Claim Ryder, Karencoml~lete this form in full and attach any additional inf,ormatlon that supports your claim.
The Claim must be filed, with the City Clerk at City Hall, 50 W. 13th 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 recom, mendation,
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.
4. Date of incident:
?, DESCRIBE ACClOE~T OR OCCURRENCE THAT CAUSED INJUR~ OR OA~AGE, {Give
full details upon which you base your clai~, II a Clty employee was Involved, give the
employee's name.) .
8. What were weather conditions like?_
9. Give name and address of any witnesses:
10. Did police invesfi. D,.,a~'? (If so, give names of officers.)
11. Was anyone iniured? (if so, give names, addresses, and extent of lnluries).
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, give name and address of insurance company and amount paid.)
15. What amount do you claim from the City of Oubuque?~%O~
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.).
18. If the answer to Question 17 is yes, have you received any payment from that source,
and if so, in what amount?
Dated at Dubuque, Iowa this _
· day of_
(Rev. 1100 & 7/01) .,
WILLIS AUTO BODY
1982 ROCKDALE RD
DUBUQUE, IA 52003
PHONE: 563-583-9329
CD LOG NO 81-1 DATE 10/31/02
SHOP: WILLIS AUTO BODY
ADDRESS: 1982 ROCKDALE RD.
CITY STATE: DUBUQUE, IA
ZIP: 52003-
INSP DATE:
CONTACT:
PHONE 1:
FAX:
10/29/02
MARK WILLIS
(563)583-9329
(563)583-9329
OWNER: RYDER, KAREN
HOME PHONE: {563)583-1977
POINT OF IMPACT: 3
LIC%:
BODY COLOR: RED
CONDITION: POOR
S'~ATE:
IA
VIN:
MILEAGE:
ACCTNG CTL#:
1G4NV54U1LM082542
DRIVEABLE: YES
VEH. INSP#:
*=USER-ENTERED VALUE
EC=REPLACE EC~
TE=PA/{TL
I=REPAIR
TT=TWO-TONE
N=ADDITIONAL L/tBOR
AA=APPEAR ALLOWANCE
E=REPLACE OEM
EU=REPLACE SALVAGE
ET=PARTL REPL LABOR
L=RE~NISH
CG=CHI~GUARD
RI=R&I ASSEMBLY
RP=P. ELATED PRIOR
NG=REPLACE NAGS
EP=REPLACE PXN
IT=PARTIAL REPAIR
BR=BLEND REFINISH
SB=SUBLET
P=CHECK
UP=UNRELATED PRIOR
1990 BOT~F~Y~K STD 4DOOR SEDAN
CODE: S3203C/F~NS C/24P
4CYL GASOLINE 2.5
OPTIONS:
TWO-STAGE - EXTERIOR SURFACES
AUTOMATIC TRANS
TWO-STAGE - INTERIOR SURFACES
OP GDE MC DESCRIPTION
EU 0014
EU 0030
EU 0083
I 0076
I M31
BUMPER ASSEMBLY,FRONT
PANEL, FRONT END
PANEL, HOOD
CRSMBR,~ PANEL UPR
~ ~ 02, 07
~T-~ FOR R~IGN.
MFG. PART NO.
SALVAGE PART
SALVAGE PART
SALVAblE PART
RE Pi~kI R
REPAIR
PRICE AJ% B% HOURS R
125.00' +25 1.5 1
100.00' +25 2.0 1
50.00* +25 0.5 1
4.0'1
2.0*3
5 ITEMS
14~ MESSAGE(S)
02 PART NO. ~O~NTINUED, CALL DEALER FOR EXACT PART NO
07 STRUCTURAL t~ARTAS IDENTIFIED BY I-CAR
FINAL CALCULATIONS & ENTRIES
PAGE 1
199~) BUICK SKYLARK
~ CD LOG NO 81-1
STD 4DOOR SEDAN
OTHER PARTS
LINE ITEM MA_RKUP
PARTS TOTAL
TAX ON PARTS @
6.000%
LABOR
I-SHEET METAL
2-MECH/ELEC
3-FRAME
4-REFINISH
5-PAINT MATERIAL
LABOR TOTAL
TAX ON LABOR
SUBLET REPAIRS
TOWING
STORAGE
RATE
42.00
50.00
45.00
42.00
26.00
REP~CE HRS ~PAIR HRS
4.0 4.0
2.0
@ 6.000%
GROSS TOTAL
NET TOTAL
ADP SHOPLINK U9956 ES CD LOG 81-1 DATE 10/31/02 03:17:22PM R6.25
PXN:N/00/00/00/00 CUM:/// HOST LOG
(C) 1998 2002 ADP CLAIMS SOLUTIONS GROUP, INC.
275.00
68.75+
343.75
20.63
336.00
90.00
426.00
25.56
8t5.94
815.94
CD 10/02
PAGE 2
AUTOMOBILE CLAIM REPORT page!
Agent copy October 24, 2002
Reporting agent: NANCY WALLACE Agent code: I5-3615 Init: NLW
Claim%:
Claim rep:
iNSURED ................................................... - ............... --= .............. - ............
Coverages: A 250/500/!00, C5000, H, U 250/500, W 250/500
Policy number: 016 3671-F!!-!5 Insured: RYDER, JOSEPH C & KAREN
Agent phone: {3!9) 582-6942
Claim office: DUBUQUE CSO
Claim rep phone:
Date of loss: 10-24-02
Time of loss: 10:15 ~
Date reported: 10-24-02
Address: 2836 iNDIANA AVE
City: DUBUQUE
Phone: H 563-583-1977
Contact:
St: IA Zip: 52001-5415
B 563-543-!679
Location of loss: BROWN ST AND UNiVERSiTY AVE City: DUBUQUE St: iA
VN!CLE ! .......... - ................ - ................................... - .............................
Insured vehic!e/year/make/model/bodystyle): 90 BUICK SKYLARK 4DR
VIM: iG4NV54U!LM082542 License namber/state: /IA Involved in loss? YES
Prior damage:
Principal damage: PASSENGER FRONT END Driveable? YES
Location: WITH INSURED
Driver: RYDER, KANEN
VEHICLE 2 - ~- .................................................. - ............ --- =- ................ = ..........
Year/make/model/bodystyle: 98 !WTL 4900 GARBAGE TRUCK
License nmmber/state: /
Principal damage: Driveable? YES
Location: CITY GARAGE
Insurance co: IOWA COMMUNITY ASSURANCE Policy number:
Owner:
Address:
City:
Phone:
St: ZiP:
Driver: Address:
City: St: Zip:
Phone:
FACTS .................................... - .............. - ................................. - ...............
INSURED WAS TURNING RIGHT ONTO UNIVERSITY AVE FROM BROWN ST AND THE CITY GARBA Police report made? YES
GE TRUCK WAS IN THE WRONG LANE AND THEY COLLIDED. Dept where reported: CiTY OFFICE
Report nmmber: 02-49351
Insured violation? YES mescrib6: FAILURE TO YIELD AT A STOP SIGN
Clsimant violation? YES Describe: DRIVING IN THE WRONG LANE
OTHER PARTIES TO THE LOSS ....... = .................... = ................. == .............. = .....................
Veh No. 1 Name: RICHARDSON MOTORS Address: I475 JFK Facility ID = 0JQE
City: DUBUQUE St: IA Zip: 52001
Phone: B 563-582-5411 Ext: Ext:
Comments: Party type: SERVICE FIRST