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BOEHMS, NELSON 42-L791-8L1

State Farm
P.O. Box 106169
Atlanta, GA 30348-6169
Fax: 1-844-236-3646
statefarmfireclaims@statefarm.com

Structural Damage Claim Policy

This estimate is priced based on estimated market pricing for the cost of materials, labor, and other factors at the time
of the loss.

Adjustments in market pricing and timing of the repairs may impact the final cost of covered repairs. Should you or
the contractor you select have questions concerning our estimate, please contact us. If your contractor's estimate is
higher than ours, you should contact us prior to beginning repairs. State Farm will work with you and your contractor
to determine the actual and necessary cost of covered repairs at the time repairs will be completed, subject to policy
terms, conditions and limits.

• We want you to receive quality repair work to restore the damages to your property.

• We will provide you with a detailed estimate of the scope of the damage and costs of repairs. Should the
contractor you select have questions concerning our estimate, they should contact your claim representative
directly.

• Depending upon the complexity of your repair, our estimate may or may not include an allowance for general
contractor's overhead and profit. If you have questions regarding general contractor's overhead and profit and
whether general contractor services are appropriate for your loss, please contact your claim representative
before proceeding with repairs.

• There may be building codes, ordinances, laws, or regulations that affect the repairs of your property. These
items may or may not be covered by your policy. Please contact your claim representative if you have any
questions regarding coverage which may be available under your policy.

• State Farm® cannot authorize any contractor to proceed with work on your property. Repairs should proceed
only with your authorization.

• State Farm does not guarantee the quality of the workmanship of any contractor or guarantee that the work will
be accomplished within any specific time frame.

• It is understood that the contractor is hired by you, our insured, and that they work for you - not State Farm.

If you have any questions or need additional information regarding your claim, please contact your claim
representative immediately.

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42-L791-8L1

Building Estimate Summary Guide

This summary guide is based on a sample estimate and is provided for reference only.
Please refer to the estimate for specifics of your claim.

State Farm Insurance 1. Line Item Total – Total value of all line
items in the estimate plus possible
Insured: Smith, Joe & Jane Estimate: 00-0000-000 adjustments for labor minimums. Labor
Minimum is to cover a certain minimum
Property: 1 Main Street Claim number: 00-0000-000 number of hours for drive-time, set up
Anywhere, IL 00000-0000 Policy Number: 00-00-0000-0 time and applicable administrative
costs and repairs.
Type of Loss: Other Price List: ILBL8F_MAR 13
Deductible: $1,000.00 Restoration/Service/ 2. General Contractor’s Overhead and
Remodel Profit – General contractor’s charge for
F = Factored In, coordinating your repairs.
D = Do Not Apply
3. Replacement Cost Value (RCV) –
Summary for Dwelling Estimated cost to repair or replace
damaged property.
Line Item Total 1 5,953.10
4. Depreciation – The decrease in the
Material Sales Tax @ 10.000% x 1,520.00 value of property over a period of time
Subtotal 6,105.10 due to wear, tear, condition, and
obsolescence. A portion or all of this
General Contractor Overhead 2 @ 10.0% x 6,105.10 610.51 amount may be eligible for replacement
General Contractor Profit @ 10.0% x 6,105.10 cost benefits.
Replacement Cost Value (Including General Contractor Overhead and Profit 3 7,326.12 5. Deductible – The insurer will pay for
Less Depreciation (Including Taxes) 4 (832.50) losses, up to the policy limits, in excess
of your applicable deductible.
Less General Contractor Overhead & Profit on Recoverable &
Non - recoverable Depreciation (166.50) 6. Net Actual Cash Value Payment
(ACV) – The repair or replacement cost
Less Deductible 5 of the damaged part of the property
Net Actual Cash Value Payment 6 less depreciation and deductible.

7. Non Recoverable Depreciation –

Maximum Additional Amounts Available If Incurred:
Total Line Item Depreciation (Including Taxes) 4
Less Non - recoverable Depreciation (Including Taxes) 7
Subtotal
General Contractor O&P on Depreciation
Less General Contractor O&P on Non - recoverable Depreciation
Subtotal
Total Maximum Additional Amounts Available If Incurred 8
Total Amount of Claim If Incurred 9
Depreciation applied to items that are
not eligible for replacement cost
832.50 benefits.
8. Total Maximum Additional Amount if
312.50 Incurred – Total amount of
166.50 recoverable depreciation after actual
repair or replacement of the property.
9. Total Amount of Claim if Incurred –
Total amount of the claim, including net
actual cash value payment and total
maximum additional amount available if
incurred.

Claim Representative

ALL AMOUNTS PAYABLE ARE SUBJECT TO THE TERMS, CONDITIONS AND LIMITS OF
YOUR POLICY.

1002989 139928.1 01-23-2013

Date: 3/30/2023 10:04 AM Page: 2
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State Farm
BOEHMS, NELSON 42-L791-8L1
Insured: BOEHMS, NELSON Estimate: 42-L791-8L1
Property: 4162 TROUGH SPRINGS RD Claim Number: 42L7918L1
ADAMS, TN 37010-9065 Policy Number: 92C5Q8732
Home: 931-358-9665 Price List: TNNA28_MAR23
Business: 931-553-4673 Restoration/Service/Remodel
Cellular: 931-320-2220
Type of Loss: Wind Damage
Deductible: $3,291.00
Date of Loss: 3/3/2023
Date Inspected: 3/20/2023
Summary for Coverage A - Dwelling - 35 Windstorm and Hail
Line Item Total 6,722.26
Material Sales Tax 199.89
Replacement Cost Value 6,922.15
Less Deductible (3,291.00)
Net Payment $3,631.15

Robinson, Angela
480-842-4889
ALL AMOUNTS PAYABLE ARE SUBJECT TO THE TERMS, CONDITIONS AND
LIMITS OF YOUR POLICY.

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State Farm
BOEHMS, NELSON 42-L791-8L1
Insured: BOEHMS, NELSON Estimate: 42-L791-8L1
Property: 4162 TROUGH SPRINGS RD Claim Number: 42L7918L1
ADAMS, TN 37010-9065 Policy Number: 92C5Q8732
Home: 931-358-9665 Price List: TNNA28_MAR23
Business: 931-553-4673 Restoration/Service/Remodel
Cellular: 931-320-2220
Type of Loss: Wind Damage
Deductible: $0.00
Date of Loss: 3/3/2023
Date Inspected: 3/20/2023
Summary for Coverage A - Dwelling - 35 Windstorm and Hail - Tree
Debris Removal
Line Item Total 200.52
Replacement Cost Value 200.52
Less Deductible (0.00)
Net Payment $200.52

Robinson, Angela
480-842-4889
ALL AMOUNTS PAYABLE ARE SUBJECT TO THE TERMS, CONDITIONS AND
LIMITS OF YOUR POLICY.

Date: 3/30/2023 10:04 AM Page: 4

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State Farm
BOEHMS, NELSON 42-L791-8L1

Roof
0.00 SF Walls 0.00 SF Ceiling 0.00 SF Walls & Ceiling
0.00 SF Floor 0.00 SF Short Wall 0.00 LF Floor Perimeter
0.00 SF Long Wall 0.00 LF Ceil. Perimeter

DESCRIPTION QUANTITY UNIT PRICE TAX RCV

1. R&R Sheathing - plywood - 1/2" CDX 32.00 SF 3.25 3.44 107.44

2. R&R Drip edge 46.00 LF 3.18 4.98 151.26

3. Laminated - comp. shingle rfg. - w/ felt 1.00 SQ 290.55 12.95 303.50

4. Additional charge for high roof (2 stories or 1.00 SQ 20.73 0.00 20.73
greater)

5. R&R Chimney flashing - average (32" x 36") 1.00 EA 448.06 9.49 457.55

Totals: Roof 30.86 1,040.48

Exterior
Rear Elevation
Rear Elevation

DESCRIPTION QUANTITY UNIT PRICE TAX RCV

6. R&R Overhead door & hardware - 9' x 7' 1.00 EA 1,116.62 73.66 1,190.28

7. R&R Gutter guard - one piece seamless 46.00 LF 36.67 72.80 1,759.62
gutter system

8. R&R Fascia - 1" x 6" - #2 pine 46.00 LF 8.73 6.95 408.53

9. Prime & paint exterior fascia - wood, 4"- 6" 46.00 LF 1.74 0.79 80.83
wide

10. R&R Soffit - wood 46.00 SF 7.65 8.35 360.25

11. Prime & paint exterior soffit - wood 46.00 SF 2.31 2.05 108.31

Invoice for weather head to be forwarded.

Total: Rear Elevation 164.60 3,907.82

Deck
0.00 SF Walls 0.00 SF Ceiling 0.00 SF Walls & Ceiling
0.00 SF Floor 0.00 SF Short Wall 0.00 LF Floor Perimeter
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State Farm
BOEHMS, NELSON 42-L791-8L1
0.00 SF Long Wall 0.00 LF Ceil. Perimeter

DESCRIPTION QUANTITY UNIT PRICE TAX RCV

12. R&R Deck guard rail - treated lumber 3.50 LF 39.93 4.43 144.19

Totals: Deck 4.43 144.19

Area Totals: Rear Elevation

Total: Rear Elevation 169.03 4,052.01

Temp repairs
0.00 SF Walls 0.00 SF Ceiling 0.00 SF Walls & Ceiling
0.00 SF Floor 0.00 SF Short Wall 0.00 LF Floor Perimeter
0.00 SF Long Wall 0.00 LF Ceil. Perimeter

DESCRIPTION QUANTITY UNIT PRICE TAX RCV

*** Start revision Angela Robinson 3.30.23 ***

13. Temporary Repairs (Bid Item) 1.00 EA 755.00 EN 0.00 755.00

*** End revisions Angela Robinson 3.30.23 ***

Totals: Temp repairs 0.00 755.00

Area Totals: Exterior

Total: Exterior 169.03 4,807.01

Debris Removal
0.00 SF Walls 0.00 SF Ceiling 0.00 SF Walls & Ceiling
0.00 SF Floor 0.00 SF Short Wall 0.00 LF Floor Perimeter
0.00 SF Long Wall 0.00 LF Ceil. Perimeter

DESCRIPTION QUANTITY UNIT PRICE TAX RCV

14. Tree - removal and disposal - per hour 8.00 HR 92.30 0.00 738.40
including equipment

Labor hours for NI to remove tree off the risk

15. Tree - removal - per hour (Labor only) 4.00 HR 50.13 0.00 200.52

16. Haul debris - per pickup truck load - 1.00 EA 165.24 0.00 165.24
including dump fees

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State Farm
BOEHMS, NELSON 42-L791-8L1

CONTINUED - Debris Removal

DESCRIPTION QUANTITY UNIT PRICE TAX RCV

Totals: Debris Removal 0.00 1,104.16

Labor Minimums Applied

DESCRIPTION QUANTITY UNIT PRICE TAX RCV

17. Framing labor minimum 1.00 EA 118.42 0.00 118.42

18. Painting labor minimum 1.00 EA 52.60 0.00 52.60

Totals: Labor Minimums Applied 0.00 171.02

Line Item Totals: 42-L791-8L1 199.89 7,122.67

COVERAGE TAX RCV

Coverage A - Dwelling - 35 Windstorm and Hail 199.89 6,922.15
Coverage A - Dwelling - 35 Windstorm and Hail - Tree Debris Removal 0.00 200.52
Total 199.89 7,122.67

Grand Total Areas:

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State Farm
BOEHMS, NELSON 42-L791-8L1

Recap of Taxes, Overhead and Profit

GC Overhead GC Profit (0%) Material Sales P Ppty Material P Ppty Cleaning Storage Rental Food Tax (7.5%)
(0%) Tax (9.5%) Tax (9.5%) Tax (9.5%) Tax (9.5%)

Line Items
0.00 0.00 199.89 0.00 0.00 0.00 0.00

Total
0.00 0.00 199.89 0.00 0.00 0.00 0.00

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