover w/o RS 1:5 2.6 3 Add for Clear Coat 1.0 4 O/H bumper assy 2.7 5 Repl LT Trim cover w/o fog lamps 96694768 1 43.60 Ind. 6 r Subl Hazardous waste removal 1 5.00 T SUBTOTALS 46.60 4.2 3.6 ESTIMATE TOTALS Category Basis Rate Cost $ Parts 43.60 Body Labor 4.2 hrs ;a $ 54.00 /hr 226.80 Paint Labor 3.6 hrs @ $ 54,00 /hr 194,40 Paint Supplies 3.6 hrs @ $ 34,00 /hr 122,40 Body Supplies 1.5 hrs a: 5 3.00 /hr 4.50 Miscellaneous 5.00 Subtotal 596.70 Sales Tax $ 596.70 @ 8.2000 1% 48.93 Grand Total 646,63 Deductible "CIO CUSTOMER PAY 0.00 INSURANCE PAY 646.63 MyPricelink Estimate ID, 251143102872436736 IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE IMPRISONMENT, FINES; AND DENIAL OF INSURANCE BENEFITS. 1/18/2017 4:35:24 PM 401274 Page 2 Preliminary Estimate Customer: Haller, Dan 2015 CHEV 5opic LT ALItornatic 4D SED 4-1.81 Gasoline Electronic Fuel Injection Silver Estimate based on MOTOR CRASH ESTIMATING GUIDE and potentially other third party sources of data. unless otherwise noted, (a) all items are derived from the Guide DRIC12, CCC Data Gate 1/17/2017, and potentially other third party sources of data; and (b) the parts presented 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 data provided by third party sources of data 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, A/M or NAGS. 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 2011 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 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 cater rr�. X=Miscellaneous Non Taxed charge category. y�il� ill ■ �»�' 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) I through 4=User Defined Labor Categories. :•01001�� Adj,=Adjacent. Alcdn.=Align. ALU=Aluminum. A/M=Aftermarket part. Blnd=blend. BOR=Boron steel. CAPA=Certified Automotive Parts Association. IS R=Disconnect and Reconnect. HSS= igh Strength Steel. HYD=Hydroformed Steel. Incl. -Included. LKQ=Like Kind and Quality. LT=Left, MAG=Magnesium. Non-Adj.=Nan Adjacent, NSI =NSF International Certified Part, O/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. Subi=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, I=PA=Environmental Protection Agency. NHTSA= National Highway Transportation and Safety Administration. PDR=Paintless Dent Repair. VIN=Vehicle Identification Number. 1/18/2017 4:38:24 PM 4011274 Page 3