Claim - Cavanaugh, DavidCLAIM 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: David Cavanaugh
2. Address: 206 Parklane Dr., E. Dubuque, IL 61025
3. Telephone Number: 815 747 2883
4. Date of Incident: 9 20 01
5. Time of Incident: 2 p.m.
6. Location of Incident (Be specific): JFK Road
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.)
City Employee Gary Nauman made improper land change and struck our above insured, David Cavanaugh.
Mr. Nauman was cited for improper lane usage.
8. What were weather conditions like? clear / dry
9. Give name and address of any witnesses:
10. Did police investigate? (If so, give names of officers.)
Yes, Report # 01 - 37553
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
N/A
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.)
$737.58 - damage to Mr. Cavanaughs vehicle to date repairs are not yet complete so don't have a final figure.
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.)
State Farm Insurance PO Box 83106, Lincoln NE 68501 Mr. Cavanaugh will incur a $100 deductivel and we will pay remainder.
15. What amount do you claim from the City of Dubuque?
$737.58 - plus?? repairs not yet complete so this is not a final totals
16. Why do you claim the City of Dubuque is responsible?
Improper lane change on the part of your employee
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 source, and if so, in what amount?
Dated at Dubuque, Iowa this 2nd day of October , 2001.
/s/ Health Schuttler (State Farm)
(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. 13t~ 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:
3. Telephone Number:
4. Date of Incide~:
5. Time of Incide,t: ~
6. Location of Incident
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
e~t31oy~e~e's name.)
9. Give name and address of any wi~es~s: -
10. Did 13olice investigate? (If so, gi~/e nam,es of offic~ers.)
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.)
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. Whydo you c,~(t~hte City~u~u, 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.) ~
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)
Damage Assessed By: AL COGHLAN
Supplemented Dy: AL COGHLAN
Type of Loss: Collision
Date of Loss: 09/20/01
Deductible: 100.00
Claim Number: 13-7479-31201
Insured:
Address:
Telephone:
Description:
Sody Style:
Mileage:
OEM/ALT:
Color:
FED ID #42-0813744
RICNARDSON MOTORS
1475 J.F.K. ROAD DUBUQUE ,IA 52002
(319) 582-5411
Fax: (319) 582-4129
DAVID CAVANAUGH
206 PARKLANE DR EAST DUBUQUE, IL 61025-9548
Home Phone: (815) 747-2883
Mitchell Service: 911618
1995 Lincotn Town Car Signature Series
40 ged Drive Train: 4.6L Inj 8 Dy[
ILNLM82WCSY728360
71,935
0
AO
Date: 10/01/01 13:58 P.M.
Estimate ID: 13~7479-31201
Estimate Version: 1
Supplement: I(P) 10/01/01 01:58:
FINAL
Profile ID: CUSTOMIZED
Line Entry Labor Line Item
Item Number Type Operation Description
I 100141BDY REPAIR L FENDER PANEL Existing
2 AUTO REF REFINISH L FENDER OUTSIDE
3 105036 BDY REMOVE/INSTALL L FENDER SIDE MLDG
4 105160 BOY REMOVE/INSTALL L FENDER ADNESIVE NAMEPLATE Existing
5 900500 REF* REFINISH/REPAIR PAINT STRIPE New
6 900500 BDY* REMOVE/REPLACE W/O MOLDING New
7 NOT FACTORY W/O MOLDING
8 LINE MARKUP %25.00
S1 9 900500 BDY* REMOVE/REPLACE FINAL REPAIR BILL New
10 114430 REF BLEND L FRT DOOR OUTSIDE
11 100296 BOY REMOVE/REPLACE L FRT DOOR MOULDING ORDER FROM DEALER
12 100822 BDY REPAIR L FRT DOOR REAR VIEW MIRROR Existing
13 AUTO REF REFINISH L FRT DOOR MIRROR
14 AUTO REF ADD~L OPR CLEAR COAT
15 AUTO ADD~L COST PAINT/MATERIALS
16 AUTO ADD~L COST HAZARDOUS WASTE DISPOSAL
Part Type/ Doltar Labor
Part Number Amount Units
75.00*
18.75
C
90.72
D
145.60'
6.00'
2.5*#
2.5
0.2
O.O*
0.0'
0.0*
1.0
O,4
0.5*#
0.5
1,3
ESTIMATE RECALL NUMBER: 09/25/01 10:50:43 13-7479-31201
U[traMate is a Trademark of Mitchell International
~MitcheLl Data Version: SEP_OI_A Copyright (C) 1994-2001 Mitchell International
Ultramate Version: 4.7.007 All Rights Reserved
Page
1 of 3
Bate: 10/01/01 13:58 P,M.
Estimate ID: 13-7479-31201
Estimate Version: 1
Supplement: I(P) 10/01/01 01:58:
FINAL
Profile ID: CUSTOMIZED
FINAL BILL
* - Judgement Item
# - Labor Note Applies
C - Included in Clear Coat Calc
ESTIMATE RECALL NUMBER: 09/25/01 10:50:43 13-7479-31201
UltraMate is a Trademark of Mitchell International
Mitchell Data Version: SEP_O1_A Copyright (C) 1994-2001 Mitchell International
Ultramate Version: 4.7.007 All Rights Reserved
Page 2 of 3
Cate: 10/01/01 13:58 P.M.
Estimate ID: 13-7479-31201
Estimate Version: 1
Supplement: I(P) 10/01/01 01:58:
FINAL
Profile ID: CUSTOMIZED
I. Labor Subtotals
Body
Refinish
Add'l
Labor Sublet
Units Rate Amount Amount Totals
3.6 40.00 0.00 0.00 144~00T
5.6 40.00 0.00 0.00 224.00T
Taxable Labor 368.00
Labor Tax @ 6.000% 22.08
Non-Taxable Labor 0.00
III. Additional Costs
Taxable Costs
9.2 390.08
Sales Tax @ 6.000%
[[. Part Replacement Summary
Taxable Parts
Parts Adjustments
Sales Tax
Total Replacement Parts Amount
Amount IV. Adjustments
6.00 insurance Deductible
0.36
Non-Taxable Costs 145.60
Total Additional Costs 151,96
Customer Responsibility
I. Total Labor:
II. Total Replacement Parts:
III. Total Additional Costs:
Cross Total:
IV.
Total Adjustments
Net Total:
Less Original Net Total:
Net Supplement Amount:
S1: AL COGHLAN
Amount
165.72
18.75
6.000% 11.07
195.54
100.00-
100.00-
390.08
195.54
151.96
737.58
100.00-
637.58
637.58
0.00
0.00
Point(s) of Impact
10 LEFT FRONT SIDE (P)
Inspection Site: RICHARDSON MOTORS
Body Shop: RICHARDSON HONDA BUICK
Address: 1475 J.F.K RD
DUBUQUE, IA 52001
ESTIMATE RECALL NUMBER: 09/25/01 10:50:43 13-7479-31201
UltraMate is a Trademark of Mitchell International
Mitchell Data Version: SEP_OI_A Copyright (C) 1994-2001 Mitchell International
Ultramate Version: 4.7.007 All Rights Reserved
Page 3 of 3