Claim by Ron and Ann BurdsI~~`;~'
CLAIM AGAINST THE CITY OF DUBUQUE, IOWA
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 13~' 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: ~cm ~ /~r~n C3vrdS
2. Address: 131t N Granc9~tct,:3 ~u6v~vv i~ -~~~i
3. Telephone Number: Sfo3 `; SL ~ ~ 3 `'i /inn 1.. c.~ 5 ~ ~ ' S 8 `t- FSCU'7~
4. Date of Incident: ~ Z~i'7~U`i
5. Time of Incident: ~~ ~ S~- ISM
6. Location of Incident (Be specific): Z9 i sand off - ~ ~b vc; w~, i A
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.)
C ;-{-y ~ .wir~l~~e~ C a~~.w~szs ~~i+i-r 1 ~os-~ ~ ~~-~~ ~~
~~ n c~ c~~ I;s ~ o ~ b~~-e-rl 1~_ -Irvc~ . My oar l~s_c~ ~-~-) a ~fil ~~ Qcie~ av~
8. What were weather conditions like? Caid , ~r~, ,~' 1 l_ ' ~ '~`~ rG~ tPCI/~~CI~ '
9. Give name and address of any witnesses: ~c{.W~.S w~ ~~1 - l(O ~~ d~ ~ W ~ ~~d
r 1
10. Did police investigate? (If so, give names of officers.)
vas ~~~ ~1~~'eS
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.)
r<=~ttC./~StyG c~cc.rnc~c„~, fiC~ body U~ G~L~94 ~'i~ ~~c~.vQ-
>_~ss er1 Pr-~ many t!5ot`~ Gc~C%~'. 'I'r~x.~0.to~r1 .
r' :f-s
13. What other damages do you claim, if any? ~~ PAC ~n~ c>~
~ e QeaC~r w~ ~A~~ ~ ca a~~ as%- ~n~ ~o~,n ~~'t ar, ~ -~->r-~ri~C ~'c c^
~~ r~ t-~ -}~tn~c~{ ~4-,` MCA
14. Have you been compensated for any part or all of your claim by any insurance company? (If so, give name a
address of insurance company and amount paid.)
15. What amount do you claim from the City of Dubuque?
:~i Qp1'~ maLc. ~~.-- itcbe~un~ ~~
S4~1~ . 7 FS~
CY.~r. Pt~s ~'e-ntr~.Q ~e~~~ i~ ~cl.cd
16. Why do you claim the City of Dubuque is responsible? ~~clr~- +- dc~.mctc,~A ~.%vtz--
C~c3' ~ ~ f t p~ C ~ t Y ~rY~ fo ~~ac.~- ~ cl.,~ i V ~. o~ q Ccn1~r~. ~~ rc~c_l~~
i,J ho [air. Cont-ro~ ~;{ 01 Lh ~ c1t.t . h ~ ~ i nc~ ~ (acc~J'L.jr_C~ Ccw
17. Have you made any claim against anyone else for damages as a result of this incident? (If yes, give name and
address.)
No
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 i-I day of ~~M~ , 20 0~.
(Signature)
~, ~~5 A>1~, B~.~ds
(Print Name)
C7 ~a
~.^
~r
J
~ ^
C_ /
~ _ l
` ~ - ?~
~_ - ~ i
•
CD ~-
0
Date:
Estimate ID:
Estimate Version:
Preliminary
Profile ID:
BIRD CHEVROLET
3255 UNIVERSITY AVE, DTIBUQi7E, IA 52001
(563) 583-9121
Fax= (563) 556-4482
Tax ID: 42-0400210
Damage Assessed By: john klotz
Deductible: 0.00
Claim Number= 8070
Insured: AELX BURDS
Address: 1311 N GRANDVIEW, DUBUQUE, IA 52001
Telephone: Home Phone: (563) 451-7929
Mitchell Senrice: 916492
Description: 2002 Chevrolet S10 LS
12/17/2009 01:19 PM
8070
0
Mitchell
Body Style= 3D PkupRCb 6' Bed 122" WB Drive Train- 22L Inj 4 Cy12WD
VIN: 1 GC CS 195728164068
OEM/ALT: O Search Code: None
Options VEHICLE ANTITHEFT, PASSENGER AIRBAG, DRIVER SIDE AIRBAG, POWER STEERING
MANUAL AIR CONDITION, CRUISE CONTROL, TILT STEERING COLUMN, ANTI-LOCK BRAKE SYS.
ALUM/ALLOY WHEELS, LEATHER STEERING WHEEL, CD PLAYER, PRIVACY GLASS
FRONT AIR DAM, CLOTH SEAT, TACHOMETER, AUTOMATIC HEADLIGHTS
DAYTIME RUNNING LIGHTS
Line
Item Entry Labor
Number Type
Operation Line Item
Description Part Type/
Part Number Dollar
Amount Labor
Unite
1 700257 BDY REMOVE/REPLACE Replace Pickup Bed Assy Qual Recycled Part 1,500.00 * 2.5
2 AUTO REF REFINISH Pickup Bed Components C 8.5 #
3 Line Markup %25.00 375.00
4 700259 BDY REMOVE/REPLACE R Rear Combination Lamp Qual Recycled Part INC 0.3
5 700260 BDY REMOVE/REPLACE L Rear Combination Lamp Qual Recycled Part INC 0.3
6 *** END OF ATG SECTION ***
7 AUTO BDY OVERHAUL Frt Bumper Aasy 1.6 #
8 600106 BDY REMOVE/REPLACE Frt Bumper Face Bar 15094048 GM PART 261.92 INC
9 600138 BDY REMOVE/R.EPLACE Frt Bumper Impact Strip 15716712 GM PART 36.31 INC
10 60014.5 BDY REMOVF,/RF,PLACF, Frt Bumper Filler To Bumper 15015660 GM PART 43.31 TNC #
11 632145 BDY REMOVE/REPLACE Frt Bumper Air Deflector 88967923 GM PART 73.50 INC #
12 AUTO REF REFINISH Frt Air Deflector C 1.6
13 600175 BDY REMOVE/R.EPLACE L Frt Bumper Brace 15716713 GM PART 26.31 INC #
14 632154 BDY REMOVE/REPLACE Grille 19180339 GM PART 179.55 0.2
15 AUTO REF REFINISH Grille C 1.0
16 600155 BDY REMOVE/REPLACE Grille Moulding 12470331 GM PART 94.95 INC #
17 600405 BDY REMOVE/R.EPLACE Grille Emblem 15634687 GM PART 19.83 INC #
18 626750 8DY REMOVE/RF,PT,ACF, Tailgate Shell 12389420 GM PART 360.56 1.3 #
19 900500 BDY * REPAIR LKQ CLEAN UP E>vating 3.0*
20 AUTO BDY OVERHAUL Rear Bumper Asay 0.4
21 602054 BDY REMOVE/REPLACE Rear Bumper Face Bar ** QUAL REPL PART 390.00 * INC
22 COMPLE_4TE HIT
23 AUTO REF ADDZ OPR Clear Coat 3.0
24 AUTO ADD'L COST Paint/Materials 493.50
25 AUTO ADD'T, COST Hazardous Waste Disposal 6.00 *
ESTIMATE RECALL NUMBER= 12/17/2009 13:19:02 8070
Mitchell Data Version: OEM: NOV_09_V U1traMate is a Trademark of Mitchell International
Copyright (C) 1994 - 2009 Mitchell International Page 1 of 2
U1traMate Vereion: 7.0.014 Al] Rights Reserved
Date: 12/17/2009 01:19 PM
Estimate ID: 8070
Estimate Version: 0
Praliminarv
Profile ID: Mitchell
* - Judl?ment Item
# -Labor Note Applies
G -Included in Clear Coat Calc
Estimate Totals
Add'1
Labor Sublet
I. Labor Subtotals Units Rate Amount Amount Totals II. Part Replacement Summary Amount
Tandy 9.6 55.00 0.00 0.00 528.00 T Taxable Parts 2.98624
Refinish 14.1 55.00 0.00 0.00 775.50 T Parts Adjustments 375.00
Sales Tax @ 7.000% 235.29
Taxable Labor 1,303.50
Labor Tax dal 7.000 °~6 91.2.5 Total Replacement Parts Amount 3;596.53
Labor Summary 23.7 1,394.75
III. Additional Costa Amount IV. Adjustments Amount
Non-Taxable Costs 499.50 Insurance Deductible 0.00
Total Additional Costs 499.50 Customer Responsibility 0.00
Paint Material Method: Rates
Init Rate = 35.(1(1 , Init Max Hours =99.9, Addl Rate = 0.(1(1
I. Total Labor: 1,394.75
II. Total Replacement Parts: 3,596.53
III. Total Additional Coats: 499.50
rmss Total: 5,490,78
IV. Total Adjustments: 0.00
Net Total: 5,490.78
THIS ESTII+JPiTE HA3 BEEN PREPARED BASED ON THE USE OF AFTERMARF~T CRASH
PARTS 3UPPI,IED BY A SOURCE OTHER THAN THE MANUFACTURER OF YOUR MOTOR
VEHICLE. ANY WARRANTIES APPLICABLE TO THESE REPLACEMENT PARTS ARE
PROVIDED BY THE MANUFACTURER OR DISTRIBUTOR OF THESE PARTS RATHER THAN
THE MANUFACTURER OF YOUR VEHICLE.
This is a prel;m;narv estimate.
Additional changes to the estimate may be required for the actual repair.
ESTIMATE RECALL NUMBER: 12/17/2009 13:19:02 8070
Mitchell Data Version: OEM: NOV 09 V UltraMate is a Trademark of Mitchell International
Copyright (C) 1994 - 2009 Mitchell International Page 2 of 2
IJ1traMate Version: 7.0.014 All Rights Reserved
Dec. 23. 2009_r 2;08P
.No. 5922-P. 2
DlNafe Name -la:l First Middle SUlfix Hortielt:etl Ynone
MEYER COURTNEY MARIE 69J 642805 x
Addreae Clb Elflle Zb
9470AdAIRST DUBU UE IA 52001
Dale of BIRh Drlvor': Llun:a Number Cilalion Charge Code 1 Cilalion charge 1
09f7~11983 120ACS33~
Gondar Stele Glsea Endoraemenlo Reslricllana Cllallon Charge Goda Z Cilorlon Charge 2
Female IA C NONE NONE cn
ll
Alcohol Teet
Dlug Teel e
on cnar0e code s Ctlallon CnerOe 3
ONerr7 Te=l Rasulls: .Olven7 Tea Ra:ulls: Citnlbn Charge Code 4 Cilalion Charpa d
1 • None 1 -None
U Saaling Poshlon0l Injury Slatua 6 lJuupanl Proteclion2 Airbag Deployment S hGbap 6v/IchSlslue 9 F,jeGlon 1 FJerAlon Peln 1 Trappsd 7
N
I TranepoRed lo: 7renapo ad y,
. T own ~
a Name. LaaL COU MARI suf(hC OLVnarCampany Neme '
R RTNEY E
003 Adtlreas
1470ADA[R ST Cip~
DU9000S 81fl1e
IA ztP
62001
Insurance Cw Nams Insurance PolicyW Licenee Plafe B 8lela Year
pROGRE6SIVECASUALTY 30917599-0 921WRP IA 2070
VIN No. Year Make Model 9tyte Tow IF approrimale Cosl lc
iFALPe534T1(1@4T@o 1888 FOrd•FORD CNT 4b YE9 RepeirorReplace
IniGalTravet VeNcle Ceed PolMo( MoatDamegad Exlanlol Undenldar Plfvalo7
^
Dfracuon 3 Acnon 01 Llmll 26 InillalYmpacl 08 Arne OD Remage 6 Override 1 52,50D.00
Totol 7ratflo Vehkle Cargo Body Vehida DlNet Vision Conl(ihuling CkGJmalanCea,
Occupenle 1 Controls 01 ConAp. 01 Type Ot Oa(aol 01 GondRlon 1 Ohecurad 01 Driver (uD to Mro) 29
SEQUENCE OF EVENTS Flraf Event 25 Second Evenl Third Evenf FouAh Evanl Moer Harmhil Event (byvenlde) 29
CommerdalTrailer Afleehedto Slele Year Attached to Blala Year EmegencY Emergency
LloenaaPlalelG poworUnil: TrailerUnie VehidaTyoe 1 SIaWa 3
Carrier Name Addreee Clb Sle(a Ztp
USDOTk or MCfe Numberor GrosaVenicle PlacerdN MfltardauaMaledefs
Axlae Welpnl Rallnp Ralerasad7
{f ProFaRy olhar lhan pbjeA Damaged ESlimale of Was ovmer or
ven)crea damaged explsln eLeCTRICAL POLE Dflmege
S6r000,00 lananl nolMed7
Yee
nafaNsme-Las flra idle uffur CompanyOvmerName
ALLIANT ENERGY ALLIANT ENERGY
SVoelorRFD City Slale 2ipCode
DUBU4U2 IA 610D1
ACCIDEN7ENVIRONMENT ROADWAY CHARACTERISTICS WORKZONE RELATE07 SEQUENCE OF EVENTS
Mato! ConUiGuCutg Cln:umaleNOas: No
tocallon of Flra[ HarmNl Event 1 Wealnor Condldan: Envirenmanl 1 Lowlion FIraPNflrmful Evenf of Crean
Mennerol CrasWColtiaial 3 (up to Iwv) 02 Roadway p1 Type (use Codas 112 only) ~ p3
Llehl Condillona - 1 Surface Condilbna 1 Typo o(RoadwayJUnalloN~aoluro 01 Workers presenFT
f `L~ ~ , .
D
I
G
I _. ap3
R
A
M
- - -~ fl1
•
W.3R0 S7.
NARRATIVE
besorlbe wh@t happened (refer In vehlclee by numher)
MV#1 (A CITY REFUSE TRUCK) WA5 COLLECTING RECYCA9LES ON CARDIFF S7. DRIVER OF #1 WAS OUT OF THE
TRUCK AND HAD ENGAGED THE HOPPER CAUSING THE TRUCKS ENGINE TO REV UP.
MVt21 JUMPED THE SET EMERGENCY BRAKE ANb BEGAN RUNNING bOWN CARDIFF S7. DRIVER OF ~f1 JUMPED BACK
INTO MV#1 1N AN ATTEMPT TO STOP IT. MV #1 RAN INTO MVt~2 WHICH WAS PROPERLY PARKED ON CARDIFF ST. MV#
WAS PUSHED OUT 1NT0 THE SB LANE OF CARDIFF ST. STRIKING MV#3 WHICH WA5 J3EING DRIVEN S8 BY DRIVER ~F3.
MV#i CONTINUED NB ON CARDIFF ST. STRIKING A UTILITY POLE OWNED $Y ALLIANT ENERGY, THE ROLE WA5
SHEARED OFF.
Prlnled A7: Dubuque Pallce Departmehl12177l2009 02:19 PM P0g@ 2 Form b: 01.09.69di6
Dec. 23.~ 2009 ~ 2.09PM NARRATIVE No. 5922-P. 3
Describe whal happened (refer to vehleles by number)
NO INJURIES REPORTED.
ORlear
8ABER9 DAN Bndga No.
60 Time pfficnr Nolmed of Accident
09:1Y Mre. Time Oar Artived AS Scene
09:70 Hra,
Neme olApency
bubu ue POllte bep en{ Dele of Report
12l17f2009 Nvesllgalbn
made alscene9 Yee T.I. S
ReportRe~i By. „
P~ d DaleR vie
~ s!~ d ency50ecI11c OlherTecMicallnveellgellonAgency
PrlntedAk Dubuque Pollce Department 1 2117120 0 9 0 2;19 PM Page 9 Form p: 01.08.66478
Dec. 23. , 2009 •2:08PM
No, 5922
HARE btA1LREPORTS TO:
Iowa Department of Transportation
sAo bwaDapeAmenlofTrenspotlalbn ei
Office of Driver 8enncas "A
F.O. Box 9704 INVESTIGATING OFFICERS REPORT OF
Law FnforcementCafe Number:
01 09 68416
Des Moines, Iowa 6oso6-9204 . MOTOR VEHICLE ACCIDENT
Legal
Inrarvendon?
Private
Property? ❑
L
Dale of Aoclden!
1211712009
Time of Acoldem
00:62 Hre.
County •
Dubuque -31
Accident occurred within corporale limile o )
Dubuque-2100
Location Literal Deacriplion
W3RbSTand
CARDIFF STenc
1.1 o
If accident occurred
show general vicinity,
outside of city
Odle
"NIA" or cereal oily "N/A"
SUMMIT ST
C
A
On Road, Street,
CARDIFF ST
or Highway:
Al Intersection with:
W. 3RD ST
T"
Note Unless
Interaeclbn N above; the apace below to give
1
accident
Vocation from a
occurred at
mllepoel or definable
an which completelydescnroed use the exact
Intersection bridge, er railroad croeeing, using two distances and directions If necessary.
XEoordfnala: 00681s1B
0
Distance
Direction
Distance Direction
Y-coordinate; 04?07324
N
"NIA"
"NIA"
and "NIA" "NIA" or
17 Divided Highway.
Provide Route
Milepost Number
"NIA"
Definable Intersection, bridge, or railroad crossing
Or "NIA"
(Cardinal) Travel
NB
Direction
DrivernName -
WELTY
Last
(Iran Middle Suffer Home/CellPhone
JAMES ROBERT
Address
18435 OLD HWY
ROAD
City Stale Tip
PEOSTA IA 62086.0000
,
Dale of BIM
Orreer's License
Number
Citation Charge Coda 1 Citation Charge 1 ,
Gender
Male
Stale
fQ
Class
A
Endorsemenle
Lid
Reelridlone
NONE
Citation Charge Code 2 Mallon Charge 2
Citation Charge Code 3
Alcohol Teal
elvers?
1.Nona
Test Results:
Drug Toot
Given?
1-None
Teal Results;
, Citation Charge 3
Citation Charge Coda 4 Mellon Charge 4
V
Sealing Posilien88
Injury SIalue
6
Occupant Protaetionl
Airbag Deployment 6
Airbag Switch Statue 3
Election 1
Ejection Path
1 Trapped I
N
Transported to;
Transported
by.
T
CI Y OF DU9UQUE
First
Middle
$u(for
Owner Company
Name
o1],I
Address
925 KERPER
BLVb
Cittyy
DUBUQUE
Slate
IA
Zip
02004
•
Insurance Co. Name
IOWA COMM.ASSURANCE
Insurance
ICAP0300
Policy el
Limners
84633
Male #
Slate
IA
Year
2020
VIN No.
1pVAEXAH?1HJ17234
Year
2001
Make
FRGT
Model
Style Tow#
TK
NO
Approximate
Repair
Coat to
or Replace
-.Initial Travel
Direction 1
Vehicle
Action 01
Speed
Limit
25
Point of
Irdeal impact 01
Most Damaged
Arca 02
Extent or
Damage
2
Undenidel Private?
Overnde 1
❑
$9,000.00
Total
Occupants 1
Traffic
Controls 01
Vehicle
Coring.
06
Cargo Body
T pe
08
Vehicle
Defect 02
DRver
Condition
1
Vieion Contributing
Obscured 01 Driver
C
(up to two)
rcumelancee,
28
SEQUENCE OF
EVENTS I Firs)
Event
09
Second Event
07
Third Event
23
Fourth Event
21 Most Hamad
Event (by vehicle)
21
Commercial Trailer
License Pieta C
Abseiled
Power Unit:
in
Stale
Year
Attached to
Treiler Unit:
Stale Year
Emergency
Vehicle Type 1
Emergency
Statue 3
Carrier Name
'
Address
City
Slate T)P
U8 00T #
or MCP
Number of
Axles
Gross Vehicle
Weight Rating
Placard
#
Hazardous Malarfala
Released?
briva?sName -Lost
.
First
Middle
Surfer
Home/Cell Phone
Address
City
Stale
Zip
Date of girth
Drlvefe License
Number
Citation Charge Code
I
Citation
Charge 1
Gender
Slate
Class
Endoraemanls
NONE
Realrletlons
NONE
Citation Charge Code
Citation Code
2
Citation
Charge 3
Acohol Tent
Given?
Teal Reaulls:
Drug
Given?
Tact
Test R.eeulls:
Charge
rg
Citation Charge Code
4
Citation
Citation
Charge 3
Charge 4
U
Sealing Position
injury Status
Occupant
Protection
Airbag
Deployment
Airbag Switch
Status
Election
Ejection Path
Trapped
N
I
Transporied to:
.
Transported by.
T
SURDS Name -Leal
Find
Suffix
Owner Company
Name
002
1311 r10RANDVIEW
CUE000E
pprrMoHie
IState2
62001
Insurance Co. Name
Insurance
Policyw
Licence
033LOP
Plate a Slate
IA
Year
2003
YIN No.
10CCS1ee723164066
Year
2002
Make
Chevrolet
-
CHEV
Model
Style
Tow
NO
it
Approe
Repair
male Cost to
or Replace
Initial Travel
Dlreodon
Vehicle
Action .12
Speed
Limit 25
Point
InntelImpact
of
06
Moat Damaged
Area 05
Ettentof
Damage 3
Undenlder
Override 1
Prtvato?
❑
$2,000.00
Total
Occupants 00
Tremc
Controls 01
Vehicle
Conng.
02
Cargo Body
Type 01
Vehicle
Defect 01
' Driver
Condition 8
Vision
Obea.rred 66
Contributing
Driver
C rctanalancea,
(up toNro)
28
SEQUENCE OF EVENTS Firer Event 21
Second Event
Third Event Fouts Event MD I Harmful
EveN (by vehicle)
21
Commercial Trailer Attached to
Uoense Plate C Power Unit
Stale Year
Alleched to Stale Year
Trailer Unit:
Emergency
Vehicle Type 1
Emergency
Statue 3
Carrier Name
Addreae
City
Stale 21p
US00Ta or MC
Number of
Axles
Gross Vehicle
Weight Rating
Placard:
HazardousMaterlela
Released?
Punted Al; Dubuque Police Gepertmen(1211TI2008 02:18 PM
Page I
Form C:01.09.50416