Claim by State Farm Insurance_William RobertsTHE CITY OF
DUB UE MEMORANDUM
Masterpiece on the Mississippi
TRACEY STECKLEIN
PARALEGAL
-Ap
To: Mayor Roy D. Buol and
Members of the City Council
DATE: April 20, 2010
RE: Claim Against the City of Dubuque by William Roberts, subrogated by
State Farm Insurance
Claimant Date of Claim Date of Loss Nature of Claim
William Roberts
subrogated by State
Farm Insurance
04/20/10
cc: Michael C. Van Milligen, City Manager
Dave Heiar, Economic Development Director
Shelly Holtz, State Farm Insurance
03/20/10 Vehicle Damage
This is a claim in which claimant alleges that as he was westbound on Loras Boulevard
at the North Grandview intersection, his vehicle was struck by a City of Dubuque
minibus.
This claim has been referred to Public Entity Risk Services of Iowa, the agent for the Iowa
Communities Assurance Pool.
OFFICE OF THE CITY ATTORNEY DUBUQUE, IOWA
SUITE 330, HARBOR VIEW PLACE, 300 MAIN STREET DUBUQUE, IA 52001 -6944
TELEPHONE (563) 583 -4113 / FAX (563) 583 -1040 / EMAIL tsteckle @cityofdubuque.org
13f — ;3
DBQ Fax 4/6/2010 8:34:52 AM PAGE 2/003 Fax Server //
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. 13 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: 1 VVY1 19) a71 11,0115
2. Address: 1v � O )iarrllVi 1 I L 70 .?-
(31141 13 - goeg-,2 , 1 3 /- A a_ i 0 , ko p,
3. Telephone Number: I Li/ I U 5heily ttb
4. Date of Incident: - ,g0 - ,$0 l C)
5. Time of Incident: q: 2 3 c '�
6. Location of Incident (Be specific): Li AVer yf l vicw /-e
dub U ue I fr
no
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.)
?k&)e wee M4Acci
Ch
8. What were weather conditions like? 6I 7 '
9. Give name and address of any witnesses: Mi
10. Did police investigate? (If so, give names of officers.)
- re cMd vAice v
11. Was anyone injured? (If so, give named, addresses, and extent of injuries).
DBQ Fax 4/6/2010 8:34:52 AM PAGE 3/003 Fax Server
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.)
�ii�lh t -{iYwrf sw�e-
-
C41111 a .0s - cfeducf
13. What other damages do you claim, if any? 1/1A
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.)
c e5 � avvn /X4JCI I, - , 63
15. What amount do you claim from th6 City of Dubuque ? J a 7a
16. Why do you clam the City of Dubuque is CW rr 711 —
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.) v
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 (L1 day of
(Rev. 1/00 & 7/01)
t Name)
iantnAn X
0!110 S Belt 10
81 :6 VII OZ 0l
Q3A13O33
State Farm Insurance Companies
April 15, 2010
Ms. Jeanne Schneider- City Clerk
City Hall- City Clerk's Office
50 W 13th St
Dubuque, IA 52001
RE: Claim Number:
Date of Loss:
Our Insured:
File Ref No:
Dear Ms. Schneider:
Enclosed please find the claim form that you requested from State
Farm. We have issued payments under our collision coverage, and
request reimbursement for our damages, and Mr. Roberts collision
deductible.
I have enclosed a copy of our estimate and payment summary for
your review.
S'ngerely,
13 -A808 -223
March 20, 2010
William F Roberts
William Roberts & Jonathan Adams
helly H
Claim Represent al'ite
State Farm Mutual utomobile Insurance Company
(309) 679 -9653
HOME OFFICES: BLOOMINGTON, ILLINOIS 61710 -0001
State Farm Claim Office
PO Box 2350
Bloomington, IL 61702
Office Number: (309) 679 -9600
Fax Number: (888) 309 -8608
•
TTTTT MOM
IN IMANCI
STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY
............... .
named insured
1=2.0 13 ERT S , W = LL TAM F
RBZ0006Z
date: 04 -15 -10
AUTO PAYMENTS BY COL
CO 4 O O
page: 1
policy number
0 3 5 8— 9 0 6— L 3 G
date of loss
O - 2 0— LO
C denotes consolidated payment
P denotes previous data
COL: 400 indemnity:
1,772.05 dir rcov:
E denotes EFT payment
0 . 0 0 expense:
0.00
payment number
E 101893444K
E 101893213K
101681037J
payee
KRUSE - WARTHAN D
KRUSE - WARTHAN D
WILLIAM F. ROBE
amount
52.96
26.64
1,692.45
status
O/S
PAID
PAID
COL
400
400
400
pay cd
1
2
2
rsn reporting party
Named Insu
Named Insu
Named Insu
DBQ Fax 4/6/2010 8:34:52 AM PAGE 1/003 Fax Server
FAX
To: Claim No. 13A808223
Company:
Fax: 1- 888 - 309 - 86081968
Phone:
From:
Fax: 563 - 583 -1040
Phone: 563-589-4113
E - mail: tsteckle @cityofdubuque.org
NOTES:
If you wish to file a claim against the City of Dubuque regarding an
incident that occurred on 03/20/10 involving your insured, William
Roberts, and Jonathan Adams, we would request that you fill out the
attached claim form and return it to the City of Dubuque City Clerk's
Office at the following address:
Ms. Jeanne Schneider, City Clerk
City Hall - City Clerk's Office
50 West 13th Street
Dubuque, IA 52001
Once the claim has been stamped in by the City Clerk, it will be
forwarded to the City Attorney's Office for investigation.
Thank you.
Date and time of transmission: Tuesday, April 06, 2010 8:34:32 AM
Number of pages including this cover sheet: 03
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Printed At Dubuque Police Dep.rlre ant 0312012010 10 37 AM
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LORDS BLVD
NARRATIVE
Describe total hoppeped Cora Iov.Ndes by amber)
H. ORANDVIEW AVE
UNIT f1 WAS W /8 ON LORAS BLVD AT THE INTERSECTION WITH N. GRANDVIEW AVE UNIT 02 WAS SIB ON N.
GRANDVIEWAVE AT THE INTERSECTION WITH LORAS BLVD. DRIVERS OF BOTH UNITS CLAIMED TO HAVE HAD THE
GREEN UGHTAND THERE WERE NO WITNESSES TO BE IDENTIFIED. BOTH UNITS COLLIDED IN MIDDLE OF THE
1MERBECTION WITH THE FRONT RIGHT OF UNIT I7 STRIKING THE LEFT FRONT OF UNIT N. UNIT 112. A CITY OF
DUBUQUE AIYNI -BUS DID NOT HAVE PLATES ON IT DUE TO IT BEING A RECENT PURCHASE AND THE TRANSIT
DEPARTMENT NOT RECEIVING THE PLATES FROM THE STATE YET.
No. lino OldarNolificddkoldent • 1TM.OteoerMtW0Attloww
Date of nape N
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Pepe Form #: 01 -0041720
TTTTT m_
INiUCANC
RBZ00032
date: 04 -15 -10
time: 09:29 AM
- h 4 444
STATE STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY
VEHICLE DAMAGE REPORT
a3:`er date of loss
...................
03 -20 -10
tic 'Ae
Estimate Vehicle Info
Vehicle Owner: ROBERTS, WILLIAM
- 2'E' Vehicle Description: 07 HYUNDAI SANTA FE WAGON PLATINUM
tic -awe -a+k -avc-3Tc -zwk -3Tc-3Tc-3Tc-aTc -awe •ae-a* e-ave de •Oe •ve•aIrc•Ifc•avc•awe.avc•Te•a+ carc -awe -3+c-zwc -2RC-2Tc-zvc- 0c-avc
Owner
Owner:
Address:
City State Zip:
Home /Day:
Work /Day:
Control Information
Claim # .
Loss Date /Time:
Loss Type:
Deductible:
Ins. Company:
Insured:
Work /Day:
Home /Day:
Claim Rep:
Work /Day:
Inspection
Inspection Date:
Inspection Type:
Address:
City State Zip:
Primary Impact:
Driveable:
Received Date /Time:
Appointment Date /Time:
Appraiser Name:
STATE FARM INSURANCE COMPANIES
500 SOUTH 84TH STREET LINCOLN, NE 68510 -2611
SUPPLEMENT FAX: (MN,WI) 800 - 230 -1949
SUPPLEMENT FAX: (IA,NE,ND,SD) 800 - 455 -9697
* ** SUPPLEMENT 3 * **
WILLIAM ROBERTS
119 RISS DR
NORMAL, IL 61761 -3228
(309) 838 -8455
(309) 452 -3267
13 -A808 -22301
03/20/2010 07:00 AM
Collision
$500.00
State Farm
WILLIAM ROBERTS
(309)838 -8455
(309)452 -3267
Team B3 Proc
(888)309 -8607
03/25/2010 10:44 AM
Field
600 Century Drive
Dubuque, IA 52002
Right Front Side
No
03/25/2010 08:36 AM
03/25/2010 08:00 AM
KELLY SMITH
Orig Appraiser Name: Jim Hoppman
Vehicle
2007 Hyundai Santa Fe Limited 4 DR Wagon
6cyl Gasoline 3.3
5 Speed Automatic
Lic.Plate: 149 4449 Lic State: IL
Lic Expire: 10/2010 VIN: 5NMSH13E57H082526
Prod Date: Mileage: 42,305
Veh Insp# : Mileage Type: Actual
Condition: Code: E7114D
Ext. Refinish: Two -Stage
Ext. Color: PLATINUM SAGE
Ext. Paint Code: TD
Options
5 Passenger Seating AM /FM CD Player Air Conditioning
2007 Hyundai Santa Fe Limited 4 DR Wagon 04/09/2010 02:08 PM
Page 1 of 4
03/25/2010 10:47 AM
S3 04/09/2010 02:06 PM
Claim # : 13 -A808 -22301 03/25/2010 04/09/2010
Alarm System Aluminum /Alloy Wheels
Automatic Dimming Mirror Bodyside Cladding
Center .Console Cruise Control
Dual Zone Auto A/C Fog Lights
Head Airbags Heated Front Seats
Heated W/S Wiper Washers Intermittent Wipers
Leather Seats Leather Steering Wheel
MP3 Player Overhead Console
Power Door Locks Power Drivers Seat
Power Windows Privacy Glass Rear Spoiler
Rear Window Defroster Rear Window Wiper /Washer Roof Rack Cross Bars
Roof /Luggage Rack Side Airbags Skid Plates
Stability Cntrl Suspensn Strg Wheel Radio Control Tachometer
Tilt & Telescopic Steer Tinted Glass Tire Pressure Monitor
Tonneau /Cargo Cover Traction Control System Trip Computer
Wood Interior Trim
Damages
Ln# Op GDE Description
1 N 6 Front Bumper Cover R ADDITIONAL OPERA
2 I 6 Cover,Front Bumper Repair
3 L 6 Cover,Front Bumper Refinish
MC #
1.4 * Surface
0.6 Two -stage setup
O .5 Two -stage
Anti -lock Brakes
Cargo /Trunk Net
Dual Airbags
Garage Door Opener
Heated Power Mirrors
Keyless Entry System
Lighted Entry System
Power Brakes
Power Steering
MFR.Part No. Price AJ% B% HRS R
1.2 SM
0.2* SM
2.5* RF
# = 10, 13
» PARTIAL COLOR FULL C/C
4 BR 83 Panel,Hood Blend Refinish 1.8 RF
1.2 Blend
0.6 Two -stage
5 E 104 Fender,Front RT 663200W260 245.97 1.1 SM
6 L 104 Fender,Front RT Refinish 2.7 RF
1.8 Surface
0.5 Edge
0.4 Two -stage
7 E 47 Skirt,Inner Fende RT 868200W000 60.62 INC SM
8 UM 919 Wheel,Front RT REMAN /REBUILT PA 179.00* 0.3 SM
» NORTH STAR DARRELL 556 -5030
9 EU 658 Hub,Front Wheel RT RECYCLED PART INC ME
» OFF 08
10 EU 656 Spindle,Wheel R/F RECYCLED PART 175.00 +33.00 1.6 ME
» POELLS 563- 659 -8111 RICK VERIFIED OFF 08 INCS HUB ABD BEARING
11 E 660 Strut Assembly,Fr RT 546602B100 135.89 S2 0.9 ME
MC 01
12 BR 208 Door Shell,Front RT Blend Refinish 1.2 RF
O .8 Blend
O .4 Two -stage
13 RI 59 W /Strip,Belt Oute RT R & I Assembly 0.2 SM
14 RI 27 Mldg,Front Door L RT R & I Assembly 0.2 SM
15 RI 61 Channel,Front Gla RT R & I Assembly 1.4 SM
16 RI 129 Handle,Front Door RT R & I Assembly 0.4 SM
17 SB CAR COVER Sublet Repair 5.00* INC* SM
18 N HAZARDOUS WASTE DISP ADDITIONAL OPERA 3.00* INC* SM
19 SB THRUST ANGLE ALIGNME Sublet Repair 59.95* INC* SM
20 SB BALANCE TIRE AND WHE Sublet Repair 12.00* INC* SM
21 SB Flex Additive Sublet Repair 8.00* INC* SM
22 I 2ND INSTALL STRUT Repair S3 0.9* SM*
22 Items
2007 Hyundai Santa Fe Limited 4 DR Wagon 04/09/2010 02:08 PM
Page 2 of 4
Claim # : 13 -A808 -22301 03/25/2010 04/09/2010
MC Message
01 CALL DEALER FOR EXACT PART # / PRICE
10 INCLUDES AUDATEX TIME TO CLEAR ENTIRE PANEL
13 INCLUDES 0.6 HOURS FIRST PANEL TWO -STAGE ALLOWANCE
Estimate Total & Entries
Gross Parts $442.48
Other Parts $357.00
Paint Materials $287.00
Line Item Markup $57.75
Parts & Material Total $1,144.23
Tax On Parts Only @ 7.000% $60.01
Labor Rate Replace Hrs Repair Hrs Total Hrs
Sheet Metal (SM) $55.00 3.6 2.3 5.9
Mech /Elec (ME) $55.00 2.5 2.5
Frame (FR) $60.00
Refinish (RF) $55.00 8.2 8.2
Paint Materials $35.00
Labor Total 16.6 Hours $913.00
Tax on Labor Q 7.000% $63.91
Sublet Repairs $84.95
Tax on Sublet @ 7.000% $5.95
Gross Total $2,272.05
Less: Deductible $500.00 -
Net Total $1,772.05
Rates / Taxes Adjustment
Deductible Adjustment
Actual Supplement Total $52.96
Less: Previous Net Total $1,719.09 -
Net Supplement Total $52.96
$324.50
$137.50
$451.00
Alternate Parts No
Recycled Parts Y /6/1 Zip Code: 52001 INV DATE: 04/09/2010
Audatex Estimating 6.0.217 S3 04/09/2010 02:08 PM REL 6.0.217 DT 03/01/2010
Copyright (C) 2009 Audatex North America, Inc.
2.5 HRS WERE ADDED TO THIS ESTIMATE BASED ON AUDATEX'S TWO -STAGE
REFINISH FORMULA.
THIS IS AN ESTIMATE. REPAIR FACILITES MUST INSPECT THE VEHICLE TO DETERMINE
IF ANY REPAIRS NOT LISTED ARE REQUIRED, AND TO CONTACT STATE FARM BEFORE
MAKING SUCH REPAIRS. REPAIRER ALSO IS RESPONSIBLE FOR CONDUCTING ANY NECESSARY
INSPECTION AND SAFETY CHECKS PRIOR TO AND AFTER COMPLETING REPAIRS.
Op Codes
* = User - Entered Value E = Replace OEM NG = Replace NAGS
EC = ** NON -OEM PART ET = Partial Replace Labo EP = ** NON -OEM PART
EU = RECYCLED PART TE = Partial Replace Pric PM = REMAN /REBUILT PART
UM = REMAN /REBUILT PART L = Refinish PC = RECOND PART
UC = RECOND PART TT = Two -Tone SB = Sublet Repair
N = ADDITIONAL OPERATION BR = Blend Refinish I = Repair
IT = Partial Repair CG = Chipguard RI = R & I Assembly
P = Check RP = RP- RELATED PRIOR
This report contains proprietary information of Audatex and may
not be disclosed to any third party (other than the insured,
2007 Hyundai Santa Fe Limited 4 DR Wagon 04/09/2010 02:08 PM
Page 3 of 4
Claim # : 13 -A808 -22301 03/25/2010 04/09/2010
claimant and others on a need to know basis in order to
effectuate the claims process) without Audatex's prior written
consent..
Copyright (C) 2009 Audatex North America, Inc.
2007 Hyundai Santa Fe Limited 4 DR Wagon 04/09/2010 02:08 PM
Page 4 of 4
STATE FARM INSURANCE COMPANIES
500 SOUTH 84TH STREET LINCOLN, NE 68510 -2611
SUPPLEMENT FAX: (MN,WI) 800 - 230 -1949
SUPPLEMENT FAX: (IA,NE,ND,SD) 800 - 455 - 9697
Recycled Real Steel Locate Report
Owner Name: WILLIAM
Claim # : 13 -A808 -22301
Vehicle
2007 Hyundai Santa Fe Limited 4 DR Wagon
6cyl Gasoline 3.3
5 Speed Automatic
5 Passenger Seating AM /FM CD Player Air Conditioning
Alarm System Aluminum /Alloy Wheels Anti -lock Brakes
Automatic Dimming Mirror Bodyside Cladding Cargo /Trunk Net
Center Console Cruise Control Dual Airbags
Dual Zone Auto A/C Fog Lights Garage Door Opener
Head Airbags Heated Front Seats Heated Power Mirrors
Heated W/S Wiper Washers Intermittent Wipers Keyless Entry System
Leather Seats Leather Steering Wheel Lighted Entry System
MP3 Player Overhead Console Power Brakes
Power Door Locks Power Drivers Seat Power Steering
Power Windows Privacy Glass Rear Spoiler
Rear Window Defroster Rear Window Wiper /Washer Roof Rack Cross Bars
Roof /Luggage Rack Side Airbags Skid Plates
Stability Cntrl Suspensn Strg Wheel Radio Control Tachometer
Tilt & Telescopic Steer Tinted Glass Tire Pressure Monitor
Tonneau /Cargo Cover Traction Control System Trip Computer
Wood Interior Trim
Ln# Part Description Year /Make /Notes VIN? Cleanup Supplier Stock #
10 Spindle,Wheel R/F 2008 International /Hyundai Y
> = ESTIMATE TOTAL IS BASED ON PRICE QUOTED BY THIS SUPPLIER.
REPAIRERS MAY USE THE SUPPLIER OF THEIR CHOICE AND MAY NEGOTIATE
SPECIFIC TERMS OF PURCHASE WITH THAT SUPPLIER.
Detailed Distributor List
S060901 Poell's Enterprises Inc. (563)659 -8111
439 Industrial
P.O. BoX 73
Included Damage for Recycled Real Steel
Assembly /Part Operation Description
5060901 10
Audatex Estimating 6.0.217 S3 04/09/2010 02:08 PM REL 6.0.217 DT 03/01/2010
Zip Code: 52001 Search Area: 52001
Copyright (C) 2009 Audatex North America, Inc.
This report contains proprietary information of Audatex and may
not be disclosed to any third party (other than the insured,
claimant and others on a need to know basis in order to
effectuate the claims process) without Audatex's prior written
consent.
Copyright (C) 2009 Audatex North America, Inc.
2007 Hyundai Santa Fe Limited 4 DR Wagon 04/09/2010 02:08 PM
Page 1 of 2
Claim # : 13 -A808 -22301
Audatex Estimating is a trademark of Audatex North America, Inc.
2007 Hyundai Santa Fe Limited 4 DR Wagon 04/09/2010 02:08 PM
Page 2 of 2
* ** SUPPLEMENT RECONCILIATION * **
Supplement S3
Claim # .
Claim Rep:
Insured:
Inspection Date /Time:
Owner Name:
Appraiser Name:
Vehicle:
Added Lines
Ln# GDE Part Operation Price AJ% B% HRS Rate
1 2ND INSTALL STRUT Repair S3 0.9* SM
Calculation Changes From To Difference
SM - Sheet Metal
Tax On Labor
$55.00
7.000%
13 -A808 -22301
Team B3 Proc
WILLIAM ROBERTS
03/25/2010 10:44 AM
WILLIAM ROBERTS
KELLY SMITH
2007 Hyundai Santa Fe Limited 4 DR Wagon
$275.00
$60.45
$55.00
7.000%
$324.50
$63.91
Actual Supplement 3 Net Total $52.96+
Summary Net Total Date Time Appraiser
Supplement 2 $1,719.09 04/05/2010 01:20 PM KELLY SMITH
Supplement 3 $1,772.05 04/09/2010 02:06 PM KELLY SMITH
This report contains proprietary information of Audatex and may
not be disclosed to any third party (other than the insured,
claimant and others on a need to know basis in order to
effectuate the claims process) without Audatex's prior written
consent.
Copyright (C) 2009 Audatex North America, Inc.
Audatex Estimating is a trademark of Audatex North America, Inc.
2007 Hyundai Santa Fe Limited 4 DR Wagon 04/09/2010 02:08 PM
Page 1 of 1
49.50+
3.46+