Claim Nicholas D. SauserCLAIM AGAINST THE CITY OF DUBUQUE
This writtenreport 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 Street, Dubuque, Iowa 52001-4864. It will the~ 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.
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 WltETHER YOUR CLAIM WILL OR WILL NOT BE
PAID.
3. Telephone
6. Locatxon of xnczdent. (Be specific)
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 employee's name. )
- . '-'
9. Give name and address of any witnesses.
10. Did police investigate? (If so, give names of officers.)
II
11. Was anyone injured? (If so, give name, address and extent Of
injuries.)
12. Was any d~m~ge done to property? (If so, describe property
and the extent of damage. Attach esti=uates 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 insuraz~ce company? (If so, give name and address of
insurance company and amount paid. )
15.
16.
What amount do you claim from the City of Dubuque?
17.
Have you made any claim against anyone else for damages as a
result of this incident? ./~9
If yeS, give name and address:
18. If the ans~er to Question 17 is yes, have you received any
payment from that source, and if so, in what amount?
Dubuque, Iowa, this --' ~/~)~ day of ~
Dated
at
2001.
(Revised January, 2000)
~i~gnat--~-re)
(Print Name)
OTTIN~ BODY SHOP
PRO TAX ~ 42-1378002
BOX 758 306 LINCOLN ST NE
CASCANE IA 52033-0758
(319) 852-3512 Fax: (319) 852-6019
ESTIHATE ~ 5123 by HARK OTTIEG
Date} 03-08-2001 Time{ 09:38 Date Writ
SAUSER / aLAN Prod Date
904 21{I). AVE. SE Remarks
CASCAQE, IA. 52033 License
Rome |852-7123
Work }
86 CHEVROLET CAVALIER
Style {TWO DOOR
~ UBSCRLETION
eul03-08-01
02/86
Set ~
Rate Code
In,Out Hi
Deductibl S0.00
EST PRICE{ LABOR{
Ins. Co.
Adjuster
A~praise
Claimant
Insured
PAINT
1 REPAIR LEFT QUARTER PANEL 6.0 2.5
2 NEE LEFT QUARTER MLDG. 20.00 0.3
3 CLEAR COAT t.0
=======================================================================================
ESTI}4ATE SUHHARY Labor Descrintive Items
PAINT 3.5 @ 38.00 133.00 20.00
BODY 6.3 @ 38.00 239.40 PAINT I4AT. 77.00
~88 0.0 @ 34.00 0.00 BODY MAT. 0.00
VEA){E 0.0 ~ 38.00 0.00 HAZARD WASTE 0.00
MECE~ICA 0.0 ~ 38.00 0.00 SUBLET 0.00
BDY-$ 0.0 @ 34.00 0.00 0.00
FORIEGH 0.0 @ 34.00 0.00 0.00
RESALE 0.0 @ 34.00 0.00 0.00
BENCH MT. 0.0 @ 30.00 0.00 TAX 0.00
OVERHEAD 0.0 @ 26.00 0.00 0.00
9.8 Labor hrs. ems 97.00
Labor 372.40
Subtotal 469.40
Tax @ .06000 23.54
Grand Total $492.94
******************* Part Prices Subject to Invoice *********************
ANTRDRIZ~D AND ACCEPTED: Ygu are hereby ~u~horized to make the. above specified r~pairs. I understand that payment,in full
wiI~ be oue upon release o~ vehicle, inctunin~ additiopal~suppl~ment~I dam~g9 charges, and h~reoy 9rant~you, ano/Qr your
empzoyees, permission to operate the car, truck or venicze ner~in oescrioeu on ssreet highways or elsewhere cur tbs
purpose pf %estin9 ~nd/or znsuectiom. An exp[gss mechan~c~ lien is hereby apknowled~ed on aBove, cas, truck or. vehicle to
secure t~e amount oz repairs %hereto~ You Will not be nero .responsible zor lOSS or oama~e to vehicle or articzes lest in
vehicle in case or fire, theft, accioent or any other cause eeyoud your control OLD PARTS ARE JUBKRD UHLHSS INSTRUCTED!
ESTIMATE authorized by ................................. date
Thank you for comin~ to our shop for your repairs.
Collision Solutions is a trademark of Co_mouSer ~esources, Inc.
uopy~"i§ht 1998 All Ri§hts Reserveu
Schell Industries
Fed ID # 42-1235~00
Damao. e Ass~$ed By: Rsnd¥
Geduc~ble: UNKNOWN
hli[chell Service: 910471
Drive Train: Z0L Inj 4 Cyi 4M
Line Entry Labor
Item Numbe¢ Type O~erat~on
Dollar Labor
Amount Units
03~§90 BDY REPAIR
AUTO REF REFIN!SH
0353~0 E~DY REMOV~REPLACE
933002 REF ADD'L OPR
AUTO ADD'L COST
L QUARTER OUTER PANEL
L QUARTER PANEL OUTSIDE
L RF-AR QUARTER PROT~'CT [~OULDING
CLF-AR COAT
PAiNT/MATERIALS
"- Judgement Item
# - Labor Note Applies
d - Discontinued by the Manufacturer
74.80*
Units
7.2 3S.O0 0.60 0,00
3.4 38.0G 0.00 0.00
~.o00%
I. To[al L~bor:
22.00
of 2
This is a preliminary estimate,
Additional cha~,qes to'the estimate may be required for the actual repair.
525.09
Page