On December 21, 2015 a
Exhibit,Appendix
was filed
involving a dispute between
Safe Touch Auto Glass Inc,
and
Permanent General Assurance Corporation,
for SMALL CLAIMS 3 - $501 - $2,500
in the District Court of Pinellas County.
Preview
NISC.
Ce ihing ? 35791791 E-Filed 12/21/2015 04:40:04 PM
Pome 1 of 1
Exhibit A
Insurance Copy
Page 1 of 3
https://fax.nextiva.com/xclient/user/ 11/19/2015
** “ELECTRONICALLY FILED 12/21/2015 04:40:14 PM: KEN BURKE, CLERK OF THE CIRCUIT COURT. PINETT Ac Cor pipeees05:35 TO:18132484684 FROM:9412518234 Page: z
SH AUTO GLASS. INC Cestomer Copy
SR 64 Exhibit A Insurance Copy
ON, FL 34208 Page 1 of 3
4941} 251-7930 FAX:(041} 251-7929 Federal Tox 0. 472096680
Remit To: 2549 McMullen Booth, Ste 510-276, CLEARWATER, FL 33761 _Flosamve 92257
| Cust State Tax ID \Workorder: W004916
Taken By: Cineyk gust Fee Tex pate: t4t0l2018
‘Time: 07:33 AM
yi Adv. Code: _. _
Bill Ter “The, Genet)
The Genera! Donnisha Cousins
Me ve { 642 Ponderosa Dr. West
LAKELAND, FI 0
(866} 653-2199 Fax: (715) 858-3975 (813) 863-3250 Home: (352) 223-7185,
en - —Tngurance Proof Of Loss _ _ - ~~
insurance Company: “The Genel Insurance Phone 866) 653-2199
Ciaim Policy
Verified : Name: Donnisha Cousins
Loss Date: 11/7/2015 Effective Date: Expires :
Cause Agent: Phone <
Location Agent Name : Deductible :
__ Vehicle information —
Model S
f Year: 2008
Odometer: VIN: KNAGE123985222397 7
Qty Part Number ~ —pesetintion __ _ Uist Disc% Total
1 FIWG2B46GENNCOM — Windshiela(WiThicd Visor Frit} $390.40 a $39 $300.40
1 90H 0 Hour (3.2 Hours} $288.00 9 $288.00 $288.00
1 HAHOOOGS4 Adhesive-(2.0,Urethane,Dam, Primer) $94.00 a $94.00 $94.00
1 WES F2646 RC Moulding-(WRain Channel} 367.00 0 $67.00 $67.0
4 MISC STORAGE/DISPOSAL FEE $25.00 S $25.06 $25.00
1 MISC SHOP SUPPLIES $15.00 @ $15.00 $15.00
Install Date: 11/10/15 10:00 AM, Required Date 11/10/16 01:00 PM, Mobile Installer: GUY
Instructions: /
a
AUTHORIZATION TO PAY Collect From Customer { 30,
Sub Total:
the above policy. Upon such 9
1c described above against the abov
Tax:
Customer's Signature: Total $940.96
Safe Touch Auto Glass, INC 4654EAST SR 64 SUITE 314 ; BRADENTON, FL34208 PH:(941) 251-7930 FAX:(941) 251-7928Manatee/Pinellas
4654 E State Road 64 #314
Sradenton, FL 34208
Hernando/Pasco
2398 Commercial Way #157
Spring Hill, FL 34606
Hillsborough/Polk
12824 Dupont Circle
Tampa, FL 33626
Auto Glass Specialist Name:
Safe Touch Auto Glass, Inc.
ESTIMATE/INVOICE
lb
Work Order
Fax: 941-251-7929
Phon 441-251-7930
Email: Ckrapfel@gmail.com
am
Insurance Copy
Page 2 of 3
Date:,
Name:,
Address:
City:
Secondary Address:
City:
Cell/Home:,
Work/Other #:
Email,
State: <_ Zip:
Kem Exp _/.
alot
2 Door
4D4Door
Vent
Ext Cab Conv
Door Quar
aF
FW/DW 2,
Other Notes:
« LIFETIME WARRANTY
NO COST TO CUSTOMER
Windshield Part Info.
Zh 4b 668M
OE GLASS
Circle All That Apply
fr
Yes |No-Rain Sensor /Yes No Third Visor
yes! NB Electric Mirror
Yes No Antenna
Yes No; Heated
es,No Shaded
Estimate good for 30 aays Safe Touc
responsible for damage caused by the
nature. | hereby authorize the above repairs, including
sublet work, along with the necessary materials. Safe Touch
‘Auto Glass, inc. and its employees may operate my vehicle
for the purpose of inspection and delivery cH
cancel repairs prior ¢o their completion for any of testing,
reason, a tear down and ceassembly fax of 5, will be
applied. Further, | hereby authorize Safe Touch Auto Giass.
Ine, £0 purchase all parts and materials required for the
x Date.
SERVICE RECEIVED/GUARANTEE ACKNOWLEDGMENT/VERIFICATION OF INSURANCE
Service: Replacement /or Repair (1, 2, 3)
nature-below constitutes agreement to terms and conditions of this form
Customer Signature:
“Yowaré authorized to make a claim on the Insurance information provided
Toa Avia GLAS PARADE AERMOWLDUMENT OF RAGES RECIED
Document Filed Date
December 21, 2015
Case Filing Date
December 21, 2015
Category
SMALL CLAIMS 3 - $501 - $2,500
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Preview
NISC. Ce ihing ? 35791791 E-Filed 12/21/2015 04:40:04 PM Pome 1 of 1 Exhibit A Insurance Copy Page 1 of 3 https://fax.nextiva.com/xclient/user/ 11/19/2015 ** “ELECTRONICALLY FILED 12/21/2015 04:40:14 PM: KEN BURKE, CLERK OF THE CIRCUIT COURT. PINETT Ac Cor pipeees05:35 TO:18132484684 FROM:9412518234 Page: z SH AUTO GLASS. INC Cestomer Copy SR 64 Exhibit A Insurance Copy ON, FL 34208 Page 1 of 3 4941} 251-7930 FAX:(041} 251-7929 Federal Tox 0. 472096680 Remit To: 2549 McMullen Booth, Ste 510-276, CLEARWATER, FL 33761 _Flosamve 92257 | Cust State Tax ID \Workorder: W004916 Taken By: Cineyk gust Fee Tex pate: t4t0l2018 ‘Time: 07:33 AM yi Adv. Code: _. _ Bill Ter “The, Genet) The Genera! Donnisha Cousins Me ve { 642 Ponderosa Dr. West LAKELAND, FI 0 (866} 653-2199 Fax: (715) 858-3975 (813) 863-3250 Home: (352) 223-7185, en - —Tngurance Proof Of Loss _ _ - ~~ insurance Company: “The Genel Insurance Phone 866) 653-2199 Ciaim Policy Verified : Name: Donnisha Cousins Loss Date: 11/7/2015 Effective Date: Expires : Cause Agent: Phone < Location Agent Name : Deductible : __ Vehicle information — Model S f Year: 2008 Odometer: VIN: KNAGE123985222397 7 Qty Part Number ~ —pesetintion __ _ Uist Disc% Total 1 FIWG2B46GENNCOM — Windshiela(WiThicd Visor Frit} $390.40 a $39 $300.40 1 90H 0 Hour (3.2 Hours} $288.00 9 $288.00 $288.00 1 HAHOOOGS4 Adhesive-(2.0,Urethane,Dam, Primer) $94.00 a $94.00 $94.00 1 WES F2646 RC Moulding-(WRain Channel} 367.00 0 $67.00 $67.0 4 MISC STORAGE/DISPOSAL FEE $25.00 S $25.06 $25.00 1 MISC SHOP SUPPLIES $15.00 @ $15.00 $15.00 Install Date: 11/10/15 10:00 AM, Required Date 11/10/16 01:00 PM, Mobile Installer: GUY Instructions: / a AUTHORIZATION TO PAY Collect From Customer { 30, Sub Total: the above policy. Upon such 9 1c described above against the abov Tax: Customer's Signature: Total $940.96 Safe Touch Auto Glass, INC 4654EAST SR 64 SUITE 314 ; BRADENTON, FL34208 PH:(941) 251-7930 FAX:(941) 251-7928Manatee/Pinellas 4654 E State Road 64 #314 Sradenton, FL 34208 Hernando/Pasco 2398 Commercial Way #157 Spring Hill, FL 34606 Hillsborough/Polk 12824 Dupont Circle Tampa, FL 33626 Auto Glass Specialist Name: Safe Touch Auto Glass, Inc. ESTIMATE/INVOICE lb Work Order Fax: 941-251-7929 Phon 441-251-7930 Email: Ckrapfel@gmail.com am Insurance Copy Page 2 of 3 Date:, Name:, Address: City: Secondary Address: City: Cell/Home:, Work/Other #: Email, State: <_ Zip: Kem Exp _/. alot 2 Door 4D4Door Vent Ext Cab Conv Door Quar aF FW/DW 2, Other Notes: « LIFETIME WARRANTY NO COST TO CUSTOMER Windshield Part Info. Zh 4b 668M OE GLASS Circle All That Apply fr Yes |No-Rain Sensor /Yes No Third Visor yes! NB Electric Mirror Yes No Antenna Yes No; Heated es,No Shaded Estimate good for 30 aays Safe Touc responsible for damage caused by the nature. | hereby authorize the above repairs, including sublet work, along with the necessary materials. Safe Touch ‘Auto Glass, inc. and its employees may operate my vehicle for the purpose of inspection and delivery cH cancel repairs prior ¢o their completion for any of testing, reason, a tear down and ceassembly fax of 5, will be applied. Further, | hereby authorize Safe Touch Auto Giass. Ine, £0 purchase all parts and materials required for the x Date. SERVICE RECEIVED/GUARANTEE ACKNOWLEDGMENT/VERIFICATION OF INSURANCE Service: Replacement /or Repair (1, 2, 3) nature-below constitutes agreement to terms and conditions of this form Customer Signature: “Yowaré authorized to make a claim on the Insurance information provided Toa Avia GLAS PARADE AERMOWLDUMENT OF RAGES RECIED