Claim by Kayla McLaughlin, Nicole Huseman11/1 ! / n -
: : )K4/ t` q'Lx
CLAIM AGAINST THE CITY OF DUBUQUE, IO A fLL^'wl
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: (,k.\\■,'■ I \ vkAk.\1111■YA
\\Y \ MON)
TA) - Z J1
2. Address:
3. Telephone Number 510''S �l2 9 zl 0 L
4. Date of Incident: \7. I I ) ( b
5. Time of Incident: k
10. Did olice investigate? (If so, give names of officers.)
3 o lain e v�
6. Locati n of J ent (Be specific
� ncid �^r e T 2512 �pmt S� , acC c.,(LVed
(v N exl S� . Y g 6� k l t,� ve �� v' Se Gtl C v
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.)
' O hO, C to , (love/\ Ncon.LQ voa fin\ c 2 Irtrnv\ kit( c
� I
- .S ki l c U, v 0- 0-fv C .
8. What were weather conditions Fke?
9. Give name and address of any witnesses:
N(*)WY
11.1 r) W as anyone injured? (If so, give names, addresses, and extent of injuries).
1y
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.)
es , rnck . c coo( th o,ce
13. What other damages do you claim, if any?
N Gv �
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. What amount do you claim from the City of Dubuque?
`��1 I
16. Why do you claim the City of Dubuque is responsible?
SC.YlCi \irlAIll \nA, rl Cow, OvAve.v u3c9 -S -k-icO d
17. Have you made any claim against anyone else for damages as a 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
sou c and if so, in what amount?
Dated this day of ekcl 0),VY1 , 20 U .
(Signature
k
( r int N me) wk9 In■,k0
rn
c-1
cn
"o
N
w
w
0
�
m
0
Damage Assessed By: Rick Stumpf
Deductible: 0.00
Claim Number: 9595
Insured:
Address:
Telephone:
Description:
Body Style:
VIN:
OEM /ALT:
Color:
Options:
Line Entry Labor
Item Number Type
1 003109 BDY
2 003111 BDY
3 AUTO REF
4 003119 BDY
5 000034 BDY
6 AUTO BDY
7 000138 BDY
8 AUTO REF
9 000146 BDY
10 936014
11 AUTO REF
12 933005 BDY
13 933018 REF
14 AUTO
15 AUTO
Mike Finnin Ford
KAYLA MCLAUGHLIN
2512 STAFFORD, DUBUQUE, IA 52001
Home Phone: (563) 557 -9172
2008 Pontiac G6 GT
4D Sed Drive Train: 3.5L Inj 6 Cyl 4A FWD
1G2ZH57N784115721
0 Search Code: None
SILVER
VEHICLE ANTI - THEFT, PASSENGER AIRBAG, DRIVER SIDE AIRBAG, POWER DRIVER SEAT
POWER LOCK, POWER WINDOW, POWER STEERING, REAR WINDOW DEFOGGER
MANUAL AIR CONDITION, CRUISE CONTROL, TILT STEERING COLUMN, ANTI -LOCK BRAKE SYS.
TRACTION CONTROL, FOG LIGHTS, AUXILIARY INPUT, LEATHER STEERING WHEEL
SATELLITE RADIO, CHROME WHEELS, POWER ADJUSTABLE EXTERIOR MIRROR, TINTED GLASS
FIRST ROW BUCKET SEAT, KEYLESS ENTRY, CLOTH SEAT, INTERACTIVE TRANSMISSION
TACHOMETER, SIDE AIRBAGS, AUTOMATIC HEADLIGHTS
PASSENGER AIRBAG CUTOFF SWITCH /SENSOR, REMOTE DECKLID OR TAILGATE RELEASE
VEHICLE THEFT TRACKING /NOTIFICATION, ONSTAR, DAYTIME RUNNING LIGHTS
Operation
OVERHAUL
REPAIR
REFINISH
REMOVE /REPLACE
REMOVE /REPLACE
CHECK/ADJUST
REPAIR
REFINISH
REMOVE /REPLACE
ADD'L COST
ADD'L OPR
ADD'L OPR
ADD'L OPR
ADD'L COST
ADD'L COST
3600 Dodge Street, Dubuque, IA 52003
(563) 556 -1010
Fax: (563) 690-1086
Email: bodyshop@finninautos.com
Tax ID: 14- 1862673
Mitchell Service: 910410
Line Item
Description
Frt Bumper Cover Assy
Frt Bumper Cover
Frt Bumper Cover
L Frt Bumper Bracket
L Front Combination Lamp Assembly
Headlamps
L Fender Panel
L Fender Outside
L Fender Liner
Flex Additive
Clear Coat
Restore Corrosion Protection
Mask For Overspray
Paint/Materials
Hazardous Waste Disposal
ESTIMATE RECALL NUMBER: 12/15/2010 10:46:54 9595
Mitchell Data Version: OEM: NOV_10_V UltraMate is a Trademark of Mitchell International
Copyright (C) 1994 - 2010 Mitchell International
UltraMate Version: 7.0.224 All Rights Reserved
-I
Date: 12/15/2010 10:46 AM
Estimate ID: 9595
Estimate Version: 0
Preliminary
Profile ID: Mitchell
Part Type/
Part Number
Existing
20819715 GM PART
20821143 GM PART
Existing
25956106 GM PART
Dollar Labor
Amount Units
3.2 #
3.0*#
C 2.6
22.83 INC #
257.18 INC
0.4
3.0*#
C 1.9
44.72 0.4
8.00 *
1.4*
10.00 * 0.2*
10.00 * 0.2*
212.40 *
5.00 *
Page 1 of 2
Driver Information Exchange Report
001
Driver's Name - Last
LUCAS
Address
2754 WASHINGTON ST
Gender
Female
Comer Company Name
CITY OF DUBUQUE
First
JOYCE
mbei I Class State
113 IA
Dubuque Police Department
563-589-4410
Middle
iANN
City State Zip
DUBUQUE IA 52001-0000
Endorsements Restrictions
P 1B
!Suffix
Insurance Co. Name
SELF -CITY OF DUBUQUE
Insurance Policy #
Owner's Name -Last
Address
50 W. 13TH
First
I Middle
City
DUBUQUE
MIN No Year Make l Model Style
4RKJNTFA22R835550 2002 RTS 62VN BUS
I Suffix
Hame'Cell Phone
Insurance Co. °hone #
t563) 589-4130 x
License Plate #
85986
State
I IA
Year 1I Most Damaged Area
2010 1
'State Zip
iIA 52001-
Vehicle Conf.guratioil
Approximate Cost to Repair or Repia-e
Driver's Name - Last
PARKED
Address
1
First
City
T Gender Driver's License Number LCIass Slate i Endorsements
NONE
OC2 ❑vicar Company Name
Middle
Restrictions
NONE
': Suffix Date of Birth
I State
Zip
Insurance Co. Name
AMERICAN FAMILY MUTUAL
Insurance Policy #
Home'Cell Phone
Insurance Co. phone 0
Ovine s Name - Last
HUSEMAN
Address
12686 QUEEN
1 VIN No.
1G2ZH57N784115721
License Plate #
APPLFOR
First 1 Middle
NICOLE MARY
City
DUBUQUE
Year Maise
2008 ' PONT
Model
G6
I Suffix
State Zip
IA 52001-
Style
State
IA
Year 1 Most Damaged Area
County Accident occurred viithin corporate limits of (city)
Dubuque-31 'Dubuque - 2100
Literal D.;'.ncucn
NIA"
! 7Coordinate
I NIA"
Vehicle Configuration
Approximate Cost to Repair or Replace
Y-Coordinate
"NIA"
If accident unwired outside of city
' iiernts shon genera! vaci city• "NIA"
C irectiort
"NW' of
Nearest City
"NIA"
al Road. Street. or Highway
MERZ "NIA"
Distance
25 Ft
Direction
13-E
7Distance
and "NA"
Direction
"NIA"
At Intersection with.
of
Route (Cardinal)
Travel Direction "NIA"
Milepost Number
"NIA" Or
Definable inteisection. brid.je, or raitrr ad crossing
STAFFORD / MERZ
Officer
FLANNERY. ROBERT
Badge No. Law Enforcement Case Number Date of accident i Time cf Accident
16A 01-10-61170 12/16f2010 07:36 Hrs,
Printed At: Dubuque Police Department 1216/2010 08:34 AM
Page 1 Form#. 0140-61170
r
Y
* - Judgment Item
# - Labor Note Applies
C - Included in Clear Coat Calc
Estimate Totals
Date: 12/15/2010 10:46 AM
Estimate ID: 9595
Estimate Version: 0
Preliminary
Profile ID: Mitchell
Add9
Labor Sublet
I. Labor Subtotals Units Rate Amount Amount Totals II. Part Replacement Summary Amount
Body 10.2 56.00 10.00 0.00 581.20 T Taxable Parts 324.73
Refinish 6.1 56.00 10.00 0.00 351.60 T Sales Tax @ 7.000% 22.73
Taxable Labor 932.80 Total Replacement Parts Amount 347.46
Labor Tax @ 7.000 % 65.30
Labor Summary 16.3 998.10
III. Additional Costs Amount IV. Adjustments Amount
Taxable Costs 8.00 Insurance Deductible 0.00
Sales Tax @ 7.000% 0.56
Customer Responsibility 0.00
Non - Taxable Costs 217.40
Total Additional Costs 225.96
Paint Material Method: Rates
Init Rate = 36.00 , Init Max Hours = 99.9, Addl Rate = 0.00
ESTIMATE RECALL NUMBER: 12/15/2010 10:46:54 9595
Mitchell Data Version: OEM: NOV_10_V UltraMate is a Trademark of Mitchell International
Copyright (C) 1994 - 2010 Mitchell International
UltraMate Version: 7.0.224 All Rights Reserved
I. Total Labor: 998.10
II. Total Replacement Parts: 347.46
III. Total Additional Costs: 225.96
Gross Total: 1,571.52
IV. Total Adjustments: 0.00
Net Total: 1,571.52
This is a preliminary estimate.
Additional changes to the estimate may be required for the actual repair.
Page 2 of 2