Claim by Darlene Ryan4 7/ /lam
CLAIM AGAINST THE CITY OF DUBUQUE, IOW
2
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 W. 13 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 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: Di'kiie_
fib 11
2. Address: / � ] (p) Pp iSi-D 1 0 r
3. Telephone Number: 5 ' c Lea(/*
4. Date of Incident: 9 / 2 � /
5. Time of Incident: a:/ D PIY1
6. Location of Incident (Be specific): On 30th i par ked h" TI1�1�
O I-to I 6hbs1 ,S ihn 1 Eifi'a cc- -
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.)
vas park 3o a i n - &ron+ of Holy GMs frwc--
tad- - then k I 1oe, 7 tnsi 1- nit �1i [u 5 artirq- Rona( i)'t�Kc a
'teg� Pf-cel -to pa , , n { rcx+- 4F , u m, s ude d 4& d r anCR.
8. W hat were weather conditions like? ci IA f 1+1, . #r a,n•1 - A r1 ex 5 CCr
6 ��� 1 C, rill its hk.. put 1 r n
9. Give name and address of any witnesses: T (a& y to Rf. ' L Sot 550 71
Er n'Iy Oe14 Row 6n,insu)ick SA
10. Did police investigate? (If so, give names of office
e„ Uffic AI i 611014 Jobc &coke. Cam
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
0 J but
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.)
11Ii Je ma fo - Frnf C vrne,r panel - b- m pe, , door
`Ni
he a 1 1, -ti 1 . 15 coopy c `eshmak. ,r mat 1 .
13. What other damages do you claim, if any? + O A ' a . da mays aS I . 39
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. W at amount do you clam fro the City of Dubuque?
as-11,z - -�� x-td fc m a i s cti on Wa Vt f hla� -r
u ril 4 fv orilina ( c&d f i O
16. Why do you claim the City of Dubuque is responsible?
� a n fiic Risen- do 1nsrt S he GOhcn ri rg tn9 -1-o pa
bus ‘1,0 ', b i c 1-(1 - Le-
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.) �)
o
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 1 la day of 06-obe-r , 20 10.
(Rev. 1/00 & 7101)
N
(Signature)
I} 4 you u (Print Name)
0
rn
0
Damage Assessed By: john klotz
Deductible:
Claim Number:
Insured:
Address:
Telephone:
Description:
Body Style:
VIN:
OEM /ALT:
Options:
0.00
8819
darleen ryan
1765 bristal, dubuque, IA 52001
Home Phone: (563) 582-3434
2007 Chevrolet TrailBlazer LS Drive Train: 4.2L Inj 6 Cyl 4WD
4D Ut
1GNDT13S2721
0 Search Code: None
VEHICLE ANTI- THEFT. PASSENGER AIRBAG, DRIVER SIDE AIRBAG, POWER LOCK
POWER WINDOW, POWER STEERING, MANUAL AIR CONDITION, CRUISE CONTROL
TILT STEERING COLUMN, ANTI-LOCK BRAKE SYS., ALUM/ALLOY WHEELS
TIRE INFLATION/PRESSURE MONITOR, SATELLITE RADIO, CD PLAYER, TOW HITCH RECEIVER
4WD OR AWD, FRONT AIR DAM, TINTED GLASS, FIRST ROW BUCKET SEAT
SECOND ROW SPLIT BENCH SEAT, SECOND ROW FOLDING SEAT
REAR HEATING, VENTILATION & AIR CONDITIONING, CLOTH SEAT, EXTERIOR RAILS
TACHOMETER, AUTOMATIC HEADLIGHTS, VEHICLE THEFT TRACKING/NOTIFICATION, STAR DDAYTT RUNNING LIGHTS
ne Entry Labor
em Number Type Operation
i AUTO BDY OVERHAUL
000015 BDY REMOVE/REPLACE
AUTO REF REFINISH
007510 BDY REMOVE/REPLACE
i AUTO BDY CHECK/ADJUST
000309 BDY REMOVE/REPLACE
i AUTO REF REFINISH
AUTO REF REFINISH
000894 REF BLEND
10 006800 BDY REMOVE/INSTALL
t 1 002033 BDY REMOVE/INSTALL
t2 006930 BDY REMOVE/REPLACE
[3 001046 BDY REMOVE/INSTALL
14 AUTO REF ADD'L OPR
t5 933005 BDY ADD'L OPR
16 933018 REF ADD'L OPR
17 AUTO ADD'L COST
18 AUTO ADD'L COST
BIRD CHEVROLET
3255 UNIVERSITY ) AVE, DUBUQUE, IA 52001
Fax: (563) 690-1423
Email: johnklotz @birdchevrolet.com
Tax ID: 42.0400210
Mitchell Service: 910501
Part Type/
D ine Item part Number
Description
Frt Bumper Cover Assy
Frt Bumper Cover
Frt Bumper Cover
L Frt Combination Lamp Assembly
Headlamps
L Fender Panel
L Fender Outside
L Add To Edge Fender
L Frt Door Outside
L Frt Otr Belt Moulding
L Frt Door Adhesive Moulding
L Frt Door Rear View Mirror
L Frt Door Handle
Clear Coat
Restore Corrosion Protection
Mask For Overspray
Paint/Materials
Hazardous Waste Disposal
ESTIMATE RECALL NUMBER: 09 /20/2010 16:52:40 8819
Mitchell Data Version: OEM: AUG_10_V Ulc pMag Mitchell
(C) 1994 2010 A hell International International
UltraMate Version: 7.0.022 All Rights Reserved
Preliminary
Profile ID: Mitchell
88937008 GM PART
25970915 GM PART
12477993 GM PART
Dollar Labor
Amount Units
1.4 #
419.51 INC #
C 2.5
313.38 0.3 #
0.4
255.72 1.6 #
C 2.2
C 1.0
C 1.0
0.3
Existing 0.4 r
ORDER FROM DEALER 318.90 0.3 #
0.6 #
1.8
4.00 * 0.2*
10.00 *
297.50 *
6.00 *
Page 1 of 2
Add'I
Labor Sublet
I. Labor Subtotals Units Rate Amount Amount Totals II. Part Replacement Summary Amount
Body 5.5 57.00 4.00 0.00 317.50 T Taxable Parts 1,307.51
Refinish 8.5 57.00 10.00 0.00 494.50 T Sales Tax @ 7.000% 91.53
Labor Summary
L Additional Costs
* - Judgment Item
# - Labor Note Applies
C - Included in Clear Coat Calc
r - CEG R &R Time Used For This Labor Operation
Estimate Totals
Estimate ID: 8819
Estimate Version: 0
Preliminary
Profile ID: Mitchell
Taxable Labor 812.00 Total Replacement Parts Amount
Labor Tax @ 7.000 % 56.84
14.0 868.84
Paint Material Method: Rates
Init Rate = 35.00 , Init Max Hours = 99.9, Addl Rate = 0.00
Amount IV. Adjustments Amount
Non-Taxable Costs 303.50 Insurance Deductible 0.00
Total Additional Costs 303.50 Customer Responsibility 0.00
I. Total Labor= 868.84
II. Total Replacement Parts. 1,399.04
III. Total Additional Costs= 303.50
Gross Total: 2,571.38
IV. Total Adjustments: 0.00
Net Total: 2,571.38
This is a preliminary estimate.
Additional changes to the estimate may be required for the actual repair.
ESTIMATE RECALL NUMBER: 09 /20/2010 16.5240 8819
Mitchell Data Version: OEM: AUG_10_V UltraMate is a Trademark of Mitchell International
Copyright (C) 1994 - 2010 Mitchell International
UltraMate Version: 7.0.022 All Rights Reserved
1,399.04
Page 2 of 2
. Printed At: Dubuque Police Department 08/2012010 03:66 PM
Page 1 Form #: 01-1045896
Driver Information Exchange Report
Dubuque Police Department
U
Driver's Name - Last
MCKIERNAN-TRONALD
First - I Middle t
i JOSEPH
Suffer
Date of Birth
N -
Address
13036 CIRCLE RIDGE ROAD
City 1 State
SHERRILL I IA
Z'p
52073-0000
Home/Cell Phcne
(553) 552-2007 x
I
'
TMale
Gender - Driver's License Number
plans State
TC,M LIA
Endorsernents
P
Restr,c:ions
L
Insurance Co. Name
ICAP
Insurance Ca. Phone #
001
Owner Company Name •
CITY OF DUBUQUE
insurance Policy
#
Owner's Name -Last First
1 Middle
Suffix
Address
60 W. 13TH
City State
�DUBUQUE IA
Zip
62001-
VIN No.
1 FDXE4OS3WHA64144 j
Year I Make
1998 I FORD
Model
E-SUPER DUTY
Style TVehicle
MINI BUS
Configuration
19
License Plate # f State
111985 IiA
Year
Most Damaged Area
02 Right Front
Approximate Cost to Repair or Replace
$100.00
u
Driver's Name - Last
RYAN
First
DARLENE
Middle
MAE
!Suffix
a of Birth
N
Address
1766 BRISTOL DR
City State
DUBUQUE I IA
Zip
52001-0000
HomerCell Phone
(563) 562.3434 x
,
Gender
Female
ben 1 Class
C
State Endorsements
IA NONE
Restrictions
B
L
insurance Co. Name Insurance Co. phone #
WESTFIELD (563) 556-0272 x
002
Owner Company Narrie
Insurance Policy #
WNP7049664
Owner's Name - Last First i Middle 1
RYAN 1DARLENE MAE
Suffix
Address
1766 BRISTOL DR
_I
City •• I State
DUBUQUE I IA
Zip
62001-0000
VIN No.
1GNDT13S272160415
Year
2007
Make
1 CHEV
Model
TBZ
Style
SW
Vehicle Configuration
04
License Plate 0 1
039AVU I
Sta a
IA
Year Most Damaged Area
2007 1 08 - Left Front
Approximate Cos! to Repair or Replace
$1.000.00
J
County
Dubuque-31
- I Accident
I Dubuque
_ J - MT
occurred within corporate limits of (city)
- 2100
Literal Description
W 30TH ST {l
X-Coordinate
00680441
Y-Coordinate
04710686
If accident occurred outside of city
limits show general vacinity: "NIA"
Direction
"NIA" of
Nearest City
"NIA"
Route (Cardinal)
Travel Direction "N/A"
On Road, Street, or Highway:
W. 30TH
At Intersection with:
"N/A"
Distance I Direction Distance
50 Ft 1 3-E and I "NIA"
Direction
1 "N/A" of
Milepost Number
"NIA" Or
Definable intersection, bridge, or railroad crossing
LEMON ST
Officer
JOBGEN, NICHOLAS B
Badge No.
77
Law Enforcement Case Number
01.10.46896
Date of Accident I Tune of Accidenl
09/20/2010 l 14:10 Hrs. -