Claim by First Financial Asset Management - Statefarm CLAIM AGAINST THE CITY OF DUBUQUE, IOWA �' �%X q '`'""`�^^
This written report constitutes your claim against the City of Dubuque, Iowa. 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. 13th 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
Efz-�1. Name of Claimant: w S
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2. Address: 1 V t n 6V 7 Peac�l� re r` .,c �3b��1
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3. Telephone Number: 1���'y `I ' � �� 1� ��095q � -7
4. Date of Incident: _ I
5. Time of Incident: `� 3 C) cyfo
6. Location of Incident (Be specific): On(-1Y® , 7U �Lkl
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.)
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8. What were weather conditions like? ��1 �
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9. Give name and address of any witnesses:
10. Did police investigate? (If so, give names of officers.)
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
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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.)
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13. What other � an you damages do claim if ?
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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.)
15. What amount do you claim from the City of Dubuque? �✓��
16. Why do you claim the City of Dubuque is responsible?
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17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.) n
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18. If the answer to Question 17 is yes, have you received any payment from that source,
and if so, in what amount?
Dated at Dubuque, Iowa this ID day of mfr- 20 .
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(Signature)
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(Print Name) .�,•
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(Rev. 7/12) � �
Confidential
This communication and any attachments may contain information which is confidential I
and privileged by law and is for the use of the designated recipient. If you are not the
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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.
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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, f
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.
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Signature Date
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I have read the information above and do not have any confidential documentation to submit to the
City of Dubuque a p ,rt of thi Claim Against the City.
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Signature Date I
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'"FAM
rlRF1 RNANCtAt ASSET MANAGRPOW%PNC,
Receivable Portfolio Solutions
Subrogation Demand Notification
From: RENE SANTOS Date: 12/29/2014
Phone: 800-348-7243 FFAM Number: 16259847
Fax: 602 778-6990 Pages: Of
Insurance Company: CITY CLERK @ CITY HALL
Attention:
Date of Loss: 08/02/2014
Claim Number: DRIVER: MICHAEL CONNER
Your Insured: CITY OF DUBUQUE
Fax#
Our Client: STATE FARM AUTO INSURANCE
Our Insured: JACOBSON, BRIAN
Property Damage: $4,830.00
Deductible: $250.00
Rental: $
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UMBI: $ h
Total Demand: $5,080.00
First Financial Asset Management Is the legal assignee/Subrogation vendor for the above named
insurance company and their insured. We have been asked by our client to file the enclosed proof
of loss documents to facilitate payment of the above referenced claim.
PLEASE REMIT PAYMENTS TO:
FIRST FINANCIAL ASSET MANAGEMENT
3091 Governors Lake Dr. Suite 500
Peachtree Corners, GA 30071
Attn: 16259847
Our Tax Id number is 412029035. Thank you for your prompt attention to our request.
If you have filed Bankruptcy or are in the process of filing Bankruptcy,this letter is for informational purposes only.
This is an attempt to collect a debt; any information obtained will be used for that purpose. Be advised that you
could be charged up to a$25 processing,fee by our company for any returned check.