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Claim by Arthur Cotton_ _ _ ___ tip ~ ~ ~ ~L;~tM ~. CLAIM AGAINST THE CITY OF DUBUQUE, I©WA 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 13t" 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: (~'~w~--\~w~.~r ~ Q ~\'\-~~r~ 2. Address: ~~L~ \1~ 1\ ~,.~` . -~~ ~ `~A~\'~~.~,~ `~ ~C ~ ~ 1 3. Telephone Number~slC~~~ ~1~ \\ ~~~~ 4. Date of Incident: ~C~\ \~~\ (~ 5. Time of Incident: \ i ~ `. C~ ,1 ~'y~ 6. Location of Incident (Be specific): ~? ~~ ~y tviC `J\V ~.C~ \~ , ~;:;~~^ :~\h `,-=~ ~'<~~CEEC~E'C1 -~c~ ~ca \ ~ -i 4~ZE ~i`c~1 ~ C£ E~ ~ 8. What were weather conditions like? ';1~ ~ ~~. C ~'`~ :~~<`l ; ~, C ~~ ". ~'~ `J C\~"C't yr 9. Give name and address of any witnesses: \~:~'~ \ r~\1~~1 3~1 ~t'~1` `~ ~S \ ~}~l1'~i \~ ~•C~-t -\uC~Cr` C,c,.'rsn r-\ C7t `~ ~~ ~~ ~ 1~ ~ _~ ~ L i~-1 i I I S-{ , # .3 ~~ ~~ ~~ [ /-E 5 ,-1 t,~ 1 [ 10. Did police investigate? (If so, give names of officers.) 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 emolovee's name.) 11. Was anyone injured? (If so, give names, addresses, and extent of injuries). 13. What other damages do you claim, if any? 15. What amount do you claim from the City of Dubuque? 4~ .-1(Y~1 .(~L~ -~' (` i~~~ i ~ C'+1f( l~ ~~ ~`\(i ~ ~.\CS~~~ cl~l (l-~ 16. Why do you claim the City of Dubuque is respon IsIible? .; ('•/~ ~ c ~ ~ ~l h ~ r ' 1. ~% '~ ~c. i V~, .r ,( r"~1 r ~~' ~ -~ h n ~;- 17. Have you made any claim against anyone else for damages as a result of this incident? (If yes, give name and address.) `l1 Q 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~~~ day of ~~~~,t11~1F_~ ~~ , 20 ~ ~_ ,--. ~ ~ - =G c; t_ . - c ~ ~-~~ ~ - (_. ~ c~ ;~ (Signature) `~ ~- ~° _~- ~=~ = .~ ~ r tt~ c,a (Prin Name) 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.) 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.) Date: Estimate ID: Estimate Version: Preliminary Profile ID: BIRD CHEVROLET 3255 UNIVERSITY AVE, DUBUQUE, IA 52001 (563) 583-9121 Fax: (563) 556-4482 Tax ID: 42-0400210 Damage Assessed By: john klotz Deductible: 0.00 Claim Number: 8084 Insured: ARTHUR COTTON Mitchell Service: 912479 Description: 1989 Chevrolet Caprice Brougham LS Body Style: 4D Sed VIN= 1G1BU51E3KR178500 Drive Train: S.OL Inj 8 Cyl AO 12/22/2009 02:14 PM 8084 0 Mitchell Line Item Entry Labor Number Type Operation Line Item Description Part Type/ Part Number Dollar Amount Labor Unite 1 208420 REF BLEND L Fender Outside C 1.0 2 209310 BDY REMOVE/INSTALL L Fender Wheel Opening MIdg Existing 0.2 r 3 219090 BDY REPAIR. L Frt Door Shell Existing 10.0* 4 AUTO REF REFINISH L Frt Door Outside C 2.3 5 220240 BDY REMOVE/REPLACE L Frt Door Rear View Mirror 10113830 GM PART 231.75 0.7 6 220810 BDY REMOVE/REPLACE L Frt Door Outside Handle 20111713 GM PART 92.25 0.2 # 7 221360 GLS REMOVE/R,EPLACE L Frt Door Moveable Glass DD06137GTN 179.15 1.2 8 222140 BDY REPAIR L Rear Door Shell E~sting 8.0* 9 AUTO REF REFINISH L Rear Door Outside C 1.8 10 238021 BDY REMOVE/INSTALL L Rear Daor Trim Panel 0.4 11 223270 BDY REMOVE/INSTALL L Rear Door Outside Handle Ezisting 0.2 #r 12 224380 BDY REMOVE/INSTALL L Rear Otr Door Belt Weatherstrip E~risting 1.2 #r 13 228650 REF BLEND L Quarter Panel Outside C 1.0 14 235590 BDY REMOVE/INSTALL L Combination Lamp Lena Existing 0.4* 15 AUTO REF ADD'L OPR Clear Coat 1.8 16 AUTO ADD'L COST Paint/Materials 276.50 17 AUTO ADD'L COST Hazardous Waste Disposal 6.00 * * -Judgment Item # -Labor Note Applies C -Included in Clear Coat Calc r - CEG R&R Time Used For This Labor Operation ESTIIVIATE RECALL NUMBER: 12!22/2009 14:14:40 8084 Mitchell Data Versioa: OEM: NOV_09 V U1traMate is a Trademark of Mitchell International Copyright (C) 1994 - 2009 Mitchell International U1traMate Version: 7.0.014 All Rights Reserved Page 1 of 2 , Date: 12/22/2009 02:14 PM Estimate ID: 8084 Estimate Version- 0 Preliminary ~ • Profile ID: Mitchell Estimate Totals Add'1 Labor Sublet I. Labor Subtotals Unite Rate Amount Amount Totals II. Part Replacement Summary Amount Body 21.3 55.00 0.00 0.00 1,171.50 T Taxable Parts 503.15 Refinish 7.9 65.00 0.00 0.00 434.50 T Sales Tax ~ 7.000% 35.22 Glaea 1.2 58.00 0.00 0.00 69.60 T Total Replacement Parts Amount 538.37 Taxable Labor 1,675.60 Labor Tax @ 7.000 % 117.29 Labor Summary 30.4 1,792.89 III. Additional Coate Amount IV. Adjustments Amount Non-Taaable Costs 282.50 Insurance Deductible 0.00 Total Additional Cceta 282.50 Customer Responsibility 0.00 Paint Material Method: Rates Init Rate = 35.00 , Init Max Hours = 99.9, Addl Rate = 0.00 I. Total Labor: 1,792.89 R. Total Replacement Parts: 538.37 III. Total Additional Costa: 282.50 Gross Total: 2,613.76 IV. Total Adjustments: 0.00 Net Total: 2,613.76 This is a preliminary estimate. Additional chanties to the estimate may be required for the actual repair. ESTIMATE RECALL NUMBER: 12/22/2009 14:14:40 8084 Mitchell Data Version: OEM: NOV 09_V UltraMate is a Trademark of Mitchell International Copyright (C) 1994 - 2009 Mitchell International U1traMate Version: 7.0.014 All Rights Reserved Page 2 of 2 Date: 12/22/2009 02:39 PM Estimate ID: E9937 Estimate Version: 0 Preliminary Profile ID: Mitchell KRUSE-WARTHAN Nissan, Pontiac, BMW 600 Century Drive, Dubuque, IA 52002 Email: bthill~dubuqueautoplaza.com Tax ID: 420655341 Damage Assessed By: BILL THILL Deductible: 0.00 Claim Number: NA Insured: ARTHUR/COTTON Address: 320 HILL STREET APT#1, DUBUQUE, IA 52001 Telephone: Home Phone: (708) 441-7808 Mitchell Service: 912479 Description: 1989 Chevrolet Caprice Brougham Body Style: 4D Sed Drive Train: S.OL Inj 8 Cyl AO VIN: 1 G1 BU51 E3KR178500 Line Item Entry Labor Number Type Operation Line Item Description Part Type/ Part Number Dollar Amount Labor Units 1 208600 BDY REPAIR L Fender Panel Existing 1.0* 2 AUTO REF REFINISH L Fender Outside C 2.6 3 209220 BDY REMOVE/REPLACE L Fender Adhesive Moulding ORDER FROM DEALER d18.90 0.2 4 219090 BDY REPAIR L Frt Door Sheli Existing 3.0* 5 AUTO REF REFINISH L Frt Door Outside C 1.9 6 219690 BDY REMOVE/INSTALL L Frt Door Moulding Existing 0.2 r 7 219710 BDY REMOVE/INSTALL R Frt Door Moulding Existing 0.2 r 8 221200 GLS REMOVE/REPLACE L Frt Door Moveable Glass 20106915 GM PART d142.00 1.2 9 222140 BDY REPAIR L Rear Door Shell Existing 6.0* 10 AUTO REF REFINISH L Rear Door Outside C 1.8 11 222510 BDY REMOVE/INSTALL L Rear Door Moulding Existing 0.2 r 12 222580 BDY REMOVEIINSTALL L Rear Lwr Door Moulding Existing 0.2 r 13 228840 BDY REPAIR L Quarter Outer Panel Existing 4.0*# 14 AUTO REF REFINISH L Quarter Panel Outside C 2.0 15 900500 BDS * REMOVE/REPLACE LEFT REAR WHEEL CENTER New 160.00 * 0.2* 16 AUTO REF ADD'L OPR Clear Coat 2.2* 17 933024 GLS ADD'L OPR Broken Glass Cleanup 1,0* 18 AUTO ADD'L COST Paint/Materials 336.00 * 19 AUTO ADD'L COST Hazardous Waste Disposal 3.50 ' * -Judgment Item # -Labor Note Applies d -Discontinued by the Manufacturer C -Included in Clear Coat Calc r - CEG R8~R Time Used For This Labor Operation ESTIMATE RECALL NUMBER: 12/221200914:39:43 E9937 Mitchell Data Version: OEM: NOV_09_V UltraMate is a Trademark of Mitchell International Copyright (C) 1994 - 2009 Mitchell International UltraMate Version: 7.0.014 All Rights Reserved Page 1 of 2 Date: 12!22/2009 02:39 PM Estimate ID: E9937 Estimate Version: 0 Preliminary Profile ID: Mitchell Estimate Totals Add'I Labor Sublet I. Labor Subtotals Units Rate Amount Amount Totals II. Part Replacement Summary Amount Body 15.0 52.00 0.00 0.00 780.00 T Taxable Parts 320 90 Bdy-S 0.2 47.00 0.00 0.00 9.40 T Sales Tax @ 7.000% . 22 46 Refinish 10.5 52.00 0.00 0.00 546.00 T . Glass 2.2 55.00 0.00 0.00 121.00 T Total Replacement Parts Amount 343.36 Taxable Labor 1,456.40 Labor Tax ~ 7.000 % 101.95 Labor Summary 27.9 1,558.35 III. Additional Costs Amount IV. Adjustments Amount Non-Taxable Costs 339.50 Insurance Deductible 0.00 Total Additional Costs 339.50 Customer Responsibility 0.00 Paint Material Method: Rates Init Rate = 32.00 , Init Max Hours = 99.9, Addl Rate = 32.00 I. Total Labor: 1,558.35 II. Total Replacement Parts: 343.36 III. Total Additional Costs: 339.50 Gross Total: 2,241.21 IV. Total Adjustments: 0.00 Net Total: 2,241.21 This is a greliminarv estimate. Additional changes to the estimate may be required for the actual repair THIS DAMAGE REPORT IS BASED ON OUR INSPECTION AND DOES NOT COVER ANY ADDIONAL PARTS OR LABOR WHICH MAY BE REQUIRED AFTER THE WORK HAS BEEN OPENED UP. THE INSURANCE COMPANY WILL BE NOTIFIED. WE GUARANTEE OUR COLLISION REPAIR WORKMANSHIP FOR AS LONG AS YOU OWN YOUR VEHICLE. ACCIDENTS ARE A PAIN BUT WE MAKE THE REPAIR A PLEASURE!!! ESTIMATE RECALL NUMBER: 12!22!2009 14:39:43 E9937 Mitchell Data Version: OEM: NOV_09_V UltraMate is a Trademark of Mitchell International Copyright (C) 1994 - 2009 Mitchell International UltraMate Version: 7.0.014 All Rights Reserved Page 2 of 2 MARS, MAIL KCYLIM I, IL)! Iowa Department of Transportation 5/3Iowa Department of TransportationPP flPfice of Driver servicesOrnINVESTIGATING OFFICERS REPORT OF P O. box 92f7R Law Enforcement Case Number 01-09-58707 Des Moines, lows 5C3D6.92C4 MOTOR VEHICLE ACCIDENT Legal bnterventiOn?❑ Private Property? • Date of Accident) Time of Accident[ County Accident occurred limits L 12/1912009 09:53 Hrs. t Dubuque - 31 within corporate of (City) Dubuque • 2100 I _Age Literal Description HILL ST Q If accident occurred show general vicinity: outside of city limits "N/A" of nearest city "WA" C A On Road, Street. HILL ST or Highway At Intersection with: "NIA" T Note: Unless accident occurred at an intersection which is completely described above. use the space below to the exact 1 location from a give milepost or definable intersection, bridge, or railroad crossing, uang two distances and directions if necessary. X-Cmrdinate: 00690978 0 Distance Direction Distance Direction Y-Coordinate.04707353 N100 Ft 1 ri and "NIA" "NIA" of if Divided Highway, Provide Route Milepost Number "VA" Definable intersection, bridge, or railroad crossing Or 3RDIHILL (Cardinal) Travel Direction "NIA" Driver's Name - WELP Last First Middle Suffix Home/C ell Phone JEFFREY RICHARD (563} 589-4196 x Address 3198 KAUFMANN Ctty State Zip AVE DUBUQUE IA 52001 Date of Birth Driver's License Number Citation Charge Code 1 Citation Charge 1 9-7-321.288 FAIL TO HAVE CONTROL of Male IA A Endorsements P-N- Restrictions M Citation Charge Code 2 Citation Charge 2 Alcohol Test Given? 1 -None Teal Results: Drug Given? 1 -None lest Test Results: Citation Charge Code 3 Citation Charge 3 Citation Charge Code 4 Citation Charge 4 U Sealing Position 01 Injury Status 5 1 Occupant I Prntection2 Airbag Deployment 6 Airbag Switch Status 3 Ejection 1 Ejection Path 1 r Trapped 1 N I Transported to REFUSED Transported by. T Owner'5Name -Last First Middle Suffix Owner OfeCompany 1A1 50 3TH DUBUQUEity StatesC� 5p001 Insurance Co. Name LA COMM ASSURANCE POOL Insurance 0 Policy # License 85983 Plate # State IA Year 1999 VIN No. 4RIUNTFA62R835645 Year 2002 / Make NOV Model BUS Style BU Tow NO # Approximate Repair Cost to or Replace initial Travel Direction i Vehicle Action 01 r Speed Limit 25 Point Initial of impact 02 Most Damaged Area 02 Extant of Damage 2 Undenidef Override 1 Private? ❑ 5500.00 Total Occupants 1 Traffic Controls 01 Vehicle Cont.g 18 Cargo Body Type 01 Vehicle Defect 01 Driver Condition 1 Vision Obscured 01 Contributing Driver Crcumstances, (up to two) 08 SEQUENCE OF EVENTS I 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 Slate Year Emergency t Vehicle Type 1 Emergency Status 3 Cartier Name Address Cily State Le US DOT fir or MC # Number t Axles of Gross Vehicle Weight Rating Placard # Hazardous Materials Released? Drivers Name -Last First Middle Sulfa HometCell Phone Address City State Zip Dare of Birth Drivers License Number Citation Charge Code I Citation Charge 1 Gender State Class Endorsements NONE Restrictions NONE Citation Charge Code 2 Citation Charge 2 Alcohol Test Given? Test Results: Drug Given? Test Test Results: Citation Charge Code Citation Charge Code 3 4 Citation Citation Charge Charge 3 4 U Sealing Position Injury Status Occupant Protection Ai bag Deployment Airbag Switch Status Ejection Ejection Path Trapped N Transported to: Transported by. T Owner'sName - Last FiatART J Middle Suffix Owner Company Name 002 Address 12837 S HDYNE ST City BLUE ISLAND State IL Zip 66426 Insurance Co. Name Insurance Policy* License Plate # X932628 ' State IL Year 2009 VW No 1G1Bt1S1E3HR17Bd00 Year 1989 Mpte, `�'i Model I CAPRICE Style 4DR Tow # NO Approximate Repair Cost to or Replace !Mai Travel Direction I Vehicle Action 12 Speed Limit 25 Pornt� tivealImpact 07 Most Damaged Area 07 Extent of Damage 2 Underridel Override 1 Private? NM $ BOO ,00 Total Occupants 0 Traffic Controls 01 Vehicle Conflg, 01 Cargo Body Type 01 Vehicle Defect 01 Driver Condition I Vision Obscured 01 Contributing C Driver (up to two) rcuntstances, 28 SEQUENCE OF EVENTS First Event 21 Second Event Third Event Fourth Event Most Harmful Event (by vehicle) 21 Commercial Trailer Attached to License Plate* Power Unit State Year Attached to State Year Trailer Una: Emergency Vehicle Type 1 Emergency Status 3 Carrier Name Address City State Zip US DOT # or MC # Number of Axles Grass Vehicle Weight Rating Placard # Hazardous Materials Released? Printed At Dubuque Police Department 1211912009 05:40 PM Page 1 Form it: 01-09-58707 ACCID T E~dVIRO~:'t~~EM1T ROADWAY CHARACTERISTICS WORKZONE RELATED SEQUENCE OF EVENTS Major Contributing Circumstances NO Location of First Harmful Event 1 Weather Conditions Environment 1 Location First Harmful Event of Crash I Manner of CrashlCollisicn 6 (up to tw°) 03 Roadway 01 Type (use codes 112 only) 2g Light Conditions 1 Surface Conditions 1 Type of Roadway JunctioNFeature 01 Workers Present? HILL ST k 3RD ST D I ~ 0 c 0 D ttt I M D 0~° ..airi:~. I HILL ST I NARRATIVE Describe what happened (refer to vehicles by number) VEH #2 WAS LEGALLY PARKED NB ON HILL JUST NORTH OF 3RD ST. VEH #1 WAS NB ON HILL ST WHEN IT SIDESWIPED VEH #2 CAUSING APPROXIMATELY $1300.00 DAMAGE. DRIVER #1 WAS CITED. Officer Badge No. Time Officer Noted of Accident Time Officer Artived At Scene LINDECKER DAVE 75A 09:58 Hrs. 10:02 Hrs. Name of Agency Date of Report Investigation T.I. # Dubuque Police Department 12/19/2009 made at scene? Yes Repo iewed By Date evi~v~d Agency Specfic Other Technical Investigation Agency Printed At Dubuque Police Department 12H9/2009 05:40 PM Page 2 Form #: 01-09-58707