Claim by Noel PloesslC~C~. ~ ~ ~~ ~'~~
~'~~~~~~IM AGAINST THE CITY OF DUBUQUE, IOW
~,
i~8 ~~~ ~ ~ ~'r~f~vr~~en report constitutes your claim against the City of Dubuque, Iowa: Y u
sh u ~ complete this form in full and attach any additional information that
,., . ,~
City` ~.•,~-~t"~ 'your claim.
tJUJU~'..'`'. I,-
The claim must be filed with the City Clerk at City Hall, 50 West 13th 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: /V ~J~'
/ G~ /~.`~
' 2. Address: ~ ~~(r ,~'J (~~r1 ~~c~:~ ~i,'L'
3. Telephone Number ~ J~~, ~L&J y~
4. Date of Incident: ~ Z /~. ~~ /~~~L~~
5. Time of Incident: ~ • ~'°~'' /// I
6. Location of Incident (Be spe~ic):
7. Describe the accident or occurrence that caused injury or damage. (Give full
details upon which you bast your claim. If a City employee was involved, give
the employee's name.) _ _ _ _ _ _
8. What~ere we ther conditions like?
9. Give name a.nd~ddress of any witnesses: __
~/ r
10. Did olice inv ti ate? If so, ive ames of officers.
11. Was anyon injured? (If so, give names, addresses, and extent of injuries).
~J
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.) (//~/~ c / i `~/ ~j ,f ~
ii 1~/~ /7
13. /W~ hat oth damp a~es do you clan, 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.)
tI
15. Wh t amount do you c im from the City of Dubuque?
16. Wh do you clad they City of Dubuque is responsibl
~yJ~'~ L /'9~/Ui~C CGf~r`.SC•~ 7~`Icr ~ a
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 this ,G ~ day of ~c~G. _ ~ 20~•
,~~/ ~ ~~
~~
(Signature)
~~~ ~ ~~i~s~~
( r-int Name)
�1
U
N
T
001
Driver's Name - Last
MCCLEAN
Address
1451 AUBURN ST
Driver Information Exchange Report
Gender ❑rivers License Number
Male
Owner Company Name
CITY OF DUBUQUE
Owner's Name - Last
Address
50 W 13TH ST
VIN No.
1 HTWDAAN46J255822
License Plate #
64557
First
KENNETH
Class
A
First
Year
2006
State
IA
State
IA
Make
INTL
Year
2099
Dubuque Police Department
563-589-4410
City
DUBUQUE
Endorsements
N-L
Middle
JOHN
Restrictions
NONE
Middle
City
DUBUQUE
Suffix l Date of Birth
State
IA
Zip Phone
52001 I (563) 556-1980 x
Insurance Co. Name
IOWA COMMUNITIES
Insurance Policy #
Model
7400 SFA 4X2
Most Damaged Area
05 - Rear
U
N
T
002
Driver's Name - Last
Address
Gender
Driver's License Number
First
Class
State
City
Endorsements
NONE
Middle
Restrictions
NONE
Owner Company Name
Owners Name - Last
PLOESSL
Address
2762 CARLTON ST
VIN No.
1FTPX14586NA02533
License Plate #
200AVX
County
Dubuque - 31
Literal Description
CARLTON ST
X-Coordinate
00688437
if accident occurred outside of city
limits show general vacinity:
On Road, Street, or Highway:
CARLTON ST
Distance
400 Ft
Direction
6-SW
First
NOEL
Year
2006
State
IA
Make
FORD
Year
2008
Accident occurred with
Dubuque - 2100
"NIA"
and
Definable intersection, bridge, or railroad crossing
BROWN ST
Officer
WALKER MATTHEW
City
DUBUQUE
Suffix
State
IA
Zip
52001-
Suffix
State
Insurance Co. Name
WEST BEND
Insurance Policy #
HH1534187709
Middle
FRANCIS
Model
xxx
Most Damaged Area
07 - Left Side
n corporate limits of (city)
Direction
"NIA" of
Distance
"NIA"
Nearest City
"N/A"
Y-Coordinate
04707396
At Intersection with:
"N/A".
Direction
"N/A"
Badge No.
70
of
Style
PK
Insurance Co. Phone #
(563) 589-4120 x
Vehicle Configuration
21
Approximate Cost to Repair or Replace
$0.00
Date of Birth
Zip
Suffix
State
IA
Zip
52001-
Style
PK
Milepost Number
"NIA"
Phone
Insurance Co. Phone #
(563) 556-1499 x
Vehicle Configuration
02
Approximate Cost to Repair or Replace
$1,500.00
Or
Law Enforcement Case Number Date of Accident
01-08-59017 12/26/2008
Route (Cardinal)
Travel Direction SB
Time of Accident
01:00 Hrs.
Printed At: Dubuque Police Department 12126/2008 03:18 AM
Page 1
Form #: 01-08-59017
' TOYS DONE RIGHT
1006 central ave
DUBUQUE, IA, 52001
Te1:563-552-1601 Fax:563-552-2207
Tax ID:26-1404014
Estimate -Preliminary
Estimate Prepared by:
Accident Date:
Date of Loss:
Arrival Date:
Type of Loss:
Policy Number:
Claim Number:
Owner:
Appraised for:
Date: 12/26/2008
Estimate#:
Contact: Noel Ploessl
Address: 582-6740 work
Year Make Model Color Trim
2006 Ford Pickup XLT Extended Cab Pickup
Unit Number License Plate # Mileage Serial#/VIN#
IFTPX14586NA02533
Sup Seq Qty Labor Labor Description Part Part List Extended Labor
Type Op Type Number Price Price Units
1 1 Ref Ref Refinish Fender Exist 2.2
Outside L
2 1 Body Repair Fender From 8-9-OS Exist 1 •~
2006 w/o Wheel
Opening Mldgs L
3 1 Body Rem/Rep R&I MUD FLAPS New •5*
ON LT SIDE
4 1 Ref Ref Refinish Door Exist 2.8
Outside Extended
Cab L
5 1 Ref Ref Refinish Door Exist •5*
Outside Add for
Jambs & Interior L [
SPOT IN]
6 1 Body Repair Shell Assy, Door Exist 4.0~
2005-08 Extended
Cab L
7 1 Ref Ref Refmish Door Exist 2.1
Outside L
8 1 Ref Ref Refinish Door Exist 1.0
Outside Add for
Jambs & Interior R L
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Database Edition CPL 08-I 1 Page 1 of 3
Sup Seq Qty Labor Labor Description Part Part List Extended Labor
Type Op Type Number Price Price Units
9 1 Body Rem/Rep Panel, Door Repair New 4L3Z $279.98 T $279.98 5.5#
2005-08 Panel, Door 1824701
Repair L CA
10 1 Body Rem/Rep Panel bonding New $25.00 T $25.00
materails
11 1 Body Rem/Rep R&I LT Door Handle New .5*
12 1 Body Rem/Rep R&I LT Vent visors New 1.0*
13 1 Ref Ref Refinish Outer Panel Exist 3.0
6 Foot Bed L
14 1 Body Repair Panel, Outer Side w/o Exist 3.Oi#*
Wheel Opening
Mldgs 6 Foot Bed L
15 1 Body Rem/Ins Moulding, Bed Rai16 Exist .4
Foot Bed Black 2006
L
16 1 Body Rem/Rep R&I tool box New .5*
17 1 Body Rem/Rep Decal, Bed Side New 4L3Z $43.22 T $43.22 .2
Shadow Gray w/o 9925622
60th Anniversary EAB
"4X4" L 07-08
18 1 Body Rem/Ins R&I Combination Exist .2
Lamp L
19 1 Body Rem/Ins R&I Reaz Bumper Exist .4
20 1 Body Rem/Rep Mirror Assy, Rear New 6L3Z $205.80 T $205.80 .3#
View (Factory 17683 CA
Installed) Black w/o
Puddle Lamp 2006
Heated Power L
21 1 Body Rem/Rep Rust Proof New $15.00 T $15.00 .5*
22 1 Ref Ref Cleaz coat Exist 2.0*
23 1 Body Rem/Rep Cover for over spray New $10.00 T $10.00 .2*
24 Paint Materials $476.00
* -Judgement Item
# -Labor Note Applies
Labor
Body 18.2 Hrs @ $55.00
Refinish 13.6 Hrs @ $55.00
Labor Total
$1,001.00
$748.00
$1,749.00
Parts
Parts Subtotal
Less Adjustments
Parts Total
Additional Costs and Operations
Addl. Costs/Ops Total
Tax
$579.00
$476.00
Labor Tax @ 7.00% $122.41
Parts Tax @ 7.00% $40.53
Tax Total $162.94
Totals
2006 Ford Pickup XLT F150
$579.00
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Database Edition CPL 08-11 Page 2 of 3
Sub Total: $2,966.94
- ~ Customer Resp. $0.00
Net Total 52,966.94
e above is an estimate based on our inspection and
oes not cover any additional parts or labor which may
e required after the work has started. Occasionally,
orn or damaged parts are discovered which may not
e evident on the first inspection. Because of this, the
bove prices are not guaranteed. Quotations on parts
d labor are current and subject to change.
This is a preliminary estimate. Additional changes to the estimate may be required for the actual repair.
RepairMate does not automatically include items required by marry business repair partners. This application
allows the author to manually enter line items such as overlap deductions.
2006 Ford Pickup XLT F 150
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