Claim K-Mart Corp.
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SearslKmart Incklent Center
Sedgwick Claims Management Services, Inc.
P.O. Box 95407, Hoffman Estates, IL 60195-0407
Phone: (866) 352-1521
Fax: (866) 876-7050
October 26, 2006
City Hall
50 West 13fu Street
Dubuque lA, 5200 I
Attention: City Clerk's Office
Re:
Our Claim Number:
Your Claim Number:
Date of Loss:
Store Location:
20061001536
Type of Loss:
9/27/06
Kmart 40 18
2600 Dodge Street Plaza 20_, Dubuque, IA 52003
Vehicle damage to property
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Dear City Clerk:
This shall notilY you that Sedgwick Claims Management Services is the Third Party Administrator for
-.;Kmart Corporation, appointed to handle all its subrogation matters_
As you are aware, on the above caption date ofloss, a city bus operated by your employee Eugene Pfab struck a
cement fire hydrant protect in front of the Kmart store_ The store was able to make repairs itself for $49_00_
As a result of this impact, there was $49_00 invoice for repair of the cement protectoL Please, note that the check
needs to be made out to Kmart Comoration and forwarded to the attention of:
Sears Holdings Corporation
Atrn: Dale Menendez E3-239A
3333 Beverly Road,
Hoffman Estates, IL 60179
Please make sure your check references the claim number 20061001536, store number 4018, and date of loss
9/27/06.
Included documentation in this recovery package is the following information:
1. The bill for repair work
2. Picture of the accident
3. Iowa Deparhnent of Transportation Officer's Report
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Michael Schirott
Property Specialist
SearslKmart Incident Center
PO Box 95407
Hoffman Estates, lL 60195
P: (847) 645-0953
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--- kmart
October 26, 2006
SearslKmart Incident Center
Sedgwick Claims Management Services, Inc.
P.O. Box 95407, Hoffman Estates, IL 60195-0407
Phone: (866) 352-1521
Fax: (866) 876-7050
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Michael Schirott
Property Specialist
Sears/Krnart Incident Center
PO Box 95407
Hoffinan Estates, IL 60 I 95
P: (847) 645-0953
F: 866-876-7050
mschirott@sedgwickcms.com
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. 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 Claimant: K lIA lUr.--t C..., ?"'" :t~
2. Address: Q. ~ ~ ~":~. S~+ ?L.u.;;(O '1'l"l"f~) ::r~3
3. Telephone Number: S 9~ ~ ~ - ;::) ':\ b I
4. Date of Incident: ~ /2.. 1 / 0 (.,
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5. Time of Incident: I ' I S"' t. M. .
6. Location of Incident (Be specific): -:c:.. -\1.. c.. - -\. i ~ <:;,~.
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.)
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8. What were weather conditions like? r l.o... AI\./
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9. Give name and address of any witnesses:
10.
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I po Ice m~stlgate . so, give names 0 0 Icers. ,
a'" -l-.W',,"- D'r.A-~-t~A'" r~'
Was anyone injured? (If so, give names, addresses, and extent of injuries).
11.
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12. Was any damage done to property? (If so, describe property and the extent of dalT)ages.
Attach estimates of damages or describe basis for ascertaining extent of damage.)
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13. What other damages do you claim, if any?
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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.)
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15. What amount do you claim from the City of Dubuque?
,I ~\. 00
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16. Why do you claim the City of Dubuque is responsible? Ik ~u" ~'..A f" - J-{---
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17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.)
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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
daYO~QJJ~Q~
(Signature)
J1 cc-L ~~\ <;; <c L, "-0++
(Print Name)
(Rev. 1/00 & 7/01)
KMART CUSTOMER INCIDENIJ~HQIOGRAPH
RETENTION ~LW"~
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Full Name of Custa~e~ Di~h\i-cU. G 4.) e C(,O
Store Number L/ C I So
Date of Incident (I /"A '6/ t u
Photo 1
Full Name of person taking photographs:
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Date and time photo taken: q 1;)7\! DiE I ,e;-
BrieRy describe what photo illustrates:
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If phota of Product: I+-
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Manufacturer: \
UPC:
Price:
Photo 2
Full Name of person toking photographs:
(YILLe C. [ ,-tJU
Date and time ph~to taken: (//&81 C (f, r . I )
Briefly describe what photo illustrates:
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Securely staple or tope photograph here
If photo of Product:/!
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Manufacturer: i!-
UPC:
Price:
(USE ADDITIONAL SHEETS IF MORE THAN 2 PHOTOS FOR THIS INCIDENT)
Mail original to: Kmart Customer Incident Center
P O. Box 5058, Tray, MI 48007-5058
Photo capy far stare file
--SEE BACK FOR PHOTOGRAPH INSTRUCTIONS--
7)0944699-115 25/pk rev 7/03
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PHOTOGRAPH THE SCENE
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.;c/.l(li1te ~nough photos of the scene ?f the incident to illustrate wha~ occurred,
'0' ''1ncludlng photos of any hazard, fixture, product or other oblect Involved.
.
Up close photo(s) of the accident scene, as well as photo(s) from enough distance
away to show what the customer would have seen as he! she approached the
incident scene, are required.
.
Do not photograph the customer since it may embarrass the customer.
.
Affix the photos to the front side of the Kmart Customer Incident Photograph Retention
Form and complete the requested information on this sheet.
The number of photographs taken must be logged on the Customer Accident log
(5000 Series), See loss Prevention Manual for this procedure.
.
INJURIES CAUSED BY PRODUCTS
· For injuries or property damage caused by products sold or on disflay, record
on the Customer Incident Investigation form what happened as wel as the UPC
code, Kmart item number, selling price and manufacturer's name,
.
Take photos of the product which include a full view of entire product then one close
up photo of identitication numbers or markings on the product.
· Affix the photos to the Kmart Customer Incident Photograph Retention Sheet (front
side) and fill out the requested information,
· Tag the product as "evidence" with a yellow Public liability Evidence Sticker and
retain product in the loss Prevention office or other designated secure area at the
store.
.
Evidence must be loil9ed on the Customer Accident log (5000 Series), See loss
Prevention Manual tor this procedure,
Products involved in customer injury: or property damaged claims are evidence and
MUST be retained by the store tor four years,
.
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MARRA 11VE
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CITY OF DUBuQUE lllJS WAS EASTBOU.\ID IN THE K MART LOT IN FRONY OF THE STORI! WiEM IT STRUCK A CEMENT
POLE PROTEcmNG A ""RE H'IDRAHT. PRIVATE LOT . NO CIlARGl;S FILeD. P~GER USTED ~ED OF
SOPl!lI(J\fEes AND ANKLES. wnNESS ZAcIf FlNeeJ..WAS ALSo ON THE BUS.
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553 582 0937 TO 12484535559
P.01/02
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Dear Kmart Customer,
We want you to have a positive experience every time you visit 'our store, If you have experienced an incident or
loss of any kind while visiting us, please provide the irtformatio,.. requested below. This information will help us
meet our goal of continuous improvement in the operation of our store, It will also help us in contacting you to
make sure we are providing the service you expect,
Please take the customer copy of this document for your records;- If after leaving the store you wish to provide further
information or have any questions about your incident, please call the Kmart Customer Incident Center at
1-248-463-7577.
We are sorry you had an unpleasant experience while our gueat, We look forward to serving you in the future,
Sincerely,
Your Kmart Store Management
TO BE COMPLETED BY CUSTOMER:
(PRESS HARD WHEN WRITING)
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Customflr's Name: ' . 'Tlf..; I (-'~' {.I ~ """"""
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Customer's Mailing Addl"f:!!I!i: _~ '-.':_' I I' '. I City:
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Customer's Street Address:
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Heme Phone; -.) \i ::1
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Ntemale Phone:
Customer's Employer:
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Custorner'lI Otnlpat.ion;v-
Customer's Date of Birth:
U injury to a child: Child'. Nome: // Ii
Customer's; SQx:
Cllst.orner'R Socjal Security Number:
Chilfl's Date of Birth: .
Parent's Name, Address, Phone Number;
Customer's Description of Incident:
DIlIt.e ofin(:id~t:
Loeation Qf incid"nt:
TimElo(incirlf>nt:
What happened?
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Do you wi~h to be contacted?
Date reported;
Signature of Customer:
137)0944499,115 25/pk ,,,,7/03
Cu.lomer Copy
09/29/2006 4:27PM (GMT-05:00)
~~~ ~~ ~~~b 17:16 FR K MRRT ~4018
563 582 0937 TO 12484636559
P.02/02
K Kmart Customer Incident Information
4018 ~~marR
2600 DODGE S ~~t~T
DUBUQUE, !A 5LUC~
~ ~)(& ~f'< #- YOI' y
TO BE COMPLETED BY LOSS PREVENTION MANAGER OR MANAGER IN CIlARGE:
N9.... bf e~"~'\,"r: {;bIltltte6 ~ &~ Date ot Incident: 9.;t 'J -(){, Time ot Incidenf: /, /J=-
Location ot lneident: (exampl.s; Sporting Good.. Re.taurant, Parking Lot, Garden Center, etc.) Q,.". L~ Lo i-
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atureo I)VGryor 8.mAf:eo served: ~'. ~ l~ "-'81C-\"(D:(11 ro~ ~I cr ~Ll:,..(.CJ(..'lO
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PartofbodYinVOlved:_~/#NC' hd_il'1 injl..\.....;e~ w<':~e (~.-..\...-~ ,_
Store'. description of incident. (what, where, when, how, why) tv/ell.I Ifl'lunr,,' I..tOAl ~<<d t-t/..!/ - "! '? t4-
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Store Stamp
Kmart associate first aware 01 incident;
t'ull Name: ,-S2A'~ 14" flfO rr~ ."
Kmart Assoc:iates who saw incident or arrived .o~tly after:
l'ullName: ,/1///1
Full Name; /f/ / /l-
Clock Number: ~ Home Phone; 536 CS'l,- ;;;109;),_
Clo<:k Number: Horn. Phone;
Non..associateg: who ~ incident or Arrived shortly alter;
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Full Name. .
Clock Number; _'_ Home Phone:
Home Phone:
Addre....,
Altemat~ Phone;
Full Name;
Home Phone:
Address;
AJtenl8te Phone~
/37)0944699-'15 25/~ ~y7/03
09/29/2006 4:27PM (GMT-05:00)
~c~ ~~ 2006 17:17 FR K MART ~4018
563 582 0937 TO 12484636559
P.01/01
. Km~rt \..5liociate who inspected scene alter incident:
~'cbd 6--' We>,V'
I"ull Name:
Cloek Numbe.: .s""V<:>~
Home Phone: 5dP3-513 -04-07
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For fall down incidents!
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1. Have aU witnesses (astH>ciate or non-assodate) fill out witness statement. see attached fonn.
2. Take photos of the scene of the incident.
3. if there was an unU:Jual condition at the scene ofthe incident:
a. Describe the condition inc:1uding, if applicable, si7::e, shapQ. color and location~
b. Was any store associate aware of the condition before the incident? YeR or No: ~ Ifso, who was aware and
when did helshe beeorne aWare:
c, Who w& the last associate in the Area. of the incident befol"'e the incident occurred and how many minutes was it before the
incident o<:curred?
d. What was the caUlS'! of the condition?
e. When was the condition created? _
r. Who corrected the l:ondition, if applicable?
g. Was th.e area guarded by an associate, wl!lmin~ sirn or object prior to the incident? If so, please desl.TIbe:
4. What was the type and general condition of the customer's footwear?
1. Have all witnesses (associate or non.a.,'Clociate) fill out witness statement _ see attached form.
2, Describe the merchandise that is said to have faUen, including make, model, type of packaging, size of container and weight:
YA-
For incidents involving falling merchandi$el
3. Take a photogr-aph of the merchandi.ge, fi:l!:ture involved. and the incident scene and attach to the Kmart Photograph Sheet.
4. What is the name of the associate last in the area before the ioc:idr.-nt occurred, and how many minutes was that before the
incident? _
For incidents involving products: #1
1. Describe the product including type, brand name and vendor name;
2. Fill in the UPC Code:
and Kmart Item *:
and Selling Prico'
:::1 Photograph the product and attach a copy of the register receipt.
4. Tag the merchandise as evidence using the yellow evidence sticker and retain in Loss Control Office for the Claims
Omee.
Date incident reponed to clain>s om.... 888-&73-44$7, 9-<Rf-tl,t- Time of telephone repo.-t: '/.'00
CaUed in by, JuYlQ..!k. J1J/orL , Claim number assigned:
A:S~'HOOMo~~NWIlb<<'Clo(kNr" .#"
Written report completed by: ~~ r.~ S-cPlJ.... Y63 - S'%:?-?J8""O<;
^.wd..14' N&l'M, H6rM Pholll.' NuiDbeT. CIOl;;k Nl.Imw.,
Signature of Store Manager who revi~d the report.
09/29/2006 4:28PM
.
Iowa Office of Public Transit
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Dubuque
City of Dubuque, Keyline Transit
Contact: Jon Rodocker
Address:
2400 Central Avenue
Dubuque, IA
52001
Telephone: 563-589-4196
Fax: 563-589-4340
Email: irodocke@cityofdubuque.org
Web Site: www.cityofdubuque.org/index.dm?pageid=41#190_190
Routes &. Schedule Number: 563-589-4196
Service Type: Fixed Route, Demand-Response, Subscription
Service Area: City: Dubuque and East Dubuque, IL
Organizational Structure: Keyline Is administered by a transit manager that reports to the city admini:
Poiicy direction is provided by the city council acting on the advice of the Dubuque Transit Trustee Board
Special Features/Highlights: Route coverage is within 1/4 mile of 90 percent of the population of Dul
Demand response service is contracted to the City of East Dubuque, Illinois.
Days/Hours of Operation: Route: Monday-Friday, 6 a.m. to 6 p.m.; Saturday, 8 a.m. to 6 p.m.
Fares structure: 65 & over, Disabled, 50~; Students, age 5-17, 50~ Adults, age 18-64, $1; Mini Bus $1.
[J Agency Characteristics
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http://www.testtransit.dot.state.ia.us/services/agency -profile.asp'!intAgency ID=2 I 0
10/18/2006
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Mail original to: Kmart Customer Incident Center
P. O. Box 5058, Troy, MI 48007-5058
Photo copy for store file
--SEE BACK FOR PHOTOGRAPH INSTRUCTIONS--
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