Claim by Ronald Koehler_Additional Claim Information Copyrig hted
March 1, 2021
City of Dubuque Consent Items # 2.
City Council Meeting
ITEM TITLE: Notice of Claims and Suits
SUM MARY: 2G2, LLC. for breach of lease;Asbury Square LLC for property
damage; Jackie Jones for property damage; additional claim information
from Ronald Koehler for property damage;Aaron Rang for vehicle
damage; Jacob Schlosser for property damage; additional claim
information from State Farm a/s/o Michael or Jennifer Connolly for
property damage.
SUGGESTED Suggested Disposition: Receive and File; Referto CityAttorney
DISPOSITION:
ATTACHMENTS:
Description Type
Claim by 2G2, LLC Supporting Documentation
Claim by Asbury Square LLC Supporting Documentation
Claim by Jackie Jones Supporting Documentation
Additional Claim Information by Ronald Koehler Supporting Documentation
Claim by Aaron Rang Supporting Documentation
Claim by Jacob Schlosser Supporting Documentation
Additional Claim Information by State Farm a/s/o Supporting Documentation
Michael or Jennifer Connolly
Providing lnsurance and Financial Services : StateFarmm
Home Office, Bloomington, !L
January 18, 2021
City Of Dubuque - City Clerk At City Hall Subrogation Services
50 W 13th St PO Box 106172
Dubuque IA 52001-4805 Atlanta GA 30348-6172
RE: Claim Number: 13-14M9-74G
Our Insured: Ronald L Koehler
Date of Loss: December 12, 2020
Your Insured: City Of Dubuque - City Clerk At City Hall
Your Insured Driver: Jarrod Pusateri
Loss Location: 1625 Ashton Place, Dubuque, IA
To Whom It May Concern:
Facts of Loss:
Snow plow struck the insured's vehicle while parked and unoccupied.
It is our understanding that you are self insured. Our investigation indicates you are responsible
for this claim. Therefore, we are seeking recovery from you. This letter is to notify you of our
subrogation claim and request your cooperation in settling this matter.
To assist you in your review, here is a breakdown of the amounts State Farm° paid by Cause of
Loss:
041/045 - Uninsured Motorist BI $
042 - Uninsured Motorist PD $
300 series/400 - Comp/Collision $4,777.20
501 - Rental/Loss of Use $124.99
600-050 - Med Pay/PIP $
Other $
Salvage Recovery $
Amount State Farm Paid $4,902.19
Insured Deductible $250.00
Total Claim Amount $5,152.19
Based on the assessment of liability between the parties, State Farm Mutual Automobile
Insurance Company is seeking 100% of the Total Claim Amount listed above. The amount
payable to State Farm Mutual Automobile Insurance Company for this loss is $5,152.19.
13-14M9-74G
Page 2
January 18, 2021
Please remit payment of this claim and include our claim number on the payment. If you have
any questions or need additional information, please call me at the number listed below. If I am
not available, any other member of my team may assist you. Thank you for your cooperation.
In order to assist you in evaluating and processing the subrogation claim we are asserting, we
may provide nonpublic personal information about our customer. We are sharing this
information to effect, administer, or enforce a transaction authorized by the consumer. However,
you are neither authorized nor permitted to: (1) use the customer information we provided for
any purpose other than to evaluate and process the subrogation claim, or (2) disclose or share
the customer information we provide for any purpose other than to evaluate and process the
subrogation claim.
Sincerely,
Stephanie Easterbrook
Claim Associate
(877) 787-8276 Ext. 6156927589
Fax: (866) 231-9276
State Farm Mutual Automobile Insurance Company
Enclosure
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RBZ00070
StateFarm State Farm Mutual Automobile Insurance Company
� Auto Payments by Participant/COL
�
Route To: Leslie Lowe
BASIC CLAIM INFORMATION
Claim Number: 13-14M9-74G
Date of Loss: 12-12-2020
Policy Number: E022-814-13A
Named Insured: KOEHLER, RONALD L
Named Insured(s) /400 - COLL
C denotes consolidated payment
E denotes EFT payment
P previousiy converted payment from CAT/CMR
Payment Issued Payable Pay Auth Rsn
Number Date Pavee COL Cd Status Amount Id Cd
101602612K E 12-18-2020 ABRA DUBUQUE 400 1 Paid $4,777.20 ECSAPY
Total: $4,777.20
Named Insured(s) /501 - RENT
C denotes consolidated payment
E denotes EFT payment
P previously converted payment from CAT/CMR
Payment Issued Payable Pay Auth Rsn
Number Date Pavee COL Cd Status Amount Id Cd
101603518K E 12-20-2020 ENTERPRISE RENT-A-CAR 501 1 Paid $124.99 ECSAPY
Total: $124.99
Date:02-03-2021 Page 1
STATE FARM CONFIDENTIAL INFORMATION
Distribution on a Business Need to Know Basis Only
RBZOOOMD
StateFarm State Farm Mutual Automobile Insurance Company
" Auto Rental Bills
• •�
Route To: Leslie Lowe
BASIC CLAIM INFORMATION
Claim Number: 13-14M9-74G
Date of Loss: 12-12-2020
Policy Number: E022-814-13A
Named Insured: KOEHLER, RONALD L
KOEHLER,JORDAN
BILL SUMMARY
Bill information
Invoice Number: 6235D20PNKZ Claim Number: 13-14M9-74G
Rental Vendor: ENTERPRISE RENT-A-CAR Date of Loss: 12-12-2020
Insured Name: KOEHLER, RONALD L Received From Renter: $0.00
Renter Name: KOEHLER,JORDAN Billed To Others:
Rental Start Date: 12-14-2020 Amount Due: $124.99
Rental End Date: 12-18-2020 Amount Paid To Date: $124.99
Current Bill Status
Primary Status Primary Reason(s)
Reviewed
Secondary Status Secondary Reason(s)
Paid
Vehicle Information
Vehicle Rental Start Rental End Assnd Class Appr Class Make Model
01 12-14-2020 12-18-2020 IC HYUN ELAN
Invoice Details
Rate Percent Extended
Vehicle Description Billed Partv Quantitv % Covered Amount
01 Daily Rental Rate State Farm 5 21.01 100.000 $105.05
Sales Tax State Farm 111.60 7.00 0.000 $7.81
Government Surcharge State Farm 111.60 5.00 0.000 $5.58
Veh Licensing/Registration Fee State Farm 5 1.31 100.000 $6.55
Subtotal Less Taxes : $105.05 Received From Renter: $0.00
Total Taxes : $19.94 Amount Due From State Farm : $124.99
Total Amount Due : $124.99
Date: 02-03-2021 Page 1
STATE FARM CONFIDENTIAL INFORMATION
Distribution on a Business Need to Know Basis Only
Confidential
This communication and any attachments may contain information which is confidential
and privileged by law and is for the use of the designated recipient. If you are not the
intended recipient, you are hereby notified that you have received this communication in
error, and that any review, disclosure, dissemination, distribution or copying of its contents
is prohibited. Please notify City of Dubuque immediately by telephone at (563)-589-4120 of
your receipt of these items and destroy the communication and any attachments
immediately. Further disclosure of this information may violate state and federal
restrictions.
Confidential information may include the following:
1) Social Security Number(s)
2) Medical/Health Information
3) Personnel/Disciplinary Information
4) Bank Account Information
5) Financial Information
6) Credit Card Numbers
If any documentation you desire to submit to the City of Dubuque contains any of the items above,
this cover sheet must be attached directly to the confidential information. Please indicate below the
type of information that is included.
�, , hereby certify that the attached documents
include the following protected information:
Social Security Number(s) Bank Account Information
Medical/Health Information Financial Information
Personnel/Disciplinary Information Credit Card Number(s)
I understand that this information may be distributed within the City organization or to agents of the
City for processing and I hereby authorize the City to act accordingly taking all precautions to
protect my information from unnecessary distribution.
Signature Date
I have read the information above and do not have any confidential documentation to submit to the
City of Dubuque as part of this Claim Against the City.
� �'��-���� January 18, 2021
Signature Date
CLAIM AGAINST THE CITY OF DUBUQUE, IOWA
This written report constitutes your claim against the City of Dubuque, lowa. You should
complete this form in full and attach any additional information that supports your claim.
The Claim must be filed with the City Clerk at City Hall, 50 W. 13t" St., Dubuque, IA 52001. It
will then be referred by the City Council to the appropriate department for investigation.
Once that investigation is completed, a report and recommendation will be submitted to the
City Council. You will be provided with a copy of that report and recommendation.
THE FINAL DECISION ON ALL CLAIMS IS MADE BY THE CITY COUNCIL. NO EMPLOYEE OF
THE CITY OF DUBUQUE HAS THE AUTHORITY TO MAKE ANY REPRESENTATION TO YOU
AS TO WHETHER YOUR CLAIM WILL OR WILL NOT BE PAID.
1. Name of Claimant: State Farm Insurance a/s/o Ronald L Koehler
2. Address: PO Box 106172 Atlanta, GA 30348-6172
3. Telephone Number: �877) 787-8276
4. Date of Incident: Saturday, December 12, 2020
5. Time of Incident: 10:05 a.m.
6. Location of Incident (Be specific): Ashton Place and Decorah St
1625 Ashton PI in Dubuque lowa
7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE. (Give
full details upon which you base your claim. If a City employee was involved, give the
employee's name.)
Snow plow, owned by the City of Dubuque, being operated by Jarrod Pusateri, struck the
insured's vehicle, a 2018 Toyota Camry, while it was parked and unoccupied.
8. What were weather conditions like? n/a
9. Give name and address of any witnesses: n/a
10. Did police investigate? (If so, give names of officers.)
Yes, Corporal Wilkens Dieujuste
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
n/a
12. Was any damage done to property? (If so, describe property and the extent of
damages. Attach estimates of damages or describe basis for ascertaining extent of
damage.)
The 2018 Toyota Camry sustained damage to the front bumper, driver side fender, front end,
hood.
13. What other damages do you claim, if any? n/a
14. Have you been compensated for any part or all of your claim by any insurance
company? (If so, give name and address of insurance company and amount paid.)
n/a
15. What amount do you claim from the City of Dubuque?
$5,152.19
16. Why do you claim the City of Dubuque is responsible?
The snow plow operator was negligent for failure fo maintain a proper lookout.
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.)n/a
18. If the answer to Question 17 is yes, have you received any payment from that source,
and if so, in what amount? n/a
MurFreesboro, TN
Dated at�l�e�a this �8 day of January � 20 21
� ������ Ste hanie Digitallysignedby
p Stephanie Easterbrook
State Farm Insurance a/s/o Ronald L Koehler Easterbrook°a`e:2°z,.°,.,8
I 11:23:44-06�00� (Signature)
Stephanie Easterbrook (Print Name)
(Rev. 7/12)
FILING A CLAIM AG/�INS1' THE C17Y OF DUBUQUE
When Should I File a Claim?
If you have sustained an injury or damage for which you believe the City or one of its employees
is responsible, you may file a claim against the City.
How Do I Request a Claim Form?
In order to obtain a claim form, please contact or visit one of the following City offices:
City Clerk's Office Citv Attornev's Office
City Hall Harbor View Place, Ste. 330
50 W. 13th St. 300 Main St.
Dubuque, IA 52001 Dubuque, IA 520Q1
563.589.4120 563.583.4113
Can I Send in Additic�nal Informa�ion witF� fF�e Claim Forrrr�?
Yes. It is recommended that you send in as much information as possible with your claim form
in order to expedite the investigation of the claim. This includes, but is not limited to, estimates, ',
receipts, medical bills, pictures and any other information you feel may be relevant to your
claim. It is also recommended that you send in copies of these items and keep the originals for
your records.
!/Vh�t Happens After I File My Claim?
Once a claim has been received and file-stamped by the City Clerk, it is forwarded to the City
Attorney's Office for investigation. Claims involving personal injury or substantial property
damage will be forwarded to the City's claims agency for investigation. You will receive a letter
from the City Attorney's Office indicating that your claim has been forwarded to the claims
agency. This letter will also contain the claims agency's contact information.
A claims adjuster will then contact you regarding your claim. At that point, any questions
regarding your claim should be addressed to the claims adjuster. All other claims will be
forwarded to the appropriate City department for investigation. After speaking with employees
and consulting department records, the department manager/ supervisor will make a
recommendation as to whether the claim should be approved or denied.
Based on that information, the Gity Aftorney will then make a recommendation to the City
Council as to whether the claim should be approved or denied. If the City Attorney recommends
that the claim be denied, you will receive a copy of the department manager/ supervisor's
report along with the City Attorney's report to the City CounciL
If the City Attorney recommends that the claim be approved, you will receive the City Attarney's
report to the City Council as well as a release form to be signed and returned to the City
Attorney's Office. These are only recommendations. It is important to note that the final decision
on all claims is made by the City Council,
No employee of the City has the authority to make any representation to you as to whether your
claim will or will not be paid. If the City Council approves the claim for payment at its City
Council meeting, a check will be mailed to you provided the City Attorney's Office has received
your signed release form.
What if My Claim is Denied by the City Council?
The City Council makes its determination at City Council meetings, which are held the first and
third Monday of each month. We recommend writing a letter to the City Council indicating why
your claim should not be denied and any additional information that you have to support your
cfaim.
It is not necessary to appeal the City Attorney's recommendation for denial of your claim before '
the City Cauncil makes its determination, however, you may do so. You are invited to attend the
City Council meeting when your claim will be decided; however, your attendance is not
mandatory and you still have the right to appeal the City Council's decision any time after it has
been made.
If your claim or appeal is denied, you have the option of filing a lawsuit in a court of appropriate
jurisdiction.
How Long Do I Have to UVait Before My Clairn is Resolved?
The length of time it takes to investigate and resolve a claim depends largely on the nature of
the claim and the amount of damages involved. Some claims may take a few weeks to resolve,
while others may take longer. If you wish to check on the status of your claim or if you have any
questions or concerns about the pracess, contact the City Attorney's Office at 563.583.4113.
How Long Do I Fiave to File a Claim?
You may file a claim at any time. However, if your claim is denied by the City Council and you
wish to file a lawsuit, you should be aware that state law may limit the time in which to file a
lawsuit.
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ABRA - Dubuque Warkfile ID: b23e3337
PartsShare: 64YhTv
3400 Center Grove Drive, Dubuque, IA 52003 Federal ID: 42-0782245
Phone: (563) 556-0696
FAX: (563) 556-1899
Supplement of Record 2 with Summary
RO Number: 29400
Written By: Chad Hahn, 12/18/2020 2:01:33 PM
Adjuster: Express Team U,(855)341-8184 Business
Insured: KOEHLER, RONALD Policy#: Claim#: 13-14M9-74G01
Type of Loss: Collision Date of Loss: 12/12/2020 10:05 AM Days to Repair: 6
Point of Impact: 10 Left Front Pillar
Owner: Inspection Location: Insurance Company:
KOEHLER,RONALD ABRA-Dubuque STATE FARM INSURANCE COMPANIES
503 KENWICK DR 3400 Center Grove Drive
GALESBURG,IL 61401 Dubuque,1A 52003
(309)371-2213 Other Repair Facility
(309)371-2213 Cell (563)556-0696 Business
Vehicle Drop Off Date: iZ/14/2020 Promise Date: 12/18/2020 Repair Start Date: 12/16/2020
Repair Completion Date: 12/18/2020 Vehicle Pick Up/Return 12/18/2020
Date:
VEHICLE
2018 TOYO Camry LE Automatic 4D SED 4-2.5L Gasoline Port/Direct Injection White
VIN: 4TiB11HK3JU596275 Interior Color: Mileage In: 25,542 Vehicle Out: 12/18/2020
License: JKOLEI2 Exterior Color: White Mileage Out:
State: IL Production Date: 3/2018 Condition: Good Job#:
TRANSMISSION CONVENIENCE FM Radio Cloth Seats
Automatic Transmission Air Conditioning Stereo Bucket Seats
POWER Intermittent Wipers Search/Seek Reclining/Lounge Seats
Power Steering Tilt Wheel Auxiliary Audio Connection WHEELS
Power Brakes Cruise Control SAFETY Aluminum/Alloy Wheels
Power Windows Rear Defogger Drivers Side Air Bag PAINT
Power Locks Keyless Entry Passenger Air Bag Clear Coat Paint
Power Mirrors Alarm Anti-Lock Brakes(4) OTHER
Power Driver Seat Message Center 4 Wheel Disc Brakes Traction Control
DECOR Steering Wheel Touch Controls Front Side Impact Air Bags Stability Control
Dual Mirrors Telescopic Wheel Head/Curtain Air Bags Xenon or L.E.D.Headlamps
Tinted Glass Backup Camera Hands Free Device California Emissions
Console/Storage Intelligent Cruise Rear Side Impact Air Bags Power Trunk/Liftgate
Overhead Console RADIO Lane Departure Warning
Wood Interior Trim AM Radio SEATS
12/18/2020 2:01:35 PM 403391 Page 1
Supplement of Record 2 with Summary
RO Number: 29400
2018 TOYO Camry LE Automatic 4D SED 4-2.5L Gasoline Port/Direct Injection White
Line Oper Description Part Number Qty Eutended Labor Paint
Price$
1 INFORMATION LABELS
2 S01 Rpl information labels 0.3
3 SOl Repl Info label coolant system US built 11285F0010 1 3.96 Incl.
4 S01 Repl Emission label 2.5 liter US built 11298FOOZ0 1 1.24 Incl.
5 S01 Repl AC label US built 8872306130 1 2.21 Incl.
6 FRONT BUMPER&GRILLE
7 0/H front bumper 2.8
8 <> Repl Bumper cover w/o prk sensor 521190X936 1 246.87 Incl. 3.0
9 Add for Clear Coat 1.2
10 Repi LT Side retainer 5253606210 1 53.01 0.1
11 R&I License bracket US built 0.2
12 Repl Bumper cover retainer clip 5387902150 2 15.06
13 Repl Bumper cover pin 4774933030 2 9.36
14 Repl Prep unprimed bumper 1 0.7
15 Repl Front w'strip 5339506070 1 41.43 Incl.
Note: PARTS: Part cannot be reused/reinstalled.
16 # Subl Recalibrate radar cruise 1 225.00 T
17 FRONT LAMPS
18 ** Repl RECOND LT Headlamp assy 8115006C40 1 721.33 0.3
19 Aim headlamps 0.5
20 HOOD
21 Repl Hood(ALU) 5330106331 1 662.35 1.6 3.0
22 Overlap Major Non-Adj.Panel -0.2
23 Add for Clear Coat 0.6
24 Add for Underside(Complete) 1.5
25 Repl RT Hinge 5341006390 1 36.32 0.5 0.5
26 Repl LT Hinge 5342006370 1 3632 0.5 0.5
27 Overlap Minor Panel -p.2
28 FENDER
29 Repl LT Fender 5380206180 1 239.99 1.9 2.0
30 Overlap Major Adj.Panel -0.4
31 Add for Clear Coat 0.3
32 Add for Edging 0.5
33 # Rpr Fender mount brackets 1.0
34 PILLARS,ROCKER&FLOOR
35 R&I LT Rocker molding L,LE,XLE 0.9
36 FRONT DOOR
37 Blnd LT Outer panel(HSS) 1.0
38 R&I LT R8cI mirror 0.3
39 Repl LT Belt molding chrome 7572006210 1 105.02 0.3
Note: PARTS: Part cannot be reused/reinstalled.
40 R&I LT Handle,outside w/o smart key 0.4
super white
12/18/2020 2:01:35 PM 403391 Page 2
Supplement of Record 2 with Summary
RO Number: 29400
2018 TOYO Camry LE Automatic 4D SED 4-2.5L Gasoline Port/Direct Injection White
41 R&I LT R&I trim panel 0.6
42 # Hazardous waste removal 1 5.00
43 # Repl Cover Car 1 5.00
44 # Repl Corrosion Protection 1 5.00
45 # Repl Flex Additive/Adhesion Promoter 1 8.50 T
46 VEHICLE DIAGNOSTICS
47 Repl Post-repair scan 1 119.95 m 0_5
48 # S02 FINAL BILL DIRECTION TO PAY 1
ON FILE
SUBTOTALS 2,542.92 12.7 14.0
ESTIMATE TOTALS
Category Basis Rate Cost$
Parts 2,309.42
Body Labor 12.7 hrs @ $62.00/hr 787.40
Paint Labor 14.0 hrs @ $62.00/hr 868.00
Paint Supplies 500.00
Miscellaneous 233.50
Subtotal 4,698.32
Sales Tax $4,698.32 @ 7.0000°/o 328.88
Grand Total 5,027.20
Deductible 250.00
CUSTOMER PAY 250.00
INSURANCE PAY 4,777.20
� ' �
For more information regarding State Farm's promise of satisfaction relating to new non-original equipment ��
manufacturer(non-OEM)and recycled parts,please visit: http://st8.fm/7X4 or QR code. �
� ■
■ �
Register online to check the status of your claim and stay connected with State FarmO.To register,go to http://www.statefarm.com/
and select Check the Status of a Claim. If you are already registered,thank you!
12/18/2020 2:01:35 PM 403391 Page 3
Supplement of Record 2 with Summary
RO Number: 29400
2018 TOYO Camry LE Automatic 4D SED 4-2.5L Gasoline Port/Direct Injection White
SUPPLEMENT SUMMARY
Line Oper Description Part Number Qty Extended Labor Paint
Price$
Added Items
48 # SOZ FINAL BILL DIRECTION TO PAY 1
ON FILE
SUBTOTALS 0.00 0.0 0.0
TOTALS SUMMARY
Category Basis Rate Cost$
Parts 0.00
Subtotal 0.00
CUMULATIVE EFFECTS OF SUPPLEMENT(S)
Estimate 4,99937 Chad Hahn
Supplement S01 27.83 Chad Hahn
Supplement S02 0.00 Chad Hahn
Job Total: $ 5,027.20
CUSTOMER PAY: $ 250.00
INSURANCE PAY: $ 4,777.20
WARRANTY VALID ONLY WITH ORIGIONAL COPY OF YOUR RECEIPT PARTS SUBJECT TO INVOICE NO
GUARANTEE ON RUST ALL PARTS NEW, UNLESS OTHERWISE NOTED
ILLINOIS LAW REQUIRES THAT VEHICLE REPAIRERS MUST BE LICENSED IN ACCORDANCE WITH SECTION 5-301
OF THE ILLINOIS VEHICLE CODE.
Estimate calculated using a preset user threshold amount for the paint and material cost.
WARRANTY VALID ONLY WITH ORIGIONAL COPY OF RECEIPT. PARTS SUBJECT TO INVOICE. NO GUARANTEES
ON RUST. ALL PARTS NEW, UNLESS OTHERWISE SPECIFIED.
12/18/2020 2:01:35 PM 403391 Page 4
Supplement of Record 2 with Summary
RO Number: 29400
2018 TOYO Camry LE Automatic 4D SED 4-2.5L Gasoline Port/Direct Injection White
Estimate based on MOTOR CRASH ESTIMATING GUIDE and potentially other third party sources of data. Unless
otherwise noted, (a) all items are derived from the Guide ARM8527, CCC Data Date 12/16/2020, and potentially other
third party sources of data; and (b)the parts presented are OEM-parts. OEM parts are manufactured by or for the
vehicle's Original Equipment Manufacturer (OEM) according to OEM's specifications for U.S. distribution. OEM parts
are available at OE/Vehicle dealerships or the specified supplier. 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 with discounted pricing. Asterisk (*) or pouble Asterisk(**) indicates that the parts and/or labor data
provided by third party sources of data may have been modified or may have come from an alternate data source.
Tilde sign (�) items indicate MOTOR Not-Included Labor operations. The symbol (<>) indicates the refinish
operation WILL NOT be performed as a separate procedure from the other panels in the estimate. Non-Original
Equipment Manufacturer aftermarket parts are described as Non OEM, A/M or NAGS. Used parts are described as
LKQ, RCY, or USED. Reconditioned parts are described as Recond. Recored parts are described as Recore, NAGS
Part Numbers and Benchmark Prices are provided by National Auto Glass Specifications. Labor operation times listed
on the line with the NAGS information are MOTOR suggested labor operation times. NAGS labor operation times are
not included. Pound sign (#) items indicate manual entries.
Some 2021 vehicles contain minor changes from the previous year. For those vehicles, prior to receiving updated
data from the vehicle manufacturer, labor and parts data from the previous year may be used. The CCC ONE
estimator has a list of applicable vehicles. Parts numbers and prices should be confirmed with the local dealership.
The following is a list of additional abbreviations or symbols that may be used to describe work to be done or parts to
be repaired or replaced:
SYMBOLS FOLLOWING PART PRICE:
m=MOTOR Mechanical component. s=MOTOR Structural component. T=Miscellaneous Taxed charge category.
X=Miscellaneous Non-Taxed charge category.
SYMBOLS FOLLOWING LABOR:
D=Diagnostic labor category. E=Electrical labor category. F=Frame labor category. G=Glass labor category.
M=Mechanical labor category. S=Structural labor category. (numbers) 1 through 4=User Defined Labor Categories.
OTHER SYMBOLS AND ABBREVIATIONS:
Adj.=Adjacent. Algn.=Align, ALU=Aluminum. A/M=Aftermarket part. BInd=Blend. BOR=Boron steel.
CAPA=Certified Automotive Parts Association. D&R=Disconnect and Reconnect. HSS=High Strength Steel.
HYD=Hydroformed Steel. Inc1.=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=UItra 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.
12/18/2020 2:01:35 PM 403391 Page 5
Supplement of Record 2 with Summary
RO Number: 29400
2018 TOYO Camry LE Automatic 4D SED 4-2.5L Gasoline Port/Direct Injection White
NON-ORIGINAL EQUIPMENT REPLACEMENT PARTS INFORMATION
Whenever ** appears next to the description of a part which is to be replaced,this means:
THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF AFTERMARKET CRASH PARTS SUPPLIED
BY A SOURCE OTHER THAN THE MANUFACTURER OF YOUR MOTOR VEHICLE.ANY WARRANTIES
APPLICABLE TO THESE REPLACEMENT PARTS ARE PROVIDED BY THE MANUFACTURER OR
DISTRIBUTOR OF THESE PARTS RATHER THAN THE MANUFACTURER OF YOUR VEHICLE.
12/18/2020 2:01:35 PM 403391 Page 6
Supplement of Record 2 with Summary
RO Number: 29400
2018 TOYO Camry LE Automatic 4D SED 4-2.5L Gasoline Port/Direct Injection White
PARTS SUPPLIER LIST
Line Supplier Description Price
18 RPW Headlamps #256808 $721.33
1809 N.9th St. RECOND LT Headlamp assy
Indianola IA 50125 Quote: 769545957
(800)336-4028 Expires: 12/21/20
12/18/2020 2:01:35 PM 403391 Page 7
For Customer Support refer to the
���I � ���I �� appropriate platForm below:
OrderPoint
800-934-9698
Orderpoint.su pport@lexisnexis.com
Accurint for Insurance
866-277-8407
Accu ri nt.su ppo rt@lexisnexis.com
Lexis.com
Law Firm accounts
800-543-6$62
PAGE COUNT: 5
CLIENT : 6625
DIVISION :
ADJUSTER : KOSV
CLAIM : 1314M974G
TRANSACTION # ; 1219442311
DATE : 0 110 512 0 2 1
DATE OF LOSS : 12/12/�020 TIME OF L055 : 0;0:0
STREET : 1625 ASHTON PLACE
CITY ; DUBUQUE
COUNTY : DUBUQUE
STATE : IA
INVESTIGATING AGENCY : DUBUQUE PQ
REPORT NUMBER : 2020-008126
REPORT TYPE : Auto Accident
PARTY 1 : RONALD L KOEHLER
PARTY 2 : .
PARTY 3 :
CAR : CAMRY MAKE : TOYOTA YEAR : 2018
TAG :
DRIVER LICENSE : K46073261237
ADDITIONAL INFO :
NOTE :
THANK YDU F�R YC]UR C�RDER!
INVESTIGATING OFFICER'S REPO
Sheet I of 4
Forte4433443111-13) OF MOTOR VEHICLE ACCIDENT \)%
MAIL REPORTS TO: Iowa Department of Transportation, orrice of Drive rSenices. P.O. Box 9204. Dea Moines, Iowa 50306-9204
Law Enforcement Case Numbers:
20208126 ..' ' J
Date of Accdent
Time of Accident
County
Accident occurred within corporate limits of (city)
12r1212020
10:09 Hrs.
DUBUQUE • 31
DUBUQUE - 2100
U
N
1
T
Driver's Name - Last
PUSATERI
First
JARROD
Middle
MICHAEL
Address
2416 GREEN ST
City
DUBUQUE
State
IA
Zip
62001.0000
Date of Birth Driver's License Number
CDL
Yes No
Citation
Charge 1
Citation Charge
2
Male Female
® C)
State
IA
Class
A
Endorsements
N
Restrictions
00
Citation
Charge 3
Citation Charge
4
Alcohol Test Giver:
1
Test Results:
Drug Test Giver:
1
Test Result:
Re. -exam: Yes N�
0 L#J
Reason For Re -Exam Request
Owner's Name - Last
CITY OF DUBUQUE
First
Middle
Address
SOW 13TH ST
City
DUBUQUE
Stale
IA
I Zip
52001
License Plate No.
124580
State
LA
Year
2099
YIN:
1GB3KZC80PF216343
Color
YEL
Year
2013
Make
CHEV
Model
3600HD
Style
PK
Trailer Plate No.
State
Year
VIN:
Tow
1
Tow #
Towed To
,SjiOn c cre!
$0.00
b Repair et Rep euz
Insurance Company Name
IOWA COMMUNMES ASSURANCE POOL
Insurance Co. Phone Number
(80O) 383-0116
Insurance Policy Number
Initial Travel Direction
0.2
Veh. Act
01
Veh. Conffg.
09
Cargo Body Type
L01 J
Veh. Defect
91
Pointof In Cal Impact
01
Most Damaged Area
15
Extent of Damage
1
Total Oce. In Veh.
1
Special Vah, Puna
08
Emergency Status
01
sus Use
Driver Condition
01
Vision
01
Obscured
Contributing Circumstances Driver (up to two)
06
Driver Distractions
02
Speed Limit
25
Traffic Controls
01
Hoti creel Alignment
01
Vertical Alignment
01
SEQUENCE
OF EVENTS
First Event
33
Second Event
Third Event
Fourth Event
Most Harmful Event
33
C
0
M
M
E
R
C
I
A
L
Carrier Name/Lessee
Street Address
City
Slate
Zip Code
Number of Axles
Gross Vehicle Weight Rating
US DOT Number
MC Number
UnderridefOverride
1-NONE
Has Mat Involvement
Has Mat Placard
Placard Number
Has, Mat Released
Has Mat Class
Has Mat Name
Tracer Plate:
State
Year
VIN
, €- .
t.
m
"
•
�,
'
Trader Plate:
State
Year
VIN
. •.
e.a i
.-
w
ra ,
Converter Dolly
Dolly Plate:
State
Plate Year
VIN
a
c
z=`.
.0,0
`a
` ;
P
E
R
S
O
NI
S N
I U
U T
R
E I
D
Phone Number: (303) 9ie-ee
6
,
r03.:.-
8
03
2.-,
01
1,..--.
01
01.
DRIVER OF UNIT I
Transported to:
Transported
by
Name
t Phone Number
COS:
Address
Transported to:
Transported
by;
Name
Phone Number
DOB:
Address
I
I
Transported to:
Transported
by:
Name
Phone Number
DOB:
Address
Transported to:
Trenspertec by:
Name
Phone Number
DOB:
c.
Address
'Transported to:
Transported by:
IPIVE5TiGAT1NG OFFICER'S REPORT sneet z of a
Form 44330IX3{11-13} OF MOTOR VEHIGLE ACCIDEIdT taw EntorcementCase Numbers:
MAIL REPORTS T0:lowa 6epartment otTransportation,Dffice of Driver Services,P.O.Box 92Q4,pes Moines,lowa 503o6•8204 2d24-0�&126
Date of Accident Time of Accident Couniy Accident occurred within cor�orate Iimits of(city)
i2112l2D2D 10:09 Hrs. �llBU�UE•31 DUBUQU�•2900
�r+ver's Name-Last F(rst Middla
U
N Address Ciry Slate Zip
I
T Date of Birth Dnver's License Number CDL Cifaf�on Charge 1 CitaUon Charge 2
2 Male Female 5tate Class EndorsemenTs RestricNons Yes Na Citation Charge 3 Gitatinn Charge 4
� �
Alcnho[Test GEven: Test Resufts: Drug Test Given: Test Result Re-exam: Yes No Reason for fte-Exam Request
1 1 � �
Ownar's Name-Last First Mlddle
KO�HLER JpRDAN NICOLE
Address City State Zip
503 KENWICKDI� �ALESBURG IL 614p1-ODOD
License Plate No. State Year VIN: Color Year Make Moctel SEyfe
JKOLE92 li. 2D21 4T1�11FiK3JU596275 WHl 2618 TOY7 CAINRY 40
TrailerPlaleNo. State Year VIN: � Tow Tow# TowedTo Approx.CostloRepairorReplace
6 53,000.00
Insurance Company Name InsuranCe Co.Phone Num@er InsuranCe PoliCy Number
STATE FARM (309}342-1088 E022814CD513A
Initial Travel L7irectlan Veh.Act. Veh.Config. Cargo Bady Type Veh.Defect Point of Initia[Impact Most Dam�ged Area Extent of namege 7otal Occ.in Veh.
01 01 81 '!0 10 3 0
Specfal Veh.Func Emergency Status Bus Use Driver Condiiion Vision Obscured Contributing Ciroumslances Driver{up io lwo) �river Distractions Speed Limit
07 D1 S8 01
Traffic Controls Horizontal Alignment Vertical Alignment gEQUENCE Firsi Evenf Second Event Third Event Fourth Event Most Harmfi�l Event
Q1 01 09 OF EVEN7S 33 33
Carrier NamelLessee
C
Q Street Address City State Zip Code
M
M Number of Axies Gross Vehicla Weight Rating US DDT Num6er MC Number ltnderridelOvernde
E 1-NONE
R Haz Mat Involvement Haz Mat Placard Placard Number Haz.Met Released Haz Mat Class Haz Mat Name
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Phone Number: (309}371-2273 k:;�`r + '�
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INVESTIGATIIdG��FICCR'S R�P017T OF sheet a of a
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Fomt 4433063(11-73) MOTOR VE�IICLE ACClD�N7" Law Enforcement Case Numbers:
MAIL RERORTS TO:lowa beparimenl of FranspoAation,Office of Driver Services.P 0.Box 9204,�es Moines,lowa 50306-9204 2020-OOB126
Date af Accident Time ot Accident County Accident occurred within corporate limits of{cfty) Legal Private
� 1219212020 10:09 Hrs. OUBUQUE-3� DUBUQUE-21Q0 Iniervention? ❑ Property? ❑
O Lileral Description County: Route:
C ASHTON PL AND�ECORAM ST 3l
A if accident occurred outside of N NE E SE S SW W NW X Coordinate:
Y cify limits show general viCiniiy �������� of nearest Gty sasass.sar
� On Road,Streeior Fiighway: At interseclion with: Y Coordinate.
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4707943
� Note:Unless accident occurred at an intersection which is completely described above,use the space below to give the exact '
locaiion from a milepost or definable Intersection,brldge,or rallroad crossing,using iwo distances and direct9ons lf neccassary. of If Divided Highway,Provlde Route
N NE E SE S SW W NW N NE E SE 5 SW W NW (Cardinal}Trave!Direction
� � ���� and � ������ NB SB EB WB
Milepost Defnable interseciion, � � � �.J
Number p� bridge,or raiiroad crossing
ACCIDENT ENVIROHMENT ROADWAY CHARACTERISTiCS _
Localion oi Firsl Harmful Event 01 Wsather Conditions�up to two) Major Contributing Circumsia�es Environment 02 'g•`
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MarmarofCrashlCo111sfon 06 Ufi Roadway 01 a- � �,
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Light Gondilions 9 SuAace Conditions 04 Type oi Roadway JunctionlFaaWre 01 Z ; � � Q m a" � �:;.
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First Harmiu[Event(Crash� WORKZONE Yes No Activity Location 7ype Workers Present x' � �" � � o � v � °� W,;
33 RELATED? � a �;
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Name �Q1 Phone Nwmber �OB; -
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�M Address: A[cohol 7esi Given Test Resuits: qrug Test Givan Result Charged Yes Na '
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� Address: Alcohal Tesi Given Tesf Results Drug Test Given Resu{t Charged Yes No
STransported to: Transpofted by: ��
IV P if Property other than abject Damaged �stimate of Damage
(�� vehicles damaged explain
pj� Owner's l.ast Name First Name kNiddle Name Phone Number
P ;
E E Address City State Zip Code Was owner or tenant notified?
H R 1=Yes 2=No 9=Unknown
I T If I'roperty other than �bject Damaged Esiimate of Damage
C Y vehicles damaged explain
(j Owner's Last Name �irst Name Middle Nam9 Phone Number
Lp
M Address Ciry State Zip Code Was owner or ienant notified?
R G 1=Yes 2=�l0 9=Unknown
Last Name First Name Address City Sfate zip Cade Phone Number
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N Last Name First Name Address City State Xip Code Phone Number
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5 Last Name First Name Address Gity Slale Zip Code Phone Numter
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Last Name Firsi Name Address City State Zio Code Phone Number
Is This a Secondary Crash? Type oi Primary Incident Roadway Clearance Date Incident Clearance�ata
Y � N O 1211212020 12l1212020
Siqnature of Officer Bedge Number Time O�cer Noiifed of Accident Roadway Clearance Time Incldent Clearance Time
CORPORAL WILKENS b€EUJUS'CE L19 10:13 �� t0:39 ��5, 10:39 H�
Name of Agency Daie of Report Time Officer Arrived At Scene Total Roadway Clearance Time Total Incident Clearance Time
DUBUQUE PflLICE D�PAR7M�P€F 1711?12020 10:21 H� Op0:26 ODU:26
Report Revlewed By Date oi Review Investi ation made at scene? T.I.No. �ther Technlcal Invest(gating Agency
W�LSW,BRENtrAN 9 214 2120 20 Y � N �
i�iV�STIGATING OFFlCER'S REPOR� sn�ec a or 4
�orm aas�ooa{ii-�a� OF MQTOi�VEFt1CLE ACC[DENT Law Enforcement Case Numbers:
MAIL REPORTS TO:lowa Departmont oPTransportation,Offca of Driver Services,P.O.Box 9204,Des Molnes,lowa 5030fi-9204 2020-OOB72fi
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Uecorah St
Unit#1{which is a snow plow;engaged in its duties)was traveling east bound on Decorah St.,near the intersection of Decorah 5t,and Ashton PI.,�ubuque,IA
526Di.Unit�2 was legally parked on the south side of Decorah 5t The plow blade on Unit#1 crashed inlo Uni#�2.No Injuries reported.
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