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HomeMy WebLinkAbout03-04-2016 Claim for Damages - Lutovsky (Redacted)A 03/04/2016 01:46:26 PM 201603040039 $0.00 Page:1 of 8 Claims Against County/rls/misc PROSECUTER Kittitas County Auditor IIIIIIII11111111111111111111111111IN111111111111111111111111111111111I11 1111 Return to: G > � NO...;� CO SSIONM J 1. �i' l w#&A fflw W-1 G KITTITAS COUNTY CLAIM FOR DAMAGES County Auditor 205 W 5th Ave, Suite 105 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): G rC3 A-• Lt oy 3k -y Pet L • -4E'L3 a C A 2. Phone (Home): (Work): 3. Address (include former address if at present address for less than 6 months): Mailing 4. Date of Birth: 5. Date and Time of Incident: .36- II 12 ✓� 6. Location of Incident: iCC l v -t. o a L kd 1 of 3 1 Kittitas County Claim for Damages Form Revised 9/2012 Filed for Record 03/04/2016 01:46:26 PM - Kittitas County, WA Auditor - 201603040039 Page 2 of 8 7. Describe in detail the defect which caused the injury: 0121 A Imp), r Co u to 1V 44hvtf t k s td w la w /Z0 Ys G L►i1/oka �i' �� q � A . . n —� i A (+V ( Vt -C S 4 r ti V/ l v 1 't I ` 4L, 4p-; 8. Describe in narrative form and in detail exactly how the in,c ident occurred: rC G y w 6'110 q/ rl 1ov) ��U /<kf �ftu lel �© sr�,� e v _�la�►� lrGb �l t��� wou � ���c /�D, .� w a 5 f'e- lo waS tra v-,i1I o-(41 �/ C/ �o u� 30 -7S ,Lp k , Kofi 9. List the names of all persof involved and contact information, if known. PC, L fi�Snkfk — dIkSS-th�iL �' r -o � K ��, �� �; �, C � All 6 wig h) 1� d"'Vt � PL ti wl-t. uv, kL�ko w h . 10. Was claim investigated by a police officer? NCS Sheriff State Patrol City Police 11. Description of claimant's vehicle: (.t ► Make Z D 1 S Year Model: Q License No. 12. Describe what you did after the accident occurred: p v o c -c ekd %a tk Kk C>r, ckW ;4jy T_"S w►- k Co - 13 Jim 0"' 1► toy wq, tis 1 bLIX C q11 Q k h Q w f'1...f C19 kL'L . S' l 1,7 C'I' Describe the conversations you had, if any, with County personnel during or after the incident occu ed: f a I kW � i'� �� kL e WJ 2 of 3 Kittitas County Claim for Damages Form Revised 9/2012 Filed for Record 03/04/2016 01:46:26 PM - Kittitas County, WA Auditor - 201603040039 Page 3 of 8 T Filed for Record 03/04/2016 01:46:26 PM - Kittitas County, WA Auditor - 201603040039 Page 4 of 8 14. Describe the damages or injuries which you sustained as a result of the incident: k c 4 ► res J -,n G,1, 7 / r-Ati1,4o,v s . N,I b f'54.e 1 61 15. What is the amount of damages claimed? (Include estimates and bills, if available): # A 19 (. /( 4,Titvr� �S 16. How did you identify the County, as the party responsible for your damage? 7f4- wa S Gauer d wv4(2-vue1< ° S" -u i ✓I 17. List the names and addresses of all witnesses to the incident: r MI Are you covered by insurance?T,7 If yes, who is your insurance agent/carrier? S 6Y - Dated this _ of Clai h ( (�4&V61rz .TYL5, - S6I - 9-0110 v wa i _Day of A,1 u- v -C 1-� , 20_L_6. 09- -5oy3 y Subscribed and sworn (affirmed) to before me this day of J, 20_1� .�ow111110o't,,� - ��` 1�A NAT ��✓i/ Seal .•ARNP.......••/ A- OTA Notary Notary Public in apA for thp State of Washington • = Residing at Ez PUBUVO ,�• Z` •/'9 • �9OAFN ••• Op /// �� ••4•••N••��\ 3 of 3 Kittitas County Claim for Damages Form Revised 9/2012 Filed for Record 03/04/2016 01:46:26 PM - Kittitas County, WA Auditor - 201603040039 Page 5 of 8 L . R&R's ABRA Auto Body & Glass Workfile ID: Federal ID: 641 WEST UNIVERSITY WAY, ELLENSBURG, WA 98926 Phone: (509) 925-5680 FAX: (509) 962-8741 Customer: Lutovsky, Greg Insured: Lutovsky, Greg Type of Loss: Point of Impact: Preliminary Estimate Written By: Tom Morris Policy #: Date of Loss: Owner: Inspection Location: Lutovsky, Greg R&R's ABRA Auto Body & Glass 641 WEST UNIVERSITY WAY ELLENSBURG, WA 98926 Repair Facility (509) 925-5680 Business VEHICLE Claim #: Days to Repair: 0 Insurance Company: Year: 2015 Body Style: 4D UTV VIN: WAIVMAFP9FA106416 Mileage In: Make: AUDI Engine: 6-3.0L TD License: Mileage Out: Model: Q5 AWD PRESTIGE Production Date: State: Vehicle Out: Color: Bahama Blue Int: Condition: Job #: Keyless Entry TRANSMISSION CONVENIENCE AM Radio Automatic Transmission Air Conditioning FM Radio 4 Wheel Drive Intermittent Wipers Stereo POWER Tilt Wheel Search/Seek Power Steering Cruise Control CD Player Power Brakes Rear Defogger Premium Radio Power Windows Keyless Entry SAFETY Power Locks Alarm Drivers Side Air Bag Power Mirrors Message Center Passenger Air Bag Heated Mirrors Steering Wheel Touch Controls Anti -Lock Brakes (4) Power Driver Seat Rear Window Wiper 4 Wheel Disc Brakes Power Passenger Seat Telescopic Wheel Traction Control Memory Package Climate Control Stability Control DECOR Dual Air Condition Front Side Impact Air Bags Dual Mirrors Navigation System Head/Curtain Air Bags Privacy Glass Backup Camera w/Parking Sensors Rear Side Impact Air Bags Console/Storage Home Link Hands Free Device Overhead Console RADIO Blind Spot Detection e60079c4 91-1875401 .lob Number: ROOF Luggage/Roof Rack Electric Glass Sunroof Skyview Roof SEATS Bucket Seats Leather Seats Heated Seats WHEELS Aluminum/Alloy Wheels PAINT Clear Coat Paint OTHER Fog Lamps Rear Spoiler Signal Integrated Mirrors TRUCK Power Trunk/Gate Release 2/24/2016 10:32:42 AM 310167 Page 1 Filed for Record 03/04/2016 01:46:26 PM - Kittitas County, WA Auditor - 201603040039 Page 6 of 8 Preliminary Estimate Customer: Lutovsky, Greg Sob Number: Vehicle: 2015 AUDI Q5 AWD PRESTIGE 4D UTV 6-3.OL-TD Bahama Blue Line Oper Description Part Number Qty Extended Labor Paint Price $ 1 FRONT BUMPER & GRILLE 2 0/H bumper assy 3.5 3 Repl Grille w/o park sensors gloss 8RO853651ALT94 1 675.00 Incl. black 4 * <> Rpr Bumper cover w/headlamp 2_0 3.2 washer(re air rock chips) 5 Rep] LT Outer grille w/distance sensor, 8ROS07681SZDE 1 311.00 Incl. w/park sensor matte black 6 Repl RT Outer grille w/distance sensor, 8ROB07682QZDE 1 •355.00 Incl. w/park sensor matte black Vu 7 _ FRONT LAMPS 8 Repl LT Headlamp assy 8RO941753E 1 1,049.00 1.0 9 Aim headlamps 0.5 10 Repl RT Headlamp assy 8RO941754E 1 1,049.00 1.0 11 Repl RT Fog lamp assy 8T0941700B 1 121.00 0.3 12 Repi LT Fog_ lamp assy ST0941699B 1 121.00 0.3 _ 13 HOOD 14 * Rpr Hood 1_5 3.0 15 Overlap Major Non-Adj. Panel -0.2 16 FENDER 17 * Rpr RT Fender frm 11/15/2011 1_0 2.4 18 Overlap Major Adj. Panel -0.4 19 * Rpr LT Fender frm 11/15/2011 1_0 2.4 20 Overlap Major Adj. Panel -0.4 21 R&I RT Lower molding w/o S -line pkg 0.3 or SQ5 22 R&I LT Lower molding w/o S -line pkg 0.3 or SQ5 23 WINDSHIELD 24 Repi Windshield w/lane change assist FW03822GTY 1 722.50 2.8 NAGS - ..... ..- 25 ....... ... ............ .- ROOF - ... -_............ ._- _._..._..._... 26 * Rpr Roof panel 2_0 4.0 27 Overlap Major Non-Adj. Panel -0.2 28 R&I RT Roof molding chrome 0.4 29 R&I LT Roof molding chrome 0.4 30 R&I RT Luggage rack black 1.5 31 R&I R&I sunroof assy 1.8 32 FRONT DOOR 33 R&I LT R&I mirror 0.4 34 R&I RT R&I mirror 0.4 35 * R&I RT Mirror cover w/lane change 0_3 pkg 36 * R&I LT Mirror cover w/lane change 0_3 2/24/2016 10:32:42 AM 310167 Page 2 Filed for Record 03/04/2016 01:46:26 PM - Kittitas County, WA Auditor - 201603040039 Page 7 of 8 Preliminary Estimate Customer: Lutovsky, Greg Job Number: Vehicle: 2015 AUDI Q5 AWD PRESTIGE 4D UTV 6-3.OL-TD Bahama Blue pkg 37 Refn RT Mirror cover w/lane change 0.4 pkg 38 Overlap Minor Panel -0.2 39 Refn LT Mirror cover w/lane change 0.4 pkg 40 Overlap Minor Panel -0.2 41 Clear Coat 2.5 42 R&I RT R&I trim panel 0.6 Cost $ 43 R&I LT R&I trim panel 0.6 4,425.50 44 QUARTER PANEL @ $ 53.00 /hr 1,383.30 45 * Bind RT Quarter panel(painting roof no $ 53.00 /hr 1.6 Paint Supplies 21.9 hrs natrual break) $ 31.00 /hr 678.90 46 * Bind LT Ouarter panell0minting roof 1.6 Sales Tax $ 7,584.80 no natrual break) 8.0000% 606.78 47 REAR LAMPS 8,191.58 48 R&I RT Tail lamp assy 0.2 0.00 49 R&I LT Tail lamp assy 0.2 50 REAR BUMPER 51 _ R&I R&I bumper assy 1.3 52 MISCELLANEOUS OPERATIONS 53 # 'Car Cover 1 5.00 0.2 54 # Rpr 'Corrosion Protection 0.3 55 # Rpr 'Color Tint 0.5 56 # Subl 'Hazardous Waste 1 5.00 57 # 'Flex Additive/Adhesion Promoter 1 12.00 SUBTOTALS 4,425.50 26.1 20.7 ESTIMATE TOTALS Category Basis Rate Cost $ Parts 4,425.50 Body Labor 26.1 hrs @ $ 53.00 /hr 1,383.30 Paint Labor 20.7 hrs @ $ 53.00 /hr 1,097.10 Paint Supplies 21.9 hrs @ $ 31.00 /hr 678.90 Subtotal 7,584.80 Sales Tax $ 7,584.80 @ 8.0000% 606.78 Grand Total 8,191.58 Deductible 0.00 CUSTOMER PAY 0.00 INSURANCE PAY 8,191.58 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. 2/24/2016 10:32:42 AM 310167 Page 3 - Filed for Record 03/04/2016 01:46:26 PM - Kittitas County, WA Auditor - 201603040039 Page 8 of 8 Preliminary Estimate Customer: Lutovsky, Greg Vehicle: 2015 AUDI Q5 AWD PRESTIGE 4D UTV 6-3.OL-TD Bahama Blue Job Number: 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 ERA1385, CCC Data Date 2/15/2016, 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 (N) 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 2016 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. 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. 2/24/2016 10:32:42 AM 310167 Page 4