The URL can be used to link to this page

Home My WebLink About12-4024CuKBERL N? ? tEW4 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION ALLSTATE INSURANCE COMPANY (1i Plaintiff No: J01, y0 q vd vs. SASSOON EXPRESS INC ROMAN KHACHATVROV COMPLAINT IN CIVIL ACTION Defendants FILED ON BEHALF OF Plaintiff COUNSEL OF RECORD OF THIS PARTY: Michael J. Dougherty,76046 WELTMAN, WEINBERG & REIS CO., L.P.A. 325 CHESTNUT STREET SUITE 501 PHILADELPHIA, PA 19106-2614 215-599-1500 FAX: 215-599-1505 09682352 C Y Jer DKM a C?µ les??oYa p"14 9 „ a3y IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNT`., PENNSYLVANIA CIVIL DIVISION ALLSTATE INSURANCE COMPANY Plaintiff VS. Civil Action No SASSOON EXPRESS INC ROMAN KHACHATVROV Defendants COMPLAINT AND NOTICE TO DEFEND You have been sued in court. If you wish to defend against the claims set forth in the following pages, you must: take action within twenty (20) days after this complaint and notice are served, by entering a written appearance personally or by an attorney and filing in writing with the court your defenses or objections to the claims set forth against you. You are warned that if you fail to do so the case may proceed without you and a judgment may be entered against you by the court without further notice for any money claimed in the complaint or for any other claim or relief requested by the plaintiff. You may lose money or property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP. IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE. LAWYER REFERRAL SERVICE CUMBERLAND COUNTY BAR ASSOCIATION 32 SOUTH BEDFORD STREET CARLISLE, PA 17013 (717) 249-3166 WELT]YIAN, WEINBERG & REIS CO., L.P.A. BY: Michael J. Dougherty, Esquire Pa. Identification No. 76046 325 Chestnut Street, Suite 501 Philadelphia, PA 19106 Phone: 215.599.1500 Fax: 215.599.1505 File #09682352 } ALLSTATE INSURANCE COMPANY } } } vs. } } SASSOON EXPRESS, INC. } and ROMAN KHACHATVROV } Attorney for Plaintiff(s) Court of Common Pleas Cumberland County NO. CIVIL ACTION - COMPLAINT Plaintiff is a business organization licensed and authorized to conduct business in the State of Virginia with a place of business located at 3800 Electric Road, Roanoke, Virginia 24018. 2. Defendant, Sassoon Express, Inc. ("Sassoon"), is a business organization licensed and authorized to conduct business in the Commonwealth of Pennsylvania and having as one of its places of business 21151 South Western Avenue, Torrance, California 90501. 3. Defendant, Roman Khachatvrov, is an adult individual who at all times pertinent hereto resided at 459 East Palm Avenue D, Burbank, California 91501. 4. Allstate issued a policy of insurance whereby Allstate agreed to insure the motor vehicle involved in this incident ("Insured Vehicle"), owned by Plaintiff's insured. 5. On or about March 5, 2012, Defendant, Khachatvrov, was the operator of a motor vehicle owned by Defendant, Sassoon, which vehicle did negligently, recklessly and/or carelessly collide with the Plaintiff Insured's vehicle at or near Pleasant View Drive, Mechanicsburg, Pennsylvania. COUNT I ALLSTATE INSURANCE COMPANY v.ROMAN KHACHATVROV 6. Plaintiff hereby incorporates all preceding and forthcoming averments as if fully set forth at length herein. 7. The negligence and/or carelessness of the Defendant consisted of the following: a. Failing to have his motor vehicle under such control as the situation warranted; b. Operating his motor vehicle in complete disregard of the point and position of Plaintiff's vehicle; c. Failing to keep a proper lookout; d. Traveling too fast for conditions; e. Disregarding traffic control devices; f. Failing to abide by the Rules of the Road and the Motor Vehicle Code of Pennsylvania; g. Being otherwise negligent under the circumstances; and, h. Being negligent as a matter of law as may be relevant through discovery and/or at the time of trial. 8. As a direct and proximate result of Defendant's negligence, the Allstate Insured's vehicle sustained property damage and/or incurred rental charges in the total amount of $2,507.51. See attached as Exhibit " 1 " a copy of the damage documentation which documents Plaintiff further intends to introduce at the arbitration in this matter. 9. Pursuant to the insurance policy issued by Allstate and as a result of the aforesaid payment, Allstate became subrogated to the claim of its Insured against Defendant. WHEREFORE, Plaintiff demands Judgment against Defendants, joint and severally, in the amount of $2,507.51 plus interest and costs. COUNT II ALLSTATE INSURANCE COMPANY v. SASSOON EXPRESS. INC. 10. Plaintiff hereby incorporates all preceding and forthcoming averments as if fully set forth at length herein. 11. At all times pertinent hereto, Defendant, Khachatvrov, was acting as the agent, servant, workman and/or employee of Defendant, Sassoon, in the course and scope of his employment and/or with the express and/or implied permission of Defendant, Sassoon. 12. Defendant, Sassoon, is liable for the acts and/or omissions of Defendant, Khachatvrov. 13. As a direct and proximate result of Defendant's negligence, the Allstate Insured's vehicle sustained property damage and/or incurred rental charges in the total amount of $2,507.51. See attached as Exhibit " 1 " a copy of the damage documentation which documents Plaintiff further intends to introduce at the arbitration in this matter. 14. Pursuant to the insurance policy issued by Allstate and as a result of the aforesaid payment, Allstate became subrogated to the claim of its Insured against Defendant. WHEREFORE, Plaintiff demands Judgment against Defendants, joint and severally, in the amount of $2,507.51 plus interest and costs. WELTWN, WEINBERG & REIS, CO., L.P.A. VMcha0I J. Dougherty, Esquire A I . D. # 76046 325 Chestnut Street Suite 501 Philadelphia, PA 19106 (215) 599-1500 WWR#09227935 EXHIBIT 1 ALLSTATE INSURANCE COMPANY HARRISBURG MARKET CLAIM OFFICE 6345 FLANK DRIVE HARRISBURG, PA 17112 PHONE: 800.726.8890 SUPPLEMENT REQUEST FAX LINE: 1.866.587.9857 *** ESTIMATE *** 03/06/2012 12:33 Ph Owner Owner: CHRIS BARNARD Address: 456 FALLING SPRINGS RD Work/Day: (717)554-2429 City State Zip: LANDISBURG, PA 17040-9206 FAX: Email: BARNARD08@EMBARQMAIL.COM Control Information Claim #: 000237209580D01 Loss Date/Time: 03/05/2012 Deductible: $500.00 Ins. Company: Allstate Fire And Casualty Insuranc Insured: CHRIS BARNARD Address: 456 FALLING SPRINGS RD City State Zip: LANDISBURG, PA 17040-9206 Email: BARNARD08@EMBARQMAIL.COM Insured Policy # : 000952407775 Loss Type: Collision Work/Day: (717)554-2429 FAX- Inspection Inspection Date: Inspection Location: Primary Impact: Driveable: 03/06/2012 12:22 PM w/s di. Right Rear Corner Yes Inspection Type: Drive In Contact: Secondary Impact: Rental Assisted: Assigned Date/Time: Appraiser Name: JOE KOONS Address: 6345 FLANK DR. City State Zip: HARRISBURG, PA 17112 Received Date/Time: 03/06/2012 12:22 PM Appraiser License # : 132645 Work/Day: (800)726-8890 FAX: L Repairer Repairer: J. W. SMITH AUTO BODY INC. _ Contact: Address: 2401 shermans valley rd. Work/Day: (717)582-4702 City State Zip: ELLIOTTSBURG, PA 17024 FAX: (717)582-2022 ? Remarks ATTN. REPAIR FACILITY: ALL SUPPLEMENT REQUESTS MUST BE FAXED INTO THE SUPPLEMENT REQUEST FAX LINE #1-866-587-9857 FOR APPROVAL, REQUEST SHEET IS ATTACHED TO ESTIMATE. ALL SUPPLEMENTS MUST BE APPROVED PRIOR TO REPAIRS. Vehicle 2011 Toyota Tacoma SR5 4 DR Crew Cab Long Bed 6cyl Gasoline 4.0 NIG IL: JC FM Page 1 of 2011 Toyota Tacoma SR5 4 DR Crew Cab Long Bed Claim # : 000237209580D01 5 Speed Automatic Lic.Plate: YTR-6689 Lic Expire: Prod Date: Veh Insp# : Condition: Ext. Color: gray Ext. Refinish: Two-Stage Ext. Paint Code: 1g3 Options Lic State: PA VIN: 3TMM U4 FN7BM025638 Mileage: 18,398 Mileage Type: Actual Code: Y8176A Int. Color: Int. Refinish: Int. Trim Code: 2nd Row Head Airbags Air Conditioning Auto Locking Hubs (4WD) Center Console Digital Clock Fender Flares Halogen Headlights Keyless Entry System Leather Steering Wheel MP3 Player Power Brakes Power Steering Reverse Sensing System Sliding Rear Window Strg Wheel Radio Control Theft Deterrent System Tow Hooks Velour/Cloth Seats 4-Wheel Drive Anti-lock Brakes Automatic Dimming Mirror Chrome Step Bumper Dual Airbags Fog Lights Head Airbags LED Brakelights Lighted Entry System Mud/Splash Guards Power Door Locks Power Windows Side Airbags Split Folding Rear Seat Styled Steel Wheels Tilt & Telescopic Steer Traction Control System AM/FM CD Player Auto Headlamp Control Bucket Seats Cruise Control Electronic Transfer Case Full Size Spare Tire Intermittent Wipers Leather Shift Knob Limited Slp Differential Overhead Console Power Mirrors Rear View Camera Skid Plates Stability Cntrl Suspensn Tachometer Tinted Glass Trip Computer Damages Line Op Guide MC Description MFR.Part No. Price ADJ% B% Hours R Bed 1 1 332 Panel,Bedside Outer RT Repair 6 0' SM 2 L 332 # Panel,Bedside Outer RT Refinish . 3.7' RF 2.5 Surface 0.6 Two-stage setup 0.6 Two-stage # = 10, 13 3 E 420 MIdg,Bedside Pnl Upr RT 6624804020 $73.73 0 2 SM 4 RI 1503 Mldg,Bedside Lwr Cnr RT R & I Assembly . 0 1 SM 5 E 1501 Tape,Bedside RT 7692504020 $28.42 . 0 4 SM 6 RI 282 Flare,Wheel Opening RT R & I Assembly . 0.5 SM Tailaate 7 1 479 Shell,Tailgate Repair 1.0` SM » rt. edge 8 L 479 10 Shell,Tailgate Refinish 2.2" RF 1.8 Surface 0.4 Two-stage 9 N 479 Tailgate R & I Additional Labor 0 3 SM 10 RI 514 Mldg,Tailgate Upper R & I Assembly . INC SM 11 E 578 N/Plate,Tailgate 7547104030 $25.74 0 2 SM 12 E 584 N/Plate,Tailgate 7542704010 $37.52 . 0 2 SM 13 E 590 N/Plate, Tailgate 7547304050 $23.16 . 0 2 SM 14 E 591 N/Plate, Tailgate 7547204030 $25.74 . 0.2 SM 03/06/2012 12:58 PM Page 2 of 2011 Toyota Tacoma SR5 4 DR Crew Cab Long Bed Claim # : 0002372095801301 15 RI 493 Handle,Tailgate Outer R & I Assembly Rear Bump er 16 RI 567 Bumper Assembly,Rear R & I Assembly Rear Bodv Lamps An d Floor Pan 17 E 534 46 Taillamp Assembly RT 8155004160 $207.71 Manual Entries 18 EC M14 Corrosion Protection COMPETITIVE PART $10.00* 19 EC M17 Cover Car Exterior COMPETITIVE PART $5.00* 20 SB M60 Hazardous Waste Removal Sublet Repair $3.00* 20 Items 03/06/2012 12:33 PP 0.6 SM 0.6 SM 0.3 SM 0.0* SM RF SM MC Message 10 INCLUDES AUDATEX TIME TO CLEAR ENTIRE PANEL 13 INCLUDES 0.6 HOURS FIRST PANEL TWO-STAGE ALLOWANCE 46 PRINTABLE ALTERNATE PARTS COMPARE ( Estimate Total & Entries Gross Parts $422.02 Other Parts $15.00 Paint Materials $135.70 Parts & Material Total $572.72 Tax on Parts & Material @ 6.000% $34.36 Labor Rate Replace Repair Hrs Total Hrs Hrs Sheet Metal (SM) $45.00 3.5 7.3 10.8 $486.00 Mech/Elec (ME) $45.00 Frame (FR) $45.00 Refinish (RF) $45.00 5.9 5.9 $265.50 Paint Materials $23.00 Labor Total 16.7 Hours $751 50 Tax on Labor @ 6.000% . $45 09 Sublet Repairs . $3 00 Tax on Sublet @ 6.000% . $0 18 Gross Total . $1 406.85 Less: Deductible , $500 00- Net Total . $906 85 Customer Owes . $500.00 Alternate Parts Y/01/00/00/01/01 CUM 01/00/00/01/01 Zip Code: 17112 NE HBG S 1ST 2/11 Requested Review On: 03/06/2012 12:58 PM Audatex Estimating 6.0.626 ES 03/06/2012 12:58 PM REL 6.0.626 DT 01/01/2012 DB 02/15/2012 Copyright (C) 2011 Audatex North America, Inc. 1.6 HRS WERE ADDED TO THIS ESTIMATE BASED ON AUDATEX'S TWO-STAGE REFINISH FORMULA. 03/06/2012 12:58 PM Page 3 of 2011 Toyota Tacoma SRS 4 DR Crew Cab Long Bed Claim # : 000237209580D01 03/06/2012 12:33 PP IMPORTANT INFORMATION ABOUT ALLSTATE'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. ALLSTATE 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 ALLSTATE'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, ALLSTATE WILL SPECIFY THE USE OF ORIGINAL EQUIPMENT MANUFACTURER PARTS, EITHER NEW OR RECYCLED AT ALLSTATE'S OPTION, AT NO ADDITIONAL COST TO YOU. ALLSTATE DOES NOT SEPARATELY GUARANTEE THE PERFORMANCE OF ORIGINAL EQUIPMENT MANUFACTURER PARTS, AND MAKES NO REPRESENTATION ABOUT THE AVAILABILITY OF ANY MANUFACTURER'S GUARANTEE. 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 THE REPAIRS IS PROPERLY EQUIPPED. ALLSTATE WILL NOT BE RESPONSIBLE FOR ANY RELATED TOWING SERVICES OR STORAGE CHARGES, KNOWN AT THE TIME OF APPRAISAL, AFTER AFTER. WHICH THE CHARGES WILL BE THE RESPONSIBILITY OF THE CONSUMER. THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF AFTERMARKET CRASH PARTS. IF THE USE OF AN AFTERMARKET CRASH PART VOIDS THE EXISTING WARRANTY ON THE PART BEING REPLACED OR ANY OTHER PART, THE AFTERMARKET CRASH PART SHALL HAVE A WARRANTY EQUAL TO OR BETTER THAN THE REMAINDER OF THE EXISTING WARRANTY. WARRANTIES APPLICABLE TO THE AFTERMARKET CRASH PARTS ARE PROVIDED BY THE MANUFACTURER OR THE DISTRIBUTOR OF THESE PARTS NOT THE ORIGINAL MANUFACTURER OF YOUR VEHICLE. ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES. IT IS TO OUR MUTUAL INTEREST THAT YOU RECEIVE PROMPT AND COURTEOUS SERVICE ALONG WITH QUALITY REPAIR WORK AT A FAIR PRICE. IF YOU HAVE A PREFERENCE FOR A PARTICULAR SHOP, YOUR ADJUSTER WILL WRITE OR APPROVE AN ESTIMATE OF REPAIRS WITH THAT SHOP BASED ON COMPETITIVE PRICES IN THE AREA. INFORMATION REGARDING REPAIR FACILITIES, WHICH MAY BE ABLE TO REPAIR THE VEHICLE FOR THE APPRAISED AMOUNT, IS AVAILABLE FROM YOUR ADJUSTER OR INSURER. HOWEVER, THERE IS NO REQUIREMENT TO USE ANY SPECIFIED SHOP. COSTS ABOVE THE APPRAISED AMOUNT MAY BE THE RESPONSIBILITY OF THE VEHICLE OWNER. ALL SUPPLEMENTS MUST BE APPROVED PRIOR TO REPAIR. AFTERMARKET CRASH PARTS ARE IDENTIFIED IN THE ESTIMATE WITH SYMBOL "EC", "EP," (COMPETITIVE PART) AND "EU" (RECYCLED PART). AN "AFTERMARKET CRASH PART" IS A NON-ORIGINAL MANUFACTURER (NON-OEM) REPLACEMENT PART, EITHER NEW OR USED, FOR ANY OF THE NON-MECHANICAL PARTS THAT GENERALLY CONSTITUTE THE EXTERIOR OF THE MOTOR VFT4TC T F TNrT TMTNC' INNER AND QTTTRR PAMWT n 03106/2012 12:58 PM Page 4 of 2011 Toyota Tacoma SR5 4 DR Crew Cab Long Bed Claim # : 000237209580D01 NEW, ORIGINAL EQUIPMENT MANUFACTURER, REPLACEMENT PARTS ARE IDENTIFIED BY THE LETTER "E" AND CAN BE LOCATED AT THE ORIGINAL EQUIPMENT MANUFACTURER PARTS DEALER. ADJUSTER: LICENSE # DATE Op Codes 03/0612012 12:33 PP = User-Entered Value EC = COMPETITIVE PART ET = Partial Replace Labor TE = Partial Replace Price L = Refinish TT = Two-Tone BR = Blend Refinish CG= Chipguard AA = Appearance Allowance E =Replace OEM OE = Replace PXN OE Srpls EP = COMPETITIVE PART PM= Replace PXN Reman/Reblt PC = Replace PXN Reconditioned SB = Sublet Repair I = Repair RI = R & I Assembly RP= Related Prior Damage NG = Replace NAGS UE = Replace OE Surplus EU = RECYCLED PART UM= Replace Reman/Rebuilt UC = Replace Reconditioned N = Additional Labor IT = Partial Repair P =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 udate Audatex's prior written consent. a Snfr,a ttv pa Copyright (C) 2011 Audatex North America, Inc. Audatex Estimating is a trademark of Audatex North America, Inc. Page 5 of 2011 Toyota Tacoma SR5 4 DR Crew Cab Long Bed Claim #: 000237209580D01 03/06/9019 1933 PI Estimate Summary Page JOE KOONS Gross Total $1,406.85 Less: Deductible $500.00- Net Total $906.85 Customer Owes $500.00 Audatex Estimating 6.0.626 ES 03/0612012 12:58 PM REL 6.0.626 DT 01/0112012 DB 02/15/2012 Copyright (C) 2011 Audatex North America, Inc. ALLSTATE INSURANCE COMPANY SUPPLEMENT REQUEST SHEET IN ORDER TO REVIEW YOUR SUPPLEMENT REQUEST, PLEASE COMPLETE THE FOLLOWING INFORMATION THOROUGHLY AND FAX IT TO 1.866.587.9857 BY SUBMITTING THIS FORM, THIS IS NOT AN AUTHORIZATION TO REPAIR. ALL SUPPLEMENTS MUST HAVE PRIOR APPROVAL. FAILURE TO DO SO WILL RESULT IN NON- PAYMENT OF A NON-APPROVED SUPPLEMENT. DATE: ORIGINAL ADJUSTER: CLAIM NUMBER: (_) SUPPLEMENT #1 (_) SUPPLEMENT #2 (_) SUPPLEMENT #3 (PLEASE CHECK THE BOX THAT APPLIES TO THE NUMBER OF SUPPLEMENT.) CUSTOMER NAME: 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 YEAR: MAKE: SHOP NAME: SHOP ADDRESS: CITY: STATE: PHONE: ( ) ZIP CODE: NATURE OF THE SUPPLEMENT: (PLEASE SUPPLY DESCRIPTION OF SUPPLEMENT REQUEST) ( ) PARTS: ( ) LABOR: MODEL: CONTACT: ( ) PARTS INCREASE: ( ) OTHER: APPROXIMATE TOTAL SUPPLEMENT AMOUNT: $ Z 12lJS Fly Page 6 of ALLSTATE INSURANCE COMPANY HARRISBURG MARKET CLAIM OFFICE 6345 FLANK DRIVE HARRISBURG, PA 17112 PHONE: 800.726.8890 SUPPLEMENT REQUEST FAX LINE: 1.866.587.9857 "** SUPPLEMENT 1 - 03/06/2012 12:33 PA S1 03/20/2012 08:06 AN Owner Owner: CHRIS BARNARD Address: 456 FALLING SPRINGS RD Work/Day: (717)554-2429 City State Zip: LANDISBURG, PA 17040-9206 FAX: Email: BARNARD08@EMBARQMAIL.COM Control Information Claim #: 000237209580D01 Loss Date/Time: 03/05/2012 Deductible: $500.00 Ins. Company: Allstate Fire And Casualty Insuranc Insured: CHRIS BARNARD Address: 456 FALLING SPRINGS RD City State Zip: LANDISBURG, PA 17040-9206 Email: BARNARD08@EMBARQMAIL.COM Insured Policy # : 000952407775 Loss Type: Collision Work/Day: (717)554-2429 FAX: Inspection Inspection Date: Inspection Location: Primary Impact: Driveable: 03/06/2012 12:22 PM w/s di. Right Rear Corner Yes Inspection Type: Drive In Contact: Secondary Impact: Rental Assisted: Assigned Date/Time: Company: Contact: Address: City State Zip: D K ERB 6345 FLANK DR Harrisburg, PA 17112 Orig Appraiser Name: JOE KOONS Address: 6345 FLANK DR. City State Zip: HARRISBURG, PA 17112 Received Date/Time: 03/06/2012 12:22 PM Appraiser License # : 151887 Work/Day: (800)726-8890x8509 FAX: (717)541-8494 Appraiser License # : 132645 Work/Day: (800)726-8890 FAX: _ Repairer: JW SMITH AUTO BODY INC Contact: JAY OR ANDY SMITH Address: PO BOX 3 Work/Day: (717)582-4702 City State Zip: ELLIOTTSBURG, PA 17024 FAX: (717)582-2022 Remarks ATTN. REPAIR FACILITY: ALL SUPPLEMENT REQUESTS MUST BE FAXED INTO THE SUPPLEMENT REQUEST FAX LINE #1-866-587-9857 FOR APPROVAL, REQUEST SHEET IS ATTACHED TO ESTIMATE. ALL SUPPLEMENTS MUST BE APPROVED PRIOR TO REPAIRS. Page 1 of 2011 Toyota Tacoma SR5 4 DR Crew Cab Long Bed Claim # : 000237209580D01 03/06/2012 12:33 PP Vehicle 2011 Toyota Tacoma SR5 4 DR Crew Cab Long Bed 6cyl Gasoline 4.0 5 Speed Automatic Lic.Plate: YTR-6689 Lic Expire: Prod Date: Veh Insp# : Condition: Ext. Color: gray Ext. Refinish: Two-Stage Ext. Paint Code: 1g3 Options Lic State: PA VIN: 3TMMU4FN7BM025638 Mileage: 18,398 Mileage Type: Actual Code: Y8176A Int. Color: Int. Refinish: Int. Trim Code: 2nd Row Head Airbags Air Conditioning Auto Locking Hubs (4WD) Center Console Digital Clock Fender Flares Halogen Headlights Keyless Entry System Leather Steering Wheel MP3 Player Power Brakes Power Steering Reverse Sensing System Sliding Rear Window Strg Wheel Radio Control Theft Deterrent System Tow Hooks Velour/Cloth Seats 4-Wheel Drive Anti-lock Brakes Automatic Dimming Mirror Chrome Step Bumper Dual Airbags Fog Lights Head Airbags LED Brakelights Lighted Entry System Mud/Splash Guards Power Door Locks Power Windows Side Airbags Split Folding Rear Seat Styled Steel Wheels Tilt & Telescopic Steer Traction Control System AM/FM CD Player Auto Headlamp Control Bucket Seats Cruise Control Electronic Transfer Case Full Size Spare Tire Intermittent Wipers Leather Shift Knob Limited Slp Differential Overhead Console Power Mirrors Rear View Camera Skid Plates Stability Cntrl Suspensn Tachometer Tinted Glass Trip Computer FDamages Line Op Guide MC Description MFR.Part No. Price ADJ% B% Hours R Cab And Components 1 BR 322 13 Pnl,Cab Side Outer RT Blend Refinish S1 1.7 RF 0.7 Blend 0.6 Two-stage setup 0.4 Two-stage 2 RI 374 Mldg,Roof Drip RT R & I Assembly S1 0.3 SM 3 E 1505 Tape,Lock Pillar RT 5874304010 $12.21 S1 0.3 SM Bye 4 E 332 Panel,Bedside Outer RT 6550004902 $636.45 S1 5 1 SM 5 L 332 Panel,Bedside Outer RT Refinish S1 . 4.4 RF 2.4 Surface 1.5 Edge 0.5 Two-stage 6 E 420 MIdg,Bedside Pnl Upr RT 6624804020 $73.73 S1 INC SM 7 RI 1503 Mldg,Bedside Lwr Cnr RT R & 1 Assembly S1 INC SM 8 E 1501 Tape,Bedside RT 7692504020 $28.42 S1 0 2 SM 9 ?n RI i 282 c'7n Flare,Wheel Opening RT -.1 ____ ^-- R & I Assembly - S1 . INC SM 03/20/2012 09:34 AM Page 2 of 2011 Toyota Tacoma SR5 4 DR Crew Cab Long Bed Claim # : 000237209580D01 03/06/2012 12:33 PP 0312012n19 nn-OR ne 11 L 570 Sill,Rear Cross Refinish 0.6 Surface T is (gate 12 1 479 Shell,Tailgate Repair » rt. edge 13 L 479 10 Shell,Tailgate Refinish 1.8 Surface 0.4 Two-stage 14 N 479 Tailgate R & I Additional Labor 15 RI 514 Mldg,Tailgate Upper R & I Assembly 16 E 578 N/Plate,Tailgate 7547104030 17 E 584 N/Plate,Tailgate 7542704010 18 E 590 N/Plate,Tailgate 7547304050 19 E 591 N/Plate,Tailgate 7547204030 20 RI 493 Handle,Tailgate Outer R & I Assembly 21 RI 412 Cover,Tailgate Access R & I Assembly Rear Bump er 22 RI 567 Bumper Assembly, Rear R & I Assembly Rear Body. Lamps And Floor Pan 23 E 534 46 Taillamp Assembly RT 8155004160 Manual Ent ries 24 L M08 Stoneguard Refinish 25 EC M14 Corrosion Protection COMPETITIVE PART 26 L M15 Color Tint Refinish 27 EC M17 Cover Car Exterior COMPETITIVE PART 28 SB M60 Hazardous Waste Removal Sublet Repair 29 BR RT ROCKER PANEL Blend Refinish 30 BR RT WINDSHIELD PILLAR Blend Refinish 31 RI RT CAB VENT R & I Assembly 32 N BACKTAPE REAR GLASS Additional Labor 32 Items Mc Message S1 0.6 RF S1 1.5* SM 2.2* RF S1 INC SM INC SM $25.74 0.2 SM $37.52 0.2 SM $23.16 0.2 SM $25.74 0.2 SM S1 0.2 SM S1 0.4 SM S1 INC SM $207.71 S1 INC SM S1 0.5* RF $10.00* 0.0* SM S1 0.5* RF $5.00* RF $3.00* SM S1 0.7* RF* S1 0.7* RF* S1 0.2* SM* S1 0.3* SM* 10 INCLUDES AUDATEX TIME TO CLEAR ENTIRE PANEL 13 INCLUDES 0.6 HOURS FIRST PANEL TWO-STAGE ALLOWANCE 46 PRINTABLE ALTERNATE PARTS COMPARE E Estimate Total & Gross Parts $1,070.68 Other Parts $15.00 Paint Materials $259.90 Parts & Material Total $1,345.58 Tax on Parts & Material @ 6.000% $80.73 Labor Rate Replace Repair Hrs Total Hrs Hrs Sheet Metal (SM) $45.00 7.5 3.8 11.3 $508.50 Mech/Elec (ME) $45.00 Frame (FR) $45.00 Refinish (RF) $45.00 11.3 11.3 $508.50 Paint Materials $23.00 Labor Total 22.6 Hours $1 017.00 Tax on Labor @ 6.000% , $61.02 Sublet Repairs $3 00 Tax on Sublet @ 6.000% . $0.18 03/20/2012 09:34 AM Page 3 of 2011 Toyota Tacoma SR5 4 DR. Crew Cab Long Bed Claim # : 000237209580D01 Gross Total Less: Deductible Net Total Actual Supplement Total Less: Previous Net Total Net Supplement Total Customer Owes $1,100.66 Alternate Parts Y/00/00/00/00/00 CUM 01/00/00/01/01 Zip Code: 17701 NE HBG NORTH 2ND 2/11 Requested Review On: 03/20/2012 08:53 AM Audatex Estimating 6.0.626 S1 03/2012012 09:34 AM REL 6.0.626 DT 02/01/2012 DB 03/08/2012 Copyright (C) 2011 Audatex North America, Inc. $2,507.51 $500.00- $2,007.51 $906.85- $1,100.66 $500.00 1.9 HRS WERE ADDED TO THIS ESTIMATE BASED ON AUDATEX'S TWO-STAGE REFINISH FORMULA. IMPORTANT INFORMATION ABOUT ALLSTATE'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. ALLSTATE 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 ALLSTATE'S EXPENSE. THIS GUARANTEE IS LIMITED TO THE REPAIR OR REPLACEMENT OF THE PART. 03/06/2012 1233 PP 0312012012 08:06 AP 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, ALLSTATE WILL SPECIFY THE USE OF ORIGINAL EQUIPMENT MANUFACTURER PARTS, EITHER NEW OR RECYCLED AT ALLSTATE'S OPTION, AT NO ADDITIONAL COST TO YOU. ALLSTATE DOES NOT SEPARATELY GUARANTEE THE PERFORMANCE OF ORIGINAL EQUIPMENT MANUFACTURER PARTS, AND MAKES NO REPRESENTATION ABOUT THE AVAILABILITY OF ANY MANUFACTURER'S GUARANTEE. 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 THE REPAIRS IS PROPERLY EQUIPPED. ALLSTATE WILL NOT BE RESPONSIBLE FOR ANY RELATED TOWING SERVICES OR STORAGE CHARGES, KNOWN AT THE TIME OF APPRAISAL, AFTER AFTER WHICH THE CHARGES WILL BE THE RESPONSIBILITY OF THE CONSUMER. THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF AFTERMARKET CRASH PARTS. IF THE USE OF AN AFTERMARKET CRASH PART VOIDS THE EXISTING WARRANTY ON THE PART BEING REPLACED OR ANY OTHER PART, THE AFTERMARKET CRASH PART SHALL HAVE A WARRANTY EQUAL TO OR BETTER THAN THE REMAINDER OF THE EXISTING WARRANTY. WARRANTTF.S APPT TC'ART F TQ TNF AFTERMARKET ("PAST-T PART4 ARE PR() 7TT)ET1 BY TTHF 03/2012012 09:34 AM Page 4 of 2011 Toyota Tacoma SR5 4 DR Crew Cab Long Bed 03/06/2012 12:33 PP Claim #: 000237209580D01 03/2012012 08:06 AP MANUFACTURER OR THE DISTRIBUTOR OF THESE PARTS NOT THE ORIGINAL MANUFACTURER OF YOUR VEHICLE. ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES. IT IS TO OUR MUTUAL INTEREST THAT YOU RECEIVE PROMPT AND COURTEOUS SERVICE ALONG WITH QUALITY REPAIR WORK AT A FAIR PRICE. IF YOU HAVE A PREFERENCE FOR A PARTICULAR SHOP, YOUR ADJUSTER WILL WRITE OR APPROVE AN ESTIMATE OF REPAIRS WITH THAT SHOP BASED ON COMPETITIVE PRICES IN THE AREA. INFORMATION REGARDING REPAIR FACILITIES, WHICH MAY BE ABLE TO REPAIR THE VEHICLE FOR THE APPRAISED AMOUNT, IS AVAILABLE FROM YOUR ADJUSTER OR INSURER. HOWEVER, THERE IS NO REQUIREMENT TO USE ANY SPECIFIED SHOP. COSTS ABOVE THE APPRAISED AMOUNT MAY BE THE RESPONSIBILITY OF THE VEHICLE OWNER. ALL SUPPLEMENTS MUST BE APPROVED PRIOR TO REPAIR. AFTERMARKET CRASH PARTS ARE IDENTIFIED IN THE ESTIMATE WITH SYMBOL "EC", "EP," (COMPETITIVE PART) AND "EU" (RECYCLED PART). AN "AFTERMARKET CRASH PART" IS A NON-ORIGINAL MANUFACTURER (NON-OEM) REPLACEMENT PART, EITHER NEW OR USED, FOR ANY OF THE NON-MECHANICAL PARTS THAT GENERALLY CONSTITUTE THE EXTERIOR OF THE MOTOR VEHICLE, INCLUDING INNER AND OUTER PANELS. NEW, ORIGINAL EQUIPMENT MANUFACTURER, REPLACEMENT PARTS ARE IDENTIFIED BY THE LETTER "E" AND CAN BE LOCATED AT THE ORIGINAL EQUIPMENT MANUFACTURER PARTS DEALER. ADJUSTER: LICENSE # DATE Op Codes = User-Entered Value E = Replace OEM NG = Replace NAGS EC = COMPETITIVE PART OE= Replace PXN OE Srpls UE = Replace OE Surplus ET = Partial Replace Labor EP = COMPETITIVE PART EU = RECYCLED PART TE = Partial Replace Price PM= Replace PXN Reman/Reblt UM= Replace Reman/Rebuilt L = Refinish PC = Replace PXN Reconditioned UC = Replace Reconditioned TT = Two-Tone SB = Sublet Repair N = Additional Labor BR= Blend Refinish I = Repair IT = Partial Repair CG= Chipguard RI = R & I Assembly P = Check AA = Appearance Allowance RP= Related Prior Damage 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 udatL.x Audatex's prior written consent. a sWe,d conlp4n Copyright (C) 2011 Audatex North America, Inc. Audatex Estimating is a trademark of Audatex North America , Inc. 03/2012012 09:34 AM Page 5 of 2011 Toyota Tacoma SR5 4 DR Crew Cab Long Bed Ciaim # : 000237209580D01 03/06/2012 12:33 Pt 03/2012012 08:06 At Estimate Summary Page Gross Total $2,507.51 Less: Deductible $500.00- Net Total $2,007.51 Actual Supplement Total $1,100.66 Less: Previous Net Total $906.85- Net Supplement Total $1,100.66 Customer Owes $500.00 Audatex Estimating 6.0.626 S1 03120/2012 09:34 AM REL 6.0.626 DT 02/01/2012 DB 03/08/2012 Copyright (C) 2011 Audatex North America, Inc. ALLSTATE INSURANCE COMPANY SUPPLEMENT REQUEST SHEET IN ORDER TO REVIEW YOUR SUPPLEMENT REQUEST, PLEASE COMPLETE THE FOLLOWING INFORMATION THOROUGHLY AND FAX IT TO 1.866.587.9857 BY SUBMITTING THIS FORM, THIS IS NOT AN AUTHORIZATION TO REPAIR. ALL SUPPLEMENTS MUST HAVE PRIOR APPROVAL. FAILURE TO DO SO WELL RESULT IN NON- PAYMENT OF A NON-APPROVED SUPPLEMENT. DATE ORIGINAL ADJUSTER: CLAIM NUMBER: ( ) SUPPLEMENT #1 (_) SUPPLEMENT #2 (_) SUPPLEMENT #3 (PLEASE CHECK THE BOX THAT APPLIES TO THE NUMBER OF SUPPLEMENT.) CUSTOMER NAME: IS THE VEHICLE AT THE SHOP AND READY FOR INSPECTION WITHIN 24HRS? ( ) YES ( ) NO ARE THE DAMAGES VISIBLE? ( ) YES ( ) NO YEAR: MAKE: SHOP NAME: SHOP ADDRESS: CITY: STATE: PHONE: ( ) ZIP CODE: NATURE OF THE SUPPLEMENT: (PLEASE SUPPLY DESCRIPTION OF SUPPLEMENT REQUEST) ( ) PARTS: ( ) LABOR: ( ) PARTS INCREASE: ( ) OTHER: APPROXIMATE TOTAL SUPPLEMENT AMOUNT: $ VEHICLE TORN DOWN: ( ) YES ( ) NO MODEL: CONTACT: 03/20/2012 09:34 AM Page 6 of ?- *** SUPPLEMENT RECONCILIATION *** Supplement S1 Claim #: 000237209580D01 Insured Policy # : 000952407775 File # : Claim Rep: Insured: CHRIS BARNARD Inspection Date/Time: 03/06/2012 12:2 2 PM Owner Name: CHRIS BARNARD Company: Vehicle: 2011 Toyota Tacoma SR5 4 DR Crew Cab Long Be d Deleted Lines _ E Line Guide Part Operation Price ADJ% B% - ----- Labor ------- Rate 1 332 Panel,Bedside Outer RT Repair 6.0* SM Added Line s Line Guide Part Operation Price ADJ% B% Labor Rate 2 322 Pnl,Cab Side Outer RT Blend Refinish S1 1.7 RF 3 332 Panel,Bedside Outer RT Replace OEM S1 $636.45 5.1 SM 4 374 MIdg, Roof Drip RT R & I Assembly S1 0.3 SM 5 412 Cover,Tailgate Access R & I Assembly S1 0.4 SM 6 570 Sill,Rear Cross Repair S1 2.0* SM 7 570 Sill,Rear Cross Refinish S1 0.6 RF 8 1505 Tape,Lock Pillar RT Replace OEM S1 $12.21 0.3 SM 9 M08 Stoneguard Refinish S1 0.5* RF 10 M15 Color Tint Refinish S1 0 5* RF 11 RT ROCKER PANEL Blend Refinish S1 . 0.7* RF* 12 RT WINDSHIELD PILLAR Blend Refinish S1 0.7* RF* 13 RT CAB VENT R & I Assembly S1 0.2* SM* 14 BACKTAPE REAR GLASS __?.._._? Additional Labor S1 0.3* SM* =Changed Lines Line Guide ._....._. Part Operation Price ice ADJ% B% Labor Rate 15 282 Flare,Wheel Opening RT R & I Assembly S1 INC SM Flare,Wheel Opening RT 0 5 SM 16 332 Panel,Bedside Outer RT Refinish S1 . 4.4 RF Panel,Bedside Outer RT 3 7* RF 17 420 MIdg,Bedside Pnl Upr RT Replace OEM S1 $73.73 . INC SM MIdg,Bedside Pnl Upr RT $73.73 0 2 SM 18 479 Shell,Tailgate Repair S1 . 1.5* SM Shell,Tailgate 1 0* SM 19 479 Tailgate R & I Additional Labor S1 . INC SM Tailgate R & 1 20 493 Handle,Tailgate Outer R & I Assembly S1 0.3 0.2 SM SM Handle,Tailgate Outer 0 6 SM 21 534 Taillamp Assembly RT Replace OEM S1 $207.71 . INC SM Taillamp Assembly RT $207.71 0 3 SM 22 567 Bumper Assembly,Rear R & I Assembly S1 . INC SM Bumper Assembly,Rear 23 1501 Tape,Bedside RT Replace OEM S1 $28.42 0.6 0.2 SM SM Tape,Bedside RT $28.42 0 4 SM 24 1503 Mldg,Bedside Lwr Cnr RT R & I Assembly S1 . INC SM MIdg,Bedside Lwr Cnr RT 0.1 SM Calculation Changees From To Difference Gross Parts $422.02 $1,070.68 $648 66+ Paint Materials $23.00 $135.70 $23.00 $259.90 . $124 20+ Tax on Parts & Material 6.000% $34.36 6.000% $80.73 . $46 37+ SM - Sheet Metal $45.00 $486.00 $45.00 $508.50 . $22 50+ RF - Refinish $45.00 $265.50 $45.00 $508.50 . $243 00+ Tax On Labor 6.000% $45.09 6.000% $61.02 . $15.93+ Actual Supplement 1 Net Total $1,100.66+ 03120/2012 09:36 AM Page 1 of 2 2011 Toyota Tacoma SR5 4 DR Crew Cab Long Bed Claim u : 0002372095BOD01 Summa Net Total Date Time Appraiser Original Estimate $906.85 03/06/2012 08:09 AM JOE KOONS Supplement 1 $2,007.51 03/20/2012 08:06 AM 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 A[Idc tex prior written consent. a SifArra ?Cxr?e¢ta7i?Y ---.++ Copyright (C) 2011 Audatex North America, Inc. Audatex Estimating is a trademark of Audatex North America, Inc. Page 2 of 2 VERIFICATION I, Michael J. Dougherty, Esquire, attorney for the Plaintiff(s) do hereby swear and affirm that the averments in the attached Complaint are true and correct to the best of my knowledge, information and/or belief. These averments are made subject to the penalties of 18 Pa.C.S.A. §4904 relating to unsworn falsification to authorities. Mich I J. Dougherty Date lab L WELTMAN, WEINBERG & REIS CO., L.P.A. BY: Michael J. Dougherty, Esquire I.D. No. 76046 325 Chestnut Street, Suite 501 Philadelphia, PA 19106 Phone: 215.599.1500 Fax: 215.599.1505 File # 9682352 THE PROTHO? Attorney for Plaintiff 2012 JUL 19 PIS Z' CUMBERLAND PERNSYLV ALLSTATE INSURANCE COMPANY vs. SASSOON EXPRESS INC ROMAN KHACHATVROV CUMBERLAND County Court of Common Pleas No.: 12-4024 CERTIFICATE OF SERVICE TO THE PROTHONOTARY: On July 9, 2012 Plaintiff served its Complaint in Civil Action upon Defendant, Sassoon Express, INC at 21151 South Western Avenue, Torrance, CA 90501 by certified mail, return receipt requested. Attached is the signed certified mail receipt number 7011 2970 0002 9462 4554 dated July 9, 2012. WELTMAN, WEINBER04 REIS CO., L.P.A. O? By Michael J. Dougherty, Esquire Attorney for Plaintiff t; 0TAR' 1: 40 A U.S. Postal ??'et'VICC? CERTIFIED MAIL RECEIPT tin (Domestic Ln ;:,.u rtl .] 141 ? Postage $ Er ? ca Certified Fee fU - G,Postmark Return Receipt Fee J Here G (Endorsement Required) Restricted Delivery Fee r3 (Endorsement Required) D' Total Postage & Fees fL ertt o cm SYreer, Apt 130-, S. t r.. Of PO BOX NO. ---- - ----------------------- e, crty, State, ZiP?,---. ¦ Complete items 1, 2, and 3. Also complete item 4 If Restricted Delivery is desired. ¦ Print your name and address on the reverse so that we can return the card to you. ¦ Attach this card to the back of the mailpiece, or on the front if space permits. Si r, ? E 13 ent x ? ddressee B. Received by led Name) C. ' e f Delivery D. Is delivery address different from Rem 1? ? es ' 1. Article Addressed to: If YES, enter delivery address below: ? No WC 5 fern lgvi f _ 3. Service Type iJ r t n i? / C ?? P mortified Mail ? Express Mail ? Registered ? Return Receipt for M hand ? Insured mail ? C.O.D. 4. Restricted Delivery? (Ex6a Fee) ? es 2. Article Number ?] ], ], 2 9 7 0 (Transfer from service1 0002 9462 4554 PS Form 3811, February 2004 Domestic Return Receipt o2-M-t t _ r.-r{` A i v-7, r _ ? r+ ( 7 y WELTMAN, WEINBERG & REIS,CO., L.P.A. BY: Michael J. Dougherty,76046 I.D. No. 76046 325 CHESTNUT STREET SUITE 501 PHILADELPHIA, PA 19106-2614 215-599-1500 FAX: 215-599-1505 File # 09682352 C Y Jer KMH Attorney for Plaintiff(s) ALLSTATE INSURANCE COMPANY IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY vs. ROMAN KHACHATVROV CASE NO. 12-4024 PRAECIPE TO SATISFY TO THE PROTHONTARY: Fs.) r -- co Kindly mark the case and judgment entered against Defendant ROMAN KHACHATVROV as satisfied. WELTMAN, WEINBERG & REIS CO., L.P.A. By Michaer J. Dougherty Attorney for Plaintiff ,q,oed 4 t ek- MIV360 3oel oco