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C0008310 CLM PDF

Page 1 of 2 Vehicle Information Claim Service Type?: Vehicle Type?: Deductible: Date of Loss Insured Last Name: Insured First Name Plate Number: Coverage Type: coll Owner Information Insured or Claimant: INSURED Claim Info Time Open: Date Created: Area of Damage: WHOLE PASSENGER SIDE AND AIR BAGS DEPLOYED No No Language Translator Needed?: Owner Last Name: Vehicle Location: Owner Email: Location Name: ROA

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0% found this document useful (0 votes)

615 views588 pages

C0008310 CLM PDF

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joby

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Download as PDF, TXT or read online on Scribd

You are on page 1/ 588

Page 1 of 2

Estimate By: ACD

Claim Number: C0008310-5 / DL Number: LA1505-141431
Claim Information

Vehicle Information

Claim Service Type?:

Vehicle Type?:

Claim Number:

C0008310-5

Deductible:
Date of Loss:

05/13/2015

Year:

2006

Make:

NISSAN

Model:

SENTRA 1818S

Insured Company:

Color:

Insured Last Name:

VIN:

Insured First Name

Plate Number:

Coverage Type:

coll

Owner Information
Insured or Claimant:

INSURED

Claim Info

Time Open:
Date Created:

Area of Damage:

WHOLE PASSENGER SIDE

AND AIR BAGS DEPLOYED

Drivable?:

No
No

Language Translator
Needed?:

Owner Last Name:

HARRIS

Vehicle Location:

Owner First Name:

PATRICIA

Vehicle Location Type:

other

Owner Email:

Location Name:

ROADRUNNER

Owner Company:

Location Phone #:

(225) 359-9989

Phone: (205) 978-3520 x 7217

Account Manager

Phone: (888) 403-4223 x 727

Backup Account Manager

Phone: (888) 403-4223 x 701

3465 HARDING BLVD

Appraiser

Centreville

Address Line 2:
(Suite, Apt, ect.)

State:

City:

Baton Rouge

Zip Code:

39631

State:

Home Phone:

(651) 274-0839

Zip Code:

70807

Mobile Phone:

Jill Dennis

Karen Carteron

City:

Work Phone:

Adjuster

Josh Myers

2448 WHITESTOWN RD Location Email:

Address Line 1:

0 minutes
05/14/2015 11:02am CDT

People on this Claim

Plate State:

Address Line 2:
(Suite, Apt, ect.)

ACCC Insurance Company

(404) 999-9999
LA1505-141431
C0008310-5
ASSIGNED

Timeline

Owner in Rental Car:

Owner Address Line 1:

Company:
Company #:
DL Number:
Claim Number:
Status:

John Otillio

Comments

Business Phone: (504) 232-6376

Mobile Phone: (504) 232-6376

ACD Auditor
Brad Kennedy
Phone: (888) 403-4223 x 732

No comments

Client Auditor
No Client Auditor assigned yet.

Note History
There are no notes for this claim.

https://auto.acdcorp.com/autolink/claim/printable_detail_page/1781431

5/14/2015

Page 2 of 2

https://auto.acdcorp.com/autolink/claim/printable_detail_page/1781431

5/14/2015

National Subro Processing

PO BOX 660636
DALLAS TX 75266

%%DPS::SI MPLEX

DTAFFFFFADTADTDTDFFDDDFTDDFDTFAFDTDFAAFAAFDAFDFTFFTDTAFFAAFTTFAAT
ACCC INS CO
PO BOX 5460
ALPHARETTA GA 300235460

%%DPS::BIFOLD

0368735353 ART

National Subro Processing

PO BOX 660636
DALLAS TX 75266

%%DPS::SI MPLEX

DTAFFFFFADTADTDTDFFDDDFTDDFDTFAFDTDFAAFAAFDAFDFTFFTDTAFFAAFTTFAAT
ACCC INS CO
PO BOX 5460
ALPHARETTA GA 300235460

%%DPS::PRIMARY
August 07, 2015
CLAIM NUMBER: 0368735353 ART
DATE OF LOSS: May 13, 2015
OUR INSURED: DAVID ODDS
YOUR FILE NUMBER: C8310-5
YOUR INSURED: PATRICIA HARRIS
ADDRESS: 1331 N SHERWOOD FOREST DR APT 119

PHONE NUMBER: 800-374-4246

FAX NUMBER: 866-447-4293
OFFICE HOURS:

CITY STATE ZIP: BATON ROUGE, LA, 708152003

LOSS LOCATION: FLORIDA BLVD AND SHERWOOD FOREST,
BATON ROUGE, , LA
AMOUNT OF LOSS: $15,353.41

Re: Subrogation Claim Notice

Dear ACCC INS CO,

:PFS

Our investigation indicates your insured was responsible for the loss referenced above.
Please accept this letter as notice of our subrogation claim. Enclosed, you will find copies of the supporting documents for
which we are seeking reimbursement. To assist you in your review, the following is a breakdown of our subrogation
demand:
Auto Damage (Company Paid):
Rental:
Towing:
Other:
Deductible (Customer Paid):
Salvage Recovery:
Insured Out of Pocket (please send directly to our Insured):

$19,159.47
$
$87.44
$
$500.00
$4,393.50
$

Please forward your payment with our claim number to:

Allstate Payment Processing Center

P.O. BOX 650271
Dallas, TX 75265 0271

0368735353 ART

Be advised that any amounts received from you for less than the amount demanded will be considered an undisputed partial
payment amount only, and we retain the right to pursue full payment.
We ask that you direct any future correspondence to the address listed at the top of this letter. Thank you.
Sincerely,

%%DPS ::P FE

Your Claim Team

Your Claim Team
800-374-4246
Allstate Property and Casualty Insurance Company

SUBU033

0368735353 ART

%%DPS::DUPLEX

Report Date: 08/07/2015

Payment Ledger
Policy Holder:
Participant:
Date of Loss:
Claim Number:

DAVID ODDS
DAVID ODDS
05/13/2015
0368735353

Payment/Credit
Date

Payee/Payor

05/29/2015

ALLSTATE ROADSIDE SERVICES

06/18/2015
07/01/2015

Total Amount Paid

Medical Deductible:
Co-payment Amount

$14,853.41
$0.00
$0.00

Check#

Amount

12463

87.44

DAVID ODDS

553144038

19,159.47

COPART INC

2512614515070106

-4,393.50

ALLSTATE
LOUISIANA CENTRAL AUTO
3900 N Causeway Blvd, Ste 510
Metairie, LA 70002
Phone: (800) 349-1444

Claim #:
Workfile ID:

000368735353D01
b3fbe5ba

Estimate of Record
Written By: THOMAS CHERICHELLO, 6/3/2015 4:34:20 PM
Adjuster: Cherichello, Thomas, (225) 380-7383 Cellular
Insured:

DAVID OLDS

Owner Policy #:

0368735353

Claim #:

000368735353D01

Type of Loss:

Collision

Date of Loss:

01/02/2015 12:00 AM

Days to Repair:

Point of Impact:

01 Right Front

Deductible:

500.00

Owner (Insured):

Inspection Location:

Appraiser Information:

Repair Facility:

DAVID OLDS
13855 KATHERINE AVENUE
BATON ROUGE, LA 70815
(225) 892-9794 Day

EDWARDS AUTO BODY

2763 SCENIC HIGHWAY
BATON ROUGE, LA 70805
Repair Facility
(225) 355-7371 Business

[email protected]

EDWARDS AUTO BODY

2763 SCENIC HIGHWAY
BATON ROUGE, LA 70805
(225) 355-7371 Business

VEHICLE
Year:

2008

Color:

BLUE Int: GRAY

License:

Make:

CHEV

Body Style:

4D UTV

State:

Model:

TAHOE 4X2 LTZ

Engine:

8-5.3L-FI

VIN:

15054074
1GNFC13058R139428

Production Date:

09/2007

Odometer:

152207

Condition:

TRANSMISSION

Overhead Console

Search/Seek

Leather Seats

Automatic Transmission

CONVENIENCE

Auxiliary Audio Connection

Heated Seats

Overdrive

Air Conditioning

Premium Radio

Rear Heated Seats

POWER

Intermittent Wipers

Satellite Radio

3rd Row Seat

Power Steering

Tilt Wheel

CD Changer/Stacker

WHEELS

Power Brakes

Cruise Control

SAFETY

20" Or Larger Wheels

Power Windows

Rear Defogger

Drivers Side Air Bag

PAINT

Power Locks

Keyless Entry

Passenger Air Bag

Clear Coat Paint

Power Mirrors

Message Center

Anti-Lock Brakes (4)

OTHER

Heated Mirrors

Steering Wheel Touch Controls

4 Wheel Disc Brakes

Fog Lamps

Power Driver Seat

Rear Window Wiper

Stability Control

Signal Integrated Mirrors

Power Passenger Seat

Dual Air Condition

Head/Curtain Air Bags

TRUCK

Memory Package

Parking Sensors

Communications System

Rear Step Bumper

Power Adjustable Pedals

Remote Starter

Hands Free Device

Trailer Hitch

DECOR

Home Link

ROOF

Trailering Package

Dual Mirrors

RADIO

Luggage/Roof Rack

Running Boards/Side Steps

Body Side Moldings

AM Radio

Electric Glass Sunroof

Privacy Glass

FM Radio

SEATS

Console/Storage

Stereo

Bucket Seats

6/3/2015 4:34:22 PM

121837

Page 1

Claim #:

000368735353D01

Workfile ID:

b3fbe5ba

Estimate of Record
2008 CHEV TAHOE 4X2 LTZ 4D UTV 8-5.3L-FI BLUE

Line

Oper

FRONT BUMPER

Description

Part Number

ALL SUPPLEMENTS MUST BE

APPROVED PRIOR TO REPAIRING
Repl

Opt OEM Bumper cover

25814570

Extended
Price $

Labor

Paint

0.00

0.0

Qty

407.43

2.2

3.0

Add for Clear Coat

0.00

0.0

1.2

Add for fog lamps

0.00

0.3

0.0

Repl

Opt OEM Impact bar

25947497

343.23

0.3

0.0

Repl

Opt OEM Air deflector

15203734

54.78

Incl.

0.0

GRILLE

R&I

Upper grille bright chrome

0.00

Incl.

0.0

R&I

Lower grille bright chrome

0.00

Incl.

0.0

Repl

Emblem

22830014

77.77

Incl.

0.0

0.00

Incl.

0.0

22853026

208.25

Incl.

0.0

0.00

0.5

0.0

527.64

FRONT LAMPS

13
14

R&I

LT R&I headlamp assy

Repl

Opt OEM RT Headlamp assy

Aim headlamps

RADIATOR SUPPORT

Repl

18
19
20

HOOD

Repl

22
23
24

FENDER

Repl

20805487

505.75

1.0

3.0

Add for Clear Coat

0.00

0.0

1.2

Add for Underside(Complete)

0.00

0.0

1.5

Opt OEM RT Fender Tahoe

15939876

420.75

2.9

2.0

Overlap Major Adj. Panel

22977476

0.00

0.0

1.0

R&I

LT R&I fender assy

0.00

2.4

0.0

Rpr

Full Frame Pull

0.00

5.0 F

0.0

FRAME

ELECTRICAL

R&I

RT Battery

Repl

High note horn

Repl

Opt OEM RT/Front Wheel 20"

code: RCS

WHEELS

6/3/2015 4:34:22 PM

0
89046919

9597195

121837

0.00 m
68.50
352.82 m

Incl.

0.0

0.2

0.0

0.3

0.0

Page 2

Claim #:

000368735353D01

Workfile ID:

b3fbe5ba

Estimate of Record
2008 CHEV TAHOE 4X2 LTZ 4D UTV 8-5.3L-FI BLUE
40

Repl

R/F Tire-Mastercraft Courser

275/55R20 B10%

Subl

Tire Mount and Balance

Subl

Tire Disposal Fee

FRONT SUSPENSION
Bleed brake system

Repl

STEERING GEAR & LINKAGE

Repl

A/M RT Outer tie rod

Repl

A/M Gear assy

COWL
Repl

Cowl grille

49
50

169.99

0.0

12.50 T

0.0

2.00 T

0.0

0.00 m

0.5 M

0.0

MRCES800223

32.49 m

0.5 M

0.0

NRP221036

332.84 m

2.5 M

0.0

25872303

165.87

0.5

0.0

RESTRAINT SYSTEMS

wheel

25966963

149.50 m

1.0 M

0.0

Repl

Diagnostic unit w/head air bag

22759738

416.67 m

0.4 M

0.0

Repl

RT Ft impact sensor

15854647

166.67 m

0.3 M

0.0

Repl

LT Ft impact sensor

19181024

180.37

0.4

0.0

65
66

PILLARS, ROCKER & FLOOR

R&I

RT Lwr ctr plr trim titanium

0.00

0.5

0.0

R&I

LT Lwr ctr plr trim titanium

0.00

0.5

0.0

FRONT DOOR

Blnd

RT Outer panel Tahoe & Yukon

0.00

0.0

1.2

R&I

RT Belt w'strip

0.00

0.3

0.0

R&I

RT Body side mldg Tahoe, w/o

chrome insert all

0.00

0.3

0.0

Repl

RT Nameplate "TAHOE"

15825693

36.82

0.2

0.0

Repl

Opt OEM RT Emblem

15223483

10.57

0.2

0.0

R&I

RT Mirror assy w/power folding,

w/turn signal black

0.00

0.4

0.0

R&I

RT R&I trim panel

0.00

0.4

0.0

7.00

0.1

0.0

73
74

75
76
77

MISCELLANEOUS OPERATIONS

Repl

A/M Cover Car

Subl

Four Wheel Alignment

Rpr

Set Up & Measure

6/3/2015 4:34:22 PM

121837

79.99 T
0.00

0.0

2.0 F

0.0

Page 3

Claim #:

000368735353D01

Workfile ID:

b3fbe5ba

Estimate of Record
2008 CHEV TAHOE 4X2 LTZ 4D UTV 8-5.3L-FI BLUE
81

RECYCLED ASSEMBLIES

Repl

RCY RT knee assy; w/2 wheel

drive; one side +25%

Repl

A/M Power Steering Fluid

OTHER CHARGES

Repl

Undercoating

5.00

0.2

0.0

A/M Flex Additive

4.95

0.0

293.92 m

2.2 M

0.0

40.5

15.5

$VJ681

E.P.C.

10.00

1
SUBTOTALS

3.00
8,870.17

NOTES
Prior Damage Notes:
STONE CHIPS IN WINDSHIELD

ESTIMATE TOTALS
Category

Basis

Rate

Parts
Body Labor

20.5 hrs

$ 50.00 /hr

Paint Labor

15.5 hrs

$ 50.00 /hr

775.00

Mechanical Labor

13.0 hrs

$ 65.00 /hr

845.00

Frame Labor
Paint Supplies

1,025.00

7.0 hrs

$ 60.00 /hr

420.00

15.5 hrs

$ 35.00 /hr

542.50

Miscellaneous

94.49

Other Charges

3.00

Subtotal

12,477.67

Sales Tax

$ 12,477.67

Total Cost of Repairs

8.6000 %

1,073.08
13,550.75

Deductible

500.00

R/F Tire-Mastercraft Courser 275/55R20 B10%

Total Adjustments

18.46
518.46

Net Cost of Repairs

6/3/2015 4:34:22 PM

Cost $
8,772.68

13,032.29

121837

Page 4

Claim #:

000368735353D01

Workfile ID:

b3fbe5ba

Estimate of Record
2008 CHEV TAHOE 4X2 LTZ 4D UTV 8-5.3L-FI BLUE

Supplemental Request Form

Fax to 866-434-9457 or Email to - [email protected]
EST COMPLETION DATE:
EST GROSS TOTAL: $_________
CUSTOMER NAME:
ADJUSTER:
CLAIM NUMBER:
YEAR:
MAKE:

MODEL:

IN ORDER TO REVIEW YOUR SUPPLEMENT REQUEST, PLEASE COMPLETE THE FOLLOWING INFORMATION
THOROUGHLY AND FAX TO: 1-866-434-9457 OR EMAIL TO: [email protected]. BY
SUBMITTING THIS FORM IT IS NOT AN AUTHORIZATION TO REPAIR. ALL SUPPLEMENTS MUST HAVE PRIOR
APPROVAL. FAILURE TO DO SO COULD RESULT IN NON-PAYMENT OF A NON-APPROVED SUPPLEMENT.
SHOP TO COMPLETE INFORMATION BELOW
TODAY'S DATE: _____________
(_) SUPPLEMENT #1(_) SUPPLEMENT #2 (_) SUPPLEMENT #3
(PLEASE CHECK THE BOX THAT APPLIES TO THE NUMBER OF SUPPLEMENT)
IS THE VEHICLE AT THE SHOP AND READY FOR INSPECTION WITHIN 24HRS?
(_) YES (_) NO
ARE THE DAMAGES VISIBLE? (_)YES (_)NO VEHICLE TORN DOWN: (_) YES (_) NO
SHOP NAME: __________________________ CONTACT: ________________________
SHOP ADDRESS:__________________________________________________________
PHONE: (___) ___________________ EMAIL ________________________________
CITY: ______________________________ STATE:________ ZIP CODE:__________
NATURE OF THE SUPPLEMENT
(PLEASE SUPPLY US WITH A BRIEF DESCRIPTION OF THE SUPPLEMENT REQUEST OR ATTACH A COPY OF YOUR
COMPLETED SUPPLEMENT)
(_)
(_)
(_)
(_)

PARTS: ___________________________________________________________________
LABOR: ___________________________________________________________________
PARTS INCREASE: ___________________________________________________________________
OTHER: ___________________________________________________________________

APPROXIMATE TOTAL SUPPLEMENT AMOUNT: $_____________________________

TO ALL REPAIR FACILITIES: BEFORE USING AN AFTERMARKET SHEETMETAL PART BE SURE TO LOOK FOR THE
CAPA SEAL. THIS IS NOT AN AUTHORIZATION FOR REPAIR. SUPPLEMENTS MUST BE APPROVED PRIOR TO
REPAIR. IF YOUR CAR IS OF UNITIZED CONSTRUCTION, IN SOME CASES THE REPAIR SHOP MAY NEED SPECIAL
EQUIPMENT TO PROPERLY REPAIR THE CAR. YOU SHOULD DETERMINE IF THE SHOP YOU SELECT TO COMPLETE

6/3/2015 4:34:22 PM

121837

Page 5

Claim #:

000368735353D01

Workfile ID:

b3fbe5ba

Estimate of Record
2008 CHEV TAHOE 4X2 LTZ 4D UTV 8-5.3L-FI BLUE

THE REPAIRS IS PROPERLY EQUIPPED.

*******************************************************************************************
IMPORTANT INFORMATION
---------------------------------------THIS IS ALLSTATE'S ESTIMATE OF THE COST OF REPAIRING YOUR VEHICLE. YOU SHOULD CAREFULLY REVIEW
THIS INFORMATION PROVIDED TO YOU, AS WELL AS REVIEW THE ESTIMATE, PARTICULARLY THE CHARGES AND
THE RATES FOR WORK SHOWN IN THE ESTIMATE.
THE SELECTION OF A REPAIR SHOP IS YOUR CHOICE. ALLSTATE DOES NOT REQUIRE AS A CONDITION OF
PAYMENT OF THE CLAIM THAT THE REPAIRS TO YOUR VEHICLE BE MADE BY ANY PARTICULAR REPAIR SHOP.
HOWEVER, THE MOST ALLSTATE WILL PAY FOR THE REPAIR OF YOUR VEHICLE IS THE HOURLY LABOR RATE AND
TIME ALLOCATIONS THAT ARE REASONABLE AND CUSTOMARY IN THE AUTOMOBILE REPAIR INDUSTRY IN THE
COMMUNITY WHERE THE REPAIRS ARE PERFORMED. ALSO, THE VALUE OF REPAIR PARTS WILL BE DETERMINED
BY USING THE CURRENT PUBLISHED RETAIL COST OF THE REPAIR PARTS SPECIFIED IN THIS ESTIMATE, OR IN
THE ABSENCE OF A PUBLISHED RETAIL COST THE REASONABLE AND CUSTOMARY COST IN THE COMMUNITY
WHERE REPAIR PARTS ARE PURCHASED.
DIFFERENT REPAIR SHOPS CHARGE DIFFERENT RATES. SOME REPAIR SHOPS MAY CHARGE MORE THAN THE
RATES SHOWN IN THIS ESTIMATE AND SOME REPAIR SHOPS MAY INCLUDE CHARGES WHICH ARE NOT SHOWN IN
THIS ESTIMATE.
IF THE REPAIR SHOP YOU CHOOSE TO MAKE REPAIRS TO YOUR VEHICLE CHARGES MORE FOR THOSE REPAIRS
THAN ALLSTATE'S ESTIMATE, WHETHER DUE TO HIGHER RATES OR ADDITIONAL CHARGES, THE REPAIR SHOP
MAY HOLD YOU RESPONSIBLE FOR THE DIFFERENCE AND MAY NOT RETURN YOUR VEHICLE TO YOU UNTIL YOU
HAVE PAID THIS DIFFERENCE.
THE AMOUNT OF THE ESTIMATE IS THE COST TO REPAIR YOUR VEHICLE TO ITS PHYSICAL CONDITION BEFORE
IT WAS DAMAGED BASED ON THE DAMAGE THAT ALLSTATE FOUND TO YOUR VEHICLE ON ITS INITIAL
INSPECTION.
THERE MAY BE ADDITIONAL DAMAGE WHICH WAS NOT DETERMINED ON THE INITIAL INSPECTION, REQUIRING
ADDITIONAL REPAIRS. IF YOU OR YOUR CHOSEN REPAIR FACILITY FIND ANY HIDDEN DAMAGE OR BELIEVE
ADDITIONAL WORK IS NECESSARY, YOU OR THE REPAIR FACILITY SHOULD CONTACT ALLSTATE IMMEDIATELY SO
THAT ALLSTATE CAN REINSPECT THE VEHICLE AND ADDRESS ANY ADDITIONAL DAMAGE.
IF YOU ARE AN ALLSTATE POLICYHOLDER AND IF ALLSTATE AND YOU DISAGREE AS TO THE AMOUNT OF THE
LOSS, BOTH YOU AND ALLSTATE HAVE A RIGHT TO DEMAND AN APPRAISAL OF THE LOSS. THE APPRAISAL
PROCESS INVOLVES BOTH ALLSTATE AND YOU SHARING THE APPRAISAL COST EQUALLY. BOTH ALLSTATE AND
YOU WILL EACH APPOINT AND PAY A QUALIFIED APPRAISER AND THOSE TWO APPRAISERS WILL SELECT AN
UMPIRE. EACH APPRAISER WILL STATE THE AMOUNT OF THE LOSS, AND IF THE APPRAISERS DISAGREE THE
DIFFERENCES WILL BE SUBMITTED TO THE UMPIRE.
IF YOU ARE NOT AN ALLSTATE POLICYHOLDER, BUT HAVE A CLAIM AGAINST AN ALLSTATE POLICYHOLDER, AND
IF ALLSTATE AND YOU DISAGREE AS TO THE AMOUNT OF THE LOSS, ALLSTATE WILL AGREE TO AN APPRAISAL OF
THE CLAIM RATHER THAN YOU FILING A LAWSUIT FOR THE DAMAGE TO YOUR VEHICLE. THE APPRAISAL
PROCESS INVOLVES BOTH ALLSTATE AND YOU SHARING THE APPRAISAL COST EQUALLY. BOTH ALLSTATE AND

6/3/2015 4:34:22 PM

121837

Page 6

Claim #:

000368735353D01

Workfile ID:

b3fbe5ba

Estimate of Record
2008 CHEV TAHOE 4X2 LTZ 4D UTV 8-5.3L-FI BLUE

6/3/2015 4:34:22 PM

121837

Page 7

Claim #:

000368735353D01

Workfile ID:

b3fbe5ba

Estimate of Record
2008 CHEV TAHOE 4X2 LTZ 4D UTV 8-5.3L-FI BLUE

Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
DR1GC07, CCC Data Date 4/1/2015, 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. Blnd=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.

6/3/2015 4:34:22 PM

121837

Page 8

Claim #:

000368735353D01

Workfile ID:

b3fbe5ba

Estimate of Record
2008 CHEV TAHOE 4X2 LTZ 4D UTV 8-5.3L-FI BLUE

IMPORTANT INFORMATION ABOUT THE NAMED INSURANCE COMPANY'S CHOICE OF PARTS POLICY.
THIS ESTIMATE MAY LIST PARTS FOR USE IN THE REPAIR OF YOUR VEHICLE THAT ARE MANUFACTURED BY A
COMPANY OTHER THAN THE ORIGINAL MANUFACTURER OF YOUR VEHICLE. THESE PARTS ARE COMMONLY
REFERRED TO AS AFTERMARKET PARTS OR COMPETITIVE PARTS, AND MAY INCLUDE COSMETIC OUTER BODY
CRASH PARTS SUCH AS HOODS, FENDERS, BUMPER COVERS, ETC. THE INSURANCE COMPANY GUARANTEES THE
FIT AND CORROSION RESISTANCE OF ANY AFTERMARKET/COMPETITIVE OUTER BODY CRASH PARTS THAT ARE
LISTED ON THIS ESTIMATE AND ACTUALLY USED IN THE REPAIR OF YOUR VEHICLE FOR AS LONG AS YOU OWN
IT. IF A PROBLEM DEVELOPS WITH THE FIT OR CORROSION RESISTANCE OF THESE PARTS, THEY WILL BE
REPAIRED OR REPLACED AT THE INSURANCE COMPANY'S EXPENSE. THIS GUARANTEE IS LIMITED TO THE REPAIR
OR REPLACEMENT OF THE PART. HOWEVER, IF YOU CHOOSE NOT TO USE ONE OR MORE OF THE
AFTERMARKET/COMPETITIVE OUTER BODY CRASH PARTS THAT MAY BE LISTED ON THIS ESTIMATE IN THE
REPAIR OF YOUR VEHICLE, THE INSURANCE COMPANY WILL SPECIFY THE USE OF ORIGINAL EQUIPMENT
MANUFACTURER PARTS, EITHER NEW OR RECYCLED AT THE INSURANCE COMPANY'S OPTION, AT NO ADDITIONAL
COST TO YOU. THE INSURANCE COMPANY DOES NOT SEPARATELY GUARANTEE THE PERFORMANCE OF ORIGINAL
EQUIPMENT MANUFACTURER PARTS, AND MAKES NO REPRESENTATION ABOUT THE AVAILABILITY OF ANY
MANUFACTURER'S GUARANTEE.

6/3/2015 4:34:22 PM

121837

Page 9

Claim #:

000368735353D01

Workfile ID:

b3fbe5ba

Estimate of Record
2008 CHEV TAHOE 4X2 LTZ 4D UTV 8-5.3L-FI BLUE

ALTERNATE PARTS SUPPLIERS

Line
3

Supplier

Description

OEM_DLR_ALLSTAR PARTS DIVISION

#25814570

Price

PARTS PARTS

Opt OEM Bumper cover

$ 407.43

13000 FLORIDA BLVD

BATON ROUGE LA 70816
(225) 298-8080
6

OEM_DLR_ALLSTAR PARTS DIVISION

#25947497

$ 343.23

PARTS PARTS

Opt OEM Impact bar

13000 FLORIDA BLVD

BATON ROUGE LA 70816
(225) 298-8080
7

OEM_DLR_ALLSTAR PARTS DIVISION

#15203734

$ 54.78

PARTS PARTS

Opt OEM Air deflector

Page 10

Claim #:

000368735353D01

Workfile ID:

b3fbe5ba

Estimate of Record
2008 CHEV TAHOE 4X2 LTZ 4D UTV 8-5.3L-FI BLUE
PARTS PARTS

Opt OEM RT Fender liner Tahoe w/o Z71

13000 FLORIDA BLVD

BATON ROUGE LA 70816
(225) 298-8080
39

OEM_DLR_ALLSTAR PARTS DIVISION

#9597195

$ 352.82

PARTS PARTS

Opt OEM RT/Front Wheel 20" code: RCS

13000 FLORIDA BLVD

BATON ROUGE LA 70816
(225) 298-8080
46

NAPA

#MRCES800223

$ 32.49

Preston Keanum

A/M RT Outer tie rod

2999 CIRCLE 75 PARKWAY

ATLANTA GA 30339
(800) 538-6272
47

NAPA

#NRP221036

Preston Keanum

A/M Gear assy

$ 332.84

2999 CIRCLE 75 PARKWAY

ATLANTA GA 30339
(800) 538-6272
74

OrioNA Bethlehem Warehouse

#15223483

John Christensen

Opt OEM RT Emblem

$ 10.57

4270 Fritch Drive

Bethlehem PA 18020
(855) 435-6746
84

LKQ GULF COAST

#$VJ681

JEFF MITCHELL / SINO

RCY RT knee assy; w/2 wheel drive; one side +25%

$ 235.14

16925 BLACKMUD RD

Knee Rt Fr RH,5.3,AUTO,4X2,LT XFE S#$VJ681 - NON-HYBRID, R.,

W/O CH OPT Z55, Z71 OR

LIVINGSTON,LA 70754
(800) 321-3209

6/3/2015 4:34:22 PM

121837

Page 11

ALLSTATE
LOUISIANA CENTRAL AUTO
3900 N Causeway Blvd, Ste 510
Metairie, LA 70002
Phone: (800) 349-1444

Claim #:
Workfile ID:

000368735353D01
b3fbe5ba

Unrelated Prior Damage

Written By: THOMAS CHERICHELLO
Adjuster: Cherichello, Thomas, (225) 380-7383 Cellular
Insured:

DAVID OLDS

Owner Policy #:

0368735353

Claim #:

000368735353D01

Type of Loss:

Collision

Date of Loss:

01/02/2015 12:00 AM

Days to Repair:

Point of Impact:

01 Right Front

Deductible:

Owner (Insured):

Inspection Location:

Appraiser Information:

Repair Facility:

DAVID OLDS
13855 KATHERINE AVENUE
BATON ROUGE, LA 70815
(225) 892-9794 Day

EDWARDS AUTO BODY

2763 SCENIC HIGHWAY
BATON ROUGE, LA 70805
Repair Facility
(225) 355-7371 Business

[email protected]

EDWARDS AUTO BODY

2763 SCENIC HIGHWAY
BATON ROUGE, LA 70805
(225) 355-7371 Business

VEHICLE
Year:

2008

Color:

BLUE Int: GRAY

License:

Make:

CHEV

Body Style:

4D UTV

State:

Model:

TAHOE 4X2 LTZ

Engine:

8-5.3L-FI

VIN:

15054074
1GNFC13058R139428

Production Date:

09/2007

Odometer:

152207

Condition:

TRANSMISSION

Overhead Console

Search/Seek

Leather Seats

Automatic Transmission

CONVENIENCE

Auxiliary Audio Connection

Heated Seats

Overdrive

Air Conditioning

Premium Radio

Rear Heated Seats

POWER

Intermittent Wipers

Satellite Radio

3rd Row Seat

Power Steering

Tilt Wheel

CD Changer/Stacker

WHEELS

Power Brakes

Cruise Control

SAFETY

20" Or Larger Wheels

Power Windows

Rear Defogger

Drivers Side Air Bag

PAINT

Power Locks

Keyless Entry

Passenger Air Bag

Clear Coat Paint

Power Mirrors

Message Center

Anti-Lock Brakes (4)

OTHER

Heated Mirrors

Steering Wheel Touch Controls

4 Wheel Disc Brakes

Fog Lamps

Power Driver Seat

Rear Window Wiper

Stability Control

Signal Integrated Mirrors

Power Passenger Seat

Dual Air Condition

Head/Curtain Air Bags

TRUCK

Memory Package

Parking Sensors

Communications System

Rear Step Bumper

Power Adjustable Pedals

Remote Starter

Hands Free Device

Trailer Hitch

DECOR

Home Link

ROOF

Trailering Package

Dual Mirrors

RADIO

Luggage/Roof Rack

Running Boards/Side Steps

Body Side Moldings

AM Radio

Electric Glass Sunroof

Privacy Glass

FM Radio

SEATS

Console/Storage

Stereo

Bucket Seats

6/3/2015 4:34:22 PM

121837

Page 1

Claim #:

000368735353D01

Workfile ID:

b3fbe5ba

Unrelated Prior Damage

2008 CHEV TAHOE 4X2 LTZ 4D UTV 8-5.3L-FI BLUE

Line

Oper

Description

WINDSHIELD

Subl

A/M Windshield w/o rain sensor

plus kit

Subl

Windshield w/o rain sensor Labor

Part Number

Qty

Extended
Price $
1

131.90 T

1
SUBTOTALS

77.00 T
208.90

Labor

Paint

0.0

Rate

Cost $

NOTES
Prior Damage Notes:
STONE CHIPS IN WINDSHIELD

ESTIMATE TOTALS
Category

Basis

Parts

131.90

Miscellaneous

77.00

Subtotal

208.90

Sales Tax

$ 208.90

Total Cost of Repairs

6/3/2015 4:34:22 PM

8.6000 %

17.97
226.87

121837

Page 2

Claim #:

000368735353D01

Workfile ID:

b3fbe5ba

Unrelated Prior Damage

2008 CHEV TAHOE 4X2 LTZ 4D UTV 8-5.3L-FI BLUE

Supplemental Request Form

Fax to 866-434-9457 or Email to - [email protected]
EST COMPLETION DATE:
EST GROSS TOTAL: $_________
CUSTOMER NAME:
ADJUSTER:
CLAIM NUMBER:
YEAR:
MAKE:

2008 CHEV TAHOE 4X2 LTZ 4D UTV 8-5.3L-FI BLUE

6/3/2015 4:34:22 PM

121837

Page 6

Claim #:

000368735353D01

Workfile ID:

b3fbe5ba

Unrelated Prior Damage

2008 CHEV TAHOE 4X2 LTZ 4D UTV 8-5.3L-FI BLUE

6/3/2015 4:34:22 PM

121837

Page 7

-----------------------------------------------------------------------------------------------Allstate Motor Club, Inc.

Bill Invoice #: 100000345675
Wholesale Billing Department
Alternate ID (Ins Claim #): 000368735353
PO Box 4443
Service Date: 05/18/2015
Carol Stream, IL 60197
[email protected]
Service Weight: Light
Auth #: 1029161181
Allstate Insurance Corporation
Provider (Total Loaded): 9.29
866-447-4293 Fax
Partner (Participant ID): E33C9C4847D0C704
ATTN : Claims
Due Date : 30 Days Upon receipt of invoice
Secondary Disablement (Pick Up):

Secondary Disablement (Drop Off):

Disablement (Pick Up):

RESIDENCE
13855 KATHERINE AVE
BATON ROUGE LA 708157229

Disablement (Drop Off):

COLLISION SOLUTIONS LLC
1334 FLORIDA BLVD BLDG B
BATON ROUGE LA 70802

Program Offered: Secondary Towing Roadside Assistance

MOS: GHRN
Customer (Insured Name): ODDS, DAVID
Disablement (Vehicle Make): CHEVY TRUCK
Disablement (Vehicle Model): TAHOE
Disablement (Vehicle Year): 2008
Secondary Disablement (Vehicle Make):
Secondary Disablement (Vehicle Model):
Secondary Disablement (Vehicle Year):
Billing Detail:
Tow
Additional Mileage
Total Amount Due:

$80.00
$7.44
$87.44

-----------------------------------------------------------------------------------------------Detach & return this part with payment

Allstate Motor Club, Inc.

Wholesale Billing Department
PO Box 4443
Carol Stream, IL 60197
[email protected]

Alternate ID (Ins Claim #): 000368735353

Service Date: 05/18/2015
Total Amount Due: $87.44

CLAIM INFORMATION
Owner:

Insured:
Loss Vehicle:
VIN:
Odometer:
Location:
Loss Incident Date:

David Olds
13855 Katherine Avenue
Baton Rouge , LA 70815
David Olds
2008 Chevrolet Tahoe 4X2 Ltz
4 Door Sport Utility Vehicle
1GNFC13058R139428
152,207
Baton Rouge, LA 70815
01/02/2015

Report Reference Number:

Claim Reference:
Adjuster:
Adjuster ID:
Claim Submitted Date:
Date/Time Last Updated:
Policy Number:
Appraiser:

54918524 -1
000368735353D01
Cherichello, Thomas
TCHER
06/02/2015
Original
0368735353
Cherichello, Thomas

VALUATION SUMMARY
Base Vehicle Value
Condition Adjustment
Date of Loss Allowance
Adjusted Vehicle Value

$ 17,557.00
+ 168.00
+ 116.48
$ 17,841.48

Vehicular Sales Tax

9.00%
$ 1,605.73
Sales Tax reflects all applicable state, county, and municipal taxes.
License/Fees (if applicable)
DMV Fee
Value before Deductible
Deductible
Total

$ ______
+ 26.50
$ 19,473.71
- 500.00

$ 18,973.71

This CCC ONE Market Valuation Report was

prepared for Allstate by CCC Information Services
Inc. The CCC ONE Market Valuation Report reflects
CCC's opinion as to the value of the loss vehicle.
CCC has been preparing market value reports for the
insurance industry since 1981.
The Base Vehicle Value is derived from comparable
vehicle(s) available or recently sold in the marketplace
at the time of valuation, with adjustments made to
reflect the loss vehicle configuration.
4 comparable vehicle(s) were utilized in this report.
The loss vehicle has been valued in the Southwest
region where it was garaged as a newer truck with
45% greater than average mileage of 104,800.

Page 1 of 16

Owner: David Olds

Claim Reference: 000368735353D01

VEHICLE ALLOWANCES

Allowances are factors influencing the value of the loss

vehicle when compared to a typical vehicle. The typical
vehicle is a vehicle of the same year, make, and model
as the loss vehicle, including average mileage, and all
standard and predominant equipment. These allowances
are displayed for illustrative purposes only.
The Base Vehicle Value is calculated from the comparable
vehicles with adjustments to reflect the loss vehicle
configuration.
Vehicle Allowances
Odometer

152,207

- 2,139.00

Options
Electric Glass Roof

Reported

+ 500.00

VEHICLE HISTORY SUMMARY

Experian AutoCheck

No Title Problem Found

Insurance Services Organization/

6 Records Found
National Insurance Crime Bureau

Page 2 of 16

Owner: David Olds

Claim Reference: 000368735353D01

LOSS VEHICLE COMPONENTS

2008 CHEVROLET TAHOE 4X2 LTZ 4 DOOR SPORT UTILITY VEHICLE BATON ROUGE,
LA 70815
VIN: 1GNFC13058R139428
Below are the components of the loss vehicle, provided to CCC by Allstate, included in this valuation.
.
Odometer
152,207
Heated Seats

Standard

3rd Row Seat

Standard

Transmission

Rear Heated Seats

Standard

Automatic Transmission

Standard

Overdrive

Standard

Power

Radio
AM Radio

Standard

FM Radio

Standard
Standard
Standard

Power Steering

Standard

Stereo

Power Brakes

Standard

Search/Seek

Power Windows

Standard

Power Locks

Standard

Power Mirrors

Standard

Power Driver Seat

Standard

Power Passenger Seat

Standard

Power Adjustable Pedals

Standard

Steering Wheel Touch

Controls

Standard

Auxiliary Audio Connection

Standard

Premium Radio

Standard

Satellite Radio

Standard

CD Changer/Stacker

Standard

Keyless Entry

Standard

Parking Sensors

Standard

Message Center

Standard

Communications System

Standard

Home Link

Standard

Hands Free

Standard

Stability Control

Standard

Remote Starter

Roof
Electric Glass Roof

Reported

Safety/Brakes

Exterior/Paint/Glass

Seating
Bucket Seats

Standard

Dual Mirrors

Standard

Leather Seats

Standard

Heated Mirrors

Standard

Page 3 of 16

Owner: David Olds

Claim Reference: 000368735353D01

LOSS VEHICLE COMPONENTS (CONTINUED)

Body Side Moldings

Standard

Clearcoat Paint

Reported

Privacy Glass

Standard

Fog Lamps

Standard

Rear Step Bumper

Standard

Luggage/Roof Rack

Standard

Trailer Hitch

Standard

Rear Window Wiper

Standard

Trailering Package

Standard

Signal Integrated Mirrors

Standard

Running Boards/Side
Steps

Standard

Other - Trucks

Page 4 of 16

Owner: David Olds

Claim Reference: 000368735353D01

VEHICLE CONDITION

Allstate uses condition inspection guidelines to determine the condition of key components of the loss vehicle. These
guidelines are based upon geographic region, age, and vehicle type. The guidelines describe physical characteristics for
the major vehicle components. Based on these guidelines, Allstate has determined the condition of the vehicle prior to the
loss. Inspection Notes reflect additional observations from the appraiser regarding the loss vehicle's condition. CCC makes
dollar adjustments that reflect the impact the reported condition has on the value of loss vehicle. These dollar adjustments are
based upon interviews with dealerships across the United States.

COMPONENT

CONDITION

VALUE
IMPACT

Private owner

Interior
Seats

INSPECTION NOTES:
N SIGNIFICANT BURNS OR
HOLES. MINOR CRACKING ON
BOTH F RONT SEATS.

Carpets

Private owner

INSPECTION NOTES:
NO SIGNIFICANT BURNS OR
HOLES. REMOVABLE STAINS IN
FRO NT AND REAR.

Dashboard

Private owner

INSPECTION NOTES:
REPAIRABLE CRACK ON L/SIDE.

Headliner

Private owner

INSPECTION NOTES:
NO SIGNIFICANT BURNS OR
HOLES. LIGHTLY SCUFFED.

Exterior
Sheet Metal

Private owner

INSPECTION NOTES:
NO PRIOR COLLISION DAMAGE
OR RUST. FEW DENTS AND
DINGS .

Trim

Private owner

INSPECTION NOTES:
ALL COMPONENTS INTACT. FEW
DENTS AND DINGS.

Paint

Private owner

INSPECTION NOTES:

Page 5 of 16

Owner: David Olds

Claim Reference: 000368735353D01

VEHICLE CONDITION (CONTINUED)

NO SIGNIFICANT PEELING OR
FLAKING. FEW CHIPS AND
SCRAT CHES.
Glass

Private owner

INSPECTION NOTES:
LIGHT SURFACE SCRATCHES.
STONE CHIPS IN WINDSHEILD
WRI TTEN AS UPD.

Mechanical
Engine

Private owner

INSPECTION NOTES:
MINOR DIRT AND LEAKS

Transmission

Private owner

INSPECTION NOTES:
MINOR DIRT AND LEAKS

Tires
Front Tires

Excellent

$84

INSPECTION NOTES:
BOTH 11/32

Rear Tires

Excellent

$84

INSPECTION NOTES:
BOTH 11/32

Total Adjustments:

$168

Page 6 of 16

Owner: David Olds

Claim Reference: 000368735353D01

VINGUARD VEHICLE IDENTIFICATION

2008 CHEVROLET TAHOE 4X2 LTZ 4 DOOR SPORT UTILITY VEHICLE BATON ROUGE,
LA 70815
VIN: 1GNFC13058R139428
Vehicles sold in the United States are required to have a manufacturer assigned Vehicle Identification Number (VIN). This number
provides certain specifications of the vehicle. Decoding the VIN, using VINguard, identifies the vehicle for which vehicle value will
be determined.
Insurer Description

VINguard Analysis

Year

2008

Make

Chevrolet

Model/Trim

Tahoe 4X2 Ltz

Tahoe 4X2

Model Number

NC13

Body Style

4 Door Sport Utility Vehicle

Engine

8-5.3L-FI

Transmission

Automatic Transmission Overdrive

Restraints

Air Bags (Driver+Pass.)

8-5.3l-Fi

Curb Weight

Air Bags(Dr.+Pass.+Side)
5,233

This vehicle was assembled in ARLINGTON, TX

VINGUARD VEHICLE HISTORY INFORMATION

Using the VIN for this vehicle, VINguard detected discrepancies or prior history requiring additional research. Please review
the information detailed below.
VINguard Messages: VINguard has decoded this VIN without any errors.
ISO Vehicle History:
Number of times reported to ISO: 6
ISO's file number: H0228529482
Activity Reported: Collision Estimate
Loss date: 05/13/2015
Insurance company: Allstate Insurance Company
Phone: Unavailable
Claim ref: 000368735353D01
Coverage: Collision
Point of Impact: Right Front Corner
Mileage: 152207
ISO notified: 05/25/2015
Activity Reported: Property & Casualty
Loss date: 05/13/2015
(C) Copyright 2015 CCC Information Services Inc. All Rights Reserved.

Page 7 of 16

Owner: David Olds

Claim Reference: 000368735353D01

Insurance company: Allstate Insurance Company

Phone: (504) 834-3185
Claim ref: 0368735353
Point of Impact:
Activity Reported: Collision Estimate
Loss date: 02/25/2013
Insurance company: Progressive Insurance Companies
Phone: Unavailable
Claim ref: 13-4809016-01
Coverage: Other
Point of Impact:
Mileage: 112264
ISO notified: 03/12/2013
Activity Reported: Appraisal Assigned
Loss date: 02/25/2013
Insurance company: Progressive Insurance Companies
Phone: Unavailable
Claim ref: 13-4809016-01
Coverage: Comprehensive
Point of Impact:
Mileage: UNKNOWN
ISO notified: 03/14/2013
Activity Reported: Property & Casualty
Loss date: 02/25/2013
Insurance company: Progressive Insurance Companies
Phone: (225) 663-5701
Claim ref: 0120134809016
Point of Impact:
Activity Reported: Property & Casualty
Loss date: 01/05/2009
Insurance company: American National Property & Casualty Company
Phone: (417) 887-4990
Claim ref: 17V1UV334
Point of Impact:

Page 8 of 16

Owner: David Olds

Claim Reference: 000368735353D01

EXPERIAN AUTOCHECK VEHICLE HISTORY REPORT

CCC provides Allstate information reported by Experian regarding the loss vehicle. This data is provided for informational purposes.
Unless otherwise noted in this Market Valuation Report, CCC does not adjust the value of the loss vehicle based upon this information.
= No Event Found
= Event Found
= Information Needed
REPORT RUN DATE: 06/03/2015 KEY:
TITLE CHECK
VEHICLE INFORMATION
THIS VEHICLE CHECKS OUT. AutoCheck's result for this
INFORMATION FOUND. AutoCheck found additional
information on this vehicle. These records will provide
2008 Chevrolet Tahoe 4X2 Ltz (1GNFC13058R139428)
more history for this 2008 Chevrolet Tahoe 4X2 Ltz
show no significant title events. When found, events often
indicate automotive damage or warnings associated with the
(1GNFC13058R139428).
vehicle.
EVENTS CHECKED
Abandoned

RESULTS FOUND
No Abandoned Record Found

Damaged

No Damaged Record Found

Fire Damage

No Fire Damage Record Found

Grey Market

No Grey Market Record Found

Hail Damage

EVENTS CHECKED
Accident

RESULTS FOUND
Accident Record(s) Found

Corrected Title

No Corrected Title Record Found

Driver Education

No Driver Education Record Found

Duplicate Title

No Duplicate Title Record Found

No Hail Damage Record Found

Emissions Safety
Inspection

Insurance Loss

No Insurance Loss Record Found

Fire Damage Incident

Junk

No Junk Record Found

Emissions Safety Inspection

Record(s) Found
No Fire Damage Incident Record
Found

Rebuilt

No Rebuilt Record Found

Salvage

No Salvage Record Found

EVENT CHECK
THIS VEHICLE CHECKS OUT. AutoCheck's result for this
2008 Chevrolet Tahoe 4X2 Ltz (1GNFC13058R139428)
show no historical events that indicate a significant automotive
problem. These problems can indicate past previous car
damage, theft, or other significant problems.
EVENTS CHECKED
RESULTS FOUND
NHTSA Crash Test
No NHTSA Crash Test Vehicle
Vehicle
Record Found
Frame Damage
Major Damage Incident
Manufacturer Buyback/
Lemon
Odometer Problem

No Frame Damage Record Found

No Major Damage Incident Record
Found
No Manufacturer Buyback/Lemon
Record Found
No Odometer Problem Record
Found

Recycled

No Recycled Record Found

Salvage Auction

No Salvage Auction Record Found

Water Damage

No Water Damage Record Found

Lease

No Lease Record Found

Lien

Lien Record(s) Found

Livery Use

No Livery Use Record Found

Government Use

No Government Use Record Found

Police Use

No Police Use Record Found

Fleet

No Fleet Record Found

Rental

No Rental Record Found

Fleet and/or Lease

Fleet and/or Rental

No Fleet and/or Lease Record

Found
No Fleet and/or Rental Record
Found

Repossessed

No Repossessed Record Found

Taxi use

No Taxi use Record Found

Theft

No Theft Record Found

Page 9 of 16

Owner: David Olds

Claim Reference: 000368735353D01

EXPERIAN AUTOCHECK VEHICLE HISTORY REPORT (CONTINUED)

ODOMETER CHECK
THIS VEHICLE CHECKS OUT. For this 2008 Chevrolet Tahoe 4X2 Ltz (1GNFC13058R139428) no indication of odometer
rollback or tampering was found. AutoCheck determines odometer rollbacks by searching for records that indicate odometer readings
less than a previously reported value. Other odometer events can report events of tampering, or possible odometer breakage.
DATE REPORTED
2007-10-04
2009-04-16
2010-05-31
2010-07-09
2011-06-03
2012-07-18
2013-08-27
2014-09-23
2015-01-13
2015-04-30

ODOMETER READING
5
17486
33284
33330
60911
98697
121132
140082
140000Not included in rollback calculation
151843

FULL HISTORY
REPORT RUN DATE: 06/03/2015 Below are the historical events for this vehicle listed in chronological order.
Event Date

Event Location

2007-10-04

2008-03-31

GONZALES, LA

2008-03-31

Odometer Reading

Data Source

Event Detail

Motor Vehicle Dept.

PASSED EMISSION INSPECTION

Motor Vehicle Dept.

TITLE (Lien Reported)

GONZALES, LA

Motor Vehicle Dept.

REGISTRATION EVENT/RENEWAL

2009-01-05

State Agency

ACCIDENT REPORTED

2009-01-05

State Agency

MINOR TO MODERATE DAMAGE

REPORTED

2009-03-20

GONZALES, LA

Motor Vehicle Dept.

TITLE (Lien Reported)

2009-03-20

GONZALES, LA

Motor Vehicle Dept.

TITLE (Lien Reported)

2014-06-17

DENHAM SPRINGS, LA

Motor Vehicle Dept.

REGISTRATION EVENT/RENEWAL

2014-09-23

Motor Vehicle Dept.

PASSED EMISSION INSPECTION

60911
98697
121132

140082
140000

Page 10 of 16

Owner: David Olds

Claim Reference: 000368735353D01

EXPERIAN AUTOCHECK VEHICLE HISTORY REPORT (CONTINUED)

2015-01-16

DENHAM SPRINGS, LA

2015-04-30

SOUTHWEST REGION,

Motor Vehicle Dept.

REGISTRATION EVENT/RENEWAL

Auto Auction

2015-05-06

REPORTED AT AUTO AUCTION

DENHAM SPRINGS, LA

Motor Vehicle Dept.

TITLE (Lien Reported)

2015-05-06

DENHAM SPRINGS, LA

Motor Vehicle Dept.

TITLE (Lien Reported)

2015-05-13

BATON ROUGE, LA

State Agency

FRONT IMPACT WITH ANOTHER

VEHICLE

2015-05-13

BATON ROUGE, LA

State Agency

MODERATE TO SEVERE DAMAGE

REPORTED

2015-05-13

BATON ROUGE, LA

State Agency

VEHICLE WAS TOWED

151843

AUTOCHECK TERMS AND CONDITIONS: Experian's Reports are compiled from multiple sources. It is not always possible for Experian to obtain complete
discrepancy information on all vehicles; therefore, there may be other title brands, odometer readings or discrepancies that apply to a vehicle that are not reflected on that
vehicle's Report. Experian searches data from additional sources where possible, but all discrepancies may not be reflected on the Report.
These Reports are based on information supplied to Experian by external sources believed to be reliable, BUT NO RESPONSIBILITY IS ASSUMED BY EXPERIAN OR
ITS AGENTS FOR ERRORS, INACCURACIES OR OMISSIONS. THE REPORTS ARE PROVIDED STRICTLY ON AN "AS IS WHERE IS" BASIS, AND EXPERIAN
FURTHER EXPRESSLY DISCLAIMS ALL WARRANTIES, EXPRESS OR IMPLIED, INCLUDING ANY IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR
A PARTICULAR PURPOSE REGARDING THIS REPORT.
YOU AGREE TO INDEMNIFY EXPERIAN FOR ANY CLAIMS OR LOSSES, INCLUDING COSTS, EXPENSES AND ATTORNEYS FEES, INCURRED BY EXPERIAN
ARISING DIRECTLY OR INDIRECTLY FROM YOUR IMPROPER OR UNAUTHORIZED USE OF AUTOCHECK VEHICLE HISTORY REPORTS.
Experian shall not be liable for any delay or failure to provide an accurate report if and to the extent which such delay or failure is caused by events beyond the reasonable
control of Experian, including, without limitation, "acts of God", terrorism, or public enemies, labor disputes, equipment malfunctions, material or component shortages,
supplier failures, embargoes, rationing, acts of local, state or national governments, or public agencies, utility or communication failures or delays, fire, earthquakes, flood,
epidemics, riots and strikes.
These terms and the relationship between you and Experian shall be governed by the laws of the State of Illinois (USA) without regard to its conflict of law provisions. You and
Experian agree to submit to the personal and exclusive jurisdiction of the courts located within the county of Cook, Illinois.

Page 11 of 16

Owner: David Olds

Claim Reference: 000368735353D01

COMPARABLE VEHICLES
LOSS VEHICLE - 2008 CHEVROLET TAHOE 4X2 LTZ 4 DOOR SPORT UTILITY VEHICLE BATON ROUGE, LA 70815
VIN: 1GNFC13058R139428
LOSS VEHICLE
2008 CHEVROLET
TAHOE 4X2 LTZ
4 DOOR SPORT
UTILITY VEHICLE
8-5.3L-FI

INSPECTED DEALER
COMPARABLE 1
2009 CHEVROLET
TAHOE 4X2 LT
4 DOOR UTV
8-5.3L

DEALER VEHICLE
COMPARABLE 2
2008 CHEVROLET
TAHOE 4X2 LTZ
4 DOOR UTV
8-5.3L

DEALER VEHICLE
COMPARABLE 3
2008 CHEVROLET
TAHOE 4X2 LTZ
4 DOOR UTV
8-5.3L

Options
Automatic Transmission
Overdrive
Power Steering
Power Brakes
Power Windows
Power Locks
Power Mirrors
Power Driver Seat
Power Passenger Seat
Power Trunk/Gate
Release
Power Adjustable Pedals
Air Conditioning
Climate Control
Dual Air Conditioning
Tilt Wheel
Cruise Control
Rear Defogger
Intermittent Wipers
Console/Storage
Overhead Console
Memory Package
Navigation System
Entertainment Center
Keyless Entry
Message Center
Home Link
Remote Starter
Bucket Seats
Leather Seats
Heated Seats
3rd Row Seat
Captain Chairs (2)
Rear Heated Seats
AM Radio
FM Radio

Page 12 of 16

Owner: David Olds

Claim Reference: 000368735353D01

COMPARABLE VEHICLES (CONTINUED)

Stereo
Search/Seek
CD Player
Steering Wheel Touch
Controls
Auxiliary Audio
Connection
Premium Radio
Satellite Radio
CD Changer/Stacker
Aluminum/Alloy Wheels
Chrome Wheels
20" or Larger Wheels
Electric Glass Roof
Drivers Side Air Bag
Passenger Air Bag
Anti-Lock Brakes (4)
4-Wheel Disc Brakes
Front Side Impact Air
Bags
Head/Curtain Air Bags
Positraction
Backup Camera W/
Parking Sensors
Parking Sensors
Communications System
Hands Free
Alarm
Traction Control
Stability Control
Dual Mirrors
Heated Mirrors
Body Side Moldings
Tinted Glass
Privacy Glass
Fog Lamps
Luggage/Roof Rack
Rear Spoiler
Rear Window Wiper
Signal Integrated Mirrors
Clearcoat Paint
Rear Step Bumper
Trailer Hitch
Trailering Package
Running Boards/Side
Steps
(C) Copyright 2015 CCC Information Services Inc. All Rights Reserved.

Page 13 of 16

Owner: David Olds

Claim Reference: 000368735353D01

COMPARABLE VEHICLES (CONTINUED)

Miles
List Price
Take Price
Adjustments
Model/Trim/Year
Options
Mileage
Comparable Vehicle
condition adjustment
Adjusted Value
Dealership
Contact
Telephone
Stock ID
VIN
Type/Date
Distance from Baton Rouge, LA

152,207

127,134
$19,900
$19,900
+1,025
-1,275
-205
-1,638
$17,807
Extreme Cars
And Trucks
Trey Phillips
318-398-1880
Stock: 203515
1GNEC23379R203515
Last Inspected
4/21/2015
155 Miles West Monroe,
LA

125,345
$21,987

123,228
$21,945

-2,275
-837
-1,638

-1,950
-936
-1,638

$17,237
Ray Chevrolet

$17,421
Carfinders

337-893-1243
Stock: I12507A
1GNFC13008R109916
Pub Date
5/07/2015
73 Miles Abbeville, LA

251-633-4200
Stock: 249491
1GNFC13038R249491
Pub Date
5/13/2015
169 Miles Mobile, AL

> Comparable vehicles used in the determination of the Base Vehicle Value are not intended to be replacement vehicles but are
reflective of the market value.

> List Price is the sticker price of an inspected dealer vehicle and the advertised price for the advertised vehicle.Take Price is the
>
>
>
>
>
>

amount that the dealership has stated it will accept to sell the inspected dealer vehicle. For advertised vehicles, the Advertised Price
is the same as List Price.
Take Price or List Price displayed above (as applicable) may differ from the advertised price where CCC obtains different price
information from the seller.
The Comparable Vehicle Condition Adjustment sets that vehicle to a common condition baseline. To see how the condition of the
loss vehicle impacts the valuation, see the Vehicle Condition section of this report.
Comparable vehicles used in the determination of the Base Vehicle Value are not intended to be replacement vehicles but rather are
included because they are reflective of the market value.
The Adjusted Value represents the price of the comparable vehicle with the adjustments displayed above. Dollar adjustments are
based upon market research.
Distances displayed indicate approximate miles between loss and comparable vehicle locations. Distances are based upon a straight
line between these locations.
Some comparable vehicles that were recently available may no longer be available.

Page 14 of 16

Owner: David Olds

Claim Reference: 000368735353D01

ADDITIONAL COMPARABLE VEHICLES

The following comparable vehicles support the Base Vehicle Value of the loss vehicle.

Local Advertisement
Source

Vehicle

List Price

Adjusted Value

Midsouth Auto & Truck Sal

Ad Date: 04/18/2015
(228) 712-2530
Pascagoula MS
151 Miles From Baton Rouge

2008 Chevrolet Tahoe 4X2 Ltz

Odometer: 109,870
VIN: 1GNFC13J78R212016

$ 22,995

$ 17,644

VALUATION METHODOLOGY
Allstate has provided CCC the VIN (Vehicle Identification Number) of the loss vehicle and the vehicle owner's zip code, which
determine the market(s) that CCC used in the valuation. Using this information, CCC searches its databases to find comparable
vehicles in these markets. CCC's database includes vehicles for sale at dealerships that CCC has physically inspected, as well
as dealer and private party advertised vehicle information from numerous resources including AutoTrader.com. Allstate has also
provided CCC with the configuration of the loss vehicle, including equipment, odometer, condition, maintenance, etc. Vehicles located
are compared to the loss vehicle, and adjustments are made for differences such as model/trim, equipment, and odometer. The
comparable vehicles are also adjusted for condition to a common condition baseline. Using the adjusted values of the comparable
vehicles, CCC calculates the Base Vehicle Value.
The Base Vehicle Value is the weighted average of the adjusted values of the comparable vehicles based on the following factors:

>
>
>
>
>

Source of the data (such as inspected versus advertised)

Similarity (such as equipment, odometer, and year)
Proximity to the loss vehicle's primary garage location
Recency of information
Comparable vehicles used in the determination of the vehicle value are not intended to be replacement vehicles, but are reflective
of the market value.

The Adjusted Vehicle Value is determined by adjusting the Base Vehicle Value to account for the actual condition of the loss vehicle
and its other reported attributes, if any, such as refurbishments, after factory equipment, and unrelated prior damage.
Please review the information in this Valuation Detail to confirm the reported mileage, condition and to verify there are no missed
options, added equipment or refurbishments, or other aspects of the loss vehicle that may impact the value.

VALUATION NOTES
Regulation information concerning vehicle value includes Louisiana Insurance Directive 18.

Page 15 of 16

Owner: David Olds

Claim Reference: 000368735353D01

MARKET DEFINITION

The loss vehicle has been identified to CCC as a 2008 Chevrolet Tahoe 4X2 Ltz 4 Door Sport Utility Vehicle garaged in the
ZIP code 70815 - Baton Rouge, LA. Details of the specific markets searched based upon that information follow.

THE STATE OF LOUISIANA is subdivided by CCC into 5 markets. The following 8 markets were used in
the preparation of this vehicle Market Valuation Report.
BATON ROUGE LA - In this market, CCC maintains a database of 1,882 inspected dealer vehicles
located at 10 dealerships, and 19,589 dealer advertised, and 911 privately advertised vehicles taken from
31 local papers or magazines.
NEW ORLEANS LA - In this market, CCC maintains a database of 2,881 inspected dealer vehicles
located at 16 dealerships, and 18,315 dealer advertised, and 603 privately advertised vehicles taken from
28 local papers or magazines.
SOUTHWEST LOUISIANA LA - In this market, CCC maintains a database of 917 inspected dealer
vehicles located at 6 dealerships, and 15,302 dealer advertised, and 234 privately advertised vehicles
taken from 20 local papers or magazines.
Other markets searched - Alexandria, Natchez, Meridian/Hattiesburg, Gulfport/Biloxi and Jackson. In these
markets, CCC maintains a database of 7,295 inspected dealer vehicles located at 43 dealerships and
38,754 vehicles taken from 76 local newspapers or magazines.
Search extended to locate additional comparable vehicles. - In certain circumstances, the area searched
may be further extended to locate additional comparable vehicles for use in the valuation of your vehicle.
That was done in connection with this valuation, and CCC was able to locate comparable vehicles in
Shreveport/Monroe and Mobile. Adjustments were made to the value of each comparable vehicle to
account for differences, if any, in year, model, body style, engine configuration, packages, options, and
mileage.

Page 16 of 16

Total Loss vs. Repair Report

Date:

6/3/2015

Insured:
Claimant:
Tech/Pro Shop:

Vehicle:

Claim Number: 000368735353D01

OLDS, DAVID
EDWARDS AUTO BODY

Alpha ID:

TCHE
R

2008 CHEV TAHOE 4X2 LTZ 4D UTV 8-5.3L-FI

Repair Cost

Total Loss Cost

Pre-tax Total Estimate $

+ Taxable Adjustment $

12,477.67 Pre-tax Base Value $

0.00
+ Taxable Adjustment $
+ Supp. Taxable Adjustment $

17,725.00
0.00
116.48

Taxable Subtotal $
+ Tax $
+ Non-taxable Adjustment $

12,477.67 Taxable Subtotal $

1,073.08
+ Tax $
0.00
+ Non-taxable Adjustment $
+ Supp. Non-taxable Adjustment $

17,841.48
1,605.73
26.50
0.00

Combined Subtotal $
- Net Deductible $
- Net Betterment $
+ Appearance Allowance $
- RPD Adjustment $
- Negligence $
+ Anticipated Settlement $
SPACER
SPACER
SPACER
+ Miscellaneous $
+ Rental $
+ Diminished Value $

13,550.75 Combined Subtotal $

(500.00)
- Net Deductible $
(18.46)
- Salvage $
0.00
+ Tear Down $
0.00
+ Salvage Processing $
0.00
- Negligence $
1,000.00
+ Storage $
+ Additional Storage $
+ Towing $
+ Additional Towing $
0.00
+ Miscellaneous $
0.00
+ Rental $
0.00
- UPD Impact $

19,473.71
(500.00)
(6,379.28)
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
(127.05)

Projected Repair Cost $

14,032.29 Projected Total Loss Cost $

12,467.38

Prior Damage Note - STONE CHIPS IN WINDSHIELD

Claim History Search Results

6/3/2015
4:46 PM
Central

ACV AGREED

Page 1of 1

Damages - Auto
Tot Loss/Thef
t Settl Summ

THOMAS CHER...

DAVID ODDS
Collision(DAVID ODD...

Acv:17841.48
Tax:1605.73
Tag:<>
Title Fees:26.50
Additional Fees:<>
Total:19473.71
Net Deductible:500
Net Settlement:18973.71
Lien Holder Pay Of
f:<>
Equity:<>

http:
/
/
ng/
AllstateCTSNG/
Desktop/
ClaimHistory/
CHResults.aspx?UIC=PolID%3d%26_Ne...

8/
7/
2015

COPART AUTO AUCTIONS

P.O. BOX 500
GREENWELL SPRINGS, LA 70739
PHONE (225) 261-0102
TAX ID# 931215150

Date

7/01/15

Visit us at www.copart.com
All Amounts are in USD

FINAL INVOICE

Copart Lot#
Loss Date
Called In
P/U Cleared
Pickup Date
Original Title
Trans Title
Sale Document
Loss Type
Description
Vehicle ID#
License#/ST
Mileage
Pickup From

25126145 50 LA - BATON ROUGE

5/13/15
6/03/15
6/04/15
6/05/15
6/17/15
6/17/15
6/22/15
COLLISION
08 CHEV TAHOE C150 GRAY
1GNFC13058R139428

BI20 PIP190A
PROCESSING CASH
ALLSTATE INSURANCE COMPANY
PO BOX 650271
DALLAS, TX 75265 0271

Claim#
Policy#
Loss Code
Reference#
Insured
Owner

152,207
EDWARD'S AUTO REPAIR
2763 SCENIC HWY.
BATON ROUGE, LA 70805
(225) 355-7371

ADVANCE CHARGES PAID

TOW SERVICE . .
YARD/GATE . . .
STORAGE . . . .

BY COPART
. . . . . . . . . . . .
. . . . . . . . . . . .
. . . . . . . . . . . .

COPART SERVICE CHARGES

TITLE PROCESSING. . . . . . . . . . . .
PIP PROGRAM CHARGE. . . . . . . . . . .

33.50
90.00
----------123.50

TOTAL COPART SERVICE CHARGES. . . . . .

NET DUE COPART . . . . . . . . . . . . . . .

COPART PAYMENTS DETAIL
COPART CHECK# 17326853

DAVID ODDS
DAVID ODDS

178.50
25.00
129.50
----------333.00

TOTAL ADVANCE CHARGES . . . . . . . . .

TOTAL DUE COPART . . . . . . . . . . . . . .

PROCEEDS FROM SALE . . . . . . . . . . . . .
PREVIOUS PAYMENTS FROM COPART. . . . . . . .

000368735353-01-D
000995043003
CLS

456.50
4850.00CR
4393.50
-----------.00

07/01/15

SALVAGE TITLE - TT&L

Bid Raised By Internet

4,393.50

SALE INFORMATION
Lot#
25126145
Sale Date
6/30/15
Sale Amount
4850.00
ACV
19473.71
Repair Est
13550.75
Return
24.9%
Cert# B6444759
Payment From Buyer

Sold To 433189 HELEN NELSON

1135 RAIN FOREST CT
DALLAS, TX 75217 3517
(214) 557-6492
Item#

1120

Invoice Date
Invoice Amount

REMIT TO: COPART

4610 WEST AMERICA DRIVE
FAIRFIELD, CA 94534

7/01/15
.00
USD

ISOCLAIMSEARCHMATCHREPORTSUMMARY
AclaimreportidentifiedbyClaimSearchidentificationnumber4L003857778wasreceivedbyISOClaimSearchon
05/14/2015.Submissionofthisclaimreportinitiatedasearchforsimilarclaims.Theclaim(s)listedbelowappear(s)
tobesimilartotheclaimsubmitted.Reasonableprocedureshavebeenadoptedtomaximizetheaccuracyofthis
report.Independentinvestigationsshouldbeperformedtoevaluatetherelevantdataprovided.
Ifyouhaveanyquestionsconcerningyourreport,pleasecontactCustomerSupportat(800)888-4476.

INITIATINGCLAIMINFORMATION
ClaimNumber:
PolicyNumber:

C0008310
MSE0259823

DateofLoss:
ISOFileNumber:

05/13/2015

4L003857778

SUMMARYFOREACHSEARCHABLEPARTY
PATRICIAHARRIS,BOTHCLAIMANT&INSURED
Coverage:
MEDICALPAYMENTS
Coverage:
COLLISION

LossType:
LossType:

MEDICALPAYMENTS
COLLISION

#ofMatches

PriorClaimsHistory

ISOFileNumber
H0181210286

2C002985474

2W003608755

5O003852441

9C003840892

ISOCLAIMSEARCHMATCHREPORTDETAILS

InitiatingClaim
Company:
RRECode:

FileNumber:4L003857778
A73400009
000011301

TIN:
SiteId:
ClaimNumber:
Date/TimeofLoss:
PolicyNumber:
PolicyType:
InceptionDate:
CompanyReceivedDate:
ISOReceivedDate:
LossDescription:
LocationofLoss:

75-2701220

InvolvedParty:
Name:
Address:

DOB:
Gender:
HomePhone:

BOTHCLAIMANT&INSURED

CasualtyCoverageInformation:
CoverageType:
LossType:
ClaimStatus:
AdjusterCompany:
AllegedInjury/PropertyDamage:
Suitfiled?:
VehicleCoverageInformation
CoverageType:
LossType:
ClaimStatus:
VIN:
Vehicle:
VehicleType:
VehicleColor:
LicenseType:
LicensePlate:

000011301
C0008310
05/13/201520:30
MSE0259823
PERSONALAUTOMOBILE
08/20/2014ExpirationDate:09/03/2015
05/14/2015
05/14/2015
IVWASTURNINGLEFTANDCVRANREDLIGHTANDSTRUC
11300FLORIDABLVD
BATONROUGE,LA

PATRICIAHARRIS
2448WHITESTOWNRD
CENTREVILLE,MS39631-3840
08/21/1968
FEMALE
(651)274-0839

MEDICALPAYMENTS
MEDICALPAYMENTS
OPEN
ACCCINSURANCECOMPANY
CHESTPAIN,BRUISES,SEATBELTSCARS
NO

COLLISION
COLLISION
OPEN
3N1CB51D26L453976(Pass)
2006NISSANSENTRA
PASSENGERCAR
BLUE
PASSENGERCAR
WKE553LicensePlateState:MS

SuitIndicator:

DecisionNetInformation:
Name:
DateofBirth:
Age:
SSN:
Address:

HARRISPATRICIAANN
08/21/1968
046
426-39-8025
380WHEELOCKEPKWY
APT324

DateFirst:
DateLast:
DecisionNetInformation:
Name:
DateofBirth:
Age:
SSN:
Address:

HomePhone:
DateFirst:
DateLast:
DecisionNetInformation:
Name:
DateofBirth:
Age:
SSN:
Address:

SAINTPAUL,MN55130-3050
08/2013
05/2015

HARRISPATRICIAANN
08/21/1968
046
426-39-8025
21MAGNOLIAEAVE
SAINTPAUL,MN55117-5021
05/2008
12/2014

HARRISPATRICIAA
08/21/1968
046
426-39-8025
2448WHITESTOWNRD
WOODVILLE,MS39669-4295
(601)888-4506
06/2014
06/2014

HARRISPATRICIAANN
08/21/1968
046
426-39-8025
2206LEXINGTONNAVE

DateFirst:
DateLast:
DecisionNetInformation:
Name:
DateofBirth:
Age:
SSN:
Address:

SAINTPAUL,MN55113-4347
05/2012
10/2013

HARRISPATRICIAANN
08/21/1968
046
426-39-8025
720MARSHALLAVE
SAINTPAUL,MN55104-6646
11/1997
12/2009

HARRISPATRICIAA
08/21/1968
046
426-39-8025
719E14THST
APTB

DateFirst:
DateLast:
DecisionNetInformation:
Name:
DateofBirth:
Age:
SSN:
Address:

DateFirst:
DateLast:
DecisionNetInformation:
Name:
DateofBirth:
Age:
SSN:

MINNEAPOLIS,MN55404-1361
07/1994
08/1999

HARRISPATRICIAA
08/21/1968
046
426-39-8025
719EAPTB
MINNEAPOLIS,MN55404
01/1999
04/1999

HARRISPATRICIAA
08/21/1968
046
426-39-8025

Address:

RR1
BOX166

DateFirst:
DateLast:

CENTREVILLE,MS39631
09/1991
11/1997

DecisionNetInformation:
Name:
DateofBirth:
Age:
SSN:
Address:

HARRISPATRICIAA
08/21/1968
046
426-39-8025
2535CLINTONAVE
APT101

DateFirst:
DateLast:
back

MINNEAPOLIS,MN55404-4442
11/1992
01/1997

back

MatchingClaim

FileNumber:H0181210286

Reason(s)formatch:
FileNumber:
Coverage:
ClaimNumber:
ActivityType:
ActivityDate:
InsuranceCompany:
PolicyType:
PointofImpact:
VIN:
Vehicle:

VIN
H0181210286
COLLISION
HHZ3966001
ESTIMATE
06/30/2011
TRAVELERSINDEMNITYCOMPANY
Unknown
LEFTFRONTCORNER
3N1CB51D26L453976(Pass)
2006NISSANSENTRA

back

MatchingClaim
Reason(s)formatch:
InsuringCompany:
ClaimNumber:

FileNumber:2C002985474
VIN
TRAVELERSINDEMNITYCOMPANY
HHZ3966001

Date/TimeofLoss:
PolicyNumber:
PolicyType:
InceptionDate:
AssignedRisk?:
InsuringCo.Address:

06/30/2011
0M24649821790491011
PERSONALAUTOMOBILE
06/01/2011ExpirationDate:12/01/2011
NO
NAPERVILLEPLCLM-A273
POBOX3095*

InsuringCo.Phone:
CompanyReceivedDate:
LossDescription:
LocationofLoss:

NAPERVILLE,IL60566-7095

InvolvedParty:
Name:

BOTHCLAIMANT&INSURED

Address:

6911CORVALLISAVEN

(800)842-6172
07/16/2011
OV1WASSTOPPEDATTHELIGHT&MADEASHARPLEFTT
,MN

JENNIFERTHEISEN

CRYSTAL,MN55428-4333

VehicleCoverageInformation:
CoverageType:
COLLISION
LossType:
COLLISION
AdjusterCompany:
TRAVELERSINDEMNITYCOMPANY
Adjuster:
JASONFIRLIT
DateClaimClosed:
04/06/2012
AdjusterPhone:
(630)961-8670
VIN:
3N1CB51D26L453976(Pass)
Vehicle:
2006NISSANSENTRA
LastYearRegistered:
2000

back

MatchingClaim
Reason(s)formatch:
InsuringCompany:
ClaimNumber:
Date/TimeofLoss:
PolicyNumber:
PolicyType:
PolicyRenewed?:

FileNumber:2W003608755
VIN
STATEFARM(R)AFFILIATE
2330S9866
04/15/2014
230232023
PERSONALAUTOMOBILE
NO

AssignedRisk?:
InsuringCo.Address:

NO
CIOS-00
ONESTATEFARMPLAZA

LossDescription:
CATRelated?:
Hit&RunAccident:
LocationofLoss:

BLOOMINGTON,IL61710
BLANK
NO
NO
,MN
US

PhysicalRisk:

380WHEELOCKPKWYEAPT324

InvolvedParty:
Name:
Address:

INSURED

SAINTPAUL,MN55130-3050

PATRICIAHARRIS
380WHEELOCKPKWYEAPT324
SAINTPAUL,MN55130-3050
US

VehicleCoverageInformation:
CoverageType:
LossType:
AdjusterCompany:
DateClaimClosed:
AdjusterPhone:
VIN:
Vehicle:
LastYearRegistered:
SuitIndicator:

TOWINGANDLABOR
TOWINGANDLABOR
STATEFARM(R)AFFILIATE
04/19/2014
(888)248-6961
3N1CB51D26L453976(Pass)
2006NISSANSENTRA
2000
NO

back

MatchingClaim

FileNumber:5O003852441

Reason(s)formatch:

LICENSEPLATENUMBER
PHONE
NAME
SSN

InsuringCompany:
ClaimNumber:
Date/TimeofLoss:
PolicyNumber:

ALLSTATEINSURANCECOMPANY
0368735353
05/13/2015
000995043003

PolicyType:
PolicyRenewed?:
InsuringCo.Address:

PERSONALAUTOMOBILE
YES
LOUISIANALIAB/CAS1640
3900NCAUSEWAY#400

InsuringCo.Phone:
LossDescription:
CATRelated?:
LocationofLoss:

METAIRIE,LA70002-0000
(504)834-3185
INTERSECTIONACCIDENT
NO
FLORIDABLVDANDSHERWOODFOREST
BATONROUGE,LA
US

InvolvedParty:
Name:
Address:

CLAIMANTDRIVER
PATRICIAHARRIS
21MAGNOLIAAVEE
SAINTPAUL,MN55117-5021
US

DOB:
Gender:
HomePhone:
SSN:

08/21/1968
FEMALE
(651)274-0839
XXX-XX-8025WASISSUEDbetween1981and1982inMS

AlsoKnownAs(AKA):
Name:

PATRICIAHARRIS

AlsoKnownAs(AKA):
Name:

PATRICIAHARRIS

AlsoKnownAs(AKA):
Address:

2448WHITESTOWNRD
WOODVILLE,MS39669-4295
US

CasualtyCoverageInformation:
CoverageType:
LossType:
ClaimStatus:
AdjusterCompany:
Adjuster:
AdjusterPhone:

BODILYINJURY
OTHERAUTO
OPEN
ALLSTATEINSURANCECOMPANY
JOHNSON,TAJMA
(504)219-3759

AllegedInjury/PropertyDamage:
VehicleCoverageInformation:
CoverageType:
LossType:
AdjusterCompany:
Adjuster:
ClaimStatus:
AdjusterPhone:
Vehicle:
VehicleOdometerReading:

SORE,SORE,SORE

OTHERAUTO
OTHERAUTO
ALLSTATEINSURANCECOMPANY
JOHNSON,TAJMA
OPEN
(504)219-3759
2006NISS
0000111111

LicensePlate:
LastYearRegistered:

WKE553LicensePlateState:MS

InvolvedParty:
Name:
Address:

INSUREDDRIVER

2000

DAVIDODDS
2052FAIRCHILDST
BATONROUGE,LA70807-5025
US

DOB:
Gender:
HomePhone:
DriversLicense:

05/02/1963
MALE
(225)892-9794
4675286

AlsoKnownAs(AKA):
Name:

DAVIDODDS

AlsoKnownAs(AKA):
Name:

DAVIDODDS

AlsoKnownAs(AKA):
Address:

13855KATHERINEAVE
BATONROUGE,LA70815-7229
US

VehicleCoverageInformation:
CoverageType:
LossType:
AdjusterCompany:
Adjuster:

COLLISION
OTHERAUTO
ALLSTATEINSURANCECOMPANY
JOHNSON,TAJMA

ClaimStatus:
AdjusterPhone:
VIN:
Vehicle:
LastYearRegistered:

OPEN
(504)219-3759
1GNFC13058R139428(Pass)
2008CHEVROLETTAHOE
2000

back

MatchingClaim

FileNumber:9C003840892

Reason(s)formatch:

LICENSEPLATENUMBER
VIN
PHONE

InsuringCompany:
ClaimNumber:
Date/TimeofLoss:
PolicyNumber:
PolicyType:
InceptionDate:
InsuringCo.Address:

LOUISIANAFARMBUREAUMUTUALINSCO
17A00066408
04/16/201503:30
AT06334
PERSONALAUTOMOBILE
12/15/2014ExpirationDate:06/15/2015
CLAIMCENTER
POBOX80319

InsuringCo.Phone:
CompanyReceivedDate:
LossDescription:
LocationofLoss:

BATONROUGE,LA70898
(225)922-6200
04/17/2015
3PWASSTOPPEDINTRAFFICWHENINSVEHR/E3PVEH
I-10
BATONROUGE,LA
US

InvolvedParty:
Name:
Address:

BOTHCLAIMANT&INSURED
ELIZABETHARRIAGA
APT704
4051BAYOURAPIDESRD

ALEXANDRIA,LA71303--406
US

DOB:
Gender:
CellularPhone:
Occupation:
VehicleCoverageInformation:

08/22/1990
FEMALE
(318)792-8920
HAIRDRESSER

CoverageType:
LossType:
AdjusterCompany:
Adjuster:
ClaimStatus:
AdjusterPhone:
VIN:
Vehicle:
LastYearRegistered:

COLLISION

InvolvedParty:
Name:
Address:

CLAIMANTDRIVER

COLLISION
LOUISIANAFARMBUREAUMUTUALINSCO
SMITH,MARCUS
OPEN
(318)445-4043
1FTEW1CM3BKD13494(Pass)
2011FORDF150SERIES
2000

PATRICIAHARRIS
2448WHITESTOWNRD
WOODVILLE,MS39669--429
US

HomePhone:

(601)888-4506

CellularPhone:
DriversLicense:

(651)274-0839

CasualtyCoverageInformation:
CoverageType:
LossType:
ClaimStatus:
AdjusterCompany:
Adjuster:
AdjusterPhone:
AllegedInjury/PropertyDamage:
VehicleCoverageInformation:
CoverageType:
LossType:
AdjusterCompany:
Adjuster:
ClaimStatus:
AdjusterPhone:
VIN:
Vehicle:
LicensePlate:
LastYearRegistered:

802678648State:MS

BODILYINJURY
BODILYINJURY
OPEN
LOUISIANAFARMBUREAUMUTUALINSCO
SMITH,MARCUS
(318)445-4043
BODYSORENESS

OTHERAUTO
OTHERAUTO
LOUISIANAFARMBUREAUMUTUALINSCO
SMITH,MARCUS
OPEN
(318)445-4043
3N1CB51D26L453976(Pass)
2006NISSANSENTRA
WKE553LicensePlateState:MS
2000

ISOStylesheetVersion:5.5ReleaseDate:03-03-2014

ISOCLAIMSEARCHMATCHREPORTSUMMARY
AclaimreportidentifiedbyClaimSearchidentificationnumber4L003857778wasreceivedbyISOClaimSearchon
05/14/2015asaReplacementofapreviouslysubmittedclaim.Submissionofthisreplacementclaiminitiateda
searchoftheClaimSearchdatabase.Theclaim(s)listedbelowappear(s)tobesimilartotheclaimsubmitted.
Reasonableprocedureshavebeenadoptedtomaximizetheaccuracyofthisreport.Independentinvestigations
shouldbeperformedtoevaluatetherelevantdataprovided.
Ifyouhaveanyquestionsconcerningyourreport,pleasecontactCustomerSupportat(800)888-4476.

INITIATINGCLAIMINFORMATION
ClaimNumber:
PolicyNumber:

C0008310
MSE0259823

DateofLoss:
ISOFileNumber:

05/13/2015

4L003857778

SUMMARYFOREACHSEARCHABLEPARTY
PATRICIAHARRIS,BOTHCLAIMANT&INSURED
Coverage:
MEDICALPAYMENTS
Coverage:
COLLISION

LossType:
LossType:

MEDICALPAYMENTS
COLLISION

#ofMatches

PriorClaimsHistory

ISOFileNumber
H0181210286

2C002985474

2W003608755

5O003852441

9C003840892

ISOCLAIMSEARCHREPLACEMENTCLAIMDETAILS

InitiatingClaim
Company:

FileNumber:4L003857778
A73400009

RRECode:
TIN:
SiteId:
ClaimNumber:
Date/TimeofLoss:
PolicyNumber:
PolicyType:
InceptionDate:
CompanyReceivedDate:
ISOReceivedDate:
LossDescription:
LocationofLoss:

000011301

InvolvedParty:
Name:
Address:

DOB:
Gender:
HomePhone:
StopCMSQuery:

BOTHCLAIMANT&INSURED

CasualtyCoverageInformation:
CoverageType:
LossType:
ClaimStatus:
DateClaimClosed:
AdjusterCompany:
AllegedInjury/PropertyDamage:
Suitfiled?:
VehicleCoverageInformation
CoverageType:
LossType:
ClaimStatus:
VIN:
Vehicle:
VehicleType:

75-2701220
000011301
C0008310
05/13/201520:30
MSE0259823
PERSONALAUTOMOBILE
08/20/2014ExpirationDate:09/03/2015
05/14/2015
05/14/2015
IVWASTURNINGLEFTANDCVRANREDLIGHTANDSTRUC
11300FLORIDABLVD
BATONROUGE,LA

PATRICIAHARRIS
2448WHITESTOWNRD
CENTREVILLE,MS39631-3840
08/21/1968
FEMALE
(651)274-0839
YES

MEDICALPAYMENTS
MEDICALPAYMENTS
CLOSEDW/OPAYMENT
05/14/2015
ACCCINSURANCECOMPANY
CHESTPAIN,BRUISES,SEATBELTSCARS
NO

COLLISION
COLLISION
OPEN
3N1CB51D26L453976(Pass)
2006NISSANSENTRA
PASSENGERCAR

VehicleColor:
LicenseType:
LicensePlate:
SuitIndicator:

BLUE
PASSENGERCAR
WKE553LicensePlateState:MS
NO

back

MatchingClaim

FileNumber:H0181210286

Reason(s)formatch:
FileNumber:
Coverage:
ClaimNumber:
ActivityType:
ActivityDate:
InsuranceCompany:
PolicyType:
PointofImpact:
VIN:
Vehicle:

VIN
H0181210286
COLLISION
HHZ3966001
ESTIMATE
06/30/2011
TRAVELERSINDEMNITYCOMPANY
Unknown
LEFTFRONTCORNER
3N1CB51D26L453976(Pass)
2006NISSANSENTRA

back

MatchingClaim
Reason(s)formatch:
InsuringCompany:
ClaimNumber:
Date/TimeofLoss:
PolicyNumber:
PolicyType:
InceptionDate:
AssignedRisk?:
InsuringCo.Address:

FileNumber:2C002985474
VIN
TRAVELERSINDEMNITYCOMPANY
HHZ3966001
06/30/2011
0M24649821790491011
PERSONALAUTOMOBILE
06/01/2011ExpirationDate:12/01/2011
NO
NAPERVILLEPLCLM-A273
POBOX3095*

InsuringCo.Phone:
CompanyReceivedDate:
LossDescription:

NAPERVILLE,IL60566-7095
(800)842-6172
07/16/2011
OV1WASSTOPPEDATTHELIGHT&MADEASHARPLEFTT

LocationofLoss:

,MN

InvolvedParty:
Name:

BOTHCLAIMANT&INSURED

Address:

6911CORVALLISAVEN

JENNIFERTHEISEN

CRYSTAL,MN55428-4333

back

MatchingClaim
Reason(s)formatch:
InsuringCompany:
ClaimNumber:
Date/TimeofLoss:
PolicyNumber:
PolicyType:
PolicyRenewed?:
AssignedRisk?:
InsuringCo.Address:

FileNumber:2W003608755
VIN
STATEFARM(R)AFFILIATE
2330S9866
04/15/2014
230232023
PERSONALAUTOMOBILE
NO
NO
CIOS-00
ONESTATEFARMPLAZA

LossDescription:
CATRelated?:
Hit&RunAccident:
LocationofLoss:

BLOOMINGTON,IL61710
BLANK
NO
NO
,MN
US

PhysicalRisk:

380WHEELOCKPKWYEAPT324
SAINTPAUL,MN55130-3050

InvolvedParty:
Name:
Address:

INSURED
PATRICIAHARRIS
380WHEELOCKPKWYEAPT324
SAINTPAUL,MN55130-3050
US

VehicleCoverageInformation:
CoverageType:
LossType:
AdjusterCompany:
DateClaimClosed:
AdjusterPhone:
VIN:
Vehicle:
LastYearRegistered:
SuitIndicator:

TOWINGANDLABOR
TOWINGANDLABOR
STATEFARM(R)AFFILIATE
04/19/2014
(888)248-6961
3N1CB51D26L453976(Pass)
2006NISSANSENTRA
2000
NO

back

MatchingClaim

FileNumber:5O003852441

Reason(s)formatch:

PHONE
NAME
LICENSEPLATENUMBER

InsuringCompany:
ClaimNumber:
Date/TimeofLoss:
PolicyNumber:
PolicyType:
PolicyRenewed?:
InsuringCo.Address:

ALLSTATEINSURANCECOMPANY
0368735353
05/13/2015
000995043003
PERSONALAUTOMOBILE
YES
LOUISIANALIAB/CAS1640
3900NCAUSEWAY#400

InsuringCo.Phone:
LossDescription:
CATRelated?:
LocationofLoss:

METAIRIE,LA70002-0000
(504)834-3185
INTERSECTIONACCIDENT
NO
FLORIDABLVDANDSHERWOODFOREST
BATONROUGE,LA
US

InvolvedParty:
Name:
Address:

CLAIMANTDRIVER
PATRICIAHARRIS
21MAGNOLIAAVEE
SAINTPAUL,MN55117-5021
US

DOB:
Gender:
HomePhone:
SSN:

08/21/1968
FEMALE
(651)274-0839
XXX-XX-8025WASISSUEDbetween1981and1982inMS
***MorematchesonthisSSNoutsidethisreport***

AlsoKnownAs(AKA):
Name:

PATRICIAHARRIS

AlsoKnownAs(AKA):
Name:

PATRICIAHARRIS

AlsoKnownAs(AKA):
Address:

2448WHITESTOWNRD
WOODVILLE,MS39669-4295
US

BODILYINJURY
OTHERAUTO
OPEN
ALLSTATEINSURANCECOMPANY
JOHNSON,TAJMA
(504)219-3759
SORE,SORE,SORE

OTHERAUTO
OTHERAUTO
ALLSTATEINSURANCECOMPANY
JOHNSON,TAJMA
OPEN
(504)219-3759
2006NISS
0000111111
WKE553LicensePlateState:MS

LastYearRegistered:

2000

InvolvedParty:
Name:
Address:

INSUREDDRIVER
DAVIDODDS
2052FAIRCHILDST
BATONROUGE,LA70807-5025
US

DOB:
Gender:
HomePhone:
DriversLicense:

05/02/1963
MALE
(225)892-9794
4675286

AlsoKnownAs(AKA):
Name:

DAVIDODDS

AlsoKnownAs(AKA):
Name:

DAVIDODDS

AlsoKnownAs(AKA):
Address:

13855KATHERINEAVE
BATONROUGE,LA70815-7229
US

VehicleCoverageInformation:
CoverageType:
LossType:
AdjusterCompany:
Adjuster:
ClaimStatus:
AdjusterPhone:
VIN:
Vehicle:
LastYearRegistered:

COLLISION
OTHERAUTO
ALLSTATEINSURANCECOMPANY
JOHNSON,TAJMA
OPEN
(504)219-3759
1GNFC13058R139428(Pass)
2008CHEVROLETTAHOE
2000

back

MatchingClaim
Reason(s)formatch:

FileNumber:9C003840892
LICENSEPLATENUMBER
VIN
PHONE

InsuringCompany:
ClaimNumber:
Date/TimeofLoss:
PolicyNumber:
PolicyType:
InceptionDate:
InsuringCo.Address:

LOUISIANAFARMBUREAUMUTUALINSCO
17A00066408
04/16/201503:30
AT06334
PERSONALAUTOMOBILE
12/15/2014ExpirationDate:06/15/2015
CLAIMCENTER
POBOX80319

InsuringCo.Phone:
CompanyReceivedDate:
LossDescription:
LocationofLoss:

BATONROUGE,LA70898
(225)922-6200
04/17/2015
3PWASSTOPPEDINTRAFFICWHENINSVEHR/E3PVEH
I-10
BATONROUGE,LA
US

InvolvedParty:
Name:
Address:

BOTHCLAIMANT&INSURED
ELIZABETHARRIAGA
APT704
4051BAYOURAPIDESRD

ALEXANDRIA,LA71303--406
US

DOB:
Gender:
CellularPhone:
Occupation:
VehicleCoverageInformation:
CoverageType:
LossType:
AdjusterCompany:
Adjuster:
ClaimStatus:
AdjusterPhone:
VIN:
Vehicle:
LastYearRegistered:

InvolvedParty:

08/22/1990
FEMALE
(318)792-8920
HAIRDRESSER

COLLISION
COLLISION
LOUISIANAFARMBUREAUMUTUALINSCO
SMITH,MARCUS
OPEN
(318)445-4043
1FTEW1CM3BKD13494(Pass)
2011FORDF150SERIES
2000

CLAIMANTDRIVER

Name:
Address:

PATRICIAHARRIS
2448WHITESTOWNRD
WOODVILLE,MS39669--429
US

HomePhone:

(601)888-4506

CellularPhone:
DriversLicense:

(651)274-0839
802678648State:MS

BODILYINJURY
BODILYINJURY
OPEN
LOUISIANAFARMBUREAUMUTUALINSCO
SMITH,MARCUS
(318)445-4043
BODYSORENESS

OTHERAUTO
OTHERAUTO
LOUISIANAFARMBUREAUMUTUALINSCO
SMITH,MARCUS
OPEN
(318)445-4043
3N1CB51D26L453976(Pass)
2006NISSANSENTRA
WKE553LicensePlateState:MS
2000

ISOStylesheetVersion:5.5ReleaseDate:03-03-2014

INITIATINGCLAIMINFORMATION
ClaimNumber:
PolicyNumber:

C0008310
MSE0259823

DateofLoss:
ISOFileNumber:

05/13/2015

4L003857778

SUMMARYFOREACHSEARCHABLEPARTY
PATRICIAHARRIS,BOTHCLAIMANT&INSURED
Coverage:
MEDICALPAYMENTS
Coverage:
COLLISION

LossType:
LossType:

MEDICALPAYMENTS
COLLISION

#ofMatches

PriorClaimsHistory

ISOFileNumber
H0181210286

2C002985474

2W003608755

5O003852441

9C003840892

ISOCLAIMSEARCHREPLACEMENTCLAIMDETAILS

InitiatingClaim
Company:

FileNumber:4L003857778
A73400009

RRECode:
TIN:
SiteId:
ClaimNumber:
Date/TimeofLoss:
PolicyNumber:
PolicyType:
InceptionDate:
CompanyReceivedDate:
ISOReceivedDate:
LossDescription:
LocationofLoss:

000011301

InvolvedParty:
Name:
Address:

DOB:
Gender:
HomePhone:
StopCMSQuery:

BOTHCLAIMANT&INSURED

PATRICIAHARRIS
2448WHITESTOWNRD
CENTREVILLE,MS39631-3840
08/21/1968
FEMALE
(651)274-0839
YES

MEDICALPAYMENTS
MEDICALPAYMENTS
CLOSEDW/OPAYMENT
05/14/2015
ACCCINSURANCECOMPANY
CHESTPAIN,BRUISES,SEATBELTSCARS
NO

COLLISION
COLLISION
OPEN
3N1CB51D26L453976(Pass)
2006NISSANSENTRA
PASSENGERCAR

VehicleColor:
LicenseType:
LicensePlate:
SuitIndicator:

BLUE
PASSENGERCAR
WKE553LicensePlateState:MS
NO

back

MatchingClaim

FileNumber:H0181210286

Reason(s)formatch:
FileNumber:
Coverage:
ClaimNumber:
ActivityType:
ActivityDate:
InsuranceCompany:
PolicyType:
PointofImpact:
VIN:
Vehicle:

VIN
H0181210286
COLLISION
HHZ3966001
ESTIMATE
06/30/2011
TRAVELERSINDEMNITYCOMPANY
Unknown
LEFTFRONTCORNER
3N1CB51D26L453976(Pass)
2006NISSANSENTRA

back

MatchingClaim
Reason(s)formatch:
InsuringCompany:
ClaimNumber:
Date/TimeofLoss:
PolicyNumber:
PolicyType:
InceptionDate:
AssignedRisk?:
InsuringCo.Address:

FileNumber:2C002985474
VIN
TRAVELERSINDEMNITYCOMPANY
HHZ3966001
06/30/2011
0M24649821790491011
PERSONALAUTOMOBILE
06/01/2011ExpirationDate:12/01/2011
NO
NAPERVILLEPLCLM-A273
POBOX3095*

InsuringCo.Phone:
CompanyReceivedDate:
LossDescription:

NAPERVILLE,IL60566-7095
(800)842-6172
07/16/2011
OV1WASSTOPPEDATTHELIGHT&MADEASHARPLEFTT

LocationofLoss:

,MN

InvolvedParty:
Name:

BOTHCLAIMANT&INSURED

Address:

6911CORVALLISAVEN

JENNIFERTHEISEN

CRYSTAL,MN55428-4333

back

MatchingClaim
Reason(s)formatch:
InsuringCompany:
ClaimNumber:
Date/TimeofLoss:
PolicyNumber:
PolicyType:
PolicyRenewed?:
AssignedRisk?:
InsuringCo.Address:

FileNumber:2W003608755
VIN
STATEFARM(R)AFFILIATE
2330S9866
04/15/2014
230232023
PERSONALAUTOMOBILE
NO
NO
CIOS-00
ONESTATEFARMPLAZA

LossDescription:
CATRelated?:
Hit&RunAccident:
LocationofLoss:

BLOOMINGTON,IL61710
BLANK
NO
NO
,MN
US

PhysicalRisk:

380WHEELOCKPKWYEAPT324
SAINTPAUL,MN55130-3050

InvolvedParty:
Name:
Address:

INSURED
PATRICIAHARRIS
380WHEELOCKPKWYEAPT324
SAINTPAUL,MN55130-3050
US

VehicleCoverageInformation:
CoverageType:
LossType:
AdjusterCompany:
DateClaimClosed:
AdjusterPhone:
VIN:
Vehicle:
LastYearRegistered:
SuitIndicator:

TOWINGANDLABOR
TOWINGANDLABOR
STATEFARM(R)AFFILIATE
04/19/2014
(888)248-6961
3N1CB51D26L453976(Pass)
2006NISSANSENTRA
2000
NO

back

MatchingClaim

FileNumber:5O003852441

Reason(s)formatch:

PHONE
NAME
LICENSEPLATENUMBER

InsuringCompany:
ClaimNumber:
Date/TimeofLoss:
PolicyNumber:
PolicyType:
PolicyRenewed?:
InsuringCo.Address:

ALLSTATEINSURANCECOMPANY
0368735353
05/13/2015
000995043003
PERSONALAUTOMOBILE
YES
LOUISIANALIAB/CAS1640
3900NCAUSEWAY#400

InsuringCo.Phone:
LossDescription:
CATRelated?:
LocationofLoss:

METAIRIE,LA70002-0000
(504)834-3185
INTERSECTIONACCIDENT
NO
FLORIDABLVDANDSHERWOODFOREST
BATONROUGE,LA
US

InvolvedParty:
Name:
Address:

CLAIMANTDRIVER
PATRICIAHARRIS
21MAGNOLIAAVEE
SAINTPAUL,MN55117-5021
US

DOB:
Gender:
HomePhone:
SSN:

08/21/1968
FEMALE
(651)274-0839
XXX-XX-8025WASISSUEDbetween1981and1982inMS
***MorematchesonthisSSNoutsidethisreport***

AlsoKnownAs(AKA):
Name:

PATRICIAHARRIS

AlsoKnownAs(AKA):
Name:

PATRICIAHARRIS

AlsoKnownAs(AKA):
Address:

2448WHITESTOWNRD
WOODVILLE,MS39669-4295
US

BODILYINJURY
OTHERAUTO
OPEN
ALLSTATEINSURANCECOMPANY
JOHNSON,TAJMA
(504)219-3759
SORE,SORE,SORE

OTHERAUTO
OTHERAUTO
ALLSTATEINSURANCECOMPANY
JOHNSON,TAJMA
OPEN
(504)219-3759
2006NISS
0000111111
WKE553LicensePlateState:MS

LastYearRegistered:

2000

InvolvedParty:
Name:
Address:

INSUREDDRIVER
DAVIDODDS
2052FAIRCHILDST
BATONROUGE,LA70807-5025
US

DOB:
Gender:
HomePhone:
DriversLicense:

05/02/1963
MALE
(225)892-9794
4675286

AlsoKnownAs(AKA):
Name:

DAVIDODDS

AlsoKnownAs(AKA):
Name:

DAVIDODDS

AlsoKnownAs(AKA):
Address:

13855KATHERINEAVE
BATONROUGE,LA70815-7229
US

VehicleCoverageInformation:
CoverageType:
LossType:
AdjusterCompany:
Adjuster:
ClaimStatus:
AdjusterPhone:
VIN:
Vehicle:
LastYearRegistered:

COLLISION
OTHERAUTO
ALLSTATEINSURANCECOMPANY
JOHNSON,TAJMA
OPEN
(504)219-3759
1GNFC13058R139428(Pass)
2008CHEVROLETTAHOE
2000

back

MatchingClaim
Reason(s)formatch:

FileNumber:9C003840892
LICENSEPLATENUMBER
VIN
PHONE

InsuringCompany:
ClaimNumber:
Date/TimeofLoss:
PolicyNumber:
PolicyType:
InceptionDate:
InsuringCo.Address:

LOUISIANAFARMBUREAUMUTUALINSCO
17A00066408
04/16/201503:30
AT06334
PERSONALAUTOMOBILE
12/15/2014ExpirationDate:06/15/2015
CLAIMCENTER
POBOX80319

InsuringCo.Phone:
CompanyReceivedDate:
LossDescription:
LocationofLoss:

BATONROUGE,LA70898
(225)922-6200
04/17/2015
3PWASSTOPPEDINTRAFFICWHENINSVEHR/E3PVEH
I-10
BATONROUGE,LA
US

InvolvedParty:
Name:
Address:

BOTHCLAIMANT&INSURED
ELIZABETHARRIAGA
APT704
4051BAYOURAPIDESRD

ALEXANDRIA,LA71303--406
US

DOB:
Gender:
CellularPhone:
Occupation:
VehicleCoverageInformation:
CoverageType:
LossType:
AdjusterCompany:
Adjuster:
ClaimStatus:
AdjusterPhone:
VIN:
Vehicle:
LastYearRegistered:

InvolvedParty:

08/22/1990
FEMALE
(318)792-8920
HAIRDRESSER

COLLISION
COLLISION
LOUISIANAFARMBUREAUMUTUALINSCO
SMITH,MARCUS
OPEN
(318)445-4043
1FTEW1CM3BKD13494(Pass)
2011FORDF150SERIES
2000

CLAIMANTDRIVER

Name:
Address:

PATRICIAHARRIS
2448WHITESTOWNRD
WOODVILLE,MS39669--429
US

HomePhone:

(601)888-4506

CellularPhone:
DriversLicense:

(651)274-0839
802678648State:MS

BODILYINJURY
BODILYINJURY
OPEN
LOUISIANAFARMBUREAUMUTUALINSCO
SMITH,MARCUS
(318)445-4043
BODYSORENESS

OTHERAUTO
OTHERAUTO
LOUISIANAFARMBUREAUMUTUALINSCO
SMITH,MARCUS
OPEN
(318)445-4043
3N1CB51D26L453976(Pass)
2006NISSANSENTRA
WKE553LicensePlateState:MS
2000

ISOStylesheetVersion:5.5ReleaseDate:03-03-2014

INITIATINGCLAIMINFORMATION
ClaimNumber:
PolicyNumber:

C0008310
MSE0259823

DateofLoss:
ISOFileNumber:

05/13/2015

4L003857778

SUMMARYFOREACHSEARCHABLEPARTY
PATRICIAHARRIS,BOTHCLAIMANT&INSURED
Coverage:
MEDICALPAYMENTS
Coverage:
COLLISION

LossType:
LossType:

MEDICALPAYMENTS
COLLISION

#ofMatches

PriorClaimsHistory

ISOFileNumber
H0181210286

2C002985474

2W003608755

5O003852441

9C003840892

ISOCLAIMSEARCHREPLACEMENTCLAIMDETAILS

InitiatingClaim
Company:

FileNumber:4L003857778
A73400009

RRECode:
TIN:
SiteId:
ClaimNumber:
Date/TimeofLoss:
PolicyNumber:
PolicyType:
InceptionDate:
CompanyReceivedDate:
ISOReceivedDate:
LossDescription:
LocationofLoss:

000011301

InvolvedParty:
Name:
Address:

DOB:
Gender:
HomePhone:
StopCMSQuery:

BOTHCLAIMANT&INSURED

PATRICIAHARRIS
2448WHITESTOWNRD
CENTREVILLE,MS39631-3840
08/21/1968
FEMALE
(651)274-0839
YES

MEDICALPAYMENTS
MEDICALPAYMENTS
CLOSEDW/OPAYMENT
05/14/2015
ACCCINSURANCECOMPANY
CHESTPAIN,BRUISES,SEATBELTSCARS
NO

COLLISION
COLLISION
OPEN
3N1CB51D26L453976(Pass)
2006NISSANSENTRA
PASSENGERCAR

VehicleColor:
LicenseType:
LicensePlate:
SuitIndicator:

BLUE
PASSENGERCAR
WKE553LicensePlateState:MS
NO

back

MatchingClaim

FileNumber:H0181210286

Reason(s)formatch:
FileNumber:
Coverage:
ClaimNumber:
ActivityType:
ActivityDate:
InsuranceCompany:
PolicyType:
PointofImpact:
VIN:
Vehicle:

VIN
H0181210286
COLLISION
HHZ3966001
ESTIMATE
06/30/2011
TRAVELERSINDEMNITYCOMPANY
Unknown
LEFTFRONTCORNER
3N1CB51D26L453976(Pass)
2006NISSANSENTRA

back

MatchingClaim
Reason(s)formatch:
InsuringCompany:
ClaimNumber:
Date/TimeofLoss:
PolicyNumber:
PolicyType:
InceptionDate:
AssignedRisk?:
InsuringCo.Address:

FileNumber:2C002985474
VIN
TRAVELERSINDEMNITYCOMPANY
HHZ3966001
06/30/2011
0M24649821790491011
PERSONALAUTOMOBILE
06/01/2011ExpirationDate:12/01/2011
NO
NAPERVILLEPLCLM-A273
POBOX3095*

InsuringCo.Phone:
CompanyReceivedDate:
LossDescription:

NAPERVILLE,IL60566-7095
(800)842-6172
07/16/2011
OV1WASSTOPPEDATTHELIGHT&MADEASHARPLEFTT

LocationofLoss:

,MN

InvolvedParty:
Name:

BOTHCLAIMANT&INSURED

Address:

6911CORVALLISAVEN

JENNIFERTHEISEN

CRYSTAL,MN55428-4333

back

MatchingClaim
Reason(s)formatch:
InsuringCompany:
ClaimNumber:
Date/TimeofLoss:
PolicyNumber:
PolicyType:
PolicyRenewed?:
AssignedRisk?:
InsuringCo.Address:

FileNumber:2W003608755
VIN
STATEFARM(R)AFFILIATE
2330S9866
04/15/2014
230232023
PERSONALAUTOMOBILE
NO
NO
CIOS-00
ONESTATEFARMPLAZA

LossDescription:
CATRelated?:
Hit&RunAccident:
LocationofLoss:

BLOOMINGTON,IL61710
BLANK
NO
NO
,MN
US

PhysicalRisk:

380WHEELOCKPKWYEAPT324
SAINTPAUL,MN55130-3050

InvolvedParty:
Name:
Address:

INSURED
PATRICIAHARRIS
380WHEELOCKPKWYEAPT324
SAINTPAUL,MN55130-3050
US

VehicleCoverageInformation:
CoverageType:
LossType:
AdjusterCompany:
DateClaimClosed:
AdjusterPhone:
VIN:
Vehicle:
LastYearRegistered:
SuitIndicator:

TOWINGANDLABOR
TOWINGANDLABOR
STATEFARM(R)AFFILIATE
04/19/2014
(888)248-6961
3N1CB51D26L453976(Pass)
2006NISSANSENTRA
2000
NO

back

MatchingClaim

FileNumber:5O003852441

Reason(s)formatch:

PHONE
NAME
LICENSEPLATENUMBER

InsuringCompany:
ClaimNumber:
Date/TimeofLoss:
PolicyNumber:
PolicyType:
PolicyRenewed?:
InsuringCo.Address:

ALLSTATEINSURANCECOMPANY
0368735353
05/13/2015
000995043003
PERSONALAUTOMOBILE
YES
LOUISIANALIAB/CAS1640
3900NCAUSEWAY#400

InsuringCo.Phone:
LossDescription:
CATRelated?:
LocationofLoss:

METAIRIE,LA70002-0000
(504)834-3185
INTERSECTIONACCIDENT
NO
FLORIDABLVDANDSHERWOODFOREST
BATONROUGE,LA
US

InvolvedParty:
Name:
Address:

CLAIMANTDRIVER
PATRICIAHARRIS
21MAGNOLIAAVEE
SAINTPAUL,MN55117-5021
US

DOB:
Gender:
HomePhone:
SSN:

08/21/1968
FEMALE
(651)274-0839
XXX-XX-8025WASISSUEDbetween1981and1982inMS
***MorematchesonthisSSNoutsidethisreport***

AlsoKnownAs(AKA):
Name:

PATRICIAHARRIS

AlsoKnownAs(AKA):
Name:

PATRICIAHARRIS

AlsoKnownAs(AKA):
Address:

2448WHITESTOWNRD
WOODVILLE,MS39669-4295
US

BODILYINJURY
OTHERAUTO
OPEN
ALLSTATEINSURANCECOMPANY
JOHNSON,TAJMA
(504)219-3759
SORE,SORE,SORE

OTHERAUTO
OTHERAUTO
ALLSTATEINSURANCECOMPANY
JOHNSON,TAJMA
OPEN
(504)219-3759
2006NISS
0000111111
WKE553LicensePlateState:MS

LastYearRegistered:

2000

InvolvedParty:
Name:
Address:

INSUREDDRIVER
DAVIDODDS
2052FAIRCHILDST
BATONROUGE,LA70807-5025
US

DOB:
Gender:
HomePhone:
DriversLicense:

05/02/1963
MALE
(225)892-9794
4675286

AlsoKnownAs(AKA):
Name:

DAVIDODDS

AlsoKnownAs(AKA):
Name:

DAVIDODDS

AlsoKnownAs(AKA):
Address:

13855KATHERINEAVE
BATONROUGE,LA70815-7229
US

VehicleCoverageInformation:
CoverageType:
LossType:
AdjusterCompany:
Adjuster:
ClaimStatus:
AdjusterPhone:
VIN:
Vehicle:
LastYearRegistered:

COLLISION
OTHERAUTO
ALLSTATEINSURANCECOMPANY
JOHNSON,TAJMA
OPEN
(504)219-3759
1GNFC13058R139428(Pass)
2008CHEVROLETTAHOE
2000

back

MatchingClaim
Reason(s)formatch:

FileNumber:9C003840892
LICENSEPLATENUMBER
VIN
PHONE

InsuringCompany:
ClaimNumber:
Date/TimeofLoss:
PolicyNumber:
PolicyType:
InceptionDate:
InsuringCo.Address:

LOUISIANAFARMBUREAUMUTUALINSCO
17A00066408
04/16/201503:30
AT06334
PERSONALAUTOMOBILE
12/15/2014ExpirationDate:06/15/2015
CLAIMCENTER
POBOX80319

InsuringCo.Phone:
CompanyReceivedDate:
LossDescription:
LocationofLoss:

BATONROUGE,LA70898
(225)922-6200
04/17/2015
3PWASSTOPPEDINTRAFFICWHENINSVEHR/E3PVEH
I-10
BATONROUGE,LA
US

InvolvedParty:
Name:
Address:

BOTHCLAIMANT&INSURED
ELIZABETHARRIAGA
APT704
4051BAYOURAPIDESRD

ALEXANDRIA,LA71303--406
US

DOB:
Gender:
CellularPhone:
Occupation:
VehicleCoverageInformation:
CoverageType:
LossType:
AdjusterCompany:
Adjuster:
ClaimStatus:
AdjusterPhone:
VIN:
Vehicle:
LastYearRegistered:

InvolvedParty:

08/22/1990
FEMALE
(318)792-8920
HAIRDRESSER

COLLISION
COLLISION
LOUISIANAFARMBUREAUMUTUALINSCO
SMITH,MARCUS
OPEN
(318)445-4043
1FTEW1CM3BKD13494(Pass)
2011FORDF150SERIES
2000

CLAIMANTDRIVER

Name:
Address:

PATRICIAHARRIS
2448WHITESTOWNRD
WOODVILLE,MS39669--429
US

HomePhone:

(601)888-4506

CellularPhone:
DriversLicense:

(651)274-0839
802678648State:MS

BODILYINJURY
BODILYINJURY
OPEN
LOUISIANAFARMBUREAUMUTUALINSCO
SMITH,MARCUS
(318)445-4043
BODYSORENESS

OTHERAUTO
OTHERAUTO
LOUISIANAFARMBUREAUMUTUALINSCO
SMITH,MARCUS
OPEN
(318)445-4043
3N1CB51D26L453976(Pass)
2006NISSANSENTRA
WKE553LicensePlateState:MS
2000

ISOStylesheetVersion:5.5ReleaseDate:03-03-2014

ACCC INSURANCE COMPANY

P O BOX 680247
HOUSTON, TX 77268

ACCC INSURANCE COMPANY

P O BOX 680247
HOUSTON, TX 77268

(281) 875-8363 or (888) 879-8363

REPORT OF ACCIDENT - INSURED/DRIVER

Claim Number: C0008310-5

Insured/Driver Name and Address:

Date of Loss: 5/13/2015

Process Date: 5/15/2015

PATRICIA HARRIS
2448 WHITESTOWN RD
CENTREVILLE MS 39631-3840

C0008310-5

ROA

Dear Sir or Madam:

Your Policy Number:
Your Agent:

MSE0259823-3
MISSISSIPPI'S BEST INSURANCE AGENCY INC.

6019220006

This correspondence confirms receipt of a claim concerning an automobile accident or loss. We represent your insurance
carrier. The undersigned claim adjuster has been assigned to complete an investigation and process this claim. This form
does not constitute an admission of liability or confirm coverage by the insurance company. Your version of how
this accident occurred is important and will assist us in determining the extent of your liability.
Please complete both pages of this Report of Accident Form. Upon completion, sign and return this Report of Accident
Form to this office immediately in the enclosed self-addressed envelope. Your prompt response is necessary to complete
our investigation. To speed the handling of your claim, please send the Police Report.
Thank you in advance for your cooperation.
Please keep and refer to the claim number referenced above in all correspondence.
Sincerely,
JILL DENNIS Ext. Number: 7217
ACCC Insurance Company Adjuster

NOTICE:

PURSUANT TO LAW, WE MAY BE REQUIRED TO PLACE A LIENHOLDER ON ANY CHECK FOR PROPERTY DAMAGE TO YOUR VEHICLE.
PLEASE FORWARD A COPY OF YOUR TITLE TO AVOID DELAY.

DATE OF LOSS

TIME OF LOSS
______A.M. ______P.M.

WAS ACCIDENT REPORTED TO POLICE?

IF YES, WHICH DEPARTMENT?

YES

NO
POLICE REPORT #

LOCATION OF ACCIDENT
IN YOUR OWN WORDS, HOW DID ACCIDENT HAPPEN? GIVE FULL ACCOUNT, STATING SPEED AND DIRECTION OF EACH CAR:

Please use the back of this form to draw a diagram of the vehicles and accident scene.
Generated 5/15/2015 3:18 PM

01_ACCC_RA1_2009_01_01

(CONTINUED)

Claim Number: C0008310-5

YOUR VEHICLE: YEAR: ___ MAKE: _ MODEL: ______________________

VEHICLE I.D. (VIN)#: ____________________________________________ COLOR(S):__________________________________ LICENSE PLATE #:_____________________ STATE:_______
IS THE CAR DRIVABLE?

YES

WAS YOUR VEHICLE REPAIRED?

WHAT WAS THE VEHICLE BEING USED FOR AT THE TIME OF THE ACCIDENT? _______________________________________________

YES

COST OF REPAIRS: $____________ WHEN: _WHERE: ________________

IF YES, PLEASE SUBMIT PROOF OF REPAIRS AND PROOF OF PAYMENT WITH THIS FORM.
DRIVER OF YOUR VEHICLE (#1):

DATE OF BIRTH:

SOCIAL SECURITY #:
HOME

DRIVER'S ADDRESS:

DRIVER'S PHONE #

DRIVER'S LICENSE #:

DL STATE:

TICKETED?

YES

MARRIED?

YES
NO IF MARRIED, NAME OF WIFE/HUSBAND:
DID DRIVER HAVE PERMISSION
TO USE VEHICLE?
YES
NO PLACE OF EMPLOYMENT:

MEDICAL TREATMENT REQUIRED?

YES

DRIVER'S PHONE #

OTHER :

HOME

CELL

WORK

OTHER :

EMPLOYER PHONE # :

IF YES, DOCTOR'S NAME:

HOSPITAL:

YOUR VEHICLE (#1) OWNER:

DATE OF BIRTH:

OWNER'S ADDRESS:

SOCIAL SECURITY #:
OWNER'S PHONE #

DL STATE:

DRIVER'S LICENSE #:

CELL

WORK

HOME

CELL

WORK

OTHER :

OTHER OCCUPANTS OF YOUR VEHICLE (#1): (If more than 2, please list all requested information on the back of this form.) TOTAL # OF PEOPLE IN THE CAR INCL THE DRIVER:
PASSENGER #1:

DATE OF BIRTH:

PASSENGER ADDRESS:

SOCIAL SECURITY #:

PASSENGER #1 PHONE #

DRIVER'S LICENSE #:

DL STATE:

INJURED?

YES

PASSENGER #2 :

DATE OF BIRTH:

PASSENGER ADDRESS:
DL STATE:

INJURED?

YES

CELL

WORK

OTHER :

SOCIAL SECURITY #:

PASSENGER #2 PHONE #

DRIVER'S LICENSE #:

HOME

CELL

WORK

OTHER :

PLEASE LIST AND PROVIDE THE FOLLOWING INFORMATION ABOUT OTHER VEHICLES INVOLVED IN THIS ACCIDENT OR LOSS:
(If more than 2, please list all required information on the back of this form.)
VEHICLE #2 YEAR: _______________________________ MAKE: _________________________________________________ MODEL: _______________________________________________
VEHICLE I.D. (VIN)#: ____________________________________________ COLOR(S):__________________________________ LICENSE PLATE #:____________________ STATE:_______
IS THE CAR DRIVABLE?

YES

NUMBER OF PEOPLE IN VEHICLE #2:

NUMBER OF INJURED PEOPLE IN VEHICLE #2:

DRIVER OF VEHICLE #2:

DATE OF BIRTH:

DRIVER'S ADDRESS:

SOCIAL SECURITY #:
DRIVER'S PHONE #

DL STATE:

DRIVER'S LICENSE #:

TICKETED?

YES

HOME

CELL

WORK

OTHER :

VEHICLE #3 YEAR: _______ MAKE: _ MODEL: _______________________

VEHICLE I.D. (VIN)#: ____________________________________________ COLOR(S):__________________________________ LICENSE PLATE #:____________________ STATE:_______
IS THE CAR DRIVABLE?

YES

NUMBER OF PEOPLE IN VEHICLE #3:

NUMBER OF INJURED PEOPLE IN VEHICLE #3:

DRIVER OF VEHICLE #3:

DATE OF BIRTH:

DRIVER'S ADDRESS:

SOCIAL SECURITY #:
DRIVER'S PHONE #

DL STATE:

DRIVER'S LICENSE #:

TICKETED?

YES

HOME

CELL

WORK

OTHER :

OTHER OCCUPANTS OF VEHICLE(S): (If more than 2, please list all required information on the back of this form.)
PASSENGER # 1 OF VEHICLE #

DATE OF BIRTH:

PASSENGER ADDRESS:

PASSENGER PHONE #

DRIVER'S LICENSE #:
PASSENGER #

OF VEHICLE #

DL STATE:

INJURED?

YES

DATE OF BIRTH:

PASSENGER ADDRESS:
DRIVER'S LICENSE #:

SOCIAL SECURITY #:

DL STATE:

INJURED?

YES

HOME

CELL

WORK

OTHER :

SOCIAL SECURITY #:

PASSENGER PHONE #

HOME

CELL

WORK

OTHER :

LIST ALL DRIVERS WHO RECEIVED TICKETS/CITATIONS AND THE CHARGES MADE: (If more than 2, please list all required information on the back of this form.)
DRIVER
CHARGE(S)
VEH. #

WITNESSES, IF ANY, TO THE ACCIDENT OR LOSS: (If more than 2, please list all required information on the back of this form.)
ADDRESS
NAME
TELEPHONE #
TELEPHONE #

HOME

CELL

WORK

OTHER

HOME

CELL

WORK

OTHER

NAME OF YOUR INSURANCE COMPANY (If different than listed): ____________________________________________________________ POLICY NUMBER:_________________________
NAME OF COMPANY INSURING OTHER PARTIES: ____________________________________________________ POLICY NUMBER: ____________________________________________
DID YOU TAKE ANY PHOTOGRAPHS OR STATEMENTS FROM ANYONE?
IF AVAILABLE, ATTACH ANY BILLS, PHOTOGRAPHS, AND STATEMENTS.

YES

DID YOU GIVE ANYONE A STATEMENT?

YES

DATE OF LAST AUTO ACCIDENT PRIOR TO THIS: __________________________________________________________________________________________________________________

YOUR SIGNATURE ______________________________________DATE _,

MONTH

DAY

YEAR

SENDING POLICE REPORT MAY SPEED UP HANDLING OF CLAIM

Generated 5/15/2015 3:18 PM

01_ACCC_RA1_2009_01_01

ACCC INSURANCE COMPANY

P O BOX 680247
HOUSTON, TX 77268

ACCC INSURANCE COMPANY

P O BOX 680247
HOUSTON, TX 77268

(281) 875-8363 or (888) 879-8363

SECOND REQUEST - REPORT OF ACCIDENT FORM

Insured/Driver Name and Address:

Claim Number: C0008310-5

Date of Loss: 5/13/2015
Process Date: 5/22/2015

PATRICIA HARRIS
2448 WHITESTOWN RD
CENTREVILLE MS 39631-3840

C0008310-5

ROA

Dear Sir or Madam:

Your Policy Number:
Your Agent:

MSE0259823-3
MISSISSIPPI'S BEST INSURANCE AGENCY INC.

6019220006

We are in receipt of a claim concerning the above-referenced automobile accident or loss. As of this date we have not
received the completed and signed Report of Accident Form as previously requested from you. Please note your
Personal Automobile Policy states:
PART E - DUTIES AFTER AN ACCIDENT OR LOSS
We have no duty to provide coverage under this policy unless there has been full compliance with the following duties:
A. We must be notified promptly of how, when, and where the accident or loss occurred. Notice should also include
the names and addresses of any injured persons and of any witnesses. If we show that your failure to provide
notice prejudices our defense, there is no liability coverage under the policy.
B. A person seeking any coverage must:
1. Cooperate with us in the investigation, settlement, or defense of any claim or suit.
Therefore, it is your duty to complete and sign the Report of Accident Form and return it to this office immediately.
Sincerely,
JILL DENNIS Ext. Number: 7217
ACCC Insurance Company Adjuster

NOTICE:

PURSUANT TO LAW, WE MAY BE REQUIRED TO PLACE A LIENHOLDER ON ANY CHECK FOR PROPERTY DAMAGE TO YOUR VEHICLE.
PLEASE FORWARD A COPY OF YOUR TITLE TO AVOID DELAY.

DATE OF LOSS

TIME OF LOSS
______A.M. ______P.M.

WAS ACCIDENT REPORTED TO POLICE?

IF YES, WHICH DEPARTMENT?

YES

NO
POLICE REPORT #

LOCATION OF ACCIDENT
IN YOUR OWN WORDS, HOW DID ACCIDENT HAPPEN? GIVE FULL ACCOUNT, STATING SPEED AND DIRECTION OF EACH CAR:

Please use the back of this form to draw a diagram of the vehicles and accident scene.
Generated 5/22/2015 9:04 AM

02_MS_RA2_2009_01_01

(CONTINUED)

Claim Number: C0008310-5

YOUR VEHICLE: YEAR: ___ MAKE: _ MODEL: ______________________

VEHICLE I.D. (VIN)#: ____________________________________________ COLOR(S):__________________________________ LICENSE PLATE #:_____________________ STATE:_______
IS THE CAR DRIVABLE?

YES

WAS YOUR VEHICLE REPAIRED?

WHAT WAS THE VEHICLE BEING USED FOR AT THE TIME OF THE ACCIDENT? _______________________________________________

YES

COST OF REPAIRS: $____________ WHEN: _WHERE: ________________

IF YES, PLEASE SUBMIT PROOF OF REPAIRS AND PROOF OF PAYMENT WITH THIS FORM.
DRIVER OF YOUR VEHICLE (#1):

DATE OF BIRTH:

SOCIAL SECURITY #:
HOME

DRIVER'S ADDRESS:

DRIVER'S PHONE #

DRIVER'S LICENSE #:

DL STATE:

TICKETED?

YES

MARRIED?

YES
NO IF MARRIED, NAME OF WIFE/HUSBAND:
DID DRIVER HAVE PERMISSION
TO USE VEHICLE?
YES
NO PLACE OF EMPLOYMENT:

MEDICAL TREATMENT REQUIRED?

YES

DRIVER'S PHONE #

OTHER :

HOME

CELL

WORK

OTHER :

EMPLOYER PHONE # :

IF YES, DOCTOR'S NAME:

HOSPITAL:

YOUR VEHICLE (#1) OWNER:

DATE OF BIRTH:

OWNER'S ADDRESS:

SOCIAL SECURITY #:
OWNER'S PHONE #

DL STATE:

DRIVER'S LICENSE #:

CELL

WORK

HOME

CELL

WORK

OTHER :

OTHER OCCUPANTS OF YOUR VEHICLE (#1): (If more than 2, please list all requested information on the back of this form.) TOTAL # OF PEOPLE IN THE CAR INCL THE DRIVER:
PASSENGER #1:

DATE OF BIRTH:

PASSENGER ADDRESS:

SOCIAL SECURITY #:

PASSENGER #1 PHONE #

DRIVER'S LICENSE #:

DL STATE:

INJURED?

YES

PASSENGER #2 :

DATE OF BIRTH:

PASSENGER ADDRESS:
DL STATE:

INJURED?

YES

CELL

WORK

OTHER :

SOCIAL SECURITY #:

PASSENGER #2 PHONE #

DRIVER'S LICENSE #:

HOME

CELL

WORK

OTHER :

YES

NUMBER OF PEOPLE IN VEHICLE #2:

NUMBER OF INJURED PEOPLE IN VEHICLE #2:

DRIVER OF VEHICLE #2:

DATE OF BIRTH:

DRIVER'S ADDRESS:

SOCIAL SECURITY #:
DRIVER'S PHONE #

DL STATE:

DRIVER'S LICENSE #:

TICKETED?

YES

HOME

CELL

WORK

OTHER :

VEHICLE #3 YEAR: _______ MAKE: _ MODEL: _______________________

VEHICLE I.D. (VIN)#: ____________________________________________ COLOR(S):__________________________________ LICENSE PLATE #:____________________ STATE:_______
IS THE CAR DRIVABLE?

YES

NUMBER OF PEOPLE IN VEHICLE #3:

NUMBER OF INJURED PEOPLE IN VEHICLE #3:

DRIVER OF VEHICLE #3:

DATE OF BIRTH:

DRIVER'S ADDRESS:

SOCIAL SECURITY #:
DRIVER'S PHONE #

DL STATE:

DRIVER'S LICENSE #:

TICKETED?

YES

HOME

CELL

WORK

OTHER :

OTHER OCCUPANTS OF VEHICLE(S): (If more than 2, please list all required information on the back of this form.)
PASSENGER # 1 OF VEHICLE #

DATE OF BIRTH:

PASSENGER ADDRESS:

PASSENGER PHONE #

DRIVER'S LICENSE #:
PASSENGER #

OF VEHICLE #

DL STATE:

INJURED?

YES

DATE OF BIRTH:

PASSENGER ADDRESS:
DRIVER'S LICENSE #:

SOCIAL SECURITY #:

DL STATE:

INJURED?

YES

HOME

CELL

WORK

OTHER :

SOCIAL SECURITY #:

PASSENGER PHONE #

HOME

CELL

WORK

OTHER :

LIST ALL DRIVERS WHO RECEIVED TICKETS/CITATIONS AND THE CHARGES MADE: (If more than 2, please list all required information on the back of this form.)
DRIVER
CHARGE(S)
VEH. #

WITNESSES, IF ANY, TO THE ACCIDENT OR LOSS: (If more than 2, please list all required information on the back of this form.)
ADDRESS
NAME
TELEPHONE #
TELEPHONE #

HOME

CELL

WORK

OTHER

HOME

CELL

WORK

OTHER

YES

DID YOU GIVE ANYONE A STATEMENT?

YES

DATE OF LAST AUTO ACCIDENT PRIOR TO THIS: __________________________________________________________________________________________________________________

YOUR SIGNATURE ______________________________________DATE _,

MONTH

DAY

YEAR

SENDING POLICE REPORT MAY SPEED UP HANDLING OF CLAIM

Generated 5/22/2015 9:04 AM

02_MS_RA2_2009_01_01

ACCC INSURANCE COMPANY

P O BOX 680247
HOUSTON, TX 77268

ACCC INSURANCE COMPANY

P O BOX 680247
HOUSTON, TX 77268

(281) 875-8363 or (888) 879-8363

REQUEST FOR INFORMATION &

ASSISTANCE IN INVESTIGATION

Claim Number: C0008310-5

PATRICIA HARRIS
2448 WHITESTOWN RD
CENTREVILLE MS 39631-3840

Date of Loss:
Insured:
Claimant:
Process Date:

5/13/2015
PATRICIA HARRIS
PATRICIA HARRIS
5/22/2015

1) Please call to arrange for the inspection of and to provide the location of your (client's) vehicle.
2) Please call to discuss your claim.
3) Please forward a copy of the police report.
4) Please provide the names, addresses, and phone numbers for all witnesses.
5) Please provide a copy of the front and back of your (client's) vehicle title.
6) Please provide the name, address, date of birth, occupation, Social Security Number, and
Driver's License Number for each injured party/client and the name of his/her physician.
7) Please forward the name and address of all treating physicians, emergency room records,
including the observation notes, lab x-ray results, discharge summary, O.R. report, if applicable,
EMS records, and all other medical documentation and bills from all medical providers for each
injured party/client.
8) Please submit the provider's final report and chart notes from:

9) Please provide wage loss information on employer letterhead with days, dates, hours missed, and
rate of pay.
10) Remarks or additional requests:
Please complete and return the Report of Accident form. Also, we need you permission to move
your vehicle as it has been deemed a total loss. We cannot make you an offer until we have a
copy of the Police Report and the Report of Accident form.

JILL DENNIS Ext. Number: 7217

ACCC Insurance Company Adjuster

Generated 5/22/2015 9:05 AM

RFI_ACCC_2010_08_16

Insured Name and Address:

ACCC INSURANCE COMPANY

P O BOX 680247
HOUSTON, TX 77268
(281) 875-8363 or (888) 879-8363

PATRICIA HARRIS
2448 WHITESTOWN RD
CENTREVILLE, MS 39631-3840

ATTN: UNDERWRITING - REQUEST FOR ACTION

Driver:

Claim Number: C0008310-5

Policy Number: MSE0259823-3
ACCC Insurance Company
Adjuster:
Jill Marie Dennis
Adjuster Office:
Date of Loss: 5/13/2015

Process Date: 5/28/2015

Police Report Available?

Yes

Claim has been paid?

Yes

Liability has been accepted?

Yes

All fields in a section must be completed before further action can be taken in that section.
A. Add the following undisclosed, licensed driver to the policy effective at the start of the policy term
prior to the date of loss:
Driver Name: First:
Marital Status:

MI:
Driver's License:

Last:

State:

Suffix:

Date of Birth:

Relationship to Insured:

B. Add the following points/violations effective upon renewal:

Same as information in Section A.

Value of Total Property Damage or Collision Claims: $

Driver Name: First:

MI:

Driver's License Number:

At-Fault Accident

C. Change address:
HOME

GARAGE

Last:

Suffix:
Other:

Street Address:
MAILING

City:

State:

Zip Code:

Telephone:

D. Cancel if policy in force 60 days or more with 30-day notice for:

Material Misrepresentation Of Claims (Fraudulent Claim)

Suspended or Revoked Driver's License or Motor Vehicle Registration

E. Cancel if policy in force less than 60 days or non-renew with 30-day notice for:
2 DUI/DWI Convictions In Last 36 Months
Accident(s) With DUI/DWI
Altered Vehicle (Hot Rods), Dune Buggy, Scooter Or Kit Car
Driver Convicted Of Felony Hit And Run In Last 36 Months
Driver Is An Entertainer, Celebrity Or Professional Athlete
Excessive At-Fault Accident Activity
Motorcycle Or Motor Home
Moved Out Of State
Vehicle Used For Excessive Travel
Named Insured Non-Owner Of Vehicle
New Vehicle Value Greater Than $35,000
No Medical Statement Received
No Signed Exclusion Form Received
No Vehicle Inspection Form Received
No Vehicle Modification Statement Received
Prohibited Vehicle
Student Attending Out-Of-State School
Temporary Resident
Vehicle Age Exceeds Underwriting Guidelines
Vehicle Equipped With A Fifth Wheel
Vehicle Equipped With Power Or Manual Winch

Vehicle Failed An Inspection Law

Vehicle Garaged Away From The Residence
Vehicle Garaged Out Of State
Vehicle Is An Authorized Emergency Vehicle
Vehicle Registered Or Titled In A Company Name
Vehicle Symbol 18 Or Greater With Physical Damage
Vehicle Used For Commercial Purposes
Vehicle Used For Delivery
Vehicle Used For Hauling Church Parishioners
Vehicle Used For Hauling Flammables/Explosives
Vehicle Used For Hauling Hotel/Motel Guests
Vehicle Used For Hauling Migrant Workers
Vehicle Used For Hauling School Children
Vehicle Used For Livery, Limousine Or Taxi Service
Vehicle Used For Messenger Service
Vehicle Used For Racing
Vehicle With Aluminum, Stainless Steel Or Fiberglass Body
Vehicle With Load Capacity Over 3/4 Ton
Your Agent Does Not Do Business With Us
Driver With DUI/DWI Conviction
Undisclosed Driver(s)

F. A total loss settlement has been paid to the insured. Delete the following vehicle from the policy:
Year:

2006

Make:

Nissan

Model:

Sentra

VIN:

3N1CB51D26L453976

G. Submit to the attention of the Compliance Officer and/or the Underwriting Manager.
Generated 5/28/2015 8:38 AM

56_MS_RFA_2009_03_30

INITIATINGCLAIMINFORMATION
ClaimNumber:
PolicyNumber:

C0008310
MSE0259823

DateofLoss:
ISOFileNumber:

05/13/2015

4L003857778

SUMMARYFOREACHSEARCHABLEPARTY
PATRICIAHARRIS,BOTHCLAIMANT&INSURED
Coverage:
MEDICALPAYMENTS
Coverage:
COLLISION

LossType:
LossType:

MEDICALPAYMENTS
COLLISION

#ofMatches

ISOFileNumber
H0181210286

H0227908504

H0227980244

2C002985474

2W003608755

5O003852441

9C003840892

ISOCLAIMSEARCHREPLACEMENTCLAIMDETAILS

PriorClaimsHistory

InitiatingClaim

FileNumber:4L003857778

Company:
RRECode:
TIN:
SiteId:
ClaimNumber:
Date/TimeofLoss:
PolicyNumber:
PolicyType:
InceptionDate:
CompanyReceivedDate:
ISOReceivedDate:
LossDescription:
LocationofLoss:

A73400009

InvolvedParty:
Name:
Address:

DOB:
Gender:
HomePhone:
StopCMSQuery:

BOTHCLAIMANT&INSURED

000011301
75-2701220
000011301
C0008310
05/13/201520:30
MSE0259823
PERSONALAUTOMOBILE
08/20/2014ExpirationDate:09/03/2015
05/14/2015
05/14/2015
IVWASTURNINGLEFTANDCVRANREDLIGHTANDSTRUC
11300FLORIDABLVD/SHERWOODFOREST
BATONROUGE,LA

PATRICIAHARRIS
2448WHITESTOWNRD
CENTREVILLE,MS39631-3840
08/21/1968
FEMALE
(651)274-0839
YES

MEDICALPAYMENTS
MEDICALPAYMENTS
CLOSEDW/OPAYMENT
05/14/2015
ACCCINSURANCECOMPANY
CHESTPAIN,BRUISES,SEATBELTSCARS
NO

COLLISION
COLLISION
OPEN
3N1CB51D26L453976(Pass)

Vehicle:
VehicleType:
VehicleDisposition:
VehicleColor:
LicenseType:
LicensePlate:
SuitIndicator:

2006NISSANSENTRA
PASSENGERCAR
TOTALLOSS
BLUE
PASSENGERCAR
WKE553LicensePlateState:MS
NO

back

MatchingClaim
Reason(s)formatch:
FileNumber:
Coverage:
ClaimNumber:
ActivityType:
ActivityDate:
InsuranceCompany:
PolicyType:
PointofImpact:
VIN:
Vehicle:

FileNumber:H0181210286
VIN
H0181210286
COLLISION
HHZ3966001
ESTIMATE
06/30/2011
TRAVELERSINDEMNITYCOMPANY
Unknown
LEFTFRONTCORNER
3N1CB51D26L453976(Pass)
2006NISSANSENTRA

back

MatchingClaim
Reason(s)formatch:
FileNumber:
Coverage:
ClaimNumber:
ActivityType:
ActivityDate:
InsuranceCompany:
ContactPhone:
PolicyType:
PointofImpact:
VIN:

FileNumber:H0227908504
VIN
H0227908504
OTHERLIABILITY
000368735353B02
VALUATION
05/13/2015
ALLSTATEINSURANCECOMPANY
(800)255-7828
Unknown
UNKNOWN
3N1CB51D26L453976(Pass)

Vehicle:
Odometer:

2006NISSANSENTRA
120100

back

MatchingClaim

FileNumber:H0227980244

Reason(s)formatch:
FileNumber:
Coverage:
ClaimNumber:
ActivityType:
ActivityDate:
InsuranceCompany:
ContactPhone:
PolicyType:
PointofImpact:
VIN:
Vehicle:
Odometer:

VIN
H0227980244
LIABILITY
000368735353B02
ESTIMATE
05/13/2015
ALLSTATEINSURANCECOMPANY
(999)999-9999
Unknown
RIGHTSIDE
3N1CB51D26L453976(Pass)
2006NISSANSENTRA
120100

back

MatchingClaim
Reason(s)formatch:
InsuringCompany:
ClaimNumber:
Date/TimeofLoss:
PolicyNumber:
PolicyType:
InceptionDate:
AssignedRisk?:
InsuringCo.Address:

FileNumber:2C002985474
VIN
TRAVELERSINDEMNITYCOMPANY
HHZ3966001
06/30/2011
0M24649821790491011
PERSONALAUTOMOBILE
06/01/2011ExpirationDate:12/01/2011
NO
NAPERVILLEPLCLM-A273
POBOX3095*

InsuringCo.Phone:
CompanyReceivedDate:
LossDescription:
LocationofLoss:

NAPERVILLE,IL60566-7095
(800)842-6172
07/16/2011
OV1WASSTOPPEDATTHELIGHT&MADEASHARPLEFTT
,MN

InvolvedParty:
Name:
Address:

BOTHCLAIMANT&INSURED
JENNIFERTHEISEN
6911CORVALLISAVEN
CRYSTAL,MN55428-4333

back

MatchingClaim
Reason(s)formatch:
InsuringCompany:
ClaimNumber:
Date/TimeofLoss:
PolicyNumber:
PolicyType:
PolicyRenewed?:
AssignedRisk?:
InsuringCo.Address:

FileNumber:2W003608755
VIN
STATEFARM(R)AFFILIATE
2330S9866
04/15/2014
230232023
PERSONALAUTOMOBILE
NO
NO
CIOS-00
ONESTATEFARMPLAZA

LossDescription:
CATRelated?:
Hit&RunAccident:
LocationofLoss:

BLOOMINGTON,IL61710
BLANK
NO
NO
,MN
US

PhysicalRisk:

380WHEELOCKPKWYEAPT324
SAINTPAUL,MN55130-3050

InvolvedParty:
Name:
Address:

INSURED
PATRICIAHARRIS
380WHEELOCKPKWYEAPT324
SAINTPAUL,MN55130-3050
US

VehicleCoverageInformation:
CoverageType:
LossType:
AdjusterCompany:
DateClaimClosed:
AdjusterPhone:
VIN:
Vehicle:
LastYearRegistered:
SuitIndicator:

TOWINGANDLABOR
TOWINGANDLABOR
STATEFARM(R)AFFILIATE
04/19/2014
(888)248-6961
3N1CB51D26L453976(Pass)
2006NISSANSENTRA
2000
NO

back

MatchingClaim

FileNumber:5O003852441

Reason(s)formatch:

VIN
PHONE
NAME

InsuringCompany:
ClaimNumber:
Date/TimeofLoss:
PolicyNumber:
PolicyType:
PolicyRenewed?:
InsuringCo.Address:

ALLSTATEINSURANCECOMPANY
0368735353
05/13/2015
000995043003
PERSONALAUTOMOBILE
YES
LOUISIANALIAB/CAS1640
3900NCAUSEWAY#400

InsuringCo.Phone:
LossDescription:
CATRelated?:
LocationofLoss:

METAIRIE,LA70002-0000
(504)834-3185
INTERSECTIONACCIDENT
NO
FLORIDABLVDANDSHERWOODFOREST
BATONROUGE,LA
US

InvolvedParty:

CLAIMANTDRIVER

Name:
Address:

PATRICIAHARRIS
21MAGNOLIAAVEE
SAINTPAUL,MN55117-5021
US

DOB:
Gender:
HomePhone:
SSN:

08/21/1968
FEMALE
(651)274-0839
XXX-XX-8025WASISSUEDbetween1981and1982inMS
***MorematchesonthisSSNoutsidethisreport***

AlsoKnownAs(AKA):
Name:

PATRICIAHARRIS

AlsoKnownAs(AKA):
Name:

PATRICIAHARRIS

AlsoKnownAs(AKA):
Address:

2448WHITESTOWNRD
WOODVILLE,MS39669-4295
US

ServiceProvider:
BusinessName:
TIN:
Address:

LAWYER-OTHER
MORRISBARTLTD
71-0921088WASISSUEDinLittleRockinAR
909POYDRASSTREET,20THFL
NEWORLEANS,LA70112-4030
US

BusinessPhone:

(228)432-9000

ServiceProvider:
BusinessName:
TIN:
Address:

LAWYER-OTHER
MORRISBARTLTD
71-0921088WASISSUEDinLittleRockinAR
909POYDRASSTREET,20THFL
NEWORLEANS,LA70112-4030
US

BusinessPhone:
CasualtyCoverageInformation:
CoverageType:
LossType:
ClaimStatus:
AdjusterCompany:

(228)432-9000

BODILYINJURY
OTHERAUTO
OPEN
ALLSTATEINSURANCECOMPANY

Adjuster:
AdjusterPhone:
AllegedInjury/PropertyDamage:
VehicleCoverageInformation:
CoverageType:
LossType:
AdjusterCompany:
ClaimStatus:
AdjusterPhone:
VIN:
Vehicle:

LEBLANC,KRIS
(504)219-3919
SORE,SORE,SORE

OTHERAUTO
OTHERAUTO
ALLSTATEINSURANCECOMPANY
OPEN
(800)349-1444
3N1CB51D26L453976(Pass)
2006NISSANSENTRA

VehicleOdometerReading:
LastYearRegistered:

0000111111

InvolvedParty:
Name:
Address:

INSUREDDRIVER

2000

DAVIDODDS
2052FAIRCHILDST
BATONROUGE,LA70807-5025
US

DOB:
Gender:
HomePhone:
DriversLicense:

05/02/1963
MALE
(225)892-9794
4675286

AlsoKnownAs(AKA):
Name:

DAVIDODDS

AlsoKnownAs(AKA):
Name:

DAVIDODDS

AlsoKnownAs(AKA):
Address:

13855KATHERINEAVE
BATONROUGE,LA70815-7229
US

VehicleCoverageInformation:
CoverageType:
LossType:
AdjusterCompany:

COLLISION
OTHERAUTO
ALLSTATEINSURANCECOMPANY

Adjuster:
ClaimStatus:
AdjusterPhone:
VIN:
Vehicle:
LastYearRegistered:

LEBLANC,KRIS
OPEN
(504)219-3919
1GNFC13058R139428(Pass)
2008CHEVROLETTAHOE
2000

back

MatchingClaim

FileNumber:9C003840892

Reason(s)formatch:

LICENSEPLATENUMBER
VIN
PHONE

InsuringCompany:
ClaimNumber:
Date/TimeofLoss:
PolicyNumber:
PolicyType:
InceptionDate:
InsuringCo.Address:

LOUISIANAFARMBUREAUMUTUALINSCO
17A00066408
04/16/201503:30
AT06334
PERSONALAUTOMOBILE
12/15/2014ExpirationDate:06/15/2015
CLAIMCENTER
POBOX80319

InsuringCo.Phone:
CompanyReceivedDate:
LossDescription:
LocationofLoss:

BATONROUGE,LA70898
(225)922-6200
04/17/2015
3PWASSTOPPEDINTRAFFICWHENINSVEHR/E3PVEH
I-10
BATONROUGE,LA
US

InvolvedParty:
Name:
Address:

BOTHCLAIMANT&INSURED
ELIZABETHARRIAGA
APT704
4051BAYOURAPIDESRD

ALEXANDRIA,LA71303--406
US

DOB:
Gender:
CellularPhone:
Occupation:

08/22/1990
FEMALE
(318)792-8920
HAIRDRESSER

VehicleCoverageInformation:
CoverageType:
LossType:
AdjusterCompany:
Adjuster:
ClaimStatus:
AdjusterPhone:
VIN:
Vehicle:
LastYearRegistered:

InvolvedParty:
Name:
Address:

COLLISION
COLLISION
LOUISIANAFARMBUREAUMUTUALINSCO
SMITH,MARCUS
OPEN
(318)445-4043
1FTEW1CM3BKD13494(Pass)
2011FORDF150SERIES
2000

CLAIMANTDRIVER
PATRICIAHARRIS
2448WHITESTOWNRD
WOODVILLE,MS39669--429
US

HomePhone:

(601)888-4506

CellularPhone:
DriversLicense:

(651)274-0839

802678648State:MS

BODILYINJURY
BODILYINJURY
OPEN
LOUISIANAFARMBUREAUMUTUALINSCO
SMITH,MARCUS
(318)445-4043
BODYSORENESS

OTHERAUTO
OTHERAUTO
LOUISIANAFARMBUREAUMUTUALINSCO
SMITH,MARCUS
OPEN
(318)445-4043
3N1CB51D26L453976(Pass)
2006NISSANSENTRA
WKE553LicensePlateState:MS
2000

ISOStylesheetVersion:5.5ReleaseDate:03-03-2014

INITIATINGCLAIMINFORMATION
ClaimNumber:
PolicyNumber:

C0008310
MSE0259823

DateofLoss:
ISOFileNumber:

05/13/2015

4L003857778

SUMMARYFOREACHSEARCHABLEPARTY
PATRICIAHARRIS,BOTHCLAIMANT&INSURED
Coverage:
MEDICALPAYMENTS

LossType:

MEDICALPAYMENTS

#ofMatches

PriorClaimsHistory

ISOFileNumber
5O003852441

9C003840892

PATRICIAHARRIS,CLAIMANT
Coverage:
COLLISION

LossType:

COLLISION

#ofMatches

PriorClaimsHistory

ISOFileNumber
H0181210286

H0227908504

H0227980244

2C002985474

2W003608755

5O003852441

9C003840892

ISOCLAIMSEARCHREPLACEMENTCLAIMDETAILS

InitiatingClaim

FileNumber:4L003857778

Company:
RRECode:
TIN:
SiteId:
ClaimNumber:
Date/TimeofLoss:
PolicyNumber:
PolicyType:
InceptionDate:
CompanyReceivedDate:
ISOReceivedDate:
LossDescription:
LocationofLoss:

A73400009

InvolvedParty:
Name:
Address:

DOB:
Gender:
HomePhone:
StopCMSQuery:

BOTHCLAIMANT&INSURED

CasualtyCoverageInformation:

PATRICIAHARRIS
2448WHITESTOWNRD
CENTREVILLE,MS39631-3840
08/21/1968
FEMALE
(651)274-0839
YES

CoverageType:
LossType:
ClaimStatus:
DateClaimClosed:
AdjusterCompany:
AllegedInjury/PropertyDamage:
Suitfiled?:

MEDICALPAYMENTS

InvolvedParty:
Name:
Address:

DOB:
Gender:
HomePhone:

CLAIMANT

VehicleCoverageInformation
CoverageType:
LossType:
ClaimStatus:
VIN:
Vehicle:
VehicleType:
VehicleDisposition:
VehicleColor:
LicenseType:
LicensePlate:
SuitIndicator:

MEDICALPAYMENTS
CLOSEDW/OPAYMENT
05/14/2015
ACCCINSURANCECOMPANY
CHESTPAIN,BRUISES,SEATBELTSCARS
NO

PATRICIAHARRIS
1331NSHERWOODBLVD.,APT119
BATONROUGE,LA70815
08/21/1968
FEMALE
(651)274-0839

COLLISION
COLLISION
OPEN
3N1CB51D26L453976(Pass)
2006NISSANSENTRA
PASSENGERCAR
TOTALLOSS
BLUE
PASSENGERCAR
WKE553LicensePlateState:MS
NO

back

MatchingClaim
Reason(s)formatch:
FileNumber:
Coverage:
ClaimNumber:
ActivityType:

FileNumber:H0181210286
VIN
H0181210286
COLLISION
HHZ3966001
ESTIMATE

ActivityDate:
InsuranceCompany:
PolicyType:
PointofImpact:
VIN:
Vehicle:

06/30/2011
TRAVELERSINDEMNITYCOMPANY
Unknown
LEFTFRONTCORNER
3N1CB51D26L453976(Pass)
2006NISSANSENTRA

back

MatchingClaim
Reason(s)formatch:
FileNumber:
Coverage:
ClaimNumber:
ActivityType:
ActivityDate:
InsuranceCompany:
ContactPhone:
PolicyType:
PointofImpact:
VIN:
Vehicle:
Odometer:

FileNumber:H0227908504
VIN
H0227908504
OTHERLIABILITY
000368735353B02
VALUATION
05/13/2015
ALLSTATEINSURANCECOMPANY
(800)255-7828
Unknown
UNKNOWN
3N1CB51D26L453976(Pass)
2006NISSANSENTRA
120100

back

MatchingClaim
Reason(s)formatch:
FileNumber:
Coverage:
ClaimNumber:
ActivityType:
ActivityDate:
InsuranceCompany:
ContactPhone:
PolicyType:
PointofImpact:
VIN:

FileNumber:H0227980244
VIN
H0227980244
LIABILITY
000368735353B02
ESTIMATE
05/13/2015
ALLSTATEINSURANCECOMPANY
(999)999-9999
Unknown
RIGHTSIDE
3N1CB51D26L453976(Pass)

Vehicle:
Odometer:

2006NISSANSENTRA
120100

back

MatchingClaim
Reason(s)formatch:
InsuringCompany:
ClaimNumber:
Date/TimeofLoss:
PolicyNumber:
PolicyType:
InceptionDate:
AssignedRisk?:
InsuringCo.Address:

FileNumber:2C002985474
VIN
TRAVELERSINDEMNITYCOMPANY
HHZ3966001
06/30/2011
0M24649821790491011
PERSONALAUTOMOBILE
06/01/2011ExpirationDate:12/01/2011
NO
NAPERVILLEPLCLM-A273
POBOX3095*

InsuringCo.Phone:
CompanyReceivedDate:
LossDescription:
LocationofLoss:

NAPERVILLE,IL60566-7095

InvolvedParty:
Name:
Address:

BOTHCLAIMANT&INSURED

(800)842-6172
07/16/2011
OV1WASSTOPPEDATTHELIGHT&MADEASHARPLEFTT
,MN

JENNIFERTHEISEN
6911CORVALLISAVEN
CRYSTAL,MN55428-4333

back

MatchingClaim
Reason(s)formatch:
InsuringCompany:
ClaimNumber:
Date/TimeofLoss:
PolicyNumber:
PolicyType:
PolicyRenewed?:
AssignedRisk?:
InsuringCo.Address:

FileNumber:2W003608755
VIN
STATEFARM(R)AFFILIATE
2330S9866
04/15/2014
230232023
PERSONALAUTOMOBILE
NO
NO
CIOS-00
ONESTATEFARMPLAZA

LossDescription:
CATRelated?:
Hit&RunAccident:
LocationofLoss:

BLOOMINGTON,IL61710
BLANK
NO
NO
,MN
US

PhysicalRisk:

380WHEELOCKPKWYEAPT324

InvolvedParty:
Name:
Address:

INSURED

SAINTPAUL,MN55130-3050

PATRICIAHARRIS
380WHEELOCKPKWYEAPT324
SAINTPAUL,MN55130-3050
US

VehicleCoverageInformation:
CoverageType:
LossType:
AdjusterCompany:
DateClaimClosed:
AdjusterPhone:
VIN:
Vehicle:
LastYearRegistered:
SuitIndicator:

TOWINGANDLABOR
TOWINGANDLABOR
STATEFARM(R)AFFILIATE
04/19/2014
(888)248-6961
3N1CB51D26L453976(Pass)
2006NISSANSENTRA
2000
NO

back

MatchingClaim

FileNumber:5O003852441

Reason(s)formatch:

PHONE
NAME
VIN
PHONE
NAME

InsuringCompany:
ClaimNumber:
Date/TimeofLoss:
PolicyNumber:
PolicyType:
PolicyRenewed?:
InsuringCo.Address:

ALLSTATEINSURANCECOMPANY
0368735353
05/13/2015
000995043003
PERSONALAUTOMOBILE
YES
LOUISIANALIAB/CAS1640
3900NCAUSEWAY#400

InsuringCo.Phone:
LossDescription:
CATRelated?:
LocationofLoss:

METAIRIE,LA70002-0000
(504)834-3185
INTERSECTIONACCIDENT
NO
FLORIDABLVDANDSHERWOODFOREST
BATONROUGE,LA
US

InvolvedParty:
Name:
Address:

CLAIMANTDRIVER
PATRICIAHARRIS
21MAGNOLIAAVEE
SAINTPAUL,MN55117-5021
US

DOB:
Gender:
HomePhone:
SSN:

08/21/1968
FEMALE
(651)274-0839
XXX-XX-8025WASISSUEDbetween1981and1982inMS
***MorematchesonthisSSNoutsidethisreport***

AlsoKnownAs(AKA):
Name:

PATRICIAHARRIS

AlsoKnownAs(AKA):
Name:

PATRICIAHARRIS

AlsoKnownAs(AKA):

Address:

2448WHITESTOWNRD
WOODVILLE,MS39669-4295
US

ServiceProvider:
BusinessName:
TIN:
Address:

LAWYER-OTHER
MORRISBARTLTD
71-0921088WASISSUEDinLittleRockinAR
909POYDRASSTREET,20THFL
NEWORLEANS,LA70112-4030
US

BusinessPhone:

(228)432-9000

ServiceProvider:
BusinessName:
TIN:
Address:

LAWYER-OTHER
MORRISBARTLTD
71-0921088WASISSUEDinLittleRockinAR
909POYDRASSTREET,20THFL
NEWORLEANS,LA70112-4030
US

BusinessPhone:
CasualtyCoverageInformation:
CoverageType:
LossType:
ClaimStatus:
AdjusterCompany:
Adjuster:
AdjusterPhone:
AllegedInjury/PropertyDamage:
VehicleCoverageInformation:
CoverageType:
LossType:
AdjusterCompany:
ClaimStatus:
AdjusterPhone:
VIN:
Vehicle:
VehicleOdometerReading:
LastYearRegistered:

(228)432-9000

BODILYINJURY
OTHERAUTO
OPEN
ALLSTATEINSURANCECOMPANY
LEBLANC,KRIS
(504)219-3919
SORE,SORE,SORE

OTHERAUTO
OTHERAUTO
ALLSTATEINSURANCECOMPANY
OPEN
(800)349-1444
3N1CB51D26L453976(Pass)
2006NISSANSENTRA
0000111111
2000

InvolvedParty:
Name:
Address:

INSUREDDRIVER
DAVIDODDS
2052FAIRCHILDST
BATONROUGE,LA70807-5025
US

DOB:
Gender:

05/02/1963

HomePhone:
DriversLicense:

(225)892-9794

MALE

4675286

AlsoKnownAs(AKA):
Name:

DAVIDODDS

AlsoKnownAs(AKA):
Name:

DAVIDODDS

AlsoKnownAs(AKA):
Address:

13855KATHERINEAVE
BATONROUGE,LA70815-7229
US

VehicleCoverageInformation:
CoverageType:
LossType:
AdjusterCompany:
ClaimStatus:
AdjusterPhone:
VIN:
Vehicle:
LastYearRegistered:
VehicleCoverageInformation:
CoverageType:
LossType:
AdjusterCompany:
Adjuster:
ClaimStatus:
AdjusterPhone:
VIN:
Vehicle:
LastYearRegistered:

COLLISION
OTHERAUTO
ALLSTATEINSURANCECOMPANY
OPEN
(800)349-1444
1GNFC13058R139428(Pass)
2008CHEVROLETTAHOE
2000

COMPREHENSIVE
COMPREHENSIVE
ALLSTATEINSURANCECOMPANY
LEBLANC,KRIS
OPEN
(504)219-3919
1GNFC13058R139428(Pass)
2008CHEVROLETTAHOE
2000

back

MatchingClaim

FileNumber:9C003840892

Reason(s)formatch:

PHONE
LICENSEPLATENUMBER
VIN
PHONE

InsuringCompany:
ClaimNumber:
Date/TimeofLoss:
PolicyNumber:
PolicyType:
InceptionDate:
InsuringCo.Address:

LOUISIANAFARMBUREAUMUTUALINSCO
17A00066408
04/16/201503:30
AT06334
PERSONALAUTOMOBILE
12/15/2014ExpirationDate:06/15/2015
CLAIMCENTER
POBOX80319

InsuringCo.Phone:
CompanyReceivedDate:
LossDescription:
LocationofLoss:

BATONROUGE,LA70898
(225)922-6200
04/17/2015
3PWASSTOPPEDINTRAFFICWHENINSVEHR/E3PVEH
I-10
BATONROUGE,LA
US

InvolvedParty:
Name:
Address:

BOTHCLAIMANT&INSURED
ELIZABETHARRIAGA
APT704
4051BAYOURAPIDESRD

ALEXANDRIA,LA71303--406
US

DOB:
Gender:
CellularPhone:
Occupation:
VehicleCoverageInformation:
CoverageType:
LossType:
AdjusterCompany:
Adjuster:
ClaimStatus:

08/22/1990
FEMALE
(318)792-8920
HAIRDRESSER

COLLISION
COLLISION
LOUISIANAFARMBUREAUMUTUALINSCO
SMITH,MARCUS
OPEN

AdjusterPhone:
VIN:
Vehicle:
LastYearRegistered:

(318)445-4043

InvolvedParty:
Name:
Address:

CLAIMANTDRIVER

1FTEW1CM3BKD13494(Pass)
2011FORDF150SERIES
2000

PATRICIAHARRIS
2448WHITESTOWNRD
WOODVILLE,MS39669--429
US

HomePhone:

(601)888-4506

CellularPhone:
DriversLicense:

(651)274-0839
802678648State:MS

BODILYINJURY
BODILYINJURY
OPEN
LOUISIANAFARMBUREAUMUTUALINSCO
SMITH,MARCUS
(318)445-4043
BODYSORENESS

OTHERAUTO
OTHERAUTO
LOUISIANAFARMBUREAUMUTUALINSCO
SMITH,MARCUS
OPEN
(318)445-4043
3N1CB51D26L453976(Pass)
2006NISSANSENTRA
WKE553LicensePlateState:MS
2000

ISOStylesheetVersion:5.5ReleaseDate:03-03-2014

ACCC INSURANCE COMPANY

P O BOX 680247
HOUSTON, TX 77268

ACCC INSURANCE COMPANY

P O BOX 680247
HOUSTON, TX 77268

(281) 875-8363 or (888) 879-8363

TOTAL LOSS OFFER LETTER

Claim Number: C0008310-5

Date of Loss:
Insured:
Claimant:
Process Date:

PATRICIA HARRIS
1331 N SHERWOOD BLVD., APT 119
BATON ROUGE LA 70815

5/13/2015
PATRICIA HARRIS
PATRICIA HARRIS
6/22/2015

Dear Sir or Madam:

We have reviewed our file along with the supporting documents that have been submitted.
In an effort to resolve this claim we are prepared to settle your property damage claim for the amount of:
IF WE RETAIN YOUR TOTAL LOSS VEHICLE
ACTUAL CASH VALUE $
+ TAX $
+ FEE $
- DEDUCTIBLE $
OUR OFFER $

4850.00
242.50
15.00
500.00
4607.50

IF YOU RETAIN YOUR TOTAL LOSS VEHICLE

ACTUAL CASH VALUE $

4850.00

- SALVAGE VALUE $
- DEDUCTIBLE $
OUR OFFER $

0.00
500.00
0.00

If you choose to have us keep your total loss vehicle, you will need to sign a power of attorney and return it
with the original title to the vehicle.

Please contact the undersigned to discuss.

Sincerely,
BRANAESHA FRANKLIN Ext. Number: 7215
ACCC Insurance Company Adjuster

Generated 6/22/2015 10:25 AM

103_ACCC_TLOL_2009_01_01

ACCC INSURANCE COMPANY

P O BOX 680247
HOUSTON, TX 77268
(281) 875-8363 or (888) 879-8363

ACCC INSURANCE COMPANY

P O BOX 680247
HOUSTON, TX 77268

POWER OF ATTORNEY TO TRANSFER

MOTOR VEHICLE
Insured/Claimants Name and Address:

Claim Number: C0008310-5

Process Date: 6/22/2015

PATRICIA HARRIS
1331 N SHERWOOD BLVD., APT 119
BATON ROUGE LA 70815

C0008310-5

TSV

THE STATE OF MISSISSIPPI

KNOW ALL MEN BY THESE PRESENT:

COUNTY OF ________________________
WILKINSON

THAT I, __________________________________________________________________________________________
PATRICIA HARRIS
REGISTERED VEHICLE OWNER/OWNERS' NAME(S) AS PRINTED ON TITLE

_____________________________________________________________________________________,
OF THE COUNTY OF
1331 N SHERWOOD BLVD., APT 119, BATON ROUGE, LA 70815
REGISTERED VEHICLE OWNER/OWNERS' ADDRESS AS PRINTED ON TITLE

_____________________________________________________________________ and the STATE OF MISSISSIPPI, owner of

the following described motor vehicle, have made, constituted and appointed and by these present do make, constitute and appoint
________________________________________________________________________________________________________
_____________________________________________________________________________________, OF THE COUNTY OF
(Address)

_____________________________________________________________________ and the STATE OF MISSISSIPPI, my true

and lawful attorney, for me and in my name, place and stead to sell, transfer and assign the motor vehicle described as follows to wit:
2006
YEAR

NISSAN
MAKE

SENTRA 1.8/1.8S
STYLE

3N1CB51D26L453976
VEHICLE IDENTIFICATION #

WKE553
LICENSE #

giving and granting unto my said attorney full power and authority to do and perform all and every act requisite and necessary to
transfer and assign the legal title to said motor vehicle to anyone whomever, as may be designated by said attorney.
FEDERAL and STATE LAW requires that you state the mileage in connection with the transfer of ownership. Failure to complete
or providing a false statement may result in fines and / or imprisonment.
I certify to the best of my knowledge that the odometer reading is the actual mileage of the vehicle unless one of the following
statements is checked:
_______1. I hereby certify that the mileage state is in excess of the mechanical limits of the odometer.
Odometer Reading
(No Tenths)

_______2. The odometer reading is not actual mileage. WARNING-ODOMETER DISCREPANCY.

IN WITNESS WHEREOF I HAVE hereunto set my hand this ____________day of ___________________________, 20 _________.
Signature of Owner, Grantor

Printed Name of Grantor (if Title is in Company Name, include appropriate Title, Partner, President,, Sec. Treas., etc.)

Before me, the undersigned authority, on this day personally appeared __________________________________________________
(Individual Name Only)

known to me to be the person whose name is subscribed to the above foregoing instrument, and acknowledge to me that he executed
the same for the purposes and consideration therein expressed.
GIVEN UNDER MY HAND AND SEAL OF OFFICE THIS ________________________day of ______________________A.D.,
20__________.
Notary Public Signature
Generated 6/22/2015 10:27 AM

POA_MS_2012_05_14

INITIATINGCLAIMINFORMATION
ClaimNumber:
PolicyNumber:

C0008310
MSE0259823

DateofLoss:
ISOFileNumber:

05/13/2015

4L003857778

SUMMARYFOREACHSEARCHABLEPARTY
PATRICIAHARRIS,BOTHCLAIMANT&INSURED
Coverage:
MEDICALPAYMENTS
Coverage:
COLLISION

LossType:
LossType:

MEDICALPAYMENTS
COLLISION

#ofMatches

ISOFileNumber
H0181210286

H0227908504

H0227980244

2C002985474

2W003608755

5O003852441

9C003840892

ISOCLAIMSEARCHREPLACEMENTCLAIMDETAILS

PriorClaimsHistory

InitiatingClaim

FileNumber:4L003857778

Company:
RRECode:
TIN:
SiteId:
ClaimNumber:
Date/TimeofLoss:
PolicyNumber:
PolicyType:
InceptionDate:
CompanyReceivedDate:
ISOReceivedDate:
LossDescription:
LocationofLoss:

A73400009

InvolvedParty:
Name:
Address:

DOB:
Gender:
HomePhone:
StopCMSQuery:

BOTHCLAIMANT&INSURED

PATRICIAHARRIS
1331NSHERWOODBLVD.,APT119
BATONROUGE,LA70815
08/21/1968
FEMALE
(651)274-0839
YES

MEDICALPAYMENTS
MEDICALPAYMENTS
CLOSEDW/OPAYMENT
05/14/2015
ACCCINSURANCECOMPANY
CHESTPAIN,BRUISES,SEATBELTSCARS
NO

COLLISION
COLLISION
OPEN
3N1CB51D26L453976(Pass)

Vehicle:
VehicleType:
VehicleDisposition:
VehicleColor:
LicenseType:
LicensePlate:
SuitIndicator:

2006NISSANSENTRA
PASSENGERCAR
TOTALLOSS
BLUE
PASSENGERCAR
WKE553LicensePlateState:MS
NO

back

MatchingClaim
Reason(s)formatch:
FileNumber:
Coverage:
ClaimNumber:
ActivityType:
ActivityDate:
InsuranceCompany:
PolicyType:
PointofImpact:
VIN:
Vehicle:

FileNumber:H0181210286
VIN
H0181210286
COLLISION
HHZ3966001
ESTIMATE
06/30/2011
TRAVELERSINDEMNITYCOMPANY
Unknown
LEFTFRONTCORNER
3N1CB51D26L453976(Pass)
2006NISSANSENTRA

back

MatchingClaim
Reason(s)formatch:
FileNumber:
Coverage:
ClaimNumber:
ActivityType:
ActivityDate:
InsuranceCompany:
ContactPhone:
PolicyType:
PointofImpact:
VIN:

FileNumber:H0227908504
VIN
H0227908504
OTHERLIABILITY
000368735353B02
VALUATION
05/13/2015
ALLSTATEINSURANCECOMPANY
(800)255-7828
Unknown
UNKNOWN
3N1CB51D26L453976(Pass)

Vehicle:
Odometer:

2006NISSANSENTRA
120100

back

MatchingClaim

FileNumber:H0227980244

Reason(s)formatch:
FileNumber:
Coverage:
ClaimNumber:
ActivityType:
ActivityDate:
InsuranceCompany:
ContactPhone:
PolicyType:
PointofImpact:
VIN:
Vehicle:
Odometer:

VIN
H0227980244
LIABILITY
000368735353B02
ESTIMATE
05/13/2015
ALLSTATEINSURANCECOMPANY
(999)999-9999
Unknown
RIGHTSIDE
3N1CB51D26L453976(Pass)
2006NISSANSENTRA
120100

back

MatchingClaim
Reason(s)formatch:
InsuringCompany:
ClaimNumber:
Date/TimeofLoss:
PolicyNumber:
PolicyType:
InceptionDate:
AssignedRisk?:
InsuringCo.Address:

FileNumber:2C002985474
VIN
TRAVELERSINDEMNITYCOMPANY
HHZ3966001
06/30/2011
0M24649821790491011
PERSONALAUTOMOBILE
06/01/2011ExpirationDate:12/01/2011
NO
NAPERVILLEPLCLM-A273
POBOX3095*

InsuringCo.Phone:
CompanyReceivedDate:
LossDescription:
LocationofLoss:

NAPERVILLE,IL60566-7095
(800)842-6172
07/16/2011
OV1WASSTOPPEDATTHELIGHT&MADEASHARPLEFTT
,MN

InvolvedParty:
Name:
Address:

BOTHCLAIMANT&INSURED
JENNIFERTHEISEN
6911CORVALLISAVEN
CRYSTAL,MN55428-4333

back

MatchingClaim

FileNumber:2W003608755

Reason(s)formatch:
InsuringCompany:
ClaimNumber:
Date/TimeofLoss:
PolicyNumber:
PolicyType:
PolicyRenewed?:

VIN

AssignedRisk?:
InsuringCo.Address:

STATEFARM(R)AFFILIATE
2330S9866
04/15/2014
230232023
PERSONALAUTOMOBILE
NO

CIOS-00
ONESTATEFARMPLAZA

LossDescription:
CATRelated?:
Hit&RunAccident:
LocationofLoss:

BLOOMINGTON,IL61710
BLANK
NO
NO
,MN
US

PhysicalRisk:

380WHEELOCKPKWYEAPT324
SAINTPAUL,MN55130-3050

InvolvedParty:
Name:
Address:

INSURED
PATRICIAHARRIS
380WHEELOCKPKWYEAPT324
SAINTPAUL,MN55130-3050
US

VehicleCoverageInformation:
CoverageType:
LossType:
AdjusterCompany:
DateClaimClosed:
AdjusterPhone:
VIN:
Vehicle:
LastYearRegistered:
SuitIndicator:

TOWINGANDLABOR
TOWINGANDLABOR
STATEFARM(R)AFFILIATE
04/19/2014
(888)248-6961
3N1CB51D26L453976(Pass)
2006NISSANSENTRA
2000
NO

back

MatchingClaim

FileNumber:5O003852441

Reason(s)formatch:

VIN
PHONE
NAME

InsuringCompany:
ClaimNumber:
Date/TimeofLoss:
PolicyNumber:
PolicyType:
PolicyRenewed?:
InsuringCo.Address:

ALLSTATEINSURANCECOMPANY
0368735353
05/13/2015
000995043003
PERSONALAUTOMOBILE
YES
LOUISIANALIAB/CAS1640
3900NCAUSEWAY#400

InsuringCo.Phone:
LossDescription:
CATRelated?:
LocationofLoss:

METAIRIE,LA70002-0000
(504)834-3185
INTERSECTIONACCIDENT
NO
FLORIDABLVDANDSHERWOODFOREST
BATONROUGE,LA
US

InvolvedParty:

CLAIMANTDRIVER

Name:
Address:

PATRICIAHARRIS
21MAGNOLIAAVEE
SAINTPAUL,MN55117-5021
US

DOB:
Gender:
HomePhone:
SSN:

08/21/1968
FEMALE
(651)274-0839
XXX-XX-8025WASISSUEDbetween1981and1982inMS
***MorematchesonthisSSNoutsidethisreport***

AlsoKnownAs(AKA):
Name:

PATRICIAHARRIS

AlsoKnownAs(AKA):
Name:

PATRICIAHARRIS

AlsoKnownAs(AKA):
Address:

2448WHITESTOWNRD
WOODVILLE,MS39669-4295
US

ServiceProvider:
BusinessName:
TIN:
Address:

LAWYER-OTHER
MORRISBARTLTD
71-0921088WASISSUEDinLittleRockinAR
909POYDRASSTREET,20THFL
NEWORLEANS,LA70112-4030
US

BusinessPhone:

(228)432-9000

ServiceProvider:
BusinessName:
TIN:
Address:

LAWYER-OTHER
MORRISBARTLTD
71-0921088WASISSUEDinLittleRockinAR
909POYDRASSTREET,20THFL
NEWORLEANS,LA70112-4030
US

BusinessPhone:
CasualtyCoverageInformation:
CoverageType:
LossType:
ClaimStatus:
AdjusterCompany:

(228)432-9000

BODILYINJURY
OTHERAUTO
OPEN
ALLSTATEINSURANCECOMPANY

Adjuster:
AdjusterPhone:
AllegedInjury/PropertyDamage:
VehicleCoverageInformation:
CoverageType:
LossType:
AdjusterCompany:
ClaimStatus:
AdjusterPhone:
VIN:
Vehicle:
VehicleOdometerReading:
LastYearRegistered:

InvolvedParty:
Name:
Address:

LEBLANC,KRIS
(504)219-3919
SORE,SORE,SORE

OTHERAUTO
OTHERAUTO
ALLSTATEINSURANCECOMPANY
OPEN
(800)349-1444
3N1CB51D26L453976(Pass)
2006NISSANSENTRA
0000111111
2000

INSUREDDRIVER
DAVIDODDS
2052FAIRCHILDST
BATONROUGE,LA70807-5025
US

DOB:

05/02/1963

Gender:
HomePhone:
DriversLicense:

MALE
(225)892-9794
4675286

AlsoKnownAs(AKA):
Name:

DAVIDODDS

AlsoKnownAs(AKA):
Name:

DAVIDODDS

AlsoKnownAs(AKA):
Address:

13855KATHERINEAVE
BATONROUGE,LA70815-7229
US

VehicleCoverageInformation:
CoverageType:
LossType:
AdjusterCompany:

COLLISION
OTHERAUTO
ALLSTATEINSURANCECOMPANY

ClaimStatus:
AdjusterPhone:
VIN:
Vehicle:
LastYearRegistered:
VehicleCoverageInformation:
CoverageType:
LossType:
AdjusterCompany:
Adjuster:
ClaimStatus:
AdjusterPhone:
VIN:
Vehicle:
LastYearRegistered:

OPEN
(800)349-1444
1GNFC13058R139428(Pass)
2008CHEVROLETTAHOE
2000

COMPREHENSIVE
COMPREHENSIVE
ALLSTATEINSURANCECOMPANY
LEBLANC,KRIS
OPEN
(504)219-3919
1GNFC13058R139428(Pass)
2008CHEVROLETTAHOE
2000

back

MatchingClaim

FileNumber:9C003840892

Reason(s)formatch:

LICENSEPLATENUMBER
VIN
PHONE

InsuringCompany:
ClaimNumber:
Date/TimeofLoss:
PolicyNumber:
PolicyType:
InceptionDate:
InsuringCo.Address:

LOUISIANAFARMBUREAUMUTUALINSCO
17A00066408
04/16/201503:30
AT06334
PERSONALAUTOMOBILE
12/15/2014ExpirationDate:06/15/2015
CLAIMCENTER
POBOX80319

InsuringCo.Phone:
CompanyReceivedDate:
LossDescription:
LocationofLoss:

BATONROUGE,LA70898
(225)922-6200
04/17/2015
3PWASSTOPPEDINTRAFFICWHENINSVEHR/E3PVEH
I-10
BATONROUGE,LA
US

InvolvedParty:

BOTHCLAIMANT&INSURED

Name:
Address:

ELIZABETHARRIAGA
APT704
4051BAYOURAPIDESRD

ALEXANDRIA,LA71303--406
US

DOB:
Gender:
CellularPhone:
Occupation:
VehicleCoverageInformation:
CoverageType:
LossType:
AdjusterCompany:
Adjuster:
ClaimStatus:
AdjusterPhone:
VIN:
Vehicle:
LastYearRegistered:

InvolvedParty:
Name:
Address:

08/22/1990
FEMALE
(318)792-8920
HAIRDRESSER

COLLISION
COLLISION
LOUISIANAFARMBUREAUMUTUALINSCO
SMITH,MARCUS
OPEN
(318)445-4043
1FTEW1CM3BKD13494(Pass)
2011FORDF150SERIES
2000

CLAIMANTDRIVER
PATRICIAHARRIS
2448WHITESTOWNRD
WOODVILLE,MS39669--429
US

HomePhone:

(601)888-4506

CellularPhone:
DriversLicense:

(651)274-0839

CasualtyCoverageInformation:
CoverageType:
LossType:
ClaimStatus:
AdjusterCompany:
Adjuster:
AdjusterPhone:
AllegedInjury/PropertyDamage:
VehicleCoverageInformation:

802678648State:MS

BODILYINJURY
BODILYINJURY
OPEN
LOUISIANAFARMBUREAUMUTUALINSCO
SMITH,MARCUS
(318)445-4043
BODYSORENESS

CoverageType:
LossType:

OTHERAUTO

AdjusterCompany:
Adjuster:
ClaimStatus:
AdjusterPhone:
VIN:
Vehicle:
LicensePlate:

LOUISIANAFARMBUREAUMUTUALINSCO

LastYearRegistered:

2000

OTHERAUTO

SMITH,MARCUS
OPEN
(318)445-4043
3N1CB51D26L453976(Pass)
2006NISSANSENTRA
WKE553LicensePlateState:MS

ISOStylesheetVersion:5.5ReleaseDate:03-03-2014

INITIATINGCLAIMINFORMATION
ClaimNumber:
PolicyNumber:

C0008310
MSE0259823

DateofLoss:
ISOFileNumber:

05/13/2015

4L003857778

SUMMARYFOREACHSEARCHABLEPARTY
PATRICIAHARRIS,BOTHCLAIMANT&INSURED
Coverage:
MEDICALPAYMENTS
Coverage:
COLLISION

LossType:
LossType:

MEDICALPAYMENTS
COLLISION

#ofMatches

ISOFileNumber
H0181210286

H0227908504

H0227980244

2C002985474

2W003608755

5O003852441

9C003840892

ISOCLAIMSEARCHREPLACEMENTCLAIMDETAILS

PriorClaimsHistory

InitiatingClaim

FileNumber:4L003857778

Company:
RRECode:
TIN:
SiteId:
ClaimNumber:
Date/TimeofLoss:
PolicyNumber:
PolicyType:
InceptionDate:
CompanyReceivedDate:
ISOReceivedDate:
LossDescription:
LocationofLoss:

A73400009

InvolvedParty:
Name:
Address:

DOB:
Gender:
HomePhone:
StopCMSQuery:

BOTHCLAIMANT&INSURED

PATRICIAHARRIS
1331NSHERWOODFORESTDRAPT119
BATONROUGE,LA70815
08/21/1968
FEMALE
(651)274-0839
YES

MEDICALPAYMENTS
MEDICALPAYMENTS
CLOSEDW/OPAYMENT
05/14/2015
ACCCINSURANCECOMPANY
CHESTPAIN,BRUISES,SEATBELTSCARS
NO

COLLISION
COLLISION
OPEN
3N1CB51D26L453976(Pass)

Vehicle:
VehicleType:
VehicleDisposition:
VehicleColor:
LicenseType:
LicensePlate:
SuitIndicator:

2006NISSANSENTRA
PASSENGERCAR
TOTALLOSS
BLUE
PASSENGERCAR
WKE553LicensePlateState:MS
NO

back

MatchingClaim
Reason(s)formatch:
FileNumber:
Coverage:
ClaimNumber:
ActivityType:
ActivityDate:
InsuranceCompany:
PolicyType:
PointofImpact:
VIN:
Vehicle:

FileNumber:H0181210286
VIN
H0181210286
COLLISION
HHZ3966001
ESTIMATE
06/30/2011
TRAVELERSINDEMNITYCOMPANY
Unknown
LEFTFRONTCORNER
3N1CB51D26L453976(Pass)
2006NISSANSENTRA

back

MatchingClaim
Reason(s)formatch:
FileNumber:
Coverage:
ClaimNumber:
ActivityType:
ActivityDate:
InsuranceCompany:
ContactPhone:
PolicyType:
PointofImpact:
VIN:

FileNumber:H0227908504
VIN
H0227908504
OTHERLIABILITY
000368735353B02
VALUATION
05/13/2015
ALLSTATEINSURANCECOMPANY
(800)255-7828
Unknown
UNKNOWN
3N1CB51D26L453976(Pass)

Vehicle:
Odometer:

2006NISSANSENTRA
120100

back

MatchingClaim

FileNumber:H0227980244

Reason(s)formatch:
FileNumber:
Coverage:
ClaimNumber:
ActivityType:
ActivityDate:
InsuranceCompany:
ContactPhone:
PolicyType:
PointofImpact:
VIN:
Vehicle:
Odometer:

VIN
H0227980244
LIABILITY
000368735353B02
ESTIMATE
05/13/2015
ALLSTATEINSURANCECOMPANY
(999)999-9999
Unknown
RIGHTSIDE
3N1CB51D26L453976(Pass)
2006NISSANSENTRA
120100

back

MatchingClaim
Reason(s)formatch:
InsuringCompany:
ClaimNumber:
Date/TimeofLoss:
PolicyNumber:
PolicyType:
InceptionDate:
AssignedRisk?:
InsuringCo.Address:

FileNumber:2C002985474
VIN
TRAVELERSINDEMNITYCOMPANY
HHZ3966001
06/30/2011
0M24649821790491011
PERSONALAUTOMOBILE
06/01/2011ExpirationDate:12/01/2011
NO
NAPERVILLEPLCLM-A273
POBOX3095*

InsuringCo.Phone:
CompanyReceivedDate:
LossDescription:
LocationofLoss:

NAPERVILLE,IL60566-7095
(800)842-6172
07/16/2011
OV1WASSTOPPEDATTHELIGHT&MADEASHARPLEFTT
,MN

InvolvedParty:
Name:
Address:

BOTHCLAIMANT&INSURED
JENNIFERTHEISEN
6911CORVALLISAVEN
CRYSTAL,MN55428-4333

back

MatchingClaim

FileNumber:2W003608755

Reason(s)formatch:
InsuringCompany:
ClaimNumber:
Date/TimeofLoss:
PolicyNumber:
PolicyType:
PolicyRenewed?:

VIN

AssignedRisk?:
InsuringCo.Address:

STATEFARM(R)AFFILIATE
2330S9866
04/15/2014
230232023
PERSONALAUTOMOBILE
NO

CIOS-00
ONESTATEFARMPLAZA

LossDescription:
CATRelated?:
Hit&RunAccident:
LocationofLoss:

BLOOMINGTON,IL61710
BLANK
NO
NO
,MN
US

PhysicalRisk:

380WHEELOCKPKWYEAPT324
SAINTPAUL,MN55130-3050

InvolvedParty:
Name:
Address:

INSURED
PATRICIAHARRIS
380WHEELOCKPKWYEAPT324
SAINTPAUL,MN55130-3050
US

VehicleCoverageInformation:
CoverageType:
LossType:
AdjusterCompany:
DateClaimClosed:
AdjusterPhone:
VIN:
Vehicle:
LastYearRegistered:
SuitIndicator:

TOWINGANDLABOR
TOWINGANDLABOR
STATEFARM(R)AFFILIATE
04/19/2014
(888)248-6961
3N1CB51D26L453976(Pass)
2006NISSANSENTRA
2000
NO

back

MatchingClaim

FileNumber:5O003852441

Reason(s)formatch:

VIN
PHONE
NAME

InsuringCompany:
ClaimNumber:
Date/TimeofLoss:
PolicyNumber:
PolicyType:
PolicyRenewed?:
InsuringCo.Address:

ALLSTATEINSURANCECOMPANY
0368735353
05/13/2015
000995043003
PERSONALAUTOMOBILE
YES
LOUISIANALIAB/CAS1640
3900NCAUSEWAY#400

InsuringCo.Phone:
LossDescription:
CATRelated?:
LocationofLoss:

METAIRIE,LA70002-0000
(504)834-3185
INTERSECTIONACCIDENT
NO
FLORIDABLVDANDSHERWOODFOREST
BATONROUGE,LA
US

InvolvedParty:

CLAIMANTDRIVER

Name:
Address:

PATRICIAHARRIS
21MAGNOLIAAVEE
SAINTPAUL,MN55117-5021
US

DOB:
Gender:
HomePhone:
SSN:

08/21/1968
FEMALE
(651)274-0839
XXX-XX-8025WASISSUEDbetween1981and1982inMS
***MorematchesonthisSSNoutsidethisreport***

AlsoKnownAs(AKA):
Name:

PATRICIAHARRIS

AlsoKnownAs(AKA):
Name:

PATRICIAHARRIS

AlsoKnownAs(AKA):
Address:

2448WHITESTOWNRD
WOODVILLE,MS39669-4295
US

ServiceProvider:
BusinessName:
TIN:
Address:

LAWYER-OTHER
MORRISBARTLTD
71-0921088WASISSUEDinLittleRockinAR
909POYDRASSTREET,20THFL
NEWORLEANS,LA70112-4030
US

BusinessPhone:

(228)432-9000

ServiceProvider:
BusinessName:
TIN:
Address:

LAWYER-OTHER
MORRISBARTLTD
71-0921088WASISSUEDinLittleRockinAR
909POYDRASSTREET,20THFL
NEWORLEANS,LA70112-4030
US

BusinessPhone:
CasualtyCoverageInformation:
CoverageType:
LossType:
ClaimStatus:
AdjusterCompany:

(228)432-9000

BODILYINJURY
OTHERAUTO
OPEN
ALLSTATEINSURANCECOMPANY

InvolvedParty:
Name:
Address:

LEBLANC,KRIS
(504)219-3919
SORE,SORE,SORE

OTHERAUTO
OTHERAUTO
ALLSTATEINSURANCECOMPANY
OPEN
(800)349-1444
3N1CB51D26L453976(Pass)
2006NISSANSENTRA
0000111111
2000

INSUREDDRIVER
DAVIDODDS
2052FAIRCHILDST
BATONROUGE,LA70807-5025
US

DOB:

05/02/1963

Gender:
HomePhone:
DriversLicense:

MALE
(225)892-9794
4675286

AlsoKnownAs(AKA):
Name:

DAVIDODDS

AlsoKnownAs(AKA):
Name:

DAVIDODDS

AlsoKnownAs(AKA):
Address:

13855KATHERINEAVE
BATONROUGE,LA70815-7229
US

VehicleCoverageInformation:
CoverageType:
LossType:
AdjusterCompany:

COLLISION
OTHERAUTO
ALLSTATEINSURANCECOMPANY

OPEN
(800)349-1444
1GNFC13058R139428(Pass)
2008CHEVROLETTAHOE
2000

COMPREHENSIVE
COMPREHENSIVE
ALLSTATEINSURANCECOMPANY
LEBLANC,KRIS
OPEN
(504)219-3919
1GNFC13058R139428(Pass)
2008CHEVROLETTAHOE
2000

back

MatchingClaim

FileNumber:9C003840892

Reason(s)formatch:

LICENSEPLATENUMBER
VIN
PHONE

InsuringCompany:
ClaimNumber:
Date/TimeofLoss:
PolicyNumber:
PolicyType:
InceptionDate:
InsuringCo.Address:

LOUISIANAFARMBUREAUMUTUALINSCO
17A00066408
04/16/201503:30
AT06334
PERSONALAUTOMOBILE
12/15/2014ExpirationDate:06/15/2015
CLAIMCENTER
POBOX80319

InsuringCo.Phone:
CompanyReceivedDate:
LossDescription:
LocationofLoss:

BATONROUGE,LA70898
(225)922-6200
04/17/2015
3PWASSTOPPEDINTRAFFICWHENINSVEHR/E3PVEH
I-10
BATONROUGE,LA
US

InvolvedParty:

BOTHCLAIMANT&INSURED

Name:
Address:

ELIZABETHARRIAGA
APT704
4051BAYOURAPIDESRD

ALEXANDRIA,LA71303--406
US

DOB:
Gender:
CellularPhone:
Occupation:
VehicleCoverageInformation:
CoverageType:
LossType:
AdjusterCompany:
Adjuster:
ClaimStatus:
AdjusterPhone:
VIN:
Vehicle:
LastYearRegistered:

InvolvedParty:
Name:
Address:

08/22/1990
FEMALE
(318)792-8920
HAIRDRESSER

COLLISION
COLLISION
LOUISIANAFARMBUREAUMUTUALINSCO
SMITH,MARCUS
OPEN
(318)445-4043
1FTEW1CM3BKD13494(Pass)
2011FORDF150SERIES
2000

CLAIMANTDRIVER
PATRICIAHARRIS
2448WHITESTOWNRD
WOODVILLE,MS39669--429
US

HomePhone:

(601)888-4506

CellularPhone:
DriversLicense:

(651)274-0839

CasualtyCoverageInformation:
CoverageType:
LossType:
ClaimStatus:
AdjusterCompany:
Adjuster:
AdjusterPhone:
AllegedInjury/PropertyDamage:
VehicleCoverageInformation:

802678648State:MS

BODILYINJURY
BODILYINJURY
OPEN
LOUISIANAFARMBUREAUMUTUALINSCO
SMITH,MARCUS
(318)445-4043
BODYSORENESS

CoverageType:
LossType:

OTHERAUTO

AdjusterCompany:
Adjuster:
ClaimStatus:
AdjusterPhone:
VIN:
Vehicle:
LicensePlate:

LOUISIANAFARMBUREAUMUTUALINSCO

LastYearRegistered:

2000

OTHERAUTO

SMITH,MARCUS
OPEN
(318)445-4043
3N1CB51D26L453976(Pass)
2006NISSANSENTRA
WKE553LicensePlateState:MS

ISOStylesheetVersion:5.5ReleaseDate:03-03-2014

INITIATINGCLAIMINFORMATION
ClaimNumber:
PolicyNumber:

C0008310
MSE0259823

DateofLoss:
ISOFileNumber:

05/13/2015

4L003857778

SUMMARYFOREACHSEARCHABLEPARTY
PATRICIAHARRIS,BOTHCLAIMANT&INSURED
Coverage:
MEDICALPAYMENTS
Coverage:
COLLISION

LossType:
LossType:

MEDICALPAYMENTS
COLLISION

#ofMatches

PriorClaimsHistory

ISOFileNumber
5O003852441

9C003840892

ISOCLAIMSEARCHREPLACEMENTCLAIMDETAILS

InitiatingClaim
Company:
RRECode:
TIN:
SiteId:
ClaimNumber:

FileNumber:4L003857778
A73400009
000011301
75-2701220
000011301
C0008310

Date/TimeofLoss:
PolicyNumber:
PolicyType:
InceptionDate:
CompanyReceivedDate:
ISOReceivedDate:
LossDescription:
LocationofLoss:

05/13/201520:30

InvolvedParty:
Name:
Address:

DOB:
Gender:
HomePhone:
StopCMSQuery:

BOTHCLAIMANT&INSURED

MSE0259823
PERSONALAUTOMOBILE
08/20/2014ExpirationDate:09/03/2015
05/14/2015
05/14/2015
IVWASTURNINGLEFTANDCVRANREDLIGHTANDSTRUC
11300FLORIDABLVD/SHERWOODFOREST
BATONROUGE,LA

PATRICIAHARRIS
1331NSHERWOODFORESTDRAPT119
BATONROUGE,LA70815
08/21/1968
FEMALE
(651)274-0839
YES

MEDICALPAYMENTS
MEDICALPAYMENTS
CLOSEDW/OPAYMENT
05/14/2015
ACCCINSURANCECOMPANY
CHESTPAIN,BRUISES,SEATBELTSCARS
NO

COLLISION
COLLISION
OPEN
3N1CB51D26L453976(Pass)
2006NISSANSENTRA
PASSENGERCAR
TOTALLOSS
BLUE
PASSENGERCAR
WKE553LicensePlateState:MS

SuitIndicator:

back

MatchingClaim
FileNumber:
Coverage:
ClaimNumber:
ActivityType:
ActivityDate:
InsuranceCompany:
PolicyType:
PointofImpact:
VIN:
Vehicle:

FileNumber:H0181210286
H0181210286
COLLISION
HHZ3966001
ESTIMATE
06/30/2011
TRAVELERSINDEMNITYCOMPANY
Unknown
LEFTFRONTCORNER
3N1CB51D26L453976(Pass)
2006NISSANSENTRA

back

MatchingClaim
FileNumber:
Coverage:
ClaimNumber:
ActivityType:
ActivityDate:
InsuranceCompany:
ContactPhone:
PolicyType:
PointofImpact:
VIN:
Vehicle:
Odometer:

FileNumber:H0227908504
H0227908504
OTHERLIABILITY
000368735353B02
VALUATION
05/13/2015
ALLSTATEINSURANCECOMPANY
(800)255-7828
Unknown
UNKNOWN
3N1CB51D26L453976(Pass)
2006NISSANSENTRA
120100

back

MatchingClaim
FileNumber:

FileNumber:H0227980244
H0227980244

Coverage:
ClaimNumber:
ActivityType:
ActivityDate:
InsuranceCompany:
ContactPhone:
PolicyType:
PointofImpact:
VIN:
Vehicle:
Odometer:

LIABILITY
000368735353B02
ESTIMATE
05/13/2015
ALLSTATEINSURANCECOMPANY
(999)999-9999
Unknown
RIGHTSIDE
3N1CB51D26L453976(Pass)
2006NISSANSENTRA
120100

back

MatchingClaim
InsuringCompany:
ClaimNumber:
Date/TimeofLoss:
PolicyNumber:
PolicyType:
InceptionDate:
AssignedRisk?:
InsuringCo.Address:

FileNumber:2C002985474
TRAVELERSINDEMNITYCOMPANY
HHZ3966001
06/30/2011
0M24649821790491011
PERSONALAUTOMOBILE
06/01/2011ExpirationDate:12/01/2011
NO
NAPERVILLEPLCLM-A273
POBOX3095*

InsuringCo.Phone:
CompanyReceivedDate:
LossDescription:
LocationofLoss:

NAPERVILLE,IL60566-7095

InvolvedParty:
Name:
Address:

BOTHCLAIMANT&INSURED

(800)842-6172
07/16/2011
OV1WASSTOPPEDATTHELIGHT&MADEASHARPLEFTT
,MN

JENNIFERTHEISEN
6911CORVALLISAVEN
CRYSTAL,MN55428-4333

VehicleCoverageInformation:
CoverageType:
COLLISION
LossType:
COLLISION
AdjusterCompany:
TRAVELERSINDEMNITYCOMPANY

Adjuster:
DateClaimClosed:
AdjusterPhone:
VIN:
Vehicle:
LastYearRegistered:

JASONFIRLIT
04/06/2012
(630)961-8670
3N1CB51D26L453976(Pass)
2006NISSANSENTRA
2000

back

MatchingClaim

FileNumber:2W003608755

InsuringCompany:
ClaimNumber:
Date/TimeofLoss:
PolicyNumber:

STATEFARM(R)AFFILIATE

PolicyType:
PolicyRenewed?:
AssignedRisk?:
InsuringCo.Address:

PERSONALAUTOMOBILE

2330S9866
04/15/2014
230232023

NO
NO
CIOS-00
ONESTATEFARMPLAZA

LossDescription:
CATRelated?:
Hit&RunAccident:
LocationofLoss:

BLOOMINGTON,IL61710
BLANK
NO
NO
,MN
US

PhysicalRisk:

380WHEELOCKPKWYEAPT324

InvolvedParty:
Name:
Address:

INSURED

SAINTPAUL,MN55130-3050

PATRICIAHARRIS
380WHEELOCKPKWYEAPT324
SAINTPAUL,MN55130-3050
US

VehicleCoverageInformation:
CoverageType:
LossType:
AdjusterCompany:
DateClaimClosed:

TOWINGANDLABOR
TOWINGANDLABOR
STATEFARM(R)AFFILIATE
04/19/2014

AdjusterPhone:
VIN:
Vehicle:
LastYearRegistered:
SuitIndicator:

(888)248-6961
3N1CB51D26L453976(Pass)
2006NISSANSENTRA
2000
NO

back

MatchingClaim

FileNumber:5O003852441

Reason(s)formatch:

PHONE
NAME

InsuringCompany:
ClaimNumber:
Date/TimeofLoss:
PolicyNumber:
PolicyType:
PolicyRenewed?:
InsuringCo.Address:

ALLSTATEINSURANCECOMPANY
0368735353
05/13/2015
000995043003
PERSONALAUTOMOBILE
YES
LOUISIANALIAB/CAS1640
3900NCAUSEWAY#400

InsuringCo.Phone:
LossDescription:
CATRelated?:
LocationofLoss:

METAIRIE,LA70002-0000
(504)834-3185
INTERSECTIONACCIDENT
NO
FLORIDABLVDANDSHERWOODFOREST
BATONROUGE,LA
US

InvolvedParty:
Name:
Address:

CLAIMANTDRIVER
PATRICIAHARRIS
21MAGNOLIAAVEE
SAINTPAUL,MN55117-5021
US

DOB:
Gender:
HomePhone:
SSN:

08/21/1968
FEMALE
(651)274-0839
XXX-XX-8025WASISSUEDbetween1981and1982inMS
***MorematchesonthisSSNoutsidethisreport***

AlsoKnownAs(AKA):
Name:

PATRICIAHARRIS

AlsoKnownAs(AKA):
Name:
AlsoKnownAs(AKA):
Address:

PATRICIAHARRIS

2448WHITESTOWNRD
WOODVILLE,MS39669-4295
US

ServiceProvider:
BusinessName:
TIN:
Address:

LAWYER-OTHER
MORRISBARTLTD
71-0921088WASISSUEDinLittleRockinAR
909POYDRASSTREET,20THFL
NEWORLEANS,LA70112-4030
US

BusinessPhone:

(228)432-9000

ServiceProvider:
BusinessName:
TIN:
Address:

LAWYER-OTHER
MORRISBARTLTD
71-0921088WASISSUEDinLittleRockinAR
909POYDRASSTREET,20THFL
NEWORLEANS,LA70112-4030
US

(228)432-9000

BODILYINJURY
OTHERAUTO
OPEN
ALLSTATEINSURANCECOMPANY
LEBLANC,KRIS
(504)219-3919
SORE,SORE,SORE

OTHERAUTO
OTHERAUTO
ALLSTATEINSURANCECOMPANY
OPEN
(800)349-1444
3N1CB51D26L453976(Pass)

Vehicle:
VehicleOdometerReading:
LastYearRegistered:

2006NISSANSENTRA

InvolvedParty:
Name:
Address:

INSUREDDRIVER

0000111111
2000

DAVIDODDS
2052FAIRCHILDST
BATONROUGE,LA70807-5025
US

DOB:
Gender:
HomePhone:
DriversLicense:

05/02/1963
MALE
(225)892-9794
4675286

AlsoKnownAs(AKA):
Name:

DAVIDODDS

AlsoKnownAs(AKA):
Name:

DAVIDODDS

AlsoKnownAs(AKA):
Address:

13855KATHERINEAVE
BATONROUGE,LA70815-7229
US

COLLISION
OTHERAUTO
ALLSTATEINSURANCECOMPANY
OPEN
(800)349-1444
1GNFC13058R139428(Pass)
2008CHEVROLETTAHOE
2000

COMPREHENSIVE
COMPREHENSIVE
ALLSTATEINSURANCECOMPANY
LEBLANC,KRIS

ClaimStatus:
AdjusterPhone:
VIN:
Vehicle:
LastYearRegistered:

OPEN
(504)219-3919
1GNFC13058R139428(Pass)
2008CHEVROLETTAHOE
2000

back

MatchingClaim
Reason(s)formatch:
InsuringCompany:
ClaimNumber:
Date/TimeofLoss:
PolicyNumber:
PolicyType:
InceptionDate:
InsuringCo.Address:

FileNumber:9C003840892
PHONE
LOUISIANAFARMBUREAUMUTUALINSCO
17A00066408
04/16/201503:30
AT06334
PERSONALAUTOMOBILE
12/15/2014ExpirationDate:06/15/2015
CLAIMCENTER
POBOX80319

InsuringCo.Phone:
CompanyReceivedDate:
LossDescription:
LocationofLoss:

BATONROUGE,LA70898
(225)922-6200
04/17/2015
3PWASSTOPPEDINTRAFFICWHENINSVEHR/E3PVEH
I-10
BATONROUGE,LA
US

InvolvedParty:
Name:
Address:

BOTHCLAIMANT&INSURED
ELIZABETHARRIAGA
APT704
4051BAYOURAPIDESRD

ALEXANDRIA,LA71303--406
US

DOB:
Gender:
CellularPhone:
Occupation:
VehicleCoverageInformation:
CoverageType:

08/22/1990
FEMALE
(318)792-8920
HAIRDRESSER

COLLISION

LossType:
AdjusterCompany:
Adjuster:
ClaimStatus:
AdjusterPhone:
VIN:
Vehicle:
LastYearRegistered:

COLLISION

InvolvedParty:
Name:
Address:

CLAIMANTDRIVER

LOUISIANAFARMBUREAUMUTUALINSCO
SMITH,MARCUS
OPEN
(318)445-4043
1FTEW1CM3BKD13494(Pass)
2011FORDF150SERIES
2000

PATRICIAHARRIS
2448WHITESTOWNRD
WOODVILLE,MS39669--429
US

HomePhone:

(601)888-4506

CellularPhone:
DriversLicense:

(651)274-0839
802678648State:MS

BODILYINJURY
BODILYINJURY
OPEN
LOUISIANAFARMBUREAUMUTUALINSCO
SMITH,MARCUS
(318)445-4043
BODYSORENESS

OTHERAUTO
OTHERAUTO
LOUISIANAFARMBUREAUMUTUALINSCO
SMITH,MARCUS
OPEN
(318)445-4043
3N1CB51D26L453976(Pass)
2006NISSANSENTRA
WKE553LicensePlateState:MS
2000

ISOStylesheetVersion:5.5ReleaseDate:03-03-2014

ACCC INSURANCE COMPANY

P O BOX 680247
HOUSTON, TX 77268

ACCC INSURANCE COMPANY

P O BOX 680247
HOUSTON, TX 77268

(281) 875-8363 or (888) 879-8363

TOTAL LOSS OFFER LETTER

Claim Number: C0008310-5

PATRICIA HARRIS
1331 N SHERWOOD FOREST DR APT 119
BATON ROUGE LA 70815

Date of Loss:
Insured:
Claimant:
Process Date:

5/13/2015
PATRICIA HARRIS
PATRICIA HARRIS
6/26/2015

Dear Sir or Madam:

4850.00
485.00
35.00
500.00
4870.00

IF YOU RETAIN YOUR TOTAL LOSS VEHICLE

ACTUAL CASH VALUE $

4850.00

- SALVAGE VALUE $
- DEDUCTIBLE $
OUR OFFER $

0.00
500.00
0.00

If you choose to have us keep your total loss vehicle, you will need to sign a power of attorney and return it
with the original title to the vehicle.

Please contact the undersigned to discuss.

Sincerely,
BRANAESHA FRANKLIN Ext. Number: 7215
ACCC Insurance Company Adjuster

Generated 6/26/2015 1:33 PM

103_ACCC_TLOL_2009_01_01

INITIATINGCLAIMINFORMATION
ClaimNumber:
PolicyNumber:

C0008310
MSE0259823

DateofLoss:
ISOFileNumber:

05/13/2015

4L003857778

SUMMARYFOREACHSEARCHABLEPARTY
PATRICIAHARRIS,BOTHCLAIMANT&INSURED
Coverage:
MEDICALPAYMENTS
Coverage:
COLLISION

LossType:
LossType:

MEDICALPAYMENTS
COLLISION

#ofMatches

ISOFileNumber
H0181210286

H0227908504

H0227980244

2C002985474

2W003608755

5O003852441

9C003840892

ISOCLAIMSEARCHREPLACEMENTCLAIMDETAILS

PriorClaimsHistory

InitiatingClaim

FileNumber:4L003857778

Company:
RRECode:
TIN:
SiteId:
ClaimNumber:
Date/TimeofLoss:
PolicyNumber:
PolicyType:
InceptionDate:
CompanyReceivedDate:
ISOReceivedDate:
LossDescription:
LocationofLoss:

A73400009

InvolvedParty:
Name:
Address:

DOB:
Gender:
HomePhone:
StopCMSQuery:

BOTHCLAIMANT&INSURED

PATRICIAHARRIS
1331NSHERWOODFORESTDRAPT119
BATONROUGE,LA70815
08/21/1968
FEMALE
(651)274-0839
YES

MEDICALPAYMENTS
MEDICALPAYMENTS
CLOSEDW/OPAYMENT
05/14/2015
ACCCINSURANCECOMPANY
CHESTPAIN,BRUISES,SEATBELTSCARS
NO

COLLISION
COLLISION
SALVAGEPENDING
07/07/2015

VIN:
Vehicle:
VehicleType:
VehicleDisposition:
VehicleColor:
LicenseType:
LicensePlate:
SuitIndicator:

3N1CB51D26L453976(Pass)
2006NISSANSENTRA
PASSENGERCAR
TOTALLOSS
BLUE
PASSENGERCAR
WKE553LicensePlateState:MS
NO

back

MatchingClaim
Reason(s)formatch:
FileNumber:
Coverage:
ClaimNumber:
ActivityType:
ActivityDate:
InsuranceCompany:
PolicyType:
PointofImpact:
VIN:
Vehicle:

FileNumber:H0181210286
VIN
H0181210286
COLLISION
HHZ3966001
ESTIMATE
06/30/2011
TRAVELERSINDEMNITYCOMPANY
Unknown
LEFTFRONTCORNER
3N1CB51D26L453976(Pass)
2006NISSANSENTRA

back

MatchingClaim
Reason(s)formatch:
FileNumber:
Coverage:
ClaimNumber:
ActivityType:
ActivityDate:
InsuranceCompany:
ContactPhone:
PolicyType:
PointofImpact:

FileNumber:H0227908504
VIN
H0227908504
OTHERLIABILITY
000368735353B02
VALUATION
05/13/2015
ALLSTATEINSURANCECOMPANY
(800)255-7828
Unknown
UNKNOWN

VIN:
Vehicle:
Odometer:

3N1CB51D26L453976(Pass)
2006NISSANSENTRA
120100

back

MatchingClaim

FileNumber:H0227980244

Reason(s)formatch:
FileNumber:
Coverage:
ClaimNumber:
ActivityType:
ActivityDate:
InsuranceCompany:
ContactPhone:
PolicyType:
PointofImpact:
VIN:
Vehicle:
Odometer:

VIN
H0227980244
LIABILITY
000368735353B02
ESTIMATE
05/13/2015
ALLSTATEINSURANCECOMPANY
(999)999-9999
Unknown
RIGHTSIDE
3N1CB51D26L453976(Pass)
2006NISSANSENTRA
120100

back

MatchingClaim
Reason(s)formatch:
InsuringCompany:
ClaimNumber:
Date/TimeofLoss:
PolicyNumber:
PolicyType:
InceptionDate:
AssignedRisk?:
InsuringCo.Address:

FileNumber:2C002985474
VIN
TRAVELERSINDEMNITYCOMPANY
HHZ3966001
06/30/2011
0M24649821790491011
PERSONALAUTOMOBILE
06/01/2011ExpirationDate:12/01/2011
NO
NAPERVILLEPLCLM-A273
POBOX3095*

InsuringCo.Phone:
CompanyReceivedDate:
LossDescription:
LocationofLoss:

NAPERVILLE,IL60566-7095
(800)842-6172
07/16/2011
OV1WASSTOPPEDATTHELIGHT&MADEASHARPLEFTT
,MN

InvolvedParty:
Name:
Address:

BOTHCLAIMANT&INSURED
JENNIFERTHEISEN
6911CORVALLISAVEN
CRYSTAL,MN55428-4333

back

MatchingClaim

FileNumber:2W003608755

Reason(s)formatch:
InsuringCompany:
ClaimNumber:
Date/TimeofLoss:
PolicyNumber:
PolicyType:
PolicyRenewed?:

VIN

AssignedRisk?:
InsuringCo.Address:

STATEFARM(R)AFFILIATE
2330S9866
04/15/2014
230232023
PERSONALAUTOMOBILE
NO

CIOS-00
ONESTATEFARMPLAZA

LossDescription:
CATRelated?:
Hit&RunAccident:
LocationofLoss:

BLOOMINGTON,IL61710
BLANK
NO
NO
,MN
US

PhysicalRisk:

380WHEELOCKPKWYEAPT324
SAINTPAUL,MN55130-3050

InvolvedParty:
Name:
Address:

INSURED
PATRICIAHARRIS
380WHEELOCKPKWYEAPT324
SAINTPAUL,MN55130-3050
US

VehicleCoverageInformation:
CoverageType:
LossType:
AdjusterCompany:
DateClaimClosed:
AdjusterPhone:
VIN:
Vehicle:
LastYearRegistered:
SuitIndicator:

TOWINGANDLABOR
TOWINGANDLABOR
STATEFARM(R)AFFILIATE
04/19/2014
(888)248-6961
3N1CB51D26L453976(Pass)
2006NISSANSENTRA
2000
NO

back

MatchingClaim

FileNumber:5O003852441

Reason(s)formatch:

VIN
PHONE
NAME

InsuringCompany:
ClaimNumber:
Date/TimeofLoss:
PolicyNumber:
PolicyType:
PolicyRenewed?:
InsuringCo.Address:

ALLSTATEINSURANCECOMPANY
0368735353
05/13/2015
000995043003
PERSONALAUTOMOBILE
YES
LOUISIANALIAB/CAS1640
3900NCAUSEWAY#400

InsuringCo.Phone:
LossDescription:
CATRelated?:
LocationofLoss:

METAIRIE,LA70002-0000
(504)834-3185
INTERSECTIONACCIDENT
NO
FLORIDABLVDANDSHERWOODFOREST
BATONROUGE,LA
US

InvolvedParty:
Name:
Address:

CLAIMANTDRIVER
PATRICIAHARRIS
21MAGNOLIAAVEE
SAINTPAUL,MN55117-5021
US

DOB:
Gender:
HomePhone:
SSN:

08/21/1968
FEMALE
(651)274-0839
XXX-XX-8025WASISSUEDbetween1981and1982inMS
***MorematchesonthisSSNoutsidethisreport***

AlsoKnownAs(AKA):
Name:

PATRICIAHARRIS

AlsoKnownAs(AKA):
Name:

PATRICIAHARRIS

AlsoKnownAs(AKA):
Address:

2448WHITESTOWNRD
WOODVILLE,MS39669-4295
US

ServiceProvider:
BusinessName:
TIN:
Address:

LAWYER-OTHER
MORRISBARTLTD
71-0921088WASISSUEDinLittleRockinAR
909POYDRASSTREET,20THFL
NEWORLEANS,LA70112-4030
US

BusinessPhone:

(228)432-9000

ServiceProvider:
BusinessName:
TIN:
Address:

LAWYER-OTHER
MORRISBARTLTD
71-0921088WASISSUEDinLittleRockinAR
909POYDRASSTREET,20THFL
NEWORLEANS,LA70112-4030
US

BusinessPhone:
CasualtyCoverageInformation:
CoverageType:
LossType:
ClaimStatus:

(228)432-9000

BODILYINJURY
OTHERAUTO
OPEN

AdjusterCompany:
Adjuster:
AdjusterPhone:
AllegedInjury/PropertyDamage:
VehicleCoverageInformation:
CoverageType:
LossType:
AdjusterCompany:
ClaimStatus:
AdjusterPhone:
VIN:
Vehicle:
VehicleOdometerReading:
LastYearRegistered:

InvolvedParty:
Name:
Address:

ALLSTATEINSURANCECOMPANY
LEBLANC,KRIS
(504)219-3919
SORE,SORE,SORE

OTHERAUTO
OTHERAUTO
ALLSTATEINSURANCECOMPANY
OPEN
(800)349-1444
3N1CB51D26L453976(Pass)
2006NISSANSENTRA
0000111111
2000

INSUREDDRIVER
DAVIDODDS
2052FAIRCHILDST
BATONROUGE,LA70807-5025
US

DOB:

05/02/1963

Gender:
HomePhone:
DriversLicense:

MALE
(225)892-9794
4675286

AlsoKnownAs(AKA):
Name:

DAVIDODDS

AlsoKnownAs(AKA):
Name:

DAVIDODDS

AlsoKnownAs(AKA):
Address:

13855KATHERINEAVE
BATONROUGE,LA70815-7229
US

VehicleCoverageInformation:
CoverageType:
LossType:

COLLISION
OTHERAUTO

AdjusterCompany:
ClaimStatus:
AdjusterPhone:
VIN:
Vehicle:
LastYearRegistered:
VehicleCoverageInformation:
CoverageType:
LossType:
AdjusterCompany:
Adjuster:
ClaimStatus:
AdjusterPhone:
VIN:
Vehicle:
LastYearRegistered:

ALLSTATEINSURANCECOMPANY
OPEN
(800)349-1444
1GNFC13058R139428(Pass)
2008CHEVROLETTAHOE
2000

COMPREHENSIVE
COMPREHENSIVE
ALLSTATEINSURANCECOMPANY
LEBLANC,KRIS
OPEN
(504)219-3919
1GNFC13058R139428(Pass)
2008CHEVROLETTAHOE
2000

back

MatchingClaim

FileNumber:9C003840892

Reason(s)formatch:

LICENSEPLATENUMBER
VIN
PHONE

InsuringCompany:
ClaimNumber:
Date/TimeofLoss:
PolicyNumber:
PolicyType:
InceptionDate:
InsuringCo.Address:

LOUISIANAFARMBUREAUMUTUALINSCO
17A00066408
04/16/201503:30
AT06334
PERSONALAUTOMOBILE
12/15/2014ExpirationDate:06/15/2015
CLAIMCENTER
POBOX80319

InsuringCo.Phone:
CompanyReceivedDate:
LossDescription:
LocationofLoss:

BATONROUGE,LA70898
(225)922-6200
04/17/2015
3PWASSTOPPEDINTRAFFICWHENINSVEHR/E3PVEH
I-10
BATONROUGE,LA
US

InvolvedParty:
Name:
Address:

BOTHCLAIMANT&INSURED
ELIZABETHARRIAGA
APT704
4051BAYOURAPIDESRD

ALEXANDRIA,LA71303--406
US

DOB:
Gender:
CellularPhone:
Occupation:
VehicleCoverageInformation:
CoverageType:
LossType:
AdjusterCompany:
Adjuster:
ClaimStatus:
AdjusterPhone:
VIN:
Vehicle:
LastYearRegistered:

InvolvedParty:
Name:
Address:

08/22/1990
FEMALE
(318)792-8920
HAIRDRESSER

COLLISION
COLLISION
LOUISIANAFARMBUREAUMUTUALINSCO
SMITH,MARCUS
OPEN
(318)445-4043
1FTEW1CM3BKD13494(Pass)
2011FORDF150SERIES
2000

CLAIMANTDRIVER
PATRICIAHARRIS
2448WHITESTOWNRD
WOODVILLE,MS39669--429
US

HomePhone:

(601)888-4506

CellularPhone:
DriversLicense:

(651)274-0839

CasualtyCoverageInformation:
CoverageType:
LossType:
ClaimStatus:
AdjusterCompany:
Adjuster:
AdjusterPhone:
AllegedInjury/PropertyDamage:

802678648State:MS

BODILYINJURY
BODILYINJURY
OPEN
LOUISIANAFARMBUREAUMUTUALINSCO
SMITH,MARCUS
(318)445-4043
BODYSORENESS

VehicleCoverageInformation:
CoverageType:
LossType:

OTHERAUTO
OTHERAUTO

AdjusterCompany:
Adjuster:
ClaimStatus:
AdjusterPhone:
VIN:
Vehicle:
LicensePlate:

LOUISIANAFARMBUREAUMUTUALINSCO

LastYearRegistered:

LOUISIANA OFFICE
PO BOX 680247, HOUSTON, TX 77268

ACCC INSURANCE COMPANY

PO BOX 680247
HOUSTON, TX 77268

(281) 875-8363 or (888) 879-8363

DENIAL LETTER - CLAIMANT/ATTORNEY/CARRIER

Claimant/Attorney/Carrier Name and Address:

Claim Number: C0008310-5

Date of Loss:
Insured:
Claimant:
Process Date:

ALLSTATE
PO BOX 650271
DALLAS, TX 75265
YOUR CLAIM#0368735353

5/13/2015
PATRICIA HARRIS
DAVID ODDS
12/18/2015

Dear Sir or Madam:

We have conducted an investigation regarding the above-referenced automobile accident or loss and believe we now
have enough information to make a determination regarding the liability of our insured.
As an Insurer we are not obligated to pay all claims that are presented but only claims in which liability rests with
our insured.
We have reviewed and evaluated all the information and documentation that our investigation has revealed. Based
on this information, we have concluded that our insured is not the proximate cause of this accident or loss.
Specifically, this denial is based upon:
WORD VS WORD.
Therefore, we will respectfully decline to honor any claim regarding this matter.
Should you have any additional information that might change and /or alter our decision, please submit that
information to us immediately for further consideration.
Sincerely,
VERONIQUE MARSHALL-LA

Ext. Number: 7106

ACCC Insurance Company Adjuster

Fax Number: (888) 241-0284
cc:

Generated 12/18/2015 3:52 PM

17_ACCC_DLCAC_2009_01_01

INITIATINGCLAIMINFORMATION
ClaimNumber:
PolicyNumber:

C0008310
MSE0259823

DateofLoss:
ISOFileNumber:

05/13/2015

4L003857778

SUMMARYFOREACHSEARCHABLEPARTY
PATRICIAHARRIS,BOTHCLAIMANT&INSURED
Coverage:
MEDICALPAYMENTS
Coverage:
COLLISION

LossType:
LossType:

MEDICALPAYMENTS
COLLISION

#ofMatches

ISOFileNumber
H0181210286

H0227908504

H0227980244

2C002985474

2W003608755

5O003852441

9C003840892

ISOCLAIMSEARCHREPLACEMENTCLAIMDETAILS

PriorClaimsHistory

InitiatingClaim

FileNumber:4L003857778

Company:
RRECode:
TIN:
SiteId:
ClaimNumber:
Date/TimeofLoss:
PolicyNumber:
PolicyType:
InceptionDate:
CompanyReceivedDate:
ISOReceivedDate:
LossDescription:
LocationofLoss:

A73400009

InvolvedParty:
Name:
Address:

DOB:
Gender:
HomePhone:
StopCMSQuery:

BOTHCLAIMANT&INSURED

000011301
75-2701220
000011301
C0008310
05/13/201520:30
MSE0259823
PERSONALAUTOMOBILE
08/20/2014ExpirationDate:09/03/2015
05/14/2015
05/14/2015
WORDVWORD
11300FLORIDABLVD/SHERWOODFOREST
BATONROUGE,LA

PATRICIAHARRIS
1331NSHERWOODFORESTDRAPT119
BATONROUGE,LA70815
08/21/1968
FEMALE
(651)274-0839
YES

MEDICALPAYMENTS
MEDICALPAYMENTS
CLOSEDW/OPAYMENT
05/14/2015
ACCCINSURANCECOMPANY
CHESTPAIN,BRUISES,SEATBELTSCARS
NO

COLLISION
COLLISION
SALVAGEPENDING
07/07/2015

VIN:
Vehicle:
VehicleType:
VehicleDisposition:
VehicleColor:
LicenseType:
LicensePlate:
SuitIndicator:

3N1CB51D26L453976(Pass)
2006NISSANSENTRA
PASSENGERCAR
TOTALLOSS
BLUE
PASSENGERCAR
WKE553LicensePlateState:MS
NO

back

MatchingClaim
Reason(s)formatch:
FileNumber:
Coverage:
ClaimNumber:
ActivityType:
ActivityDate:
InsuranceCompany:
PolicyType:
PointofImpact:
VIN:
Vehicle:

FileNumber:H0181210286
VIN
H0181210286
COLLISION
HHZ3966001
ESTIMATE
06/30/2011
TRAVELERSINDEMNITYCOMPANY
Unknown
LEFTFRONTCORNER
3N1CB51D26L453976(Pass)
2006NISSANSENTRA

back

MatchingClaim
Reason(s)formatch:
FileNumber:
Coverage:
ClaimNumber:
ActivityType:
ActivityDate:
InsuranceCompany:
ContactPhone:
PolicyType:
PointofImpact:

FileNumber:H0227908504
VIN
H0227908504
OTHERLIABILITY
000368735353B02
VALUATION
05/13/2015
ALLSTATEINSURANCECOMPANY
(800)255-7828
Unknown
UNKNOWN

VIN:
Vehicle:
Odometer:

3N1CB51D26L453976(Pass)
2006NISSANSENTRA
120100

back

MatchingClaim

FileNumber:H0227980244

Reason(s)formatch:
FileNumber:
Coverage:
ClaimNumber:
ActivityType:
ActivityDate:
InsuranceCompany:
ContactPhone:
PolicyType:
PointofImpact:
VIN:
Vehicle:
Odometer:

VIN
H0227980244
LIABILITY
000368735353B02
ESTIMATE
05/13/2015
ALLSTATEINSURANCECOMPANY
(999)999-9999
Unknown
RIGHTSIDE
3N1CB51D26L453976(Pass)
2006NISSANSENTRA
120100

back

MatchingClaim
Reason(s)formatch:
InsuringCompany:
ClaimNumber:
Date/TimeofLoss:
PolicyNumber:
PolicyType:
InceptionDate:
AssignedRisk?:
InsuringCo.Address:

FileNumber:2C002985474
VIN
TRAVELERSINDEMNITYCOMPANY
HHZ3966001
06/30/2011
0M24649821790491011
PERSONALAUTOMOBILE
06/01/2011ExpirationDate:12/01/2011
NO
NAPERVILLEPLCLM-A273
POBOX3095*

InsuringCo.Phone:
CompanyReceivedDate:
LossDescription:
LocationofLoss:

NAPERVILLE,IL60566-7095
(800)842-6172
07/16/2011
OV1WASSTOPPEDATTHELIGHT&MADEASHARPLEFTT
,MN

InvolvedParty:
Name:
Address:

BOTHCLAIMANT&INSURED
JENNIFERTHEISEN
6911CORVALLISAVEN
CRYSTAL,MN55428-4333

back

MatchingClaim

FileNumber:2W003608755

Reason(s)formatch:
InsuringCompany:
ClaimNumber:
Date/TimeofLoss:
PolicyNumber:
PolicyType:
PolicyRenewed?:

VIN

AssignedRisk?:
InsuringCo.Address:

STATEFARM(R)AFFILIATE
2330S9866
04/15/2014
230232023
PERSONALAUTOMOBILE
NO

CIOS-00
ONESTATEFARMPLAZA

LossDescription:
CATRelated?:
Hit&RunAccident:
LocationofLoss:

BLOOMINGTON,IL61710
BLANK
NO
NO
,MN
US

PhysicalRisk:

380WHEELOCKPKWYEAPT324
SAINTPAUL,MN55130-3050

InvolvedParty:
Name:
Address:

INSURED
PATRICIAHARRIS
380WHEELOCKPKWYEAPT324
SAINTPAUL,MN55130-3050
US

VehicleCoverageInformation:
CoverageType:
LossType:
AdjusterCompany:
DateClaimClosed:
AdjusterPhone:
VIN:
Vehicle:
LastYearRegistered:
SuitIndicator:

TOWINGANDLABOR
TOWINGANDLABOR
STATEFARM(R)AFFILIATE
04/19/2014
(888)248-6961
3N1CB51D26L453976(Pass)
2006NISSANSENTRA
2000
NO

back

MatchingClaim

FileNumber:5O003852441

Reason(s)formatch:

PHONE
NAME
VIN
ADDRESS
NAME

InsuringCompany:
ClaimNumber:
Date/TimeofLoss:
PolicyNumber:
PolicyType:
PolicyRenewed?:
InsuringCo.Address:

ALLSTATEINSURANCECOMPANY
0368735353
05/13/2015
000995043003
PERSONALAUTOMOBILE
YES
LOUISIANALIAB/CAS1640
3900NCAUSEWAY#400

InsuringCo.Phone:
LossDescription:
CATRelated?:
LocationofLoss:

METAIRIE,LA70002-0000
(504)834-3185
INTERSECTIONACCIDENT
NO
FLORIDABLVDANDSHERWOODFOREST
BATONROUGE,LA
US

InvolvedParty:
Name:
Address:

CLAIMANTDRIVER
PATRICIAHARRIS
21MAGNOLIAAVEE
SAINTPAUL,MN55117-5021
US

DOB:
Gender:
HomePhone:
SSN:

08/21/1968
FEMALE
(651)274-0839
XXX-XX-8025WASISSUEDbetween1981and1982inMS
***MorematchesonthisSSNoutsidethisreport***

DriversLicense:

802678648State:MS

AlsoKnownAs(AKA):
Name:

PATRICIAHARRIS

AlsoKnownAs(AKA):
Name:

PATRICIAHARRIS

AlsoKnownAs(AKA):
Address:

1331NSHERWOODFORESTDRAPT119
BATONROUGE,LA70815-2003
US

AlsoKnownAs(AKA):
Address:

2448WHITESTOWNRD
WOODVILLE,MS39669-4295
US

ServiceProvider:
BusinessName:
TIN:
Address:

LAWYER-OTHER
MORRISBARTLTD
71-0921088WASISSUEDinLittleRockinAR
909POYDRASSTREET,20THFL
NEWORLEANS,LA70112-4030
US

BusinessPhone:
CasualtyCoverageInformation:
CoverageType:
LossType:
ClaimStatus:
AdjusterCompany:

(228)432-9000

BODILYINJURY
OTHERAUTO
OPEN
ALLSTATEINSURANCECOMPANY

Adjuster:
AdjusterPhone:
AllegedInjury/PropertyDamage:
VehicleCoverageInformation:
CoverageType:
LossType:
AdjusterCompany:
ClaimStatus:
AdjusterPhone:
VIN:
Vehicle:
LastYearRegistered:

InvolvedParty:
Name:
Address:

LEBLANC,KRIS
(504)219-3919
SORE,SORE,SORE

OTHERAUTO
OTHERAUTO
ALLSTATEINSURANCECOMPANY
OPEN
(800)349-1444
3N1CB51D26L453976(Pass)
2006NISSANSENTRA
2000

INSUREDDRIVER
DAVIDODDS
2052FAIRCHILDST
BATONROUGE,LA70807-5025
US

DOB:
Gender:
HomePhone:

05/02/1963

SSN:
DriversLicense:

XXX-XX-0278WASISSUEDbetween1978and1978inLA

MALE
(225)892-9794

4675286State:LA

AlsoKnownAs(AKA):
Name:

DAVIDODDS

AlsoKnownAs(AKA):
Name:

DAVIDODDS

AlsoKnownAs(AKA):
Address:

13855KATHERINEAVE
BATONROUGE,LA70815-7229
US

VehicleCoverageInformation:
CoverageType:
LossType:
AdjusterCompany:

COLLISION
OTHERAUTO
ALLSTATEINSURANCECOMPANY

Adjuster:
ClaimStatus:
AdjusterPhone:
VIN:
Vehicle:
LastYearRegistered:
VehicleCoverageInformation:
CoverageType:
LossType:
AdjusterCompany:
Adjuster:
ClaimStatus:
AdjusterPhone:
VIN:
Vehicle:
LastYearRegistered:

LAWRENCE,THERESAL
OPEN
(504)219-3658
1GNFC13058R139428(Pass)
2008CHEVROLETTAHOE
2000

COMPREHENSIVE
COMPREHENSIVE
ALLSTATEINSURANCECOMPANY
LEBLANC,KRIS
OPEN
(504)219-3919
1GNFC13058R139428(Pass)
2008CHEVROLETTAHOE
2000

back

MatchingClaim

FileNumber:9C003840892

Reason(s)formatch:

LICENSEPLATENUMBER
VIN
PHONE

InsuringCompany:
ClaimNumber:
Date/TimeofLoss:
PolicyNumber:
PolicyType:
InceptionDate:
InsuringCo.Address:

LOUISIANAFARMBUREAUMUTUALINSCO
17A00066408
04/16/201503:30
AT06334
PERSONALAUTOMOBILE
12/15/2014ExpirationDate:06/15/2015
CLAIMCENTER
POBOX80319

InsuringCo.Phone:
CompanyReceivedDate:
LossDescription:
LocationofLoss:

BATONROUGE,LA70898
(225)922-6200
04/17/2015
3PWASSTOPPEDINTRAFFICWHENINSVEHR/E3PVEH
I-10
BATONROUGE,LA
US

InvolvedParty:
Name:
Address:

BOTHCLAIMANT&INSURED
ELIZABETHARRIAGA
APT704
4051BAYOURAPIDESRD

ALEXANDRIA,LA71303--406
US

DOB:
Gender:
CellularPhone:
Occupation:
VehicleCoverageInformation:
CoverageType:
LossType:
AdjusterCompany:
Adjuster:
ClaimStatus:
AdjusterPhone:
VIN:
Vehicle:
LastYearRegistered:

InvolvedParty:
Name:
Address:

08/22/1990
FEMALE
(318)792-8920
HAIRDRESSER

COLLISION
COLLISION
LOUISIANAFARMBUREAUMUTUALINSCO
SMITH,MARCUS
OPEN
(318)445-4043
1FTEW1CM3BKD13494(Pass)
2011FORDF150SERIES
2000

CLAIMANTDRIVER
PATRICIAHARRIS
2448WHITESTOWNRD
WOODVILLE,MS39669--429
US

HomePhone:

(601)888-4506

CellularPhone:
DriversLicense:

(651)274-0839

CasualtyCoverageInformation:
CoverageType:
LossType:
ClaimStatus:
AdjusterCompany:
Adjuster:
AdjusterPhone:
AllegedInjury/PropertyDamage:

802678648State:MS

BODILYINJURY
BODILYINJURY
OPEN
LOUISIANAFARMBUREAUMUTUALINSCO
SMITH,MARCUS
(318)445-4043
BODYSORENESS

VehicleCoverageInformation:
CoverageType:
LossType:

OTHERAUTO
OTHERAUTO

AdjusterCompany:
Adjuster:
ClaimStatus:
AdjusterPhone:
VIN:
Vehicle:
LicensePlate:

LOUISIANAFARMBUREAUMUTUALINSCO

LastYearRegistered:

2000

SMITH,MARCUS
OPEN
(318)445-4043
3N1CB51D26L453976(Pass)
2006NISSANSENTRA
WKE553LicensePlateState:MS

ISOStylesheetVersion:5.5ReleaseDate:03-03-2014

ACCC INSURANCE COMPANY

LOUISIANA OFFICE
PO BOX 680247, HOUSTON, TX 77268

ACCC INSURANCE COMPANY

PO BOX 680247
HOUSTON, TX 77268

(281) 875-8363 or (888) 879-8363

DENIAL LETTER - CLAIMANT/ATTORNEY/CARRIER

Claimant/Attorney/Carrier Name and Address:

HAROLD G. TOSCANO
PARK TOWER STE. 8300
400 EAST KALISTE SALOOM RD.
LAFAYETTE, LA 70508

Claim Number: C0008310-5

Date of Loss:
Insured:
Claimant:
Process Date:

5/13/2015
PATRICIA HARRIS
DAVID ODDS
2/16/2016

Dear Sir or Madam:

We have conducted an investigation regarding the above-referenced automobile accident or loss and believe we now
have enough information to make a determination regarding the liability of our insured.
As an Insurer we are not obligated to pay all claims that are presented but only claims in which liability rests with
our insured.
We have reviewed and evaluated all the information and documentation that our investigation has revealed. Based
on this information, we have concluded that our insured is not the proximate cause of this accident or loss.
Specifically, this denial is based upon:
WORD VS. WORD. BOTH DRIVERS ARE STATING THEY HAD THE GREEN LIGHT.
Therefore, we will respectfully decline to honor any claim regarding this matter.
Should you have any additional information that might change and /or alter our decision, please submit that
information to us immediately for further consideration.
Sincerely,
VERONIQUE MARSHALL-LA

Ext. Number: 7106

ACCC Insurance Company Adjuster

Fax Number: (888) 241-0284
cc:

Generated 2/16/2016 1:10 PM

17_ACCC_DLCAC_2009_01_01

INITIATINGCLAIMINFORMATION
ClaimNumber:
PolicyNumber:

C0008310
MSE0259823

DateofLoss:
ISOFileNumber:

05/13/2015

4L003857778

SUMMARYFOREACHSEARCHABLEPARTY
PATRICIAHARRIS,BOTHCLAIMANT&INSURED
Coverage:
MEDICALPAYMENTS
Coverage:
COLLISION

LossType:
LossType:

MEDICALPAYMENTS
COLLISION

#ofMatches

ISOFileNumber
H0181210286

H0227908504

H0227980244

2C002985474

2W003608755

5O003852441

9C003840892

ISOCLAIMSEARCHREPLACEMENTCLAIMDETAILS

PriorClaimsHistory

InitiatingClaim

FileNumber:4L003857778

Company:
RRECode:
TIN:
SiteId:
ClaimNumber:
Date/TimeofLoss:
PolicyNumber:
PolicyType:
InceptionDate:
CompanyReceivedDate:
ISOReceivedDate:
LossDescription:
LocationofLoss:

A73400009

InvolvedParty:
Name:
Address:

DOB:
Gender:
HomePhone:
StopCMSQuery:

BOTHCLAIMANT&INSURED

000011301
75-2701220
000011301
C0008310
05/13/201520:30
MSE0259823
PERSONALAUTOMOBILE
08/20/2014ExpirationDate:09/03/2015
05/14/2015
05/14/2015
WORDVWORD
11300FLORIDABLVD/SHERWOODFOREST
BATONROUGE,LA

PATRICIAHARRIS
1331NSHERWOODFORESTDRAPT119
BATONROUGE,LA70815
08/21/1968
FEMALE
(651)274-0839
YES

MEDICALPAYMENTS
MEDICALPAYMENTS
CLOSEDW/OPAYMENT
05/14/2015
ACCCINSURANCECOMPANY
CHESTPAIN,BRUISES,SEATBELTSCARS
NO

COLLISION
COLLISION
SALVAGEPENDING
07/07/2015

VIN:
Vehicle:
VehicleType:
VehicleDisposition:
VehicleColor:
LicenseType:
LicensePlate:
SuitIndicator:

3N1CB51D26L453976(Pass)
2006NISSANSENTRA
PASSENGERCAR
TOTALLOSS
BLUE
PASSENGERCAR
WKE553LicensePlateState:MS
NO

back

MatchingClaim
Reason(s)formatch:
FileNumber:
Coverage:
ClaimNumber:
ActivityType:
ActivityDate:
InsuranceCompany:
PolicyType:
PointofImpact:
VIN:
Vehicle:

FileNumber:H0181210286
VIN
H0181210286
COLLISION
HHZ3966001
ESTIMATE
06/30/2011
TRAVELERSINDEMNITYCOMPANY
Unknown
LEFTFRONTCORNER
3N1CB51D26L453976(Pass)
2006NISSANSENTRA

back

MatchingClaim
Reason(s)formatch:
FileNumber:
Coverage:
ClaimNumber:
ActivityType:
ActivityDate:
InsuranceCompany:
ContactPhone:
PolicyType:
PointofImpact:

FileNumber:H0227908504
VIN
H0227908504
OTHERLIABILITY
000368735353B02
VALUATION
05/13/2015
ALLSTATEINSURANCECOMPANY
(800)255-7828
Unknown
UNKNOWN

VIN:
Vehicle:
Odometer:

3N1CB51D26L453976(Pass)
2006NISSANSENTRA
120100

back

MatchingClaim

FileNumber:H0227980244

Reason(s)formatch:
FileNumber:
Coverage:
ClaimNumber:
ActivityType:
ActivityDate:
InsuranceCompany:
ContactPhone:
PolicyType:
PointofImpact:
VIN:
Vehicle:
Odometer:

VIN
H0227980244
LIABILITY
000368735353B02
ESTIMATE
05/13/2015
ALLSTATEINSURANCECOMPANY
(999)999-9999
Unknown
RIGHTSIDE
3N1CB51D26L453976(Pass)
2006NISSANSENTRA
120100

back

MatchingClaim
Reason(s)formatch:
InsuringCompany:
ClaimNumber:
Date/TimeofLoss:
PolicyNumber:
PolicyType:
InceptionDate:
AssignedRisk?:
InsuringCo.Address:

FileNumber:2C002985474
VIN
TRAVELERSINDEMNITYCOMPANY
HHZ3966001
06/30/2011
0M24649821790491011
PERSONALAUTOMOBILE
06/01/2011ExpirationDate:12/01/2011
NO
NAPERVILLEPLCLM-A273
POBOX3095*

InsuringCo.Phone:
CompanyReceivedDate:
LossDescription:
LocationofLoss:

NAPERVILLE,IL60566-7095
(800)842-6172
07/16/2011
OV1WASSTOPPEDATTHELIGHT&MADEASHARPLEFTT
,MN

InvolvedParty:
Name:
Address:

BOTHCLAIMANT&INSURED
JENNIFERTHEISEN
6911CORVALLISAVEN
CRYSTAL,MN55428-4333

back

MatchingClaim

FileNumber:2W003608755

Reason(s)formatch:
InsuringCompany:
ClaimNumber:
Date/TimeofLoss:
PolicyNumber:
PolicyType:
PolicyRenewed?:

VIN

AssignedRisk?:
InsuringCo.Address:

STATEFARM(R)AFFILIATE
2330S9866
04/15/2014
230232023
PERSONALAUTOMOBILE
NO

CIOS-00
ONESTATEFARMPLAZA

LossDescription:
CATRelated?:
Hit&RunAccident:
LocationofLoss:

BLOOMINGTON,IL61710
BLANK
NO
NO
,MN
US

PhysicalRisk:

380WHEELOCKPKWYEAPT324
SAINTPAUL,MN55130-3050

InvolvedParty:
Name:
Address:

INSURED
PATRICIAHARRIS
380WHEELOCKPKWYEAPT324
SAINTPAUL,MN55130-3050
US

VehicleCoverageInformation:
CoverageType:
LossType:
AdjusterCompany:
DateClaimClosed:
AdjusterPhone:
VIN:
Vehicle:
LastYearRegistered:
SuitIndicator:

TOWINGANDLABOR
TOWINGANDLABOR
STATEFARM(R)AFFILIATE
04/19/2014
(888)248-6961
3N1CB51D26L453976(Pass)
2006NISSANSENTRA
2000
NO

back

MatchingClaim

FileNumber:5O003852441

Reason(s)formatch:

PHONE
VIN
NAME
ADDRESS
NAME

InsuringCompany:
ClaimNumber:
Date/TimeofLoss:
PolicyNumber:
PolicyType:
PolicyRenewed?:
InsuringCo.Address:

ALLSTATEINSURANCECOMPANY
0368735353
05/13/2015
000995043003
PERSONALAUTOMOBILE
YES
LOUISIANALIAB/CAS1640
3900NCAUSEWAY#400

InsuringCo.Phone:
LossDescription:
CATRelated?:
LocationofLoss:

METAIRIE,LA70002-0000
(504)834-3185
INTERSECTIONACCIDENT
NO
FLORIDABLVDANDSHERWOODFOREST
BATONROUGE,LA
US

InvolvedParty:
Name:
Address:

CLAIMANTDRIVER
PATRICIAHARRIS
21MAGNOLIAAVEE
SAINTPAUL,MN55117-5021
US

DOB:
Gender:
HomePhone:
SSN:

08/21/1968
FEMALE
(651)274-0839
XXX-XX-8025WASISSUEDbetween1981and1982inMS
***MorematchesonthisSSNoutsidethisreport***

DriversLicense:

802678648State:MS

AlsoKnownAs(AKA):
Name:

PATRICIAHARRIS

AlsoKnownAs(AKA):
Name:

PATRICIAHARRIS

AlsoKnownAs(AKA):
Address:

1331NSHERWOODFORESTDRAPT119
BATONROUGE,LA70815-2003
US

AlsoKnownAs(AKA):
Address:

2448WHITESTOWNRD
WOODVILLE,MS39669-4295
US

ServiceProvider:
BusinessName:
TIN:
Address:

LAWYER-OTHER
MORRISBARTLTD
71-0921088WASISSUEDinLittleRockinAR
909POYDRASSTREET,20THFL
NEWORLEANS,LA70112-4030
US

BusinessPhone:
CasualtyCoverageInformation:
CoverageType:
LossType:
ClaimStatus:
AdjusterCompany:

(228)432-9000

BODILYINJURY
OTHERAUTO
OPEN
ALLSTATEINSURANCECOMPANY

Adjuster:
AdjusterPhone:
AllegedInjury/PropertyDamage:
VehicleCoverageInformation:
CoverageType:
LossType:
AdjusterCompany:
ClaimStatus:
AdjusterPhone:
VIN:
Vehicle:
LastYearRegistered:

InvolvedParty:
Name:
Address:

LEBLANC,KRIS
(504)219-3919
SORE,SORE,SORE

OTHERAUTO
OTHERAUTO
ALLSTATEINSURANCECOMPANY
OPEN
(800)349-1444
3N1CB51D26L453976(Pass)
2006NISSANSENTRA
2000

INSUREDDRIVER
DAVIDODDS
2052FAIRCHILDST
BATONROUGE,LA70807-5025
US

DOB:
Gender:
HomePhone:

05/02/1963

SSN:
DriversLicense:

XXX-XX-0278WASISSUEDbetween1978and1978inLA

MALE
(225)892-9794

4675286State:LA

AlsoKnownAs(AKA):
Name:

DAVIDODDS

AlsoKnownAs(AKA):
Name:

DAVIDODDS

AlsoKnownAs(AKA):
Address:

13855KATHERINEAVE
BATONROUGE,LA70815-7229
US

VehicleCoverageInformation:
CoverageType:
LossType:
AdjusterCompany:

COLLISION
OTHERAUTO
ALLSTATEINSURANCECOMPANY

LAWRENCE,THERESAL
OPEN
(504)219-3658
1GNFC13058R139428(Pass)
2008CHEVROLETTAHOE
2000

COMPREHENSIVE
COMPREHENSIVE
ALLSTATEINSURANCECOMPANY
LEBLANC,KRIS
OPEN
(504)219-3919
1GNFC13058R139428(Pass)
2008CHEVROLETTAHOE
2000

back

MatchingClaim

FileNumber:9C003840892

Reason(s)formatch:

LICENSEPLATENUMBER
VIN
PHONE

InsuringCompany:
ClaimNumber:
Date/TimeofLoss:
PolicyNumber:
PolicyType:
InceptionDate:
InsuringCo.Address:

LOUISIANAFARMBUREAUMUTUALINSCO
17A00066408
04/16/201503:30
AT06334
PERSONALAUTOMOBILE
12/15/2014ExpirationDate:06/15/2015
CLAIMCENTER
POBOX80319

InsuringCo.Phone:
CompanyReceivedDate:
LossDescription:
LocationofLoss:

BATONROUGE,LA70898
(225)922-6200
04/17/2015
3PWASSTOPPEDINTRAFFICWHENINSVEHR/E3PVEH
I-10
BATONROUGE,LA
US

InvolvedParty:
Name:
Address:

BOTHCLAIMANT&INSURED
ELIZABETHARRIAGA
APT704
4051BAYOURAPIDESRD

ALEXANDRIA,LA71303--406
US

DOB:
Gender:
CellularPhone:
Occupation:
VehicleCoverageInformation:
CoverageType:
LossType:
AdjusterCompany:
Adjuster:
ClaimStatus:
AdjusterPhone:
VIN:
Vehicle:
LastYearRegistered:

InvolvedParty:
Name:
Address:

08/22/1990
FEMALE
(318)792-8920
HAIRDRESSER

COLLISION
COLLISION
LOUISIANAFARMBUREAUMUTUALINSCO
SMITH,MARCUS
OPEN
(318)445-4043
1FTEW1CM3BKD13494(Pass)
2011FORDF150SERIES
2000

CLAIMANTDRIVER
PATRICIAHARRIS
2448WHITESTOWNRD
WOODVILLE,MS39669--429
US

HomePhone:

(601)888-4506

CellularPhone:
DriversLicense:

(651)274-0839

CasualtyCoverageInformation:
CoverageType:
LossType:
ClaimStatus:
AdjusterCompany:
Adjuster:
AdjusterPhone:
AllegedInjury/PropertyDamage:

802678648State:MS

BODILYINJURY
BODILYINJURY
OPEN
LOUISIANAFARMBUREAUMUTUALINSCO
SMITH,MARCUS
(318)445-4043
BODYSORENESS

VehicleCoverageInformation:
CoverageType:
LossType:

OTHERAUTO
OTHERAUTO

AdjusterCompany:
Adjuster:
ClaimStatus:
AdjusterPhone:
VIN:
Vehicle:
LicensePlate:

LOUISIANAFARMBUREAUMUTUALINSCO

LastYearRegistered:

2000

SMITH,MARCUS
OPEN
(318)445-4043
3N1CB51D26L453976(Pass)
2006NISSANSENTRA
WKE553LicensePlateState:MS

ISOStylesheetVersion:5.5ReleaseDate:03-03-2014

ACCC INSURANCE COMPANY

PO BOX 680247
HOUSTON, TX 77268

ACCC INSURANCE COMPANY

LOUISIANA OFFICE
PO BOX 680247, HOUSTON, TX 77268
(281) 875-8363 or (888) 879-8363

OFFER LETTER - ATTORNEY

Claim Number: C0008310-5

Date of Loss: 5/13/2015
ALLSTATE
400 E. KALISTE SALOOM RD STE. 8300
LAFAYETTE, LA 70508

Our Insured: PATRICIA HARRIS

Claimant: DAVID ODDS
Process Date: 5/25/2016

YOUR CLIAM#0368735353.1

Dear Sir or Madam:

Thank you for your recent communication regarding the above-described claim. The following offer is made on behalf of our
insured person(s), PATRICIA HARRIS, in an effort to resolve the bodily injury claim in this matter. For purposes of this
offer and any Release of Claims described below, ACCC Insurance Company shall mean ACCC Insurance Company, any
parent, affiliate, subsidiary, employee, agent, or any officer or director thereof, and any successor-in-interest, Trustee or
receiver. (Collectively referred to as "ACCC").
ACCC will pay to DAVID ODDS the amount of $3,000.00 in exchange for a full and final release of all claims, liens, and
assignments, whether asserted or not, by or through you or your client. A full and final release of all claims, liens, and
assignments will include:
RELEASE OF ALL CLAIMS
DAVID ODDS will sign a separate Release of Claims. This Release of Claims shall indicate that DAVID ODDS fully
releases and forever discharges both ACCC and its INSURED(S), from any and all claims, demands, rights and causes of
action of whatsoever kind and nature, arising from, and by reason of any and all known and unknown, foreseen and
unforeseen bodily and personal injuries, and the consequences thereof, resulting from the accident which happened on or
about 5/13/2015 for which DAVID ODDS claims PATRICIA HARRIS to be legally liable. Liability of both ACCC and
PATRICIA HARRIS is expressly denied. Further, said Release of Claims will provide that all DAVID ODDS's releases
therein shall extend to DAVID ODDS's heirs, executors, administrators, assigns, assigns, and successors-in-interest and that
they also surrender, release and forever discharge any claim against ACCC and PATRICIA HARRIS.

Generated 5/25/2016 2:27 PM

OLA_ACCC_2011_09_20 Page 1

ACCC INSURANCE COMPANY

LOUISIANA OFFICE
PO BOX 680247, HOUSTON, TX 77268

ACCC INSURANCE COMPANY

PO BOX 680247
HOUSTON, TX 77268

(281) 875-8363 or (888) 879-8363

OFFER LETTER - ATTORNEY (Continued)

Claim Number: C0008310-5

Date of Loss: 5/13/2015
ALLSTATE
400 E. KALISTE SALOOM RD STE. 8300
LAFAYETTE, LA 70508

Our Insured: PATRICIA HARRIS

Claimant: DAVID ODDS
Process Date: 5/25/2016

YOUR CLIAM#0368735353.1

RELEASE OF ALL LIENS/ASSIGNMENTS

1. All government agencies and programs, including but not limited to any claims, rights, liens or subrogation interests,
regardless of whether or not asserted, held by Medicaid, Medicare/CMS, Tricare/Champus, any state or federal funded
child healthcare plan or fund, and any Child Support Liens;
2. All assignments, claims, rights, subrogation interests, or liens of hospitals, nursing homes, and emergency or nonemergency medical service providers, to include but without exclusion, those arising under any federal or state statute,
constitution or common law applicable;
3. All insurance carriers including, but not limited to, ERISA-qualified plans, any workers compensation insurer, healthcare
insurer, or assignments of interest made to healthcare providers; and
4. All other attorneys asserting claims for fees or expenses.
Please provide your check drafting instructions along with your firm's Tax Identification Number. At your option, ACCC
will issue one check jointly to all known interested parties. Alternatively, please provide proof of payment and/or releases
from each party asserting or entitled to an interest in the proceeds of the settlement.
This offer will remain open for a period of thirty (30) calendar days from the date of this correspondence, or until the statute
of limitations expires, whichever occurs first. This offer may be withdrawn at any time should new information become
available as our investigation continues. Should you accept this offer, please provide the information below and sign where
indicated.
We await the requested information. Thank you.
Sincerely,
VERONIQUE MARSHALL

Ext. Number: 7106

ACCC Insurance Company Adjuster

Fax Number: (888) 241-0284

Generated 5/25/2016 2:27 PM

OLA_ACCC_2011_09_20 Page 2

ACCC INSURANCE COMPANY

PO BOX 680247
HOUSTON, TX 77268

ACCC INSURANCE COMPANY

LOUISIANA OFFICE
PO BOX 680247, HOUSTON, TX 77268
(281) 875-8363 or (888) 879-8363

OFFER LETTER - ATTORNEY (Continued)

Claim Number: C0008310-5

Date of Loss: 5/13/2015
ALLSTATE
400 E. KALISTE SALOOM RD STE. 8300
LAFAYETTE, LA 70508

Our Insured: PATRICIA HARRIS

Claimant: DAVID ODDS
Process Date: 5/25/2016

YOUR CLIAM#0368735353.1
C0008310-5

ATT

ACCEPTANCE:
On behalf of DAVID ODDS, I accept the above offer in full and final settlement of DAVID ODDS's bodily injury claims in
this matter and I agree that DAVID ODDS will execute the necessary Release of Claims form(s) in order to complete this
matter in exchange for payment of $3,000.00.

Firm:_____________________________

X________________________________
Attorney Signature
__________________________________
State Bar Number
__________________________________
Tax ID

Drafting Instructions:

Generated 5/25/2016 2:27 PM

OLA_ACCC_2011_09_20 Page 3

Claim #: C0008310-A

ALA
Claim Summary
Owner: PATRICIA HARRIS
Vehicle Year: 2006
Make: NISS

Model: SENTRA S

Engine: 4-1.8L-FI

Body Style: 4D SED

Insurance Information
Adjuster:

JILL DENNIS

Adjuster License #:
Policy #:

Appraiser:

ELY, RYAN

Appraiser License #:

115688

MSE0259823-3

Vehicle Owner
Insured:

PATRICIA HARRIS

Loss Type:

Collision

Owner:

PATRICIA HARRIS

Evening:

(651) 274-0839

2448 WHITESTOWN RD
CENTREVILLE, MS 39631

Vehicle Information
Year:

2006

Color:

BLUE Int: GRAY

License:

WKE553

Production Date:

Make:

NISS

Body Style:

4D SED

State:

Odometer:

Model:

SENTRA S

Engine:

4-1.8L-FI

VIN:

3N1CB51D26L453976

Condition:

Fair

Drivable:

Primary Impact Point:

Right Front

Secondary Impact Point:

Right Rear

120101

Inspection Information
Place of Inspection:
Address:

5/19/2015 1:15:31 PM

3465 HARDING BLVD

BATON ROUGE, LA 70807

115688

Page 1

Claim #: C0008310-A

ALA
Claim Summary
Owner: PATRICIA HARRIS
Vehicle Year: 2006
Make: NISS

Model: SENTRA S

Engine: 4-1.8L-FI

Estimate to Repair

Body Style: 4D SED

Total Loss Valuation

$ 7,799.19

Estimate

Vehicle Valuation
Supp. Taxable Adjustments

$ 7,799.19

Taxable Subtotal
Tax

0.00
$ 7,799.19

Non-Taxable Subtotal
Betterment

0.00

Deductible

500.00

Appearance Allowance

0.00

0% Negligence

0.00
$ 7,299.19

Calculated Net Loss

LKQ Parts Not Included

Taxable Subtotal

$ 4,850.00
0.00
$ 4,850.00

Tax

0.00

Supp. Non-Taxable Adjustments

0.00

Non-Taxable Subtotal
Owner Retained Salvage
Deductible
0% Negligence
Calculated Net Loss
Vehicle Valuation Request#

$ 4,850.00
0.00
500.00
0.00
$ 4,350.00
54811662

A/M Parts Not Included

Opt OEM Parts Not Included
Recond Parts Not Included

Settlement Information
Settlement Type:

Total Loss

Negotiated Settlement:

$ 4,350.00

Settlement Outstanding:

$ 4,350.00

Comments
TOTAL LOSS VALUE
Claim #: C0009310-A is a Total loss
Owner: PATRICIA HARRIS
Vehicle: 2006 NISSAN SENTRA
Date vehicle arrived: 5/13
Location: ROADRUNNER TOWING
Address: 3465 HARDING BLVD
City: BATON ROUGE
Zip Code: 70807
Phone: (225) 359-9989 x
Charges: 333.76
** Breakdown **
Towing fee: 161.25
Storage per day: 19 A DAY X 7 DAYS = 133
Admin Fee:25
Miscellaneous charges: FUEL CHARGE 14.51
Owner needs to release vehicle Y/N YES

Events
5/13/2015

Loss occurred

5/14/2015

Loss reported

5/19/2015
5/19/2015

5/19/2015 1:15:31 PM

Date assigned.
7:06 AM

Assignment Retrieved.

115688

Page 2

Claim #: C0008310-A

ALA
Claim Summary
Owner: PATRICIA HARRIS
Vehicle Year: 2006
Make: NISS

Model: SENTRA S

Engine: 4-1.8L-FI

Body Style: 4D SED

5/19/2015

12:54 PM

Workfile Created.
Comments: Workfile was created.

5/19/2015 1:15:31 PM

115688

Page 3

Page 1 of 2

Estimate By: ACD

Claim Number: C0008310-5 / DL Number: LA1505-141431
Claim Information

Vehicle Information

Claim Service Type?:

Vehicle Type?:

Claim Number:

C0008310-5

Claim Info
Company:
Company #:
DL Number:
Claim Number:
Status:

Year:

2006

Make:

Nissan

Model:

Sentra

Insured Company:

Color:

BLUE

Insured Last Name:

VIN:

3N1CB51D26L453976

Insured First Name

Plate Number:

WKE 553

Deductible:
Date of Loss:

05/13/2015

Coverage Type:

coll

Owner Information
Insured or Claimant:

INSURED

Owner in Rental Car:

Timeline

Area of Damage:

WHOLE PASSENGER SIDE

AND AIR BAGS DEPLOYED

Adjuster

Drivable?:

Jill Dennis

Language Translator
Needed?:

HARRIS

Vehicle Location:

Owner First Name:

PATRICIA

Phone: (205) 978-3520 x 7217

Account Manager

Vehicle Location Type:

other

Location Name:

ROADRUNNER

Owner Company:

Location Phone #:

(225) 359-9989

Josh Myers

2448 WHITESTOWN RD Location Email:

Address Line 2:
(Suite, Apt, ect.)

Address Line 1:

Phone: (888) 403-4223 x 727

Backup Account Manager

Karen Carteron

3465 HARDING BLVD

City:

Centreville

Address Line 2:
(Suite, Apt, ect.)

State:

City:

Baton Rouge

Zip Code:

39631

State:

Home Phone:

(651) 274-0839

Zip Code:

70807

Work Phone:

05/15/2015 11:30am
05/14/2015 11:02am CDT
05/18/2015 9:35am CDT

People on this Claim

Owner Email:

Owner Address Line 1:

Appointment Date:
Date Created:
Date Completed:

Plate State:

Owner Last Name:

ACCC Insurance Company

(404) 999-9999
LA1505-141431
C0008310-5
CLIENT AUDIT

Phone: (888) 403-4223 x 701

Appraiser
Aaron Theall
Business Phone: (337) 258-9886
Mobile Phone: (337) 258-9886

ACD Auditor

Comments

Brad Kennedy

Mobile Phone:

No comments

Phone: (888) 403-4223 x 732

Client Auditor
No Client Auditor assigned yet.

Claim Estimate Type: TOTAL LOSS

Appraisal Type:

auto

Vehicle Location:

Original Estimate Amt:

$ 7799.19

Vehicle Location?:

(initial estimate)

Location Name:

Final Estimate Amt:

other
ROADRUNNER

$ 7799.19

Location Phone #:

(225) 359-9989

Engine Starts?:

yes

Location Address Line 1:

Impact Point 1:

right_t_bone

3465 HARDING BLVD

Baton Rouge, LA 70807

(includes supps & revisions)

Impact Point 2:
Open Amt:

$ 0.00

Storage Total Amt:

$ 57.00

Days in Storage:

Appt/Inspection Date:

05/15/2015 11:30am

Estimate Notes
VEHICLE IS NON-REPAIRABLE, RT SIDE HAS HEAVY DAMAGE, COMPLETE APETURE REPLACEMENT, DOORS, AIRBAG RESTAINTS

SUPPLEMENTS
There are currently no supplements.

Note History
Author
Brad Kennedy
Josh Myers

Date
05/18/2015
9:37am CDT
05/15/2015
4:08pm CDT

Note
Please be advised this vehicle is a Total Loss and is located @ the tow yard listed on the assignment. Thank you
Sent To: David Hester

Sure - its: 3N1CB51D26L453976

Jill Marie Dennis

https://auto.acdcorp.com/autolink/claim/printable_detail_page/1781431

5/18/2015

Page 2 of 2

Author

Date

Note
Property Damage Adjuster
ACCC Insurance Company
Phone: 205-978-3520, ext. 7217
email: [email protected]
Sent To: Aaron Theall

Sure - its: 3N1CB51D26L453976

Jill Marie Dennis

Property Damage Adjuster
ACCC Insurance Company
Jill Dennis

05/15/2015
3:41pm CDT

Phone: 205-978-3520, ext. 7217

email: [email protected]

________________________________
Sent To: Josh Myers

Josh Myers

05/15/2015
2:53pm CDT

HI Jill,
I just left you a voice mail. Do we have a VIN for this vehicle? The tow yard will not let the appraiser inspect without the VIN.
Thanks.
Sent To: Jill Dennis

Josh Myers

John Otillio

05/14/2015
11:18am
CDT
05/14/2015
11:10am
CDT
05/14/2015
11:08am
CDT

HI Jill,
Do we have a VIN for this vehicle? The tow yard will not let the appraiser inspect without the VIN. Thanks.
Sent To: Jill Dennis

I need the vin. number yard can't find car without it please send asap as this is delaying the file.
Sent To: Jill Dennis, Josh Myers

The appointment date was set for 05/15/2015 from 11:30am to 4:45pm
Sent To: Jill Dennis

https://auto.acdcorp.com/autolink/claim/printable_detail_page/1781431

5/18/2015

ACD
3132 Tiger Run Court
Carlsbad Ca, 92010
Shop Hotline(844)469-7877 Fax: (855) 432-9223
Supplements: www.acdcorp.com/supp
(Note: CCC & Mitchell users, use the above link in place of email address)***
*** ESTIMATE ***
05/16/2015 10:55 PM
Owner
Owner: PATRICIA HARRIS
Address: 2448 WHITESTOWN RD
City State Zip: CENTREVILLE, MS 39631

Work/Day: (651)274-0839
Home/Evening: (651)274-0839
FAX:

Control Information
Claim # : C0008310-5
Loss Date/Time: 05/13/2015
Deductible: Unknown

Insured Policy # :
Loss Type: Collision

Ins. Company: ACCC INSURANCE COMPANY

Insured: PATRICIA HARRIS
Address: 2448 WHITESTOWN RD
City State Zip: CENTREVILLE, MS 39631

Work/Day:
FAX:

Claimant: UNK UNK

Claim Rep: Jill Dennis
Inspection
Inspection Date:
Inspection Location:
City State Zip:
Primary Impact:

05/15/2015 02:30 PM
ROAD RUNNER
Baton Rouge, LA 70807
Right Side

Assigned Date/Time:
Appraiser Name: AARON THEALL
Address:
City State Zip: Youngsville, LA 70592

Inspection Type: Field

Contact:
FAX:
Secondary Impact:
Received Date/Time: 05/16/2015 10:51 PM
Appraiser License # :
Work/Day: (337)258-9886
FAX:

Repairer
Target Complete Date/Time:

Days To Repair: 0

Vehicle
2006 Nissan Sentra 1.8S 4 DR Sedan
4cyl Gasoline 1.8
4 Speed Automatic
Lic.Plate: WKE 553
Lic Expire:
05/16/2015 11:02 PM

Lic State: MS
VIN: 3N1CB51D26L453976
Page 1 of 5

2006 Nissan Sentra 1.8S 4 DR Sedan

Claim # : C0008310-5

05/16/2015 10:55 PM

Mileage: 120,101
Mileage Type: Actual
Code: Z1763G
Int. Color:
Int. Refinish:

Prod Date:
Veh Insp# :
Condition: Fair
Ext. Color: BLUE
Ext. Refinish: Two-Stage
Options
AM/FM CD Player
Bucket Seats
Digital Clock
Keyless Entry System
Power Brakes
Power Steering
Rem Trunk-L/Gate Release
Tilt Steering Wheel
Velour/Cloth Seats

Air Conditioning
Center Console
Dual Airbags
Lighted Entry System
Power Door Locks
Power Windows
Split Folding Rear Seat
Tinted Glass

Alarm System
Cruise Control
Intermittent Wipers
Overhead Console
Power Mirrors
Rear Window Defroster
Tachometer
Trip Computer

Damages
Line Op

Guide

MC Description

Front End Panel And Lamps

1 PC
42
Headlamp Assy,Halogen RT
2 N
973
Headlamps Aim

MFR.Part No.

Price

ADJ% B%

Hours

Replace PXN Reconditioned

Additional Labor

$137.50

INC
0.4

SM
SM

Replace PXN
Refinish
1.9 Surface
0.5 Edge
0.4 Two-stage

$118.87

1.4
2.8

SM
RF

Dashboard And Components

5 E
832
Module,Airbag Control
6 E
960
01 Airbag,Instrument Pnl

285566Z524
K85154Z602

$382.88
$863.71

0.4
INC

ME
ME

Upper Steering Components

7 E
822
Clock Spring
8 E
878
01 Airbag,Steering Wheel

255675M000
K85104Z304

$180.42
$793.86

0.5
INC

ME
ME

Front Doors
9 EU

LIKE KIND & QUAL.PRT

$350.00*

1.6

3.3

Front Body And Windshield

3 EP
104
Fender,Front RT
4 L
104
Fender,Front RT

208

Door Assembly,Front RT
>> LKQ, BIRMINGHAM
Door Shell,Front RT

10 L

208

11
12
13
14
15

E
E
E
EP
L

250
232
199
230
230

W/Strip,Frt Door Body RT

01 Pnl,Inner Door Trim RT
Tape,Front Door RT
Mirror,Outer R/C RT
Mirror,Outer R/C RT

16 NG

216

Glass,Front Door T RT

Rear Doors
17 EU

288

Door Assembly,Rear RT
>> LKQ BIRMINGHAM

05/16/2015 11:02 PM

Refinish
1.9 Surface
1.0 Edge
0.4 Two-stage
769214Z000
809006Z600
808124Z000
Replace PXN
Refinish
0.5 Surface
NAGS FD21029-GT

$151.90
$407.66
$16.12
$21.09

0.5
INC
0.2
INC
0.5

SM
SM
SM
SM
RF

$180.50

0.7

LIKE KIND & QUAL.PRT

$300.00*

1.1

Page 2 of 5

2006 Nissan Sentra 1.8S 4 DR Sedan

Claim # : C0008310-5

05/16/2015 10:55 PM

18 L

288

Door Shell,Rear RT

19 E

405

Tape,Rear Door RT

Refinish
1.6 Surface
1.0 Edge
0.3 Two-stage
828124Z000

Quarter And Rocker Panel

20 E
45
# Panel,Bodyside Front RT
# = 01, 07
21 L
45
13 Panel,Bodyside Front RT

760225M030

2.9

$18.32

0.2

$370.19

25.8

3.8

Refinish
2.5 Surface
0.2 Edge
0.6 Two-stage setup
0.5 Two-stage

Items
MC

Message

01
07
13

CALL DEALER FOR EXACT PART # / PRICE

STRUCTURAL PART AS IDENTIFIED BY I-CAR
INCLUDES 0.6 HOURS FIRST PANEL TWO-STAGE ALLOWANCE

Estimate Total & Entries

$3,185.06
$1,107.96
$532.00

Gross Parts
Other Parts
Paint & Materials
Parts & Material Total
Tax on Parts & Material
Labor

Sheet Metal (SM)

Mech/Elec (ME)
Frame (FR)
Refinish (RF)
Paint & Materials
Labor Total
Tax on Labor
Gross Total
Less: Deductible
Net Total

$4,825.02
$434.25

@ 9.000%
Rate

$50.00
$78.00
$60.00
$50.00
$40.00

Replace Repair Hrs

Hrs
31.5
0.9

0.4

13.3

Total Hrs

31.9
0.9

$1,595.00
$70.20

13.3

$665.00

46.1 Hours
@ 9.000%

$2,330.20
$209.72
$7,799.19
Unknown$7,799.19 TOTAL LOSS

Alternate Parts Y/03/03/00/00/00 CUM 03/03/00/00/00 Zip Code: 70506 Geo 70506

Audatex Estimating 7.0.417 ES 05/16/2015 11:02 PM REL 7.0.417 DT 03/01/2015 DB 05/08/2015

Copyright (C) 2015 Audatex North America, Inc.
2.2 HRS WERE ADDED TO THIS ESTIMATE BASED ON AUDATEX'S TWO-STAGE REFINISH FORMULA.

This estimate was created by an independently contracted appraisal company, under a subcontractors agreement for ACD INC. "AMT
APPRAISALS" is an independently held and operated company and is not a division of, subsidiary to, owned by, operated by, or financially
invested in by ACD INC. It is "AMT APPRAISALS" sole responsibility to hold its own required licenses; own and maintain its own equipment;
05/16/2015 11:02 PM

Page 3 of 5

2006 Nissan Sentra 1.8S 4 DR Sedan

Claim # : C0008310-5

05/16/2015 10:55 PM

maintain its own business hours; hire its own staff; schedule its work; and, comply with all federal, state and local laws and regulations of
any type, including tax laws. Neither ACD INC. nor ACD INC'S client assumes liability, responsibility, or approval, for any product and/or
estimate this appraiser has written until the product and/or estimate is reviewed and approved by company authorized employees. ACD INC.
is not responsible for any acts of negligence, omissions or errors, or fraudulent acts made by "AMT APPRAISALS".
THIS IS NOT AN AUTHORIZATION TO REPAIR. THIS IS AN APPRAISAL OF DAMAGES ONLY. NO APPRAISER HAS THE AUTHORITY
TO
AUTHORIZE REPAIRS.
AUTHORIZATION AND GUARANTEE OF PAYMENT CAN ONLY BE GIVEN BY THE OWNER OF THE VEHICLE. ACD (AUTOCLAIMS
DIRECT)
AND ITS CLIENTS ASSUME NO RESPONSIBILITY FOR REPAIR QUALITY AND SAFETY. ACD (AUTOCLAIMS DIRECT) SPECIFIES AND
INTENDS THAT ALL REPAIRS AND PART REPLACEMENTS LISTED HEREON ARE MADE IN STRICT ACCORDANCE WITH THE
MANUFACTURER'S RECOMMENDATIONS AND SPECIFICATIONS. SUPPLEMENTAL DAMAGE IS SUBJECT TO REINSPECTION.
ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS IS SUBJECT TO
CRIMINAL
AND CIVIL PENALTIES.
Notice: All crash parts on this estimate are new-OEM (Original Equipment Manufactured) unless otherwise specified. Parts that are
described as Quality Replacement Parts, NWCPP, and QRP, CAPA, are Non-OEM crash parts or Aftermarket parts. If this estimate includes
the use of non-OEM Aftermarket crash parts, then the supplier of the aftermarket parts and/or the insurer that pays for them warrants that
such parts are of like kind, quality, safety, fit and performance as the original manufactures equipment that came on the vehicle.
THIS IS AN ESTIMATE ONLY AND NOT AN AUTHORIZATION FOR REPAIRS.THE
OWNER OF THE VEHICLE MUST AUTHORIZE VEHICLE REPAIRS. GAINSCO AUTO
INSURANCE MUST INSPECT AND APPROVE ANY AND ALL SUPPLEMENTARY DAMAGES
PRIOR TO REPAIRS. NO ADDITIONAL PAYMENT (SUPPLEMENT) WILL BE MADE
WITHOUT PRIOR APPROVAL AND SUPPORTING DOCUMENTATION. THESE INCLUDE,
BUT ARE NOT LIMITED TO:
* PARTS PRICE DIFFERENCES
* BLEND OPERATIONS
* R&I FOR ACCESS/BLEND
* TOWING
* GLASS AND PARTS INVOICES.
THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF AUTOMOBILE PARTS
NOT MADE BY THE ORIGINAL MANUFACTURER. PARTS USED IN THE REPAIR OF
YOUR VEHICLE BY OTHER THAN THE ORIGINAL MANUFACTURER ARE REQUIRED TO
BE AT LEAST EQUAL IN LIKE KIND AND QUALITY IN TERMS OF FIT, QUALITY
AND PERFORMANCE TO THE ORIGINAL MANUFACTURER PARTS THEY ARE REPLACING.
WARRANTIES APPLICABLE TO THESE REPLACEMENT PARTS ARE PROVIDED BY THE
MANUFACTURER OR DISTRIBUTOR OF THESE PARTS RATHER THAN THE
MANUFACTURER OF YOUR VEHICLE.
ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR
PAYMENT OF A LOSS IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES
AND CONFINEMENT IN STATE PRISON.
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR
05/16/2015 11:02 PM

Page 4 of 5

2006 Nissan Sentra 1.8S 4 DR Sedan

Claim # : C0008310-5

05/16/2015 10:55 PM

DECEIVE ANY INSURER, FILES A STATEMENT OF CLAIM CONTAINING ANY FALSE,

INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE
THIRD DEGREE.
Name:_______________________ Estimated Completion Date:_____________

THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF CRASH PARTS
SUPPLIED BY A SOURCE OTHER THAN THE MANUFACTURER OF YOUR MOTOR VEHICLE.
WARRANTIES APPLICABLE TO THESE REPLACEMENT PARTS ARE PROVIDED BY THE
MANUFACTURER OR DISTRIBUTOR OF THESE PARTS RATHER THAN THE MANUFACTURER
OF YOUR VEHICLE.
ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT
OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN
APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES
AND CONFINEMENT IN PRISON.

Op Codes
* =
EC =
ET =
TE =
L =
TT =
BR =
CG =
AA =

User-Entered Value
Replace Economy
Partial Replace Labor
Partial Replace Price
Refinish
Two-Tone
Blend Refinish
Chipguard
Appearance Allowance

E =
OE =
EP =
PM =
PC =
SB =
I =
RI =
RP =

Replace OEM
Replace PXN OE Srpls
Replace PXN
Replace PXN Reman/Reblt
Replace PXN Reconditioned
Sublet Repair
Repair
R & I Assembly
Related Prior Damage

NG =
UE =
EU =
UM =
UC =
N =
IT =
P =

Replace NAGS
Replace OE Surplus
LIKE KIND & QUAL.PRT
Replace Reman/Rebuilt
Replace Reconditioned
Additional Labor
Partial Repair
Check

This report contains proprietary information of Audatex and may not be disclosed to any third party (other than
the insured, claimant and others on a need to know basis in order to effectuate the claims process) without
Audatex's prior written consent.
Copyright (C) 2015 Audatex North America, Inc.
Audatex Estimating is a trademark of Audatex North America, Inc.

05/16/2015 11:02 PM

Page 5 of 5

CCC Valuescope Basic Claim Information Form

Report Retrieval

Fax

Other (Specify)

Method
CCC Phone: 1-800-621-

CCC Fax: 1-800-

8070

621-7070

CCC Email: [email protected]

Office ID Number

Claim Number

Adjr Name (First & Last)

Appr Name (First & Last)

Jill Dennis

Adjr Contact#

Insureds Name

Owners Name

PATRICIA HARRIS

Owners Phone

Loss ZIP Code

39631

Loss State

Loss Type

Other

Theft

3rd Party Claim

Yes

Coverage code
No

AARON THEALL

PATRICIA HARRIS

Liability
Date of Loss

C0008310-5

Collision

Comprehensive

Other

Leased Vehicle

Yes

Exch#Policy #

05/13/2015

Adjuster ID#

Claim Class

PA Appr ID#
VIN

3N1CB51D26L453976

Year

2006

Make

NISS

2DR

Body Style

Model

SENTRA 1.8S

4DR
Hatchback

Ton

Short

Ton
Engine Size

1.8

Convertible

Bed
3

Cylinders

Wagon

Long

Chassis

Fleetside

Fenderside
Diesel

Turbo

68,062
S6

Transmission

Utility

8
10

Mileage (UNK if unknown)

Van

Cab &

Bed
4

Pickup

Automatic
Power Options

Seating

PS Power Steering

CS Cloth Seats

PB Power Brakes

LS Leather Seats

PW Power Windows
PL Power Locks

Roof
EG Electric Glass
Roof

RL Reclining/

ES Electric Steel

Lounge Seats

Roof

SP Power Driver Seat

BS Bucket Seats

OR Skyview Roof

PC Power Passenger Seat

SH Heated Seats (2)

SD Dual Power

PA Power Antenna

RH Rear Heated

PM Power Mirrors

Seats

PT Power

R3 Retractable Seats

Pedals

2P 12 Passenger
Seating

DP Dual Power Sliding

5P 15 Passenger
Seating

Conditioning
RD Rear Defogger

D2 Deluxe 2 Tone
Paint
HP Three Stage Paint
IP Clearcoat Paint
MP Metallic Paint

TG Tinted Glass

VR Vinyl Roof

2T Two Tone Paint

GT Glass T-

RM Detachable Roof

(6)

Wiper

FL Fog Lamps

Convertible Roof
B6 Captain Chairs

WP Rear Window

SL Rear Spoiler

VP Power

(4)

CL Climate Control

WG Woodgrain

TT T-Top/Panel

Convertible Roof
B4 Captain Chairs

RR Luggage/Roof
Rack

FR Flip Roof

MV Manual

(2)

DA Dual Air

MG Manual Glass
Roof

Top/Panel

B2 Captain Chairs

Dcor/Convenience
AC Air Conditioning

Roof

3P Power Third Seat

PP Power Adjustable

Doors

MS Manual Steel

3S Third Row Seat

Trunk/Tailgate

PD Power Sliding Door

Roofs

Exterior/Paint/Glass

DT Privacy Glass
BN Body Side
Moldings
DM Dual Mirrors
HM Heated Mirrors
HV Headlamp
Washers

BCIF 13,20

IW Intermittent Wipers

RF Cabriolet Roof

Radio

MX Signal Integrated

TW Tilt Wheel

AM AM Radio

LR Landau Roof

Mirrors

TL Telescopic Wheel

FM FM Radio

LP Padded Landau

Other

CC Cruise Control

ST Stereo

KE Keyless Entry

CA Cassette

CN Console/Storage

SE Search/Seek

CO Overhead Console

CD Compact Disc

EC Entertainment Center
NV Navigation System
C2 Communications
System
HU Heads Up Display
WT Wood Interior Trim
EI Electronic
Instrumentation
IB On Board Computer

Roof
PV Padded Vinyl
Roof

SK CD

TQ Steering Wheel

BY Bedliner (Spray
On)

XG Front Side

CP Fiberglass Cap

Impact Air Bags

M3 Auxiliary Audio
Connection

8T 8 Track Tape

BL Bedliner

RG Passenger Air
Bag

Touch Controls

CB CB Radio

AR Bed Rails

AG Air Bag

XM Satellite Radio

RJ Remote Start

XE Xenon Headlamps

Safety/Brakes

UR Premium Radio

MM Memory Package

Running Boards

HT Hard Top

Changer/Stacker

EQ Equalizer

UP Power Retractable

CT Soft Top

Player

MC Message Center

BD Running
Board/Side Steps

GG Grill Guard

ZG Rear Side

SB Rear Step Bumper

Impact Air Bags

SS Swivel Seats

DG Head/Roof Air
Bags

SW Rear Sliding
Window

TD Theft

Player

Deterrent/Alarm

PG Power Rear
Window

VZ Night Vision

Wheels

IC Intelligent Cruise

AW
Aluminum/Alloy

PJ Parking Sensors

Wheels

PX Parking Sensors
W/Equip

CJ Chrome Wheels

AB Anti-Lock

W2 20 or Larger

Brakes (4)

Wheels

A2 Anti-Lock

DC Deluxe Wheel

Brakes (2)

Covers
FC Full Wheel Covers
SA Spoke Aluminum

DB 4-Wheel Disc
Brakes
RB Rollover

Wheels

Protection

SY Styled Steel

TX Traction Control

Wheels
WW Wire Wheels

T1 Stability Control

WC Wire Wheel

AL Auto Level

TB Tool Box
(Permanent)
TN Tonneau Cover
Soft
TZ Tonneau Cover
Hard
TP Trailering
Package
WD Dual Rear
Wheels
XT Auxiliary Fuel
Tank
3D 3rd Truck Door
4D 4th Door
Truck/Van
BC Bumper Cushions
BG Bumper Guards

Covers

EM California

RW Rally Wheels

Emissions

KW Locking Wheels

SG Stone Guard

LC Locking Wheel

WI Winch

Covers

BCIF 13,20

CCC Valuescope Basic Claim Information Form

Office ID Number

(Continued)

Claim Number

REFURBISHMENTS
Transmission

Purchase Price

Mileage

Tires

Purchase Price

# of Tires

Basic

Paint

Standard

Engine

Date Painted

Purchase Price

Mileage

Purchase Price

Custom
Interior

Purchase Price

Date

Camper Shell

Purchase Price

Date

Special Wheels

Purchase Price

Date

Other

Description

Leather
Carpet Kit

Vinyl

Cloth

Purchase Price

Date

Purchase Price

Date

Restored Amount

Restored

Package/Special Features/Additional Options (XXXX=CALL BACK)

CONDITION RATING: Rate each of the following 0=Major Wear, 1=Normal Wear, 2=Dealer Ready,
3=Exceptional

COMMENTS

Seats
0

Carpet
0

Headliner
Body
Glass
1

Engine
Transmission
Front Tires
1
1

MINOR WEAR, CLEANABLE STAINS

NO CRACKS, NO FADING,

NO TEAR, MINOR STAINS, NO HANGING

NO DINGS

NO CRACKS

FINISH APPEARS MAINTAINED, NO OXYDATION,

CLEAN, NO RESIDUE, HIGH MILES

NO LEAKS

50% TREAD LEFT

Rear Tires
0

Paint

MINOR WEAR, CLEANABLE STAINS

Dashboard

3
2

ADJUSTMENTS
Pre Tax

Add

Deduct

Add

Deduct

Adjustment 1
Pre Tax
Adjustment 2
Sales Tax %

Leave

Deductible

blank if using AutoTax

BCIF 13,20

Post Tax

Add

Deduct

Add

Deduct

Adjustment 1
Post Tax
Adjustment 2

BCIF 13,20

05/16/2015

2006 NISSAN Sentra-4 Cyl.

Sedan 4D 1.8S

VIN:

3N1CB51D26L453976

Mileage:

120,101

Vehicle Location:

Baton Rouge, LA 70807

Estimated ACV *

Borderline Alert **

$4,525.00

$3,832.50

Values
Rough Trade-In

Average Trade-In

Clean Trade-In

Clean Retail

Base Price:

$2,275.00

$3,025.00

$3,650.00

$5,550.00

Mileage (120,101):

$-75.00

Total Base Price:

$2,200.00

$2,950.00

$3,575.00

$5,475.00

Price With Options:

$2,200.00

$2,950.00

$3,575.00

$5,475.00

Data provided by NADA

* Estimated ACV is formulated by averaging the NADA Clean Trade-In and Clean Retail values.
** Borderline Alert is 70% of the NADA Clean Retail value, indicating a potential Total Loss.
This data is for information purposes only. All state and federal regulations in determining values of vehicles for settling auto
claims must be applied by the insurance company. Estimated ACV and Borderline Alert are not to be used to determine the ACV
of a vehicle. These are only approximate indicators and an adjuster should follow their own internal company policies in
determining a total loss and coming to a settlement with their customer.

2006 Nissan Sentra Sedan 4D 1.8S Prices, Values & Specs - NADAguides

Page 1 of 1

NADAguides Price Report

5/16/2015

2006 Nissan Sentra-4 Cyl.

Sedan 4D 1.8S

Values
Base Price
Mileage (120,000)
Total Base Price

Rough
Trade-In

Average
Trade-In

Clean
Trade-In

Clean
Retail

$2,275

$3,025

$3,650

$5,550

N/A

$2,275

$3,025

$3,650

$5,550

$2,275

$3,025

$3,650

$5,550

Options:
Price with Options

Rough Trade-In - Rough Trade-in values reflect a vehicle in rough condition. Meaning a vehicle with significant mechanical defects requiring repairs in order
to restore reasonable running condition. Paint, body and wheel surfaces have considerable damage to their finish, which may include dull or faded (oxidized)
paint, small to medium size dents, frame damage, rust or obvious signs of previous repairs. Interior reflects above average wear with inoperable equipment,
damaged or missing trim and heavily soiled /permanent imperfections on the headliner, carpet, and upholstery. Vehicle may have a branded title and un-true
mileage. Vehicle will need substantial reconditioning and repair to be made ready for resale. Some existing issues may be difficult to restore. Because
individual vehicle condition varies greatly, users of NADAguides.com may need to make independent adjustments for actual vehicle condition.
Average Trade-In - The Average Trade-In values on nadaguides.com are meant to reflect a vehicle in average condition. A vehicle that is mechanically sound
but may require some repairs/servicing to pass all necessary inspections; Paint, body and wheel surfaces have moderate imperfections and an average finish
and shine which can be improved with restorative repair; Interior reflects some soiling and wear in relation to vehicle age, with all equipment operable or
requiring minimal effort to make operable; Clean title history; Vehicle will need a fair degree of reconditioning to be made ready for resale. Because individual
vehicle condition varies greatly, users of nadaguides.com may need to make independent adjustments for actual vehicle condition.
Clean Trade-In - Clean Trade-In values reflect a vehicle in clean condition. This means a vehicle with no mechanical defects and passes all necessary
inspections with ease. Paint, body and wheels have minor surface scratching with a high gloss finish and shine. Interior reflects minimal soiling and wear with
all equipment in complete working order. Vehicle has a clean title history. Vehicle will need minimal reconditioning to be made ready for resale. Because
individual vehicle condition varies greatly, users of NADAguides.com may need to make independent adjustments for actual vehicle condition.
Clean Retail - Clean Retail values reflect a vehicle in clean condition. This means a vehicle with no mechanical defects and passes all necessary inspections
with ease. Paint, body and wheels have minor surface scratching with a high gloss finish and shine. Interior reflects minimal soiling and wear with all
equipment in complete working order. Vehicle has a clean title history. Because individual vehicle condition varies greatly, users of NADAguides.com may need
to make independent adjustments for actual vehicle condition. Note: Vehicles with low mileage that are in exceptionally good condition and/or include a
manufacturer certification can be worth a significantly higher value than the Clean Retail price shown.

http://www.nadaguides.com/Cars/2006/Nissan/Sentra-4-Cyl/Sedan-4D-1-8S/Values/Print

5/16/2015

ACD
3132 Tiger Run Court
Suite #103
Carlsbad, CA 92010
(888) 403-4223
Tax ID: 56-2410145

INVOICE
PAYABLE UPON RECEIPT

Appraiser: Aaron Theall

INVOICE #: 1737611
DIRECTLINK #: LA1505-141431
DATE: 05/18/2015

Total Amount

$125.00

Bill To:
ACCC Insurance Company
390 Benmar Dr, Suite 225
Houston, TX 77060
4049999999

Adjuster:
Jill Dennis
[email protected]

Item Info:
Base Fee

Billing Info

Type
C laim Number
Owner Name
Vehicle

$125.00

Mileage Fee

$0.00 (0 miles @ 0.90 per mile)

Remote/Travel
Fee

$0.00

Additional Fee

$0.00 (see notes)

Total Fee

$125.00

Appraisal Standard & AC D Management Services

C 0008310-5
P ATRIC IA HARRIS
2006 Nissan Sentra

Invoice Note:
No Notes.

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