Claim Ruff, Rose & American Fam
~-
AMERICAN FAMILY
_...............-... '--=-",
AMERICAN FAMILY INSURANCE GROUP
5)00 WESTOW:-J I'KV'iY STI-: IHO . PO BUX (,.~(,J() . WEST UES MOINES].I\ 502h)-(j630 . PHONE' 15l5) 223-] 14<;
January 27, 2005
JEANNE SCHNEIDER, CITY CLERK
CITY HALL - CITY CLERK'S OFFICE
50 WEST 13TH ST
DUBUQUE IA 52001
RE: Our Claim Number:
Our Policy Number:
Our Insured:
Date of Loss:
Your Employee:
00-271-442958-0322
14-242620-11
Rose Ruff
November 24, 2004
Garry Clauer
Dear Ms. Schneider:
We are the automobile insurance company for Rose Ruff. We are writing you regarding an accident
that occurred on November 24, 2004.
To follow up our letter of December 14, 2004, and in reply to your letter of December 20,2004, please
find enclosed our supporting documents for the damage to our insured's vehicle. We also include the
documentation you have requested. Please note our total subrogation claim is $1700.00, including a
$200.00 deductible. Please forward your payment at this time.
Thank you for your cooperation.
Sincerely,
~tZ/
Robert W. Holley, AIC
Casualty Claims Examiner
American Family Mutual Insurance Company
Phone: 515-224-1555 Ex\. 60158
800-374-1111
E-mail: rholley@amfam.com
Fax: 515-224-9841
,
Ene.
'r;
J
'I
(,;
Barry A. Lindahl, Esq.
\=orporation Counsel
Suite 330, Harbor View Place
300 Main Street
Dubuque, Iowa 52001-6944
(563) 583-4113 office
(563) 583-1040 fax
balesq@cityofdubuque.org
TD{;B~E
~ck~
December 20, 2004
Robert W. Holley, AIC
Casualty Claims Examiner
American Family Mutual Insurance Company
5500 Westown Pkwy,Ste. 180
PO Box 65630
West Des Moines, IA 50265-0630
RE: Claim Against the City of Dubuque on behalf of Rose Ruff
Dear Mr. Holley:
If you wish to file a claim against the City of Dubuque on behalf of your insured, Rose
Ruff, we would request that you fill out the enclosed claim form and mail it to the City
Clerk's Office at the following address:
. Ms. Jeanne Schneider, City Clerk
City Hall - City Clerk's Office
th
50 West 13 Street
Dubuque, IA 52001
Once the claim has been stamped in by the City Clerk, it will be forwarded to the Legal
Department for investigation. Enclosed is an addressed envelope for your convenience.
Very sincerely,
~~
Tracey Stecklein
Legal Department
Enclosure
cc: Jeanne Schneider, City Clerk
Service
Peorl~
Integrity
Responsibility
Innovation
Teamwork
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 flied 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 Clalmant:&S;~'L-r+
2. Address: '3 1(0 vt< (I A A~ fl'\.Cf n n rl u Q-
3. Telephone Number: S ((j ~ S~4 0'1 GS
{! IdCj /05
5. Time of Incident: '1 ' / S f}/f/
6. Location of Incident (Be specific): h'1ln-h>,c,u*rOI\ r* -If 1<1 In a,vul
+hw. 300 1 [6tK. o+- J.\'t1 utvrldl1Y\ 4U'{' (tin -k'CVU+vrccLflV'\
4. Date of Incident:
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
mployee's name.
e 'rIcK (" -to e if)
tDn-\- 0 -t VY\9.111\ ,",1M -\. lac,) ~+ -\'1 0.-\.\ \ L 0 \1\ 1((1).,.~V)\(lnh A v f. t1 'lnC1.,.rkLt /l
-t(J m11 IctCj S b \(\~mo~ Iv ) Jrt V" (), 5' /\ j YV'--Ll~'(Clfl+ E' nfl.
8. What were weather conditions like? (1 j<ea r "f d. ry
9. Give name and address of any witnesses:_f::. II'" il"V'\ {;I ~~
31 G ~CUl-\'maJ1YI /h:<
C1Jll.lfJ'i' 1A
52--CO I
10. Did police investl~te? (If so, ~ive names of officers.)
trS J' () s.;.,c..Q ( ,,0 V'\ ,) ~~'\\( 'I f'-f
~
11. Was anyone injured? (If so, give name$, addresses, and extent of injuries).
VI r,
,
.., ? /_#'5/ 7 C} <;'" y" Z ;'.:J ____________
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.)
() -+ \'r\ -t( "I I),
(n~ lIY\(jo ( S (() (\ +- \>CA.V\ ~ l lJJQJQ..
d(uW1~f \Ua/j $1 ~ 02.2 S
13. What other damages do you claim, If any?
company?
14. Have you been compensated for any part or all of your claim by any insurance
(If so, give name and address of insurance company and amount paid.)
A IfYJJ((1 ( 0 VI f CAVYli 1\ j l~~f1 ~ \ \lei ~I( (' G V 0 IAf
'-\'~ (l 1/)\ (" -"-VI+- () -\' ;ft, l ~ b o. ~
4<l?~
s:;: D ,
15. What amount do you claim from the City of Dubuque? <'V\ lA Jl; .:2 0 CJ ' C (,
,
r'\ ", rtucct G.- U~
16. Why do you claim the City of DUbuqUe'is responsible? --\~ ~l-t1 d n V ~ (
C.,c., (~i rrdM'K ~ \o.Uf( QC\uSfc\ ~ damO<-~l hi hOcckl/lji;{-to
yY\{?~ (l V\A \JJa S ~;\-'Iec~ C'A +1 (. b\ -+()( , \r(\~( oV\> r \j ({ c k I '''j
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.)
\1\ 0
18. If the answer to Question 17 is yes, have you received any payment from that source,
and if so, in what amount?
Dated at Dubuque, Iowa this S vL. day of j "'-1\."'- c.'- (' (..1 ' , 20-a...s;.
~a~4
(Signature)
:Rose f\ ~ \.'r\~ '
(Print Name)
LE :[,
qZ :[) vU J30 h.UUZ
S\'~;~ll): ':' "',,:";13,l(,1'
(Rev. 1/00 & 7/01)
Form 433003
01.()1
J.) I..:,t:.._
,tlO" ~"Iowa Department Of Tral iOrtatlon
..~ INVESTIGATING OFFICER'S REPORT
OF MOTOR VEHICLE ACCIDENT
MAIL REPORTS TO:
Iowa [)ep.wtment of Trans..
Office of Dfiver Serwices
Part Fair Mall. 100 Eudid Avenue
P.O. Btlx 9204 .
Des Moines, Iowa 50306-9204
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Accident occurred within
COfPorate limlts of (city)
NNEESSswWt-NtI
miles 0 00 0 0 0 0 0 ofneareslcity
On Road, Street, N Inteneetion
or Highway: with:
Not.~ Un\u$ accident occurred at an ir.lar&.Qc.lion which is completely described above. use the space below 10 gi...e lI1e exact Iocat'on from a milepost
or det'nable intersection. bridge. or railroad crossing, using two dlslaflces and directions if neC8S$lIry.
Feet
Miles
Feet
Miles
N NE E SE S SW W NIN
0000000001
NNEESESSWWNW
00000000
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Or Oeflnablelnlerseclion.
bridge,orreilroadcrossirtg
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PlUJ.e~)(.k..
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CitatiClll
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Sheet
Law Ellforcemer1t Case Numbers:
leaal
Intervention? 0
Private
Property?
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Counly:_Rot..te:_
X.Coordin~le:
Y-Coordir'l<lle
If Divided Highway. PrClvide Route
(CardJnall Trav&1 Di,ecllor'l
NB SB EB VIIB
o 0 0 0
State
-0
Z'p
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None 3. Unne 5. Vitreous Test Results;
Blood 4 Breath g, ReluSEld
Drug I 1 NOlle 3, lJfine
Test GIVen? W 2. Blood g, Refused
Pos Neg
o 0
Commercial Trailer AHached II)
License f'L1Ita # Powsr Unit
carrier
N.,....
US DOT# or MC#
o 0
Stale
City
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Drivets Na)'jejY-311t. Flrs..Yjiddle)
f(...++ Mo ~
Dille ot Birth Drlvets Lic8flS& Number
City
Cilation
Charge
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3
0"2
2
4
M..
o
1. None 3, Urine 5. Vitreous Test Results:
2, Bbod 4. 6reatfl 9. Refusecl
Drug 1. None 3. Urine
Tes: Giv~? l1J 2. Blood 9. Refused
City State
Zip
U
N
I
T
2
Commercial Trailer AHached to
Lcense Plate # Power Unit.:
Carrier
p.;ame
City
uS DOT'li or ....C#
o 0
Placard II
If Propertyot1l{<rlnan
vehide5 dam3l;ea eJCpain
Ow<wr'$ I"ull """me
(LaR First, Middle)
SlreetOf
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ACCIDEoNT Er.'/IRONMENl
ObJ9ct
Ollmaged
u
~ . Ye.. 9. Unknown
2-No
City,Slate.
&. Zip Code
ROADWAY CHARACTERISTICS
Major Contrlbulirlg DJ'CUmst"nUlS
WORK ZC~.E RELATED?
o Yffi l!(N~
ULO'.-i1tion
U 1,....-..4
U WO"'lef'ii Present?
Locaticn of Fir;t Ham-iul EVllnl lLJ
Marvlef of C...m/Coliis<on ~
light Cor\ditio....... W
10131
L.LJ
W
Weall1erCClnditions
(uptCI twv)
Environment
W
IWJ
RO;;Idway
Type: of Roadway Junct.ionlFeatlJfe ~
Suriaca Conditions
Offlce(s Name
J t" J, tk..kl~
Badge No.
~~
Stale
Emergency 3
s_ ~
Zip
HI%atdolsMa.lafiuISU
I.U Re~~sed?
z,p
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Pos, Nag
o
T~'
Year
AWroximaleCostlo
Rltp8irOfReplace
Pri..,ate'?
o
$
Err.erger.cy I ~
Status. ~
Stale
Zio
1 -u ~:~a;:;~ Matenals U
Unit 1
SEQUEt-:ce OFEVENT
UJ)it2
~ lQtLLJ First E...ent
L...l..J LLl Secona Event
LU U-J Tnifd Evenl
L1..J LLJ Fourth Event
------------------------
b1J..1J i.2W
IsWJ
Most Harmful EVlln:
(byvehidll)
tirsl Harmful Event of Cr.ll.h
(u!ecodes 11-42or.;y)
'--",
V\i
NON-MOTORIST
Type LJ
Motorcycle ~ osition
01-MotoreyCIe": ,...er
04.fJolorcyCle Passenger
88. Other (eXplain In narrative)
.'
SEATING POSITION 10 - Sieeper Seelion
11-EnclosedCargoNea ~ .
12. Unenclosed Cargo Area . i
. . ~
13."Traillng Unl1 i E
., .2 00 14.Exterior '" r I ;;
l .
15-Plildeslr'ian i ~ It
.. . !
... .5 06 16.Pedalcyclist .; 2- . . ~
17 - Pedalcycllst. p.assenger z f .. g l Jl ~
@ € u .~ ~
8a. Other (e~plail1ln nlnlllr.e) . .. ~ m- .
07 O. o. gg - Unknown :l ~ ~ c or ~
.''''''':j~ -~:>i.~ Sdl to 3 I 1/ I
Transported to: Transported by'
locallon U
CondWof'l U
Safely Equipmenl U
ContribUlln~ CI~cumstal"lCesLU
Action U
Unit NQ. or \lehicl& Striking
0 ;X )('x
R ?'x
I ;X
V
E ~ ;X
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S V"
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E Address
R
S ~.me
0 2
N Address
S
I ~a.me
N 3.
J Address
U
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0 Address
LJ
l' DRlVE~~F UNIT 1 2<
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,
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)( DRIVER OF UNIT 2
X xvV\?'
TrarlfJported to "Transported by
Date of Birth
DIAGRAM WHAT HAPPENED: I(l!Jtror;tion
Number each vehicle and ,how dlretliOl1 of travel byarr-ow,:
Trilfl8ported to: Tran15ported by:
Date of8irth .: ,I
Transponed 10: Transpated by:
Date ofBlnh .
Transportlld 10' Transported by:
Dale of Birth .
.
Trar.&pOr1ed to: Transpor1i!ld by:
INDICATE 9
NORTH
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Use s"ofid line 10 show path before OII;cident.:
-CJ>
Dotted line to show peth aflet accident.:
- --c:J>
Show peClestnsr'I by.:---O
ShQw rallrcad by.: +tttt+
Show utility poles by.: <P
Show motorcycla by' -e-e-
ShOW Sl'limal by.: A
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Name(Last,Flrsl)
Phone
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Crt,
Slate
Zip
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~:='dOY i.JI ,,;- ~-...... (;}.. - l--t"'-
I Time Otficer:o~ed ot Accident
I 1\. H~
JnvesUgallon Supplemental ITI. #
maCe v N Information Y N
81 scene? ~ 0 Will Follow? 0 &t
R.epor1 Giverl a I Other Technical
to All Drivers' Y IlnvesSgalrng
o AnerC'"
S~natur.e
of Qtfic.er
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Time OfflCf!f" ArtNi!d At Scene
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AMERICAN FAMILY
_..............-... '--=-31
AM ER I c::_i\._~__F A M...!.L 'i:'...! r-;r~U .8~j'.J' CE QI<_QU P__
5500 WESTOWN PKWY STE 180 . PO BOX 65630 . WEST DES MOINES IA 50::!.65-0630 . PHONE: (515) 223-1145
December 14, 2004
CITY OF DUBUQUE
50 W 13TH ST
DUBUQUE IA 52001
Our Insured:
Our Claim:
Our Policy Number:
Your Employee:
Date of Loss:
Amount of Our Payment:
Insured Deductible Payment:
Total Amount of Loss:
Rose Ruff
00-271-442958-0322
14-242620-11
Garry Clauer
November 24, 2004
PENDING
$200.00
PENDING
Dear Sirs:
We are the automobile insurance company for Rose Ruff. We are writing concerning the accident that
occurred on November 24, 2004, involving your employee, Garry Clauer.
With regard to the above accident, we are putting you on notice of our subrogation claim. Our
investigation reveals that the negligence of Garry Clauer was the cause of this accident due to his
improper lookout and inattention while backing.
Our supporting documents will follow. We ask that you notify the automobile liability insurance carrier
for the city of Dubuque and have them contact us directly.
We look forward to concluding this matter soon. Thank you for your attention to this matter.
Sincerely,
Robert W. Holley, AIC
Casualty Claims Examiner
American Family Mutual Insurance Company
Phone: 515-224-1555 Ex!. 60158
800-374-1111
rholley@amfam.com
515-224-9841
E-mail:
Fax:
rwh
cc: Charlie Miller #158722
AMERICAN FAMILY INSURA~C GROUP - MADISON, WISCONSIN
NORTHWEST REGIONAL OFFICE . MINNEAPOLIS. MINNESOTA
_;PAYABL~THROUGH U,S. BANK NA OCIATION. WAUSAU. WISCONSIN
1__ L.-' I.
/\ I..~ {' ::,.'_ I. G 1- {"
I,c
AMOUNT
L! Ji (
IN PAYMENT OF
-+ I, , '.
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)
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POLICY
NO. 'L
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INSURED
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79-1160
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OFFICECOOE
DAAFTNUMBER
E
01377
2 7
/"...~ /- 1--
DOlLARS
5c'--c~-
~~0EED / ;!- //7 0 L;
. VOID AFTER 1 YEAR.
,~- ----
~'i'Wi~@(Q)Jr.OM~~
~
TYPE OF DRAFT (CHECK ONE) CODING IF PAYMENT INVOLVES NO SPLITTING CODING IF SPLIT PAYMENT CODING IF SPLIT PAYMENT
lOSS PAYMENTS
CLAIMANT 01 []/ COV. OR COV. OR COV.OR
0 1.0. NO. PERil CODE AMOUNT 1.0. NO. PERil CODE AMOUNT LO, NO. PERIL CODE AMOUNT
SALVAGE 06
SUBROGATION 07 0 ~ 02,(,- $ i ) (.k: UJ $ $
EXPENSE PAYMENTS
LEGAL 03 0 D ENTER CLAIMANT INFORMATION to NO. TAX IDENTIFICATION TIN DATE ENTERED
, ON CRT
MEDICAL 04 0 o NEW CLAIMANT NO. T " TYPE
OTHER 05 0 .<;~l { 1{p?{O~
NAME NAME ".:.0' )<~:. '~;:\:""I " .-
EXPENSE PAYEE '.:~, :Cj:;CCH...1 . ~ " . ,~~; ....
C\_,...... ;1....
CODE STREET ADDRESS STREET ADDRESS~~ ": OPERATOR
CODE/INITIALS
REASON CODE CITY/STATE/ZIP
C1TY/STATElZIP ~ ~!>-r~
(See Cover For Codes) PHONE NUMBER ( )
C-35 <o.kOQRe', '1J{J~
SIOCk~~
CRT Operator must enter draft number when entering field drafts.
TOTAL LOSS
CLAIM #z, ? II{ L{ 2. 'l. ~;?
W 0 R K SHE 'E T OATEA$$IGNEO,illd.
OWNER'S NAME -!-..5 ~~ k '*
(
~Nrn~~~~~rn~~~~B~~~
The 10th digit indicates model year on 1990 & newer vehicles: ~ c::J
L=90 M=91 N=92 P=93 R=94 S=95 7=96 V=97 W=98 X=99 Y=OO 1=01 2=02 3=03 4=04 5=05 6=06 = =
MAKE I ~l,q(1 MODELIc.e...f(<;(/, I YEARITJ G Iill[] EDITIONIc..( e"'<i>~~ ~
o 2 DR 03 DR R4 DR 0 WAG Lie, # POW E R ~ ~
SIZE CY. 1 2 3 4 5 6 8 10 12 DIESEL TURBO SUP CHG OEM AiM c::J c::J
ENGINE I I DO 0 D~ 0 0 0 0 0 0 ~= POWER STEERING ==
TRANS. 0 AUTO l!rAUTOIOO 05 SP 04 SP 03 SP OTHER I$2l = POWER BRAKES = =
I "7 I AIRBAGS c::J c::J ASS BRAKES c::J t::J
MILEAGE t '70 I'i' DRIVERS 0 PASS D SIDE 0 ~ = POWERWINOOWS = =
~ c::J POWER MIRRORS c::J c::J
PICKUP I UTILITY I VAN q:J = POWER LOCKS = =
o 1/2 TON 0 3/4 TON 0 1 TON 0 4WD c::J c::J POWER ANTENNA ~ ~
D SHORTBED NoD A'S & CHASSIS c::J c::J PWR DRIVE SEAT c::J c::J
c::J c::J PWR PASS SEAT
o FLEETS1DE NDER 0 EXT. CAB c::J c::J PWR SLIDING DOOR OrtiER
o CARGO 0 PA SENGER CONVERSION c::J c::J POWER TRUNK
TYPE OTHER
TIRES: I ] BW)..J WW [ ] OTHER_ BRAND
TREAD: IF ~f32 RF ~2 lR-A::132 RR $; 132
VERIFIED DEALERlPRIVAT
DEALE
PHONE #
STOCK #
ASKING $
TAKE $
NAME
SUPERB
DEALER
PRIVATE
FAIR
TOTAL
DO NOT
USE
RATINGS
ON BASIC
TRANS, OR
CURRENT
MODEL
YEAR
I
I
,
J
\~":..-' ..
ROOF
OEM AiM
==
==
==
==
==
==
OTHER
VINYL ROOF
MANUAL SUNROOF
ELECTRIC SUNROOF
T-TOPS
ROOF RACK
CONVERTIBLE
VERIFIED DEALER/PRIVATE
DEALER
PHONE
STOCK #
ASKING $
TAKE $
NAME
Add'l Options
t.-.-Lti +~
Establishes Ad'usted NADA Value
EXTERIOR TIRE INTERIOR MECHANICAL
35 (See reverse 30 35
34 side for 29 34
33 SUPERB 28 33
~ explanation) ~~ ~~
30 15 25 30
@) ~
29 14
~ ~
26 11
25 10
I52l + [ill +
BASIC TRANSPORT
AGREED ACV
+
"
"
20
~+
"
'" BOOK NADA
25 RATING RETAIL
~=~X2-'tIO
Repal' Option
NADA:
= ADJUSTED NADA
OEM AiM
OEM AIM
AIR CONDITIONING c::l
DUALAIRCONOITIONINGD
TILT WHEEL C:J
TELESCOPIC WHEEL CJ
CRUISE CONTROL c:J
REAR DEFROST c:J c::J
REAR WIPER CJc:::J
FOG LIGHTS c::J c:::J
lEATHER SEATS c::::JCJ
3RO SEAT (WAGONS) c:::J c:J
B PASSENGER CJ C:J
POWER ANTENNA c::J c::J
4 Wl1L DISC 8RKS c::J
ALARM SYSTEM c::J
TWO TONE PAINT c::J
DEEP TINTED GLASS c:J
=
==
OTHER
RADIO
OEM AIM
==
==
~=
==
==
==
==
OTHER
CYCLE
NONE
AM/FM
AMiFMTAPE
EQUALIZER/AMP
CD PLAYER
ADDITIONAL SPEAKERS
CD CHANGER
WHEELS
OEM AIM
==
==
==
==
OTHER
ALUMINUM
STYLED STEEL
WIRE
WIRE COVERS
IIN RENTAL: YES 0 NO~
Is current title a salvage title? Yes 0 No
ACV Calculations
$
$
Repair Estimate: (minus Tax if Appl.) $
+ Hidden Damage: $
+ Rental: $
- Tow/Storage: $
-Deductible: $
Net Cost 10 Repair Vehicle: $
Net Cost to Replace Vehicle: $
"1
k. iQMATED: Autosource, Autobid, etc, $
D:..2ier AverageNerified Take: $
C- -:ER SOURCE: Newspaper, Internet, private, elc.
RETAIL VALUE: S
O..J DAMAGE: (. major dmg. elc.) $
F,~..andilioning:(-) (notuSedwithrating%) $
Mscellaneous:(+/-) $
(!) OO.UJ
PAYMENT INFORMATION
AC'I: $
$
Lr;;nseTransfer:(+l
~esTax:(ifappl):(+}
TolaIPayrr.entDue:
S SO(!).O-E>
S ~ ,
S -
,rOt). t.P
s
$
TOTAL:
PartiaIPa'fl1lentMade:
w
BALANCE DUE:
II
EA1.ER TA
RIVATE~
I ~-l~ I F AVERAGE ACV
ll'.l
~j""., '
G=::cuclible:(-}
DRAFT ISSUED: YES
TAX PO: 0 YES
NO
E!;jmatedSalvageVaJue
f\,~! Loss:
AmE~;can Family Insurance Group
C-15448 Rev. 9/02
Page 2 of 6 - Robert Holley
Journal Entries
Date: 12/14/2004 7:32:30 AM IUser: DESCR 110: GENERIC CASUALTY
Comments:
EMAILED REPORT TO FILE MANAGER
Date: 12/13/2004 5:52:00 PM IUser: TFROMMEL 110: Frommelt, Tim M,
Comments:
SETTLED WITH OWNER SHE RETAINED SALVAGE AND I SENT DRAFT
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1/27/2005 - Robert Holley
Preliminary Valuation Report
AMERICAN FAMILY INSURANCE CO
Date: 12/13/2004
Claim: 00271442958-0
Policy: 1424262011
Customer: ROSE RUFF
Loss Date: 11/24/2004
Deductible: $200
Payer Code:
Valuation ID: 00271442958-0
Type of Loss: C
Classification: Total Loss
Assessor: TIMOTHY FROMMELT
Assessor ID: TFROMMEL
Profile: DEFAULT
State: IA
-------------------------------------------------------------------------------.
Vehicle:
VIN:
Mileage:
Condition:
1995 Oldsmobile Cutlass Ciera SL 4D Sed 3.1 L Inj 6 Cyl AO
1 G3AJ55M9S6424013 Type: Auto
79,018 License:
Color: WHITE
-------------------------------------------------------------------------------.
N.A.DA(C),
OLDER VEHICLE VALUES
AJ5 CUTLASS CIERA SL-V6 SED 4D
Base Value
Mileage Adjustment
NADA(C),
OLDER VEHICLE VALUES
AJ5 CUTLASS CIERA SL-V6 SED 4D
$2,750 Base Value $2,750
$160 Mileage Adjustment $160
Total Retail Value $2,910 Total Retail Value $2,910
Mitchell International Corporation warrants that this valuation is an accurate representation of the
N.A.D.A.(c) value guide.
-------------------------------------------------------------------------------.
Taxable Adjustments Total
Pre-Tax Subtotal
STATE TAX Tax 5.00%
$2,910.00
$0.00
AVERAGE BOOK VALUE (Taxable)
Taxable Adjustments
$2,910.00
$145.50
Post-Tax Subtotal
$3,055.50
Non-Taxable Adjustments
Deductible
<$200.00>
Non-Taxable Adjustments Total
<$200.00>
$2,855.50
NET TOTAL
-------------------------------------------------------------------------------.
Customer: ROSE RUFF
316 KAUFMANN AVE
DUBUQUE, IA 52001
Inspection Site: residence
316 KAUFMANN AVE
316 KAUFMANN AVE
DUBUQUE, IA
-------------------------------------------------------------------------------.
Impact Points:
Total Loss
-------------------------------------------------------------------------------.
Copyright (c) 1994-2004, Mitchell International. All Rights Reserved.
1
Appraisal Report
Valuation Report
AMERICAN FAMILY INSURANCE CO
Date: 12/13/2004
Claim: 00271442958-0
Policy: 1424262011
Customer: ROSE RUFF
Loss Date: 11/24/2004
Deductible-: $200
Payer Code:
Valuation 1D: 00271442958-0
Type of Loss: C
Classification: Total Loss
Assessor: TIMOTHY FROMMELT
Assessor 10: TFROMMEL
Profile: DEFAULT
State: IA
Vehicle:
VIN:
Mileage:
Condition:
1995 Oldsmobile Cutlass
IG3AJS5M9S6424013
79,018
Ciera 8L 40 Sed 3.1L
Type: Auto
License:
Color: WHITE
Inj 6 Cyl AD
N.A.D.A. (C),
OLDER VEHICLE VALUES
OLDER VEHICLE VALUES
AJ5 CUTLASS CIERA SL-V6
Base Value
Mileage Adjustment
N.A.D.A. (C) I
S~D 40
$2,750
$160
AJS CUTLASS CIERA
Base Value
Mileage Adjustment
SL-V6
SED 40
$2,750
$160
Total Retail Value
$2,910
Total Retail Value
$2,910
Mitchell International Corporation warrants that this valuation is an
accurate representation of the N.A.D.A. (cl value guide.
AVERAGE BOOK VALUE (Taxable)
$2,910.00
Taxable Adjustments
Taxable Adjustments Total
$0.00
Pre-Tax Subtotal
$2,910.00
STATE TAX Tax 5.00%
$145.50
Post-Tax Subtotal
Non-Taxable Adjustments
Deductible
Non-Taxable Adjustments Total
$3,055.50
<$200.00>
<$200.00>
NET TOTAL
$2,855.50
Custo~er: ROSE RUFF Inspection Site:
316 KAUFMANN AVE
DUBUQUE, IA 52001
residence
316 KAUFMANN AVE
316 KAUFMANN AVE
DUBUQUE, IA
Impact Points: Total Loss
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Images
Description: Image 1
Comments: Dec-13-200405:41p
'"";~ ','''''III
Description: Image 3
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Description: Image 4
Comments: Dec-13-200405:41p
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Description: Image 5
Comments: Dec-13-2004 05:41 p
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