Claim by Jennifer Connolly Copyrig hted
February 1, 2021
City of Dubuque Consent Items # 2.
City Council Meeting
ITEM TITLE: Notice of Claims and Suits
SUM MARY: Jennifer Connolly on behalf of State Farm I nsurance; Ronald Koehler on
behalf of State Farm I nsurance for vehicle damage.
SUGGESTED Suggested Disposition: Receive and File; Referto CityAttorney
DISPOSITION:
ATTACHMENTS:
Description Type
Claim by Jennifer Connolly Supporting Documentation
Claim by Ronald Koehler Supporting Documentation
Providing Insurance and Financial Services �. StateFarm�
Home Office, Bloomrngton, !L
January 06, 2021
City Of Dubuque StateFarmClairm
50 W 13th St P 0 Box 106169
Dubuque IA 52001-4805 Atlanta GA 30348-6169
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RE: Claim Number: 15-15D4-64Q y
Insured: Jennifer Connolly �
Date of Loss: January 02, 2021 �
To Whom It May Concern:
We are writing to you regarding a loss sustained by our insured. �
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Our investigation indicates you may be responsible for this Ioss. By virtue of our payment to our t
insured, we are entitled to recover from the responsible party. �
_
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If you have liability insurance, please refer this letter to your insurance company and provide us
with your in�urance information. If you do not have insurance, we are entitled to recover from you
directly for incurred losses.
Your cooperation is appreciated.
If you have questions or need assistance, call us at (402) 327-4134. If I am not available, any
other member of my tearn may assist you.
Sincerely,
Esmeralda Balderas
Claim Specialist
(402) 327-4134
State Farm Fire and Casualty Company
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Pr�c+vidrng tnsurance and Ff.naneial Servic�s � �� �i� � 'i
Home Offic�, 8loomington, IL �
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January 6, 2021
City Of Dubuque State Farm Claims �
50 W 13th St P 0 Box 106169
Dubuque IA 52001-4805 Atlanta GA 30348-6169
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RE; Claim Number: 15-15D�-64Q
Date af Loss: January 2, 2021
pur Insured: Jennifer Connolly _ �
Loss Location: Dubuque, IA
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Dear Jennifer Connolly: i
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We are writing to you in reference to a loss sustained by our insured an January 2, 2021. �
- To��#e, the +o#�I am��n:^f#h� lo�s "as not ��er deterr�ined. H��vev�r; our investigation ;!
indicates you may be legally liable for this loss and we will look to you for reimbursement once
the final amount of damages is known.
If you have insurance, please refer this letter to your insurance company immediately. Please �
complete the attached form and advise us of your insurance company's name, address, �
telephone number, and your policy number. If you do not have insurance, please cantact us to
discuss this matter further.
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
infprmation 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 pravide 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.
Thank you for your cooperation in this matter.
15-15D4-64Q
Page 2
January 6, 202�
Sincerely,
Esmeralda Baldeas on behalf of Natalie Green
Claim Specialisfi
(972) 657-2721 ,
Fax: ($44) 236-3646
State Farm Fire and Casualty Company
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Enclosure(s): Return Envelope �
_ _ _ _ � �
Name: _
Address.
_ _ 6
Our Claim Number: 15-15D4-64Q -
Please complete this page and return it ta us in the enclosed envelope.
Name of yaur insurance company:
Address of insurance campany:
Phone number of your insurance Company:
Your policy number:
Your agent's name and phone number:
Have you reported this loss to your insurance company? Y N �
If yes, what is the claim number your insurance company has assigned to this loss?
Thank you for your cooperation.