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Claim - Farm Bureau Mutual Ins ~-~-~-~ a-' CLAIM AGAINST THE CITY OF DUBUQUE, IOWA This written report const!tutes 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. 13m 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. 1. Name of Claimant: Farm Bureau Mutual - Ins. 2. Address: P.O. Box 609 Waverly, IA 50677 3. Telephone Number: 1 800 765 1485 4. Date of Incident: 9 09 01 5. Time of Incident: 17:13 Hrs. 6. Location of Incident (Be specific): Sheridan Rd., Dubuque, IA 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. 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 Vehicle No. 1 was DB on Sheridan RD (3200 blk), Behicle #2 WB. Vehicle #1 lost control of vehicle as he came around corner, due in part to fact that the roadway was full of loose rock. 8. What were weather conditions like: Clear 9. Give name and address of any witnesses: See Police Report. 10; Did Police investigae? (If so, give names of officers) Yes, T. Kramer Bade 40, Case # 01- 359-22 11. Was .anyone injured? (If so, give names, a~dresses, and extent of injuries). Samuel Z. Ellerbeck, 2975 Abor Hills Dr., Dubuque, IA Bumps/Bruises Earl R. Hinzmann, 4832 Peacock Dr., Dubuque, IA - Fracture ????? 12. Was any damage done to property? (If so, describe property and the extent of dama'g~s. Attach estim.a, et~.~f dama. ges, or describe basis for ascertaining extent of damage.) Paul Ellerbeck - Vehicle 1999 Olds Alereo $14,227.50 Earl Hinzman 1996 Ply. Breeze $7781.50 13. What other damages do you claim, if any? Personal injry to Earl Hinzman 14. Have you been compensated for any part or all of your claim by any insurance company? (If so, give name and address ofinsurence co~mpany and amount paid.) 15. What amount do you claim from the City of Dubuque? Damages to both vehicles and personal injury to Earl Hinzmann 16. Why do you calim the City of Dubuque is responsible? Since Rock in roadway this caused vehicle #1 to lose control as he came around the corner. 17. Have you made any claim against anyone else for dmaages as a result of this incident? Farm Bureau Insuranced settled both claims and filing subrogation against the City of Dubuque for contribution. (If y,es, 18. If the answer to Ou e and if so, in what amount? Dated at Dubuque, Iowa this 4th day of January, 2002. s.e for damages as a result of thi.s incident? /s/ Farm Bureau Mutual Ins. Mike Flanders .ave ~u re~ y payment from that source, t~day ~f (Print Name) (Rev. 1/00 & 7/01) ~o.,. o.,..~,.~ .~Tr..~o.~.. Iowa Department of Transpo~ation P.o. ~o~9204 INVESTIGATING OFFICER'S REPORT o~ ~o~.~, ~ s~ OF MOTOR VEHICLE ACCIDENT C~. ~ ~ ~ F~t ~es N ~ ~ S~ S SW W NW Fe~ M~ N NE ~ SE $ ~ W NW IfDivid~Hig~y Pr~eR~te ~dep~t ~ O O O O O O a.d ~1 t O O O O O O O O o~ (Ca~i~ei)T~Dim~on ~ O ~ t ~,~ /T,G,ven?~ ZBI~d 4. Bma~gR~ g . 1. None 3. Unne Pos. Number · o o ~ I"t (Last. First, Middle) Estimate of I'D( I1.?.-II I SecondEvem (by vehicJe) L'~' ]1 F~mt Harmful Event of Cr~.h Officer's Name_ ~ Bad~ge'~Nc, Date: 9/18/01 Claim: Policy: 2255819 Customer: Paul Ellerbeck Loss Date: 9/18/01 Deductible: $250 Payer Code: Preliminary Valuation Report Waverly Farm Bureau ClaLms PO Box 609, Waverly IA 50677 (319)352-0852 Valuation ID: 578 Type of Loss: '- Classification: Total Loss Assessor: Mike Flanders Assessor ID: Profile: Mitchell Standard State: IA N.A.D.A.© MIDWEST VALUES ALERO-V6 SED 4D GLS Base Value Mileage Adjustment A~um/A!loyWheets Power Brakes Power Windows Power Door Looks Power Seats TiAt Steering Wheel Cruise Control Electric Defogger A/~-~Mstereo Leather Seats Total Wholesale Value N.A.D.A.© MIDWEST VALUES ALERC-V6 SED 4D GLS $10,450 Base Value $12,550 $800 M~leage Adjustment $800 $200 A!um/~lloy Wheels $200 Standard Power Brakes Standard Standard Power Windows Standard Standard Power Door Locks Standard Inclusive Power Seats Inclusive Standard Tilt Steering Wheel Standard Standard Cruise Control Standard Standard Electric Defogger Standard Standard ~/~-FM Stereo Standard Inclusive Leather Seats Inclusive $11,450 Total Retail Value $13,550 Mitchell International Corporation warrants that this valuation is an accurate representation of the N.A.D.A.© value guide. AV~P~GE BOCK V~_LUE Taxable Adjustments Taxable A~justments Total Pre-Tax Subtotal Post-Tax Subtotal Non-Taxable Adjustments Deductible Non-Taxable ~djustments Total <$250.00> $12,500.00 $0.00 $12,500.00 $12,500.00 <$250.00> -.NET TOTAL $12,250.00 Customer: Paul Ellerbeck Inspection Site: IA : iA Vehicle: 1999 Oldsmobile hero GLS 4D Sed 3.4L Inj 6 Cyl 4A VIN: 1G3NF52E4XC307089 Type: Auto Mileage: 17,197 License: IA Condition: Color: Property Casualty The American Exprass Property Casualty companies 1400 Lombarcli Avenue Green Bay, Wisconsin 54304~3922 AMEX Assurance Company IDS Property Casualty Insurance Company December 20, 2001 MR MIKE FLANDERS FARM BUREAU INS CO PO BOX 609 WAVERLY IA 50677 OUR CLAIM NO.: OUR INSURED: DATE OF LOSS: YOUR FILE NO.: YOUR INSURED: 309658-I~101 EARL I:IINZM.a2fN 9/9/01 2255819 PAUL ELLERBECK Dear Mr. Flanders: We previously put you on notice of our property damage subrogation claim. The salvage has now been resolved. We are hereby notifying you of our total damage in the mount of $7,781.50, which is broken down as follows: Total Loss $7,500.00 Deductible $ 250.00 Salvage $ ~-31.50 Please issue payment at your earliest convenience to Amex Assurance Company, PO Box 19018, Green Bay V~I 54307-9018. This will also serve to remind you of our medical payment subrogation claim in the mount of $5,000. We e~ect our interest to be protected when settling our ins~ed's injury claim. Should you have questions or concerns in this matter, do not hesitate to contact me. Sincerely, Candy S. Bailey, AIC Sr. Subrogation Representative 800.872.5246 Ext. 5179 Amex Assurance Company