Claim by Susan Farber, National Subrogration ServicesMasterpiece on the Mississippi
TRACEY STECKLEIN
PARALEGAL
M H;MORAN
To: Mayor Roy D. Buol and
Members of the City Council
DATE: November 19, 2013
DUM
RE: Claim Against the City of Dubuque by Susan Farber, Subrogated by
National Subrogation Services, LLC
Claimant Date of Claim Date of Loss Nature of Claim
Susan Farber 11/18/13 06/12/13 Property Damage
(Subrogated by
National Subrogation Services, LLC)
This is a claim in which claimant alleges that the water meter located at 2455 Spires
Court and owned by the City failed causing property damage.
This claim has been referred to Public Entity Risk Services of Iowa, the agent for the Iowa
Communities Assurance Pool.
cc: Michael C. Van Milligen, City Manager
Bob Green, Water Department Manager
National Subrogation Services, LLC
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
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:
2. Address: ICJ C; z ��9 f.� '� \� xd ZS 9 ) \<)`-‘' rl-)ci7
3. Telephone Number: (5I
4. Date of Incident: / VL I '..c \'
5. Time of Incident:
6. Location of Incident (Be specific): '1,5a
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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.)
8. What were weather conditions like?
9. Give name and address of any witnesses: TV \n,,w,���x,� 0,N" ,N0
10. Did police investigate? (If so, give names of officers.)
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.)
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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.)
15. What amount do you claim from the City of Dubuque?
16. Why do you claim the City of Dubuque is responsible?
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.)
18. If the answer to Question 17 is yes, have you received any payment from that source,
and if so, in what amount?
Dated
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this \ day of
National Subrogation Services, LLC
100 Crossways Park West
Suite 415
Woodbury, NY 11797
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(Signature)
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National Subrogation Services, LLC
100 Crossways Park West, Suite 415, Woodbury, NY 11797
Phone: 516- 949 -3620 • Toll free 877 - 983 -3600 • Fax: 516- 949 -3621
City of Dubuque
City Clerk at City Hall
50 W 13th St
Dubuque, IA 52001
November 15, 2013
CERTIFIED MAIL - RETURN RECEIPT REQUESTED
Regarding: Insured:
NSS Matter Number:
Date of Loss:
Loss Location:
Amount of Paid Claim:
Plus Deductible:
Total Claim:
Attn: City Clerk
Susan Farber
13049532
06/12/2013
2455 Spires Ct; Dubuque, IA
$24,230.65
$1,000.00
$25,230.65
Chubb has paid their insured, Susan Farber, for damages sustained in a loss on 06/12/2013.
National Subrogation Services, as recovery agent for Chubb, has investigated the facts and
determined the loss was caused by the failure of a water meter owned by the City of Dubuque
Water Department.
We are filing a claim against the City of Dubuque. The completed Claim Form is attached.
Sincerely,
Richard Steinhauer, Recovery Analyst
Direct dial: (516)688 -8974
Direct fax: (516)342 -3529
E -mail: rsteinhauer @nationalsubrogation.com
National Subrogation Services, L
100 Crossways Park West, Suite 415
Woodbury, NY 11797
RETURN SERV CE REQUESTED
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