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Claim Mueller, Thomas JCLAIM 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 W. 13th 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: Thomas J. Mueller 2 Address: 2650 Broadway ` 3. Telephone Number: 563 583 8719 4. Date of Incident: 3 20 04 5. Time of Incident: 11:50 AM 6. Location of Incident (Be specific): 15th & Central 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.) I had to stop at green light because of merging traffic and was hit from behind by a Police Officer on duty. 8. What were weather conditions like? Sunny 50 degrees 9. Give name and address of any witnesses: 10. Did police investigate? (If so, give names of officers.) Russ Stecklein 11. Was anyone injured? (If so, give names, addresses, and extent of injuries). Thomas Mueller bruised elbow, neck and back discomfort. 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.) Ford Explorer had 4000 damage - see attached est. 13. What other damages do you claim, if any? Medical bills 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.) 4000-4400 for truck plus medical 15. What amount do you claim from the City of Dubuque? I was hit from behind by a Police Officer on duty. 16. Why do you claim the City of Dubuque is responsible? 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 at Dubuque, Iowa this 24th day of March, 2004. . /s/ Thomas J. Mueller (Signature) (Print Name) (Rev. 1/00 & 7/01) Nar,n 2004 11 :48AM BARRY A LINDAHL, ESQ I. Jtü;ffi~'.'..~n-... '3 d.ýi{D~ D2l fL1i/f11 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 W. 13th 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: --yv¡ f)1NV'1 S J VYìu.eJ t!2f 2. Address: ;¿ b5 '() -:&- f')(\ Aw CÀ- ~ 3. Telephone Number: "S<ó3- 58'3- 3') (CJ 4. Date of Incident: 3 ~ ,;¿ 0 ~ [) L-{ I r ;S ð AVv\.. 5. Time of Incident: 6. Location of Incident (Be specific): t.5 -f'^. rt- (1æV\i4-iI"e-l 7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE. (Give full deta¡¡:s upon which you bãse you; cla;m. !f:: City employee was invo!ved, give the employee's name.) 'I ..L I -Í f-r' d to S-{" P ö--t b~1A. 1:'1 ~r ~ c?\\,) ç.A'- J' ý'fuX7; ") Trcc4; ( M d \,.)«-;c; hA- JJJ D '" he1 ,'VI. <?l h~ 0... <P~ (C L.'¿ a{~. W-v- f'J'^-..J)v+1 8. What were weather conditions like? .j (; "V) { 9. Give name and address of any witnesses: 50" 1 O. Did polìèe investigate? (If so, give names of officers.) «\15S 5t.e c-[(1iz ,tL-1 11. Was anyone injured? (If so, give names, addresses, and extent of injuries). ----;l\O\1!\Ú9 ff\v{J lIe.-r- f:>(u;7.e<1 t,(bl\\,J N{~k t',V\.r:~ bit J)15LV(~+vJ- .Mar,n 2004 11:49AM BARRY A LINDAHL, ESQ No,3949 p, 3/3 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& C'ilf'(IÚ~ -~ ~ A -hlvL- t:.- $. ~ £..(000. Dc-1M. <.."\] J 13. What other damages do you claim, if any? MLGcA ß,,\lf 14. Have you been compensated for any part or all, of your claim by any insurance company? (If so, give name 'ànd address of insurance company and amount paid.) NO 15. What amount do you claim from the CIty of Dubuque? '7ÔOD - L/ttoo 4..-- -r;cn:./C{ fJlvf /!'\.c.d/c-c.! ~ l{ *rc~ {) 0+1 16. Why do you claim the City. of Dubuque is responsible? .-L (, 'Ie. .s V.e. n; hi b'{ . G{ Si6/ ~( -( ð.fJ~C£.d- D""- 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 thatßource; and If so, in what amount?' Dated at Dubuque, Iowa this ,)'1 day of ~~. ..20~.O . ~ ~ure) ~f)~tf~ l!V\Oe;( [{l r (Pri ame) Vi 80 :2 i.jd t¡Z ;:¡VH:¡O (Rev. 1100 & 7101) 03/\I:::JJ::ki Form 433033 MAIL REPORTS Td: 01-01 Iowa Department of Transportation Ioowa Department of Transportation office of Driver Servlorra • Park Fair Mail,100 add Avenue INVESTIGATING OFFICER`S REPORT P.O. Box 9204 Des Moines, lord a 503069204 OF MOTOR VEHICLE ACCIDENT PLEASE TYPE OR PRINTLegal Sheet of _I Law Enforcement Case 4 4.-/ - 1 7741 intervention? Private rhate Property? Date of Aaaderd 4. i Terse od drat tri1t, ; . - 7 i Accident oxnrre d wittdn County: Route: 11 llaccident occurred outride of I NNE E SE SSW W 1NW - city knits show general vicinity • miles 0 0 0 0 0 0 0 'fl 9T heereat dIT .X-Coccdin : ' - On Road, 5lrest.tra or Highway: C •. ay,i i 5,AL At Weisectian } rrilYt i ? 'ti ry- Y-Coordinate: ' •iIota: Unless accident occinred a1 an intersection which is completely siesaibed ebovi, use the space celowto give the exact location from a milepost or definable intersection. bridge, or railroad crossing, using hvo dish and di/s di* tf neoesssry. Feet : Mies . N NE E SE S SW W NW Feet . Miles N NE s S 914 W N_ or O O O 0 O O O O and or 0 0 L L. 0 O❑ O of if Divided highway, (Cardinae Travel Direction Na a i. Provide Route We Q Milepost O, Definable IntersectIon. Number bridge. or railnmd crossing Ddvers�N.avv-ee (Last. First, Mi1die) �j. t '•+- S. �' � f S 'i Address f.{ ( Gty Slate 1��rT u - - �•- •-! t� i -� Yd f %., tJ '"^' t NIA' { ZIP • ] A Date of Birth Mare Female d Br. ,: . ._.._.: r vs ,- Citalion 1. 3. Charge ' 2 4 i Stale Class Endorsements "` Re.Arictiona Ale0twl Te 1. None 3. thine 5. Vitreous SE Results: Test Given? LJ 2- Blood 4. Breath 9. Refused Drug 1, None 3. Linn' Test. Giver7?Lj 2 Stood 9. Raft Pow. Nag. 0 C Owners Name (Leet. First P 9ddie) Address City State PIP Insurance Co. - llatne - r ! ?.. - n CPO Insurance ti PoRry # -+ a L. License Plate # L� Year, 111N1.. 3 E 1 �/ t +� t �. •rrJ Y rak6 1 i t,i , >r t�} i. t Siy1e rt . t'•'� 3r d \ • Tow # Approximate Castro Repair tr RITMO Inidarfrave} Diredie n L' �I Vehicle i Action LL_J1 1 I 1 Point of bnpect I I__ 1, Moat d • I I I 6dentaf .Dame 11 UnderrideJ Override L_1 P, ? /OW < Occupants. I 'TrafFiC I can vas L_LJ Vehicle us*,LJJ Cartto Oaf Type L VDefect L1J Condition LJ o ,accred LL_J Driver OA/lo two) • i__f LJ_J -1. Commercial Trailer # License Piste Adache: to • Paw kirkkirkTrailer .LJToes! Stale Year Attached to Unit; Slate Year Emergency, , Vehicle L_i Emergency I , Status u Carrier - Address City State ZIP US DOT#C or 1NCA O 0 L -1 I I 1 I' ; -t --1 r,:._ ...::..;-..::-' f A es eWel*sie • - . Weigh( Rating Placard # • I 1 i .1 1-Li Hazardous Marmara - 1. -_I Drriiver•skN.ame (Lest, First, M8e) ; Address . Cry State Zap Data of Bush Drivers License Number Citation 1 { Z. Charge 2. 4. State Endorsemerata Restrictions... — Femme O. ass • ,..-- Al F;41C1 TestGiven? 2.Blood 4, Breath Reftrsed1. NMI 3. Ufk1P 5... VitreousTeai Results Drug 1. None Test Given? L[J 2. Blood 3. Urine Pols Neg. 9. Refused 0 0 Owner's Name Fisk M ddle) Address City State PIP 1 time 5 f- A (2._ tr+ PmiZn 71 2v# O • ? - Avs - ‘ SL. Plans # '.3 A. x. 'VI - Y T VIDi # �•/ .c i U2 ,�..— 'z 9 q s 2 Y � { PJ _# r• i f , % Taw # Appruodmete Cost to Repair et Repkece 2E Inklat Trani Medial L1 Vehicle Action LJ_J Lei 1 I Paint of Initial LLJ Most Damaged Area LJJ of Damage LJ Underridet Override LJ Pnvate? . ❑ -, ca Oparrs Taw 1 1 I Controls Traffic I I. I 1 eNcle C LLW Cargo Body Tyne LJLJ Veiride Defect L f I Wier L Condition ion Obabscured I_ I I 'Contributing LLJ L_LJ Driver (up to two . Ccenmerdal Trailer Attached to Stake Year Attached to State Year License Plate # Power Unit Trails Una Emergency �'' 11 Vehicle TyPr J Emergency Vitus LJ o Cartier Name Address - City State' • Zip F US DOT# or M�f a 0 1 1 1 •1 1 1 I I Number atA, s Gross Vehicle Weight Rating Placard iC 1 1 1 1 I -LJ Hazardous Maulerst { Rosesed4 LJ if Property other Men vohtdss damaged explain Object Damaged - Estimate of •. Damage $ Unit 1 tali 2 SEQUENCE OFEVENTS, 1 1 1 1 1 1 First Evert Owners Full' Name (Last, First, Middle) Was 'owner or 1 - Yes a • Unknown tenant noes d? LJ 2 - No I I I I 1 I Second Event - Street nr RFD City, Stale, 8 Zip Cade - •1 1 1 1 1 1 Third Event ACCIDENT ENVIRONMENT Location of Fast Harmful Event IJ Weather Condrtov I I I RbADWAY CHARACTERISTICS raaJorCankrmwrwg Circumstances: U WORK ZONE RELATED? 0Yes 0Na I I I I I I Fourth Event {lip to two) MarteroFCrashiCeitrsion LJ LJJ Erroironment Roadway 1. I• I Li Wootton - L I Tyre Most Harmful Event 1 1 1 1 l I i Ligt1J SttConditions to e Conditions 11 Type of Roadwa,r.lunctio&FseI ue I 1 1 LJ Workers Present? I 1 J " Enactrash (,armful 1 2 oink) rc [ C < -r' fire. Y . ;;,....., ., y , Date: 31221200401:19 PM ¡:Stimate 10: 9245 EStimãlè Version: 0 'Preliminary Profile 10: Milchell FED ID *42-0813744 RICHARDSON MOTORS 1475 J.F.K. ROAD DUBUQUE,IA 52002 (563) 582-6411 Fax: (563) 582-4129 Damage Assessed By: JASON CHARLEY Deductible: UNKNOWN Owner tom mueller Address: 2650 broadway dub, IA 52001 Telephone: Work Phone: 1563) 599-$783 ," Home Phone: (563) 583.8719 Mitchell Service: 918622 Description: 1998 Ford Explorer Sport Body Style: 2D Ut 102" WB Drive Train: 4.0L In] 6 CyJ 4WD VIN: 1FMYU24E3WUC55229 Options: ALUM/ALLOY WHEELS, AIR CONDITIONING, POWER WINDOWS, POWER DOOR LOCKS CRUISE CONTROL, AUTOMATIC TRANSMISSION, AM-FM STEREO/CDPLAYER(SINGLE) Line Entry Labor Line Item Part Type! Dollar Labor Item Number Type Operation Description Part Number Amount Units ~- 1 802555 BDY REMOVEIREPLACE EXHAUST MUFFLER WIPIPE F67Z 6230 BAA 212.87 0.7 2 900500 BDY' ADD'L LABOR OP HEATRE SHAPE RTQTR MLD Existing 0.6" 3 802785 BDY REPAIR R QUARTER OUTER PANEL ExiSting 0.5"# 4 AUTO REF REFINISH R QUARTER PANEL OUTSIDE C 3.4 5 802786 BDY REPAIR L QUARTER OUTER PANEL existing 0.5'/1 6 AUTO REF REFINISH L QUARTER PANEL OUTSIDE C 3.0 7 801075 BDY REMOVEIREPLACE WIPOWER LOCKS 0.3 8 804326 BDY REMOVE/REPLACE LlFTGATE SHELL XL2Z 7840010 BA 708.70 5.5 # 9 AUTO REF REFINISH LlFTGA TE OUTSIDE C 2.4 10 AUTO REF REFINISH ADD FOR JAMBS & INSIDE C 1.0 11 802890 BDY REMOVEIREPLACE LlFTGATE ADHESIVE NAMEPLATE F87Z 7842528 PA 22.50 0,1 12 802899 BDY REMOVEIREPLACE LlFTGATE ADHESIVE NAMEPLATE F87Z 9842528 EA 1U8 0.1 13 801216 BOY REMOVEßNSTALL R REAR COMBINATION LAMP 0.3 14 801217 BDY REMOVEßNSTALL L REAR COMBINATION LAMP 0.3 15 AUTO BDY OVERHAUL REAR BUMPER ASSY 1.5 16 803729 BDY REMOVEIREPLACE REAR BUMPER FACE BAR Qual Recycled Part 350.00" INC 17 SMART PARTS QOUTE#79856 18 LINE MARKuP %0.25 0.88 19 900500 BOY" REMOVE/REPLACE REAR SILL PLATE F5TZ7842624D 2I!.58" 0.3" 20 AUTO REF ADD'L OPR CLEAR COAT : 2.6 21 933005 BDY ADD'L OPR RESTORE CORROSION PROTECTION 6.00' 0.2" 22 933006 FRM ADD'L OPR FRAME/RACK SET UP , 2.0" 23 933018 REF ADD'LOPR MASK FOR OVERSPRAY 6.00' 0.2' 24 933034 FRM ADD'L OPR PULL FOR SAG 15.0'" 25 FRAME IS BACK AND DOWN ON BOTH SIDES 26 AUTO ADD'L COST PAINT/MATERIALS 353.40" ESTIMATE RECALL NUMBER: 3/221200411:10:57 9245 UltraMate is a Trademark 01 Mitchellintemalional . Mitchell Data Version: A~04_A Copyright IC) 1994 - 2003 Mitchell International ." ,P"!I" 1 of 2 UltraMate Version: 5.0.021 All Rights Reserved 27 AUTO ADD'L COST HAZARDOUS WASTE DISPOSAL Date: 3/22/2004 01:19 PM Estimate 10:; 9245 Estimate Version: 0 Prermrinary Prome ID: Mitchell 6.00' . -Judgement Item # - Labor Note Applies C -Included in Clear Coat Calc I. Labor Subtotals Body Refinish Frame 0, Add1 Labor Sublet Units Rate Amount Amount Totals 10.8 46.00 6.00 0.00 502.80 T 12.6 46.00 .6.00 0.00 585.60 T 17.0 53.00 0.00 0.00 901.00 T II. Part Replacement Summary Taxable Parts Parts Adjustments SalesTax @ Amount 1,341.53 0.88 93.97 1.000% Taxable Labor Labor Tax @ 1.000 % 1,989.40 139.26 Total Replacement Parts Amount' 1,436.38 Labor Summary 40.4 2,128.66 w. Additional Costs Taxable Cost. Sales Tax @ 7.000% Amount 6.00 0.42 IV. Adjusbnents Customer ResponsibHity Amount 0.00 Non-Taxable Costs 353.40 Total Additional Costs 359.82 I. It W. Total Labor: Total Replacement Parts: Total Additional Costs: , Gross Total: 2,128.66 1,436.38 359.82 3,924.86 IV. Total Adjustments: Net Total: 0.00 3,924.88 This is a preliminary estimate. Additional chanQes to the estimate mav be required for the actual repair. ESTIMATE RECALL NUMBER: 3122/2004 11:10:57 9245 UltraMate is a Trademark of Mitchell International Mitchell Data Version: APR 04 A Copyright IC) 1994 - 2003 Mitchell International UltraMate VerSion: 5.0.021 - All Rights Reserved Page 2 of 2 . "~' ,MAR-22-2Ø04 01:0; ph ~FIHHIH BOÐY$HOP \. V.... f!.¡V'" 563 690 10B6 P.01 Dale: 212M_01:82PM EII-.IO: 2T. ell_.VomDn: a -..., Proftle 10: Machin MIKE FINN IN FORD - DOOGI! 8TRUT DUBUQlJE.1A 1200' 10'10""0'0 F.., ceu'"O.lm T..ID'. '..1"2113 DIm... A.....ld 8y: RICK STUMPF Doduc\lble: UNKNOWN lnllUl1td: TOM MUELLI!II -....: 2UOIIROAIIWAY DUBUQUE, IA 12001 Tllephonl: Wort -.: I-I&ft.e,o "- Phone: I.IS, 1..-1". MIIoM" S.",lcl: 1'1822 Desa1pllon: 1m Ford II_pion. Sport 8ody 1ItyIe: 20 \11102" we an.. T..in: I.DL 1nj I CyI.WO VIN: 'FMYUJ.ESWllCOO221 Option.: ALUM/ALLOY WHHLS. AIR CONDITIONING, POWER WINDOWS, POWER DOOR LOCKS CIM8E CONTROL. AUTOMATIC TRANSMISSION. AM-FM STEREOICDPLA Yl!R(StNOLE LIn."'" Deocrlpllon REAR 8UfM'ER I. LAMPe REMO\/I!/REPLACE REAR REPUl.CE BUMPER UNE MARKUP 1120,00 -END OF ATO SECTION '" EXKAUIIT . _0 BOY REMOVEIREPLAC! EXHAUIIT MUFFLER- MANUAL ENTRIES HEAT RESHAI'!! liT QUATER PANEL MLDG QUARTER PANEL R QUARTER OUTI!R PANEL R QUARTER PANEL OUTSIDE L QUARTER OUTER PANEL L QUARTER PANEL OUTSIDE LIfTGATE LIFTOATI! III1I!LL LIFTQATEOUT8tDE ADO FOR JAMBS I.IN8IDE UFTOATI! ADHESIVE NAMEPUl.TI! LlFTGATI! ADHEIN! NAM!PLATI! REAR BODY 11 IIOaln BOY REMOI/!/REPUl.CE REAR BODY SILL PANEL '1 REF REFINISH RIAR CROSSMEMBER REAR LAMPS 17 80UM BDY REMOV£I\N8TALL RCOM8INAT1ONLAMPUSEMBLY 18 nZl" 8DY RlMOVI!IINSrALL LCOMBtNATIONLAMI'ASSEMBLY REAR BUMP&R .. _f' BOY OVERHAUL REARBUMPERASSY ESTIMATE RECALL NUM_: ,- 1':02:". 2'" UllnlMII. to , T,.- oI_ø 1nI....- ~:ir-A Copytlght \CI :..~..¡::~ I_II Li"" Entry L.bor ~ ~!Ie... _Ion ..11202 80Y _100 BDY . REPAIR 0 , I I lOrn BOY REF I12rn BOY REf REPAIR REFINI1IH RlPAm REfINISH 10 11 12 13 I. RIlMOVI!/REl'LACE REFINISH REF1NI8H RlMOVE/REPLACE IlIIMOVEJREPLACE 10UH BOY REf REF milD BOY 10'" 8OY MfteMnOatav.rolon: un..-. V.rolan: P." Typo! P""- au." -,clod Part F17% IUD BAA ExI8IIng E_isting E.11l1ng XLJZ _10 8A FI7Z TMU" PA mz _.H EA An 711- A " II_toting 1!II,1tIIna 00II.. LoIJor ~ !:!!!!!- 280,10' tNC " I"" 21U7 0,7 , 0'" 0;1." C S¡4 0.'" C 1,0 'OUD u" CIA C 1;0 22.10 oa '1." M ".17 UII 1:0 0;3. 0." liD P_1011 IMAR-~2~2004 01:04 PM FINNIN BODY SHOP 563 690 1086 P.02 0...: 3I221_81,02'M E_IO:. 174 ' £11- V_IOn: 0 l'nllimlniry ProilelO'. _8 2Ø 21 22 23 24 21 ZI Ref 13SO1J!1 BOY n3m fRM 933011 REF 8330" FRM AOJ)"\. CPR AOD'L CPR AOD'L OPR AOO'L OPR ADO'L OPR AOO'L COST AOO'L COST ADDITIONAL OPERATIONS CLEAR COAT RESTORE CORROBION PROTECTION fRAMElRACI( SET UP MA81( fOR OVERBPRAY PULL FOR SAG PAINT/MATERlAL8 HAZARDOU8 WASTE OISPO8AL 2.1 4.01 ' O,Z" 2... 12.00' 1.2' 11.0' STUO' I.". . - Judgement Item II - Labor Note Applies C . Included In Clear Coat Calc Add' Llbor aubl.' I. L-- .!!!!!!!. ~ ~ Amoun' ~ H. Part RepIocomenlS"""'ry lI<MIy 14.7 8.00 4.""., D."" 7G...I T - T...IM P.". _loft 13.1 41.10 12.00 O.GO HUOT Ports Ad uoImonIO Fr8IM 17.1 II." 0.00 0.00 HUIT sa... T.. . Amoum 1.371:12 lUG 102.10 7,- T...1IIo L_' Llbor Tu . UGGy, 2,1H.1O 1"'" URAl T_I"",,-P-- 1._.72 LIbor Summory 41.1 lB. _II Colt. Non-T._Coot. Amount u;:¡¡- IV, Ad U1ImonI. C- R8opanItbI y Amount --¡¡o T"""-C- 211.20 I. a, m. Totll Lllbor: ' Totol R....- P- T \1181 AddIIIoftlll Coots: - Tot'" UGUI ""0.72 HUO 4.442.40 IV. Tot.. ~: Not T_, O,VII 4.4420'0 This is . oNliminarv HUmatlt. Additiona' chanaea to the a.timata mav be l'8CIulred for the lIdue' Noair. E8T1MATI! RECALL NUMBER, 1I2JIZOM 11:02,M 274 . IIItroM.,./t. Tr",-~" Ma-.ntomotIolIIIl "'ft_1I Dol. V,mOft: MAR.IN.!' copyright (CI1," .I8OS Mitchoa 1111_- UltroMate V",""n: I.O,UI Aft RIght. R...rved ""lie 2 01 I ..