Claim State Farm - Tim GrassState Farm
February 2, 2001
Insurance
Compan
es
Subrogation Unit
P.O. Box 83106
Lincoln, NE 68501
City Of Dubuque
Attn: Carol Gnlick
50 West t3th St
Dubuque, IA 52001-8464
Your Claim Number:
Your Insured : City of Dubuque
Date of Loss : November 1, 2000
Our Claim Number : 15-3028-921
Our Insured : Timothy Grass
Dear Carol:
We have been informed that you are the insurance carrier for the
above named individual.
Our investigation establishes that your insured was responsible
for this accident. We were called upon to provide payment for
our insured's damages. The total amount of subrogation interest
is $872.94.
We are enclosing our supporting documentation for our subrogation
claim as outlined below.
Repairs/Total Loss paid by Company
Rental Paid by Company
UM-BI
Medical Payments
Other (Explain Below)
Less Salvage
Total Company Portion
Insured's Deductible
Rental Paid by Insured
Total Amount of Loss
$253 . 75
+$
+$
+$
+$
$
$253.75
+ $500.00
+ $74.19 & $45.00 Tow
= $872.9,~ '~'/'~ t~.,~ ~.,,F~ft
HOME OFFICES: BLOOMINGTON, ILLINOIS 61710-0001
Page 2
February 2, 2001
Please send your reimbursement directly to State Farm Insurance
for the total amount and we will reimburse our insured their
deductible.
If we do not hear from you within 30 days of the date of this
letter, we will have no alternative but to file in arbitration or
file suit against your policyholder.
Sincerely,
KellY'bott
Claim Expediter
(888) 248-6961
State Farm Mutual Automobile Insurance Company
CLAIM AGAINST THE CITY OF DUBUQUE, IOWA
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. Name of Claimant: Timothy W. Grass
2. Address: 721 W. 8th St., Dubuque, IA 52001
3. Telephone Number: (319) 557 4013
4. Date of Incident: 11-1-00
5. Time of Incident: 7:30 AM
6. Location of Incident (Be specific): W. 5th St. Dubuque, IA
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.)
Tim Grass was driving 20 MPH down W. 5th St. when he hit pot hole and damaged
vehicle (mark Stone Deputy Sheriff stated he contacted City of Dubuque on 10/31/00 in reference to Pot Hole
for repairs)
8. What were weather conditions like? Clear
9. Give name and address of any witnesses: Mark D. STone, Deputy Sheriff 31-18 Phone (319 589 4427
10. Did police investigate? (If so, give names of officers.) Yes, Fairchild, Officer, w City of Dubuque (319) 589 4415
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
No
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.)
Yes, Vehicle '92 Toyota
13. What other damages do you claim, if any?
$74.19 Renting Vehicle Expense - while his vehicle in shop $45.00 towing
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.)
Yes, State Farm Insurance $253.75
15. What amount do you claim from the City of Dubuque?
16. Why do you claim the City of Dubuque is responsible?
Negligence in maintaining roadways - failrue to repair pothole even after notification failed to post signs notifying of hazard.
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.) No
18. If the answer to Question 17 is yes, have you received any payment from that source, and if so, in what amount?
Dated at Dubuque, Iowa this 31 day of January , 2001.
/s/ Timothy W. Grass
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
CLAIM A~AIN$~ T~E C~TY .OF DUBUQUE
PA~D.
~D~Oyee was in~lv~, ~ive ~h~ ~1oyee's n~e. )
il. Was anyone i~uted? (If so, ~iv~ n~o, addrmss ~d ~tent of
and ~ ~t~ o~ d~e. A~tach es~ .... '.~ ~o~e~
17.
18.
RBZ00032
date: 02-02-01
time: 08:17 AM
STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPAi~f
VEHICLE DAMAGE REPORT
date of loss
11-01-00
Estimate Vehicle Info ~
Vehicle Owner: Grass, Tim ~
Vehicle Description: 92 Toyota Paseo 2D Cpe ~
Date: 11/13/00 11:05 A.M.
Estimte ID: 15-3028-92101
Supplement: I(P) 11/13/00 11:05:
Profile ID: Mitchell
Dar~age Assessed By: Robert Hanle¥
Supplemented By: Robert Hanley
Type of Loss: Collision
Date of Loss: 11/01/00
Deductible: 500.00
Claim Number: 15-3028-92101
HanleyAuto Body [nc.
1030 Century Circle Dubuque ,IA 52002
(319) 583-7220
Fax: (319) 583-8355
Address:
Telephone:
TIMOTHY GRASS
721Y 8TH ST DUBUQUE, IA 52001-6656
Some Phone: (319) 583-9836
Description: 1992 Toyota Paseo
Body Style: 2D Ope
VIN: JT2EL45F1NO030139
OEM/ALT: 0
Mitchell Service: 914748
Drive Train: 1.5L Inj 4 Cyl 5M
Line Entry Labor
item Number Type Operation
Line item Part Type/ Dollar Labor
Description Part Number Amount Units
* - Judge~aent Item
# - Labor Note Applies
87.~4 0.6 #
45.00*
ESTIMATE RECALL NUMBER: 11/10/00 14:54:1g 15-30Z8-92101
UltraMate is a Trademark of Mitchell International
Mitchell Data Version: ROV_OO_A Copyright (C) 1994,199~ Mitchell international
Ultramate Version: 4.6.004 All Rights Reserved
Page 1 of 2
Date: 11/13/00 11:05 A.M.
Estimate ID: 15-3028-92101
Esti~te Version: 1
Supplement: liP) 11/13/00 II:05:
FINAL
Profile ID: Mitchell
Add~ l
Labor Sublet
Eoc~ 0.8 36.00 0.00 0.00 28.80T Taxable Parts
Frame 1.0 36.00 0.00 0.00 36.00T Sales Tax
Mechanical 3.0 36.00 0.00 0.00 I08.00T
Taxable Labor 172.80
Labor Tax @ 6.000~ 10.37
Non-Taxable Labor 0.00
Labor Summary
III. Additional Costs
Taxable Costs
4.8 183.17
Sa[es Tax @
Total Replacement Parts Amount
Total Additional Costs
A~t IV. Adjustments
45.00 Insurance Deductible
2.70
47.70
I. Total Labor:
II. Total Replacement Parts:
III. Total Additional Costs:
Gross Total:
IV.
Total Adjustments
Net Total:
Less Original Net Total:
Net Supplement Amount:
Sl: Robert Hanley
Amount
495.28
@ 6.000% 29.60
Amount
500.00-
500.00-
522.88
47.70
753.75
500.00-
285.36
Inspection Site: HANLEY AUTO BODY INC.
Body Shop: F~LEY AUTO BODY
Address: 1030 CENTURY CIRCLE
DUBUQUE, IA 52002
ESTIMATE RECALL NUMBER: 11/10/00 14:54:18 15-5028-92101
UltraMate ~s a Trade~rk of Mitchell International
Mitchell Data Version: NOV_O0~ Copyright (C) 1994~1~9 Mitchell International
Ultramate Version: 4.6.004 All Rights Reserved
Page 2 of 2
RBZ0003H
date: 02-02-01
page:
STATE FARM MUTUAL AUTOMOBILE INSURAi~CE COMPAI~f
AUTO PAYMF NTS
named insured
GP~SS . TIMOTHY
! d
enotes consolidated pay~t
denotes previous data
payment nu~er payee
106052191J F_A/~T,E¥ AUTO BODY INC. ON
policy number
G189--690--15
date of loss
11--O~_--OO
total amount issued status
253.75 11-15-00 PAID