Claim by Progressive Classic Insurance_Paul Olson.~ ~ ,.
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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 West 13`h St., Dubuque, IA 52001. It will then be referred to
the appropriate department for investigation and to the City Attorney's Office. 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.
_~. ~y
1. Name of Claimant: ~a01''P~l~l~ Q%5oC~1~ • (D • ~~/O ~n
2. Address: ~d ~ ,~' ~/~Q~-~°~p ~~2~T ~ i,~O
3. Telephone Number://i / ~ ~ p '~Q t,~~
4. Date of Incident: .~'~7""'Q
Time of Incident: _Q~~ ~'/_
Location of Incident (Be spec^ic): d~'J9 ~ ~~ ~~ ~np , ~~
7. Describe the 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.)
10. Did police investigate? (If so, give names of officers.)
11. Wa,,s /anyone injured'? (If so, give names, addresses, and extent of injuries.)
1lLOr
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.)
8. What were weather conditions likes J
9. Give name and address of any witnesses: /
13. What other damages do you claim, if any? /1l/q .
14. Have you been compensated for any part or all of your claim by any insurance company? (If so, give name and
addre~ of insurance company and amount paid.) ~,
15. What amount do you claim from the City of Dubuque? f ~~~ . ~ (D
17. Have you made any claim against anyone else
address.)
damages as a result of this incident? (If yes, give name and
18. If the answer to Question 17 is yes; have you received any payment from that source, and if so, in what amount?
Dated this _~ day of
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16. Why do you claim the City of Dubuque is responsible?
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Payme~rrt Address Document Address
?_4344 Network Place P.O. Box 89440
Chicago, IL 60673-1243 Cleveland, OH 44101
Phone: (877)818-0139
Fax: (888) 792-5922
09/02/2009 01:33:00 PM
Certified Maii Return Receipt Requested 91 7108 2133 3934 2078 3329
CITY CLERK AT CITY HALL
50 WEST 13TH STREET
DUBUQUE, IA 52001
Your Client: KEYLINE TRANSIT
Your Claim Number:UNKNOWN
Our Insured: OLSON, PAUL M
Our Claim Numk;2r:09-3129432
Amount Subject to F~eimbursement:1,512.56
Amount of Insured's Deductible: 500.00
Please take this as formal notice of our subrogation rights relative to the above -captioned
claim. We have corr~pleted our investigation into the facts of the above-captioned loss and find
that your insured was the proximate cause of the accident.
Locatiorf o Loss: LURAS ST/ BLUFF ST. DUBUQUE, fA.
Date and Time of Loss: 05-14-08 2:OOPM
Description cif Loss: OUR INSURED'S VEHICLE WAS PARKED ON LORAS STREET IN THE
PARKING LAND: WHEN A KEYLINE TRANSIT VEHICLE FAILED TO MAINTAIN PROPER
LOOKOUT AND STRUCK THE OPEN DOOR TO OUR INSURED'S 2003 PONTIAC GRAND
PRIX CA'JSINU vAMAGE TO THE LEFT FRONT AND REAR DOORS.
Please make your draft payable to Progressive Classic Insurance Co. as subrogee of
"OLSON, PAUL M ", in the amount stated above and mail it to the attention of the undersigned
at your earliest corr~enience.
All supporting documentation is enclosed. I have diaried my file ahead fifteen (15) days. Thank
you for your- ant cipated, prompt attention to this matter.
BRIDGE- {,/I~~L.~~R
Subrogation Represantative
I'rogres:>,ve Classic Insurance Co.
Tel. 877-818-0139 Ext 37152
Fax 888-i'a2-5922
BRIDGET _MAGAR(a~PROGRESSIVE.COM
Date: 8/13/2009 10:39 AM
Estimate ID: 09-3129432-01
Estimate Version: 0
Committed
Profile ID: MadWest:all part typ
PROGRESSIVE
Damage i~ssesse:i By: DREV: ~1~1v'EGAR Appraised For.: DREW WINEGAR
(6G8) 215-6430
Type of Loss: Auto
Date of Loss: 5/19/2008
Deductible: 500.00
Claim Number: 09-3129432-01
Insured: PAUL OLSON
Owner: PAUL OLSON
Address: 980 JACKSON APT 1, PLATTEVILLE, WI 53818
Telephone: work Phone: (608) 348-2463 Home Phone: (608) 642-2890
Mitchell Seraice: 915493
Description: 2003 Pontiac Grand Prix SE Vehicle Production Date: 00/00
Body Style: 4D Sed Drive Train: 3.1L Inj 6 Cyl 4A
VIN: 1G2WK52JX3F123339 License• 831LTZ WI
Mileage: 166,665
OEM/ALT: A Search Code: BROOKFIELI
Color: MAROON
Gptions: ALUM/ALLOY WHEELS, AIR CONDITIONING, CP.UISE CONTROL, AUTOMATIC TP.ANSMISSION, 4-DOOR
Line Entry Labor
Item Number Type Operation
1 500790 BDY
2 REF
3
4 500798 BDY
5 500800 BDY
6 500802 BDY
7 500840 BDY
8 500870 BDY
9 700122 BDY
10 AUTO REF
11 AUTO REF
12
13
REPAIR
REFINISH/REPAIR
REMOVE/INSTALL
REMOVE/INSTALL
REMOVE/INSTALL
REMOVE/INSTALL
REMOVE/INSTALL
REMOVE/REPLACE
REFINISH
REFINISH
Line Item
Description
FRONT DOOR
L FRT DOOR REPAIR PANEL
L FRT DOOR REPAIR PANEL
MODIFIED REFINISH WITH FULL CLEAR COAT
L FRT LWR DOOR MOULDING
L FRT BELT MOULDING
L FRT DOOR POWER MIRROR
L FRT DOOR TRIM PANEL
L FRT OTR DOOR HANDLE
REAR DOOR
L REAR REPLACE DOOR ASSY
L REAR DOOR
L REAR ADD FOR JAMBS & INTERIOR
Smart Parts - Quote#2838160
LINE MARKUP $25.00
Part Type/
Part Number
Existing
Used/Recycled
Dollar Labor
Amount Units
1.0 *#
C 1.1
0.3
1.0 #
INC #
INC
0.3 #
300.00 * 1.4
C 2.2
C 1.0
75.00
19 70C124 BDY REMOVE/REPLACE L REAR DOOR HINGE ~@O.GO Used/Recycled INC C.6
15 500950 REF REFINISH L REAR LWR DOGR MGULDIIQG C 0.6
16 500952 BDY REMOVE/INSTALL L REAR BELT MOULDING 0 3
17 500959 BDY REMOVE/INSTALL L REAR LWR DOOR MOULDING ;_3
18 use mldg off Li:Q door
19 500968 BDY REMOVE/INSTALL L REAR DGGR TRIM PANEL II,1C
EST 1i~1ATE RECAL L NUMBEF.: 8/13/2009 10:49:53 09-312u432-O1
Mit chell D ata Version: OEM: JUPd_09 _V0810 UitraMate is a Trademark of Mitchell International
I~1APP:I<1P.Y 09 V08G9 Copyright ("; i~i99 - 2009 Mitchell Intei_,ariotial gage 1 cif 5
U1t raMate Version: 6.S.G26 All Rights Reser~red
Date : 8/13,'2009 10:39 AM
Estimate ID: 09-3129432-O1
Estimate Version: 0
Committed
Profile ID: MadWest:ail part typ
20 500982 REF REFINISH L REAR UPR DOOR HINGE DOOR SIDE C 0.2
21 500984 REF REFINISH L REAR LWR DOOR HINGE DOOR SIDE C 0.2
22 500986 BDY REMOVE/INSTALL L REAR OTR DOOR HANDLE 0.7 #
QUARTER PANEL
23 501118 REF BLEND L QUARTER PANEL OUTSIDE
C 1.J
REAR LAMPS
29 501292 BDY REMOVE/INSTALL L REAR COMBINATION LAMP 0 3
REAR BUMPER
25 501319 BDY REMOVE/INSTALL REAR BUMPER ASSY 0.5 *
25 drop L side for quarter refinish
ADDITIONAL OPERATIONS
27 REF ADD'L OPR CLEAR COAT 1 8
ADDITIONAL COSTS & MATERIALS
28 ADD'L COST PAINT/MATERIALS 267.30
29 ADD'L COST HAZARDOUS WASTE DISPOSAL 1.00
MANUAL ENTRIES
30 900500 BDY* REPAIR CLEAN AND RETAPE MLDGS Existing 0.4
* - Judgement Item
# - Labor Note Applies
C - Included in Clear Coat / Three Stage Calc
All manufa ctur ers requirements regar ding seat belt and supplemental
res traint syst em replacement must be adhered to. If additional parts
or operati ons are necessary to prope rly accomplish this, please
con tact th e es timating claims rep.
ESTIMATE RECALL NUMBER: 8/13/2009 10:49:53 09-3129932-01
Mitchell Data Version: OEM: JUN_09_VO810 U1traMate is a Trademark of Mitchell In*_ernational
MAPP:MAY_09_V0809 Copyright (C) 1994 - 2009 Mitchell International Page 2 of 5
U1traMate Version: 6.5.026 All Rights Reserved
Date: 8/13/2609 10:39 AM
Estimate ID: 09-3129432-01
Estimate Version: 0
Committed
Profile ID: Madwest:all part_typ
I. Labor Subtotals Units Rate
Body 7.1 52.00
Refinish 8.1 52.00
Taxable Labor
Labor Tax @
Labor Summary 15.2
Estimate Totals
Add'1
Labor Sublet
Amount Amount Totals II. Part Replacement Summary
0.00 0.00 369.20 T Taxable Parts
0.00 0.00 421.20 T Parts Adjustments
Sales Tax @ 5.500%
790.90
5.500 93.47 Total Replacement Parts Amount
833.87
Amount
300.00
75.00
20.63
395.63
III. Additional Costs Amount IV. Adjustments Amount
Taxable Costs 268.30 Insurance Deductible 500.00-
Sales Tax @ 5.500 14.76
Customer Responsibility 500.00-
Total Additional Costs
283.06
I. Total Labor: g33,8'7
II. Total Replacement Parts: 395.03
III. Total Additiona]. Ccsts: ~93.0~
Gross 'Total: 1,51?,5
I`J. Total Adjustments; :; ;;i~,0,n_
Net Total: 1,012.5r
Point(s) of Impact
9 Left Side (P)
Inspection Date: 8/13/2009
ESTIMATE RECALL NUMBER: 8/13/ 009 10:49:53 09-3129432-01
Pflitchell Data Version: OEM: JUN_09_V0810 U1traMate is a Trademar;: of Mitchell International
MAPF:MAY_09_V0809 Copyright (C) 1994 - 2009 Mitchell International Page 3 of 5
U1traMate Version: 6.5.026 All Rights Reserved
Date: 8/13/2009 10:39 AM
Estimate ID: 09-3129432-01
Estimate Version: 0
Committed
Profile ID: MadWest:all part typ
THIS IS A DAMAGE ASSESSMENT ONLY - NOT AN AUTHORIZATION TO REPAIR -
BASED ON DAMAGE VISIBLE OR CERTAIN AT THE TIME IT WAS WRITTEN.
IF FRAME OR UNIBODY REPAIR IS INCLUDED ON THIS ESTIMATE, THE AMOUNT
SHOWN INCLUDES TIME OR ALLOWANCE FOR MEASURING BEFORE, DURING AND
AFTER THOSE REPAIRS.
THE OWNER OF THE VEHICLE MAY SELECT THE REPAIR FACILITY OF HIS/HER
CHOICE.
TO ENSURE PROPER AND PROMPT PAYMENT FOR ADDITIONAL DAMAGE DISCOVERED
DURING THE COURSE OF REPAIRS, CONTACT PROGRESSIVE FOR SUPPLEMENT
your vehicle to its pre-loss condition with proper installation.
After repair, if any sheet metal or plastic body part included in the
estimate fails to return your vehicle to its pre-loss condition
(assuming proper installation), ~n terms of form, fit, finish,
durability or functLOnality, Progressive will arrange and pay for the
replacement of the part, to the extent not covered by a
manufacYu,-er's or other warranty. This service will be performed at
no cost to you (includi~ig associated .repair and rental car costs;. ,_
obtain service under_ this Guarantee, call Progressive at
1-80C-I74-4t",~1. This Guarantee applies as long as you own or lease
the vehicle. This Guarantee rs not transferable and terminates if you
sell or otherwise transfer your vehicle.
THIS GUARANTEE DOES NOT COVER NORMAL WEAR AND TEAR OR DAMAGE CAUSED
BY IMPP.OPER MAINTENANCE, NEGLECT, ABUSE OR SUBSEQUENT ACCIDENT. THIS
GUARANTEE IS LIMITED TO AP.RANGING FOR THE SELECTION OF REPAIR PARTS
THAT WILL RETURN YOUR VEHICLE TO ITS PRE-LOSS CONDITION. ACCORDINGLY,
PkOGRESSIVE WILL NOT BE LIABLE FOR ANY INDIP.ECT, INCIDENTAL OR
CONSEQUENTIAL DAMAGES THAT RESULT FROM THE INSTALLATION OR USE OF
THESE PARTS.
Part Type Terms and Abbreviations
NEW and OEM or part number. displayed - These refer to a new, original.
equipment manufacturer part.
IdON-OEM and A/M and Qual REPL - These refer to an after-market part,
which is a new, non-original equipment manufacturer part.
USED/RECYCLED and LKQ - These refer to a used OEM part,
F.EMANUFACTURED and RECOP?D. and RECORE - These refer to used/recycled
OEM parts that have been refurbished.
REPAIR SHOP'S AUTHORIZED REPRESENTATIVE'S SIGNATURE INDICATING
AGREEMENT ON COST TO RETURN THE VEHICLE TO FRE-LOSS CONDITION
INCLUDING TOW/STORAGE CHARGES:
SHOP SIGNATURE:
EST. COMPLETION DATE:
ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE/SHE IS
FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION OR
FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF
INSURANCE FRAUD.
Event Log
File Created:
Estimate Started:
Estimate Printed:
Estimate Committed:
Estimate Uploaded:
08/13/2009 10:08:07 AM
08/13/2009 10:29:47 AM
08/13/2009 10:39:47 AM
08/13/2009 10:49:53 AM
08/13/2009 12:09:11 PM
ESTIMATE RECALL NUMBER: 8/13/2009 10:99:53 09-3129432-01
Mitchell Data Version: OEM: JUN_09_V0810 UltraMate is a Trademark of Mitchell International
MAFP:MAY_09_V0805 Coppri7ht (C) 1994 - 2009 Mitchel]. International Page 5 of 5
TlltraMate Version: 6.5.026 A11 Riahts Reserved
_-. September 02, 2009, 13:28:41
CMSD2 340 /CMSM2340 P A C M A N SEP 02 09 - 13:28
OPID: DRW0015 CLAIM PAYMENT INQUIRY TERMID: ?000
INSD: OLSON, PAUL M POL: 27659136 -4
DOL MAY 14 08 WI-MAD ISO-BRN-A CLM: 093129432 ACTIVE REP: A KLINE
PAY TO THE ORDER OF: TOTAL DRAFT AMOUNT: 1,012.56
LINE 1: PAUL M OLSON, ONLY******************************************
LINE 2:
LINE 3:
ADDRESS: 980 JACKSON APT 1
CITY: PLATTEVILLE ST/PR* WI ZIP/CPC: 53818 CNTRY* USA
IN PAYMENT OF: COLL- 03 PONTIAC- LESS $500 DEDUCTIBLE
1099 ? N FEDERAL TAX ID: LAST UPDT REP: DXW0145
CDS CODE * 13 PCL EFT TRACE #: ISSUING REP: D WINEGAR
BANK CODE* AS2 ISSUE DATE AUG 13 09 APPROVED BY:
STATE * WI AREA * REVIEW DATE: 00 00
STOP RSN * DRAFT # 462495173 REVIEWED BY:
COMMAND: