Claim Matthew SmothersClaim Form Page 1 of 2
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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 West 13~h St., Dubuque, IA 52001. It will then be
referred to the appropriate department for investigation and to the City Attorney's 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: ~Q-`E-`~-"Vl eG+.J ~ ~mD`'-h~ ~
1 ~ r ~• #-
2. Address: ~ ~-C~(~D ~~~'F`~°_r l~~lG~ ~ 1 ~ l.Lb~~~i Guy . ~~ `J~c~
3. Telephone Number: C~nnOf K2 ~ P~`~ `
4. Date of Incident: 1~.1 i_ ~fTc
5. Time of Incident: L.Q ~- 77~ Pf'1'~
6. Location of Incident (Be specific): ~ , 1 "[ ~' ~ G-L.1"l~l ~h ~ ~ 51', ~>~~ ~ 1 ~ C~~ I.4
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? C i ~ ;
9. Give name and address of any witnesses: i,c tiiC-rt bw n
10. Did police investigate? (If so, give names of officers.)
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11. Was anyone injured? (If so, give names, addresses, and extent of injuries.)
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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? /U
http://www.cityofdubuque.org/printer_friendly.cfm?pageid=155 12/27/2006
Claim Form
Page 2 of 2
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.)
l~rr-e~jrd~s~ye G~2 vic_I+y ~r~~:.+~cne~Ca~ p~'d ~~C~-~4 11 ~~~rndc(~,
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15. What amount do you claim from the City of Dubuque? $ ~ ~ "~~' ~• ~ ~
'~1--; 5 i ~~C~~'S ~ ;~T , rtSCcr"~d`~ ~~~ib~C,(r~~ic.c.+~'Y~l~. --
16. Why do you claim the City of Dubuque is responsible? Thy ~' ~~ r`'* ~` ~
CCU-~-~Ut- by `VDU-r d~~ ~e~~5 i rn,p:-~p~ h.~,~~: ~ .
~a r~r~ v~T i S ~ct,~;~il~ ~~~2.5}gin .
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 this t- ~ : day of - -~ t ~' , 20 (_= l>. .
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(Signature) LL 5 ~ ~~~ rv ; ~ e ~ F iYl a...~-~h ~~ S ~/r1~~t ~lr~/
(Print Name)
print this page
http://www.cityofdubuque.org/printer_friendly.cfin?pageid=155 12/27/2006
FAX
TRANSMITTAL
To:
Company:
Our Insured:
Our Claim#:
Date Of Loss:
Your Insured:
Your Claim/Policy#:
SUBROGATION January 04, 2007
CITY CLERK
CITY OF DUBUQUE
MATTHEW J SMOTHERS
06-0446521
12-04-06
CITY OF DUBUQUE
UNKNOWN
P.O. Box 89440
Cleveland, OH 44101
Facsimile:888-792-5922
Progressive.com
Total Subrogation Balance: $1266.11. This includes our insured's $500.00 deductible.
We are seeking reimbursement at 100 %, for a total of $ 1266.11.
Please take this as formal notice of our subrogation rights with regards to the above captioned
claim. We have completed our investigation into the facts of the above captioned loss and find
that your insured was the proximate cause of the accident.
Please make draft payable to "Progressive Casualty Insurance Co as Subrogee of MATTHEW
J SMOTHERS", in the amount stated above and mail it to the attention of the undersigned.
All supporting documentation is enclosed. I have diaried my file ahead fifteen (15) days. Thank
you for your anticipated, prompt attention to this matter.
JESSICA ACKROYD
Progressive Casualty Insurance Co
Subrogation Representative
Toll Free 1-877-818-0139 ext. 37101
Jessica Ackroyd@Progressive.Com
**PLEASE INCLUDE MY NAME AND CLAIM # ON ANY AND
ALL CORRESPONDENCE**
PROOREll/!/E®
Not what you'd expect from an insurance company.s""
Date: 12/7/2006 10:26 AM
Estimate ID: 06-0496521-01
Estimate Version: 0
Committed
Profile ID: dubuq:all part types
PROGRESSIVE
Damage Assessed By: SCOTT FEUERBACH Appraised For: RACHEL DAVIS
(563) 585-2684
Type of Loss:
Date of Loss:
Deductible:
Claim Paid:
Days to Repair:
Policy No:
Insured:
Claimant:
Address:
Telephone:
Owner:
Address:
Auto
12/4/2006
500.00
Y
4
9708850
MATTHEW SMOTHERS
MATTHEW SMOTHERS
1600 BUTTERFIELD#212 DUBUQUE, IA 52002
Work Phone: (563) 582-1875
MATTHEW SMOTHERS
1600 BUTTERFIELD#212 DUBUQUE, IA 52002
Claim Number: 06-0946521-01
Home Phone: (563) 588-4215
Telephone: Work Phone: (563) 582-1875 Home Phone: (563) 588-4215
Mitchell Service: 914752
Description: 2001 Toyota Celica GT-S Vehicle Production Date: 00/00
Body Style: 2D HB Drive Train: 1.8L Inj 4 Cyl 4A FWD
VIN: JTDDY32TX10037142 License: 538JEC IA
Mileage: 72,733
OEM/ALT: A Search Code: BETTENDORI
Color: SILVER
Options: Alum/Alloy Wheels, Air Conditioning, Power Steering, Power Brakes, Power Windows, Power Door Locks,
Tilt Steering Wheel, Cruise Control, Automatic Transmission, Custom Pkg., AM-FM Stereo/CDPlayer(Single),
Passenger-Front Air Bag, V6 Engine, 2-Door, Driver-Front Air Bag.
Line Entry Labor Line Item Part Type/ Dollar Labor
Item Number Type Operation Description Part Number Amount Units
FRONT BUMPER
1 400021 BDY REMOVE/REPLACE FRT ADD W/FOG LAMPS 0.4
2 400022 BDY REMOVE/REPLACE FRT BUMPER COVER Remanufactured 155.00* INC #
3 REF REFINISH FRT BUMPER COVER C 2.2
4 BDY OVERHAUL FRT BUMPER COVER ASSY 2.8 #
5 400037 BDY REPAIR FRT BUMPER VALANCE PANEL Existing 0.5
6 REF REFINISH/REPAIR FRT BUMPER VALANCE PANEL C 0.6
7 MODIFIED REFINISH WITH FULL CLEAR COAT
8
9
10
11
12
13
14
15
1
17
18
400029 BDY REMOVE/REPLACE FRT BUMPER SEAL 53395-20030 13.55 INC
FRONT LAMPS
400045 BDY REMOVE/REPLACE L FRT COMBINATION LAMP ASSEMBLY **Qual Repl Part 186.00* 0.4 #
BDY CHECK/ADJUST HEADLAMPS 0.5
400069 BDY REMOVE/REPLACE L FRONT SIDE MARKER LAMP 81741-14160 17.21 INC #
FRONT FENDER
400228 BDY REPAIR L FENDER PANEL Existing 3.0 *#
REF REFINISH/REPAIR L FENDER PANEL C 0.9
MODIFIED REFINISH WITH FULL CLEAR COAT
ROCKER/PILLARS/FLOOR
ESTIMATE RECALL NUMBER: 12/7/2006 0 9:46:50 06-0446521-01
U1traMate is a Trademark of Mitchell International
Mitchell Data Version: NOV_06_ A Copyright (C) 1999 - 2006 Mitchell International Page 1 of 4
U1traMate Version: 6.0.019 All Rights Reserved
Date: 12/7/2006 10:26 AM
Estimate ID: 06-0496521-01
Estimate Version: 0
Committed
Profile ID: dubuq:all_part_ types
900851 BDY REMOVE/INSTALL L ROCKER MOULDING 0.4
FRONT BUMPER
6 400034 BDY REMOVE/REPLACE L FRT BUMPER RETAINER 52117-20110 18.92 INC
ADDITIONAL OPERATIONS
REF ADD'L OPR CLEAR COAT 1.5
ADDITIONAL COSTS & MATERIALS
ADD'L COST PAINT/MATERIALS
* - Judgement Item
# - Labor Note Applies
C - Included in Clear Coat / Three Stage Calc
All manufacturers requirements regarding seat belt and supplemental
restraint system replacement must be adhered to. If additional parts
or operations are necessary to properly accomplish this, please
contact the estimating claims rep.
Add'1
Labor Sublet
I. Labor Subtotals Units Rate Amount Amount Totals
Body 8.0 49.00 0.00 0.00 392.00 T
Refinish 5.2 49.00 0.00 0.00 254.80 T
Taxa ble Labor 646.80
Labor Tax @ 7.OOOg 45.28
Labor Summary 13.2 692.08
II. Part Replacement Summary
Taxable Parts
Sales Tax @ 7.OOOo
Total Replacement Parts Amount
156.00*
Amount
27.35
418.03
III. Additional Costs Amount IV. Adjustments Amount
Non-Taxable Costs 156.00 Insurance Deductible 500.00-
Total Additional Costs 156.00 Customer Responsibility 500.00-
I. Total Labor: 692.08
II. Total Replacement Parts: 418.03
III. Total Additional Costs: 156.00
Gross Total: 1,266.11
IV. Total Adjustments: 500.00-
Net Total: 766.11
THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF AFTERMARKET CRASH PARTS SUPPLIED BY A SOURCE OTHER THAN THE
MANUFACTURER OF YOUR MOTOR VEHICLE. ANY WARRANTIES APPLICABLE TO THESE REPLACEMENT PARTS ARE PROVIDED BY THE
MANUFACTURER OR DISTRIBUTOR OF THESE PARTS RATHER THAN THE MANUFACTURER OF YOUR VEHICLE.
ESTIMATE RECALL NUMBER: 12/7/2006 09:96:50 06-0946521-01
U1traMate is a Trademark of Mitchell International
Mitchell Data Version: NOV_06_A Copyright (C) 1994 - 2006 Mitchell International Page 2 of 9
U1traMate Version: 6.0 019 All Rights Reserved
Date: 12/7/2006 10:26 AM
Estimate ID: 06-0496521-01
Estimate Version: 0
Committed
Profile ID: dubuq:all part types
Point(s) of Impact
Inspection Site: brimeyer auto body
Inspection Date: 12/7/2006
Body Shop: BRIMEYER AUTO BODY
Address: 10727 JFK ROAD
DUBUQUE, IA 52001
Telephone: (563) 563-6656
Fax phone: (563) 583-1838
THIS IS A DAMAGE ASSESSMENT ONLY - NOT AN AUTHORIZATION TO REPAIR -
BASED ON DAMAGE VISIBLE OR CERTAIN AT THE TIME IT WAS WRITTEN.
IF FRAME OR UNIBODY REPAIR IS INCLUDED ON THIS ESTIMATE, THE AMOUNT
SHOWN INCLUDES TIME OR ALLOWANCE FOR MEASURING BEFORE, DURING AND
AFTER THOSE REPAIRS.
THE OWNER OF THE VEHICLE MAY SELECT THE REPAIR FACILITY OF HIS/HER
CHOICE.
TO ENSURE PROPER AND PROMPT PAYMENT FOR ADDITIONAL DAMAGE DISCOVERED
DURING THE COURSE OF REPAIRS, CONTACT PROGRESSIVE FOR SUPPLEMENT
HANDLING PROCEDURES.
PROGRESSIVE HONORS THE PREVAILING LABOR MARKET RATE IN YOUR AREA FOR
YOUR PROPERTY. IF YOU CHOOSE A SHOP THAT CHARGES IN EXCESS OF
PREVAILING LABOR MARKET RATES, YOU WILL BE RESPONSIBLE FOR THE
DIFFERENCE.
LIFETIME GUARANTEE FOR SHEET METAL AND PLASTIC BODY PARTS
ESTIMATE RECALL NUMBER: 12/7/2006 09:46:50 06-0446521-01
UltraMate is a Trademark of Mitchell International
Mitchell Data Version: NOV_06_A Copyright (C) 1994 - 2006 Mitchell International
UltraMate Version: 6.0.019 All Rights Reserved
Date
Estimate ID:
Estimate Version:
Committed
Profile ID:
Page 3 of 4
12/712006 10:26 AM
06-0446521-01
0
dubuq:all_part_types
January 04, 2007, 16:30:29
CMSD2340 /CMSM2340 P A C M A N JAN 04 07 - 16:30
OPID: KXG0102 CLAIM PAYMENT INQUIRY TERMID: ?OK9
INSD: SMOTHERS, MATTHEW J POL: 09708850-9
DOL DEC 04 06 IA-DUBUQU-GRP- CLM: 060446521 ACTIVE REP: R FITZPATRIC
PAY TO THE ORDER OF: TOTAL DRAFT AMOUNT: 766.11
LINE 1: BRIMEYER AUTO BODY INC ON BEHALF OF MATT SMOTHERS
LINE 2:
LINE 3:
ADDRESS: 10709 COLLISION DRIVE
CITY: DUBUQUE ST/PR* IA ZIP/CPC: 52001 CNTRY* USA
IN PAYMENT OF: LOLL LESS DEDUCTIBLE O1 TOYOTA CELICA GTS
1099 ? N FEDERAL TAX ID: LAST UPDT REP: SXF0066
CDS CODE * 13 PCL EFT TRACE #: ISSUING REP: S FEUERBACH
BANK CODE* AS2 ISSUE DATE DEC 07 06 APPROVED BY:
STATE * IA AREA * 001 REVIEW DATE: 00 00
STOP RSN * DRAFT # 448719917 REVIEWED BY:
COMMAND: