Claim, Weydert, ChadCLAIM AGAINST TwR CITY OF
DUBUQUE
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 musu be filed with the City Clerk at City Hall, 50
West 13th Street, Dubuque, Iowa 52001-4864. 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.
Tm 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: Chad Weydert
2. Address: 4877 Embassy Ct.
3. Telephone No. 556 3935
4, Date: 12/11/00
5. Time of Inciden 0805
6. Location of incident. (Be specific) Bunker Hill Maintenance Lot, in front
of shed.
7. Describe Accident:
Timothy A. Kelly backed a snowplow into my parked vehicle, hencing causing
damage to the rear bumper.
(Give rut1 details upon which you base your claim, if a City
8. Weather: Snow
Address:
Telephone ~,~her:
Date of Incident:
employee was involved,
give the employee's name.)
8. What were weather conditions like?
9. ~ive name and address of any witnesses.
10. Did police investigate? (If so, give names of officers.)
11. Was anyone injured? (If so, give ~e, address and extent of
injuries. )
12. Was any d~mage done to property? (If so, describe property
and the extent of damage. Attach estimates of damages or
describe basis for ascertaining exten~ of damage.)
Damage to rear bumper on my vehicle.
13.
What other d~,-~ges do you claim, if any?
Have yo%~ been compensated for any part or all of your claim by
any insurance company? (If so, give name and address of
insurance company and amour= paid.)
What amount do you claim from the City of Dubuque?
14.
15. Amount: $250.00
16. why do you claim the City of Dubuque is responsible?
City Employee during working hours operating city owned vehicle on City owned
property.
?
17. Have- y2u made aLy'cLaim ~ainst anyone else for dama,es as
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
20 61
day of
(Print Name)
/s/ Chad Weydert
Date: 5/21/01 01:03 PM
Estimate ID: 3662
Estimate Vemion: 0
Preliminary
Profile ID: Mitchell
Riley's Olds-Mazda-Subaru
4455 Dodge St. Dubuque, IA 52003
(319) 688-2326
Fax: (3t9) 588-9286
Tax ID: 42-9957277
Damage Assessed By: KEITH KNIPPER
Deductible: UNKNOWN
Insured: CHAD WEYDERT
Address: 4877 EMBASSY CT DBQ, IA 52002
Telephone: Home Phone: (563) 666-3936
Mitchell Service: 918367
Description: 1987 Volkswagen Golf GL
Body Style: 2D HB
VIN: tVWBA9179HV023391
Drive Train: 1.8L Inj 4 Cyl 5M
Line Entry Labor Line Item Part Type/
item Number Type Operation Description Part Number
Dollar Labor
Amount Units
I AUTO BDY OVERHAUL REAR COVER ASSY
2 84.3600 BDY REMOVE/REPLACE REAR BUMPER COVER
3 843040 BDY RE~',~OVE/REPLACE REAR UPR BUMPER COVER MLDG
4 843080 BDY REMOVE/REPLACE REAR LWR BUMPER COVER MLDG
$ 84~700 BDY REMOVE/REPLACE R REAR BUMPER BRACKET
d - Discontinued by the Manufacturer
176 807 393
176 853 95t L
176 853 951 M
165 807 193 A
1.0
d144.10 INC
d15.00 INC
d10.40 INC
1.40 INC
Add'l
Labor Sublet
L Labor Subtotals Units Rate Amount Amount Totals
Body 1.5 40.00 0.00 0.00 60.00 T
Taxable Labor 60.00
Labor Tax @ 6.000 % 3.60
1.5 63.60
Labor Summary
II. Part Replacement Summary
Taxable Parts
Sales Tax
Total Replacement Parts Amount
Amount
168.90
6.000% 10.19
179.03
01. Additional Costs Amount IV. Adjustments Amount
Total Additional Costs 0.00 Customer Responsibility 0.00
I. Total Labor: 69.60
II. Total Replacement Parts: 179.03
II1. Total Additional Costs: 0.00
Gross Total: 242.63
ESTIMATE RECALL NUMBER: 5/21/01 13:30:22 3662
UltraMate is a Trademark of Mitchell International
MitchellDataVerston: MAY_01_A Copyright (C) 1994-2000Mitchelllaternational Page I of 2
UltraMate Version: 4.7.006 All Rights Reserved
Date: 5/21/0101:33 PM
Estimate ID: 3662
Estimate Version: 0
Preliminary
Profile ID: Mitchell
IV. Total Adjustments:
Net Total:
This is a preliminary estimate.
Additional chanqes to the estimate may be required for the actual repair.
"I HEREBY AUTHORIZE THE REPAIR WORK HEREIN SET FORTH TO BE DONE
(INCLUDING PARTS AND MATERIALS) AND AGREE TO MAKE PAYMENT
THEREFOI~E IN CASH, UNLESS IT IS OTHERW~/SE AGREED AND SO SET
FORTH IN THIS ORDER. I UNDERSTAND THAT AS A MATTER OF IOWA
LAW YOU MAY RETAIN POSSESSION OF THE VEHICLE UNTIL SUCH CASH
PAYMENT IS MADE. YOU ARE NOT RESPONSIBLE FOR ANY DELAYS CAUSED
BY UNAVAILABILTY OF PARTS OR DELAYS IN PARTS SHIPMENTS NOR FOR
LOSS OR DAMAGE TO VEHICLE IN CASE OF FIRE, TREFT OR ANY OTHER
CAUSE BEYOND YOUR CONTROL".
0.00
242.63
ESTIMATE RECALL NUMBER: $/21/01 13:30:22 3662
UltraMate is a Trademark of Mitchell International
Mitchell Data Version: MAY_01_A Copyright (C) 1994 - 2000 Mitchell International
UltraMate Version: 4.7.006 All Rights Reserved
Page 2
of 2
Date: 5/21/0t 02:12 PM
Estimate ID: 4651
Estimate Version: 0
Preliminary
Profile ID: Mitchell
MIKE FINNIN FORD, INC.
3600 DODGE STREET DUBUQUE, IA 52003
(319) 556-1010
Fax: (319) 556-5249
Tax ID: 42-1074463
Damage Assessed By: JEFF LEICK
Deductible: UNKNOWN
Insured: CHAD WEYDERT
Address: 4877 EMBASSY CT DUB 52002
Telephone: Home Phone: (319) 556-3935
Mitchell Service: 918367
Description: 1987 Volkswagen Golf GL
Body Style: 2D HB
VlN: 1VWBA9179HV023391
DHve Train: 1.8L Inj 4 Cyl 5M
Line Entry Labor
Item Number Type Operation
Line Item
Descdption
Part Type/
Part Number
Dollar Labor
Amount Units
I AUTO BDY OVERHAUL
2 843500 BDY REMOVE/REPLACE
3 8436'10 BDY REMOVE/REPLACE
4 843820 BDY REMOVE/REPLACE
5 843830 BDY REMOVE/REPLACE
REAR COVER ASSY
REAR BUMPER COVER
REAR BUMPER REINFORCEMENT
R REAR BUMPER MOUNTING BRACKET
L REAR BUMPER MOUNTING BRACKET
176 807 393
176 807 308 A CPD
t76 807 332 J CPD
'176807331 E CPD
t.5
d144.10 INC
d55.90 INC
d41.95 INC #
d40.70 INC #
# - Labor Note Applies
d - Discontinued by the Manufacturer
Labor Subtotals Unite
Body
IlL
Labor Summary
Add'l
Labor Sublet
Rate Amount Amount
Totals
1.5 45.00 0.00 0.00 67.50 T
Taxable Labor 67.50
Labor Tax ~ 6.000 % 4.05
1.5 71.55
Additional Costs Amount
Total Additional Costa 0.00
0. Part Replacement Summary
Taxable Parts
Sales Tax
Total Replacement Parts Amount
IV. Adjustments
Customer Responsibility
6.000%
282.65
16.96
299.61
Amount
0.00
ESTIMATE RECALL NUMBER: 5/2'1/01 14:09:15 4651
UltraMate is a Trademark of Mitchell International
Mitchell Data Version: MAY_01 _A Copyright (C) 1994 - 2000 Mitchell International
UltraMate Version: 4.7.006 All Righta Reserved
Page I
of 2
Date: 5121~01 02:12 PM
Estimate ID: 4651
Estimate Version: 0
Prelimina~j
Profile ID: Mitchell
I. Total Labor:
II. Total Replacement Paths:
IlL Total Additional Costa:
Gross Total;
IV. Total Adjustments:
Net Total:
This is a Dreliminarv estimate.
Additional chanaes to the estimate may be reouired for the actual repair.
71.55
299.6t
0.00
371.16
0.00
371.16
ESTIMATE RECALL NUMBER: 5/21/0t 14:09:15 4651
UltraMate is a Trademark of Mitchell International
Mitchell Data Version: MAY_01_A Copyright (C) t 994 - 2000 Mitchell International
UltraMate Version: 4.7.006 All Righta Reserved
Page 2 of
2
ADDRESS
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STA~E 'r~'E ~ESTRICTIONS
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CONP~qY
ADDRESS
ZIP CODE VEHICLE LICENSE
~ CO~R
SUEAN CO
l:l~S~I]~~ Ol~Im(S)
STATE/Iq~AR