Claim by Michael Mahoney_State Farm InsuranceCLAIM AGAINST THE CITY OF DUBUQUE, JOWA
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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 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. �jj �M
1. Name of Claimant: (I_I i r"� • I _ I PA a' (�' " J
2. Address: 0 Wki X37 0. 'v , CO 7O 2 37/
3, Telephone Number: 8 % 7 ` TX 7 ' ( 7 / L' (e D
4. Date of Incident: I i `)J - 1 3
5. Time of Incident: 1 i r
6. Location of Incident (Be specific): WI- ' byt, -e / V L 1 P O'v . vla s7 •
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.)
8. What were weather conditions like?
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9, Give name and address of any witnesses;
10. Did police investigate? (If so, give names of officers.)
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? 4.4V1-
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? $ 3 d ( 5
16. Why do you claim the City 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.)
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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
day of r'' r= , 20
(Signatyire f
(Print Name)
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Providing Insurance and Financial Services
Home Office, Bloomington, IL
February 14, 2014
City Clerk Of Dubuque
50 W 13th St
Dubuque IA 52001 -4845
S a eFarm
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
15 -26G2 -837
Michael Mahoney
November 08, 2013
City GarbageTruck
David Cole
Mt. Loretta Ave & Ramona St., Dubuque, IA
Facts of Loss:
Insured was Eastbound on Loretta when insured passed a garbage truck and truck pulled from
curb into the road and struck insured vehicle.
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 $
042 - Uninsured Motorist PD $
300 series /400 - Comp /Collision $2,830.54
501 - Rental /Loss of Use $
600 -050 - Med Pay /PIP $
Other $
Salvage Recovery $
Amount State Farm Paid $2,830.54
Insured Deductible $250.00
Total Claim Amount $3,080.54
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 $3,080.54.
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.
15 -26G2 -837
Page 2
February 14, 2014
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,
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,
Natalia Ryan
Claim Representative
(877) 457 -8276 Ext. 60
Fax: (866) 231 -9276
State Farm Mutual Automobile Insurance Company
Enclosure