Claim by Mark and Sandra WillisWisconsin Mutual
Insurance Company
8201 Excelsior Drive
Madison, Wisconsin 53717 -1907
(608) 836 -4663 FAX# (608) 836 -1645
November 11, 2010
Ms. Jeanne Schneider, City Clerk
City Hall — City Clerk's Office
50 W. 13 St.
Dubuque, IA 52001
Re: Claim #: 40- 5415 -10
Insured: Mark & Sandra Willis
Date of Loss: 8/26/2010
Dear Ms. Schneider,
Enclosed please find the completed "Claim Against the City of Dubuque, Iowa" form you
requested us to complete. Also attached is our subrogation letter for the above - referenced
motor vehicle accident as well as our supporting documentation for the expenses we have
paid.
If you have any questions or concerns, please let me know.
Sincerely,
Alexandra Sage
Claims Administrative Supervisor
Wisconsin Mutual Insurance Company
asage cr,wiins.com
ORGANIZED 1903
'enbngna
G01110 S: pe! X10
CS :01 S AONO1
QGAEEQ1:!
Noverber 11, 2010
City of Eituque
925 Kesper Blvd.
Duque, IA 52034
FE: Or Insured: Mark & Sara Willis
Cllr Claim No: 40- 5415 -10
thte of Doss- 8/26/2010
Claimant.
Dear Sir / Madam,
Wisconsin Inutuc[
Insurance Company
8201 Excelsior Drive
Madison, Wisconsin 53717 -1907
(608) 836 -4663 FAX# (608) 836 -1645
4Je are criting you abaft the aa3dart in With yxr case involved
With our insured cri the date skirl. ()Jr investigation indicates
that you are reepalsible for this accident
If you have insurance to protect yxu please sari us the nate of
oir insurance only, its address and yxrr Policy rather or sari
this letter to your autPany. If you cb not have insurance coverage
phase antact cur office to discuss reirrursexmt of this claim.
We have made de fo11 curing pats and request reurbur'sstt=rrt as
shoal below:
N re of cur Payee
Insured & Kdms Auto Body
Net Pym nt Paid by 0:maly
Insured's Ljx.'tible
TOM $2,832.17
S.j xrting cbazrentatian is attached.
SST V,
A1err3ra Sage
C7 1MS 1»IINr
CC
ORGANIZED 1903
Payrlts Made
$2,332.17
$2,332.17
$500.00
11/11/10 11:37:35 CLAIMS CHECK DISPLAY CLODSPM
Check Detail
Posted Date: 2010 - - Date Voided
Check # 610928 Check Issue Date 2010 - -
Payment #...: 000266176 Account Number
Payee..: MICHAEL W & SANDRA L WILLIS
900 E MADISON ST
PO BOX 82
PLATTEVILLE WI 53818
Comment: 88
Insd vehicle repairs less deduct
F3 =Exit Fl2= Cancel Enter
Check Amount...: 2,332.17
Check Status...: PAID
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 1,1;I11 ,
2. Address: - 1o11S ( . 1 i.a: t.,,.." i i C ,,a\e, WI. 5Vsit
3. Telephone Number: (001 - - lti�t3
4. Date of Incident: I a c,1 av lu
5. Time of Incident: 11. 3Co
6. Location of Incident (Be specific): E q 1k a � � AL,
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.)
ratiti rAerc,�;, va.\"lr lJ a ar \l CA-7 CA h am,, �,< < .. 1 , ;ven(
8. What were weather conditions like?
9. Give name and address of any witnesses: Su,,,4,t„ U;1■; ,�,,, �� t'l<� u,A,
10. Did police investigate? (If so, give names of officers.)
V ty r-e ,rte ca„n, Oc&h:ell , ( .d.e 11 * 'Z"
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
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.)
Ootfrs 'Trl� Co
d a l 3a " �;�, 1\4
13. What other damages do you claim, if any? —
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.)
WP . �n trL �r�. J" d 1 . �` (v31\1S■<1r� rin rn�2S c - c,L } 11
WS nf
r'�l/v1V1(�+W�
15. What amount do you claim from the City of Dubuque?
a % . i (f .sno iwA..rl.rl. ;.. - �1:5 ice - ox., :n��rcr}.s dcola c�il�c .1
16. Why do you claim the City of Dubuque is responsible?
!o \p o- ze-ge_ �,,�, el, flat rr Ol, - - e,-' J o - ir,sur
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.)
. 1.n'.w- cA.„ra , U. l S`6. �htbn�cr r, 'Wt S nZ
18. If the answer to Question 17 is yes, have you received any payment from that source,
and if so, in what amount?
N1 y '-(.e a
Dated his I I day of o,,t.,�„ , 20 at) .
(Signature)
HAo -A+-, Xer. G ���,r,.,, (�� � .�e SA.p.(Print Name)
(Rev. 1/00 & 7/01)
renRa """" "` °r"''" ""� Iowa Department of Transportation
5/03 Iowa Department of Transportatio
orr«;eox 9204 Services INVESTIGATING OFFICERS REPORT OF
P.O. Box 6204
Des Moines, Iowa 50306 -9204 MOTOR VEHICLE ACCIDENT
Law Enforcement Case Number.
01-10-41134
Legal _
Intervention?
Location Literal Description
US 00521E 9TH
Property? ❑
ST and WHITE
-JoC<) - -OZ 1
Date of Accident
08126/2010
Time 01 Accident
11:36 Hrs.
County
Dubuque - 31
Accident occurred within corporate limits of (' )
Dubuque - 2100
If accident occurred outside of city limits
show general qty: "WA" of nearest city "NIA"
ST
On Road. Street. or Highway.
E. 9TH ST.
At Intersection with:
WHITE ST.
Note: Unless accident occurred at en intersection which is completely described above, use the space below to give the exact
Iocation from a milepost or definable Intersection, bridge, or railroad crossing, using two distances and directions W necessary.
X-Coordinate: 00691891
Y- Coordinate: 04708221
Distance Direction Distance Direction
"N/A" "NIA" and "NIA" "NIA" of
If Divided Highway, Provide Route
(Cardinal) Travel Direction
"N/A"
Milepost Number Definable intersection, bridge, or railroad crossing
"NIA" Or "NIA"
Driver's Name - Last First Middle Suffix Home/Cell Phone
WELTER JERED JAMES (563) 495-0610 x
Address City State Zip
2901 DAVENPORT ST DUBUQUE IA 52001
Citation Charge Code 1 Citation Charge 1
Citation Charge Code 2 Citation Charge 2
Citation Charge Code 3 Citation Charge 3
Citation Charge Code 4 Citation Charge 4
Gender
Male
State
IA
Class
B
Endorsements
L
Restrictions
8
Alcohol Test
Given?
1 - None
Test Results:
Drug Test
Given?
1 - None
Taft Results:
Seating Position 01
Injury Status 5
Occupant Protection9
I Airbag Deployment 5
I Airbag Switch Status 9
Ejection 1 Ejection Path 1
Trapped 1
Transported to
I Transported by.
Owner's Name - Last
CITY OF DUBUQUE
First
I Middle
Suffix
Owner Company Name
Address
925 KERPER BLVD
�y
DUBUQUE I
IA 1e
1 52
004
Insurance Co. Name
IOWA COMMUNITIES
Insurance Pit it
CITY OF DUBUQUE
License Plate # 84633
IA State
1 Year
2020
Year
2001
Make
FRGT
Model
Style
TK
Tow 8
NO
Private?
❑
Approximate Cost to
Repair or Replace
$0.00
Initial Travel
Direction 1
Vehicle
Action 01
Speed
I Limit 25
Point of
Initia Impact 01
Most Damaged Extent of
Area 01 Damage 1
Underride/
Override 1
Total
Occupants 01
Traffic
Controls 02
Vehicle
Config. 05
Cargo Body Vehicle
Type 08 Defect 01
Driver
Condition 1
Vision
Obscured 01
Contributing C'rcumatances,
Driver (up to two) 27
SEQUENCE OF EVENTS I First Event 13 Second Event 06 Third Event 21 Fourth Event Most Harmful Event (by vehicle) 21
Commercial Tracer Attached to State Year Attached to State Year
License Plate # Power Unit Trader Unit
Emergency
Vehicle Type 1
Emergency
Status 3
Carrier Name
I Address City State Zip
US DOT # or MC #
I Number of Grose Vehicle
Axles Weight Rating
Placard 8 Hazardous Materials
Released?
U
N
I
.r
002
Driver's Name - Last First Middle Suffix Home/CeN Phone
WILUS MICHAEL W (608) 732 -1443 x
Address City State Zip
4915 US HIGHWAY 151 PLATTEVILLE WI 53818 -0000
Citation Charge Code 1 Citation Charge 1
Citation Charge Code 2 Citation Charge 2
Citation
Gender
Male
State
WI
Class
DM
Endorsements
NONE
Restrictions
8
Alcohol Test
Given?
1 -None
Test Results:
Drug Test
Given?
1 -None
Test Results:
Charge Code 3 Citation Charge 3
Citation Charge Code 4 Citation Charge 4
Seating Position 01
Injury Status 5
Occupant Protection9
Airbag Deployment 5
1 Airbag Switch Status 9
Ejection 1
I Ejection Path 1
I Trapped 1
Transported to:
I Transported by
Owner's Name - Last
WILUS
First
MICHAEL
Middle
W
l Suffix I
Owner Company Name
Address
4915 US HIGHWAY 151
City
PLATTEVILLE
State Zip
WI 53818 -0000
Insurance Co. Name
WISCONSIN MUTUAL
Insurance Policy #
AP9755
License Plate 8
520MLZ
State
WI
I Year
VIN No
1NXBR32E38Z969658
Year
2008
Make
Toyota - TOYT
Model
COROLLA
Style
40
Tow#
NO
Private?
❑
Approximate Cost to
Repar or Replace
$1,400.00
Initial Travel
Direction 2
Vehicle
Action 01
Speed
Limit 25
Point of
Initial Impact 05
Most Damaged
Area 05
Extent of
Damage 3
Underridei
Override 1
Total
Occupants 02
Traffic
Controls 02
Vehicle
Confg. 01
Cargo Body Vehicle
Type 01 Defed 01
Driver
1 Condition 1
Vision
Obscured 01
Contributing Circumstances,
Driver (up to two) 28
SEQUENCE OF EVENTS I First Event 13 Second Event 06 Third Event 21 Fourth Event Most Harmful Event (by vehicle) 21
Commercial Trailer Attached to State Year Attached to State Year
License Plate # Power Unit Trailer Unit
Emergency
Vehicle Type 1
Emergency
Status 3
Carrier Name
I Address City State Zip
US DOT # or MC #
Number of
Axles
Gross Vehicle
Weight Rating
Placard #
Hazardous Materials
Released?
Printed At Dubuque Pollee Department 08/2612010 02:27 PM
Page 1
Form it 01- 1041134
U
N
I
T
Drivers Name - Last First Middle Suffix Home /CeNPhone
PAYNE BRUCE GLEN (563) 557 -7450 x
Address
425 2ND &JEFFERSON ST COLESBURG IA 52036
Citation Charge Code 1 Citation Charge 1
9 -7- 321.311 TURNING FROM IMPROPER LANE
Citation Charge Code 2 Citation Charge 2
Citation Charge Code 3 Citation Charge 3
Citation Charge Code 4 Citation Charge 4
Gender
Male
State
IA
Class
C
Endorsemenl Restrictions
NONE NONE
Alcohol Test
Given?
1 -None
Test Results:
D
Drug
Given?
1 -None
Test
Test Results:
Seating Position 01
I Injury Status 5
I Occupant Prolection9
1
I Airbag Deptoymant 5 I
Airbag Switch Status 9
I Ejection 1
I Ejection Path 1
I Trapped 1
Transported to:
Transported by
Owner's Name - Last
Frst
I Middle
Suffer
Owner Company Name
TSCHIGGFRIE EXCAVATING
003
' mess
425 JULIEN DUBUQUE DR.
DUBUQUE BUQUE
State Zp
I IA 1 52003
Insurance Co. Name
ACUITY
Insurance Policy #
K77023
License Plate #
594HW8
State I
IA
Year
2010
Year
2005
Make
Chevrotet - CHEV
Model
C4500
Style
Tow #
NO
Private?
❑
Apprmdmate Cost to
Repair or Replace
$0.00
Initial Trawl
Direction 1
Vehicle
Action 02 I
Speed
Limit 25
Point of
Initial Impact
Most Damaged
Area
I Extent of 1
Damage 1
Underrida/
Override 1
Total
Occupants 01
Traffic
Controls 02
Vehicle
I ConfIg. 05
Cargo Body 1
Type 09
Vehicle
Defect 01
Driver
Condition 1
Vision
Obscured 01
Contributing Circumstances,
Driver (up to two) 05
SEQUENCE OF EVENTS I First Event 13 Second Event Third Event Fouts Event Most Harmful Event (by vehicle) 13
Commercial Trailer Attached to State Yew Attached to State Yew
License Plate # Power Unit Trailer Unit:
Emergency
Vehicle Type 1
Emergency
Status 3
Carrier Name
I Address City State Lp
US DOT* or MC*
Number of
Ades
f Gross Vehicle
I Weight Retie I
Placard #
Hazardous Materials
Released?
ACCIDENT
Location
Manner
Light
ENVIRONMENT
of First Harmful Event 1 Weather Conditions
of Crash/Coltsion 3 (uP to Iwo) 01,10
Conditions 1 Surface Conditions 1
ROADWAY CHARACTERISTICS
Major Contributing Circumstances:
Environment 8
Roadway 01
Type of Roadway Junction/Feature 11
WORKZONE RELATED?
No
Location
Type
Workers Present?
SEQUENCE OF EVENTS
First Harmful Evert of Crash
(use codes 11.42 only) 21
0 —< 0 re Q 2 II
I=
L
White
Fa
St
3
E.9th St.
I
NARRATIVE
Describe what happened (refer to vehicles by number)
UNIT 2 WAS STOPPED FOR A TRAFFIC LIGHT AT WHITE ST. IN E. 9TH ST TRAVELING EASTBOUND. UNIT 1 WAS
STOPPED BEHIND UNIT 2 ON E. 9TH ST. WHEN THE LIGHT CHANGED UNIT 1 AND 2 BEGAN MOVING EASTBOUND UNTIL
UNIT 2 WAS CUT OFF BY A TSCHIGGFRIE EXCAVATING TRUCK WHICH MADE AN ILLEGAL LEFT TURN FROM THE
SOUTHERNMOST EAST BOUND LANE ONTO WHITE ST UNIT 2 HAD TO STOP QUICKLY TO AVOID THE TSCHIGGFRIE
TRUCK AND UNIT 1 WAS UNABLE TO STOP IN TIME STRIKING THE REAR OF UNIT 2. BOTH DRIVERS AGREE THE
ACCIDENT WAS CAUSED BY THE ACTIONS OF THE TSCHIGGFRIE TRUCK DRIVER. TSCHIGGFRIE MANAGEMENT WAS
CONTACTED AT 563 -590 -9991 AND THE SUPERVISOR STATED THAT HE WOULD ATTEMPT TO TRACK DOWN WHICH
TRUCK WOULD HAVE BEEN IN THAT AREA AT THE TIME OF THE ACCIDENT AND GET BACK TO REPORTING OFFICER
WITH THAT INFORMATION. TSCHIGGFRIE TRUCK WAS DESCRIBED AS A 4 DR CHEVY NEWER 5 TON WORK TRUCK
WITH WORK BOXES IN THE BACK HAVING A WHITE CAB AND LIGHT BLUE BOX.. TSCHIGGFRIE WAS CONTACTED AND f
WAS DIRECTED TO THE OPERATER OF THAT VEHICLE IDENTIFIED AS PAYNE. PAYNE WAS OPERATING THE VEHICLE
MARKED AS UNIT 3 IN THE DIAGRAM AND ADMITTED TO MAKING A LEFT HAND TURN FROM THE WRONG LANE AT 9TH/
WHITE BECAUSE HE THOUGHT THE CAR IN
Printed At, num inl .a On.Ma m1Ane inert• nancrumn nn.n• n••
age
Form #: 01-10-41134
NARRATIVE
Describe what happened (refer to vehicles by number)
THE LANE NEXT TO HIM WAS ALSO TURNING LEFT. PAYNE WAS CITED FOR TURNING FROM THE IMPROPER LANE
BUT WAS NOT CITED FOR FAILURE TO ID AS HE CAUSED A NON - COLLISION WITH HIS VEHICLE AND STATD HE WAS
UNAWARE HE HAD CAUSED AN ACCIDENT.
Witness Name - Last Fist Middle Suffix
WIWS SANDRA LEA
Address
4915 US HIGHWAY 151
City State Zip Code
PLATTEVILLE WI 53818
Home/Cod Phone*
(608) 732 -1443 x
Work Phone*
Officer
BASTEN DANIELLE
Badge No. Time Officer Notified of Accident Time Officer Arr At Scene
23A 11 36 Hrs. 11:38 Hrs.
Name of Agency
Dubuque Police Department
Date of Report
08/26/2010
Investigation
made at scarfs? Yes
T.I. N
Report Reviewed By
gr, fl- ' . ,,�
Date ev
CP/24 In
Agency Specific
Other Technical Investigation Agency
Printed At Dubuque Police Department 08126/2010 02:27 PM Page 3 Form B: 01- 10.41134
Front•Pat Friesen Fax10:8087238440
b
SHOP: KOHN'S AUTO BODY
CXTY STATE: PLATTEVI1LE, WI
ZIP: 53818-
Page 3 of4
KOHH'S AUTO BODY
230 EAST MAIN STREET
PLAraprILLE, WI 53819
PHONE: 608 -348 -3168 FAX: 608 -348 -3168
FEDERAL TAX ID 420- 0962126
CD LOG NO 5272 -1
� OF is„�, 9 a, Pl f�r� w
DEA ,�rS, � M.IKE / �� /�l� LA)/
PO OF IMPACT• 9 J
S.3gig
LIC4:
BODY COLOR: GREY
CONDITION:
*_4JSER- ENTERED VALUE
EC- REPLACE ECONOMY
UMmRT.MAN /REBUILT PRT
OE- REPLACE PXW OE SRPLS
T'E -PARTL REPL PRICE
I- REPAIR
TT- TWO -TONE
N- ADDITIONAL LABOR'
AA- APPEAR ALLOWANCE
STATE:
E=REPLACE OEM
UE- REPLACE OE SURPLUS
EU -REPLY SALVAGE
PC-PXN RECONDITIONED
ET =PARTL REPL LABOR
L=REPINISH
CG=CHIPGOARD
RI-R6I ASSEMBLY
RP- RELATED PRIOR
OP GDE MC DESCRIPTION MFG.PART NO.
1 0389 PANEL,QUARTER LT REPAIR
L 0389 PANEL,QUARTER LT REFINISH
BR0390 PANEL,QUARTER RT BLEND REFINISH
BR0397 D00R,FUEL FILLER LT BLEND REFINISH
E 0479 LID,REAR DECK 6440102100
USED SMART PARTS- -$450
L 0479 LID,REAR DECK REFI1ISH
8 0481 HINGE,DECK LID LT 6450312160
L 0481 HINGE,DECK LID LT REFINISH
8 0482 HINGE,DECK LID RT 6450312160
L 0482 HINGE,DECK LID RT REFINISH
E 0566 01 COVER,REAR BUMPER 5215902911
L 0566 COVER,REAR BUMPER REFINISH
E 0173 FILLER,REAR BUMPER LT 5255302020
L 0173 13 FILLER, REAR BUMPER LT REFINISH
DATE 08/27/10
INSP DATE:
CONTACT:
CELL PHONE:
VIN:
MILEAGE:
ACCTNG CTL4:
2008 TOYOTA COROLLA CE 4D0014 OEDAN 4CYL GASOLINE
CODE: Y2114A/F OPTNS R/24
NG- REPLACE NAGS
UC =RECONDIT10 ED PRT
EP- REPLACE PXN
PM REMAN /RE90ILT
IT++PARTIAL REPAIR
BR -BLEND REFINISH
SE- SUBLET
P -CHECK
UP- UNRELATED PRIOR
1.8
OPTIONS:
TWO -STAGE - EXTERIOR SURFACES TWO -STAGE - INTERIOR SURFACES
PRICE AJ% B% HOURS R
430.91
30.21
30.21
222.12
29.87
08/27/10
BRIAN KOHN
Date 8/30/2010 t 0:34 AM Page:3 of 4
t')Pcri 55
(608)732 -1443
1NXBR32E382959658
2.0 *1
3.0 4
1.4 4
0.2 4
2.1. 1
3.5 4
2.0 1
0.4 4
0.3 1
0.4 4
0.6 1
3.1 4
1.5 1
1.1 4
PAGE 1
08/27/10
From:Pat Friesen FaxdO:60072345440
2008 TOYOTA COROLLA CE 4DOOR
CD LOG PO 5272 -1
L NO3 FLEX ADDITIVE
N M14 CORROSION PROTECTION
• !417 COVER CAR EXTERIOR
I LT QTR. PULL
INCLUDES SET -DP
EC HAB. WASTE REM.
19 ITEMS
MC MESSAGE(S1
01 CALL DEALER POR EXACT PART DUBBER / PRICE
13 INCLUDES 0.6 HOURS FIRST PANEL TWO -STAGE ALLOWANCE
FINAL CALCULATIONS 6 ENTRIES
GROSS PARTS
OTHER PARTS
PAINT t4 T'ERIAL
PARTS & lin1TERIAL TOTAL
TAX ON PARTS & MATERIAL @ 5.500%
LABOR
1 -SLEET METAL
2- MECH/ELEC
3 -FRAME
4- REFINISH
5 -PAINT MATERIAL
LABOR TOTAL
TAX ON LABOR
SUBLET REPAIRS
TOWING
STORAGE
GROSS TOTAL
NET TOTAL
SEDAN
REFINISH 3.00*
ADDNL LABOR OPERA 10.00*
ECONOMY PART 5.00*
REPAIR
•
Facie 4 of 4 Date 8f30l2010 10.34 AM Page:4 of 4
ECONOMY PART
RATE REPLACE HRS REPAIR HRS
56.00 6.5 5.8
68.00
68.00
56.00 13.1
38.00
8
3.00*
OP q
743.32
21.00
497.80
1,262.12
69.42
688.80
733.60
1,422.40
5.5009 78.23
2,832.17
2,832.17
SHOPLINE 06177 ES CD LOG 5272 -1 DATE 08/27/10 03:12:560M R6.37 CD 08/10
FEN: Y /00 /00 /00 /00 /00 CUM 00/00/00/00/00 GEOCODE 53818
HOST LOG
(C) 1998 - 2008 AUDATEX NORTH AMERICA, INC.
3.1 HRS WERE ADDED TO THIS EST. BASED ON AUDATEX TWO - STAGE REFINISH FORMULA.
4*
0.3 *1*
4*
3.5 *1*
4*
PAGE 2
08/27/10