Claim by Jennifer Ney 2 11 09F
v
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 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:
2. Address:
3. Telephone Number
4. Date of Incident:
5. Time of Incident:
1 F >>
pI ~
i
~ ~ 4
6. Loca ' _n of ident specifi
~/ - ~ ,
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 vvea. ,e n.ditions like?
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).
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.)
13. What other damages do you claim, if any?
14. Have you been compensated for any part or all of your claim by any
insurance company? (If so, dive name and address of insurance company and
amount paid.)
1
15. What amount do you claim from the City of Dubuque?
16. Why do you claim the City of Dubuque is responsible?
17. Have you made any claim against anyone else for damages as a result of
this incident? (If yes, give name and address.)
T
18. If the answer to Question 17 is yes, have you received any payment from that
source, and if so, in whgt amount?
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ARS MAIL REPORTS T0: IowaDepartment of Transportation
day zoos Iowa Department of Transportation
Office of Driver Services c8 INVESTIGATING OFFICERS REPORT
Park Fair Mall, 100 Euclid Avenue
P.O. Box 9204 � OF MOTOR VEHICLE ACCIDENT
Des Moines, Iowa 5030E-9204
Law en7nrcement Case Number.
01-09-3588
LetelVentionv
Property?
L
Date of Accident
01/25/09
Time of Accident
03:11 Hrs.
County
Dubuque - 31
Accident occurred within corporate Ilmlts of (city)
Dubuque - 2100
Location Literal Description
Off Roadway/Roadway Not
Found
0
If accident occurred outside of city limits
show general vicintty: "NIA" of nearest city "NIA"
C
A
On Road, Street, or Highway:
"NIA"
Al Intersection with:
"NIA"
T
I
Note: Unless accident occurred at an intersection which is completely descrbed above. use the space below to give the exact
location from a milepost or definable intersection, bridge, or railroad crossing, using Iwo distances and directions if necessary,
1C-Goordlneta: 00686763
Y-Coordinate: 04707803
O
Distance Direction Distance Direction
50 Ft 7-W and 50 Ft 5-S 01
it Divided Highway. Provide Route
(Cardinal) Travel Direction
"NIA"
N
Milepost Number Definable Intersection, bridge, or railroad crossing
"NIA" Or PENNSYLVANIA AND SYLVAN
Drivel's Name - Last First Middle Suffix Phone
MERTZ KATHERINE MARIE (563) 589-4415 x
Address City Zip
770 IOWA STREET DUBUQUE IAte 52001
Driver's License Number
Citation Charge Code 1 Citation Charge 1
Citation Charge 2
er
Female
fate
IA
ass
C
Endorsements
NONE
Restrictions
B
Citation Charge Code 2
Citation Charge Code 3 Citation Charge 3
Alcohol Test
Given?
1 - None
Test Results:
Drug Test
Given?
1 - None
Test Results
Citation Charge Code 4 Citation Charge 4
U
Seating Position01
Injury Status
5
Occupant Protection2
Airbag Deployment 5
Airbag Switch Status 9
Ejection 1
Ejection Path 1
Trapped 1
N
Transported to:
Transported
by:
T
Owner's Name -
Last
' First
Middle
Silk
Ownerp
OF OUBU4se
y
UE
dal
Address
770 IOWA STREET
City
DUBUQUE
State
IA
zip
52001
Insurance Co. Name
IOWA COMM.
ASSURANCE
insurance
Policy*
License
107584
Plate #
State
IA
Year
2009
VIN No.
2FAHP71V85JC131262
Year
2008
Make
Ford FORD
Model
CROWN VICTORIA
Style
4D
Tow*
NO
Approximate
Repair
Cost to
er Replace
Initial Travel
Direction 4
Vehicle
Action 09
Speed
Limit
Point of
Initial Impact 02
Most Damaged
Area 02
Extent of
Damage
2
Underridef
Override
1
Private?
�
$100,00
Total
Occupants 2
Traffic
Controls 01
Vehicle
Confg.
01
Cargo Body
Type
01
Vehicle
Defect 01
Driver
Condition
1
Vision
Obscured
01
Contributing
Driver
C'rcumstances,
(up to two)
22
'
SEQUENCE OF
EVENTS First
Event
23
Second Event
Third Event
Fourth Event
Most Harmful
Event (by vehicle)
23
Commercial Trailer
License Plate #
Attached
Power Unit-.
to
State
Year Attached to
Trailer Unit
State
Year
Emergency
Vehicle Type 1
Emergency
Status 3
Carder Name
Address
City
State Zip
US DOT #
or MC #
Number of
Axles
Gross Vehicle
Weight Rating
Placard
#
Hazardous Materials
Released?
Driver's Name -
Last
First
Middle
Suffix
Phone
063) 582-2258 x
Address
City
State
Zip
Date of Birth
Driver's License
Number
Citation Charge Code
1
Citation
Citation
Charge
Charge
1
2
Gender
State
Class
Endorsements
NONE
Restrictions
NONE
Citation Charge Code
Citation Charge Code
2
3
Citation
Charge
3
Alcohol Test
Given?
1 - None
Test Results:
Drug
Given?
1 -
Test
None
Test Results:
Citation Charge Code
4
Citation
Charge
4
U i
Seating Position
Injury Status
Occupant
Protection
Airbag
Deployment
Airbag Switch
Status
Ejection
Ejection Path
Trapped
N
Transported to:
Transported by:
f
TwY
s Name - Last
ist JENNIFER
Middle
Suffix
Owner Company
Name
002
Address
3520 PENNSYLVANIA
City
DUBUQUE
IA Slate
Zip
52002
'
Insurance Co. Name
Insurance Policy if
License Plate #
366MTD
Stale
WI
Year
2009
VIN No.
JH4DA94a0L5060033
Year
1990
Make
Acura
- ACRA
Model
INTEGRA
Style
2H
Tow #
NO
Approximate Cost to
Repair or Replace
Initial Travel
Direction
Vehicle
Action 12
Speed
Limit
Point of
Initial Impact 06
Most Damaged
Area 06
Extent of
Damage 2
Underridel
Override 1
Private?
❑
5500.00
Total
Occupants 0
Traffic
Controls 01
Vehicle
Config. 01
Cargo Body
Type 01
Vehicle
Defect 01
Driver
Condition 8
Vision
Obscured
Contributing C raunstances,
Driver (up to two) 28
SEQUENCE OF EVENTS I First Event 23 Second Event Third Event Fourth Event Most Harmful Event (by vehicle) 23
Commercial Trailer Attached to State Year Attached to State Year
License Plate # Power Una: Trailer Unit
Emergency e Type 1
Status Emergency
Carrier Marne
Address City State Zip
US DOT # or MC #
Number of
Axles
Gross Vehicle
Weight Rating
Placard #
Hazardous Materials
Released?
Printed At: Dubuque Police Department 01/25/2009 05:16 AM
Page 1
Form #: 01-09-3588
ACCIDENT ENVIRONMENT
Location of First Harmful Event 6 Weather Conditions
Manner of CrashlCollisiori 6 (up to two) 03
Light Conditions 4 Surface Conditions
ROAD WAY CHARACTERISTICS
Major Contributing Circumstances:
Environment 1
Roadway 01
Type of Roadway Junction/Feature 05
WORKZONE RELATED? SEQUENCE OF EVENTS
No
Location First Harmful Event of Crash
Type (use codes 11-42 only) 23
Workers Present?
D
I
A
G
R KEY APT. PARKING LOT
A 3520 PENNSYLVANIA ~~,+
M 1
~_
- -__~
t ~
NARRATIVE
Describe what happened (refer to vehicles by number)
UNIT 1 WAS BACKING OUT OF A PARKING SPOT IMMEDIATELY ADJACENT TO UNIT 2. UNIT 1 BEGAN TO TURN TO THE
LEFT TOO EARLY AND HIT UNIT 2 ON THE LEFT REAR SIDE CAUSING MINOR DAMAGE TO BOTH VEHICLES.
yy Witness Name -Last First Middle I Suffix
I BAUER BRANDON JOSEPH
T Address City State Zip Code l
N 770 IOWA STREET DUBUQUE IA 52001
E Home Phone # Work Phone #
I
S (563) 589-4415 x
y~ Witness Name -Last First Middle Suffix
I BASTEN DANIELLE M
T Address City State Zip Code l
N 77010WAST. DUBUQUE IA 52001 I
S Home Phone # Work Phone #
g (563) 589-4415 x
Officer Badge No. Time Officer Notified of Accident Time Officer Arrived At Scene
BAUERBRANDON 72 03:11 Hrs. 03:11 Hrs.
Name of Agency Date of Repor[ Investigation T.I. #
Dubuque Police Department 01/2512009 made at scene? Yes
Report Reviewe Dat
e Revie
wed Agency Specific Other Technical Investigation Agency
~ /
/
~tl~l®q DPD
Printed At: Dubuque Police Department 01/25/2009 05:16 AM Page 2 Form #: 01-09-3588
Date: 2/10/2009 01:51 PM
Estimate ID: 30028
Estimate Version: 0
Preliminary
Profile ID: Mitchell
Damage Assessed By: MATT RYAN
Deductible: 0.00
Claim Number: N/A
Owner: JENNIFER NEY
Address: 3520 PENNSYLANNA AVE, DUBUQUE, IA 52002
Telephone: Home Phone: (563) 582-2258.
Mitchell Service: 915702
Description: 1990 Acura Integra GS
Body Style: 2D HB Drive Train: 1.8L Inj 4 Cyl 4A
VIN: JH4DA9460LS068033 License: 366MTD WI
Mileage: 160,398
OEM/ALT: O Search Code: None
Color: RED
Line Entry Labor Line Item Part Type/ Dollar Labor
Item Number Type Operation Description Part Number Amount Units
1 529360 BDY. REPAIR REAR BODY PANEL Existing 2.0*#
2 AUTO REF REFINISH REAR BODY PANEL C 1.8
3 529530 BDY REMOVE/REPLACE REAR BODY DECAL ORDER FROM DEALER 22.25 0.2
4 529780 BDY REMOVE/REPLACE L COMBINATION LAMP ASSEMBLY 33550-SK7-A01 d214.38 0.4
5 530740 REF REFINISH REAR BUMPER COVER C 2.0*
6 900500 BDY * ' ADD'L LABOR OP COVER CAR FOR OVERSPRAY ** QUAL REPL PART 5.00 * 0.2*
7 530750 BDY REMOVE/INSTALL REAR BUMPER ASSY INC
8 530760 BDY OVERHAUL REAR BUMPER COVER ASSY 1.8 #
9 530830 BDY REPAIR REAR BUMPER COVER Existing 2.0*#
10 936014 ADD'L COST FLEX ADDITIVE 5.00 *
11 933000 REF ADD'L OPR TWO TONE 1.0*
12 900500 BDY * REPAIR ATTACH REAR BUMPER Existing 2.0*
13 AUTO REF ADD'L OPR CLEAR COAT 1.1
14 933005 BDY ADD'L OPR RESTORE CORROSION PROTECTION 5.00 * 0.2*
15 AUTO ADD'L COST PAINT/MATERIALS 224.20 *
16 AUTO ADD'L COST HAZARDOUS WASTE DISPOSAL 4.00 *
* -Judgment Item
# -Labor Note Applies
d -Discontinued by the Manufacturer
C -Included in Clear Coat Calc
ESTIMATE RECALL NUMBER: 02/10/2009 13:51:10 30028
Mitchell Data Version: JAN_09_A UltraMate is a Trademark of Mitchell International
Copyright (C) 1994 - 2009 Mitchell International Page 1 of 2
UltraMate Version: 6.7.019 All Rights Reserved
Date: 2/10/2009 01:51 PM
Estimate ID: 30028
Estimate Version: 0
Preliminary
Profile ID: Mitchell
stirnate Totals
Add'I
Labor Sublet
I. Labor Subtotals Units Rate Amount Amount Totals II. Part Replacement Summary Amount
Body 8.8 60.00 5.00 0.00 533.00 T Taxable Parts 241.63
Refinish 5.9 60.00 0.00 0.00 354.00 T Sales Tax @ 6.000% 14.50
Taxable Labor 887.00 Total Replacement Parts Amount 256.13
Labor Tax @ 6.000 % 53.22
Labor Summary 14.7 940.22
III. Additional Costs Amount IV. Adjustments Amount
Taxable Costs 4.00 Insurance Deductible 0.00
Sales Tax @ 6.000% 0.24
Customer Responsibility 0.00
Non-Taxable Costs 229.20
Total Additiona l Costs 233.44
I. Total Labor: 940.22
II. Total Replacement Parts: 256.13
III. Total Additional Costs: 233.44
Gross Total: 1,429.79
IV. Total Adjustments: 0.00
Net Total: 1,429.79
This is a areliminarv estimate.
Additional chances to the estimate may be required for the actual reaair.
Insurance Co: CUSTOMER PAY
ESTIMATE RECALL NUMBER: 02/10/2009 13:51:10 30028
Mitchell Data Version: JAN_09_A UltraMate is a Trademark of Mitchell International
Copyright (C) 1994 - 2009 Mitchell International
UltraMate Version: 6.7.019 All Rights Reserved
Page 2 of 2