Claim by Mary Heister_State Farm MutualTHE CITY OF
DUB
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TRACEY STECKLEIN
PARALEGAL
M IH MORANDUM
To: Mayor Roy D. Buol and
Members of the City Council
DATE: February 10, 2014
RE: Claim Against the City of Dubuque by Mary Heister, Subrogated by State
Farm Insurance Company
Claimant
Mary Heister
Date of Claim Date of Loss Nature of Claim
02/07/14 11/27/13 Vehicle Damage
This is a claim in which claimant alleges that a City of Dubuque Public Works driver
merged his dump truck into claimant's lane of traffic and struck claimant's vehicle.
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
Don Vogt, Public Works Director
Ryan Perno, State Farm Insurance
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, I01NA
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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 West 131" St., Dubuque, IA 52001. It will then be referred to
the appropriate department for investigation and to the City Attorneys Office. 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:. � � . ,� i♦�� �
2. Address:
3. Telephone Number: 9, ` -,
4. Date of Incident: 7[6-127-/5
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5, Time of Incident: f ?qv
6. Location of Incident (Be specific):
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7. Describe the 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? . `.d
9. Give name and address of any witnesses,,POLf
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 ather dmages do you claim if any?
14. Have you been compensated for any part or all of your claim by any insurance company? (If so gve name and
address of insurance company and amount paid.)
15. What amount do you claim from the City of Dubuque?
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16. Why do you claim the Cfty of Dubuque is responsible?
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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.)
18. f the answer to Questfon 17 is yes, have you received any payment from that source, and if so, in wha amount?
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Providing Insurance and Financial Services
Home Office, Bloomington, IL
StateFarm®
February 03, 2014
City Of Dubuque
City Clerk At City Hall
50 W 13th St
Dubuque IA 52001 -4845
Certified Mail - Return Receipt Requested
RE: Claim Number.
Our Insured:
Date of Loss:
Your Insured:
Your Insured Driver:
Loss Location:
To Whom It May Concern:
State Farm Claims
P.O. Box 2371
Bloomington IL 61702 -2371
13 -374K -973
Mary M Heister
November 27, 2013
City Of Dubuque
David Bakey
Dodge St. Hwy 20 & Wacker Dr., Dubuque, IA
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It is our understanding that you are self insured. Our investigation indicates you are responsible
for this claim. Therefore, we are seeking recovery from you. This letter is to notify you of our
subrogation claim and request your cooperation in settling this matter.
To assist you in your review, here is a breakdown of the amounts State Farm® paid by Cause of
Loss:
041/045- Uninsured Motorist BI $0
042 - Uninsured Motorist PD $0
300 series /400 - Comp /Collision $2,360.27
501 - Rental /Loss of Use $0
600 -050 - Med Pay /PIP $0
Other $0
Salvage Recovery $0
Amount State Farm Paid $2,360.27
Insured Deductible $250.00
Total Claim Amount $2,610.27
Based on the assessment of liability between the parties, State Farm Mutual Automobile
Insurance Company is seeking 100% of the Total Claim Amount listed above. The amount
payable to State Farm Mutual Automobile Insurance Company for this loss is $2,610.27.
Please remit payment of this claim and include our claim number on the payment. If you have
any questions or need additional information, please call me at the number listed below. If I am
not available, any other member of my team may assist you. Thank you for your cooperation.
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
information to effect, administer, or enforce a transaction authorized by the consumer. However,
13-374K-973
Page 2
February 03, 2014
you are neither authorized nor permitted to: (1) use the customer information we provided 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.
Sincerely,
tiiko iU)4
yan Perno
Claim Representative
(877) 457 -8276 Ext. 309 - 763 -9150
Fax: (866) 231 -9276
State Farm Mutual Automobile Insurance Company
Enclosure
Confidential
This communication and any attachments may contain information which is confidential
and privileged by law and is for the use of the designated recipient. If you are not the
intended recipient, you are hereby notified that you have received this communication in
error, and that any review, disclosure, dissemination, distribution or copying of its contents
is prohibited. Please notify City of Dubuque immediately by telephone at (563) - 589 -4120 of
your receipt of these items and destroy the communication and any attachments
immediately. Further disclosure of this information may violate state and federal
restrictions.
Confidential information may include the following:
1) Social Security Number(s)
2) Medical /Health Information
3) Personnel /Disciplinary Information
4) Bank Account Information
5) Financial lnformation
6) Credit Card Numbers
If any documentation you desire to submit to the City of Dubuque contains any of the items above,
this cover sheet must be attached directly to the confidential information. Please indicate below the
type of information that is included.
I, , hereby certify that the attached documents
include the following protected information:
Social Security Number(s) Bank Account Information
Medical /Health Information Financial Information
Personnel /Disciplinary Information Credit Card Number(s)
I understand that this information may be distributed within the City organization or to agents of the
City for processing and I hereby authorize the City to act accordingly taking all precautions to
protect my information from unnecessary distribution.
Signature Date
I have read the information above and do not have any confidential documentation to submit to the
City of Dubuque as part of this Claim Against the City.
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