Claim Price, LisaCLAIM 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: Lisa Price
2. Address: 3232 Sunnyside, Davenport, IA 52802 - I just moved.
`
3. Telephone Number: (563) 212-1965 (309) 732 0368
4. Date of Incident: 9/27/04
5. Time of Incident: ?
6. Location of Incident (Be specific): 1500 Delhi
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.)
A bus driver hit my driver's side mirror and shattered the mirror and it was hanging so I had someone cut it off.
8. What were weather conditions like? Perfect day.
9. Give name and address of any witnesses: I don't know my daughter had my car and was seeing a doctor.
10. Did police investigate? (If so, give names of officers.)
Yes - Kane
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
No
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.)
Zimmerman - $217.09 - I prefer Lujac $318.61
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? $217.09
16. Why do you claim the City of Dubuque is responsible?
The bus driver hit my parked car, called the police to file a report then my daughter was called.
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 4th day of October, 2004.
/s/ Lisa Price
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
SEP-2B-04 rUE 01: 12 PM DUBUQUE CITY CLERK FAX NO, 563 b139 01390
. /ß/h/ ol.f¿;c~ I1!j ¿/ ¡11
CLAIM AGAINST THE CITY OF DUBuaUE,lOWA . .~
'í' /ÝJaN¿
O[ his wriU£¡!ì report con<.1Îtutc!J your claim <¡gains! the City of Dubuque. Iowa. You shoul~
complete. IhIs form in full Elhd attach nny ",ddiliorw Information that supports your claim.
The CI"im must be filr:d wilh thl;: City Cieri, ,It Gily Hall, 50 W. 131h St., Dubuque, IA 52001.
It will thei, be rl'Jerrr;d by th~) City Council 10 th:'; appropriate department for invc:stigation.
Opt..;¡; thllt i¡¡V¡;,Slit¡<llion Is t~<; npl()tød. .1 report and r[;(',oJ11mendation will be submitted to the
City Council. YcJU will be provided with a copy 01 thai report and recommendation.
y, Ul
'HIE FINAL OEGi8l0N ON ALL CLAIMS IS MAnE BY THE CITY COUNCIL. NO EMPLOYEE,
OF TI-'\;: CITY 01" DUIJIJCIUE !-.AS 1HE AUTHORITY TO MAKE ANY flEPAESENTATION 'TO
YQU AS TO WHít'_HIER VOUB CLAI~ WI~l OR WILL NOT BE PAID.
-I. Nf,me 01 CII-llmont:- .__l. \.?.::-:_n..__r : ~--_...---- __n____._---------'---~ . u<;>-k
:.>.. Ad d {li-.,~';; :__3>_~-~-~_...s_\Uì(\~-~ -\:..-O.etJ:f4~&~.5À~~-:""_~~~ eel,
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4. Dall?- 0: h (:¡d<}nt:_-_ql~'"LLQ.:L-.--_n_--_..._-_..__.----_._.__._----------
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---.-............,--......--......- .....-...- ....-.-----.----...--....-----".""""" --.......--....-...-----..----------""
"7- DESChlUI': ACCIPI::.NT OR OCCURRENCE 111A1" CAUSED INJURY OR DAMAGE. (Give
lull d~tal!". upon which you baSt: your claIm. If a City employee was involved, give the
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8. Whot \"/('1'(: wcath...r conditions likr;'i' __..~..£.L~ ~-_.._.._--_.-
9. Give r:m,I" and nddh)S$ of any wllncsse~~;__,*=,_dq~-t......IÇ(\\D~~3---
_ch~~\~{ ._blliL___fu~..::b.W.~n--5-Q..;ù_f\\~oL2 d-ùr ---",
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i 1. War.; imY,JnlJ injured? (If so, Hive names, !\fklie¡;ses, and extent of injuries).
--......_./Y-S:;L......_- .---..-..---------- ....-.., --........-..---..".....---.....-- --.-------..-------., -.---------- -------..
........---..---.... -""'-----"--"--"'--'--"""""""-- -..-------.---........-..., .-.--.-.....-..---...--.-------------..----
09/28/04 TOO 13:47 [TX/RX NO 7118]
. .,.- "3' I" Q'J u<,:~';r me property and the extent of damages"
'\Il~C:ll (!:!ttir¡"¡atei'> fit damage:;; or de$cribe basis fo( I1sr:ertaining extent of damage.)
, -~ ~
-.__.._---='-~S..~ ~1'2:i(L-~--2a<-t~.~-Q3.--_~_~~ -------
--'-"- .m....._.._-~ ~ cJ;--=--~-31~lg~. . -.. - -- ._--._..._--~.._-------
121. 'Nhz1t othcr ¡ amag.~s ftoyou claim, If any?_.._.Û.Of'::::~__---_.
. """'-""'---'" ,_...__.. '--"""---. .._--, -"'-""""_n___. ---. ,_... -." ----"----'--'---_...~--
----
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14. lIa'Je YiJU ¡¡,:en (';ol1\ Jensnled lor /lny !,3rl or aU of your claim by any insurance
COmpAny? (i"I !,o, tJive mlrne <1l1d IHldrcss of insllrnnCi) company and amount paid.)
--~---
¡ ;~~~:t~';::~"~O~::::;:~:~~:f ;',~,:".?!ah- - ~=~=--=-
I :-~~~::~ ~;::,~~~;':;;;::U';~':~~~:¡~I'~ \,-~ dr:- ~r-
I_h.'" . JY>~.J~illW.=c, .éA.1Le.rL~~ c~~-
'. ---Ri:eA_.. -Q..._.S_~~ .~..~~~~~~ -$ c~l1:~L
11- Hnv(¡ Y'ill mnde any (;I"im !1{1f1JlIst anyone elf:C for damagt1s as Ii result of this inciçlcnt?
_~i ~-~~,~'_.~:~ ..~~:'~~.,f~ n~.,~~d r~~~~NJJ__, ----'---,--_..._- .._~------~-,---.._-
... .._-í\Q.. ...-.-.-....--.-...-..--..-. ....--.......----.'..-.'..--.....-----.-------..----.-----
If!. If the ¡!nSW(~r to Ouestion 17 is yes, h(\ve yon r(;l~oíved any payment from thaI source,
¡>lId it so, in W!h)t amount?
- '-"---"""""--"- -... -.... .---......---..... -""--..-. -""""---'-...--..-.-........- '--""'~~'-'-~'-~--
lJl'I\,"d at f)t,¡tlUi: Uo;;;, lowtI this y-~
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t1;
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dt¡y 0:.1 --~~--_._, 20.Q~.
--~Q~_...._-
(Signature)
--_U.s~ Ç)r\~..~
(Print Name)
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(Hew. I!()O ,:~ 1Jí¡1)
09/28/04 TUE 13:47 (TXlRX NO 7118]
D81e: 812912004 04:31 PM
Esttmate 10: 8217
Estimate Version: 0
Prellml""ry
ProftleID: STATE FARM
ZIMMERMAN- PONTIAC- CAD- OLDS- HONDA
2118 -8TH AVE P.O. BOX 4744 ROCK ISLAND. IL 81201-4744
(308) 783-G088
Fex: (308) 793-&140
~ -- By: SHILOH O'CONNOR
Deductible: UNKNOWN
Insured: USA PRICE
AddreSs: 3232SUNNYSIDEDAVENPORT.1A 12802
T8I8phon8: Hom8 PIIon8: (308) 732.0388
M_I øervIce: 811483
DescrIption:
Body Style:
VIN:
Options:
1888 - O..ncI PrIX BE
40-
1G2WJ82M8WF281888
ALUMlAU.OY WHEELS. AIR CONI)ITIONING. POWER STEERING. POWER WINDOWS
POWER DOOR LOCKS. TILT STEERING WHEEL. CRUISE CONTROL. ELECTRIC DEFOGGER
AUTOMATIC TRANSMISSION, AM.fM STEREOICDPLAYER(SINGLE)
LIfIII Entry LabM
118m N- Type
,- iõõï34 ïiïiY
2 AUTO REF
3 lO0I4O BOY
4 AUTO REF
I AUTO
I AUTO
Une 118m
DøcripIIon
L FRT DOOR POWER MIRROR ASSY
L FRT DOOR MIRROR
L FRT DOOR TRIM PANEL
CLEAR COAT
pAINT IMA TERIALS
HAZARIJOUS WASTE DISPOSAL
0perIIII0rI
RI!MOVEJREPLACI!
rœFlNIIH
REMOVE/INST AU.
ADD'\. OPR
ADD'\. COST
ADD'\. COST
. - Judgement Item
# - Labor Note Applies
C - Included In Clear Coat Calc
I. LabM SubtotalS
Body
Refinish
Add'
Labor
Units Rate Amount
0.7 48.00-¡¡:¡¡¡-
0.1 48.00 0.00
S-
AmoUnt T -
~~
0.00 23.00
Non-Tax- Labor
11.20
LabM sunmary
1.2
11.20
DriVe Train: 3.1L Inj 8 Cyt AO
Part Type!
Part N-
ORDER FROM DEAlS!
II. Part Replacement Sunmary
Taxable 1'-
_Tax @
Total RapIecemenI Parts AmoUnt
ESTIMATE RECAU. NUMBER: 8J2812OO4 18:31:48 8217
UItraMIIIe Is a T'-""'" of MIlch8lIIrrIerfIIIIIona
MIIch8II D8Ie Version: SEp 04 A Copyrlghl eC) 1884 - 2003 M- In\ernIIIIOfIII
UItraMate Version: 8.0.024 - All RIghts Reserved
Dollar Labor
Amount IInIIs
~ 0.3#
COA
OA
0.1
14.00 .
1.80 .
7.000%
Amount
~
8.81
148.41
Page 1 01 2
10. Addltionlll Costs
Taxable Costs
Sales To
Amount
14.00
0.88
1.50
@
7.0lIO%
Non-T"'- Costs
Total Addltionlll COSts
18.48
ESaIll8le 10: 11211
E-.aIe Version: 0
PrelImInary
Profile 10: STATE FARM
IV. AdJu-
Customer Responsibility
I.
II.
III.
Total Labor:
Total Replacement_:
Total Addltionlll Costs:
Gross Total:
IV.
Total Adj"-:
NetT.....I:
This is a Dl8llminarv estimate.
Additional chanG.. to the estimate mav be reQuired for the actual reDair.
ESTIMATE RECALL NUMBER: 81291200418:31:48 8217
UftraMaht .. . T-....rk of M-1nternationaI
Mitchell Doto Version: SEP 04 A Copyright ICI IBM - 2003 M- international
UItr.MoIe Version: 8.0.m - All Rights -
Amount
0.00
811.20
148.41
18.48
217.08
0.00
217.08
P_2of2
LUJACK NORTH PARK AUTO PLAZA
3700 HARRISON STREET
DAVENPORT, IA 52806
563-388-2712 FAX 563-386-7790
TAX ID #42-0664731
PHONE
CD LOG NO 28654-1
DATE 09/30/04
SHOP:
ADDRESS:
LUJACK NORTHPARK AUTO
3700 HARRISON STREET
LUJACKCOLLISION.COM
DAVENPORT, IA
52806-
pLAZA
INSP DATE:
CONTACT:
PHONE 1:
PHONE 2:
FAX:
CITY STATE:
ZIP:
OWNER: PRICE, LISA
ADDRESS: 3233 SUNNYSIDE
CITY STATE: DAVENPORT, IA
ZIP: 52802-
HOME PHONE:
WORK PHONE:
LIC#: 796NJE
BODY COLOR: DARK GREEN
CONDITION: EXCL
:3TAT~: IA
VIN:
MILEAGE:
ACCTNG CTL#:
DRIVEABLE:
YES
VEH. INSP#:
*~USER-ENTERED VALUE
EC=REPLACE ECONOMY
EU=REPLACE SALVAGE
PM=PXN REMAN/REBUILT
IT=PARTIAL REPAIR
BR=BLEND REFINISH
SB=SUBLET
P=CHECK
UP=UNRELATED PRIOR
E=REPLACE OEM
UC=RECONDITIONED PRT
EP=REPLACE PXN
TE=PARTL REPL PRICE
I=REPAIR
TT=TWO-TONE
N=ADDITIONAL LABOR
AA=APPEAR ALLOWANCE
I CjCjB PONTIAC GRAND PRIX 5E 4DOOR SEDAN
CODE: W3263A/B OPTNS M/24R
09/30/04
STEVE HOLUB
(563) 388-2712
(563)388-2729
(563) 386-7790
(563) 212-1965
(309)732-0368
IG2WJ52M6WF298956
98,000
NG=REPLACE NAGS
UM=REMAN/REBUILT PRT
PC=PXN RECONDITIONED
ET=PARTL REPL LABOR
L=REFINISH
CG=CHIPGUARD
RI=R&I ASSEMBLY
RP=RELATED PRIOR
6CYL GASOLINE 3.1
OPTIONS:
TWO-STAGE - EXTERIOR SURFACES
TRACTION CONTROL SYSTEM
TWO-STAGE - INTERIOR SURFACES
01' GDE MC DESCRIPTION MFG. PART NO.
-- ----------- ------------
RI 0231 PNL,INNER DOOR TRIM LT [\&1 ASSEMBLY
RI 0255 MLDG,FRONT DOOR BEL LT [\&;¡ ASSEMBLY
E 0229 46 MIRROR,OUTER R/C LT 10312053 G11 PART
L 0229 13 MIRROR,OUTER R/C LT REFINISH
E 0276 GLASS,MIRROR OUTER LT 12530001 GM PART
L M15 COLOR TINT REFINISH
SB M60 HAZARD. WSTE. REM. SUBLET REPAIR
7 ITEMS
MC
MESSAGE(S)
PRICE AJ% B% HOURS R
----- -
INC 1
0.2 1
135.90 0.7 1
1.4 4
INC 1
0.2*4*
5.00* *1*
PAGE 1
09/30'/04
1
PONTIAC GRAND PRIX
LOG NO 28654-1
SE 4DOOR SEDAN
] 3 INCLUDES O. G flOURS FIRST PANEL TWO-STAGE ALLOWANCE
46 PRINTABLE PXN COMPARE
FINAL CALCULATIONS & ENTRIES
GROSS PARTS
PAINT MATERIAL
PARTS & MATERIAL TOTAL
TAX ON PARTS @
7.000%
LABOR
I-SHEET METAL
2-MECH/ELEC
3-FRAME
4-REFINISH
é,-PAINT MATERIAL
LABOR TOTAL
TAX ON
SUBLET
TAX ON
TOWING
STORAGE
!iATE
46.00
70,00
50.00
46.110
2H,uO
REPLACE HRS
0.9
REPAIR HRS
1.6
LABOR
REPAIRS
SUBLET
@
7.000%.
@
7.000%
GROSS TOTAL
NET TOTAL
ADP SHOPLINK U3879 ES CD LOG 28654-1 DATE 09/30/04 05:21:13PM R6,35
PXN: Y/01/00/00/01/01 CUM 01/00/00/01/01 GEOCODE 52806
HOST LOG
(C) 1998 - 2004 ADP CLAIMS SOLUTIONS GROUP, INC.
0.7 HRS WERE ADDED TO THIS EST. BASED ON ADP TWO-STAGE REFINISH FORMULA.
--------------------------------------------------
135.90
44.80
180.70
9.51
41. 40
73.60
lI5.00
8.05
5.00
0.35
318.61
318.61
CD 09/04
THIS ESTIMATE HAS BEEN PREPAREQ BASED ON THE USE OF AFTERMARKET CRASH PARTS
SUPPLIED BY A SOURCE OTHER THAN THE MANUFACTURER OF YOUR MOTOR VEHICLE. ANY
WARRANTIES APPLICABLE TO THESE REPLACEMENT PARTS ARE PROVIDED BY THE
MANUFACTURER OR DISTRIBUTOR OF THESE PARTS RATHER THAN THE MANUFACTURER OF
YOUR VEHICLE. .
ORIGINAL EQUIPMENT MANUFACTURED PARTS WARRANTED FOR 1 YEAR
OR THE REMAINDER OF THE VEHICLES LIMtTED WARRANTY.
PAINT WARRANTED BY SIKKENS
AGAINST MANUFACTURER DEFECTS A~) LONG AS YOU OWN YOUR VEHICLE
WORKMANSHIP ON THE ESTIMATED REPAIRS ARE WARRANTED AS LONG
AS YOU OWN THE VEHICLE.
THIS ESTIMATE HAS BEEN PREPARED AS ACCURATELY AS POSSIBLE,
HOWEVER, ADDITIONAL COSTS MAY Arn~,:E 'BECAUSE OF HIDDEN DAMAGE
PARTS PRICE INCREASES, LABOR COSTS, PR UNFORESEEN
CIRCUMSTANCES LUJACKS HAS NO CONTROL OVER.
SORRY, WE CANNOT WARRANTY ANY RUST REPAIRS PERFORMED TO YOUR VEHICLE.
PAGE 2
09/30/04
Form 433003
01-01
Iowa Department of Transportation
Law Enforcement Case Numbers:
q Pm
PLEASE TYPE OR PRINT
Date of deny
r_.)q
MAIL REPORTS TO:
Iowa Department of Transportation
Otece of Driver Services
Pais Fair Mall, 100 Euclid Avenue
P.O. Boer 9204
Des Moines, Iowa 5030S-9204
Time of Accident
Hrs.
II aoditent oodurred outside of
city frosts show general vicinity
County
`441 INVESTIGATING OFFICER'S REPORT
OF MOTOR VEHICLE ACCIDENT
ti..
Accident occurred within
corporate limits of (city)
N NE E SE S SW W NW
miles 0 0 0 0 0 0 0 0 of nearest oily
Legal Private
l Intervention? ❑ Property?
On Road, Street- Al Intersection
or Highway: /�7 j ~t. � with:
Note: Unless accident occurred at an infereeaicn which is completely deecnted above. use the space below to give the esacf location from a milepost
or definable intersection, bridge, or railroad crossing, using two distances and directions if necessary.
County:_
X-Coordirtale:
Route:
Y-Coordirlale:
U
N
I
T
2
Feet
4j
Milepost
Number
Miles
N NE E Sic S SW W NW
00000a.00
Defneble Intersection,
Or bridge, or railroad crossing
Driver's Name (Leal first. Middle)
1�D ►.j ' J tip
B Driver's License Number
Owner's Name (Last First. Middlel
4 V�f-,4i Cx-ki uSr
Insurance Co.
Name
and Feet or Miles 0 0 0 0 0 0 0
3L..._
L..�,T' - _,....14 .=:_..„,_
MOMS
MN
Oct
if Divided Highway, Provide Route
(Cardinal) Travel Direction
0 0 0 0
City State Zip
Citation 1 3.
Charge
2" 4,
Medial 1. None 3" Urine 5. Vitreous Test Results:
Test Given? JJ 2. Blood 4. Breath 9" Refused
CA waaurarw
VIN # Y f `Year
el
,>5
Ce lei nvel J Action j I Iit retied. I, 1 Initial impact of W Ares Damaged WJD DIndent amage (J
Drug 1" None 3. Urine Pos. Neg.
Test Gruen? w 2. Blood 9. Refused 0 0
License ;1 3 \ 5
Plate #
Style
Undernd&l
Override Li
Skala Zip
(Zr'‘
State Year
Tow Of AdprOWumate Coat to
Repair or Repiece
Private?
0
Taal
Occupants LJJ
Traffic
Controls L U
Vehicle
Contfig• L_LI
Ono Type Body LJJ
Vehicle
Defect I 1 1
Dover
Condition U
Vision
Oasoured uJ
Contributing Circumstances,
Driver (up to Swot L ..J L IJ
Commercial Trailer
Attached to
Llpr Flats II Power Unit:
State Year
Attached to
Trailer Unit'
State Year
Emergency
Vihicle TypeL
Emergency u
Status
Carrier
Marne
• x a I` 11 1 1 1 1 1 1
Driver's Name (Last, First, Mklde)
Number
of Axles
Address
Address
Gross Vehicle
Weight Filing
City State Zip
Placard
�1111.0
City
Hazerdota Materiels
Refeassed?
State • Zip
1-7
Dale of birth
Driver's License Number
Male Female
0 0
State
Class
Owner's Name (Leal, First. Middle)
trlesrartce Co.
Name
Endorsementsi Restrictions
Citation 1 3.
Charge
2. 4.
Alcohol 1. None 3. Urine 5. Vitreous Test Results
Test Given? LJ 2. Blood 4. Breath 9. Refused
1 Insurance
Policy Or
VIN# /6.2 =S2 F.29815
Initial Travel Vehicle
Direction U Action I I I f Limit 1. 1:71,..e,„ I I
Tote
Occupants I I I
Traffic
Controls I I
Year
Dreg 1, None 3. Urine Pos. Neg.
Test Chen? LJ 2. Blood 9. Refused
Address CAT Slate Zip
.3r�i . mil`' -"r f 41 a
Paint of
initial impact I I I
Vehide
Conryg" I I f
Cargo Body
Type
LLJ
Mike
Moat Flapped
Area
Vehicle
Defect: f LJJ
Model
Driver
Condition LI
Plate f 711.0
Style
Undenkdel
Override 1__1
vision
ObeaaredI I I
Commercial Trailer Attached to Stale Year Medici to
License Plate # Power Unit:_. _ TrafkrUret o
Carrier
Name
Address
Tow if
Private?
State Year
fl t
Approximate Cost to
Repair or Replace
$
Contributing Circumstances,
Driver (up to two)
State Year
City
Emergency
Vehicle TypeLJ
Stale
LLJ LLJ
Erne:Deno
Status LJ
rip
USDOTS or rro 1 1 1 1 1 1 1 1
If Property other than Objaxi
vehicles damaged explain Damaged
Number
of Aides
Gross Vehicle
Weight Rating
Estimate of
Damage
Placard
Nazarenes Materials
Released?
Unit 1 Unit 2 SEQUENCE OFEVENTS
Owner's Full Name
(Last. First, Mlddtti)
Was owner or 1 - Yes 9 • Unknown
tenant notified? Li 2 - No
Street or
RFO
City, State,
s Zip Code
ACCIDENT ENVIRONMENT
Location of First Harmful Event Li Weather Conditions I I I
(up to too)
Manner of CrastVCollision
Light Condilons
u
I I Surface Coedrlir as
LJJ
u
ROADWAY CNNARACTERiSTIC$
Maim Contributing Circumstances:
Environment _ r
RoedwaY
u
Type or Roadway Juridic/retire 1
WORK ZONE RELATED'?
O Yes 0 No
u Location
LI Type
u Workers Present?
First Event
Second Event
Third Event
Fourth Event
LLJ LJ
Most Harmful Event
(by vehicle)
W First Harmful Event of Crash
One codes 11-42 only)
r �
Officer's Name,'
Badge No. ,4