Claim - ServiceMaster by BanfieCLAIM 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: ServiceMaster by Banfield Seven Hills
2. Address: P.O. Box 832, Dubuque, Iowa 52004-0832
3. Telephone Number: 563 557 7459
4. Date of Incident: 8/2/01
5. Time of Incident: 18:44
6. Location of Incident (Be specific): Central at 17th St. - Dubuque
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.)
Police Car Ran a Red Light - Josh Abitz
8. What were weather conditions like? Normal
9. Give name and address of any witnesses:
Fernie Pineda, Mike Finnin Mtrs., 3600 Dodge, Dubuque, IA 52001 (556 1010)
10. Did police investigate? (If so, give names of officers.)
Yes
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.)
Van Damage - Estimate Attached
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.)
No
15. What amount do you claim from the City of Dubuque?
Attached
16. Why do you claim the City of Dubuque is responsible?
Driver Given Ticket
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 17th day of August , 2001
/s/ Jayne M. Banfield
ServiceMaster by Banfield
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
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.
3. Telephone Number:
4. Date of Incident:
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, g ve the
employee's name.) ~ IIC~ _~/~ ~/ ~q' ~)
8. What were weather conditions like?
9. Give name and address of any witnasses:F
lO~?~.p._.~lice investigate? (If so, give names of officers.)
1 l'-W~Soany~ne 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.)
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 ,,/give name
so, and address of insurance company and amount paid.)
/VO
15. What amount do you claim from the City of Dubuque? ~'
16. Why do you claim the City of Dubuque is responsible? _-~ ~_'t L~~'~
17. Have you made any claim against anyone else for damages as a result of this incident?
(If Yes, give name and address.)/'q~O
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
(Rev. 1/00 & 7/01)
I-~ dayof -J~ ~'l _<~-Ti . 20o,
(Print Name)
Dete: 811510t 09:34AM
Estimate ID: 5323
Es~;~&~= Veminn: 0
Preliminary
Profile ID: Mitchell
BIRD CHEVROLET
325~ UNIVERSITY AVE. P.O. BOX 57 DUBUQUE, IA 52001
(563) 583-9t2t
Fax: (563) 656-4482
Damage Assessed By: JOHN .K[-_OTZJR.
Deductible: UNKNOWN
Owner SERVICEMASTER,~BANFtELD
Mitchell Service: 9134~5
Description: 1984 Chevrolet ChevyVan G20
Body Style: Van
VIN: 1GCEG25H8E7173257
Drive Train: 5.OL 8 Cyt 2WO
Line Entry Labor Line Item Part Type/
Item Number Type Operation Description Part Number
Dollar Labor
Amount Unite
_301230 BDY REMOVE/REPLACE
303178 BDY CHECK/ADJUST
303810 BDY REMOVE/REPLACE
REF REFINISH/REpAIR
312880 BDY REPAIR
AUTO AD_D'L COST
AUTO ADD'L COST
* - Judgement Item
# - Labor Note Applies
FRT BUMPER FACE BAR 464304
DAMAGED OWNER DID NOT WANT REPAIRED
HF-AOLAMPS
R H/LAMP BEZEL 14048646
R H/LAMP BEZEL
R FENDER PANEL Existe~
DAMAGED OWNER DID NOT WANT REPAIRED
PAINT/MATERIALS
HAZARDOUS WASTE DISPOSAL
GM PART
GM PART
0,00 * INC"
0.5
33.50 0.2
0.5'
INC*#
13.00 *
0.42 *
Add'l
Labor Sublet
L Labor Subtotals Units Rate Amount Amount Totals
Body 0.7 42.00 0.00 0.00 29.40 T
Refinish 0.5 42.00 0.00 0.00 21.00 T
Taxable Labor 50.40
Labo~ Tax _~ 6.000 % 3.02
~borSummary 1~ ~.42
Part Rep;&ce,,ent Summary
Taxable Parts
Sales Tax ~
Total Replacement Parts Amount
6.I00% 2.04
ESTIMATE RECALL NUMBER: 8/'15/0t O9:29:59 5323
UitraMate is a Trademark of Mitchell International
Mitchetl Data Vemion: AUG_0'I_A Copyright (C) 1994 - 2000 Mitchell international
UltraMete Version: 4.7.007 All Rig h~s~ileserved
Page ¶ of 2
Date: 8/t$10t 09=34 AM
Estimate ID: 5323
Pmliminary
Profile ID: Mitchell
IlL Additional Costs Amount tV. Adjust~er~s Ameu~t
Non-Taxable Costs 13.42 Customer Responsibility 0.00
Total Additional Costs 13A2
I. Total Labor; 53.42
IL Total Reple~mtent Parts: 35~1
fll. Tetal ~ C~,;~: t342
Gross Total: 102,35
IV. TQ~M Adj~f4menta: 0.00
No~ Ti:dad: 102.35
This is a preliminary estimate.
Additional chan,qes to the estimate may be required for the actual repair.
PARTS PRICES ARE SOBJECT TO CHANGE
ESTIMATE RECALL NUMBER: 8/t5/O1 09:29:59 5323
Ul~aMate ~ a Trademark of Mitchell International
M[~,.he;; Data Version: AUG_01_A Copyright (C) 1994 - 2000 Mitchell tntematioftal
UlUaMate Version: 4.7.007 All Rights Reserved
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