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HomeMy WebLinkAbout04-12-2018 Wales, Ryan - Claim for DamagesRO', sC ITOR, ly-L— COIVW-SSIONERS DI;PAIt'I'MEAfT L INSURANCE Return to: 04/12/2018 02:20:26 PM 201804120025 $0.00 Pawl of 7 Claims Against County/ris/miso PROSECUTOR Krltitas. County Auditor 111111111111111 1 111,1111111111111111111111111111111111111111111111111111111111 KITTITAS COUNTY CLAIM FOR DAMAGES County Auditor 205 W 5th Ave, Suite 105 Ellensburg, WA 98926 509-962-7504 Instructions: Please read the entire form before completion. Fill out each question as completely as possible, to the best of your ability. Do not hesitate to use the back side of this form if you need more than the space provided. An incomplete response may delay the processing of your claim. 1. Name (Incl ding spouse, if married): 2. Phone (Home): (,50q -q99 -a'1 aR (Work): 3. Address (include former address if at present address for less than 6 months): grol S+w-a--r3e 26 VILejSburq. t.JA R$q" Physical P6 Qoyc 445 E14�sb��y , �l W ag�ia 6 Mailing 4. Date of Birth: 101-7/ / 0 q 0 Date and Time of Incident: Wal /8O1'; ee,+,.wen 17:30ow, o a : 00P w� 6. Location of Incident: --1x00 Block ocn V MA+-anuw% Q (,900MV% TAO owrp4ss aid cewce Lake 1 of 3 Kittitas County Claim for Damages Form Revised 9/2012 'Filed for Record 04/12/2018 02:20:26 PM - Kittitas County, WA Auditor - 201804120025 Page 2 of 7 7. Describe in detail the defect which caused the injury: 1 0 Cdr K�`-j e!! d c -ee WkO t,%!os �prQiI 'r�Q 4 -✓,j c k � 16 xp "- S2 C u re 8. Describe in narrative form and in detail exactly how the incident occurred:: 1 � S V ir.9 ®wyaMp ' 4 na o& 06 �u�Jc.rus i%w v% 4j6_&% � a (OOK -i ``C\XMp ick- die pQS4- mv- ke*dw -fiV_ opp"Ile a��QCF:On.I 1 H i*- psSSe� 5+iCICS)C z,4z'rock% e+ -r- C-let.J ou4- kilt- Vk j 1r.VC�, W4e� L [00 �1 i'�0-o +`PSe.✓cJ i,Gt� 9/�a i �'' r or T %,4 �,�� �- 4fie l w ct S vt o� Co U" a4 � du w p f-r-ve-k co�.�l��(l �o spread bebrfS ail OVQr . +461C rq, 9. List the names of all persons involved.and contact information, if known. Rt- 4-S }-I�.s dri J��' wwci $a,�. sll ir•�.eCLS w � IJ G©v� d%Jw.o {-,ruck 04 exp Ian, �,e 10. Was claim investigated by a police officer? WcL% C', ko 1,1Vo S k&ri aero+ Sheriff State Patrol City Police 11. Description of claimant's vehicle: AC. Make ;'O« Year Model: 15W Sit rr�cX License No. �- © �� < < AA 12. Describe 'what you did after the accident o�crc�urred: tu.e ac,v-tawa,.a +b ask +(-et" +° k�- ie u bhC works 13. Describe the conversations you had, if any, with County personnel during or after the incident occurred: a yes � T_ c��l� �-�- 51�+�r;C� � s o�,•� �� C. a`� -b L'Ir le q C[C« P-^ w i \-" +t,.e Audi �ac . 2 of 3 Kittitas County Claim for Damages Form Revised 9/2012 'Filed for Record 04/12/2018 02:20:26 PM - Kittitas County, WA Auditor - 201804120025 Page 3 of 7 14. Describehe damages or injuries which you sustained as a result of the incident: �L%L Oryer`S SccJe. 0�- Jrt' k nOW kqS Sf_dtr-c` I _P014- c4ys- grow Int*(" '1 �. 15. What is the amount of damages claimed? (Include estimates and bills, if available): � 1, pip. do - see a44aCk46 rTa„r- U4 -f . 16. How did you identify the County as the partyfesponsible for your da age? r�Sel r. ck ..e� SQwk 4F IIn ev , e�� 4-wF +ke 00"P +u -00t w i f -V., +kx COO+ti ► 090 Ot- 1,H . 17. List the names and addresses of all witnesses to the incident: e5ay.. £ l I tnater %o C--,OQ*"riC1CJQ. Or. Elk"s-b'yJ , t -i A 9%qXo q- 927ct- 9"19-7 18. Are you covered by insurance? VeS If yes, who is your insurance agent/carrier? s4c,4e Sco if go Il i ,,'S Dated this l)L Day o A r� f , 20 1,x -A^ � of Claimant Subscribed and sworn (affirmed) to before me this' day of J, 20 Ir \\��t\llllll-11//j�/s Seal .�`��eL`y •Sso �'!p''' .O 9 • �' %AOTAgy N — PUBLIC �9�FA B 3� 16 -A- EH 1WASY\ Notary Public in p#dlfor the State 4 Washington Residing at en' 3 of 3 Kittitas County Claim for Damages Form Revised 9/2012 Filed for Record 04/12/2018 02:20:26 PM - Kittitas County, WA Auditor - 201804120025 Page 4 of 7 R&R's ABRA Auto Body & Glass Workfile ID: 9ea727ab Federal ID: 91-1875401 ra 641 West University Way, Ellensburg, WA 98926 Phone: (509) 925-5680 FAX: (509) 962-8741 Preliminary Estimate Customer: Wales, Ryan Written By: Tyler Morris Insured: Wales, Ryan Policy #: Type of Loss: Date of Loss: Point of Impact: Owner: Inspection Location: Wales, Ryan 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: 2018 GMC Sierra 1500 SLT Crew Cab 153" WB 4WD 4D LONG 8-5.3L Flex Fuel Direct Injection White VIN: 3GTU2NEC9JG130951 Interior Color: Mileage In: Vehicle Out: License: Exterior Color: White Mileage Out: State: Production Date: Condition: Job #: TRANSMISSION CONVENIENCE Search/Seek Reclining/Lounge Seats Automatic Transmission Air Conditioning CD Player Leather Seats Overdrive Tilt Wheel Auxiliary Audio Connection Heated Seats 4 Wheel Drive Cruise Control Satellite Radio WHEELS POWER Rear Defogger SAFETY Aluminum/Alloy Wheels Power Steering Keyless Entry Drivers Side Air Bag PAINT Power Brakes Alarm Passenger Air Bag Clear Coat Paint Power Windows Message Center Anti -Lock Brakes (4) OTHER Power Locks Steering Wheel Touch Controls 4 Wheel Disc Brakes Fog Lamps Power Mirrors Telescopic Wheel Traction Control Signal Integrated Mirrors Heated Mirrors Climate Control Stability Control TRUCK Power Driver Seat Backup Camera w/Parking Sensors Front Side Impact Air Bags Rear Step Bumper Power Passenger Seat Remote Starter Head/Curtain Air Bags Trailer Hitch Power Adjustable Pedals Home Link Communications System Trailering Package DECOR RADIO Hands Free Device Power Trunk/Gate Release Dual Mirrors AM Radio Xenon Headlamps Body Side Moldings FM Radio Positraction Privacy Glass Stereo SEATS 4/3/2018 9:49:23 AM 403474 Page 1 Eiled for Record 04/12/2018 02:20:26 PM - Kittitas County, WA Auditor - 201804120025 Page 5 of 7 Preliminary Estimate Customer: Wales, Ryan 2018 GMC Sierra 1500 SLT Crew Cab 153" WB 4WD 4D LONG 8-5.3L Flex Fuel Direct Injection White Line Oper Description Part Number Qty Extended Labor Paint Price $ 1 FRONT BUMPER 2 R&I Upper cap paint to match 0.5 3 * Rpr Upper cap paint to match 2 1.6 4 Add for Clear Coat 0.6 ---5 CAB 6 * Rpr LT Uniside assy s 0 5 1.5 7 Add for Clear Coat 0.6 8 PICK UP BOX _ .... ...... 9 * Rpr LT Outer panel GMC 0.5 3.3 10 Overlap Major Non-Adj. Panel -0.2 11 Add for Clear Coat 0.6 12 # Repl Cover Car 1 5.00 0.2 13 # Rpr Corrosion Protection 0.3 14 # Refn Color tint / color match 0.5 15 # Hazardous waste removal 1 5.00 16 R&I LT Upper molding GMC 0.3 17 REAR LAMPS 18 R&I LT Tail lamp assy w/o LED 0.3 19 REAR BUMPER 20 R&I R&I bumper assy 2.4 SUBTOTALS 10.00 5.2 8.8 ESTIMATE TOTALS Category Basis Rate Cost $ Pars 10.00 Body Labor 5.2 hrs @ $ 56.00 /hr 291.20 Paint Labor 8.8 hrs @ $ 56.00 /hr 492.80 Paint Supplies 8.8 hrs @ $ 36.00 /hr 316.80 Body Supplies 1.7 hrs @ $ 5.00 /hr 8.50 Subtotal 1,119.30 Sales Tax $ 1,119.30 @ 8.3000% 92.90 Grand Total 1,212.20 Deductible 0.00 CUSTOMER PAY 0.00 INSURANCE PAY 1,212.20 MyPriceLink Estimate ID: 410474835957784576 4/3/2018 9:49:23 AM 403474 Page 2 .Filed for Record 04/12/2018 02:20:26 PM - Kittitas County, WA Auditor - 201804120025 Page 6 of 7 Preliminary Estimate Customer: Wales, Ryan 2018 GMC Sierra 1500 SLT Crew Cab 153" WB 4WD 4D LONG 8-5.3L Flex Fuel Direct Injection White WARRANTY VALID ONLY WITH ORIGNAL COPY OF YOUR RECEIPT. PARTS ARE SUBJECT TO INVOICE. NO GUARANTEES ON RUST. ALL PARTS ARE NEW EQUIPMENT, UNLESS OTHERWISE SPECIFIED. THIS REPAIR ESTIMATE MAY BE BASED IN WHOLE OR IN PART UPON THE PAINTLESS DENT REPAIR METHOD. EACH ITEM OF DAMAGE ADJUSTED USING THAT METHOD SHALL BE IDENTIFIED; PAINTLESS DENT REPAIR MAY NOT BE THE APPROPRIATE REPAIR METHOD FOR ALL TYPES OF DAMAGE; IF THE INSURER IS LIABLE FOR THE DAMAGE LISTED ON THE ESTIMATE, THE INSURER SHALL PROVIDE SUFFICIENT COMPENSATION TO RESTORE THE VEHICLE TO SUBSTANTIALLY THE SAME PHYSICAL CONDITION; AND FOR ANY DAMAGE WHICH PAINTLESS DENT REPAIR IS APPROPRIATE, THE INSURED MAY CHOOSE NOT TO REPAIR THE VEHICLE OR TO HAVE THE VEHICLE REPAIRED USING A DIFFERENT METHOD OF REPAIR. IF THE INSURED CHOOSES EITHER OF THESE OPTIONS, THE INSURER IS LIABLE ONLY FOR THE COST OF THE PAINTLESS DENT REPAIR METHOD. 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. 4/3/2018 9:49:23 AM 403474 Page 3 I Filed for Record 04/12/2018 02:20:26 PM - Kittitas County, WA Auditor - 201804120025 Page 7 of 7 Preliminary Estimate Customer: Wales, Ryan 2018 GMC Sierra 1500 SLT Crew Cab 153" WB 4WD 4D LONG 8-5.31- Flex Fuel Direct Injection White 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 DR1GH14, CCC Data Date 3/16/2018, 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. 4/3/2018 9:49:23 AM 403474 Page 4