Claim, D & A Cable Inc.
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: D & A Cable, Inc.
2. Address: 15146 170th St. Rockwell, Iowa 50469
3. Telephone Number: 641 822 4921
4. Date of Incident: refer to CR# 01-14643 Police Report
5. Time of Incident: "
6. Location of Incident (Be specific): "
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.)
Backing truck up and lug nut or some part of truck hit corner of front bumper and pushed back.
8. What were weather conditions like? Clear & dry
9. Give name and address of any witnesses: Wayne Dahtey, 103 Cherry St.
Rockwell, IA 50469
10. Did police investigate? (If so, give names of officers.) Yes, Officer Tupper 21A
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
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.)
'
Bumper, estimate attached. Bumper, Estimate attached.
13. What other damages do you claim, if any? None.
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.)
No.
15. What amount do you claim from the City of Dubuque?
Estimate from body shop
16. Why do you claim the City of Dubuque is responsible?
Our truck was parked with cones and beacons on and City Truck backed up.
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?
No.
Dated at Dubuque, Iowa this 11th day of July , 20 .
/s/ Daniel J. Dahley
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
CLAIM AGAINST THE 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 must 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 ' ' ·
lnvest~gatmon 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.
3. Telephone
4.
¸.
Date of Incident:
Time of Incident:
6,, Location of incident. (Be specific) j/
10.
11.
DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJORY OR DAMAGE.
(~ive full details upon which you base your claim, if a City
employee was involved, give the employee's name.)
~at were weather co=ditions l?ke? ~r % ~r~ _~ ~
Was ~yone injured? (If so, Dive n~e, address and extent of
injuries. )
Was any damage done to property? (If so, describe property
and the extent of damage. Attach estimates of damages or
describe basis for ascertaining extent of damage.)
13. What other damages do you claim, if any?
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?
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 ma~e 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?
2001.
{Revised January, 2000)
(Prmnt Name)
Date: ?! 6/2001 02:09 PM
Estimate ID: 28~0
Estimate ~ersion: 0
Prelhe~mry
Profile ID: Mitchell
CUSTOM AUTO BUILDERS INC
335 S DELAWARE AVE. MASON CITY, IA 50401
(641) 423-6360
Fax:
Tax ID: 42-139-6606
Damage Assessed By:. STEVE TASS
Deductible: UNKNOWN
Owner
Address:
Telephone:
D&A CABLE
103 CHERRY ST ROCKWELL, IA
Home Phone: (641) 822-4921
Mitchell Service: 916489
Description: J997 Chevro~t CheCab
Body Style: 2D Pkup 135" WB
VIN: 1GBJK34ROVF022095
Options: 4 WHEEL DRIVE
Drive Train: $.7L Inj 8 Cyl 4WD
Line Entry Labor
Item Number Type Operation
I AUTO BDY OVERHAUL FRT BUMPER ASSY
2 *~0840 BDY REMOVE/REPLACE FRT BUMPER FACE BAR
3 50BOJ7 BDY REM~LACE L FRT BUMPER BRACKET
4 900500 BDY * ADD'L LABOR OP REPAIR BRUSH GARD
5 900500 BDY* REMOVE/INSTALL BRUSH GARD
6 S00039 BDY REMOVE/REPLACE GRILLE FILl. ER PANEL
7 AUTO REF REFINISH CTR FILLER
8 AUTO REF ADD'L OPR CLEAR COAT
9 AUTO ADD'L COST PAINT/MATERIALS
10 AUTO ADD'L COST HAZARDOUS WASTE DISPOSAL
* - Judgement Item
# - Labor Note Applies
C - Included in Clear Coat Calc
Part Type/
Part Number
Dollar Labor
Amount Units
15545110 GM PART
15888151 OM PART
Existing
12376285 GM PART
1,6 #
213.20 INC #
2730 ;NC
0.6*
O,8*
6~20 0.4 #
C 0.8
26.00 *
3.00*
L Laber ~
Uni~ Rate
3.4 40.60
~0 40.00
Taxable Labor
Labor Tax
Labor Summary 4.4
Add'l
Labor Sublet
· Nt~4xmt Amount Totals
0.00 0.00 136.00 T
0~10 0,O0 40.00 T
176.00
6.000 % 10.56
ESTIMATE RECALL NUMBER: 5/3/200t 15:26:33 28S0
Mitchell Data Versior.: JUL_OI_A
Ul~'aMate Version:
Tax~ble
Total Replacement Pints Amount
UitmMats is a Tradema~ of Mitchell International
Copyright (C) 1994 - 2000 Mitchell International
309.70
6.000% 18.~8
Page I of 2
IlL Additional Costs
Taxable Costs
Sales Tax
Total Additional Costs
6.000%
3.00
0,t8
26:00
29.18
Date: 716/2001 02:09 PM
Estimate ID: 2850
Estimate Version: 0
Preliminary
Profile ID: Mitchell
IV. Adjustments
Customer Responsibility
L Total Labor:
0. Total Replacement Parts:
IlL Total/~td';lionai Costa:
Gross Total:
IV. Total Adjustments:
Net Total:
This is a preliminary estimate.
Additional char~les to the estimate may be required for the actual re~-~_;.r.
186.56
328,28
29'.t8
544.02
0.00
544.02
ESTIMATE RECALL NUMBER: 5/3/2001 15:26:33 2850
UltraMate is a Trademark of Mitchell letemaiJonal
Data Version: JUL_01_A Copyright (C~ 1994 - ~ Mitchell Intent
UltraMete Version: 4.7.007 All Rights Reserved
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